key: cord-0831249-4w8qhup2 authors: Moloney, Kim; Moloney, Susan title: Australian Quarantine Policy: From Centralization to Coordination with mid‐Pandemic COVID‐19 Shifts date: 2020-05-19 journal: Public Adm Rev DOI: 10.1111/puar.13224 sha: d11f1b0beaf8f7de506d8c0aef0ed64273e17ec9 doc_id: 831249 cord_uid: 4w8qhup2 By combining a historical institutionalism approach with institutional isomorphism and punctuated equilibrium, this paper analyses quarantine policy change across 120 years of Australian quarantine history. By anchoring our analysis within specific time periods (years before the Spanish flu, seven decades of inaction, and multiple post‐1997 pandemic updates and responses), we highlight when and why policies did or did not change and how constant push‐and‐pulls between State and Commonwealth institutional ownership altered policy possibilities. The heart of our analysis showcases how Australia's successful COVID‐19 response is a unique output of prior quarantine policies, institutional evolution, and mid‐pandemic alterations of key national pandemic response plans. This article is protected by copyright. All rights reserved. offices [of the Board of Health] were damaged‖ (Townsend 2007, n.p.) . This incident helped lay the groundwork for quarantine policies in newly-independent Australia. Australia's early quarantine policy adoption contrasted with colonial Britain's abolishment of human quarantine in 1896. While Britain viewed quarantine as -anti-commercial, anti-social, and anti-Christian,‖ Australia did not (Maglen 2005 , 197, citing Earnes 1899 . Early Australian sanitation standards 9 and vaccination rates were less robust than Britain but Australia had another obvious difference: diseases endemic in Britain -only occurred in Australia when imported from abroad‖ (Maglen 2005, 215) . As such, Australian understanding of its immense geography 10 and significant distances between itself and others are irremovable from quarantine policies. Quarantine became central to an -imagining of Australia as an island-nation, in which ‗island' stood for ‗immunity'‖ and which non-Australians were -perceived as diseased‖ (Bashford 1998, 388) . In this history, the individual body and its ‗disease' or ‗purity' became a racialized metaphor for institutional and policy behaviors. In Australia's first and only Constitution (1901) , public health was mentioned twice. Section 51(ix) gives Parliament the power to quarantine and Section 69 requires the States to transfer quarantine services to the Commonwealth. With the 1908 Quarantine Act and the 1909 establishment of the Federal Quarantine Service, quarantine policy biopolitics became entwined with Australia's geographic isolation to influence immigration policy. The pairing of the Quarantine Act with the Immigration Act in 1909 created the legal precedent for Australia's infamous ‗White Australia' policy (e.g. Jupp 2002) . These Acts altered Australian responses to international trade and when epidemiological responses were required, Australia's -prophylactic quarantine‖ (Bashford 1998, 393 , citing Report on Quarantine 1883, 5) meant that Australia's ports had become locations of immigration, trade, biopolitics, and biosecurity. Yet this early national approach to quarantine was incomplete and controversial. In 1913, Sydney experienced a smallpox outbreak. The Commonwealth declared Sydney a quarantine zone and the New South Wales Premier -protested strongly, arguing the move hurt commerce‖ (Brew and Burton 2004, n.p.) . Later-day quarantine policies initially stopped Australian infections from the initial Spanish flu wave in 1918 (Shanks 2019 ) before collapsing in 1919 as insufficiently quarantined soldiers returned home from World War I. Many soldiers attempted to break quarantine including one solider being charged with -inciting a mutiny to break out‖ of a quarantine location (McQueen 1976, 565) . The flu led to the deaths of between 12000 and 16000 Australians (Townsend 2007, Curson and McCracken 2006) . The policy response to Spanish Flu by Australian States and Territories was reminiscent of a pre-federation Australia from just two decades prior (Beddie 2001) . Not only was Australia unprepared, but State/Territory and Commonwealth disputes hampered coordinated responses. This included the failure of a 1918 agreement in which only the Commonwealth could declare interstate quarantine after notification by a State/Territory Chief Health Officer of regional concerns. Once the Commonwealth deemed interstate quarantine was needed, only the Commonwealth and not the State/Territory could manage the response and as importantly, had the power to stop border closures. When Victoria and New South Wales quibbled over whether New South Wales had accurately diagnosed an influenza epidemic, the situation devolved into -every State for itself‖ (McQueen 1976, 566) . Some states closed while others like Queensland battled the Commonwealth on whether soldiers could land at quarantine stations and still others like Western Australia, -seized the trans-Australian trains‖ (McQueen 1976, 566) . Some