Author: gg@gordongregory.net

On Friday 27 August National Cabinet discussed plans for the vaccination of 12-15 year olds and gave further consideration to the use of the Doherty Institute’s model of the dynamics of covid-19 infection and vaccination. The agendas for its future meetings should include the following five matters.

1 – The nation needs and deserves a detailed schedule of the numbers of various vaccines due to be delivered to Australia in the next 12 months. It is understood that there may be some unavoidable delays, even when contracts have been entered into. These could include the sort of batch quality issues currently being experienced in Japan with Moderna. 

Everyone is now aware that the ‘dark matter’ that has hung over Australia’s vaccination program from the very beginning is insufficient supply. The public and those working on the pandemic need to know what the expected schedule is. Apart from anything else, such a schedule is required in order to agree to the second of these five agenda items: a new priority order for vaccination.

2 – A new priority order for vaccinations must be drawn up for all to see and discuss. It would be a tragedy if those groups which were in 1a all those months ago were to be pushed down the ranking before they have been accorded what they were originally promised: to have all of their group fully vaccinated. 

However the overriding purpose of vaccination has shifted from the situation in which, with very little Covid in Australia, the most important criterion for ranking was vulnerability to serious illness and death. Vaccination is now a key asset in efforts to reduce the number of infections. And even though it would be a tragedy, it is now clear that some tragedies simply will not be avoided.

If year 12 students in the most affected LGAs in Sydney are to be a higher priority than people in aged care facilities, let’s have public discussion and understand the reasons why this is so.

If it is simply impossible to deliver to the Aboriginal Medical Service in Orange the 900 doses a fortnight it needs, let’s understand that now so that remedial action can be taken immediately. The alternative is to dissemble, to let the actual situation dribble out, delaying mitigating action and making the situation even worse. 

To some extent the responsible agencies have hidden behind the phrase ‘The Most Vulnerable’. No-one could argue against vaccinating ‘the most vulnerable’ first. However someone has to convert the phrase into action.

From the beginning, to this vulnerability criterion were added practical, commonsense criteria about the potential seriousness of the impact on health and other essential services of staff having to isolate and be away from work. That remains a critical criterion.

The new criteria for allocation include geographical and demographic characteristics. Where you live and what contribution you are likely to make to spread of the disease have become as important as the extent to which you are likely to be severely affected by the condition.

If vaccine is still in short supply in September and October, very difficult decisions will have to be taken. Teenagers or the 20-39 year olds? Home aged care workers or teachers? People living with disability or those in remote areas with little access to health services?

3 – The Commonwealth must take the lead in developing protocols and systems for determining which employees in which sectors will have a mandated requirement for vaccination.

Notwithstanding the legal complexities that apply, this is too important an issue to leave to individual companies or workplaces. If it is agreed, for instance, that all hospital staff, teachers, childcare workers or food distributors should have mandated vaccination, then the implications for distribution of available vaccine (2 above) can be factored in.

Individual entities such as District Health Boards for hospitals and Departments of Education for schools can be expected to deal with specific matters such as how to manage people on their staffs who have sound reasons for avoiding vaccination.

This issue will have to be considered in conjunction with plans for a ‘vaccine passport’ (by whatever name).

4 – if he hasn’t already got one, Lieutenant-General Frewen needs to appoint a supremo to ensure that resources and other encouragement are provided to the wide range of community groups that, between them, are having success in helping to ensure that particular groups who are marginalised are getting vaccinated. There are also many valuable local initiatives providing care for communities affected by the pandemic in other ways.

Absolutely no ‘centralisation’ is required but support, information, data and publicity will all help such effort. The circulation of case studies can contribute to these practical remedies and to the morale of communities everywhere. Support should be provided by both state and federal governments to ensure that the efforts of such groups are optimised. 

The new emergency brought about by Delta is what has seen such community groups mobilised. Perhaps even community spirit needed a jolt to overcome complacency. Also, at last, the various jurisdictions have injected urgency into their management of covid, including through adopting practices that have been applied in other countries months ago. This includes flying squad type programs to target particular areas or groups of people, mobile clinics, and a range of incentives for getting vaccinated. 

5 – Some appropriate, energised and capable agency needs to be commissioned to produce (for the public) data on all aspects of the pandemic and its management. One of the gravest and most surprising aspects of the pandemic to date has been the lack of good data at national, state, regional and demographic group levels. This needs to be rectified as a matter of urgency.

There is still much to be done in relation to the pandemic and the vaccination program in particular. With action on these five matters Australia can put the muddle behind it and move on to better ways and better days. Public discussion of the priorities for vaccinations (which priorities may or may not be new), informed by plentiful data, can help make sure that confidence replaces hesitancy. 

It needs to be accepted that if supply remains inadequate some very challenging choices will have to be made about which people are the top priority and which will just have to be delayed.

