As Daniel Andrews and his most trusted advisers gathered in the Treasury Place office of his chief of staff on the morning of June 30, two things were clear: the government was facing the most serious political crisis of its six years in power, and the Premier was livid.

Andrews rarely raises his voice in anger. Those who have worked closely with him say that even in the most confronting circumstances, he almost never shouts. His is a cool anger. On this morning, it was barely contained.

A short time earlier Victoria’s Chief Health Officer, Professor Brett Sutton, had sent an incendiary email. Attached to it was a genomics report prepared by the Doherty Institute’s microbiological diagnostic unit, which, under the government’s direction, was closely tracking the state’s COVID-19 epidemic.

The report showed that Victoria had all but eliminated its first wave of viral infections. It also showed that the second wave surging across Melbourne’s northern and western suburbs could be traced almost entirely to two city hotels where people returning from overseas were supposed to be safely quarantined from the rest of the population.

The problem wasn’t that Sutton had sent the report to the Premier’s chief of staff, Lissie Ratcliff. It was that he had also shared it with other people working across Victoria’s pandemic response. Those in the room didn’t know how many and understood what this meant – that it could break into the open at any time.

Just as an exhausted public health team was having to chase down a lethal virus unleashed by a botched government program, the Andrews government needed to move fast to contain the political damage.

Three people were called to the emergency meeting with the Premier. Ratcliff and her deputy, Jessie McCrone, were political operatives, their loyalty hardwired to the ALP and the Premier. Chris Eccles, one of the nation’s most experienced bureaucrats, had run the Department of Premier and Cabinet for six years and in recent years had also become a greybeard counsel to Andrews.

Health minister Jenny Mikakos – a factional ally of the Premier and an MP for more than 20 years – joined this gang of four after the meeting had started. She had come to prominence in the early months of the pandemic as a face of the government’s health response. That would change once Andrews stepped in.

Professor Sharon Lewin of the Doherty institute.

Professor Sharon Lewin of the Doherty institute.Credit:Simon Schluter

Professor Sharon Lewin says Victoria has achieved something remarkable. Lewin is the director of the Doherty Institute, an infectious diseases research body which has advised the Victorian government throughout the pandemic. As far as she knows, Melbourne is the only city in the world other than Wuhan – the source of the original outbreak – that has managed to free itself of COVID-19 after the virus got its hooks deep into the community.

While European and American cities still ravaged by COVID-19 await their first doses of vaccine, Victoria has demonstrated that with strong political leadership and community engagement, the virus can be overcome by public health measures. Melbourne, for all it has been through, offers a lesson to the world. Lewin’s caveat is that we’re not sure what that lesson is.

This pandemic was the first time governments ordered their citizens to stay at home en masse to stop the spread of an infectious disease. We may never know for certain what the decisive measures were. ‘‘There isn’t a lot of science around lockdown measures,’’ she says. ‘‘No one had done lockdown before coronavirus. Maybe we wouldn’t have even thought of it had Wuhan not done it.

‘‘There are still enormous gaps in the science – how much do you need to do, what is redundant and what really makes a difference? It is a very murky scientific area because most places, including us, threw everything at it at the same time.’’

Over the past six weeks, as Victorians tallied our run of ‘‘doughnut days’’ and basked in the promise of a virus-free Christmas, The Age has retraced the government’s response to the second-wave epidemic and examined critical decisions taken – and not taken – in the depths of our COVID winter. What follows is an inside account of how Victoria beat COVID and how the Andrews government confronted its greatest crisis.

Chris Eccles had been in politics long enough to know you don’t come to an emergency meeting without a solution. Having run the public service for Mike Rann in South Australia and earned the Pulp Fiction moniker “Mr Wolf” in NSW as someone who fixed things fast, Eccles also understood what can happen when political leaders are caught flat-footed. He was overseas on leave when NSW premier Barry O’Farrell failed to recall before the state’s Independent Commission Against Corruption that he’d been gifted a bottle of Grange by a businessman. By the time Eccles could arrange a flight home, he didn’t have a boss to come back to.

