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What Will It Take to Pandemic-Proof America?

On September 29, 1982, a twelve-year-old girl named Mary Kellerman woke up with a cold. Her parents gave her some extra-strength Tylenol and, within a few hours, she had died. That same day, in a town near the family’s Chicago suburb, a twenty-seven-year-old postal worker named Adam Janus felt ill; he, too, took Tylenol and died hours later. Janus’s brother and sister-in-law gathered at his home to grieve, developed headaches, and took Tylenol from the same bottle; both died shortly thereafter. Three more mysterious deaths soon followed. State and federal investigators descended on the Chicago area. They quickly determined that the Tylenol had been laced with cyanide: someone had taken bottles off the shelf, injected the capsules with poison, and put them back into stores.

Within a week, more than ninety per cent of Americans had heard that cyanide-laced Tylenol was killing people in Chicago. Sales of the medication plummeted by four-fifths. Johnson & Johnson recalled every bottle in the country, at a cost of more than a hundred million dollars, then began working with the Food and Drug Administration to develop tamper-proof packaging. Tylenol had come in capsules, which were easy to swallow but could be opened and adulterated; the company replaced them with “caplet” pills that were much harder to contaminate, and started packaging them in foil-sealed childproof containers. Not long afterward, Congress made it a federal offense to tamper with consumer products, and the F.D.A. started requiring tamper-resistant packaging for all drugs. In the years since, there have been scattered attempts at similar crimes, but none as deadly as the Tylenol murders. Today, Americans hardly ever worry that their medications or groceries might contain poison.

Some problems we confront and eliminate. Others become part of the fabric of our society. Gun violence is an obvious example: more than a hundred Americans die of gun-related injuries each day, but we still don’t embrace the policies that could help. sars-CoV-2 has killed one in every six hundred Americans, and future pandemics are basically unavoidable—and so, as the end of this pandemic approaches, the question is whether we’ll embrace the policies that could protect us next time. Will our path resemble the one that resulted in the near-total elimination of tainted drugs, or the one that’s led to our weary acceptance of mass shootings?

When it arrives, the next pandemic could very well be worse than the one we’re experiencing now. sars-CoV-2, the virus that causes covid-19, is less deadly than sars-CoV-1, which, when it broke out, in 2002, killed eleven per cent of those it infected. sars-CoV-2 is less transmissible than measles, which is at least ten times more communicable; it has proved easier to vaccinate against than H.I.V., for which a shot has yet to be developed. From the midst of the next pandemic, we’ll almost certainly look back on the Biden Presidency as a time when we either seized or squandered the chance to prepare for the inevitable. The moment to pandemic-proof America is now.

ome countries came into our current pandemic prepared by experience. South Korea, for example, had confronted mers—Middle East Respiratory Syndrome, caused by another coronavirus, mers-CoV—in the spring of 2015. That outbreak began when a businessman returned to Seoul after spending ten days in Bahrain, the United Arab Emirates, and Saudi Arabia. Within a week, he developed fevers and muscle pains. He soon visited a nearby clinic, a local hospital, and a large academic medical center, where mers was finally identified; he recovered, but during his journey through the medical system he infected more than two dozen people, including another man who travelled between hospitals, spreading the disease to at least eighty others.

As mers spread in South Korea, testing was often slow or unavailable, and the government didn’t share what it knew about where outbreaks were occurring. The virus shuttled undetected through the medical system—nearly half of all infections would eventually be linked to hospitals—and people started avoiding medical care altogether. In the two months it took to get the virus under control, South Korea quarantined more than sixteen thousand people and recorded a hundred and eighty-six infections and thirty-eight deaths. (The coronavirus that causes mers is twenty times as deadly as sars-CoV-2.) The economy faltered, and seven in ten Koreans said they disapproved of the government’s response.

 

In the years afterward, South Korea introduced major changes to prepare itself for the next virus. It passed a law that empowered labs to use unapproved diagnostic tests in case of emergencies. It dramatically expanded the power of health officials, allowing them to close hospitals when needed and to access surveillance footage and other information for confirmed and suspected carriers. In future outbreaks, local governments would be required to alert residents to the number and location of nearby infections; the isolation of potentially infectious individuals would be mandatory, with fines for those who failed to comply. (In the U.S., during this pandemic, measures like these have been optional.) The directorship of the Korea Disease Control and Prevention Agency was elevated to a top position within the government. A new public-health emergency-response team was established, and a special department was created to focus on risk communication. The government hired more epidemiologists, bolstered border-screening measures, and required hospitals to increase the number of negative-pressure isolation rooms. All this contributed to the fact that, beginning last year, South Korea mounted among the most effective pandemic responses in the world, recording around seventeen hundred covid-19 deaths across a population of fifty-two million people.

