Politicians and public health experts weigh the risks and rewards of re-opening the country’s borders. David Williams reports
Last weekend, Australian Prime Minister Scott Morrison signalled a break with the country’s previous Covid-19 strategy – and New Zealand’s.
In an opinion piece, Australian Prime Minister Scott Morrison said his country’s focus needed to shift from Covid case numbers to how many people are becoming seriously ill and being hospitalised.
He used the loaded phrase “living with Covid”, borrowed, perhaps, from British Prime Minister Boris Johnson.
While acknowledging people will get sick (and staying mute on how many might die), Morrison listed the reasons it could “get on with our new normal and treat Covid like other infectious diseases”: achieving vaccination targets, a strong public health system, retaining “common sense” public hygiene measures, and using more effective treatments for Covid-19.
“The case numbers will likely rise when we soon begin to open up. That is inevitable,” the Australian PM wrote.
“But our focus needs to be on the rate of people being hospitalised. That's the measure that should now start to guide our response.”
New Zealand’s road to re-opening, meanwhile, has been framed by a trio of reports from an expert panel, chaired by epidemiologist Sir David Skegg. The reports, released earlier this month, state the country’s elimination strategy continues to be a viable approach when the borders re-open.
In response, Prime Minister Jacinda Ardern outlined a risk-based approach to re-opening our borders from early 2022, which would happen after a vaccination push and trialling a self-isolation scheme.
That was less than a fortnight ago but to many it may seem like a year. Our border re-opening has been blown off the agenda while the country scurries to contain a Delta outbreak and emerge from an extended Level 4 lockdown.
Morrison’s announcement at the weekend that his country would walk away from “Covid zero” raises questions about New Zealand’s strategy. Is elimination the right move if Australia has abandoned it?
At yesterday’s post-Cabinet press conference, Prime Minister Jacinda Ardern noted the “different approach” (a break from within, perhaps?) between Australian states like Queensland and Western Australia, and the “devastating circumstances” in New South Wales, which recorded 818 community cases and three deaths.
Elimination worked for New Zealand before and was the right strategy now, Ardern said.
“That’s the way that we have managed to have a larger number of days where we have been without restrictions, than countries like the UK, or like the United States, and not had our people gravely ill and hospitalised and, unfortunately, losing their lives.”
What the strategy means for the country now is getting cases down to a point where restrictions can be removed and the vaccination programme can be continued – “because that will be the thing, that, in the future, lessens the need for this”.
Ardern was asked if Covid circulating in Australia, which has higher vaccination rates – 10.9 million people, or 53 percent of Australians aged over 16, have had at least one jab, compared to 1.66 million, or 33 percent of all New Zealanders – was compatible with a porous border between the two.
“Not for the period in which we are vaccinating our people, no,” she said, leaving the door ajar for a change later. But that door was left swinging in the wind, somewhat, when the Prime Minister was asked when the elimination strategy would be reviewed, and what difference the Delta variant has made.
Ardern said, somewhat vaguely, the Government will continue to get advice from officials, external advisors and experts, including on whether experiences, like Delta, should change the approach. It’ll learn and adapt, she said – but, it seems, it will try to avoid making definitive statements.
Yesterday, Newsroom asked all political parties in Parliament a series of questions about a possible border opening. Labour, the ruling party, approached through the offices of Ardern and Covid-19 Minister Chris Hipkins, didn’t respond.
ACT and the Māori Party answered our questions, while National and the Greens issued statements. (Full responses can be found at the bottom of this article.)
We also asked public health experts what important factors need to be weighed when our border protections are weakened.
All agree vaccination rates must be much higher than they are now but there’s a split over what that figure is, or if there’s a magic number at all. There are also concerns that a move to open up too early could disproportionately weigh on unvaccinated children, as has happened overseas.
Is elimination right for NZ?
National’s Chris Bishop doesn’t explicitly state whether his party supports an elimination strategy, but says re-connecting to the world is “critically important”.
The party has argued the Government needs to set a vaccination target to “avoid future costly lockdowns”. That target, based on research, Bishop says, is about 70-75 per cent.
