Go8 Road to Recovery

COVID-19
Roadmap to Recovery
A Report for the Nation

GO8 COVID-19 ROADMAP TO RECOVERY – 3
Co-Chairs’ Foreword 4
A Roadmap to Recovery – A Report for the Nation 6
Chapter 1: An Ethical Framework for the Recovery 23
Chapter 2: The Elimination Option 26
Chapter 3: The “Controlled Adaptation” Strategy 58
Chapter 4: Border Protections and Travel Restrictions 83
Chapter 5: The Importance of Public Trust,
Transparency and Civic Engagement 92
Chapter 6: Australia’s Optimal Approach for Building
and Supporting a Health System within the
“Roadmap to Recovery” 102
Chapter 7: Preparing to Reopen 114
Chapter 8: Mental Health and Wellbeing 140
Chapter 9: The Care of Indigenous Australians 150
Chapter 10: Equity of Access and Outcomes in Health Support 164
Chapter 11: Clarity of Communication 174
Methodology 187
Acknowlegements 189
Contents

4 – GO8 COVID-19 ROADMAP TO RECOVERY
Co-Chairs’ Foreword
As Co-Chairs of the “Roadmap to Recovery” taskforce
it has been a privilege to work with over a hundred of
the brightest scholars in Australia’s leading universities
to address the most pressing question of our times –
How can society recover from COVID-19?
This report is independent, was not
commissioned by a Government,
and was produced by the leading
researchers in this nation based
on the latest evidence available.
COVID-19 is not just a medical or a
scientific issue, it is something that
affects each of us, and all of us.
Therefore, this is addressed as a
Report for the Nation. It is shared
with the National Cabinet, our Federal,
State and Territory Governments in
the hope that it may help inform the
many decisions they have to make.
For a problem as vast and complex
as COVID-19 there is no one
solution. That is why our Roadmap
to Recovery, offers two alternatives,
with many side roads – but all taking
us to the destination. We provide
choices because at the moment
there are many uncertainties in the
data and in predictions. Under such
circumstances it is the job of our
research community to illuminate the
possibilities, rather than offer simple
solutions.
How this document differs from the
hundreds of articles and opinion
pieces on this issue is that this
report specifies the evidence on
which it is based, it is produced by
How this document differs from the
hundreds of articles and opinion
pieces on this issue is that this
report specifies the evidence
on which it is based …

researchers who are experts and
leaders in their area, and it engages
the broadest range of disciplines –
from mathematicians, to virologists,
to philosophers.
Over a three-week period, this
taskforce has debated and discussed,
disagreed, and agreed, edited and
revised its work over weekdays and
holidays, Good Friday and Easter. All
remotely. All with social distancing.
It is a testimony to their commitment
to the Australian community, to our
enviable way of life, to securing
our standard of living, to increasing
national productivity and to protecting
the values all Australian’s hold dear.
It is research collaboration in action –
a collective expression of a belief that
expert research can help Government
plot the best path forward and of
a commitment to provide this help
in support of the nation and the
Australian community.
As Co-Chairs we recognise the
enormous effort expended by our
researchers, and they join with the
Go8 Board and with us the Co-Chairs,
to acknowledge that the hardest task
belongs to Government which must
now make the decisions.
… it is produced by researchers
who are experts and leaders in
their area, and it engages the
broadest range of disciplines
– from mathematicians, to
virologists, to philosophers.
Prof. Shitij Kapur
MBBS, PhD, FRCPC, FMedSci, FAHMS
Dean and Asst.Vice Chancellor
(Health) University of Melbourne
Vicki Thomson
Go8 Chief Executive

In this Executive Summary, we
provide: one ethical framework; two
options for pandemic response; three
requirements for success in recovery
regardless of which path is taken; and
six imperatives in the implementation
of recovery plan.
Nature of this Report
and the Reasons for it
Rather than recommend a single
dominant option for pandemic
response in Australia, we present and
explain two options for the nation’s
consideration – Elimination or
Controlled Adaptation. We offer two
choices for several reasons:
First, there are considerable
uncertainties around what we know
about Covid-19. Estimates of critical
determinants, such as the number of
carriers, vary by a factor of ten. With
such uncertainties in facts, there is a
limit to how sure one can be.
Second, we completed this report
in late April 2020, when the Prime
Minister had already set the course to
May 15th. Therefore, our job was to
consider possibilities beyond that date.
The facts regarding the pandemic will
evolve and change between now and
Executive Summary
Covid-19 has changed the course of
history. What started off as a flu-like
illness in one person in one corner
of the world, has changed the lives,
livelihoods and futures of billions.
Australia saw its first case on January
25 and now has over 6,600 cases,
the country is in partial lockdown,
schools and universities have left their
campuses, hundreds of thousands of
jobs have been lost. Fortunately, the
tide appears to be turning and we can
start thinking of Recovery.
To chart a Roadmap to Recovery we
convened a group of over a hundred of
the country’s leading epidemiologists,
infectious disease consultants,
public health specialists, healthcare
professionals, mental health and
well-being practitioners, indigenous
scholars, communications and
behaviour change experts, ethicists,
philosophers, political scientists,
economists and business scholars
from the Group of Eight (Go8)
universities. The group developed
this Roadmap in less than three
weeks, through remote meetings
and a special collaborative reasoning
platform, in the context of a rapidly
changing pandemic.
A Roadmap to Recovery
– A Report for the Nation
from Australia’s Leading Universities

then. Therefore, rather than prescribe
an outcome for three weeks hence
– we propose to present a balanced
case for two of them.
Any choice between these two
options entails a delicate trade-off
between protecting health, supporting
the economy and societal well-being.
It is not the role of researchers, or
this report, to make this choice. That
is the role of our Government. We are
responsible for setting out the trade-
offs and that is what this report looks
to provide.
Finally, this report focusses on the
impact of the virus and short term
recovery. The pandemic will change
global economies and international
relations. This will have significant
impacts for Australia, its society and
economy for years to come. That is
not the focus of this report.
An Ethical framework to
guide decision making
At a time of national crisis, and in
turning our minds to the recovery, it
is vital to clarify the key values and
principles that will guide us in the
many difficult dilemmas we face.
There are things we should not be
prepared to sacrifice, whatever the
circumstances. However, the severity
of this pandemic will force us to
sacrifice some things we may not
have ordinarily done. Therefore, we
should know the conflicting values
at stake and the consequences of
our choices.

A Roadmap to Recovery – A Report for the Nation
We propose the following principles
to guide us:
yy Whatever measures we implement
to manage COVID-19 must be
compatible with a commitment
to democratic accountability and
the protection of civil liberties.
Special measures that require
the restriction of movement, the
imposition on freedoms, and
the sharing of private data must
be proportionate, time-bound,
grounded in consent and subject
to democratic review.
yy Equal access to healthcare and a
social safety net must be provided
for all members of our community.
Attention should also be paid to the
needs of the non-citizens, keeping
in view their unique circumstances.
yy The virus has impacted us all,
some more than others. The
economic cost must be shared
fairly across the whole community.
yy Although equal treatment is a
fundamental Australian value,
the virus, and our policies to
control it have impacted some
disproportionately. Therefore,
renewal and recovery programs
should focus on those most
affected first. In the long run, they
should foster social and economic
innovation that will make all
Australians more resilient in the
face of future shocks.
yy Finally, there is the issue of
partnership and personal
responsibility. Recovery is not
only what Governments can do
for us. Strong recovery will require
a trusted partnership between
governments and civil society,
including business, community
sector, unions, academia and
local communities. Recovery is
something each person owes their
neighbour. We need to look out for
each other’s welfare in times like
this. That is our way.
This is not meant to be a
comprehensive or an exclusive list
of values, but an effort to articulate
the values that should guide our
strategies today. In the long run,
how we respond to this pandemic
will define us.

At the very outset, the Taskforce
rejected the third option which would
entail somewhere close to 15 million
Australians becoming infected. The
disruption of healthcare, the lives
lost, the inequalities of impact and
the tragic consequences on society
did not make this a viable option for
Australia, as Government has made
clear. This report focused on the
remaining two.
Australia is unique among comparable
Western nations, and fortunate, to
have two options – elimination or
suppression. This is afforded because
of our success in controlling the
number of cases. From the peak of
the epidemic in late March when
we saw nearly 500 cases a day, the
number of daily new cases now
are fewer than 25. During the peak,
90% of cases were imported or a
direct consequence of importation, a
pathway that has now been practically
stopped. Australia’s testing rate is
amongst the highest in the world,
and its test positivity rate and case
fatality rate amongst the lowest. This
confirms the government’s strategy
in controlling the epidemic and the
population’s embrace of it.
Therefore, while most countries
simply cannot consider the prospect
of elimination, for Australia, a State
by State Elimination Strategy remains
a conceivable, and some would say
desirable, option for Australia. This
option is detailed in Chapter 2.
Two Options Proposed and a Third Rejected
For any jurisdiction facing an epidemic, there are three
fundamental options:
1. Eliminate the illness;
2. Suppress the illness to a low level and manage it; or
3. Allow the epidemic to run through the population in a way that
does not overwhelm the healthcare system. Some have called
this approach “herd immunity.”

Option 1: Elimination Strategy
yy The Elimination strategy should
lead to fewer total infections,
hospitalisations and deaths, and
better protection of vulnerable
populations than any of the
alternatives.
yy Once achieved, elimination would
allow for a faster decrease in social
distancing and other restrictions.
yy To achieve this elimination,
Australia would likely have to
continue the lockdown in certain
jurisdictions beyond mid-May,
possibly for another 30 days.
yy It necessitates waiting for new
local cases to fall to zero, and then
maintaining this for two incubation
periods, i.e. about two weeks.
yy This strategy will require extensive
testing and contact tracing, but
modelling shows the extra testing
should be achievable within our
system with reasonable additional
investment.
yy It is hard to predict exactly when
the cases of locally acquired
disease might fall to zero, and
whether current measures may
need to be enhanced to achieve it.
Hence the option entails greater
uncertainty regarding the timing
of relaxation of social distancing
measures.
yy The number of asymptomatic
carriers in Australia is not known
for certain and may pose a
potential risk to this strategy.
However, modelling shows
that provided the number of
asymptomatic cases is modest,
the strategy should still be viable.
yy If some jurisdictions have
achieved elimination and others
have not, it will require extended
travel barriers within Australia.
yy The risk of re-introduction of cases
from abroad will remain , requiring
strict international border control
measures. Australia’s unique
geography, strong border control
and quarantine procedures would
enable this.
yy Once achieved, the psychological
sense of safety and social well-
being that would result from
“elimination” of all local transmission
would allow for a fuller and more
vigorous recovery of the economy.

The second option acknowledges the
likelihood of ongoing international
infections, a limit to the duration
of social distancing measures and
the potential of asymptomatic
or undetected transmission and
therefore accepts that some low level
of cases may remain active. It accepts
this reality and tries to manage it.
We call this strategy “Controlled
Adaptation” because it entails
controlling the spread of the virus,
while making sure that society adapts
to live with ongoing infections.
Option 2: Controlled
Adaptation Strategy
yy The major immediate advantage
of this strategy is that the phased
lifting of restrictions can begin as
early as May 15th.
yy The major long-term advantage
of this approach is that it
acknowledges the high likelihood
of prolonged global circulation
of this infection, and starts off
by preparing Australians and the
system to adapt to living with the
ongoing risk of infections
yy This approach provides a feasible
strategy to safely manage current
and future infections within the
health system.
yy The strategy accepts a slightly
higher number of cases,
hospitalisations, and deaths.
yy This strategy will require extensive
testing and contact tracing, but
with a special emphasis on a very
tight feedback to those managing
the public health response so that
they can adjust the restrictions,
in regions, or in segments of the
population, as appropriate.
yy However, there is always a risk that
the number of infections could
spike, and some of the spikes could
lead to more extensive “surges”
which may require resumption of
some stricter social distancing, as
has occurred in Singapore.
yy What is hard to predict is how
confident the public will feel
when restrictions are lifted with
new cases ongoing, therefore
economic and social life may
resume slower, even though the
restrictions may be lifted earlier.

What the public must know
and understand
The choices are not binary, but along
a continuum. They will both require
some restrictions, large scale testing,
tracing and isolation systems to keep
us safe. In that regard they are similar.
They differ in the depth, breadth and
duration of how these measures
are applied.
The big difference is that while
Elimination will require the restrictions
for a longer duration at first, it
offers the reward of lower cases
and greater public confidence about
safety and all its attendant benefits.
The Controlled Adaptation sends
a signal of pragmatic acceptance
of low infections right at the start,
and in return promises a somewhat
earlier return, greater flexibility with
measures, and manages the risk of
flare ups within the capacity of our
adapted health system.
Neither of these two will allow for
a return to life as we knew it over
Christmas 2019. As with air travel
after 9/11, some restrictions and
impositions are here to stay. In both
cases, enhanced hygiene, some
measures of physical distancing and
greater testing and tracing, will be the
new norm.
In both cases most of us will remain
susceptible. The final “exit” from
both pathways will require a vaccine
that confers immunity to all of us.
We cannot predict when that will
be. It seems reasonable to expect
one in the next year or two. Should
it become clear that the chance of a
vaccine is remote – current strategies
will need to be revisited.
The challenge over the coming
weeks will be to evaluate the relative
attractiveness of the two options;
to assess, despite considerable
uncertainty, how best to trade off the
potential rewards of the Elimination
option against the greater sacrifices
required in a framework of values
we share.
The Go8 looks forward to working
with the nation and its Government
to continue its contribution.

Regardless of which path Australia
chooses in mid-May, some things do
not change.
1. Early Detection and
Supported Isolation
yy Both strategies will require an
extensive system of testing,
tracing and isolation.
yy Two kinds of tests are useful. Tests
detecting the virus (also called,
PCR, antigen) and tests that detect
personal immunity (antibody,
serology). At this stage the virus-
PCR test is the critical one.
yy The purpose of testing is to identify
the cases and isolate them, identify
the contacts and quarantine them,
and assess the level of community
prevalence.
yy Both strategies envisage that
testing is widely available and
accessible (including in remote
areas), free of charge, with minimal
wait times and a short turnaround
time (less than one day). Sentinel
testing, which entails testing of
a few selected persons, alone
will not be sufficient. Therefore,
testing capacity will need to be
significantly increased.
yy The precise application of testing
and contact tracing differs between
the two strategies. In devising
these new approaches Government
should explore the possibility of
engaging the community, private
and business sector.
yy In both strategies, those who are
positive must isolate in a safe way
– with support and monitoring in
Three requirements for success
1. Early Detection and Supported Isolation
2. Travel and Border Restrictions
3. Public Trust, Transparency and Civic Engagement

an appropriate way. Their potential
contacts must be traced and
contacted, and advised quarantine
and testing if appropriate.
yy Isolation and quarantine should only
end after confirmation of no further
viral shedding.
yy Digital contact tracing apps can
assist – however they are not
a panacea and work best when
integrated with traditional manual
contact tracing methods.
yy The Taskforce recommends the
exploration and use of these
innovative digital techniques but
cautions that automatic uptake
may be low, and may require public
campaigns to increase acceptance.
Any such use must be with the
person’s consent, for a time-limited
period, only for the purposes of
public health, and without prejudice.
2. Travel and Border
Restrictions
yy Given the state of the pandemic
in the rest of the world, we
recommend that the government
continue the two-week period of
enforced and monitored quarantine
and isolation for all incoming
travellers regardless of origin
or citizenship.
yy International travel bans remain
on all Australians, other than for
sanctioned “essential” travel, for the
next six months and any returning
essential travellers be subject to
the quarantine restrictions.
yy If some countries have their
epidemics under control in a
manner same as ours, then
our Government may explore
establishing a special bilateral
travel understanding.
Rather than waiting for a
vaccine, we recommend that
the Government fund research
into developing and testing
new strategies based on virus
and/or immunity testing and a
combination of in-country/overseas
quarantine which may allow for an
earlier resumption of international
travel.

yy The Australian Government
should engage with the World
Health Organisation (WHO) to
anticipate a regime of “International
Vaccine Certification” were a
vaccine to become available.
yy We do not find evidence for a
reliable “immunity passport” at
the moment.
yy Rather than waiting for a
vaccine, we recommend that
the Government fund research
into developing and testing new
strategies based on virus and/or
immunity testing and a combination
of in-country/overseas quarantine
which may allow for an earlier
resumption of international travel.
3. Public Trust, Transparency
and Civic Engagement
yy Given the months and possibly
years of measures and compliance
that are required, winning
public trust, transparency of the
information used to make decisions
and the degree and quality of civic
engagement are critical to success.
yy Communication is the central link
to building trust. Prioritise trust
by acknowledging uncertainty,
communicating clearly and with
empathy for everyone, especially
those with vulnerabilities.
yy The Australian population has a
sophisticated understanding of
Covid-19 issues and has engaged
actively in the social distancing
issues. Treat them as a partner by
clearly communicating rationale for
decisions, including what evidence
is being used, who was consulted,
and what impacts were considered
and why a choice was made.
The Australian population has a
sophisticated understanding of
Covid-19 issues and has engaged
actively in the social distancing
issues. Treat them as a partner by
clearly communicating rationale for
decisions, including what evidence
is being used, who was consulted,
and what impacts were considered
and why a choice was made.

yy This is especially critical if there
is use of citizen-generated data
(i.e., from mobile contact tracing
applications). Governments must
address real and perceived privacy
concerns and mitigate against
the potential for misuse. Where
possible use trusted independent
bodies to oversee some of these
activities to avoid the politicisation
of health data and to ensure
continuity.
yy Maintaining civic engagement for
the long haul is critical. Where
possible, involve communities,
industries, business organisations,
and other stakeholders in decisions
about options for strengthening and/
or relaxing containment measures.
yy The young have been particularly
displaced by the social distancing
policies and many will find it hard
to gain a foothold in the economy.
Consideration should be given
to the establishment of a funded
national service program (e.g.
Aussies All Together) to inclusively
engage the young from across
the nation in the process of social
reconstruction across the country.

Six imperatives in the implementation
of Recovery
1. The Health of our Healthcare System and its Workers
2. Preparing for Relaxation of Social Distancing
3. Mental Health and Wellbeing for All
4. The Care of Indigenous Australians
5. Equity of Access and Outcomes in Health Support
6. Clarity of Communication
1. The Health of our Healthcare
System and its Workers
Australia has done an effective job
of reinforcing its hospitals and its
critical care capacity. For now, that
seems sufficient. At the same time,
the Australian health research sector
has excelled by isolating the virus,
developing vaccines candidates, and
testing new therapeutics. However, it
must now prepare for the long run and:
yy Support healthcare workers by
ensuring they have sufficient
and assured PPE supplies and
comprehensive training in the
appropriate use and bespoke
programs to support their mental
health and well-being.
yy Many have delayed or deferred
their ongoing care and elective
procedures. Support direct
messaging to assure all Australians
of the safety of the healthcare
system and urge a gradual return
to usual patterns of healthcare.
Care of COVID-19 patients must
not come at the expense of others.
yy Create a national, real-time, data-
repository of all COVID-19-related
care in primary, secondary and
acute care to ensure best care
for all. This is critical because we
know little about COVID-19 care
now. Developing such a national
resource will improve outcomes
for all.

yy Continue to support medical
research that integrates laboratory,
epidemiological and clinical
trial-based and health services
research that models the projected
dissemination and spread of
COVID-19 in an Australian context,
informs strategies to minimise the
number of infections and optimise
the treatment of Australians.
yy COVID-19 has resulted in a huge
increase in video/tele-health and
eHealth use. The valuable aspects
of this new model should be
sustained as an important part
of routine health care, supported
by nationally agreed standards
and quality indicators. The digital
divide in Australia must be closed
or we risk even further entrenching
existing health inequalities amongst
lower income groups.
yy The training and education of
thousands of healthcare students
has been disrupted. The National
Principles for clinical education
during the COVID-19 pandemic are
a significant step towards flexibility
in health care worker training
requirements to ensure viability
of the health workforce pipeline.
2. Preparing for Relaxation
of Social Distancing
Australia will soon face the complex
challenge of resuming campus
teaching in schools and universities,
and businesses returning to premises.
While many will look forward to this,
many others will be concerned and
some will personally be at greater
risk. How this transition is supported
will have a major impact on societal
wellbeing and economic recovery.
yy Return to physical schooling
with special consideration of
the following groups: children
in primary schools as they have
additional needs in regards to
socialisation, emotional and
academic support and require
greater parental involvement
in schooling at home; students
for whom this is the final year
for transition to further study or
employment; students and teachers
who have pre-existing conditions
and who may feel particularly
vulnerable on return.
yy All schools may need to coordinate
a range of additional resources to
help educators identify and address

learning gaps, mental health issues
among students and concerns and
wellbeing of staff.
yy There is no one-size-fits-all formula
for the return of all businesses.
Consideration should be given to
the creation of a sophisticated
national “risk tool” that businesses
can use to review and self-assess
their own situation and create
the appropriate and optimal
environment for return.
yy A workforce health-tracking system
specific to COVID-19 and should be
developed to ensure that reopening
practices are safe to the workforce
and public. Information from such a
system should be used to learn and
design best practices, and those
should be widely shared.
3. Mental Health and Wellbeing
for All
The unprecedented scale and speed
of the COVID-19 pandemic has
implications for the wellbeing of all.
Evidence from previous large natural
disasters and pandemics shows that
in its aftermath there is a significant
increase in anxiety, depression, post-
traumatic stress syndromes as well
as substance abuse. These symptoms
extract a huge individual and family
price and a significant economic
toll. People with psychological
vulnerabilities and pre-existing mental
illness are at higher risk. The greatly
increased demand for services will
continue throughout the recovery
phase. The following is recommended:
yy Coordinated and sustained public
health messaging on the risks
associated with COVID-19 and
actions that can be taken to maintain
mental health and wellbeing.
yy Rapid scaling of secure evidence-
based Health and Telehealth
interventions in addition to
strengthened provision of
community-based support.
There is no one-size-
fits-all formula for
the return of all
businesses.

yy Increased capacity to ensure
timely assessment and effective
treatment for people with ongoing
mental illness and those at risk
of suicide.
4. The Care of Indigenous
Australians
The disproportionate impact
of pandemics on Indigenous
populations worldwide is well
documented. Thanks to the
leadership by Australian Indigenous
organisations and their partnership
with Governments, the number
of cases is proportionately lower.
However, Indigenous Australians
are particularly at risk as Australia
“reopens” with a weakened economy
and the resulting consequences.
yy We recommend the continued
financial and logistical support
of Indigenous COVID-19 planning
taskforces in all jurisdictions for
the remainder of the pandemic.
yy Lack of adequate housing
particularly adversely affects
the ability of local aboriginal
health services to control virus
spread – immediate and more
enduring interventions are needed
to address the shortage of
appropriate housing.
yy The COVID-19 pandemic has
exacerbated vulnerabilities of local
workforces which were dependent
on staff from interstate and even
New Zealand. Short and Long-term
initiatives to build local workforce
capacity are needed.
Lack of adequate housing
particularly adversely affects the
ability of local aboriginal health
services to control virus spread
– immediate and more enduring
interventions are needed to
address the shortage of appropriate
housing.

5. Equity of Access and
Outcomes in Health Support
History tells us that pandemics affect
those with the least resources and
with specific vulnerabilities hardest
and longest. We must guard against
that. Subsequent generations will judge
us for how equitably we supported
and included in decision-making the
people who are most at risk.
yy The report identifies several
populations that are particularly at
risk: women who are pregnant and
women at risk of family violence,
children and young people, those
living in out-of-home care; older
adults and those living in residential
aged care; people with disabilities;
people living with a life-threatening
illnesses amongst others.
yy Those who are at the intersection
of these attributes, often bear the
greatest brunt.
yy The main purpose of this section
is to alert the nation to its special
responsibilities to these many
populations.
yy The main thrust of our
recommendations is that there isn’t
a single silver bullet for all these
diverse populations. However, a
central principle is for Governments
to engage and partner with these
groups in designing and delivering
solutions for them.
6. Clarity of Communication
The overall success of the recovery
will depend upon engaging
widespread public support and
participation regardless of which
strategy is chosen.
If the Elimination Strategy is
pursued, it is important that the
public understands the additional
It is also critical that the public
understand that even with the
Elimination Strategy, life will not
return to the ‘old normal’.

sacrifice needed, why it is worth it
and what benefits they can expect
in return. It is also critical that the
public understand that even with
the Elimination Strategy, life will not
return to the ‘old normal’.
With the Controlled Adaptation
strategy, it is critical that the public
understand that in exchange for an
earlier relaxation, there will be a need
for ongoing adaptation. The public
should also be prepared that should
numbers worsen, the course may
need to be temporarily reversed.
This would not be a failure of the
strategy – rather it is the strategy.
It is important that Governments
continues to:
yy Communicate the approach and
associated measures using specific
and empathetic language that helps
people feel empowered to act,
rather than just passive recipients
of instructions.    
yy Enlist the support and assistance
of independent, credible and
trustworthy advocates (e.g.
healthcare workers, educators,
community leaders) to convey
key messages.
yy Enhance the impact of
communication by establishing
community reference groups to
provide ongoing input into the
decisions that affect them and also
how best to communicate them.
Collectively they should represent
Australia’s demographic and socio-
cultural diversity.
yy Be proactive in identifying and
actively combatting misinformation
and conspiracy theories by
transparently providing factual
and current information.
Several community reference
groups should be established so
that collectively, they represent
Australia’s demographic and
socio-cultural diversity.

1
There are things we should not be
prepared to sacrifice, whatever the
circumstances. While in other cases,
we must be clear about conflicting
values and the consequences of our
choices. To facilitate that discussion,
1. Democratic accountability and
the protection of civil liberties:
Whatever measures Australia
implements to deal with the virus
now, and in recovery, must be
compatible with a commitment
to democratic accountability and
the protection of fundamental civil
we articulate the six core principles
that should frame Australia’s
decisions and policymaking. They
are not only guides for decision-
making about recovery, they are also
preconditions for its success.
liberties. Special measures that
require restriction of movement
or data-sharing, by either
public or private bodies, must
be proportionate, time-bound,
grounded in consent and subject
to democratic review.
An Ethical Framework
for the Recovery
At a time of national crisis, and in turning our minds to
the recovery from it, it is vital to clarify the key values
and principles that will guide decision-making when
we will face many difficult challenges and trade-offs.
Six core principles to frame Australia’s
decisions and policymaking
1. Democratic accountability and the protection of civil liberties
2. Equal access to healthcare and social welfare
3. Shared economic sacrifice
4. Attentiveness to the distinctive patterns of disadvantage
5. Enhancing social well-being and mental health
6. Partnership and shared responsibility

2. Equal access to healthcare and
social welfare: Equal access to
healthcare and core universal
services and to a social safety
net for all in our community must
remain a fundamental principle
now, and later, as we recover.
Attention must also be given to
the healthcare and social needs
of those within our society who
are not currently citizens, with
appropriate recognition of their
special circumstances.
3. Shared economic sacrifice:
While the virus’s economic impact
is significant and affects all of us
in different ways, some bear more
of the cost than others. Many such
inequities are not a direct impact
of the virus, but a consequence
of the choices we have made
in responding to it. These and
future economic sacrifices
must be shared fairly across the
community.
4. Attentiveness to the distinctive
patterns of disadvantage: Equal
treatment is a fundamental value
in Australia, nonetheless the
impact of policies and measures
on people varies depending
on their social circumstances.
Aboriginal and Torres Strait
Islanders, minorities, women,
children, people with disability, the
elderly and others, will experience
distinctive disadvantages as
a result of their relative social,
economic and cultural position.
Any policies and measures to
contain the virus, and for recovery,
must explicitly identify and
address the negative distributional
effects of implementation.
Chapter 1: An Ethical Framework for the Recovery
Many such inequities are not a
direct impact of the virus, but
a consequence of the choices
we have made in responding to
it. These and future economic
sacrifices must be shared fairly
across the community.

