SHE Pod Season 3 Episode 10: Prof. Kelley Lee on Controlling Borders During the Covid-19 Pandemic

11:04PM Nov 30, 2022

Speakers:

Kathryn MacKay

Kelley Lee

Keywords:

measures

countries

evidence

people

travel

jurisdiction

travel restrictions

pandemic

terms

virus

ethics

unfolding

studies

australia

events

decisions

important

values

restrict

impacts

Hello, and welcome to the sheen research podcast. I'm your host Kathryn McKay. And today it's my pleasure to present to you a talk given by Professor Kelly Lee from Simon Fraser University in Canada. Professor Lee joined Sydney health ethics recently to present her work on controlling borders during the COVID 19 pandemic. This is a bit of a longer episode, but we hope that you will enjoy it. So without further ado, here's Professor Lee and her talk.

Thank you so much Shana, for that lovely introduction. And just to add my thanks to University of Sydney, and the Australian Global Health Alliance, and the colleagues that are working this week, to really welcome me to Sydney, I haven't been back for a number of years. And it's just just a wonderful week, so far catching up with old colleagues. And also, hopefully, some new colleagues being developed as well, I really have enjoyed myself very much. So I appreciate it very much. And it's really probably appropriate that I'm here after, after such a shutdown of Australia to talk about this subject, it seems a very apt topic to come back to Australia for. And it's something that really brings together the themes of this seminar series around evidence, ethics and complexity. I'm not sure how much people are aware, but in Australia, because of of being so I think, subject to these measures, but outside of Australia, and I'm one of those people, I've often held up the country as a role model for a lot of other countries on how to use border, to do border management to use tribal measures. But on the other hand, I'm also aware that there's been a heavy price to pay for many of these measures, and that we're only really beginning to understand that. So I think in that sense, border measures and travel restrictions, particularly is a really ideal topic to kick off this series. And so I'm very pleased to be able to share some of the research that we've done over the last few years. And before I really get into that research, and to really review some of the findings that we've heard, I just wanted to acknowledge that our team is, is the appendix and borders project. We started out scrambling in March 2020, when all this was unfolding. And it literally was just a handful of us who really got together and was scratching our heads about what was going on. And over the last three years, we've grown into quite a large group, and quite a multidisciplinary group, which covers everything from political economy, to genomic sequencing, mathematical modelling, and so on. It's the kind of multidisciplinary perspectives we need, I think, to sort through the complexities that we've had to deal with over time. So our project, this is what our project was set up to do to, you know, really just understand what these tribal measures were that were being used, kind of review the evidence on the effectiveness, kind of analyse it as a complex policy issue. And we're moving increasingly towards looking at the equity considerations of these measures. And finally, to try and help policymakers, decision makers to make better decisions, or at least follow better processes to make decisions in future if we have to use these sorts of measures. So that's our group. And we're, I think, pretty set up to continue our work for some time, given the many questions that have been raised. So what am I gonna do, and I've been given, I think, 50 minutes to kind of go through, you know, this issue and to spark a conversation among us and those of you who are online, is to start by getting a bit of background. And, you know, we all we all are familiar with these measures in our own countries. But I just wanted to give a little bit of background, to set us up for looking at the evidence and the ethics around this. The background is interesting, and it's a very much global picture, obviously. But I think you'll all see, you know, different contexts within that. And then I'm going to look at what we see as the evidence around this subject area, what we knew at the time, but also what we know now, and it's very different, those two things. And then thirdly, really, I'm I feel very much amateur