In the next phase of the crisis, public health priorities will be replaced with more active adaptation to sustain economic activity and normalise life again. Professor Igor Rudan looks at what has been, and what is yet to come as the coronavirus crisis continues to unfold.
April the 26th, 2020 - After Croatia closed its borders and schools and then introduced quarantine, in a column I wrote on March the 20th, 2020, explained that Croatian epidemiologists used figures and information to protect the population from the spread of the infection. That was now five weeks ago. I finished the column (which you can read in the link provided above) with the words: If anyone thinks this is the end now, I'm afraid he's living in fantasy land. This is just the end of the beginning.
Indeed, the decision to quarantine marked the end of the first chapter of this pandemic in Croatia.
To better understand the transition from the second to the third chapter, let's briefly recall how the first chapter ended and how the second one began. First, a new coronavirus appeared in Wuhan. Its spread was prevented by the largest and most restrictive quarantine ever seen. It was known that the virus can kill a very small amount of people among all of those who are infected, but it was not known then just how quickly it spreads.
On the front lines of the epidemiological defenses, the virus was halted by some thirty large provinces of China, as well as China's neighbouring countries in Asia. A possible arrival of the virus in Europe was then expected. Everything was still looking good back then. Flights from China to Europe and the USA were suspended or were being rigorously checked. However, the virus penetrated beyond the first line of defense in Italy and then entered many other countries of the European Union.
It began to spread among the population at a tremendous speed. That sadly led to a large number of deaths in a short time. Following all the information in the environment, I explained in my earlier posts why March the 12th would be a good day for the activation of quarantine in Croatia. The [National Civil Protection] Headquarters also thought along those same lines, and over the next few days, Croatia withdrew into quarantine through a series of measures.
With the withdrawal into quarantine, the second chapter of this pandemic began immediately. There were also clear plans and goals for this phase in Croatia. By the end of March, it could be seen that any free spread of the new coronavirus in other European Union countries would inevitably lead to thousands, and sometimes tens of thousands, of deaths in a mere few weeks. This could have happened to Croatia. On March the 1st, I explained that the virus has the potential to kill tens of thousands of people in Croatia, but also that with the application of proper anti-epidemic measures, we will reduce that number to just a few hundred, and hopefully even less than that.
Thanks to the timely implementation of all of the lines of defense, the number of deaths in Croatia has indeed been reduced to significantly smaller numbers. In addition, the Croatian Government has introduced a package of economic measures to provide support to the economy. At first, it was too modest in regard to this very new context. But then, after business owners began being more loud about what was needed, other measures were also passed, and those were significantly more generous. The measures were to mitigate the effects of five weeks of isolation, and the move was generally well received. Croatia, therefore, managed to overcome the second phase of this crisis.
However, it is now very important to explain, as well as to truly understand, that today the second chapter of the COVID-19 crisis in Croatia is coming to an end. At the same time, a third, entirely new chapter is beginning instead. In the third phase of the fight against the virus, public health goals will let, at least temporarily, their position as the leading priority go to other pressing issues. First and foremost, the preservation of economic activity and the attempt to return to the life we used to know will come to the forefront. So, we're entering a whole new chapter, where everything will change once again.
Chapter three's planning should have been properly elaborated during the quarantine. In my column discussing how we could quarantine, published by Vecernji list on March the 26th, I outlined five criteria against which each country's success in fighting this crisis would be evaluated. The first criterion was the good preparation and maintenance of the first line of defense against the virus, the second was the timely declaration of quarantine and the third was the successful suppression of the spread of the infection during quarantine.
As can be seen, all three initial priorities were primarily, in their very nature, about public health. However, I also stated that the fourth criterion would be: "How quick and active the state was in mobilising its capacities and human resources, as well as its creative and innovative solutions, to develop a plan for quarantining and coexistence with coronavirus as soon as possible?"
Finally, the fifth criterion was: "How effectively, after quarantine, has the state allowed its residents to move into a relatively normal way of life and prevent the collapse of their economy with permanent control of the spread of the virus?"
In all countries across the world, these two issues will dominate the new, third chapter of the COVID-19 crisis. Some nations will be more successful in their responses, others will be much less so.
