It is a fundamental problem in fighting a war against an invisible enemy, one that hides among us.
When is the battle over?
We know that we are not there yet. That end is months, not weeks away.
We know we have not yet reached the “peak” but that it is coming. Like an invisible wave, we won’t see it when it arrives, we will see only its effects. We have watched it wash over other countries: the grimly climbing toll reported daily, even hourly; the overwhelmed intensive care wards; the shuttered businesses and closed school gates; the empty streets and full mortuaries.
“This health crisis and economic crisis is a battle on two fronts,” the prime minister, Scott Morrison, has warned, “and it is going to be waged in an unimaginable and unprecedented way over the next at least six months and potentially beyond that.”
But it is a balancing act for governments. Weighing lives against livelihoods, the financial imperative to restart shattered economies against the medical necessity to stay home and save lives.
The New South Wales premier, Gladys Berejiklian, has promised her state’s restrictions on work, gathering and movement would be assessed regularly, and flagged they could start to be eased as soon as next month. But it came with this blunt caveat: “Every time you relax a restriction, more people will get sick, more people will die.”
All over the world there is far to go, but restrictions are easing in China, where this Covid-19 outbreak began, and elsewhere planning is under way for a world beyond the pandemic.
There will be – and have been already – massive economic, societal, environmental and ideological changes wrought by the virus. But right now, the medical questions remain fundamental: when do we know Covid-19 is sufficiently suppressed, how should the restrictions and the lockdowns be eased, and what does a post-Covid world look like?
The risk of relaxing too early
There is danger in complacency. Singapore, for weeks the darling of international comparison, the exemplar of how best to suppress the Covid-19 pandemic, has since seen a dramatic spike in the number of infections – a 60% jump in new daily infections – and has announced a further tightening of restrictions.
It will now close all schools and most workplaces – only essential services such as supermarkets and banks will stay open – for a full month. It has instituted jail terms for breaching stay-at-home orders, and banned visitors and transits through the country.
Comparisons between countries are always flawed, too great are the differences in size, development, governance and demographics. Singapore, an island city-state ruled by a single party since independence, with a high-quality public health system and a population broadly adherent to government diktat, was always inherently advantaged.
Japan, similarly, having kept infections low for two months, has now declared a month-long state of emergency in response to a jump in new cases.
But the risk of lifting restrictions too early and unleashing a devastating “second wave” applies to countries all over the world, and the international community itself.
“If Australia comes out of our isolation too early, we risk an even bigger peak,” Associate Prof Ian Mackay from the University of Queensland told the Guardian this week.
“This could take six months or more. We cannot lose focus. It’s annoying, it’s hard, it’s very tough for a lot of people, there is real pain and economic hardship in the community. But we have to stick it out, because if we relax too soon, and allow the virus to re-emerge and spread widely, all the pain we have suffered will have been for nothing.”
There is historical precedent in Australia too. In the immediate aftermath of world war one, Australia was spared the very worst of the Spanish flu outbreak, aided by geography and the delay the steam-ship age afforded a distant continent to implement a strict quarantine regime.
But when the flu did break in Australia, it killed an estimated 17,000 people, and it did so in three waves, the first in February, the second in April. The third wave, in July, was by far the most deadly.
‘What’, not ‘when’
There is an argument that asking “when” the restrictions will be lifted is the wrong question. The question that needs to be asked is “what?”. What needs to be in place, what needs to have been achieved, before restrictions can be lifted?
Scott Gottlieb, a former US Food and Drug Administration commissioner, co-authored a paper with the American Enterprise Institute, proposing a four-phase “road map to re-opening”. The first phase – in which Australia firmly remains – is to suppress the spread of the virus as quickly and as comprehensively as possible, to stop the “curve” from rising to an unmanageable peak that overwhelms public health systems.
If there are more critically ill people than there are hospital beds, people who could have been saved will die.
This suppression involves physical distancing measures, banning gatherings, closing public spaces and potentially schools, having people work from home, and limiting all travel.
In the second phase, individual states, or even cities, would be able to gradually ease certain restrictions, but only when they have built up their capacity to identify, test and isolate most confirmed Covid-19 contacts and their close contacts.
The third phase would allow for remaining restrictions to be lifted when a vaccine is developed, an effective therapy is widely available, or when testing data shows widespread immunity.
But there is a fourth stage too. When this pandemic is over – and it will end – governments must learn its lessons, and invest heavily in medical research and public health systems. They must prepare for the next one.
A phased recovery
Dr Raina MacIntyre, a professor of global biosecurity at the University of New South Wales’s Kirby Institute, has argued for Australia to impose a “short, sharp lockdown … followed by a phased lifting of restrictions”.
“A short, sharp lockdown of four to eight weeks will improve control of the epidemic in Australia, reduce case numbers more rapidly and bring us to a more manageable baseline from which phased lifting of restrictions and economic recovery can occur. If we fail to do this, we face continued epidemic growth, potential failure of the health system, and a far longer road to recovery.”
