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Episode 8: Lost Voice - COVID's impact on eliminating malaria

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Tracy Parish: When the world’s attention shifted to COVID-19 it put some communities at risk, more so than the pandemic itself.

The years of effort that had gone into shielding them from other diseases was suddenly in danger of neglect.  

Dulcie Lautu: We may end up losing the gains that we as a country have made with malaria in the past 10 years.  

Tracy: That’s malaria researcher Dulcie Lautu. She’s right in the thick of it in Papua New Guinea and the COVID complications Dulcie talks about are also being felt in other places that are prone to Malaria, like Kenya.

Herbert Opi: COVID just adds another layer of complexity to what people are really finding very difficult to deal with even under normal circumstances.

Tracy: Burnet’s Dr Herbert Opi is a Postdoc scientist and he’s experienced firsthand the kind of havoc a disease like Malaria can wreak, even before COVID came knocking.

Herbert: It kept me down for quite some time. I got the initial infection, got treated two weeks later, it came back, and I was quite sick for a while – hallucinations, headaches, and shivers and that was and that was without even getting admitted to hospital.

Tracy: Across Africa the human cost of malaria has been unimaginable.

Herbert: In places where there was historically a lot of admissions from young children dying from malaria, I think that is very troubling in a sense. It kind of makes you think, what could be done better?

You never really want to see young children - those very early years dying from malaria. Something that we know is treatable, preventable, but just the complexity of malaria and resource-poor settings just doesn't deliver those answers to those communities.

Tracy: As the limelight has been taken away from malaria and other infectious diseases, with resources shifting and pivoting towards COVID, where has this left our fight against malaria?

James Beeson: And as it turns out, vaccines really are the thing that's going to enable us to combat COVID and return to pre COVID world. We haven't had that for malaria and it's incredibly hard to get funding for malaria.

It saddens me that we, where we are now, we could have been five years ago. We could have been 10 years ago.

Malaria elimination is a dream. It's not a must. It's not, we have to achieve malaria elimination. COVID, is we have to eliminate it.

Tracy: This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish.

Throughout this series, you’ll meet some of Australia’s visionary scientific thinkers.

You’ll find out what keeps them awake at night as they grapple with a pandemic – and how science is playing a leading role in shaping our response.

My co-host is Professor Brendan Crabb, head of the Burnet Institute, a microbiologist, malaria researcher and one of the best minds in infectious diseases and global health.

Today, Lost Voice: COVID’s impact on eliminating malaria.  

James: I guess for us working mainly on malaria and other diseases that affect resource limited countries, we started to think about the wider impacts of COVID on some of the diseases that we work on, like malaria.

And for me, having worked most of my career in populations that have limited resources and are impacted by infectious diseases like malaria, TB, issues of nutrition - I really started to think about what was the impact of COVID going to be in those communities.

Hi, I'm James Beeson, I'm a deputy director at Burnett Institute and I work on malaria and maternal and child health.

The impact in countries like Australia is bad enough. We've got one of the best resourced health systems, and we're a rich country.

In countries with much less resources in remote and rural populations in resource limited areas in Africa, or in parts of Asia, Papa New Guinea, the impacts could be huge. And that's what really concerned me at the time.

Tracy: But as the COVID cases skyrocketed ­with increasing numbers getting out of control, something else also caught James’ attention.

James: What was some surprise, was it was slower impacting many African countries and there's been a lot of discussion about why that was. And we still don't completely understand that, and we have to give credit to some African countries that took steps early to try and alleviate the impacts.

They could see that COVID was going to be a potential disaster. I think also somewhere Papa New Guinea made an early call to stop international flights, to stop international movements because they knew they would struggle to deal with the impact of COVID, and that did protect them for some time, which was helpful in buying time to get prepared for the impacts of COVID.

Brendan Crabb: I was going to ask you James about Africa and why it did well pretty early on and of course Africa is many countries, but at least some countries did very well, not all.

Is that just that they're, battle-hardened when it comes to pandemics, do you think that had something to do with it? Whether it's West or central Africa and Ebola outbreaks and so on, they seemed from this far away to click into gear a bit.

James: That's part of it probably in some places. But there are a range of other factors - a lot of interactions and activities occur outdoors. Markets are often outdoors, a lot of social gatherings and things like weddings and other celebrations are often outdoors, are not in a completely enclosed space. So that's probably a factor.

More of the population are younger, especially adolescent age group and children who are less effected by COVID. So that's a factor.

Some of the experiences of African countries and African communities with things like Ebola, more recently, but also things like cholera pandemics had prepared people to respond and that having to respond was not something that they hadn't experienced before.

And I was just speaking to one of my students, who's from Africa, she commented that they'd been through similar sorts of lockdowns and restrictions before for other reasons like cholera.

Brendan: We've been exploring a bit through this series, the notion that those who have done well aren't necessarily the wealthiest countries.

In fact, it doesn't seem to be a great correlation in this part of the world. Some of the Asian countries and Southeast Asian countries have done very well. Some of those are reasonably wealthy, some of those are not. And I guess that's extended out to Africa as well.

And of course, mainland Europe and the US have done very poorly, and the UK of course, and they've got lots of resources. There's some big lessons in managing pandemics, I imagine in all of that?

James: There is another interesting angle and that is the way the immune system functions in different populations.

We're all the same. We're all got the same immune system, but our exposure and our experiences during life influence and shape the immune system.

So, one theory, which is not being pursued and something that we're trying to work on is that it's possible that a lot of exposure in some African populations and other communities say in PNG for example, a lot of exposure to different infections has shaped the immune system so that it responds in a different way.

So, it's plausible that this has influenced, how the immune system responds to COVID and the impact of COVID in those communities.

So that's something that we're trying to understand - we don't have the answer yet, but there are plausible explanations there.

Tracy: And does that happen at birth? Or is that in the first five years of life, or where do you think that change happens?

James: Bottom line is we probably don't know the answer to that yet.

How much of it was your exposure in early life, how much of it is ongoing exposure?

And so, we do know that if you get a serious infection, it will change your immune system. How long does that last, we don't really understand terribly well, how long that lasts.

If it happens multiple times over years, does that become imprinted? So that you're really set then on a course of the way your immune system responds

Tracy: And there's been a lot of distress by pregnant women around the world about the impact of COVID. But do we think that there might be a link down the track that they will create antibodies, for example, for the newborn?

James: When you get an infection in pregnancy, or if you get a vaccine in pregnancy that could generate antibodies that are then transferred to the baby.

So, a good example of that is tetanus. Hopefully we've all had tetanus vaccines.

The idea is that it protects us against an infection, that the bacteria creates a toxin, which has terrible effects.

When a baby's born, they have a cord and the cord gets cut, they could get an infection and they could get tetanus. So, a vaccine was developed to combat that, that's a tetanus vaccine.

So, around the world, we give that vaccine to pregnant women. They generate antibodies. Those antibodies go into the baby, protects the baby.

So that the concept is established.

Given that young children are not, hugely impacted by COVID. For reasons, we don't fully understand, they don't get as sick. It's probably not something that we would use for COVID, but it is something that's being explored for other infections.

Brendan: This point about people with different immune systems having different outcomes. I assume you're talking about disease severity rather than actually whether or not you get infected.

And why is it that disease severity is related to our immune response?

James: We know that there are mechanisms that exist that could explain, moderation of the immune response through having had other infectious diseases, that then has an impact on how the immune system combats COVID.

We don't necessarily know exactly what's happening there. But it could reduce the infection, could stop you getting infected potentially, or it could reduce the severity

Brendan: When you're starting to need to go into hospital and potentially need oxygen, what's going on? As a non-clinician looking from the outside, there seems to be an inflammatory response that's more important than the virus numbers.

James: We have to think about the immune system in the two sort of fundamental components. One is what we call the innate response. The immune system will just respond to any foreign pathogen or infection.

The advantage is it’s rapid. It will happen, within a couple of days. The downside is that it's relatively non-specific, so it will just fire away at whatever comes along.

So as a result, you can imagine if it fires away too much, it's like a blowtorch and fire gets out of control - it can cause collateral damage.  So, there's an advantage of this innate response, it's our first line of defence, it happens quickly, and it works against viruses. So that's a really important one.

The second part is what we call the adaptive immunity and that's what vaccines do. So, we say, what happens is you get an infection, your immune system generates this response that encodes a memory of that infection. Or you get a vaccine, the vaccine stimulates an immune response, and it encodes a memory of that organism.

Then let's say further down the track, you get exposed. This what we call adaptive immunity brings back the memories and says we've seen this before; we know what to do here and it blocks the infection.

So, the innate response is what our immune systems are firing when we get an infection, whether we get COVID or something else.

So, if the tuning of that response is wrong - it's too much of certain components. You can get really sick.

Tracy: It’s scary to think that we could set off a blow torch in our own bodies.

So, does this go some way towards explaining the different immune responses to different vaccines?

Some people have not had a hint of a symptom, while others have needed over a day in bed.

James: At the end of the day, we all have different responses to vaccines and

when we look at vaccines, we tend to look at the whole population. So, we vaccinate 2000 people. How well did it protect? And we go it protected it by 80%, but we don't necessarily know why didn't that protect in those 20%.

We can dig deeper, and we can say in the 80% who were protected, they didn't get sick. Some actually didn't get infected at all. Their immune system fought off the infection, completely cleared it. And for some, they got infected, but they controlled it. And what's the difference between those two?

It's that level of fine detail that we don't have a lot of knowledge on for most vaccines, because we tend to look at the whole population or a larger group. It’s digging down to those fine details and there may be answers there for next generation COVID vaccines, but also for things like malaria vaccines.

In a malaria vaccine, we see level of protection of more like 50%, even 30% depending on the group. It's more profound because you see some people respond very poorly.

In other words, their immune system doesn't fire up after having the vaccine very well at all. And in others in particularly in children, you see the immune system fires up and then it disappears rapidly. So, they don't sustain that immunity and we just don't understand that level of detail right now.

And that's a huge barrier to getting the sort of level of protection that we need to eliminate something like malaria. That knowledge is being developed around COVID to get next generation vaccines or refine current vaccines to get better control in populations and eliminate COVID.

Brendan: When COVID first came about.  the world was still very much focused on malaria as one of its biggest infectious disease problems.

Why is it still such a big problem and why when COVID came, did we worry about it more than if COVID wasn't here?

I know we both stressed a lot about COVID, but also about blimey what's going to happen to malaria, to HIV, to TB, especially in the developing world.

Can you paint that picture a bit for us?

James: For malaria, what we've seen was a concerted global effort and increased funding and that increased funding kicked in, in the early 2000s.

And we saw over a period of about 10 years, some reduction in the global burden of malaria. But then tracking the numbers from about 2014, 2015, there's really been no decline.

So then along comes COVID and we are already seeing in some places increasing malaria.

So, we are going to see increasing malaria in many countries, in many populations, and that's going to be harder to get back under control. Especially in an environment where there may be less resources around that been diverted to COVID and that's a reality.

It's going to be hard to, claw back those gains and get back to where we were before the COVID pandemic.

Tracy: Winning back those gains – now seems just so out of reach.

We’ve already had bleak reports that state eliminating TB has now been pushed back 12 years.

We don’t know where malaria will land in the ashes of the COVID inferno.

So, what are the chances that the malaria response will actually ramp up?

James: Countries and national departments of health have had to divert a lot of resources into combating the COVID emergency and to dealing with that. And that's having an impact on diseases like malaria and TB and the timeframe for elimination, or at least maintaining control of maintaining status quo is going to be impacted.

Brendan: Yeah. It's not the first time we've faced a malaria elimination campaign that has stalled.  In the fifties and sixties, of course it went really well and for various reasons it stalled badly.

And one of the lessons there that shocked, I think even the people who worked on malaria was the speed with which it came back. So, there are all these other infectious diseases that you spoke about, that we're worried about, but it's hard to imagine any of them coming back with the speed that malaria does.

Are you worried about it this time that we see a sudden surge in malaria, or can we keep a lid on it?

James: Historically that is something that we really worry about, isn't it? Particularly in the 1900s, in the forties, fifties, sixties, there were countless examples of countries that got malaria right down and then resources were diverted away and then we got an explosion.

In some cases, the numbers went to higher than they were before the elimination campaign started. So that's a big issue.

Look, on the positive, there are some countries that have recently been declared themselves malaria free, and there's some really valuable lessons to learn from those countries.

Tracy: Including China.

James: Yeah, China has done huge work in wiping out malaria, Sri Lanka recently, going back a bit further Algeria, and there's some really great lessons to learn from them about how they achieved that.

I think history shows that gains can be made against malaria in many places through intensified efforts, but our gains are relatively brittle. They reverse quite quickly, and malaria is very different beast to COVID.

It's not transmitted directly from person to person. We walk around Melbourne with masks on to prevent direct person to person transmission.

We don't need to do that for malaria because it's transmitted by mosquitoes. And if there was a mosquito buzzing around in the room now, and I had malaria and it bite me, it couldn't transmit it to you.

It would have to develop for several days in the mosquito first, before that mosquito becomes able to infect someone else. So, it's quite complex.

It's surprisingly complex and it's surprisingly durable this impact of malaria. It has persisted, for tens of thousands of years and there are other species that have evolved with us since the dawn of humanity. So, it's an incredibly enduring and resistant pathogen that’s lived and co-evolved with humans.

I think there's two elements to the achieving the malaria elimination. One is the funding level and that global commitment and the commitment from governments to implement things that we know work.

But there are still missing elements that we need research to provide the answers for. Ultimately a really highly effective vaccine, could be a silver bullet.

If we had a vaccine for malaria, like we have for another childhood infection like measles - very highly effective, 90% of protection lasts for several years - that would be a silver bullet for malaria, but we don't have anything near that level yet.

That's gotta be a goal for the future.

Brendan: We have good testing and treatment protocols for malaria. They're the things that have made the big gains. What, why isn't that enough?

I just want to explore why the current tools maybe can't do the job.

James: The current tools can get us progress, but the limitations are, we've got increasing drug resistance.

So, the drugs that we use become less effective over time and we're seeing that spread particularly in Southeast Asia and increasing elsewhere. We've had reports in PNG of drug resistance to the main drug that we use Artemisinin and that's one factor.

Then, bed nets rely on the use of insecticides treating those bed nets and we're seeing in some places, frightening rates of insecticide resistance. So those nets become less effective.

Brendan: So, this is the mosquito's actually becoming resistant?

James: Yes, the mosquitoes becoming resistant to those insecticides and similarly for spraying of insecticides in houses and dwellings to try to kill mosquitoes they're becoming resistant, or they change behaviour.

So, another example is, you sleep under a bed net at night, walk around with a bed net on you. So, mosquitoes shift to daytime biting. It's just natural selection.

If you're using an intervention that combats mosquitoes that bite at night, you'll select for those that don't bite at night. And we've seen that in many places around the world.

We've got tools that have partial effectiveness. We have to acknowledge, they really are valuable, but they're not the solution. Yeah, they’re not enough.

Tracy: What all this means is that a vaccine for malaria is vital, but how are we able to develop a COVID vaccine with blazing speed, yet one for malaria has been decades in the making?

Just how complex is it to find an effective vaccine for malaria?

James: There are two elements to the malaria vaccine - it's a tough challenge

much tougher than COVID.

So, when COVID hit, there was a global response from governments around the world, from pharmaceutical companies, from the big pharmas, from biotech companies and from the research community and academic community.

There had to be a solution for this, and the solution had to be vaccines.

And as it turns out, vaccines really are the thing that's going to enable us to combat COVID and return to pre-COVID world.

We haven't had that for malaria and it's incredibly hard to get funding for malaria. And it saddens me that where we are now, we could have been five years ago. We could have been 10 years ago.

There's such a delay in having a breakthrough or having some major advance to getting funding to progress that, it's a several year process that it slowed our progress towards getting a vaccine so much to getting more effective vaccines.

Tracy: And how much of that is because it's not in our backyard. We talk about 400,000 people die every year of malaria. We've got something like, a couple of million people are suffering from malaria at any given time.

Is that the thing? COVID was in our backyard, both in the UK and in the states and Australia and obviously globally as well.

It's over there it's in developing countries, is that part of the uphill battle that you face?

James: We see that play through commitments of global leaders and those leaders with funding. We also see it play through even things like the journals that publish results and that give attention and raise awareness about diseases.

There's less focus and there's less attention given to diseases affecting less resourced communities, underrepresented communities.

And we've seen that play out a little bit with the Black Lives Matter movement. Publishers recognising that they could do better. That was pre COVID and I'm not sure how well that's going to be sustained, time will tell.

So, that's one factor, certainly that doesn't affect the resource rich countries that have the resources to invest in funding.

It's also the other is that it requires pharmaceutical companies or biotech companies to invest in new drugs or vaccines for Malaria and they're not financially as attractive as many other things that they could invest in, whether that's COVID or whether that's new treatments for cancer or auto immune disease or other things - drugs for mental health.

So, that's a big factor as well. Another example is even in the diagnostics field, we need tests for malaria, where they have to be super cheap. We're talking about a dollar each. And that's a really tough margin to work with for diagnostic manufacturers.

So, if along comes a disease like COVID and that's offering a much better financial return, better financial security for those companies, you can imagine that's going to draw them away from making large numbers of tests for malaria that have a very small profit margin.

So, there are these sorts of economic drivers as well.

The one other thing I would say is that, because malaria has always been with us there's almost an acceptance.

And I would say, malaria elimination is a dream. It's not a must. It's not, we have to achieve malaria elimination. COVID, is we have to eliminate it. We have to control it, but that's not necessarily the same thinking for malaria, it's still a dream.

Brendan: Really great point and I guess I'd just add in having thought about this myself a fair bit, part of the answers to the question you raised Tracy about, is it neglect for population is actually being played out in COVID as well.

Just because we do have a vaccine doesn't mean it's in the arms of the poorest hundred countries in the world who at the moment still stand at less than 1% vaccinated and are many years away from dealing with COVID in the same way that the more developed countries are.

So, it's there as well. We've seen it with HIV. We've had solutions for HIV for a long time that have largely dealt with it in a country like ours, yet it's a major problem in the developing world.

So, it doesn't necessarily play out that even when there's a technical solution that's in any way equitably distributed. So, the story of malaria as a problem can be told through even the successes of COVID and HIV that we’ve faced in the past.

But James, you mentioned your frustration around funding and us needing to find a solution, but also that malaria is a technical challenge at a different scale to COVID.

I'd like to explore that a little bit more. Why is it so much harder?

James: It's easy to look at COVID and the speed at which the globe has developed several vaccines against COVID and think, okay, this is obviously something that we can do for all pathogens.

But malaria and other organisms like HIV, other diseases like HIV, TB, are much tougher.

And for malaria if we contrast them - malaria versus COVID. COVID, the vaccine targets one protein or one part – a protein is a component that makes up the virus - that targets one part of one protein of the virus. That's it. That's what the vaccine developers had to work on.

And as it turned out the solution to getting a vaccine, based on that one protein was relatively straightforward, using the concepts that have been around for centuries really. For malaria, we don't have that simple starting point.

There are actually about 5,000 proteins that make up the malaria parasite organism. We've probably got more like 50 to a hundred possible what we call candidates or proteins that we could target with a vaccine.

And so, this has created a bit of a barrier.

So, firstly, there's a question of complexity, which one do we target? Or do we need to target multiple? So, if you start to think of, let's say, 50 different proteins, and we might need a combination, you can see already there's going to be hundreds, thousands of potential combinations that we have to test.

I think to some extent there's a bit of a, kid in a lolly shop effect. You go into the Lollyshop or candy store, and there's all these choices, all these things you'd like to try and that diverts you away from focusing on a smaller number of things.

And I wonder in retrospect, whether we might've got further with malaria vaccines, had there been a much more concerted focus on a smaller number of vaccine targets.

Brendan: I know you're a global leader in understanding why and how it is that some children after they've been exposed to malaria a lot become immune. They don't get sick anymore from malaria, they still actually get the parasite, but they don't get sick.

And you're interested in using that knowledge to help make a vaccine. How does that line up?

James: Overall, our objective is getting a vaccine that is highly protective and long-lasting - can last several years. So, there are three elements that we're particularly focusing on. So, we need to understand what is it about the immune system, what are the functions or actions of the immune system that are needed, to get that optimal immunity, optimal protection.

We know that we can focus on one element and get some protection, but what we're looking for is, 80% protection, 90% protection as seen with some of these COVID vaccines or a vaccine like measles.

So that's one element. What is it about the immune system? And our line is, and our data, our findings suggest that we need multiple components. It makes sense, you want to maximise what the immune system has to offer.

Not everyone responds, not even everyone generates the right sort of response to the vaccine. We're particularly see in African kids that a lot of kids don't develop a good response to a vaccine. We have to understand why that is.

So, that's another element of our work, so that if we've got the best vaccine, everyone responds well, it works well in everyone. So, we're not leaving some people behind. So, that's an important element.

The third element is understanding, what is it specific element or component of malaria, the immune system should target to get the best response.

Tracy: James dedicated his scientific life to conquering the malaria puzzle.

It was after seeing the devastating impact of malaria on pregnant women in Malawi and Kenya. His early days in medical training became a turning point as he went from a medical career – into research. 

James: Really my first experience was when I was a medical student, and I went to Malawi and worked in a hospital there for a short time. That was at the height of the HIV pandemic. Malaria was very high, higher than it is now and TB a massive problem.

And really just seeing, firsthand the extent of the problem and the impacts on the community really convinced me then that's what I wanted to focus my career on. The other lesson I learned was there was only so much I could do as a highly specialised, highly trained single clinician working in a context like that.

What I felt was I could achieve more, have a bigger impact if I focused on public health and research and training.

I guess that the other thing is as a clinician, when you're at the bedside, talking to a patient is you think, how could I have prevented you from ending up here.

Of course, you're thinking, how am I going to treat this person? But you're also thinking, what was it that led to them becoming sick and how could we stop that in the first place?

So, that's always been a strong part of my thinking and that led me to move into research.

Tracy: Is there someone that stays in your mind, is there a young child or a mother or a case that still stays with you?

James: I think that's it's various memories of working in an antenatal clinic and seeing dozens of pregnant women each day and get the tests back malaria, repeatedly. People getting treated for malaria and still being infected - it not clearing - those sort of memories stay with you.

Every day there are literally tens of thousands of parents waking up with a sick child who has malaria or who you don't know if they have malaria. And you're having to work out, where will I get my child tested? How will I get treatment? Will the treatment work? are they going to get really sick? That's happening to hundreds of thousands of people millions every year.

Brendan: With so many more people getting malaria each year and it's not the common cold. How does it impact on communities to have malaria through their children, through their adult populations?

James: Yeah, with over 200 million cases per year it's a huge impact. There are so many ways it does impact. Kids getting sick and they don't go to school.

Many areas where malaria is most prevalent are the areas where families have the lowest financial resources and other resources. A single episode of malaria illness that requires them to go to a healthcare centre - it's time away from work, it's time away from farming for example, it's the cost of transport to get there, it's the cost of going to the clinic and paying for drugs, which many people have to or going to purchase drugs?

These are huge impacts on the, that microeconomics of the family and it can be a breaking point. If there are several episodes in a year, it really can be a breaking point.  

Tracy: Malaria for many people has been a driver of poverty.

An endless loop where they get chronically ill, can’t go to work, can’t go to school.

How an earth does anyone ever get out of that? 

Brendan: Twelve hundred of those kids will die each day. It's still a major human tragedy. And I know you're very interested in solutions there, but I know that what really drives you is societies being more equitable.

And I find that link between infectious diseases as a barrier to communities and countries progress absolutely fascinating. Is that still a major motivator for you?

James: That inequity is a big driver still, and as the COVID pandemic was evolving and vaccine development was in progress, there were a lot of tweets and messages on social media about how the vaccine was going to be for everyone, and this was going to be the people's vaccine. And we looked at that and thought that will be fantastic.

And yet what we saw was stockpiling of vaccines by wealthy countries. And what we're seeing now is rollout of vaccines in wealthy countries first and in resource-limited countries second or third.

Tracy: And on a positive, what are the big learnings to come out of COVID and the response, that malaria researchers can take forward?

James: Yeah. I think it's been a reminder of the power of vaccines. A huge reminder about how a highly effective vaccine could be a game changer for malaria.

Another is the importance of strong healthcare systems. It’s really, I think, a change of thinking from saying malaria elimination is a dream, to it's an absolute, we have to achieve it. In the same way as we're thinking we have to achieve COVID elimination.

Someone said for COVID they think regularly, are we doing enough? And are we doing the right things? And we need to be asking ourselves those questions for malaria regularly. Are we doing enough?

And of course, we can sit here, passionate about malaria, but we need those partnerships from global leaders and funding organisations.

And I think there's a fantastic opportunity and a real need to better engage communities. We need communities to be driving that, to demand, essentially their rights, to malaria treatment, diagnosis prevention and to a solution.

Tracy: And finally, James what keeps you up at night?

James: I guess the thing that worries me is, the future of the world’s children. I don't mean to sound corny with that, but you think about the impacts of things like malaria and many childhood infections are still huge problems around the world - even where we have vaccines.

Nutrition, providing kids with a healthy start to life. Life's got enough challenges as it is without all these other huge insults. I think that's something that worries me.

The other is a more local one. I do worry about the future for our next generation of leaders, with funding being so incredibly difficult for them to achieve.

There's a danger that we're going to lose some of those really passionate leaders. We've got to find ways to support them and grow their career and ensure that they can live that goal of being the next generation of leaders to carry the goals forward. 

Tracy: Just how far have we tipped the balance with malaria, only time will tell.

The way we’ve embraced science in our response to COVID may help find solutions to other infectious diseases.

HOW SCIENCE MATTERS was produced by Written & Recorded.

This is a Burnet Institute podcast.

