Week in Review

Long read: NZ wasn’t ready for a pandemic

Analysis: New Zealand scored just 54 out of 100 on an international assessment of pandemic preparedness in October. Marc Daalder investigates how we've nonetheless managed to weather the storm so far.

In November 2019, University of Otago epidemiologist Nick Wilson was already concerned about a pandemic.

He knew nothing of the novel coronavirus that reports indicate had already emerged in Wuhan, China, but had just reviewed an international assessment of pandemic readiness which found New Zealand had barely half of the measures in place that it needed.

Although the new assessment, the Global Health Security Index (GHSI), ranked New Zealand 35th out of 195 countries, this in itself simply reflected how unready the world was for a pandemic threat. New Zealand had a score of just 54 out of 100 points and ranked 30th among the 60 high-income countries reviewed.

The GHSI confirmed what Wilson had long known - New Zealand's health system wasn't ready for a pandemic. Combined with the knowledge, sitting in the back of every epidemiologist's mind, that the next global pandemic could be right around the corner, the new information spurred Wilson to action.

Alongside fellow Otago epidemiologist Michael Baker and Matt Boyd, a public health expert and former advisor at the Ministry of Health, Wilson wrote a blog post detailing the GHSI findings and flagged it to the Ministry, which he says was less than receptive. Wilson understands the Ministry had considered releasing a media statement defending its pandemic preparedness.

Then Covid-19 took the world by storm. As the death toll passes 200,000 and confirmed cases rocket past the three million mark, New Zealand appears to have weathered the storm comparatively well so far. Why is that? Was the GHSI wrong? If not, what happened?

'No country is fully prepared to handle a pandemic'

The GHSI should have been a warning sign. It should have galvanised the world to action in the face of a threat that was not just likely to occur in the coming years, but inevitable.

The researchers behind it were certainly concerned. Ernest Moniz, the CEO of the Nuclear Threat Initiative, which helped found the GHSI, said in October the results were "alarming".

"All countries—at all income levels—have major gaps in their capabilities, and they aren’t sufficiently investing in biological preparedness. The bottom line is that global biological risks are growing—in many cases faster than health systems, security, science, and governments can keep up. We need to ensure that all countries are prepared to respond to these risks."

The average score in the GHSI was 40.2. Just 14 countries scored above 66 and just five scored above 75.

New Zealand scored particularly poorly in the "early detection and reporting epidemics of potential international concern", coming 107th out of 195 countries with just 36.7 points out of a possible 100. The GHSI found that New Zealand's epidemiological workforce was lacking and that there were not enough training programmes for epidemiologists in the country.

The capacity of New Zealand's health sector also came in for criticism.

New Zealand came in 80th place for hospital beds per capita, with just 280 beds per 100,000 people. That's half of what Croatia had, for example, or a quarter of the beds per capita that second-place Japan has.

It also came 42nd in the ranking of doctors per capita, with 306.1 per 100,000 people, but fared slightly better when it came to nurses and midwives per capita, where it came 16th.

Overall, New Zealand scored 45.7 out of 100 for healthcare capacity, coming in 39th place.

The sector the country scored best in was "rapid response to and mitigation of the spread of an epidemic", with 58.1 points out of 100 and a 21st place finish. Within this category, the GHSI congratulated New Zealand on its emergency preparedness, where it came 10th.

Even here, however, aspects of New Zealand's readiness were found lacking. The country had not completed a biological threat-focused exercise with the World Health Organisation in the past year, earning it a score of zero for "exercising response plans". Its National Health Emergency Plan - which debuted in 2015 - has not been updated in the past three years.

In their blog post, Wilson, Baker and Boyd highlighted previous public health failings as evidence of New Zealand's poor preparedness.

"Recent problems with infectious diseases in the country strongly suggest that more should be done to prevent and mitigate," they wrote.

