5 Years on from COVID-19: lessons from past health crises and the future of global health

5 Years on from COVID-19: lessons from past health crises and the future of global health

Join an engaging discussion with our distinguished panel of public health and virology experts, who explore enduring infectious diseases like HIV, tuberculosis, and mpox, five years after the discovery of COVID-19. This episode highlights how pandemics have historically reshaped our world and demonstrates the transformative impact of cross-disciplinary collaboration in addressing global health challenges. The panelists confront the stigma and misinformation surrounding mpox, HIV and Covid-19, advocating for empathy and transparent communication to build trust. They dissect the role of public values in shaping policy decisions and reveal how political rhetoric affects scientific communities during health crises. Tackling the persistent threat of diseases like tuberculosis and the growing danger of antimicrobial resistance, the discussion underscores the global inequities laid bare by COVID-19 and outlines a vision for improving responses to future health emergencies.

Many thanks to our panel:

• Edward Holmes, Professor of Virology, University of Sydney, and NHMRC Leadership Fellow
• Claire Hooker, Associate Professor in Health and Medical Humanities, University of Sydney, and President of the Arts Health Network NSW/ACT
• Julie Leask, Professor of Public Health, University of Sydney, and Visiting Professorial Fellow, National Centre for Immunisation Research and Surveillance
• Brent Mackie, Director Policy, Strategy and Research at ACON
• Bernadette Saunders, Associate Professor in Life Sciences (Cellular Immonology) and Tuberculosis & Respiratory Diseases Group Head, University of Technology Sydney
• Susana Vaz Nery, Professor at Kirby Institute UNSW, and Neglected Tropical Diseases research group lead
• Jane Williams, Research Fellow (public health ethics), University of Wollongong
• Facilitated by Philippa Nicole Barr, ANU and Western Sydney University

This History Council of NSW event is supported by the Australia New Zealand Society for the History of Medicine (NSW) and the Australian Health and Medical Humanities Network. Our event venue partner is the Sydney Mechanics’ School of Arts (SMSA).

Chapters

• 0:10 Interdisciplinary Panel on Health Crises
• 6:22 Managing Infectious Disease Misinformation and Stigma
• 14:05 Combatting Stigma in Infectious Diseases
• 24:14 Pandemic Communication and Stigmatization
• 33:13 Global Health Ethics and Responsibilities
• 40:53 Understanding Zoonotic and Infectious Diseases
• 51:17 Global Health Equity and Vaccination Priorities
• 59:21 Lessons From Past Pandemics
• 1:13:39 Investment and Stigmatization in Global Health
• 1:19:10 Building Trust and Community Engagement
• 1:26:40 Lessons in Global Health Priorities
• 1:42:48 Acknowledgements for Event Organization

Transcript

Amanda Wells: 0:10

Hello everyone. I'm Amanda Wells from the History Council of New South Wales. Welcome to everyone in the room on Zoom and listening to the podcast afterwards, I'm very excited about this panel. So I'd like to begin by acknowledging the traditional owners of the land we meet on today, the Gadigal people of the Eora Nation, and pay my respects to elders past and present, and I extend that respect to any Indigenous people who may be with us today or listening to us in the future. I'm very honoured to be here on Gadigal land here at the Sydney Mechanics School of Arts for this panel about pandemics past, present and future.

Amanda Wells: 0:46

When I suggested this idea as a panel as we approach the five-year mark of the discovery of COVID-19, I couldn't have imagined inviting such a broad range of experts as we have here today. So who do we have? We've got Edward Holmes, professor of Virology at the University of Sydney and NHRMC Leadership Fellow. Claire Hooker, associate Professor in Health and Medical Humanities at the University of Sydney and President of the Arts Health Network New South Wales and ACT. Julie Leask, professor of Public Health at the University of Sydney and Visiting Professorial Fellow at the National Centre for Immunisation Research and Surveillance. Brent Mackie, director of Policy Strategy and Research at ACON. Bernadette Saunders, associate Professor in Life Sciences, cellular Immunology and Group Head for Tuberculosis and Respiratory Diseases at the University of Technology Sydney. Susana Vaz Nery, professor at Kirby Institute University of New South Wales and the Neglected Tropical Diseases Research Group Lead. And Jane Williams, research Fellow in Public Health Ethics at the University of Wollongong.

Amanda Wells: 1:55

And finally, I'll introduce our facilitator for this evening and the brilliant mind who brought this impressive panel together, Philippa Nicole Barr, who's an interdisciplinary scholar of medical history and anthropology. She's the author of Uncertainty and Emotion in the 1900 Sydney Plague, published by Cambridge University Press this year in April 2024, and which won the History Council of New South Wales' Addison Road Multicultural History Award this year as well. Philippa works at both ANU and Western Sydney University. Thank you, Philippa.

Philippa Nicole Barr: 2:30

So when studying history, we kind of often overlook infectious diseases. Yet in 2021, around 20% of all deaths were from an infectious disease. Diseases shape history in fundamental ways, just as history shapes the way diseases are understood and managed. As we mark five years since the onset of COVID-19, this panel will explore the lasting legacies of significant health crises like HIV, tuberculosis and COVID-19 to discuss what we can learn from each other to solve these present and future challenges. This is a very interdisciplinary panel for a reason An interdisciplinary approach can transfer knowledge from one field onto another to gain a better understanding of complex phenomena. It allows for the cross-pollination of ideas and methods between different disciplines, leading to new insights and a broader understanding between different disciplines, leading to new insights and a broader understanding. Yet interdisciplinary research is not just about borrowing tools and methods from one field to another, but also about critical analysis of the assumptions, methods and frameworks within a particular discipline, which can also lead to new ideas and potentially transformative changes. So thank you for joining us tonight to be part of this exchange of diverse perspectives and knowledge and to think about the enduring and emerging challenges faced in global health.

Philippa Nicole Barr: 3:54

Okay, so I'm actually going to start us off in the present.

Philippa Nicole Barr: 3:58

This year in Australia we have seen around 400 cases of mpox reported, and many of them have been coming from New South Wales.

Philippa Nicole Barr: 4:07

In 2022, there were also some cases of MPOCs in New South Wales, and Kyle Sandilands suggested that his way of trying to avoid contracting MPOCs was and thank you for Jane for this idea, by the way was you know he stated on words on the radio, words to the effect we have decided to keep our baby away from gay people because we think monkeypox is affecting the gay community. We're worried about the symptoms, such as scabs. And I do want to make it clear that Sandil ands was found in breach of decency rules by ACMA for these comments, so I have not repeated them verbatim. So I'm going to start off this discussion by asking the panel in an era where misinformation can spread rapidly and stigmatise people, what kind of communication strategies best balance the need to inform without inciting unnecessary fear or stigma? How can the explicit communication of values like empathy and transparency enhance both public trust and better understanding of new health concerns? And I want to start by asking Brent Mackie, here from ACON and has decades of experience in this area. Thank you, thank you very much.

Brent Mackie: 5:16

Thank you for that and for the question it's an excellent question, but I just want to comment on that comment by Kyle, which was an incredibly stigmatizing comment and really was. It was a sensational comment in order to get attention, in order to get an audience, but really thoughtless, and it is one that I suppose the communities that I come from, the LGBTQ communities, have experienced for a very long time, especially in the face of epidemics like HIV, but also monkeypox.

Brent Mackie: 5:52

So it's something we've faced a lot from the media, and it's one that we've had to deal with as a community on an ongoing basis. And I think the experience that we had from that especially in public health, you know, that kind of disinformation or misinformation that is communicated has made it incredibly difficult to respond to these epidemics. And my experience I was actually involved with the AIDS Council, with ACON, back in the late 80s, early 90s, so I was there. There was an incredibly difficult time in terms of the stigmatisation of people living with HIV. People were often rejected by their families, their loved ones ones, even their partners in those early days because we didn't have a lot of information about what HIV was and people developed a whole lot of misinformation about particularly what it was. And it's an experience that we get today with monkeypox. It's an experience we get today. We've had with COVID as well. You know, know, and it comes in lots of different ways, like claims that the virus doesn't cause the disease. That happened with COVID, that happened with HIV as well. People in positions of power, like Kyle saying those things. I know with HIV, many people, politicians included, really transmitted that kind of disinformation. I know in South Africa, the Prime Minister, the President at the time, Thabo Mbeki, some years ago now, really was a denialist, an AIDS denialist, and said it was caused by the antiretroviral treatments and it was an incredible, incredibly bad situation in South Africa where people't take their treatments but they could have taken these life-saving treatments.

Brent Mackie: 7:49

I think countering it is incredibly difficult and challenging. I think the reasons why people look at disinformation and misinformation are varied and they're not always about ignorance. It's not always about that. They don't know, sometimes because those views agree with their worldviews. Sometimes it might be cultural or religious, sometimes it may be just emotionally safe to to invest in those, those, those, those, those views. I think coming from a trusted source, coming from a source like a community-based source or a source that they know is going to communicate information that is factual, that is clear, that is logical, is an important way and, as you pointed out, values like empathy and respect are incredibly important in shaping those sorts of messages and getting them out to the communities and really getting that factual, consistent messaging, warning people in advance, getting it out as quickly as possible, perhaps as fast as you possibly can managing it over a period of time is the way to go, and shaping those sorts of messages and getting them out to the communities and really getting that factual, consistent messaging, warning people in advance.

