Three years into the Covid -19 pandemic the many weaknesses and disconnections within the jurisdictional decision-making arrangements are clear. These fault lines significantly impair our national capacity to reliably detect and respond to this ongoing outbreak in a timely, effective and efficient manner. We urgently need to develop integrated national and international responses to disease prevention and control, particularly pandemic planning and management capacity. Unsurprisingly the recognition of this need for basic reform in areas such as communicable disease surveillance, interjurisdictional data integration and improved communication, is not new.
In 2014 a report submitted to the Australian Office of Health Protection identified many problems and advocated steps to further integrate and streamline communicable disease management across the jurisdictions. Similarly, the AMA position paper (2017) called for the creation of an Australian Centre for Disease Control. Nothing of substance has been implemented.
Over the last few years, the difficulties in managing a pandemic across nine jurisdictions has also highlighted the lack of strategic leadership and the separation, isolation and disintegration of evidenced based, agreed and efficient policy making at heads of government level. To achieve more integrated national policy and better outcomes, the integrity, span, transparency, access and trust of cross jurisdictional communication platforms needs to be reviewed, rebuilt and repaired. Such an outcome can only be achieved by formal health policy declaration(s), bipartisan commitment and sufficient resource allocation for the reform processes.
We previously raised a number of issues regarding interjurisdictional pandemic planning, suggesting reform of existing systems to better coordinate operational responses and improve national health outcomes before the next pandemic arrives in the Australian Health Review (Australian Health Review 46(4) 450-452 https://doi.org/10.1071/AH22158).
We also examined the role and effectiveness of Centres for Disease Control (CDCs) in the USA and Europe and considered lessons for the adoption of a CDC model in Australia. We also “mapped” key interjurisdictional communication pathways and propose a number of steps that could be taken to upgrade and harmonise the collection, distribution accessibility and timelines of key data and information required to improve infection control, pandemic management and national health outcomes.
While it is hard to contemplate a rapid move to more integrated national capacity when we are only just emerging from the worst of the pandemic, there is a unique opportunity to at least push the review process. Use the lessons learned to transform our systems rather than “tinker” with them and ensure we are better prepared for next time.
The budget support to explore the establishment of ACDC is a very positive step.
Evidence, opinion, media and politics
Although the need for a national communicable disease and pandemic planning framework might seem clear during times of obvious community morbidity and mortality, realistically, once the risk of individual and social jeopardy decreases so it seems does the focus and impetus for reform. Governments have many conflicting priorities and little appetite for structural changes which would be time consuming and difficult to negotiate and legislate.
Furthermore, a major lesson of the pandemic is that over the last decade, the separation between evidence, opinion and political expediency has become much weaker. As the health instrumentalities have become more “siloed”, the polity has also become more partisan with policy often being driven by media outlets that portray experts as despised elites and advocate for “alternate facts” and opinions in the name of “balance”. The multimedia push and resultant political support for untested treatments such as Ivermectin and Hydroxychloroquine largely overwhelmed any evidence-based approach to such treatments by health professionals.
In this complex and fast-moving mix of challenged data, many loud and conflicting voices, political gaming, daily media opinion and narrow casting it is little wonder that the clamour for maintenance of “Individual rights and freedoms” threatens to overwhelm the tried and tested public health messaging and interventions of previous decades. Even now, deep state theorists, antivaxxers, pandemic deniers, quack remedy peddlers and political opportunists continue to have a loud and disproportionate presence in some media outlets, internet channels and within the extremes of the populist political spectrum. There is no reason that this will change any time soon.
It is therefore instructive to assess the pandemic performance of the two most famous and influential international CDCs, the Centers for Disease Control and Prevention (CDCP Atlanta USA) and the European Centre for Disease Prevention and Control (ECDC). Did they make a difference to the trajectory and outcomes of the pandemic within their jurisdictions?
It should also be remembered that early on, the origin and cause of the disease was shrouded in mystery and confusion. Nevertheless, it might have been expected that CDCs would provide early, timely and reliable information to address the outbreak and refresh information as needed. That is, provide “gold standard “, trusted evidenced based advice and communications services for use by governments and the health system to limit the damage of the pandemic. Recently both CDCs have undergone performance reviews and unfortunately it is reported that inter alia, their impact on shaping and influencing the early and ongoing responses to the pandemic was somewhat poor and ineffectual.
The CDCP (Atlanta) reviews validate widespread criticism about data collection, reliability and interpretation, confused messaging and inadequate timeliness. It has been reported that the influence of the CDCP was also diminished by the sheer size of the organisation, its number of bureaucracies and spokespeople. Effectiveness and trust in messaging were also tested by way of administrative and political pressure to control data flow and content that could be used to support a particular posture or direction, eg the safety of early opening of schools.
In anticipation of the Review, the CDCP Director, Dr Rochelle P Walensky, said:
“For 75 years, CDC and public health have been preparing for COVID-19, and in our big moment, our performance did not reliably meet expectations,”
“The C.D.C. must refocus itself on public health needs, respond much faster to emergencies and outbreaks of disease, and provide information in a way that ordinary people and state and local health authorities can understand and put to use” and concluded;
“My goal is a new, public health, action-oriented culture at C.D.C. that emphasises accountability, collaboration, communication and timeliness.”
The European CDC is markedly different to the CDCP (Atlanta).
It has a much more limited scope, role and budget and has no legislated authority over member states. Accordingly, its role has been much more passive but was seen to be effective in providing reliable and timely data, status reports and updates. Nevertheless, it was largely sidelined by individual European member states with regard to public health policy decisions and local interventions and actions.
Perhaps the lesson here is that the existing, high profile CDC models can play different roles but will always be subject to the new turbulent, fast moving and mixed environments. The most common theme for the role of CDCs seems to be the provision of accurate, timely, accessible and trusted data. How that is used by the political machines can be problematical but at least it provides a bedrock for track and tracing, health decisions, societal interventions and research.
Perhaps the best way to explore and move towards improved disease control and better future pandemic outcomes in Australia would be to initially focus on two key areas.
Firstly, there needs to be a clear commitment by the National Cabinet to review and restructure all existing national policy, legislation and regulations relating to interjurisdictional pandemic communications and responses.
Secondly, as part of this commitment, there needs to be an early review of existing jurisdictional communicable diseases frameworks and reporting capacity. Building an agreed, standardised, accessible national data base, communication and reporting system is an essential early step. While the ACDC model is being explored/ evaluated, there could also be an interjurisdictional expert working group to plan the early implementation of a national communication hub, ie one that NOT ONLY provides standardised integrated, rapid, reliable surveillance and outbreak information/ advice but ALSO is easily accessed by jurisdictional decision makers and operatives, state health systems and community practitioners and of course, the public, ie a hybrid system combining centralised hardware “grunt” and data standardisation but with local control of the information and communication processes.
In other words, and as a priority, address the most obvious domestic information system weaknesses and failures of the last few years and as part of this process, adopt the lessons learnt by the CDCP and the ECDC.
With wide-ranging experience in the health care industry at Australian Government and state levels, Dr Lewis-Hughes is especially interested in contemporary health issues as they relate to strategic and business planning for clinical services across Queensland. In 2009 he received a Queensland Health Australia Day Achievement Award for Clinical and State-wide Services. Later that year Dr Lewis-Hughes left Queensland Health but continues to provide advice on all aspects of health policy, service delivery, review and reform.
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