Transcript
MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians. The COVID-19 pandemic left a lasting impact on many aspects of our lives. As much as we’re sick of thinking about it, we do need to reflect on how well prepared we’d be for the next such event and how we might respond differently. I’m going to look at this question mostly from a public health perspective in Australia though Aotearoa-New Zealand did chart a very similar course. I’ll ask which policies proved themselves to be effective at reducing transmission and which ones might future governments not have the social licence to implement once again.
I’m not going to spend much time on technical preparedness because those things speak for themselves with little controversy. Plenty has been written already about better data sharing between health services, better surveillance of zoonoses and improvements in standards for indoor air filtration. And in December 2024 Moderna opened an mRNA vaccine manufacturing-facility on the campus of Monash University, which would have a potential turnover of 100 million doses per year.
The number of deaths formally chalked up to COVID-19 worldwide is usually given as 7 million though computational estimates suggest there were at least twice as many excess deaths whose direct cause we don’t really know. In Australia, thirteen and a half thousand people died from or with COVID-19 in the three years up to December 2022. That’s a good date stamp to use because it’s when non-pharmaceutical interventions were ceased entirely in all Australian jurisdictions. By some coincidence, another thirteen thousand people have been killed by COVID-19 in the three years since we decided to “live with the virus.” That’s in a population that was almost totally inoculated when social restrictions ended, whether by a vaccine or infection. Without any complex statistics, this tells you right off the bat how much work the non-pharmaceutical interventions were doing in the naïve population.
Over the next two episodes we’ll look carefully at the border closures, the vaccine directives, the lockdowns and mask mandates. It’s estimated that these interventions spared up to 50,000 Australian lives by the end of 2022 and that vaccines saved three times as many again. I’ll explain where these numbers come from along the way. While our public health response is described as one of the most effective in the world at suppressing the virus, there were unintended social harms. The lingering resentment around this in some parts of the community means there could be more resistance to such policies were we to face another rapidly moving pandemic any time soon.
To discuss how the cost-benefit calculation stacks up for these interventions I’ve brought together what may be the most esteemed panel the podcast has ever hosted. Four people from diverse disciplines who have been responsible for some of the most influential thinking on the pandemic. Professor Paul Kelly, needs little introduction, as most listeners will know he was Australia’s Chief Medical Officer when COVID-19 struck.
PAUL KELLY: Thanks Mic. So, my background is in infectious disease, epidemiology and public health. I have travelled and worked around the world in clinical roles, in academic roles and in public health since the late 90s. I found myself in. As a member of the Australian Health Protection Committee (AHPC) when I became ACT Chief Health Officer in 2011 and then transferred to the Commonwealth in 2019, just in time to be put in the hot seat.
MIC CAVAZZINI: Thank you. Professor Catherine Bennett is another expert most listeners will have heard, chiefly as co-author of the Commonwealth Government’s COVID-19 Response Inquiry along with Robyn Kruk AO, Dr Angela Jackson. Catherine what are two other things you’d like us to know about your professional life?
CATHERINE BENNETT: My original training was in microbiology, population genetics and biostatistics. Post PhD, I did training in field epidemiology, so infectious disease epidemiology through ANU and the Master of Applied Epi program. But my population-based research is really focused on transmission in community but also antimicrobial resistance. And what was interesting for me was I drew on all of those fields in the pandemic. Field epi is quite different sometimes the way we try and create the perfect research world in in academia as well.
MIC CAVAZZINI: There were a lot of models competing for attention over the pandemic, but one of the most significant emerged in the National Plan, commissioned by the Federal government as a roadmap for behaviour change as vaccine coverage increased. Professor James McCaw at the Uni of Melbourne School of Population and Global Health was one of the leads long with Prof Jodie McVernon. And James there was just one of many reports you contributed to.
JAMES McCAW: Yeah, thanks for the opportunity to join this podcast. Just a little bit of background. I studied theoretical physics of all things way back in the day, but then a bit over 20 years ago now moved into this field of infectious disease modelling and dynamics. And from around 2005 actually worked As part of it with many people around Australia to help establish this field of modelling in Australia and then work with the Commonwealth periodically on about three revisions to our health management plans for pandemic influenza.
And one thing led to another and then with a few other colleagues in early mid-January 2020, we're on some WHO meetings about this novel transmissible coronavirus, and then was invited to AHPPC, as Paul just mentioned, to help brief the government on that and from there became a member of that committee as an invited expert meeting daily to weekly to help guide that response.
MIC CAVAZZINI: Thank you. It sounds a bit like the set up to a joke. A public health physician, a microbiologist, an epidemiologist and a mathematician walk into a bar. It wouldn't be complete without a lawyer. I’m very honoured to have Lorraine Finlay with us, who is the Australian Human Rights Commissioner and author of an important retrospective titled ‘Collateral Damage’ which describes some of the friction points for public health interventions. Welcome, Lorraine, what are a couple of more things we should note from your CV?
LORRAINE FINLAY: Well, thanks so much for having me. It's really great to be with you all. I think the key thing to note is I'm not a public health expert. So, I don't bring that background to the table, but my background is instead in law and human rights. I'm currently the human rights commissioner at the Australian Human Rights Commission. And I started in that role midway through the pandemic in late 2021. And prior to that, I worked in a variety of roles, including as a state prosecutor and as an academic specializing in criminal law, constitutional law and human rights law, all of which were areas that were impacted on at various points in the pandemic.
MIC CAVAZZINI: Before we get started, there is some “assumed knowledge” and non-negotiable premises I want to get out of the way. All of the findings I refer to throughout these podcasts are linked to academic citations you can find in the transcript at our website racp.edu.au/podcast, then just click on episode 145. Okay, the first premise is that the SARS-CoV2 virus responsible for COVID-19 was highly transmissible with significant morbidity and mortality. Remember that the basic reproduction number of a virus, R0, gives you an estimate of how many people will become infected from one case. The original Wuhan strain of SARS-CoV2 had a basic reproduction number of around 2.5, and for Delta it was reported to range from 3 to 8. The Omicron variant, first detected in South Africa in November 2022, managed to get higher still.
