Between September 20 and October 4, New Zealand went from being on the verge of eliminating Delta to admitting defeat. Marc Daalder explores what went wrong
The public health advice that landed on Chris Hipkins’ desk on September 19 was optimistic.
Just over a month after the whole country had moved to Level 4 after the discovery of a mystery Covid-19 case in Auckland, case numbers were falling steadily. The source of the outbreak had been identified, almost all of the clusters had been ring-fenced, and the rest of the country was now in Delta Level 2.
“Overall, I am confident that the outbreak in the Auckland region is contained. It appears to have peaked on 28 August with daily numbers generally decreasing or remaining static at low levels as the expected tail of the outbreak manifests,” Director-General of Health Ashley Bloomfield wrote in the advice to Hipkins, one of a trove of documents proactively released by the Government on Friday.
“There has been no indication of any community transmission of Covid-19 outside of Auckland and Wellington throughout the outbreak. Close to 100 percent of known contacts outside of Auckland have been reached and have had at least one test.”
The situation wasn’t perfect. There were 19 known clusters, 10 of which had been linked back up to the broader outbreak and nine which hadn’t been. All but two of the clusters were considered dormant or contained, meaning either no recent cases in the cluster or the recent cases which had been found were all known contacts who had already been isolated.
The two clusters of concern – one involving 73 cases in Manurewa and Māngere households and another known only as “South Auckland Households 2” encompassing 19 cases – were “complex and need to continue to be monitored closely, particularly with respect to welfare and social compliance issues”.
Nonetheless, Bloomfield felt comfortable recommending a move to Level 3 for Auckland and to the full Level 2 for the rest of New Zealand.
While the outbreak was expected to have a long tail, the Government fully intended to return to zero cases and even to maintain an elimination status after reopening the borders in 2022.
Just two weeks later, Cabinet threw in the towel on elimination.
“In previous outbreaks, restrictions have been used to drive case numbers to zero before substantive changes to Alert Level settings are used. Delta has made this approach less effective. Restrictions should now be used to maintain control of the outbreak and ensure it does not become widespread while vaccinations continue,” Hipkins wrote in an October 4 Cabinet paper that introduced the three-step system for easing restrictions in Auckland.
None of the proactively released documents cover, with substance, the 14 days between the triumphant announcement that Auckland could move to Level 3 and Prime Minister Jacinda Ardern’s public acknowledgement that New Zealand would never see another day of zero Covid-19 cases.
But these two weeks proved critical for the fate of the outbreak.
‘We expect to retain elimination’
Early hints of what went wrong are available in the late September documents.
The paper Hipkins took to Cabinet on September 20, which recommended an end to Level 4 in Auckland, conceded that it was theoretically possible that elimination might not be achieved. In discussions of a new alert level system – which would evolve to become the traffic light system – Hipkins said elimination would continue to be maintained into the future.
“At this stage, we expect to retain elimination as a goal under the new approach, but vaccination and more widespread testing will help to reduce the speed and danger of outbreaks, so an individual case will not be an immediate public health emergency,” he wrote.
That, of course, would depend on reaching zero cases again in the present outbreak.
“Our central scenario is that we eliminate this current outbreak in Auckland and then move to the new framework once vaccinations are sufficiently high. But officials are also working on a transition scenario where the current outbreak is not eliminated, and we instead gradually move into the new framework while vaccination rates continue to build.”
This was more of an afterthought, however. All signs pointed to a diminishing outbreak that was fully under control. Sure, there were the two sub-clusters of concern, but only seven cases from the previous fortnight were not linked to the rest of the outbreak. Elimination was at our fingertips, Cabinet felt, and stepping down to Level 3 was warranted.
Gangs and transitional housing
Bloomfield’s warning about the complex welfare and compliance situation in some sub-clusters also proved prescient.
The Ministry of Health’s Director of Pacific Health, Gerardine Clifford-Lidstone, told a September 28 select committee hearing that the virus “seems to have seated itself in a gang environment and the homeless”. These communities “are less likely to be trusting of the health system,” Clifford-Lidstone said.
Just eight cases of Covid-19 were reported in the community that day. Clifford-Lidstone’s comments were interesting, but seized on more for the purpose of gang-bashing than for solving the public health crisis.
In reality, they should have been a massive red flag that something was wrong. The daily case count at that stage still reflected people infected under Level 4 conditions. But if the cases that were coming through were in transitional housing and gangs, that might have flagged more widespread, undetected transmission.
