Transcript
MIC CAVAZZINI: Welcome back to Pomegranate Health, I’m Mic Cavazzini. This is part 2 of our series on “Dealing with the next pandemic.” It’s an examination of what public health got right in responding to COVID-19 and what we might do differently next time.
We already discussed how international border closures did protect Australia before vaccines were widely distributed. On the flipside of that was the overcooked parochialism between the federated jurisdictions. We also discussed whether vaccine mandates were an acceptable onus to put on the public or whether, instead, they squandered trust and buy-in.
Most people did roll up their sleeves and get the jab and serious adverse events fortunately impacted only a tiny fraction of vaccine recipients. However, the burden of social measures, especially stay-at-home orders, was one that was felt by the majority of our urbanised populations at some point. These resulted in measurable impacts on physical and psychological wellbeing that we need to consider before deciding how hard we’d go in controlling the next such pandemic.
In the previous episode I said up to 50,000 lives were spared thanks to our strict non-pharmaceutical public health interventions in the three years up to December 2022. That’s a crude estimate from looking at the mortality rate seen across the European Union or in less severely affected American states which averaged around 2800 deaths per million. Multiply through by Australia’s population and that gives you a potential death toll of 74,000. Subtract from that the thirteen and a half thousand deaths that actually occurred and that’s how you get a possible 50,000 saved.
If that sounds generous, take a look at the Burnet Institute’s retrospective analysis of Melbourne’s Delta wave of August 2021. This shows that without social restrictions, at least 16,000 more lives would have been lost in that one outbreak. I thank lead author Dominic Delport of the Burnet Institute for explaining his work to me.
The case fatality rate for COVID-19 started at 5% in some countries and then dropped to as low as 2% by the second year of the pandemic. It was so transmissible because people infected with SARS-CoV2 could be shedding virus for a few days before becoming symptomatic, if they ever did. So the true infection fatality rate would be an order of magnitude lower .
By contrast, people infected with the 2002 SARS virus or the 2012 middle east respiratory virus would be sick in bed or in hospital by the time they became contagious so there was much less community transmission. But they were deadly. SARS virus killed 15 percent of around 8000 confirmed cases while MERS killed 34 percent of the two and a half thousand people it infected. It’s quite possible to imagine a future virus with a more wicked balance of virulence and transmissibility.
These are the sorts of numbers that we need to sit with, and take ownership of, if we’re going to advocate for personal freedom and dignity over strict public health social measures. A valued perspective in this discussion this came from lawyer Lorraine Finlay, who co-authored a sociological and legal retrospective titled ‘Collateral Damage’.
LORRAINE FINLAY: I'm currently the human rights commissioner at the Australian Human Rights Commission.
MIC CAVAZZINI: I also welcomed Professor James McCaw from the Uni of Melbourne School of Population and Global Health. He is one of the computational modelers who contributed to Australia’s National Plan, a roadmap for easing of social restrictions as vaccine coverage increased.
JAMES McCAW: And from around 2005 actually worked periodically on about three revisions to our health management plans for pandemic influenza.
MIC CAVAZZINI: Professor Catherine Bennett was the lead author of the Commonwealth Government’s COVID-19 Response Inquiry published in 2024.
CATHERINE BENNETT: My population-based research is really focused on transmission in community but also antimicrobial resistance.
MIC CAVAZZINI: Finally, I was honoured to have the frank and fearless contribution of public health physician Professor Paul Kelly, who was Australia’s Chief Medical Officer when the COVID-19 pandemic struck.
PAUL KELLY: I found myself in as a member of the Australian Health Protection Committee 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: For the purposes of this podcast I wanted to try understand which PHSM policies were individually more effective than others and which might not have been worth the hardship. In Australia, four tiers of increasing severity were applied at various times and there’s a good representation of their cumulative effect in the National Plan. This modelling was commissioned by the Commonwealth government to advise on use of non-pharmacological measures up to the point that herd immunity was reached. As discussed in the last episode, one way of expressing viral transmission rates mathematically is the R value. The basic reproduction number for the modelled variant of SARS-CoV2 was 8; 8 people infected for every new case. The aim of the game is to bring this number down, ideally below one, to stop an exponential increase in case numbers.
When the National Plan was published in August 2021, about half the population had received one dose of COVID vaccine, knocking the effective R value down by a couple of points. This is shown in the papers as a stacked bar chart, with another 4 points eliminated from the stack by introduction of “baseline” restrictions. This meant a cap on the density of people in indoor venues and a 70 per cent capacity limit at large sporting venues. Always in the background there was our contact tracing regime, or to give it its full name, Test – trace – isolate – quarantine. The idea of TTIQ was that if you tested positive for COVID-19 then public health staff would interview you about all your movements and interactions over the previous week and alert potential contacts to self-isolate.
What were described in the model as low level PHSMs required venues to keep records of entry and restrict seating density further. The model suggested this would bump effective R down by 0.3. Under medium level restrictions, people were expected to work and study from home if they could and concerts and non-essential travel were off the cards. This was predicted to reduce R by just a quarter of a point, but in combination, all the above measures could get effective R below 1.
That’s if contact tracing was working optimally. This was very effective at stamping out embers while the caseload was low, but once there were hundreds of new cases a day then there just weren’t enough personnel to follow up every single one. That’s when high level restrictions would have to invoked to get you over the line. This includes the infamous hard lockdown, meaning that only workers from nominated industries were permitted to leave the house for work. People could leave the house for essential tasks like shopping or care work but had to stay within a 10km or at times a 5km radius. School education had to be entirely online and outdoor exercise could only be done in pairs. The National Plan model also assumed implementation of night-time curfews which were used at various times in Melbourne but not other cities.
