The Dutch corona strategy maintains a complex relationship with reality. While immunity buildup was previously relabelled as a 'desirable side effect', Prime Minister Mark Rutte later denied even ever having given a speech about it. It does not end there: this week, multiple members of the Dutch advisory/policy/outbreak management council Outbreak Management Team (OMT) such as Marc Bonten have demonstrated the audacity to sign the John Snow Memorandum, an international scientific manifesto against herd immunity – while simultaneously reaffirming their support of the Dutch pandemic response strategy, which is exactly the kind of approach the Memorandum sets out to condemn. For those who are lost in the Dutch corona labyrinth, we offer a text-analytical Ariadne's Thread which points the way to the exit. A longread.

Published October 17, 2020

On October 14, the medical journal The Lancet published a major manifesto, strongly rejecting the pursuit of "herd immunity" in tackling the coronavirus. It has been signed by dozens of professors of epidemiology and related academic disciplines. They argue that if the virus is not suppressed and contained, it is unlikely that protective herd immunity will develop. Instead, they paint a bleak situation where the epidemic will flare up again and again. This is how it turned out with other infectious diseases (unless a vaccine was developed).

Since COVID-19 is several times more deadly than influenza and may also causes severe long-term health defects, that would be an inhumane scenario. The experts are therefore calling to contain the virus (although they call it "suppression" and "control"), such as "in Japan, New Zealand and Vietnam". This must be done at a level of few infections and with the means that the World Health Organization is always insisting on: large-scale testing, tracing (source and contact research) and isolation (quarantine of the sick) - in short: TTI - and the wide use of masks. Incidentally, Japan is a complex case, where masks are possibly being worn en masse.

This so-called John Snow Memorandum (Snow is one of the founding parents of modern epidemiology) was recently signed on Twitter by one of the designers of the Dutch corona policy, the physician-microbiologist Marc Bonten, as a member of the Outbreak Management Team (OMT). influential advisor to the Rutte cabinet.

The fact that Bonten says he supports the pamphlet is a travesty; such a misleading move that the initiators of the Memorandum would do well to remove his name from the list. Otherwise, they would unintentionally help legitimize exactly the kind of policy that the manifesto is meant to reject.

1

The Speech

From the very outset, Marc Bonten has been in agreement with OMT chairman Jaap van Dissel, who has served as the chief advisor to Prime Minister Rutte during the pandemic.
Mark Rutte in zijn tv-toespraak van 16 maart

On March 16, in his first live, nationally televised speech in almost half a Century, Rutte explained his choice for the "scenario" of keeping "maximum control" of the virus.

According to Rutte, "maximum control" is to be understood as the sensible middle way, between letting the epidemic take its course without any measures being taken on the one hand (which would result in chaos in hospitals) and a "never-ending lockdown" on the other hand. The latter may seem "attractive", said Rutte, but: "In that scenario we would actually have to shut down our country for a year or even longer, with all the consequences that entails."

The definition of 'maximum control' (the official translation of the speech can be read here ):

  • not exceed healthcare capacity;
  • "protecting" the elderly and the vulnerable;
  • building immunity until "herd immunity" forms a "protective wall" protecting the elderly and vulnerable.

The Prime Minister received praise from all sides for his supposed display of determined and wise statesmanship. There was also widespread appreciation for his supposedly relying entirely on experts. As Rutte stated:

Let us rely on that knowledge and experience. And on experts such as Jaap van Dissel and his colleagues both at the National Institute for Public Health and the Environment and elsewhere. On the virologists, intensive care doctors and other specialists.
Mark Rutte

In other words, the Outbreak Management Team – which is comprised of exactly those disciplines.

Only a handful of people on social media and the occasional journalist were shocked by Rutte's remarks, and put forward questions such as:

  • Why was the option of containment by means of test/trace/isolate (as demonstrated by South Korea and China) not mentioned at all, while containment was strangely defined as a "never-ending lockdown"?
  • "Maximum control" is Newspeak (the John Snow Memorandum contrasts sharply with this): suppression/containment with test/trace/isolate gives a much larger degree of control over the virus than allowing the epidemic to grow up to the point of reaching max healthcare capacity.
  • "Protecting" the vulnerable is Newspeak as well: when aiming for herd immunity, protecting them is next to impossible. And even if you would succeed in doing so, this 'protection' constitutes a forced isolation from society, which is inhumane itself.

