A Virologist of much experience who led a US team studying the SARS virus has explained how unprepared public authorities in the West are for coronavirus
Open letter to the Belgian Prime Minister and to my fellow citizens
Dear Prime Minister, dear fellow citizens,
Belgium has experienced many political crises, it is a local specialty for which we are famous in the world, but it is facing today its first real crisis since the Second World War, and it turns out to be very badly prepared to respond to it effectively.
The attitude of the Ministry of Public Health is paternalistic, with the message: we are prepared, we have a pandemic plan, we have groups of experts, we are monitoring the situation closely, we are controlling the situation, we are communicating as it is necessary, and we are not interested in independent criticism of health professionals or scientists.
However, apart from the disinterest in the opinion of professionals independent of the government, nothing could be further from the truth: we are not prepared, we do not have a pandemic plan, government experts demonstrate a lack of knowledge of this new coronavirus characteristics, they follow the situation closely but refuse to anticipate it, and communication remains incoherent, for the simple reason that they do not sufficiently understand the nature of the danger we face.
Belgium does not have a pandemic plan.
This information will probably even surprise the Minister of Health, but Belgium does not in fact have a pandemic plan! Instead of having one, Belgium has an epidemic plan and there is a crucial difference between the two.
Contrary to epidemics where the foci of infections remain localized in certain regions of the globe, as was the case for both SARS and MERS, in a pandemic these foci continue to spread uncontrollably in most countries.
The consequence of this difference is a logistical problem; the supply chains of materials necessary for health care are interrupted. For this reason, a true pandemic plan is based on the concept of strategic reserve: all the material necessary not only to ensure the normal functioning of our health care system, but also to have the capacity to absorb the inevitable increase in the number of patients to be treated must be kept in stock in sufficient quantity if it is not produced on Belgian territory.
We are already in shortage of masks, so Belgium does not have a pandemic plan. Contrary to the assertions of the Minister of Health, we are therefore not prepared and it is urgent that the government takes all the measures necessary to remedy this deficiency.
Confronting the reality of the situation.
Those who do not have the professional skills to judge the situation for themselves are reduced to trying to determine which expert is closest to the reality of the situation, an exercise in futility.
I believe, on the contrary, that it is possible to explain the reality of the situation in an intelligible way to the government and to the general public, but that requires everyone to make a little effort to understand the two most important figures in epidemiology from a public health perspective. Once this information is understood, everyone will be in a position to assess the proportionality of the public health measures that have been taken and that remain to be taken.
What are the conditions that favor the emergence of a pandemic?
A new contagious virus for which the population has no immunity. The more contagious the virus, the greater the difficulty in containing it, the greater the risk of a pandemic. The flow of people and goods in the modern world, as well as the concentration of the population in urban areas increase the pandemic potential of emerging viruses.
Public health measures to counter the spread of the virus.
The spread of a virus is closely linked to the frequency of contact between individuals, the more contact there is, the more the probability of transmission increases. And so the essence of public health measures for a pandemic virus is to reduce the frequency of contact between individuals as much as possible, it is no secret.
Can we contain the spread of a virus with pandemic potential?
Yes, if the required public health measures are implemented without delay. Hong Kong, Singapore and Japan, countries that have much closer contacts with China, have been able to stem the spread of the virus in their country. They were exposed to the SARS epidemic in 2003 and their public health officials learned the right lessons. They were ready, and that proves that it is possible to have an effective response to a pandemic.
Containing a pandemic virus is a race against time.
On the starting line, we have a new virus and public health systems around the world. The virus starts first, but slowly, and it is up to health systems to respond without delay, as the virus spreads faster by the day. The virus respects neither borders nor schedules, and it does not take a break during the carnival holidays. The Minister of Health assures us that we are 5-6 weeks behind Italy. We are 22 days behind Italy. Every day counts.
Usual dangers and unusual dangers.
