Open Letter to National Cabinet from OzSAGE – 13 Dec 2022
OzSAGE calls on National Cabinet to urgently revise the Strategic Framework for Transitioning COVID-19 Measures released on the 9th December 2022.
While OzSAGE supports the intent of the strategic principles, many of the accompanying statements contained in the framework have serious inaccuracies and are not supported by the evidence or current real-life experiences.
The supporting commentary is a misleading narrative that the pandemic is now manageable and in a stable state. Experience of the SARS-CoV-2 virus over the last 3 years, combined with current evidence, clearly indicates that this is not the case. Many of the key elements in the framework are either contradictory, inaccurate or completely incorrect.
In its current format the framework could encourage a false belief that nothing further can be done and that Australians must now learn to "live with" the virus and revert to pre-COVID behaviours, despite this also correctly being described in the document as being unachievable.
This approach will lead to greater disease transmission and continuing avoidable morbidity and excess deaths, with inevitable negative impacts on the community and economy.
For the risk profile to state that ‘the crisis phase has passed and the risks of widespread COVID- 19 deaths, overwhelming health system capacity and a significant economic shock from COVID-19 have subsided’ is false and unconscionable, given the high numbers of cases, workforce shortages, hospital admissions resulting in cancellations of elective surgery, ambulance ramping and significant ambulance response delays, direct and indirect COVID-19 deaths we continue to experience.
The health system remains under considerable stress, and the statement that the crisis has passed is likely to be offensive to the majority of health care workers.
The risk profile also claims, ‘This changing risk landscape allows us to recalibrate focus back towards sound decision making processes to ensure the continuing COVID-19 response is evidence based, fiscally responsible, consistent and proportionate’. This statement implies that previous decision making was not sound, responsible or evidence based, all of which are inaccurate. All the evidence suggests that prior to December 2021 Australia had one of the best responses to the pandemic resulting in fewer social, health and economic losses than comparable OECD countries.
The current National Cabinet Framework is a missed opportunity to reduce the ongoing risk from COVID to the Australian community and the economy. It is neither sustainable nor morally appropriate for National Cabinet to solely rely on infections, waning vaccinations and ‘hybrid’ immunity against COVID as a recovery plan. It is obvious that this strategy has not worked in the UK, the US or anywhere else it has been tried.
The side effects of infection, including Long COVID, pose significant long-term risks to the Australian community and its economy. Pressure on the health system remains extreme. Until the emergence of better vaccines, a strategy that includes a range of measures such as that adopted by Japan and Thailand, requiring the use of masks in public settings, and indoor air quality regulations such as adopted in Belgium and The Netherlands, is required.
The key elements of the framework that are of most concern to OzSAGE include the following:
‘National Cabinet Strategic Principles’
• Only focusing on ‘Minimising the level of severe COVID-19 and death’ ignores both the harms of less severe cases of acute COVID-19 disease, for example the costs of disrupted social, educational, work and travel activities, and the long-term morbidity that is now becoming apparent from even mild infection. Long COVID is emerging as a significant enduring health and economic liability for both the community and governments. A focus on minimising severe COVID and death also disregards the social and economic effects of ongoing persistent illness in the community. Therefore, only targeting the most vulnerable and at-risk populations will not address these issues. The primary objective of the Australian health response to COVID-19 should be to reduce as far as is reasonably possible the number of cases of COVID-19, as opposed to merely minimising the level of severe acute COVID-19 and death.
• ‘Ensuring the health, economic and social systems as a whole have the capacity and capability to respond to future waves’ is vital. Unfortunately it is improbable that this framework will achieve this unless the primary issues identified here are addressed.
• ‘Promoting and creating an environment that mitigates pandemic fatigue and generates self-reliance, resilience and capacity building which reduces the reliance on government interventions’. These measures are important yet there are no strategies within the framework to achieve this. Rather than hoping that we can do this by simply returning to pre-COVID behaviour, the framework should be looking to provide public education on how individuals can reduce their risk of infection. Communities cannot be expected to be self-reliant, resilient and build their capacity without being provided with the knowledge and resources informing them how to do this. Education is a primary public health principle and has been used in tobacco control, road toll reduction and every other successful public health initiative.
• ‘Continue to promote the importance of vaccinations, including boosters, to improve health outcomes’ is important, yet vaccines are only one part of the strategy. There is no mention of the other components that make up a Vaccines-Plus approach such as ensuring clean air in public spaces, the importance of mask use when this is not achievable, access to free public PCR testing sites, and isolation with support for people while infectious.
• ‘Supporting the economic and social well-being of those living in Australia, as well as Australians living overseas’ are sensible principles. However, the current framework is unlikely to achieve this. Ongoing high levels of circulating virus in Australia and globally
will have serious economic and social impacts including reduced workforce in the short term (acute illness) and medium to long term (long COVID) and add considerable burden in terms of health, disability and social welfare costs.