at this, I know the room was filled with experts on ethics. So this is my attempt to try at least to identify some of the tensions that were emerging and still are present around this subject area, what we should have done and what was actually done in particular. And then finally, where I think our research could be most useful is to think about the complexity to bring together those two areas, the evidence and the ethics and see where we can move forward because of course, I think everyone's pretty confident and Unfortunately, that this is not the last pandemic that we will see. So we'll have to figure it out in how we do this better. So let me start with the background. And the background is that if you think back to 2019, the world was a very, very different place than it is now, we may never go back to that world where we were very, it was a very mobile world, it was a very interconnected world, the level of population mobility in 2019, was historic. So if we look at just tourist arrivals, what we see is that in 2019, that was a record year of tourist arrivals. Worldwide, every region had a positive increase in tourism arrivals. There wasn't some uncertainties, you know, there was a course Brexit was unfolding. There was some, of course, always geopolitical tensions. But there were also looking ahead, you know, we were anticipating in 2020, the Tokyo Olympics were going to be held, there were major events, there was no inkling that what was about to unfold, was going was going to unfold. And so again, you know, every region was seeing growth in mobility, it was so much part of our lives worldwide. And then within a few short months, we had this, and from a hyper mobile world, where there were, you know, hundreds of millions of people moving about, for various purposes, we saw airports virtually empty, we saw many land crossings restricted or in some cases closed. And we saw cruise ships stopped, and many other types of ships being docked and stopped from from movements. So it was a very sharp pivot from what anyone would have would have predicted going forward. Now, if you also think back in January 30 2020, when these events started to unfold, who made a number of recommendations from that point, in the sense that this should not have happened in a way or at least it? You know, how did this happen, given what who was recommending so because back to 30, of the January, when who declared its public health emergency of international concern, the fake declaration, it did not recommend the adoption of travel or trade restrictions based on the current information that was available. And that was very clear, it was a blanket recommendation at the time. A month later, it reiterated that recommendation more or less, but there was a little bit of a qualifier in a sense that there was a recognition that, under some circumstances, and if countries were to engage in careful risk assessment, if there was to be some assessment of measures proportionate to the public health risks that was unfolding, that there would be some temporary use of these measures, and that they would be reviewed over time, then who considered that permissible, but only under those conditions. And so that was the second statement that wha who made on that on this issue. And then a few weeks later, just a couple of weeks later, really and knowing that, I think, as you remember, countries were generally not taking to account you know, some of the really strong recommendations that who was making about having to respond to this unfolding pandemic, on the 11th of March, who officially declared COVID-19, a global pandemic. And it was really a political statement to, to, to push countries to step up. And really try and nip this pandemic, unfolding pandemic in the bud. Those are the events, the three sort of really key declarations that were made by WHO, but when you look at what happened in terms of travel, measure use, and this is something that our project team has tried to try to document. And each of those after each of those declarations, what you see is not a kind of non use of these measures, but quite the opposite. So after the January 30 declaration, you see a spike in new measures, new travel measures adopted after the February 29, you see another spike, but particularly after the pandemic was declared officially, you see a very large spike. And by that point onwards, most countries in the world had adopted some form of travel measure. Many of those were restrictions on travel.

