You might also like
In Australia, the story of dealing with the coronavirus pandemic so far has been largely a positive one. Leadership and speed of response to this point has been recognised as critical to containment and management of the pandemic (Tiffen 2020). If we were to award the gold medal, it should go to our public health community. But we have seen strength in many quarters and for that reason, Valerie Braithwaite argues that we sell everyone short by singling any one group out.
Yet the strengths warrant recognition in terms of preparing for the next health emergency. The relatively successful outcome was not a lay down misere. For reasons we need to better understand, three major and powerful forces worked in concert. People for the most part have listened and responded positively to isolating, distancing and testing – all of which were possible due to lifestyle, resources and good governance. Professionals have communicated with clarity, and shared their knowledge and uncertainties openly. They have supported each other through acknowledging others’ expertise, and when they have disagreed, they have explained the reasons, recognised complexity, and been respectful to other parties. Even our politicians have surprised us by putting aside their political point scoring to talk to us, the public, about our health. We may have wished for more of this genuine engagement at times, but the very fact that we could distinguish political messaging from genuine health messaging attests to the fact that something changed some of the time when our politicians spoke to us. Equally importantly, they were not ashamed to disclose to us that they could work together and support and respect each other in the actions each was taking. To my mind, the standout players in this over the three months when the coronavirus was most active were the state premiers and the Federal Health Minister, Greg Hunt. Arguably for these politicians the cost of failure was highest. Nevertheless, to borrow from Shakespeare, they chose wisely. They chose to connect with the people, for the most part, with a genuine spirit. Moreover, with practice, they got better at it.
A critic might respond in two ways. People comply with authority, as long as authorities are clear on what must be done. Therefore, no pats on the back are needed. Partially correct, but as the pandemic demonstrated, not enough are sufficiently trusting of authorities to do as they are asked. Trust is an issue that we need to understand better as a result of this pandemic. If authorities wish to be trusted they must genuinely connect with people, showing knowledge and competence, empathy and understanding. To do this they need local knowledge. Orders and directives, and public relations and advertising, even celebrity poster boys and girls, are not enough when things get serious. After all, appeals to download the COVIDSafe app won over only about a third of the adult mobile phone carrying population. And refusal to be tested as fears of a second wave lurk for authorities suggests a level of defiance that will make containment of the virus more difficult. More needs to be done to establish community trust.
A critic might also respond to self-congratulations by pointing to a litany of mistakes. The rebuttal is that in a pandemic with a sophisticated system of governance and a diverse population, mistakes are expected. The standard operating procedures of authorities and the rituals and predictability of response that follow in their wake do not necessarily deliver expected outcomes. True that politics reared its ugly head at times and reduced the credibility of authorities. But even then, self-correction is possible. What is important is quick acknowledgment, rectification and recovery from mistakes. And the intriguing question is how have we managed to do this reasonably well so far, so much better than we might have expected given our performance before the pandemic?
One obvious answer is that the stakes were high for everyone - we all were potential victims, no-one was safe, so everyone put their best foot forward largely from fear and the desire for self-preservation. We had the advantage initially of being protected as an island and able to watch the new coronavirus wreak havoc in other countries. We can thank our press for keeping us well informed on international experiences. So too the WHO which sent out warnings and technical advice to public health officials in the first two weeks of January and set in place an R&D Blueprint for coordinating and accelerating scientific efforts to manage COVID-19 across the world. But knowing is not doing what is in the best interests of a nation, a state, a community or individuals as the global trajectory of the virus’ spread has shown us.
The strength and breadth of the network of public health and the credibility of medicine as a field of research and practice in Australia has to be a central explanation for why Australia was effective in its response. The government health committees that bring together academics, practitioners and bureaucrats may be mind-numbing in their prevalence and complexity, but any overlaps and redundancy, including the same people sitting on different committees, appears to have served us well. Shared knowledge and established relationships among health experts and bureaucrats meant there was a basis for acting collectively and confidently in an emergency. This history warrants a critical and systematic analysis in the fullness of time. All indications are that medical experts and public health officials were gifted deference by the public and by politicians. The media questioned. Health experts stayed firm and prevailed.
