Ireland's COVID Response, Part 2: Public Health is a Snail

Institutions weren't nimble enough

Note: This is part two of a four-part series on Ireland’s COVID response. You should read part one first. Any fact that isn’t linked is sourced from the book Pandemonium: Power, Politics and Ireland’s Pandemic.

2.1. Public health advisors were too slow

Irish public health advisors were slow to appreciate almost every new Covid development. Slow relative to what? Slow relative to what they could have been. Slow relative to smart generalists. Slow relative to public intellectuals like Zeynep Tufekci. Slow relative to superforecasters. They were slow on community transmission, airborne transmission, asymptomatic spread, (the lack of) surface transmission, the importance of ventilation, new variants, travel bans, and they were glacially slow on testing. They were also slow on long Covid, but I am still uncertain how big a deal this was. Still, the UK opened long Covid clinics, which at least seems like a step in the right direction.   

Tony Holohan was not taking Covid particularly seriously until mid-March 2020, e.g., he advised against the cancellation of the St. Patrick’s Day parades. The turnarounds were often rapid: Holohan publicly criticised Nursing Homes Ireland for suspending visits on March 6th, before advising that it become government policy a matter of days later. I’m not making some childish point about “flip-flopping”; changing your mind is good. But the pandemic was both foreseeable and foreseen. The problem is that the Chair of NPHET is currently a poor selector for understanding expected value and uncertainty. 

A friend of mine helped 3D print visors for a local hospital at the beginning of the pandemic. He reported that he didn’t have much demand because nurses were being told not to wear masks. They didn’t have enough to protect them all, and just some of the nurses wearing masks would inspire panic and jealousy. When there aren’t enough chairs for every student, everyone must stand. This is not a total anecdote: an unpublished report from the Health Service Executive (HSE) records one instance of nurses being told that they “weren’t allowed to wear masks”.

In a press conference in April 2020, Holohan warned about the dangerous side-effects of masks, including that they would give their users a “false sense of security”. This dithering about masks was an absurd breed of academic contrarianism. Masks obviously work to stop the spread of a respiratory disease, at least to some extent. Yet NPHET still searched for complicated and counterintuitive social effects that might make the obviously good thing actually bad. Martin Cormican, a major figure on NPHET, claimed that mask use “rapidly degenerates into poor practice, which could increase the risk of Covid-19 transmission”. You can model this using Bayes’ theorem, but suffice to say, the idea that masks (or testing) would actually increase spread requires you to make some truly implausible assumptions about how ineffective they are. At its worst, this contrarianism had hints of a bizarre Orientalism: masks had been used to great effect in Japan and South Korea. Why would they work there and not here?

2.2. Testing was half-hearted at best

Before continuing, some context: Ireland held an election in February 2020, in which there was a leftward shift toward Sinn Féin, and a generally poor showing for the established Fine Gael and Fianna Fáil. The incumbent government was led by Fine Gael under Taoiseach Leo Varadkar. The first three months of the pandemic were managed by a caretaker government while the parties negotiated to form a coalition. This is probably one of the reasons why NPHET had an unusual degree of autonomy in the early months. In June, Fine Gael and Fianna Fáil agreed to form a coalition, and Fianna Fáil’s Micheál Martin took over as Taoiseach. Simon Harris was replaced by Stephen Donnelly as the Minister for Health. Donnelly was adamant on widespread asymptomatic testing in Ireland, so much so that he convened a clandestine advisory group, outside of NPHET, to produce a report on the use of antigen tests, led by Professor Mark Ferguson. As you can imagine, the optics were terrible: the Minister for Health created a new body to circumvent the bad conclusions of the public health advisors.