Namely, in addition to suppressing the spread of the coronavirus infection, another important goal of quarantine was the buying of time. We had to stock up on as many new insights about the virus that we didn't have in the beginning. Based on these findings, the best plan for the third phase of the crisis should then be developed, practically, and as we go. If we want to evaluate Croatia's success in the second chapter of the crisis, ie, during the five weeks of quarantine, then the assessment of the effectiveness in combating the infection should be added to the assessment of agility in gathering information and developing the best possible plan going forward for the next chapter.
Assessing infection control in Croatia first of all, I would divide the five quarantine weeks by the period of the first three weeks, ie, until approximately the 8th of April, and into the fourth and fifth weeks, ie, from the 9th of April to the present day. Everything done since the first confirmed case of infection, from February the 25th to April the 8th, was truly excellent. Our National Civil Protection Headquarters, our epidemiologists and our other healthcare professionals have tackled the contagion in a way which is comparable to some the most successful countries in the world.
During the first three weeks of quarantine, Croatia's ambitious goal was not to make the number of newly infected people reach triple digits. Admittedly, our system could handle up to 250 newly infected people each day. However, given the unpredictability of epidemics in retirement homes and hospitals, it was advisable to leave as much reserve as possible. The peak of the epidemic wave of newly infected people was reached on April the 1st with 96 new cases, and then things started to subside.
Such a result, where the number of confirmed new infections has never reached one hundred in a single day, will be a proverbial ''badge'' only worn by the most successful public health systems in the entire world. In addition to succeeding in stopping the epidemic, the Croatian Government put forward, at the end of the second week of the quarantine, a significantly boosted package of measures to assist the economy, which has been generally very well received.
In addition to all of the above, a Government Scientific Council was established. In this way, leading Croatian scientists at home and abroad have regularly made themselves available and offered the Croatian Government and the National Civil Protection Staff the latest credible insights into the new coronavirus from all parts of the world. The second Scientific Council, held on the 6th of April, saw particular praise given to Croatia's success so far in safeguarding retirement homes from the epidemic. By then, the country was already finishing its sixth week without any major incidents. It was another good result, of which very few countries could boast. The high quality management of the COVID-19 crisis in virtually all its aspects was therefore at its peak on around the 8th of April.
As of April the 9th, however, problems that characterise many other countries across the world began to catch up on Croatia, too. First in Split and then elsewhere in Croatia, COVID-19 began to spread in retirement homes. This meant that higher numbers of deaths would also have to be expected. However, it's difficult to completely avoid such incidents. In Italy, Spain, Belgium, the Netherlands, France and the United Kingdom, such cases dominate the COVID-19 epidemic and contribute quite disproportionately to the overall death toll.
Therefore, the differences in mortality between countries that manage to protect their elderly and the sick well during this pandemic, and those that fail in doing so, can be truly dramatic. I will showcase this using three examples.
Today, France and Germany have a comparable number of confirmed infected people, just over 150,000. 22,200 people have already died in France and 5,700 have died in Germany, which is about four times less. The difference between Sweden and Israel is even greater: just over 15,000 people have been confirmed to have contracted COVID-19 by both countries, with Sweden having more than 2,100 deaths and Israel only having 194, which is ten times less.
The most drastic comparison is that of Mexico and Singapore, both with about 12,000 confirmed infected people, with Mexico already having 1,069 deaths and Singapore having only 12, which is a massive 90 times less.
Therefore, the Croatian results during the last two weeks of quarantine, ie, the fourth and fifth quarters, remain very solid. Countries that have protected their most vulnerable groups more effectively will have better results during this period. How, however, do we evaluate everything that has been done in Croatia during the five weeks of quarantine when it comes to the gathering of information, the better understanding of the virus and planning for a safe exit? Significant progress has been made since mid-March.
Research on ways the new coronavirus manages to spread among humans has been closely followed to provide clearer recommendations on the need for the wearing of masks and gloves. Which age groups are mostly at risk from the virus have also been confirmed. Healthy people under the age of fifty have been shown to be at a very low risk. This awareness is important in planning possible new quarantines as well as special protection for the most vulnerable among us.
Following on from that, the results of a very large number of studies are constantly being monitored, where existing medicines and known active substances are being sought to adapt in order to be useful in the treatment of COVID-19.