Chris Eccles, who was secretary of the Department of Premier and Cabinet, testifies to the Coate inquiry.

Chris Eccles, who was secretary of the Department of Premier and Cabinet, testifies to the Coate inquiry.Credit:

On the morning of June 30, Eccles advised Andrews to immediately establish an inquiry into hotel quarantine. He also suggested who should run it: Jennifer Coate. An experienced jurist who had served as a judge of the Children’s Court and the Family Court, a Victorian coroner and a royal commissioner, Coate had impeccable legal credentials.

Just as importantly, she knew her way around government. Eccles told the meeting she would bring a common-sense level of independence to a politically charged inquiry. The Coate inquiry, due to deliver its final report by December 21, provided an up-close and at times uncomfortable view of the poor planning, inept management and opaque governance of the hotel quarantine program and more broadly how the public service operates in Victoria.

It exposed a dysfunctional tribalism within the Department of Health and Human Services, where a long-neglected public health team saw itself – and was seen by the rest of the bureaucracy – as a separate fiefdom. It also revealed the contradictory impulses of Victoria’s popular Chief Health Officer: a desire to be given greater responsibility set against a reluctance to take it when the opportunity arose.

Sutton said he wanted to be state controller, in charge of Victoria’s pandemic response, but did not mention this to either the Premier or health minister, with whom he shared a podium on most days. As early as mid-April he expressed ‘‘moral and legal’’ unease about his lack of oversight of hotel quarantine – yet he didn’t take it upon himself to find out what was going on.

When questioned about this last week by Liberal MP Richard Riordan in parliamentary estimates, Sutton confirmed he hadn’t raised his concerns about hotel quarantine directly with Mikakos or DHHS secretary Kym Peake. Instead, he asked members of his public health team to raise the issue with their emergency management colleagues.

‘‘You were just happy to do the odd little email and have the odd conversation with people in your office, not to go straight to the top on it?’’ Riordan asked.

‘‘I think that is a mischaracterisation,’’ Sutton replied.

He told the Coate inquiry that before the virus broke out of quarantine, he was not aware of what infection controls were in place at the two hotels.

The Coate inquiry didn’t set out to ascribe blame or apportion political responsibility for decisions. It saw its primary role as examining the systems and practices which allowed the virus to breach quarantine. Fundamentally, the inquiry was established for a political purpose: to defer the government’s day of reckoning on a catastrophic policy failure until it had the virus back under control. In Ratcliff’s office on June 30, neither Eccles nor Mikakos could have imagined that their appearances before the Coate inquiry – followed by testimony from the Premier – would bring an abrupt end to their time in Victorian public life.

For Andrews, bringing the virus under control a second time would prove far more difficult than managing the immediate crisis created by Sutton’s early-morning email. The day the Premier read the genomic report, he announced the first step of what would become an incremental lockdown policy: the return of stage three stay-at-home orders in 10 suburban postcodes. The decision had been approved by Victoria’s crisis committee of cabinet a day earlier, before anyone knew the genomic report was about to reshape the government’s COVID-19 response.

 The Premier and the Chief Health Officer in late June.

The Premier and the Chief Health Officer in late June.Credit:Penny Stephens

As he prepared to take the stage in the Treasury Theatre shortly after 3.15pm, his face not yet concealed by the masks that would soon become ubiquitous, the Premier did not acknowledge Sutton’s presence. ‘‘Dan was so furious with him he did not even glance at him,’’ a government figure who observed the press conference says. Not for the last time, Victoria’s Chief Health Officer felt the inside of the Premier’s ‘‘freezer’’, the political sin bin he reserves for those who disappoint him.

