Saturday, 28 November 2020

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

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

Friday, 20 November 2020

Croatian Scientist Igor Rudan Among Top 0.1% Most Cited Scientists in World

November the 20th, 2020 - The esteemed Croatian scientist Igor Rudan has found himself on a highly respected and prestigious list for the fourth year in a row. One look at his remarkable work and you'll see that this really shouldn't come as a surprise.

As Vecernji list/Zoran Vitas writes, Clarivate has published its annual list of the world's most cited scientists, a list that is widely considered to be the most relevant in the world. The list, officially called Highly Cited Researchers 2020, identifies scientists who have made a significant impact in their fields of scientific research with multiple cited papers over the past decade. The truly remarkable Croatian scientist Igor Rudan has found himself among them.

The papers of scientists whose names have been published in the list must be among the one percent most cited in the Web of Science, a database that is part of Clarivate. This database draws data from the world's leading journals from across all the many fields of science. The list of most cited scientists is compiled by experts from the Clarivate Institute for Scientific Information, and this list also makes it possible to identify the most successful institutions and countries in which these scientists work. This year, the prestigious list includes 6,167 researchers working in more than 60 countries. Just like every year, we're able to find several of eminent Croatian scientists on the list. It doesn't come as a shock that the doggedly determined and hard working Igor Rudan is present.

However, it should also be said here that the list doesn't recognise the nationality of the scientists included, so it is necessary to thoroughly browse the 639 pages of this list.

Prof. dr. sc. Ivan Djikic from the University of Goethe in Frankfurt, otherwise a Croat, has been included in the list of the most cited scientists for the third year in a row, just as he was last year, and this time he finds himself listed in the field of molecular biology and genetics. On that occasion, his university issued a statement stating that six more of Djikic's colleagues were also on that list. In addition to the names of the scientists on the list, their short profile is also connected. When it comes to Professor Djikic, it can be seen that 322 of his published publications were cited a total of 34,852 times.

Prof. dr. sc. Igor Rudan of the University of Edinburgh, who is also a member of the Royal Society there, is almost a veteran on this highly respected list. This is the fourth time the dual Croatian-British national has been included, first back in 2017 and then again 2018 for publishing in the fields of molecular biology and genetics, and then, over the last two years, he has been included for interdisciplinary fields of science. In total, 582 papers from Igor Rudan have been cited an incredible 60,526 times.

Professor Igor Rudan is an advisor to the World Health Organisation, UNICEF, the World Bank… The two most cited works of his have been cited more than two thousand times, an incredible feat indeed.

Croatian scientist Igor Rudan well and truly activated himself during the time of the pandemic, offering a calming, rational voice which was sorely lacking otherwise, especially back at the beginning when very little was known about the new coronavirus which had taken the world by storm.

His incredible talent for making a highly complex situation easy and enjoyable to read is a talent worthy of envy, and his English language works can be found on his Medium profile, and of course here on TCN. Find out more about Rudan's upcoming book, The First Wave/Prvi val here.

Friday, 9 October 2020

Esteemed Croatian Scientist Igor Rudan Prepares New Book on Pandemic

October the 9th, 2020 - Esteemed Croatian scientist Igor Rudan is planning to release yet another book, Prvi val (The First wave), which will offer an expert's take on the unfolding of the ongoing coronavirus pandemic across the world.

When it comes to the topic of coronavirus, COVID-19, SARS-CoV-2, more ''affectionately'' known as ''Rona'', there is a whirlwind of information that you can easily be bombarded with. In the day and age in which we live, there is no excuse not to be informed about, well, just about anything. It's all right there at the tips of our fingers in a way that was impossible to imagine not so long ago.

Everything, however, has a down side, and the negative side of having so much information freely and easily accessible is that human nature tends to cause some to only seek out information which benefits and confirms beliefs they already hold, rather than perhaps open their minds to something new and in some cases - more factual. This sort of dogma leads to an infodemia of sorts, which scientist Igor Rudan has already spoken about extensively in his many texts on the new virus and the pandemic caused by it.

Croatian scientist Igor Rudan is everything but a slacker. Having come to know each other since the outbreak of the ongoing pandemic, I have been consistently impressed at his ability to knuckle down. They say that if you do what you love, you never work a day in your life, and I'd dare to suggest this is the case for Rudan, who effortlessly pens texts explaining the ins and outs of not only this virus but of many others, with an enviable ease. These texts could be boring, full of scientific jargon that only a select few might understand, and as such lead more people to come to their own conclusions about the pandemic. Instead, he manages to convey it in a simplistic, interesting, and dare I say even entertaining way which grips the reader with, yet again, apparently very little effort.

One tends to think of scientists and immediately picture Albert Einstein locked away in an office struggling to understand the often superficial reality of the world around him. Quite on the contrary to that image, Croatian scientist Igor Rudan knows how to ''speak to the people'' as it were, very well indeed.

 His texts, which he wrote freely and with care and love, were crucial back when the virus penetrated Croatia's first line of defense and gradually began to spread among the population back in spring. His texts excellently calmed any anxieties, fears, and panic in an educated, easy to understand and compelling manner. Conspiracy theories will always be rife, as will perfectly reasonable people who have different views, but if you want to really understand this virus (in as much as anyone can at the moment), and the way pandemics happen, Rudan is the person to watch and read.

For Croatian speakers, watch Igor Rudan discuss coronavirus back in March this year:

If you're not confident in English and would prefer to read Igor's texts published by Vecernji list on the pandemic and other scientific matters, you can do so by clicking here.

We at TCN were instantly captivated by scientist Igor Rudan's texts when he first began publishing them, entirely at his own will, and I took to translating them, feeling that someone so educated who can still be so down to earth must be heard by the English speaking community who read our portal. You can read his incredible texts in English on his Medium profile here.

He's no stranger to writing books, having already published several. I'd highly recommend reading Zao zrak (Evil air), which is currently only available in Croatian, which discusses health and disease in the 21st century in a way that reaches people in a way that is quite remarkable. That brings me to the point (yes, finally). Of course, that point is English. Rudan, having the type of mind that he has, was quick to understand the need for his extensive and truly impressive works (both articles, longer texts and indeed books) to be available to the English speaking world during this utterly unprecedented time. It is, however, far from the first time that he has dipped his toes into that, having lived for a long time in Edinburgh and having made documentaries in English which excellently discuss survival against the odds. You can view this captivating YouTube series below, with the first video linked:

His next book, which will be translated into English and made widely available to all those for whom the name Igor Rudan is still new, is certain to impress all those who read it. The texts in it, many of which I have worked on, have garnered an enormous level of interest from our readers who were consistently asking when the next one was coming. They too were surprised at how interesting and in depth yet easy they were to follow and they did excellently each and every time a new one was published. Being an English language portal in Croatia, tourism is never far from the surface, and with the endless questions and indeed often confusing instructions issued to would-be travellers back when we knew much less about the virus than we do now, scientist Igor Rudan's texts acted as a calmant of sorts for those wishing to better understand the situation in Croatia, and indeed the world.

If you'd like to learn more about Rudan, click here. You can follow scientist Igor Rudan on his English platforms, you can follow his Twitter, his Medium (linked above), and his English language Facebook page. Keep your eyes peeled for the release of his next book, we'll be certain to provide the update as soon as it can be found on the shelves and online.

Sunday, 26 April 2020

Igor Rudan: 4 Strategies Available to Croatia for 3rd Stage of COVID-19 Crisis

In the next phase of the crisis, public health priorities will be replaced with more active adaptation to sustain economic activity and normalise life again. Professor Igor Rudan looks at what has been, and what is yet to come as the coronavirus crisis continues to unfold.

April the 26th, 2020 - After Croatia closed its borders and schools and then introduced quarantine, in a column I wrote on March the 20th, 2020, explained that Croatian epidemiologists used figures and information to protect the population from the spread of the infection. That was now five weeks ago. I finished the column (which you can read in the link provided above) with the words: If anyone thinks this is the end now, I'm afraid he's living in fantasy land. This is just the end of the beginning.

Indeed, the decision to quarantine marked the end of the first chapter of this pandemic in Croatia.

To better understand the transition from the second to the third chapter, let's briefly recall how the first chapter ended and how the second one began. First, a new coronavirus appeared in Wuhan. Its spread was prevented by the largest and most restrictive quarantine ever seen. It was known that the virus can kill a very small amount of people among all of those who are infected, but it was not known then just how quickly it spreads.

On the front lines of the epidemiological defenses, the virus was halted by some thirty large provinces of China, as well as China's neighbouring countries in Asia. A possible arrival of the virus in Europe was then expected. Everything was still looking good back then. Flights from China to Europe and the USA were suspended or were being rigorously checked. However, the virus penetrated beyond the first line of defense in Italy and then entered many other countries of the European Union.

It began to spread among the population at a tremendous speed. That sadly led to a large number of deaths in a short time. Following all the information in the environment, I explained in my earlier posts why March the 12th would be a good day for the activation of quarantine in Croatia. The [National Civil Protection] Headquarters also thought along those same lines, and over the next few days, Croatia withdrew into quarantine through a series of measures.

With the withdrawal into quarantine, the second chapter of this pandemic began immediately. There were also clear plans and goals for this phase in Croatia. By the end of March, it could be seen that any free spread of the new coronavirus in other European Union countries would inevitably lead to thousands, and sometimes tens of thousands, of deaths in a mere few weeks. This could have happened to Croatia. On March the 1st, I explained that the virus has the potential to kill tens of thousands of people in Croatia, but also that with the application of proper anti-epidemic measures, we will reduce that number to just a few hundred, and hopefully even less than that.

Thanks to the timely implementation of all of the lines of defense, the number of deaths in Croatia has indeed been reduced to significantly smaller numbers. In addition, the Croatian Government has introduced a package of economic measures to provide support to the economy. At first, it was too modest in regard to this very new context. But then, after business owners began being more loud about what was needed, other measures were also passed, and those were significantly more generous. The measures were to mitigate the effects of five weeks of isolation, and the move was generally well received. Croatia, therefore, managed to overcome the second phase of this crisis.

However, it is now very important to explain, as well as to truly understand, that today the second chapter of the COVID-19 crisis in Croatia is coming to an end. At the same time, a third, entirely new chapter is beginning instead. In the third phase of the fight against the virus, public health goals will let, at least temporarily, their position as the leading priority go to other pressing issues. First and foremost, the preservation of economic activity and the attempt to return to the life we ​​used to know will come to the forefront. So, we're entering a whole new chapter, where everything will change once again.

Chapter three's planning should have been properly elaborated during the quarantine. In my column discussing how we could quarantine, published by Vecernji list on March the 26th, I outlined five criteria against which each country's success in fighting this crisis would be evaluated. The first criterion was the good preparation and maintenance of the first line of defense against the virus, the second was the timely declaration of quarantine and the third was the successful suppression of the spread of the infection during quarantine.

As can be seen, all three initial priorities were primarily, in their very nature, about public health. However, I also stated that the fourth criterion would be: "How quick and active the state was in mobilising its capacities and human resources, as well as its creative and innovative solutions, to develop a plan for quarantining and coexistence with coronavirus as soon as possible?"

Finally, the fifth criterion was: "How effectively, after quarantine, has the state allowed its residents to move into a relatively normal way of life and prevent the collapse of their economy with permanent control of the spread of the virus?"

In all countries across the world, these two issues will dominate the new, third chapter of the COVID-19 crisis. Some nations will be more successful in their responses, others will be much less so.

Namely, in addition to suppressing the spread of the coronavirus infection, another important goal of quarantine was the buying of time. We had to stock up on as many new insights about the virus that we didn't have in the beginning. Based on these findings, the best plan for the third phase of the crisis should then be developed, practically, and as we go. If we want to evaluate Croatia's success in the second chapter of the crisis, ie, during the five weeks of quarantine, then the assessment of the effectiveness in combating the infection should be added to the assessment of agility in gathering information and developing the best possible plan going forward for the next chapter.

Assessing infection control in Croatia first of all, I would divide the five quarantine weeks by the period of the first three weeks, ie, until approximately the 8th of April, and into the fourth and fifth weeks, ie, from the 9th of April to the present day. Everything done since the first confirmed case of infection, from February the 25th to April the 8th, was truly excellent. Our National Civil Protection Headquarters, our epidemiologists and our other healthcare professionals have tackled the contagion in a way which is comparable to some the most successful countries in the world.

During the first three weeks of quarantine, Croatia's ambitious goal was not to make the number of newly infected people reach triple digits. Admittedly, our system could handle up to 250 newly infected people each day. However, given the unpredictability of epidemics in retirement homes and hospitals, it was advisable to leave as much reserve as possible. The peak of the epidemic wave of newly infected people was reached on April the 1st with 96 new cases, and then things started to subside.

Such a result, where the number of confirmed new infections has never reached one hundred in a single day, will be a proverbial ''badge'' only worn by the most successful public health systems in the entire world. In addition to succeeding in stopping the epidemic, the Croatian Government put forward, at the end of the second week of the quarantine, a significantly boosted package of measures to assist the economy, which has been generally very well received.

In addition to all of the above, a Government Scientific Council was established. In this way, leading Croatian scientists at home and abroad have regularly made themselves available and offered the Croatian Government and the National Civil Protection Staff the latest credible insights into the new coronavirus from all parts of the world. The second Scientific Council, held on the 6th of April, saw particular praise given to Croatia's success so far in safeguarding retirement homes from the epidemic. By then, the country was already finishing its sixth week without any major incidents. It was another good result, of which very few countries could boast. The high quality management of the COVID-19 crisis in virtually all its aspects was therefore at its peak on around the 8th of April.

As of April the 9th, however, problems that characterise many other countries across the world began to catch up on Croatia, too. First in Split and then elsewhere in Croatia, COVID-19 began to spread in retirement homes. This meant that higher numbers of deaths would also have to be expected. However, it's difficult to completely avoid such incidents. In Italy, Spain, Belgium, the Netherlands, France and the United Kingdom, such cases dominate the COVID-19 epidemic and contribute quite disproportionately to the overall death toll.

Therefore, the differences in mortality between countries that manage to protect their elderly and the sick well during this pandemic, and those that fail in doing so, can be truly dramatic. I will showcase this using three examples.

Today, France and Germany have a comparable number of confirmed infected people, just over 150,000. 22,200 people have already died in France and 5,700 have died in Germany, which is about four times less. The difference between Sweden and Israel is even greater: just over 15,000 people have been confirmed to have contracted COVID-19 by both countries, with Sweden having more than 2,100 deaths and Israel only having 194, which is ten times less.

The most drastic comparison is that of Mexico and Singapore, both with about 12,000 confirmed infected people, with Mexico already having 1,069 deaths and Singapore having only 12, which is a massive 90 times less.

