Neil Michael: Under-investment in public health undermines zero Covid efforts

While there is a growing interest in pursuing a zero-Covid strategy, the gaps in public health undermine the likelihood of this working, writes Neil Michael.

The dire state of regional public health departments - this country’s “forgotten frontline” - could hinder our efforts to attain zero covid

Professor Ivan Perry is one of an ever-widening community of academics and professionals in favour of aiming for zero or near zero-Covid.

But University College Cork's Professor of Public Health and other public health experts see a rather large elephant in the room.

It is the continuingly dire state of regional public health departments, or - as some have described them - this country’s “forgotten frontline”.

He bemoans the historic and ongoing lack of both resources for and recognition of the work done by teams in those departments led by Specialists in Public Health Medicine (SPHMs).

These highly qualified specialists, of which there are only around 60 or so working full time, are this country’s first line of defence against pandemics and other infectious disease outbreaks.

While their primary role is investigating complex Covid-19 cases and outbreaks, they also work across a wide number of other areas, including managing regional health intelligence and data, and public health initiatives and advice.

Since last January, however, all other roles have effectively fallen by the wayside and they are all now mainly concentrating on complex contract tracing and managing large outbreaks.

Many are working up to 80 hours a week, and - astonishingly - with far fewer resources now in this wave than they had in the first one.

Take the HSE South East Public Health Department, for example. It looks after a population of 500,000 across counties including Waterford, Wexford, and Kilkenny.

Between March and May last year, they had about 100 full and part-time staff at their disposal and there were 1,000 cases in the region.

But between November and today, there have so far been around 14,000 cases in the same region, yet the department now only has around 50 full and part-time staff.

At the beginning of February last year, they had five SPHMs but they have since lost two of them.

Dr Sinead Donohue, one of the three remaining specialists, says there is also another stark contrast between last March and now.

“Back at the start of this, we would be all over every suspected case in a residential care setting,” she says.

Now? We simply haven’t got the resources anymore to respond to suspected cases in these settings.

“We can only go after confirmed cases, and even then, we are generally having to concentrate on the big outbreaks.”

Worryingly, public health departments all around the country are having to ration the amount of time they spend dealing with smaller outbreaks.

If they can even deal with them at all, they are often only able to advise those involved on what to do to minimise the spread of infection. They don’t have time to go back and make sure staff are doing what they are supposed to do.

As one SPHM told this reporter, the specialists “know full well” their advice is often only partially implemented and that to be effective, they need a more intensive follow-up approach.

And that would mean more resources, which Minister of Health Stephen Donnelly is all too aware has been a historic issue in public health.

"Has regional public health been underinvested in for years? Yes, it has," Mr Donnelly said, speaking to the Irish Examiner yesterday.

"What am I doing about it?

"I have sanctioned a doubling of the workforce, but you can't magic public health specialist out of thin air."

Dr Donohue and other specialists like her, however, make another point: Covid has been dominated by weekly Nphet briefings about deaths, new cases and the “all-important” ICU numbers.

She asked:

Who is asking us what is happening at the local level on a regular basis? 

"Nobody is routinely asking about levels of capacity in our public health departments. The whole narrative is absolutely dominated by what is happening in acute hospitals, and the ICUs.”

Professor Perry, who agrees the narrative has to be shifted back towards regional public health departments, believes the government must set a target to aim for near-zero community transmission and make sure once achieved, it stays there.

“It doesn’t mean there won’t be cases from time to time,” he says, adding a note of caution.

“Not everything will be perfect and not everything will work.

“But it is all about having a range of different measures and multiple layers of protection all working together.”

He says the first thing is to carry on the current “crushing the curve” phase and to try and get to a stage where there are only around ten to 30 cases a day.

And it is then that Ireland will need the services of what he describes as a “world-class test, trace and isolate infrastructure”.

There is, however, a flaw.

As he sees it, we don’t actually have one.

“More than a year into this pandemic, public health departments are having to cope with a bigger workload with fewer resources,” Dr Donohue says.

“If anybody seriously wants to implement a successful near-zero Covid policy in Ireland, they are going to have to stop pussyfooting around the resources issue.

“ICUs are the last line of defence, and we are the front line of defence.

“The powers that be in health and in government need to take our work more seriously, and give us what we need for any serious Covid strategy to work, never mind one that sets as its target near zero.”