The tiers described in the model don’t map in every detail to the stages 1 to 4 framework that you’ll hear Professor Bennett refer to later in the context of Victoria, but that idea of an incremental impact on community transmission is what’s important. The modelling showed, as you’d expect, that by the time you reached 80 per cent of the population vaccinated, baseline density restrictions alone would be sufficient to stop the spread. For the first year of the pandemic, Australia maintained manageable levels of transmission without forced stay-at-home measures. But that all changed when the more transmissible Delta and Omicron variants hit our shores in 2021, particularly in the Victorian capital, Melbourne.
It was argued by some that that hallowed target of herd immunity was better reached by natural inoculation, let the virus rip through the community in one fell swoop, rather than putting millions of people through the burden of lockdowns. Later, I’ll make some attempt to quantify the psychological impact of keeping people away from friends and loved ones and even their school mates. But first, I asked Professor James McCaw to explain how accurately those decrements in effective R that I described earlier reflected the known efficacy of different PHSMs.
JAMES McCAW: So, there's a few important things here. One, these are based around as much of the data and evidence we had at the time, but of course the pathogen was not static it kept changing. And that's where the value of these modellings comes from. It wasn't the precise numbers, but it was actually the idea that as vaccine coverage increased, it allowed for reasoning on the benefits of maintaining the public movement restrictions, maintaining that system while the vaccine rolled out, such that when society was like freed up again and in that reopening strategy, that we wouldn't then have rampant spread of the pathogen which would put us back into a problematic situation where hospitals were under stress, the pointy end deaths that were avoidable were occurring.
MIC CAVAZZINI: That's a good point. The modellers don't claim to be savants, but it helps guide the policy and despite all the...
JAMES McCAW: I think there were some modelers internationally and in Australia who were making that claim, unfortunately. They were suggesting that they could precisely predict the future. They could build a model that was complicated and say that, “On this date, the numbers would be this”. And I think that's very poor science. That's my critique of broadly some people in this sort of modelling community. There were lots of new ID epidemiologists and there were people who came in who had the same technical skills as the group that I co-led with Jodie and a different group I co-led with Associate Professor, Freya Shearer, in my institute, but they didn't have the epidemiological and they didn't understand the value or the not value of modelling in terms of the decision-making process.
MIC CAVAZZINI: Well, all models are wrong, but some of them are useful. But despite all the argument over which model was better, Catherine, since the pandemic, there's been a lot of analysis over real numbers of infections and deaths, and trying to tease apart what real life, real-world impact these various social restrictions had. I've tried to wade through the literature and it's quite messy. Have you got a sort of confidence synthesis of that literature?
CATHERINE BENNETT: Yeah, look, I think it was the ascendancy of modelling and modelling has been used a lot to try and sort of unpack what worked and what didn't work since as well. Australia actually went on a different journey when it came to our developing an immune history as a population was very different to the rest of the world or most of the rest of the world. And we implemented a lot of our early decisions under the precautionary principle. So, you know, that's you don't wait for evidence, you do things that are likely to work and to do no harm.
But I think we got very comfortable there. And I don't think we were collecting all the data we needed, even to supply the modelers with what they needed in a concerted way, in a consistent way across jurisdictions, but also to evaluate what was working and what was not. So, if you put things in place, particularly as significant as curtailing people's liberties and movement, you really need—you know, we can't do any public health without having an evaluation built in and we really needed that. And it would have generated really useful data to both refine what we were doing to make sure that we were minimising it to get maximum effect. And most importantly, to communicate that to the decision makers and to the community.
So, what we heard in the inquiry was that people were willing to go through restrictions again, including vaccination—drops off a bit for vaccination—but the majority of people would still be vaccinated again, if they were given the evidence and it was communicated in a way that respected their ability, that gave it to them in an accessible way, that trusted them to actually make the right decision because they did do it this time.
I think we've got data that would allow us to know where outbreaks were occurring when we had restrictions in place, so where they were failing. We could potentially separate out what were additional controls that were about policing the containment on movement, not necessarily health-based. I think it was presented to the community as they're all health-based, but things like having a curfew. You didn't change the allowance to go out and shop or do other things for an hour, exercise and so on, but you gave them a shorter time frame to do it in so you actually pushed people together. So, there were things that actually were counterintuitive epidemiologically, they were all kind of packaged in together because some of that was supporting the policing that was to minimize movement and contain.
And finally, I just want to say one of our longest lockdown in Victoria of 112 days in the second wave, it was actually missed by most people, that the vast majority, two thirds of our cases, were either residents in aged care and workers or their immediate family contacts. So, in fact, it's really hard to measure the impact because for the majority of the population in Victoria, this was about keeping the dry grass watered so that if a spark landed from aged care, it wasn't going to start another fire. So that's using very strict lockdown to manage risk rather than to control an outbreak and internationally the view is lockdown should be used as a control measure not as a prevention measure so, you know.
JAMES McCAW: I'd really like to reiterate that. I’m in Victoria as well. And I wrote a piece in the Australian very, very strongly on this where I was critical of the Victorian government and saying that—because we actually had this data, there's this other part of my work which was very data driven—and we had that information and we were putting it to government that it wasn't, in my view, a necessary response to hold those lockdowns on for as long as they were. We took too long to start responding to that second wave in Victoria and then it took too long to adapt. And that's not a revisionist understanding, that's actually what was understood in real time by many of us.
MIC CAVAZZINI: That’s interesting.
