The WHO calls the virus SARS-CoV-2 and the disease Covid-19. The virus would be genetically very much like the original SARS-CoV from 2003, with many similar properties like the effect on age and sex, also on superspreading events (“clusters”), which explains the success of source and contract tracing in Japan. Molecular biologist Peter Borger argues that we are basically dealing with the same virus but a bit less deadly (as happens over time), and he wonders why the world did not prepare for its remergence and why it was claimed that the virus would be “new” and “unknown” – though admittedly the outbreak of 2003 did not reach the West.
Let us discuss:
- Parliament goes into recess and takes a two-month vacation till the end of August
- European recovery funds
- Where we are now
- The exit strategy
- How did we get into the emergency brake of the lockdown ?
- The medical world and litigation
- The failure of the Dutch source and contact tracing (SCT)
- What are major unknowns ?
- Repair of national trust
Parliament goes into recess, but inadvisably so
The government has asked the Dutch Safety Board, chaired by Jeroen Dijsselbloem, to evaluate how Holland responded to the SARS-CoV-2 pandemic.
“With the investigation the Board will look at the preparations for a pandemic, crisis management, the measures taken and the phasing out of these measures. The Safety Board will also look at the effects of the corona crisis on the safety of vulnerable people in the society, for example due to discontinuation of regular care or social services. Medical treatments and economic support measures fall outside of the scope of the investigation. The goal of the investigation is to draw lessons for potential future epidemics.”
Since this report may be expected somewhere in 2021, Dutch parliament arranged, though not without some struggle, that another report will be available before September 1. Satisfied with the job done, Dutch parliament apparently intends to have the recess July 3 – August 31.
This attitude by Dutch parliament is flabbergasting.
The situation is not in control, national trust is corroding, the lack of information still is huge, the financial loss to families is large, and the risks of coming Fall and Winter are huge: with reduced buffers, while the economy is in recession and people fear bankruptcies and unemployment.
For a sense of perspective, the Winter 2017-2018 flu took 9500 excess deaths, see my earlier discussion, so that the figure of 9000 excess deaths in 2020 should not be dramatised. However, the basic facts remain: (1) SARS-CoV-2 can be deadlier than the flu, (2) the virus can also be nasty for younger healthier persons, and thus might better be eradicated, (3) the risk of a 2nd wave has not been avoided yet, (4) the economy must somehow recover with these unknowns.
Parliament should not rest till it has provided clarity about the following.
- The government still hasn’t formulated an exit strategy other than muddling through, and RIVM still leans on notions of herd immunity that conflict with the containment / suppression / eradication. There is need for a clear choice.
- There is not only RIVM that looks at the infection dynamics but there is also Zorginstituut Nederland (comparable to the US NIH), that advises on cost-effectiveness of health care, and that ought to advise on the (quality adjusted) “life years” (qaly). Are the infected adequately monitored (given the nastiness of the virus) ? The ZiN agenda on Covid-19 however is rather timid. The blogs by its advisory council are more informative. Advisable is the blog by Hugo Keuzenkamp, former editor of economics journal ESB and former hospital director. There seem to be more questions than ZiN can answer, and how has it been arranged e.g. within Europe that this capacity to answer questions is best allocated ?
- Without such clarity on strategy, the European discussion is vague too. You cannot bargain for a result when you do not know what you are bargaining for. The next EU council is planned for July 17.
- The lack of information still is huge, not only because of lack of research funds, but also because key agents like RIVM and ZiN do not provide the information that they have. They might be overworked on what they are doing but what they are doing may also be misguided. When parliament thinks that such information will be available in that new report of September 1, then this is ostrich behaviour, and it may well be that parliament isn’t even aware of what questions must be asked. RIVM indeed applied the emergency brake in March so that the death toll was restricted to 9000 instead of 250,000 (see below), and it must be greatly appreciated that they eventually did so, but this does not imply that they know what they are doing overall, see below. To make sure that answers are given, parliament must ask questions itself, and provide a bridge for questions coming from science and society.
- If there would be this new report by September 1 then this information can indeed be used for the discussion about the national budget for 2021, but this is too late for the Fall of 2020. Preparations must be made in July – August already.
- For example, the scientific evidence on aerosol transmission is overwhelming, but OMT / RIVM seem to be mentally blocked by the linguistic distinction between “infectious” (the capacity to infect) and “having infected” (having performed the actual deed), see this deconstruction. We are now on a path to lose the Summer months for adaptation of ventilation systems. (Admitting that “ventilation has a role” opens the can of worms that it is not clear for each ventilation system when and how. But it is better to specify this uncertainty than deny the causal influence.)