5. Enhancing social well-being
and mental health: Any policies
or measures should aim to
enhance and strengthen individual
mental health, social solidarity
and reciprocity, both now and as
we recover. Economic renewal
programs should focus on lifting
the most disadvantaged first.
We should foster economic and
social innovation that will make
Australia more resilient in the face
of future shocks.
6. Partnership and shared
responsibility: Recovery is not
just what governments can do for
us, but what we can do for each
other – and in partnership with
our community organisations,
businesses and industry. Each of
us has an individual responsibility
to respond in this moment of
crisis. We have a duty to act
in ways that both respects the
dignity and equal worth of others,
contribute to their safety, and
to ensure that the measures
implemented now and in recovery
are equitable and just.
It is important also to recognise the
inter-relatedness of these principles.
Each principle reinforces the other.
Democratic accountability depends on
an engaged community, which in turn
depends on its social and economic
well-being. The protection of our
civil liberties, as well as the universal
provision of health and social welfare,
depends on our shared commitment
to upholding the necessary conditions
required for civic life.
In the next few months and years, we
will not just be responding to a virus.
Our response will be defining who we
are and what we will become.
Economic renewal programs
should focus on lifting the most
disadvantaged first.

2
A jurisdiction-by-jurisdiction
elimination approach would
only relax internal containment
and social distancing measures
once there was no evidence of
community transmission in the
relevant jurisdiction, and once
appropriate early detection and
control measures were in place. It
would aim to maintain elimination
through border control and detection
and control of transmission chains.
This contrasts with the “controlled
adaptation” method (next chapter),
which would allow for an earlier
relaxation of social distancing
measures while there is still some
minimal evidence of community
transmission – seeking instead to
maintain such transmission at levels
for a prolonged period.
Key Points:
yy Elimination of community
transmission, and maintenance of
that elimination is achievable and
feasible in Australia, unlike many
other countries. This has already
been achieved in some of our
jurisdictions and could be made to
occur for the last State/Territory by
June, and hence nationally.
transmission could optimise
health, social and economic
outcomes for Australia and provide
particular safety to the vulnerable
groups who are especially at risk
if we allow ongoing background
transmission.
The Elimination
Option
Definition: Elimination is defined as the eradication of
community transmission of SARS-CoV-2 at a country,
State/Territory or regional level. In practice this would
mean no new SARS-CoV-2 cases linked to community
transmission or unknown sources of infection over
two incubation periods since the time of the last
known community acquired case, provided a highly
sensitive early detection, case and contact tracing and
management surveillance system is in place.

transmission in Australia will
present unique geopolitical and
economic advantages, positioning
Australia as a global and regional
leader, and attracting and
reinvigorating business activity
at a greater pace.
Goal and objectives
The goal of Elimination is to optimise
outcomes in Australia through:
yy Elimination of local transmission of
COVID-19 on a State and Territory,
and then national basis;
yy Maintenance of such elimination,
through border control, highly
sensitive early detection systems
and effective control of detected
transmission chains;
yy Implementation of gradual and
targeted relaxation of internal
containment and social distancing
measures once elimination is
achieved with continuing avoidance
of large gatherings and other
potential super-spreading activities;
yy Use of a State and Territory approach
means that social and economic
activities can be resumed as each
jurisdiction achieves elimination and
builds its surveillance and control
capacity, with appropriate jurisdictional
border controls in place until there is
elimination across all States.
Methods and
requirements
The methods of the elimination
approach are broadly summarised as:
1. Continuation of current
containment, social distancing,
testing, contact tracing and
management measures to bring
about elimination of community
transmission of SARS-CoV-2.
2. In parallel, further enhancement of
a highly sensitive early detection,
case and contact tracing and
management and border control
system, with monitoring of
important parameters. This would
build on existing systems and is
required for both the elimination
and controlled adaptation options;
it is outlined in detail below.

3. Community engagement is critical
to any early detection and control
system, to ensure appropriate
support for and engagement
with the required measures. The
Australian community has shown
itself to be highly engaged and
compliant with COVID-19 control
measures (see below).
4. Once early detection, case and
contact tracing and management
and border control systems
are functioning at the required
capacity and these systems
show that elimination has been
achieved, gradual and targeted
relaxation of social distancing
measures can be implemented.
5. Strong border control measures
and quarantining of people
coming into Australia from areas
affected by COVID-19 will need to
be maintained. It is anticipated
that internal containment and
social distancing measures will
be able to be relaxed to a greater
extent under the elimination
than the controlled adaptation
approach, since the risks of
resurgence of community
transmission will be minimised.
6. The overall system will need to be
responsive to community needs
and will need to be able to take
advantages of technological
advances as they occur, including
progress with contact tracing apps
and potential self-testing for SARS-
CoV-2. Systems requirements will
need to be reviewed regularly and
adapted (Lurie et al, 2020).
Chapter 2: The Elimination Option
It is anticipated that internal
measures will be able to be relaxed
to a greater extent under the
elimination than the controlled
adaptation approach, since the
risks of resurgence of community
transmission will be minimised.

Details of early detection and
case and contact management
systems, including performance
indicators and targets
In addition to current testing, testing
should be implemented to detect all
SARS-CoV-2 transmission chains.
This should occur through testing all
syndromic fever and cough primary
care presentations, in combination
with exhaustive and meticulous
case and contact identification
and management (Lokuge et al).
These measures will enable
appropriate early detection
and elimination of community
transmission of COVID-19 and are in
addition to established regimes such
as the testing of very fast increasing
here symptomatic travellers, contacts,
health care workers and hospitalised
pneumonia cases. If testing capacity
is limited, interventions such as
pooling allow increased case
detection, even given reduced test
sensitivity. Though our first preference
is to increase testing capacity to meet
the potential need.
Wider identification and testing of
all upstream contacts, (i.e. potential
sources of infection for identified
cases, and their related transmission
chains) is critical, and to be done
exhaustively requires more resources
than downstream contact tracing.
Symptom definitions may be broadened
as evidence emerges (see below).
An Australian study investigated
detection and elimination of community
transmission of SARS-CoV-2 and
maintenance of such elimination
(Lokuge et al). It compared efficiency
and sensitivity to detect community
transmission chains through testing
of hospital cases; primary care fever
and cough patients; or asymptomatic
community members, using
surveillance evaluation methods and
mathematical modelling, varying
testing capacities and prevalence of
COVID-19 and non-COVID-19 fever and
cough, and the reproduction number.
This analysis showed that, assuming
20% of cases are asymptomatic and
that all symptomatic COVID-19 cases
present to primary care – there are
13 unrecognised community cases

(five infectious) when a transmission
chain is identified through
hospital surveillance versus three
unrecognised cases (one infectious)
through primary care surveillance
(Lokuge et al) – making primary care
detection a better choice. These three
unrecognised upstream community
cases are themselves estimated to
generate a further 22–33 contacts
requiring follow-up. The unrecognised
community cases rise to five, if
only 50% of symptomatic cases
present to primary care. Screening
for asymptomatic disease in the
community could not exhaustively
identify all transmission under any of
the scenarios assessed. Thus primary
care driven identification seems the
preferred mode.
System requirements for increasing
testing to allow exhaustive
identification of all transmission
chains, and then enable complete
follow-up of all cases and contacts
within each chain, were assessed
per million population. The additional
capacity required to screen all fever
and cough primary care patients
would be approximately 2,000 tests/
million population per week using
1/16 pooling of samples (Lokuge et
al). Australia could easily enhance its
capacity to meet these numbers and
with the availability of greater testing
may even be able to dispense with
pooling.
The following are recommended
indicators for elimination
achievement and maintenance. They
relate to the ability of the system to
cover and test the population (A),
indicators which will assure one that
elimination targets are being met (B)
and being maintained (C).
… there are 13 unrecognised
community cases (five infectious)
when a transmission chain
is identified through hospital
surveillance versus three
unrecognised cases (one
infectious) through primary care
surveillance …

A) Indicators of system
coverage, uptake and
completeness:
yy Proportion of fever and cough
(influenza-like-illness) in the
community screened for COVID-19
(target=100%): weekly percent
population screening target for
all locations to be based initially
on State/Territory-specific
targets in Table 1, varying with
expected monthly total fever and
cough incidence (i.e. 0.6%–3%
of the population). This percent
target should be reassessed
monthly based on sentinel
influenza surveillance systems
(e.g. Flutracker, plus additional
community-based surveys.)
Surveillance system performance
should also be validated through,
for example, random community-
based surveillance for unreported
fever and cough at household and
in general primary care settings.
Fever and cough prevalence have
decreased due to social distancing,
however as these measures are
lifted, it would be expected that
prevalence will increase, especially
if lifting occurs during winter.
yy For the elimination option, the
above indicator is the primary
indicator to be monitored on an
ongoing basis, regardless of
whether phase of response is
aiming towards elimination or
maintaining elimination.
yy Related performance indicators:
»» Uptake of screening for COVID-19
in patients with fever and
cough in sentinel surveillance
populations (target=100%), this
can be part of the information
collected during sentinel follow-
up and monthly fever and cough
prevalence surveys recommended
above.
»» Community understanding of
testing criteria, attitudes towards
uptake of screening, practices
related to screening, views on
feasibility and burden, support
services for enabling screening
(again, can be included in sentinel
surveillance and surveys).

B) Indicators of successful
progress towards
elimination of
community transmission,
given indicators in (A)
have all been met:
yy Proportion of newly reported cases
that are travel related and/ or
known contacts of confirmed cases
(target=100%).
yy Proportion of newly reported cases
that are tested on day of symptom
onset (target=100%).
yy Proportion of newly detected cases
that have been under quarantine
from time of exposure event
(target=100%).
yy Proportion of complete follow up
of all contacts (target=100%).
Initially, as the modelling suggests,
the number of upstream contacts
under follow up per case should
be at least 2 times number of
downstream contacts under
follow up (as there will be 2–3
upstream transmission branches
for every identified case, and total
number of contacts under follow
up per case should be >35, unless
there is a clear justification for
lower). This figure should also be
reviewed regularly, and contact
case definitions updated based
on sero-surveys and screening for
viral shedding around identified
cases, including in high-risk settings
(institutional settings, schools,
health care facilities). Complete
follow-up includes:
»» For upstream contacts: PCR and
serological testing at time of case
detection
»» For downstream contacts:
documented quarantining for 14
days after last contact, linked to
PCR testing at end of quarantine
period to exclude asymptomatic
viral shedding.
yy Proportion of hospitalised new
cases and/or deaths relative to total
new community-acquired cases
(target=0%).
yy Proportion of tested patients
provided results within 24 hours
of testing (target = 100%).
… total number of contacts under
follow up per case should be >35 …

C) Indicators of successful
elimination of community
transmission, given (A)
and (B) have all been met:
yy Proportion of new cases are travel
related introductions of disease
(target=100%).
yy Proportion of new cases that are
classified as unknown source or
local community transmission-
related exposure (target=0%).
Elimination-relevant evidence
and technologies regarding early
detection and case and contact
management systems should be
reviewed rapidly on an ongoing
basis, incorporating new evidence-
based developments as they emerge.
Such developments include: data on
symptoms that would be appropriate
to include in addition to fever and
cough in primary care (e.g. anosmia,
milder influenza-like-illnesses); analysis
of wastewater; and use of apps related
to contact tracing and management.
There is relevant evidence available
from countries and jurisdictions with
experience of effective COVID-19
control, including China, Singapore,
South Korea, Hong Kong and Taiwan
(see Appendix).
Evidence: rationale,
benefits and risks of
the jurisdiction-by-
jurisdiction elimination
approach
Elimination is a desired outcome
and the lowest risk approach. Apart
from global eradication, elimination is
the most effective measure to control
mortality and morbidity from and
health services impacts of infectious
disease. The desirability of this goal
is not disputed, the main concerns
regarding an elimination approach are:
i. that it may not be achievable;
ii. that it may not be sustainable; and
iii. that it may be too costly in social
and economic terms to achieve
and maintain.
We address these concerns below,
including demonstrating the feasibility
of the approach, its safety and the fact
that it is likely to result in better health,
social and economic outcomes than
its alternatives.
Elimination is feasible, even in
the presence of asymptomatic
infections, based on detection and
management of transmission chains.

Concerns have been raised regarding
the proportion of individuals
infected with SARS-CoV-2 who are
asymptomatic and the implications
of this for elimination and disease
control. Most screening in high
income countries such as Australia
targets detection of sporadic
disease in asymptomatic individuals,
scattered throughout the population
e.g. for breast, bowel and cervical
cancer, PKU, neonatal deafness
(see Figure 1). Population testing
for asymptomatic cases is critical
to the success of such screening.
In contrast, infectious diseases like
COVID-19 occur in transmission
chains, where each case is linked to
another series of cases (see Figure 2).
Detection and control of these
types of infectious diseases relies
on first detecting the transmission
chains, then exhaustive upstream
and downstream identification and
management of all of cases in each
chain. The World Health Organisation
recommends management of
COVID-19 using transmission chains
(World Health Organisation, 2020).
Provided a proportion of the cases
in each transmission chain are

Figure 1. Sporadic disease Figure 2. Disease in Transmission Chains

Figure 1. Sporadic disease
Figure 2. Disease in
Transmission Chains

Figure 1. Sporadic disease Figure 2. Disease in Transmission Chains

symptomatic, each chain will be
detectable. Subsequent contact tracing
aims to identify and manage cases in
the chain regardless of whether they
are symptomatic or asymptomatic; for
example, quarantining of downstream
contacts of cases will prevent spread
of disease regardless of whether
someone develops symptoms.
The crucial question for COVID-19
control is not the proportion of
cases which are asymptomatic, but
whether the early detection system
that is applied will detect cases and
prevent transmission. This relates to
the proportion of transmission chains
(rather than individuals) that are totally
asymptomatic. While the proportion
of SARS-CoV-2 cases which are truly
asymptomatic is currently not known,1
our analyses indicate that virtually
all transmission chains will include
symptomatic individuals (Lokuge
et al). Added to this, early detection
systems should include a broad
range of testing, including conducting
wide serological testing in potential
upstream contacts, testing of sentinel
and vulnerable populations, such as
health care workers, as well as testing
with expanded sensitivity (such as that
which may be possible with sewerage)
and sequencing viral samples,
allowing investigation of relatedness
of infections. Finally, general
measures such as containment,
social distancing and border control
work on both symptomatic and
asymptomatic infections.
Australia is on track to eliminate
community transmission of SARS-
CoV-2 and elimination is likely
to have already been achieved in
multiple jurisdictions. Australia is
in the enviable position of having
elimination as the preferred option
Australia is in the enviable position
of having elimination as the
preferred option for COVID-19
control, thanks to a range of factors,
including the timely actions of the
Australian community.
1 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200402-sitrep-73-covid-19.
pdf?sfvrsn=5ae25bc7_6

for COVID-19 control, thanks to a
range of factors, including the timely
actions of the Australian community.
The low number of cases overall
mean that elimination is possible
within a relatively short timeframe
if containment measures are
maintained. A number of jurisdictions
are already at or close to elimination,
in that they have recorded no
cases where the source was not a
known case (presumed community
transmission) or have recorded <10
such cases during the course of the
pandemic to date (e.g. Australian
Capital Territory, Northern Territory,
South Australia, Tasmania, Western
Australia).2
Other jurisdictions are
showing rapidly declining case
numbers, especially those from
unknown sources. Hence, the most
recent available national data indicate
small and declining numbers of cases
with an unknown source (Figure 3).
2 https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-
19-current-situation-and-case-numbers#in-australia

Figure 3: Number of COVID-19 cases by place of acquisition over time, Australia (n =
6,394) From: Commun Dis Intell 2020 44 https://doi.org/10.33321/cdi.2020.44.34 Epub
17/4/2020

Figure 3. Number of COVID-19 cases by place of acquisition
over time, Australia (n = 6,394)
From: Commun Dis Intell 2020 44 https://doi.org/10.33321/cdi.2020.44.34 Epub 17/4/2020

A basic reproduction number in
the range 2.2–2.7 has been used
in relevant Australian modelling
studies and appears consistent
with local dynamics (Change et al,
2020; Moss et al 2020, Coatsworth
2020, Jarvis et al 2020). Currently,
effective Rt is below 1 across virtually
all jurisdictions in Australia, with
the increase in Tasmania due to an
identified cluster of cases. This is
evidenced by declining prevalence
across states and territories;
estimates from multiple approaches,
including modelling, are that the
effective reproduction number (Rt)
to about 0.5 at present in NSW and
Victoria (Figure 4).
The reductions in the effective
reproduction number that have been
achieved indicate approximately
a two thirds reduction in overall
transmission since early March. This
has been achieved through social
distancing combined with contact
tracing and increasingly effective
public health control as case numbers
have dropped and notification delays
have fallen. The updated model of
Chang et al. (2020) suggests that the
social distancing compliance levels
in Australia have approached 90%
between 24 March and mid-April 2020,
providing evidence of high community
engagement with the measures.
Hence there is good evidence that,
if the current efforts are continued,
elimination will be achieved, state-by-
state. Estimates based on modelling –
and from calculations based on an Rt
of 0.5, current national case numbers
of 50/day and a serial interval of five
days – indicate that elimination of
The updated model of Chang
et al. (2020) suggests that the
social distancing compliance
levels in Australia have
approached 90% between
24 March and mid-April 2020,
providing evidence of high
community engagement with
the measures.

Figure 4. Time-varying estimate of the effective reproduction
number of COVID-19

(light blue ribbon =
90% credible interval;
dark blue ribbon = 50%
credible interval) up to
5 April based on data
up to and including 13
April, for each Australian
State/Territory with
sufficient local
transmission (excludes
ACT, NT). Confidence
in the estimated values
is indicated by shading
with reduced shading
corresponding to
reduced confidence.
The black dotted line
indicates the target
value of 1 for the
effective reproduction
number required for
control. The red dotted
line indicates the
reproduction number
estimated for the
early epidemic phase
in Wuhan, China in
the absence of public
health interventions
and assuming that
the population was
completely susceptible
to infection (2.68).
Estimates from
Tasmania should be
regarded with caution.
From: Price et al, 2020

community transmission for the last
remaining state in Australia is likely
to occur within 30–60 days from
the time of writing (i.e. from 16 May
to 14 June). This is assuming no
major institutional or other outbreak
events. Empirical evidence suggests
it may be quicker than this, depending
on levels of community action: in
Hubei province case numbers fell
from around 80 cases to <1 case on
average per day in two weeks, albeit
with extreme containment and social
distancing. It would be expected
that with further enhancements of
surveillance in Australia and resultant
early case detection and case and
contact management, the rate of
elimination would be increased.
The reductions in the effective
reproduction number that have
been achieved indicate approximately
a two thirds reduction in overall
transmission since early March. This
has been achieved through social
distancing combined with contact
tracing and increasingly effective
public health control as case numbers
have dropped and notification delays
have fallen.
Maintenance of elimination is
achievable and feasible. Australia has
a long history of successful disease
elimination and of maintaining long
term elimination, including for human
conditions with and without vaccines.
It has also demonstrated its ability to
maintain biosecurity for a wide range
of animal and plant diseases – such
as equine influenza, bovine brucellosis
and foot and mouth disease3
– that
remain widespread in the rest of the
world. A number of Asian countries –
including China, Hong Kong, Taiwan
and South Korea – and New Zealand
have either implicit or explicit aims to
control COVID-19 through elimination,
at a regional or national level. Policies
in many other countries, particularly
Australia has a long history of
successful disease elimination
and of maintaining long term
elimination, including for human
conditions with and without
vaccines.
3 https://www.health.qld.gov.au/cdcg/index/brucell

in Europe, are predicated on assuming
elimination is not possible – partly
given the extent of their spread and
partly because they do not account
for the impact of community-based
case detection and contact tracing
on transmission control (Ferguson
et al, 2020).
Mantaining elimination of COVID-19
community transmission will require
demonstrable high-performing border
controls, case and contact follow-
up, along with sufficient testing and
surveillance to detect a low risk of
COVID-19 circulation in the population
(Baker et al, 2020).
In a very low transmission setting,
which is tending to elimination
and where interventions have been
partially relaxed, it is important to
be prepared to rapidly respond to a
breakout spike in cases. Modelling
suggests that such a reactive strategy,
where the strength of social distancing
measures is rapidly increased, is
highly effective.4
In general, such
outbreaks can be managed with
effective surveillance, even if very
large (e.g. as has been seen in South
Korea) but limitation of non-essential
mass spreading events will mean the
surveillance and case management
systems will not be overwhelmed.
Once elimination, surveillance and
control system and border control
indicators are met, gradual and
targeted relaxation of containment
social distancing measures can be
implemented.
There is a chance for rebound cases
if the current containment and social
distancing measures are relaxed
simultaneously and broadly. A phased
approach, tailored to specific cohorts
of the population and sectors of
the economy, is recommended.
4 Figure 1, Milne and Xie, medRxiv https://doi.org/10.1101/2020.03.20.20040055
In general, such outbreaks can
be managed with effective
surveillance, even if very large …
but limitation of non-essential mass
spreading events will mean the
surveillance and case management
systems will not be overwhelmed.

Employees in several prioritised
sectors of the economy can be
excluded from strict social distancing
and added in a staggered fashion
to the essential services which are
currently exempt.
Priority can be decided by
Government, with a focus on:
1. manufacturing, construction,
mining, agriculture, forestry
and fishing;
2. wholesale and retail trade; and
3. tourism, education, media
and communication, arts
and recreation.
There is a trade-off between
compliance/adoption levels and
duration of the restrictions (Chang
et al., 2020), and so an elimination
strategy would need to err on a side
of caution in recommending time
intervals for resumption of activity.
Consideration would be given to
continuing social distancing tailored
to specific community cohorts
(e.g. elderly, immunocompromised
individuals, and other vulnerable
groups). Given the experience in
South Korea, avoidance of large
gatherings would reduce risk.
Elimination of community
transmission and maintenance
of this elimination will optimise
outcomes for Australia. The
elimination strategy will result in
the fewest cases of disease and
lowest mortality compared to
other proposed strategies. Given
the value of life and health and the
uncertainties about the long-term
effects of COVID-19 infection, this
is a critical consideration. It will
also place the least burden on the
health care system, protecting our
health care workers and ensuring
they are able to support the health
of the broader community. This is
particularly important given the
likely co-circulation with seasonal
influenza. Elimination will also permit
the greatest resumption of health
programs – including screening
programs – critical to reducing
morbidity and mortality in Australia.
The marginal costs of achieving
elimination are low relative to the
alternative of controlled adaptation
and, overall, the total economy costs
may be lesser than other strategies.
After elimination has been achieved
it should permit greater social and

economic activity within the region of
elimination than its alternatives, up
to the point where a vaccine and/or
effective treatments become available.
Additionally, once one region has
demonstrated the requirements for
sustained elimination in the context
of lifting of control measures, this
provides guidance and unparalleled
incentives for other settings to
implement such measures. As
the areas and regions achieving
elimination grows, the economic
benefits continue to accumulate for
those regions. However, those areas
not achieving elimination will suffer
comparatively greater social and
economic marginalisation.
Elimination of domestic transmission
would not only provide tangible
benefits, it would result in substantial
intangible benefits related to change
in people’s perception in relation to
infection; it would be expected to
result in increasing participation in
the entertainment and hospitality
sectors. Controlled adaptation would
likely have a greater ongoing impact
on perceptions and behaviour, and
therefore on such sectors. Elimination
would be expected to positively
influence consumer and business
confidence and would also reduce
the uncertainty and associated risks
with a new outbreak and subsequent
re-introduction on social distancing
controls. Importantly, repeated,
large-scale outbreaks, with possible
re-introduction of controls, as may
occur with controlled adaptation,
would likely have negative impacts on
business confidence and investment
as it would make business planning,
beyond the very short term, difficult.
Elimination may mean a slower
relaxation of mandated controls
(say a maximum of 30 days or so
after controlled adaptation begins
to relax mandated controls, for the
latest jurisdiction). Thus, elimination
implies initially higher economic costs
until mandated controls are relaxed.
The estimated economic costs per
30 days of current levels of mandated
controls is approximately 2% of GDP.
After mandated controls are relaxed,
there is a higher level of economic
activity as Australia moves closer
to (but is still below) pre-COVID-19
economic output – thus leading
to greater improvement in the
medium term.

The relative economic performance of
elimination and controlled adaptation
is illustrated in Figure 5. In this
figure, area B (economic output
with elimination, less economic
output with controlled adaptation
after 1 August 2020) exceeds area
A (economic output of controlled
adaptation, less economic output
with elimination before 1 August
2020). An elimination strategy may
be expected to deliver, say, about a
5% higher level of economic activity,
on average, for each month from 1
August. Thus, an elimination strategy
might be expected to deliver, over
an 18-month period, about 50%
more increase in economic output
compared to controlled adaptation.
Even in the extremely conservative
projection that elimination only
delivers a 1% extra economic output
per month, on average, from 1 August
2020 onwards compared to the
adaptation strategy, it remains the
preferred strategy in terms of the
economy.
Both elimination and controlled
adaptation overwhelmingly dominate
an uncontrolled epidemic attempting
to achieve herd immunity. This is
illustrated in Figure 6 where the
vertical axis measures economic loss.
The uncontrolled strategy results
in at least THREE times greater
economic loss than an elimination
strategy. Figure 6 also shows that
an elimination strategy dominates a
controlled adaptation strategy where
a vaccine is not available, at the
earliest, until the second half of 2021.
Figure 7 provides a comparison of
the possible number of COVID-19
infected people in Australia with the
elimination and controlled adaptation
strategies. It illustrates that a
controlled adaptation strategy has a
greater probability of recurrence of
another outbreak. This is shown by
the ‘ups and downs’ in the number
of infected persons with a controlled
adaptation strategy but not with the
elimination strategy.
The uncontrolled strategy results
in at least THREE times greater
economic loss than an elimination
strategy.

Figure 5

Figure 6

Figure 7
Figure 5
Figure 6


Figure 7

Figure 7
There are significant risks to
allowing continuing background
community transmission of SARS-
CoV-2 in Australia, including for
vulnerable populations. Cases of
COVID-19 in the community will
inevitably lead to morbidity and
mortality. The greater the number
of cases in the community at the
time when measures are relaxed, the
greater the probability of a spike in
new cases. Controlled adaptation is a
higher risk strategy than elimination,
as with a positive number of cases
there is a higher probability that an
outbreak will occur resulting in more
deaths and the possibility of the
reintroduction of physical distancing
controls. This phenomenon has
already been seen in settings where
measures have been relaxed while
community transmission is still
occurring.5
Even in settings with
limited transmission, without
enhanced surveillance transmission
resurgence occurs, but with enhanced
surveillance such resurgence is
prevented (as has been seen in South
Korea: see Appendix).
5 https://www.bbc.com/news/world-asia-52305055

This issue is further emphasised by
recent modelling work demonstrating
that, in the European setting, Rt
only becomes <1.0 when multiple
strong measures of social distancing
are implemented (see example for
Denmark in Figure 8). Hence, if social
distancing measures are relaxed
when community transmission is
active, the Rt may increase to >1.0
and remaining cases then become
foci for resurgent infection.
To date, even when there have been
small numbers of cases nationally,
it has not been possible to prevent
vulnerable community members from
contracting COVID-19, especially
within institutions such as aged
care homes. This is because these
individuals remain connected to
community members for their care
and other needs. The greatest
protection from infectious diseases
for the vulnerable comes from
minimising the potential pool of
infection they are exposed to, with
elimination providing the greatest
assurance of such protection.

Figure 8. Relation of different non-pharmaceutical interventions to Rt: example from Denmark
(Flaxman et al).