JAMES McCAW: And one thing I think that's worth adding here is that early on in the pandemic when we had little understanding of the biology and the epidemiology and durations of requirement for quarantine or the probability of virus coming through we, and I think justifiably, needed to take a precautionary approach. And then as we learnt more about the pathogen, having the ability to more rapidly adapt policy is something that I think will serve us well in the future.
The characteristics of a new pathogen will be different and we'll have to learn that again. But the key is to have a framework, a management plan, that acknowledges the need for continual reassessment and therefore refinement of policy and I think that will help go a long way in helping us be brave and act early and then adjust our responses to minimise the collateral harms that Lorraine and Catherine have both teased out.
CATHERINE BENNETT: And I think it's a truism as well, James, that our waves last six to eight weeks, the main part of the peak, and often when something kicks off, you have to go in very early. So, we then move to these very quick short, sharp lockdowns, they would call them. And when they were analysed, as James said, not every spark starts a fire or every cigarette butt. So, you know, again, you need to learn from those to decide when you even put those in place.
But for bigger responses, by the time you put things in place, you're probably reaching the peak. And so, when things start coming down, then, “Oh it's worked!” But in fact, you know, maybe not. And finally, in Victoria, we overlaid masks in the latter part, or the mid part of the second wave in Victoria. So we had stage three and then we introduced masks and when you looked at the glide path of the infection, it impacted it actually brought that back to about one pretty quickly in the time frame you'd expect within two weeks of masks, but they went to stage four before because they just didn't feel they could wait for those results to come through.
And so even when that happened, they didn't use that to say, “Well okay actually we can pull back,” because stage four would have a lag time because infections take a week or two to be to present and then be recorded but we just kept on going. Whereas New Zealand actually contracted their interventions, made them more focused when they figured out what worked. So, I do think we tended to expand and then back that up with fear messaging to try and drive it home which then made it very difficult to pull back from that because you'd sort of painted yourself into a corner.
MIC CAVAZZINI: The findings that Professor Bennett is talking about came from a cross-sectional study of Melbourne’s Delta wave in mid 2021 and are published in the journal PLoS One. On July 23rd a mandate for mask-wearing in public places was implemented two weeks after a soft lockdown had already been declared. This gave researchers a unique opportunity to analyse the impact of the mask policy in its own right. Case numbers had been almost doubling every sixteen and a half days until they turned a corner with the introduction of the mask mandate even before stage 4 restrictions were imposed on the 5th August. Another Canadian study found a similar impact on growth rate of cases in Ontario that wasn’t seen in comparable provinces which didn’t introduce a mask-wearing policy.
And there’s an interesting case-control study conducted over 2022 in California. Almost 2000 residents were recruited after receiving COVID lab results on the condition that they hadn’t had a known case contact in the previous fortnight but had spent time in indoor public settings. When asked about their mask-wearing habits, those who claimed to have always worn a surgical mask indoors were a third as likely (aOR 0.34) to have received a SARS-positive lab result as those that never did. For those who specified use of an N95 mask the adjusted odds ratio was just 0.17. The authors of the Australian study did give the caveat that their findings didn’t necessarily say anything about the physical efficacy of masks. It could just be that wearing masks or seeing them around makes people more conscious of other social distancing and hygiene measures.
Now, none of the observational findings I’ve described were included in a 2023 Cochrane review which looked at a dozen randomised controlled trials of mask use in real-world settings. There were a quarter of a million participants captured in the meta-analysis from settings as diverse as university dorms during the US flu season, tents full of pilgrims congregated for the Hajj in Mecca and Bangladeshi villages over the COVID-19 pandemic. The authors concluded that people assigned surgical masks were only marginally less likely to get diagnosed with influenza or COVID-19 than those who were not. While these findings were leapt upon by libertarians opposed to masks it was never mentioned that the Cochrane authors raised concern the low or unreported levels of adherence to the intervention and poor blinding of outcome assessment.
Early on in the pandemic there was some of confusing messaging about masks even from the World Health Organisation and the US Surgeon General. And there was defensible concern over maintaining sufficient supply for health workers most at risk. Way back in episode 73 I explained also the origins of mistaken dogma that respiratory infections were transmitted only in heavy droplets of spittle. When the record was corrected with an understanding that SARS-CoV2 was capable of aerosol transmission, the haters suddenly had science on their side. Take for example, veteran Newscorp journalist, Adam Creighton, who Tweeted “Imagine having an IQ above 90 and thinking mask mandates stop viruses. Just like barbed wire keeps out mozzies.”
But of course, science is never that simple. Yes, it’s true that surgical masks have pores that are a few times larger than the smallest SARS orinfluenza aerosols. But masks also restrict airflow and have electrostatic properties that can trap particles. Australian lab experiments have shown that if you cough into a petri dish while sick with the flu, a mask will prevent viral RNA from being detected on the dish. We know that not everyone will take the advice to wear masks, or wear them properly, so further research and public education would certainly be informative. But it does seems plausible that better adherence to masks advisories and basic social distancing could’ve obviated the need for stay-at-home orders in some instances. Perversely, however, the same people who were most opposed to “draconian” lockdowns also didn’t want to have anything to do with so-called “face nappies.”
The Human Rights Commission reported that a quarter of 3000 Australians surveyed thought that people should have a right to refuse to wear a mask. Lorraine Finlay and colleagues did receive, in open submissions, legitimate and perhaps intractable concerns from people reliant on lip reading who were gravely impaired in their ability to communicate in public as a result of face masks. Public health is messy. Even with the best of intentions, every intervention will disadvantage some community, somewhere. And the messaging has to be simple. Yes, there were some silly rules about wearing a mask even when you were at the park with a friend, but introduce too many caveats and people get confused. In fact, one of the most commonly heard sentiments over the pandemic was that people just couldn’t keep up with the ever-changing advice. Catherine Bennett and Paul Kelly pick up from here with some general comments about how much we still don’t know about these behavioural problems as well as epidemiological ones.
