Four keys, but only one can unlock this Covid-19 golden cage

For Australia, starting from its position of local elimination, international travel may mean a slight increase in risk and may feel like a step backward. Picture: NCA NewsWire/Jenny Evans

The Australian response to COVID-19 is an enviable success. Australia has achieved what many thought unachievable: elimination of local transmission, and a string of zero local cases across the nation. It leaves us remarkably safe and splendidly isolated — in a golden cage. The challenge now is when and how to open the doors.

At 1134 cases of COVID-19 per million, Australia’s tally is an order of magnitude lower than the US (84,000), Britain (60,000) and Canada (22,000); significantly better than every European country; better even than Singapore (10,000) and South Korea (1700), which are regarded as benchmarks for public health preparation and societal compliance. While COVID-19 did lead to 900 Australian deaths, that is a fraction of what has been seen in other countries; and ironically fewer people died from any respiratory illness last year than from 2015 to 2019, presumably because of the protective effect of social distancing and lockdown on other respiratory illnesses.

This emphasis on health has not deprived us of wealth. The OECD weekly tracker of gross domestic product across nations shows Australia back in positive territory (plus 2.8 per cent as compared with a year ago) while most other advanced nations linger in negative territory and even the US, which emphasised protecting the economy ahead of health, trailing at -1.4 per cent.

This success came at the price of major incursions into people’s lives, huge infusions of cash by governments, significant disruption of business along with the strictest quarantine measures. Thousands of Australians are stuck abroad and international travel and tourism are at a standstill.

How does one leave this golden cage? There are four options.

One, wait until the rest of the world gets to local elimination so borders can be opened with no additional risk (for example, smallpox). Second, vaccinate Australians completely so one can open borders with no risk (as we do with measles).

Third, build an extensive quarantine system so at least a quarter of normal travel can resume yet nothing gets through.

Or fourth, as I think is likely, accept a slightly greater risk of occasional sporadic cases and small outbreaks with minimal mortality as the price of re-entry into the post-pandemic world.

Smallpox is the only human viral disease eradicated and it took decades after effective vaccines were available, helped by the fact smallpox had little asymptomatic transmission. The universal spread of COVID-19 and its common transmission by asymptomatic individuals makes eradication a distant dream.

Fortunately, we have effective vaccines and in a few months most willing Australian adults will have had the vaccine. The vaccines are not yet approved for children, who will remain susceptible to the virus and may spread it around. Also, not every adult will take the vaccine; and even among those who do the efficacy ranges from 70 per cent to 90 per cent. Assuming 80 per cent of Australians are adults and 95 per cent of them take a vaccine that is 80 per cent effective, that will mean only about 60 per cent protection from infection. Those who are most vulnerable (the elderly, those with multiple other illnesses), however, could be nearly universally protected. Such an outcome will likely keep the epidemic in check and minimise mortality but will not stop single cases or small outbreaks.

Australia could continue with its enforcement of strict quarantine and scale it up to accommodate an even larger number.

In 2019, Australia had nearly 20 million international arrivals — half tourists, half residents. Even if we opted for only a quarter of the usual travel, the hotel quarantine system will have to deal with 420,000 arrivals a month. We currently are dealing with only 20,000 a month and even that has created episodic leaks necessitating lockdowns. The possibility of scaling it to deal with anywhere near the normal flow of travel is remote.

This leaves us with only one viable option: at some time in the coming months, when a sufficient number of Australians has been vaccinated, Australia will have to give up on the universal two-week hotel quarantine and will need to settle on some regime of vaccine passports and pre and post testing. While science and modelling can help determine the optimal regime, any practical regime will mean accepting a higher risk than the currently enviable zero cases.

And herein lies the unique challenge for Australia. For the rest of the world, where the infections are on a downward trajectory from their present highs, the slight additional risk of international travel will be absorbed at a time of a decreasing trajectory of risk. It would seem like a step forward. For Australia, starting from its position of local elimination, any such regime may mean a slight increase in risk and may seem like a step backward.

Scientific modelling can tell us how vaccination and testing can be used to manage risk. It cannot tell us what our risk appetite should be. That can emerge only from a federally brokered national conversation. If we hope to leave the golden cage in the foreseeable future, it is time to begin that conversation now.

Shitij Kapur is President and Principal (Designate) of Kings College London.