The recent World Health Organisation (WHO) announcement that the Covid pandemic is coming to an end may draw down the curtain on what has been a challenging two plus years.

There have been many management mistakes, and many questions remain unanswered.

The origin of the virus is unconfirmed, but increasing circumstantial evidence points to the Level 4 viral lab in Wuhan where gain-of-function research into bat viruses was being carried out. The initial Chinese concealment in late 2019, deletion of lab records, and obfuscation gave the virus a chance to spread from the Wuhan Ground Zero.

A limited WHO-led investigation over a year later was allowed limited access to the lab and staff or records. It failed to reach a conclusion.

Sharri Markson’s book, What really happened in Wuhan, detailed the investigation that the WHO should have carried out and offered little doubt as to the virus’ origin. In addition, the politicisation of the Covid outbreak by the Democrats (largely in an effort to discredit Trump) did them no credit.

The early behaviour of the WHO is also suspect, with concerns its leader Dr Tedros Ghebreyesus, whose controversial election campaign was supported by China, might have looked the other way. It would explain the unusual delay between recognition of the outbreak and advice on pandemic management measures allowed the virus to spread. We, in Australia, bought some time to prepare by going directly against the WHO by closing our borders.

The WHO had previous experience with coronavirus outbreaks following the SARS outbreak (in 2002) and MERS (in 2012); the SARS epidemic killed fewer than 1,000 people but cost the world economy an estimated $33 billion. A review by the Lancet Medical Journal in 2016, found the WHO to be ‘bureaucratic, slow to act, and poorly coordinated’. These comments failed to produce any noticeable change in process by the time 2020 came around.

In Australia, a pandemic plan intended for influenza pandemics had been developed under the Abbott government. Following an exercise in 2005, which involved three states in a simulated bird-flu outbreak, a more detailed plan was formulated and delivered in 2006. It was this plan that was conspicuously ignored by all the state and federal health ministries involved in managing Covid.

The rapid development of vaccines was, to some extent, the result of preceding work done on the related SARS and MERS coronaviruses. The first vaccine produced, although not very effective, appeared in China within three months of the pandemic onset, suggesting it had been (at least partly) in development before the outbreak occurred. Other Chinese activities also raised suspicion, including the ordering of excessive medical and testing equipment from overseas prior to the pandemic declaration. This should have raised flags.

Vaccine production elsewhere was remarkably rapid, with supplies available in Europe by late 2020 and Australia in early 2021.

Although not 100 per cent effective, the Covid vaccines significantly diminished the severity of illness, with reduced hospital admission and death rates. As with all vaccines, there is a small risk of side effects, a risk which anti-vaxxers amplified, aided and abetted by Queensland’s Chief Medical Officer (now Governor).

Much medical management advice has been based on political and economic, rather than public health indications. Chief Medical Officers have often given conflicting and arbitrary advice, undermining public confidence. The Covid modellers have much to answer for after their dire predictions failed to materialise. It turns out they were about as reliable as the treasury forecasts!

The regular gathering of Premiers seemed to add to the confusion, with measures introduced to save lives, ending up costing lives. The Biosecurity Act, a means of controlling both animal and human diseases, was updated in 2018; it gave the Federal Health Minister extraordinary powers to control movement and assembly, overruling all other existing freedoms. This central authority was never utilised, leading to dysfunctional individual state management.

The various public health measures introduced have rightly come under scrutiny. Despite its widespread mandatory use, there is little evidence of the effectiveness of mask-wearing; there are obvious limitations relating to the type of mask, how fitted, and how long worn, but fundamentally they do not work. Those who had the virus reduced spread by mask-wearing, and the use of HEPA (high-efficiency particulate absorbing) masks in treating the ill, were sensible measures. Otherwise, it was inconvenient window dressing. Similarly, hand hygiene, or the more impressive but even less effective deep cleaning, has no evidence of benefit in preventing spread.

