Medical: Learning From the COVID-19 Failure — Before the Next Outbreak Arrives

Chronicle of a Pandemic Foretold –

Michael T. Osterholm and Mark Olshaker – HEADS OF STATE 

“Time is running out to prepare for the next pandemic. We must act now with decisiveness and purpose. Someday, after the next pandemic has come and gone, a commission much like the 9/11 Commission will be charged with determining how well government, business, and public health leaders prepared the world for the catastrophe when they had clear warning. WHAT WILL BE THE VERDICT?” 

That is from the concluding paragraph of an essay entitled “Preparing for the Next Pandemic” that one of us, Michael Osterholm, published in Foreign Affairs in 2005. The next pandemic has now come, and even though COVID-19, the disease caused by the new coronavirus that emerged in late 2019, is far from gone, it is not too soon to reach a verdict on the world’s collective preparation. THAT VERDICT IS A DAMNING ONE.           

There are two levels of preparation, long range and short range, and government, business, and public health leaders largely failed on both:

FAILURE ON THE FIRST LEVEL IS AKIN TO HAVING BEEN WARNED by meteorologists that a Category 5 hurricane would one day make a direct hit on New Orleans and doing nothing to strengthen levies, construct water-diversion systems, or develop a comprehensive emergency plan.

FAILURE ON THE SECOND IS AKIN TO KNOWING that a massive low-pressure system is moving across the Atlantic toward the Gulf of Mexico and not promptly issuing evacuation orders or adequately stocking emergency shelters.

When Hurricane Katrina hit New Orleans on August 29, 2005, preparation on both levels was inadequate, and the region suffered massive losses of life and property as a result. The analogous failure both over recent decades to prepare for an eventual pandemic and over recent months to prepare for the spread of this particular pandemic has had an even steeper toll, on a national and global scale.

The long-term failure by governments and institutions to prepare for an infectious disease outbreak cannot be blamed on a lack of warning or an absence of concrete policy options. Nor should resources have been the constraint.

After all, in the past two decades, the United States alone has spent countless billions on homeland security and counterterrorism to defend against human enemies, losing sight of the demonstrably far greater threat posed by microbial enemies; terrorists don’t have the capacity to bring Americans’ way of life to a screeching halt, something COVID-19 accomplished handily in a matter of weeks. 

And then, in addition to the preparations that should have been started many years ago, there are the preparations that should have started several months ago, as soon as reports of an unknown communicable disease that could kill started coming out of China. 

THIS PANDEMIC IS PROBABLY NOT “THE BIG ONE.” 

The public health community has for years known with certainty that another major pandemic was on the way, and then another one after that — NOT IF BUT WHEN.

Mother Nature has always had the upper hand, and now she has at her disposal all the trappings of the modern world to extend her reach. The current crisis will eventually end, either when a vaccine is available or when enough of the global population has developed immunity – if lasting immunity is even possible – which would likely require some two-thirds of the total population to become infected. Neither of those ends will come quickly, and the human and economic costs in the meantime will be enormous. 

Yet some future microbial outbreak will be bigger and deadlier still. In other words, this pandemic is probably NOT “the Big One”, the prospect of which haunts the nightmares of epidemiologists and public health officials everywhere. The next pandemic will most likely be a novel influenza virus with the same devastating impact as the pandemic of 1918, which circled the globe two and a half times over the course of more than a year, in recurring waves, killing many more people than the brutal and bloody war that preceded it.

Examining why the United States and the world are in this current crisis is thus not simply a matter of accountability or assigning blame. Just as this pandemic was in many ways foretold, the next one will be, as well. If the world doesn’t learn the right lessons from its failure to prepare and act on them with the speed, resources, and political and societal commitment they deserve, the toll next time could be considerably steeper. Terrible as it is, COVID-19 should serve as a warning of how much worse a pandemic could be — and spur the necessary action to contain an outbreak before it is again too late.

WAKE-UP CALL 

For anyone who was NOT focused on the threat of an infectious disease pandemic before, the wake-up call should have come with the 2003 outbreak of SARS. A coronavirus — so named because, under an electron microscope, the proteins projecting out from the virion’s surface resemble a corona, a halo-like astronomical phenomenon — jumped from palm civets and ferret badgers in the markets of Guangdong, China, made its way to Hong Kong, and then spread to countries around the world. By the time the outbreak was stopped, the animal sources eliminated from the markets, and infected people isolated, 8,098 cases had been reported and 774 people had died.

Nine years later, in 2012, another life-threatening coronavirus, MERS, spread across the Arabian Peninsula. In this instance, the virus originated in dromedaries, a type of camel. Since camel owners in the Middle East understandably will not kill their valuable and culturally important animals, MERS remains a regional public health challenge. Both coronaviruses were harbingers of things to come, even if, unlike COVID-19, which can be transmitted by carriers who are not even aware they have it, SARS and MERS tend not to become highly infectious until the fifth or sixth day of symptomatic illness.

