Jacinda Ardern hasn't set a timeline for opening up Fortress New Zealand due to the many unknowns: vaccine uptake, new virus variants, public appetite for change. Derek Cheng looks at what next year might look like, what we know already, and the curveballs that may put us back to square one.
Gaze into the crystal ball for a moment. It's the start of 2022, 80 per cent of the population is fully vaccinated, and Prime Minister Jacinda Ardern announces that the borders will open up more.
Within weeks, a flight arrives from China, which has more or less eliminated Covid-19, and vaccinated people walk off the plane without any need to quarantine, having had a negative pre-departure test.
It's followed by flights from the US and the UK, where the virus remains prevalent, and passengers are sent to an MIQ facility for 14 days if they aren't vaccinated, and seven days if they are. Vaccinated Kiwis on those flights are allowed to isolate at home.
People in countries with low vaccination rates and high daily cases of the virus are not allowed in unless they are Kiwi citizens – the same restrictions that currently apply to people in India, Brazil, Pakistan and Papua New Guinea.
As is the case now, travel arrangements are flexible, meaning quarantine-free bubbles can be paused and blanket 14-day MIQ stays brought back in.
Any emergence of the virus in the community is met with swift contact-tracing and case-isolation – or even a brief lockdown.
All border workers are vaccinated, masks are still required on public transport and, to help contact-tracers, it is mandatory to scan QR codes at bars, restaurants and other busy indoor venues.
New research into how the virus behaves in vaccinated populations and improvements on how to treat Covid patients has Ardern mulling over whether elimination continues to be the best path forward – especially as other countries signal a move to "living with the virus".
Modelling suggests that mitigation in a vaccinated New Zealand with more open borders could lead to fewer than 100 Covid-deaths a year - but would that be politically acceptable?
On the flipside, 2022 could also turn out to be little different from the Fortress NZ we have now - especially if the vaccine rollout is delayed, uptake is low, and the world is grappling with a new virus variant that is more contagious and resistant to vaccines.
Ardern's huge decision
Leaders of other countries, including Australia, the UK and Singapore, have recently laid out plans for opening up their countries, which has inevitably led to questions about how New Zealand will open up.
Ardern has not set out any timeline but has talked about a phased, risk-based approach, while the Government is preparing for what next year might look like.
An independent advisory group - chaired by epidemiologist Sir David Skegg - has finished a report into risks at the border, which is expected to be released as part of a public consultation process in a few weeks.
Last week a meeting among health experts and border agencies discussed what needed to be in place so countries – other than Australia and the Cook Islands – can be quickly added to our quarantine-free travel bubble, if and when Ardern deems it safe enough to do so.
Ardern has previously floated the idea of allowing vaccinated people into New Zealand before our rollout is complete, a question that the Skegg group specifically considered.
But Covid-19 Response Minister Chris Hipkins has already suggested that shorter MIQ stays for vaccinated people is a 2022 conversation, rather than for this year.
That timeline is echoed by founding director of Te Pūnaha Matatini Professor Shaun Hendy, who is a special adviser to the Skegg group.
"Right now, with only about 10 per cent of New Zealand's population vaccinated, it would be too high-risk here to bring in vaccinated people without MIQ stays. The population here is still too vulnerable.
"Once you start to get up to 60 to 70 per cent, then we might want to start to have those sorts of conversations."
Hendy also echoes Ardern's comments that different vaccine choices might be a "sticking point" for reopening borders.
"It will come down to looking at what kind of vaccine people have had – not all vaccines are created equal - and whether they're coming from a higher risk destination," Hendy says.
Initial data shows that the Pfizer vaccine was doing well in preventing onward transmission, he adds.
"Maybe it's not completely unrealistic to allow vaccinated people in, but we wouldn't want to open up the border wholesale.
"We might let in 1000 people from a low-risk country who have been vaccinated, for example, without unduly increasing the risk to the New Zealand population, particularly with a pre-departure test and rapid tests at the border."
If vaccines remain effective, regardless of what Covid variants may emerge, a high vaccination uptake by the end of the year would give Ardern the confidence to begin easing border restrictions while continuing to strengthen domestic public health measures.
Uncertainty the only certainty
There are many unknowns in the way forward.
Shipments of the Pfizer vaccine might slow to a crawl, and the rollout could be pushed well into next year.
Ardern may also face a dilemma if the rollout finishes with only 50 to 60 per cent of the population vaccinated. More travel bubbles and shorter MIQ stays would make elimination much harder to maintain with such a high proportion of the population still vulnerable.
A low uptake would also leave our healthcare system, which currently has 744 ICU-capable ventilators nationwide, more exposed.
"We should probably look to boost our ICU capacity in preparation for an outbreak," Hendy says.
"If it combines with a winter flu season, we already know that our flu season puts a strain on the healthcare system. Throw in Covid - even with a highly vaccinated population – and you've got the potential for a crisis."
Vaccine rollouts overseas are plateauing at around 60 per cent, but Hipkins is optimistically hoping for 70 to 80 per cent.
Te Pūnaha Matatini modelling suggests that ongoing public health measures and border restrictions are needed to stay the elimination course against the Delta variant, unless as high as 97 per cent of the population is vaccinated.
Director-general of health Dr Ashley Bloomfield has already discussed being at alert level 1.5 (he mistakenly said level 2.5 at the time) for up to five years.
The major curveball is whatever new variants might emerge.
