This article is a synopsis of a Trans Tasman panel discussion on the topic of ‘Responsiveness in a highly dynamic context with significant variability in local priorities and practices depending on the latest local pandemic status, with a mix of strategies’.
Dr. Pete Rive (host),
Senior Advisor, S23M
Prof Michael Baker,
Public Health & Director, Health Env. Infection Research, University of Otago
Prof Judy McGregor
Chair, Waitemata DHB
CEO, Allied Health Professions Australia
Bill Bowtell AO,
Adjunct Professor, University of New South Wales
Thijs de Blok,
Senior Advisor, Buurtzorg (Japan / APAC / Netherlands)
Jorn Bettin (Q&A),
PR: Good evening, everyone. Thank you for joining us this evening. The intent of this evening is to keep this very much a conversational approach. This is very much about knowledge sharing, at S23M we believe strongly in co-design and collaboration. We have an interest in the healthcare area, and getting knowledge to the right places.
I’d like to kick off with with a question for you all around what you think are the most important variablities between different locations with respect to the strategies for either elimination or suppression of the pandemic?
CH: I certainly think from the point of view of being in Australia, and being in a federation, local responsiveness has become one of the most confusing things for everybody to deal with. And there are still a lot of other health issues and other things going on that we can’t drop the ball on. Trying to deal with those things in the background of constant, almost daily changes of “you can do this, you can’t do that”, and people working literally across areas with completely different standards and requirements, it has become something of a nightmare, I have to say.
PR: Yes. I saw just today there was a comment from the Deputy Prime Minister about lifting the cap on people coming back to the individual States, which, we don’t have to worry about, having one government to make the decision.
BB: Back in the days of AIDS, when we had to do with that viral challenge in Australia, the government of the day made a very important decision, which was, there would be one national response. So, when COVID came along, I was one of those who really thought that we had to put a lot of effort into making one national response. But that wasn’t the view that the government had, and they devolved it to the states, and inevitably, the way in which the virus moved, and all the problems in Sydney and Melbourne, Brisbane and Perth, and the speed with which it moved around, on the 22nd of March, all edifice of a national response is just collapsed.
The states went their own way by closing the borders. Under the influence of Michael in New Zealand, most of them moved to look for local elimination. But other states didn’t quite do that. So, we’re now in a funny post federation situation.
The states now have this border problem. The federal government in its wisdom has decided to impose a problem with Australians returning home. It’s very hard to see how this will be resolved anytime soon. Although I believe in local elimination, I also really think that this is not desirable to go on forever, at least within the Australian Federation and with New Zealand.
We’ve got to come down to a common set of policies and common outcomes, and then allow people, as much as they can do, move around, at least the 30 million people who are in Australia and New Zealand. I think that’s an economic imperative. But there has been a great fracturing of leadership and common sense in Australia, even though outside Victoria the results have been good, as they have been in New Zealand.
PR: Michael, have you thought about this?
MB: Firstly, the thing that I found intriguing was that, actually, there is almost an East-West split, because the Asian model was highly effective, which they had demonstrated by the end of February.
This pandemic was stopped in full flight in Wuhan and moved on. Even if you doubted some of the details, this was a very credible group of scientists who turned around and said, yes, it has been stopped. That was a lesson. There was a message for the whole world saying containment works. It would have been tough at that stage, but it was possible.
I think people like me in New Zealand and I think I’m sure people in Australia and other countries were saying yes, actually this is containable. Elimination is a paradigm that’s been around for more than three decades anyway. There’s nothing original about it. It was being fully contained in Taiwan and other Asian countries at that point.
That seemed to be a preferable model. The whole Eastern Hemisphere has largely eliminated this virus. We’ve got one point four billion people in China who are protected from it, 24 million people in Taiwan, a very similar population to Australia. We’re not getting this. Even low-income countries like Vietnam with long complex borders can stop this virus. The economies of those Asian Tiger countries are all expanding from last year. So it’s a very successful combination of protecting health and protecting the economies. It’s not a choice.
And Australia is also hugely successful, at least based on the number of states and territories that have eliminated the virus for longer than New Zealand did. The exceptions in this part of the world really are Victoria and New South Wales. There are only minor disagreements about tactics.
Of course with our resurgence, which began in mid August, we were doing things differently from the first outbreak, with a regionally focused approach, and avoiding an intense lockdown by using high volume testing, contact tracing, phasing in face masks for the first time, and limiting gathering sizes. The difference was that it was going to be more focused on Auckland than on the rest of country, so right away that created a bit of tension.