COVID-19 was not “just like a seasonal flu” which has a basic R value around 1.4 and a much lower mortality rate. In a western setting seasonal influenza kills 1 to 10 people per 100,000 infected. The best guess for the emerging COVID-19 is that it had an infection fatality rate of 1 in 150, on average, though as we’ll discuss later this was hugely age-dependent.
The second premise for today’s conversation is that there’s a well-defined capacity to the health system and you need to prevent huge surges in hospitalisation in order to keep everyday healthcare ticking over. This is most starkly represented by the fact that Australia didn’t even have two and a half thousand permanent beds across all its intensive care units. Another couple of thousand ventilated beds were cobbled together early in the pandemic, but modelling demonstrated that letting COVID-19 off the chain in the unvaccinated population would have led to tens of thousands of patients needing ICU management at any one time.
Premise Three. To keep the number of patients requiring hospitalization below that capacity threshold there is a suite of public health and social measures that reduce population interactions and suppress transmission. This can be quantified as knocking down the effective R, or “flattening the curve” of daily active cases. This strategy buys time for vaccinations to be rolled out, to eventually reach a point of herd immunity.
The bluntest tool in the PHSM toolbox is closure of borders. Way back in podcast episode 63 I discussed how historically, countries had been deterred from reporting novel disease outbreaks because of the risk of having trade and tourism cut off to them. In order to incentivise information sharing, the World Health Organisation has over the years tried to present international border closures as a last resort. Even on the 1st March 2020 the WHO was advising that travel bans have a “significant economic and social impact," warning that restricted movement of health personnel and resources would hamper development efforts in low income countries.
The WHO officially declared COVID-19 a pandemic a week later on the 11th March after the virus had reached 114 countries and killed more than 4,000 people. Five of these deaths were in Australia and over the first three weeks of that month we started to close off intake of travellers from abroad. First from Iran, then South Korea, then Italy, and finally, on the 20th March, Australia became one of the first countries to pull up the drawbridge to everyone but returning residents. A week after that, international arrivals were required to quarantine for 14 days at designated hotels or facilities. In the COVID-19 Response Inquiry Report, Catherine Bennett and co-authors describe the international border closure as a courageous leadership decision which contributed a big chunk of those 50,000 lives saved. I asked Professor Bennett how this policy squared with other obligations such as those to the WHO’s International Health Regulations.
CATHERINE BENNETT: The International Health Regulations are really about our obligations to support the international effort. You know, if you have the beast within, they probably want your international borders closed to try and contain a potential outbreak or pandemic. It has a trade element. So, it is about allowing critical resources to be moved around the world and richer countries to contribute to poorer countries in accessing medical supplies and so on.
The IHR, the International Health Regulations, were updated last year. So, from September 2025 they've included some more detail, lessons learned from the pandemic, but they still aren't that specific. They don't say, “you cannot close international borders” or “you must keep this chain of supply open”. We will be vaccine producers in the next pandemic. That's, you we now have onshore mRNA facilities being developed, so there will be ongoing obligations under the IHR that will impact the way we implement some things including, potentially, international border closures. Look, I think the other thing it did was give us options. We avoided multi-seeding across the country and were able to contain that first wave. That was a really critical outcome that changed the paths that we took or could take in the pandemic.
MIC CAVAZZINI: As well as our responsibilities to the WHO, Australia is signatory to various UN conventions on human rights. The most broad-ranging is probably the International Covenant on Civil and Political Rights. As discussed in the Human Right’s Commission report, Article 12(4) of the ICCPR provides that “no one shall be arbitrarily deprived of the right to enter [their] own country.” But in April 2021, the government banned all incoming flights from India, as the very virulent Delta strain was infecting a few hundred thousand people every day in that country. And this left 9000 people with Australian citizenship unable to return home. Lorraine, the ICCPR does allow for the right to enter to be “derogated” in circumstances where community good demands it. Was this an acceptable instance?
LORRAINE FINLAY: Well, the short answer is no. In my view it was an extreme step and I recognise the issue of border closures as we've just mentioned is a complex one and there is a need from a public health perspective. There's no doubt that was a really critical decision for Australia to take but I think the Indian travel ban is a really good example of those types of decisions needing to be proportionate and needing to think not just of the immediate public health benefit or cost but the broader impact.
So, for example, Article 12 (4), as you said, talks about the right not to be blocked from coming home effectively and I think where this travel ban crossed the line is it wasn't just about closing borders and protecting Australians, it was actually about criminalising Australians from being able to return home. And what the international human rights law around this says is that having an infectious disease is not a good enough reason to lock your own citizens out of the country, that actually you should bring them back and manage that risk in a safe way.
And I think what made this particular ban even more troubling was that it only applied to India at a time when the virus was spreading globally. And it is hard to imagine Australia taking that step, for example, to block Australian citizens who are trying to return from the United Kingdom in such a blanket way or some other countries. I think the problem with this particular decision was that it was made in a way that left thousands of Australians stranded, it really undermined the value of Australian citizenship. And it showed why emergency powers will need to be used, there will need to be really tough decisions taken, but if you take those decisions without having really strong human rights safeguards in place and that commitment to non-discrimination in the application of those decisions, then you can have some really troubling human rights impacts.
MIC CAVAZZINI: Paul, are you dying to add this, or can I put the next question about quarantine to you?
PAUL KELLY: Sorry, but I do feel as the person who was right at the centre of that particular decision, I need to set some of the record straight. Firstly, it was one of the few times when I disagreed with the government decision, but it was a government decision. And there's some things about that I can't talk about still. But that was the decision.
So, decisions cannot be made under the Biosecurity Act until and unless the Chief Medical Officer, at the time, now the head of the CDC, provides advice and that advice must take into account the various things that Lorraine highlighted in her excellent report from the Human Rights Commission. It should be proportional. It should be evidence-based. Equity is a key component of the decision-making. The main reason why we went ahead with that was that the quarantine system, which was flawed and it already had several breaches, including the one that led to the Victorian outbreak in 2020, was under strain.
We had several weeks of people coming from India with Delta virus at a much higher rate than anywhere else in the world, orders of magnitude higher. And there was a real concern that the quarantine system would actually collapse and that no-one would be able to come back. So, when we're talking about proportionality, this was a particular place based on a particular issue. But that's not taking any disregard from what Lorraine was said and the fact that your point is well made about it being India and not other places. But that was that.