News about the first vaccine tests is also constantly being expected, as well as whether it only causes temporary or permanent immunity to the virus. In addition to diagnostic tests, which are constantly being refined to determine who is currently infected with the new coronavirus, tests are being intensively developed to detect antibodies created against it. Such tests are also important, as they allow for the assessment of so-called "seroprevalence". This will answer the question of how many people were exposed to the virus and got over COVID-19 without even knowing it.
When we consider all of them, only then will we receive the correct "denominator" by which we will be able to divide all those who died in the numerator. In doing so, we will finally be able to estimate the "death rate" among all those infected with this virus, which will greatly help us with our planning, estimates and calculations.
With all these insights reported on a daily basis by scientists, it is useful in planning the third chapter to constantly monitor all other countries in the world and to better understand the results of all of their respective approaches to it. All of them are currently working to slow down the spread of the virus. In doing so, each approach was adapted to its context, so, the measures varied from very mild to extremely restrictive, but the results differed as a result of that.
At the same time, countries which are rich enough and more developed could devote several weeks to quarantine activities to strengthen their technological capacities, as well as to train additional human resources. Thus, post-quarantine testing could increase testing for the virus among the population, strengthening the first line of defense. Thanks to GPS data, the effect of maintaining distance between humans on the rate of the spread of the virus was evaluated, leading to the thought of innovative measures of physical distance.
Google and Apple, as well as many others, are rapidly developing completely new technologies that can track the contacts of infected people without compromising their privacy. In the next phase of the pandemic, such innovations are likely to be supported by the first line of defense in at least some countries. In conclusion, quarantine has also provided us with a period of five weeks that has generated a wealth of new knowledge and useful information. This was all analysed on a daily basis and the plans for the third chapter of the COVID-19 crisis were all based on it.
I'm now going to return to the key feature of the final quarantine period in Croatia. Specifically, the first three weeks went so well that the small possibility of ending the fourth week of quarantine with single-digit numbers of newly infected people began to appear. However, during the first three weeks, citizens were still under the impression of the events unfolding in neighbouring Italy. They followed, in part and for that reason, all of the instructions given to them fairly well.
In the fourth and fifth weeks, partly due to incidents in retirement homes, but also probably due to increasing fatigue because of the quarantine, Croatia failed to bring the epidemic almost to its end. On the contrary, during most of the fifth week, practically until yesterday, the numbers of newly infected people were still in the double-digit range. That's why the virus will continue to circulate among the population even when the anti-epidemic measures are loosened up. This is a bit of a shame, as it has made certain scenarios impossible to think about during the last two weeks of quarantine.
Namely, the initial development of events in Croatia was so favourable that it allowed for the thinking of four different strategies for the new chapter of this crisis. The first and second strategies were proactive. They would give us initiative over the virus. The third and fourth were more passive, defensive, and in them, the virus took the initiative and conditioned our actions.
I will now describe these possible strategies for the next chapter and explain why one of them didn't come to be. I'll sort them from the most active to the most passive.
At the end of the third week of quarantine, I began to hope that perhaps from the plan to "mitigate" the contagion, that is, to slow its spread among the population down, we might start thinking more seriously about moving to a "complete suppression" plan. This would mean eradicating the virus within Croatia's borders. It would require an extended quarantine, but the goal would be to become one of the first "corona-free" zones in the whole world.
This would be analogous to creating "liberated areas" during wars, in which life can then be normalised. Moreover, such a strategy could even be agreed as common to several countries that had a favourable epidemiological situation back in early April. These countries were certainly Slovenia, Slovakia, Bulgaria and Montenegro. This could start creating a "corona-free" area within Europe, within which life would be normalised and the free movement of people would be established. Such countries would allow travel between them with the confirmation of mutually recognised, authorised institutions on non-contamination.
The tourist season in Croatia could then be based primarily on Croatian holidaymakers as well as those from the aforementioned countries which practically suppressed the coronavirus epidemic. Moreover, even for guests from third countries, where the epidemiological situation is worse, people with certificates of confirmation of their health could stay in hotels that are isolated by their location and that have been properly prepared for that purpose. There are quite a few such complexes along the Croatian coast.
