It’s almost as if someone has been reading these posts on the course of Covid-19 in Ireland. Fintan O’Toole’s latest column (paywall) in ‘The Irish Times’ also notes some of the mistakes made in its early management and, while he treats the Irish approach as one of ad-libbing and improvisation, he lends a sympathetic ear to the early performance. To what extent is this justified?
Well, let’s start with the scope afforded by this forgiveness: “when it’s all trial and error, no one should be tried for making an error – even when, as in the case of nursing homes and residential institutions – the flaws were fatal.” But consider if we change the tense of the sentence – ‘even when . . . the flaws are fatal’.
‘Error’ he goes on to say ‘is moreover built into the structure of science . . . but science isn’t a set of certainties . . . to follow science is to follow evidence and with a new disease the evidence has been constantly evolving.’
Well, yes and no. The important link between the worst effects of the virus and a person’s underlying conditions has been more and more understood. On the other hand, as I noted at the end of the previous post – ‘one aspect . . . has appeared stubbornly consistent, the median age of those dying was reported in mid-January to be 82.’ Most recently, of over 1,500 deaths in care homes 369 were in January alone, a five-fold increase from December to January.
The Health Service Executive (HSE) noted on 21 January that the 27th of the month would be the anniversary of the first meeting of the National Public Health Emergency Team (NPHET), the crisis management team for the pandemic. It was noted in April that no mention of nursing homes had been made in its first 11 meetings, with the HSE claiming that the Health Information and Quality Authority (HIQA) that attended the meetings were supposed to represent the interests of older people.
While boasting of the support given to care homes the HSE officials were at this time unable to provide up-to-date figures of deaths within them or a breakdown between state and private providers. Neither did they answer as to whether any of the deaths could have been avoided.
Around the same time that NPHET was being set up a number of important academic papers were just being published on the effects of the new disease (here and here), including evidence of the effect of the pandemic in China. The notable paper from Imperial College in London included further disclosure of the much greater threat to older people posed by the virus. While the infection fatality rate was 0.002% for children aged 0 – 9, the rate for those 80+ was 9.3%, 4,650 times higher. While these absolute figures were too high the relative differences remained.
Clearly avoiding infection was many multiples more important for older people than for the very young. Even between the age groups 40 – 49 and 60 – 69 the relative fatality rate was nearly 15 times higher for the latter group. So protecting the older age groups was vital, which involved isolating them from potential infection. How could these most vulnerable people be effectively separated?
Fortunately, many of these people were already relatively isolated in social care facilities, while identification of those in the community would be relatively straightforward. Unfortunately, this relative isolation was not a protection.
While the health regulator was supposed to represent the interests of older people the HSE was there to protect the health of the whole population. It became apparent however that the facilities they managed, controlled and regulated had become prime sites of infection, all while the NPHET engaged in interminable debate about opening or closing shops, hospitality, schools and workplaces etc.
When it wasn’t about the various levels of lockdown that were never applied at the levels specified, it was about testing and tracing, which didn’t identify where the virus was coming from and was later no longer advised for close contacts of confirmed cases. So, what had been the point of it?
At the beginning of this year ‘senior sources’ were reporting the exhaustion of their approach, admitting that there was “not much else that can be done”, which didn’t stop the debate of vanishing returns continuing. Today it revolves around rules for entry from outside the state, which is almost a moot point given the levels of domestic infection. More honestly, it is being reported that ‘Ministers and senior officials’ view it as ‘more about politics than public health.’
Yet the places where around half of the deaths have occurred – residential homes and hospitals – are spared the outrage they properly deserve. On 26 January it was reported that the level of infections among staff and patients in health care settings had never been higher. And three days later the Chief Medical Officer was explaining that there was an “exceptionally elevated” infection rate among those aged over 85; that 55 recent deaths were associated with hospitals and 140 with nursing homes; and that we could “expect a large number of additional deaths in the coming weeks.” Not much had changed over the year despite the ‘trial and error’ of ‘following the science.’
The state has incurred increased debt of around €20 billion in 2020 through various lockdowns but it is still unable to target resources effectively at the greatest problem: the daily death toll for Tuesday was the highest of the pandemic and the median age is still 80+.