Therefore, the Croatian results during the last two weeks of quarantine, ie, the fourth and fifth quarters, remain very solid. Countries that have protected their most vulnerable groups more effectively will have better results during this period. How, however, do we evaluate everything that has been done in Croatia during the five weeks of quarantine when it comes to the gathering of information, the better understanding of the virus and planning for a safe exit? Significant progress has been made since mid-March.

Research on ways the new coronavirus manages to spread among humans has been closely followed to provide clearer recommendations on the need for the wearing of masks and gloves. Which age groups are mostly at risk from the virus have also been confirmed. Healthy people under the age of fifty have been shown to be at a very low risk. This awareness is important in planning possible new quarantines as well as special protection for the most vulnerable among us.

Following on from that, the results of a very large number of studies are constantly being monitored, where existing medicines and known active substances are being sought to adapt in order to be useful in the treatment of COVID-19.

News about the first vaccine tests is also constantly being expected, as well as whether it only causes temporary or permanent immunity to the virus. In addition to diagnostic tests, which are constantly being refined to determine who is currently infected with the new coronavirus, tests are being intensively developed to detect antibodies created against it. Such tests are also important, as they allow for the assessment of so-called "seroprevalence". This will answer the question of how many people were exposed to the virus and got over COVID-19 without even knowing it.

When we consider all of them, only then will we receive the correct "denominator" by which we will be able to divide all those who died in the numerator. In doing so, we will finally be able to estimate the "death rate" among all those infected with this virus, which will greatly help us with our planning, estimates and calculations.

With all these insights reported on a daily basis by scientists, it is useful in planning the third chapter to constantly monitor all other countries in the world and to better understand the results of all of their respective approaches to it. All of them are currently working to slow down the spread of the virus. In doing so, each approach was adapted to its context, so, the measures varied from very mild to extremely restrictive, but the results differed as a result of that.

At the same time, countries which are rich enough and more developed could devote several weeks to quarantine activities to strengthen their technological capacities, as well as to train additional human resources. Thus, post-quarantine testing could increase testing for the virus among the population, strengthening the first line of defense. Thanks to GPS data, the effect of maintaining distance between humans on the rate of the spread of the virus was evaluated, leading to the thought of innovative measures of physical distance.

Google and Apple, as well as many others, are rapidly developing completely new technologies that can track the contacts of infected people without compromising their privacy. In the next phase of the pandemic, such innovations are likely to be supported by the first line of defense in at least some countries. In conclusion, quarantine has also provided us with a period of five weeks that has generated a wealth of new knowledge and useful information. This was all analysed on a daily basis and the plans for the third chapter of the COVID-19 crisis were all based on it.

I'm now going to return to the key feature of the final quarantine period in Croatia. Specifically, the first three weeks went so well that the small possibility of ending the fourth week of quarantine with single-digit numbers of newly infected people began to appear. However, during the first three weeks, citizens were still under the impression of the events unfolding in neighbouring Italy. They followed, in part and for that reason, all of the instructions given to them fairly well.

In the fourth and fifth weeks, partly due to incidents in retirement homes, but also probably due to increasing fatigue because of the quarantine, Croatia failed to bring the epidemic almost to its end. On the contrary, during most of the fifth week, practically until yesterday, the numbers of newly infected people were still in the double-digit range. That's why the virus will continue to circulate among the population even when the anti-epidemic measures are loosened up. This is a bit of a shame, as it has made certain scenarios impossible to think about during the last two weeks of quarantine.

Namely, the initial development of events in Croatia was so favourable that it allowed for the thinking of four different strategies for the new chapter of this crisis. The first and second strategies were proactive. They would give us initiative over the virus. The third and fourth were more passive, defensive, and in them, the virus took the initiative and conditioned our actions.

I will now describe these possible strategies for the next chapter and explain why one of them didn't come to be. I'll sort them from the most active to the most passive.

At the end of the third week of quarantine, I began to hope that perhaps from the plan to "mitigate" the contagion, that is, to slow its spread among the population down, we might start thinking more seriously about moving to a "complete suppression" plan. This would mean eradicating the virus within Croatia's borders. It would require an extended quarantine, but the goal would be to become one of the first "corona-free" zones in the whole world.

This would be analogous to creating "liberated areas" during wars, in which life can then be normalised. Moreover, such a strategy could even be agreed as common to several countries that had a favourable epidemiological situation back in early April. These countries were certainly Slovenia, Slovakia, Bulgaria and Montenegro. This could start creating a "corona-free" area within Europe, within which life would be normalised and the free movement of people would be established. Such countries would allow travel between them with the confirmation of mutually recognised, authorised institutions on non-contamination.

The tourist season in Croatia could then be based primarily on Croatian holidaymakers as well as those from the aforementioned countries which practically suppressed the coronavirus epidemic. Moreover, even for guests from third countries, where the epidemiological situation is worse, people with certificates of confirmation of their health could stay in hotels that are isolated by their location and that have been properly prepared for that purpose. There are quite a few such complexes along the Croatian coast.

Corridors from the airport to these accommodation facilities and back again would prevent the spread of the infection to the local population. In such a case, the staff of these hotels should move to the hotels themselves for a few months, and anti-epidemic measures would be introduced into their work. Even if a contagion occurred at a hotel, the epidemic would be limited to that hotel complex, or even just to a small part of it. When considering all these possibilities, it may be truly possible to think that in the fourth week of quarantine in Croatia, the numbers of new infections could have quickly dropped down to mere single digits.

However, we have been overtaken by problems in retirement homes, and quarantine discipline may have also somewhat subsided. It was enough that such a plan to emerge from this crisis, with the complete suppression of the epidemic, the significant normalisation of life, and with very strict border controls and the early detection of any new foci of infection, and waiting for a cure or a vaccine in a country without any new cases, would have to be dropped.

I also saw the second strategy as more desirable than the third or fourth one because it is proactive and wouldn't allow the virus to condition our behaviour. It would protect us from the new need for quarantine. It would be a strategy of further empowering our first line of defense and relying heavily on it. It would allow us to coexist with the virus through the application of more "insurance measures", which would protect us from its rapid spread. Maintaining physical distance, and wearing masks and gloves, which have already been being slowly being adopted by the population, would greatly increase the capacity and application of testing for the presence of the virus.

Testing would be especially regularly used to protect retirement homes as well as hospitals and rehabilitation centres. In addition, the identification of the contacts of infected persons would be actively pursued and new technological capabilities would be utilised that would rely on GPS tracking in the most acceptable form. Small, mobile epidemiology teams would constantly identify and isolate the infected and their contacts. Measures of "thinning" the population would also be elaborated so that at least the sub-populations of Croatia are allowed to gain considerable freedom of movement during their days of the week.

Such measures, and those similar to them, have enabled Taiwan, South Korea and Vietnam to remain the most successful countries in the fight against COVID-19 to date. They continue to rely on their strong and active first lines of defense. So far, they have not had to introduce a major quarantine at all. It is a strategy for coexistence with the virus that incorporates many mechanisms that make it significantly more difficult for it to spread.

However, the acceptability of these measures to the general public is an extremely important factor that must be constantly considered in the management of the COVID-19 crisis. As we move from each preceding chapter to the next one, it is precisely the acceptability of the decisions made that will become increasingly important to the entire population and, over time, perhaps the only truly important one. When this happens, the question of admissibility of the measures will dictate any further decisions if no scientific solution to the virus emerges in the meantime. I wrote about the key role of the admissibility of measures earlier on, explaining why the authorities of many countries hesitated in their initial responses.

They knew that the population would get tired of quarantine quickly, so they'd just start going back out anyway. They also hesitated with the ''release'' of the virus and permitting its free spread to preserve the economy, because they knew that the population would be scared of the large number of deaths, so they would simply shut themselves inside their homes. This is still visible in Croatia today. When the public was disturbed by what was happening in Italy and feared that the same scenario could be repeated in Croatia, the level of support for the quarantine measures was unprecedentedly high. As many as 94 percent of respondents believed that the Croatian Government was taking appropriate action against the virus.

Moreover, in an additional question, a significant proportion of citizens said they would also agree to even more stringent anti-epidemic measures. Now, not even three weeks later, opinions on the need for the same measures have already become quite divided in public opinion, and now many want to just be able to go back out as soon as possible. Therefore, it was evident that some new measures that would divide the population into subgroups would not be favourably accepted by the Croatian public.

Although scientifically grounded, these measures would remind many people of some of the earlier times of economic crises. It has also been shown that there is considerable resistance to any reliance on technology, and in particular the use of mobile phones for any kind of monitoring. Most people don't understand the benefits of a strong front line of epidemiological defense well enough, which can save us all from the need for a new quarantine.

Because of all of this, the reverberation of ideas offered under the second scenario was too lukewarm. It was to be concluded that Croatia isn't like Taiwan or South Korea after all, and it can hardly be expected that the Croatian population will support such measures as more desirable than the alternative we have left. In the absence of the ability to activate one of these two proactive strategies, which were quite ambitious in their nature, we need to adopt a third strategy.

Most other European countries are now likely to resort to that one, too. It will be a strategy of "tightening and loosening" these measures. It will be guided by the monitoring of the "infection spread parameter", designated as R0, which indicates how quickly the infection spreads. I estimated the R0 for the new coronavirus to be between 2.5 and 4.0. This means a very rapid spread as each infected individual can infect three more healthy ones. It is important for the R0 to be lower, to a value below 1.0. In that case, each infected person, on average, spreads the infection to less than one healthy person, and in that way - the epidemic slowly begins to fade.

Thanks to our brilliant scientist Petra Klepac from the London School of Hygiene and Tropical Medicine, who has ensured that these institutions include the Republic of Croatia in their reports on the movement of the R0 parameter in individual countries, we now know that we have reduced the R0 for Croatia to 0.8 thanks to quarantine measures. This isn't a bad result, as most other European countries are still struggling to reach 1.0 at all. This value points to two very important conclusions. The first is that over the course of five weeks, we've been able to show that the Croatian health system is able to control this new epidemic.

In the case of a new need for this, we now know exactly what measures need to be taken to suppress the virus, which is very reassuring. The second conclusion is that with all the measures taken so far, epidemics are still smoldering. They can be re-inflamed, and the maneuvering space for these measures is actually quite small. In addition, over time, life spent between "tightening up'' the measures and "loosening'' them back up again will also result in boredom for people. The question is also whether or not it will be easy to get those under fifty years of age to undergo any other quarantine at all, should such a need arise. Today, therefore, the second chapter ends and the third chapter of this unexpected crisis begins.

I'm not sure if a sufficient number of people in Croatia understand how much this third chapter will, in many respects, be more uncertain than the two chapters which came before it. During the first phase, a plan was prepared. The movement of the virus was monitored around the world, and the first line of defense was protecting us, with the aim of preventing any free spread of the virus within Croatia's borders. And during the second phase, there was a clear plan in place. The quarantine measures were supposed to save tens of thousands of our fellow citizens from death at the hands of the epidemic, while at the same time, reducing the effects on the economy with the introduction of a package of economic measures. That was also successfully done.

Now, we are entering a third phase, in which the goal is the relatively secure co-existence with the virus while adjusting our economic activities appropriately and maximising the re-normalisation of regular life. However, the duration of the period of loosening the measures and the avoidance of needing to tighten them back up again will depend primarily on the behaviour of the population itself and their individual efforts to limit the spread of the virus.

Will there be another quarantine, and when will it happen? Then, in that case, will it protect only the old and the sick, but not other people? Will a booming epidemic occur in Croatia in the next chapter, as has already happened to some other countries, despite a lot of attention having been given to it? Will the virus still be able to show at least some seasonal characteristics and slow its own spread down during the warmer months? Or, perhaps, will news come from the world of science about an effective drug or a vaccine?

In the absence of some really good, fresh news on the matter, we could be doomed to switching between "tightening" and "loosening" these anti-epidemic measures over the coming period, and the duration of something like that is not easy to predict at all.

I also mentioned the fourth scenario, but this one is really rather pessimistic indeed. There is still a chance that solutions from the world of science and medicine will begin to arrive, they just need to be given time. But, unless there is clear progress, if the virus doesn't slow its spread down but instead it continues to mutate, and if some more dangerous strains of it begin to emerge, and in the meantime, if the process of "tightening" and "loosening" the measures begin to exhaust citizens and the economy, the level of acceptability of the measures outlined in the third strategy to the general public could alter.

However, with the impossibility of implementing the first two scenarios and the saturation of the population in regard to the third, what do we have left in our arsenal?

I will save a more detailed elaboration of that fourth strategy for one of my next columns. For now, for the sake of reflection, I will only offer a definitive answer: If this crisis persists, and if it continues to worsen in the absence of scientific solutions, then the (in)acceptability of all that has yet to happen follows, that will dictate the resolution of the COVID-19 crisis.

In the fourth, final scenario, the solution will come from neither science, nor medicine, nor economics. It will be delivered instead by lawyers in the form of a law. It will introduce a fundamental human right to become infected and die from the new coronavirus.

This text was written by Professor Igor Rudan and was originally published on Vecernji list. It has been translated into English from Croatian by Lauren Simmonds

For more on coronavirus in Croatia, follow our dedicated section. For more from Professor Igor Rudan, follow his author page here, his LinkedIn here, his Facebook page here, his Twitter here, and his Medium profile here.

Monday, 20 April 2020

Igor Rudan: Why Singapore, Japan, Qatar and Emirates Now Have Coronavirus Outbreaks

April the 20th, 2020 - Can Croatia leave a long ''quarantine'' period? Here are the answers to seven very difficult questions, as explained by Professor Igor Rudan.

Six weeks ago, I published my first comprehensive article in the Croatian media on COVID-19. In the meantime, thanks to numerous articles by Croatian scientific journalists as well as scientists who have participated in the public debate, the public's understanding of the COVID-19 pandemic has increased. Thanks to this, In this text, I'll also offer answers to a number of new questions that have now arisen as time has passed.

1. What are the basic types of strategies that characterise the responses of most countries in the world to the spread of this new coronavirus infection?

Since taking anti-epidemic measures, we've seen four different types of strategies. I'll rank them from least to most interventionist. The first type of response was to allow the virus to spread among the population in order to expose as much of the population as possible to it, to ''get over'' COVID-19 and thus ''immunise'' ourselves against it while preserving normal life and economic activities to the fullest extent. Sweden, the United Kingdom, the United States, the Netherlands and, to a certain extent, Germany, led the way in this regard.

The second type of response was to rely on a deep "first line of defense", this was facilitated thanks to a high level of development, modern technologies, a strong capacity to test people for the presence of the virus, as well as the rapid monitoring and isolation of their contacts with modern technologies. The best examples of this approach were South Korea, Singapore, Taiwan, Japan, United Arab Emirates, Qatar and Iceland. The third group of countries, where the vast majority found themselves, after a short time, trying to stop the virus with the "first lines of defense" had to move to another plan which involved them closing the borders. They were then quarantined for several weeks to prevent the spread of the virus and significantly reduce the daily number of new cases of coronavirus infection. During the quarantine period, a plan for ''getting out'' of quarantine and co-existing with the virus until effective drugs or vaccines appeared was made.

