COVID-19 Keeps the Home Fires Burning
A recent throat clearing cough more prolonged than usual prompted me to take a precautionary look at HSE guidance on COVID-19. A cough is listed as a common symptom of COVID-19. “This can be any kind of cough, not just dry.” The website advised that, if I have any common symptom, I should self-isolate and phone my GP straight away to get a COVID-19 test. The website also advised:
Self-isolation means staying indoors and completely avoiding contact with other people. This includes the people you live with. If you live with other people, stay on your own in a room with a window you can open, if possible.
We had tickets for a play in Ennis the same evening and a reservation for dinner beforehand, our first since indoor dining re-opened. As a “close contact”, the website guidance to my wife is also to take a test and likewise restrict her movements (i.e., stay at home) for 14 days — even if the test is negative.
Although most of my “contacts” over previous days fell clearly within the definition of “casual contacts”, one or two others might, at a stretch, have fallen inside the definition of “close contact” too.
As it happened, that throat clearance was a once-off. We proceeded with our plans without unease and remain in rude health 10 days later.
But, of course, it could have turned out otherwise.
An imponderable challenge in managing COVID-19 is that macro-level strategy is largely only a framework for steering the behaviour of several million individuals, all of whom constitute a relevant independent “variable” whose activity can only be influenced rather than dictated from the top, but which contributes to shaping the overall picture with which those at the top have to deal.
On 1 October, Dr. Ronan Glynn, then Acting Chief Medical Officer reported by letter to the Minister for Health, Stephen Donnelly, on the latest NPHET assessment of the situation and it’s recommendations for future action.
Overall, the epidemiological situation nationally remained concerning, having deteriorated since the previous week. Key numbers; cases, deaths, hospital and ICU admissions, the reproduction (“R”) rate, positive testing rate, were all heading in the wrong direction. Its conclusion: “…while the current trajectory of the disease is very concerning, the current epidemiological data does not support a move to Level 3 nationally at this time”.
Accordingly, NPHET recommended extending the then current Level 2 arrangement for three weeks with the additional restriction of household visitors to a maximum of 6 from one other household. The Level 3 regimes already in place in Dublin and Donegal would continue.
However, NPHET was convened in emergency session only three days later on Sunday, 4 October, the returning Dr. Tony Holohan, Chief Medical Officer, reporting similarly by letter to Stephen Donnelly that evening. The overall conclusion was gloomier.
The measures currently in place are not sufficiently controlling the disease as evidenced by a high volume of community transmission and sustained increases across key indicators, particularly since the NPHET’s last meeting….
The advice:
It is therefore recommended that the Government apply Level 5 measures across the country from midnight Monday 5 October for a period of four weeks.
…taking this action proactively for four weeks from now is the only opportunity to get this disease back under control while keeping schools open, keeping health services for non-COVID activity operational and protecting the medically and socially vulnerable.
NPHET also dismissed any temptation to more gradual escalation:
A graduated approach would, ultimately, result in application of Level 5 measures as mitigation, in contrast, the immediate application of Level 5 is intended to limit the impact on public health of COVID-19…
In other words, we were on our way to Level 5 anyway. Better take the direct route than the scenic one. By accident or design, this eliminated any need to justify moving up to Level 5 as opposed to either Level 3 or 4.
There is room for argument about how significant is the shift from Level 2 to Level 5, but not about whether it is significant at all. It is more than a tiller adjustment.
An aspect that bothered me about Dr. Holohan’s letter of 4 October was the absence of any doubt. There was appropriate recognition that this medicine might be hard to swallow but total conviction that it was the only possible useful medicine.
We don’t know anything about the level of consensus within NPHET about this course of action. Was there a vote, and if so what was the majority or was the outcome simply a reading of the virtual room?
I am doubtful that the sudden “ramping up” of concern reflected a desire on the part of the returning Dr. Holohan to reassert his authority over NPHET after a long absence, not least because of the insult this would imply towards his deputy, Dr. Glynn. I am even more doubtful that he or NPHET as a whole, were desirous of asserting their authority over the government. That would be straightforward hubris.
