The United States and Australia share similar demographics, but their pandemic death rates point to very different cultures of trust.
If the United States had the same Covid death rate as Australia, about 900,000 lives would have been saved. The Texas grandmother who made the perfect pumpkin pie might still be baking. The Red Sox-loving husband who ran marathons before Covid might still be cheering at Fenway Park.
For many Americans, imagining what might have been will be painful. But especially now, at the milestone of 1 million deaths in the United States, the nations that did a better job of keeping people alive show what Americans could have done differently and what might still need to change.
Many places provide insight: Japan, Kenya, Norway. But Australia offers perhaps the sharpest comparisons with the American experience. Both countries are English-speaking democracies with similar demographic profiles. In Australia and in the United States, the median age is 38. Roughly 86 per cent of Australians live in urban areas, compared with 83 per cent of Americans.
Yet Australia's Covid death rate sits at one-tenth of America's, putting the nation of 25 million people (with around 7,500 deaths) near the top of global rankings in the protection of life.
Australia's location in the distant Pacific is often cited as the cause for its relative Covid success. That, however, does not fully explain the difference in outcomes between the two countries, since Australia has long been, like the United States, highly connected to the world through trade, tourism and immigration. In 2019, 9.5 million international tourists came to Australia. Sydney and Melbourne could just as easily have become as overrun with Covid as New York or any other US city.
So what went right in Australia and wrong in the United States?
For the standard slideshow presentation, it looks obvious: Australia restricted travel and personal interaction until vaccinations were widely available, then maximised vaccine uptake, prioritising people who were most vulnerable before gradually opening up the country again.
From one outbreak to another, there were also some mistakes: breakdowns of protocol in nursing homes that led to clusters of deaths; a vaccine rollout hampered by slow purchasing. And with omicron and eased restrictions, deaths have increased.
But Australia's Covid playbook produced results because of something more easily felt than analysed at a news conference. Dozens of interviews, along with survey data and scientific studies from around the world, point to a lifesaving trait that Australians displayed from the top of government to the hospital floor and that Americans have shown they lack: trust, in science and institutions, but especially in one another.
When the pandemic began, 76 per cent of Australians said they trusted the health care system (compared with around 34 per cent of Americans), and 93 per cent of Australians reported being able to get support in times of crisis from people living outside their household.
In global surveys, Australians were more likely than Americans to agree that "most people can be trusted" — a major factor, researchers found, in getting people to change their behaviour for the common good to combat Covid, by reducing their movements, wearing masks and getting vaccinated. Partly because of that compliance, which kept the virus more in check, Australia's economy has grown faster than America's through the pandemic.
But of greater import, interpersonal trust — a belief that others would do what was right not just for the individual but for the community — saved lives. Trust mattered more than smoking prevalence, health spending or form of government, a study of 177 countries in The Lancet recently found. And in Australia, the process of turning trust into action began early.
Government: Moving quickly behind the scenes
Greg Hunt had been Australia's health minister for a couple of years, after working as a lawyer and investor, when his phone buzzed January 20, 2020. It was Dr. Brendan Murphy, Australia's chief medical officer, and he wanted to talk about a new coronavirus in China.
Murphy, a low-key physician and former hospital executive, said there were worrisome signs of human-to-human transmission.
"What's your honest, considered advice?" Hunt recalled asking.
"I think this has the potential to go beyond anything we've seen in our lifetime," Murphy said. "We need to act fast."
The next day, Australia added the coronavirus, as a threat with "pandemic potential," to its biosecurity list, officially setting in motion the country's emergency response. Hunt briefed Prime Minister Scott Morrison, visited the country's stockpile of personal protective equipment and began calling independent experts for guidance.
Sharon Lewin, director of the Peter Doherty Institute for Infection and Immunity, one of Australia's top medical research organisations, received several of those calls. She fed his questions into the meetings that had started to take place with scientists and officials at Australia's public health laboratories.
"There was a very thoughtful level of engagement, with politicians and scientists, right at that early phase in January," Lewin said.
The first positive case appeared in Australia on January 25. Five days later, when the Centers for Disease Control and Prevention confirmed the first human transmission of the virus in the United States, President Donald Trump downplayed the risk. "We think it's going to have a very good ending for us," he said.
