News

As the federal government pushes towards reopening on the back of high vaccination numbers, the nation can learn its biggest lessons from other countries that have exited harsh lockdowns in a bid to establish Covid normal. By Hannah Ryan.

What can the world teach us about opening up with Covid-19?

A packed venue at the GALA dance music festival in south London in July.
Credit: Reuters / Henry Nicholls

The advantage to losing a race is getting a good view of how those ahead of you are running. As Australia’s leaders squabble over whether and how to leave lockdowns and border closures behind, other nations are moving towards life after the pandemic.

“We have all these experiments, in inverted commas, being done for us in countries with good public health infrastructure,” says Peter Collignon, an infectious diseases doctor and microbiologist at the Australian National University. “We can learn from that as to what we need to do.”

The experiment in Britain is what happens when you let Delta loose. Freedom Day arrived in mid-July, with Boris Johnson ending almost all Covid-19 restrictions and effectively handing over responsibility for avoiding infections from the government to the individual.

But minimising infections was not the goal: Health Secretary Sajid Javid admitted the decision could lead daily cases to rise above 100,000 a day, exceeding even the caseload seen in December 2020. “But what matters more than anything is hospitalisation and death numbers,” he said.

That spike never eventuated, at least not yet. Cases are rising steadily, tens of thousands of people continue to be infected daily, and hundreds are dying every week; but hospitalisation numbers are about 20 per cent of the January peak.

Paul Hunter, a microbiologist and professor in medicine at the University of East Anglia, says he’s sleeping easier these days – easier than he would be if he were living in Sydney.

“It’s not going to be that long before, in the UK at least, we can start thinking about Covid as something in our history rather than something in our present,” he says. “I think we’re probably in as good a position as we could have expected.”

Britain is approaching what many experts now see as the goal: endemicity. When the virus that causes Covid-19 becomes endemic, there’ll be plenty of cases but we won’t care that much. Widespread immunity will make severe illness much rarer.

“The problem for Australia and New Zealand is to get to that point without vaccine a lot of people are going to die,” Hunter says.

In Britain, more than 78 per cent of those aged 16 and over have received two doses of Covid-19 vaccine, compared with Australia’s 36 per cent. “We’ve got a hell of a lot more people that have actually had the infection and recovered – and that’s the crucial thing,” Hunter says.

In England, an estimated 94 per cent of the adult population tested positive for Covid-19 antibodies in early August, suggesting they’d had the vaccination or the disease.

Antibody studies in July suggested two-thirds of 17-year-olds had been infected and recovered in Britain. Without that kind of immunity, vaccination is particularly critical in Australia’s journey to living with Covid.

But while national cabinet’s four-phase plan, fleshed out by the Doherty Institute modelling, has pinned Australia’s opening-up debate to vaccination rates, another international experiment offers a cautionary tale about a singular focus on vaccines.

Israel was once the success story that proved we could vaccinate our way through the pandemic. Mass vaccination began last December. By April, the country had all but declared victory over Covid-19. More than half the population was double-dosed and it recorded its first day without a death in nearly a year. Restrictions were eased, international travel roared back and compliance fell away. Even the Green Pass, a vaccine passport scheme, was abandoned.

“During April to July there was a false perception that Covid was over,” says Nadav Davidovitch, a member of Israel’s national Covid advisory committee and director of the public health school at Ben-Gurion University. After several months in which the approach to vaccination was very active, “a sense of urgency was lost”.

By July, the Delta variant was loose in the community. By August, thousands of cases were being recorded every day. Relatively high vaccination rates had concealed the reality that pockets remained undervaccinated, including people aged between 12 and 20, the ultra-Orthodox community, the Bedouin and other Arabs. Even in Israel’s vaccinated population, immunity began to wane.

The Israeli example is dispiriting, but it could yet illustrate how a relatively well-vaccinated society can manage high case numbers without resorting to a lockdown. In the past few weeks, many of Davidovitch’s advisory group’s recommendations have “finally” been accepted, and the virus’s reproductive rate is starting to fall.

Proactive vaccination and targeting of minority groups is back. The Green Pass will return. Mass serological testing of children, plus at-home testing kits, will allow kids to attend in person when school returns this month.

