Month: March 2020

Dr. Alexandra Phelan: Tackling the COVID-19 pandemic and you should know

Dr Alexandra Phelan is a faculty member at the Center for Global Health Science & Security at Georgetown University School of Medicine, and Adjunct Professor of Law at Georgetown University Law Center.

A global expert in pandemics, Misha Zelinsky caught up with Alex to talk about all things related to COVID-19, including the nature of the threat we face from the virus, the challenges coordinating government responses, the vital role universal healthcare plays in stopping pandemics, why the Chinese Communist Party’s delays at the start were so costly and what Australia and the world should be doing right now.

As a serious note please make sure you are listening to authorities and taking the most up to date advice as this crisis unfolds. The situation may have changed by the time you have listened to this. 

EPISODE TRANSCRIPT:

Misha Zelinsky:

Welcome to Diplomates. This is Misha Zelinsky. I’m joined today by Dr. Alexandra Phelann from the United States. She’s Australian but she’s joining via the magic of the internet, which is not yet crashed with all the traffic that’s on it. Alex, can you hear me? Welcome to the show.

Alexandra Phelan:

I can, Misha. Thanks so much for having me.

Misha Zelinsky:

Oh, pleasure’s all mine and the listeners. I might start, there’s a lot of places you can start with this topic relating to, we’re obviously going to be talking a lot about coronavirus or COVID-19, which is much more sinister-sounding name. Firstly, maybe you could just start by explaining what exactly the virus is. I mean, a lot of people say it’s a bad flu, it’s a killer virus, is it somewhere in between? Maybe you could start there with a short definition.

Alexandra Phelan:

Yeah, absolutely. So, I’ll firstly start with sort of two terms. We’ve got COVID-19 which describes the disease, so when people are ill and then we have SARS-CoV-2 which is the name that has been given to the virus itself, the coronavirus and you might here in there that SARS-CoV-2, so SARS coronavirus two, is because it’s closely related to the coronavirus that we saw in the SARS outbreak back in 2002, 2003, but it is a different new novel coronavirus.

Alexandra Phelan:

There are four coronaviruses that normally circulate during the year. They’re sort of a type of virus, a coronavirus, and they normally cause mild illness, so like mild colds, but we do know of two before this virus, more serious forms of coronavirus and that’s SARS that I mentioned and MERS, Middle East Respiratory Syndrome, is caused by the MERS coronavirus. And those are two viruses that showed us that the coronaviruses can actually cause this serious disease and this third novel coronavirus, so this sort of severe coronavirus is another example of a coronavirus that can cause quite serious respiratory illness being COVID-19.

Misha Zelinsky:

Right. Okay. And so in terms of the next question I think’s useful to get, as long as we’re doing a quick round of definitions. A pandemic. What is a pandemic and how do we define one?

Alexandra Phelan:

Great question. A pandemic is actually is not necessarily a legal term or a specific technical click, it’s more a descriptive term. A pandemic is simply a way of describing an outbreak or an epidemic that has gone over the entire world. And there are different definitions that people use to describe what is over the entire world. Some definitions are simply that it’s to two or three continents. Some definitions say everywhere except Antarctica. But essentially, it describes the spread of disease, rather than the severity of a disease, and as we look at the cases around the world of coronavirus, it’s quite clear that this is a pandemic. Now when the WHO confirmed that this was a pandemic the other week, it didn’t necessarily change anything from say an international law or a governance perspective. There maybe some contracts around the world that might have the word pandemic in them and that’s a triggering event or some pieces of domestic legislation that have pandemic as a triggering event, but as a term, it’s more a descriptor rather than any sort of significant legal designation.

Alexandra Phelan:

There is a term that is significant legally and that’s a public health emergency of international concern or PHEIC and that was declared on January 30th by the World Health Organization director-general under international law.

Misha Zelinsky:

And say that we’re now officially in a pandemic and we’ve got this rather severe version of the coronavirus, I mean, it’s hard to be how worried to be. I mean, can you give a sense to me, because there is so many different projections and people making various calculations as to mortality rates based on data out of China and other places. How worried should people be because it seems that early sentiment, certainly in Australia and I think around the world was people were relatively sanguine about it. How worried should people be and how concerned should we be about the various projections?

Alexandra Phelan:

Yeah, so worry versus being informed is a difficult one. I work in pandemic preparedness. This has been my life for the last 10 years and so for me, the idea of worry is not necessarily a good one. I think though how seriously should we take this is very seriously. And the reason being is, I mean models are models and there are limits to what models can actually demonstrate and what models can factor in and there are lots of different models that are being used for this outbreak, but what we are learning based on the observed data and I guess the consistency we’re seeing a range of different models that are coming out of this is that this is going to have beyond what it already has, a significant human health and life impact. If we start to compare it to other, comparisons can be useful to get a sense of things, right?

