At the end of May, when the Prime Minister has just announced a new deconfinement package, it is useful to make an initial transitional assessment of the Covid-19 epidemic. For Professor Jean-François Toussaint, who signs the following article, from the very beginning of the crisis, some things were taken for what they were not. We were not at war, we were not in a position of collective suicide, we were not in a position to renounce elementary rules or to dismiss the rigour of analysis. Analysis should have continued to guide our actions, had we not unfortunately succumbed to panic. Models have been misguided, projections have been wrong; yet it is on such simulations that the paralysis of half of humanity has been played out..
The Covid-19 outbreak in Europe is coming to an end. It has stopped in more than 70 countries and regions of the world. In terms of global mortality, this phase will present a total of nearly 600,000 deaths. Seasonal or not, its resurgence is a hypothesis to be considered among others, as the pandemic may also be maintained at low levels or stop spontaneously. In addition to those directly related to the essential measures to combat SARS-CoV-2, the social, economic and health consequences of widespread containment will be considerable. All these effects are expected to lead to a decrease in life expectancy in the coming years.
At the end of May, it is useful to draw up an initial assessment of the Covid-19 epidemic, albeit transitory but instructive. It is now over in more than 50 countries, a quarter of those that have reported at least one case. On the European continent, this phase is currently leading to a reduction of 85% in the daily number of contaminations and deaths. Compared to the maximum levels established on 16 April, this reduction is now more than 50% worldwide (Figure 1), as well as in North America. In six months, this global wave will likely total close to 600 000 deaths, compared to the 28 million deaths from other causes or 600 000 deaths from annual epidemics of orthomyxoviruses (influenza viruses) during the same period.
So now we need to understand where we're going and in what state of mind
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The main prognostic factor for this disease is age, and by far the most important one is1. A previous episode, the heat wave of 2003, had already shown the vulnerabilities of our elders: we open our eyes to a fragile life and ephemeral successes. But this virus will have particularly affected nations that did not imagine themselves among the most fragile. The Latin European countries - Italy, France, Spain - are those which, before this crisis, had the highest life expectancy values or even world records. Moreover, the two countries that counted the highest number of deaths (USA for North America and the United Kingdom for Europe) are those that have seen their life expectancy begin to decline in recent years. This fragility, announced as early as 19902The study, which is based on a study by the French Institute for Health Economics, shows the extent to which certain lifestyles leading to sedentary lifestyles and obesity are added to ageing to create conditions of absolute vulnerability to new constraints or new pathogens.
Helping the decision by assessing the real risk
Covid is in a phase that extends into the future and into the past. To understand it correctly, it is necessary to scrutinize reality, to excavate the terrain, to dissect time and to take into account only reality without obscuring it with erroneous concepts or falsified simulations. The nature of the real risk must remain the only indicator to guide our decision.
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In an environment (temperature, air renewal, altitude ...) that cannot be changed most of the time, the risk depends mainly on two factors: viral circulation (contagiousness) and the vulnerability of those affected.
Even if it is not very lethal (between 995 and 997 people out of 1000 contaminated survive it), it is still very dangerous.3), the specificities of this epidemic should not be minimized. It was unique in its speed of spread and the speed with which patients suffering from severe forms were destabilized. Here again, we must pay tribute to the major role played by healthcare workers, city practitioners, public and private hospital teams, and their unfailing commitment and prevarication, as well as those who supported them.But, from the beginning, some things were taken for what they were not. We were not at war, we were not in a position of collective suicide, we were not in a position to renounce the elementary rules or to dispense with the rigour of analysis. Analysis should have continued to guide our actions, had we not unfortunately succumbed to panic.
The error may have come first from difficulties in organising reliable data collection. On several occasions, the official French figures disagreed with themselves and with those that the government transmitted to the WHO (since April 12, the number of contaminations differs every day by 22,000 to 35,000 cases between these two sources). The recent subtractions of 342 deaths in old people's homes (on 19/5, after those of 13 and 15 May) show to what extent it will be necessary to take up the exact count of misattributed deaths in order to understand the reality of what Covid-19 was. Moreover, attribution is also subject to great difficulties: in New York, in the initial panic, up to 15,000 deaths of cardiac - not infectious - origin were wrongly attributed. On 25 May, Spain also subtracted 1918 deaths from its initial account. The necessary re-evaluation of all accounts will take time but will put the Covid precisely back on the pandemic scale. It could show a posteriori the price of fear in our decisions.