Professor of International Health Philip Hill says there will be a limit to how dangerous the virus can become, but how far we are along that path remains unclear.
"It is therefore crucial that we continue to treat the virus on its own merits and that we are agile enough to be able to respond to how it is moving," says Hill, who is a member of the Skegg group.
"We have a lot of things that we can improve ourselves in our response to the virus. We've seen improvements regularly with the way in which we can do rapid case contact management, with developments in testing and the tools to enhance contact tracing being obvious examples."
Vaccines are also adaptable, he said, and Pfizer has been working on staying ahead of the variants' curve.
"It is relatively straightforward, for example, to adjust mRNA vaccines to give different 'instructions' to the immune system to combat a new variant."
There are two main issues that will shape how the border can reopen in the medium- to long-term, according to epidemiologist Professor Michael Baker.
"One is the consequences of widespread infection. If you're vaccinated and get infected, it seems that the risk of long Covid (longer-term health effects) may be much less," Baker says.
"For the unvaccinated and partially vaccinated, that's the almost barbaric experiment that [UK Prime Minister] Boris Johnson's Government is inflicting on the English, particularly in allowing the virus to infect maybe up to 10 million young people over the next few months.
"Hopefully the outcome won't be as bad as some people predict."
He said the other issue is the performance of the vaccines and how the virus behaves in a highly vaccinated population - and he is optimistic.
"It may be that the vaccines are going to be as effective as they're looking like at the moment."
Hill adds that what happens in Israel, where a 60 per cent fully-vaccinated population is experiencing fewer severe health outcomes, will also be instructive.
"It looks like eliminating all mild infections in Israel will require supplementing vaccination with more aggressive public health measures, at least for a period," Hill says.
"Not doing so could come back and bite them, as it enables the virus to maintain a constant presence, and opportunity to evolve in relation to the setting it finds itself in."
No public hankering for open borders – yet
Ardern has talked about opening up to the Pacific before Asia, but she is unlikely to do so without public support.
A recent Government survey found 90 per cent of respondents do not expect life to return to normal after they are vaccinated, 53 per cent of people are worried about opening up quarantine-free travel zones beyond Australia and the Cook Islands, and 84 per cent of people are happy with stopping travel from very high-risk countries.
And while some businesses are suffering from border restrictions – especially in the tourism and hospitality sectors – Business NZ chief executive Kirk Hope says it is generally accepted that the rollout has to finish before any major reopening.
"I don't think there's too many people that would be keen to open the borders early with the current risk of outbreaks," Hope says.
"We've already seen what's happening in Australia."
Hope is a business adviser to the Government along with Rob Fyfe, who recently said that businesses should plan for multiple scenarios including the possibility of borders being restricted for two or three years if new variants emerge.
"If there's no genuine appetite from the public to open borders, if they don't feel safe, then it's going be quite difficult, politically, for the Government to make any kinds of moves," Hope says.
In the meantime, business groups, border agencies, and airlines and airports want everything ready for more quarantine-free travel bubbles.
"The technical detail around what needs to occur for more bubbles to be open, pre-departure testing requirements, how to appropriately manage all the risks – that work is underway," Hope says.
"We want that work done so we are ready to go when conditions can be met."
Top of the list for Business NZ are those where exports and trade negotiations are focused - China, the US, the UK, and Europe.
Elimination for now – but for how long?
Hope adds that there isn't a huge push from the business sector to abandon elimination anytime soon.
"A significant outbreak shuts down economic activity almost instantaneously, as we saw when we started to get 80 cases a day in March last year. That is so much harder on business.
"Elimination has served us well."
There is a risk, however, that New Zealand's increasingly isolated pursuit of elimination will become a competitive disadvantage, especially as the likes of Australia, Canada, the UK and the US have all signalled moves towards mitigation or suppression.
That means treating the virus like the flu, which is far less lethal, and living with it in a way that keeps the health system from being overwhelmed.
New modelling led by Professor Tony Blakely sheds some light on what mitigation in New Zealand might look like. It looks at different levels of herd immunity alongside a "moderate elimination" strategy followed by a year of "tight suppression".
If the borders were open to vaccinated people with negative pre-departure tests from low-risk countries, New Zealand could expect one infected person arriving at the border every day who didn't need to go into MIQ.
"The good news is that they are vaccinated and half as likely to pass it on to somebody else," Blakely says.
"When we run all these models, you see outbreaks, but the contact-tracing is good enough to control it."
With an R0 value of six (one infected person on average infects six others, which most closely reflects the Delta variant) and 70 per cent of adults vaccinated, that would translate to 11 infections per day, and up to 74 deaths and 276 hospitalisations a year – albeit with high uncertainty.
Communities would be in lockdown 8 per cent of the time - or one month every year.
"One of the key points we're making here is that even at 50 per cent vaccination coverage, you could be opening your borders up to really low-risk countries like Singapore, South Korea, because the risk is minimal," Blakely says.
"The question is: What risk will we tolerate?"
Baker, an architect of New Zealand's elimination strategy, says elimination makes sense for the foreseeable future, but the endpoint remains an open question.
"Do we eliminate it like we do for measles and polio, so we choose not to live with it on a routine basis? Or do we accept that it's going to be an endemic infection like other seasonal respiratory infections?
"These are two very different ultimate endpoints with the virus. We may not be able to answer that question for a little while - until we have more data."