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New Zealanders are confronted with a new reality: to learn to “live with COVID-19” until such time as we have herd immunity, hopefully by way of a vaccination in the next 18 months or so. This always was the reality, although 100 days with no community transmission tempted us to think it wasn’t true. The real question is “how best do we live with this virus”?

In our view, it makes no sense to continue to automatically resort to extensive social lockdowns because we are not well enough prepared to contain an outbreak without running unacceptable health risks if we don’t. Indeed, this strategy is unlikely to be sustainable, given that each time a lockdown is triggered it further undermines the twin foundations on which this approach rests: cheap public borrowing capacity and voluntary public compliance.

There is a better way: more disciplined border management, earlier detection through more testing along with faster contact tracing and isolation of cases, combined with approaches to social distancing (including masks) that are far more selective than full-scale Level Three or Four lockdowns.

The fact that we are still struggling to get the basic elements of this smarter approach right after so long suggests that we need a new approach. Einstein’s definition of insanity is doing the same thing over and over and expecting a different result.

Why haven’t we been able to shift our approach?

It is not a matter of cost. The financial cost of properly resourcing a smarter containment strategy must be small in comparison with locking down large sections of the economy for weeks. The health and other personal costs of lockdown are also significant and likely to fall disproportionately on those least well placed to weather them.

We have not been able to execute a smarter containment strategy because we have not planned well enough and because delivery has been patchy at best across the whole spectrum of activity that needs to be executed well for a smarter containment strategy to work.

First time around we were “caught with our pants down”.1 Our tendency to keep telling ourselves how well we had done left us poorly placed the second time around. So how do we avoid a third lockdown?

We need to be better prepared, better resourced and the execution of our pandemic plan needs to be better managed. It is not fair to ask a “policy shop” like the Ministry of Health, who have limited operational experience or capacity, to take up what is a complex operational command and control role. The Ministry needs to focus on the important job of maintaining a health system that faced considerable challenges well before COVID-19.2

Being better prepared requires a best-practice plan that is informed and reformed by objective data and provides as much confidence as possible about what the ‘reaction’ will be in specific contexts. It requires clarity about the standards that have to be met for each of the key elements of the approach (ie, border management, testing, contact tracing and isolation, and social distancing).

Better resourcing requires a commitment from the government to resource the plan and, in particular, to provide the funds for the standards set out in the plan to be met.

Better governance and management is more complex because it requires a balancing of political, health and economic considerations. The primary focus needs to be on reducing health and economic risk and maintaining public trust and confidence, with political judgements reflected in the objectives given to the governance group. Operational decisions need to be made independently, on the basis of expert health and economic opinion, as they are in many other areas of public provision. There would also be a need for governance skills to ensure that the right monitoring and auditing processes were in place so that the governors could be realistically held accountable for what goes on further down in their organisation.

We are suggesting that the key objective for such a group would be to ensure that we can contain the health and economic risks of the pandemic, without the need for Level Three or Four lockdowns. Other objectives, or operational constraints, would need to be as explicit as possible to allow operational independence.

We are suggesting that these objectives and constraints are decided on a bi-partisan basis, so they are widely “owned” and not subject to ongoing political contest. It would be desirable if all these objectives and constraints could be made explicit ex ante, so operational decisions could be made entirely independently, and the governance group populated by experts in health, economics and governance.

However, this may be trickier than in other areas where this model works well, such as the Reserve Bank. In our case, bipartisan representation in the governance group may be necessary to reflect those concerns that are harder to specify ex ante; for example, those actions that infringe on individual liberty and lifestyle. It may also be necessary to secure support for necessary regulatory or legislative changes. In this case, an independent chair would be desirable.

Ultimately, however, Government must be free to govern so, like most other areas of state operations, there needs to be an ability for Government to give explicit and transparent instructions to the governance group that certain things be done or not done.

The key to getting the balance between health, economic and wider political considerations right is to require transparency in the decision-making process. Some degree of direct public interaction would help. The point is that transparent decision making requires well-justified decisions that build public confidence and make it harder for partisan interests to prevail.