For over 30 years we’ve been at the forefront of infectious disease research, public health, and national health security.

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FULL TRANSCRIPT
Episode 7: Modelling COVID-19 - Can we predict the future?

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Tracy Parish: When COVID-19 landed on our doorstep, we had to quickly learn new concepts, concepts that most of us had never heard of before - like modelling.

Victoria’s Former Deputy CHO Allen Cheng: A common approach to modelling is to give similar data and scenarios to different groups and see where they agree or differ. So, we’ve been looking at two models about the historic glide path, so this is this effective reproductive ratio.

Tracy: And it came down to this modelling data, whether we would be returning on-site at our workplaces, reopening bars, and restaurants, or meeting up with our friends.

Victorian Premier Dan Andrews: On the modelling, and on the evidence the data and the analysis of all of that, we believe that we will be able to take, all things being equal, the next step, which is when all the restrictions leaving your home, when there’s much more freedom of movement, we believe that we will be able to take that important step.

Tracy: Without seeing the data, many felt modelling was like a game of chance – as we anticipated the chance of an outbreak!

Mark Stoové: The government’s relying on some modelling at the moment that effectively models the chance of an outbreak, given the number of cases. What those models do is also incorporate compliance with particular restrictions and settings for those restrictions.

Tracy: And as Burnet’s Professor Mark Stoové hinted, the modelling had to shift, with our change in behaviour and the more data that was collected

This led to a lot of public confusion.

Brendan Crabb: Oh, your models were wrong because all those cases and deaths didn't happen. Of, course just skipping over the fact that the models led to policy change that prevented them in the first place.

Tracy: Whether something may or may not happen has been a huge learning curve for us all, including the scientists doing the modelling.

Margaret Hellard: You're taking a punt at what do you think are going to be the important sort of factors in the model of more than this number of people or less than this number of people going to the MCG for footie or not? Community sport being in a house or not.

Tracy: So, what shows our modellers that there could be a 41 per cent chance of a third wave within four weeks?

How do they crunch the numbers?

Nick Scott: And we don't look at just the average number of people. We actually look at the distribution of that. So, if we think about social networks and how many friends we might have it's a really long tail distribution.

Tracy: This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish.

Throughout this series you’ll meet some of Australia’s visionary scientific thinkers. You’ll find out what keeps them awake at night as they grapple with a pandemic –

and how science is playing a leading role in shaping our response.

My co-host is Professor Brendan Crabb, head of the Burnet Institute, a microbiologist, malaria researcher, and one of the best minds in infectious diseases and global health.

Today, Modelling COVID-19. Can we predict the future?

But if you’re expecting modellers in white coats – think again.

Here’s what modelling actually involves from a scientific perspective.

Nick: Yeah, definitely not a white coat. It involves a lot of, firstly data analysis and understanding of the data. And really what models do is they can bring together all of the different pieces of data that you have, put them together in a cohesive way and use that to tell the story and to really understand what's going on.

Nick: Hi, I'm Dr. Nick Scott, the head of modelling and biostatistics at the Burnett Institute.

Tracy: You understand the story, but I was rung by a journalist who said, look could we interview a modeller, and what we'd like is to put them in front of a whiteboard and they can scribble the algorithms and they can show us how it's done.

And other than saying, I think that's very 1975. I said, that's not how it's done anymore. What do you think the public perception is of what model actually do?

Nick: I'm not actually sure, but I can tell you what we do do, and it's a lot of computer-based work. So, we set up our models on the computer, it involves writing code and sifting through data sets and incorporating them in the code.

We also do a lot of maths, and so the code consists of series of equations that determine how people will behave in the population that we're modelling.

Brendan: I would have thought, it's a pretty safe environment. You're mathematicians at heart and you're able to crunch large amounts of data and put things out and get wonderful publications.

And then along comes COVID, and if it's not the most controversial area and most powerful area, in managing the whole pandemic, it must be close to it.

Firstly, on the controversy, has that taken you by surprise? Just how triggered people seem to be by modelling outcomes and why do you think that is?

Nick: It's been really interesting because for years before COVID we would spend ages doing modelling and we would show people the models and really try and get people to pay attention to them. And we'd also go to quite a lot of lengths to get data, to inform those models.

And then when COVID hit, suddenly it flipped and everyone was demanding more modelling rather than saying, oh, we don't need modelling. Everyone suddenly wanted more. They wanted it faster. And it became the spotlight because it's such a useful tool.

I think the benefit of it just became front and centre for everybody because you can run scenarios in the model to just test things before you do them in real life, you can ask ‘what if’ questions. It's really powerful for helping decision-making.

Margaret: It doesn't surprise me that in public health and policymakers, that they suddenly go, oh, we need this. It has surprised me in the past that, despite what I would say quality models, that they've ignored them.

I should say on a certain level, it surprised me. They've been allowed to ignore things which have been really high-quality science, but they go oh it's a model, whereas now they need it.

Tracy: That’s Professor Margaret Hellard – a Deputy Director at Burnet.

Margaret: And that's the other bit that I always find fascinating is that people suddenly think they understand things that are much more nuanced because they think it's simple or easy when it's not.

You're trying to turn a milieu of numbers and stuff and information into a clear narrative to provide guidance to policymakers – it's actually quite difficult.

Brendan: So, is it fair to say, you're trying to predict the future?

Margaret: You're trying to say in the future, what are reasonable likely scenarios that will occur?

I think of models as very much like life. You're trying to understand what future risk might be.

We do it with our finances. We do it with the car we buy. We do it with the house we buy, we do it all the time in life, but don't realise we're doing it.

We're trying to understand the likelihood of something occurring in the future and the risk around that. Models are just trying to do that in a more precise way. And for COVID, you're trying to understand future risk. A, B or C might happen. Even though A might be less likely to happen, if we get it wrong, like a lockdown, or don't lock down and we get A we're stonkered. It's constantly trying to get these things right in your mind. 

Brendan: The degree of confidence we have that something may or may not happen has been a huge learning curve for all of us. But I think those in science generally live and breathe it – certainly comfortable with it.

When you present something to a government or to a policy maker, you're giving a degree of confidence and that is actually the crucial bit. Do you think that's been well, received and well understood?

Nick: It's not so much we give a degree of confidence, but we give a lot of uncertainty around things. And quite often the people in government or who we're working with, they'll want to know, 'so what's going to happen if we do this' and our answer will be well you've got a 10% chance of this, or some percent chance of this and it's this wide range.

And quite often they're looking for a single response. But of course, we know with COVID, we just need to look at the real world that anything can happen.

You can have one person enter the community with an undiagnosed infection and nothing can come of it, or you can have one person enter and everything can come of it.

So, the model needs to capture that, which means that our outcomes need to capture that uncertainty as well. So, it's very wide.

Tracy: But that breadth of uncertainty it what concerns government. Because during the lockdown in Melbourne in 2020, there were daily press conferences, so a lot of the impact of COVID was shifting and they wanted some real answers, and the public were getting really upset about some of the situations.

How hard is that for you as a modeller to keep ahead to be able to help government?

Nick: We kept framing it in a way that I think was useful, talking about the probability that strategies were going to be successful. And so, there's a lot of different outcomes that can happen, and really you can group a lot of them together and say, we don't want any of those, so let's just group them as bad outcomes.

We've got one good outcome, which is COVID zero. Let's look at the probability that will happen, then let's look at it for the different options. So, you've got different policy options, which ones have the greatest probability of getting back to there.

And that's the kind of information that can be used.

Margaret: I actually think governments, both our state and federal governments and others have missed opportunities though, about being really honest to the public and explaining the truth of going actually, there are things we can't absolutely know, but what we are aiming for is this, and so it's on the balance of probability because we don't know for certain.

So, in the same way as when I'm talking to a patient, the thinking that one might do - when a patient comes to see me as an individual, I go through with them, what may be the scenarios.

I always think we should be better at explaining our decision-making processes so that public goes, ‘I know they can't tell me till two weeks time whether we open or shut, because they don't really know’. 

It's not like the contact tracers don't know what they're doing. It's actually, because of the way numbers work, they won't know yet. And in two weeks they might not know, but they'll know more.

I don't think we did that well.

Tracy: While modelling may sound like forecasting it’s strictly a numbers game, and not understanding the figures can pose a huge risk

We’ve seen this play out in the community and in the media, with people grabbing onto one number and then later questioning why we never had 20,000 deaths

Brendan: Yeah, hasn't that happened a lot, ‘oh, your models were wrong because all those cases and deaths didn't happen’. Of course, just skipping over the fact that the models led to policy change that prevented them in the first place. So, it's been a hard series for the community to follow.

Margaret: I have often had the discussion about what's the role of media and for them to actually take responsibility of explaining stuff properly, rather than trying to gotcha people, as opposed to actually putting in some thoughtful effort to say, how do I appropriately explain to people what's going on?

A really good journalist can try to understand it and explain it well to people so that they're not gotchering and understanding complexity, to help people, particularly people who are vulnerable, marginalised, whichever words we want to describe, so that they're less anxious.

They just make them more anxious.

Tracy: And Nick, when you're presenting to government or to others, how much pushback is there? On the numbers?

Nick: They're generally accepted and there's a relatively good understanding that the model outcomes are driven by the data that goes into them and the estimates that go into them.

But in general, there's a bit of confusion in the public, probably, about the difference between forecasting and running scenario analyses.

There's a lot of models out there that do forecast and what they try and do is just predict what the numbers are going to be tomorrow or next week or next month.

And then there's a lot of models out there that are useful for policy. You can be in a situation where you've got 10 options available to you, and so you run 10 different scenario analyses looking at what happens if we did any of these.

And by definition, nine of them are going to be wrong in the sense that they won't match the data, because that scenario never actually happened in the real world.

It's just that the scenario they projected never actually happened. And so, this was the case with all the early models that were saying, we were going to have tens of thousands of deaths. And it's not that those models were wrong, it's just that they ran a scenario where we didn't do lockdowns and didn't have those responses.

And that never happened. Fortunately.

Brendan: Just on that scenario analysis, Victoria's second wave is coming to an end - very substantial second wave in this state. We were coming toward the end.

The case numbers were getting very low, and people were getting, understandably, very edgy about opening up. Been months in heavy lockdown in Melbourne. Cases were low. There's, hardly any COVID around. And the pressure was on.

Pressure from right at the top. The Prime Minister, the Treasurer and so on, saying are you guys thinking about opening up.

Those scenarios that you talked about – hey, if you open this open that – how did that play out in Victoria's second wave and what turned out to be a very smart move to keep the lockdowns going for a while?

Margaret: So, we actually had that model quite early on, even coming out of the first wave. Nick and his team, with IDM (Institute for Disease Modelling) had developed the COVASIM model. And we could see that you needed to come out slowly, but it was really early days.

I can remember sending it off to a number of state governments to say, whatever you're doing, don't come out too fast. And this is where this likelihood happens - you may get away with it, but the nature of this bug might mean that you might not get away with it.

The reality is Victoria was unlucky or the others were lucky because somebody was possibly not going to get away with coming out as fast as we did across the country.

Nick: During the second wave, there were lots of genuine decisions being made about how long do we need to hold on to this for because the case numbers were dropping.

So being able to run projections where we looked at what would happen if we released restrictions now compared to if we waited another week or another two weeks, and just seeing how firstly how high the probability of a resurgence was for doing something early, I think scared a lot of people, and also seeing the benefits of holding on for extra time.

And you do get a plateauing of benefits. So, holding on for one more week, you can really reduce your risk. Two weeks, you still reducing your risk, but there's a point where your risk is leveling out. It's not going much lower.

And these are really good indicators for when to start doing things.

Brendan: And it can get quite granular can't it. You can have X number of people in a venue rather than Y number of people in a venue, and those sorts of things, rather than just the binary lockdown or no lockdown.

Nick: We spent quite a bit of time developing the detail in the model where we could implement these sort of micro policies, so changes that would happen in very specific settings. Things like the density limits in cafes and restaurants and bars community sports, things that happen on public transport, working from home, all of these little changes so that we could actually capture the kinds of decisions that were being made by the government

Tracy: What the modellers have shown us is that we’re all part of a complex web of human connectivity, and how we behave in each situation changes the COVID goal posts.

While we might hug and kiss at a wedding for 100 people, we probably won’t do that in another venue, even with similar numbers.

So, how did our collective behaviour appear in the modeller’s playbook?

Margaret: And that's where, when we were initially setting up the original model, where you're going, what do we think will be the critical scenarios? And trying to work out, what is going to be important?

And you don't know what's going to necessarily be important. You're taking a punt at what you think are going to be the important factors in the model of more than this number of people or less than this number of people going to the MCG for footie or not? Community sport, being in a house or not.

And then something changes where you actually get some real data and you go, okay household transmission is actually probably more important than we might've originally thought - we ramp that up. But transmission over there is less important than we thought - we'll dial that down.

Also, one of the things that we were trying to do is say what how many contacts do we all have with each other and over what period of time - what's average?

When you look for true contact data, hardly any is there, we have to use data from studies 10 years ago. But now we can use more recent data from our own work because we set up studies to actually inform the models.

But it's really quite a complex business, the initial setting up, and then the constant sort of trying to adjust.

Tracy: You talked about the model and how you have to model certain scenarios. How much of a cultural lens do you apply to the behavioural differences between people and how they gather and what their general socialisation is like?

Nick: Yeah, we simulate individual people in the model and that allows us quite a bit of flexibility because it means that each person in the model can have their own characteristics.

And we don't look at just the average number of contacts that someone has, we actually look at the distribution of that. So, if we think about social networks and how many friends we might have it's a really long tail distribution.

So, there's a lot of people that might have a small number of close friends that they come in contact with all the time. And then there's groups of people that would just come in contact with hundreds of people.

And in the model, we can allocate those characteristics to individual people. What that means is that whenever we run the model, sometimes if you introduce new cases, you can get lucky and the first person who gets infected just has a few contacts, or you can get really unlucky and the first couple of people who get infected have large number of contacts.

And so, we get these distributions and we allocate it across the whole population.

Tracy: So, you have to make sure you've got a broad reach culturally, across that data?

Nick: Yeah, that's right. And some of its shown in the population level averages.

If we look at a lot of the transmissions, we need to calibrate the model to make sure that it produces what we've already observed. And so, we do need to make sure that it's reliable in that sense.

Tracy: With the vaccine roll-out marching ahead in some parts of the world, there’s a renewed sense of hope that the world may be inching closer, towards COVID normal, well at least for some.

So, what does this mean for the future of the model in the next couple of years? Will it be used differently?

Nick: I think it will change, but it'll still be used to guide the sorts of policy decisions that we'll face.

And in Australia, I think it's unlikely that we'll reach a herd immunity for COVID with a vaccine.

And so, I think we need to be thinking about what we can complement that vaccination coverage with. And so, using the model to answer those kinds of questions, I think is going to have some implications.

The other thing we're doing a lot more work of is his work overseas, particularly in low- and middle-income countries, and I think it's going to be ongoing for a long time.

In some of these settings where adapting the model so that it can simulate multiple strains at the same time and the way they interact with one another.

There's different immunities to the different strains through the different vaccines and in a lot of countries they've got three or four different types of vaccines. So, it's a lot more complex doing that work and because the vaccine rollouts are going to take a while and the virus will keep getting into those countries I think there's going to be a lot more to do there.

Brendan: So, if we don't reach herd immunity, which I take to mean, we're not just going to reach a point of vaccination coverage where we can go back to normal set and forget. So, if that's the case, which I agree is a likely scenario, what does that mean?

We don't want borders shut forever. We don't want the threats of lockdowns if we can help it.

How does modelling help us manage that post heavy vaccine, but not magic forceshield time?

Margaret: The vaccines are not going to cut the mustard. I must confess when I looked at that model first, I remember just looking at it thinking, I hope I'm not reading this, but unfortunately I was.

But we are not going to get there alone with vaccines. So, in my view, we have a series of steps we have to do. We have to number one, explain to the public that situation, so that people understand that even when they're vaccinated, that we will need to have public health responses.

That includes them getting tested when they're symptomatic, it includes them quarantining themselves.

If we get to a good level of vaccination, the lockdowns may not have to happen at all, or very often if we have a high level of vaccination.

But questions like do we want just light restrictions being held or do you go in and out of things, they're partly decisions for government. Because it's, what's good for business – are you better off having certainty with a low level of restriction ongoing, or do you say, look, we can hold it for this long and then it needs to come in at a higher level.

I loathe the word but ‘socialise’ the community that this is going to be happening for the next one, two, possibly three years.

Second, we do need to really have what I would classify as really sophisticated thinking around what we're doing with our border control with COVID.

If we constantly have people coming in from overseas, Australian residents or people for workforce, which is required - we did a work last year in mid 2020, late 2020 called the traQ study where we looked at this.

It's an economic imperative for Australia that we have people come in to work. We know that.

So, then you need to think, how do we open the borders in a way that's not seeding in cases constantly because the model says you're stonkered if you do that, no matter what level of vaccine. Then can we have things like, if you're vaccinated and you're a returning resident going into your own home, where all of the family is vaccinated, if the community is 60% vaccinated, can you actually home quarantine and only be there for a week or does it need to be two.

But can you be at home with really low risk of seeding it to the community is a question that needs to be asked.

If I'm coming from a country, like a New Zealand bubble, because they've been vaccinated, how long do I need to quarantine if I'm a worker coming in from the Pacific, can I get away with five days in a purpose-built quarantine, these are things we need to set our minds to sorting out so that we can have a really clear policy and we can have more people returning.

And then finally we have to help vaccinate our region and other countries so that they get to a level where COVID prevalence, the proportion of people with disease in their communities is so low that the risk becomes much less.

Brendan: Vaccines have been developed in record time and there's a record amount of them, and of course, the wealthier countries who did the development or who can afford to buy them are doing almost all of the vaccinating.

At the same time, we have a raging epidemic going on in low- and middle-income countries.

Are we doing things around the wrong way by vaccinating ourselves first and effectively letting the pandemic run wild, even from a self-interest point of view?

Margaret: We've been able to with a whole lot of diseases, put it over in a corner with rare exception. We don't have to worry about malaria because malaria doesn't fuss us, so we don't even have to invest in the vaccine. We don't have to worry about that disease over there because we're juicy fruit ripe, no problems for us.

And COVID is giving us our global comeuppance that if we ignore things beyond our borders or if we ignore communities within our country who are really marginalised - it comes back to bite us cause we can't put them over in a corner anymore.

So, it's a really interesting philosophical place where we've got ourselves and I actually think it's really good for us.

A whole lot of us are realising you can't just leave low and middle-income countries across there in the corner and buy roses cheap or get cheap labour or get cheap shoes and just say, do whatever you like over there.

If we don't do something now, we've stonkered ourselves for ages.

We probably haven't modelled it fully, but I would have just thought it has to be both.

We're so used to putting ourselves first and then leaving scraps for second or saying, we'll take from you what benefits us, and you'll get a benefit from it, and you'll get the trickle-down or the whatever effect with the economic thing of the day.

But the reality is if we don't do it now, hard and fast and help build their systems because we know it is not just giving them a vaccine. Good on ya. Go deliver your vaccines. 20 million. Let's drop him in a country.

If you don't have health systems - oh pity, we didn't help them do that over the last 20 years - they won't deliver the vaccines in a timely way to those places.

So, we are getting our global comeuppance and we need to take our medicine, in my view, and start building health systems in low- and middle-income countries and help them get everybody vaccinated.

Nick: What we've seen in Australia and all around the world is how much problems the Delta variant of the virus is causing.

In Australia, it's escaping quarantine more frequently than anything else it's causing lockdowns. Overseas it's causing all kinds of chaos.

And it emerged from a country where the world hadn't chipped in yet to vaccinate. So in a lot of these countries, if we don't get the vaccination rates up, a new variant will emerge and it will cause just as much trouble for the rest of us.

Tracy:  We need to focus on all countries in need, but that doesn’t mean we can drop the ball in our own backyard.

So, what’s it going to take for us to feel confident going about our daily lives?

What sort of measures are the models suggesting we embrace?

Brendan: Is there some things that are really shining through that are going to be crucial part of our post opening, in inverted commas, world, or do we still have to do those hard yards?

Nick: This is where modelling groups work really well with other public health teams. So, we can work with public health teams to get a series of options on the table.

What would be feasible things that we could live with, restriction wise or combinations? It might be that we need to maintain ongoing really light restrictions that could be in the form of wearing masks or optional working from home, just maintaining that. It might be that we're not prepared to do that on a full-time basis.

And then there's this trade-off between, do we want to have lighter restrictions in place for longer or harder restrictions in place for shorter?

These are questions, not for the modellers, but what we can do is we can say how long we think they'd need to be in place for how many times we think you'd need to change your settings over the course of 12 months and provide that to people and just see, these are your options, which one do you prefer?

Margaret: But in the same way, as the government might bring business together to say, how do we improve vaccine rollout or bring people together, my argument would be, that's the thing that you put to business.

So that rather than me or Nick or you or government saying it, my question to the restaurant business or the hospitality business or the tourism business, is would you prefer option A - very light restrictions where you're just wearing a mask like Nick said, or you not having people come into the office, but does the city die?

Actually, we don't like that. Melbourne city or Sydney nobody's in the offices. No, that's not actually what we want is the option. We don't like your nobody comes to the office thing.

Okay, well your other option is this. You might need to in your bars and restaurants have density limits. Actually, for me as the hospitality industry, I don't want that. Well then nobody's going to be on your bar on Friday night or Thursday, either.

These are conversations that they will know far better than us, what they think is the trade off and the community will know far better than us what they want to trade off.

That's where it has to be a conversation amongst others, not us.

We're just about to do that with a whole bunch of people from culturally and linguistically diverse communities - what do you reckon - to get their input into it.

but that's a different conversation.

Nick: By not being transparent it puts unnecessary pressure on the politicians as well.

If they can explain early and show early, these are the options that would work. We're having conversations about which ones to take; the public can understand that there's no certainty in COVID and there's difficult decisions.

They're genuinely difficult decisions and this is their rationale for making them

Margaret: I think the lack of trust in the public's ability to understand what's going on – vacuum, chasm, call it whatever you like - the public really does understand that it's uncertain and they just want a conversation about that uncertainty, and they want transparency around the conversation on uncertainty.

That's the feedback we get all of the time.

Tracy: With so much confusion and so much uncertainty why don’t we have a modeller who’s the communications “go to” for the government and for the rest of us?

Someone who can explain well what the data is showing – and what it all means.

Margaret: Allen Cheng, who was the deputy chief health officer is an excellent modeler and an excellent communicator in my view. He was in Victoria, but there's other similar people nationally as well.

What you have to be super careful of is that that modeller doesn't just talk about their own work.

There are countless different types of models and the really useful thing about models is - people go that model is different to that, but only at the edges. They've mostly been very much marching in step with a few admirable outliers, or non-admirable outliers.

So, what you need is somebody who can have that conversation, but doesn't necessarily have a vested interest in their own model, who really is happy to talk about - when we bring all of this information together, this is the model for now and this is a different type of model for another time because there's different styles of modelling

But it's really important to understand different models have different strengths to be used at different moments.

Tracy: We've seen vaccinologist, we've seen epidemiologists, they're all becoming these rising stars of science in communication and helping demystify some of the concerns about COVID. We're not seeing that with modelers though.

Nick: Not to the same extent. It'd be great to see more, and it'd be great to see more communication of the details of modelling through the media to people, particularly people who are studying, maybe they're at university, not sure what they want to do just to acknowledge that it's an active field that is great to get into.

Tracy: How did you get into it? I believe you were in the transport industry originally. Same as Jeroen Weimer.

Nick: So, I spent a little bit of time doing rail transport models, but I guess I got into maths and modelling as a, sort of a cheating way out at school. I always liked it over English and some of the other subjects, because you could just put down the right answer and leave early. And that really appealed to me.

Margaret: The work he's done on hepatitis C elimination has had global impact, same with hepatitis B and vaccination globally. So COVID is just another part of the work that Nick and his team have done. At the moment is having national influence ­– but his other work has had global influence.

Brendan: More and more in Australian health and medical research world, and also in the global health world, it's fascinating to see people and disciplines really prominent that didn't start out like you Margaret with a medical degree, or like me with a biomedical science degree.

They are computer scientists, or they are mathematicians, or they are chemists, or they are physicists contributing to a health-related problem because they've all come together now in solutions. Mathematics and modelling seems to be a classical example of that.

Margaret: If you like maths, but you also want to have a massive impact on health and humanity and those things then modelling is a really clear place to take your energy and your skills because maths and modelling leads to massive impact in big decisions being made about ways forward for health, in all sorts of areas.

Tracy: Nick you seem like a pretty chill dude, actually. But does anything keep you up at night?

Nick: In general, no, I think I think it's great to be doing what I do.

Margaret: We only employ people that sleep well.

Tracy: Margaret and Nick are behind the Victorian adaptation of the COVASIM Epidemic model – which was first developed by the Institute for Disease Modelling in the USA.

HOW SCIENCE MATTERS was produced by Written & Recorded. This is a Burnet Institute podcast.

For over 30 years we’ve been at the forefront of infectious disease research, public health, and national health security.

COVID-19 is a complex global health challenge – so join us in the fight against the pandemic and help us remind everyone how science matters.

If you liked this episode, catch Brendan and I for our the next one – Lost Voice:

COVID’s impact on eliminating malaria.

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I’m Tracy Parish, see you next time.

FULL TRANSCRIPT
Episode 6: Motherhood in a time of pandemic

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Tracy Parish: Becoming a mum is one of life’s great joys

For many mums in Australia, preparing for the baby’s arrival often meant – baby showers, maternal wear shopping and prenatal classes.

And having your partner by your side during health visits, and while giving birth.

But in this pandemic world, that journey to motherhood looks very different.

It’s been a strange and lonely experience for many women.  

