Igor Rudan: How Can We Move from Defence to Attack in Coronavirus Fight?

By 26 March 2020

Why does the director of the World Health Organisation keep repeating: "test, test, test"? How are the conditions for quarantine created, how might coexistence with coronavirus look, and how can the virus be attacked?

As Igor Rudan/Vecernji list writes on the 26th of March, 2020, Croatia has become a major quarantine - temporarily. This prevents the new coronavirus from spreading too quickly. As a result, the number of serious COVID-19 cases in our country shouldn’t increase too rapidly. This will enable our healthcare system to help anyone who develops a more severe form of the illness. Our healthcare professionals will save many lives in the coming weeks. If we all adhere to the quarantine provisions, our health care system will continue to be able to help those with other illnesses in need of intensive care. By staying in our own homes, we’re all now protecting our health care system from overloading, which could otherwise occur under the pressure of too many coronavirus patients.

After all of us found ourselves in such an unusual situation, many people have been asking me questions over recent days. The most common of these are: "What will happen next?"; "How long will this last?"; "Why didn't we test a lot more and avoid quarantine, like some Asian countries did?" Many people are also wondering if we really have to threaten the economy this way in order to, as they say, "extend the lives of those among us who are already the oldest and the most unwell?"

It isn’t even clear to many why societies have created a climate that stops people's "right to die from COVID-19"? By comparison, about eight million people worldwide die directly from smoking annually. Nearly one million of those deaths are of non-smokers, who smoke their household members’ cigarette smoke. Why aren't the deaths of all these hapless "passive smokers" tracked in the same way? Furthermore, more than one million people die each year in road accidents. All drivers are exposed to it, but not everyone survives it, nor are they always guilty of it. Why is exposure to coronavirus different from driving exposure? Finally, about one million people die of AIDS a year. However, even with the total of ten million deaths per year, nobody is stopping people from smoking, driving cars, or having sex among their population. And now, because of COVID-19, we're all in our houses at once. We are also at risk from viruses and economic catastrophe, and obviously from earthquakes.

What’s going on here, then? Why are half a million people who end up dead from the flu every year completely uninteresting to the general public, but any deaths from COVID-19 are interesting to the point that country after country in the developed west sees this as economic suicide? Or, why aren’t the six million deaths of poor children worldwide interesting to the public? It seems that it would be even more reasonable to save the victims of all the aforementioned diseases than the predominantly retired, elderly and sick people around the world who are now at risk of being infected with COVID-19.

These are not simple questions at all and I'm not sure I have clear answers to them. I’m pleased, however, that the first clear plans, scientifically based ones, are finally coming out, on how to get out of this situation relatively quickly with minimal human casualties and avoiding the complete collapse of the economy.

The first step of all these plans is always to quickly and decisively close the pathways of further spread off to the virus. This avoids creating the situation of having too many infected people too quickly. The health system is then protected from complete collapse and many human lives will be saved. After that, there is a very wide range of further options. The author Tomas Pueyo recently outlined the currently most sensible coronavirus strategy and called it "The Hammer and the Dance." I expect that over the next few weeks, the governments of many developed countries will resort to some variant of this solution, because it’s reasonable. It protects people's lives and it protects the health system, but it also protects the economy. The ‘’hammer’’ is an intensive and not too long of a quarantine that reverses the flow of the epidemic and reduces the number of infected people. The ‘’dance" is then our coexistence with the virus, much like the escalation of Muhammad Ali-style strikes, where we must never again allow it to spread quickly to a large number of people.

Therefore, once this unusual situation is over, the assessment of each country's performance in dealing with the coronavirus crisis will be based on the following five questions:

1. How long and effectively did the "first line of defense" manage to prevent the free spread of coronavirus among the population? In the case of Croatia, we were practically the best in Europe.

2. When the virus broke through the "first line of defense" and began to expand exponentially throughout the population, how quickly and decisively was a strict quarantine measure activated? In the case of Croatia, the activation measures started at the right time, with the plan being not to have the number of infected people reach more than a few thousand and for the number of serious cases to reach only a few hundred. Were it not for the earthquakes and the fleeing of many from Zagreb down to the south, these figures would probably have been reached, but we’ll see in a few days just where the number of infected people will peak.

