We all want the same thing. For society to move into a more functional place, socially and economically. The question is how best to achieve this.
Right now we are moving backwards into reactive mitigation measures intended to curb the spread of coronavirus. We need to turn this around and move into a stable and sustainable way of life. But we’re not going to find ourselves there by accident. At the moment, we are floundering exactly because of our lack of strategy and direction.
We have to make a choice. Either we consciously decide to live with a virus that does not afford us the same courtesy, or we make the decision to drive for elimination of its transmission in the community. When making this decision, we need to keep in mind the realities of the end goals – what does success look like for both options?
Suppression, when done well, means living with the virus and living with restrictions. It means reduced economic capacity, social distancing and limited gatherings. With rigorous testing and social distancing, it can mean a stable situation without lockdowns. But it means never really opening society fully until there is a widely available vaccine. South Korea and Germany are two leading nations in the successful suppression of Sars-CoV-2.
While suppression is living with the virus, elimination is living without it. It means opening up fully, without restrictions. It means allowing for a vigorous domestic economy and a normal social life. New Zealand is the poster child for zero-Covid elimination, with Taiwan and Vietnam nearby.
Ireland is not New Zealand. If it was, we would be living under much improved circumstances already. We have different geographical and political challenges than their islands. A zero-Covid plan for Ireland is not about copying New Zealand. We can aim to attain the same result, but by a different method.
To many of us it seems that the zero-Covid option has been misrepresented and confused in our public discussion. It cannot be summarily dismissed by any expert, commentator, politician or special interest group. No one can say that elimination is impossible. Science does not work on the basis of authority, and it does not work on consensus. It works on what works. And elimination has been shown to work, with the right measures.
Nuanced approach
To most of us, the end result of a zero-Covid strategy is obviously the most appealing of our options. But what would it cost to first achieve, and then maintain? A crude lockdown, with foreign travel restrictions, would of course achieve elimination. But it is not the most nuanced approach, and we would then be vulnerable to new seeding from abroad. Persistent lockdown defeats the purpose. This week, a concrete “green zone” strategy was developed by Prof Anthony Staines at DCU, Prof Gerry Killeen at UCC, and Prof Yaneer Bar Yam at the New England Institute for Complex Systems in Boston.
Science does not work on the basis of authority, and it does not work on consensus. It works on what works
The proposal includes a 14-point actionable plan for achieving elimination by a hybrid approach that combines travel restrictions between sensibly defined “regions” (towns, rural areas and counties) with brief and decisive localised lockdowns where necessary, and an aggressive programme of find/test/trace/isolate/support (FTTIS) to “hunt” the virus from the island proactively within one to two months.
Crucially, this is an approach that would allow us to travel to a zero-Covid end goal by transitioning through a more effective suppression situation, and away from our current mitigation reality. In other words, the effort would yield its own rewards in controlling the virus in our population, right up to the point of eliminating it. Then, the same methodology would be employed to maintain a state of effective elimination of community transmission with carefully regulated international travel into the country.
Critics of zero-Covid have said it involves sacrificing the economy. In fact, elimination is the only viable way of opening the economy fully, and we need to level with people that “living with the virus” does not mean a normal economy. Some have implied that zero-Covid involves living in lockdown perpetually, when its purpose is the opposite. The Border with Northern Ireland is frequently thrown in to shut down the conversation. Yet, the Northern Ireland Assembly Committee for Health have given cross-party support for a zero-Covid strategy, following the lead of first minister Nicola Sturgeon in Scotland. Northern Ireland is ahead of us here, and a zero-Covid island is a potential joint project. Two days ago in Westminster, an all-party parliamentary group on coronavirus wrote to prime minister Boris Johnson to call for a zero-Covid strategy in the UK.
International travel
Ireland is, of course, a global economy and serial testing of travellers before and after travel, combined with limited and appropriate quarantine, would allow for sufficient international travel in the current world. New and rapid testing technologies such as reverse transcription loop-mediated isothermal amplification (RT-LAMP) will help facilitate this. People are rightly concerned that New Zealand suffered new seeding of Sars-CoV-2 after just over 100 days of full opening. But nothing is perfect, and this will be managed on a regional basis. The occasional reversion into increased restrictions is the reality of any strategy when things go wrong, including our current situation. But there is a world of difference between allowing a perpetual fire to burn in your home, and the problem of new embers coming from the outside. Elimination is not about a static number, it is a continuous journey towards a vigorous and inclusive society.
There is a world of difference between allowing a perpetual fire to burn in your home, and the problem of new embers coming from the outside
Zero-Covid is not a fringe idea – it is a goal pursued in the UK by Dr Gabriel Scally and the independent Sage (Scientific Advisory Group for Emergencies) group calling for a zero-Covid Britain. In Ireland, it has been endorsed by some of our leading epidemiologists and public health experts including Prof Patricia Kearney, Prof Ivan Perry and Prof Sam McConkey. It has also been backed by a range of scientists including immunologist Prof Luke O’Neill, geneticist Prof David McConnell, neuroscientist Prof Kevin Mitchell, and the former chief scientific adviser to the Government, Prof Patrick Cunningham.
Whether we can achieve a zero-Covid scenario in Ireland is neither a scientific nor a medical question. It is one of political will. It can happen, if enough of us want it to happen. Some of the most important work during the pandemic has been done by journalists, who have been shining a light on how we have been managing our situation. But the media also has a responsibility to open up an inclusive conversation on the zero-Covid option, regardless of how uncomfortable it might be for the Government or lobby groups. This will require a diverse range of perspectives from every sector of society, and clear communication from many kinds of medical and scientific expertise.
Let’s put all the pieces on the table and start an inclusive, national conversation about our options. If, as a society, we really do decide to live with the virus then so be it. But the honest discussion has yet to happen, and people are curious. Elimination of Sars-CoV-2 from the population could be seen as a positive and constructive project of solidarity, and that is surely a better way to live than the confused and meandering uncertainty of mitigation.
Tomás Ryan is associate professor in the school of biochemistry and immunology at Trinity College Dublin