ANALYSIS
Decisive but agile.
That was what the Government needed to be in response to the Covid-19 crisis, according to epidemiologist Sir David Skegg.
The virus was so unknown that the Government had to be able to change its mind in light of new evidence, yet the consequences of inaction were catastrophic, with estimated death tolls ranging from 14,400 to 80,000.
The rush into lockdown was so imperative and sudden that Prime Minister Jacinda Ardern warned that it would not be perfect - and it hasn't been.
People haven't been tested when they should have been, frontline workers have been frustrated over personal protective equipment, and distribution issues have hindered the early rollout of the flu vaccine.
There has also been confusion about what is and is not allowed under lockdown, and what does and does not constitute an essential service.
But as we pass the halfway mark in the minimum four-week lockdown, there is really only one criteria for success.
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Skegg said that New Zealand was in a "brilliant" position to be the only western country in the world to eliminate the virus.
The signs of success, Ardern told us, would start emerging at the beginning of this week, and the number of new cases has levelled off and even started to fall.
"Cautiously optimistic" and "doubling down" on compliance were the phrases Ardern used this week, treading a fine line between delivering good news while stressing the price of any let-up.
She has made early, bold decisions, but she has also shown flexibility to adapt as the feast has continually moved.
The first test was done on January 22, but the number of daily tests only reached double digits twice in the first five weeks.
The initial testing criteria had a high hurdle to clear, with sign off needed from a Medical Officer of Health.
The daily number remained mostly in the mid-30s or lower until the criteria was changed on March 14, ditching the sign off and enabling a test for someone with symptoms and a link to either overseas travel or a confirmed case.
As anecdotes poured in about testing requests being rejected, Ardern defended the criteria, saying repeatedly that if a clinician wanted a test done, it would be done.
• Covid19.govt.nz: The Government's official Covid-19 advisory website
Experts including Otago University epidemiologist Professor Michael Baker started making public pleas for more testing, and the daily numbers started to ramp up, topping 1000 for the first time on March 18 and ballooning to 2592 a week later.
But it didn't really reach a decent level until Ardern broadened the criteria again so that anyone with symptoms - regardless of any overseas travel or close contact with a confirmed case - met the criteria.
She announced that on March 31, a few hours after Skegg told MPs: "I keep hearing of patients that should have been tested but they weren't because they had not been overseas recently."
She has, however, pushed back on any suggestion the criteria should have been loosened earlier, saying it has always been at the discretion of clinicians.
Yesterday saw more than 4000 tests in a day for the first time, and the total number of tests - 46,875 - puts the per capita testing rate higher than South Korea, long considered the benchmark.
Epidemiologists have been reluctant to pat the Government on the back until there is comprehensive testing data, which remains a key factor before the lockdown can be lifted.
The previous testing criteria meant that the data was skewed towards cases linked to overseas travel or those who were close contacts to confirmed cases.
In other words, the data doesn't really show the prevalence of Covid-19 in communities because general testing hasn't been done - particularly among demographics or regions where access to testing is limited.
Is an outbreak spreading undetected?
Another issue was that the data was not published, and experts wanting to contribute were in the dark.
Director General of Health Ashley Bloomfield seemed to acknowledge the issue yesterday when he released, for the first time, the ethnic breakdown for the tests of 35,000 people.
The breakdown was: European (64.2 per cent), Maori (13.6 per cent), Asian (12 per cent), Pasifika (7.8 per cent) and Middle Eastern and Latin American (2 per cent).
This is not too dissimilar to the ethnic breakdown of the population: European (70.2 per cent), Māori (16.5 per cent), Asian (15.1 per cent), Pasifika (8.1 per cent), and Middle Eastern/Latin American/African (1.5 per cent).
Bloomfield added that the contact-tracing platform is being linked to lab-testing data, which will show where the gaps are by region, ethnicity and age group "and so on".
The Ministry of Health is now moving to fill these gaps, including using what is known as surveillance testing - which basically means collecting information to see where coronavirus is present in the population or among certain demographics.
Health Minister David Clark said three weeks ago that the rollout of surveillance testing was "imminent", but details are still being worked through.
One option, Bloomfield said, is to swab a group of people and then run a batch of 50 swabs, and only test the rest if there was a positive test.
Other options, as outlined in a blog by public health experts, include testing in deprived areas, testing essential workers including healthcare or supermarket staff, or testing sewage.
Despite the data gaps, there are signs that there are no undetected outbreaks including:
• The mortality rate; a high rate relative to the number of cases has indicated such outbreaks overseas, but New Zealand has suffered only one fatality in 1210 cases
• The number of new cases is dropping, despite more testing
• Hospitals have not been overwhelmed by pneumonia cases; currently there are 12 people in hospital, including four in ICUs, two of whom are in a critical condition.
Many were shocked when Ardern announced that all overseas arrivals from March 16 onwards would have to self-isolate for 14 days - except those from the Pacific.