“We need greater clarity, and we need a target,” he says. “The Government has done the modelling – so it needs to publish it and be upfront with the public.”
Bishop goes on the attack, saying it’s scandalous this country has the slowest vaccine rollout in the developed world. “We were slow to sign contracts, slow to approve Pfizer, slow to order and now we’re slow to roll out. We didn’t even bother seeking to pay more to get early delivery, and now we haven’t even ordered any boosters.”
The Government should scrap its health reforms and spend the money on nurses and doctors, he says, as well as clearing the residency backlog and offering migrant workers that are already here a pathway to residency.
Te Pāti Māori supports an elimination strategy.
“Of course we do,” co-leader Debbie Ngarewa-Packer says, while noting, historically, Māori have been severely impacted by pandemics, pointing to Spanish flu as an example. “Any elimination strategy must include Māori to establish our Covid response and to support the efforts of this nation.”
Ngarewa-Packer says the country should re-open “when we can guarantee our whakapapa [genealogies] is protected”, which requires herd immunity.
“What should be in place is a continued bolstered health response that asserts our Tiriti relationship. Part of the response should be regular random swab tests; they should be happening now.”
The Māori Party co-leader chastises Newsroom for asking a deliberately provocative question about how many deaths are acceptable. “None – what a stupid question. Fact is influenza isn’t as contagious as Covid.”
Our health system simply isn’t prepared for Covid, Ngarewa-Packer says.
“The nurse and hospital capacity needs to be addressed now to better prepare ourselves, not just for Covid, but to sustain a solid health system.”
Time to eliminate elimination
ACT leader David Seymour, meanwhile, is against elimination.
“With the rest of the world, including Australia, abandoning it, elimination means isolation for New Zealand,” he says, adding: “We cannot afford to be out of sync with Australia in the long term.”
(This isn’t entirely true, as China, Hong Kong and Taiwan still embrace it.)
He criticises the Government for self-congratulations (press releases announcing vaccine shipments) and “massaging statistics” by including appointment bookings in vaccine statistics.
The Government needs to aggressively embrace other vaccines, such as Medsafe-approved Janssen, and Moderna, Seymour says, with the aim of achieving 100,000 vaccines a day to complete the rollout by December.
In comments that may bristle with its more libertarian supporters, the ACT leader says mask-wearing should be required “to the extent that there is evidence for its effectiveness”, and organisations such as businesses and schools “should be able to make their own rules about vaccination”.
And while it’s preferable no one dies from the virus, Seymour says the country should evaluate what it’s willing to spend to prevent Covid deaths, compared to spending on road safety and funding cancer drugs.
The Green Party backs elimination.
“The best way to achieve this is a high vaccination rate paired with alert level restrictions when outbreaks occur,” Julie Anne Genter of the Green Party says.
The Greens won’t be making “guesstimates” of specific vaccination levels or border policy choices, Genter says, as it hasn’t seen the expert, science-based advice, information and modelling the Government has.
“We are certainly open to things like more mask wearing and testing in the community, provided there’s good evidence that they will make a difference.”
Everyone who can get vaccinated should be vaccinated as soon as possible, she says. The Green Party worries about nurses and other frontline medical staff who are exhausted, stressed and worried, Genter says.
“Nurses and midwives postponed their strike to again put their lives on the line for our country as we deal with this current outbreak. It is in the best interests of everyone that we get behind the nurses’ call for safer staffing levels, better pay, and better working conditions.”
“What we’re finding is people who have had the vaccine and are infected with the virus still shed large amounts of virus.” – Lance Jennings
Health experts say New Zealand has a lot to learn from looking overseas.
The United Kingdom had hoped to remove all public restrictions on movement, gathering and mask-wearing on June 21. There were 16 Covid-related deaths that day. But so-called “freedom day” was delayed until July 19.
(“Freedom day for who,” asks Associate Professor Siouxsie Wiles, a University of Auckland microbiologist. She says a policy of learning to “live” with the virus “throws our vulnerable people under the bus”.)