3. How closely did the population adhere to quarantine? We’re now dependent on the discipline of all of us, so that the problems that the Italians and the Spaniards now have because of their indiscipline don’t happen to us. So stay, if you can, inside your houses.

4. How fast and active was the state in mobilising its capacities and human resources, as well as creative and innovative solutions, to develop a concrete plan for quarantining and coexistence with coronavirus as quickly as possible? This is the next urgent task for Croatia. This will include the empowerment of technological capabilities and human resources for virus testing, innovative ideas on social removal measures, effective virus control measures, the use of technologies to understand human contacts and the spread of viruses, and other things.

5. How effectively, after quarantine, has the state allowed its inhabitants to move into a relatively normal life situation and preserve their economy from collapse, with permanent control over the spread of the virus? This is our fifth task, but it isn’t one that is unsolvable either.

How are we going to achieve this over the next month, and how can we continue after that? I will try to explain this with this simple story, which will explain our current situation to you, and the options at our disposal.

Let's first imagine the whole of Croatia as a group of one hundred people. Working on their computers, the group works a night shift at an office on the ground floor near Maksimir forest.

You can enter this ground floor through a rather long corridor. In Maksimir forest, as we know, there is a zoo. It is also said that a vampire wanders through the forest at night. Due to the proximity of wild animals and these rumours of a vampire, these one hundred office employees created a round ‘’net’’ made of very tough rope. They also tied one hundred bricks around the round edge of that net.

One night, a tiger escaped from the zoo. We heard about it on the radio and hoped it wouldn't come right to us, but we still pulled that net out of the closet. A moment later, the tiger walked right into our office. We threw the net at it and then each one of us firmly gripped those bricks on its edge and pressed the net down against the floor. As strong as it was, the tiger was now pressed down by the net thanks to the joint action of all of us one hundred people.

The tiger can't really do us any harm as long as each of us presses their own brick firmly against the floor. This is our current situation with coronavirus, this is quarantine.

However, all the tiger wants to do is take away just one of us and eat that person somewhere in the woods. He would leave everyone else alone and return again in a year. The oldest and most unwell people sit next to the hallway door, so the tiger would probably drag one of them away. To protect one of us, all one hundred must now hold their respective bricks pressed against the floor. It is not only tiring but it’s also boring. Nobody wants to live like that. But what else could we do? Some begin to slowly look at the old men among us, wondering if they’re really worth so much to us. Does it make sense to sacrifice the quality of life for ninety-nine of us just to save one of our old men? It is amazing that this virus has placed this type of doubt in front of us in the 21st century. Our response to the crisis will, in fact, reflect the value system of our society.

Still, everyone wondered how long we should keep this tiger pressed under the net and how to get out of this situation. Someone then remembered that vampire. If the tiger was accidentally bitten by the vampire on the way to the ground floor, then at sunrise, the tiger could simply disappear when it was illuminated by the sun. This is analogous to the disappearance of coronavirus when the warmer weather arrives. So, it seemed reasonable to endure it for at least some more time. Then one of us asked the person next to them to press down their brick with their free hand, while they try to load their rifle, with which they could simply kill the tiger. That would be an analogy for the discovery of a vaccine for this virus. Another, however, also freed himself and began to develop a fluid that would kill any appetite the tiger had. Then the tiger would leave us all alone and just walk away outside. This would be an analogy for the COVID-19 drug, which would reduce the need for respirators for the seriously ill and relieve the pressure on the health system.

Suddenly, there seemed to be as many as three options - the disappearance of the tiger at sunrise, the loading of a rifle, or the development of a fluid that would kill the tiger's appetite. The problem is, there can be no certainty that any of those measures would work. During this time, the people are less and less attached to the net. If only two or three loosen their grip in the same place, the tiger will crawl out from there, and then it would once again need to be caught in the net. However, more and more people, eager for a normal life, are beginning to wonder whether it’s better to gamble with the 99 percent chance that the tiger will not grab them than to live like this, crouching down on the floor and pressing the net against the floor with everyone else. This is especially the case for younger, faster and more adept people.