CATHERINE BENNETT: And the data we have, like in Victoria collected in that second wave, particularly by the end of it we went out to the second ring of contacts so we could actually see how the virus tracked through those close contact circles, incredibly valuable, but it's all kind of long text. We don't have the data in a way that we can start doing some really smart analysis. But there is this opportunity to start to unpack some of that in a more detailed level.
So, when you come back to, you know, did curfew work, well how many outbreaks were seeded from events where know that someone was breaching curfew? If it's none, then why have curfew? You know, if it's not happening in that part of the community, if it was still being seeded out of aged care, we may never know what worked because it wasn't tested. Because there wasn't the virus going through the community to show where there were gaps in the policies or the orders in place at the time. So, I do think there's more to be learnt but I don't think we'll ever have the complete answer.
MIC CAVAZZINI Paul, you wanted to add something?
PAUL KELLY: Oh look, there’s so much to unpack there. Firstly, two Victorians talking. Victoria had a very different pandemic to Western Australia, for example, where I've been doing bit of work over the last month. And they tell us on one side, “Oh, the pandemic was terrible”. But then actually had two and a half years with not a single case in the community. So, they didn't have a pandemic, really.
A couple of things I'll pick up on there. One is, James, great insight into what models are and what they're not. Put that into a political sphere and then the way they were used at the time was sometimes quite disturbing. They were definitely seen as a crystal ball and the sort of, we got to reach this level of vaccination. I think it was 80 per cent, it was taken as black and white.
The other thing that was happening, and this is another hindsight bias issue, is all Australian governments were captured by the eliminationists at that time. This idea that we just needed to get rid of that very last case, we had to find that last case, and we couldn't lift any restrictions until that last case was found and got better and was not transmitting. And that’s just rubbish. That was never going to be the case that we would just magically never have COVID in Australia. New Zealand was worse, but that was certainly an issue.
So, what that led to, many of the things that have been talked about, it comes back to proportionality again, we did too much for too long through the pandemic. I think for some things we were quick, others not so much, but it was complicated at the early stages of that second wave in Victoria. I was part of those conversations. Partly because we had very little understanding about how our cities work, certainly at that political sphere. So, there was these ideas we could have hot spots. Remember hot spots?
JAMES McCAW: Yeah, it never made any sense.
PAUL KELLY: No, was totally ridiculous.
MIC CAVAZZINI: For the benefit listeners outside Australia, hotspots were sometimes declared around postcodes if there had been steep increases in case numbers among residents. These post-codes could then be subjected to selective stay-at-home orders which my guests explained by email were just guided by the political motivation to minimise social and economic disruption. But there’s no realistic way to geographically contain a highly transmissible virus in an immune naive population, and the hotspots were always swiftly followed by city-wide lockdowns.
The most egregious example of this took place in July 2020, in housing tenements in the northern suburbs of Melbourne. These nine buildings were home to a total of 3000 people many of them not native English speakers. With very little warning hundreds of police showed up to prevent people from leaving, before residents even had time to stock up on groceries. Food was brought in by Health personnel as the lockdown lasted several days but the Victorian Ombudsman later found that the lockdown violated state human rights law and ordered the government to pay $5 million in compensation to those affected. Another point relevant to the conversation ahead, is that we outright banned visits to aged care residences until vaccines had been widely administered. That’s because more than a third of all Australian deaths up to 2023 occurred in that setting, mostly in private facilities with poor standards for staff numbers and professionalism. Alright, back to Paul Kelly.
PAUL KELLY: You know all aged care workers are low paid and in insecure jobs, live in the poorer suburbs of Melbourne. They work wherever they work. And because they were in an essential industry, they were able to go to work. So of course it spread. And so, hotspots made no difference. Brett Sutton, the Chief Health Officer in Victoria at one point talked about, “the colander of steel around Melbourne”. That was one of the better quotes of the pandemic, I think. It was leaky.
But the public health orders in the states have to be black and white because they're enforced as laws by police. And then the other thing for the fairness factor. Regardless of what James was saying, that most people did the right thing, if there was any sense at that in those early days in particular, that we're all doing the right thing, but that person over there is not doing it, they need to be punished, That was a very strong or prevented by a law. That was a very strong narrative through that time.
We know that these things work though. It's a respiratory virus. If you lock everyone up in their house, as happened in other countries, for two weeks, you get rid of it. Until it comes back again. We saw that in China, we saw that in Vietnam, many other centralised countries. And the lockdowns, whilst they were very severe, even at stage four in Victoria, they weren't that. So, there's gradations of what is acceptable to the community from there. And that comes back to your original premise there, Mic, about which is the most effective. A lot of it's about introducing things that are acceptable as well as work.
And I really like the Singapore approach that they've put together in their new communicable disease agency where they describe it as LEGO. So, they've got their pieces of LEGO; it’d be masks, would be border closure, would be various other public health and social measures. And then add vaccine, which of course we didn't have at the time. And they had that and communicate with the public that these are the sort of things that we might use but it will depend on what the virus is much more than this kind of levels approach, I think that was too restrictive.
CATHERINE BENNETT: I also just want to make the point, which I think it's relevant here, is that in public health we never expect 100 per cent compliance. And you don't need it, you won't vaccinate everybody and it won't be 100 per cent efficacious. And likewise with masks and other things, if someone's infectious and they don't wear a mask that is a greater risk to other people. But, at the same time if they're wearing masks or most are it reduces the chance of that transmission event. What you're doing is you're kind of disrupting that transmission potential. So, I do think that's important because you can spend a lot of time focusing on trying to convert people who are unconvertible to actually comply, and it makes it punary and negative and so on rather than kind of reinforcing, “we're doing okay”.