At the press conference, Andrews revealed he’d received a ‘‘comprehensive genomics briefing’’ showing that ‘‘at least a significant number and possibly more of the outbreaks’’ were attributable to staff members in quarantine hotels. The evidence to the Coate inquiry showed that 99 per cent of cases in Victoria’s second wave – a deadly epidemic that seeped into nursing homes and hospitals and killed 800 people – could be traced back to private security guards given the wrong advice and next to no training or supervision regarding infection control protocols.

Sutton described the day as a ‘‘heartbreaking turn’’ in the pandemic but urged Victorians to keep faith in the response. ‘‘We can absolutely turn this around,’’ he said. ‘‘We can stabilise numbers over the next few days.’’ We didn’t. On June 30, Victoria recorded 76 new confirmed cases. By mid-July, there were more than 300. On August 4, the second wave peaked with 687 new infections.

Melbourne University epidemiologist Professor James McCaw.

Melbourne University epidemiologist Professor James McCaw. Credit:

Professor James McCaw, a University of Melbourne epidemiologist and member of the Australian Health Principal Protection Committee (AHPPC) which advised the national cabinet, says it is difficult to appreciate how much more is known about COVID-19 now than when the Victorian government first confronted the second wave. Hindsight judgments cannot gainsay the difficulties involved in tackling a disease which has turned out to be more infectious and less predictable than anyone understood six months ago.

The first breach of hotel quarantine occurred on May 26, when members of a family recently returned from Bangladesh passed the virus to staff and security guards working at the Rydges on Swanston. At that stage, the World Health Organisation did not recommend the use of face masks other than for medical staff treating COVID-19 patients. Yet by the time Andrews announced the postcode lockdown, McCaw and other infectious disease experts were warning Victoria needed to be doing more.

McCaw believes the most important decision in Victoria’s response was the one announced a week later, on July 7, when Andrews flagged that all of Melbourne and Mitchell Shire – the local government area which borders greater Melbourne to the north – would be subject to stage three restrictions. Although all of Victoria would eventually come under the tightest restrictions imposed for an extended period on any Australian jurisdiction, McCaw says it was the July 7 decision, which came into effect two days later, that broke the second wave.

This was the moment the crisis changed how a city of 5 million people lived, worked, related to one another and thought about the virus. ‘‘I and many of my epidemiological colleagues advocated for it and by the time it came, it couldn’t come soon enough,’’ McCaw says. ‘‘People started mixing less and when they did mix with people they were more cautious and more people were compliant with the public health recommendations. We now know it was stage three that turned it over. You can see that in hindsight.’’

Victoria’s COVID-19 curve suggests that the stage three restrictions, later augmented by the introduction of mandatory face covering, stabilised the rate of new infections. The problem was that the plateau of new cases that had been created – an average of nearly 500 a day once the restrictions took effect – was well above the capacity of the state’s contact tracers.

At the start of each day they would arrive for work in the Health Department offices at 50 Lonsdale Street and relentlessly hit the phones, trying to chase up the friends, colleagues and acquaintances of people who’d been infected to tell them to get tested. Each day they would finish deeper in the hole, with new cases coming in quicker than they could trace old ones. They needed more people and better systems, but multiple sources from senior levels of the government’s pandemic response say the public health leadership either didn’t accept or were unwilling to admit they had serious problems and were reluctant to ask for help.

The simplest explanation is they were overwhelmed. The pressure was particularly acute on Deputy Chief Health Officer Annaliese van Diemen. As the second wave neared its peak, Van Diemen was serving as Victoria’s Public Health Commander, responsible for the day-to-day direction of all contact tracing and case management and regularly filling in for Sutton at press conferences and AHPPC meetings.

The people interviewing new COVID-19 cases to work out where they got it from and who else they might have infected would take down longhand notes. Sometimes these would be faxed to the department. These would then be typed into the Public Health Event Surveillance System (PHESS), a 12-year-old database designed to help public health officials contain outbreaks of diseases such as measles and rubella. It was a proven system – a variant is used by public health officials in NSW – but it was severely limited.

