Australia needs to start mass testing for Coronavirus if we want to truly get a grip on this epidemic. Otherwise, those reluctant to present to medical authorities may continue to unwittingly spread the virus.
Australia has been boasting that it has been doing more mass testing for Coronavirus than almost any other country. But in fact, it is doing no mass testing at all. It is simply doing a lot of testing of people suspected, with good reason, of having Coronavirus, and other tests designed to protect health workers.
Using tests to stream patients is not a substitute for research into the spread of the virus into the population. And until we understand that epidemiology, particularly before we get a vaccine, we are doomed to have to slay the hydra over and over again, as fresh victims emerge.
Most of those presenting for the present tests for Coronavirus will be turned away unless they “qualify” by way of travel or known exposure, and have serious symptoms. Even if there is good ground for suspecting exposure, but no evidence of any acute illness, the person will generally be told to go home and avoid contact with others for at least a fortnight. She or he may be put on a quarantine list –with compliance monitored by random checks – but, most likely will be in the same sort of isolation as most other Australians. They are, after all, not ill. And the health system has its hands full with those who are – and its problems will, in the short term be only getting worse.
If mild cases are not going to be treated, some say, why bother to test them at all? Our collective efforts have to be focused on “smoothing the hump” of acute cases requiring treatment and threatening to overwhelm the available facilities, the equipment and the specialist staff able to help them. If we do not smooth that hump, after all, doctors will be forced to make choices about who gets treatment and who must be, in effect, written often. Will the criteria be age? Or having Alzheimer’s. Or being immobile? Past credits, or future potential? These are not exactly novel choices for doctors working in acute care, on a battlefield or in a refugee camp. They are choices already being made as COVID-19 has spiralled out of control in Italy, Spain and the United Kingdom, and, presumably, in China when the virus first appeared as a novel form of flu or Iran.
When doctors are rationing life and death here, we will all think that the Australia public health system has failed. And failed us. Some of those who felt that their relatives – old or young – received less than optimal care will blame the system, and the politicians. They will, we hope, not blame the actual health practitioners at the frontline, because they will know that these faced impossible choices and were working extended hours heroically, and at considerable personal risks to themselves.
If only a very small proportion of those under the age of 50 are going to require hospital treatment, should we be diverting resources to finding out who has a mild or symptomless case (and who doesn’t)? Shouldn’t our efforts be focused on saving the lives of those who are at the greatest risk? That line of thinking has led some people, including a vice-chancellor-cum- health economist writing in The Conversation this week to say that mass surveys of the population are not the best value for money. Not a priority. Much the same has been said by many doctors in the European Community (and Britain) after the World Health Organisation, two weeks ago, called for mass surveys.
There are frontline doctors who think like that too. They are focused on the patients they have, most with a life-threatening illness. They don’t have the time, they think, to worry about people without acute symptoms.
Most Australians are perfectly healthy. They present themselves to doctors when they feel ill. Doctors are used to the patients coming to them. They assume that with most conditions, the sum of presentations to the health system is a fair average sample of the prevalence and incidence of disease in the general population.
Yet we know that with an array of conditions, whole classes of Australians are ignorant, ashamed, or otherwise reluctant to seek medical advice. Younger less-educated men, for example, are notorious for seeing the doctor only after acute trauma, such as a car accident. Probably half of the cases of Diabetes type two are undiagnosed. Some conditions widely prevalent in the community – sexually transmitted disease for example – can be controlled only by vigorous case finding and a degree of legal coercion. Over the past 50 years, indigenous Australians have devised community-controlled medical services to deal with physical and cultural problems that have historically reduced Aboriginal access to health care.
About 43 years ago, Fred Hollows was leading teams going out into communities and conducting mass surveys for eye disease, including trachoma and cataract. The team came on one occasion to a town regularly visited by an ophthalmologist who held clinics at the hospital. He told Fred, proudly, he would see no blind people in this community. The team found 16. They found them because they did not wait for people to present, but used people in the community to bring in people needing help. People lost to the system even in a case where a public-spirited volunteer was available but not hooked in.
The trouble with ignoring the need for epidemiological research, or denying its priority, is that the reservoir of the virus in the community is now among the groups who are asymptomatic or have only mild conditions. It is growing. And we have almost no idea who they are. We can no longer guess at who they are with questions about overseas travel, or physical closeness to a known victim.
Most of our future acute cases, more and more every week, are going to come from this reservoir in the general population. Not from airports or boat terminals. The carriers will not be deliberately shedding and spreading the virus – most, indeed, will have no idea that they carry it. From what we know – and we know too damn little – a virus from an asymptomatic case can pass through several transmissions to further mild cases before catching a very vulnerable person who will die in agony. A mild or an asymptomatic case is as much a risk to the community as a florid severe case.
The reason we know too damn little is the lack of good research into the population dynamics of the virus and the conditions it causes. We have studied the course of the disease, or its aetiology, in any number of particular serious cases. By now we have a fairly good idea of the best treatments pending the development of a vaccine.
But we have very little idea of how the disease is transmitted from person to person, about the incidence and prevalence of the virus (as opposed to mild or serious cases) in the general population, and how that risk can be contained or countered.
When we have such knowledge, we can plan more effective strategies and tactics to reduce incidence and prevalence, and, possibly, its virulence, and rate of spread through the community. A few other countries – South Korea and Singapore – have started some studies but these have tended to work out of infected groups into the broader community, rather than from the community into those at risk.
We need such studies too because sooner or later the incidence of the condition will decline, even before we develop a vaccine. We will breathe sighs of relief, and reduce precautions. But there will still be many in the community who have not had the virus and have no resistance to it. There will still be people carrying the virus. A second outbreak a month or two after we have declared victory is perfectly possible. If we drop the ball, we could have another epidemic among the still susceptible, and further periods of lockdown. We can’t have a plan to cope with Coronavirus or COVID-19 until we know all there is to know about it.
Australia could pioneer a systemic understanding of COVID-19 for the whole world. But it is justification enough that we need it for our own response to the condition. We have to pay a lot more attention to the pattern of prevalence in the population, even, or especially, among those who think they have little to fear.
At least until the government began enforcing bans on gatherings, and being in public, our young people posed the greatest risk to the health of the population, including of themselves. But it’s the failure of public health authorities to research and appreciate the who and how of virus-spreading, rather than the behaviour of young people, that is now becoming the most serious threat to public health. Scott Morrison has shown a commendable willingness to spend any amount of money to defend our health. There is no economy in saving money here.
Jack Waterford is a former Editor of The Canberra Times