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This article was first published on March 20, 2020
The COVID-19 pandemic has exposed structural flaws in the way we prevent and treat ill health, reports Jennifer Doggett.
This article is published as part of a collaboration with Inside Story, where it first appeared.
Jennifer Doggett writes:
After a century of advancements in healthcare and living conditions, it’s understandable that the emergence of the coronavirus pandemic has taken many of us by surprise. But it’s important to remember that it was only in 2008 that total worldwide deaths from infectious diseases fell below the number of lives lost to heart attacks, strokes and other non-communicable diseases. In Australia, we are still only a generation from the polio epidemic of the 1950s, which saw the widespread closure of schools, swimming pools and other meeting places.
Epidemics of infectious diseases have continued to devastate affected groups in Australia. But these have generally been smaller (and often marginalised) populations, including Aboriginal and Torres Strait Islander people, injecting drug users and gay men. Except for brief periods, such as the early days of the HIV epidemic in the 1980s, mainstream Australia has largely been able to ignore these outbreaks. The viruses we have come to worry most about have been the ones on our computers.
Just like the Australian population, our health system has little experience in dealing with a crisis of this scale. The National Communicable Disease Plan, drawing on experience gathered by the Exercise Cumpston system test in 2006, has assisted in guiding the government’s response. But the realities of responding effectively to the virus have demonstrated the vulnerability of a fragmented, poorly coordinated and inequitable health system. The way it has met (or not met) expectations, so far at least, offers important lessons for our response to similar events in the future.
Health isn’t a solo event
Health policies and programs focus on changing individuals’ behaviour and treating disease and disability. But treating health much more as a team sport will be crucial to successfully combating the coronavirus pandemic. Developing strategies to halt the spread of this virus means thinking not only about how to protect our own health but also about how to work together to minimise its impact on the community.
A commitment to health equity is crucial. Like a soccer team with a poor defence, our abilities are only as good as our weakest players. A stockpile of hand sanitiser in the garage won’t protect you or your family if this means others will expose themselves to infection and become vectors of transmission.
It’s not just about being altruistic (although this is important). When it comes to health even the most selfish among us has an interest in helping others.
This perspective on health isn’t new, of course. It’s more than a decade since the World Health Organization’s Commission on Social Determinants of Health described the vital role in good health played by employment, class, social status, housing and other social factors. A commitment to acting on these issues was recently renewed by the WHO.
Yet, despite a multi-party Senate committee unanimously recommending that the federal government adopt the WHO report, Australia has not acted on any of its recommendations. In fact, some measures of inequity, such as wealth distribution, have worsened: the wealthiest one-fifth of Australians now own nearly two-thirds of all wealth, while the least-wealthy half own less than a fifth. Although there’s said to be “no better place to raise kids,” an estimated 1.1 million Australian children live in poverty.
Despite these inequities, the advice coming from health authorities seems oblivious to the circumstances of many Australians. People are asked to self-quarantine at home; patients arriving at hospitals are told to “return to their cars” and phone for instructions; it’s suggested that we stock up on two weeks’ food. No advice is provided for people who don’t have stable and safe housing, regular employment, a car, a mobile phone, internet access, the capacity to deal with a short-term lack of income, or the ability to purchase and store bulk foods. As lawyer Thalia Anthony points out in relation to prisoners, who are among the most marginalised populations in our community, this failure risks undermining the effectiveness of Australia’s response to the virus.
Fragmentation creates confusion
It goes without saying that viruses don’t respect borders. Cooperation and collaboration between the federal government and the states and territories is essential, but challenging when healthcare responsibilities are split.
For its part, the Commonwealth is responsible for primary healthcare, Medicare, regulation of therapeutic goods (including testing kits and protective equipment), aged care, the medical stockpile, and non-health policies including border control. The states and territories, meanwhile, have primary responsibility for the public hospital system, disease surveillance and quarantine (within their jurisdictions), ambulance services, and most community and social care.