PHESS was a test reporting tool, not a searchable database which could be used to link different cases. Once Victoria started its testing blitz, PHESS was overwhelmed by the mountain of information coming in and, like any system that relies on manual data entry, was vulnerable to human error. Misspelling a street name or transposing a phone number could add precious hours and days to the time it took to tell people who might have the virus to get tested.

When Navy Commodore Mark Hill was seconded to the Victorian public health team in mid-July as part of an ADF team to help with logistics, he reported back to Canberra a dire situation where a backlog of up to 1000 cases had not been traced. For all its limitations, PHESS was the system Victoria’s public health team knew.

Earlier in the pandemic, when the hotel quarantine program was being established, senior figures in the State Control Centre and DHHS began exploring whether a separate database used by a federal agency could help keep track of returned travellers entering and leaving Melbourne hotels. An email tendered to the Coate inquiry showed the suggestion was met with opposition from the public health leadership.

“The Public Health Commander [Van Diemen] has requested that there should NOT be a separate database for tracking and managing individuals who are in quarantine and is not PHESS at this time,’’ wrote a senior DHHS public health doctor, Finn Romanes. The idea to use the federal database was abandoned.

On the same day Dr Romanes, the Deputy Health Commander, wrote that email, half a dozen DHHS officials received something else in their inboxes; an unsolicited, pro forma approach from Salesforce, a Silicon Valley tech giant, offering a high-tech platform to support their entire COVID-19 response. The same email was sent to health officials in New Zealand, Western Australia and South Australia, who eagerly took Salesforce up on the offer. Victoria would too – some four months later, after the second wave had swamped the state.

The problems in Victoria’s approach to contact tracing and outbreak management should have been apparent to everyone in government before the second wave even began. The canary in the coal mine was the outbreak at Cedar Meats.

Cedar Meats in Brooklyn.

Cedar Meats in Brooklyn.Credit:Jason South

On April 2, the DHHS was notified that an employee of Cedar Meats, an abattoir in Melbourne’s west, had tested positive. It took another 27 days for the department to tell the company. By that stage, four workers from the abattoir’s boning room had tested positive. Sutton ordered the facility shut and all staff into quarantine. At the time, he briefed his AHPPC colleagues and his minister, Jenny Mikakos, that the response had been ‘‘textbook’’. Armed with this advice, Mikakos, Andrews and the Commonwealth’s chief medical officer at the time, Brendan Murphy, all publicly endorsed it. Mikakos in particular would come to rue her comment that the outbreak had been ‘‘handled absolutely perfectly’’.

It was anything but, as Sutton conceded in a May 14 radio interview with 3AW’s Neil Mitchell which infuriated his political masters. Breaking with what he had previously told the government, he suggested the abattoir should have been shut much earlier.

Mikakos’ response was swift. On the same day as Sutton’s radio interview she asked Professor Euan Wallace, chief executive of Safer Care Victoria, to conduct what is known as a ‘‘rapid improvement review’’ of the Cedar Meats outbreak. Under the terms of reference provided to Wallace, an independent team of examiners would have interviewed the owners and staff of Cedar Meats and Fawkner McDonald’s, to which the virus had spread, as well as Sutton and the authorised officers and contact tracers who responded to the breakout and the pathology providers who did the testing.

It would have pieced together a timeline of events, decisions made and policies and procedures employed. It was intended to ‘‘report opportunities for improved contact tracing and isolation of future clusters, minimising impact on the public and on business’’.

The review never took place. Government sources say it was blocked by the Premier’s office, which expressed concern that its findings would embarrass those who had publicly backed the outbreak response. With the lessons of Cedar Meats unlearnt, the second wave crashed upon Victoria.

Sandy Pitcher stepped in to help rebuild Victoria's contact management capacity at the height of the second wave.

