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Covid endgame: ‘The writing was on the wall for the last week’

With cases falling and rules easing, what happens next and what will become of Nphet?

In the days after Christmas, as Omicron cases surged, a senior official said it felt like putting one’s hand on the door, trying to tell if there was a dangerous fire on the other side.

Thanks to Christmas, data reporting gets interrupted, and systems for tracking the disease get less reliable. During that time, the official said, you will only know you’re really in trouble if the door bursts into flames – like last winter.

In a warning to the National Public Health Emergency Team (Nphet) just before Christmas, the HSE said: “It is difficult to see how critical care units will cope if the impact of Omicron results in large increases in case numbers and associated increases in the number of patients requiring critical care”.

And so, over Christmas and New Year, they waited for a signal – something in the data that would indicate real trouble. Cases shot up, test positivity skyrocketed, and hospitals got busier – all of which was troubling, but also, to an extent, expected.

Positive signals began to faintly emerge. The pressure on intensive care units can often be gauged by the number of Covid patients getting non-invasive oxygen therapy outside ICU, where they are helped to breathe mechanically, but short of intubation.

That number is “a canary in the coalmine of the pipeline into ICU,” a HSE source told The Irish Times. It climbed and climbed and climbed to about 150, or so, but it started to drop around two weeks ago.

Planners in the health system already had a good feeling. Anecdotally, they saw the public cancel Christmas plans, while restrictions curtailed transmission. The intention, in the face of Omicron, was not to stop infection – but to “have 30,000-40,000 [cases] per day, not 150,000 per day”.

“We knew we wouldn’t be able to control it, it was about managing it so it wouldn’t get out of control” – and waiting for a descent that would, hopefully, be as quick as the spike, said a source in Government.

“What’s more, they knew there was an enormous wall of vaccines in place – hurriedly put together in the run-in to Christmas. In the four days leading up to the 25th, some 420,000 vaccines were administered,” the individual went on.

Omicron ran into this wall – not in terms of transmission, but people simply were not as sick. This week, one minister remembered asking his GP how it was going, only to be told that just one person had been sent on to hospital for weeks, and that person was unvaccinated.

The hospital data backed this feeling up. Initially, politicians were ultra-cautious, terrified to declare victory lest they encourage a change in behaviour, or end up looking silly. There were “potential grounds for very cautious optimism,” one Minister quietly confided in the first week of January.

Far from being the last bastion of Covid-19 conservatism, a shift has been under way within Nphet itself since last summer

After Nphet’s meeting on January 6th, however, members were bullish. “Our biggest problem is how we reverse out [of restrictions] and reverse out fast,” one insisted the next day. “In two weeks’ time we have to abandon it all on the presumption it stays as positive as it is.”

There were ethical dilemmas, too, since the risk of over-emphasising the role Covid-19 was having on the health system could be over-emphasised, or in society at large – all of which would damage public trust, if wrongly articulated.

Far from being the last bastion of Covid-19 conservatism, a shift has been under way within Nphet itself since last summer, when a series of papers were drawn up by the HSE's clinical lead on infection control, Martin Cormican.

These detailed how the State would transition to a “normalised” way of treating Covid in the light of high levels of vaccination. These papers informed the relaxation of restrictions over autumn, which was planned to culminate in a lasting shift at some time this year.

The Delta wave of Covid-19 that preceded mass boosting, and then the arrival in late-November/early December of Omicron, put the whole process into deep freeze. But in the early days of this month, that approach was dusted off.

Caution remained the watchword, however, for several days. Time was needed, another team member urged, before declaring the all-clear on ICU. On January 10th, Holohan issued a typically-guarded tweet.

Covid levels were high, large volumes were still being admitted to hospital, he said. There were things that had to be done before a more general relaxation: schools resumed; close contact rules were relaxed. The numbers in hospital began to plateau – and then cases collapsed.