of these early policy patterns are partially observable in response including each State and Territory enacting its own legislation with minimal This article is protected by copyright. All rights reserved. in the Philippines (which at the time was a US colony) to promise Australia that the Foundation would -supply for at least one year of experts in industrial hygiene, sanitary engineering, and tropical health‖ along with -training in the USA of Australians to take over these tasks when the Americans withdrew‖ (Roe 1976, 180) . With the Commonwealth Department operational by 1921, this new centralization of Australia's political-administrative response to quarantine and public health would continue until the late 1990s. As noted in Table 1 , State and Territory-enacted human health legislations were infrequently updated. Queensland, for example, passed its first Health Act in 1872. This Act was found to be inadequate with the onset of the bubonic plague and thus, another Health Act was passed in 1900. Queensland's Health Act of 1937 consolidated ten previous health-focused Acts but it was not until 2005 that another Health Act was passed. COVID-19 amendments to the 2005 Health Act allowed Queensland's Chief Health Officer to declare a COVID-19 public health emergency, make it a notifiable and quarantinable disease, and issue public directions to restrict movement of persons, ban non-essential gatherings, and other public health directives. The current Health Act and this amendment consolidates significant pandemic policy power in the State, not the Commonwealth. This reflected that while Commonwealth involvement in the health system has greatly increased so that it is now the dominant public funder, States/Territories remain responsible for public hospitals and significant aspects of public health and safety. Other States/Territories similarly updated their legislation in the last 15-20 years. Each update is a partial reversal of Australia's post-Spanish flu policy response. Insert Table 1 About Here In the next seven decades of Commonwealth-led public health, it was understood that -quarantine and epidemiology both required layers of government, but also justified layers of government‖ (Bashford 1998, 396, original emphasis) . Australian governments linked quarantine surveillance to national survival. This surveillance extended to immigration, barring entry of those with identifiable communicable diseases, and removal of persons with infectious diseases identifiable at arrival. This task's racialization becomes apparent when a 1920s Australian journalist noted that Australia's top public health official -controls quarantine service and conducts a ceaseless war against the foreign germ declared by his department to be a prohibited immigrant‖ and thus, partaking in an explicit -conflation‖ of -the germ and the immigrant‖ to reinforce a -racialized order‖ (Bashford 1998, 398, 399) . As the 1920s progressed, the international relations of quarantine and globalization created a drumbeat of worry. When Kingsford Smith flew across the Pacific from San Francisco to Brisbane in 1928, the internal journal of the then-Department of Public Health Affairs wrote that Australia's -sense of security from a geographical isolation has received a shock‖ (Bashford 1998 , 396, citing Health 1928 . However, and as noted in the next section, this ‗shock' was reflected less in updates to Australia's human health pandemic policy responses than new interactions of Australian distance and geography with international trade and quarantine. With no major human health pandemics or epidemics in Australia for seven decades after 1920, 11 Australia entered a period of -apparent complacency‖ (Brew and Burton 2004, 1) as human health quarantine policies faced few update pressures. One national Cabinet-level review in 1977 12 even concluded that the -disease threat to people has reduced to almost insignificant proportions‖ (Brew and Burton 2004, 1) . As such, Australia's human health quarantine -became overshadowed by the focus on animals and plants of agricultural importance‖ (Nairn et al. 1996, 30) . While this separate history could be another paper, there are at least four quarantine-relevant observations for human health pandemics from Australia's trade-focused biosecurity policy shifts. Each relate to Australia's current COVID-19 quarantine policy responses. The first observation is that border biosecurity has always mattered. As Australia's distance barrier lessened, policy shifts occurred. The Nairn Review (1996) of Australia's nonhuman health quarantine policies suggested that Australia must change from its border-focused approach to a managed shared risk approach in which quarantine was viewed -as [a] continuum of activities involving pre-border measures to reduce the threat of entry, well-targeted border controls and post-border measures such as monitoring and surveillance to detect incursions at an early stage, backed-up emergency response plans to contain, control or eradicate pests and diseases when incursions occur‖ (Tanner and Nunn 1998, 451) . The