These types of warnings were also delivered to the Government by an independent advisory group chaired by Sir Brian Roche. A September 23 letter and report from Roche were focused more on reopening New Zealand safely, but they highlighted shortcomings in the outbreak response as well.
“The current Delta outbreak has exposed the shortfall in proper engagement of Māori and Pacific providers in the outbreak and overall response while it has also exposed the huge potential of proper engagement even when done at pace,” Roche wrote.
Other issues could be found with the pace of rolling out new technology, the health system’s readiness for Delta and the operating model for the Covid-19 response – Roche has long advocated for a dedicated Covid-19 unit to handle the pandemic.
“Rapid antigen testing is a critical prerequisite – we cannot afford the delays in its introduction that have been experienced with saliva testing,” he wrote. “The current outbreak has revealed the very poor level of preparedness of hospitals for Delta. The system’s ability to deal with Delta and other business as usual functions of the health system has been found wanting.”
The new Covid-19 unit would need to be in place by the time the vaccine rollout finished, “as the current arrangements put the country at unnecessary risk”.
Auckland’s long tail
Some of these warnings were heeded. Few were handled quickly enough.
Even had they been picked up earlier, the lag time between infections occurring and the system picking them up means it may well have been too late to change course when Roche or Clifford-Lidstone’s concerning predictions came in.
Nonetheless, the Government was slow to realise what was happening. When Bloomfield sat down for an exclusive interview with Newsroom on September 29 – just five days before Ardern called it quits on elimination – he said zero cases was still possible.
The day after the interview, Bloomfield expressed frustration at “a persistent tail of cases in Auckland with continuing spikes” in public health advice to Hipkins. This was a first round of advice ahead of the weekend and an update would be provided on Sunday, before Cabinet met on Monday.
“The most recent of these was a spike to 45 cases on 29 September 2021. This was primarily due to transmission in several very large households across several clusters. There remains a risk that the South Auckland sub-clusters may not be contained and continued close monitoring of the outbreak is still required,” Bloomfield warned.
“The virus is now circulating in communities that face complex socio-economic issues.”
These complex socio-economic issues may have slowed down contact tracing, Bloomfield reported.
“Due in part to the short infectious period of the Delta variant, we are now discovering some linkages between cases after a case has been identified, rather than finding cases as a result of contact tracing. This suggests that, while we are continuing to successfully detect the virus, it is ahead of contact tracing in some instances,” he wrote.
“This may be, in part, because some people are not readily sharing information about contacts. It may also be because some of the communities involved face a range of socio-economic challenges, such as homelessness and transitional housing arrangements.
“Service avoidance tendencies of some members of the communities involved can undermine the effectiveness of contact tracing and testing; both require the individuals concerned to come forward and reveal sometimes personal information to authorities.”
Nonetheless, with the outbreak confined to Auckland, Bloomfield felt comfortable recommending the city move to the first step of an easing of Level 3 restrictions, allowing bubbles to mix in outdoor environments. This was based in part on a desire to maintain public buy-in for the restrictions, he said.
“In designing the three stage step-down for Alert Level 3, and recommending the first step be taken, I have considered the need to retain social licence. This matters because without strong community support for, and compliance with, the public health measures needed to contain Covid-19, those measures will not be effective.”
Pressure for Level 2
Even as this report was sent to the Beehive, pressure was mounting for an easing of restrictions. Businesses and some vocal, frustrated Aucklanders called for a move to Level 2.
On October 1, six health experts unanimously urged against moving to Level 2 in comments to Newsroom. Their advocacy was picked up by Ardern’s own Chief Science Advisor, Juliet Gerrard, who shared the Newsroom article on Twitter with the caption, “Clear consensus on this”.
The weekend was tense as health experts read the Government’s foreshadowing of the step system as flagging a move to Level 2 and as the business community pushed for a faster and more expansive loosening of restrictions.
That tension was shattered at 10:44am on Sunday, October 3, when a press release from the Ministry of Health revealed two new cases had been found in different parts of the Waikato.
Health experts grew demoralised. Michael Baker said elimination could still be done, but that for the first time since the strategy was adopted in April 2020, the Government may not have the guts to pursue it.
“Technically, elimination is still possible. It’s just whether there is the political and social will to do it,” he told Newsroom on that Sunday afternoon.
