Having been battered by the third wave of Covid-19, public health restrictions remain in place across the island of Ireland. Visiting Professor of Public Health, University of Bristol and President of Epidemiology and Public Health section, Royal Society of Medicine, Gabriel Scally talks with Ciarán Galway about zero Covid, north-south cooperation and vaccinations.
Currently, there is a complete absence of a discernible Covid strategy on the island of Ireland, epidemiologist and public health expert Gabriel Scally argues. In this vacuum, momentum has gathered behind proponents of a zero Covid strategy. Scally is one such advocate. The zero Covid approach, as implemented by Australia, New Zealand, Taiwan, and Vietnam, seeks to effectively eliminate the SARS-CoV-2 virus within a defined geographic entity. The absence of community transmission for a defined period of time enables the safe reopening of society and the economy. While there would still be a potential for imported cases, these can then be swiftly brought under control to keep transmission as close to zero as possible.
The two missing components of any successful zero Covid strategy in Ireland are firstly, mandatory hotel quarantining for travellers arriving on the island and secondly, effective north-south cooperation.
“You cannot have this situation, which we know doesn’t work, of voluntary self-isolation combined with a lack of cooperation north and south… Government ministers in Dublin insist that it is impossible to cooperate with the North because of the DUP and we can’t have an all-island strategy. In reality, it’s a failure of the body politic, both north and south.
“Meanwhile, we have now far exceeded the number of deaths from ‘the Troubles’. Don’t tell me it’s impossible for the administrations north and south to cooperate on this; that is stupid,” the prominent epidemiologist remarks.
However, as recently as February 2021, Fist Minister Arlene Foster MLA suggested that “a zero Covid approach would work only on a five-nations basis”. Similarly, Taoiseach Micheál Martin TD has asserted that zero Covid is “simply not a realistic option”. Scally disagrees.
“Zero Covid is only impossible if politicians want to make it impossible. What is disproportionate? What on earth does that mean? People are dying, hospitals are overwhelmed, patients are not receiving the treatment that they need for their cancer or heart disease, health service staff across the island are exhausted, children are being denied access to education, and businesses are going bankrupt,” he outlines, adding: “None of that is beyond solution.”
Rather, the public health expert suggests, the alternative was within touching distance in summer 2020. “The ground was perfectly laid for a zero Covid approach. Unfortunately, politicians chose not to go in that direction, and they led us into the position that we are in now, north and south, which is extremely difficult,” he says.
In late February, the Irish Government approved primary legislation determining that passengers arriving in Ireland from Austria, the United Arab Emirates, Brazil, 13 additional central and south American countries, as well as 17 African countries will be required undertake mandatory State quarantine in hotels for two weeks. Having completed all stages in the Oireachtas, the Health (Amendment) Bill 2021 will now be signed into law by the President.
While New Zealand has been a prime exemplar of zero Covid, Scally recognises that, alongside democratic values, airline route connectivity, economic performance and population density of other island nations or states with one shared boundary, opposition to zero Covid is often grounded in arguments about geographic remoteness.
“Okay. Let’s leave New Zealand to one side and talk about Taiwan. Taiwan has a population of 24 million people, a population density many times greater than Britain or Ireland, some of the busiest airline routes in the world and is an economic powerhouse. It has done the job fantastically well.
“Consider Japan, with a population of over 126 million people and four primary islands, which has done similarly well. It is a democracy which has done it properly and successfully. Closer to home, the Isle of Man has implemented this without anyone noticing, as has Guernsey. Take the biggest island of them all, the continent of Australia, which has also done it,” he illustrates, adding: “[The Irish administrations] should look at the success of these other places, understand what they did and how they did it, then copy it.”
While a zero Covid strategy has remained politically unobtainable in Ireland, hitherto, both jurisdictions have instead sought to suppress Covid-19 incidence rates to an ‘acceptable level’, enabling the economy to reopen between surges while awaiting vaccination rollout. Recurring lockdowns have been utilised as the primary tool to achieve this. However, lockdown itself should be a tactic, not the entire strategy.
“My mantra is: Get it down. Keep it down. Keep it out. You have to do those three things, as well as pursuing a vaccination programme.”
Indeed, in April 2020, WHO Director General Tedros Adhanom Ghebreyesus stated: “So-called lockdowns can help to take the heat out of a country’s epidemic, but they cannot end it alone. Countries must now ensure they can detect, test, isolate and care for every case, and trace every contact.”
Months later, speaking with The Spectator’s Andrew Neil in October 2020, David Nabarro reiterated: “We in the World Health Organization do not advocate lockdowns as a primary means of control of this virus. The only time we believe a lockdown is justified is to buy you time to re-organise, regroup, rebalance your resources, protect your health workers who are exhausted, but by and large, we’d rather not do it.
“We really do appeal to all world leaders: stop using lockdown as your primary control method. Develop better systems for doing it. Work together and learn from each other.”
During the same month, The Lancet published a letter titled: Scientific consensus on the Covid-19 pandemic. In the letter, signed by 80 public health experts and doctors (and subsequently signed by over 4,000 more), the rationale for lockdowns is acknowledged as being about slowing the spread of the virus and ensuring that health systems are not overwhelmed. It identifies Japan, Vietnam and New Zealand as having demonstrated that “robust public health responses can control transmission, allowing life to return to near-normal”.
