© Matthias Leuhof

Pandemic management, Dutch style: ‘ping-ponging responsibilities back and forth’

Amrish Baidjoe is one of the few Dutch outbreak experts with broad experience in crisis situations. At the end of July, he and other experts founded a think tank, the Red Team, to advise on alternative strategies for dealing with the pandemic. After it published a report on facemasks last weekend, prime minister Mark Rutte decided that the Outbreak Management Team, which advises the government, should take another look at the issue. Baidjoe is moderately positive about the tighter rules issued by the government yesterday. ‘We’ve reached the stage where we can no longer stop the flow of infections with testing and contact tracing alone,’ he says.

[The original interview was published on Tuesday, September 29.]

In mid-September, for the first time, Amrish Baidjoe got frustrated. The country’s testing capacity was not keeping up, there was almost nowhere to get tested, and the number of infections was rising sharply. Hospital admissions were also increasing again: one more day of figures like these and the alarm bells would start to sound. When a member of the Outbreak Management Team (OMT) reassuringly tweeted that the target numbers on the government’s coronavirus dashboard were ‘nowhere near exceeded’, Baidjoe called him out and was promptly blocked by the OMT member. At the end of that week, on Friday 18 September, Mark Rutte and Health Minister Hugo de Jonge reported that things were indeed trending the wrong way, but took no concrete measures.

Baidjoe has been warning for months that testing capacity needs to be scaled up considerably, and that contact tracing is not working properly. He says the public health department (GGD) is short staffed, budgets too little time per contact, and adopts a superficial approach. It now sends letters to contacts instead of having detailed conversations with them, and sometimes asks infected people to approach their contacts themselves.

Baidjoe, who works at the International Red Cross headquarters, was in the Netherlands when the country went into lockdown, but has been commuting between Geneva and Amsterdam again since the measures were relaxed. Together with others, he founded the Red Team in July: a group of scientists and experts who critically monitor Dutch measures against the coronavirus. Their aim is to give unsolicited and constructive advice. This proved effective for the first time yesterday. At the coronavirus press conference, Prime Minister Mark Rutte announced that their report on face masks prompted the Cabinet to ask the OMT once again for advice.

Follow the Money has been talking to Baidjoe regularly in recent weeks, and interviewed him at length at the end of August. We asked him what is going wrong, how things could be done better, how to get public support for the measures, and how to manage a public health crisis.

Background: from zika to malaria, and Kenya to French Guyana

Amrish Baidjoe was born in Amsterdam in 1984. He studied biology in Wageningen, gained his PhD, and trained in field epidemiology at the European Centre for Disease Control and Prevention. He has carried out research in French Guyana, Tanzania (where he studied the influence of micronutrients on malaria), the Democratic Republic of the Congo (ebola), Suriname (zika), and Kenya (malaria). Baidjoe has also worked at the Erasmus University Medical Center under virologist Ab Osterhaus, the Institut Pasteur in Paris as co-lead of the international Outbreak Investigation Task Force, and at the Imperial College London in the department of government coronavirus adviser Neil Ferguson. He is an honorary assistant professor of infectious diseases at the London School of Hygiene and Tropical Medicine.

Baidjoe was vice president of the R Epidemics Consortium (RECON), which uses open source software to improve data analysis in areas hit by humanitarian or public health crises. He is also chairman of the European alumni network of field epidemiologists.

In 2019 he worked for the World Health Organization in Cox’s Bazar in Bangladesh, the world’s largest refugee settlement, which houses Rohingya expelled from Myanmar. He helped coordinate the health organisations active there, and implemented practical research and evidence-based decision making. Since 2018 he has led the epidemiology working group of the WHO’s Global Outbreak Alert and Response Network (GOARN).

On 5 February, Baidjoe started a new job with the International Red Cross in Geneva, in their Covid-19 crisis team. He was one of 200 experts present at the first-ever global conference on the new virus in Geneva on 12 February.

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The study that changed everything

After graduating in biology, Baidjoe spent four and a half years researching malaria outbreaks in Kenya. He says the disease is ‘terribly predictable’: ‘After each rainy season, the mosquito population grows, and then off it goes again. We now know that there are four kinds of interventions: mosquito nets, spraying insecticides indoors, clearing larval breeding grounds such as stagnant water and puddles, and making medicines available.’

These can stop malaria, but they require money and people, and both are often in short supply. ‘Then the next question is how can you scale up these interventions? Can you make them more targeted? Which is most effective, and what is the best approach for a specific region?’

