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COVID+ Pathways: Victoria’s second-wave successes and the social determinants of health

Marie McInerney writes

Victoria on Wednesday reported just three new cases of COVID-19, down from its daily  peak of 725 cases in early August — an achievement that is being hailed by many experts as a “remarkable” response to a coronavirus second wave in international terms.

Yet you might struggle to appreciate it amid the deluge of criticism from politicians and media of the Victorian Government over its “botched” hotel quarantine program and the toughness of its lockdowns, much framed as something of a false dichotomy around public health interventions versus economic harms.

As cities and countries across western Europe also return to lockdowns and other measures to contain the latest surge in cases, Burnet Institute epidemiologist Michael Toole and Burnet director Brendan Crabb wrote on Monday that Victoria had crushed its substantial coronavirus resurgence “like no other of the 73 countries that have experienced a second wave”.

“It is a monumental success,” they said of Victoria’s efforts to get down from a peak of almost 8,000 active cases in early August to just 109 on Wednesday, though they warn the responses to new outbreaks need to be “rapid, nimble and proactive”, with immediate testing, tracing and isolation of contacts, contacts of contacts, and beyond.

“This response needs to be particularly vigorous in high-risk populations such as those living in crowded housing. Community engagement and involvement in this process is essential,” they said.

ABC health expert Dr Norman Swan also cautiously hailed Victoria’s efforts: “While there’s a long way to go, Victoria’s success in crushing the virus hasn’t been seen many other places in the world,” he said, adding that the rest of Australia owed thanks to Victorians for their sacrifices.

That’s not to say, of course, that the Victorian Government hasn’t made major mistakes — the inquiry into failures in the hotel quarantine system that has been blamed for most of the second wave will report next month and has already prompted the departure of Health Minister Jenny Mikakos. As important, experts agree that the pandemic has shown up huge gaps in the state’s public health capacity, stemming from decades of under-investment.

While Victoria has been under fire for being too tough, Guardian Australia reported this week that, had it gone straight into Stage 4 lockdown and not tried more localised and lenient restrictions first, it might have eliminated COVID-19 in just six weeks, versus the four months and counting of lockdown.

But, as the #LongRead article below outlines, Victorian health authorities and services have learnt on the job to find better ways to stamp out future outbreaks, including by focusing firmly on the social determinants of health and across community, primary and tertiary health.

Health teams door-knocked thousands of homes in Melbourne’s north and west as the second coronavirus wave surged, offering free testing at the end of streets

“The missing piece in the puzzle”

A pilot program that brought together community health, GPs and hospitals in Melbourne’s second wave coronavirus “hot spot” areas found that more than half of the people it worked with required social and welfare support in order to be able to safely self-isolate.

One of Australia’s largest community health organisations, cohealth, which led the program, has described it as “the missing piece of the puzzle” for combating Victoria’s second wave.

The COVID+ Pathways program found that caring obligations, insecure housing, a lack of internet access to enable online grocery shopping, social isolation, language issues, family violence, drug and alcohol use, and the threat of job loss are just some of the social risk factors that may stop people from safely isolating while they are still infectious.

Those involved in the program say it debunks a misconception that people are deliberately disregarding health directions and offers important lessons nationally for COVID-19 outbreaks, as well as a model for better chronic disease management in future.

cohealth chief executive Nicole Bartholomeusz said there has been a lot of focus from the State Government on encouraging people to get tested, and issuing strict quarantining directions for those who are positive.

“But we now know that we also need to ensure everyone is able to comply with the directions. Many don’t need support – they’re well-resourced people with friends and family. But not everyone has the same social supports,” Bartholomeusz said of the pilot, which she presented on behalf of cohealth to an AHHA event last week.

The lessons, she said, are vital for future outbreaks in Victoria and more broadly in Australia, showing that “the only way we are going to be able to fully transition out of COVID is if we address the social inequities that prevent people from self-isolating”. She says:

Rather than ask ‘Why are they disregarding the rules?’, this model asks ‘what will help you to comply with the rules? The need for this service is an important learning to share with other states and territories who are trying to prevent outbreaks.”

But the effectiveness of the program also raises questions about why Victoria’s public health system – criticised by many for its highly centralised approach versus New South Wales’ hailed “cottage industry” response – wasn’t considering the financial and social needs of people required to isolate from the start.

It also challenges Victoria’s highly punitive approach to the pandemic, where defence force personnel and police knock on the door of every COVID positive person to make sure they are isolating and individuals face fines of nearly $5,000 for breaching social distancing restrictions.


