A Sydney physician has broken ranks to warn that New Zealand could struggle if the Delta variant of Covid-19 is not brought under control.
In the corridors and wards of Sydney's Liverpool Hospital, a life-and-death struggle goes on, under a cone of silence.
Doctors are banned from speaking publicly about this war against the Delta variant of Covid-19, but one has agreed to talk to the Listener on condition of anonymity. He is a clinician who works on a Covid team in Sydney's largest hospital. Let's call him Alex Winter.
Jacinda Ardern has made the point repeatedly that New Zealand has done a better job of protecting its population than some Australian cities, moving harder and faster with strict lockdowns.
But as New Zealand edges closer to more normal life, Winter feels compelled to speak out. He is breaking rank at the behest of New Zealand physicians who are deeply concerned about what the future might hold. Many believe that the public health system they work in is suffering from years of underfunding, and has now fallen well behind Australia.
Modelling released by the Counties-Manukau District Health Board last week shows that when border restrictions are lifted, even with a 90 per cent vaccination rate the South Auckland area could see at least 1000 cases and 30 hospital admissions a week. If vaccinations reach only 80 per cent, it expects 1400 cases and 45 admissions.
University of Auckland public health associate professor Collin Tukuitonga warned that vaccination levels were currently well below 80 per cent in South Auckland and a target of 90 per cent was unrealistic, given current rates among the area's significant Māori and Pasifika populations.
Death takes a toll
Back in Sydney, hospital admissions at Liverpool were beginning to fall by the second week of October. Four months into New South Wales' Delta outbreak, Winter was seeing a glimmer of hope for his beleaguered state. Liverpool had reduced its seven Covid wards to five. With ongoing admissions, the number of Covid patients lay between 25 and 30.
The fall in admissions coincided with a rise in vaccination rates to more than two-thirds of the local population. But it came with a hefty price. By the second week of October, nearly 500 people had died of Covid in New South Wales since the crisis began in mid-June.
Each one of those deaths is a personal tragedy, and not just for the families and loved ones of those who have died. It has also taken a huge toll on the medical staff entrusted with their care. "I've seen a lot of deaths in my time, but there have been some particularly tragic circumstances that touch your heart strings," says Winter.
For him and many other medical staff, the Covid nightmare began in earnest three and a half months ago. As with New Zealand, Australia got its vaccination programme into gear in February. In June, a single infection appeared in Bondi, in the middle-class eastern side of Sydney.
But the highly infectious Delta variant soon found a host among the poorer immigrant workers from the city's southwest who commuted to service-industry jobs in east Sydney. They took the virus back home, where it spread to vulnerable victims among the closely packed extended families around Liverpool Hospital.
"At first, we had a single ward, then it went to two Covid wards and then every couple of weeks the need has risen higher."
As the crisis deepened, seven wards were earmarked for potential Covid cases. "There was room to expand up to 10 wards, but you have to staff them."
In many cases, entire families were admitted, all suffering from Covid.
Winter recalls one such family, including a man in his late seventies. "He was pretty sick and they were treating him with some of the stronger treatments and giving him a high level of oxygen support."
His elder adult daughter and his wife were in other wards. "And then one morning, his wife on another ward had gone to the bathroom during the night and she collapsed and died coming back."
The clinical team were faced with a quandary: how to handle a grieving husband, alone in the other ward. "The daughter was doing relatively well so they brought her to his ward and put them together in the two beds so they could grieve together.
"They kept the two of them together for a couple of days. She could have gone home, but for human sympathy she was kept a bit longer. But eventually she had to go because there were more people needing to come in."
Contact on a floor busy with about 20 patients is kept to a minimum to avoid cross-infection. Once on his own, the elderly man's only support was the surreal presence of staff clad in goggles, face shields, hair caps, full-length gowns and double gloving.
"He had to grieve in these strange circumstances where people stay away from you as much as possible."
An earlier outbreak was in an aged-care ward. "That was a couple of months ago now and all of those people were highly vulnerable. Most of them are now deceased."
For clinicians, however, there is little time to dwell on their circumstances. "You've just got to look at that and do the best you can and move on, because there is someone else who needs your care."
Although the State government keeps a record of total deaths, physicians are kept in the dark about the exact situation in their own hospitals, says Winter. "The person who runs the ICU will have them, and will have them on a daily basis, but they're not openly and widely distributed."