continuum idea would be transferred into Australia's post-2002 human health pandemic policy approaches. The second observation is an Australian fear of pests and disease importations that devastate local flora and fauna. Australian newspapers are littered with the failed import of introduced species (e.g. cane toad to control cane beetle, European rabbit 13 with the First Fleet) or failures to stop unauthorized imports (e.g. South American fire ant, Asian papaya fruit fly). These fears led to enhanced veterinary surveillance and as first-time travelers to Australia learn, strong international border biosecurity. This history provided the basis for human screening to occur and ultimately resulted in increased traveler screening at the onset of the COVID-19 pandemic response. This importation fear has been exacerbated with a March 2020 criminal investigation into why New South Wales health authorities and the Australian Border Force allowed travelers infected with COVID-19 to disembark a cruise ship in Sydney and to transmit the virus around Australia while other international travelers were quarantined. This article is protected by copyright. All rights reserved. The third observation is that Australia's borders are not only its international ones. Questions have been raised about whether the unique environments of Australia's six states and two territories require domestic barriers to trade (Kellow et al. 2005, Cook and Fraser 2002) . Others note that Australia's northern border, the land closest to Australia's nearest neighbor Papua New Guinea, functions as a -frontline‖ with a -task as production of the border is at once ‗pushed out' to offshore locations and ‗pulled in' to smaller scale borders within Australia's north‖ (Muller et al. 2009, 784) . In response, the Northern Australia Quarantine Strategy provides early warnings for exotic pests (e.g. citrus canker), weeds, and disease detections. The final observation is that the line between quarantine to protect Australia's flora and fauna and quarantine for human health is infrequently precise. This includes concerns about henipavirus transmission from fruit bats to humans as well as mosquitos carrying Japanese encephalitis, the Chikungunya virus, and the Zika virus. Despite seven decades of no significant human health pandemic or epidemic in Australia after the Spanish flu, its non-human health quarantine policies incrementally evolved as Australia's international trade increased. The necessity of a continuum-based quarantine policy approach, historic Australian fears about importation, domestic border concerns, and links between imported pests and disease keep quarantine policies near the forefront of Australian decision-making. There are strong epidemiological histories of Australia's eight quarantinable diseases 14 along with several post-1997 instances where alarms were raised despite no pandemic being declared. Each alarm was a potential punctuated equilibrium where rapid quarantine policy change was possible. This section is focused on how incremental shifts and punctuated equilibria health threats altered Australian public health pandemic responses. Until This article is protected by copyright. All rights reserved. Despite highly pathogenic avian influenza-like virus H5N1 being detected in China and Hong Kong in 1997 not leading to worldwide spread, the event led Australian government analysts to later observe a -distinct complacency within government about Australia's vulnerability‖ (Brew 2004, np) . This included no post-1920 test of Australia's emergency health response for pandemics, 15 disconnects between immigration and internal disease surveillance, and an Australian -infectious disease control system [that] appears to rely more on unofficial networks and personal contact than on bureaucratic structures‖ (Brew and Burton 2004, n.p.) . March 2003. While Australia had only six of the nearly 8100 cases worldwide and none of the 770+ deaths, this pandemic was -seen as a test for other potential pandemic infectious disease threats, such as… influenza pandemic or deliberate release of a bioterrorism agent such as smallpox or anthrax‖ (Herceg et al. 2005, 277) . Australia responded with incremental policy shifts such as discouraging nonessential travel and screening of incoming passengers. The former was not part of the 1999 Influenza Plan while the latter was encouraged (Health 1999, 28 ). This article is protected by copyright. All rights reserved. AHMPPI encouraged States/Territories to create plans -broadly based on the federal approach‖ even if they need not be -completely similar‖ (Kotsimbos et al. 2010, 303) . This led to multiple State/Territory updates but also differences among state plans. Several states also updated legislation last modified more than 50 years ago (see Table 1 ). The first opportunity to test AHMPPI occurred in March 2009 when a new swine origin influenza strain (H1N1) was identified, declared a pandemic by the WHO in April and in late April, Australia declared H1N1 a quarantinable disease. On 9 May, Australia had its first case with