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A few weeks ago the new living with Covid-19 ‘step by step’ national masterplan was launched, and, shortly thereafter, we were threatened with a deviation from the agreed approach via an escalation of restrictions to a Level 5 country wide, based on an increase in the number of new infections of the virus.
Our numbers are still relatively small compared to March and April when it is reasonable to make an educated assumption that tens of thousands of cases were circulating undiagnosed throughout the country. At that time we only had the capacity to test 500 per day at the National Virus Reference Laboratory.
In recent weeks we have scaled up testing, and are currently testing in excess of 80,000 per week and identifying between 500 and 1,000 cases daily. In March we had over 150 patients in our intensive care unit (ICU) departments with Covid-19, and recently we have reported 30 cumulative in the ICU departments nationally.
Is this a reason for concern? Yes. But is it a reason to panic, NO. Living with Covid means that we accept that until there is a vaccine we must proactively find ways to coexist with the virus. It means finding ways to keep the virus at bay, not to count the numbers and to threaten lockdown measures which cause further erosions to our already fragile society. Covid kills directly and Covid kills indirectly. We kept the hospitality sector (wet pubs) closed over the summer so we would not ‘jeopardise’ the schools opening. We introduced different green and red list travel restrictions in an effort to keep Covid-19 at bay. Did those tactics work? No. they obliterated many small businesses that could not reopen, and it created mass unemployment in the travel industry at a time when airline staff could reasonably have operated safely over the summer when Covid risk was low. We sacrificed our economy for poorly thought through decisions, made in a void, without appropriate multi-sector stakeholder engagement.
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When Covid hit we knew very little about the virus and the implications for the wider societal structures. Lockdown measures in March were appropriate at the time as they gave us the opportunity to build capacity in the health sector with respect to procurement, testing, contract tracing, creating additional ICU beds and general preparedness. We have learned so much about this virus in a short period of time, we are not in the same position as we were back then. We now need to push the agenda forward, we know what the problem is, we have Covid-19 in Ireland and the numbers are increasing. What are the solutions, besides an over reliance on lockdown measures, to control the spread of Covid? The Centre for Disease Control (CDC), the World Health Organisation (WHO) and other experts have published and stated that lockdowns are not a long term solution. An interesting interview with Dr David Nabarro of the WHO by political presenter Andrew Neil should be required viewing for our Government and by the National Public Health Emergency Team (Nphet). In short, lockdowns should be a very last resort. There are alternatives.
1. The need for strong and decisive leadership and accountability.
We need our politicians and experts to make informed decisions, not just to wait for Nphet to communicate daily on the Six One news that they are ‘concerned’ about the increasing ‘metrics’. We need Nphet in their advisory capacity to report to Government, and in turn to have our elected officials take responsibility for announcing the plans that mitigate against the threat of this virus. These plans should be made in in consultation with representatives across all sectors. Clearly safety is paramount but safety to the average Irish citizen means protection not just from Covid but all the other threats that undermine their own personal security and protective factors such as health, economic, education and employment.
2. We must follow the living with Covid plan.
We agreed to have a ‘measured response’. Clearly counties with significant increases in Covid-19, where standard measures are not working, should be increased to the appropriate level of the plan. Counties, such as Waterford, should have been permitted to stay at Level 2 in the recent change. The reward for ‘good Covid behaviour’ on the part of Waterford citizens should be staying open at current levels, preserving the Waterford citizens health, and economic and mental health. This is a measured response.
3. We need to stop the media controlling the agenda.
Responsible media have a prominent and constructive role to play in combatting this virus however some of the recent coverage has served no other purpose than to create ‘sound bites’. Recently the media raised the issue of schools staying closed for mid-term break. Where did this story come from? Like every other sector the media need to be included in a wider comprehensive stakeholder engagement plan. We need the media to report accurate and up to date information as a trusted tool in this fight. We do not need announcements about plans to lockdown (if the public does not behave) and open up (when the numbers drop as a function of lockdown). We need a strategy to safely ‘live with Covid-19’.
4. We need more focus on the only intervention to date that has shown to work, the face mask.
Dr Antony Fauci of the National Institute of Health (NIH ) says they work; Bob Redfield from the CDC says a mask will likely work better than any Covid vaccine; Ireland published a ‘Return to work safely’ document in May 2020, providing guidance to businesses and organisations. The document gives direction on ‘preparing their facilities’ to live with Covid. It outlines the Covid prevention measures that need to be implemented. It focuses on social distancing, hand hygiene and disinfection and yet pays lip service to face coverings.
We need to look closely at well performing countries. For example Asian countries have adapted to ‘a new normal’ and are successfully living with Covid, opening up businesses, minimising Covid transmission, taking holidays safely, and the virus continues to remain controlled. Masks and adherence to Covid prevention is encouraged and, if necessary, enforced. As we see Covid surge in Ireland, there continues to be an absence of a strong face mask message. Just media coverage of ‘anti-mask’ protests.