27 August 2021

In terms of influence over Australia’s vaccination program, nothing has been more significant than the fact that, from the beginning, there has been an overall shortage of supply. This has cast a dark shadow over all aspects of the program.

Details of the schedule for receipt of vaccine supply must determine absolutely the timing of vaccinations and which groups of people will be first. The public has been kept in the dark about this delivery schedule.

Agreement on the priorities for allocation of vaccine will be critical for as long as there is a supply shortage.

Public debate on the matter has been impossible because most of the planning and management has been done secretly. A sad and surprising feature of the response to the covid pandemic has been the failure to assemble, analyse and utilise data on all aspects of the phenomenon and to keep the public informed. There is so much the public (and, apparently, researchers) don’t know about a disease that threatens everyone.

In the lead-up in Australia to the availability of vaccines and in the first stages of their application, the most important criterion for their allocation was a judgement about which groups or classes of people were ‘the most vulnerable’.

Decision makers and commentators could, in effect, hide behind the phrase. No-one would argue against vaccinating ‘the most vulnerable’ first. However someone – in the case of vaccines, governments – had to convert the phrase into action. They have to decide whether to allocate the last vial of vaccine, as it were, to an elderly person, a nurse, an infant, a mobile 25-year old, someone with a disability, an Aboriginal or Torres Strait Islander person, or a worker in the hotel quarantine system. The decision is difficult and has ethical, practical, clinical, economic and global implications.

To this vulnerability criterion were added practical, commonsense criteria about the potential seriousness of the impact on health and other essential services of sickness and the resulting absence of members of their workforce.

Largely because the processes in train were not under any single agency’s control, management of the early days of the vaccination program was missing. There was no national leadership and an extraordinary absence of urgency. Things just drifted.

It seemed as if the standard dynamic in play was for political pressure to be applied to the Commonwealth, following which it ‘got off the hook’ by announcing some new initiative, with the actual operationalisation of the decision falling to the States and Territories or to GPs. This was the case, for instance, with the sudden weekend announcement in April 2021, just a week  before the first general practices were due to come online, that over 4,500 general practices would be providing vaccination. Very little vaccine was actually available to GPs and their phone lines ran hot with frustrated patients.

Initiatives such as pop-up and drive-through vaccination clinics, local support for local rollout to specific cultural groups, and a flying-squad type approach to communities facing special risks were slow to emerge, despite the demonstrated success of such activities in other countries.

The media and other leaders of the debate about covid must take some of the blame for the fact that, even after all these months, the priorities first agreed (those groups allocated to category 1a) have not yet been fully vaccinated. We have allowed the debate about vaccination to move on from one priority to another without any care about whether those of the highest order have first been met.

Delta has re-written the story. With the Delta variant rampant the competition for scarce vaccine has become even stronger. Given the second wave in Sydney and the rest of NSW, the balance between various criteria for prioritisation has shifted. It is no longer agreed that ‘vulnerability’ is the key criterion and that a focus on minimising death and serious illness after infection is the standout purpose.

Rather, vaccination is now a key asset in the battle to limit the number of infections. The new key criteria for allocation include geographical and demographic characteristics. Where you live and what contribution you are likely to make to spread of the disease have become as important as the extent to which your health is likely to be severely affected by the condition.

This means that some of the priority tasks originally agreed are in danger of remaining unfinished. This is likely to have serious implications for the groups affected such as the elderly, Aboriginal and Torres Strait Islanders, hospital staff and people with a disability.

The Federal Government has permitted this change, but it has not led on it. It has been the States and Territories and their health advisers who have taken the lead.

Ironically, with the narrative changing from the  suppression of cases to ‘living with covid’, the main purpose of vaccination will to some extent switch back and once again be to minimise illness and death.

The most urgent challenge is to complete the work contingent upon the original priorities, including complete coverage of patients and staff in residential healthcare, aged care and disability facilities.

From 17 September all staff of residential aged care facilities will be required to have had at least one dose. One assumes that the number of doses allocated for this purpose has been  checked off against the schedule of vaccine supply.

Such an approach illustrates the fact that the exercise is akin to a complex logistical exercise in planning and management of stocks and flows. Such challenges are familiar to the defence force, for example when it engages in war games or assistance after a natural disaster. It is therefore good to have the military involved.

The Commonwealth must provide the public with more and more detailed data. It must also lead on seeing that Australia is a strong contributor to global and regional initiatives to support vaccination programs in poorer nations.

With greater understanding of the importance of vaccination and how decisions relating to it are made, people are likely to be more invested in the vaccination campaign and thus be more willing to comply with and support it.

17 August 2021

Calling something as poorly designed as Australia’s Covid vaccination system ‘a rollout’ gives wheels a bad name. The failure to manage effectively the identification of priority groups for coronavirus vaccination, and to deliver vaccines to them, has to date been an awful failure of public administration.