- The theory of infections contains a notion of “herd immunity”. If a population is not mixed – say the strong animals form a protective circle around the vulnerables – then predators may die from hunger before they can do any harm. If a population is mixed, then a predator may still die when the chance of meeting a strong animal is much larger than meeting a vulnerable one. In general, when you do not specify what model you are using then you are at risk of (spreading) confusion. This is a major problem in the current discussion about SARS-CoV-2. My paper on redesign of didactics, section 1.5.5 on page 26, questions what RIVM (the Dutch CDC) has stated about the virus, and section 6.11 on page 105 has a longer discussion of the theory. For SARS-CoV-2, RIVM has stated that herd immunity would be at 60% of infected people in the population. As far as I know, and please correct me if I am wrong, RIVM hasn’t explicitly stated how they arrived at this figure. RIVM stated that they intended to protect the vulnerables (eldery and younger with comorbidity) but many deaths actually occurred in homes for the elderly. And if you lock down the economy so that R0 becomes much lower, how do you intend to achieve that herd immunity ? RIVM has been so ambiguous and inconsistent on this issue that tough questioning is required to arrive at clarity about what the Dutch policy approach is.
- What institutional structure would you want to have, such that there is adequate and transparant planning with not only “lives saved” (lives extended) but also (quality adjusted) “life years gained” – or the compromise of the “unit square root” – and with the distinction between statistical data collection for the past and planning for the future ?
- Most of all: apparently there still is too little awareness that the pandemic has been caused by policies that are environmentally unsustainable. It is scientifically obvious that current policies are inconsistent on economics and climate change, see here. It is absurd that Dutch parliament hasn’t made such statement yet. Europe is already moving into this direction but let this be a key cornerstone of the discussion of July 17 and let Holland support this. Impose a carbon tax. For investments, companies require as much certainty as can be provided.
- The proposed support of about EUR 3.4 bn for Air France / KLM is a case in point. The government argues that the company and Schiphol are important for some 100,000 jobs, but the government does not state that this employment is fundamentally at odds with the goal on environmental sustainability. The government states that CO2 emissions per passenger must be reduced “by 50% in 2030 compared to 2005” – which causes the question why 2005 ? – but why not target a level of 5% of passengers for 2021+ anyhow ? Why not acknowledge that tourism in distant countries is not environmentally sustainable with our present world population and technology ?
- For the Fall and Winter on the Northern hemisphere, my suggestion is that unemployment, also for the transition to environmental sustainability, is avoided by allowing and encouraging people to get more education. One day per week education for the work force would mean a 20% reduction of the labour force, with time mostly spent studying at home. The scheme could be financed by a general tax also on wealth, replacing such capital by human capital. Pay for the educational day would be at 70% of normal pay, with a minimum of the net legal minimum wage and a maximum at half the prime minister’s salary, with regular testing and check-up, and ending of participation if not studying. I take my inspiration for this scheme from the late Louis Emmerij (1934-2019). If one would agree with this kind of idea, then it obviously requires preparation for the educational system to make this possible.
European recovery funds
There is a disastrous economic imbalance between on one side Germany and Holland and on the other side Southern Europe. The world is advised to boycott Holland till the censorship of economic science in Holland since 1990 is resolved. It might seem as if every crisis is another excuse to ride one’s hobby horses, but my hobby horses are fundamental issues that apparently must be emphasized again and again.
The loss of lives and livelihoods because of SARS-CoV-2 causes sorrow all over Europe. There are expressions of compassion and solidarity all over.
On SARS-CoV-2, the distinction between North and South was broken by Greece in the South (doing well) and Sweden in the North (doing worse). Diversity of nations gives a great reward in information.
While Greece responded immediately and adequately to the virus with source and contact tracing (SCT), with now 191 deaths (18 per million) (not counting “other excess mortality”) apparently the systems of health in Italy and Spain suffer from similar problems as the Dutch system does, and these problems could be resolved nationally, without the need for European supervision. It is only in the areas of economies of scale and scope, of deliberate interdependence by trade and monetary union, and the overall impact on the environment, that the European Union has relevance. With the historical process towards closer co-operation, there is also the awareness for common justice and civil liberties and the defense of the borders of the larger region. (It must also be remarked that Brexit has basically been caused by a non-proportional electoral system, and scientific failure of “political science” still locked in the humanities, see my proposal of a buddy system of physicists and such “political scientists”.)
Italy and Spain have pointed to their problematic state finances and heavy death tolls: Italy 34.7 thousand (574 per million) and Spain 28.3 thousand (606 per million) (not counting other excess mortality) (compared to Holland 356 per million).
Italy and Spain can raise taxes on their own rich, who are much better off than the average German or Dutch.
Nations like Italy with 60 million people and Spain with 47 million people, with their proud histories and highly developed governments and often excellent universities, really do not need Europe to help out. When politicians in Southern Europe use the European Union and Northern Europe as scapegoats to distract attention from their own failure to properly manage their own economies and systems of health care, then this is better said clearly, so that voters in Southern Europe are advised not to vote for such politicians. (There is a distinction between scapegoating Holland and boycotting it for said specific reason.)
By mid April, the Italian debt / GDP ratio was expected to rise by 20% to 156% (IMF table 1.2). Italy and Spain were also earlier in the pandemic and the Dutch death toll hadn’t fully materialised yet. The Italian proposal was to have Eurobonds, so that country-specific rates of interest would not be hit by stigma as happened during the financial crisis of 2007+. I myself had agreed, for that particular crisis in this period, that such bonds might be used temporarily indeed, obviously with conditions.
The Italian prime minister Giuseppe Conte must have known that relaunching the proposal of eurobonds is a slap in the face of Northern Europe. He decided to slap anyway. This attitude is unhelpful and anti-European.
