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Should Ireland be like Sweden or New Zealand? Experts disagree on the next steps in the pandemic

What can Ireland learn from other countries as we enter the second wave of the Covid-19 pandemic?

Souvenir shop selling face masks in Stockholm, Sweden, in April.
Souvenir shop selling face masks in Stockholm, Sweden, in April.
Image: Eklund Robert/Stella Pictures/ABACA/ABACA/PA Images

ON WEDNESDAY THERE were a number of headlines suggesting Ireland should consider a ‘herd immunity’ approach or ‘controlled’ spread of Covid-19, citing Sweden as an example.

The comments of former Chief Epidemiologist in Sweden, Dr John Giesecke, and what happened afterwards, suggest that absolute or near-absolute expert advice should often be treated with caution.

Speaking to the Dáil’s Oireachtas Covid-19 committee, Giesecke stressed the best approach was not necessarily “herd immunity” – when a large portion of a population develops immunity to a disease – but one that allowed Covid-19 to spread in a “controlled” way among people under the age of 60, and a “tolerable spread” of the virus in older people.

He told politicians that an “elimination strategy”, backed by other virologists, was not likely to succeed.

Yet hours later, on RTÉ Radio One’s Drivetime programme, he backtracked somewhat after it was put to him that the differences between Ireland and Sweden’s population densities, classroom sizes and sick pay entitlements would likely lead to a different outcome if that approach was adopted here.

Giesecke said: “I’m not prescribing anything for Ireland. You have to make your own decisions. That’s not up to me. I’m just saying the way it’s happened in my country.

“I just reported back on our experiences. I’m saying that other countries might do the same thing, but I’m not saying they should.”

As Covid-19 has raged across the world, a fragmented approach to handling the virus has emerged. Countries such as Australia and New Zealand have kept it largely under control, while several Asian countries have had major successes in returning to a more normal way of life.

Some experts are divided about what the best approach to suppressing the virus is, as well as how to re-emerge from lockdowns and other restrictions.

Sweden is often used as the poster country for how it ‘handled’ the pandemic without a strict lockdown.

Although the public health advice in Sweden was largely voluntary, adherence to it was high – people travelled a lot less and reduced their interactions with others, for example. Vulnerable people and the over-70s were told to isolate, and gatherings of over 50 people were banned.

But it was reported this week that Sweden may indeed introduce a short-term lockdown if the incidence rate of the virus increases.

Ireland’s 14-day incidence rate of Covid-19 per 100,000 is 70.7, while Sweden’s is about half this. There have been over 90,000 cases of the virus to date in Sweden and almost 6,000 deaths, in a population of about 10.3 million.

The total number of confirmed cases in Ireland is 33,994 and there have been 1,797 deaths.

‘You cannot compare’

Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, said he “despairs” at the continual comparisons between Sweden and other countries, saying “you cannot compare the Swedish experience” with countries such as the UK and Ireland.

He said Sweden has better health infrastructure and more stable employment, as well as “really well functioning public institutions and a very high level of trust in government” – something many countries don’t have.

“Even when they followed what many of us view as a misguided policy in Sweden, they didn’t do as badly as some other countries. Because, in fact, people did actually comply with advice. The same way that in Sweden, during the global financial crisis, while other countries were seeing big rises in suicides, you didn’t see that in Sweden.

“Even though you had job losses, the Nordic countries have all got strong welfare states, lots of protections. So people are not in the gig economy, not working in substandard working conditions, you know like in the meatpacking plants in the west, in the midlands of Ireland.”

McKee said Ireland “absolutely” needs to address outbreaks in meat factories, as well as crowded living conditions experienced in places such as Direct Provision centres. He said “very rigorous inspections of places like that” are needed.

Another reason Ireland and the UK are not comparable to Nordic and Scandinavian countries is in terms of healthcare systems, he said. 

Lack of investment in healthcare services over many years and the impact of austerity means certain countries were starting from a disadvantaged point when the Covid-19 pandemic arrived.

“That’s absolutely critical,” McKee said, “A number of countries went into the crisis, having disinvested in the public sector over many years, and unfortunately they’re paying the price for that now, we can see that those were false economies.”

