As Australia plans its inquiry into the pandemic response, there is still no evidence key recommendations to deploy the National COVID-19 Health Management Plan are in place, six months after its release. By Rick Morton.
What’s next in Australia’s Covid-19 response
As the government considers the form and breadth of a Covid-19 inquiry to examine Australia’s response to the pandemic, similar hearings in Britain this week offer a taste of the future.
The circumstances in both jurisdictions in late 2019 were remarkably similar: whatever concrete pandemic plans existed were based largely on the very different virus of influenza, and contained precious little detail about actual decisions that would be required in an emergency.
“The starting point for your Inquiry is that whilst we may not know the moment that this virus came into existence, or how exactly it made its way into the human race, we do know that the possibility of a pandemic had been foretold and thought about,” lead counsel for the British inquiry, Hugo Keith, KC, said on Tuesday.
“Indeed, it had long been assessed by planners that there was a significant risk of a non-influenza pandemic and an even greater risk of a flu pandemic. Such risks were assessed and thought about, and planned for, and prepared for, and written about by the departments, bodies, agencies, services, responders and personnel who make up the United Kingdom’s emergency preparedness, resilience and response structures.”
These plans, however, were vague and high-level.
“Fundamentally, in relation to significant aspects of the Covid-19 pandemic, we were taken by surprise,” Keith said.
“Huge, urgent and complex policy decisions were required to be taken in relation to shielding, employment support, managing disruption to schools, borders, lockdowns, and non-pharmaceutical interventions, restrictions, social restrictions, and, equally importantly, the profoundly unequal impact of the pandemic on the vulnerable and the marginalised. Few of those areas were anticipated, let alone considered in detail.”
These are the hugely consequential decisions Australia must also confront in constructing a plan for the next health crisis.
On May 5, the World Health Organization’s director-general, Tedros Adhanom Ghebreyesus, declared an end to the global health emergency associated with the SARS-CoV-2 virus.
“For the past year, the emergency committee and WHO have been analysing the data carefully and considering when the time would be right to lower the level of alarm,” he told reporters.
“Yesterday, the emergency committee met for the 15th time and recommended to me that I declare an end to the public health emergency of international concern. I have accepted that advice,” he said.
“It is therefore with great hope that I declare Covid-19 over as a global health emergency. However, that does not mean Covid-19 is over as a global health threat.”
Just days before that declaration, Australia’s Health minister, Mark Butler, was at the National Press Club defending Medicare and launching a war on vaping.
He was asked about the prime minister’s commitment to hold an inquiry into the effects of Covid-19.
“We said before the election and have said since, just given the enormous dislocation, stress, death and expenditure involved in this pandemic, it would be extraordinary not to have a thorough inquiry into it and that remains our position,” Butler said on May 2.
“Particularly through the course of last year and summer, where there were significant waves that posed a lot of stress on health systems and communities, we didn’t think that was the right time to announce that. We are giving consideration to this question. We will have more to say about that in the future.”
There is no perfect time to hold an inquiry into systemic responses to a pathogen that is still circulating in serious volumes. Piecemeal work across a shattered public service, at the federal and state level, has been happening behind the scenes.
The relative centrality of Australia’s response has its benefits, however.
As one chart documenting Britain’s pandemic preparedness structures in August 2019 shows – now infamous as the “spaghetti” diagram – more than 50 offices, departments, secretaries and administrative bodies with various functions were involved in planning for a pathogen emergency. When feedback channels are included, the arrows between the dozens of agencies oppose the diagram’s clarity so violently as to defeat it.
These are not just technical concerns. The bureaucratic confusion that led to the Ruby Princess cruise ship debacle was debilitating and costly, for example.
Australia’s own review process is under way at the margins but, so far, it is atomised and slow-moving.
The Albanese government commissioned former Department of Health secretary Jane Halton’s review into vaccine and therapeutic procurement contingencies, which was handed to Minister Butler in September last year.
Professor Halton was explicit in her call to action. “Pre-pandemic structures and processes were not fit for purpose in an emergency context. With the likelihood of continuing waves of COVID-19 and the need for ongoing, integrated advice, new advisory structures and mandates will be required,” she wrote.
“It is timely to consider the role and nature of existing structures and processes. The ad hoc arrangements put in place at the beginning of pandemic require updating.”
