ANALYSIS
As Delta swept through Auckland, Jacinda Ardern kept easing restrictions while case numbers trended higher. It looked like she was abandoning public health advice, but the opposite was true. Is she over-cautious, or is the Health Ministry's risk radar way off?
The Waitangi Tribunal heard from numerous Māori leaders last week about how the Government had apparently turned its back on a public health-led response in favour of business and economic interests.
One submitter went as far as saying the Government had put Māori lives at risk so Aucklanders could leave the house and buy a flat white on K Road.
The sentiment isn't senseless.
Prime Minister Jacinda Ardern repeatedly eased restrictions as case numbers were trending up in October and November, which saw the proportion of daily cases become increasingly Māori.
But official documents reveal a pattern that has been consistent since the start of the pandemic: Ardern has been more risk-averse than the Health Ministry's public health advice.
This is unusual in the sense that she would be expected to consider this advice, and then temper it after factoring in economic interests and people's right to freedom of movement.
But on numerous occasions she has redrawn the ministry's risk assessment in a more safety-centric way.
That's not to say that New Zealand's relatively benign Delta position - with case numbers dropping as summer arrives - might still have been the case if Ardern had allowed more freedoms as per the ministry's advice.
Those in the hospitality industry in Auckland, for example, see Ardern's stance as unnecessarily cautious and to the detriment of livelihoods; GDP fell by 3.7 per cent in the September 2021 quarter.
The health impacts might also have been much worse. Public health experts outside the ministry favoured stronger restrictions than those imposed by Cabinet, for example calling for a "circuit-breaker" return to level 4 in Auckland.
The ministry has also been seen as thinking it knows best, sometimes going so far as to defy Cabinet's wishes.
The question that becomes increasingly important as the first case of Omicron landed in New Zealand this week is this: how good is the ministry's risk radar?
In June last year, Bloomfield and the ministry came under intense scrutiny when it was revealed that people were allowed to leave MIQ without first returning a negative test.
As well as being an easy measure to reduce risk, this was contrary to Cabinet's wishes.
A couple of months later, the same thing happened over the regular testing of border workers; Cabinet had declared it to be so, but the ministry decided it only needed to be encouraged.
Bloomfield brushed off the difference in ministers' expectations with what was actually happening - or not happening - on the ground as "dissonance".
A ministry suffering from a degree of "we know best" is the subtext of independent reviews calling for the ministry to put more stock in independent expert advice.
"We strongly recommend that there is formal input of external scientific expertise through established processes to incorporate external expert peer-review and advice," Sir Brian Roche's continuous improvement group told the Government earlier this year.
Such experts, for example, were calling for a mask mandate long before the ministry adopted one. Ardern then rejected ministry advice earlier this year to drop the mask mandate for public transport.
The ministry does have a technical advisory group that includes public health experts, but it only meets once a month, and how much it is listened to is unclear.
Roche's group, as well as others including one led by NZSIS director Rebecca Kitteridge, also identified a lack of scenario-planning and stress-testing of the testing and contact-tracing systems, which raised concerns about the Covid response reacting to a crisis rather than being prepared for one.
The ministry had also been reluctant, for more than a year, to increase contact-tracing capacity, and was roundly criticised for being slow to add PCR saliva testing and rapid antigen testing to the toolbox.
When Delta hit, saliva-testing was underused while people queued for hours at testing stations, while key performance targets for contact-tracing were only met after the second week, when case numbers were falling - though the Government puts this down to the challenges of engaging with complex cases, rather than capacity issues.
Had more testing and contact-tracing strategies been in place, it's not unreasonable to think the outbreak would have been more contained, with fewer cases and fewer people suffering severe health effects.
Ardern appears to have compensated as if she thought the ministry had, at times, misread how difficult Delta could be.
The ministry suggested moving Auckland out of level 4 five days earlier than Ardern was comfortable with. It also floated moving parts of the country to level 1 while Auckland was still in lockdown - even though the strategy outside Auckland was still elimination and, as expected, cases leaked out of Auckland.
Then there was the Plan B, or rather the lack of one.
As director general of health Ashley Bloomfield admitted to select committee last month, the ministry's plan for Delta was the same as it was for previous variants: eliminate it.
But as highlighted in Melbourne and Sydney, elimination was far from a sure thing, and when zero cases slipped out of reach in Auckland towards the end of September, the ministry scrambled to bring forward its 'living with Covid' model.
Planning for this was well underway, but far from ready as it wasn't expected to be implemented until the start of next year, when the borders were to start reopening.
When the number of active cases were too many for MIQ rooms by mid-October, cases isolating at home fell through the cracks.