The Federal Government’s approach to prioritising population groups for covid vaccines can be characterised as one that has favoured and promoted whichever group has newly-acquired media coverage while having no compunction whatsoever about whether higher priorities have been met. One of the clearest and most shameful examples of this procedure relates to staff in residential aged care facilities.

When vaccines first became available, aged care residents and staff were identified as one of the first priorities. They were in 1a. On 7 January 2021, the Prime Minister announced that 4 million Australians would be vaccinated by the end of March 2021; this would include all residents and staff of residential aged care facilities.

The importance of the allocation of a priority was that vaccines were in short supply. And because there was very little coronavirus in Australia at the time, no one demurred about the decision to look after the elderly and their institutional carers first. In the unlikely event that the virus did appear it was the elderly who would be most vulnerable to serious illness and death. And society owed a debt of gratitude to the grandparent generation.

Surprising though it may seem in a country that has generally been well-served by agencies that collect and use quantitative information, the absence of good data on this matter has been an ongoing problem. Despite the fact that the aged care workforce had been given a top priority back in January, in the first week of June the responsible Federal Ministers, Greg Hunt and Richard Colbeck, admitted that they were not able to say what number of aged care staff had received zero, 1 and 2 covid vaccinations. Greg Hunt, Minister for Health, apologised to Parliament for an incorrect report on the matter. He confirmed that 20 aged care facilities had not yet been visited as part of the national vaccination rollout.

There are over 2,600 residential aged care facilities in Australia. Around 240,000 people are employed in direct aged care, of whom about 150,000 are in that residential sector. The other 90,000 direct care workers are employed in community aged care. Over 85% of this quarter of a million are female.

The wisdom of making aged care staff one of the highest priorities for vaccines had been tragically illustrated by the second wave in Victoria. Of the 730 covid-related deaths in that State in the period from early July to late October 2020, 655 were of patients in residential aged care.

Some of the particular fragilities of the aged care system had also become clear. Because of low wage rates and the casualisation of staff, it was not uncommon for individuals to work in more than one facility, thus increasing the risk of infection spreading from place to place. And the care system could be compromised by the temporary loss of staff to illness.

Another problem was that, unlike the situation with previously required vaccinations, the status of staff with respect to covid inoculation was not linked to payroll. Furthermore, it was not until June 2021 that operators were required to report each week to a central agency (the Federal Health Department) on the covid immunisation status of their staff.

Some of these issues were compounded by confusion or overlap between federal and state jurisdictions. The Victorian government moved to ensure that staff of the facilities it managed could no longer work across multiple sites. The Federal Government, which is responsible for the regulation of the majority of aged care homes, scrapped that policy in November 2020. It was replaced with a set of principles that would see that “ideally” (sic), an aged care worker would be limited to working at a single aged care site. The federal government reinstated the regulation in June 2021.

At the end of that month, two-thirds of staff working in aged care homes across Australia were still not fully vaccinated.

Finally, something stirred. On 2 July National Cabinet agreed to adopt the “strong advice” from the Australian Health Protection Principal Committee (AHPPC) to make vaccination against covid mandatory for all staff of residential aged care facilities. The new requirement comes into operation on 17 September 2021. All staff will be required to have had at least a first dose of a COVID-19 vaccine.

This action will be underwritten by a grant program to help the centres and, through them, their individual staff members. Eligible payments will help with travel to the nearest vaccination site and cover for lost wages. The Federal Government will oversee compliance by all centres.

Lt General John Frewen is now Co-ordinator General of the National Covid Vaccine Taskforce. Given this pivoting of leadership, it should be permissible to observe that if military precision and logistics had been applied from the very beginning, the promised commitment to aged care workers could have been acquitted in the six weeks to the end of March.

The mandatory vaccination of aged care staff must be completed on time, with a high level of competence and effectiveness. In some respects, it will be harder than it would have been in February and March. There is now much greater competition between population groups to be prioritised, due in particular to the situation in NSW. Some might even dare to whisper that the elderly ought to have no higher priority than young adults – the mixers and spreaders – and Aboriginal and Torres Strait Islander people.

We want leadership. And no more unmet goals or unreached horizons. Because it is now clear and alarming that the priorities set eighteen months ago are no longer fit for purpose.

25 July, 2021

Jack¹ from Bathurst phoned into Life Matters this week. He thought to help the Covid vaccine situation by bringing forward his second AstraZeneca jab. But no one could tell him what effect that would have on the efficacy of his jabs.

Jack’s second jab is due in mid-August. So he had the capacity to fast track it by four weeks. He called the local clinic and was told that he would lose 16% of immunity for each week the second jab was brought forward. Having “fallen out” with the person he was speaking to, he called again. Another clinician said he would lose 10% of immunity per week.

Jack’s question is a good one. It needs to be answered if those in a similar situation are to help by bringing forward their second AZ jab.

