We have the knowledge and the skills to do it but we just don't have the numbers
In the autumn of 2020, as Ireland's second wave of Covid-19 gathered force, the country's eight public health departments found themselves asked to repeat a heroic effort they had already made once — without the people, systems, or structural reforms needed to sustain it. Public health work is invisible in ordinary times, but in a pandemic it becomes the architecture of everything: contact tracing, outbreak investigation, transmission mapping, risk assessment. Dr Ina Kelly of the HSE Midlands was warning that this architecture was crumbling not from sudden disaster, but from years of quiet neglect meeting a moment that demanded more than neglect could give.
- Ireland's public health departments entered the pandemic already understaffed, and by autumn 2020 exhausted staff were being asked to manage a rising second wave with no structural reinforcement in sight.
- The detective work of outbreak control — mapping contacts across workplaces, schools, and homes, conducting risk assessments case by case — requires trained, present, and rested people, and those people were burning out or leaving for New Zealand and Australia.
- Reforms designed to create larger, consultant-led public health teams had been promised for July but never delivered, leaving a critical gap that temporary redeployments and general HSE recruitment could not fill.
- The HSE pointed to its winter plan and 4,700 new hires across the health service, but Dr Kelly's warning cut deeper: without structural investment in public health itself, the system could not suppress transmission to levels that would allow restrictions to ease.
- The consequence was not only medical — if public health failed to hold the line, hospitals risked being overwhelmed and the restrictions defining Irish life in 2020 would simply continue, with no targeted path out.
In September 2020, as Covid-19 cases climbed again across Ireland, the eight public health departments forming the country's first line of defence were already running on fumes. Dr Ina Kelly, a public health medicine doctor with the HSE Midlands and chair of the Irish Medical Organisation's Public Health committee, was sounding an alarm that few seemed to be hearing.
Public health work is invisible until it matters. When a Covid-19 case is confirmed, it is public health — not the contact tracing centre — that does the real detective work: investigating the virus's origin, mapping contacts across workplaces, schools, and homes, conducting risk assessments, and deciding what further action is needed. It is meticulous, exhausting work requiring data analysts, surveillance scientists, nurses, and doctors who are trained and not already depleted.
During the first wave, public health had kept Irish hospitals from being overwhelmed. But by autumn the cost was showing. Staff were tired. Reforms that were supposed to introduce consultant-led public health teams across the country had been scheduled for July — and October arrived without them. Doctors trained in public health were leaving for New Zealand and Australia. Temporary redeployments were not filling structural gaps.
Dr Kelly's warning was direct: without suppressing transmission to very low levels, normal life could not resume. But with proper resources, restrictions could actually be lighter and more targeted. The knowledge and skills existed — what was missing was the people, the systems, and the investment.
The HSE pointed to its winter plan and nearly 4,700 new hires across the health service that year, with over 200 temporary resources in public health departments. Dr Kelly's point, however, was structural. Temporary measures did not address the chronic underfunding of public health itself. The July reform was not optional — it was critical. The virus was not waiting, and neither could Ireland afford to.
In September 2020, as Covid-19 cases began climbing again across Ireland, the eight public health departments that form the country's first line of defence against infectious disease were running on fumes. They had entered the pandemic already short-staffed and under-resourced, and nothing had changed in the months since. Dr Ina Kelly, a public health medicine doctor working in HSE Midlands and chair of the Irish Medical Organisation's Public Health and Community Health committee, was sounding an alarm that few seemed to be hearing.
The work of public health is invisible until it matters. When a case of Covid-19 is confirmed, it is not the contact tracing centre that decides what happens next—that centre handles testing and movement restrictions, but the real detective work falls to public health. They investigate where the virus came from. They map the contacts, often dozens per case, and trace those contacts across multiple settings: workplaces, schools, homes, shops. For each potential exposure, they conduct a risk assessment. They determine whether further action is needed. They do this not to blame anyone, but to understand the virus's path and to stop it from spreading further. It is meticulous, exhausting work, and it requires people—data analysts, surveillance scientists, nurses, doctors—who are trained, present, and not already burned out.
