Dr Rawiri Taonui Covid Maori | The Risk of a Second Wave
|06 Aug 2020 19:45 PM|
|Author: Dr Rawiri Taonui|
|Photo images supplied / Dr Rawiri Taonui|
Dr Rawiri Taonui Covid Māori | The Risk of a Second Wave
CURRENT NEW ZEALAND SITUATION
The New Zealand campaign against the first wave of Covid-19 eliminated the virus in 100 days. The first case was notified on 28 February, we closed our borders on 18 March, imposed a comprehensive Level 4 lockdown on 26 March, the last new case was notified on 22 May and the last active case recovered on 7 June.
There have been 65 cases on our borders since 16 June, including 2 Māori and 4 Pacific. There is concern about a second wave of Covid-19. Before assessing that risk, we must differentiate between cases at the border and in the community. The new cases at the border are in isolation and quarantine. There have been no new cases in the community for 75 days since 22 May.
A second wave, spike or surge of a disease is the steady or sudden increase of an infection after a significant decrease. This can impact an entire country all at once or more usually impact separate geographic areas, towns, or areas in cities and at separate times. It can comprise multiple waves sweeping across a country and over several months.
Covid-19 is Accelerating
The rate at which Covid-19 is accelerating across the globe is the main risk to a second wave in New Zealand because this is what generates the greatest pressure on our first line of defence at the border.
The first five million coronavirus cases came at the average rate of 21 days each. The last five million have come at 4.8 days each, and the last million in 3.0 days. At the current 7-day average of 257,991 cases per day, there will be 60 million cases by Christmas. If that rate increases, there could be 70 million.
The True Scale of the Pandemic
The true scale of Covid-19 is higher than the official figures say. Infections are likely closer to 50 million, and deaths, officially around 700,000, closer to two million.
Countries like North Korea, Turkmenistan, Myanmar and Iran are under-reporting probably for political reasons. Others lack the resources to conduct wide-scale testing. Low per capita testing combined with high positive tests indicates significant undercounting in 16 countries in the Middle East, Europe, Africa, Asia and Latin and North America. Comparing antibodies in individuals with official case numbers suggests the real rate of Covid-19 in 10 states in the United States (US) is six to 24 times higher than official figures.
Deaths numbers are also higher. Countries often exclude non-hospital and unconfirmed deaths who were never tested. One study, comparing official Covid-19 figures and excess deaths (deaths higher than averages over the same period in previous years), shows that Covid-19 deaths might be 60% higher than official counts in 14 European countries and 13 other cities and countries around the world. Another shows excess deaths well over official totals in more than 40 states in the US, 12 countries in Europe, and in Indonesia, Turkey, Mexico, Brazil, Ecuador, Peru, and Chile. Excess deaths in South Africa, are three times the official figure of 6,000.
Covid-19 will occur when and if the disease overwhelms the health system, governance, and infrastructure of a country. The situation in parts of the US and Latin America indicate a saturation scenario is possible.
Developing countries have held the line for some time. Many closed their borders well before New Zealand. However, Covid-19 is now well on its way to scythe through these countries as it exploits densely populated urban centres, weak medical infrastructure, and the chasm of inequality between the rich and poor. India, Brazil, South Africa, Mexico, Peru, Chile, Pakistan, Iran, Colombia, Bangladesh, Argentina, Indonesia and the Philippines are now among the highest 24 countries with most cases. Covid-19 is yet to take full hold in Africa. Saturation in any of these countries will have horrific outcomes.
Covid-19 complacency and fatigue are major risks precipitating second waves. Western countries, who have the strongest health systems, have suffered worse numbers of coronavirus during the first wave because, in vain attempts to keep their economies open, they under-estimated the virus, were slow to restrict travel and implement isolation and opted for limited lockdowns. Nevertheless, there was a point bridging May/June when new cases fell across the West. That work was undone through a combination of lifting lockdowns and border restrictions too early and widespread complacency, such as in social distancing.
In both contexts, the US has fared worst. During the first three months of Covid-19 emerging, the US let in 3.4 million travellers, including over 1.5 million from the hot spots of China, Spain and Italy. By April, the USA was awash with Covid-19. And just when many states had begun to flatten the curve, restrictions were relaxed too early. A complacent pro-freedom anti-restriction movement also emerged. Consequently, cases are now on their way to 5 million and many hospitals are running out of ICU beds. In Europe, countries that eased lockdowns too early are experiencing second waves, including Spain, Luxembourg, Belgium, France, Germany and Britain.
Maintaining Border Integrity
It is tempting to open borders once countries have control over the first wave. This is a mistake. Borders must remain secure until international control over coronavirus is achieved.
Montenegro had its first case on 17 March. They imposed a comprehensive lockdown and prohibited public gatherings and inter-city traffic. Peaking at 324 cases, the last first wave case recovered on 25 May, just 68 days after the first. Montenegro declared itself virus-free. Heavily dependent on tourism, Montenegro reopened its borders. Three weeks later, seven new cases were reported. Today, there are 3,000 more. In one month, Montenegro went from virus-free to having the highest per capita rate in the Balkans.
