Daily Post – May 19th | I do it my way

Living through a pandemic

in the south of France

425 days in Carcassonne since

1st lockdown in March 2020

DAILY AND WEEKLY STATISTICS HERE

▫️ CARCASSONNE NEWS / PLACE CARNOT

D-day for the new life of the Place Carnot

▫️ CARCASSONNE NEWS / FESTIVAL

Carcassonne’s mayor Gérard Larrat has presented the 2021 edition, which will take place from 5 to 31 July at the Château Comtal and the Jean-Deschamps theatre. While the municipality will continue to organise the Cultural Encounters from 10 July to 7 August for smaller shows in the city, the Off Festival, the Fireworks on July 14th and the Feria at the end of August have been cancelled due to health constraints.

▫️ INFORMATION

Here is an article / interview published by L’Express magazine which I found quite interesting. It reflects pretty well my views. I have therefore translated and posted it.

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Since Emmanuel Macron asked him last June to “draw lessons” from the French management of the health crisis, he has had to delegate to his deputy the direction of his infection prevention and control service at the University Hospitals of Geneva. Co-inventor of the now famous hydroalcoholic gel, Prof. Didier Pittet went back and forth between Switzerland and France to preside over the independent national mission on the evaluation of the management of the Covid-19 crisis and on the anticipation of pandemic risks. The mission, composed of five experts, is today publishing its work in the form of a 180-page final report full of international comparisons. In an extensive interview with L’Express, the Swiss infectious disease specialist and epidemiologist points out the weaknesses, but also praises the French adaptations during the first two waves of the epidemic. If our country failed in its preparation for the pandemic as well as in the logistics of the vaccination campaign, according to him, it was able to “improve its management over the months”. Didier Pittet also makes proposals for structural improvements to French public health. Some will accuse him of complacency towards his sponsor Emmanuel Macron, while others will say that it sometimes takes a foreign perspective to see that we have not done everything wrong…

🔹 L’Express: In your report, you distinguish three categories of countries. Those spared by Covid, with a health record and little or no economic losses, such as Asian nations or those in Oceania. Those affected by the crisis, but with limited health and economic losses in international comparison, such as Norway. And then the countries very affected by the crisis, with a heavy health and economic toll, such as France…

🔸 Didier Pittet: Yes, but even among the highly affected countries, not all were affected in the same way. We were not equal in the face of the first wave. It is very important to realise that the differences in mortality between European countries are essentially explained by the difference caused by the initial shock. From March 2020 onwards, Italy, France, Spain and Belgium were the most strongly affected by the epidemic. The United Kingdom too, with the particularity of having wanted to “let the virus run” at the very beginning, which meant that it paid more heavily in terms of mortality, even though it had a little more time. In contrast, the Eastern European countries, but also part of Germany, were spared the first wave. Then, in the autumn of 2020, there was a much more widespread and uniform second wave. Germany was much less affected, as were Switzerland and the Eastern European countries.

A special case is Sweden, which has let the virus go. Although the Swedes were not inactive, they were much less restrictive than in Norway, Denmark or Finland. The result: in the first wave, Sweden suffered an economic downturn as severe as Denmark, Finland or Norway, but with eight times as many deaths. In the second wave, Sweden ended up doing what the other countries did, which allowed it to correct this excess mortality.

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🔹 Much has been said about the differences between France and Germany, long presented as a “model”. But your report reminds us that the difference in mortality between European countries is essentially due to the first wave…

🔸 For the second wave, which was much less well managed in Germany, there was disorganisation, probably linked to federalism, as in Switzerland. The obligation to find a compromise with the Länder or the cantons delayed decision-making in these countries, and we saw aberrations. When Geneva closed its restaurants and non-essential shops, the people of Geneva could go to the canton of Vaud, 60 kilometres away, to do their shopping. It was a general mess, including traffic jams on the motorway on Saturdays, which illustrated the limits of this decentralisation. In Switzerland, it was the health ministers themselves who asked the Federal Council to take over governance.

