Marie McInerney writes:
Australia’s leading scientists are calling for the data underpinning COVID-19 decisions to be made public, saying it is critical the public has confidence that governments are basing their decisions on the most up-to-date scientific advice and evidence.
The call from the Australian Academy of Science comes after a visibly worried Chief Medical Officer Professor Brendan Murphy on Tuesday night urged the community to take growing social distancing restrictions seriously, in the face of “very, very steep growth” in the number of cases of COVID-19 in recent days.
(Meanwhile, the World Health Organization and others are pushing for the term “social distancing” to be dropped in favour of “physical distancing”, recognising the importance for people to remain socially connected during these traumatic times).
By 3pm on Wednesday (25/3), there had been 2,423 confirmed cases of COVID-19 in Australia, up 287 over the previous 24 hours, led by New South Wales with 1,029 and Victoria with 466 (the ABC has reported that per population South Australia is testing for the virus that causes COVID-19 at more than twice the rate of Victoria and WA, and nearly five times the rate of Tasmania).
See also this real-time view of Victorian #COVID-19 data, released on Wednesday by Victorian Chief Health Officer Professor Brett Sutton.
Media have speculated that Victoria and/or New South Wales may escalate restrictions from ‘stage 2’ (announced on Tuesday by the Prime Minister), with Victorian Premier Daniel Andrews warning that moving to ‘stage 3’ will happen, though “not today” (Wednesday).
The tweet below illustrates the different approaches of Federal and Victorian public health advisors.
With the possibility emerging of different responses in different jurisdictions, the Academy of Science said the Federal Government must make public the scientific evidence that is informing its thinking, so the “scientific know-how of the nation can be brought to bear” on the crisis.
“Transparency must be at the core of the government responses” in such a fast-moving emergency, the Academy said in a statement recommending Australia follow the UK model where the scientific evidence is published by the UK Government Office for Science, led by the Chief Science Adviser.
Amid mounting concerns about the escalating crisis, the Federal Government has berated Australians who have not complied with restrictions, particularly those returning home from overseas or who have received a positive test and not gone into immediate self-isolation.
Former Australian of the Year Professor Fiona Stanley and colleague Professor Jonathan Carapetis have written an open letter to Western Australians, promoting tougher actions the government could take but also highlighting stories of “people downplaying the severity of this pandemic”, including grocery shopping while waiting to receive their test results.
But the messaging to the public, from the Federal Government in particular, has been often confusing and rambling, delivered mostly at media conferences where it is often impossible for others watching to hear the questions put to the politicians and officials.
Many have also argued the need for clear and precise written and graphic communications to be made promptly available on line in accessible formats.
On Wednesday the Federal Government finally began sending direct text messages alerting people about they should be doing – as per in bushfires and other emergencies.
It was welcome, but already there are concerns about how the texts are being sent (many appear as if they are a ‘service’ message from Telstra) and the message they are sending (“stay home if sick” versus “stay home if you can”).
Many in the health sector and wider community have been left wishing far more detail was available to them than can be found in the Australian Health Sector Emergency Response Plan for Novel Coronavirus.
This article details some of the latest major developments affecting health care and links to some of the questions being raised about capacity, access, workforce and other issues being shared with us at Croakey and elsewhere.
It canvases many questions and answers being proffered about practical efforts: whether retrieval services will continue for rural and regional patients, how many extra ventilators and specialist staff to use them have hospitals secured, and to provide support and care for the health workers on the frontlines.
Difficult questions are arising about who to treat (and who not to treat) if hospitals cannot meet demand, the role of private hospitals, and ethical and human rights concerns about digital surveillance and policing, as well as what risks may lie ahead for our democracy and global security.
Latest news
Despite urgent efforts to secure more tests, the Federal Government is saying we are at the forefront globally.
Health Minister Hunt said on Tuesday that around 147,000 pathology tests had been carried out in Australia, representing 558 tests per 100,000 or greater than 0.5 per cent of the population – which he said is higher than Korea, and way higher than UK 117; USA 22. Who is tested is also critical, as this earlier Croakey story details.
Prime Minister Scott Morrison on Wednesday announced that all non-urgent elective surgery would be cancelled from midnight. This followed much lobbying and a joint statement earlier in the day from leading medical groups who warned it was unnecessarily putting patients and staff at risk of infection with the novel coronavirus and consuming vital reserves of medicines and resources, including personal protective equipment (PPE).
The Government has set up a National COVID-19 Coordination Commission (NCCC) that will coordinate advice on how to anticipate and mitigate the economic and social effects of the coronavirus pandemic. It is headed by former mining executive Nev Power, but does not have a clear social or health policy member. Prime Minister Morrison said it would “work in tandem” with the Chief Medical Officer (CMO) Dr Brendan Murphy. 
