Introduction by Croakey: The Federal Government has finally launched a national information campaign on the novel coronavirus, amid ongoing concerns about confusion and inconsistency in its public messaging.
In Victoria, the State Government has announced that new hospital beds will be opened to manage COVID-19 patients, and more than 7,000 Victorians will be fast-tracked for elective surgery in the next few weeks. More than $60 million will be made available to public and private hospitals to undertake additional surgery such as thyroid, prostate, hernia or gynaecological surgeries – so they can be done before the predicted peak of the pandemic.
Meanwhile, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists has issued advice to members (14 March) urging them to:
- Consider cancelling all elective surgery and consultations.
- Consider reducing “active” staff and, where possible, create “teams” so that if one team is incapacitated due to illness or isolation, another “well” team can step in. This approach should apply to medical, nursing, midwifery and ancillary staff.
- Screening through targeted questions and temperature measurement. Social distancing between patients and staff.
- Reduce, postpone and/or increase the interval between antenatal visits. Limit routine antenatal visits to less than 15 minutes. Consider telehealth consultations, either as a replacement, or in addition, to routine visits. Close access to hospitals and maternity units to visitors (excluding partners). Consider early discharge from hospital.
- Contact all retired staff and those on leave as potential back-up workforce. Prepare and disseminate a disaster management plan in case of sudden escalation.
The Australian Society of Anaesthetists has released guidelines (14 March) to help anaesthetists manage known or suspected COVID-19 patients in operating theatres. The Society also recommends all anaesthetists:
- Familiarise themselves with their local or institutional personal protective equipment (PPE) requirements for contact, droplet and airborne precautions and to supplement this with additional training if required.
- Start scenario planning the management of patients with suspected or known coronavirus presenting to theatre for urgent or emergency surgery.
- Consider keeping a logbook of all patients they have been in contact with who have respiratory symptoms or possible coronavirus infection in the rare event this may assist future contact tracing.
Meanwhile, University of Tasmania researcher Jen Brown raises concerns about the potential implications of inconsistent and confusing messaging to the public.
Jen Brown writes:
Australia’s Prime Minister is now facing a major test of leadership in managing the COVID-19 Pandemic. Minister for Home Affairs Peter Dutton has tested positive for the infection. If Scott Morrison has been a close contact with Dutton, he must take the advice given to all Australians to self-isolate for at least 14 days.
A leader’s failure to self-isolate despite close contact sends the wrong message to the community about its seriousness. Australia is not the only country to experience such a scenario. Confusing decisions by politicians is leading to mixed messaging that could see restrictive laws applied unnecessarily to force self-isolation.
In the early days of the COVID-19 epidemic, Australian politicians reported that Australia is “well prepared” for its arrival and presented the plan for activation. In his address to the nation on Thursday 12 March 2020, the Prime Minister repeated this response.
Sadly, the presence of a written plan does not constitute a comprehensive emergency response, nor is it evidence of state or local preparedness. At a local level, there are widespread reports of confusion and mixed messaging.
Complete containment of COVID-19 in Australia is now impossible, but if the rate of infection can be slowed, the broader impact on health services can be manageable. This is what makes self-isolation so important. With clear information and lots of support, individuals should be capable of self-isolation.
The modelling from China on the progression of COVID-19 is evidence that the impact of fast-paced wide-spread transmission will mean ICU’s could become inundated; people with a life-threatening illness would be competing for life-saving treatment. The hospital system will need to triage and make tough choices on who to prioritise for mechanical ventilation, negative pressure rooms, or other treatment.
It is concerning that individuals testing positive for COVID-19 are failing to appropriately self-isolate. GP services are reporting confusion with some refusing to see patients and turning to media to tell chronically ill patients to stay away.
A lack of consistent approach and uncertainty is taking away from the critical message about why self-isolation is necessary and how best to do it. There is little support for individuals who are self-isolating, despite the potentially negative impact on their welfare.
Quarantine as a practice has been tested repeatedly since the Spanish flu outbreak of 1918. Mathematical modelling and vast research show it does work to control and prevent the spread of disease. The control of the Ebola virus is one such example. Quarantine restricts the movement of individuals who have an infection to prevent the spread of disease. Self- isolation at home is one form of quarantine and is used in Australia before a test result is positive, or when a patient is positive for infection, but well enough to care for themselves.