Alexandra Phelan:

If we compare some of the data that we do have, and again, this is just observed and this is likely to change, we do have some early, what we call case fatality rates. They’re a form of mortality rates that look at out of everyone who gets the disease, how many people actually die and this is being updated because every country in every situation will change the factors that cause whether people die or not die. And so there’s an average case fatality rate of about 3.4% and there’s out of everyone that gets it 3.4% will pass away, but that changes based on the situation. In Italy it’s looking like the case fatality rate is sitting up at that sort of higher-end, maybe 3.4%, perhaps even a little bit higher, but in other countries we’re seeing in say South Korea, we’re seeing it at sort of the lower end, sort of closer to 1%. Now that being said, that number, 1% is still significant.

Alexandra Phelan:

If we compare to past outbreaks and obviously this is the first time we’ve had a COVID-19 outbreak, this is a new type of coronavirus, if we look at say influenza pandemics, and they’re perhaps the most useful comparison, but you can’t really compare them exactly because they’re different diseases and different circumstances, but if I said, we’ve got this 3.4% global case fatality rate, we look at say seasonal influenza. Seasonal influenza each year has around a 1% case fatality rate typically, I mean it sort of changes a little bit, and that does a significant health burden. If we look at say the H1-9, so 2009 influenza pandemic, swine flu, which people may remember, that was about 0.1%. So, if we go from 0.1% to about 1% and then we’re looking at that’s between 1% and 3.4% or so depending on the circumstances, we’re looking at a pretty significant global health burden.

Alexandra Phelan:

The 1918 Spanish flu, just sort of think back to that, which killed more people than both wars combined, had a case fatality rate of about 2%. So, if we’re hovering at around that 2% and we get global spread and we get that 2% globally, and again, it depends all on the situation in each country, what measures countries take to protect their citizens and protect the health of their citizens will affect it, but if we’re looking at those sorts of figures, then we are in this, this is going to be a marathon, this is not going to be a sprint, the global impact and the health impact of this outbreak is currently expected to be significant.

Misha Zelinsky:

Well, that’s certainly sobering those statistics as compared to the Spanish flu which killed 10s of millions if not 100s of millions of people. So, just curious, you talked about the kind of the responses and sort of the impact. One of the things that people are talking about a lot is sort of this flattening of the curve, which is essentially governments trying to reduce the speed of the rate of infections, how much can that impact on how the health system responds and preventing the health system being overrun and not having access to respirators et cetera. How critical is that to the response?

Alexandra Phelan:

Yeah, so this is what makes this virus particularly concerning is the ability to overwhelm health services. Because when you do have the severe form of illness, which still appears to be only about 20% of everyone who gets it, gets this severe form, because that’s a really important point to make, it looks like 80% of the population will have a mild illness as 20% who are severe, but if we’re seeing 20% of the population with severe illness, that is guaranteed health care system overwhelm. And what we’re seeing in Italy for example, what we saw in Wuhan specifically, not necessarily in other parts in China, but in Wuhan, in Italy, and we are likely to see in other countries around the world, the intensiveness and the severity of care needed is what makes that health care overwhelm. So this flattening the curve, the idea here that is a term that those of us in pandemic preparedness have worked with and it’s wonderful to see this is rolling out and people understanding it, but what it’s worth understanding is whilst it’s about reducing the number of people with the severity of the illness over time, so reducing from being everyone overwhelming the health care system at once and trying to spread it out and delay the people who are getting the severe illness as long as possible so that the health care system can cope.

Alexandra Phelan:

One of the things that’s not reflected in a lot of those graphs is health care services are already overwhelmed in most places in terms of our ICUs, in terms of our beds. Around the world, governments have consistently under-funded health systems or non-nationalized health systems, and so we’re already kind of at health care capacity or very close to. So, even if we are doing this mitigation, this flattening of the curve by focusing on slowing, but necessarily stopping the spread of an epidemic, we’re still likely to meet that sort of peak health care demand at that level, it’s just about mitigating that as much as possible. So that’s where those mitigation strategies are really key.

Alexandra Phelan:

But then the other strategy that we’ve sort of talked about is this idea of suppression, which is not just about mitigating and reducing the impact but also actually stopping the spread to people. So, that’s where we start to talk about things like social distancing, which we can get into. The idea of social distancing is you try to prevent people who are infected from coming into contact with people who are susceptible, and that includes people who may not have severe illness but could then pass it onto people who are vulnerable, which includes older populations. We say older, we’re looking at maybe over 65 as the data again is coming in, but also people with underlying medical conditions that make them more at risk, and again, a lot of this data is observational and on the fly, and so it’s likely to change and that has to inform government policy as well.

