Let me be clear, we do not yet have a complete understanding of the long term sequelae of COVID, but a picture is emerging that makes a policy of mass infection grossly irresponsible. It’s time for our medical leaders to give strong and assertive advice to politicians, to leave them no plausible deniability, and for politicians to explain their reasoning for rejecting clear medical advice. We need our political leaders to come together in bipartisan efforts to stop the spread and avoid the temptation of wedge politics when lives and the future health of the nation are at stake.

I WAS living in New York in March 2020, working for the United Nations, when COVID-19 shut the city down. I left New York not long after that, responding to the Department of Foreign Affairs and Trade’s advice for expats to return to Australia.

Seeing Virgin ground its fleet, and Qantas announce that it would follow, I got on the last flight I could reliably book and started months of remote work, clocking on at 11 pm in Brisbane, to keep New York hours.

When I left New York, the streets were deserted, shops were shuttered, restaurants were closed. There was a sense of panic in the air, and a sense of peril associated with every human interaction. While I watched aghast at what was happening to my colleagues who remained there, New York peaked at 800 deaths a day, with a total of almost 23 000 deaths in the first 4 months of its pandemic. There were refrigeration trucks doubling as mortuaries, mass graves at the Potters Field on Hart Island, and a field hospital in Central Park. Bodies were being misplaced, and some people were choosing to die at home, rather than risk that undignified fate. Living in “zero COVID” Australia felt surreal, and for months I felt guilty.

In March 2020, when I landed back in the country, Australia was virtually COVID-free, and every case was investigated. Genomic tracing was the rule, and strict border measures were in place. Test, trace, isolate – we were fully on board with the fundamentals of public health practice. We had mostly intermittent lockdowns, with Victoria being the exception, with one of the longest lockdowns in the world. But through enormous effort, we achieved the unachievable of zero COVID after uncontrolled spread. There was a sense of unity, of science leading the way, and of politicians avoiding politicising the response.

Then it all started to fall apart.

Federal state relations started being defined by (to use a US phrase) red/blue delineation. “Blue” (Coalition) states were less likely to criticise the federal government response, “red” (Labor) states were keen to point the finger. Masks, a key tool in the public health response, became a political flashpoint, as did vaccine mandates. The public health messaging failed to evolve. We seemed stuck at droplets and objects (keep 1.5 m distant, clean touchpoints and sanitise your hands), with no public discourse about airborne spread. State Premiers made heroic gestures about abandoning masks, making any walk-back difficult. The most memorable (and regrettable) of these was the Queensland Premier’s “Smiles are back” video, closely followed by the New South Wales Premier visiting a pub with several unmasked mates while a mask mandate was still in place.

Australia set out almost its entire strategy for “living with COVID” based on vaccination rates. There was an ill-informed belief that vaccines would eliminate transmission and disease, and we could return to pre-pandemic life. Concepts of herd immunity became commonplace in the media and political discussion, and terms such as “wall of immunity” were bandied around.

In reality, this was never going to happen.

Coronaviruses initially target the upper respiratory tract where they replicate, with varying degrees of spread (and replication) in the lower respiratory tract. Mucosal IgA, while able to mediate protection in the respiratory tract, is usually relatively short-lived, whether induced by vaccination or infection. Virologists were advising me, back in March 2020, that the vaccinated would likely still transmit the virus, and this has been shown to be true (here and here), albeit at somewhat reduced rates. Our current vaccines protect against severe disease, but do not eliminate the risk of infection and only partially reduce transmission. This is exacerbated by the constant evolution of the virus, with variants evading both vaccine and infection induced immunity. This means that effective herd immunity will likely never occur, unless there is a significant leap in vaccine technology. Due to vaccination, we are unlikely to see the horrific scenes of the first waves overseas in 2020, but our hospitals are currently overwhelmed in spite of our vaccination rates. Governments around the world who were aiming for herd immunity, are coming to this realisation and are increasing public health messaging accordingly (here, and here).

Visiting New York this April it was striking how much more sophisticated their response was than ours. New York health was (and still is) publishing daily figures of testing, not just numbers of cases, but test positivity rates and adequacy of sampling. They were actively messaging certain postcodes to get more testing if the numbers were too low to give confidence in the sampling. Masks and tests were being distributed free of charge, and there were PCR kiosks on street corners every few blocks in Manhattan, and mobile testing vans visited under-sampled postcodes.