Holohan said that because of the risk of “inappropriate use”, incentivising the use of rapid testing “risks promoting rather than reducing transmission of the disease”. Now, I don’t know what the rates of improper usage are, nor how concerned I should be about this, but I’m pretty sure he doesn’t either. Please, let’s do the maths! When you’re advocating a policy that depends upon long-run and uncertain social effects, and many people will die if you’re wrong, your reasoning needs to be airtight. A desire to emphasise that antigen tests were not a “silver bullet” (as if anyone thought that) led to a denial of their usefulness. Philip Nolan, who headed Ireland’s modelling efforts, went so far as to describe antigen tests as “snake oil”. This level of fearmongering was, to the best of my knowledge, unique in Europe.

The HSE eventually began distributing antigen tests to close contacts in October 2021, though they were never subsidised for everyone else. Ironically, antigen testing would become the primary form of testing that Christmas, as demand far outstripped the supply of PCRs.

Ireland was never good at testing. The UK has tested three times more per capita, despite comparing unfavourably to Ireland in many other respects. At one point, in January 2022, the test positivity rate was an astounding 50%. Even the tests that were given out weren’t distributed efficiently. In the first wave, it was taking 21 days for some tests to return a result – and some never did at all. The healthcare system usually deals with accurate tests used for individual diagnosis, and it’s good at this. It’s not accustomed to widespread testing to control the spread of disease. Many of our problems came from applying the first mindset to the second problem. For instance, we required rapid tests to be highly accurate, leading to a shortfall in supply, ironically leading to more spread of the disease. Fast, frequent and cheap is better than sensitive. 

Ireland also never had much of a contact tracing system to follow up on positive tests. Partly this related to a union dispute: the Gardaí refused for a long time to enforce quarantines (which were initially two weeks but eventually shortened), out of concerns that it was too authoritarian. When they finally agreed, they checked up on isolating individuals only very rarely. My impression is that few countries outside of Oceania and Asia took contact tracing particularly seriously. The Irish contact tracing smartphone app was rolled out in July 2020, and, considering it was built on top of the Apple and Google Bluetooth tracking released two months earlier, I have no idea why it took so long. The app had some initial success but usage stagnated, in part because of a glitch which drained Android batteries. 

If you are sceptical, various papers look at this and do indeed conclude that, even in highly imperfect systems like the UK’s, testing and contact tracing do indeed reduce spread. Evidence from false negatives indicates that someone receiving a positive result causes them to spread the disease substantially less.

2.3. Travel bans were too late to be effective

There’s a nonlinearity to the efficacy of travel bans. Banning all travel is much more than twice as effective at reducing infections as banning half of travel. And while banning travel early gives you precious time to prepare, it’s slightly unclear what the utility is when you already have raging community spread. Depending on the time, entering Ireland required a test, a two-week quarantine, a vaccine, or some combination thereof. Travellers were less risky on average than general members of the population! 

Commentators would sometimes ask: why wasn’t Ireland the European New Zealand? One answer is that this was politically infeasible due to the land border with the United Kingdom. First Minister of Northern Ireland Arlene Foster made it clear in the early days that she would not cooperate with any kind of travel restrictions between the Republic and the North. Though there were various travel restrictions between the Republic of Ireland and mainland Britain, one doubts their usefulness, given that you could circumvent them by travelling via the North. When restrictions on travel between North and South were finally introduced, it took complicated legal manoeuvring to not violate any of the existing treaties. If Ireland had employed harsh travel restrictions, the model to follow would have been Australia or South Korea rather than New Zealand: getting infections under control through testing and regional lockdowns, rather than avoiding importing the virus to begin with. 

In any case, there wasn’t much political appetite in March 2020 for Ireland to introduce harsh travel restrictions. In January 2021, ‘Zero Covid’ approaches were advocated, in particular by the Independent Scientific Advisory Group. Zero Covid advocates succeeded in influencing the government to adopt mandatory hotel quarantines, but these were not nearly enough to bring Covid rates to zero. It’s possible that they delayed the introduction of new variants into Ireland, but Ireland has just about every variant there is, and it’s slightly unclear what would have been done with the extra time. Other than the beginning of the pandemic, the only other time where it was plausible to eliminate Covid was Summer 2020, when cases fell as low as four per day and the test positivity rate was less than 1%. 

