01 Commissioners’ foreword Kupu Whakataki
Among the many shocks COVID-19 dealt Aotearoa New Zealand was a profound and prolonged loss of certainty. When we first saw footage of deserted streets in Wuhan and overflowing wards in Italian hospitals, we were bewildered. What was this new infection, would it affect us and how bad would it get? When would things go back to normal?
Very soon, it was clear there would be no escaping COVID-19 and normal life would be on hold for some time to come. By mid-March 2020, the Government knew it needed to respond strongly, given the risk that COVID-19 would otherwise over-run our health system and cause many deaths. As an island state, we had an opportunity unavailable to many countries already in the grip of COVID-19: we could stamp it out to the extent it had reached Aotearoa New Zealand already and then do our best to shut out further incursions, at least for a while. And so, at the end of March 2020, the Government made the difficult decision to, in effect, close the borders and put the whole country into lockdown.
Almost overnight, the routine and familiar was upended.
Almost overnight, the routine and familiar was upended. Everyday activities we took for granted – going to work or school, catching up with family and friends, a quick trip to the shops – were suddenly out of reach. Our lives were governed by strict rules that were rolled out rapidly and rolled back again as outbreaks waxed and waned. To navigate this new landscape, we acquired a whole new vocabulary: alert levels, locations of interest, personal protective equipment (PPE), rapid antigen tests (RAT), traffic lights.
Most of us learned to live with the unknowns, the instability and the sheer strangeness of it all. We recognised that, however tough things seemed here, many other countries had it far worse. International comparative studies have since borne that out. Our COVID-19 mortality rate was much lower than most other countries, including the United States and the United Kingdom (see Chapter 1 for an overview of Aotearoa New Zealand’s comparative pandemic outcomes).
Our health system was never overwhelmed by COVID-19 cases, although it was often strained in other ways. While our use of lockdowns was among the most stringent in the world, it was relatively sparing: we spent more of 2020 free from onerous restrictions than people elsewhere. A generous economic response cushioned people from the worst of the pandemic’s immediate impacts and – initially at least – Aotearoa New Zealand’s social and economic outcomes were better than most other OECD countries.1
But still, the pandemic hit Aotearoa New Zealand hard, and it was harder on some people than others. For more than 4,000 New Zealanders who died between 2020 and the end of October 2024, COVID-19 either caused or contributed to their deaths.2 Many others became seriously ill and some remain so today, due to long COVID. A disproportionate share of the health burden fell on Māori and Pacific peoples.3 And of course the pandemic’s impacts extended well beyond health. Some people lost jobs or businesses (although government intervention mitigated these losses), while others in essential roles had to keep working when they didn’t feel safe to do so. Rights most of us take for granted were curtailed. Families were separated from relatives overseas, and some New Zealanders were unable to get home. Ongoing disruptions in the education sector saw some young people drop out. Women gave birth without the support of friends or family. People died alone or with only a few loved ones present. In 2024, this country (like many others) is still reckoning with the array of economic and social challenges which the pandemic either caused or worsened.
Whatever satisfaction we draw from the fact that Aotearoa New Zealand emerged from the pandemic in considerably better shape than many other countries, we cannot look away from the undeniable harm New Zealand sustained. Contentious public health measures like vaccine mandates wore away at what had initially been a united wall of public support for the pandemic response; along with the rising tide of misinformation and disinformation, this created social fissures that have not entirely been repaired. Certain groups, many already disadvantaged or vulnerable well before the pandemic, were left worse off when it subsided. As a country that has always professed its belief in equity and fairness – values also enshrined in te Tiriti | the Treaty of Waitangi – we need to make sure the response to the next pandemic does not lead to inequitable and damaging outcomes.
How can we do better next time? The importance of answering that question is, in essence, the reason for our Inquiry.
How can we do better next time? The importance of answering that question is, in essence, the reason for our Inquiry. Our terms of reference require us to review Aotearoa New Zealand’s response to COVID-19 and identify lessons that will ensure we are better prepared for another pandemic. In fact, we think many of our lessons can be usefully applied to other threats that could also disrupt our country in this century of heightened risk – whether these hazards are familiar or unprecedented, natural or human in origin.
There will be another pandemic and it will not be the same as COVID-19.