One of the experts on the Life Matters radio program gave some very precise figures about the efficacy of the two vaccines available to us in Australia – but did not directly answer Jack’s question. I thought there must surely be a table of such numbers somewhere, so I went searching online. I couldn’t find a consolidated tabulation but there are of course miles of research papers on individual aspects of the question.

So I started to compile my own. I have included in it the stats from the ABC interview with Associate Professor Margie Danchin. (I will be very happy to hear from someone about where I can find a decent, professional table of this sort. Surely?)

If Jack’s question is answered in such a way as to make it clear that there will be no, or very little, loss of efficacy by bringing forward the second jab, it will make a significant contribution to the acceleration of the effective use of AstraZeneca which so many people are now hoping for.

I’ve called it A current policy and information hotspot. All we need is reliable scientific evidence that there will be little loss of efficacy and a whole cohort of people who have already demonstrated their willingness to be vaccinated with AstraZeneca can provide an immediate boost to the nation’s well-being and prospects.

¹ close to his real name.

The efficacy of AstraZeneca and Pfizer against Alpha and Delta variants

– figures from a small number of online sources,speedily compiled on
22 July 2021

Sources:

PHE – Public Health England, May 2021. ‘Analysis of real-world data.’ Radio interview on Life Matters, Hilary Harper with Assoc. Prof. Margie Danchin, Murdoch Children’s Research Institute. (Monday 19 July 2021). New England Journal of Medicine. ‘Nature’, article by Delphine Planas et al, 8 July 2021.

Note: this piece was published in Pearls and Irritations on 25 July 2021.

19 July 2021

If enough of us ever get vaccinated to get over the immediate emergency, it will be useful to take time to reflect on the medium-term implications of the global pandemic for the governance of Australia and the world. There is much to be done and much we can learn.

The pandemic has thrown new light on the benefits and costs of globalisation.

The economic status of Australia and the well-being of its citizens are closely tied to aspects of globalisation. Australia is a relatively small economy with limited domestic demand. The nation has prospered through having natural resources in abundance which, given a worldwide free trade regime, can be sold to countries less well endowed.

However, the pandemic has woken Australia to the risks of too great a dependence on globalisation. It is now clear that the single most serious issue for the nation was supply of vaccine. In preparing for vaccination, the Federal Government made errors in commissioning and negotiating supply from other nations. This was compounded by decisions made by some of those other nations which were in their own interests and over which Australia had no control.

The problems posed by the absence of sovereign capacity to manufacture goods and services that become essential when the world faces a widespread emergency were apparent even before vaccination started. There were shortages of items of personal protective equipment and hand washing gel (in the days before we understood that soap and water was best). These were mitigated to some extent by the flexibility of some manufacturers who re-tooled rapidly; and by home-grown household activity, such as mask-making.

Incidentally, perhaps it would be wise to include toilet paper as a bottom-line commodity in forthcoming trade agreements that Australia signs.

On the other side of the globalism ledger, the pandemic led very rapidly to the effective closure of two of Australia’s major export sectors and employers: international tourism and international education. This was caused by interruption of another key element of globalism: the free and untrammelled movement of people around the world.

Fortunately, the export of natural resources, particularly iron ore and coal, as well as agricultural produce, seems to have proceeded unabated. The astonishing increase in the international price for iron ore, not related to the pandemic, has done much to shelter Australia from the worst economic effects of Covid-19.

Building manufacturing capacity and finding ways to make existing industries more resilient will have beneficial economic effects. Just as the shift to renewable energy sources is making new industries economic, so will national re-tooling for greater emergency self-sufficiency help to build Australia’s economy and provide employment opportunities.

Moves to mitigate against inadequate supply of goods and services needed in an emergency, and in response to the decline of major industries, provide incentives for Australia to rebuild its manufacturing sector.

In the 1960s manufacturing provided one quarter of GDP. By 2010 this had fallen to 6%, providing 8.6% of employment. In 2020 it was 4.2% of GDP and 7% of employment –  or 853,000 people.

The Federal Government has indicated that it has plans for what it calls A Sovereign Manufacturing Capability Plan. It will apparently cover business opportunities both small and large, from manufacturing for niche markets right through to the production of guided weapons.

International agencies

As a middle-sized nation which benefits from both international trade and the rule of law, Australia has traditionally been a strong supporter of the bastions of globalism: multilateralism and international agencies. Once the health emergency is over it will be useful to scrutinise the performance of these agencies and to act on lessons learned about their structure, operation and value.

The agency most closely involved in the pandemic has obviously been the World Health Organisation (WHO). The majority view seems to be that the WHO had a poor start due to being slow in declaring the novel coronavirus outbreak ‘A public health emergency of international concern’, its highest level of alarm. Some commentators have attributed this to sensitivity about China’s potential reaction to such a declaration.

