Christmas in Ireland will be a strange mixture of darkness and light – increased risks of transmission for all and the likelihood that a rising number of vulnerable people will be infected, fall ill and die from the virus.
Risks are mixed with the realistic hope that 2021 will bring us a vaccine. For some, there will be the light of the Nativity; and for many the joy of Christmas time with children. But for others, the hope that livelihoods can be restored in the new year is slipping away or long gone.
There is no reason to think that news of vaccines is a false dawn; but Covid-19 is likely to be only the first such pandemic to sweep the globe, as population densities grow and other viruses mutate and cross from animals to humans. Therefore, it is time to take stock and learn lessons from how we as communities and as a nation have done; what we could have done better; and how to be better prepared and make more timely and effective decisions the next time.
By September, the growth in new cases was exhausting testing and contact tracing capacity
Some lessons are clear-cut. The timeliness and clarity of Ireland’s initial response compared well with the UK, where a 13-day delay in effective implementation in March led to a much worse first wave than in Ireland. And yet our response was tardy compared with countries that imposed more timely and effective border controls and quarantine measures, countries as diverse as New Zealand and Vietnam.
Belatedly, we learned the importance of more stringent protection of those living in residential care homes, screening staff in high-risk settings, and the need to address the chronic lack of investment in our overcrowded hospitals. Ireland was among the worst performers globally in proportions of Covid-19 deaths of nursing home residents and infections among hospital staff.
Other lessons need to be unpacked, such as the failure of the Government to take account of the evidence from the weekly Amárach survey, which showed growing public support for keeping closures and movement restrictions in place, as the Government was prematurely relaxing these measures.
Lost opportunity
By relaxing restrictions from June, once daily figures had fallen to double and single digits, we threw away the opportunity to aim for Covid-19 elimination. By then, we had the testing and contact tracing capacity in place to not only chase down contacts and screen high-risk groups; but to implement an intensive community testing strategy that could have brought us close to eliminating the virus before it embedded itself deeply into communities and households.
By September, the growth in new cases was exhausting testing and contact tracing capacity, which came near to collapse by October, requiring again the blunt hammer of Level 5 closures. Between June and October, those surveyed who reported the Government’s response as inadequate rose from 12 to 45 per cent, and those calling for more restrictions from 20 to 58 per cent.
The light of science burned bright in 2020. Remarkable advances in vaccine technology and global co-operation mean we can expect accelerated development of vaccines for existing and new diseases, as they emerge.
With 75 per cent of clusters and perhaps greater proportions of transmissions taking place in private houses, reliance on top-down guidelines simply won't work
Science also benefited from the lens of common sense. The precautionary principle, or the wisdom of the crowd, made the case for face coverings well in advance of scientific consensus. Not all preventive measures need to be tested rigorously before being adopted. Reported adherence to (if not actual) mask wearing had reached 90% in Ireland by August.
Science is built on hypotheses, not facts. People find more reassurance when international agencies and scientists acknowledge uncertainties and lessons learned, and when governments listen to them.
The downside of Ireland’s top-down approach – nightly National Public Health Emergency Team (Nphet) and ministerial briefings, media interviews with “experts” and adversarial chat shows involving sectoral interest group representatives – has been the lack of systematic listening and engagement with communities.
Ethical issues
Whether the decision to open gastropubs and other risky venues in early December was right or wrong – for now this is a moot point, until we see the consequences – the people have a right to question the lack of consultation and transparency in the decision-making.
Communities should be given the opportunity to consider and respond to the difficult ethical questions around the rights and duties of citizens, when the autonomy, behaviour and livelihoods of some put the health and wellbeing of others at risk; and when the physical survival of perhaps a few is balanced against the material, mental and social wellbeing of the many.
Very high compliance is needed with Covid-19 prevention measures: physical distancing, mask-wearing and avoidance of indoor mixing. When communities – made up of our families, friends and neighbours – lack the opportunity to have input to – and are not required to endorse – behavioural change rules, there is little opportunity or incentive to build such compliance.
The power of communities to effect behaviour change – without recourse to the imposition of levels of social control, tracking of individuals and invasions of private space that are acceptable in SouthEast Asia – needs to be explored. With 75 per cent of clusters and perhaps greater proportions of transmissions taking place in private houses, reliance on top-down guidelines simply won’t work. Imposed restrictions need to be cognisant of and underpinned by an understanding of the diverse needs and behaviours of those who make up our communities.
Third wave
Ireland’s epidemic is around the half-way point, given the time it will take to roll out vaccines. First there is the need to mitigate and limit the loss of human life that will result from the Covid-19 third wave in January. We then will need more sophisticated communication strategies to combat vaccine misinformation; and to listen to, educate and reassure the vaccine hesitants, over the following months. People who are consulted and listened to are more likely to listen and make wise decisions.
Bottom-up, tailored approaches – essential for controlling household spread and influencing those who engage in reckless behaviour – require engagement with local communities and the diverse groups that make up our nation. This could be done through local democratic institutions (isn’t it time we gave county councillors a real role?), and through national bodies such as the National Youth Council and Sport Ireland, which are already active in Covid-19 education.
Poor vaccine uptake, along with a premature relaxation of preventive measures, could suck us into further waves of Covid-19, later in 2021. Communities need to be informed and empowered to prevent this. Let us start to use their resources – GPs, public health doctors and nurses, teachers, community volunteers and others – to build healthy resilient communities capable of adopting the measures to overcome current and future threats to the health of the population.
Ruairi Brugha is emeritus professor, RCSI University of Medicine and Health Sciences. He is based in Addis Ababa