Suppression or elimination

The worst is not over even if there is no second wave

What a painful lesson. On June 6th Victoria had no new cases. Breathe a sigh of relief. Three weeks later, 42 new cases most of which could not be linked to known outbreaks. ‘Lockdown Two’ for the hot-spots quickly followed.

The spots, unfortunately, were swarms; ‘Lockdown Three’ came just one week later.  Daniel Andrews transformed from ‘political god’ to interstate ‘whipping boy’ at a cost, according to the Treasurer, of $5bn.

No doubt there were missteps in Victoria. Perhaps we should have skipped straight to lockdown three. There are reports of carnal assignations between guards and ‘guests’ in quarantine, presumably not wearing facemasks. But the most likely candidate, unintentional as may be, was the 30% of those in quarantine who refused a test upon release.

A moment’s thought will tell you how unwise this was. A returning Australian catches COVID-19 two days before flying home. It takes from 2 to 14 days for symptoms to emerge if they emerge. They are then infectious for 7 to 10 days; it could be longer. Released from quarantine untested, they can infect the community anywhere from a day to a week. And often the first thing they do on release? Party.

Testing in quarantine must be compulsory, as it now is, and quarantine should be extended for the positives.

Even so, Victoria was unlucky. COVD-19 is a beast to stop because of its long gestation and asymptomatic infections. One missed case and it escapes into the community before you know it. NSW’ experience with the Crossroads Hotel, well named, reinforces the point.  Located on the busiest road in Sydney, drawing customers from an enormous catchment to its newly renovated function rooms, one infection in early July triggers a flurry. Learning from Victoria’s difficulties, NSW is right on it, but it will be hard to contain. I would not be surprised if it is simmering away in southeast Queensland even now.

We continue to learn more about COVID-19, which changes what we do. Last week I wore a mask just because Donald Trump didn’t. Australia was not pressing the case. New data suggests that airborne transmission is more important than we thought (and surface based transmission less so).

So, we should all wear facemasks in supermarkets, shopping centres, workplaces, public transport, casinos, any enclosed spaces shared with others, even large indoor family gatherings.

Which presents something of a dilemma for restaurants, pubs, and clubs where facemasks are less practical. If they are to stay open while infections persist, we will have to rely on low occupancy, ‘no mingling’ 1.5m rules, hardly perfect and particularly hard when mingling is point.

Based on our modelling, I believe that Australia would weather the pandemic better with more focus on isolating and protecting those at risk with a more relaxed approach to those that are not. We already know the risk factors for severe outcomes; a simple genetic test could identify them more accurately still.

That road was not taken. But employers may want to consider this when, in due course, they change their work at home and travel policies. A genetic test that helps them decide who to safely bring back to the office and who to support at home, or who can travel and who should not, could ease the burden of returning to normality.

Now the choice is between elimination and suppression.

Elimination is what it says on the tin. Strict quarantine to prevent infections from outside. Intense social distancing, lockdowns and quarantine, state and regional border closures, until there is a sustained period with no community cases. Social distancing can then be relaxed, mingle as you like, but borders stay shut.

Suppression is based on earlier relaxation of social distancing with more open borders. Tolerate some infections. Extensive testing to quickly identify new cases. When they arise, adopt a whack-a-mole response with immediate, strictly policed but highly targeted interventions such as first, second and third tier isolation.

The choice should come down to the health and economic harms that results under each. Regardless, I think we are destined for elimination. I do not advocate it. As I have said before, the economic costs are high. Suppression within the limits of our hospital capacity is much better.

But ACT, NT, SA, Tasmania and WA brag about their successful elimination policies. They won’t open their borders to states with ongoing infections. NSW talks about putting the economy first, but it still quickly closed the Victorian border. It is also very difficult to walk the suppression tight rope. One evening at the pub and it all unravels. Tilt just a little the wrong side and, if you will forgive the mixed metaphor, you prize the lid off Pandora’s Box.

We are not willing to view mortality through a health-economic lens. No politician dare touch on the issue. Nor have we put in place policies that specifically identify and then isolate those at risk. So, when infections grow, deaths grow as quickly, which we will not tolerate. Our leaders must address these difficult issues for suppression to work and the economy to recover.

Instead we adopt policies, like the Melbourne lock down, that target elimination in all but name. Not because elimination strikes the right balance but because, as Daniel Andrews found out, the danger of suppression is that it runs amok.