"In August 2016 Havelock North suffered the world’s worst ever waterborne campylobacteriosis outbreak, costing $21 million and tragically several lives. Additionally, 2019 has seen a large national measles epidemic, which threatens our measles elimination status and has resulted in NZ exporting this infection to vulnerable Pacific Island nations. These public health emergencies were both preventable and support the GHSI assessment that NZ needs to improve its public health infrastructure."

Wilson said that while many aspects of the GHSI scoring system relied on information being publicly available, this was a valid way to assess pandemic preparedness.

"It will give a country a low score when they don’t have documents on their website that are available, which is absolutely critical for transparency," he said.

"I mean the Ministry can have all these hidden documents but what good is that? What confidence does that give to independent commentators and academics and researchers? It’s hopeless if you have hidden documents because they could all be full of errors."

When he brought the results of the GHSI to the Ministry's attention, Wilson said they retorted by pointing to a 2018 Joint External Evaluation (JEE) of New Zealand's public health systems with the World Health Organisation. But the JEE evidence is less compelling than that of the GHSI, Wilson told Newsroom.

"Their argument was that they’d done a Joint External Evaluation with the WHO and that had given them confidence that they were doing well. Now the trouble with those assessments is that there’s all sorts of fudge factors and it doesn’t have the regularity and objectivity that the Global Health Security Index has, which is applied to all countries in a completely systematic way," he said.

"When I talked to the Ministry people, they persisted in the illusion that the JEE is a good indicator. And we know how political the WHO is. It likes to just be very positive about countries’ progress and not too critical. The Global Health Security Index is much better."

In a statement, a Ministry of Health spokesperson reemphasised the value of the JEE.

"New Zealand has both a very positive recent international external evaluation of our pandemic readiness and a good plan – the Influenza Pandemic Plan – which had been tested as part of the 2009 swine flu response," the spokesperson said.

"The joint external evaluation – published late last year – is thorough – it covers New Zealand’s preparedness in 19 different areas and assessments across 49 indicators. The evaluation endorses New Zealand’s preparedness and approach. It recognises our commitment, our preparedness and the testing of New Zealand’s response capability through a series of recent challenges and that’s reflected in the assessments which are predominantly rated well - as ‘demonstrated capacity’ and ‘sustained capacity’ (the top two assessment levels)."

Future pandemics a question of when, not if

At the same time as he was reviewing the results of the GHSI, Wilson knew in the back of his head what he had known for years: it was a matter of when the next global pandemic would occur, not if.

In September, prior to the release of the GHSI, a report from a joint-World Bank and WHO project underlined that risk. The Global Preparedness Monitoring Board found "there is a very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen killing 50 to 80 million people and wiping out nearly 5 percent of the world’s economy. A global pandemic on that scale would be catastrophic, creating widespread havoc, instability and insecurity. The world is not prepared."

Epidemiologists have been warning the world for decades about the possibility of a severe pandemic. Every few years, an isolated outbreak of a deadly pathogen or a mild pandemic would jolt the world into action, but complacency inevitably returns within a matter of years. The pattern can be seen after SARS - which pushed New Zealand to create its first health emergency plan - MERS, the 2014 Ebola outbreak in West Africa and the 2009 H1N1 pandemic.

In recent years, the risk has only grown as humans have encroached further on the natural world - exposing themselves to zoonotic diseases - and as biotechnology has created a whole new avenue for the release of lethal pathogens.

Wilson said he was focused on "natural pathogens as humans interact with the remaining natural world. And especially in parts of Africa where poverty and population pressures are driving people to consume bush meat. The links, the exposure to zoonotic sources, is just increasing."

"Ebola probably came from a child handling a bat; human interactions with chimpanzees killed for bush meat may have been the cause of the transmission of HIV into the population. And obviously this coronavirus is probably related to a bat reservoir, maybe a pangolin. So this killing of wild animals and trade in wild animals is a concern."

Influenza was also a cause for concern, particularly after the 2006 bird flu outbreak and the 2009 swine flu pandemic.