By the start of this week, it was getting harder to hold back the tide. It was now locked in: “The big thing that has changed is the clear evidence with Omicron in the face of high levels of immunity, the harm the virus is causing is very much less than expected,” a senior public health source said yesterday. In the last week, it became undeniably clear that both cases and hospitalisations had turned a corner.

Every Monday morning, Minister for Health Stephen Donnelly holds a meeting with senior officials in the Department of Health – including secretary general Robert Watt, Holohan and his deputy, Ronan Glynn. "It was just very good," said a person present. The clear view emerging was that the peak had passed – all the relevant indices had been declining from around January 12th. More data had come in last week, on critical care and conversion rates from cases to serious disease, that had solidified the view that all restrictions could be lifted."

Already that morning, indications from senior people in the Coalition were that restrictions would be eased: there was “no reason” there shouldn’t be a full house at the Aviva for Ireland-Wales in the 6 Nations on February 6th, said one. That afternoon, another said they “weren’t bothered” about January but expected rapid progress in February.

There was rapid progress, however, even in the 24 hours that followed – a Cabinet meeting was suddenly scheduled for Friday, the day after Nphet. People spoke of reopened pubs in time for this weekend – optimism radiated outwards, driven by encouraging signals from the Coalition. Minister of State Ossian Smyth, Stephen Donnelly and Leo Varadkar all intoned their hopes and expectations that restrictions would be lifted, and fast. Donnelly told this newspaper of his expectation that there was a "big reduction in public health measures" coming, which would now have "as minimal an impact as possible on people's lives".

The Coalition certainly was not shy about letting Nphet and the public know what result it wanted to see; people wondered if this was gamesmanship, an attempt to box Nphet in – and to an extent it was.

The Department of Health press office quietly nudged Nphet members to stay off the airwaves, if they could. It would be tactically smart, given how relations had frayed at times, to let the Government carry this one

“We definitely sent out the message both publicly and privately that this was the direction we wanted,” said one senior Minister. However, the 4D chess was probably unnecessary; at one point, Holohan is said to have told Donnelly he could be surprised at the pace of change recommended by Nphet.

“It’s entirely possible we have a future variant of concern and it is just as pressing also – what will happen in terms of Omicron as national immunity which is currently very high begins to wane, that to me is one of the most immediate questions,” Donnelly said. More modelling is being sought on this, and another wave of Omicron is clearly possible, especially as immunity wanes and contact increases.

Several ministers were taken aback in the end. Within Nphet itself, a process of gently probing views among members was happening: its secretariat set up discussion sessions for members, to feel out their views, and kick ideas around.

Alarm bells were not being sounded – this percolated across to Government. The Taoiseach was said to be briefed by Holohan as the week wore on, and quietly, the ground was being prepared for a big bang announcement.

The Department of Health press office quietly nudged Nphet members to stay off the airwaves, if they could. It would be tactically smart, given how relations had frayed at times, to let the Government carry this one.

Midweek, one source quipped that the ground was being prepared for a “three day festival of spin” by the Coalition. The creeping optimism took root more widely: one Nphet member on their way into work was stopped by a person, who asked hopefully: “Am I alright for a pint on the weekend?”

There was more work to get out of the way: the tricky issue of the pandemic bonus was slated for Wednesday’s Cabinet meeting. After it clumsily dominated the run-in to the budget, it provoked predictable kick-back from those left out of the scheme. The Government never believed it was going to be pain-free. “We never looked at this as something we would win on,” confided one Minister. The best the Government hoped for was a score-draw, they said, which drew a line under the issue without kicking off a major controversy. That was squared away, as Nphet’s meeting on Thursday beckoned.

Discussion of Covid was sparing at Cabinet on Wednesday, but afterwards, the usual weekly meeting of the Covid Oversight Group took place. That forum is chaired by Martin Fraser, the secretary to the Government, and attended by senior officials, Nphet members and the leaders' chiefs of staff. It has become a vital clearing house for Covid policy – to ensure there are as few surprises as possible. It was here, in mid-October, that Nphet flashed the first warnings of trouble as Delta took hold again, which culminated in new restrictions coming in before Omicron reared its head.