We cannot know when or where the next pandemic will break out, nor what form it will take. But we can be sure of some things. There will be another pandemic and it will not be the same as COVID-19. It will most likely be triggered by another respiratory virus, perhaps even another coronavirus, although an influenza virus is more likely. But in all likelihood, its transmission characteristics and virulence (the rate of fatal cases) will be different and therefore warrant different policy response options. If we have prepared well, those options will be better than last time. Our society will be different too, not least because of the scars which COVID-19 left behind. Our personal and collective resilience, our social cohesiveness, our willingness to comply with restrictions and our tolerance of risk – all severely tested by COVID-19 – may be greater or less than last time.
This uncertainty presents challenges, but it does not make us powerless. As this report sets out, there is much Aotearoa New Zealand can do – and needs to do – to get ready for the next pandemic. We can start by developing a range of pandemic scenarios, working out the probability of them occurring and identifying their likely effects – not only on public health but on all aspects of our wellbeing. From this basis, we can decide where to prioritise investments, then plan and practise accordingly.
Aotearoa New Zealand must have (or have access to) a suite of the very best epidemiological, economic and social tools and resources: treatments, vaccines, technologies, economic and social supports, data and knowledge.
Of course, no country can afford the investment needed to maintain all possible preparedness and policy responses in an optimal state. But, by quantifying the likelihood of future pandemic scenarios, and knowing the best way to prepare and respond to them should they occur, Aotearoa New Zealand can make rational and cost-effective decisions about investment and preparedness. We can put ourselves in a better position still if we also lay the groundwork now for the agile response strategies and delivery mechanisms we may need in future – and underpin them with even better decision-making arrangements and structures across government than we had in COVID-19.
It is not just Government that must take up these challenges. When the response to COVID-19 was at its most effective, it was due not only to the hard work of public servants and politicians but also to businesses and industries, iwi and Māori, Pacific communities and other ethnic communities, social service providers, charities, volunteers and many more. They knew the needs of their sectors or communities, they knew how to reach them, and they could often do what central government could not. The response to the next pandemic, and preparations for it, must therefore harness their strengths.
COVID-19 showed us the capacity of New Zealanders, individually and collectively, to rise to a challenge that proved bigger and more complex than was initially anticipated. As we travelled the country hearing from people about their experiences, we were repeatedly struck by the extraordinary effort, commitment and selflessness shown throughout the pandemic. Across the private and public sectors alike, people worked huge hours, often from home in less than ideal and sometimes stressful conditions.
They did the best they could, making difficult decisions on the basis of imperfect information. They found ways to keep things going in a rapidly-changing and sometimes frightening environment. Whether they contributed on the national stage or away from the public eye, these people made Aotearoa New Zealand’s pandemic response happen. It has been one of the biggest privileges of our working lives to meet them and hear their reflections.
Aotearoa New Zealand has much to be proud of when it looks back on its response to COVID-19. But, as nearly everyone we engaged with over the course of the Inquiry agreed, there is significant room for improvement. Not only will the next pandemic be different, but our response must be different too – and better. This report aims to make a practical contribution to that goal. We have looked back, honestly and scrupulously – not to assign blame, but to enable us to move forward, as prepared as we can be, for what will be a challenging future.
Na mātou noa, na
Professor Tony Blakely, Chair
John Whitehead CNZM KStJ, Commissioner
Grant Illingworth KC,iCommissioner
I roto i ngā mea ohorere maha i puta i te KOWHEORI-19 ki Aotearoa ko te kaha o te noho rangirua. I tā tātau kitenga tuatahi o ngā tiriti mahue i Wuhan me te pokea o ngā hōhipera i Ītari, i pōkīkī tatau. He aha tēnei mate hou, ka pā mai ki a tātau, ā, he pēhea te kino? Āhea tātau ka hoki ki ngā ritenga noa?
Kāore i roa ka pā mai te māramatanga e kore e taea te karo te KOWHEORI-19, ā, ka tārewa ō tātau ake ao mō tētahi wā. I te weherua o Maehe 2020, i mōhio te kāwanatanga me taikaha tana urupare, nā te mōrea o te KOWHEORI-19 ka pokea tā tātau pūnaha hauora, ā, ko te mutunga he parekura. Hei whenua ā-motu, ko tō tātau waimarie, rerekē ki ētahi atu whenua e pēhia ana e te KOWHEORI-19: ka taea e tātau te aukati te hōrapatanga o te mate, ahakoa kua tae mai, otirā mō tētahi wā. Nō reira, i te pito o Maehe 2020, i tau i te Kāwanatanga te whakatau uaua, kia katia ngā pae o te whenua ka whakatau kia noho rāhui te whenua katoa.
