Dear Jacinda Ardern, Prime Minister of New Zealand

A Covid-19 testing plan for Kiwis, Aussies, and the world

Dear Prime Minister,

cc: Scott Morrison, Prime Minister of Australia

Struck by a notion, likely wrong, that you’ve been following me, I feel emboldened to offer an idea that might help, in just one area, in your already inspirational response to Covid-19.

It involves a different type of mass testing, not being done elsewhere as far as I’m aware, for which New Zealand is uniquely placed.

I intend to write no more on this topic, so this will be a reasonably full explanation, with a brief article and letter to Scott Morrison.

Unique opportunity to get ahead of the virus

Every nation has learned a great deal from the actions of Singapore, Taiwan, and South Korea in dealing with SARS-Cov-2, but arguably the core lesson seemingly remains unnoticed by most countries responding to the virus.

Singapore’s real lesson, in my view, is not so much about its initial actions in response to the virus, but an outcomes-oriented way of thinking. Not to remain in the bubble of orthodox pandemic thinking and respond to the virus, as many nations did, but to think laterally, draw widely, and get ahead of the virus.

In short, rather than a pandemic framework for action, Singapore’s immediate response was a framework for outcomes.

But the same challenge remains [including for Singapore, which failed to apply the same outcomes focus when returning residents brought the virus back, triggering a reactive response like other nations]. I believe that this letter is necessary because there now seems to be a second opportunity.

Rather than continue responding with decisive action, there may be another chance to get ahead of the virus — for better health outcomes, and better economic outcomes.

Overview

This letter suggests two main things:

1. Health and economy. Health or economy is, as you have said, a false dichotomy. Nor is it a tradeoff, or even sequential. This means that it is not necessary to focus on health outcomes first, as a perceived enabler of economic outcomes. That approach simply triggers poor economic outcomes. Instead, it is possible to leave lockdown in a way that improves both health and economic outcomes, simultaneously.
2. Testing, with a difference — for Kiwis, Aussies, and the world. There’s huge clamor for mass testing, with some nations seemingly doing it in response to pressure, and others for reasons similar to South Korea, boosting outcomes for their citizens, like Germany. There also seems to be a fatuous ‘arms race’ over who’s doing ‘more’ mass testing. Cutting through the noise, however, there is a window of opportunity for New Zealand to institute a smart mass testing program to (a) improve health outcomes, (b) reduce or eliminate the need for debilitating “pulsed” lockdowns; and (c) deliver a significant benefit for every nation, at just the time when many will need it most.

Health and economy

Government ministers in the UK are reportedly “riven by infighting” over whether to prioritize the health system or the economy. However, commonly perceived dichotomies between ‘health over economy’ and ‘economy over health’ are both false.

Nonetheless, such perceptions persist. Advocates of the ‘health over economy’ rubric (often rationalized as ‘better health outcomes enable better economic outcomes’) are reinforced in such thinking by examples of the poor health and economic outcomes of nations said to have followed an ‘economy over health’ mantra. Such outcomes were indeed poor (as summarized in 17 syllables, here and here), but one does not prove the other, either way.

The ‘health over economy’ rubric offers a simple rallying cry, and a metaphorical ‘othering’ club with which to vilify opponents seeking to improve economic outcomes. But the rubric is false, because it suggests an exclusive or linear relationship between health and economic outcomes (one or the other, or one for the other), which is not necessarily true.

As Dr Anthony Fauci observed, public health advisers are not economists. They are cognizant of financial effects, he said, but recommend lockdowns solely as a public health measure to get the virus under control. Although he focuses on health outcomes, Dr Fauci does not appear to ascribe to the ‘health over economy’ rubric. It is not one or the other, or one for the other.

A multidisciplinary approach suggests instead that it is possible to meet public health and economic objectives simultaneously, without compromising either.

Sudden testing increase

Last week, extending an earlier piece, I released an article (respectfully) calling New Zealand’s Covid-19 testing regime inadequate. Only people recently overseas or in contact with known cases could then be tested for the disease, continuing persistently low testing. Then, about 1,700 per day.

That night, on national TV, you announced that everyone with symptoms could soon be tested. The presenters reckoned tests would double.

The next day, I released Covid-19: The Book, with the earlier article as chapter 15 (“Lockdown”). It repeated WHO calls to “test, test, test.”

That night, on national TV, you reportedly instructed officials to “test, test, test.” Anyone with symptoms could now be tested, you said, but not, an official added, anyone else. Asymptomatic people are excluded. With testing to help “ease anxieties,” according to commentators, officials are planning to conduct up to 5,000 tests a day. Work has also started on a “surveillance plan” for community sampling, to get a better understanding of the problem. You declared that this disease “can’t be allowed to spread in silence.”

