Hard lockdown and a “health dictatorship”: Australia’s lucky escape from covid-19
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4910 (Published 23 December 2020) Cite this as: BMJ 2020;371:m4910Read our latest coverage of the coronavirus outbreak
The journalist Donald Horne dubbed Australia the “lucky country” in the title of his 1964 book. Though intended as a criticism of its government, Australians have taken the moniker literally. Australia’s so-far successful battle with covid-19 makes this seem even more apt.
One key decision was that of the National Security Committee to shut borders with China, one of the country’s major trading partners, on 1 February.1 The border closure went against World Health Organization advice and at the time led to accusations of government xenophobia. The policy was adopted on the advice of the chief medical officer Brendan Murphy, who was alarmed by reports of community transmission outside China’s Hubei province, where reports of covid-19 originated. Borders to all non-residents were shut on 20 March. In the early days of the crisis, Murphy made daily TV appearances alongside Prime Minister Scott Morrison, offering viewers a fast track education on viral epidemiology and explaining why a growing list of restrictions, including bans on non-essential travel, internal border restrictions, and quarantine for all overseas travellers, were needed.
During the first wave of the pandemic the number of new cases grew to around 350 per day, mainly in the state of New South Wales. Throughout 2020 the virus was largely contained to two states: New South Wales and Victoria. Cases began to fall as social restrictions came in. By the end of April, there were just 20 cases a day being recorded across the country and with it a belief that it was through the worst. That proved to be naive.
Mistakes
Two mistakes made the virus’s menace very real. The first was the government decision to allow 2400 passengers to disembark the Ruby Princess cruise ship at Sydney’s Circular Quay on 19 March without testing, despite passengers with influenza like illnesses and acute respiratory illnesses. The passengers returned to their homes; when they were tracked down, 660 tested positive for covid-19 and 28 later died.2
The second mistake was a breakdown in quarantine at the Rydges Hotel in the centre of Melbourne, Australia’s second largest city, which was used to isolate foreign travellers—including a family of four who would later be identified as the source of 90% of 18 000 second wave infections in Victoria.
An official inquiry3 was later told that private security guards, rather than police, had been used to enforce quarantine. They were given limited training on infection control—in some cases lasting no more than 30 minutes—and insufficient supplies of personal protective equipment. It also emerged that some guards had escorted travellers on shopping trips around the city.
It was this second outbreak that eventually triggered, on 7 July, one of the world’s toughest covid-19 lockdowns, lasting 112 days, in Melbourne. The city’s five million residents were subject to the strict stay-at-home orders that one media report described as an entire city put into a form of protective custody.4 Police had been used to stop around 3000 residents living in some of the most deprived areas of Melbourne from leaving their tower block apartments. These buildings were dubbed “vertical cruise ships” by acting chief medical officer Paul Kelly. Food supplies were brought in and healthcare had to be delivered by medical teams from outside.5
In the following weeks, as cases continued to rise, nightly curfews were imposed on the rest of the city; schools and businesses were shut and people were told not to travel more than 5 km from their homes without authorisation. They were allowed outside for an hour for exercise.
What was not known at the time, however, was that the structural inadequacies of the state of Victoria’s public health department would undermine these efforts.
Consequences
Catherine Bennett, Deakin University’s chair in epidemiology at the Institute for Health Transformation, says the test and trace system in Melbourne failed during lockdown. “We were struggling to get the testing regime working: the results weren’t coming back quickly enough for the contact tracers to act, and then the tracers were overwhelmed. It was the difference between documenting an outbreak and bringing case numbers down and stopping new outbreaks.”
In April the whole of Victoria had just 57 contact tracers including public health clinicians, logisticians, phone operators, and data entry staff. As the crisis worsened the state government was forced to increase staffing to over 2000.
Bennett told The BMJ that contact tracing and isolation were finally on course by October, “but it came late and there’s an argument that the lockdown would not have been needed for so long had the resources for testing and contact tracing been in place earlier.”
