“No population in the world stands to attention like that in 2-3 days”

Confronted with a "totally unprecedented biological, social and political event", Jean-Hervé Bradol spoke with Mediapart about the difficulties of basing all prevention on behavioural measures: "It takes time for a society to fully acknowledge the existence of the event, which is unfolding as it tries to understand it.”

We hear a lot about a state of war, the war against the virus, and finally war zone medicine. Is it the same thing to fight an epidemic?

The common point between war zone medicine and epidemic medicine is that both of them belong to the field of catastrophe medicine: when there is a large number of sick or injured people, for the same reason, in a short time. That is what an epidemic is, with a greater or lesser number of cases. Whether they are sick, war-wounded or accident victims, it doesn't make much difference.

The particularity of an epidemic, its dilemma, is that the first thing to think about is protecting the staff; otherwise the health care system collapses. During the Ebola epidemic in West Africa, it was measured that health workers were 40 times more likely to be infected than the general population.

Afterwards, the number of new cases must be reduced, either by vaccination when it is possible, or by behavioural means, hoping but not knowing for sure, that it will work. 

Then, patients must be treated to avoid deaths. 

Have MSF already started intervening against the coronavirus? 

We have teams in Lombardy, around the city of Lodi. We are pondering on France. Could we open hospitalisation sites, to help the French hospital sector? The Mulhouse area is particularly worrying; if this situation were to become widespread, continuity of care would be difficult to ensure, whatever pathologies, coronavirus or other. This would lead to a disaster. 

And anywhere else in the world? 

We are in discussions with the Iranian and Nigerian authorities. But we can't send any more staff, all the borders are closing, so all the teams are being told to look at what they can do on the ground. We can no longer work in a conventional way by sending our teams.

What explains the differences between continents, or large areas of the world? Is it a difference in time, or in detection and care capacities? 

Both. The epidemic first spread to areas with the greatest contact with the region of origin. In Russia, we assume it's incubating because there's no reason why it shouldn't be. It makes sense that the tropical areas are being delayed. 
But the epidemiological realities are very difficult to know at first hand. Live epidemiology is a very, very difficult sport. Epidemiologists are asked to predict the future, but no one is able to predict the future. You can predict a few weeks into the future, no more. So we set limits.

The worst estimate takes us very far, but we know that measures to take distance between individuals have an impact. The number of people who have been in contact with the virus and have been immunised is also increasing every day. What we don't know is whether the virus will keep the same virulence, how it will mutate. Regarding these three main parameters, there is a lot of uncertainty, we have to fly without instruments. 

Flying without instruments is precisely what the government is accused of…. 

If we’re realistic, and a little honest, no one has the gospel truth about a totally unprecedented biological, social and political event. We find out about the event at the same time that we try to respond to it. While we barely have enough to protect the medical staff, at this stage, the absolute priority is to drastically increase the capacity for care, to do everything possible to keep treating the sick.  

We saw on Sunday, especially in Paris, that social distancing was difficult to implement. 

We are in a fairly classic situation, with a great deal of concern, a strong political mobilisation, but no bio-medical resources, no treatment, no vaccines. The whole burden relies on behavioural measures, to try to control the epidemic, using statistical models, by disrupting daily life.

But no population in the world stands to attention like that in 2-3 days. There has been a lot of fantasising about China, but we don't know exactly how the measures that were taken applied in reality. We realise that it is difficult to change all aspects of daily life in only a few days. 

The attitude of Parisians is rather typical, the whole of society cannot bend to such orthodoxy. What happened does not surprise me at all, it is classic of these situations where we expect everything from behavioural change because we have nothing else.

In Great Britain, people's behaviour is called upon in the opposite direction, it is a behavioural injunction of a slightly different nature from that of France, but a behavioural injunction nonetheless.

Maintaining municipal elections did not help this prevention through behaviour. 

It is a paradoxical injunction. The state, like families, makes compromises. Should we bring in a babysitter to look after the kids? You are told not to bring a new person into the home; and everyone adapts, as does society as a whole, to integrate the recommendations into daily life. All this is done in a few days, so the realisation is limited and the impact just as much.

We often talk about the Ebola experience, less about HIV. Has the memory of AIDS faded in our western societies? What can it bring? 

The memory of HIV has not been forgotten, but today it kills someone without treatment in ten years...

Throughout the early 1980s, there were very aggressive attitudes of denial, sometimes nationalistic, a bit like Trump did when he said that the danger came from abroad. Aggressive nationalists are less audible today because the need for close national cooperation has become obvious.

This denial was undermined when the hospitals became overcrowded. It was then that society had to change its attitude, as two thirds of patients on tropical medicine wards were HIV patients.

This is the strength of public health and collective security issues: when they are no longer insured, health policies regain their power, in both democratic and authoritarian societies. It had already been a lesson in 2003; the WHO wanted to teach China a lesson, and China made amends and agreed to change.

Would authoritarian societies be better armed?

Spectators are very impressed by authoritarian regimes and by their ability to translate behavioural directives into action. But under undemocratic regimes, health events are hidden, there is a denial about the onset of epidemics that develop and an abnormally long reaction time. This is the case with cholera; very few countries accepted to admit that a cholera epidemic has started. So one shouldn’t be captivated by authoritarian regimes, where epidemics are often not recognized in time. 

I remember a press conference in Ethiopia in 2004, where the Minister of Health said that the malaria epidemic did not exist, that we were charlatans.

Do behavioural measures, confinement, restrictions on movement, threaten our freedoms?

The question has been taken from the wrong angle, it is a nonsense to oppose public liberties and health security. To talk about what is going well, let's take the example of public authorities' information policy. It is indispensable. Every evening, the director of health, Jérôme Salomon, goes out of his way to explain it, and the epidemiologist Arnaud Fontanet, director of the epidemiology unit for emerging diseases at the Pasteur Institute and professor at the CNAM, has done a vast amount of work to explain as well. 

In order to do this, you need freedom of speech, and you need to be perceived as acting in good faith. That is why their words carry weight, why they are credible. They would not be trusted in an authoritarian regime.

Is this what happened in China, that we did not want to believe them? Is that a reason why they were slow off the mark?

I don't know whether we didn't believe the Chinese. But it takes time for a society to fully acknowledge the existence of the event, an event that is unfolding as it tries to understand it; society cannot be completely apace with live events; the social, the political, these lag behind real time. Societies need a period of adjustment compared to biological time. We are always lagging behind but we try to ensure that the gap does not keep growing wider.