BULLETIN of the NETHERLANDS SOCIETY for TROPICAL MEDICINE and INTERNATIONAL HEALTH

N O 0 2 / a u g u s t 2 0 2 0 - v o l u m e 5 8

COVID-19 EDITORIAL

COVID-19: CONTENT CONTRADICTIONS, EDITORIAL - 2 CONFUSION, AND

REVIEW COMPLEXITY Management of Covid-19 - 4 It is mid-July 2020. Some A novel virus, a recurring countries are experiencing threat: looking at past the peak of the Covid-19 pandemic threats to understand ­pandemic, while ­others have how SARS-CoV-2 has evaded loosened their lockdown global control efforts - 7 With pleasure we ­measures, anticipating a continued slowdown of In the shadow of the announce our renewed the epidemic. Meanwhile coronavirus: a global rise media pages: scientists around the of infectious diseases due world are working on the to Covid-19 containment linkedin.com/company/mtbulletin development of an effective measures - 13 vaccine. facebook.com/BulletinoftheNVTG PERSONAL REFLECTIONS FROM CONTRADICTIONS THE FIELD - 9 In Japan, the management of a sea Covid-19 in context - 9 aquarium invites visitors to video chat How Ebola prepared us to fight with their 300 sea eels and wave at them Covid-19 in the DRC - 9 Corona free country? - 10 as they showed signs of stress because The heritage of a highly lethal virus of the absence of the public in the outbreak - 11 past months. Hundreds of thousands Suddenly working in the intensive care of mainly female garment workers unit - 12 YOUare invited to visit these in Bangladesh ignore the nationwide INTERVIEW lockdown in order to earn back some of Moria, 20,000 refugees waiting pages for additional the income loss they experienced over for a disaster to happen - 15 articles, blogs, and other the past months. More than 49 million posts on topical issues in women are lacking contraceptives, a OPINION global health and tropical situation which according to the WHO Covid-19 and the Trojan horse is likely to result in a baby boom. Donald that eroded the World Health medicine. Also, on these Trump asks scientists to research the Organization - 17 pages you can access effect of injecting disinfects into a per- previous editions of MTb son in order to fight the virus. While the Pooling of knowledge, and International Health Italian government still provided food know-how and intellectual rations for the needy, shrewd business- property to counteract vaccine Alerts. men developed protective plastic shields nationalism - 22 for the sunbeds – in anticipation of the tourists that would come as soon as RESEARCH lockdown restrictions in Italy were to Outbreak of Covid-19 like be released. State prisons in California illness in a remote village in are releasing 3,500 inmates to protect Papua, Indonesia - 19 them from potential exposure to the virus as a result of the conditions in BOOK REVIEW the prisons. Research from Stanford Epidemics and pandemics - 21 University shows that, in a country were some 1.6 million people die each year A constant state of emergency: of respiratory diseases, the improved Paul de Kruif, microbe hunter air quality has saved the lives of more and health activist - 23 than 1,400 children under age 5, and 51,700 adults above 70 years of age. Meanwhile the virus has spread to 188 countries, with more than 13,876,441

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confirmed cases of Covid-19 (7.3 million of the USA the situation is spinning in the Americas), including 593,087 out of control, and African countries deaths reported to the WHO.[1,2] are experiencing an early state of the epidemic. Europe seems to be some- CONFUSION where in between.[6] It feels like we are at In the absence of a vaccine we have wit- a crossroads, and much will depend on nessed a wave of containment measures, the choices that we the public, our gov- roughly ranging from total lockdown ernments, and world leaders are mak- to the so-called intelligent lockdown ing - choices that will have an impact (relying on the idea of group or herd on societies at large, impacting on all immunity and a sense of responsibility aspects of life. The Covid-19 crisis is on the part of the population) intro- testing our capa­city to deal with the soci- duced in the Netherlands. The Dutch etal consequences of pandemics and to were accused of lacking solidarity with balance economic interests without los- neighbouring countries’ approaches - an ing sight of the (health) risks involved. interesting observation, given the overall lack of solidarity and coordination at With this edition of MTb, we intend to European (and global) levels.[3] With challenge these three Cs in a construc- this approach, the Dutch government tive manner with articles shedding wanted to ‘cushion the social, economic light on the clinical management of and psychological costs of social isola- the disease, Covid-19 against a his- tion and make the eventual return to torical perspective of epidemics, field normality more manageable’.[4] And experiences in LMICs, the effect of while social distancing in high-income the pandemic on the refugee crisis countries may have saved lives, the in Greece, the role of the WHO, and question is at what cost? Low-income efforts to counteract vaccine national- countries are anticipating counterpro- isms. We look forward to your reflec- ductive effects, including a potential tions and invite you to react using rise in other (infectious) diseases and one of our (social) media channels. rising morbidity and mortality figures caused by other diseases, as well as a Esther Jurgens, Ed Zijlstra devastating effect on fragile economies and informal sector workers. Adding to the confusion are the many variations in tracking and reporting approaches and misleading or missing data. Reflecting REFERENCES on the past months challenges us to 1. World Health Organization [Internet]. Geneva: World Health Organization. WHO coronavirus decide on a “new” normal. Can we disease (COVID-19): dashboard; [updated 2020 push a “reset” button, thereby building Jul 21]. Available from: https://covid19.who.int 2. Contradictions collated in the magazine 360 (2020 on some of the (positive) lessons – for Jul 9-Aug 20;183), based on experiences from correspondents of the Swiss magazine Reportagen. example working from home and reduc- 3. Deen B, Kruijver, K. Coronavirus: EU’s existential ing our ecological footprint by (r)evolu- crisis: why the lack of solidarity threatens not only the Union’s health and economy, but also [5] tionizing international conferences. it’s security [Internet]. The Hague: Clingendael Institute; 2020 Apr. 5 p. Available from: https:// www.clingendael.org/sites/default/files/2020-04/ COMPLEXITY Alert_Corona_Existential_Crisis_April_2020.pdf 4. Holligan A. Coronavirus: why Dutch lockdown Currently it still feels like a global Catch- may be a high-risk strategy. BBC News [Internet]. 2020 Apr 5. Available from: https://www. 22. Without a concrete prospect of a vac- bbc.com/news/world-europe-52135814 cine or treatment, the virus will hold the 5. Bousema T, Yakar D, et al. Opinie: wetenschappers, het is niet van deze tijd de wereld over te vliegen voor ieder world in its grip for months and possibly congres. De Volkskrant [Internet]. 2020 Jul 1. Available from: https://www.volkskrant.nl/columns-opinie/ years to come. While some countries opinie-wetenschappers-het-is-niet-van-deze-tijd-de- seem to have succeeded in containing wereld-over-te-vliegen-voor-ieder-congres~b4ed69ab/? referer=https%3A%2F%2Fwww.radboudumc.nl%2F Covid-19 (China, Taiwan, Vietnam), 6. The new normal: Covid-19 is here to stay: the world is working out how to live with it. The Economist others are experiencing a peak in infec- [Internet]. 2020 Jul 4. Available from: https://www. tions (countries in Latin America and economist.com/international/2020/07/04/covid-19-is- here-to-stay-the-world-is-working-out-how-to-live-with-it South Asia). Meanwhile, in some part

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Management of Covid-19

The Covid-19 (corona virus di­ ­sease, SARS-CoV-1. The virus enters the body RISK FACTORS AND DIAGNOSIS detected in 2019) pandemic is through person-to-person airborne Risk factors for a severe course of the keeping a firm grip on the world transmission. There is no proven animal disease are co-morbidities such as and affects the health of those reservoir; in the Netherlands, the infec- chronic heart disease, diabetes mellitus, ill with Covid-19 as well as those tion was detected in mink farms but was underlying respiratory conditions such with other illnesses; it overbur- thought to originate from humans. The as COPD and asthma, malignancy and dens health services and causes virus is spread in crowded conditions obesity. In addition, the risk for severe delays in diagnosis and treatment and mass gatherings: the celebration of disease increases with advanced age of other conditions. While there is carnival (province of North Brabant, the >60 years. In contrast, young children universal fear of infection, this is Netherlands), winter ski holidays (North are usually asymptomatic. The diag- especially evident among service Italy, Austria) and (international) foot- nosis is made by demonstrating the providers and people accessing ball matches like the Champions League virus via PCR in a nasal and/or throat health facilities. Population-based match between Atalanta Bergamo vs swab. Serological tests for IgM and IgG screening programmes to detect Valencia on February 19 with 40,000 antibodies are currently continually breast, cervix and colon cancer have Italian and Spanish supporters (with being improved in terms of sensitivity been suspended; the waiting lists subsequent outbreaks in Italy and and specificity; these tests only indi- for elective surgical procedures are Spain) are thought to have contribu­ cate past exposure and are not suitable becoming longer. In addition to the ted to major outbreaks in Europe. yet for confirmation of the diagnosis impact on health, severe damage to in someone who is sympto­matic. the economy is caused by lockdown The clinical picture is dominated by Currently, in populations in Europe measures affecting small and big respiratory symptoms, with fever, not more than 5% of people tested have businesses. Especially in low- and shortness of breath, and cough. Fatigue antibodies showing previous infec- middle-income countries, lock- is common and other non-respiratory tion (asymptomatic or symptomatic); down and social distancing affect symptoms include confusion and diar- it is not clear whether these antibodies the informal sector and thereby rhoea. Most infections are only mildly are fully protective and for how long. people’s livelihoods, resulting in symptomatic and self-cure within food shortages and malnutri- days or weeks. Other patients require INTERVENTIONS tion. Control efforts for various hospitalization and develop pneumonia Currently there is no treatment with tropical diseases and vaccination with so-called ground glass opacities proven efficacy. A multitude of observa- programmes have been suspended. on a CT scan; oxygen administra- tional and randomised controlled trials The overall morbidity and mortality tion is needed and other supportive (RCTs) are ongoing, that initially mainly caused by the pandemic is therefore care, including admission to intensive focused on drugs that had been studied not restricted to Covid-19. There is care units with intubation and artifi- for SARS, MERS (Middle East respira- no specific treatment for Covid-19 cial ventilation, often because of the tory syndrome) or Ebola disease, but infection, and the pandemic has adult respiratory disease syndrome that unfortunately were not develop­ed sparked a flurry of research projects (ARDS). Severe pneumonia and death further when these outbreaks lost their that focus on inhibiting the replica- occur in 4-5% of admitted patients in epidemiological importance. Some tion of the virus, on its effects on a setting with optimal care (Lancet, drugs are still experimental and have the human respiratory system and Covid-19 clinical research coalition, 25 not been used or studied in humans, other organs, and on the immune April 2020). While in hospital, sud- and therefore existing drugs (for what- response triggered by Covid-19. den deterioration may occur caused ever indication) that can be re-purposed by thromboembolism in the major for Covid-19, are clearly preferred. While In this paper, current insight into lung vessels and the brain, with poor most studies focus on mitigation of the management of Covid-19 infec- outcome. Viral sepsis has been sug- Covid-19 disease, other efforts focus tion as well as the main features of gested among explanations causing on prophylaxis. The early drugs that ongoing drug studies are discussed. damage to blood vessels; other organs are considered for potential benefit in Lastly, issues in publication inclu­ may be affected as the virus spreads to Covid-19 are included in the Solidarity ding peer review are discussed. other parts of the body. An overreaction trial of the World Health Organization of the immune system may occur with (WHO) in patients hospitalized for CLINICAL SYNDROME cytokine release storm (CSR) which confirmed Covid-19. It has four arms: Covid-19 infection is caused by the may also contribute to organ damage. • HIV protease inhibitors: SARS-CoV-2 virus; the name refers to All this may contribute to development lopinavir/ritonavir the severe acute respiratory syndrome of acute renal failure, viral myocardi- • antimalarials: hydroxychlo- caused by a similar corona virus, tis, multi-organ failure and death. roquine and chloroquine

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PHOTO: MOHSEN NABIL / SHUTTERSTOCK.COM

• antiviral (RNA polymerase inhibitor): remdesivir • immunomodulatory agent: lopi- navir/ritonavir with interferon 1a

Other early major studies include the RECOVERY trial (randomised evalua- tion of Covid-19 therapy) in the United Kingdom in hospitalised patients, primarily studying the effect of hydroxy- chloroquine, lopinavir/ritonavir, azithro- mycin, dexamethasone vs no additional treatment. Patients are further random- ized to receive tocilizumab (an interleu- kin-6 blocker) and convalescent plasma.

