I explicitly chose to not focus this book on COVID-19 — there are plenty of excellent books that do this, and I have lectured on it countless times — as my aim is to really outline general principles as well my thoughts on infectious diseases and pandemics. However, COVID-19, in addition to being the greatest infectious disease threat the human species has faced in over 100 years, concretizes many of the points that I think this book makes clear about infectious diseases. In this chapter, I do not intend to rehash the details of the pandemic but to highlight some of the most salient aspects of it. These highlights will be in the form of what I take to be general principles.
Principle 1: An efficiently spreading respiratory pathogen with an animal host cannot by eliminated or eradicated.
SARS-CoV2, the cause of COVID-19, is a coronavirus. It is the 7th human coronavirus discovered and of those 7, 4 cause about 25% of cases of the common cold (there are reports of sporadic cattle related coronavirus infections in humans as well). The other two cause SARS and MERS.
It is critical to recognize that for any pathogen to be a cause of the common cold it has to possess a few key attributes: the capability to be able to spread efficiently, cause a spectrum of illness shifted towards the mild side (to facilitate transmission), and be able to get around immunity to some degree in order to re-infect. There are myriad viruses that cause the common cold. Some of them include rhinoviruses, adenoviruses, and parainfluenza viruses.
When it became clear that SARS-CoV2 — unlike MERS and SARS — was able to efficiently transmit from person to person, it was a foregone conclusion that it would infect virtually everyone over time and settle in to eventually become the 5th seasonal coronavirus. Even before the virus was discovered, it had already spread from China and was likely mixed in with flu and other respiratory viruses unbeknownst to anyone.
A corollary to this principle is that if a pathogen has the ability to spread before symptoms develop, it is extremely — if not impossible to contain — as the infected unknowingly go about their activities of daily life spreading the infection. This phenomenon, characteristic of influenza, was not something known to occur with coronaviruses justifying the lack of early mask recommendations for the asymptomatic. In the first months of the pandemic, it became clear that SARS-CoV-2 behaved in a different manner than its other family members in terms of the potential for pre-symptomatic spread prompting major guidance changes to reflect the new context of knowledge. It is still unclear what underlies this divergence from other coronaviruses. Perhaps with the 4 common cold causing coronaviruses the rigor of study on pre-symptomatic spread was not high enough to firmly exclude it (although with SARS and MERS it was). As SARS-CoV-2 behaves, in terms of transmission, rather unlike SARS and MERS it could be that the genetic traits conferring this enhanced transmissibility profile also confer a propensity for pre-symptomatic spread.
What invariably unfolded, because there was zero immunity in the population and a marked ability of the virus to cause severe disease in those with high-risk conditions, was death and destruction, even if the case fatality ratio was about 0.6 — a small number multiplied by a large number is still a large number. This is what underlies the 1 million plus U.S. deaths that resulted from the millions and millions of cases that occurred here.
Because of the biology of the virus, in my analysis, the objective should never have been to pursue a flawed “COVID-zero” program or to have some expectation that the post-pandemic world be anything like 2019. The goal should have been to prevent severe disease and develop and distribute medical countermeasures that tamed the virus in high-risk populations. It should have included a frank conversation with the world’s population about the destined endemicity of the virus and the need to develop methods of risk calculation to reduce the harm the virus could cause. This is how individual patient-level thinking smoothly integrates with population-level thinking.
A critical component among the required activities would be preventing hospitals from getting overrun by augmenting capacity, ensuring supply of medical equipment and personal protective equipment, facilitating regional load-balancing of patients, and provisions for adequate staffing. Also, because we understood early on the predilection for this virus to devastate the elderly, nursing homes should have been fortified significantly. There also would be a need to sustainably buttress long-standing deficits in public health infrastructure required for testing, tracing, and isolating. Most nations of the world failed — repeatedly — to do this, but notable exceptions like Taiwan and South Korea exist.
Taiwan avoided lengthy stay-at-home orders and societal disruption because they proactively jumped into action on December 31, 2019. 2019! They were able to test, trace, and isolate meeting cases as they occurred. This is not just because it is an island nation, it is because they prepared for infectious disease threats almost like no other nation. I was part of a team who, in 2013, evaluated their infectious disease preparedness because sadly Taiwan is not permitted to be a member of the World Health Organization (WHO). Infectious disease preparedness is an activity that is interwoven with national security in Taiwan, and they have even had a Vice President with a PhD in epidemiology. Sadly, during COVID-19, the U.S. Vice President was not an epidemiologist, and the results speak for themselves.
