In France it is the ’ground zero’ of the Coronavirus or Covid-19 outbreak. The département or county of Oise, just north of Paris, has so far recorded at least 99 cases of the virus out of the 577 announced in France by Friday March 6^th. Nine of its communes or towns and villages, including Creil, Crépy-en-Valois and Croix-Saint-Ouen, have had to close their schools.

The mayor of Créil, Jean-Claude Villemain, described the measures that have already been taken: “Those who are able to are working from home. People are advised not to move outside of the clusters. All gatherings are banned: sports competitions, mass, political meetings...”

But the mayor then highlighted the inconsistencies in this strategy: “We have a very large shopping centre at Creil which remains open and which attracts people from across the département and even the Paris region...”

The main lesson to be be drawn from the Oise is that “we’re no longer in control of anything ” declared Françoise Courthalac, a family doctor or GP at Croix-Saint-Ouen, one of the most affected communities.

She herself has been confined to her home since last week, when her GP surgery partner tested positive during his holidays in Nantes in western France. The link with the virus was swiftly found. The very first case in the Oise, that of someone who worked on the military airbase at nearby Creil, was treated at their surgery right at the start of their illness. That person is now being treated at hospital in the northern city of Amiens.

Françoise Courthalac, who is vice-president of the Oise branch of the medical association the Ordre des Médecins, has had the time to keep up to date with what is going on. “But in the end I’m not absolutely sure of what I’ve understood. The administrative and political messages, at national and regional level, are different and change all the time...” She thinks the health authorities are overwhelmed: “Out of the three doctors in the practice, who are all in isolation, only one has been called by the regional health agency [ARS],” she said.

As for the criteria for being tested for Coronavirus, Françoise Courthalac gathers that they are being tightened. “The only ones tested are those who have had initial contact with ill people who have clinical signs, as well as cases of respiratory distress,” she said. “For example, I am fine and I haven’t been tested.”

The GP is not also sure about the effectiveness of the 14-day isolation or quarantine period for those who have been in contact with a person with the virus. And local nurse Marie-Odile Guillon, who went to a meeting of the Hauts-de-France regional health authority meeting in the northern city of Lille on Tuesday March 3^rd, is categorical on the issue: “If they don’t have any symptoms, then the isolation of [health] professionals is lifted. And they won’t be tested.”

In the hospitals at Creil and Compiègne the 14-day isolation for two hundred nurses who were in contact with two ill people in hospital without any precautions has also been lifted. “They’ve been called back in,” said Loïc Pen, an accident and emergency doctor at Creil. The regional health authority or ARS for the Hauts-de-France region of northern France said in a statement: “This decision is an application of the national policy (which has changed on this point).”

Meanwhile at the Tenon hospital in Paris, where many nurses were exposed to a patient with Covid-19, those nurses who are healthy have been called back to work. “...We can’t afford to keep nurses off work for 14 days if they don’t have symptoms,” said Éric Caumes, a specialist in infectious diseases at Pitié-Salpêtrière hospital in Paris.

Officially France is at ’Stage 2’ of the health response strategy which provides for hospitalisation in all confirmed cases and a test and isolation in all those case where there has been high-risk contact. But in reality it has passed to Stage 3 in those areas where the virus is circulating, such as the Oise. In Stage 3 the strategy concentrates on people who have Covid-19, and they are the only ones to be isolated, tested and taken to hospital.

Even people suspected of close contact with the virus are no longer automatically hospitalised under this approach. Philippe Veron, a GP at Tracy-le-Mont in the Oise, said that the ambulance service sent him a “diabetic patient with a temperature and a cough, who had however been seen by the endocrinology department at Compiègne hospital where someone was ill with Coronavirus virus, and where no precautions had been taken”.

How does he treat people in such circumstances? “I put on an out of date FFP2 [editor’s note, particulate respirator] mask which dates from the H1N1 flu [editor’s note, known as swine flu] episode in 2009. I have four left. After that, what do I do?” he asked.