ANTIMALARIAL DRUGS Recently published preliminary data on antimalarials are not encourag- ing. Hydroxy-chloroquine and chloro- quine were among the first candidate drugs suggested. The effect of these anti­malarials is thought to be a pH- mediated at the level of virus entry in the cell as well as disruption of viral replication.[1] A combination therapy with azithromycin was suggested to have a beneficial effect.[2] This publica- tion was recently criticised and could not stand up to scrutiny. There is increasing evidence that these drugs are of no clini- cal benefit and severe cardiotoxicity has been reported, which seems aggravated by co-administration of azithromy- Lopinavir/ritonavir, an antiretroviral there is concern of prolonged viral cin.[3] Prophylactic use of hydroxy­ drug used in HIV/AIDS has so far shedding and secondary infections.[9,10] chloroquine after high-risk or moderate failed to show a clinical benefit in early The timing of such intervention in the risk post exposure to Covid-19 did not reports. In hospitalized adults with course of the disease may be crucial. prevent illness in a recent study.[4] severe Covid-19 infection, no clini- cal benefit was found.[6] Combination The excessive immune response in ANTIVIRAL DRUGS treatment with interferon and ribavirin the cytokine release is characterized Remdesivir is an antiviral drug (RNA showed better alleviation of clinical by high levels of cytokines such as polymerase inhibitor) that inhibits symptoms as well as shortening of dura- interleukin (IL)-6. Tocilizumab is an SARS-CoV-2 (that causes Covid-19), tion to negative nasal swab and hospital IL-6 blocker that is used for example as well as SARS-CoV-1 (that causes stay in mild to moderate Covid-19.[7] in rheumatoid arthritis; a small study SARS) and MERS-CoV (that causes RCTs on other antiviral drugs against in 22 patients recently published MERS) in animal models. In a recently SARS-CoV-2, including favipiravir are showed remarkable clinical improve- published RCT, there was no clinical ongoing as there are mixed reports ment in Covid-19, and RCTs are eagerly benefit although early treatment might about their in vitro and in vivo efficacy.[8] being awaited.[11] Similarly, the effect shorten time to clinical improvement.[5] of inhibition of IL-1 is being studied. There is no evidence yet that remdesivir IMMUNE MODULATION is beneficial in severe Covid-19 infec- This is also a subject of study; the Other immune therapies include tion in a patient on the intensive care. evidence on the use of corticosteroids the use of immunoglobulins and The drug was recently registered by the is controversial. While the immuno- re-convalescent plasma of patients European Medicines Agency (EMA). suppressive effect may be beneficial, who have recovered from Covid-19.

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ALTERNATIVE DRUGS PUBLICATION STRESS REFERENCES

Ivermectin and nitazoxanide have Every week a plethora of reports are 1. Sturrock BR, Chevassut TJ. Chloroquine and COVID- 19: a potential game changer? Clin Med (Lond). shown anti-SARS-CoV-2 activity published in scientific journals includ- 2020 Apr 17;20(3):278-81. Online ahead of print in vitro and are licensed for other ing the authoritative The Lancet and 2. Gautret P, Lagier JC, Parola P, et al. Clinical and microbiological effect of a combination of conditions, and thus they can be the New England Journal of Medicine hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: studied directly in Covid-19. (NEJM). While publication, often after A pilot observational study. Travel Med Infectious expedited peer-review, of any useful Dis. 2020 Mar-Apr;34:101663. Epub 2020 Apr 11 3. Juurlink DN. Safety considerations with chloroquine, Latest reports: in a webinar on 30 June result in Covid-19 is clearly impor- hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection. CMAJ. 2020, the RECOVERY trial showed tant, mistakes have been made. Both 2020 Apr 27;192(17):E450-E3. Epub 2020 Apr 8 unpublished data indicating that in The Lancet and NEJM have retracted 4. Boulware DR, Pullen MF, Bangdiwala AS, et al. A randomized trial of hydroxychloroquine as admitted patients who are on oxygen or papers that were criticized for meth- postexposure prophylaxis for Covid-19. N Engl J Med. 2020 Jun 3;NEJMoa2016638. Online ahead of print ventilation, mortality was reduced by 1/5 odological flaws or poor quality of 5. Wang Y, Zhang D, Du G, et al. Remdesivir in adults and 1/3, respectively, after administra- data after publication.[12-16] The above with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. 2020 tion of low dose (6 mg) dexamethasone mentioned work on hydroxychloro- May 16;395(10236):1569-78. Epub 2020 Apr 29 6. Cao B, Zhang D, Wang C. A trial of lopinavir- for 10 days. In similar patients, hydroxy- quine by the French virologist Didier ritonavir in Covid-19: reply. N Engl J Med. 2020 chloroquine or lopinavir/ritonavir did Raoult, who is held in high esteem in May 21;382(21):e68. Epub 2020 May 5 7. Hung IF, Lung KC, Tso EY, et al. Triple combination not show an effect on mortality. It France, particularly in his hometown of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted should be noted that the latter two drugs Marseille, was criticised as many of to hospital with COVID-19: an open-label, were studied for their antiviral effect, his publications appeared in journals randomised, phase 2 trial. Lancet. 2020 May 30;395(10238):1695-704. Epub 2020 May 10 whereas dexamethasone in general in which he or his co-workers were 8. Coomes EA, Haghbayan H. Favipiravir, an antiviral for COVID-19? J Antimicrob Chemother. influences inflammatory damage to among the members of the editorial 2020 Jul 1;75(7):2013-4. Epub 2020 May 18 the lungs and is already used in severe board. (The Economist, June 13th, 2020; 9. So C, Ro S, Murakami M, et al. High-dose, short-term corticosteroids for ARDS caused by th ARDS caused by other conditions. NRC Handelsblad, June 13 , 2020). COVID-19: a case series. Respirol Case Rep. 2020 Jun 4;8(6):e00596. Epub 2020 Jun 10 10. Fadel R, Morrison AR, Vahia A, et al. Early CONTROVERSY CONCLUSION short course corticosteroids in hospitalized patients with COVID-19. Clin Infect Dis. 2020 The SARS-CoV-2 virus uses receptors Covid-19 causes severe and fatal disease, May 19;ciaa601. Online ahead of print 11. Xu X, Han M, Li T, et al. Effective treatment of severe to bind to a respiratory cell before being be it in a minority of cases. Currently COVID-19 patients with tocilizumab. Proc Natl Acad Sci able to enter the cell and replicate. The there is no drug treatment that has been U S A. 2020 May 19;117(20):10970-5. Epub 2020 Apr 29 12. Mehra MR, Desai SS, Kuy S, et al. Cardiovascular angiotensin-converting enzyme (ACE) proved effective and safe, in prophylaxis disease, drug therapy, and mortality in Covid-19. N Engl J Med. 2020 Jun 18;382(25):e102. Epub 2020 May 1 2 receptor is among these. Patients with or in mitigation of clinical disease. 13. Mehra MR, Desai SS, Kuy S, et al. Retraction: high blood pressure have higher levels Management is therefore largely sup- cardiovascular disease, drug therapy, and mortality in Covid-19. N Engl J Med. 2020 Jun 25;382(26):2582. of these receptors and treatment for portive with intervention by administra- DOI: 10.1056/NEJMoa2007621. Epub 2020 Jun 4 14. Rubin EJ. Expression of concern: Mehra MR et al. hypertension with an ACE inhibitor or tion of potentially effective drugs based Cardiovascular disease, drug therapy, and mortality angiotensin receptor blocker (ARB) such on clinical experience and evolving in Covid-19. N Engl J Med. 2020 Jun 18;382(25):2464. DOI: 10.1056/NEJMoa2007621. Epub 2020 Jun 2 as losartan may increase expression of evidence in the scientific literature. 15. Solomon MD, McNulty EJ, Rana JS, et al. The Covid-19 pandemic and the incidence of the receptor. It has therefore been specu- acute myocardial infarction. N Engl J Med. lated that these patients are at increased Note of the author: every week new 2020 May 19. Online ahead of print 16. Mehra MR, Desai SS, Ruschitzka F, et al. RETRACTED: risk of severe Covid-19. However, there studies are published that change hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a is also the possibility that losartan treat- insight on the management of Covid- multinational registry analysis. Lancet. 2020 May ment may be beneficial by blocking the 19; this paper summarized informa- 22;S0140-6736(20)31180-6. Online ahead of print binding of the virus. Currently, there tion available up to 30 June 2020. is no conclusive evidence and patients on losartan treatment are advised not to discontinue their treatment. Ed Zijlstra Internist, Specialist in Infectious Disease and Tropical Medicine, Rotterdam Centre for Tropical Medicine, the Netherlands [email protected]

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A novel virus, a recurring threat: looking at past pandemic threats to understand how SARS-CoV-2 has evaded global control efforts

Shortly after the New Year, the TRANSMISSIBILITY of SARS-CoV-2 is estimated to be only reporting of emerging clusters It was late in the year when health care slightly higher than that of SARS (3-5.3 of pneumonia from an unknown practitioners in Southern China first and 2-5, respectively), SARS-CoV-2, pathogen in Wuhan, China, began encountered cases of a mysterious possesses numerous qualities that to draw the attention of infectious viral illness that manifested as severe make it not only more transmissible, disease experts and public health pneumonia leading to acute respira- but more able to evade the surveillance officials globally. In spite of Chinese tory distress. With variant strains of measures that had been able to stop control efforts, including what up avian flu starting to become a seasonal SARS.[2] The period of infectious­ness until that point was the largest norm, Chinese public health officials in SARS-CoV-2, for example, not only population lockdown in human did not at first sound any global alarm begins before the onset of symptoms, history, it did not take long for the bells. After spreading to Beijing and but in many cases peaks days before localized viral infection to disperse then Hong Kong, it boarded planes most people even know they are sick. itself ubiquitously throughout bound for other continents and began [3] This makes mitigating the spread of much of the world. As of the end of to make its way across land. Almost the virus much more challenging than June, SARS-CoV-2, the once novel simultaneously, three separate labs in SARS, which during its 2003 out­break coronavirus, has claimed nearly half Hong Kong, Germany, and the United was transmitted primarily when patients a million lives and affected roughly States of America, finally identified the were severely ill and clearly symptom- 213 countries and territories. pathogen causing this fatal pneumo- atic. Furthermore, there were only a SARS-CoV-2 is categorized as an nia as a novel coronavirus. The Global few known documented asymptomatic emerging infectious disease, defined Outbreak Alert and Response Network SARS cases, which differs vastly from by the World Health Organiza- was activated, and the WHO provided a SARS-CoV-2, where asymptomatic cases tion (WHO) as any disease that has rapid and measured response helping to are suspected to climb into the millions ‘appeared in a population for the advise every affected nation. By July, the globally. Epidemiologist are still seeking first time, or that may have existed virus was controlled. But this was 2003, to understand the capacity for asymp- previously but is rapidly increasing and the novel coronavirus was SARS. tomatic cases to spread the virus, but in incidence or geographic range.’[1] like all unknown elements, it presents Emerging infectious diseases are The international community learned further challenges in creating control primarily zoonotic, meaning they numerous lessons from SARS, namely strategies and finding methods to estab- are transmitted to humans from about the importance of having strong lish normalcy in a world with Covid-19. animal hosts, and have been the disease surveillance and centralized Additionally, other elements such as culprits of most pandemic threats health systems. The outbreak led to longer relative incubation periods for in the past decades, like SARS-CoV many countries boosting their infec- SARS-CoV-2 (most likely 3-10 days, but (SARS), Ebola, Swine influenza and tious disease control capacities, which potentially as long as 14) may have facili- Zika. With emerging infectious included the creation of the Center tated its spread during the initial out- diseases now making an appearance for Infectious Disease Control here break, allowing people to carry the virus on the global stage every few years, in the Netherlands, the resources far from disease epicenters under the it is vital to look at the specific of which have been integral to help- assumption that they had not contracted characteristics of SARS-CoV-2 and ing the control efforts for combat- the virus since they were not yet sick.[2] the coronavirus disease (Covid-19) ting the current outbreak nationally. that have allowed the virus to Global detection systems, however, PATHOGENICITY evade global control efforts and had evidently not prepared enough Ten years after the last cases of SARS pose such a grave threat to society. for handling the very different trans- were treated, a much more virulent Comparing SARS-CoV-2 to disease mission dynamics of the SARS coro- threat began lurking in the jungle of agents that have caused former navirus successor, SARS-CoV-2. Southern Guinea. By the summer of pandemics and global health crises 2014, the Ebola virus disease (EVD), helps to contextualize the threat of The basic reproductive number, or R0, never before seen in Western Africa the current viral outbreak, and also refers to the average number of cases or able to reach an urban area, had illuminates how response efforts generated by an infectious person, and infiltrated the capital cities of Guinea, have been shaped in the wake of is considered an important indicator Sierra Leone and Liberia. For two chaos international disease threats. of transmissibility. Although the R0 driven years, the worst Ebola outbreak in