Simulators & Predicationsthe models got it wrong, the projections got it wrong. Yet it is on such simulations that the paralysis of half of humanity was played out.The main ordinance (the total containment of the populations) was guided by estimates which were proposed on 12 March to the representatives of our Republic. In this work, however, many things were wrong: the models were wrong, the projections were wrong; the simulations are still not reproducible, the justifications remain unfounded. And the studies currently published repeat the same errors: models naive and outdated, the options were so far apart that the gap between the options was so wide that the predictions were useless. It is however on such simulations that the paralysis of half of humanity was played out.
Inadequate response can result in death. At the societal level, it can lead to the collapse of a society and the future of our children.
Our adaptive limits being essentially technical (lack of respirators in Lombardy) or material (masks, over-blouses, ...), two options were available to the rulers:
- Test and isolate (patients and contact subjects: this was the case in Korea and Germany) or
- Immobilize the entire population (by reproducing the strategy that China had nevertheless deployed for only 6 % of its population: that of Hubei).
In the absence of any possibility of randomized control group experimentation, Oxford University has done a remarkable job, involving hundreds of students, in detailing the exact nature and temporality of the measures taken (closed schools, banning of collective demonstrations, test campaigns, etc., summarized in a stringency index in order to compare countries with each other.
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These studies show that there is no link between the "strict" nature of the measures decided upon (their intensity of containment, with or without military supervision, for example) and the seriousness of the epidemic. The WHO could therefore have been mistaken in suggesting this as the only means of responding to the pandemic.These studies show that there is no link between the "strict" nature of the measures decided upon (their intensity of containment, with or without military supervision, for example) and the seriousness of the epidemic. The WHO could therefore have been mistaken in suggesting this unique means of response to the pandemic; it will be necessary to understand the reasons that led its management to maintain until May the threatening nature of the epidemic for humanity, thus justifying a containment whose absence of additional gain compared to screening and distancing measures, or even its capacity to amplify contamination in retirement homes, is measured.
During periods of high or accelerated viral circulation (at the beginning of the epidemic phase, which is almost exponential), only distancing is effective: barrier gestures, masks, distance of 2 metres between people; suspension of crowd circumstances (public transport, matches in closed stadiums or halls, concerts, etc.); prohibition of places without air renewal (confined rooms, air recirculation by air conditioning, etc.).
Similarly, the Atlantic beaches were closed for two months (in complete confusion with the crowded sandy strips of the French Riviera in July). Éric Caumes, declared on Tuesday, May 5: "Je do not understand why beaches are not accessible. ». This professor specialising in infectious diseases at the Pitié Salpétrière and a member of the scientific council of Covid-19, shows that a great many measures are not related to the risk: confinement encourages familial transmission and contagion between confined persons (EHPAD), whereas air renewal, especially outdoors, is the best guarantee of a reduction in viral propagation. Beaches, along with forests and wide open spaces (mountains, national parks, etc.), are the place where the risk of contamination is nil in the absence of encounters between people. Walking alone (keeping any possible encounters at more than 2 metres) should therefore not only be prohibited during the most active phase of the pandemic but should even be recommended to maintain one's physical condition, the only therapeutic bulwark against the disease.
Did you have to confine?There was no evidence in the international scientific literature that there were any efficiency gains.There was no evidence in the international scientific literature of efficiency gains beyond the distancing measures described above. Based on this evidence, Sweden has developed a very different response plan to the epidemic and, in the absence of any possibility of experimentation, only the "historical" comparison between countries remains open to interpretation, despite all possible biases. However, by this yardstick, global containment does not always appear favourable to the populations that have practised it.