And so where does that leave us? I guess when we think about you know what, what could have happened? What should have happened? Well, let's Look first, you know, the spread of countries, there certainly wasn't any pattern, it was just pretty much almost every country I, I'm still trying to look for the one country that didn't maybe one of the Pacific Islands. But generally what you saw was a wide range of measures being adopted. And if you look at this first slide is our world and data maps, which are we were glued to downloading them every sort of few weeks, what you see is that almost every country in October 2020, was had some form of measures that affected travel, the fact that the US isn't highlighted, because there was no data at that time, not that they didn't use these measures. Of course, they did a year later, again, different colour pattern, but still very much a global picture. And then what is really also important is that many countries adopted domestic sub national measures to restrict travel. And this was a pattern that, again, was something very new, very widespread, and changing over time. But it wasn't an unusual thing, to have some sort of internal domestic restriction on travel. So our our group was really then set up and we were starting to try and I guess, just describe what was happening. And that was actually more challenging than one would expect. So if you think back to these measures, they were adopted very quickly, those things are unfolding in real time. And that they were being called very different things. So people would use lots of different terms, there was a few datasets that were being produced that kind of was tracking what was happening. So what are one key task of our team is to try and create this global dataset of you know, sort of standardised terminology to see what different countries are doing. So we'll be producing these graphs, which really kind of summarise what different jurisdictions did. So this is the one for Hong Kong that we produced. And, you know, you can just learn a lot from what happened by looking at these kind of graphs that Hong Kong went quite early. This goes from January 2020, to around April 2021. And you'll see that Hong Kong was an early adopter that they adopted measures and kept them in place. That the, the large part of the story is that they closed a lot of their points of entry, and then fortified a lot of the ones that were left open. And they used quarantine and testing very early on. Whereas earlier than a lot of other other jurisdictions. You compare that with, say, Canada, which is a country we've been studying, of course, very closely. And you know, you can see patterns very different, you see slightly later adoption of some of these measures, but also different measures. So testing didn't come in until quite quite a bit later, in sort of late 2020, early 2021, quarantined didn't happen until spring, 2021, and so on. The details aren't important. But what I think is is important is that, really, we need to understand what each jurisdiction did, if we're ever going to figure out, you know, how effective Lee it was done, what impact these these measures had. And, again, this is very sort of basic description, but I think it's really important to do for as many jurisdictions as we can, and we are getting there. Of course, in Australia here, all of these measures were used, and, you know, be very interesting graph, if we are able to do this. For Australia, what you see is probably the adoption of these measures, and then just a long line, as it was just remained in place, probably an easy graph to do in terms of creating this case study. The key things are really that first of all, who, despite you know, the kind of recommendations that made found all of the member states adopting some form of travel measures by April 2020, that there were a wide range of measures adopted, when they were applied, who they were apply to, whether it's countries or different populations. Countries largely had these exemptions, you know, you could, depending on whether it might be because of your occupation or some sort of national status. But these are exempted a lot of countries exempted a lot of populations from these measures. Also unprecedented was the duration of the way these measures were applied. So a very prolonged use, and a lot of change over time is a very dynamic picture that you'll see in most cases, perhaps not so much in Australia, but certainly in most countries. And finally, I think from from my point of view, is as a global health governance Staller, the lack of coordination across different countries so countries did what they thought was right, for their own jurisdiction. So very diverse use of these measures. The reaction was interesting. Some and particularly international law scholars, legal scholars were very against the use of these measures and really backed up who is saying that this was a violation of the International Health Regulations, which is, of course, the international treaty that, that countries are committed to when they're responding to international disease outbreaks. And according to the scholars, there were a number of papers published saying that this was a violation of international law. But then other scholars and actually legal This is a legal scholar, Carolyn Foster, argue that actually isn't a isn't a violation of international law. And and she made the argument, you know, there is a sense of an ability to adopt these measures in a precautionary sense, based on what another treaty, which is the sanitary and phytosanitary agreement under the World Trade Organisation, made the legal argument that the ihr could actually be applied using those kind of as a precedent. And therefore, you know, this, this was kind of a similar situation. So there was a, there was certainly a lot of argument about, you know, whether these measures were appropriate, whether they, they were legal, and so on. So that's really the the background to where we were, when we picked up this story. And there was a lot of, you know, a lack of, I guess, precedent to build on in terms of our understanding of its unfolding events. So then I'm gonna talk a little bit with the evidence, then. And this is the evidence, of course, which has unfolded over three years, we have to be really careful not to, I guess, look back and apply the lens that we what we know now versus what we knew, then, that's really important to separate because, you know, we have 2020 hindsight, that's that's important to distinguish, when we interrogate some of the decisions that were made. But I think the having said that, that the important thing really is recognise is that in 2020, when these measures started to be adopted, the evidence base was very much against the use of these measures, previous events and disease outbreaks showed that either they were unnecessary, or that they were to the price to be paid was too high, and could be very counterproductive to the kind of cooperation that we need across countries so that the received wisdom really was that they, they were frowned upon. So take HIV, and AIDS, for example. So, you know, we forget but you know, when HIV first came on the scene, there was a lot of reaction to allowing people who were travelling and potentially were infected with HIV, that whether or not they could come into your jurisdiction, and many, many countries actually restricted travellers at that time, we know a lot more about the virus, there's a lot more treatments, of course, if the situation has changed. But in 2021, UNH still reports that a large number of countries still do restrict travellers who are potentially or are actually, HIV positive. So 46 countries, territories, and areas still either require testing, or do not allow people to come into the jurisdiction through their jurisdictions, so that it generally frowned upon in the public health community. Of course, it's not something that is considered necessary. And it's also very discriminatory. So it's not something that is encouraged. The other example is, of course, the Ebola virus in 2013 2015, when West Africa was the subject of particularly air travel restrictions, 33 countries, including Canada, and Australia, applied travel restrictions by air and to the region and from the region. And this was again based on not much evidence that it was very useful, of course, you know, the virus wasn't spread by