I remember in Sydney when they had to keep extending their Delta outbreak precautionary measures and lockdowns and I was asked to contribute a piece to The Guardian I think initially and it was followed up the next day by the Sydney Morning Herald to talk about what was working. Because they had maintained an effective reproductive number in Sydney of 1.3 when it was—Delta was eight, you know, if it was uncontrolled or thereabouts. And so, it was working. So, they were still seeing more cases, but nothing like they would have seen if they didn't have these precautions in place. And no one was talking about that. They were all talking about why numbers were still rising and that not everyone was complying and so on. But in fact, it was a story of extraordinary control.
Victoria was a month behind in that wave—that started a month later in Victoria. And the media were focused more on, “Victoria’s doing better and they've got more strict lockdowns, we need stricter lockdowns here”. Victoria never achieved the same level of control in that Delta wave that New South Wales did. By the time they were caught up, 30 days, you line them up and they were epi week-aligned, they were always behind New South Wales.
Now, that was probably because there was more fatigue they'd had the second wave in Victoria prior to that they'd lost some of that community buy- in so it wasn't just about the measures. But it certainly wasn't just about ramping up the measures. It was clear information about what was working. From measures to immunity. That was the way out, that's where we were going.
And some of the quotes from the pieces I wrote in the weekend were used by Premiers the following Monday, and I think that was really telling, that we were helping people understand what's working, how it's working and how we're constantly analysing it, so we're not asking them to do things that are ineffective, but we're also focusing and doubling down on the things that are and bringing them with us so they know why. They got that and they needed it. And I do think that's where we can do a lot better next time and it will give people agency and that's what we try and do in public health.
MIC CAVAZZINI: When the sixth period of stay-at-home orders in Melbourne ended in October 2021, it was described as being the most locked down city in the world, having tallied up 262 days of stage 4 restrictions. I wanted to understand whether the sacrifices Australians made over that period could be justified at least in terms of epidemiological control or whether “the cure was deadlier than the disease”, as predicted by some commentators. I vainly thought I was going to come up with a synthesis of the evidence more comprehensive than any before it and that the numbers would not lie. That I’d be able to calculate the cost of PSHMs in some health economist’s best guess of QALYs lost and then weigh that against the lives that would have been sacrificed had society remained more open.
But there are just so many variables to tally up when considering excess morbidity attributed to the social restrictions and there definitely were interruptions to routine healthcare. In a synopsis for the NH&MRC it’s reported that up to June 2022 there were 345 excess deaths from heart attack, strokes and heart disease that would have been avoided by regular checkups. There was a roughly 8 percent reduction in cancer-related diagnostic and therapeutic procedures, and delays in screening may have resulted in 90 deaths. Each one of these deaths is certainly a tragedy for the family involved but the numbers we’re talking about are orders of magnitude smaller than the COVID-related deaths that were averted under these policy settings. It’s also worth noting that in countries like the UK, where COVID-19 was not being suppressed so aggressively, there were high levels of healthcare avoidance. And evidence that patients who attended ED departments for presentations other than COVID had poorer health outcomes than normal simply because care was stretched so thin.
The more hefty argument against lockdowns and other social restrictions relates to the psychological morbidity associated with curtailed freedom of movement and human interaction. [I do remember reading of an increased rate of calls to Australia’s national Kid’s Helpline as the pandemic took hold and emergency rooms in New South Wales also saw a 36 per cent increase in youth mental health presentations compared to the previous year. But there weren’t extensive lockdowns in NSW at the time so how much of this was just down to a broader climate of anxiety?]
A well-rounded systematic review of population surveys is the 2024 Lancet Psychiatry Commission on youth mental health which highlights interacting risks and also protective factors from different health systems around the world. The Uni of Melbourne’s Professor Patrick McGorry was the first of more than 50 authors, and to get a little deeper I pulled out two of the reviewed studies that were conducted in Australian settings using robust data sets. One 2022 paper from researchers at the ANU reported findings from a survey of three and half thousand Australians. Yes, psychological distress spiked with the onset of the pandemic and yes, it correlated to an increase in self-reported loneliness. But scores returned to pre-pandemic levels as social restrictions ended by then end of 2022 and this was not the only paper that identified such a correction.
Another Australian study published in the Lancet Public Health is described by its authors as the world’s first analysis on the effect of stay-at-home orders independent of other confounding drivers. They used data from the very large, longitudinal HILDA survey which includes assessments on the Mental Health Inventory. The study took a quasi-experimental design to compare Victorians who had experienced lockdowns in 2020 to people in other states who had not. This comparison showed a small, but significant deficit of 1·4 points on the MHI scale, which the authors describe as clinically relevant and “equivalent to that of major life events such as being laid off from work.” Across the population this meant an additional 2·6% of people being likely to test positive for a mental health disorder. Interestingly, the overall mental health impact of lockdowns was not driven by the populations that would have been considered most vulnerable a priori; adolescents between the ages of 15 to 19, older adults living on their own, or those with chronic physical or mental health conditions.
The message I take from all these data is not that lockdowns were harmless, but that they might not have been quite as heavy a cross as we expected them to be at the time. I drew the same conclusion when looking at findings around the effect of school closures on the educational progress of some 4 million children in Australia. Our strict policies meant that teaching had to be delivered online for periods ranging up to 36 weeks in Victoria. Much has been made of the increasing rates of school refusal by Australian teenagers though that trend was already on the way up even before to the pandemic. And it’s no lower in Western Australia where they only had three weeks of lockdowns.
