Intended for healthcare professionals

Editorials

A European roadmap out of the covid-19 pandemic

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1556 (Published 17 April 2020) Cite this as: BMJ 2020;369:m1556

Read our latest coverage of the coronavirus pandemic

  1. Martin McKee, professor of European public health
  1. London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
  1. martin.mckee{at}lshtm.ac.uk

Coordination between countries is crucial

Europe has been hit especially hard by the covid-19 pandemic, with Italy, Spain, and France occupying the top three positions in the global league table of deaths.1 All EU countries have imposed measures to contain the spread of the virus, although these vary considerably. Now, as some countries see death rates falling, they are looking at how to get back to something resembling normality, and the European Commission has published a roadmap to guide them.2 Reassuringly, the roadmap places epidemiology in the driving seat.

Key elements

The roadmap has three key elements. First, no country should consider lifting restrictions until it is certain that the disease is under control. This will pose a challenge for some, as it presupposes that national authorities have accurate and timely information on cases and deaths. As the United Kingdom’s experience shows, this can be difficult. The importance of this information cannot be overstated. Measures taken must be judged against their ability to keep the reproduction number, or R0, below 1. In other words, each infected person should not infect more than one other. Second, countries should ensure that they have sufficient health system capacity, especially to provide intensive care, given the risk of a second wave of infections. Fortunately, there have been many examples of countries with spare capacity, such as Germany, offering care to patients from other countries that have been hit especially hard.3 Third, there must be sufficient capacity for large scale testing and monitoring, linked to the ability to track and trace contacts of those infected. This too will be challenging for some and will necessitate bringing additional laboratories on board.

The roadmap emphasises the importance of coordination after the decision to lift restrictions has been made. This is especially important in border areas. In the twin towns of Nova Gorica and Gorizia, for example, the Italian-Slovenian border divides the main square, and it would be bizarre to have different policies on either side. Although not stated in the commission’s document, the special status of Northern Ireland after Brexit will require similar measures across the Irish border. So, the European Commission has called on governments to notify their neighbours, and the EU, when they propose loosening controls.

What the roadmap does not do is prescribe what measures should be taken. These are the responsibility of national governments. It does, however, emphasise that whatever decisions are taken should be accompanied by a robust system of reporting and contact tracing, expanded testing capacity, strengthened health systems that are adequate to cope with any resurgence of infection after restrictions are lifted, improved personal protection, and progress in developing new treatments. All of these measures should be harmonised, making it possible to exchange information. Ultimately, however, the European Commission recognises that the threat will be lifted only when there is a safe and effective vaccine.

Principles

The roadmap proposes principles to underpin any loosening. First, change should be gradual, allowing enough time to determine any impact. Second, general measures should be replaced with progressively more specific ones; for example, continuing to protect vulnerable people for longer. Third, when border controls are lifted, there should be careful coordination, paying particular attention to the situation facing those who live in border areas. Fourth, economic activity should be phased in; for example, by allowing those who can work at home to continue to do so for longer. Fifth, the risks of transmission in different gatherings, such as sports activities, cafes, or schools, should be considered carefully. Sixth, measures such as enhanced hygiene and social distancing should continue. Lastly, again, there should be careful monitoring.

Finally, the roadmap looks to the future. In his speech to the French people on 13 April, President Macron said: “In this crisis there is a chance . . . to build another project.”4 This vision is echoed in the call to revitalise the economy, returning to a path of sustainable growth and a greener society, supported by a major recovery programme, accompanied by a package of measures including research on vaccines and treatments and international cooperation.

The initial European response to covid-19 was fragmented and poorly coordinated. The European Commission’s president, who trained as a public health physician, has said that Europe owes Italy an apology for failing to respond adequately.5 But the commission’s powers are limited. Covid-19 is a reminder that there is little point adopting national measures against a virus that crosses borders with ease. A stronger Europe, with enhanced powers in health, will be an essential barricade against the next pandemic.6 The recovery will take a very long time, but at least the roadmap provides a way forward.

The UK is, of course, now outside the EU and initially declined an invitation to join the joint procurement initiative.7 At some stage it will have to develop its own roadmap. Neil Ferguson, epidemiologist and professor of mathematical biology who advises the British government, has said that there is “little leeway” to relax measures without “something . . . in their place,” such as testing and contact tracing.8 Given the limited progress so far, this seems a long way off. When the plan finally emerges, it will very likely look much like what the EU has produced already. We can only hope that it avoids what has become the norm over the past four years, whereby the EU publishes detailed proposals while the corresponding British documents, lacking substance, have to be prised from the hands of ministers. Maybe, given the urgency involved, this time we could borrow some ideas from our neighbours.

Footnotes

  • Competing interest: MM is a member of the European Commission’s Expert Panel on Effective Ways of Investing in Health and is research director of the European Observatory on Health Systems and Policies. He holds grants from the European Union’s Horizon 2020 Research Programme.

This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

References

View Abstract