Divided responsibilities inevitably cause gaps, fragmentation and confusion. Getting eight jurisdictions and the Commonwealth to agree on a joint approach can slow the response to a fast-moving and rapidly changing environment. As a 2004 Parliamentary Library research paper observed, “Overlapping Commonwealth/state responsibilities and divisions between clinical health practitioners and public health policymakers were identified as two broad problem areas in Australia’s national arrangements for responding to an infectious disease outbreak.”
During Australia’s response to the epidemic thus far, different governments have provided conflicting advice. People experiencing symptoms have been told to visit their GP, to call (but not visit) their GP, to ring Healthdirect, to self-monitor, or to go to a public hospital for testing. Communication between governments, GPs and hospitals has been inadequate, with GPs receiving inconsistent information about testing protocols and facilities.
“To take one example,” says the president of the Royal Australian College of General Practitioners, Harry Nespolon, “there has been confusion about the type of face masks that GPs need to wear… We are also getting different advice from the states and territories on the tests for coronavirus and who should be taking them — should they be done by a GP in a clinic or should they be done in a hospital in a negative-pressure room?”
This fragmentation is not just a practical problem. It also adds to the confusion and anxiety in the community and reduces trust in governments’ ability to coordinate an effective response to the pandemic.
Coordinated primary care must be a priority
Even if every other part of the health system worked perfectly (which of course they don’t), a primary healthcare sector — GPs and other frontline practitioners — that is under-resourced, poorly coordinated and not always accessible will seriously undermine the effectiveness of our response.
Over the past month it has become clear that Australia’s primary care system is poorly prepared to respond to a major public health threat. This is not the fault of the profession or a reflection on individual doctors and their staff, who are generally highly dedicated professionals doing their best under extremely difficult circumstances. But their efforts have been challenged by a flawed system inadequately resourced by successive governments.
Despite this neglect, governments have counted on GPs to deal with patients concerned about their symptoms or potential exposure, and to provide advice on testing and deal with other enquiries, all on top of their normal workload. Governments’ first advice to people concerned about the virus or experiencing symptoms was to “call your GP,” but their unrealistic expectations of what GPs can and can’t do have exposed the vast gap between the government’s idea of general practice and the reality.
Most GPs are either small businesses or employed by profit-driven companies. They have neither the resources nor the incentive to carry additional capacity — such as quarantine rooms and stockpiles of equipment — to deal with crises. Expecting a local general practice to meet the increased demands for healthcare during a pandemic is like expecting the corner shop to supply everyone’s food and household goods.
“I don’t know of any GP practices that would be capable of testing or seeing a suspected case,” Sydney GP Richard Nguyen told the Guardian earlier this month. “In our practice we have four consulting rooms plus a procedure room. We’d have to dedicate one room as an isolation room. And then you’d have to clean and disinfect the room — logistically it’s just impossible for several reasons, including that we don’t have the physical space.”
In the short term, our primary healthcare system can probably muddle its way through this crisis, largely because of the professionalism and dedication of GPs (and their practice staff). But it won’t be ideal. GPs will take risks, as healthcare workers often do with infectious diseases, and some will undoubtedly get sick. This is not fair to these doctors or to their patients.
Solving this problem means tackling the fragmentation and variability built into the present system and better integrating primary care with other parts of the health system. For years experts and health groups have advocated exactly this kind of reform. The 2009 National Health and Hospitals Reform Commission, for example, called for “strengthened primary health care services” and “the development of Comprehensive Primary Health Care Centres and regional Primary Health Care Organisations… to support service coordination and population health planning.”
Successful examples already exist, including innovative private practices and Aboriginal Community Controlled Health Organisations, and could serve as models for reform. Learning from them and building on the existing (but limited) Primary Healthcare Network infrastructure would strengthen the capacity of the primary healthcare sector to manage future public health threats.