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history rocked Western Africa, sending that Zika virus had hit its herd immu- bodies issued public health warnings ripples of fear that the epidemic would nity threshold (HIT).[8] Herd immunity centered around three components: try spread globally.[4] EVD is infamous for occurs when a certain percentage of to stay inside, socially distance yourself its devastating hemorrhagic symptoms the population becomes immune to from others whenever possible, and if and high pathogenicity, with case fatal- a disease, either through contracting you must leave your house wear a mask. ity rates (CFRs) from previous outbreaks the illness or from getting vaccinated. If it is disheartening to see how little being as high as 90%. The CFR for the The herd immunity required to reduce has changed in our individual capac- 2014-2016 West Africa Ebola outbreak transmission to below epidemic levels ity to control the spread of a pandemic was 40%, making early estimates of varies for every disease, but is in theory virus, perhaps there is solace in the SARS-CoV-2 appear relatively low at easier to achieve in diseases like Zika understanding that remarkable advances 2.3%.[2] With SARS-CoV-2, however, that are limited to specific geographic have been made in surveillance, the virus’s capacity to transmit so boundaries or demographic factors, diagnostics, and vaccine production, efficiently, ability to evade control, and in this case to areas in which the Zika largely informed by previous epidem- prevalence worldwide in addition to its transmitting mosquito was endemic. ics of emerging infectious diseases. pathogenicity is what makes it so lethal. Learning from the disease specific To understand the true pathogenic- SARS-CoV-2, conversely, is ubiquitous elements that made SARS-CoV-2 so ity of SARS-CoV-2, one can compare and not limited by any geographic area, uncontainable will help shape cur- its CFR to another virus that trans- gender, race, or for the most part, age, rent control efforts and inform future mits globally, the seasonal influenza. although it has shown significantly outbreaks. Every large-scale epidemic Seasonal influenza, with a CFR of under higher associations of severe disease should come with numerous lessons not 0.1%, is over twenty times less likely and mortality with older age groups. only for containment, but for prepared- to cause death than SARS-CoV-2,[5] The herd immunity needed for reduced ness, as the arrival of a new pandemic which would seemingly discredit the transmission of SARS-CoV-2 to below threat is merely just a matter of time. minority of people who have claimed epidemic levels is estimated to be that Covid-19 is just ‘another flu’. somewhere between 50% and 75% of the population.[9] These estimates take Jake Mathewson, MSc The Ebola outbreak being primarily many characteristics of the pathogen Infectious Disease Consultant, the contained to three countries in West into account. There are very few, if Netherlands Africa does not mean that it was not any, health care systems in the world [email protected] a global threat. Partly due to very late capable of handling the volume of intervention from the WHO – for which Covid-19 patients if a country were to they have been vehemently criticized attempt to reach herd immunity as a REFERENCES

– the virus became unmanageable in control measure. Even if that weren’t the 1. LeDuc, JW, Barry, MA. SARS, the first pandemic of the 21st Century [Internet]. Emerg Infect Dis. 2004 West Africa and made appearances case, some would suggest that allow- Nov;10(11),e26. DOI: 10.3201/eid1011.040797_02 in seven other countries.[4] Following ing for 75% of the population to get 2. Chen J. Pathogenicity and transmissibility of 2019-nCoV: a quick overview and comparison with the outbreak, the global health com- infected with a disease that has such other emerging viruses. Microbes Infect. 2020 Mar;22(2):69-71. DOI:10.1016/j.micinf.2020.01.004 munity demanded that the WHO a high case fatality rate (CFR) would 3. He X, Lau EHY, Wu P, et al. Temporal dynamics improve responsiveness to emerg- result in an unconscionable amount in viral shedding and transmissibility of COVID- 19. Nat Med. 2020 May;25(5):672-675. Epub 2020 [6] ing infectious diseases. In 2019, of deaths. Perhaps most significantly, Apr 15. DOI: 10.1038/s41591-020-0869-5 4. Centers for Disease Control and Prevention [Internet]. perhaps with the understanding that herd immunity is dependent on the 2014-2016 Ebola outbreak in West Africa; [reviewed the next emerging infectious disease population becoming immune. As we 2019 Mar 8]. Available from: https://www.cdc.gov/ vhf/ebola/history/2014-2016-outbreak/index.html outbreak was merely a matter of time, still have no conclusive evidence that 5. Russell TW, Hellewell J, Jarvis CI, et al. Estimating the infection and case fatality ratio for coronavirus the WHO did make major adjustments Covid-19 infection grants lifelong or disease (COVID-19) using age-adjusted data from the to help them focus on preparedness even long-term immunity, reaching herd outbreak on the Diamond Princess cruise ship, February 2020. Euro Surveill. 2020 Mar;25(12):2000256. and improve emergency response - a immunity and ultimately controlling DOI:10.2807/1560-7917.ES.2020.25.12.2000256 6. World Health Organization [Internet]. Q&A: influenza component that would become useful SARS-CoV-2 will most likely be contin- and COVID-19: similarities and differences; 2020 just months after its implementation.[7] gent on the development of a vaccine. Mar 17. Available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/ question-and-answers-hub/q-a-detail/q-a-similarities- and-differences-covid-19-and-influenza? EPIDEMIOLOGY CONCLUSION 7. World Health Organization Regional Office for As Ebola terrorized West Africa, a mos- The characteristics that make SARS- South-East Asia. Five-year regional strategic plan to strengthen public health preparedness and response quito-borne pathogen called Zika virus CoV-2 so transmissible, pathogenic, [Internet]. India: World Health Organization, 2019- 2023; 2019. 35. Available from: https://apps.who.int/ was making its way through much of and widespread have presented extreme iris/bitstream/handle/10665/326856/9789290227236- Brazil and spreading throughout South challenges to disease control special- eng.pdf?sequence=1&isAllowed=y 8. Netto EM, Moreira Soto A, Pedroso C, et al. High Zika and Central America. While Zika virus- ists, as well as to a considerable percent virus seroprevalence in Salvador, Northeastern Brazil limits the potential for further outbreaks. mBio. 2017 associated birth defects rose at incred- of the global population in some form Nov 14;8(6)e01390-17. DOI: 10.1128/mBio.01390-17 ible rates, the disease strangely began to or another. During the 1918 Spanish 9. Britton T, Ball F, Trapman P. A mathematical model reveals the influence of population recede within a couple of years of its ini- influenza pandemic that killed between heterogeneity on herd immunity to SARS-CoV-2. Science. 2020 Jun 23;eabc6810. DOI: 10.1126/ tial emergence. Epidemiologists suspect 20 and 40 million people, governing science.abc6810. Online ahead of print

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few cases of Covid-19 in our region, we Covid-19 in context How Ebola prepared us to compiled small information sheets in fight Covid-19 in the DRC French and Congolese Swahili about The end of my work in a symptoms, prevention and the most hospital in rural Congo- It was in October 2019 that I received important dos and don’ts. When bring- Brazzaville coincided with my first patient infected with Ebola. ing this to chiefs, government officials, the worldwide Covid-19 There is a first time for everything, church leaders and anyone interested, outbreak. It was painful but some things can better be avoided. I found myself directly amidst good to leave, knowing that the Within a few days, I found myself alone conversations, clarifying many things pandemic would also hit in our house: my wife and our three about Covid-19. Outbreaks often Congo-Brazzaville in the children were temporarily elsewhere, as negatively impact continuity of care for very near future. Luckily, violence against Ebola response teams other conditions, such as malaria and my fellow doctors and put the whole village in turmoil. Our obstetric complications in affected areas, I had recently prepared 55-bed mission hospital in the Northeast because of closure of health facilities, for a possible spread of of the DRC became almost empty with lack of staff or fear among patients to Ebola virus disease, and no outpatients anymore. Now, eight contract the disease in the facilities. we had stockpiled a months later, we have no more [3] That is what we saw with the Ebola big container with Ebola in our area and I gladly cases in our hospital, and that is what I personal protective use the experience that I also feared when Covid-19 would hit us. equipment acquired and apply it to But luckily, with all Covid-19 measures just before the Covid-19 outbreak that in place now (borders, schools and global demands is threatening us now. churches closed, and meetings >20 skyrocketed. When people forbidden), hospital visits did not I left, the hospital In reality, every epidemic decline and villagers accepted the com- staff was worried has its own characteristics, bined Ebola/Covid-19 triage at the gate that I would contract and I have learned to see differ- knowing that it would help everyone. Covid-19 in Europe, as ences and similarities. The mortality the number of new cases of Covid-19 in the DRC (2.2%) is much I have yet to see the first Covid-19 case was rising quickly. It felt lower than for Ebola virus disease (EVD) in our hospital. We feel at least a bit like the world upside during the epidemic in the area served prepared with a triage and a small down, and leaving amidst by our hospital (66%).[1] Contact tracing isolation unit, but we know that there all this was difficult as it and isolation of suspect cases, however, are many things we cannot control. gave me a sense of letting seems much easier for EVD than for The Ebola epidemic brought us teams them down. Many of Covid-19, since EVD hardly occurs with- of experts in 4x4s and NGOs with my fellow global health out any symptoms. Vaccines are crucial water, sanitation and hygiene (WASH)- doctors had to adapt to in fighting against an outbreak, and projects. Covid-19 brought us a pro- the pandemic. Everybody the EVD vaccine possibly saved my life. vincial response protocol and many was eager to connect Some epidemics gain more attention restrictions, but the government’s main professionally, share than others. For instance, few people focus has been on the highly urbanized resources, ask questions know that the DRC had almost 370,000 area of Kinshasa, the country’s capital and discuss evidence, but measles cases and 6,779 deaths by mea- thousands of kilometres away, where there are personal stories sles in just the year 2019.[1] However, cases augment rapidly. Our provincial as well. Here, we share when I asked the Ebola surveillance health authorities designated hospitals four experiences of global team that was visiting our hospital without even an oxygen concentrator health doctors around the on a daily basis in their 4x4s whether world during the Covid-19 they had seen the measles-epidemic- outbreak in the spring of Landcruisers, they grinned sheepishly. 2020. There are also many similarities. In an outbreak it is crucial to inform all relevant parties and get them on board. If you forget to respect a village chief in Remco van Egmond, MD the Congolese culture you will struggle Global Health and Tropical Medicine, to get anything done. Community previous affiliation: Clinique Médicale resistance had massively hindered a CIB, Pokola, Congo-Brazzaville thorough uptake of EVD cases, contact [email protected] tracing and clinical management in our area.[2] So, when we saw the first

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as Covid-19 treatment centres. Not a persisted for a week. Early March, the single hospital in our area can provide Corona free country? first Covid-19 cases were reported. But advanced respiratory support. We feel that was in Jakarta, not on our island, blessed with two oxygen concentrators ‘My little son has a fever and we will be far away to the east of Java. Strangely powered by our hospital generator, but travelling tomorrow, what shall we do?’ enough, our expat medical team got we are certainly highly underequipped January, 2020, a colleague was return- more and more questions about people compared to high- or middle-income ing from abroad to Papua, Indonesia. who were coughing with fever and settings. Unfortunately, most WHO Something was going on in China, and shortness of breath. Really healthy and NGO experts have left the region. airport authorities in Thailand started people suddenly got sick - sicker than doing prior temperature checks on trav- they ever had been before. An interior Our area continues to be plagued ellers as part of boarding procedures. village reported that all of the villagers by insecurity, and outbreaks add Wasn’t this just a kind of flu, not became ill after they had received to these difficulties. I am learning too severe? ‘Don’t worry, just visitors from Jakarta, and two resilience from my colleagues, some give him some paracetamol people died. In the meantime, of whom have fled war zones or have so that you can pass that messages from all over the been kidnapped or lost relatives and temperature check. They are world came in, from Italy, have learned to rebuild their lives just a little nervous there.’ Iran, and the Netherlands. after the loss of all their possessions. There were not so many Our hope and our prayer is that this A month later this “mild flu” cases in the United States of Covid-19 epidemic will make us apparently was something more America (USA) yet. It was inter- stronger, as the Ebola epidemic did. serious. More and more deaths were esting to see how we as expats reacted reported and suddenly two brand new differently to this illness in Papua. I hospitals were built in China. Indonesia heard messages about the rapid spread- Mark F.P. Godeschalk, MD has quite strong ties with China, includ- ing of Covid-19 in the Netherlands and Global Health and Tropical Medicine ing daily flights to Wuhan, so I expected elsewhere in Europe and was advising (AIGT), Lolwa Referral Hospital, Democratic to hear very soon about cases of this people who had travelled, especially Republic of the Congo. new illness. All countries in Southeast expats, to go into quarantine so they [email protected] Asia reported rapidly rising numbers, would not spread the virus to vulner- [email protected] but not Indonesia. Instead, the govern- able people. American doctors and nurses were more laid-back. In the USA www.gzb.nl/ZorginCongo ment invested millions of dollars to advertise Indonesia as a corona-free it was not a big deal, so why would it country: ‘Come for holidays to Bali!’ be a problem in Indonesia? But it did REFERENCES become a big deal. New cases and deaths

1. World Health Organization. Weekly bulletin on Late February, one of my patients was rose steeply. Jakarta and other parts of outbreaks and other emergencies [Internet]. Brazzaville: WHO Regional Office for Africa; 2020 May 31 (22): 19 evacuated from Papua to Jakarta for Indonesia went into local self-imposed p. Available from: https://apps.who.int/iris/bitstream/ surgery. He was admitted to one of the lockdowns, also in Papua. As a family handle/10665/332246/OEW22-2531052020.pdf 2. Nguyen VK. An epidemic of suspicion: Ebola and best hospitals in Indonesia, which was we had to travel to renew our visa; these violence in the DRC [Internet]. N Engl J Med. 2019 Apr;380:1298–9. DOI: 10.1056/NEJMp1902682 apparently filled with dengue patients. plans, however, got thwarted as other 3. McQuilkin PA, Udhayashankar K, Niescierenko M, et He got a mattress on the floor. The countries closed their borders. After a al. Health-care access during the Ebola virus epidemic in Liberia. Am J Trop Med Hyg. 2017 Sep;97(3):931–6 strange thing was that these patients quick Jakarta-Kuala Lumpur-Jakarta were coughing persistently; some looked trip, we got stuck in Jakarta without a really sick and disappeared secretly work permit and our kids had fever and during the night. He got his surgery and a cough. After six years in Indonesia finally a normal bed on a surgical ward. we were suddenly forced to go back to After a few days, he developed fever and the Netherlands. What we can still do is started having a sore throat and a dry give advice and moral support to friends cough. What to do? I advised him to ask and colleagues in interior Papua, and for a Covid test. His doctor was startled: send them patterns for batik-masks, ‘We don’t have that illness in Indonesia, templates to 3D print face shields, and you didn’t come from abroad. and money to make that possible. EBOLA Furthermore, your blood tests and X-ray IS MORE were totally fine on admission. No need to test. Your wound might be infected, Wijnanda van Burg-Verhage, MD OF AN OPEN so I will start antibiotics.’ The only Global Health and Tropical Medicine, WOUND thing I could do was to strongly advise Stichting Lentera, Wamena, Papua, self-quarantine after he got back in our Indonesia THAN A SCAR little Papuan town. The wounds looked [email protected] perfectly clean and healing, but the fever

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Admissions The heritage of a highly lethal virus outbreak 1st confirmed I sneezed. Wrong timing. My caretaker Covid-19 in SL flinched. ‘I always get a cold from the air-conditioning on the plane’, I quickly First IPC measures mumbled. I had just arrived in Sierra in SL Leone amidst the exponential rise

SL = Sierra Leone IPC = infection, prevention and control

Figure 1. Bed occupancy Masanga Hospital during the Covid-19 pandemic.