We will never be able to design a perfect form of quarantine because, in many cases, we will need to isolate people who don’t feel very sick or worse those who have been exposed but are perfectly healthy otherwise. Consequently, there will always be people who don’t care and find a way around quarantine. This is where the law helps.
Without wide cooperation across the community, we may need to use restrictive laws that force individuals into isolation. In preparation for COVID-19, the United Kingdom introduced new regulations to allow enforced isolation of individuals on reasonable suspicion of infection with COVID-19. Australian state and territory public health legislation grant similar powers; and if necessary, so does the Commonwealth Biosecurity Act 2015. If an individual with or suspected of having the disease fails to self- isolate then these laws are there to help. Some states are now revising these laws and considering updates.
The aim of these laws is to restrain the individual’s right to participate as they freely choose. They isolate and restrict the movement of an individual with, or suspected of carrying an infectious disease. Restraining the rights of one, or a few, to protect the health of the broader population is a core aim of many public health laws.
Critics view these laws as draconian, invasive and interfering with human rights. This represents a long-held dilemma faced by those who deal with the public health law. Certainly, interfering with rights is precisely what these laws are doing. Western nations have been exercising soft versions of the principle in a host of laws for a long time. Food safety, seat belt, speed limit and product safety laws are common examples. The United States has compulsory vaccination laws, and Australia leads the world in highly restrictive tobacco laws. However, mandatory quarantine laws are on the harsher end of the restrictive spectrum and contain a broad range of powers to test, isolate and direct individuals, or even business, as necessary.
The authority behind executing these restrictive state and territory public health laws is a medical doctor. Chief Health Officers or Directors of Public Health (CHOs), as they are known in some states, are statutory positions filled by medical doctors with specialist public health training. We should take some comfort in the knowledge that CHOs are at the top of their professional tree and got there by years of intensive hard work and training. As doctors, they are also bound by the Hippocratic oath.
The CHO’s role is to exercise these laws according to the underlying principles of the public health profession: to pursue the highest possible level of physical and mental health in the population consistent with the core values of social justice. In some states like Western Australia, this is even written into the legislative objectives with a list of guiding principles that their decisions must follow. This provides an extra safeguard for these tough quarantine decisions. Ideally, such criteria should be uniform across State and Territories, particularly when the legislation confers such broad powers.
CHO decisions during times of disease outbreak will be laden with many complex underlying considerations. They must consider and balance social justice, with proportionality, sustainability and the precautionary principle to weigh up how the best community protection can occur.
For example, a decision to close public events, schools and university must be weighed against the risk of transmission, the individual’s right to participate in society and the economic cost. Economic impacts of school and university closure are high, and if infection risk is low, then closure may cause more significant problems and potential a failure of social cohesion. These decisions of closure must come at precisely the right time and there will always be mixed community sentiment about that.
The CHOs are well trained to deliver a response to COVID-19, but they must have the support of the Minister for Health and accurate representation by media.
CHOs are only as good as the government they work with; health ministers can override their decisions. So, ultimately the government is responsible for the COVID-19 response, and if health ministers don’t have a sound background in health, this can prevent the free flow of information or politicisation of the response.
An historical politicisation of health in Australia may well be contributing to the current failure in clear and consistent messaging. Hopefully it doesn’t lead to unnecessary implementation of the quarantine laws.
• Jen Brown is a nurse with a Master of Public Health and Tropical Medicine a, Juris Doctor of Law and is currently a PhD candidate at the University of Tasmania, Faculty of Law researching public health law.
See Croakey’s archive of stories on the novel coronavirus outbreak.
Tweets commenting on interviews with Chief Medical Officer Professor Brendan Murphy and Health Minister Greg Hunt on ABC TV’s Inside program.
Also read Michelle Grattan, on how the Government has been giving “confusing signals”.
Public health communications
Infographic from Victorian Health Department
Australian Government newspaper advertisements (The Mercury, Hobart, 15 March 2020)