And I am only slightly suspicious that the medical community would be happy for the economy to be laid to waste altogether provided there was still some spare ICU capacity in our hospitals; that they would see this as a successful operation despite the death of the patient.
However, it is hard to reconcile a recommendation on Thursday that most of the country remain at Level 2 with a recommendation three days later that the entire country move to Level 5 for a minimum of 4 weeks. These positions are at least in tension with each other if not altogether incompatible. They cannot both be right.
It might have helped if Dr. Holohan’s letter of 4 October had offered a specific “then and now” tracking comparison to explain the sudden shift in gear. Instead, his letter relies mainly on a gloomy snapshot of the state of affairs on 4 October itself.
The letter was copied to a senior civil servant in the Department of the Taoiseach and it emerged subsequently that Dr. Holohan spoke with Stephen Donnelly before and after the NPHET meeting. Mr. Donnelly has confirmed that Dr. Holohan advised him of the Level 5 recommendation in the latter call, that he immediately called the Taoiseach and that senior staff of Tánaiste, Leo Varadkar and Eamon Ryan were also contacted.
By 9 p.m. on Sunday evening, NPHET’s recommendation was in the public domain. The source of the leak is unknown.
So to Leo Varadkar’s interview with Claire Byrne the following evening.
I am an “early to bed, early to rise” merchant, so I didn’t see the interview live. Some newspaper headlines the next morning:
Irish Daily Mail: Varadkar in withering attack on Holohan’s ‘bolt from the blue’ to move the country to full lockdown
Irish Examiner: Leo Varadkar blasts CMO over level five plea
The Irish Sun: Leo hits out at NPHET advice
The Irish Times: Varadkar criticises Holohan: says Level 5 advice ‘not thought through’
In a broadly balanced account of the content of the interview, The Irish Times report said it exposed “deep tensions” between NPHET and the Government. Its Political Correspondent, Harry McGee, was more trenchant:
There was no doubt about which direction Tánaiste Leo Varadkar was pointing his finger during an extraordinary appearance on RTÉ’s Claire Byrne Live on Monday night. He launched into a full-blooded attack on NPHET, and by extension on Chief Medical Officer Tony Holohan, for the Sunday bombshell.
Members of NPHET were taken aback by the ferocity of the criticism — it was a filleting, pure and simple. There was no pulling of punches, no euphemisms, no sugaring of the words. There is no doubt that, downstream, this episode will have consequences for the relationship between the two entities. At this moment in time, none of the outcomes look good.
The newspaper’s editorial comment was less frothy:
Nphet erred by suddenly recommending an immediate Level 5 lockdown on Sunday evening, having done little to prepare public opinion and apparently without having flagged it with Government.
Varadkar legitimately pointed out the gravity of that step and the multitude of complex questions that flowed from it — all questions that Nphet could not be in a position to answer but that any responsible Government would have to consider before turning the lights off on the economy.
I caught up with the interview to see what the fuss was about.
It was 14 minutes long, but here is my summary of the main points the Tánaiste made.
- Ministers had met with NPHET that day and decided that it was not yet time to move to Level 5 because of (a) the wider societal impact; employment, business, disability services, mental health, social isolation, etc.; (b) the “jump” was out of line with the plan of graduated movements between levels; and (c)hospitals were not imminently facing the possibility of being overwhelmed.
- The move had been proposed as a “circuit breaker”, a short, sharp, strict lockdown for 3 or 4 weeks. This has never been tried in Europe. Would 4 weeks be enough? What would happen after 4 weeks if it didn’t work? Could schools be kept open? To go to something experimental requires proper thought, prior consultation and a Plan B if it doesn’t work. Overall, Ministers felt it “hadn’t been thought through properly”.