Figure 8. Relation of different non-pharmaceutical interventions to Rt
Example from Denmark (Flaxman et al., 2020)

There are also risks to regional
Australia from removing restrictions
prior to elimination of community
transmission. In our prior work,
we distinguished between urban
and rural epidemic peaks: “the
first wave is observed in highly-
urbanised residential centres where
the pandemic first reaches a nation
(e.g. near international airports),
whilst the second wave is observed
in sparsely connected rural regions”
(Zachreson et al, 2018). “In contrast
to many other countries with a more
even spatial population distribution,
Australia comprises a relatively
small number of densely populated
urban centres distributed along the
coastline, sparsely connected to many
more low-density inland towns and
rural/regional communities.
This particular population distribution
has been implicated in Australia’s
highly bimodal epidemic curves,
with modes associated with its
urban, and rural communities”. For
the COVID-19 pandemic early results
indicate that the first wave may
peak in metropolitan areas about
45 days before the smaller second
wave in regional Australia (seen as
an inflexion in Fig 3b from Chang
et al. 2020). This effect disappears
under the elimination strategy. Failing
to eliminate the current spread
concentrated in/near major urban
centres may result in secondary
waves in regional Australia.
Risks of the elimination approach.
While States and Territories will
vary in the time taken to SARS-
CoV-2 elimination, the jurisdiction-
by-jurisdiction approach is likely
to require greater time before
measures can be relaxed to the
fullest extent possible. There are
also risks related to controlling
For the COVID-19 pandemic early
results indicate that the first wave
may peak in metropolitan areas
about 45 days before the smaller
second wave in regional Australia …

internal borders while States/
Territories are at different stages of
control. The approach depends on
being able to establish and maintain
strong international border controls,
including quarantining of people
coming into Australia from areas with
active COVID-19 transmission. It is
also dependent on the functioning
of a highly sensitive early detection
system, and on resultant case and
contact tracing and management.
Such a system requires additional
investment and will need to adapt and
mature as the pandemic continues.
All aspects of control require the
engagement and trust of the Australia
people, over an extended period.
There will be multiple challenges to
this – including the possibility that
the community may be unwilling
to continue with certain aspects of
disease control and early detection
– and clear strategies will need
to be devised, factoring in the
stages when engagement may
be most at risk. Confidence can
be gained in this regard from the
very effective adoption of social
distancing measures by the Australian
community. As demonstrated by
the strong positive support for
leaders that took early decisive and
consistent action,6
the community
can and will act appropriately with the
right leadership and support.
At a global scale, it has been shown
that it is possible to repeatedly
eliminate diseases such as Ebola
virus disease, including in low-
resource settings. Nevertheless, it
remains possible that Australia may
not be able to achieve elimination.
As demonstrated by the strong
positive support for leaders that
took early decisive and consistent
action, the community can and
will act appropriately with the right
leadership and support.
6 https://www.abc.net.au/news/2020-04-19/wa-premier-mark-mcgowan-applauded-in-coronavirus-crisis-
analysis/12159020

In this case, the strategy may need
to change to one of controlled
adaptation. Even if this is the case,
the interventions in place to support
elimination, such as enhanced
surveillance, will ensure that any
transmission that does occur will be
much lower.
The other challenge that elimination
strategy may pose is to international
travel, especially if the entire world
developed “Herd Immunity” while
Australia did not. That is very unlikely
without a vaccine. Were a vaccine
to become available, it is very likely
that Australia will be one of the first
jurisdictions to use it.
One may think that using the
Controlled Adaptation strategy could
allow for easier travel, because of
greater immunity. This is very unlikely
at any scale. Even if the infection
rate were managed at the current
rate of say about 100 cases a day, it
would take years and years before
sufficient numbers of Australians
have been safely exposed to change
the international travel restrictions.
Thus, the only risk of the elimination
strategy, given its many and
significant benefits across the
spectrum, is the extra cost of about
30 additional days of controls and
social distancing. Should it fail for
any reason – all the elements will be
in place to revert to the Controlled
Adaptation.
Even if the infection rate were
managed at the current rate of
say about 100 cases a day, it
would take years and years before
sufficient numbers of Australians
have been safely exposed to
change the international travel
restrictions.

In response South Korea
introduced both focused efforts
to contain the church outbreak
(testing ~10,000 members) and
introduced wider social distancing,
in particular preventing schools
and childcare reopening.
Appendix:
Brief summaries
of experiences of
countries with evidence
of effective COVID-19
control, aiming for
elimination7
South Korea
South Korea’s initial response was
largely focused on international
travellers and local healthcare
responses, with enhanced screening
for travellers from Wuhan initiated in
early January and then progressively
stronger restrictions for travellers
applied over the period from late
January to mid-February. South Korea
then experienced a superspreading
event (or potentially a series of
these) connected with members of
the widespread Shincheonji church.
This led to very rapid growth from
one or two cases per day to 100s
of cases per day. In response South
Korea introduced both focused
efforts to contain the church outbreak
(testing ~10,000 members) and
introduced wider social distancing,
in particular preventing schools and
childcare reopening. They have not,
however, been as restrictive in terms
of business with restaurants and
shopping malls remaining open. After
spikes to as high as 800 cases a day
during the outbreak, case numbers
fell to about 100 per day by mid-
March and in the last two weeks have
fallen further, with only eight cases
recorded on 18/04 with just three of
these locally acquired.
7 Note all of these charts are sourced from the worldometers site: https://www.worldometers.info/coronavirus/


Daily new cases in South Korea
Daily new cases in Singapore

Singapore
Singapore has until recently had
the least restrictions on movement
and business, focusing on strong
border controls and quarantine
requirement, well-resourced contact
tracing widespread fever-screening
and hospital-based isolation of all
cases. This strategy appeared highly
effective until around the middle of
March, when as in Australia, imported
cases increased substantially. Over
the 2nd half of March, unlinked cases
started to grow, suggesting that local
transmission had become established
and a series of tighter measures
started to be established. However,
by this point infection had become
established in the population of
foreign workers housed in dormitory
accommodation. This has now led to
an escalating growth in cases in these
populations and required Singapore
to adopt a similar social distancing
approach to Australia since early
April but with special measures
for the foreign worker populations.
With around 700 cases per day at
present, it seems likely that this
specific population outbreak will
continue for at least the next two
to four weeks despite the extra
restrictions. This highlights the
need to identify and focus specific
measures on transmission-related
high-risk sub-populations.
With around 700 cases per day at present, it seems likely that
this specific population outbreak will continue for at least
the next two to four weeks despite the extra restrictions. This
highlights the need to identify and focus specific measures
on transmission-related high-risk sub-populations.

Hong Kong
Hong Kong has paralleled Singapore
but has not experienced a large
scale outbreak of the kind seen in
either South Korea or Singapore.
They experienced large case
growth from March 15 connected
with international arrivals as
seen in Australia and Singapore.
However, this has not led to
large local case outbreaks. Hong
Kong has maintained fairly strict
home quarantine requirements
for travellers (wristband monitors
etc.) but has selectively relaxed
these (including not requiring these
since late March for travellers from
mainland China).
Hong Kong has introduced similar
but slightly less restrictive social
distancing rules to Australia since
early April. Previously schools had
been closed and remain closed.
Case numbers have fallen to four
to five per day in the last week and
their public estimates of Rt now have
95% uncertainty intervals below 1 in
this period.

Daily new cases in China, Hong Kong SAR

Taiwan
Taiwan has operated in a similar
fashion to Singapore’s initial approach
but with perhaps a slightly stronger
focus on border control. They have
encouraged wearing of masks and
in recent weeks encouraged social
distancing. They also delayed return
to school in February but have kept
schools open since then. Businesses
remain open. Perhaps due to their
strong focus on border control and
home quarantine, they have seen very
little local transmission, with >85% of
cases being overseas source. They
have reported fewer than 5 cases per
day in the last week – almost all of
these are imported.
China
China as the first location affected
had a large epidemic on their hands
by the time of the shutdown in
Wuhan, with estimates from early
modelling studies suggesting
~75,000 cumulative infections
by this point.8
The shutdown was
progressive, initially isolating Wuhan
but quickly extending to much of
Hubei province due to high travel
volumes out of Wuhan prior to
shutdown. A widely reported, social
contact outside of the household
was almost entirely prevented,
while the public health and health
system response was scaled up to
find and isolate cases and expand
8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159271/
A widely reported, social contact outside of the household
was almost entirely prevented, while the public health and
health system response was scaled up to find and isolate
cases and expand treatment capacity.


Daily new deaths in China
treatment capacity. Restrictions
were less severe in the rest of
China due to lower case numbers
but still strong, with movement
restrictions later applied in mid-
February using a rapidly developed
mobile app. The lockdown appears
to have been highly successful in
reducing transmission, with Hubei
province reporting no new cases by
mid-late March. From that point on,
symptomatic cases have primarily
occurred via importation with 14-day
quarantine restrictions preventing
onward transmission. China does
appear to be in an elimination phase
but their recent reporting of moderate
daily numbers of asymptomatic
cases suggests some remaining
challenges in entirely removing local
transmission in settings that have
experienced widespread, uncontrolled
transmission.9
9 http://weekly.chinacdc.cn/news/TrackingtheEpidemic.htm

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The “Controlled
Adaptation” Strategy
Definition: What is meant by “controlled
adaptation”?
Controlled adaptation is an approach to achieving a
targeted or minimal level of symptomatic COVID-19
cases with three objectives:
yy Minimal COVID-19 case load;
yy Keeping within health system capacity; and
yy Maximising societal and economic functioning.
3
Controlled adaptation – at its heart
– is a constrained optimisation
problem (and solution). Some just
call it “suppression.” We have called
it “Controlled Adaptation” because
it entails two elements:
1. controlling the virus by increasing
and decreasing the restrictions as
indicated by data; and
2. adapting society to function with
it for a long time.
This strategy accepts that the virus
is here to stay, and therefore our best
response is to adapt our ways until a
vaccine becomes available.
If the number of new cases of
infections continue to be low as
they are, we think it may be possible
Figure 1. Controlled adaptation as an
optimisation problem (and solution)
Health
system capacity
and resourcing
Societal
and economic
funtioning
Minimal
or target
case load
OPTIMISE

as a major criterion for relaxation. In
this scenario you relax measures, the
cases surge, you clamp down again.
And repeat. They indicate that such
an intermittent strategy will likely
continue in the United States until
2022, and suggest a resurgence could
occur as late as 2024, necessitating
ongoing monitoring.
The other approach is to aim for
carefully staged relaxation that has
a low probability of needing severe
tightening up again in the future.
This approach is already occurring in
other countries including China and
various European nations. However, in
drawing international comparisons, it
is important to bear in mind variations
in case load, testing and surveillance
measures, and health system
capacity put Australia in a uniquely
advantageous situation to deliver
this strategy.
to start lifting social distancing
restrictions in a phased manner
around mid May.
This chapter provides the rationale for
relaxing social distancing, the kind of
testing-tracing-isolation system that
would need to be in place to make it
happen, which restrictions could be
lifted first, how this could be done while
protecting the vulnerable in society.
We then show how to monitor the
success of the strategy, its economic
impact as well as its flexibility, so
that it is truly adaptive in the face of
uncertain outcomes.
In the end, we propose how the
decisions required could be best
made and provide a simple table of
the pros and cons of such a strategy.
What are the best
approaches to relaxing
restrictions?
There are (at least) two schools of
thought to relaxing restrictions.
One approach is intermittent
application of social distancing
restrictions, an on-off scenario
laid out by Kissler et al (2020) who
singled out health system capacity
This strategy accepts that the virus
is here to stay, and therefore our
best response is to adapt our ways
until a vaccine becomes available.

Chapter 3: The “Controlled Adaptation” Strategy
Once relaxation begins, it will be
critical to set the target infection rates
in a manner that is mindful of reserve
in the event of a surge or cross-cover
of localised explosive outbreaks.
This is particularly important should
outbreaks occur in those with high
rates of chronic disease, and in aged
care facilities, correctional centres,
homeless shelters and with other
vulnerable communities.
The goal of Controlled Adaptation
over the next month (i.e. to mid
May) would be to suppress new
infections to a minimum using
the currently-in-place social
distancing measures and travel
restrictions. This period will provide
time to prepare for relaxation of
distancing measures through
enhanced surveillance capacity and
planning, improved understanding
of COVID-19 epidemiology and
modelling scenarios, building public
health capacity (especially testing
and contact tracing – including
app technologies), creating reserve
health system capacity, developing
better knowledge regarding effective
therapeutic options, and creating
stable supply lines for medical
consumables and ventilators.
In the medium-term, distancing
measures would be progressively
lifted but with the ability to reinstitute
as the need arises.
Recommendation
Lift measures in phases, with
an interval/pause of a minimum
of three weeks to determine
the impact on spread and case
numbers, and a close watch on the
effective reproductive number to
keep it below one.
This involves a cycle of release,
evaluate, learn, release some more.
Timelines and case load thresholds
for lifting of measures are likely to
differ between states, particularly if
interstate travel restrictions remain,
as well as per factors such as varying
local health service capacities,
climate, population density and
contact tracing capacity.
This involves a cycle of release,
evaluate, learn, release some more.

What are the essential
requirements before
lifting restrictions?
Recommendation
Put in place extensive testing
and surveillance, rapid, effective
case detection, case isolation
and contact tracing, including
potential re-introduction of some
distancing measures if it seems
that Reff will overshoot 1.
The key to Controlled Adaptation is
maintaining the effective Reproduction
Number, or the number of new cases
that a current generates, to just
under one (i.e Reff ~<1). Modelling
will be required to identify the level of
coverage of individual measures and
their mix to achieve an average Reff of
1 across time and sub-populations.
Modelling and analysis will continue
to be required to monitor and ensure
that we are achieving this target. Real
fluctuations and statistical errors
mean we will aim for just under one,
and not exactly for one.
Possible criteria for lifting
restrictions
Possible criteria for continuing/
imposing restrictions
Health care has been expanded
to adequate capacity
Geographic areas of high COVID-19
activity (Reff>1.0)
Contact tracing capacity has
been enhanced
Defined communities or geographic
areas containing high proportion
of at-risk individuals (by age,
comorbidity)
Testing is available on a
significantly wider basis,
and results are available
more rapidly
Syndromic surveillance suggests an
increase in respiratory presentations
which is not matched by an increase
in testing, perhaps due to temporary
shortfalls in capacity (such as from
inadequate reagent supply)

This explains in part why the
current testing approach has failed
to identify the sources of a number
of cases, and reinforces that testing
strategies need to be expanded.
Border and travel controls
Border and travel controls are likely
to be needed over the long term
unless the traveller has documented
immunity (natural or vaccine-related)
or is willing to submit to a two-week
quarantine period upon arrival.
International border controls will
impede tourism and education, which
has traditionally been a key driver
of growth in Australia. The period of
quarantine may, however, reduce as
testing capacity, speed and accuracy
improves – and more innovative
mechanisms of ensuring safety may
be considered (pre-testing before
presenting at border, off-shore pre-
arrival quarantine, etc.).
Surveillance systems
and contact tracing
Surveillance of all infections with a
range of mild and often non-specific
symptoms is always challenging, with
reported case numbers reflecting
testing rates and methodology.
An unknown proportion of cases
with a SARS-CoV 2 infection are
asymptomatic or only mildly
symptomatic (Zhou et al, 2020).
Prevalence rates of asymptomatic or
mild disease have been as high as
50–78% of cases in studies reported
from different countries and contexts
(Day, 2020a; Day 2020b; Nishiura
et al, 2020). Modelling to estimate
the proportion of asymptomatic
cases on the Diamond Princess
cruise ship suggested much lower
rates (17.9% (95% credible interval
(CrI): 15.5–20.2%)), although this
population was older and largely
contained (Mizumoto et al 2020).
Recent data from Austria, which
instituted containment measures early
in the epidemic, indicated there were
three times as many acutely infected
cases than initially thought by testing
patients that were symptomatic but
not hospitalised (Groendahl, 2020).

Prevalence rates of asymptomatic
or mild disease have been as high
as 50–78% of cases …
Surveillance for COVID-19 disease
to date has focused on high-risk
cases based on epidemiology and/
or symptoms, which underestimates
the true case numbers to an unknown
degree. This explains in part why the
current testing approach has failed
to identify the sources of many cases
and reinforces that testing strategies
need to be expanded.
Emerging data suggests
asymptomatic cases can transmit
SARS-CoV 2 (Huang et al, 2020), even
if transmission may be less efficient
than from symptomatic cases. This
implies that it will not be possible to
identify all cases and transmission
chains, rendering an elimination
strategy difficult to achieve through
case-targeted measures alone.
The prospect of environmental
transmission poses an additional
challenge. The Controlled Adaptation
strategy accepts this reality, and is
built in response to it.
There are two potential approaches
to surveillance: sentinel and
universal.
Intensive universal surveillance is
necessary to underpin the control
strategy, while the role of sentinel
surveillance is secondary. We explain
both below.
There are two types of tests,
both have a role. We specify their
respective roles in this strategy.
Virological testing
Universal surveillance aiming at
detecting the vast majority of
symptomatic cases would require
widespread virological testing of
people presenting with symptoms
that could be consistent with
COVID-19, even when mild.
In addition, the public would need
to be encouraged to seek testing as
soon as they develop symptoms.
For this to happen, testing centres
would have to be widely available
and accessible (including in remote
areas), free of charge, with minimal
wait times and a short turnaround
time (less than one day).

The following would need to be in
place:
yy sufficient laboratory capacity and/
or point of care testing
yy electronic test result tracking
yy sufficient trained workforce
for taking throat swabs and
communicating results
yy sufficient capacity to manage waste
yy sufficient PPE
yy social marketing to encourage
people to come forward for testing
yy education for medical practitioners
yy spaces suitable for sample
collection while allowing social
distancing
yy logistics expertise.
Standardised systems of
demographic data collection could
also be established at the network of
COVID-19 testing sites to determine
biases in voluntary presentations. In
addition, mechanisms for managing
people with more severe symptoms,
including diagnosing other conditions,
would need to be in place.
Recommendation
Create a comprehensive,
adequately resourced and swift
testing infrastructure supported by
strong incentives and messaging
to encourage public engagement.
Virological testing of people with
no symptoms would be unlikely to
be useful except when investigating
clusters (including in households). A
single negative test in someone with
no symptoms would only indicate that
they had no detectable virus at the
time of testing. If testing were done
early post symptom onset, some false
negative results may occur (Arima et
al, 2020), and consideration should be
given to repeat testing for cases with
a high level of suspicion.
Sentinel surveillance strategies
based on selective person case-
testing cannot be used as part of a
control strategy but can be useful to
detect trends. Sentinel surveillance
could include testing of all people
presenting to selected health care
services regardless of whether they
have symptoms. The selected health
care services could be targeted

to communities considered to be
particularly susceptible to COVID-19,
such as remote Aboriginal and
Torres Strait Islander communities.
The sentinel surveillance would be
additional to the current universal
case-based surveillance system
– it cannot replace it.
Serological testing
To inform whether the removing
restrictions in high-risk settings, for
example, on inter-generational (mixed)
gatherings should be undertaken, an
accurate understanding of the level
of positive seroprevalence to infection
in the community would be needed.
Modelling could do this based on
the number of recorded cases and
the likely relative proportion of
asymptomatic individuals with
SARS-CoV-2.
However, modelling is unlikely to
provide localised information and
may, therefore, be unable to inform
the lifting of localised high-risk
control measures. When a reliable
serological test (for IgG) becomes
available, periodic population-based
serological surveillance will be a
useful adjunct to inform control
strategies, and monitor levels of
population immunity.
Recommendation
Conduct at least periodic (say,
monthly) random antibody
testing snapshots of a cross-
section of the community to
inform decisions on relaxation
of local restrictions. Solicit
detailed statistical advice on
whether to have regionally and
socio-demographically weighted
sampling, conditional on
variations in infection rates and
sequelae.
SARS-CoV-2 immunity registers
have been proposed and while they
may have some use in restricted
settings (e.g. some businesses
or occupations), at a population
level they are unlikely to be useful
given both the small proportion of
the population being infected and
uncertainties about the degree
and duration of immune-protection
following primary infection.

10 See international hub of research on apps living document
“Unified research on privacy-preserving contact tracing and exposure notification” at
https://docs.google.com/document/d/16Kh4_Q_tmyRh0-v452wiul9oQAiTRj8AdZ5vcOJum9Y/edit#
Contact tracing
Contact tracing is most efficient while
strong social distancing measures are
in place, as the number of potential
contacts for each case are low and
likely to be known to the case. As
social distancing measures are
relaxed, contact tracing becomes
more challenging because of the
likelihood of each case having more
contacts, some of whom may not be
well known to the case. Due to the
short latent period of SARS-CoV-2
(possibly as low as two to three days),
it is necessary for contacts to be
quarantined within two to three days
of contact with the case. This may
not be possible with current contact
tracing methods or even with more
rapid case identification, particularly
given that transmission is possible in
the pre-symptomatic period.
Recommendation
Promote and incentivise the use
of contact tracing apps to ensure
sufficient speed of contact tracing
for use as a control strategy.
For this to be most effective,
high uptake of contact tracing
apps dispersed widely among the
population would be necessary.
Ferretti et al (2020) suggested
a population uptake of 60% was
sufficient to be effective as a control
strategy, but this depends on the
distribution of smartphones and
apps in the population. Community
organisations and businesses may
have a role here, in building effective
initiatives for testing and for tracing.
There are many ethical and social
considerations that would need to
be addressed to increase uptake
of the App10
(Calvo et al, 2020).
If social license allows, the apps
can also be used to monitor the
level of adherence of contacts
to quarantine.
… it is necessary for contacts to be
quarantined within two to three
days of contact with the case.

What aspects of
Social Distancing
should be relaxed
initially and how?
Controlled adaptation is about the
phased reintroduction of ‘normal’
societal conditions, with learning from
each phase and the ability to pivot
back to controls as needed. We have
suggested a possible path below but
it is important to note that this will
be critically dependent on the precise
conditions existing around mid-May.
Graduated relaxation (and
when required, tightening)
of physical distancing policies
Relaxation Options:
Schools and Universities
Schools should be a high priority
for resuming activity given there
is limited evidence on the role of
children as a source of infection, and
the importance of schools in reducing
inequity of education outcomes.
Universities should provide online
education as much as possible but
restrictions regarding face-to-face
laboratory practicals and clinical
placements could be loosened.
Relaxation Options:
Group Gatherings
Because of the potential for
considerable population mixing and
close contact between attendees at
mass gatherings, it is unlikely that
mass gatherings would be compatible
with maintaining the Reff close to
1. Until there is a sufficient level of
immunity in the population mass
gatherings are not advisable.
A context specific risk assessment
tool has been developed by the
WHO Novel Coronavirus-19 Mass
Gatherings Expert Group (McCloskey
et al., 2020) which could be applied
as circumstances change.
Schools should be a high priority
for resuming activity given there
is limited evidence on the role of
children as a source of infection,
and the importance of schools in
reducing inequity of education
outcomes.

Relaxation Options:
Differentiation of High-Risk groups
In other contexts, such as return to
work, restrictions could be determined
by health status, age or geographical
/postcode data identifying areas of
high demographic vulnerability.
While age is one risk factor, in
fact co-morbidities appear more
important, at least until advanced
age (say, 80+), when the impact of
age on the immune system generally
seems to reduce the resistance of
organ function to the severity of the
infection.
There is good evidence for the
proposition that a simple age-based
criterion may be needlessly costly.
Unpublished analysis from the
CHAMP study of older men (Cumming
et al., 2009) suggests about a third
of men in their 70s have none of the
medical conditions associated with
severe COVID-19.
This suggests that if multiple
morbidities, rather than age alone,
are the primary correlate of COVID-19
fatality, then the incidence of
morbidity should be an indicator
of risk.
Recommendation
Urgent analysis is required on
the independent effects of sex,
age, ethnicity and comorbidity of
sequelae of COVID-19 infection, to
improve recommendations on who
should be self-isolating.
Possible staged return of societal
activity, should the effective
reproductive number remain at
or below an average of 1.
This suggests that if multiple
morbidities, rather than age
alone, are the primary correlate
of COVID-19 fatality, then the
incidence of morbidity should
be an indicator of risk.

Containment and
social distancing
requirements
Immediate term
(Next 30 days)
Medium Term
(30–90 days)
End Game
(Beyond 90 days and
until vaccine is available,
say, end of 2021)
Travel and border
controls
yy Maintain travel for
essential services
or serious family
issues
yy Allow domestic travel
subject to border
quarantine or testing
yy No overseas travel
– unless quarantine
observed or testing
Workplaces and
Businesses
yy Staged return –
some working at
home
yy Modified workplace
practices
yy Younger workers
without key
comorbidities at work
yy Regional plans based
on comorbidities and
demographics
practices
yy Full return – high risk
workers, if able, to
work from home
practices
Schools yy Staged return yy Full return but
voluntary
yy Modified practices
students and staff,
if able, to work from
home
Universities yy Staged return yy Full return but
voluntary
students and staff,
if able, to work from
home
Mass and Public
gatherings (Games,
Concerts, Rallies)
yy Banned yy Banned yy Banned – context
specific

Modify Workplace and
Business Practices
In the process of a staged relaxation
of social distancing there are
important measures that can be
taken to enhance access to work
while mitigating health risks, thereby
increasing the economic efficiency of
social distancing. These include:
yy Fractional Schooling. Schools can
return with classes divided and half
the students attending each day.
yy Canteens and school/university
cafes as take-away only, physical
distancing in classrooms, hand
hygiene practices maintained.
yy Routine use of PPE in high risk
occupations such as dentists,
optometrists and allied health
workers.
yy Job sharing and shift-work.
Working from home could be
combined with workplace shifts to
allow a fraction of people to return
to their workplaces but with greater
physical space to allow social
distancing. Policies could allow
working from home for people with
co-morbidities, older age groups, or
people who live with these groups.
Work hours could be made flexible
to facilitate this, especially in States
with strong restrictions on hours.
yy Internal voluntary measures
around physical distancing and
rigorous hand hygiene in meal
preparation could be extended to
restaurants and public places that
are currently closed.
Recommendation
In the short-term workplaces
should be encouraged to stagger
the schedule of workers, and
undertake other hygiene and
physical distancing measures,
to allow a safer return to work.
Protecting vulnerable
populations
Residential aged care facilities
are internationally recognised as
exceptionally high-risk environments
for the transmission of COVID-19,
among individuals for whom severe
disease outcomes, including death,
are highly probable. As such, they

are likely to be the last environments
in which liberalisation of physical
distancing measures would be
recommended.
However, there are also serious issues
regarding the adverse impact of
social isolation in these settings. If
elderly people and those with chronic
conditions need to be in isolation
for much of the next year or so, we
should prioritise support for these
groups and also provide simple
understandable information to guide
their isolation.
Similar to fire risk or sunburn indices,
there could be a daily or weekly (and
regionally varying) risk index to allow
vulnerable people to determine the
degree to which they need to self-
isolate.
Strict biosecurity controls have been
implemented in Australia’s north at
the request of, and in consultation
with, Aboriginal and Torres Strait
Islander community leaders. These
controls have been instigated in
recognition of the increased risk of
severe infection outcomes in these
communities, coupled with limited
access to medical care because of
remoteness. These controls have
been successful and provide a good
exemplar of how community-led and
owned initiatives may work well.
Economic impacts
Social distancing and border
restrictions have “brick walled” the
travel and hospitality industries which
account for around 9% of GDP and
employ 1.7m people or approximately
14% of the labour force (ABS Labour
Force 2020, IBisWord 2020). Further
unemployment has also been created
by reduced demand and supply
constraints with 49% of business
impacted, rising to 89% in the next
two months (ABS Business Impacts
of COVID-19, 2020).
Unemployment generated by the
partial shutdown measures will
cause immense hardship to millions
of Australians. Job loss is already
estimated to have increased by
approximately 2.1 million people –
or 15.5% of the labour force (Roy
Morgan, 2020, ABS, Labour Force
2020). This is likely to be costing

Australia approximately 1% of GDP
per month, cumulating to 12% of
GDP over a year, which is a similar
annual decline to those experienced
in the 1930s. The costs would fall
disproportionally on the low-income
and low wealth households, socially
disadvantaged groups, those with less
secure employment and contingent
workers, such as in Arts, and also
differ by sector.
The costs could rise further. Stronger
social distancing measures in G7
countries are estimated to amount to
over 2% of GDP per month or 25% of
GDP over a year (OECD 2020). Further
losses due to a decline in confidence,
trade wars, long lasting barriers to
immigration, supply chain disruptions
and global economic conditions, that
will transmit to Australia through
the terms-of-trade (McKibbin and
Fernando, 2020), could also increase
the economic costs.
Other considerations include financial
losses, particularly the wealth effect
on superannuation and retiree
incomes. Mature workers who
become unemployed through this
period will find it difficult to regain
equivalent employment in a recovery.
Some may never work again.
An important consideration for
Australia is the impact of economic
differences across States and
Territories, including the possibility
that some may adopt an elimination
strategy and maintain closed borders,
which will increase trade and travel
costs.
Given that economic costs
accumulate, they have the potential
to quickly match health risks as a
social priority. Notwithstanding this
concern, maintaining social isolation
for some period appears to be a
good investment to allow the health
system to prepare and to reduce
the probability of an uncontrolled
escalation as well as obtain
Stronger social distancing
measures in G7 countries are
estimated to amount to over 2%
of GDP per month or 25% of GDP
over a year.

more information about medical
interventions. But the costs of these
measures, in human and financial
terms, need to be carefully weighed.
Extending the current regime into the
second half of the year risks rising
economic and social costs with
very harmful consequences through
rising unemployment, income losses,
inequality and social unrest.
Recommendation
A staged relaxation of social
distancing should be introduced
as soon as the infection rate,
health capacity and testing
thresholds are met to mitigate
the economic costs which will be
disproportionately borne by some
segments of society.
Recommendation
The adverse impact of border
controls on trade, tourism,
business services, education and
immigration to Australia, and
their impact on economic activity,
needs to be considered and
innovative solutions developed.
What are indicators
of success of this
strategy? And how do
we monitor these?
It will be important to have in place
data collection and analysis of
KPIs for contact tracing and case
identification, in order to provide
sufficient confidence that this
strategy can be delivered. This would
also be useful to inform modelling
where ‘real-life’ data could inform
assumptions used in the modelling.
Such KPIs would be by public health
unit area, and could be monitored
monthly then collated by state/
territory health departments using
line-listed data. These could include:
yy Number of tests performed by age,
gender, location
yy Duration between symptom onset
and test request (in hours or days)
– median, IQR, range
yy Duration between test request and
test result notified to public health
(for action) (in hours) – median,
IQR, range

These KPIs are more focussed
on the objective of controlling the
infection rate and keeping it below a
Reff of 1. Indicators would also have
to be established for rejuvenation
of economic activity and social life.
A controlled adaptation strategy
will require the active and adaptive
balancing of all three.
Flexibility of the strategy
Controlled adaptation can be thought
of as a flexible ‘holding position’.
Depending on future developments,
one can take several paths:
yy If an effective vaccination
becomes available, we can
pivot to vaccination;
yy Or relax social distancing further
should better treatments become
available or measures improve to
protect the vulnerable.
These pivots and fine-tuning cannot
be detailed now. Rather, as more
research and understanding of how
to manage COVID-19 emerges over
the next few months, these options
can be further explored.
yy Duration between case
identification and notification of
contacts (in days/hours) – median,
IQR, range (by contact)
yy Number and proportion of cases for
whom a source or contact can be
identified
yy Number and proportion of identified
contacts able to be contacted.
Key indicators of success will be:
yy No sustained increase in positive
tests, even as testing rates remain
high
yy No sustained increase in rates of
severe disease and ICU admissions
in at-risk populations
yy Rapid response to any clusters or
areas of increased transmission.
Recommendation
Create key performance indicators
for the controlled adaptation
strategy by jurisidiction, establish
a reliable system of compiling
them, monitor and transparently
share them.

