It is easy to be wise after the event, and it is evident that health officials and politicians have been doing their best - on the run. And that is the point. Australia was not sufficiently prepared for a viral outbreak like that of COVID-19.
Why so? Well, let's look at the experience of various countries. It is generally recognised that the countries that have handled the crisis best so far have been Singapore, Hong Kong and Taiwan, and this was due in no small part to the experience those countries had with SARS. Their diagnostic, testing, contact-tracing and isolation facilities and policies have been well developed.
Trying to keep a public health crisis a secret is really bad policy, as happened early on in China and went on for far too long in Iran. The result was the draconian policies which appear to have been successful so far in China - but at enormous cost.
Populism and burying your head in the sand, which seems, at least in the early stages, to have been combined in the United States with an almost unbelievable breakdown in diagnostic capabilities, will wreak havoc, not just in the US but around the globe. It is significant that the largest source of imported cases to Australia is the US.
The UK's apparently bizarrre initial experiment of building up herd immunity while potentially treating the vulnerable as collateral damage, albeit with well-intentioned but ineffectual protective measures, is likely to come at a very significant cost, and has now been replaced by more draconian measures.
The drastic situation in Italy is not well understood, but is thought to be related to an ageing population and the virus spreading undetected for some weeks. There is also speculation that industrial air pollution may play a role - which, if true, could have relevance for the added effect of air pollution in Australia from future bushfires.
Australia is somewhere in the middle, but in hindsight there are some important lessons we can take from our experience. Firstly, we moved far too slowly to restrict imported cases, particularly from the US but from other countries as well. Secondly, there were insufficient diagnostic kits to detect the cases, and inadequate local facilities to rapidly rectify the shortages. Hopefully the new tests will go someway to filling the gaps but, in a situation where every single day counts, any continuing shortage at this stage would be a major issue. Related to these shortages is an inadequate approach to tracing the contacts of detected cases. And thirdly, every case needs to be properly isolated and quarantined instead of sending serious cases to hospital and mild cases into self-isolation at home. We are paying, and will pay, dearly for these deficiencies in term of the consequent necessity now for blanket disruptions to population movement - with enormous social and economic costs.
Perhaps the most interesting country is South Korea, because there is some evidence that, with a massive effort at case-detection and proper isolation of those found to have the virus, it could be that what looked to be a potentially disastrous situation has been moderated. But it is perhaps too early to tell. The good news for Australia at this stage is that there have been relatively few deaths, perhaps because of the measures introduced so far and a world-class health service - but there is absolutely no reason for complacency.
Is it too late to take on the lessons of South Korea? It is hard to know, because proper case-detection would depend on a massive boost to the availability of diagnostic kits. Some increase is on the way, but it is not clear whether supplies will be able to meet the challenge, at least in the immediate future - and in an exponential process, each day counts. But it should be possible to convert hotels and other facilities to effective quarantine and isolation facilities for all those found to have the virus.
This a very contagious virus, affecting people across most age groups, but it is selective in the degree to which serious consequences are distributed. Case fatality rises rapidly with age and comorbidity, and the government has moved rapidly to try and contain the consequences for the elderly, both in and out of institutions.
But the most vulnerable within the Australian population are Aboriginal and Torres Strait Islander people, because of high levels of all the illnesses that are associated with adverse outcomes - hypertension, heart disease, diabetes, and cancer - and worse, much higher levels of comorbidity (combinations of these conditions). Preventable hospital admissions and deaths (conditions which could and should have been prevented by primary healthcare services) are three times as high in Aboriginal and Torres Strait Islander people, due, in part, to failures in implementation of the "close the gap" policies. These failures reflect both unfunded implementation plans and relative under-spending on a needs basis, particularly by the Commonwealth. As a consequence, many Indigenous people lack sufficient access to services. This is both for the conditions that put them at higher risk of suffering severe effects of the coronavirus, and also for the kinds of services required for its prevention, detection and treatment - and the consequences are potentially devastating for Australia's first peoples. We must avoid repeating the devastating consequences that Aboriginal people experienced from the Spanish flu and from smallpox, measles, tuberculosis and other diseases in the early days of European settlement.
Some measures for the control of coronavirus have been introduced for remote Indigenous communities, and while these are welcome, they are nowhere near enough. Firstly, where is the national recognition of the high priority that should be given to Aboriginal and Torres Strait Island people for the prevention and management of coronavirus? While remote communities pose particular challenges, what specific measures and levels of funding are proposed for the prevention, case-detection, isolation where required, and treatment for Aboriginal and Torres Strait Islander people all around Australia, including the majority of Indigenous people who are at high risk but live in cities and towns rather than remote areas? Additional satellite and outreach Aboriginal and Community Controlled Health Services to fill current service gaps are an absolute priority.
In the end, the message for control of epidemics is as old as time: stop the import of new cases into the population, detect the cases that are there and isolate and treat them. We have done OK, but nowhere near as well as we could have. While recognising the sterling efforts of those tasked with dealing with our lack of preparedness, we need to learn the lessons of history - and of those dealing with the problem now around the world - as to how to best to deal with the current pandemic and prepare for any future occurrences.
- Dr Ian Ring, AO, is a former principal medical epidemiologist at Queensland Health.
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