Me kī, i te hikitanga o te awatea kua rerekē katoa ō tātau ao. Ko ā tātau mahi o ia rā – te haere ki te mahi, te kura, te whakawhanaunga ki te whānau me ngā hoa, te haere ki ngā toa – kua kore ērā e taea ināianei. I noho tātau i raro i ngā ture pākaha i whakatakotoria wawetia, ka mutu i whakatakotoria anōtia i te putanga me te hekenga o te mate. Kia puta ai tēnei āhuatanga hou, i whakaarahia ngā kupu kōrero hou; ngā taumata whakatūpato, wāhi pūtake, PPE, ngā whakamātautau ākipaturopi tere (RAT), ngā rama ikiiki.
Mō te nuinga, i tau tā tātau noho i roto i te kore mōhio, te āhuatanga pāhekeheke me te tino rerekē o aua mea katoa. I mōhio tātau, ahakoa ngā uauatanga o konei, he kino ake ngā āhuatanga i whenua kē. Kua puta i ngā rangahau whakataurite o te ao tērā. He iti iho te rahinga o te hunga i mate i te KOWHEORI-19 i konei tēnā i ētahi atu whenua, tae atu ki Amerika me Piritana Nui (tirohia te Upoko 5 mō te tirohanga whānui o ngā putanga mate urutā whakataurite o Aotearoa). Kāore i pokea tā tātau pūnaha hauora e te kēhi KOWHEORI-19, ahakoa i pēhia i ētahi atu āhuatanga. Ahakoa ko tā tātau whakamahi noho rāhui tētahi o ngā mea tino pākaha i te ao katoa, he itiiti noa te whakamahinga: ko te nuinga o te tau 2020 i noho wātea i ngā rāhuitanga tēnā i ngā tāngata o whenua kē. Nā te urupare ōhanga ohaoha kāore i pā mai te tino kino o ngā pānga wawe tonu o te mate urutā – heoi, i te tuatahi – i pai ake ngā putanga pāpori me te ōhanga o Aotearoa tēnā i te nuinga o ētahi atu whenua OECD.
Engari, i kaha pākia a Aotearoa e te mate urutā, ka mutu i uaua kē atu mō ētahi tāngata. Mō ngā tāngata neke atu i te 4,000 o Aotearoa i mate i waenga i te 2020 me te paunga o Oketopa 2024, i mate rātau i te KOWHEORI-19, i whai wāhi ai rānei te KOWHEORI-19 ki tō rātou matenga. He maha hoki te hunga i tino māuiuitia, ā, pērā tonu ana i tēnei rā, nā te KOWHEORI roa. He nui rawa te Māori me ngā uri o ngā Moutere i pāngia e te mate. Ka mutu, arā kē atu te whānui o te pānga o te mate urutā i tua atu i te hauora. I kore ngā tūranga mahi, ngā pakihi a ētahi (ahakoa i whakangāwaritia ēnei ngaronga e ngā āwhina a te kāwanatanga), ā, ko te hunga i ngā tūranga waiwai i mate ki te mahi tonu ahakoa kāore i te tino haumaru ki a rātau. I tauporoa ō tātau tika. I noho wehe ngā whānau mai i ō rātau whanaunga i tāwāhi, ā, kāore ētahi tāngata o Aotearoa i āhei ki te hoki mai ki te kāinga. Nā te haere tonu o ngā whakararuraru i te rāngai mātauranga i wehe mai ētahi tamariki. I whakawhānau ngā wāhine me te kore whai tautoko a ngā hoa, whānau rānei.
I mate mokemoke ētahi tāngata, he tokoiti rānei te whānau i reira. I te tau 2024, kei te pā tonu ngā uauatanga ōhanga me te pāpori ki tēnei whenua (pērā i ētahi atu) mai i te mate urutā, kua tino hē kē atu rānei.
