April the 18th, 2020 - Just what has the coronavirus pandemic taught this leading (yet ever curious) Croatian scientist so far? Igor Rudan lists ten things he's learned since the epidemic began.
1) It taught me that people don’t have the faintest awareness of just how much of a dangerous disease flu actually is.
Influenza must have been largely responsible for the horrendous pestilence among American Indians, Aztecs, Mayans, Incas and Australian Aborigines when they came into contact with the first European colonists. The "Russian flu" ravaged the years 1889 to 1890, had the antigenic composition of H3N8 (or H2N2) and killed one million people at a time when the world's total population was only about one and a half billion people in total.
Then, "Spanish flu" was the worst flu of all. It struck an exhausted, hungry, and deployed humanity at the end of World War I, between 1918 and 1920, and had the H1N1 antigenic composition. It probably killed up to 75 million people at the time when the total population was 1.8 billion, and had a significantly higher mortality rate in the community than this new coronavirus has. Asian flu then plagued the world from 1957 to 1958. It had the antigenic composition of H2N2, killing more than 3 million people directly and indirectly at a time when there were 2.9 billion people on Earth. Finally, Hong Kong flu toured the world from 1968 to 1969, had H3N2 antigens, killing more than three million people directly and indirectly at a time when there were 3.5 billion people on Earth in total. Today, even with the vaccination of the most vulnerable among us who might die, the flu continues to kill 250,000 to 650,000 people a year. It does so to a lesser extent directly (by causing respiratory symptoms) and more indirectly (by the exacerbation of pre-existing diseases in the elderly).
In Italy, according to properly conducted research and calculations, which took into account both direct and indirect deaths, influenza has been killing 7,000 to 24,000 people a year over the last decade. In the USA, the flu takes at least 20,000 to 50,000 lives each year. In both cases, these figures are valid even with the vaccination of vulnerable groups of people. If those people were not vaccinated, that figure would be significantly higher.
2. I have learned that people are quick to lose their fear of everything that is well known to them, even if they shouldn’t, but they have an overwhelming fear of everything that is completely unknown to them.
It's difficult to explain just how people have been able to "get used" to flu mortality to such an extent that they don't even bother to vaccinate against it when they can, but now every coronavirus case in every country is being reported as if it’s the "black plague" once again. Influenza is predominantly a serious illness, which pins every infected person to their beds for a few days. COVID-19, caused by the new coronavirus, is a disease that has a wide range of symptoms. Globally, 90 percent of those infected, of which there are currently 60,000 active cases, are classified as having "mild symptoms" and only 10 percent of them are classed as "severe or critical". However, the intense focus of some media on the "tropism" of coronavirus for the pulmonary alveoli, and not just the bronchi, results in a very serious clinical picture in the most severe cases of COVID-19, as well as the fact that COVID-19 causes lung problems in all patients, whereas that occurs with only maybe one-fifth of those infected with the flu. This, combined with only the most severe cases, doesn’t provide the correct impression of how relatively dangerous these two diseases actually are.
As I said, for an epidemiologist, the most dangerous one is the one which kills more people. For now, that’s still the flu, even with vaccinations. The flu has probably killed an average of about 300,000 people or more over the past few years, regardless of vaccination. This new disease, COVID-19, caused 5,000 deaths after three months of spread. There will be significantly more deaths when the pandemic spreads across the globe, but for now, the question remains whether or not it will reach flu’s level. But I see that these days, because of the huge fear of something unknown, many people in Croatia can't see, hear, and somehow just can't understand that.
3) I have learned that even the most reasonable and intelligent people will easily mix up apples and cherries when they don’t have enough experience in a particular field.
The current estimates of the mortality rate from coronavirus represent a basket of apples and cherries mixed together. When coronavirus sweeps through hospitals, among people who are already unwell and who have issues, it can kill one person out of every 20, maybe out of every 10 or even out of every 5, depending on how many cases of infection in the hospital ward occurred in people who were already suffering from serious illnesses and how old they were. But when the disease is spread among a healthy population, it kills about one person in every hundred or two hundred, and maybe even less than that.