Returning citizens are a main source of second wave infections. Australia operated a successful strategy across multiple states during their first wave. April to June per capita cases were lower than New Zealand. Restrictions were eased. Returning citizens were housed in isolation facilities.
New South Wales used the Police, Defence Force staff and private security to manage isolation. Victoria used only private security. Underpaid and poorly trained, there were two outbreaks amongst the guards totalling 54 cases. With surveys indicating a drop in public willingness to embrace social distancing, the conditions were ripe for the virus to transfer into the community. A survey found 25% of positive test cases were ignoring self-isolation. Victoria now has 12,000 cases, double the rest of the country. The national per capita rate has tripled and now more than twice that of New Zealand.
Racism and inequality translate into higher rates of disease for cultural minorities. The rate of Pacific Island, African American and Indigenous Americans infections and deaths in the US is two to three times higher than the national average. A debacle is unfolding in the Navajo Nation.
In Brazil, serial racist President Jair Bolsonaro has vetoed measures to protect Indigenous communities. In South Africa, rich people and private hospitals are buying all available ventilators stripping the health provision for poor townships and Indigenous communities.
The top 13 Covid-19 hotspots in the US are in prisons. African Americans are disproportionately the largest ethnicity in American jails. Hundreds are reported to have died. Similar concern is emerging for Aboriginal prisoners in Victoria Australia. These experiences have concern for Māori and Pacific communities if there is a serious second wave. Our history is one of death by racism during epidemics.
NEW ZEALAND - SECOND WAVE RISKS
Will there be a Second Wave?
A wave of secondary infection in our communities is “not a matter of if but a matter of when”. Within a month, possible; by the end of the year; probably.
Complacency is a major risk. When New Zealand moved to Level 1, we were asked to remain vigilant and avoid complacency. Unfortunately, that memo did not go to Ministry of Health officials.
Since 26 March, all returning New Zealanders were held in quarantine and isolation facilities. On 16 June, after 24 days without any new cases, two British women, released early from isolation on compassionate grounds, tested positive in Lower Hutt. Stories emerged about poor social distancing in isolation. Hotel staff lacked Covid-19 training. About 1200 of 2200 people left isolation without being tested. The majority were found and tested, 300 were not found and 120 who were found refused a test.
The government has tightened the border. Minister of Education Chris Hipkins has taken over health. Minister of Housing Megan Woods and Air Commodore Darryn Webb have taken charge of isolation and quarantine. Defence personnel and Police have reinforced security.
There have been five escapes from isolation. Each was also quickly resolved. It is tempting to think that escapes from isolation are the main threat of a second wave in New Zealand. That is not the case.
Isolation Facilities | Number, Location and Staffing
After complacency, the main risk is the number of isolation facilities, their location and the number of staff working in these sites. Each is potentially an ignition point for community transmission.
- Number of Facilities
There are 32 isolation and quarantine hotel facilities across five cities: Auckland (19), Hamilton (3), Rotorua (3), Wellington (2) and Christchurch (5). Multiple sites in several cities create a risk of community transmission.
- Facilities in high Māori and Pacific population areas
This is not wise. Rotorua has a 40% Māori population. The Māori population of Hamilton is 20%. Six hotels are in Manukau, the combined Māori and Pacific population is 36%. There is a risk of transfer into vulnerable communities. As in Victoria, one to two weeks of non-detection could have devastating consequences.
- Facilities Staff
Multi-star hotels usually one to two staff per room. Hotel staffing is currently reduced. With an occupant capacity of 7,100, we can assume about 2-3,000 hotel staff. They work alongside 500 Ministry of Health, Defence, Police and Ministry of Social Development staff in isolation facilities. Staff wear PPE and are randomly tested. Staff return home at night. The risk is clear.
There are other people risks at our borders. Freight continues to arrive by air and sea. A 14-day isolation requirement applies to maritime crew. All border staff are subject to regular testing. This is still a point of risk.
Air New Zealand Aircrew must follow strict protocols in flight and during layovers. As such, they are mostly exempt from isolation requirements. If they have had a high-risk layover they are required to self-isolate, undertake testing and continue to self-isolate until cleared. Non-New Zealand aircrew overlay in New Zealand isolation facilities. All returning flight crew should isolate until cleared through testing.
PREPARING FOR A SECOND WAVE
New Zealand’s biggest advantage is that we are one of several water-locked countries, islands and territories. Alongside, Jamaica, Cuba, Seychelles, Taiwan, Madagascar, Greenland, Fiji, Tasmania, and Gibraltar have much lower rates per capita of infections.
Term of Isolation
At some point, we may need to consider our policy 14 days isolation policy. This is standard across the globe. However, new evidence is emerging that in up to 5% of cases Covid-19 can have an incubation period of up to 17 days. Some countries are moving on this, China now requires 21 days isolation, and Bulgaria and Serbia require 28.
