The Netherlands is currently retreating from its “intelligent lockdown” as one of the hardest-hit countries in the world. Although the strategy of allowing the virus to spread while building herd immunity was never abandoned, the Dutch have somehow escaped much international scrutiny – until now.
May 30, 2020 - by Jaap Stronks
The evening of The Speech is when things started to really fall apart. On March 16th, Prime Minister Mark Rutte of The Netherlands was going to address the nation about the government’s plan to battle the coronavirus, which had just four days prior been declared a pandemic by the World Health Organization.
The herd immunity speech was met with near-unanimous praise
Finally, I thought, anticipating a perhaps belated but assuredly robust plan of attack to stop the virus in its tracks.
Just that afternoon on March 16th, the United Kingdom’s Imperial College had backtracked on their herd immunity fantasy, after some number crunching had led to the realization that it would have dealt a death sentence to at least a quarter of a million British people.
Herd Immunity? What had they been thinking, I thought, wondering at the recent British political propensity to self-sabotage. I flicked on the television, only to hear my own Prime Minister Mark Rutte explain 'herd immunity' as being foundational to the Dutch approach.
I had a panick attack.
As Rutte explained in his address to the nation on March 16th, the Netherlands opted for a scenario dubbed 'Maximum control of the virus'. It depends on a rather curious definition of 'control', as it entails a gradual, controlled spread of COVID-19. An excerpt from their explanation of the 'maximum control' scenario:
The virus will not be able to spread as quickly, and we can spread out the infections over a longer period. That leads to a controlled spread among the groups least at risk. [.,,] Most people will build immunity, so the virus has less and less chance to make other people sick (the “protective wall around the vulnerable older people and people with underlying health issues”, as the Prime Minister put it).
The rejected alternatives are called 'Allowing the virus to run its course unchecked' and 'Maximum containment of the virus'. What is weird, though, is that 'containment' is made synonymous to 'a lockdown'. Let's quote RIVM's definition of 'maximum containment' in full:
3) Maximum containment of the virus. This approach is also known as a lockdown. That means shutting down everything completely and requiring everyone to stay in their own homes. Such a rigorous approach may initially seem like an attractive option. The major disadvantage is that it has to be maintained for an extended period. Not just days or weeks. Essentially, all activities would have to be shut down for a year or even longer. That would have huge consequences for schools, for the economy, etc. Moreover, it is very likely that the virus would simply start spreading again once the lockdown is over. When everyone starts going outside again, the virus would be transmitted from person to person – and the lockdown and all its consequences would have been pointless. This risk remains until there is a drug or vaccine for the virus.
This definition is strikingly different from most conventional definitions of containment. Containment primarily consists of widespread testing, contact tracing and isolation (TTI) of people who are (suspected of being) infected. However, testing and tracing are conspicuously absent from the web page about possible Covid-19 strategies (actually absent, not even mentioned), supposedly including the approaches of other European countries.
A containment strategy has been successfully implemented in many countries
A (short-term, quickly deployed, locally targeted) lockdown can be considered as an optional emergency measure in the event if a outbreak is out of control. That is what The Netherlands could have resorted to in early March, after carnival festivities and skiing enthusiasts returning from Italy were responsible for a wave of infections that was too large for the regional health centers to cope with.
To this day, it remains a mystery why a fast and strict yet temporary lockdown was not deployed to quickly curb the virus at that time, which would have allowed regional health centers to catch up and continue containment efforts.
Presumably, at that point, the Dutch government and their advisors had become convinced that succesful containment of Covid-19 was impossible. Therefore, the plan was to allow the virus to spread while building herd immunity. There was some criticism, but it was quickly quenched by portraying herd immunity as a welcome side effect, rather than a primary policy goal, as Jaap van Dissel (head of the RIVM Center for Infectious Diseases) explained on March 18th to members of Dutch Parliament:
Although 'herd immunity' as a concept has continued to draw international criticism, it is still central to the Dutch strategy (see our Dossier: herd immunity in The Netherlands for more information).
In the mean time, as the world is still far from herd immunity, many countries are showing that containment is possible. It has now been successfully implemented in many countries, in Asia as well as Europe: from South Korea to Greece, the virus has been reduced to dozens of infections per day at most, and on average zero deaths.
As Devi Sridhar, Professor of Global Public Health at the University of Edinburgh, rightfully concludes: containment is not rocket science. It merely requires leadership, hard work, attention to detail and good logistics.
We are losing our window
However, the Netherlands is now leaving our lockown before having reached a point where it would have been safe to do so – we are still reporting double-digit numbers of daily deaths. As for daily infections: testing rates are still abysmally now, so it is hard to provide a reliable estimation of the amount of infections still occurring on a daily basis. We are losing our window of opportunity for containment, simply because the mitigation strategy was never abandoned.
Why was the option of containment never allowed back on the table? We have analyzed and summarized all policy statements statements from the Cabinet, RIVM and OMT in this timeline. One event immediately stands out: Jaap van Dissel mentioned the possibility of test / trace / isolate in Dutch Parliament on March 25th, but quickly dismissed it, noting a supposed lack of test materials and arguing that containment would only postpone eventual later outbreaks.
However, this line of reasoning doesn't hold up to closer scrutiny. Although there is a worldwide scarcity of testing materials, it seems inconceivable that the Netherlands would be one of the only countries who would be unable to purchase sufficient materials to control the virus. Portugal was faced with the same problem but just decided to produce test kits themselves, and are now testing twice as much as almost any other country.
About the probability of later outbreaks, the essence of containment is not the elimination of such a risk, but being able to deal with it: to detect and extinguish outbreaks with large-scale testing, intensive contact tracing and isolation of infected individuals.