Health ministry officials hold a lot of information close to their chests, he says. "They won't even distribute it to staff members in the hospital where it happens in a timely way."
About 12 people have died in the local community who never got to hospital. Half of them weren't even known to have Covid.
Fears for the future
Is the Sydney situation a glimpse of the future for Aotearoa, or could our future be even worse?
Respiratory physician and Thoracic Society of Australia and New Zealand branch president James Fingleton thinks it's possible that New Zealand, largely sheltered from the virus since it struck worldwide last year, could suffer worse even than Australia. "We are starting with a baseline of fewer ICU beds per head of population," he says.
To Kiwi intensive care specialists, the gap between Australian and New Zealand public health has been widening for decades.
Health Minister Andrew Little was recently reported as saying that in the middle of last year, New Zealand had about 240 ICU beds. Since then, he claimed, the number had risen by another 100 beds.
Intensive care specialist Rob Bevan was driving to work when he heard the minister speak. "I nearly crashed my car," says Bevan, who is vice president of the College of Intensive Care Medicine of Australia and New Zealand.
Last month, the college directly surveyed all the charge nurse managers for intensive care units in New Zealand to determine the number of critical care nurses currently available. It showed that in the year to June 2020, New Zealand had 227 beds. A new survey done last month showed the number had fallen to 170. "The same survey showed we have 63 beds for Auckland."
One explanation is that some ICU nurses may have left the country, possibly to earn more money overseas.
Bevan also questions the minister's claims that the British experience shows that hospitals will be able to rapidly train nurses from other areas to meet a surge of patients.
As a British-born specialist, Bevan also notes that the UK has already endured nearly 140,000 deaths. Talk to him about the months ahead and you will hear words such as "scared" and "worried".
The first line of defence, without a doubt, is vaccination, he says. "Once you increase that vaccination rate past 90 per cent, and once you start adding in the young people, then the numbers who might become critically ill drop off steeply."
But there will still be an unknown number of people with underlying conditions who catch Covid and for them the backstop is still the ICU bed.
Specialists have determined that 5.3 nursing staff are needed to oversee a single ICU bed over the course of a week. "So, if you divide the total number of nurses that New Zealand has employed today in intensive care, plus the vacancies, on that data we have got approximately 170 staffed adult intensive care beds nationally."
Words without action
Those statistics coincide with an international study by the OECD, which puts New Zealand well behind most of the world for ICU facilities. It shows us as second to bottom in the OECD, with just 3.6 ICU beds per 100,000 people, and just ahead of Mexico. According to the study, Australia has 9.4 beds for the same number of people, while Germany has almost 34.
A Ministry of Health report from 2001 shows we have been slipping behind for years. Back then, we had approximately six available ICU beds per 100,000 people. The ratio appears to have shrunk since then because the number of beds has not kept pace with New Zealand's rapid population growth.
Even in 2001, the report warned that Wellington needed more beds. One clinician privately describes that failure as "a disgrace".
"Most of those New Zealand ICU beds are already occupied by patients with conditions such as life-threatening asthma, chronic inflammatory lung disease, pneumonia, post-operative complications and severe trauma injuries. We would need to reduce surgery to nothing other than acute or day-stay surgery for a whole year."
Besides needing nurses, ICUs also need the support of respiratory physicians and specialist nurses. Again, New Zealand appears to be near the bottom of the OECD.
Europe has one respiratory physician for every 20,000 people. Australia and the United Kingdom have one for every 50,000. New Zealand has one for every 75,000, and 800,000 of our population have no ready access to a respiratory physician.
Bevan blames decades of neglect. "There has been a considerable deterioration in the resourced intensive care capacity in New Zealand over many years and multiple governments."
Various claims have been made about the number of ICU beds around the country, some sourced to the Ministry of Health. But Bevan is sticking with the figure provided by intensive care teams around New Zealand, which coincides with the OECD data.
And forget the idea, he says, of simply buying ventilators for more ICU beds. "We have hopefully moved past the narrative where an intensive care bed is defined by the presence of a bed and a ventilator. It is defined by the machinery, the physical bed and the specialist staff to make all that work."
It takes at least two years to train a junior intensive care nurse, he notes, and at least four years to train an intensive care nurse who can look after others on the ICU. To train an intensive care specialist takes seven to nine years. "And we haven't even got enough of those. We have intensive care medical specialist vacancies throughout New Zealand as well."