The most difficult element in the equation is the need to rapidly put in place the operational experience and expertise needed to deliver on the decisions of the governance group. Clearly, that would need to be seconded from across the public sector as well as contracted in from the private sector where specific expertise is needed. While this grouping may well evolve into something more permanent, the initial assignment should not need to last more than a couple of years. Departments are reluctant to release their best people and those on the “fast track” worry about being overtaken if they step off the ladder, even for a short assignment. This ‘problem’ will be a lot easier to solve if the State Services Commission is actively supportive.

It will take some time to establish a new operational framework, to identify and recruit necessary operational and logistical expertise, to align functions with existing public health units,3, 4 and for the transfer of activities currently undertaken by the latter and the MOH. In the interim, it is essential that the resources and investment needed to secure the border and to improve levels of contact tracing and isolation are identified and made available.5, 6 This investment needs to be seen in the context of the counterfactual, which is the cost of lockdowns.

Living with COVID-19 until such time as we have herd immunity will involve more constraints on our liberties and lifestyle than we would like. This can only be considered reasonable if governance and management of the pandemic is actually best practice. A publicly accountable and transparent process is essential for the restoration of trust and confidence, which in turn will underpin necessary community compliance with the hygiene and behavioral responses that are required.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Des Gorman, School of Medicine, University of Auckland, Auckland; Murray Horn, Company Director, Auckland.

Acknowledgements

Correspondence

Professor Des Gorman, School of Medicine, University of Auckland, Auckland.

Correspondence Email

d.gorman@auckland.ac.nz

Competing Interests

Nil.

1. Gorman D, Horn M. On New Zealand’s weak, strong and muddled management of a COVID-19 epidemic. Internal Medicine Journal 2020; 50 (8): http://10.1111/imj.14928

2. Commonwealth Fund. http://www.commonwealthfund.org/publications

3. Public Health Expert, University of Otago, blog posted 05 February 2020. A preventable measles epidemic: Lessons for reforming public health in NZ. http://blogs.otago.ac.nz/pubhealthexpert/tag/measles/

4. Public Health Expert, University of Otago, blog posted 20 December 2017. The Havelock North drinking water inquiry: A wake-up call to rebuild public health in New Zealand. http://blogs.otago.ac.nz/pubhealthexpert/2017/12/20/the-havelock-north-drinking-water-inquiry-a-wake-up-call-to-rebuild-public-health-in-new-zealand/

5. Public Health Expert, University of Otago, blog posted 15 April 2020. We need rapid response on digital solutions to help eliminate COVID19 from New Zealand. http://blogs.otago.ac.nz/pubhealthexpert/2020/04/15/we-need-rapid-progress-on-digital-solutions-to-help-eliminate-covid-19-from-new-zealand/

6. Verrall A. 2020, Rapid Audit of Contact Tracing for Covid-19 in New Zealand. Wellington, Ministry of Health (www.health.govt.nz>publication).

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

New Zealanders are confronted with a new reality: to learn to “live with COVID-19” until such time as we have herd immunity, hopefully by way of a vaccination in the next 18 months or so. This always was the reality, although 100 days with no community transmission tempted us to think it wasn’t true. The real question is “how best do we live with this virus”?

In our view, it makes no sense to continue to automatically resort to extensive social lockdowns because we are not well enough prepared to contain an outbreak without running unacceptable health risks if we don’t. Indeed, this strategy is unlikely to be sustainable, given that each time a lockdown is triggered it further undermines the twin foundations on which this approach rests: cheap public borrowing capacity and voluntary public compliance.

There is a better way: more disciplined border management, earlier detection through more testing along with faster contact tracing and isolation of cases, combined with approaches to social distancing (including masks) that are far more selective than full-scale Level Three or Four lockdowns.

The fact that we are still struggling to get the basic elements of this smarter approach right after so long suggests that we need a new approach. Einstein’s definition of insanity is doing the same thing over and over and expecting a different result.

Why haven’t we been able to shift our approach?

It is not a matter of cost. The financial cost of properly resourcing a smarter containment strategy must be small in comparison with locking down large sections of the economy for weeks. The health and other personal costs of lockdown are also significant and likely to fall disproportionately on those least well placed to weather them.

We have not been able to execute a smarter containment strategy because we have not planned well enough and because delivery has been patchy at best across the whole spectrum of activity that needs to be executed well for a smarter containment strategy to work.