But suddenly, an engineer comes up with something else. He teams up with the miner next to him. They ask those next to them to hold down their bricks with their free hands, and they go out into the hall. The engineer instructs the miner to dig a tunnel under the corridor, which would lead back into the forest. During this time, he places ten tiles instead of the hall floor, each of them with a sensor. He installs a laser beam on the ceiling, which alternately illuminates one of these tiles. If the beam is directed at the tile sensor and the sensor doesn’t register the beam, it means that there is probably a tiger sneaking onto those tiles. Then the tiles will collapse and the tiger will fall down into the tunnel, and will have to go back into the woods and he’ll need to sneak up on us again from scratch. If the tiger ever manages to get through such a security system, we still have a rope with a bell at the end of the hall. It will alert us to the fact that he has broken through that defense and then we will catch it once again in the net. But in the meantime, we will at least be able to live more normally and continue to do our work, regardless of the fact that there is a tiger outside our building. When the system is installed and tested, we will push the tiger out together with our net, then allow it to keep falling through the floor tiles, let it fall into the tunnel again, and then return to the forest. That's how coronavirus testing works, roughly.

There is only one thing to remember in any epidemic: we need to do everything we can to find out who is infected and who isn’t, and then physically separate the infected people from the healthy ones. This should be done among the population, but especially in hospitals, where the virus poses the most danger if it can enter them. Since coronavirus has entered several of our hospitals, anyone considering the complete relocation of all COVID-19 infected people from all hospitals to reception centres, to new hospitals, which is what was done in Wuhan, has my full support. Every action of separating the infected from the rest of the population makes it impossible for the virus to spread further. The most important thing is to prevent it from spreading to uninfected hospital patients who are most at risk.

If we can be that active in finding infected people and isolating them and their contacts, we will significantly slow down the spread of the virus. This virus is currently spreading at a tremendous pace as each infected human can transmit it to two, three or even four healthy people with their next step. But if, by taking an active approach to finding infected COVID-19 spreaders who don’t yet have symptoms, and by constantly separating them and all of their contacts and putting them into self-isolation, then we manage to get to a situation in which one infected person manages to infect, on average, less than one healthy person, then we are all pretty safe. The epidemic will slowly go away on its own, and the vast majority of us will be able to live relatively normally. The minority, on the other hand, will constantly rotate in isolation.

With proactive testing, for example, by small epidemiology teams that will go to the households of everyone who reports having symptoms and test them and then isolate them and their contacts if they’re positive for the virus, we will allow the vast majority of the population to live safely with the virus. I would definitely recommend the daily testing of all staff at hospitals, dispensaries, health centres, as well as people employed in retirement homes, as there will also be an enormous amount of damage if a COVID-19 epidemic develops in those places.

In addition to actively seeking out, testing, and then isolating infected people and their contacts, there are two other elegant ways by which we can further protect ourselves. The first is to build some kind of "safety net". We could define a very representative sample of Croatia's population of about 10,000 people, and test them once a week. In this way, we would make sure that the virus isn’t "sneaking" behind our backs and escaping into exponential growth in some part of Croatia.

Namely, when we quarantine, it will be possible for mini-epidemics to break out anywhere in Croatia. They, as we’ve seen in Italy and some other European countries, can grow very quickly to very large numbers of infected people. With this "network" that we would regularly monitor, we’d know that our virus isn’t spreading anywhere in Croatia, and we’d also know how many Croats are infected. Another approach we could take is to start looking for people with antibodies, who apparently have become infected with coronavirus, even though they aren’t aware of it, and then issue them passes and include them in normal life in important roles. However, we will still have to wait for solid scientific proof that immunity against this new coronavirus is indeed permanent.

Virus testing is somewhat comparable to counter-espionage in war. We’re confronted with an enemy who is invisible, and we only become aware of the effects of its actions a week later. In the meantime, we don’t know where the virus is and what it is doing behind our backs. SARS and MERS were significantly easier to control because the infected didn’t transmit the virus before the onset of coughing and other symptoms. With coronaviruses, the infection spreads during the incubation period, while the infected don’t have any symptoms yet, which is a big problem for us. But we can at least resolve it, somewhat, with more active testing.

If we allow it to, the virus will jump from the first infected person to two or three more people, then from each of them to two or three people again, and then do so again. That way, if the first infected person is drawn at the bottom of a piece of the paper, the wider and denser ‘’canopy’’ of infected people is constantly spreading over them, step by step. Through active testing, we’re able to find those who are infected among us. So, we constantly prune that "canopy" to make that situation as rare as possible. If the canopy ceases to spread from step to step because we constantly cut branches wherever we reach, then we’re in coexistence with the virus. We slowly get vaccinated, we treat the seriously ill, and there are fewer and fewer people who don’t have immunity for the virus to be able to jump on.