air travellers, of course, it was considered very discriminatory, and it actually really hindered hair, healthcare workers from helping in the region, essential supplies from arriving and reaching the affected regions. So generally, again, frowned upon not useful, counterproductive to use travel measures. And so we get to then January 2020, and, you know, the looking back the evidence was very thin that, you know, that, I guess, journalists started to write that, who recommended this and wasn't really very, I guess, very clear about what the evidence was. There's there seem to be calm. debate, you know, did who actually base its recommendation on evidence. Others were writing that the evidence isn't there or it is there and they don't work. So again, still contested at that point, when, when these events started to continue to unfold. Since then, over the last three years, there's been, of course, a flurry of studies about tribal measures, and various using various methodologies. And I just want to touch on some of these, because they're important to, I guess, at least acknowledge. And so just to understand what we know, now, coming out of three years, the use of these measures, the first is that a really clear evidence from largely genomic sequencing studies, that travel is deeply implicated in the spread of the virus worldwide. And it's not a probably a revelation, you know, the virus didn't swim, fly and walk around the world, it was trialled it was moved by travellers to different geographies. And that's something that, you know, it's not surprising, but having that evidence to show that was very important. So there's been various studies of repeated introductions and seeding of seeding events into different jurisdictions. And this is a couple of studies from 2020, to show that. And this type of analysis is difficult to refute. You know, it doesn't. It's very difficult to argue that, that when you're you're tracking the virus, and so on, it doesn't necessarily mean that travel measures are warranted. But it certainly does clarify that travel is something that needs to be considered, especially in a globally interconnected world that we had in 2020. A different way of looking at it is the role of travel and travel measures on virus introductions. So studies have tried to look at, you know, what would have happened if there weren't use of travel measures? Or that, you know, if you did use tribal measures, how did that impact the number of introductions into a particular jurisdiction. And so this is a study, which predicted compare the predicted level by our introduction, with or without, and without travel measures into Australia, and, and other jurisdictions and the, you know, the, what the graph shows is that the solid line is the sort of lesser level of introductions into Australia versus what would have happened if the government had not restricted travel into the country. And so there's something like, you know, lowered the introduction is by about 87, over 87%. So that's another way to kind of look at this and, and to, you know, start to build a picture of well, you know, what use these travel measures had, the similar studies have been done for other jurisdictions who have also used these measures. A study that we were did for our group is kind of just looking at the evidence around the effectiveness of travel measures during that early few months on virus imperfections. And particularly, kind of the, you know, the evidence around the restrictions on movements within China, but also in and out of China in those few first few weeks, first few months. And generally, the, the evidence suggests that wrap those countries or those jurisdictions and introduced restrictions to travel from those jurisdictions were effective at slowing the importation of the virus into their own jurisdictions. And it ranged from, you know, a few days to a few weeks, but you had to do it very quickly. And you had to do quite stringently. And a few countries did that. Taiwan, Hong Kong, South Korea, I think were some of them. But that, you know, this is not an enduring impact, but certainly, it was a positive that for public health. So that was our general finding is that we did find that a lot of the studies were modelling studies, and rather than were of limited, I think, are lower quality, because some of the assumptions made were very different across different studies. But generally, that was the conclusion. And our conclusion really coincided with a Cochrane review that was going on pretty much similar time they came up very similar findings that, you know, there is some evidence of effectiveness of the use of tribal measures at controlling the spread of this source code to Kobe to virus. But, you know, we needed better, better quality data so it's not conclusive, but certainly But it was very different from what was previously believed that you just don't use these measures. They're just not useful at all. So that suggested something was different. And then I guess the other studies that were we caught our eye, and we found was useful to think about was that, as you'll remember, there were so many different what are called non pharmaceutical interventions being introduced. And this study by Palghat, and colleagues, were looking at, you know, what, what are the measures that are most effective at reducing transmission? Which the ones should we keep, which ones are actually not that useful? And they, they base their methods on, I guess, regression analysis and try to look at, you know, the, the data that was out there around infections, and link them to different interventions, which we'll see there's a long list of them. And the conclusion was that, really, that social distancing, and travel restrictions came out on top in terms of the most effective ways to reduce transmission of this virus. And again, against, you know, kind of the received wisdom at the time. And it was another piece of evidence that somehow, you know, there is something here that is useful in terms of in terms of responding to an unfolding pandemic. So so that's a mixed bag of studies, you know, and I know there are a lot of other ones out there. But that's kind of where we kind of came in and thought, Well, if that's the case, you know, that there is all of this kind of emerging evidence. How can we make sense of this, especially when different countries were doing so many different things at different times, and it was changing in real time, it was very, very difficult to study something that was so dynamic, but one of the things we wanted to look at, and I guess a final point about evidence is that when we're trying to make sense of all these different studies in these comparative analyses, one of the problems with the evidence was that the terminology was just all over the place. And so people, you know, looking at genomic sequencing people looking at policies, they lacked a shared shared definitions, shared terminology that really reassured us that they were comparing apples and apples instead of apples and pears. So it's probably because of the newness of the practices and the rapid way in which they were introduced. But and also the rapidly politicised or, you know, sort of media frenzy around these measures that terms were just bandied around bantered around. So bandied around travel bans, travel restrictions, border closures, border restrictions, and all sorts of things, which often you didn't get any detail. But what that meant, so country, x would really just close their borders, right, and you just assume that there's some big wall, some doors shut. But actually, when you look at it, actually, people were still coming through the border, like Canada was a good example where what political message was that we've closed our borders. So you can be reassured that you're, you know, safe within, but actually, you know, there was a lot of traffic still coming through for trade purposes, their trucks, and, you know, all sorts of sort of work essential workers, this SP ended up calling them. So comparing, you know, trying to figure out what actually countries did was was, was difficult. So we wrote this paper, and we tried to kind of tease out, you know, what measures were taught to being talked about, but also, what kind of movements were being restricted? Was it people or was it trade?

