How to deal with a potential pandemic was often on my mind during four years as health minister in the Australian government of John Howard.
In those days, hundreds of people – nearly all in East Asia and living in close contact with poultry – contracted bird flu; and about a half died.
The fear back then was that a pandemic variant could become an even more deadly form of the Spanish flu, that killed up to 50 million people, mostly between 20 and 40, in the wake of the Great War (including over half a million from a then-US population of just on a hundred million); or a supercharged version of the Asian flu that killed upwards of a million people world-wide in the late 1950s; or the Hong Kong flu that killed another million or more in the late 1960s.
As things worked out, there was no pandemic on my watch as minister – but there was one, swine flu, in 2009, that’s thought to have killed about 300,000 people world-wide, including 191 from just under 40,000 cases in Australia.
Perhaps surprisingly, that pandemic barely rippled the public’s consciousness.
Still, as the minister who would have been blamed for any deficiency in Australia’s pandemic preparedness, I beefed up the National Medicine Stockpile (including one of the world’s largest holdings of anti-viral drugs), established the Australian Health Protection Committee, and made formal speeches laying out the initial plan to deal with any crisis.
Essentially, this involved close screening at the national border (as soon as there was a widespread outbreak anywhere), strict quarantine of incoming travellers, the establishment of mobile testing and treatment teams, and designated pandemic hospitals with extra ventilators.
I certainly envisaged the compulsory wearing of masks on public transport, and the temporary closure of places where large crowds were in close contact – like theatres, concerts and night clubs. But not for a moment did I ever contemplate ordering people to stay home. That would have struck me as contrary to our nature; and just adding to the worries of a dire time.
In any serious pandemic, people would naturally avoid going out unnecessarily; and where they did, it would be for some vital reason: work that couldn’t be done from home, essential supplies, and compassionate visits.
The way I saw it, in any pandemic, the focus would be to get people to stay at their posts to keep the economy going, not to lock everything down lest disease spread, because people would be taking precautions anyway. My general view was, that avoiding as many risks as reasonably possible, people should get on with their lives even in the presence of death.
This pandemic is not quite the one we had planned for, back then. This virus is certainly more infectious than the seasonal flu, and more deadly, but it mostly has the same victims: the very old and the very sick.
A highly infectious and potentially deadly corona virus was always going to be very difficult for governments to respond to, because leaders’ normal focus is both to keep people safe and to make people prosperous; yet here, for once, saving lives and protecting livelihoods did not quite go hand-in-hand; and minimising a pandemic’s risk to health could easily maximise its damage to economies.
When reports started to emerge out of Wuhan of a surge of deaths from a strange new virus, and especially when footage emerged of people dying on trolleys in the corridors of northern Italian hospitals, a degree of panic was understandable.
No decent government could allow its hospitals to be overwhelmed, or contemplate with equanimity a new disease predicted to kill over two million people in the United States, up to half a million in Britain, and 150,000 in Australia.
Faced with the prospect of death on such a scale, of course governments were going to ban travel, to close places of gathering, and to order people to stay at home as far as possible. And with the economy in an induced coma, governments really had no choice but to subsidise wages, freeze foreclosures and scrap rules about seeking work.
But with a corona virus incubation of up to a fortnight, lockdown could have been for a few weeks, as opposed to a few months, while isolation and quarantine arrangements; testing, tracking and treating facilities were put in place; and suitable precautions were recommended, especially for older people; so that the health system wasn’t swamped, the economy didn’t become dependent on government support, and people were reassured that they were as safe as they reasonably could be.
With the wisdom of hindsight, not enough attention was given to keeping the virus out of nursing homes and how to respond once cases were present. Whole societies were locked down, essentially to protect the elderly, yet the elderly were still very vulnerable once the infection was among them.
Six months into the pandemic, the aim in most countries is still to preserve almost every life at almost any cost; with renewed lockdown most governments’ instinctive response to any increase in the virus.
The New Zealand government has locked down Auckland after just four new cases, and postponed the national election with under 100 active cases.
When new cases peaked at about 700 a day, the Victorian government put five and half million Melburnians into virtual house arrest, under nighttime curfew, and banned at other times from leaving home for more than an hour a day, or from travelling more than five kilometres.
For more than six months now in Victoria, under disaster and emergency declarations, homes can be entered, people can be detained, and the ordinary law of the land suspended; and the Premier now wants to extend this health dictatorship for at least another six months.
As with the Spanish Flu state border closures, only worse, it’s been every jurisdiction for itself, in a form of “pandemic protectionism”. One Australian state with virtually no corona cases won’t admit people from another state with virtually no corona cases. States that want to admit foreign students, because they need the money, don’t want to admit Australians from another state.
And every day, premiers and their chief health officers front the media with casualty lists, and stern warnings that it could easily get worse unless people stay in their homes and avoid each other.
It’s a bad time, obviously, for anyone with the virus.
It’s also a bad time for anyone who would rather not be dictated to by officials, however well-meaning; or who instinctively chafes under a policy that’s clearly unsustainable yet may be kept up indefinitely in the absence of an effective vaccine.
Given that lockdowns can reduce disease but hardly eliminate it, the result is not just a stop-start economy, but a stop-start life.
In this climate of fear, it was hard for governments to ask: “how much is a life worth?” because every life is precious, and every death is sad; but that’s never stopped families sometimes electing to make elderly relatives as comfortable as possible while nature takes its course. Likewise, people anticipating serious health problems sometimes elect not to be resuscitated.