 

In the United States, the coronavirus pandemic has revealed a specific set of systemic weaknesses that need to be addressed for next time. The country’s stockpile of emergency equipment proved inadequate, as did its test-and-trace infrastructure. Federal public-health agencies and programs and local health departments were underfunded and unprepared. Michael Osterholm, an epidemiologist at the University of Minnesota and a member of President Biden’s covid-19 transition advisory board, told me that there was a sense in which these failures were unsurprising: before the coronavirus, Americans were collectively incapable of imagining just how deadly and disruptive a wildly contagious pathogen could be. “We’ve long had this complacency, because we thought of infectious diseases as something that affected low-income countries,” he said. “We’ve had this attitude of, ‘As long as it’s over there, it’s not our problem.’ Well, now we’ve had a taste of what it means to live with a deadly virus. What are we going to do about it?”

 

The changes we need to make can be grouped into three broad categories. The first is disease surveillance. “We have no idea what’s out there,” Farzad Mostashari, a former assistant commissioner of New York City’s public-health department and the Obama Administration’s national coördinator of health information technology, told me. Health agencies must be able to identify and track outbreaks before they get out of control; to do so, they must collect viral samples and send them to local laboratories on a continuous basis. This requires funding, but, Mostashari said, it also demands an investment in the nation’s “public-health informatics” infrastructure. Mostashari cited his experience at New York City’s health department, from 2005 to 2009: he regularly handled fifty-nine separate data feeds—Word files, Excel files, CSV files, TXT files—from the city’s fifty-nine emergency departments, spending hours each week trying to make sense of it all. There have been improvements since then, but the basic problem persists. “What we need is a single national platform—a common set of tools—that brings in data from every state in an organized way,” he said. “There would still be local control and governance of the data, but it would be standardized and interoperable across the country.”

Funding for such a system must be not just substantial but long-term. After 9/11, hundreds of millions of dollars were sent to state and local health departments—but, Mostashari said, the money later dried up. “We need to think of public health like defense,” he said. “The systems we maintain during peacetime are the ones that allow us to succeed at war.” Mostashari told me that he thinks a set percentage of U.S. health-care spending should be earmarked for public-health efforts. Sylvia Burwell, who ran the Department of Health and Human Services under President Barack Obama, concurred: she argued that the federal government should create a single strategy spanning every agency involved with public health. “This is about more than health,” she said. “It’s about our national security and our economic prosperity. We need to start acting like it.”3

Early in the pandemic, widespread shortages of P.P.E., ventilators, and medications revealed deep vulnerabilities in America’s medical-supply chains. Seventy per cent of the drugs used in the U.S. are manufactured overseas; supplies were limited for twenty-nine of the forty drugs vital to the treatment of covid-19. The Department of Defense is required by law to purchase some military equipment from U.S. companies. Similarly, federal health agencies could be required to funnel purchase orders for respirators, ventilators, and some drugs to domestic suppliers.

Another group of necessary improvements centers on vaccine development. There’s no way to say for sure which virus will cause the next pandemic; still, we know that some viruses are more dangerous than others. Viruses that use RNA for their genetic code tend to mutate faster than those that use DNA, because RNA-based viruses have less sophisticated “proofreading” machinery. Those that circulate in animals are more likely to mutate in dangerous ways while evading human detection. (Some three-quarters of new infectious diseases are thought to originate in animals.) Viruses that travel by means of respiratory droplets—as opposed to water, feces, mosquitoes, or sex—have the most explosive potential. Researchers could develop treatments and protocols in advance for viruses that combine these and other characteristics: the likely suspects include influenzas, coronaviruses, filoviruses (such as Ebola and Marburg), and paramyxoviruses (a viral family that includes measles and mumps, but also deadly pathogens for which there are no vaccines, such as Nipah virus and Hendra virus).

“We now have this incredible mRNA technology which allows us to make vaccines very quickly,” Seth Berkley, the C.E.O. of Gavi, an organization that helps vaccinate children in poor countries, told me. “And for vectored vaccines, we could partially develop them, freeze them for a time, and then complete the development process more rapidly when they’re needed.” That sort of pre-planning will require strong partnerships between universities and industry. “Academic research is critical, but professors rarely make vaccines,” Berkley explained. “The goal should be for academia to let a thousand flowers bloom and then for institutions skilled in product development to cultivate the right ones.”

Encouraging companies to develop vaccines ahead of time will require restructuring the financial incentives behind them. When I spoke with Amitabh Chandra, an economist at Harvard, he outlined three reasons that vaccines are bad investments for drug companies: pandemics are sporadic, and can end before a vaccine is finished; vaccines are targeted at specific pathogens, and so aren’t reusable (“People always get diabetes and have heart attacks—those are much surer bets”); and it’s hard to price vaccines at a level that generates large profits. “You’re probably selling your vaccine in a public-health emergency,” Chandra said. “That means you’re selling to governments and philanthropies, not private insurers that pay high prices.”