Since then, the WHO has been a critical and positive contributor to management of the pandemic. The challenge for the WHO was all the greater given that it was confronted by active opposition from the United States under Donald Trump. He cut funding for the WHO in May 2020.

Some of the WHO’s most important work is concerned with global vaccine equity and the gap between richer and poorer nations – the so-called ‘two-track pandemic’. The scale of this challenge is illustrated by the fact that several affluent countries are already discussing the rollout of booster shots to their populations, while the majority of people in developing countries—even front-line health workers— have still not received their first shot.

This is a matter that needs urgent international agreement and action, in which Australia, as an affluent country, should take an active part. There is much to be done in the medium term to make the world a fairer place before the next pandemic or similar crisis emerges.

The most critical immediate task in world health is to ensure that developing nations are given all necessary support for obtaining and using vaccines. Supply in sufficient quantities is the core challenge and spreading it fairly between richer and poorer nations. One way to achieve this would be to assist medium-sized countries to establish the capacity for producing vaccines. Cost is a key factor and it is to be hoped that ways can be found for the sort of generosity shown by governments and the private sector over the last 18 months to continue to be demonstrated.

Given the massive impact on world trade and damage to the budgets of all countries, including those that are affluent that have been donors of international aid, the impact of the Covid-19 emergency on the people and governments of poorer countries may yet become unmanageable. Much will depend on the role played by international aid and trade in the new order.

One particular example of successful collaborative international action is COVAX. Its aim is to accelerate the development and manufacture of Covid-19 vaccines, and to guarantee fair and equitable access for every country in the world. Among other things it is working to ensure that donations of vaccine to developing countries are synchronized with national vaccine deployment plans.

Apart from the WHO, international agencies concerned with the pandemic include the International Monetary Fund (IMF), the World Trade Organisation (WTO), the World Bank and the OECD.

The IMF is preparing a Special Drawing Rights (SDR) allocation to boost the financial reserves and liquidity of its members.

The WTO is involved because cooperation on trade is needed to ensure free cross-border flows and increasing supplies of raw materials and finished vaccines. It is working on negotiations towards a solution around intellectual property, which remains the main sticking point in relation to making medications available at low prices. The WTO is also working on freeing up supply chains for vaccines and other medicines.

The World Bank has provided a $12 million financing facility for vaccination and has vaccine projects in some 50 countries.

In anticipation of an end to the immediate Covid crisis, preparations can begin for evaluation of the way international agencies have performed since the beginning of 2020.

Note: a modified version of this piece was published as Part 1 of Preparing for an evaluation of Australia’s response to the Covid-19, 13 July 2021.

_{Note: these three pieces were written over a week ago and things move very fast with the Covid-19 pandemic! The pieces are ‘published’¹ here as a record of my views at a particular moment in time, notwithstanding the crowded space which is commentary on the pandemic and the updating that might be necessary. Among the revisions that could be noted is a reappraisal of the politics of National Cabinet, which have festered somewhat. [¹ The word implies a move to expose the piece to global gaze. In fact the blogg doesn’t even have global immediate family readership. The world is too congested.]}

If enough of us get vaccinated to move beyond the immediate emergency, it will be useful to reflect on the medium-term implications of the global pandemic for the governance of Australia and the world. As well as the gloom and uncertainty, there have already been just a few welcome developments and there will be more to unearth.

PART 3: Some better news

National Cabinet

One of the most positive developments in governance to have emerged during the pandemic was a National Cabinet. This worked well for some time and showed the value of close collaboration between all governments on issues of urgency and national significance. It was so successful that, for a while, it no doubt increased the public’s respect for government and politics – albeit from a very low base.

Questions have already been asked about whether the partial success of this National Cabinet suggests ways in which inter-governmental work (including meetings about Federal fiscal relations) can be undertaken in a manner that improves on the Council of Australian Governments (COAG) model.

That is not to say that the National Cabinet for Covid was devoid of politics. During the period when it was cohesive and decisive, the Federal Government was not averse to taking advantage of the (politically desirable) position of backing the options that were most popular, knowing that, in fact, decisions on these matters were not within their compass. This was the case with lockdowns in general, and with parts of lockdowns such as school closure, masks and inter-State travel.

With schools, for example, for some time the Prime Minister was able to argue the critical value of schooling, the difficulties with home schooling, and to express the general belief that, for these reasons, schools should remain open. All the while, decisions on the matter lay with the States and Territories.

The National Cabinet was faced with the challenge of balancing health (as  measured by cases, hospitalisations and deaths) against the economic and social effects of lockdowns. To date it has been unwise or unpopular to be too explicit about this balance. All governments, at least as far as public commitments have been concerned, have leaned towards suppressing the virus as a prerequisite for economic recovery.