Was it? Were they adopted by the public sector? And largely, they were, but there were some other private sectors, some airlines were cancelling flights, you know, that's a travel measure of some kind. And that came from the private sector. So nobody was studying that. What level of jurisdiction is it just International, we know very much that it was also sub national, there also regional measures, the European Union. So that was that was adding to the confusion in some ways. And where and at your point of the journey, where are these measures being applied. So some were pre border before people were even heading to the airport, or to you know, getting into their vehicles, some were applied right at border crossings, points of entry, and some were applied after you arrived, and you had to do for example, testing, quarantine and so on afterwards, when she arrived at your destination. So there was lots of variation there. And then finally, there was lots of variation in who was targeted in terms of population jurisdiction, how long these measures were. What kind of, you know, penalties, there were, what kind of exemptions and so on. So, when we tried to tease all this out and just show that there were so many dimensions that needed to be looked at, that we're trying to elevate the level of evidence that was being collected and hopefully come to some sort of standardised way of looking at this and thinking about this. But at the time over the last few years, it hasn't been the case and still isn't. So all of his say is that the evidence is partial, very messy, very evolving, and not necessarily coherent in its in what it was saying to us. But I think the key thing is, it certainly wasn't saying no, never use these measures that are totally pointless, I think there was enough there to say there's something there. So now, I want to just turn to a little bit about the ethics. And, you know, there's an imperfect context of evidence, there's also an sort of very messy situation with with ethical considerations. And, and again, I'm conscious very much of the, the experts in the room. But I do want to say that like that, like the scientific evidence, that consensus has been elusive around this area, in terms of the sort of values and the norms that should be driving this. So start with a quote really from Maxwell Smith that I know Diego, you've written with Max and Ross Upshur was a former colleague of yours. And, you know, it's just trying to find something to hang on, hang these considerations on. And the important point about this quote, really, is that there's no one. And you I don't need to tell you this, but there's no one ethical framework to guide these sorts of difficult decisions, it is a very contested area, and, and so trying to land on something, you know, that could really bring the evidence together or something, maybe that is, like a unicorn. But, but it's important to to just acknowledge that this is a really complex area for trying to sift through. And so what we really what we tried, we're trying to do is just figure out, you know, what, what is the menu of ethics out there, and how do we apply, how might we apply them, and which of them actually are relevant to this particular issue area. And so, you know, been discussing in our group around the kind of values that could guide an ethical approach to pandemic responses. And this one is, of course, influenza outbreak, which has, you know, there's a precedent there and people trying to define how we would respond to an influenza outbreak. And these are the some of the some of the values that have been discussed in the past. And I took this as a starting point, because, you know, we prepared for influenza, and we got COVID. So there might be some transferability. Here in terms of what we might take away from our previous planning. One of them is courses. And this is something that is often you will hear from policymakers who made the decision to use these measures that we need to to make the decision to protect the public from a severe problem. And this would justify the use of, of these measures. And so, of course, Scott Morrison made this argument many times that there were so many deaths prevented, because Australia had decided to really restrict its borders, and quite a consistent and continual way and in a relatively stringent way compared to most countries. So that his his sort of, I guess, you know, fallback argument that, you know, if you hadn't done that, then we would have far more more deaths. And I guess that study I showed previously kind of supports that. So that's one consideration. Difficult, and I suppose to argue that, was there proportionality? Was there, you know, that the measures that were taken, did they justify the kind of impacts that were not only on public health, but one might argue, yes, did you save 30,000 lives or whatever it was, but did it wasn't justified by the kind of wider impacts? And these were economic impacts, of course, but also social impact? So we all have, you know, or have heard stories of really heartbreaking stories of people who could not travel during the last three years and who, who have had, you know, very severe impacts on their lives because of that. So there's that weighing of argument, and I don't have an answer for it. But this one sort of value that that could we could, we could discuss later on after this talk. Certainly, I know that this country has seen many, many stranded nationals. We never had that in Canada, we have a Charter of Rights, which didn't allow the government to restrict the trial, the mobility of Canadians in and out of the country in such a way and I know Australia does not have such a Charter of Rights. But this is really, I guess, part of the reflection as we go forward. Is that? Do Australians feel that that was a port proportionate response, taking into account the kind of human impacts that these measures had. And I think you won't get consensus, to be honest, you know, people will feel very differently about this. The principle of equity is something that we're we're hoping to get funding for a project. Obviously, you know, the government, in some countries apply these measures to everyone coming in and out of the of their jurisdictions, others had exemptions. And so people could still come in under certain conditions, certain people could come in others were completely barred from coming into a country. And obviously, then, you know, we have to reflect on was this equitable? How equitable was this, who was disproportionately impacted? Was it a fair system, and bearing in mind that, you know, this, these things were being rolled out in real time, there will be there adjustments. Certainly in both Canada and Australia, you see the changing of policies over time, the tweaking of exemption categories, and so on. But that is something that we may judge these measures on. And again, I'll set those aside as a consideration. It's not straightforward. But certainly there was an equity in terms of who was impacted, and the costs and benefits that were distributed across populations. And we also know, of course, that there were opportunities to be quite discriminatory about the use of these measures. And sorry to trigger everyone put his picture up. But, you know, remember back in the early pandemic, if even before the pandemic, US President Trump was using the migration issue in a very unpleasant way, and was built his campaign on this wall that he wanted to build. And so there's this Association of Tribal measures with this sort of rhetoric. And it's hard to deny that this rhetoric can become quite volatile, but also quite, I guess, quite hard to distinguish between measures that you're taking for more public health purposes versus these kinds of discriminatory purposes. And so they become very enmeshed in it and, and difficult to unravel. But there's always a risk of how these measures are used, and whether they are, you know, inequitable in terms of the different populations. And then, I guess the other value that I wanted to put on the table was whether these measures were taken in an open and transparent way. So at least in Canada, the the message to people who were questioning, you know, is this really, you know, necessary? Why are these vendors keep changing? There was always that, well, you know, we're just following the science, we're evidence driven, and so on. In general, there wasn't a lot of detail on what was the science you were being informed by.

