Obstacles to Public Health that even Pandemics cannot Overcome: The Politics of Covid-19 on the Island of Ireland

The relationship between politics and public health is increasingly evident as governments throughout the world vary in their acceptance and implementation of technical guidance in the response to the SARS-CoV-2 pandemic. This paper reports a qualitative study of public health policies for Covid-19 in Northern 226 Irish Studies in International Affairs Ireland (NI) and the Republic of Ireland (RoI) across a timeline emphasising the first wave of the pandemic (February to June 2020). Inter-jurisdictional commitments for health as contained in the Good Friday Agreement provide a framework for cooperation and coordination of population health on the island of Ireland. This study of north-south cooperation in the response to Covid-19 applies ten indicators from the Oxford Covid-19 Government Response Tracker (OxCGRT) codebook to establish if cooperation and policy alignment of key public health measures are evident in the Northern Ireland Assembly and Government of Ireland responses. The study concludes that notwithstanding the historical and constitutional obstacles to an all-island response to Covid-19, there is evidence of significant public health policy alignment brought about through ongoing dialogue and cooperation between the health administrations in each jurisdiction over the course of the first wave of the pandemic.

Ireland (NI) and the Republic of Ireland (RoI) across a timeline emphasising the first wave of the pandemic (February to June 2020). Inter-jurisdictional commitments for health as contained in the Good Friday Agreement provide a framework for cooperation and coordination of population health on the island of Ireland. This study of north-south cooperation in the response to Covid-19 applies ten indicators from the Oxford Covid-19 Government Response Tracker (OxCGRT) codebook to establish if cooperation and policy alignment of key public health measures are evident in the Northern Ireland Assembly and Government of Ireland responses. The study concludes that notwithstanding the historical and constitutional obstacles to an all-island response to Covid-19, there is evidence of significant public health policy alignment brought about through ongoing dialogue and cooperation between the health administrations in each jurisdiction over the course of the first wave of the pandemic.