Chandra argues that a federal agency should serve as a guaranteed buyer of vaccines, therapies, tests, and emergency medical supplies for possible pandemic-causing viruses. He singles out barda—the Biomedical Advanced Research and Development Authority—as a plausible candidate. Created in response to the 9/11 attacks, barda, which sits within the Department of Health and Human Services, is responsible for vaccine research, pandemic preparedness, and bioterrorism response; it currently has limited funding and independence. Chandra thinks that barda should be expanded into “an entity that promises to purchase products if they are successful—that will pay handsomely for success in specific domains and will give companies a clear sense of how much money they can expect to make.”

It’s important, Chandra argues, for the government to consistently fund the creation of vaccines and other treatments, even if they end up not being used. “When it comes to something like vaccines, you don’t want the best deal,” he said. “You don’t want to pay the minimum price. You want to overpay and attract the attention of many companies simultaneously.” This is especially true because vaccines are so hard to develop—they can look good in the lab but fail afterward. “Imagine if AstraZeneca and Merck were the only ones who had taken up the vaccine challenge,” Chandra said. “We’d be screwed.”

In a globalized age, it’s not enough for the U.S. to focus only on its own problems. A third category of improvement is our engagement with the rest of the world. As my colleague Jerome Groopman explains, in his recent review of Peter Hotez’s new book, “Preventing the Next Pandemic,” American diplomacy can play a meaningful role in fighting outbreaks: many poor countries lack the basic medical and public-health infrastructure to prevent and treat infectious diseases, which then spill across borders and over oceans. War and political instability are accelerants for the emergence and resurgence of deadly pathogens, through disruptions in sanitation, housing, and infrastructure. To the extent that the U.S. can help bring about a more peaceful, more prosperous world, it can help create a healthier one.

But the U.S. must also take some crucial steps in the specific realm of global health policy. The Biden Administration has begun that process by reëngaging with the World Health Organization; despite some stumbles early in the pandemic, the W.H.O. remains the world’s most important global-health body, performing an indispensable convening and communication function. Investing in the W.H.O. and other similar organizations is vital for the worldwide surveillance of emerging diseases, and also for influencing international policy on activities that pose a high infectious risk (including the proliferation of the wet markets that are thought to drive the “spillover” of many diseases).

 

The U.S. also has a vested interest in more directly insuring that people around the world have access to vaccines. In our current pandemic, countries with rampant viral spread—including the U.S.—have fuelled the emergence of coronavirus variants; the longer people go unvaccinated, the longer we live with the possibility of new and dangerous variants surfacing. In a future pandemic, with a more transmissible or lethal pathogen, the need for fast worldwide vaccination could be even more urgent.

Billions of people live in countries without the money, infrastructure, or geopolitical clout to get vaccines; they may have to wait until 2024 to get vaccinated against covid-19. Since the start of the pandemic, Berkley, Gavi’s C.E.O., has been trying to fix this predictable problem. Last spring, Gavi, along with the W.H.O. and a Davos-based organization called the Coalition for Epidemic Preparedness Innovations, launched covax, an ambitious global effort to promote equitable access to the covid-19 vaccines. covax aims to coördinate the development, manufacturing, purchase, and global distribution of vaccines; the idea is to move the world away from bilateral deals between individual countries and companies, instead pooling global resources to distribute vaccines according to a population’s need and size. “It’s of course right for every political leader to think about his or her own constituents,” Berkley said. “But it’s foolish to think only of them in a global pandemic. You will never vaccinate one hundred per cent of your population. If there are large pockets of virus circulating around the globe, it will eventually get back to you. That has huge implications for trade, commerce, travel, and safety.”

After holding out for much of last year, the U.S. recently committed four billion dollars to covax; more than a hundred and ninety countries are now participating in the project, which has secured nearly two billion vaccine doses for distribution in 2021. Ninety-two of those countries—those deemed low- and middle-income—can receive vaccines at steeply discounted rates or free of charge. Most of the two billion doses will be distributed according to population size, but five per cent will be reserved for acute outbreaks. The goal is to vaccinate twenty per cent of the participating countries’ populations this year. “That would shift the character of the pandemic globally,” Berkley said. “It would protect the most vulnerable people and do a lot to reduce fear and health-system burden.” By participating in covax, the U.S. isn’t just helping to end this pandemic; it’s laying the groundwork for a better approach to the next one.

What can be done to insure that we’re more united when the next plague strikes? Good policy might make our health system more pandemic-proof, but technocratic solutions can do only so much to address a lack of social cohesion. Beliefs about science, freedom, individual responsibility, and collective action are profoundly influenced by one’s community and sense of identity. For some Americans, pandemic denialism has become a misguided form of patriotism.

But the story of this pandemic isn’t yet over. For all Americans, the arrival of covid-19 was a calamity without precedent. It was the first time in generations that the country had faced such a threat. Instantly and persistently, the virus has upended how we think, act, work, and live. Looking back now, it’s hard to fathom how bizarre today’s routines would seem to our pre-pandemic selves. That fact alone suggests that transformational change is possible, and that, once it arrives, it no longer seems so unattainable.

 

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