Indeed Philippe Veron, who is president of the Oise branch of the Ordre des Médecins, is furious at the way health professionals are being treated. “GPs have been left to their own devices, the health authorities have abdicated from their responsibility. The regional health authority [ARS] is missing in action,” he said. “They send us into the front line without us being either informed or equipped.”

All GPs, plus community nurses and and midwives, are in the process of being sent fifty one-use surgical masks. “That doesn’t quell the anger on the ground,” insisted Philippe Veron. “Fifty one-use surgical masks isn’t sufficient. The best masks – the FFP2s – have been reserved for hospital doctors. For the H1N1 flu outbreak we received a parcel of FFP2 masks, glasses and overalls, everything that was needed,” he recalled.

At Crépy-en-Valois, where the geriatric hospital has been affected, as well as two retirement homes, the pharmacist Cécile Lefeuvre is also angry. “We are short of hydroalcoholic solution,” she said. “Masks are reserved for doctors, nurses and midwives. We pharmacists don’t have anything! The authorities have not anticipated this. The handling of this crisis is rubbish.”

The GP Françoise Courthalac takes a similar view from the vantage point of her isolation: “They’ve not interested in us, the non-employed medical staff [editor’s note, in France most GPs work in the private sector and are not employed by the health service, unlike hospital doctors], I’m fed up with it.”

But even at the hospital in Creil accident and emergency doctor Loïc Pen said: “They are asking us to be economical with our use of FFP2 masks, which is unacceptable.” An indication of the shortages comes from the fact that more than 10,000 masks have so far been stolen from French hospitals.

On Tuesday March 3^rd the Ministry of Health announced that it was getting “15 million to 20 million” masks out of state reserves. The same day President Emmanuel Macron announced that the state was going to requisition “all the stocks and production of protective masks. We will distribute them to health professionals and to French people who have Coronavirus”.

Yet talking to Libération one of the major French manufacturers of masks, Valmy, explained that they were busy with making masks for the National Health Service (NHS) in Britain who had sent in an order before the French authorities. “We’ve been telling [the French authorities] for six weeks that there was going to be a problem,” the director of production told the newspaper.

However, there is no sense of panic in the Oise. “We’re worried for elderly and vulnerable people, just like with the flu,” explained pharmacist Cécile Lefeuvre. “It’s journalists who are spreading panic.”

At his GP practice Philippe Veron has “fortunately” not noticed an increase in the number of patients. “On the contrary, some patients have cancelled appointments or non-urgent examinations,” he noted.

The GP Françoise Courthalac says she is not worried about her own health nor that of her practice partner who is doing well. But she is worried about the elderly and the more fragile members of society. “Even if I’m not ill I can transmit the virus to them,” she said. “From the moment that there are healthy carriers we’re no longer in control of anything at all.”

Specialist Éric Caumes at Pitié-Salpêtrière, one of three benchmark establishments in the Paris region for handling the virus, and an institution in the vanguard against the epidemic, said: “From the moment when a large number of infected people are not ill, you can no longer stop the virus.” But at the same time he seeks to reassure about the severity of the virus:“I think that we’re faced with a flu. But is it a little flu or a big one?”

’The real problem is the health system getting overwhelmed’

The largest Chinese study carried out so far, which was published on February 24^th in the Journal of the American Medical Association, suggests that 14% of virus cases are severe and 5% critical, and that it has a death rate of 2.3%.

However, according to specialist Éric Caumes this study is not “reliable”. He said: “...we only know the tip of the iceberg, not its depth. There are many cases without symptoms, and most of them are not tested. The real problem is that the health system gets overwhelmed. Because this Coronavirus is going to hit a lot of people: the population has no immunity, there’s no vaccine, no treatment. So it can cause a lot of deaths in a short time. But I remind you that the flu kills around 10,000 people each year.”

In the Oise the medical services are facing up to the situation. “It’s chaotic in the accident and emergency unit, there are lots of patients in the corridors, but the situation is pretty much the same as usual,” said Creil hospital emergency unit doctor Loïc Pen. “For the moment we have more flu cases than Coronavirus. The problem for the nurses is to distinguish between the two, the symptoms are the same. On the other hand Samu [editor’s note, the ambulance service] at Beauvais [editor’s note, a city in Oise to the north west] is completely overwhelmed by emergency calls. There are three thousand a day which is 2.5 times the normal.”