- pharmaceuticals. Food prices increased and medicine stocks slowly ran low as most exporting countries kept sup- plies to themselves. Suddenly some patients had to pay for their medication. Normally in Sierra Leone, health care for children under five years of age and of the pandemic, and any sneezing for pregnant women is provided free white person was treated as a potential of charge, but if drug stock runs dry, biohazard. This country knows how eventually, patients will have to pay. to deal with outbreaks. From the very start, Covid-19 was approached the same Halfway through March, at the general way as Ebola. While wreaking havoc in hospital meeting with all employees Europe and the USA, Covid-19 numbers present, the fear was tangible. Ebola were still low in Africa. However, Sierra is more of an open wound than a scar. Leone had already closed its airspace Everyone knows someone, or knows result. Negatively tested Ebola suspects and borders for non-essential supplies. someone who knows someone who as well as survivors were stigmatised A state of emergency was declared, died of Ebola. It is hard to explain to and sometimes excommunicated. Not schools were closed and a lockdown put people, even the skilled health care a surprise then that Sierra Leoneans in place until further notice. All this, workers, that this virus is less fearsome feared a repetition of this with corona. without a single confirmed case in the than its highly lethal haemorrhagic country. These decisions do not come counterpart from only five years ago. Until now, two-and-a-half months after without consequences. The country Not surprisingly, the utter paralysis the first case got detected, Sierra Leone is largely dependent on imports of of the developed world and its crash- has not follow the exponential path that vital commodities: food, non-consum- ing economies do not temper the fear. many other countries have, at least if we ables and - not least for the hospital Not only were the personnel scared. go by the official numbers. Although A steep decline in hospital admis- the risk factors are limited with fewer sions followed after downscaling the old people (life expectancy is 54 years), hospital to just emergency operations less obesity, and less smoking, we [Figure 1]. When I asked my landlord didn’t know how HIV and tuberculosis what people’s reasoning could be to patients and malnourished patients stay away from the hospital, she told would be hit. Recently, we had our me that they feared to contract corona first case in the hospital. Because the at the hospital, but more importantly, government still anxiously carries out they feared to be isolated. Logically, extensive contact tracing (even though suspected corona cases are kept in clear community spread is present), isolation until the test results become many mostly asymptomatic staff had to known. The same happened during be quarantined. Hence, the hospital was the Ebola outbreak. Isolation alone had forced to scale down even further as did repercussions, regardless of the test several other health facilities. It goes

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without saying that this has devastating the next day. I saw piles of protection consequences for a country with already Suddenly working in the materials; my colleagues were very dramatically low numbers of health intensive care unit strict with hand-hygiene rules and I was workers. Like in previous disease out- surprised by my mail box which had breaks, the provision of routine health It’s March 2020, and I’m working in a exploded and was filled with regularly care suffers. Many villagers, includ- rural hospital in Ghana, together with updated guidelines on procedures and ing our landlord, turned out to suffer four colleagues from the Netherlands. the implementation of rules and regula- from some sort of ailment. With a dry During our two-week stay, we teach tions. Compared to this, the lack cough, low grade fever, muscle pain and (student) nurses and physician of personal protective equip- anosmia she insisted she had malaria assistants at the neonatal and ment and even hand sanitizer and sought treatment for it. I let her take paediatrics unit, and at the in Ghana was confronting. her own decision. The fear is clearly still same time we learn a lot from present, and I cannot blame her. I am them. While I’m working It’s April 2020, and I start however comforted that the majority of in Ghana, the coronavirus is working at the ICU. The WHO people will recover from this disease spreading throughout the world. director has declared Covid-19 a smoothly. Over here, compared to Ebola, The first patient in the Netherlands pandemic, something I had only read corona is a shark without teeth. The real was detected a week before we left, about in literature and books, or heard dangers are the repercussions of the which made us hesitate whether or not about at conferences and seen in movies. governments’ containment strategy. we should travel to Ghana. We didn’t I felt like I had to help, not only because want to be “patient zero” anywhere, I wanted to, but because it is my duty as especially not in a country with a poor a global health doctor. I started reading Anne van der Breggen, MD health care system. However, at that and learning about Covid-19 and about Global Health and Tropical Medicine, time, a pandemic seemed far away and pandemics, checked the news almost Masanga Hospital, Masanga, Sierra Leone we concluded travelling to Ghana would every hour, talked about nothing else [email protected] not be a big risk. We followed the news but corona, and followed webinars about about the coronavirus spreading Covid-19 on the ICU, for family doctors, in Europe, and I must confess for gynaecologists, from Médecins Sans that we underestimated the Frontières and for the national army. crisis and even thought the At the same time, I prepared myself to drastic measures in Europe work on the ICU, which is something were a bit farfetched. We I had never done before. I knew little had never before stopped about mechanical ventilation, and felt shaking hands to prevent a cold insecure about managing the airway or maybe a severe flu, so why now? in a resuscitation setting. I was work- Was this virus really so harmful? ing hard, studying a lot and sleeping too little. I even dreamt about patients The Ghanaian medical staff appointed lying in prone position, family mem- I FELT LIKE I HAD an outbreak management team, which bers who became ill and people dying. presented guidelines for the hospital. It felt like a roller coaster ride, together TO HELP, NOT ONLY They concluded that the hospital was with other health care workers in the BECAUSE I WANTED TO, not prepared for an outbreak, but on the world. It felt as if we were working in other hand they did not fear a severe one big team. The support of so many BUT BECAUSE outbreak in Ghana, which is generally people was overwhelming for me. IT IS MY DUTY warm and sunny. They used to fear Ebola, and the corona virus seemed It’s May 2020, and I’m driving back AS A GLOBAL to be less pathogenic. In the weekend home after another shift at the ICU. HEALTH DOCTOR of our return home, we finally under- Eric Clapton’s song Tears in heaven stood that this virus was a serious is on the radio, and the tears stream threat. We were worried about our down my face. He sings about hold- flight being cancelled, but everything ing hands, and I wonder when we went well and we arrived home safely. can finally hold hands again.

Home had changed. We had to keep our distance from one another, stop shaking Maud Ariaans hands and stay inside as much as pos- Global Health and Tropical Medicine Doctor sible. I drove to the hospital to see what in training, the Netherlands. was going on, and to explore at what [email protected] kind of hospital I had to start working

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In the shadow of the coronavirus: a global rise of infectious diseases due to Covid-19 containment measures

The global outbreak of SARS-CoV-2 distribution of insecticide-treated-bed some areas reduced willingness to seek has a firm grip on the world. As of nets (ITNs) and indoor residual spraying out health services and contributed mid-June 2020, there have been (IRS) of houses, would put millions of to problems of vaccine hesitancy. 8,700,000 confirmed cases and more additional people at risk. A modelling than 460,000 deaths related to study from Imperial College London More than half of the 129 countries Covid-19. While many high-income presented a few potential outcomes where data is available indicate ­moderate countries have overcome the peak that could occur if the ­distribution of to severe disruptions of child immunisa- of the first wave of infections, the ITNs were to be inhibited by lockdown tion services in March and April of 2020, majority of low- and middle-income measures, the worst of which would according to the WHO.[3] If the current countries (LMICs) are now await- result in an additional 400,000 people trend continues, WHO, UNICEF and ing the complete unfolding of the dying of malaria globally within the Gavi, the Vaccine Alliance estimate that Covid-19 pandemic. next year, roughly doubling what was more than 80 million children under the Meanwhile, global efforts to contain expected in the years prior to Covid.[2] age of 1 could be at risk of contracting the spread of SARS-CoV-2 have in- This model does not take into account diseases such as diphtheria, measles and directly challenged the continuity of disruptions that could occur in access to polio globally.[3] These disruptions could many vital infectious disease control treatment, chemoprophylaxis, or other also severely impact child mortality, as interventions for diseases that pri- forms of prevention, which could further ­demonstrated by a modelling study from marily affect LMICs, such as malaria, precipitate the impact of malaria in the London School of Hygiene & Tropical tuberculosis (TB) and HIV, as well SSA. Sustained interruptions in vector Medicine, which predicts that deaths as numerous vaccine-preventable control interventions could additionally prevented by sustaining routine child- illnesses. Lockdown measures aimed exacerbate the already growing issue hood immunisation in Africa would at mitigating the spread of Covid-19 of insecticide resistance in mosquitos highly outweigh the additional Covid are subsequently restricting the across the region, a problem of immense related deaths attributed to infections mobility of health workers, causing gravity that threatens to reduce the effi- acquired during health care visits.[4] disruptions in supply chains due to cacy of the two most prominent malaria border closures, and inhibiting the control tools available, ITNs and IRS. TUBERCULOSIS AND HIV distribution of life-saving supplies With approximately 1.5 million deaths in and medicine to the community. The VACCINE PREVENTABLE DISEASES 2018, TB kills more people yearly than result is a ballooning crisis lurk- Measures to contain Covid-19 are also any other infectious disease. Successful ing in the shadow of the Covid-19 impacting current vaccination cam- treatment of TB requires rigorous case pandemic, one that will require paigns and routine vaccination programs management and often close clinical significant and timely attention to across both high- and low-income supervision to provide daily doses of prevent parallel epidemics of other countries. The global disruption of therapeutic drugs for around six months, infectious diseases in the months supply chains and travel restrictions both of which may prove difficult to and years to come. have threatened to impede vaccine sup- maintain amidst movement restrictions plies, especially in rural areas in low and overwhelmed health care facilities. MALARIA resource settings.[3] Most mass vaccina- Lockdown measures in high-prevalence Malaria is one of the world’s deadliest tion campaigns have been temporar- countries threaten to interrupt supply diseases, killing over 400,000 people ily suspended in an effort to mitigate chains which would limit the availability yearly, 90% of whom are in Sub-Saharan the spread of SARS-CoV-2. While the of therapeutic drugs to maintain treat- Africa (SSA). The progress that has World Health Organization (WHO) ment. As with vector control in malaria, been made in containing malaria in recommends that routine vaccination sudden cessation and restarting of SSA over the past two decades has should continue under infection control treatment creates a heightened potential been largely contingent on sustaining guidelines, many healthcare workers for drug resistance, which could in the vector control programmes, some of involved in such vaccination efforts future inhibit the last lines of defence which could be threatened by move- have been re-allocated to the Covid-19 against TB. A recent modelling study by ment restrictions and the reallocation response, leaving health care facilities the Stop TB Partnership, in collaboration of resources aimed to slow the spread without sufficient staff to maintain with Imperial College London, predicted of SARS-CoV-2.[1] Sudden lapses in the immunisation services. Compounding that a three-month lockdown could lead vector control program activities, like the these issues, fear of the virus has in to an additional 6.3 million cases in the