The same day, Hunt struck a more practical tone. "Border, isolation, surveillance and case-tracing mechanisms are already in place in Australia," he said.
Less than 24 hours later, on February 1, Australia closed its border with China, its largest trading partner. On February 3, 241 Australians were evacuated from China and placed in government quarantine for 14 days. While Americans were still gathering in large groups as if nothing was wrong, Australia's Covid containment system was up and running.
A full border closure followed. Hotels were contracted to quarantine the trickle of international arrivals allowed in. Systems for free testing and contact tracing were rolled out, along with a federal programme that paid Covid-affected employees so they would stay home.
For a business-friendly, conservative government, agreeing to the Covid-containment measures required letting go of what psychologists describe as "sticky priors" — long-standing beliefs tied to identity that often hold people back from rational decision-making.
Morrison trusted his close friend Hunt. And Hunt said he had faith in the calm assessments and credentials of Lewin and Murphy.
In a lengthy interview, Hunt added that he also had a historical moment of distrust in mind: Australia's failures during the 1918 flu pandemic, when inconsistent advice and a lack of information sharing led to the rise of "snake oil" salesmen and wide disparities in death rates.
In February and March, Hunt said, he retold that story in meetings as a warning. And in a country where compulsory voting has been suppressing polarisation since 1924, Australia's leaders chose to avoid partisanship. The Morrison government, the opposition Labor Party and state leaders from both parties lined up behind a "one voice" approach, with medical officers out front.
Still, with a highly contagious virus, scientists speaking from podiums could do only so much.
"Experts 'getting on the same page' only matters if people actually trust the actions government is taking and trust their neighbours," said Dr. Jay Varma, director of Cornell's Center for Pandemic Prevention and Response and a former Covid adviser to Mayor Bill de Blasio of New York.
"While that type of trust is relatively higher in New York City than in other parts of the US," said Varma, who has worked extensively in China and Southeast Asia, "I suspect it is still quite low compared to Oceania."
Health care: Sharing the burden
The outbreak that many Australians see as their country's greatest Covid test began in late June 2020, with a breakdown in Melbourne's hotel quarantine system. The virus spread into the city and its suburbs from guards interacting with travellers, a government inquiry later found, and within a few weeks, daily case numbers climbed into the hundreds.
At Royal Melbourne, a sprawling public hospital built to serve the poor, clusters of infection emerged among vulnerable patients and workers. Case numbers and close contacts spiralled upward. Vaccines were still a distant dream.
"We recognised right away that this was a disaster we'd never planned for, in that it was a marathon, not a sprint," said Chris Macisaac, Royal Melbourne's director of intensive care.
A few weeks in, the system started to buckle. In mid-July, dozens of patients with Covid were transferred from nursing homes to Royal Park, a satellite facility for geriatric care and rehabilitation. Soon, more than 40 per cent of the cases among workers were connected to that small campus.
Kirsty Buising, an infectious disease consultant at the hospital, began to suspect — before scientists could prove it — that the coronavirus was airborne. In mid-July, on her suggestion, Royal Melbourne started giving N95 masks, which are more protective, to workers exposed to Covid patients.
In the United States, hospital executives were lining up third-party PPE vendors for clandestine meetings in distant parking lots in a Darwinian all-against-all contest. Royal Melbourne's supplies came from federal and state stockpiles, with guidelines for how distribution should be prioritised.
In New York, a city of 8 million people packed closely together, more than 300 health care workers died from Covid by the end of September, with huge disparities in outcomes for patients and workers from one hospital to another, mostly according to wealth.
In Melbourne, a city of 5 million with a dense inner core surrounded by suburbs, the masks, a greater separation of patients and an intense 111-day lockdown that reduced demand on hospital services brought the virus to heel. At Royal Melbourne, not a single worker died during Australia's worst institutional cluster to date.
In the US, coordination within the health care system was haphazard. In Australia, which has a national health insurance programme and a hospital system that includes both public and private options, there were agreements for load sharing and a transportation service for moving patients. The hospitals worked together, trusting that payment would be worked out.
"We had options," Macisaac said.
Society: Complying and caring
"I'd just hate to be the one who lets everyone down."
When Australians are asked why they accepted the country's many lockdowns, its once-closed international and state borders, its quarantine rules and then its vaccine mandates for certain professions or restaurants and large events, they tend to voice a version of the same response: It's not just about me.