Finally, the fourth example is countries that started with their quarantine measures early enough, or implemented them so intensively, that they practically eradicated the virus within their respective borders. China is an early example of this, but thanks to the success of its measures so far, there is hope for New Zealand, Vietnam and even for Montenegro.

2. What have been the results of individual strategies so far?

It turned out that all four initial approaches, after enough time, were more or less forced to switch to the same strategy, a quarantine of varying degrees of severity. Although they have sought to preserve their normal lifestyle and indeed their economy for as long as possible, the United States and the United Kingdom now have an enormous number of infected people within them. The United States is sure to have the highest absolute death toll after the first wave of the epidemic. The United Kingdom will also have a large number of coronavirus casualties. Germany is managing to keep the death toll quite low compared to the number of infected people, thanks to the spread of the infection among mainly younger age groups, as well as excellent epidemic prevention measures in hospitals and retirement homes, and the strongest intensive care facilities. The Netherlands, like the aforementioned countries, has since moved to stricter quarantine measures. Only Sweden continues to rely on the discipline of its citizens and its social distancing measures to try to keep the virus at bay. We'll see over time what the results of that move will be, and how much life is currently "normal" for them compared to the period before the pandemic. Currently, the death toll is significantly higher in Sweden than in a dozen countries with comparable numbers, but it's obviously not yet large enough to isolate the entire population, regardless of government recommendations.

Unfortunately, we're increasingly seeing that even those nations that have sought to defend themselves against the COVID-19 epidemic by maintaining a "first line of defense" are slowly yielding. For ten weeks, they have been fighting hard to prevent the virus from spreading freely among the population through mass testing and the rapid isolation of patients and their personal contacts. Although it seemed for a long time that these countries would succeed in this approach, Singapore recorded as many as 623 new cases on Friday and a real epidemic is now ''booming'' there.

The same is true for Japan with 556 new cases of infection, Qatar with 560 and the United Arab Emirates with 477 newly infected people in just one single day. All four of these countries have now introduced quarantines and substantially tightened their respective measures. Only South Korea and Taiwan seem to be succeeding in the "first line of defense" approach. There, the number of newly infected people is still successfully maintained at a low figure and without the need for quarantine, but with a massive amount of population testing and the use of highly intrusive methods of monitoring mobile telecommunications. These two countries have learned from the SARS experience and they were greeted by this pandemic excellently prepared, and they remain the only ones to still be resisting it with their "first line of defense."

Iceland and New Zealand have been able to reap the benefits of their favourable geographical locations and owing to that, they could, much like China, completely eradicate new infections on their territory. The best reaction in the world in general was probably that of Vietnam, another country which recalls the SARS pandemic very well. Vietnam recorded 63 cases and 5 deaths of SARS back at that time. Today, that country, with a population of almost 100 million, still doesn't have one single victim of COVID-19.

Admittedly, the same may be true of North Korea, but it's hard to know what's going on there at all. However, a new challenge for all countries that have managed to completely suppress the spread of the virus at an early stage is that in the next phase, every person entering the country will be a new potential source of the epidemic. Therefore, they will only be able to relax their measures when medicines or vaccines are developed, and until then, they will need to depend on the tight control of their borders and quarantine for everyone who enters them.

But what can be generally concluded is that, more or less, all countries across the world were forced, at least over time, to abandon their initial strategies and move to stricter quarantine measures, with the exception of only a few very rare exceptions, otherwise the extremely rapid spread of the new coronavirus simply couldn't be stopped.

3. Are the quarantine measures justified, given the real danger of the virus and the damage done to the economy?

In order to give a clear answer to this question, we should first know with sufficient certainty what the real threat of the virus is at the level of the entire population, and what are the economic, health, and any other indirect threats from ''halting the world'' in just several weeks. Unfortunately, at the moment, we don't know with sufficient precision the answer to any of those questions. Therefore, all countries are making their own decisions in the face of an entirely new and unknown situation in modern history. The extent to which their measures were justified will be carefully evaluated by science for years to come. The epidemiological profession is still trying to assess the real threat of the virus by employing various methods. The parameters of epidemiological models have been changing and refining for weeks with each new survey conducted. During this time, it's quite understandable that many people in Croatia, as well as across all other countries in the world, are now becoming very impatient. In Croatia, a specific problem could be that the results of our health care system's fight against COVID-19 are so good at the moment, that increasing numbers of people don't find the measures justified and start criticising them. They don't understand that the results are good precisely because the measures were timely and rigorous. In that sense, Croatia is slowly becoming a "victim" of its own good results.

However, most people in countries that have experienced a significantly worse and more severe epidemic than Croatia have quickly realised that the economy being "preserved" is very much an illusions until that country somehow manages to control the spread and effects of the new coronavirus. Just look at the world's largest power - the United States of America. There was huge public support there for no strict anti-epidemic measures to be taken if they would ultimately harm the whole nation rather than benefit it. The problem, however, is that in New York, Detroit and some other areas, many people are starting to die and hospitals are becoming heavily burdened overnight. The media's intense focus on monitoring the pandemic has forced most of the population to retreat into their homes, regardless of their plans and the recommendations in place for them. As a result, jobs began to vanish at an extraordinary rate, and the number of unemployed people in the United States has increased at a rate likely not seen since the "Great Depression" that began in late 1929, and it may now surpass it. Thus, in the USA, tens of thousands of people will die in the initial wave of this epidemic, and the economy will also receive a major blow.

However, there is still a lot of fairly loud and articulate thinking in the public opinion that, if that must be the price that needs to be paid to ''immunise'' the population and resume normal life as quickly as possible, along with the recovery of the economy, in the long run, such an approach will prove to be better than quarantine and the consequent collapse of the economy.

The premise for such thinking is that in this first epidemic wave, the level of the population exposure sufficient for "collective immunity" against coronavirus and stopping its further spread will be reached. This level, however, depends on the "spread rate" of the virus, ie - its infectivity. Unfortunately, the level of infectiousness of the new coronavirus appears to be higher than the initial estimates from Wuhan actually suggested. When infectiousness is higher, then the proportion of the population that needs to get over the infection to stop the epidemic and reach collective immunity is also higher.

With a very high level of infectivity, a sufficient proportion will no longer be 40 percent or 50 percent of those who have managed to acquire immunity, but perhaps more than 70 percent, or even 80 percent. In the US, however, not enough people have been exposed to the infection so far. Barely 10 percent of the total population has been infected there to date. However, in a country of almost 330 million people, this is a huge number, so the casualties are already very significant. Furthermore, in the context of population exposure strategies, while maintaining the economy, one should also have faith that this immunity will be long lasting. However, there has not yet been enough time for this to be scientifically investigated, let alone clearly confirmed. Finally, it's hoped that the genome of this virus will remain stable. If it mutates from year to year, much like the flu virus does, the immunity acquired the previous year will no longer protect someone the following year. If we don't receive the vaccine or effective medicines by then, we'll have to face a large number of new coronavirus victims once again, and all of the casualties of the first wave of the epidemic will be in some way futile, as that situation could have been prevented with the introduction of quarantine measures.

In conclusion, this major problem with COVID-19 may, in some unforeseen way, be resolved faster than it currently appears. After that, economies may then recover very quickly, or they may not. We're yet to see this in the coming months. Until now, in modern history, the development of the economy has always meant better human health. It also worked the other way around, too, meaning that the better health of the people also contributed to economic productivity. However, in this unusual and entirely new situation, the concern for public health threatens the functioning of the economy.

Moreover, there is no "theoretical model" of how much life can be reasonably saved, with the sacrifice of a percentage of the economy. Moreover, there are no good estimates as to whether this economic downturn will have worse health consequences than the pandemic itself. However, one of the most important reasons as to why the vast majority of the world's countries have chosen measures to physically remove people to prevent the spread of the virus is the fact that we still know too little about the virus itself. It seemed reasonable, therefore, for us to buy some time. This will give us a much better idea of ​​what kind of danger we're dealing with and what strategies might or might not be effective.

Things are changing, quite literally, day by day, and it's becoming clearer which measures will work and which are less likely to succeed.

4. What does all this mean for the anti-epidemic measures being taken in Croatia and when they could be completely abolished?

Thinking about Croatia, maybe it might help to say that here, where I've lived and worked for two decades, in Scotland, about 50 people have died every day from COVID-19, with an estimated 1,000 casualties. It would be very similar in Croatia, if we were only two weeks late with these anti-epidemic measures. Unfortunately, this scenario can still happen to Croatia if we underestimate this virus after we leave quarantine, and coronavirus' free spread among the population occurs.

Even if 50 people died in COVID-19 every day in Croatia, it is likely that many people would retreat inside their homes. Then it would be difficult to save the economy and tourism again. If it were so easy to get out of this situation, countries across the world wouldn't be resorting to these strict anti-epidemic quarantine measures. In the vast majority of them, national economies are highly dependent on SMEs and as such, they're in the same situation. Therefore, you should work as actively as possible to plan your exit from quarantine as quickly as possible, but also to do so with a good deal of caution.

It's certainly good that we've shown in Croatia that we're able to curb the COVID-19 pandemic with anti-epidemic measures. Of the EU member states, Italy currently accounts for 22,745 deaths, Spain 20,002 and France 18,681, while the UK, an EU member until recently, had 14,576 casualties. Belgium, Germany, the Netherlands and Sweden have between 1,000 and 5,000 deaths, and even non-EU member Switzerland is in this class. Portugal, Austria, Ireland, Poland, Romania, Denmark, the Czech Republic, Greece and Hungary can count their death tolls in three-digit figures, as can Norway and Serbia, which are both outside of the EU.

Croatia, with 36 deaths so far after the first eight weeks of fighting the virus, is certainly among the most successful countries in the whole of the European Union. We have several hundred times fewer deaths than Italy, and I explained the reasons for this in one of my previous columns. These results still stand even in the face of reported incidents of the spread of contagion in retirement homes and in healthcare facilities. Only Slovakia, Latvia and Malta currently have fewer deaths than Croatia within the European Union. This is certainly encouraging is a praiseworthy success for Croatia's National Civil Protection Headquarters and epidemiologists.

However, I've already stated in my earlier columns that if one wants to understand the true state of affairs with this epidemic, one should always look first at Singapore, the United Arab Emirates, Qatar and Japan. These are ambitious nations that strive to be the best in the world in solving every single task. That's why the state in those countries is the most reliable reflection of what can be expected in the best case scenario. All four of these countries currently have freely spreading COVID-19 outbreaks, and they've introduced strict quarantines - something that only a handful of people would have expected a week or two ago.

What does this mean for Croatia? Suppose we managed to reduce the number of people infected within the Croatian borders to just a hundred by quarantine. Those 100 or so infected people aren't visible to us yet. Specifically, we have yet to discover them through testing. We will be able to do this based on the symptoms that they will all develop following the loosening up of the measures. Some may have already started developing symptoms, but they have not yet reached the stage of the disease in which they need to be tested.

Unfortunately, if all the precautions are completely absolished, those one hundred infected people will lead to a thousand infected in just one week, and a thousand in the next week, then to ten thousand. This will mean a new quarantine, but it will probably go on for longer this time. Why is that? Because of those 10,000 infected people that we expect to develop symptoms of the disease, about 5 percent of them will need intensive care and respirators. That's as many as 500 people. Therefore, the number of casualties in Croatia during that second quarantine would add at least 200 or 300 more to the death toll in the first wave. This would be a likely consequence of just two weeks of the complete loosening of all of the anti-epidemic measures. This virus is spreading so quickly, and so easily, with an enormous speed of spread, and that in itself presents us with big problems and some very difficult decisions to make.

I'd like as many people as possible to understand that an uncontrolled COVID-19 epidemic has occurred in Singapore, the United Arab Emirates, Qatar and Japan over the past two weeks. For the first time, the virus forced them into taking harsh measures of social isolation. If we don't want the same thing to happen to us in Croatia two to three weeks after the loosening of the measures, and then being forced to quarantine another two months during the tourist season, we'll need to be more thoughtful and successful in our "loosening" of the measures than they were over in Singapore, the United Arab Emirates, Qatar and Japan. Just think for a second about that sentence. Can we do that? We'll definitely try, but I really don't know. If they failed, we will now need another highly anticipated endeavor to avoid such a scenario and another wave of epidemic for Croatia.

5. If it's too difficult to assess the effects on the economy and other indirect adverse effects at present, when would we at least be able to determine the real danger of the virus? Recent reports from several countries have reported dozens of times more infected people than those found by testing. Doesn't that mean that COVID-19 is nowhere near as dangerous as it seemed?

It may be time to return to the very beginnings of this epidemic, as well as the "infodemia" in Croatia, and try to clarify a few important facts. The danger of a virus in any epidemic depends, in principle, on its two basic characteristics. In my popular science articles, I refer to them as the "rate of death" and the "rate of spread". I do this for clarity because there are other professional names for them.

In my first address to the Croatian media back at the end of February, I explained that the "death rate" was calculated by dividing the total number of deaths from COVID-19 by the number of all who were infected with the virus. The English name for this parameter is "case-fatality rate". I explained that for the COVID-19 infection, the death rate cannot be 3.4 percent, which is an estimate made officially by the Director of the World Health Organisation. Specifically, with the 3.4 percent estimate, the denominator was based only on persons who had reasons to be tested and ended up being positive for coronavirus. In doing so, the denominator didn't include all those infected who weren't tested, and we cannot know how many of them there were.

We knew then about the Hubei province that about 3,000 died and that the number of deaths divided by the number of confirmed infected was 2.9 percent, and in the City of Wuhan, it was as high as 5.0 percent. Based on the experience of previous respiratory outbreaks, I didn't believe that it meant that every twentieth infected person would die. Specifically, infected physicians at Wuhan's hospitals had a significantly milder clinical picture when infected with coronavirus when compared to their patients with severe COVID-19. This was a sure sign that patients in hospitals represented only the extreme, that is, the most severe part of the much broader range of symptoms among the wider population. How many more were actually infected on the streets of Wuhan and had milder symptoms? No one could know that.

Wuhan is absolutely huge and there could be as many as 100,000 infected people at the time, as the first figures on the "death rate" roughly indicated. But there could be as many as a million, so those first rates should then be divided by ten. But because of the size of the Wuhan, the figure could theoretically be as high as ten million, so, those first rates should be divided by one hundred. So, I then assumed that the number of infected people should be at least several times the number of people who tested positive for coronavirus in Wuhan, and instead of death rates of 3.4 percent for the world, 2.9 percent for the Hubei province, or 5.0 percent for the City of Wuhan, I recommended that a large number of people who have milder symptoms and hadn't been tested needed to be taken into consideration too.