At the beginning of an epidemic, most of the people who die will have been infected in hospitals, so, the death rate among those infected will seem very high. Over time, the vast majority of cases will come from the community, so the death rate will begin to approach this lower value, for example; one death in every one hundred or two hundred infected people. In doing so, the overall potential of the virus to do harm to the entire nation depends significantly more on its spread in the community than it does on it killing people in hospitals. Therefore, the current death rates at the beginning of a pandemic should not be mapped to entire nations and their populations. But even that, it seems, isn’t an easy thing to explain these days.
4) I have learned that, thanks to a Croatian invention - quarantine - humanity is much safer from biological dangers today.
When the coronavirus epidemic erupted in Wuhan and met the local population, which was quite unprepared, on January the 16th, 2020, they had 500 newly confirmed cases in their hospitals, which meant that there were at least several times more real cases out there in the community. Then, on January the 19th, nearly 1,000 newly confirmed cases were recorded. Then, on January the 21st, another 1,500 newly confirmed cases were recorded in hospitals. Well, on January the 23rd, 2,700 new cases were confirmed in just one day, and they had cases in just about every one of their over 30 provinces. The number of deaths in those days had already begun to be measured in four digits. The epidemic had totally
escaped control. And then a plan was adopted, which was implemented in a totalitarian way. On January the 23rd, 2020, people were barred from entering or exiting Wuhan, with its 11 million inhabitants. All of the people already in Wuhan, however, were ordered to shut themselves away into their apartments and not leave them at all. Everything in the city was closed. One day later, on January the 24th, 2020, the number of new cases confirmed in hospitals climbed up by a further 2,750, with the government ordering another 15 Chinese cities to be quarantined. These were truly draconian measures, which would be very difficult to implement in countries that lack a collectivist mentality.
The decisions of January the 23rd and 24th, 2020, in China, are unprecedented in human history. Tens of millions of people were quarantined. That’s something like the whole of Eastern Europe being placed in quarantine. And not only to the rest of the world, but also to each other, from each other. Everyone was in their apartments, just waiting. But it worked. They reduced the daily numbers of newly infected people and deaths down to double digits, and the total death toll in China is now just over 3,000. Given the size of the population, this would correspond to about 8 deaths throughout the whole of Croatia. The ability to rigorously quarantine tens of millions of people in order to curb epidemics that could be even more dangerous than this one is the most important new piece of knowledge that this new coronavirus has given me so far.
5) It taught me that we’re potentially in an important historical moment after which the East will become more important than the West.
We’re currently living in an interesting period that may be touched on in the history books in the future. It seems to me that the full range of challenges awaiting humanity in the 21st century, such as climate change and climate refugees, food and water availability, the mortality of the poorest among us, the pollution of the oceans, renewable energy, demographic growth and an aging population, health care and inequality, could require some form of clear plan ‘’from above’’, as well as community action that will have the characteristics of inclusiveness and solidarity, and won’t just be simply solved by free-market mechanisms.
Fires in the Amazon, Alaska, Siberia, and Australia, and now temperature in the South Pole that have never been higher, confirm the justification for climate change concerns to a certain extent. The US also received an invitation from top executives from the largest companies and the Financial Times to reform such "rentier" capitalism, and companies began to be asked to provide greater care in fulfilling their social roles, as additional motivation alongside making a profit only. It was a vocal call from the very heart of capitalism to reform from within, which didn’t question the justification of capitalism as the best system out there at all, but merely sought its adaptation to these new historical circumstances. The last time I was in the US, last autumn, more than 40 percent of the US population declared themselves in favour of "some form of socialism." These were unimaginably high figures for that country.