Sandy Pitcher stepped in to help rebuild Victoria’s contact management capacity at the height of the second wave.Credit:Simon Schluter

Sandy Pitcher got the call from Eccles and Peake on a Saturday night, July 12. Eccles told her he’d spoken that day to Andrews. ‘‘It is clear to me that they had a pretty serious conversation,’’ Pitcher says.

The Premier, despite being repeatedly assured that Victoria’s contact tracing and outbreak management was keeping pace with the virus, had lost faith in the public health team. A week earlier, Kate Houghton, a Department of Premier and Cabinet (DPC) secretary who’d attended national cabinet meetings with Andrews and Eccles, had been inserted into DHHS to help sort out the hotel quarantine mess. She reported back to the Premier that the bigger problem was in contact tracing.

Andrew was now deeply worried about what was going on at the heart of the pandemic response. He told Eccles to put all his best people on the job.

Pitcher, a career public servant who’d worked as Eccles’ deputy in SA and Victoria, was given the hottest seat in Victoria’s newly rebranded COVID-19 Public Health Division: deputy secretary in charge of case, contact and outbreak management. She was part of a bureaucratic surge force which, over the next two months, would supervise the rebuilding of Victoria’s frontline COVID response while the pandemic raged around them.

She shared her new role with Wallace, who as chief of Safer Care Victoria for the previous four years had developed a deep knowledge of the strengths and weaknesses of the DHHS. When the sprawling health bureaucracy is broken up early next year, Wallace will be secretary of a streamlined Health Department while Pitcher will run a new Department of Families, Fairness and Housing, which takes in what used to be known as Human Services.

The other reinforcements called in by Eccles were pinch hitters from DPC. Jeremi Moule and Nicola Quinn were made deputy secretaries overseeing a renamed COVID-19 Public Health Division. Houghton, took the lead on policy. Jeroen Weimar came in from the Department of Transport to take over testing logistics. Terry Symonds, also a deputy secretary, was seconded from another part of the health department. In effect, Victoria’s public health response was placed under DPC administration.

An empty Federation Square in Melbourne on August 26.

An empty Federation Square in Melbourne on August 26.Credit:Getty Images

Wallace tapped his hospital and health contacts for some of the state’s top infectious disease experts; Allen Cheng from The Alfred hospital, Paul Johnson from Austin Health, Rhonda Stewart and Michelle Giles from Monash Health. While Sutton was kept as head of the public health team and in his prominent, front-of-house advisory role, the Victorian government now had the backroom of health and clinical expertise it had lacked. And no one had any doubt that the Premier was in charge.

The government response took on the shape of a rolling election campaign, run out of the Premier’s office. It was designed to control two things: the virus and the message. Ratcliff and deputy Jessie McCrone, who together ran Labor’s 2018 re-election campaign, started their days in 6am media strategy meetings and finished at midnight after receiving the latest updates from the public health division. Andrews began his marathon run of daily press conferences and other government ministers disappeared from public view. On most days, Pitcher, Wallace, Moule and other key figures embedded in the health response reported back to the Premier in Zoom meetings.

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‘‘I have worked in Premier and Cabinet for years,’’ Pitcher says. ‘‘The attention of the Premier and his office on this issue was laser-like. I was never left in any doubt about what the top 10 priorities were and they were all in my world.’’

Everyone and everything was thrown at the problem. Evidence provided to the parliamentary inquiry into contact tracing shows that, at the time of the Premier’s July 12 intervention, there were 452 people working in case, contact and outbreak management. By the end of July, that number had more than doubled, with an influx of 183 ADF personnel to help with logistics and more than 200 additional bodies provided by labour hire companies Health Direct, Helloworld and Stella.

Local health units were belatedly formed to push the public health response out of 50 Lonsdale Street and into the suburbs where the virus was now threatening aged care residents and staff. But Pitcher and Wallace quickly realised the problem wouldn’t be solved just by adding more people.

