This opinion piece, written by Burnet’s Professor Brendan Crabb, Professor Mike Toole AM and Dr Suman Majumdar, was originally published in The Age.
In what was the definitive clarion call to the ‘go hard, go early’ pandemic response mantra, WHO Deputy Director Mike Ryan famously said, “If you have to be right before you move, you will never win… the greatest error is to be paralysed by the fear of failure”.
Premier Steven Marshall and Chief Health Officer Nicola Spurrier have been rightly commended for adhering to this principle; it gave South Australians the best chance of avoiding a second wave.
But in the aftermath, upon learning that a part-time worker at the centre of the outbreak had changed their story to contact tracers, the Premier and his team broke a cardinal rule, ironically one that is implicit when seeking a licence for the ‘go hard, go early’ approach; the rule of avoiding wanton blame.
“To say I am fuming about the actions of this individual is an absolute understatement,” the South Australian Premier said on Friday. An over-the-top reaction followed, including a 20-person police unit to investigate this worker’s ‘alleged crime’.
The US Centres for Disease Control and Prevention (CDC) wrote the playbook, on outbreak investigation, which has been adopted internationally. According to the CDC, requisite knowledge and skills for case investigators and contact tracers include:
- The ability to conduct interviews without violating confidentiality;
- Sensitive interpersonal, cultural sensitivity, and interviewing skills such that they can maintain trust with patients and contacts; and
- Cultural competency appropriate to the local community.
The Australian health system is built on the principle of person-centred care – trust, mutual respect and responsibility between providers and patients.
This applies to COVID-19, where building trust is part of effective community risk communication and engagement. Public shaming and blaming of an individual – a presumably lowly paid person working two jobs, while employed in a quarantine hotel by a private subcontractor – contravenes all the above principles.
First, there is the risk to the individual. The Premier revealed enough details to enable identification of the person in question. Such a revelation could adversely affect their future employment prospects, current social interactions, and health and wellbeing.
Second, the betrayal of trust by SA Health and the Premier may negatively impact on future contact tracing. Individuals who fear revealing illegal – or simply private – activities may be reluctant to tell the truth. Fearing punitive measures or the kind of media storm that has engulfed the pizza worker will be a strong deterrent to truth-telling. Stigmatisation has proven to be a major obstacle to the control of other infections, such as HIV and tuberculosis.
Third, outbreak investigation and management, including contact tracing, relies on a broader sense of community trust, engagement and involvement. This has been amply demonstrated during outbreaks in Melbourne and Sydney. It is particularly critical in culturally and linguistically diverse communities and those with insecure work.
As Australia enters a phase of very low numbers of infections, there needs to be a strong commitment to those interventions that we know work effectively. In addition to distancing, hand hygiene and masks, a well-resourced test, trace, isolate and support system is essential. In NSW, a series of clusters since early July has been effectively suppressed by such a system. While Victoria got off to a slow start, its system has effectively eliminated recent clusters.
The fact that SA Health identified 4000 contacts and their contacts within a few days demonstrates that the state’s contact tracing system is efficient. However, this widely publicised breach of confidentiality jeopardises the ongoing effectiveness of the system.
Punitive, top-down, one-dimensional and blame-oriented approaches are counterproductive, undermine public trust, and risk all that good work being undone.
Other questions also remain about the South Australian outbreak.
The first question concerns the initial assumption that the virus might have spread through contact with pizza boxes. A number of laboratory studies have demonstrated that the virus may linger on hard surfaces for some time. A study published in April in the authoritative New England Journal of Medicine found that no viable SARS-CoV-2 could be detected on a cardboard surface after 24 hours. Even if the virus could survive for less than 24 hours, there is still no evidence in any COVID-19 studies that someone has contracted the virus from a surface alone.
The second question relates to the claim that the virus introduced via a traveller from the UK was a mutant, rapidly spreading strain. An incubation period of fewer than two days is short but within the realm of what we know about SARS-CoV-2. This claim was withdrawn on Saturday.
The third question concerns the early claim by SA Health that the hotel quarantine leak was probably due to contact by a hotel cleaner and/or security guard with a contaminated surface. Given that the traveller was diagnosed on November 3 and the cleaner was diagnosed some days later, this theory is impossible to prove. Although the Adelaide cluster has been linked genomically to the UK traveller, we will probably never know how transmission to the hotel staff occurred.
These three questions suggest that the evidence was slim for the theories used to initially justify an unprecedented lockdown. Nevertheless, using a lockdown to “buy time” for contact tracing and testing is consistent with the goal of elimination of community spread in Australia.
In the same speech cited earlier, WHO’s Dr Ryan said that “perfection is the enemy of the good”. But so too is undermining trust and its resultant stigma.