It only lasted two weeks and in that time we really rushed to get people on the ground from Australia to try and help out with the pre-travel system and within two weeks we were able to bring that proportion of people who are positive back to a manageable level and convince those in charge of quarantine to start accepting people from India again. It was a huge step and as I said, initially I did not agree with it but that was the rationale.
MIC CAVAZZINI: You mentioned quarantine. Australia was one of the first countries in the world to implement a mandatory quarantine on entry and this is credited as one of the main reasons Australia avoided the infection rates seen abroad. People were restricted to designated hotels for 14 days and permitted to leave on providing a negative COVID test. But still, there were dozens of breaches, both in Australia and New Zealand some of which led to community lockdowns. And you ended up with this ugly political stoush between Feds and states as to who was to blame. Catherine, in your report it’s written that quarantine is a responsibility of the Commonwealth under the Biosecurity Act. But the implementation was palmed off to states and territories, who then sub-contracted to hotels and security companies not really set up for this role. Going forward, is there a common standard that all jurisdictions would be signed up to?
CATHERINE BENNETT: Yeah, look, quarantine was really interesting. It was something that—and I've talked to James about this in the past as well—but you know, it wasn't really factored into our plans. We didn't have a detailed playbook on how to go about this. The decision was taken unanimously and quite quickly with our National Cabinet, it was put in operation very quickly.
The Commonwealth coordinates, you’re right, has that responsibility for quarantine, but it doesn't have a frontline workforce. So, it has to be in partnership with states. And states approach it differently in different states. Victoria and New South Wales were always going to be under the greatest pressure. I think it's worth mentioning here too that the Australian government didn't go for a COVID zero plan. They always knew we were going to get incursions across the border. You cannot allow people in in the numbers that we have without expecting, you know, some breaches at the border. So, but also we didn't—you know, it was a bit ad hoc initially, and there were problems around training of people and so on to actually try and get the best out of the border controls we put in place.
So, I think a lot of lessons were learned and even in Victoria where, as Paul said, we had a couple of breaches in the middle of 2020 that led to that second wave in Victoria, some really good work was done then learning from that and trying to know share that information across borders. Unfortunately, at the same time there was some building resentment about some states apparently not controlling things as well as others or posing a risk to other states. And so, what had started as a really unified approach did break down in the second half of 2020, which was really unfortunate.
The other thing was, of course, some states went down the path of setting up purpose-built facilities. We had Howard Springs which naturally lent itself to being a quarantine station. It wound up having some of the best outcomes with a high turnover of people passing through, whereas hotels had intrinsic problems in trying to manage indoor closed corridors and so on. So, there was that element. Now that's a really difficult thing to invest in because you have to keep investing in. Quarantine facilities aren't just physical facilities, it's about the people in them.
But the other thing, and think we'll come back to this later, was also the impact of quarantine varied. So people who came into quarantine with mental health issues, for example, people particularly traumatised by their own circumstances of being in quarantine, sometimes travelling because they had an unwell or dying relative, all of those things actually made them very complex kind of community enterprises, if you like, with people working there who were also working under really difficult conditions. So, I think we didn't have the plans in place that we needed. We've learnt a lot from the past. Whether we ever go down this path again may not be necessary if we've got technology supports that allow people to quarantine at home and so on.
And a final point on that actually, when they looked into quarantine and isolation for people who were known to be infected, even if they weren't particularly unwell, they generally did. So, I do think we can rely on the population to do the right thing as well in ways that we perhaps didn't at the start you know there was this sort of lack of trust in the community yeah
MIC CAVAZZINI: Yeah, the novelty of it, yeah. James
JAMES McCAW: So, two separate things. We did behavioural surveys throughout the pandemic asking the population about all sorts of things about their compliance, their sense of community and responsibility and all the way through the vast majority of Australians were committed and responsible. It was a story I said over and over again in the media at the time. And it pushes up against this narrative of people not being compliant or not trustworthy, which was prevalent but not true when you looked at the data on how people were actually choosing to behave on all sorts of fronts, from quarantine to testing behaviour, all sorts of things.
And then, just reiterating from Catherine, We can clearly make our quarantine systems more effective and more leakproof but we can't—we will never have a system which has no issues. One other thing on that is of when a leak occurs at least for the coronavirus most of the times it didn't start an epidemic. Just like say a bushfire analogy not every cigarette dropped out a window on a hot day start to bushfire but of course all bushfires or many bushfires will start from a cigarette so there's a an important point there.
MIC CAVAZZINI: No, I agree. I think there are a few opportunities to make that point. We've talked about closure of international borders. Now let's look around the friction of state borders. And to make sense of that, we need to know where the relevant legislation sits. The main one is the Biosecurity Act of 2015. A piece of federal legislation that has some components relevant to everyday matters, but also authorizes additional powers on declaration of a human biosecurity emergency. Paul, as the Chief Medical Officer, you were also the director of human biosecurity named within this Act. What godly or despotic powers did this include? And did that impinge on states directly?
PAUL KELLY: So, just to make it very clear, the CMO's role is mentioned and there's a statutory role within the Biosecurity Act. Some of the day-to-day things that you mentioned, are some decisions that can be made, are delegated by the Minister for Health to the CMO. But in the emergency setting, there are checks and balances. For example, in relation to the border closure with India for that period, there is a responsibility of the health minister to seek advice, and the CMO has mentioned in that, but it can be others, and now that's been changed to the CDC director.
To declare an emergency, though, is a Governor-General's power. So, it's the head of state that needs to make that decision. And in early February of 2020, I actually went with the then Minister of Health, Minister Hunt, to the Governor-General's house with a lawyer, to explain to the Governor-General what his, at the time, role was and responsibilities.
Once that emergency is declared though, it actually other than the Constitution, can override any Commonwealth or state laws, it's very broad. So, when you talk about godlike powers, there certainly is that. They were used, in a sense, sparingly, and quite specifically most of the time, and mostly related to the external border, airports, some issues around supply chains and a few other things to do with vaccines and so on but that was the extent.