‘I learned that you have to build and disseminate knowledge together, and that it doesn’t work if you just come to collect things

‘Our team was mainly put together locally: eighty Kenyans, a Dutchman, a Brit, and a Canadian. That’s where I learned that you have to build and disseminate knowledge together, and that it doesn’t work if you just come to collect things: collect your samples, go home and publish an engaging article in a scientific journal. Because I was opposed to that approach, I had partly left the academic world. I often felt guilty about the grand promises we made as scientists, which got us a lot of subsidies and funds, because we rarely kept those promises. It’s a great pity: many projects fail not because their methods are flawed, but on the implementation side of things.’

Baidjoe says the same mistakes are being made again and again. ‘In research like this, we usually invest too little in infrastructure and knowledge building, which is a major necessity, especially if you want to gain public confidence. And we don’t realise that health crises are never purely biomedical. The irony is that bodies with colonial roots, such as the Institut Pasteur in Paris or the London School of Hygiene and Tropical Medicine, are good at them. They have solid networks, they’re embedded in the community, and they employ a lot of local people. They’ve managed to make something good out of their colonial past, though there’s plenty of room for improvement. They know that you can never fight an epidemic with medical interventions alone, and that a top-down work approach is doomed to failure.’

Baidjoe’s team studied an area of five by twenty kilometres where malaria was infrequent. They hypothesized that even here, the disease was probably not evenly distributed: there would be hotspots, very localised flare-ups, usually near pools where mosquitoes thrived. What if you attacked those?

‘Mathematical models showed that it would have a big impact, but how would it work in practice? We divided the area into sections of 500 by 500 metres, and with the help of dozens of people we spent less than a month taking samples. We examined these and plotted the results on a map, so we knew where the hotspots were, and then we looked at what happened if you took action only in those places. That led to a greater reduction of malaria, and with much more minimal interventions than usual.’

It sounds like a great success. ‘But we merely looked at that arbitrarily demarcated area, and outside there were all sorts of pools and ponds that hadn’t been cleared of larvae, and had an impact on “our” area. That had major consequences for the long-term implementation of our approach: you can’t carry it out in isolation. The study took three years, and cost about a million euros. We concluded that our strategy had not been immediately successful, purely because we hadn’t paid enough attention to the effect exerted by the surrounding area. That was my ultimate wake-up call: context is everything.’

Fixation on hospital capacity

Now that the Netherlands has a health crisis, Baidjoe sees the same classic mechanisms at work here. ‘The Outbreak Management Team has hardly any people with crisis experience. Almost all of the members are biomedical scientists, and they’re great academics, but where are the people with practical experience of crises, who know what to do when there’s a disaster? Where are the first-line emergency workers, the behavioural scientists? Where are the field epidemiologists?’

In a crisis, by definition, everything is in short supply. You lack knowledge, you don’t have enough people or testing equipment and, above all, you have no idea what exactly is going on or how it will develop. Everything is unknown territory. ‘You need people who dare to make decisions based on uncertainty, and who give priority to prevention. A stitch in time saves nine: do everything you think will help, and adjust your policy as you gain more knowledge and room for manoeuvre.’

‘Hospital capacity should be the final element of your approach, not your main focus’

The government and the Outbreak Management Team have put a lot of effort into improving hospitals and increasing the number of beds, respirators, and nurses. ‘That’s what they were working towards, focusing on maximizing the number of seriously ill patients they could handle. But it shouldn’t be like that – you should focus on preventing people from becoming infected in the first place and requiring admission, partly because we don’t yet know what the long-term effects of Covid-19 are. Hospital capacity should be the final element of your approach, not your main focus.’

This fixation on beds has caused a lot of damage, Baidjoe says, and not enough attention has been paid to things like domiciliary care, nursing homes, and the pandemic’s impact on society. ‘And that’s still affecting our approach: the number of infections has been rising steadily since the end of July, but the government and the OMT are only now expressing concern, because hospital admissions are on the increase – but that means they’ve largely lost control over the spread of the virus.’

Baidjoe criticizes the OMT’s emphasis on pure scientific evidence, be it concerning the transmission of the virus via children or the usefulness of face masks. ‘You don’t have time for that in a crisis, you have to experiment. If you wait for irrefutable evidence before you come up with a policy, you’re always going to miss the boat, especially if you focus on the biomedical aspects of the evidence, but ignore insights about behaviour, communication and health economics. No health crisis has ever been solved by academics alone.’