Effective communication is vital
The Communicable Disease Network Australia’s National Framework for Communicable Disease Control was supported by health ministers from all jurisdictions after it was released in 2014. One of its key conclusions was that identifying “a credible and trusted leader” and providing timely, effective and consistent communications were vital during a health emergency.
During this crisis the government has failed to meet this goal in a number of ways. Information has been inconsistent, patchy and sometimes contradictory; key details about the virus and its threat to the community are perceived to have been withheld from the general public; and positions have shifted significantly on some key issues (travel bans, border control, the financial impact of the epidemic) within days and sometimes hours of official announcements.
Political leaders and health authorities have fumbled when answering simple questions and struggled to explain in precise language the reasons for seemingly conflicting advice. When the Council of Australian Governments announced that non-essential gatherings of more than 500 people should be cancelled, the prime minister stated that this did not apply to workplaces, childcare centres, schools, university lectures, public transport, airports “or things of that nature.” The most important messages about behavioural changes required to limit the impact of the epidemic (washing hands, minimising social contact) risked being lost in the confusion.
Efforts by the government to communicate with health professionals have been similarly inadequate. Doctors working at the frontline of the epidemic have described the government’s dealing with them as a “shambles.” The Australian Medical Association has called for authorities to start “singing from the same song sheet” and the Australian Nursing and Midwifery Federation urged the federal government to send “clear and consistent messages to the community in order to contain the rapid spread of the coronavirus (Covid-19) and ease growing anxiety, confusion and concern about this public health emergency.”
Compounding this problem has been the seemingly contradictory behaviour of political leaders. At the same time that the prime minister announced the ban on non-essential gatherings of over 500 people he also said he would be going to a rugby league match. People in hazmat suits cleaned the Parliament House office of home affairs minister Peter Dutton after he tested positive, yet chief medical officer Brendan Murphy said that the prime minister and other cabinet members who had been in contact with Dutton needn’t be tested or self-isolate. Despite the recommendation to adopt social distancing, the PM continued to be seen in close contact with other political leaders, journalists and advisers.
This degree of inconsistency is a serious problem for a government trying to persuade people to change their behaviour in ways that can seriously limit their freedoms. Advice that seems contradictory or frankly impractical (staying 1.5 metres from other people on public transport, for example) or that is not being followed by political leaders themselves undermines the credibility of the message and the authority of the government, and risks people ignoring it altogether.
Of course, communicating in this complex and rapidly evolving situation is challenging. Both under- and overreacting carries significant potential costs. Maintaining a balance between encouraging sensible concern among the community and preventing public hysteria is crucial.
It is understandable that the government focused on avoiding panic. As health promotion expert Daniel Reeders has pointed out, panic encourages a range of ineffective behaviour: it encourages panic buying; it can prevent people from processing what they read or hear, making it much harder to convey accurate information; it puts people in a “me-and-mine first” frame of mind at a time when collective action is required; and it can cause people to dismiss “emotionally dissonant” messages — such as health experts giving calm, measured advice — in favour of hyper-emotive rumours and conspiracy theories.
But it is also important to acknowledge the limitations of the authorities’ knowledge about health threats. As the WHO’s guide to Communicating Risk in Public Health Emergencies puts it, public communications “should include explicit information about uncertainties associated with risks, events and interventions, and indicate what is known and not known at a given time.”
“My biggest concern is people are not talking to their populations like adults,” says the WHO’s Bruce Aylward. “They’re cherry-picking the best possible survival rates [and] outcomes, the lowest possible incidences. You’re just going to compromise confidence of your population.”
These problems are not just a failure of communications but a failure of leadership, which is an essential component of effective risk communication. According to the US Environmental Protection Agency’s Seven Cardinal Rules of Risk Communication, trust and credibility are a spokesperson’s “most precious assets” when communicating risk information. “Long-term judgments of trust and credibility are based largely on actions and performance. Trust and credibility are difficult to obtain. Once lost they are almost impossible to regain.”