‘‘We had enough humans doing contact tracing,’’ Pitcher explains. ‘‘We had choke points that were far more boring; data entry choke points and people doing interviews and not having enough time to get that data into the system.’’

These systemic issues weren’t unique to Victoria, but only in Victoria were they being exposed by the volume of second-wave COVID-19 cases. ADF personnel helped with the data entry and for a while, tens of thousands of negative results coming in each day were kept out of the PHESS database.

Although this helped, Victoria needed a more substantial fix. Pitcher had what she describes as her scariest conversation with the Premier: a proposal for contact, case and outbreak management to shift to an entirely new data management system at the height of an epidemic. It was like trying to repair a jumbo jet while the plane was in the air. If they pulled it off, they would bring Victoria’s response to public health emergencies into the 21st century.

The Premier approved the plan. Pitcher and Wallace started talking to Salesforce.

Deputy Chief Health Officer Allen Cheng.

Deputy Chief Health Officer Allen Cheng.Credit:Simon Schluter

Across the beleaguered DHHS, the Premier’s decisive intervention was welcome. It was also fatally late. A week earlier, on July 7, there had been no active cases in Victorian nursing homes. On July 13, the day bureaucratic reinforcements arrived, there were 28.

Sutton was not available to be interviewed for this story. In response to questions from The Age, he defended the performance of his public health team.

“As the second wave developed in Victoria, our case and contact tracing management capacity faced the same challenges that any public health team would have. As numbers grew, the ideal response to any and all cases and their contacts [became] harder to maintain – any jurisdiction would have struggled with the rate of growth in cases that Victoria faced.”

Professor Allen Cheng’s first day as Victoria’s acting Chief Health Officer was July 30, a Thursday. He remembers this because when you decide to tell the Premier he needs to lock down his entire state as a matter of urgency, it’s not a first day on the job you easily forget.

Cheng was not new to Victoria’s pandemic response. As the director of infection prevention and healthcare epidemiology at The Alfred and professor of infectious diseases epidemiology at Monash University, he had sat alongside Sutton on the AHPPC. But he arrived at 50 Lonsdale Street unburdened by past decisions. Where Pitcher and Wallace were focused on improving Victoria’s outbreak response, Cheng was worried about the bigger picture.

‘‘One of the first realisations I had coming in is contact tracing is only one tool,’’ he says. ‘‘There is limited capacity to do it and you need to be able to find a case. Every step along the way there is delay and the risk you might miss someone. When there were lots and lots of cases out there, it was becoming less effective as a tool.

‘‘What I thought very early on is whatever solutions we might come up with to fix the capacity of contact tracing or the turnaround time for tests … would probably break if we had twice the number of cases. And all the problems we had would probably be fixed if we had 100 cases a day instead of 500 a day.

‘‘We needed to do something to get those cases down to give ourselves a fighting chance. We needed the population to stop transmission and that is when further restrictions were required.’’

This put Cheng at odds with the public position of Andrews and Sutton, who had spent that week defending existing policy settings. Just a day earlier, Sutton had questioned whether tighter restrictions were the solution.

‘‘It may well be that it’s an awful impost on the economy and on people’s lives with no material benefit if we go to a New Zealand-style lockdown,’’ he said. ‘‘I wouldn’t make assumptions that a harder, more constrained lockdown is necessarily the way to go.’’

Cheng was convinced nonetheless, and adds he wasn’t the only person in the Public Health Division to hold this view. He made his case to the division’s leadership team and that night found himself on a Zoom call talking directly to the Premier.

‘‘It was a pretty intimidating moment, I have to say. I have no idea what he would have thought about it. It was literally the first time I had met him.’’

The Premier wasn’t immediately persuaded, but an important seed had been planted. On August 2, stage four restrictions were announced. For the first time in the state’s history, Melbourne was subject to a curfew. At 6pm on a Sunday night, Victoria was officially in a state of disaster.

Tomorrow: The way out.

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