A unified health front has brought benefits so far, but it also brings risks. Obviously, if the unified front had dithered or made the wrong calls we would be in great strife now. To date, decisions and advice have been timely and correct for the most part. But risks are emerging as we try to live with the new coronavirus. Governance requires balancing decisiveness and consultation, and consultation and contestation. When stakes are high and there is urgency to do something, consultation can fall be the wayside and engaging with contestation even more so. Therein lies danger. As community fear of COVID-19 recedes and people feel they are “immune”, re-balancing is required. And there is no reason to assume uniformity across the population in the extent to which fear subsides and complacency rises. Many factors will play a role including individual risk appetite, the threats associated with where we live, and other more immediate demands that we cannot ignore (from a severe non-COVID illness that might force us to hospital to knowing that others will be let down if we don’t go to work to having no money to pay rent or buy food that might compel us to go to work and hope on the bright side that we are not COVID carriers). Central to re-balancing decisiveness, consultation and contestation is building networks of knowledge and understanding beyond what might be thought of as the health node. Such networks are essential to communication being open, seamless and timely.
Challenges to what has been a health-node led policy in Australia have already emerged. These should be understood as warnings of the dangers if the health node competes for domination instead of negotiating for co-existence with other sources of knowledge and understanding. Several warnings have captured public attention.
Protection of privacy conflicted with health-first policy early on in relation to the COVIDSafe app.Most Australians did not download the app, though part of the explanation that emerged over time was its ineffectiveness.
Economic activity in all forms currently is fighting for more oxygen, with stories of hardship being told by employers, sole traders, workers in the gig economy and employees. Keeping a business afloat, a roof over one’s head, supporting a family and providing food are the immediate priorities for those struggling to survive from day to day. Government support from federal and state governments is taking the edge off for some, but not all, as concerns for the future rise (Essential Report, 23 June, 2020)
The democratic right to protest to support Indigenous Australians and oppose police violence was pitted against health-first policy in the Black Lives Matter rallies. The conflict assumed symbolic significance creating social divisiveness and undermining the “all in this together” mantra.
The opening of schools and concerns of teachers about catching and spreading the virus placed educators at odds with the health node because it seemed to breach health first for everyone else.
The lock-down of nursing homes when cases of COVID-19 were detected and the consequences of inadequate care and isolation from loved ones has challenged the nexus between public health and care for people, particularly older people.
We have yet to experience an onslaught of stories of failures of medical care during the pandemic. Perhaps the plea by the medical profession to get patients back into their surgeries was in part anticipating the possibility of such events.
The loss of a vibrant local arts and culture industry, an important part of community recovery from disasters and pandemics, could also easily be laid at the feet of the health node’s single-minded pursuit of COVID-19 suppression. At the time of writing the government’s package to support the arts may ameliorate such an eventuality. But the fact remains that lives devoid of cultural events are less meaningful and hopeful than lives with them. An arts and culture led recovery may be impossible. Indeed, the potential of the arts and cultural community to enhance messaging through culturally meaningful ways has already been lost.
And finally, if Australia continues to face hotspots, as is currently occurring in Melbourne, and manages to avoid a full blown second wave that affects us all, there is the question of the health node’s capacity to connect meaningfully with those who distance themselves from authority. They may be suspicious and mistrustful of authority, there may be language or cultural barriers, or a history of trauma may prevent an appreciation not only of the dangers of COVID-19 but also of the benefits of a coordinated, collective response. If we consider not taking the advice of authorities as a layered response, we see how important it is to understand the particular circumstances in which particular communities find themselves. For example, low trust in authority, a history of trauma, casual employment in high risk services, and a large, interdependent family can lead to segments of the community being dismissive of warnings and instructions to self-isolate or be tested. Any one of these characteristics presents a challenge to authority, but through layering them we appreciate the need for special provisions and special networks for getting the message across.
Testing and tracing are the standard public health responses, but a different kind of networking may be necessary. The resistance or dismissiveness of some groups in the community may also spring from the health node being too Anglo and too remote to have any influence. It is worth remembering that for many Australians this is the greatest threat to collective security that they have ever faced. For immigrant Australians, the fear of contracting COVID-19 may pale in significance compared with dangers in their countries of origin. Those dangers may be current, with extended families overseas facing terrible conditions and loss. Or those dangers may relate to their past histories in places ravaged by war, famine and disease. Many people who live with trauma, whatever the reason, may be numb to messages from authorities that work on activating fear and self-protective measures.
