Inside Story

Precautionary principles

Can infectious disease outbreaks help strengthen Australia’s response to another health crisis?

Melissa Sweet 6 February 2020 2863 words

Test run: passengers leaving a simulated flight at Brisbane International Airport during Exercise Cumpston. Bruce Long/Courier Mail/AAP Image

Back in 2006 the federal Department of Health and Ageing, as it was then called, led a massive operation to test whether Australia was prepared to deal with an influenza pandemic. At a cost of $4.1 million, Exercise Cumpston involved more than 1000 participants from across government and non-government sectors in a series of events and simulations, closely observed by independent evaluators. The exercise was named after epidemiologist John Howard Lidgett Cumpston, the first director-general of the Department of Health and a former quarantine official.

Under scrutiny were medical preparedness, border control policies, decision-making within and between governments, the deployment of the National Medical Stockpile, and public communications. In the three years leading up to the exercise, the federal government had invested $623 million on an accelerated research program, strengthened surveillance systems, a communications strategy focused on health professionals, businesses and the general public, and the development of a whole-of-government national action plan.

The years following Exercise Cumpston saw the release of a series of plans to guide governments’ responses to serious outbreaks of infectious diseases. Between 2009 and 2015, at least five formal reviews investigated how well the health sector had actually responded to various communicable disease emergencies, including the 2009 H1N1 influenza pandemic. In 2018, the Department of Health published an emergency response plan for nationally significant communicable disease incidents, outlining how agencies across federal, state, territory and local governments should work together if a major communicable disease threat arises.

With all this activity, it isn’t surprising that Australian governments were ready to swing into action when concerns began to emerge about the spread of a new pneumonia-causing coronavirus. They could draw on expertise, planning and processes developed over many years.

The novel coronavirus, yet to be officially named, is the seventh member of this family of viruses known to affect humans. While four other strains simply cause cold-like symptoms, the severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) have caused serious respiratory disease outbreaks.

The impact of the latest coronavirus won’t be fully understood for some time, but governments recognise they can’t afford to wait to act. Instead, they are guided by the precautionary principle, as explained by the World Health Organization, “that in the case of serious or irreversible threats to the health of humans or the ecosystem, acknowledged scientific uncertainty should not be used as a reason to postpone preventive measures.”

Political imperatives are also in play: failures in epidemic control tend to be well documented and can take a heavy toll on lives, reputations, national security and economies. In 2003, SARS spread across four continents and is estimated to have cost the global economy between US$13 billion and US$50 billion.

The Morrison government, of course, has had an added incentive to get on the front foot, following widespread condemnation of the prime minister’s leadership during summer’s devastating bushfire crisis. The government was also slow to deal with health-related concerns arising from the bushfires, especially the smoke that exposed millions of Australians to hazardous air quality, in some cases for months.

When health minister Greg Hunt eventually announced funding for bushfire-related health research and for mental health support in affected communities, his statements conspicuously avoided the words “climate change.” Yet an increased risk of bushfires is accepted in the medical literature and by leading health organisations as one of many health-related consequences of climate change. It’s hard to imagine a health minister issuing a statement about an infectious diseases outbreak that does not mention the cause.

This omission is part of a much bigger silence. Last year researchers searched federal parliamentary websites for legislation, programs, policy, speeches and statements on health and climate change, and also scoured the health department’s site for policies, programs or statements on climate change. “We found no engagement in health and climate change by the Australian government during the past ten years,” they reported in the Medical Journal of Australia in November.

“Given the current and projected impacts of climate change on the health of the Australian population, and the related escalation in frequency and severity of extreme weather events,” they continued, “the lack of engagement by the Australian government is of significant concern… The lack of Australian national policy to address threats of climate change to health — and the consequent failure to realise the enormous opportunities that doing so would afford our nation — is disappointing to say the least. This work is urgent and should be undertaken within a complex systems thinking framework.”

“As a direct result of this failure,” the researchers concluded, Australians are at significant risk of worsening health due to climate change, and “substantial and sustained national action is urgently required in order to prevent this.” The Climate and Health Alliance, a coalition of health groups and individuals, has been unable to get a meeting with Minister Hunt despite releasing a draft framework for a national climate and health strategy in mid 2017.

While the government may be hoping that its swift action on the coronavirus distracts media and public attention from its much-critiqued responses to the bushfires and wider climate crisis, there is another possibility. Many people, from cartoonists to health professionals, are drawing comparisons between the government’s responses to viral emergencies, on the one hand, and the broader climate-related emergency, on the other.

