As most doctors will testify, changing human behaviour is a major and enduring challenge.
With the introduction of an unprecedented State of Disaster in Victoria on August 2, an upgrade from the State of Emergency, Premier Daniel Andrews foreshadowed the most draconian restrictions yet in an effort to contain, if not eliminate, the spread of COVID-19 in Melbourne.
In the space of a month we have seen the incidence of infections in Victoria grow from less than 2000 to over 12,000 and the number of deaths grow from 20 to 120 with over half of these deaths occurring in nursing home patients.
There have been well defined clusters that make contact tracing relatively easy (nursing homes, quarantine hotels, meat works). But it is the disturbing increase in community spread, with hundreds of cases where the incident case cannot be identified, that is causing the most concern.
We in Victoria have watched the grim faces of Mr Andrews and state Chief Health Officer Brett Sutton replace those of the Prime Minister Scott Morrison and commonwealth Chief Medical Officer Brendan Murphy as they declare yet another day with record numbers of infections.
It was on May 8 that Morrison declared an easing of restrictions and it seemed that Australia’s tackling of the pandemic had been “exemplary”. But despite the Prime Minister’s optimism, six of the eight states and territories kept their borders closed and ran their own agenda.
These states – all but Victoria and NSW – have had zero or very few cases in the past two months. This serves to highlight one of the fundamental flaws in our health system, namely the commonwealth-state divide.
The commonwealth is responsible for Medicare and aged care, the states are responsible for hospitals and public health. The virus, however, does not recognise these boundaries.
As the death toll in nursing home patients was mounting, it took some days for the commonwealth to acknowledge that aged care was its responsibility and to indicate that it would contribute financially to Victoria’s effort to deal with this part of the crisis.
It is noteworthy that the commonwealth has not committed to contribute fully. So it may well be that the state will need to fund hospital costs.
The Royal Commission into Aged Care will no doubt expose numerous weaknesses in the system, many of which the COVID-19 crisis will highlight. But the reality is, for a country of 25 million people, to have three layers of government responsible for various aspects of healthcare seems absurd.
It may be more efficient and effective to have a single commonwealth health department with state branches administering policy and practice.
The tragedy that has befallen nursing homes was predictable and possibly preventable. We failed to learn from overseas experience or from our own experience with the Newmarch House nursing home in Sydney. In the UK, more than 2000 nursing homes were affected and accounted for with 40% of the country’s more than 46,000 deaths.
In most cases, it is the staff working in nursing homes who bring the virus into the home. Given this knowledge, it would seem reasonable to test all staff working in Victorian nursing homes for COVID-19 after the Newmarch and UK experience and keep testing them on a regular basis, as well as ensuring adequate supply and use of PPE. After all, AFL footballers are tested three times a week.
COVID-19 has highlighted other major issues in relation to the aged care sector, namely the casualisation of the workforce and outsourcing of labour to employment agencies. This is a problem not confined to the health sector, also occurring in the private security sector which was responsible for the outbreak among poorly trained and ill equipped security staff charged with looking after people in the quarantine hotels.
Had well-trained personnel wearing PPE been used in these hotels this source of community spread might have been prevented.
Another major outbreak occurred in the towers in Flemington and North Melbourne which house 3000 residents. Many are migrants or refugees from a range of countries where police brutality is the norm. Calling in the police to enforce a sudden lockdown resulted in fear and panic.
We pride ourselves in supporting a multicultural society. More sensitive communication using community leaders would have been a better strategy.
In Melbourne, it is the northern and western suburbs that contain the largest numbers of new COVID-19 cases. These suburbs are culturally and ethnically diverse and provide a major challenge in communicating the need for social distancing, especially when it comes to family gatherings, resulting in significant spread of the virus.
Despite best efforts to implore Victorians to follow preventive measures clearly set out at the beginning of Stage 3 and repeated on numerous occasions, these guidelines were frequently being flouted. Parties, lack of adherence to physical distancing, driving to prohibited rural areas and subsequently failure to wear masks, with some claiming these guidelines represented infringement on human rights, all incurred fines. It is clear that changing human behaviour remains a major and enduring challenge.
This should not surprise our medical colleagues and other health professionals who have battled with issues such as smoking cessation, drink-driving, exercise promotion and safe sex practices, to mention a few.
The countries that have enjoyed greatest and sustained success, namely New Zealand and Taiwan, adopted a policy of elimination rather than suppression. In most other countries where economic considerations outweighed health concerns, with policies directed to suppression (or worse, as in Sweden, which did virtually nothing), have seen high morbidity and mortality and recurrent outbreaks.
The adage “ go early and go hard”, which has proved successful in managing Ebola, SARS and other epidemics, was not adopted in Victoria even with this second wave.
Failure to do so at the very outset, including late compulsory wearing of face masks, has compounded an already difficult situation. This also further undermines public faith in our leadership, enhances frustration and leads to greater despair as job losses mount and the economy is catapulted into oblivion.
We will undoubtedly eventually emerge from this plague, but it will leave indelible scars on this generation and on generations to come.
Let us hope that as we confront future pandemics, which will certainly come, we apply some the lessons learned from this one.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for 40 years.