It was now just days after Clifford-Lidstone’s comments on transitional housing and it had already become crystal clear that the virus had seized onto New Zealand’s preexisting inequities.
“We need a different strategy and a rapid refresh based on what we know about the virus and also really getting those representatives from the marginalised groups around the table to say, ‘How do we stop this virus transmitting in those groups?’ If we can’t do that, that is the nucleus of what will sustain the outbreak,” Baker said at the time.
The paper Hipkins took to Cabinet on October 4 had been written prior to the discovery of the Waikato cases and while the pressure in favour of relaxing was at its peak. It had adopted Bloomfield’s recommendation of a step down of restrictions in Auckland through allowing limited outdoor gatherings, but fell short of recommending a full move to Level 2.
Modellers at Te Pūnaha Matatini had simulated the effects of a move to Level 2 and found that this would rule out elimination.
“Under Alert Level 2 assumptions, the main effect of stochasticity is when and how sharply case numbers rise. In all scenarios, more significant transmission would be expected from any undetected cases in an Alert Level 2 environment,” Hipkins wrote.
“By early November, daily reported cases may approach or exceed the outbreak’s earlier peaks in August and results suggest that almost all Alert Level 2 simulations are not contained over the course of October and November.”
In fact, the August peaks were exceeded in mid-October.
The number of unlinked cases over the past fortnight had grown from seven on September 20 to 17 by October 1. In the same period of time, the number of active sub-clusters of concern had grown to five.
The public health teams in Auckland were being run into the ground.
“The workforce in Auckland is stretched, tired and fatigued. There has been good progress through the week to share work across the country and to identify additional staff for Auckland, however, they are having limited impacts on relieving the ARPHS workforce pressures,” Hipkins wrote.
“If there were another significant incursion/outbreak in the next two months New Zealand would struggle to respond like it has in this August outbreak. This highlights the importance of a cautious approach to the current outbreak, however the Ministry and Auckland DHB are actively working to support ARPHS to manage the current outbreak and to prepare for another incursion in Auckland or elsewhere in NZ.”
Public sentiment based on anecdotes
Then Hipkins considered the non-health factors. The current settings cost the economy $250 million a week. Public sentiment may have been turning against the lockdown.
The evidence for this latter claim is thin. Polling from the Government found common emotions had gone from “neutral” and “joy” in July to “neutral” and “sad” in September, though “neutral” was still the most common.
“Most New Zealanders continue to agree with lockdown as an approach and with different Alert Level settings being applied across the country. The level of support for these has remained consistent from July’s survey, however there is less support for lockdowns in Auckland,” Hipkins wrote.
Actual compliance had increased, however, particularly within Auckland. Aucklanders were more compliant than the rest of the country when it came to staying home when sick and to using the NZ COVID Tracer app. There was also broad support for masking.
Proof of declining compliance came from anecdotes and media reports, Hipkins said.
“Police advice that anecdotal information and media reporting suggest compliance with Alert Level 3 restrictions in Tāmaki Makaurau is waning. Examples of breaches include people playing touch rugby, walking on crowded beachfronts (unmasked) and holding gatherings with people outside of their bubble.”
Nonetheless, this still helped sway the Government to relax restrictions in line with Bloomfield’s advice. Even so, Hipkins had by now acknowledged that New Zealand would not eliminate Covid-19.
“Vaccination will play an important part in the management of this outbreak, which is unlikely to reduce to zero cases,” he conceded.
Later on October 4, when she announced the three step system for Auckland, Ardern echoed the same message publicly.
“We’ve managed to largely control the outbreak, but as you can see with this outbreak and with Delta, the return to zero is incredibly difficult and our restrictions alone are not enough to achieve it quickly,” she said.
Ardern spoke about elimination in the past tense. It was clear that, just two weeks after promising a return to zero and just days after Bloomfield himself had said it was still possible, New Zealand wouldn’t see another day of zero cases again.
The next morning, Auckland medical officer of health and public health official Nick Eichler said New Zealand’s failure to eliminate Delta came as a result of its past failure to eliminate racial, economic and housing inequities.
“For anyone upset or anxious about a move away from elimination, always remember that we couldn’t get back to zero because Covid took hold in the communities that ‘mainstream’ society forgot,” he wrote on Twitter.
“Our current situation is entirely due to poverty, housing and colonisation.”