From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Belgium’s Response to the Coronavirus Pandemic – the August update (2020)

Erik Schokkaert, Jeroen Luyten (KU Leuven)
Corresponding author: erik.schokkaert@kuleuven.be

In Belgium, the numbers of new covid cases started to decline from April 10^th onwards. From mid-May until the second half of July there was a more or less stable incidence of around 100 new cases per day. The imposed restrictive measures had succeeded in “flattening the curve” as Belgian hospitals were never overwhelmed. There were also causes of concern, however. The number of deceased in nursing homes was very high. Moreover, the collateral damage of the lockdown became obvious. Examples were the worsening of the situation of the vulnerable groups in society and the postponement or cancellation of non-covid-related healthcare. On top of that came the large economic costs.

At the beginning of May, the exit strategy was worked out, with relaxations of the restrictions in different stages. The government was advised by a so-called Group of Experts for an Exit Strategy (GEES), composed of virologists, economists and top managers. Collaboration between scientists and politicians went less smoothly than at the moment of the lockdown, however. Economic and other lobbying groups became more active, there was less compelling scientific guidance with regards to which measures to relax first, and the population was less and less patient. It was almost unavoidable that some choices were perceived as arbitrary by some part of the population.

In fact, the exit went rather fast, with public life re-opening sooner and the allowed numbers of contacts higher than what the medical experts in the GEES considered appropriate. The weakness of the minority government and the complicated structure of the Belgian political system, with its various regional layers and diffused responsibilities, increased the difficulty of taking effective decisions and communicating them in a transparent way.

In general, there was a growing feeling among the population that Belgium was over the hump. Yet the number of new cases started again increasing rapidly from mid-July onwards, this time concentrated in densely-crowded communities in the cities. The system of contact tracing and isolation of new infections, largely relying on telephone calls and people’s recollection of their previous contacts, appeared to be deficient. The ensuing sequence of events created a feeling of déjà vu. Again, virologists and epidemiologists were warning that exponential growth goes faster than one thinks and that new measures were urgently needed. Again, national politicians reacted slowly and had to be pushed by civil society, by local mayors and by the academic world to take stricter measures. Again, as in the very first stage of the pandemic, politicians finally implemented new restrictive measures, referring for justification to the advice of the scientists.

There is now a (near universal) duty to wear masks in public spaces and a restriction of social contacts (without mask) to at most five persons per household. Clients in pubs and restaurants have to register so that possible loci of infection can be better defined. An interesting phenomenon has been the increase of the power given to local authorities to work out the specific implementation of the rules or to introduce stricter measures than were decided at the federal level. In the severely hit province of Antwerp, a curfew was imposed to avoid gatherings of larger groups of (mostly young) people outside pubs and after parties. All this started a discussion (that was largely absent in the first wave) about the “proportionality” of the measures, more specifically about the question of whether they are an unacceptable infringement on personal rights. This discussion is largely fed by academics, however, as the majority of the population seem to accept and respect the measures.

Almost everybody agrees that the main policy shortcoming of the previous months was the failure to set up an effective system of contact tracing and isolation, which is seen by everybody as an essential component of an efficient post-lockdown policy. Tensions are growing between the centralized political level and local authorities (including local associations of doctors) with the former claiming that coordination is necessary and the latter arguing that they are better informed about the specific social situations and are closer to the people that have to be contacted. If an equilibrium is found here, this may have consequences for the future organization of the Belgian health care system. The failure of this tracing by “humans” seems to have reduced the resistance against the introduction of a mobile phone app that can list past contacts of infected persons. It is now planned to make such app available in the coming months, with due caution to avoid any infringement on personal privacy.

Belgium’s response to the coronavirus pandemic: Update (May 2020)

Erik Schokkaert, Jeroen Luyten (KU Leuven)

Corresponding author: erik.schokkaert@kuleuven.be

On 27 March, the National Security Council decided to extend the containment measures until 19 April, two weeks longer than initially planned. This included a ban on grouping more than two persons (that don’t live together) meeting in public, the closure of all non-essential shops and the prohibition of all non-essential travel. Anyone breaching these rules risks an on-the-spot fine of 250€ (thousands have been fined). Schools remained closed but childcare facilities were provided for families unable to telework.

These measures seem to have succeeded in “flattening the curve”. On the whole, containment strategies were followed up adequately by the population. April 10^th was more or less the peak of the epidemic, with 2,321 confirmed new cases and 421 new hospitalizations occurring that day. From that day onwards, all these numbers have gradually started to decline, indicating that the (first) peak of the pandemic is behind us. At the time of writing, May 5^th, 129 new infections were confirmed, 116 new hospitalizations occurred and 42 people died.

Belgian hospitals were never overwhelmed and the feared scenario of having to ration ICU care never occurred. To the contrary, several hospitals even started to scale down their sealed COVID departments in order to be better able to provide care for other types of patients. Indeed, there were substantial concerns that large groups of patients postponed essential medical care because of the fear of corona, or because of a wish not to burden the health system any further.