In France, on the other hand, you have learned during this crisis to territorialise decisions in a way that I find exemplary. We can always discuss the details. But by basing yourselves on indicators, you have managed to achieve decentralised management of the crisis, while maintaining the centralisation of important decisions, something that federal states such as Germany have found difficult to impose.

In our report, we compare centralised countries with decentralised countries. But we also compare ‘test, trace and isolate’ with some so-called model countries such as South Korea or Singapore. South Korea, marked by the MERS epidemic in 2015, did not want to take any risks and used an intrusive policy in terms of tracing. There, even cameras in supermarkets can be used to trace transmission chains. And your neighbours will report you to the police if you don’t respect the isolation. You can imagine that this is not the case in Europe…

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🔹 You analyse the different phases of the crisis. As regards the level of preparation for a pandemic, you emphasise without surprise that it was clearly insufficient in France…

🔸 This is the big problem at the beginning, but it goes back more than ten years as far as masks are concerned. There was a problem of doctrine: who should keep what type of mask and how many? Then there was a storage problem, with part of the reserves necessarily perishable. This management was entrusted to Santé publique France, even though it is not an agency designed to handle logistics. Result: as soon as there was a significant need for masks, we realised that part of it was out of date.

As far as the tests are concerned, there have also been errors of doctrine in France. At first, we said we had to develop serological tests, whereas the most important thing was to do PCR tests for diagnosis. Christan Drosten, a German virologist specialising in coronaviruses, was the first to develop a test in January 2020, but the Pasteur Institute quickly followed him. On the other hand, France was faced with a structural defect in medical biology. Germany has a highly concentrated and ‘industrialised’ private sector, which is well equipped in molecular biology, unlike the French private sector, which is not very involved in molecular biology examinations carried out almost exclusively in hospitals. Germany was thus able to carry out 100 000 tests per week from the beginning of March 2020, compared with 13 000 in France. But in the first decontamination phase, France achieved a spectacular roll-out, to the extent that by mid-summer it was the country that was testing the most. With some collateral damage, the laboratories had difficulty in prioritising between people coming to be tested for symptoms and others. This meant that results could take more than 24 or 48 hours. It took time to get started, but today the organisation is remarkable. In France, we are able to carry out large-scale tests and identify variants. It should also be pointed out that in France, these tests are free, whereas in Switzerland, for example, we fought for months to achieve this. I congratulate you on this. Where there are still shortcomings is in the field epidemiology, with the understanding of clusters. But this is a difficulty for all countries in the world.

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🔹 But in the summer of 2020, we failed to control the epidemic when the virus circulation was low. Could we have done better?

🔸 Let’s be clear. Every country in Europe failed to control the circulation of the virus last summer. Everyone wanted to go on holiday. So the virus became hyper-endemic during that period, which many scientists feared. In September 2020, there was a cold snap with an exponential resumption of the epidemic…

“I welcome the French decision to keep schools open”.

As regards the second containment in France, your mission considers that it was “better calibrated” than the first, but late…

In the autumn, everyone in Europe was surprised to have such a high circulation rate and ended up imposing restrictions. France reacted relatively quickly with the curfew decision. It was reactive.

On the other hand, France also quickly decided to keep schools open. Personally, I welcome this decision. Because poor Italian children could have gone more than 12 months without going to school. In Germany, schools remained closed for several months and reopened in a scattered manner. Today we are not in a position to measure the impact of these school closures. But in the first wave, we could see the social consequences.

Of course, the virus is transmitted in schools. But infected children have an extremely low chance of developing a serious inflammatory disease. This is such a tiny proportion that it seems ridiculous to me to close the schools. France has made an intelligent and strong choice in this matter, because closing schools is likely to be very costly from a social point of view.

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🔹 You also highlight the delay in the vaccination campaign. Has France been too cautious, taking into account the lack of confidence in vaccines among a part of its public opinion?

