Preparing for the Next Pandemic
The Covid-19 crisis has clear lessons for what we can do now to stop a future global health emergency
After this, then what? We’ve all run out of words—unprecedented, enormous, heartbreaking—to describe Covid-19, finding ourselves reading so much depressing news while hoping that the curve of infection and death starts to flatten. But the pandemic, or more likely this phase of it, will end, and it is not too early to ask, what happens next? More important, what needs to happen next so that we do not find ourselves in our current situation ever again? I see three key areas that need to evolve to make it less likely that the world will face future pandemics.
Global Governance and Readiness. In 2015, Bill Gates was prescient in pointing out that countries carried out tabletop exercises planning for nuclear war but did not practice thoroughly to get ready for pandemics, especially the most threatening sort of pandemics—those, like Covid-19, spread through the respiratory route. The World Health Organization would be the natural convener of these kinds of preparation exercises. But many countries, especially wealthier ones, are highly skeptical of WHO and the need for cooperation to ensure that the world stays healthy.
The perception—and at times, the reality—is that WHO is slow and bureaucratic. The organization’s need to answer to 194 countries necessarily limits its ability to move nimbly, and expectations for its rapid action are hard to square with the fact that the organization is chronically underfunded.
As a result, the world lacks a shared understanding, or even a shared vocabulary, for pandemic preparedness and cooperation. Just look at the communication of events associated with Covid-19. A “pneumonia of unknown cause” detected in Wuhan was first reported to the WHO office in China on December 31. A month later, WHO declared the outbreak a “public health emergency of international concern,” and then on March 11 declared a “pandemic.”
Despite these announcements, much of the world acted like Covid-19 would not have an impact on their citizens. As evidence to the contrary mounted, despite weeks of warning, it was clear that the U.S. faced this peril with no readily accessible diagnostic tests, no proven therapeutics, no vaccine and a shortage of medical supplies needed by patients (ventilators) and care providers (personal protective gear).
Future leaders must be challenged to do much better. It is essential to develop an early-warning system that closely tracks global disease trends and distributes accurate, real-time information about them. Every country must be able to assess and contribute global health data in nonpolitical ways to maximize the chance of keeping its own citizens healthy. And on the supply front, we need a detailed plan that allows for raw materials and rapid response capability when essential medical supplies and equipment are needed. This means reinstatement of the U.S. Pandemic Response Team within the National Security Council and fully funding the global disease outbreak prevention efforts of the Centers for Disease Control and Prevention (CDC).
The U.S. can draw two broad lessons from the tragic unavailability of the equipment that health care workers need to safely treat coronavirus patients.
First, there is no substitute for federal preparedness when it comes to ensuring a ready supply of personal protective gear. Companies like Apple and Facebook stepped up to donate masks they had stockpiled when California wildfires pushed them to protect their staff, and other private companies were able to leverage their global supply chains to pitch in. As grateful as we should be for these efforts, it’s not the private sector’s job to save us in a public health emergency.
It is the role of the federal government to adequately stockpile and plan for a pandemic. Clear accountability on the National Security Council, matching the authority that already exists for the military procurement and supply chain, would allow asset allocation to the states and regions in greatest need. It would avoid what we see today, with states competing against each other for vital supplies.
Second, the concept of “surge capacity” does not appear to have been part of the planning for ventilators, and current needs massively exceed normal demand. There is not only a lack of supply but also a lack of readiness—parts, established partnerships, training—for quickly manufacturing more machines. No single ventilator company has significant excess capacity, and none can produce large volumes, so federal leadership is needed to maximize the use of available capacity. There is also a clear need for simpler ventilator designs, with standard parts to allow production to scale up quickly.
The U.S. established the Strategic National Stockpile in 2003 as an emergency repository for antibiotics, vaccines and other critical medical supplies, but it has not adequately served its role in this crisis. Covid-19 will focus attention on funding and supplying it properly and planning for distribution. For their part, the governors and mayors making requests for aid today need to be making “just in case” plans for tomorrow, using their experience with Covid-19 to encourage the reform and expansion of the Strategic National Stockpile
Public Health. It is a common complaint that health systems and insurers are too focused on urgent and acute health problems, treating disease rather than investing in prevention. We treat lung cancer but underfund tobacco control, treat opioid addiction without enough work on pain management, and treat babies in intensive care rather than give their mothers adequate prenatal care.
This tendency to address what’s right in front of us rather than preventing what might happen in the future is clear from the numbers. According to the Trust for America’s Health, in 2017, public health represented just 2.5% of all U.S. health spending ($274 per person). That small portion covers prevention, preparedness, wellness and community recovery for all Americans. A pandemic takes full advantage of such underinvestment, especially our failure to make primary medical care widely and easily available.
Good public health means that individuals are far less likely to be struggling with hypertension, obesity or diabetes. People who start out healthier will experience lower rates of morbidity and mortality when infectious disease is spreading. Higher vaccination rates are essential too, since they mean that fewer people will be sick with flu and other preventable infections and occupying precious hospital beds.
Even more important, we must have functional public health departments for essential disease-control efforts like contact tracing and quarantine. While our global governance for public health derives from WHO, the national entity we count on is the CDC and ultimately state and local public health departments.
