Pearls and Irritations

My recent review of the book, Australia’s Pandemic Exceptionalism, by Steven Hamilton and Richard Holden (H&H) highlighted its ‘convincing, frank and honest account’ in just over 200 pages, and encouraged the Health Department in particular to listen to its lessons. The official COVID-19 Response Inquiry Report by Robyn Kruk, Catherine Bennett and Angela Jackson ( KB&J) may lack H&H’s punchiness but is an equally impressive document that deserves careful reading not only by Health but across the Commonwealth and the States.

KB&J were given terms of reference which precluded them from examining actions by the States that were not conducted jointly with the Commonwealth, but their views on many of those actions are pretty clear from their consideration of issues of coordination, consistency and communications. Theirs is a much more comprehensive examination than H&H’s, as indicated by its 877 pages (including 4,647 footnotes!), so its findings go well beyond those of H&H, but they encompass most of H&H’s conclusions: overall success, particularly in the early stages when the health and economic responses clearly complemented each other, but avoidable delays in achieving high levels of vaccination and failures to monitor developments adequately, leading to excessive restrictions and lack of appropriate targeting, with both financial and personal wellbeing costs.

KB&J not only provide a more comprehensive review, but differ from H&H in consciously adding hindsight to their assessments of the actions taken at the time. This is mentioned throughout the report, but the reasoning is probably most clear on page 553:

‘The panel heard that there would have been real and ongoing costs of letting perfection get in the way of providing support in a timely way. That said, this increases the value in reviewing individual measures and design features to learn what worked well and what could be improved. In particular, some decisions had unintended consequences. Leveraging the benefit of hindsight, these should be avoided in any future pandemic response.’

The more comprehensive study also highlights more of the scale of the actions taken, particularly by the Commonwealth, and the impressive agility and competence shown across so much of government. It adds weight to H&H’s general point about the importance of the administrative state and its capacity.

To an extent, this leads to less virulent criticism than H&H’s of health actions in late 2020 and 2021. KB&J, however, do not hesitate to identify, with hindsight, other shortcomings that adversely impacted on people’s physical and mental health, material wellbeing and human rights, and added to costs for taxpayers and subsequent economic instability, which better planning and preparedness might in future avoid.

A central message in the report is that planning for and response to a pandemic must take into account not just economic and health priorities but also social and equity priorities , and human rights.

The following picks up some of the issues canvassed in the report which I found of particular interest: most I agree with, some I am less supportive of, all are worth careful consideration.

Preparedness, leadership and governance

The chapters on preparedness, leadership and governance acknowledge the leadership demonstrated through the National Cabinet arrangements and the agility exhibited across the Commonwealth particularly in the early period, but that this unified direction and national leadership deteriorated.

They also highlight the lack of adequate preparedness for such a pandemic and the need to increase investment in public health capability. These latter concerns underpin KB&J’s recommendation for an Australian Centre for Disease Control.

KB&J draw attention to problems relating to roles and responsibilities. In a federation, this is always a thorny issue. The establishment of the so-called National Cabinet papered over some of that thorniness (I still do not like the term, believing ‘Council of Australian Governments’ better reflects the Constitution and the degree of sovereignty of each government), though it certainly helped to achieve shared leadership in the emergency. Weaknesses identified by KB&J include the excessive secrecy from claiming ‘Cabinet’ confidentiality and the limited way in which National Cabinet was informed.

The latter weakness was complicated in part by the provisions of the Biosecurity Act and the powers it confers on the Commonwealth Minister for Health and the Chief Medical Officer. The minister wisely chose to exercise his powers after consultation with the (Cwlth) Cabinet, and he also attended many meetings of the National Cabinet. The CMO used the Australian Health Protection Principal Committee (Commonwealth, State and Territory CMOs) to involve wider public health expertise and achieve greater consistency in the responses across jurisdictions. National Cabinet’s exclusive reliance on the AHPPC, however, led to failures to consider broader health and related social issues.

KB&J rightly question the lack of direct input to National Cabinet from Health Ministers and their chief executives who exercise wider health responsibilities and draw on more than public health expertise. With more input from PM&C as well, that might also have led to greater consideration of equity and human rights issues.

A challenge for the proposed Australian Centre for Disease Control will be its authority and its relationship with the States. Notwithstanding the degree of cooperation shown through the AHPPC (and ATAGI and related forums), there was a disappointing lack of consistency amongst the actions different jurisdictions took on the advice of their expert members of AHPPC (and ATAGI). One would have thought that the experts could (and should) have reached agreed positions in the interests of consistent messaging to the public, setting aside personal differences (while always agreeing to reconsideration in the light of experience or new evidence). It is not clear from KB&J’s report how the proposed ACDC will avoid such inconsistent approaches by jurisdictions in future.

Health response

The chapters covering the health response endorse the precautionary approach taken early and acknowledge the extent of agility shown by Commonwealth authorities. But the subsequent varying arrangements across jurisdictions and lack of adequate consideration of human rights undermined community trust.

While emphasising the importance of real-time evaluation, KB&J are, surprisingly, less critical than H&H about the delays in utilising RATs which might have facilitated such evaluation and better targeting of responses and restrictions.