The Dutch finance minister Wopke Hoekstra rejected the proposal of eurobonds and pointed to the national responsibility to adhere to the targets of the Maastricht Treaty, with a debt / GDP ratio of at most 60%. Southern Europe hadn’t done enough in the years since the financial crisis and was accountable for its own errors. This rejection caused anger in Southern Europe and Hoekstra apologised for not having been emphatic enough in this particular statement, and for not expressing enough his compassion for the plight in Southern Europe.
As said, it is problematic to discuss European funds when there is no clarity on the common exit strategy and embedding within the discussion on climate change and the environment overall. I regard it as valid that the ECB and the EU stepped in with emergency plans to keep the economies afloat but it would also be a grave error when the structural imbalances are not tackled, when censorship of science is allowed, when there is no clarity on environmental sustainability, and when Southern Europe does not deal with its financial elites too.
Where we are now
Holland has 17.4 million inhabitants, of which 0.65 million showed antibodies for SARS-CoV-2, a prevalence of 3.7%. The total death score in Holland today is about 9000, of which some 6000 have been officially tested (356 per million) and some 3000 are “other excess mortality” including non-SARS-CoV-2 deaths in unknown proportion. A raw estimate, also given by RIVM (the Dutch CDC), is that the infection fatality factor (IFF) is 9000 / 650,000 = 1.38%. The IFF for 60+ is 4.84% and for <60 it is 0.06%.
- The SARS-CoV-2 pandemic landed in Holland in apparently some four genetic variants with people returning from ski holidays and from Northern Italy, around Valentine’s day (February 14) or Carnival (February 23) (my guess at a super-spreader-event).
- The Dutch lockdown started in steps on March 11 and can be taken as effective on March 18 (day 24 since Carnival). It may be mentioned that the virus likely came via Italy but also that scenes in Italian hospitals had an influence on the Dutch decision on a lockdown.
- The Dutch death count per day reached its top around April 5, six weeks after Carnival.
- Today we are some 17 weeks after Carnival with hardly any recorded deaths and excess mortality.
- All-cause mortality is annually some 150,000 persons on average anyway. We may be speaking about 1% loss of life expectancy, but the risk of the virus of course is that it may still explode to the level of 250,000 (see below) additional deaths.
- For climate change, the 2020-2030 decade still is crucial, and the world is in dire need of policies that work, see here.
Addendum July 5 2020: The figure of 250,000 deaths derives from a didactic scenario with R0 = 4 and an IFF of 1.5%. The figure assumes that Rt = R0 = 4 whatever happens. It is not claimed that this is a realistic scenario though I am inclined to think that it might be close to a worst case scenario. The point is that a realistic scenario has endogenous reactions, with people noticing the epidemic and reducing contacts themselves before the government steps in with additional measures. With endogenous reactions, perhaps the death toll might be a factor 10 less, thus 25,000, so that the effect of government measures is only the last 1/3 to 9000. The issue of what would be realistic scenario’s forms part of the huge unknowns in this discussion.
In the former weblog entry, I discussed: (i) my change of viewpoint towards containment / suppression / eradication, and current rejection of the scenario of using the virus as its own vaccine while shielding the vulnerables, (ii) a redesign of didactics of some epidemiological models, (iii) the abuse of the notion of “herd immunity” in much discussion about the virus. (Recommended reading is Pueyo.)
The new Dutch government “dashboard” gives a daily or weekly figure and doesn’t allow you to trace the history or look at a forecast yet. RIVM has always declined to make projections about mortality and loss in (quality adjusted) life years. RIVM neither states the economic cost of the policy. The dashboard states that it is being developed, and perhaps we may hope for such crucial information in the future. Today the estimate is that there would be 1715 infected persons. It is remarkable that so few people can threaten the entire EUR 800 bn Dutch economy. (It is not clear to me how this number has been estimated, and if tests have been used how the false positives have been accounted for.) The key problem is the asymptomatic transmission, because most people with symptoms would tend to see their social duty of self-quarantine. This week, the 5-day Rt would be 1.05 which roughly means that over 5 days there could be 1715 * 1.05 infected persons. The infection fatality factor (IFF) of 1.38% over February-June indicates that 24 of these people could die. Perhaps a point of reference are the 661 / 52 = 12.7 weekly deaths in traffic accidents. However, many deaths occurred in care-homes, and perhaps the country has now learned to better protect the vulnerables. If those 1715 people would be only healthy <60 with an IFF of 0.06% then there would be 1 death. The dashboard doesn’t give the age distribution of the estimated 1715 infected persons. Presumably these are like the population age distribution but this is dubious. This means that the “dashboard” doesn’t give us the crucial information about what these figures actually mean. The government has been working on the SARS-CoV-2 issue since January and they still do not grasp what relevant information is. It is not so that the crucial information isn’t there, but they simply do not collect or present it. Somehow the world of medicine and epidemiology are still at a far distance from the world of public health (economics and statistics). (See also the Appendix, example 6 on the “dashboard”.)