Dr Alyce Wilson: A lot of the restrictions meant that women had to attend appointments by themselves, ultrasound appointments by themselves – those really exciting times during a pregnancy, you know, taking your partner along to see the ultrasound. But they couldn’t do that.

Tracy: That’s the Burnet Institute’s Dr Alyce Wilson.

We know that having a newborn can also be isolating. There’s big emotions and uncertainties that come with this life-changing moment.

Now, add in physical distancing restrictions, and health staff in PPE gear.

Women in Australia have felt a sense of grief, being separated from their support network and loved ones.

But in some countries, even basic maternal care is hard to come by.

Caroline Homer: In countries like Fiji – in the most recent lockdown in their country have really struggled – closed the hospital. They've had to open a new maternity unit and unit would be a generous term, but a couple of rooms down the side of the hospital have now become the labour ward and they've had to move all of their staff.

Tracy: There’s no doubt that responding to COVID-19 has come at the cost of essential health services for many women and newborns all around the world.

Burnet’s Associate Professor Josh Vogel says now is the time to improve health for pregnant women and their bubs.

Josh Vogel: There’s never been a more important time to focus on how to improve health for pregnant women and newborns.

Tracy: And the good news is we’re starting to see some real positive changes with a shake-up of age-old systems and ways of doing things.

Caroline: Hospitals are really difficult to shift. They're these big ships – hard to turn around. In March, we changed antenatal care in two weeks.

Tracy: This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish.

Throughout this series, you’ll meet some of Australia’s visionary scientific thinkers.

You’ll find out what keeps them awake at night as they grapple with a pandemic – and how science is playing a leading role in shaping our response.

My co-host is Professor Brendan Crabb, head of the Burnet Institute, a microbiologist malaria researcher and one of the best minds in infectious diseases and global health.

Today, motherhood in a time of pandemic.

Caroline: The data is getting pretty clear that being vaccinated in pregnancy is a safe thing. We have guidelines in Australia saying you should get vaccinated. It doesn't matter at what stage in your pregnancy. It's all gonna be good.

Tracy: That’s Professor Caroline Homer, a leading midwifery researcher and maternal and newborn health expert at Burnet Institute.

She’s been closely watching how the pandemic has affected new mothers.  

It’s been a harrowing experience for some and rewarding for others.

So, what do we know about its impact?

Caroline: I think becoming a mother in COVID time has been an extraordinary experience for women, partners, families, grandparents, siblings. Babies haven't stopped being born during the pandemic.

In Australia, we have 300,000 babies born a year and actually every single one of those babies has been impacted, because our lives have been impacted. So, the indirect effects of COVID have seeped into every part of maternity care – affected the midwives, the doctors, the hospitals, but most importantly, really impacted on the women's experiences.

And their relationship with those early weeks and times of being pregnant and then those early weeks of having a baby

Tracy: Before COVID, there were so many support systems. People used to go to antenatal classes, everyone joined in the process. Every everyone felt much more supported. I can imagine it was such an isolating time for so many women.

Caroline: Yeah, and lots of women have told us that. Suddenly their antenatal care stopped. Essentially face-to-face – it went online. And while we say video conferencing, actually most of the hospitals in this country are not set up to do video conferencing. So, it was on the phone.

And while in the workplace, we've gone on to Zoom and Teams and all sorts of clever technologies, in hospitals it's not like that. So, it is a phone call. And there's a lot of antenatal care you can't do in a phone call.

Even showing women how to measure their tummy, to see if their baby's growing. That's a kind of midwifery skill and obstetric skill and we had to teach women how to do it. And that's scary as well.

Women were going to pharmacies to buy blood pressure machines so that they could take their own blood pressure and write that down on a piece of paper and tell the midwife when they rang. So those sorts of bits of care, that would be normal, all stopped or changed.

And yeah, the social support from even people's grandmothers or mothers visiting. We live in a very multicultural society in Australia and many of the women that I've seen over this last year, normally would have their mother come from India or China or England or New Zealand even, to be with them in these early months. And that all stopped.

So, not only did their care provision really change, but their social support network really changed.

Tracy: Has there been a story or personal insight from a mum that has just stayed with you, through this?

Caroline: Yeah. So, we've been doing a study called cocoon, which is a global study, particularly looking around perinatal loss around, around COVID time.

I have talked with a woman who was doing her normal antenatal care and sadly it was on the phone for the most part, but she went in for her ultrasound. And at that time, in the state she was in, lockdown meant she couldn't take her partner.

So, mostly ultrasounds, they're exciting things, you get to see the baby's heartbeat and the baby moving and the ultrasound people are all really excited and measure the baby.

And her baby was still, with no heartbeat. And clearly her baby had died. And to do that on her own, she said it was just, wanted to sob and she did, but her ultrasonographer was all in PPE and empathetic and kind, but she just wanted a big hug and she wanted her partner.

And then she got her partner on the phone on FaceTime - which was good in one level, but imagine for him, out in the car park he was, hearing that his baby had died and his partners inside in the ultrasound room and he can't get in there and she wasn't ready to come out.

And that really broke my heart, actually, hearing that story. That we really messed up for that family.

Surely, we could have done better, couldn't have been that hard to have done a better thing.

And knowing that yes, most ultrasounds, 99% of ultrasounds are going to be gorgeous, but wouldn't we like to have joy as well, so couldn't we have him in for the joy.

But the percent that it's really bad news, you do not want women to be on their own. It's just inhumane. So, we have to make that better. Even in the midst of a pandemic, we have to make that better.

Brendan Crabb: And will we have to wait until these babies of today are teenagers or whatever to know what the impact was, or are we getting some indication now as to what the downside is - sticking to the Australian context?

Caroline: So yes, as you know lots of things will have to be washed out over time. But very early on in the pandemic, there were concerns from other high-income countries about changes in maternity services - and so increased stillbirth rates, decreased prematurity, which is really interesting and increased mental health, social, and emotional issues.

So, some of those we can work out now. I think the mental health issues and the kind of social and emotional, I don't like to use the word bonding, but that sort of human connection around growing a family - those early weeks and months are so important to have all your people around you, and that's going to be different.

Tracy: Caroline, you've had such a rich history as a midwife, as a researcher, somebody who works closely with the WHO and other esteemed organisations. Have you been surprised at the change that's come finally into maternal health, that COVID actually has been a chance to make change?

I know that years ago they said, ‘we'd never be working from home’. There were managers who said, ‘you can't work from home’ and come March in Australia, that had to be the reality.

What's been the reality of maternal and child health at a global level that you've seen as a remarkable change, that you didn't expect?

Caroline: So, there's some good things from COVID I'd have to say in, in all the services. In Australia, we've basically done antenatal care the same forever.

It was invented in 1929 in England, we’ve done the same eight antenatal visits, the same thing, your blood pressure, your tummy check, blah, blah, blah.

And lots of research has been done along the way to try and change that. But hospitals are really difficult to shift. They're these big ships – hard to turn around.

In March, we changed antenatal care in two weeks. In almost every hospital in this country to flexible telehealth, we rearranged the way the ultrasound happens so it could happen at the same time as a visit rather than on a separate day to reduce traffic.

We changed antenatal education, put it on zoom. We did all this stuff really fast. Now we've got to work out, which bits to take back and the unravelling.

Tracy: And how much of that was surprising that when people said it couldn't happen, would never happen?

Caroline: Very surprising. I'll give you one example. At Burnett, we do a lot of training of midwives in the Asia Pacific region.

So, we've got this faculty development program that we invented a couple of years ago to up-skill the midwives working in schools across the region.

And so, we had a big planning, we were going to go to Bangkok in the middle of 2020 and do a train the trainer with two midwives from every country and bring them all together. And it was all going to be great.

Anyway, that all didn't happen. And so, we thought let's do it on zoom. And everyone said you can't. This is going from basically Iran to Papua New Guinea, that region – 22 countries.

We can't do it on zoom. It's too hard. I went, oh, let's have a go.

Amazing midwife Rachel Smith, who works with us, and we've done now four modules. We have last count, a hundred midwives online. Some of them with more than one in the room. They do this training, they listen to the podcast, they come every week for an online session.

We break them into small groups. They talk to each other. They've got WhatsApp groups in their language. I never would have been brave enough to do it

Tracy: Reaching midwives in remote areas, poorer countries and in places that are difficult to get to – this has been one of the great pandemic success stories for maternal health.

It’s confirmation of what can be achieved with ‘out of the box’ thinking.

And it’s already having benefits for our closest neighbours across the Pacific.

Caroline: So, it's now rolling out across the Pacific and in countries that are actually really hard to get to. So, to go to Kiribati, it's basically a four-day trip because you've got to go via somewhere else and via somewhere else - and so it's quite hard to get to, and nobody goes there for very long.

Niue, Tokelau, little places don't have many staff. They are joining online training and doing this feedback, working in a workbook, there's a Facebook site. It's extraordinary, the enthusiasm.

The nonsense that we did all these years around, oh they couldn't do online training because it's a low-income country and they don't have very good internet. They don't, but they still do it.

Brendan: That sounds like some actually really exciting possibilities to use the shakeup from the pandemic to change things that were always there.

I'm certainly no expert in this area but having been at the Burnett long enough I've never seen an area in global health with the starkest difference between the haves and the have-nots, especially of a safe pregnancy.

Can you paint that picture a bit for us as to just how stark a difference it is? How big the challenge is?

Caroline: We've now got really good data that midwives make a difference. And so, in 2020, we did a study with the UNFPA, WHO and the international Confederation of midwives - a modelling study, looking at the impact of midwives.

So, if you had midwives 95% coverage, you would reduce your numbers of maternal deaths in your country in a low to middle income country by 60%. If you only had 25% coverage, it's still going to be about 50% reduction - maternal deaths, newborn deaths, still births.

That started to make a real difference. So, we rolled out that study the end of 2020, and then in May 2021, we launched the state of the world's midwifery report, which for the first time was all countries in the world. 192 countries are in that report.

So, for the first time we can look at what's the impact in low-income countries, middle, high, and so many of the things are similar. So, leadership is critical. Education is critical. Government advocacy is critical. It doesn't matter where you fit on the income spectrum.

Bangladesh is a really interesting example. They, about four years ago, decided to fix their midwifery cadre. They'd had nurses who did a year's training - probably not very good, got sent out to the hospitals, expected to do an awful lot with nothing.

This is one of the other challenges people say, ‘oh, we grew midwives and we put them out there and look, they didn't make any difference’. We gave them one year training. We sent them to a village with no transport, with no vehicle, with no drugs, with no syringes with no mechanism to get them anywhere else and so of course they can't make a difference.

But if you can fix some of those things. So, if you grow a midwife properly, and so it's three years of training to grow a midwife properly. You send her out into a village or a community with support, a phone, perhaps even these days now stuff on an iPad where you can do telehealth consult with the village next door or the bigger town.

And you've got a blood pressure machine, some oxytocin to stop a postpartum haemorrhage and a few drugs to manage blood pressure. Then you start to make a huge difference.

And now we're equipping midwives with family planning, contraceptive skills. Contraceptive skills will save mothers lives because they don't get pregnant again quickly.

So, then I think there is huge impact now that we can show and COVID's helped us say, ‘okay, now we need to make that happen faster’. We can't wait another 10 years.

The advances we've made in the last decade, we've actually gone backwards. So, we're not going to get to 2030 sustainable development goals - we're just not in maternal health. We might get to 2040, but only if we do something now, absolutely have to do it now. To catch up.

And so increasingly countries are saying, okay, let's grow midwives quickly. And let's support them

Tracy: There’s an undeniable lesson for maternal health as a result of COVID-19.

While the pandemic has eased barriers to telehealth, it’s also highlighted just how crucial the role of a midwife is, especially in developing nations.

Brendan: The impact of midwives, of course I can see on paper, but you and I have travelled together, and I remember one small clinic in PNG we were at, which happened to have a midwife there one morning, which often wouldn't be the case when we visited.

And I remember them being particularly devastated there and the midwife herself was devastated. They'd had a woman overnight who'd lost a baby.

And they were shattered as you can imagine. Any clinic would be.

And I remember you putting your hand on her arm and saying, ‘you probably saved that woman's life last night’.

And it did really come down to that. If she hadn't been there, and there's every chance that midwife would not have been there, it would have been a pretty different outcome.

Caroline: I think she'd had twins and the first baby was born fine, and then the second baby got stuck, it was a breach, and she couldn't get the baby out.

And I remember her explaining to me exactly what she'd done, and she'd done textbook stuff.

You remember we drove up a long dirt road to get to this health centre right on the top of a hill. It was in the middle of the night, there was nowhere for the midwife to go. She didn't have a functional phone. She'd ran out of credit on her mobile and she did the best she could.

And what we know from lots of research as well, that saving women's lives makes an enormous difference to the community. The return on investment of preventing maternal death is three to four-fold for that community.

And for every child who survives, you reduce maternal mortality. Because what happens, intuitively when you lose a baby, for most women is they want to get pregnant again. And so, they do get pregnant quickly and so their risk of a maternal death happens again.

So, if you can save a baby's life, you're going to save that mother's life.

Tracy: And the rate of death is so huge still, in a place like PNG. 80 times more likely, a mother to die in PNG giving birth or than a woman in Australia.

We know that over 5,000 babies don't reach their first year of life and we've seen that firsthand at places like Kokopo and Nonga hospital.

But when you do visit an amazing country like PNG, you'll see up to 20 or 30 women who are pregnant, all waiting, and the so-called waiting room is outside. It's just a bench.

They're all sitting there in they're very colourful outfits and trying to give each other support, but they've walked for hours to get there. So, the gaps in their care is often months at time. Sometimes they don't even present until they're well into their pregnancy or about to give birth.

Can we close the gap on some of that disparity between how we look after pregnant women in countries like Australia and what happens elsewhere in our region?

Caroline: WHO guidelines are that you should have eight contacts. In Australia we have 10 or 12 probably for each woman. In PNG about 40% of women get four antenatal visits, but that's probably less now in COVID time. It's probably much less than that.

And you're right. Women walk for miles to get antenatal care. They cue up, probably luckily in COVID time, outside. But they still all queue up outside for visits.

They might see a midwife. She might not be there today. She might not have come today. She might've had a family emergency; she might've gone and had some training. She might be sick.

So, they might've walked for two or three hours to get nobody there.

When they do get a midwife, fortunately the midwives in PNG these days are really well-trained. The Australian government's really supported midwifery training in Papua New Guinea, and really raised the standards hugely, which I think is a fantastic initiative and we need it to continue.

We can close the gap. Even in countries like Papua New Guinea, everyone has a mobile. So, an antenatal initiative would be give every woman mobile phone credit so she can talk to her midwife.

And even if she just did a texting every month through that pregnancy, surely that's better than not seeing anybody for eight months and arriving late in labour or not at all for that matter.

Brendan: Australia's in a funny position - Australia, New Zealand, one or two other places - where we're having big effects of COVID without actually having much COVID, as opposed to the US the UK, France, Germany, and so on who have had both.

Has the mentality of Australia made it worse or better, or no different than having lots of COVID? I mean clearly, it's good to not have a lot of COVID for the society.

Caroline: Look, I think in some ways it's worse, because it's not out there, you're not seeing it.

And so, women have certainly said in our research, there's no COVID in my state, there's no COVID in this hospital, I don't know anyone who's got COVID, but I can't have my partner with me in antenatal care, I can't have my mother visit me in the hospital, the midwives are all dolled up in full PPE and the doctors and I'm finding it hard to justify this experience.

Whereas, particularly in countries like Italy, the US, and the UK, where it's everywhere and health workers particularly were getting affected in larger numbers than in Australia, I think women felt more justified, like I get it that we have to do this.

You're only going to have this baby once, even if you have lots of babies, you're only having this baby once and we changed that experience.

Brendan: It is interesting - there’s a number of consequences of our success, in inverted commas, like that. And what about places that are not Australia - you do a lot of work in the region and beyond.

We all stress a lot about the non-COVID effects of COVID as you've already said, and of course maternal and child health is at the very top of the list.

Pretty much 18 months in, at the highest level, where is that at?

Caroline: So, in our region, many countries as Brendan did very well in the early time of COVID 2020. We now seeing the waves, particularly in our region - Papua New Guinea, Fiji the biggest ones around and Timor-Leste state to some degree.

Providing maternal health services in PNG and Timor-Leste on a good day is tough. You take away all those standard services, redeploy the midwives to somewhere else, or the nurses or the community health workers to do COVID testing or COVID treatment. It's a very finite workforce.

So, you haven't got a lot of people to play with. You haven't got pool staff that you can get in or casual staff. So, we really have seen big changes in the indirect effects on disrupted services- it’ really disrupted PNG particularly.

Brendan: What do we need to do to try to at least mitigate this if we can't turn it around altogether?

Caroline: So, I think one of the really important things that got missed early on was maintaining essential services and maternal and child health, being an essential service. Like as important as your COVID wards - TB would be the other one and malaria.

Those are the acute services that we can't drop for anything. What happened in maternal health though, is that maternal health experts, haven't been round the table.

So, in many countries there isn't a midwife, there isn't an obstetrician on the emergency response team, because the emergency response team are virologists, microbiologists, epidemiologists as they should be, but we actually need the other people as well, to make sure that essential services are essential and that they keep happening.

And maybe in a new way, maybe out of the hospital. So, a lot of people in lots of countries, in PNG particularly haven't gone to hospital because they're frightened, and they see in the media and it's all terrifying and they don't want to go to hospitals.

Brendan: Do you think that's on our agenda. The Australian authorities I think have been pretty impressive in their attitude to dealing with COVID in the region from very early on.

Significant commitments of funds and, to a degree holistic more than just vaccines, we're going to need to strengthen health systems and so on.

But I don't see them talking about what you're talking about, saying okay we're really worried about babies being born under this circumstance.

Do you think that's on the radar or there's more that we could do in that context?

Caroline: I think there's always more we could do. I think the radar is pretty narrow in lots of countries.

Like Fiji, in the most recent lockdown in their country have really struggled – closed the hospital. They've had to open a new maternity unit and unit would be a generous term, but a couple of rooms down the side of the hospital have now become the labour ward, and they've had to move all of their staff.

So, if I was a woman in the community, I would think what's the point of going to the hospital? There isn't anyone there. I've been putting the funny little room down the hill. I think I'll just stay at home.

So, that's what we've seen across the region.

Tracy: Experts are telling us that that pandemic will still be around in years to come.

In Australia, unlike many, many other places around the world, we’ve mostly avoided widespread community transmission of COVID-19.

But with this, we’ve also seen rising vaccine hesitancy. And in our region, in countries like Papua New Guinea, there’s a real fear of being vaccinated - we know this from recent studies.

So, how safe is it for pregnant women to get vaccinated?

Caroline: The fear of being vaccinated in this country is high as well from different groups and we're coping with a lot of misinformation and anti-vax sentiment even in Australia.

But I think the data is getting pretty clear that being vaccinated in pregnancy is a safe thing. We have guidelines in Australia saying you should get vaccinated. It doesn't matter at what stage in your pregnancy. It's all gonna be good.

We vaccinate women for other things in pregnancy - whooping cough, flu, we vaccinate their babies against hepatitis B. Midwives are good at vaccination and we can have this conversation.

And I've been advocating that midwives have the conversation with everybody, every woman who walks through the door. Where are you up to with your COVID vaccination story?

We have to make it normal care, not something weird and separate. It has to be just part of normal practice.

Tracy: So much talk about mum's getting vaccinated or the general population, but what we know about babies needing to be vaccinated against COVID.

Caroline: There's very few trials. There’s a couple of trials at the moment going on, but very few of pregnant women and vaccination. So, what we know is from the non-pregnant population.

Mostly we know that children do very well, and babies seem to be born with antibodies from their mother. There are many instances of babies getting COVID - we don't think in utero, so we don't think from the mother to the baby while they're pregnant

I don't know Brendan, have you ever seen anything on vaccination of babies?

Brendan: No, it's not really on the radar yet because the risk benefit equation comes out so strongly in favour of not vaccinating at the moment - directly for the baby and the same goes for young children.

Actually, ethically it's still very tricky call. There’s got to be a benefit directly for the person you're vaccinating. And so that's what our, very good, regulatory authorities struggle with.

And so the moment it's pretty unlikely that's going to happen.

Tracy: While women are officially being told that getting vaccinated is safe during pregnancy, there’s still so much confusion and fear, creating a major stumbling block, especially when women are turning to social media and their friends for advice.

So, how has health communication fared in this pandemic? 

Caroline: Communication's been really problematic, even for people who are well-informed. If you go onto many of the government websites at the moment and try and work out what you can and can't do, or what you should or shouldn't do, it's been designed by committee over a long period of time, and it's really hard to get your head around.

We've got pregnant staff at Burnet who say to me, ‘I can't work out what to do about vaccination, can you just tell me - go and get vaccinated?’

But they can't work it out, even though they work in this field, they know stuff. If you actually go looking, it's really difficult to unravel it all.

Tracy: Caroline, I don't think I've seen one ad with a pregnant woman who’s actually spoken to other pregnant women on TV and said it's safe, that they would identify with.

Caroline: We're doing research here, looking at the communication that women seek out. So, we’ve been doing a study on a number of social media sites, actually looking at what do women look for?

They're looking at, should I get vaccinated? That's the kind of number one question.

We don't have a push button answer for them.

Tracy: Why is it so hard to get that answer?

Caroline: Yeah, I know. So, I'm a member of the college of midwives and we're running a campaign called ‘don't hesitate, just vaccinate’ to try and persuade midwives to get vaccinated.

We're not even pushing it to pregnant women.

A survey we recently did - still about 40% of midwives aren't going to get vaccinated they say. That's their intention. That's a real problem.

And my message to them is - pregnant women don't get COVID more than non-pregnant women, but when they get COVID, they get really sick. They end up in intensive care, they end up on oxygen, they get really sick.

So, whatever we can do to reduce the chance that they're going to get COVID and maybe they haven't heard the message of getting vaccinated, so they're not, but we sure can.

Tracy: Do you see a time where they won't be able to work in a hospital setting?

Caroline: Look, I've been really surprised. I, as a midwife, can't work in a hospital unless I'm vaccinated against measles, mumps, rubella, hepatitis B, and influenza in wintertime.

And I have to have my certificate to go to work. I can't understand why it's not the same for COVID.

Brendan: Look, I think we are learning in the developed world, some of the lessons we know very well as global health workers - that having an intervention is the beginning of the solution, but it doesn't provide the solution.

It doesn't mean it's going to be used by people. And we know well, in the global health context, that there's a science to what it takes to have a good intervention used by people.

I think in the west, in the developed world, we've forgotten that.

So, it is good advertising. I agree with that, but I also think there's a science to asking the communities, what it would take. A science, not just a questionnaire.

For me, it's one of the missing links, social and behavioural research in general.

Caroline: You and I listened to the 11 o'clock press conference every morning, but we're in a minority - most people out there don't listen to it, they don't hear what the Prime Minister or the Premier or the Chief Health Officer tells us to do today.

We are really missing how to make it easy, and we need to learn some lessons from other vaccination campaigns, childhood vaccination, for example.

I was talking to someone last week who said, when there's an outbreak of measles in a community, she sends the vaccinators to stand at the school gate. So, as children come through you need to be vaccinated, otherwise you need to take your child home.

And do you imagine what happens? They all get vaccinated. Because everyone wants the children to keep going to school. So of course, they're not covered that morning when they've been vaccinated, but it's a really strong message about what we need to protect everybody is you need your child to be vaccinated, or you need to take your child home.

So why don't we have vaccinators standing in antenatal clinics?

Tracy: I mean it's nice to learn, but I just feel a bit of doing would be good. We're in a rich country of knowledge and combined with the scientists and, as you say, behavioural research, and there's been no progress. I'm still seeing the same silly icons and confusion.

Caroline: Doctors with stethoscopes around their necks, no disrespect to stethoscopes around their necks, but that's not what the community wants to see.

Brendan: That's quite right. I think the scale of the problem here - we have two, it's not just pregnant women, we have 20 odd percent of Australians in the vaccine hesitancy class.

A good ad campaign, you can imagine making a dent in that. I can't imagine it solving the whole lot. We need to understand what's really behind some of it.

But I can't explain why. We look at France, New Zealand, UK with pretty impressive campaigns, at least from what we can see from afar. What the hesitancy is, no pun intended, but hesitancy is to doing those campaigns.

I think we have a government juggling apretty tricky set of circumstances with what vaccines they have available, and that would be a factor. But we're also pretty paternalistic, pretty top down in how we operate. And I would include myself in that, but it's something that we need to think, is that really going to be effective? Of course, it's not.

My 23-year-old daughter is not going to listen to me, or anyone like me. There's gotta be another way of communicating.

Caroline: The tragedy with maternal death is that we could actually prevent almost all of them now. We know. We don't need any more research.

Big killers are postpartum haemorrhage, sepsis, unsafe abortion - in our country, mental health suicide. We might not prevent all of those, but we can certainly prevent probably 80% of them now.

And so, we need political will, investments on the ground, enthusiasm and commitment to making a change.

Tracy: And what keeps you up at night?

Caroline: I think the global burden of maternal mortality keeps me up, having been a midwife for a long time you do take all those bad things on - scars on your soul, we call it, every death is a little scar that you live with, but it is there.

And I just think about all those midwives out there in really tough circumstances, frightened for themselves with COVID and for their families, but also really trying to do the best for the women who come through the door.

Tracy: And to finish on a positive note, what actually has brought you joy during this COVID period.

Caroline: Lots of joy from being, seeing how many people can be creative and all the things that we can do that we didn't think we could.

Even my 87-year-old mother now can FaceTime me and do Zoom. She hates it when you hit the end meeting cause she says, you just went, which is true.

That’s been revolutionary, that we've been able to do things that we'd never would before.

