Paul Hosford: Something went wrong somewhere in dealing with Covid-19
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Also in today's analysis:
- Government should give reasons for deviating from Nphet advice
- When Varadkar played the man, not the ball, in TV interview
"I need to speak to you about coronavirus."
Nearly 10 months to the day on March 12, then-taoiseach Leo Varadkar stood on the steps of Blair House in Washington DC to issue a grim warning.
The National Public Health Emergency Team (Nphet) had been meeting to discuss the virus since January, but the situation was worsening. Ireland's containment phase against the virus, which had first been detected a fortnight beforehand, was over. We now needed to delay the spread of Covid-19.
The letter sent by chief medical officer Dr Tony Holohan to then-health minister Simon Harris on March 11, the day on which the World Health Organisation had designated the virus a global pandemic, was stark.
Nphet noted that the country had seen an uptick in cases, hospitalisations, community transmission, and the country's first death. Now was the time for action, the team argued. It proposed that from Friday March 13 to Sunday March 29, new restrictions were needed.
Social contacts should be cut by everyone, those with symptoms of the disease should self-isolate for days, elderly and vulnerable people should reduce their contacts outside the home, and gatherings over 100 people indoors and 500 outdoors should not go ahead.
Most crucially schools, colleges, creches, and childcare facilities were to close.
However, within government there was little resistance to the restrictions, sources say, with the prevailing feeling that they were necessary and the warnings from public health experts "like nothing we'd ever seen".
However, somewhere along the line the relationship between those responsible for public health advice and the Government became strained to the point that the Tánaiste Leo Varadkar was making open attacks on them on TV at the same time that the health minister was saying everything was fine on the other station.
To chart how we got there, it is important to understand that in the words of one member of the last government "nobody had any experience with anything like this" when the virus arrived on our shores in late February.
In that context, trusting Nphet was all that the government had, with blunt instruments in its armoury. With the pandemic first envisaged as a weeks-long crisis and public buy-in at high levels, the government was always going to be happy to turn control over to experts to protect as many people as possible.
The severity of the Nphet letters would increase as March wore on. On March 24, Dr Holohan said that further measures were needed. However, with the public and government on board, this would be possible.
These were biting restrictions, which if imposed, would have upended life for many. The closure of clubs, theatres, gyms, libraries, and hairdressers, the limiting of hotels to essential guests only, the cancellation of sport, a ban on household visits, and social distancing everywhere with gardaí empowered to enforce the rules if needed.
Within three days, however, things would deteroriate again, with Dr Holohan writing to Mr Harris again on March 27, sounding the alarm that ICU admissions had doubled that week. Drastic action was required from the Taoiseach and Government, prompting a televised address to the nation from Government Buildings.
Dr Holohan had asked for a stay-at-home order to be issued, for the vulnerable to cocoon, for more non-essential retail to close, for non-urgent healthcare to be postponed and for a 2km exercise restriction to be imposed, making people stay near their homes in a bid to fight infections. The regulations would run until Easter Sunday.
In his address, Mr Varadkar directly said that his government was acting on the advice of Nphet.
"Throughout all of this, the government has acted on the advice of the chief medical officer and the National Public Health Emergency Team — an expert team of public health doctors, virologists, and scientists."
He went to the well of public resolve and urged the public to fall in line behind health staff.
That round of restrictions was due to be lifted on April 12, Easter Sunday but on April 10, Mr Varadkar would be advised by Dr Holohan to keep the restrictions in place.
"There are now encouraging signs that the measures implemented to date have positively impacted the progression of Covid-19 in the Irish population," the letter read.
Dr Holohan, however, cautioned that ICU numbers were around 150 and community transmission was high.
With the warning clear, the government acquiesced to the medics, which was very much the rhythm of the early days of the pandemic, with a caretaker government which was faced with a generational challenge falling into lockstep with the country's top doctors in a bid to stave off the worst health and social impacts of the virus.