First time around we were “caught with our pants down”.1 Our tendency to keep telling ourselves how well we had done left us poorly placed the second time around. So how do we avoid a third lockdown?

We need to be better prepared, better resourced and the execution of our pandemic plan needs to be better managed. It is not fair to ask a “policy shop” like the Ministry of Health, who have limited operational experience or capacity, to take up what is a complex operational command and control role. The Ministry needs to focus on the important job of maintaining a health system that faced considerable challenges well before COVID-19.2

Being better prepared requires a best-practice plan that is informed and reformed by objective data and provides as much confidence as possible about what the ‘reaction’ will be in specific contexts. It requires clarity about the standards that have to be met for each of the key elements of the approach (ie, border management, testing, contact tracing and isolation, and social distancing).

Better resourcing requires a commitment from the government to resource the plan and, in particular, to provide the funds for the standards set out in the plan to be met.

Better governance and management is more complex because it requires a balancing of political, health and economic considerations. The primary focus needs to be on reducing health and economic risk and maintaining public trust and confidence, with political judgements reflected in the objectives given to the governance group. Operational decisions need to be made independently, on the basis of expert health and economic opinion, as they are in many other areas of public provision. There would also be a need for governance skills to ensure that the right monitoring and auditing processes were in place so that the governors could be realistically held accountable for what goes on further down in their organisation.

We are suggesting that the key objective for such a group would be to ensure that we can contain the health and economic risks of the pandemic, without the need for Level Three or Four lockdowns. Other objectives, or operational constraints, would need to be as explicit as possible to allow operational independence.

We are suggesting that these objectives and constraints are decided on a bi-partisan basis, so they are widely “owned” and not subject to ongoing political contest. It would be desirable if all these objectives and constraints could be made explicit ex ante, so operational decisions could be made entirely independently, and the governance group populated by experts in health, economics and governance.

However, this may be trickier than in other areas where this model works well, such as the Reserve Bank. In our case, bipartisan representation in the governance group may be necessary to reflect those concerns that are harder to specify ex ante; for example, those actions that infringe on individual liberty and lifestyle. It may also be necessary to secure support for necessary regulatory or legislative changes. In this case, an independent chair would be desirable.

Ultimately, however, Government must be free to govern so, like most other areas of state operations, there needs to be an ability for Government to give explicit and transparent instructions to the governance group that certain things be done or not done.

The key to getting the balance between health, economic and wider political considerations right is to require transparency in the decision-making process. Some degree of direct public interaction would help. The point is that transparent decision making requires well-justified decisions that build public confidence and make it harder for partisan interests to prevail.

The most difficult element in the equation is the need to rapidly put in place the operational experience and expertise needed to deliver on the decisions of the governance group. Clearly, that would need to be seconded from across the public sector as well as contracted in from the private sector where specific expertise is needed. While this grouping may well evolve into something more permanent, the initial assignment should not need to last more than a couple of years. Departments are reluctant to release their best people and those on the “fast track” worry about being overtaken if they step off the ladder, even for a short assignment. This ‘problem’ will be a lot easier to solve if the State Services Commission is actively supportive.

It will take some time to establish a new operational framework, to identify and recruit necessary operational and logistical expertise, to align functions with existing public health units,3, 4 and for the transfer of activities currently undertaken by the latter and the MOH. In the interim, it is essential that the resources and investment needed to secure the border and to improve levels of contact tracing and isolation are identified and made available.5, 6 This investment needs to be seen in the context of the counterfactual, which is the cost of lockdowns.

Living with COVID-19 until such time as we have herd immunity will involve more constraints on our liberties and lifestyle than we would like. This can only be considered reasonable if governance and management of the pandemic is actually best practice. A publicly accountable and transparent process is essential for the restoration of trust and confidence, which in turn will underpin necessary community compliance with the hygiene and behavioral responses that are required.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Des Gorman, School of Medicine, University of Auckland, Auckland; Murray Horn, Company Director, Auckland.

Acknowledgements

Correspondence

Professor Des Gorman, School of Medicine, University of Auckland, Auckland.

Correspondence Email

d.gorman@auckland.ac.nz

Competing Interests

Nil.