At the beginning of April, preparations started for the second stage: the gradual ‘exit strategy’. On 7 April, a Group of Experts for an Exit Strategy (GEES), composed of ten scientists, economists and top managers, was set up to advise the government. On 15 April, the government decided to extend the containment measures until at least May 3rd. In the meantime, serologic tests in the Belgian population indicated that only 4% of the population has had the virus. As the virus has high transmissibility, this indicates that social distancing has not missed its effect. On the other hand, in combination with uncertainties about the duration of acquired immunity through infection, this raised doubts on whether a relaxation of containment measures was really justified. New spikes in incidence are certainly possible and would potentially destroy progress in containing the virus.

However, the pressure to relax containment measures increased markedly. There were increased concerns about the mental health of the population, especially from people living on their own (singles, elderly, etc.) and families with young children. Also, economic pressure mounted to reopen the economy. 1.25 million people across Belgium (about one in three of the workforce) signed on for temporary unemployment benefits due to the corona crisis. The government then launched a plan to relax the containment measures from May 5^th onwards. Businesses are now allowed to reopen and on May 11 shops will be also reopened (of course respecting physical distancing). People will also be allowed to meet within a ‘bubble’ of up to four different persons.

Almost all specialists warned that lockdown is easy, but exit from lockdown is difficult. Lobby groups play a more important role because there is not always a clear scientific rationale for why particular measures can be relaxed and others not, beyond the rationale that not all measures can be relaxed at the same time. It is therefore more difficult for the politicians to hide behind the public health specialists. In fact, although the official advices of GEES have not been made public, it is generally suspected that the exit goes faster than what the medical experts propose. All in all, the communication to the public has become more confused and less efficient. Communication about the numbers is still very efficient, communication about the measures much less so.

At the level of health policy, Belgium has been facing the same problems as most other countries. International comparisons are playing an important role in the public debate, but only a few observers are able to take sufficient distance to go beyond cherry picking the cases that fit their own predetermined convictions. At some point, one of the hottest issues in the debate was the high ranking of Belgium in terms of COVID casualties. The scientists kept claiming that this was due to the way casualties were counted. Whereas in hospitals all deaths were tested, only a minority of deaths in care homes were tested on covid but all ‘suspected’ deaths are recorded in the statistics. Despite some political pressure, the scientists refused to change their way of counting, because in their view it had indicated quickly that there was a real problem in the nursing homes. It has now become clear that they were right. Recently, comparisons with mortality occurring in previous years showed that excess mortality was higher than reported in many countries but not in Belgium, suggesting that other countries likely underestimate their total covid death count. And the issue of the situation in the care homes has also come up later in other countries. Surely, the need of a better organization of the care homes and of a better coordination between care and health care is one of the main lessons of this crisis.

Another problem that Belgium shares with most other countries is the scarcity of medical material and of tests, and resources for contact tracing. There were substantial problems in getting access to large amounts of face masks of sufficiently high quality and several orders had to be cancelled because of a lack of quality. Since face masks play an important role in in the exit strategy, all over the country, people have started to sew their own face masks. Some see this as a hopeful sign of the resilience of the population, others claim that it is a symptom of a failing government. Several initiatives were taken to develop a mobile phone app that can list past contacts of infected persons. However, there were doubts on the practical feasibility and accuracy of such novel apps and, more importantly, there was a growing concern about the infringement on personal privacy. Therefore, the government decided instead to recruit 1,200 human contact tracers and to rely on people to voluntarily keep a diary of the persons they have met.

It turns out that the predictions of the experts were right: the exit strategy is much more difficult than the lockdown. Economic and other interests play a more important role, political differences are more outspoken, feelings among the population are stronger and there is less compelling scientific guidance with regards to which measures to relax first. It remains to be seen whether the pace of the exit is optimal. What about the expected second peak? Will we be able to build-up sufficient immunity in the population and will the new policy of test, track and isolate be effective enough to avoid a necessary second wave of containment measures? Many people seem convinced that they know the answer to these questions, but, of course, nobody really knows.

Belgium’s response to the coronavirus pandemic – Original post (April 2020)

Erik Schokkaert, Jeroen Luyten (KU Leuven)

 

When Italy went in lockdown (March 9), there were 267 confirmed corona infections in Belgium, but everybody knew that this was an underestimation. The first COVID-related death was on March 11. In the weeks before, the main warning given to the Belgian population had been to take basic behavioural precautions, mostly to wash hands regularly. Holiday travel to Italy had not been forbidden – and the returning travellers became one of the main sources of the spread of the virus.

On March 10 the government introduced some soft restrictive measures, including a recommendation to not organize large events. Much stricter measures were imposed on March 12: restaurants and bars were closed, there was a complete ban on mass events and teleworking became recommended as the norm. The implemented measures followed closely the advice of scientific experts. Somewhat more ambitious than that advice, however, the government also decided to close primary and secondary schools. This decision was at least partly motivated by the French example. From the beginning it was communicated that the purpose of the measures was to slow down the spread of the virus so that hospitals – and specifically ICU’s – would be able to cope. The developments were closely monitored with daily briefings by experts about the severity of the situation, and the experts referring to underlying epidemiological models.