According to an early forecast by UNSW Professor of Economics Gigi Foster the disruptions to classroom teaching would result in a deficit on lifetime earnings adding to billions of dollars and was, "tantamount to a ritualistic human sacrifice". While we can’t predict the future, we can evaluate the educational attainment of students on the national standardized assessments in literacy and numeracy that take place every year known as NAPLAN. An analysis of these acquired during the pandemic shows comparable scores to those of students undertaking the tests in 2019. The study authors from the University of Sydney and UNSW used regional variations in lockdown duration in a sort of “dose-response” analysis and found a small but insignificant relationship. There was also no significant increase in the number of students failing to meet minimum standards. Some other analyses of these data sets indicated that, with the exception of indigenous students and those from non-English speaking households, socioeconomically disadvantaged cohorts were not disproportionately affected.
[A similarly designed study from Finland also found no negative association on graduation scores of students whose final years of school took place during the pandemic. Finland is renowned as having the best and most equitable public education system in the world but not so the USA. I’ll link to couple of papers from that country that suggest a negative impact on school results from the interruption of face-to-face teaching.]
The final point in this calculus is, of course, whether school closures actually did much to reduce community transmission of SARS-CoV2. In one metanalysis looking across 178 countries, it was concluded that from 18 interventions, “only [school closures and internal movement restrictions] showed unequivocal evidence of being associated with a decrease in Rt regardless of the assumptions made.” But also take note of the prospective case-based research conducted across almost 9000 schools and daycare centres in New South Wales. They found that even for SARS CoV2 variants of concern, outbreaks within schools seemed to track community transmission but were not a major driver of it. One of the research leads, paediatrician and ID specialist Archana Koirala, told media that this was surprising given what we know about transmissibility of influenza in the young.
Infants, in particular, are vulnerable to pandemic influenzas because they don’t have an immune memory against seasonal variants. In 1957 and 1968 two closely related N2 influenzas emerged out of southern China that killed between one and four million people. As a proportion of the world’s population they were about half as lethal as COVID-19 [and were associated with low disease severity and rapid recovery]. But 45% of excess deaths were in the under 5 age group and another quarter comprised everyone else up the age of 65. The first pandemic in this century was the 2009 H1N1 ‘swine flu.’ While it killed no more than half a million people around the world, the median age of death was just 53. I wonder if the libertarian pundits would be so keen to “let it rip” with a virus that kills infants and people in their prime as they were with one that preyed largely on the old.
I don’t quite know how to synthesise all the information I’ve dumped on you. Future governments will certainly be more squeamish about reaching for levers like lockdowns and school closures but they shouldn’t rule them out. While journos like Adam Creighton described the public health response to COVID-19 as “the Great Insanity”, it’s rhetorically unconvincing to catastrophize the outcomes of the intervention in trying to argue that we catastrophized the threat of the virus itself.
In the two hours I had with my interview panel I didn’t get the chance to put all these thoughts to them, but they all expressed that we need a better appreciation of the qualitative outcomes in public health. Take for example, the final year students who recently told the ABC that they’d lost social confidence as a result of the disruptions to their early years of high school. And quite apart from academic results, some felt that they’d been denied the chance to progress in sports or the performance arts. Faced with these unquantifiable factors, I came to understand why my guests felt it wasn’t the role of technocrats to make such consequential value-judgements, but politicians elected to represent the public sentiment. Here’s Lorraine Finlay to add some final thoughts on this theme.
LORRAINE FINLAY: Could I just make one very quick point, and we've had a really good conversation about data and modelling and what we can know and the numbers and how it can guide policy-making, that's all critical. But the real nub of the issue in relation to lockdown is that the numbers can't capture, no data can capture the cost of what was lost by people. We can measure the lives that we think we've saved, we can measure the public health impacts that we think we've had, but in terms of the things that people lost through lockdowns, be that the separation from loved ones, missing the birth of a child, missing the funeral of a relative, you can't ever get those things back and you can't put a cost on them.
And I think the idea that we were just throwing everything we possibly could at this to try to get those numbers down or flatten the curve or whatever it was, I don't think there's been enough acknowledgement of the fact that that had such significant impacts on people and those impacts that can't be measured by data. And to me, that's really the heart of the lockdown issue, that really it was the things that make our lives worth living, the things that make us human, that are things that are taken away from you when you're locked down. And again, there might be very good reason for that, but I still don't think there's been a proper acknowledgement of those costs.
JAMES McCAW: I couldn't agree more Lorraine. Those considerations, I hope this doesn't sound defensive because I don't think it is, those considerations, they were enormous in the discussions about should we or should we not be making recommendations to government on these things. That tension—you didn't know what it would be, you knew it would be a negative impact and that you could never measure it, loomed large in every conversation about what would be a recommendation or an appropriate public health response or not. And being able to communicate that awful kind of trade-off that you could never really work through was a big part of our Australian decision-making process.
This reminds me of a really pertinent—this is a relative risk discussion, i would have been in mid-February or early March 2020, sitting around the table with the Chief Health Officers and Paul and others—so this was at AHPPC—and we were trying to figure out if we instituted certain interventions that would restrict or modify people's access to other health services, we were trying to think through like, what would be perhaps a drop in breast screening attendance and so in 15 years or 20 years how many more extra deaths due to breast cancer may we expect.
And it was a real conundrum, like how do we trade off or try and understand the downstream implications. And these are calculations one can imagine, but you can't actually put numerical values on all these different points. No one knew in March 2020 what, how long it would go, how many women would change their behaviour or change access to getting the screening and so on and so forth. Things like that were large on our minds, Paul, you’ll remember these sorts of discussions.