Recent CNN commercials provide the platform to promote the message: ‘A mask says a lot about the person who wears it. But more about the person who does not.’ We need to promote this very message in a national face mask campaign in Ireland. Our national celebrities, sports stars, lifestyle influencers could provide an ideal platform to engage the wider community, by sending a clear message on the importance and benefits of masks. Our gardaí, could also take a more proactive role in engaging the community, they should be using every opportunity available to them in the course of their daily work to hand out badges and bumper stickers that say ‘wear a mask, save a life’.
5. We need Covid support teams.
They can work with community organisations, to teach them to do the Covid prevention interventions correctly. Many are doing it wrong. Why? They were handed a glossy brochure, told by the HSE to ‘assign a Covid officer, and implement a plan (déjà vu our nursing homes in March and April). We have gotten it wrong in many building sites, crèches, schools, restaurants and pubs, and athletic facilities (ie my gym in Dublin!). No doubt individual business are doing their best but they are continuing to make mistakes. We need to train up support staff, and make them trainers, educators, and inspectors for the Covid-19 prevention effort. We know that there are skilled individuals sitting at home on Covid payments who would welcome an opportunity to be back in employment.
6. We need to salvage our travel industry.
We need our ministers to meet with travel experts, and to develop a plan to secure and manage the airport, the ports, and our borders. Technology companies who have Covid PCR and antigen tests could be used. Another measure worth closer inspection is the ‘sniffer dog’ model used in Finland. We have had from May to figure this one out. We have not done so. We can do it in a time sensitive way if you get the right people in the same room to develop a plan to achieve this goal. How are we going to deal with securing our northern Border? Covid-19 is surging in the North and we need to protect our border counties against this threat. But we also need to support our neighbours. This late in the game why do we not have a ‘joined up’ all Ireland approach?
7. We need Covid SWAT teams.
They can go out to the clusters around the country. Safetynet Primary Care is a charity who delivers care to marginalised groups, they operate from a mobile health unit and have a PCR machine on their vehicle, and they are currently being used by the HSE to go out to address the clusters. This organisation need to be supported to train a team of ambulance crews to replicate their mobile health unit. Remember what Dr Michael Ryan (WHO) said back in April he said “We need to chase the virus and not let the virus chase us”.
8. The Government need to sit down with our publicans, hoteliers and hospitality industry experts.
They must work out a plan to continue to operate safely in the time of Covid. Temple Bar, located in Dublin city centre, generated €1 billion in revenue annually pre Covid and employed thousands of people. It has been in ‘deep freeze’ since before St Patrick’s day. The businesses located their have developed a comprehensive Covid start up plan, modelled on the Hong Kong model for safe reopening. Despite substantial investment in research and the inclusion of best practice in the detail of their plan they have still not yet managed to get an opportunity to present it to the Government. Who is listening? We need our ministers to sit down with our industry experts and work towards re opening safely.
9. We need to progress non-Covid related health care in the community.
Community GP services, cancer prevention and treatment services, STI services, mental health and drug treatment services have suffered, the consequences are being seen now; and will be worse in six months. We need to keep these services going in parallel with Covid-19 community preparedness. We have ‘relocated’ staff from the community services to Covid, at the expense of these critical services, and we cannot continue justify this.
10. We need to forge ahead with a new approach.
It must conceived through collaboration with all of the necessary stakeholders. I share with you a comment expressed to me by one of my colleagues in the hospital.
‘We have a lot of bright innovative people in this country. But if you are not in the inner circle your opinion does not matter. It is an extraordinary inertia as we sleep walk to the brink of economic meltdown’.
As an individual I am fearful of getting Covid. I don’t want personally to experience it or be part of the chain of transmission. I am ever anxious that the numbers will increase, but I do not believe they will surge if we do the right thing now. I am a bit disillusioned if not demoralised about facing into another season with Covid-19. However, lockdown is the last resort. We cannot continue to feed fear, anxiety and depression.
The right thing is for the Government to get the Irish people behind them, give strong messages on what they can do to be part of the solution. We also need to remember that we are not in this scenario in isolation the whole world is facing the ‘Living Safely with Covid-19’ challenge.
We must look globally and to our EU counterparts and quickly come up with a multi-sector plan that safely allows Ireland to live with Covid-19, not die with Covid19. In this commentary I have provided a number of suggestions, not a comprehensive plan by any means, which was put together by reading international documents, studying about Covid, talking to people, and listening to all stakeholders.
Dr Jack Lambert is professor of medicine and infectious diseases, Mater and UCD School of Medicine