What we can learn from other countries 

McKee is a co-author of a new international report, published in The Lancet journal, that analyses the strategies for easing Covid-19 restrictions that were implemented in nine high-income countries after the first wave of infections: Germany, Norway, Spain, the United Kingdom, Hong Kong, Japan, New Zealand, Singapore, and South Korea.

The report notes that after instituting full or partial lockdowns, many governments “face the challenge of reopening society while balancing health, social, and economic considerations”.

Based off the experiences of the nine countries, the authors of the report are advising governments to consider five key factors when devising lockdown exit strategies:

  • knowledge of infection levels
  • community engagement
  • public health capacity
  • health system capacity
  • border control measures

New Zealand’s ‘Zero Covid’ approach 

The authors also state there is “a strong argument for adopting a so-called zero-Covid strategy, like in New Zealand, which aims to eliminate domestic transmission, particularly considering emerging evidence on the effects of long Covid (which occurs in people who have survived Covid-19 but continue to have symptoms for longer than expected)”.

McKee said governments should be ambitious and consider adopting a “zero Covid strategy”, in the knowledge that this likely cannot be achieved.

“You have to recognise that with the best will in the world, you’ll never eliminate it completely, but [New Zealand has] done incredibly well, they’ve had very few deaths, they were able to open up most of the economy.”

McKee noted that while there has been been another lockdown in and around Auckland, the numbers are “nothing like what you’re seeing in other parts of the world”.

He said governments should “not be judged for failing to get to zero Covid”, but should still make that their aim.

McKee said countries need to get the number of cases as low as possible before they start opening up their economies.

You need to get it down, and then you need to ease the restrictions with great care, with really good data, really good surveyance, really good testing and tracing.

In New Zealand there is a four-level alert system; a so-called ‘social bubble’ approach allows a gradual expansion of small social groups; testing and tracing capacity has been increased; efforts were made to increase number of ICU beds; the border is closed to most visitors, and all arrivals are tested and quarantined for 14 days.

People are advised to maintain a physical distance of two metres in public spaces and one metre is recommended in schools and workplaces at high alert levels, but there are no distancing requirements at alert level one.

‘Infection grows at exponential rate’

McKee said he doesn’t believe there is “trade-off” between public health and the economy in terms of coming out of a lockdown.

“I would definitely not say that there’s a trade off, because all the evidence shows that if you don’t get the rates [of the virus] down, even if you do open up places, people won’t go to them.

“The main thing, I think in opening up is, first of all, get the rates down to be as low as possible. And then you can start safely opening up a bit, but always titrating it very carefully so that as soon as you get signs of an upsurge, then you have to respond in some way.

“The thing is that this infection grows at an exponential rate. So if it is increasing at all, it will rapidly accelerate. It has to ideally be kept so that it’s declining. Even a tiny bit above this R value of 1 means that you’re in danger of losing control.”

To stop this from happening, McKee said, countries need really robust testing, tracing, isolation and support systems to be in place.

“You need a strategy, and somebody in charge who knows who’s meant to be doing what, and so on. So I think those are the fundamental messages.

“You need really good data. You also need community engagement, public trust, as of course that has been a huge problem in England because of the Dominic Cummings affair (Boris Johnson’s senior adviser drove from London to Durham amid the lockdown in March) and the general lack of trust in the government.”

McKee and his co-authors’ other recommendations include:

  • A clear plan with a transparent decision-making process is essential, ideally explicitly stating the levels or phases of easing restrictions, the criteria for moving to the next level or phase, and the containment measures that each level or phase entails.
  • Governments should have robust systems in place to closely monitor the infection situation before easing measures. The authors point out that the R value is important, but caution that this requires high quality data in real time (like in Hong Kong) to be accurate and needs to be interpreted using epidemiological knowledge. “For example, a small localised outbreak can drive a country’s R value up but does not require a national lockdown to be controlled,” the report notes. 

Lead author Dr Helena Legido-Quigley, of the National University of Singapore and London School of Hygiene & Tropical Medicine, said Covid-19 is “a serious disease that will be with us for a long time”.

“There is increasing realisation that easing of lockdown is not about returning to a pre-pandemic normal, and governments have to find strategies that will prevent rapid growth of infections in ways that are sustainable and acceptable to the public over many months.”

