We are fighting a war, and while doing so it can be difficult to look forward into the future. Right now, we are just trying to decide when will this disease “peak,” level off and decline and when is it safe to relax restrictions that have been placed on Americans.
But, for the purposes of this blog post, I want to look beyond this pandemic. One day, this pandemic will be history. And, as the oft quoted saying goes, “those who do not learn history are doomed to repeat it.” We must be bold enough to admit that there are many opportunities for improvement and we must capture those soon, and put improvements in place, before life returns too much back to normal and this is no longer at the top of our consciousness. The following are the conclusions I think we need to come to, and then at then end, I will list my recommendations:
- Let’s stop saying that no one could have foreseen this. I understand that the public at large never imagined this, but scientists, health care experts and the government have contemplated this kind of event for nearly two decades (and not only have we had other pandemics, we have had a number of close calls), and the realization of such a threat is very well documented. This is not our first pandemic, and I hate to tell you, but this will not be our last. If we can stop talking about this like it is unimaginable or some kind of fluke event, we can start preparing for the next one. We will then have the opportunity to avoid some of the loss of life and damage to the world’s economies that we are experiencing now.
- Let’s also not pretend that this health crisis has been led and managed perfectly and the outcome we are suffering could not have been avoided to some extent. If we don’t, then we will not take advantage of all the lessons that can be learned to improve our response the next time. To just reinforce my point, there will be a next time, perhaps not in my lifetime, but I cannot imagine there will not be another pandemic, or at least epidemic posing the risk of a pandemic, in my children’s or grandchildren’s lives.
- Let’s admit that we were not prepared. This is not about Trump-bashing. Let me be clear, no president in modern history has been prepared for the kinds of disasters that scientists, health care experts and even members of their own administrations have warned them about. It seems to me that one of the failings of having public health and disaster planning under the President and subject to his budget is that politicians are generally not rewarded for major long-term investments that their constituents cannot feel the benefit of and that may only pay off when they are no longer in office.
- Let’s realize that we were slow to act in a day and age that requires a much faster response to a pandemic threat than before we were a global society and economy. And, this is always likely to be the case as long as the decision to act will be under the direction of a politician, and it is hard to fault them. No one wants to be criticized for “overreacting.” But, in a world where more than 115 million people travel internationally a day and about 320,000 people arrive to the U.S. every day from other countries, it is not hard to see how quickly an infectious disease can spread across the world, when the doubling time of an infection is measured in days.
- Let’s also realize that we need the cooperation of the world to adequately defend against these threats. We all need to share public health and medical information real-time. This is probably a good time for us to reach international agreement on this. Further, any time we identify a “novel” virus, as we did on January 10, 2020, this must be our highest level and quickest response from all over the world. A “novel” virus means (1) we don’t know who has the infection, (2) who can transmit the infection, (3) how the infection is transmitted, (4) whether someone can be infected yet asymptomatic, (5) whether someone who is asymptomatic (or more likely, pre-symptomatic) can transmit the virus, (6) how long it takes to develop symptoms once someone is infected, (7) how deadly the virus is, (8) how to contain the virus and prevent its spread, (9) how to prevent health care workers from being infected, and (10) how to treat someone infected with the virus. Thus, when we first detect an outbreak of a novel virus, we must have the world’s agreement that we are going to shut that area of the world down immediately. No one travels in or out of that area until we can answer a good number of these questions.
Just to emphasize this point, in the time between we knew that there was an outbreak of infection with a novel virus until the time we restricted travel from China to the U.S., we likely had more than 6 million travelers arrive in the U.S. from foreign countries. Even with the restriction, we were allowing people from China to return to the U.S. if they were residents without knowing yet that perhaps 20% of those who are infected are asymptomatic and yet, contagious. Thus, temperature screening of travelers turned out not to be an effective way to prevent someone from inadvertently bringing the infection into the U.S.
Now, in full transparency, I have no proof that even a full lock-down by the time we become aware of an outbreak with a novel virus would be fast enough to contain the outbreak. There is still likely to have been travel by the time we realize this is a new type of infection. Nevertheless, it seems likely if we can limit the number of people coming into the U.S. who are infected, perhaps we can slow down the spread and give us additional time to prepare and develop our testing capabilities.
If we can agree on some or most of the above, here are my recommendations:
- When we get to a more stable situation, we need to have a neutral party (someone who does not have to worry about political embarrassment or grandstanding) do a comprehensive review of the preparation and response, including the successes and missed opportunities of the White House, the CDC, FEMA and all levels of the federal government, the state governments, local governments and health care providers. We must capture best practices to embed in our pandemic plans for the future, as well as learn from the challenges and failures we experienced so as to make them less likely in the future. The party doing this study should also document the lessons learned from the successes and failures of the WHO and other countries.
- When this review is completed, we need to bring together those who were involved in the management of the COVID response from the Trump administration and from state governments, as well as leaders involved in public health and disaster planning from past administrations, pandemic experts from the government, academic and private sectors; and members of Congress to review the findings, prepare a new pandemic plan for the future and identify the changes in government structure, function and funding required to prepare us for the next threat.