IN TRODUCTION
Political systems are the means through which the science of public health achieves its objectives, and population health is central to the realisation of economically and socially viable communities. SARS-CoV-2 has highlighted the interdependence of this relationship, not least as political regimes and health systems struggle to keep pace with an unprecedented level of scientific development. Multilateral actors like the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) have endeavoured to harness the pace of scientific insight for the prevention, treatment and containment of the spread of Covid-19. However, governments have varied-across and within countries-in the technical guidance that they have adopted and when they have adopted and implemented it. 10 Italy was one of the first countries in the European Union (EU) to introduce large-scale public health interventions like social distancing, border closures, school closures and society-wide lockdown measures. Spain and other countries, including Ireland, followed suit from mid-March. 11 Other countries, such as Sweden, responded less invasively with no general lockdowns and 10 Thomas Hale et al., Tracker from Blavatnik School of Government' (Oxford, 2020 an emphasis on slowing, rather than stopping, the pandemic. 12 Whatever the measures adopted by individual countries, they have prompted widespread debate with policymakers balancing disease prevention with policies to mitigate wide-ranging socio-economic disruption. 13 It has been well-established that public health policy is almost always contingent on the socio-political landscape. 14 Politics involves trade-offs between competing societal and constituency values and priorities, and science is very often in competition with these other factors. 15 Disease outbreaks have long been the subject of political analyses, including HIV and AIDS; 16 the West African Ebola virus outbreak; 17 the Zika virus outbreak in Brazil in 2015 18 and more recently, emerging examples of the relationship between politics and  Analysis of the political decisions that have resulted in particular response pathways for public health in the context of Covid-19 is critical to our understanding of disease progression in different jurisdictions, but also to how we will respond to future outbreaks. 20 This paper reports a qualitative study of a range of public health policies for Covid-19 in Northern Ireland (NI) and the Republic of Ireland (RoI) across a timeline emphasising the first wave of the pandemic (February to June 2020). It endeavours to establish if inter-jurisdictional commitments for 12 Jonas Ludvigsson, 'The first eight months of Sweden's Covid-19 strategy and the key actions and actors that were involved', Acta Paediatr 109 (12) (2020), 2459-471. 13 Ukertor G. Moti and Daniel T. Goon, 'Novel coronavirus disease: a delicate balancing act between health and the economy', Pakistan Journal of Medical Sciences 36 (2020), 134-37. 14 John W. Kingdon, Agendas, alternatives, and public policies (Boston, 1984) health as contained in the 1998 Belfast / Good Friday Agreement (hereafter 'The Agreement') have led to coordination and cooperation on the island of Ireland. It is a part of a larger project which seeks to disentangle psychological, behavioural, media and governmental responses to  CON TEXT AND INSTI T U TIONS The first two cases of Covid-19 were identified at the end of February 2020; one in NI (27 February) and one in the RoI (29 February). The island of Ireland was partitioned in 1920 under the Government of Ireland Act along a contested land border between the RoI, an independent state, and NI, a constituent part of the United Kingdom. The partition line, known as 'the border', was drawn along county lines in 1922 with six counties in NI and twenty-six counties in the Irish Free State (subsequently the Republic of Ireland in 1948). 22 The border is a contested political space that has been marked by inter-community strife, particularly between 1968 and 1998. This violent conflict between Protestant unionists (loyalists) who desired the province to remain part of the United Kingdom of Great Britain and Northern Ireland, and the mostly Roman Catholic nationalist (republican) community who favoured unity with the RoI, resulted in almost four thousand deaths and forty-five thousand injured in bombings and shootings. 23 Relative to population size (1.8 million in 2019), this era marked the most intense conflict in western Europe since the Second World War.
The 1920 Government of Ireland Act had conceived the establishment of a 'Council of Ireland' with membership from both the Parliament of Northern Ireland and the Oireachtas, the Parliament of the Irish Free State, but this never came to fruition. 24  John Coakley 26 suggests that a more benign acceptance of the reality of partition towards the latter decades of the twentieth century has made north-south cooperation in a range of policy areas more feasible. While the Anglo-Irish Agreement in 1985 initially generated opposition, it has since been credited with promoting greater acceptance of the need for cross-border cooperation. 27 The Good Friday Agreement is the peace agreement that effectively ended the conflict in NI and a sizable majority of the population in both jurisdictions supported the Agreement in referendums. It is also an international agreement registered with the United Nations. A democratically elected Assembly in NI, with legislative and executive authority on a devolved basis, was a key provision of the Agreement. Strand Two emphasised cross-border cooperation and the establishment of a North-South Ministerial Council (NSMC) to develop, …consultation, co-operation and action within the island of Ireland, including through implementation on an all-island and cross-border basis-on matters of mutual interest within the competence of Administrations, North and South. 28 However, Deirdre Heenan 29 contends that comparative analyses of health outcomes, so frequently a feature of policy and practice in international health, are 'actively discouraged' between administrations, north and south. The absence of comparable data or structures to facilitate cross-border comparison and shared learning tend to belie high-level commitments to 'co-operation and action within the island of Ireland'. Attempts to draw comparisons between policy responses to Covid-19 across the four nations of the UK have fallen foul of incomparable structures and data reporting  Several plenary meetings have been held during the Covid-19 crisis, health 33 being one of the key areas earmarked by the Agreement for cross-border cooperation with an emphasis on reaching decisions by consensus. 34 At jurisdictional level, these commitments are acted upon by the Public Health Agency in NI, which is responsible for public health functions, notably concerning communicable disease control, overseen by the Chief Medical Officer in the Department of Health. In the RoI, the National Public Health Emergency Team (NPHET) is responsible within the Department of Health for the provision of expert advice and guidance to government and the health service in response to  Cross-border cooperation necessitates civil service cooperation in the areas designated by the Agreement. The implementation bodies 36 also work closely with relevant civil service departments to facilitate extended cross-border administrative cooperation, 37 which in the case of Covid-19 refers to cooperation between the offices of the chief medical officers in each jurisdiction.
Both governments have been required to monitor cooperation in civil service departments to ensure that it is prioritised in crucial areas, but it is goodwill and good relationships between civil servants on both sides that have copper-fastened the remit of the NSMC and Secretariat. 38 The Agreement has been a catalyst for inter-jurisdictional cooperation funded by 30 Emily Cameron-Blake et al., Variation in the response to Covid-19 across the four nations of the United Kingdom: Blavatnik School Working Paper (Version 1.0) (Oxford, 2020). 31 Chris Ham, 'Integrated care in Northern Ireland, Scotland and Wales: lessons for England', available at: https:// www.kingsfund.org.uk/publications/integrated-care-northern-ireland-scotland-and-wales (13 April 2021). 32 Mark Dayan and Deirdre Heenan, Change or collapse: lessons from the drive to reform health and social care in Northern Ireland (London, 2019), available at: https://www.nuffieldtrust.org.uk/research/change-or-collapselessons-from-the-drive-to-reform-health-and-social-care-in-northern-ireland (13 April 2021). 33 The other areas are: Agriculture; Education; Environment; Tourism and Transport. John Coakley, The northsouth institutions: from blueprint to reality (Dublin, 2002). 34 Coakley, The north-south institutions. 35 Patrick O'Sullivan, Forty years of public health medicine in Ireland 1976-2016(Dublin, 2016. 36 The implementation bodies are: Inland waterways; Special EU programmes; Food safety; Trade and business development; Language; Foyle, Carlingford and Irish Lights. Coakley, The north-south institutions. 37 Tannam, 'Cross-border co-operation'.  the EU, intergovernmental and philanthropic agencies. 39 Still, the cross-border administrative relationship retains many challenges and political obstacles. Most recently, the UK's decision to leave the EU, more commonly known as 'Brexit', has reignited tensions. The invisible line that marks partition between the RoI and NI is now the sole land border between the UK and the EU. Brexit, which the majority of citizens in NI did not support (56% voted to remain), has made the border visible again. 40 The threat of a resumption of violence has been of considerable concern since the Brexit vote. At the time of writing, a trade deal struck between the EU and the UK has maintained a soft border on the island of Ireland but tensions are once again heightened. The UK-EU trade deal presents challenges for the unionist community as, while NI remains part of the UK's customs territory for practical purposes and the maintenance of a soft border, it is part of the customs and regulatory domain of the EU. The outbreak of Covid-19 in Ireland coincided with uncertainty around the possible imposition of a hard border on the island, resulting in a resurgence of conflict narratives directing Northern Ireland's territory towards either loyalist or republican preferences. 41