Tracy: For many it’s been a very tough challenge, bringing their babies into the world at such an incredible point in history. But for others, the start of an amazing journey.

Will the pandemic have enduring effects on mothers and their babies – only time will tell.

HOW SCIENCE MATTERS was produced by Written & Recorded.

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FULL TRANSCRIPT
Episode 5: Is COVID-normal really possible?

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Tracy Parish: When the COVID-19 threat first reared its head, it wasn’t long before it was called the great equaliser…

Because it seemed no one was immune to the virus.

Margaret Hellard: I contracted COVID when I was overseas, I was working in France at the time. And then I was going to have a holiday and we were aware that COVID was happening. It was just bubbling in the background.

Tracy: But fast forward into a multi-year, long-haul pandemic and we know now that it’s a great magnifier of inequality.

Margaret: What are we going to do about the mother on the seventh floor of the North Melbourne housing commission flats who has two small children, and she needs to stay home, and she doesn't have any milk and she doesn't have any bread. So, she wants to comply, but she's also got two small children and there is nobody because she is socially isolated, because of either ethnicity or because of just personal circumstance, that can go and get her bread and milk.

Tracy: Without a doubt, the coronavirus has taught us some key lessons about disparity, differences, and discrimination.

Melbourne resident: My letterbox one card come. I reading, only says wash the hands and go to test and one-and-a-half metre, not close. One-and-a-half metre.

Tracy: That’s despite being told over and over that “we’re all in this together” and that it’s up to all of us to make this work.

Australian Government COVID-safe advertisement: We’re ready to get back out there again, as we do, it’s up to all of us to stay COVID-safe.

Tracy: We’ve also been exposed, hard and fast to crisis, communication, and misinformation.

UK Prime Minister Boris Johnson: I’m shaking hands continuously. I was at a hospital the other night where I think there were actually a few Coronavirus patients, and I shook hands with everybody. I think the scientific evidence is – well I’ll hand over to the experts. Our judgement is wash – washing your hands is the crucial thing

Tracy: So, are we reaching across all cultures, socio-economic groups, and age brackets?

Margaret: what I know works with young people is it has to be slightly naughty. It has to be slightly funny. It has to be slightly mischievous. It has to poke fun at people like you and me and authority.

Tracy: This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish.

Throughout this series you’ll meet some of Australia’s visionary scientific thinkers.

You’ll find out what keeps them awake at night as they grapple with a pandemic – and how science is playing a leading role in shaping our response.

My co-host is Professor Brendan Crabb, head of the Burnet Institute, a microbiologist, malaria researcher and one of the best minds in infectious diseases and global health.

Today, is COVID normal really possible?

Margaret: Essentially, what you're asking people to do, is to do something. And we know in our everyday life to get somebody to do something different to what they would normally do, is really complicated.

Hi, this is Margaret Hellard. I'm deputy director of the Burnet Institute and do a whole lot of work on a whole lot of stuff. Hope you're interested.

Brendan: Margaret in thinking about what you do to, to some degree some traditional sciences of epidemiology and infectious diseases – you specialise in both of those. But I guess it's your social and behavioural science side has had the most impact on me and my thinking in the last year or so.

I remember once in Victoria's second wave, the premier got up and he seemed exasperated that so many people weren't getting tested.

Victoria Premier, Dan Andrews: we have a proven track record of being able to, as recently as a few weeks ago, to get on top of these cases quickly. But I need, I need, we need, every single Victorian who’s got symptoms to get tested. That’s what I’m asking of you, and I know I’ve asked a lot of all of you these last 12 months, but if we’re going to keep this as one case or a small number of cases, testing is the only way we can do that.

Brendan: One of the mantras that you repeat came to me and that is that the intervention is just the start, not the finish. It doesn't make people do things. I guess I've sensed that it's been, to a degree, a neglected part of our whole response. Have I got that right?

Margaret: From the get-go, the most neglected part of it was to understand that this was all about human behaviour and remains all about human behaviour. Life is about human behaviour.

So, if you, in some way, want to modify what humans do you need to think about how one might do that. And in a pandemic, what you're essentially asking people to do is to change what they would standardly do. And you've got to think about it. I have a view that most of us don't think hard enough or stop and think.

I always argue that I'm not a particularly clever person, but I probably try to think a little bit more than other people to make up for that. I think there's been a lack of thinking, and I think there's been a lack of quiet reflection on that very simple thing that regardless of whether you have a vaccine, a cure, you have a test, essentially, what you're asking people to do is to do something.

And we know in our everyday life to get somebody to do something different to what they would normally do, is really complicated.

So, there's all sorts of fancy frameworks that we can have about behaviour change about this, that, or the other. But in essence, I get it back to three key things.

Number one, to get somebody to do something you need to actually let them know what you want them to do in a way that they understand.

Now that might be a language thing, it might be the way they read, they write, but they need to know what it is they need to do. Pretty simple. We're crap at it. We've done it very poorly the whole way through the messaging has been confusing.

The second thing is, when you tell somebody, you need to do this - you need to clean your room, you need to wash up the dishes, you need to go and get a test for COVID - the person has to agree that's what they need to do.

I've been singularly unsuccessful all my life in having my children agree with me that they should tidy their room. They have a philosophical objection to tidying their room. Actually, it's my problem, not theirs. Why should they tidy their room?

You've got to expect that when you think it's very reasonable, that somebody, when you say you should go and get a COVID test, they might not agree with you. They may actually go, I actually disagree with the premise of your thing that you require of me. So, you have to have acceptance of that.

So that's the second thing is that you have to actually have an agreement, a shared agreement within the community that at the slightest symptom, I will get a COVID test.

So, I need to know that I need to get a COVID. He wants me to get a COVID test with the slightest symptom. I need to agree that's what I think I should do.

And then once I know, and I agree then the really complicated bit, which we've also managed to not do it all well with all levels of COVID is to make it easy for you to do so. For me to act on what is required of me is a super difficult thing for many people. Often, we've blamed the person that hasn’t acted as opposed to said actually the blame lies with us, the people that put the system in.

It's a really common thing in health systems that we design health systems, what I would argue to suit ourselves - the health professional, the researcher, the government, whoever it is. We don't design a system to suit the person who actually we want to use it.

And then when they don't use it or use it how we want them to, or think they should, we say the fault is with them and not with us. Invariably, the fault is with us. And COVID in my view, highlights our hubris. Our thought that we know better than everybody else.

We know better than a bug as well. I don't know whether you realise Brendan, but the Delta virus is quite a sneaky bug. It's a bit harder to contain.

The virus clearly shows us, we're not that clever, because we're actually poor behaviour and we don't invest in it. And there's been very little money in terms of the investment in what I would call quality behaviour change.

Tracy: Australians have shown that they're willing to take up behavioural change at times where they're shown the positive outcomes of that. So, we saw it with seatbelts, for example, decades ago, where no one wore a seatbelt and then it was mandated and finally, lives were saved.

Masks to a certain extent were that answer, but not really until the effectiveness of that second lockdown, Margaret, in Melbourne. How hard was it to get that message out in the early days?

Margaret: I think it was hard and not hard.

To me masks is really interesting and masks I'm going to use as an example of being really open and not having hubris for want of a better word.

I was a mask sceptic.

This is back in about March, April 2020. I'd go, the evidence for mask is not strong. But to me, I'm so regularly wrong about so many things.

One of the things I actually do is when I think surely nobody does that. Surely that's not right. I invariably know that probably it's a very common behaviour, and once again, I'm wrong. My whole scientific career has been based on my incorrect reaction to circumstances - it's been very successful.

Anyway, during the lockdown there was growing evidence overseas, that masks might be effective. And so, you've just got to that stage, say, let's have a go at it and let's have a look at it. And also, to me, life is a whole lot of things in terms of behaviour, of the balance of benefit and risk.

So, the risk of wearing a mask there is none. Okay, I guess you could choke on a mask, but I'm not aware of any case reports of that, but there's really no downside to wearing a mask against what looked like a growing benefit. And then when we measured it, it clearly showed in Melbourne that masks were effective in stopping the transmission at a community level.

Tracy: But the evidence around the masks wasn't just masks, it was the fact that once it was mandated in Melbourne, the number of people who wore masks, so that was the clear change.

Margaret: So, in Melbourne, two things happened – people, number one were asked to wear masks. And initially it was like, nah, and then it was mandated and there were fines and stuff. But when we look at work we've done and looked at photos before and after – people just put them on, and people began to put them on just slightly before the fines came in.

This is where in terms of behaviour change, you get a choice. I'm going to lock you or ask you not to leave your house for a long period of time, or I'm going to ask you to wear a mask, to make it more likely you can leave your house. Of course, people will choose that one, but a lot of behaviour change is more nuanced than that.

So, what we're needing is what I call proactive behaviour. It's more difficult to get people to wear a mask when we don't have disease than when we do have disease floating around the community.

Tracy: You talk about behavioural change, but also you need policy change, and the key was that a lot of epidemiologists and researchers were working behind the scenes to create change amongst the thinking with politicians.

Margaret: Yeah, so you need to have evidence to provide a cogent argument to whoever has some level of power - and power is an interesting business because power sometimes lies where you don't expect it to lie. But for people who have influence to then say, we will change some rules here.

But power also lies in community. And saying actually, how do I make sure that the community also is agreeing with this policy?

You need to translate that policy into people, knowing what the policy is. You need the people to agree and mostly people were agreeing at that time, but in other places people don't, we know we get pushed back at the edges. I always don't worry too much at the edges. I think we want the main people. And then you have to make it that you can get hold of the mask and you can use a mask.

Brendan: I'm distant from this as a as a science, but you say we want to know what would make community X or community Y take up whatever intervention. But there doesn't seem to be a science very often of going out and asking them what it would take. 

Margaret: This gets back to this stopping and pausing and going, ' I wonder what Brendon wants for breakfast?'

Gee, I wonder what Brendan, Tracy, what do you reckon Brendon wants for breakfast?

I've got no idea what Brendon wants for breakfast. I reckon he might like toast. And you might say, I think he likes cornflakes. How about muesli?

Let's go and buy some muesli. Oh, I don't know, maybe we'll buy some bread.

Oh, I've got a better idea. Brendan. What would you like for breakfast?

Tracy: What we need to do from a behavioural perspective sounds just so obvious.

So, why does it seem so hard for governments to get the messaging right?

What should they be doing?

Margaret: Our whole training in certain areas, and not just in science, in economics is evidence like a linear sort of thing. And what it is instead is, you have to say, I'm going to triangulate and I'm going to bring in behavioural things and it's not as clean.

And if you said to me, absolutely do I believe all of it? No, I don't. But I triangulate it. It's much more nuanced. And if you say what absolutely worked, we don't know.

But it's like in advertising, that old advertising thing is that 50% of advertising works, we just don't know what 50%. So as well, I know that in the science of behaviour change, it is advertising in a way.

We're advertising, encouraging trying to get information for behaviour change. Most of it will not work, but some of it will, and we may never know exactly what it is, but we know we have to keep on going.

For some reason, despite politicians actually being naturally good at that, at selling themselves and their party, they just don't seem to want to invest in that when the rubber hits the road, for a pandemic.

Tracy: Why have we left it in the hands of politicians and perhaps the Department of Health to, to frame up communication with the public? They seem to have done it so poorly.

Margaret: In medicine, we talk about a guy called Willie Sutton, who was a bank robber, and they said, Willie, why do you keep on robbing banks? And his answer was because that's where the money is.

So why do the politicians and the departments of health keep on doing it? Because that's where the money is.

And to get them to feel confident to give money somewhere else for this particular thing, I think we've been unsuccessful.

Tracy: Australia is one of the most multicultural societies in the world.

We have over 270 different ancestries and over a quarter of Aussies say they were born in non-English speaking countries.

Our vast country is home to a melting pot of cultures, experiences, beliefs, and traditions.

But when it comes to communicating with people from all different backgrounds, how do we score? 

Margaret: We've been really poor at this. We've had moments where we've done it really well and what I'll call lucidity on a background of general muddlement and confusion. And when we get anxious, our politicians then will stand up and blame somebody.

The fact that people have been named virtually as having caused that problem. And if go back anything, number one, that's just such a wrong way to get somebody to change behaviour is to think that if I get a test, I might be identified and told that I did something wrong when we desperately need somebody to test and they look around and say yeah, but they got outed or they got outed.

It's bizarre to me that we've done this.

And I can understand people being anxious and wanting to explain why it wasn't their fault as in if I'm in charge of a health department or I'm the government or whatever.

But actually, it requires a level of maturity to say, I'm not going to blame any individual because I need every individual within the community to get on board and to be cooperative.

And I hate the word co-operative on a certain level because it sounds like I'm trying to control you, but we need actually them to believe in this as a unified approach, as opposed to feeling like I'm either going to do it because I'm scared - I'm going to get into trouble because that never works, or that I'm being forced to in a way that I don't want to cause that's not sustainable.

Tracy: We talk about no one being left behind, yet we've got CALD communities, people who don't speak English who have immigrated to Australia, they look overseas for some of their information and the situation is so different overseas to here. What still needs to be done Margaret, in terms of community engagement?

Margaret: The first thing we have to do is go, actually, they're very varied. So, if you come from the Chinese community and what your problems are, there might be very different from if you come from the Arabic or the Dinka community or the Indian community.

So, the first thing is an acknowledgement of difference.

The next thing is to say there are some similarities that might be going on here, and one of them is that just translating something from English into Dinka – well Dinka is hardly a written language, so most people are Dinka speakers, can't even read Dinka. So that's not going to work for you. An awareness of that kind of thing.

But translating something from English into multiple languages and popping it in a letterbox is not going to do the job.

If we think about where people are getting information from it's from all around the place, from their local community, from overseas, from different places. So, one leaflet translated from English that was pretty crap in English anyway, in the first place - I actually find it difficult to follow some of those English things, English is my first language and I struggle. It’s a problem.

So instead, we need to say how do we engage with key people? Community engagement is not me telling you something. Community engagement is me working with you to say, how do we best get information into your community?

Who is it? How is it? Where is it? And ask you what it looks like and you, and whoever you think, and then to get in there. So, then the big question is who's the ‘you’? So, then you've got to do a whole lot of work looking across community saying, where are the community leaders or where are the key people within communities to start having the conversation.

It takes time. It takes money. And there has not been investment here.

I have been entirely flummoxed of the lack of understanding of the investment required to do that well. Because at the very essence of everything, to control it and manage this pandemic, we need proper community engagement of all community.

Tracy: Investing properly in community engagement is the start.

Then it takes resourcing to collect the data, crunch the numbers, and agree on what needs to happen before advising the government

Brendan: So, it’s incredibly pertinent in relation to vaccines, in relation to any intervention, but of course in relation to vaccines - not just, we've got the tool, how do we get people to take up the tool?

We've talked about the absence of science, but it's not completely absent. You run a program called Optimise, how does that work?

Margaret: My first thing is you set up a multi-platform approach, where you don't just take one way of looking at information or evidence, you do it in multiple different ways. What we call a cohort study, where we recruit a bunch of people and we follow them over time and get what we call, in my area of work, quantitative information or evidence.

So, we ask people questions, every month going forward about what they're doing, their behaviour, their testing, their thoughts on vaccines, their attitudes.

As well we do qualitative work because we know that I could ask you a thousand questions sometimes, and I still can't get to the nub of the problem.

So, a qualitative piece of work is where I do an in-depth interview on a smaller number of people to get a more nuanced understanding of what they're thinking about a topic, say vaccines.

So that's the first thing we did.

But not only that, with that cohort we set up, we said, not just you, but could you recruit your family and your friends and your contacts, so we have a network effect. And that's really important because we don't act as individuals, we are influenced by our networks.

So, we use the quantitative data and the network data and the qualitative data to inform our models.

Normally at the end of a piece of work, which might go for two years or however long a study runs for, then you write up papers and reports. But we knew that can't be the case here. So instead, we deliberately set up a knowledge translation and policy working group, where we report to government every four weeks.

But prior to even going to government, that report, we then get input from a community engagement group who are reading the report to get their flavour of actually what they think is the strength, the weaknesses, their agreement, and that then goes into the report that goes to government.

Brendan: A very complicated and difficult road to get there and conceptually quite simple outcome. You're saying to government, if it's intervention X, this is what the community is saying will work for them?

Margaret: Yes. And as well, we do things and we're just about to start one very soon - they're called design sprints or co-design work, where we're literally about to start a piece of work funded by the Department of Families, Fairness and Housing.

It’s a piece of co-design work with key community based organisations, plus researchers, plus government come together to explore the question - number one with people from culturally and linguistically diverse communities, what's their understanding of getting vaccinated, but getting vaccinated in a situation where even when we're now all vaccinated, you will still, if you have symptoms, need to have a test or have restrictions - how do we message that?

And the idea is that then we work together with a communications company to then say, this is actually the way messaging needs to happen in these communities, which might be different in a Dinka community, to an Arabic community, to the Chinese community, to the Indian community.

But what does that messaging need to look like as we explore this question? And we give them information from the reports and all of those different things that I just talked about, but as well from any data to say, what should this look like? And then we create that content.

Tracy: So, can we identify vaccine hesitancy in specific communities using network studies?

And what role do community influencers have to play? 

Margaret: So, within that network study that we look at, we can find essences of things and saying, yes, absolutely people’s network structure is influencing whether or not they will get a vaccine or not.

And we won't overcall that data, we'll be very careful about what we see, but we will use that in this co-design work so we can take it there. So I won't write it in a peer reviewed paper and I won't tell the government absolutely you must do this based on that, but I'll go I believe that enough to use it over here to have a conversation with community and community leaders about ‘this is what we're seeing’, ‘is this what you're seeing?,’ because often they're seeing something different or similar or nuanced - and that's then when we'll create that content around, how do you communicate with your community?

Who are you communicating? Is it the young people? Actually, is it the mums who are influencing their sons or their daughters? Who's the influencers, because we can see there are influencers that then you use to get the messages out.

Brendan: Your career has had so much to do with infectious diseases that have had a stigma element to them, that's been a big barrier in and of itself. And I guess when COVID came along, I thought at least stigma won't be involved in COVID, but turned out to be incredibly wrong. How does that play out?

Margaret: Well stigma plays out in the community everywhere. So, it's as simple as that. And part of stigma is fear.

So why are people stigmatised? Because the people who are doing the stigmatising of that person have fear for some reason. They're fearful that that person's behaviour that they don't think is moral will be transmitted to the rest of the community in some mysterious way.

People are fearful that if you do work in the gay community, that you might suddenly become gay.

This fear that my child will suddenly inject drugs because they could get a clean needle and syringe - well you feel like saying they can get one anyway for diabetes, like really get a grip.

So, it's these fears of things that might happen. The fear that I might catch COVID means that I'm not going to be nice to somebody who's of Chinese background because this arrives from China.

That's just fear then being translated to stigma. I fear people because they might give me something and I don't get to control them.

Brendan: So, it is a real barrier with COVID I guess. And we saw the, I don't know if it's stigma, but people with insecure work as well, not wanting to tell, get tested for understandable reasons and so on.

Margaret: That's a barrier. That's not stigma.

And it wasn't that people were naughty or bad. This is what I always say, people aren't mad, bad or malingering or anything. It's actually that they can't do it.

What are we going to do about the mother on the seventh floor of the North Melbourne housing commission flats who has two small children, and she needs to stay home, and she doesn't have any milk and she doesn't have any bread?

So, she wants to comply, but she's also got two small children and there is nobody because she is socially isolated, because of either ethnicity or because of just personal circumstance, that can go and get her bread and milk.

So, we're asking her to do something that is impossible. Not only are we asking her to do something that's impossible, but she works actually in casualised workforce because that's the nature of it.

So also, why don't you just get in Uber eats? Why don’t you just get a brain - what a stupid thing to say to that woman. She can't afford Uber eats. She'd love to afford Uber eats. Or why don't you get Marley Spoon or how very middle-class Brighton of us, aren't we darling getting Marley Spoon. Get a grip. She's lucky to be able to afford baked beans.

Brendan: So, we were really slow on the pickup there to support people. Have we got that right even now?

Margaret: No, we're careless with people. We constantly are. That to me is the biggest frustration. Things that I think should be super simple, we remain careless with how we expect people to be able to behave because we have not thoughtfully considered what their lives and the circumstances of their lives may be.

I still do clinical medicine. And the thing that I learned, and I learn from my patients all the time is to not think that they're going to do what I ask them. And again, it's not because they're wrong, bad, mad, they don't believe me. It's that they actually can't and I'm actually making an unreasonable request of the person.

So, when I say to somebody, who's just been released from prison, to look after their hepatitis C meds. And they say where would you like me to put them, Margaret? Because in the rooming house that I have, where I actually don't have a door that can be locked, and somebody steals them, and also did you say anything about refrigeration? Like, actually that was pretty stupid. So, you must think about the people.

Brendan: Clearly you have to look after everyone, you can't leave anyone behind, but I certainly detect that we're now more aware of the interconnection. If you get that wrong, if you get that wrong with anybody you affect everybody.

Is that been something that you think about, there’s a weak link in the chain type thing, as much as of course just the right thing to do?

Margaret: So still we managed to stigmatise people and still what I'll call the invisible groups - they're not invisible, we just don't look at them and work with them and deal with them, which is terrible when you think about it - are still struggling and the pandemic has impacted on them most.

Always when these things happen, it is people who are in fragile situations where they are impacted on most. Fragile economies in Australia and overseas, people with other health issues, mental health issues.

Whether or not, we're learning the lessons fast enough Brendan, I remain unconvinced.

I would like to think that we emerge from this pandemic a fairer and better community and society and a fairer and better world. But at the moment, I think it's very human, but our nature is to blame, to point or whatever and when we're under pressure, we still do it.

We need to vaccinate our region, but we still struggle to share out our wealth and our resources in our country. So, I remain hopeful, but unconvinced.

Tracy: While the pandemic has magnified the inequalities and vulnerabilities that we already knew existed in the world, this unprecedented event has also led to another plague of sorts – an infodemic.

There’s been a rise of rumours, conspiracy theories and spread of panic.

Brendan: Margaret, even with the pre pandemic lessons of misinformation, led to the whole drama surrounding the Trump presidency and so on. We knew the power of misinformation and social media being a force for bad really - but it's been an active area of research for you and your team. Can it be a force for good?

Margaret: I'm sure everything can be a force for good and a force for bad. Sounds like Star Wars.

So, we're doing that work at the moment as to how do you get messages out to young people.

And even when we were doing that early work trying to talk to young people about sexuality, sex, getting tests, sexually transmitted infections, people later on asked me what was the behavioural framework that I used.

And what I know works with young people is it has to be slightly naughty, it has to be slightly funny, it has to be slightly mischievous, it has to poke fun at people like you and me and authority.

Essentially, I have to always have in mind where my mother would go, oh Margaret really? And if I can get the oh Margaret really, did you really need to say it like, that's a bit icky don't you think - that's actually what young people like - my mother going oh Margaret really?

And I actually think there's been an entire lack of the understanding of how it has to be a combination of naughtiness and humour.

There are now social frameworks and behavioural frameworks around this, but it should be really the Elaine Hellard ‘oh Margaret really framework’ of that's a bit naughty, did you really need to say it like that?

Of course, I did because I wasn't talking to you or me mum, I'm talking to an 18-year-old.

Brendan: And I guess there's just no other way than social media. My 23- and 25-year-olds, they just don't watch television in the traditional way or any of those modes -read newspapers.

Margaret: So, you need to watch what young people are doing and how they're doing it. And then say, how do I, in a way invade that space with their knowledge that you're invading the space.

It's a bit like going into their bedrooms. You knock on the door, you have a conversation, you ask permission, you don't just barge in as well. You can't just barge in and say, I'm coming into your room. That is a good way to get anybody's back up.

So, you actually need to again, have a respectful conversation, with young people about how they would like you to communicate with them and get them involved.

Tracy: But doesn't this define the problem - that's still a top-down type thinking that the governments got. Surely, it's about young people talking to young people about, what they need on the right platforms?

Margaret: Yeah. For want a better way to put it - this lack of respect of the person or the community that you're working with - be it a group of young people, be it a culturally and linguistically diverse community, be it people who inject drugs - have a bit of respect for the fact that they will know how to do this better than you.

You are an outsider, where you're saying I know I need to be providing some support and help here.

We're about to do for entirely different work, a big advertising campaign around trying to get people to have hepatitis C testing. That whole piece of work is co-designed with community.

I am not going to tell people how to do that. They can work with their community as to how best to do that. It requires respect and trust.

Tracy: When you look at vaccine uptake, there's been whole sectors of the community that have had access to the vaccine up to now and have decided not to have it for various reasons. Do we need incentives to change their thinking?

Margaret: So, I'm going to go back to a whole series of things.

Number one, people need to know that they should get vaccinated.

Number two, they need to agree.

And then number three, you need to make it easy for them to do so.

Most people probably know that they should get a vaccine and there's very good vaccines out there.

A small group of people actually disagree with getting a vaccine. People talk about vaccine hesitancy; it actually doesn't mean you're not going to get a vaccine. It means you've just got a couple of reasonable questions perhaps about the vaccine. I don't call that a problem.

We'll end up with a very small percentage of people who will always refuse to get vaccinated.  Sweet be cool about them. We'll say 3% over there.

The rest of the people actually are really interested in getting vaccinated, if you wouldn't mind, actually making sure that they know where to get it and that they don't have to hang online for three hours to book for a vaccine and a whole series things.

And then you can bring in this thing of, do I actually pay somebody to get vaccinated?

I always am fascinated by the squeamishness which people display about paying somebody to do something.

It's a bit like asking somebody to get a test. It's easy for me. I have sick leave, not that I hardly ever use it, but if I needed to go up to the road for half a day to get a test or to do something, it doesn't cost me any money. Because I do it on my work time, or I can take a sick day or whatever it is.