The key research necessary to guide
decision making in the medium and
long term will include:
yy vaccine development and
clinical trials of their safety and
effectiveness;
yy new treatments or re-purposing of
existing treatments;
yy information on the impact of social
and physical distancing measures
on SARS-CoV-2 infection rates and
sequelae, both in isolation and as
packaged measures (e.g. from
improved agent-based simulation
models and “nowcasting”, and cross-
national comparisons of strategies
implemented in similar societies);
yy durability of immunity following
infection. Viral mutation and
waning immune-protection may
both contribute to risks of infection
recurrence. Multiple tests are
now available for identifying
SARS-CoV-2 and have been
registered by the TGA11
, but their
accuracy is uncertain. The positive
predictive value of these tests
should be calculated for both an
asymptomatic screening population,
and symptomatic ‘case’ population;
yy the extent of asymptomatic
infections and the role of
asymptomatic individuals in
disease transmission. This may
vary by age and co-morbidities,
but knowledge on this would help
underpin decisions regarding
removal of restrictions. As an
example, understanding the
potential contribution of school
age children in transmission of
infection to teachers would provide
scientific data to underpin decisions
regarding school closures;
11 https://www.tga.gov.au/covid-19-test-kits-included-artg-legal-supply-australia
Multiple tests are now available for
identifying SARS-CoV-2 and have
been registered by the TGA, but
their accuracy is uncertain.

yy economic decision modelling
on the health gains and costs
(health system and societal) of
various policy options, relative to
each other, and impacts of social
restrictions, including border control
restrictions, on unemployment and
economic activity more generally;
yy public preferences and responses
to measures such as surveillance,
testing, and ongoing restrictions
on extended family and public
gatherings.
Recommendation
Federal and State Governments
and Health Agencies develop
a coordinated repository of
emerging COVID-19 research
information, perhaps in
collaboration with universities
and other research organisations,
to guide decision making during
Controlled Adaptation.
Optimising the strategy
There are a range of methods
and approaches for balancing the
competing concerns and available
alternatives, from mathematical
optimisation procedures to decision
analytic approaches. Economic,
epidemiological and simulation
modelling is critical. In the absence
of a ‘single’ best method, more
flexible methods such as multi-
criteria decision analysis have
been developed. Capacity for such
optimisation resides in Governments,
universities and the private sector
but is currently fragmented and not
directed as a coordinated mission.
In the absence of a ‘single’ best
method, more flexible methods
such as multi-criteria decision
analysis have been developed.
Capacity for such optimisation
resides in Governments,
universities and the private sector
but is currently fragmented and not
directed as a coordinated mission.

Recommendation
Commission a coordinated stream
of modelling, data collection
and analysis in multiple sectors
to help optimise the adaptation
function of the Controlled
Adaptation strategy, make the
data transparent, and use it in the
medium to long-term for decision-
making on COVID-19.
Existing political decision-making
approaches (e.g. Australian Health
Protection Principal Committee
(AHPPC) and other agencies
advising Government) have
effectively managed approaches
to date. However, rising social and
economic costs will bring political
pressure upon State, Territory and
Federal governments to relax social
distancing faster than the data may
suggest. It may help to create an
independent, multi-sectoral body to
advise on the relaxation of social
distancing with agreed targets, to
reduce this political pressure in the
medium to long term.
Recommendation
Consideration should be given
to creating a multi-sectoral,
independent advisory body to
manage and depoliticise the
process of controlled adaptation.
However, rising social
and economic costs
will bring political
pressure upon State,
Territory and Federal
governments to relax
social distancing faster
than the data may
suggest.

Risks and benefits of this strategy?
Benefits of controlled adaptation Risks of controlled adaptation
Controlled adaptation is a flexible
strategy, and allows policies to quickly
pivot in response to new information
Allows a progressive re-opening of
sectors of society, up to the set target
of manageable infection rates
Impacts of climate on transmission
of COVID-19 are uncertain, but
reducing restrictive measures in
the next 1–3 months, precisely co-
incident with the known period of
maximal transmission of respiratory
viruses in Australia, could be a risk
Allows a much-needed earlier
economic recovery to be initiated,
thus alleviating widespread economic
and personal hardship
Calibrate restrictions to COVID-19
case load and health system capacity
Calibration of relaxed distancing
policies to infection rates may go
awry, and outbreaks may not be able
to be contained without moving to
full lockdown
Contact tracing capacity enhanced Compliance with contact tracing
app may be suboptimal leading to
pressure on manual contact tracing,
potentially exceeding available
resourcing
Testing is available on a significantly
wider basis, and results are available
more rapidly
Development of a rigorous, rapid and
comprehensive testing system will
require significant resourcing and
infrastructure

Benefits of controlled adaptation Risks of controlled adaptation
More rapid return to normal operations
by the healthcare system
There is evidence that individuals
are delaying or forgoing medical care,
potentially leading to poorer health
outcomes in the long term (Tam et
al 2020)
If we aim for elimination and fail, we
may lose community responsiveness
to hand-washing and social distancing
messages, meaning that next time
extreme distancing measures are
needed to avoid an impending
exponential growth in cases, we
may not succeed
Success of the strategy depends on
long-term societal acceptance of,
and compliance with, behavioural
restrictions. This includes the
prospect of localised escalation of
distancing requirements in response
to outbreaks

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cmi.2020.03.024

4
This crisis is a pandemic which
means that Australia’s ongoing
success in containing the spread
of the SARS-CoV-2 virus is also
contingent on what other countries do
to contain their respective epidemics.
A clinically proven, efficacious,
vaccine will be important to aiding
both Australian and global recovery.
Until a vaccine is developed and
widely available border measures
and travel restrictions remain critical
to Australia’s health security and
economic recovery.
Recommendations
and Key Findings
yy Recommendation: A two-week
period of enforced and monitored
quarantine and isolation is
maintained for all incoming
overseas travellers, irrespective
of origin and citizenship, for a
minimum of the next six months.
yy Recommendation: International
travel bans remain on all
Australians, other than those
sanctioned for “essential” travel,
for the next six months and any
returning essential travellers
be subject to the quarantine
restrictions.
yy Recommendation: In the event the
Australian Government enters into
an agreement with another country
to permit entry of its citizens
and/or permanent residents (i.e.
New Zealand), the border control
policies of the other country must
be identical to Australia’s and
stringently enforced.
yy Recommendation: The Australian
Government initiates discussions
and policy development with the
World Health Organization for the
creation of a new internationally-
accepted vaccination certificate for
clinically-proven COVID-19 vaccine
candidate(s).
Border Protections
and Travel Restrictions
Key issue: What regime of border protection and
travel restrictions will be needed in the short and
medium term? How should Australia coordinate its
response to the changing realities of the pandemic
elsewhere?

Chapter 4: Border Protections and Travel Restrictions
yy Key Finding: Approximately two-
thirds of Australia’s COVID-19 cases
have arisen from either international
travellers or close contacts of
international travellers. As a result,
the risk of reintroduction of the virus
into Australia from international
travellers remains very high.
yy Key Finding: Based on the evidence
to date, travel restrictions including
travel bans appear to have been
effective internationally in slowing
the spread of the virus. Retaining a
ban on Australian citizens travelling
overseas will reduce the risk of
travellers potentially re-introducing
the virus on their return to Australia,
as well as reduce the risk that
Australian citizens may become
sick overseas, requiring repatriation
and/or consular assistance.
General Background
The World Health Organization has
tended to advise against the use of
travel restrictions in disease outbreaks
and epidemics. This position has
been adopted on the basis of the
International Health Regulations
(2005) to which Australia is a
signatory. The evidence surrounding
the effectiveness of trade and travel
restrictions has historically been
very weak, with what limited studies
that have been done revealing they
prove economically costly, require
considerable resources to implement,
and have limited benefit in delaying
the start of a local epidemic, eg., by
only a few days or weeks (Ryu, Gao,
Wong, et al 2020; Mateus, Otete, Beck,
et al 2014; Otsuki and Nishiura 2016);
although others have noted that a
delay of even two or three weeks
can be important for preparedness
(Epstein, Goedecke, Yu, et al 2007).
Further, travel restrictions and flight
cancellations in particular have been
observed to harm public health efforts
by preventing or delaying the arrival of
healthcare workers and supplies such
as personal protective equipment into
affected countries (Tambo 2014).
Border measures that are too
restrictive will adversely harm
Australia’s economy not only via
reduced tourism, but also through
Australia’s balance of payments
and export industries.

Following the announcement by
the World Health Organization of
a novel coronavirus – now known
as SARS-CoV-2 – a number of
countries implemented travel
restrictions against China before
expanding these measures to include
the worst-affected countries. The
Australian Government was one
of the first countries to implement
travel restrictions, initially against
residents of China’s Hubei province
(29 January) before extending this
to all of China (1 February), Iran
(1 March), South Korea (5 March),
and Italy (11 March). On 19 March,
the Prime Minister announced
Australia was closing its borders
to all non-citizens and non-residents
from 9pm on 20 March.
Current Context
Irrespective of the pathways taken
by State and Territory Governments
to relax social distancing measures
internally within their respective
jurisdictions, the decision regarding
national border controls and travel
restrictions remains firmly within the
authority of the Federal Government.
Border measures that are too restrictive
will adversely harm Australia’s economy
not only via reduced tourism, but also
through Australia’s balance of payments
and export industries. Conversely, if
border measures and travel restrictions
are too loose, Australia will face the
ongoing risk of re-introducing the virus
after it has been largely controlled
and contained. For these reasons, the
Australian Government must strike the
right balance between reducing the
risk of further importation of COVID-19
cases and the commensurate risk to
our healthcare system arising from
significant human morbidity and
mortality, with Australia’s economic
recovery and a return to normal social
functioning as much as possible.
Although the evidence on the use of
travel restrictions and border closures
during the COVID-19 pandemic
remains preliminary and has yet to
be sufficiently peer-reviewed, there is
nevertheless sufficient indication that
travel-related measures have proved
effective in slowing the international
spread of the virus. Maintaining
restrictions on incoming and outgoing
travellers gives the Australian
Government flexibility to pursue
either a full elimination strategy or
suppression strategy.

Evidence and
Analysis to support
Recommendations
and Key Findings
In this section the main
Recommendations and Key
Findings are expanded upon.
Recommendation
A two-week period of enforced
and monitored quarantine and
isolation is maintained for all
incoming overseas travellers,
irrespective of origin and
citizenship, for a minimum
of the next six (6) months.
This is based on the evidence to date
that two-thirds of Australia’s COVID-19
cases are international travellers
or close contacts of international
travellers. Modelling studies have
identified that between 45.6% and
64% of infected incoming travellers
may not exhibit symptoms on arrival
or be pre-symptomatic (Quilty,
Clifford, CMMID nCoV Working Group,
et al 2020; Wells, Sah, Moghadas,
et al 2020). Accordingly, an ongoing
focus on limiting the ability for
incoming travellers to circulate
amongst the wider community
during a 14-day incubation period
is essential to ensure that the virus
is not re-introduced after it has
been controlled or contained across
Australia (Leung, Wu, Liu, et al 2020).
In addition, maintaining a focus on
quarantining incoming travellers in
hotels allows Australia to lift the ban
on all non-citizens, non-residents and
international students allowing for the
progressive recovery of the tourism,
hospitality and education sectors.
One of the considerations in
maintaining this policy is whether
the cost of the 14-day period of
quarantine is met by the State or
Territory of disembarkation (current
policy), the Federal Government,
or the individual traveller. This is
an important issue to resolve as it
has implications for the long-term
sustainability of this policy, as well as
impacting the viability of additional
policies such as creating special
travel arrangements with individual
countries (Recommendation below).

At the moment we do not find any
good evidence for the popular idea of
a “immunity passport.” There may be
other innovative ways of managing
safe travel (e.g testing in the
embarking country, or part quarantine
in the embarking country). However,
none of these have been rigorously
tested or proven. Given the critical
importance of travel for Australia,
for Australians and for our economy
– the Government is encouraged to
support further research into these
initiatives. Any such initiatives should
only be adopted after they have been
thoroughly tested.
Recommendation
International travel bans remain
on all Australians, other than for
sanctioned “essential” travel,
for the next six months and any
returning essential travellers
be subject to the quarantine
restrictions.
Exceptions could include travel for
essential purposes or compassionate
grounds (i.e. to attend a funeral of a
close family member); but returning
travellers must then enter a 14-
day period of quarantine as per the
earlier Recommendation. In the
event the current travel ban is not
maintained, it is considered highly
likely we will see Australian citizens
seek to travel overseas for leisure or
business. Given 185 countries have
documented COVID-19 cases, no
overseas destination can currently be
considered safe for travellers. There
is a high-risk Australians travelling
overseas during the next six months
will be exposed to the virus. Further,
most Australian travellers will travel
for short periods and then want to
return to Australia, increasing the risk
of reintroducing the virus, or become
unwell while overseas, necessitating
medical repatriation and/or high
levels of consular assistance. This
situation is likely to persist until a
vaccine becomes available, or a
significant proportion of the world’s
population develops a level of
immunity to the virus preventing
onward transmission.

Recommendation
In the event that the Australian
Government enters into an
agreement with another country
to permit entry of its citizens
and/or permanent residents (i.e.
New Zealand), the border control
policies of the other country must
be identical to Australia’s and
stringently enforced.
This recommendation is predicated
upon the assumption that an effective
vaccine is not yet widely available.
In this context, should the Australian
Government agree to permit
international travel from any country
in order to help re-invigorate the
Australian travel and tourism industry
and support economic recovery, it is
essential that a number of conditions
are met. The first is that any country
seeking relaxation of Australia’s
border controls must be certified as
free from COVID-19 infections for
a minimum of 28 days (i.e. double
the length of the incubation period).
Second, the requesting country must
commit to implement external border
control policies identical to Australia,
such as mandatory quarantine for
all international travellers other than
Australian citizens and permanent
residents. This is to both protect
each respective country while also
ensuring costs are shared equitably
(i.e. if the other country requires
mandatory quarantine costs be
recovered from international travellers
but Australian States and Territories
meet these costs, it could result in
disproportionate costs to Australian
taxpayers). Third, these policies
must be strictly adhered to and
enforced. Any deviation would result
in the suspension of any special
arrangements given the risk of re-
introduction of the virus into Australia.
… any country seeking
relaxation of Australia’s
border controls must
be certified as free from
COVID-19 infections
for a minimum of
28 days …

Recommendation
The Australian Government,
via the Department of Health,
initiates discussions and policy
development with the World Health
Organization for the creation of
a new internationally-accepted
vaccination certificate for
clinically-proven COVID-19
vaccine candidate(s).
This recommendation is based on the
Yellow Fever vaccination certificate
model, which required internationally
agreed standards on certification of
vaccination to avoid unnecessary
disruption to international travellers
(Barnett, Wilder-Smith and Wilson
2008; Gear 1948). An internationally
agreed vaccination certificate will be
critical to global economic recovery.
Key Finding
Approximately two-thirds of
Australia’s COVID-19 cases have
arisen from either international
travellers or close contacts of
international travellers. As a
result, the risk of reintroduction
of the virus into Australia from
international travellers remains
very high.
As the virus is now present in 185
countries and there are now multiple
epicentres, the risk of reintroduction
into Australia from international
travellers remains very high and
without quarantine measures in
place the virus will spread given
pre-symptomatic cases are unlikely
to be detected by exit and entry
screening. Border measures such
as strict quarantine and isolation of
all incoming travellers are essential
to limiting the overall number of
COVID-19 cases in Australia.
… the risk of
reintroduction
into Australia from
international travellers
remains very high …

Key Finding
Based on the evidence to date,
travel restrictions including travel
bans appear to have been effective
internationally in slowing the
spread of the virus. Retaining
a ban on Australian citizens
travelling overseas will reduce
the risk of travellers potentially
re-introducing the virus on their
return to Australia, as well as
reduce the risk that Australian
citizens may become sick
overseas, requiring repatriation
and/or consular assistance.
The general consensus is that
travel restrictions help delay the
international spread of COVID-19
and give countries time to prepare
and strengthen their public health
response. Without these restrictions
remaining in place, there is a high
risk the virus will be re-introduced
via returning Australian travellers.
In addition, Australians travelling
overseas are at increased risk of
contracting the virus given there are
multiple epicentres that are common
destinations for many Australians.
This increases the risk of Australian
travellers becoming seriously unwell,
potentially necessitating medical
repatriation, or dying. Either scenario
requires considerable consular
support, placing multiple persons
at increased risk of infection. Given
that COVID-19 cases are also still
present in Australia, it is possible that
Australian travellers may inadvertently
spread the virus to other countries
in the event they are permitted to
travel, which would reflect negatively
on Australia especially within our
immediate region.
References
Elizabeth Barnett, Annelies Wilder-
Smith and Mary Wilson (2008) Yellow
fever vaccines and international
travellers. Expert Review of Vaccines
7(5): 579-587.
Edward De Brouwer, Daniele
Raimondi, Yves Moreau (2020)
Modeling the COVID-19 outbreaks and
the effectiveness of the containment
measures adopted across countries.
Pre-print MedRxiv, https://doi.org/10.1
101/2020.04.02.20046375.

Ramses Djidjou-Demasse, Yannis
Michalakis, Marc Choisy, et al (2020)
Optimal COVID-19 epidemic control
until vaccine deployment. Pre-print
MedRxiv, https://doi.org/10.1101/202
0.04.02.20049189.
Joshua Epstein, Michael Goedecke,
Feng Yu, Robert Morris, Diane
Wagener, Georgiy Bobashev (2007)
Controlling Pandemic Flu: the Value
of International Air Travel Restrictions.
PLoS Med 5: e401.
H S Gear (1948) Problems of Interna-
tional Travel. BMJ 1(4561): 1092-1094.
Kathy Leung, Joseph Wu, Di Liu,
et al (2020) First-wave COVID-19
transmissibility and severity in China
outside Hubei after control measures,
and second-wave scenario planning:
a modelling impact assessment.
The Lancet, published online 8 April
2020, https://doi.org/10.1016/S0140-
6736(20)30746-7.
Ana Mateus, Harmony Otete, Charles
Beck, Gayle Dolan and Jonathan
Nguyen-Van-Tam (2014) Effectiveness
of travel restrictions in the rapid
containment of human influenza a
systematic review. Bull World Health
Organ 92(12): 868-880.
Shiori Otsuki and Hiroshi Nishiura
(2016) Reduced Risk of Importing
Ebola Virus Disease because of Travel
Restrictions in 2014: A retrospective
Epidemiological Modeling Study.
PLoS One 11(9): e0163418.
Billy Quilty, Sam Clifford, CMMID
nCoV working group, et al (2020)
Effectiveness of airport screening at
detecting travellers infected with 2019-
nCoV. Eurosurveillance 25(5): 2000080.
Sukhyun Ryu, Huizhi Gao, Jessica
Wong, Eunice Shiu, Jingyi Xiao, Min
Whui Fong, and Benjamin Cowling.
Nonpharmaceutical Measures for
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Settings – International Travel-Related
Measures. Emerg Infect Dis. 2020 May
– early release article.
Earnest Tambo (2014) Non-conventional
humanitarian interventions on Ebola
outbreak crisis in West Africa: health,
ethics and legal implications. Infectious
Diseases of Poverty 3(42): https://doi.
org/10.1186/2029-9957-3-42.
Chad Wells, Pratha Sah, Seyed
Moghadas, et al (2020) Impact of
international travel and border control
measures on the global spread of
the novel 2019 coronavirus. PNAS
117(13): 7504-7509.

The Importance of Public
Trust, Transparency and
Civic Engagement
Key issue: The ongoing success of Australia’s
pandemic response points to the critical importance
of public trust, transparency, and civic engagement as
part of the Government’s optimal approach.
5
The most promising evidence-
informed strategy is only possible if
public involvement and cooperation
can be sustained. Here, we focus
on importance of transparency
and civic engagement, Chapter 11:
Communications elaborates further on
the specific forms of encouragement,
support and communication needed
to control COVID-19.
Recommendations
yy Recommendation: Prioritise trans-
parency and trust by acknowledging
uncertainty and communicating
clearly and with empathy.
yy Recommendation: Communicate
rationale for decisions including
what evidence is being used, who
was consulted, and what impacts
were considered and why a course
was chosen.
yy Recommendation: Involve commun-
ities, industries, organisations, and
other stakeholders in decisions about
options for strengthening and/or
relaxing containment measures.
yy Recommendation: Consideration
should be given to the establishment
of a funded national service program
for younger Australians (e.g. Aussies
All Together) to inclusively engage
the young from across the nation in
the process of social reconstruction
across the country.
Federal, State and Territory
governments have responded
quickly and at scale, and a
recent Newgate Australia survey
(2020) reports that 76% of the
public strongly supports social
distancing measures, bans on mass
gatherings, and limiting outdoor
activity to essential tasks.

Background/Context
Australian efforts to contain
transmission of the SARS-CoV-2
virus and achieve a ‘flattening of the
curve’ have so far been successful.
Federal, State and Territory
governments have responded
quickly and at scale, and a recent
Newgate Australia survey (2020)
reports that 76% of the public
strongly supports social distancing
measures, bans on mass gatherings,
and limiting outdoor activity to
essential tasks. These strategies
have been enabled by strong
pandemic planning and public
health workforce infrastructure and
high levels of cooperation from
all sectors. In the months ahead
however, Australians will have a
less immediate sense of risk while
continuing to feel the impact of
public health measures on all parts
of their lives. The ongoing success
of Australia’s pandemic response
points to the critical importance
of public trust, transparency, and
civic engagement as part of the
Government’s optimal approach.
Evidence and
Analysis to support
Recommendations
Public trust
Trust is a key resource in harnessing
public cooperation and sustaining
the behaviours needed for pandemic
management. Trust is affected by
perceived competence, objectivity,
fairness, consistency, sincerity, faith
and empathy (Renn and Levine,
1991). A lack in one area may be
compensated if there is a surplus
of the other. Credibility and trust
are key factors in effective crisis
communication (Briñol & Petty,
2009) and can be expressed at the
messaging, personal, institutional and
political/cultural levels (Renn, 2008).
Levels of trust in Government
differ between socio-economic
and demographic groups (Stoker
et al., 2018). For this reason, broad
messaging aimed at the general
public must be complemented
with more targeted communication
and involvement. While policy
decisions should be announced

Transparency and Civic Engagement
and articulated by political figures,
public health officials and other
relevant experts must continue to
provide public communications, to help
communicate that such policies are
underpinned by appropriate evidence.
Where possible, appropriately
summarised abstracts of this evidence
should be made publicly available on
the Government COVID-19 websites.
The Commonwealth Dashboard,
and the various State Dashboards,
are welcome developments – keep
them current.
Inconsistency between jurisdictions
in policies may sometimes be justified
but cause confusion because they
result in different emphases on risk
and the ‘right’ approach. When Federal,
State and Territory approaches are
not in alignment, the reasons must
be clearly explained to the public.
Furthermore, since ‘evidence’ is facts
plus values, both should be clearly
articulated (Carter et al., 2011).
When communicating, leaders
should express genuine empathy and
concern (Reynolds & Quinn, 2008).
The more Australians believe that
leaders empathise with them and
are genuinely concerned for their
wellbeing, the more likely they will
respond favourably to Government
advice. Leaders should also
communicate respect and a belief that
they trust the public, as this is more
likely to elicit cooperation (Van Bavel
et al 2020).
Transparency
Trust in government and organis-
ations is enhanced when there is
transparency of information, evidence,
and a clear decision-making process.
Governments and organisations should
therefore seek to provide access to
accurate information, both positive
and negative, so that people may
build accurate expectations. Change
should be communicated early, even
with incomplete information, as
acknowledging uncertainties does not
undermine trust in the information or
its source (van der Bles et al., 2020).
While people dislike uncertainty, a
perception of obfuscation is worse
because it diminishes trust. Moreover,
withholding information can motivate
people to look for information
elsewhere, which can foster belief
in misinformation (Kovic & Füchslin,
2018).

There should be appropriate levels
of transparency in decision-making
processes. This includes what
evidence is used in decisions, who
was consulted, and what impacts
were considered. Where risk is
inherent, acknowledgment of risks
and their magnitude enhances
trust. Strong risk negations (e.g.,
it’s perfectly safe) may make people
more risk averse (Betsch & Sachse,
2013). It is better to acknowledge
a risk when it is present including
information about its magnitude,
even if outweighed by the benefits.
Governments should prioritise
transparency and trust in situations
where the State acts rapidly and
with limited consultation for the
greater good, as is often the case in
health emergencies. Elimination and
controlled adaptation scenarios both
require significant data collection,
analysis, and sharing to reduce
ongoing chains of transmission.
Aggregated anonymised data from
telecommunications, social media
and satellite-based systems have the
potential to improve traditional public
health data collection approaches
(Buckee, 2020; George & Taylor et
al., 2019), however, digital tracking
applications also raise justified
concerns by experts and some
members of the public. Using data-
driven approaches, including new
tracking applications to accelerate
contact tracing, has the potential for
perceived and actual Government
overreach. The public will have many
legitimate questions. Government
transparency on what information
is collected, how it is encrypted,
who has access, where the data
is stored, and whether dual-use of
health-related data is allowed, must
be addressed by the Government in
advance of deploying mobile tracking
applications. Addressing these issues
is especially important with respect
to data collection relating to First
Nations peoples (Kukutai and Walter,
2019; Mann, DeVitt and Daly, 2019).
Change should be communicated
early, even with incomplete
information, as acknowledging
uncertainties does not undermine
trust in the information or its source.