The timing, I’m sure, is coincidental, with your sudden announcements to ramp up testing appearing hours after my latest calls seeking just that. After all, there’s now a general clamor for more testing, and you take advice from a powerful technical advisory group. I’m a nobody.

But, on the off-chance you’re listening, my call about testing was different; nor was it about the numbers, as about the potential impact.

More impactful testing

One option might be better for Kiwis, and a window of opportunity for New Zealand to help every other nation. This idea also differs from growing calls for mass testing, often seemingly based on simple notions of “more is better”.

This is no complaint about ramping up testing. Checking people with symptoms is long overdue. In the words of a popular philosopher, it can be filed under the category “Doh.” It’s also important to assuage anxieties. Your empathetic response remains as clear in this tragedy as another, barely a year ago. I’m apolitical, concerned only with policy effectiveness and outcomes, and even I acknowledge a sense of pride that your empathy reflects who we are as a nation. And the sampling idea is good. Done well [and quickly, before evidence of community transmission evaporates under lockdown], it should fill some of the gaps, helping New Zealand and every country deal with the virus more effectively.

But, I’m puzzled. Testing symptomatic people risks missing possibly most people with the disease, leaving it to continue “spreading in silence,” something you are (rightly, I believe) adamant must be stopped.

As expressed by leading experts* with knowledge of all the usual standards and recommendations — but recently extended with direct, empirical evidence from a full-population study they conducted in an Italian town:

asymptomatic or quasi-symptomatic subjects represent a good 70% of all virus-infected people and, still worse, an unknown, yet impossible to ignore portion of them can transmit the virus to others.

During lockdown, that’s not such a problem, and decent sampling will give useful insights. But it won’t tell you if the virus has been eradicated, or help mop up any remaining pockets, so you may still need to extend the lockdown. (As Scott Morrison and UK officials say, lockdowns might need six months to work, for reasons explained here. And Spain has again extended its lockdown by another three weeks, and is signaling more).

In any event, not knowing what’s really out there at the end of the lockdown, we’ll be right back to the ‘wait and see’ approach that just about everyone except South Korea, Taiwan, and Singapore adopted in January (as explained here). That hasn’t exactly worked out so well in scores of countries.

In practical terms, if the virus isn’t eradicated when Kiwis come out of lockdown, it means that a series of “pulse” lockdowns, each triggered by rising transmission rates, might be needed.

Sorry, this sounds a bit negative. It’s not. I reckon you’ve done an inspirational job compared to just about every other leader on the planet. [Even The Trump Effect might need to be renamed for Brazil’s Bolsinaro, who seems intent on ignoring reality even longer].

But, it doesn’t get us, or anyone else, ahead of the virus. We’re still responding to the virus.

That would be a shame, because it may still be possible to get ahead of the virus, New Zealand is one of the few countries able to do so in a unique way, and you are just the person to do it, I reckon.

Arguably more than any other leader, you’ve been running hard to catch up to the virus. You’re now right on its tail, and there’s a brief opportunity to close the gap, so why stop now? (Please don’t be offended by that, I know you’re not stopping; but that, with respect, is the effect of coming out of lockdown with a ‘monitor and respond decisively’ approach, rather than a different approach that might just get ahead of the virus).

It is of course technically possible that the virus will be eradicated by lockdown alone, making this moot. (Although the perceived value of a Covid-19 transmission map might be even higher, from the first country to eradicate the virus). Given some Kiwis’ actions just before and during lockdown, and what we now know about transmission, it seems unlikely that lockdown alone will eradicate the virus, but there is a way to improve the odds — capitalizing on New Zealand’s geographical advantage, and your leadership and decisions to date.

Missing community transmission was a foot fault (shared by most countries), but you wasted no time as a ‘denier’, your messaging was consistent and clear, and a 4-week lockdown period was inspired. A bold call, when others started with shorter periods, immediately improving the eradication odds.

So, why ease off with a weak ‘safety’ shot now? Testing remains insipid, but the sampling plan is good. Very good, in fact. But it’s not great. Or bold. At the end of lockdown, cases and transmission rates will be down, but in terms of getting ahead of the virus, we’ll be right back to ‘wait and see.’ That’s not what differentiated Singapore’s success in round one, in terms of getting ahead of the virus. (And even Singapore missed the ball recently, with a spike from overseas travelers, requiring a partial shutdown). Nor is a ‘monitor closely and respond decisively’ approach likely to differentiate resounding success now — even if the virus is eradicated at the end of lockdown.