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coming five years, causing 1.4 million The WHO has recognized that many REFERENCES [5] more TB related deaths globally. nations, particularly in SSA, have a 1. Shretta R. Safeguarding the malaria endgame in the midst of the COVID-19 pandemic. Centre for ‘window of opportunity’ to expand their Tropical Medicine and Global Health [Internet]. The potential interruption of antiret- disease control efforts while they still 2020 Apr 25 [accessed 2020 Jul 5]. Available from: https://www.tropicalmedicine.ox.ac. roviral therapy (ART) and the realloca- have a relatively low burden of Covid-19. uk/news/safeguarding-the-malaria-endgame- [9] in-the-midst-of-the-covid-19-pandemic tion of facility and community health This could involve large campaigns to 2. Sherrad-Smith E, Hogan AB, Hamlet A, et al. workers are also major threats for the distribute insecticide treated bed nets, Report 18: the potential public health impact of COVID-19 on malaria in Africa. London: Imperial approximately 37.9 million people living increase efforts to stockpile and distrib- College London; 2020. 9 p. Report No.: 18 3. World Health Organization [Internet]. Geneva: World with HIV globally. Modelling of even ute life-saving HIV and TB medication,­ Health Organization. At least 80 million children under minor disruptions of ART drug supplies and ensure that routine vaccinations one at risk of diseases such as diphtheria, measles and polio as COVID-19 disrupts routine vaccination demonstrates the potential for consider- are sustained during ­lockdown as efforts, warn Gavi, WHO and UNICEF. 2020 May 22 [accessed 2020 Jun 20]. Available from: https://www. able increases in HIV-related deaths and an absolute priority. Finding ways to who.int/news-room/detail/22-05-2020-at-least-80- transmission.[6] Both TB and HIV rely safely reintroduce community health million-children-under-one-at-risk-of-diseases-such- as-diphtheria-measles-and-polio-as-covid-19-disrupts- heavily on community access to encour- workers could help to ensure the routine-vaccination-efforts-warn-gavi-who-and-unicef 4. Abbas K, Procter SR, van Zandvoort K, et al. Routine age routine testing, and to initiate and continuity of such programs through- childhood immunisation during COVID-19 pandemic ensure the continuation of life-saving out the duration of the lockdowns. in Africa: a benefit-risk analysis of health benefits of routine childhood immunisation against the excess risk treatment. A lack of access for com- of SARS-CoV-2 infections. Lancet Glob Health. 2020 July 17;S2214-109X(20)30308-9. Online ahead of print munity health workers due to govern- It is essential for the global health com- 5. Stop TB Partnership. The potential impact of the ment-imposed lockdowns will cause munity to also acknowledge another covid-19 response on tuberculosis in high-burden countries: a modelling analysis. [Internet]. 2020 May limitations in condom distribution, peer important window of opportunity, the [accessed 2020 Jun 20]. Available from: http://www. stoptb.org/assets/documents/news/Modeling%20 education and case management that period directly following the lifting Report_1%20May%202020_FINAL.pdf are likely to further contribute to disease of lockdowns. Ensuring the restora- 6. Jewell B, Mudimu E, Stover J, et al. Potential effects of disruption to HIV programmes in sub-Saharan Africa progression and mortality in the future. tion and expansion of program activi- caused by COVID-19: results from multiple models. 2020 May 11. Available from: https://doi.org/10.6084/ ties during this time period may have m9.figshare.12279932.v1. Online ahead of print A NARROW WINDOW OF OPPORTUNITY significant implications for infectious 7. Wehrens E, Bangura JS, Falama AM, et al. Primum non nocere: potential indirect adverse effects of If the goal of SARS-CoV-2 containment disease control in the future. This will COVID-19 containment strategies in the African region. Travel Med Infect Dis. 2020 May-Jun;35:101727. measures is to reduce mortality and pre- involve increased active case finding DOI:10.1016/j.tmaid.2020.101727. Epub ahead of print vent the collapse of health care systems, efforts for TB and HIV, vaccine catch 8. Roberton T, Carter ED, Chou VB, et al. Early estimates of the indirect effects of the COVID-19 it will not be achieved by allowing a up programs, and efforts to improve pandemic on maternal and child mortality in low- income and middle-income countries: a modelling significant resurgence of other infec- and re-establish supply chains. With study. Lancet Glob Health. 2020 Jul;8(7):e901–8 tious diseases that are in some cases no promise of a Covid vaccine, LMICs 9. World Health Organization [Internet]. Geneva: World Health Organization: WHO urges countries to move more deadly than Covid-19. As the first cannot afford to wait to address the quickly to save lives from malaria in sub-Saharan Africa. 2020 Apr 23 [accessed 2020 Jun 20]. Available principle of medicine states do no harm, myriad of infectious diseases that from:https://www.who.int/news-room/detail/23- it is integral to consider the collateral are likely to remain endemic long 04-2020-who-urges-countries-to-move-quickly-to- save-lives-from-malaria-in-sub-saharan-africa damage that may be caused by lockdown after the pandemic subsides. measures in LMICs.[7] In these settings, many of the restrictions in their current form threaten to undermine decades of Victoria von Salmuth, MD, MSc progress in combatting malaria, HIV, Global Health Doctor in training, the TB and vaccine preventable diseases. A Netherlands surge in other infectious diseases on top [email protected] of the Covid-19 crisis may push many of these already fragile health care systems Jake Mathewson, MSc and economies to their breaking point, limiting their ability to deal with other Infectious Disease Consultant, the Netherlands looming crises like the staggering rise in malnutrition and mass migration.[8] [email protected]

PHOTO: FIVEPOINTSIX / SHUTTERSTOCK.COM

14 MT BULLETIN OF NVTG 2020 AUGUST 02 INTERVIEW

Moria, 20,000 refugees waiting for a disaster to happen

PHOTOS: TESSA KRAAN

Interview with Steven van de Vijver, We interviewed Steven van de general practitioner and volun- Vijver, a general practitioner in teer for Stichting Bootvluchteling Amsterdam with prior experience (Boat Refugee Foundation) as a tropical doctor, who went to camp Moria in March this year to Moria, a former military site on work as a volunteer for the Dutch the Greek island of Lesbos, is seen Stichting Bootvluchteling. Together as an entrance gate to Europe for with gynaecologist Sanne van der many refugees. In theory, Moria is Kooij he initiated #SOSMoria: an equipped to house a maximum of urgent appeal to all the leaders of 3,100 refugees, but in March this the European Union (EU) to take year the camp was packed with refugees into their countries, in more than 20,000 people in one order to tackle the already existent km2.[1] About 40% of the residents humanitarian crisis and prevent a of the camp are under eighteen and medical catastrophe. many suffer from serious illnesses, injuries or mental problems.[2-4] In CAMP MORIA IN TIMES OF addition to living with ten persons THE CORONA CRISIS in one tent or box, the refugees also According to Van de Vijver, the situa- have to queue for consultations at tion in Moria is extremely problematic: the clinic, to receive food, and for ‘When I came to Moria last year, I was administrative matters.[3] Due to already shocked by the living conditions these cramped living conditions, within this camp on European terri- social distancing is an illusion. tory. But this year, it was even worse. Furthermore, with lack of water, The number of refugees in Moria has sanitation, and electricity, the camp increased from 6,000 in February 2019 is a ticking time bomb for a cata- to 22,000 at the beginning of this year. strophic spread of the coronavirus.[5] Some refugees have been living in the Since the 17th of March, lockdown camp for a year instead of a few months, measures have been taken in the which is the period aimed for by the worse than the conditions that led the camp. This means that from 7 a.m. authorities. Some people have to wait people to seek refuge in the first place.’ to 7 p.m. only, limited movement in line for hours to receive their food.’ within the camp is allowed, there Situated on the edge of the EU, Greece According to Van de Vijver, refugees are police checkpoints, and only a has been functioning as the gateway to describe the camp as hell, having regrets maximum of 100 persons a day are other European countries. But in real- of getting there. He is worried about the permitted to leave the camp. Other ity the refugees get stuck there as the dilemmas doctors find themselves in, than this, no visitors are allowed transfer to other countries has halted. as they may feel that they are violating into the camp, and activities like Hippocrates oath because the circum- schooling and sports have been ‘Due to the high number of refugees stances in the camps have a severe discontinued.[3] in the camp, it is impossible to treat damaging effect on refugees’ health. By mid-June 2020, Greece had over all diseases and injuries. Time and To support this last statement, Van 3,000 confirmed cases of Covid-19 resources in the medical units are de Vijver mentioned that a part of the with almost 200 deaths.[6] On Les- limited, and the lockdown has even mental traumas among the refugees, bos four asylum seekers had been aggravated this. Medical aid has to such as hopelessness, are caused by confirmed positive for Covid-19.[3] be focused on life-threatening cases, aggression, fires and rape within the Fortunately, so far, there have not which means that we can’t even provide camp itself, and are not traumas that been any positive cases inside the refugees suffering from diseases like the refugees brought from their home Moria camp.[3] But one could imag- scabies with the proper treatment. countries. The same holds for all sorts ine the disastrous prospect after a Moreover, there are many injuries of infectious diseases such as scabies. first positive case, as it might rap- and infections as a consequence of idly cause a high number of cases the conditions in the camp itself. The The corona crisis added an additional requiring hospitalization. circumstances in the camp are often strain on the mental health of the

AUGUST 02 2020 MT BULLETIN OF NVTG 15 INTERVIEW

refugees, explains Van de Vijver. ‘To all refugees. Via the SOSMoria call, some extent, the people are more Stichting Bootvluchteling joined forces Daily Krijnen anxious now than before the corona with other organisations to evacuate at MSc student Selective Utrecht Medical threat. When a total lockdown in least 500 children to other European Master, Utrecht University, Utrecht, the the camp was enacted, the refu- countries (#500kinderen).[7] These Netherlands gees felt as if they were trapped.’ children arrived in Moria without their [email protected] parents or any guardian, traumatised, THE SHAPE OF OUTBREAK some suicidal, and they often resort Gerine Nijman PREVENTION IN A REFUGEE CAMP to auto-mutilation. Many countries in MSc student Biomedical Sciences and Refugees in the camp are informed Europe have already welcomed some of Research Intern, Radboudumc, Nijmegen, about the importance of basic infection these children, but the Netherlands is the Netherlands prevention measures such as washing not one of them. In the Netherlands, a [email protected] hands, coughing in elbows, and main- lot of municipalities (150) and churches taining distance. However, all these are enthusiastic and willing to welcome things are very hard to put into practice these children, but the governing parties Olga Knaven, MD in camps such as Moria. People have in The Hague are not heeding the call. Global Health and International Medicine in to wait in line for half an hour to wash They seem to be afraid to lose voters and training, the Netherlands their hands, and maintaining distance is instead of welcoming these children in [email protected] even more unfeasible in a place crowded the Netherlands, Ankie Broekers-Knol, with 20,000 people. Upscaling of test- the Dutch State Secretary for Justice and Read more on the appeal, and the ing, as suggested by previously pub- Security, drafted a proposal to spend support from European doctors and lished articles, faces some obstacles as four million dollars to relocate refugees citizens on the initiative website: https:// testing of all refugees is difficult to put on the island. However, the proposal www.sosmoria.eu/?lang=en in practice and could cause further panic was criticized by both Dutch and Greek and chaos. ‘Stichting Bootvluchteling, parties for being a naive and useless together with Kitrinos [Greek NGO plan that would not solve anything. REFERENCES that provides medical care] and Doctors 1. Chapman A. A doctor’s story: inside the ‘living hell’ of Moria refugee camp. The Guardian. 2020 Feb Without Borders have materials and COVID-19 COMPOUNDING THE PLEA FOR 9 [accessed 2020 Jun 7]. Available from: https:// plans to treat Covid-19 cases, but there SOLIDARITY AND IMMEDIATE ACTION www.theguardian.com/world/2020/feb/09/ moria-refugee-camp-doctors-story-lesbos-greece is very limited capacity in the nearby ‘I guess you could say that Covid is some 2. Nutting T. Headaches in Moria: a reflection on mental healthcare in the refugee camp hospital. In case of an outbreak in the kind of catalyst in the Moria refugee population of Lesbos. BJPsych Int. 2019 camp, provision of ventilatory support crisis. The situation before the outbreak Nov;16(4):96-8. DOI:10.1192/bji.2019.2 3. Sherally J. The corona pandemic: How to is essential, but the nearest hospital has was already completely inhumane, and prevent a medical disaster? Lecture presented at; 2020 Apr 20; Utrecht University only six ICU [intensive care unit] beds, I wanted to do something about that. 4. Iacobucci G. Covid-19: doctors warn of which is not even close to what would be I had hoped that in this time of fast humanitarian catastrophe at Europe’s largest refugee camp. BMJ, 2020 Mar 17;368:m1097. necessary.’ According to Van de Vijver, decisions, the Dutch government would 5. Greek Reporter [Internet]. MSF Says Greece’s Moria Migrant Camp is a Coronavirus “Time Bomb”; 2020 Apr the focus should be on the problem decide to welcome these refugees from 3 [accessed 2020 Jun 7]. Available from: https://greece. itself rather than finding temporary Moria too. I had hoped for solidarity and greekreporter.com/2020/04/03/msf-says-greeces- moria-migrant-camp-is-a-coronavirus-time-bomb/ solutions for Moria: ‘In my opinion, that people would act faster. I am disap- 6. Worldometer [Internet]. Greece; [updated 2020 Jul 15; accessed 2020 Jun 7]. Available from: https://www. the main goal should not be to upgrade pointed with the lack of political action worldometers.info/coronavirus/country/greece/ Moria with ICU beds and other fancy on a national level, even though munici- 7. #500kinderen [Internet]; [accessed 2020 Jul 7]. Available from: https://www.500kinderen.nl/petitie-griekenland measures. The goal should be for Moria palities are very willing to contribute.’ to disappear. There should not be any camp in the first place.’ However, there As Van de Vijver stated clearly, Moria is is disagreement between the NGOs that a ticking time bomb in terms of a Covid- provide support and local, Greek and 19 outbreak, but also for many other other European politicians about which problems. The lives of many refugees policy would be best: whether to focus are at stake and it is time to act now. on direct measures on site or evacua- tion of the refugees to other countries.

