Analysis: Seven weeks after the Government promised to regularly test all border-facing workers, it was nowhere close to having done so. How did the Government so badly botch its border testing promise? Marc Daalder reports
On Thursday, Ashley Bloomfield admitted what experts and officials had been saying for a week: The Government was forced to plunge Auckland into Level 3 lockdown over a border failure.
“What we can rule out is that the first infection doesn’t seem to have been from contamination from a refrigerated product. Which means it’s more likely to be, and probably always was, person-to-person,” the Director-General of Health told reporters.
Testing of samples taken from chilled goods found little or no evidence of SARS-CoV-2 on surfaces in Americold facilities. Occam’s razor would indicate that the virus then made its way from overseas via a person – perhaps a worker on a cargo ship or a returnee in managed isolation – into the community. With low rates of community testing (just eight tests were conducted outside of managed isolation and quarantine (MIQ) facilities on July 21, for example), the virus was able to spread for at least a week-and-a-half without detection.
By the time the outbreak was identified, the lack of any obvious connection to the border or the MIQ system meant the Government had little choice but to shut Auckland down and put the rest of the country at a heightened state of alert, in an effort to blunt or halt any ongoing chains of transmission. Although the response to the outbreak itself has received praise from health experts, the Government has been beleaguered by revelations that a promise in June of “regular health check and asymptomatic testing of all border facing workers” was never kept.
How did that crucial policy fall through the cracks?
Policy by announcement
On June 23, David Clark was running late.
The then-Health Minister was due in Wellington for the early afternoon release of the Government’s national testing strategy, which Cabinet had approved the previous day. Plane delays meant, however, that he was stranded at Auckland Airport for most of the day, missing the sitting of the House and arriving at Parliament at 5pm for a press conference that had been scheduled for 4.30pm.
When he at last arrived on the black-and-white tiles in Parliament Buildings, Clark unveiled the new strategy.
“Its basic premise is that we want to continue to make sure that we have one of the safest regimes at our border in the world and that we continue to be able to test to convince ourselves to be sure that that strict border regime is continuing to be effective,” he said.
One part of the strategy as announced was regular testing of “border-facing workers” – which the Ministry of Health’s testing strategy says “includes but is not limited to managed facilities where arriving travellers are housed, those working in the shipping industry, at ports and in frontline contact roles with international arrivals (e.g. customs, biosecurity, aviation)”.
The announcement came after a whirlwind week of scandal – the previous Tuesday, Bloomfield had revealed two returnees who eventually tested positive for Covid-19 were allowed to travel from Auckland to Wellington without a test and before their 14 days in managed isolation were up. Over the subsequent days, officials revealed that more than 1,000 people were allowed to leave MIQ facilities without a test despite the imposition of a requirement on June 8 that every returnee be tested on days three and 12 of their stay.
Clark minced no words at his June 23 press conference on the testing strategy, promising “there will be an expectation that people working in those [border-facing] roles will be tested regularly, because we want to make sure that our borders are safe. We know that New Zealanders have put an incredible amount of effort in – with the Government moving early, New Zealanders’ sacrifices mean we are where we are. Those borders are the thing that we want to make sure are secure.”
Under questioning from reporters, Clark was unable to say exactly how often these workers and high-risk airline crew would be tested, saying the time period would be “set clinically by experts”. But he did guarantee that the testing would occur regularly. When asked why he would have confidence in the system to implement asymptomatic testing of border-facing workers when the testing of MIQ residents fell through, he did not answer the question.
Strategy differs from the plan
Evidently, the Ministry of Health didn’t get the message.
The “technical version” of the national testing strategy document states: “Screening of all asymptomatic border facing staff would represent a zero-risk approach, however given that risk mitigation measures are in place at the border, the invasive nature of the available test and the fact that the role of asymptomatic infections in the spread of disease cannot be verified this approach is not thought to be viable”.
It is unclear when this plan was released – the Ministry of Health website dates it as June 2020 but metadata on the document itself indicates it was only created on July 21.
So, did the Ministry of Health ever attempt to implement a plan to test all asymptomatic border-facing workers? That remains unclear – ministry officials on Thursday refused to answer Newsroom’s detailed questions on the subject.
