Matthew Fox on Covid19: ‘The approach that Iceland has chosen to take is a risky strategy’





Èric Lluent / Reykjavík


Matthew Fox is Professor of Epidemiology and Global Health at Boston University School of Public Health. We interviewed him today to talk about the Covid19 pandemic in Iceland and the way Icelandic government is handling the outbreak.


Q. The government of Iceland has stated that the objective of measures taken “is not to prevent the spread of the virus to Iceland” but “to ensure that the necessary infrastructure is able to withstand the strain that the illness will cause”. Today in Iceland we have 409 infected in a country of 357.000 inhabitants. Is this a good strategy in the global context of the Covid19 pandemic? 

A. I think is really important to emphasise that we don’t know yet what the right or the wrong approach to take is. There is a lot to consider when you think about what is the best strategy to take because the strategies that are being used in various places have huge impacts, not just on the spread of the virus or public health, but they have huge implications for economies and long-term mental health. So, I think we don’t yet know what the right or the wrong answer is. That said, the approach that Iceland has chosen to take is a risky strategy in some sense. You have a population that is smaller than the size of Boston, and you already have more confirmed cases than we had –although who knows what the real number of cases in Boston is given limited testing-, but you already have transmission that can’t easily be stopped but it likey can be slowed. If you have limited space in hospitals to be able to care for the sickest you want to spread that out over as long a period of time as you possibly can to reduce the strain on the healthcare system. I don’t know exactly how the situation is in the hospitals in Iceland at the moment but they may become very stressed.

“There is a lot to consider when you think about what is the best strategy to take because the strategies that are being used in various places have huge impacts”

 Q. There are 409 confirmed cases, 7 hospitalised and 1 death, a tourist from Australia. 

A. When you have situations like this, many who have any kind of respiratory symptom are going to be concerned that they have Covid19, so even if you don’t have many cases in the hospital now, you probably have a lot people who want to get tested. With the confirmed cases that you have now, in the next weeks that number is going to start to go up and you are going to start to see hospital beds being used and potentially overwhelmed, so it is a risky strategy in the sense that if you don’t take super aggressive action, as they have done in places like South Korea, China or Singapore, the action may not be aggressive enough to slow transmission enough to prevent overwhelming the health care system.

Q. The Icelandic company deCode is helping the public health care system testing people, and they roughly estimated that 1% of the population could have the Covid19 after testing more than 2000 people. The argument of how many tests have been taken in Iceland is used by authorities to calm down the population, pointing that the confirmed cases are higher here because of a better testing system. From your point of view, is this argument right?

A. I think that a sample of who is infected is useful for a population of 357.000. But I do think that, if you are not taking aggressive action, that 1% number is destined to grow. There are different models out there, some saying that 40-50% of the population will become infected, others say 60-70%, nobody knows what the actual number is, but certainly it is going to be a large part of the population that will become infected if you don’t take very aggressive action. And it may happen even if you do take strong action, but it will just be slowed down. I think it is really a question of how do we plan the number of people that will be eventually infected. That 1% is not going to stay at 1%, it is going to grow, so the number of people needing hospital beds is going to grow. Can the healthcare system handle it? I think is going to be a really rough next couple of months.

Q. Since the Icelandic economy relies on Tourism, Iceland has decided to keep borders open, even for those coming from high-risk areas. [At the time of publishing, Iceland has decided to ban travel from outside the EFTA and EEA. Still borders are open to travellers from high-risk areas]. So, even thought numbers of tourists have dropped, it is technically posible to reach Iceland, from places like Spain. These tourists have no restrictions or medical checks to entry the country, while residents coming from abroad are sent to quarantine. Actually, through oficial channels in English authorities are publishing messages saying tourists are welcome to Iceland. Is this understandable from the point of view of Public Health Care?

A. If you are asking me as a Public Health expert, I would say this is not the best approach. If we are thinking only about how do we manage what appears to be a highly contagious condition that is going to be resulting in severe morbidity for a percentage of those that are infected the goal has to be to slow things down. Again, I don’t know the Icelandic situation in terms of hospital beds and capacity, but if health care workers become infected you start to lose capacity to deal with the really sick. If beds become full, you have to make tough decisions about who you are going to save, who is going to get respirators and who isn’t. So, from a Public Health point of view, this does not seem to me like the best approach, but I really want to emphasise that governments are thinking about more than just Public Health, and those are tough decisions than none of us are prepared for. 

“If you are asking me as a Public Health expert, I would say this is not the best approach”

 Q. The main argument to keep borders open to travelers from high-risk areas is that experts have been tracing the origin of the infection of local residents an none has relation with tourists. On the other hand, 35% of infections are of unknown origin. Is more difficult to trace infection spread by tourists than by locals?

A. I’m not an expert on this specific aspect, but I think that with 1% of the population that could be infected now -we are talking about more than 3000 people- this number will grow exponentially, at least in the early stages without action, and you pass a point at which tracing is no longer super effective, so at this point you need to emphasise that anyone that has symptoms needs to stay home in self-quarantine. But, with the current strategy I don’t see that there is much value in trying to trace where the infections are coming from at this point. 

Q. Bars, restaurants, hotels and all shops are still open. The government proposes a distance of 2 meters with other people, which in many cases is difficult to keep, at least at work. Should the government implement other measures? 

A. I am looking at this from a Public Health perspective. If you look on the website they are proposing the flattening-curve strategy that everyone is trying to use. But I don’t think that the measures that are in place at the moment are going to flatten the curve dramatically, some but not dramatically, so just thinking about from the health care perspective, which is my area, I think stronger measures would help.

“I don’t think that the measures that are in place at the moment are going to flatten the curve dramatically, some but not dramatically”

Q. In Spain 20 days ago experts were saying that there was no threat for the health care system and the situation was absolutely under control. Now the scenario is horrific. Is there something unknown about this coronavirus that makes predictions so difficult?

A. It is really tough because there were so many unknowns in the beginning and people were trying very hard to keep people calm and keep things moving economically, but we have seen what happened in Italy, we have seen what happened in Spain and other countries, where delayed action has led to overwhelmed health care systems and I do think we should do our best to learn from those lessons. There will still continue to be a lot of unknowns and we don’t have time to wait and see what the impact of doing nothing is going to be. My hope is that we are just able to slow the spread of this virus enough that we can manage it.   

Q. From your point of view, in global terms, what’s the best plan to handle the current situation?

A. We live in a global and connected world, so it does not seem to me that one country can make decisions that are going to be effective just internally. So global coordination would be nice but I am not very optimistic that we can coordinate at a global level, particularly in the current political climate. But I do think that we are in an emergency situation and all countries are making emergency decisions, but pretty soon we have to figure out what is the next action we are going to take, how long are we going to continue with the measures that we are doing and what is the strategy for returning to normal. Those are going to be hard decisions to make, because we have no examples to follow yet, we don’t know what the best approach is, but we can’t do what we are doing forever, so really thoughtful approaches to what comes next are going to be really important.


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