‘You have to acknowledge that you’re making choices based on scarcity, rather than pretending they’re being made on scientific grounds’

Scientists are very good at gathering data, making hypotheses, and weighing evidence, and in this respect they play an essential role. ‘But that approach doesn’t work so well if you want to know how effective face masks or social distancing are.’ He argues that the benefits of masks depend on the context. ‘If a handful of people wear them, their effect is zero. The more people who put them on, especially in situations where social distancing is difficult or ventilation is poor, the more effective they are. The more people are infected, the more it makes sense to wear them, especially in high-risk environments such as hospitals.’

The entanglement of science and politics

Sometimes the health ministry puts pressure on the RIVM, the country’s national research institute for public health and the environment. ‘This is nothing new,’ Baidjoe says. ‘It also happened with Q fever and swine flu. It’s not necessarily a bad thing, provided you openly acknowledge where and why it happens. We also had shortages of protective equipment at the Red Cross; but you have to acknowledge that you’re making choices based on scarcity, rather than pretending they’re being made on scientific grounds.’ In July, The Council for Public Health and Health Care warned that the RIVM and the government have become too intertwined during this crisis. ‘This is not good for policy, it’s not good for science, and it’s certainly not good for public confidence.’

It doesn’t help that the OMT cherry-picks research results. In July, Jaap van Dissel, the head of the OMT and the RIVM, stated that there were no grounds for making face masks compulsory. ‘There is simply no scientific evidence for this,’ he said, citing a Norwegian study.

‘When [the TV programme] Nieuwsuur contacted the researchers, they protested against this interpretation of their results,’ Baidjoe says. ‘On the contrary, they found that outcomes differed enormously, depending on the local level of infection, and recommended face masks in crowded places. Some studies even showed a 60 percent risk reduction.’ He sighs. ‘But the OMT doesn’t seem to have done anything about this, and they haven’t changed their advice. That attitude undermines their credibility, and it’s a pity. This is not something we need right now – more than ever before, we need to have confidence in our institutions.’

Policy recommendations are sometimes insidiously coloured by political realities. Take the issue of face masks in nursing homes: the RIVM announced, again citing scientific evidence, that these were not necessary where personnel only briefly came into contact with residents. But this advice was partly prompted by the shortage of face masks at the time. In mid-August, the RIVM tacitly withdrew its guideline, and has since said they are necessary even for the briefest of contacts. However, it did not inform the care sector about this change.

Top-down, reactive, and disorganised

Baidjoe himself has learned by trial and error that two things are crucial to crisis management: impartiality, and clearly defined responsibilities. ‘You have to ensure that your team can operate independently of politics, but in the full knowledge that every crisis also has a political component. If you insist that you’re apolitical, you’ll get a forced reaction from academics. They’ll say no, we only do the science, we provide the evidence, but decision making is not up to us.’

Its biggest shortcoming: the dashboard includes all kinds of benchmarks, but severs them from their implications

Baidjoe is astonished at the Netherlands’ wait-and-see attitude. ‘We’re reactive, not proactive. The coronavirus dashboard is a prime example of the problem. It appears to show the current figures, but it actually records the infections that occurred a fortnight ago, under the measures in place at the time. You don’t see the effects of your actions or inaction until at least two weeks later.’

In addition, the dashboard only shows the tip of the iceberg: people with symptoms who have been tested or admitted to hospital. ‘So you can’t base your decisions on the dashboard alone: it’s in a permanent state of flux. The biggest shortcoming is that it includes all kinds of benchmarks, but severs them from their implications. Nobody knows what to do when the numbers increase, and that rebounds on us. Last week, for example, the infection benchmarks were far exceeded, but the government didn’t take any action.’

When the members of a crisis team have crystal-clear responsibilities, this helps to separate them from the political decision-making process. But there are no clear lines of demarcation. ‘So nobody knows exactly who is responsible for what, and who should take the first step in which process. Take the question of why testing capacity lagged so far behind. Minister De Jonge said that local health authorities weren’t keeping up with the crisis; they said they hadn’t been told to scale up, and blamed the health ministry and the GGD GHOR, the public health federation. GGD GHOR said it had not been given any instructions by the RIVM, and the RIVM said again that it had not received any from the health ministry. Or if it had, they consisted of one crucial sentence buried somewhere deep in a report, which the minister later said he’d overlooked.’

