Efforts to control Covid-19 across Europe, including Ireland, have a serious flaw: the lack of workable rules that ensure people who must self-isolate do as they are told.
In the United Kingdom, a survey of almost 32,000 people between March and August last year found only 18 per cent obeyed the isolation rules. In the Netherlands, the figure is less than half.
Public focus has centred on quarantine rules for travellers into the State, but this is just one tool in preventing infections: "We have got to break the chains of transmission," says the World Health Organisation's Dr Michael Ryan.
"Self-isolation has barely been mentioned, but it's the most important pillar. Otherwise, chains of transmission can't be broken," says University of Edinburgh researcher, Jay Patel, "Policy around it has been quite poor."
A variety of measures have been tried. In New York City, teams go from door to door to check, but also to offer help to people self-isolating. Early data shows that this help encourages people to abide by the rules.
In East Asia, countries have learned from past experience with pandemics, such as Sars. Self-isolators are given daily necessities, plus sick pay. But there are also twice daily checks on their mobile phones and face-to-face spot-checks.
No fines
By contrast in Ireland, if someone receives a positive Covid-19 test and their fridge is bare, they are left to their own devices to procure essential supplies without breaking their isolation.
Furthermore, Ireland has no fines for people breaking self-isolation, though people deemed at risk of infecting others can be detained. In Belgium, for example, people who break the rules can be fined €250.
But fines can deter people who feel they have symptoms from going for a Covid-19 test in the first place. In the UK, some people broke the rules on self-isolation because they feared losing their job, or they needed a day's pay for rent or food. "It's not because they're being defiant, it's because they're not being supported," Mr Patel said.
The problem posed by unsympathetic employers was illustrated during Ireland’s meat factory coronavirus outbreaks last year, when a survey by the Migrants Rights Centre found 90 per cent of employers fail to offer sick pay to ill workers.
State action helps. In the United States, where 27 per cent of all employees have no paid sick leave, the introduction of emergency federal illness support saw 400 fewer confirmed Covid-19 cases per state per day, according to the journal, Health Affairs.
The Irish rules distinguish between people who must “self-isolate” and those who must merely “restrict their movements”. While the Health Service Executive defines self-isolation as staying in one’s room, restriction of movements merely means staying at home.
“People can isolate at home, but only if they can fully separate from other family members,” Mr Patel said. If not, the State needs to provide a place for them to be isolated, such as a hotel, he argues.
One of the world's best performers is Taiwan. Despite its proximity to China, where the virus first originated, infection has been kept to just 895 cases and seven deaths in the country of 24 million people. Strict quarantine was introduced early. Travellers coming in to the country can quarantine at home, but only if they can separate from others. State health workers arrange transport, meal delivery, medical care and rubbish collection, and conduct daily follow-up calls.
Such supports are easier to offer in countries with strong, decentralised public health hubs.
Without targeted restrictions on those exposed to the virus, blanket stay-at-home orders for all become the only control measure left.