Back in July, 85 percent of UK people aged over 16 had at least one dose of vaccine, and 67 percent had two doses, University of Canterbury mathematics professor Michael Plank says. Since “freedom day” more than 2500 people in the UK have died within 28 days of a Covid-positive result, according to official data.
Plank, a disease modeller at Te Pūnaha Matatini, says that’s almost 40 deaths per million of population – the equivalent of almost 200 deaths in New Zealand, in just one month.
But there are big differences between the UK and this country: such as confirmed case numbers (6.5 million versus just over 3000), and vaccinations (47.6 million, or 70 percent, with at least one dose versus 33 percent, or 1.66 million). Because of the jabs and acquired immunity from exposure to the virus, it’s estimated nine in 10 UK adults have virus antibodies.
Some might argue a more important comparison is deaths. There have been 131,640 deaths (with 28 days of a positive test) in the UK, compared with 26 deaths in New Zealand. Australia, meanwhile, has had almost 1000 deaths.
Lance Jennings, a clinical virologist, is Clinical Associate Professor in the pathology department at University of Otago, Christchurch. He was instrumental in the development of this country’s influenza control strategies.
He says the dynamics of the Delta variant and how it spreads are vital considerations for re-opening the borders, pointing to lessons from Israel, in particular.
“With this particular virus, even when vaccine coverage is high in the particular country, once it gets established it’s rapidly transmitted through the population.”
The Pfizer vaccine is good at protecting individuals from death, hospitalisation and serious disease, Jennings says, but isn’t effective at stopping community spread.
“What we’re finding is people who have had the vaccine and are infected with the virus still shed large amounts of virus, equivalent to individuals who haven’t received the vaccine.”
Wiles, the University of Auckland microbiologist, says vaccinated people transmit the virus because of the different immune responses generated where the infection starts – which for Covid-19 is in the nose and throat.
“The next generation of vaccines will be inter-nasal vaccines that can help mount a better immune response at the nose. That would be a bit of a game-changer.”
Concerns about children
Clinical virologist Jennings says the Delta variant infects susceptible individuals who haven’t been exposed or vaccinated – “in our case it’s going to be children”.
Without vaccinating children, New Zealand is unlikely to approach the rate modellers predict is needed for herd immunity, he says.
About a million New Zealanders are aged under 15. Approval has been given for those aged 12 and over to be vaccinated.
Microbiologist Wiles says it’ll be some months before the data from vaccination trials for under-12s are available. “Until we know that, and until the vaccine is rolled out to children, then the reality is that opening up puts them at risk.
“You only have to look at various states in the USA to see now the number of children being hospitalised, the number of paediatric intensive care units that are filling up and are at capacity, to know that should not be an acceptable thing for us.”
New Zealand experts warn the safest and most equitable action is not to allow children to be exposed to Covid-19 in large numbers.
“Because Delta’s very, very transmissible, if you have a large proportion of the population infected all at once, you should expect to see a surge of cases in children just because of it,” says Dr Jin Russell, a developmental paediatrician and PhD student in child epidemiology at the University of Auckland.
Jennings, the clinical virologist, says keeping the country’s borders relatively shut is its best protection until satisfactory vaccination levels are achieved. That will insulate the health system from being overwhelmed, and the greatest number of individuals, he says.
The elimination strategy was concocted to buy New Zealand time while a vaccine was developed. Lucky, the vaccine chosen is extremely effective – “it’s more effective than the seasonal influenza vaccine,” Jennings says.
“We need to keep the virus out until we’ve got a satisfactory level of coverage nationally – and I can’t define that satisfactory level.”
Again, picking on Israel’s situation, Jennings says without children being vaccinated the disproportionate burden of the virus, including hospitalisations and long-term effects, would fall on younger people.
(Wiles notes people hospitalised with Covid-19 can be in hospital for many, many weeks.)
Jennings says: “I think we’ve got to hold out as long as possible.”