Of the decisions made by the National Cabinet, none was more important than the one relating to quarantine. International quarantine is a Federal responsibility but decisions on internal borders lie with the States and Territories. Tasmania locked its borders on 19 March 2020. Australia’s national borders were closed the following day and on 24 March Australians were prohibited from leaving the country.

Thus it was that a complex, layered Commonwealth-State system emerged in relation to quarantine. The Federal Government took the decision to require all overseas arrivals to quarantine for 14 days. And through National Cabinet the States and Territories agreed to run hotel quarantine as part of their responsibility for public health. They also agreed to fund most of it.

This turned out to be a massive false economy for the Commonwealth. The fact that there has been no national system or standardised procedures for hotel quarantine has been one of the causes of the leakages from the hotels involved. These have resulted in huge financial commitments from the Commonwealth to support the economies affected by lockdowns determined and managed by the States and Territories.

For any kind of National Cabinet arrangement to persist will require leadership from the Commonwealth. And the situation in which one level of government makes lockdown decisions with another picking up the bulk of the economic costs that result looks like an unlikely bargain.

Decisions are ‘evidence based’

One of the phrases we have heard most often during the pandemic is when governments, federal and state, have attributed a decision to “the best possible advice from the health experts”.

It is surely a positive development for policy decisions to be made on the basis of scientific and other real evidence. Some parts of the world have had their fill of ‘alternative facts’.

The thought that occurs is what other issues have the same characteristics as a viral pandemic and, also, are accompanied by the same volume of applicable science. Climate change is one obvious case. And perhaps the challenge of improving the health and well-being of Australia’s Aboriginal and Torres Strait Islander people is another.

The considerations of the Chief Medical Officers have enabled governments to say, in effect, “Don’t blame or credit us governments; we are simply following independent, world’s best scientific advice.” In turn, the Chief Medical Officers have been guided by modelling of COVID-19 transmission and infection dynamics. It is perhaps surprising to note that the only three pieces I posted in the early days of the pandemic (April 2020) focused on modelling and a re-reading of them shows very little that needs to be revised or regretted. An extract from the post of 10 April 2020 is at the end of this piece.

It could be argued that governments’ constant deferral to scientific advice is a kind of delegation of responsibility and avoidance of accountability. It is politically attractive to have someone to blame for difficult decisions or to blame if decisions taken were the wrong ones. But one cannot argue against the idea that all policy decisions should be determined on the basis of evidence from science.

The fact that the distribution of money for sports grants and suburban car parks has not been based on evidence is one of the reasons why there is such a lack of respect for and trust in governments and politics.

Institutional flexibility

The good things to have come out of the pandemic include an extra  measure of flexibility in certain policy and regulatory matters.

Consider, for example, the supply of oxygen. The Australian New Zealand Industrial Gas Association is the peak body for suppliers of medical oxygen to hospitals and similar facilities. Because of the public benefits that would result, the Australian Competition and Consumer Commission (ACCC) has granted ANZIGA temporary authorisation to exchange information and work through arrangements which in other circumstances might be deemed to reduce competition in the sector.

Another positive spin-off from the pandemic has been the extension of publicly-funded telehealth services. When I was at the National Rural Health Alliance we battled persistently to achieve small steps forward on telehealth, one at a time, painfully and slowly! Over time there were extensions to the geographic areas in which funded telehealth was available; eligibility for additional health care settings, for additional  professionals (eg specialist to GP link-ups), and for additional interventions (eg for mental health).

Rural people and their advocates were no doubt delighted when, for the pandemic, there were major extensions made in one fell swoop to telehealth services under Medicare. Some 300 additional items became eligible. Over 30 million services were claimed in the first six months at a cost of over $1.5 billion.

There will need to be evaluations. When they are done, telehealth and other things such as e-prescriptions and home delivery of medications should be evaluated as initiatives that make access to service more equitable, not only for what they do to facilitate social distancing or contactless care.

In the face of the pandemic, governments in other countries have granted pharmacists greater authority. In Canada, for example,  pharmacists have been given opportunities to join actively in the fight against the virus. Aimed at assisting an overloaded health system, the extensions for pharmacy practice in that country have included performing COVID-19, influenza, and Group A Streptococcus screening tests, and vaccine administration.

In Australia, due almost certainly to the vexed political situation relating to medicine v. pharmacy, it is still unclear as to where and when pharmacists are involved in Covid vaccinations. In any case the vaccination ‘system’ is already mixed-mode and unclear enough.

It is to be hoped that the passing of the health emergency will not see the end of such sensible increased flexibility of these sorts.

Evaluations can start now

A main course of co-ordinated decision making on national emergencies, with better use of scientific evidence (when available) in making policy decisions, plus a larger serve of sensible flexibility may not seem to be much of a feast. But any trauma and disruption as great as the world is currently facing must yield some opportunities for positive change management as well as misery and uncertainty.