Brent Mackie: 9:15

getting it out as quickly as possible, perhaps as fast as you possibly can, and managing it over a period of time is the way to go.

Philippa Nicole Barr: 9:25

Thank you for that. You've mentioned things like really important words or concepts like trust, and you know I was wondering, Julie, if you have any comment on, you know, the importance of trust or using values to build trust in these sorts of, with these sorts of communication strategies, or if you wanted to comment on stigma and stigmatising communication more generally.

Julie Leask: 9:46

There's a lot there and thank you also for all your preparation for this evening, philippa. So trust is the bedrock of how we manage infectious disease events, crises, pandemics, because if you have the public's trust, you have cooperation with what needs to be done. And because infectious diseases are social, you do need that solidarity and collaboration. But because they're social, there is that huge risk of stigmatisation. I think we have all these borderlines in life, boundaries, ideas of what's us and what's other, and they can come into discussions about infectious diseases. So we can manifest biases, prejudice, racism, xenophobia through infectious diseases threats and we've seen examples of that and politicians who actively use those to ferment public anxiety about other groups to forward political agendas. So I think that a lot of responsibility for managing these issues lies with leaders, with the mass media, with journalists as well, because media are often curating information and often very conscious of these issues as well in the way they put news together, and we often don't see that because we don't see what ends up in the cutting room floor and we often don't see that because we don't see what ends up in the cutting room floor. So trust is foundational and Claire and I have done some work and she will talk more about this, I think, on how public values are so important in how we communicate.

Julie Leask: 11:39

So, for example, with COVID-19, there were a lot of public values that influenced policies, but they were often not made clear and transparent, and we argue that it's important to do that so that you are transparent with people about where you're coming from as a leader. So our politicians had to synthesize information from public health, from all sorts of different you know forms of departments, and put the economy, society, workforces and put all that together into policies. And they would often say I'm following the science. But they were doing that. They were following the medical advice, but there were definitely times when they either weren't following the medical advice and were following values and anxieties of society, or they were following the medical advice plus a set of values that they weren't clear about.

Julie Leask: 12:40

So you know, being transparent about values sounds waffly and sort of namby-pamby, but it's actually fundamental to how policies were made during COVID, including about vaccine prioritisation, but they were often not made clear and transparent with the public. And the reason that you want to do that is that you, as Brett says, transparency with the public about where we're coming from. Timely, honest, frank and open communication is particularly needed in a crisis and when people are worried, when they're scared, when there's fear, when there's a risk of people using their fast thinking and often that's where our biases lie. It's so important to have that need for self-determination respected by politicians and leaders, being upfront about what could be ahead, what the scenarios are, how we're planning, and being very honest, frank and open with people, and that's foundational to self-determination.

Philippa Nicole Barr: 13:52

Fantastic. Well, there's a really good point that you've just made and I just want to ask, you know, this is sort of we've been thinking a little bit about MPOCs, you know, and COVID as well, so these really kind of fast moving situations. Susanna, I wanted to ask if you have any comment on how stigma white work with diseases that are more sort of borrowed in, shall we say. You know, some of the neglected tropical diseases that you work have a long history of stigmatizing individuals leprosy, for example, I think that you Typhus is another one. Do you want to make a comment on? You know how?

Brent Mackie: 14:31

In shaping those sorts of messages and getting them out to the communities and and and really getting that factual, consistent messaging, warning people in advance. Getting it out as quickly as possible, perhaps as fast as you possibly can, and managing that over a period of time, is the way to go.

Philippa Nicole Barr: 14:51

Thank you for that. You've mentioned things like really important words or concepts like trust, and you know I was wondering, Julie, if you have any comment on, you know, the importance of trust or using values to build trust in these sorts of, with these sorts of communication strategies, or if you wanted to comment on stigma and stigmatizing communication more generally?

Julie Leask: 15:12

There's a lot there and and thank you also for all your preparation for this evening, Philippa.

Julie Leask: 15:19

So trust is the bedrock of how we manage infectious disease events, crises, pandemics, because if you have the public's trust, you have cooperation with what needs to be done. And because infectious diseases are social, you do need that solidarity and collaboration. But because they're social, there is that huge risk of stigmatisation. I think we have all these borderlines in life, boundaries, ideas of what's us and what's other, and they can come into discussions about infectious diseases. So we can manifest biases, prejudice, racism. So we can manifest biases, prejudice, racism, xenophobia through infectious diseases, threats and we've seen examples of that and politicians who actively use those to ferment public anxiety about other groups to forward political agendas. So I think that a lot of responsibility for managing these issues lies with leaders, with the mass media, with journalists as well, because media are often curating information and often very conscious of these issues as well in the way they put news together, and we often don't see that because we don't see what ends up in the cutting room floor. So trust is foundational and Claire and I have done some work and she will talk more about this, I think on how public values are so important in how we communicate, how public values are so important in how we communicate.

Julie Leask: 17:09

So, for example, with COVID-19, there were a lot of public values that influenced policies, but they were often not made clear and transparent, and we argue that it's important to do that so that you are transparent with people about where you're coming from as a leader. So our politicians had to synthesise information from public health, from all sorts of different you know, forms of departments, and put the economy, society, workforces and put all that together into policies. And they would often say I'm following the science. But they were doing that. They were following the medical advice, but there were definitely times when they either weren't following the medical advice and were following values and anxieties of society, or they were following the medical advice plus a set of values that they weren't clear about.

Julie Leask: 18:06

So you know, being transparent about values sounds waffly and sort of namby-pamby, but it's actually fundamental to how policies were made during COVID, including about vaccine prioritisation, but they were often not made clear and transparent with the public. And the reason that you want to do that is that you, as Brett says, transparency with the public about where we're coming from. Timely, honest, frank and open communication is particularly needed in a crisis and when people are worried, when they're scared, when there's fear, when there's a risk of people using their fast thinking and often that's where our biases lie. It's so important to have that need for self-determination respected by politicians and leaders, being upfront about what could be ahead, what the scenarios are, how we're planning, and being very honest, frank and open with people, and that's foundational to self-determination.

Philippa Nicole Barr: 19:16

Fantastic. Well, there's a really good point that you've just made and I just want to ask you know, this is sort of we've been thinking a little bit about Mpox, you know, and COVID as well, so these really kind of fast moving situations. Susanna, I wanted to ask if you have any comment on how stigma might work with diseases that are more sort of borrowed in, shall we say. You know, some of the neglected tropical diseases that you work have a long history of stigmatizing individuals. Tropical diseases that you work have a long history of stigmatizing individuals leprosy, for example, I think that hepatitis is another one. Do you want to make a comment on? You know how sort of how you've seen stigma work in those cases and you know to what extent what can be done to combat it? I suppose?

Susana Vaz Nery: 20:05

Thanks, yes, so I guess I'm here to bring attention to sort of another group of diseases, the neglectotropic diseases, where I guess I think a lot of these concepts that have been mentioned before apply as well. I mean, I think stigmatization in the case of HIV comes from many times from a place of prejudice, so, um, you know, kind of in relation to behaviors, or to sort of um, exploit the me versus them, sort of uh, you know, guilt shaming, or just to, yes, uh, kind of uh, reinforcing these differences across groups, or either by race or gender orientation or like whatever cause. But also because of misinformation or exploitation of misinformation right, and taking advantage of of a power situation to disseminate wrong information. And in the case of leprosy, I guess, as you mentioned, a lot of stigma comes from poor information.

Susana Vaz Nery: 21:12

Leprosy because of, I guess, the stigma associated with the really sort of bad lesions and deformities that both leprosy or infantilis is causing people that have the disease.

Susana Vaz Nery: 21:24

And these are infections that are chronic infections and are easily treatable, though the chronic manifestations of diseases do cause, like in the case of elephantiasis, enlarged limbs and genitals that are very obvious to everybody else in the community. And the same with leprosy that I'm sure you probably have seen photographs and for instance, with leprosy it led for people patients with leprosy being isolated and not removed from society, when in fact casual contact with people with leprosy doesn't actually lead to infection. And so I guess with these sort of diseases you know it comes from sometimes from a place of just poor information, and what is needed, I guess, is, as you have also mentioned, like you know, interventions at community level to sort of you know kind of fight against that bad information. But also, I think we use a lot of you know the terminology of champions, so people who have had the infection and disease and have been treated and have been able, you know, to overcome those stigmas and are also valuable contributions for the rest of those communities at risk to live and those needs.

Philippa Nicole Barr: 22:50

Yes, I think Anthony Brown, who's in the audience somewhere, did also have a question about engagement, of sorry engagement sorry, now I'm the one not talking into the microphone sort of engagement of the community during COVID. Did you want to make a comment, or?