The modellers from Te Pūnaha Matatini concluded this country is unlikely to reach herd immunity for the Delta variant through vaccination alone. Their study estimated if the country opened up completely, with no restrictions, even with 90 percent of over 15-year-olds fully vaccinated, there might be as many as 3000 deaths.
Plank says this shows the importance of other public health measures like masks, testing, case isolation, contact tracing and, “as a last resort”, alert level restrictions.
“The more people we can get vaccinated, the better position we’ll be in and the less we’ll have to rely on those other measures.”
(Wiles, of University of Auckland, says the Government and businesses must also ensure sick people can take time off work without being penalised; that they won’t be docked holidays, for example.)
Plank says New Zealanders aren’t choosing between getting vaccinated and not getting vaccinated.
“It’s really a choice between getting vaccinated and getting Covid. Because if you’re not vaccinated you will get Covid, more than likely, in the long term, because we’re not going to be able to keep it out forever.”
Clinical virologist Jennings, a former director of New Zealand’s World Health Organisation national measles laboratory, admits he’s not an economist. But, by and large, he says the country has done incredibly well under an elimination strategy – “the economy has survived”.
On the other hand, if politicians can’t keep the “team of five million” together, and, like Australia, society’s cohesive bond disintegrates into civil disobedience, then there can be no winners.
“It’s very much a balancing act,” Jennings says. “I don’t envy the job of the politicians at the present time.”
Full political responses
Green Party COVID-19 response spokesperson Julie Anne Genter:
The Green Party supports an ongoing elimination strategy, and the best way to achieve this is a high vaccination rate paired with alert level restrictions when outbreaks occur. We have always been, and continue to be guided by an evidence-based approach to COVID-19 that puts peoples’ health first. It would take long-term, sustained investment in specialist medical education to be able to increase our ICU capacity. Therefore, elimination is the best strategy to protect all of our population in the short to medium term, especially given young children are still unable to be vaccinated. Without seeing all the expert, science-based advice, information, and modelling that the Government has, we will not be making guesstimates about specific vaccination levels or border policy choices, like some other political parties might. We are certainly open to things like more mask wearing and testing in the community, provided there’s good evidence that they will make a difference.
This crisis has shown us that the systems put in place to govern our communities can be quickly changed to care for everyone. We are in a privileged position to still be able to pursue an elimination strategy, so we should use every tool in the toolbox to continue with that strategy. We support the call for everyone who can get vaccinated to get vaccinated as soon as it is available to them. Getting a vaccination is one of the most powerful tools we have to take care of our loved ones, whānau, communities and ourselves.
Our nurses and other frontline medical staff are exhausted, stressed and worried about their patients and the future of our health system. They continue to put themselves on the line for us during this pandemic and as a country we need to support them. People become nurses because they want to care for others. When people are overworked and not able to do their job as well as they know people deserve, the toll on their wellbeing is really significant. Nurses and midwives postponed their strike to again put their lives on the line for our country as we deal with this current outbreak. It is in the best interests of everyone that we get behind the nurses’ call for safer staffing levels, better pay, and better working conditions.
National Covid-19 spokesperson Chris Bishop:
The most immediate priority for New Zealand is to get through this lockdown, caused by a border failure and by our negligently slow vaccination rollout.
Everything – getting through the lockdown and reconnecting to the world – turns on vaccination. That’s why it is scandalous we have the slowest vaccine rollout in the developed world. We were slow to sign contracts, slow to approve Pfizer, slow to order and now we’re slow to roll out. We didn’t even bother seeking to pay more to get early delivery, and now we haven’t even ordered any boosters.
We’ve argued that the Government should set a vaccination target to avoid future costly lockdowns. Our suggestion, based on research, is around 70-75 per cent. The system should be mobilised to go for that target as quickly as possible. It is outrageous that seven months into the rollout, 35 per cent of frontline port workers haven’t had a single vaccine and 3000 Auckland hospital workers are unvaccinated.
Setting a target means mobilising the collective energy of the country to achieve a goal and the benefits that brings – avoiding economically and socially devastating lockdowns, and setting New Zealand up to open back up to the world.