Minister Hunt said more than 150,000 health and aged care workers had done the Health Department’s new COVID-19 Infectious Control Training eLearning course over the past week.
And among many other announcements, the Federal Government heralded a “whole of population” expansion of telehealth services, funding for services in remote Australia, and training for registered nurses to get back into the workforce.
Surge preparations
This week Health Minister Greg Hunt filled in some of the gaps many had been asking about hospital capacity, access, resources, and supports, saying there is standing capacity of about 2,000 ventilators through the ICU beds , which the government is looking to double, using existing arrangements and stock that is currently available.
Chief Scientist Alan Finkel is leading work on Australian production which, Hunt said, could add an additional 5,000 invasive and non-invasive respiratory and ventilator units to Australian capacity, though there’s no timeline for that yet nor an answer to what we might need.
Croakey asked our networks, including on Twitter, about how well hospitals are preparing for the expected surge of patients. Concerns raised included:
- Plans for staffing issues as people are quarantined/sick. Bed plans; clearing wards, converting OTs to ICU, field approaches like tents or co-opting local buildings. How will isolation of staff be managed? Staff who can’t go home to their families, where will they sleep, eat?
- Medication and PPE shortages: already happening (Panadol and gentamicin where I am). How are they planning for this? What treatment algorithms are being followed, is this going to be nationally standardised and is there plan B, C etc for when the relevant drugs are short?
- Must not forget about the administration workers. Many are crammed into small office spaces. Social distancing does not exist.
- Guarantees of extra funding for hospitals to deal with coronavirus?
- Questions for hospitals: How many new ventilators has your hospital acquired? How many did you already have? How many nurses have been trained to run ventilators in the last several weeks? How many new beds have you opened/identified – where are they? What about overflow care centres, like basketball stadiums – have you set any up yet? How many beds do they hold? What contracts have you signed on such facilities?
- Increasing ventilator numbers alone without having sufficient staff to operate them is futile.
- On quarantined/sick staff: what protocols are in place to guide safe return to work and who will make these decisions?
#ShutDown
Meanwhile, thousands of doctors have signed an open letter to Australian governments urging a total shutdown of non-essential services, in part to give healthcare workers and systems more time and resources at the frontline, saying “preparations remain incomplete”.
They point to inadequate supplies of PPE and the need for training to use it properly, to make environmental changes to minimise the risk to staff from COVID-19 and to adopt measures to increase capacity to care for critically ill patients.
“Many hospitals are still performing elective surgery, repurposing of areas remains incomplete and vital equipment has yet to arrive,” they said.
See also:
- This Twitter thread from paediatric rheumatologist Dr Jane Munro, calling for “China level PPE” and for health care to “over-prepare like freaks”.
- A graphic and detailed ‘tweetorial’ of an interview with Italian intensivists Drs Giovanna Colombo and Lorenzo Grazioli on the frontlines of the Italian #COVID19 outbreak.
- A Spanish thread “full of brilliant organisational gems (learnt the hard way)”, as one tweep put it, regarding arrangements to manage COVID-19 in hospital.
- A thread about what family medicine is doing right now to support patients and the health system in Canada.
Supporting health workers
Efforts are underway, across the health sector and wider community, to provide support for health workers.
See this Twitter thread, warning them to not put themselves at unnecessary risk: “There is no emergency in a pandemic”.
Others are calling on the rest of the community to help with child minding, cooking, shopping etc for health workers, and for things like free parking (including commandeered neighbourhood spots) for all hospital and health care workers so they don’t have to search for spaces or use public transport.
The United Kingdom is looking for 250,000 volunteers to help the National Health Service (NHS) and vulnerable people hit by the coronavirus crisis: to help with delivering medicines from pharmacies, driving patients to and from hospital appointments and phoning people isolating at home to check up on them.
Fair resource allocation
A question haunting many is about what happens when the demand for care exceeds any possibility of providing that care equally to all and, as Queensland Emeritus Professor Gerard Fitzgerald has written, “very difficult decisions have to be made involving triage of patients”.
The New England Journal of Medicine has published a series of graphic, confronting articles on these issues, including one describing the impact of the outbreak in Italy: operating rooms turned into ICUs, patients who are admitted for other reasons contracting the disease and health workers falling ill.
Another says physicians in Italy have proposed directing crucial resources such as ICU beds and ventilators to patients “who can benefit most from treatment” while in one South Korean city, a hospital bed shortage meant patients died at home waiting for admission.
The authors make six recommendations: maximise benefits, prioritise health workers, do not allocate on a first-come, first-served basis, be responsive to evidence, recognise research participation, and apply the same principles to all patients, whether they have COVID-19 or not.