🔸 France was too cautious at the beginning of the campaign. But let’s not forget that the main problem with vaccination was the lack of doses. It was the same in all the European countries that showed solidarity. Furthermore, the option taken in France to protect people in old people’s homes first was the right one, because in terms of excess mortality by age category, people over 85 were by far the most affected category.

In the appendices of the report, we make an international comparison. We can see that there is no excess mortality in countries such as Australia, South Korea or Taiwan, which is not surprising, because there were very few cases. Sweden, on the other hand, has paid heavily for its policy choices, with a big difference from its Scandinavian neighbours. Eastern European countries did not suffer during the first wave, but much more so with the second. France was much better at protecting its population during the second wave, and we can see that Germany managed it much less well. The United States had a real tragedy, with excess mortality not only in the over-65 age group, but also in the 15-64 age group. This is also the case in Spain, Italy, Belgium and the United Kingdom, but not in France.

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🔹 Your report does not mention the controversial management of the third wave…

🔸 Emmanuel Macron asked us to submit the report for the World Health Assembly, which starts on 24 May. So we had to finalise the report in March. But we could redo a health analysis for the third wave at a distance this summer, for example.

As far as the current management is concerned, the French situation is similar to what is done in all the other countries, with a decontamination plan in stages, which can be revised from one territory to another according to the epidemiological data. We are all making progress on a daily basis.

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🔹 “Public health in France is not what it should be. The report makes forty proposals, notably centred on the idea of public health. Why is this so?

🔸 This is the main message of our report. Public health in France is not what it should be in a nation like yours. You have brilliant scientists, but this crisis has underlined the too marginal place of public health in society in general, and more particularly in the practice of health professionals and in research. It must be made more attractive. Many young people who finish their medical studies want to become surgeons or have an academic career, but very few say to themselves “I have a public health soul”. This field is often perceived as being humanitarian. Yet the fight against obesity, hypertension or health injustices is very important.

The United States has the most expensive health system in the world as a percentage of GDP. And yet public management during the Covid crisis was catastrophic. Because there were bad decisions made by Donald Trump, but also because public health was not ready to respond to this crisis. We see that good political decisions and real public health often go hand in hand. In the United States, statistics have shown that obese people and people of colour have died in greater numbers, which is a great injustice. In France, we have also seen that Seine-Saint-Denis has an excess of mortality.

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🔹 In particular, you recommend a reform of scientific expertise, with the Haut Conseil de Santé Publique (HCSP) being attached to the Haute Autorité de Santé (HAS) or the “refocusing” of Santé publique France…

🔸 We have to ask ourselves how, when France has the means at its disposal, we can get everyone to work together so that it is useful for centralised health management, but also for research and the academic world. Perhaps some of the agencies’ missions should be reviewed in order to optimise all of this within a true public health vision. By promoting the independence of these agencies, we have perhaps cut back too much on the Ministry of Health. There were not enough connections with the ministry or between them. Santé publique France has done some wonderful work during this crisis. We need to strengthen its resources, but also to put all this back into the service of real French public health.

In conclusion, we can say that your mission points out errors and shortcomings, but also underlines the fact that France’s management was not catastrophic in comparison with other countries…

Some things could have been managed more quickly, but that is the way it is everywhere. France is characterised by an adaptation of strategy that has been almost permanent. Probably because the executive has been constantly at the bedside of this crisis. Some have criticised the fact that the indicators change regularly, but it is precisely the nature of intervention epidemiology to adapt. That is our job.

