How governments and public health systems respond to a pandemic determines a lot of important measurements: rate of spread, effectiveness in implementing a consistent strategy, quality of health care, and mortality rates. The coronavirus pandemic has shined a light on the cracks in our health care system and the unpreparedness of the federal and local governments to handle such a health crisis. According to the Johns Hopkins Coronavirus Resource Center, one of the most important ways to measure the burden or impact of COVID-19 (the disease caused by the novel coronavirus) is mortality. As of April 27, China, the country where the virus originated, currently has a mortality rate of 5.5%. The United States, a country with greater health care resources and, to be conservative, a four-to-six-week advance awareness of the virus’s presence, has a 5.7% rate. Compare our mortality rate to that of Germany, a country that had a well-organized response to the pandemic. Their mortality rate is 3.8%.
The pandemic is far from over, and every day there seems to be a new and urgent health care–related development to address. But at this point in the unfolding pandemic, it is helpful to look at some of the errors made and lessons learned.
The Role of the Federal Government
The United States has tremendous financial resources. According the International Monetary Fund, we have the world’s largest economy. One way this is measured is by Gross Domestic Product (GDP). GDP is a key indicator of a country’s economic health. With all of our financial strength, the government could have organized a better pandemic response. Germany’s GDP was fourth in the world, and they did a far better job.
Planning to include key sectors of the U.S. economy was not even considered in a federal response, and from the beginning we were unnecessarily in a position of playing catch up. On March 16, the Bay Area of California was the first place in the nation to order a shelter in place. Not until the first week of April did Ford and General Motors stop making cars and begin making ventilators. And while no one could have predicted the speed and scope of this worldwide pandemic and the equipment requirements needed to protect our health care workers, our country had ample warning. In 2014, the West African Ebola epidemic occurred, and the United States had four cases. On Dec. 2, 2014, in a speech in Bethesda, Maryland, then-president Obama urged Congress to cast aside partisan differences and have the United States lead the world in creating a worldwide pandemic detection network. His urgings went unheeded.
More recently, our country saw the devastation that occurred in Wuhan, China. The warnings of what was to come were clearly visible. There was no one in the White House to begin fashioning a plan. Of course, articles appeared in various scientific journals, but there was no one to compile and synthesize information and present a compelling enough argument to the president. In 2018, the White House disbanded the global health security team within the National Security Council (NSC). The NSC is the president’s main agency in evaluating national security and matters of foreign policy. Shutting down the global health security team ensured that no senior administration official would be focused solely on global health security. This action resulted in a lack of coordination and responsiveness at the federal level. In addition, this also diminished the administration’s ability to coordinate pandemic public health efforts within the White House and federal agencies.
A key piece to battling the pandemic is no-cost, accessible testing. And the current administration did not have a testing plan. On March 12, Rep. Katie Porter, a Congress member from California, questioned Robert Redfield, M.D., the director of the Centers for Disease Control and Prevention (CDC), on access to testing. She told him he had the authority to make testing free to every American. At the hearing, she made him state he would make this happen. The pandemic health strategy should not be made at congressional hearings.
“Flattening the curve” is spreading the amount of people who contract the virus needing hospitalization over a longer period of time so that an area’s health care resources are not overwhelmed. Referring again to the Johns Hopkins Coronavirus Resource Center, out of the current 10 most affected countries, the United States has had the most difficulty in flattening the curve. These countries include Germany, France, China, and Iran. The global health security team needs to be re-established and have capable, experienced people running its activities.
Testing: the Most Important Aspect in Pandemic Surveillance and Allocation of Resources
If a country does not implement a well-thought-out testing program, then its health care resources will not be used to maximum advantage. By far, our country’s biggest errors came in the implementation of a testing program.
Testing is not only important to see whether someone has the virus or not. Just as critical to mitigate or slow down the spread is “identifying the individuals who are infected and then identifying who the contacts are.” This is known as “contact tracing.” Sheltering in place is important, but this is a very blunt instrument. Testing allows public health authorities to more accurately gauge how to allocate resources.