Similarly, South Korea was able to muster their diagnostic companies in an all-hands-on-deck approach in early 2020. The U.S. government, by contrast, willfully erected bureaucratic barriers that virtually precluded diagnostic companies and laboratories engaging in the testing enterprise.
Today, our rapid tests, vaccines, monoclonal antibodies, antivirals and, most notably, our knowledge of the virus, its epidemiology, its clinical features, its complications, and its treatment have succeeded in taming the virus. The remaining task is to get more people to be accepting of the pathbreaking tools scientists have developed.
Principle 2: If you can’t test, you’re blind.
One of the most basic ingredients to any infectious disease response on both the individual and regional level is to be able to actually know who is infected. From the early days of the pandemic up to the minute I am writing this line, testing has been the original sin of the pandemic. In the early days of the pandemic, the U.S. deployed a flawed test manufactured by the Centers for Disease Control and Prevention (CDC) that was only able to be performed at state health departments and only on those who met strict testing criteria. Paradoxically, as the public health emergency was declared it eliminated a pathway, used every day for many infectious diseases, for university and commercial labs to make their own laboratory-developed tests ensuring supply would be no where sufficient to keep up with even a modicum of cases. The market needed to be flooded with tests in South Korean fashion then, (and even now) but what was delivered was a trickle. It is also true that restricting testing to those from China long after the virus had departed and those with lower respiratory symptoms only was a perfect recipe for allowing chains of transmission to get out of control and land on vulnerable populations, including nursing home residents.
When it is not clear who is infected, it is difficult to determine how they were infected and, subsequently, what activities are at higher and lower risk. This type of risk differentiation is needed for risk calculation guidance and is a key component of harm reduction.
In recent years, the advent of home tests — long delayed and resisted by some — has somewhat rectified the problem but shortages and short-sightedness continued to restrain testing from being deployed optimally. The myriad regulatory constraints on home tests underlie why they were initially far from ubiquitous, and these regulations served as a major barrier to entry for manufacturers. The resistance to home tests is long-standing in the U.S. and is responsible for the fact that pre-COVID only an HIV test was available to use in the home (this itself was the result of about a decade of regulatory wrangling). The paternalism over testing stems from an inability to imagine a layperson operating testing material and is ridiculous on its face. Laypersons operate all sorts of devices more complicated than a lateral flow assay everyday. Home testing puts the public back into public health, as it has been shown that people modify their behavior based on results. These tests should be seen as public health tests akin to the cheap fentanyl test strips with which injection drug users test their materials with.
Principle 3: A long range approach is needed
With an endemic infectious disease is mandatory that any control plan be long-range in nature, not something expedient and in response to public panic. The danger of short-range solutions to COVID is everywhere you look. Privileging one type of Illness over all other illnesses and everything else in the world leads to cascading consequences that must be dealt with some time in the future. This is the folly of using blunt tools such as lock-downs — which were indicated in some places for a short and defined period of time in the very early days of the pandemic to preserve hospital capacity — because they treat all activities as equivalent for transmission. Categorizing some economic activity and those who perform it as essential and others as non-essential is also a consequence of short-range thinking that ignores the fact that without productive activity life ceases. As Elon Musk bluntly stated, “if you don’t make stuff, there is no stuff”.
In the future, it will not be surprising to see the aftershocks of COVID on cancer diagnoses, substance abuse, mental illness, and other chronic infections. The amount of economic disruption will be incalculable as we will not know what could have been where it not for the pandemic-induced disruption.
Another aspect of long-term thinking that was absolutely required was to deal with the hospital capacity problems that regularly recurred. Hospital emergency preparedness is perennially neglected and an afterthought for most hospital executives. Financial considerations have incentivized hospitals to be similar to hotels as empty beds mean less revenue. While hospital preparedness exists for short term emergencies like a mass casualty event, preparedness for a sustained surge like a pandemic requires much more effort. A pandemic is very different than dealing with acute surges from a mass casualty incident and beyond the scope of much what is done in hospital emergency preparedness.
Infectious disease emergencies, by their very nature, spread and hospitals in a given region need to act in a coordinated manner to withstand the onslaught of patients. Hospitals, though nominally part of coalitions with other hospitals, seldom acted like coalition members to load-balance during the pandemic. The convening of regular conference calls to check a box is not sufficient. It also must be emphasized that it is near impossible to build a hospital rapidly (or even semi-rapidly) in the U.S. — just think of all the municipal government officials that would need to sign off just on the land zoning issues.