Michael J Ryan, the executive director of the World Health Organization’s health emergencies program, told policymakers each country needs to determine an individual “calibrated, step-wise approach” to easing restrictions on movement, travel and work.
He said countries need to have come off the “peak” of infections and have capacity in their healthcare systems – spare beds in hospitals – as well as good data on infections, and a low positivity rate, which is the proportion of all samples tested that return positive.
“You’ll see in somewhere like [South] Korea, they’re testing, and 2% to 6% of their samples are positive. Last week in New York 37% of tested samples were positive. So you need to carefully look at what proportion of people that are tested are positive.”
But Ryan stressed that “there are no absolutes here, there are no answers”.
A phased lifting of restrictions appears to be Australia’s likely strategy – “steps and stages that we can test and reverse”, the health minister, Greg Hunt, says.
The Australian Health Protection Principal Committee, led by the country’s chief medical officer, Prof Brendan Murphy, is working on an ‘exit strategy’ to be presented to government.
But Morrison has already forecast a staggered recovery – a gradual easing of particular restrictions, in certain places, always with the caveat that they may need to be re-imposed if infections again start to rise.
“You will have some jurisdictions, some states and territories, that might be in a position to move when others are not, then we will learn from the experience of those states that may have trialled things.”
Tasmania, with fewer cases, and the geographic advantage of being a small island with firmly established biosecurity laws, may be able to move sooner than other states. Those areas hardest hit by Covid-19 cases – New South Wales, Victoria and south-east Queensland – are likely to be the last to be able to move.
South Australia, with a relatively low number of infections, few hospitalisations, and the highest per capita testing rate in the country, could also be an early mover.
Prof Lyn Gilbert, the chair of the Infection Prevention and Control Expert Advisory Group that reports to the nation’s chief health officers, has warned restrictions could wax and wane with the rate of infections.
“Everyone wants to know when it will end, and I know the politicians are desperate to be able to say when it will end, but I think we’ve got to be cautious,” she said.
“I think the only way to do it properly is to watch what’s happening and calibrate the response according to what’s happening. And if restrictions were lifted, at least partly, and the numbers started to go up again, they’d probably have to be reimposed.”
Governments across the country are bracing their populations for a “marathon not a sprint”.
“I can’t tell you when this is going to end,” the Victorian premier, Daniel Andrews, said this week. “It is not going to be over in weeks, it is going to be months and months.”
There is shrewd political positioning that overlays the medical advice informing this position: better to tell a population to prepare for six months of pain and proscription, and be able to lift it early, than to promise a rapid solution and find yourself apologising, and explaining why it must be extended again.
And Morrison has repeatedly stressed there is no plan yet to ease restrictions anywhere.
“There is no map for this. We are in uncharted territory.”
The Chinese experience
Wuhan, the original centre of the virus, has begun to lift the restrictions on movement after 76 days of near-total lockdown. Movement is now allowed out of the city to the wider Hubei province and beyond.
At its peak, Wuhan’s lockdown was extreme: images of doors being welded shut to lock people in their homes shocked the world.
Authoritarian regimes are less concerned about curtailing their citizens’ civil liberties and human rights. Liberal democracies find such measures harder to implement: their populations will not tolerate such extreme impositions.
“We’re not going to go and cut and paste measures from other places, which have completely different societies. I mean, in China they were welding people’s doors shut,” Morrison told reporters bluntly. “That might be OK with them, but … we have different ways of doing things in Australia.”
China has been condemned, queried and praised for its response to Covid-19: lauded for its swift and effective lockdown measures; questioned over the veracity of its infection reporting and suppression of information; and excoriated for its failure to adequately warn the world in the initial stages of outbreak and silencing doctors who tried to raise the alarm.
But, even as restrictions ease across the world’s most populous nation, freedom there post-Covid is scarcely unrestrained.
China’s Health Code app has been downloaded by 700 million people. It is mandatory in some Covid-19-affected areas, such as Wuhan, for even the most fundamental freedoms – to enter a supermarket, catch a taxi, ride the subway or see a doctor.
Users must first fill in their personal details, including their national ID number, where they live and whether they have been in contact with confirmed cases of the virus. The app then gives them a colour-coded rating: green means they are free to travel; yellow mandates seven days quarantine, and red requires 14 days.
The app also quietly collects – and shares with police – a user’s location and travel data.
The “freedom” provided by this technological development has not been universally welcomed.
“I thought the days when humans are ruled by machines and algorithms won’t happen for at least another 50 years, one blogger on Zhihu wrote. “This coronavirus epidemic has suddenly brought it on early.”
Human Rights Watch described the Health Code app as “automated tyranny”.
Digital contact tracing
Singapore has also used technology to surveil its citizens, pulling together a database of personal details to allow health authorities to track potential Covid-19 carriers. The TraceTogether app sends bluetooth signals to other users, and sends messages to phones warning that a person may have come into contact with a known or suspected case.
