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Karine Lacombe: « If we act as if the epidemic is over, the slap in the face is likely to be strong”

The infectious disease specialist refers to « the most crucial period of all that we have gone through », but also responds to the attacks of the far-right as well as of some colleagues…

L’ExpressInterview by Stéphanie Benz and Thomas Mahler

Translation by Citizen4Science courtesy of L’Express, link to the original article in French, 12 May 2021

In the media, she is one of the leading figures of a scientific language that wants to be rational. But after having been one of the first to criticize hydroxychloroquine (a meta-analysis published in Nature Communications has just underlined its inefficiency…), Karine Lacombe has become the recurrent target of violent attacks from supporters of Professor Raoult as well as from far-right figures. In the case of Florian Philippot, one can even talk about obsession… In her usual straightforward manner, the head of the Infectious and Tropical diseases Department at Saint-Antoine Hospital (Paris, France), in a major interview with L’Express talks about the health situation, which is still a cause for concern despite the decline in the number of infections. But Karine Lacombe also clarifies her proposal of an allowance for vaccinated people which has caused controversy, explains why France is far from being today a « sanitary dictatorship », and speaksabout cyberharassment coming from alt-right as well as from people close to the IHU in Marseille, an institute of which she denounces a « deleterious influence »…

L’Express : The health situation is improving and still, you recently announced that »the summer may become a nightmare »

Karine Lacombe : First, it is a quote taken out of context, taken in the middle of a 20-minute interview with Jean-Jacques Bourdin, and itself taken from another television interview, but as the media game requires, we only retain this kind of shocking sentence! Having said that, I have often been accused of playing the Cassandra, but I have only used the models that are being released. Santé publique France, the Scientific Council and even to some extent Olivier Véran, the Minister of Health, say the same. If we do not accelerate the pace of vaccination, if we reopen the country too early and too widely, if this opening is not accompanied by strong public health messages in the media, if there is not very close monitoring of indicators with very rapid decision-making, regionalized if necessary, yes, we are heading for difficulties, with an epidemic that will start again.

Be careful not to be influenced by talks about declining number of cases: what is important is the level at which we will find ourselves when we reopen everything. However, with an incidence rate of over 300/100,000, 4,000-5,000 patients in intensive care and 2-300 deaths per day, this level is very high, well above that of all other European countries when they started to soften sanitary measures. When the UK began their release of lockdown, the vaccination rate of the population was much higher than ours, and more importantly, the incidence of the disease was  extremely low. We have none of these parameters. It’s a bet, an equation with many unknowns. Besides, the English have opened their borders without quarantine for several countries such as Portugal or Iceland, but not for France…

This does not mean that we should not be optimistic. But we mustn’t pretend that the problem has been solved either, because the slap in the face could be very strong.

Are you afraid of a fourth wave?

Of course. Given the current indicators and what is known about the epidemic dynamics, we probably should have been more cautious and postponed the announced release of lockdown schedule by at least 15 days. Thus the number of cases would have been lower, and in addition we would have saved fifteen days of vaccination. Now, if we have this fourth wave, what are we going to do? I am very concerned that it will be said that it is impossible to put severe restraint measures back in place, and that we will continue to try to « live with the virus. »

As a result of the policy implemented in recent months, France is one of the few European countries to record a continuous excess of deaths since October. If we continue like this, we will be left with high rates of transmission, overcrowded hospitals, and excess mortality. Not to mention the threat of variants, in a context where the majority of the population will not be vaccinated with two doses, which is known not to be the optimal protection. Especially since France has decided to extend the time between the two Pfizer or Moderna injections to 42 days, without any real scientific data, simply to have more vaccine doses available. In the United States, they sticked to 21 days. With 42 days, we don’t know if the vaccine response will be as good or as long-lasting, and there is no guarantee that we will have the same level of protection, especially against variants.

 « 20% to 30% of French people will not spontaneously show up to get vaccinated…”

 With 25% of the population vaccinated with one dose but only 10% with two doses, we are indeed still far from it…

 The rate of vaccination is still too slow in France. We perform 500,000 injections per day, while Germany performs one million injections on certain days, for example. The Germans have more vaccinodromes than we do, they also have more health centers, more structures in the community allowing to be vaccinated next door. They also opened faster on weekends and evenings. In addition, in France, vaccination has slowed down because of public holidays, but also because for two weeks we have reached a ceiling among the people authorized to be vaccinated, with a part of the eligible public not wishing to receive an injection. That’s why we said it was imperative to open up access to other categories. In such conditions we will quickly be able to vaccinate all those who want to. So we still gained time compared to the planned schedule. But then we run a risk of bumping into this famous ceiling. That’s why we need to win over the percentage of people who don’t want to be vaccinated today.

You put forward the idea of an « allowance » for vaccinated people, which caused a scandal. What are the foundations?

