Long read: A lot done, more to do!
EXPERT Faster testing needed and Ireland should be pursuing 'zero Covid island' strategy
It’s coming up on 10 months since doctors noted the first cases of SARS-CoV-2 in the city of Wuhan, in Hubei province, China at the end of December 2019.
A couple of weeks later Professor Samuel McConkey, the Associate Professor and Head of the Department of International Health and Tropical Medicine at the Royal College of Surgeons in Ireland, flagged COVID-19 as a potential threat to the health of the Irish citizenry.
Clones native Prof McConkey, who is also a consultant at Beaumont Hospital in Dublin and Our Lady of Lourdes Hospital in Drogheda, drew on his experiences in pandemic stricken areas to form his opinion.
Fast forward to September 2020, he suggests that January’s observation is the reason he features as a regular commentator on the Coronavirus pandemic.
The professor’s impressive CV covers time in Washington University School of Medicine, Trinity College Dublin, and his clinical fellowship at the Nuffield Department of Clinical Medicine at the University of Oxford.
His opinions on the novel coronavirus are profound because they are based on informed observations on his main field of endeavour – and not just from a medical view point, but also a social, economic and personal perspective.
This comes across in a moment during a conversation that traced how a 120 nanometre virus could stop the world. Prof McConkey emphasises the government’s Covid tracker app as a valuable tool in fighting the virus but says it has its limitations.
“Unfortunately you need a newish phone. It’s not compatible with older phones,” he said of the app. “There are people like my mother in Killeevan. She has a little Nokia phone, they don’t even run apps. She doesn’t even want a new phone or apps, she doesn’t even know what an app is. She says ‘Ah no, I wouldn’t be having any of those.’ She doesn’t even take the phone with her, she leaves the phone charging at home and goes off to Clones on her own,” he says, for example.
That’s the thing about this pandemic. At the end of the day, it will always come to our home town. Every action the State takes, be they restrictive or supportive, is ultimately about home.
“My mum is funny now, she walks the little lanes around Scottshouse. She’s fairly active. She doesn’t like to be stuck in the house. She is fairly stoic, she doesn’t fear anything. She was driving to Clones when she was allowed to get her hair done – her hair has to get done,” he says with mirth in his voice.
In a discussion dominated by the sombre, from the responsibility for the high mortality in nursing homes to the prospect of the next pandemic, the professor’s quip on his mother’s hair is a moment of levity.
A specialist in a topic that dominates conversations from Bali to Ballydehob, Prof McConkey’s does not shirk away from expressing his views. Informed by a life in the scientific field, from his secondment to the Medical Research Council Laboratories in The Gambia early in his career to his current role with the RCSI, those views spring from a unique insight.
Back to the beginning
To explain where we are now, he went back to the beginning: “Back in March and April, we were in a very bad way in the whole country. 1,700 people would die, a lot of people got sick, our health service was not quite overwhelmed but getting near that point at one stage. We transformed the whole country, [by introducing] serious restrictions that none of us could ever have imagined. Those were effective in bringing down the numbers.
“By the time it got to June and July, we had really controlled the spread very well. Now we realise we have to get our economy up and running. Unless we have people at work, with jobs and schools happening, then we will all be desperately poor. We rightly realised we have to get back to work,” but still those allowances come at a cost.
“Since July things have gradually gotten worse, especially in Dublin, but they are not getting worse as fast as they were the last time, it’s more gradual.”
Prof McConkey is quite precise in his observations. This is not an Irish pandemic but one that infiltrated almost every society on our planet. After sacrificing months of interaction, frustration that COVID-19 is still ‘a thing’ is rife in Irish society. How could it continue to spread when our lockdown was longer than the virus’s incubation period?
“I don’t use the word lockdown because it find it very confusing. It has been used in many different parts of the world to mean very different things. In Spain you could only go out of your house once a week to go shopping. In China you were picked up by the army and more or less forcibly detained in what they called ‘a hospital’, but was a quarantine centre you could not leave.
“In Ireland we were allowed go two kilometres, so the idea that we were locked in our houses was completely false. So we were able to get out and do things. Essential things like supermarkets stayed open. The Garda Síochána stayed open, the media stayed open, and healthcare was open.
“In fact we in healthcare were overworked, there were a lot of public service still open. The ‘essential’ part of the economy went on. The narrative that we all stayed in our houses is completely false. From March 27 to May 18, it was about 61 days, but it wasn’t keeping us all in our houses. There were still people moving around. You can’t keep everyone in their house or we would all die of starvation,” he explained.
Power of the people
As the infection numbers and the R rate, the number that identifies the disease’s ability to spread, continue to climb the professor issued a warning on Twitter that we could face an increase to 5,000 infections per day, resulting in 25 to 50 deaths per day. Preventing this happening is not down to healthcare professionals, or government, but the people of Ireland.
“I am hoping we are smarter than that. The whole idea is that we change what we do, as we did in March. I am saying, if we continue to do what we did for the last two months, then clearly we will end up there, but the obvious thing is that we have a plan now that we are going to change how we do things.
“It’s like, if you are driving a car and you are heading for a tree, you know the tree is coming so you change the direction of the car and don’t head for the tree. We do that all the time when we drive a car, or when we conduct our business.
“All of us have to adjust our behaviour and our activity to take account of where our predictions show we are heading. If it shows us that, by changing, we get a better outcome, then that is what most of us do,” he says.
In March Ireland watched as the Italian health system floundered. Our first public health announcement on COVID-19 was an urge that we had to ‘Flatten the Curve’. The notion that this was more about preventing the Irish healthcare system from being overwhelmed rather than saving lives is dismissed by the professor. “The two are the same thing,” he insists.