In relation to the use of citizen-
generated data (i.e., from mobile
contact tracing applications),
Governments must address real and
perceived privacy concerns and data
ethics, and mitigate the potential for
misuse, including the politicisation of
health-related data (Daly, Devitt, and
Mann, 2019). There should be sound
evidence justifying data surveillance
especially if less imposing measures
would be sufficient. Consultation on
the use of surveillance technologies
should include cybersecurity
experts, data ethicists, public health
researchers and other stakeholders.
With respect to anonymised public
health data, there should be a
strong commitment to data sharing,
exchange, and interoperability
(Wilkinson et al., 2016; Research
Data Alliance COVID19 Working
Group, 2020).
Civic engagement
As the threat of COVID-19 becomes
less immediate but costs continue to
be felt, Australia will need to prioritise
active and ongoing engagement
with communities, industries,
organisations and other stakeholders.
Civic engagement is about enabling
communities and social networks to
be involved in the decisions that will
affect them (Miranti & Evans 2019;
Adler & Goggin 2005). However, this
can be challenging in times of crisis
when Governments must make rapid,
life-saving decisions that may require
imposing strict measures with little or
no time for community involvement.
Australia’s initial success in reducing
the rate of transmission has provided
a valuable window of opportunity
to establish deliberative processes
in which social groups, businesses,
and organisations can influence
the containment measures that
are likely to affect them (Cammett
& Lieberman 2020). Meaningful
stakeholder engagement will improve
the effectiveness of containment
measures (Renn 2008). It will
encourage greater ownership of
Civic engagement is about
enabling communities and social
networks to be involved in the
decisions that will affect them.

decisions and accordingly more
chance of public cooperation
(Head 2011).
Community groups, businesses,
and organisations also have specific
expertise and local knowledge that
is needed to devise implementable
containment measures over the
long-term (Wynne 2002). An
excellent example of this is the
way in which the major Australian
supermarket chains have translated
a set of general social distancing
requirements into specific, workable
shop-floor practices. Stakeholder
engagement also permits input
from those groups who are likely to
shoulder the consequences and risks
of a potential cause of action and,
as the subsequent chapters describe
in some detail, some communities
and professions are more vulnerable
than others.
Australia’s approach must, therefore,
be a collaborative one.
The specific consultative process
will depend on measures being
considered and the types of groups
that are likely to be involved. When
options for strengthening or relaxing
containment measures are being
considered, it is important to identify
which specific groups have a stake
(Renn 2008). These could be groups
whose health may be affected (such
as older Australians, or teachers), or
sectors that have a direct financial
interest (such as the hospitality
industry). Representatives from these
groups, identified via community
organisations, professional or
industry associations, unions, or
patient advocacy groups, should then
be considered as participants in a
deliberative process. It may be useful
to establish COVID-19 community
reference groups to represent key
groups that could then provide
ongoing guidance for the duration of
the pandemic (see for example, the
Aboriginal and Torres Strait Islander
Advisory Group on COVID-19).
When options for strengthening or
relaxing containment measures are
being considered, it is important to
identify which specific groups have
a stake.

Groups should be provided with an
opportunity to delineate and appraise
the risks as they perceive them (Renn
2008). They could be provided with
decision parameters, permissible
options and methods for minimizing
harm. Industry representatives could
be encouraged to consult more widely
and present a plan for commencing
commercial activity in a way that
minimises risk.
Establish a funded national
service program
Due to the COVID-19 response in
Australia, the young have been
particularly displaced by the social
distancing policies and many will
find it hard to get a foothold in the
economy. As social distancing begins
to be relaxed, they will have an
increased capacity to serve Australian
communities, but potentially few
options. Civic engagement, including
both community and industry, has
been a purposeful component of
Australian policymaking for several
decades (Head 2011). There also
exists a wealth of expertise and
experience among governments,
communities, industry and academia
in public policy focused on
volunteering (Volunteering Australia,
2014; Walsh & Black 2015).
Aussies All Together (suggested
title) could be an inclusive program
that provides opportunities for skills
development and engagement in
the aftermath of emergencies within
Australia’s borders. Participants will
receive culturally appropriate training
to support communities in order to
improve health and wellbeing, (re)
build infrastructure, provide peer-
tutoring, perform conservation
and wildlife preservation. Such
a program could offer meaning,
purpose and social connectedness
to those involved, and will contribute
Research shows that young people
are influenced by “top down”
signals from policies and programs,
and are motivated by grassroots or
“bottom up” programs to support
communities.

to Australia’s long-term national
health and education strategy.
Research shows that young people
are influenced by “top down” signals
from policies and programs, and are
motivated by grassroots or “bottom
up” programs to support communities
(Walsh & Black, 2015). There is
considerable empirical evidence
on the benefits of fostering youth
volunteerism in Australia and New
Zealand (Black, 2012; Lewis, 2013).
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Australia’s Optimal
Approach for Building
and Supporting a Health
System within the
“Roadmap to Recovery”
Building and supporting our health system requires
focus on two interrelated key aims:
1. resuming and optimising routine, comprehensive
health care; and
2. simultaneously managing COVID-19 across the
healthcare system using ongoing preparedness
and readiness to re-escalate crisis management.
6
Recommendations
and Key Findings
Recommendations
yy Recommendation: Agree and
optimise national guidelines,
training (including evidence-based
use of PPE and other infection
control approaches) and supply
chains for managing SAR-CoV-2
and COVID-19 screening, testing
and management that strengthens
primary and hospital care
collaboration.
yy Recommendation: Establish a
national real-time health data
repository starting with COVID-19
related data that links primary,
secondary and acute care that can be
extended to other areas of heath care.
yy Recommendation: Maintain e-health
(e.g. video/telehealth and apps) as
an important part of routine health
care, supported by nationally agreed
standards and quality indicators.
yy Recommendation: Support
community messaging to seek
medical care in managing existing
conditions and diagnosis and
treatment of both COVID-19 and
non-COVID-19 conditions.

yy Recommendation: Provide the
flexibility in health care worker
training requirements that will
ensure the viability of Australia’s
essential health workforce
pipeline.
yy Recommendation: Provide
accessible mental health care
support specifically designed
for health care workers.
Key Findings
yy Key finding: Lack of transparency,
inconsistent messaging and
uncertainty undermine confidence
and performance in health care.
yy Key finding: Australia has a
strong, Government-supported
primary and community health
sector led by general practice and
supported by PHNs. Voluntary
patient registration would further
strengthen the ability of general
practices to engage with their
patients on an ongoing and
proactive basis.
yy Key finding: Australia has a
strong public hospital sector
combined with a private sector
that particularly supports elective
surgery. The public sector could
maintain, and if needed escalate,
COVID-19 care while elective care
(public and private) is escalated
in collaboration with private care
providers.
yy Key finding: PPE is vital for both
staff protection and to maintain
health services across the spectrum
from community to hospital care.
Uncertainty about appropriate use
and supply are therefore obvious
major stressors for health care
workers and the system. Misuse
includes both inadequate PPE and
overuse of PPE.
yy Key finding: The pandemic is
threatening both educational
opportunities for students and the
health care workforce pipeline and
this must be rectified.
yy Key finding: As with the
likely ongoing uptake of
videoconferencing in the broader
community, video or other eHealth
options are likely to be able to
offer high value care when used
appropriately.

Chapter 6: Australia’s Optimal Approach for
Building and Supporting a Health System within
the “Roadmap to Recovery”
yy Key finding: There has been marked
reductions in pathology testing
and clinical presentations for non-
COVID-19 problems indicating a
possible delay in the management
of existing conditions and lack of
attention for new problems.
yy Key finding: Electronic health
records and data linkage are
key to comprehensive COVID-19
surveillance as well as managing
non-COVID-19 clinical problems.
yy Key finding: All critical care
specialties have previously
supported advanced care planning
for patients likely to have poor
outcomes, COVID-19 has further
emphasised this need.
yy Key finding: Medical research
integrates laboratory,
epidemiological and clinical
trial-based programs aimed at
understanding the fundamental
molecular, biological and
biochemical characteristics
of COVID-19 and for devising
treatments and vaccines.
yy Key finding: Epidemiological
modelling of the dissemination
and spread of COVID-19 in an
Australian context has been
critical in informing strategies to
minimise the number of infections
and optimise the treatment of
Australians who have already been
infected. More Health Services
Research is now needed to prepare
for the changes in the healthcare
system to deal with COVID-19 and
its consequences.
General Background
Current Context
The COVID-19 crisis challenges
all aspects of health care and all
overlapping sectors of our system.
For patients with COVID-19, 80%
can be adequately cared for in the
community, 15% require hospital
inpatient acute care; and 5%
require critical care (ICU) usually
for respiratory support. Health care
professionals are also at increased
risk of contracting COVID-19. Dealing
with the crisis has led to delaying non-
urgent elective surgery; i.e. surgery
unlikely to lead to death or significant
harm within 30-days. Also, many
patients are avoiding the health care
system for non-COVID-19 problems.

Evidence and Analysis to
support Recommendations
and Key Findings into
Australia’s recovery phase
ARS-CoV-2 testing and
screening and vaccination
With the dual aims of managing the
pandemic and increasing clinical
activity for non-COVID-19 needs,
both community and hospital sectors
require agreed expert evidence-based
guidance on testing and screening
for SARS-CoV-2, as epidemiology and
antibody and antigen tests evolve.
This advice should include managing
those who screen or test positive.
Escalating elective surgery will be
highly dependent on this advice
including Australian epidemiology.
Similar guidance will be needed
should a vaccine become available.
Analysis:
yy Ensure updated national guidelines
on managing SARS-CoV-2 and
COVID-19 screening and testing in
community and hospital settings.
yy Link screening and testing data to
enhance national surveillance.
The central role of primary care
in the “Roadmap to Recovery”
The centrality of primary care has
been re-enforced during the COVID-19
pandemic as countries with strong
primary care have demonstrated
greater capacity to flexibly respond.
Recovery will be prolonged – this is a
marathon, not a sprint. Primary care
has a key role in preventing, testing,
tracing and managing COVID-19.
Primary Health Networks have played
a vital role in supporting primary care
in the response.
The understandable focus on
COVID-19 has led to the unintended
consequence of a reduction in those
seeking health support for non-
For patients with COVID-19,
80% can be adequately cared for
in the community, 15% require
hospital inpatient acute care; and
5% require critical care (ICU)
usually for respiratory support.

COVID-19 care. Tele(video)health
(with new MBS item numbers) has
helped to some extent. Many hospital-
based ambulatory services including
outpatient clinics have also moved
to telehealth. Concern remains that
we will see increased morbidity and
mortality from the current altered
focus of health care workers and
from patient reluctance to engage
on non-COVID-19 problems. This is
also likely to be disproportionately
the case in socioeconomically
marginalised groups.
As hospital services, particularly
elective surgery resume, the
severity of both comorbidity and the
underlying reasons for the patient
requiring surgery may have worsened
increasing risks of complications
and mortality. This places greater
demands on all three areas: primary
community care, acute hospital care
and critical care.
Analysis:
yy Primary care should be supported
as the central component of the
health system including care for
conditions well managed using
care in the community.
yy Collecting, curating and linking
health data across the health
care system should be supported
including MyHR.
Hospitals as Partners in the
To date, Australian hospitals have
avoided the nightmare of other
countries such as the UK, Spain, and
the US. Our acute and critical care
sectors are treating an unexpectedly
small number of COVID-19 patients
but are prepared for many more. There
is now a need to resume elective
diagnostic and therapeutic procedures
(medical and surgical) in low risk
patients as soon as possible. There is
concern that following the pandemic
there will be the adverse effects
of neglecting other health issues,
including worsening mental health.
This is a public health problem.
Primary care and hospital clinicians
need to increase collaboration to
improve patients’ chronic conditions
that may have deteriorated during the
pandemic and ensure that access to
procedures is based on need rather
than the loudest voices. Escalating
elective diagnostic and therapeutic
procedures will require Government

facilitated collaboration between the
public and private sectors.
Due to our timely response, the
Australian health care system has
been provided with time to plan.
It is well documented that older
Australians are more likely to require
intensive care and ventilation than
younger Australians. Now is the time
for general practitioners, emergency
medicine, anaesthetists, intensivists to
promote there being early goals of care
discussions for patients at high risk of
death or severely impaired functional
recovery. Some patients who have
died in ICU from COVID-19 may
have benefitted from goals-of-care
discussions before their final illness.
The health care system needs to be
primed for a COVID-19 resurgence as
has been seen in other countries and
to be able to pivot quickly in response.
Primary care and public hospitals will
need to maintain COVID-19 readiness
and the ability to escalate.
Analysis:
yy The public must be supported to
seek medical care for existing cond-
itions and diagnosis and treatment
of non-COVID-19 conditions.
yy Support community-based “goals-
of-care” discussions for patients
at risk of poor outcomes – so
patients are better prepared should
circumstances so require.
yy Facilitate public and private
sector collaboration in escalating
elective diagnostic and therapeutic
procedures.
yy Priorities for resuming care must be
based on need – and may require a
communications campaign to build
momentum.
Now is the time for general
practitioners, emergency medicine,
anaesthetists, intensivists to
promote there being early goals
of care discussions for patients
at high risk of death or severely
impaired functional recovery. Some
patients who have died in ICU from
COVID-19 may have benefitted
from goals-of-care discussions
before their final illness.

Mental Health and Wellbeing
of Healthcare Workers in the
Recovery phase
Supporting the wellbeing of
healthcare workers at elevated
risk of experiencing psychological
distress and adverse mental health
symptoms is vital for both their health
and for managing the pandemic. The
intensive workload, uncertain PPE,
fear of infection and spread to family
members, saturation media coverage,
inconsistent messaging and reduced
contact with loved ones all contribute
to the added mental burden on
healthcare workers. The psychological
harm of the pandemic for healthcare
workers is a continuum from stress
and burnout to post-traumatic stress
and other mental health symptoms.
Analysis:
A targeted mental health plan for
healthcare workers is essential
including:
yy Optimising informal and formal
support networks and education on
the possible psychological impact
of COVID-19.
yy Screening of healthcare workers for
psychological distress and mental
health symptoms.
yy Access to free evidence-based
eHealth mental health interventions,
and face-to-face treatment for
individuals requiring more intensive
support.
Personal Protective Equipment
(PPE)
Personal protective equipment has
been an important and emotive subject
during this COVID-19 pandemic.
However, PPE is only one part of
protecting staff and other patients
from COVID-19 cross-infection.
PPE is a collective term for differing
levels of protection, and it has been
complicated by the lack of any
agreed terminology. There has also
been uncertainty about when to use
The psychological harm of the
pandemic for healthcare workers
is a continuum from stress and
burnout to post-traumatic stress
and other mental health symptoms.

the various levels of PPE, and also
uncertainty about availability of PPE
with a marked disparity of access
across community and hospital care.
Appropriate PPE use significantly
reduces risk of viral transmission.
PPE should be matched to the SARS-
CoV-2 risk, which will depend on
location, and should be based on
national case definitions and guided
by local infectious diseases and
public health advice. It should also be
matched to the potential mode of viral
transmission occurring during patient
care – contact, droplet, or airborne.
Suggested Levels of PPE based on
mode of transmission risks:
1. Low risk: Standard work clothes
and procedures;
2. Contact precautions: Gloves and
plastic apron;
3. Droplet precautions: Gloves,
plastic apron, surgical mask and
eye protection;
4. Airborne precautions: Gloves,
fluid repellent long sleeved gown,
goggles or full-face shield and
N95 mask. (Purified Air Powered
Respirators (PAPRs) with training.)
Availability of PPE is dependent on
both supply and use. Unnecessary
use (misuse) does not enhance safety
and undermines availability. Clear
understanding of the levels of PPE
and when they are needed is required
to sustain stocks and de-escalate
use of PPE during the return to pre-
pandemic clinical activities. Adhering
to guidelines such as those from the
College of Anaesthetists (ANZCA)
should help de-escalate use of PPE
and re-escalate if needed.
Analysis:
yy Use of consistent terminology of
levels of PPE based on method of
transmission
yy Ensure a nationally coordinated PPE
stockpile with reliable, accessible
estimates of different PPE
components and greater certainty
about adequate access for hospital
and community workforce.
yy Develop agreed national guidelines
in collaboration with relevant
professional bodies (such as the
medical Colleges) for appropriate use
of PPE for each level of transmission
risk, including: an agreed list of
aerosol-generating procedures.

Managing the Professions and
the training pipeline within the
Prior to the COVID-19 pandemic
Australia was already facing major
challenges in maintaining and
sustaining a health workforce to meet
the growing and distributed demand
for health care. Workforce strategies
to address these pre-existing
imbalances in supply and demand,
particularly in nursing and midwifery,
will not be sufficient to meet the
added immediate and longer-term
impacts of the COVID-19 pandemic.
The immediate surge in workforce
demand from the pandemic along
with any subsequent waves, will
continue to require rapid up-skilling
and re-deployment of large numbers
of health professionals to the frontline
for up to 18 months. Interruptions are
anticipated through natural attrition,
work stress, burnout, sick leave,
isolation leave, and added caring
responsibilities.
Further, healthcare workers will
access annual and long service
leave which will have been limited
during the pandemic. Workforce
disruption is expected due to loss of
required clinical training. Universities
and other training organisations
are working within jurisdictions to
leverage existing resources, capability
and capacity in order to provide
scalable, high quality, interdisciplinary,
evidence-based training solutions to
rapidly upskill the health workforce
and support workforce supply while
providing career pathways that aid
retention.
Analysis:
yy Professional regulators should
consider removing minimum
mandatory hours as a requirement
for registration and adopt a flexible
approach to the assessment of
work readiness that includes work
experience, scope of practice and
clinical competence and recognise
and promote innovative approaches
to clinical education within new
models of care (such as telehealth).
yy Pandemic preparedness should
be compulsory curriculum for all
health care courses and students
should be trained to the highest
standards in the correct use of PPE
and consideration to how students

can be safely involved in learning
about COVID-19, including the use
of virtual health care placements.
yy Ongoing in-person clinical
placements should recommence
when there are sufficient supplies
of appropriate PPE. Final year
students should be prioritised to be
involved in COVID-19 related care
as they will commence practice in
2021 and must be prepared for their
role.
The National Principles for Clinical
Education during the COVID-19
recently published by the Australian
Government are a helpful contribution
in this space. It is important the
professional accreditors now conform
to these principles.
The silver lining of a digitally
connected health care system as
we move into a recovery phase
COVID-19 has catapulted our health
care systems into the digital delivery
of health care. This has been largely
welcomed by the public and the health
care workforce. There is an opportunity
to build upon the experience of
tele and video consultations and
incorporate these permanently
into health care, yet this must be
accompanied by appropriate standards
and guidelines for training, and quality
indicators and management. Virtual
healthcare can be extended beyond
voice/video interaction to include
asynchronous communication,
consumer empowerment and
biomedical monitoring.
The COVID-19 pandemic has also
demonstrated the importance of
real-time health data in the planning
response and management of the
crisis. The engagement of the public
in following the daily data updates
has been unprecedented. The time is
ideal to capitalise on the alignment
of the public, practitioner and policy
need for data.
Analysis:
yy eHealth (virtual Healthcare) should
become routine health care.
Standards and Quality indicators
should be developed in conjunction
with the relevant professional
bodies to support the integration of
virtual healthcare into routine care.
Consider how to integrate virtual
healthcare into training health care
professionals.

The contribution of medical and
health research to Australia’s
capacity to manage the COVID-19
pandemic
Australia’s medical research
community has made significant
contributions to Australia’s response
to the COVID-19 pandemic through
universities, medical research
institutes, hospitals and other
research institutions. Australia has
been at the cutting edge being one of
the first outside China to isolate the
virus, develop virus-detection tests,
publish on the immune response
to the virus and lead in developing
innovative Vaccine candidates.
Analysis
yy Medical research integrates
laboratory, epidemiological and
clinical trial-based programs
aimed at understanding the
fundamental molecular, biological
and biochemical characteristics
of COVID-19 and is critical for
treatments and vaccines.
yy Medical research models the
projected dissemination and spread
of COVID-19 in an Australian context,
to inform strategies to minimise the
number of infections and optimise
the treatment of Australians who
have already been infected.
yy Health services research will be
critical in supporting the health
system more broadly in the recovery
from COVID-19.
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Australia has been at the cutting
edge being one of the first outside
China to isolate the virus, develop
virus-detection tests, publish on
the immune response to the virus
and lead in developing innovative
Vaccine candidates.

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Australasian College of Surgeons
(RACS): Medical colleges support
resumption of selective elective
surgery for low-risk patients.
http://www.anzca.edu.au/
communications/media/media-
releases-2020/medical-colleges-
support-resumption-of-selective-e
Choosing Wisely. ANZCA, ANZICS,
ACEM. https://www.choosingwisely.
org.au/recommendations
Australian and New Zealand Intensive
Care Society. COVID-19 resources
for critical care professionals. https://
www.anzics.com.au/coronavirus/
The Australian Commission on
Safety and Quality in Health Care.
A guide to the potentially preventable
hospitalisations indicator in Australia.
2017.https://www.safetyandquality.
gov.au/sites/default/files/migrated/A-
guide-to-the-potentially-preventable-
hospitalisations-indicator-in-Australia.
pdf

Preparing to Reopen
Key issues: What are the special considerations,
preparations and support needed to assist the
reopening of businesses and workplaces, schools
and tertiary education institutions?
7
Recommendations
and Key Findings
Businesses and Workplaces
yy Recommendation: Create a national
risk diagnostic tool with review
criteria for businesses to review and
self-assess their own shortage of
resources, ability to reopen/reform,
challenges and limitations in post-
COVID-19 situations.
yy Recommendation: Develop a health
tracking system and new hygiene
standards to ensure reopening
practices are safe for the workforce
and public.
yy Recommendation: Develop a
staged approach to a return to
work, taking account of geographic
location, occupation/industry type,
and characteristics of workers
which might indicate high risk of
serious infection.
yy Recommendation: Diversify
opportunities for new employment
styles and extend the criteria for
receipt of the JobKeeper allowance.
Tertiary Institutions
yy Key finding: Losses in research
and teaching capacity of post-
school educational institutions
(universities, colleges, VET
providers) as a result of the current
crisis will greatly hinder economic
recovery and long-term prosperity.
yy Recommendation: Federal and
State Government support the
post-school education sector
to help prevent researcher and
teacher job losses, and support
a swift return to capacity in both
teaching and R&D.
yy Key finding: It is important
that post-school educational
institutions account for gaps in
syllabus knowledge and work/
vocational placement skills through
students’ first year of candidature.
yy Recommendation: Post-school
educational institutions make
appropriate accommodations and
take necessary actions to assist
the transition of incoming first year

students who may not have all the
assumed syllabus knowledge or
expected work/vocational skills.
yy Key finding: Students in accredited
programs due to graduate in 2020
and research students collecting
data and undertaking fieldwork
in 2020 are at significant risk of
disruption.
yy Recommendation: Australia
develop a coordinated, national
(or state-based, as appropriate)
response to graduating students
and apprentices/trainees from
accredited programs agreed by
the relevant accrediting bodies.
yy Key finding: Australia’s response
needs to balance consideration of
the priority of domestic students,
with the important benefits that
come from a strong, vibrant
international education sector.
yy Recommendation: Balanced with
critical health and epidemiological
considerations, there is a need for
early decision-making about when
and how international students
return to Australia for on-campus
learning.
Schools
yy Key finding: Online and remote
learning remain useful temporary
measures, but place significant
burdens on students, families and
educators. Continued use of remote
learning for some or all students,
as opposed to school-based
in-class teaching, may deepen
existing inequalities in educational
attainment and engagement.
yy Key finding: Schools face several
major challenges in the return to full
operations in terms of addressing
student well-being, mental
health concerns, as well as other
operational issues.
Australia’s response needs to
balance consideration of the
priority of domestic students, with
the important benefits that come
from a strong, vibrant international
education sector.

Chapter 7: Preparing to Reopen
yy Recommendation: Any resumption/
expansion of in-class school
operations should be contingent
upon physical distancing measures
appropriate to each school
context. A staged return of school
operations should consider the
social, emotional, developmental
and academic needs of different
groups.
yy Recommendation: To support
academic, mental health, and
school to post-school transitions,
government should provide schools
with adequate funding, resources,
and coordination support to
facilitate adaptive responses
to current circumstances and
emergent contingencies.
Context
The Australian economy, in common
with most of the rest of the world,
will confront serious recession in
coming months, and will probably not
regain levels of activity recorded at
the end of 2019 for two years or more
(Ketchell, 2020). Updated forecasts
from the International Monetary
Fund suggest real GDP growth of
–6.7% in 2020. This indicates the
recession Australia is facing will
dwarf those that came before it. In
order to realise the projected 6.1%
real GDP growth forecast by the IMF
in 2021, government needs to support
businesses in a number of ways.
Tertiary Institutions
The Australian Higher Education
sector comprises over 1.5 million
students enrolled in 136 universities
and non-university higher education
institutions (Department of Education,
Skills and Employment, 2019), with
about half a million of them from
overseas (DESE, n.d). More broadly
across the tertiary education sector
In order to realise the projected
6.1% real GDP growth forecast by
the IMF in 2021, government needs
to support businesses in a number
of ways.

the Australian Bureau of Statistics
estimates that in May 2019 there
were over 2.1 million people in
Australia aged 15–64 studying
for a non-school qualification at
Certificate III level or above (ABS,
2019a). Many of the educational
challenges and recommendations
relevant to the tertiary education
sector are substantially the same
as the ones for schools. However,
there are also issues particular to
the tertiary education sector and the
contributions this sector makes to
Australia’s national benefit.
Universities play a vital societal/
economic role in research and
development (R&D), contributing
$41 billion to the national economy
and employing 259,100 full-time
equivalent staff (Deloitte, 2018).
International education brought in
around $40 billion in 2019 (ABS,
2020). Despite amounting to around
40% of Australia’s exports of services
and nearly 10% of all goods and
services, Commonwealth funding has
fallen from 37% to 30% (DESE, 2020)
as the share of university revenue
from international students has risen
(between 2003 and 2018 from 14%
to 26% or more). At the same time,
there has been a collapse in gross
Australian expenditure on R&D, falling
from 1.88% in 2015–16 to 1.79%
of GDP in 2017–18 (ABS, 2019),
while the OECD average annual R&D
spend was 2.37% of GDP in 2017
(OECD, 2020). While universities’
role as a major export industry is
increasingly recognised, this is not
always so with R&D activities which
also support significant innovation-
driven economic growth. Independent
modelling by London Economics
estimates that Go8 research activity
alone contributed $24.5 billion to the
economy each year, with an estimated
$10 return to the private sector for
every $1 of Go8 research income
(London Economics, 2018).
Universities play a vital societal/
economic role in research and
development (R&D), contributing
$41 billion to the national economy
and employing 259,100 full-time
equivalent staff.