This is unsurprising, given that New York lived through a pandemic Armageddon. The US overall has not handled the pandemic well, but the Biden administration has just released a seven-point response, which includes free testing, free high-quality masks (specifically N95 respirators), ventilation, and data dissemination. The US is also afflicted with red/blue division, but clear federal leadership is making a difference.

Contrast that with Australia, where testing has progressively become harder to find, political leaders studiously tiptoe around the issue of mask mandates, there is no requirement to generate accurate test positivity rates and no real ability to enforce even the reporting of positive tests. Wastewater testing results are not widely shared, locality targeted interventions are invisible and there is no signalling about transmission risk at the community level.

This means we are driving blind, with no clear indication of population prevalence to allow us to anticipate and manage. The lack of public sharing of these key data has deprived Australians of the tools they need for “personal responsibility”.

We have largely given up on “test, trace, isolate”. While cessation of contact tracing is explicable in the current levels of spread, testing and isolation should remain paramount. Mitigations to prevent airborne transmission are sadly lacking. There has been no political leadership on this in the public discourse. Prime Minister Anthony Albanese even received his fourth vaccination, in a health care setting, wearing no mask.

Masks (preferably N95 or P2 respirators), ventilation and HEPA filtration work. The failure to use these measures to protect unvaccinated children is particularly egregious, and interstate variability in following the science is inexplicable. Hundreds of discussions with patients over the course of a year and the constant sight of floppy cloth masks under noses have convinced me that Australian people genuinely do not know how to prevent spread, so confused has the messaging been.

I still believe Aussies are a decent lot, who would inconvenience themselves to save a life. If the average punter knew that their decision to not wear a mask could actually result in someone else dying, I, perhaps naively, think the majority would wear a mask. Messaging that people who feel vulnerable should wear a mask has undermined any sense that masks protect other people and that wearing a mask is an act of altruism, not just personal protection. People are unaware that they can be asymptomatic or pre-symptomatic and infectious. They don’t understand that they can spread it before they are aware they are doing so. And people have been led to believe that getting infected doesn’t really matter, because it’s a “mild illness no worse than a cold” and we have antivirals. Antivirals are only available for those at high risk of hospitalisation, and are only useful if people can get a prescription within 5 days of the onset of symptoms, not easy in a climate of underfunded and overstretched general practice. Then there is the issue of distribution, with many patients needing to contact several pharmacies to find out where they can have their antiviral prescription filled.

Let me be clear, we do not yet have a complete understanding of the long term sequelae of COVID, but a picture is emerging that makes a policy of mass infection grossly irresponsible (here and here). It’s time for our medical leaders to give strong and assertive advice to politicians, to leave them no plausible deniability, and for politicians to explain their reasoning for rejecting clear medical advice. We need our political leaders to come together in bipartisan efforts to stop the spread and avoid the temptation of wedge politics when lives and the future health of the nation are at stake.

We have the tools to dramatically slow the current acceleration of transmission and hospital admission. We cannot undo past infections, but we can reduce the cycle of repeated re-infections. To do so, we need to reignite our fundamental belief that Australians can and will work together for the good of all, and stop the divisive politics.

We need an urgent public health campaign to educate people with real information about spread, about positivity rates, and about risk so that they can make sensible decisions. Personal responsibility is not just about for self, but about responsibility to society and to the vulnerable. Let’s have that conversation. GPs can help with information at the practice and individual patient level, but ultimately, public health is a whole-of-population effort.

We need to get all testing reported, positive and negative, so epidemiologists can better model where we are and where we are going. We need a clear and unambiguous level of transmission risk signalling, so people understand the risks they may be exposed to or expose others to. And we need to rebrand masking as a life-saving act for other people – just like learning CPR or stopping our car at a crossing for a pedestrian.

We should also heed the pleading of the Director General of the World Health Organization (and here) and not abandon aggressive genomics, which helps to trace the evolution of this rapidly adapting virus. Given the rates of transmission in Australia, new variants may well emerge here, and we owe it to the world to identify and analyse them. And, most vitally, we need to flatten the curve so that our health care system can continue to function.

Dr Jillann Farmer is a Brisbane-based GP and former Medical Director of the United Nations.

 

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

Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.

If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.

 


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17 thoughts on “COVID-19: Time to put people ahead of politics

  1. Amelia says:

    So very well said. I urge everyone to write to your state and federal local member asap and let’s see if we can make a difference.

