By Suresh Kumar
All facts and statistics are as of noon March 31, 2020.
"Beware the Ides of March” is an ominous warning. By March 30, COVID-19 had infected over 809,000 people globally and killed almost 40,000. The U.S. led the world in infections (165,482) and deaths (3,186). The situation remains fluid; the U.S. belatedly prepares for an inevitable ramp up in cases, while epidemiologists look warily for signs of abatement or resurgence in countries where the disease struck early. As the U.S. confronts its flawed responses, it now respects but does not as yet fully comprehend the pandemic that this column predicted COVID-19 would become weeks before the WHO’s declaration. Global public health is U.S. health — that is the profound meaning of a pandemic. We are all connected, and without precautions, we are all vulnerable. A pandemic is a new disease for which people do not have immunity, but one that spreads across the world with impunity.
Prevailing over such disease needs rapid deployment of global learnings with inventive interventions. The first priority is containing the disease. Early impacted countries must share facts and experiences of what works and what does not. Responses cannot be immediately perfect; successive waves of countries that combat outbreaks must nimbly adapt learnings while optimizing resources and response. Speed of intervention, more than accuracy of testing, is required to identify, test, isolate, treat, and contain infections. The public is trying to keep safe despite a faltered response in the world’s richest and most resourceful nation. COVID-19 may have occurred naturally elsewhere, but responsibility for its catastrophic spread in the U.S. must rest with the federal government.
The “Putting Patients First” principle consistently advocated in these columns requires pre-empting and retarding spread of disease. Public health policies — insurance to keep populations safe — are predicated on a core set of priorities:
identifying and prioritizing risk and investing in testing and treatment options (rapid respiratory infections are perennial high risk)
streamlining regulatory pathways to enroll and enable the private sector to bring essential products and services to market
establishing rapid preparedness protocols to deploy medical workers and equipment.
The foundation of a country’s public health is the robustness of its institutions. The ability to deliver national priorities rests on the country’s scientists and clinicians, on public health infrastructure, and on the programs in which we invest. Keeping populations safe requires leaders to act responsibly and assertively in the public interest. This U.S. administration, however, has either dismantled institutions like the Office of Global Health Security at the National Security Council or hollowed out resources (e.g., budgets and headcount) at HHS, CDC, FDA, BARDA, and even FEMA.
THE GOOD, THE BAD & THE UGLY
China’s draconian steps of locking down Hubei province and enforcing travel and social distancing initiatives nationwide likely contained a calamitous spread of the virus and saved lives. Taiwan and Singapore leaders quickly articulated clear policies and enforced stringent screening and travel controls. South Korea’s diagnostic interventions were three times more robust per capita than that of the U.S. It helped rapidly roll out the test, identify, isolate, and treat protocol to contain infection. These are examples of real-time learning and action that likely saved lives.
The 100 days since the Wuhan outbreak would have been a call to action for productive U.S. White House administrations. Testing and treatment protocols and prototypes would have been developed (CDC); emergency equipment would have been ordered and stockpiled (BARDA); regulatory pathways would have been streamlined, the private sector would have been enrolled, and priority approval queues established (FDA); incentives would have been in place to rapidly develop diagnostic kits, vaccines, and therapies (HHS); and manufacturing would have been mobilized for stockpiling necessary supplies from masks to respirators to ventilators (FEMA). None of this happened.
Instead, the CDC pursued its own 3-probe test kit that later turned out to be faulty, instead of sourcing and rapidly deploying the 2-probe WHO test that had served patients elsewhere. This alone could have saved U.S. lives and likely retarded the disease trajectory. By Feb. 16, the WHO had shipped 250,000 kits to 70 labs. By the end of February, only 4,000 of the CDC kits were used. Without tests, surveillance and contact tracing is impossible, which has contributed to the steep infection curve.
Global, national, provincial, and local collaborations are necessary to establish and refine testing, treatment, travel, and social distancing protocols, and to more effectively source and distribute supplies. But building collaborations is not this administration’s style or forte. Abdicating its responsibility to intervene and failing to timely invocate its powers under the Defense Production Act have reportedly resulted in 58-cent masks being quoted at $7.50 in New York and accentuated the shortage and cost of ventilators. The administration’s disdain for institutions and due process, proclivity to cut investments that secure the nation’s future, and inability to constructively engage and negotiate with the private sector are all well documented. It has consistently put politics, party, and private interests ahead of patients.
YESTERDAY, TODAY, AND TOMORROW
Currently it is unclear what trajectory the disease will take in the U.S. Will it reach China’s 4 percent mortality rate or Italy’s 11 percent (i.e., 11,600 deaths)? One thing we know is that COVID-19 has disproportionately impacted high-density urban dwellings, but less-dense areas are not off the hook. Thus, we must learn what worked in some countries and why others struggle to cope. Then, we must adapt and act purposefully.
America deserves the truth. Can the president, not a pandering committee, ever be able to stand daily in front of a factually updated chart highlighting the cumulative number of U.S. infections and deaths and inform the public what has been done to keep Americans safe? No spin, just facts, such as:
▶ number of test kits manufactured and how many distributed to how many labs by state
▶ similar information on ventilators and their availability by state
▶ current testing and treatment protocols
▶ when America can expect a new vaccine or drug to be commercially available and the number of drug or vaccine candidates being tested.
Can the administration post ZIP code-enabled facts on its website, such as:
▶ where and when testing takes place and how long it takes from test to diagnostics report
▶ social distancing, stay-at-home, and other protocols
▶ access to and timing of essential services such as grocery stores, pharmacies, and ATMs
▶ available number of doctors, PAs, and nurses
▶ available number and locations of hospital beds?
U.S. mortality is now projected to be between 100,000 and 200,000 with perfect adherence to stay-at-home restrictions, and 1.6 million to 2.2 million without social distancing protocols. Consequently, in the future, COVID-19 will likely influence profound ongoing behavioral changes such as how many people commute versus telecommute to work, or how much we embrace tech-enabled interactions (e.g., video conferencing) compared to physically traveling. It also will affect urban planning, city codes, and how resources related to healthcare or this pandemic experience are allocated at home and work.
Public health is an integral part of national security, and COVID-19 has taught us that urban planning and global mobility are fundamental elements of public health policy. “Make America Great Again” means investing in our institutions and programs. Putting America first requires keeping Americans safe, essential supplies within reach, and leading the world with our resources, infrastructure, institutions, and talent.
Throughout this crisis, the public has been the hero — exercising abundant caution and behaving admirably and even inspirationally. It is time for our leaders and politicians to learn and follow. Churchill once said, “You can always count on the Americans to do the right thing after they have tried everything else.” Alas, pandemics like COVID-19 don’t afford us the luxury of time.
SURESH KUMAR serves on the board of Jubilant Pharmaceuticals and Medocity. Formerly, he was U.S. assistant secretary of Commerce and executive VP at Sanofi.