Introduction by Croakey: Ever since the COVID-19 pandemic began early last year, governments have imposed restrictions on commercial activity and individual freedom of movement that were last seen a century ago in response to the 1919 influenza pandemic.
When these restrictions are announced, political leaders invariably claim they are acting on the “health advice” from their Chief Medical Officers, Chief Health Officers or other expert committees and advisers.
In the article below, Croakey contributors Charles Maskell-Knight and Jennifer Doggett explore the role of these health advisers to government over the course of the pandemic.
They identify the strengths and weaknesses of how expert advice has been used to inform Australia’s COVID-19 response, and propose three strategies to improve the way governments receive and act on health advice in the future.
Charles Maskell-Knight and Jennifer Doggett write:
Governments have always been advised by health and medical experts when developing health policies and programs.
But before COVID-19 these experts rarely had a public profile.
Over the past 18 months, Chief Medical Officers (CMOs) and Chief Health Officers (CHOs) have become an almost daily presence at media conferences, often standing next to the Prime Minister or a Premier (as pictured below), and given greater prominence than any other government representative, including even the health minister.
Along with the CMOs and CHOs, other government expert advisory committees and external sources of expert advice have also informed Australia’s COVID response.
There is no doubt that the influential role of medical and health experts is one contributor to the overall success Australia has had in limiting the health impacts of the pandemic. Despite tragic outbreaks of COVID-19 in residential aged care facilities, quarantine failures and a slow vaccine rollout, Australia’s mortality rate has so far been far lower than most other countries.
Evidence from around the world also supports this conclusion. Countries where the COVID-19 response was based on scientific and medical advice have fared better than those where expert advice was ignored in favour of political or economic imperatives.
However, it’s also the case that some of the measures advised by health experts have created extreme hardship for many Australians – separating families, preventing children from attending school, and isolating people in their homes.
As the pandemic moves into a more “chronic” stage, it is timely to consider how to preserve the benefits of Australia’s science-led approach while addressing some of its limitations.
In particular, we suggest there is a need to increase the accountability of governments when using health advice and to minimise the potential for adverse effects of public health responses, in particular on marginalised and under-served groups.
The changing role of medical advice
Health and medical advice has played an important role throughout Australia’s response to the pandemic but this role has changed as the pandemic has progressed.
In the early stages, both the Federal Government and state leaders made a point of stressing that their decisions about the public health response were driven by “medical advice”.
In March last year on the ABC’s Insiders program Health Minister Greg Hunt set the tone:
we’re very focused on… ensuring the medical advice is paramount… it is very important that we listen to the medical experts… it is important that we follow the medical advice and not the armchair experts.”
This approach is what led the Prime Minister, Scott Morrison, to hold the extraordinary 7.30pm press conference on 8 April to announce the advice of the Australian Technical Advisory Group on Immunisation (ATAGI) that the Pfizer COVID-19 vaccine should be preferred to the AstraZeneca vaccine for people aged under 50. This was followed by a later statement that he was making “constant appeals” to ATAGI to change this advice.
More recently the Federal Government has chosen not to follow medical advice to the letter, for example when this would severely restrict the numbers of journalists attending the Prime Minister’s press conferences.
There is also evidence that state governments are moving away from a blanket acceptance of recommendations from health experts. NSW Premier Gladys Berejiklian said on 10 September “what we need to do is always weigh up that health advice with public policy and I would never do anything where the health experts completely objected to anything or did not think it was safe”.
And it has been widely reported that the NSW CHO, Dr Kerry Chant, argued strongly that restrictions should not begin to be removed when vaccination rates reached 70 percent of the eligible population, but was overruled by politicians.
Importance of public trust
Differences in views between health advisers and politicians are not a problem in themselves and are to be expected on an issue as complex and multi-faceted as COVID-19.
As political commentator Waleed Aly said on Insiders on 12 September 2021: “The politicians’ job is not to follow health advice. Their job is to take health advice, consider it, place it in its proper context.”
