As the Avalon cluster in Sydney’s northern beaches continued to swell this week and a new outbreak took hold in the city’s inner west, NSW’s recent run of good luck had come to an end. In just over two weeks, the state had gone from zero cases to 173.
Friday brought three new locally acquired cases, all in western Sydney with no known links to the Avalon cluster.
The state government’s goal is not elimination of the virus – an almost impossible task so long as Australia’s border remains ajar to people and imports alike and NSW is responsible for almost half of all returning travellers, quarantine or not.
Instead, Premier Gladys Berejiklian is relying on NSW’s juggernaut public health operation to track and trace chains of transmission rather than locking down the entire state or its capital of 5.23 million people at every sign of an outbreak.
“We know that until there’s a vaccine that’s rolled out to the vast majority of the population that we’re going to have to live with COVID,” Ms Berejiklian said. “So the strategy we’ve taken in NSW is how can we firstly maintain public health and safety, without putting unnecessary stress on our citizens.
“We have to really make decisions on the basis of how can we keep a COVID-safe existence whilst keeping the economy open and that’s a fine line we’re balancing.
“We are planning, not just for the next six months and 12 months but also for the next three or four years.”
It’s a controversial move even among infectious disease epidemiologists, and difficult to separate from the inevitable emotions and anxieties more contagious than the virus.
On Tuesday morning, just hours before the fate of the New Year Test at the Sydney Cricket Ground was to be decided at a board meeting of Cricket Australia, Berejiklian phoned chairman Earl Eddings. Her trusted Tourism Minister Stuart Ayres, known for his love of sport, asked the Premier to call Eddings and reassure him that NSW was comfortable with the Test going ahead.
Ayres says he knew it would take a call from the top to calm the board. “I had been speaking regularly to Earl Eddings but nothing really trumps hearing it from the Premier,” Ayres says.
By 10pm, Cricket Australia confirmed Sydney’s iconic Test would start as planned on January 7 with reduced crowds. The decision was applauded but also derided.
The match was going ahead, yet people across greater Sydney were being told to cancel New Year’s Eve parties and restrict visitors to their homes to just five people. Questions were raised about the NSW government’s strategy for keeping the state safe but also open.
Ayres says the decision was less about the Test and more about sticking to the course set in NSW. “The SCG Test should be seen through the wider lens of how NSW has managed COVID over the past nine months,” Ayres says.
“The Test is a demonstration of NSW’s strategy which has been about striking a balance between health and the economy without taking unnecessary risks. We made the investment in health at the beginning of the pandemic to make sure we can handle any surge and because of that we can cash in that dividend and not have to lock down.”
It’s a decision that has exasperated many who cannot reconcile a five-guest limit at households with a crowd of 24,000 at the cricket.
“I just can’t justify those differences,” says Dr Ian Norton, an emergency response expert and former head of WHO’s emergency medical team initiative. “It smacks of being political.”
“We know mass gatherings are effectively super-spreader events and we’re going to have people sitting and shouting in a stadium when we have unmanaged chains [of transmission] in Sydney,” Norton says.
For Norton, playing a Test match with no spectators is a far more reasonable restriction than a city-wide lockdown.
“Lockdown is the very bluntest tool and should only be used when all public health efforts [to contain spread] have failed and at the very end of sequential risks,” he says.
“The mantra seems to be ‘go hard go early’ but that’s not required,” describing Sydney’s current circumstances as a “modest cluster”.
“If a population is well-messaged and part of the conversation they are more likely to comply with incremental increases [in restrictions] and also expect them to drop away as soon as possible when the risk passes.
“If not then they can lose faith in the system … if they feel [a lockdown] is not required and it’s being done for other reasons then you’ve lost them and it’s very hard to get them back.”
Epidemiologist and public health consultant Dr Henning Liljeqvist says now’s the time to enforce harsher restrictions on Greater Sydney.
“It’s better in my view to come down heavy early and then lift restrictions gradually,” he says.
