Prof Alex Friedrich on why the northern Netherlands diverged from national Coronavirus policy

I interviewed Professor Alex Friedrich, head of microbiology and infection control at the University Medical Center Groningen (UMCG), about why he led the northern Netherlands to diverge from national Coronavirus policy for the Irish Times.

The interview was wide-ranging and I couldn’t fit everything into the article. Here are some additional quotes from the interview that add some interesting new perspectives.

 

On diverging from national policy:

“Containment was stopped, and the whole country went over to mitigation, and this was correct only for Brabant, because in the rest of the country could contain it still, especially the north.”

On the importance of slowing infection:

“Maybe we will find out in two weeks or two months many things that will solve the problem, that will help people who are infected. If you say ‘I let it go’, it gives no chance to all the people who must be admitted to hospital to be treated optimally to avoid this. ”

About the importance of a cross-disciplinary approach:

“There are very few experts on coronaviruses in human medicine. But for veterinarians, coronaviruses are very important pathogens that cause all kinds of problems. So I called veterinarians in Germany, the Netherlands, and Italy, and they told me in our world it’s a real problem compared to other pathogens. It’s a big problem in chicken stocks. It’s incredibly transmittable. You cannot control this if you have this in your flock. And immunity does not occur in all animals, it’s local and it’s short term. So they give them different cocktails of vaccinations, but then the pathogen changes and it stops working… they have a lot of knowledge about it. In human medicine very few people have knowledge about this.”

“You need to have a broad range of people. Not only medical people, virologsts, microbiologists, but veterinarians, economists, psychologists, even linguists. Because we know that not only coughing spreads the virus, but also talking, and there are differences between languages. There are even differences between people, who make more or less droplets. We need linguists who know about how sound is made in the mouth and throat, and they could tell us: in this region half a metre of distance is OK, and here it needs to be two metres.”

On the limits of basing policy on scientific studies alone when a virus is new:

“The literature is not very reliable, because it’s something that only goes back to January. And I think everybody who was involved [in setting policy] at that moment had everything but the time to research. We cannot just rely on the literature and you cannot rely on the transfer knowledge from other diseases, because it’s just not the same virus, you can use this knowledge of course you need really careful.”

“I think the most important thing was to pick up the phone and call your colleagues that are seeing Covid patients in other countries, and ask them about it. That’s the reason why I picked up the phone, I wanted to know how long these patients spend intubated, because this is a very important indicator.

“So I called my colleagues in Rome who had the first cases, and asked them: how long do they stay? And they told me three to four weeks. I said: oh my god, our models need to be changed. So we changed the models in our hospitals to this duration. But then I saw that nationally, they were still taking into account two weeks. Somebody could have said: no! Call your colleagues in Rome! I think they are just not used to looking through windows to the outside world.”

On failures in the EU:

“I think that this [insularity] is not a Dutch problem, this is an EU problem. The European Union was not very visible, and did not take any action or responsibility, because maybe it was not able to do so, because the countries decided to close their borders. We had a big problem because we help each other across the border with Munich in Germany, we were missing swabs and they send us swabs, and suddenly it was forbidden to export to us this material, which was really dangerous to us because we couldn’t help each other any more. It was a total failure of concerted European action and support.”

“At the European level there is no European laboratory, they are depending on the national laboratories, and that’s part of the problem. The more laboratories you have the less blind you are in the fight against the disease. And we made ourselves blind… on the European level somebody should have said in Europe we will approach it this way, we put a priority on diagnostics.”

“This is a structural problem. On the European level there is no laboratory capacity, we have never been allowed to do this. There was a clear decision that there must not be laboratories on a European level, just on a national level…. Diagnostics had no priority in January or February in the discussion. ”

“Ten years ago we did not have such rapid diagnostic tools, you might have had a diagnosis in ten days or five, how within a few hours you have a result. This is so strong.”

On the importance of slowing the spread:

“If you slow down the epidemic, you have more time. If we have more time, we will learn more about the disease. We are learning now it’s not really a pneumonia, many times the arteries and the veins in our body, they are blocked, it is in the brain, it is also in the liver and gut, everywhere. It can have so many differences that we have to learn. But if we don’t have time we will not know. Maybe we will find out in two weeks or two months many things that will solve the problem, that will help people who are infected. If you say ‘We let it go’, it gives no chance to all the people who must be admitted to hospital to be treated optimally.”