North-south cooperation for health
Piecemeal attempts have been made, to establish cross-border dialogue for public health, before the Agreement, generally driven by individuals and professional bodies rather than by the initiative of statutory authorities for health. The Institute of Public Health in Ireland is one such example, with an all-island remit to inform policy and practice for public health. Equally, informal gay community networks joined forces during the initial decade of Acquired Immune Deficiency Syndrome (AIDS) to establish the Irish AIDS Initiative, a body of activists dedicated to an all-island strategic approach to HIV. 42 This objective was never met, but during the early years of the AIDS  Interjurisdictional cooperation for health, tourism and the development of inland waterways has been supported at a political level by the Anglo-Irish Intergovernmental Conference, a result of the Anglo-Irish Agreement, but this body had a consultative function only. 43 More successful collaborations for health have been realised since the Good Friday Agreement, not least in cancer research and training, with the establishment of the All-Ireland Cancer Consortium (AICC) in 1999. The AICC has improved cancer services and better outcomes in both jurisdictions. 44 One of the more successful inter-jurisdictional collaborations was the joint response to the outbreak of Foot and Mouth disease in 2001 45 and this standard has been much quoted by commentators promoting an all-island response to

North-south cooperation for Covid-19
The Good Friday Agreement includes straightforward, structured institutional collaboration for north-south cooperation on health. The NSMC meets in respect of the health sector to 'make decisions on common policies and approaches in areas such as accident and emergency planning, cooperation on high technology equipment, cancer research and health promotion. ' 47 Importantly, north-south cooperation on agriculture has meant that both territories constitute a 'single epidemiological unit' (SEU) for disease control relating to animal health. 48 While the Institute for Government, a UK-based think tank, claims that 'similar practical considerations apply to the spread of human diseases such as Covid-19' this has effectively been ruled out by political leaders in both jurisdictions for several reasons that will be consid-  While an all-island response to the pandemic has not proved possible, a Memorandum of Understanding (MoU) was signed between the Departments of Health in the RoI and NI on 7 April 2020 to strengthen north-south cooperation on the public health response to the Covid-19 pandemic. The MoU commits the Northern Ireland executive and the Irish government to 'coordination and cooperation' in the response to Covid-19, with the active involvement of health administrations to protect, as paramount, 'the lives and welfare of everyone on the island…and no effort will be spared in that regard'. 52 Notably, the memorandum does not create legally binding obligations on either government or agency, but there is clear evidence of dialogue and cooperation between ministers and the chief medical officers who held weekly teleconferences to update each other and 'ensure mutual ongoing understanding'. 53