This is bad news for a government in Canberra already struggling with criticism over its handling of the recent bushfire season. The trust and credibility that it will lose as a result of its poor response in the early days of the coronavirus pandemic may prove impossible to regain.
Health literacy matters
Part of the communication challenge facing governments is the low level of health literacy in the Australian population. Good health literacy helps people make decisions that maximise their own health and that of others. Poor health literacy makes communicating complex messages and trying to effect behaviour change in a stressful environment even more difficult.
Data on health literacy in Australia isn’t great (which is a problem in itself) but the indications are that it is pretty poor. The most recent national data available from the Australian Bureau of Statistics, which dates from 2006, shows that only 41 per cent of adult Australians were sufficiently literate about health matters to meet the complex demands of everyday life. This rate was even lower for older Australians, with only 28 per cent of people aged sixty to seventy-four considered to have adequate levels of health literacy.
Among the health stakeholders who have recognised this problem is the Australian Commission on Safety and Quality in Health Care. It says that low health literacy can significantly drain human and financial resources and may be associated with extra healthcare costs of 3 to 5 per cent. The problem has been evident in the seemingly irrational response of many in the community to the pandemic, such as avoiding Chinese restaurants.
One of the greatest challenges has been to explain the urgency of slowing the transmission of the virus (or “flattening the curve”), a desired outcome of government policy but a difficult concept to explain.
Also important is health system literacy. When a system is experiencing dramatic increases in demand, it helps if people know where to go for information, advice and care. Talkback radio calls have made it clear that many Australians lack even a basic understanding of our health system. Callers described calling the national Australian Medical Association office for information about where to access telehealth consultations in their local communities, contacting their state health department for information on Medicare-funded services, and being frustrated when their local pharmacies didn’t provide testing services.
The public health system will always bear the burden
Despite the government’s (and the media’s) obsession with private health insurance, this crisis has made clear that it is the public health system we rely on when serious health risks emerge.
The coronavirus pandemic is the greatest health crisis our country has faced for a generation, and private health insurance is basically missing in action. Our annual investment of around $11 billion into this sector does not appear to have strengthened our overall capacity to respond to the pandemic in any respect. At all stages it has been the public health system that has stepped up to manage our response to the virus.
Our public universal insurer, Medicare, is funding bulk-billed and telehealth consultations for people at risk or showing symptoms of coronavirus. Public health microbiology laboratories developed the capability and capacity to detect and confirm cases following publication of the genome sequence for the virus at a publicly funded research institute. In Victoria, testing centres have been established at nineteen hospitals and health services, not one of which is private; nationwide, public hospitals are performing Covid-19 tests as well as treating people who are seriously ill with the virus, all at no out-of-pocket costs to patients.
Far from the “Better Cover, Better Access, Better Care” promised by the private health funds, people with private insurance are being left high and dry by their funds. Anyone who purchased private insurance under the illusion that a policy named “Security” or “Ultimate Health Cover” would be useful in the context of a major health threat would now be experiencing a major reality check.
As one reader of the health policy blog Croakey wrote, “I have maintained private hospital cover for many years because of a suspicion that the Lib-Nats would do away with Medicare if they could. Today I rang the largest, most modern private hospital in Perth and asked what they could do for me if I came down with Covid-19. The answer? Nothing, sorry, you’ll have to go to a public hospital, you can go as a private patient, we don’t have the facilities.”
International experience in responding to the coronavirus pandemic indicates that the countries with strong universal public health systems are having more success than those with a privatised and less equitable approach to healthcare. The message from this pandemic is that private health insurance is (at best) an optional add-on that doesn’t merit the resources it currently receives. If Australians ever needed convincing of the benefits of a strong and well-functioning public health system, this pandemic should be more than sufficient to persuade them. •
Many thanks to Dr Ruth Armstrong for her help with this article.
Jennifer Doggett is Chair of the Australian Healthcare Reform Alliance and a Croakey editor.
Read the series of articles published in collaboration with Inside Story.