People are generally well prepared for the dangers they face regularly, because these dangers correspond to their usual experience. No one is psychologically prepared for a pandemic, the last one took place a little over 100 years ago and therefore no one has personal experience of a pandemic: it is very difficult for people to anticipate the explosive nature of the spread of an infectious agent, even though it is well established scientifically that a virus spreads exponentially.
Apart from financiers, engineers and scientists, the properties of the exponential function remain very abstract for members of government and the general public, and I will try to make them more concrete. We are all very familiar with the functions of addition and multiplication because we use them daily. The exponential function is a series of multiplication, and our intuition is less developed on the implications of a series multiplication, because there are few phenomena around us that flagrantly follow this function.
To make it clear what is going on in a pandemic, I would like to make the connection with two exponential phenomena with which most people are familiar.
The compound interest loan and the stick of dynamite
A stick of dynamite and compound interest are two exponential phenomena with which we are familiar. What happens when dynamite explodes?
One molecule of TNT reacts and makes 1000 other molecules react a fraction of a second later, and that is 1000 molecules in turn make each 1000 other molecules react the same fraction of a second later, and this million molecules which react, produce a billion, then a trillion etc., every fraction of a second until all the TNT has reacted in less than a second. Result? BOOM, the stick exploded.
At the other end of the speed spectrum, you can take compound interest. Consider buying a loan-funded home with an annual interest rate of 2.5%. You may think, 2.5% is not much, but if you do the math, on a 30-year contract you end up paying as much in interest as the price of the house. And that’s the power of the exponential function, it goes up quickly, with an annual rate of 5%, we pay more than 3 times the price of the house in interest! The predatory and amoral character of our financial system is a debate for another day, but is an important factor in the systemic precariousness of modern society, which can only be exposed by the developing crisis.
A pandemic is halfway between a compound interest loan and a stick of dynamite. The three phenomena are explosive, but at different time scales, of the order of the week, year and millisecond.
What do the two key figures in epidemiology mean?
From a public health point of view, the most important figure is the doubling time, the lapse of time required for the population of symptomatic people to double, because it is that which allows anticipating the progression of the number of case that will have to be absorbed by the hospital system.
For a loan with 2.5% annual interest, the doubling time is thirty years. For a stick of dynamite, the doubling time is a very small fraction of the millisecond.
In the case of COVID-19, various groups of epidemiology experts conclude that the doubling time in the absence of public health measures is only 2.4 days, which is extremely short and explains the meteoric increase in the number of cases.
Some might think that the case progression is not that rapid. To disabuse them, let’s do a simple calculation. In a doubling period, 2.4 days, the number of people infected doubles. In ten doubling periods, 24 days, the number of people infected is multiplied by a thousand; we can count on our ten fingers: 2, 4, 8, 16, 32, 64, 128, 256, 512, 1024, it is an exponential function.
Most people follow this calculation without much objection. However, if we continue the progression of the exponential curve, what do we find? In the absence of public health measures, the epidemiologist calculates that from one COVID-19 case we obtain a thousand cases after 24 days, fine, a million after 48 days, oops!, and a billion cases from only one case after 72 days… and nobody wants to believe that‼ This is the explosive power of the exponential curve, this is a pandemic, and these figures are rejected because we do not have personal experience, a living memory, of the destructive power of a pandemic.
A nuclear reactor to explain the reproduction number of a virus.
Let’s turn to the second key figure in epidemiology: the reproduction number, which represents the contagiousness of the virus. The exponential function is a series of multiplications: in a loan at 2.5% over thirty years we multiply 1.025 thirty times in succession, that is to say 1.025 to the power of 30, and we get 2. The figure 1.025 corresponds to the reproduction number, as long as it is greater than 1, the cost of interest increases exponentially over time.
In a nuclear reactor, the reaction is controlled by keeping the number of neutrons reproduced just below one, and the heat produced by this reaction can be converted into electricity. If the reproduction number of neutron exceeds one, the operator must very quickly take an action to reduce this number back to below one, otherwise the neutrons multiply exponentially and the reactor becomes critical. Result? BOUM: Three Miles Island (U.S.A.), Chernobyl (U.S.S.R.) and Fukushima (Japan).