1. Gorman D, Horn M. On New Zealand’s weak, strong and muddled management of a COVID-19 epidemic. Internal Medicine Journal 2020; 50 (8): http://10.1111/imj.14928

2. Commonwealth Fund. http://www.commonwealthfund.org/publications

3. Public Health Expert, University of Otago, blog posted 05 February 2020. A preventable measles epidemic: Lessons for reforming public health in NZ. http://blogs.otago.ac.nz/pubhealthexpert/tag/measles/

4. Public Health Expert, University of Otago, blog posted 20 December 2017. The Havelock North drinking water inquiry: A wake-up call to rebuild public health in New Zealand. http://blogs.otago.ac.nz/pubhealthexpert/2017/12/20/the-havelock-north-drinking-water-inquiry-a-wake-up-call-to-rebuild-public-health-in-new-zealand/

5. Public Health Expert, University of Otago, blog posted 15 April 2020. We need rapid response on digital solutions to help eliminate COVID19 from New Zealand. http://blogs.otago.ac.nz/pubhealthexpert/2020/04/15/we-need-rapid-progress-on-digital-solutions-to-help-eliminate-covid-19-from-new-zealand/

6. Verrall A. 2020, Rapid Audit of Contact Tracing for Covid-19 in New Zealand. Wellington, Ministry of Health (www.health.govt.nz>publication).

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

New Zealanders are confronted with a new reality: to learn to “live with COVID-19” until such time as we have herd immunity, hopefully by way of a vaccination in the next 18 months or so. This always was the reality, although 100 days with no community transmission tempted us to think it wasn’t true. The real question is “how best do we live with this virus”?

In our view, it makes no sense to continue to automatically resort to extensive social lockdowns because we are not well enough prepared to contain an outbreak without running unacceptable health risks if we don’t. Indeed, this strategy is unlikely to be sustainable, given that each time a lockdown is triggered it further undermines the twin foundations on which this approach rests: cheap public borrowing capacity and voluntary public compliance.

There is a better way: more disciplined border management, earlier detection through more testing along with faster contact tracing and isolation of cases, combined with approaches to social distancing (including masks) that are far more selective than full-scale Level Three or Four lockdowns.

The fact that we are still struggling to get the basic elements of this smarter approach right after so long suggests that we need a new approach. Einstein’s definition of insanity is doing the same thing over and over and expecting a different result.

Why haven’t we been able to shift our approach?

It is not a matter of cost. The financial cost of properly resourcing a smarter containment strategy must be small in comparison with locking down large sections of the economy for weeks. The health and other personal costs of lockdown are also significant and likely to fall disproportionately on those least well placed to weather them.

We have not been able to execute a smarter containment strategy because we have not planned well enough and because delivery has been patchy at best across the whole spectrum of activity that needs to be executed well for a smarter containment strategy to work.

First time around we were “caught with our pants down”.1 Our tendency to keep telling ourselves how well we had done left us poorly placed the second time around. So how do we avoid a third lockdown?

We need to be better prepared, better resourced and the execution of our pandemic plan needs to be better managed. It is not fair to ask a “policy shop” like the Ministry of Health, who have limited operational experience or capacity, to take up what is a complex operational command and control role. The Ministry needs to focus on the important job of maintaining a health system that faced considerable challenges well before COVID-19.2

Being better prepared requires a best-practice plan that is informed and reformed by objective data and provides as much confidence as possible about what the ‘reaction’ will be in specific contexts. It requires clarity about the standards that have to be met for each of the key elements of the approach (ie, border management, testing, contact tracing and isolation, and social distancing).

Better resourcing requires a commitment from the government to resource the plan and, in particular, to provide the funds for the standards set out in the plan to be met.

Better governance and management is more complex because it requires a balancing of political, health and economic considerations. The primary focus needs to be on reducing health and economic risk and maintaining public trust and confidence, with political judgements reflected in the objectives given to the governance group. Operational decisions need to be made independently, on the basis of expert health and economic opinion, as they are in many other areas of public provision. There would also be a need for governance skills to ensure that the right monitoring and auditing processes were in place so that the governors could be realistically held accountable for what goes on further down in their organisation.