However, it is important that governments take full responsibility for their policies and do not hide behind health advice when making difficult decisions.
A crucial ingredient of a successful public health response is trust. Without this public trust governments have no way of enforcing the public health measures, such as lockdowns, crucial to Australia’s successful response.
Australians have so far displayed a remarkable degree of trust in their governments to steer them through the pandemic but this trust can be quickly eroded if governments attempt to politicise or scapegoat health advisers when announcing unpopular public health measures.
The role of CMOs and CHOs
Avoiding politicisation is particularly important in relation to advice from the CMOs and CHOs. These officials occupy ambiguous positions at the junction of the bureaucracy and the political executive. Some are appointed by the Governor, some by the Health Minister, and some by the head of the health department.
They generally have no specific statutory protection against summary removal. They are essentially public servants within departments headed by Ministers, who are accountable to the public through Parliament.
On many public health issues they are advisers to Ministers, who are responsible for making decisions and taking executive action. Their role as advisers is particularly important now when health department secretaries and ministers for health are more likely to have economics or law degrees than health or medical qualifications (as discussed previously at Croakey).
In many jurisdictions CMOs and CHOs also have largely unfettered statutory powers to deal with communicable diseases by making public health orders, enforceable through criminal sanctions, and regulating most elements of people’s conduct in society and the economy.
For example, under section 117 of the Victorian Public Health and Wellbeing Act 2008, the CHO may require a person who has COVID-19 or who has been exposed to it to:
- participate in counselling, education or other activities
- refrain from certain activities or forms of behaviour
- refrain from visiting a specified place or class of place
- live at a specified place
- submit to the supervision of a nominated person
- receive prophylaxis, including a vaccination, and undergo specified pharmacological treatment, and
- be detained or isolated or detained and isolated.
These are extraordinary powers to be exercised by a person who is neither directly publicly accountable and is not a judicial officer.
It’s easy to see on a superficial level how useful the CMOs and CHOs can be to a government. One reason politicians make such a virtue of acting on the health advice is that if things go wrong, or if the course of action is unpopular, no blame can attach to the political decision-maker.
Preserving the balance between their roles as independent advisers, holders of potentially draconian legal powers, and public servants is important if medical and health advisers are to be effective.
But this requires an ongoing commitment on the part of government to take responsibility for unpopular decisions, and to be clear about when they are departing from the health advice, rather than trying to bend the health advice to their will.
It is the independence of health advisers that gives them credibility. The community is more likely to respect and trust a source of advice they see as not being influenced by political considerations.
The United States experience under the Trump Administration showed what happens when political leadership overtly disagrees with and disparages public health authorities.
Preserving the independence of the CMO/CHO roles should be a priority to assist Australia’s response to future public health threats.
Narrow base of health advice
Another issue for consideration is the narrow base of health and medical advisers informing Australia’s response to the pandemic.
As outlined previously at Croakey, CMOs at the Commonwealth level have been almost all male (all but one) and there is little racial and socioeconomic diversity.
We have not done a similar analysis of expert committee members but suspect they are also from similar high SES, professional and mostly white urban-based backgrounds.
These committees and advisers clearly have an important role to play, but as Australia moves into the chronic stage of the pandemic other sources of expertise and advice should be included.
A significant omission in Australia’s response so far has been the recognition of the knowledge and expertise of communities and community leaders whose perspective and experience should also inform government decisions.
In the short-term it was clearly difficult to undertake meaningful consultation with communities, but this should be a priority in the future. The success in community-led responses in Aboriginal and Torres Strait Islander communities indicates how important this can be, particularly in under-served and disadvantaged sectors of society.
There’s advice and then there’s advice
Health advice needs to be contextualised within a specific social and political context. The frequent citing of “health advice” by politicians creates the false impression that there is a single opinion shared by all experts – a universally agreed and objective position. But experts have provided a range of different and sometimes conflicting advice during the course of the pandemic, and governments have chosen which advice to follow.