Within months, Butler had released a 16-page National COVID-19 Health Management Plan for 2023. Nine months after Halton released her review, there is no evidence her forceful recommendations with respect to it have been implemented.
The Department of Health said, in response to Halton’s report, that “a new National Partnership Agreement to Protect Priority Groups from COVID-19 will be available to help states and territories target Polymerase Chain Reaction (PCR) testing and vaccine uptake to those most at risk of severe COVID-19 and death – safeguarding the health system”.
No such plan has been published.
Halton also recommended “advisory structures … be streamlined, and advice should be integrated to enable decision-makers to undertake their role”.
“The role of decision-makers and advisors should be clarified. Reasons for decisions should be evidenced including indicating where they are based on judgment,” she wrote.
“Care should be taken to prevent confusion at the clinical level about who is eligible to receive vaccines/treatments and recommendations for use including in respect of target populations.”
A spokesperson for the Department of Health and Aged Care tells The Saturday Paper that “a procurement is under way to engage a service provider to undertake the review of governance and advisory arrangements as detailed in the Halton review. It is anticipated that the review will be completed in 2023.”
If there is an approach to market for this particular contract, it has not yet been published.
While these domestic arrangements unfurl slowly, the World Health Organization and its members – including Australia – have embarked on a mission to develop a new international pandemic instrument “or treaty on pandemic prevention”.
Chief Medical Officer Paul Kelly flew to Geneva, Switzerland, late last month to attend this year’s deliberations but the work isn’t expected to end until May next year.
The so-called “zero draft” of that new instrument would represent a binding agreement on member states – an arrangement that has, predictably in the post-Covid fracturing of public health debate, become a beacon for some to assert Australia will give away its sovereign decision-making power.
Not true, outgoing secretary of the Department of Health and Aged Care Brendan Murphy told senate estimates this month. The instrument won’t become binding until it has gone through “all of the mechanisms” and deliberations, he said.
“And there is nowhere in any of the negotiations where it says that sovereignty will be … that decisions made by sovereign nations will be influenced by this,” he said.
“This is all about sharing of information and sharing of resources.
“Certainly, we would like the world to be much more united and co-ordinated in their approach to pandemics … I don’t think the World Health Organization can compel us at all but we would feel obliged to justify why we were not complying with an agreed protocol.”
The draft document contains tentative provisions that would represent an extraordinary commitment to public health from nations, such as Australia, that have traditionally managed such concerns on the strengths and weaknesses of prevailing health systems and without specific consideration.
The draft calls on members to “commit to prioritise and increase or maintain, including through greater collaboration between the health, finance and private sectors, as appropriate, domestic funding by allocating in its annual budgets not lower than 5 per cent of its current health expenditure to pandemic prevention, preparedness, response and health systems recovery, notably for improving and sustaining relevant capacities and working to achieve universal health coverage.”
It goes on to nominate “XX% of GDP” should be ring-fenced for spending on international co-operation and pandemic planning, particularly for developing countries. That figure, currently undefined, will become the subject of intense scrutiny – one of the chief lessons of the pandemic is that the world can only go as fast as its slowest nation. Weaknesses anywhere are threats everywhere.
In the British inquiry, chief counsel Keith noted the impact of the global health emergency beyond the simple and devastating arithmetic of lives lost.
“The pandemic has had profound financial and economic consequences. It’s put National Health systems under enormous and continuing pressure,” he said.
“The impact on the healthcare systems, its operations, its waiting lists and on elective care has been immense. Millions of patients have either not sought or received treatment and the backlog has now reached historic levels.
“Jobs and businesses have been destroyed, and livelihoods were taken away. The pandemic disrupted the education of children and young people, put children at risk, and has left us with an enduring concern that the pandemic furthered disparities in attainment and development.
“The pandemic impacted the most disadvantaged communities in society all the more, both in terms of the consequences of getting the virus and in terms of the steps taken to combat the virus. Societal damage in terms of the exacerbation of inequalities and the denial of access to opportunity has been widespread. Its impact will be felt for decades to come.”
In this regard, the British inquiry is instructive. These are concerns that, through proper scrutiny, might translate to better and more robust funding for the areas of government service upon which all citizens rely.
“The ability to recover is closely connected to the general health and wealth of the country as a whole,” Keith told the inquiry, chaired by retired Court of Appeal judge Heather Hallett.