Anthony Brown: 23:07

Thanks so much, Pip. I'm Anthony from Health Consumers New South Wales and one of the things we saw during COVID was a lot of the good work that's happened about involving patients and community in designing health services and then designing health. Messages really fell away and we know that there's a lot of strength and HIV is a great example of where you bring people in to help say, well, this is what we need and these are the messages that are important to us. They just seem to fall away a lot, particularly in New South Wales, and took a long time that to get back to where it was pre-COVID. So you're just interested in the panel's thoughts about the importance of involving the community and patients, not just you know, as people to treat and people to give messages to, but actually involving us in designing what those messages are, because I think that's where the real cut through comes from

Jane Williams: 24:09

Yeah, thanks, Anthony.

Jane Williams: 24:10

Um, so I think it's interesting. I think a lot of things fell away, and falling away is a um is a kind of very euphemistic way of putting it right. So what happened was that people were like it's an emergency, we don't know what to do, and I think a lot of the principles of good research and good design and so on were which involved transparency, which involved communicating well with a real variety of people in the community, in the population, communicating well with a real variety of people in the community, in the population those sorts of things, I think, were stripped away in the. We don't have time for this kind of, I would say. That was the excuse used.

Jane Williams: 24:58

I think that that timeliness was certainly a real issue. However, I also think and I don't want to downplay how difficult it was, you know the work that people were doing under immense pressure, to try and make decisions really quickly when they didn't have any information. But I think, as the pandemic progressed and as everybody became much more really, I guess attenuated to the idea that it wasn't just what the virus was doing to us, but it was how we were interacting with the virus and how we were interacting with each other and so on. That lack of kind of I suppose, tested social messaging and messaging that really spoke to a lot of different people was really lost. I would agree with you on that.

Philippa Nicole Barr: 25:46

Thank you. While we're on this topic of transparency, I'm kind of interested in addressing this more explicitly. I know that sort of in emergencies like the COVID-19 pandemic, we may have a bit or have to make a compromise between you know, sharing data rapidly to sort of facilitate vaccine development or public health measures, but then there's also certain standards, critical processes, peer reviews, government regulations, things that we really need to observe and that are very fundamentally important for maintaining, you know, trust and also for not compromising or putting individual people at risk. I'll go to Edward Holmes. Your decision to share the SARS-CoV-2 genome online in January 2022 kind of enabled researchers worldwide to initiate the kind of process of developing mRNA vaccines and different diagnostics, but this actually exposed you and your colleagues to really significant personal risk and I was just wondering if you could comment on that and maybe what the pandemic might have looked like if we didn't have that information.

Edward Holmes: 26:58

Yeah, nice to be here. So I think, alas, I think it would look pretty similar to how it was, and that's because it was going to be a pandemic long before I released the sequence. We're talking about a respiratory virus that's pretty infectious. By the time the authorities realised what was going on, it was probably too late. It was in the community and it would have Wuhan's an extremely well-connected city, so it would have got out. I don't think there's any doubt about that. So I don't think I think the pandemic was going to happen.

Edward Holmes: 27:30

There was a narrow window, maybe in November, december, for a couple of weeks, but that was that In terms of personal risk. It wasn't me, it was my colleague, zhang Zhengzhang in China, who really was under and has suffered because of this. What has suffered because of this? Um, what I, what I did was share the sequence and I was thinking at that point about pcr testing, because you need to have the genetic code of the sequence make a pcr test. So that's what I was thinking. What I did not expect was the speed at which vaccines were designed was actually breathtaking. So I released a sequence on a friday evening us east coast, us time by monday morning they designed the vaccine, that was the moderna vaccine, that was the one and everyone used the same technology basically. And so two researchers in the us they saw my, my sequence downloaded it over the weekend they worked out how to stabilize it and turn it into a vaccine extraordinary. But then it takes months to do the trialing again. So so you know, overall, if I hadn't released it, that release would have been delayed maybe a few weeks at most.

Edward Holmes: 28:27

In the great scheme of trying and how it's done, it wouldn't have made a huge difference. Bigger consequences were made by governments, probably in China, and lots of governments failed right. So China took overly long to accept those human-to-human transmission. It was blindingly obvious. It was because the number of healthcare workers being infected was huge. That wasn't getting reported In Europe. The UK, particularly Boris Johnson, and Italy just didn't take it seriously at all. The US were very slow in their response. So I think initially people were in denial actually of what was going on. So you know, I think it would have panned out pretty quickly.

Edward Holmes: 29:09

But on the plus side, we, you know there have been definite improvements since on the biomedical side. If improvement since it started and one is in is in vaccination. I think our countries realise we need to have vaccine capacity, production capacity in different locations. Mrna vaccines will be transformative. The next thing you'll see will be multiple mRNA vaccines in single doses. So you'll get a single shot for flu, covid, rsv in one day. That will happen soon and in the bank they are already designing vaccines to recognise what they think might be pandemic threats coming forward. So that is definitely a positive thing. Scientifically, whether governments have got any better, I was much more sceptical about that. You know, politics is unfortunate. As someone very famously said, when you mix politics and science, you get politics right. So, sadly, the politics is awkward.

Edward Holmes: 30:07

Awkward, but the scientifically it would've definitely improved

Philippa Nicole Barr: 30:10

um on the politics or the um, the issue of sort of whether there was sufficient transparent, early communication, um, Claire, do you have any comment on on that topic? You know whether sort of official, how official communication impacted public trust? We had a question from Rowena Ryan online who sort of asked if public health communication could have been better from day one. So what would be your take on that?

Claire Hooker: 30:37

I don't think anyone was really happy with communication in a pandemic and I don't think anybody ever is. And, to Jane's point, we understand why. We understand that everybody was under immense pressure and things were not always managed in the most ideal form. Having said that, I kind of was trying to keep the thread of all of these different ideas around the panel. I thought I would circle back to where you started with stigmatisation, because it's a very concrete element that can be addressed through communication and it made me think about how stigmatisation of particular groups has been an absolute feature of pandemic experiences historically, back into the mists of time, as long as we've had historical written records of pandemics, including bubonic plague and various the English sweat, and in fact pandemics often have the names of countries, just so that you know who to blame. But one thing that we that's true and at the same time, the other flip side of that is true that pandemics, as somebody has written in an entire book, have also been stories of, like any crisis, of incredible generosity, enormous amounts of solidarity, a lot of mutual support, a lot of people who are understanding and coming together. So both stories are actually very true and have been historically sustained. The media that although in the very, very early stages there were some use of a lot of references to China, for example, or talking about the China virus or those sorts of things, it was not very long before there was a lot of conscious intention to correct that. And I say that because I thought that was also a feature of a lot of communication during COVID-19 in Australia. There were many ways in which I could look back and talk about how I would like it to be improved. Ideally, for example, the people who are going to be affected by a decision will have the earliest and first notice of it, and that is always something that people are concerned about if they hear on the news first a policy that's going to have a direct impact on what it is that they do. You can't always manage it, but it always feels more like an imposition if you're not being given some kind of additional communicative support around that set of responsibilities. And I certainly would be very happy to talk at length about the inestimable, in my view, public value of being as maximally open about the basis on which you're formulating a decision, including the evidentiary basis on which you're formulating a decision, including the evidentiary basis on which you're formulating a decision as possible, and it goes to what Julie said.

Claire Hooker: 34:11

She alluded to the work that we have both done in identifying. Well, we didn't identify. We had taken note of extensive amounts of cognitive science research that shows that people's responses to communications are very strongly determined by whether or not they trust the speaker. I mean, it's actually. That sounds almost like a truism, it doesn't sound like an insight, but of course, it's something that people need to be taking into account.

Claire Hooker: 34:40

Well, what makes you trust somebody? One of the first things that makes you trust somebody is that you know they're being transparent with you and that works on a population basis. In a country like Australia that is, despite the fact that we might want to critique it, that is, on the whole, fairly civic minded in both its public health decision making and its communication around that. This space in which that kind of transparency can be your best guide, and what it does is. It allows people to do a couple of things. It allows people to understand what's uncertain, even if that makes them feel uncomfortable. It allows people to understand that there is no single right answer. People to understand that there is no single right answer and, even if you don't like the answer that the authorities pick, you can at least also, at the same time, accept that you're still within the zone of possible reasonable responses. So you might not like that one, but at least they're all potentially reasonable and you can understand the parameters of that. It allows people to feel like they are being trusted, and that is so critical and key to bringing them with you as partners in your decisions in a pandemic.

Claire Hooker: 35:57

A pandemic is an uncertain situation, so I'm just going to tell you right now. So I'm just going to tell you right now we will all get it wrong. My favourite article in the news in the entire pandemic was when a journalist asked maybe even you, eddie, somebody, at least a number of people what were things they'd gotten wrong so far. I loved hearing that they were absolutely the most expert people. So we're all going to get something wrong. So the other thing that being really transparent in a pandemic lets you do is make a mistake and still have the public with you, and you will be making a mistake.

