Gabriel Scally: It is essential Ireland tightens borders in fight against Covid-19

No excuses – we must ramp up public health resources and suppress Covid-19

Today marks exactly a year since the World Health Organisation designated the Covid-19 outbreak a “public health emergency of international concern”. There were only five such announcements in the last decade, and it should have acted as a wake-up call to every country in the world. Since then, more than two million people have died from this eminently preventable disease. We know that Covid-19 is preventable because of the enormous variation in deaths between countries and regions across the world. We also know that what works is to suppress the virus, keep it suppressed and act decisively to curb the possibility of importing new cases. Speed of action and robust and effective implementation of control measures have spared many countries worldwide from the agonisingly high death rates experienced in many parts of western Europe.

The death toll on the island of Ireland, with more than 3,000 deaths in the Republic of Ireland and over 2,000 in Northern Ireland, far exceeds the death toll from the Troubles or the combined total of deaths in the Irish War of Independence and the Civil War. With appropriate action at the very earliest stage of the pandemic, the vast majority of those Covid-19 deaths would have been avoided. There was a second opportunity to stop the pandemic in its tracks in Ireland, during the summer when deaths were at zero, both North and South, and case numbers were minuscule. Again, the opportunity went a-begging.

There were, however, severe limitations in Ireland’s capacity to respond to the virus once it reached the island. The country does not have a modern public health infrastructure. Public health doctors, although exceptionally well-trained, are undervalued and under-resourced. Successive reports urged the Department of Health to modernise and adequately resource the public health system and recognise the public health doctors and their leaders, the directors of public health around the country, as equals to their colleagues in clinical medicine. There was masterly inaction from the department, despite the explicit advice it received about severe public health deficits over the past 15 years.

Travel and infection

Nevertheless, it is unacceptable that one of the stated reasons for it being impossible to suppress and eliminate Covid-19 is insufficient local public health capacity. There has been a whole year to rapidly strengthen public health capacity across the country, energise and empower its leadership, and pour resources into a well-organised Find, Test, Trace, Isolate and Support (FTTIS) system. Local directors of public health are well-placed to work with local communities and councils to gain and maintain control over community spread of the virus. Directors of public health should also be the country’s local voices of pandemic response, amplifying the messages and making them relevant to local communities and organisations. Starting today, the local public health resource should be ramped up substantially.


Directors of public health should be the country's local voices of pandemic response

The virus has only one mode of transportation: the human body that carries it. If you stop infected individuals from travelling and infecting others, it can be controlled and eliminated from communities and countries. Countries that have Covid-19 under control, and kept it under control, have benefited socially and economically. They do have cases sporadically, but most are detected in quarantine, which is, of course, its prime purpose. When rare community outbreaks occur, these countries react with great speed and vigour. Countries that have done well include zero-Covid exemplars like Taiwan, a densely populated, highly connected island of 24 million people, with only seven deaths. Japan, also a country of islands, has a population of 126 million people and has had, in crude numbers, fewer Covid-19 deaths than the island of Ireland. Closer to home, Finland, Norway and Iceland have all succeeded in keeping the virus under control and have per capita death rates well under 20 per cent of the island of Ireland.

Danger of variants

Copying other countries is not only allowed; it is essential. A good strategy for Ireland might consist of, first, strong and rigorously observed societal measures to get the new cases down to tiny numbers. Second, an effective FTTIS and rapid outbreak management system that is well-resourced and locally well-connected. And, third, mandatory public health measures at borders that will prevent reintroduction of the virus, and particularly new variants.

The entirely predictable arrival on the scene of these new and dangerous variants of Covid-19 is a game-changer. The likelihood of a variant emerging that will negate, at least partially, the benefits of vaccination needs to be taken seriously. On Wednesday, the UK announced the introduction of managed isolation for people arriving from 22 countries. People coming from those countries will be taken to a designated quarantine facility and will stay there until the isolation period is over. When the UK does this, it is surely inconceivable that Ireland will leave its doors open and rely on what amounts to voluntary self-isolation.

The likelihood of a variant emerging that will negate the benefits of vaccination needs to be taken seriously

There have been surprising comments about how we can’t suppress Covid-19 because open borders and connectivity are central to modern Ireland’s culture. But this is not germane to our priorities amid this lethal pandemic. We have reset our cultural norms of connectivity. Teleconferencing, often an unreliable technology, has changed the working lives of many and probably forever. It is nonsense to think that Ireland’s open, engaging and productive relationships are dependent, amid this crisis, on allowing visitors and returning citizens to bring the virus to our shores.

Other countries, notably Germany, may well set the pace in shifting towards what they call “no-Covid”. The people who dogmatically state that we can’t have a Covid-free Ireland are wrong. In today’s edition of a world-leading medical journal, the Lancet, its editor, Richard Horton, writes: “After more than two million deaths worldwide, perhaps there is an emerging agreement that the elimination of this coronavirus is not only necessary but also achievable.”

It is entirely doable if the politicians would pause and think. They need to tell their officials to stop making unevidenced assertions that it is impossible and start asking them what needs to be done to achieve it.

Dr Gabriel Scally is president of epidemiology and public health at the Royal Society of Medicine in London