Michael Baker figures he was the first public health expert in the world to talk about eliminating Covid-19, though he’s not sure why.
“Using that terminology which is straight from the infectious disease 101, it’s a really standard term,” he tells Newsroom during a recent interview in Newtown, near the University of Otago’s Wellington campus.
“The world has a measles and rubella elimination approach. New Zealand has theoretically eliminated those diseases. There’s certainly a global polio elimination/eradication programme. So I just thought I was saying the obvious, but it can’t have been the obvious because no one else was saying it.”
This was before New Zealand even made the decision to go into lockdown, when Baker — a professor at Otago’s Department of Public Health and a member of the Government’s Technical Advisory Group on Covid-19 — was the lone voice for what he was then terming a “pulse lockdown”.
Over the course of the pandemic, this role has become a natural fit for Baker. On masks, lockdown, managed isolation and a centralised Public Health Agency, he has lobbied for new and more innovative measures to fight Covid-19 and ultimately succeeded in getting the Government on-side. Perhaps his greatest achievement, however, was convincing the Government to go for elimination.
“It’s taken a while to assemble all the evidence, but the case [for elimination] from a human health point of view and economics point of view seems very convincing,” he says.
A systems view
It took a while for Michael Baker to get where he is today.
The first hint, for him, that a population health perspective could have the greatest impact came in the late 1980s. At that stage, he was involved in New Zealand’s handling of the AIDs epidemic.
“The thing that got me into public health was actually working in Parliament a bit over 30 years ago, when the AIDs epidemic was still really terrifying to people,” he says.
“The Government already was containing the pandemic among men who have sex with men, it was doing really well on that. But New Zealand has a big [injecting drug user] population and they felt that that was really a real weakness. So I went away and worked out the needle exchange programme for New Zealand and we actually became the first country in the world to have a national needle exchange programme.”
From there, Baker learned he enjoyed being able to make a difference on a system-wide level.
“At that stage, I was still a clinician but I had a spell, a bit over a year, working for a minister. I thought I quite liked the view from the top because you could get things done,” he says.
He moved to ESR and helped set up health surveillance systems before hopping over to the University of Otago, Wellington. There, he began to get involved in environmental health, which looked at how housing or the environment might be responsible for poor health outcomes.
Campylobacter, for example, was sickening tens of thousands of New Zealanders every year, but it could be traced back to dirty chicken.
“It was so easy to turn the tap off. They finally regulated the allowable levels of Campylobacter in chicken and our rates halved in three months. It reminded me that regulation and strong government is often what you need. I thought the industry was just doing what it was allowed to do but actually it was government that was asleep at the wheel.”
The final aspect of Baker’s pre-Covid research involved rheumatic fever.
“It is the most inequitable disease in New Zealand and something we are almost alone in the high-income countries in having. It’s Australian Aboriginals and then Māori and Pasifika in New Zealand.”
Pandemic strikes
When Baker first heard about the coronavirus, he found it interesting because of the impact previous novel coronavirus outbreaks — SARS and MERS — had had. However, “most new emerging diseases don’t go anywhere, just by their very nature”.
“And also, you just get suspicious about information coming from certain parts of the world. Certainly from the SARS era, one of the legacies was a slight distrust in the information from China because of the way information is withheld. It’s not even at the federal level, because at the local level, an overly officious [official] can feel they have a need to be economical with the truth.”
As the virus started to spread around the world, modelling from the Imperial College London estimated that the outbreak in China had to be much larger than official reports, based on the rate of overseas infection. By the end of January, a credible group of pandemic watchers in Hong Kong reported that coronavirus was going to be a global pandemic.
“Basically, they said every country in the world should brush off its pandemic plan and not delay. For me, that was the first of these three lightbulb moments,” he says.
“The second one was late in February when we had the report of the joint WHO commission to China. They had a big international group saying that Wuhan had stopped the pandemic in full flight. That seems like a miracle, because no one had ever stopped a respiratory pandemic at that point. So that convinced me that, actually, it was more like a SARS virus and we should act accordingly and try and contain it and eliminate it if possible.
“Then the next moment was in mid-March when it was clear that transmission in New Zealand had gone from imported to local transmission and that we didn’t have anything like the capacity, infrastructure or organisation to stop it, so we had to go for the full lockdown.”
That view wasn’t shared by most others in New Zealand in mid-March. As Newsroom has previously reported, New Zealand ran the initial stages of its Covid-19 response off of the influenza pandemic plan, which doesn’t mention shutting the borders and focuses mainly on how to manage the impacts of the virus once it has arrived.
SARS-CoV-2 — the virus that causes the Covid-19 disease — is not influenza. The key difference from a management perspective is in the incubation period. In influenza, the virus usually becomes contagious around one to three days after infection takes place. This means contact tracing and isolation of cases is virtually impossible, as it would have to occur within a matter of hours at best.
Meanwhile, Covid-19 has a longer incubation period of between three to 14 days. A study in mid-March found the median incubation period is five days – plenty of time to trace and isolate the contacts of someone who has tested positive.