The exit strategy
The following could also have been discussed and settled in January / February, with the information available then (and the R0 estimated back then at 2.7). See the articles that had been published in The Lancet in January. RIVM failed in its task of protecting the country from the epidemic. See the next section with some causes why it wasn’t settled back then.
In all exit strategies, there is (i) research for vaccines, tests and treatment, and (ii) while such do not exist yet, society better is segmented, and the vulnerable section of society (currently the 60+ aged and those with comorbidity) would be shielded by a “quarantine border” of test, test, and test of source and contact tracing (SCT). The only issue is what to do with the less vulnerables.
- Containment, and at best eradication. The age <60 healthy population is less likely to suffer an infection, but when they do have an infection then the virus may have nasty properties. This suggests that eradication is a better strategy. Thus, test, test, and test, with source and contact tracing (SCT) and quarantine of those who have been in contact with someone infected (or suspected of being infected). Eradication is only feasible if the WHO establishes the virus as unacceptable indeed, with international agreement. My preference has shifted to this scenario, see Tabarrok (2020). It is urgent that the Dutch ZiN provides clarity about the burden of disease and the qaly corrections.
- Mitigation. The virus can be used as its own vaccine. See here how this could be done in Holland. Since even the less vulnerables might still appear to be vulnerable after all, we need to reserve ICU capacity. Also, shielding of the vulnerables might not be perfect, and there still may be quarantine breaches with some transmissions. Since a vaccine may take a while, or might not work well for this part of society, many vulnerables might prefer to move to gated communities or larger protected areas, with specialisation of hospitals and such to particular service areas. With proper management, the number of deaths and life-years lost would be comparable to other diseases. (De Vlas & Coffeng (2020), Van Bunnik et al. (2020), Colignatus (2020 – April 5), Eichenberger et al. (2020).)
- Muddling through and lock on-off. This assumes that the above two options are not feasible, or society doesn’t make a decision, and we muddle through, a bit as we have been doing. This would be the “Harvard study”, Kissler et al. (2020), but they do not elaborate on the effect on the economy, as RIVM hasn’t done either. Overall, the WHO commission on macro-economics and health (CMH) is underdeveloped, even though it is a key chapter for public health (economics).
How did we get into the emergency brake of the lockdown ?
The choice between containment (eradication) or mitigation could already have been made in Holland in early February, with the information available from China.
There is the WHO PHEIC of January 30, the article by Wu et al. (2020) in The Lancet January 31, and the WHO research roadmap of February 12. We ought to assume that the epidemiologists know about pandemics. They ought to be able to inform their medical colleagues, public health authorities and policy makers about the risks of a pandemic.
Dutch microbiologist and former president of the Dutch federation of associations for research in medicine, John Jacobs, states that the Dutch agencies were lost in a well-mapped world (Dutch).
Example countries who chose for containment are Taiwan and South Korea, and in Europe there is Greece (though I did not see excess mortality yet). Sweden adopted mitigation with the deliberate build-up of herd immunity, and later admitted to having misjudged the protection of the vulnerables in care homes.
In Holland, RIVM (the Dutch CDC), supported by the advisory council called “Outbreak Management Team” (OTM) from the medical world and universities, on January 27 advised the minister of health to declare the virus as a risk of category A, meaning that mandatory quarantine was possible. However, RIVM still underestimated the problem so that the month of February was lost, see the convention on the virus at the Dutch Academy of Sciences (KNAW) on February 21. Even virologist Marion Koopmans (Erasmus MC), who has been warning for some years about the risk of a pandemic, now (interview June 19) acknowledges that she underestimated the asymptomatic transmission of the virus, even while it had been reported. However, the Dutch system of source and contact tracing (SCT) failed more structurally, see below.
In March, the government and RIVM applied the emergency brake of the national lockdown. The cost of the delay was 9000 deaths and economic disaster, but the emergency brake prevented some 240,000 deaths and other economic fall-out. At least Holland is not like the USA or Brazil. (PM. Also for comparing hospital data, it is important to recall that the USA has a different system, and that not all infected persons have the option to go to the hospital. Perhaps the notion of universal health care might make more sense to Americans now ?)
PM. Richard Horton, editor of The Lancet, regards the UK handling of the issue as catastrophic:
“Individually, they’re great people, but the system was a catastrophic failure.”
In a review of Horton’s book, reviewer Mark Honigsbaum, with a background in politics, philosophy and economics at Oxford and a PhD on the history of influenza (cv), makes a very strange comment:
“Horton is on firmer ground when he points out that by the end of January, the Lancet had published five papers setting out the risks of a global pandemic and how Sars-CoV-2 could be controlled using track-and-trace measures successfully employed during the first Sars outbreak in 2003. However, given the confusing data coming out of China in January, it is an exaggeration to say that the WHO’s declaration of an international public health emergency on 30 January was the “wake-up call” the world needed, especially as the WHO did not recommend travel bans and waited until 12 March to declare a pandemic.”
This is very strange since:
- The PHEIC is by definition the wake up call, that announces the risk that there can be a pandemic. By definition it differs from the observation that there is a pandemic.
- Honigsbaum does not extend on what would be “confusing” about the articles published in The Lancet (having passed some peer review as opposed to media reports). (Let me again refer Dutch readers to the review by Jacobs that Holland got lost in a well-mapped world.)