Indeed, criticism of Nphet at that time was seen as unduly negative, even unpatriotic as murals of Dr Holohan dressed as Superman sprung up. Labour's Alan Kelly, however, was one of the few politicians to air his grievances publicly, noting that at that time in April, minutes from Nphet meetings were not being published.
As April became May, the government announced a new phased plan to open up the country.
The government said that the roadmap "also sets out a framework for future decision making, which will at all times be underpinned by public health advice".
While the plan would be sped up and then jettisoned in favour of the current five-tier system, it was clear that the government and Nphet still saw eye-to-eye on the restrictions, despite pressure coming from lobby groups to reopen hospitality as the summer approached.
On May 1, ahead of the roadmap's announcement, Dr Holohan wrote to the government and said that the risks of Covid-19 meant that the restrictions first announced in March were "warranted".
While the R, or reproductive, number had fallen, there were still concerns about the "extent of this disease in the community" and the "specific burden being experienced by residential care facilities".
Mindful that social distancing measures were impacting on people's lives, Dr Holohan agreed with the Government that the 2km exercise restriction should go to 5km, that cocooners could leave home for exercise and that masks should be worn in public.
He wrote that the framework should "inform a slow, gradual, step-wise, and incremental reduction of the current public health social distancing measures".
While Mr Varadkar told people that day that there was "hope" he stressed the Nphet advice.
As restrictions began to ease on May 18, the virus situation continued to improve. To the point where on June 5, Mr Varadkar would announce that Ireland was moving to what he called "Phase 2 Plus".
The advice was most simply put as a change from the advice to "stay home" to "stay local".
He said that this would be a "Phase 2 plus" and confirmed that there would be four phases instead of five, with Ireland's economy nearly fully open by July 20 instead of the original date of mid August.
The focus was again on summer for the then-taoiseach who was increasingly aware of the risk of public fatigue and the damage which would have been done to the hospitality sector if it stayed closed.
"Summer is not lost," he said.
The restrictions allowed county-wide travel, allowed outdoor and indoor home visits, set a reopening date for pubs and fully reopened the retail sector.
If anyone on Nphet was worried about the acceleration, the correspondence does not show it.
The Nphet advice recommends a move to Phase 2 of the plan with measures broadly adopted and a letter sent on June 4, while urging caution and asking for improvements to public health and tracing measures, does the same.
Within two weeks, Mr Varadkar had announced another acceleration of the plan, with hairdressers, barbers, gyms, and cinemas allowed to open from the end of June.
Cabinet made the move after Nphet discussed and approved a reworking of the phases relating to the planned lifting of restrictions. The Nphet advice from June 18 praises the work of the Irish people and agreed with the plan to remake Phases 3,4, and 5 into two phases.
On June 29, the hospitality sector reopened and a summer of staycations began, all as case numbers stayed relatively low.
The new Taoiseach Micheál Martin and his Minister for Health Stephen Donnelly seemed to have inherited if not an enviable position, one which had something of an end in sight.
Two weeks into office, however, Acting CMO Dr Ronan Glynn would push the alarm. In his letter to Mr Donnelly, he recommended that the Government not advance its roadmap to reopening the economy as planned and instead wait until August 10 to reopen so-called wet pubs.
Mr Martin said that the decisions had been made due to the rise in cases in recent weeks, which he said represented a "very real" threat but publicans called it "a hammer blow".
Mandatory wearing of face coverings was also brought in and numbers of visitors in homes cut.
Mr Martin denied that the "pause" in reopenings did not mean that the last government had made a mistake in accelerating through the roadmap.
He said that the document was always "flexible" and said that it was "the right thing to do to pause".
"The Nphet considered today [July 14] that a cautious approach must now be pursued."
In his letter, Dr Glynn had urged the Government to be "cautious", advice which was taken up.
Sources within Government at the time said that they felt the Nphet advice was "reasonable" and felt that a three-week delay to get an uptick in cases back down was the best option, rather then shutting the economy down completely.
There were, however, more cavalier attitudes around Leinster House with some TDs furious that wet pubs would not open.
A few weeks later, Dr Glynn once again urged a "cautious but measured approach", saying that pubs should not reopen and the roadmap be delayed to the end of August.