They certainly share H&H’s concerns about the delay in purchasing and approving vaccines and in managing the rollout (‘strollout’), but they pull their punches. They endorse the ‘portfolio approach’ to the purchasing without highlighting the failure to retain the mRNA vaccine developers in the portfolio (adding them again much later), and they lend support to TGA for ‘balancing speed of assessment with clinical rigour’. The issue H&H highlight about failure to assess risks against the substantial background risk at that time of an unvaccinated population is mentioned but not given the weight it deserves: almost certainly that would have demanded greater urgency by the Health Department and the TGA.

Where that issue does get highlighted is in medical authorities’ responses to the AstraZeneca vaccine risks (particularly by the Queensland CMO and now Governor) which increased vaccination hesitancy in the community.

Overall, KB&J judge the achievement of over 80% vaccination coverage before the end of 2021 a success, being ahead of the schedule set in late 2020. Like H&H, I would draw more attention to how slow we were to get off the mark (for months we were dead last amongst OECD countries as KB&J acknowledge) and the huge financial costs that delay caused ($31 billion is mentioned by both KB&J and H&H).

Amongst the human rights issues KB&J rightly raise is the use of vaccine mandates. This is not a simple issue as it requires careful assessment of risks as well as human rights. Perhaps the best approach is to avoid mandates as far as possible (as KB&J prefer) but also to make clear that those choosing not to be vaccinated will face costs in terms of extra restrictions in order to keep others safe. Denial of travel on aeroplanes, for example, is not really a vaccine mandate in my view; it is more a justifiable restriction when the risk to others’ safety is high.

An important point made by KB&J is the benefit in future of embedding the primary healthcare sector in planning and response. Some commentators have (validly) criticised the Commonwealth’s initial insistence on using GPs to roll out the vaccination when earlier mass vaccination centres managed by the States would have increased coverage more quickly. However, primary care ends up playing a critical role as first contact with cases and the continuing coordination of care and so should be involved in planning and response.

Despite the establishment of Primary Healthcare Networks some years ago, their success in building close relationships with State hospital networks is mixed, as is their success in gaining the active support of all GPs and other primary healthcare providers in their respective regions. My own view is that the Commonwealth department should attach staff to each network to help strengthen their capability and to promote more systematic cooperation with State hospital networks such as through cross-membership of boards. Commonwealth Health having some people on the ground might also ensure closer linkages with aged care providers and better feedback to policymakers in Canberra.

Loss of trust over time is a major theme throughout the report, with the inconsistent actions and poor communications in the later stages of the pandemic, and the use of vaccine mandates and heavy-handed restrictions, being major contributors. I wonder if the main reasons for loss of trust are the failures surrounding the vaccine rollout in particular and the inadequate targeting of responses because of limited real-time evaluation. It was these which drove the heavy-handed restrictions and prolonged the whole pandemic response. Perhaps trust can be regained more readily than KB&J fear if such ‘competency’ failures are not repeated in future.

Economic and industry response

Like H&H, KB&J highlight the role of strong economic leadership in Australia’s successful response in 2020. This prioritised harm minimisation above all other considerations. Jobkeeper and the Coronavirus Supplement to Jobseeker were particularly vital.

Similarly, they highlight that delays in the vaccine rollout prolonged the need for economic as well as health responses.

With hindsight, KB&J also refer to the inadequate support for some industries and individuals (those on visas caught in Australia by travel restrictions being a particular concern), and the failure to anticipate supply-side constraints.

I am less convinced of KB&J’s analysis of the subsequent surge in global demand when economies reopened and its negative economic impact including persistent high inflation and widespread labour and housing shortages that have continued for almost five years now. KB&J acknowledge that over-responding at the beginning of the pandemic would have lesser consequences than under-responding, but still consider that, in hindsight, the economic response was too large and went for too long. Perhaps. Some of the stimulus measures did not work well, and in a future pandemic a Jobseeker might be able to incorporate some form of income-contingent loan given better forward planning. Given the delayed vaccination rollout, however, prolonging the economic response was necessary, and the cessation of Jobkeeper and the Coronavirus Supplement attracted strong political criticism at the time in any case.

The failure to raise interest rates more quickly is open to more valid hindsight criticism, reflecting the limited appreciation of supply chain issues at the time. Better understanding of those, as KB&J recommend in future, might avoid such a failure.

I must admit to being pleased about the comments in the report about Jobseeker and the Coronavirus Supplement. The supplement was certainly warranted, but to a large extent its generosity was a function of the inadequacy of the base rates of Jobseeker which remain at below-poverty levels even now.

Conclusion

The COVID 19 Response Inquiry Report is a substantial document. Despite lacking the powers of a Royal Commission, having somewhat constrained terms of reference and a one-year timeframe, it provides a pretty comprehensive and balanced view of Australia’s performance and lessons for the future.

There is much more to it than this article conveys.

To an extent its comprehensiveness has diluted a few of its messages. For a punchier assessment, go to H&H’s book. Reading both is essential for anyone likely to have responsibility for planning for or responding to any future pandemic.

 

Republished from The Mandarin, 12 November, 2024