I appreciate that last bit sounds odd. Eradicating the virus is a great outcome, even if — with limited testing — we won’t know for sure for some time. In outcomes science, it might be termed an intermediate outcome, because a better outcome involves eradication with greater certainty, sooner, thereby locking in both optimal health and economic outcomes — and a mechanism to help facilitate better outcomes, globally. That is what this letter is about.

Without wider testing, we won’t know if there really was little community transmission, as officials assert, curiously, despite the science. Nor if the disease has “washed through” some of the population, with few or no symptoms, leaving many people as surprised as the BBC’s Fergus Walsh. Either is possible, but it is knowledge, either way, that would inform ongoing public health measures — and deliver a considerable confidence boost for every Kiwi family, and ‘NZ Inc’.

Certainly, the results from well-designed representative sampling (which I assume you mean by “community surveillance plan”) will give a better picture of how the virus transmits — if it is done quickly and well — but you’ll still have no idea where the virus still lurks. Nor will you know if it’s gone, or not. That uncertainty would continue to strain mental health and business confidence.

And if the virus hasn’t been eradicated, after more demoralizing uncertainty and a second wave of cases we’d be right back to lockdown.

After getting tantalizingly close to it, the virus will be miles ahead, again.

Or we might have an extended period in some form of lockdown (as UK officials and Australia’s Scott Morrison warned about the ‘lockdown as strategy’ option) —economically debilitating, and constantly playing catch-up with the virus.

In contrast, full population testing would not only give a definitive roadmap of the virus’ transmission pathways, it’s the missing intelligence needed to mop up pockets of the disease. That’s got to be good for Kiwis. There are, of course, no guarantees, and the tests aren’t perfect, but there are practical ways to resolve such issues — that’s just part of the territory with bold calls.

If you can serve just one more ace, it really could be game, set and match.

As you’ll know, Germany’s doing up to 200,000 tests a day. But even at that rate, it’d take them at least 14 months to test everyone. Nor do they need to. To save Germans, and protect their economy, they can target key groups, supported by ongoing testing. It doesn’t matter if the testing regime is skewed. There’s growing public clamor to ramp up testing, and more leaders are doing it, but health economists are probably right. It doesn’t make sense to test everyone.

Except when it does.

New Zealand uniquely placed for better outcomes, for Kiwis, Aussies, and the World

Unlike Germany, South Korea, the UK and others with huge populations, New Zealand could test everyone in about 3 weeks. This puts New Zealand in a league of its own.

Public health experts and economists are calling for better data. Representative sampling helps, but full population data is the holy grail. Health authorities can then isolate or treat the infected, and everyone else gets back to work. You could even start releasing people in days, not the months that lockdown theory envisages.

It can also help sidestep the risk of a second wave of coronavirus infections, now feared in Asian countries.

And if you cycled full population testing, say every 10 days or so, you wouldn’t even need to bother with the onerous population surveillance tools that China and others used (mentioned here). So, no civil rights or privacy issues, and one less logistical nightmare. Nor do you even need to make testing compulsory. It’s hard to imagine many people refusing. Likely, the opposite, I expect.

The logistics will be hard (and it may need a shift from centralized testing to Germany’s decentralized system, leveraging government and private sector resources), but the benefits are almost incalculable in health outcomes (if it averts “pulsed” lockdowns), the certainty for Kiwis and businesses, and, overseas, if New Zealand data helps save lives and restart economies sooner.

English epidemiologist and statistician Julian Peto reckons it would be possible to test everyone in the UK once a week, with nearly 10 million self-administered postal tests a day. Health economist Cam Donaldson thinks its “worth exploring” but probably too difficult with such large numbers. But with New Zealand’s tiny population, we could share Peto’s template and do it with just 480,000 tests a day. It sounds a lot by New Zealand’s current (frankly, pitiful) levels, but it’s only a 20th of what Peto thinks do-able.

The real issue, however, is not about the numbers, which seems to be a simplistic metric consuming overseas debate. Unlike other countries ramping up numbers either in response to pressure, or to do just enough to tackle their immediate problem, New Zealand, almost uniquely, has a chance to do it in a way that delivers unparalleled benefits for Kiwis, Aussies, and the world.

New Zealand Post would be up for it, I reckon. The value for other countries as well as New Zealand also suggests that any support that might be needed (test kits, PCR machines, etc), might well be forthcoming.

In any event, done well, full population testing, cycled a few times — even with New Zealand’s comparatively simple contact tracing program — could be at least as safe as lockdowns, and it lets the economy get back up sooner.

Health comes first, but it doesn’t need to be a tradeoff. Nor is it health and then the economy. The principles of outcomes science rather than health science alone enable better health and economic outcomes simultaneously.