It would later turn out (see reports in De Telegraaf ) that thousands of elderly people, including in nursing homes, died under horrific circumstances – often, not even additional oxygen was available. Currently, Minister De Jonge is using the Government Information (Public Access) Act in an improper way to keep documents from being disclosed to the public.)

2

The misdirection

After OMT member Marion Koopmans confirmed the estimation of high expected numbers of casualties in the tv news program Nieuwsuur on March 17, criticism of Rutte's herd immunity plans mounted.
Marion Koopmans bij Nieuwsuur
Marion Koopmans bij Nieuwsuur

His well-known political agility served him well: in the parliamentary debate the following day, the prime minister got away with a semantic diversion, relabeling herd immunity as not a "policy goal" in and of itself, but merely as an "effect".

The fact that almost everyone accepted this explanation speaks volumes of the state of Dutch public debate.

In the following months, the left-wing opposition slowly started to push for the type of policy that Germany had been pursuing with reasonable success (albeit to a lesser extent than South Korea): the suppression of the virus, keeping it below levels manageable for a robust testing & tracing system.

It seemed to have some effect: in a parliamentary debate in June, Rutte actually stated he wanted "as few infections as possible".

The illusion of suppression

Rutte said: “One of the tools we utilise in the strategy of maximum control is: as soon as an outbreak looms, you suppress and contain it through testing and contact tracing.” That did sound like an improvement. But the Prime Minister added something as well:

It is also possible to set containment as a strategic goal. However, that ignores the fact that people do not always adhere to the rules of conduct, and also the fact that The Netherlands is an open economy, where people will reintroduce the virus upon reintry. […] It would require a long-term lockdown, or something resembling it closely.

This answer was a display of vintage Rutte: using semantic tricks to deflect criticism. As he did on March 16, he outlined a false distinction between the strategy of "maximum control", within which, he now says cleverly, "suppression" ('indammen') - is "one of the tools" on the one hand – and an eternal lockdown on the other. He explicitly does not have "suppression" as a "strategic goal"; for him it is an instrument, a means, a tactic.

The opposition allowed itself to be lulled to sleep, because Rutte conflated the strategy of containment with the destruction of the economy. With that rhetorical ruse the Prime Minister obscured the fact that countries like China, South Korea, Taiwan, Vietnam, New Zealand and (to a considerable extent) Germany, have adopted containment as a "strategic goal" without any problem – although it is not something you can strive for somewhat, but is something that has to be pursued wholeheartedly. The outcome is not worse economy-wise – on the contrary, as more and more colleagues of public health economist Xander Koolman argue, at home and abroad.

Any strategy of suppression should simply have realistic assumptions regarding behavioral compliance, and compensate for the expected lack thereof. Rutte and his team apparently wish to do so inadequately. This offers a useful excuse for policy failings: the citizen failed to behave in the manner they were modeled to in computer simulations.

"Preferably to zero"

Jaap van Dissel surprised many in a parliamentary briefing in August.

Van Dissel: "Regarding the strategy: in the beginning we were understandably unsure about what exactly would happen. We have found that it is possible to suppress the virus to very low levels. That means that the suppression of the virus, preferably to zero, is the goal. In practice, though, partly because we are an open society, we will experience outbreaks."

De uitleg over 'Het virus maximaal controleren'
De RIVM-pagina over het gekozen scenario, d.d. 27 juni 2020

The remarks appear to indicate a switch to a suppression strategy, although certain degree of doubt remains. On the website of the National Institute for Public Health and the Environment (RIVM), the original page about the strategy of "maximum control" via "gradual spread" (which can be found here in The Internet Archive, recorded on June 27, 2020) of the virus was removed and a text appeared elsewhere on the webssite which contained the following passage:

"Maximum control means preventing the spread of the coronavirus as much as possible. As a result, the number of new infections goes to (almost) zero and new outbreaks are prevented or remain manageable. The goal is to keep the reproduction number (R) below 1."