Claire Hooker: 36:34

So you need the public to be with you and in the literature, this is referred to as sustainable public trust. That is public trust that you're not going to lose simply because it turns out that the decision that you made was not, in retrospect, the correct one. And people will do that again where the conditions of civic, democratic discourse are met and we are, despite our complaining. We have those here, and I think all of us need only look to highly polarised countries to appreciate the privilege of maintaining and sustaining that kind of civic space. Things shift where you have an incredibly polarised set of circumstances, because there you don't have the same affordances. You still have the correct response of being reasonable and factually oriented, but you do that knowing that it will not have the kind of reach that under those circumstances.

Claire Hooker: 37:41

In my view, some of your most effective tactics are to align more explicitly with social identity and social values, because they are often strong drivers for how people appraise information. So all of us appraise information in ways that is framed by some of our prior values and commitments. We've got lots of studies that show that. So all of us are open to appraising information in a way that's we will never appraise information from a position to which we are opposed. With an unbiased brain, I guess, is what I'm trying to say. So in those circumstances, then, communication is about looking for common ground, and sometimes it's about social identity, and sometimes it's about values where transparency can no longer hold you.

Philippa Nicole Barr: 38:36

I find that very interesting and I'm particularly interested in this notion of values and sort of civic identity and to what extent we are able to cooperate But oftentimes, obviously, these pandemics, sort of civic identity, and to what extent we are able to cooperate when we feel like we share an identity, but oftentimes, obviously, these pandemics sort of you know, they're global experiences we have to depend on decisions being made in countries where we have no control over what's going on, where we can't really, you know, contribute and yet somehow we're still going to be affected by how other countries manage diseases and by how, you know, by how these things sort of play out on a global level. And I want to address that and also then maybe think about, you know, some of the diseases that are, you know, more prevalent outside Australia and why we should potentially think about that. Jane, I saw you nodding when I was saying that. Did you have any comment on this kind of you know, how we can think about this ethics of the global health? I suppose you would say.

Jane Williams: 39:40

by closing the borders and trying very, very hard not to be part of the global health story, and I think that was a not unusual for Australia response but one that obviously worked well for most people most of the time. But it's not the way that we usually manage global health issues.

Philippa Nicole Barr: 40:10

Yeah, I wanted to kind of think about I suppose you know what's happening. We do sort of often forget that there is a world outside of Australia where a lot of things are quite different, and you know, I guess I just wanted to maybe reflect on the way that diseases can kind of the way that we might need to have some or share some responsibility for what's going on beyond our own borders In terms of zoonotic diseases. You know there's a lot of things going on that are changing the world and changing the way diseases spread and changing the way that you know, people are engaging with their own environments. Susanna Vazneri, did you have any kind of comment on why we should be thinking about zoonotic diseases, how the relationships are with you know, why they're increasing or would appear to be increasing in frequency, and what the global community can potentially do about it?

Susana Vaz Nery: 41:11

zoonotic diseases have always existed and, um, and they will continue to do so at the moment. Yes, you're right, it is believed that maybe six out of ten emerging diseases will be zoonotic diseases, but it is, I think. I guess they are becoming more common because of of human activity. Um, you know urbanization and like including this deforestation sort of you know urbanization and like including deforestation, sort of like you know anything that? Well, zoonotic diseases sort of imply that people are infectious agents that's used to only infect other animals will be able to also then jump and infect humans, and sometimes they evolve in such a way, like in HIV, that food originated in an animal but then strains became just human only. But so this process has occurred over and occurs over time.

Susana Vaz Nery: 42:04

But the more we sort of destroy and affect our natural environment and make, you know, deprive animals from their original habitats and expose humans to those sort of wildlife that wouldn't share the same habitat as us, we will be increasing the odds of this happening. And then there's also climate change, obviously. You know, particularly for vector-borne diseases, so diseases transmitted by mosquitoes, for instance, that with the temperature increase globally, mosquitoes will be able, or some species of mosquitoes that are, I guess more concentrated in tropical areas, will be able to then also kind of expand and transmit those diseases to other areas where they usually didn't exist and also, you know, kind of increased flooding and increased levels of precipitation, again sort of increased breeding sites for mosquitoes. So yes, human activity is leading to an increase in the arisal of zoonotic diseases, including, you know, I guess maybe not the only theory about the emergence of COVID, but I guess the more accepted one is that it is a zoonotic disease and jumped from you know animals to humans, as others did.

Edward Holmes: 43:35

Can I say that these jumps happen every single day.

Edward Holmes: 43:39

If you go into Southeast Asia not just Southeast Asia you look at people who interact with wildlife, who work in animal markets, and you test them. They've been exposed to animal viruses and coronavirus. It happens every single day, and so every time is a roll of the dice and eventually your number will come up. Okay, and we need to. We need to understand that, that that process just goes on continually and with climate change, it's just going to magnify it thousands of fold. Okay, so covid could be a walk in the park compared to what comes next. Unless we kind of take it seriously, then then it could be, you know, much, much worse.

Philippa Nicole Barr: 44:19

And this is a good reason to think about what's going on beyond our borders, absolutely so, on that point, I want to talk to or ask you know, bernadette, you about your research, because you know you focus on a disease that you know has existed for millennia. Is, you know, still the 10th biggest killer of people or 10th biggest cause of death worldwide I think in 2021 or 2022, and, you know, has been present since homo sapiens evolved. So obviously you like a challenge. I'm getting lunch. I'm getting um, you know, um, can I ask you why, what, why or how has TB managed to persist and adapt for millions of years? And, um, yeah, you know, how, does the rise of sort of treatment resistant TB reflect a kind of broader problem of antimicrobial resistance as well? Um, I'd be very interested in in the global.

Bernadette Saunders: 45:14

So we've as you mentioned, we've had tuberculosis for a long time and one of the reasons it survives so well is it has adapted with us um, it has lots of characteristics that allow it to survive. So a disease that is so virulent that it kills its host really quickly. That's not a good survival strategy for the disease because it doesn't have enough chance to infect the next person and then and survive, so that the organism and tuberculosis is a bacteria it wants to survive. So one of the things that's quite amazing about tuberculosis is we estimate that about a quarter of the world's population is infected and TB is one of those really interesting diseases where infection and disease are very separate things. So most people who get tuberculosis, their immune system does what we want. It protects them. They never get disease, they never get sick. A small portion of people will at some stage go on, maybe very quickly. Sometimes it can be years or decades after they were first infected. They will go on to develop active disease and spread that disease to the community. So for tuberculosis, it can live in the community for a long time and move quite gradually. It's a very slow growing organism and move from person to person and so it creates huge problems. One of the problems about being a very slow growing organism. So it takes about 24 hours for the bacteria to double, whereas normal bacteria double in about 20 minutes, most of them. So if you normally get sick and you need some antibiotics, five days is probably about average for a course tuberculosis. It's four antibiotics for about six months, or at least two months to start and then a couple to keep, continue on. And that's because it's very slow growing. It's hard to kill. It manages to sort of burrow its way into our cells. It's very well adapted. The strains areulent, but they're not so virulent that they normally kill people quickly.

Bernadette Saunders: 47:19

One of the problems about antibiotic resistance is that we have antibiotic resistance strains everywhere. It can be magnified by the fact that you know how many people in this room could be honestly admit that you had a five-day course of antibiotics and you forgot to take one of your antibiotics one day. You know we're not very good. Imagine being told right here's your big chunk of pills. I want you to take them every day for the next six months. Your pee will go red. Sometimes they have liver disease. They can cause toxicity of the liver. It's hard to get people to take their antibiotics for that long, so that increases the risk of them developing antibiotic resistance. Antibiotic resistance is much harder to treat. The drugs we have to treat it are terrible. They cause deafness, they can cause people to get psychosis. They cause terrible side effects. So it just compounds the problem.

Philippa Nicole Barr: 48:16

You've done. I mean, I find this very interesting because obviously it's a huge problem but it sort of seems very invisible in Australia and history has kind of almost forgotten this disease, which is amazing because it's persisted for so long. But you've actually done some research on a similar-ish infection and a non-tuberculosis mycobacteria infection I hope I'm getting that right that appears in Queensland and other parts of Australia, and so I'm interested in this because it seems like a little bit of a jump into Australian territory and a reason for us to kind of another reason. Obviously there are good reasons, but another reason to think about this Can you explain this research?

Bernadette Saunders: 48:52

So mycobacteria is the name of the species that cause tuberculosis. Mycobacterium leprae cause leprosy. All the other bacteria in that species we call non-tuberculous mycobacteria, and there's a couple of hundred of them. A couple that we might you might've heard of are the ones that cause ulcerans, those nasty ulcers that you see in people, and there's a couple of other strains that who are part of the non-tuberculous mycobacterium, mycobacterium avium. That got a lot of prominence in Australia because early on in the days of the HIV it caused a lot of death in people to what we would call an opportunistic infection. So people who are immunocompromised are more at risk.