"Concern about pandemic influenza was also growing because you have these massive pig farms and poultry farms. Especially in parts of Asia, where there are pigs and ducks and chickens all together. Because the virus - influenza viruses - move between those species, pick up new genes, and then sometimes spill over and produce a new pandemic," Wilson said.

There are, Wilson said, "influenza pandemics several times a century. They’re a guarantee, a future influenza pandemic."

"And then the biotechnology is proceeding so rapidly. The skill sets to be able to do things in labs, it’s not PhD level anymore. You can order gene sequences over the internet. People have recreated various – a polio virus, for example, was completely synthesised by mail order gene sequencers. All these things are making people very concerned about the potential for a future biohazard.

"So, all those things, combined with jet travel and people moving in larger and larger numbers, more quickly around the world, is a problem."

'We had a good plan for the wrong virus'

Given all of this, when Covid-19 came knocking, Wilson wasn't surprised. He and Baker wrote a blog post on February 6 titled "NZ Should Prepare for a Potentially Severe Global Coronavirus Pandemic".

"Government agencies can now justifiably leverage this crisis by starting to prepare the population for a massive upgrade in protective practices in case border control fails and there is uncontrolled spread of this new coronavirus in NZ," they wrote.

"Health officials have wisely mentioned hand hygiene and respiratory hygiene – but this messaging should be far more prominent (and involve paid mass media efforts). Also officials should be talking more about the critical importance of staying home when sick and for being prepared to work from home in some situations."

Although New Zealand acted quickly on introducing phased border restrictions, banning the entry of people from some countries while requiring others to self-isolate for 14 days, both Wilson and Baker soon became concerned that the Government's response wasn't fit for dealing with Covid-19.

The last emergency plan that specifically dealt with infectious diseases was the 2017 Influenza Pandemic Plan, which epidemiologists locally and abroad have held in high esteem. That said, SARS-CoV-2 - the virus that causes the Covid-19 disease - is not influenza.

The influenza plan mentions SARS four times, including once in the glossary. The broader National Health Emergency Plan, from 2015, mentions SARS three times, including once in the glossary. Neither mention other coronaviruses at all.

To find the last plan that deals substantially with the possibility of a coronavirus outbreak - or any non-influenza pandemic - you have to look back to 2004, when the Ministry of Health released its first National Health Emergency Plan, specific to infectious diseases.

Although the Influenza Pandemic Plan states "the approach in the plan could reasonably apply to other respiratory-type pandemics (such as severe acute respiratory syndrome – SARS)", neither Wilson nor Baker felt this to be true.

The key was in the incubation period. In influenza, the virus usually becomes contagious around one to three days after infection takes place. This means contact tracing and isolation of cases is virtually impossible, as it would have to occur within a matter of hours at best.

Meanwhile, Covid-19 has a longer incubation period of between three to 14 days. A study in mid-March found the median incubation period is five days - plenty of time to trace and isolate the contacts of someone who has tested positive.

"With this coronavirus, at the level of spread that it got to in New Zealand, if that was pandemic influenza, it would be impossible to control, because the incubation period of pandemic influenza is less and so it will spread rapidly before you can do all the contact tracing," Wilson said.

"With this coronavirus, with a five to six day incubation period, you’ve got more time and so the ideal pandemic plan would have said: 'Pathogens can vary enormously and for some pathogens, if they have a long incubation period, you should as a country put a lot more investment into things like contact tracing, case isolation and home quarantine'."

Nonetheless, Wilson says, bureaucratic inertia meant the Government treated the virus like influenza, in which containment or elimination would not be possible and contact tracing a waste of resources.

"And then you might be able to eliminate them again. But you know, we drifted along thinking, ‘Oh it’s going to be very hard to eliminate, we’re going to do suppression too’. Until we shifted to elimination, we weren’t geared up and thinking enough about that this was a fairly different disease. You start off on a particular path with your Influenza Pandemic Plan in your hand and you don’t realise it’s the wrong plan."

Baker was similarly distraught in the early stages of New Zealand's response to Covid-19 by the Ministry's over-reliance on the influenza plan.