Misha Zelinsky:

And so that’s really kind of critical then how the government responds. Can you give a sense, I mean, you’ve mentioned Italy a bit, maybe what Italy got wrong and maybe some of the countries that seemed to have maybe tackled the challenge. I mean, China had a very aggressive response essentially locking down Hubei province and then having people essentially report to fever clinics et cetera. Are you able to give a very kind of high-level delineations in who’s doing it well and who isn’t and what the key factors there are?

Alexandra Phelan:

Yeah, absolutely. I mean, let’s start with the good example. The good example is South Korea, and they’ve been touted as a good example, and this may change over time. But to date, South Korea have appeared to reduce the spread, have a health care system more able to cope, and have managed to start to reduce the cases going forward from here. What South Korea implemented was a bit of this multi-pronged strategy that looked at both mitigation and suppression. So, what they did is implemented significant testing processes whereby individuals could essentially access tests, to get tested to check if they were infected regardless of their illness and their symptoms, or their travel history, and South Korea was able to run 20,000 tests a day at some point. And that included things like drive-up car testing facilities, as well as actively testing individuals.

Alexandra Phelan:

Now if an individual tested positive in South Korea they were essentially put into sort of a self-isolation and there were a range of different measures that the South Korean government used that helped implement that, which may or may not transfer to other places. So they used extensive mobile phone surveillance and monitoring to help enforce that, which I think that depends on the acceptability of an entire population because, at the end of the day, public health requires public trust. You don’t want to be doing anything that undermines peoples willingness to engage with the government. So, they implemented that testing and surveillance, and so it meant the people that were infected were taken away like they were at home, they took themselves away from the potential risk of spreading it to other people. And coupled with broad social distancing, meaning that people weren’t necessarily going out to restaurants and bars and people were working from home, engaging those sorts of policies so even if someone hadn’t got a test, you’re reducing the opportunities for transmission before someone knows whether they are sick or not. So, the testing coupled with the social distancing measures were incredibly effective.

Alexandra Phelan:

If we now look to say Italy. Italy started its surveillance and testing significantly too late. The social distancing that were put in place were put in place probably two weeks too late and the thing to I guess think about with pandemics and when we do this pandemic preparedness, we say that when you think it’s too early, you’re probably just about to get too late. The whole point of these social distancing measures is to have it in place before you have transmission occurring because remember when you actually are doing a test and you’re finding people are turning up and they’re sick, so you’re doing a test based on them being sick, not like South Korea where they’ve just got testing happening, if you’re waiting for people to get sick, you’re probably two weeks down the track already. There’s been two weeks of … We still don’t know exactly the details of pre-symptomatic transmission, like how long before people show symptoms, can they transmit it, that’s still getting that precise data, but it appears to be an element here. Once people are showing up and they’re sick, it’s already a bit too late.

Alexandra Phelan:

And so this sort of a week and two-week timeframes we’re seeing sort of roll across the world, and so in Italy, once these measures were implemented, sure they might have assisted in bringing down the curve, but by that stage, the system was primed for overwhelm and that’s what we’ve seen in the Italian ICU units in the north of the country. There are some more nuanced sort of distribution of ICU beds within the country that could assist, but the overwhelm has occurred because these measures were put in too late and Italy was the first country in Europe to really be` hit, so it’s also not surprising that these measures were put in too late.

Alexandra Phelan:

I do want to sort of take a moment to mention Wuhan. In China, in other cities, in Beijing, [Shanghai 00:17:16], [Sichuan 00:17:16], et cetera, they implemented these sorts of social distancing measures very similar to what we saw in South Korea and that was very successful. Wuhan is a special category and I think it’s really important to distinguish the successful measures done in other China cities from Wuhan. By the time Wuhan implemented their lockdown, which is a phrase, and if we look at what it technically was it was a cordon sanitaire, which is not a quarantine, it’s essentially a geographic area that has a rope tied around it and said no one can come and no one can go. By the time that had been implemented, there was already significant local transmission occurring. The impact of the cordon sanitaire in Wuhan appears to have potentially delayed the spread, not within China, you know this was happening during Lunar Year travel periods, but perhaps could’ve delayed the spread internationally by a couple of days.

Alexandra Phelan:

Now the question is at what cost those couple of days because we don’t know how many people in Wuhan died from secondary causes as a result of the lockdown from the health care system overwhelm and the appropriate counterfactual would be what if Wuhan back when they had the first notifications from doctors at the end of December or during December and early January, if we’re being flexible with the timing there, if they’d implemented social distancing and extensive testing and gotten those diagnostic tests up and running in time and had that in place, could have it been a very different picture, and I think that is a counterfactual we’ll have to explore in the after reviews of this outbreak.

Misha Zelinsky:

You sort of touched there about the importance of quick response and not waiting too long, but as I think from an Australian point of view, we’re watching the world seemingly going into lockdown, is it inevitable that every country’s going to be lockdown in some way, or is that not inevitable. Because one of the things I’m struggling to understand just as a complete layman in this space is, is lockdown really the best and most effective way of dealing this in a social distancing way but in an almost complete social distancing sense or can it be measured and mitigated in different ways?