Then, on Sunday at 2 (Croatian TV show), I put in an estimate that was between 0.5 percent and 1.0 percent. However, in doing so, I said that even a "death rate" of 0.5 percent was actually a "conservative" estimate, since those infected in Wuhan could in principle be between ten and a hundred times higher, due to Wuhan's sheer size. Therefore, the rate of death in the community of COVID-19 could be as low as 0.5 percent. But, if it is indeed less than 0.5 percent, it's already in the rough area of ​​the rate of death from more severe flu, for which we don't have a vaccine.

However, until we have a good understanding of what the denominator is, we won't be able to properly assess the risk of this new coronavirus. Over recent says, we've finally been getting the first reports from the Netherlands, Denmark, Italy, Iceland, but to me, the most valuable of them all are from my long-time acquaintance and highly regarded colleague, Professor John Ioannidis from Stanford University in California. His research seems to me to be the best designed and implemented. Researchers at all of these sites have finally begun to search for antibodies in the blood that indicate that people have become infected with COVID-19 and have become immune to the virus without even knowing it.

When such a survey is conducted on a sample of the entire population - for example, among voluntary blood donors or a randomly selected sample of volunteers - we say that we're carrying out so-called "seroprevalence".

Efforts are made to determine the frequency of previous population exposure to the virus with the demonstration of an immune response. What are the conclusions of the first studies conducted in as many as five different places? They're exactly what epidemiologists have assumed from the beginning. The number of people infected with the new coronavirus was several dozen times higher than the number tested positive in all of the aforementioned countries. A percentage of the population is now infected, but it's still less than 10 percent. In the California survey, between 2.5 percent and 4.0 percent of the population were infected.

What does that mean? In those countries where "death rate" in the figure have been contributed to by numerous deaths in retirement homes, this will mean a death rate that will be within my projected range, ie between 0.5 percent and 1.0 percent. But in Santa Clara, California, where this wasn't the case, it would mean a "death rate" of between only 0.12 percent and 0.2 percent, therefore - quite comparable to a a more severe flu, even with vaccination. This is in line with my previous interpretation of the events in Wuhan and Italy, which no longer seemed possible to many because of the way the crisis was being reported on there.

These new insights also explain that everything that experts, scientists and the national civil protection staff have said from the start about COVID-19 hasn't been wrong. There are two reasons, however, why the correct interpretation of the danger of COVID-19 to the public may still seem wrong for a long time. The first is that the public in general, as I've learned in recent weeks, doesn't even have an approximate impression of the danger of influenza as an infectious disease. Flu is not a "virus", neither is it "just a flu", nor is it "a little case of the flu". The real flu is a disease that claims between 250,000 and 650,000 victims worldwide every year, even with vaccination readily available. Now in Croatia, the public has finally started to realise that in flu season, respirators in hospitals for infectious diseases and other hospitals across the country are completely occupied. In Italy, about 20,000 casualties were attributed to the flu during the 2014-15 flu season, and as many as 25,000 in the 2016-17 season. Over in the US, as many as 61,000 deaths were attributed to the flu in the 2017-18 season. But the impression of the population about the danger of the flu has become so mild that people don't even borther to get vaccinated, although they're free to do so.

I explained even then, at the very beginning, that the panic about COVID-19 in Croatia wasn't reasonable, because in the Croatian population, this new virus will have effects similar to the more severe influenza for which we don't have a vaccine, but we will be able to stop it with a series of anti-epidemic measures, such as by those which have been employed. This has been claimed by other Croatian scientists as well as by members of the Civil Protection staff.

Flu is, of course, a completely new and different disease each and every year. During the course of about three and a half months a year, during its season, influenza in Croatia can take up to 100 victims directly, and up to 500, or even more, indirectly, by exacerbating their existing diseases. The Seattle-based American Institute for Health Metrics and Evaluation, in its latest estimates, predicts that between 50 and 200 may die from COVID-19 in Croatia by autumn 2020. So, this prediction is also in line with the initial predictions I made. The peak of the epidemic wave in terms of deaths is scheduled for Croatia on April the 20th, 2020, meaning right now, and that's exactly what we're witnessing.

I hope that Croatia's results so far, as well as all of this data, will contribute to the public's continued confidence in the epidemiology profession. Another reason why the comparison with a more severe flu appeared to have been wrong was the events in Italy and the way they were monitored by the media. Namely, everything we watched and listened to from Italy for weeks was incompatible with our estimates that this was not a very dangerous and pernicious epidemic. However, in my previous articles, I tried to explain that in Italy we were looking at a COVID-19 picture in which the epidemiological response was missing, ie, things werre significantly delayed.

As a result, the number of infected, and thus of the dead, rose very sharply to several hundred times the numbers that epidemiologists would have initially expected. Then, the situation was dominated by epidemics in retirement homes and hospital wards. There, the "death rate" from values ​​of less than 1 percent rose to about 10 percent. This is because the virus spread rapidly among the population who were most likely to die. The average lifespan in Italy was about 80. Almost 90 percent of the deaths were in people who were over 70 years old, and in the vast majority of those cases, every one of those individuals was already suffering from one or more serious illnesses. All this important information was not clearly communicated by the media. They reported only on the huge number of deaths, and occasionally any isolated younger patient, and terrifying individual testimonies.

However, in my first public address at the end of February, I announced that the victims would be predominantly elderly people, and for most COVID-19 victims, their lives would be shortened by a few years, which would be spent at an older age and undergoing treatment for pre-existing illnesses.

I'd also like to recall another important detail now that I also emphasised in all of my first media appearances, but due to the then lower level of understanding of pandemics then compared to today, few people noticed and understood it. At the time, journalists paid the most attention to the question of whether the virus could mutate to increase that "death rate," and thus start killing more people among everyone it infects. Of course, this is what they cared about the most, because that, at first glance, seems to be the most important information. But I kept saying at the time that the virus could mutate in another way, that is, it would start spreading more rapidly among people, and I said that, personally, I was much more afraid of the developments if things went in that direction.

But, the idea of the virus spreading too quickly seemed far less important to people at the time than the death rate. The rapid spread of the virus puts epidemiologists in greater trouble when planning anti-epidemic measures than the "death rate" itself does. Even a high "death rate" at which we can still easily monitor and isolate all infected persons and their contacts is easier to deal with epidemiologically than a low "death rate" with very rapid spread. The best example is this new coronavirus, which has caused us significantly greater problems with its death rate of less than 1 percent compared to SARS, MERS and Ebola, whose death rates were 10 percent, 35 percent and about 50 percent.

When the virus arrived in Europe, my greatest fear, unfortunately, came to fruition. The virus' "spread rate", which was significantly underestimated initially, made it significantly more dangerous than its "death rate." Initial estimates of the "spread rate coefficient" were around 2.2, but now there are estimates suggesting a figure of 5.7. This would mean that each infected individual could infect another five to six healthy individuals. It is possible, however, that this estimate is a little bit too high - my own calculations currently suggest an R0 number of between 2.5 and 4.0 when the virus spreads freely in most countries. But, that is also extremely quick and should not be underestimated.

6. If the "death rate" is now almost certainly less than one percent, and it may turn out to be close to 0.2 percent, which would correspond to more severe flu, does this mean that we can end the quarantine measures and ignore COVID-19, just as we neglect the flu?

I would be the happiest person to be able to say that this is the end of a major public health emergency. However, many things in this pandemic are much more complicated than what is typical for public communication on most other topics. Therefore, I will try to explain why the conclusion that follows from the reduced estimates of the "death rate" is still not all that simple. Namely, unlike more or less all other diseases that the Croatian healthcare system is facing, this virus also has a "fourth dimension" - time - that causes us problems that we're not used to in medicine. In medicine, there are too many cases of capacity-related illness mainly when the trauma clinic needs to deal with injured people from a large train or bus collision. Another example is wartime surgery, where several surgeons have to deal with the sudden emergence of a large number of wounded people in an unforeseen battlefield tragedy. But beyond that, too many patients aren't something we often have any real reason to think about.

So, let's suppose for a moment that this relatively small "death rate" when the new coronavirus is spreading among the population, which we can now slowly assume will be somewhere between 0.1 percent and 1 percent, is really the only danger associated with it. Then the new coronavirus could be compared to a monster slowly approaching us from afar, but we can see more and more clearly that the monster is physically small, that is, it reaches our navels when up close. So, we begin to relax, because whatever it is, we'll be able to knock something so small to the floor and master it. But, we're only looking at it from the front, we're not taking care to check what it has behind its back. There, in a dimension we cannot see, he is hiding three metal bars. When he finally stands before us, if we let him out of our sight for one moment and relax, he will be able to hit us over the head with one of these metal bars at an unbelievable speed.

The first problem that the new coronavirus causes us from that fourth dimension, beyond the death rate itself, is its absolutely incredibly rapid spread. If we allow it to spread freely among the population, it will infect up to one million Croats in just over a month from just one infected person. Even with a small "death rate", in just a few weeks, we will have thousands of severely ill patients, with fewer than a thousand intensive care units with respirators available.

All those who don't receive care will then simply have to die of suffocation.

They would die in hospitals alone because their family should not be in the infected ward. The burial conditions of all the deceased would also be extremely limited and quite different from the usual customs. I believe this is not a fate that anyone would wish on an older member of their family, and it should be avoided. This brings us to one big problem. Another big problem is that the new coronavirus has two faces. When spread in the community, it goes around relatively harmlessly, causing mild to moderate symptoms in most people and boasting a fairly small "death rate". But, when it enters into a vulnerable population, such as hospital wards, rehabilitation centres, or retirement homes, it spreads at a tremendous rate, because everyone is particularly receptive. We have also seen this in Croatian retirement homes. It also increases its "spread rate", but this is an even smaller problem in these situations. The bigger problem is that the coronavirus "death rate" then increases by at least ten or twenty times, and among such subgroups, it can kill up to every fifth or tenth infected person, depending on how old and sick they already are.

In many European Union countries, a very large proportion of the total number of deaths is caused by severe outbreaks occurring in retirement homes. This is another major danger that I have pointed to from the beginning, writing that anyone who brings the infection with them into a retirement home can contribute to the untimely death of twenty or more people.

The third metal bar this little monster has in its arsenal, that is, the third big problem that we have no answer to, is the indirect effect of the virus on the health system, which causes mortality from all other diseases to increase rapidly. Specifically, if the virus was simply allowed to spread freely, hospitals would temporarily be crowded with infected patients, doctors, nurses, as well as people who come for checkups or visits. The vast majority of health care professionals would end up either on sick leave due to COVID-19, or in self-isolation so as not to spread the infection to patients in serious conditions. To prevent hospital outbreaks with a significantly higher "death rate", as many patients as possible should be evicted immediately to be cared for at home. There would be a complete disruption of the functioning of the health system at all levels, which would cause those with other health conditions to die more frequently and more quickly.

These are the three big problems that no one in the world has a clear answer to yet and why more or less everyone has resorted to going into quarantine. In Croatia, these measures have now been in force for about one month. Thanks to them, the Croatian death toll is among the smallest in Europe, with thousands of deaths occurring across many other European Union countries. The three problems I just mentioned have also been prevented to a substantial degree. I hope that all the subsequent analyses will show that quarantine for four weeks to avoid all these problems was worth it. But now, it's necessary to ''get out'' slowly, but with enormous caution. The virus is still among us and we have seen at what speed it will continue to spread if we allow it to do so. The first quarantine decision also allowed us to think about supporting the economy. But a second quarantine would really hit the economy hard and frustrate the tourist season. Therefore, one should think about all of this the loosening up of these measures is introduced.

7. What are some new pieces of news from the world of science that we should pay attention to?

It should be noted first that all scientific research on COVID-19 is currently being conducted in a way that would otherwise be unacceptable to serious science in other circumstances. Work is done at speed, on small amounts and and often not sufficiently representative samples, it highlights the numerous imperfections of research design, many details that otherwise must be taken into account are being ignored. All of this leads to a real epidemic of superficial research, seeking to answer the open-ended questions as soon as possible. Unfortunately, a quick and wrong answer can do more harm than one that comes a little bit more slowly but ends up being correct.

An additional issue is that just about every piece of published research is receiving a lot of media attention from all over the world, and more and more often that results in so-called "pre-prints", that is, scientific papers that anyone could write and publish on a platform for pre-publications, without them having had any serious scientific and professional review. It will be clear to scientists whether it is serious research or it has major shortcomings, but journalists will have a harder time assessing that. Therefore, we should expect a full set of reports on various "scientific research results" from day to day, which will prove to be false or unfounded in about a week or two. It's a shame that so much time and media space is constantly being spent on completely unfounded reports and results. But it is one of the basic features of this "infodemia" that has now taken hold.

I'll only provide you with a brief overview of the most important open-ended questions and scientific insights that have been written in recent weeks here, which will be worth following in the coming weeks. Several science news outlets currently appear to be unfavourable in the fight against COVID-19, but much more needs to be investigated. It seems that the virus can come back to the bodies of those who have already had it and got a negative coronavirus result on the test. This is now being investigated in more detail, as it is possible that the tests aren't reliable enough, or that it may take much longer for the virus completely disappear from the body than was initially thought. However, if it turns out that those who have already had the disease can become infected again very soon after getting over it, that would be pretty bad news indeed.

It would mean that the immunity acquired after having the new coronavirus is not permanent, and that the vaccine may not be able to help as much as we had hoped it would. But, it's still far too early for such conclusions, new and better research needs to done. Furthermore, it is less and less likely that the virus will disappear with the arrival of warmer weather, as recent data from West Africa and many other very hot and humid places shows that it is still spreading rapidly and very successfully there. When the numbers of infected and dead people in a large number of countries are reduced, few countries will be willing to open their borders freely without two weeks of isolation on the cards for all who enter.

This will make international travel significantly more difficult in the coming months, so we should expect domestic guests in the tourism industry, and that's if we manage to avoid entering into another quarantine. Foreign guests pose quite an uncertain question at the moment, but let's still allow for the possibility that some positive turnarounds may occur in the coming weeks, which would change the current pessimistic forecasts. The bad news is that the antiviral drug lopinavir, which works by inhibiting proteases, and together with ritonavir, which is effective against the HIV virus that causes AIDS, has not shown efficacy against COVID-19. This was expected to be the case.

Still, there is some positive news to be had. For the time being, by comparison with the data from China, Italy, Spain and the US, the new coronavirus hasn't mutated in terms of a higher "rate of death" or a higher "rate of spread", but it turns out that its genome is more stable than that of the flu virus. In addition, there are some of the first indications (that science has yet to confirm) that blood plasma transfusions from those who have recovered from COVID-19, through early-response circulating antibodies, can be effective and give a bit of hope to severely ill coronavirus patients.

