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Amid cascading failures, where is the leadership?

Introduction by Croakey: Today a record 77 COVID deaths were reported nationally and this toll is expected to keep increasing; the Federal Government activated a 2020 agreement with private hospitals to help the COVID response (though the significance of this announcement was later disputed by the Australian Private Hospitals Association); and the Victorian Government announced a Pandemic Code Brown across all public metropolitan and major regional hospitals, which is expected to last four to six weeks.

It’s time politicians and health officials stop calling the Omicron variant “mild”, and invest in testing, tracing, good quality masks and safe indoor air, and a range of other strategies, according to Professor Raina MacIntyre, Head of the Biosecurity Research Program at the Kirby Institute at UNSW.

She also calls for an explicit commitment from governments to protect people: “We do not have that commitment yet – we have talk of personal responsibility, but have been left without the tools to survive.”


Raina MacIntyre writes:

Omicron is not mild. Omicron is less severe than Delta, but in NSW alone it’s killing people at the rate of a Boeing 737 crashing every fortnight, including children and fit young people. It’s causing thousands of hospitalisations a day.

Yet the people tasked with protecting public health tell us it is inevitable, even necessary, that we get infected. Then when people take the “necessary” message on board and have COVID-19 parties, these same officials backtrack frantically.

After all, we cannot openly, as public health officials, sing from the same song sheet as anti-vaxxers. Having measles and chicken pox parties are core anti-vax, anti-science moves, which 10 years ago would have been condemned by any public health expert.

Today, the anti-science movement has become mainstream, confusing and confounding the community and being propagated by politicians and health officials alike to suit their own agendas.

Living with COVID-19 means loss of control, because we cannot order a set amount of infection to “live with” like ordering takeaway. For two years we have believed that the worst societal consequence of COVID-19 is health systems collapse. Unless you need hospital care for a broken leg, a heart attack or COVID-19, you can ignore the plight of hospitals right now and pretend it is 2019.

But when you can’t buy chicken at the supermarket or receive your Amazon order, then we start caring. Unlike the toilet paper panic of 2020, empty supermarket shelves are not the result of a surge in demand. It is the result of mass infection causing so much worker absence that product cannot be moved from warehouses to the shelves. Farmers are affected because people shortages mean they cannot harvest their produce or get it transported. Instead, they have been forced to dump rotting produce.

Exponential growth

Most pandemic plans are health-centric and fail to consider the essence of what gives an infection like SARS-COV-2 pandemic potential – exponential growth. Over two years we have seen it at least four times in four waves of different variants that have surged rapidly enough to overload health systems.

As early as April 2020 we watched in horror as bodies piled up in refrigerator trucks outside hospitals in New York and Barcelona, because mortuary capacity was exceeded. This sudden surge does not occur with endemic infections like hepatitis C or malaria.

Endemic and epidemic are different patterns of disease, and respiratory transmissible infections like influenza, measles or SARS-COV-2 do not become endemic. They cause recurrent waves, and each wave is disruptive to society because it grows rapidly, within days or weeks. Even influenza, which is milder than SARS-COV-2, requires surge planning for extra hospital beds for the seasonal epidemic every winter.

Omicron has brought the lesson home harder than ever before because it is so contagious. It is up there with measles, the most contagious virus known, with a R0 estimated to be 18. That means in a completely non-immune population, one infected person will infect 18 others on average.

So any gains from the less severe clinical outcomes of Omicron are negated by the sheer volume of cases, which has eclipsed anything we have seen before. With Omicron spiralling out of control, we are told case numbers do not matter.

Let me explain why case numbers matter. If Delta caused 1,000 infections a day and 11 percent were hospitalised, that’s 110 hospitalisations a day. If Omicron causes 50,000 infections a day and is half as severe as Delta, then only 5.5 percent are hospitalised, but that’s 2,750 hospitalisations a day. The impact of Omicron, therefore is greater.

Cases beget hospitalisations, and hospitalisations beget ICU admissions. Exponential growth in case numbers means we rapidly run out of capacity for hospital care, ambulance call outs, testing, tracing and even capacity to manage vaccine roll outs.

Cascading failures

Loss of testing capacity means inability to track case numbers. There is much speculation about the Omicron wave having peaked, but with collapse of testing and surveillance, how would we know?

Most people who need a test are not eligible for a PCR, which is now subject to tight gate keeping, and those who want a rapid antigen test cannot find one or if they can, cannot afford one. So case numbers are not informative, especially as restrictions to access have worsened over time.

The only way to reliably ascertain the peak is by seeing hospitalisations decline several days in a row, but that is a delayed signal because hospitalisation lags cases by one to two weeks. Low testing capacity also means we cannot work out correct hospitalisation and ICU rates to compare severity with previous variants, because we do not know the true denominator, total cases. A high-income country like Australia should be able to do better.

The closure of many testing centres and lack of capacity of genomic sequencing means we have also lost the ability to differentiate the effects of Delta and Omicron. Only ICU patients are reliably sequenced.

In December, there was a fair amount of Delta around, and ICU admissions were more Delta than Omicron, but that has reversed by January, with the majority of ICU patients now having Omicron. But that is only a small snapshot from a broken testing system.

