An Taoiseach Micheál Martin, TD &
Minister Stephen Donnelly, TD
Leinster House, Dublin.
October 18th, 2020.
Dear Taoiseach & Minister for Health,
We, the undersigned, write to you to request an urgent independent review and oversight of the National Public Health Emergency Team (NPHET).
We believe that current public health policies lack definitive direction and do not take cognisance of current data.
We are in the midst of a once-in-a-generation crisis. The control and management of Covid-19 have necessitated unprecedented sacrifice on the part of the general population. Long-term medical and social consequences with respect to mental health, missed cancer and health screenings and unemployment continue to worsen. The educational and social deprivations of children and students are significant and difficult to quantify. Industries such as aviation and tourism have been decimated. The near-total shutdown of theatre and the arts is having an enormous impact on national wellbeing and mental health. Public health restrictions have had devastating effects upon families with disabilities and those dependent on incomes from small business. Throughout this difficult period, Government decisions have been directed by NPHET which leading Irish Times columnist Fintan O’Toole described as having: ‘a top-down, command-and-control approach’1https://www.irishtimes.com/opinion/fintan-o-toole-baffling-government-decision-to-tear-up-crisis-plan-has-three-bad-effects-1.4239071?mode=sample&auth-failed=1&pw-origin=https%3A%2F%2Fwww.irishtimes.com%2Fopinion%2Ffintan-o-toole-baffling-government-decision-to-tear-up-crisis-plan-has-three-bad-effects-1.4239071.
NPHET modelling at the outset of this pandemic suggested that Ireland faced a potential death toll of 85,0002https://www.independent.ie/world-news/coronavirus/coronavirus-explainer-where-the-85000-death-toll-forecast-is-coming-from-and-why-its-irelands-worst-case-scenario-39034911.html. This prediction was wildly inaccurate. The WHO now estimates that 10% of the world’s population of 7.5 billion has already contracted Covid-193https://www.bostonglobe.com/2020/10/05/nation/world-health-organization-estimates-that-10-worlds-population-has-been-infected-by-coronavirus/?camp=bg%3Abrief%3Arss%3Afeedly&rss_id=feedly_rss_brief&s_campaign=bostonglobe%3Asocialflow%3Atwitter, suggesting an infection fatality rate of 0.13% and there is a strong possibility of cross-immunity from other coronaviruses. Yet NPHET’s policies appear consistently guided by the epidemiology of Spring 2020.
Current NPHET containment policy is inconsistent and fraught with contradictions. The increasing prevalence of Covid-19 has led many to ask ‘Are such policies working at all?’ Moving the nation in and out of stringent economic and social lockdowns, for an indefinite period into the future, is not a sustainable strategy. It is one that is indifferent to the ongoing and unavoidable development of acquired immunity within the population. It is a strategy that does not formally correlate the natural evolution of viral infections to vulnerable cohorts, and/or demographic distinctions that are unique to our population. This strategy ignores many of our strengths, reinforces many of our weaknesses and represents a national cost that is causing more harm than the disease itself.
We suspect that the ideology behind this approach is reactive rather than proactive and that it is not sufficiently cognisant of up-to-date research or criticisms. The current strategy changes like a weathercock increasing or decreasing the intensity of lockdowns as case numbers rise and fall. This strategy compels the Irish nation to remain entirely dependent upon the arrival of a vaccine as the sole means by which to emerge from this crisis.
We are concerned that prominent Irish scientists, with strong and somewhat conflicting links to vaccine manufacturers, are presenting the notion that repeated ‘lockdowns’ are the only option until the arrival of a vaccine4Discussed here: https://cassandravoices.com/science-environment/covid-19-the-perfect-storm https://www.nature.com/articles/s41577-020-00460-4. We believe an evolved and more nuanced approach needs to be considered, one that might navigate us out of this crisis rather than simply awaiting a pharmaceutical solution.
We feel NPHET should acknowledge the significant and legitimate concerns being raised in relation to current objectives. Most notably, Professor Carl Heneghan of the Centre for Evidence-Based Medicine in Oxford raised concerns in respect of policies and PCR testing at the Oireachtas Special Committee for Covid-19 Response.
We commend the Government for rejecting earlier NPHET directives to return to a Level 5 ‘lockdown’ – a ‘circuit break’ strategy, ‘untested anywhere else in Europe’ according to Tánaiste Dr Varadkar. We believe the Government was correct to question the soundness of this guidance. Such strategies must be subject to scientific and medical peer review if unsettling contradictions between Government and NPHET are to be avoided.
Given the current scope of NPHET’s influence upon the entire fabric of Irish society, we put it to you that if its directives are to be resisted by the body-politic, NPHET must reasonably become the subject of review and oversight. If the Government itself conflicts with NPHET guidance, what does this say to the medical profession who implement these guidelines and the general public who must adhere to them?
While we support proportionate and focused measures to control the spread of Covid-19, we consider current guidance to be flawed in that it is almost entirely reliant upon ‘positive cases’ detected via PCR-testing. Significant issues have been identified in relation to the interpretation of ‘positive case’ data, specifically in relation to false positives5Reference: https://www.cebm.net/covid-19/covid-cases-in-england-arent-rising-heres-why/ and cycle threshold values6Reference: https://www.cebm.net/study/covid-19-testing-and-correlation-with-infectious-virus-cycle-thresholds-and-analytical-sensitivity/ used. The sensitivity of the PCR tests is such that it can pick up ‘old infections’ among those who have long since been exposed to and/or recovered from Covid-19. Therefore, positive cases are not an entirely reliable variable upon which to base far-reaching political, social and national decisions. Furthermore, no distinction is being made between a ‘positive case’, an ‘active case’ and a ‘transmissible case’ of Covid-19 infection. Clinically relevant statistics such as ICU admissions, numbers on assisted-ventilation and mortality data offer more reliable benchmarks for increasing or reducing lockdown measures.