More controversially, third shots of Pfizer are being offered to over-30s to boost their diminishing immunity and protect them from serious illness. Davidovitch received his third dose last month. The evidence shows the booster dose is safe and effective, but he is uneasy about vaccine nationalism that could see rich countries buy up booster shots while others struggle to do a first round of vaccination. In the West Bank and Gaza, under 10 per cent of the population is fully vaccinated. Israel must proactively help more Palestinians, Davidovitch insisted, though he said the new health minister was doing better at outreach.

The lesson from Israel’s experience is that vaccination alone is not enough. A Covid-19 defence requires other weapons, deployed nimbly: masks, targeted mass testing, restrictions on large gatherings, vaccine passports.

Australia’s pandemic experience has more closely matched Singapore than Israel and Britain. The city-state has largely enjoyed a Covid-zero life, but its leadership has warned the public that stance is impossible to maintain, explicitly working to a goal of endemicity. Singapore is now recording about 100 cases a day.

Professor Teo Yik Ying, dean of the National University of Singapore’s public health school, says Singapore is now a natural experiment in whether high vaccination rates can reduce the burden on the healthcare system to tolerable levels. About 78 per cent of Singapore’s population – including children – are fully vaccinated, making it one of the most vaccinated countries in the world. Strict border measures and aggressive testing and tracing have helped keep a lid on cases, as well as two very different sets of rules for the vaccinated and unvaccinated.

Life in Singapore is not exactly what you’d call normal, or free. People have only recently returned to the office, with 50 per cent of the workforce allowed to return at a time. Dining is allowed for groups of five if all are fully vaccinated; otherwise, it’s capped at two in open-air settings. There’s a gradated quarantine system for international travel, with free travel only allowed to and from Germany and Brunei.

Teo describes the approach as cautious and prudent. The government takes one step at a time, closely monitoring the consequences. The country would never use vaccine coverage thresholds the way Australia has, he adds.

“If we just look at an overall figure of 80 per cent, we may realise that we hit 80 while vaccinating all the young and healthy, but for the vulnerable we are only at 50 or 60 per cent,” he said. “If we open our society at that point, we will continue to see a lot of hospitalisations and deaths.”

Even if they are eventually able to vaccinate all children and reach 90 per cent or more coverage, Teo will still worry, as unvaccinated people will remain “completely vulnerable” to the Delta variant. That’s one reason differentiated measures for the vaccinated are likely to stay in Singapore: not only do they act as an incentive to get vaccinated, but they protect the unvaccinated.

Right now, the Singaporean experiment seems to be working. But if there were to be an uncontrolled outbreak that puts intolerable stress on the health system, the consequences will be devastating beyond the island’s border, Teo says.

“The world would be in a state of shock for a while, because it does suggest that you can only open up your borders or relax your measures at the risk of more people dying from Covid-19,” he says.

Britain thrust open the door. Israel opened it, then eased it shut again. Singapore is inching it ajar ever so cautiously. What will Australia do?

The international experience shows that it’s not possible to return to normalcy without high vaccination numbers. The rapid pace of vaccination in Australia, particularly in New South Wales, is cause for hope. There’s reason to hope that the stage of the pandemic we’re in right now is the worst it will get: we’ll never again be as patchily vaccinated as we are today.

But while vaccines are necessary, they’re not enough. A range of other public health measures – masks, contact tracing, surveillance testing, vaccine passports – will need to be used depending on what the virus is doing at any given time. There are also warnings from overseas not to be deceived by top-line vaccination numbers: vaccine distribution must be equitable to avoid difficult outbreaks in unvaccinated groups. Indigenous vaccination rates are well below the country average, for instance.

For Australia, open and closed won’t be a binary. There will be no Freedom Day where all restrictions are dropped. And while Australia’s national plan makes reopening seem linear – phase A, then B, C and D – international experience shows the need to be cautious in claiming victory too soon. Australia also has to be ready to reimpose restrictions when necessary.

Eventually, the daily melodrama of the Covid-19 press conference will be behind us. Case numbers won’t excite us the way they once did. The world outside our homes won’t be so scary. The pandemic will be over, the virus endemic. We can let out a deep breath. We just have to get there first.

This article was first published in the print edition of The Saturday Paper on Sep 4, 2021 as "Open plan".

A free press is one you pay for. In the short term, the economic fallout from coronavirus has taken about a third of our revenue. We will survive this crisis, but we need the support of readers. Now is the time to subscribe.

Hannah Ryan is a journalist based in Sydney.