"The emerging system was not able to address the rapid increase in the volume of patients, resulting in significant and clinically detrimental delays, and an inability to prioritise those at highest risk," said a report into two potentially preventable deaths in home isolation.
Patients at home weren't contacted quickly, clinical assessments weren't done in a timely fashion, alarms weren't raised when phone calls went unanswered, and tragedy followed.
"The response has been relatively late in terms of planning," Dr Bryan Betty, medical director of the Royal College of GPs, told the Herald when asked about preparing for Covid among us.
"It should have been happening six months ago. GPs should have been involved in that planning so by the time it happened - it was obvious it was going to happen at some point - we were prepared for it."
Primary care, in the Government's announcement of how community care would be run, has now been given a central role in the clinical assessment.
Counties-Manukau director of public health Dr Gary Jackson expressed a similar sentiment last month: "A lot of that stuff you could argue we should have been doing a bit sooner, but how this thing was going to play out was suddenly brought forward by the outbreak starting just a bit sooner than we were anticipating."
It's also true, though, that there was little if any screaming from the rooftops during the Covid-free months about hospitals setting up negative pressure rooms, or readying a model to care for thousands of cases in self-isolation.
But as Roche points out in his group's latest report, it's best to be ready for slightly worse than the worst-case scenario - especially when the stakes can be so high.
Ardern has continued to be more cautious than ministry advice as the country moved to the traffic light system.
She left the Auckland boundary up even though the ministry said it would make no material difference to the level of risk if it was scrapped at the same time as moving to the new system.
And she started several districts in red, rather than orange, even though official advice was for everywhere bar Auckland and Northland to start in orange.
She has explained repeatedly that she does not wish to follow other countries overseas, especially in Europe, which eased restrictions and then hurriedly reimposed them when case numbers surged again.
"My impression throughout the pandemic," says epidemiologist Professor Michael Baker, "is that the public health advice from the Ministry of Health has not been as assertive as I'd hoped."
Baker has made suggestions throughout the pandemic that Cabinet was initially resistant to but eventually adopted, including around mask use, mandatory QR scanning and minimising the number of arrivals from high-risk countries.
One suggestion of his that hasn't been taken up is a high-level science strategy council to give expertise in complex emergencies - such as the one that officials faced in the Auckland outbreak with marginalised communities.
But he notes that Ardern has the voices of her chief science adviser close to hand, as well as the views of Associate Health Minister Ayesha Verrall, an infectious diseases expert before becoming an MP, around the Cabinet table.
In a recent interview with the Herald, Roche singled out Verrall as a reassuring presence around the ministry's contact-tracing system.
"I think we're in pretty safe hands with her in an oversight capacity," he said.
The ministry has also done well in battling Delta.
While the impact of moving to the traffic light system is still coming through in daily case numbers, the outbreak was slowed, the lockdown bought time as vaccination coverage surged, and Auckland didn't suffer to the same degree as Sydney or Melbourne.
New Zealand is undoubtedly in a good position as it heads into the uncertainty of what summer will bring, and has avoided much of the suffering and fatalities that the virus has inflicted on much of the rest of the world.
It's also entirely possible that the ministry's recommendations were more on the money than Cabinet's decisions, and that the current position wouldn't be much different had Auckland been moved out of level 4 sooner, or if the Auckland boundary had been lifted at the start of December, with more regions starting the new system in orange.
Voices from the squeezed hospitality industry have been just as loud as those from the likes of Baker and other health experts, and bars and cafes would have certainly benefitted if Ardern had followed all of Bloomfield's advice - perhaps without intolerable health consequences.
But the shortcomings of the Delta response - highlighted in Roche's September report - are a reminder that being in a good position doesn't mean that the preparation couldn't have been better.
Many of Roche's recommendations - a stronger role and more resources for Māori and Pasifika health providers, increased testing and contact-tracing capacity, a proactive plan to improve health outcomes in South Auckland - have now been adopted.
Roche also notes that no one really knows how long there will need to be a Covid response, but it will always need to be as prepared as it can be, as well as agile for when circumstances quickly change.
That is happening now, with Omicron sweeping through parts of the world and landing in MIQ in New Zealand. Early indications are that it spreads more quickly than Delta, but has less severe health effects.
The Government is expected to shorten the booster-shot window from six months after a first dose.
A more challenging decision is what to do about time in MIQ, which is due to be partially lifted in January, and if Omicron escapes MIQ, whether to employ localised lockdowns.
The Ministry of Health will be providing public health advice on these matters soon.
Expect Ardern to view it through a lens that is more cautious than the ministry's.
It follows concerns about use-of-force powers being given to staff.