This shift of the electorate to the left in the US itself has apparently led the business leaders themselves to rethink everything and start thinking about reform. It is now opening up to the possibility that this unexpected pandemic may also become part of these continuing stories of the lack of existing models in dealing with global crises. Pandemics are an excellent example of situations where the interest of the entire community must be outweighed by the interests and personal freedoms of each individual. To the Chinese, this is intuitive, because they still live under the rule of the Communist Party to this very day.
China has succeeded, and now the US needs to show how it will tackle the epidemic, but President Trump is hesitant. He doesn't like the idea of quarantine because he knows how painful it will be for the economy. In addition, such a move will mainly save older people, which is a cultural norm in China and is never called into question. But because of the recession, it will harm the health of middle-aged and younger people in later years. A coronavirus crisis now awaits the US, after China has already shown what its comprehensive health system knows and can do.
Placing the personal freedoms of their citizens above the interests of the entire community in the US could have major unintended consequences, and the same applies to the UK. I hope it will not be so, because I don’t want any unnecessary contagion anywhere in the world. But if some level of reason in those in power in the US and its federal states which oversee the health systems there doesn’t occur, and if they think that curbing the pandemic is an ideological issue for their politicians, economists and sociologists, and not for scientists and doctors, there could be an unwanted embarrassment of the US on the international stage on the horizon in the next few weeks, with more lasting consequences for the new dominance of the East over the West.
6) I learned what an ‘’Infodemia’’ is.
Even back during the earliest stage of this pandemic, I realised that the huge differences in how the media and the scientific community function would become an extremely important part of this story. Specifically, in the early days of the spread of the contagion in China, I was being contacted by reporters, who made every effort to cover the subject. They wanted to get experts' estimates of possible further developments, but failed to extract nearly enough information to satisfy the public's interest in the topic from them. As I’m among the few Croatian scientists to have succeeded in accumulating experience both in the scientific community and in the media, I would explain to the press that the further development of this epidemic depends on at least thirty parameters that all need to be very well and thoroughly understood, and we don’t currently understand three or four of them well enough, let alone all thirty of them.
No scientist or expert will risk his or her reputation at such an early stage, rushing in and saying that there will be hundreds of millions of deaths, and in the end, thousands end up being killed, or worse - estimate that there will not be many deaths, and eventually there ends up being many more than expected. That's why, at such an early stage, we have those in charge of slowly informing us of everything, the World Health Organisation (WHO), the American Centre for Disease Control (CDC), and the New England Journal of Medicine, Lancet and JAMA. It is best to consider any other information rather unreliable until proven otherwise. Furthermore, as the situation develops, even the estimates of these reliable sources can be expected to alter several times, as we’re faced with a new and dynamic event which is difficult to predict.
It was then that I first realised that this pandemic would cause an information chaos, because in order to truly understand what its course and development all depend on, several very thick medical books need to be read and understood. However, all this knowledge cannot be summarised or transmitted to the public in the form of short media articles today. They were written to stay interesting for a mere 24 hours after publication, and often not even for that long. I understood that the public would be bombarded day by day with information about a pandemic that would often be insufficient in terms of its accuracy, incompletely explained, taken out of a much wider context that had been ignored, presented in the same way, though some bits of that information might be significantly more important and other bits of it might be entirely irrelevant in terms of understanding what is going on, which will all contribute to people's state of confusion and concern.
So, we end up with an "infodemia" - an epidemic of information that precedes the development of the real epidemic. I believe that once the spread of this disease is over, infodemia, its causes, and its effects and indeed its consequences, will be the subject of interest for many scientists. But interestingly, this is no novelty, because even in the Middle Ages, information about the spread of terrible epidemics was spread from village to village, and because of that, fugitives from the affected villages created panic by spreading stories about what was to come.