In Europe, the rates for countries that have not strictly confined themselves (Germany, Sweden, the Netherlands) are currently 165 deaths per million inhabitants compared to 432 for the others. Similarly, similar regions bordering (between Norway and Sweden, for example) show no evidence of a high rate of deaths per million inhabitants. no difference in terms of contamination (yet this is the criterion on which containment should have had the greatest impact). In Sweden, it was mainly the Stockholm area that experienced a major increase in mortality related to inadequate crisis management in the old people's homes.
A study The recent experience shows that the initiation of containment measures does not change the growth rates of the explosive phase. Finally, the return to normal is much less difficult in a population that has understood and accepted the risk. In all the other countries, especially for those who had the means, it is not surprising that after having sounded the alarm about a mortal risk for all citizens if they did not bury themselves, and that they are still paid in such a situation of fear as well as incomprehension, very few of them have the desire to come out of it.4.
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FeaturesThere is a spontaneous progression of the disease. It is better understood now that unconfined countries are completing their journey. The catastrophic promises that were made to them have not been fulfilled.There is a spontaneous progression of the disease. It is better understood now that unconfined countries are completing their journey. The catastrophic promises that were made to them have not been fulfilled. But these prospects were already present in the 30 Chinese regions outside Hubei that did not force their population to follow a regime as severe as in Wuhan. Finally, Brazil, which passed the 100 deaths per million inhabitants mark (while Belgium reached 800 at the same time), also provides keys to understanding the "natural" evolution of the pandemic in the absence of a coordinated response by a State.
Why does this epidemic affect only 5 to 6% (in estimated value) of the populations in areas that have confined and no more than 20 to 25% (in measured serological value) in the very few States that have opted for herd immunity? No one knows this yet, but it is likely that this trait is specific to the virome-human genome interaction of SARS-CoV-2 and that the fractal nature of the sub-exponential evolution of its growth rate is responsible for limiting the extension that this virus can take.
Hence the discrepancy between the morbid reality of Covid-19 (the order of magnitude of the impact at the end of this pandemic phase will be comparable to that of an orthomyxovirus, far from that of HIV or the infectious diarrhoea that carries millions of children around the world every year) and the perception of a disease comparable to the plague of 1347. 5 ?Positive reinforcement loops, through the repetition of a single message (death, number of deaths, mortality risk, premature deaths, hospitalized deaths, hidden deaths, forgotten deaths, ...) end up saturating the cognitive space.Positive reinforcement loops, through the repetition of a single message (death, number of deaths, mortality risk, premature deaths, hospitalized deaths, hidden deaths, forgotten deaths, ...) end up saturating the cognitive space. The development of instantaneous information techniques and competition from the means of communication6 that contribute to it cause a deluge for which our brain is not prepared; it is then no longer able to sort it out. Hannah Arendt's analysis goes on to say: " For those who no longer want to rely on their experience, because it no longer allows them to find their way around, there is the constraint that one imposes on oneself to be dragged along by the irresistible current of superhuman, natural or historical forces. "7.
Finally, the emergence of a property, not included in the initial simulations but linked to the synchronisation of response modes (the confinement of most of the affected countries results in the paralysis of half of the human population), leads to economic collapse and its attendant social and health consequences.
To maintain optimal adaptive response capacity, all possible futures must be kept in mind. And being able to juggle one form of response to another according to the reality that will be observed in the field. This virus can: disappear (as was the case with SARS in 2003), persist (at low noise levels), or become cyclical (seasonality hypothesis) with winter alternation between the northern and southern hemispheres.
In addition to these three hypotheses, a fourth one (the persistence of a high level of contamination) already seems to be ruled out since all the countries and regions that have experienced this wave have experienced the same dynamics:
- an undetected set-up phase (possibly as early as autumn 2019 - several athletes from different European countries presented particularly severe flu syndromes on their return from the military world championships held in Wuhan from 18 to 27 October 2019);
- an explosive phase (that of February/March in Europe) of about four weeks, which occurs when multiple conditions are met (the question remains as to which ones: temperature; vulnerabilities; expansion threshold of the previous period; microbiological competition? ...) ;
- a peak (31 March in France (Figure 2), 16 April worldwide) ;
- then a decline over 8 weeks that can lead to the cessation of the epidemic (see Box).