‘We ping-pong responsibilities back and forth. But crisis management is about moving fast and staying in control’

‘Gosh, minister, you’re the one in charge! Ask those guys what the situation is, and they’ll have to give you an answer and then you can proceed. Because of the polder mentality [the Dutch tradition of government by consensus, eds.], we ping-pong responsibilities back and forth. But crisis management is about moving fast and staying in control.’

Many people’s voices are not being heard properly, Baidjoe says. ‘Primary and emergency care providers say they can’t talk to the press themselves, everything comes from above and is streamlined.’ That means you need very close contacts with the OMT if your message is to get through to the top. ‘Back in early March, when things in the Netherlands still seemed to be quite relaxed, a microbiologist at the Amphia Hospital in Brabant, Jan Kluytmans, decided to start testing all staff members and patients with flu-like symptoms. He discovered that many people already had the virus, and a slow-burn fire had begun. In mid-March, he sounded the alarm when the number of admissions began doubling every day. Yet it took another five days before his message reached the corridors of power – even while he had immediately phoned Jaap van Dissel, the head of the OMT.’

The Red Team

Baidjoe says the OMT should be more open minded, and more responsive to comments, suggestions and criticisms from other experts, but it turns its back on dissenting views too easily. ‘In the Netherlands, we tend to listen mainly to people who can organise themselves into groups. We know this perfectly well, but we don’t adjust our policy to it. That’s why there should be more primary carers in a crisis team, like general practitioners and district nurses. Specialist care workers are well represented, but they’re three steps further up the hierarchy.’

In July, Minister De Jonge announced that he had asked Baidjoe, and a long list of other outside experts, to review ways of improving the response if there was a second wave. Baidjoe was not impressed. ‘He was going through the motions, not taking the criticisms seriously. As it turned out, all we were allowed to do was write a two-page review and hold a two-hour Zoom meeting. That’s not a review, and certainly not as defined in the European Centre for Disease Prevention and Control’s international standards.’

De Jonge also consulted health economist Xander Koolman, former chief inspector at the Healthcare and Youth Care Inspectorate Wim Schellekens, and epidemiologist Arnold Bosman. All had previously advised members of parliament, and had been criticized by the OMT for doing so. ‘Their general opinion was that we were being abused by the opposition, but you know, the OMT didn’t want to speak with us either.’

The four took advantage of the opportunity. ‘De Jonge’s request to carry out a review gave us legitimacy. On the same day that he asked us, 22 July, we sent an urgent letter to Rutte and De Jonge, pointing out the increase in infections and insisting on new measures. We couldn’t wait until September; we felt that something had to be done now.’

The group condemned the government for blaming the rise in infections on the public’s behaviour, saying this was an oversimplification. They pointed to the lack of contact tracing and testing, and the fact that more people were travelling by air without being quarantined when they arrived in the Netherlands. They also recommended that professions in close contact with the public be required to wear masks. The government did nothing.

As the number of new cases continued to increase, team members were more frequently invited to make appearances in the media

The four then established the Red Team, which on 12 August provided a briefing for the house of representatives. As the number of new cases continued to increase, team members were more frequently invited to make appearances in the media, but the policy hardly changed at all. On 26 September, Jaap van Dissel repeated publicly that the real problem was not testing policy but the public’s behaviour, and again stated that the Norwegian research did not demonstrate the usefulness of facemasks. Baidjoe resplied on Twitter: ‘These days, I increasingly think I’m living in the twilight zone.’

Faltering response

Baidjoe is concerned about the lack of a proper testing policy. ‘When you say in the Netherlands: “We need to test a lot more,” people’s first reaction is: “We can’t do that, because of so and so.” Your answer should be: “Okay, we’re going to do it by any means possible, within reason.” You can bring in companies and NGOs to find ways of eliminating or circumventing those obstacles. There’s plenty of knowledge and expertise in the Netherlands, and people truly want to contribute. Make use of that social potential, because it also strengthens support for the measures you take. If you approach people as your partner and share the problems as much as possible, you can mobilise them, and more solutions will inevitably emerge.’

Get too fixated on science, and you miss out on the potential that lies in other areas. Things that science considers impossible – scaling up testing, developing protective equipment – may be possible for others. ‘How many examples have there been of companies saying: guys, we can make face masks? Why don’t we use the capacity of the commercial labs that offered their services months ago? If you’re not open minded, these initiatives aren’t going to transpire.’