While the hallmark of the summer was a stop-start mix of different openings and warnings, at all times the Government had stuck closely to what medics advised. At the beginning of August, however, there was a notable diversion from the advice.
The health experts advised restaurants close at 10.30pm, but the Government set that limit at 11pm.
Tánaiste Leo Varadkar said this was being done to "prevent restaurants essentially acting as pubs".
He said the timing only applied to when customers had to leave the premises.
In the scheme of things, it was a minor difference, but it was a step from the Government to control at least part of the situation.
With the the roadmap now delayed or abandoned in September, the Government introduced a new five-tier plan in a chaotic week. On September 15, the Living With Covid strategy was published, outlining the tiers of restrictions.
Mr Martin announced that the entire country would be placed on Level 2 as recommended by Nphet but Dublin would be placed on a level "somewhere between Level 2 and Level 3", as a source told the .
This would include limits on household visitors and the continued closure of wet pubs in the capital as Mr Martin warned that Dublin was "going in the wrong direction".
However, the opposition called the launch "confusing" and accused the Government of "bottling it" when it came to Dublin.
Not long after that Cabinet press conference concluded, the entire Government would be forced into self-isolation as Mr Donnelly began to feel unwell.
TDs were told the business of the parliament was suspended by Ceann Comhairle Seán Ó Fearghaíl before they were recalled as Mr Martin moved to ensure junior ministers would replace their senior colleagues in the Dáil chamber. Mr Donnelly would test negative for the virus, as the opposition called events "an incredible shambles".
Just two days later, Nphet warned that things in Dublin were getting worse. It warned that there could be 600 cases a day in Dublin by mid-October of things were allowed to continue. This meant that just days after moving to Level 2 and a bit, Dublin would be put to Level 3 as Cabinet approved Nphet advice "without deviation".
If September was a rough month for the framework, October would see the relationship between Nphet and Government would "change utterly" with recriminations and blame being widespread.
Over the first weekend of the month, Dr Holohan returned to his role and held an emergency meeting of Nphet, alerting Mr Donnelly to this fact on the Saturday.
By Sunday, however, a letter had been sent to the Government that was not so much sounding alarm as it was blaring it from the mountaintops and running through towns yelling that "the virus is coming".
That the contents of the letter were leaked to RTÉ and ahead of their Sunday night bulletins left a bitter taste for many in Government.
The letter warned that Level 5 restrictions were the "only way" to get the virus back under control.
Dr Holohan said that a graduated approach “will not have sufficient or timely impact on the trajectory and scale of the disease”.
He said: “Nphet advises that it is vital to do everything in our power now to arrest the current trajectory nationally and suppress the virus back down to a low level of transmission in advance of the winter months.”
The Government was furious, with some believing Dr Holohan was trying to "railroad" them into making a decision. In the end, the Government would announce Level 3 restrictions nationwide, a move Mr Donnelly said was "the best decision on behalf of the country".
However, while Mr Donnelly was telling journalists that the decision did not mean that Nphet was wrong or the relationship was strained. Mr Varadkar was on the programme saying that the Nphet advice "came out of the blue" and implying that Nphet was disconnected from the impact of its advice.
He said: “None of those people [in Nphet], for example, would have faced being on the pandemic unemployment payment. None of them would have to tell somebody that they were losing their job, and none of them would have had to shut their business for the last time."
Dr Holohan, however, would confirm that he had spoken to Mr Donnelly before sending the letter.
"I was very clear about the level of concern that I would have, and had,” Dr Holohan said.
This caused considerable anger on the opposition benches and forced Mr Donnelly to take Dáil questions on the matter.
The controversy could not rage for long, however, as on October 16, Nphet would once more recommend a move to Level 5.
Holohan’s letter stated:
At Cabinet, there was a sense of shock and concern about the scale of the decision being taken.
Simon Harris, a known Nphet supporter, suggested three weeks with a review, but this was countered by the argument that such a short period would give “false hope” as a six-week period is deemed necessary to give effect to the measures.
