Is Australia a COVID-19 Role Model for Canada? Outcomes Alone Don’t Tell the Tale
Australia by the Numbers: An Enviable Story So Far
I write from Melbourne, unhappy home to the so-called second wave of COVID-19 infections. For months Australia has been lauded as one of the countries that did things right. I’ve lived here for over two years but don’t claim to know it well. But its pandemic savvy seemed oversold from the beginning – more about which below.
Things looked great for months while country after country experienced varying degrees of misery. In a country with two-thirds the population of Canada, the national death count didn’t reach 100 until May 19 and stood at 119 two months later. There were three main elements to Australia’s early pandemic response. First, like the US, it banned travel to and from China in early March. But unlike the US, the freeze was truly a freeze, with no exceptions. Second, it banned all mass gatherings, imposed physical distancing protocols and shut down bars and restaurants. Third, officials allowed passengers from the cruise ship Ruby Princess to disembark in Sydney despite known infections on board. The first and second mirrored what many other jurisdictions did. The third was spectacularly ill-conceived and led to an outbreak, which was quickly contained. Cases in New South Wales rose rapidly, peaking at 213 new infections on March 27 and plummeting to single digits by early April.
Western Australia, with a population of 2.75 million (the populations of Manitoba, Saskatchewan and PEI combined), has averaged less than one new case a day since early April. South Australia (population 1.7 million) has had 24 new cases since May 1.
Then there is Victoria, where I live (population 6.5 million). It experienced the same spike as other states in late March, peaking at 458 new cases on March 28. The first wave was over 10 days later, and until late June new infections never exceeded 25 a day. Since then numbers have trended up, peaking at 715 on August 5. It’s the only significant second wave (if it is the second wave) in the country.
In the halcyon days of April through June, the entire country was congratulating itself on its brilliant performance. Now Victoria appears to have relapsed. The Commonwealth health minister said that this was the inevitable result of gradual reopening of the economy. Nonetheless, officialdom is not amused.
Once the State numbers passed 500 a day, exasperated Victoria Premier Daniel Andrews imposed stage 4 lockdown through at least September 13: 8 p.m. curfew, mandatory mask wearing even outdoors, written permission required to work outside the home, an hour of outside exercise a day, no travel more than 5 kilometres from home except for approved work sites and shopping for essentials only (which, mercifully, include booze). If caught without a mask, you can get a $200 fine on the spot. If you breach a stay at home order, it’s $1,652 for a first offence and up to $10,000 for repeat offences. Breaching an isolation order after testing positive can cost you up to $20,000.
It appears to be working: the number of new cases in Victoria had dropped well under 200 a day three weeks following the August peak. But what, precisely, is working, and what is the mechanism of action? Are the measures necessary but not sufficient, sufficient but not necessary, both or none of the above?
Jurisdictions Must Act despite Scientific Uncertainty
How COVID-19 travels and its impact are still not fully understood. The science and the scientific debates are in a constant state of flux. Among the lingering controversies:
- The virus transmits by droplets but is not aerosolized/it is aerosolized but maybe not in sufficient concentration to cause infections.
- You can get it from surfaces/the risk of surface transmission is very low.
- A successful vaccine is on the horizon/we may never get a successful vaccine/monoclonal antibodies may be more effective than a vaccine.
- Exposure confers long-term immunity/long-term immunity may not occur.
- Blood type predicts vulnerability/no, it doesn’t.
- Masks don’t work/yes, they do/yes, they do, but healthcare workers with good PPE still get infected.
- Young people don’t have much to worry about/there are significant numbers of younger “long haulers” with debilitating symptoms, etc.