THE EFFECTS OF THE SOSMORIA DISTRESS CALL THE MAIN GOAL SHOULD NOT BE TO PIMP MORIA Approximately 7,000 doctors and more than 50,000 other emergency workers WITH ICU BEDS AND OTHER FANCY MEASURES. have joined the call. According to Van de THE GOAL SHOULD BE FOR MORIA TO DISAPPEAR. Vijver, the only solution for the prob- lematic situation in Moria is to evacuate THERE SHOULDN’T BE A CAMP IN THE FIRST PLACE

16 MT BULLETIN OF NVTG 2020 AUGUST 02 OPINION

Covid-19 and the Trojan horse that eroded the World Health Organization

The Covid-19 pandemic has created which impacted mainly countries (WTO), for example, uses international havoc around the world since the in West Africa (2014-2015), as well dispute settlement mechanisms and early days of 2020. My attendance as other emerging zoonoses such a sanction regime when international at a civil society meeting in Geneva as avian flu, Zika, and Lassa fever. trade rules are violated. It has become coincided with the World Health These epidemics all raised global clear that WHO’s IHR provides only Organization (WHO) declaring the concern (some more than others), limited resources, ­mandate, and legiti- Covid-19 epidemic a public health and inspired global health actors macy to direct sovereign countries in emergency of international concern and national government leaders to addressing their approaches to disease (PHEIC).[1,2] Mike Ryan, director of underscore the need to strengthen outbreaks and other public health WHO Health Emergencies Pro- global health security. Sadly, few risks. Interestingly though, a hundred gramme was worried, yet still opti- countries really acted upon their years before WHO’s establishment,­ mistic, estimating that the epidemic initial commitments and failed to countries already tried to regulate could be contained at the regional invest in an essential public health international public health responses. level in Asia. I shared the same function that others have labelled a [9] In the words of leading global health sentiment and travelled on after the global public good.[5] lawyers: ‘The IHR is no “magic bullet” meeting to Indonesia without real for global health problems. Previous concerns. I returned to the Neth- INTERNATIONAL HEALTH REGULATIONS transformations in international law’s erlands just before the epidemic Following the 2003 SARS epidemic, the relationship with public health have over escalated and international borders World Health Assembly (WHA) adopted time atrophied into insignificance.’[7] were closed. a revised version of the international June 2020, we are six months into health regulations (IHR), which since POLITICAL TENSIONS BETWEEN THE the pandemic and over 9 million their adoption in 1969 had served as the UNITED STATES OF AMERICA AND CHINA confirmed cases of Covid-19 have main framework governing the interna- The recent critique by the Trump now been reported to the WHO, tional response and a country’s capacity administration that WHO has an ­including more than 470,000 to deal with public health emergencies, ‘alarming lack of independence from deaths. [3] Questions have been including major infectious disease out- the People’s Republic of China’ in raised about the role and capacity breaks.[6,7] Under the IHR, and upon dec- addressing the Covid-19 pandemic is of the WHO and other international laration of a PHEIC, the WHO has the unfounded.[10] Donald Trump’s deci- actors in assisting countries to power to provide countries with tempo- sion to sever ties with the WHO and prepare for and respond to a viral rary, non-mandatory recommendations his threat to halt funding must be seen pandemic of this magnitude. Ac- on how to deal with the emergency at as part of a larger geopolitical conflict cording to Dr Tedros, WHO’s director hand. Countries are not legally obliged between the USA and China. A kind of general, the main reason for declar- to adopt such recommendations, such Cold War 2.0 meant to divert atten- ing this PHEIC was ‘not because of as in this case testing for Covid-19 virus, tion from the disastrous response and what is happening in China, but be- tracking possible cases, and identifying poor performance of the USA’s health cause of what is happening in other risk-groups. However, the IHR obliges system itself.[11] China has made errors countries. Our greatest concern is countries not to implement policies that in dealing with Covid-19, especially the potential for the virus to spread would prevent international trade and in terms of transparency at the begin- to countries with weaker health mobility. For example, WHO member ning of the epidemic. Human rights systems, and which are ill-prepared states cannot suddenly make medical violations have been an issue in the to deal with it.’[1] examinations, vaccinations or prophy- stringent lockdown and surveillance by The WHO was prepared, in the laxis compulsory for travellers in case the Chinese state.[12] Nevertheless, the sense that it was well aware of the they are potentially infectious. This did rapid public health response by China, emergence of another “Disease- not prevent Austria and other European and Southeast Asia more generally, X” – a yet unknown pathogen states from requesting foreign travellers has so far proven effective in contain- causing a human disease which to their countries to provide a certificate ing the virus. This has been noted by eventually would lead to a seri- of a negative Covid-19 test result. These other low- and middle-income coun- ous epidemic.[4] The world had actions clearly constituted a breach of tries (LMICs) and by the WHO. In the witnessed such epidemics before, the IHR,[8] but they could not be fol- report by a WHO evaluation mission like the SARS epidemic in 2003, lowed by any sanctions. Other multilat- to China in February, Dr Tedros hailed which remained largely contained eral organisations perform better in this the country’s swift response and to China, the ­Ebola-epidemic sense. The World Trade Organization approach.[13] For diplomatic and global

AUGUST 02 2020 MT BULLETIN OF NVTG 17 OPINION

health objectives, it is important that witnessed a surge of global health initia- not a luxury item; it’s the cornerstone the WHO keeps working closely with tives for disease-specific approaches, of security, stability and prosperity.’[19] the world’s most populous country (1.4 such as the Global Fund to Fight AIDS, billion inhabitants). At the same time, Tuberculosis and Malaria (GFATM), Germany has announced it will make there are informal complaints regarding Gavi, the Vaccine Alliance, the Global an unprecedented € 500 million pledge controlled and restricted access to China Health Security Agenda (GHSA), and to the WHO. This must be seen as a for the WHO officials. Meanwhile, others. They generally deliver short term plug for the large funding gap left by China has committed to stepping up results, over which the donor countries the withdrawal of the USA.[20] It can multilateral collaboration, pledging US$ have more direct control. In the process, also be seen as a geopolitical signal to 2 billion to the United Nations (UN) for the WHO has become hamstrung by the world. Germany prefers in these its Covid-19 response, and it has agreed its donors, limited in its autonomy, uncertain times to invest in health to a full evaluation of the international and become relatively neglected in a security (WHO) rather than military response once the pandemic is over.[14] neoliberal era in which policy objec- security (NATO). So far, the Dutch In any case, this is a watershed moment tives such as “value for money” and government has committed US$ 6.5 in global health, not only for the WHO. “enlightened self-interest” received million to the WHO for the Covid-19 In the coming years we are likely to see priority over the provision of global response.[21] At the same time, it is the USA retreating from international public goods, such as the international providing its national airline, KLM, with health cooperation in LMICs while capacity to respond to pandemics. a € 3.6 billion (!) guarantee to secure China may considerably step up its bilat- This trend is also described as “Trojan its position in international trade and eral health collaboration with African, multilateralism” and has seriously mobility. Will the Netherlands eventu- Asian and Latin American countries.[15] eroded the UN over the last decade.[16] ally realize that this interconnectedness relies on the peace, wellbeing and health THE EROSION OF THE WHO SOLIDARITY AND SHARED of societies in other parts of the world? Ironically, the USA, along with some RESPONSIBILITIES Isn’t it time to put aside such a frugal affluent European countries are respon- The World Health Report 2007 on attitude and instead invest seriously in sible for WHO’s limited capacity to deal health security stated that ‘57 countries, global public health? That would be the with transnational health emergen- most of them in Sub-Saharan Africa and real call, in the current era of pandemic cies. The roots of this problem lie in Southeast Asia, are struggling to provide threats, climate emergency, economic the governance structure, in which the even basic health security to their popu- instability and growing disparities. WHA, composed of all 190+ member lations.’[17] In response to the 2014-2015 states, decides collectively on WHO’s Ebola epidemic, there has been much programme of work. In the 1980s, high- talk about the need to develop strong Remco van de Pas, MD income countries, in response to the and resilient health systems. No less Global Health Policy, Institute of Tropical growing influence of LMICs, decided than four international commissions Medical, Antwerp, Belgium, and Clingendael to review their financial contributions have provided recommendations on how Institute, The Hague, the Netherlands to the UN and the WHO in particular, to improve the international response [email protected] changing to voluntary payments. In the to health emergencies.[18] All of these current set-up, eighty percent of WHO’s commissions recommended strength- budget is comprised of voluntary con- ening WHO’s mandate, autonomy and REFERENCES tributions by member states, philan- financial basis, as well as reforming the 1. World Health Organization [Internet]. Geneva: World Health Organization. WHO Director-General’s thropic organisations (such as the Bill & IHR with a view to strengthen its capac- statement on IHR Emergency Committee on novel Melinda Gates Foundation), and private ity to address global public health risks. coronavirus (2019-nCoV); 2020 Jan 30. Available from: https://www.who.int/dg/speeches/detail/ donors. This has led to a situation in The Covid-19 pandemic may provide the who-director-general-s-statement-on-ihr-emergency- committee-on-novel-coronavirus-(2019-ncov) which donors no longer provide core “shock momentum” that was needed to 2. G2H2 Geneva Global Health Hub [Internet]. Geneva: funding, but rather support particular stabilize and improve – in a democratic Geneva Global Health Hub. Civil society meetings ahead of the 146th Session of the WHO Executive programmes, i.e. those that fit their own way – the only internationally man- Board, 31 January and 1 February 2020; 2019 Dec 30. Available from: http://g2h2.org/posts/january2020/ (domestic) interests. Examples include dated health organisation in the world. 3. World Health Organization [Internet]. Geneva: the USA’s financial support for polio World Health Organization. WHO coronavirus disease (COVID-19) dashboard; updated 2020 Jul eradication, and the Netherlands’ target- In his media briefing in late June 15. Available from: https://covid19.who.int/ 4. World Health Organization [Internet]. Geneva: ing of funds to sexual and reproductive 2020, Dr Tedros made a plea for global World Health Organization. Prioritizing diseases health and rights programmes of the solidarity and urged countries to work for research and development in emergency contexts; 2020. Available from: https://www.who. WHO. The result has been severe under- together to ensure that supplies (e.g. int/activities/prioritizing-diseases-for-research- and-development-in-emergency-contexts funding of certain other programmes, dexamethasone, oxygen, personal 5. Smith RD, MacKellar L. Global public goods and such as emergency preparedness, health protective equipment) and vaccine the global health agenda: problems, priorities and potential. Global Health. 2007 Sep 22;3:9 systems strengthening (including health development are prioritized for coun- 6. World Health Organization. International Health Regulations (2005): third edition [Internet]. workforce strengthening) in LMICs and tries with large numbers of critically Geneva: World Health Organization; 2016. programmes aimed at achieving univer- ill Covid-19 patients. ‘The world is 84 p. Available from: https://www.who.int/ ihr/publications/9789241580496/en/ sal health coverage. Meanwhile, we have learning the hard way that health is 7. Fidler DP, Gostin LO. The new International