The basic reproduction number of the new coronavirus when it leaves Wuhan, calculated by the same groups of epidemiologists mentioned above, is ~ 7, namely that an individual infects 7 others on average, and a doubling time of 2.4 days. In the presence of the first public health measures in China on January 23, the effective reproduction number of the new coronavirus is reduced to 3.24, its contagiousness decreases, and the doubling time increases to 3.5 days. Extreme quarantine measures have been taken in China to reduce the number of effective reproductions below one and thereby control the spread of the virus.
The objective of public health measures is to reduce the effective reproduction number of the coronavirus to bring it below one and thus stop the exponential spread of the virus. When the basic reproduction number of a virus is 7, think about the contagiousness of mumps before vaccination, it is extremely difficult to reduce it below one, extreme measures are essential.
Presence of infected individuals outside of China
In a pandemic, the progression of the number of cases is exponential, it is explosive. Take the situation of the countries outside China where the virus has been most widespread so far, namely South Korea, Italy and Iran. In these three countries there are enough cases to derive figures that are statistically significant, and where one can have the most confidence in the veracity of the data.
In South Korea, the number of cases doubles every 3.2 days, in Italy, the number doubles every 3.3 days, in Iran, every 1.5 days. I will ignore Iran for this because it could be an artifact of a screening process that was overdue. For what follows, I take the Italian doubling time in the presence of the public health measures that were in force until yesterday, i.e., 3.3 days, because it is the country closest to ours (this number has been fluctuating between 3.1 and 3.5 for more than 3 weeks).
Why are our Italian friends taking drastic measures?
Italy has 3,858 cases at the time of this writing on March 5. What prediction can we make from this figure? We can say that after 10 doublings, this number will be multiplied by a thousand! 10 doublings, namely 33 days, thus if the transmission dynamics do not change drastically in Italy, we can expect a thousand times more cases in 33 days, i.e., almost 4 million cases!
A figure that can only completely overwhelm the Italian hospital system, and this is why the Italian government reacted with more drastic measures, the measures taken until yesterday were not affecting the doubling time of the virus. The previous Italian measures are identical to those recommended by the Ministry of Health in Belgium as of today, which indicates that they have very little chance of stopping the progression of the virus in our country.
We are told of collective hysteria, and of a spread of fear more dangerous than the spread of the virus, presenting us with the false equivalence of comparisons with influenza and with other infectious diseases. This position ignores the reality of the destructive power of a pandemic virus.
What projection can we make for Belgium?
The epidemiologist calculates just as above, from 50 cases listed today in Belgium, that in 33 days, there will be 50,000 cases, and a week later, 200,000 cases, if we do not start immediately the most drastic measures possible. I sent a file to SPF Public Health on February 12 where I detailed the threat that the new coronavirus posed to the integrity of the Belgian hospital system, and I calculated that 110,000 symptomatic cases, 1% of the population, would put this system in serious danger.
This file still remains unanswered and it seems that it took my open letter to the Minister of Health 16 days later for the penny to finally drop, and for the experts who advise her to recognize the existence of this risk! They instantly minimize the danger to our hospital system by calculating that in 9 weeks, 63 days, the number of cases in Belgium would only be 13,000, of which 2,500 would require hospitalization, a number that could be absorbed by the Belgian hospital system.
Denying reality will not help us.
It would seem that the main concern of the Ministry of Health, since the beginning of this crisis, is to reassure the population by minimizing the nature of the danger. One wonders on the basis of what figures the government experts arrive at 13,000 cases in 63 days?
While at the same time, scientific figures that are publicly available indicate that, if we do not drastically change public health measures, there would already be 200,000 cases in Belgium in 40 days?
So far, the government’s anti-pandemic actions can be boiled down to ‘too little, too late,’ accompanied by confused and paternalistic communication.