And, so the Taoiseach told the nation on Monday, October 19 that a six-week period of Level 5 was to be implemented.
Nphet had hoped that the six-week lockdown would bring cases numbers to under 100 per day but as November wore on, they remained closer to 300, putting what Mr Martin deemed a "meaningful Christmas" in doubt.
However, despite Nphet warnings, the Government pressed on with a multi-phase plan to reopen the economy and society from December 1. This included the reopening of hospitality from December 4 and the lifting of household and travel restrictions from December 18.
This despite the grim warning of Nphet which said Ireland was in a "precarious" position. Dr Holohan said that there was "growing evidence" that indoor settings such as bars and restaurants contribute to viral spread, meaning that the Government must choose between opening the hospitality sector and household visits and should only allow religious services from December 21.
He said: "The advice of Nphet is that we do not have the flexibility to reopen the hospitality sector if we are to ease the prohibition on household visits."
In ignoring this advice, the Government would lose its political cover, but gambled on numbers staying low and the public buying into the restrictions on a reasonable but limited basis.
Neither happened.
Since the beginning of the pandemic, Nphet has kept the Government appraised of matters with a weekly letter.
Sent on a Thursday, the letter outlines the latest epidemiological situation and makes suggestions on public health measures. There is usually one a week unless there are extenuating circumstances.
In December, the team sent seven, with five coming in the final 14 days of the month.
The letters paint a grim picture of a situation getting worse and worse.
On December 17, one day before household visit and intercounty travel restrictions were to be lifted, Nphet said that it was "especially concerned at how rapidly case numbers have increased", particularly noting that "the timing of the current cases is clearly related" to the opening of hospitality. It urged the Government to end the Christmas period on December 28 and close hospitality.
Four days later, a letter urged a full Level 5 suite of measures be introduced and raised concerns about tracing and testing of household contacts.
On December 22, the Taoiseach confirmed that the country would enter a fresh period of Covid-19 restrictions from Christmas Eve. Pubs would be closed along with salons and barbers, with Micheál Martin saying the Government was acting “quickly and aggressively” in response to rising infection rates.
A day later, Nphet would once again push for a full lockdown, with a letter saying that a "further significant deterioration" would "seriously impact" the ability of the State to protect public health. It said that only schools and some third-level facilities should remain open.
Another letter on December 28 warned of a continuing deterioration in the status of the virus. Once again, Dr Holohan asked for a full Level 5 lockdown.
"Given the overall transmission of the disease and the impact it is having on hospitalisations, as well as emerging concerns about the increased transmissibility of the UK and South African variants, I am of the view that the current set of measures, which are less than the full suite recommended by the Nphet last Wednesday, will not be sufficient to bring the current trajectory under control."
On December 30, Dr Holohan wrote to the Health Minister saying that the situation was " the most concerning observed since the onset of the pandemic in Ireland". It recommended that the "the full suite of Level 5 measures" be put in place for six weeks.
He said: "However, the Nphet cautions that the situation remains extremely fragile, with disease incidence and hospitalisations accelerating faster than the most pessimistic modelling scenarios had projected."
That night, the Taoiseach announced Ireland would move to Level 5 — a Level 5 which would be made more severe just a week later.
That Nphet and the Government are not always in agreement is sometimes painted as a cause for concern.
It is not a bad reaction or one borne out of mendacity. It is just alarming for people who are worried about their own health and the health of their loved ones to hear that those in charge of the country sometimes deviate from the advice of medical experts.
For the majority of us, ignoring or diverting from a course of treatment set out for them by a medical professional seems strange.
However, it is important to note that the Government's considerations have always and must always be wider than those of Nphet.
When Nphet, which deals with Covid-19, was established in January 2020, it was given seven terms of reference, the first of which reads that the team is to:
"Oversee and provide direction, guidance, support and expert advice across the health service and the wider public service, for the overall national response to Coronavirus, including national and regional and other outbreak control arrangements."