Bernadette Saunders: 49:35

The non-tuberculous mycobacteria are big risks in cystic fibrosis patients, people with chronic lung disease, because they're mainly lung infections. In Australia you're more likely to catch a non-tuberculous mycobacteria than you are TB. All around us, particularly in our Pacific neighbours, tuberculosis is a major problem. Tuberculosis has still killed more people globally than any other disease and it still last year killed about 1.3, 1.5 million people. So it is something that we can treat with antibiotics. So it is something that we need to improve treatment. It remains a risk.

Bernadette Saunders: 50:18

The non-tuberculous mycobacteria are actually even harder to kill and the reason why we we often talk about them in Queensland is because Queensland collects better data than any other state about the non-tuberculous mycobacteria. It's a a reportable disease there, whereas it's not in New South Wales, so that makes it much harder for us to know actually how many people are infected. But again, antibiotic resistance and a lot of these organisms have intrinsic resistance so that they're hard to kill. They have quite different structures to other bacteria, which impacts their slow-growing nature and, being slow-growing, it's harder for the antibiotics to get there and to kill them.

Philippa Nicole Barr: 51:02

Very interesting, this kind of idea of all of the things around us that we think we've got solutions or we're keeping them at bay, but they keep kind of growing and changing and evading us. That's how they survive. Yeah, yeah, yeah. I want to just touch again on this issue of sort of the global nature of this problem. Julie Lee asks I'm wondering if you want to make a comment on sort of why the health of people beyond our own borders might matter to the Australian community. I know that you know just taking us back to COVID for a minute but during COVID-19 Australia was sort of accused of vaccine hoarding. There were calls for more support of, you know, vaccination, covid vaccination in the Pacific, southeast Asia, some of these places where Bernadette has drawn attention to you know a prevalence of TB. I'm just wondering if you wanted to make a comment on that.

Julie Leask: 52:01

Remember when the Prime Minister was accused of the stroll out, the vaccine stroll out and everyone was so frustrated and annoyed that we had to wait. And then we had that problem where we'd relied a lot on locally made vaccines and the UQ vaccine didn't quite work out and then we were relying on AstraZeneca. That caused this rare but serious clotting disorder, and so AstraZeneca was recommended, you know, mostly for people over 50, then 60. And the mRNA vaccines Moderna and Pfizer were going to come to the country, but we're only going to get most of them by September 2021. And so there was a lot of community anger because we're all being held hostage to COVID at home waiting for the vaccine rollout to happen so we could get sufficient population immunity so we could go back to normal life. I'm sure all of you are feeling a bit re-traumatized by hearing about that again. What was interesting in that discussion was, yeah, we were understandably frustrated as a nation, but rich countries like ours had the power to get contracts with the vaccine manufacturers and get those vaccines a lot earlier than countries such as most African countries got vaccines in those countries in sufficient quantity for a vaccine rollout After COVID was well and truly established in those countries. So there was less motivation, less urgency. It was harder to get the vaccinations out to people and harder to get the motivation of people and that was the problem of vaccine inequity. And in Australia, in all of that public discussion, at least about the rollout, there weren't many people saying, hey, if we rush on this and we're controlling COVID relatively well here compared to other countries, then other countries will potentially miss out. Now, we're a small population so we probably wouldn't have had that much impact on it. But what struck me was that lack of global citizenship in the public rhetoric, in the media rhetoric, and you talk to journalists, and it wouldn't make the cut. You know, it wouldn't end up on the telly or the newspaper because we were thinking about ourselves and that vaccine nationalism, as it was called, is understandable, it's human, but it's unfortunate because the health of other people in other countries will affect ours. But also we should care, you know we should care about the health of people in countries that are less well resourced as well. So what do we do about it? I think it's really it is very difficult. So we had COVAX, which was designed to put a lot of money together and buy vaccines and distribute them more equitably, but that was challenged because of this vaccine the purchasing plans. Australia did have bilateral deals where we were donating vaccines, particularly AstraZeneca, to other countries in the region and that was a perfectly good vaccine in many respects. It just had this rare clotting disorder risk.

Julie Leask: 55:33

So what many people are saying the answer is now is that we need local manufacturing. So African nations need to have their own manufacturers of vaccination so that they can get access to those vaccines in a more timely way than they did with COVID-19. To those vaccines in a more timely way than they did with COVID-19. There needs to be thoughts, you know, with MPOCs. For example, the Democratic Republic of Congo needs vaccine now because they've got an epidemic of it there. How are other countries supporting timely access of that country to that vaccine? These are important questions and we need to think about these as national citizens in a global way.

Jane Williams: 56:23

Can I add something to that?

Audience Member: 56:25

as well.

Jane Williams: 56:27

Because it's if we're going to. I agree, julie, that local manufacturing capacity is super important. No-transcript, and you know, maybe that was justified, maybe it wasn't, but it wasn't explained and it wasn't justified. Well, it wasn't justified using evidence or whatever. So I I completely agree with what you're saying and I think there needs to be more, you know, there needs to be less racism.

Julie Leask: 57:16

And we need the Pentagon to not use anti-vaccination campaigns as a tool of espionage and propaganda, because that's what they did in trying to undermine confidence in the Philippines in the Sinovac vaccine from China was that the Pentagon seeded anti-vaccine propaganda in that country to stop people wanting that. This is not a conspiracy theory, even though it sounds like it. It is a well-documented report from a media organisation recently that the Pentagon has not denied. So you know, let's not allow governments to also see misinformation about vaccines as well in that process.

Philippa Nicole Barr: 58:03

It's very interesting. I mean, I think not only are these ethical concerns of you know, to what extent should nations think about what's going on beyond their own borders, but then there's also the question of to what extent should we be thinking about how? You know, these sort of other you know, I don't know if I'd call TB endemic, but you know these kind of really persistent, ongoing diseases are creating kind of weaknesses that should be addressed before we get to a crisis moment and particularly with you know, the kind of continuing emergence of zoonotic diseases and these sort of you know, climate change, whether we're getting a global health situation that is sort of so weak that we won't be able to deal with the next crisis as well. I wanted to kind of ask Susanna, you and Bernadette about sort of resource allocation, again, thinking about what happened beyond our borders. What kind of things happened with resource allocation for TB programs or for some of the neglected tropical disease programs when COVID hit? Susanna, do you want to?

Susana Vaz Nery: 59:09

Yeah, but yes, I mean, I think, sorry, just kind of a step back as well. I mean I think, sorry, just kind of a step back as well. I mean, when COVID hits. I think we've been talking about inequities and sort of. You know how we dealt with the control measures and how the decisions were made, and I think, and also like how to communicate information, including sort of differences in opinion of information.

Susana Vaz Nery: 59:42

I mean, even in Australia, at the beginning of the pandemic, there were voices sort of against the sort of shut everything down and lockdowns, particularly then when it continued in 2021. And, you know, one can argue that a lot of those measures were actually quite not equitable, because, you know, it's very different for people who have, you know, jobs or non-casual jobs to stay at home and work online, whereas you know people on casual contracts or manual labours and they don't have an option to do zooming or online whatever. So you know, like you're, you're there there, there was still many other levels of society, even in high-income countries like australia, beyond, uh, covid and other disease programs that and and people suffering from other conditions that were, you know, affected, you know, like cancer, chronic diseases, people needing surgery, chronic pain, all that those situations, if we look then at, you know, low and middle income countries, what I've said in terms of social inequalities becomes amplified. So these neglected tropical diseases, particularly in countries that you know I guess have population demographics that are quite different from kind of high-income countries, but also where infectious diseases do cause a lot more mortality and morbidity than they do in high-income countries. So you know, there are global targets to sort of eliminate a lot of these neglected tropical diseases as public health problems and you know, with the control measures that were established at the beginning, that derailed those control programs and and now people kind of look back and it is, it's estimated that, um, you know, like a stop in these programs. So the, so the for neglected tropical diseases, and sorry about the jargon, but these diseases are very easily, most of them, or quite a number of them, are very easily treatable. Of them, or quite a number of them, are very easily treatable but they require mass drug administration campaigns. So they require people or health staff going out to communities and giving medications to people and because of these social distancing measures they were interrupted, not for very long. So the WHO did tell countries stop all these master administration programs, but maybe six months into after that Still in 2020, they started sort of going back because they realized that interrupting all these efforts would have huge consequences, and they did so. They set back control programs for every year that they were interrupted.

Susana Vaz Nery: 1:02:35

You probably lost five years of progress, and I'll let Bernadette talk about TB.

Susana Vaz Nery: 1:02:41

But in malaria, you know, that's kind of. You know it still causes 600,000 deaths every year, most of them children, and until 2020, in recent years before that, the world was in a good trajectory to decrease malaria cases and deaths because of, I guess, renewed global interest. Sorry again about the numbers, but malaria it is believed that malaria, over the history of human humans, has killed 50 billion humans. That's half of the entire number of people that ever lived. I mean, if you think about it, it's like really kind of really hard to believe how come malaria still exists and still causes 600,000 deaths a year and why there is okay, now there's two vaccines, but you know COVID vaccine was developed in a year and rolled out, and malaria vaccine has been in a pipeline for like 30 years. It took 30 years to develop a vaccine that is now being rolled out. So there is a lot of social inequalities. That that you know we should reflect beyond COVID-19. And, ashley, I don't know if I've answered your question.

