In mid-February of 2020, I had to attend a routine outpatient appointment at the Royal Victoria Hospital (RVH) in Belfast. For the previous three weeks I had been working on pandemic preparedness and forecasting. On the morning of the outpatient appointment I had sent a message to a colleague simply stating the following, ‘the wheels have completely come off this now – pandemic for sure’, there was absolutely no question that the novel coronavirus, which would soon be named SARS-CoV-2, was going to cause a devastating pandemic. After the doctor had administered the vaccination I was attending the clinic for I said to him, ‘you’re going to be very busy, very soon’. He looked at me quizzically, and replied, ‘you mean the thing in China? We’re an island off an island – it’ll never get here’.
An island off an island. Although the underlying assumption behind his statement was correct, that the island of Ireland was well-placed, purely by virtue of its geography, to prevent a novel pathogen from arriving and taking hold on its shores. Tragically, we failed to do so, and as a result, thousands of people on the island of Ireland, in both the Republic of Ireland and Northern Ireland, died unnecessarily. And although there was a multiplicity of reasons for this decision, what they boiled down to was this: an almost complete disregard by policymakers both north and south of the border of the fact that the island of Ireland is a single epidemiological unit (SEU). As the Belfast-born public health physician and then President of the Epidemiology and Public Health section of the Royal Society of Medicine, Dr. Gabriel Scally, stated in June 2020, ‘the virus does not respect borders and there are people who live and work on a cross-border basis. We treat Ireland as one epidemiological unit for animal health purposes, so why does it not make sense to treat it as a single unit for human health? To avoid doing so is throwing away our advantage’[1]. The advantage Dr. Scally was referring to was exactly that which the doctor in the RVH expressed – that islands provide unique opportunities for defending themselves from invading pathogens. Opportunities that we catastrophically missed.
There were two opportunities – both based on the fact that the island of Ireland is a SEU – that policymakers completely failed to utilise, the first can be described as the New Zealand approach, and second the cross-border harmonisation approach. The former approach, as will be seen, would have been contingent on the full adoption of the latter. Simply, the New Zealand approach would have involved maximum suppression of SARS-CoV-2 until effective vaccines became available at the end of 2020. The island of Ireland and New Zealand have roughly similar population numbers, and, had the political will been present to both treat the island of Ireland as a SEU and impose strict travel bans to and from both political jurisdictions on the island, as New Zealand did, it is perfectly possible that, following an initial short lockdown, cases of Covid-19, and attendant fatalities, could have been kept at an absolute minimum. To put this in stark perspective – combined fatalities from Covid-19 in Northern Ireland and the Republic of Ireland from March 2020 to December 2020 were 3559; during the same period New Zealand had a total of 25 deaths. During that year, as I watched with horror as the disparity in deaths became obvious between Ireland and New Zealand, it was painfully clear to me that the mounting death toll on the island of Ireland was absolutely preventable, because we had simply folded the winning geographical hand that we had been dealt. So, what would this approach have required, and what, other than preventing the deaths of over 3000 people would we have gained? Simply put, it would have required, as previously noted, full cross-border harmonisation (in terms of pandemic response measures), and a willingness on the part of both the UK government and the Irish government to recognise that the health security threat posed by a novel coronavirus justified extraordinary but temporary geopolitical measures. These temporary measures would have disconnected the island of Ireland from the island of Great Britain for passenger travel, and, of course, from every other part of the globe. It is, of course, the former travel ban – to and from Great Britain – that would have been by far the most contentious, a damning indictment of the power of partisan politics in Northern Ireland. As the bodies piled high on the island of Ireland, to paraphrase Boris Johnson, it struck me that in Northern Ireland especially, a region that has made an industry out of exporting the peace process, there was an uncharacteristic and uncritical silence in the usual quarters on a death toll in ten months that came close to approaching the death toll of the entirety of the Troubles[2]. A death toll that was almost entirely preventable. Freight would still have had to move between the island of Ireland and Great Britain, but this could have been managed with only a modicum of disruption; biosecurity systems exist to allow offshore facilities to remain free of infection at minimal cost[3]. These same systems could easily have been put in place at every port on the island of Ireland. From an economic point of view, and assuming robust cross-border harmonisation of contact tracing services, it is entirely possible that after the initial short lockdown, the entire island of Ireland could have safely opened up every sector of society – education, industry, retail, hospitality, and entertainment, with the exception of non-domestic travel. By drastically reducing the number of imported cases, and by using a short lockdown to achieve a very low level of community transmission, contact tracing and isolation could have kept cases to a minimum until vaccines were deployed.
This, in turn, would have undoubtedly given Ireland the lowest number of Covid-19 fatalities in Europe, not to mention having a much more open and significantly less disrupted society than Great Britain.
It is very easy indeed to think of this and instantly dismiss the idea as being too complicated or too problematic, but if the enemy was not a virus, but a hostile state’s armed forces, then the health security is national security approach resonates more readily. And yet, the New Zealand approach was not seriously discussed between the UK and Irish governments.
However, even simple cross-border harmonisation of pandemic response measures could have made a significant difference to case numbers and fatalities. The island of Ireland is, by definition, a SEU, having different public health measures in place on either side of a highly porous border with significant cross-border interdependencies (especially traveling for work and education), was not only nonsensical, but posed a number of threats. First, differences in quarantine policy between the UK and Ireland regarding overseas travel led to the earlier and more stricter regulations in Ireland being diluted by international travellers simply bypassing them by flying to and from Belfast. Second, with no defined allowed travel radius in place for Northern Ireland residents, many flouted Northern Ireland public health regulations and travelled to border counties, especially Donegal, during the Easter Holidays of 2020. Third, in the summer of 2020, flights landing in Ireland from regions with high rates of Covid-19 posed a threat to Northern Ireland, and fourth, discrepancies in hospitality opening dates and times between Northern Ireland and the Republic of Ireland during 2020 led to surges of cross-border travel – primarily by young people – during that period. Crowded cross-border public transport services almost certainly facilitated numerous superspreader events. In the face of all of these problems, the only real outcome of note was the April 2020 Memorandum of Understanding (MOU) between the Departments of Health in Northern Ireland and the Republic of Ireland, which, while ambitious in scope, was vague, non-binding, and did not account for the consequences of Brexit on the Irish border – being described as, ‘much like a New Year’s resolution: good intentions, but capable of being cast aside when inconvenient’[4]. In short, even the self-evident benefits of the eminently sensible but minimal approach of cross-border pandemic response harmonisation was not implemented in any meaningful way.
While these missed opportunities seem much longer ago than 2020, another opportunity still waits to be seized, both north and south of the border of the island of Ireland: the recognition that proven solutions exist to reduce the transmission of Covid-19 and other airborne pathogens, specifically HEPA filtration of indoor air. Contrary to popular opinion, SARS-CoV-2 remains a dangerous virus, with a significant risk of chronic illness with each infection. Learning the lessons offered from 2020 and putting plans in place to reduce transmission will improve the population health of the entire island of Ireland.
Conor Browne is a biological risk consultant working in the global energy, and novel diagnostics sectors.
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[1] https://www.eolasmagazine.ie/covid-19-turning-the-final-page-of-this-story-2/
[2] https://cain.ulster.ac.uk/victims/docs/group/htr/day_of_reflection/htr_0607c.pdf
[3] https://www.siemensgamesa.com/explore/journal/2020/07/siemens-gamesa-offshore-responds-to-covid-19