And so there was a lack of transparency and how these decisions were made, on what basis and that you just had to accept that somehow, somewhere, someone was poring over the scientific literature that was emerging. There was also an incredible amount of confusion, especially in countries where the rules kept changing. And if you were lucky enough to leave Australia and try navigate through into other countries, their rules are different, they could actually change while you're in flight. And I did hear stories of that get on a plane, a tiny land was the rules had changed to the country that you were going to and you no longer comply with them. Especially if you had to bring a test, you know, that you couldn't actually get on the plane? That That caused a lot of confusion. So it was It was chaotic. For sure. And that, again, that doesn't lend itself to openness and transparency, in terms of process. The, I guess, the final set of values that I think would be worth maybe thinking about is that of solidarity and whether they're valid, or that these measures create a solidarity and accountability of you know, who about who were the consequences? Did people you know, we're all in this together? Were the measures fair in the sense that they tried to, they were complied with by people, they were enforced? And it was, you know, considered a sort of a process of, I guess, effective implementation. And these are just some of the headlines we had in Canada. I guess you wouldn't have maybe so many because we have so many people still of travelling, but there were very prominent people, on the one hand, you know, making policies and the other hand jumping on aeroplanes and going on holiday. So it was a sense of real hypocrisy. And that actually, this isn't a really a principle of solidarity. You know, some people were just feeling very, that this is a very unfair system, and there was no accountability, people were not being held to account. And as time went on, there was a lack of faith in the, in the system. So public trust began to erode. So all of these values, really, you know, they kind of swirl around, and we really haven't had time to pause. And I guess you interrogate these these measures in those sorts of ways. And there's a whole list of other values, I'm sure that we could, we could talk about, especially with a roomful of ethicists. And so that leaves us with a very kind of messy situation, we have evidence that is unfolding over time in real time. And it's, you know, not necessarily coherent, we have a swirl of values, which are complicating the picture, which aren't really toxic spot, you know, talk through, there wasn't a public forum where you could discuss these things. There just wasn't time maybe, you know, things were moving so fast. And we come to this, you know, what is the way forward and, you know, this picture sums up what is that way forward in such a sort of tangled set of ethics and the evidence, the road ahead is indeed very complex. And it's made complex by first of all, you know, the virus itself, the virus itself is not done with us, and we are, you know, still really in a situation of great uncertainty, for me great concern, that blob of yellow sub variants to the right is, you know, it's just hovering there, and we just don't know what's coming. So it's the virus continues to mutate continues to change. And that in itself, is creating this uncertainty, that we have to deal with this, because scientific complexity, you know, the, the duration of our immunity, the effectiveness of vaccines, the the severity of this, any new variants that may come along that vaccine escape qualities, and so on. So there's lots of uncertainty with just the vaccine itself. There's also uncertainty around the evidence, and some of the evidence suggests that travel measures can be useful. But the foundation on which is based, I suggested as well, given the terminology and given the kind of varying methodologies. And also the lack of data that is consistently collected and shared, is limited. So we still don't really have a good sense of, you know, the effectiveness in terms of which measures should we put in place, say we do get any variant that is highly concerning? What are the measures we should put in place, and so on? So there's continued scientific complexity? And, you know, we have to continue with that work, because there is this likely need to make those decisions again. And the whole question of how do we apply the precautionary principle still hasn't really been resolved. And it certainly isn't legally something that is in place. So that's, that's, again, adding to the complexity. Of course, I've already described, there's a whole set of ethical issues that we hopefully can talk about in this in this next little while. And there are, of course, different frameworks that we could apply to think about this, these issues as well. I've heard I've read, you know, Trisha help. Greenhalgh who's a UK academic who's written very clearly about these issues, has made the point that we seem to be driven by clinical ethics. And really what we have lost sight of his public health ethics in terms of managing this, this virus. And, you know, how do we reconcile this? Where does travel measures land in this kind of really complex space? So eventually, you know, we're going to have to face this difficult situations, especially for decision makers about these trade offs that we're continually making. And it's inevitable that we make these trade offs but can we make them in a more informed, informed and reasoned way? These trade offs lead to very different outcomes, and they are trade offs that have both material costs and benefits. But they're also they have other impacts on On social values and how we want to govern ourselves. So, you know, there's there's this that we're grappling with in terms of trying to make sense of what we do going forward. We did write a very detailed based on what I've just said, we try to write a very detailed case study of the Canadian use of tribal measures over the last couple of years. And we tried to bring together how politics and evidence really into that, you know, how it is influence the kinds of decisions that were made. And the basic argument he made was that there was this gap in evidence that policymakers then did take a precautionary approach, but at the time, kept stating that they were driven by evidence that wasn't actually there. In the meantime, there was this real vacuum, and the more political aspects became, I guess, to became to fill that vacuum, and created a kind of passive tendency where they couldn't really change the policy by that point, in a substantial way. But the main point is that this coming together of values and evidence throughout the pandemic is something we have to hold our hands up to, rather than keep coming back to the, you know, the the kind of claims that somehow this was driven by, by evidence, and I think that's, hopefully somewhere we'll get to. So during which time I have I probably I'm running out of time, but I just wanted to, then take you just to where do we go forward from this? You know, I'm not gonna leave you with, it's complicated, because I think that's kind of always a cop out. So I wanted to just give you a sense of where we think we're heading and where we could make contributions to this area. So if we go back to the ihr, and particularly article 43, it does set out some criteria for when what are called additional health measures, including travel restrictions can be used by states parties, when outbreaks occur. And they, here they are, and I don't need to read them out. But they it does set out on this criteria, which I think still holds, as long as we can improve on the availability of scientific evidence that we can really think through what are the what do we mean by dignity and human rights and fundamental freedoms and so on. So you don't necessarily advocate for need to revise the ihr? It may be that it's the measures are there, or the criteria there. But it does tell us that something didn't happen, that should have happened. It's there already in the HR. So why didn't you know, events unfold the way that perhaps you would have expected? And I'll remind you, you know, going back to what, who was declaring in 2020, right, it was a very

