The coronavirus crisis raises questions...

The coronavirus crisis is asking us questions. Are we ready to hear the answers?

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Across Europe, the weekend of 14 March will mark a turning point in the approach to the coronavirus crisis. States of alert, population confinement, bans on going out, social distancing measures are being announced one after the other. Europe closes shop and Schengen collapses: Germany restores its borders with France. The countries barricade themselves. At the same time, the figures for the epidemic climbed and began to rise exponentially. The daily Le Monde reveals a study by a British epidemiologist predicting between 300,000 and 500,000 deaths in France alone. These are certainly the most pessimistic hypotheses, but even if these figures were to be divided by 10 or even 20, it would still be a lot. This unprecedented crisis is coming down like a stroke of fate and requires exceptional measures; it also raises questions whose answers are not all good to hear.

The coronavirus pandemic poses challenges to governments, public health authorities, medical personnel and the public, each and every one of us. Challenges in the form of immediate ethical issues. Are we willing to give up our freedoms to contain the pandemic? Will we agree to ration limited medical resources that could save lives? Will we sacrifice the usual safety rules to speed up the implementation of treatments and vaccines? Will we be docile to social distancing injunctions imposed by health authorities and governments?

So many questions-which are far from exhaustive-which arise when the majority of us were not ready to hear them. Will we nevertheless be able to answer them? And will we learn from them once this crisis is over?

Are we willing to give up our freedoms to contain the pandemic?

The coronavirus pandemic is having a major impact on how we view the balance between our essential freedoms and the need to limit them. Democratic Western peoples, including the French who are pioneers, have a precious commodity: freedom. Freedom to come and go, to choose how to live one's life, to decide whether or not to undergo medical treatment... When television and social networks broadcast the first images of the deserted Chinese city of Wuhan, transformed into a ghost town, we received them as exotic oddities. Only a regime like Beijing's is able to lock up its population without riots or rebellion.

This Sunday, March 15, new images were broadcast on social networks: those of the deserted city of Madrid, the terraces of its famous ramblas empty of any human being. It was not China but Spain. This weekend, the French Prime Minister announced the closure of all restaurants, bars, cafés, theatres, cinemas... Paris and all the French communes were going to be deserted as spring is just around the corner and everyone is longing to share the carefree happiness of lounging on a bistro terrace.

For the first time, we are undergoing a measure that suddenly affects one of our fundamental freedoms. And there is no revolution in the streets. Almost everyone submits to the measure, understanding it as an imperative of general interest.

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Citizens of Europe in general, and of France in particular, are under house arrest. The government invites them not to go out anymore, to work at home if possible, to keep their children at home as schools are closed. These measures are having a serious impact on our way of life, our freedom to work, to educate ourselves and to meet each other. Measures whose economic impact is immeasurable and affects everyone.

Today, these measures in France are not yet coercive in nature. The military does not patrol the streets and there is no provision for fines or imprisonment if they are not complied with. Yet that is what happens elsewhere, including China, where offenders are taken away manu militari and put at great risk.

If citizens do not comply with government orders, the epidemic will inevitably continue its course and the government will be forced to implement more restrictive measures. To what extent will we be prepared to accept home quarantine or isolation in a medical facility? Are we going to allow the authorities to enter our homes to arrest and take away those infected? Will we support mandatory and total containment for two to three months?

The health emergency will take us to an unknown world where our freedoms will be compromised. When the crisis is over, will we easily return to the world before? Won't the exceptional measures be at least partly absorbed by daily life and permanently installed?

Will we agree to ration limited medical resources that could save lives?

The great danger of the coronavirus epidemic is not so much the virus itself as the capacity of hospitals to absorb the sick. COVID-19 is in 80 % cases a relatively benign disease. For a portion of the population, however, it can be a major concern and can lead to heavy and lengthy resuscitation care. putting great strain on hospital capacity.

The question will therefore arise fairly quickly as to how best to allocate scarce resources, such as medicines, access to intensive care treatment, personal protective equipment, personnel and research funding.

As the number of cases increases around the world, the number of critically ill patients will quickly outstrip available facilities, forcing us to make difficult choices.

We will have to decide who is being treated or who has access to rare drugs or technologies, how and to whom health professionals and emergency services will be deployed, and how food, protective clothing, masks, and alcohol-based gels will be rationed.

The tragic question of "triage" of patients in disaster situations will inevitably arise. How will doctors distribute chances of survival? According to age, state of morbidity, wealth, origin? What will be the relevant criteria, when the usual medical criteria will no longer suffice?