Now, an emergency had never been declared and therefore emergency orders had never been issued up until that time of COVID. So, this was brand new, we were breaking new ground. And it's time limited, three months maximum. And if it needs to be renewed, then it needs to be re-argued. And we did that 73 times through the pandemic. Each time went through this process and so you know it's all documented. There is no—and this was repeatedly has been a concern in the parliament—there is no parliamentary oversight, there's no ability to examine or to override those laws from the parliament. So, it's a big deal. Having said that, you mentioned state borders. None of those 73 were in relation to state borders.
MIC CAVAZZINI: No, but it sounds like you could have overruled the states if you'd really felt gung-ho.
PAUL KELLY: We, yeah, and that came up. There was, you know, there was at one point a constitutional challenge. But ultimately they have their own powers, under their public health acts, in their state legislature, which they can use, which they did. And all of those state-based elements, including lockdowns, were done by the particular state authorities.
LORRAINE FINLAY: If I could just touch on something that Paul said about emergency powers, I do think this is an aspect of the pandemic that we haven't given enough thought to and reflection on. Because the process Paul described was very consultative and involved expert advice and reviews and transparency and looking at the evidence but, I'm not sure that was the case across the board throughout the entirety of the pandemic. And the reason I say that is WA is a great example. The state of emergency declaration lasted for 963 days and it lasted across a period where WA was hosting international sporting events and declaring that it was open for tourism and investment despite a state of emergency being declared.
And the state of emergency declarations are extraordinary measures that grant a lot of power to unelected bureaucrats, reduce parliamentary oversight, allow for really restrictive incursions into people's human rights, and they should only be used sparingly when they're needed and for the shortest amount of time possible. And in WA, for example, you had the extraordinary situation where the minister responsible for renewing those declarations admitted to parliament that he actually didn't review or receive any health advice from the chief health officer concerning the pandemic in respect to which the state of emergency was declared, it was effectively a tick-the-box exercise to just extend it on a rolling basis. That's a real problem and shouldn't be happening.
MIC CAVAZZINI: It is quite messy. There were some perverse episodes during the pandemic where overseas arrivals might have to quarantine first in Melbourne then in Adelaide. There were holiday-makers to New South Wales who risked being shut out of their home states because of snap border closures following an outbreak. Freight services were severely and in 2020, the government of Western Australia was taken to court by mining magnate Clive Palmer who claimed it was unconstitutional for them to deny his trucks entry. Strictly speaking he was right about that. Section 92 of the Federal Constitution makes it clear that that, “trade, commerce, and intercourse among the States, whether by means of internal carriage or ocean navigation, shall be absolutely free.”
The Federal Court and the High Court actually knocked that down and supported the WA government, but there were problems at the borders because of communities that were torn apart. Lorraine, you received many submissions from people living in regional towns who were denied access to their nearest hospital, unable to visit a dying relative. When these conversations are taking place in the corridors of power, rights-based arguments give an appropriate weight alongside the epidemiology or the economic arguments.
LORRAINE FINLAY: Well, it won't surprise you to hear a human rights commissioner saying no, they weren't. And I think that is a problem. And one of the things I think we do need to do in Australia is recognise obviously the public health component of this is incredibly important, but the human rights impacts also are. Because we can't just measure this in numbers and statistics. It actually is about human impact and the quality of human life and making sure that we respond in a way that is proportionate and recognises that one size doesn't fit all.
And in terms of the constitutional aspects, you mentioned the case brought by Clive Palmer in the High Court. Section 92 of the Constitution has never been interpreted by the High Court as meaning that borders are absolutely free in that sense. The Court has always allowed border controls or border restrictions to be put in place around section 92 in certain circumstances, again, when they're proportionate, not for protectionist purposes, effectively. And so, the ruling in that case made a lot of legal sense.
But I would also say in a democracy, what it actually showed is that it is far better for democratically-elected governments who are accountable at the end of the day to make those decisions about where do you draw the line, when should borders be closed, when should they be open, versus unelected judges who don't have that same accountability in a democratic sense.
And so, I think what the courts really said in those cases is that it's up to governments to make those decisions, their best place to make those decisions. But that those decisions need to be explained, reviewed and winded back promptly, and to my mind, that's the lesson that we really need to learn from all of this, that there will need to be hard decisions taken in emergency situations, but you have to have those fair and compassionate exemptions built into them.
CATHERINE BENNETT: Just a broader point also about domestic border closures. There's sort of this assumption out there that it was done for health reasons and we didn't think through all the others necessarily. But in fact, as an epidemiologist, it was one of those areas that I found really confusing. You can't put a line down a street in the town or a bridge and not allow people to cross for work or for the rest of their family that live a kilometre away but are suddenly out of bounds.
We also had another famous example where we had a miner who lived in central Victoria, zero COVID in the area at the time. They were flying into a mine in the Northern Territory and we were very concerned about our remote communities. This person had to fly via Brisbane, when they got to Brisbane, they were forced into hotel quarantine. They only needed to be there for one night, but that was enough to inoculate them with SARS-CoV-2 and then send them with the virus into the Northern Territory and that's something we need to think about.
There was this sort of almost moral high ground in the end about, “Well, our state, need to protect it from those awful people from the South who might be bringing the virus”. But in fact, our border controls should be like a double door extra protection, not actually putting people at higher risk when they come from a zero-risk home. And so, I do think epidemiologically and from a public health perspective, we didn't get that all right and we need to do a lot more in that space so that, we never repeat some of those mistakes.
PAUL KELLY: Just to follow up from Catherine's anecdote there, that was one of the more frightening moments for me in the pandemic. I really thought that we were going to lose control of the COVID pandemic, starting in the Tanami Desert, one of the most isolated places on earth, frankly, but certainly within Australia. There were over a thousand contacts that needed to be—that had flown out of this same place when that guy arrived, to every state and territory and internationally. Ultimately, he was isolated and there was no ongoing risk. But yes, was one of those interesting things and it talks to that issue of proportionality. It was ridiculous that he needed to do the quarantine that he did in Queensland overnight.