Moreover, it’s likely a safer health option than pulse lockdowns, which wreck the economy and risk more deaths — because fresh lockdowns are triggered by rising transmission rates (and its natural consequence, cases spiking).

You might even save Air New Zealand from mothballing. Inbound tourists could test at home, say 5–7 days prior, and test again on arrival. Don’t quarantine everyone, just the few that test positive. Tourists would be welcome again. Kiwis will know they’re in the clear, just like us. (The current ‘lockdown as strategy’ option is much worse. To limit new infections when lockdown restrictions ease, like Singapore and Hong Kong, the alternative might need to see in-bound tourism closed off until other countries become virus free, which could be quite some time— likely realizing Air New Zealand’s fears of being reduced to mostly a domestic airline).

But the good keeps on giving.

Immense benefit for others: that’s just who we are

As one of the world’s 26 most influential leaders, you’ll have noticed that some of your compatriots on that list lead countries just getting to the base of the exponential. They face massive challenges, but they’ll get on top of it, eventually.

Kudos to you and the team that New Zealand’s not in that position, but we could use the relative respite that your team has conjured up, to help others not so fortunate.

We could of course think only about Kiwis, and leave everyone else to their own. That’s popular in some quarters. But even the self-proclaimed leader for doing it alone needs help, and that’s what we do.

It’s who we are, right?

Even in a close-knit neighborhood like the EU, the stresses are huge. You’ll have seen the row that risks ripping the European Union apart more than Brexit. That might ease over time, but New Zealand could help them too.

And we have our own good neighbors in that regard. Relations have been a bit strained over the past few years, but they recently showed the real measure of Australians, with compassion.

As Scott Morrison said: “We’re all in this together, that’s what’s fair, that’s what’s Australian.”

Anyway, this takes both countries back to 1918. That means something.

As I said, we could do just enough for New Zealand. Come out of lockdown, monitor what happens, use the sampling results to improve existing systems, and mop it up as we go along. If the disease has been eradicated in New Zealand, your actions will (rightly) be lauded. Your team has put the country in a good place for that.

If that’s enough, that’s your call; and fair enough. It’s been a hard road.

Or, with just one more big push, we could do something better for Kiwis, better for the economy, better for the Aussies and their economy. And better, together, for the world.

We only have one thing of value, for all of those things.

But it is immense.

When those other nations reach the peak of their infections, and get on top of it, as they will, this one thing could help design better ways to knock out the virus’ transmission pathways better than anything now available, or likely anytime soon — unless we make it.

It can help restore some semblance of calm until a vaccine arrives, without constantly fighting quite so many fresh outbreaks, with a powerful new tool, “made Down Under”.

The first detailed map of the virus’ transmission mechanism — from the world’s first full country population testing (especially, combining Covid-19 and antibody tests)—would give every nation one of the best tools to help put this thing down, for good. It would help people everywhere return to work, with a vigilant ‘new normal’ until a vaccine becomes available. A ‘transmission map’ showing how the virus gets around would also help speed up vaccine development.

Anyway, just a thought…

Sincerely,

• The above quote (from here) was from Andrea Cristani, professor of microbiology at the University of Padua, and Antonio Cassone, former director of the department of infectious diseases at the Italian Institute of Health. They conducted a full-population testing case study in an Italian town, eradicating Covid-19 (outlined here)

PS: The other elephant in the room (foresight procurement and logistics). If one of the reasons for New Zealand’s limited testing regime is that authorities haven’t manufactured or ordered enough test kits in time, and medical supply companies are now stretched to capacity, no worries. Our Aussie mates are very, very good at rustling up stuff, fast. The United States and European Union could help, but may be too distracted with immediate problems. But China, Viet Nam, and Jack Ma might be ready and willing to help. Otherwise, although many countries that would benefit from this opportunity face immense pressure to be seen to be ‘doing something,’ New Zealand’s population is so small that it needs only a few national leaders elsewhere with foresight for their own and global benefits to share a tiny fraction of their orders. You have their ear, more than most. In this, too, you may be just the right leader, at just the right time, to make a difference. Alongside our good neighbors. [Update: Led by Trump, supported by Australia’s foreign minister, the pressure for an international inquiry into the outbreak has ramped up. China might be even more delighted to help New Zealand help the world].

Update (26 April). UCSF researchers are conducting all-population Covid-19 and antibody testing in urban and rural settings (link below). Hopefully a country, eventually, may do likewise, as a model to the world….

Viet Nam manufactured fast, cheap, testing kits, and is exporting them as well as using them to good effect locally:

Also