The Second Wave of COVID-19 in Europe: the Aims are No Longer Clear
It is becoming difficult to prioritise between the health crisis, economic downturn and security risks.
The pandemic has spread throughout the world throughout 2020. As such, some areas have always been hit harder than others. In January, the focus of interest was China, and in February, that same focus was directed towards its neighbouring countries — South Korea, Japan, Taiwan and Singapore. Then the pandemic took Iran and Italy by surprise, and spread to the whole of Western Europe, and then to North America.
Since back in May, the most difficult situation has occurred in Brazil, and then the whole of South America. During the summer months, media interest moved to distant Australia, which was then battling the peak of its pandemic wave. And then, with the arrival of autumn, Europe was hit by a strong second wave of the pandemic, in line with what the epidemiologists had previously predicted.
In the United States, due to the lack of a decisive epidemiological response, the third pandemic wave is now in full swing. The death toll in the United States would soon exceed 250,000. This, unfortunately, is still not the total number, as the third wave is stronger than the previous two were. Nonetheless, President-elect Joe Biden has announced that curbing the contagion will be among his priorities. Across the vast Atlantic Ocean, European Union countries found themselves in a situation similar to that which had already been experienced back in mid-March, and many countries decided to reintroduce very strict epidemiological surveillance measures as a result of that.
How are European Union countries responding to the second wave of the pandemic? Over the past few weeks, many European countries have had to reintroduce very restrictive epidemiological measures in varying degrees. Each country had to choose its respective response to the second wave of the spread of the COVID-19 pandemic. Some also resorted to a total and extremely strict closure.
At the same time, I’d like to emphasise that epidemiologists consider complete closure only as an extreme epidemiological measure. The introduction of a “lockdown” in each individual country actually means that they have previously failed to properly assess the danger and successfully curb the spread of the infection through targeted and specific, and less harmful public health prevention measures.
That is why many EU countries introduced the so-called “traffic lights’’ system. They very clearly define to residents which measures will be automatically activated in their area in case of established signs of a stronger spread of the infection. Therefore, the response to the pandemic in the EU has now been regionalised.
If these “traffic lights” are well adjusted and the population strictly adheres to the prescribed measures, then it is possible to avoid the rapid spread of the epidemic by the use of a combination of measures that are tightened in line with the increasing danger. However, if anything in this system fails to adhere to the plan, and the uncontrolled spread of the infection among the population is established, then there remains a complete shutdown for a shorter time (so-called “circuit breaker”) or, if such a measure lasts for a somewhat longer time (so-called “lockdown”).
What did the epidemiologists from EU countries expect from the move of regionalisation and the “traffic light” system, in which measures are automatically applied when a certain level of the spread of the infection is determined? This approach to controlling the spread of a pandemic is what’s known as so-called ‘’precision public health”. Key epidemiological data is very closely monitored and the measures taken in response to it are constantly harmonised. If the system is well-adjusted, the measures are properly chosen, and the population adheres to the measures, then the spread of the infection shouldn’t spiral out of control and turn into uncontrolled, exponential growth. This approach would correspond to a long “dance” with the virus, as described in the “hammer and dance” model.
A well-tuned “precision public health” system allows the population to have longer periods of time without fear of the explosion of the pandemic. It protects the economic activity of EU countries, but also the situation surrounding safety and security in society. However, if the epidemic waves spiral out of control and threaten to overload the healthcare systems, then there aren’t many options left. Some countries have decided to prevent the overload of the healthcare system with a “lockdown” — ie, a new application of “the hammer”.
Why has there been such a strong second wave, which seems to have come as a surprise to many EU leaders? Viruses have very complex transmission dynamics. The new coronavirus has been shown to be highly dependent on human behaviour and movement. It is becoming increasingly clear that the rate of SARS-CoV-2’s spread can be accelerated by so-called “super-spreading events”, where a small proportion of those already infected will lead to the majority of new infections in the next cycle of its spread. Therefore, large social gatherings, especially those indoors, and those that take place in a shorter time sequence can lead to the rapid spread of the infection and as such result in the congestion of the healthcare system.