Creating a “safe place” for contact tracing

Victoria’s second wave  is close to being brought under control after 16 weeks of varying lockdowns, including more than 11 weeks at Stage Four which included a curfew and strict limits on leaving home.

These are now beginning to lift, but there remains concern about the pace of relaxation, and whether all the systems are in place to be able to quickly address any new outbreaks.

Last week a high-risk new COVID-19 cluster in the regional Victorian town of Shepparton was sparked by a truck driver who did not immediately tell contact tracers he had stopped there.

Premier Daniel Andrews and his team have been urging Victorians to consider an interview with contact tracers as being like “a consultation with a doctor”, rather than something that could result in punishment. 

For example, said Deputy Chief Health Officer Professor Allen Cheng, some cases had told contact tracers who they injected drugs with.

“We’re not going to refer that to police. We just want to know what is relevant to controlling this infection and it is a safe space for people to tell contact-tracers exactly what they have done and we want to make sure people know that.”


“Case study of the social determinants”

The COVID+ Pathways program had its genesis in the lessons of the distressing hard lockdown of more than 3,000 people in nine public housing towers in July,— without warning,  under police guard and with no consultation or collaboration with the local community, despite their urging for months for a plan for such an outbreak.

As Bartholomeusz wrote then for Croakey, around 1,000 of the residents in the Flemington and North Melbourne estates were existing clients of cohealth, who after early days of distress and chaos were able to step into the breach and work with community.

Chris Turner, who coordinated cohealth’s program at the towers, said it was quickly clear how difficult it was for people “living in close confines” — families with six people or more in a two bedroom home with one bathroom – to be able to stay safe and adhere to social distancing messages.

But there were also many other factors in play.

Yes, he said, the State Government was making payments available to cover lost earnings if people had to quarantine or isolate and could not access sick leave.

“But if someone was in a casualised role, it was not so much the cash concern but ‘am I going to be seen as replaceable?’, ‘is my boss going to stop giving me shifts’.”

In response to a range of concerns about people’s ability to access the support they needed to isolate, cohealth pitched for the COVID+ Pathways pilot, in partnership with the Department of Health and Human Services, the North Western Melbourne Primary Health Network (NWMPHN) and the Royal Melbourne Hospital – a collaboration that will look for many New South Wales people like a Local Health District arrangement.

The pilot program has been operating 7-days per week since early August from a control centre in inner city Footscray with a team of 40 GPs, nurses and allied health professionals, rolled out across northern and western Melbourne and now replicated in  other areas.

Alongside the clinical triage, the program’s social risk assessment asks a set of questions including ‘do you have enough money to pay the rent this month?’, ‘do you have someone who can bring your food?’, ‘do you have reliable internet?’, and ‘is it safe for you to remain in your home?’ to establish what supports each person needs to quarantine after a positive diagnosis.

A snapshot of its first six weeks in operation found that 58 per cent of the 1,263 people it worked with required social and welfare support (financial, food packages, housing, drug and alcohol support, access to Medicare) in order to be able to safely self-isolate.

Turner said they included many people who without the program could not access Medicare, mostly international students, as well as refugees and asylum seekers who, according to this Saturday Paper report, are now set to face further destitution.

Many in the program were at other form of risk. The team worked with police to support a number of people at risk from family violence to get into alternative accommodation. Some older people did not have credit cards or computer access so they could shop for food online. Others needed support with drug withdrawal or opioid replacement therapies.

The program also sought to reduce the numbers of calls that an uncoordinated response meant for people who tested positive, when multiple agencies might get in touch to the point of “fatigue” for someone already feeling stressed and/or unwell.

Turner said cohealth’s community health lens had been really important in a pandemic that has become “a case study of the social determinants of health”

He’s not sure whether this was something that Victoria was missing that other states have, “but what I would say is if states don’t have it in place, they should be thinking about it.

“It’s an absolute learning for all jurisdictions and for any future health crisis…you can’t just focus on the immediate clinical side. There are different needs in different communities that require a local and connected response.”

Public housing towers that were placed under hard lockdown

“We know our patients better than others”

While referrals are now slowing as the wave is contained, still every person in the COVID+ Pathways catchment who tests positive and wants to be involved in the program is called regularly.

Those assessed to be low risk clinically are connected to a GP. Medium risk means being put in touch with local hospitals (Royal Melbourne, Western, Mercy, Werribee) or Djerriwarrh Health for support managed in their home, and anyone acutely unwell is taken by ambulance to hospital.