“There is clearly a disparity, a gulf between the decision-making based on science as far as the coronavirus and the decision-making based on science as far as climate science,” says
Chris Moy, a GP in Adelaide and president of the South Australian branch of the Australian Medical Association. Dr Moy has been active in public communications around both the coronavirus and the health impacts of the climate crisis, and was influential in the federal AMA declaring climate change an emergency last August.

Since the novel coronavirus hit the headlines, he has been working with health authorities in developing messaging and resources for GPs and the wider community around the outbreak. Yet he can’t remember a time when any health department has asked for his help in climate and health communications.

Why are the responses to these public health crises so different? When I asked more than a dozen health professionals and researchers this question, they put forward many different explanations. “Infectious diseases crises are not seen to be political in an ideological sense,” says a former senior health bureaucrat. “So we just go on as governments and bureaucrats and do things. There is not that whole ideological battle that stops there being a response. In the case of climate change, people think, ‘If I respond, I will be admitting there is climate change.’”

Many also noted that, unlike the situation with the fossil fuel lobby, there is no powerful vested interest actively working to undermine action on the coronavirus, no matter the cost to human health. Rather, there is a general alignment of public, political, professional, economic and commercial interests in seeing the outbreak controlled (notwithstanding the human rights concerns arising when specific populations face quarantine and stigma).

This confluence of interests is evident in the fact that senior federal health officials, including the chief medical officer, have been providing regular briefings to shadow health minister Chris Bowen, who has also toured the National Incident Room at the invitation of the health minister. Yet it almost goes without saying that the health department has not provided Bowen with any briefings on an issue described by the World Health Organization as one of the greatest public health threats facing the world: climate change.

And while questions will be raised about the extent to which Australia and other countries are implementing best-practice policies in the coronavirus response, the prime minister and his team repeatedly stress that they are following medical advice. In an infectious diseases outbreak, scientific and medical evidence has an authority that it has not been able to muster during the slow-burn climate emergency.

Others mention the primal nature of the threat of infectious diseases, and also that it typically takes decades to galvanise action on even significant public health challenges, especially if the responses challenge societal norms, established systems and entrenched ideologies and interests. Some researchers also cite the government’s apparent lack of understanding that climate change is a critical national security threat.

Another explanation is that the causes of infectious diseases are usually more straightforward to understand and seem closer to home. When people become ill from an infection, for example, the cause is usually obvious to those affected and their clinicians. By contrast, the pathway of climate change’s impact on health is complex; how many people who develop kidney disease realise that climate-related heat stress may be a factor? And there are no sophisticated notification systems for reporting the prevalence and impact of climate-related deaths and health problems in Australia, making it harder to engage public, political and policy support for action.

The national and global responses to coronavirus involve considerable complexity and disruption, but the climate crisis demands change that is far more challenging for existing systems and ways of doing business — how we eat, work, travel, power our lives, how we “do” health and healthcare. “An unprecedented challenge demands an unprecedented response,” says the latest report from the Lancet Countdown, which is tracking progress on health and climate change.

This “unprecedented response” must involve more holistic, integrated and ecological approaches to health, according to University of Melbourne honorary professor Kerry Arabena, a descendant of the Meriam people from the Torres Strait and president of EcoHealth International. She argues that these different methods will only become more important as the health impacts of climate change escalate and manifest in increased rates of respiratory and other diseases.

Rather than putting climate change and incidents such as the coronavirus outbreak in separate boxes, we need to appreciate the interconnections, including how climate change is changing the spread of diseases between animals and humans, says Professor Arabena. Governments, policymakers, educators, researchers and practitioners need to develop a deeper understanding of the links between ecological integrity and the health of all species.

In this, she says, they have much to learn from Indigenous peoples. “We really need to be able to take into account the loss of life across all different species and groups, not just privilege our own, because we are all linked.”

After this traumatic summer in Canberra, cardiologist Arnagretta Hunter’s perspectives on climate change are now also informed by lived experience, including prolonged smoke immersion. She judges climate change as the biggest health risk facing Australians, and thinks it is affecting her own life expectancy, including how she ages.

“The magnitude of this threat is huge,” she says. “It will affect all our lives in ways we haven’t begun to imagine. If as a health sector, if our primary concern is the wellbeing, quality of life and life expectancy of the population that we care for, then all of our focus should be on climate change.”

