NPHET Advised Against Border Quarantine When We Needed It Most - Part 2

This is the second part of an article that reviews NPHET’s decision to advise the Irish government against a border quarantine in February 2020. You can read the first part here. NPHET would later go on to reverse its position on the matter, but by that stage it was too late. The first wave was already well underway, and NPHET’s indecision at this key moment would go on to cost Ireland dearly. The episode also revealed a concerning pattern in how decisions were – and presumably still are – being made in NPHET.

Part 1 took us back to the first week of February 2020, when the information from China was patchy, but the outbreak clearly wasn’t going away. NPHET’s attention had been drawn to the risks posed by Ireland’s repatriation flights, as any of the passengers on board could have been carrying the virus. To protect its people from this risk, the UK had decided that returners would undergo a mandatory 14-day quarantine on arrival. The EU had issued no directive on the matter.

What should Ireland do?

The government decided that this was a matter for NPHET to advise on. NPHET sought the advice of the Expert Advisory Group (EAG) and the EAG recommended that the best course of action would be not to wait and see, on the grounds that a border quarantine would have imposed a “disproportionate burden on the individual”.

Why the EAG chose to prioritise the convenience of a relatively small number of individuals over the health of the entire country, we do not know. The EAG neglected to include the rationale for the decision in its meeting minutes. Indeed, the minutes lacked much of the information one would normally expect to see in a set of official documents.

There was no record of any arguments being raised either in favour or against the policy, and no explanation of how the Group’s 17 members reached its consensus. No data or modelling – internal or external – had been presented to the Group for discussion. Most glaring of all, the EAG had nothing to say about the impact the border quarantine would have on public health outcomes – the very thing they had been asked to assess.

According to the Chair of the EAG, Cillian de Gascun, the matter had been discussed “at length”, yet on these issues of central importance, the EAG’s minutes have nothing to say. The EAG is more than capable of providing detail in its minutes – as it had done in other sections of the same document – but on this matter it was uncharacteristically brief.

But, perhaps it’s not so concerning that we don’t know the EAG’s thoughts on border quarantine. One could argue that the EAG’s discussions were largely moot since NPHET had the final say on policy guidance. The EAG’s position would surely influence NPHET’s discussions – not least because the groups shared senior members – but it was NPHET that would sign off on all communications with the government.

Five days after the EAG’s first meeting, the Chair of the EAG sent a letter to the Chair of NPHET, Tony Holohan, communicating the EAG’s position. NPHET would meet the following day to discuss the border quarantine, the EAG’s position on the matter, and to agree the final policy recommendation.

11 February 2020: NPHET’s 4th Meeting

The outbreak had developed over the week since NPHET’s last meeting. Despite a robust response from the CCP, the virus had spread to most of China’s provinces, demonstrating its ability both to confound policymakers and to move quickly across large landmasses. Of most concern for Ireland, the number of new cases identified outside of China had more than doubled, and there were growing signs of community transmission in Europe.

Having received the EAG’s advice the previous day, it was now NPHET’s turn to address the risk posed by Ireland’s repatriation flights from China. Given the current status of the global outbreak, was some form of border control justified to protect the public health? Were individuals entering the country from other high-risk regions? What did the EAG’s research suggest? Other countries had found themselves in the same situation; how were they managing the risk?

There was plenty to consider. Whether any of it was actually discussed by NPHET, we will probably never know, although it does seem unlikely. The meeting minutes state only the following:

“First meeting was held last week. It was noted that the EAG considered the question posed to them by NPHET last week and have reverted in writing to the NPHET Chair.”

That is all we know about how NPHET, in February 2020, came to the conclusion that Ireland should not implement a border quarantine in the face of a growing international outbreak. Those brief sentences summarised, defined, and ended the matter. The EAG Chair had written a letter to the NPHET Chair and, apparently, the NPHET Chair had decided that it was settled.

Did anyone in NPHET see the letter? Was it forwarded to them, or presented at the meeting for discussion? Did the members of NPHET have the opportunity to review the EAG’s recommendation, or the data and analysis that supported it? Was there any reference to the international experience with border quarantine? Was there any discussion of how this policy would impact the public health? Did any members of NPHET have the opportunity to raise any concerns about this recommendation, or how it was reached?

Was there any discussion at all?

NPHET’s Uncomfortable Relationship with Transparency

NPHET’s meeting minutes contain scant information at the best of times. It is normal for their notes to be wholly insufficient for an outside observer to ascertain what was discussed, the data that was provided, or how decisions were made. This behaviour has been so consistent in NPHET’s minutes that it is, I believe, intentional.

But, this was different. This wasn’t a lack of information about what NPHET was doing; this seemed to be the opposite – confirmation of what NPHET wasn’t doing. No further information had been provided in the minutes, because there was no further information to provide. There was no discussion because the CMO, it seems, had personally decided that there was no need for one.