The COVID-19 crisis has directly and
substantially impacted the tertiary
sector through closures of campuses,
cessation of in-class learning, and a
rapid shift to remote online learning.
Even though off-campus learning
already represented part of the
regular experience for one in three
higher education domestic students
in Australia (Norton, Cherastidtham
& Mackey, 2018), that applied mostly
to adult learners and postgraduate
students.
The COVID-19 crisis has also
highlighted the crucial need for
innovation and productivity-driven
growth for our national economy and
the health of our citizens. A strong
tertiary education sector is one of our
greatest assets, strongly positioned
to provide a pathway through the
current crisis and return to wellness
and prosperity. Australian health and
medical researchers are engaged in
world-leading programs to develop
effective treatments and vaccines for
COVID-19, with Australian universities
training the future workforce in ways
that are crucial to responding to this
crisis. Our vocational colleges and
TAFEs are also providing critical
workforce training needed for this
recovery. Perhaps the greatest demand
on universities and other post-school
institutions comes at a time when they
are also most under threat.
The following Key Findings and
Recommendations take into account
all post-school educational institutions
and pathways.
Schools
In 2019, nearly four million students
were enrolled in 9,503 Australian
schools (ABS, 2020). While the re-
opening of schools to face-to-face
operations needs to be considered
from the public health perspectives,
it is also vital that the diverse
educational impacts of moves to
Rapidly developing policies
surrounding the operations of
schools within the COVID-19
pandemic context have been a
flashpoint for public media debate.

remote online teaching and learning
on young people, educators, education
systems and the broader Australian
economy are recognised. This report
examines the key educational issues
that must be considered alongside
epidemiological factors when
determining the reopening of
schools around Australia.
Schools play a complex role in
society, integrating the production
of both public and private goods
(Labaree, 1997), and balancing
multiple, overlapping purposes of
academic learning, socialisation, and
individual development (Biesta, 2015).
Considerations for the re-opening of
schools need to remain aware of this
complexity.
Rapidly developing policies
surrounding the operations of schools
within the COVID-19 pandemic
context have been a flashpoint for
public media debate. Federal and
State/Territory governments have at
times appeared at odds over strategy,1
and teachers and education unions
have expressed strong concerns
regarding the health and safety of
staff, especially those with relevant
pre-existing health conditions, as
schools remained open into late
March.2
Anecdotal reports from mid-
March have attendance rates at only
35% to 50%.3
Numerous medical
experts and the Federal Government
have not been entirely supportive
of families removing children from
schools in the absence of illness
or other specific concerns (Creagh,
2020),4
drawing on modelling and
epidemiological support (e.g., Viner
et al 2020) – though positions on
this shifted with rapid change in the
national and international situations.
1 https://www.abc.net.au/news/2020-03-23/federal-and-state-governments-school-closures-amid-
coronavirus/12080062
2 https://www.abc.net.au/news/2020-03-19/coronavirus-why-is-australia-keeping-schools-open/12070702
3 https://www.theage.com.au/national/victoria/parents-are-voting-with-their-feet-school-attendance-rates-in-
freefall-20200317-p54aw0.html
4 https://www.abc.net.au/news/2020-04-15/coronavirus-covid19-education-schools-scott-morrison-
response/12149984

By the end of Term 1 and immediately
following Easter, schools moved
students to remote online learning.
Schools remain open for in-school
remote learning for children of
essential service workers and
vulnerable students; however, there
has been some confusion as to what
constitutes an essential service
worker, with contrasting messaging
from Federal and State/Territory
levels.5
Currently, it is envisaged
that students will start returning
to in-class learning some time in
TermTwo, but it is unclear who, how
many, and when they will return to
in-class learning. Thus, Australian
schools seem to be transitioning to a
mix of in-class, remote, and flexible
learning arrangements—with precise
arrangements and plans varying
between states, and likely, between
schools.6
5 https://www.theguardian.com/commentisfree/2020/mar/27/more-harm-than-good-the-cases-for-and-
against-closing-schools-during-the-coronavirus-pandemic
Argoon, A. (2020) Victorian schools will close and childcare centres have rigid rules eased Herald Sun
Newspaper, Victoria March 24, 7.29am heraldsun.com.au
6 https://www.abc.net.au/news/2020-04-15/coronavirus-covid19-education-schools-scott-morrison-
response/12149984
Evidence and
Analysis to Support
Recommendations
and Key Findings
Recommendation
Create a national risk diagnostic
tool with criteria for businesses
to review and self-assess their
own shortage of resources, ability
to reopen/reform, challenges
and limitations in post-COVID-19
situations.
Recommendation
Government should facilitate
information-sharing to support
business reopening and recovery
with centralised information sharing
platforms to be developed at State
and Federal Government levels.

For those firms with cash reserves,
the hibernation policy will work.
However, firms without sufficient
cash reserves will not have the ability
to pivot to adapt to the changing
business environment, nor pay the
accountants and other business
professionals required to develop
business strategies (Sneader and
Singhal, 2020).
The advice of financial professionals
with expertise in business strategy
could be of assistance. Government
could encourage and facilitate legal
and financial advisory assistance for
small and medium sized businesses
at low cost, through subsidies to the
service providers. The $100,000 cash
flow support for small and medium
businesses the Government has
already implemented is an appropriate
strategy to assist in this area.
In addition, an exit strategy for firms
with high risk of financial distress
can be an important foundation for
strategic renewal (Ren, Hu and Cui,
2019) as they free up committed
resources and, therefore, contribute
to the formation of new ventures
(Carnahan, 2017).
Another important tool in helping
businesses to recover are revenue-
contingent loans (RCL). This facility
could, for example, be deployed
to continue wage support as the
JobKeeper scheme is wound down
through the recovery period for
firms not at risk of financial distress
(Botterill, Chapman and Kelly, 2017).
It can also be useful to consider
strategies that have worked in the
past. Following the Great Depression,
the United States introduced Federal
Government programs to provide
employment and support businesses,
such as the Reconstruction
Finance Corporation that loaned or
invested billions of dollars to rescue
important parts of the economy.
Government could encourage
and facilitate legal and financial
advisory assistance for small and
medium sized businesses at low
cost, through subsidies to the
service providers.

The Corporation was able to push
assistance beyond banks into local
economies thus restoring confidence
in the financial system (Vossmeyer,
2014), and has been used as a
stabilisation agency and device to
redirect the flow of capital investment
to socially desirable enterprises such
as small businesses (Sprinkel, 1952).
In general Government needs to
simplify, where possible, the process
and complexity of supporting
resources (such as business loans,
grants, or other stimulus schemes) to
increase the uptake and engagement
of small businesses who have limited
time dealing with operational issues.
Recommendation
Develop a health tracking system
and new hygiene standards to
ensure reopening practices are
safe for the workforce and public.
Basic temperature testing can be
implemented at public places to
prepare for reopening. A health colour
code – such as the system being
used in China or a tracking app –
such as the TraceTogether used in
Singapore,7
can be used to slow the
coronavirus spread and limit any
further outbreak when the mass
population attempts to return to
work and mass gatherings.
Hand sanitizers at entry and
egress points in business should
be mandated and installed at
minimal cost to ensure basic
health standards.
Contactless service rules and
maintenance of social distancing
is required until reliable preventative
vaccines or effective treatments
are available at scale
Recommendation
Develop a staged approach to a
return to work, taking account of
geographic location, occupation/
industry type, and characteristics
of workers which might indicate
high risk of serious infection.
7 https://www.zdnet.com/article/singapore-introduces-contact-tracing-app-to-slow-coronavirus-spread/

Links between prevalence of medical
condition, geographic area, and
occupational type could be used to
formulate a staged opening by area,
or, if a geographically uniform re-
opening is undertaken, where medical
resources might be needed. While
observed prevalence of COVID-19 in
a given area is clearly a relevant risk
factor, other considerations are also
important (Chomik, 2020).
Workers with co-morbidities are
probably more at risk of serious
infection than older workers, and
should be guided appropriately
in returning to work. There is a
significant fall in infections in men
with no medical condition between
the 70–74 age group compared to
later age groups (Cumming et al.,
2009). Pre-existing medical conditions
appear to be present in almost all
serious infections (Onder, 2020).
Recommendation
Diversify opportunities for new
employment styles and extend
the criteria for receipt of the
JobKeeper allowance.
Many owner-operators do not
take wages or salaries from their
businesses, but instead rely on
drawings or dividends for their income.
Where evidence can be provided that
these owner-operators are losing
income from lost work opportunities,
eligibility criteria for the JobKeeper
allowance should be extended.
Mass layoffs across a range of
business and projections from the
International Monetary Fund of
unemployment of 8.9%, up from 5.2%
in 2019, [15] signifies the need for
redeployment of the labour force.
This will also require many individuals
to upskill or reskill in order to adapt
to the new business landscape
post COVID-19 restrictions. Many
businesses around the world are
already requiring staff to improve
their skills to refocus in longer term
preparations [16].
Workers with co-morbidities are
probably more at risk of serious
infection than older workers …

Retraining and upskilling programs
could be geared towards providing a
workforce able to deliver on building
up national supply chains for health-
related essential goods with less
reliance on international markets.
International trade flows, however,
should not be impeded with moves
towards old protectionist trade policies.
Tertiary Education
Key finding
Losses in research and teaching
capacity of post-school educational
institutions (universities, colleges,
TAFEs) as a result of the current
crisis would greatly hinder
economic recovery and long-term
prosperity.
Recommendation
Federal and State Government
support the post-school education
sector to help prevent researcher
and teacher job losses, and
support a swift return to capacity
in both teaching and R&D.
As a case in point, universities
play a key role in delivering high-
level training in critical nation-
building skills such as education,
medicine, psychology, minerals
and engineering, and research
and development (R&D) activities
(Deloitte, 2018). A loss in R&D
and teaching capacity as a result
of this crisis would greatly hinder
economic recovery and long-term
prosperity (Universities Australia,
2020). Continued isolation threatens
both, especially as critical aspects
of tertiary education and research
cannot be conducted in an online
environment. Universities will play
a significant role in developing
the evidence base, treatments,
and policies, as well as in training
the professionals of the future
(Universities Australia, 2019), but
remaining closed hampers those
endeavours. Universities have been
set back markedly in their capacity
to deliver on these objectives
(Universities Australia, 2020). Post-
school colleges and TAFEs face
similar challenges in preparing the
tradespeople of the future.

Key finding
It is important that post-school
educational institutions account
for gaps in syllabus knowledge
and work/vocational placement
skills through students’ first year
of candidature.
Recommendation
Post-school educational
institutions make appropriate
accommodations and take
necessary actions to assist the
transition of incoming first year
students who may not have all the
assumed syllabus knowledge or
expected work/vocational skills.
Due to disruptions to in-class
learning in 2020, there may be
students entering university, college,
or TAFE from school who do not
have all the assumed syllabus
knowledge or who may not have
the met all the required work/
vocational placement hours/days.
To the extent this is the case, these
students’ pathways through post-
school education may be hampered.
Possible mitigating strategies include
institutions offering a pre-university/
college bridging week or revision
in Week 1 (specific to a course to
ensure subject-specific readiness),
and using teaching staff to monitor
and attend to identified knowledge
or skill gaps as courses proceed
through first year. Vocational colleges
and TAFEs may offer pre-college
or Week 1 practical instruction to
address practical skill gaps (arising
from lost work placements in Year
12). This may also require institutions
offering first year students expanded
support through learning/counselling
support units.
Possible mitigating strategies
include institutions offering a pre-
university/college bridging week
or revision in Week 1 (specific to a
course to ensure subject-specific
readiness) …

Key finding
Students in accredited programs
due to graduate in 2020 and
research students collecting data
in 2020 are at significant risk of
disruption.
Recommendation
Australia develop a coordinated,
national (or state-based,
as appropriate) response
to graduating students and
apprentices/trainees from
accredited programs agreed by
the relevant accrediting bodies.
Students due to graduate in 2020
are most at risk. Research students
collecting data in 2020 are also at
risk. Strong coordination between
Government services, industry
(major employers), accrediting
bodies, and universities is essential
to ensure staff are available to
teach and conduct research, as
well as to manage the transition
of 2020 graduating students into
the workforce or further study. This
is especially critical for accredited
university programs (e.g. engineering,
medicine, exercise science,
psychology, podiatry, teaching,
etc.) and also apprenticeships
and traineeships. There are
inconsistencies and instances
of inflexibility across accrediting
bodies’ response to this issue. If
there is delay in achieving practice/
placement hours, some students
may require significant revision of
preparatory units. Some students
may have to wait so long to achieve
those hours that they risk dropping
out. This could leave Australia short
of the very specialists and skilled
tradespeople needed to rebuild
post COVID-19. Australia requires a
coordinated, national response (or
state-based response if appropriate)
to graduating students from relevant
programs agreed by the accrediting
bodies in a given profession. Similar
considerations will be needed for final
year apprentices and trainees.
If there is delay in achieving practice/placement hours, some
students may require significant revision of preparatory units.

Key finding
Australia’s response needs to
balance consideration of the
priority of domestic students, with
the important benefits that come
from a strong, vibrant international
education sector.
Recommendation
Balanced with critical health and
epidemiological considerations,
there is a need for early decision-
making about when and how
international students return to
Australia for on-campus learning.
Whilst the recovery focus is and
should be on domestic students,
international education is a key
export for Australia and must be
safeguarded. Australian university
degrees are highly regarded around
the world and Australian tertiary
education is thus a highly attractive
export opportunity (Universities
Australia, 2018). If the shift to
remote, online learning persists
there may be a decreased incentive
for international students to choose
Australian educational institutions,
rather than other international
competitors, ceasing to occupy the
third position among the favourite
countries to study abroad (UNESCO-
UIS, 2017). That scenario would
threaten the viability of the Australian
tertiary education sector; in the
case of universities, one-fourth of
total university revenue comes from
overseas student fees (Universities
Australia, 2019). Alongside critical
health and epidemiological
considerations, there is a need for
early decision-making about when
and how international students return
to Australia for on-campus learning.
If the shift to remote, online
learning persists there may
be a decreased incentive for
international students to choose
Australian educational institutions,
rather than other international
competitors …

Schools
Key finding
Online and remote learning remain
useful temporary measures, but
place significant burdens on
students, families and educators.
Continued use of remote learning
for some or all students, as
opposed to school-based in-class
teaching, may deepen existing
inequalities in educational
attainment and engagement.
There is growing concern about
the ‘digital divide’ in education, and
the corresponding likelihood that
online learning will lead to deepening
existent inequalities among students
(Karp & McGowan, 2020). There
are considerable gaps in terms of
the proportion of internet access at
home between areas (88.3% access
in greater capital cities versus 77.1%
in remote or very remote areas)
and by incomes (88.9% access in
the highest quintile versus 67.4%
in the lowest quintile) (ABS, 2018).
Students in early childhood settings,
including prep/kindergarten and Years
one to three also face additional
challenges engaging in a purely online
environment without significant help
and face-to-face support, as do young
people with developmental delay,
such as ADHD or autism (Tanner et
al., 2010). Australian teachers may
not have sufficient time, resources or
expertise to adequately and promptly
shift teaching into online modes
(Reimers & Schleicher, 2020). Failure
to ensure learning continuity can lead
to learning gaps that adversely impact
in-school, post-school transition
outcomes, mental health, and post-
education employment (Cutler &
Lleras-Muney, 2014).
Key finding
Schools face several major
challenges in the return to full
operations in terms of addressing
student well-being, mental
health concerns, as well as other
operational issues.
Pandemic conditions, physical
distancing and remote learning may
exacerbate youth wellbeing issues,
in a context where evidence shows

that one in four students already
suffer from mental health issues
(Mission Australia, 2017). For some
the current crisis comes after the
devastating bushfire season along
with other extreme weather events
(floods and cyclones), traumatic
disruptions which may lead to
increased family and sexual violence
and mental health issues which
all impact life at school (Cahill,
2020). Students’ elderly family
members may have passed away
or remain very sick. Reduced social
mixing with friends and peers over
extended periods will itself have
negative effects (Collington &
McLaws, 2020; Brooks et al 2020).
Schools, universities, and colleges
are uniquely placed to provide a
safe and supportive space and to
help emotional and social recovery
post emergencies (Cahill 2020),
but this will be reliant on sufficient
resources, training and support.
This confluence of significantly
disruptive circumstances highlights
the need to provide ongoing social
and emotional interventions as part
of a wide-ranging school-based
response to young peoples’ wellbeing
(Recommendation 2).
Recommendation
Any resumption of school
operations should be contingent
upon physical distancing
measures appropriate to each
school context. A staged return
of school operations should
consider the social, emotional,
developmental and academic
needs of different groups.
Limited evidence exists regarding the
use of social distancing measures
within schools in response to
communicable disease, beyond the
strategy of closure. However, a recent
review (Uscher-Pines et al, 2018)
provides a good account of the types
of practices which schools could
consider as they resume substantial
face-to-face operations:
yy Cancellation of all non-essential
and high-mixing activities (e.g.
field trips, camps, assemblies,
performances)
yy Students remain in constant class
groupings (where possible) and
remain in the same classroom,
while teachers move between
rooms where necessary.

yy Well-defined walking paths within
school buildings.
yy Separating individual desks within
classrooms to the maximum
amount possible.
yy Grade or class dismissal instead
of full school dismissal in case of
registered infection.
yy Staggered start/end to the school
day.
yy Staggered break times for different
student groups; allocating groups
of students to classrooms for
break times.
yy Enhanced cleaning and disinfection
of school buildings.
Hand-hygiene practices could be
integrated more intensively into school
routines, for example using hand
sanitizer when entering and leaving
classrooms. Close and sustained
contact of students on public
transport services to/from school,
university, etc. potentially poses a
significant issue to be addressed.
Three groups may deserve special
consideration in the return to face-
to-face schooling. Young people and
older staff with pre-existing medical
conditions, who face the possibility
of more severe COVID-19 disease if
infected (Sinha et al, 2020; Centers
for Disease Control and Preventions,
2020), may not elect to return to
school campuses, and will require
continuing remote and online support.
Final year secondary students
face a high-stakes period of their
education which has been thrown
into significant uncertainty with the
disruption to schooling (Roberts,
2020). Students in the early primary
school years have additional needs
regarding socialisation, emotional
and academic support in comparison
to older students, and while at home
have a greater impact on the working
capacity of parents. These student
groups may be prioritised if a staged
return to face-to-face schooling is
instituted.
Final year secondary students
face a high-stakes period of their
education which has been thrown
into significant uncertainty with
the disruption to schooling.

Recommendation
To support academic, mental
health, and school to post-
school transitions, government
provides schools with adequate
funding, resources, and
coordination support to facilitate
adaptive responses to current
circumstances and emergent
contingencies.
To address the academic, mental
health and personal wellbeing issues
identified under Key Findings, school
systems may need to coordinate a
range of additional resources and
training. This includes funding for
school-psychologists, but also up-
skilling of staff in areas such as
trauma-informed education (Brunzell
et al, 2016). Teachers will need
time and professional development
support to identify and address
learning gaps, identify mental health
issues among students and to
deal with them both from a referral
perspective and with targeted in-class
support. Staff also will need to receive
mental health and wellbeing support
(Beltman et al 2016) as workloads will
be highly demanding and variable. The
development of national or state-based
taskforce(s) integrating key school
stakeholders could assist in effectively
managing the complexities of
resuming school operations (Reimers
& Schleicher, 2020), and maintain
adaptive preparedness in regards to
a potential second wave of COVID-19
infections (Wood & Geard, 2020).
Children require special consideration
with respect to the current crisis and
its management. There is strong
evidence exposure to adversity can
be encoded in the developing child
and be expressed as a range of
physical and mental health throughout
their lifetime and subsequent
generations (Shonkoff et al., 2012).
There is strong evidence exposure
to adversity can be encoded in the
developing child and be expressed
as a range of physical and mental
health throughout their lifetime and
subsequent generations.

The social changes caused by the
COVID19 crisis and associated social
distancing measures are and will
be accompanied by an increased
likelihood of such exposure for
Australia’s children. This exposure
is likely to be manifest as increased
mental, physical and social health
costs for this generation. Ensuring the
health of children during this crisis
by minimising exposure to adversity
should be a priority investment in
Australia’s future and a preventative
measure against future burden.
Positive parenting is the clean water
of child mental health and support
for parents is potentially the best,
and most evidence-based method for
maximising children’s health through
this crisis (Boparai et al., 2018; Rae &
Zimmer-Gembeck, 2007).
Australia leads the world in the
development and dissemination
of parent support strategies that
empower parents to provide a positive
child caregiving environment. These
programs improve parent mental
health, reduce parent-child conflict,
and improve child mental health over
the course of several parent support
sessions (Rae & Zimmer-Gimbeek,
2007; Sanders et al., 2017).
Further, recent evidence shows that
these treatments are equally effective
when delivered online as either
therapist assisted programs (Dadds
et al., 2019) or self-directed programs
(Piotrowska et al., in press). Thus,
a major initiative should be a public
campaign to steer parents toward
these programs during this phase.
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Mental Health
and Wellbeing
Key question: What are the expected impacts
and needed interventions for maintaining societal
well-being and individual mental health through
this process?
8
Recommendations
and Key Findings
yy Key Finding: The universal nature
of the COVID-19 pandemic has
implications for whole of society
wellbeing.
yy Key Finding: People with
psychological vulnerabilities and
pre-existing mental illness are
at higher risk of experiencing
worsening mental health.
yy Key Finding: COVID-19 has
placed unprecedented demand on
Australia›s mental health system
and its capacity to respond to
that demand, which will continue
throughout the recovery phase.
yy Recommendation: Coordinated
and sustained public health
messaging on the risks associated
with COVID-19 and actions that can
be taken in response to maintain
mental health and wellbeing.
yy Recommendation: Rapid and
stepped scaling of secure evidence-
based eHealth and Telehealth mental
health interventions for people who
require treatment and support in
addition to strengthened provision
of community-based support.
yy Recommendation: Strengthen
provision of community-based
support to maintain individual
health and societal wellbeing.
yy Recommendation: Increased
capacity to ensure timely
assessment and clear care pathways
to effective treatment and support
is essential for people with mental
illness and those at risk of suicide.
Current Context
The measures being implemented
to manage the threat of COVID-19
will have broad short and long-term
effects across the whole population,
beyond the fear of contracting and
spreading the virus. These include:

yy As individuals and families retreat to
their homes, feelings of confusion,
anxiety, stress and loneliness can
arise (Brooks et al 2020).
yy Social isolation can negatively
affect a person’s social, emotional
and physical health (Relationships
Australia 2018; Holt-Lundstad et al.,
2015).
yy Economic insecurities and financial
hardship cause stress and increase
the risk of conflict and violence,
particularly to women and children
(Peterman et al., 2020).
yy Increased risk of self-harm and
suicide may result from the
combination of home confinement
and increased economic and
mental stressors (Gunnell et al.,
in press).
yy Disruption to ability to earn and
work will lead to loss in sense of
purpose and identity for many
(Harms et al., 2015).
yy Grief and bereavement will
be experienced beyond the
pandemic from loss of lives,
from losing, autonomy and sense
of purpose, and from being
socially disconnected. The grief
process ranges from anticipatory
grief, complicated grief to
disenfranchised grief (Wallace
et al., 2020).
yy Early reports of increased suicides
associated with COVID-19 are
concerning (Montemurro, 2020).
Most importantly, these various
factors interact and intersect
to produce and reinforce the
consequences from the pandemic,
requiring a comprehensive and
holistic approach to managing
the road to recovery.
Economic insecurities and
financial hardship cause stress
and increase the risk of conflict
and violence, particularly to
women and children.

Chapter 8: Mental Health and Wellbeing
People with previous or existing mental
health problems are at particular risk:
yy A higher likelihood of suicidal
thoughts and self-harm from health,
social and economic consequences
(Reger et al., 2020);
yy People with mental illness are
also at increased risk of physical
comorbidities (Copeland et al.,
2007; Seminog & Goldacre, 2013;
Firth et al., 2019), which in turn
places them at high risk of negative
health outcomes from COVID-19;
yy Physical distancing strategies may
increase loneliness and exacerbate
or trigger the onset of mental health
problems;
yy People with mental illness
experience barriers in accessing
health services due to stigma
and discrimination in healthcare
settings (Yao et al., 2020), which
can be exacerbated with COVID-19.
The Australian mental health system
was struggling with demand before
the COVID-19 crisis and has limited
capacity to cope in the face of
escalation of demand. Mobilising and
redeploying the health workforce to
test, treat and care for individuals with
COVID-19 reduces resources available
to manage individuals with other health
conditions. Reforms are required to
ensure the mental health system can
cope with the increased demand.
Tele- and digital mental health service
provision provides some response
capacity (Wind et al., 2020) with
the unique benefits of accessibility,
flexibility and scalability. Critically,
there is evidence supporting the
utility of self-guided internet-based
interventions (Karyotaki et al., 2018),
telephone counselling, (Leach et
al., 2006), internet-based cognitive
behavioural therapy (Titov et al., 2018),
and psychological therapy delivered
via video conferencing software for the
treatment of mental health problems
such as depression, anxiety, PTSD,
insomnia and substance misuse
(Bashshur et al., 2016; Totten et
al., 2016; Zhou et al., 2020). These
conditions are likely to arise from
Critically, there is evidence
supporting the utility of self-guided
internet-based interventions …

and be exacerbated by COVID-19.
Examples of these programs have
been shown to be effective in Australia
and are scalable (Titov et al., 2019;
Rice et al 2018; D’Alfonso et al. 2017;
Hickie et al.; 2019). In addition, other
low intensity services such as the
Improving Access to Psychological
Therapies (IAPT) program that have
been shown to be successful in
Australia and could also be expanded,
as demonstrated in the UK (Cromarty
et al., 2016; Clark, 2018).
Child Mental Health
The key factor in child mental health
is parenting. Australia leads the world
in parenting interventions for child
mental health and they are available
in e-delivery form. Currently hundreds
of thousands of parents are isolated
at home caring for children many
of whom have severe behaviour,
emotional and developmental
disorders. Rates of conflict and abuse
are at risk of escalating. Rolling out
these interventions, if parents will be
isolated at home with their children,
may be a first-line evidence-based
response.
Evidence and
Analysis to Support
Recommendations
A stepped care model of service
delivery is recommended which is
consistent with the directions in
the Fifth National Mental Health
and Suicide Prevention Plan
(Commonwealth of Australia, 2017).
This will ensure interventions are
provided at the right time and level
of intensity to meet the needs of the
target population or the individual.
Recommendation
Coordinated and sustained
public health messaging on the
risks associated with COVID-19
and actions that can be taken
in response to maintain mental
health and wellbeing.
All communication should be
in simple and clear language,
such that it is accessible to all
Australians …

Clear and concise public
communication across a range of
media platforms likely to be accessed
by different demographics is essential
to foster preparedness for facing the
problem; increase knowledge through
education and provide outreach
for those most affected. The likely
impacts of COVID-19 (stress, grief
and loss, risk of violence) should be
articulated and normalised. Public
communication should explain
symptoms that indicate a need for
additional support; and provide clear
guidance on where support can be
sourced. All communication should
be in simple and clear language, such
that it is accessible to all Australians,
including those with low levels of
health literacy and from culturally and
linguistically diverse backgrounds.
Recommendation
Rapid and stepped scaling of
secure evidence-based eHealth
and Telehealth mental health
interventions for people who
require treatment and support in
addition to strengthened provision
of community-based support.
Significant national investment and
well-designed, accessible and flexible
national service infrastructure will
be required. Due consideration must
also be given to quality standards for
adjunctive digital mental health tools
(e.g., apps) and personalised digital
literacy for culturally and linguistically
diverse populations.
Recommendation
Strengthen provision of
community-based support to
maintain individual health and
societal wellbeing.
Individuals should be better
assisted to maintain their health and
wellbeing, including assisting in self-
management of chronic physical and
mental health conditions, as well
Public communication should
explain symptoms that indicate a
need for additional support; and
provide clear guidance on where
support can be sourced.

as a broader whole of population
support aimed at maintaining healthy
living. Strategies include healthy diet,
exercising, meditation, and engaging
in daily activity. Interventions for
delivering these strategies with allied
health professionals can be accessed
to help to maintain mental health.
Active community involvement is
helpful for both individual mental
health and community wellbeing.
Recommendation
Coordinated and sustained
public health messaging on the
risks associated with COVID-19
and actions that can be taken
in response to maintain mental
health and wellbeing.
A multi-faceted approach is
essential. Face-to-face assessment
and treatment by specialist mental
health clinicians, at times including
hospitalisation, cannot be effectively
provided via the phone or internet.
Individuals with mental illness,
particularly those with suicidal
thoughts or behaviours require
clear care pathways. Public health
messaging needs to focus on risk
factors for self-harm. These include
campaigns about safe and responsible
drinking, increased risk of violence to
women and children and the importance
of checking in on friends, neighbours
and work colleagues (Gunnell et al., in
press). Maintaining and expanding the
paid (e.g. crisis helplines, safe houses,
shelters) and volunteer workforce to
provide services to support individuals
is urgently needed during this transition
from responding to recovering
from COVID-19. In addition, flexible
work options and mobilising other
support services to supplement and
complement the existing workforce
will be necessary.
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The Care of Indigenous
Australians
Current Context
The disproportionate impact of pandemics on
Indigenous populations worldwide has been well
documented. In responding to the global COVID-19
pandemic, Australian Indigenous organisations
have shown exemplary leadership and innovation in
their efforts towards preparedness. Urgent action is
required to ensure Australia’s indigenous community
is protected from COVID-19, now and especially in
the recovery phase as the nation ‘reopens’. Plus, the
inevitable recession will aggravate an already critical
situation for many Indigenous people.
9
A failure to act decisively will have
devastating consequences that not
only compound existing traumas and
disadvantage, but will also result in
many needless Indigenous deaths
and suffering on a catastrophic
scale. The COVID-19 response must
address four issues for Indigenous
people: housing, workforce, data and
organisational support.
During the COVID -19 pandemic,
enormous efforts have been put in
place to mitigate risks of COVID-19
for Aboriginal and Torres Strait
Islander Communities. This has
resulted in significant outcomes
including at the time of writing
just under 50 cases of COVID-19,
representing 0.7% of all Australian
cases. Just over half of these were
acquired overseas and the remaining
identified as local acquisition. This is
a significant outcome thus far.
A key attribute of the COVID-19
response has been the banding
together of Aboriginal leadership
across all sectors (health, education
land councils together with
government agencies.).
This health response is also a clear
demonstration of self-determination.
The National Aboriginal Community