It cannot be that a targeted prevention strategy would cost too much or that resources could not be prioritised – €2 billion would go a long way towards protecting older people never mind €20bn. If even half the current death toll had been avoided and it was now around 1,750 who had died, would this justify the lockdown of society along with its enormous cost? Would it not have been possible to identify those with the underlying conditions that make them vulnerable apart from advanced years, accounting for well over 90% of deaths? And would it then not have been possible to recognise the difference between those dying with Covid-19 and those from Covid-19?
But why would new problems be adequately addressed by the Irish health system when forever problems have not? When it turns out that the new problems are really the old ones? As was pointed out by one TD early on, the Health Regulator – supposed to represent the interests of older people – had already reported that in care homes the compliance rates for risk assessment and infection control had fallen from 27 per cent to 23 per cent between 2017 and 2018.
Repeated problems identified have never been adequately addressed, with the HIQA complaining in November that nursing home residents were picking up the infection in hospitals and then being returned to their homes, while care home staff were being lost to contact tracing teams and agency staff were not being included in testing.
As Prof Sam McConkey, an infectious disease specialist with the Royal College of Surgeons, put it “nursing homes have been chronically under-staffed for several years. They are going to have to start cherishing their staff as the most important thing they have.” If staff were paid adequately they wouldn’t have to take second jobs, which might for example go some way to addressing the problem that staff weren’t turning up for testing and some were showing up for work while showing symptoms.
Some care homes were simply too small with too few resources. In some residential facilities for people with disabilities derogations were given to staff to continue working though they were identified as having possible close contact with infection. They had not been tested and it was not clear when they would.
Yet, repeatedly bizarre statements have been issued by those in charge, including that NPHET was proposing setting up an infection-control team – in mid-December! As if infection control was not a standard and routine hospital requirement. Or that there were difficulties in approving employment of nurses for care homes from India, Philippines and other countries outside Europe, reported in January, when many problems were the result of shortages of staff.
All this was occurring at the same time as repeated statements were made by the NPHET, which we noted in the previous post, that “there was simply no way of protecting nursing homes or any other institutional setting if we don’t control the spread of this infection in the community.” Then saying that vulnerable groups in care settings were a priority although also saying that it was “not realistic to think we could keep it out of homes.”
Unfortunately, seeking to prevent community infection through a generalised lockdown makes all talk of prioritisation a nonsense. A general lockdown is precisely not to prioritise, and the actions and non-actions of the state are convincing evidence of this lack of ordering of risk. To talk then, as O’Toole does, of inevitable mistakes is itself to fall into the error of identifying policy as simply mistakes. Even in the case of vaccination, the representative body of private nursing homes has complained that just 10 per cent of the initial 77,000 vaccinations administered by mid-January were within nursing homes.
The identification, right from the start, that Covid-19 represented a specific threat should have been met with targeted and focused measures to protect those most vulnerable. The ramshackle and incoherent attempt to lock everybody up, that cannot be sustained, has diverted attention away from this task.
That diversion continues with a false debate over a ‘Zero-Covid’ strategy, which is simply a variant of the current approach. Like the existing approach, it targets what measures are required to support closing society instead of what measures are needed to keep it open. It again ignores experience of just who is threatened and how specific measures might be implemented to protect them.
Both the current approach and its extension into a ‘Zero-Covid’ one can’t tell us how long we would have to be locked up for and how we could be sure that whatever metric of success is decided upon could be achieved on a sustainable basis. What ‘Zero-Covid’ would gain in reducing deaths associated with Covid-19 would be more than offset by the costs of an intensified and indefinite lockdown, which if the advocates of it had been followed, would have been in place since March. Both ultimately can only be sold to an increasingly weary population by promising something that they can’t deliver: the development of the pandemic has had more to do with the weather than lockdown measures, and the end-point of immunity through vaccination may be illusory if new variants are impervious to the vaccines just developed.
In this case, and it may be the situation anyway, living with Covid-19 will be required and immunity through infection become the outcome, if not the objective. In any case and in the meantime, the policy should be directed to protection of the most vulnerable. In relation to the assessment of O’Toole, the prerequisites for forgiveness do not exist.
Back to part 3