“It is for this reason that part of the module, as well as later modules in your inquiry which will focus specifically on inequalities, will explore what state the nation was in as we entered the pandemic. Did the high levels of heart disease, diabetes, respiratory illness and obesity render us more vulnerable? Had there been a slowdown in health improvement in the decade before?
“Had health inequalities widened? Did emergency planning sufficiently account for pre-existing health and societal inequalities, deprivation, structural racism and other forms of discrimination which undoubtedly exist in society?
“As for wealth, it is self-evident that the capacity of any country’s public health care and social care systems to be able to cope with a pandemic is constrained by funding, and therefore you need to inquire how well funded were the United Kingdom’s health structures.
“To what degree have our public services, especially those of health and social care, suffered from underinvestment? How well resourced were the United Kingdom’s public health structures?”
Australia awaits its turn to ask the same questions of its systems.
At the end of May, the federal government stopped publishing its “common operating picture” reports about Covid-19 and measuring the various impacts via colour-coded traffic light metrics. The final report, featuring data as of May 24, is littered with red alerts that, under the old system, required “harder, wider or different” responses to bring under control. These affected metrics were in relation to Covid-19 cases in rural and regional communities, new cases among Aboriginal and Torres Strait Islander people and the number of cases reported in aged-care facilities in the previous seven days.
“Due to Australia’s changed public health response since the COP [common operating picture] was developed, the indicators and thresholds are no longer informative of the current situation,” the Health Department website says.
In advance of the establishment of an Australian Centre for Disease Control – for which the federal budget has allocated roughly $90 million over two years – single agencies and departments such as Health remain focused on the immediate effects of Covid-19.
The Australian Bureau of Statistics reported 190,775 deaths from all causes in 2022, about 20,000 more deaths than usual and “not considered to be a typical year for mortality in Australia”.
At least half of this increase above the long-run baseline is attributed to people who died as a result of SARS-CoV-2 infection, but that only measures the direct effect of the virus.
Phillip Gould, first assistant secretary of the health economics and research division within the Department of Health, told senate estimates on June 1 that the figure itself was not up for debate.
“We’ve entered into a contract with the Australian National University, for example, recently to examine potential causes for this. At this point, it’s very hard to give a definitive answer but we have what we believe are a combination of likely causes,” he said.
One possible explanation is a period of significantly lower excess deaths in Australia in 2020 as a result of less circulation of other respiratory illnesses. This implies a delay in some deaths that would otherwise have happened then, to 2022.
“We also have a population with an increasing median age for each year,” Gould said, explaining that changing demographics affected baseline deaths.
Gould also noted the likely contribution of long-term impacts of Covid, adding the government was “investing significantly in better understanding long Covid”.
“I have teams looking into potential longer-term impacts of Covid, the MRFF [Medical Research Future Fund] is funding more research into this. So this is, again, something that’s being taken very seriously.
“In terms of possible drivers, we believe that the reduction in timeliness of access to emergency and routine healthcare services during the pandemic period may have had some impact there. Pandemic-influenced lifestyle changes are also factors which we are looking into as possible second cause, although we can’t draw a definitive causal link at this point.”
Gould noted the department also worked with the highly respected National Centre for Immunisation Research and Surveillance on a paper examining the relationship between vaccine coverage for people aged over 65, Covid mortality and all-cause mortality. The paper is out in preprint with The Lancet but not yet peer-reviewed.
That study, the first of its kind in the world, showed the effectiveness of vaccines at preventing death in over 65s was as high as 93 per cent in the three months after a third Covid-19 vaccine dose and 63 per cent after six months.
Even as the effectiveness against transmission wanes over time, vaccines represent the best defence against serious illness and death from Covid-19. The question now for Australia is: what will the prescription be for its health, social and financial agencies to strengthen and prepare for future shocks?
“The inquiry will look at how the lives of different types of people with different experiences were regarded by those with a duty of protecting them,” Hugo Keith told the British inquiry.
“For each of the decision-makers, the civil servants and those tasked with the responsibility of preparing our systems, were social and clinical vulnerabilities considered by them at all?
“When the emergency plans were drawn up, did they have regard to the social inequalities and health inequalities which would undoubtedly be exacerbated by the outcome of that planning? The evidence will reveal the reality to that question.”
It is, he said, the most important question of all.
This article was first published in the print edition of The Saturday Paper on June 17, 2023 as "What’s next in our Covid response".
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