There was a lull in testing after we went to Level 1, in part because of complacency, in greater part, because the Ministry of Health handed management for testing back to DHBs and medical centres. They closed several CBACs, particularly in the regions. While testing was free, the doctors were not. People stayed away. The Ministry of Health has moved to re-initiate random testing. Internationally, New Zealand has slipped from the 25th to the 44th most tested country in the world. We need more testing.
Previous official resistance in Western countries to facemask wearing by the public was because the European health fraternity does not like to take advice from Asian medical experts and because the white middle-class health decision-makers preferred to stockpile facemasks for their staff.
This has changed. The World Health Organization (WHO), in its updated advice dated 5 June 2020, now recommends that the general public should wear non-medical fabric masks where there is known or suspected widespread transmission and where physical distancing is not possible, and that vulnerable people and people with any symptoms suggestive of COVID-19 as well as caregivers and healthcare workers should wear medical masks.
About 100 countries now require facemask wearing in certain situations. Today, two months after the WHO announcement, New Zealand said facemasks would be part of our response if there is a second wave of Covid-19. This is positive.
Coordinated Covid-19 Responses
The best Covid-19 responses are thorough lockdowns, widespread testing, comprehensive contact tracing, social distancing, isolation, and face mask-wearing in public spaces. They are also well coordinated. The best engage community co-equally with the government.
Informed by discrimination during the 2009/2010 Swine Flu, such as withholding hand sanitiser from Indigenous communities lest (as alcoholics) they drink it, Canada has the best template for Indigenous peoples, sectioned into Prevention, Emergency Response and Communication. This model focusses on longer-term planning. Our situation is more immediate.
The government has produced a template available through Te Arawhiti “ Māori Crown Relations. Their model is good at organising the dissemination of information from the Crown to Māori communities. Māori (and Pacific) need something promoting equal engagement. Several iwi have developed plans. These have strength in organisational response and assessing community needs.
Plans for a second wave require rapid response. Lockdowns will be local. The principal elements are:
- Understand the history
Māori and Pacific have suffered worse in all pandemics and epidemics to awash our shores. Māori have suffered four stages of pandemic/epidemic: immune-deficiency, impoverished immuno-suppressed, permanent epidemic, and today, intergenerational health racism.
- Understand the Risks
All Indigenous people aged over 50 years of age are at risk. Comorbidities (heart and lung conditions, kidney and liver conditions, smokers, obesity, high blood pressure, diabetes) exacerbate risk. Covid-19 kills the aged and damages the young. Expect remote communities to be isolated. High percentage Māori and Pacific suburbs are at risk. Suburbs near isolation facilities are at risk. Expect racism. Racism is a virus.
- Needs Assessment
Iwi, hapū and community plans are the main priority. Form a coordinating group. Assess your needs. Gather long-lasting emergency food. Stockpile face masks or make your own. Consider Checkpoints. Formulate tikanga plans. Prepare coms.
- Connect with Government
Talk to government departments. Call them together. Scope health care and testing access and delivery. Consider the option of bringing health staff home to work.
- Emergency Response
Be ready to act. Run exercises. Disseminate government alerts and information.
HOW LONG WILL Covid-19 LAST?
We are five months in. Many expected normality by Christmas. Internationally, Covid-19 has not peaked. We have not yet seen the worst. Covid-19 will last well into next year. The social, cultural, economic, and political impacts will increase. Covid-19 saturation could disrupt the international food supply.
Covid-19 is Resilient
Covid-19 does not mutate as fast as other viruses like the flu and HIV. There are minor variations rather than new strains. A new more deadly form of Covid-19 has not emerged. There is debate about whether one of the new mutations is more infectious than the original. This is not confirmed. Nevertheless, Covid-19 is resilient. It is less deadly (500 to 1500 deaths per 100,000 infections) than SARS (15,000 per 100,000) but more deadly than flu (1 to 10 per 100,000) and more infectious than both and over a longer period including being infectious when not showing symptoms. Some suggest Covid-19 will decline in summer, like influenza. With soaring cases in both hemispheres, this seems unlikely.
The Old and the Young
The death rate for older people is higher than for younger persons. However, no one should be complacent about the young. Evidence shows serious post-recovery issues for young and old, including scarring of the lungs, high rates of blood clots due to inflammatory responses to infection causing lung blockages, strokes, heart attacks, and other complications with serious, lasting effects. Young people who suffer strokes are less likely to die but as many as 40-50% are unable to return to work. As many as 20% of all cases young and old suffer heart damage. There is concern about long term neurological damage and male infertility. There are also cases of Multisystem Inflammatory Syndrome in Children associated with Covid-19 in the very young.
A Vaccine for the Rich
There is an emerging consensus that the world will need a vaccine to defeat Covid-19. There will not be an accessible vaccine until toward the end of next year. There are 170 vaccine projects. Six are in final trials. One advanced project, a partnership between the German company BioNTech, Pfizer in the US, and Fosun Pharma in China, aims to produce 1.3 billion doses worldwide by the end of 2021. The US has paid $1.5 billion in advance for up to 600 million doses. Japan has paid for 100 million. A vaccine will be a race between the rich and the poor.
Noho haumaru, stay safe and self-sovereign
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