Speaking about the report’s findings, Legido-Quigley said: “Our review of international experiences identifies lessons governments can learn from each other’s successes and failures. We are not advising that the exact same measures should be replicated in different countries, but it is not too late for governments to consider novel policy solutions developed by other countries and adapt them to fit their own context.”

Austerity

The Lancet study acknowledges that healthcare systems around the world are at differing levels of preparedness for handling a pandemic.

“In Europe, more than a decade of austerity measures have substantially weakened health systems and social protection in many countries,” the study notes. In contrast, the experience of SARS and MERS prompted major investment in the healthcare systems of many Asian countries.

These are the same states that have been roundly praised for the handling of Covid-19 over the last six months.

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Yet experts disagree over whether Ireland’s fragile health system should be a barrier to following these more successful countries.

To some, immediate public investment – aided, where needed, by the private sector – could help Ireland follow the path of these more successful countries. For others, policy decisions over the last few decades have already left Ireland more flat-footed than most in the face of the crisis.

Niall Conroy, an Irish consultant in public health medicine working in Queensland, Australia, said that it would be unwise to imagine that a successful system in one country could be translated wholescale into another.

“You have to look at experiences from other countries and take them as a guide, not as an absolute,” he said.

“I don’t think you can ever absolutely take a plan – an elimination plan, a significant suppression plan – for a virus and transplant it from one country to another.”

But Conroy, who personally supports an Australian-style plan that aims for widespread elimination of the virus, also said that there was no reason Ireland couldn’t change strategy.

And while Australia’s healthcare system was far better resourced than Ireland’s, he said that that was no barrier to taking a more radical approach into the future for suppressing Covid-19.

“I think it would cope. It needs a lot of resources,” Conroy said. “But a lot of those resources need to go into areas that haven’t necessarily been stretched. You would have the military or the police working at the mandatory quarantine sites.”

Tómas Ryan, a neuroscientist at Trinity College Dublin, has become one of the most prominent advocates of a ‘Zero Covid-19’ strategy that would see the virus suppressed to its lowest possible levels.

Speaking at the Dáil’s Special Committee on Covid-19 Response on Wednesday, he said that Ireland should be paying close attention to the approach being taken in Finland, which has one of the lowest infection rates in Europe.

“Finland is the clear winner by all measures of economic activity, healthcare outcomes and infection rates. We should be paying close attention to what Finland is doing,” he said.

Speaking to TheJournal.ie, he acknowledged that every country is different. “We seem to be looking for a clever approach to make our problems go away. The reality is a lot of countries have dealt with this very well, but in different ways,” Ryan said.

“We have many things to learn from each of them and not all of the things they’ve done are going to suit us,” he said.

But he said that while Ireland had differences with countries that have handled the pandemic particularly well, the solution was relatively straightforward.

“What you need is massive investment in public health,” he said. “And a very organised system that brings in the private sector where necessary.

“There is no magic bullet that takes us out of this. It needs organisation and effort.”

Not every scientist would agree. Others who spoke to TheJournal.ie said that Ireland’s historically underfunded public health system might be a major hurdle to a strategy that would pursue elimination.

Another area where difficulties remain is the narrow specialism of some experts. Dr Kim Roberts, a virologist in Trinity College Dublin, said that tackling the virus requires a broad swathe of perspectives, from behavioural scientists to public health policy-makers.

“We study viruses. We’re thinking about how a virus transmits and causes disease. That’s useful,” she said of virologists. “But it’s limited in its scope in terms of producing policy.”

One of the lessons of the pandemic, she said, was that “it’s looking increasingly likely that we need to put more resources into increasing the public health specialists we have”.

Yet the real weakness of assessing which experts are right and which countries have been successful is simple – the world is only six months into the pandemic.

The authors of the study acknowledge that it provides a “snapshot, rather than a conclusive analysis”.

While South Korea, Vietnam and Taiwan remain on top of the virus, recent outbreaks in New Zealand have revealed the difficulty of keeping the virus suppressed. The rising number of cases across Europe in recent weeks show how quickly the situation can change as the continent heads into winter.

In six months time, outbreaks around the world may look very different. Experts say that the approach taken to Covid-19 is something of an experiment – only hindsight will reveal who handled the pandemic best.

About the author:

Órla Ryan and Dominic McGrath

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