On Wednesday morning, Air Commodore Darryn Webb, who is in charge of the MIQ system, indicated testing was voluntary and widespread testing was not pursued.
“Certainly in that early stage, testing for personnel was a voluntary arrangement. What we were of the view of [was] that asymptomatic testing wasn’t necessarily going to conclude anything categorical either way,” Webb told TVNZ.
David Willis, the director of the Nurses Society of New Zealand, similarly indicated that asymptomatic testing was not a priority for the Ministry of Health.
“Routine asymptomatic testing of personnel whilst important is obviously not the only risk mitigation measure that needs to be applied, and arguably may have been seen by some as a lower priority than some of the other measures. Hence that may have be a factor in the delay with the implementation of the routine asymptomatic testing of all personnel,” he told Newsroom.
“At the operational level testing was not mandatory for asymptomatic personnel until last week so that probably made some believe it was not essential.”
However, he said that there was a move in the works for more on-site testing at MIQ facilities.
“Things were being geared up for the nurses in the MIQF to do testing onsite. Training for this had occurred earlier in the month,” he said.
Testing wasn’t happening
Either way, very few border-facing workers have been tested in the intervening weeks.
Over the almost six weeks between the June 23 announcement and August 3, just 1,089 border-facing workers in Auckland were tested for Covid-19, according to Ministry of Health data released to Newshub. That amounts to less than 36 percent of the border-facing workforce there.
Webb also revealed that, in MIQ facilities, just two in five staff had been tested prior to the advent of mandatory testing on August 12.
The revelations from Newshub led to Health Minister Chris Hipkins saying the ongoing testing “has not met the very clear expectations of ministers”, something Prime Minister Jacinda Ardern has seconded.
Although Hipkins insisted he was not aware of the poor state of testing of border-facing workers, he was forced to walk that back in Parliament under questioning from National Party health spokesperson Shane Reti.
“Since I became the Minister of Health, and it’s been, I think, by my count, roughly seven weeks now, I have been receiving regular updates on the scaling up of testing at the border. I’ve been receiving that information primarily to inform my Cabinet colleagues each Monday, but also to be prepared for the regular press conferences that I’ve been doing on Tuesdays and Thursdays, where I’ve answered extensive questions on the rate of testing at the border,” he said.
“So did those regular weekly updates demonstrate incomplete testing at the border?” Reti asked in response.
“Yes,” Hipkins said.
Why did it take seven weeks?
How did this happen?
Bloomfield has been unable to give a clear reason why the Government’s intended testing plan was not in place after seven weeks. However, he did indicate that the health system simply didn’t have the capacity to roll out a complex plan in less than two months.
“There seems to be a massive lack of understanding of how much pressure the health system is under. The fact that it was under-funded probably for decades – that’s why we had to shut down in the first place …”
“There was a degree of complexity in rolling out regular testing amongst a large number of workforces in a large number of settings and it required a degree of coordination between the health system, including the District Health Boards making an increasing number of teams available to do that, whilst not compromising any other very important testing both in the community and the day three/day 12 testing of the guests in the MIF facilities,” he said Thursday.
“It required a lot of coordination because of the number of workforces and an increasing number of sites with the addition of airports and of maritime ports. We were in the process of rolling that out. There was testing being done and of course it just required more scale-up and more coordination across government agencies to ensure that all the staff who required testing were being rotated through. And that’s the planning we are doing now so that it’s sustainable.”
Siouxsie Wiles, a microbiologist and expert on infectious diseases at the University of Auckland, told Newsroom she thought the system, operating at peak capacity at Level 1, simply wasn’t able to cope with the requirement to regularly test thousands of people in 32 different MIQ facilities as well as Auckland Airport and ports around the country.
“There seems to be a massive lack of understanding of how much pressure the health system is under. The fact that it was under-funded probably for decades – that’s why we had to shut down in the first place – it needed a massive investment in order to ramp up contact tracing and all these kinds of things. At Level 1, the health system is doing all of the stuff it’s supposed to do and then we’re asking it to do something quite extraordinary on top of that,” she said.