Unfortunately, the government didn’t stick with what I think was the real model, which is you stop people travelling out of Auckland if you’re doing a focused approach. They couldn’t stick with it because it was too difficult and impalatable. Even though it was good plan, the execution was a bit muddied. But it does – it may work. It looks like we are close to achieving elimination again, but there are no guarantees. It’s a tough virus.
PR: Thijs, I was just thinking about your experience in Japan, but also across Europe, looking at borders and those sorts of things. What’s your take?
TdB: I want to continue on what Michael Baker was saying. We have a lot of collaborations in the Tiger countries, China, Taiwan, Vietnam. And what we saw there, across Buurtzorg as a whole company, is that they doubled down on PPE, especially on face masks.
Whereas in Holland the message was that face masks are unnecessary, even for primary healthcare nurses and community nurses.
– And then the shortage. We at Buurtzorg went out of our way and were taking to our partner in China, to get it in contact with the factory that produced masks, and we were able to get four millions masks within weeks in The Netherlands in our own backoffice.
We got highly scrutinised by the government “oh, it’s this scarcity of masks and you’re taking them away from other countries”. We said no, it’s created scarcity. We only wanted to protect our frontline workers. What happened a couple of week later was that everyone started to double down on masks. Buurtzorg as the market leader in community care in Holland has the least cases of Corona virus infections per capita per employee over all the primary healthcare organisations. I think this is for a reason.
If you keep on following only what the government introduces as the benchmark, and you have to perform above this, you will always trail behind. You have to make your own decisions. So, we set up a Corona team.
We work in small teams, and we found that there is a nurse who also has a background as an epidemiologist, working for Buurtzorg. So, we asked her to join our Corona team, and we have some IT experts joining the team. Every day, they would meet, including myself, to think about solutions and what can we do to help these nurses. But we don’t enforce solutions, we advise everyone, and they can implement what is appropriate for their situation and their environment as needed.
This lead to the result that the nurses and the frontline workers are all very comfortable with the approach, because they still get to make their own decisions. Nothing is forced on them. They’re also aware of what the risks are, of working as a primary health nurse in this time of Corona. So rather than enforcing it, it’s still the Buurtzorg way of educating, discussing, and having a team based approach on what everyone feels comfortable with.
Our approach was strengthened with international knowledge. We created a webinar with our international partners to talk about these things.
PR: If we look at the difference between, say, federalism or centralised government control. There is something to be said for a localised approach, that the people on the ground know what they need. Claire, I think you’d be also very aware of that.
CH: Absolutely. People on the ground to know what they need. But the caveat to that is a pandemic is obviously different to normal operations, and particularly in terms of allied health. The majority of allied health professionals don’t use PPE, especially those working in private practice or in community, which is big in Australia.
It’s not something that is normally used, and when you’re told by central government, oh, just use your normal supply chains to get it – well, you don’t have any “normal supply chains”. From the beginning there was an understanding of portions of the healthcare system of what their needs were, but there was a complete lack of understanding of the needs of other parts of the health system.
There were assumptions that people knew what they needed and knew what they had to do, knew where I needed to get things, which, of course, they did not. And then, when allocations were made, there was not enough. We were told, suddenly, you must have masks to go into any disability setting, you must mask to go into aged care.
Well, basically no one had anything, so no one could go and provide services. So services into age care stopped, and services into disability stopped, because people couldn’t get their hands on the right material. It’s resolved itself now. I think part of the problem is there had been no really good pandemic planning. And allied health certainly had not been factored into anything. We have played catch up ever since and it hasn’t been pretty.
All the definitions in every state are different about who is essentially what is essential. So, you literally don’t know. You could be in one border town, and you can cross the river, and everything’s different.
So, it has been really, really difficult.
PR: Michael, it’s a big call, right? You’re making a call. In effect, everybody’s looking to you for for some sort of certainty and all you can say is I think that’s right. How do you think we’ve progressed from a policy based, political approach towards a more evidence based, scientific approach, in terms of forming some of these policies?
MB: The huge lesson from all of this for me, is that good science and good political leadership, if you could put them together, it’s a great combination. And as many people are saying, we have other scenarios where the science is being contested, and we’re waiting a long time before acting. Climate change is obviously the key example.
We had incomplete knowledge, but I think the consensus is forming around doing something differently from what we had been doing, and then we acted. I think it gives government a sense of agency that the actions of governments can actually both protect the population, and also spread the burden. One of the main functions of the state, I think, is to say: well, if we enact these really tight lockdown controls, it’s very tough on some segments of society that are carrying the load to protect us all, and therefore we need very targeted interventions to support those sectors that are suffering.