While the terms are broad in the context of anything that we have seen before in the health realm, it is important to note that Nphet is not tasked with saving the economy or protecting jobs.
However, CMO Dr Tony Holohan knows his decisions do not happen in a vacuum and that the weapons in his armory are the bluntest possible far too often.
So when we argue about the effectiveness of lockdowns, we base those discussions on a range of factors. Dr Holohan's focus, as seen through months of correspondence, is purely based on limiting or stopping the spread of the virus.
For the Government, there is a much larger balance to be struck and it has consistently said that its first priority is protecting lives, but that livelihoods did factor in, as well.
When Cabinet is faced with Nphet advice, it must weigh up the cost in both monetary and societal amounts.
When rejecting the Nphet advice in November, the calculation was made that a weary populace would not accept having Christmas taken from them in a year of unrivalled hardships.
That even if the Government had deemed home visits against regulations, people would have ignored that in favour of as close to a traditional Christmas as possible.
In that instance both Nphet and the Government got it wrong. Nphet's projections underestimated how bad things would get, while the Government strayed from Nphet's dire warnings and has been forced to put the country back into lockdown due to astronomical spread of the virus.
The differing viewpoints of both organisations does not make one bad and one good and we do ourselves and each other no good by pretending that the decisions being made by anyone are done without a care for people's wellbeing.
This is not Star Wars. What this difference makes them is groups of adults trying their best to navigate an unprecedented situation.
Where the Government gets it wrong, however, it will likely cost lives in the short term or lead to a situation where the health service is placed under immense strain. And those mis-steps should be acknowledged.
The Taoiseach, when announcing the December 30 restrictions, put the spread of the virus down to the new variant, a position contradicted by Nphet. He did not accept that the Government got it wrong.
The two will differ again as the months roll on. That is inevitable. When they do, the public should be given clear reasoning and mistakes should be acknowledged without necessarily demanding a pound of flesh.
After all of this, it is the least we can expect.
While the relationship between the Government and Nphet was never unimpeachable, there is one incident that many pinpoint as highlighting how it has changed over the year.
On October 5, Taoiseach Micheál Martin addressed the nation live on the RTÉ News at 9pm, while journalists went to the bunker that is the press centre at Government Buildings. There, underground, Health Minister Stephen Donnelly, Finance Minister Paschal Donohoe, and Transport Minister Eamon Ryan set out to explain the reasoning for straying from Nphet advice.
Much of the questioning, naturally, was focused on Mr Donnelly as health minister. The relationship with Dr Tony Holohan, the chief medical officer, and Nphet was fine, he reiterated. Nphet had given its advice and the Government had disagreed, simple as that. “The relationship with Nphet is absolutely fine," he said.
As those assurances were being given, journalists' Twitter feeds were lighting up with tweets about . According to the tweeters, Tánaiste Leo Varadkar had "thrown Dr Holohan under the bus".
The interview remains remarkable, with Mr Varadkar laying bare the frustration that had built up among Government and Fine Gael with Nphet.
“Last Thursday, when we received our advice from Nphet, there all in writing, there was no suggestion whatsoever that they were contemplating suggesting that we move to level 5.” The recommendation was “not crazy, but not thought through”, he said.
“Government and Nphet have to get back on the same page."
Most in the medical community took issue with Mr Varadkar's assertion that Nphet was out of touch with the consequences of its decisions.
"They don’t advise the public, they advise the Government and Government decides," Mr Varadkar said.
“None of those people [in Nphet] would have faced being on the pandemic unemployment payment yesterday."
One minister said Mr Varadkar had played the man, not the ball, but others rallied around him, particularly within his own party.
Nphet sources say the interview had given rise to "some distrust" from the side of public health experts, though they said that "everyone is ultimately on the same team here".
Sources at the time suggested internal polling conducted by Fine Gael may have bolstered Mr Varadkar's confidence in criticising Nphet but the Tánaiste has seen his own reputation dented by the interview.
In accepting Nphet's advice two weeks later, Mr Varadkar was made to seem petulant in the interview, stung only by the timing and manner of Nphet's advice and not its content.