This appears to be a more convincing choice for suppression than Rutte's rhetorical juggling in June had been. And the new text seems to be incompatible with a telling parliamentary briefing by Van Dissel on March 18 (two days after Rutte's national speech).

3

The briefing

In the briefing on March 18, Van Dissel said the following.

An exhaustive quote, because it is too little known and because it is important to Marc Bonten's current position.Van Dissel:

People will get infected […]. The vast majority will be able to fight the infection themselves with their immune system. This means that afterwards there will be resistance against reinfection, because otherwise we would not be able to explain the course in China [sic; Van Dissel apparently incorrectly assumed that herd immunity instead of a successful suppression strategy had stopped the virus in its tracks in China]. The immunity that you build up with this can of course concern a person, but can also concern an entire group. If it concerns a whole group, you speak of herd immunity. What is the advantage of that? The advantage is that all the infections people will get, since it is nature that stirs, eventually result in a group of people who no longer contract the infection. As a result, they reinforce the effect of other interventions. That's an important thing. [...] Why is effect enhancement important? Well, that is the difference between a total lockdown [...] and an approach where you try to control it as closely as possible and try to ensure that there is sufficient ICU care capacity. The important thing is that if immunity among individuals increases, other measures may be relaxed to a certain extent. Herd immunity will help us to combat and protect vulnerable groups. [...] so, the point is not to develop heard immunity for the entire Dutch population. That is something that may develop or that we will eventually achieve through a vaccine. The point is that what is happening now does contribute to the control measures. [...] What I mean by that is that you invest in something. You actually get that with maximum control and the fact that you then build up immunity. So we think it is an important aid in titrating measures and enabling measures. [...] Then I would like to talk about the concept of the lockdown [which according to van Dissel is prevented in his scenario of "maximum control"]. [...] the big point is that at that moment you don't do anything to build up any resistance.

This is clear language. According to Van Dissel, the build-up of immunity among the population was not just an "advantage", but even "an important thing", as a result of which "the measures could perhaps be reversed somewhat". "The point is" that this "contributes to control measures". You "invest in something". It is an "important aid" in "titrating measures and enabling measures". He does not want to drastically stop the virus, because then no "resistance" is developed, thanks to nature, which simply takes its divine course.

Van Dissel compared his investment scenario to taking out a mortgage on a house:

  • the repayment = allowed infections in the population, with sacrificed health & lives as a regrettable downside
  • social & economic restrictions = interest you have to pay on the mortgage. Once you build up more immunity (develop more ownership), the monthly interest payment decreases. If you decide not to invest (do not allow the virus to spread), these restrictions would still have to be paid in the form of rent (the so-called neverending lockdown). It may be cheaper in the short run, but not in the long run.
  • the accumulation of gradual ownership of the house = the building up of immunity among the population;
  • the ultimate pleasure of burden-free living = a society where social & economic restrictions are no longer necessary, hospitals can deal with a stable influx of patients, and the weak & frail are supposedly protected by herd immunity.

See also the video outtake:

It sounds tempting, and the MPs ate it up. Unfortunately, they failed to note with justified indignation that the house on which Van Dissel took out his mortgage, quite resembles a morgue, and his 'investment' payments are a stream of of corpses. A few did bring it up, they had watched Nieuwsuur, but without inspiration.

Earlier in the briefing, Van Dissel gives the impression that tens of thousands of deaths would only occur if no measures would be put in place to suppress the virus. Or that the policy he advises would result in a the development of a vaccine which would happen much sooner than the time it would take to develop spontaneous herd immunity and the high numbers of deaths in the run-up to it.

The first is strange; the second does not alter the fact that he does not make the ethically correct choice to primarily save human lives in a situation of uncertainty about both a possible vaccine and the consequences for the economy. The precautionary principle.

Schadenfreude

These days, people abroad may hardly be able to suppress a certain feeling of Schadenfreude about the sky-high second wave of the epidemic in the Netherlands, with its "maximum control" and its "intelligent lockdown" in the spring.

Despite polite, repeated and well-founded warnings from the now established "Red Team" of concerned field epidemiologists, among others, Rutte and his OMT recklessly loosened the reins of the lockdown in the summer (up to and including almost encouraging the resumption of the international tourism, which later turned out to be a major contamination route). They blatantly failed to build an adequate TTI infrastructure and to overrule Van Dissel's stubborn rejection of face masks (the latter has only recently been done).