These agencies have been front and center for our safety in the face of multiple prior infectious threats, from HIV/AIDS to Ebola and Zika. This safety is grounded in public health basics. The essential tool in an epidemic is information: who has the disease and who have they been in contact with?
Surveillance and epidemiology are key tactics in this quest, but critical gaps in our capacity have been clear since Covid-19 hit the U.S. Of greatest impact were the now well-known mistakes in novel coronavirus testing that left the government blind to its spread. This inability to trace the pandemic was exacerbated by the clinical manifestations of Covid-19. Current estimates suggest that 25% of those infected do not have symptoms. Failures in testing and high rates of asymptomatic patients meant that leaders, healthcare providers and decision makers did not know the incidence or prevalence of Covid-19, which is the basic information necessary to effectively contain an epidemic.
Finally, public health must provide expertise in an aspect so far lacking in this pandemic: serologic surveillance. This allows us to ask a second key question: not whether individuals currently have Covid-19 but whether they were ever infected and are now immune. The ability to do such testing would allow us not just to understand the biology and course of Covid-19 but also, potentially, to certify health caregivers and other workers who will not risk acquiring or transmitting the infection.
For future epidemics to be managed more effectively, we must have better information, and that means having well-funded, well-trained and well-prepared public health experts—trained in statistics, epidemiology, and laboratory and clinical medicine—at the CDC and in the states
Innovation. Our ability to tap into scientific innovation may turn out to be one of the success stories in our fight against the pandemic. Since China released the SARS-CoV-2 genetic sequence in early January, countless labs around the world have been working to develop new ways to test, treat and prevent Covid-19.
On diagnostics and testing, scientific innovation is not yet making a difference. Serologic tests for antibodies have lagged behind testing for the disease itself, and despite multiple academic and laboratory successes in viral detection, these advances have yet to improve access to testing, accuracy of results or speed of turnaround. Issues have included inadequately trained staff as well as the availability of testing swabs and testing reagents. Dealing with what might be considered the more mundane aspects of diagnostics is just as important as technical breakthroughs.
A true bright spot in innovation has been the work happening on treatment. Since the novel coronavirus was reported in Wuhan, healthcare providers have been working to repurpose existing medications. Biotech and pharmaceutical companies have fully participated in the early tests. These have included work with anti-viral compounds, such as remdesivir, a compound developed by Gilead Sciences, which failed in treatments for Ebola but have shown promise with some Covid-19 patients; antimicrobials, such as the antimalarial drugs hydroxychloroquine and chloroquine, used together with the antibiotic azithromycin, which have shown mixed results in small trials; and remedies for severe Covid-19, such as the compounds sarilumab from Regeneron Pharmaceuticals and Sanofi, and toclizumab from Roche Holding. This is just a small subset of medications furthest along in their development.
The pursuit of therapies will be further advanced by funding from the newly launched Covid-19 Therapeutics Accelerator (funded by the Bill & Melinda Gates Foundation, the Chan Zuckerberg Initiative, Wellcome Trust and Mastercard), specifically intended to speed up R&D. There is also the FDA’s Coronavirus Treatment Acceleration Program, designed to fully staff and support an accelerated regulatory path for novel therapeutics. Many new approaches to product development are under way, using tactics ranging from artificial intelligence to CRISPR gene-editing.
An example of unprecedented collaboration is the QBI Coronavirus Research Group, involving hundreds of scientists at the University of California, San Francisco. These investigators have found 50 drug candidates that shield proteins that the coronavirus needs to thrive. It is an important model for the future.
In all of these efforts, an essential balance must be struck between the wish to quickly get remedies to severely ill patients and the potential for intolerable side effects. In addition, media hype can lead to treating patients with ineffective medication in the face of better choices. The experience with Covid-19 is a powerful reminder of the importance of conducting excellent clinical trials that generate the proof needed to assure caretakers and patients.
Anyone who studies the Covid-19 pandemic knows that we need a vaccine, and we need one quickly. Yet, even more than diagnostics and therapeutics, a safe and effective vaccine will take time. Both the pace and the breadth of the efforts to produce a vaccine are impressive. The biotech company Moderna was the first to treat a patient with an experimental vaccine only 66 days after the viral sequence was available. Today, WHO lists dozens of vaccine approaches under study.
Perhaps the key organization focusing on long-term preparedness is the Coalition for Epidemic Preparedness Innovations, funded jointly by the Bill & Melinda Gates Foundation, Wellcome Trust, the European Commission and seven nations. Since 2017, CEPI has been working to produce a “plug and play” platform approach for dealing with “Disease X,” a newly emerging epidemic disease such as Covid-19. The concept of a platform technology would enable rapid vaccine development, elicit rapid onset of immunity, and enable production to be scaled up quickly to respond to outbreaks.
This is the way forward—to focus not only on the pathogens we know but on preparing ourselves for the pathogens we don’t expect. Today’s epidemic is a powerful reminder that infectious agents do not respect borders and that global cooperation is essential for dealing with them. Classic public health tools are a must: We cannot control what we cannot understand. And we need to maintain the collaborative and generous spirit that has emerged in response to Covid-19. It may feel like a once in a lifetime experience, but that, alas, is unlikely to be the case.