- Overall this review is misrepresenting and sloppy, and uses a gimmick to seem “balanced and unbiased” (as is expected from a review). Honigsbaum is advised to retract this or his thesis.
The medical world and litigation
Remarkably, the medical world will not use the virus as its own vaccine, but they will allow the virus to spread “by itself”, so that “herd immunity” can be built up.
Think about this for a while. You reject the responsibility of creating and monitoring driver’s licenses but will allow that people simply start driving and learn it the hard way. How much sense does this make to you ?
It must be an issue of legal responsibility. A vaccinator apparently might be sued for malpractice but cannot be held accountable when looking away. The “Harvard study” (Kissler et al. (2020) in Science) mentions the process towards “herd immunity”: those infected get a fair chance at the ICU, even though 30-50% of the vulnerables would die at the ICU. It is your own responsibility, or a “natural phenomenon” when you get infected.
It is scientifically sound of course when mathematical properties of reduced infection rates are described (perhaps also with the label “herd immunity” even when the label is inaccurate).
However, the issue now is whether you can use such phenomenon as an acceptable component in a public health strategy.
The ethical view is that if you allow a virus to spread then you must also consider using it as its own vaccine. And if you reject using it as its own vaccine (and thus don’t consider it safe enough), then you should not allow it to spread.
Dutch viewers might look at the tv interview with Jaap van Dissel (RIVM) by Marielle Tweebeeke, “Hoe werkt groepsimmuniteit?”, broadcast March 16. The interview shows Van Dissel as incompetent and manipulative and untrustworthy.
- Van Dissel does not mention the strategy of containment / suppression by SCT.
- He does not mention that RIVM goofed in February by not developing this scenario so that they needed the emergency brake of the lockdown. He does not present any excuse for his failure.
- He presents the psychological frame of three options, of which two are extreme and the third is the proposed one. This is clearly a political frame and no scientific listing of the options.
- He does not mention that the virus has nasty properties that can show also in younger and healthier persons. (Personally I only discovered this rather late in tracking the discussion about the virus, and I suppose that doctors knew this much earlier.)
- He allows people to get infected “by natural processes” but doesn’t mention that if he considers the virus to be so safe that he allows it to run around, that by implication it can also be used as its own vaccine. He focuses on the younger and healthier persons and suggests protection of the elderly and comorbid risk groups, but is vague on the contacts between the groups.
- He mentions herd immunity as a goal (which later will become a by-product) but does not specify that this goal cannot be attained when the lockdown reduces Rt to a much lower value.
Apart from Van Dissel’s disingenuity on RIVM’s goofing on SCT, this kind of reasoning in epidemiology is rather conventional, see also the Harvard study, though it still is (horribly) irrational. The reasoning dates from medieval times before Bismarck and the creation of public health. It is akin to the Anglo-Saxon, but rather Viking, mentality of preferring contest above co-operation. However, we are no longer in pure nature anymore. Public health by definition has the objective to balance benefits and costs.
The issue of legal responsibility for allowing a potentially lethal virus to run its course better be discussed in the open.
In Holland RIVM on January 27 activated SCT but later tended to emphasize “herd immunity” (exit strategy 2 or 3) rather than containment (with SCT). (See this discussion.) Indeed, if you want people to become infected then you don’t need to test them. In this manner, however, RIVM tended to overlook the importance of SCT for the quarantine protection of the vulnerables too: and many deaths were recorded in the care homes, while others at home were not tested and showed up as “excess mortality”.
The failure of Dutch source and contact tracing (SCT)
RIVM might not have been aware enough of the situation for SCT for a pandemic, though they did warn about understaffing at GGD before. An early RIVM document of January 27 2020 already advised the ministry to give alert status A to the infection by the virus, but only in case of symptoms. The document did not deal with one of the known key properties of this virus of asymptomatic transmission – which had been reported about in China. When the number of cases exploded, the Dutch stopped SCT instead of hiring more people to do it. The Dutch system of SCT failed:
- The Dutch GGD are bureaus assigned to municipalities without a central headquarter. They still have responsibility for source and contact tracing (SCT) for the entire country. Eventually the nestor spoke up for all but without legal position. They appear to have been underfunded and less prepared for a pandemic, see here. The GGD in 2014 reported to “being below the capacity of a pilot light“, and RIVM in 2015 confirmed that more than half of the GGD bureaus had insufficient numbers of doctors to do the job of infection control. Apparently, GGD even lost the capacity to understand what was needed for a pandemic even though it is their job. They waited for instructions from others while it is their job to do something. In April almost four weeks were lost on “waiting”.
- We now see a blame game between RIVM, GGD and the ministry of health about who would be responsible for the January / February disaster and also the lost month of April, while Dutch parliament takes a vacation and hopes that all will be clear by September 1, and properly prepared if the 2nd wave would arrive.
- Unfortunately, the Dutch method of SCT is lackluster compared to the German manner anyway. The Dutch instruction looks at symptoms indeed while the German instruction allows for contacts with an infected person anyhow. At first, the GGD nestor suggested to “write a letter”, like with a sexually transmitted infection, instead of using the phone.