Alexandra Phelan:

So I think the first thing I’d say is the term lockdown is getting used to describe just relatively normal social distancing measures that we’d say are quite legitimate as well as very punitive, arbitral and authoritarian measures because the term lockdown doesn’t mean anything right? It’s a descriptive term-

Misha Zelinsky:

Well, for example in LA, right, they’ve just now closed restaurants and bars to the public. I mean, in Australia it was just said, it was no football games, but I think it was quite stark to see cities around the world now where they’re restaurants are shut, bars are shut, any sort of social event is shut.

Alexandra Phelan:

Yeah, so that’s happened here in New York as of tomorrow wherein all restaurants, bars et cetera closed. In reality that’s already been happening to some degree. So, if we’re thinking about that, so if we want to use lockdown to mean a few things. I think the measures that we want to be seeing are working from home policies, that should be implemented. It’s already here in New York, that is getting people working from home if they can because not everyone can and not every business can, but where people can work from home. No gatherings, I think the current, and please feel free to correct me was 100 people or 500 perhaps even, I mean that’s way too … 20 people versus 500 people that’s an arbitrary distinction, really it’s about removing people having contact, so I would say even getting the point where people aren’t meeting up with more than 5 people. I think that is what we need-

Misha Zelinsky:

Wow.

Alexandra Phelan:

to be sort of be reducing this transmission, right? Obviously in families, that’s not necessarily feasible, but I wouldn’t be having a dinner party. If they are going outside, making sure they’ve got that physical distance, but I think though when we start to think about things like schools, which this becomes tricky because it might seem counter-intuitive, schools and universities, universities I think there is more of a justification for moving classes to online and reducing that contact, but for schools, one of the things that needs to be consider in this process is the fact that if you cancel schools a parent has to be able to stay home and not all parents have jobs where they will be able to work from home and in particular the workforce that we are particularly concerned about are our health care workforce.

Alexandra Phelan:

One of the most direct ways to stymie say the US health care workforce, and I’m not as across the Australian data, is if single parents have to stay home and look after their kids because a significant number of health care workers, particularly nurses, are single parents with primary carer responsibilities to stay home and look after kids. And the alternative might be to be looked after by their grandparents who we know are a high-risk group, whereas children, thankfully, on the current data appear not to be high risk, so closing schools, particularly say primary schools, can have really significant negative impacts on your ability to respond. And so whilst it might seem counterintuitive, the closing of schools needs to be really well thought through and considered in regards who are the parents that might have to stay home to look after the kids, and that’s why as a social distancing measure, in a lockdown, that may not actually be the appropriate thing.

Alexandra Phelan:

There are lots of in-between, right, you can stagger recess, you can stagger arrival times, you can increase recess times, that’s why it’s a lot more nuanced than I think the discussion has been to date in a lot of the data in Australia, but certainly, mass gatherings, restaurants, bars. There is a social responsibility on all of us that if we take measures now, we could save our grandparents, our parents, and our friends and other loved ones who may be particularly vulnerable to this outbreak.

Misha Zelinsky:

And so this social distancing, or maybe it’s moderate lockdown or that this really like closing down of large parts of the economy, what’s not clear to me at least is how long will this last for and what the aftermath looks like? So I mean it’s 14 days, it’s eight weeks, but then at the end of that period, are we sort of through the worst of it, or can it sort of spike again? That bit’s not clear to me either and I think that’s causing a lot of confusion at least in my mind.

Alexandra Phelan:

Yeah, yeah. I guess from a pandemic planning point of view we always put upfront the economic costs of a pandemic and the reality is the more people who are getting sick and ill and if you don’t mitigate and reduce the spread the bigger the impact on the economy, so it’s like just accepting there’s going to be a loss, it’s just how much of a loss. So in terms of the timeframes and how that factors in, as I said, models are models and they’re not necessarily, you know, they’re not forecasts, they’re not Nostradamus or Cassandra.

Alexandra Phelan:

But some modeling that came out overnight from a group at Imperial and they’re work has been informative for the UK government response and other responses previously, is that we would likely need to be using a combination of mitigation and suppression, so social distancing as well as reducing peak health care demand until we have a vaccine and it becomes widely available and we know from other vaccines we’re probably looking at the 12 to 18 months. So, there has to be some sort of combination with both measures.

Alexandra Phelan:

Now how does that work in practice? Well, we saw that in South Korea, and also in parts of China, we’ve seen the ability to bring cases under control and get case numbers low enough that you can go back to perhaps the testing model of testing if someone’s sick and then isolating them and quarantining their contacts. So because suppression is possibly in the short term, if we could potentially loosen interventions and measures provided that we don’t see a rebound, so it all depends on how good the system in place is for that period in between. So, we could see these temporary relaxations in short windows, but it needs to be able to put the switch back on if we see case numbers moving again. And that can relatively disruptive obviously, but that might be a way of easing the economic and social costs of interventions that are being used over that period until we have a vaccine.