Regardless of Government interventions, the development of some degree of herd or ‘natural’ immunity within the population is inevitable. Although frightening for the general public, this process is unavoidable as ‘cases’ continue to rise. Yet this process does not form part of the current strategy? Natural immunity is not being appropriately studied and utilised as a potential aid toward navigating a way out of this crisis. All efforts are entirely focused on protecting the entire population from contracting the virus in anticipation of a vaccine. David Nabarro of the WHO warned in July, however, that a vaccine could take over two years to be delivered safely and effectively7Reference: https://www.thejournal.ie/covid-19-vaccine-2-years-5161819-Jul2020/. Furthermore, this vaccine may not be effective for the elderly who need it most, as is the case with the influenza vaccine.
Therefore, we are advocating urgent consideration of an alternative strategy, one of ‘focused protection’ which carries enormous benefits for society at large. It allows resumption of educational, social and employment activities, and a massive reduction in the current social, medical and financial costs of managing this crisis. Immediate formal consideration of this strategy is required along with renewed efforts to appropriately protect the vulnerable. We can now identify those at risk of morbidity and mortality with considerable accuracy. We can protect them in a more focused manner than is currently being achieved via broad population-based directives/restrictions.
It is to Ireland’s advantage in tackling Covid-19 that we have the youngest population in Europe. There are only 650,000 people over sixty-five years of age in this country, out of a population of nearly five million. In contrast, the UK has a population of twelve million over the age of sixty-five, out of a population of almost sixty million. According to the CSO, 92% of all Covid-related deaths are over 65 years. Our national strength lies in the manageable size of this population in an Irish context.
‘Focused protection’, as defined in the Great Barrington Declaration, means targeting resources towards the vulnerable as opposed to dissipating resources upon the entire population. For example, our present situation where a majority of the population are compelled to wear potentially sub-standard paper, cloth, or homemade masks, could evolve into a strategy whereby proven and effective N-95 standard masks are procured and made available to those who are at risk.
It must be reiterated that as natural-immunity inevitably increases within our population, so too does the degree of natural protection that is afforded to the vulnerable population. We are not recommending that a dangerous infection be allowed to ‘let rip’ through the population – but rather we are suggesting consideration of a controlled and viable means of navigating a path out of the crisis – one that is not dependent on recurring lockdowns until the arrival of a vaccine. Alternatives to severe lockdowns are being applied in other jurisdictions and much has been learned from their successes and failures.
In our capacity as medical professionals we fully support the HSE at this time of crisis and urge members of the public to adhere to all public health guidelines. Guidance of the highest standard can only be developed in the context of open professional and scientific discussion. Irish medics who have questioned the current approach have been the subject of job loss and medical council enquiry. State-sponsored media has been reluctant to give voice to scientists and clinicians, at home and abroad, who find NPHET guidance problematic. This has had a ‘myopic’ effect upon essential scientific dialogue, and has facilitated a narrow view of our nation’s inherent demographic strengths and resources.
Specific concerns we identify in NPHET’s “top-down, command-and-control approach” throughout this crisis are as follows:
- Highly inaccurate modelling of; expected fatalities, need for ICU beds, required hospital capacity.
- The lack of resource and/or withdrawal of testing services in/from the nursing home sector during the height of the crisis.
- The mismanagement of the crisis with respect to nursing homes including transfers of patients from hospitals into nursing homes without testing.
- Failure to characterise minimal transmission and mortality potential in relation to children and young adults.
- The recent failed attempt at escalation from Level 3 to Level 5 in the absence of empirical evidence for such an escalation.
- Absence of scientific review/oversight for a body that exerts an unprecedented level of control and influence upon the social and economic function of the entire State.
Ultimately our wishes and objectives and those of NPHET and Government are in harmony. We are ‘all in this together’. However, under NPHET’s guidance, we are travelling a singular path with no options. We do not have a clearly defined objective. We do not have a defined endgame. There are less socially destructive alternatives – a strategy tailored to our demographic, one that takes advantage of our strengths as a nation and uses the natural evolution of the virus itself, as a powerful aid towards its eradication. We cannot afford to simply await a hurried and uncertain vaccine as the only means of escape from this crisis.
We must try to overcome fear itself and cautiously learn to live with the virus. We must consider and encourage its eradication by controlled and natural mechanisms, in addition to waiting for a vaccine. Those who are least vulnerable are in need of Government reassurance. Those who are most vulnerable are in urgent need of more focused protection. We are all in need of a roadmap that will use our expertise, our national strengths, and the most up-to-date science to navigate a course out of this crisis. What is in abundance is fear. What is lacking is the courage to revise current policy and to consider an alternative strategy tailored to our nation and its people.
Dr Peter Sloane GP
Dr Marcus de Brun GP
Dr Patrick Morrissey GP
Dr Andrew Rynne GP (retired)
Dr William Ralph GP
Dr Anne McCloskey GP
Dr Vincent O’Carroll GP
Mr Asem Hamdy Consultant Surgeon
Dr Paul McKenna Consultant Public Health
Dr Neville Wilson GP