Controlled Health Organisation
(NACCHO), their State and Territory
Peak Organisations as well as
member services across the country
have participated in a national
Advisory Group that reports directly
to the Chief Medical Officer. The
Advisory Group is Co-Chaired
by NACCHO with the Australian
Government’s Department of
Health. The group’s outcomes have
been significant, taking leads in
developing a National Management
Plan, clinical guidelines, and specific
initiatives to mitigate risk and prepare
communities for COVID-19.
Together these actions which were
enacted early in the pandemic
phase arising from Aboriginal and
Torres Strait Islander Organisations,
communities and individuals is
an exemplary example of self-
determination in practice in
contemporary Australia. Recognising
that there is some time to go before
the COVID-19 pandemic is over, we
make the following recommendations
regarding the road to recovery in
respect to Aboriginal and Torres Strait
Islander peoples.
All sections contained within this
report concern Aboriginal and
Torres Strait Islander peoples and it
is critically important to work with
Indigenous organisations, Elders,
communities, and public health
sectors to appropriately implement
the proposed recommendations
outlined throughout the report.
Recommendations
and Key Findings
It is recommended that the
Government addresses four key
issues to design the COVID-19
recovery roadmap for Aboriginal
and Torres Strait Islander people
and communities.
yy The right to self-determination
& coordination
yy Housing Supply
yy COVID-19 Public Health and
Clinical Responses should be
maintained
yy Aboriginal and Torres Strait
Islander Health Workforce Review

Chapter 9: The Care of Indigenous Australians
Recommendation
Self-determination & Coordination
The creation of the Indigenous
COVID-19 planning force and
taskforces in all jurisdictions led by
Aboriginal Controlled Health Services
to coordinate and implement effective
localised responses to the pandemic
has been a success. We recommend
the continued financial and logistical
support of Indigenous COVID-19
planning force and taskforces in all
jurisdictions for the remainder of the
pandemic. This will enable a single
point of engagement with health
services, police, education, and family
and community services.
This recommendation is based on
the right of self-determination to keep
our communities safe, recognition
of local cultural practices, and
the need for efficient pandemic
responses. Aboriginal and Islander
health services are most familiar
with the social determinants of
our health in local areas, relevant
cultural considerations, and are the
most well-equipped to advise on the
correct allocation of funding. The
effective allocation of resources,
in light of an expected shortfall
between emergency funding and
community needs, is best undertaken
in partnership with Indigenous
health organisations. Supporting the
expansion of jurisdictional Indigenous
COVID-19 advisory groups to oversee
this process during recovery would
avoid navigating complex Federal and
State responsibilities.
Recommendation
Housing Supply
The ability of families to self-isolate
and quarantine effectively has been a
significant issue with COVID-19. Many
communities are limited by critical
housing shortages in urban, regional
and remote areas. Lack of adequate
housing has a direct impact on the
ability of local health services and
communities to control virus spread,
as well as exacerbating interrelated
issues including child and family
safety, pre-existing overcrowding
and ageing infrastructure. During
COVID-19 this has also been
exacerbated by many people returning

to their traditional homelands. Many
communities remain extremely
vulnerable to COVID-19 without any
ability to isolate or to quarantine
suspected and/ or confirmed cases.
An immediate supply of alternative
housing is needed in local
communities to alleviate the pressure
on over-crowded households and
enable effective disease suppression.
Housing is a long-standing issue.
Some communities have been able to
work with government and business
such as Minerals and Exploration
companies to secure emergency and
temporary housing, but for many
this remains a significant risk for
widespread disease transmission
and disastrous outbreaks. In the
medium-term an urgent supply of
permanent housing infrastructure
and sustainable supply of utilities
is required to ensure that future
outbreaks are containable. To this
end, community infrastructure
building projects should be awarded
to Indigenous enterprises that provide
jobs and skills training to Indigenous
workers perhaps as alternatives
to replacing schemes such as
Community Development Programs.
Recommendation
COVID-19 Public Health and
Clinical Responses should be
maintained
It is recommended that the existing
Health Advisory Group be maintained
until Australia has fully recovered
from COVID-19.
Availability of reports of COVID-19
cases and outcomes: Particular
efforts will be required to ensure
adequate monitoring of COVID-19
cases and detailed epidemiology
reports are reported regularly
and publicly. Accurate data which
includes notifications, testing
numbers and rates, location of
notifications at a local area level,
… community infrastructure building
projects should be awarded
to Indigenous enterprises that
provide jobs and skills training to
Indigenous workers …

rates and types of complications,
rates of hospitalisation, including ICU
admissions, number of deaths, as well
as the economic impacts, differential
care burden and the incidence of
family violence including child abuse
notifications in all jurisdictions is
required.
Public health messaging will need to
be maintained throughout recovery.
Timely, accurate and accessible
information must be communicated
regularly to the Indigenous public to
develop strong health literacy.
Research into the effects of
COVID-19 on community social
and emotional wellbeing and
mental health will be required to
evaluate how Aboriginal and Torres
Strait Islander peoples have fared
through COVID-19 that will provide
important learnings for future
pandemics and crises. Such research
must be Indigenous-led and based
on scholarly and cultural ethical
practices. To conduct this research
and enable rapid decision-making,
issues of data quality and sharing
must be addressed quickly.
Recommendation
Aboriginal and Torres Strait
Islander Health Workforce Review
The COVID-19 pandemic has
exacerbated vulnerabilities in local
health workforces who are dependent
on staff from interstate and even
New Zealand. Long-term initiatives
to build local capacity are needed.
This recommendation is made
because significant issues have
arisen for Aboriginal and Torres Strait
Islander communities throughout
the pandemic thus far relating to
workforce. This issues have arisen
for several reasons, such as the need
to quarantine locum staff before they
can provide clinical services; and the
restrictions on Aboriginal and Torres
Strait Islander people aged 50 and
over with a chronic disease being
isolated. We strongly recommend that
NACCHO, as a lead agency, instigate
a Health Workforce reform process in
partnership with Commonwealth and
State and Territory governments.
This will need to encompass the
following:

yy How to best increase and retain
Aboriginal Health Practitioners in all
areas of Australia to help reduce the
reliance on overseas and interstate
locum staff.
yy How to scale up Aboriginal Public
Health and Infectious Disease
expertise so that each Federal and
State Health Department has a
senior Public Health Group.
yy The need for surge workforces
should outbreaks occur in
communities.
In addition to the four primary
recommendations, there are broader
considerations that impact the
roadmap to recovery, including:
yy Food security: Continue efforts
initiated during COVID-19 to guarantee
grocery and medication supply,
across communities and water for
those communities still impacted by
2019–2020 natural disasters.
yy JobSeeker: Maintaining the
JobSeeker allowance at the present
emergency levels to help reduce
poverty and to stimulate economic
activity throughout Australia.
yy Economic recovery: Recognition
that many Indigenous organisations
including Aboriginal Community
Controlled Health Organisations
(ACCHOs) will require specific
economic recovery and income
support programs to help in
the recovery from COVID-19.
Expansion of existing commitments
for Indigenous businesses
should be considered. This will
assist in revitalising economies
in Indigenous communities,
supporting local businesses and
improve the health and wellbeing
of individuals both now and in the
recovery phases.
This issues have arisen for several
reasons, such as the need to
quarantine locum staff before they
can provide clinical services; and
the restrictions on Aboriginal and
Torres Strait Islander people aged
50 and over with a chronic disease
being isolated.

General Background
At present, approximately 800,000
people, or 3% of Australia’s population
identify as Indigenous, and most
Indigenous people (approximately
80%) live in cities and non-remote
areas (Australian Bureau of Statistics,
2018). The median age of Indigenous
people is significantly lower than
non-Indigenous Australians (23
and 38, respectively), with higher
mortality rates making early middle
age and older Indigenous people
and Indigenous Elders especially
vulnerable (ABS 2018).
The discrepancy between Indigenous
and non-Indigenous populations
is particularly pronounced in
Australia(United Nations, 2009). It
is well established that Indigenous
Australians have higher rates of
health problems, such as high
blood pressure, respiratory and
circulatory disease, obesity and
diabetes(Australian Institute of
Health and Welfare, 2018; Australian
Bureau of Statistics, 2019), as well as
higher rates of psychological distress
compared to other Australians
(McNamara et al., 2018).
Due to the relative social and economic
disadvantage, Indigenous peoples
also experience significant barriers to
accessing health care services (Peiris
et al., 2018). Preventable hospital
admissions and deaths (conditions
which should have been prevented
by primary healthcare services) are
three times as high in Aboriginal and
Torres Strait Islander people, due, in
part, to failures in implementation of
the “close the gap” policies (Australian
Government, 2013). The health gap
is the result of historical long-term
systemic neglect and recurring social
determinants of health.
Neither do remote Indigenous
communities have a sufficient local
workforce. Initiatives to build local
capacity are needed.
Evidence and Analysis
to support Key Findings
yy In addressing the global challenges
posed by pandemics it needs to
be acknowledged that Indigenous
populations are potentially highly
vulnerable.
»» The disproportionate impact
of pandemics on Indigenous

populations worldwide (La Ruche
et al., 2009) and in Australia
(Trauer et al., 2011; Flint et
al., 2010; Rudge and Massey,
2010), was well documented
during the 2009 H1N1 influenza
and prior (Kelm, 1999). During
the 2009 Influenza A H1N1,
Indigenous communities in
Australia were particularly
affected with higher levels of
hospitalisation and fatality
from reduced and delayed
access to care, cultural health
approach differences, as well as
healthcare-seeking behaviour.
The poorer socioeconomic
status of Indigenous peoples
and the relational way of
living and being means risk of
exposure and transmission may
have devastating effects.
»» Current evidence from the US
shows COVID-19 is more prevalent
and fatal in African American1
and Indigenous Americans2,3
.
»» The rapid spread of COVID-19 on
cruise ships has demonstrated
that crowded living quarters
facilitate the transmission of
respiratory illness and create a
high-risk environment. These
case studies demonstrate
that COVID-19 in over-
crowded Australian Indigenous
communities is likely to have
dire consequences4,5
.
»» There is a real concern that
COVID-19 will compound
existing health and mental
health issues in Indigenous
communities due to the
restrictions on community
mobility and interaction (United
Nations, 2020); in addition to the
higher risk of virus fatality in the
presence of underlying health
conditions. Youth vulnerability
is a particular concern. Ensuring
Indigenous children and youth
have continuing access to
quality education through the
1 https://www.bbc.co.uk/news/world-us-canada-52194018
2 https://www.kob.com/albuquerque-news/statewide-data-reveals-native-americans-are-disproportionately-
impacted-by-covid-19-/5701649/
3 https://edition.cnn.com/2020/04/07/opinions/native-american-nations-risk-from-covid-19-sepkowitz/index.html
4 https://www.health.com/condition/infectious-diseases/coronavirus-cruise-ship-sickness
5 https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e3.htm

acute and recovery phase of
COVID-19 is essential. Not all
Indigenous households have
ready access to technology or
reliable internet and parents will
need to be supported.
»» Indigenous children and youth
who are particularly vulnerable
are those in out of home care
and in juvenile justice detention.
At 30 June 2019, about 18,000
Indigenous children were in
out-of-home care—a rate of 54
per 1,000 Indigenous children,
which was nearly 11 times
the rate for non-Indigenous
children (Australian Institute
of Health and Welfare, 2020a).
Additionally, on an average night
in June 2019, 53% of juveniles
in detention were Indigenous
(Australian Institute of Health
and Welfare, 2020b).
»» The interrelationship between
child abuse and neglect with
domestic and family violence
has long been established
(Commission for Children and
Young People, 2016). With
concerns already raised about
the increase in domestic and
family violence during the acute
phase of COVID-19 it is likely that
mandatory reports of children’s
exposure to violence by police
will increase. The need for clear
and consistent messaging
about what this means and
what supports are available is
essential, especially if children
are being removed including
commitment to the Aboriginal
Child Placement Principle and
keeping children on country.
»» Children and young people
are the subject of custody
orders with shared parenting
arrangements may also
be vulnerable to changed
circumstances that may put
them in unsafe situations.
yy The core requirement for both the
acute phase and the recovery is
sound evidence-based policy. That
policy needs to be developed by
and led by Indigenous peoples,
based on Indigenous values,
funded on a needs basis, with clear
accountabilities and systematic
evaluation.

yy The level of need for health care
in Indigenous Australians is
approximately 2.3 times higher
than other Australians. In response
to COVID-19, there is a pressing
need for the allocation of needs-
based funding.
yy Under the international norm
of Indigenous peoples right to
self-determination, the Food and
Agriculture Organization of the
United Nations (FAO) encourages
Governments to include Indigenous
peoples’ representatives, leaders
and traditional authorities in
emergency and health response
committees or any entity dedicated
to the COVID 19 pandemic, both
during the outbreak as well as in
the aftermath/recovery.6
»» Community controlled healthcare
has shown commendable
innovation in the COVID-19 crisis.
The response from Indigenous
communities7,8,9
and organisations
(e.g., NAACHO (Australian
Department of Health, 2020),
Kimberley Aboriginal Medical
Services (KAMS)10
, CAAMA11
) and
affiliate member services has
been swift and effective (planning,
advocating, managing spread of
virus, creating resources, health
promotion), yet they still lack
sufficient funding.
»» Many Indigenous communities
have restricted entry onto their
lands and assumed responsibility
to ensure health information is
reaching their people.
6 http://www.fao.org/indigenous-peoples/news-article/en/c/1268353/
7 https://www.smh.com.au/national/nsw/we-treat-them-like-gold-aboriginal-community-rallies-around-elders-
20200327-p54ekl.html?fbclid=IwAR3G7GtKb54cA0le917a-z5TYQQjeX8FbhxzYA6u1VB8rf4YamI2dSo5W0M
8 https://www.abc.net.au/news/2020-04-02/indigenous-dot-paintings-coronavirus-health-message-uluru/121
10988?fbclid=IwAR17fg73d2rmCd8_uvBE3mSoGGPo2B1bSCPu635TSe2QEW-O4Jyg5lx6OMM
9 https://www.abc.net.au/news/2020-03-28/battle-to-keep-coronavirus-out-of-remote-communities-
translation/12084886
10 http://kams.org.au/covid19/
11 https://www.gayaadhuwi.org.au/coronavirus/

yy Indigenous leadership, worldviews
and values should be at the
forefront on the path to recovery.
»» There is a need to ensure
Indigenous health workers are
supported especially in areas
where there are worker shortages
and risk of infection could result
in no care being available.
»» Aboriginal and Torres Strait
islander people in more remote
areas must make final decisions
about their readiness to, and the
conditions under which, they
will open their communities to
non-essential workers and other
visitors, such as FIFO workers
and tourists, as well as when
their schools should re-open.
The health in these communities
is poor, their elders in particular
are highly vulnerable, and they
are entitled to exercise their right
to self-determination in these
matters of life and death12
.
yy Immediate health and mental health
concerns need to be balanced with
longer term cultural, social and
emotional wellbeing of individuals
and communities.
»» A whole-of-community approach
to healing is needed, as well as
culturally appropriate services for
grief and community wellbeing.
»» Valuing the Indigenous
knowledges of Australia’s
First Peoples and especially
the knowledge that our Elders
possess. Losing a number of
Elders would be devastating
to the ongoing practice and
transmission of cultural
practices. It would be a loss to
the community and Australia.
12 https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html
Valuing the Indigenous
knowledges of Australia’s First
Peoples and especially the
knowledge that our Elders possess.

References
Estimates of Aboriginal and Torres
Strait Islander Australians, June 2016,
Cat no: 3238.0.55.011. https://www.
abs.gov.au/ausstats/abs@.nsf/
mf/3238.0.55.001
National Aboriginal and Torres Strait
Islander Health Survey, 2018-19, Cat
no: 4715.0. https://www.abs.gov.au/
ausstats/abs@.nsf/mf/4715.0
Australian Government (2013).
National Aboriginal and Torres Strait
Islander Health Plan 2013-2023,
https://www1.health.gov.au/internet/
main/publishing.nsf/content/
B92E980680486C3BCA257
BF0001BAF01/$File/health-plan.pdf
Australian Government (2020).
Australian Health Sector Emergency
Response Plan for Novel Coronavirus
(COVID-19), Department of Health,
https://nacchocommunique.
files.wordpress.com/2020/03/
management-plan-for-aboriginal-and-
torres-strait-islander-populations.pdf
Welfare (2018). Aboriginal and Torres
Strait Islander Health Performance
Framework (HPF) Report 2017, https://
www.aihw.gov.au/reports/indigenous-
australians/health-performance-
framework/contents/tier-1-health-
status-and-outcomes
Welfare (2020a). Child protection
Australia 2018-19. https://www.aihw.
gov.au/reports/child-protection/
child-protection-australia-2018-19/
contents/table-of-contents
Welfare (2020b). Youth detention
population in Australia 2019. https://
www.aihw.gov.au/reports/youth-
justice/youth-detention-population-
in-australia-2019/contents/table-of-
contents
Commission for Children and Young
People (2016). Always was, always
will be Koori children. https://ccyp.vic.
gov.au/assets/Publications-inquiries/
always-was-always-will-be-koori-
children-inquiry-report-oct16.pdf

Flint, S.M., Davis, J.S, Jiunn-Yih,
S., Oliver-Landry, E.P., Rogers,
B.A., Goldstein, A., Thomas, J.H.,
Parameswaran, U., Bigham, C.,
Freeman, K., Goldrick, P., and Tong,
S.Y.C. (2010). Disproportionate
impact of pandemic (H1N1) 2009
influenza on Indigenous people in
the Top End of Australia’s Northern
Territory, Medical Journal of Australia,
192 (10): 617-622. https://www.
mja.com.au/journal/2010/192/10/
disproportionate-impact-pandemic-
h1n1-2009-influenza-indigenous-
people-top-end
Kelm, M.E. (1999). British Columbia
First Nations and the influenza
pandemic of 1918-1919. BC Studies,
122, 23-47.
McNamara, Bridgette J., Banks,
Emily, Gubhaju, Lina, Joshy, Grace,
Williamson, Anna, Raphael, Barbara
and Eades, Sandra (2018). Factors
relating to high psychological distress
in Indigenous Australians and their
contribution to Indigenous-non-
Indigenous disparities. Australian
and New Zealand Journal of Public
Health, https://doi.org/10.1111/1753-
6405.12766
Peiris, David, Brown, Alex and Cass,
Alan (2018). Addressing inequities
in access to quality health care for
indigenous people. CMAJ, November
04, 179 (10) 985-986; DOI: https://doi.
org/10.1503/cmaj.081445
La Ruche, G., Tarantola, A., Barboza,
P., Valliant, L., Gueguen, J., Gastellu-
Etchegorry, M., epidemic intelligence
team at InVS (2009). The 2009
pandemic H1N1 influenza and
indigenous populations of the
Americas and the Pacific. Euro Surveil
Oct 22: 14(42), https://www.ncbi.nlm.
nih.gov/pubmed/19883543
Rudge, S., and Massey, P.D. (2010).
Responding to pandemic (H1N1) 2009
influenza in Aboriginal communities
in NSW through collaboration
between NSW Health and the
Aboriginal community-controlled
health sector, New South Wales
Public Health Bulletin 21(2) 26-29,
https://www.phrp.com.au/issues/
volume-21-issue-1-2/responding-
to-pandemic-h1n1-2009-influenza-
in-aboriginal-communities-in-nsw-
through-collaboration-between-nsw-
health-and-the-aboriginal-community-
-controlled-health-sector/

Trauer, J.M., Laurie, K.L., McDonnell,
J., Kelso, A., and Markey, P.G. (2011).
Differential effects of Pandemic
(H1N1) 2009 on Remote and
Indigenous Groups, Northern Territory,
Australia, 2009. Emerg Infec Disease,
Sept: 17(9): 1615-1623, https://
www.ncbi.nlm.nih.gov/pmc/articles/
PMC3322054/
United Nations (2009). State of
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socdev/unpfii/documents/SOWIP/en/
SOWIP_web.pdf
United Nations Declarati
United Nations Expert Mechanism
on the Rights of Indigenous Peoples
(EMRIP) 6 April 2020

Equity of Access
and Outcomes in
Health Support
What special considerations could be required
for the vulnerable in society during an exit and
recovery phase?
10
General Background
The impacts of COVID-19 are not
felt equally across the community.
The next steps of a recovery strategy
will be critical to improving equity in
outcomes. Special considerations
will be required for: women who are
pregnant and women at risk of family
violence; children and young people,
specifically those living in out-of-
home care; older adults and those
living in residential aged care; the
homeless; people with disabilities;
people living with a life threatening
illness(es); LGBTQI+ people; ethnic
minorities and refugees and asylum
seekers; and socioeconomically
disadvantaged groups. groups. It is
also the case that those who are at
the intersection of these attributes
often bear the greatest brunt.
There are key community groups
deserving of targeted policy support
as Australia works to manage
COVID-19 recovery. There follows
a number of recommendations on
how those groups can be supported,
each backed by evidence-based key
findings and subject specific research.
Recommendations
and Key Findings
yy Recommendation: Government
advances its policies against
family violence by recognising an
additional $180 million is needed to
fund the ‘Keep Women Safe in Their
Homes’ program which is designed
to address the scale of need. That
it develops tailored responses to
address the specific and diverse
needs of: women with disabilities,
The next steps of a recovery
strategy will be critical to
improving equity in outcomes.

indigenous women, and women
from culturally and linguistically
diverse (CALD) backgrounds who
are experiencing family violence.
yy Recommendation: That maternity
health services and postnatal care
should be virus free and safe for
women screened as high risk to
attend in person; to reduce their
stress. Women pregnant during
disasters such as a pandemic and
at risk of family violence require
extra support while women’s needs
before during and after giving
birth should not be de-prioritised
because of COVID-19 healthcare.
yy Recommendation: An infant, child
and youth reference committee20
to provide expert advice (i.e.
educational, mental health and
social aspects) be established
as children and young people
may require tailored support to
manage the stress of COVID-19.
Support for young people’s
pathways to employment through
government funded projects, such
as construction projects employing
young people as trainees is
another key recommendation as an
investment in Australia’s future.
yy Recommendation: Funding for the
evidence-informed “Home Stretch26
”
program to offer in-care and post-
care support to children in OOHC
until they are 21 to foster their
COVID-19 recovery process because
those are young people who are
forced to live out of home (OOHC).
It is also recommended that police
are conscious of the vulnerability of
those in OOHC.
yy Recommendation: Government
support community service
organisations and health services
to help older adults self-isolate by
providing access to in-home medical
care, medication, and regular
assessment of social isolation
risk.32
It is critical that online and
telephone strategies are available
to foster social connections with
family, friends and volunteers.33
Health security methods that
support safe visitation from select
primary visitors or informal carers
to older adults who will suffer undue
distress from social distancing
measures is a prime need.
yy Recommendation: For LGBTQI+
people, pharmaceutical companies
ensure the provision of gender
affirming hormone products and

Chapter 10: Equity of Access and Outcomes
in Health Support
PrEP, and clarification regarding
what products are available, what
PBS covers, and whether products
can still be shipped into Australia.
yy Recommendation: The continued
funding of services such as
Foodbank and Community Meals
programs, community outreach,
healthcare programs, and legal aid
to support refugee and migrant
groups is required.
yy Recommendation: Compassionate
policies for the homeless with
a continuation of funding of
Isolation and Recovery Facilities
to ensure they have a safe place
to self-isolate and quarantine and
that we ensure the homeless are
not targeted for breaching social
distancing regulations.
yy Recommendation: That there
be flexibility, sensitivity and
responsiveness to modifying,
managing and implementing NDIS
plans and other support for people
with disabilities.
yy Recommendation: Policies such
as JobKeeper and the increased
JobSeeker allowance are kept
in place to ensure that these
investments achieve their goals,
especially for those disadvantaged
by socio-economic issues.46,47,48,49
yy Recommendation: COVID-19
responses should not be at the
expense of, or result in a reduction
of, capacity to treat existing acute
care needs.
Key findings
yy Reports suggest that web
searches on domestic violence
are up by 75 %, and that family
violence perpetrators were using
COVID-19 restrictions as a new
way of exercising coercive control
over victims. Women in abusive
domestic violence circumstances
are at increased of harm.
yy For pregnant women enduring high
levels of stress (i.e. in a pandemic)
and at risk of family violence it
can be shown that their babies are
often born small for gestational age
due to restricted foetal growth and
additional stress.13,14
While pregnant
women are more susceptible
to COVID-19 than the general
population.15

yy The UN Convention on the Rights
of the Child, ratified by Australia,
stipulates that children have the
right to participate in decisions
that affect them.16
A total of
50,000 children and young people
of schooling age are known to
already be fully disengaged (i.e.,
not enrolled) in school,17
which may
increase with schools currently
disrupted and youth unemployment
has increased as young people
often work as casuals in hospitality
and retail.18,19
It is also known that
children often experience mental
health or learning issues following
severe adversity, such as disaster
and loss.20, 21, 22
yy Young people living in out of home
care, OOHC, experience higher rates
of adverse physical and mental health
outcomes and continue to experience
disadvantage in educational
achievements, employment, housing,
and health after care, compared to
other young people.23,24
yy For older Australians
superannuation is a key source of
their household income allowance.27
Social distancing is stressed during
COVID-19 but immediate and
urgent needs to support this must
include access to medical support,
affordable basic supplies and social
support in homes.28, 29
It is known
that social isolation increases older
adults’ risk of morbidity/mental
health concerns30, 31
and that some
aged care facilities have adopted
discretionary policies of removing
all visitor access.
yy For LGBTQI+: gender diverse
populations report high levels
of discrimination in mainstream
healthcare settings34
so may be
less likely to report COVID-19
symptoms, that they are likely to
experience mental illness, and
suicidal tendencies.35,36,37,38,39
Social distancing measures may
be additionally challenging for
those forced to isolate with family
members who don’t accept their
sexual or gender identities.38
A total of 50,000 children and
young people of schooling age
are known to already be fully
disengaged (i.e., not enrolled)
in school …

yy Those from asylum seeker and
migrant backgrounds faced
social distancing measures that
further isolated and compounded
their stressors.40,41
Also, many
from refugee and asylum seeker
backgrounds do not currently have
access to any form of financial
support, experience insecure
housing and have no access to
Medicare. COVID-19 information
may not always be accessible to
those people from non-English
speaking backgrounds and there
is also a concern that taking a
COVID-19 test may mean risk of
arrest or detention.
yy Australia’s homeless or those
without secure accommodation
and who cannot self-isolate
or quarantine are at great risk
of contracting COVID-19 while
homeless groups and individuals are
being fined by police for breaches
of social distancing regulations
and given ‘move on’ notices,
when homeless individuals often
congregate in groups for safety.
yy Eighteen per cent of Australians live
with physical or intellectual disability
and face high health vulnerability if
they became infected with COVID-19;
while they may have reduced their
support services within the home to
reduce exposure to infection.44
The
current inability to attend regular
support and health services outside
home may result in a short- term
increase in support needs during the
COVID-19 recovery phase.
yy Those with a socio-economic
disadvantage are often in casual
and insecure employment have
greater risk of unemployment and
that unemployment effects endure
over individuals’ careers and across
generations if no sufficient support
is offered to help.
yy People with life threating illnesses
face high risk of infection and
in Health Support
Also, many from refugee and
asylum seeker backgrounds do not
currently have access to any form
of financial support, experience
insecure housing and have no
access to Medicare.

compromised immune systems,
so are at greater risk of COVID-19
and that any neglect of existing
acute care needs would increase
mortality and morbidity risk beyond
COVID-19.
yy Women are at the “front line” in so
many ways. Affected by every group
in the above recommendations and
the key findings they also:
yy are more likely to work in front-
line care occupations (e.g., 80% of
all healthcare workers and 95.6%
of the childcare workforce7,8
),
increasing their risk to infection.9
yy more women than men live below
the poverty line, and receive
Centrelink are more likely than men
live to below the poverty line, and
receive Centrelink payments.9,10
yy have a casual employment
rate of 27%, without paid leave
entitlements.11
yy are affected by school closures that
mean women who are the primary
caregiver face a ‘double burden’ of
working in formal employment and
managing children’s schooling.12
References
1. Crenshaw, K. (1991). Mapping the
margins: intersectionality, identity
politics, and violence against
women of colour. Stanford Law
Review, 43(6), 1241–1299.
2. Davis, K. (2008). Intersectionality
as buzzword: a sociology of
science perspective on what
makes a feminist theory useful.
Feminist Theory, 9(1), 67–85.
3. Gaillard, J. C., Sanz, K., Balgos,
B. C., Dalisay, S. N. M., Gorman-
Murray, A., Smith, F., & Toelupe,
V. A. (2017). Beyond men and
women: a critical perspective on
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41(3), 429–447.
4. Jay, T., Barry, M., Thiagalingam, A.,
Redfern, J., McEwan, A., Rodgers,
A., & Chow, C. (2016). Design
considerations in development
of a mobile health intervention
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TEXTMEDS experience. JMIR
mHealth and uHealth, 4(4), e127.