Timeo hominem unius libri. I fear the man of a single book, St. Thomas Aquinas told us. Closer to now, George Orwell warned us about the danger of groupthink. The government cannot afford to continue to reject the opinion of independent experts, when the health ministry fails to assume its responsibilities and takes disastrous decisions after disastrous decisions, flaunting the most basic public health rules.
What should have been done.
As early as February 6, it became clear to scientists that the new coronavirus was very dangerous because its pandemic potential is very high. As this is a race against time, the first public health response must be very quick, starting with the establishment of what is called a sanitary cordon.
In practice, all exchanges with the infected region must be suppressed, for example canceling all air transport. We must be adults and recognize that such a measure is in no way xenophobic towards our Chinese friends or our Italian friends, since it is temporary, limited in time until the local epidemic can be controlled.
Freedom of movement cannot be exercised at the expense of the survival of others, and it is legitimate to restrict it temporarily in a health crisis situation.
We should have taken advantage of our luck that the virus landed in Europe south of the Alps rather than north, to set up specific screening tests for the new coronavirus in all medical laboratories in the country, and to road test them on all influenza cases circulating at that time.
Excuses, excuses, excuses!
We should have recommended canceling the carnival holidays in France and Italy; we should have taken the temperature of the individuals upon their return from regions where the virus was circulating, and given them clear instructions on how to quarantine themselves pending the results of systematic screening, and accompanied by appropriate social and medical supervision throughout the quarantine, this is essential.
We heard that taking the temperature of returning travellers would have caused queues at the airports …, what is more important, a little delay or allowing the wolf to enter the fold? It was said that identifying carriers of the coronavirus from Italy was like looking for a needle in a haystack.
Yet, this is exactly what the ant-like work of public health teams is all about, to identify the first cases as soon as possible, trace their contacts, and thus gain these precious weeks that could make all the difference for our hospital system.
“This is not an exercise. This is not the time to give up, this is not the time to make excuses, this is the time to go all out,” said the WHO Director, Tedros Adhanom Ghebreyesus.
What are we waiting for?
Authorizing Batibouw is playing Russian roulette.
We should have already canceled all the crowd events. It is simply absurd to allow a construction show like Batibouw, where captive populations, the exhibitors, are exposed to a constant flow of visitors. The containment and interactions are the ideal conditions for a super-spreading event, as on the cruise ship Diamond Princess, where the effective reproduction number was 14.2! Namely, contagiousness greater than that of the most infectious disease in the world, cholera!
What happens if exhibitors become infected within the first few days? The majority of them will become contagious before the end of the expo. A study indicates that the viral load the day before the onset of the first symptom is the same as in the days that follow. A person who is still asymptomatic is therefore just as contagious the day before his conversion as a sick person, but as he does not know it, he cannot take the isolation measures that he would have otherwise taken. These asymptomatic but contagious exhibitors would then be able to infect a proportion of the thousands of visitors who come towards the end of the expo in conditions of contagiousness exceeding that of cholera…
Why take such a risk of getting a super-spreading event, when it could dramatically accelerate the dynamics of spread of the virus in our country, and thus increase the risk run by our hospital system? It’s just irresponsible.
What to do now.
All those who have returned from a region at risk must identify themselves to the authorities and quarantine themselves, and this applies to those who live under the same roof, even if they have not been in a region risk. Systematic screening of all these individuals must then be organized, as well as their social and medical assistance.
All crowd events must be canceled and we must go to phase three of the ‘pandemic’ plan. This includes events like the next session of the European Parliament. The green MEP, Philippe Lamberts asked me whether it should be held in Strasbourg or in Brussels. My answer was that it should be canceled, but the president of the European parliament chose to move it to Brussels, another unnecessary risk.
Ms. De Block made the excellent suggestion to mobilize industry for an accelerated production of the most necessary equipment, namely N95 masks or their equivalent, FFP2 or FFP3 masks.
To the masks, citizens!