- He had full confidence in Dr. Holohan. But, the Sunday advice “came out of the blue”. There was no hint of it in the advice of Thursday. There had been differences in the past between Government and NPHET but they were thrashed out before decisions were made. There should have been a meeting first. Perhaps a call to the Taoiseach: “NPHET’s thinking of doing this. Could we sit down and thrash it through? There could be some things as politicians that you might have thought about that we mightn’t have thought about.”
- Government and NPHET need to get back on the same page. “We’re all good people. We all want to do what’s best for the country. We all want to save lives.” “What happened in the past couple of days wasn’t good for anyone. Wasn’t good for NPHET and wasn’t good for government, wasn’t good for the Irish people many of whom were worried sick today.”
- This was not a matter of economy versus public health, but the public interest, recognising that your best economic policy is to put public health first. But it can’t be public health only. I have confidence in NPHET “to dispense public health advice”. “They don’t advise the public. They advise the government.”
Frankly, The Irish Times editorial writer seems to me much closer to the mark than its Political Correspondent. The editorial did single out one Varadkar comment for censure as “gratuitous”:
One thing that needs to be borne in mind. Very good people. 40 of them. But all coming from medical, scientific or civil service backgrounds. None would have faced being on the Pandemic Unemployment Payment.
But I am inclined to read that less as a swipe at NPHET than a nod towards those who would have been facing relying on the payment.
The media continues generally to describe the Government’s reaction as a “rejection” of NPHET advice rather than the more emollient truth that it was a partial acceptance of it. The thermostat was raised from Level 2 to Level 3 — nationwide, rather than only in those counties with high incidence of cases.
Just over a week later, the general indicators are continuing to head broadly in the wrong direction. But those trends would have been largely baked into the picture when the Government made its decision because of the incubation period for the disease. It is still too early to say what effect the nationwide Level 3 escalation will have.
No matter what though, there will be no shortage of hurlers shouting from the ditch that the Government should have followed NPHET advice to the letter, either because NPHET are supposed to be the “experts” or because a Level 5 “lockdown” would certainly reduce the spread of the disease more thoroughly than Level 3 will. But few will be able to shout as loudly credible answers to the questions raised by the Tánaiste about the equally certain downsides and risks associated with that approach.
Likewise, there will be others promoting their own pet salvations; whether at the level of strategy (Zero Covid, All Ireland co-ordination) or key ingredients (testing and tracing, quarantine enforcement, monitoring meat plants and direct provision) which sound great and do matter but whose individual roots of impact are unlikely to run as deep as their proponents claim.
Arguing for counterfactuals is always more potent than defending actual decisions. The latter have to stand the test of confrontation with reality — and the inevitability of results that are less than perfect and take time to unfold. The former remain pure and pristine in their glass case.
But presented with a kickable penalty in rugby, it is generally wiser to take the prosaic option of kicking the 3 points than the more exotic one of going for the corner and hoping for 5 or 7. In snooker, if you break off a new frame by belting the cue ball into the pack of reds, and a red finds a pocket, you are probably set up to take the frame. If none does — as generally happens, you can probably kiss the frame goodbye.
Although we are beset on all sides by genuine and pseudo-experts in infectious diseases, 100% confident that they know exactly what should be done at every stage, navigating this pandemic is the archetypal journey through uncharted waters in a fog and wearing a blindfold. Much better to feel our way carefully than go full steam ahead. Even among the genuine experts, there is not a uniform consensus. The “science” can support different and sometimes conflicting approaches.
But the comparatively muted reaction to the Government’s decision to go only part of the way with NPHET this time reflects gloomy recognition that we are locked in an indefinite seesaw struggle between resurgence at one end and restrictions at the other. Until the cavalry of a vaccine rides over the hill, the aim is less to beat the virus, as was perhaps our optimistic expectation going into the first “lockdown” in March, than to keep it at bay. Maybe there is a meaningful sense in which we can “save” Christmas, but it is hard to imagine that the troops will be back from the front by then.