- RIVM stated that there would not be enough capacity for testing, which might have been literally true at some point, but did not investigate the issue. It later appeared that such capacity could easily be expanded. RIVM misinformed the Dutch.
- The ministry announced recently that in July there would be an app for contact tracing by phone.
What are major unknowns ?
I am an econometrician and teacher of mathematics and no medical doctor. The literature about this virus is already huge and there will be more known than I can oversee. Key issues with lack of knowledge for me are:
- What kind of model will cover epidemiology (days) and the national budget cycle (year and medium term) and long term sustainability (world population in 2100) ? Acemoglu et al. (2020) suggest that we might need another modeling format and more complex modeling for all the interactions that are relevant for a more realistic discussion of the pandemic. Even these authors do not explicitly mention the life-years – though they link the life-years to lost economic output.
- Apparently we still know relatively little about the aetiology (natural history) of the virus. Also a study by Ganyani et al. (2020) in which RIVM participated uses data of some 200 follow-up cases from the early outbreak in China. There are some 40,000 hospital cases in Holland for which GGD might have performed a statistical analysis for key model parameters, and comparable cases known by general practitioners. As far as I know, there is no such study yet. Perhaps such study has been delegated to GGD but then they do not have the funds to do so ?
- For testing, a fairly quick method, comparable to a pregnancy test, apparently has been developed at MIT (“Sherlock“). It is not clear to me whether the race for a vaccine and the race for a treatment are accompanied by a similar race for such testing. The criteria for a vaccine appear to be rather tough (see above on litigation, and using the virus as its own vaccine), but the criteria for a test might be much easier (including sensitivity and specificity). Perhaps such a test might be taken as a pill and produce an artificial symptom (e.g. a different colour of one’s urine), so that asymptomatic transmission by the virus need no longer be such a problem: for the person with such an artificial symptom knows that self-quarantine is required.
- RIVM (the Dutch CDC) still publishes only deaths and not (quality adjusted) “expected life years lost”, and thus still has an epidemiological and no Public Health focus (though their mission and very name concerns public health and the environment). My first weblog on the SARS-CoV-2 pandemic also pointed to the Unit-Square-Root as a compromise between lives and years (March 31). The combined CDC’s and National Institutes of Health of Europe ought to be able to present a study of the cost-effectiveness of handling SARS-CoV-2, and such study ought to have the same quality as a cost-effectiveness study on the annual flu vaccine – using measures that avoid a national lockdown. It is too simple to argue that the medical world can only do cost-effectiveness studies when a vaccine already exists: if there is no vaccine yet then consider measures other than the emergency brake of the lockdown of the national economy.
- There now is an official proposal about triage in the 3rd stage of ICU treatment, in which the life-years gained criterion has been given more attention. Medical ethics can be rather mundane at times – like “first come first served” – with rules that allow for emergency decisions based upon little information. In the modern world, with electronic patient dossiers, such information however tends to be available, and the emphasis lies on the willingness of the medical world to consider more complicated algorithms. They are advised to consider that also other areas – like construction, transport, economics – have considerations about the value of life. There is a key distinction between macro problems, like allocating funds for food security versus national defense, and the micro problem about the next available bed, but such aspects can better be discussed than neglected. (At least, if you neglect it, do not base this upon an axiom as if medical problems would be of special uniqueness, or that issues of life and death are medical by definition.)
- CBS Statistics Netherlands has mortality statistics that look at the “recorded cause” like “pneumonia” or “heart failure”, or whatever doctors record as the cause of death, and it is quite a statistical exercise for example to determine the impact of a flu season. Apparently such statistical exercise is still in the making for SARS-CoV-2 (with uncertainty about excess mortality), and it is unclear why there was no immediate action on this (e.g. with taking of samples of people dying since February, with the option to test them later). Overall, medical research would be served by a more sophisticated recording of diseases, treatments and causes of death. (For cancer, risk factors are body mass (number of cells), age (time for processes to go wrong) and cell specialisation (specialised cells don’t change much).)
- There is no clarity about the delay in the normal health care due to the SARS-CoV-2 episode in the first half of 2020. What is the burden of disease and death of this effect ? It is no use crying over spilled milk but what can we learn about maintaining common care if there would be this 2nd wave or the next pandemic (if we don’t do anything about environmental sustainability) ?
- What is the situation on immunity and mutation ? As we know little about this, what are the risks and how will we be dealing with those ?
- What would be the relevant path to allow the WHO to decide, with proper data, on whether the virus better be eradicated or not ?
Repair of national trust
National trust has corroded. The captain of the ship had been given the task to steer the ship between Scylla and Charybdis, but hit Scylla with 9000 deaths and hit Charybdis with a dent in the economy and people’s income and savings.
It is true that the government and RIVM by using the emergency brake have prevented some 240,000 deaths, but today the same arguments on content apply that already existed in January / February, so that the delay since February doesn’t make sense.
More and more people understand that this delay, of now a half year, was not caused by lack of information, as RIVM claims, but by indecision at the cost of the general public.