Perhaps the most contentious issue has been the lockdown. Evidence accumulating from many countries has shown this produced financial pain for little medical gain. The printing of money to keep economies afloat in lockdown has led to the predictable inflation we now see, and a likely recession. Following its authoritarian control, China is reaping what it sowed with its own lockdowns being even more draconian than in Victoria.

One area which has received woefully little attention is air-borne infection spread. In the initial Australian ship-born outbreaks, spread to those locked in their cabins suggested transmission by air conditioning. This has been confirmed in many studies, but did not result in any action. Subsequently, the use of hotel quarantine also allowed spread when A/C systems were not isolated. The fitting of HEPA filters was never considered.

Quarantine belatedly evolved, at great cost, creating purpose-built facilities that arrived too late to be of use, but maybe next time… Quarantine time (the word means 40 days) has progressively shortened as the virus has weakened – from 14 days, to 10, then to 7, and finally 5. As testing and contact tracing fades out, this has belatedly been deemed unnecessary. Similarly, mandatory vaccination for some jobs was necessary in the Delta phase, but with the milder Omicron variant, this is no longer relevant.

The purpose of these manoeuvres was to slow the rate of spread and prevent the health system from being overwhelmed. What has belatedly been recognised is that hospital bed numbers were inadequate before the pandemic. Increasing outpatient options and residential care improvement has to be part of the future management.

Testing, initially with PCR and then rapid antigen tests, has been useful to document the spread and number of infected. It has enabled some measure of disease incidence, but many cases were untested, estimated at as many as 3 per diagnosed case; monitoring case fatality rates have also been undermined by inclusion of those who died with the virus, rather than from it – an example being a man killed in a car crash who tested positive.

The Spanish flu outbreak over 100 years ago killed 50 million out of a population of 2 billion. The latest world stats (16/09) for Covid report over 600 million cases, with 6.5 million deaths in a population of 8 billion, the estimated true number of deaths is calculated at around 17 million; the peak of the Omicron wave, which started in December 2021, seems to have passed. Australia, with a high vaccination rate, has had 10 million cases, with around 15,000 deaths; the number of daily new cases peaked in January and is now below 2,000, and deaths peaked in July to now (mid-September) less than 30 per day. The average age of death is around 85, so the question needs to be addressed, should future lockdowns be aimed at the elderly at risk and not the young who maintain the economy?

In assessing the severity of the pandemic, we also have to look at non-Covid complications. Studies have shown a surge in psychiatric disorders. Domestic violence has increased while school education has been lost. Routine medical treatments were missed, new diseases were not diagnosed, and surgical waiting lists have blown out. In addition, we have the enormous financial implications of lockdown; Australia’s national debt has doubled from around $500 billion in 2019; printing money inevitably leads to inflation, with recession perhaps around the corner. Did we need to restrict business activity or could we have, like the Swedes, protected the vulnerable and maintained business? WHO figures in May 2022, confirmed they had one of the lowest death rates in Europe, as well as a healthier economy.

As we have gained more experience, treatment has improved. The initial clotting problems are better managed, steroids have a significant place, and the newer, expensive, anti-virals are now available for the elderly and at high risk. The contentious issue of use of Hydroxychloroquine, as supported by Donald Trump, became a political football. A final overview in November 2021 confirmed the lack of benefit in treatment and unlikely benefit in prevention. We are now more aware of the long-term complications of the infection, with its cardiac involvement, and the problem of Long Covid. Any management option is a balance between risk and benefit, the use of vaccines in the young is a contentious example.

As the virus has mutated, it has become less aggressive but more infectious; it is likely this will continue, and future outbreaks (if any) will be milder still. Annual vaccination, as with the flu, may be the simple solution. This event has demonstrated the forgotten effect of a virus pandemic on the world, this will not be the last. Questions need to be asked about gain-of-function research and its potential misuse for biological warfare; we need many answers from a Royal Commission about pandemic management in Australia.

Even sleepy Joe Biden thinks it’s all over, perhaps he has also heard a fat lady singing?

Dr Graham Pinn is a retired Consultant Physician and Tropical Medicine Specialist