However, more research will be needed before we can think about such a recommendation, even though it does make scientific sense. The best two news stories, however, are the early described efficacy of the antiviral drug Remdesivir, which I know from my colleagues is already available to patients in Croatia. This drug, which is extremely elegant in its way of fighting RNA viruses, was supposed to be a cure for Ebola, but it didn't show the desired efficacy. However, this drug is an adenosine analogue and is inserted into the strands of the viral RNA molecule, ie the genetic instructions of the virus, causing the premature termination of protein synthesis which is required for new viruses.

In the first study, it showed possible efficacy in about two-thirds of severe coronavirus patients, and the mortality of those on respirators decreased from about 50 percent to 15 percent. Because of this, Remdesivir is currently a new news item that needs to be closely monitored. However, it should also be noted that the studies conducted so far have not adhered to the usual standards, they have been conducted without a control group, and we will require much more extensive and better-designed research to properly understand the effectiveness of Remdesivir. But in light of all current insights, Remdesivir, with the knowledge of a lower "death rate" in the community, is still the best news we currently have on the matter.

This text was written by Professor Igor Rudan, was first published on Vecernji list, and has been translated into English by Lauren Simmonds

For more on coronavirus in Croatia, follow our dedicated section. For more from Professor Igor Rudan, follow his author page here, his LinkedIn here, his Facebook page here, his Twitter here, and his Medium profile here.

Friday, 17 April 2020

Professor Igor Rudan - What Coronavirus Has Taught Me So Far

April the 18th, 2020 - Just what has the coronavirus pandemic taught this leading (yet ever curious) Croatian scientist so far? Igor Rudan lists ten things he's learned since the epidemic began.

1) It taught me that people don’t have the faintest awareness of just how much of a dangerous disease flu actually is.

Influenza must have been largely responsible for the horrendous pestilence among American Indians, Aztecs, Mayans, Incas and Australian Aborigines when they came into contact with the first European colonists. The "Russian flu" ravaged the years 1889 to 1890, had the antigenic composition of H3N8 (or H2N2) and killed one million people at a time when the world's total population was only about one and a half billion people in total. 

Then, "Spanish flu" was the worst flu of all. It struck an exhausted, hungry, and deployed humanity at the end of World War I, between 1918 and 1920, and had the H1N1 antigenic composition. It probably killed up to 75 million people at the time when the total population was 1.8 billion, and had a significantly higher mortality rate in the community than this new coronavirus has. Asian flu then plagued the world from 1957 to 1958. It had the antigenic composition of H2N2, killing more than 3 million people directly and indirectly at a time when there were 2.9 billion people on Earth. Finally, Hong Kong flu toured the world from 1968 to 1969, had H3N2 antigens, killing more than three million people directly and indirectly at a time when there were 3.5 billion people on Earth in total. Today, even with the vaccination of the most vulnerable among us who might die, the flu continues to kill 250,000 to 650,000 people a year. It does so to a lesser extent directly (by causing respiratory symptoms) and more indirectly (by the exacerbation of pre-existing diseases in the elderly).

In Italy, according to properly conducted research and calculations, which took into account both direct and indirect deaths, influenza has been killing 7,000 to 24,000 people a year over the last decade. In the USA, the flu takes at least 20,000 to 50,000 lives each year. In both cases, these figures are valid even with the vaccination of vulnerable groups of people. If those people were not vaccinated, that figure would be significantly higher.

2. I have learned that people are quick to lose their fear of everything that is well known to them, even if they shouldn’t, but they have an overwhelming fear of everything that is completely unknown to them.

It's difficult to explain just how people have been able to "get used" to flu mortality to such an extent that they don't even bother to vaccinate against it when they can, but now every coronavirus case in every country is being reported as if it’s the "black plague" once again. Influenza is predominantly a serious illness, which pins every infected person to their beds for a few days. COVID-19, caused by the new coronavirus, is a disease that has a wide range of symptoms. Globally, 90 percent of those infected, of which there are currently 60,000 active cases, are classified as having "mild symptoms" and only 10 percent of them are classed as "severe or critical". However, the intense focus of some media on the "tropism" of coronavirus for the pulmonary alveoli, and not just the bronchi, results in a very serious clinical picture in the most severe cases of COVID-19, as well as the fact that COVID-19 causes lung problems in all patients, whereas that occurs with only maybe one-fifth of those infected with the flu. This, combined with only the most severe cases, doesn’t provide the correct impression of how relatively dangerous these two diseases actually are.

As I said, for an epidemiologist, the most dangerous one is the one which kills more people. For now, that’s still the flu, even with vaccinations. The flu has probably killed an average of about 300,000 people or more over the past few years, regardless of vaccination. This new disease, COVID-19, caused 5,000 deaths after three months of spread. There will be significantly more deaths when the pandemic spreads across the globe, but for now, the question remains whether or not it will reach flu’s level. But I see that these days, because of the huge fear of something unknown, many people in Croatia can't see, hear, and somehow just can't understand that.

3) I have learned that even the most reasonable and intelligent people will easily mix up apples and cherries when they don’t have enough experience in a particular field.

The current estimates of the mortality rate from coronavirus represent a basket of apples and cherries mixed together. When coronavirus sweeps through hospitals, among people who are already unwell and who have issues, it can kill one person out of every 20, maybe out of every 10 or even out of every 5, depending on how many cases of infection in the hospital ward occurred in people who were already suffering from serious illnesses and how old they were. But when the disease is spread among a healthy population, it kills about one person in every hundred or two hundred, and maybe even less than that.

At the beginning of an epidemic, most of the people who die will have been infected in hospitals, so, the death rate among those infected will seem very high. Over time, the vast majority of cases will come from the community, so the death rate will begin to approach this lower value, for example; one death in every one hundred or two hundred infected people. In doing so, the overall potential of the virus to do harm to the entire nation depends significantly more on its spread in the community than it does on it killing people in hospitals. Therefore, the current death rates at the beginning of a pandemic should not be mapped to entire nations and their populations. But even that, it seems, isn’t an easy thing to explain these days.

4) I have learned that, thanks to a Croatian invention - quarantine - humanity is much safer from biological dangers today.

When the coronavirus epidemic erupted in Wuhan and met the local population, which was quite unprepared, on January the 16th, 2020, they had 500 newly confirmed cases in their hospitals, which meant that there were at least several times more real cases out there in the community. Then, on January the 19th, nearly 1,000 newly confirmed cases were recorded. Then, on January the 21st, another 1,500 newly confirmed cases were recorded in hospitals. Well, on January the 23rd, 2,700 new cases were confirmed in just one day, and they had cases in just about every one of their over 30 provinces. The number of deaths in those days had already begun to be measured in four digits. The epidemic had totally 

escaped control. And then a plan was adopted, which was implemented in a totalitarian way. On January the 23rd, 2020, people were barred from entering or exiting Wuhan, with its 11 million inhabitants. All of the people already in Wuhan, however, were ordered to shut themselves away into their apartments and not leave them at all. Everything in the city was closed. One day later, on January the 24th, 2020, the number of new cases confirmed in hospitals climbed up by a further 2,750, with the government ordering another 15 Chinese cities to be quarantined. These were truly draconian measures, which would be very difficult to implement in countries that lack a collectivist mentality.

The decisions of January the 23rd and 24th, 2020, in China, are unprecedented in human history. Tens of millions of people were quarantined. That’s something like the whole of Eastern Europe being placed in quarantine. And not only to the rest of the world, but also to each other, from each other. Everyone was in their apartments, just waiting. But it worked. They reduced the daily numbers of newly infected people and deaths down to double digits, and the total death toll in China is now just over 3,000. Given the size of the population, this would correspond to about 8 deaths throughout the whole of Croatia. The ability to rigorously quarantine tens of millions of people in order to curb epidemics that could be even more dangerous than this one is the most important new piece of knowledge that this new coronavirus has given me so far.

5) It taught me that we’re potentially in an important historical moment after which the East will become more important than the West.

We’re currently living in an interesting period that may be touched on in the history books in the future. It seems to me that the full range of challenges awaiting humanity in the 21st century, such as climate change and climate refugees, food and water availability, the mortality of the poorest among us, the pollution of the oceans, renewable energy, demographic growth and an aging population, health care and inequality, could require some form of clear plan ‘’from above’’, as well as community action that will have the characteristics of inclusiveness and solidarity, and won’t just be simply solved by free-market mechanisms.

Fires in the Amazon, Alaska, Siberia, and Australia, and now temperature in the South Pole that have never been higher, confirm the justification for climate change concerns to a certain extent. The US also received an invitation from top executives from the largest companies and the Financial Times to reform such "rentier" capitalism, and companies began to be asked to provide greater care in fulfilling their social roles, as additional motivation alongside making a profit only. It was a vocal call from the very heart of capitalism to reform from within, which didn’t question the justification of capitalism as the best system out there at all, but merely sought its adaptation to these new historical circumstances. The last time I was in the US, last autumn, more than 40 percent of the US population declared themselves in favour of "some form of socialism." These were unimaginably high figures for that country.

This shift of the electorate to the left in the US itself has apparently led the business leaders themselves to rethink everything and start thinking about reform. It is now opening up to the possibility that this unexpected pandemic may also become part of these continuing stories of the lack of existing models in dealing with global crises. Pandemics are an excellent example of situations where the interest of the entire community must be outweighed by the interests and personal freedoms of each individual. To the Chinese, this is intuitive, because they still live under the rule of the Communist Party to this very day.

China has succeeded, and now the US needs to show how it will tackle the epidemic, but President Trump is hesitant. He doesn't like the idea of ​​quarantine because he knows how painful it will be for the economy. In addition, such a move will mainly save older people, which is a cultural norm in China and is never called into question. But because of the recession, it will harm the health of middle-aged and younger people in later years. A coronavirus crisis now awaits the US, after China has already shown what its comprehensive health system knows and can do.

Placing the personal freedoms of their citizens above the interests of the entire community in the US could have major unintended consequences, and the same applies to the UK. I hope it will not be so, because I don’t want any unnecessary contagion anywhere in the world. But if some level of reason in those in power in the US and its federal states which oversee the health systems there doesn’t occur, and if they think that curbing the pandemic is an ideological issue for their politicians, economists and sociologists, and not for scientists and doctors, there could be an unwanted embarrassment of the US on the international stage on the horizon in the next few weeks, with more lasting consequences for the new dominance of the East over the West.

6) I learned what an ‘’Infodemia’’ is.

Even back during the earliest stage of this pandemic, I realised that the huge differences in how the media and the scientific community function would become an extremely important part of this story. Specifically, in the early days of the spread of the contagion in China, I was being contacted by reporters, who made every effort to cover the subject. They wanted to get experts' estimates of possible further developments, but failed to extract nearly enough information to satisfy the public's interest in the topic from them. As I’m among the few Croatian scientists to have succeeded in accumulating experience both in the scientific community and in the media, I would explain to the press that the further development of this epidemic depends on at least thirty parameters that all need to be very well and thoroughly understood, and we don’t currently understand three or four of them well enough, let alone all thirty of them.

No scientist or expert will risk his or her reputation at such an early stage, rushing in and saying that there will be hundreds of millions of deaths, and in the end, thousands end up being killed, or worse - estimate that there will not be many deaths, and eventually there ends up being many more than expected. That's why, at such an early stage, we have those in charge of slowly informing us of everything, the World Health Organisation (WHO), the American Centre for Disease Control (CDC), and the New England Journal of Medicine, Lancet and JAMA. It is best to consider any other information rather unreliable until proven otherwise. Furthermore, as the situation develops, even the estimates of these reliable sources can be expected to alter several times, as we’re faced with a new and dynamic event which is difficult to predict.

It was then that I first realised that this pandemic would cause an information chaos, because in order to truly understand what its course and development all depend on, several very thick medical books need to be read and understood. However, all this knowledge cannot be summarised or transmitted to the public in the form of short media articles today. They were written to stay interesting for a mere 24 hours after publication, and often not even for that long. I understood that the public would be bombarded day by day with information about a pandemic that would often be insufficient in terms of its accuracy, incompletely explained, taken out of a much wider context that had been ignored, presented in the same way, though some bits of that information might be significantly more important and other bits of it might be entirely irrelevant in terms of understanding what is going on, which will all contribute to people's state of confusion and concern.

So, we end up with an "infodemia" - an epidemic of information that precedes the development of the real epidemic. I believe that once the spread of this disease is over, infodemia, its causes, and its effects and indeed its consequences, will be the subject of interest for many scientists. But interestingly, this is no novelty, because even in the Middle Ages, information about the spread of terrible epidemics was spread from village to village, and because of that, fugitives from the affected villages created panic by spreading stories about what was to come.

This particularly bothered me because I’d already developed some sort of PTSD from everything that went on about the counterfeit research on the relationship between autism and vaccines. I have already described how the media at the time was very enthusiastic at first transmitting it as disruptive information that would attract a lot of attention, although the entire scientific community reacted to it with enormous skepticism. The media, then, in misunderstanding the details of the scientific basis of the study, portrayed the denouncement of the fraudsters by the rest of the scientific community as a public debate, giving equal media coverage to the statements of all scientists who denied this obvious, malicious error with 99.999% probability, as well as to those who defended their forged study. Thus, the media then, in misunderstanding the details of the scientific background, presented the public with scientific evidence and clearly rejected the wrong hypothesis as an unresolved, public debate in which both parties have equal credibility. That "public altercation" attracted much more attention, with the result being more than a third of parents taking the side of the deceivers and vacillation having dropped from about 95 percent to about 60 percent. Because of all of this, I was worried that a lack of understanding of all the scientific details of this pandemic would cause some similar damage.

7) I have learned that topics in the media are much more determined by the public's hunger for information than they are by the media itself imposing topics on the general public.

I always thought that the media had the greatest power to impose topics on the public. But on this occasion, I could see that the topics actually impose themselves, depending on how much "hunger" the public has for them. And vice versa - if this hunger doesn’t exist, one can try as much as one wants, but the topic cannot be easily imposed on the public. For example, I could do as much as I wanted, but I could hardly write a column or give an interview that would be read by more than ten thousand people on the Vecernji list portal.

But last Tuesday, whatever I wrote about coronavirus, even without much effort involved, was being read by over one hundred thousand people.

So, there is an objective "hunger" for the public for topics, as well as their saturation, which changes literally hour by hour. I have learned that it is up to the media to decide for themselves how far they will go in exploiting this objective "hunger" of the public, and how much restraint they are to have towards that exploitation, and how much criticality they should show. They differ from each other here, too, so that their role cannot be generalised to all media.

In this situation, we need a quality reconciliation between the hunger of the public, the interests of the media themselves and the functioning of the scientific community. What is most interesting to me is the incomprehensibility of the question of how this "hunger" is created, a collective emotion that then becomes easy to sway - is it with factual data, dramatic decisions by the authorities and institutions (quarantines), or the stories, images and films that began to spread from Wuhan, just as it was back in the Middle Ages? It seems that we all have some deep emotions embedded in us, related to fear, death, and the various forms and types of love that events like this can inspire. Jo Nesbo wrote beautifully in the foreword of one of his books that publishers at the very beginning of his career told him to write either about great love or about murder, because nothing else could be sold to a large number of people, so it wasn’t worth even writing about.