formal public health responses beginning on 17 June and by early July, the virus had become -widespread in the Australian community‖ (Waterer et al. 2010, 52) . Nonetheless, it was felt Australia's low casualty count was largely due to -the relatively benign course of H1N1 This article is protected by copyright. All rights reserved. Accepted Article infection in most patients, not due to any public health success‖ (Waterer et al. 2010, 52) . By 8 November, Australia had over 37000 cases with 189 deaths (Kotsimbos et al. 2010 ). Post-H1N1 analysis often shares the following conclusion: Australia's -containment… failed almost immediately with widespread dissemination just 20 days after its being declared a quarantinable disease‖ (Kotsimbos et al. 2010, 302) . Policy failures included screening practices expecting typical flu symptoms, non-isolation of exposed cruise passengers, testing limited to persons who had travelled only to affected locations, continuation of national sporting events, public perceptions that H1N1 was mild, and insufficient communication between health officials and citizens (Waterer et al. 2010 , Eastman et al. 2010 , Seale et al. 2009 , Fogarty et al. 2011 , Grayson and Johnson 2009 , Holland and Blood 2013 . The Australian Medical Association criticized the government for -being too slow, creating fever clinics at major hospitals only when GPs' surgeries were overrun‖ and not quickly distributing stockpiles of personal protective equipment (Rouse 2009 , Eizenberg 2009 ). While limited quarantine was implemented in Victoria along with partial school closures in Western Australia, neither were widespread policies (Effler 2010 , Eizenberg 2009 ). Reminiscent of early Australian quarantine history, State/Territory practices -did not always align… [each] dealt differently with quarantine, school closure, tourist screening, medical and nursing staff screening, and travel restrictions‖ (Kotsimbos et al. 2010, 304 ). Australia's 189 H1N1 deaths were 189 too many. If this H1NI response had been Australia's response with SARS-COV-2's higher clinical severity, Australia would not be congratulated as COVID success story. A key post-H1N1 institutional response was to create a new whole-of-government 16 coordination point among State-and Territory-level Chief Health This article is protected by copyright. All rights reserved. Officers and the Australian Chief Medical Officer (Firman 2016) Accepted Article to reconsider pandemic responses. In contrast, Australia's COVID-19 has not (yet) led to postvirus response updates but is being updated in the midst of the pandemic. The AHMPPI's quarantine policy instruments and its mid-crisis updates are discussed in the next sections. In South Wales with the initial case and the next 11 cases having links to China (Liebig 2020) . The second group arose in Queensland with one person in a travel group infecting three others (Liebig et al. 2020 ). Since then case numbers have increased with nearly 63% of cases in Australia having acquired their disease overseas (Health 2020b). Territory. The Australian Health Sector Emergency Response Plan for Novel Coronavirus was released on 18 February. Its purpose to guide a -whole-of-government‖ (Health 2020a, 5) approach, to clarify the roles and responsibilities of the health sector, where national guidance and coordination are provided, and how decision makers are supported via scientificallyinformed and proportionate responses. This plan, only released to the public after pressure was placed on the Commonwealth to explain its responses, is in many ways a partial restatement of AHMPPI but with an enhanced focus on clinical severity scenarios rather than quarantine policies. As such, the 2020 Plan noted that the AHMPPI remains the -key national agreement document to guide Australia's response‖ (Health 2020a, 1). This article is protected by copyright. All rights reserved. This paper has linked Australian quarantine policy history and its interaction with public health crises, biosecurity, and trade. With this history and its institutional and policy shifts in This article is protected by copyright. All rights reserved. Accepted Article mind, this section engages in a quarantine-focused analysis 17 of Australia's COVID-19 response with the two of four possible pandemic actions within the AHMPPI. Analysis is centered within AHMPPI quarantine guidance and in particular, its border control and social isolation actions. The AHMPPI has three categories of border measures of quarantine policy: Early empirical analysis suggests that the China ban limited Australian exposure to COVID-19 (Costantino et al. 2020) . By 15 March, the Prime Minister signaled that Australia's international borders would close and all arrivals would face a 14-day self-isolation period. By 18 March, the Prime Minister asked Australians to not travel abroad. By 20 March, Australia closed its borders to non-residents and non-citizens as the entire world was designated a -do not travel‖ zone by the This article is protected by copyright. All rights reserved. Government's Smartraveller