The spread of a new coronavirus may be affected to some extent by factors that cannot be easily controlled. It is known that respiratory viruses can have seasonal peaks in a variety of climatic conditions, where the alternation of wet and dry periods affects the speed and success of their transmission. Then, changes in the proportion of time spent indoors or outdoors can also trigger new epidemic waves. Viruses can also move between species during different parts of the year, and prefer one “reservoir” over another, only to return to the initial one at another time which better suits it. Therefore, a certain set of preventive measures may, at one point, keep the epidemic under control well, but at another, it is necessary to strengthen the measures to prevent exponential growth.
When the measures are sufficient enough, there will be no sudden large growth. However, when the beginning of the growth of the number of newly infected people in a country is determined, regardless of the measures which already exist, it means that they are no longer sufficient and should be further tightened.
Why have so many EU leaders decided to resort to “lockdown” measures of varying degrees over recent days? Does this mean that the measures that were applied during the summer weren’t sufficient enough? Couldn’t they think more about the economy and the harmful effects of the lockdown itself on the health of the population? Over the past couple of weeks, I’ve commented on the effectiveness of these measures, as well as the decisions made, and I have answered these questions for many international media outlets. In addition, my colleagues at the Centre for Global Health at the University of Edinburgh, of which I’m the director, have conducted the most thorough analysis of the effectiveness of individual measures and published this scientific paper in one of the world’s leading scientific journals. As such, I have been a guest on BBC News recently, where I expressed my views, and I have also answered questions from journalists from CNN, the Financial Times, the Guardian, New Scientist and iNews. I tried to explain all of the options as thoroughly as I could, as well as the likely scenarios that EU leaders considered.
In short, in Europe, the main reason for some countries to resort to lockdown was the need to protect the healthcare system, and especially hospitals, from the overload of patients that would follow due to the rapid spread of the infection. This reduces the risk healthcare workers are exposed to, as well as those suffering from all other diseases who can’t receive adequate care.
Namely, when the healthcare system is overloaded, then the so-called “social contract” between the state and its citizens comes into question. If citizens have paid contributions to their healthcare, then the state should provide it when they’re in need of said service. If it does not allow it, “Pandora’s box” then opens and what else the state may fail to guarantee comes into question. These are issues of great sensitivity to many EU citizens, and their leaders still prioritise avoiding such a scenario over other options. Saving lives and preserving the social contract in Europe is, for the time being, still the paramount priority.
Other priorities, such as the economy and public safety, are also being talked about more and more. Are the reasons for the second lockdown in several EU countries the same as for the first lockdown, or are there differences now? There are certainly some similarities, but there are also some extremely important differences. When the first wave of the pandemic hit Europe, the goal was clear: to save as many human lives as possible, to support the economy during lockdown measures, and to learn more about this virus as quickly as possible. We had to understand the death rates among all those infected in a much better way, not just those who tested positive, then the rate of spread of the virus, as well as the modes of transmission and the options available to us for prevention.
The findings back in March and April bought time to develop PCR tests which are as fast and as accurate as possible in order to diagnose the presence of the virus, as well as tests to detect the presence of antibodies in the blood that indicated an assessment of previous exposure to the virus among the population, known as seroprevalence.
Seroprevalence research was crucial at the time, because although epidemiologists initially correctly assessed the danger of this infection based on initial data which had arrived from China, few expected COVID-19 to break through the first lines of defence in European countries. However, the first lines of defence of Asian countries, due to their previous experience with SARS and MERS, turned out to be much better prepared than those of European nations. The first surprise — the virus breaking through the first line in Italy and the free spread of the infection — was followed by another unpleasant surprise, and that was the speed and unpredictability of its subsequent spread, which was later explained by the virus spreading via aerosol.
