By Susan Blumenthal MD MPA and Matina Kakalis
More than 40 new infectious diseases have emerged since the 1960s, but until the recent coronavirus pandemic, many nations had amnesia about the devastating impact of these outbreaks. As of March 28th, over 621,636 people globally have been infected with more than 28,658 deaths. In America, more than 105,470 cases of COVID-19 have been reported with over 1,730 deaths thus far. On Monday, the World Health Organization director-general said the pandemic is accelerating; it took 67 days to confirm the first hundred thousand cases, 11 days to confirm the second hundred thousand cases and just four days to confirm the third hundred thousand cases. Cases are expected to increase rapidly in the coming weeks.
This life-threatening illness is overwhelming all sectors of society including health care systems with a lack of adequate testing, insufficient personal protection equipment (PPE) for medical providers, not enough hospital beds and a lack of plans in place for schools, businesses, and individuals to effectively respond. Without a vaccine or effective treatments for the disease currently available, we need to take immediate action to follow proven public health practices, like social distancing and personal hygiene, to reverse the curve of this pandemic.
Battling this invisible enemy is very much like fighting a war requiring the mobilization of all sectors of society; each of us must contribute. The choices and decisions we make as individuals and communities now will impact the severity of the outbreak in the weeks and months ahead. An effective response should include the following key components:
Re-establish the White House’s National Security Council Directorate for Global Health Security and Biodefense
The White House should permanently re-establish the National Security Council Directorate for Global Health Security and Biodefense, which was dismantled by the Administration two years ago. With a permanent office dedicated to pandemic and bioterrorism preparedness planning, the federal government would always have senior leadership in place to immediately mount a comprehensive whole-of-government response. Moreover, annual funding for this permanent office would help break the “boom and bust” appropriations cycle that surges when a public health emergency occurs and diminishes when the threat subsides. While it was an important step forward that the White House appointed a Coronavirus Response Coordinator on February 27th within the National Security Council, this appointment came late in the pandemic response trajectory, missing a crucial window for earlier intervention and containment. Although delayed, the government is now mobilizing all federal agencies working with the private sector to contribute their resources to fighting the disease. Additionally, a trusted medical spokesperson must be at the forefront in consistently communicating with the public about a disease outbreak. This office should also work to develop a Pandemic Response Corps that works across the uniformed services but also includes a reserve corps of health practitioners, computer scientists, engineers, retired military and others who would be trained and ready to response in a pandemic or other large scale health emergency.
How Early Testing Shaped the Pandemic: Lessons Learned from Other Nations
Diagnostic testing at scale is essential to pandemic control with decisions about early testing shaping the course of the pandemic across the world. South Korea significantly slowed its epidemic by utilizing the most expansive and well-organized diagnostic testing systems available combined with extensive efforts to isolate infected people and trace and quarantine their contacts. The country also enacted a key regulatory reform that allowed officials to give near-instantaneous approval to coronavirus testing systems during this public health emergency, so that the country could test more than 10,000 people a day.
As the first coronavirus cases were reported in China, within hours Hong Kong moved rapidly to obtain travel and exposure histories from symptomatic patients, and then quickly isolated those individuals. With memories of the devastating national security, economic, and health impacts of the SARS and MERS epidemics, Hong Kong, Taiwan, and Singapore marshaled political and public will, implementing advanced tracking systems and interventions that have kept coronavirus cases and deaths relatively low.
In February, problems with reagents in the CDC’s coronavirus test kit impeded the rapid expansion of screening to state and local public health laboratories in America as did not adopting the WHO’s recipe for the test used in many other countries. Moreover, failing to swiftly navigate the FDA’s Emergency Use Authorization regulations, the government was stalled for about a month before expanding testing capacity to academic centers as well as to public health and commercial labs. On March 16th, the Administration stated that millions of diagnostic tests would become available by the end of that week, but this has not yet occurred. Additionally, the promised website that would show where tests have been conducted and positive cases have been detected across the country has not yet been established.
The United States has now accelerated the FDA approval process, so that high throughput platform testing will become possible. Such testing can process tens of thousands of tests each day, as compared to the hundreds of manual tests that had been conducted until recently. However, most clinicians and commercial testing labs will not administer tests to patients with COVID-19 symptoms in their offices, given the potential for viral spread to health care workers and other patients. For this reason, the US has begun establishing special testing units outside of hospitals and the drive-through testing stations, like those used in South Korea, to expand early detection safely and prevent viral transmission to others. Moving forward, America needs a rapid diagnostic test (one was just approved by the FDA this week), as well as home testing kits that provide results in a matter of minutes rather than days.
In the United States, hospitals are becoming overwhelmed with patients and do not have enough ventilators and personal protection equipment (PPE) for their health providers. Such scarcities put both providers and their patients at risk. In Italy, COVID-19 has seriously overloaded the healthcare system forcing rationing of treatment. These circumstances underscore the crucial importance of supporting the healthcare workforce with the resources and the PPE they need. The United States must take decisive action to prepare its healthcare system before cases reach similar crisis levels. After a call from Congress, the President invoked the Defense Production Act, to scale up production of these lifesaving medical resources. However, although masks and other equipment are now coming from a variety of sources, the President has not used his authorities to require companies to repurpose their factories to manufacture medical supplies at the massive scale needed now by our health care facilities.