“Once your health care system is overwhelmed, as happened in Wuhan, in Italy and in New York, people end up dying of other things. If you come in with appendicitis or sepsis and the healthcare system is overwhelmed...” he tails off not needing to explain the inevitable outcome.
The requirement in September 2020 is the same as in March 2020: “What we need to do is prevent all transmission of COVID-19 on the island. We need to limit the transmission down to zero. This is like if your have an infestation of mice in a house. If you control the population by 99.9%, but there’s still two left, then gradually you will get back to where you were before you took the actions to control them,” he says employing his clear gift for analogies.
Zero Covid target
“We did get rid of the virus, but not completely. We did not get it down enough and now it is getting back up. My view is that we should follow South Korea, Vietnam and New Zealand and go for a zero Covid island. Of course there will be some cases coming in from abroad, because we have to keep our borders open. But we have to be able to control all transmission of the virus on our island. People coming from abroad will have to adhere strictly to their own place of residence for a couple of weeks. Any outbreaks we find are then very thoroughly controlled,” he explains.
Ireland now finds itself back in the to the situation where we are hearing squeaks in the kitchen: “The feeling is that it has got away on us again because we did not get it down completely. Possibly we relaxed things slightly too fast. The original plan was to have four to six weeks between every phase, but that was sped up. Perhaps we should have stuck with the original plan.”
Vaccine
Things are not all doom and gloom. While the prospect of a vaccination is still up for debate, many hospital admissions are resulting in better outcomes: “There is a lot of good research going on. There’s a steroid called Dexamethasone, it’s very widely available. It can work quite well, it does not cure everyone, but could mean that there are 20% to 30% less deaths. So there is some improvement, but that 30% improvement still leaves 70% that might die. It’s just a partial cure as yet.”
High rates in Cavan
In the first few months of the pandemic in Ireland, Cavan had one of the highest per capita infection rates. Why this was the case is something that has yet to be clearly defined: “Unfortunately there were a number of big outbreaks in nursing homes in Cavan and also in Cavan General Hospital. That could be from patients that came in, it could be from relatives of staff members. A nursing home could have 50 to 100 or even 200 people in it. They could also have a couple of hundred staff coming in and out to look after the residents. You can’t put a wall around a nursing home to keep everyone out because the staff have to get to work. A lot of the cases in Cavan were in very vulnerable older people and a lot of people died.”
Healthcare settings were not the only sites to experience clusters of infection: “Food processing has been very badly hit. Fortunately Lakelands, and much of the milk processing industry, have done phenomenally well in this. They took a lot of action and kept it out of the facilities. Unfortunately the meat factories and food processing have suffered a lot across the country.
“In this situation a lot of the staff live in hostels together, sometimes perhaps 20 or 30 people living in the same house, perhaps travelling together by bus to work. In some situations the terms and conditions of employment aren’t great.”
Prof McConkey says this raises issues of social responsibility: “Employers need to let their workers know they will get paid even if they are out sick. So, if they take a day off with a runny nose to get a swab, they know they will not be docked pay; or if they are out due to COVID-19 because the swab is positive, they are not docked pay. Unfortunately some employees are on zero-hour contracts and this means they don’t get paid if they are not working,” he said.
Returning to the devastating impact the virus had on the nursing home sector, Prof McConkey says management have to accept responsibility for failing to identify the threat. The professor was previously a board member of the national regulator for medical and social care in Ireland, the Health Information & Quality Authority (HIQA), but feels their role was not to flag the danger the virus presented.
“HIQA is a regulator but the primary responsibility lies with the owners and managers of the nursing homes,” Professor McConkey says. “The nursing homes realised they did not have extra nurses, healthcare assistants, cleaners or managers to step in and help out if they had five or 10 members of staff sick.
“Their staffing tends to be a bit on the low side. They struggle to get staff at the best of times, they did not have extra staff to cover the shortfall. We all need extra staff to cover for us, I don’t believe the owners and managers in nursing homes had that extra ‘surge capacity’. From a human resource point of view all industries need to have extra staff, a plan, and people on standby to step in if people get sick.”
He is not without sympathy for the situations managers found themselves in: “Managing is not an easy job in the middle of a crisis like this. A lot of us have struggled through this. It’s been tough to make good decisions. We have to be a bit gentle and forgiving of the people who have struggled through this because it’s nothing we have ever seen before, or expected. It’s fair to say it hit all of us as a shock.”
Diseases spread more quickly
Prof McConkey says the way the world is changing means the pattern of dispersal of infections disease will also change.
“Things like the Bubonic Plague spread through Europe multiple times in the previous millennium. There was wave after wave of plague. There were also waves of malaria, we had HIV, Spanish flu. When you look back there have been many outbreaks every few decades. The world is changing. There are always new things happening, the world has become very open. We are flying around a lot. That means that diseases spread much quicker,” he said.
As a Clones native his background makes him acutely aware of the impact of the relationship between Northern Ireland and the Republic in having an all-island approach to dealing with the pandemic: “An essential part of our response is to work with the good people of Northern Ireland. Obviously that is challenging, because they have a history of not really working with each other very well,” he said.
“I think they have done great in the last six months. The DUP and Sinn Féin leaders worked together very well for a while and had good control. What happened here has happened there and now their numbers are increasing, but I think they are now working together well again,” he said, commending the role of the public service and the political leaders.
Faster testing
On this side of the border the medical professional identifies the most important tool in ensuring a positive outcome: “I think we need faster testing and faster contact tracing. Only 1.7 million of us have the app and there are five million people in the Republic. That means 3.4 million are not using the app, so we are not getting the numbers.”
And with that, the conversation turned to the personal and how this tiny virus, even without infecting people, has made its way into every home in the country.