There is a huge range of matters that will need to be evaluated, at global and domestic levels and at every level in between. And it will include positive changes which may not yet be even contemplated.

Evaluation will be useful. And some of those qualified in the field should start soon.

————————————————————-

From the post to this blogg of 10 April 2020:

Modelling the transmission of infectious disease

Mathematical models of disease transmission can be used to estimate the potential impact of public health responses to infectious diseases. Recently (7 April) some details of the particular model that is being used as the basis for the decisions of Australian governments on the COVID-19 crisis have been published.

How do such models work? How can we be sure they are accurate? What do they tell us?

The headline findings from the modelling are the ones that have been delivered to us consistently in governments’ media conferences and other information activities: 

“An uncontrolled COVID-19 epidemic would result in a situation dramatically exceeding the capacity of the Australian health system over a prolonged period, notwithstanding the increases in that capacity that are possible.”

“A combination of case-targeted isolation measures with general social measures will substantially reduce transmission and result in a more prolonged epidemic with lower peak incidence, fewer overall infections and fewer deaths.”

As we all know, we have to stay home.

How it works

These general prescriptions from the modelling are clear and largely unchallenged. But as time passes it will be good  if there is closer scrutiny of this and other modelling. This will result in better understanding of both the general applicability of such modelling and the specific work being done on the Australian government’s preferred model.

The key variables on which mathematical models of infection are based are the latent period (i.e. the interval following exposure before an individual becomes infectious and transmits the disease), the infectious period (i.e. the period during which an infected person can transmit a pathogen to a susceptible host), and transmissibility. Transmissibility is described by the reproduction number – the number of secondary cases generated by a single infected case introduced into a susceptible population.

If the transmissibility number is less than 1, infection is receding. If it’s greater than 1, infection is spreading.

For models of this kind it is useful to know the extent to which outputs (in effect, the model’s  predictions) change in response to a given amount of variation in its inputs, and the particular input to which altered outputs can be attributed. The inputs include both the assumptions made about the structure of the entity being modelled and the data fed in.

This is the business of uncertainty and sensitivity analysis. In effect they provide information about the robustness of the model – the probability of the model and its predictions being accurate reflections of reality. The greater the model’s uncertainty or sensitivity, the more its outputs change with a given amount of variation of its inputs – and the less useful it will be.

Such analyses can help check the accuracy of a model’s structure or specification by assessing the individual contribution of a variable and the need to include it or not.

They can also help interpret the results of a model by identifying thresholds for certain variables that trigger outcomes of interest.

The value of  any such modelling is limited if the model’s structure is imperfect (that is, if it makes false assumptions about the relationships between elements of the model) or if incomplete or inaccurate data are fed into it. The modelling can be run again and again with greater confidence about its accuracy as, each time, more is known about the characteristics of the pathogen and more local (Australian) data are added in.

Critically, accurate estimation of the transmissibility of a disease requires reliable data on its incidence in the total population. As we have been told time and time again, this requires “testing, testing and testing”.

This is the second of three posts on aspects of Australia’s Covid-19 response that it will be useful to analyse. The pandemic has exposed some hitherto under-emphasised realities of Australia’s federal system. Some of them are positive but a greater number can be described as challenges of the Federation.

PART  2: The Australian Federation

The pandemic has thrown new light on both the benefits and the challenges of Australia’s federal system. The positive elements include a new understanding of the need for inter-governmental cooperation within the nation and ways in which it can be effected, and some major (and rapid) changes in the way services are provided to the public. One example of the latter is how the pandemic led to a major extension of the provision of subsidised health services through telehealth.

 However there is a longer list of issues relating to Australia’s governance that have emerged – in particular as it relates to service delivery –  that are negative or even dysfunctional. Given their importance and general acceptability, some of the required changes to Australia’s system of governance that have come to light can and should be implemented as soon as possible.

Probably none is more serious (or more familiar) than the need to rationalise, re-order and clarify governmental responsibilities for health-, aged- and disability-care.

Australia’s care systems

 Major reforms to the health, aged care and disability care systems have been called for by many people for very many years. But never before has there been such a naked, loud and transparent series of events that attest to the need for Big Reform to these care systems as have occurred during the Covid-19 pandemic.

Coupled with the Report of the Royal Commission into Aged Care Quality and Safety – an important piece of work, but just the latest in a long series of inquiries into aged care – the pandemic has surely demonstrated to everyone’s satisfaction that Australia’s aged care system needs massive, urgent change. It is under-funded, under-staffed and inadequately regulated.

To date the residential aged care sector in Victoria has been the location of the largest group of Covid deaths in Australia. Down the track it will be useful and important to unpick the evidence about rates of mortality, management and ownership structures, staffing, and emergency procedures in that sector.

The results of such analyses will be valuable in the consideration of changes that, at last, seem inevitable.

