In his first interview since taking the reins of the Covid-19 response, Dr Andrew Old speaks to Newsroom about social licence, living with the virus and his hopes for the new Public Health Agency
The new Dr Bloomfield would really like everyone to stop calling him that.
Andrew Old has assumed the role of deputy director-general of health with a dual mandate: Rebooting New Zealand's public health policy and taking the reins of the Covid-19 response. He's the head of the country's new Public Health Agency, the first department with a specific population health focus since the short-lived Public Health Commission of the 1990s.
He's also, like the former director-general of health Ashley Bloomfield, a public health doctor by training who dearly wishes his job didn't involve regular press conferences.
"I have said to people that they need to stop comparing me to Dr Bloomfield," Old joked to Newsroom in an interview. "To be honest, it's not a role I relish, but I do respect the importance of fronting and being available to answer questions."
The good news for Old is that he probably won't have to front anywhere near as many as the 307 press conferences as Bloomfield has led over the past couple of years. The new Covid-19 czar freely admits we've moved out of the emergency phase of the response (and the daily briefings that accompanied it) and his job is now to bed in a strategy for managing the virus in the long term.
"For quite a long time, each time we re-did the plans, there was still this hope that it would be the last time we needed to do that and this time Covid was going to go away. I think everyone recognises now that we're going to be managing Covid, one way or another, possibly forever. But clearly, hopefully, not in the way that we're managing it now," he said.
"That does put a different lens on the sorts of measures and management options that are available to us. Me coming in now, at this time, as we're just coming off our winter peak with Omicron and BA.5 particularly, is an opportunity to look at the range of measures that we're currently using, what their longevity is, what their usefulness is, as the variants change."
"We manage tuberculosis with rules around isolation, with rules around compulsory treatment ... Now that we're going to be living with it for a while, where does Covid sit?" – Dr Andrew Old
The Government will start to seriously grapple with these questions as part of future monthly reviews of the traffic light system and other Covid-19 settings. Old said he doesn't have an inherent view on whether or not public health measures should be used over the long haul, but that it would be imprudent to rule it out.
"I dearly wish I had a crystal ball. What I can say is that, where we have had a single disease focus on Covid for a long period of time now, part of the shift is to put it on the spectrum of the other infectious diseases we manage and say, how is it different?
"Possibly a good example is tuberculosis. We manage tuberculosis with rules around isolation, with rules around compulsory treatment in some settings, and that's managed under existing Health Act legislation and tuberculosis disease regulations. Where we're getting to is to say, now that we're going to be living with it for a while, where does Covid sit?
"Things like, will we be able to maintain isolating cases over the longer term, where that might be tens of thousands of people at any one time is a different calculus than if it was hundreds of people at any one time or hundreds of thousands of people at any one time?"
In other words, proportionality is now Old's guiding principle. Exactly what counts as proportionate depends on the changes in the virus (new variants are always the elephant in the room), its prevalence in the population and the sustainability of different measures. He points to a concept in public health that states the goal is always to implement the "least restrictive alternative".
Declining social licence
Social licence is also on Old's mind as he looks out over the Covid-19 response.
There's clearly a hard cap on how stringent restrictions could get without a drastic change in the epidemiological situation. That cap is really a sinking lid, as repealed restrictions are increasingly difficult to reinstate – the Government's inability to reintroduce any of the measures it scrapped in March to deal with July's BA.5 wave is evidence enough of that.
That's offset, Old said, by the waning licence for restrictions that are kept in place when no longer needed.
"I would hope that if we did get a more serious variant ... we would be able to tell that story to the public who would then, as they have previously, accept that actually there is a public health case to be made here for increasing restrictions again." – Dr Andrew Old
"One of the challenges that we have is it's often obvious when the need to put restrictions in place happens. It's much harder to see an obvious point where we don't need them anymore. The challenge that we have in terms of social licence is, the longer you have restrictions in place, the less people adhere to them, the less people accept them."
Does that mean there's no future where new restrictions are introduced?
"In order for the public to tolerate greater restrictions than we currently have and for them to be justified, the nature of the virus would need to change significantly from where it is now. I would hope that if we did – and I dearly hope we don't – but if we did get a more serious variant that had significant immune escape and was more severe, putting more people in hospital, greater mortality, that we would be able to tell that story to the public who would then, as they have previously, accept that actually there is a public health case to be made here for increasing restrictions again."
Agency won't back off a fight
That's all serious enough, but Covid-19 is only part of Old's new job. As the head of the Public Health Agency, he has a range of other infectious and noncommunicable diseases on his plate.
In dealing with them, Old says he has learned lessons from the Public Health Commission which was closed down after just three years in operation. That was an independent body, which gave it more room to criticise policy-making but less protection from a vindictive sugar, alcohol and tobacco lobby.
"Being more integrated inside the Ministry of Health is helpful, rather than seeing us as a standalone entity," Old said.
"There's a risk that, if you let ideology take over the argument, then you do open yourself up for more challenge." – Dr Andrew Old
That doesn't mean the agency will back down from a fight, if that's what's required. There's no ideological quest here, but the agency will back its evidence-based policy.
"There is a need for whatever we do when we're talking about, whether it's food environments or alcohol or tobacco, is to be really solidly grounded in the evidence and in what we know. There's a risk that, if you let ideology take over the argument, then you do open yourself up for more challenge," he said.
That said, "there is a real, fundamental and probably irreconcilable difference between the need for certain companies to deliver profits to shareholders and the ideals and aspirations of pae ora and broader public health. And that's just a reality we need to deal with."
The Public Health Agency will also offer an opportunity to reset the approach to public health policy more broadly, Old said. He wants to see the views of academics, non-governmental organisations and communities woven into the policy-making process from the start.
"I do think that there is significant opportunity in having a dedicated agency that is responsible for weaving the threads together. Although the agency won't do everything, we're really well placed to be a collecting point and a connection point for a lot of thinking and a lot of ideas."