8) It taught me that in the heat of an infodemia, people without enough knowledge will undermine potentially useful health education attempts, in both a conscious and an unconscious way.

In talking to a few colleagues who have the scientific authority to educate the public during these days of crisis, I’ve noticed that there are an incredible number of examples where the under-informed, either consciously or unconsciously, twist what we say and write, they misinterpret, and even maliciously interpret it, then pass it on, and hope that over time we will also turn out to not know what we’re talking about.

We note that our health-education efforts may, therefore, cause harm to us and others more than they provide use. The biggest concern is when our texts are broadcast with uncritical or even completely incorrect large titles and subheadings, which have nothing to do with what was actually said.

To reduce this mutational effect of "infodemia" on useful messages, I renewed my collaboration with Vecernji list for the fourth time, and will comment further on this pandemic only for them, and share their article here, to somehow ensure that the information I convey doesn’t mutate spontaneously and cause the opposite of the desired effect.

9) It taught me what ‘’moral panic’’ is.

"Moral panic" is a sociological and anthropological term used by British scientist Young, who dealt with youth addiction, in the context of the overreaction of the media, the police and the public to the deviance of young people's behaviour. Today, it signifies any social situation where, on a case-by-case basis or sensationally interpreted statistics, one is convinced that the community and its value system are at great risk. Today's speed of information sharing is leading to constant "waves of moral panic" around one topic at a time. Because of this, even though people have never lived with less risk and more resources, many feel permanently scared and anxious.

In the first phase of moral panic, something like the new coronavirus is defined as a major threat to the community. In the second phase, the news confirms this, but bases that largely on incorrectly presented statistics or individual cases taken from a much wider context. In the third phase, public concern is continually raised to levels of inappropriate and exaggerated behaviours that don’t correspond to reality. In the fourth stage, the reaction of those in power who are trying to restrain fear and panic, then strikes against the threat. Then democracy is suspended, and in the interest of "safeguarding security" everything becomes permissible. Finally, in the fifth stage, the "moral panic" either disappears in the same way it appeared, or results in major social changes, which are mostly unwanted and radical.

Unfortunately, in this situation with the coronavirus, I had the opportunity to witness different stages of the development of "moral panic". In addition to the problems of distorting and changing the specific statements of our foreign experts, or misinterpreting our statements due to inadvertent reading, I’ve noticed a third problem. It began to seem to me that more and more people wanted the experts to be wrong in their forecasts. It seems to me that there are indeed people in Croatia who would be happier if at least a few of their fellow citizens died during the first two or three weeks of the epidemic than for us, the Croatian scientists abroad, to be right about this problem. I didn't even know how to classify this type of behaviour. But then, in his column, Croatian writer Miljenko Jergovic explained that there was a name for such public defeats of common sense, called "moral panic". Mr. Jergovic, who, like Ivan Djikic and I, is not a member of the Croatian Academy of Sciences and Arts, explained moral panic in a perfectly clear way to me, as I had tried to explain COVID-19 to him in my article the day before. He wrote the following:

"What happens when those who are incomparably more competent about COVID-19 come forward, even if they themselves aren’t all that well acquainted with it? In the Croatian case, these people are Alemka Markotic, Ivan Djikic, Igor Rudan. We don’t believe her, much like a death-fearing hypochondriac doesn’t believe the doctor when he provides him with a moderately favourable assessment of his condition. And as for Djikic and Rudan, who are trying to intervene in a society of moral panic, are either viewed as equal interlocutors in the murmur of ignorant people, or even suspected as some hired alternatives. Instead of bringing about calm, their words seem to provoke anger and contempt. Why? Because in the midst of moral panic, a person is more likely to believe less believable, even idiotic news, lies and misinformation, which, if true and probable, would testify to the threat against him, than to news that would competently confirm that he may indeed have been threatened, but not to such an extent.’’

10) I learned that we must not turn away from health education, even when its very sense is called into question in this sort of collective psychosis.

When I’d already thought more than once that it made no sense to attempt to write about the pandemic in order to clarify the events to as many people as possible and their health education, some dear colleagues reminded me that we were all students of the great prof. Dr. Andrija Štampar. He wrote down 10 principles we all needed to know by heart, as they released the world from the fear of infectious diseases back during the second half of the 20th century. They still remain the cornerstone of public health and social medicine today, and if the late academic was at least still with us in this situation, he would have seen that they are just as relevant now as they were 50 years ago when he left them for us:

1. Informing people is more important than the law.

2. The most important thing is to prepare the ground and the right understanding about health issues in one area.

3. The issue of public health and the work to improve it should be addressed by everyone, without distinction.

4. Social therapy is more important than individual therapy.

5. The doctor must not be economically dependent on the patient.

6. No distinction should be made between the economically strong and the economically weak (egalitarianism).

7. In a healthcare organisation, the doctor should look for the patient, not the other way around, to take care of all those who need protection.

8. The doctor should be the people’s teacher.

9. The issue of public health is of greater economic significance than it is of humanitarian significance.

10. The main place of medical activity is where people live, and not the practice.

This text was written by Professor Igor Rudan, was first published on Vecernji list, and has been translated into English by Lauren Simmonds

For more on coronavirus in Croatia, follow our dedicated section. For more from Professor Igor Rudan, follow his author page here, his LinkedIn here, his Facebook page here, his Twitter here, and his Medium profile here.

Thursday, 16 April 2020

Igor Rudan on Andrija - Digital Assistant in Croatian Coronavirus Fight

April the 16th, 2020 - Andrija is the very first digital assistant here to help with his 'superhuman' strength, all on the basis of artificial intelligence, in Croatia's fight against the coronavirus pandemic. Andrija is a digital personal assistant intended for every resident of Croatia, and you can communicate with him on WhatsApp. You can read more about Andrija in English here, and on Croatia's official website here. What does eminent Croatian scientist Igor Rudan think about Andrija? We bring you his Facebook status on the matter, translated into English, in full:

This pandemic is full of interesting stories. One of them regards Croatia's new digital assistant "Andrija", which should definitely be recorded for the "pandemic chronicles". About a month or so ago, I was contacted by my "reader of the month" from January 2020, Zoran Segic, who was almost arrested in the United Arab Emirates because he and Karla took pictures of themselves with my books everywhere, so the local authorities were interested in what was in those books, and if the content could possibly be offensive to their customs. Zoran and Karla sent me a whole album from there, as they also did later on from Africa, called "The Occupation of Dubai and Zanzibar in 26 Pictures", and they hid one of my books somewhere in each and every picture. However, this time, Zoran called me to join something that sounded really interesting, but unfortunately I couldn't find enough time: the development of a digital application for COVID-19 based on artificial intelligence.

But I was glad to hear that for this project, Zoran connected with prof. dr. sc. Branko Kolaric. I saw Branko back in 2001 as a particularly talented young epidemiologist, and as such, I included him in all of my projects: I wanted him to develop, as far as possible, a broader view and refinement in analytics alongside the ''routine'' part of his job at the Public Health Institute. Branko was with me in Edinburgh, he participated in field research as part of the "10,001 Dalmatians" project, and I'm particularly pleased, as part of that project, to have sent him to the summer school of Epidemiology at Erasmus University in Rotterdam, which was then the best place in Europe, for his postgraduate education, where he took courses such as those of Stanely Lemeshow to learn how to analyse epidemiological phenomena.

Then, he was at the European Centre for Disease Control. It's one of my greatest personal pleasures to see over and over again how any completely speculative investment in supporting young and capable people pays off over time. Here, now, seventeen years later, Branko and I have met once again, we're sitting together on the scientific council of the Government and trying to come up with some original solutions that would help Croatia to overcome this crisis as soon as possible.

In addition to those two, Mislav Malenica, President of CroAI and the director of AI at Mindsmiths, and Mr. Zvonimir Frka Petesic, the head of the Prime Minister's Office, and many others, also played major roles in this project.

Andrija's project manager was the Ministry of Administration, which implements the digitisation of Croatia's public administration. The solution was created by a team of experts led by epidemiologist Branko Kolaric, with the technical and IT support of the combined forces of the Croatian companies Mindsmiths, Neos and Oracle Croatia, who are members of the Croatian Association of Artificial Intelligence, CroAI, along with Infobip. All of the Croatian companies involved in the project have decided to make their respective contribution(s) to it for free.

Andrija is apparently named after the academic. Andrija Stampar, who emphasised the belief that "the issue of public health and the work on its promotion should be addressed by everyone, and without distinction", placing significant emphasis on the importance of citizens' cooperation and their involvement in public health programmes. The Andrija project is designed to keep up to date with the latest protocols, guidelines and knowledge that changes frequently in times of crisis.

As a contribution to the pandemic chronicles, the events have evolved as follows:

Mindsmiths decided to develop a solution to help fight coronavirus that will focus on providing citizens with the correct advice.

Mindsmiths developed a prototype of a triage algorithm in collaboration with prof. Branko Kolaric from the Andrija Stampar Institute.

Other companies from the CroAI Association; Neos, Infobip, Oracle Croatia all joined the initiative.

A meeting was held to present the idea of ​​the digital assistant made by CroAI companies to the Director of the "Dr. Fran Mihaljevic" Clinic for Infectious Diseases, Alemka Markotic, CES Assistant Director Marija Bubas and the Head of the Prime Minister's Office, Zvonimir Frko-Petesic.

Companies from the CroAI Association made the digital assistant available to the Government of the Republic of Croatia, free of charge.

Andrija's triage algorithm was tested by the profession led by prof. Branko Kolaric. Based on the feedback received, its algorithm was further refined.

At a Government meeting attended by Prime Minister Andrej Plenkovic, Andrija the digital assistant was given the green light.

Andrija's first test with 500 citizens was given a great first reaction. Symptom descriptions and simplified location division were further clarified.

A working group was officially established to lead the new Andrija digital assistant, headed by Branko Kolaric in front of the Ministry of Health, which also included representatives of the Ministry of Administration and members of the CroAI Association.

Facebook approved the name: Andrija of the Ministry of Health of the Republic of Croatia, and Andrija got a green check mark next to his name.

Journalists began testing Andrija. The first questions arrived. Preparations for Andrija's official launch were underway.

Andrija was officially presented by the Croatian Government at a press conference.

These are the statements from key people involved in the ''Andrija'' project:

Mislav Malenica, CroAI President and Mindsmiths' AI Director:

''CroAI brings together companies from Croatia who believe that artificial intelligence is a fantastic opportunity for our country that we must not miss out on. In these uncertain times, we're proud of the fact that our member companies have become active and are trying to help combat the pandemic with their solutions. Andrija is one such solution, and at the same time, it's proof that artificial intelligence can be smartly integrated into the public health system and motivate people to actively adhere to the guidelines for the benefit of their health.''

Branko Kolaric, PhD, epidemiologist from the Andrija Stampar Institute:

"Countries that have had the most successful responses to the spread of the disease during this pandemic, such as South Korea and Singapore, have used digital technology to address people on an individual basis. Andrija will help Croatian epidemiologists and the entire healthcare system control the COVID-19 epidemic. During these times, when doctors more burdened than they usually are, a digital assistant can quickly and efficiently provide citizens with up to date information and recommendations. Bravo to Mislav Malenica, Zoran Segic, Jan Stedul, Olga Plazibat, Kristina Fister, Tanja Nemeth Blazic, Mario Sekerija, Mario Aunedi Medek, Bruno Cvetkovic, Zvonimir Frka-Petesic and everyone else who supported this.''

Zoran Segic, Oracle, wrote on his Facebook profile:

"For the last four weeks, we've been intensively working and socialising with open, smart, proactive, critical, positive and optimistic people from across the public and real sectors, from different professions, with different values, and with different political commitments, with the sole purpose of delivering something that will help to relieve our health and hospital systems and enable partial self-diagnosis and proactive communication with citizens in the fight against the currently present COVID-19.

The result of this work are the ePasses (e-propusnice) and Andrija the digital assistant. I know that there will always be critical and distrusting people, but for me, as a citizen of this country who doesn't want to leave it and go to a better place because I want to remain enthralled with the belief that there is no better country or better place to live, I've been positively surprised, so I'm free to say that I'm also delighted to see that there were no divisions at any time, that any differences and opinions of the interlocutors were properly appreciated, that the public and private sectors encouraged each other when things were difficult, and that they brought out the best in each other through positive reviews and suggestions, and that they managed to produce two exceptionally beautiful stories in less than a couple of weeks.

They will, like with any other story, have their supporters as well as their critics, for me personally, when we collect impressions, they somehow provide hope that everything is possible if we think rationally, respect each other and if we reach for some higher goals for the future society or state, I won't say prosperity, but those [goals through which] everyone could live well and promisingly, with some of their small and particular interests. Team, you've been wonderful, I'm sorry if I accidentally missed someone out, I consider it a privilege to be able to spend time with you and have the opportunity to work with you, exchange experiences, learn what tolerance, discussion, the appreciation of your interlocutors and difference of mind mean, and as such, grow a little more.

And let's not forget one important thing, which regards volunteering and donation, where there was almost no material or financial interest on either side... Branko Kolaric, Jan Stedul, Mario Aunedi Medek, Davorin Capan, Neven Bratranek, Igor Rudan, Nika Lazic, Stjepan Oreskovic, Mislav Malenica, Mladen Vukmir, Bojan Stipic, Zvonimir Frka-Petesic, Ivan Malenica, Sasa Bilic, Bernard Grsic, Tomislav Pokaz, Mate Car, Alemka Markotic, Vili Beros, Ivan Lakos, Ivan Miljak, Olga Plazibat, Robert Kopal, Kreso Zmak, Gino Simic, Izabel Jelenic, Marin Tadic, Ana Marija Mlinaric; Vladimir Knezevic. And a special thanks to the self-sacrificing Mladen Novosel who mentored and encouraged us all like a story being told from start to finish.''

Congratulations to Mislav, Branko, Zoran, Zvonimir and everyone else. Personally, I only regret the fact that we needed a pandemic to get people in Croatia to start doing things like this, because so many people in Croatia have excellent ideas, but they're rarely allowed to develop them further. I believe that many people have been surprised over the past month to see what we, who have been living abroad, have been hinting at for a long time now: Croatia's isn't all that far behind EU countries, nor are many EU member states these excellently functioning, promised lands that we've become used to thinking of them as.

This text was written by Professor Igor Rudan, originally posted on his Facebook profile, and translated by Lauren Simmonds

For more on the coronavirus pandemic in relation to Croatia, follow our dedicated section.

