When studying disease outbreaks, think like a microbe.
That’s the lesson that was drummed into Prof Catherine Bennett, chair of epidemiology at Deakin University, when she was undergoing her scientific training, and she’s never forgotten it.
“In moving through a community, where are your opportunities as a microbe?” she says. “We need to think about that in how we work, how we live, how we build those structures – physical, social and economic.”
The Covid-19 pandemic has revealed just how many opportunities there are for an adaptable microbe to emerge and thrive in the structures of today’s society. Despite being a mindless virus driven solely by evolutionary pressures, it has been remarkably effective at highlighting the weaknesses and fault lines in health workforces, aged care, public health infrastructure, health communication, social support systems, and between state and federal governments.
But there’s a fear that despite at least 620 million confirmed infections and 6.5 million deaths globally, we are still ill-prepared for whatever crisis the “Pandemicene” has in store for us next. “I had a lot of my worst fears confirmed about the fact that we have learned a lot but the lessons rapidly get forgotten as soon as the crisis subsides,” says Prof Lyn Gilbert, an infectious diseases physician and clinical microbiologist at the Sydney Institute for Infectious Diseases.
Research window closing
With Covid-19 in Australia at its lowest ebb since the Omicron variant roared into existence in late 2021, and before the predicted wave of a new variant, those who work at the pandemic coalface are taking stock of what this particular microbe has revealed about Australia’s strengths and weaknesses, with the hope that Australia can build on those strengths, and shore up the weaknesses in time for the next pandemic.
Doing that will require understanding which public health interventions worked or didn’t work, for whom, and why. But Bennett is worried that not only has there not been enough of this research, but the window in which to do it is closing.
“What was missing from an epidemiological point of view … was the middle analysis,” she says. There was the modelling, which was important in planning and policy setting, and there was detailed analysis of individual cases and small outbreaks. “But we had none of the usual analytic epidemiology we normally do around assessing risk, who’s particularly at risk, how do we manage risk in a more nuanced way so we don’t have a lot of collateral damage from control measures but we’re getting the best control of the virus?”
She argues there needed – and still needs – to be a much more forensic dissection of the impact of public health interventions, particularly those that caused the most disruption. “You don’t just say, ‘we don’t quite know what’s going to work so we’re going to go big’,” she says. “If you do that, that’s even more of a responsibility to move to do evaluation alongside it.”
Part of the reason that this evaluation didn’t happen, or didn’t happen enough, was that the data infrastructure wasn’t in place to enable it. “Our reporting systems in Victoria weren’t designed for that,” she says. “Doctors were still faxing in results or reports and people had to physically hand-enter them into a system that wasn’t capable of doing clever analysis.”
The establishment of an Australian centre for disease control – which the federal government has committed to – is an important step in the right direction, says Prof Tania Sorrell, infectious disease physician and senior researcher at the Sydney Infectious Disease Institute.
“A critical starting point is to have comprehensive data readily available to guide decision-making, and that requires disease surveillance and it requires being linked to a response structure,” Sorrell says. “If you want data to drive public health responses, then it’s got to be quick, it’s got to be able to be assimilated from different databases quickly, and informed decisions made and presented to government.”
The right, transparent advice
An independent national infectious diseases body could also help with another lesson hopefully learned from the pandemic: government decision-making about public health needs to be evidence-based, consultative and transparent.
“One of the big things that we continue to see is this failure to explain the rationale for decisions in a very transparent way,” says Prof Julie Leask, a social scientist specialising in vaccination and public health at the Sydney Institute for Infectious Diseases. That was evident early in the pandemic, when it took a long time for health officials to be open about the prospect of the pandemic arriving in Australia and what Australians could or should do to prepare for it.
“We had an early phase of communication that was characterised by a great deal of paternalism,” Leask says. “That changed because it had to, because the government saw that it needed to take the public into its confidence much more than it had before.” That shifted into the phase where governments adopted the mantra that they were ‘just following the health advice’, and put chief health and medical officers front and centre at press briefings.