The third surprise was the death rate in Italy, which seemed extremely high at first, because at the time, epidemiologically, it wasn’t entirely clear that this was primarily the result of the spread of the infection among the very elderly population of Lombardy. Due to the death rate there among those who had been confirmed to be infected, which at the time, until a seroprevalence study in late April, could only be considered as solid evidence, epidemiologists could no longer be sure what to think about the data they had received from China. The age structure of those who were infected and the dead in Italy was announced only later on, and it slowly began to clarify that unexpectedly high death rate. All these unpleasant surprises contributed to the sudden decision to close down in mid-March until what really happened in Europe was investigated and a new line of defence was prepared.
Quarantines also bought time for the development, testing, production and procurement of protective equipment for health professionals, but also for the general population, as well as respirators in hospitals and the necessary additional equipment for their permanent work. Some health professionals also needed to be trained to work in infectious disease departments.
During these weeks, guidelines for controlling the spread of the virus through “precision public health” were developed and improved, and the general public needed to be provided with the best and most comprehensive health education on the pandemic.
In addition, research began to test the effectiveness of existing drugs and to accelerate the development of new vaccines. The closures which took place in the spring of 2020 should, therefore, be only an exceptional measure given the very specific circumstances of the time, their duration should be as short as possible, they should be as effective as possible, and they should leave behind a favourable epidemiological situation that could even enable a partially rescued tourist season for the summer months.
However, in this, the second wave, the goals are no longer as clear as they were before. The second wave surprised many EU countries with its ferocity, although epidemiologists predicted it for October and November almost without exception. It is now very difficult to predict what other challenges we will have to deal with with this priority public health problem.
This is the key difference between the first and the second wave. In the first wave, the public health problem was a priority. That goal was quite clear and the economy needed to be protected through one-off supportive governmental intervention. In this, the second wave, in addition to public health, we now have a very difficult economic and security aspect owing to this crisis. At the same time, the goals are no longer clear enough, because we don’t know how much longer the crisis may last.
What are all the options available to EU governments when their “traffic light” and “precision public health” systems give way before a new pandemic wave? Their options are quite limited indeed. We cannot say with certainty when we can expect a wide distribution of effective vaccines or drugs, and how long we will remain in these cycles between pandemic waves. EU governments are now developing strategies that will minimise the risks of the healthcare system collapsing, the economy collapsing or even social unrest during each new wave. They are thus in a passive position, where they will remain locked in a vicious circle of solving the biggest of these three problems until the pandemic somehow draws to a close.
In a few years, it will be possible to scientifically assess exactly what strategy would optimally reduce all of the inevitable damage that awaits us in Europe in the coming weeks. However, at this point, we cannot know for sure.
Admittedly, the approach of several Asian countries is also worth mentioning, which relies on very strong systems and procedures for testing, monitoring and isolating the infected, then quickly and carefully monitoring and isolating all of their contacts, wearing masks, social distancing and very careful border controls.
If we use the criteria of saved lives and retained GDP as the two main criteria for the success of individual countries’ response to the COVID-19 pandemic, then the approach of Asian countries during most of 2020 seemed superior in the results achieved so far when compared to European Union member states.
However, as most European countries don’t seem to have sufficient capacities to implement similar measures, nor sufficient support from the general public to implement such measures, then strategies based on “traffic light’’ systems, “precision public health” and solving the biggest of the three problems work at least clearly enough. Science now needs to closely monitor what results will eventually be recorded.
It has certainly been shown that all of those countries that have focused on the health aspect of the crisis, and resolutely addressed this problem, have also managed to significantly alleviate other problems — both in an economic and security sense. However, if a country is late at some point with its reaction to the health part of this crisis, it will soon have all three problems on its hands.
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Declaration: Professor Igor Rudan, FRSE, is the President of the International Society of Global Health; co-Editor-in-Chief of the “Journal of Global Health”; Joint Director of the Centre for Global Health and the WHO Collaborating Centre at the University of Edinburgh, UK.
Translation by: Lauren Simmonds
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