service. On 7 April, the advice was -all overseas travel is currently banned, with few exceptions‖ (Smartraveller 2020). On 23 April, the Prime Minister told Australians that the international border will be closed for at least three more months. Before border closures, screening measures were slowly implemented despite the AHMPPI noting screening importance (Health 2019, 130-133 ). News reports indicated either limited or no advice given upon arrival, or as one journalist noted on 23 March, passengers were asked to wear masks upon arrival despite no masks being provided, an ushering through dutyfree before visa/customs checks in which flyers saw staff without masks, and an arrivals hall with persons not social distancing (Bramston 2020) . Information about whether policy improvements occurred soon became a non-issue as the international border closure began. While news reports indicated that thermal scanners were deployed at eight Australian This may reflect evidence from SARS that if Australia only implemented border screening, such measures would only -reduce the probability of a major epidemic by up to 7%‖ (Glass and Becker 2006, 1096) and that -screening and distribution of information at borders play a relatively minor role in reducing the international spread of SARS when compared with control measures applied in the infected region and preparedness in the uninfected region‖ (Glass and Becker 2006, 1098) . Other international border measures included an initial 14-day self-quarantine and later, on 28 March, a mandated 14-day quarantine for all international arrivals in designated hotels. This article is protected by copyright. All rights reserved. Self-quarantine with a 14-day specification is within the AHMPPI but interestingly, is neither recommended nor not recommended (Health 2019, 139) . Moreover, mid-pandemic quarantine policy shifts in late March are not specified in the AHMPPI. This may reflect a national document prepared for influenza and not a disease in which persons are highly infective during incubation with asymptomatic persons infecting others. In fact, Australia's SARS and H1N1 experiences suggested that influenza epidemics in which persons are not infective during incubation may not require border measures (Health 2019, 129) . This expectation is counter to COVID-19 viral concerns about asymptomatic carriers and thus, we see an initial mid-pandemic policy shift to self-quarantine and later, another policy shift to mandatory quarantine as a response to advice given to the newly created National Cabinet. In addition, and since early April 2020, Australia has encouraged (but not required) its Replicating sub-national border closures during the Spanish flu, Tasmania (19 March) and Northern Territory (21 March) were the first to implement hard border closures. The closures refused entry to the State/Territory even for its residents. Such closures were not recommended by the AHMPPI (Health, 2019, 142 ) and yet on 24 March, South Australia also closed its borders, Queensland followed on 25 March, and Western Australia on 6 April. The only states with no hard border closures are the most populous, New South Wales and Victoria, This article is protected by copyright. All rights reserved. Accepted Article despite both having higher community spread than the other States/Territories combined (Health 2020a). 18 Although not closed, they are effectively enclosed (to other states but not to each other) given closures and domestic travel bans elsewhere. This creates an impression of Australia protecting itself against international outsiders as well as the rest of Australia protecting itself against the 58% of Australians who live in New South Wales and Victoria. 19 Despite sub-national border closures being a mixed lesson from the Spanish flu and not recommended by the AHMPPI, Western Australia went even further. On 31 March, Western Australia prohibited movement (enforced via police checks) at its eight sub-region borders while Queensland chose to ban travel of more than 50 kilometers from home. More generally across Australia, messaging to discourage all but local travel increased before the four-day Easter break. concerns that rural towns with limited health capacity may face disproportionate health impacts. Reports of reduced travel during Easter did occur. Given just 300 new cases diagnosed since one-week past mid-April, exhortations to -stay home‖ appear to have been heeded. Notwithstanding a 15 March ban on cruise ships docking in Australia, Australia experienced a progressive increase in infected incoming cruise passengers. This includes passengers returning from the Diamond Princess in Japan, the disembarking of COVID-infected Ruby Princess passengers in New South Wales, and the arrival of Artania in Western Australia. In the latter, Western Australian citizens were disembarked for a 14-day quarantine at Rottnest Island 20 while other Australians and foreign nationals were moved via police escort directly from the Artania to onward flights. As of early May, nearly 15% of 551 Western Australian cases arose