Complete and definitive disappearance is also unlikely since this virus, if it stops circulating, should remain in culture in certain P4 laboratories, which are authorised to keep them under very high surveillance, as are the smallpox and SARS viruses, from which SARS-CoV-1 escaped noiselessly and fortunately without damage in 2004.The second wave is for the moment only one hypothesis among others and it is not seen in any country in the world.The second wave is for the moment only one hypothesis among others8 and it doesn't appear in any country in the world. However, if it does occur, it could be the return of an outbreak kept active during the southern winter in one of the South American countries. Health surveillance is taking a very close interest in it. But, should it occur, should this wave be equal to the first one? At its peak, the world experienced nearly 100 000 contaminations and 10 000 deaths every day. France peaked at 10,000 cases and 1,440 deaths daily between late March and early April.9 and reached 275 new cases and 95 deaths on 27 May. Vigilance is still required, but we are currently far from these maximum values, which were recorded 8 weeks ago.
At the same time, we have witnessed a phenomenal redistribution of thinking efforts and experimental forces. Everyone, in biomedical science as in many other fields, is now working only on the coronavirus. In all these areas of research, as in the media, we will have to learn how to detoxify ourselves. But you'll also have to get used to death again.... Firstly, because the whole generation born after the Second World War is reaching an advanced age in our countries. Then because, for the past decade, we have been approaching the limits of our capacities and, perhaps, the limits of our evolution. 10.
This last hypothesis will remain unanswered from the point of view of humanity, but the fact that it regularly lurks at the bottom of our ulterior motives says a lot about the amount of knowledge that goes in this direction. Life expectancy could then only be maintained or fall, especially if our decisions contribute to its worsening.
All the more so as violent constraints (infectious, climatic, economic...) are now going to be reproduced at increasingly high frequencies. The rearmament of our primary predators (viruses, bacteria, parasites and fungi) and the increase in their capacity to resist our entire therapeutic arsenal show that the balance achieved in our favour was only transitory and precarious. The balance now has every chance of returning to their advantage.
Jean-François ToussaintProfessor of Physiology, University of Paris. Director of IRMES, with Quentin de Larochelambert and Andy MarcResearchers at the IRMES.
1- The median at death, between 82 and 84 years of age, is similar in most developed countries.
2- Olshansky SJ, et al. Estimating the upper limits to human longevity. Science 1990; 250: 634-64
3- https://www.springermedizin.de/covid-19/epidemiologie-und-hygiene/die-erkenntnisse-aus-der-coronavirus-studie-in-heinsberg/17890088This figure is bound to increase as the actual number of people infected becomes more and more significant.
4- Covid-19 is China's Chernobyl moment. Unherd, 20/5/20
5- On April 25, Jerome Salomon, DGS, brought the great historical pandemics and Covid-19, which "...is the first of its kind in the world. can be compared to the plague pandemic of 1347 or the Spanish influenza pandemic in 1917 ». The plague of 1347 claimed the lives of a third of the European population. On a global scale in 2020, a comparable pandemic would have wiped out 2.5 billion human beings. It will cause 4,000 times fewer. Why is the Director-General for Health making this comparison? Does he wish to enlighten or obscure the debate?
6- Since February, there has been the traditional race for records in newspapers and news channels to find out who will announce the greatest number of deaths in China, Iran, Italy, Spain, New York and then Brazil.
7- Ideology and TerrorHannah Arendt, 1953
8- « So far there is no indication that this virus will reappear over the winter... "according to Maria Van Kerkhove, WHO, Health Emergencies Programme Leader, Press Conference of 25 May 2020
9- According to sources: 12490 new cases for the CSSE of Johns Hopkins University and 7578 for Santé Publique France on March 31, 2020.
10- "Are We Reaching the Limits of Homo sapiens? "by Adrien Marck et al. https://www.frontiersin.org/articles/10.3389/fphys.2017.00812/full