But if you're actually on casualised work, it's just cost you a large amount of your income.

Why wouldn't we then say, as you're doing me a public service - cause this is the thing, we require everybody to do us a public service, why wouldn't we support somebody who needs that?

We do it already for middle-class people in terms of vaccination programs for their children. And so that they get family benefits supplements and all that kind of stuff.

I've never understood the squeamishness - in fact, it's not a bribe, it is appropriately reimbursing people for their time to participate in a public health response.

Tracy: Margaret is acutely aware of the gulf between the ‘haves’ and the ‘have nots,’ especially when it comes to COVID.

And what’s she’s learned is that even for someone with a comfortable life and robust health, the disease can really knock the wind out of your sails.

Margaret: I contracted COVID when I was overseas, I was working in France at the time. And then I was going to have a holiday and we were aware that COVID was happening. It was just bubbling in the background.

And as we were catching the kind of those, one of those really weird parabola things, you catch up to you wherever we were staying, some fellows got on it with us and we're chatting about the fact that Macron had just closed the ski fields.

Yup. France is closing.

So, we thought right, jumped on the phone booked a train back out of there because we figured we've got to get a train back to Paris and then get out. And also, suddenly we realised Scott Morrison's closing the country.

So, I've got to say the train that we got on - we had a ticket - it was a bit like a Japanese subway. And I can remember up until then, we'd been ferociously social distancing, wash your hands, and I was just laughing. This is not exactly what I call social distancing, not a lot of one and a half meters going on here.

The train was a mess. It was full of people everywhere and I just said to John, we are such in such big trouble here.

The train went so slowly back to Paris that it was rather than a four-hour journey it was a seven-and-a-half-hour journey. They had to offload people. It couldn't go at the speed. So, I'm thinking to myself, I just think we might be in a little trouble here.

We both fly out in different directions, John and I, because we just got on whatever flight we could get.

We arrived 12 hours different. Get into the house. We’d rung our daughter, she'd set up the house for us, so we went into quarantine.

So, we'd decided that once we got back to Australia, we’d get ourselves sorted for the 24 hours in Melbourne and then get down to the countryside. And as I was driving down to the countryside, I thought to myself, I've got one of those airplane snuffles.

I'm biologically a little weird. I don't get jet lag and I can remember just thinking I'm a little tired. And John's, feeling a little less flash

And then the crunch came. I had a glass of wine - a very nice Pinot - I remember it well, because it's a favourite Pinot of a winery just near the farm. It tasted crap and I knew that this was a really good Pinot.

And then John tasted it and says I can't taste anything. I'm thinking that's a little weird.

And then I had a cup of coffee. My next favourite thing to have. It tasted like I was drinking grounds of dirt nothingness.

And I can remember just jumping online - I've looked up the symptoms and I suddenly thought there's this early description of dysgeusia, which means stuff tastes crap, or it doesn't taste at all. So, you either, you don't have taste or tastes crap. And I thought, oh, we are such in trouble.

So, we went and got tested, got positive.

I began to feel really not well as well. And that is an unusual thing for me. I couldn't recall when I needed to take time off work to be sick, and I've had time off with accidents and injuries and children, but not actually illness.

I actually had to go to bed and not do things, also I began to get a bit worried about John, because he began to have this really terrible cough. And I was thinking at what stage do we actually get him into hospital?

People that know me know that I'm not a person that worries about much at all. Would probably help if I did.

But I can remember on the Tuesday, I was literally saying to him, hold your breath. You got to hold your breath for 30 seconds, and if you can't hold your breath for 30 seconds, I'm driving into the Barwon hospital.

And then it broke.

It broke as if it just suddenly stopped, and you felt so much better. You felt a little unwell, but so much better, your energy was down, but you suddenly thought no I'm right now.

Every now and then I think, oh, I wonder if I'm more tired than I should be?

Tracy: Margaret, what keeps you up at night?

Margaret:  Nothing. I am a gifted sleeper. I can't help it, and nothing keeps me up at night and I thought I could make up a lie for this podcast to look like I was a caring, sharing, non-sociopathic person, but it's just not true. I'll be telling you a lie. 

Tracy: If we are to achieve COVID normal we need to be researching more than just a vaccine and understand how to communicate effectively in an internationally connected world where messages good and bad can literally go viral.  

HOW SCIENCE MATTERS was produced by Written & Recorded.

This is a Burnet Institute podcast.

For over 30 years the Burnet Institute has been at the forefront of infectious disease research, public health, and national health security.

COVID-19 is a complex global health challenge – so join us in the fight against the pandemic and help us remind everyone how science matters.

If you liked this episode, catch Brendan and I for our next one –Motherhood in a time of Pandemic.

To hear more, search for HOW SCIENCE MATTERS on the Burnet Institute website or wherever you get your podcasts.

And please share this episode with two friends, or more. If they’re new to podcasts, show them how to follow our show.

We want this podcast to spread like a virus – but in a good way.

I’m Tracy Parish, see you next time.

FULL TRANSCRIPT
Episode 4: Everyone's an epidemiologist

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Tracy Parish: Without a doubt, it’s been a dramatic few years for Australians …

Prime Minister Scott Morrison: The rate of transmission of the virus outside of China is fundamentally changing the way we need to now look at how this issue is being managed here in Australia.

Tracy: In our fight to contain the deadly COVID-19 virus…we’ve had to endure lockdown after lockdown …

Queensland Premier, Annastacia Palaszczuk: So, the risk is real and we need to act quickly - we need to go hard, we need to go fast. We’ve just gotta do this, and we’ve gotta do this for three days so there’ll be a lockdown for three days …

Victoria Premier, Dan Andrews: We are declaring a state of emergency in Victoria under the public health and wellbeing act. That state of emergency will be effective from twelve noon today and will run for four weeks …

New South Wales Premier, Gladys Berejiklian: All of greater Sydney, the Blue Mountains and Wollongong will go into a lockdown with stay-at-home orders in place until midnight Friday the ninth of July …

Tracy: While there’s no turning back the clock, what we do know now, is that most of the world was not ready for a pandemic. Including here in Australia.

Mike Toole: Australia had not done any kind of simulation exercise for the last eight or nine years. That really led to a lack of preparedness, for example, for the arrival of a cruise ship in a large city with people infected.

Tracy: And since our own patient zero first emerged down under, we’ve looked to science to solve the coronavirus mystery.

Specifically, it’s the epidemiologists that we’ve relied on to understand exactly how the virus is spreading.

Mike: The situation in Europe is worsening, many countries are seeing all-time record cases, so these are cases higher than during the first wave. So, the UK reported 17,540 cases yesterday, France almost 19,000 followed by Spain almost 13,000.

Tracy: These disease detectives have become our new ‘rock stars’ and who we have turned to for hope. Unsurprisingly, they’ve been thrust into the limelight, and they keep popping up across our media all over the world.

Tracy: This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish.

Throughout this series you’ll meet some of Australia’s visionary scientific thinkers.

You’ll find out what keeps them awake at night as they grapple with a pandemic – and how science is playing a leading role in shaping our response.

My co-host is Professor Brendan Crabb, head of the Burnet Institute, a microbiologist, malaria researcher and one of the best minds in infectious diseases and global health.

Today, Everyone’s an epidemiologist!

But, what exactly is that?

Mike: I think prior to the pandemic, many people thought they were skin doctors and at least by now most people realise we don't actually treat skin diseases.

Hi, I'm Mike Toole I'm an epidemiologist at the Burnet Institute and the technical advisor to the Know-C19 Knowledge Hub.

And also, this is Mika, my adorable pandemic companion. She is going on two-years old and unusually, she is a breed from Madagascar.

I did most of my training at the US Centers for Disease Control and Prevention. They have a very short definition of epidemiology, it's the study of the occurrence of disease.

We look at who is affected. It doesn't have to be an infectious disease; it could be a chronic disease. Who, when and where, so person, place and time is the basic rule of epidemiology.

You try and characterise the spread of a disease or the evolution of a disease in those terms.

Who's most at risk? That could be an age group, could be an occupation - it could be male or female.

When? So that looks at the evolution of the infection or the disease.

And where? So, in what places are you most at risk for that infection or that disease.

Brendan Crabb: You know there's a lot of disciplines that have come together to have to deal with the pandemic, but it's epidemiology that is the one - it's the one everyone's practicing around the dinner table. Literally everyone virtually in the whole world.

Why is it above say a virologist or a vaccinologist, or these other specialties – the clinicians? It's the epidemiologist that everybody wants to be.

Mike: I think that's probably because everyone is interested in and often nervous about how the virus has been spreading and is spreading and might spread in the future.

So, people really look to epidemiologists to help them interpret trends. For example, during an outbreak, the number of daily cases may jump around. It might be, 18 one day, 30 the next and then 14 the next. And so, you can help interpret that by, for example, introducing the concept of say rolling averages - five days, seven days, sometimes it's only three days.

That's called descriptive epidemiology, that's just looking at the figures. The how involves a more sophisticated form of epidemiology. So those studies that are sometimes called cohort studies, case control studies - seek to explain the reason why an infection arose and is continuing to transmit.

Brendan: And on the how with COVID, were there some big surprises or lessons, things that jumped out at you that were different to what you'd expected or experienced before?

Mike: I think going back early in the pandemic say January 2020, people knew it was a respiratory pathogen. Remember initially it wasn't even clear if it was spreading from person to person. That was clarified around the end of January. So, people looked to previous respiratory infections, or pathogens to see how they spread. And it took quite a long time to really understand how it was spreading.

Even today, there's still debate about how it spreads.

So initially it was thought to spread mainly through close contact, large respiratory droplets that fell to the floor, within 1.5 meters or six feet. That guided the initial precautions. It took quite a while to recognise that the virus could also spread through very small particles called aerosols and consequently it took probably six months for the big public health agencies and governments to recommend mask wearing.

Initially, also there was a lot of attention paid to hand hygiene. A lot of sanitiser. Every time there were some cases linked to a venue like a shop or a nightclub or a hotel. Now that was based on a feeling that, that the virus could spread through contact with surfaces. And that did occur, though only on a few occasions during the first SARS outbreak and it was in Hong Kong, and it was spread via a button in a lift. There's not been a single documented case of of COVID-19 via contact with the surface.

Not a single one.

 Tracy: While there’s been heated discussions about just how this nasty virus spreads, in the early days some people simply referred to COVID-19 as being just like a bad cold or flu.

So, did this downplaying of the threat of COVID set the pandemic response back?  

Mike: I think it probably did, particularly in countries like the United States, where at the time there wasn't really clear public health leadership. The US Centers For Disease Control and Prevention was very slow to, to really engage with the pandemic. You'll recall a very slow to develop an effective test for the virus.

And there were very conflicting signals coming from the US government about whether it was just like a cold, which the then President was saying, or mild flu, it'll go away – it'll go away in the summer. So, there were a lot of misconceptions and that confused people. And so many were very slow to adopt the recommended measures.

Brendan: Since the last great pandemic of HIV, there's been alot of little scares along the way - you mentioned SARS earlier. When did you realise hell, this is this is something we really do have to worry about, do you have a moment there or something that happened?

Mike: Yep. So early in January, I was in Egypt, and I tried to avoid the news as much as I could. I was on holiday in the south of Egypt.

And I checked on my phone the New York Times and there was this report out of China of a pneumonia disease. I thought then, well we've been here before with respiratory pathogens coming out of China.

But I didn't pay much attention until I was flying home and was in Beirut airport and once again, I checked the New York Times and saw that the World Health Organisation had declared a public health emergency of international significance.

And then I saw the number of cases in Wuhan had increased substantially and that was the moment when I thought, here we go, this could be the big one. Because many people have been expecting a pandemic for many years now.

Most people thought it would be a strain of influenza. It turned out to be a different virus, but it shouldn't have been a surprise because these things were so predictable, knowing that there was increasing contact between wild animals and humans.

Tracy: There was a lot of rhetoric about pandemic preparedness, both at a world level and at here in Australia, but clearly the world wasn't ready for it.

Mike: Most of the world was not ready. If any countries were at least half prepared, they were all in Asia. And so, China in a way and Taiwan, Hong Kong, Singapore, Vietnam the rest of the world was not prepared.

Brendan: Do you think they weren't prepared mentally or they weren't prepared?

Mike: There were no plans. So there had been a movement to better address these threats to health. And there was the global health security movement that started in the US - Australia signed up to it. And a lot of resources during the Obama administration went into that program.

Resources were largely in response to Ebola, which was not a pandemic, it was a localised epidemic in three countries. When the following administration came into power, they basically cut off all those resources. Now, interestingly, there was in 2019 and assessment of which countries are best prepared for a health emergency and the US came number one. And yet it proved to be one of the worst.

Brendan: So why is that? It didn't turn out to be a great predictor of who would do well.

Mike: Because it didn't really take into account human behaviour in particular, the behaviour of politicians and governments. Now, Australia ranked fairly well, but if you look at the details, Australia was not prepared at all.

There was a preparedness plan developed after the swine flu pandemic, but it really wasn't implemented. For example, Australia had not done any kind of simulation exercise for the last eight or nine years.

That really led to a lack of preparedness, for example for the arrival of a cruise ship in a large city with people infected. If they'd done a simulation of that exercise, everyone would have known what they were responsible for, who was in charge. When it actually happened, no one had a clue.

Tracy: But Mike, even though you might have these plans, when you've got a country like Australia, who's not used to having epidemics like this changing behaviour of the populace is super hard. And that only really came about when there were big lockdowns or other major issues confronting the population. I guess we shouldn't be surprised that Australians took a while to really adapt to it.

Mike: Yes, compare that to a country like Taiwan where not only did the government have a very detailed plan for an event like this, the people were used to wearing masks. It'd become a kind of routine way of protecting people around you.

So, if you had a cold or the flu in Taiwan, you would wear a mask to protect others.

In Australia, and other Western countries, there was no tradition like that. Those plans were not perfect, but you can see in Singapore how there was a major blind spot in the Singapore preparedness plan. And that was to make sure that migrant workers were protected because they were living in crowded dormitories. And that totally escaped the entire response.

Brendan: It seemed for whatever reason to be pretty binary, China, South Korea, Taiwan, and then Australia, New Zealand deciding to have nothing, if they could, to go for aggressive suppression and to just not live with the virus. I don't think we were considering the word elimination at that stage. And then others had a very different view which now seems like folly. Is that the way it was at the time? Was it a line ball decision or were they just really out of line, some of those countries that let it go?

Mike: Just staying in Asia, even within Asia and east Asia, there were different approaches.

South Korea and Japan were very reluctant to introduce lockdowns like we have done in Australia. They weren't saying let's live with the virus, but they were in a delicate balancing act between shutting down the economy and, allowing the virus to spread in an uncontrolled manner. And while South Korea was relatively successful, they're still paying the price of that juggling act.

So, I'd say Vietnam was closer to the approach taken by Australia and New Zealand in that they had a policy of not tolerating any transmission. They didn't do a national lockdown, but they did a lot of localised lockdowns of say Da Nang or Hanoi.

Tracy: Have you ever wondered why is it that some countries can’t get to COVID zero?

In Australia, we know it can be done. We’ve achieved it many times.

But why not elsewhere? Does it come down to the sheer number of cases?

It is about the length of lockdowns, or are there other factors at play?

Mike: Countries where the government was slow to launch the initial response have done very poorly. Like Brazil look like they can just never get out of it. It's just getting worse and worse in Brazil. And that of course initially was due to a President of the country, not taking it seriously and saying in public that it was just like a cold.

And so, Brazil's paid a very heavy price and to slightly lesser degrees, the US and UK suffered from that lack of leadership. And therefore, a reluctance to introduce what by the middle of 2020 was pretty clear what you had to do. You had to keep people from mixing and mingling once you had the virus out into the community.

Brendan: Mike, the perception is from what you've been saying about these successful countries, in inverted commas, that are at zero versus those that have a lot. In countries that have done well, they've had a lot of lockdown to get to doing well, whereas the countries that have done badly have at least been freer. But I think it's totally the opposite as I understand it. Have I got that right?

Mike: Yes. Just look at the UK as an example, they were initially very reluctant to go into a lockdown. And after their second wave last year, they basically opened up the country just before Christmas. And you may recall the scenes on TV of crowds in London, no one wearing a mask - Harrods, and all the stores full of people. And yet at the time there was still reporting thousands of cases a day.

So then in came their catastrophic third wave and they were very slow. It wasn't actually until Christmas day that they took some kind of action.

Tracy: There’s whole new words that have come into our vocabulary over this pandemic. And the R word - we know it as reproduction number - it was really up close and personal last year. It was everywhere wasn't it, the R number? What's the reproduction number, is at 1.0, has it gone 2? It seems to have dropped away in 2021, why is that?

Mike: I think it was used in a different way early 2020 than it is today. So, it was applied to whole populations rather than what truly is an average of how many people will be infected by an individual.

So, that's a good basis for tracking what's going on, but it doesn't explain everything. It doesn't really explain, for example, there's something called the dispersion factor for coronavirus, which in summary means that around about 20% of people who are infected will infect anyone else. And the other 80 per cent won't infect anyone.

And that's probably due to variation in the viral loads, the amount of virus people are carrying in their throat and nose.

Brendan: So that's the super spreading events?

Mike: Yes. So, it means, if you have a combination of a person who just recently been infected and about to develop their symptoms, or have just developed their symptoms, goes into an environment where there's poor ventilation, maybe people are shouting like in a bar or singing like in a church, and you can have this super spreading event.

We saw it in a church last July in Western Sydney where an infected man was a member of the choir of the Our Lady of Lebanon church. He was sitting with the choir upstairs, 3.5 meters above the congregation, and infected 12 people. One of whom was sitting 14 meters from him.

Other people don't infect anyone. For example, a case in Perth has not infected her partner.

So, it is not a predictable virus.

I'll compare it with Measles. If a child has Measles and goes into a room with a group of other children who are not vaccinated, they will all get infected, all of them. The reproductive rate for measles is about 18, compared with around 2.5 to three for the Wuhan strain of the virus.

Tracy: Just before COVID-19 struck, Mike was planning a life away from disease control.

After 40 years of working in more than 30 countries, across five continents, he was ready to pull up stumps.

But retirement had to take a backseat …

Mike: I had planned to retire in June 2020, and after my long service leave, I had a chat with my boss, Brendan Crabb.

Tracy: He said go for it, just enjoy your time, Mike.

Brendan: Yeah, that's right.

Mike: He said I wonder if you could stay on until at least till September.

Tracy: Of 2024? 

Mike: The year wasn't specified. So, it did change. I had concrete plans for my retirement.

They included an oral history project on an island in the Nile where probably the oldest documented Jewish settlement was 3000 years ago. So that was put on hold.

And then I guess I was working a lot harder than I had the previous year. And of course, the media was something I had not anticipated.

I had been in the media when I was in the US. It was usually to do with crises like Rwanda or Northern Iraq or Somalia and it was usually with just one or two media outlets - almost always the New York Times and the Washington Post. But now I have all the whole range of media contacting me.

So that was a big change. Phone calls out of the blue, so not really being out to plan my day. Not being able to visit Egypt of course, it's the biggest personal issue that I've had to address. That's my second home. I have a flat there in a nice part of Giza.

But I haven't been there and I'm not sure when I will be able to visit again. And here I am still working.

Tracy: Epidemiologists like yourself Mike have played such a key role in demystifying, some of the big issues around COVID and helping explain the evidence for us. You've been in huge demand with media, both in Australia and internationally.

I know there's been Al Jazeera and there's been Korean media and Israel. And I'm aware you really trended in Ireland.

Mike: Russia today.

Tracy: Unfortunately, you got bumped, I believe, from Good Morning Britain. What happened there?

Mike: I was signed up to appear live on Good Morning Britain, interviewed by Piers Morgan who's a very controversial journalist. Just before I went on, which of course was around-about 5:00 PM Melbourne time. I got a call saying no a certain princess or wife of a prince, was about to give birth.

Tracy: I think she's a Duchess.

Mike: So, I got bumped. But I've had some other interesting and challenging media encounters.

Probably the most memorable one to me, which wouldn't be known to many Australians is that I did a very long zoom interview with a Japanese journalist who I later found out is like, considered almost the number one journalist in Japan. And he was very easy going and the topic was an opinion piece that I'd written about the danger of holding the Tokyo Olympics.

So halfway through, I got ambushed in a big way.

He said, what do you think of the comments made by the chair of the Japanese Olympic committee and former Prime Minister Mori about women. And I thought well it is on Zoom, I could just turn it off.

So, I said I thought they were old-fashioned and disrespectful.

So, the next day I started getting texts from my friends in Japan saying your photos on the front page of Tokyo's biggest paper Mainichi and you're in the headline. And the headline is, in Japanese, "Former prime minister old-fashioned and disrespectful, says Australian doctor."

But then friends got in touch, and they were looking at the Facebook page of Mainichi the newspaper, and they said 99% of people agree with you.

Brendan: So, he lost his job because of you?

Mike: Yes, next day,

Tracy: Well aside from making international headlines, for all the wrong reasons and finding himself in uncharted territory, Mike was also up against armchair or amateur epidemiologists.   

What was the cost of that?

Mike: Many of those people had strayed way out of their field and were quickly trying to catch up on what epidemiologists do. Some of them, of course, weren't even health professionals, they were self-made experts.

And of course, the most vociferous and dangerous with those that would say, and they'd quote figures, was that this virus is not very dangerous. So, I think that was the, probably the worst mistake because it did influence a lot of people to not take the virus seriously.

Brendan: A big lesson of the pandemic is that it's a pandemic. That it isn't an Australian disease and that it targets those with the least, poorest countries, the poorest in our own community, those who are otherwise vulnerable.

Do we still have a blind spot there?  Is the world tackling this? Do we really realise that unless we deal with that, this isn't coming to an end?

Mike: I think it may be just natural that people have focused on their own country and their own communities within that country, because it is a virus that can kill you.

So, I think people have understandably looked inwards, but I think now is the time to basically acknowledge that we won't get rid of the virus in any single country until the whole world is protected. And the only way to do that is to vaccinate the whole world.

So, I think there's an increasing realisation of that, that we will be trapped inside our own country until other countries are safe. And I think, you can see now the current administration in the US has acknowledged that and donating quite large numbers of vaccines to poorer countries.

And I think probably will gain momentum, but probably not until the wealthy countries are vaccinated - and some of them are still behind. They're mostly in our region, so South Korea, Japan, Taiwan, Australia, New Zealand.

And it's going to take a while before we can, we as Australians, say okay, we feel safe now we'll share our bounty with neighbours.

Tracy: How much do you think the WHO's reputation has been bruised by the last eighteen months or so of this pandemic? It used to be revered as an organisation that was a world leader and yet, I know in this country, we don't hear much from them and it doesn't have as much traction now as perhaps it did.

Mike: I think some of the criticism of WHO has been misplaced. Much has been made of the delay - it was only by a week in declaring a public health emergency of international concern.

But WHO really had their hands tied, because following the Ebola outbreak and other outbreaks of respiratory disease, there was something called the International Health Regulations, which were endorsed around 2007 by all the member nations.

And those international health regulations were good in one way, but they also tied the hands of the director general of WHO, who could not unilaterally go out and say, we've got a problem. The country involved had to be consulted and WHO had no authority to send in a team to investigate and help control an outbreak.

So, I think overall, since those first bumps in January 2020, their performance has been good. And they've certainly stood up for the poorer countries of the world.

Brendan: Mike, we're fond saying that we've been following the science. But it's not been universal that there's been an embracing, in inverted commas, of the science. Why has that been so tough when other science gets accepted so readily, do you think?

Mike: I think, saying something like follow the science and listen to the medical experts has been challenging, because not all medical experts agree with each other.

And particularly in those first six to nine months, when it still wasn't clear how the virus circulates and what works in preventing it. And you have very different opinions emerging and that’s really the nature of science and medicine is that there is a healthy debate about certain issues.

Now, airborne transmission is a tough one. A lot of people think that the resistance to acknowledging airborne transmission was due to a dogma that really emerged in the 1950s around about tuberculosis and also measles, that they were transmitted by these large droplets.

And that dogma has stuck even though it's been acknowledged that both TB and measles can be spread through these small aerosol particles, there was a resistance to really look closely at COVID-19 transmission. And some people are still stuck in that dogma, and of course, it included very senior people in the World Health Organisation, in the US Centers for Disease Control and in a number of expert committees, including in Australia.

I'd say we're not there yet in Australia. We've seen in one city in Brisbane, three separate leaks in hotel quarantine that could only be explained by airborne spread. So, from one room to another.

And that's because the expert advice that is guiding the Queensland Health’s practices has not acknowledged airborne transmission. And so, you have this huge difference between different states. Some states have acknowledged the importance of airborne transmission and have therefore done audits and rectified problems with ventilation in hotels - and they're giving their frontline staff the very best protections through respiratory or N95 masks, but others are not.

We lack national leadership that could using the authority of the federal government bring the states and territories together and insist on developing what I call a national code of practice.

Why weren't these problems fixed last year when we had plenty of evidence that there were leaks in hotels and therefore maybe shifted to fit for purpose facilities like Howard Springs, near Darwin, which has never had a leak. When you get three lakes in a week, in Queensland it's really beyond a joke. It really is.

Brendan: Mike with the global pandemic as it's progressed one of the things that might have surprised people is, yes, you'll learn a lot about it, but also it keeps changing. There's shifting sands.

The vaccines obviously made against the original virus. Now we have variants. Is this a continual game of catch-up? Do you see an end game?

Mike: It's hard to use a crystal ball with this pandemic, because as you say, the situation changes so abruptly.

We haven't totally learned that we need to be nimble and adapt to the changing situation. In this case, the Delta variant.

Vaccination is the key to even thinking about living with a low level of virus. Two countries that I've seen that are developing, or have developed, pretty comprehensive plans for exit strategies are Singapore and Malta which have similar vaccination levels.

