Professor Igor Rudan: How Can We Lower Number of Croatian COVID-19 Victims?

By 28 November 2020

November the 28th, 2020 - Esteemed Croatian scientist Professor Igor Rudan, recently declared as being among the top cited 0.1% of scientists in the entire world, has taken to answering some of the most common questions about the current situation we're in in the battle against the spread of the new coronavirus. Here they are in full.

How can we bring down the number of victims of COVID-19 in Croatia?

The current spread of the COVID-19 pandemic in Croatia has become extremely concerning. From March this year until today, more than 1,600 people have died from COVID-19 in the Republic of Croatia. However, most of those people died in a mere one month period - November. Most of Europe, as well as North America, has been hit by a strong new wave of the pandemic. It became clear that the protection measures put in place in October had failed to prevent the strong spread of the second wave of the pandemic and as such, they failed to prevent a large number of new casualties in Croatia, Europe and over in North America.

November brought with it not only a large number of deaths, but also the continued spread of the infection across all parts of Croatia. That is why December, unfortunately, will now bring us yet another large number of new victims of COVID-19. Due to the nature of this disease, we can no longer significantly influence that, although our health professionals are working extremely hard to save every human life in these totally new and unprecedented conditions.

If we want to reduce the further increase in the number of deaths and not put such huge pressure on the Croatian healthcare system in 2021, it is clear that the available measures to prevent the spread of the infection should be significantly tightened. The government did precisely that just a few days ago, opting for the strictest measures it deemed feasible at the time. The scientific community immediately recognised and supported such a decision as a rational and pragmatic one, because it is in line with everything that scientists around the world have so far been able to learn about the ongoing COVID-19 pandemic.

It has been understood that having to make decisions on strict prevention measures once again has not been an easy feat. It will jeopardise the businesses of many people in Croatia during the month of December, which is something nobody wants. Therefore, it should be understood that, due to this natural disaster that has hit humanity, the whole world has been engulfed in a situation in which all of the solutions have been, to a greater or lesser extent, bad for months now.

Until the pandemic is brought to an end with vaccination, countries around the world will not be able to save important segments of the entire community from greater stress. Many of those people will end up bearing some of the burden of fighting the pandemic to keep the overall level of damage to society as small as possible in the end. Nobody wanted to find themselves in this situation, but yet - here we are. That is why every country is now trying to get out of it with the least sacrifice possible.

Having already realised this earlier on, more specifically back during the months of April and May this year, some countries opted for truly pragmatic approaches, which may seem to be leaning more to the radical side. Asian countries such as South Korea, Taiwan, China, Vietnam, Japan and Singapore have managed to protect the lives of their citizens with these measures, but also to save their economies from major damage. In addition, they managed to preserve a relatively normal sort of daily life. Deciding early on that every day spent without having to worry about spreading the virus was worth the effort, they secured their borders for the long haul. Every single person arriving in those countries must enter into a strict two-week quarantine, and within the borders of those countries, the spread of the virus is decisively monitored and controlled by the employment of systems for mass testing, monitoring and the isolation of contacts of those confirmed to be infected - a move with which the population is in agreement.

An important lesson from the examples of successful Asian countries is that both the economy and the situation surrounding safety and security in society are best protected by the decisive control of this public health crisis. However, the aforementioned Asian countries have succeeded thanks to their experience with the previous epidemics of SARS and MERS. Over recent years, they have developed thorough defence plans against the spread of infectious diseases. They have also strengthened their testing and monitoring capacities, preparing in advance for the next epidemic. The populations of these countries are very well educated about their health. What stands out in particular is that the population clearly understands the need for general social solidarity when it comes to protection against communicable diseases. Therefore, the residents of the most successful countries in this regard have great confidence in the experts managing the COVID-19 crisis and as such, they strive to comply with all of the regulations and measures adopted in the interest of the entire community.

Here in Europe, the example of Asian countries was primarily followed by Iceland, Norway, Denmark and Finland. In contrast, other European countries didn’t want to rely on such strict border controls, nor on excessive methods of monitoring their population. However, regardless of the concrete measures, they also decided to give priority to the public health aspect of the COVID-19 crisis during the pandemic’s second wave. They knew that adhering to the prescribed measures would mitigate the impact of the second wave.

However, the intensity of the second wave hit many like a tonne of bricks in October, and showed that these measures were simply not enough. It was not only important to slow down the growth of the number of infected people, but it was necessary to reverse the situation and actively encourage a rapid decrease in the number of infected people. Thus, healthcare systems would be relieved and pandemic surveillance re-established by testing and isolating contacts. After thorough analysis, many European countries concluded that they should resort to a new, preventive lockdown, even though nobody wanted that. Despite the total lack of desire for such a move, they judged it the least evil of all the bad solutions available to them in the fight against the second wave of the pandemic.

