A year after New Zealand entered lockdown, Associate Health Minister for public health (and former public health expert) Ayesha Verrall speaks with Newsroom about how the system has changed
When New Zealand entered its first lockdown on March 25, 2020, officials were unsure whether it would work – whether people would comply with the rules.
“The only realistic way to ensure a comprehensive response to the measures in Level 3 and Level 4 is through community-endorsed compliance,” the Cabinet paper mulling the alert level escalation noted.
Ayesha Verrall, however, wasn’t worried at all. As a doctor, she knew most people would accept and follow the health advice they were given.
“I know that most of my patients follow advice and want to do the right thing,” she tells Newsroom in an interview to mark the anniversary of the lockdown.
“If it’s basically the case of me standing at the bedside and asking 100 people to do that, yeah, I think 95 percent of people would. But I guess, talking to colleagues now, they had no idea what that actual number would be. I guess that’s probably not a surprise, but [it] is an amazing feat: That people were so motivated to do the best they could for each other.”
Now, Verrall doesn’t spend her days writing academic papers and chatting with patients, but rather in discussing issues in Cabinet meetings and answering questions in Parliament. The public health doctor who shored up New Zealand’s contact tracing system in April is now charged with managing all aspects of New Zealand’s public health system.
And that system has changed significantly since this time last year, Verrall says.
“Clearly we have seen new things be deployed in the public health response in a way that has never been seen before. As someone who’s now here but was previously working in the health system and public health, that [is what] I have the greatest visibility of.”
Take genome sequencing as an example. The technology has proved fundamental to New Zealand’s ability to identify the seriousness of new outbreaks and stamp them out, but its adoption as a public health tool is relatively new.
Verrall herself was part of a group of public health experts who (unsuccessfully) lobbied the government to adopt whole genome sequencing for fighting tuberculosis and other infectious diseases a few years back.
“It just had such poor cut through. There was some academic interest but no actual public health interest for deploying this, no clear avenue for deploying the technology and certainly no money. Whereas we’ve seen a variety of new technologies roll out to support the public health response. The change in the way that is done and the fact that public health can have things from the top shelf, in terms of technology, is one of the changes.”
New innovations in behind-the-scenes information technology infrastructure has also been consequential, Verrall says.
“We’ve moved from basically health IT systems being a repository – basically a digital set of the patient notes, which offers very little additional functionality over and above paper – to one that offers amazing functionality. It links to the Government’s health IT strategy, but I don’t think it was planned that we were going to start with public health,” she says.
“The principle is that everything has to be interoperable. So, as a result, we can have consumer-facing parts like apps. We don’t currently, but you can see how in the same way, things like wearables could be part of that in the future.”
Making life easier for public health professionals means a more efficient and effective response to public health issues. The Covid-19 response exemplifies the benefits of the new technology, Verrall believes.
“It is changing the way we work. For example, contact tracing is now done throughout the country. We visited Hutt Valley Regional Public Health at the Hutt Hospital where they were tracing the Auckland, Papatoetoe High School outbreak.”
New data collection methods also mean that contact tracing and other aspects of the response can be more easily audited. Looking at the Valentine’s Day cluster, Verrall says the data from the contact tracing effort can be used to vet whether people’s contact labels – casual, casual-plus, close or close-plus – corresponded well with their actual risk levels.
“Because of the amazing data capture that we have, [we can ask], when it comes time to debrief, of those over 5000 contacts going through the system for this outbreak, most of whom are casual, what was the actual risk of Covid in that group? And we can come up with an assessment of whether that is the way we should do it in the future.”
The ‘Verrall report’
Verrall also breaks in here to raise the issue of her own audit of New Zealand’s contact tracing system, performed over the course of a few days in March and April of last year. The report at the time concluded that the system was under-resourced and struggled to deal with even the 70 or so cases a day that testing identified in late March and early April. Any outbreak of a size comparable to what has been seen overseas, where hundreds if not thousands of new cases are found every day, would have overwhelmed contact tracers.
At the time, the audit called for contact tracers to be able to handle 1000 new cases and their contacts every day. It also set up metrics to mark progress against – like what percentage of cases are contact traced in the 48 hours after someone tests positive.
“At that time, the thing I was aware of was the last big test of our contact tracing had been the mumps and measles response, which illustrated the gap between what we could do and what we needed to be able to do,” she says.
But events since her report have shown her that some of the assumptions baked into it might not have foreseen how the response would work after lockdown.
“Even since then we’ve obviously been through these outbreaks and had experience of how the elimination strategy actually plays out. Remember in April we just had that big spike of cases of returning New Zealanders and the associated clusters from there, but I hadn’t appreciated how this year would actually be about chasing up these little fires and exactly how that would play out with these little chains of transmission. Much better than the nightmare scenario I had imagined because of the strength of the border and other controls that have been put in place,” she says.
“What I’ve learnt is that the recommendation to have 1000 cases and their contacts traced a day isn’t actually on the cards for New Zealand because we’re not going to let it get that bad. What we actually need is a contact tracing system that can respond to, basically, the event we’ve just had,” Verrall says, referring to the Valentine’s Day cluster.
“We’ve had to change how we’re contact tracing because this is the real system, not the community outbreak with so many cases. So for example, we’re much less tolerant of risk than even I had envisaged with a contact tracing system that would be part of contributing the elimination goal.”
Alongside new technology and a beefed up public health system, the Covid-19 response pioneered new – or old but long-unused – public health practices. For Verrall, community mobilisation is the key concept here – something that had previously been a crucial tool in the public health arsenal but which fell out of vogue in recent decades.
“One of the methods that we’re using now is community mobilisation, which has really fallen out of use as a tool. That’s how I would describe the Unite Against Covid-19 campaign, as being one in which every New Zealander was called upon to do their bit,” she says.
“We’ve had little bits of it in the past. For example, there’s an example of community mobilisation out at Wainuiomata about school children mobilising to get their community to stop exposing them to smoke in cars.
“One of the questions to come out of the pandemic, then, is how do we build on that renewed confidence in this tool to make positive public health change? So I think about that a lot in relation to smoke-free, for example. But arguably it could be for many other things as well. I think it’s part of the response to some of the challenges posed by Māori aspirations for their own health. You see a community very ready to organise around their health concerns [and] that’s an opportunity.”
Overall, Verrall says, the pandemic’s key lesson has been that we can accomplish amazing things when public health is given he attention and resourcing it deserves.
“Public health has been pretty underinvested in. For 10 years [prior to Covid-19], public health units haven’t had an increase in funding and, in real terms, their funding has shrunk,” she says. That’s true – prior to Covid-19, public health units were receiving a third less funding in real terms than they had in 2010, when funding was effectively frozen.
“Public health practitioners haven’t been able to spread their wings. Now they can bring all their skills to bear to address the pandemic.”