• ‘Returning funding and policy efforts to a more sustainable footing, including for business and individual supports, aged care and health funding’ are important principles for sustainable long-term growth. These can only be achieved if the current and future pandemics are appropriately managed to reduce the health and fiscal impacts. This cannot be done by simply hoping that things will return to normal, there must be decisive action by governments to create a safe and well-educated community. However as stated in the framework under structural responses ‘COVID-19 has fundamentally changed parts of health, economic & welfare systems. Some responses will continue permanently as Australia has adapted to be able to manage COVID-19 & other emergencies’. As such governments will need to continue to provide funding and adapt policy to address these issues.
‘The 2023: Transition to Sustainable Responses’ section contains a number of questionable statements as follows:
‘Pandemic response’
• ‘Some measures will need to continue as our baseline response to the pandemic (with a clear transition plan) to reduce shocks to the health system and the economy & to provide additional capacity for systems to respond’. It is not clear what is meant by transitioning to something we already have. Yet this clearly accepts that many, not just some, measures will need ongoing government funding and policy development to continue, which supports our concerns about some of the previous statements.
‘Steady State Overarching’
‘We are unable to revert to a pre-pandemic state, the new normal should include:’
• The statement, ‘Managing COVID-19 like any other respiratory illness – enough people will gain immune protection from vaccination and natural protection that there will be less transmission and less COVID-19 related hospitalisation and death, even as the virus continues to circulate’. Firstly, we currently do not treat respiratory illnesses as if they are all the same, because they are not, for example; tuberculosis.
Furthermore, COVID is not just a respiratory illness, it is a multi-system disease that can result in significant sequelae in multiple body systems which means this statement is misleading. Secondly there is no evidence that natural protection exists. If this is referring to "hybrid immunity", convincing evidence suggests that this is short term and not necessarily transferable between variants.
COVID-19 continues to have far more impact, including hospitalisations, death and long- term disability than that caused by influenza and other common respiratory illnesses. Therefore, it is incorrect to suggest these measures will be mitigating factors that can be
relied on.
In reality as the virus continues to circulate there is continuing pressure for it to mutate independent of its virulence, which may increase, decrease or remain the same. The evidence for this is well known, and it is also obvious from the last 3 years that immunity alone will not stop transmission, be everlasting or transferable to new variants.
To suggest that ‘no bespoke measures, existing systems will be able to respond’ indicates that we have learnt nothing from the last 3 years. Pre-pandemic planning must continue, and bespoke measures must be considered and available when required.
To suggest that existing systems will be able to respond is to ignore the current dire situation of our public health system, which is also evident in other COVID-affected health systems across the world.
Additionally, ongoing lack of accessibility to PCR tests and possible reduced sensitivity of RATs means that patients who are eligible for antiviral medication are unable to access them within the useful timeframe. There is also a persistent false belief that a negative RAT indicates no ability to transmit a COVID infection leading to ongoing unnecessary transmission. It also ignores the emerging long-COVID epidemic that will see health and social systems overwhelmed.
This statement contradicts previous ones in the framework, that some measures will need to be maintained and ‘COVID-19 has fundamentally changed parts of health, economic & welfare systems’.
‘Overarching Public Health Principles’
• ‘All COVID response actions need to be considered in the wider context in which we operate’ is a vague statement. We need to be clear that inaction can have a much worse effect on the wider context in which we operate. The evidence suggests that countries that did not act during the early part of the pandemic were worse off both socially and economically than similar countries that took steps to slow transmission, including Australia.
• ‘Move from public health orders to work health and safety and individual behaviour change paradigm’, requires a plan for public education and support, none of which are addressed in the framework. Expecting individuals to modify behaviour without education around how and why this is important is unreasonable, unachievable and already a demonstrable failure in Australia.
• To ‘Move from mandates to strong recommendations’ requires a plan for public education and support, none of which are addressed in the framework. There has been inadequate education around how COVID is spread and the likelihood that many may have a “passive” aquired COVID infection. Additionally, it is well known from other public health campaigns such as quit smoking or drink driving that public adherence to
recommendations requires regulatory support as well as education from governments to achieve compliance.
• ‘COVID exceptionalism, in the current Australian context of high vaccination rates and rising hybrid immunity and relatively low case load, needs to be replaced by enduring structural change in our approach to respiratory illness’. This is not a public health principle; it is a statement which ignores the current waning vaccination rates and rising numbers of cases. Additionally, it misrepresents the impact of hybrid immunity which is known to be limited.
Without a coherent strategic statement that addresses the ongoing direct and indirect death and disability from ever new variants of SARS-CoV-2, Australia is doomed to worsening acute and chronic disease and mortality, all of which will also impact the economy.
We urge Australian governments to look again at the evidence of excess disease, disability and death and to opt for a Vaccines-Plus approach that will ultimately lead to better health, economic and social outcomes.
Public health experts know what to do, but we need our leadership to start the country on the right path rather than just wish this disease was like any other. It is not.