difficult situation. But they did make, remember, I said that they made this kind of slight modification in the recommendation on 29. February, and I think that actually, this is where there may be a glimmer of hope. So they mentioned this idea of risk assessment. And interestingly, you know, it's something that it's not, it's not new to the ihr. Certainly, you know, we use risk assessment quite extensively when we're trying to deal with outbreaks, of course. And, in fact, when who realised No, all these countries were adopting travel restrictions, and other measures that clearly that there was something that wasn't quite right about the EHR. So by December 2020, who put out these, this risk assessment tool to say, Okay, you're going to use these measures, then here's a tool that you might use to kind of think through whether and what measures you're going to use. And that was followed in July 2021, with kind of technical considerations. So they were trying to think through this and trying to insert a kind of more methodological, systematic approach to this than the chaos that was clearly unfolding at that time. So we wanted to take that as a jumping off point. And I should say, in the ihr, also, you know, if a country has an event and decide needs to decide whether to report it, to who there's this kind of decision instrument that you follow, and some of you may, who are working in infectious diseases, we'll be familiar with this kind of decision tool, when you work your way through and, you know, there's certain types of events where, if it, you know, has a significant risk of international spread or if it's a new type of event, it's an unknown pathogen or so on. Then you do report this event to Rachel. So there is a kind of model to follow. And so what, who tried to do is create this kind of similar approach and then create this kind of diagram where you would get an event and you would decide, you know, you kind of work your way through. And so this is available on the December 2020. document. So, you know, we're very, very much about based on data, of course, you you have this data to some testing, you can track it over time, and are the infections going up? Are they going down? How many travellers coming in are tested positive for which jurisdiction? So they're trying to figure out which variables to use? How could governments decide? And, of course, this wasn't really useful for Australia, because Australia would have already made the decision that nobody was coming in, or everybody was coming in there have been quarantine regardless. Right? So this was for countries that were trying to keep travel, lowing, and even to to remove some of those kind of more blanket restrictions. So this, this is what who was trying to do and what we found actually, who wasn't alone, there was actually, we identified a lead and other methodologies that tried to take this approach, and try to find a way of deciding how, you know, what level of risk and how do we use travel measures to mitigate that risk. So this is a report that's going to come out soon published by the Migration Policy Institute, that we kind of reviewed these methodologies. The main thing, though, is that there was really not a lot of consistency and what was considered in these methodologies, they were, there was a lot of variation, there's a lot of variation in what the risk was seen to be, who was at risk is risk is important. And even, you know, what your risk tolerance should be, there was just so much variation. And that in itself is a finding, of course, that everybody was struggling to try and apply this general approach. But I would say that, you know, it's useful to look at those and then to try and maybe match those to some empirical evidence of, you know, which ones were maybe more or less effective. But the main thing I think we came away with is that it's not just a technical issue. And, you know, we come up with the most amazing decision tool. But if we don't recognise that this is not just a technical, we're not going to solve this with data. This is not just a technical question, that there are very much normative aspects. So we tried to develop our own. So and this is, I have to say, this is just a really first attempt at trying to set out some of the key decision points that need to be made, if we were to have another event that was unfolding, and whether we did use travel measures or not. And it is really a work in progress. But the key thing is to point out, first of its that we went beyond just the technical considerations. And this, this was really important. And in that we tried to bring together I guess, the elegance and the ethics into one decision instrument. So at the top, you would have some sort of notifiable event who maybe it's like a, you know, us some kind of pneumonia that's, you know, unusual. And you start to think about the pathogen characteristics, what is its transmissibility? What is it severity? Is it novel? You know, there's all sorts of very clear characteristics, and there's some that will be more alarming than others, obviously, and some less alarming. So we've matched those to say, Well, do you know, is this something that warrants travel measures, most probably won't, and that's going to the left. But if you have a sense of maybe this is something that travellers could spread quite rapidly across the world, then down and then you think about your jurisdiction, you think about your healthcare capacity, think about your demographics? Do you have a lot of, you know, susceptible people, geography, all sorts of characters that we can, you know, work on what those characteristics are, and then you move down and if you feel confident that this is not something that's concerning to your jurisdiction, you can go left but otherwise keep going down. And then you would consider this is where the the ethics come in the values, the norms, you know, what is it that you value in your society? Who do you value? What do you value? What are your priorities when it comes to these, this this response? And so that's where you know, these grey boxes or a triangle of rectangles are, where you start to think about these things in a kind of transparent way that you can integrate and you recognise that these things are important. This is what's driving this will also drive your decisions. This happened, but it was always very much either denied or done behind closed doors, there's not a lot of discussion. So we need to have those conversations before this, these events happen. This then shaped your response strategy. So it's not some, you know, a fact based strategy, no countries decided on their response strategy based on their priorities. And that's why you see so much variation. You have to do all of this. And then you get to the point where you can assess risk in terms of travel measures, specifically based on what your response strategy is, if you decide to go zero COVID, then you have one particular way of seeing what the hazard is, who are the people at risk, and so on. If you decide to go with a mitigation strategy, you're going to have a very different risk assessment. And all this then, you know, is a loop. So you have to evaluate as you go. I say this is only the first attempt at trying to just kind of visualise what the decision making process would be, and to try and integrate the complexity. And I think it's still a lot of work to be done a lot of thinking through. And also what's behind those little shapes, is very important. So that's really the end of my talk, though. And just to leave you with that as something that might be taken forward. It may not need an ihr revision, it could be an appendix. And then, you know, that might be in itself, an improvement to what happens. But just leave you some key messages, I guess. One is that what's happened is pretty unprecedented. We have not had this situation where we've had widespread and prolonged use of travel measures. To respond to such a, an event. And it's happened because we have a novel virus. And because we have global interconnectedness, historically, like never before. So it was a very different context, I think we have to recognise that. The second thing is that we saw decision makers make decisions in real time, in the most difficult circumstances, but limited and evolving evidence, and very contested norms and values, these are all swirling around, I would not invite that job, you know, it's the most difficult choices that were made. And so you know, very much not trying to dump on those, those poor souls that had to make those decisions, but really try and understand the experience and to try and see if they can be supported and improved in terms of the processes that were that had to be that were undertaken. Thirdly, that, despite, you know, who was advice was to not use these measures.