Corridors from the airport to these accommodation facilities and back again would prevent the spread of the infection to the local population. In such a case, the staff of these hotels should move to the hotels themselves for a few months, and anti-epidemic measures would be introduced into their work. Even if a contagion occurred at a hotel, the epidemic would be limited to that hotel complex, or even just to a small part of it. When considering all these possibilities, it may be truly possible to think that in the fourth week of quarantine in Croatia, the numbers of new infections could have quickly dropped down to mere single digits.
However, we have been overtaken by problems in retirement homes, and quarantine discipline may have also somewhat subsided. It was enough that such a plan to emerge from this crisis, with the complete suppression of the epidemic, the significant normalisation of life, and with very strict border controls and the early detection of any new foci of infection, and waiting for a cure or a vaccine in a country without any new cases, would have to be dropped.
I also saw the second strategy as more desirable than the third or fourth one because it is proactive and wouldn't allow the virus to condition our behaviour. It would protect us from the new need for quarantine. It would be a strategy of further empowering our first line of defense and relying heavily on it. It would allow us to coexist with the virus through the application of more "insurance measures", which would protect us from its rapid spread. Maintaining physical distance, and wearing masks and gloves, which have already been being slowly being adopted by the population, would greatly increase the capacity and application of testing for the presence of the virus.
Testing would be especially regularly used to protect retirement homes as well as hospitals and rehabilitation centres. In addition, the identification of the contacts of infected persons would be actively pursued and new technological capabilities would be utilised that would rely on GPS tracking in the most acceptable form. Small, mobile epidemiology teams would constantly identify and isolate the infected and their contacts. Measures of "thinning" the population would also be elaborated so that at least the sub-populations of Croatia are allowed to gain considerable freedom of movement during their days of the week.
Such measures, and those similar to them, have enabled Taiwan, South Korea and Vietnam to remain the most successful countries in the fight against COVID-19 to date. They continue to rely on their strong and active first lines of defense. So far, they have not had to introduce a major quarantine at all. It is a strategy for coexistence with the virus that incorporates many mechanisms that make it significantly more difficult for it to spread.
However, the acceptability of these measures to the general public is an extremely important factor that must be constantly considered in the management of the COVID-19 crisis. As we move from each preceding chapter to the next one, it is precisely the acceptability of the decisions made that will become increasingly important to the entire population and, over time, perhaps the only truly important one. When this happens, the question of admissibility of the measures will dictate any further decisions if no scientific solution to the virus emerges in the meantime. I wrote about the key role of the admissibility of measures earlier on, explaining why the authorities of many countries hesitated in their initial responses.
They knew that the population would get tired of quarantine quickly, so they'd just start going back out anyway. They also hesitated with the ''release'' of the virus and permitting its free spread to preserve the economy, because they knew that the population would be scared of the large number of deaths, so they would simply shut themselves inside their homes. This is still visible in Croatia today. When the public was disturbed by what was happening in Italy and feared that the same scenario could be repeated in Croatia, the level of support for the quarantine measures was unprecedentedly high. As many as 94 percent of respondents believed that the Croatian Government was taking appropriate action against the virus.
Moreover, in an additional question, a significant proportion of citizens said they would also agree to even more stringent anti-epidemic measures. Now, not even three weeks later, opinions on the need for the same measures have already become quite divided in public opinion, and now many want to just be able to go back out as soon as possible. Therefore, it was evident that some new measures that would divide the population into subgroups would not be favourably accepted by the Croatian public.
Although scientifically grounded, these measures would remind many people of some of the earlier times of economic crises. It has also been shown that there is considerable resistance to any reliance on technology, and in particular the use of mobile phones for any kind of monitoring. Most people don't understand the benefits of a strong front line of epidemiological defense well enough, which can save us all from the need for a new quarantine.
Because of all of this, the reverberation of ideas offered under the second scenario was too lukewarm. It was to be concluded that Croatia isn't like Taiwan or South Korea after all, and it can hardly be expected that the Croatian population will support such measures as more desirable than the alternative we have left. In the absence of the ability to activate one of these two proactive strategies, which were quite ambitious in their nature, we need to adopt a third strategy.
