The opening of the boundary with Auckland will be a death sentence for many in unvaccinated Māori communities and could lead to debilitating long-term conditions for some infected children, Marc Daalder reports
Analysis: In November 1918, Māori were dying in Hokianga.
In fact, they were dying all over the country as a new influenza strain swept through the population. By the end of the epidemic, one in every 20 Māori had died – a mortality rate more than eight times higher than the general population.
Dame Whina Cooper later recalled the crisis in Hokianga, where 158 Māori died. "Everyone was sick, no one to help, they were dying one after the other," she said.
"My father was very, very sick then. He was the first to die. I couldn't do anything for him. I remember we put him in a coffin, like a box. There were many others, you could see them on the roads, on the sledges, the ones that are able to drag them away, dragged them away to the cemetery. No time for tangis."
Now, with the boundaries around Auckland loosening and many Māori communities still under-vaccinated, history risks repeating itself.
Health experts say Covid-19 will soon spread to every corner of the North Island and could spark massive outbreaks in Māori communities. While those living in the hyper-vaccinated urban strongholds may not experience too much disruption, the virus will go wild wherever vaccination rates are low. Children too could suffer, with an immunologist warning that most kids under the age of 12 are likely to contract Covid-19 in the coming months.
It all stems from a sense in Government that keeping Auckland shut up is no longer politically possible. But opening the floodgates is a much easier decision to make when the consequences won't be visible for some weeks to come.
The Government's hope now is that vaccination rates will be high enough to slow the spread of the virus – and that the combination of the threat of disease and the restrictions under the new traffic light system will spur vaccine uptake in the regions. The consequences of getting it wrong will be dire, but they wouldn't be felt by those calling the shots - another reason Cabinet may be able to insist it has a clean conscience.
Covid-19 will spread
Experts say it's too early to open the boundary, but the Government has chosen to do so anyway.
Epidemiologist Nick Wilson says the rest of the country needs more time to up its vaccination rates and to roll out vaccines to children aged between five and 11.
"This could give the rest of the country more weeks or months to get vaccinated, to get boosters, to vaccinate five-11-year-olds, to improve access to anti-viral medicines, and to make ventilation upgrades to buildings," he said.
Soon, Covid-19 will be everywhere, these experts say.
"It makes it inevitable that we will see an increasing number of cases cropping up all around the country," University of Canterbury mathematics professor and Te Pūnaha Matatini disease modeller Michael Plank told Newsroom.
"There is such a diaspora from Auckland around Christmas and New Year that people will be going everywhere," University of Otago epidemiologist Michael Baker agreed. "I would expect the virus to become very widespread in the North Island over the Christmas and New Year period."
The South Island might still be spared, with the requirement to be vaccinated or tested actually being enforced on every traveller by air or sea. But one of the largest loopholes in the border - that children under the age of 12 won't need to be tested - could still see the virus spread there as well.
"Not everyone might realise, but about one in five cases at the moment are in under 12s. It's a significant number of cases. Altogether, that makes it inevitable that cases will travel around the country," Plank said.
The other issue is the relatively lax penalties for violating the border rules. With the land border around Auckland only being enforced with spot checks, many might be willing to risk the trip without being vaccinated or tested, Baker said.
"Breaking these laws could kill people. I don't think we should trivialise it," he said.
"Taiwan succeeded with what looked like quite soft measures by having gigantic fines. If you were in quarantine and you breached it, it was a $30,000 fine."
Beyond that, neither pre-departure tests nor full vaccination are completely foolproof. If enough people are travelling out of Auckland, Covid-19 will accompany at least some of them.
The inequity of outbreaks
Once Covid-19 reaches the rest of New Zealand, there's no guarantee it will take off.
"It's quite likely that some cases will fizzle out. When it lands in highly vaccinated communities, it's likely the virus will end up hitting a dead end and the outbreak will fizzle out," Plank said.
On the other hand, some places are primed for an explosion in cases.
"The flip side is that if cases happen to land in under-vaccinated communities, it's likely they will spark a serious outbreak if that's the case."
In New Zealand, increasingly, the least vaccinated communities are also the most Māori communities.
There are 203 suburbs or local areas where more than a fifth of the population is Māori. Just two have a first dose rate at or above 95 percent.
If Covid-19 finds its way into these unvaccinated communities, the inequities of the 1918 flu pandemic could be repeated.
"We're going to see a stratified outbreak that unfortunately follows the historic patterning of infectious disease according to deprivation and ethnicity," Baker said.
"Even in Auckland, we're seeing it now, aren't we? A majority of cases are Māori and Pasifika - Māori in particular. That pattern is going to get more entrenched with social inequalities."
Rawiri Jansen, a GP and co-leader of Te Rōpū Whakakaupapa Urutā, was asked by the Science Media Centre to provide comment on the border opening announcement. He said he was unable to as he was overwhelmed dealing with the current Covid-19 caseload.
"I'm too busy trying to support hundreds of whānau who are trying to manage with Covid," he said. "I'm feeling resigned to the Government's changes - more loosening leads to more spread, with the greatest impact upon whānau with the least resources."
Baker worries about a scenario where the white, wealthy and vaccinated parts of the country remain immune to Covid-19 - and maybe don't even notice as it ravages Māori, poor and unvaccinated communities like Kawerau or Murupara.
"Most of our children will end up getting Covid." – Dr Nikki Turner
"Unfortunately, I think we're going to see some pretty tragic events over the next few months where whole extended families get infected, perhaps in more isolated parts of the country. People will die at home or be admitted to hospital. We might see real pressure in some parts of the country on local health systems," Baker said.
"It's going to be a very mixed, patchy process from December and January onwards, when they open up."