Philippa Nicole Barr: 1:04:03

Yes, fantastic. I want to go to Bernadette. Why is there no TB vaccine? And also, can you comment on sort of what happened during COVID with you know the TB treatment programs and what was going on in terms of resource allocation?

Bernadette Saunders: 1:04:17

So well, there is a TB vaccine, so it's called BCG and many people will have a scar on their arm. I'm looking at all these people hitting their arm. We don't give it in Australia anymore as a general rule because it wouldn't actually help Like there's, so it wouldn't save people from getting TB in Australia because we have very little TB. The vaccine is still given globally. Most children get it in the first 24 hours of life, particularly in any part of the developing world, and it's still very effective at preventing deaths by children. Children, when they get TB, unfortunately often get meningitis TB in their brains and it has a high fatality rate. So the vaccine works well at preventing deaths in children. The problem with the vaccine is it starts to wane when people become late teens, into early adulthood, and they start to develop active TB disease then and of course that's a population who are having children, who are working, who are supporting the rest of the community, unfortunately succumbing to TB.

Bernadette Saunders: 1:05:24

What we found happened during the pandemic is that TB is a respiratory disease, so finite resources of numbers of doctors and nurses and respiratory clinics. So they put their efforts into COVID because it was a more immediate problem. People were scared to go to hospital because they didn't want to contract COVID and die. There was lots of people didn't understand the disease so they were scared. So lots of people who had symptoms didn't want to go to hospital or there were no clinics to go to because they had been turned into looking after the COVID clinics. The hospitals were looking after COVID patients, so it was a juggle of resources. As a result of that, lots of people missed being diagnosed and so now we've seen increases in the number of deaths and cases the number of deaths and cases and, like malaria and some of the other neglected tropical diseases they estimate we've kind of put our progress towards declining TB back about 15 to 20 years. So it's had a major impact on tuberculosis control globally that we're still trying to deal with now very persistent these diseases.

Philippa Nicole Barr: 1:06:34

None of them have kind of none of them are closed, I suppose you would say.

Philippa Nicole Barr: 1:06:38

I think that that's kind of it's a good. It's a good point to reflect on the kind of the way that these sort of other diseases, if left kind of without sufficient resources, kind of create a situation where, you know, the pandemic will really create a major setback, I suppose. So it's a kind of like a global weakness If we were to think about, you know, health internationally rather than nationally potentially not having well, having these other diseases without sufficient resources, without sufficient you know, the right, the best treatments, or having such large case numbers, is really creating a weakness that's going to, you know, cause bigger problems when a pandemic comes. And I wonder if that should be one of the lessons that we learn from COVID-19. I kind of want to go to sort of a more general question now and really kind of think about you know what lessons from pandemics prior to 2020 should have been useful in the COVID-19 pandemic and what we might take away from COVID-19 that we should sort of bring to the table next time. Julie Leas, do you have anything?

Julie Leask: 1:07:52

Well, in fact, some of our pandemic planners had read the 19 um 19 about the 1918 1919 uh, what they called it the spanish speaking of country naming there, the was the original h1n1 um influenza uh pandemic and it came to Australia in 1919. And there was a report about that from our who was the Chief Health Officer of New South Wales at the time, I think, and some of our very own pandemic planners who were, you know, writing pandemic plans 10, 15 years ago, had read that and were taking lessons from that. So we actually had a bit of that noticing of history and it was very useful because the past teaches us a lot about what could happen now and what we should anticipate. And some of the things that were observed in 1919 were that people were getting terribly sick and they didn't have people to care for them. People wouldn't go near the houses, they'd put flags outside the homes of sick people and visibly stigmatize them and people were terrified of them. So there was not enough care. That was happening.

Julie Leask: 1:09:14

But also what they saw happen was communities rallying, didn't they, claire? And the importance of community. And of course we rediscovered that with COVID-19 and just how essential it was to have strong community-based, community-level responses that involve community engagement, that heard from communities as well as informed communities. So I think we could have taken a lot more notice of what had been learned in 1918 and 1919. Polio epidemics in Australia in the 50s there were controversies. They closed the beaches, they closed schools. Lessons from then that could have informed how we managed COVID-19 more than they did.

Philippa Nicole Barr: 1:10:05

Yeah, good point. Brent, you had a lot of experience with the sort of HIV AIDS pandemic and with working with ACON for a very long time and I just want to ask if there was anything from that experience that you were able to bring to your work during COVID-19 and sort of how ACON responded and also that element of community that Julie was referring to.

Brent Mackie: 1:10:30

Yeah, yeah, of course. So appreciating that COVID was a very different epidemic to HIV in many respects yes, it was very quick and it spread quickly. It was transmitted in a very different way. I think there are still some really valuable lessons that we can learn from the experience of HIV in COVID and we talked earlier about community involving community, community-led organisations, getting them involved in designing and leading many of the responses. I think some of the issues that we faced with COVID could have been alleviated or lessened if that was followed more. And I do understand that we need to respond quickly, but you can still involve community in those decisions and I know some of the issues communities in South, western and Western Sydney face could have been responded very differently to community involvement and building that trust we talked about earlier, that trust and responses.

Brent Mackie: 1:11:32

I think some of the lessons we also could use with COVID include things like not using a fear-based response and at the beginning with HIV, you know, with campaigns like the Grim Reaper, which really did alienate a lot of people living with HIV, that really did, you know, provide little information about how to deal with HIV and scared a great deal of the community.

Brent Mackie: 1:12:02

I think taking those lessons in terms of how we communicate around COVID and other epidemics into the future, bringing people along, using trust and also using, you know, empathy as you talked about earlier um, is a far more productive way of responding to those, to those um, to emerging new uh epidemics. I think um and I I think one of the last ones I probably would touch on is with HIV, and I think it's kind of important because there's a lot of talk about we've talked earlier about stigmatizing people and discriminating against people with these conditions and a lot of that time it's signaling people or groups of people out, very often vulnerable people as the spreaders of those diseases. And I think if we really focus on our responses, on the behaviors, rather than these groups or individuals as the ones that are the problem, you know, and I think there was a lot of that in COVID, I remember when that I think it was a taxi driver or an Uber driver was signalled out as being a person who has, you know, destroyed lockdown the limo driver.

Brent Mackie: 1:13:22

The limo driver. Yes, and there was a lot of talk about his ethnicity, which was really, I think, very damaging and would have been incredibly painful for him as a person. But we need to talk about the behaviours how you spread it, and we certainly learnt that over time. In HIV, you talk about prevention activities as using a condom or using PrEP or PEP. I think that's far better than saying one particular group. I think we can transfer to future epidemics.

Edward Holmes: 1:13:56

So can I say something that we didn't learn? Okay, and that was we'd had two previous COVID outbreaks in the previous 10 years of SARS and MERS, and yet there was no investment in vaccine. There was short-term vaccine funding and then it was stopped. There was no investment in antivirus for those, nor in the basic biology of those infections. So they came and they went and we just forgot about them. And that data was there and our models for how the pandemic would go were based on flu, which is not a bad model, but it's not COVID, and COVID behaves in a different way than flu and so they were there and we just didn't pay attention.

Philippa Nicole Barr: 1:14:34

Yeah, I know that. Well, I'm not sure if this is true, but I heard that virology got a bit of a funding boost from the HIV pandemic, in a sense, because there was a sort of renewed attention on it, I suppose. Has the same result kind of emerged from COVID-19? Is there more investment in it?

Edward Holmes: 1:14:53

Well, unfortunately, yeah, yeah, it's been offset by the let's just think about the conspiracies. It's offset by by, um, the blame that people have now attached to virologists for this pandemic, and I think that has been massively detrimental. What you've seen in the US has been science on trial, and my colleagues, in fact the us senate, had a, had a place set for me at their hearings. You've seen people on trial for writing a scientific paper, and so there's been a massive anti-establishment, anti-science movement in the us. But you know why? Because science counters populist rhetoric.

Edward Holmes: 1:15:32

Because in populist rhetoric you can have alternative facts right, which you can just alternative facts right, which you can just spew out. Science, you have one fact and that's the truth. So science is kind of, it's anti, that way of thinking, and so science scientists have been, I've been been vilified and it's been been absolutely horrendous. Okay, and if and if, if the election goes the way it might, you know it could continue us election. I should say so, um, you know, so I, I, yes, there has been some money in, in, in, in neurology funding, but I think an offset by by the damage that um, it's been, it's been done by the politics of this that will go on for a generation yeah, we stigmatize virologists.

Philippa Nicole Barr: 1:16:14

Yeah, um, claire, I just wanted to kind of go back to some of the points that Brent was making about, you know, targeting people who are vulnerable. We've been sort of chatting today about how you know vulnerable people around the world are possibly going to suffer, or more likely to suffer, a disease. Certainly, you know from people from potentially lower socioeconomic backgrounds or where healthcare standards are different in Australia, and we also, you know, potentially will also blame people that extra kind of vulnerability to infection will then be sort of translated into blame for spreading the disease, even, you know, without really kind of taking into account context. So I just wondered if you had any comment on that.