"We had a good plan for the wrong virus," he said.

"We had a mitigation approach when in fact the Chinese had shown us really very convincingly I think by the end of February that you could take a containment approach with a view towards elimination."

Baker spoke to Newsroom while emphasising that he thought it was too early to make any declarative statements about New Zealand's success or lack thereof and that any sort of post-mortem would be more appropriate after the country has left the "acute response" phase.

The Ministry spokesperson rebutted the notion that reliance on the Influenza Pandemic Plan led to undervaluing contact tracing or testing.

"The Influenza Pandemic Plan provided a solid framework which was able to be easily and quickly adapted as we’ve learnt more about the SARS-CoV-2 virus," the spokesperson said.

"The Ministry rejects claims that testing and tracing were undervalued.  In fact testing and tracing have always been a core part of our response to Covid-19.  We quickly stood up testing and went from having no capacity in New Zealand at the beginning of the outbreak to an average of 5,223 tests across ten laboratories per day now."

In the end, scaling up New Zealand's contact tracing regime has been the slowest part of the country's response to Covid-19, perhaps due to the de-emphasising of contact tracing in February and early March.

A report on contact tracing commissioned by the Ministry of Health from University of Otago infectious diseases expert Ayesha Verrall found Public Health Units were overwhelmed by the case numbers they faced in late March.

"When New Zealand moved to Alert Level 4 on 25 March, many PHUs were at or beyond their capacity to manage cases and contacts, even with increasing support from the newly established [National Close Contact Service]. During that week, nationwide daily case numbers ranged from 70-86," Verrall wrote.

Even two weeks into lockdown, only 60 percent of contacts could be easily reached by phone and PHUs had no insight into what happened to cases they referred to the centralised NCCS. Verrall wanted to see the PHUs and NCCS able to trace all the contacts of 1000 new cases every day, up from just 70 on March 25.

These issues seem to have been alleviated in recent days, with Director-General of Health Ashley Bloomfield saying 80 percent of contacts were now being traced within 48 hours - even faster than the key performance indicators Verrall set out for the Government in her report. Bloomfield now insists New Zealand has a "gold standard" contact tracing system, but it took four-and-a-half weeks of lockdown to get there.

"Our contact tracing, always a key function of our public health units, has with support and central assistance now reached the point where our Public Health Units and National Close Contact Service (NCCS) can make 5000 calls a day with the ability to scale up to 10,000 calls if required.   Our most recent information from public health units and the National Close Contact Service, for the period 13-17 April, shows 80 percent of close contacts were traced within 48 hours of the case being notified to the units," a Ministry spokesperson told Newsroom.

Why have we fared so well?

Despite the low GHSI score, despite the over-reliance on the wrong plan, despite slow scaling up of contact tracing, New Zealand is one of the world leaders in responding to Covid-19. Our daily case numbers are in the single digits and have been for more than a week.

International media have heralded New Zealand's claim to be on the path towards elimination.

How could we get it so right - so far - despite being utterly unprepared for the pandemic?

Wilson has a theory. In his eyes, a country's outcome during a pandemic is determined by its preparedness, its response in the moment and no small amount of luck.

New Zealand aced its response and got lucky, Wilson said, which made up for the lack of preparedness.

"The relatively fast response and the pretty intense nature of the lockdown has allowed us to be given time to ramp up testing and contact tracing and other systems," Wilson said.

"Also, the leadership has been pretty good and Jacinda [Ardern] is a very skilled communicator, explaining different levels. The idea of levels also gave people some idea of what might happen in the future, so that was probably a good approach. And New Zealand’s got quite a good system with the science advisors who have been in [the Ministry of Health] and the Chief Science Advisor."

To Wilson, the borders are a prime example of our quality response. He and Baker have been warning for years that New Zealand needed to be prepared to close its borders in the event of a serious pandemic or re-emergent smallpox, but the Ministry didn't seem to heed their advice.