from the Artania (Hedley 2020) . This crisis is ongoing as other cruise ships remain in Australian waters despite Australian Border Force orders to leave by 15 June (ABC 2020). On 4 This article is protected by copyright. All rights reserved. April, New South Wales police launched its largest peacetime operation in Sydney Harbor to refuel/restock five crew-only cruise ships to allow departure to home countries. The AHMPPI recommends cruise ship passenger screening only if clinical severity is high while expecting -disease surveillance systems‖ on board (Health 2019, 138) . Despite previous Australian experience of cruise ship affected passengers and crew during H1N1 (2009), the plan does not specify whether the cruise ship or the local public health authority must screen passengers before disembarkation (Health 2019, 138) . The recent launch of a criminal investigation into the Ruby Princess disembark decision with 369 cases or ~13% of New South Wales' cases (Health 2020a) suggests such policy confusion will receive attention. This aspect of quarantine and border control policy has had limited research (e.g. MacIntyre 2020). The second category of AHMPPI quarantine-related measures is self-isolation or social and physical distancing. The AHMPPI divides this category into seven parts: school closure (proactive and reactive), workplace closure, working from home, mass gathering cancellation, contact tracing, voluntary case isolation, and voluntary quarantine of contacts. Within this component of quarantine policy, we also found mixed results. While certain present-day actions are found within the AHMPPI (partial or full workplace closure, public space closure), most others were unplanned mid-pandemic policy expansions of AHMPPI recommendations (limiting movement to grocery, medical appointments, pharmacy, and daily exercise, monitoring at-home quarantine of positive COVID-19 patients). Such mid-pandemic shifts may reflect early evidence of category importance in limiting exposure with COVID-19's high clinical severity (Dalton et al. 2020 ) and the activation of national coordination measures during this pandemic. This article is protected by copyright. All rights reserved. The AHMPPI does not recommend school closures unless there is evidence of -high clinical severity and/or high transmissibility specifically in children‖ (Health, 2019, 144-145, our emphasis), a situation not present in COVID-19 (Wu and McGoogan 2020) . Prime Minister Scott Morrison was criticized in March/April for non-clarity on whether schools should close. This concern was amplified with questions about child care for health and essential workers along with internet access inequalities for home education. The first state to mandate school closures was Victoria on 24 March. The others followed in late March as public schools neared their break between Terms 1 and 2. By late April, it was agreed that decisions on how school will be structured, how teaching will occur, and the care of children unable to stay home would be led by each State/Territory. In last days of April, schools reopened in two States and one Territory while Australia's more populous states chose different strategies. On 11 May, only certain grades will return to school in Queensland while in New South Wales, students will attend in-person one day a week. Where schools have been fully open for more than one week (Western Australia, South Australia), attendance averages range between 60-75% while the rest learn from home (ABC 2020a). In contrast, a public battle between the Commonwealth and Victoria has broken perceptions of relative COVID-19 intergovernmental unity. This includes the Federal Minister of Education stating that Victoria was taking a -sledgehammer‖ to children's education by refusing to open Victorian schools (ABC 2020a). Given historical precarities between levels of government (whether during a pandemic or not), the Federal Minister was forced to apologize just a few hours later (ABC 2020a). Even in states where schools fully reopened, local newspapers in Western Australia displayed competing advertisements from the Department of Education asking parents to send their children to school while the Teachers Union only This article is protected by copyright. All rights reserved. supported schools opening for -vulnerable students and the children of essential workers‖ (Warriner 2020, n.p.) . The AHMPPI recommends working from home and workplace closure if -moderate to high clinical severity‖ is present and if such measures can be -reasonably accommodated‖ (Health, 2019, 147-148) . This recommendation has been largely followed. While there have been no mandated workplace closures across Australia, many employers allow some employees to work from home and/or closed offices so employees could work from home. Google's COVID-19 Community Mobility Report indicates drops between 37% (Victoria) to 23% (Northern Territory) for work-related visits since mid-February with public transit utilisation reductions between 68% (Victoria) and 55% (South Australia, Northern Territory) (Google 