Whenever B follows A, the instinct is to impute cause and effect. We attribute different infection and mortality rates among jurisdictions to what governments did or didn’t do. New Zealand and Taiwan may well deserve kudos for taking decisive action. But they, like Australia, are also islands without bordering countries. New Zealand went for eradication, which, if nothing else, is unambiguous. It looked like an unmitigated triumph until new cases emerged, seemingly out of nowhere. It is easier to identify the anatomy of failure: Brazil and the US are led by science-denying bloviators who ignore the advice of experts, with predictable results.
Containing COVID-19 Is a Natural Experiment in Progress
Many statistical models estimate that hitting the pause button on much of the economy and restricting person-to-person interactions prevented hundreds of millions of infections and millions of deaths worldwide. But what about the many countries that took similar measures but experienced vastly different results? Maybe the results are not so different on closer inspection. A study comparing case fatality rates in nine countries, which, on the surface, ranged from under 1% in Germany to over 9% in Italy, found that after adjusting for age, two-thirds of the differences disappeared. (Sudharsanan et al.)
But some highly developed countries didn’t follow the standard operating procedure, notably Sweden. It gambled on its tradition of social solidarity and rationality to allow people to go about their normal activities, with only a few restrictions on mass gatherings. Schools and bars remained open. The bargain was that you could go light on the policy if people went all-in on prudence. The bet was controversial from the beginning, the critics’ case bolstered by data: as of late August, Sweden’s cumulative COVID mortality rate was six to 10 times higher than that of its Nordic neighbours. But it was no higher than in Italy and Spain, which imposed more restrictions. Since August 1, an average of two people have died per day in Sweden. There is a similar paradox at the other end of the spectrum: the US and Brazilian cumulative death rates as of late August were slightly lower than Sweden’s, although they will certainly escalate given the numbers of active and new cases.
When all is said and done, it may well be that Sweden will regret its approach. But all is not said and done because the pandemic has not run its course. It is too early to close the books. The shape of the Swedish curve parallels that of other European countries even though the initial numbers were higher. It could be that Swedes adapted to new information and increased their vigilance. It could be that a decline is built into the natural course of the pandemic regardless of policy. It could be temporary good fortune that will reverse later.
COVID-19 is labelled highly contagious, yet it does not appear to spread easily in what should be some ideal transmission environments. The Japanese and French transit systems are densely packed but were not the site of any cases over a month-long period. (O’Sullivan) Wearing masks, some ventilation and especially travelling in silence seem to be protective. Even within households the rate of transmission appears to be less than 20% according to a recent meta-analysis. (Madewell et al.) That it is relatively difficult to get infected through long-term exposure in a confined space and easy to get infected in church assemblies and choirs suggests that we need a more nuanced understanding of COVID-19’s contagion.
Some preventive measures have been described as “pandemic theatre.” (Tufekci) Mask wearing may be more symbolic than prophylactic. In Melbourne, the busiest indoor spaces throughout the months of restrictions have been grocery stores, and, until recently, mask wearing was optional. Stores did limit the number of shoppers, but it is impossible to keep 1.5 metres away from people anxiously surveying the depleted pasta supply in narrow aisles. Literally millions of hands have had contact with millions of items over time. Yet very few cases have originated in grocery stores.
Similarly, it is much harder to contract the virus out of doors and nearly impossible without prolonged exposure to multiple people singing, talking animatedly or exerting themselves. Wearing a mask walking down a mainly empty street prevents nothing except the modest pleasure of feeling the world on your face. It is also annoying as hell, especially if you wear glasses.
Incredible talent has been mobilized to figure out how to limit the damage. The dilemma is that the problems originate in specific behaviours and environments, whereas the solutions are typically generic, imposing major disruptions and restrictions on large numbers of people and enterprises at little risk. Most people follow the rules, but only a few non-adherers can spark an outbreak. Melbourne’s originated in a botched hotel quarantine protocol where poorly trained, contracted private sector security guards and returning travellers mingled when they shouldn’t have. Genomic analysis has verified that 90% of the second-wave cases trace back to this failure.