Motivations for accepting public health interventions can be diverse. Most of the people involved have a personal interest in this, they want to protect themselves. Some are also very sensitive to altruism, they protect themselves but also others. There are also anti-vaccine people, who represent a small minority, probably 5% of the population. We will never be able to reach them (and even then, general practitioners can win some of them over to the vaccine cause thanks to their proximity status). And then there is a segment of the population, perhaps 20% to 30%, for whom this is simply not the priority. Because they don’t have the time, they’re caught up with money, they don’t have access to the internet to make an appointment, or they don’t understand the issues. They are often people in vulnerable social, economic or psychological situations. Public health studies, notably by Nobel Prize-winning economist Esther Duflo, have shown that « incentive » mechanisms can change the situation and bring these populations to public health intervention. There are many examples, in the HIV screening, viral hepatitis, tuberculosis.

This can be adapted to the context. If 80% to 90% of the population must be vaccinated to achieve herd immunity, we will need to implement public health actions to reach those 20% to 30% of French people who will not come forward spontaneously. These « incentives » can be translated in different ways. In the United States, where the problem is the same, this is done through monetary donations. But it can also be buses that go to areas that are difficult to access (geographically or socially) and that offer a cup of tea, a moment of conviviality. Perhaps the best « incentive » will be the health pass (we see how it is beginning to be applied in Germany for access to certain places of conviviality) and the possibility of travelling freely, of having access to cultural places, etc. In any case, it is imperative to look into the subject, and it is not for me alone to say what should be done: a think tank should be organized, with economists, sociologists, psychologists, public health specialists… Anyway we must think about it.

You defended the « Zero Covid » strategy. In a recent study published in the Lancet, economists and public health experts show that countries that have sought to eliminate the virus (South Korea, Australia, New Zealand…) rather than « live with it » have not only benefited from lower mortality, but also from a faster economic recovery and less restrictive measures overall…

I was not the only one to defend this strategy. But maybe I have been the most vocal about it in the media. If we had had a lockdown in January, as everyone had requested and expected, we would be in a completely different situation today. It seems that the reason for not confining was the fear that it would not be the last time, thus a political decision and not a sanitary one. But now, in France, this option of zero Covid is no longer possible. Since last summer, the massive offer of screening has not been accompanied by an optimization of the triptych testing – tracing – isolation due to a lack of human resources, but also because of inconsistencies in decisions (for example, no virological control at the time of arrival on French territory). Similarly, not enough attention has been paid to the evolution of health indicators, and curbing measures have always been taken too late, always against the wall and never in anticipation. Politics has largely taken over from health and today, unfortunately, we are very far from being able to eliminate the virus.

« It may even be an honor to be the target of the far right, like Philippot”.

People like the controversial expert Martin Blachier have described this strategy as being totally out of touch with reality…

But health economists are reporting the same thing! The Lancet article is the first on the subject, but there will be more. Work is underway on the decisions made by the various governments. We will see with the hindsight of the analysis how the strategy taken in France is positioned on the economic level compared to the rest of Europe. We physicians are not motivated by health considerations alone, as some have claimed.

Putting a country on life support and trying to live with the virus was not only not a normal life, but it also affected the mental health of many people. This situation in which everything is closed but not really, where you reopen before going back, is extremely deleterious on the psychological level.

Decision-making in times of health crisis is probably the most difficult to argue and no one can guarantee in advance that it is the right choice that will be made, hence the importance of deciding in a collegial manner and not alone, relying on all sensitivities, economic, health, social.

You are violently attacked by the extreme right, like Florian Philippot or Nicolas Dupont-Aignan. A petition to withdraw your Legion of Honor has even been launched by the Patriots movement. How do you explain this hatred?

I don’t know why. I think it started at the beginning of the epidemic, with the hydroxychloroquine story. I found myself stigmatized by Facebook groups of yellow vests (« Gilets jaunes »). Then it was taken up by the far-right activists. Since then, I must inspire a lot of representatives of the extreme right (including Florian Philippot), who sometimes tweet compulsively about me! I really don’t care about that. It may even be an honor. The only thing that would worry me would be acting out. For now, it remains mainly on social networks. But undoubtedly a channel like Cnews has also played a role, by complacently giving voice to some polemicists without facing contradictors…

On Cnews (French TV channel), Martin Blachier accused you of being an « opportunist » who « surfs on trends » with « toxic statements »…

I don’t talk about colleagues. I never accuse anyone, I try to stick to the facts, and give an opinion based on scientific arguments. So, if I may, I will continue in this vein.  On the other hand, one can wonder about his underlying motivations…

Citizen4Science Association, of which you are a member, has just denounced the cyberharassment of which Dominique Costagliola, Elisabeth Bik and yourself are victims. They also denounced « threats and legal proceedings », which would emanate « directly from the IHU Marseille-Mediterranean »