And it works. Singapore and South Korea may draw headlines in the Netherlands whenever there is a new outbreak; regrettably, their ability to succesfully contain these outbreaks receive less media attention. Singapore has only counted 23 fatalities to this day.
Other arguments against containment, put forward by cabinet or OMT members, are demonstrably false or logical fallacies. For example, Margreet de Graaf of GGD Fryslân's rebuttal to criticism of contact tracing plans, consisted of her claiming that calling contacts more often would not be in line with the Dutch national character.
And Sjaak de Gouw (of GGD GHOR, the central coordinating body of the regional health centers) stated on May 18 that gradual distribution, including the build-up of herd immunity, was the only possibility because the Netherlands would not be able to permanently close its borders, arguing that such a move would be necessary in order to keep the virus out (note that he also explicitly defends the build-up of herd immunity in this video, see below).
That last line of reasoning is not only false, it is also an inverted portrayal of international relations: it's the Dutch who will not be welcome to visit other countries, as long as we are allowing the virus to spread around freely within our own borders.
Countries who have succesfully contained the virus are right now drafting lists of countries from where tourists are eligible to visit them. Greece just published their list of 29 countries, and The Netherlands did not make the cut.
Containment does not equal a lockdown
Last week, RIVM modeller Jacco Wallinga told publish broadcaster NOS that containment was to be ruled out, as it would require a continuous lockdown. That is a myth: on the contrary, it is only possible to ease restrictions if the virus is under control.
It is only possible to ease restrictions if the virus is under control
Remarkably, he subsequently argued that large-scale testing and contact tracing would be able to prevent a second spike or wave. That is odd; if TTI is indeed the key to keeping the virus from spreading – no argument there – he would have to agree that this is only easier to do in a situation where there are fewer daily infections. As you can imagine, if there are fewer daily infections, there is a smaller number of people you have to test, trace and isolate.
We would currently be in that situation if we had started the lockdown earlier, if we had made it slightly more strict, or if we had combined it with measures such as an order to wear face masks in public situations.
The good news is that the testing and tracing capacity is being significantly expanded, although we are already late. It remains to be seen how effective these measures will be and how thoroughly they will be implemented, as rior plans and promises to expand testing capacity did not result in an actual larger number of daily tests performed.
The new contact tracing protocol met some heavy criticism as it did not meet European requirements for effective containment; it primarily relied on letter notifications to contacts instead of repeated phone calls by health care professionals, and quarantining will merely be advised instead of compulsory. This led to an admission that contacts will be called and more often than just once or twice, 'if desired' – but it does not give the impression that they're very enthusiastic about it.
There is no public debate about our strategy
It may come as no surprise that many aspects of the Dutch approach are reported, discussed and criticized heavily in Dutch talk shows and in the opinion sections of our newspapers. There is one exception, however: the overall strategy and our decision to allow the virus to spread is rarely, if at all, discussed.
The idea that the spread of the virus cannot be stopped, only delayed, is not only an unspoken assumption underlying any Dutch policy debate, its acknowledgement appears to be required to even participate. And after ten weeks, we are tired of trying.
We started the petition campaign 'Testing, testing, testing!' on March 23th, directly following the report that our northern provinces publicly denounced the Dutch overall strategy and RIVM guidelines, led by microbiologist Alex Friedrich, who contradicted numerous claims made by RIVM (about the supposed lack of testing materials and the claim that children would not transmit the virus) and who remains a rare, outspoken opponent of the overall Dutch strategy. Instead, he continues to pursue a policy of large-scale contact tracing and testing for the three provinces of Groningen, Friesland and Drenthe, where as of three days ago, only two COVID-19 patients were still receiving ICU care.
Although we are continuing to gain ground especially on social media, we have not found a way to get an opinion piece published in larger Dutch newspapers. Independent experts such as Bert Slagter have received some mainstream attention for their 'crush the curve' approach (which is essentially 'containment'), including invitations to talk shows. However, as NRC reports, even a passionate defense of containment with TTI was dismissed by hospital executive Ernst Kuipers who said containment is 'only possible on an island' (full clip in Dutch can be found here).
The Dutch approach is ineffective and inhumane
The Dutch government has been slower and less thorough in its response to the coronavirus, and we are leaving our 'intelligent' lockdown prematurely. We are less focused on containment in other regards as well: face masks are discouraged (being compulsory to wear them in trains and buses was demanded by public transport companies), the importance of ventilation is denied, the role played by pre-symptomatic transmission is denied or downplayed, and schools are being opened even before we have full knowledge of the risks involvefd.
If you expect most people to get infected anyway, why bother?
All these actions are perfectly understandable when seen in the light of the Dutch strategy of allowing the virus to spread. It may sound macabre and inconceivable, were it not for the fact that it is our official policy. If you expect most people to get infected anyway, why bother to protect everyone at all costs?
All communicated measures exude this overarching sense of defeatism. There are numerous reasons why this sentiment and the strategy based on it on it should be condemned in the harshest terms: this approach leads to higher mortality rates, survivors often have long-term or chronic health problems, shielding the elderly and vulnerable people is almost impossible, and even if if were possible, keeping them fenced off from society is inhumane in and of itself.
And it is not as if this would all somehow be better for the economy: we simply will not be be able to 'open up' with a virus still on the loose. And once other countries will place us in a cordon sanitaire, we will have even bigger problems.
Containment is a must
There is no way around it: containment must happen, period. Our official policy of allowing a deadly and disruptive virus to spread before the possibilities for containment have been exhausted is a governmental failure to the point that it constitutes a crime against humanity.
- Read this thread by Devi Sridhar: https://twitter.com/devisridhar/status/1266418899408519168?s=21
- And this thread on our English account @containmentnow about cost-utility analysis: https://twitter.com/containmentnow/status/1266666908264390668?s=21