When the first wave hit Ireland in spring, public health had managed to keep hospitals from being overwhelmed. Intensive care units that colleagues in Northern Italy and New York feared would be inundated never reached crisis. Public health had done that. But the cost was already visible by autumn. Staff were tired. The planned reforms that were supposed to introduce larger, consultant-led public health teams across the country had been scheduled for July. October arrived, and it still had not happened. The government had deprioritized public health restructuring when the pandemic arrived, pushing it aside in favour of immediate crisis response. Now the crisis was not receding; it was accelerating.
Dr Kelly explained the bind plainly. Public health had come into this pandemic already under strength. The lack of a consultant contract for public health specialists made it nearly impossible to recruit or retain people in the field. Doctors trained in public health were leaving for New Zealand and Australia. The temporary redeployments that had helped during the first wave were not filling the structural gaps. The contact tracing centre, while useful, did not replace what public health actually did. And now, with cases rising and energy levels dropping, the department was being asked to repeat a performance that had already stretched it to its limit.
The stakes were not abstract. If public health could not suppress transmission to very low levels, normal life could not resume. The restrictions that had defined 2020 would continue. But those restrictions could actually be lighter, could be more targeted, if public health had the resources to do its job properly. The knowledge was there. The skills were there. What was missing was the numbers—the people, the systems, the investment. Without it, Dr Kelly warned, the public and the economy were at risk. This was not just a problem for public health workers. It was a problem for everyone.
The HSE responded to the warnings by pointing to its winter plan and noting that it had recruited almost 4,700 extra staff across the health service that year. It also noted that over 200 temporary resources were currently in place in public health departments. But Dr Kelly's point was different. Temporary resources and general recruitment did not address the structural underfunding of public health itself. The reform that was supposed to happen in July was not a nice-to-have. It was critical, and it needed to happen immediately. The virus was not waiting for the end of the year. Neither could Ireland's public health system afford to.
Notable Quotes
We came into this pandemic already under strength. The plan was to introduce larger, consultant-led public health teams in July this year but that has not happened.— Dr Ina Kelly, public health medicine doctor, HSE Midlands
This is our emergency system for pandemic control and it's creaking. Everyone is worn out.— Dr Ina Kelly
The Hearth Conversation Another angle on the story
Why does it matter that public health departments were understaffed before the pandemic even arrived?
Because you can't suddenly build capacity in a crisis. Public health is detective work—tracing contacts, assessing risk across multiple settings, understanding transmission patterns. That takes trained people who know the system. You can't hire and train them overnight.
But didn't the contact tracing centre help fill that gap?
It helped, but it's not the same thing. Contact tracing is one piece—testing, telling people to isolate. Public health does the outbreak control. When a case is complex, when contacts span multiple settings, it all comes back to public health. The centre doesn't replace that work.
Dr Kelly mentions that the first wave didn't overwhelm hospitals. Wasn't that a success?
It was, but at a cost. Public health managed it, but the staff were already stretched. By autumn, they were exhausted. And now cases were rising again, but the energy and resources hadn't improved. They were being asked to do the same thing again with less left in the tank.
What's the deal with the consultant contracts she keeps mentioning?
It's about retention and recruitment. Without proper consultant-level positions, you can't attract or keep specialists. Doctors trained in public health were leaving for Australia and New Zealand. You lose expertise, you lose continuity, and you can't train the next generation.
Is this just about public health workers being tired, or is there a bigger problem?
It's both. The tiredness is real and it's dangerous—mistakes happen when people are exhausted. But the bigger problem is that public health is the system that keeps transmission low enough that society can function. If it fails, hospitals get overwhelmed, restrictions stay in place longer, the economy suffers. It's not a specialist problem. It's everyone's problem.
What would have actually fixed this?
The reforms that were supposed to happen in July—larger, properly staffed teams with data analysts, surveillance scientists, nurses, doctors, all working under consultant leadership. That wasn't a luxury. It was the minimum needed to handle what was coming.