As in a number of other countries, we are still not experiencing a total collapse of the healthcare system, because the percentage of sick people requiring care is considerably lower than in the spring. As the schools have reopened without adequate security measures, the virus is now circulating among young people who run less risk. But it doesn't have to stay that way. It would be a matter of sheer luck if it would turn out that COVID-19 mortality has decreased due to unknown causes; it is more likely that the virus will catch up with higher age groups relatively quickly.

Now what?

The press conference of the Prime Minister and the Minister of Health on October 13 and the parliamentary briefing by Van Dissel and the parliamentary debate the following day were eagerly awaited. Would a suppression strategy finally be formally announced, as so many people have asked for?

The answer is no. Mark Rutte did not admit to having made any mistakes except for a few minor things. His current narrative boils down to the same story as his answer in June (see above), which was another repackaging of his March 16 speech, with a false pretense of containment.

Did Jaap van Dissel change his mind, then? I wish it was true. He said that as soon as the latest, half lockdown (probably even more 'intelligent' than the first) brings the reproduction number R back to below 1 and the pressure on the hospitals will decrease – he expects by January at the latest – the OMT would consider the easing of restrictions already. Whether our TTI is finally in order became not very concrete, nor did the realization that TTI can only work at all at a low infection level.

It doesn't really sound like "suppression of the virus, preferably to zero in my opinion". Was he lying, in August?

4

Back to Bonten

Bonten added something important to his announcement that he signed the manifesto in The Lancet

In his Tweet, Marc Bonten referred to his his article which was published on the website of the Dutch Journal of Medicine: "... this is what I wrote about herd immunity on May 25th. And I still stand by that."

In that article, he wrote the following:

"When the concept of herd immunity was first used in this context, a number of (foreign) experts thought that developing herd immunity was the only measure against SARS-CoV-2. That would indeed have been a reprehensible strategy. [...] The epidemic had passed through the country in a few months, and with 1% mortality as a result of the infection, we are talking about 100,000 deaths due to COVID-19 – that is excluding collateral mortality due to the collapsing health care system. As far as I know, that was never the plan. [...] the chosen strategy to [suppress] the first wave and then control its spread reduces the build-up of herd immunity. The more effective the measures against the spread of the virus, the longer it will take for us to conquer the virus based on herd immunity. Best estimates come down to a few years ... [...] However, this does not mean that a slowly growing immunity in the population has no effect whatsoever. Depending on the distribution of immunity in different population groups and on the interaction between these groups, a seroprevalence of 20% may already allow for the easing of restrictions. But that will take a while, because recent seroprevalence figures from the Netherlands, Spain and France were all between 3% and 5%. [in May]"
Nederlands Tijdschrift voor Geneeskunde

So, things are not going all too well with this herd immunity. "Ultimately, we hope that an effective vaccine will become available," said Jaap van Dissel earlier this week in the House of Representatives.

It goes without saying that Bonten's remarks are very similar to those of Van Dissel in the parliamentary briefing on March 18 (and Rutte in short in the speech on March 16). Crucial is the word "only" in the first paragraph above – he says the Dutch strategy would not reprehensible, because measures are taken to prevent the healthcare system from overflowing, which would result in many additional casualties.

Just like Van Dissel, Bonten sees the development of a large reservoir of immune citizens – he mentions 20 percent as an example – as one of the pillars of the current policy. Both men offer a false choice between 'letting it rip' and the current policy of "controlling" the epidemic by allowing it to spread within the limits of the healthcare system. The possibility of containment as a strategy, at a contamination rate well below 20 percent, is remarkably absent.

Both men posit that immunity buildup is also (or even) useful if it would not lead to full herd immunity. Both consider this 'partially developed herd immunity' as a useful brake on the epidemic, as in their view, partially developed herd immunity would make it possible to ease other restrictions. Both hope for a vaccine, but conclude that the develoment of herd immunity will continue, even expecting this to possibly "protect" or save us in the future. Both hardly question whether that protection is realistic, although Bonten places slightly more question marks elsewhere in his argument than Van Dissel and is more transparent about the possible number of deaths associated with this strategy.