“The fact that it’s taking time to ramp up is not surprising at all. It’s not a failure, it’s the way the system works. Frankly, if we want a system that can respond at a minute’s notice, there has to be huge amounts of slack in that system. And there isn’t. You get what you pay for.”
Clinicians spoken to by Newsroom said they still weren’t operating at pre-lockdown levels even at Level 1, but agreed the broader health system simply isn’t structured or resourced to cope with changes of this size.
“In the circumstances the delays may have been more or less inevitable. Resourcing in terms of funding has never been an issue. The use of outside contractors was understandable for initial health staffing of the MIQFs. This use of outside private sector providers may have contributed to many of the hiccups. Moving to DHB control and management of the health staff MIQFs earlier might have made a difference in some areas including onsite testing,” Willis said.
David Murdoch, an expert on infectious disease at the University of Otago, Christchurch and an associate of one of the labs running Covid-19 tests, said lab capacity wouldn’t have been an issue during Level 1.
“I would not have thought it was lab capacity. The lab has had capacity. I’m not aware that there would have been an issue with testing capacity in the lab,” he told Newsroom.
But there are plenty of other potential blockages in the system.
Did the health system fail us?
Des Gorman, an expert on health system design and a professor at the University of Auckland, believes the structure of the system simply couldn’t operationalise the necessary measures.
“This is a systems failure. It is not a public health failure, per se. It’s not an infectious diseases failure, per se,” he said.
“It’s failed governance, it’s failed management and it’s a consummate loss in trust and confidence.”
“So you turn around to a policy shop and say: Take on a command-and-control function for a complex operational issue like this. You shouldn’t be surprised that we’ve had six months of absolute bungling.”
There is no central, operational body in New Zealand’s health system, Gorman told Newsroom.
“The health system – particularly the Ministry of Health – is not remotely equipped to take on a command-and-control function. It’s a policy shop. And day-to-day governance of the health system is with the District Health Board boards. So it doesn’t even have any governance experience.
“So you turn around to a policy shop and say: Take on a command-and-control function for a complex operational issue like this. You shouldn’t be surprised that we’ve had six months of absolute bungling.”
In an editorial for the New Zealand Medical Journal released on Friday, Gorman and former Treasury secretary Murray Horn argue that the ministry should be stripped of its operational role for the duration of the pandemic. That would instead be assumed by an independent board, inspired by the board of the Reserve Bank of New Zealand, with business experts, union leaders, health experts and politicians. This board would also carry out operations with more transparency, including publicly releasing documents like resurgence plans.
“The primary focus needs to be on reducing health and economic risk and maintaining public trust and confidence,” Gorman and Horn write.
This is the latest call for some sort of new body to take over operational and public health functions from the Ministry of Health. University of Otago epidemiologists Michael Baker and Nick Wilson have long argued for an independent public health body, as exists in most other countries.
Baker says Taiwan’s model, with a public health body in its Centers for Disease Control and an emergency operational pandemic agency, the Central Epidemic Command Center, is part of what allowed it to respond so well to the Covid-19 pandemic. Taiwan has had just 486 cases of Covid-19 and seven deaths.
ACT Party leader David Seymour is also a fan of a special epidemic body. On Thursday, the party announced a policy to create an Epidemic Response Centre.
“New Zealand’s Epidemic Response Centre would be tasked with maintaining elimination while maximising overall wellbeing. Its first task would be to improve contact tracing to the standard that lockdowns are not required to contain an outbreak with a single chain of transmission,” the policy promises.
“We’re such a small country, at a certain point you have to say, actually we have to put a whole lot of these population health functions together into organisations of critical mass. That also makes it much more adaptable because they’ve got more surge capacity. There’s no accident all around the world, pretty much every high-income country has a dedicated public health agency,” Baker told Newsroom in April.
“The line is repeatedly: We must spend more on prevention, prevention is better than a cure. All this other stuff that is trotted out and it almost sounds trite and predictable, because then we do the opposite. The way we organise our systems is we systematically, not deliberately, but have just eroded these capacities for 20 years. It’s not even one particular government doing it. It’s just winding them down and worse than that, in New Zealand, fragmenting them into little bits.”