HSE chief executive Paul Reid and vaccine tsar Brian MacCraith presented, emphasising the importance of boosters and the former speaking of ongoing pressure on hospitals – but arising mainly from absenteeism, not providing Covid care. Holohan told the meeting he remained concerned about the high case numbers – but nobody walked away thinking a reversal was in the offing. "The writing's on the wall for the last week," one attendee said afterward. "You cannot restrict the public to the extent we are from normal activities without justification".

The main discussion at Nphet was not whether to relax measures, but rather whether to advise a stepwise approach. This was the expectation across Government and among some members, but there was a new momentum now running through the group. Some members worried about the advice that all restrictions could be lifted – but others pointed to the inequity of allowing pubs open, but not nightclubs.

The meeting heard that 20 per cent of people aged 18-40 have had a documented infection in the last three months, and the true scale of infection is likely 2-3 times higher. About 40 per cent of 18-29 year olds are boosted, and half of those aged 30-39. There is simply massive immunity in the population. There was a strong argument for persuading these people to stay home and isolate if symptomatic, but not for blanket bans, which could be politically toxic. One member outlined the fear of a backlash from saying: “Your da can go to the pub but you can’t go to the nightclub. The chances of losing the dressing room are very significant.”

Major change

Holohan’s letter to Donnelly, sent on Thursday, does not signal the end of the pandemic, but does suggest a major change. Firstly, the fine detail of what policies and when is being left to Government, and secondly, the focus is now firmly on monitoring the harm caused by the virus, not attempting to stop transmission entirely. Omicron crystallised debates that had been underway for some time. Given the political impossibility of zero Covid, the extra infectiousness of variants, and the protection of vaccines, some version of this was likely to become the standard. Omicron just meant it moved at warp speed.

Another wave of Omicron is clearly possible, especially as immunity wanes and contact increases – but as one senior source said yesterday: “We have just proved we can have a very significant wave of infection with minimal harm. What we need to do is anticipate harm”.

This presents a big challenge in and of itself – specifically how to redesign testing, tracing and vaccination to surveil and intercept threats before harsh restrictions are necessary. This is a fiendishly complex policy problem, and equally difficult for the HSE, which has to figure out how to make it work. “It’s not easy to scale it down [and] put Humpty Dumpty back together again,” muttered one senior health source this week.

There is a clear desire to step back from the cycle of meetings, policy changes and letters that has framed public debate since March 2020

Waste water surveillance, monitoring for the disease through GPs rather than mass testing, and ongoing investment in hospital capacity will all be key in the future. Further boosters will likely be needed. There are problems borne of how bruised people are. One Nphet member spoke of how challenging it will be to dismantle entrenched behaviours, Covid anxiety and medicalising day-to-day life. There will be a big job reorganising legislation, regulations and advice into something coherent that fits the new way of doing business, but safeguards core messages around isolating when symptomatic, and getting boosters.

Finally, there is the question of Nphet itself. Within Government and Nphet, there is a growing sense that its race may be run – that now is the time to make good on moves to disband or replace it floated last autumn. The charged political economy of the crisis meant the group became a power bloc, a source of deep frustration within Government, and a polarising force within politics itself. There is a clear desire to step back from the cycle of meetings, policy changes and letters that has framed public debate since March 2020.

“We should be moving out of the emergency management of a public health crisis and into the management of an infection which may precipitate an emergency at some point in future or may be on path to endemicity,” a senior public health source said .

“The next meeting of Nphet is four weeks from now. This is certainly the opportunity to restructure our response and make it simpler and routinise it.” This is a view mirrored at senior levels of Government – that disbanding or replacing Nphet (or allowing it to do so itself) is something that should be examined “certainly in the next couple of months”.

Donnelly is guarded but said a new medium term response is being developed “including testing and tracing, vaccines, public health surveillance, genome sequencing and expert advice in numerous forms, including public health” and other fields.”

Two years ago, the world shifted on its axis. Now, it seems a more welcome change is on its way.

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