The country’s health minister, Olivier Veran, has tried to head off potential panic by calling for “transparency”. But here in the Oise there is still confusion as to the source of the local outbreak. “The Creil conurbation has had the finger pointed at it even though there has been no case locally,” said its mayor Jean-Claude Villemain. “All the cases have been on the military base.”

It is certainly true that the first case in the Oise was a civilian employee on that military base, who is now in hospital in Amiens. On February 29^th the director general of France’s public health agency, Jérôme Salomon, acknowledged that ten personnel on the base in all had the virus. But he ruled out the idea that the original source patient for the virus – the so-called patient ’zero’ – was on the base. “The investigation has discovered that two people were ill earlier at the start of February, having been exposed to an earlier ill person who still remains to be identified, who would be patient zero,” said Jérôme Salomon. “One of these [two] people had regular contact with a female friend who works at Creil airbase. That is the current theory for the virus going around the airbase at Creil.”

However, the senior health official admitted that some personnel at the base, from the Estérel squadron, had taken part in the repatriation of French citizens from Wuhan, the virus’s epicentre in China, at the end of January. “This flight did not have any passengers on board who tested positive, I remind you that every person was tested twice, and that the flight crew was protected and monitored for 14 days,” said Jérôme Salomon.

In a statement the French military also insisted: “No, the military personnel from Estérel squadron who carried out the reparation operation from Wuhan to Paris on January 31^st 2020 did not bring back the Coronavirus from China. No member of the crew entered Chinese territory. On the aircraft’s return the crew was subject to the surveillance protocol of 14 days spent at home. Their temperature was taken twice a day. After 14 days of surveillance none of them showed any symptoms.”

However, none of them was in fact tested. And it is now known that people who are infected but who do not fall sick can still transmit the virus.

The infectious diseases specialist Éric Caumes does not believe that it was the air force that transmitted the virus. “The military are rigorous, and have excellent doctors who are infectious disease specialists. It is also possible that the base was contaminated through a soldier’s child. Many personnel from Charles-de-Gaulle airport [editor’s note, to the north-east of Paris] live in the Oise. Chinese tourists sleep in hotels in the suburbs around Paris. The virus probably started to circulate from there, then contaminated the schools,” he said.

That is the reason why schools are closed in the towns and villages where the virus is circulating. Children themselves have virtually no symptoms – in China just 2% of those diagnosed with the virus are under 20 – but they can contract and transmit it.

For example, a link has been found between a 60-year-old teacher at Crépy-en-Valois who died and an older man who tested positive at the Tenon hospital in Paris; the latter’s granddaughter was at school in the same place as the teacher. The girl herself is fine.

“Children transmit the virus via dirty hands, they touch their mouth and nose all the time, then touch their friends’ hands,” said Éric Caumes. “But it should be repeated: children have no problem with this virus! It won’t spare many people but like a flu outbreak it will be more serious if you are older or have respiratory problems or other illnesses. It’s going to be older people who are going to pay a heavy price for this illness because they are the most vulnerable.”

Italy has tried to stop the spread of the virus by shutting schools and universities until at least mid-March. But Éric Caumes is surprised at this approach. “We’re in the process of following China’s example. Yet so far there have only been only 3,000 deaths in two months, in the world, and that’s nothing. And the measures only delay the problem: in China the virus will start to spread again when economic activity returns. There are already four coronaviruses going around, which cause colds, flu-like symptoms and sometimes serious pneumonia. This one will probably end up joining the other four and we will soon no longer speak about it.”

In the meantime Oise, like the rest of France, is having to face up to local elections over two rounds of voting, on March 15^th and March 22^nd. “We are asking a lot of questions,” said Creil mayor Jean-Claude Villemain. “For example what should we do with the registration book, which is touched by everyone? The election monitors talk with all the voters. Should they wear gloves, masks? We haven’t had a response. The election is in ten days.”

Caroline Coq-Chodorge

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