This particularly bothered me because I’d already developed some sort of PTSD from everything that went on about the counterfeit research on the relationship between autism and vaccines. I have already described how the media at the time was very enthusiastic at first transmitting it as disruptive information that would attract a lot of attention, although the entire scientific community reacted to it with enormous skepticism. The media, then, in misunderstanding the details of the scientific basis of the study, portrayed the denouncement of the fraudsters by the rest of the scientific community as a public debate, giving equal media coverage to the statements of all scientists who denied this obvious, malicious error with 99.999% probability, as well as to those who defended their forged study. Thus, the media then, in misunderstanding the details of the scientific background, presented the public with scientific evidence and clearly rejected the wrong hypothesis as an unresolved, public debate in which both parties have equal credibility. That "public altercation" attracted much more attention, with the result being more than a third of parents taking the side of the deceivers and vacillation having dropped from about 95 percent to about 60 percent. Because of all of this, I was worried that a lack of understanding of all the scientific details of this pandemic would cause some similar damage.
7) I have learned that topics in the media are much more determined by the public's hunger for information than they are by the media itself imposing topics on the general public.
I always thought that the media had the greatest power to impose topics on the public. But on this occasion, I could see that the topics actually impose themselves, depending on how much "hunger" the public has for them. And vice versa - if this hunger doesn’t exist, one can try as much as one wants, but the topic cannot be easily imposed on the public. For example, I could do as much as I wanted, but I could hardly write a column or give an interview that would be read by more than ten thousand people on the Vecernji list portal.
But last Tuesday, whatever I wrote about coronavirus, even without much effort involved, was being read by over one hundred thousand people.
So, there is an objective "hunger" for the public for topics, as well as their saturation, which changes literally hour by hour. I have learned that it is up to the media to decide for themselves how far they will go in exploiting this objective "hunger" of the public, and how much restraint they are to have towards that exploitation, and how much criticality they should show. They differ from each other here, too, so that their role cannot be generalised to all media.
In this situation, we need a quality reconciliation between the hunger of the public, the interests of the media themselves and the functioning of the scientific community. What is most interesting to me is the incomprehensibility of the question of how this "hunger" is created, a collective emotion that then becomes easy to sway - is it with factual data, dramatic decisions by the authorities and institutions (quarantines), or the stories, images and films that began to spread from Wuhan, just as it was back in the Middle Ages? It seems that we all have some deep emotions embedded in us, related to fear, death, and the various forms and types of love that events like this can inspire. Jo Nesbo wrote beautifully in the foreword of one of his books that publishers at the very beginning of his career told him to write either about great love or about murder, because nothing else could be sold to a large number of people, so it wasn’t worth even writing about.
8) It taught me that in the heat of an infodemia, people without enough knowledge will undermine potentially useful health education attempts, in both a conscious and an unconscious way.
In talking to a few colleagues who have the scientific authority to educate the public during these days of crisis, I’ve noticed that there are an incredible number of examples where the under-informed, either consciously or unconsciously, twist what we say and write, they misinterpret, and even maliciously interpret it, then pass it on, and hope that over time we will also turn out to not know what we’re talking about.
We note that our health-education efforts may, therefore, cause harm to us and others more than they provide use. The biggest concern is when our texts are broadcast with uncritical or even completely incorrect large titles and subheadings, which have nothing to do with what was actually said.
To reduce this mutational effect of "infodemia" on useful messages, I renewed my collaboration with Vecernji list for the fourth time, and will comment further on this pandemic only for them, and share their article here, to somehow ensure that the information I convey doesn’t mutate spontaneously and cause the opposite of the desired effect.
9) It taught me what ‘’moral panic’’ is.
"Moral panic" is a sociological and anthropological term used by British scientist Young, who dealt with youth addiction, in the context of the overreaction of the media, the police and the public to the deviance of young people's behaviour. Today, it signifies any social situation where, on a case-by-case basis or sensationally interpreted statistics, one is convinced that the community and its value system are at great risk. Today's speed of information sharing is leading to constant "waves of moral panic" around one topic at a time. Because of this, even though people have never lived with less risk and more resources, many feel permanently scared and anxious.