Investments in Research Can Bring Lifesaving Dividends
As a result of revolutionary scientific advances, the COVID-19 genome was sequenced in two weeks after the coronavirus was identified as compared to the six months it took for SARS. This facilitated efforts to fast track the development of a vaccine. Pursuing an accelerated timeline, several vaccine candidates at the NIH and in the private sector are under development. In fact, last week a clinical trial began in Seattle of one of these vaccine candidates. However, the results of this study and subsequent production and distribution of this immunization, if proven safe and effective, could still take 12-18 months. Additionally, medications used for treating malaria including chloroquine and other anti-viral drugs such as remdesivir are currently being evaluated in clinical trials for treatment of COVID-19.
With three serious global coronavirus outbreaks occurring over the past two decades, exploring the feasibility of a universal coronavirus vaccine and establishing a national vaccine production center would be extremely worthwhile investments. Incentives should be provided to support public-private partnerships that help to mitigate the financial risks of developing life-saving vaccines.
Investigating Sex Differences
Emerging data indicates that while there are similar numbers of COVID-19 cases among women and men, more men than women are dying of the disease. This trend has been consistent across many countries severely impacted by the virus, including confirmed cases in China, hospitalized cases in Italy, and confirmed cases in South Korea, where men were 65%, 75%, and 89% respectively more likely to die than women. At this time, it is unclear whether these sex differences are due to biological differences such as hormonal or immunological factors, or behavioral factors such as higher smoking rates among men, a risk factor for severe disease.
As more data is collected about this pandemic, sex based analyses should be conducted. Gender norms, roles, and behaviors that influence women’s and men’s differential vulnerability to infection, exposure to pathogens, and treatment received should be considered and addressed. Understanding how pandemics affect females and males differently would be an important step forward in illuminating the effects of a health crisis on individuals and communities and for establishing equitable, effective policies and interventions.
Leverage Technology to Inform and Connect Us
Mobile devices present important platforms for instantaneously sharing information, tracking disease spread in real-time, facilitating professional training and research collaborations across communities and countries. Public health officials must work closely with the media to ensure accurate reporting of outbreaks and counter disinformation that can occur in social media.
Moreover, as individuals across the United States use social distancing and proven public health practices to #FlattenTheCurve, the media, the Internet with resources like coronavirus.gov and social media can provide important information as well as connectivity that can serve as an antidote to feelings of loneliness and isolation. The MIT Media Lab, in collaboration with Tufts Public Health and other organizations, has launched a creative social media campaign, #BeattheVirus, that is engaging celebrities, athletes, and citizens in implementing the personal actions that can help decrease viral spread.
Health in All Policies
The coronavirus pandemic has significant implications beyond health. Its economic toll must be urgently addressed with increasing unemployment and a plummeting stock market. Congress has passed several bills, including $8.3 billion to ramp up vaccine research, provide funding to state health officials, and boost prevention programs. On March 18th, the Senate approved a $104 billion bill that would provide direct help to Americans with expanded sick and family leave. What is now being negotiated in Congress is $2 trillion economic stabilization legislation to address the needs of individuals and businesses that have resulted from this devastating pandemic.
Additionally, as schools close their doors indefinitely and move online, approximately 30 million children who rely on the National School Breakfast and Lunch Programs for daily meals risk going hungry. Legislation must address ways to provide nutrition for these children. Moreover, for the five million households with school-age children who have no access to broadband Internet at home, school closures represent more than a temporary inconvenience. That is why the E-Rate should be expanded from public schools and libraries to homes so that children in low income families can keep learning during this public health crisis.
At the state and local levels, officials are making critical decisions in the battle against the coronavirus pandemic. Absent clear direction from the federal government, ten states including Massachusetts, California, New York, Illinois, Connecticut, New Jersey, Delaware, Louisiana, and Ohio have asked residents to shelter in place. One in three Americans have been told to stay at home amid this pandemic. The federal government should expand its coronavirus response guidelines to adopt consistent recommendations nationwide so that there is clear messaging for everyone. Social distancing and personal hygiene can only be maximally effective if every state and every person puts these practices into action.
Looking to the Future
Not since the 1918 pandemic flu, has there been an infectious disease outbreak that has threatened the health and economy of our country and world with such devastating and rapid impact. Making significant investments now to increase the scientific knowledge base, developing new technologies that can be deployed in combination with proven public health practices, as well as strengthening health systems, businesses and schools with coordinated, permanent public health preparedness plans, will boost our ability to better contain spread of this life-threatening coronavirus outbreak as well as fight other emerging disease threats more swiftly and effectively in the years ahead.
The United States is at a critical inflection point in our pandemic response, reporting cases at the level of Italy two weeks ago. In the coming days and months ahead, the choices we make will shape the trajectory of this pandemic. From the White House in Washington, DC to every other house across America, everyone must play their part to #BeatTheVirus and #FlattenTheCurve. As President Franklin D. Roosevelt said during World War II, together, “we must face the arduous days before us in the warm courage of national unity” if we are to ensure that COVID-19 is a disease found only in history books.
Rear Admiral Susan Blumenthal Markey, M.D. (ret) is former U.S. Assistant Surgeon General, Senior Fellow in Health Policy at New America, Senior Medical Advisor at amfAR, The Foundation for AIDS Research, and a Clinical Professor at Tufts University School of Medicine. She also serves on the Visiting Committee of the Harvard TH Chan School of Public Health. Admiral Blumenthal is the Public Health Advisor and co-founder of the #BeatTheVirus education campaign. She has received numerous awards including honorary doctorates and has been decorated with the highest medals of the US Public Health Service for her landmark contributions to advancing health in the United States and globally.
Matina Kakalis, a graduate of Duke University, is a Research Associate in Health Policy at New America. She will be a first year medical student at Icahn Mt. Sinai School of Medicine this fall.
An earlier version of this article was originally published in the newsletter of Women and Foreign Policy.