METHODOLOGY
The primary objective of this study was to track public health policy for Covid-19 in NI and the RoI across a timeline (27 February to 30 June 2020) that captured the first wave of the pandemic in each jurisdiction. The study relied on policy documents in the public domain from: 1. The Irish government 49 Institute of Government, 'North-south co-operation on the island of Ireland' (2020); P. Leahy, 'Why is there no serious engagement on joint north-south approach to Covid?' Irish Times, 28 January 2021.  Directed qualitative content analysis uses existing theory or prior research to organise data collection, while supporting comprehensive and organised reading of texts based on specific questions. 55 The method is frequently applied to policy research as it facilitates the identification of themes, subthemes and patterns that generate new understanding of a policy phenomenon. 56 Ten indicators from the Oxford Covid-19 Government Response Tracker (OxCGRT) codebook directed this study's data collection in two policy groups: 1. Containment and closure policies; and 2. Health system policies. 57 As NI is a region within the United Kingdom of Great Britain and Northern Ireland, a public health policy timeline in Great Britain, specifically England vis-à-vis the Westminster parliament, was also undertaken.
We stored all policy texts in an Excel spreadsheet (Version, 2019) in chronological order by OxCGRT theme. A stakeholder consultation followed this on 5 November 2020 with thirty public health specialists, academics and policymakers from both jurisdictions to support analysis from the practitioner perspective. The data from this consultation, which was hosted online due to coronavirus restrictions, supported thematic analysis with important practitioner insights but was generally limited in application due to the low attendance of policymakers and public health specialists from NI. The data revealed two key meta-themes: 1. Levels of policy alignment with multilateral actors in NI and the RoI, and 2. Levels of cross-border policy collaboration  between the RoI and NI. This paper presents data supporting meta-theme 2 with cross-case and within-case analysis of policy alignment and divergence between NI and the RoI across ten OxCGRT indicators. This paper examines the introduction of policy responses to the Covid-19 pandemic on the island of Ireland. The comparison between the two jurisdictions is limited to the top-line features of particular interventions. It is not the purpose of this study to identify how effectively or ineffectively any particular intervention was applied at an operational level. Comparative policy analysis moves beyond each case's specifics to arrive at broad themes and patterns across and within cases, settings and periods. 58 As such, the comparative design of this study does not analyse the detail similarities or differences of specific public health policies, but assesses whether and to what extent the response to Covid-19 during the first wave illustrates interjurisdictional alignment or nonalignment.

COMPARING CON TAINMEN T AND HEALTH POLICY RESPONSES TO COVID-19 IN NI AND THE ROI
The following containment measures included in this study are: 1. closing schools and universities; 2. workplace closing; 3. cancelling public events and mass gatherings (2 separate OxCGRT indicators); 4. policies regarding the use of public transport; 5. lockdown or shelter-in-place policies, and 6. restrictions on internal movement. Each of these containment policies will be considered separately using a colour-coded key: Red indicates policies in England as directed by the Westminster Parliament and in some cases applied UK-wide; Green indicates policies in the RoI, and yellow indicates containment and health policies in NI.