Richard Horton, editor of The Lancet, can say: “Individually, they’re great people, but the system was a catastrophic failure.” However, for a government it is expected that it observes that something is amiss structurally. When that conclusion isn’t made and when repairs aren’t started, then people become restless and wonder why there is such delay at their cost. Not far away is the question: Would the government dodge the issue again at the next event ? Can I still trust that my life and livelihood are safe in their hands ?
Overall, I would also say that the Dutch government structurally misinforms the public also about the situation on environmental sustainability (see here) and the options for economic policy (see here). But okay, the objective is to focus on SARS-CoV-2 now.
Today, the government and RIVM and NiZ are still ambiguous about “containment” (with SCT) and “mitigation” (with “herd immunity”). The situation has improved, with few infections and hardly any recorded new deaths anymore, and with the availability of personal protection equipment (PPE), and testing and SCT. Nowadays, policy makers can choose for containment more easily.
But economic uncertainty is still large, and employers and employees still fear the Fall and the risk of a second wave. The lack of clarity in choice, the lack of admission of mistakes, and the highly problematic economic situation: they now have created a smoldering fire of distrust.
And Dutch parliament intends to take a two-month vacation ?
NB. An evidence-based diagnosis of the corrosion of trust might require an opinion poll, but opinions might also be misguided, as the media still tend to portray RIVM as an anchor in the storm. Journalists love authorities and distrust outside scientists. This weblog diagnoses corrosion not by opinion poll but on content. When people refer to these points of content and state that they no longer trust the government and RIVM, then they cannot be said to be incorrect. When the media still portray RIVM as an anchor in the storm then the media apparently neglect this evidence. The appendix contains some other examples how RIVM clearly destroyed trust. Such examples might be seen as anecdotal only but the above clarifies that they are a result of a decision making structure.
Appendix. Some examples of corroding national trust
These examples might be seen as anecdotal only but the above clarifies that they are a result of a decision making structure.
Example 1. Earlier, the Dutch government did not want an evaluation by September 1. It required a petition and parliamentarian involvement before the government agreed to have it made. It still is not clear what the evaluation will involve in particular.
Example 2. John Jacobs is a biomedical researcher and has a clear statement in favour of containment and suppression (in Dutch). Why is this clarity missing at RIVM ? What is their answer ? Jacobs explains that scientific advice must be open access. When scientists participate in the OMT and longer have open access, then they no longer do science in this OMT.
(If RIVM keeps information secret (perhaps to avoid panic in the population) then they should not parade the involvement of scientists. But okay, it would be another extreme when the very existence of such contacts would be secret too … My diagnosis is that the position of scientists and scholars also involved in actual advice requires a key improvement, see here.)
Example 3. Jasper Lukkezen, editor of the Dutch economics journal ESB, reports that it now has occurred twice in the last months that an article about the cost-effectiveness of the virus policy has been withdrawn by the authors themselves. In one case, there was too much uncertainty about key assumptions. (Such uncertainty indeed holds in general. Lukkezen doesn’t say so, but I infer that it also relates to the lack of information by RIVM: you cannot check what they do when they control the information. In economics, we have a distinction between CBS that establishes the statistical data and CPB that does the planning.) For another case there was the “large political and social pressure concerning the lockdown measures”. This author referred to the case of Alfred Kleinknecht who since the 1990s presents an analysis that the Ministry of Economic Affairs disagrees with, so that they no longer gave him contracts for research. (See: (a) Kleinknecht’s website, (b) my disagreement with Kleinknecht.)
Example 4. There was the focus on the (end of pipe) ICU and the lack of attention for the (begin of pipe) home care that sends patients to the ICU. There was the curious discussion about closing schools and the role of children. There is the issue of aerosols and ventilation. RIVM first rejected the relevance of face masks and later agreed with using them in public transport. As said, RIVM misinformed the Dutch about the capacity on testing. There is the ambiguity and inconsistency on SCT and herd immunity. RIVM has made many errors and has tried to cover up and spin those errors too often.
Example 5. If Rt = 10 holds in one week then R(t+i) = 10 need not hold also in subsequent weeks, because the situation can change. Maurice de Hond rightly criticises RIVM for stating only Rt < 1 or Rt > 1 without clarifying the effect size. When the number of infected people concerns a small number of people, like the 1715 people on a population of 17.4 million, as reported on June 25, then even a value like Rt = 10 may have a limited impact. If over 5 days 1715 * 10 = 17150 people would be infected, and if these people would be youngsters with IFF = 0.06%, then 10 youngsters would die, while traffic accidents have 55 deaths per month. There can be safeguards, like proper reporting also about the effect size, so that Rt and the effect go down again. De Hond denounces the RIVM focus on Rt only as scaremongering and “malevolent”. I regard De Hond’s denunciation as over the top. It may also be a result from an overall lack of communication between RIVM and De Hond: however, we should expect a government institution to decently answer to fair questions. My impression is that RIVM is aware of this issue of the effect size, but simply hasn’t been creative enough to develop the proper dashboard. Aspect are: (1) RIVM refuses to state forecasts of expected deaths, as “speculative”, but then neglects that this is precisely the kind of information that is required (with nuances on qaly’s and cost-effectiveness). (2) Epidemiological models give projections of the developments of infections, clearing and deaths, and it is precisely this kind of information that best is provided by such a dashboard, so that users can see what is involved over what time horizon. (3) While RIVM states that it calibrates the calculation of Rt with hospital admissions, I think that they use a more complex model, while De Hond suggests that they use those numbers directly. I suppose that this can be clarified.