On this subject, I would like to set the record straight. Representatives of the government, and the journalists of the audio-visual and the written press who echo them, keep repeating that the N95 masks are not effective in protecting the average citizen in good health, and is only possible useful to limit contamination by people already infected.
Who are we kidding? ! We say that only because there is a shortage of these masks, you see, we must keep them for medical personnel … If it effectively protects medical personnel, it will protect the public just as effectively when they are available, right?
This is part of the paternalistic attitude where one justifies lying to the public “for their own good” when it is not. We castigate those who want to protect themselves by buying these masks, when they have the right to defend themselves in a situation where the government has failed in its responsibility for collective protection. They have in fact only been able to collect some 19,000 packets of masks, almost nothing compared to the quantity that Belgium should have had in its strategic reserves (400 million masks at least, there are 11 million inhabitants including half a million medical staff who use them intensively).
We must mobilize the country!
We must recognize, as China did in January, that each country infected with a pandemic virus is essentially in a situation of war, not against a military power, but against a much stronger power, nature, in the form of a new infectious agent in an immunologically naive population.
The excellent suggestion by the Minister of Health to produce more masks in Belgium did not meet the enthusiasm of the textile federation or the clothing federation, while textile masks for the general public would have the advantage of being easily and ecologically recyclable.
In a war situation, it is necessary to be able to requisition the industrial tools that can be converted for the production of essential equipment, such as FFP2 masks. Our Chinese friends have built hospitals in record time, who says we are not able to put together the necessary production lines?
Belgium is not psychologically ready to face a pandemic and while it is the role of the government to prepare it for this very unpleasant reality, members of the government also suffer from the same difficulty, which complicates the execution of their responsibilities.
What to expect in the future?
We all hope that an early spring and a massive effort by all Belgians will allow the transmission of this virus to decrease significantly and thus avoid too much damage to our hospital system. If the contagiousness of this new coronavirus decreases enough with the good weather, the summer must be used to prepare very seriously for the very probable return of this virus next October.
With a 6-month transmission season and such a contagious virus, only the wearing of FFP2 masks by the general public can provide the necessary protection. Textile and recyclable masks for adults and children are essential, and an opportunity for the development of an industry and fashion phenomena that are sure to be associated with it.
It’s hard to be Minister of Health during a pandemic.
I can hardly imagine the stress for people in positions of responsibility in this situation, I sympathize, and I thank them for their efforts. Between the public, the media, and the contradictory information that circulates, it is difficult to perceive what is real and what is not, their task is immense.
The questionable figures of the W.H.O.
Nor are they served by the misinformation emanating from the W.H.O., which acts as if official Chinese figures represent the reality of the epidemic in that country. The increase in the number of cases in China followed a quadratic function with a practically perfect correlation coefficient, r = 0.9995, instead of an exponential function: it can only be artificial figures.
As a result, the W.H.O. calculates an artificially long doubling time, 6.7 days, and an artificially small reproduction number, 2.5! This minimization of the pandemic potential of the new coronavirus is scandalous because it interferes with the perception of the danger by public health authorities around the world.
Similarly, the description of the mode of transmission of the new coronavirus by the W.H.O. does not reflect the reality that it can be transmitted by aerosol, a condition where the virus remains suspended in the air carried by micro-droplets. As a result, the recommended insulation measures are not effective enough.
Without further ado.
A good response is possible, let’s do what the countries that are successful against the virus did and are doing!
Madam Prime Minister, it is your responsibility to exercise your prerogative under phase 2 to move the country to phase 3, and to take all the measures necessary to ensure the protection of the country.
The author has a Ph.D. in molecular biology, studied the interactions between viruses and the innate immune response throughout his career, led a small group of researchers in the US to work on human coronaviruses in general and on the one responsible for the 2003 SARS outbreak in particular, both as a faculty member of the University of Cincinnati College of Medicine, and as a scientist at the only institute focused exclusively on respiratory diseases, in Albuquerque.