- We should also bring the WHO and the world’s leaders together to share lessons learned and to develop better systems to monitor the world for new health threats and to better coordinate the world’s response to these threats. This should begin with pressure on China from all the world’s governments and the WHO to outlaw the wet markets, where exotic animals are kept in close proximity and sold for consumption. We have now had two novel coronaviruses that previously were limited to animals, but spread to humans from China and very likely from these markets. This is no longer a China issue; this is a world health issue.
- As I mentioned above, the world’s response to a novel virus must be swift and much more drastic than in the past. Before, we could not contemplate a situation where we would implement a strict travel ban, not allowing citizens to return home for a period of time. However, we have now seen first-hand that the consequence is relatively fast spread to most of the countries of the world. I am not suggesting that U.S. citizens remain trapped overseas, but rather that anyone in the area of an outbreak with a novel virus remain there until the home government can provide for safe travel home that protects others from possible spread of the infection and a period of isolation or quarantine upon arrival home to the U.S. until we can learn enough about the infection to ensure that the likelihood that they will transmit it to their families, co-workers and others is very low.
- The plan for the next pandemic needs to be clear about roles and responsibilities. I, and I think most of my colleagues who are health care leaders, thought that the federal government was well-prepared for this scenario, including ample supplies in the Strategic National Stockpile. That proved not to be the case. Most of us were shocked when we heard the White House tell physicians, hospitals and health systems that we should rely on our traditional supply chains, not the federal government or the Strategic National Stockpile. Our traditional supply chains were broken. There was hoarding, price gouging and limitations on supplies and equipment that we could purchase, even if providers were willing to pay the asking price. Further, this meant that hospitals were negotiating and competing for supplies with other hospitals, states, the federal government and the approximately 160 other countries who were all trying to buy supplies. Further, we learned that over the years, budgets for the Strategic National Stockpile and maintenance of equipment in the Stockpile had been reduced, and, as a consequence, most of what was available could only be directed to the several states who were in most need.
- The plan for the next pandemic must provide for multiple sources of tests and supplies, not just the CDC. The sole reliance on the CDC to develop the test for the coronavirus meant that there was no back-up plan if something went wrong, and something did go wrong. This led to serious delays and a missed opportunity for containment strategies. Further, we need to appreciate that having a test is only as good as the ability to ramp up testing capacity, attain testing reagents, attain testing supplies that are needed to obtain specimens and personal protective equipment (PPE) to protect health care workers in obtaining the specimen from a patient.
- Every disaster the U.S. has ever responded to has required private industry. The U.S. simply does not have all the resources needed under control of the government. Yet, we have to acknowledge that private industry, while we have seen numerous acts of amazing community support, often acts according to economic incentives. As an example, many companies that were producing badly needed equipment and supplies for the American heath system, were at the same time exporting these goods to other countries who were in need. I am certainly not suggesting that we should not help other countries. However, before we do, we must ensure that we have Americans taken care of. This in of itself would be a good reason to use the powers of the Defense Production Act. Further, we are more than four months into this pandemic and we still have health care providers who do not have sufficient PPE, medications, ventilators, testing reagents, and testing supplies. As a consequence, we cannot be sure who is infected and who is not, which causes us to utilize more PPE than we ordinarily would and unfortunately, we have had many health care workers exposed or infected, which can further compromise our response to this health crisis. We are just now getting rapid testing deployed to some areas of the country. But, until recently, it was not unusual to not have test results back for 7 – 10 days, a situation that further compromises our ability to respond to a public health threat effectively. My point being that in the future, we should be far quicker and more aggressive in utilizing the authority under the Defense Production Act. Americans would understandably be upset if we sent our young men and women into war without an adequate supply of uniforms, bullet-proof vests, weapons and ammunition, tanks, etc., but that is in essence exactly what has happened with our health care workers as we have sent them in to fight this war against an invisible invader.
- We have seen first hand how important it is to have real-time data on numbers of new cases, hospital admissions, ICU admissions, number of patients on ventilators, deaths, days of supplies on hand, etc. Much of this has required reporting by hospitals and laboratories to their states, the CDC and many other agencies and systems that need this data. Let’s take this opportunity to see how much of this we can automate, so that we don’t have to recreate it for the next health emergency, and let’s look at the opportunity to utilize artificial intelligence so that perhaps this can augment our disease surveillance and reporting for other infectious diseases that we deal with annually or even year-round, even when we are not dealing with a pandemic.
- Finally, we need to have a difficult conversation about how we manage a disease outbreak within the U.S. At the time the U.S. was imposing a travel ban on persons from Ireland travelling to the U.S., NYC actually had more confirmed cases than Ireland did. People debate the wisdom and effectiveness of travel bans. I get it. However, even those who argue against them seem to agree that it can slow down the spread of an infectious disease. That is what the U.S. needed – more time. More time to better understand the virus, to study potential therapeutic options, to develop a vaccine and to prevent our hospitals from becoming overwhelmed. So, should we implement travel restrictions within the U.S.? Ask those towns that are ski resorts. Almost all of them have significantly higher numbers of cases of COVID than other parts of the U.S. Why? People who were infected elsewhere and did not realize it, traveled to these resorts and transmitted the virus to others.
I’m sure I will have more about this in future blog posts, but I think this is an important discussion for us to have as a country.