But once unleashed, the virus spreads for less indictable reasons. An infected security guard seeds the virus in a large, densely populated public housing complex. Some residents go to work when they shouldn’t because they’re poor, work multiple jobs and don’t think they have a viable option to stay home. Many may be asymptomatic when they infect others. Still other cases result from social interactions among families and kinship groups who may not be fluent in English or effectively engaged in pandemic control efforts.
What the World Has Learned So Far
What lessons can we draw from experiences to date? I would suggest the following:
- Without repeated testing of random samples of populations, we cannot know the true incidence or prevalence rate of the virus. And without tests that can produce results more or less instantly, it will be impossible to prevent the spread from asymptomatic people. This is especially problematic given the shift in incidence toward younger age cohorts less likely to become seriously ill.
- Effective containment is entirely dependent on timely and comprehensive contact tracing and effective isolation.
- If most people behave with reasonable caution and avoid indoor, interactive gatherings, the curve will flatten and decline regardless of peak levels of infection in a jurisdiction. If you take fairly modest precautions and don’t work in a healthcare facility with a high infection rate or a COVID-friendly workplace such as a meat-packing plant or live in crowded communal housing, you have to be unlucky to get infected. It is likewise quite easy to avoid infecting others if you wear a mask and minimize contacts.
- The extent to which major restrictions on normal commercial and other activities (aside from mass gatherings and bars) are essential to keep numbers down is unclear. If grocery stores can stay open without generating many new cases, there is no obvious epidemiologic reason why hardware and clothing stores can’t be equally safe as long as the same rules apply. Universal and undifferentiated containment approaches may work, but they are highly disruptive, costly and almost certainly overkill for the great majority of people and circumstances.
- There is no one-size-fits-all approach to changing individual behaviours. Messages effective for 98% of people may not get through to the remaining 2%, with potentially devastating consequences. Risk–benefit perceptions will vary by age, education, belief system and social media consumption habits. Some responsible people will be asymptomatic vectors who do not deserve the label “cynical spreader.”
- Geography matters. It helps not to have land borders and to be relatively isolated.
- Most governments prefer to err on the side of doing too much than to be perceived as having done too little.
Australia’s Success: Engineered or Gift of Circumstance?
Governments can do sensible things but still see numbers grow to worrisome levels and can perform erratically but not get overwhelmed with new cases. With the benefit of hindsight, how should we judge Australia’s performance, especially Victoria’s?
I’d say middling at best. The Ruby Princess and Melbourne hotel quarantine fiascos were entirely avoidable. Victoria refused the Australian Defence Force (ADF) offer of trained soldiers to help with the hotel quarantine. That might have been fine had there been good quality control over the training and deployment of the contracted security guards. There wasn’t.
Contact tracing was pretty good when numbers were low. That is when it is easiest. It has proven much more difficult with a few thousand recent cases, even with ADF personnel knocking on doors. The community engagement effort was very late getting going. The information system cannot generate accurate, up-to-date contact information on many people who have tested positive. But even a system with accurate information and sufficient capacity to interview all known cases faces major difficulties. It’s no easy task to recall everyone with whom one has had enough contact to put them at risk. Talking to contact tracers and identifying people require trust. Disadvantaged groups may be suspicious of authorities and reluctant to “out” their friends and families.
As in Canada, a disproportionate number of cases and deaths have occurred in long-term residential care. The sector is widely regarded as a disaster in Australia; an ongoing commission has been investigating years of reports of scandalously poor care. It took months for some states to forbid working in multiple facilities, a measure essential to infection control but that puts already vulnerable workers in more precarious financial straits. Victoria, with the most aged-care facility cases, has not restricted workers to a single site.