MIC CAVAZZINI: I'm conscious that there are five minutes left of the time allotted to talk about school closures and the psychological harm and there've been attempts to quantify that. You know, increases in mental health presentations. There was the concern over increases in domestic violence, and I'm trying to pack everything into one question here. Lorraine, you discussed this, a lot of this very well in the report. So, can you speak to some of the rights issues, some of the rights that you would argue for, legal rights that would cause pause for thought the next time considering these interventions?
LORRAINE FINLAY: What makes this such a challenging issue is there is a direct conflicts of rights. I mean the right to life is a core human right but then also the right to movement, the right to family life, the right to privacy, there are a whole range of human rights that come into play here, all of which were conflicting with each other and that's before you ever get to the question of individual rights versus broader community rights and so I think the core of this is to recognise there are no perfect answers. When you're dealing with something like this, first of all, even in a perfect world with perfect information, there's never going to be a perfect answer that doesn't involve some adjustment or compromises when it comes to trading off human rights in particular ways.
But then in an emergency, you're dealing with an imperfect situation where you don't have perfect information, you don't have the time to make these decisions in a consultative, lengthy process, you don't have the benefit of hindsight. So, I think the only way you can deal with these types of things is to actually do a lot of that work ahead of time and to build human rights analysis into your planning and your preparation to make sure that, as James was saying, when you're having these discussions around public health responses, human rights is front of mind, but it's also communicated to people that it's front of mind. So that even when people are forced to comply with decisions that they may not individually agree with, they understand what the thinking was behind them and they understand why those decisions have been put in place.
And in a response, hopefully that learns from the pandemic, we'd have a framework that not only builds human rights in, but it also builds humanity into the responses in terms of ensuring that you do have those fair and compassionate exemption pathways. That you do have a recognition that one size doesn't fit all. In this particular pandemic, it really was the most disadvantaged amongst us who in many cases were asked to bear the biggest burden. So, actually putting in some of those considerations around equity into our responses.
I think there is a lot that Australia got right, and I don't want to leave this conversation without acknowledging that. There is a lot that we did that we should be really proud of and a lot of really positive leadership that was shown. But gosh there are a lot of lessons that we also have to learn and we really want to do better next time and we recognise that while we did get things right there was a really significant erosion of trust and residual anger amongst people who don't feel as though their needs were taken into account and who do feel as though they were collateral damage.
MIC CAVAZZINI: Well, your report was really interesting in that way in that the surveys revealed that three quarters of Australians surveyed were largely on board with the policies. They agreed that individuals might have to give up certain rights for the broader community safety. But then the individual submissions were just so raw and so powerful. And I think it really depended on, we've already talked about this, one's individual experience of the pandemic. We have to recognise that 90 per cent of COVID deaths in Australia were people over the age of 70. So, I suspect that those people whose elders did make it through the pandemic might focus more on the deprivations that they were forced to undergo, the isolation. Whereas people whose parents or grandparents died because of a breach in containment might see this as an avoidable death that was due to negligence. So, Paul, have we had—I don't think we've had a grown-up conversation about what value we attribute to dignity versus life at all costs and what loss of life would we be prepared to accept next time round to preserve some of that dignity?
[In his book, ‘Pandemic Ethics’ ANU academic Ben Bramble writes about the intrinsic value an elder person’s life; seeing “grandchildren start to walk, talk, or grow into adulthood…. or further significant world events take place” has intrinsic value. “As for elderly people for whom additional life would add very little or nothing to lifetime well-being, this is often because society has failed these people. Also, the sudden loss of so many older people, including the loss of their collective wisdom and memories of former times, can profoundly diminish a society.”]
PAUL KELLY: I mean this comes to ethics and a very complex conversation that we do need to have and I agree with Lorraine. And when I read the report I just thought it was so wonderful to see the depth. The irony of all this of course about taking human rights perspectives into account—we've been talking a lot about Victoria—Victoria is a human rights-compliant state. It has specific laws from their parliament that says that any decision of government must take into account human rights. But that's the challenge. Having that as law is not the answer. It needs to be something about attitude and explicit in the planning and the response, in the way that James has already mentioned.
We, of course, took all of this into account every time we met and it was 583 times, I think, over three years the AHPC met. We were given the task, “save lives at all costs”. That was our role. What can you advise us to do to save lives in Australia? It wasn't, “Can you just make sure that you think about school performance in 10 years time” and all that, that wasn't there. But inherently it was, we were all of us around that table thinking about those things. But that was the task that was given and that was the answer. And more than once I was asked by my political masters to get back in my box and stop talking about society. They know society. Just give me the medical information.
JAMES McCAW: Swim lanes, not boxes, Paul, if I remember.
PAUL KELLY: Swim lanes, exactly. Swim lanes was used a lot. And I am a swimmer, so I understand it. So, I think all of those things are absolutely crucial for us next time. And there will be next time. It will have similarities, as Mark Twain famously said, “History doesn't repeat itself, but it often rhymes”. And we can do as much planning as we like. Ultimately, to quote another author, Mike Tyson— So, Mike Tyson very famously says, can plan all you like. The plan is only good until the first punch in the face for a fight.
JAMES McCAW:I think Napoleon said something similar about war.
PAUL KELLY: Napoleon said something similar and Eisenhower said something similar too. Anyway, the point is you can plan as much as you like but ultimately there will be some things that will be the same and other things will be different. So agility, being able to get the sort of amazing people that were around the table trying to decide with the information at the time—and, you know, hindsight bias does tend to oversell that, how much we knew at the time. We knew very little about this virus early on and it continued to surprise us—but that's not an excuse not to plan because that's how you get people around the table. But also to have that wider view that Lorraine has so well spoken about.