There are fundamental questions about whether the Commonwealth has the capacity and skills to manage aged care, including the regulation of staffing. The pandemic has also laid bare basic questions about the legal rights and responsibilities of residential aged care facilities, for instance in relation to the mandating of staff vaccination.

There will be studies and comparisons made of the performance of various Health Departments – Federal, State and Territory. In particular, their public health operations and staff will come under close scrutiny. Also under the microscope will be Australia’s body of public health and related health professionals, and the research, teaching and practice settings in which they work.

The universities will be able to claim the Australian response to the pandemic as evidence of the need for extra investment in public health and other health-related research and teaching, as well as in clinical practice.

It is certain that the capacity of our health system and the agencies within it to do effective public relations and communications (‘messaging’), and for the management of data, will come under particular scrutiny. Eighteen months ago we were promised an open approach to the decisions made in the pandemic and the modelling behind them, and the numbers of patients involved. In fact the data systems relating to the pandemic, and relating to vaccination in particular, have been appalling.

Efficiency of the public service

 The pandemic has drawn attention to a number of matters related to the confidence and flexibility of institutions in the health sector. Given the daily widespread publicity associated with the pandemic, the public has had the opportunity to peek inside Health Departments and health research agencies. We have become familiar with some of the country’s epidemiologists and we now have some idea of what they do.

Overall Australia seems to be well-placed where public health management and research are concerned. As someone who has been glued to current affairs television, I can attest to the fact that the nation’s public health professionals have proved themselves to be a hard-working and charming lot, whether from research institutes, universities or state health agencies.

When it is time, there will inevitably be comparisons drawn between the various agencies that have been ‘out front’ during the pandemic. Underlying the criticism of the Federal response on vaccination is the question of the efficiency or competence of the Federal Department of Health. There will be comparisons of the efficiency with which various jurisdictions have undertaken the tracking and tracing work which have been so central to suppression of the virus.

At one stage in 2020 the differences in the apparent success of suppression activities as between the two largest States were attributed to the different structure of public health activity in the respective jurisdictions. This is the kind of assertion it will be useful to analyse.

One of the most surprising things has been a general inability of governments and the public service to inject a real sense of urgency into responses to the pandemic. This is particularly the case for the vaccination regime. The Commonwealth knowingly grabbed responsibility for vaccination at the beginning, presumably because it seemed to be an obvious way in which to win political points and public support. However it turns out that, on vaccines and vaccination, the Commonwealth is now being slowly hoist by its own petard.

The lack of urgency related to vaccination has been compounded by mixed messaging and uncertainty as to what arrangements relate to which parts of the population and to which vaccine at any given time. There has been  no decent information campaign, no use of appropriate celebrities.

Clear messaging is important but is a second order issue if the target for the messaging is uncertain. A good campaign will be one that achieves some specific action or attitude. But it has not been clear whether ‘a good campaign’ would be one that moves people to be supportive of vaccination, or inspires them to get an appointment with ‘their GP’ (if they have one), or drive to a pop-up clinic, or attend a health clinic, ask at the local pharmacy, run the gauntlet of an on-line system or phone the dreaded telephone number to learn what number they are in the queue.

At the risk of seeming parochial, it may be that the ACT has been  an exception to the charge of failing to take urgent action. Just down the road from my home, a cricket ground was transformed eighteen months ago into a temporary field hospital for Covid-19. It cost $23 million and was built in just 37 days. In May 2020 it was thought that it would never be used. It is now a vaccination hub for the administration of the Pfizer vaccine.

Care of vulnerable groups

One of the worst characteristics of the vaccination regime has been its failure to identify and treat population groups in order of their vulnerability to illness and hospitalisation as a result of Covid-19.

 When comes the time for evaluation of what went wrong there will be important lessons to learn about who is vulnerable, in what settings, and how their needs can be swiftly met. It will be clear that there then needs to be clear communication of these priorities, built in to the schedule or road map made public.

So far, when it comes to protection from risks, elderly people in residential care and at home, and people with a disability, have been badly let down.

It was during the 2020 lockdown in Victoria that the majority of Australia’s pandemic deaths occurred. The greatest number of those deaths was among elderly patients in aged care accommodation. And in this group a disproportionate number were in private aged care institutions rather than the State’s public facilities. This raises the question as to whether there are some structural, attitudinal or operational characteristics of facilities in the various sectors which may help to explain the different rates of illness and mortality.

In contrast to care of the elderly and those with a disability, one of the standout successes of Australia’s suppression of the Covid-19 virus to date has been with Aboriginal and Torres Strait Islander people. Aboriginal and Torres Strait Islander communities have barely been affected. It will be important and useful to understand how and why this has been the case – and critical to prioritise Aboriginal and Torres Strait Islander people in the vaccination queue, especially communities in more remote areas where there are limited numbers of health clinicians.

[See Part 3 of this post: Some better news]