Responding to the COVID-19 pandemic in a country with over 300 islands: Bernadette Welch PSM

Bernadette Welch PSM, who until recently was the Permanent Secretary for Health and Medical Services for the Government of Fiji, was interviewed recently for the WORK WITH PURPOSE — GLOBAL PERSPECTIVES podcast by Dr Gordon de Brouwer PSM, IPAA National President.

Bernadette has almost three decades of public service experience in Australia and Fiji in a range of government departments. She was awarded a Public Service Medal in 2007 for outstanding public service in leading the restructure of the HIH Claims Support Scheme and the logistical arrangements for the Meeting of G20 Finance Ministers and Central Bank Governors held in Melbourne in November 2006.

Bernadette became Permanent Secretary for the Civil Service in Fiji in 2016 before taking up the position in the Health portfolio and led the Fijian response to the COVID-19 pandemic. Putting in train quarantine, health, contact tracing and training was no small task for a country made up of 300 islands, 130 of which are populated.

The immediate response to the COVID-19 pandemic

Prior to the coronavirus outbreak the Government of Fiji had already stood up a task force to deal with a measles outbreak. The task force was headed by the Head of Health Protection and had members drawn from the World Health Organization (WHO), the Pacific community, Fiji National University, the private sector, leaders from the Ministry of Health, and communicable disease experts. Bernadette repurposed that task force and turned it into the COVID-19 Task Force, chaired by the Chief Medical Advisor.

By the third week of January, divisional emergency operations centres and headquarters were in operation. Bernadette also chaired a consultative committee across government which meant she had direct access to permanent secretaries and heads of some of the other relevant agencies in leading a coordinated response.

‘One of the first things that we did through that forum was to implement a Health Arrivals Card.

So, I had Immigration involved in that forum, and they took the Health Arrivals Card that we had designed with the help of WHO, and that was implemented by the 1st of February. I think we were probably one the first countries in the world to introduce a COVID-specific arrivals card for people coming into the country.

And it also had a tear-off card to tell people what the symptoms were that they should look out for, and what numbers they should call.

So, we were acting on border control and management very early in the piece as well.’

Mitigating the risk of infection for those most vulnerable

The COVID-19 Task Force took a risk management approach to keep Fiji safe.

Fiji has a big problem with type-two diabetes and had those people caught COVID-19 there could have been severe consequences for them.

‘When you’ve got control of COVID, you can manage risk by border controls, contact tracing, and testing and all this sort of thing.

Once you get widespread community outbreaks one of the things that you have to focus on is mitigating the risk of the most at-risk people getting the disease and dying from it. 

…

So we thought about, “Well, what do we do if we get widespread community transmission?”.

We didn’t want to break our health system. We didn’t want to put everybody who had the disease in a hospital if they weren’t really sick, but we didn’t want people who weren’t really sick to spread the disease to older people or people with diabetes.

So we thought, we’ll set up community isolation, so that people who have the disease but aren’t really very sick, can be moved out the family home where people live in larger numbers than what we’re used to in Australia, and they can be isolated from those at-risk family members.’

By the time Bernadette left Fiji, about six weeks ago, there were 18 cases of COVID-19. Six had come in through the boarder, four of those cases did not spread the disease to anybody else, and two had spread the disease to a number of people, mostly family members they lived with. At that point of time no one had been in intensive care and no one had died.

When Fiji got its first case Health quickly moved the whole family unit into isolation.

‘Rather than relying on home quarantine to stop the spread of the disease, we thought it was probably inevitable that some family members would’ve caught it.

We moved the whole family into monitored isolation in a hospital facility and over the period of time that they were in isolation three of them tested positive. But we were able to stop the spread of the disease and it worked so successfully that we used that approach with every one of the six cases.

We moved the people who were living in the family home, who were most at-risk, into monitored isolation, and that’s how we broke the chain of transmission very early.’

Effective, creative communication to keep people safe

The Ministry of Health had built public confidence in its ability to deal with a health outbreak through its work on the measles campaign. One of the reasons for this was the appointment of an official spokesperson early on in the campaign who built trust in the community.

Bernadette explained:

‘… it’s really important when you’re dealing with any sort of a crisis, that you have a spokesperson who is authentic, honest, articulate, and can be trusted by the community.

…

So when it came to COVID, I appointed two official spokespersons. One was the Chief Medical Advisor, and one was the same spokesperson I’d had for the measles, the Head of Health Protection’.

The task force had to respond to fake news on social media and the ‘coconut wireless’, which is the rumour mill, very quickly.

When the rumours started, the task force were able to clamp down on them with media releases and press conferences by the official spokespeople. This messaging reminded people that they could trust the Ministry of Health to give them honest and timely information, and that they should only get their information from reliable government sources or the WHO about COVID.

‘We said that over and over again, and people came to lose their fear, because there was a lot of fear at first, because nobody understood the disease. We didn’t understand it. WHO didn’t understand it. It was new.

… they lost their fear over time but also listened to the words of advice that we were giving.’

To get the important health messages across, a banner was published on the Fiji Sun every day for about three months, which said, “Wash your hands. Don’t touch your face”.

The Fiji Sevens rugby team were also brought in to do an advertisement to tell people what they needed to do. The Fiji Sevens are very highly regarded in Fiji — even revered — and their advertisement went viral with tens of millions of hits globally.