In Croatia back in the spring, during the very beginning of the COVID-19 crisis, the emphasis was also placed on the public health dimension of the pandemic. As the year progressed, however, the economic and security dimension of the crisis also gained in significance. Nevertheless, experiences from around the world have clearly shown that any neglect of the public health dimension of the crisis only works to deepen both economic and security risks as time goes on. This is then followed by a very long and hard road to recovery. That is why it is better to learn from the mistakes made by other countries than to become a negative example to others oneself. As soon as a country underestimated the spread and effect of the new coronavirus in any way during this pandemic, the virus found a way to punish it for such an underestimation shortly after.

After good initial results, the transition of summer to autumn saw the Croatian media begin to spread hypotheses that the virus may have become less dangerous. It could also be read that a second wave might not even be expected. In addition, thanks to the good prevention of the first wave and the later summer hotspots, one could get the impression that we will also manage to curb the autumn wave of the pandemic quickly and easily. However, all this contradicts what epidemiologists have been warning the public about since back in May: the inevitability of a strong second wave of this infection during the months of October and November, and the need for good preparation for the challenges it will bring us.

Therefore, during the lull between the first and second waves in Croatia, any underestimation of the dangers of COVID-19 and the undermining of the authority of people trained to fight epidemics incurred damage, which we’ve been witnessing over recent days, and are unfortunately continuing to witness. The spreaders of misconceptions have been described throughout history as a side effect of all epidemics, but reality always succeeds in denying the things they try to perpetuate over time. As such, in Croatia at the end of November, it became clear to everyone that Croatia was suffering from a very strong second wave of the pandemic and that, quite on the contrary to certain reports in the media, the virus had not weakened at all. On top of all of that, there was no rapid restraint of growth in early November, which would be a deviation from all surrounding European countries. On the contrary, the number of infected people in Croatia is continuing to grow. Therefore, Croatia now finds itself in a difficult and highly challenging situation.

There was a heavy workload to be dealt with for hospitals, with a significant daily number of deaths occurring. At the same time, estimates of future developments can no longer be based on the data we collect because its reliability and relative importance has altered quite significantly in these new circumstances in which we’re experiencing the free spread of the virus. In my last column, I thoroughly explained why the data we now have on the spread of the infection in Croatia is no longer reliable enough to allow for accurate planning.

The saturation of the testing system and the changes implemented within that system are one of the most important reasons why the number of newly infected people in Croatia has been underestimated for a long time now. Furthermore, the number of people hospitalised in previous months is no longer comparable to the current number of hospitalised coronavirus patients, as the criteria for hospitalisation has had to change due to this increased level of pressure. In the circumstances of the rapid growth of the number of infected people, we know from the experiences of some of the hardest hit countries in Europe that even the number of deaths can end up being significantly underestimated, when, due to the overcrowding of hospitals and stricter “requirements” for hospital admission, some patients simply begin dying in their own homes. In the most heavily affected countries, such deaths were counted only subsequently. The mortality rate of those on respirators also becomes very high when healthcare teams are overloaded and aren’t well rested, which changes the dynamics and trends in the number of people on respirators.

In Croatia, signs of a heavy workload placed on the healthcare system should also be expected throughout December. Epidemiological knowledge and experience from other countries affected by the pandemic indicate that the situation in Croatia is currently probably worse than the figures currently show.

How much worse could things get?

The simplest possible estimate indicates that in environments in which the spread of the virus was completely free for weeks, without any prescribed safeguards, COVID-19 became the leading daily cause of death during the worst weeks of the pandemic. We know that in Croatia, before the pandemic, i.e. in 2019, an average of 140 people died on a daily basis, and that about 60 of these daily deaths were caused by diseases of the circulatory system, and about 40 were the result of various malignant diseases. So, we’re already able to see that COVID-19 has become the second leading daily cause of death in Croatia. If there were no previously prescribed measures that, obviously, do indeed work, the number of daily deaths would increase above 60, and COVID-19 would become the leading daily cause of death in Croatia as well. For now, this isn’t yet the case, but the number of new victims of this virus should continue to be actively reduced with the proper employment of preventive measures coupled with responsible behaviour.

How long can this difficult situation in Croatia last? 

Unfortunately, it’s likely to last for quite some time to come unless stricter measures are introduced. Croatia is not yet close to self-limiting the infection. The example of the USA shows that their third wave of the pandemic is now the heaviest and worst of them all, although enormous casualties have already been suffered during the first two waves. Therefore, strategies should not be built on the expectation that this tragedy in Croatia could be somehow self-limited by achieving "collective immunity", we should instead very actively defend ourselves against it. This is best shown by the example of the USA, where 270,000 people have already died, and in the third, current wave, which is the most severe of all, there are now days on which there are more than 2,000 deaths, which are the worst figures for the USA since the pandemic began.