SARS, MERS, and a number of other recent outbreaks — the 2009 H1N1 flu pandemic that started in Mexico, the 2014–16 Ebola epidemic in West Africa, the 2015–16 spread of the Zika flavivirus from the Pacific Islands to North and South America and the Caribbean — have differed from one another in a number of ways, including their clinical presentation, their degree of severity, and their means of transmission. But all have had one notable thing in common: THEY ALL CAME AS SURPRISES, AND THEY SHOULDN’T HAVE.

For years, epidemiologists and public health experts had been calling for the development of concrete plans for handling the first months and years of a pandemic. Such a “detailed operational blueprint”, as “Preparing for the Next Pandemic” put it in 2005, would have to involve everyone from private-sector food producers, medical suppliers, and health-care providers to public-sector health, law enforcement, and emergency-management officials. And it would have to anticipate “the pandemic-related collapse of worldwide trade . . . the first real test of the resiliency of the modern global delivery system.” Similar calls came from experts and officials around the world, and yet they largely went unheeded.

PREEXISTING CONDITIONS 

If anything, despite such warnings, the state of preparedness has gotten worse rather than better in recent years — especially in the United States. The problem was not just deteriorating public health infrastructure but also changes in global trade and production.

DURING THE 2003 SARS OUTBREAK, FEW PEOPLE WORRIED ABOUT SUPPLY CHAINS. Now, global supply chains are significantly complicating the U.S. response. The United States has become far more dependent on China and other nations for critical drugs and medical supplies. The Center for Infectious Disease Research and Policy at the University of Minnesota, where Osterholm is the director, has identified 156 acute critical drugs frequently used in the United States — the drugs without which patients would die within hours.

All these drugs are generic; most are now made overseas; and many of them, or their active pharmaceutical ingredients, are manufactured in China or India. A pandemic that idles Asian factories or shuts down shipping routes thus threatens the already strained supply of these drugs to Western hospitals, and it doesn’t matter how good a modern hospital is if the bottles and vials on the crash cart are empty. And, in a strategic showdown with its great-power rival, China might use its ability to withhold critical drugs to devastating effect. 

Financial pressure on hospitals and health systems has also left them less able to handle added stress. In any pandemic-level outbreak, a pernicious ripple effect disturbs the health-care equilibrium. The stepped-up need for ventilators and the tranquilizing and paralytic drugs that accompany their use produce a greater need for kidney dialysis and the therapeutic agents that requires, and so on down the line. Even speculation that the ANTIMALARIAL HYDROXYCHLOROQUINE might be useful in the treatment of COVID-19 caused a shortage of the drug for patients with rheumatoid arthritis and lupus, who depend on it for their daily well-being.

It remains unclear what impact COVID-19 has had on the number of deaths due to other conditions, such as heart attacks. Even if it is mostly a matter of patients with severe or life-threatening chronic conditions avoiding care to minimize their risk of exposure to the virus, this could ultimately prove to be serious collateral damage of the pandemic.

IN NORMAL TIMES, THE UNITED STATES’ HOSPITALS HAVE LITTLE IN THE WAY OF RESERVES AND THEREFORE LITTLE TO NO SURGE CAPACITY FOR EMERGENCY SITUATIONS:

NOT ENOUGH beds, NOT ENOUGH emergency equipment such as mechanical ventilators, NOT ENOUGH N95 masks and other personal protective equipment (PPE). The result during a pandemic is the equivalent of sending soldiers into battle without enough helmets or rifles. 

The National Pharmaceutical Stockpile was created during the Clinton administration and renamed the Strategic National Stockpile in 2003. It has never had sufficient reserves to meet the kind of crisis underway today, and it is fair to say that no administration has devoted the resources to make it fully functional in a large-scale emergency.

PLANS VS. PLANNING 

Humans do not have the power to prevent all epidemics or pandemics. But with the sufficient will, resources, and commitment, we do have the power to mitigate their awesome potential for causing premature deaths and attendant misery.

To begin with, Americans must change how they think about the challenge. Although many people in the public health sphere don’t like associating themselves with the military — they heal rather than kill, the thinking goes — there is much that they can learn from military planning. The military focuses on flexibility, logistics, and maintaining readiness for any foreseeable situation. As U.S. General Dwight Eisenhower noted, “Peace-time plans are of no particular value, but peace-time planning is indispensable.” 

The starting point should be to prioritize health threats in terms of their likelihood and potential consequences if unchecked. First on that list is a deadly virus that spreads by respiratory transmission – coughing, sneezing, even simple breathing. By far the most likely candidate would be another high-mortality influenza strain, like the 1918 one, although as revealed by SARS, MERS, Zika, and COVID-19, new and deadly non-influenza microbes are emerging or mutating in unpredictable and dangerous ways.

AS EMERGENCY PLANNERS ARE FOND OF SAYING, YOU DON’T WANT TO BE EXCHANGING BUSINESS CARDS AT A DISASTER SITE.  

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