18 MT BULLETIN OF NVTG 2020 AUGUST 02 OPINION

Health Regulations: an historic development 14. Lau S. Xi Jinping defends China: WHO coronavirus opening remarks at the media briefing on for international law and public health. J Law response for first time on world stage. South Covid-19: 22 June 2020; 2020 Jun 22. Available Med Ethics. Spring 2006;34(1):85-94, 4. China Morning Post [Internet]. 2020 May 18. from: https://www.who.int/dg/speeches/detail/ 8. Schengen Visa Info [Internet]. Schengenvisainfo.com; Available from: https://www.scmp.com/news/ who-director-general-s-opening-remarks-at-the- 2012-2020. Number of EU countries asking travellers china/diplomacy/article/3084916/coronavirus-xi- media-briefing-on-covid-19---22-june-2020 for COVID-19 negative test results is on the rise; 2020 jinping-defends-china-and-who-response-world 23. Health Policy Watch [Internet]. Germany makes Jun 1. Available from: https://www.schengenvisainfo. 15. Husain L, Bloom G. Understanding China’s growing € 500 million pledge to WHO: plug for ‘major com/news/number-of-eu-countries-asking-travellers- involvement in global health and managing processes funding gap’ left by United States: 2020 Jun 2020. for-covid-19-negative-test-results-is-on-the-rise/ of change. Global Health. 2020 May 1;16(1):39 Available from: https://healthpolicy-watch.news/ 9. Fidler DP. The globalization of public health: the 16. Van de Pas R, van Schaik LG. Democratizing germany-makes-e-500-million-pledge-to-who-a- first 100 years of international health diplomacy. the World Health Organization. Public plug-for-major-funding-gap-left-by-united-states/ Bull World Health Organ. 2001;79:842-9 Health. 2014 Feb;128(2):195-201 24. World Health Organization [Internet]. Geneva: World 10. Letter by The White House to Dr. Tedros 17. World Health Organization. The world health Health Organization. Donors and partners: 2020 Jun Adhananom Ghebreyesus, Director-General of report 2007: a safer future: global public 19. Available from: https://www.who.int/emergencies/ the World Health Organization on May 18, 2020. health security in the 21st century. Geneva: diseases/novel-coronavirus-2019/donors-and-partners Available from: https://www.whitehouse.gov/ World Health Organization; 2007. 96 p. wp-content/uploads/2020/05/Tedros-Letter.pdf 18. Gostin LO, Tomori O, Wibulpolprasert S, et al. Toward a 11. Huang Y. Trump’s decision to pull U.S. out of WHO common secure future: four global commissions in the will boost China’s influence. Washington Post wake of Ebola. PLoS Med. 2016 May 19;13(5):e1002042 [Internet]. 2020 Jun 23. Available from: https://www. 19. Van de Pas R, van Schaik LG. Democratizing washingtonpost.com/politics/2020/06/23/trumps- the World Health Organization. Public decision-pull-us-out-who-will-boost-chinas-influence/ Health. 2014 Feb;128(2):195-201 12. Zhangrun X, Barmé GR. Viral alarm: when 20. World Health Organization. The world health fury overcomes fear. ChinaFile [Internet]. report 2007: a safer future: global public 2020 Feb 10. Available from: https://www. health security in the 21st century. Geneva: chinafile.com/reporting-opinion/viewpoint/ World Health Organization; 2007. 96 p. viral-alarm-when-fury-overcomes-fear 21. Gostin LO, Tomori O, Wibulpolprasert S, et al. Toward a 13. World Health Organization. Report of the WHO: common secure future: four global commissions in the China joint mission on coronavirus disease 2019 wake of Ebola. PLoS Med. 2016 May 19;13(5):e1002042 (COVID-19): 16-24 February 2020. Geneva: 22. World Health Organization [Internet]. Geneva: World World Health Organization; 2020. 40 p. Health Organization. WHO Director-General’s

RESEARCH

Outbreak of Covid-19 like illness in a remote village in Papua, Indonesia

The Covid-19 pandemic is hitting to 30 people in one hut). The clos- health workers are typically absent, low- and middle-income coun- est neighbouring village to M20 is as is common in this region.[3] In tries, where health care resources about 1.5 hour by foot, with people M20, lay health workers hold daily are already stretched. This article visiting multiple times a week. The clinics where they perform primary describes the spread of a Covid- actual population varies with these health care and dispense medica- 19-like illness in M20 (a pseud- interactions and ranges from 150 to tion. onym), an isolated village without 200 people. M20’s gender distribu- medical facilities in Indonesia. M20 tion is estimated at 60% women, METHODS is situated at an altitude of 6,700 and 40% men, due to a combina- This account of an outbreak in a remote feet in the central mountain range tion of a higher life expectancy of village in Papua is compiled from of Indonesia’s easternmost prov- women (66.8 years compared to patient care records kept by lay health- ince, Papua. It is typically served on 63.0 years for men) and men spend- care workers in M20 during and after request by a small six to eight-seat ing most of their time in towns.[1] an outbreak, as well as medical doc- aircraft, or reached by trekking on Approximately half of the popula- tors responding to online requests for foot from other villages. The vil- tion is under twelve years of age. help. We use a pseudonym to conceal lage consists of seven hamlets of There are four to six matriarchs, and the name of the village and protect its two to six huts, separated by five others are teenagers, young adults population; patient data were analysed to ten-minute walks. Villagers are and adults in their thirties to fifties. anonymously. Symptoms of villagers closely related to inhabitants of Most men smoke, and most people seeking medical help were recorded other villages in the area, and visit live in huts with central fire pits, by lay health workers, so initial mild each other often. In the villages which are used throughout the day symptoms were not systematically of the Papuan highland, men and/ for cooking and during the evening recorded. In most cases with infectious or families sleep together in one and night for heating.[2] The closest diseases the exact onset of infection is hut, and children sleep with their government health centre is about not clear. A major caveat is that poly- mothers or families (sometimes up three hours by foot, but trained merase chain reaction (PCR) testing

AUGUST 02 2020 MT BULLETIN OF NVTG 19 RESEARCH

Male | Mild Female | Mild Physicians are involved through online consultation. for Covid-19 was not possible due to the Male | Severe Physical distancing measures lack of tests and test facilities. Our team Female | Severe implemented. repeatedly contacted the government health services, but PCR testing, or testing using reliable antibody tests, was not possible until the time of submis- sion of this report (as of end of June). To collect information on Covid-19 symptoms of all villagers present during the outbreak, the lay medical workers also asked individuals who did not seek medical help about Covid-19 symptoms. Figure 1: Number of patients with symptoms observed over time. EPIDEMIOLOGIC TIMELINE On 22 March 2020, the first case of those with moderate symptoms mainly a different antibiotic: amoxicillin/ confirmed Covid-19 was reported in received paracetamol, up to four times clavulanic acid (2% of the patients) or Indonesia. However, suspected cases a day. Severely ill patients were given azithromycin (3% of the patients). The with links to Wuhan China were empiric amoxicillin treatment (49% of actual effect of antibiotics on recovery reported earlier in Jakarta in February 101 patients) to prevent and/or treat a is not evident. Based upon advice early 2020. On 20 February 2020, the first possible secondary bacterial pneumonia. on in the worldwide epidemic to use suspected Covid-19 patient reported in Those with fevers over 40°C received chloroquine as a possible treatment M20 for care with symptoms of fever, sore throat, cough and stomach com- MILD TO MODERATE SYMPTOMS SEVERE SYMPTOMS plaints although at that time Indonesia AGE MALE FEMALE MALE FEMALE had no official Covid-19 cases. Two 0-5 7 6.9% 5 5.0% 2 2.0% 2 2.0% weeks after the index case in M20, the 6-10 7 6.9% 15 14.9% 1 1.0% 1 1.0% number of cases rose steeply with 26 patients on one day (Figure 1). Covid-19 11-15 2 2.0% 2 2.0% 0 1 1.0% had become the top of the differential 16-20 8 7.9% 1 1.0% 0 0 diagnosis list, as symptoms were in line 21-25 2 2.0% 2 2.0% 1 1.0% 0 with the WHO definition of Covid-19, 26-30 4 4.0% 3 3.0% 1 1.0% 3 3.0% and the index case had been in con- 31-35 3 3.0% 6 5.9% 1 1.0% 0 tact, prior to symptom onset, with a 36-40 3 3.0% 5 5.0% 1 1.0% 0 person who had travelled to Jakarta where probable Covid-19 cases were 41-45 1 1.0% 3 3.0% 0 0 reported.[4] On 3 June 2020, Papua 46-50 2 2.0% 1 1.0% 3 3.0% 1 1.0% had 862 cases of Covid-19, while all 50+ 0 0 0 1 1.0% [5] of Indonesia counted 28,233 cases. (median = 17) Total 39 38.6% 43 42.6% 10 10.1% 9 8.9% Clinic records showed symptoms as Table 1. Suspected Covid-19 patients treated in M20. summarized in Table 1. Table 2 presents the characteristics of the 101 suspected Covid-19 patients in M20. The illness SEVERE SYMPTOMS APPROXIMATE PERCENTAGE OF PATIENTS REPORTING started with several days of sore throat, Fever (either mild 37-38.5°C or high <38.5) 80% followed by stomach complaints, and Shortness of breath 70% fever within 24 hours of stomach complaints. Fever and fatigue were MILD SYMPTOMS constant, lasting 3-5 days. In severe Sore or dry throat 90-95% adults. 60-70% children cases (Table 2), fevers above 40°C often accompanied shortness of breath and Coughing (usually at night) 80% chest pain, starting after day five of ill- Fatigue 90% ness. Two villagers died after 48 hours Lethargy (most of the children) 80-90% children of extreme shortness of breath. Both Headache (late in the illness) 60% were male, over 40 years of age, and Muscle and joint pain 10-20% had underlying chronic illness (most Diarrhoea 20-30% likely chronic kidney disease). The lay healthcare workers treated patients with Vomiting 10% the limited resources available to them; Table 2. Symptoms of patients with suspected Covid-19.

20 MT BULLETIN OF NVTG 2020 AUGUST 02 RESEARCH

for Covid-19, severely ill and high-risk CONCLUSION patients (aged above 40), were given 150 This outbreak pattern of suspected mg chloroquine twice a day for seven SARS-CoV-2 in a village in the high- Wijnanda van Burg-Verhage, MD [6] days (14% of the patients). Except for lands of Papua (Indonesia) presents a Global Health and Tropical Medicine, the two patients who died, all patients unique report of the course of infec- Stichting Lentera Papua, Wamena, Papua, recovered. The effect of chloroquine and tion in an entire village population. Indonesia antibiotics on recovery is unknown. The dense social structure of the [email protected] village resulted in the rapid infection As Figure 1 shows, the entire epidemic of 90-95% of the population within Elco van Burg (corresponding author) curve involved 101 patients (about four weeks. Physical distancing and School of Business and Economics, Vrije half of the population of the village) isolation measures were used, but Universiteit Amsterdam, the Netherlands over a period of four weeks. Informal probably not implemented optimally [email protected] ­questioning in the community revealed and too late. An effect on the ill- that only about ten villagers denied ness course could not be observed. having had any symptoms yielding a REFERENCES presumptive infection rate of 90-95% of The M20 population is young, which 1. Badan Pusat Statistik Provinsi Papua [Internet]. Jayapura: Statistics Indonesia; all residents. Of the twelve patients over partially may explain the impact of the 2020. Informasi terbaru; [cited 2020 Apr 23]. age 40, five were severely sick (41%), suspected Covid-19 outbreak and the Available from: https://papua.bps.go.id 2. Anderson B. Dying for nothing [Internet]. and two died (17%). Approximately 50% relatively low case fatality rate (CFR) Inside Indonesia. 2014 Feb 11;115:1–16 3. Vriend WH. Smoky fires: The merits of had mild or no symptoms (Table 2). The and overall death rate (1%), given development co-operation for inculturation of median patient age is low (17 years), the scarcity of direct health facilities health improvements [dissertation]. Amsterdam: Vrije Universiteit Amsterdam; 2003. which might explain the unexpectedly and the difficulty of complying with 4. World Health Organization. Coronavirus disease 2019 (COVID-19). Geneva: World Health low mortality of 1% given minimal mitigating measures like physical Organization; 2020. 9 p. Report No.: 49 health facilities and no mitigating distancing. Treatment was provided 5. World Health Organization Indonesia. Coronavirus disease 2019 (COVID-19). Geneva: World Health [7] measures. The high proportion of in the form of chloroquine phosphate Organization; 2020. 20 p. Report No.: 10 6. Wang M, Cao R, Zhang L, et al. Remdesivir females in the population may explain and azithromycin for severely ill and chloroquine effectively inhibit the recently that more women (51.5% of the patients) and high-risk patients. However, no emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-71 were affected than men. Physical unequivocal conclusions regarding 7. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl distancing measures were imple- their efficacy can be drawn, something J Med. 2020 Apr 30;382(18):1708-20 mented, but their effect was unclear. which requires further studies.[8] 8. Wong YK, Yang J, He Y. Caution and clarity required in the use of chloroquine for COVID- 19. Lancet Rheumatol. 2020 May;2(5):e255

BOOK REVIEW Epidemics and pandemics

By Roel Coutinho outbreak in 2014, them, and to what extent Singel Uitgeverijen the cholera epidemic they had been anticipated ISBN 978 90 253 1257 2/ NUR 680 in Haiti after the by epidemiologists, micro- Fifth edition 2020, 159 pages, in Dutch 2010 earthquake, biologists and virologists. and the 2009 swine Other potential public oel Coutinho, medical flu pandemic. It health threats include bio- doctor and microbiologist, is an account of logical warfare and declin- emeritus professor of Life recent epidemics ing vaccination coverage. Sciences at the Utrecht and pandemics that UniversityR Medical Center (UMC) have gripped the The earliest known case and former director of the Centre for world and cost many of HIV-1 infection was Infectious Disease Control (CIb) in the lives. The author in 1959 in Kinshasa, Netherlands, takes us on a journey of shows how these, Democratic Republic of discovery to many corners of the globe as well as age-old the Congo. However, HIV where epidemics occurred, some of infectious diseases exploded in the beginning which developed into pandemics. He such as plague, cholera, and influenza, of the 1980s worldwide, especially in writes extensively about the spread of developed and spread, how profession- Southern Africa where it caused 20% to HIV from 1980 onwards, the Ebola als and affected populations coped with 25% seropositivity among the general

AUGUST 02 2020 MT BULLETIN OF NVTG 21 BOOK REVIEW

population with many people succumb- Ebola ravaged Western Africa from The book concludes with a reflexion ing to AIDS and a steep decline in life 2014; Guinea, Sierra Leone and on the recent Covid-19 pandemic. It expectancy as a result. Forty years later, Liberia suffered great losses. Many shows that new infections as well as it has become a chronic condition, and health personnel died. Following this their spread are difficult to contain, there is still no vaccine available. The outbreak, a vaccine was developed resulting in enormous economic 2009 Mexican flu and 1918 Spanish with a very high protection rate and losses as well as social implica- flu epidemics, especially the latter, formally approved and licensed by the tions in our globalised world. took a huge death toll; probably one World Health Organization (WHO) in hundred million people died, more November 2019. Agents that can be In his vote of thanks at the end of than in both world wars combined. used as biological weaponry, such as the book, the author emphasises anthrax, yersinia pestis, cowpox, and that he himself has gained more Another interesting chapter to read is salmonella typhimurium, as well as insights in epidemics and pandem- about the cholera epidemic in Haiti, diseases transmitted by mosquitoes, ics while writing the book, and read- which started in 2010, brought into the such as chikunkunya and malaria, ers may experience the same. country from Asia by Nepalese soldiers are described with suggestions on who were based on the island because how to deal with them in the future. of a devastating earthquake earlier that Jan Auke Dijkstra year. Yersinia pestis and plague are The anti-vax movement gets criti- Specialist General Medicine, France usually considered a problem of the cal comments from the author; there [email protected] past but plague was not uncommon are some 250,000 people in the during the Vietnam War due to acts Netherlands - mostly living in the of violence, and these days the disease so-called bible belt - who reject vac- is still endemic in Madagascar and in cination on religious grounds. California, United States of America.

