Covid-19 in Australia: How did a country that fought so hard for extra time end up so ill prepared?BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p469 (Published 27 February 2023) Cite this as: BMJ 2023;380:p469
When the covid-19 pandemic began, Australia was in a global subgroup of countries that, as island nations, could close their international borders to buy time to prepare for community transmission of SARS-CoV-2. Australia only fully opened its borders to international visitors in February 2022, and throughout 2020 and 2021 different territories were implementing lockdowns and social restrictions to varying degrees in response to new incursions of the virus caused by incoming travellers and quarantine failures. For Australians, the past year has marked a transition to countrywide community transmission. What has it shown us?
Even with its borders open and widespread infection happening for the better part of a year, Australia’s covid-19 mortality is 736 deaths per million—less than a quarter of Italy, the UK, and US, and just over half of Canada and Denmark.1 Applying the death rates of other countries on 20 February 2022 to the Australian population provides a rough indication of the lives saved through border closures and other measures to contain outbreaks in the first two years of the pandemic. If Australia had experienced the same cumulative fatality rate as Denmark, which had around 733 deaths per million people, then its death count would have been over 19 000, whereas it stood at 4901 on 20 February 2022.1 All other large western countries also fared worse, with mortality in Italy, the UK, and US exceeding 2500 per million people.1 Australia saved upwards of 60 000 lives by avoiding those very high death tolls.
Australia still retains most of that advantage a year later, showing that staving off community transmission until high vaccination coverage was achieved has provided lasting benefit. Yet it squandered opportunities to get ahead of the virus in other key areas. The population’s encounter with covid-19 has been different from much of the rest of the world: the country had a limited number of infections before the omicron subvariant emerged and before vaccination programmes were rolled out. Infection rates, vaccination rates, and the proportion of people locked down or actively shielding from covid-19 have also varied considerably in different age groups and across the country. Taken together, these facts made it clear that Australia has a unique SARS-CoV-2 immunity history, and needed to be collecting and analysing its own clinical and epidemiological data to inform policy and practice.
Over the past three years, Australia should have been shoring up the protection of vulnerable communities and elevating the collection, quality, and reporting of public health data. It needed to establish real time, rapid research machinery to keep abreast of an evolving pandemic, recognising the need to measure transmission and infection rates and the effectiveness of vaccine and non-pharmaceutical interventions, so that next steps could be planned. Instead, for much of that time, it largely fixated on trying to plug ever growing gaps in international quarantine and internal border closures to contain incursions of the virus.
An uphill battle
Harsh and lengthy lockdowns in the most populous states heightened divided public opinion. The unintended health, social, and economic consequences of public health interventions pushed some to argue that the country should open up before the vaccine rollout was complete. Others, meanwhile, took the messaging that had been used to maintain compliance with lockdowns as proof that it could never be reasonable to be expected to “live with the virus.” By 2022, it was clear that the virus was here to stay and becoming more impossible to hold back using early pandemic strategies.
Honest conversations about what had changed, and what was coming, as borders opened were needed. But without data to model the trajectory and convince the public,2 Australia has had an uphill battle to find the balance of public awareness and engagement with managing fear and anxiety. The vaccine rollout also suffered under a mix of “it’s just the flu” or “no rush, we can keep the virus out” attitudes that prevailed.
As a result, the eastern states were undervaccinated when the delta wave hit in winter 2021,3 and Australia’s covid-19 deaths doubled from 34 per million people to 70 per million in the space of a few months.1
Division in public opinion is more likely to surface when there isn’t compelling data to underpin policy decisions, and the scientific and political consensus to implement them with confidence. Australia still doesn’t have a national SARS-CoV-2 surveillance system to standardise reporting across its eight states and territories. It is a way off from building a register for long covid cases, which tracks outcomes and provides treatment monitoring. Cohesive research efforts have also been lacking and there’s been no substantial attempt to coordinate data collection and the evaluation of interventions across jurisdictions. How did a country that fought so hard to win extra time to prepare for communitywide transmission end up so ill prepared when it happened?
Perhaps Australia’s general success in keeping the virus out and containing outbreaks reassured people that collectively what was done was right and that there was no need for the systematic, real time evaluation of interventions. Yet an opportunity to learn more about the types, triggers, and duration of interventions that worked, and whether similar “success” could have been achieved with fewer costs, was missed. Transparency is also critical for building trust in public health policy makers, yet the few analyses that were completed have rarely been publicly shared.4
If countries don’t evaluate the interventions used, or the effectiveness of vaccines and antivirals in their population, then they can’t move out from the shadow of the precautionary principle.
In reflecting on what needs to be learnt from the pandemic response in Australia, colleagues and I nominated comprehensive and transparent data collection, reporting, and communication as our top recommendations.5 We are not there yet and will struggle as long as essential public health data aren’t routinely collected and released.
Competing interests: I have been an independent expert on the AstraZeneca Australian Covid Vaccine Advisory group, ResApp Health Covid Scientific Advisory Committee, and the Scientific Advisory Boards of Impact Biotech and OutbreakSafe I have received funds from the Medical Research Future Fund, National Medical Research Council, and VicHealth, but not for research related to this article.
Provenance and peer review: commissioned; not externally peer reviewed.
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