2020). Despite early evidence suggesting an 80% stay-at-home rate is necessary for Australia to flatten the curve and limit community spread (Hanrahan 2020) , progress is being made. The public space closure was rapid. This included international sporting events (e.g. Melbourne's Round 1 in the Formula One World Championship) and domestic events played without fans before full stoppage. Public spaces such as the arts, movie theatres, national parks, beaches, playgrounds, and skateboard parks were progressively closed. This matches AHMPPI expectations that if clinical severity is -high‖ with -moderate to high transmissibility‖ (AHMPPI 2019, 149) such closures will occur. Not mentioned in the AHMPPI is current national guidance encouraging (but not requiring) non-infected Australians to limit their outside trips to just the grocery store, pharmacy, and medical appointments. This includes allowing persons to engage in daily exercise if they are in groups of no more than two (excluding family groups) and if they maintain social distance. The failure of persons to abide by such guidance in public spaces has seen the deployment of new technologies such as drones to monitor gatherings and the issuance This article is protected by copyright. All rights reserved. Accepted Article of significant fines in Brisbane, Melbourne, and elsewhere. As Australia reduces its case load, the decision to allow increased numbers of individuals to gather is being made on a state-by-state basis. This is in contrast to the pandemic start where guidance originated from the Accepted Article to international arrivals quarantined in hotels. In one recent case, a quarantined traveler in Western Australia was caught leaving their hotel and was jailed and denied bail (Menagh 2020) . Such State/Territory actions are not discussed within the social isolating option of the AHMPPI. Instead, current quarantine policies appear to have migrated from border control policies and into domestic spaces as Australia modifies the AHMPPI for the COVID-19 era. Australian quarantine policies are irremovable from its self-perception as nation, its view of non-citizen ‗others', its international trading prerogatives, and its reaction to human health pandemics. This paper created a framework for early analysis of quarantine policy responses. Analysis was enhanced through a historical institutionalism approach that identified moments of institutional isomorphism and punctuated equilibrium across 120 years of Australian quarantine policy history. By combining historical institutionalism with public administration concepts while carefully ensuring that typical pitfalls are minimized (Raadschelders 2011 , Radaelli et al. 2012 , this study showcases the potential of institutionalist and policy-administrative approaches for pandemic analyses. This paper showed that while Commonwealth and State/Territory contestation remains, significant sub-national action is occurring in cooperation with the Commonwealth. This is confirmed by a 2020 COVID-19 Plan and the rapid formation of a National Cabinet where the Commonwealth role is largely to communicate, to coordinate, to apportion and provide services where necessary, and to evaluate. Quarantine policy placement in Commonwealth hands in Australia's first twenty years remains in place at Australia's international borders even as the Commonwealth ceded domestic borders and other human health quarantine measures to States/Territories. Where mixed messaging occurs (thermal scanners, cruise ships, and schools), This article is protected by copyright. All rights reserved. Accepted Article the reasons include poor communication on the government's integration of science into screening (thermal scanners), and unclear lines of responsibility between states and the Commonwealth (cruise ships). Bickering about school re-openings between levels of government highlight historical disagreements about Commonwealth influence over State/Territory schooling. Potentially new COVID-19 related empirical research on border closures (e.g. Costantino et al. 2020 , Adekunle et al. 2020 , Liebig et al. 2020 ) and social distancing (e.g. Williem et al. 2020 , Neufeld and Khataee 2020 , Milne and Xie 2020 , Chang et al. 2020 ) are under review. Ongoing policy actions within Australia's COVID-19 response and its post-COVID action plans will be enhanced as policy learning and epidemiological learning accelerates. Overall, we find that Australia's quarantine policy history and pandemic responses have been largely reactive. This includes its Spanish flu responses, the 1999 Influenza Plan creation after H5N1 in 1997, and the 2008 creation of the AHMPPI after 2004 H5N1. In contrast, the current Australian COVID-19 quarantine policy responses are being proactively modified mid-pandemic. This has led to instances where AHMPPI plans are not followed or are extended beyond previously planned policy responses. Australia's capacity to competently navigate policy shifts mid-pandemic given COVID-19's clinical severity, its national coordination and collaboration with sub-national actors, and