The $2B Sydney lockdown: Quarantine transport once again in focus

In a December 2020 article for The Age, I called for a comprehensive review of quarantine transport in Australia. The Victorian COVID-19 Hotel Quarantine Inquiry omitted to provide any substantial focus on quarantine transport—high risk, confined settings and a single point of failure in the quarantine system. Whilst recommendations were provided with respect to the “transit of returned travellers”, the transit of air crew, typically undertaken by ground transport companies under contract to airlines, was not afforded the same level of consideration.

Greater Sydney (including the Blue Mountains, Central Coast, Wollongong and Shellharbour) has commenced a 2-week lockdown costing the economy $143M per day, which led us to stand at the brink of a national outbreak (resulting in lockdowns in Darwin, Alice Springs, Perth, Brisbane, Gold Coast and Townsville, plus restrictions in other states/territories), due to the infection of an air crew ground transport worker with the Delta COVID-19 variant. Investigations have shown that the driver failed to wear a mask, whilst systemic issues surrounding daily testing and the failure to vaccinate (linked to deficiencies in the definition of “border worker”) continue to proliferate.

On 26 June 2021, NSW Health quietly updated its air transportation quarantine guidelines, but significant accountability and quality control questions remain. Continued quarantine failure also demands a rethink of our national priorities and our accepted approaches to risk mitigation.

Governance failure

The public deserves to know the regulatory and performance regime governing quarantine transport operators. Whilst returning travellers are transported by large bus and coach operators (e.g., ComfortDelGro, Kinetic) under contract to state governments, the transport of crew is more opaque and involves a relationship between airlines and small, private ground transport companies (e.g., Sydney Ground Transport, Legion Limousines). Any breach is of catastrophic consequence, as we are once again witnessing.

We need clarity in the chain of responsibility (and who forms this chain), based on principles of shared responsibility and accountability for ensuring all infection control measures are maintained. Questions remain over whether ‘guidelines’ are legally enforceable, and whose role it is to monitor and police. Perhaps there should be separate accreditation requirements for quarantine operations too.

Quarantine transport operators must be sufficiently incentivised beyond the protection of personal health (which in a low COVID-19 risk environment like Australia is a difficult imperative). Contractual obligations should be independently vetted, whilst a stringent punishment and reward system could raise the stakes, with offending operators even named and shamed. Infection control breaches could also be grounds for the termination of employment as part of contract stipulations.[1]

Operator responsibilities

An appropriately incentivised operator should go above and beyond to protect its employees and, by extension, the rest of the community. In Australia, we have seen a light-touch approach to personal protective equipment provision. The use of fit-tested P2/N95 masks, goggles, headwear and medical gowns in all high risk scenarios is a fail-safe solution. Retrofitting vehicles with physical barriers, and the use of anti-epidemic technologies such as anti-microbial coatings, and disinfection solutions like ultraviolet, fogging and nano-technologies can reduce error and inconsistency. These initiatives may be mandated or encouraged via appropriate market forces (operationalised through contract design).

Whilst technological solutions are important, they are only as effective as individuals’ personal responsibilities and behaviours. We have seen little invested by way of proper infection control training for frontline quarantine staff. Border workers could be trained in the same way medical staff are, plus given added directives such as the quarantining and disinfection of clothing and personal items to reduce the risk of spread to household contacts.

Focus should not only be on compliance but on building a zero-tolerance culture that stigmatises complacency and error. Total quality control and elements of the Six Sigma Doctrine have been effective in many sectors (e.g., manufacturing) in reducing the variance in outcomes. Pointing-and-calling, pioneered in the 1920s as a Japanese railway safety protocol, is a low-cost occupational safety strategy. Verbalising intended actions increases attention and awareness and has been found to reduce errors by 85%.

Philosophical approaches to risk mitigation: The upstream problem

Living in a Western liberal democracy means that we often take as granted ‘orthodox’ knowledge, including in the health sphere. Whilst we see some level of variation amongst different State Premiers and Territory Chief Ministers, we can still benefit from a wider perspective on alternative health and risk mitigation approaches, particularly having witnessed how management and response measures have varied around the world (between the East and West, in particular).

In general, Western medicine tends to focus on diagnosing/treating the symptom rather than preventing the disease. This puts us at a significant disadvantage when it comes to pandemics, which are highly time sensitive. With the benefit of hindsight, we are able to see issues in the context of waiting for evidence of asymptomatic and people-to-people transmissions some 18 months ago, as well as the misguided debate over the efficacy of universal mask wearing.

In Eastern philosophies, there is a high focus on prevention, body strengthening, balance and wellbeing. This is guided by systematic thinking, with the objective of achieving harmony between the mind and body. The idea of vitalism is captured by concepts like feng shui[2], yin/yang[3] and qi[4], with links to airflow and ventilation which are (finally!) becoming a focus in the West in the context of aerosol spread.

One useful analogy is to associate Eastern schools of thought with having a focus on upstream thinking and Western ideology with having a downstream focus—exhibited in the principles guiding management of the COVID-19 pandemic. A number of pandemic-related examples of upstream- and downstream-dominant thinking are listed below:

Australia has averaged one quarantine breach every 2 weeks (and 8 since the beginning of June). We seem resigned to the fact that quarantine breaches are inevitable. The debate appears fixated on how to handle community cases, at what stage to implement lockdowns and restrictions, and argy-bargy around state border controls and closures. Australia has now jumped to reducing international arrivals as a solution for quarantine failure.

The reality is that, were it not for cases of leakage from the quarantine system, we would not be having this discussion. It’s time we adopt an upstream-focused mindset, with a zero-tolerance approach to quarantine breaches. Why is there not more outrage from the community on every quarantine breach—and a demand for accountability?

We also see in places like the UK and Israel, even with widespread vaccination, the failure to re-educate society (and change culture), as well as an obsession with "returning to normal” may not work in a pandemic-induced world. Meanwhile, we see universal mask culture in East Asia (based on collective responsibility, not compliance) continuing to offer a major defence mechanism against flare-ups. In Australia, we see constant fluctuations in mask rules and social distancing measures (e.g., on public transport) as the level of community transmissions rises and falls—neglecting the fact that these very measures are what keeps COVID-19 transmissions at bay.

There are both strengths and weaknesses in Eastern/Western cultural approaches to problem solving and harm minimisation.[7] We should start with a broader perspective and select amongst a menu of options in a way that is not myopic/dogmatic but values-driven and a conscious, rational choice. The path towards more diverse ways of thinking may be manifested through more diverse governance amongst our elected officials and health authorities. Combining different disciplinary and cultural perspectives can offer benefits that are often only apparent in retrospect. Perhaps more upstream/holistic, systematic thinking can bring about a different set of investment and reform priorities, including better governance and quality control in our quarantine transport operations.

[1] Many errors call for the immediate dismissal of bus drivers, such as the failure to engage the handbrake. A deliberate disregard for infection control measures should be treated no differently.

[2] Literally meaning “wind and water”, describing the study of flows in the environment

[3] Interpreted as “dialectical monism”—yin/yang etymologically translates as the French ubac "shady side of a mountain" and adret "sunny side of a mountain"

[4] Translates literally as “air”, and figuratively as “life energy”

[5] In the West, we expect the external environment to change for us. In the East, we change ourselves to fit the external environment.

[6] The irony is that by not placing faith on a single solution (i.e., immunisation), society is better placed to adopt behaviours that result in a virus elimination outcome.

[7] As Henry Kissinger notes, “America has a problem-solving approach; China is comfortable managing contradictions without assuming they are resolvable.”