This short-range thinking also was evident in the way public health infrastructure was managed during the pandemic. State, county, and municipal health departments have been woefully underfunded and understaffed trapped in a cycle of panic/neglect and boom/bust for decades. Long shorn from their core function of communicable disease control, some health departments budgets are more non-infectious disease focused than infectious disease focused as elected leaders value headline grabbing health threats like vaping, obesity, or pollution more than the actual functions that health departments were constituted to address. Throughout the pandemic, it was mind-boggling that political leaders seemed befuddled about cases escalating and unknown chains of transmission when they failed, over and over, to actually hire the case investigators and contact tracers required to keep cases to a manageable level. We also see short-range thinking on display when resources for testing were shifted to vaccination and, when testing resources were again needed, consternation ensued.
Much of this stems from the fact that political leaders are, by their very nature, short-ranged thinkers whose vision is bound by the next election cycle. They are unprincipled, range-of-the-moment, and, especially in today’s context, view things through the narrow lens of what political tribe they have sworn allegiance. They also possess an irresistible urge to been seen taking action, doing something, even if it is the wrong thing (the Biden administration’s South African travel ban in response to the Omicron variant is a paradigmatic example).
Principle 4: Infectious disease subject matter experts are not policymakers.
As I wrote above, political leaders are a major factor in why the pandemic went the way it did. These events can only be viewed as a failure of the government at all levels from federal to state to local to school board. Those that occupy our elected offices, at all levels, do not want to be blamed for anything and often abuse subject matter experts tasking them with activities that they themselves defaulted on. Subject matter expertise involves analyzing a situation and presenting scenarios and options. It is the responsibility of a policymaker to take the subject matter expert’s analysis and integrate it with countless other considerations such as laws, individual rights, feasibility, negative impacts, practicability, and sustainability. For much of COVID-19, political leaders leaned heavily on subject matter experts to make these calls and abdicated their responsibilities. For a communicable infectious disease that thrives on social interaction, minimizing social interaction surely will diminish transmission but is it the correct solution to forbid people to leave their residences for extended periods of time? What metrics should govern the order? What is the legal framework for such action? Does it apply to the infected and uninflected alike? What about people’s liberty? What about the survival of people’s businesses? All of these questions are to be weighed by a policy maker before implementation, it is not the role of a subject matter expert.
A subject matter expert is tasked with controlling the infection and, naturally, might provide options that are the most devastating for the pathogen. In this task they are not, as Dr. Anthony Fauci once stated, “talking about liberties”. Similarly, former NIH director Dr. Francis Collins, stated:
If you’re a public health person and you’re trying to make a decision, you have this very narrow view of what the right decision is, and that is something that will save a life. Doesn’t matter what else happens. … You attach zero value to whether this actually totally disrupts people’s lives, ruins the economy, and has many kids kept out of school in a way that they never quite recover from.
These exchanges called to mind an interesting exchange from the movie The Siege in which an army general is asked about using the military in an American city to capture a terrorist. He replies:
The Army is a broadsword, not a scalpel. Trust me, senator, you do not want the Army in an American city.
Make no mistake, Senator. We will hunt down the enemy, we will find the enemy, and we will kill the enemy. And no card-carrying member of the ACLU is more dead set against it than I am. Which is why I urge you - I implore you. Do not consider this as an option.
This is the unenviable position our political leaders put subject matter experts in.
Principle 5: Don’t underestimate the anti-vaccine movement
The reason why the U.S. remains mired in pandemic purgatory is surprising to many because vaccine availability is unrivaled. The signature achievement of the Trump administration is inarguably the delivery of vaccines through Operation Warp Speed in record time — I wish they were delivered even faster. However, even before the vaccine was developed the anti-vaccine movement sprang into action sowing misinformation and distrust. Using the tools of the 21st century, the voice of the Dark Ages hit a note with many Americans, including those who possessed risk factors for severe disease. So, even over a year after the availability of the vaccine, hospitals were still held hostage by high-risk unvaccinated individuals who reside in their communities and choose to keep hospital capacity in their cross hairs.
The threatening intimidation to which vaccine advocates have been subject to, including myself, seems to be at record levels. The cowardice of hospital administrators in the face of unvaccinated healthcare workers who were holding their heads high while the vaccinated were on the defensive is something many did not anticipate. What has been needed is a proactive approach to addressing the anti-vaccine movement and illustrating to all that they are, for all intents and purposes, a nihilistically motivated movement that eschews rationality, reason, and evidence. The attacks on science, if they go forcefully unanswered, will come back to haunt us.
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Integrating the COVID-19 pandemic with the theme and message of the book, it should be clear that COVID-19 is no where near an extinction level event and is a perfect illustration of how human factors magnified a threat to greater proportions than it could ever have achieved without blunder after blunder. Coronaviruses will continue to be an infectious disease threat, but they are not an extinction level threat or even a 1918 level threat if they are met with the appropriate response.