Example 6. Science journalist Jop de Vrieze reported on May 20:
“Hans Heesterbeek is not comfortable with the situation. The professor of theoretical epidemiology at Utrecht University also founded a Slack group in late March, together with chief modeler Jacco Wallinga of RIVM and professor Sake de Vlas of Erasmus MC, with the objective to also give RIVM an opportunity to submit modeling questions to experts from outside the institute, notably questions that are relevant for the Dutch exit strategy. “But these questions have not yet been asked since RIVM has been so busy.” As a result, precious time has been lost. Although contact tracing is now being scaled up, and the lockdown is being relaxed step by step, the substantiation for the dashboard that the Cabinet wants to use is minimal, says Heesterbeek.”
(Dutch; “Hans Heesterbeek is er niet gerust op. De hoogleraar theoretische epidemiologie aan de Universiteit Utrecht richtte nota bene eind maart samen met hoofdmodelleur Jacco Wallinga van het rivm en hoogleraar Sake de Vlas van het Erasmus MC half maart een Slackgroep op, waarin het rivm aan experts van buiten het instituut modelleringsvragen kon voorleggen die relevant zijn voor de Nederlandse exit-strategie. ‘Maar die vragen zijn er door de drukte nog niet gekomen.’ Hierdoor is er kostbare tijd verloren gegaan. Het contactonderzoek wordt nu weliswaar opgeschaald, er wordt stap voor stap versoepeld, maar de onderbouwing voor het dashboard dat het kabinet wil gaan gebruiken is minimaal, zegt Heesterbeek.”)
Example 7. Science journalist Jop de Vrieze reported on May 6: Yaneer Bar-Yam, who has been warning about a pandemic for 15 years and who set up www.endcoronavirus.org, sent a letter to RIVM on March 9, advising to do more and asking why RIVM wasn’t doing more. He did not get a reply yet. One might argue that RIVM may select itself whom it communicates with, but one cannot exclude valid questions by fellow scientists.
On May 5, De Vrieze quotes Bar-Yam on face masks:
Question: “The WHO does not yet advise the public to wear masks.” Answer: “Well, the question remains: if something is evident, are you waiting for an extensive study, or will you assume that it helps if you apply them correctly? We want to stop the outbreak. A good article has appeared that covers all of this: Why we all need to wear masks. If you continue to emphasize that masks are of no use, you swap absence of evidence with evidence of absence. That It [has no proven use][?] becomes a kind of mantra. They think they are talking about science, but they don’t. ”
Dutch: “De WHO geeft nog niet het advies om massaal mondkapjes te dragen. ‘Tja, de vraag blijft: als iets evident is, wacht je dan op een uitgebreide studie of ga je er vanuit dat het wanneer je ze goed toepast helpt? We willen de uitbraak stoppen. Er is een goed stuk verschenen dat dit allemaal behandelt: Why we should all wear masks. Wie blijft benadrukken dat maskers geen nut hebben, verwisselt absence of evidence met evidence of absence. Dat Het [geeft geen bewezen nut][?] wordt een soort mantra. Ze denken dat ze het over wetenschap hebben, maar dat doen ze niet.’”
Example 8. Science journalist Jop de Vrieze on April 15 reported that Denny Borsboom invites government institutes to use open access methods to better use expertise at the academia and research institutes. There is this grassroots project but the harvest is not great. Scientists are aware that it isn’t efficient to put in energy without knowing that results will be used.
Example 9. On April 5, Maarten Keulemans, who studied history and antropology but still got a job as “science journalist” at Volkskrant, distorted a view that had been expressed by lawyer Jort Kelder. The latter had proposed to protect the elderly and make more speed with RIVM / Van Dissel’s “herd immunity” so that the economy could be saved. Keulemans applied the case fatality rates as published by the Imperial College in The Lancet, with instant flooding of the ICUs and not spreading the case load over time, and then he criticised Kelder instead of RIVM. Thus he distorted a critical view and was not critical enough w.r.t. the figure of authority. To this day Keulemans portrays Van Dissel as the wise national doctor instead that he performs critical journalism and informs the newspaper readership about the failure and spin. (This is not the first error made by Keulemans over time.) (The Volkskrant readership tends to be in education and health care.)
Example 10. I saved explicit lunacy for the last. Pepijn van Erp deconstructed the reasoning errors by Willem Engel, but the latter still managed to set up a demonstration on June 20 that ended in violence with 400 arrests. Remarkably Engel called for an end of the lockdown and such ending was quite in sight for July 1 but they still had the demonstration. Lunatics might not see their own errors but they might spot errors made by the national authorities (and then regard such errors by officials as proof that they themselves would not make errors). There is a tv channel around gold-bug Willem Middelkoop which tv channel parasitically feeds upon unrest and conspiracy theories, but there were two remarkably correct tv interviews, one with Cees Hamelink (on the government abuse of science) (wikipedia) and another with Michaela Schippers (on mass hysteria) (cv).