It is difficult to understand why the supervisory authorities do not react. There may be a difficulty on their side to react in the moment. And then it’s very complicated to file a complaint, you have to be supported, it takes a lot of time, and frankly we have a lot of other things to do right now than filing a complaint for harassment or defamation. One day we’ll get out of this epidemic, and this will all be over. I am quite philosophical about this. As for the attacks coming from members or relatives of the IHU Marseille-Mediterranean, it is up to each institution to clean up its own house. In particular, there have been edifying attempts to intimidate Elisabeth Bik, an internationally renowned microbiologist and scientific integrity specialist. The problem is that the Assistance Publique – Hôpitaux de Marseille (AP-HM), the supervisory authority of the IHU, is dependent on this institute for its budget. The day hospitalization for the delivery of hydroxychloroquine, with a bill of more than 1,000 euros per patient, is a real scandal which allowed AP-HM to recover a lot of money on the back of the government and the citizens. You will therefore understand that AP-HM is paralyzed. It is a political-financial system that has been in place for decades, and it works well like that. It is difficult to rethink everything in the name of ethics. That would be up to the Ministry of Health and the Ministry of Research.

But when you know that ministries have endorsed the IHU for decades, president after president, it is complicated… That said, we must not forget that the CNRS and Inserm withdrew this institute’s accreditation as a research organization, well before the Covid-19 crisis. the institute’s long-standing and well-known dysfunctions. Finally, the change in management at the head of the AP-HM, with the arrival of François Crémieux, former DGA of the AP-HP, is perhaps a first sign of normalization of the functioning of this institution in which many colleagues work who can no longer bear the deleterious influence of the IHU therein.

As Dominique Costagliola stated in “Le Monde” (French newspaper), do you go so far as to think that Macron’s visit to Didier Raoult in his office at IHU in April 2020 represented an original sin for the executive in terms of defending scientific speech?

I often agree with Dominique Costagliola. The executive justifies itself by saying that it needs to listen and consult with everyone. But this is an open door to irrationality. This raises questions about the choices that are made. In this epidemic, the scientific community, in its vast majority, has been on similar positions. But it is the dissident 5% who are the most vocal and the most interviewed in the media. Those who are listened to are precisely those who have a dissonant voice. That’s what attracts the buzz…

How do you respond to those who like Philippe De Villiers, believe that we are in the midst of a « health dictatorship »?

In a pandemic situation, it is obvious that health measures must be taken to protect the population. But the proof that we are very far from a « sanitary dictatorship » is that there has been a mixture of politics, economic imperatives and sanitary considerations in the decisions, and that all the currents, even the most harmful ones, have been able to express themselves (I take as an example the hydroxychloroquine scandal). The real problem is that we are in a country where decision-making is very centralized, whereas a health crisis of this dimension would undoubtedly have required collegiality and decentralized implementation. What has been missing in this crisis is a real role for parliament and a citizens’ committee, whose existence was requested by the scientific council in May last year. Nothing has been discussed democratically. But this is not the fault of the doctors, it is the fault of the functioning of the 5th Republic.  The Scientific Council analyses the situation and makes proposals. Then the president can use or not use these reports. President Macron followed the Scientific Council at first, and then paid less attention to it. There is no real counter-power, this is probably one of the lessons of this health crisis. The French context is probably not adapted to the management of such a crisis. In Germany or in any other country where there is regionalized decision making, it has happened in a different way, with a better consideration of the democratic process.

« The most crucial time of all we’ve been through.”

India and Brazil have shown that political inaction can lead to calamitous situations…

These are experimental models, and it is unfortunately quite impressive. This is what denial of the epidemic can lead to. We will never experience the situation of India or Brazil because we have a much better health system. It is clear that when there is a health alert, even if it is reluctantly, braking measures are taken.

Should we always be afraid of variants? The vaccines seem to be effective for the moment…

If we vaccinate fast enough, especially with Pfizer and Moderna, we should be able to contain the evolution of these variants. But even AstraZeneca and Janssen, if not optimal, still protect better than nothing.

For the Indian variant, we do not have enough data on its spread in France, but a good isolation and tracing strategy should contain its spread. The Brazilian variant is also somewhat present in France. These variants are more transmissible and may result in more severe forms. But for both Brazilian and South African variants, Moderna and Pfizer vaccines remain highly effective.

When will we see the end of the tunnel?

We’ll get there! The month ahead of us will be crucial, until the summer. We have to see how the variants, vaccination and incidence rate will evolve once we reopen. These next six weeks will be perhaps the most crucial period of all that we have been through for over a year. We now have all the weapons we have been waiting for: broad access to vaccination, but also broad resources for testing, which we must not forget. In the hospitals, the work done has been remarkable, and care techniques have made great progress. What we probably lack are spots on TV, radio, press or social networks. Not to celebrate the reopening as was done in a demagogic way. But to remember that everything depends on our behavior. If we miss and have an epidemic rebound, we will find ourselves in the same situation as in March/April.

We now know how this epidemic works. When the first wave came out, reassurance was given that it was over. We were saying « beware! ». Unfortunately, this has been confirmed. Some have denied the third wave, but when you look at the dynamics of the infections, there has been an upturn after a high plateau. There, the contaminations go down. But when we reopen, it may stabilize on a plateau that will remain high. So whether or not there is a fourth wave will depend totally on us.

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