MIC CAVAZZINI: Paul, in 2024 you were appointed director of the much-anticipated Australian Centre for Disease Control, at least an interim form. After 40 years of being talked about, the ACDC will become a real thing in 2026, reporting directly to the Federal Minister for Health. I don’t know if it would have any authority over state jurisdictions but how well would it help navigate these issues around borders and quarantines that we’ve being talking about?
PAUL KELLY: The CDC, great fanfare. I was privileged to be the head of the interim CDC there in 2024. And when I retired from CMO towards the end of that year, others took that on and the important task of getting the legislation through the parliament and the final stages of the plan. It's kept pretty closely to the original ideas that we developed from 2022 to 2024. And so, I'm really delighted that it did, in fact, start on the 1st of January, so it's into its fourth week now. There has been an appointment of the Director General who will be starting in a couple of months. And I think that will be very important. And there will be a coordinating function there in terms of nationally-consistent guidelines and pandemic preparedness and surveillance and so forth for infectious diseases, initially, and then a more broader remit as time goes on.
I don't think we should be hopeful that in any way this would change what might happen in the future in terms of states going in their own direction. They, as the High Court has said, they are sovereign states and even under our Constitution they're allowed to make their own decisions. They have their own parliaments, their own elected representatives and they will do what they do. However, my sense of it is that the CDC can be a bit more bold now that it is an independent agency, and hopefully they will take that on and actually provide better guidance and rapid assessment of threats as they turn up in a way that all the states don't have to do eight times like they do now in the states and territories. And because they'll be a trusted place with great experts and expertise and a track record of doing that in peacetime, hopefully the next time we have a pandemic they will be trusted and seen as experts and help. But they're not a panacea.
MIC CAVAZZINI: One of the most encouraging outcomes of the COVID-19 pandemic was to see release of a brand new vaccine a year to the day of the disease outbreak in China. Australia started distributing vaccine from February 2021, and within a year, most of the adult population had received at least one dose.
Having said that, a worrying social phenomenon of the worrying social phenomena to come out of this experience was vaccine hesitancy. To understand that better, it’s important to lay out some fundamental stats associated with vaccines against SARS-CoV2.
Being vaccinated against the virus doesn’t eliminate your chance of being infected but it does reduce the viral load you build up. That directly determines how sick you get and how likely you are to pass the infection on to someone else. But these are not fixed values. As you’ll hear from Professor Bennett later, the balance between community risk and personal risk shifted over the pandemic.
The benefits of vaccine are clearly seen in the population data from the earliest phase of the rollout. Hospital admission records from five and a half million people across Scotland showed that a single dose of the Pfizer-BioNTech or Oxford-AstraZeneca vaccines reduced the risk of hospitalization to almost zero.
[In another paper in the Lancet Infectious Diseases, computational models suggested that 15 to 20 million lives were saved in the first year of the global vaccination campaign.] As Gideon Meyerowitz-Katz from Wollongong University has put it in one of his great explainers, “There are many countries where vaccines prevented more than 1 death for every 100 people [vaccinated], which would make Covid-19 immunizations arguably the most effective medical intervention of the 21st century.”
But these observations I’ve shared have a fair bit of hindsight bias from the viewpoint of an ivory tower. In the thick of the vaccine rollout, with all the panic in the air already, it was understandable that some members of the public would be sceptical of taking a new drug that seemed to have been rushed out the door. Particularly in the face of emerging adverse events that hadn’t turned up in trials. But this wasn’t because of any shortcut in safety testing. It just came down to simple maths.
The Oxford-Astrazeneca vaccine was approved in the UK on the 30th December 2020 and it was listed by the Australian drug regulator several weeks later. Early trial data collected to that point represented fewer than 9,000 vaccine recipients with no serious complications observed. Even from a Phase 3 trial on 22,000 Americans concluded in March there was no sign of this blood-clotting side effect that would come to paralyse deployment.
Instances of vaccine-induced immune thrombotic thrombocytopaenia or VITT were first detected only with the mass public rollout of the Astrazeneca vaccine. Denmark was the first country to suspend its administration on the 11th March, and it was soon followed by Austria, Italy, Ireland and some other countries
Australia’s first case of VITT occurred on the 1st April, a 44-year-old man who had blood clots in his gut, his liver and his spleen. Two weeks after that a 48-year-old woman died from the same complication. After a second death in June, it was announced by ATAGI, the Australian Technical Advisory Group on Immunisation, that AstraZeneca vaccine was no longer the first line option for people under 50. The challenge was that alternative vaccines were still in short supply.
The rate of thrombotic thrombocytopaenia complications internationally settled at 3 cases per 100,000 vaccine recipients, and the rate of death at around 1 in a million. For recipients of the alternative mRNA vaccines, myocarditis was a serious complication which occurred with a similar frequency as VITT.
For those of us who live and breathe public health that doesn’t sound like such a high risk, but for the general public you can see why it might have felt like an unnecessary punt. There were many people who didn’t realise that infection with SARS-CoV2 was all but guaranteed once variants of concern started circulating and that the infection fatality rate averaged at 1 in 130 for an unvaccinated 60 year old.
But that IFR dropped off exponentially in younger people. For a 45-year-old like me, the risk of death from COVID-19 would have been around 1 in 1000, which was several hundred times higher than the chance of dying from vaccine-associated complications. But if I’m well and feel like I have control over my circumstances, how do you convince me to step up and take my chances with this new vaccine? I asked Paul Kelly how such risks could be better explained to the public.
PAUL KELLY: So, if I was to list the worst days of the pandemic, the one that you described about the decision to restrict AstraZeneca vaccine was one of them. And there's so much, we could fill a whole podcast in this. The issue of risk communication is something I've read a lot about and practiced for more than 20 years. Just how the theory played out here was exactly, again, able to be predicted. And there's an issue of hindsight bias here remembering where we were at that time. We had no COVID at all in Australia. There was we were having these double donut days, we called them, you know, no cases, no deaths. And we were introducing something, whilst it wasn't mandated, there was a very strong social push and political push for people to get this vaccine so we can get back to normal. That was the that was the narrative at the time.
