Croatian Scientist Igor Rudan Provides COVID-19 Quarantine Clarity

By 12 March 2020

March the 12th, 2020 - If you've been following us since the COVID-19 outbreak began, we've been translating and transmitting the musings of prominent and highly cited Croatian scientist Igor Rudan. Rudan is an extremely highly educated individual who has a vast knowledge of coronaviruses.

We bring you his latest statement, posted on Facebook, translated into English in full below:

''I was pleased to see today that my namesake, Igor Stagljar, has decided to stop making press statements about COVID-19, given the psychosis we're currently in. It's interesting that a leading world scientist in Toronto, such as Igor Stagljar, doesn't feel specialised enough to write about this topic. It's worth thinking about it a bit.

Yesterday, however, I received more than thirty requests for interviews from all over former Yugoslavia, because the article in, regardless of its extreme length, has gone viral from Kranjska Gora to Gevgelija in the past 48 hours. It now has over 6,400 Facebook shares and is crawling slightly towards 200,000 views. Respect, Matija Babic, for giving it that level of exposure.

Let's think about this for a moment too: people across the former state [ex Yugoslavia] are being educated voluntarily and massively about something scientific. I'm pleased with this, of course, so I have nothing more to add through any interviews. If I have anything new to convey that could help and save people's lives, I'll write it here, so feel free to continue sharing it further.

Your reaction to my post yesterday "Panic, but in a moral way" and the messages I got in my inbox convinced me that there are still enough people in Croatia for whom it's worth clarifying things occasionally, so thank you all. Admittedly, I will no longer be able to be regular with these posts anymore, I'm back at work. Among other things, I'm editing the current issue of the Journal of Global Health on COVID-19. A dozen excellent new scientific papers have arrived, more than half of them from China, so I'm preparing a pandemic conference for the international press here in Edinburgh in one week or so.

For Croatia, I will occasionally comment on details that few people can intuitively understand unless they've specialised in this field. The role of the occasional event commentator isn't a problem for me. Moreover, I have agreed with Drazen Klaric to continue to do so from now on for my "mother ship'' - Vecernji list, which always has the right of priority for me because it taught me to read. I managed to come to terms with Drazen about conditions that aren't too stressful for me, so I will only write for one Croatian medium, and a day later I will share those posts here on Facebook.

Now let's raise the level from which we look at everything that is going on, to show you how depressing most of the discussions currently are in Croatia, and especially the division into the camps "this is a new plague" and "this is just a flu". I called this post "contrast is the mother of clarity." It will try to explain the issues that are VERY relevant to those in power who must make unprecedented political decisions in the next 48 hours.

Many wonder how I can be so laid back when I write and talk about this pandemic. But it's like someone who professionally demining minefields marvels leisurely as he strolls through them. He knows a bit about demining, while you, walking alone through a minefield, will think that every second is going to be your last. A similar thing is happening here now.

An epidemiologist is not afraid of an epidemic because he knows that any epidemic can be effectively suppressed, it's only a matter of drastic measures. That's what I said in my initial press statements - if the situation gets worse, we have at least a few more safety nets that we can activate. Today I will explain what I meant by that, because the time has come for that.

So, if it wanted to, Croatia could become the "world champion" in the fight against COVID-19. In less than two months, we could declare Croatia a coronavirus-free zone. The total number of cases would probably not exceed 1,000, and the death toll would indeed be very small. And that's why all the debate about the severity of COVID-19 symptoms and the flu has been aroused, because that's not what an epidemiologist primarily cares about. It is important for the epidemiologist to curb the epidemic. Any epidemic will be on a safe path towards extinction when every infected person infects on average less than one healthy person. Also, it will be on the safe path of exponential spread when every infected person infects, on average, MORE than one healthy person.

Without anti-epidemic measures, this new coronavirus spreads from every infected person to at least 2.2 new healthy subjects, predominantly in the incubation phase, while the infected person doesn't yet show any symptoms. All one has to do is reduce that number to below 1.0 and the epidemic will slowly be extinguished, which can be achieved by strict quarantine.

Read that again, because that's the key thing for epidemiologists. Otherwise, it could be said that rabies is "much more dangerous than the flu" because 100 percent of those infected with it die, and in a much worse way. But for the epidemiologist, it doesn't matter, because the last indigenous rabies case in Croatia was probably recorded in 1964. And for all hunters who are bitten by a rabid boar, fox or dog, immunoprophylaxis can be easily performed, so the epidemiologist knows what to do. So, it's already starting to go that way with coronavirus. We now know that we can suppress it with strict quarantine.

For an epidemiologist, more dangerous is the disease from which more people will die this year, no matter what symptoms they have before they die, they're not so concerned with that. And if we really want to, we can suppress and control coronavirus through strict quarantines, as the Chinese did for one sixth of the world's population, with fewer than 3,200 deaths currently per one billion and four hundred million people.

So, if Croatia were to decide today that it wanted to be the "world champion" in the fight against coronaviruses, it would have to apply the following measures to prevent the spread of the virus - we'll call it "extreme left and planned" measures. It should:

- completely close and control all borders, preventing anyone from entering and exiting;
- all Croatian citizens wishing to return to Croatia should be received but be quarantined for at least 30 days before being released to their homes (this is the longest incubation recorded);
- order everyone to stay in their houses and flats for the next two months (during which time all infected people would become ill and infect other people, until the virus no longer had anyone to transfer to and would thus disappear);
- only self-service shops and an absolute minimum of public services (heating plants, power plants, telecommunications, TV and radio) would operate;
- allow only the youngest member of the household to go to the self-service once every three days (the youngest, because children have the lowest risk of dying), wearing a mask and gloves, and only if they have no symptoms;
- arrange a neighbour to go and pick up things for all elderly people and then supply that person with a mask and gloves;
- almost all patients would be treated by mobile medical teams coming to households with portable respirators; efforts should be made at all costs to avoid bringing infected persons to hospitals, so as not to cause hospital outbreaks, which would have a much higher rate of death than community outbreaks;
- banks, mobile operators, and others should be instructed not to charge loan installments during those two months.

