Ian Powell: Let’s Not Over Glorify The Government’s Performance Fighting Covid-19
In assessing the effectiveness of the Government’s response to the Covid-19 threat it is important to distinguish between responsiveness and preparedness. The better the former, the greater the likelihood of glossing over weaknesses in the latter.
New Zealand’s response to Covid-19 has been extraordinary. Compared with much of the rest of the world we have per capita very low death rates, our neglected and vulnerable hospitals have been saved from the expected tsunami of patients, the risk of deadly community transmission remains but has been substantially reduced, and we are the world leader in seeking to eliminate the killer virus. Although our economy will take a hammering, unlike many other economically developed countries to date, we have avoided having to struggle through this with a heavily infected workforce.
The reasons for this success include acceptance of advocacy from public health medicine and other specialists and acceptance of their expert advice, committed workers in essential industries, the Ministry of Health stepping up, and the maturity and goodwill of the public in responding to the need for bubbles. But none of this would have happened without exceptional political leadership from Prime Minister Jacinda Ardern and those around her. All this makes journalist Andrea Vance’s column on hero-worshipping in the Sunday Star Times (26 April) apt.
We disrespect this political leadership by hero-worshipping. We also demean ourselves and take away a critical component of functioning democracy, that is, scrutiny. Vance’s warning provided the perfect coincidental cue for Marc Daalder in Newsroom raising serious doubts about our preparedness for the pandemic.
Scrutiny requires drilling down into the specifics. In late November 2018 the World Health Organisation (WHO) conducted a four day ‘Joint External Evaluation’ (JEE) of New Zealand by international and national experts.
The purpose of WHO’s JEEs is to review and then strengthen a country’s preparedness for public health outbreaks and emergencies. It concluded that New Zealand had developed a high level of core capacity but needed to remain vigilant in light of pandemic and other outbreak threats. It called for increased funding and resources. One of the areas we were weaker in was the coordination, surveillance, and infection prevention and control of ‘anti-microbial resistance’ (resistance found in different types of microorganisms to the effects of medication against threats such as viruses, bacteria, parasites, and fungi).
As recently as October last year the Global Health Security Index (GHSI) reported on its assessment of 195 countries. GHSI is an international collaborative non-government organisation (including the John Hopkins Health Security Centre) that assesses global health security capabilities.
GHSI concluded that no country was completely prepared for epidemics or pandemics, with New Zealand rated mediocre. Ranked 35th out of 195 countries (30th out of 60 ‘high-income’ nations), New Zealand scored 54 out of 100; in other words, we were assessed as having barely half the measures in place that we needed. Further, we had a serious shortage of epidemiologists (including inadequate training positions), ranked 80th out of 195 for hospital beds per capita, ranked 42nd for all doctors per capita, and were particularly weak for early detection. While GHSI noted that New Zealand had a good pandemic plan (2017), it was for influenza rather than respiratory viruses.
This blunt assessment was prior to the breakout of Covid-19 in Wuhan. GHSI worked on the assumption that it was only a question of when there would be a pandemic, not if. Alarmed New Zealand epidemiologists promptly advised the Ministry of Health of this assessment but were reportedly ignored. Instead the Ministry was apparently comforted by the earlier WHO JEE.
There are differences between the WHO JEE and GHSI assessments, in part because they appeared to be looking at New Zealand through different lens. The JEE seemed to be more process focussed, which encourages a ‘tick box’ approach, whereas the GHSI emphasised more actual capability. But they are not oppositional assessments. Both, especially the second, provided warnings that needed to be heeded.
GHSI’s analysis is open to criticism because it looks at capability and does not consider responsiveness. The United States was ironically the highest ranked, despite concern expressed about the absence of a public health system (something with hindsight that should have been given greater weighting). Both this absence and reckless and incompetent political leadership put the US up there with countries like Brazil and Belarus as the worst performing responding countries.
New Zealand was mediocre in capability but overall responded very well. At a certain point in March we could have ended up looking like (per capita) Italy or Spain if the Government had behaved like a possum in the headlights. Our public hospitals facing neglected severe specialist shortages were in no position to cope if we had been.
But the Government was not blinded by headlights. Instead it noted both how Europe was being swamped by the virus and the measures taken in China to achieve its remarkable turnaround. It quickly acted on the advice of epidemiologists and scientists.
We were also helped by luck. New Zealand is two main small islands at the bottom of the world so very much at the end of the queue for Covid-19’s arrival. Further, Europe and North America were hit in their winter which is more conducive to virus spread whereas we (and Australia) were still enjoying summer.
There is still the remaining concern over border controls at least in the earlier days of Covid-19 turning up on our shores. There are sufficient anecdotal experiences about laxness when entering New Zealand to cause ill-ease. This is reinforced by the fact that our much touted pandemic plan (2017) did not explicitly address closing borders where justified by the severity of risk. In situations like this implicitness (the Health Ministry’s justification) does not cut it. It is also surprising the pandemic plan is for influenza and that there is no specific plan for respiratory viruses, although many of the core principles no doubt would apply to both.
This international concern was reinforced by a revealing audit of contact tracing conducted by epidemiologist Dr Ayesha Verrall and released on 10 April (Rapid Audit of Contact Tracing for Covid-19 in New Zealand). Her audit was critical to the Government’s decision to exit Level 4. Commendably it was commissioned by Director-General of Health Ashley Bloomfield in the full knowledge that Dr Verrall had been publicly critical of the extent of testing and contact tracing.
The audit notes that rapid case detection and contact tracing combined with other basic public health measures has over 90% efficacy against Covid-19 and is central to the elimination objective. She warns of a ‘new normal’ after leaving Level 4 of local community transmission and small clusters with the potential for the virus to expand quickly to large outbreaks for the next two years.
Fortunately, Dr Verrall does not pull her punches despite the Director-General understating the severity of her audit in his daily media briefing immediately prior to the audit’s release. She identifies the prime reason for limiting the effectiveness of contact tracing as the under-resourcing of the 12 Public Health Units (PHU) in the country. PHUs largely comprise public health nurses, medical officers of health (public health medicine specialists experienced in communicable diseases), and health protection officers (experts in environmental and communicable diseases whose role is to identify and manage potential health risks to the public). PHUs are complemented by the National Close Contact Service (NCCS), a hub in the Ministry of Health which coordinates centralised contact tracing.
Dr Verrall is adamant. This under-resourcing meant that PHUs were unable to meet the demand for contact tracing even though in March the cases were less than 100 a day. When New Zealand moved to Level 4 on 25 March many PHUs lacked the capacity to manage contact tracing. Further, after Level 4 was lifted, it was highly likely that there would be multiple instances of community transmission and the risk of new outbreaks. The capacity of PHUs (and NCCS) needed to be rapidly increased in order to manage up to 1,000 cases of contact tracing per day. Three to four-fold workforce expansion was required and urgently.
The directness of Dr Verrall’s audit of contact tracing is an excellent example of the scrutiny required even when we have experienced high quality political judgment and leadership. She drills down further than the earlier international assessments. Scrutiny clarifies our comprehension of this judgment and leadership. Capability was deficient and, in some areas, poor. But when the rubber hit the road responsiveness was first rate whereas the United States was a car wreck. Hero-worshipping has a powerful feel good effect but is not helpful for learning how to do better in the future because Covid-19 is almost certainly not the last pandemic we will experience. Scrutiny is not just helpful, it is vital
Ian Powell was formerly the Executive Director of the Association of Salaried Medical Specialists for over 30 years until December last year. He is now a health commentator based in Otaihanga on the Kapiti Coast.
First published on the https://democracyproject.nz/