And we need to get away from away from just blanket travel restrictions or bad to recognising that there can be appropriate use of those measures, that there are a wide range of measures. And the idea is not to restrict travel, but to sustain and manage human mobility. Despite these events happening. Again, it's kind of a different way of seeing it. But I think really important that if we can find ways of framing it as enabling, rather than restricting, I think that's a much more more useful way forward. OPC research has to continue, there's so much more to learn about this. And the evidence base was to improve that. But forums like this will also enable us to have discussions about the norms and values that are behind this research, but also behind the policy decisions that were made. So eventually, we you know, if we can integrate these two things together, and we hopefully will, we'll move forward with this and maybe have a framework as as I've described, something like it. And then finally, I think too, we're all have a stake in this if we want to keep travelling, going is to put in place the enablers of better science and policy on travel measures, we have so many data problems, we have so many blind spots. There are opportunities to use big data to use all sorts of interesting ways of getting better science, but also creating the government structures to have better policy processes that can bring that science and ethics together. So I think that's really me, I really want to thank you for listening and for inviting me to share what we've been working on. It's been one of the most difficult policy issues I've done. Never thought it would be so complex. So I appreciate any advice and collaboration, especially in Australia where we have to live through this because a very different experience for you than it was for me. But I think we can learn from each of these experiences and to, I think, be better prepared the next time, we may need to use these measures. Thank you very much.

Hey, thanks for listening to this special episode of The she research podcast. You can find a transcript of Professor Lee's talk in the show notes. We'll be taking a little break over the summer here in Australia, and we'll be back with you in early 2023. With new episodes and a new host, Dr. Diego Silva will be taking over with the she research podcast. It's been my pleasure to accompany you through these interesting talks. She pod is produced by she network and edited by Madeline Goldberger. You can find our other episodes on Spotify, radio, public Apple podcasts or wherever you get your podcasts of quality. Thanks again for listening. Bye