OPINION Pooling of knowledge, know-how and intellectual property to counteract vaccine nationalism

ver the past two months, hamper equitable access. At Wemos, Non-exclusive licensing will be key for numerous news articles on a Dutch NGO working on various future Covid-19 treatments and vac- potential Covid-19 treat- global health topics, we believe that a cines, as it seems very unlikely that a ments and vaccines have global crisis requires a global response. single pharmaceutical company will Obeen published. Even though the vast Current and future efforts must make be able to produce enough vaccines majority of these new medical technolo- sure that they result in maximising both or medicines to satisfy the worldwide gies are still in a development stage, availability and affordability. Creating demand. Since the desired outcome of governments are already looking for a pooling mechanism of knowledge, such a pool is global access to future ways to secure them. This may induce patents and know-how is the best pharmaceutical products against Covid- “vaccine nationalism” – countries answer to growing vaccine nationalism 19, Wemos believes the best organisa- wanting to skip the queue to be first to and monopolies for life-saving medical tion to manage such an initiative is the access vaccines once they have proven technologies. The concept of collect- World Health Organization (WHO). effective and become available. The cur- ing expiring pharmaceutical patents rent system of pharmaceutical develop- and licensing them non-exclusively­ to The government of Costa Rica was the ment incentivises innovation through manufacturers of generic products is first to suggest a global database. In an patents, leading to monopoly positions not new. The Geneva-based Medicines open letter to the WHO, it suggested for pharmaceutical companies, who Patent Pool (MPP) has been doing creating a voluntary pooling mechanism then unilaterally decide on the market exactly this for almost ten years.[1] – in line with the MPP – for Covid- price for their products. The combina- With this concept, the organisation is a 19 related knowledge, know-how and tion of vaccine nationalism and market crucial actor in increasing ­competition intellectual property.[2] The initiative monopolies is dangerous for Covid-19 and improving access to medicines prompted NGOs in various WHO mem- treatments and vaccines because it will against HIV, hepatitis, and tuberculosis. ber states to call upon their governments

22 MT BULLETIN OF NVTG 2020 AUGUST 02 OPINION

to support this Costa Rican initative. In attaching conditions to public funding. investments. This is vital: it is in the the Netherlands, Wemos won the sup- Such a condition could be that patents best interest of the public and would port of many Dutch NGOs and public of Covid-19 pharmaceutical products be a strong signal of global solidarity. health experts.[3] Together with follow- that are developed with Dutch public up lobbying activities, this resulted in funding are automatically shared with support from the Dutch government the C-TAP. In order to counter vaccine Tom Buis, MSc for a Covid-19 technology access pool, nationalism and promote global access Global Health Advocate, Wemos, or C-TAP in short.[4] The Dutch health to new pharmaceutical products, coun- Amsterdam, the Netherlands minister was one of the only country tries around the world should embrace [email protected] representatives at the World Health C-TAP. It is likely to be the best way to Assembly (WHA) to mention C-TAP in maximise production and affordabil- his statement to the rest of the WHA. ity. Now that C-TAP has been formally REFERENCES

The permanent representative of the established, it is essential that countries 1. Medicines Patent Pool [Internet]. About us; [accessed 2020 Jun 6]. Available from: https:// Netherlands to the United Nations in do their best to make it work. The role medicinespatentpool.org/who-we-are/about-us/ Geneva, Switzerland also made a strong of national governments in supporting 2. Knowledge Ecology International [Internet]. Open letter to the WHO and its member states on the proposal by statement during the official launch C-TAP to become a successful global Costa Rica to create a global pool for rights in the data, th knowledge and technologies useful in the prevention, of C-TAP on the 29 of May. Despite access mechanism for Covid-19 vaccines detection and treatment of the coronavirus/COVID- the compelling presentations, it is not and treatments is crucial, starting with 19 pandemic; 2020 Mar 27 [accessed 2020 Jun 30]. Available from: https://www.keionline.org/32599 yet clear how the Dutch government convincing pharmaceutical companies 3. Wemos Health Unlimited [Internet]. The Netherlands supports a global ‘Covid-19 pool’; 2020 Apr 8 [accessed will translate these words into action. to contribute to the pool. Considering 2020 Jun 30]. Available from: https://www.wemos.nl/ At Wemos, we believe that despite the the large amount of public funding that en/the-netherlands-supports-a-global-covid-19-pool/ 4. World Health Organization [Internet]. Solidarity voluntary character of C-TAP, govern- is currently being spent on research call to action; making the response to COVID- 19 a public common good; [accessed 2020 ments are in a good position to negoti- and development, governments have Jun 30]. Available from: https://www.who.int/ ate with pharmaceutical companies to a powerful tool to promote access, emergencies/diseases/novel-coronavirus-2019/ global-research-on-novel-coronavirus-2019-ncov/ contribute to the pool, for instance by namely by attaching conditions to these covid-19-technology-access-pool/solidarity-call-to-action

BOOK REVIEW A constant state of emergency Paul de Kruif, microbe hunter and health activist

By Jan Peter Verhave health insurance. Also, in his final years is still in reprint. Enthusiasts described Van Raalte Press he converted back to religion, after Microbe Hunters as a most exciting ISBN-10: 1950572064; being a lifelong atheist although born book ‘dealing with villains and heroes, ISBN-13: 978-1950572069 into a conservative Calvinist family in blood and thunder’, and as a ‘war upon 2020, 678 pages Zeeland, Michigan (USA). pathogenic organisms coming out of the labora- ow apt, this title for the There is no statue for tory’. These descriptions biography of Paul de this remarkable person, make you want to pick Kruif – microbiologist, though one could con- up a copy of this book, journalist, and health sider Jan-Peter Verhave’s especially now that the activist.H Apt, considering the current biography as such. The Covid-19 pandemic has Covid-19 pandemic sweeping across bulky book reads as a many scientists work- the world. Also, De Kruif seemed to tribute to this man who ing against the clock to be in a constant state of emergency seemed to be overlooked unravel the pathogenic himself, considering the rapid speed at by (medical) historians and effects of SARS-CoV-2. which he produced articles and books policy makers, although As in the early decades of on medicine and science, his politi- some may remember Paul the twentieth century, it cal swinging from progressive during de Kruif (1890-1971) as is a very challenging and the Great Depression, to eventually the author of the Microbe arduous task to develop more conservative, leaving behind his Hunters (1926), the book a safe and effective vac- (in those times) more radical views on that became an international bestseller, cine. De Kruif brought the pioneers socialized medicine and compulsory translated into eighteen languages and of microbiology and biomedicine,

AUGUST 02 2020 MT BULLETIN OF NVTG 23 BOOK REVIEW

and their discoveries of cures for of his personal life, his flamboyant life various infectious diseases to life by style, and his friendship with famous telling the fascinating story of the writers, including the poet Ezra Pound, Membership of the Netherlands microbes and scientists involved in Ernest Hemingway, John Steinbeck, Society for Tropical Medicine and language everyone could understand. and Sinclair Lewis, with whom he wrote International Health (NVTG) runs from Arrowsmith – a novel about a young med- 1 January to 31 December and may With this book, the promising microbi- ical doctor who gradually diverges from commence at any time. Membership ologist definitely changed his career path caring for patients to focusing on public will be renewed automatically by trading the laboratory for his type- health and controlling disease out- unless cancelled in writing before writer. No more experiments, as when breaks. As a “champion for the poor” he 1 December. Membership includes in the context of a study on the agents was on speaking terms with President MTb and International Health Alerts. of influenza and the common cold he Franklin D. Roosevelt, and a close friend An optional subscription to TM&IH volunteered to shut himself up naked of Vice-President Henry Wallace and carries an additional cost. Non in an icebox for an hour day after day. Surgeon General Thomas Parran. NVTG members can subscribe to Gradually he became a household name MTb through a student membership and, as a star reporter for The Reader’s In many ways, he was ahead of his time, of the Society for € 40 per year by Digest and other magazines, he was able as De Kruif fully understood the public sending the registration form via our to reach large audiences with his popu- benefit of disseminating his work using website www.nvtg.org/lidworden or lar writings on medical discoveries, new mass media like theatre, film, radio, by sending name and postal address drugs, causes and cures of diseases, vita- and even the new medium of the 1930s, by e-mail to: [email protected] mins and hormones, and health insur- comic books. The staging of one of his Please submit your contributions and ance. He did so much to the appreciation plays Yellow Jack in the Netherlands in announcements to the editorial office of the general public, but to a lesser 1934 impressed the audience, though by e-mail: [email protected] extent of the medical professionals, who considered a dicey experiment of bring- rejected him as someone writing about ing science to the stage. The play was Netherlands Society for Tropical medical matters ‘while not even being based on a chapter in Microbe Hunters on Medicine and International Health a medical doctor’, expressing their fear the tragic death of yellow fever research- president that public health systems would take ers dying in Cuba from experimental J.A.E. (Joop) Raams away their patients (and their fees). exposure to infective mosquitos. secretary J.J. (Jaco) Verweij

Verhave’s book is a treat, as it took me Six hundred words are not enough to secretariat on a journey learning about his lifelong cover the wealth of information Verhave J.M. (Janneke) Pala-Van Eechoud mission to popularize medicine and presents us in the more than 600 P.O. Box 43 8130 AA Wijhe | The educate people, and getting to know the pages of a biography of ‘a hard-drinking Netherlands | +31(0)6 156 154 73 | person behind this public health advo- womanizer with a blasphemous tongue’, [email protected] | www.nvtg.org cate for policies that take into account as Verhave describes De Kruif in his the social determinants of health. To foreword. For Verhave, retired biologist COLOPHON do so, he had to leave the “ivory tower” and parasitologist (and author of The MT Bulletin of the Netherlands Society of science, using his typewriter as ‘a Moses of Malaria (2011), a biography for Tropical Medicine and International Health weapon against medical abuses and a of the parasitologist Schwellengrebel), ISSN 0166-9303 fist to bounce the table’. And it bounced. it was clear that the man who fought

He rallied the public against tuberculo- against poverty and horrible diseases CHIEF EDITOR sis in Detroit, unsilenced “the big S” of deserved more attention. He definitely Leon Bijlmakers syphilis (a condition that had become succeeded in placing De Kruif in the highly prevalent during the economic spotlight by taking us along ‘a medi- EDITORIAL BOARD crisis in the 1920s with one out of ten cal history, a history of taking risks in Maud Ariaans, Jan Auke Dijkstra, Americans infected), and steering polio moving doctors, scientists and lay Remco van Egmond, Esther Jurgens, eradication. His quest resulted in more people toward each other and toward a Olga Knaven, Daily Krijnen, Jake Mathewson, Gerine Nijman, Ed Zijlstra than 200 articles on the common health commonly shared healthcare system’. problems of his time: the dangers of raw A story to note and to learn from. SECRETARIAT milk, maternal deaths, childbed fever, Olaf van Muijden diabetes, parrot fever, health insurance, and the deplorable health situation in Esther Jurgens LANGUAGE EDITING Midwestern states and city slums. Eliezer Birnbaum Editor MTb, Policy Advisor NVTG and Consultant Global Health Ingeniously, Jan Peter Verhave inter- COVER PHOTO [email protected] weaves Paul de Kruif’s work as a catalyst Hanneke de Vries for change with a quite detailed account DESIGN Mevrouw van Mulken 24 MT BULLETIN OF NVTG 2020 AUGUST 02