Saturday, 4 April 2020

Igor Rudan: How to Maintain Good Results and Exit Quarantine as Soon as Possible

April the 4th, 2020 - In the ''exit strategy'' we'll plan for ''coexistence'' with the coronavirus, making it more difficult for it to spread but allowing for a ''smouldering'' infection with double-digit numbers of newly infected people. Croatian scientist Igor Rudan takes a look at our options.

When the crisis caused by the new coronavirus from Asia began to spread to Europe and the United States, and then the virus managed to penetrate beyond the front lines of defense in highly developed Western countries, the rulers of these countries were faced with two very poor options. Both were so bad that they found it difficult to judge which one was worse.

With the first option, the reaction was to be instictive - nations would be pulled into strict quarantines to prevent the virus from spreading rapidly, and the move would protect human lives. But it was clear to everyone that such a measure was entirely unsustainable in the long run. It would be enormously damaging to the entire society if enacted without some sort of strategy for getting out of that situation also put into place.

Namely, after a month, many people will be left without means for the further purchase of basic groceries. Many will start to lose their jobs as restaurants, movie theaters, concerts, transportation, various services, many shops, beauty salons, gyms and fitness centres will shut down. Therefore, the "large quarantine" strategy will be undermined by its unacceptability to a large number of people over time, and it will be increasingly difficult for them to expect to adhere to the responsible behaviour needed to keep the epidemic under control.

Two bad options.

After a few weeks of quarantine, the number of infected people in Croatia should drop from a few thousand back down to just a hundred or even a dozen or so remaining infected people. But, even if it went down to just ten infected people nationwide, if we went back to our pre-COVID-19 lifestyle, it would lead to a hundred infected people within a week of people leaving isolation, and a thousand after two weeks.

Croatia would then need to start a new cycle of isolation at that point, because the most our health system can handle is several thousand infected people. It should be borne in mind that quarantine is really needed when the number of infected people in the population of Croatia reaches about one thousand. This is because with its very next step, one thousand to ten thousand infected people, the virus will be able to make a successful jump to the household members of already infected people while we're in a new wave of isolation.

Any more infections than a few thousand could endanger the health system and the respiratory deficiency for all those in need. So, if the isolation measures we're currently implementing in Croatia manage to curb the infection from a few thousand infected back down to just a dozen or so, and then we leave these isolation measures, we would have a maximum of two weeks of normal life before a new, longer stay in isolation.

Of course, this is only true if during these weeks of quarantine we don't come up with some way of "coexistence" with the virus, where it would no longer spread exponentially after our ''release'' from these measures and in that case we'd still have a much longer time and a relatively normal life than this.

Another option for the rulers of Western countries, quite contrary to this one about defending isolation, was to let the virus spread and infect a significant portion of the population. Many citizens would gain immunity by overcoming the disease. As a result, after a while, the virus would have fewer and fewer people to jump on. So, it would start to spread more and more slowly until we gained "herd immunity". It's a given that we have neither drugs nor vaccines for the time being, we should count on more deaths, especially among the elderly population and among those people with existing diseases, but life would continue normally and the economy would be saved.

Yet, such a strategy was also associated with many risks. First, no one has managed to estimate, with sufficient certainty, just how many human lives this virus could endanger in the worst-case scenarios, if allowed to spread freely. This is because this virus kills not only directly, infecting humans, but also with a very high rate of spread, thus suddenly creating far too many severe cases, and it also kills indirectly, because the overloaded health system can no longer care for other patients.

Given the fact that we don't always know precisely how many people become infected with the virus and don't actually present with any significant symptoms, it's difficult to determine the direct effects of the virus. However, that number should be up to one percent of all deaths at the national level.

However, the effects associated with the rate of the virus' spread and the indirect effects of this virus are significantly more dangerous than the direct ones are, and this is not something commonly encountered in medicine. The speed of the virus in managing to create new and severe cases that cannot then be helped due to a health system overload makes the virus more risky than the fact it infects individuals alone does.

A third related problem is that the consequent overload of the health system indirectly leads to further casualties due to the inadequate treatment of all other diseases. For this reason, it is extremely difficult to estimate the cost of free spread of the virus to the population.

The strategy of allowing the free spread of the virus is very dangerous because no one can predict the mutation of the virus after allowing it to reproduce in so many human carriers. Some new strains could, in principle, become even more deadly than the current one. A further danger of this strategy is that even those small percentages of risk for young people become very high if millions of people are infected. The large number of relatively young victims in the short term would surely become a central topic and undermine any support this plan has enjoyed so far.

Additionally, no one can be quite sure that the immunity to the virus acquired by recovering from COVID-19 will be permanent immunity at all. And lastly, even if this strategy of allowing the virus to spread freely succeeded to some extent or another, even with considerable casualties, the virus would still continue to mutate regardless.

Therefore, next season, in its new circle around the world, coronavirus is likely to shorten human lives again, as the immunity people acquired last year may no longer protect them, just as it doesn't protect them against the flu. In order for anyone among those in power to bet that all these unknowns will turn in his favour during the spread of the virus among the population... well... that ruler must be really, really optimistic.

An important problem in choosing this other possible path, ie allowing the virus to spread, is, once again, the very behaviour of humans. Namely, even if the plan were explained to the population and supported by a large majority, the situation in which the death toll is increasing rapidly from week to week, especially in relation to quarantined countries, will become less acceptable to the population.

In this scenario, too, it will be increasingly difficult to maintain the responsibility and discipline needed to preserve the economy. When they realise that they might end up in intensive care units, many will find excuses to take to their homes and not come out of them for a long time. Then, many businesses will collapse and the number of unemployed people will increase sharply, despite the fact that this plan initially sought to save jobs.

In conclusion, in both the first and the second possible approach to this crisis, the behaviour of the population, which after a while will increasingly decline in terms of the willingness to participate in both plans, is what will undermine their consistent implementation. In the former case, they will resent it for economic reasons, in the latter, for fear of their lives and the lives of their loved ones.

This was quite clear to the leaders of the Western countries, which is why many of them were quick to seek their own, third approach. But the only thing that would certainly be worse than these two extreme scenarios is to fight the virus with one strategy and then change your mind after a few weeks and move on to another approach. Consistent adherence to the first solution would at least save the maximum number of human lives, albeit only temporarily, but it would significantly harm the economy.

Consistent adherence to the other solution would preserve the economy and our lifestyle, but with significant sacrifices that are extremely difficult to assess. But, if it goes one way, and after a few weeks it goes another, then the economy will surely suffer, and the casualties will be quite large. So, governments were facing two seemingly very bad solutions and a third, middle way, which was even worse.

People are always creative and resourceful.

Fortunately, faced with such difficult challenges throughout history, people have always shown creativity and resourcefulness. That's why we're probably the only human species of at least a dozen that have survived to this day. First, China has shown, with its drastic measures, that the epidemic can be suppressed within a few weeks and then maintained with a smouldering one. Another heavily affected country was South Korea, which had an epidemic begin behind the front line of defense, but it showed that by mass testing a huge number of people, it could keep up with the virus instead of constantly cowering behind it.

In addition, Japan, Singapore and Hong Kong have, through a series of measures, including very active testing and the continuous isolation of those who are infected and their contacts for two weeks, and with reasonable measures of isolation and social distancing, have succeeded in achieving some coexistence with the virus without risking it ''escaping'' into quite free expansion and then exponential growth, which would lead to too many seriously ill people in too short a time.

All that is required is to prevent the virus from spreading from one infected person to two, three or more healthy people, and to limit its rate of spread in all possible ways so that one infected person transmits the virus just one healthy person at the most. Thus, they will need to live that way until a vaccine is developed, or at least until the first effective medication arrives which will reduce the need for intensive care and respirators for the seriously ill.

What does this mean for Croatia?

We're currently in the phase of "first virus suppression", which needs to be done decisively in order to complete the task as quickly as possible. The goal is to reduce the number of infected people in our country to less than a hundred, a climb down from several thousand. No one wants to remain in isolation for a day longer than necessary, but because of the exponential nature of the virus' growth, it is also important that after isolation, the number of those infected is not too large, because then, it can quickly start growing again.

Croatia will then have to put in place a number of measures that will make it more difficult for the virus to spread to keep the number of newly infected at day counts below 100. The calculation is simple: let's suppose, for simplicity's sake, that the number of severe cases that require a respirator will be about 5 percent of all infected individuals. In addition, let's say that everyone will need a respirator for a month until they recover. If 100 newly infected people are identified every day, it will mean 3000 within a month with some COVID-19 symptoms.

Among them, 5 percent will have such severe symptoms that they will need a respirator, which is 150 people over a month. Croatia's capacities are also much larger, but it's important to leave a significant margin. Namely, if the virus spreads to hospitals or retirement homes, then the proportion of infected people who will need a respirator will no longer be only 5 percent, but perhaps rise up to 20 percent or even 30 percent, so any such incident can overwhelm our health system very, very quickly.

In addition, respirators are needed for patients with other diseases that occur Croatia, so for COVID-19, about 500 of them should be sufficient in all plans. That's why it will be important in the "exit strategy" to plan for "coexistence" strategies with the virus, where we will, in every possible way, make it difficult for it to spread, while allowing for a "smoldering" infection with double-digit numbers of newly infected people every day so that everyone who becomes seriously unwell can receive adequate care.

How do we preserve such good initial results in the fight against COVID-19 in Croatia now, and exit quarantine as soon as possible?

There are several key tasks to complete in the coming weeks. First of all, it should be well understood that this is an epidemic. All one has to keep in mind during an epidemic is that we need to know as much as possible about who is infected and who isn't infected and then actively physically separate the infected from the uninfected. If we're constantly actively detecting new infected people with testing and constantly physically separating them from the uninfected people, then we can't go wrong. But if we have the opportunity to separate the infected from the uninfected, and fail to do so, then we will very likely regret it over time.

An emphasis on hospitals and retirement homes.

The next important thing to keep in mind is that not all uninfected people are equally important. The most important group of uninfected people are immunocompromised people - hospital patients in transplant wards, patients with malignant tumors receiving radiation or chemotherapy, patients with diabetes or cardiovascular disease, especially those with high blood pressure, as well as anyone over seventy years of age.

They should be particularly protected from infection if they already have a chronic underlying illness and if they live together in a large number in retirement homes. These are uninfected persons who should absolutely not be allowed to come into contact with infected persons. In this next phase of the fight, the successes of individual countries will be measured first and foremost by how well they have managed to protect their hospitals and retirement homes from limited COVID-19 epidemics during the isolation period.

Consider the following: A community outbreak can reach figures of as many as a hundred infected people, resulting in only one death of one of those infected persons. However, an epidemic in a retirement home or hospital ward, infecting a hundred people, can cause twenty or thirty deaths. It really is a huge difference and that's why these groups should be guarded now. How do we secure that? It would be advisable to test every day for the presence of coronavirus on all employees in healthcare institutions and retirement homes.

However, it is very difficult to implement that, for a number of practical reasons. Therefore, a register of people in Croatia who have already acquired coronavirus and acquired immunity may be started and entrusted with the strategically important role of "guardian". However, while this idea may seem good in principle, the problem is that this virus is an unknown one and we don't yet know how long immunity against it lasts, or after how long the virus is ejected from the body, so we need to wait for research to be done that can answer these questions for us.

It is obvious that good organisation of hospital care and retirement homes and their protection against the spread of infection will be important in the coming weeks. It is important that hospitals, as far as possible in individual cities, are strictly separated from those hospitals, or at least their buildings or floors, where COVID-19 infected persons are treated from all other places. Other sick and elderly people, as well as healthcare professionals not involved in the fight against COVID-19, should not approach these sites until the epidemic is over.

Inside hospitals, it is quite important for people needing respirators to be exposed to fresh air as much as possible as it enhances the recovery of the airway mucosa. Dry heated air, on the other hand, makes it difficult for the mucous membrane to recover because it dries out, and this benefits the virus. In this new situation, all creative ideas and resources can be of use to us. Therefore, infected physicians with very mild symptoms of the disease, or physicians who, due to contact with infected persons are in self-isolation, may be able to treat individual respiratory patients in tents outside the hospital, which could increase the capacity to provide intensive care in the event of an extreme need.

It is important, at the national level, to preserve at least one institution as a "reserve" to handle any epidemiological incident, as they are always possible. If an outbreak is detected at another hospital or retirement home, the emergency transport of infected patients, doctors, retirees and staff is required, or if incidents occur in smaller locations where the local health service will not be able to cope with smaller outbreaks, all those infected should then simply be transported by ambulances or helicopters to such a "backup" facility, and all the patients with milder symptoms need to be moved to tents outside the hospital, and severely ill patients to that facility.

With such a "back up", I believe that many lives would be saved in the most dangerous situations, namely the spread of contagion in hospitals or retirement homes. In such a ''back up'' facility, the risk of health professionals contracting the virus will be high, so it is good for them to stay within the hospital and receive care from their colleagues, rather than spreading the infection to their families. Such a "back up" establishment would be the last line of defense for all cases where the contagion would begin to spread among the most vulnerable members of the population.

In conclusion, hospitals are currently the most dangerous places during this epidemic. Therefore, wherever the infected can be separated from the uninfected in hospitals, this should be done constantly. It would be reasonable for all patients in hospitals, as well as administration staff, and anyone who doesn't need to be present in the hospitals because their lives are not threatened, to be sent home so that our exposure to hospital outbreaks is kept to an absolute minimum.

How should Croatian citizens behave in order to reduce the spread of the virus during isolation measures?

I noticed that most of the ambiguities of the past few days were related to whether or not people could leave their homes, whether or not it was advisable to sing on windows and balconies, whether or not people should wear masks, gloves, and how to dispose of shoes; and whether or not we should disinfect packaging from grocery stores.

Here, I will briefly try to answer these questions through my personal example and explain it. First, we're being confronted with a virus that has shown that it spreads rapidly and very successfully among humans, and it is not yet clear how it does so. Such viruses are usually transmitted by droplets of exhaled air, but also by fingers after someone who is infected touches their eyes or their mouth and nose, because we can expect the presence of the virus in tears, and in mucus from the nose, as well as in saliva.

Another person may inhale it, but also touch the location or object that an infected person has previously touched. What does this mean for the issue of leaving our homes? This, in fact, means that you're only safe while in your home. As soon as you go out onto the stairs, you can breathe in the air where someone has previously coughed or spoken loudly, you can touch the handrail where someone infected by the virus has touched it, the same is true for door handles. The risk of being infected in this way is, of course, extremely minimal, but the transmission of the virus in such a way is no longer impossible and it will continue to spread in that way at least somewhere. Because of this, I personally avoid going out if it isn't necessary, especially while still trying to control the number of infected people for the first time.