Ahakoa te āhuareka ki a tātau i te mea i pai ake te āhua o Aotearoa mai i te mate urutā tēnā i te maha o ētahi atu whenua, e kore e taea te tahuri atu mai i te kino i pā ki Aotearoa. Ko ngā whakaritenga hauora tūmatanui tautohetohe pērā i ngā mana rongoā āraimate i wetewete haere i ngā tautoko mō te urupare ki te mate urutā; i te taha o te nui haere o ngā mōhiohio parau me te horihori, i uru mai te wehewehe i waenga i te iwi, ā, kāore anō tērā kia tino tau. Ko ētahi rōpū ake, he maha rātau he rawakore, he whakaraerae rānei i mua noa atu i te mate urutā, i tino hē kē atu i te maurutanga atu. I te mea he whenua tēnei kua roa e whakapuaki ana i tōna pono ki te mana ōrite me te tōkeke – ngā uara kei roto i te Tiriti – me mātua whakarite tātau kia kaua e pā mai ngā putanga kore tōkeke, tūkino rānei i te urupare ki te mate urutā whai ake.
Me pēhea e pai ake ai ā muri ake? Ko te mea hira o te whakautu i taua pātai, me kī koinā te pūtake mō tā mātau Uiui. E herea ana mātau e ā mātau tūtohu mahi kia arotakehia te urupare a Aotearoa ki te KOWHEORI-19 me te whakaatu i ngā akoranga hei whakarite ka takatū ake tātau mō tētahi mate urutā. Otirā, e whakapono ana mātau ka taea te whakamahi te nuinga o ā tātau akoranga ki ētahi atu mōrea ka whakararu pea i tō tātau whenua i tēnei rau tau whakamōrearea – ahakoa he pūmate ēnei e mōhiotia ana, he mea hou rānei, he tūturu, he whaihanga rānei.
E kore tātau e mōhio ki te wā, te wāhi rānei ka pakaru mai mate urutā whai ake, tōna āhua rānei. Engari tērā ētahi mea e tino mōhio ana tātau. Ka pā anō he mate urutā, ā, kāore e rite ki te KOWHEORI-19. Kāore e kore ka pupū ake i tētahi atu huaketo arahau, tētahi atu mate korona rānei, heoi tērā pea ko tētahi mate rewharewha. Engari tērā tonu pea ka rerekē ōna āhuatanga hōrapa me te nui o te hunga ka mate, nō reira me rerekē ngā kōwhiringa urupare kaupapahere. Mēnā kei te tino takatū tātau, kai pai ake aua kōwhiringa tēnā i mua. Ka rerekē hoki tātau te iwi whānui, tētahi take nā ngā pānga mauroa o te KOWHEORI-19. Ko tō tātau tū pakari takitahi, takitini, tō tātau pipiri ā-pāpori, tō tātau hiahia kia ū ki ngā here me tō tātau rata ki te mōrea – i tino whakamātauria ēnei mea katoa e te KOWHEORI-19 – ka nui ake, ka iti iho rānei pea tēnā i mua.
Ka pā mai te whakapātaritari i tēnei mea pāhekeheke, engari ehara i te mea kua mana-kore tātau. E kī ana tēnei pūrongo, he nui ngā mea ka taea e Aotearoa – ka mutu me pērā ka tika – kia takatū ai mō te mate urutā ā muri ake. Ka taea e tātau te tīmata mā te waihanga i ngā tūmomo āhuatanga mate urutā rerekē, te whiriwhiri i te tūponotanga o te pā mai me te tautuhi i ōna pānga ka taea – kaua i te hauora tūmatanui anake engari ki ngā āhuatanga katoa o te oranga. Mai i tēnei āhuatanga, ka taea te whakatau me haumi ki hea, kātahi ka whakarite mahere me te whakatinana hoki. Me mātua whai a Aotearoa (te āhei atu rānei) ki ngā momo utauta me ngā rawa mātai tahumaero, ōhanga me te pāpori tino pai rawa; ngā maimoatanga, ngā āraimate, ngā hangarau, ngā tautoko ōhanga me te pāpori, ngā raraunga me ngā mōhio.
Otirā, e kore e taea e tētahi whenua kotahi ngā haumitanga e hiahiatia ana mō ngā momo takatū me ngā urupare kaupapahere katoa ki te āhuatanga tiketike. Engari, mā te rapu kia mārama ai ka pēhea ngā mate urutā o muri mai, me te mōhio ki te āhuatanga pai rawa mō te takatū me te urupare ki te pā mai, ka taea e Aotearoa ngā whakatau i runga i te mārama, i te tika o te utu mō te haumitanga me te takatū. Ka pai ake mō tātau mēnā ka tahuri tātau ki te whakariterite ināianei mō ngā rautaki urupare kakama me ngā tikanga whakarato ka hiahia pea tātau ā muri ake – me te paihere i ērā ki ngā whakaritenga whakatau tikanga me ngā hanganga puta noa i te kāwanatanga kia pai ake ki tērā i te KOWHEORI-19.