  2. Margarite Vale says:

    I am appalled that masks are not mandated. Proper PREMIUM PROPERLY FITTED N95 MASKS should have been provided by the government from the very beginning. They should be provided NOW. This is a small price to pay to keep everyone safe and to keep our precious older generations safe, vulnerable people safe, keep our hospitals safe and all healthcare workers and school teachers safe.
    Mandates exist for many other things like bike helmets and safety belts in cars etc.
    I agree with every word in Dr Farmer’s article.
    More than 70% of the readers of this journal STRONGLY AGREE that masks should be mandated. I am so angry that politicians (and not the medical community) are making life and death decisions for all of us.

  3. ASA says:

    When the Covid 19 virus was declared a global health emergency by the WHO 2 years ago, NO ONE world wide is prepared how to respond to its deadly infectiousness, mortality impact to the vulnerable individuals, how to prevent or stop the virus spreading and initially how to treat and manage this new viral menace that started in China.

    Australian health authorities and politicians could have handled it better if an established CDC like facility is available in the departmental government with its scientific and medical experts as the single expert adviser to be taken by all states to a continent like ours.

    On matters of health care workers acute shortages in times of Pandemic emergencies, all permanent residents living in Australia with medical knowledge or nursing training overseas (IMG), can be used to help and support whatever they can do for the public under the DOH/DHHS, not necessary working as registered doctors or nurses.

    INTERNATIONAL MEDICAL OR NURSING GRADUATES willing to give a hand if possible as contact tracers, covid testers, paramedic assistants or any other tasks the DOH might need to cover even in regional areas.

    This mutating Pandemic virus is not over yet, possible it may get worse- “hopefully not”, available Testing Centres or clinics should continue until this virus is totally eradicated or controlled.

    Should include also the influenza virus with the Covid testing for specific diagnosis and management.

    We Australians are all in this, do what ever help we can offer now or never.

  4. Scott D says:

    I think the “red/blue” dichotomy of the states by party is not quite so clear-cut. The (Moderate faction) Liberal premier of SA seemed to mostly do bettter than the (Labor Right) Labor premier who replaced him.

    Marshall’s main mistake was in not re-closing the border and tightening the restrictions when Omicron became prevalent only a week after the border and restrictions were eased. In the lead-up to the opening, there was talk of managing entry and limiting it to being from “low risk” LGAs, but by the time it happened, there was only one LGA in NSW that wasn’t “low risk” (as assessed by NSW I think).

  5. Hilary Warren says:

    I am becoming so despondent. The young people I have asked as to why they don’t wear a mask say ‘because I don’t have to’. Nothing will change without leadership. Society has turned off, they don’t want to be informed, personal responsibility is interpreted as self interest. When I walk into a shop and am greeted by ‘How are you’ my response is ‘Well, thank you’ as I point to my mask and say ‘And I hope to remain so’. I suspect I make little difference with my comments. We need the sort of advertising campaigns for masks that we had with the AIDS epidemic in the ’80’s. People need to be shocked at the disastrous situation we are in and will continue to be in in the foreseeable future.

  6. Anonymous says:

    If you knew over two years ago that vaccines were not likely to prevent transmission and never would, did you share this information with the public?
    Trust in government and pharmaceuticals was broken by their continued claims that the vaccines prevented transmission, and that this was a ‘pandemoc of the unvaccinated’. They continued on this line for far too long; anyone could tell that their claims contradicted reality, yet they insisted, mandated and insulted those who questioned nonetheless. People were lied to at a time when experts, who now apparently knew, either didn’t have the courage to come out with the truth, or did choose go public and careers and reputations torpedoed as a result.
    In this environment, how then can the public trust that vaccines are safe and actually work, that other measures are effective, or anything else they say when they have been proven time and again to be the dissiminators of disinformation. Trust in medical experts and governments who used to be on your leash is gone. Be transparent and honest, and trust may slowly be rebuilt.

  7. Anonymous says:

    Public health officials do not inspire confidence, especially when the Chief Federal Chief Health Officer declines to define his understanding of what the term ‘woman’ means.
    Witness the attempts to use the phrase ‘ birthing parent’ to replace the term ‘mother’, without consultation
    Fortunately the Minister responsible put a quick end to that experiment.
    More than enough evidence has emerged of the long term harm inflicted on the general community by lockdowns and the evidence for mask use, especially in children, is virtually non existent.
    The health bureaucrats , who are not answerable for the advice they give, must always be accountable.
    Politicians must be transparent.
    There have been too many instances of politicians insisting they are following expert advice but then declining to release the advice itself, and many instances of politicians, in various jurisdictions, giving blatantly conflicting advice.