MIC CAVAZZINI: I think that's a pretty good place to end for the moment and you guys have been incredibly generous with your time. Is anyone else burning to get one last comment off their chest?
JAMES McCAW: No, could just continue chatting for ages.
CATHERINE BENNETT: I just want to pick up on the point, as Paul said, we can't anticipate everything that's going to happen. And in research, we were doing emergency funding for really focused research on critical policy-relevant questions, or basic science that we needed to understand the virus, but they could get approval and then wait six months to get ethics approval to actually use the funds. And so, we need to have things that we've thought through and are sitting on the shelf that we can then activate that recognise a shift in risk and manage the ethical process in a more expedited way without compromising individual rights and so on.
And I do think the other thing that has come through here is the difference between individual rights and community or population rights. And a lot of that does sit in the analysis, in having evidence that actually asking someone to do something is not just about them, it's about the broader community risk.
You know, we think the very young and the very old were from the inquiry were the ones most impacted in our response to the pandemic and particularly the elderly, as you said, Mic, have the impact of deaths both in the pandemic itself and since. But at the end of the day, we did take away individual choice in our elderly. If they were in a setting where they could see family and it wasn't a risk to other people we didn't give them that choice by actually putting these blanket rules in place.
And I think there's some of the areas is that difference between your risk to self and risk to others, you should have a different level of agency in some of those decisions and you know even around the vaccine in those situations where it wasn't about onward transmission. So, I do think they're the complexities we need to think through. We need to have the difficult and philosophical conversations about whether it's life at all costs and what that looks like. How much do we compromise education in our young and socialising in a young for what may be only a year or two's life in the elderly. That was really tricky and you couldn't actually do that conversation in the midst of a pandemic. We need to be doing that now so that the community is brought along before we face a crisis like this again.
MIC CAVAZZINI: There's also the other side of that argument where we now know that these social restrictions eliminated all deaths from seasonal flu amongst the elderly. Every year there are several hundred deaths directly attributed to influenza and couple of thousand deaths precipitated by flu. And does that put an onus on us to do a little bit more, at least wear masks to reduce that?
CATHERINE BENNETT: Well, is it masks or was it that we didn't seed new variants into the country because the people that did come in were at border control?
JAMES McCAW: There was very minimal transmission of the virus itself.
CATHERINE BENNETT: That's true, but it probably peters out after you've had a wave when you build immunity to the circulating strains. And if you don't introduce the next season strains, it's untested.
MIC CAVAZZINI: Well, should we close all borders every flu season?
LORRAINE FINLAY: I feel like I have to just put on the record an objection to that.
JAMES McCAW: Exactly, Lorraine. I mean, this makes no sense to any of us.
MIC CAVAZZINI: I better stop the recording there before we get carried away.
MIC CAVAZZINI: Before I go, I just want to share some further nuggets I wasn’t able to cram in earlier. Many commentators have argued about the folly of public health measures that restricted people’s livelihoods and economic prosperity of the country as a whole. If you go back to podcast Episode 72 you can hear me discuss some analysis suggesting that as measured by relative change in GDP, countries that acted with a stronger public health response had better economic performance that those that took a more lax approach. Similarly there was little difference in the relative scale of Australia’s government-funded job subsidy program and the bailouts seen in the USA, Sweden and Germany.
I’m sure there is plenty of conflicting literature I’ve missed, and my point is simply that there’s no open and shut case either in either direction, whether we’re talking economics or epidemiology. There are so many unknowns and so much dependence on context.
Have a think about the H5N1 influenza strain that has kept researchers awake since 2003. While we call it ‘the bird flu’, it can now be transmitted between cows and even seals, large numbers of which are now dying with devastating respiratory and neurological symptoms in and around the Antarctic. So far, it hasn’t been transmitted between people so there have been fewer than 1000 confirmed cases, mostly among rural inhabitants of south-east Asia. But the mortality rate among these has been 48 percent, which is just another red flag that future pandemics could force much more difficult decisions from society than the last one did.
Influenza is obviously closely surveilled, and we keep a close eye on poultry stocks for economic reasons. But the species jump that gave us COVID-19 was a complete surprise. At an Emerging Diseases conference I attended last year, some presenters joked that humans are the sentinel species. That was hosted by the Australasian Society for Infectious Diseases, who will be collaborating with Pomegranate Health to bring you some expert content. The first episode to be released very soon will actually be addressing vaccine hesitancy.
Many thanks to Profs Catherine Bennett, James McCaw and Paul Kelly, and Human Rights Commissioner Lorraine Finlay for their wonderful contributions to this podcast. And thanks as always the physicians on the podcast editorial group who reviewed drafts of this story. They are doctors Rahul Barmanray, Zac Fuller, Aidan Tan, Maansi Arora, Joseph Lee and Fionnuala Fagan.
For academic citations supporting almost every detail discussed today, please go to the website racp.edu.au/podcast then click on episode 145. There, you can also sign up to an email alerts list for newly published episodes although it’s much to stay tuned with a pod browsing app. Just go in and search for Pomegranate Health and do the same with your colleague’s phone while you’re at it.
If you’ve got any feedback and suggestions send an email to podcast@racp.edu.au. I’d love to know where the recent surge of listeners has come from, so please let me know where you came across the show. The podcast was recorded on the lands of the Gadigal clans of the Yura Nation. I pay respect to their custodianship over tens of thousands of years. I’m Mic Cavazzini. Thanks for listening.