Here, with such radical measures and completely impermeable borders, Croatia would get rid of coronavirus probably within two months, given the current situation, with a truly minimal number of deaths. It's absolutely crucial to prevent the introduction of coronaviruses into non-infectious wards. This was the main cause of the horrific numbers [of those dying] from the outbreak of the epidemics in Wuhan and Lombardy.

However, like any interesting story, this one has its own unexpected twist. The consequences of such drastic measures for the national economy would be catastrophic. Two lost months of work, to become virus free before anything else, sometime in mid-May. Just in time for the tourist season. But the problem is that others would not have succeeded by then. That is why we'd still not be able to welcome anyone to Croatia. And so, the agony for the economy would continue all summer long.

And because of the catastrophe for the economy, the number of unemployed and illiquid people will increase, people will turn to alcoholism, be depressed, suffer from insomnia, marriages will fall apart, cancer and cardiovascular mortality rates will rise. Finally, those rescued from coronaviruses will suffer from diseases that will result from a new wave of poverty and recession. Only, these diseases and deaths will not happen in front of the cameras and nobody will blame those in power for them. And for literally every single coronavirus death - they will.

If you've followed all this by now, you'll understand that in this scenario, both outcomes are, in fact, bad. But by curbing the epidemic, government officials will appear more competent, and no one will later blame them for perhaps more deaths and problems that will later arise as a result of a recession.

Another extreme approach could be called "extremely neoliberal". At the moment, Donald Trump may be intensely thinking about it, but probably at least some other countries have it. Specifically, the virus can be allowed to spread freely. In doing so, as few people would be tested for the virus to minimise the number of deaths attributable to the coronavirus, especially among very old people. It would come to, perhaps, to a death rate of up to 1 percent among all those infected, but it would save the economy and avoid that "subsequent wave" of deaths. Because in this extreme scenario, mostly older people would die. This would, from some radically neoliberal point of view, even "unburden" pension funds and the health system. Many people in the most productive age for society, who would otherwise be the majority victims of the recession, would be saved.

The problem with this approach, however, is that there should be accuracy in estimating how many people will die, that is, to gamble with the certainty that scientists have in the rate of death from a virus in the community. I estimate that it is 0.5 to 1 percent, which puts it just outside the margins around which such an approach can be considered, and that the death toll from the epidemic roughly corresponds to the estimated number of post-recession deaths.

It's possible that Trump is currently awaiting reports from American soil about these death rates and wants to have as much security in them as possible. This is like a chess game with China for him. But he came across an unforeseen obstacle, which is that with this strain of the virus in Italy, it seems like something is wrong. Perhaps that's why Trump ordered the suspension of Europeans' entry into the US today, with the exception of the British.

He may have a plan that makes him look smarter than anyone, but he knows he needs to be sure that "their" virus in the US kills less than 1 percent of those infected, with the potential to gamble on the possibility of the virus disappearing in late spring. But it bothers him, like all of us, that no one is sure of the death rate for this ''Italian'' virus. So, things are a bit more complicated than most Croatian experts on Facebook think.

Trump's biggest problem, however, is the media and the public reaction. And the worst possible choice is to hesitate between these two extremes, so deciding to "not act" and letting the virus spread greatly, but when people start to die, under pressure from the public and the media, the introduction of quarantine is too late. Because, then, it would be a disaster for both the economy and for public health. A lot of people would die and the quarantines would last much longer after such a decision, until the virus disappeared.

I've already estimated for Croatia that the "extreme left and planned" approach would immediately and now be able to stem the epidemic in our country, maybe only up to a thousand cases and with a small number of deaths, if everything went perfectly according to plan - this is the ideal, "best case scenario'' for Croatia. However, over time, several thousand people would later die indirectly as a result of the economic recession. They would probably be middle-aged and older, and would be saved from coronavirus by perhaps the same number of average elderly people. The economy would be put into reverse, but the media would rate the moves of those in power favourably.

On the other hand, the "extreme neoliberal" approach of allowing the virus to freely spread would be met with strong condemnation by the media and the public in Croatia. Thousands of people could die from the epidemic, but life would go on. Instead of about 60,000 deaths in 2020, Croatia would have about 70,000 deaths. But only on condition that we've accurately estimated the death rate of the virus and that nothing goes unforeseen.

The decision of Croatia's ruling bodies, but also those of other countries, will be somewhere between these two extreme approaches - rigorous quarantine and a complete failure to act. I think this second extreme is becoming an increasingly unlikely choice because of such an intense media focus on the pandemic. This is why many European countries are now looking at each other and waiting for what and when to do it, because it's not an easy decision.

I hope that you now understand what the current issues are which are important to people who have to make decisions over the next two or three days that will determine the lives of all of us over the coming months. Two scenarios, thirty hours. Like in a movie.''

This text was written by Igor Rudan and translated by Lauren Simmonds

For rolling information and updates in English on coronavirus in Croatia, as well as other lengthy articles written by Croatian epidemiologist Igor Rudan, follow our dedicated section.