Alexandra Phelan:

A vaccine isn’t guaranteed. We do have incredibly a potential candidate of vaccines out there, but we’ve got to remember the only tool we actually have in our power right now, as humans together against this virus is our solidarity and our ability to act to socially distance and until we have a vaccine and it’s available it’s going to be our solidarity that is going to be what keeps us safe.

Misha Zelinsky:

Well, it sounds like people should be digging in for the long haul, so maybe switching now just to what maybe individuals should be doing social distancing. What should people be doing as of now, working from home clearly but are there specific measures people should be taking in terms of preparing themselves?

Alexandra Phelan:

Yeah, so I think some of the measures we’ve seen in Italy and what we’re seeing here in New York, closing of bars and restaurants and people working from home, but keeping grocery stores and pharmacies open so people can still go get food, and so there’s this sort of rush and panic to have a 18-month prep, that’s not necessarily be required. Having a stockpile of food to sort of get through the next two weeks is a good way of doing it, or having to get through in sort of periods and bursts and that way when people run out it’s sort of much more staggered and people can go to the shops and get groceries. In terms of other additional measures, I think the most important thing, and this is particularly for people who are not in high-risk categories, who are healthy, who are younger, so like under 60, is to realize that they have perhaps one of the most important role to play in stopping the spread of this outbreak and that that is more important than going to a bar with mates or having friends over, and we’re very lucky this has happened at a time where we have tools where we can chat with our friends through video and audio link and there is some really innovative and creative ways we can keep ourselves not socially isolated whilst we’re doing this social distancing.

Alexandra Phelan:

I think the other sort of very individualized measures are clearly washing your hands often and properly, I think people are getting that message. If you do feel sick to contact the relevant hotline that’s made available or health care service to check with them. If you do have any symptoms, to stay home. The reality is, is we say mild illness, up to 80% of mild illness, that still can include pneumonia, so you can still get pretty sick and pretty unwell, but you’re not necessarily at the point of hospitalization and needing the health care service, and so I think there’s going to have to be an understanding that it’s not going to be pleasant for everyone that gets it and has a mild form. Some people will just get a sniffle, some people will get quite sick, but what we need that is our ICUs and our hospitals are available for people who are going to die without that support. So, I think that individual recognition of what is serious and what’s not serious.

Alexandra Phelan:

And I think the final thing is we all have a part to play in protecting the most vulnerable members of our community not just in our behaviors but also ensuring that they’re not socially isolated. Our elderly population or people with disabilities, or other members other community, just anyone in the community might not have the social connections and/or the support systems to be able to go get groceries and do things like that, so I think ensuring that we’re protecting those individuals. And that includes things like ensuring that sick leave is not a limit on people’s ability to stay home. Ensuring that casualized workforce in Australia have access to sick leave and have access to payment protections. There are lots of models around the world where the government’s actually gave hand-outs, gave amounts of money, and not just sort of what we’ve seen in Australia so far, but a broader range of people, and I think those sorts of measures we really need to be thinking about our restaurant workers, our casualized workforce, that need to be part of this because we need to be safe and staying home and not feel the economic individual economic pressures to have to be going to work.

Misha Zelinsky:

I absolutely agree with you around the issue around insecure work and the lack of access to health care. Certainly a concern in Australia, and I know it’s a bigger concern in countries like the United States. In terms of reassuring people, I mean we saw, I think at first everyone was having a bit of a laugh about the toilet paper crisis that seemed to have started in Australia and has spread around the world, but the prospect of panic buying is now very real. We’re seeing queues for things around the world and in the United States, people are queuing for guns, which is concerning, do you think we’ve done enough to reassure people? Because there’s a balance between scaring the bejesus out of people and also making sure they’re properly aware of the facts. So, how have you got that [crosstalk 00:32:09]?

Alexandra Phelan:

Yeah, it is a really challenging example of science and political, and governance communication. There are people who are experts at this, right, people who are experts in how to communicate that tension-

Misha Zelinsky:

Like Twitter, right?

Alexandra Phelan:

… I think if we saw government engaging these experts, in fact in our pandemic plans that is right up there in our top-10 priorities is have expert communicators for this exact issue. So, what people should be doing is having enough food and supplies that they feel that they can stay at home for the two weeks, in case they are sick and they stay at home for that entire period. And recognizing that hoarding is … You know, you see these posters during WWII, hoarding is unpatriotic, we’re kind of in that sort of period, right, where this is take only what you need to keep you and your family safe, and you might need to change some behaviors to be able to take less than what you would normally need. And I think that’s where there’s also a role for government in communicating what’s going to happen in terms of supply chains and logistics about access to food and how those supply chains are going to be kept active so people know that hey in two-weeks’ time when I’ve served my period of isolation, I need to go out and get some more supplies, get some more food and whatever that they know that they can.

