Bill Bowtell is both deeply concerned and immensely frustrated.
He is concerned by the coronavirus, which is spreading in Australia at rates that put the country on a trajectory similar to Europe. And he is frustrated with the government, which has let it happen.
“Let’s cut to the chase,” he fires down the phone line, before even being asked a question. “They were warned 12 weeks ago by WHO [the World Health Organization] and others what was coming. They did not accumulate test kits. They did not accumulate the necessary emergency equipment. They did not undertake a public education campaign. They gave no money to science, no money to research, no money to the International Vaccine Institute, no money to WHO. They diligently did not do anything useful.”
Bowtell is an adjunct professor at the Kirby Institute for infection and immunity at the University of New South Wales. He was the architect of Australia’s world-leading response to the AIDS epidemic several decades ago. More recently, he worked for 15 years with the Global Fund to Fight AIDS, Tuberculosis and Malaria. He knows a bit about the insidious way diseases spread.
“I am deeply scared,” he says, twice, before substituting the more moderate word “concerned”. But the examples he cites are more than concerning: they are scary.
New coronavirus cases in Spain are growing exponentially. In Denmark, infections are up tenfold in a week. In Norway, up sixfold. Italy, where the authorities acted way too late, has had almost 36,000 confirmed cases and 3000 deaths.
In contrast, Bowtell and other public health experts point to a handful of nations – China, South Korea, Japan, Taiwan, Hong Kong – that responded early and decisively and have succeeded in flattening the curve of infections, if not stopping the spread of Covid-19 almost completely. We should have been emulating them, says Bowtell, but instead Australia’s response to the plague has been more akin to Europe and America.
Australia’s slow reaction is all the more unforgiveable because we were granted, largely due to good luck and geographic isolation, the luxury of time to watch and learn. But we were slow learners. Now, the spread of the disease is showing up deficiencies in our short-term response as well as pre-existing shortcomings in Australia’s health system.
First to the short term. By the end of December last year, both WHO and Wuhan health authorities were alert to the appearance of a new disease. Just over three weeks later, the Chinese central government ordered what has been called the largest quarantine in history. This was decisive action.
In response, the Australian government also acted quite decisively, announcing a travel ban on China from February 1 – although even then there were almost 12,000 confirmed infections in China, and 130-odd in another 23 countries, including this one. Bans on Iran, South Korea and Italy followed.
“The first step of travel bans was the right one, but implemented too late with Italy,” says Stephen Duckett, health program director at the Grattan Institute.
“That was one mistake. The other was to think that was enough.
“We were out there thumping our chests and putting people on Christmas Island, but we should have at the same time been saying, ‘Okay, what are the scenarios from here? Can we order some ICU machines? What else will we need?’
“And we should have been paying more heed to what was happening elsewhere in the world.”
Elsewhere, the disease was spreading at very different rates in different countries. China, for example, had likely passed its peak infection rate even before our travel ban came into effect. According to one study in Nature, “the number of new daily infections in China seems to have peaked on 25 January – just 2 days after Wuhan was locked down”.
China did it by enforcing a draconian regime of social distancing. By late February new infections outside China far exceeded those within. The virus was raging in Italy, and cases were rising sharply in many other European countries.
On February 27, when Scott Morrison held a joint media conference with the Health minister, Greg Hunt, and the deputy chief medical officer, Paul Kelly, to announce the government was activating a coronavirus emergency response plan, there were still just a handful of cases in Australia. At that stage, all cases had arrived from abroad.
Between them the three men said the word “plan” 32 times, but in reality it was more like a blueprint for bureaucratic consultation. There were no concrete actions mentioned. None of the three men uttered the words hygiene, handwashing or social distancing.
Morrison assured Australians: “There is no need for us to be moving towards not having mass gatherings of people. You can still go to the football, you can still go to the cricket … You can go off to the concert, and you can go out for a Chinese meal. You can do all of these things because Australia has acted quickly.”
After that, the rate of infections accelerated dramatically.
By the time Morrison announced his government’s “comprehensive $2.4 billion health package to protect all Australians”, the number of cases was 128. A week later, this Wednesday, it had almost quadrupled, to 454.
Finally this week the government appeared to grasp the seriousness of the situation. It told Australians not to travel internationally. Morrison spoke out strongly to those who have been engaged in panic buying in the shops: “It’s ridiculous, it’s un-Australian, and it must stop.” Social distancing was emphasised. People were not to gather in crowds of more than 100.
But this message should have come much earlier, especially the importance of stringent social distancing.
Instead, as recently as last Friday Morrison declared his intention to watch his NRL team, the Cronulla Sharks, in defiance of his government’s own advice. He reversed his decision within hours.
On Sunday morning, the chief medical officer, Brendan Murphy, said in an interview on Insiders that people should practise social distancing with recently returned travellers and others who have had known contact with the virus, but that it was otherwise permissible to be close and shake hands.