By means of the three dots at the end of the paragraph about "measures against the spread" versus "the build-up of herd immunity", Bonten subtly sighs that he finds it quite a dilemma (*), because with effective measures the hoped-for herd immunity might take "years". What exactly explains the ambiguity of the Dutch policy, not "all" for containment as a strategy, that is, choosing not to suppress, at the expense of thousands of unnecessary victims, whose suffering is changing too fast a neat statistic.

5

Necropolitics

Now that Bonten has stated that he still endorses this approach, there can hardly be any doubt about the Dutch corona strategy

The Dutch strategy is still not suppression or containment, but mitigation or a 'controlled allowed spread', ostensibly within the limits of healthcare capacity (although those are now being severely exceeded for the second time) and supposedly while protecting the vulnerable – which in practice is secured only by empty words and in fact sacrificed in what one radical critic of the policy has not quite falsely called "necropolitics". The route to herd immunity must and will remain open.

Our prime minister is more like a cunning Minotaur - one that keeps building new policy labyrinths to hide his true nature – than a compassionate statesman. The cold-blooded, heartless Dutch policy, sold to the public as paternal-protective, against which Containment Nu/Now has been fighting since the spring and which the Red Team is now increasingly criticizing as well, is alive and well, virtually unchanged since the beginning. That is a monumental shame. We must hope that this country will ever come to its senses, organizes a parliamentary inquiry, and condemns the actions of this government in the harshest terms.

But given the ever-growing popularity of his party, the advancing (virus) madmen of Forum for Democracy and the influential pub table culture of our talk shows, even that hope may turn out to be in vain.

Much thanks go out to @globalgreendeal (follow his Twitter account on climate action) for lots of editorial input.

Note (*) Bonten's tweets often exude a similar ambiguity with regard to containment (suppression, keeping virus circulation at very low levels indefinitely) versus mitigation (delaying the spread, protecting healthcare systems). On May 4 in the afternoon, Bonten responds to someone's comment "I am still a strong containment advocate", with: "Me too, but in my view, we think too lightly of containment", indicating it would not be feasible in practice. On May 4 in the evening: Bonten tweeted that the government policy, in Rutte's own words, is "mitigation" and that he chooses to do so "very carefully". August 25: "Don't really understand the difference between containment and mitigation", Bonten tweeted. On the radio that day he had rejected "containment" because, according to him, it was equivalent to the (total) eradication of the virus; but the common meaning is to contain the virus at very low levels of infection, allowing for large-scale testing and tracing to keep it that way. September 8: In the Dutch Journal of Medicine, Bonten again sows terminological confusion: at first, he dismisses "containment" as the near-impossible goal of zero infections (which is usually called "eradication"), while subsequently dubbing the Dutch policy as "containment within the limits of what is possible and socially acceptable", only to add that "you can also call that mitigation, if you want to."

It is Bonten's way of doing exactly the same as Rutte: obscuring the possibility of pursuing suppression like South Korea and New Zealand (and to a considerable extent Germany). This is done in one of two ways: either by pretending that the Netherlands is already doing the same thing as those countries (namely, containment), or by dismissing containment by equating it with eradication. The containment countries show that with large-scale use of TTI and masks without (many) drastic lockdowns, the epidemic can be kept at a very low infection level, both in terms of weekly new infections and cumulatively.

The following comment by Bonten in the NTvG of September 8, therefore again betrays which motive continues to play a role for him: to keep the formation of group immunity going (possibly gradually) in case no vaccine is allowed (note the word "hopefully"):

Bonten: “Like most other countries in the world, we will have to accept that SARS-CoV-2 is among us and that we must continue to take control measures until group immunity makes them unnecessary. Hopefully we will achieve that soon with a vaccine. But even then it is likely that the virus will continue to circulate, similar to the flu. " Whether the virus could eventually be defeated worldwide with internationally coordinated damming policy, however difficult such a process may be, is apparently already a foregone conclusion for Bonten. From the outset, the nasty COVID-19 disease was "similar to the flu" for him and the rest of the OMT.

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