Determined and active defense against the pandemic over the coming months is now even more important in Croatia because scientists from across the world have worked on the development of vaccines to finally provide us with a way out of this crisis. Initial research indicates that these vaccines will indeed be effective and available as early as next year. Therefore, the scientific community views the Croatian Government's decision to introduce strict prevention measures as a humane and ethical act, which is also medically justified. Metaphorically speaking, it should be understood that a train is hurtling towards Europe and it will certainly hit us.

That is why the brakes need to be put on and that move should be made in all possible ways, and that proverbial train needs to grind to a halt on its very rails as soon as possible. We can’t put the brakes on when we spot it 100 metres away from us, heading towards us at full speed, because then it’s going to be much too late. That is why many countries in Europe have closed down resolutely, despite the fact that the self-initiated withdrawal of the population into their homes even before the lockdown began to slow down the intensity of the spread of the infection. They wanted that blow, when it happened to the fullness of its intensity, to be as weak as possible.

What is key to understand during a pandemic like this, is that one cannot simply sit and follow the numbers and only react to them after the fact. An epidemic like COVID-19 punishes approaches like that. Countries are therefore often forced to react in a way that may seem to the public as if too much is being done without any real need for it. That would correspond to hitting the brakes on an oncoming train when it is still far away, while nobody can even see it yet. However, this is the only way to do well when it comes to prevention measures. One needs to constantly be in front of a pandemic, which is a move that will seem too extreme in the eyes of the general population.

Strict measures recently adopted by the government will protect the lives of the most vulnerable citizens. In pandemics, it is always better to prevent the very appearance of those infected than to have to treat them. We can clearly see this now in Croatia as well if we sit and compare the consequences of the first wave with the second. European countries that experienced all the dangers of COVID-19 during the first wave didn’t have much doubt about whether they wanted to prevent the second wave as much as possible and also do so in time, or instead - deal with its dire consequences.

However, it is also important to emphasise that we won’t be able to see the effects of these newly introduced measures for weeks yet. Due to the nature of this pandemic, the effects of the new measures will not be seen until around Christmas and New Year. Because of this constant delay in the consequences for the causes during this pandemic, and the interval is typically around a few weeks, we should always try to remain ahead of events and anticipate them, and not react only when they catch up with us.

These new and stricter measures will affect many sectors of society. Unfortunately, during a pandemic, not everyone in society bears the same burden of disaster. This is the fundamental nature of all emergencies - from wars and earthquakes, to floods and meteor strikes. Some, unfortunately, always suffer more than others do. Over more recent months, science has discovered that this contagion is successfully spreading indoors where people are gathering together and socialising, talking, singing and engaging in close physical contact. Activities that depend on such things will therefore be the hardest hit of all. High schools and colleges are also, for very similar reasons, places in which the infection is spreading, while children in the lower grades of primary schools may not be strong spreaders, although science has yet to make a firmer judgment on this. The measure of working from home wherever possible is also now extremely important until the pandemic in Croatia is brought under the control of the epidemiologists once again.

The adopted prevention measures are additionally significant due to the upcoming festive period, when, at the end of December, there will be increased numbers of people and as such an increased intensity of contacts within groups of family and friends. Epidemiologically, it should be expected that at the beginning of next year, this behaviour will affect the number of infected, hospitalised and, unfortunately, dead people. Therefore, any relief for the healthcare system until the very beginning of next year will be extremely important and very welcome, so that the festive period doesn’t lead to an additional burden by the time January rolls around. It would probably be too severe a blow to this already exhausted system and healthcare workers, who would have been battling the second wave of the pandemic intensively since October of the previous year.

Given that the vaccine is now within our reach, I believe that the majority of the Croatian population understands the prioritisation of the protection of life over the next few months, and that they’ll also notice the same sort of thinking across Europe. If the growth of the pandemic in Croatia continues, and if several thousand people die of COVID-19 in Croatia by the summer of 2021, it would become a national tragedy recorded in history as one of those that could indeed have been prevented, if we compare it with other European countries.

Croatia is less wealthy, but still has the resources to prevent the country from seeing the pandemic draw to a close as one of the hardest hit. Unfortunately, data from the European Centre for Disease Control shows that Croatia is currently moving in that very direction. Therefore, the scientific community sees the introduction of stricter measures as an active move to change this undesirable course of events. It should also be understood that the failure to control the pandemic would certainly have a negative impact on the economic situation, but also on the next tourist season. Millions of tourists who chose Croatia this year precisely because of its epidemiological safety, could quite easily choose other destinations in the spring and early summer of next year.