Alexandra Phelan:

In New York, a number of restaurants have shifted to go and delivery so that they can keep their staff on board and can continue to provide food and done in a way where it’s pick up and drop off so you don’t have any individual contact between the people delivering and people who are at home. And so in facilitating those sorts of supplies and facilitating a much clearer communication is really key to addressing that balance. It’s a hard one but it’s possible.

Misha Zelinsky:

What’s the role here? So, how concerned are you as someone as an expert, I mean I was half-joking about Twitter, it seems to me that every single person’s now an expert in infection rates and global health policy, but how concerned are you about the role of social media in driving fake news and being able to distinguish what’s happening and what’s not happening? And also, I think, it’s very difficult for people as well with the flood of information from around the world, not just in their own jurisdiction, how do you see those challenges in amongst all this?

Alexandra Phelan:

Yeah, so I think there are two elements here. The first element is accuracy of information and the second element is mental health. So, the accuracy of information is we’ve become accustomed to receiving information from multiple sources, reliable and unreliable, and over the last four years, in particular, there’s been a lot of discussion about how do you stop unreliable information and where do you get reliable information. One of the advantages of a public health threat is we do have already established authorities on public health and that’s the World Health Organization, that’s the Center for Disease Control for the US, that’s the different public health departments in Australia, and I think I haven’t been up to date on what the Victorian Department of Health has been communicating. WHO and CDC have lots of really shareable memes on social media, they’re not actually memes they’re just images, but really shareable ways of communicating accurate information. So, if you are using Twitter and Facebook, I would make sure you’re following WHO and your state, as well as the federal health department, because they have been engaging in really active and proactive communication on those tools and I would limit where you get your information to those sources as much as possible, partly because of the first reason, for getting correct information, but also the second reason is mental health.

Alexandra Phelan:

A pandemic is a scary thing. There’s a lot of uncertainty and in that uncertainty, we can get worries and fears, as well as misinformation. There is constant information coming from other countries, accurate and not accurate, there’s constant levels of panic and fear and people telling other people not to fear and not to panic and dismissing what are quite legitimate concerns in many respects, so I think if you are not working on the outbreak directly, and it’s not necessarily directly relevant to what you need to be doing in your day-to-day apart from what you are doing to protect yourself and your family and your community, limiting the information you get to perhaps once a day. Maybe it’s the news broadcast at night or even radio at a certain time of day, or to the WHO or CDC or where ever you’re getting your news and limiting it, because I can tell you from someone who’s been following this outbreak since 31 December 2019, it can very quickly because overwhelming and very quickly that sense of lack of control, like what can you do as an individual. So I would focus on those steps that we spoke about and limit your time on social media in so far as you can while staying connected with your friends and family and loved ones.

Misha Zelinsky:

Staying off social media generally is good advice, so [crosstalk 00:37:56]. So, yeah you talked a lot about governments and the important role that they play here, I mean unfortunately in some instances we’ve seen I think rather poor leadership. I mean how helpful or unhelpful do you think the political class has been around the world on this issue? Who’s doing it well, who’s not, and what should they be really doing to restore a sense of calm to this?

Alexandra Phelan:

I think one of the best examples that we’ve seen in terms of political communication and political messaging and leadership is in Singapore, we saw the Singapore government very early come out say what they’re going to do, very clear messaging, balanced, and I think there’s a couple of rules for political and health communication that we try to follow. You say firstly, what do you know, what you don’t know, what you’re doing to find out and when you’re going to speak with people next? I’ve seen the state of Victorian Premier Andrews do exactly that framework in a number of the messaging and I’m sure there are plenty of other examples within different levels of government in Australia as well. So, I think clear messaging and leadership upfront and early is really key and that Singapore is a great example.

Alexandra Phelan:

We look at WHO, I’ve openly critiqued them on a number of different issues with this outbreak, particularly on human rights and international law norms, as well as public health messaging, but to their credit, one of the most incredible things WHO and the Director-General Tedros and others have been doing these daily updates to press, really clear messaging, again, what we know, what we don’t know, what we’re doing to find out, and when we’ll be back and I think those are some really great examples of communication. And it really shows how communication is so central to leadership and when people don’t hear from their leaders, they get worried. And I think having clarity of messaging is one of my biggest concerns with the current outbreak back in Australia and how it’s being dealt with. Yeah.

Misha Zelinsky:

Just expanding on the Australian response, it seems that we are at least somewhat behind the rest of the world maybe by fortune of our geographic isolation, ability to control our borders, I mean what would your advice be to Scott Morrison and the rest of the authorities that are responsible for this, what should we be doing urgently?