  8. C says:

    Max, wearing masks should not hinder the economy.
    I wear a mask all day at work and whenever I go to the shops or to the MCG.
    no hindrance at all.
    to grow the economy and make more money, first of all people need to stay healthy and alive.

  9. Chris Davis says:

    Referencing an earlier comment, any presumption that public health measures as proposed by Dr Farmer are made without regard for other considerations is without foundation. A healthy economy requires a healthy populace, and the “plain man” knows the hurt of ill-health that no amount of wealth can replace.

  10. John Goldrich says:

    Preserving the maximal number of lives is not the be all and end all of life. Politicians are acting the way they are because the people they represent think the way they do.

  11. C says:

    kind of a crazy response Max.
    a medical forum should be about the medical response to a pandemic and trying to save lives.
    after all to make money and grow the economy, people first need to stay healthy and alive

  12. Lynton Giles PhD says:

    Dr Farmer’s article is refreshingly straightforward and honest. I fully support her valuable contribution to the Covid dilemma and can only hope that politicians will take heed of this important publication and stop what I believe is political grandstanding. Furthermore, I believe Dr Farmer’s precautionary approach on how to intelligently deal with the overall Covid pandemic and the important issue of long-Covid, should be adopted. For example, it is my opinion that the simple precautionary step of promptly mandating the wearing of masks in public should be reinstated, as well as politicians accepting all Dr Farmer’s advice and acting on it, rather than pursuing what is, in my opinion, a haphazard approach due to political self-interests. Inappropriate action will undoubtedly cost billions of dollars to take care of the sequelae of ‘long-term Covid’ in Australia.

  13. Dr De Leacy says:

    My son lived and worked in Mt Sinai ICU during and after the 2020 holocaust hit that city and, along with me has been totally appalled at what the stupid self-serving politicians of this country have done since late last year whilst being totally aware of the warning about the inevitable arrival of the highly infectious Omnicron variant. Lets be quite plain, the State Premiers and Federal parties have deliberately condemned to death thousands of aged and immune compromised people over the last 7 months through their ‘let it rip’ stupidity. They learnt absolutely nothing from Sweden’s mass death experience in Aged Care initially or in the subsequent two years of the pandemic from expert advice by virologists. Political self-serving expedience front and centre.
    Question, why does a disclaimer need to be made about the stance of the AMA, the MJA or insight?

  14. Max says:

    Medical experts have a monomaniacal focus (often with an inflated sense of their own importance).
    There is so much more to managing the response to COVID than just the medical aspects. Every other expert group (economists, educationalists etc) could equally forthrightly inform government so as to negate plausible deniability; many of those recommendations may contradict the medical ones.

    “Nothing would be more fatal than for the Government of States to get in the hands of experts. Expert knowledge is limited knowledge, and the unlimited ignorance of the plain man who knows where it hurts is a safer guide than any rigorous direction of a specialized character”.
    Winston Churchill

  15. Anonymous says:

    Since covid vaccines do not prevent transmission and infection, is it not in the public interest that mandates are ceased ?

    We need these doctors, nurses and other health professionals working in our hospitals.

  16. ANDREW COCHRANE, Cardiothoracic surgeon says:

    I completely agree with the comments.

    Infection in 20 to 30 % of the population is not necessarily mild (elderly, diabetics, transplanted patients, on immunosuppressants / corticosteroids) and deaths are at 100 per day.

    The longterm effects of a novel virus will not be known for 20 to 30 years, and we will have suffered infection of the majority of the population. We are still just discovering the longterm effects of viruses that we have known for 60 years (e.g. multiple sclerosis now known to be due to EB virus infection / glandular fever)

    The withdrawal of proper funding for masks, testing, time off work has been very short-sighted.

  17. Chris Davis says:

    Sage advice from Dr Farmer. The trouble with politicians making public health decisions is that they don’t know what they don’t know. Specifically and especially concerning the damage through auto-immune means of repeated Covid infections on vital systems such as the blood-brain barrier and the cardiovascular system. We are already getting warnings about these events in the form of long-Covid, but the cumulative burden of such insults to individuals and society could be massive as we continue this ““La Belle Indifférence.”

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