It was interesting that even quite large corporations looked to the government to in a sense spread that burden. That’s one of the big lessons that hopefully we have all absorbed.
In countries that did not have that, the role of the state was being highly contested. In fact, if anything, there’s a winding back of the state, done very badly. But you’ve also got really effective democracies. Taiwan is a democracy that’s delivered the single best response internationally.
We’ve done a very detailed comparison in collaboration with a Taiwanese epidemiologist that is coming out in the Lancet journal shortly. It’s all about infrastructure and being able to make these really tough choices quickly, having the scientists right at the table making the decisions.
PR: I’m going to throw this open to everybody. To what extent do you think we are now cognisant that we need sustained investment in health care? And to what extent do you think we’re preparing for other disasters such as global warming?
MB: Can I add just two comments.
One is, I think sometimes scientists are not very good at emergencies, because they want to be very certain before they speak out. And typically, you have the 95% certainty before we think something is really significant, before you feel really comfortable. I was in a room filled with scientists who were sitting there mutely, effectively saying we really don’t know, we don’t have enough knowledge to act.
Politicians often had to make the hard calls. And they often do better than scientists. So I think you have to have the right mix. And you can also get too much certainty. I think we saw this with the advice in the UK from the SAGE group, which was full of disease modellers, not enough other disciplines, not enough allied health professions and other groups, and they I think got it horribly wrong. So I think you need this dance. You can’t create this overnight. You’ve gotta have these people working together for years, so they build up trust. And they also they’re trusted by politicians. I think one of the things in New Zealand that helped us a lot was having chief science advisors in the Prime Minister’s department and other departments. They were really marvellous as circuit breakers in getting information to move swiftly around, even if it wasn’t exactly their discipline.
The other point is the distinction between pure population health, and preventive health and healthcare delivery. They did two different and complementary functions. But what has tended to happen is, with the erosion of health care systems, the path that has withered the most is the preventive care side, because it’s often seen as expendable, because if it goes, you don’t notice until you really miss it. And then its too late, because you can’t create it overnight.
BB: That was certainly the case in Australia, when it devolved into the states and territories. It was very obvious to see the states and territories that had kept investing in public health. In public health, like everything else, you get what you pay for.
And I can say New Zealand, in New South Wales and Queensland for example, they had invested a great deal every year, building up their public health infrastructure and their people, most importantly, their people. And it was treated very seriously at senior levels in New South Wales.
It was a necessary condition when the problem arrived, to deploy very quickly the structures, the personnel, the senior expertise, and the money.
Now, in Melbourne, in Victoria, over 20 years under a succession of governments, they had really disinvested out of public health. And it was extremely difficult, impossible really, to build up that labor intensive contact tracing system over a couple of weeks, in a crisis.
And when we look at, eventually, what did not go well in Victoria, it will be that lack of investment. In countries that had let it all run-down or affected by outsourcing and neoliberalism and cuts, frankly, the system just crumbled.
PR: Claire, you must see the patchwork of responses across Australia, in terms of who invites you to the table, and who is interested in what your allied workers have to say.
HC: Definitely. There are different responses I would say. We were invited pretty quickly to the table, which was really good. But unfortunately, it would appear that, to a large extent, the response you get when you raise an issue is they say “yes, but that’s a state decision”. So, being engaged is great, but you don’t get anywhere, because they actually can’t do anything with what you’re saying.
The other aspect is the immediate response to the pandemic, the infectious part of the whole thing, and the aftermath. There’s a lot of evidence coming out now that people, particularly people who have been very ill or have been on ventilators, they can have significant disabilities for quite a long time, are going to need a lot of rehabilitation. Nothing has been done about that. There is at this stage, as far as we can work out, no co-ordinated community response to what do we do with these people who have been really sick, and we’re very worried about that.
PR: That’s a direct throw to you Thjs, I think.
TdB: What I like about what Claire is saying is that it’s an obvious statement from first-hand primary healthcare experience. And it’s frustrating. We’re trailing behind. Every primary health nurse has been saying in the past 15, 20 years that we have to double down on prevention. We have these networks around the community, and around the systems that, we can utilise for things like this, and they just haven’t been listened to ….
Now there is a pandemic and suddenly everyone’s interested. Too little too late, It’s as simple as that. With Buurtzorg, we try to challenge the government approach. So I hear that in Australia there is a state by state approach, which is very confusing for people that live there, but also for the workers.
I think what’s really important is how do we educate people on what really helps. We put tutorials on our website, how to make a face mask out of a paper towel. The families of the nurses saw that and they started making loads and loads of these hand made face masks.