The preferred option would be targeted, harsher restrictions that further limited gatherings and movement and mandated face masks in high-risk indoor public areas which “wouldn’t allow [the cluster to grow much further],” he says.
The other option would be a total lockdown of no less than two weeks, ideally with a staggered easing of restrictions, with each step linked to community transmission and testing thresholds similar to Victoria’s strategy during its second wave.
“But the decision is a difficult one for those in a position to make it, with great consequences on mental health and physical health problems separate from the viral pandemic,” Liljeqvist says.
“Remember also that I don’t have access to all the information available to people sitting in the control room at NSW Health. Contact tracing efforts by NSW Health are working really well but there is a great probability they will be overwhelmed.
“Almost all cases are linked to a specific cluster, which is encouraging because we know where [those infections] came from. But there is always the chance of people being infected in the community and a super-spreader event occurring.”
He says it is “reasonably likely that we are only detecting one third of cases”.
Masking the problem
With the Test announcement came more pressure for the government to make mask-wearing compulsory. On the back of the two clusters in Sydney, Victoria has not only slammed its borders shut to NSW but also mandated masks in all indoor venues.
Berejiklian has resisted pressure from epidemiologists, the Australian Medical Association and the Labor Party to mandate masks, insisting she is trying to “strike the right balance”. She has also made it clear that she would make necessary changes to any policy decision if the health advice dictated it.
Labor has been urging Berejiklian to mandate the wearing of masks on public transport for months but there has been reluctance within the government. There is no ideological opposition to compulsory masks, government insiders insist, but it is a complicated proposition, because social and equity issues around access to masks need to be taken into account, as well as the health benefits.
Chant’s advice to the government has been consistent – masks are only one line of defence and not the silver bullet. But the government is prepared to change tack should Chant recommend it. This includes consideration of further lockdowns.
One insider says: “Masks have become ultra-politicised but it is simply not that Labor is pro-masks and Liberals are anti-masks.”
Liljeqvist understands Berejiklian’s position. “I don’t like laws telling people to wear masks,” he says, acknowledging that it was preferable to have a willing and compliant community rather than one forced into action.
“But under the current circumstances, yes, make masks mandatory in public indoor settings,” Liljeqvist says.
One government minister says while the northern beaches lockdown had so far proven to be effective, it was a unique situation that could not be easily replicated. The geography of the area, as well as its socio-economic makeup, made it an easy decision.
“But the reality is, had the same outbreak happened in Campbelltown or Fairfield or Penrith, would we have made the same decision? I doubt it,” the minister says. There was also no benefit in comparing Victoria’s second wave lockdown with the NSW situation, the minister says.
One insider says Victoria was experiencing hundreds of mystery cases each day during its darkest periods, while there are clear links in NSW’s latest clusters. “This is our reality now. We can’t keep opening and closing every time we have an outbreak.”
Mandatory hotel quarantine would also be a reality for years to come – long after a vaccine has been rolled out across Australia.
Earlier this week, Australia’s Chief Medical Officer Paul Kelly said Australia’s vaccination approval process was “on target” but “vaccination will not be an alternative to 14-day quarantine”, he said.
While some countries were already vaccinating their citizens, other parts of the world would be far slower to distribute effective vaccines to their populations.
For a global gateway city like Sydney, the only option is to strengthen its quarantine systems.
“The biggest threat to us is international travellers in quarantine, which we assume is the cause of the latest Sydney outbreak,” Liljeqvist says.
Liljeqvist and Norton are part of an alliance of infectious disease and emergency response experts pushing for the state government to implement screening with rapid antigen testing of all personnel working in the quarantine system – from security guards and drivers, to cleaners, caterers and nurses.
“We would be able to have much greater confidence then that they weren’t taking the virus home to their communities,” Liljeqvist says.
It may be the strategy that could prevent the next cycle of outbreak risks and the spectre of lockdowns NSW had hoped would be a relic of 2020.
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Alexandra Smith is the State Political Editor of The Sydney Morning Herald.
Kate Aubusson is Health Editor of The Sydney Morning Herald.