We were giving something and yes, the risk was very low, but it wasn't zero. The personal benefit of that vaccine was cloudy for the reasons we've all talked about. You know Australians were very insular at that time and so, they didn't see the benefit. They saw a risk, even though it was low. And those are exactly what Peter Sandman, who's person who's written most about this particular issue, talks about risk being hazard plus outrage. I think it's times outrage. So, people who feel they're not in control, that they don't see the benefit outweighing the risk, it's something unknown, that really highlights that outrage and makes a perception of risk much higher.
And so, for all those reasons, even though it was a very difficult decision, I think it was the right decision which was made. The wrong decision was to make the, do the press conference at eight o'clock at night. It was the only time we did one after hours. We had the Prime Minister, the Health Minister and me standing up saying, “Look, it's not so bad, but just in case”. It was the wrong message. “It's not so bad, but—Most people can still take it, but—” And then we had one state CHO come out that next morning saying, “there's no way we're going to have 15 year-olds dying in unnamed state”. And they banned it, they banned it completely, the use of that vaccine. And that was the only thing we had at the time. Anyway, tough day. Thanks.
CATHERINE BENNETT: And I think there were some real challenges here. One was that the people who were most at risk, potentially, from an adverse reaction to the vaccine weren't the same people who were at most at risk of severe disease from infection. So, there was a bit of an imbalance. We were looking at trying to control disease in a population and vaccination did still change people's risk of being infected and onward transmission, but not as much as it did during the original trials with the changing variants.
So, all those things were challenges but at an individual level we were arguing that actually infection is worse—and all the numbers that were coming out supported that—than the very small risk of having a serious adverse reaction to a vaccine, but at a time where Australia was working really hard to have no virus circulating. So, in people's heads, it wasn't ubiquitous, it wasn't a certainty that they would be infected. And so, they were kind of grappling with that disconnect as well.
But we should also remember that a lot of the public health messages particularly in certain jurisdictions like Victoria, really did focus on a fear campaign to try and keep people compliant and that bled its way into our vaccine programs as well. And the other part to that was the counter information being provided by a very organised anti-vaccination program that was then supported by a reasonable-sized portion of the community that were just uncertain and expressing those uncertainties and being then vulnerable to, you know, not being able to detect what was valid information and what was not. And so, it was a very confused information world.
And finally, the fact that actually the health consequences weren't just from infection, it was from an overloaded health system. And a lot of the decisions that were put in place were trying to protect hospitals. And my biggest frustration to this day is that people say that they weren't overloaded so therefore we didn't need those interventions. But, of course, they weren't overloaded because we had the interventions and thankfully we'll never know how it would have played out here but also you know we saw what did happen in places like Italy and others in New York you know in the US.
MIC CAVAZZINI: My family is Italian and so I asked my paediatrician aunt what the response of Italians was like to vaccine mandates and lockdowns. And, you know, Italians are famously shy of big government and speed limits and taxes. But she said that everyone was aware of the bodies piling up in the morgues and ice rinks. So, they were quite compliant, even with lockdowns of 200 meters from their door. So that availability heuristic, Catherine, that you mentioned.
JAMES McCAW: So it's well known that people, general people in the population actually have a great deal of trouble evaluating risks. And not just actual versus perceived risks, but what does one in a thousand mean? What does one in a hundred mean? One of the challenges that we faced during COVID was actually just tied to that there are some ways of presenting certain numbers that make it look like, say, the vaccines were risky, but they were just ignoring, they were just incorrect calculations. And the correct calculations which showed that the vaccines were highly effective are just another number. I can't say how we go about explaining those things apart from, in my view, it goes back to literacy education all the way from our education in primary school and onwards and helping develop a society in which people understand how to critically engage with material and I think it's that sort of question which is not my area but I think that's where a lot of this the solution to these conundrums lie.
MIC CAVAZZINI: Catherine, I'll put the next question to you. I still haven't grappled with how to weigh up this idea of vaccine mandates. I mean, no one was strapped down and forced to undergo medical intervention against their will, and that's, of course, enshrined in the Geneva Convention. But people working in government jobs and public-facing settings did have to get vaccinated to keep their jobs. The Human Rights Commission did hear from police officers and teachers who did choose to give up their jobs and received comments such as, “Being forced to take a vaccine under the threat of losing your job does not constitute consent”. I don't know if that's quite right, but it does create this two-tiered system, that a professional keyboard warrior like me can easily work from home in my quiet apartment, whereas people in front-line jobs and services that keep society ticking over might not have that luxury. How do think we should weigh that, play that next time to be more fair?
CATHERINE BENNETT: So, I think there were sort of tiers, layers to this. There were mandated vaccinations as part of occupation. I don't know that anyone chose to leave their job to not get vaccinated. I think they would say they were forced because the alternative was unacceptable. There were shadow mandates. So, you couldn't go and have a cup of coffee other things, there were limitations on people that actually spread through to children. So, a teenager might not be able to go out with their vaccinated parents to a cafe if the parents decided they didn't think it was necessary for their child to be vaccinated. And then there was the availability of vaccines. And sometimes there were frustrations there that people felt particularly vulnerable, were struggling to access vaccines. And we did have a vaccine supply challenge. But I do think you have to separate recommendations about vaccines from mandates.
The other thing we had to do was acknowledge that very quickly, as we were reaching the end of our rollout, we were hit by Omicron and that did two things. One was it made it more necessary to have a booster because you really didn't get the same effect from your primary course compared to previous variants, including Delta. But the other was that it then meant that everyone was going to get infected. You know, it was actually going to push up our infection rates very, very quickly. And that then narrowed the gap between someone acquiring immunity through infection, unvaccinated and vaccinated. And a few of us were saying that, depending on how the BA-1 wave, Omicron, travelled through community, you had to watch that because it changed the arguments for having mandates around occupation. If people had acquired immunity through infection, the difference between that person as a risk to themselves from infection and the kind of duty of care to that person as an employee who might be exposed in their workplace, but also their risk to other people, all changed—not Western Australia, that was still closed, but in the open states.
And we also knew that we had waning immunity, so the value of a vaccine, and was it the booster was the timing from the last booster how do you manage that, became more tricky and complicated as it went on. But that should have basically undermined a case for mandates, occupationally-based mandates, earlier. Perhaps not in healthcare that's a special area, I think, but probably by that stage by you know not far into 2021 we really didn't have an epidemiological argument for people who were you know whether it was frontline police or firefighters or teachers.