Like Professor Arabena, Dr Hunter believes our responses to the climate health crisis are held back by narrow biomedical approaches to health. Social and environmental conceptualisations of health need to be urgently integrated with biomedical frameworks, she says. “The starting point might be that on a policy basis we recognise that the environment in which we live influences our health profoundly, and that being able to protect things like water quality and environmental security is at the core of what we do.”

She is scathing about Scott Morrison’s failure to act early and decisively on the bushfire threat, following warnings from bushfire and emergency leaders several months before the fires took hold of much of southeast Australia. “Imagine if he had come out with messaging in November and December that is similar to the messaging for the coronavirus, that says this is a serious threat, that you should go into this summer with some preparation,” she says.

“It could have really reduced the mental health impacts of the bushfire season. From a Canberra and south coast of New South Wales perspective, a good number of people went on holidays thinking, ‘Well, we’ve always had bushfires, it’s just another summer, it’s a bit hot, and the PM said, we’ve always had bushfires and then he went on holidays, so how bad can this be?’”

Hunter wants the health sector to communicate the science of climate and health much more actively, and to train health workers to be more knowledgeable and engaged in the field.

“If we don’t address this, if we don’t change the politics of this in 2020… we can see large parts of Australia become uninhabitable.”

Similarly bleak predictions are made by Helen Berry, honorary professor of climate change and mental health at the University of Sydney. Like many climate and health researchers in Australia, Berry has struggled to find research funding and employment, and has been working in a largely honorary capacity since mid 2016.

If the Australian government continues to block transformative climate action, Berry predicts that in coming years Australians will start to move to other countries as the impacts of the climate crisis increase exponentially. As a nation, Australia will start to resemble a declining rural community hit by a brain drain, as people leave in search of the opportunity to take meaningful action and to live in relative safety.

“You will see academics and people like that going first, people in middle age and older with income, young people with ambition, all the people you want here to solve the problem,” Berry says. “Those with the fewest resources will be left to cope.”

Despite the lack of national leadership, many in the health sector and other areas are acting. Next month the WA government will receive detailed recommendations on how the health system should respond to climate change. In June, Queensland will host a symposium and workshops by leading international experts on health-system responses to the climate crisis. Among the participants will be the University of Washington’s Kristie Ebi, who has developed a tool for stress testing how health systems respond to emergencies, and the University of Exeter’s David Pencheon, former director of the Sustainable Development Unit for NHS England and Public Health England.

One of the organisers of these events, Linda Selvey, a public health physician at the University of Queensland who has worked in infectious diseases control and disaster responses in Australia and globally, says the history of infectious diseases control has useful lessons for climate and health action. These include the importance of strengthening health and social systems as part of preparation, investing beyond acute responses in long-term prevention efforts, and continually reviewing and revising plans, Exercise Cumpston–style.

Apart from Western Australia, Associate Professor Selvey isn’t aware of any jurisdiction that has done any vulnerability and adaptation assessment on climate and health. “We need to be continually exercising and stress testing the health system, looking at new threats and preparing for them, and obviously the health sector’s involvement in mitigation is critical; we need to reduce our emissions as part of the overall reduction effort.”

Elizabeth Haworth, a medical epidemiologist at the Menzies Institute for Medical Research in Hobart who has long experience in both infectious diseases control and climate health sciences, also highlights the need for greater public literacy about climate and health. “Few governments have invested adequately in research into climate change and effective responses; the Australian government in particular has cut research funding year on year over the past decade,” she says. “Without really clear evidence and coordinated expert, authority and government advice, the public behaves like ostriches.”

Dr Haworth adds, “Overall and worldwide, though quite distressingly in Australia, disease prevention is weak, especially in a coordinated programmatic way. Australia might do better if it had a national centre for disease control, like many other developed countries.”

Having followed climate science for many years, Linda Selvey was not surprised by the devastating bushfires this summer. She hopes they may be a wake-up call for others who have been resisting action on climate change.

“The extent and level of devastation happening contiguously in so many different places is devastating and the ability of the natural systems to recover, as well as our food and human systems, is going to be really challenged,” she says. “It’s a disaster, but the opportunity is to raise the level of concern and to finally get action. My concern is how quickly those things can fade from the public eye except for those people deeply affected.”

Meanwhile, while we wait to gain a better understanding of what appears to be an unfolding pandemic, it is also important to consider how this will play out for the climate health emergency. The spread of the coronavirus will not only affect health systems, economies and populations. But it will be some time before we fully understand the outbreak’s impact on greenhouse gas emissions, not least because of the health sector’s considerable carbon footprint. •