Particularly Malta has had a very thorough, comprehensive consultation process, and that will be critical. You just don't want a room full of people in Canberra brainstorming and writing and plan.

It needs to be based on consultation and of course, vaccination coverage will be the big decider, but there are also other issues. 

Tracy: As the goalposts keep shifting around our pandemic response, Professor Mike Toole has become a household star.

But it’s not just his no-nonsense and reassuring breakdown of the crisis that’s quelled our anxiety.

His fury COVID companion, Mika the pooch, has also become very popular.

Mike: I was very lucky. I got Mika after I came back from Egypt and she immediately changed my life, because we went into lockdown in March.

She's been an adorable dog. She's extremely popular in my neighbourhood. People fight over having her to dog sit. And of course, she's just watched this train of camera crews arrive and she just sits there and watches them and sometimes appears in the shoot. I don't know what I would have done without Mika.

Tracy: And just finally, Mike, what keeps you up at night?

Mike: It comes and goes. Some nights I just go straight to sleep.

And I think it's fair to say that across Australia, now, most people, many people in the cities, particularly have a degree of anxiety that they haven't had for a very long time.

Also of course what keeps me awake is if I have to get up early in the morning and give an interview on Seven Sunrise or something, I do start practicing, and that's not a good way to get to sleep.

Tracy: Between media appearances, Mike Toole continues to work tirelessly to stay one step ahead of the virus.

An unlikely celebrity perhaps, but a hero nevertheless in a time of coronavirus

HOW SCIENCE MATTERS was produced by Written & Recorded.

This is a Burnet Institute podcast.

For over 30 years We’ve been at the forefront of infectious disease research, public health and national health security.

COVID-19 is a complex global health challenge – so please join us in the fight against the pandemic and help us remind everyone how science matters.

If you liked this episode, catch Brendan and I for the next one – Is COVID normal really possible?

To hear more, search for HOW SCIENCE MATTERS on the Burnet Institute website or wherever you get your podcasts.

And please share this episode with two friends, or more. If they’re new to podcasts, show them how to follow our show.

We want this podcast to spread like a virus – but in a good way.

I’m Tracy Parish, see you next time. 

FULL TRANSCRIPT
Episode 3: No-one is safe, until everyone is safe

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Tracy Parish: For almost two years now, the world has been gripped by a relentless pandemic.

Millions of people have been infected. And many, many others have died.

Mike Toole: It’s not an equitable virus so the death rates in Black, Indigenous and Latino Americans is three times that of whites. So that’s a very grim picture.

Tracy: The scale and pace of this deadly virus has also shown cracks in our humanity.

Steinhard Hiasihri: Our health system is very weak. That's because we have very limited human resources and financial resources, plus basic essential medicines.

Tracy: That’s Doctor Steinhard Hiasihri. He’s based in PNG – one of the hardest hit countries in the world. 

Stenard: So, there's a lot of myths, and misconceptions about the virus and the benefits of getting a vaccine. Back in the villages and in the communities, the importance of wearing face masks or hand washing or social distancing – it's not really a priority.

There's a lot of work that still needs to be done in terms of preparedness for what lies ahead of us.

Tracy: What’s become increasingly obvious is that COVID-19 threatens to leave developing countries like PNG behind. 

And that’s putting all of us at risk.

Leanne Robinson: COVID-19 has highlighted for a lot of us in global health. And my background in malaria and neglected tropical diseases has highlighted just how inequitable healthcare and public health programs are throughout the world. So, I think certainly it's been disappointing, but I wouldn't say it's been surprising.

Tracy: When we look across to the south-western Pacific, there’s no doubt our close neighbours in PNG have felt the full brunt of the pandemic.

Dr Suman Majumdar is Deputy Program Director at the Burnet Institute. He explains how a disease like this cripple’s vulnerable health systems.

Suman Majumdar: So, there’ve been a number of deaths in young people - a couple of twenty-five-year-olds in the past week which is really concerning. Overall, in the country, we’re talking about a place that has one doctor per 20,000 people, compared to one per 200 in Australia.

Tracy: As a developing nation, and as one of the most culturally diverse countries in the world, PNG has a unique set of challenges.

Misinformation and scepticism can spread faster than the virus.

PNG is also right on our doorstep. 

Which begs the question, does this island nation pose a grave threat to the health of our region?

Is anyone really safe, if everyone isn’t safe?

Tracy: This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish.

Throughout this series, you’ll meet some of Australia’s visionary scientific thinkers.

You’ll find out what keeps them awake at night as they grapple with a pandemic – and how science is playing a leading role in shaping our response.

My co-host is Professor Brendan Crabb, head of the Burnet Institute, a microbiologist malaria researcher and one of the best minds in infectious diseases and global health.

Today, the issue on everyone’s mind. Why can’t we just shut out COVID-19? And is the only way to protect ourselves, to protect others?

Leanne: The fact that this became a pandemic highlights that we, as people live in an interconnected world and we can't just barrier ourselves off in, in whatever country that may be from the world as people, but also as economies. That can't last.

Hi, my name's professor Leanne Robinson and I'm program director for health security at the Burnet Institute.

I think here in Australia, and even with our own vaccine rollout, I think we see that people have very quickly adapted to the lack of threat from COVID in Australia. And yet we're at risk of an outbreak next week, next month.

Even if our vaccine rollout continues. To scale up and increase uptake, because we don't know for certain that there won't be some variants of concern that arise that mean our vaccines might not be as effective. We don't know that for certain yet. So, it's a real issue.

Tracy: And has the approach by Australia and other countries been just so much through a Western lens - where they think this is the best way of doing it, and we've had success obviously in Australia. So why don't you just roll it out like we do? Why isn't there a ‘here's the yellow brick road and this is why you do it,’ but obviously that's not realistic in other countries where you've worked and lived.

Leanne: Absolutely. And I think even the expectations of how COVID-19 would emerge and spread through many countries in our region, hasn't met the expectations of many Western or developed high-income countries.

So, I think the actual natural extension of that is a COVID-19 vaccination role that is also not going to unfold in the same way, for really obvious reasons - in terms of the way that health systems are set up, the inaccessible areas of, many countries in our region that make vaccine rollouts difficult, even under normal situations of routine immunisation, this can be challenging.

And in this situation with almost no, or very limited preparation, really, when you think about how long people have had to get used to the idea of not only a new pathogen, that is a risk to them and their family, but also to the fact that we now have a vaccine against this pathogen.

We still don't have one for malaria. We don't have one for other infectious diseases that they have lived with for decades, but we now have one for this very new pathogen that they have very little lived experience with.

I think that presents so many challenges. To a rollout.

Brendan Crabb: So, the vaccine hesitancy issue that we talk about here is just as significant in PNG or even more so. Next to the logistical issues that you just mentioned, what's the biggest barrier in PNG?

Leanne: Definitely the biggest barrier at the moment appears to be vaccine hesitancy. At least in my experience in living and working in Papua New Guinea, people trust health interventions through lived experience.

Even during 2020, when many parts of the world were severely impacted by COVID-19 and people saw loved ones, get incredibly sick and even die. In Papua New Guinea, this didn't eventuate, the way that it was supposed to, or that people thought it would.

Even now that cases in PNG, have escalated substantially and to it to an incredibly concerning level, I think that lived experience is still very different from a population where that occurred quickly and early on in the pandemic. And that influences perceptions of risk from COVID-19, risk from the vaccination and the unknowns associated with adult vaccination programs, which are a very new thing in a setting like Papua New Guinea.

So, I think all of this is contributing to vaccine hesitancy against a backdrop of vastly increased access to technology and social media, which has resulted, I think, in a blurring of the sources of truth that people normally reach to. It's become very blurry for people to know whether to trust their church leader or somebody from a reputable organisation on social media with a completely opposing point of view.

Tracy: Leanne picking up on that point. In Australia, we've relied so much on scientists and data analysts and epidemiologists to be at the forefront of the truth as you call it. We've heard government many times say, trust the science, trust the data. In a country like PNG do they trust the science? Do they trust the data?

Leanne: Hard question. I think yes. When the data and the science is presented in a way that can lend itself to that trust and over a period of time.

I still feel that the speed of the situation has contributed a lot to that inability to know where to look to for that source of truth. The information coming through on social media is instant, it's there, it's all of the time.

The information that might come through previous trusted sources, it's not so frequent and I certainly think that PNG's response early in the pandemic was very strong. Like in many countries, in fact, it was very top down. And yet non-pharmaceutical interventions like social distancing and masks or vaccines, they all require masses of people to accept them and take them on to, to be effective.

So, I think if there was one thing that probably has been slower, it would be that community level engagement and empowering of communities to have access to the science they trust, rather than to just not really be sure which source of information they trust.

Tracy: And when we talk about communities, there are so many in Papua New Guinea and they're so diverse and they do face so many difficulties. Take us inside the country for people who have never travelled there, who have that expectation of what they think Papua New Guinea is like.

It's not till you go there and that you live there, that you really have a true insight, and then it's only just one glimpse of whether you're on the coast or in the highlands or on an Island. What have been your experiences?

Leanne: Papua New Guinea is world renowned for being one of the most diverse countries with more than 9 million people who still largely, 80% of which, live in rural areas of the country.

And just represent very distinctly different cultural backgrounds, belief systems, and understandings.

Tracy: Across PNG’s 22 provinces, the average age is around 22 years old.

For a nation of largely young people, you’ll also find some really old beliefs – like sorcery and witchcraft.

Like Leanne says, these beliefs sit alongside a flood of conspiracies that swirl on social media. 

Against this backdrop, the other real health challenge is posed by simple geography.

Leanne: When we say that, people are living in remote and rural areas of the country, they're often hours walk from a health facility. So just understanding the way the population and the health system interact as well, can give some insight into just how difficult it is to get that timely messaging of the correct health information

Tracy: And on a personal level, has it has been difficult to leave PNG because you're so used to traveling in and out of PNG supporting the community, supporting some of the researchers - you've got close connections there. How hard was it for you to sit in Australia and watch what's happening?

Leanne: Oh, it's been so tough. At so many different levels over the course of the past year. Pre-COVID, I would be in PNG at least once every couple of months working with my colleagues at the IMR in the health department on numerous programs that we're working on in health.

Before that, I've worked in PNG for more than 15 years and I lived there full-time for eight years and raised two of our children there for the first few years of their life.

And so, it's been incredibly difficult both from that work perspective, but also from a personal perspective to deal with feeling quite useless, really in a hands-on sense as all of my friends and colleagues have needed to adapt - not only to the way they're living their life and the risk that COVID-19 poses to them, hearing and watching them get sick with COVID-19, but then also to the incredible burden that they, and we as a team have had to undertake to continue working in this environment and not only try and continue to progress the work, but also adapt the work to include COVID-19 elements.

It's been really challenging.  

Tracy: Leanne tell us about an experience of someone that's been close to you that has had COVID 19, particularly up in PNG, has that been a concern and what has been the impact on their lives?

Leanne: Yeah, it's absolutely been a concern. It's been difficulties in isolating and trying to ensure that they can protect family members from becoming infected.

Many Papua New Guineans live in multi-generational households and it's incredibly difficult to isolate properly. And so, I think that's been both a real challenge and a real fear with that knowledge that it might be their elderly parents that would suffer more from this than what they might be experiencing.

And then something we haven't really talked about, I think has just been the stigma of COVID-19 - of not even wanting it to be known or told that they had this, because of the way that they would be treated within the community, I think has just been so incredibly challenging.

And it's certainly something that has really limited the testing rates that have been low and have underestimated, for sure, the actual cases and transmission that we see.

Brendan: You and I have both had lots of experience in PNG and we’ve also had experience with diseases that we understand surrounding stigma - particularly HIV of which in Australia itself is a major driving force behind why HIV has been a problem in this country and of course, a huge problem in PNG.

But stigma surrounding other things is more of a surprise to me. TB's been one I've come to understand a bit from colleagues. But COVID too, you say stigmas significant.

Where's that come from? Why is that the case? Is that something more generic about disease in general or is it COVID specific?

Leanne: From what I can understand from what we've seen in PNG is it comes from fear.

If you're known to your community, to have been positive or you are positive for COVID-19, are you then going to be blamed for every infection that arises in the community from that point on?

And that could have some really serious ramifications for you and your family if you're seen to be the person that brought this virus into an area where previously there had been none.

And even health workers who, I think in some parts of the country, even were fearful to go to work themselves at a certain period of time in the outbreak and the escalation of cases for fear of catching COVID-19 and then what that would mean for them and their families and all of the flow on impacts.

But I think it's also important to highlight we've mentioned before, just how strong and robust Papua New Guineans are as well. And so, people don't actually seek diagnosis and treatment generally for what might be mild or moderate respiratory symptoms.

So, I think it's also been a huge hurdle to overcome, to try and provide appropriate education and messaging that even a mild respiratory symptom should receive, a test.

Brendan: Leanne you speak of PNG with such affection. And as you know I grew up there as well. And know many people who have experience of PNG who feel infected by it, which is probably the wrong expression in the COVID era.

With you personally have I read that right? Has PNG really affected you in that way? And what do you think is behind that?

Leanne: Yeah, it absolutely has. We went to PNG for what we thought would be a two-year period of time to work on malaria studies and that blew out to eight years and even then, was an incredibly painful process to rip off that band-aid and transition out.

And for me it's very hard to pinpoint. I think PNG has absolutely shaped who I am and the way I live my life.

And I think it's because I see in, especially my friends and colleagues, but to be honest, even in community members that I might get the chance to interact with just once - such a strong sense of self, of belonging, of place, such that if everything else were to crumble around them, there's a resilience and a strength that is just so inspiring to me.

And yet I've obviously also seen firsthand, the inequities in health care and access to health care and preventative public health strategies that also drive significant suffering and burden of diseases.

And so, I think it's for me, that combination of being inspired by, but also seeing that by working together, we can do more to ensure that the best tools and strategies can be implemented in a community-led way to reduce that suffering. That really is what I guess has kept me so strongly tied to PNG.

Tracy: It’s fair to say all Australians have a connection to PNG that goes back almost a century.

For nearly 60 years, PNG was under Australian administration, before it gained sovereignty in 1975.

So, we have a relationship that goes beyond governments and diplomacy. It’s personal.

Brendan: This is something we both wrestle with a lot is this combination of PNG so capable as you've just described - Australia wealthy and really willing to help, what is that right balance?

The Western ways to want to go in and fix everything. We know that doesn't work in a place like Papua New Guinea. It doesn't make it inappropriate to offer assistance.

How's that balance working? Have we got it right, and can COVID maybe help us reshape that a bit?

Leanne: Yeah, I think it's such an important point and I think it's about finding the equity in the partnership and being really clear about what each partner is bringing to the table.

There are clearly strengths and weaknesses on both sides, and I think it's acknowledging those strengths and weaknesses and where the outcome can only be achieved by bringing them together.

Even something like the COVID-19 response has been PNG led from the very beginning, although obviously Australia has provided a lot of support throughout.

And having a relationship, I think, that means that can continue to be offered in certain areas, and upon mutual agreement that this is actually the right thing for the country.

Tracy: You're right about the fact of Australia and others wanting to come in and solve it. Both of you are right in that way.

And it's not until you go to the country - I remember my first visit to Kokopo up in East New Britain. I met this young midwife, and she was up in a clinic in a remote part. And I remember she said her first night of being on her own, up in that clinic, she had a woman presented with twins, but they were breech.

And the matron or whoever was supervising was down in the main hospital, down at Nonga hospital. And she had this little mobile phone, and I remember I'm looking at her and she in her twenties and I said, you must've been terrified, and she said, I was, and she said, I finally got onto somebody, and they said, just pull the legs and hope that's okay.

She said in the meantime, while that was happening, she went over to a textbook, which was like a tome that you get from the library to look up how do you deliver twins that are breech.

And I just thought, it's not till you see that and some of the conditions that women give birth, the effects of malaria, and then you have the overlay of COVID-19 - it's hard to believe that Australians aren't outraged by what is happening on our doorstep.

What is the next step in helping a country like that, both overcome COVID-19 and also to assist in making a different life? What can we do?

Leanne: I think many of us have reflected over the past months on just how difficult a challenge escalating COVID-19 cases were going to be for what is a recognised under-resourced and understaffed health system in PNG.

Yet, there was also this knowledge of the resilience of the health system and of the health workers, because of what you just described, which is people may not have everything they need at their fingertips but there's a willingness to try and do the best with what they have and a strength of character to do that.

And I think that has always and will always hold PNG as a country and a health system in very strong stead with COVID and beyond. But it's being able to then fill those gaps, with interventions, with tools that are wanted and needed to ensure that a young midwife doesn't face that situation alone or, so unprepared in the future.

And having firsthand delivered one of my boys prematurely in PNG at the labour ward of Modilon hospital, I can absolutely attest to the resourcefulness and the inner calm that that is inherent within health workers in PNG.

Tracy: Against unfairly stacked odds, PNG’s stretched health system is working hard to keep COVID-19 in check – as well as major diseases like malaria, TB and HIV. 

Despite sounding completely overwhelming, there are some positives coming out of this experience.

Leanne: I'm an incredibly optimistic person, but I think that COVID really has demonstrated what can be done with the resources and the will. And I think in many settings and certainly in PNG we've seen a response and things happen that we would never have thought, could happen in that timeframe for other infectious diseases.

But obviously we're in this period of caution or transition where it also feels like there's the very real risk that we lose momentum, you know with control of malaria, TB and HIV, which have been really hard fought for in a country like PNG, strengthening the health system to be able to bring down rates of these infectious diseases.

And so I feel like the period of time that we're in at the moment is about trying to sustain or maintain those gains whilst learning from COVID, like what can we learn from yes, the vaccine roll out, but even from the challenges that are being experienced right now with misinformation, with low vaccine uptake.

Brendan: How does a country like PNG get its 10 million people, not just practically vaccinated, but the actual vaccine that's going to do the job?

Leanne: I think it comes back to that ‘leave no one behind type approach’, whether it's for COVID or whether it's for endemic diseases that we are global citizens.

Tracy: As global citizens, what can we do to ensure we protect everyone?

Well, so far, Australia has contributed to the COVAX vaccine access facility.

It’s also stumped up $500 million to support PNG’s vaccination rollout.

By and large, Aussies seem to be in favour of supporting their Pacific neighbours in their fight against COVID-19.

Brendan: Australia on the face of it looks like it's recognised that it should make a contribution to these global efforts. Is it doing enough?

Leanne: No. No, I would think we're in a fairly fortunate position where we could do more. Certainly, we are an active contributor and I think we can be proud of the support that we've shown to PNG and the region, but the need is great, and we have the tools to actually make a difference now.

Tracy: The balance of nationalism versus global equity or that sense of us all being a global community, when we say no-one's safe until everyone is safe, I sense that some countries, particularly the big powerhouses of the United States and GB and places like that are quite happy to look to help developing countries once their communities are safe and then they'll realise no-one else is safe until they're safe. Is that how you see it playing out?

Leanne: Yeah, look, I think so. Unfortunately, I think many of these countries and probably including a decent proportion of our own, will still feel that there's a self-interest element that needs to be prioritised alongside a development assistance program.

It's great to, to have that knowledge that 83% of Australians, would support vaccines going to PNG, but I guess the flip side or the devil's advocate, there would be that we're in that position where we can. And if we weren't, if we had community transmission, would it be that high? You and I would like to think it would be that high, but would it? So, I think that's perhaps the factor in the US and the UK that is also influencing that approach.

Tracy: And when you talk about the capacity of the country to roll out the vaccines, I think they've got something like 500 doctors and 4,000 nurses for 9 million people. How's that even possible?

Leanne: Yeah. It's possible because of I think the very strong community-based programs that can and are being launched, associated with the vaccine rollout. But it will take time.

We're seeing it takes time here in Australia as well. But I think it will take time in PNG, not only because of that very real operational constraint of the health system and the logistics of getting vaccines into arms, but also because of that gradual process of acceptance that is going to need to occur throughout that program, and there are some fabulous COVID-19 vaccine champions that are becoming incredibly vocal throughout the country now - Professor William Pomat, Dr. Moses Laman, really close colleagues at PNGIMR (Papua New Guinea Institute of Medical Research), Dr. Gary Nou at Port Moresby General Hospital, WHO and religious leaders, I think are doing a fantastic job of really trying to lead.

But it's difficult and they are encountering real difficulties, especially on social media even in their role to do that.

So, I think it will be with time.

Tracy: And as a scientist, sometimes, you know too much. What keeps you up at night?

Leanne: This. And I think it's probably really back to that point of being fearful of how can we manage COVID while also not losing so many of the gains in health systems and health programs for other infectious diseases.

How can it be managed in such a way that there's not other public health catastrophes in addition - to try and minimise that dual burden.

I think I'm not actually very good at change. And yet, we've had to adapt to just constant change - you can't even plan anything really.

So, I think if there was one truly honest answer it’s probably that. How long are we going to have to keep being like, so okay, with just uncertainty around everything.

Tracy: And just finally Leanne, I like to always leave on a positive note. We often think anything is possible. What is possible?

Leanne: I think that science can deliver effective public health interventions with the right support at both ends of the spectrum - the right financial and political support, but then it ultimately needs that community level understanding and support.

It's highlighting the possibilities with effective tools and effective community engagement and showing us how we just have to be doing those things at the same time in order to actually achieve impact.

Tracy: As one of our closest neighbours and strategic partners, PNG offers a stark example of how it’s in all of our interests to make sure that no country collapses under the weight of fragile medical systems.

In Australia, it’s in our national interest to keep everyone safe, so that we can be safe.

HOW SCIENCE MATTERS was produced by Written & Recorded.

This is a Burnet Institute podcast.

For over 30 years the Burnet Institute has been at the forefront of infectious disease research, public health and national health security.

COVID-19 is a complex global health challenge – so join us in the fight against the pandemic and help us remind everyone how science matters.

If you liked this episode, join Brendan and I for our next instalment – Everyone’s an epidemiologist.

To hear more, search for HOW SCIENCE MATTERS on the Burnet Institute website or wherever you get your podcasts.

And please share this episode with two friends, or more. If they’re new to podcasts, show them how to follow our show.

We want this podcast to spread like a virus – but in a good way.

I’m Tracy Parish, see you next time. 

FULL TRANSCRIPT
Episode 2: Are vaccines the silver bullet?

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Tracy Parish: In early 2020 the world looked to science to solve the COVID-19 pandemic

Astra Zeneca, Pfizer, Moderna, Sinovac…

These COVID-19 vaccines have now become part of our everyday conversation – we shorten Astra Zeneca to A-Z, debate their efficacy, question who is eligible for what.

And since the first alarm was sounded about this contagious virus, vaccines have dominated our news cycle.

Mike Toole: One thing that’s been done with new vaccines in the past, and I have direct experience of this with Ebola in the West African country of Guinea, is something called ring vaccination. So, when some cases emerge as they did in the northern beaches, then you can start vaccinating people around where those cases have occurred. That’s been very effective. It was certainly effective with Ebola; in fact, it basically eliminated the disease in that country.

Tracy: As Australia grapples with containing outbreaks of COVID-19, these vaccines offer a glimmer of hope for us all – a COVID-safe life – especially, when everyone is vulnerable.

Heidi Drummer: For SARS-CoV-2, everyone is susceptible to infection. This will not leave anyone untouched in 20 years’ time, we will all have had some SARS-CoV-2 infection. It might be mild; it might be severe.

Tracy: Vaccines are not new. For a long time, they have helped reduce the burden of disease – diseases like smallpox, polio, and measles.

In fact, since 1932, Australians have rolled up their sleeves for community vaccination programs.

We know vaccines help the immune system develop protection from illness – and also prevent infectious diseases.

As Burnets Professor Caroline Homer reminds us, we even vaccinate pregnant mums and bubs. 

Caroline Homer: We vaccinate women for other things in pregnancy – whooping cough, flu – we vaccinate their babies against hepatitis B. Midwives are good at vaccination.

Tracy: This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish.

Throughout this series you’ll meet some of Australia’s visionary scientific thinkers.

You’ll find out what keeps them awake at night as they grapple with a pandemic – and how science is playing a leading role in shaping our response.

My co-host is Professor Brendan Crabb, head of the Burnet Institute, a microbiologist, malaria researcher and one of the best minds in infectious diseases and global health.

Today, a burning issue. Are vaccines the silver bullet?

Heidi: The vaccines are the silver bullet, for sure. We've got to get everyone vaccinated or as many people as we can, who are willing to take the vaccine. I think the risk of infection is obviously massively reduced once you've been vaccinated.

I’m Professor Heidi Drummer and I’m Program Director for Disease Elimination.

It is an exciting time. I think it's been an incredible journey over the past year for vaccines in general, seeing so many vaccines, not only developed, but actually going through the entire life cycle of a vaccine from phase one all the way through to registration. And what that means for the future of other infectious diseases is enormous of course.

Tracy: And being a vaccine expert is now popular. People want to know about it, that wasn't always the case, was it?

Heidi: That's exactly right. Yeah. Everybody wants to know. Every dinner party conversation centres around or what's going on in the vaccines and what's new, what can you tell us? What should we be getting? Should we get this vaccine or that vaccine.

Brendan: I spent the first few months of the pandemic trying to water down expectations of saying, look there's going to be a lot of effort in this field, but we're not certain we're going to get one. And if we do get one, it might not be very good. And yet here we are with this sort of what looks like a plethora of riches. If that's a phrase, did that take you by surprise?

Heidi: A lot of diseases, like the low hanging fruit, vaccines had already been developed against those. So, what we were left with a really troublesome ones, like malaria, hepatitis C, HIV, where vaccine development has been intractable and gone on for years. And we were all feeling like will we ever have a vaccine for these diseases?