“With this coronavirus, at the level of spread that it got to in New Zealand, if that was pandemic influenza, it would be impossible to control, because the incubation period of pandemic influenza is less and so it will spread rapidly before you can do all the contact tracing,” Baker’s “partner in crime”, University of Otago epidemiologist Nick Wilson, said in April.
“With this coronavirus, with a five to six day incubation period, you’ve got more time and so the ideal pandemic plan would have said: ‘Pathogens can vary enormously and for some pathogens, if they have a long incubation period, you should as a country put a lot more investment into things like contact tracing, case isolation and home quarantine’.”
Eliminating the virus
So while the Government worked to keep the virus out without closing the borders and prepared a rearguard action of managing it, Baker lobbied strenuously for a new approach: eliminate it.
Being a member of the Government’s Technical Advisory Group for the virus didn’t help much, it turns out.
“It never really had strategic discussions. That decision-making was happening elsewhere,” he said.
“I was advocating at those meetings, saying we need to get very strategic about this and switch from influenza to containment approach. That process wasn’t really designed to do that sort of thing, it was designed to look at technical documents and the details.”
So Baker took his case to the media.
“I was talking with the media very intensely, putting out blogs [on Otago’s public health expert website]. You realise that the decision-makers are also wondering what to do and the one common thing is everyone is listening to the media, so that became the way of actually injecting these ideas into the discourse,” he says.
As early as March 18, a week before the country would go into lockdown and while the borders were still open, Baker was telling me he thought New Zealand should launch a “pulse” lockdown for two or four weeks. That we only had 20 confirmed cases as of that day didn’t faze Baker — it only underscored the unique opportunity we had to lock down, eliminate the virus, and open up with a semblance of normality.
When the Prime Minister announced the alert level system on March 21, she indicated we would be in Level 2 for several weeks. Baker doubled down, calling for a lockdown once again. He says sentiment within Government began to change by the end of that day, and on Sunday he took part in a conference call with Jacinda Ardern, Grant Robertson and a number of business leaders who pushed for the Government to move to Level 4.
I’ve had probably over 30 years in the field and just occasionally you see an opportunity where you’ve done something and its made a big difference.
“I have to say, I did shed a few tears then, because it seemed to me like we were really choosing the right direction after a lot of advocacy,” Baker says.
Even then, the Government wasn’t fully on board with elimination, but Baker continued his advocacy. In early April, he published the first elimination strategy for Covid-19 in the world, in the New Zealand Medical Journal. By mid-April, it was clear that New Zealand had managed to quash the case curve and that we had acted early enough in closing the borders and locking down that we could live our lives without Covid-19 in the community.
It was at that point that Ardern and Director-General of Health Ashley Bloomfield began to talk about eliminating the virus, instead of containing or suppressing it.
What’s next?
Looking ahead, Baker is keen to return to his work on rheumatic fever, but he also expects to continue advocating for more strategic handling of the pandemic. The Roche/Simpson review of border testing, released in mid-December, found there was an inadequate level of attention paid to long-term forward planning.
Baker wants a system-wide review of the response to identify these sorts of gaps. A piecemeal approach to reviews, which focus only on contact tracing or only on testing, can miss the sort strategic deficits that had us using an influenza plan to fight a coronavirus in the first place. Arguably, the Roche/Simpson reviewers were only able to find these gaps because they went beyond their remit of investigating how the rollout of border testing prior to the August outbreak was botched so badly.
There are also lessons from Covid-19 for other crises, Baker says.
“This year has been the most powerful demonstration you could conceive of of why you need to invest in prevention and invest in planning for things that don’t happen very often,” he says.
“Everyone says prevention is better than the cure, yet everything is organised the opposite. It’s the simple dynamic that, if you prevent something it’s not visible.”
That leads to a backlash against well-funded prevention programmes, as with the defunding and dismantling of New Zealand’s public health commission in the 1990s.
Another lesson revolves around listening to scientists.
“You need good science and good political leadership together, a fusion of those two. That’s a winning combination. If you have one without the other, it’s not going to work and it’s going to be very frustrating,” Baker says.
He touts the twofold achievements of science in the past year. First, the rapid development of working vaccines for a novel threat is astounding, he says. Second, for the first time in human history some countries have managed to control and even eliminate a virus solely through non-pharmaceutical interventions — masks, social distancing, hand washing, lockdowns and so on — instead of treatments or vaccines.
“The next big lesson I have is that, actually, this thinking we have to apply to other threats on the horizon. If the scientists say that actually climate change is going to be appalling in its health and environmental consequences you need to listen to them and move away from the short-termism,” he says.
“The difference [between a pandemic and climate change] is that [the impact of the] pandemic is a few months away, versus something where the worst effects will be mounting progressively. A pandemic is a transient threat. It may be horrible but it will eventually disappear, probably not on its own in this case but with the help of vaccines, within a couple of years. But climate change is really different. All that CO2 going into the atmosphere doesn’t go out again.”
Despite his concern for the future, Baker says he’s satisfied with what he’s been able to do this year.
“I’ve had probably over 30 years in the field and just occasionally you see an opportunity where you’ve done something and its made a big difference,” Baker says.
I ask him if his work on the elimination strategy counts as one of those opportunities.
“I’m just very relieved,” he demurs.