Closing schools and universities
The ECDC coronavirus guidance suggested that school closures are not warranted in the containment phase of an outbreak unless as a consequence of widespread virus transmission. 59 After a schoolboy in Dublin tested positive for Covid-19, the school closed for 14 days from 1 March 2020 and the taoiseach announced the closure of all schools on 12 March. On the same date, the UK prime minister announced that schools and colleges would not close in the UK. 60 However, individual institutional authorities began to close schools and colleges from 20 March in England, Wales and Scotland, while NI formally closed all educational institutions on 23 March. 61 While the first minister and deputy first minister jointly announced that the executive would not be moving to close schools on 12 March, Sinn Féin 62 changed position the following day. NI's minister for education, Peter Weir (Member of the Legislative Assembly), emphasised during Parliamentary Questions that the decision to keep the education sector open was not a political decision. Instead, it was a decision he took on the chief medical officer's advice, and this policy reflected Westminster policy and the advice of SAGE. 63 Some schools maintained by the Catholic sector in NI disregarded the minister's decision, closing their doors from 18 Marchsee Figure 1. Six Nations rugby fixture against Italy due to be played on 7 March 2020 in Dublin. However, Italian supporters still travelled to Dublin in large numbers that weekend. 67 In the UK, the Cheltenham Racing Festival with 60 to 70,000 racegoers attracted significant numbers from across the island of Ireland. On 9 March, the Irish government and the Northern Ireland assembly cancelled the St Patrick's Day parades usually celebrated on 17 March. Further restrictions on mass gatherings were announced in the RoI on 12 March with workers urged to stay home if possible, while the UK cancelled mass gatherings within a few days. By the week commencing 23 March, it became clear that the spread of Covid-19 was gathering momentum, prompting the introduction of 'lockdown' or 'shelter-in-place' policies in each jurisdiction within days-see Figure 3.  Subsequently, on 23 March, Johnson announced lockdown or shelterin-place policies, which was the same day that both the Northern Ireland executive and the Irish taoiseach, Leo Varadkar, introduced lockdown measures-see Figure 4.

Public transport
The UK prime minister urged the general public to avoid public transport with the London Underground reducing its service during the week commencing 16 March 2020 (Department of Health and Social Care and Public Health England, 2020). NI and the RoI adopted similar measures within one day of each other, but a north-south transport service was maintained, albeit on a reduced service basis-see Figure 5.

Restrictions on internal movement
During the lockdown, there were differences in each jurisdiction in terms of internal movement. The RoI imposed a distance-from-home limit of two kilometres on 27 March, extended to five kilometres on 1 May 2020. The UK, including NI, did not specify a distance-from-home limit, but exercise was limited to one form a day with people urged to otherwise stay in their homes. 69 In effect, this meant that people living in NI were not affected in how far they could travel, but people in the RoI were-see Figure 6.

Face masks
The benefits of wearing face masks appear to outweigh any potential harms when Covid-19 is spreading in a community, but the policy for face masks has been one of the more controversial measures. 73 In RoI, it became mandatory to wear a face mask on public transport in all jurisdictions between June and July, and it became compulsory to wear a face mask in all enclosed spaces on 10 August-see Figure 8.

Testing
This study's review of testing policies between NI and the RoI has largely defied comparison. The pace at which guidance and case definitions changed, coupled with local differences in interpretation and system capacity, and missing data in both jurisdictions, have placed comparisons beyond the scope of this study. While the number of tests conducted is a poor indicator of disease management overall, it is one of the few areas with at least partially complete data to illustrate alignment or nonalignment in the policy approach. Insofar as it has been possible to determine, given the extent of missing testing data from RoI 74 and NI, 75 particularly in the early weeks of March, data available for each jurisdiction on the numbers of tests for Covid-19 per 100,000 population appear to suggest that the RoI tested more people across our timeline than NI. However, it is unclear if the reported data includes home testing kits used in the NI and the UK. One study has further challenged claims by the Department of Health 76 and the Health Service Executive that Ireland ranked among the 'top tier' in the world in terms of the number of tests conducted. 77 In the first month, both jurisdictions conducted testing in hospitals 78 with the RoI moving to some limited testing in people's homes provided by the ambulance service from the week of 9 March. 79 Neither NI nor the RoI had the system capacity to maintain the original intention to provide widespread community testing of those with symptoms and from 12 March in NI and 24 March in the RoI, the eligibility threshold for testing was lowered. 80 While the timeline of divergence in case definition has proved very difficult to track, differences indeed emerged in policy for testing asymptomatic close contacts, as advised by the ECDC, from 18 May onwards when the RoI reported that testing capacity was 'exceeding demand'. 81