“We can’t accept that people will all get infected. It’s not a law that we’re all going to get infected. It’s just the consequences of our insufficient action to protect people. That’s my personal view and I understand that others feel differently. But that will not change my mind. Our goal is to protect as many people as possible.”

“We acted to control it much too late, we should have done the Asian approach. Control it. Contain it. “

How one big medical centre could change policy for a region:

“At the university medical centre we have 15,000 people working, we are a very large healthcare institution. We get our patients and our staff from the whole country even from abroad. If we do something right we can protect the whole region, and if we do something wrong we can bring risk to the whole region.

“We have communication lines between all the colleagues in microbiology. We have a network of all infection protection, 500 or 600 people  — set up to work together against antibiotic resistant infections. We just switched from resistance to another infectious disease.”

“We talked to the public health service and said we are going to do something different from the national way. And they said why. And we explained it, and they said OK, but we don’t have the manpower and we don’t have enough personal protective equipment. And we said no problem, we make a screening on our UMCG terrain. You tell us who will come from the healthcare institutions. We had a lot of students who were staying at home and they were happy to come to work.”

“The Netherlands and this region is not the same, so we need to take different action. And all the medical staff agreed. We just did it.”

On lack of testing in the Netherlands:

“They [national authorities] said they didn’t have testing capacity. The laboratories I know didn’t really have shortage of capacity… the problem is in the swab-taking capacity… you need someone to go to the patient and take a swab. The public health service have no capacity to do so. My solution would have been to hire a thousand medical students who are all sitting at home would be happy to do the swabs. But I wonder if at the end if it is a question of costs.

“Some countries have the idea that diagnostics cost. Other countries don’t have that idea, they just have a cost that is existing, and we do as many diagnostics as we need [i.e. cost versus overheads – ed.]. Countries such as the Netherlands that think that every test will generate cost, you think about is it possible and do you have the people, because you think of diagnostics as a cost factor. But this is your eyes. You make yourself blind. And then you have a disadvantage.

“It’s a system and structural problem. Why make diagnostics a cost factor and say diagnostics cost money? You can turn it around and say it is included in the price of therapy, because if you can’t do any therapy without any diagnostics. You can’t give chemotherapy to a cancer without diagnostics. it’s a healthcare structure problem.

“Now we have to do it, because there is no other way we can solve this problem.”

How EU countries compare:

“If you ask me, the really good example of a country that is really doing well is Greece. And they did it without much resources. Look into that.”

“The Italians are the best in publishing on a database all the data on a very regional and provincial level. They gave to us how many healthcare workers are infected, how many people are infected again. That’s impressive how Italians did this, we really learned from them. I was able to compare it and say oh my god, that’s a very different infection from other infections. We really owe a lot to them.”

“The countries of the east are very strict, and they control it. People are afraid of infection. If the government says stay at home or you might die, they just stay at home.”

“Germany was very well prepared because they prepared for the Ebola epidemic. That changed the whole system, they were already prepared for that because they had the infrastructure and laboratories. They have 540 public health offices. We [in the Netherlands] have 25, and they are a lot smaller than in Germany. Germany was able to never stop containment. They could write to people and say they were exposed and now you are obliged to stay home. The absorption capacity in Germany was much higher.”

“If you do not listen to your neighbours and colleagues you will not learn. We all have to learn in this situation because we just do not know. ”

On re-opening borders:

“You cannot just decide each member state whatever you want, you can only do that by connecting with you neighbour. But it’s the border regions you really need to think about, because there you will see the differences most strikingly.”

“The problem is the member state approach, that we are looking at the statistics of the member states. Why are we not taking into account the regional differences in the epidemic all over Europe.”

“Otherwise you would say the mean of Brabant and Groningen equals the Dutch level. That way no one can learn from what happened in Brabant and what happened in Groningen. Yet we continue giving statistics on a national level which makes us blind to the reality.”

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