Claire Hooker: 1:17:01

I thought when you asked me before what would I improve about communication in COVID-19, I had something to say then that came from the research that I share with Jane and Julie in particular, and that's what I told you.

Claire Hooker: 1:17:15

But after I finished speaking, I thought that I actually should have spoken back to you, anthony, and said what Brent said, which was what was the worst part of communication during COVID, and it was the way we absolutely did not communicate well with the most affected populations in lower SES, culturally and linguistically diverse communities in Melbourne and Sydney.

Claire Hooker: 1:17:45

That was the major failure. That question is the answer that Brent and Anthony and our colleagues would deliver, which is that you have to involve community with you every step of the way, in the spirit of Lila Watson and her colleagues to say, not to help them, but because my health is bound up with yours and we need to work together. So, as a basic lesson that can be understood globally, like any catastrophe, any catastrophe is defined first and foremost by the systems that generate inequality, and a pandemic is no different. And finding ways to counter that, that be they at a macro level um, or with global pandemic treaties in an ideal way, or at a meso level and the actions of our own state agencies and actors or at a micro level in the community, is always going to be first and foremost priority.

Julie Leask: 1:18:56

So yeah, I agree that you know marginalised populations are not usually first on the list for communication. So that is the 11am media conferences. Sbs ended up translating those but it took quite a while. So you know there's always that delay in even simply language translation. But to be fair, there was quite a lot done. That wasn't always completely obvious as time went on.

Julie Leask: 1:19:31

So in Victoria and New South Wales, which I'm familiar with, the vaccine rollout did involve. For example, in Victoria they funded community groups and migrant community groups to run their own community engagement. In New South Wales there were people I remember talking with people in Western Sydney and we've got the former Director of Public Health of Western Sydney here, steve Corbett who were embedded in their communities and working for the local health district. So that provided an embedded channel of communication between health and the communities in Western Sydney and that would happen across many LHDs. In Hunter, new England, for example, we had some very strong Aboriginal leaders who were running a COVID response for Aboriginal communities in that district. So there was good stuff happening and you know that too, claire, but it just it took time and I think one of the big lessons for even some of our public health leaders has been. We need to prioritize those communities much more quickly and build stronger communities yeah.

Philippa Nicole Barr: 1:20:46

Stronger health systems and communities, yeah um.

Audience Member: 1:20:49

So I actually come from a low socioeconomic area and there was a lot of conspiracies going around. A lot of people felt like they were being deliberately excluded or that things weren't being told to them because people thought they were stupid or things like that. But there was obviously some people who still took the health advice and whatnot. But how can we in the community actually tell others who may be angry at the world or angry at what they're not being told or falling down conspiracy rabbit holes? Actually educate our community and keep everyone safe.

Claire Hooker: 1:21:21

My first answer is that you can't change people's mind unless you're in a relationship with them. So it's about the relationships. Many things come down to the relationships that you build prior to a crisis and to the alliances that you can form within a community in order to respond to it. And then I feel, as Julie's alluded to, that we have people with lived experience and expertise who can speak to that with far more depth and complexity, who can speak to that with far more depth and complexity and I think, if I, it's a terrific question, by the way, thank you.

Jane Williams: 1:22:01

I think, also adding in respect. You know, if you continually treat some populations with the lack of respect, then you can't all of a sudden expect sort of compliant buy-in, because that just it's not the way people work.

Brent Mackie: 1:22:22

I would just also add and we've spoken about it before it's about building that trust with those people and with those communities, and that takes time. That's something that takes considerable time, and also providing them with clear and factual evidence or information. And I think it is difficult when a new epidemic emerges, because you don't always have that to hand. But then you've got to be honest about that. You don't know. All of the answers that are still being worked out, and I think that was some of the issues with COVID is that we said things that we thought were true but they weren't, and we weren't clear about that as a health sector circulating in some communities that were saying that they were largely imported from the US, that the vaccine was a conspiracy to control people and harm people.

Julie Leask: 1:23:24

And what worked there was for First Nations community leaders to be promoting vaccination. So Uncle Ray Minicon, who was also a pastor, got on a video and said to and this was particularly designed for Christian communities, indigenous Christian communities vaccination is an act of love. Get yourself vaccinated. And so working with those community leaders, uh, was incredibly important and one of the reasons why you know where I did 50 webinars with different community groups, for example, because that informing them about vaccination, guiding them on how to have conversations, address conspiracy beliefs, build relationships, relationships, use trusted sources, that was really the best way to deal with that challenge.

Stephen Corbett: 1:24:22

Yes, my name's Stephen Corbett. I was Director of Public Health at Western Sydney. There's two things I'd like to say. Trust is a two-way street, and I mean I've been reading a lot recently about the Swedish example, which I just am amazed about, because they had very little lockdown, very little policing of behaviour, and one of the keys that they've identified is that the government trusted the people to do the right thing. And I'm really interested, brent, in the analogies with the HIV epidemic, because I know that happened as well. Sure, there was education and everything, but there does seem to have been an investment in people rather than we had police patrolling the streets enforcing behaviour. That's not a signal about trust, that's a signal about authoritarian control, and I just wondered whether, if Sweden can do it, and they had an excess mortality about the same as ours at the end of the day. So to me that's a remaining question.

Stephen Corbett: 1:25:23

The second thing is, I would say, about Western Sydney and this is the thing that really shocked me was how some groups are incredibly disconnected from government.

Stephen Corbett: 1:25:34

We had Somali people and Pacific Islanders particularly, because when the threat happened, they hunkered down into their family groups and they weren't hearing. Or it's not just a matter of them trusting you. I mean, we had imams and we had Zoom meetings with lots of Islamic populations of Western society. We did all that stuff. But there were some people whose response and that was the thing that we, I guess, and when we were successful it was just through individual contacts and giving people your telephone number and having lots of contact with people. But that was the thing that shocked me the most was just how some groups were so living within their communities. They didn't really they weren't interested to hear what the government was telling them about how to protect themselves, and in some situations to great harm. You know, the Pacific Islanders suffered particularly badly from COVID in Western Sydney, so I don't know if any of the panel would like to comment upon that.

Brent Mackie: 1:26:36

Thanks, stephen. Yeah, I mean it is very interesting. In the early days of the AIDS epidemic or HIV epidemic, governments did show a great deal of trust for the LGBT community to take on the messages. Part of it was also, I would have to say, is that messages that we were communicating, had to communicate, were unpalatable for government organisations to do in the 1980s. It was a time when homosexuality was just being legalised and coming out with those messages was really difficult for public health in government institutions. But also there was that trust they did provide the money reasonably well.

Brent Mackie: 1:27:17

In New South Wales, but not everywhere like Queensland, there was a very conservative government and they wouldn't fund the community there. And I know money came through the federal government, through an order of a Catholic nuns who then passed it on to the community. So it was kind of like we're funding nuns who then passed it on to the community. So it was kind of like we're funding nuns but we weren't situation. But you know those workarounds were thought through by, you know, governments, bureaucracies at the time and you would have to say some of that perhaps was a result of. You know there's certainly a level of privilege that you know inner-city gay men have that aren't in those marginal communities in southwestern and west Sydney, especially recent migrant communities, and perhaps that had an impact on how they were perceived in those circles and governments.

Philippa Nicole Barr: 1:28:17

I think we've probably got time for one more question from the audience before we conclude.

Audience Member: 1:28:24

I wanted to ask. In 1974 in Australia we had a massive bovine TB eradication campaign and I don't know how they managed buffalo up in the Northern Territory and all the rest of it, but anyway, and we were all as veterinarians involved in that, my understanding was that the tuberculosis passed to humans through milk wasn't that high in Australia. But also I know that in New Zealand possums had a high infected rate of tuberculosis and I just wanted to ask if you, for my interest at least anyway, could and hopefully some of the audience could make a comment or would you like to make a comment on that.

Bernadette Saunders: 1:29:15

And certainly the tuberculosis that you that passes through animals is the same strain that infects humans. Pasteurization of milk is. You know. We see outbreaks occasionally in places where there is still bovine tuberculosis in the animals and milk is not pasteurized. Australia worked very hard to reduce our TB levels. You know people went for chest x-rays when antibiotics became available. We put people on antibiotics and we worked very hard to reduce our level of tuberculosis Globally. Now you would definitely say tuberculosis is a disease often associated with poverty. There's a lot of stigma in having tuberculosis so people will sometimes not come for treatment because they don't want people to know they're sick. So you know, in terms of the health and ensuring people have access to good health, we still have a long way to go globally. But yes, we worked very hard in Australia to reduce our level of bovine tuberculosis. But there's still quite a lot in New Zealand and it's often spread by the possums UK, it's the badgers.

Edward Holmes: 1:30:26

That's uh, that's controversial.

Claire Hooker: 1:30:31

Brian May, yeah, Brian May, I want to know the truth of this.