In July, across Victoria, 700 people a day were testing positive for SARS-CoV-2. Care facilities suffered the brunt of the outbreak. Long underfunded, care homes were left to flounder as the virus spread, with staff given little training or the protective equipment to deal with the threat to residents.6
Some 1100 aged care workers and more than 400 aged care nurses were infected. At one facility, the Edithvale aged care home in Melbourne, 18 residents died. From the point when the first staff member became ill it had taken four to five days for the home to get the test result. “We thought they would be testing straight away, but apparently not,” Lexie Dennis, the home’s general manager, told ABC News, “There wasn’t much contact tracing assistance from the health department, we had to undertake our own contact tracing and then send our information to them.”7
Outbreaks continued to seed the virus back into the community months into lockdown. According to Bennett, healthcare workers accounted for one third of covid-19 cases through the later stages of the second wave in September and October, with their close contacts accounting for another third.
Health dictatorship
Royal Melbourne Hospital, the biggest hospital in the city, faced the largest institutional healthcare worker outbreak of all, with 260 staff diagnosed with the virus during July and August, including 179 nurses and 21 doctors. Some 15 staff members required inpatient care and two ended up in intensive care, though there were no deaths.8
Overall demand on intensive care units during the second wave remained relatively small according to Chris MacIsaac, head of intensive care at the hospital. Bed capacity had already been tripled following reports and distressing images from northern Italy’s first wave at the start of the year.
MacIsaac believes the lockdown “gave us breathing space.” “There were two cohorts of patients,” he said, “The fit and well, and the very vulnerable in aged care. A judgment was made that it was generally not appropriate for the latter to undergo heroic life support, so they were usually not referred to us.”
As the hospital system coped, wider public debate over pandemic measures intensified. Many doctors questioned whether the Melbourne restrictions were excessive. In an open letter to Dan Andrews, the premier of Victoria, a group of doctors argued that focusing purely on reducing the number of covid-19 cases was an “unsophisticated way of looking at disease management.”9
“Factors such as the side effects of any policy, its cost effectiveness, the quality of life years lost, and the cost per life saved are fundamental when considering disease management,” they wrote. Pointing to the 4000 influenza deaths Australia sees each year, they said, “the medical, psychological, and social costs of the lockdown are disproportionately enormous compared with the limited good being done by current policies.”
Australia’s former prime minister Tony Abbott claimed a “health dictatorship” was emerging under the numerous disaster and emergency declarations—largely as a result of what he described as “viral hysteria.” “Homes can be entered, people can be detained, and the ordinary law of the land suspended,” he said in a speech to the UK think tank Policy Exchange.10 “Governments have approached the pandemic like trauma doctors instead of thinking like health economists trained to pose uncomfortable questions about a level of deaths we might have to live with.”
The lucky country
Despite all this, most people across Victoria complied with the lockdown. Bennett says the response of ordinary Australians was remarkable. “They trusted in the scientific advice they were given; they trusted the leadership. Even if they didn’t believe they were at risk themselves, they understood the harm that could be caused to other people.”
“People lost their jobs, their livelihoods, some were put in tough lockdown with heavy restrictions, and we don’t know what the longer term health implications will be. But they did what was asked of them.”
Melbourne’s hard lockdown ended on 27 October. The second wave, which began in June, had at that point killed 905 people (mainly in aged care), making up 95% of Australia’s total covid-19 deaths. But the restrictions worked: “Covid zero” was achieved in Melbourne, across Victoria, and throughout Australia. The term “double donuts”—days when there were no new cases, no deaths—became familiar.
“Other countries can look to Australia and see what happens in strict lockdown. I don’t think those other places have to feel it has to run for so long, to assume they have to stay in a holding position for 120 days,” Bennett said. “Such lockdowns should work in about 8-10 weeks. If you have a city and the virus is in 10% of households, the intervention that works is the same as one in which the virus is in 50% of households.
“What drives the wave and stops it from being contained is the cycling between social places, workplaces, and homes. That’s the vicious cycle where it’s a struggle to contain the virus.”
At the time of writing, Australia has seen 28 000 cases in total and 908 deaths. And outside of Victoria and New South Wales, the country has remained largely untouched—just 35 deaths from less than 3000 cases. Despite the blunders, in contrast to elsewhere around the world, Australia’s numbers are extremely low. The lucky country, indeed.
Footnotes
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Commissioned, not peer reviewed.