COVID-19: after more than a year, what happens now?

FIFTEEN months ago, under the looming shadow of the SARS-CoV-2 pandemic, I wrote an article for InSight+ about the variety of uncertainties in what lay ahead.

We did not know how the disease itself (ie, morbidity and mortality) and its disruptive effects on society and the economy at large would play out over the coming months. We were unsure how our communities would behave in response, and whether our leaders understood the challenge and were up to the task.

However, it was obvious that, if the virus was as virulent as it seemed, preventive measures could not be sustained forever and that the pivotal factor for the global community in the longer term would be the development of vaccines.

I wrote that in the meantime:

“pending the development of a vaccine, the almost inevitable appearance of community transmission in Australia will mean that we will become individually responsible for undertaking the personal protection that can slow the spread, but will not eliminate our risk of catching COVID-19.”

And considering the longer term:

“Governments will face the challenge of identifying when overall community interests will be best served by restoration of communication and trade in support of the effective functioning of communities and their struggling health care systems, even though it may risk increasing the spread of disease.”

Given what we have known about disasters for many years, it seemed reasonable that we should assume that from the outset governments understood their role in this pandemic as being to sustain a long-term strategy to minimise the harm in terms of both COVID-19-related human mortality and morbidity, and the broader consequences of the disruption of the complex social and economic systems on which our communities depend. And that, as part of such long-term planning, they would be preparing for the inevitability of those moments when goals and expectations must shift.

Now, 15 months on from my speculative commentary at the beginning of the pandemic, we are approaching just such a point:

• we have a reasonable understanding of the biology of the virus, and of the scale of the morbidity and mortality caused by COVID-19;
• we have a good understanding of the effectiveness and limitations of behavioural and physical means for restricting viral transmission, and their social and economic costs;
• we are rapidly learning about the impact of vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on both individual morbidity and mortality from COVID-19 and its spread in the community;
• in the not too distant future, hopefully in Australia at least, we will have saturated the market for vaccination;
• we have learned that, as the pandemic surges through communities around the world, random mutations are creating numerous variants of SARS-CoV-2;
• we understand that more virulent and/or novel strains may perpetuate the pandemic if they can re-infect members of communities that have been exposed to earlier strains; and
• there is a growing recognition that we are likely to be living with this virus for some time, and that we will have to consider carefully how we might best organise ourselves to address its broader consequences.

Unless or until we can create a vaccine that provides lasting immunity against all variants, our vaccines will always be one step behind in terms of their specificity and effectiveness. It still takes time to develop new versions of the mRNA and other modern vaccines that can be modified much more rapidly than traditional vaccines. And even with accelerated development, testing and large-scale manufacturing, a highly transmissible and unstable virus circulating in a culturally and politically diverse, yet physically connected, global population of 7.9 billion people presents a huge challenge.

Some time in the next 12 months (or so), the rate of vaccination in Australia will start to decline because almost everyone who is willing to accept vaccination, and for whom it is not contraindicated, will have done so.

This will be the point at which we achieve the peak of net benefit from suppressing local spread until vaccination had been rolled out. Persisting with isolation will not bring any additional benefit, cannot prevent a local outbreak of a more severe strain, and, all the while, economic and social harm will continue to accrue.

Governments will recognise this milestone as the trigger for activation of the obvious next phase of their strategy: moving on from exclusion and eradication by starting to open internal and external borders and learning to live with SARS-CoV-2 as a long-term feature of human life on Earth.

Our community, our economy and our lives are deeply and inextricably intertwined with those of the rest of the world. We cannot thrive while trying (and inevitably failing) to remain isolated indefinitely through a pandemic of unknown duration. Not to mention the urgent need to resume the transitions necessary to deal with the interconnected global issues of climate change and ecosystem degradation. The contemplation of complexity is key here (here and here).

This is a calculation that our governments should have commenced more than a year ago. If the numbers who have accepted vaccination are insufficient to suppress transmission, our community will have no choice but to accept a level of illness and associated morbidity and mortality. People who have chosen not to accept the small risks of vaccination will have decided to take their chances with their individual unknown susceptibility to SARS-CoV-2 (natural selection). Unfortunately, they will also be a source of risk to those who did not achieve a sufficient response from the vaccine or for whom it was contraindicated.

Our leaders should already be forewarning us that Australia will be opening up to the world and that vaccination is strongly advised for those who have not had it. To do so, they will need ignore their political instincts, warn the community of the risks and discuss the reasons for their decisions. And perhaps the advance notice will prompt some of those who refused vaccination to reconsider their decision in the light of their evolving risk.

On first reading, this sounds like something that a risk-averse community such as ours would find unacceptable.

However, many recognise that it is impossible for us to repel viral boarders indefinitely – we would remain vulnerable in our leaky boat that had become a prison, while the rest of the world, with little choice, had sailed on.

It also seems necessary in the public interest that a decision to refuse vaccination (other than on legitimate medical grounds) when it has been offered will result in exclusion from activities such as air travel and communal gatherings. Some might object, but in a society founded on the benefits of cooperation and collaboration for mutual benefit, the privilege of exercising the right of free choice is not unencumbered by consequences and comes with responsibilities to the interests of the community as a whole, particularly during a disaster. Sanctions may also encourage more people to accept vaccination.

Fortunately, our long run of very low rates of COVID-19 has allowed our health services to prepare – staff, supplies, organisation and infrastructure – to deal with a certain level of illness. The experience of disease elsewhere has taught us how to treat COVID-19 with moderate success and that people who have been vaccinated are significantly less likely to become seriously ill.

However, there are risks and there will be costs: that larger numbers of patients will become more seriously ill than hoped for; that people will not be able to address the balance of risks and become fearful and panicked; that, even in the best scenarios, some people will die; and that our health care systems will be stretched and treatment for people with other diseases will be relegated to a lower priority.

In many ways the challenges of transition that we are facing are in part the product of our success in keeping SARS-CoV-2 at bay for so long. If we had descended into the COVID-19 abyss, as did so many other places, we might be seeing the next phase as a positive move, even with the risks and likelihood of some mortality and morbidity. As it is, many of us, not having been personally exposed to the realities of COVID-19 and struggling to grasp the concept of the need to weigh the balance of risks, are unwilling to accept any risk in opening up.

Unfortunately, there is no path for the journey that we must make – from where we are now to a state where we are living with the possibility of SARS-CoV-2 in our community – that does not pass through a place that exposes us to a period of increased risk. And, given the vagaries of viral evolution, the scale of that risk will remain unknowable.

The reality is that our compliance with quarantine, lockdown and mask wearing has achieved the goal of holding COVID-19 at bay until the availability of vaccines. When the pandemic ends, our reward is likely to be that, even with further cases, we will have suffered relatively low overall mortality (and avoided numerous cases of long COVID-19) and achieved reasonable social and economic outcomes that will remain the envy of most of the world.

It is always the case that in a disaster, as our leaders must remember and we as a community must accept, the broad, long term interests of the community as a whole take priority ahead of the interests of any particular individual members of the community, however harsh that may seem.

The challenge for Australia’s leaders will be to remain above the affray of the political subculture that has selected them and shapes their behaviour and beliefs, and to continue to look beyond the horizon of the election cycles that drive so much decision-making. Only then will they be able to engage with the entire community in the apolitical duty of a candid and open conversation about the balance of the benefits and the risks, and the uncertainties intrinsic to the path that we must take. And then they must convince us that we should join them on that journey.

Dr Will Cairns OAM is Consultant Emeritus Palliative Medicine at Townville University Hospital, and Associate Professor at James Cook University.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.