The novel coronavirus is a part of a large family of viruses, ranging from the common cold to the severe acute respiratory syndrome, or SARS. The U.S. already has a system in place to deal with influenza and other mild illnesses, but how prepared is the American healthcare infrastructure is to take on an eventual pandemic of COVD-19?
There is one chronic problem that afflicts governments in their preparedness for dangerous unforeseen pathogens. They fall into a negative cycle of governments veering between crisis and complacency. They think the situation is important but mobilize on a crash basis, but as the crisis fades, they lapse into complacency again and underinvest in the kind of preparedness needed. The U.S., in comparison with other governments, is reasonably well-prepared but still has significant deficiencies. The Nuclear Threat Initiative and Johns Hopkins put out a Global Health Security Index last fall. This goes into great detail evaluating preparedness capacity for every country in the world. The U.S. comes out looking better than almost every other country.
However, there are weaknesses too. In the 2008-09 financial crisis, the budgets at local and state levels for public health personnel declined by 25% and were never replenished. Our public health capacity is at about 200,000 health professionals in the States but are still understaffed by a quarter. The CDC, NIH and other institutions within HHS have suffered budgetary erosion in the last few years which has weakened the U.S. The Trump administration has attempted to slash these budgets, which has further contributed.
Another weakness is that we don't have a solid, continuous, senior level capacity within the White House to coordinate, manage, and respond to programs across multiple agencies, and to guide the response when unforeseen and dangerous things happen. So, we have weaknesses but also have a very strong government. The CDC has 14,000 career professionals and another 10,000 on call. This doesn't exist anywhere else in the world. The NIH has exceptional capacity as well. Also, much of what happens in health preparedness happens in the private sector, in terms of new vaccines, therapies, diagnostics, and cures. We have within the U.S. the premier multinational biopharmaceutical and biotech firms. We also have exceptional foundations outside the government, like the Bill and Melinda Gates foundation and the Wellcome Trust (UK) which are very important in developing technologies needed in this crisis.
China’s strategy of containment of the virus was drastic and draconian--forcibly quarantining entire cities, shutting down schools, factories, and workplaces, and limiting or banning travel by shutting down airports. Based on the declining rate of infection, the Chinese approach seems to be working. But did China adopt unnecessarily harsh measures in stopping the virus?
We have never seen a quarantine lockdown measure imposed over a period of time for such a vast population. At its peak, there were 150 million people under total lockdown stretching over two months and half of the population under some form of controlled movement. We need to acknowledge how extraordinary this reality is. Only the Chinese government is capable of doing anything like this, with the speed and scale we have seen. Authoritarian enforcement of quarantines like this need to be done at the right time. If they come into effect too late, they’re useless. Moreover, quarantines can backfire. People can become sicker not less sick. People in this midst of the crisis still need their basic and urgent health needs taken care of, but they are asked to isolate.
Isolation was meant to slow and interrupt transmission of the virus. The Chinese have begun to show results. However, many of the accompanying issues remain around this enforced quarantine, like respect for civil liberties, the repression of journalists and individual citizens expressing themselves on social media. Are people suffering because of these provisions? We can’t really see it, since we have no access. We don't know much about how the Chinese people are responding to this scenario and we don't have survey instruments to reach and collect data. The data we do have are anecdotal and fragmented. The Chinese government would like you to believe that this has been a huge success and that they are moving back to normal. It is hard to believe that since they control the release of data on how many people have been infected, cured, or died. They have very tight control over epidemiological data with the ability to control the narrative. And they enforce that pretty brutally. Whatever hardships or violations of civil liberties are difficult to see in these situations. China is setting a precedent for a response to pandemics around the world that is very authoritarian.
The Chinese will say that this is proof of their model of highly authoritarian, top-down control working. It's important to note a few things. When the doctor, Li Wenliang, died of coronavirus, that was a turning point. He was the initial young doctor in Wuhan who in December noticed this curious new virus and began to communicate this via social media. But he was ordered to stop since the government repressed the release of information, thus slowing the response for 6 weeks. When he died in January, there was a major outpouring of sympathy, grief and anger by the Chinese people. Over a billion social messages of solidarity with him were posted on social media. This is an important data point.