Alexandra Phelan:

So, the first thing I would say actually is to push back a little bit on that. Pathogens don’t respect borders. So, the fact that Australia’s a little bit behind in terms of timing is not a factor of border security, in fact at one point, we can maybe at another date how border enforcement can actually make things worse, or perceived border enforcement. But it is potentially a fact of our geographic isolation in terms of just number of travelers from the relevant parts of the world that has made a big, big step. Sorry, I got so distracted with making a particular point I forgot the rest of your question, Misha.

Misha Zelinsky:

That’s okay, it’s an important point to make and as I said, I’m more than happy to be corrected on this topic, I do not claim to be an expert.

Alexandra Phelan:

No, no, no.

Misha Zelinsky:

No, no, so what would you be advising the government in Australia to be doing if for whatever reason we do seem to have some time still up our sleeve?

Alexandra Phelan:

Yeah, absolutely that’s spot on. So, what we have right now is that time up our sleeve. There is already local transmission in Australia and so we need to start recognizing that we need to have measures in place now that address social distance and for people to limit that local transmission. We can’t rely on trying to control who comes in and out of the country, it is already here, it is already in Australia. So, what is needed is, I think there should be a move to issue advisories about limiting all mass gatherings, so I would say, over 20 people. People should and this is advisory and I’m deliberately using the word voluntary and advisory here, we can sort of talk about mandatory and criminal in a moment. There should be a prioritization of testing. We’re already at risk of running out of certain re-agents as I understand in Australia, so I think guaranteeing and shoring up our supply chain to actually conduct testing and to continually proactively test anyone who is showing symptoms, regardless of their travel history and perhaps facilitating testing through things like drive-through testing, continuing to set up specified clinics and to have that testing for people who have symptoms or who are our contacts of people who have symptoms or are confirmed.

Alexandra Phelan:

We then also be needing to look at our own measures. We should be looking at an encouragement and people who can, working from home. If they can, work from home. I think the universities, makes sense also to be shifting to a university-from-home model, where applicable, where okay. The school closures, as I mentioned earlier is a little bit more tricky and a little bit more difficult and I think that should be thought through very carefully because of the risk it will have on our health care workforce and our vulnerable elderly populations if those measures are implemented. The next thing we need to be doing is preparing a health care system. We do not have enough ventilators in Australia to cope with this. We do not have enough ICU beds in Australia to cope with this if we have transmission what is modeled in other countries and what we’re seeing in other countries.

Alexandra Phelan:

What we need to be doing is can we increase those direct items, do we have ability to get more ventilators, and get more beds, and that includes being ready to … When I say ready, I mean within the next two weeks, if we don’t see any particular shift in transmission being ready to be able to have our hospitals in surge capacity, that includes cutting elective surgeries and getting ready to have our system and perhaps already depending on what capacity is like in hospitals now, already be switching to have our hospitals in crisis standards of care, which that’s when we’re determining who gets access to ventilators. We need to have those plans in place now because you don’t want to be making those ethical decisions on the fly. And to be having our hospitals ready and supported ready to go for when to surge does hit.

Alexandra Phelan:

We’re going to be seeing, I think the thing I would say to people is do not be surprised and alarmed as we see cases doubling or exponentially growing because that’s exactly what we’re expecting the virus to do. So, when you see breaking news cases have doubled overnight, or whatever, that is expected and what you see today is two weeks after the infection occurred. So, we need to be putting those measures in place now so we are stopping that spread and it may seem like it’s too early, but that’s exactly when we’re talking about a pandemic, that is exactly when you need to be putting these measures in place. I think the cancellation of mass sporting events I think they’re absolutely the right decision and I think we need to be moving to those measures now.

Alexandra Phelan:

Now I mentioned the mandatory and criminal thing. Something that has concerned me is, so I worked on these laws in my undergraduate law dissertation was on these laws in Australia, when you use punitive criminal laws, you push people away from the public health system. You push them towards the criminal system, you push people towards avoiding interaction with authorities, whether they be police or public health.

Misha Zelinsky:

Because you don’t want to admit that you have it so you’re better to hide from it.

Alexandra Phelan:

Absolutely. And that’s when it goes underground. That’s when we see transmission, right, because people don’t want to engage. I was deeply disappointed to hear the Prime Minister say talking about dobbing in your mate who comes into work to the police. That’s is a strategy for underground transmission in Australia that we cannot track and it is not the right message, because we are about to go into a pandemic most likely in Australia, well we are in an epidemic, we are mostly likely drawn into the scale that we’re seeing around the world to some degree, we may be able to flatten it and move it to a different trajectory if we act now. What we need right now is solidarity and trust in our authorities and trust in each other and it is much better than if your mate comes into work that you say, “Hey, you go home right now. You have to go home.” Than you’re calling the cops. We need to be in this together and we need to support each other, and support our most vulnerable populations and moving towards a criminal model, I can tell you now from someone who’s worked in this field for a decade. criminalizing anything to do with health will always make health worse.