Expert judgements don’t emerge from a vacuum, but arise from specific contexts and contain embedded assumptions. Different experts and different disciplines involved in this area – epidemiology, virology, public health, health system management – all come with different perspectives. It is important that these contexts and assumptions are explicitly identified and acknowledged, together with any limitations on the advice that is being provided.
This is what occurs at the individual level when doctors provide advice on treatment options, taking into account the age, health condition and social circumstances of patients. Where there are options for different clinical approaches, doctors should set out for their patients the alternative treatment options and their risks and benefits as part of the process of informed consent.
The same principles apply at a population health level.
In considering action to address a public health problem in a community, public health physicians should consider factors such as the demography, health service availability and health status of the area, along with other factors such as languages spoken, employment and childcare patterns and cultural beliefs and practices.
This will help assess the impacts of alternative approaches to a public health threat. What will be the likely impacts on morbidity and mortality of the different options? How will these impacts differ by demographic group and by region? Will the health system have the capacity to cope with the demand for health services under the different options?
These equations are crucial now as we contemplate an exit from current COVID-19 restrictions. Returning unvaccinated children to school may benefit healthy children but put students and teachers with underlying health conditions at risk. Opening borders may help families reunite but risk causing outbreaks which lead to lockdowns and other measures that create hardship for others.
An ear for community input
A strength of public health and epidemiology is that it operates on the population-wide level. It can use data to identify patterns which are not apparent when looking at individual experiences.
But trading off the costs and benefits across different groups in the community are not questions that medical and health experts should answer on their own, or indeed are able to answer on their own.
In complex public health situations, such as COVID-19, there are no risk-free options. Expert health advice has an important role to play but it is critical there is input from consumers and affected communities.
The approaches of the NSW, Victorian and Queensland governments to recent outbreaks of COVID-19 suggests that decision-makers have divergent views about the risks and benefits of lockdowns as a means of controlling the spread of the virus. In our view it is highly unlikely that the NSW CHO would have provided completely different advice to that offered by the Victorian and Queensland CHOs on the best response to a handful of COVID-19 cases in the community.
The different responses of the state governments are not a problem in itself (although it can present some logistical barriers to dealing with a virus which does not respect borders). But the lack of transparency around political decision-making and the role of health and medical advice in this process is an issue.
In a democracy it is appropriate that decisions about public health measures such as lockdowns are made by politicians accountable to the public through the electoral process but accountability needs to be supported by transparency. This means that decision-makers should make public health advice public and be explicit about their assumptions about the health risks and benefits of different options.
How can we improve accountability?
Australia has so far managed the impacts of the COVID-19 pandemic better than many other nations, and the readiness of political decision-makers to take into account health advice has played a significant part in this success.
However, problems are emerging in the relationship between health advisers and governments and we believe there are reforms that would improve that relationship, and result in a better allocation of responsibility for making difficult decisions affecting the community.
- CMOs and CHOs should be established as truly independent statutory office holders to provide governments with independent advice on public health matters. They should be appointed for a fixed (renewable) term, and subject to removal only for physical or mental incapacity or misbehaviour.
- A public health council should be established to broaden the base of the advice that CMOs and CHOs provide to ministers and governments. This council should specifically include members who are health workers and people from culturally and linguistically diverse communities and Indigenous communities.
- The power to make public health orders should be vested in health ministers. CMOs and CHOs may be given delegated authority to make orders affecting small numbers of people or small geographic areas to deal with localised public health emergencies such as outbreaks of food poisoning, legionella in cooling towers, or chemical spills.
To ensure proper accountability the power to make orders imposing restrictions on large numbers of people or large areas should be reserved for ministers. Ministers should only be able to make such orders after considering advice from CMOs and CHOs, and this advice should be made public at the same time as the order.
These reforms would ensure governments receive independent health advice, informed by a wider perspective than a single public health physician. They also provide a mechanism for groups most likely to be adversely affected by public health orders to have input into these decisions.
The reforms would address concerns around the lack of transparency in the current system and ensure that the decision makers imposing public health orders have greater accountability to the communities they serve.
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