Most other European countries are now likely to resort to that one, too. It will be a strategy of "tightening and loosening" these measures. It will be guided by the monitoring of the "infection spread parameter", designated as R0, which indicates how quickly the infection spreads. I estimated the R0 for the new coronavirus to be between 2.5 and 4.0. This means a very rapid spread as each infected individual can infect three more healthy ones. It is important for the R0 to be lower, to a value below 1.0. In that case, each infected person, on average, spreads the infection to less than one healthy person, and in that way - the epidemic slowly begins to fade.
Thanks to our brilliant scientist Petra Klepac from the London School of Hygiene and Tropical Medicine, who has ensured that these institutions include the Republic of Croatia in their reports on the movement of the R0 parameter in individual countries, we now know that we have reduced the R0 for Croatia to 0.8 thanks to quarantine measures. This isn't a bad result, as most other European countries are still struggling to reach 1.0 at all. This value points to two very important conclusions. The first is that over the course of five weeks, we've been able to show that the Croatian health system is able to control this new epidemic.
In the case of a new need for this, we now know exactly what measures need to be taken to suppress the virus, which is very reassuring. The second conclusion is that with all the measures taken so far, epidemics are still smoldering. They can be re-inflamed, and the maneuvering space for these measures is actually quite small. In addition, over time, life spent between "tightening up'' the measures and "loosening'' them back up again will also result in boredom for people. The question is also whether or not it will be easy to get those under fifty years of age to undergo any other quarantine at all, should such a need arise. Today, therefore, the second chapter ends and the third chapter of this unexpected crisis begins.
I'm not sure if a sufficient number of people in Croatia understand how much this third chapter will, in many respects, be more uncertain than the two chapters which came before it. During the first phase, a plan was prepared. The movement of the virus was monitored around the world, and the first line of defense was protecting us, with the aim of preventing any free spread of the virus within Croatia's borders. And during the second phase, there was a clear plan in place. The quarantine measures were supposed to save tens of thousands of our fellow citizens from death at the hands of the epidemic, while at the same time, reducing the effects on the economy with the introduction of a package of economic measures. That was also successfully done.
Now, we are entering a third phase, in which the goal is the relatively secure co-existence with the virus while adjusting our economic activities appropriately and maximising the re-normalisation of regular life. However, the duration of the period of loosening the measures and the avoidance of needing to tighten them back up again will depend primarily on the behaviour of the population itself and their individual efforts to limit the spread of the virus.
Will there be another quarantine, and when will it happen? Then, in that case, will it protect only the old and the sick, but not other people? Will a booming epidemic occur in Croatia in the next chapter, as has already happened to some other countries, despite a lot of attention having been given to it? Will the virus still be able to show at least some seasonal characteristics and slow its own spread down during the warmer months? Or, perhaps, will news come from the world of science about an effective drug or a vaccine?
In the absence of some really good, fresh news on the matter, we could be doomed to switching between "tightening" and "loosening" these anti-epidemic measures over the coming period, and the duration of something like that is not easy to predict at all.
I also mentioned the fourth scenario, but this one is really rather pessimistic indeed. There is still a chance that solutions from the world of science and medicine will begin to arrive, they just need to be given time. But, unless there is clear progress, if the virus doesn't slow its spread down but instead it continues to mutate, and if some more dangerous strains of it begin to emerge, and in the meantime, if the process of "tightening" and "loosening" the measures begin to exhaust citizens and the economy, the level of acceptability of the measures outlined in the third strategy to the general public could alter.
However, with the impossibility of implementing the first two scenarios and the saturation of the population in regard to the third, what do we have left in our arsenal?
I will save a more detailed elaboration of that fourth strategy for one of my next columns. For now, for the sake of reflection, I will only offer a definitive answer: If this crisis persists, and if it continues to worsen in the absence of scientific solutions, then the (in)acceptability of all that has yet to happen follows, that will dictate the resolution of the COVID-19 crisis.
In the fourth, final scenario, the solution will come from neither science, nor medicine, nor economics. It will be delivered instead by lawyers in the form of a law. It will introduce a fundamental human right to become infected and die from the new coronavirus.
This text was written by Professor Igor Rudan and was originally published on Vecernji list. It has been translated into English from Croatian by Lauren Simmonds
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