Cost-benefit analyses that found border closures would in most modelled severe scenarios be worth the cost were sent to the Ministry but met with a stony response. Wilson despaired that in a serious situation, New Zealand wouldn't close its borders in time.

"Reading the Influenza Pandemic Plan, which sort-of said that we’d only possibly close the border in extreme circumstances, I knew that was a silly thing. They had to plan for the future with potential developments in biotechnology, with synthetic bioweapons, even if some terrorists released small pox, that would be justifiable closing the border for at least a few weeks to get a chance to prepare," he said.

"So we published these cost-effectiveness analyses which showed that, yes, most times it’s not worth closing the border, but in extreme situations, it is. And we gave that material to the Ministry and then we went in and met with them, but they said, 'Oh, it’s WHO advice never to interfere with borders so we’re ignoring this'."

In the end, New Zealand did act fast, showing that a competent policy response would enable some countries to overcome their preparedness deficits. At the same time, Wilson said, luck played a major factor in New Zealand's progress so far.

"You know, I’m a scientist, so I know about chance. There’s chance acting in everything. We could have just been lucky that we possibly had travellers from Asia in January and early February who may have infected other people, but maybe the summer conditions with high temperatures and different humidity may have slowed virus spread so those virus chains went extinct," Wilson said.

"We know with other coronaviruses that they’re highly seasonal, so I’m expecting that summer transmission is low, winter is high. That’s lucky for Australia and New Zealand and other Southern Hemisphere countries. But no politician ever talks about luck. It’s all to their good credit, isn’t it?"

The flip side is also true. Many countries that ranked highly in the GHSI for pandemic preparedness, including the United States and United Kingdom, which came first and second respectively, have struggled with Covid-19.

"The two top performers in the GHSI were the US and the UK, which shows that they can have a lot of things in place and a lot of good processes and systems, but if you have dysfunctional political leadership from the top, particularly like [Donald] Trump, you can possibly screw up anything," Wilson said.

The GHSI itself also released an analysis of why the US has struggled, noting the deficiencies highlighted in the GHSI were now revealing themselves in the country's response to Covid-19.

"Although the United States received the top score of 195 countries assessed and was ranked number one, its score and rank do not indicate that the country is adequately prepared to respond to potentially catastrophic infectious disease outbreaks. Significant preparedness gaps remain, and some of those are playing out in the current crisis," the GHSI stated.

"The United States’ response to the Covid-19 outbreak to date shows that capacity alone is insufficient if that capacity isn’t fully leveraged. Strong health systems must be in place to serve all populations, and effective political leadership that instills confidence in the government’s response is crucial."

In fact, New Zealand's poor pandemic preparedness may have meant the country responded in the right way to Covid-19. While high-ranking countries might decide they had the resources and health system capacity to grapple with the virus without needing to resort to a lockdown, as the scale of the threat became apparent to the New Zealand Government, it could have held no illusions about its readiness for a pandemic.

"In the modelling work we did for the Ministry, we did include information about the low ICU capacity, which is I think in most European countries, the ICU beds per population is often several times higher," Wilson said.

"So it gives countries like Sweden confidence in their mitigation strategy. You know, they might be able to manage it. I think their numbers of fatalities are increasing so they may have made the wrong decision there. But if you are a country with a very big ICU capacity, then you might think you’re going to get away with it."

In the end, the Government came to understand that there was no alternative to a "pulse lockdown" to give New Zealand time to ramp up testing and contact tracing abilities - the argument that Baker and Wilson had been making for a week prior to the announcement of a move to Level 4.

After the virus

What New Zealand's lack of preparedness highlights most, Wilson and Baker say, is the need for a greater emphasis on public health.

"I would hope that given the huge cost of the lockdown, billions of dollars a week, that improved planning around rapid border closure and having really state-of-the-art contact tracing and testing systems for a wide range of potential biohazard threats is a very good investment," Wilson said.

"I think Treasury would see the sense of that. The whole health system would see the sense of that, you know. So I think it will be a big wake-up call.