New Zealand had only six cases at the time, and Ardern described the measures as the toughest in the world.
Asked about a border closure, Ardern said self-isolation would be effectively the same thing, citing the trickle of arrivals from regions where the self-isolation rule was already in place - northern Italy, China, South Korea and Iran.
But it failed as an effective border closure, and as reports came in about foreign tourists engaging in all manner of non-self-isolating activities, Ardern closed the borders to non-Kiwis, effective from March 20.
According to Customs, 7187 foreigners poured over the borders between March 16 and March 20.
It is unclear how many of them were Covid-19 carriers.
A quick search of the Health Ministry's information about cases and their inbound flights show that about 150 cases had arrived during that period, but their nationalities are not specified.
Forty one per cent of the total 1210 cases - or 496 people - have a strong link to overseas travel.
Ardern imposed a quarantine that came into force at the same time as the start of the lockdown, but not a blanket one.
All overseas arrivals showing symptoms would be quarantined, while anyone without a suitable self-isolation plan would be put in supervised accommodation. The rest could head home.
Just over 6500 people have come through the borders since then; 144 were placed in quarantine (32 are still in quarantine and 112 recovered people are awaiting clinical clearance for release or completing their 14 days in isolation), and 1050 are in supervised accommodation.
Since April 2, 29 people have been tested and eight have returned a positive result. None of these cases have exited the quarantine facilities.
About 5400 have been allowed home.
Ardern said the reason a quarantine wasn't imposed earlier was the sheer volume of people flying into New Zealand; the number of incoming New Zealanders didn't drop below 1000 a day until March 28.
The other consideration was whether putting thousands of people into a hotel would turn it into a Petri dish where, like on cruise ships around the world, a handful of cases could suddenly mushroom into dozens of cases.
As calls became louder for mandatory quarantine, Ardern continued to trumpet the success of self-isolation despite the failure of police compliance checks.
But this week she signalled a move towards mandatory quarantine.
The number of people arriving is now undeniably manageable. Over the last week, daily arrivals has not topped 300, and only 96 people flew into New Zealand on Tuesday.
Ardern said she needs a "water-tight" solution. Expect her to announce a blanket quarantine today.
Contact-tracing and the role of smartphone technology has become more important as the number of new cases began levelling off.
Quick and comprehensive contact-tracing could be the difference between isolating and containing a case, or an outbreak ripping through a community.
Lacklustre contact-tracing could see us in lockdown for longer than four weeks, as well as moving in and out of lockdown more frequently.
Amid calls from experts to ramp up capacity, the Health Ministry on Sunday said it could trace about 700 close contacts a day.
That may be adequate for the lockdown, when close contacts amount to the two or three people in a person's bubble.
But as Skegg pointed out this week, people will be itching to interact outside of their bubbles once lockdown is over.
We should be aiming to trace close contacts for 1000 cases a day, according to Otago University infectious diseases specialist Dr Ayesha Verrall.
After lockdown is lifted, that means being able to reach 7000 close contacts a day - or 10 times the current capacity.
Importantly, Verrall now has a front seat in overseeing capacity as she has been brought in to audit the ministry's process.
She has also supported the use of smartphone technology, an idea that last week Ardern appeared to dismiss.
But this week that has changed and the ministry is now actively pursuing it to complement its manual contact-tracing.
Among others, New Zealand is looking at the model used in Singapore, the success of which depends on voluntary uptake. Consenting people download an app that records whenever they're in close proximity to consenting others using the same app.
Skegg seemed to think that uptake would not be a barrier, saying on Tuesday that he would be happy to have Google share his location data in order to fight Covid-19, as should most Kiwis.
The Government has been caught flat on some issues, but overall has put weight behind its mantra to "go hard, go early".
It is certainly valid to argue that New Zealand would be less coronavirus-hit if Ardern had shut the borders on March 16 instead of asking arrivals to be happy self-isolating campers, or if she had broadened the testing criteria earlier.
It is equally valid to think that without the measures she put in at the time, as well as announcing a nationwide lockdown when there were 102 confirmed cases, New Zealand would be in the grip of an out-of-control epidemic.
Ardern has also moved to change the testing criteria and strengthen the border to improve the chances of stamping out Covid-19.
She now appears to have made a similar adjustment by explicitly endorsing smartphone-enhanced contact-tracing.
There will likely continue to be cases of people unable to be tested or others breaking quarantine or lockdown rules, but New Zealand is now in a position where the goal of eliminating the virus is - remarkably - not impossible.
If that transpires, then the "new normal" of border controls, self-isolation and contact-tracing - potentially until a vaccine is ready - will be a small price to pay.
Ardern would still have the monumental task ahead of rebuilding the economy, but that would be much more difficult if Covid-19 had been allowed to spread unimpeded.
We're only just past halftime, but based on her performance so far, expect Ardern to continue to listen to experts and act boldly and decisively - but also to be unafraid to make changes where necessary.
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