Ehara ko te Kāwanatanga anake me kawe ake i te mānuka. I te wā i tino whaitake ai te urupare ki te KOWHEORI-19, ehara nā te whakapau kaha a ngā kaimahi kāwanatanga me ngā kaitōrangapū anake engari nā ngā pakihi anō hoki me ngā rāngai, ngā iwi me te Māori, ngā uri o ngā Moutere me ētahi atu hapori mātāwaka, ngā kaiwhakarato ratonga pāpori, ngā kaupapa aroha, ngā kaitūao me te maha atu. I te mōhio rātau ki ngā hiahia o ō rātau rāngai, hapori rānei, i mōhio rātau me pēhea te toro atu, ka mutu ka taea e rātau ngā mea kāore i taea e te kāwanatanga. Nō reira ko te urupare ki te mate urutā whai ake, ā, kia takatū hoki mō tērā, me mātua whakamahi i ō rātau kaha.
I whakaatu te KOWHEORI-19 i te kaha o Ngāi Aotearoa, ā-takitahi, ā-takitini hoki, ki te whakatūtaki i te wero tino nui ake, matatini ake ki tērā i whakaarohia ai. I a mātau i huri haere i te motu ki te whakarongo ki ngā whakaaro o ngā tāngata, hoki atu, hoki atu i mīharo mātau ki ngā mahi, te pūmau me te ohaoha i whakatauiratia puta noa i te mate urutā. Puta i ngā rāngai tūmataiti me te tūmatanui, he tino maha ngā haora i te mahi ngā tāngata, otirā mai i te kāinga i ngā āhuatanga kāore i pai, ā, kāore i tika. I tino kaha rātau, ki te whakatau tikanga ahakoa kāore i whānui ngā mōhiohio. I kitea e rātau ngā ara kia mahi haere tonu i roto i tētahi taiao tere te hurihuri, whakawehi hoki i ētahi wā. Ahakoa i tautoko rātau i mua i te aroaro o te motu, muna rānei, nā ēnei tāngata i tutuki ai te urupare mate urutā o Aotearoa. Koinei tētahi o ngā hōnore nui rawa o ō mātau ao mahi te tūtaki ki a rātau me te whakarongo ki ō rātau whakaaro.
Ka nui te ngākau whakahī o Aotearoa i te hoki o ngā whakaaro ki te urupare ki te KOWHEORI-19. Heoi, ahakoa i whakaae te nuinga o ngā tāngata i toro atu mātau i roto i te Uiui, he nui tonu ngā wāhi hei whakapai ake. Ka rerekē te mate urutā whai ake, nō reira me rerekē anō tā tātau urupare – ka mutu me pai ake. E whai ana tēnei pūrongo kia whaitake te tautoko i taua whāinga. Kua hoki mātau ki te tirotiro, i runga i te tika me te uhupoho – kaua ki te whakatau hē engari kia anga whakamua ai tātau, kia tino takatū ai tātau, mō tētahi anamata whakapataritari.
Professor Tony Blakely, Chair
John Whitehead CNZM KStJ, Commissioner
Grant Illingworth KC,iCommissioner
i Grant Illingworth KC was appointed as a commissioner for Phase One of the Inquiry from 2 August 2024 to 28 November 2024, with his appointment to continue into Phase Two. He was later appointed as the Chair for Phase Two. His appointment to Phase One was made at a time when evidence collection had been completed. In accordance with the terms of reference for Phase Two, Mr Illingworth has not had access to any non-public material gathered in evidence during Phase One. This includes consideration of any evidence that was adduced during the natural justice process, or any other involvement in that process. His primary role during Phase One has been to review near-final drafts of this report. Mr Illingworth notes and emphasises that there are areas in the report that overlap with the Phase Two terms of reference, and that Phase Two of the Inquiry may look more deeply into some issues and make findings, identify lessons and make recommendations beyond those in the Phase One report.