When it comes to allocating ventilators, another article in the Journal recommends the creation of triage committees to “help mitigate the enormous emotional, spiritual, and existential burden to which caregivers may be exposed”.
It describes Italian physicians “weeping in the hospital hallways because of the choices they were going to have to make.”
And it’s not only those in health care facing these sorts of decisions. Others are raising the need for everyone to have conversations with loved ones about our preferences and values around treatment if we become seriously ill (and still have choices).
Beyond the cities?
The pandemic’s equity implications are enormous for rural and remote Australia, where people experience poorer health and poorer access to health care.
The Federal Government this week held a rural and regional health roundtable on the coronavirus. Its communique raised a host of issues, including the need to boost the health workforce in areas of need, to provide continuity of services if local health providers need to self-isolate, and the importance of providing culturally appropriate services for Aboriginal and Torres Strait Islander people (interesting not to use the AHPRA-endorsed concept of cultural safety).
The Rural Doctors Association of Australia (RDAA) and the Australian College of Rural and Remote Medicine (ACRRM) on Wednesday called for an urgent allocation of resources, saying the window of opportunity to supply rural, regional and remote Australia is “rapidly closing”.
A rural journalist asked:
Responses pointed out that most rural hospitals do not have ICU capacity for extended critical care, or the specialist staff to operate ventilators, and rely on transferring critical patients out.
Will the Royal Flying Doctor Service be able to do this in the numbers required, and will the metro hospitals take them?
See also this interview from ABC TV’s 7.30 Report with Kalgoorlie GP Dr April Armstrong on the issues being faced by regional Australia.
Another rural doctor said so far the private clinic where he worked had seen “zero input from the public health sector”, had taken it on themselves to begin modelling scenarios and planning logistics, and had “purchased thousands of dollars of protective farm equipment as makeshift PPE”.
See also thread by Dr Louis Peachey.
Aboriginal and Torres Strait Islander concerns
Health professionals also raised issues for Aboriginal and Torres Strait Islander communities, particularly those in remote areas:
- With remote communities to be locked down and at highest risk, but also largely dependent on locum workforce which typically does very short rotations, how do we manage staffing in these areas?
- Seriously huge issue. FIFO has made medicine possible in some remote places – 24/7 for a week then changeover – exact same model increases spread risk, no? solo docs can’t just go & stay. Can we adapt fast to a team approach? For example, 3 docs go in for 2 months?
- Balancing infection risk with staff burnout risk in these places very challenging. Do we quarantine people prior to deployment there? Do we deploy teams for longer rotations?
Associate Professor Megan Williams, Research Lead and Assistant Director of the National Centre for Cultural Competence at the University of Sydney and a contributing editor at Croakey, said issues for the broader Aboriginal and Torres Strait Islander community raised with her this week included:
- Strategies to improve access to information about prevention, testing and transmission of infected? Any new funding streams available? Including use of local language, via training of staff and regular updates for radio.
- Addressing misinformation.
- What capacity is there to provide support for children and dependents when parents must be in quarantine, eg referrals, financial support?
- What arrangements can be made to inform and prevent transmission to homeless people, such as longer stays and lower/no fees in hostels, and greater access to hygiene care?
- Ongoing issues of low access to hospitals, distrust for mainstream information and services, and having to use staff for coronavirus-related action unfunded and therefore at the risk of other work.
Risks to justice, democracy
In Australia, Parliament will not sit for some months, raising concerns about the state of our democracy. Meanwhile, in New Zealand…
In Victoria a taskforce of 500 police has been deployed to ensure people are complying with self-isolation on return from overseas, while concerns are also being raised about new powers for NSW police.
Scholars from Harvard and other US institutions have warned that coronavirus ‘triage decisions’ should protect/preserve the essential elements of political institutions and social fabric. See this Twitter thread from Croakey’s Dr Melissa Sweet.
Historian Yuval Noah Harari also writes that many short-term emergency measures will become a fixture of life after the outbreak. He says:
Decisions that in normal times could take years of deliberation are passed in a matter of hours. Immature and even dangerous technologies are pressed into service, because the risks of doing nothing are bigger.
Entire countries serve as guinea-pigs in large-scale social experiments.”
The International Crisis Group also writes about COVID-19 and conflict, warning the global outbreak has the potential to wreak havoc in fragile states, trigger widespread unrest and severely test international crisis management systems.
And the Global Alliance for Food and Nutrition is asking whether governments, businesses and civil society are thinking enough about food access and the wider food system?
PostScript
The image below was published with our first story on the outbreak, on 28 January: Catch up with useful news and sources on the new coronavirus.
At that time, there had been 4,474 cases confirmed with 107 deaths and 63 people recovered. Contrast those numbers with the feature image above this story: 436,159 cases confirmed, with 19,648 deaths and 111,847 people recovered.
Note from Croakey Health Media
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