The immediate appeal is clear, but what is the end point? Frances Cowell takes an in-depth look at the different approaches in the fight against Covid-19 and notes that a zero tolerance level must also be balanced.
The “Russian or Asiatic Flu” pandemic of 1889-1890 killed about seven of every thousand people in the world at the time. For comparison, Covid-19 is recognised so far to have killed four of every thousand, though that is certainly a significant undercount, and the true toll will be known only when excess mortalities are tallied world-wide.
Like Covid-19, the Russian Flu virus was new and little understood, at least at first; but unlike Covid-19, medical science had few tools to learn about and treat the disease, which certainly aggravated the toll it took.
It is now believed that it was caused not by influenza, but by an ancestor coronavirus of Covid-19, which many think may be related to what is now known as a cold. That few people die from a cold these days is put down to widespread resistance through ongoing exposure to it. When it first appeared though, lack of general resistance made it very dangerous. What lessons should we draw from the Russian flue and Covid-19 that might help us prepare for the next pandemic?
First of all, Covid-19 spread quickly because of lack of understanding and some early reluctance to share what information there was. By the time enough was known, snuffing it out, as the first SARS virus had been in 2003, was infeasible in most places. Governments then followed one of four broad strategies. The first was severe restrictions coupled with invasive surveillance of people’s movements. This strategy was favoured by authoritarian regimes and shunned by more democratic governments. They seem to have worked, though reliable data are not always available, and still those countries’ borders remain largely closed. The other three strategies could be thought of as head-in-the-sand, zero tolerance and living with the virus.
Head-in-the-sand policies are characterised by inactivity or even denial by governments, while vaccinating as quickly as resources allow, as Brazil seems to be doing; or reporting cases inaccurately, if at all, while vaccinating at a leisurely pace, as in some East Asian countries. The problems with these approaches are obvious, and governments adopting them are widely criticised for the massive death tolls they engender.
At the other extreme, some countries have effectively eliminated the virus by hermetically sealing their external – and some internal – borders. Notable are Iceland, New Zealand and Australia, all remote islands with relatively small populations. This, zero tolerance strategy is typically coupled with draconian quarantine provisions and immediate, comprehensive confinement of the population each time a single, new case is detected. Implicit in this strategy is an inability or unwillingness to reinforce local health services to deal with a flux of Covid-19 patients.
Yet zero tolerance is proving politically very popular, not least because it has allowed normal economic activity to resume relatively early, thereby truncating the economic and social costs of the pandemic compared to other parts of the world. Perhaps this is why New Zealanders and especially Australians, seem to accept relative slow vaccination rates and, with the exception of some privileged individuals, forfeiting their rights to leave and return to the country, even for the most urgent reasons. More importantly, by effectively stopping the virus’ spread, zero strategy blocks the evolution of new strains and variants, although such small countries do not make much difference to the global aggregate.
By contrast, many governments, notably in the US and Europe, more populous and with very long land borders, recognise that eliminating the virus on their territories is not feasible without unacceptably depriving their citizens of basic democratic rights and freedoms. They have instead resorted to a policy of “living with the virus”. This entails tolerating some level of new infections while, in the case of the EU at least, reinforcing health facilities to keep mortality as low as possible, and investing in massive vaccination programmes. A difficult trick to pull off which, in common with zero tolerance, has necessitated disruptive, stop-go episodes of confinement, and restrictions.
With relatively high levels of vaccination – and presumably therefore immunity, Europeans and Americans anticipate more freedom of movement this Summer, even if life will still be far from “normal”. As part of this deal, most people accept that there will still be a steady stream of new infections and some mortality, though hopefully less and less as more of the population is vaccinated and general resistance builds up.
Of the three strategies, zero tolerance is by far the most popular. You can see why: the immediate benefits are clear. As mass vaccination of the Earth’s human population proceeds unevenly, many have, for some time, looked wistfully to zero-tolerance countries as they enjoy nearly pre-pandemic freedoms. But what of the longer term? How do you exit a zero-tolerance strategy so that people can again travel freely?
People’s desire, and in some cases, pressing need to travel exposes the limitations of zero tolerance. Consider the “travel bubble” between Australia and New Zealand. Introduced on 18 April this year, and burst six days later, when a case was revealed in Western Australia, five time zones distant. Travel bubbles in other parts of the world have had similarly mixed results.
For zero tolerance to eliminate the virus globally, then every single country on earth would need to enforce it equally rigorously. The Australia-New Zealand travel bubble illustrates perfectly how difficult that is. And few countries are as easy to isolate than they are!
The implication here is that, in order to retain the “normal” rhythm within their borders, zero-tolerance countries’ external borders need to remain hermetically sealed until the virus disappears completely – and even then, the risk remains of it reappearing. To see why, consider that even the most optimistic scenario, where 100% of the world’s population is given a vaccine that is 90% effective. That would leave 750 million people vulnerable to the disease. In practice, of course, some people will choose not to be vaccinated and others cannot be because of pre-existing medical conditions, so the actual number of people who can both become infected and pass on the infection, will be much higher.
If even a single case in a distant city causes borders to slam shut, they can never really open in the first place. And as it is very unlikely that the world will ever see the virus disappear, then at some point governments will have to accept some cases and be ready to deal with them. It follows that, if zero-tolerance countries are to restore their residents’ freedom of movement, they will need to adopt some kind of living-with-the-virus strategy. That begs the question of when they will pluck up the courage to tell this to their electors? Not yet, it seems: on 7 May, 2021, the Australian Trade Minister warned that borders may not open completely before the end of 2022. By then the country will have been completely isolated for nearly three years.
Time will tell if Covid-19 ends up being about as deadly as a common cold is now, or more like small pox. In the meantime, governments have a duty to juggle the challenges of protecting their citizens and respecting their democratic and human rights.