By Bridget Judd
As another coronavirus cluster was linked to hotel quarantine, Australia's Acting Chief Medical Officer Professor Paul Kelly didn't mince words.
"That is our major risk now of reintroduction of Covid-19 into Australia, as we have seen in Adelaide over recent days," he warned on Wednesday, as South Australia prepared to introduce some of the nation's toughest coronavirus restrictions since the pandemic began.
The Parafield cluster, which has grown to more than 20 confirmed cases, is but the latest in a series of problems linked to hotel quarantine.
Victoria's second wave, for example, was found to have stemmed from failures in the state's "hastily assembled" system, while nearly 400 returned travellers were removed from a quarantine facility in Sydney following complaints over hygiene.
It begs the question: if quarantine facilities pose the biggest risk to Australia's path out of the pandemic, should we be doing more to safeguard them? Or is it time to find a new system?
"This is not just the first [incident]," said epidemiologist Mary-Louise McLaws, a UNSW professor and World Health Organization advisor.
"It really needs to be re-evaluated right now."
How many people have gone through quarantine?
Since the introduction of international border restrictions earlier this year, all returning travellers have been required to undertake 14 days of quarantine in a "designated facility".
Between March and August, some 130,000 Australians rotated through the nation's quarantine programme, about 850 of whom tested positive for Covid-19 (a positivity rate of just 0.66 percent).
In total, more than 5700 cases in Australia have been designated as "acquired overseas".
"Quarantine and returned travellers have always been an imperatively important point to protect the vulnerable in the community," McLaws said.
"And it becomes more imperative that those infections don't leak into the community as time goes on."
Indeed, with returned travellers in quarantine facilities now making up the bulk of new daily cases, and with outbreaks linked to hotel quarantine garnering national headlines, our national approach has been put under increased scrutiny.
But Maximilian de Courten, a health policy lead and professor in global public health at Victoria University's Mitchell Institute, does not believe recent outbreaks are indicative of systemic problems.
"If you think about the logistics [of processing thousands of people], I'm not surprised that sometimes mistakes happen," de Courten offers.
"It of course has consequences… but I don't think the operation is so big that we could say 'Oh, it's a failure'."
An expensive 'lucky dip'
Those who have experienced Australia's hotel quarantine programme first-hand have likened it to a "lucky dip" - and perhaps none more so than Remi Durrenberger.
Remi, who lives in France, was forced to fly back to Australia twice this year, after losing both his mother and father just months apart.
"When I heard about the people in South Australia who were about to finish quarantining, only to to be told they had to do it for another two weeks, I had tears in my eyes for them," he said.
For Remi, who finished his second stint of hotel quarantine on Thursday, the experience was "difficult".
He recalls suffering constant headaches because of limited airflow in his room, and questions whether the $3000 bill - which he is now required to foot - is justified.
"[Because headaches are a symptom of coronavirus] I did five or six tests throughout my quarantine, they all came back negative, but you still have to sit out the 14 days because of the incubation," he said.
"You think about all those things in quarantine and it just drives you nuts."
'An occupational injury that impacts the wider city'
For McLaws, the Parafield cluster is in no way surprising. She likens outbreaks linked to hotel quarantine to those experienced in residential aged care facilities, which the nation was collectively "slow to learn from".
"You don't put Covid patients in the centre of town and expect them to be looked after by people who haven't got really top level training, only for them at the end of the day to go home, back into a highly densely populated city," she said.
"And we are doing it in every major city. You have to expect that occasionally someone will acquire [it].
"This is an occupational injury that impacts the wider city."
In a bid to mitigate the problem, authorities this week introduced new national guidelines requiring quarantine workers to be tested on a weekly basis.
But McLaws contends it's simply "not frequently enough".
"Fifty percent of cases become infectious to others on the fourth day that person was exposed and got infected themselves. So 50 percent of people can spread it on day four, and less a proportion on day three," she said.
"If you can start to infect people on day three, four and five, you need to test not once a week, but everyday."
Should we move quarantine out of cities?
For some within the health sector, these arguments have become a sticking point for the case against hotel quarantine.
McLaws believes the programme should only ever have been an "interim measure", in the absence of purpose-built facilities.
"A purpose-built facility would [ensure] those who are returning have the ability to open up the doors, open the windows, get fresh air, get into the sunshine and do some exercise, without coming into contact with others outside their germ bubble," she said.
"It also means they don't have to be supervised by a guard, and place that guard at risk. The less contact that people have, the better."
A similar system is currently in place in the Northern Territory, where a disused workers camp, about 25 kilometres south of the Darwin CBD, has been repurposed as a quarantine facility.
While de Courten agrees that "we certainly can do better" and there is a need to "beef up our system", he argues moving quarantine facilities to remote locations, like Christmas Island, is not the solution.
"We need to get the balance right. It's not only about quarantine, what do we do with cases where somebody has been diagnosed? Because they need medical care," he said.
"And the question is, are those remote locations equipped to do so?
"We have still thousands of Australians wanting to come home, and they have family and they have kids, so to put them into a very remote island or location is very tough and has other consequences on their wellbeing."
Hotels see 'an absolute risk to their brand'
At the centre of the debate, of course, are the hotels themselves.
Dean Long is chief executive of the Accommodation Association of Australia, which represents more than 3500 providers across the country, including the nation's major hotel groups.
At the start of the pandemic, he said, companies stepped up to participate in the programme because they saw it as "their duty".
And while they remain committed to "assisting the government where they deem it appropriate", he said successive decisions by authorities to name individual hotel brands linked to an outbreak, when they are operating as a quarantine facility, has made some rethink taking part.
"We've seen a number of hotels withdraw from the programme because the reputational risks are too large," Long said.
"There's two brands in particular who refused to be part of it, because they saw it as an absolute risk to their brand both when the international market returns and when domestic returns in a significant way."
The onus to appropriately manage quarantine programmes, Long stressed, lies with governments, not accommodation providers.
But should the programme continue into the new year, he believes the Federal Government will need to bolster support.
"The biggest thing that's going to happen is that a lot of these hotels participating in it are completely reliant on JobKeeper for the number of staff they have working there," he said.
"And when that ends, there's definitely going to have to be some additional resources allocated to those hotels that are participating to make sure the safety can be maintained through that."
Do we send them home instead?
So could home quarantine be a viable alternative?
For McLaws, it's a resounding no.
"If you don't then stop [everyone in that household] from going to work and you don't stop them from socialising, they then become the security guard, the cleaner and the hotel manager," she said.
Healthcare workers are already "exhausted", added Dr Holly Searle, a senior lecturer in the School of Public Health and Community Medicine at the University of New South Wales, and there are only a "finite amount of resources".
"If you can keep all the suspected cases in a central place and monitor there, that probably takes up less resources than having people out and about in the community," she said.
"So I think we have to be mindful of [health workers] too and their need to reserve their capacity, especially if we do see an outbreak."