Plank isn't so sure that the situation will play out this way.
"Trying to predict anything with Covid makes a fool of you pretty quickly. It's a bit tricky to know how it will pan out over summer, because summer's a different time with schools on holiday, workplaces are more quiet and people are outside more," he said.
But he concedes that it's certainly possible Baker's concerns come to pass.
"It could be that the virus hits an under-vaccinated community and it's able to take off, even during the summer period."
Children at risk
The other unvaccinated community is children under the age of 12.
This is a concern for two reasons. First, vaccinating children will provide a higher level of immunity for the entire population, including their families. Modelling from Te Pūnaha Matatini found that a 95 percent vaccination rate for 12-and-overs would be needed to slow the spread of Covid-19, but if those between five and 11 were included, just 90 percent would be needed.
Second, children themselves can experience negative outcomes from Covid-19.
"The relative risk to a child is much lower than the relative risk to an adult," immunologist Nikki Turner told Newsroom at a health briefing on Tuesday.
"But, because New Zealand is non-immune, all our children are at risk. Any one child is at quite low risk of Covid, but the numbers are big because all our children could be exposed."
Baker agreed with that. "A very small proportion of kids suffer serious inflammatory illness. But we still don't know much about long Covid in kids. It could be a lifelong disability and I think it's really vital to know that."
Protecting children would also keep schools going
"They get sick, schools shut down for periods, they miss quite a bit of schooling anyway. If you get any outbreak in a school, people don't feel comfortable with the school carrying on. It's very disruptive. We are going to see a lot of that."
Turner went on to say that Covid-19 will spread widely among children in the coming months.
"There's two reasons for considering children vaccination. One is to protect their whānau. The other is because the numbers game will be big. Even though any one child is at low risk, most of our children will end up getting Covid," she said.
"That's what you've seen in other countries, where they're beginning to get control over Covid disease in other age groups and then it runs through the children."
"I'm just not sure if we're ready to see 10 [or more] deaths a day, because we could easily be in that situation by next year." – Michael Baker
"It's going to transmit very rapidly through the child population," Baker said.
Despite this, Ashley Bloomfield says the vaccine rollout for those aged between five and 11 won't take place until the first quarter of next year at the earliest. Baker thinks it should be accelerated.
"We just need more time to get that uniformly high vaccine coverage. I would say we ideally want to be vaccinating children, since it looks safe and effective," he said.
"Obviously we've got rigorous checks to go through but because the Māori age structure is so much younger, they'd benefit greatly from that. The pity is we can't delay Christmas and New Year for about two months. Because that's what we need to do - it's too soon."
The nightmare scenario
Then there's Baker's nightmare scenario - one where the inequities of the outbreaks remain but where even highly-vaccinated populations are threatened by Delta.
Baker spends about as much time checking the latest Covid-19 data from Singapore as he does that from New Zealand. In Singapore, 86 percent of the entire population is fully vaccinated with highly effective mRNA vaccines - the same type used here.
Nonetheless, they've seen a surge in cases, at one stage reporting a daily average of 3776 cases. In New Zealand, that would translate to nearly 3500 cases.
There are of course differences between New Zealand and Singapore. The latter is a dense city-state, not a country with a mix of rural and urban populations. But it also has a much higher vaccination rate and about three times as many ICU beds per capita as New Zealand does.
Plank said the health system should manage through the summer, but that a rapid surge of cases would put immense pressure on it.
"At the moment things don't look too bad from a health service point of view, but if we do suddenly get an acceleration of cases, that could change quite quickly," he said.
The main issue is that our health system capacity is already low and overstretched. Staff at Wellington Hospital were told the facility was essentially at capacity last week. There are zero people being treated for Covid-19 in the hospital.
That could soon change. The surges overseas have seen hospitals flooded once again, despite relatively high vaccination rates. Countries across Western Europe are either locking down again or talking about doing so.
In the worst case scenario, our vaccination rates just aren't high enough to keep the health system standing and to avert mass death. Last year's Government slogan - "Make summer unstoppable" - might be co-opted by the virus. It could become Covid's unstoppable summer.
Even if it doesn't eventuate this summer, that possibility might always be lurking in the shadows.
"The summer travel period will be very effective in dispersing Covid and seeding it into various different parts of the country. But it may be that that just sort of stutters along over the summer period, but then of course once schools go back and people are back at work, that will be a risky time where we could see outbreaks growing more rapidly," Plank said.
First, contact tracing would falter. More and more infected people who might have previously been warned that they had been exposed would instead be out and about, infected others. Then the hospitals would buckle. Those seeking treatment for something other than Covid-19 would be turned away. Even some Covid-19 patients needing a hospital bed would be cared for at home, as happened in New South Wales and Victoria.
Some would die there.
For nearly a month, Singapore has had a daily average death rate of more than two per million residents. That would mean about 10 deaths a day in New Zealand. Sustained over a year, that rate would see 3500 deaths - seven times worse than the average flu year.
"We're seeing that in quite a few places with pretty high vaccine coverage. It needs to be exceedingly high before you start pushing that mortality rate down," Baker said.
We're not there yet. Just over two thirds of our population is fully vaccinated and only three quarters has had a first dose.
"I'm just not sure if we're ready to see 10 [or more] deaths a day, because we could easily be in that situation by next year," Baker said. "That's adding about 10 percent to our annual mortality."
It's hard to predict the future. But these are realistic possibilities, according to modelling from Te Pūnaha Matatini and to observations of the situation overseas. This will be the risk Cabinet weighed up in deciding to lift the Auckland boundary for Christmas. Hopefully the holidays are worth the risk.
This article has been updated after further discussion with Michael Baker.