5. https://www.thesmithfamily.com.
au/get-involved/partnerships/
corporate-social-responsibility/
our-current-partners/optus
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7. Haddad, A. (2020). COVID-19 is
not gender neutral. http://www.
broadagenda.com.au/home/
covid-19-is-not-gender-neutral/
8. Boniol, M., McIsaac, M., Xu, L.,
Wuliji, T., Diallo, K., Campbell.,
J. (2019). Gender Equity in the
Health Workforce: Analysis of 104
countries. Working Paper 1. World
Health Organization, Geneva.
9. Davies, S.E., & Bennett B. (2019).
A gendered human rights analysis
of Ebola and Zika: locating gender
in global health emergencies.
International Affairs, 92, 1041-
1060.
10. Australian Bureau of Statistics
(2019). Australian Labour Markets
and Related Payments. Canberra:
ABS.
(2018). Gender Indicators
Australia, Sept 2018. Canberra:
ABS.
12. Ruppaner et al. (2018)
13. Harville, E. W., Xiong, X. &
Buekens, P. (2010). Disasters and
perinatal health: a systematic
review. Obstetrical & Gynecological
Survey, 65(11), 713-720.
14. King, S., & Laplante, D. P. (2005).
The effects of prenatal maternal
stress on children’s cognitive
development: Project Ice Storm.
Stress, 8(1), 35-45.
15. Qiao, J. (2020). What are the risks
of COVID-19 infection in pregnant
women? The Lancet, 395(10226),
760-762.
16. UN Convention on the Rights of
the Child
17. Watterstein & O’Connell (2019)
18. Borland, J. (2020). The next
employment challenge from
coronavirus: how to help the
young. The Conversation, April 14,
2020.
19. Craig, L., Churchill, B., & Wong,
M. (2019). Youth, Recession, and
Downward Gender Convergence:
Young People’s Employment,
Education, and Homemaking in
in Health Support

Finland, Spain, Taiwan, and the
United States 2000–2013. Social
Politics: International Studies in
Gender, State & Society, 26(1),
59–86.
20. Emerging Minds & Australian Child
and Adolescent Trauma, Loss and
Grief Network. (2020). Submission
to the Royal Commission into
National Natural Disaster
Arrangements.
21. Gibbs, L., Nursey, J., Cook, J.,
Ireton, G., Alkemade, N., Roberts,
M., … & Forbes, D. (2019). Delayed
disaster impacts on academic
performance of primary school
children. Child development, 90(4),
1402-1412.
22. Spuij, M., Reitz, E., Prinzie,
P., Stikkelbroek, Y., de Roos,
C., & Boelen, P. A. (2012).
Distinctiveness of symptoms of
prolonged grief, depression, and
post-traumatic stress in bereaved
children and adolescents.
European child & adolescent
psychiatry, 21(12), 673-679.
(2013). Australian Health Survey:
2011–2012. Canberra: ABS.
24. Smales, M., Savaglio, M., Morris,
H., Bruce, L., Skouteris, H., & Green
(nee Cox), R. (2020). “Surviving
not thriving”: Experiences of
Health Among Young People with
a Lived Experience in Out-of-Home
Care. International Journal of
Adolescence and Youth. Accepted
April 20.
25. Baidawi, S. & Sheehan, R. (2019).
‘Cross-over kids’: Effective
responses to children and young
people in the youth justice and
statutory Child Protection systems.
Report to the Criminology
Research Advisory Council.
Canberra: Australian Institute of
Criminology.
26. http://thehomestretch.org.au
27. Australian Bureau of Statistics.
(2019). Household Income
and Wealth, Australia, 2017-18,
Cat No. 6523.0, Spotlight –
Superannuation and investments
as a main source of household
income. Canberra, ABS.
28. Armitage, R., & Nellums, L.
B. (2020). COVID-19 and the
consequences of isolating the
elderly. The Lancet. Public health.

29. National Seniors Australia.
(2019). Australian Seniors speak
about impacts of the COVID-19
pandemic. 3rd National Seniors
short report.
30. Santini, Z. I., Jose, P. E., Cornwell,
E. Y., Koyanagi, A., Nielsen, L.,
Hinrichsen, C., … & Koushede, V.
(2020). Social disconnectedness,
perceived isolation, and
symptoms of depression and
anxiety among older Americans
(NSHAP): a longitudinal mediation
analysis. The Lancet Public Health,
5(1), e62-e70.
31. Newman, M. G., & Zainal, N. H.
(2020). The value of maintaining
social connections for mental
health in older people. The Lancet
Public Health, 5(1), e12-e13.
32. https://blogs.bmj.com/
bmj/2020/04/09/the-effects-of-
isolation-on-the-physical-and-
mental-health-of-older-adults/
33. http://www.euro.who.int/en/
health-topics/health-emergencies/
coronavirus-covid-19/news/
news/2020/4/supporting-older-
people-during-the-covid-19-
pandemic-is-everyones-business
34. Riggs, Coleman and Due (2014)
35. Gower et al. (2018)
36. McDermott, E., Hughes, E.,
Rawlings, V. (2016). Queer Futures:
Understanding LGBT adolescents’
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seeking behaviours (Final Report),
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38. Katz-Wise, S. L., Rosario, M., &
Tsappis, M. (2016). Lesbian, gay,
bisexual, and transgender youth
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Clinics of North America, 63(6),
1011-1025.).
39. Thomas, J. (2020). LGB Youth,
in P Gerber (ed.), Worldwide
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and Bisexuals: History, Culture, and
Law, Praeger Press, California
40. Dowling, A., Enticott, J., Kunin,
M., & Russell, G. (2019). The
association of migration
experiences on the self-rated
health status among adult
humanitarian refugees to Australia:
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study. International journal for
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41. Hynie, M. (2018). The social
determinants of refugee mental
health in the post-migration
context: A critical review. The
Canadian Journal of Psychiatry,
63(5), 297-303.
42. system: http://www.cclj.unsw.edu.
au/article/open-letter-australian-
governments-covid-19-and-
criminal-justice-system
43. https://www.abc.net.au/
news/2020-03-25/coronavirus-
fears-asylum-seekers-plead-for-
release-detention/12084604
44. ABS (2018)
45. Manzoni & Mooi-Reci (2018)
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51. https://pwd.org.au/covid-19-plan/

Clarity of
Communication
The overall success of the recovery will depend upon
engaging widespread public support and participation
through partnership with civil society regardless of
which strategy is chosen.
11
If the Elimination Strategy is
pursued, it is important that the
public understands the additional
sacrifice needed, why it is worth it,
and what benefits they can expect
in return. It is also critical that the
public understand that even with
the Elimination Strategy, life will
not return to the ‘old normal’.
With the Controlled Adaptation
strategy, it is critical that the public
understand that in exchange for
an earlier relaxation, there will be
a need for ongoing adaptation.
Specific containment measures
may be carefully relaxed in several
phases to achieve a balance between
constraining the infection rate and
enabling economic activity. And if the
infections increase, the measures
may need to be reinstated.
Recommendations
and Key Findings
yy Recommendation: Communicate
the approach and associated
measures using clear, specific
and empathetic language.
yy Recommendation: Enrol individuals
who are perceived as credible and
trustworthy (e.g. healthcare workers
and population health scientists) to
convey key messages publicly.
yy Recommendation: Enhance the
cultural appropriateness and
thus impact of communication.
A number of community
reference groups for this should
be established that represent
… it is critical that the public
understand that in exchange for
an earlier relaxation, there will be a
need for ongoing adaptation.

yy Recommendation: Define and
implement a color-coded public
health alert system. A color-coded
public health alert system with
four levels (“Prepare”, “Reduce”,
“Restrict”, and “Lockdown”), enables
the community to see and plan for
the restrictions that governments
may be required to put in place.
The public health alert system
may be geo-targeted at the town,
council, state/territory level, and
shows increased or decreased
limits on human contact, travel
and business operations.
yy Key Finding: Health professionals
and population health scientists)
are generally viewed as credible
and trustworthy sources of public
health-related information.
yy Key Finding: Previous research
illustrates that people’s willingness
to act on public health advice
during a pandemic is driven by
their sense of pragmatism as well
as trust – they want to know what
actions will benefit in their personal
circumstances Hence, public health
messaging has more impact if it
helps with empowerment.
yy Key Finding: Broad communications
need to be supplemented with
messages tailored to particular
communities and social groups.
Engagement with public health
messaging is heavily influenced by
socio-economic background, cultural
and social identity, age, gender etc.
Australia’s efforts to contain COVID-19
and ‘flatten ‘the curve’ have been
successful.
The Government responded quickly
(Swerissen, 2020), and this resulted in
the rapid and widespread uptake of a
range of behaviours by the community.
Below is a communication strategy
aimed at engaging maximum public
support and participation in Australia’s
optimal approach going forward. This
reflects decades of research into
effective public communication from
a range of inter-related disciplines,
including psychology, sociology, risk
communication, health promotion, and
science and technology studies. This
communication approach is one that
occurs in a spirit of participation and
consultation; which is attentive to the
diversity of Australia community that
and appeals to people’s capacity to act.

Chapter 11: Clarity of Communication
Evidence and
Analysis to support
Recommendations
and Key Findings
General Principles of Risk
and Crisis Communication
Communication matters. There is
evidence of a significant relationship
between the communication
strategies of agencies responding
to a crisis and the level of public
reassurance and compliance. (Carter
et al., 2013). Some general principles
of risk and crisis communication are
summarised below (Covello, 2003;
Reynolds, 2004; Seeger, 2006).
It is worth pointing out two
constraints that will be elaborated
on in the following sections: first,
communication, while essential, is
not sufficient to change behaviours
because communication tends to
focus on changing motivation. People
also need to have the capability and
opportunity to perform the needed
behaviours and thus environmental
factors are also relevant, along with
having sufficient resources (Michie
et al., 2020). Second, the unique
communication needs of special
and diverse audiences need to be
respected; different audiences will
to some extent benefit from distinct
frames, messages, and messengers
(Moser, 2010).
As the development of such tailored
communication strategies requires
an investment of time and other
resources, the following principles
should form the backbone of
immediate communication strategies.
… the unique communication needs of special and diverse
audiences need to be respected; different audiences will
to some extent benefit from distinct frames, messages,
and messengers.

Principle 1
Engage in clear, consistent
communication
Principle 2
Strive for maximum credibility
Principle 3
Communicate with compassion,
care, and empathy
Principle 4
Communicate with openness,
frankness, and honesty
Principle 5
Recognise that uncertainty
and ambiguity is inevitable
Principle 6
Help people to feel
empowered to act
Principle 7
Consider health and statistical
literacy in messaging
Principle 8
Be proactive in combating
misinformation
Principle 9
Recognise and embrace
diverse audiences
A communication strategy for
maximum community support
and participation
There are four specific
recommendations which should
form the basis of a strategy in
which broad community messaging
is supplemented with tailored
communications for particular
groups.
Recommendation
Communicate the approach
and associated measures using
specific and empathetic language
that helps people feel empowered
to act, rather than just passive
recipients of instructions.
Provide a succinct and clear
explanation as to why ongoing
containment measures are necessary.
Be explicit about the goals of the
controlled adaptation approach, and
the reasons for undertaking particular
measures. The risks of pursuing the
approach and specific measures
also need to be clearly articulated.
Empathise by explicitly recognising
hardships of measures.

Recommendation
Enlist the support and assistance
of independent, credible and
trustworthy advocates (e.g.
healthcare workers, educators,
community leaders) to convey
key messages.
Continue to use those from trusted
professions to explain and justify the
controlled adaptation approach. It
is obviously highly appropriate that
key policy decisions are announced
and articulated by politicians while
authoritative health officials (such
as the Chief Medical Officer), and
key public health and scientific
experts must continue to provide
public communications. This will
help to convey that such policies are
underpinned by ‘apolitical’ evidence.
Recommendation
Enhance the impact of
communication by establishing
community reference groups to
provide ongoing input into the
decisions that affect them and
also how best to communicate
them. Several community reference
groups should be established so
that collectively, they represent
Norms and modes of communication
differ between social and cultural
groups. In addition, some groups will
be impacted much more severely
than others by Australia’s response
to COVID-19. Communications
should be tailored towards these
groups by working closely with group
representatives. The following groups
in particular require tailored messaging:
yy Young children (up to 12 years old)
and their parents
yy Secondary school children
yy Young adults (18–30)
yy Older adults (70+) and those living
in residential care
… authoritative health officials, and
key public health and scientific
experts must continue to provide
public communications.

yy Aboriginal and Torres Strait Islanders
yy Gender diverse / LGBTQ+
communities
yy People affected by bushfires
yy People with life-threatening illnesses
(i.e. immunocompromised)
yy Hearing-impaired community
yy Vision impaired community.
Community reference groups would
advise on: key messages and
approaches; ensuring the framing
and tone of messages would
be most appropriate to ensure
engagement; and the modes of
communication (e.g. Auslan, TV
broadcast, SMS, health messages
on social media platforms) that will
increase dissemination among their
communities.
There is a likelihood that as different
Governments and jurisdictions find
themselves at different levels of
risk that they use different labels
and wording for risk. The different
messages in different jurisdictions
along with different restrictions in
different areas will create confusion
amongst the community, dilute the
message and over time lead to fatigue
and non-compliance. It is critical that
the labels used and their implication
be uniform across the country.
Australia has long experience with
fire-risk warnings and most of the
population understands and responds
to escalation and de-escalation of
these warnings. It is recommended,
that in consultation with experts
and the different jurisdictions a
uniform public health alert system
be developed.
Recommendation
Define and implement a color-
coded public health alert system.
A color-coded public health alert
system with four levels ( e.g.
“Prepare” [blue], “Reduce” [amber],
“Restrict” [brown], and “Lockdown”
[red]), enables the community to
see and plan for the restrictions
that governments put in place.
The public health alert system
may be geo-targeted at the town,
council, state/territory level, and
shows increased or decreased
limits on human contact, travel
and business operations.

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ACP481>3.0.CO;2-J

Methodology
The Roadmap project was designed
to provide considered and evidence-
based responses to questions
of critical and pressing national
importance.
Experts were recruited from across
the Go8 universities – Australia’s
leading research-intensive universities
– in areas as diverse as epidemiology,
statistical modelling, infectious
diseases, public and mental health,
psychology, economics, political
scientists, Aboriginal and Torres
Strait Islander expertise, business,
international relations scholars and
political scientists.
Individuals ranged from eminent
professors to early career researchers,
to capture the diversity of expertise
across generations of talent.
The Task Force faced the challenge
of articulating the collective wisdom
of this large and diverse group on a
complex set of questions in a short
period, under conditions of great
uncertainty and rapid change and
where no members could physically
meet.
Standard remote collaboration
methods, such as circulating drafts
by email, have many drawbacks such
as the difficulty of keeping track of
document versions, integrating edits
and comments on many different
versions, and ensuring that everyone
can see the latest version. It seemed
clear this approach would struggle
with an expert group as large as the
Roadmap Task Force.
The Steering Committee made the bold
decision to try a new crowdsourcing-
inspired approach. All members were
given access to the SWARM cloud
collaboration platform, a research
prototype being developed by a team at
the University of Melbourne’s Hunt Lab
for Intelligence Research. The platform
is the result of a three-year research
effort funded by the US Intelligence
Advanced Research Projects Activity,
aimed at developing better ways
to support groups of analysts to
work through difficult problems and
produce high-quality reports. The
platform’s design is generic enough
that it can support analytical work in
many other domains.

On the platform, all Task Force
members were able to access nine
workspaces, one for each of the main
questions being addressed. Within a
workspace they could view, create,
and collaboratively edit contributions
of various kinds, including draft
section reports; rate and comment
on contributions; and use real-time
chat. While these activities are
supported by many cloud platforms,
a combination of design features
makes the SWARM approach unique.
These include:
yy A “groupsourcing” model in which
small teams from within the large
expert pool coalesce and self-
organise to tackle specific questions;
yy Support for “contending analyses,”
where any member can put up
a draft report and the group as
a whole can select the most
promising via “readiness” ratings;
yy Use of pseudonyms, intended to
mitigate social dominance effects
arising from the differing status of
members.
The Steering Committee understood
from the outset that the approach
would need to be carefully monitored
and that adjustments may be
required. In the second week, three
such changes were made: addition
of new Task Force members to cover
expertise gaps; off-platform video-
conferencing to accelerate coordination
of small emergent teams; and, where
appropriate, relaxation of anonymity.
By the end of week 2, draft reports
were available for all nine questions.
These were woven together into
a single Final Report by a small
editing team from the Group of Eight
Directorate. Task Force members were
briefly given a final opportunity to
provide comments. The Final Report
was then reviewed by a team of
selected independent commentators
and approved by the Go8 Board
of Directors before being provided
directly to Government.
The result is a comprehensive,
independent, evidence-based report for
Government that provides guidance as
to how and when Australia can move
to the recovery phase.
Dr Tim Van Gelder
Dr Richard De Rozario
Methodology

We thank the following for active participation
on the SWARM platform:
Professor Charles Abraham
University of Melbourne
Professor Karen Adams
Monash University
Associate Professor Eva Alisic
Dr Kelly-Anne Allen
Monash University
Dr Erik Baekkeskov
Professor Emily Banks
Australian National University
Associate Professor Anthony Bell
University of Queensland
Dr Andrew Black
University of Adelaide
Dr Andrew Black
University of Sydney
Professor Tony Blakely
Dr Chris Blyth
University of Western Australia
Ms Katrina Boterhoven de Haan
Professor Robert Breunig
Professor Alex Broom
Dr Matthew Brown
Group of Eight
Professor Romola Bucks
Professor Jim Buttery
Monash University
Dr Katherine Carroll
Professor Allen Cheng
Monash University
Professor Alex Collie
Monash University
Professor Rae Cooper AO
Professor Kim Cornish
Monash University
Dr Kyllie Cripps
University of New South Wales
Professor Donna Cross
Professor Mark Dadds
Professor Sara Davies
Griffith University
Professor Megan Davis
Professor Patricia Dudgeon
Professor Sandra Eades
Associate Professor Ullrich Ecker
Ms Nicole Ee
Professor Jane Fisher AO
Monash University
Professor John Freebairn
Dr John Gardner
Monash University
Professor Ross Garnaut AC
Professor Marie Gerdtz
Associate Professor Kathryn Glass
Professor Quentin Grafton
Professor Len Gray
Professor Jane Gunn
Professor Ian Hickie
Ms Anna Hickling
Professor Keith Hill
Monash University
Professor Richard Holden
Professor Eddie Holmes
Ms Bernadette Hyland-Wood
Associate Professor Tim Inglis
Associate Professor Andrew Jackson
Professor Jolanda Jetten
Ms Yawei Jiang
Professor John Kaldor
Associate Professor Adam Kamradt Scott
Professor Shitij Kapur
Ms Alex Kennedy
Group of Eight
Dr Elise Klein
Professor David Le Couteur AO
Professor Julie Leask
Professor Karin Leder
Monash University
Mr Yulin Li
Associate Professor Kamalini Lokuge
Professor John Mangan
Professor Andrew Martin
Professor James McCaw
Dr Christopher McCaw
Professor Lisa McDaid
Dr Siobhan McDonnell
Professor Patrick McGorry AO
Professor Warwick McKibbin AO
Acknowlegements

Professor Jodie McVernon
Professor Tracy Merlin
Professor George Milne
Dr Nikki Moodie
Dr Lucy Morgan
Professor James Morley
Associate Professor Julia Morphet
Monash University
Dr Sally Nimon
Group of Eight
Professor David Paterson
Dr Collin Payne
Dr Michael Phillips
Monash University
Professor John Piggott AO
Professor Jane Pirkis
Ms Maeve Powell
Professor Mikhail Prokopenko
Dr Signe Ravn
Professor Ian Reid
Professor Peter Robertson
Mr Ross Roberts-Thomson
Associate Professor Simon Rosenbaum
Professor John Savill
Dr Ashley Schram
Mr Roberto Schurch
Dr Theresa Scott
Associate Professor Linda Selvey
Professor Louise Sharpe
Dr Kirsty Short
Professor Helen Skouteris
Monash University
Dr Joseph Smith
Professor Tania Sorrell AM
Professor Marc Stears
Professor David Story
Ms Vicki Thomson
Group of Eight
Professor Carla Treloar
Professor Tim Usherwood
Professor James Ward
Professor Jim Watterston
Professor Peter Whiteford
Professor Harvey Whiteford
Professor Simon Wilkie
Monash University
Professor Deborah Williamson
Associate Professor James Wood
Dr Mandy Yap
Professor Paul Young
Special Acknowledgements to the Following:
Chapter 1: An Ethical Framework for the Recovery
Professor Duncan Ivison, Deputy Vice Chancellor,
Research, University of Sydney, Professor Marc
Stears, University of Sydney and Prof Susan
Dodds, LaTrobe University
Professor Emily Banks, Australian National
University, Dr Grazia Caleo, Australian National
University, Dr Stephanie Davies, Australian National
University, Associate Professor Kathryn Glass,
Australian National University, Professor Quentin
Grafton, Australian National University, Associate
Professor Kamalini Lokuge, Australian National
University, Professor George Milne, University of
Western Australia, Professor Mikhail Propenko,
University of Sydney, Dr Leslee Roberts, Australian
National University, Ms Tatum Street, Australian
National University, Associate Professor James
Wood, University of New South Wales
Chapter 3: The Controlled Adaptation Option
Professor Tony Blakely, University of Melbourne,
Professor Karin Leder, Monash University,
Professor John Mangan, University of
Queensland, Professor James McCaw, University
of Melbourne, Professor Jodie McVernon,
University of Melbourne, Professor Warwick
McKibbin AO, Australian National University,
Professor Tracy Merlin, University of Adelaide,
Dr Collin Payne, Australian National University,
Professor John Piggott AO, University of New
South Wales, Professor Peter Robertson,
University of Western Australia, Associate
Professor Linda Selvey, University of Queensland
Chapter 4: Border Protection and Travel Restrictions
Associate Professor Adam Kamradt-Scott,
Dr John Gardner, Monash University, Ms Bernadette
Hyland-Wood, University of Queensland, Professor
Julie Leask, University of Sydney
Professor Jane Gunn, University of Melbourne
Professor Jane Gunn, University of Melbourne,
Mr Roberto Schurch Santana, University of
Queensland, Professor Romola Bucks, University
of Western Australia, Associate Professor
Andrew Jackson, University of New South
Wales, Dr Chris McCaw, University of Melbourne,
Professor Andrew Martin, University of New
South Wales
Ms Anna Hickling, University of Queensland,
Professor Harvey Whiteford, University of
Queensland
Chapter 9: Considerations for Aboriginal and
Torres Strait Islander Peoples
Professor Patricia Dudgeon, University of
Western Australia, Dr Kate Derry, University
of Western Australia
Chapter 10: Key Populations
Professor Helen Skouteris, Monash University
Chapter 11: Communications
Dr John Gardner, Monash University, Associate
Professor Ullrich Ecker, University of Western
Australia, Professor Julie Leask, University of
Sydney, Ms Bernadette Hyland-Wood, University
of Queensland
Thanks to Prof. Neville Yeomans for helping
consider the Contributions
We acknowledge Associate Professor Tim van
Gelder and Associate Professor Richard de
Rozario and their “SWARM” team: Ashley Barnett,
Dr Ariel Kruger, Yao Pan, Tamar Primoratz, Dr
Morgan Saletta, Sujai Thomman, Luke Thorburn,
Dr Ivo Widjaya, Andrew Wright, Zeyu Zha
Thanks to our additional Contributors:
Dr Elizabeth Adamson
Professor Jon Altman
Dr Jacqueline Anderton
Professor Nicholas Aroney
Professor Gabriele Bammer

Associate Professor Margo Barr
Dr Megan Blaxland
Dr Alexandra Bloch-Atefi
Dr Karen Block
Dr Noreen Breakey
Associate Professor Julie Brimblecombe
Monash University and University of Queensland
Dr Timothy Broady
Professor Deborah Bunker
Dr Beatriz Cardona
Dr Susan Carland
Monash University
Deputy CEO Dawn Casey
National Aboriginal Community Controlled
Organisation (NACCHO)
Dr Andrzej Ceglowski
Monash University
Associate Professor Mark Davis
Monash University
Professor Simon Dennis
Professor Sara Dolnicar
Associate Professor Frank Donnelly
Dr Antony Eagle
Dr Elizabeth Edwards
Dr Thorlene Egerton
Dr Christian Ehnis
Dr Megan Ferguson
Monash University and University of Queensland
Dr Tony Florio
Professor Pauline Ford
Dr Paul Garrett
Dr Lynn Gillam
Professor Sharon Goldfeld
Murdoch Children’s Research Institute
Professor Bronwyn Harch
Associate Professor Ian Hardy
Associate Professor Ben Harris-Roxas
Dr Trish Hill
Dr Jessika Hu
Associate Professor Janet Hunt
Professor Raja Junankar
Associate Professor Nicole Kaims
Monash University
Professor Yoshi Kashima
Professor Ilan Katz
Associate Professor Sabina Kleitman
Professor Stephan Lewandowsky
Associate Professor Daniel Little
Professor Simon Loertscher
Professor Nigel Lovell
Dr Sue Lukersmith
Professor Guy Marks
Professor Greg Marston
Miss Antje Martins
Professor Kirsten McCaffery
Dr Ros McDougall
Professor Alistair McEwan
Dr Susan Mendez
Professor Patricia Morrell
Dr Jack Noone
Dr Sze-Yuan Ooi
Associate Professor Roger Patulny
University of Wollongong
Associate Professor Amy Perfors
Dr Michelle Peterie
Professor Ove Peters
Dr Kate Power
Dr Bridget Pratt
Associate Professor Gaby Ramia
Professor Ian Ring AO
James Cook University
Mr Tyler Riordan
Dr Penny Round
Monash University
Professor Richard Saffery
Professor Andreas Schloenhardt
Dr Brett Scholz
Ms Naomi Schwarz
Professor Anthony Scott
Dr Jennifer Skattebol
Dr Pearl Subban
Monash University
Dr Stewart Sutherland
Dr Cathy Thomson
Associate Professor Cathy Vaughan
Professor Melissa Wake
Mr Josh White
Dr David Whyatt
Associate Professor April Wright
Dr Yongxin Xu
Monash University
Professor Neville Yeomans AM
Professor Alison Young
Dr Adam Zulawnik
Monash University
Thank you to our independent reviewers:
yy Mr Jeff Connolly, Chairman and CEO, Siemens Ltd
yy Professor Glyn Davis AC, CEO of the Paul
Ramsay Foundation
yy Professor Stephen Duckett, FASSA,
Grattan Institute
yy Ms Kathryn Fagg, AO, FAATE
yy Dr Alan Finkel AO, Australia’s Chief Scientist
yy Dr Cassandra Goldie, CEO, Australian Council
of Social Service (ACOSS)
yy Mr Andy Keough CSC, Managing Director,
Saab Australia
yy Ms Linda Nicholls, AO, Chair of Melbourne Health
yy Dr Jennifer Westacott AO, CEO, Business
Council Australia

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