Making sure the health messages got through

As well as taking creative approaches to communicating public health messages, the Ministry of Health also translated this information into Hindi and iTaukei which are the two main languages other than English spoken in Fiji. A series of communication materials were produced in three languages and distributed by civil servants to communities across the country.

‘In Fiji, we have some communities that are located in areas where there are no roads, in mountainous areas.

I used to have some nurses who ran nursing stations, who in order to visit their patients, their communities, would have to trek through the mountains on horseback or by foot.

And so, some of the people who were being sent out with this messaging were doing just that: they were wading through rivers and climbing up hills and mountains to go to communities to get this face-to-face messaging across.

We also, quite effectively, used the Health Minister and the Prime Minister to do that because the Health Minister was very articulate, very engaging, very popular, as was the PM. So when they went out to communities, they were armed with the information that they needed to put some of this messaging across as well.’ 

Getting the right health expertise and logistical responses in place

Bernadette said their achievements in managing the pandemic would not have been possible without the early focused help they received from the WHO in developing Fiji’s policy response.

The WHO provided presentations and updates on what was happening globally and facilitated a regional consultation group with the Heads of Health and Ministers from across the Pacific region to share their experiences. The WHO also provided testing consumables, so that very early on molecular testing could be undertaken, delivering rapid results.

A key turning point in the government response was Bernadette’s decision to establish an incident management team.

‘… we went from the Ministry of Health consulting with other agencies and asking for help, to a Ministry of Health led multi-agency incident management team with liaison officers and secondees from all over government, including the military and the police who helped to run our operations room, and that was when we truly started to lead a very well-coordinated national response to COVID.

And the WHO provided us with an experienced epidemiologist that they flew from Manila who’d worked in incident management teams before, and he helped us set up that IMT up, and he was still with us on secondment when I left FIji.

So, they made an enormous contribution to us.’

Bernadette also spoke about the value of the strong relationships she had with the military and the police.

‘When we first started briefing the Prime Minister and Cabinet, they brought the Commander of the Military Forces and the Police Commissioner into the room for those briefings, right from the first briefing.

It helped them to understand very quickly the nature of the challenge that we were dealing with, and right from that first meeting they were thinking about “How can we help?”, “What can we do?”.

…

The first thing that we did with the military was to train up a group of soldiers to be contact tracers under the leadership of Health. They were trying to think right from the start about how they could help. They ended up running our operations room and the incident management team once that was set up. They ended up helping to run our contract tracing deployments … They also coordinated our quarantine service.

…

The police were mainly doing the enforcement on the ground of the different regulatory decisions that we’d had to make, because there were a lot of regulations that we signed in so that we could make sure that we could monitor the spread of disease, and we could enforce effectively the things that needed to be done to keep the country safe.’

Maintaining continuity of services

The Ministry of Health was very conscious of the need to ensure continuity of services while dealing with the global pandemic.

‘That came into stark relief for both Health, and the whole of the system, when we had a tropical cyclone, a deadly tropical cyclone, and we all had to coordinate our response to a tropical cyclone while trying to ensure that we were complying with all of our COVID-19 measures.

That was very challenging, but it was done, they were able to do it.’

It was also recognised that supplying the resources needed for the COVID-19 response would impact the budget, with civil servants putting their minds to ensuring that there was continuity of service.

‘There was a lot of re-prioritisation that had to go on. And of course, a lot of different parts of the Civil Service had to quickly develop policy advice on how the government could support the population when there were mass job layoffs, and when people were struggling to survive because of the impact on the economy.’

What Australia could learn from the Fijian experience

As Bernadette described earlier in the interview, Fiji is a small country with one health system, one health service, that coordinates everything. And therefore they had one Task Force and one Incident Management Team.

‘Australia is different in the way it’s organised, but I think that level of simplicity can be introduced when trying to deal with a crisis.

The more complex your system is, the harder it is to pivot, and with something like this, where you’re learning on a daily basis about how this disease works and the impacts that it has, and what’s happening to the global supply chain, and how it’s affecting economies et cetera, you really need to make it as uncomplicated as possible, and ensure that you’re focusing clearly on risk management.’

Reflections on what she learned about herself

Bernadette had previously worked in a lot of challenging scenarios and in crisis management before dealing with the COVID-19 pandemic. In responding to a question from Gordon de Brouwer, on what she had learnt about herself, Bernadette said:

‘I learned about how it feels to have that sense of how honoured you can be, to be given such a responsibility at such a time.

I’d always felt the importance of the roles I have had in the past, but there was much more of a depth to this because I had responsibility for the health of a nation in a once in 100 year pandemic.

I also learned through this, more about listening and hearing what others have to say.’

Bernadette continued:

‘It’s really important when you’re dealing with something like this to make sure that you’ve got the right people giving you advice and you are open to that advice.

And I also learned about when it’s time to step back, when you realise that you’ve done what you can to put in place everything that’s needed, and when your value-add has diminishing returns, and when it’s time to step back and let others step in and take up the rein of leadership.’

WORK WITH PURPOSE is produced in partnership between contentgroup and IPAA ACT, with the support of the Australian Public Service Commission.

The podcast can be accessed from the link below and is also available on Spotify, SoundCloud and iTunes.