We have data gaps in the community, worse in regional and remote Australia, including Aboriginal  and Torres Strait Islander communities where genomic sequencing is even less available. Many labs do not even report Indigenous status for COVID-19 testing, so we cannot estimate the impacts on Aboriginal and Torres Strait Islander people relative to non-Indigenous people. And with international borders open, there is every chance a dangerous new variant will be missed.

Omicron has shown that mass infection and workplace absence results in cascading failures in all of society, not just the health system. In addition to sick people, close contacts (of whom there may be 10 to 20 per case) are also meant to quarantine.

We know that workforce absences are 20-30 percent or higher in many essential sectors compared to normal rates of one to five percent at any given time.

The workforce crisis is so great that National Cabinet expanded categories of workers classified as “critical” or essential to include health, welfare, care and support (including production and provision of medical, pharmaceutical and health supplies and pharmacy workers), emergency services, safety, law enforcement, justice and correctional services, energy, resources and water, and waste management, food, beverage, and other critical goods (including farming, production, and provision but not including hospitality), education and childcare; and telecommunications, data, broadcasting and media.

They also changed contact management to enable close contacts to keep working if asymptomatic. The problem is, the virus is just as contagious before symptoms start and in people who are asymptomatic, and close contacts are the most likely next tranche of infections.

This is a short-term solution akin to using a Band-Aid to stop Warragamba dam from bursting. It may provide a few days of additional workers, but will accelerate transmission in the workplace and leave us in a worse position.

Rural and remote areas are particularly vulnerable to workforce and supply chain disruptions because they operate with much lower reserves and fewer back up options. When a whole state is facing shortages and lack of workforce, big cities with larger populations will be prioritised.

Even in big cities, people living with disability or chronic medical conditions or who are otherwise disadvantaged may suffer more than others. Disability workers and carers, for example, have been unable to access RATs or personal protective equipment, leaving Australians living with disability without care and in some cases stuck in their wheelchairs. One in 10 disability workers has become infected and almost a quarter have been unable to get paid sick leave or government support.

Ensure security

So what governments can do to ensure security of the economy, the population and our health?

It should be patently obvious now that Omicron is not the common cold, as much as we would like it to be. Control of the pandemic will improve health, security and the economy, but we cannot rely on vaccines alone. Although the dream vaccine may come in the future, for now vaccines wane and new variants like Omicron are far removed from the original Wuhan strain that the vaccines were developed against. Three doses are essential for those who are eligible, because two doses barely protects against symptomatic Omicron.

We need investment in testing, tracing, good quality masks and safe indoor air and a range of other strategies as outlined by OzSAGE. A multi-pronged ventilation and vaccine-plus strategy is achievable with foresight and political will – but what will it take to generate this?

First, we need an explicit commitment from governments to protect people. We do not have that commitment yet – we have talk of personal responsibility, but have been left without the tools to survive.

Personal responsibility is fine for the privileged and wealthy who can jump the queue and get the fanciest of drug treatments, but for the rest of us it is a jungle of survival of the fittest, fighting for scarce resources whether they be hospital beds, a rapid antigen test (RAT) or chicken on the supermarket shelf.

We have been left as two tiers of society. The 50 percent who are fit, young and healthy, and the other 50 percent who are older, or live with disability or “underlying conditions”.

Daily, we are reminded that the deaths of the old and the weak half do not matter as much as the deaths of the young and strong half. We need a commitment from government that we all matter equally.

We have the tools to minimise damage to both the economy and health, and we have better vaccines and treatments to come. We need to call out anti-science disinformation, especially when propagated by experts or people in power.

Instead of surrendering because we are sick of the pandemic, we need ambition to do the best we can, moral courage and a shared vision of what we want as a society. And we need leaders to show the way.

Professor Raina MacIntyre is Head of the Biosecurity Research Program at the Kirby Institute at UNSW and Professor of Global Biosecurity & NHMRC Principal Research Fellow.

Editor’s note: The introduction to this article was updated on 19 January to reference the Australian Private Hospitals Association commentary on the Federal Government’s announcement.


Further reading

The Atlantic: Calling Omicron ‘Mild’ Is Wishful Thinking

The Conversation: Government management of Omicron blighted by false assumptions, bad planning 

The New Daily: Alan Kohler: Neoliberalism is at the heart of the Omicron shambles


See Croakey’s archive of articles on health inequalities.

 

Comments 2

  1. Dale Johnston says:

    Thanks Raina.
    Sad to hear ICU staff have gone on strike. Inevitable.
    And now we find out that everyone in this country is needed..that truckies are indispensable, that you need people to stack the shelves.
    Lockdowns did work. We are in a self -imposed lockdown as we would never get an ICU bed ahead if a 30 yr old. Reality tells me that.
    We used not to treat over 70’s intensively. Different though, when you are there yourself.

  2. Derek Louey says:

    An alternative to maintaining economic activity is simply allowing those with mild communicable disease to continue working. There is only one rationale for Public Health measures and vaccination. This is to flatten the curve and maintain health system capacity, not only to manage COVID caseload, but also the ongoing disease burden of non-COVID conditions. Nevertheless, the virus will continue to spread throughout the population and there will be inevitable deaths and disability. All we are doing is spreading this effect over time to maintain health system function. The 50:50 quote figure is also misleading. COVID disproportionately affects the over 70s and they represent just over 10% of the population. However numerically, they represent the largest group that benefit from restrictive measures.

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