Make use of that social potential – that also strengthens support for the measures you take’

If your goal is to reduce the number of new cases to zero – work towards elimination – then you need to invest as much as possible in testing and contact tracing. ‘But we don’t make a clear choice, and that leads to a faltering policy. Without a clear objective on the horizon, you lose support and, ultimately, the public’s confidence. You’re rudderless. If you don’t have a destination, it’s difficult to determine your course. Not just for members of the public – what are the rules, why do we have them, what are the consequences – but also for first responders, people working in healthcare and in labs. They no longer know what to rely on. They worked their socks off, and then they saw people were being crammed into planes.’

And the country’s testing policy continues to falter. ‘The GGD initially said they didn’t see much point in contact tracing, and a few weeks later they announced they were going to invest as much as possible in it. In Rotterdam, after the first expansion, the local GGD refused to hire more people because they would just end up ‘twiddling their thumbs’. Soon afterwards, three weeks later, it turned out that they could no longer handle all the work. Now, one local GGD after another is giving up on contact tracing, they just can’t keep up. That proves that policy makers are not thinking ahead. Unfortunately, we’ve now reached the stage where tests and contact tracing can’t stop the influx of new infections, and we’ll have to resort to measures that make our social bubbles smaller.’

Crisis management and community

Innovation is needed in a crisis, but Baidjoe prefers to see it introduced steadily. ‘Not through disruptive technology, as De Jonge did with his coronavirus app.’ That was simply a distraction, he says; moreover: apps are useless without a solid policy on testing and contact testing. 

The government’s policy reversals worry him. ‘Not just because they reduce public support, but also because they force us into hurried decisions. Stringent measures should never be announced out of the blue, that’s disastrous. And if the testing and contact tracing had been working properly, as the Red Team argued we should strive for in July, we wouldn’t have needed to make so many hasty decisions anyway; we could have intervened on a much more flexible and regional basis.’

The government has shifted responsibility to the regions, leaving them to sort out the mess

Instead, the government has shifted responsibility to the regions, leaving them to sort out the mess. Eindhoven mayor John Jorritsma complained last week that local councils were ‘at their wits’ end’ as they were forced to take unpopular measures. In practice, this means that each regional safety authority is having to reach agreements with the hospitality industry, football federations, and everyone else. Jerritsma says this is totally unfeasible. Baidjoe agrees: ‘Crisis management is about just that: taking the lead.’

Baidjoe fears that the debate about how to deal with this crisis has become too politicised – hence the controversy over face masks. ‘We could have promoted them differently and said “Hey, masks seem to help, so we’re going to try them, join us!” We could have tried them in part of the country, for example, and monitored the experiment closely, and after a month we’d know if they had any effect. Now we’ve been bickering for months, and we still don’t know the answer. Unfortunately, Van Dissel has contributed to this by saying he doesn’t believe in masks. What he believes, however, is irrelevant, and surely someone in his position doesn’t want this kind of reasoning to take root. It just encourages people to lose confidence in science and in institutions.’

Scientists shouldn’t be afraid to say we don’t know, Baidjoe argues. ‘It does take courage to admit that you haven’t figured things out yet. But as an epidemiologist or crisis manager, you sometimes have to act without certainty. That requires agility, adaptability and honesty. You have to tell people that you’re uncertain, which is not the same as adopting a wait-and-see attitude. Focus on experimentation, monitoring, building on what seems to work; start small and scale up. If things go well, then you can always rest on your laurels for a while, but first you need to be sure that any improvement is permanent, and not due to bad data, underreporting, a fluke, or just coincidence.’

‘You should treat the public not as an object of policy, but as your best ally’

Solid contact tracing is also terribly informative in other respects. If you call everyone who has been in contact with someone who’s tested positive, you can discuss their concerns about the consequences of testing positive themselves. You can help them arrange time off work, ask if someone can do their shopping for them, and possibly arrange home care.

This is how policymakers can learn what people’s hesitations are, and what stops them getting tested. ‘You can then involve local organisations and community effort, for example to arrange a shopping service,’ Baidjoe points out. ‘You should treat the public not as an object of policy, but as your best ally – that’s the crux of the matter. When there’s a pandemic, this approach always has the greatest benefits, and it also keeps morale high.’

His parting shot: ‘This is a global crisis that’s shaking society to its foundations. And it’s just the beginning: the climate crisis is coming in its wake. Why on earth do we think we have the luxury of endless bickering?’