When a trauma victim comes into an emergency department, almost no effort is spared to keep that person alive. But when a cancer patient wants access to very expensive new drugs, governments normally ask tough questions about how much good life will be gained before making it available; and what the alternative might be.
So far, with Sweden the most notable exception, governments have approached the pandemic like trauma doctors; instead of thinking like health economists, trained to pose uncomfortable questions about a level of deaths we might have to live with.
So far, Australia’s national government has committed some $300 billion to soften the economic consequences of state governments’ enforced social distancing. Even if mandatory shut-down really was all that avoided the initially-predicted 150,000 deaths, that still works out at about $2 million per life saved.
If the average age of those who would have died is 80, even with roughly 10 years of expected life left, that’s still $200,000 per quality life year – or substantially beyond what governments are usually prepared to pay for life-saving drugs.
Once it was clear that a 60 per cent infection rate and a 1 per cent death rate was unlikely, shouldn’t we have started to ask whether the cure was proportionate to the disease?
Based on the anti-bodies present in blood tests, the NSW Chief Health Officer has recently said that up to a half million Australians could already have been infected, most of them asymptomatic. On that basis, while our case fatality rate is close to two per cent, our infection fatality rate, would be more like one in a thousand, or zero point one per cent.
Of course, there is still much that we don’t know (like why infections haven’t increased that much in Europe as restrictions have eased; why deaths haven’t ticked up as infections have; and why death rates seem to have fallen everywhere despite little agreement on the most effective treatments).
And it’s sensible to err on the side of caution.
Sometimes though, officials get trapped in crisis mode longer than they need to, especially if the crisis adds to their authority or boosts their standing.
One of the surprising features of this pandemic has been the lack of published modelling from government and the dearth of officially-accepted epidemiological data, after the daunting initial predictions from the Imperial College team in London changed most governments’ strategy from herd immunity to preventing infections via drastic, compulsory social distancing.
Along the way, official objectives have shifted from “flattening the curve”, so hospitals wouldn’t be overwhelmed, to “suppression”, to “zero-community transmission”.
Governments have justified it as following “the expert advice”, as if this has always been clear; or as if we should be ruled, rather than merely guided, by unaccountable experts.
Inevitably, much of the media has spread virus-hysteria with the occasional virus-linked death of a younger person highlighted to show that deadly threat isn’t confined to the very old or the already-very-sick or those exposed to massive viral loads.
As Sweden demonstrates, you can cop both the corona deaths and the economic costs even without the government-imposed lockdowns as people choose to travel less, to go out less and to spend less.
But for a free people, there’s a world of difference between a course of conduct that individuals choose for themselves and one that government orders them to adopt, even if turns out to be much the same.
There’s no doubt that lockdowns, at least initially, reassured worried populations that governments had their well-being at heart.
A recent poll showed that only 7 per cent of Australians thought that COVID restrictions were “too tough”, while 33 per cent thought them “too lenient”. Only 11 per cent thought that “getting the economy moving” was more important than “stopping the virus’ spread”, hence most governments’ tendency to make rules rather than let people make their own judgments.
Faced with an unprecedented challenge, governments were always going to be damned if they do, and damned if they don’t. Or perhaps: damned now if they didn’t lock down and damned later if they did.
Because it’s clearly not possible indefinitely to keep 40 per cent of the workforce on some kind of government benefit, and to accumulate debt and deficit on a scale not seen since the Second World War, while the world goes into a slump not seen since the great depression – caused as much by governments’ response as by the virus itself.
Almost a million people in Victoria, close to 20 per cent of the workforce, still technically have a job but aren’t actually working due to the lockdown.
In the absence of effective treatment or a vaccine that may never come, at some point, we just have to learn to live with this virus, in ways that can be kept-up more or less indefinitely: with borders managed but open; businesses vigilant but otherwise fully operational; and normal life continuing, with more precautions, more humane ones, for the sick and elderly.
Sadly, most of the elderly victims have died alone – without the solace of family and friends – because of the measures put in place to protect them.
It’s this psychic damage, I fear, that will be at least as bad as the pandemic’s toll on health and wealth: people once sturdily self-reliant looking to government more than ever for support and sustenance, a “something for nothing” mindset reinforced among young people spared the need of searching for jobs, and magic pudding economics entrenched under the guise of “modern monetary theory”.
Governments paying businesses’ wages bill for them, borrowers freed from mortgage repayments, and tenants no longer having to pay rent: none of this can last, yet every day it goes on risks establishing a new normal.
The sooner citizens don’t have to offer police an explanation for their movements, the less anxious we will feel. The sooner the airwaves are not filled by officials telling us not to go out, not to see people, and not to shake anyone’s hand, the more resilient we will be, even if there may be some modest uptick in corona cases.
From a health perspective, this pandemic has been serious; and from an economic perspective it’s been disastrous; but I suspect that it’s from an overall wellbeing perspective that it will turn out worst of all: because this is what happens when, for much more than a mere moment, we let fear of falling sick stop us from being fully alive.
Now that each one of us has had six months to consider this pandemic and to make our own judgments about it, surely it’s time to relax the rules, so that individuals can take more personal responsibility and make more of their own decisions about the risks they’re prepared to run.
For me, the recent 75th anniversary of the end of World War Two prompted this reflection: that generation: ready to risk life to preserve freedom; this generation: ready to risk freedom to preserve life.
Yet we don’t think of our parents and our grandparents as too brave, do we; I wonder what judgment history will pass on us?