Australia has high-powered universities and beautiful beaches, but there is nothing unusually competent about the country, nor is it a beacon of evidence-based policy making. The Commonwealth (federal) government is led by a prime minister who admiringly held up a lump of coal in Parliament to show his deep understanding of the climate change that habitually ravages his country and went on holiday while large swaths were consumed by bushfires. He is prime minister because his predecessor, Malcolm Turnbull, was too moderate for his caucus, which turfed him out – the fourth sitting PM done in by his colleagues since 2010. The country holds elections every three years to deliver governments from the temptations of long-range planning.
Healthcare federalism is designed for chaos. The Commonwealth is responsible for physician services, the drug plan and aged care. The states run the hospitals and community care programs and are responsible for population health. Local governments have significant roles in public health and health promotion. What could go wrong in a pandemic?
Yet as of August 24, Australia had but 20 deaths per million compared to 240 in Canada – a difference on the scale of Sweden (575) versus Finland (60), its neighbour. But it simply does not pass the eye test to attribute these results to inspired leadership, better science or more coordinated and effectively implemented policies.
Australia didn’t alter the planet’s tectonic plates to locate itself as an island at the edge of the earth without a 6,500-kilometre border with the US, yet these are big advantages. Elsewhere in the world, luck has played a major role in how things have turned out. If your early cases are healthy, younger skiers returning from alpine vacations (Germany), you will do better than if they are elderly people in small, close-knit communities (Italy). If those with a cynical spreader mentality don’t get infected, their behaviour doesn’t matter. If, as some have theorized, there is “dark matter” immunity in some populations (perhaps Germany again), the assumption of uniform susceptibility falls apart.
Hence, only some of what happens is within the control of decision makers. The pandemic is an exercise in decision making under conditions of major and shifting uncertainty. Some day we may learn the full inside story of what went on in various places. What did officials talk about every day? How did they make their decisions? On what basis did they decide to intensify or relax restrictions? What was their approach to localized outbreaks? How did they respond to trends in real time? Were there important differences of opinion, and whose views prevailed and why? The worldwide pandemic experience will spawn a massive analytic and evaluative industry in the coming years. Doctoral dissertations will be the contagion following the contagion. Until the final counts are in and all of the consequences tallied – including the short- and long-term sickness and death wrought by major economic disruption – it is premature to award medals to any country or, with a few notable exceptions, issue failing grades to the inept. My suspicion is that factors such as social cohesion, the state of participatory democracy and citizen engagement, public trust in science and the strength of the social safety net will turn out to be as or more important than all but a few broad-brush policies and restrictions.
Perhaps the biggest element of pandemic preparedness is solidarity among citizens who take seriously their collective obligation to do their part for the common good. And other than in outlier countries that either imposed the equivalent of martial law or ignored the most basic public health practices, the biggest determinant of case counts and deaths may well turn out to be chance.
About the Author(s)
Steven Lewis Adjunct Professor of Health Policy, Simon Fraser University firstname.lastname@example.org. +61 490 943 221
Sudharsanan, N.,Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany (N.S., T.B.), O. Didzun, Justus Liebig University Giessen, Giessen, Germany (O.D.), T. Bärnighausen and Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany (N.S., T.B.). <https://www.acpjournals.org/doi/10.7326/M20-2973>
O’Sullivan, F. 2020, June 9. In Japan and France, Riding Transit Looks Surprisingly Safe. Bloomberg CityLab. <https://www.bloomberg.com/news/articles/2020-06-09/japan-and-france-find-public-transit-seems-safe>.
Madewell, Z.J., Y. Yang, I.M. Longini Jr., M.E. Halloran and N.E. Dean. 2020. Household Transmission of SARS-CoV-2: A Systematic Review and Meta-analysis of Secondary Attack Rate. medRxiv. doi:10.1101/2020.07.29.20164590.
Tufekci, Z. 2020, April 7. Keep the Parks Open. The Atlantic. <https://www.theatlantic.com/health/archive/2020/04/closing-parks-ineffective-pandemic-theater/609580/>.
This essay is significantly longer than the usual format, however, the publishers made the decision to publish in its entirety due its potential value to readers
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