So, when SARS-CoV-2 came along, we were a little bit cautious about over promising and under delivering potentially on what could happen when these vaccines went into humans. Now, luckily, it's all turned out beautifully really, and we couldn't have hoped for better, not just to have one vaccine registered for use in humans, but a whole plethora of them. That's been incredible to witness.

Brendan: Why what's different about those that we have trouble with HIV, Hep-C, malaria at that high level and the virus that causes COVID, that's allowed this to work?

Heidi: They're very different pathogens, obviously. For the viral pathogens, they've been in the human population for quite a long time. They've had time to really adapt to being in humans. They know how to evade our immune response. So, it's not easy to actually generate immunity to HIV and hepatitis C.

It's very difficult to conduct a clinical trial for both of those pathogens because you need to recruit tens and tens of thousands of people to actually demonstrate that your vaccines efficacious. There aren't any easy animal models to test vaccines in for those pathogens. So, you're really only option is to go straight into a human study and there's a lot of risk associated with doing that.

So, you can spend a long time optimizing your vaccine candidate before you actually get into a clinical trial. And that costs a lot of money. So, there's a shortage of investment for some vaccines. HIV has had the benefit of billions of dollars invested in it, but it still hasn't come up with anything, promising yet.

So, it's really complex, whereas for SARS-CoV-2, there's the spike protein it's never been in humans before and the benefits doing a clinical trial in a pandemic is there's no shortage of new cases. So we were able to really rapidly understand whether these vaccines worked or not.

Tracy: When did you realize this is going to be a bit more of a thing than just a bad flu as people were talking about it? Obviously as a scientist, you knew so much more and obviously someone working in vaccines as well, but there must have been a moment where you thought this is really quite serious, we need to find a vaccine and we need to find it in a hurry?

Heidi: I think for me, the penny dropped around the middle of January 2020. I was listening to a news report coming out of China and what was going on and I thought, this is it. This is going to be a problem.

Tracy: What flagged it in your head?

Heidi: The increase in the number of cases every day. The fact that we were still allowing flights in and out of China at that time, which gave clearly gave the virus opportunity to seed in multiple countries around the world, which is exactly what did.

We could still probably have gotten on top of it. I think at that point, if we had, have been more aggressive about shutting down air travel around the world. Because I think that was really the mosquito in this case, to draw the analogy with malaria, the airplane was the mosquito that travelled this virus all around the world. 

Brendan: I still can't believe, and I have been involved in vaccines, not as intensely as you, but my whole scientific career. To have it in people in a year. What allowed that to happen? How did we get there so fast?

Heidi: For a number of different platforms, MRNA, the viral vectored platforms in particular. They didn't come out of nowhere. We have been using those platforms for 20, 30 years and using them for different diseases, mostly in preclinical studies, phase one studies had been done and even up to phase three, for some of the viral vectored studies to show that these platforms worked.

But they'd never been to the point where they are actually licensed for use in humans. So, a lot of the groups and the vaccine manufacturers who switched to COVID at that time were able to just swap in the gene for the spike protein of SARS-CoV-2, and immediately hit the ground running by manufacturing the vaccine and getting it into humans very quickly.

And for BioNTech, for example, they had been working on this MRNA vaccine, for 30 years and they partnered with Pfizer because they had the manufacturing and then the distribution side of things. That was their speciality, whereas BioNTech were like the discovers and the early-stage scientists.

So, the putting the two of them together gave them the whole package that they needed to actually advance that Pfizer vaccine all the way through. And then the next thing that happened was as soon as they had initiated the phase one, they were already planning and getting ethics approval for the phase two and the phase three. So, everything just went one after the other.

Normally, what would happen is, you do phase one, maybe for three or six months, you'd review the data, then you'd have to raise money and you go to phase two. So, you'd have a bit of time loss there. It's really shown us that investment in vaccines is a huge part of the equation.

Tracy: While the speed of vaccine development for COVID-19 has amazed even the most seasoned of scientists, the BIG question is – why haven’t we seen this pace and resolve when it comes to other infectious diseases?

Perhaps the answer is, it hasn’t always been a sexy, vote-winning area to invest in.

Heidi: The issue is who's being infected and for SARS-CoV-2, everyone is susceptible to infection. This will not leave anyone untouched in 20 years’ time, we will all have had some SARS-CoV-2 infection. It might be mild, it might be severe.

But for something like hepatitis C, HIV, malaria, people put them in boxes. So, malaria affects people in, tropical areas, mosquito-borne disease. Oh, it doesn't affect us. It affects them.

And for hepatitis C you can say this is a disease of people who are injecting drug users or who don't have access to clean blood supply or clean medical equipment.

So again, it's not us, it's them. Similarly, HIV, it's us and it's them. And I think that definitely impacts our ability to raise enough money for these diseases so that we do get vaccine development accelerated.

And there's also other options. So, for HIV, we now have people living with HIV - people on treatment who live the same life span as people who don't have HIV.

So, there are options. And similarly for HCV, you have direct acting antiviral therapy. And so a lot of people make the argument, if it's so difficult to develop a vaccine for those diseases, why don't we just invest that money in the prevention, strategies - bed nets prep, et cetera, to prevent the infection rather than investing in vaccines.

I think here, we're looking at an infection that will eventually reach everyone. So really the need for a vaccine is just so much higher. It's up there with measles or smallpox.

Tracy: Do you think people realise that it might reach everyone?

Heidi: I think there needs to be a bit of a change in public perception on this.

I think, the vaccines are the silver bullet, for sure. We've got to get everyone vaccinated or as many people as we can, who are willing to take the vaccine. I think the risk of infection is obviously massively reduced once you've been vaccinated.

But we can't say in 10- or 20-years’ time that a variant might come along where our vaccines aren't fully protective, and we may get a mild case of COVID.

Hopefully we won't progress to a severe form of COVID, but it's like the flu. If you get a flu vaccine, I have no expectation that I won't get influenza this year, but I will have an expectation that I won't spend two weeks in bed doing absolutely nothing with a high temperature for two weeks.

I have an expectation that I might have some mild form of flu. So, I think that change in people's mindset needs to occur.

Brendan: This issue of effectiveness, you mentioned disease, severe disease, infection, transmission - How effective are they? Where's the silver bullet aspect that you're most confident about, where are there still uncertainties?

Heidi: I definitely think there's incredibly good evidence coming out of England, Scotland. Israel, of the effectiveness of both the Pfizer and the AstraZeneca vaccine for preventing hospitalisation. Severe disease, definitely a massive reduction, 90% for Pfizer, plus probably around 85% AstraZeneca.

When we get down to transmission, that's where we're still uncertain.

How effective are the vaccines at actually preventing transmission? And one of the difficulties of that is of course, how do you study that? You'd have to do that in households. Find people who are infected and look at transmission in the household, amongst the vaccinated people.

So, it's a really difficult study to do.

Then of course, we've got the variants that are emerging around the world, which also impact that equation. So, what we understand today might not be true tomorrow.

Tracy: So many new buzzwords - efficacy, MRNA - have all come into our vocabulary over the last 12 months in particular. The efficacy of these vaccines people pin their hopes on one that might be 85% efficacy up against 90% efficacy.

Heidi: I think it's incredibly difficult to r compare efficacy in one study versus another study.

The studies are done at different times in different countries. People have used different ‘n’ points. There hasn't been a consistent method of doing the clinical trials around the world. And I guess if that would be one of the take home messages we would say is that we need to really early on in a new pandemic decide what are the ‘n’ points for our clinical trials and tell everyone to use the same one so we can actually compare these.

But even when you do that, we've seen that variants are emerging around the world independently of one another. And not all of the early studies were actually looking at what were the infections? Did every infection get sequenced? Do we actually know?

So, it's difficult to compare across studies, I think. Where I think I have more confidence is in the effectiveness reports that are coming out of say England, where they're actually using AstraZeneca and Pfizer in huge population numbers where you can really start to compare.

 Tracy: While the efficacy of vaccines has been top-of-mind, there’s been another curveball - many different strains of COVID-19 circulating around the world.

The World Health Organisation classifies these variants as ‘variants of interest’ and ‘variants of concern’.

World Health Organisation: Variants of interest have properties, have mutations that have been identified that need further study. Variants of concern have demonstrated changes for example you may have increased transmissibility, there may be a change in disease presentation or severity, or there may be a change in our ability to control the virus with public health and social measures or the use of diagnostics, therapeutics, and vaccines.

Tracy: While viruses constantly change through mutation, in this pandemic the most concerning variants have been Alpha, Beta, Gamma, Delta and now Delta-plus.

So, will these variants outrun the vaccines?

Brendan: Can you tell us a little bit about what variants are, how they've come about and where they sit on your concern-o-meter barometer, and crystal balling a bit. Why have they come about? And are they really a spanner in the works, as far as the vaccine programs concerned?

Heidi: So, variants occur because the virus itself has a limited capacity to correct errors in its genome when it replicates. So, it will naturally generate these errors, it's a bit like a random number generator in a way. And some of the mistakes it makes when it replicates its genome might actually turn out to be beneficial for the virus.

So, it might actually give the virus an advantage in terms of its ability to attach to our respiratory tract cells and infect us, and or, it could actually have a benefit in terms of being missed by our immune system.

So, our immune response that we've generated previously, either that's from a previous infection, or it could be through vaccination, doesn't recognize that variant as effectively. And so, the virus has this ability to expand that population of viruses that our immune response hasn't recognized.

Brendan: So Darwinian evolution we are watching play out.

Heidi: Basically, that's it, it's Darwin in action and it's happening on a microsecond scale at the moment.

Tracy: Do you see them as having personalities? In the way that they behave.

Heidi: I guess the BETA variant would be the Voldemort personality, I think, on my barometer at the moment. I see the alpha variant as being a modest change to the virus in the broad context now that we see these. It did seem to give the virus an ability to be more transmissible, but it hasn't had such a big impact on vaccine efficacy.

The beta variant on the other hand has a couple of mutations in there that are particularly worrisome that really knock out our ability of the antibodies that we generate, either through natural infection or vaccination, to recognize that variant.

On the other hand, the Delta variant is somewhere in the middle. It is definitely looking more transmissible, but the effectiveness of the vaccine still only seems to be modestly effective. So that's somewhere in the middle, I think.

Brendan: Your horror scenario is a mixture of the transmissibility increase in Delta and the immune evasion of beta?

Heidi: Yeah. That would be pretty bad, I think for vaccines, if that combination were to come up – a beta Delta hybrid virus of some description.

Brendan: What are some of the vaccine processes or changes to what we originally thought we might work that we might have to adapt?

Is the variants going to outrun us or can the vaccines deal with it?

Heidi: I think the first thing is we need to basically adopt what we've done with influenza, where we have ongoing monitoring of viruses that are emerging around the world and adapt the vaccines.

We don't know yet how often but let's say annually at the moment, we might think while the pandemic's raging, we might want to think about doing an update annually. That would allow us to create a new vaccine that's matched to the current variant of concern. And we could then give people booster shots.

Where I think the difficulty currently sits is how long are you going to test? And what are you going to test for each of those new vaccines that you develop?

With influenza, we don't currently test any of the annual update vaccines. They get made; they get straight into people – no questions asked. The efficacy will be what it is and the safety we know, so we just go ahead and make the new influenza update every year.

But for this, we're not quite at that point yet, we're still doing quite extensive immunogenicity trials with the variants, as I understand it. And we need to come to some sort of agreement about what is the minimum requirement, so that we can minimize the amount of time we spend testing vaccines before we offer people a booster shot.

I expect we will all have a booster shot at some point in the next year to update our immunity, to match it to what's circulating around the world. And they may be mix-and-match vaccines - that's the other question we need to think about.

If I've had AstraZeneca, can I get a Pfizer booster shot in a year's time or a Moderna booster shot?

Brendan: And what do you think, will we?

Heidi: I think that would be ideal actually, because one of the limitations of all of the viral vectored vaccines is that we actually develop immunity to the viral vector itself, which actually then dampens our ability to boost that response in the future.

We know that spacing the AstraZeneca vaccine three months apart increases efficacy. And we think it's because our immunity to the viral vector actually drops a bit and it gives us a window where we can really boost the response more effectively.

So similarly, if you've had two shots of AstraZeneca, you may have quite significant immunity to the viral vector.

So it might be good to actually switch the vaccine for that third shot that you get or the fourth shot so that you have that boosting capability. Now that's not relevant for the MRNA vaccines because there's no viral vector. You're not developing immunity to anything other than the spike protein itself.

So, for those vaccines, you can probably just think about getting a third shot of the same vaccine. And I understand those trials are already underway in the US, to give people that third shot.

And that's another way actually, of boosting your immunity by using the same vaccine a third time - actually elevates your immunity even higher and gives you that protection against the variants.

 Tracy: Globally, the vaccine roll-out has been anything but streamlined. We’ve seen immense logistical challenges, often with patchy outcomes and inequity.

Social media chatter has reinforced vaccine nationalism, fear, and discrimination, so what does this all mean for vaccine confidence?

Heidi: At the moment in the US, they've approved Johnson and Johnson, Moderna and Pfizer – and AstraZeneca is a vaccine that hasn't been approved yet. But they are actually saying to people ‘you've got the AstraZeneca vaccine, therefore you can't come to a rock concert’, but that could just be a semantic issue really, because the vaccine hasn't been approved yet by the FDA - once it is approved, perhaps they could go to the rock concert.

But it is an interesting question about how we operate as a global citizen in the future. If we're trying to travel around the world and perhaps, I want to go to Israel on a holiday and I've had the AstraZeneca vaccine, would I be able to travel into Israel? I think there needs to be some global agreement reached about this, that we need to accept that different vaccines have been used.

And as long as anyone is vaccinated, they should be able to travel freely. Now that raises, of course, the question of do we have vaccine passports, which I think is another minefield really to navigate through and not one that I have an easy answer for. There are pros and cons to those vaccine passports.

Tracy: And what about if you've had Sputnik?

Heidi: Oh, Sputnik’s great. I'd have Sputnik tomorrow. I think it's a terrific vaccine. And I think, this is another thing we need to really review - perhaps a bit of vaccine nationalism here. Just because the vaccine was developed in Russia doesn't mean it's any lesser, a vaccine than the one that was developed in the US. It actually has shown very good efficacy right up there with Pfizer and Moderna.

Brendan: We still don't just click our fingers and get the vaccine we want, or the whole suite of them. We've got money, this is one of the richest countries per person in the world. What is it about making a vaccine? Why don't we just make them all here? What is it that makes it so tough for us to just get our 40 million doses of X or Y when we want them?

Heidi: Yeah. I think our only vaccine manufacturer in Australia is CSL and they've done an amazing job being able to so quickly switch their manufacturing capacity and capability towards the AstraZeneca vaccine.

We don't have a big enough population, I think, to support multiple CSL sized vaccine manufacturers in Australia. So, it's an incredibly specialized, expensive complex facility that needs to be built.

We've been able to import most of our vaccines from other manufacturers around the world. We've never been challenged like this before to make enough vaccines for the globe all at once on top of our existing manufacturing requirements for all the other vaccines, we need to keep immunizing people with.

Tracy: And so much depends on the supply chain too when the EU decided to block the fact that we were having vaccines coming to Australia.

Heidi: Yeah. And so, I think there needs to be a rethink about this, not just for vaccines, but for so many things that we use on a day-to-day basis in Australia - having that, in country capacity and capability to manufacture products that we need, particularly in an emergency situation like this.

And I also think we need not just large-scale manufacturing, but we need to actually support researchers who are working on all the other diseases, where they just want a phase one trial to get that really essential data, to know whether their vaccine is safe - and whether it generates an immune response in people before they try and ask for big amounts of money to do the phase two.

Tracy: Take us inside the lab and explain what's in it. So, what's actually in a vaccine. Is it like a car where there's different components? I know different car manufacturers are having trouble at the moment because they can't get certain electronic components, for example, which is just holding up all production. Some of those ingredients as such need to come from overseas, or can we produce them ourselves? What's in it. What's in the recipe, Heidi?

Heidi: You usually start with the sequence of the target protein that you want to generate immune response to. You might choose to put that sequence in a viral vector, for example, like an Adenovirus vector.

Tracy: Is a vector like a transportable third party?

Heidi:  It is a little bit like a car. You sit in the car, and you put that car in a garage that replicates the car.

Tracy: Wouldn't that be good?

Heidi: Yeah, so you've got your viral vector, you then put it into it into a tissue culture, which is just, cell line that used to actually amplify that viral vector. So, it goes through a whole series of processes that purify it from all the impurities that you have in your tissue culture experiment. You then take that purified product, and you would use that to immunize. Now, normally we would immunize animals to determine whether that vaccine actually generates an immune response at all and understand how many doses you need.

Then you might actually go back to the beginning and go look, that didn't work particularly well. I'm going to change something about that sequence to emphasize this region where I really want the antibodies to stick to. And so, you might go all the way back to the beginning and re-engineer the whole thing, put it back into the car and put the car in the garage and make lots of new cars and then do the immunization experiment again.

And you might go through that cycle 5, 6, 10, 20 times before you actually land on the final car that you want to drive out of the garage.

Tracy: How do you upscale that? And do it well. And will it change every time you're going to create a new vaccine booster next year, will the parameters change? Which adds more complexity.

Heidi: So, if you've said you've used the vaccine and you've done your stability testing at minus 80, and that's all the data you've got, then that becomes the requirement that the TGA will put on the storage and the use of the vaccine.

So, you need to go back and actually show that, yes, I've got evidence now that I can store this Pfizer vaccine at four degrees for a week. And it still works the same way as I would have used it if it had been at minus eighty and I thawed it and put it in someone straight away.

So, it's actually evidence-based and you need to generate that evidence and present it to the regulatory agency for approval before they'll actually say, okay, you can now store your vaccine at a GP clinic for a week at four degrees.

So, it's not magic, but it's also not witchcraft. It is an evidence-based approach that's required.

Brendan:  It's a great line of questioning because we talk a lot about what the different sort of vaccines are and the innovation behind the MRNA or behind the Adenovirus vector and that's like crucial, but first base.

What we don't talk about is how do you make a vaccine exactly the same way in different factories, all over the world? Exactly the same way, every time, in a way that's perfectly contaminant free and going to behave.

It is really important, I think, everyone understands that there's a so much goes in to being reliably able to put something in your arm that's the same here in Melbourne, as it was in the UK, as it is in Israel and so on.

Tracy: The pressure on scientists to solve this global pandemic is unrelenting. Variants are emerging. Vaccine development is complex. 

For those scientists on the frontline of vaccine discovery, it must sometimes feel like there’s no off switch.

For Heidi, it’s “double the trouble” – she’s married to another scientist. In this COVID-world, together they live, eat, and breathe the science and work as a close unit running a lab.

So, how’s that working out?

Heidi: Oh, it's been fun actually, because we both got right into the lab work to really accelerate what we were doing and create a whole suite of new reagents. And we basically created this really big encyclopedia of reagents for the lab within just a few months.

We're still creating them because we're trying to keep up with the variants now and with the new antibodies that have been discovered. So, we're constantly making new things, but we don't go home and necessarily talk shop.

We just have normal lives. Occasionally we're looking on the phone at a new paper, ‘I'll just send you a new paper’.

Tracy: Come on, how much are you sitting there watching a movie and then you think, look, I've been thinking about that variant. What do you think about such and such? Is it all pervasive? Very few scientists can turn off.

Heidi: Yeah, I guess so. Andy has a lot of other interests though, so he's very diverse. I'm probably a bit more of the person who works a lot at home. I have also found, I've had to find ways of switching off though, because it can become an obsessive thing. So I've had to take up things that I'm not particularly good at.

Tracy: Not knitting?

Heidi: No, painting.

Tracy: Painting by numbers?

Heidi: No, just freehand painting. And it's not about how good I am, but it's about that mindfulness of just taking your mind off work for half an hour and doing something different. Because scientists, I think are an obsessive personality type in general.

Brendan: I'm trying to say as little as possible about this. I even feel like I have to sneak work in home so that it's not noticed.

For Heidi and myself, you go into crisis mode doing what we can for the pandemic. But it's also a very exciting time where science is all of a sudden, the first thing, any news piece, any newspaper anyone talks about. And of course, the science itself is moving very fast. So, it's a really exciting time at the same time.

Tracy: I heard you once say Heidi, that what Australia needed was a vaccine rock star, like Anthony Fauci, have we found one? And are you willing to be it?

Heidi: I don't think I'm the right person to be it, but I think Brendan's doing a great job. I think, definitely we need leadership in this area to really convey a clear message on the vaccines, how they work, safety concerns. And really, I think we need much sexier ad campaigns to encourage people to get vaccinated.

There's still a lot of hesitancy out there which concerns me. And even in the countries that have done an amazing job vaccinating people, they reach about 60% and then there's this plateau. There's probably about 20% of people who are just really resistant to getting a vaccine and are hard to reach. And it's interesting to watch the U S tackle this - paying people to get vaccine or excluding people who haven't been vaccinated from events.

Brendan: Why does that extra 20% or so matter? Why do you think that is?

Heidi: If you've got 20% of a population who aren't vaccinated, that's a big number of people. We've seen how quickly this virus spreads and can find those people.

And with the R-factor going up, creeping up all the time, that becomes an even bigger concern. We probably need to reach at least 80% of people fully vaccinated to start thinking about we've got herd immunity here.

If we've got 20% of a hundred million that's 20 million people who are susceptible. In 300 million it’s 60 million people. That's a massive number of people and that could really put a burden on healthcare systems.

And it just seeds the source of new variants. The whole idea is to suppress replication everywhere, in every country, as much as possible, so that the vaccines we've got today will work tomorrow. We can't keep chasing the virus.

Tracy: What's keeping you up at night.

Heidi: I think the variants are a concern and the lack of vaccines going to low- and middle-income countries is a big concern.

Brendan: I've still been a bit shocked by the degree of vaccine inequity - the difference. We're normally better at that gap, even though it's always a big gap. Is that how you see it?

Heidi: It's wagons around a campfire at the moment. I think countries are going, ‘we've got to get everyone in our country vaccinated,’ and you can understand that. But we've really got to start thinking about how are we going to get Africa vaccinated and how are we going to get the rest of Asia vaccinated?

It's a big concern, and I think the other concern is sequencing capability in those countries. We've got to make sure that they're sequencing the viruses that are circulating there. So, we understand what variants could be traveling out of those countries and reaching us in the future.

Brendan: So, replication, there is obviously bad for them, but it's bad for us too?

Heidi: It’s bad for us. It's super bad for us. They're the viruses of the future. So, wherever you've got high rates of transmission, that's where you're going to get the concerning variants that could emerge, and you don't want them to emerge in the first place. So, getting everyone vaccinated is absolutely essential.

Brendan: Heidi we're in a really unusual circumstance in Australia. Relative to other countries, we've had this zero COVID strategy, no tolerance for COVID in the community.

And of course, that's had its huge benefits. No question about it from a health point of view economically and so on.

As we sit now, we in Australia have a very low level of vaccine coverage relative to some of our peer countries around the world. How do those two things fit together? Are we more exposed or is it a good thing?

Heidi: Yeah, I think we've definitely fallen into a mindset where we think we've got time because it's not here.

So, I think definitely the COVID zero thing has impacted our psychology about when we need to go and get vaccinated.

How do you tackle that? It's really difficult, but I think the outcome has to be, ‘we want to be able to live the life we had two years ago’, and the only way we're going to be able to achieve that is if we're all vaccinated.

And that has to be the message people are given. But people need to understand that we can't continue living in this bubble. It's unsustainable for our society to live like these it's ruining so many sectors of our businesses, our education system, and just generally how we live our lives has been severely impacted by this.

Tracy: Some people are hesitant to have the vaccine, as we said. There's anti-vaxxers and this is just another evolution in their thinking, but then there's conspiracy theorists.

How do we help change views? And do we have a right to do that? And can science change the view of an anti-vaxxer?

Heidi: Well, there's not just anti-vaxxers, there's people who think COVID is a conspiracy theory. We've got a neighbour in our street who we have conversations with about this topic.

He does not believe in COVID. He thinks it's a government conspiracy to control us, etcetera. So, I think those people are probably the hardest group to change their beliefs because they probably already had those beliefs.

But they don't become so important if you reach the rest of the population who you can actually convince to have the vaccine.

Tracy: And just to bring you back full circle, do you believe the vaccines are the silver bullet for any normality in life moving forward?

Heidi: I think they are. They may not be the total solution right now.

I think in countries with high levels of transmission I'd like to see a combination of masks and vaccines in use until they've reached a good level - at least 60, 70% people vaccinated.

Masks reduce the viral load significantly. You're reducing your risk of getting infected. We haven't heard that discussed a lot.

Some of the surges might come when we relax the restrictions on mask wearing after we’re vaccinated, because we're assuming that the vaccine is going to do everything.

But masks could perhaps bridge that gap and further increase the efficacy of the vaccines to do all those other things that we like to do.

Tracy: What we do know about vaccines, is that they work. They prevent disease and sickness. But to do that we need a large percentage of the population vaccinated to achieve herd immunity.

High vaccine uptake, along with other effective public health measures are our strongest weapons against this contagious enemy – COVID-19. 

HOW SCIENCE MATTERS was produced by Written & Recorded.

This is a Burnet Institute podcast.

For over 30 years we’ve been at the forefront of infectious disease research, public health and national health security.

COVID-19 is a complex global health challenge – so join us in the fight against the pandemic and help us remind everyone how science matters.

If you liked this episode, please keep an eye out for our next one – No-one is safe, until everyone is safe.

To hear more search for HOW SCIENCE MATTERS on the Burnet Institute website or wherever you get your podcasts.

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I’m Tracy Parish. See you next time. 

FULL TRANSCRIPT
Episode 1: A year like no other, the pandemic continues

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Tracy Parish: In early 2020, Australians faced a catastrophe like never before.