2.4. The supply of hospital beds is too inelastic

Irish healthcare is complicated. 70% of people have private health insurance, and the rest (including retirees and low-income people) have ‘medical cards’ qualifying them for free public healthcare. Health insurance is highly regulated, and the ‘co-payments’ are capped (e.g., visiting A&E costs only €100), meaning that most of the bill is footed by the government. [Edit: This is incorrect. The percentage of people that have private health insurance is 46%. The reason why this and the percentage holding medical cards don’t add up to 100 is that there are other government subsidies for healthcare, and also, everyone has a right to access the public system, even though there are fees attached for individuals who don’t hold medical cards. Thanks to John for pointing this out.] During the pandemic, the government took this further and nationalised the healthcare system.

Wait, what? It is not as crazy as it sounds. The initial deal lasted only until June 2020. It took six months to negotiate a successor deal, in which the Private Hospital Association agreed to provide up to 30% of its capacity for public patients.

Early commentators in America and elsewhere stated that Covid proved the need for a robust public healthcare system. Their predictions didn’t fare well; public and private health systems have fared about equally poorly. Within Ireland, there was no statistical difference in outcomes between public and private nursing homes. Public versus private is too coarse a distinction. But one does get the sense that institutional structure is a key variable here. March 2020 involved lots of bureaucratic infighting between nursing homes, the HSE, NPHET, the government and the private healthcare system. The temporary nationalisation of healthcare was presumably intended (among other things) as a remedy to this. This infighting makes one consider whether Ireland is too dependent on informal relationships. In Ireland, change begins down the pub. When the pubs are closed, change is much messier and tenser. Many of the relevant bodies had little formal relationship before the pandemic – for example, the HSE didn’t even have a list of all the country’s nursing homes.

One of the distinctive problems with Irish healthcare is patients with “delayed transfers of care” – less charitably known as “bed blockers”. For one reason or another, people who are fit to leave get stuck in the hospital system. Discharging these people was a top priority in March 2020. 

At the start of Covid, Ireland had 255 intensive care beds. By January 2021, the baseline capacity was 280, and it could be expanded in an emergency to 330. That means that, in a pandemic, Ireland had barely more than a fifth as many ICU beds per capita as America does in a normal year. Moreover, Ireland’s hospital bed occupancy rate is 95%, the highest of any country for which we have data. Throughout the pandemic, we were told we needed to “flatten the curve” to stop hospitals from being overwhelmed. But then we did almost nothing to increase hospital capacity! And we totally failed to make being hospitalised with Covid less costly. For example, as of May 2022, only 65 doses of Pfizer’s Covid drug Paxlovid have been administered in Ireland, despite the fact that the results showing that it is highly effective were released in November, and it was approved by the European Medicines Agency in January.     

There is such a thing as too efficient. Previous essays on the Fitzwilliam discussed how electricity grids balance demand and supply, and how a renewable-only grid would have to be massively overbuilt. This is like hospitals: you have to be able to meet demand in an emergency. You can have a demand-side response (delaying people’s non-essential appointments) or a supply-side response (increasing the number of beds). The part where the analogy breaks down is that there’s no equivalent of a battery, which can “store up” illness when there is too much of it and wind it down when there is less. You really do have to overbuild. 

The way to do this affordably is to lower your standards. “But”, you may object, “shouldn’t patients always receive the highest standards of care?” Not really. Insisting that every hospital bed meet rigorous standards will ensure that supply can’t be grown affordably. When there are few beds, they will be of excellent quality; when there are many, they will be slightly worse. When there is a huge number of beds, they will be of mediocre quality and only cover the basics in a crisis. The experience of other countries indicates that “many” means a great many. Japan has four times as many hospital beds per capita, which are probably nicer to boot. We’re not even close to facing a tradeoff between quantity and quality.