"What I would say is that New Zealand had a whole succession of very dramatic examples of things like [campylobacteriosis] in Havelock North or measles, that we shouldn’t have had. And I think everyone acknowledges that. Here’s another thing which I think raises the question of how you organise your preventive healthcare services and your population health systems. And so they’re all dramatic examples," Baker said.

Both epidemiologists have long campaigned for a greater focus on public health within the Ministry of Health and perhaps some form of centralised public health agency. As it stands, public health functions are distributed across an array of Government bodies, including the 12 regional public health units, the Ministry of Health, a new drinking water regulator and more.

"We’re such a small country, at a certain point you have to say, actually we have to put a whole lot of these population health functions together into organisations of critical mass. That also makes it much more adaptable because they’ve got more surge capacity," Baker said.

"Even though our Ministry of Health has done, I think, very well, it still clearly has not enough staff to do this properly. Also, for policy-making agencies, it’s hard for them to take almost a wartime or civil defence mode of operating. There’s no accident all around the world, pretty much every high-income country has a dedicated public health agency. Public Health England, Scotland, Wales even, Ireland, CDC in the US, Public Health Canada. New Zealand’s really out on its own a bit."

An independent Public Health Commission, started in the 1990s, was short-lived. It was closed after it went after tobacco, alcohol and unhealthy foods, according to its former chair Sir David Skegg.

Now, the Ministry of Health's executive leadership team, which consists of 15 people, still doesn't include Director of Public Health Caroline McElnay.

"I was in the ESR when it was separated out as the Crown Research Institute almost 30 years ago and it’s a very unusual move, to put it into a corporate model, your national surveillance and lab capacity. So this is partly a neoliberal thing from the nineties leftover, in a way we’re still trying to pick up from that era. The legacy of that era."

Baker stressed that the middle of a pandemic isn't the time for reorganising the country's public health functions, but that some of the shortcomings in New Zealand can be laid at the feet of the current public health structures and that the situation will be well worth a look after the crisis abates.

"I don’t want to be too critical, we’re in the middle of an acute response, but you can see that some of the things that have been slow to get going are a function of having this process now distributed across several agencies," he said.

"The line is repeatedly: We must spend more on prevention, prevention is better than a cure. All this other stuff that is trotted out and it almost sounds trite and predictable, because then we do the opposite. The way we organise our systems is we systematically, not deliberately, but have just eroded these capacities for 20 years. It’s not even one particular government doing it. It’s just winding them down and worse than that, in New Zealand, fragmenting them into little bits."

A Ministry spokesperson said that discussions about the structure of the health system were premature.

"It’s too early to say if an alternative structure would have helped or hindered New Zealand’s response and this is something that may be covered by the Government’s Health and Disability System Review – the release of which has been delayed by the Government’s Covid-19 response," the spokesperson said.

Wilson sees East Asian countries like Taiwan and South Korea as a model for a robust public health system. Both countries have managed to handle the virus without resorting to lockdowns and New Zealand, if it took the mission of creating a competent public health regime seriously, might be able to do the same in future pandemics.

"Maybe for some extreme pathogens, you will have to still have lockdowns, but if you can do it Taiwan-style - good border quarantine, lots of testing and fantastic contact tracing systems - you should. South Korea has also had very good use of digital technologies with contact tracing, though some of them may be problematic from a privacy perspective, so you need to have those safeguards built in. But yes, I think New Zealand doesn’t learn from these Asian countries adequately," he said.

"On the plus side, New Zealand has been one of the few places to ever eliminate some diseases like brucellosis. It did an amazing job eliminating the southern salt marsh mosquito that had spread around the country. And it’s planning to get rid of this mycoplasma bovis and it’s got grand plans to eliminate rats, bovine tuberculosis, things like that. So, yeah, when it focuses on it, and if it’s going to help the agricultural sector sell produce, then it does do some good things.

"When it’s organised, New Zealand can achieve some pretty remarkable things."

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