Brendan Crabb: Well, there’s no doubt Australians don’t have a culture of mask wearing. So, it was phenomenal to be in a circumstance where masks were quite literally flying off the shelf, and we were considering not just what the most appropriate mask was but whether we had availability and how on earth we were going to get enough of them.

Tracy: To help – nearly 100,000 N95 respirator masks were loaded onto a Qantas plane in Los Angeles and were headed towards us – because large parts of Australia were choked from heavy smoke.

Australians were experiencing the worst bushfires in memory.

Bushfire survivor:  Kilometres of fire just coming towards you and you’re thinking how are we ever going to stop that. You could hear it - just a roar coming towards you.

Bushfire survivor:  Kilometres of fire just coming towards you and you’re thinking how are we ever going to stop that. You could hear it - just a roar coming towards you.

Prime Minister Scott Morrison: Despite the scale of this disaster and the tragedies, Australia is not and will never be overwhelmed.

Tracy: This scale of destruction was devastating – and made international headlines. Almost 50 million hectares were scorched – killing people, destroying homes and uprooting livelihoods. But what we didn’t know at the time was that there was an even BIGGER inferno on the horizon – COVID-19. Masks would become part of what we now call, our ‘new normal.’ This is HOW SCIENCE MATTERS. A Burnet Institute Podcast. I’m Tracy Parish. Throughout this series you’ll meet some of Australia’s visionary scientific thinkers. You’ll find out what keeps them awake at night as they grapple with a pandemic – and how science is playing a leading role in shaping our response.

Brendan: I don't know that I thought it would be as 24/7 as it was. But that moment in early March, when there was an open discussion about should Australia let the virus circulate as had happened in other places. I couldn't tell you how serious a discussion that was. It was just enough to say to me for a while I needed to do nothing else.

Tracy: That’s Professor Brendan Crabb, head of the Burnet Institute, a microbiologist malaria researcher and one of the best minds in infectious diseases and global health today. Brendan will be my co-host throughout this series. So, how did COVID-19 begin for him? 

Brendan: That was a Sunday. I worked all day on the Sunday on that message of quite literally writing with colleagues to the prime minister. Go hard, go early message.

Prime Minister Scott Morrison: So that means barbecues of lots of friends or even family, extended family coming together to celebrate one year old birthday parties and all these sorts of things - we can’t do those things now.

Prime Minister Scott Morrison: So that means barbecues of lots of friends or even family, extended family coming together to celebrate one year old birthday parties and all these sorts of things - we can’t do those things now.

Tracy: That was the early days – now, news reports and social media are flooded with stories about the pandemic. From COVID clusters to vaccine hesitancy and the voices of those traumatised from its impact. For most of us it’s been an exhausting time of uncertainty and anxiety. But what’s it like for someone who solves problems like this and provides advice to governments.

Brendan: It was easily the toughest year for me in that respect and especially that first four to six months where I was so worried about the direction that the country and the world would take. Disease can seem abstract to a lot of people.

 

To me, it's very real. You can actually get it, your parents can get it, your friends can get it, and if they get it, they're going to be on oxygen. And you're going to be wondering whether they're going to live. That's very real to me.

You know we’re here a year later-ish and I don't think I can imagine a time that COVID wasn't around. It's been that intense a year, so transformational for every person in the world. But especially for me, who's lived and breathed pandemics and infectious disease for my whole working life.

I can't even remember a time before to be frank. I thought we would have this solved by now as a world.

Tracy: Why were you so positive that would happen? 

Brendan: We've done it before. We've had a few pandemic scares before - related virus to this one SARS of course - 15 to 20 years ago. There've been some other scares MERS and Zika virus and Nipah virus in Malaysia, Hendra virus here in Australia.

We've had examples of how the worlds snuffed those out on and off with Ebola in West Africa. So, I expected that and then as things got going, it, it looked doable. China did it, for example, and I guess I thought with wishful thinking that we would all respond in that way.

Alas, it didn't happen.

Tracy: People are quite cynical about China and how they did it. How did they do it? 

Brendan:  Well, they didn’t know a lot at the time. Of course, we know a lot more now. But the first and most important thing they did is have the right attitude that the best way to live is with no COVID. And if every country, especially every country with resources had had that attitude, regardless of the technique, it would have happened.It doesn't, as we've learnt over the course of the year, really relate to how much money you have, what resources are there.  If you've had the attitude that the best way to live with COVID is without it, by and large it's happened.

Tracy: is one of the successes of some countries about their cohesiveness of their populations and their thinking.

Tracy: is one of the successes of some countries about their cohesiveness of their populations and their thinking.

Brendan: I don't think it relates to the different ways in which societies are governed or their cultures. I think the most important element is his leadership and what flowed from that. The United States in the UK who have been such drivers of the epidemic. Ironically, prior to COVID they were ranked one and two in the global health security index - the official league table of your capacity to respond to a pandemic. So, they should have been the best and they ended up being close enough to the worst.

I know we're different challenges, we're an Island and different opportunities, but we've managed to do it with that very similar culture to the UK and the US. They've got a lot to answer for.

Tracy: In terms of leadership, if we go back to the first rumblings of a threat of pandemic in that probably January 2020 period. Australia, particularly Victoria and new South Wales were being ravaged by Bush fires. Around that time no doubt news was coming through to the prime minister about a threat that was coming in from overseas.

It was a brave move to close the border less than two months later, when Australia was hurting from the effects of bushfires How do you assess the leadership there?

Brendan: I remember where I was down at Lorne, a coastal town in Victoria for a very important malaria conference – we were all talking about it.

But that wasn't the ‘hit me between the eyes’ moment. I think what evolved after Australia made a tough decision with closing its borders, at least to China, was that recognition that other countries and especially two great global health leaders in the US and the UK took a different path. And there was open discussion, especially in UK about this idea that maybe we should let the virus go through a community in different ways, shapes or form that was called herd immunity via natural infection not by vaccination.

Tracy: And Sweden as well.

Brendan: Yeah, it was talked about

Tracy: They very much let it run.

Brendan: They did indeed and that was a big topic of discussion. And we in Australia were wrestling with what do we do? Here are these global health leaders quite naturally, we're looking to see what they did.

And that's when there was a press conference of some sort where the prime minister talked about it, not in any way that said Australia was about to do it, but the fact that it was even a discussion point - that was the moment I went into panic mode and really, I've been 24/7 on COVID ever since that day.

Tracy: You certainly have. I read somewhere when, at the height of COVID Greg hunt was getting anything up to a thousand messages on his phone alone and not able to cope with it. When did it really ramp up for you? Because you were very vocal very early. You pushed hard to make sure that Australia understood the need to consider closing their borders or at least go hard. You talked about go hard, go fast. And when did that change for you that all of a sudden you realise this was going to be a 24/7 life?

Brendan: I don't know that I thought it would be as 24/7 as it was. But that moment in early March, when there was an open discussion about should Australia let the virus circulate as had happened in other places. I couldn't tell you how serious a discussion that was. It was just enough to say to me for a while I needed to do nothing else.

That was a Sunday. I worked all day on the Sunday on that message of quite literally writing with colleagues to the prime minister. Go hard, go early message.

It's actually relatively straight pandemic practice. You don't react proportionally, you act disproportionately - much stronger than the amount of infection suggests you should. That's go hard, go early with the payoff being that you don't have the infection later on.

That means pretty harsh measures. It means shutting borders. It means locking down and so on and so forth. That’s what that very first message was, to firstly say the best thing for Australia is to live without the virus.

It was the first of a number of major public health messages that I've tried to promote in the last year and a half with colleagues here and colleagues throughout Australia.

As for credit, I do credit our leadership, our prime minister and our territory and state leaders, because on their watch - and you could go through it, all the issues of saying, oh, they didn't do this or do that - but on their watch, they have delivered what is at least the equal of the best outcome in the world. And they deserve credit for that. 

Tracy: It became a bit of a catch phrase of leadership -trust the science, we're listening to the experts. I don't think that used to be in their rhetoric. 

Brendan: Unfortunately, a lot of countries that have failed use the same mantra. So, I'm not sure that just our leaders saying it means a great deal. But in the case of Australia, the chief medical officer was really listened to by the health minister and the health minister was really listened to by the prime minister.

So yes, the science has been phenomenally put into the spotlight in this country. And it's science that was real time and it was also science that was 20 and 30 years in the making, which is a story that perhaps hasn't been told.

The reason we can diagnose the fact that it's a Corona virus within days is because we know a lot about coronavirus, because that, that research has been funded over a very long period of time. The reason we knew how to start to make a vaccine from that first day was because those vaccine technology platforms, including for coronavirus, but also for other things have been up and running and being developed literally for three decades.

So, science is very important in real time and very important in history and so to have leaders in this country, quite genuinely listening to it was pretty satisfying.

Tracy: I’ve had the privilege of working alongside Brendan for a few years now and I’m often amazed by his extraordinary brain.

He’s a visionary thinker who couldn’t switch off in the middle of a COVID pandemic – even if he wanted to.

So how hard is it to live inside that head?

Brendan: My brain is much more simple than you portray Tracy so that side of being visionary isn't one I'd concur with. The first thing to say is that the work of the Burnet, where I am now, that I've always been involved in as a scientist, has involved life and death issues, intersecting with poverty and neglect.

So that's been my 30-year work history, stressing a lot about how those things can come together for answers for those communities that are, home to me - they’re not just abstract. So that side of it is something I've had to learn to live with and how it vacillates between being so incredibly depressing and the opportunities so great.

That was normal life and then along comes COVID and a couple of things happen. First is it's right here in our own community, the reality is there for us. We're obviously close to the healthcare sector, my partner Michelle is a medical doctor and the people most likely to get infected in a pandemic are healthcare workers because they're closest to the patients that come in.

And so, it's very real and tangible.

And then the second thing is, the communities that we focus on in our normal daily life, especially here at the Burnet, that happens to be people who are otherwise poor or marginalised or vulnerable, people in the region and throughout the world in those conditions, are far more threatened.

We know it very well, they're far more threatened than us, because you only need a slight upset to a health system that exists in a fragile setting and everything collapses.

More women die in childbirth, vaccination programs for other things, don't progress, malaria, TB, HIV, normal interventions don't happen or don't happen at the same rate.

To me, it's, I viscerally live that and so it's enormously anxiety producing to, to have a pandemic and see that playing out.

So, I do go into a panic mode, but for me, that's channelled into nonstop work and just. I don't know if it ever makes a difference, but I can control that if I leave no stone unturned, as I see it, in doing all, I can.

Tracy: living with a health care worker who is in a hospital setting as well. Is there jumbo containers of hand sanitiser and things at your house. Are the protocols at the front door. Did you make a sleep in the shed? Like I've heard of some poor doctors have done. What were the fears as she came in the door? 

Brendan: I think our, how purchasing of hand sanitiser was a single household that was responsible for the shortage that Australia faced soon after. We did all of that.

As early as February before Australia announced border closure, we had already bought up a couple of weeks supply of food.

Tracy: What did you buy?

Brendan: That's a good question.

Tracy: What was on the list?

Brendan: The biggest things of course were essential things for our little kids, three-year-old twins and making sure we had all of the essentials for them. Tins of lots of stuff and stuff you'd have in the bunker.

We certainly realised that society could shut down for a while and it pretty much did.

But of course, the supermarket stayed open. We didn't bulk buy toilet paper, which is probably a mistake. 

Tracy: So did I and Panadol, if you ever need any Panadol, I’m now looking at the expiry dates on the ones I've still got in the shed.

Tracy: The race to find a vaccine began much like a sporting race around the world.

One of the contributing factors to the pace of the breakthrough of not just one effective vaccine, but several, was science’s collaborative approach.

Collaboration has always been a strength of science, but to discover a vaccine this fast even took Brendan by surprise.

Brendan: I could not have predicted that vaccine development would be anything like this successful in that timeframe. To have, eight or nine strong candidates now, many more on the way, over a million people, over a billion people in fact immunised already, not far over a year since the pandemic is just phenomenal.

It's unheard of, vaccines normally take a decade or two to develop. So phenomenal speed. Yes, built on collaboration. Built on money. A reason for speed is the, is that the amount of money spent on it, didn't matter to a large extent and enabled a lot of clinical trials to happen, that normally take a long time, to happen much faster.

They are this brilliant tool that we've been very fortunate to have been produced in large amounts. But if we are myopically focused on them, we will fail.

And we're seeing, at the moment, countries with huge epidemics in the world with, as a result of letting the virus go, mutant forms of the virus, that are very different to the original form that threatening us for a number of reasons.

And one of the things they threaten is the vaccine program. If we didn't just see everything through the vaccine lens, I think we would have kept the numbers down without vaccines and ironically preserved the potential to use the vaccine.

So, they really have been this double edge, seen as the silver bullet, which is in the end, gonna cost us a bit before we regroup and hopefully use them wisely.

Tracy: You talk about the silver bullet. Some people think we'll all get vaccinated once or have the two jabs and that'll solve that. There's fatigue in the community, not just in Australia, but globally of even addressing the impact of COVID. How do we convince people and even talk to people about what's ahead? It's almost like people aren't willing to even go there.

Brendan: And isn't that so understandable. It's such a difficult discussion to have, unfortunately the keep the virus low in the world possibility has gone.

And when that decision was made, starting in number 10 Downing Street and in the White House and in Brazil, for example, then what that consigned us to was years more of this problem. That’s what those decisions consigned us to.

And so, for Australians, in this relatively COVID free world, it's incredibly hard to conceive of us having to worry about this for 12 months or 24 months or beyond. But unfortunately, that's the reality.

The original Wuhan strain of the virus didn't actually transmit that well. The worst of the variants at the moment, transmits sort of three times faster than that. And then as also expected with Darwinian evolution, the viruses will evolve to avoid the immunity other than natural immunity, or the vaccine induced immunity. And so, we are still learning about what that's going to mean.

What level of vaccination in our community will be enough to cope with these different viruses? Will it ever be, and do we need new vaccines that represent the variants? And can we keep up with that because the variants of today are not the variants of tomorrow.

So, we now have this ongoing learning that we have to undertake and unfortunately live with a very real threat of COVID for years as depressing and hard to grasp as that is.

We have to find a way to do that, in Australia and throughout the world.

Tracy: People are fatigued, so therefore they're almost willing to allow some level of COVID infection to return to Australia and that we just have to live with it.

Others are saying, no, I think it was 70% of the population in a random poll were asked, did they want to open the borders? And they said not if it means, COVID coming back in.

How is that going to be addressed by, by leadership moving forward? When does it become too much? 

Brendan: I think in Australia we've come to value, the vast majority of Australians deeply value what being COVID zero brings. That means no COVID in the community or the occasional leak from hotel quarantine and so on that's squashed.

This is not happening almost anywhere else in the world. But in most places, they have to live with COVID, sometimes a little bit of COVID sometimes a lot of COVID, and that matters of course, for human suffering, but actually living with a little bit of COVID is dramatically different to living with no COVID.

Living on the tenterhooks of knowing that at any moment COVID might break out in your suburb or in your community - and of course, mostly it does, it's a pretty binary thing. There's no method to somehow keep COVID in this suppressed state without lots of public health action of course.

So Australians have come to really appreciate this incredibly precious thing that first we stumbled upon, which is this community elimination. And then deliberately did, especially through Victoria’s second wave in a way that I don't think has happened anywhere else in the world.

What I think we'd need to get through to Australians and particularly to our leaders, it's going to take their leadership, is that all things being as they are COVID zero is the best way to live.

It's a much better way to live and some apocryphal ‘it's okay, we're exhausted, we want to open our borders and a little bit of COVID comes in’. That will be a much worse lifestyle than saying ‘we really value COVID zero, our aspiration is to remain that for the indefinite future until we know much more about variants and in vaccination rates and so on, but we're going to be really ambitious and clever about letting people in and out and not the virus in and out’.

I think Australians think it's precious. We need to reinforce that, but find really clever ways to have borders more and more open. 

Tracy:  And take me back to the dark days of the lockdowns in Melbourne and what it was like to be at the forefront of not only some of the media coverage to try and explain some of the things that needed to happen …

Radio interview with Brendan: What we need to do is to stop community transmission getting to high levels before we have the tools to know where all those infections are and at the moment, we don’t have the tools. We will have them in a matter of weeks to much better degree to what we have now. We’ve got to buy ourselves that time.

Tracy: … but also you would have no doubt felt the pressure among family, among friends. Was there a time where you wanted to keep it a little bit quiet that you're a scientist or that you led the institute and the push that we did through research.

Brendan: What a bizarre time that was. It was a time that took a toll. Of course, I worked at home, I have young kids, as well as older kids.

Tracy: You got to bond with them 24/7 though, what a bonus.

Brendan: I did indeed what a, crazy time that was. My partner suffered a lot too and works also on COVID. So together we somehow struggled through. I think there'll be a bit of our own version of PTSD to deal with someday.

But the, the prize was a pretty big one. At one stage Victoria had 20,000 people infected. It's still a big outbreak, but at that point, you thinking, where are we at the point of no return?

And the decision was taken to try and defeat it. And the decision was taken to finish it off.

And that was the single most important decision next to closing the borders, was the decision to finish it off in Victoria. I think the nation would still be living with COVID if that call wasn't made and it was against enormous pressure.

I was familiar enough with transmission to say that it was much more possible than perhaps what people thought.

One of the quirks of COVID is that most people who have it don't transmit it to anybody. And some people transmit it to a lot of people.

And really it was that quirk, that meant it was achievable. So yeah, that, that was very heady days and congratulations to all of those who made the hard calls here in Victoria and all the support that was received from around that, around the country.

A big decision to eliminate it.

Tracy: Have you ever asked yourself why COVID-19 was the virus that become a pandemic?

I can remember first hearing about it in the news like we did with SARS and MERS and thinking to myself ‘I hope this doesn’t take off’.

So how did this virus manage to evade a lot of the preventions we threw at it?

Brendan: The first thing is to say it's a garden variety zoonosis. So, zoonosis is a fancy word for a virus that is not normally in humans, it’s in animals, and for some reason, or another jumps across into humans. Now it's not normal actually for animal viruses to do that.

Most species out there, all mammalian species, all reptilian species, every species of animal has its own group of viruses, and that group of viruses stick to that species. But occasionally when one jumps across into another species and can, for whatever reason start to transmit the big problem is that no one has any immunity to it.

It's never been seen in the whole, in every single person. So, we're all a hundred percent susceptible in a way that we're not to infections that are normally in us. 

So that's the first thing. It was a standard pandemic but what made it so much worse?

The thing about COVID and it is that it's an in-between virus. It's Goldilocks virus. If it had been much worse, it would have most likely been crushed. You can have worse viruses – Ebola-like haemorrhagic fevers that kill a large percentage of the people they infect.

I don't think we would have had the debates about whether to shut it down completely or let it run through the community if it was a little bit worse.

On the other hand, it is much worse than the flu and different to the flu. Literally 10 times worse for severe disease in all age groups than influenza and influenza is already a terrible disease.

So, this Goldilocks nature of it, not too hot, not too cold, if I'm not mixing my stories is what led to this being such a problem. Worse would have probably been better and led to it being eliminated by now.

This one transmitted readily enough caused enough harm, but not enough to convince every government that it needed to be shutdown.

Tracy: Is that, because they felt that you could live with it. There was a way of containing it in some way, that it was liveable.

Brendan: Yeah. I think they genuinely thought that, and they probably were relatively poorly advised to some degree as well by people who are not expert in pandemics and infectious diseases, but influenced by business leaders and so on.

I wasn't in the rooms, of course, when these decisions were made, but they are pretty dumb decisions.

We're paying a huge price - they were dumb then, and they're dumb now.

But you can see where it came from. Is this terrible? Is it bad enough? What about the economy? It would cost so much shut this down, which of course it does, but what they weren't seeing was pretty obviously how much it costs, if it's left to run.

That's the unfortunate history of COVID-19. So yes, it was in the sweet spot of infection. 

Tracy: To most of us, COVID-19 is an invisible enemy because it’s only scientists that can see the spiky ball shape of the virus in a lab.

But as we’ve all discovered, the more you learn about COVID-19, the more visible it becomes.

Brendan: When you're a microbiologist, like I am, literally the term microbiologist means something you can only see under a microscope.

But I do see it. I see it in this room now that we're in, I see the bugs on our hands on the couch that I'm looking at. I know that they're there. So, it is very visceral, the organisms that are in us, good ones and bad ones. We've got more bacteria in us than we have human cells at that moment.

So, it's not like I see it as a good and evil thing, but I do see it and so do healthcare professionals. And so, they are especially brave because they know exactly what they're getting themselves in for. And yet they rock up with COVID patients being brought into them, knowing that that this could be their day 

But all of that pales into, not so much insignificance, but pales into comparison to what healthcare workers are facing in countries with raging epidemics. Reports of 50 doctors dying in a single day in India.

Can you imagine it was most likely hundreds, if not thousands of healthcare workers more broadly, so I'm not emphasising doctors, it's just a stat. I know as a marker of a tragedy and also as a tragedy in and of itself, the very people you need to help pull you out of the problem. It's just extraordinarily tragic.

The loss for the world, which we can't really calculate accurately now, is already immense. And the impact is going to be way beyond COVID. What we worry about in the health world and in the health science world is the non-COVID impact of COVID, more than we worry about COVID itself, even though we stress like crazy about COVID itself, but it's that big.

And losing a lot of healthcare professionals around the world is one of those reasons.

Tracy: Will it ever be a memory or is it going to stay with us annually like the flu?

Brendan: My suspicion is that we might reach a stage where we want to get rid of COVID altogether. Now that's a big statement. Most people will say the cat's out of the bag we've got to live with COVID forever, and there's every chance that's true. We may not though.

The worlds on a pathway to eliminate polio. It's already eliminated smallpox or eradicated smallpox -that means there's absolutely none in any place in the world. Eliminate means it's gone from particular regions of the world and that's the case of polio, there’s no polio in Australia.

There's no measles in many countries either, and that's on a pathway to global eradication.

But I do worry about what I've seen with the variants of concern, their increased transmissibility and their capacity to immune avoidance, and their virulence, they really are nasty infections that we might choose to get rid of it altogether.

Tracy: Science does have the floor at the moment. The scientists are like rock stars really. Anthony Fauci is probably the biggest rock star of the world. We would never have known his name, a lot of us that weren't connected directly connected with science. We've named these podcast series, how science matters, from a science scientist's point of view what does matter next? What hope do you have for the world in solving not only COVID, but not worrying about the next pandemic round, the corner, which I know you're preparing for already.

Brendan: Science does matter. It's why we're not in the dark ages. It's why we can deal with it. It's why we will deal with COVID.

We just know so much, and science is across the board, it's technical as people understand - develop a vaccine development, drug develop a diagnostic - but it's community, it's modelling, it's understanding disease transmission and so on.

Science matters an awful lot. It's the reason why Australia has eliminated and why the world will end up dealing with this.

The second big lesson is that not only does science matter, the products of science have to be available to everybody. And gee we've learned that in COVID, it's not just a nice feel-good thing to say health care needs to be equitable, if it's not, you pay a big price.

Even here in Melbourne, it was people with insecure work, people in housing commissions, people who are working multiple jobs because they couldn't afford to do otherwise under the radar that were particularly susceptible, making the whole community susceptible.

Regionally in places like Papua New Guinea and Timor-Leste and Solomon Islands and so on, poverty is a major driver and that's terrible for them, but it also helps the epidemic get a foothold in the region and then threatens everybody.

So, we've learned and hopefully the world is still learning more and more that not only science, but everybody having access to science really matters.

I think the final and most positive lesson is that things that we never thought remotely were possible are possible. The development of vaccine in a year is the big one, so many vaccines and so many that work well fully developed into people and making a big difference in the world is just literally 10 times faster than you could have imagined.

There are other just never thought possible lessons. Expenditure is one. What it's okay to spend to crush a health problem is a big mindset change, that it is worth it for the economy, it's worth it for our society to invest big in dealing with health issues. And, maybe that's going to come together in dealing with the biggest challenge of all and that's the rapid global warming and its effects that we tend to think of in terms of 2050 timeframes and so on for when we might reach carbon zero and how we might head off a two degree warming of the planet.

COVID tells us that we don't need to be constrained by that sort of conversation. Be more ambitious. It can be achieved. And, to a reasonable degree, as terrible as it is, COVID is a dress rehearsal for something much bigger, which is the problem we face of the more or less irreversible global warming and its effects.

Tracy: And does anything keep you up at night other than the young children?  

Brendan: I wouldn't say I, I literally don't sleep, but I do stress about the growing pandemic in the world at the moment. I find the juxtaposition of our relative freedom and the degree of crisis that I find hard to explain.

It's all throughout the world, that degree of suffering and stress and worry as people lose their parents and their brothers and their sisters is really distressing to me.

I find myself lying, awake thinking, what more can I do? What more can I do to help influence our government, influence governments in the region, influence scientists, keep our eye on the ball?

We have missed a trick; the globes missed a trick. We've seen in the US and I don't mean to be at all political, but the change of the president made a very big difference. That was an attitudinal difference, not just the arrival of the vaccines.

We need a global attitude change like that. And things will turn around.

So that's what I stress about. What can I do in my little corner of the world to influence that? 

In Australia, every person can ask, what can they do? The first thing they can do is get vaccinated. Stop equivocating Get vaccinated, do it for yourself, do it for your community, do it for your parents, do it for people you love and care about. Don't wait for a minute to get vaccinated. 

Be pro-science. Back those who are working in this space

Tracy: After a year like no other Brendan Crabb continues to focus 24/7 on the pandemic – and he’s determined to see Australia through to a COVID safe reality.

HOW SCIENCE MATTERS was produced by Written & Recorded.

This is a Burnet Institute podcast.

For over 30 years we’ve been at the forefront of infectious disease research, public health and national health security.

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I’m Tracy Parish, see you next time.