Reconnecting to the world is critically important but as the Prime Minister acknowledged in her speech last week, it all turns on vaccination. Her argument is coverage needs to be “high” – but what does high mean. We need greater clarity, and we need a target. The Government has done the modelling – so it needs to publish it and be upfront with the public.
We have serious workforce shortages in our health sector that need to be immediately addressed.
The Government could for a start scrap its ideological health reforms and spend the half a billion dollars it has budgeted for the reforms on our nurses and doctors. It should also clear the residency backlog by unfreezing the residency pool and streamline and fast-track residency processing. Then we need to offer our migrant workers here a pathway to residency.
Te Pāti Māori co-leader Debbie Ngarewa-Packer:
Do you support an elimination strategy post-reopening? Do you think it's even viable?
Of course we do, historically we know Māori are severely impacted by pandemics, taking the Spanish flu as an example. Any elimination strategy must include Māori to establish our COVID response and to support the efforts of this nation. Aotearoa has proven that elimination is viable in terms of protecting our whakapapa and whānau. We have been successful with our first attempt of elimination and have reaped the benefits of having some of the most unrestricted life quality in the developed world.
Under what conditions should NZ re-open to the world? (I realise Labour has already laid out a plan – other parties, what would you do differently?)
When we can guarantee our whakapapa is protected.
Our whānau in Aotearoa are needing herd immunity to effectively prevent further outbreaks. Our hauora needs resourcing and this country needs to learn from our experiences. Until the government is transparent with our providers, and until we are continuously resourcing our providers on the ground to enable their own effective response plans, then we can look to re-open.
At that point of opening up, what extra suppression measures would be in place? For example, mandatory mask-wearing indoors in large gatherings, regular random swab tests in the community, restrictions for the non-vaccinated?
What should be in place is support for whānau, and especially the minority communities to stay safe. What should be in place is a continued bolstered health response that asserts our Tiriti relationship. Part of the response should be regular random swab tests; they should be happening now.
A University of Otago study said there were roughly 500 influenza deaths a year in NZ. How many Covid-19 deaths a year are acceptable? Only a few dozen? Hundreds? Thousands (which would mean a rise in mortality risk)? (Large numbers of elderly and vulnerable have been vaccinated, so at least some of those deaths would be of otherwise “healthy” people.)
None - what a stupid question. Fact is influenza isn’t as contagious as COVID. The intubation period is longer for COVID at 2-14 days compared to the 1-4 days then the flu. Our health system simply isn’t prepared for COVID.
Would a re-opening of the country be accompanied by an increase in nurse/hospital capacity? Why/why not?
It shouldn’t take a pandemic to justify the required increase in nurse and hospital capacity. Even prior to COVID our health system, nurses and hauora providers have been severely under resourced. The response has been naive about their obligations to Te Tiriti and providing equitable outcomes for Māori. The nurse and hospital capacity needs to be addressed now to better prepare ourselves, not just for COVID, but to sustain a solid health system.
Nurses are already feeling the strain and many have already left because of the job pressures, even without a surge in Covid cases. A re-opening to the world might, as in other countries, overwhelm hospitals. What would your Government do to ensure the hospital workforce will stay on?
The most important thing is to look after all front-line essential workers. The health workforce is special, their mahi cannot be done by anyone else, and so Te Paati Māori will always advocate for their interests. Increasing their pay and ironically, ensuring they have healthy working conditions - is the first step to creating an environment where the hospital workforce feel valued in Aotearoa.
Other comments:
From the word go, we have needed to have a response that resources and includes Māori providers. The response needs to encompass the way we move collectively, the way we communicate, and the way in which we populate the front line. The one stop shop vaccination model simply isn’t working. Tracking doesn’t work, our data is whakapapa and the vanilla response doesn’t acknowledge this.
There have been opportunities missed, the GOVT is continuing to keep Māori out of decision making. We need to look at what we have learnt and identify how our learnings support a Māori led COVID response.