For cohealth GP Dr Karen Linton, boosting GP engagement has been a critical part of the program. Many had been asking why they were not being involved, “(saying), ‘we know our patients better than others’.”

A huge 38 per cent of people contacted did not have a regular GP. cohealth itself provided access to GPs for those, like overseas students and those on working visas, who did not have access to Medicare.

Among her patients, she observed a lot of confusion about COVID-19, particularly around  atypical symptoms —  patients with lower back pain or who had lost their sense of smell or taste and didn’t think for a moment they might have COVID-19.

Stigma also emerged as a big risk to address, with people being evicted from share houses because they were COVID-19 positive, or others who didn’t want to tell housemates they had tested positive because they thought they’d be evicted.

What also stood out for Linton was just how long some people and households had to remain in isolation, and the impact that had  not just financially and socially but also on health, including some who had to postpone  cancer treatment and surgery.

In some households, prolonged isolation particularly hit some children and teens who don’t become COVID-19 positive but have to stay isolated until everyone else in the household is cleared — sometimes weeks or months.

She knew of one man who was still in isolated at Day 55 because he had a cancer diagnosis and was immune-compromised, causing his swabs to keep coming back positive. A woman still had symptoms six weeks after testing positive. She finally tested negative but at the five week mark, her husband tested positive, leaving them both in quarantine again.

Linton believes the COVID+ Pathways program has saved lives, saying she was struck by the number of relatively young people — people in their 20s, mostly on temporary visas, working in aged care or as cleaners, and with no access to Medicare — who “got sick very, very quickly”. Some ended up being intubated within 24 hours.

In many of those cases, she said, patients didn’t realise how sick they were until someone assessed them clinically over the phone — “this is the thing with respiratory disease and hypoxia, you get a bit confused but don’t know why”.

Others didn’t know how to navigate the health system because of language barriers or concerns about money — not having ambulance cover or, having private health insurance, but not the cash to cover upfront payments.

“I absolutely think people could have died (without the program),” she said.


“A relatively seamless escalation pathway”

For Professor George Braitberg, an emergency physician and head of Royal Melbourne Hospital’s quality team, the COVID+ Pathway program served as a critical “monitoring and early warning system”.

The Royal Melbourne operated within the program as a “virtual hospital” with a tiered pathway to monitor patients via telehealth with trained nurses or through ‘hospital in the home’ to prevent deterioration and the need for hospitalisation, and with a system in place to get them to hospital quickly if they needed more acute care.

Braitberg said that there were some early frustration when privacy concerns and regulatory restrictions delayed notification of COVID-19 positive patients in the catchment, leaving clinicians unable to intervene in that crucial first 5-8 days. Once this was addressed, there was rapid transfer of contact lists and enrolments.

Like so many hospital staff in Melbourne, Braitberg is hugely relieved that, despite early fears and high numbers of aged care patients, “we never saw in Victoria the scenes we were first frightened about, looking at the Italian, French and Spanish experiences”.

With the reintroduction of lockdown measures, the program enrolled a little over 800 COVID-19 patients in north west Melbourne, compared to earlier projections of 2,500. Of those, only 12 per cent required admission to an inpatient bed at the hospital at any one time, he said.

Braitberg said that while a thorough evaluation of the COVID-19 Positive pathway is being undertaken, because the number of patients enrolled into the program was lower than anticipated it may be difficult to measure how many hospitalisations were avoided.

But he said, it’s “self-evident” that if you can successfully support someone who is COVID-19 positive to quarantine, who for a number of social and welfare reasons would find it difficult, you’re likely to contain the viral spread effectively.

Asked whether Victoria was playing catchup with this program or forging a new pathway nationally, Braitberg says he doesn’t know, but he believes it is among the most innovative across the country. He would welcome a forum that reviews the different responses across the country, “so that we can look at what was done well, what could be done better and what we have learned needs to change.”

One of his takeaways from program and responses to the health care needs of people in the public housing was learning what could be achieved when primary care, health department and hospitals work so closely with one another.

For him, it offers a great model of chronic disease management, “providing the support GPs and community health need to be able to manage patients well in community but also giving them a relatively seamless escalation pathway when things start not to go well.”.

The COVID+ Pathways program is, he says, now winding up as the patient numbers dwindle.

But the partners are still meeting as a group and, as Melbourne looks cautiously and anxiously at emerging from lockdown, they are “considering how we can ‘snap back’ the program when required”.

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