Fear of COVID-19 has been an important, and for most of us, an effective driver of compliance. Success so far in protecting Indigenous communities may in no small way be linked to the Victorian health official’s evocative tweet likening COVID-19 to Cook’s arrival in 1770. The tweet evoked memories of the painful history of imported diseases decimating Indigenous populations. Shame may have been expressed as anger by some pillars of the community, but the message of prioritizing protection was heard and actioned. Reaching out to other non-Anglo communities may require similar connection through narratives that have special meaning through the historical experiences of these groups.
What are the implications for the health node? Its strengths are the breadth of its networks, nationally and globally, and its excellence in research, practice and policy. Its weakness is its lack of local depth. In all of the above cases, the health node lacked understanding of and empathy with the local. What was happening in Barcaldine was different from what was happening in the Aboriginal communities outside Broome, which was different again from what was happening in Bondi, Sydney. All of these places have experienced the new coronavirus differently from Keilor Downs, Melbourne.
The 8 challenges listed above are current examples of the limits of the health node’s effectiveness. Maybe acknowledging these limits and becoming listeners rather than tellers is the pathway forward, providing we do not have a second wave. It is a passive pathway forward, but maybe the health node has done enough of the heavy lifting and now needs to consider taking a back seat. That said, there is a more active pathway for the health node to consider. That pathway involves reaching down into communities and forming coalitions with local nodes that are deserving of recognition as different kinds of enablers of recovery.
These enablers of recovery are currently operating in communities and reaching out to contribute to community well-being. Some are formal and have health connections. For example, walk-in clinics that provide an array of health services under one roof have been designed in some parts of the country to physically co-exist with meeting places to address other community needs such as child care, library services, youth centres, aged care services, relationship management services and cultural events. When an array of services that provide for community well-being are located in community hubs, the capacity of high-level governing bodies to connect with communities in emergencies is greatly enhanced. When the health node meets the community hub, information is exchanged both ways and learnings take place. Had that taken place more assiduously as the new coronavirus was entering communities, all of the 8 issues above could have been pre-empted and more adequately addressed. In emergencies, be they pandemics, fires or floods, information and knowledge need to flow both ways with community hubs having confidence in higher governance nodes (such as health) and those nodes having confidence in a community’s knowledge of its place and people, and of its needs. Community hubs can also feed back to higher level governing bodies innovations, be they apps for contact tracing or straps for holding personal protection masks in place. Already there is a suggestion that New South Wales may have benefitted from having a more de-centralised formal government health structure than Victoria. In New South Wales, infectious disease notifications involve local health districts and public health units with responsibility for monitoring and responding to local outbreaks. It is likely they have stronger community links than central government offices (Benjamin Cowie quoted in Rushton, 2020).
The argument so far has been that communities need a voice because of what they have to offer. But they also need it for themselves, for their own recovery. In a seminal article by Leamy et al. (2011) in the British Journal of Psychiatry, a conceptual framework for recovery from mental illness was proposed, based on a review of empirical research. The model hinges on five social-psychological states, social in the sense that they depend on having the right kind of relationships with others. For mental recovery, which is relevant to all of us after collective disasters and pandemics, we need CHIME – Connectedness, Hope, Identity, Meaning and Empowerment. As we live through a pandemic we might interpret CHIME as follows. We need C for connectedness to others for support, knowledge and comfort, H for hope that we can realistically look forward to better times, I for identity in so far as we are comfortable and insightful about who we are and who we want to be, M for having meaning in our lives, a purpose and activities that give us joy, and E for empowerment such that we are able and capable of steering a path for ourselves and those we love to safe waters. CHIME for recovery does not mean allowing the community to languish in obedience waiting for orders from on high. It is a paradox that community transmission may have been hastened by the very presence of CHIME – extended families that supported each other and continued to do so through difficult times (Main 2020). The implication is to harness CHIME beneficially. It means engagement of members of the public in activity that is safe and productive, where we all rise to the occasion to learn how to look after ourselves, our neighbours, our health node, and our government. The health node needs to clear the pathways to allow communities’ voices to be heard.