He also notes that most ICU beds are already well used. "They are being used for business as usual now. We are a bit worried about this."
Bevan says it is important to understand that a mass Delta infection won't necessarily be fleeting, like most natural disasters.
"What we are scared of is if this Covid pandemic breaks out. This isn't one tsunami, this is a sustained deluge.
"You can't split our bed capacity 50-50. We have got to provide it for those that need it when they need it, where they need it."
The Government insists it can increase bed capacity during outbreaks and has had DHBs train more than 700 non-ICU nurses to help with the pandemic response.
According to Little, importing more nurses is not the answer because there is a worldwide shortage. "For any nurse, working in an ICU environment is top of scope for their job, that is why we are training more nurses to work in an ICU environment," he was reported as saying last week.
Little said the country would cope, "if we filled every vacancy" and trained more nurses to work in intensive care.
But at Wellington Hospital, Fingleton says there is a real concern patients needing regular surgery may be forced aside. The longer the delay, the greater the risk, he says.
So does he believe we can cope with an outbreak such as New South Wales and Victoria have suffered? "You can't start with a small fraction of the number of ICU beds and inpatient ward capacity required and expect to be able to cope with the same level of outbreak," he says.
"I think that is why high levels of vaccinations are going to be essential, or we could have real problems with the amount of normal hospital work that would have to be cancelled in order to cope with Covid patients."
Fingleton says solutions may include a non-invasive form of ventilation through a mask, which can be given outside of intensive care. But this will also need training. For every one Covid patient in ICU, there are four who will need care in medical wards catering for less-acute patients.
The Government has imported large numbers of ventilators for these lower-risk patients. But these wards will have to replace existing ones. "You can't just have them in an open bay where they will spray Covid everywhere. So there is a lot of reconfiguration that needs to happen for this."
Until now, many district health boards have categorised several levels of care under the one heading, which made an accurate count of life-support facilities difficult to estimate, he says.
"I don't believe there is anybody specifically tasked with the overarching responsibility for respiratory support units around the country.
"A lot of work has been done around the country, but I am not confident at this point that enough work has been done for us to be able to cope without significant disruption, and I think the extent to which they have managed to achieve it is variable."
Clinicians seem to agree vaccination is our best hope. But even if we do well, there are still likely to be many unvaccinated people.
Covid-19 data modelling expert Shaun Hendy, from Te Pūnaha Matatini research centre, provoked a storm when one of his scenarios predicted that with 80 per cent vaccine coverage, there could be about 60,000 hospitalisations and 7000 deaths per year from Covid.
Scotland-born physician Craig Carr says the Hendy report had him wondering, too, until he took a second look at his homeland.
Carr, New Zealand regional chairman of the Australian and New Zealand Intensive Care Society, settled here seven years ago after a worldwide search for a new home.
From the safety of Dunedin, he observed the outbreak of Covid as it swept across Scotland. Since last year, Scotland has had nearly 600,000 confirmed cases of Covid and more than 9000 deaths, all in a country with the same population as New Zealand.
The Hendy modelling recognised the fatality rate depended on the profile of those who were unvaccinated.
"If they were a high-risk population who were elderly, who had obesity, kidney impairment, hypertension or other risk factors, then we might expect significantly higher hospitalisations and fatalities, even at 90 per cent," says Carr. "People were saying, 'This is apocalyptic; this is exaggerated,' but the Scottish population had a high vaccination rate but were still having more than 1000 patients in hospital every day.
"Imagine 1000 patients in hospital. Dunedin Hospital has about 380 beds, Invercargill has about 200 beds, so those hospitals would be nothing but Covid. It is a very high number of patients."
But as the vaccination programme reached the most vulnerable in Scotland, hospitalisations and deaths began to fall. This is why Carr believes so much rides on the public response to vaccination here in New Zealand.
Nobody knows the true human tragedy behind those statistics better than Australian medical staff. Winter has lived with it for months now.
"You can tell people are dying. You have done all you can and you are reduced to a situation where the nurse or the junior doctor sits next to the dying person with an iPad and makes the connection to the family that way.
"When people are dying, they are hardly in a set state to interact with intelligent comments, so every person who dies is a tragedy and it is a tragedy not just for them but for their family, obviously, and even for the people caring for them. It goes wider than that."