Also, I understand that many people need to move and exercise to maintain good health. For this reason, it's difficult to make a strict recommendation that would apply in all situations and for everyone, because for older and very old people it is certainly better to stay indoors now, while for younger people, it is probably better to take a lower risk of going out and maintain better health. For the same reason, singing on windows and balconies is probably not a big risk, but it is conceivable that, under certain conditions, some viruses could be transmitted.

Whenever I go out, I always wear the same shoes and gloves that I keep right next to my door, and I either put a surgical mask over my mouth and nose, or cover I cover them with a scarf. I remove my gloves and my shoes and leave them by the door whenever I return home. I believe that wearing gloves while going out is important because touching a hand grip, doorknob or ATM could be beneficial for the spread of the infection. People unknowingly touch these surfaces during the day and then they touch their mouths, noses or rub their eyes.

If they have touched a surface where the virus was present, they will become infected in this way, but gloves will help prevent that.

There were a lot of ambiguities surrounding the issue of masks. There are several sub-questions that should be distinguished. First, do masks primarily serve to protect you or others? If they serve to protect ourselves, then they need to be special, more expensive masks. But in that case, everyone should wear them. As it is difficult for each country to plan for the procurement of special protective masks for all of its citizens, especially since they also have a shelf life, personal protection masks from infection are procured and kept for healthcare professionals. They will certainly be exposed to infected people.

Life with the virus.

It would also be reasonable for them to also obtain the masks, or to distribute such masks to those who are particularly at risk for the virus because of their age or their state of health. But for everyone else, if they were just walking down the street, they'd need to meet about a thousand people in Croatia before meeting someone who is infected. Thus, protecting yourself in such situations from an epidemiological point of view is not so crucial. It is much more important, however, that someone who is infected but has no symptoms yet doesn't go on to infect others.

Given that we cannot know just who is infected until they present with symptoms of the virus, it is reasonable for everyone to cover up their mouth and nose in some way so as not to inadvertently spread the infection to others. This is significantly more epidemiologically justified. So, whatever can be done to make it more difficult for the virus to jump from one person to another, should be done. The reason why in many countries there is no strict recommendation on wearing masks is that medical recommendations need to be made on the basis of solid scientific evidence. However, in the case of mask effectiveness, it's difficult to obtain a sufficient type of evidence when the required outcome of the study should be whether or not there is more or less contamination.

When it comes to such research, no one would be granted ethical approval to conduct it in peacetime. Therefore, what we know about the effectiveness of masks is based on studies that were not optimally designed, which is why it is difficult to get a firm recommendation from any official body. Personally, I believe that masks will help to spread the infection less and that everyone should make sure that they somehow cover their nose and mouth so as not to accidentally infect others. They can also use a scarf, a handkerchief, a surgical mask, anything that covers their nose and mouth.

In addition, anyone who wants to, or is particularly at risk can, of course, also wear a more expensive protective mask, even if they are not a healthcare professional. Common sense suggests that any disruption of the virus and its behaviour will help combat this pandemic, even where we don't have the solid scientific evidence we would like in order to make for such a recommendation.

Should packaging from supermarkets be disinfected before use?

Similar to the question of singing on balconies or going out for a walk alone, the risk of such a transfer is probably very small, but until it is better explored, it can't be completely ruled out. However, those who become infected in this way are likely to have a significantly lower initial dose of the virus enter them than would enter them via inhaled air, so the course of the disease may be milder, although science has yet to confirm that. But it would be no surprise to epidemiologists if this was proven, although it should always be reiterated that surprises are always possible with new viruses.

Currently, an "epidemic wave" is making its way over the population of Croatia, but the numbers of newly infected people remain in the double-digits day by day, while in many other countries, they are four-digit, indicating how good Croatia's early response was in the first few steps. Our healthcare system still has plenty of reserve. However, now is really the time for disciplined isolation so that we can see at least a few days of consecutive declines in the numbers of newly infected people. This would convince us all that Croatia is able to curb the spread of this contagion with the use of the available anti-epidemic measures.

But, any failure to adhere to the instructions of the Civil Protection Headquarters will mean more infected persons, then more severely ill persons, and thus more pressure on the health system, as well as a longer stay for us in isolation. Adhering to the measures will reduce the number of infected and seriously ill people, keep the health system unburdened and shorten the time spent in isolation.

In the next step, however, we will need to get out of isolation as soon as possible and learn to live with the virus. In order to be able to do this as soon as possible, we will need to devise a series of measures that will work together to minimise the rate of spread of the virus to humans. It's important that each infected person does not infect more than one other person, so that the number of those infected can no longer transition into exponential growth, as this would mean a new quarantine soon. Every day, there are more and more ideas among epidemiologists emerging on how to do this. The exit will most likely involve a combination of several measures that could slow the spread of the virus.

Distancing, masks, gloves, testing...

First, we ourselves will adopt the ''maintenance'' of the gap we need to have between each other, covering our noses and mouths, wearing gloves, and acting with caution and responsibility. This alone will significantly reduce the virus' ability to spread. Then, testing capacities will be increased so that we can follow the good examples from South Korea and Singapore and, in addition, actively seek out and isolate those who have become infected.

So, we will constantly "cut paths" for the virus in its spread. Then, the hope remains that during the warmer weather, the virus will spread at least more slowly if it does not disappear entirely. Technological solutions are likely to be developed to quickly identify and isolate infected contacts. Innovative solutions could also include "dividing" the population into several completely separate subgroups to "dilute" the population available to the virus.

These are all measures that together, could be sufficient for the relative normalisation of life after this shock wave. Personally, I'm pleased to see that Croatian experts have dealt with the phases of the first line of defense so well, as they have with the withdrawal into quarantine, and now they continue to do so with the maintenance of isolation measures.

Obviously, there is already very active thinking going on about measures to get out of isolation as soon as possible, and a recent package of measures has shown that the economy has not been forgotten either. If you recall the grave doubts of the governments of the Western countries from the beginning of this text, it's hardly possible to go through this unexpected crisis in a more reasonable way. Until we get a coronavirus vaccine, or at least medication that could reduce the need for respirators, it will unfortunately not be easy for us to return to the lives we're used to. But so many people are working on solutions now that patience and hope for the best are required.

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

For rolling information and updates on coronavirus in Croatia, as well as more scientific texts from Croatian scientist Igor Rudan, follow our dedicated section.

Friday, 3 April 2020

Jurgen Klopp & Igor Rudan: the Only COVID-19 Opinions You Need

April 3, 2020 - With hundreds of millions of online corona opinions out there, why there are only two you need to pay attention to - Jurgen Klopp and Igor Rudan.

One of the joys of being a writer in the era of social media, online self-entitlement and short attention spans is the fact that many people comment on an article without reading it (this observation is not directly relevant to the topic of this article, before the abusive comments start). It used to really frustrate me, so much so that I posted on Facebook a couple of years ago a simple request to Facebook - could they introduce a feature whereby only people who had opened the link could comment?

It will not happen, of course, and I soon learned a very effective way of dealing with the problem, which I adhere to 99% of the time. 

Simply stop reading the comments. 

I start the article with this observation because it came back to me last night. Many countries are now under different forms of lockdown, severe restrictions placed on their citizens. Some unnamed foreign owners of news portals in this region are even getting official threats in an effort to control their content. Allegedly. But people are free to express their opinions and insight about corona. 

And, boy, are they exercising their right... 

From a socioanthropological point of view, watching people spouting forth about corona over these last few weeks has been absolutely fascinating. People with absolutely no scientific credentials whatsoever posturing as online corona experts, many with a range of opinions which I am sure they would come to regret a week later if someone had screenshotted them. 

Perhaps someone has...

In this era of control, I mused, what if Facebook had a feature that you had to have some kind of scientific qualification to post an opinion that can, and does, influence others. It would take a ton of garbage, disinformation, and unqualified scientific opinion out of our lives just like that. 

It will not happen, of course - those opinions and the keyboard warriors they send into battle keep us addicted to the big social media networks. 

Which brings me to the topic of this article - reaction to yesterday's article by me called As Millions of Croats Self-Isolate Responsibly, Split's Sporting Picigin Tradition Continues.

You can see the traditional Split beach game being played yesterday in the Dalmacija Danas video, as well as more information in their article, including the results of their online poll on whether or not this was deemed responsible behaviour at the current time. 

Although I almost never read comments these days, friends do alert me when there is an interesting discussion. 

And discussion on this article WAS interesting. And very divided. 

My opinion on this is not important as I am not a scientist, but the reaction was very polarised, as one might expect. Some struggling with cabin fever in their apartments were outraged, while others could not see the problem, as they were appropriately socially distanced. 

Tim Bourcier was kind enough to contribute yesterday to our series, Foreigners Self-Isolating in Croatia: Do You Feel Safer?  It is a worthy read if you have time. 


But Tim's response to the picigin article was even worthier, as it has crystallised a REALLY important and confusing topic for many of us. 

What is, and what is not, ok? Tim's drawing - you will have to teach me how to do that when all this is over - shows quite correctly that the picigin players are appropriately self-distanced in the video. 


Monique Lafitte, saw no problem with this whatsoever - and it should be noted from the post on TCN FB, that there were others who agreed with her. As well as disagreed. 

So who is right?

There are only two people whose opinions I follow religiously about COVID-19 - Liverpool coach Jurgen Klopp and eminent Croatian scientist, Igor Rudan, Professor at Edinburgh University. 


So I asked both Jurgen Klopp and Igor Rudan what they thought about playing picigin in Split at the current time. 

First up, the Liverpool legend:

And no, I didn't really ask Jurgen Klopp what he thought about picigin, but his comments a few weeks ago when asked about corona went viral. 

And they remain the very best opinion for non-experts. 

I DID, however, ask Igor Rudan, for his opinion. 

For those of you who do not know Igor, his texts on corona are easily the best I have read, and TCN editor is busy translating them into English. To get a flavour, this was my favourite so far:

Igor Rudan: Cascade of Causes That Led to COVID-19 Tragedy in Italy and Other EU Countries 

(You can read others by Igor on TCN here)

For those with cabin fever looking for something to watch, Igor's series on YouTube - Survival: The Story of Global of Health is the most interesting thing I have watched this year. Trailer below and full series here.

In addition to writing these fabulously instructive texts, Igor is also working closely with the Croatian Government to keep us all safe, but he did have a minute at 5am this morning to give his opinion on the picigin incident, and when I mentioned the Jurgen Klopp angle for this article, this was his reply.

Jurgen Klopp is my absolute favourite person! I said many times that if I wasn't a scientist, I would be a football manager.

Yes, ok, Igor, that is great, but can we concentrate on the science for now... 

I am preparing a new article for tomorrow, so I will try to clarify many things about life in quarantine.

Lauren will translate this into English as soon as her schedule allows, and we will publish on TCN and share it immediately. 

I asked Igor if he had a one-sentence answer while we wait for what could be his most important text so far. In order to encourage him, I promised to post his photo next to his Liverpool idol. Here is what he said:

I can only say that, if you leave home, you are no longer safe, because we still have no idea how this virus can spread so easily. Until we do, I would rather stay in.

I don't know if Tim or Monique follow my writing or not, but I would like to thank them both for highlighting this issue. It is an issue which urgently needs clarity, and if a global expert such as Igor can provide that clarity AND people adhere to that clear advice, lives will undoubtedly be saved. Thank you both. 

The only thing that remains is to speculate on whether or not Igor Rudan will be a Premier League manager next season.

I, for one, would not rule it out. 

To follow the latest on coronavirus in Croatia, follow the TCN dedicated section









Tuesday, 31 March 2020

Making Science Sexy: Igor Rudan's Incredible Video Series: Survival, the Story of Global Health

March 31, 2020 - Eminent Croatian scientist Igor Rudan has written some of the most authoritative and clear texts on COVID-19. Now watch him explain Survival, the Story of Global Health. Science IS sexy. 

I wrote an article a couple of days ago in which I said that I was not in the habit of writing an article praising people I had never met, which is true.

And yet, here I go again... Maybe it is the cabin fever starting to show. 

Croatia has many heroes at the moment, from the dedicated health workers on the corona frontline to those in power with the huge responsibility to keep Croatia safe and navigate the most unpredictable waters that the world has known in my lifetime. 

And these heroes and heroines are more than rising to the task, and I think them sincerely on behalf of me and my family (and, I suspect, the rest of the country). We have already written about new Health Minister Vii Beros and the legendica that is Almenka Markotic

And so we come to our third hero of the hour, whom I have also never met. Indeed - please don't tell him, as I am a little embarrassed to admit it - I had no idea who he was until my colleague Lauren starting translating and publishing his amazing texts about corona on TCN.  

 survival-the-story-of-global-health (1).PNG

(Just like Alemka and Vili, Igor Rudan also makes the list of the current top 10 most positive people in Croatia)

And when I read the articles on corona by Igor Rudan, I felt even more embarrassed. They were the most detailed, clear and factual articles I have read since this madness began. His latest answers one of the questions that maybe people are asking, but nobody seems to know the answer to - but Igor does. 

Igor Rudan Explains What Went So Wrong With COVID-19 in Italy

You can read more of Lauren's translations of Igor's corona masterpieces here.

I decided to seek him out for a TCN interview and was surprised to find that we were friends on Facebook. I have currently 3,546 FB friends, and I know about 200 of them, but many Croatians seem to like to connect with a fat Irishman living in and writing about their country, which is great. 

As we were friends on FB, that made the communication easier, so I sent him a link to one of Lauren's translations and said we would be happy to do more, so that his wisdom could go beyond the confines of the svjetski jezik, hrvatski, and into English. 

Not only did Igor agree, but he was happy to add his superstar name to the TCN team of writers, thereby tripling the TCN IQ in one fell swoop, insisting that the texts appear in English first on TCN, and then he hired Lauren to translate lots of his other work. 

It is a marriage made in heaven, and I have not seen young Simmonds as enthused about translating since we first met 4 years ago. 

An extremely funny man from our messaging exchanges, he is the person I am most looking forward to meeting after all this madness is over (as well as holding Mate Rimac to his promise to let me drive him around in his $2.75 million C2 electric wonder car - I have promised to drive slower than Richard Hammond). 

And then THIS!

My wonderful wife sent me a link to a YouTube video yesterday - Igor Rudan presenting Survival, the Story of Global Health. 

It is sensational! Beautifully filmed, calmly and intelligently presented by Igor himself, mostly shot in Croatia, as well as Edinburgh, where he is a Prof at the university. 

We called the kids to watch it together as a family. Watching their initial lack of enthusiasm turn to fascination during the first episode was a joy. 

For those of you watching reruns of NCIS and Law and Order, THIS is for you. Check out the full series below. 

And the final bit of reassuring news for this article. Igor messaged us last night to apologise for a short delay in sending us an article update. He explained that he had spent most of the day advising the Croatian authorities on the response to corona. 

Doesn't it make you feel just a little safer knowing that those tasked with keeping us safe are taking advice from the very best?










Page 1 of 2