One must wonder what point there was in assembling a multi-disciplinary group of physicians, officials, and experts, if one individual was going to make decisions on their behalf, and without even consulting them.

Kicking Snow Over a Rope

Leaving the individual decision-makers to one side, we should take a moment to consider the effectiveness of this structure and the process through which these decisions of national importance were being made.

The question at hand was whether the government should issue a recommendation to returning travellers to self-isolate. The government passed the decision to NPHET, and NPHET passed it to the EAG. The EAG – having no one to its left – was forced to make a decision. It decided that the best thing to do, was to do nothing.

A few points stand out.

Firstly, the EAG and NPHET were considering a recommendation to self-isolate (they meant ‘quarantine’ but we’ll use their terminology for now). It being a recommendation to self-isolate, there was no suggestion that the government would be obliged to enforce the policy, or allocate any resources to it. The potential burden that the policy could have put on the government was trivial.

Secondly, the recommendation would have only applied to “returning travellers”. We don’t know what distinguishes a returning traveller from any other – surely all travellers from China would have been just as risky – but we can be confident that the advice would have only applied to a small subset of all arrivals at our border.

Finally, even if the EAG had made the recommendation, NPHET would not have been bound by it. The EAG only advises NPHET, so if NPHET had disagreed with the recommendation for any reason, it could have amended it or dismissed it entirely. And even if NPHET had agreed with the recommendation, it still would not have come into effect until the government had agreed to it too.

Putting those points together and we have the EAG failing to issue a recommendation to NPHET, to issue a recommendation to the government, to issue a recommendation to a small number of people, to self-isolate on arrival from China.

A recommendation to issue a recommendation to issue a recommendation to self-isolate… the stakes could barely have been any lower (for the policymakers – not for the people of Ireland). This was kicking snow over a rope. And the EAG couldn’t manage it.

Had NPHET and the EAG taken their responsibilities more seriously in February 2020, a border quarantine would have been in place long before now. The significance of this point seems to be lost on the media. Once the initial quarantine had been established, and the people had had the chance to see its value, it could have been expanded as the threat from abroad increased. Given that thousands of punters would head off to Cheltenham 6 weeks later, one can’t help but think the first lockdown would have been considerably shorter had Ireland a functioning border quarantine in place at the time.

Or a functioning public health emergency team.

A Case Study in Buck-Passing and Decision Laundering

Tracing this decision on border quarantine, from the government to NPHET to the EAG and back again, reveals a series of errors, omissions and questionable decisions. The most egregious of these was the EAG’s assessment that Ireland should not implement a border quarantine on the grounds that some travellers might be inconvenienced. This decision was unequivocally incorrect from a health perspective, and one doesn’t need a PhD to understand why.

Attempting to prevent a deadly, contagious virus – for which we had neither vaccine nor cure – from entering the population was clearly the correct course of action. Any effort in this direction would have reduced the total viral load to hit the nation, and the malign downstream effects of emergency PPE orders, traumatised health care workers, an overburdened health care system and the interminable lockdowns would not have cascaded through the country. (Had every country in Europe taken the same approach it would have been more successful again, but that is a topic for another day.)

One must also wonder why the decision had even been passed to the EAG in the first place. Surely NPHET – with the CMO, two deputy CMOs, a Chief Clinical Officer and several other senior medics besides – had the skills to work this out. What did they need from the EAG? I could understand if NPHET’s capacity had been stretched and it wanted the EAG to provide some backing analysis, but then, where is the analysis? There is no record of any research being commissioned, performed, referenced or discussed.

Why did the policy only apply to “returning” travellers? Why weren’t all travellers who had been through at-risk areas in the previous 14 days included, as was the case in Australia and New Zealand at the time? Why did it take the EAG 5 days to respond to NPHET’s request? And why was NPHET only meeting once a week when the WHO had warned us that the threat to Ireland was “High” and declared the outbreak a Public Health Emergency of International Concern?

There are so many questions that we could ask but, at a fundamental level, I think they will all lead to the same conclusion. Some people like being in positions of responsibility, but they are less keen on the responsibilities that tend to come with them. I don’t think there was ever an intention to implement any kind of border policy. The whole episode looks like a box-ticking exercise. They passed it around the houses so that responsibility for the outcome couldn’t be attributed to any one individual, and when they had the decision they wanted, it disappeared, down the Tony Hole.

Maybe it was the answer that the government wanted too. Given the way Simon Coveney is behaving in the current border quarantine fiasco, it would hardly be a surprise to find out that he had asked Tony to make the problem disappear. Considering the lack of information in NPHET’s and the EAG’s minutes – which lies in stark contrast to the extensive analysis provided for other matters – it certainly looks as if someone wanted it to go away quietly.

Whatever your position on border quarantine, or on any part of this national catastrophe, I think we can agree that when important decisions are made behind closed doors, by unelected, unaccountable technocrats, staggering levels of dysfunction and incompetence will follow. The people – always the people – will pay the price. One year on, and nothing has changed.