One example where testing has worked exceedingly well in lowering mortality rate is South Korea. The country had experience in this area due to the Middle East Respiratory Syndrome (MERS) epidemic in 2015. They became adept in this area and were able to quarantine those with COVID-19 and then track down and quarantine, or at least closely observe, all their recent contacts. They were able to keep the mortality rate down by immediately testing 440,000 people.
South Korea focused their health care efforts on treating people with severe symptoms rather than mild ones. This could not have been done without extensive testing. This identifies where the outbreaks are occurring, who is infected and not infected. Then government is able to identify infection hotspots, pinpoint individuals with the virus, and do contact tracing.
They were able to do contact tracing so efficiently via technology. The Korean government in concordance with South Korea’s Centers for Disease Control and Prevention (KCDC) created a database from 28 organizations to monitor the movements of people living with the COVID-19 virus. The process to analyze the moves of individuals with the virus takes 10 minutes. And for people who come in contact with that person, the KCDC informs the public health center near the infected person’s home, and the health center sends notification to them. If the person tests positive, they are hospitalized at certain facilities. Those not positive are asked to self-quarantine for 14 days.
While these methods may sound eerie to Americans, the legal basis was prepared and discussed after the 2015 MERS outbreak. To protect the public, only KCDC officials have access to the database, and after the pandemic, the data is purged.
Another key vulnerability the United States had with testing was scaling up the number of tests for the population. Our governmental agency, the CDC, can construct and evaluate reliable tests but are not test manufacturers. Partnerships with the private sector were at best disjointed.
Testing is vital and critical in managing a pandemic. And we must devise procedural and legal methods to incorporate efficient contact tracing in America. While this could make those who value rights of privacy shudder, some better surveillance system is necessary. And laying the groundwork for public-private collaboration in test manufacturing is important for getting information in pandemic health care management. The United States has the technology and allies around the world that could guide us.
Communication From the Federal Government
Certainly, it is no secret to anyone that this country is divided by an ideological chasm. And who you voted for for president and why are not important at this time. What is important is how government communicates with the public during times of crisis. Nothing is easy to stomach in the time of a pandemic. People need facts and actions explained to them in a consistent matter.
Science and the press are not the public’s enemies. Rather, they can be used with the government to not only make the administration in power look credible but, more importantly, help convey scientifically reliable information. This country’s health care system is fragmented, and the needs in each part of the country are different. But the new coronavirus does not care or understand the difference. It will infect and kill people in New York and Nebraska. What is important from a public health standpoint is that there is a consistent plan in place at the onset of a pandemic. Public health government officials are trained to make the course correction. Having the roles of the federal government clearly and consistently defined makes fighting a pandemic easier.
There is no communication playbook for a pandemic. Yet, a study in contrast is observing the difference between the briefings of the governor of New York State and the president of the United States. The two show stark contrasts in communication style. The governor conveys knowledge, humility, resolution, and consistency. His positive message is applauded by both sides of the political aisle. The president does not convey a calming, consistent message. Rumors and poorly formulated ideas from many areas of health care and pandemic response are generated and have not consistently been accurately responded to—regrettably, in recent times, from the president himself. In both cases of these public servants, it is not how you got there but what you are doing to lead and protect the public. Future presidents need to evaluate how communication is being conveyed during this pandemic. Messages need to be simple and designed to calm and unify Americans, not sow confusion and division.
There will come a time when science prevails, and the pandemic will be a painful memory. Hopefully not forgotten are the three lessons we should learn from the COVID-19 pandemic. The federal government needs to have an office of global health within the NSC. This will allow the president to make rational decisions on how each key public health component works and how to properly align them. This in turn will improve response times to a critical area like testing.
Creating a viable testing strategy that incorporates scientific reliability, technology, manufacturing prowess, and respect for important, temporary changes in an individual’s privacy is vital. Testing is the most critical part of a government’s response to a pandemic. It helps to marshal health care resources where they are needed and hastens re-opening the country in a safer and quicker manner.
And in terms of communication, the president needs to realize that being on the dance floor of a pandemic is a complicated, lethal place. Rather he needs to move to the balcony where he can oversee the workings of federal government and receive advice from public health experts. These insights will in turn help him make decisions and craft initiatives to help the states. Having this broad perspective will allow the president to give the public the honest, realistic appraisal of a pandemic it so desperately needs.