The inelastic nature of bed supply (and, particularly, ICU bed supply) meant that, from the perspective of the government, there was no option but to have repeated harsh lockdowns. For all that America’s loose restrictions were criticised in Ireland, they were better able to “afford” it without overwhelming hospitals.

Many of the patients discharged from hospitals went to nursing homes, and this is where the real carnage began. Patients discharged into nursing homes were not all tested until June 2020, despite many being exposed to or even symptomatic with Covid. The government even threatened to withdraw funding from nursing homes if they insisted upon a testing requirement, in a clause to a financial deal with the sector that was later scrapped.

Covid reached nursing homes through several different pathways, and this was long before vaccines. So I don’t know whether the discharging fiasco contributed to the final death toll. But it’s certainly emblematic of a poor decision-making apparatus and a great example of the ‘cheems’ mindset. We let quasi-moral arguments (but isn’t it unfair to discriminate against patients that aren’t tested?) and minor concerns (but what about patients who can’t afford tests?) get in the way of the bigger picture. Two months after this debate, the HSE was considering allowing Covid-positive employees to work in nursing homes. They were concerned that simply loosening the requirements to work in a nursing home would result in “unqualified” staff. This policy was not pursued, but again, it’s a cheems mindset. Less qualified people working in a nursing home temporarily is not that big a deal. Keeping Covid out of nursing homes really is. 

Nursing homes were ground zero of the Irish pandemic, and they remained a mess after the first wave. In the early Summer, a report by the Health Information and Quality Authority found literally zero nursing homes that were in compliance with all the public health regulations.

How can the supply of hospital beds still be so inelastic? There are at least two answers. The first is a lack of available labour. You can’t spell ‘intensive care unit’ without ‘intensive care’. And medicine has just about the strictest occupation licensing of any profession. Medicine also saw a wave of resignations and early retirements during Covid. Another answer is that complying with all the regulations to build or expand a hospital is unbelievably complicated. A new children’s hospital in Dublin has been tied up in legal disputes and planning permission issues for years. Apparently, a pandemic is not a big enough deal to slash through Ireland’s byzantine building codes. Seriously, are we really going to argue that it’s more important that we maintain the “historic beauty” of Dublin than that we have enough beds to care for people in a pandemic? We need YIMBY – Yes In My Back Yard! – for hospitals.

2.5. New variants weren’t taken seriously enough

The UK was much better at genetically sequencing Covid cases than Ireland. At its peak, Ireland was sequencing 40% of its cases, compared to the UK’s 60%. Varadkar described Cillian De Gascun, head of NPHET’s Coronavirus Expert Advisory Group, as considering variants to be of “academic interest”. I strongly suspect this is an exaggeration, but still: people at the highest levels of power did not take variants seriously enough. We still don’t know when Covid entered Ireland, in part because the 2019/2020 flu samples in the National Virus Reference Laboratory were binned in Summer 2020 to free up space in the freezers. Ireland simply doesn’t have the infrastructure for large-scale storage of virus samples. It’s not sexy, but it’s important.  

The January 2021 peak was driven by the Alpha (Kent) variant, at least in part, and the January 2022 peak was driven by Omicron. Cases in Ireland had been at quite a low level for much of the previous Spring and Summer, which perhaps contributed to the obscenely fast growth (Ireland at one point had the highest Covid infection rate in the world). Early January 2022 probably saw 500,000 cases a week, which totally overloaded testing. A period of perhaps just a week saw as many cases as had been recorded previously in the entire pandemic. At one point, almost two-thirds of my friends were isolating, either because they had Covid or someone in their family did. It was almost as unusual a time to live through as the first lockdown. 

Most of the harms of this January 2022 wave could easily have been avoided with a better vaccination policy, which is the subject of the next post.

Sam Enright is executive editor of the Fitzwilliam.