Misha Zelinsky:

That’s a very strong message and I think that’s something we should absolutely take on board here and around the world. Now just one, as we get towards the end of this. I know you got important conversations to have and important work to do. You talked before about the Wuhan situation and the origins of this outbreak, I mean, you talked all about the government response information sharing, how big a stuff up, and would it have made a difference had the Chinese authorities sort of acted earlier rather than covering it up. I mean it’s all sort of been forgotten now in the flurry of activity, but of course, at the time doctors were being arrested for diagnosing the illness and things like of that nature, as essentially the system tried to manage up, to hide the problem emerging. How big a problem was that delay in the beginning to where we are today?

Alexandra Phelan:

I think we will get some really interesting counterfactual model or sort of post hoc models to look at exactly that, that if this was reported. Again, this ties into the point that I was just making, that we know that a system that shares information, that is transparent, that is based on public health principles and is based on human rights, including the right to health and the right for everyone to have their health protected by the government, we know that those systems are much better at responding to infectious diseases and so measures that discourage notification that penalize individuals speaking or reporting, or a bureaucracy that deliberately slows down the sharing of information upwards and the reactions out of concern of potential punishment, we know that already, we know that that makes health worse, so I think that it will be very unsurprising if we have after-action reviews that sort of look at if we had had action by the Wuhan government in early January. So, even when this was reported globally, but if Wuhan specifically, we’d seen action in early January, rather than keeping the lid on things whilst the regional meetings were being held, then I think they’re quite conceivably could’ve been an appropriate response that mitigated and contained the outbreak at a much earlier stage.

Alexandra Phelan:

The nature of exponential growth means that the earlier that you can get in the more lives saved and the economics, like the economics, aren’t really what’s going to be at play here, but that’s the early you intervene the less the impact. I don’t know how helpful that’s going to be going forward because we’re going to have a long way before we get to those sorts of after-action reviews, but yeah, I think that will definitely be a point of many, many PhDs to come.

Misha Zelinsky:

Sounds like you’ve got one in the making there for yourself, but how do we future proof ourselves against future pandemics. I’m sure there’s someone who’s thought about these for a very, very long time, probably been jumping up and down producing reports saying that we’re not prepared for pandemics, we’re not pandemics and being ignored. What are the things that, you know, we obviously need to control this outbreak now, but what are the real things we need to be doing to future proof ourselves against future problems like this?

Alexandra Phelan:

Yeah, we need a couple of things. The first is we need investment in strong domestic health care system. We’re incredibly lucky to have Medicare in Australia and we should not be cutting it, we should not be underfunding it, we should be supporting our systems. To be able to have the capacity to prepare for pandemics like this let along every day health of Australians and that’s around the world, universal health care around the world. So, ensuring that health care is affordable, it’s available, it’s acceptable and it’s accessible and it’s quality around the world.

Alexandra Phelan:

There are a range of different capacities as under the piece of international law called The International Health Regulations there are these core capacities that countries are obligated to implement. There is an external evaluation available of countries to assess whether they’ve met those requirements and so there are tool kits, there are frameworks, and there are legal obligations that already exist for pandemic preparedness. And yes, we have been jumping up and down for the last 10 years and longer, so investment in not just in our own countries but the investment in the health systems and pandemic preparedness of other countries around the world, because we’re interconnected. If this pandemic has shown us anything is an outbreak anywhere is a public health threat everywhere and rather than placing blame on countries it’s about building up their support and their capacity to prevent, detect and respond to these outbreaks in the future.

Misha Zelinsky:

Well, Alex, this has been a hell of a conversation. I’m certainly more informed, though I don’t know if I’m any less alarmed, but to bring some kind of levity to this conversation, I normally find some clunky way to segue and I can’t possibly think of one for the final question about a barbecue at Alex’s place with three foreigners. Now, it is three, which does make it under your number of small gatherings, so we can still go ahead, though you might need to buy some stuff ahead of time and I can’t guarantee everybody’s going to make it there, but who are the three foreigners at a barbecue at Alex’s and why?

Alexandra Phelan:

You know what? I might need you to ask this question again, Misha, at some point, because I have been so busy I haven’t been able to sit and think about who I would invite to my barbecue. I think I’m still in social isolation mode.

Misha Zelinsky:

Well, you know what? I’m going to let you off the hook. Ordinarily, I don’t let my guests out of here without answering the question but given that you’re fighting the good fight on behalf of Aussie’s in the global debate, I think I’ll let you off the hook, but-

Alexandra Phelan:

I appreciate it.

Misha Zelinsky:

… it’s been a fantastic conversation. Really appreciate your insights and good luck with the fight against not only this pandemic, but all future pandemics. Thank you very much.

Alexandra Phelan:

Thanks, Misha.