Why we must stay in the fight
The lockdown is tough, but New Zealand’s elimination strategy is right, and could eventually create a better society, argue Michael Baker and Nick Wilson.
Less than two weeks ago, on March 23, the Government announced the unthinkable – a ‘‘lockdown’’ of New Zealand to stop a threat that had caused barely a ripple of illness in the country at that time. In doing so, it set New Zealand on an ‘‘elimination’’ path to combat Covid-19.
Here we summarise why we think this is the right thing to do, and also put out two challenges to our fellow inhabitants of Aotearoa. Make elimination work by doing all you can to wipe out this virus. And then use the recovery period to plan the more sustainable, safer and equitable society we want to emerge from this global catastrophe.
1. The health impact of the pandemic will be high unless we eliminate it
The new coronavirus that causes Covid-19 has been relentless in its spread to almost all countries on Earth. It is a more infectious virus than influenza, with the average case infecting two to three others. Consequently, we can expect it to infect about 60 per cent of the world’s population over the next one to two years. Given that it kills about half a per cent of those it infects, it could cause 20-30 million deaths, predominantly in older people and those with underlying illness.
In New Zealand our disease modelling, based on a plausible scenario where efforts are made to slow its spread, suggests that it could cause about 14,000 deaths (equivalent to the deaths caused by 30 influenza seasons all happening at once). Without extreme control measures, this pandemic will overwhelm our health system at all levels, potentially increasing the death toll further if intensive care bed capacity is saturated. It will also cause cancellations of elective healthcare and prevention services, resulting in further negative impacts on health.
2. If it takes off, the pandemic will increase health inequalities
Pandemics always hurt the poor and vulnerable the most, and therefore greatly magnify social inequalities. Ma¯ ori, Pacific peoples and low-income New Zealanders are more likely to be living in crowded households with fewer opportunities for physical distancing and therefore have an increased risk of infection. These groups also have a higher prevalence of longterm conditions, such as diabetes and chronic lung disease, so will have worse outcomes if infected with the new coronavirus.
3. A vigorous elimination strategy is far better than the alternatives
Pandemic planning has focused on managing influenza – justifiably, given its ability to cause destructive global pandemics every few decades. Such pandemics cannot be stopped, except in islands that completely close their borders. So the typical response strategy for influenza pandemics is ‘‘mitigation’’. This involves a range of measures to slow the arrival of the pandemic, slow its spread, and improve the health service response.
Unfortunately, mitigation has not worked well against Covid19, which has now overwhelmed health services in many countries. Almost all countries have ramped up measures to further slow the spread, increasing physical distancing and travel restrictions into long periods of lockdown. This is called a suppression strategy.
However, the new coronavirus is not influenza. As was shown in China, and now a small number of other Asian jurisdictions, it is possible to contain and eliminate this infection. This is the elimination path that New Zealand is now heading down.
It has two big advantages: if started early it can prevent many cases and deaths. If successful, it provides an exit strategy where New Zealand can return to a ‘‘new normal’’ much sooner than with suppression.
4. Much of the economic damage is unavoidable but can be minimised if elimination is successful
New Zealand is now having to choose the ‘‘least bad’’ option for the health of the population and economy. The two are closely related because public health relies on contributions from all sectors of society (eg highquality education, meaningful employment, healthy housing and effective social welfare), which in turn depend on a healthy, sustainable economy.
Much of the economic damage from this pandemic is at a global scale and is completely beyond New Zealand’s influence. What we do have control over is choosing a health response that minimises net economic harm and the use of other economic stimulus measures to cushion the effects of the pandemic, particularly for those who are most vulnerable.
An intense national lockdown
is obviously harsh for the economy and can only be justified if it has a good chance of achieving a suitably positive outcome. The benefit from elimination, if achieved, is that the country could emerge and return to reasonable functioning much earlier than with other control strategies.
5. Responding well to this pandemic could help build a better society
The New Zealand response to this crisis has mobilised huge reserves of people and innovation. Our national health agencies, which have been shrunk from decades of erosion and fragmentation, have been supplemented with public health staff from universities. Our laboratories have been supported by other organisations repurposing their facilities and staff to help. Prominent business leaders (such as Sam Morgan, Graeme Hart, Robert Fyfe, Stephen Tindall and the late Rodney Jones) have also assisted in multiple ways.
As a result, a small country with very limited resources is developing a highly effective response. Hopefully, these new collaborations will continue long after the pandemic has gone.
Beyond the acute response, we know that the world we had two weeks ago has gone forever. While there is much to be nostalgic about, that world was not sustainable and was on a trajectory that would result in escalating climate change and environmental destruction.
While the pandemic has terrible global health consequences, it is still a finite shock.
The longer-term environmental shocks we were creating are likely to be far more destructive to health and the economy, and some are becoming locked-in for generations.
The ‘‘silver lining’’ of this global crisis might therefore be the opportunity it provides for a major reset in how we organise our society and our relationship with our environment. Once we have Covid-19 firmly under control, then we can turn our attention to planning the new world that we will emerge into.
The pandemic is likely to continue circulating for the next one to two years, even with an effective vaccine and new antivirals. We will therefore have time to plan what our new world will look like. Already, we can see some of the likely positive changes:
A public health system which places prevention, protection and preparedness at its centre.
A healthcare delivery system that uses information technology, remote consultations and advances in artificial intelligence to improve delivery of care to all.
Building on the momentum towards a more cohesive society, including ways of promoting connectedness and inclusion with ‘‘kindness’’ enshrined as a guiding national principle.
Building on the need to ensure a living income for all New Zealanders, which will be particularly important during the period of economic recovery.
Far more efficient use of local and international transport, with a big shift to videoconferencing and home working.
A return to greater selfreliance and maintenance of critical infrastructure within countries considering supply lines, strategic stockpiles, and retention of versatile manufacturing capacity.
Improved political processes for making decisions in the national interest to prevent and mitigate severe external threats, including pandemics, terrorist attacks, climate change and environmental degradation.
Greatly strengthened global institutions (such as the UN and WHO) that can lead the increasing need for highly coordinated responses to global health threats.
A strongly enforced global shutdown of the trade in wild animal species and wet markets, and application of other One Health approaches to limit the interspecies spread of diseases.
Conclusion
New Zealand is now the only Western nation to pursue an elimination strategy (though this is the model being used in Asian countries, including China, Hong Kong, Taiwan, Singapore, and Taiwan). It will be only with the wisdom of hindsight that we know whether this was the right decision in terms of the human and economic health of the nation.
On balance, we think this is the right decision, based on what we know now about this threat, its likely high impact on health and inequalities, the available alternative strategies, and potential co-benefits.
What we do know with certainty is that the success of New Zealand’s elimination strategy depends on the actions of all New Zealanders to support this national prevention effort. Once we have the pandemic under control, we can shift our collective creativity to building a better, more sustainable New Zealand, which will ensure we extract as much benefit as possible from this global crisis.