Noting that lockdowns have been both socially and economically disruptive, the letter asserts that “these effects have often been worse in countries that were not able to use the time during and after lockdown to establish effective pandemic control systems”.
In the absence of an adequate strategy to mitigate this disruption, many countries, including Ireland, have faced ongoing restrictions, demoralisation and diminishing trust. This, Scally argues, is what creates a vacuum which is then filled by individualism and undermines social solidarity.
“If there is a growth or prospering in individualism, it’s because of the bankruptcy of leadership. When people lose trust, lose confidence, and don’t see where we are going in the absence of a discernible strategy, that’s what creates the space for individualism,” he adds.
Having consistently advised that the island of Ireland be treated as a one epidemiological unit, Scally initially welcomed the memorandum of understanding (MOU) on public health cooperation on an all-Ireland basis co-signed by Chief Medical Officer Tony Holohan and the North’s Chief Medical Officer Michael McBride.
Now, however, he is scathing of what he regards as “a meaningless document”. “The language remains great and the sentiment is excellent, but I don’t think anyone could point to anything that it has influenced for the better… There is no use in having this wonderful tool if no one is prepared to pick it up and use it,” he asserts.
The public health expert elaborates on his assertion that Ireland is exhibiting a deficiency in political leadership. “I think [the governments] know what should be done but think it would be too difficult to do so and are afraid that they will fail. Whereas if they don’t bother trying, they can point to the people and say, ‘you’re the people that went to restaurants and had house parties’ or whatever. It’s called victim blaming.
“Each time things go wrong; they point at a few people who aren’t doing the right thing and choose them as scapegoats. It’s a much easier place to be because you don’t have to take responsibility for anything. Nobody ever said it would be easy to do leadership, but if you don’t do leadership, you see the consequences.”
“Zero Covid is only impossible if politicians want to make it impossible.”
Referencing polling data which suggests that people would take strident public health measures, support, and observe them, Scally admits that he has limited sympathy for politicians, even in the context of intense industry lobbying.
“Who’s on the pro-health side here? Who’s paying anyone to go lobbying the departments of health, north or south, to do the right thing on public health? No one is paying for that. It is only health professionals and citizens saying it,” he insists.
Speaking on RTÉ Radio 1 in December 2020, Scally suggested that Minister of Health Robin Swann MLA should resign. Reiterating the soccer analogy he used at the time, the epidemiologist stands by his rationale. “If Northern Ireland was a football team playing in a league and it had performed as badly as it has done in responding to Covid, the entire backroom team would be out the door. It’s all about performance.”
Scally is particularly perturbed by comments made by Minister Swann in the aftermath of the decision to relax public health restrictions over Christmas 2020 and the subsequent surge in transmission and deaths. Discussing that decision and conceding that it was wrong, the Minister qualified: “I think everything is fine in hindsight.”
“It can’t be hindsight. Hindsight is when you look back and discover something that you had no prior knowledge of. That’s hindsight and you say, ‘gosh, how did I miss that?’ Well, no one missed this one.
“There were plenty of voices, me included, who said, ‘if you take your foot off the brake here and you loosen things up for Christmas, we will pay a terrible price.’ That is exactly what has happened. In foresight, [the Executive] decided to do something that it had been told was dangerous, destructive and likely to end up in a huge upsurge of the virus and that’s what happened,” Scally affirms.
NISRA figures indicate that from 18 March to 1 January 2021, there were 1,921 Covid-19 related deaths. From 2 January until 5 March 2021, there were 924 deaths.
Now in the initial phases of the vaccination programmes, the administrations, north and south, are rolling out the vaccine to priority cohorts. However, it is not necessarily a panacea. Scally is cautiously optimistic though warns against an “overoptimism”. The epidemiologist’s most significant concern is that emerging variants of the SARS-CoV-2 virus will be less amendable to prevention by the vaccine.
“We have to undertake additional measures. For instance, preferably stopping new variants coming in until we have a handle on it. That means border controls. We also need to vaccinate as many citizens as we can, while having the local public health teams staffed up and ready to jump on any outbreaks or flareups that occur.
“I am very worried about this period that there will be overoptimism about the vaccine; that we’ll take the foot off the brake, witness an acceleration of cases and we won’t know what the consequences are until that happens. It’s not a nice scenario. My mantra is: Get it down. Keep it down. Keep it out. You have to do those three things, as well as pursuing a vaccination programme.”
Likewise, achieving sufficient vaccination of the population is a challenge. “This virus is so infectious that you really need almost everyone to be vaccinated in order to avoid really serious outbreaks. Sufficient supply of vaccines will take time and it is difficult to run a vaccination programme.
“I know that, having done it, getting to 60 or 70 per cent is easy. Getting to 80 per cent is tough. Getting over 90 per cent is really tough, particularly if you have a lot of people who are making use of it for their own strange ideas, notions or publicity seeking vaccine scepticism. It is a perfect time for people who wish to disrupt,” he emphasises.
What policy choices are the decision makers now faced with? “Crunch time again. Lots of people, including many politicians, now admit that we should have gone for Zero Covid last summer. There is another opportunity in the making right now. The circumstances are different, with vaccines and variants, posing opportunity and threat. But there is a groundswell of public support for getting rid of the virus, keeping it out, and getting back to something like normal.
“I have no doubt that the effort should be made, and we should do it thoroughly and determinedly. We can beat this virus, save lives and livelihoods, and show exactly what Ireland is capable of,” Scally concludes.