DISCUSSION AND CONCLUSION
Public health and containment policy responses to Covid-19 in the RoI and NI have been broadly aligned, including in the pace of their introduction. However, there are also some notable exceptions with policy for testing generally defying comparative analysis in this particular study. This issue, in itself, warrants independent investigation, while the challenges encountered in comparing testing policies reinforce longstanding concerns around data and structures that do not support interjurisdictional comparison.
The MoU committed each jurisdiction to ensure that every possible effort to cooperate and coordinate the response to Covid-19 would be jointly undertaken. 82 While specific similarities and differences are evident, comparative policy analysis that moves beyond such specifics broadly points to policy alignment and complementarity in most public health indicators selected. The MoU did not create legally-binding obligations in either jurisdiction. Still, Hansard and Departmental minutes of meetings point to regular dialogue between the Public Health Agency in NI and NPHET in the RoI and weekly dialogue between the CMOs on a range of cross-border Covid-19-related matters. Some differences in the number of tests conducted appear to suggest policy divergence at the point at which the first wave began to subside, but workplace closures, while again defying direct comparison, reveal temporary differences of one week in NI's enactment of workplace closures in early March. This divergence is significant as the prevention of Covid-19 is time-sensitive, with modelling demonstrating that an immediate response has a prolonged effect on Covid-19 related mortality. 83 Similarly, the first case of Covid-19 was identified on 27 February in NI and on 29 February 2020 in the RoI, when 31 and 48 cases had already been identified in Great Britain. 84 As the disease gained momentum in March 2020, the four regions of the UK (England, Scotland, Wales and Northern Ireland) implemented similar policies simultaneously, 85 notwithstanding that, by that time, Great Britain's Covid-19 caseload was significantly more advanced. Differences in the rate of testing and the slightly slower pace of workplace closures in NI may be partly explained by the financial dependence of the region on the Treasury in the United Kingdom, with devolution resulting in limited reserves and restricted borrowing from international markets, irrespective of the social policy challenges faced by the Assembly Executive at Stormont. NI has been described as an example of multi-level governance, with the EU highly relevant to its financial structure. Brexit has heightened concerns and fears about economic consequences for the region 86 and this, in turn, may have exacerbated pressures on health system capacity throughout the Covid-19 crisis.
The school closure case reveals a more cautious and conservative tendency in the RoI with school closures announced on 12 March 2020, contrary to 83 ECDC guidance. 87 This particular policy area spotlighted Northern Ireland's political divisions, with some schools under Catholic-sector management closing their doors in response to RoI policy, while republican parties aligned their position with Dublin and unionist parties with London. 88 Other policy indicators point to inter-jurisdictional alignment in the joint cancellation of St Patrick's Day parades on 9 March 2020; lockdown / shelter-in-place policies (23 March 2020) and restrictions on internal movement, public transport, social distancing measures (although NI made a brief deviation to 1-metre in June 2020 before reverting to 2-metres) and the mandatory wearing of face masks. While it is tempting to suggest that this is evidence of cross-border cooperation, this study has been limited to reviewing the top-line features of particular interventions and can make no such claim. Coincidence is, however, an unlikely explanation for such close alignment given the frequency of dialogue between the two administrations.
Goodwill, relationships between civil servants and inter-jurisdictional cooperation funded by the European Union, intergovernmental and philanthropic agencies in a range of social policy areas, have served the interests of peace and social well-being on the island of Ireland in the last two decades. 89 The frequency with which ministers, NPHET and the PHA report dialogue with each other is a further testament to continued efforts to cooperate and collaborate in the spirit of the Agreement. But challenges and political obstacles in the cross-border administrative relationship endure, and these have been foregrounded in the political response to Covid-19.
The island of Ireland is an SEU for the containment of the spread of animal disease, as articulated by the Northern Ireland and Ireland Position Paper. 90 When viewed through a purely neutral public health lens, a similar all-island response to Covid-19 appears eminently sensible. However, the public health narrative has defaulted to a purist position that largely ignores the well-established principle in which public health policy is contingent on the socio-political landscape, 91 with similar national and international case 87 ECDC, Guidelines for the use of non-pharmaceutical measures. 88