South Korea’s mass testing regime and radical transparency have suppressed Covid-19 infections, but at the price of civil liberties. Granular details of new infections and their whereabouts are routinely made public, leading to doxxing of suspected cases – even speculation of alleged illicit affairs – and leading the country’s National Human Rights Commission to warn that people infected by the coronavirus face a potential second trauma of harassment, ridicule and social stigma.
Israel, Taiwan and Iran have also used mobile phone data to trace potential Covid-19 contacts and monitor its citizens’ movements. The European Data Protection Supervisor (EDPS) has called for a pan-European mobile app to track the spread of Covid-19 instead of the current miscellany of apps used across the EU that risk breaching people’s privacy.
Immunity certificates
In Britain, the health secretary, Matt Hancock, has said the UK would consider “immunity certificates” for its population – medical recognition that a person has had Covid-19 and recovered, and can’t catch it again or spread it. Determined through a serology test for coronavirus antibodies in an individual’s blood, an immunity certificate would authorise a person to return to work and re-enter the community.
“We are looking at an immunity certificate,” Hancock said, “how people who have had the disease, have got the antibodies and therefore have immunity can ... get back as much as possible to normal life.”
In Germany too, one of the first countries in Europe to begin to ease restrictions, researchers are preparing a large-scale study into immunity to Covid-19, with a hope it could allow authorities to issue passes to exempt workers from restrictive lockdown measures.
Such a certificate could be particularly effective in getting healthcare workers – disproportionately affected by the virus – back to work more quickly when they are no longer sick, and no longer at risk of spreading the virus.
Denmark has also flagged lifting some of its restrictions, forecasting “a gradual and controlled opening of society starting mid-April”.
Part of Denmark’s plan is to offer widespread testing, not only for the virus, but also for antibodies – to determine who has immunity, and how widespread immunity is across the community.
There are questions, however, over the reliability of serology testing, and whether the presence of antibodies provides long-term immunity.
And there are potential risks. Immunity certificates could create a two-tiered society of those with antibodies and a measure of immunity who are allowed out, and those without who must remain isolated.
They could also create a perverse incentive to catch the virus, particularly among demographics for whom the illness is likely – though not certain – to be mild. The certificates, too, have the potential to act as a reward to people who have not adhered to physical distancing and who have developed immunity but at the risk to others’ health.
We are not alone
In the chaos of the coronavirus, the nation-state has reasserted its dominance in the global order. Country is king.
The virus has spread quickly because of the modern world’s breath-taking interconnectivity.
But the reaction to this rapid global spread has been its antithesis: national governments and their people have turned inwards, closed borders, told foreign nationals to leave, and relied on national leaders and institutions for guidance through the crisis.
Countries have formulated and run their responses on strictly national lines. Each country’s “curve” is compared with others as to whose measures are best (despite the inherent flaws in such comparisons). The national fight is all that most people have the energy for, the looming global calamity is almost beyond contemplation.
But the international pandemic must be Australia’s, must be every country’s, concern.
Covid-19 is no respecter of national borders. Its virulent spread across the world is evidence that the problem is a global one, and so its solutions must be too. It can only be defeated collectively.
“Fortress Australia” might work temporarily – and Australia has the inherent advantage of being a large island nation-state with borders it can lock down – but it is not sustainable for a country so dependent upon exports and imports, and a people who travel.
Other countries, many in Australia’s region, face a far more challenging battle than Australia does. The virus carries the potential of immense suffering.
Many nations in the Asia-Pacific are densely populated, with developing economies and healthcare systems ill-prepared for the Covid-19 wave to wash over them.
The physical distancing enforced by countries around the world, in reality, is a privilege of the rich. Developing nations face the far grimmer choices in choosing to lock its populations down to keep them alive or allowing them to work in order to survive.
Hundreds of millions of daily wage labourers in India – a country under total lockdown – don’t eat if they don’t work.
Pakistan’s prime minister, Imran Khan, has warned his country cannot enact the distancing measures it needs to without people starving.
There are other challenges too.
Indonesia, late to the fight against Covid-19, now finds itself battling the virus blind, because it doesn’t have adequate testing. And Pacific nations are braced for the potential devastation of a virus sweeping through small close-knit communities, isolated from tertiary health care.
Vanuatu, already on high alert for a Covid-19 outbreak, bore the brunt of yet another category 5 cyclone this week, a reminder that climate-influenced catastrophes remain ever-present in Australia’s region.
Humanity’s other grave challenges have not been eradicated, only momentarily obscured, by the Covid-19 crisis.
Even if Australia succeeds in bending its Covid-19 infection curve to its will – which is at this point unusual for an Anglophone country – there will be more to do internationally before restrictions such as travel bans can be lifted.
Australia’s success in defeating Covid-19 will depend on its willingness to help other countries less able to defeat it too.
You can never be safe from a virus if you are surrounded by it.