We are suggesting that the key objective for such a group would be to ensure that we can contain the health and economic risks of the pandemic, without the need for Level Three or Four lockdowns. Other objectives, or operational constraints, would need to be as explicit as possible to allow operational independence.

We are suggesting that these objectives and constraints are decided on a bi-partisan basis, so they are widely “owned” and not subject to ongoing political contest. It would be desirable if all these objectives and constraints could be made explicit ex ante, so operational decisions could be made entirely independently, and the governance group populated by experts in health, economics and governance.

However, this may be trickier than in other areas where this model works well, such as the Reserve Bank. In our case, bipartisan representation in the governance group may be necessary to reflect those concerns that are harder to specify ex ante; for example, those actions that infringe on individual liberty and lifestyle. It may also be necessary to secure support for necessary regulatory or legislative changes. In this case, an independent chair would be desirable.

Ultimately, however, Government must be free to govern so, like most other areas of state operations, there needs to be an ability for Government to give explicit and transparent instructions to the governance group that certain things be done or not done.

The key to getting the balance between health, economic and wider political considerations right is to require transparency in the decision-making process. Some degree of direct public interaction would help. The point is that transparent decision making requires well-justified decisions that build public confidence and make it harder for partisan interests to prevail.

The most difficult element in the equation is the need to rapidly put in place the operational experience and expertise needed to deliver on the decisions of the governance group. Clearly, that would need to be seconded from across the public sector as well as contracted in from the private sector where specific expertise is needed. While this grouping may well evolve into something more permanent, the initial assignment should not need to last more than a couple of years. Departments are reluctant to release their best people and those on the “fast track” worry about being overtaken if they step off the ladder, even for a short assignment. This ‘problem’ will be a lot easier to solve if the State Services Commission is actively supportive.

It will take some time to establish a new operational framework, to identify and recruit necessary operational and logistical expertise, to align functions with existing public health units,3, 4 and for the transfer of activities currently undertaken by the latter and the MOH. In the interim, it is essential that the resources and investment needed to secure the border and to improve levels of contact tracing and isolation are identified and made available.5, 6 This investment needs to be seen in the context of the counterfactual, which is the cost of lockdowns.

Living with COVID-19 until such time as we have herd immunity will involve more constraints on our liberties and lifestyle than we would like. This can only be considered reasonable if governance and management of the pandemic is actually best practice. A publicly accountable and transparent process is essential for the restoration of trust and confidence, which in turn will underpin necessary community compliance with the hygiene and behavioral responses that are required.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Des Gorman, School of Medicine, University of Auckland, Auckland; Murray Horn, Company Director, Auckland.

Acknowledgements

Correspondence

Professor Des Gorman, School of Medicine, University of Auckland, Auckland.

Correspondence Email

d.gorman@auckland.ac.nz

Competing Interests

Nil.

1. Gorman D, Horn M. On New Zealand’s weak, strong and muddled management of a COVID-19 epidemic. Internal Medicine Journal 2020; 50 (8): http://10.1111/imj.14928

2. Commonwealth Fund. http://www.commonwealthfund.org/publications

3. Public Health Expert, University of Otago, blog posted 05 February 2020. A preventable measles epidemic: Lessons for reforming public health in NZ. http://blogs.otago.ac.nz/pubhealthexpert/tag/measles/

4. Public Health Expert, University of Otago, blog posted 20 December 2017. The Havelock North drinking water inquiry: A wake-up call to rebuild public health in New Zealand. http://blogs.otago.ac.nz/pubhealthexpert/2017/12/20/the-havelock-north-drinking-water-inquiry-a-wake-up-call-to-rebuild-public-health-in-new-zealand/

5. Public Health Expert, University of Otago, blog posted 15 April 2020. We need rapid response on digital solutions to help eliminate COVID19 from New Zealand. http://blogs.otago.ac.nz/pubhealthexpert/2020/04/15/we-need-rapid-progress-on-digital-solutions-to-help-eliminate-covid-19-from-new-zealand/

6. Verrall A. 2020, Rapid Audit of Contact Tracing for Covid-19 in New Zealand. Wellington, Ministry of Health (www.health.govt.nz>publication).

Contact diana@nzma.org.nz
for the PDF of this article

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