Is it politically feasible for the U.S. to adopt Chinese-style containment measures in case the virus gets out of control? How far do you think the U.S. government will go to protect public health?
We have laws on the books that give state and local governments the right to quarantine, but they are used very sparingly. The quarantine for repatriated Americans from China was very narrow and administered in a fair way with a 14-day quarantine that did not elicit any significant negative reaction. However, we are now in a situation where we are seeing an explosion of cases with increased outbreaks, clusters, and transmission cases.
We are discovering that the virus spreads fast and if we find ourselves in a state where health systems are overwhelmed there will be pressure to impose controls--via voluntary self-isolation, which means staying home from work, restaurants, religious events--trying to minimize any congregational activity. But we also are likely to see governors and mayors declaring states of emergencies to suspend things to force people to socially distance themselves.
The early episode with respect to how a democracy deals with quarantine was Italy. The Italian government first announced it was imposing a quarantine lockdown on Northern Italy. This included 16 million people under lockdown--a quarter of the population in the wealthiest part of Italy including Milan and the Lombardy region, along with 14 other provinces taken under lockdown. This was an act of desperation since the outbreak was out of control, overwhelming the health service infrastructure.
Providers were saying it is necessary to slow the progression, or there will be collapse--they hope to flatten the curve to lighten to load on the health system to slow transmissions. But in Italy, it came in very late and they were slow and sluggish in their response and were chaotic without clear command and control and integration of their efforts. We will see what will happen. The Chinese are facing this right now--how do you keep people fed, keep the economy alive, and then try to maintain the economy, while preventing reigniting the transmission of the infection. It’s very difficult, no matter if you're doing it in China, Italy, or elsewhere.
How would you compare the U.S. and Chinese efforts with those of other countries that have reported large numbers of infections, particularly to South Korea?
The Koreans have an outbreak that is very large and dangerous, particularly in the city of Daegu and is concentrated within a Christian sect. In the initial phases of the outbreak, it got worse because that sect was uncommunicable and isolated from the rest of Korea, and so the many coronavirus cases proliferated. To its credit, the Korean government came in quickly and aggressively and put pressure on the leadership of the sect to disclose membership and contacts to trace transmission.
Additionally, the government was extremely aggressive at bringing forward testing at scale. They still have not won the game, but they moved sensibly and quickly to contain and trace. The U.S., on the other hand, did not move aggressively and quickly to develop and provide testing. There was a false belief in the States that the disease would be short-lived and more a problem of containment. They thought that we wouldn't see the virus spill into the States in a significant way, but that belief was wrong as we now know. We are now seeing a last-ditch effort to test and find out where the virus is, which is at too late a stage in comparison to Korea.
On a positive note, the speed and mobilization of resources to study the novel coronavirus is unprecedented. From the few weeks it took for Chinese scientists to sequence the genome to be shared with the world, to the global scientific community working hard to find a vaccine, the fight against the novel coronavirus outpaces previous outbreaks. However, obstacles still persist, as touched upon before. In your estimation, how long will we take to find a vaccine against the novel coronavirus. What are the main obstacles you see in its development, and then deployment?
We have significantly improved our ability to perform genetic sequencing to gather the data required in developing potential vaccines and antivirals for the coronavirus. The good news is that we are moving rapidly in that way. But there are obstacles. We don't know a lot about it. This is a new virus, so we could encounter a lot of problems.
Many of the candidates have come forward in their efforts to develop a vaccine--examples include the Coalition for Epidemic Preparedness Innovations (CEPI), and Johnson & Johnson Innovation too. This is all promising. One obstacle is that there needs to be very significant capital infusion to get to Phase III trials, which is where we have enough data about the vaccine or antiviral to know about efficiency. That may happen 18 months, or two years from now. We don't know, but it will take a lot of capital to get the vaccine to the point of beginning and succeeding in Phase III trials. However, if we do get through that entire process, we need to be successful at getting Emergency Use Authorization from the FDA, the European Agency, and the WHO. Next, we have to go into production to decide many things. We need to determine the volume needed of the vaccine, who is going to manufacture it, and how we are going to pay for it. Moreover, once you have the vaccine, you have to decide how are you going to get it to people in a way that is rational and fair. Huge uncertainties about this still remain.
Photo Credit:Content Providers(s): CDC/Dr. Fred Murphy / Public domain