Common sense will save us all in this pandemic. People with the right experiences and with the right vision on how to prevent this, or how to control this, and who can really speak face-to-face with community members, will also be effective. We have communities that don’t like to be lectured by mainstream media. You really have to go into the community and engage with the right people, in my view.
JM: In addition to under investment and public health, the pandemic has highlighted the need for different public health experts, not just epidemiologists, but also specialists in health, communication, community development, and emergency management. In Auckland, it has been apparent that when the response to contact tracing and community transmission has been culturally embedded, it has been more successful.
PR: Very good point.
JM: Pacific lead responses to the church cluster, Maori blockades in Northland, which have kept others and COVID out of the regions. In Maori communities, trusted voices are often not experts, but elders, and this informal workforce has been used to great effect, and is a lesson to the established systems and traditional delivery models.
PR: Totally agree with you Judy. Any comments from anyone about that? Michael, your thoughts?
MB: That absolutely is correct. I’m still a fan of the Ottawa charter for health promotion as a very good starting point for strategies. It pretty much says you have to have communities owning and managing these problems, and you have to make the health system extremely responsive. If you if you have marginalised groups, your response will fail.
PR: And, don’t you think also, that in the world we’re going into, we’re not going to see less of these kinds of public health crises? I don’t want to be a doomsayer, but I think it’s well known that some of these problems that we’re going to face, will require better co-ordination and collaboration.
MB: I think there’s a commitment to have a workforce which represents the diversity of the population, but it is not always successful. This is a bit of a New Zealand thing at the moment, that is happening at Otago University, when they’re trying to increase the proportion of Maori and Pacifica in the medical workforce and getting push back against that. I think it requires a massive long-term commitment. They have to make all institutions representative of the diversity our populations and to deal with racism, which is so embedded in our systems.
CH: I think that’s very, very true. And I think in Australia there have also been great examples of indigenous populations really looking after themselves very well during this pandemic. They’ve taken it upon themselves to make their community decisions about how to protect communities, particularly in the more remote areas, where they are at very high risk, and that has been a very successful approach.
I think the contrast between New South Wales and Victoria was very clear. In New South Wales the public health units in their own areas were much more connected with their communities and much more connected with those different ethnic groups and migrant groups.
You need that real connection. You can’t necessarily have completely representative workforce, that you need a workforce that works with those communities and that is culturally safe to work with those communities.
PR: And that’s not something that can happen in an urgent emergency situation. I was just thinking about your experience with HIV, Bill.
BB: With HIV, we learned very quickly, we detonated the whole orthodox structure of having highfalutin professors of this and that, and everything else, and ministers and so on at the top, issuing orders. And finally, to his great credit, Neil Blewett, the Health Minister and the government said, we’re just going to invert the whole pyramid.
And we’re going to not just going through the motions of consulting with the people closest to it. And by that, I mean gay men and sex workers, intravenous drug users and so on, but also doctors and GPs and nurses and allied health professionals. Dr Neil Blewett got them in, to the horror of the health department at the time, and said, what should we do to stop transmission of this virus to look after those who are ill? And they did all the right things and said it could all be done.
Then they were funded generously, and out the door and off they went and they came right into the heart of policy making and funding. And that was the model that worked. It’s been a great success, because if you give people money, and power, and empowerment, you don’t have to have this top-down command and control centralised approach that, honestly, is just a dismal failure.
I’m very tired of watching politicians give press conferences at the top. They give it to the mainstream press. They give it to press gallery journalists who go and print this stuff on dead trees, will put it on the six o’clock news, when the rest of the Australian population is on Facebook, or Tik TOK or Instagram or something.
They use all of the ways of talking to the population that are as obsolete as chiseling something in stone and sending it off in a bull cart, even when everyone knows it doesn’t work. We learned all of that 40 years ago. Just how many times do you have to keep on re-learning the lesson?
PR: We have just had some feedback from a viewer saying, Hi. All great panel. For all the experience in Australia, the clinicians in GP land and communities did not feel involved and consulted in the process, and needed to do their own thing initially. And as per professor Bowtell, awful communications.
BB: Michael mentioned that Vietnam’s communications on this were just tremendous, and maybe Thijs knows examples in Europe and so on. But from the beginning, I just thought Vietnam did such a good job, particularly for young people.
PR: Thijs I think you talked a bit about the experience. Your decentralised, distributed, and self-organised teams are very much at the frontline all around Europe and the world. How was Buurtzorg retrieving and collating that information and then communicating back out to the various teams?