And it should be remembered that this was the first time that modern states had carried out containment. Nobody had the recipe. I worked on the first decontainment in Switzerland, and I can tell you that there was no plan available anywhere, neither at the WHO nor elsewhere. So we have to be very humble and modest in realising what we have experienced. Not since the Spanish flu have we experienced such an epidemic. With Covid-19, there are at least 1,200 deaths per million inhabitants in France, compared to 450 for the Asian flu, 600 for the Hong Kong flu or 240 for the 2003 heat wave. And we are not finished yet. For a hundred years, the world has not experienced such a health crisis in terms of deaths, but also of economic and social consequences. In 2008, following the financial crisis, GDPs did not fall by more than 2%. Here in Spain, it has fallen by more than 12%. There is no comparison. No head of state or minister of health in any country in the world has ever been exposed to such a phenomenon.

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🔹 You will be criticised for being too indulgent with the executive…

🔸 As an epidemiologist, I don’t only have a health vision. With this mission, we sought to understand how the various decisions were weighed up. It is impossible today to evaluate the non-closure of schools. But we can see that these closures are dramatic in terms of the social divide, even in Switzerland where we are spoiled. The health data must therefore be balanced by other elements. Of course, one death is always one too many. Unfortunately, we have become accustomed to these excess mortality figures. But we also have to realise that students in Switzerland or in other countries are depressed because their university is closed. How do we weigh this up? As far as I know, the French management of the crisis has tried to take these different issues into account at all times. What is the weight of a 92-year-old’s life compared to a student who has been deprived of classes for six months or even 15 months? It is in five years, perhaps more, that we will be able to really evaluate the decisions. But at the beginning, there were no elements to know whether or not to close the hairdressers like other sectors of activity. Everyone did the best they could.

On the other hand, there is undoubtedly a disappointment in relation to French research. We are all disappointed that Sanofi has not managed to produce a vaccine so far. Why is there a lack of innovation in France? The head of Moderna is French. Ten years ago, unfortunately, we did not feel the need to support RNA techniques. But we did not have time to evaluate this problem in this report. Perhaps we should have another mission on the subject.

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🔹 So your message to the French is to be less critical of themselves?

🔸 I have heard a lot of criticism in France, from the left and the right, often on a day-to-day basis. But we must keep an international vision. If we look at the countries first hit by the epidemic, I think that the management of the epidemic has been quite remarkable overall. We can all improve, in France as well as in Germany and Switzerland. There have been real health disasters, like in the United States, Brazil and India. In Europe, there has unfortunately been a lack of coordination at EU level. The WHO was slow in many decisions. We could all have done better. But perhaps when you live in France, you are more critical of your authorities…

Some people will find us too complacent or too severe. I expect that, that’s the game. In any case, we have been honest, free and totally independent. Emmanuel Macron, when we met last June, told me “I want you to be totally independent and if this is not the case, let me know directly”. But we were given total freedom. I say hats off to you. We interviewed more than 200 people, in the scientific fields as well as in the public services. We had no restrictions. We made an effort to find the truth.

I recommend that all countries adopt this kind of initiative. This is what the Director General of the WHO had asked for, when he said that all countries should review their crisis management. But if a few other states have also carried out an assessment mission, I can assure you that none of them has sought to take into account the health, economic and social aspects at the same time. There is a mission in Sweden, but it will not deliver its conclusions until 2022. The same is true in Denmark and Singapore. So France has been exemplary in this respect.

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🔹 Are you optimistic about the future?

🔸 We have clearly seen that the risks of transmission are linked above all to social interactions. When we trace the transmission chains, we always find the same conclusions. People become infected when they eat together, when they have parties, when they are in meeting rooms without masks and distancing or when they do not respect barrier gestures. Hence the importance of testing and field epidemiology. This message is fundamental, because it will be the same this summer. Nothing will change. Yes, we are going to be allowed to do more activities, because the number of people vaccinated is increasing and slowing down the contagions. But we have to be able to continue to apply some of these measures so that we can live with this virus that is going to last. When we have reached a very high level of population immunity, we will be able to allow ourselves even more. But we have to be realistic about this virus. We can no longer bury our heads in the sand. Everyone is therefore a manager in the fight against this epidemic.

▫️ TRAVEL (🔸 = NEW)

Countries that have reopened their borders to French travellers