The Politicizing Of Healthcare Vs. Principled Public Health Policy

By Suresh Kumar

Figures and Projections as of June 30, 2020

Within five months “COVID-19 has brought this nation [U.S.] to its knees” and has already infected “ten times more [people] than currently reported”, admitted CDC Director Redford. That’s 23 million, or 7 percent of all Americans, yet just 10 percent of the estimated 70 percent level required for herd immunity. With a spike in infections, positive testing rates, and hospitalizations, by the end of June, COVID-19 will claim 130,000 lives. The nation is on track to realize the high end of the White House’s projection of 240,000 pandemic-related deaths.

Infection was underreported first due to a lack of tests, then because of inadequate and unreliable testing, and even now owing to a large number of asymptomatic infections. This does not alter the deadly nature of the pandemic; it merely means that more people are infected, and while deaths as a percent of infections are lower, human toll (i.e., absolute number of fatalities) is the same — very high. Consistent with his proclivity for confusing rather than clarifying, President Trump reaffirmed his desire to dump tests when the U.S. reported alarming spikes in daily infections. Florida Governor DeSantis called “test dump” the culprit when his state reported 9,000 new cases, 14 percent positive testing rate and a steep increase in hospitalization. While the Houston Health Department warned of “catastrophic cascading consequences” and serpentine queues bore testimony to long COVID testing wait times across Texas, the federal government announced plans to withdraw funding support for seven test centers in the state. Callous, cavalier comments and short-sighted actions from self-absorbed and insular administrations exacerbated the recent spikes. They prompted the EU and more responsible states that value citizen well-being over partisan politics to close borders to Americans or require travelers from states with less accountable governments to quarantine.

Lives Versus Livelihoods

People cannot remain locked down indefinitely. Governments must create the conditions for safely going back to work. Approximately 47 million Americans have filed for jobless claims in 14 weeks, including 1.48 million last week. Businesses need to know unambiguously what constitutes safe work environments so they may comply and manage risk. Feds must have a policy, states must have a plan, and local authorities must have the wherewithal to enforce compliance.

• The federal government establishes norms of social behavior, such as distancing and wearing masks in public and at work. It also establishes an appropriate stimulus to assist affected citizens, vocations, and businesses.

• States ascertain how federal rules will be applied to keep citizens safe, identify essential services, prioritize and sequence reopening by vocation to determine who can go back to work and when, and establish timelines to restart economies.

• Counties and cities adapt to local realities to safely open public facilities (e.g., schools, parks, beaches, retail commerce) and to enforce federal and state government thresholds including social distancing guidelines necessary to keep populations safe.

Both inaction and rash action are derelictions of public office responsibilities, as is inability to articulate, promote, and enforce social behaviors. Pandemics accentuate tension between life and livelihoods, and ambiguous regulations divide communities and further amplify tension. The consultative and collaborative approach necessary to drive compliance has been compromised. This is evident between several states and the federal government and between large urban cities and the Sate (e.g., Houston and Texas). Sensitive management advance prosperous societies; poor planning and execution risks public health and retards economic recovery.

Learnings from the Pandemic 

• Acting rapidly to contain COVID-19 is paramount — everything else is secondary.

• Behavioral adjustments, not science, medicines or politics, has protected populations, thus far, and likely will for the foreseeable future.

• We are still in the first wave of the epidemic: The virus is hitting different parts of cities at different times.

• No alternative is currently available to testing, contact tracing, and isolating to contain COVID-19, and the USA continues to lag most countries on contact tracing

• Evaluating infections by clusters could identify genetic mutation of the virus to better understand presymptomatic transmission.

• Collaborations across academia, the private sector, foundations, and public health institutions will speed up vaccine development, but unrealistic expectations can compromise commercial development and drive poor social behaviors.

• The federal government’s inability to issue timely guidelines and secure critical supplies, and leadership’s failure to lead by example in complying to guidelines (or communicate honestly) have compromised public safety.

• Inept leadership has resulted in stockpiling ineffective therapies and required redundant investments that will cost billions of dollars.

Rapidly applying learnings from past outbreaks is as critical as the need for scientific inquiry to confirm and restrict the virus’ modes of transmission. Until a vaccine is found, Nobel laureate Paul Romer advocates testing every American every two weeks as a precursor to opening economies. He estimates this costing significantly less than the $500 billion loss of output per every month of lockdown. His motto “Just because something is unfamiliar does not mean it is impossible” can extend to epidemiology and virology too. Focusing through the SARS lens meant missing low symptom or symptomless transmission of COVID-19; people appear to be contagious before the onset of coronavirus symptoms. In other words, this happens before they even know that they are spreaders. How do we contain such spread? Science cannot remain hostage to dogma, history, or politics.

Enduring Principles & Forward-Leaning Goals

Scientific: Drug and vaccine approvals must continue to be based on double blind, placebo-controlled studies that demonstrate safety and efficacy and have gone through extensive peer reviews. Treatment protocols must not be based on presidential whims but be the domain of medical experts and institutions and based on scientific outcomes. Safeguards must be established to ensure the approval process is independent of political pressures.

Economic: The essence of Health Economics Outcomes Research (HEOR) is that beyond safety and efficacy, drugs and vaccines must demonstrate economic value to the patient and society. Just as America cannot endure protracted lockdowns, it cannot sustain runaway drug prices and widening deficits. 

New drugs, vaccines, and treatments must demonstrate value over existing treatments, establish quantifiable societal savings, and demonstrate return on taxpayer investment and how that investment will be recouped (e.g., preferred pricing).

Institutional: Institutions like the CDC were muzzled from issuing timely public safety guidelines for reopening the economy. The White Houses' lack of enthusiasm and urgency regarding COVID, and subsequent watering down of the CDC recommendations, influenced some states to ignore the guidelines and re-open their economies even before meeting the diluted “established criteria." How can safeguards be established to ensure that public health guidelines are not willfully flouted?

Communications: To ensure public and patient safety, mandates are required that only FDA-approved claims for regulated medical products and services can be communicated in advertising, sales pitches, physician detailing, media briefings, and interviews. To discourage irresponsible communications such as the ones on hydroxychloroquine and disinfectants, punitive actions must be established without exception for transgressions.

Worries & Establishing Safeguards

How can politics be kept out of public health? How do we protect population and do right by citizens?

Having to choose between lives and livelihoods is a flawed construct. They are part of a continuum that needs to be managed sensitively by engaging citizens, inspiring compliance to healthy practices, and developing targeted stimulus programs to assist the affected and the economically vulnerable. Our policies, principles, and programs have not inspired thus far.

Politics must not drive population health. How do we safeguard against October surprises and ensure that announcements on drug and vaccine developments and approvals are driven by science and not politics? How can we insulate the FDA from coercion for premature approval of a vaccine — even for emergency use — before safety and efficacy are established? Fake news and false promises could drive hunkered citizens to euphorically drop guard and risk catastrophic infection. They can cause stock market volatility, ruin economic well-being, and tarnish corporate reputations. 

While the situation calls for empathy and encouraging healthy behaviors, a President in denial focuses instead on repealing the ACA and adding 23 million more Americans to the ranks of the uninsured. This, while his own administration claims as many as 23 million Americans may already be infected by COVID-19. “When leaders fumble, responsible public prepares to ward off a pandemic” was the title of the first COVID-19-centric column. Sadly, rudderless, this is still the case, and we hope that a resilient public remains responsible.