MIC CAVAZZINI: How coercive were these nudges, Lorraine, with respect to other policies we have like the No Jab No Pay, which is a federal policy that requires people who want to receive family benefits to vaccinate their kids on the National Childhood Immunisation Schedule. At state level you can be barred from enrolling your kid at public education centre, if you haven't had the shots they. We call this no jab no play. Were these mandates with the COVID-19 vaccine so much more coercive?
LORRAINE FINLAY: In terms of coercion, you said originally no one was strapped down and forcibly injected. That might be true, but the people we spoke to said, well, “if I didn't get the jab, I lost my job.” People did feel in certain circumstances that they were forced to get a vaccination and they wouldn't have had otherwise and it did have real impacts.
And I think the other really important aspect of this that Catherine touched on around misinformation. One of the real challenges when responding to misinformation is to ensure that you don't respond in such a way that every concern that's raised, every question that's asked is then lumped into the same category. And I think that's partly what did happen in relation to the questions around vaccinations because it became very easy for anybody who was expressing doubts to be dismissed as, “you're just a conspiracy theorist” or you're just, you know, “not in it with the community, not doing the right thing” when actually people had legitimate concerns and legitimate questions.
You know, one of the ones that really stuck with me that we referred to in the report was the young woman who was pregnant and was really concerned about not knowing the impact that the vaccination would have on her unborn child. I think that's an entirely legitimate question to ask, a really legitimate concern to have. But all of the heat around the vaccination discussion meant we didn't engage in those conversations, I think, in a way that showed a level of trust across the community and a recognition that there were legitimate concerns out there.
MIC CAVAZZINI: James, what did you want to add?
JAMES McCAW: Yeah, I just want to circle back and really, from a sort of the numbers side of things, really strongly agree with what Catherine said about how the nature of the vaccine and how its epidemiological action was changing, it was dynamic through the pandemic and therefore the scientific rationale or reasoning for different sorts of responses was changing rapidly. And this is actually something that we had excellent information on from around the world and in Australia. In real time we were able to see how rapidly immunity was being developed through exposure, even subtle things like if you got infection prior or following vaccine, what vaccines you had. We had information on how this changed your own risk if you were exposed and your risk of spreading it onwards. And we were able to incorporate that information int the advice or the scientific background information was then provided into the decision-making processes. And so, I'm very clearly separating the scientific knowledge from how it was or wasn't used and then how government did or didn't respond to the advice. There's three layers there.
MIC CAVAZZINI: Well, has the knowledge changed now in terms of should we be prioritising the elderly who are more likely to die or frontline workers and younger people who more likely to spread it?
JAMES McCAW: Well, I mean, SARS-CoV-2 is in the past. The next pathogen or pandemic will have different characteristics. But the ability to work through these problems rapidly, make the best use of the epidemiological data and clinical data as it arises is rapidly improving.
CATHERINE BENNETT: And just following on, thinking about how we face the next pandemic. And as James rightly says, it will depend. There will be different parts of the community that might be impacted. Based on mixing patterns, we know who are more likely to spread transmissible diseases. But at the same time, I think there were things that we did miss. And our traditional approach to providing advice through ATAGI on vaccination is at an individual level, it’s based on risk of exposure and risk of severe consequences of exposure and we did that again here. So, it did have a sort of a population view in that it was looking at those areas where there was potential risk but it didn't come at it from a decision around how to best distribute a limited supply of vaccine for maximum benefit for the whole population.
So, we had outbreaks occurring in a repeatable pattern that identified the areas that had a higher transmission potential. So even where the outbreaks hit, we knew where outbreaks were more likely to seed and where they would get footholds and where they would take off in community. Did we prioritise those communities? You know, in New South Wales and Sydney, it was out to the west in particular. In Victoria it was also the north and south-east where we had a lot of our casual workers, where you had that exposure coming back and impacting a population.
We also had immigrant communities that weren't all engaged in the same way in the health system. A lot of them, we found in the inquiry, were getting their information from overseas so we didn't have control over even what they were hearing. But they had the biggest impacts. They had the earliest outbreaks, the largest outbreaks. If they had access to mRNA vaccines that had a shorter interval between the first and second shot, it could have actually made a difference to those communities and it would have benefited the rest of the population because you would have been putting the hose at the seat of the fire rather than having a priority system that was sort of distributed based on personal characteristics but not on community dynamics. So, I do think that's something that we really need to focus on going ahead is looking for opportunities, particularly when you just can't vaccinate everybody really quickly, to be as smart as we can and to offer protection both direct and indirect that gives us the best outcome for as many people as possible.
MIC CAVAZZINI: Thanks. Yeah, that was the kind of perspective I was looking for. Of course, it's, I guess it's hard to do that in a changing way without seeming arbitrary. Paul, in all the pandemic debriefs I haven’t heard much about the COVID-19 Vaccine Claims Scheme. This was supposed to pay compensation for specific harms caused by the vaccines including thrombosis, capillary leak syndrome, Guillain Barre Syndrome, myelitis... In an ABC report from September I read that 522 claims had been approved. But five times as many had been denied and over 700 remained unresolved. One woman told reporters she’d spent tens of thousands of dollars on appointments and medications for pericarditis but wasn’t eligible for compensation because she’d never been admitted to hospital, despite many presentations to ED. Another guy who had lost the ability to work did get compensated but only after a year-long battle and a thousands pages of supporting documents. How would we do this better? I know that your deputy Nick Coatsworth has expressed some regrets over it.
PAUL KELLY: Very important issue right now. So, I know that that compensation scheme was set up. It's time limited. I think it will be finishing if it hasn't already. So, it's only [for] vaccinations against one disease, not more broadly. There are a number of compensation schemes for vaccination and much broader than COVID in some countries. So, there are there are various schemes, one of which is being dismantled in the US, for example, which has led to essentially indemnity for vaccine suppliers and a public scheme which supports the vaccination program in the US. And two caveats I should have put before I started talking about this. One is I'm still a named respondent in a class action with regard to compensation for vaccine harm. So, that is going through that process. So just note that. The second thing is I am actually a member of ATAGI now. I wasn't at the time of the COVID pandemic but I am. And so, any views I say here are my own, not representing a ATAGI.