This way, one can live with the virus present in the environment and thus control the epidemic. What the Director of the World Health Organisation, Dr. Tedros Adhan, tells us is that we must not constantly be on the defensive, in quarantine, and wait for people with symptoms to report for testing. That would mean we're constantly behind the virus. The enemy will then constantly surprise us and strike us from somewhere. That's why it's important to test people as much as possible, but cleverly and reasonably so, and with clear goals.

Quarantine, simply, cannot be a longer-term solution to fighting the virus in Croatia. Initial estimates suggest that about half of Croatian private sector companies cannot withstand this situation for more than a month, and another 43 percent won’t manage for more than three months, which is a terrifying fact. Their exhaustion will also see the end of the filling up of the budget through corporate income taxes, so, there will be no funding for public sector wages either. This will mean that most people now sitting in their homes will no longer be able to buy food, and soon there will be no food to buy, either.

In addition to testing, there are a number of innovative approaches that we may need to resort to in order to be as safe as possible from the virus and escape the Italian scenario of exponential growth. For example, we might initially switch to a work week where people living in house numbers ending in 1 or 2 work on Mondays, those with 3 or 4 on Tuesdays, those with 5 or 6 on Wednesdays, those with 7 or 8 on Thursdays, and those with 9 or 10 on Fridays. This would turn the Croatian population into a so-called "metapopulation", that is, they’d be divided into five smaller non-contact populations. This is similar to a ship or submarine that is internally divided into bulkheads, so they can protect it from sinking if the hull breaks somewhere. That way, we would protect ourselves if the virus somehow triggered an epidemic within one of these populations, it couldn’t then spread to the other four fifths. Perhaps a two-day Monday-Friday work week for everyone would work in an even better way, as it wouldn’t allow the virus to spread day by day, and would still allow us to return to having nine working days a month, with additional work from home where possible. Perhaps even a "one week work, three week quarantine" option would be effective and safe.

The combination of all of these measures: (i) the continuous, active detection of infected persons and their separation; (ii) a "safety net" of 10,000 people for continuous nationwide testing; (iii) splitting the whole of the population into fifths, or working twice a week, on Mondays and Fridays; (iv) various measures to avoid social contact, such as banning large public gatherings, recommendations on wearing masks and gloves, and restrictions on travel and quarantine for arrivals from abroad; and (v) various innovative technological solutions, such as applications that inform all residents of the status of infection of people they have in their contact list, all of which seem feasible. This would probably protect us enough from the virus and allow the vast majority of people to continue, more or less, with normal life as much as possible. Because we need to get out of this quarantine situation as soon as possible and we need to make plans now.

Perhaps this unusual situation will be a historical reminder to both countries and individuals of the importance of self-sustainability and independence from others. It may be that many people in the world left without work because of the economic aspect of this crisis are encouraged to consider moving to cottages or to villages. Now that wireless internet can be accessed everywhere, it doesn't matter where the person on Earth actually lives. But if he has his own garden and his own well, at least he won’t get into the kind of awkward situation that many are now finding themselves in recent times. Perhaps one of the consequences of this crisis will be some new idea of ​​organising the lives of individuals and countries, based on self-sustainability. This would also make Croatia, in general, a more robust country in the face of a number of possible new challenges of the 21st century.

Coronavirus will cause losses for humanity in 2020 on the one hand, but it will reduce those same losses on the other. For example, it will reduce the number of traffic accidents, the number of victims of violence, and deaths from polluted air. In addition, until yesterday, spears were breaking around every percent reduction in fossil fuel use, and now all of a sudden this reduction is forced and massive. In a rather improbable way, this pandemic at least helps combat humanity's climate change problem. In Zagreb, however, self-isolation due to the COVID-19 pandemic saved perhaps tens of lives of people who would have perished during the earthquake. If I paid for a ticket to watch a movie with such a scenario, i.e. an earthquake that affects people who are quarantined by a pandemic, so they can no longer be outside or inside, I would feel cheated. But, as the Chinese proverb goes, "There are countless things that cannot be imagined, but there are none that can’t happen.’’

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 more articles by Igor Rudan - follow our dedicated section.