TdB: We asked the teams, what do you see in daily practice? We’ve got a COVID team, and they collect information. A large part of that information collected comes directly from the nurses. So we have a comprehensive IT system in Holland, with a sort of Facebook inspired community platform. Nurses can write messages to their colleagues and respond “Oh, with 3 or 4 teams we’ve started a Corona route to minimise risk” etc. so, any client infected with the virus will be visited by one and the same nurse on this route. Prior to the pandemic that was not needed, but this is a good solution.
A solution gets picked up by COVID teams of specialists, and if it works, if we see cases decreasing or we see a better approach, then we also communicate this internationally. I think Taiwan is one of the interesting countries, because they’re not part of the WHO, that approach has been magnificent. We have a partnership in Taiwan, and we were discussing approaches with them, and they say, “this has worked well for us with regards to PPE, and this has worked for us in institutional care”.
And people looked at us in Holland and the rest of Europe, as we lost our minds, how can you trust a country that’s not part of the WHO? We have to all pull the same line, otherwise the outcomes will be all over the place.
We said, we want the best for our clients, and we want the best for our nurses, And if this is the approach that we have to take, and that’s the right one. And everyone, bit by bit, came back to us. So it seems like it’s the most pragmatic approach to take, to really be involved in the local environment.
Also on Vietnam, funnily enough at the start of the outbreak, in the first weeks of cases in Vietnam, I was there and I was in Da Nang, where now the hotspot of Corona is in Vietnam, and you couldn’t enter a public building without a face mask. All the things that five or six months later are implemented all around the world, were there within a week following the outbreak.
It was achievable, because there were community services going into the community and handing out free face masks for the people that didn’t have access to them. If we would have done this, in let’s say France, where COVID has struck hard, I believe it would led to a significant amount of change in the number of cases, it would have protected real people, and it would have avoided real deaths.
I think we’re not rid of this virus, yet. There are good approaches and there are best practices. And I think it’s key to listen to these best practices around the world, collect the information, and distribute it, not through mainstream news, but by other experts, and put it in a context that everyone can understand.
PR: Thijs, your nurses are engaged in a lot of aged care. This is very pertinent to this part of the world, because we had disturbing numbers of cases in aged care facilities and a high mortality rate of aged patients.
That whole point about fast response to the requests of the nurses it is really essential I think. People are putting their lives on the line. This is a life and death situation, if you’re not being heard.
TdB: I visited several aged care institutions in Australia, and then I see pretty much the same thing as in Europe. Big facilities with the most frail and fragile people all grouped together in one place. Public health experts have been pushing for years to decentralise these places. And Buurtzorg in Holland are already doing it, creating good community living. We create smaller facilities, 15 people, elderly people with complementary skills, who can live together in one house, where they can do certain things themselves, and other things together with the support of an aged care worker, and certain interventions everyday get provided by someone who works in public health. And this is going better and better.
But in Holland, the largest mortality rate is still in these large institutions. And people act surprised, “oh, COVID hit in an institution of 300 elderly sick people living together”, and we have a mortality rate of 20%. But, hey, don’t act surprised, any public health worker knows the outcome.
I don’t think the key is spreading enough protective protective gear. I don’t think the key is educating these people enough. Decentralise them. You spread your risk, and you make a proper risk assessment. If the virus strikes in in one place, we should keep it there. And I think this will also be the future, luckily. It is sad that the COVID pandemic was needed for this to happen.
PR: I’d like to just throw to Micheal. We’re almost out of time. Someone’s is asking the question, do our policies keep up with the evolving knowledge about the virus? And do we have all the feedback loops in place to ensure we can we continue to learn in a timely manner?
MB: No. I think we are on prisoners in a way of the systems, even in a country like New Zealand, which is small, and that should be nimble.
I can see that across in Australia the states are doing their own thing. They are pretty similar size to New Zealand, almost cities states. That’s an advantage, in terms of the ability to respond. And in most of Australia, New Zealand, and the Pacific Islands they made the right strategic choice, I think, to basically keep the virus out, an exclusion approach. And it’s worked. The system eventually did head in the right direction, I think.
But since then, I think it’s been very poor, generally, at innovating, evaluating, and learning. Still, the public service, which is generally running this in some ways, has done extremely well. But remember, they’re not very geared up ministries, good for running acute crisis responses and emergency responses. So I think that’s a huge lesson. You need to be able to hand over to different kind of agencies in this situation it seems to me.
PR: Well thank you all so much. We could go on for a lot longer. Thank you so much. Thank you all for joining us tonight.
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