In Australia there's been many many years, probably at least as long as calling for a CDC, to have a true compensation scheme for vaccines broadly, not just COVID. And the reason for that comes back to another important component of public health action, which is reciprocity. So, we talk about proportionality, we've talked about it several times. Reciprocity means we are asking you to be vaccinated for the good of society and society has a responsibility to compensate for the people that are harmed. And like, vaccination is part of the public health project.
We all, well I did, signed up when I graduated from medical school, to the Hippocratic oath; “First do no harm.” And in public health that is not possible 100 per cent of the time. And I remember being asked at one of the 52 times I was grilled by the Senate in various formats around vaccines, you know, “Can you hand on heart say that vaccines don't harm anyone?” And I said to the Senator at the time, “Of course I can't, Senator, that there is harm sometimes, it's very rare, and that's taken into account”. So, given that, it's a no-brainer for me to have a compensation scheme.
Now, how you actually set that up and where you put the lines, you mentioned some figures there, Mic. It's open to abuse and to people having spurious claims. So, there has to be some guidelines around that but where you've set those guidelines is the real challenge. And much of that is political and financial rather than health or medical decision-making, as it should be. We've talked already about the fact that it should be democratically elected people that are responsible for these really difficult decisions. And I can say that both sides of the aisle in the parliament are against these sort schemes. For the reason of political and particularly financial risk and that's a matter for advice that come from other parts of government. So, I hope that answers the question.
MIC CAVAZZINI: Yeah and again, in that ABC article from September it was reported that $40 million dollars had been disbursed, which doesn't sound like a huge lot compared to the, was it $80 billion on the work job keeper?
LORRAINE FINLAY: It was a lot more.
MIC CAVAZZINI: Yeah, the billions disbursed in the JobKeeper subsidies.
PAUL KELLY: It's a drop in the ocean.
MIC CAVAZZINI: And it averaged $77,000 per claim. This might be appropriate for some harms, but one family who received a mere $70,000 after the death of their 34-year-old daughter from thrombocytopaenia obviously was jarred by that. That was one of 14 deaths attributed to vaccine side-effects up to February 2023, from over 20 million vaccine recipients. This penny pinching seems like a false economy when you consider how priceless trust is.
CATHERINE BENNETT: I think that point is a really key one. You can't buy trust, but you can lose it. And the fact that that was slow to be put into effect and was opaque to a lot of people, I think played into the hands of people that were arguing that there had to be something wrong, why else would you provide indemnity and it gave some of the misinformation out there more credence because it seemed to start to fit with this sort of broader story about it.
And finally, just on Paul's point, you know, there is this assumption that people will game the system so you have to put protections in place. But we made some really key and expensive decisions in the pandemic around compensation to business. And we know, know, some big businesses did quite well out of that and there was no way to follow up because it was set up in a way that said, “Well, that's probably going to happen, but we need to do this very quickly”. But it's interesting that when it comes to something so close to the heart, when it comes to trust in the community, not just for the impacted individuals, but for everyone else watching it, that we actually seem to set those very tight. Whereas other countries like Japan had a broader approach to it. And you know, you could, in fact, buy trust in this situation.
MIC CAVAZZINI: Yes, a rare opportunity.
CATHERINE BENNETT: And having a timely and more generous I think approach to it would have been worth its weight in gold.
LORRAINE FINLAY: Yeah, and I think Paul summarised the principle at the heart of this really effectively and the principle is really simple. You know, if we're, as a community, if we're asking individuals to take on a risk for the greater good, to protect the community as a whole, then the community actually owes those individuals the proper support when things go wrong. And I think the real difficulty here is that we have a system where there is a lot of confusion around it. It feels as though there's been slow acknowledgement of adverse events. The scheme feels opaque to a lot of people. And ultimately, it shouldn't take year-long battles and thousands of pages of paperwork to get basic recognition and support when what you were trying to do was the right thing by the community and what you were told you were meant to be doing.
I think it's important not just for the individuals who are adversely affected, but actually there's a broader community trust component because I think the community as a whole needs to feel confident that there are those supports in place, that they can have that trust in the broader system and know that when things go wrong, people will be protected and we will do the right thing by them. And again, it feeds into this broader conversation we've been having around the pandemic where unfortunately, I think a lot of decisions that may have been taken with the best of intentions or that may have been taken for a whole variety of good reasons due to the really difficult choices that had to be made have ultimately led to this erosion of trust.
A lot of the people we spoke to said well, “We didn't feel as though we were trusted. We felt as though we were forced to do things that actually, if you've just taken the time to explain it to us, to give us the information, to let us make the right decisions for ourselves, our families, our communities…” And that's where when it comes to vaccines, I fully accept they save lives, they're absolutely vital tools for us to have. But from a rights perspective, persuasion is always better than mandates because the fear I have is what we're seeing in Australia now because of the loss of trust, the erosion in that sort of community spirit around the pandemic restrictions, you're seeing that play out in vaccination uptake rates now across the board and that has really significant public health impacts.
MIC CAVAZZINI: That was Human Rights Commissioner, Lorraine Finlay ending this episode of Pomegranate Health. I just want to share some parting observations from her report about the legality of vaccine mandates. In September 2021, up to a sixth of NSW Health Staff reported being reluctant to get vaccinated. Ultimately courts have found that such mandates can be lawfully upheld in high exposure settings but “Australian cases have largely focused on questions of lawfulness from an administrative or employment law perspective, rather than from a human rights law perspective.”
Further to this, “Safe Work Australia and the Fair Work Ombudsman released guidance in February 2021 suggesting that most employers would not have a right or obligation to require employees to be vaccinated against COVID-19.” We’ll see what legal and political test vaccine mandates might go through next time we face such an urgent threat
I also want to thank Profs Catherine Bennett, Paul Kelly and James McCaw for being so generous with their time and insights. In the second part of this series we examine the effectiveness and the tolerability of other non-pharmacological public health interventions including lockdowns and mask mandates. I hope to catch you then, I’m Mic Cavazzini, recording on the lands of the Gadigal people of the Yura Nation.