Edward Holmes: 1:30:35

Brian May of Queen has led a campaign um, because there was a badger culling program, because badgers were thought to be spreading bovine TB and, bizarrely, Brian May of Queen has been the research trying to show that in fact badgers were not passing the.

Claire Hooker: 1:30:51

Do you have a call to make about this, Eddie? I really want to know it is certainly not proven.

Philippa Nicole Barr: 1:31:01

That's all I can take from that okay um, well, I think we're kind of at about time. I just want to sort of round up by going around the panel and just sort of asking what lesson you would like the world to learn or what problem you would like them to solve, um, in order to kind of improve global health. And you might focus on your particular disease. And, yeah, it's a small question with a little answer. So there you go, bernadette. Do you want to start us off? What would you like to see happen to?

Bernadette Saunders: 1:31:27

Sharing our resources. I mean, a lot of these diseases are treatable. You can see what amazing things we did with COVID incredibly quickly and we could apply that to a lot of other neglected diseases, particularly in the developing world.

Philippa Nicole Barr: 1:31:45

Eddie Holmes?

Edward Holmes: 1:31:47

there was a lot of talk after

Edward Holmes: 1:31:49

gonna talk about pandemic, future pandemics, that's my thing. There's a lot of talk after covid of this global pandemic radar to set up, to have, you know, a global way of mechanism, seeing new things and responding quickly. Just hasn't happened okay, and it was talked about a bit, very quickly went off the agenda. Um, I think we, we could do that, we could, we could, and it's actually the science behind surveillance now and um, tracking outbreaks is really good and and as is making vaccines and antivirals. We could easily do that and the cost is is minuscule, given how much covid costs. Sadly, it's political will okay, and it the political will is is is undermining the basic science. So if I get all the world leaders bang their heads together and kind of make them take it seriously, because it's very, very doable and we should, you know, very doable jane

Edward Holmes: 1:32:42

Jane williams illiams?

Jane Williams: 1:32:45

I think include social scientists. Give me a job. I knew I was like, - oh, I get to go before Claire and Julie!

Jane Williams: 1:32:58

There was still so much at the beginning of COVID. That was all about science and all about the virus and not about the people. I'm still seeing that now. I went to a conference recently. It was called the Pandemic Sciences Institute. There was very little social science, almost no ethics. It's like we all say we've learned, but I don't really know that. We have very little social science, almost no ethics. It's like we all say we've learned, but I don't really know that we have Positive note to end on.

Philippa Nicole Barr: 1:33:29

Learning? Possibly?

Claire Hooker: 1:33:32

Yeah, I'll go all out on that. I'll meet your social sciences and I'll raise you the humanities. Yeah, yeah, I got one cheer from the audience which is not to say - I actually really love the sciences. I just want Eddie to know that because I actually really really do.

Claire Hooker: 1:33:54

But I'm sure many of you in this room and those of you who are watching online know the incredibly famous, indeed symbolic, story of the great pathologist Rudolf Virchow, who was sent to Silesia, now Poland, to investigate typhoid epidemics typhoid or typhus?

Claire Hooker: 1:34:12

I cannot now remember, and when asked for his recommendations for how to control those pandemics which were widespread and devastating in the great control, those pandemics which were widespread and devastating in the great era of pandemics which is the 19th century, his answer was to give everybody the vote, because voting was not universal. To educate them in their own language, because they were supposed to be only educated in school in German and not in Polish, and essentially, to enfranchise them and give them freedom. So I know it's not a direct answer and we love direct impacts, but all I want for Christmas is a repeal of the Jobs Ready graduates package and for everybody to be able to go and do a basic BSc and a basic BA for free, because that investment, in my view, is how we have a population that can come with us to confront an epidemic. Top that!

Susana Vaz Nery: 1:35:14

Thank you - that's what I was going to say!

Susana Vaz Nery: 1:35:15

That's going to be hard to beat, but I mean, I guess what I wish for Christmas and Christmas every day, so maybe today, I mean, you know, I wish COVID is an infectious disease and I wish people in countries like Australia and other high income countries, you know, would reflect a bit more on that threat, because you know we live in countries where, in fact, you know, people die more of non-communicable diseases but that's not true for the vast majority of the population and I think we forget.

Susana Vaz Nery: 1:35:57

I mean I don't because I work on tropical diseases because of that, because I think we forget. I mean I don't because I work on tropical diseases because of that, because I think, you know, I'm very lucky and fortunate to have been born where I was, but you know there's lots of people who don't, who are not born in places where they are. Given those opportunities, and you know, the opportunity to live a life free of infectious diseases or poverty are, you know, is something that doesn't happen to a lot of people worldwide, and so I wish people in countries like these would, including politicians and donors, would not. I understand the need to fund research and policies to protect us globally from emergent diseases, but I hope that that is not at the cost of divesting from diseases that have been around for many, many years and still affect a lot of marginalized and poor people.

Brent Mackie: 1:36:58

It's hard acts to follow. It's a hard acts to follow, but I would say I was lucky enough in July to go to the International AIDS Conference in Munich and one of the big themes for that conference was communities are experts, and I think I would think what we can learn, what we can take forward, would be to value the lived experience of people in the communities and the expertise that is there when designing and developing public health responses.

Julie Leask: 1:37:32

And because Jane stole mine, which was support social sciences and stop putting all that money into consultant companies.

Julie Leask: 1:37:40

I'm going to end on a positive note because I think tonight, you know, when we think about infectious diseases, there can be a bit of doom and gloom.

Julie Leask: 1:37:50

But what overwhelmed me throughout the pandemic which has officially ended, even though COVID is still with us and still a huge burden is that we people did incredible things and I feel incredibly grateful for all of the heavy lifting that so many people did in so many different ways people within government departments so my husband, for example. He was seconded into the emergency response and he that's the guy in the blue shirt there. He's going to hate this, but people like him were working very hard within governments to help answer ministerials really difficult questions, deal with challenging policy dilemmas, enact difficult policies, and they were working extremely hard getting data together, reporting, communicating. People in the community, community groups who rallied people. All of you you're interested in infectious diseases, clearly, because you're here tonight or you're online, you are all probably doing important things. So my wish is that we acknowledge each other and all the things that we did to manage this last pandemic and have hope that we can do this again if we need to.

Stephen Corbett: 1:39:22

And I'm going to take my right to reply and say that it was the entire population of New South Wales, it was the entire population of New South Wales which responded to the advice that was coming from the government, with all its shortcomings, I mean, my sense is we did a poor job in saying why the decisions that were made were made, why the choices, what was behind that. But, despite that, the community of New South Wales are the people that brought New South Wales through the pandemic with a very, very low cost in terms of death and infection. There were all sorts of costs for school children who couldn't go to school and all those other things. But, in compliance and, Claire, I completely agree, we are an obedient, you know sign reading community, obedient, you know sign reading community, and and that that's what got us through and we are extremely fortunate to to be part of this, this statewide community that we're part of.

Philippa Nicole Barr: 1:40:29

Thank you, what a note to end on. Thank you all very much. I'm just going to say some concluding remarks because we do have to wrap up and I I, as we sort of conclude today's discussion. I really think it's clear that this sort of contested end of a pandemic doesn't really guarantee that diseases won't persist, won't resurface, won't evolve and change and won't beat us in the end. And that tb man, that's a good on you for tackling that one, because that one is tough.

Philippa Nicole Barr: 1:40:55

Um, and this sort of reality really underscores the kind of vital importance of public engagement and the need to kind of continuously bridge the gaps between scientific advancement and sort of public knowledge. Knowledge isn't really static like diseases. It's sort of constantly changing and adapting and you know, like all of us I suppose, and it is relational. I think that was a really great point that was made earlier. You know, the knowledge we have is the knowledge we share and the things we learn from other people. So I think moments like this, between crises, focusing on these issues, is really essential to building knowledge, to building trust, enhancing community involvement in public health decision making, as I think we've all emphasised, is very important and our strategies for addressing health challenges has to be dynamic and flexible as these pathogens that we're battling.

Philippa Nicole Barr: 1:41:49

What's more, the global nature of diseases, which are infectious diseases which, you know, really don't respect our national borders as much as we'd possibly like them to mean that we do need to think about international solutions and we need to think about what is going on beyond our borders, as Susanna has pointed out. So the challenges we discussed today are shared and we do really need to come together and think about them in groups, in a concerted effort, and we need to consider these sort of diseases that, while currently more prevalent in other regions, still pose potential risks everywhere. And you know, consider the idea that if a disease is prevalent in one region, then it needs to be addressed by the whole community and not just left for that community to suffer and deal with and be blamed for. So this global perspective is really crucial and it highlights the imperative for continual international cooperation and innovation so to respond to sort of both existing and emergent health concerns.

Philippa Nicole Barr: 1:42:48

So thank you to everyone, thank you to the audience, thank you to the panel Today. You know it was a bit of an experiment. I really want to thank Amanda particularly, and also Catherine from History Council of New South Wales for presenting this event tonight and for being so tirelessly organising everything behind the scenes, and SMSA as well, if they're still in the room. So thank you, you, you, you, you.

Amanda Wells: 1:44:51

Yes, thank you