In the first phase of moral panic, something like the new coronavirus is defined as a major threat to the community. In the second phase, the news confirms this, but bases that largely on incorrectly presented statistics or individual cases taken from a much wider context. In the third phase, public concern is continually raised to levels of inappropriate and exaggerated behaviours that don’t correspond to reality. In the fourth stage, the reaction of those in power who are trying to restrain fear and panic, then strikes against the threat. Then democracy is suspended, and in the interest of "safeguarding security" everything becomes permissible. Finally, in the fifth stage, the "moral panic" either disappears in the same way it appeared, or results in major social changes, which are mostly unwanted and radical.
Unfortunately, in this situation with the coronavirus, I had the opportunity to witness different stages of the development of "moral panic". In addition to the problems of distorting and changing the specific statements of our foreign experts, or misinterpreting our statements due to inadvertent reading, I’ve noticed a third problem. It began to seem to me that more and more people wanted the experts to be wrong in their forecasts. It seems to me that there are indeed people in Croatia who would be happier if at least a few of their fellow citizens died during the first two or three weeks of the epidemic than for us, the Croatian scientists abroad, to be right about this problem. I didn't even know how to classify this type of behaviour. But then, in his column, Croatian writer Miljenko Jergovic explained that there was a name for such public defeats of common sense, called "moral panic". Mr. Jergovic, who, like Ivan Djikic and I, is not a member of the Croatian Academy of Sciences and Arts, explained moral panic in a perfectly clear way to me, as I had tried to explain COVID-19 to him in my article the day before. He wrote the following:
"What happens when those who are incomparably more competent about COVID-19 come forward, even if they themselves aren’t all that well acquainted with it? In the Croatian case, these people are Alemka Markotic, Ivan Djikic, Igor Rudan. We don’t believe her, much like a death-fearing hypochondriac doesn’t believe the doctor when he provides him with a moderately favourable assessment of his condition. And as for Djikic and Rudan, who are trying to intervene in a society of moral panic, are either viewed as equal interlocutors in the murmur of ignorant people, or even suspected as some hired alternatives. Instead of bringing about calm, their words seem to provoke anger and contempt. Why? Because in the midst of moral panic, a person is more likely to believe less believable, even idiotic news, lies and misinformation, which, if true and probable, would testify to the threat against him, than to news that would competently confirm that he may indeed have been threatened, but not to such an extent.’’
10) I learned that we must not turn away from health education, even when its very sense is called into question in this sort of collective psychosis.
When I’d already thought more than once that it made no sense to attempt to write about the pandemic in order to clarify the events to as many people as possible and their health education, some dear colleagues reminded me that we were all students of the great prof. Dr. Andrija Štampar. He wrote down 10 principles we all needed to know by heart, as they released the world from the fear of infectious diseases back during the second half of the 20th century. They still remain the cornerstone of public health and social medicine today, and if the late academic was at least still with us in this situation, he would have seen that they are just as relevant now as they were 50 years ago when he left them for us:
1. Informing people is more important than the law.
2. The most important thing is to prepare the ground and the right understanding about health issues in one area.
3. The issue of public health and the work to improve it should be addressed by everyone, without distinction.
4. Social therapy is more important than individual therapy.
5. The doctor must not be economically dependent on the patient.
6. No distinction should be made between the economically strong and the economically weak (egalitarianism).
7. In a healthcare organisation, the doctor should look for the patient, not the other way around, to take care of all those who need protection.
8. The doctor should be the people’s teacher.
9. The issue of public health is of greater economic significance than it is of humanitarian significance.
10. The main place of medical activity is where people live, and not the practice.
This text was written by Professor Igor Rudan, was first published on Vecernji list, and has been translated into English by Lauren Simmonds
For more on coronavirus in Croatia, follow our dedicated section. For more from Professor Igor Rudan, follow his author page here, his LinkedIn here, his Facebook page here, his Twitter here, and his Medium profile here.