It is now much clearer in Croatia that the quarantine we saw introduced back in spring protected thousands of lives and made it possible to save the tourist season, at least in part. However, with all the benefits, no one wants to apply such a harsh and non-specific protection measure as lockdown. That is the very last resort, the ultimate epidemiological measure, which means that everything else has failed. It is therefore important to understand that prescribed measures aren’t the most important thing when it comes to pandemic control, although they are debated and discussed at length. What matters is the actual behaviour of people and their adherence to these measures. Namely, the SARS-CoV-2 virus cannot know what measures have been put in place, it is doing nothing but constantly looking for an opportunity to move from an infected person to a healthy one. If we all reduce our number of mutual contacts and ensure that the contacts we do have aren’t too close, we will manage to reduce the number of infected people, and thus the number of deaths.

Is there any way in which we could reverse the course of the epidemic without needing a lockdown, in periods when its waves are spreading so quickly and so well, much like the current situation in Europe?

Epidemiologists have been very innovative and come up with answers to this question over recent months. The very idea of ​​mass quarantine for tens of millions of people, like what was seen at the beginning of the pandemic in Wuhan, was already a novelty that would enter the textbooks of epidemiology. It, in spite of everything, then proved to be an effective first measure until more knowledge could be gained about this new virus. However, new approaches are also interesting and they could help us to avoid lockdowns in the waves to come or indeed in future pandemics. Fortunately, the first successes in this very direction are already in sight.

The most interesting of them is currently the example of Slovakia. It tested virtually its entire adult population, more than 3 million people, in just a few days. In this way, it wanted to gain an insight into the reality of the current situation, and not constantly lag behind the spread of the virus. It then immediately separated all those confirmed to be infected, as well as their contacts from the uninfected population, to abruptly reverse the course of the pandemic. This measure has been effective in a very significant sense and now consideration is being taken into whether Slovakia has sufficient resources, and whether it can quickly procure enough tests to repeat this measure once more.

A similar approach, which could begin to be adopted by more and more European cities, has been tested in Liverpool. There, in many places across the city, the population was provided with free rapid tests, so during the first week, as many as 20 percent of Liverpool’s residents were tested, and the infected and their contacts were placed into isolation.

Those results are also promising in their nature, as the course of the pandemic has been reversed, especially in Liverpool’s most heavily affected neighbourhoods. Owing to this, the prevention measures have been relaxed in Liverpool, unlike in many other cities across the United Kingdom. With this approach to mass testing, which was already done earlier this year in some cities in China, we are probably coming closer to another innovation based on epidemiological science. That could prevent the need for a lockdown. It should be understood that without new knowledge and the technologies available to us in the 21st century, such an approach would not be possible at all, and this will now also enter epidemiological textbooks.

In epidemiology, we also learn that epidemics are emergencies in which the struggle to save human lives is paramount, and everything else during such a disaster becomes secondary. It would be a similar situation during floods, earthquakes, meteor strikes or during imposed war. At the same time, the assumption of epidemiological textbooks is that the population also places the protection of human lives above all, and that many dead fellow citizens isn’t something anyone wishes for. Additionally, the assumption is that the population wants to protect themselves from infectious diseases with vaccination, so that they themselves, or members of their families, wouldn’t end up contracting these diseases.

However, epidemiology textbooks in the 21st century will obviously have to be rewritten because for the first time, we’re seeing that a significant number of people no longer accept that saving human lives during epidemics is the only priority, but cite many other values ​​in  society which are worthy of protection, indicating both indirect and long-term damage from the introduction of epidemiological measures. On top of that, a significant number of people no longer want to be vaccinated in order to protect themselves and others from dangerous infectious diseases. These are indeed novelties to which new and separate chapters in anti-epidemic textbooks will be dedicated. In an age of general poverty, ignorance, and the severe consequences of infections which have occurred over the past centuries, the older generations of epidemiologists couldn’t have even foreseen such thoughts, let alone record them in their books that we have since inherited from them.

Finally, I’d like to return to the question from the title: how can we reduce the number of new victims of COVID-19 in Croatia?

Examples from many other countries have shown that only trust in people who understand the epidemiology of infectious diseases, listening to their instructions and strictly adhering to the prescribed measures, as well as general social solidarity and togetherness in disaster, can reverse a pandemic. If this trust, togetherness, and general solidarity in a disaster no longer exists within communities, but instead the community is divided, distrustful of each other, burdened with many misconceptions, and everyone thinks mostly of their own short-term interests only, then the response to the pandemic can hardly be in any way successful. Consequently, the agony for everyone will only be prolonged and continue for even longer. It is therefore an enormous responsibility placed on the shoulders of the people who decide on the introduction of these measures and bring them in for the whole community, so that they themselves, by their own examples, constantly remind us of these values, and thus gain the trust of all who should follow their instructions in order to reduce the number of new victims of this pandemic.

This text first appeared on Vecernji list and was translated by Lauren Simmonds

For more English language content from Professor Igor Rudan, follow his Facebook, Twitter, LinkedIn and Medium and TCN profiles. For more on his upcoming book, Prvi val/The first wave, click here