The fact that the information is centralised and doesn’t reach providers is centralised bureaucratic absurdity. We should be using the live data to its full potential and informing us of where in the community we need to surge test, vaccinate and support based on locations of these close contacts.
ACT leader David Seymour:
The Skegg report recommended New Zealand continue to eliminate Covid-19 after reopening through less onerous measures. Do you support an elimination strategy post-reopening? Do you think it's even viable?
No, elimination with Delta is very difficult. With the rest of the world, including Australia, abandoning it, elimination means isolation for New Zealand. Sooner or later we will have to join the rest of the world, or watch more investment and opportunity follow the Amazon TV project. The most important question is how quickly we can vaccinate.
Under what conditions should NZ re-open to the world? (I realise Labour has already laid out a plan – other parties, what would you do differently?)
The current Government needs to
- Drop the self-congratulation and massaging of statistics (such as putting out press releases when vaccine shipments arrive and announcing the percentage of a subset of the population who’ve booked for a vaccine), and accept it has failed in many key respects
- Appoint an Epidemic Response Governance Committee, to implement policy within broad goals
- Openly share the options that New Zealand has from no intervention to continued reliance on lockdowns, then ask what a middle pathway would look like. Bring all of New Zealand into ownership of the plan.
- Aggressively open up new vaccine supplies, such as Janssen that is Medsafe approved, and Moderna that has been used 142 million times in the U.S. They should also renegotiate with Pfizer to get faster delivery. They should then roll out more drive through and school vaccination sites with a goal of 100,000 per day and the roll out completed by December
Do you have a rough vaccination percentage of the population (say, 80%) in mind for this point of opening up?
We should synchronise our level with Australia, they have said 70 per cent. We cannot afford to be out of sync with Australia in the long term.
At that point of opening up, what extra suppression measures would be in place? For example, mandatory mask-wearing indoors in large gatherings, regular random swab tests in the community, restrictions for the non-vaccinated?
The Government should embrace technology. Rapid Lateral Flow Tests are recommended by the NHS, but the New Zealand Government has actually banned the importation of self-test kits. Its hesitancy in adopting saliva testing in spite of the evidence has been frankly bizarre. Wastewater testing should be daily because every day counts getting ahead of an outbreak. Mask wearing should be required to the extent that there is evidence for its effectiveness. Vaccinations should not be state mandated, but organisations such as businesses and schools should be able to make their own rules about vaccination.
A University of Otago study said there were roughly 500 influenza deaths a year in NZ. How many Covid-19 deaths a year are acceptable? Only a few dozen? Hundreds? Thousands (which would mean a rise in mortality risk)? (Large numbers of elderly and vulnerable have been vaccinated, so at least some of those deaths would be of otherwise “healthy” people.)
There is no such thing as an ‘acceptable’ level of deaths. We would prefer if nobody died. What’s important from a policy point of view is that we evaluate what we’re prepared to spend preventing COVID deaths in comparison with what we spend preventing other types of death, such as when deciding to improve road safety or fund cancer drugs. The Government should use a Quality Adjusted Life Year framework, as it does in other policy decisions, with a focus on maximising New Zealanders’ wellbeing.
What measures would your Government take if deaths rose above this level?
The previous answer addresses this question.
Would a re-opening of the country be accompanied by an increase in nurse/hospital capacity? Why/why not?
Ideally yes but there are serious capacity constraints that are difficult to overcome. One of the greatest is the shortage of skilled labour, both from people unable to enter the country and unable to get visas processed. The most tangible step would be to fix visa processing and increase MIQ capacity with private MIQ as outlined in ACT’s COVID Recovery plan.
Nurses are already feeling the strain and many have already left because of the job pressures, even without a surge in Covid cases. A re-opening to the world might, as in other countries, overwhelm hospitals. What would your Government do to ensure the hospital workforce will stay on?
ACT’s alternative budget would deliver over $2000 in net pay increase, to a full time nurse. We also believe that reducing shortages with easier border crossings and visa processing would take pressure off nurses. Our COVID response would prioritise medical workers for such things as COVID testing and any future vaccination booster shots.