This also was subsequently corrected.
There have been other examples of confused information. A couple of weeks ago Hunt publicly said: “If in doubt, get yourself tested – that’s the important message… We would rather people over-test rather than under-test.”
In response, there was a run of people seeking tests. A couple of days later Murphy countermanded the instruction, tactfully referring to “some confusion” in the community. “Our focus at the moment is testing people who are returned travellers who have acute respiratory symptoms,” he said.
Dr Chris Moy, president of the Australian Medical Association (AMA) in South Australia, says the signage initially produced by federal and some state health authorities, intended to go up in doctors’ windows, was wrong, potentially disastrously so.
It instructed people to “tell staff immediately” upon entering a surgery if they were a coronavirus risk.
He emails images of the wrong sign, distributed in Victoria, and the correct advice on South Australian posters, which, in bold capitals, instructs people who think they might have the virus “Do not enter” and to phone instead for advice.
Despite such missteps, Moy says, Australia has still “done pretty well so far compared to other countries”.
Australia has a generally strong health system, but there are some critical weaknesses relevant to this crisis. OECD data shows us well down the list on the number of hospital beds: 3.8 per 1000 population. That is about the same as Norway, a little ahead of Italy and Spain, but way behind Japan and Korea, which have nearly four times as many. Even China has more.
Between 2012-13 and 2016-17, according to the Australian Institute of Health and Welfare (AIHW), funding for public hospitals rose by an inflation-adjusted 1.8 per cent on average each year, while private hospital funding went up 2.9 per cent.
But health cost inflation is far higher than the general rate. Furthermore, Australia’s population grew at more than 1.5 per cent annually during the period. Most critically, the number of Australians over 65 increased at roughly twice the rate of the working-age population.
During the past two decades, the number of people aged 85 and over – the group most at risk from Covid-19 – increased by 117.1 per cent. That’s three times the general rate.
No surprise, then, that the AIHW found the yearly increase in public hospitalisations was three times the rate at which new public hospital beds were being added to the system.
According to a 2018 report by the Australian and New Zealand Intensive Care Society, Australia has just 2229 intensive care unit beds.
There has been much publicity about plans to increase the number of ICU beds by cancelling elective surgery. But Stephen Duckett doesn’t think that will help much. “The problem is people who have elective surgery don’t take up many ICU beds, because by and large they are otherwise pretty healthy. That’s why it’s elective,” he says.
“Second, most hospitals probably have some new ventilators available, can bring those online and not replace the old ones. That will increase capacity as well. That’s not going to be enough, though.”
The truth is Australia’s hospitals are pushed to their limits by even a moderately severe flu season.
“Our hospital system runs very lean, with no regular surge capacity,” says Vlado Perkovic, dean of medicine at UNSW. “And that means that we’re exposed to any sort of event that leads to a large increase in resource requirements.”
And that is where we are now.
“We’ve got 400 to 500 cases now,” Perkovic says. “And what that means is that there’s thousands out there in the community that we don’t yet know about, but will shortly. And hundreds of those will end up in intensive care units and a substantial number will die. That’s sort of locked in.”
Like Bowtell and many others, Perkovic notes that a small number of east Asian countries have performed conspicuously well in responding to Covid-19. He thinks the fact they had experience with SARS and other outbreaks means they responded with “a commonality of purpose” not apparent elsewhere.
“Not only the public health people, but also the population were very anxious and responded very quickly to the sorts of social distancing measures that were put in place. People understood why it was important, and they did it immediately,” he says. “We see that in Singapore and Hong Kong, in China, in Korea. We haven’t seen it in Europe yet. We haven’t seen it in the US. And I think Australia is somewhere in between.”
Here such commonality of purpose has been lacking. Even this week 2GB’s Alan Jones opined to his mostly elderly listeners that coronavirus was “the health version of global warming … exaggeration in almost everything”.
There are structural and logistical problems, too. Dr Chris Moy says the outbreak underlines the need for a national centre for disease control, something the AMA and other medical organisations have pushed for years. Not only would that provide faster and more consistent messaging, but also help in dealing with “major practical issues” around the provision of medical supplies – testing equipment, personal protection equipment for medical staff, et cetera.
A couple of lessons emerge. We need more beds, and we need to be more self-sufficient in crucial medical gear. But the most immediate response is up to us, the general public. Two words: hygiene and distancing.
Perkovic notes the quadrupling of confirmed cases this week and issues a dire warning. “It’ll probably be 2000 next week. And the week after that, 8000. And if we don’t do anything, potentially 32,000 a week after that.”
In Bill Bowtell’s view, had the government acted sooner and more decisively, those figures could have been very different.
This article was first published in the print edition of The Saturday Paper on March 21, 2020 as "What Morrison did wrong on coronavirus".
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