But they weren’t always directly following that advice, because strategies to deal with a pandemic will take into consideration a broader range of factors. That created some tension between state, territory and federal governments, and sometimes even within those governments.
“Whilst people can tolerate inconsistency across time and space to some degree, what they find very difficult to tolerate is inconsistency between people, so between experts or between a chief health officer and a premier,” Leask says.
Gilbert says a body such as a CDC could publicly provide evidence-based health advice to all governments, and then it would be up to those governments to individually decide what to do with that advice.
“It would be nice if the states were more or less required by public opinion to explain why they’re doing something differently, because there was so much confusion and anger about the fact that there seemed to be different regulations, different mandates, different rules in different states and territories,” she says. “From the point of view of getting the public to cooperate, I’m sure they’d cooperate much better if they were told why things were happening the way they were happening.”
There have also been some hard lessons learned about tailoring and targeting communication to at-risk communities, Leask says. “In terms of what directly contributed to deaths, it will probably be the failure to very rapidly, in the early parts in particular, engage with culturally and linguistically diverse communities, because they’re the groups where the data shows us the highest death rates.”
This was one area where New South Wales’s structure of localised health units gave an advantage over Victoria’s more centralised health infrastructure. “You have much more opportunity to engage directly with communities,” Leask says, pointing to areas like western Sydney and Tamworth where local health units were much more embedded and able to work closely with local migrant and Aboriginal communities. Victoria has now moved to establish and scale-up local public health units.
The people problem
However, there’s one key weakness in Australia’s health system that became critical during the pandemic and no one seems to have a solution for: workforce shortages.
“You can buy ventilators but training an ICU nurse takes years,” says Prof Ed Litton, intensive care specialist at Fiona Stanley hospital in Perth. A survey of 194 Australian intensive care units in 2021 found that staff numbers – especially of critical care nurses – were the single biggest limiting factor in their ability to cope with surges in Covid-19 infections. Overall, fewer than half the additional ICU beds that could be freed up during surges could be staffed.
“In ICU, the ratio for [nurses to] ventilator patients [was] always one to one, but that was broken during the pandemic,” Litton says. Some of that was pre-existing staff numbers, but it was also the result of nurses being ill or furloughed by Covid-19. That shortfall has persisted, even as hospitalisation rates have waned.
Rand Butcher, a critical care nursing consultant and CEO of the Australian College of Critical Care Nurses, says nursing shortages are the “elephant in the room” for pandemic preparedness. “It’s a really complex problem,” he says, pointing to high levels of exhaustion and stress among critical care nurses, and to high levels of hospital vacancies for these nurses. Efforts are under way to model what will be needed for future pandemics, including standards for how many nurses are needed for intensive care units. “We’ve got to look for what’s the new normal that you want terms of staffing, and it’s probably quite significantly more than what we have now.”
The pandemic isn’t over. Maybe it’s shifting into a new phase, or maybe we are temporarily in a lull before the northern hemisphere winter coughs up a new and more challenging variant.
There are some things that will work in humanity’s favour: the development of new vaccine delivery platforms such as mRNA and viral vectors that will enable the rapid development of vaccines against new pathogens in future, and a greater awareness of the need to deploy those vaccines in vulnerable communities and frontline workers well ahead of outbreaks.
But there are still so many unanswered questions, such as the risks versus benefits of school closures, how Australia should manage its external and internal borders in future outbreaks to prevent the spread of infection, and how to secure the supply of vital medical and research equipment to make us less reliant on uncertain overseas sources.
It’s clear from the experts who have been on the frontline that we have a long way to go before we are, as Bennett’s adviser taught her, thinking like a microbe and applying those lessons to prepare for the next microbial onslaught.
“For every life impacted – whether it’s because a family member was lost or a child’s education was disrupted, or someone lost their livelihood or someone is living with long Covid – we owe all of those people the promise that we will learn as much as we possibly can from the last nearly three years,” she says.