its reliance on evidence-based science and medical analysis are potential exemplar behaviors for other countries. Australia's pandemic responses and its history of tight biosecurity have institutionalized quarantine policies into Australian identities. While certain path dependencies and policy contestations arising from the birth of the Australian nation remain, the adoption of a policy continuum approach after the Nairn Report (1996) This article is protected by copyright. All rights reserved. Article learning after the late 1990s has strengthened Australia's response. Given that the present mix of Commonwealth and partially delegated and coordinated State/Territory responses are flattening the curve, there is still room to adjust the AHMPPI in light of current experiences and to strengthen pandemic health relations between the Commonwealth and States/Territories. Nonetheless, its arguable that Australia's quarantine policy response to COVID-19 has been more effective than many other countries. Assuming no significant outbreak spikes, the competent management of any new pandemic waves, and an appropriately timed return to normality, Australia's response will become a model for others. We thank our reviewers along with Kanishka Jayasuriya, Leslie M. Pal, and Diane Stone for comments on earlier versions She is co-editor of a Transnational Administration and Global Policy Book Series with Bristol University Press, co-editor (with Diane Stone) of the Oxford Handbook of Global Policy and Transnational Administration Associate Professor at Griffith University in Queensland, and a Queensland Health Pre-Eminent Specialist. She is a previous President of the Paediatric and Child Health Division of the Royal Australasian College of Physicians and is a RACP Medal (2016) awardee This paper uses the institution-focused calculus approach within historical-institutionalism instead of historical-institutionalism's cultural approach. A discussion of whether Australia's culture (e.g. Collins 1985) helped or hindered change is a separate paper For discussion of another successful COVID-19 response, see Moon (2020) on South Korea discuss interactions of Australia's national government (aka the ‗Commonwealth') and its federalist structure Hand hygiene, personal protective equipment, and cough/sneeze etiquette Queensland Museum memoir, the author discussed Queensland's pre-Federation legislation, its difficulty in implementing new health regulations in the early 20 th century, and creation of -rat gangs and disinfectors‖ who struggled against doctor denialists claiming Australia had not yet witnessed -true Asiatic plague‖ Australia's land mass is ~size of the US ‗lower 48' despite a population 1/15 of the US there was an outbreak of -Asian influenza‖ (H2N2) in 1957-58 and a Hong Kong influenza (H3N2) in 1968. A Russian influenza (H1N1) in 1977 was a pseudopandemic given immunity among those born before the late 1950s. In Australia, none of the three led to significant fatalities and none imposed quarantine This report was likely written in response to US (H1N1) swine flu in 1976. For more on this US epidemic and its failed vaccination campaign, see Sencer The idea was borrowed from Western Australia's construction of a 3256-kilometer (2023-mile) fence in the first decade of the 20 th century. This fence intended to prevent rabbits from entering Western Australia. The fence's impact upon Australia's Aboriginal communities, Australia's ‗stolen generations', and the fence's contribution to Aboriginal marginalization are portrayed in an award-winning film Australia's National Notifiable Diseases Surveillance System (created in 1991) also collects data on six bloodborne diseases, twelve gastrointestinal diseases, four other bacterial infections, six sexually transmissible infections, fifteen vaccine preventable diseases, nine vector-borne diseases Australia's first influenza pandemic plan (1999) only provided two planning exercise scenarios, one of which was -taken from the US draft influenza pandemic plan‖ (Health 1999, 67-68). For the importance of community-level scenarios and collaborative engagements This includes a A$100 billion stimulus (largest in Australian history at ~10% of GDP), the first-ever postponement of Australia's national budget discussions, concerns about insufficient Commonwealth and State/Territory-level stockpiles, private/public donations of stockpiles to China early in the crisis, strict testing limits until late March, and civil rights questions. Australia's post-pandemic economic realignment will be very important. For lessons from Australia's response to the 2008 financial crisis, see Bell & Hindmoor The Australian Capital Territory (1.7% of Australia's population) had no domestic border closure as it is surrounded by New South Wales Given small case pockets in both states in early May and in contrast to South Australia (two weeks of no new cases) and Western Australia (one week of no new cases) This island was removed of its vacationers so that quarantine could begin. 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