All these measures were introduced by a provisional government. In fact, since the elections of May 2019 the two largest parties on both sides of the linguistic border (Flemish Nationalists and Parti Socialiste) had not yet been able to reach an agreement. During the weekend of March 15, an attempt to form a representative government to fight the corona crisis, failed. The main parties, however, agreed (without much enthusiasm) to continue with the minority government and to give it special powers.

On March 17, on the basis of new available figures, the restrictive measures were tightened further. Social distancing measures were strengthened, e.g. by banning all outdoor gatherings and closing all the shops except essential ones for food and medicines.  On March 20, the Belgian borders were closed for all non-essential travel. The government, again following the advice of the experts, made it clear that people were allowed to leave their house to bike, walk or run – if not with more than two persons and respecting social distance. This was seen as important, both for the mental and the physical health of the population. Overall the general public has been highly compliant with these measures, although young people were generally more difficult to convince of the necessity. Violations were gradually more controlled by the police, beginning with non-consequential warnings but became more strict with fines up to 250€.

In addition to the public health measures, both the federal and the regional governments have introduced a series of measures to mitigate the economic consequences of the restrictions.

In the meantime, and already before the government had taken any measures, hospitals had been reorganizing to increase the number of beds in ICU, to restructure their emergency care units, to prepare staff (and volunteers) for the increase in COVID-patients. A system was set up to guide people with symptoms first to their GP with telephonic consultations. GP’s would then decide to direct patients to emergency or not. On March 30, there were 1,765 ICU-beds for COVID-patients, of which 53% were occupied. In some regions occupancy rates were larger but the transfer of patients to less occupied hospitals has worked smoothly. At the time of writing (April 6), the number of COVID-patients taken to hospitals is still increasing but at a slower pace (the curve has started to flatten), and one may hope that hospitals will indeed be able to treat all patients. This would mean that the basic objective of the whole policy is reached.

The main cause of concern now, as in most other countries, is the possible shortage of medical material (masks and testing material). It is not easy for an outsider to evaluate how much of the shortage is due to the situation on the international market, and how much is due to government failures. Yet at least one government mistake is clear: the government had not sustained the strategic stock of masks that was built up after previous epidemics. A second cause of concern is the situation in nursing homes, where there is a high concentration of high risk people and less well trained nursing staff. The shortage of material is even more outspoken there, since nursing homes were in the beginning not seen as a priority sector.

Overall, the response of Belgian policy makers was rational and not panicked. Of course, with hindsight, the severity of the Italian situation has been underestimated, but given the information available at that time decisions were rational (we believe) and measures were introduced rather quickly. They were gradually strengthened, with the deliberate purpose to try to reach an equilibrium between medical needs, economic costs and public support for the measures. It can be expected that measures will be relaxed in an equally rational way, if the optimistic predictions indeed are verified. Experts are preparing the population already now for a long period with cyclical strengthening and weakening of the measures, until vaccines will be available. They are also preparing for more testing as soon as there will be sufficient material, as test-and-trace may be a crucial component of an efficient post-lockdown policy.

Virologists and epidemiologists have played a crucial role in the decision making process and in the communication of the policies to the population. In general their advice has been followed, the main exception being the closing of schools. A bit paradoxically, this may be partly explained by the political weakness of the government. Scientific insights created the consensus that was needed to introduce restrictive measures. This has worked well, but at the same time may also be a danger, in that the political opposition (more or less silenced in the political game because of the special powers) gets an incentive to attack experts who look like policy makers, although they do not take the final decisions. This has become clear in recent discussions about the generalized use of masks. The experts and the government were against, partly because there was a shortage and priority had to be given to health workers, partly because their effectiveness is doubtful. Yet, the international scientific community is more and more divided about this issue, with a growing number of experts arguing that after all masks might be effective to slow down the spread of the virus. Opposition parties have used this argument to criticize the government and the Belgian experts, helped by the (likely, and certainly perceived) mistakes of the government in the procurement of medical material. This raises interesting questions about the position of scientists in policy debates. Of course, scientific knowledge is not 100% certain, and even less so with a new disease such as COVID. Policy advice is always partly based on intelligent judgment, rather than hard facts – and judgment is likely to be more intelligent when backed by scientific knowledge. For the general population, however, this is not easy to understand, and it gets even more difficult if scientific experts are so strongly involved in policy communication.

Let us end on a cautionary note. If Belgium is successful in avoiding the breakdown of the hospital system, this will not only be thanks to the policy measures. Already before the outbreak of the pandemic, Belgium had a larger number of beds in ICU-units than, e.g. Italy or the Netherlands. In fact, many economists would have evaluated the number of ICU-beds as inefficiently high. Will we be lucky now, because we were inefficient before? This raises interesting questions about what is the optimal capacity of hospital beds if demand is uncertain, and extreme demand shocks are possible.

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