Will we agree to sacrifice safety rules to speed up the implementation of treatments and vaccines?

In the urgency of the health crisis we are going through, how can we develop new medicines quickly and safely? The question that arises is how to strike a careful balance between the unknown risks associated with the development of a vaccine or other drugs and the need for a rapid enough response to limit the spread of the virus. Part of this challenge is to ensure sufficient oversight of clinical trials while we also accelerate the development of new therapies.

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We will have to decide whether it is appropriate to accept higher levels of risk to research participants and patients when the stakes are higher. It has taken many years to put in place an elaborate framework to ensure that clinical research is conducted ethically. However, under the pressure of today's urgency, will we need to find ways to reduce bureaucracy and red tape, speed up decision-making and make the system more responsive?

Will we be docile to social distancing injunctions imposed by health authorities and governments?

The first countries affected by the coronavirus, such as China, South Korea, a few Asian countries and then Italy, quickly chose a drastic defence strategy to stop the spread of the epidemic: completely embolizing the economic activity of their countries. Quarantine, containment and prohibition measures were brutal, but the health of the population took precedence over the laws of economics.

Other countries such as Germany, the United Kingdom and France adopted a different approach at the beginning of the spread of the epidemic in their territories. Their strategy consists in slowing down the course of the virus, its spread from person to person, by encouraging the adoption of "barrier gestures" and "social distancing" behaviours. The idea is to flatten the epidemic's propagation curve to reduce it to proportions compatible with the hospital capacities of the countries.

This strategy is based on a premise: appropriate behaviour of populations, with each individual becoming an agent for reducing the epidemic if he or she adopts the right attitudes. In doing so, the strategy avoids measures that are too painful for the economy by allowing activities deemed "essential" to continue. Ultimately, the epidemic would be contained by depleting the virus by no longer finding hosts benevolent enough to receive it. This strategy is based on a rational approach to crisis management, which strikes a delicate balance between the health of the population and the continuity of the economy.

We must hope that this strategy succeeds, but it is based on questionable assumptions. Can we count on the goodwill of the entire population of a country to adopt the behaviours advised by the medical authorities? Nothing is less certain. There are still many French people who, in spite of the bans issued by the government, have continued to gather together, to walk in the sun, and cheerfully free themselves from any measure of caution. An unbearable lightness in the face of risks, or a brave spirit in the face of fate, comparable to that which some adopted in the face of terrorism. But the virus is not a terrorist and has no use for heroic postures.

Could the containment measures be sustained over the long term? Epidemic specialists predict that containment should last two to three months. This is a long period that will take place at the dawn of spring, and will make confinement difficult to bear. Containment measures inevitably have an impact on people's economic activity. Their tolerance will then largely depend on the effectiveness of the accompanying measures taken by the government.

The third issue in this "controlled pandemic" strategy is the ability of hospital systems to cushion the impact of the epidemic. In this respect, the European countries already affected have very unequal resources. Germany is the best off with 29.2 intensive care beds per 100 000 inhabitants compared to 11.6 beds in France and 6.6 beds in Great Britain.

The foreseeable figures of the epidemic announce 60 to 70 % of the population of a country like France or Germany which would be contaminated by the coronavirus. The proportion of patients in respiratory distress and in need of intensive care is already far beyond the resources available.

The chosen controlled pandemic strategy therefore accepts that a very large part of a country's population is infected with the virus and that several tens of thousands of people will die from the disease. On the other hand, if this expression is tolerable in this case, it avoids a lock down of the country's activity, i.e. it reduces the economic damage while waiting for the end of the epidemic or the development of an effective vaccine or treatment. A strategy in the form of a gamble or a race between the spread of the virus and the means to contain it.

This strategic choice involves questions that will inevitably arise among the populations concerned. Is it legitimate to accept that millions of people are infected by the virus while waiting for a possible "collective immunity"? Will we accept that the weakest members of the population (the elderly or vulnerable) be sacrificed as a kind of tribute to the virus? Will the choice to preserve the economy ultimately be accepted by the population when the time comes for a morbid reckoning? Italian journalist Giuliano da Empoli reminds that " Even China, which is not known for its humanist values, has not dared to bring economism to such a point: the colossal Chinese machine has chosen to slow down, almost to a halt, for several months, rather than inflict a pandemic on its population. "

All these issues add to the pressure from scientists on the government, urging it to implement total containment measures as quickly as possible. Despite all the questions this choice raises.

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