The idea that one's actions affect others is not unique to Australia, and at times, the rules on Covid stirred up outrage.
"It was a somewhat authoritarian approach," said Dr. Greg Dore, an infectious diseases expert at the University of New South Wales in Sydney. "There were lots of mandates, lots of fines for breaching restrictions, pretty heavy-handed controlling, including measures that were pretty useless, like the policing of outdoor masking."
But, he added, the package was effective because the vast majority of Australians stuck with it anyway.
"The community coming on board and remaining on board through the tough periods of 2020 and even into 2021 was really, really important," Dore said. "There is a general sense that for some things, where there are major threats, you just have to come together."
Studies show that income inequality is closely correlated with low levels of interpersonal trust. And in Australia, the gap between rich and poor, while widening, is less severe than in the United States.
During the toughest of Covid times, Australians showed that the national trait of "mateship" — defined as the bond between equal partners or close friends — was still alive and well. They saw Covid spiral out of control in the United States and Britain, and chose a different path.
Compliance rates with social distancing guidelines, along with Covid testing, contact tracing and isolation, held steady at around 90 per cent during the worst early outbreaks, according to modelling from the University of Sydney. In the United States, reductions in mobility — a key measure of social distancing — were less stark, shorter and more inconsistent, based in part on location, political identity or wealth.
In Australia, rule-following was the social norm. It was Mick Fanning, a surfing superstar, who did not question the need to stay with his American wife and infant in a small hotel room for 14 days of quarantine after a trip to California. It was border officials cancelling the visa of Novak Djokovic, the top male tennis player in the world, for failing to follow a Covid vaccine mandate, leading to his eventual deportation.
It was also all the Australians who lined up to get tested; who wore masks without question; who turned their phones into virus trackers with check-in apps; who set up food services for the old, infirm or poor in lockdowns; or who offered a place to stay to women who had been trapped in their homes with abusive husbands.
At a recent awards luncheon in Melbourne for people who made a difference during Covid, those were the kinds of people being celebrated. Jodie McVernon, director of epidemiology at the Doherty Institute, was the only scientist lauded at the event.
"Care is so undervalued," she said. "This was all about the power of care."
And, perhaps, the power of adaptability.
When the delta variant flooded the country last year as vaccine supplies were low, Australia's ideas of protection and compliance changed.
Hunt scrambled to procure vaccines — far too late, critics argued, after the AstraZeneca vaccines made in Australia seemed to pose a greater-than-expected risk of heart problems — while community leaders fought against a moderate burst of fear and scepticism about vaccines.
Churches and mosques became pop-up Covid inoculation clinics. Quinn On, a pharmacist in western Sydney's working-class suburbs, took on extra staff at his own cost to get more people vaccinated. Mayor Chagai, a basketball coach in Sydney's South Sudanese community, hosted Zoom calls with refugee families to answer questions about lockdowns and vaccines.
Many Aboriginal Australians, who have countless reasons to distrust authorities, also did what they could to get people inoculated. Wayne Webb, 64, a Wadandi elder in Western Australia, was one of many to prioritise a collective appeal.
"It all goes hand in hand with protecting our old people," he said he told the young men in his community.
Vaccination uptake in Australia surged last year as soon as supplies arrived, rushing from roughly 10 per cent of Australians over age 16 to 80 per cent in six weeks. It was the fastest rate in the world at the time. Once that 80 per cent was reached, Australia eased open its national and state borders.
Now, more than 95 per cent of Australian adults are fully vaccinated — with 85 per cent of the total population having received two doses. In the United States, that figure is only 66 per cent.
The arrival of the omicron variant, which is more transmissible, has sent Australia's case numbers soaring, but with most of the population inoculated, deaths are ticking up more slowly. Australia has a federal election Saturday. Covid is far down the list of voter concerns.
"We learned that we can come together very quickly," said Denise Heinjus, Royal Melbourne's executive director for nursing, whose title in 2020 was Covid commander. "There's a high level of trust among our people."
This article originally appeared in The New York Times.
Written by: Damien Cave
Photographs by: Asanka Brendon Ratnayake and Matthew Abbott
© 2022 THE NEW YORK TIMES
