The SARS coronavirus 2 pandemic may be the first truly global contagion in a century. But it won’t be the last. So, the United States – and partners around the world – would do well to anticipate the next one(s).
What is involved? And what does this have to do with system-wide American healthcare reform?
This post will look at preparedness recommendations made last month by several leading experts. And it will look at the obstacles both to building preparedness and to reforming healthcare more generally – power concentration, greed, and tactics used by the powerful and greedy that disrupt social cohesion.
A group of recognized experts, led by long-time medical thought leader Ezekiel Emanuel M.D, PhD., detailed ideas in last month’s Journal of the A.M.A. They note that the same conditions that brought us COVID-19 will bring us another pandemic, probably sooner rather than later – human habitation encroaching on wild animal habitat, global warming, and global interconnectedness through travel and commerce.
Pandemic Preparedness and Healthcare Reform
Let’s answer the second question first about the relation of pandemic preparedness to health system reform.
What’s different between pandemic preparedness and general healthcare is that preparedness is a national security matter and a subset of public health policy. Preparedness is clearly the purview of government and, in this case, of trans-national public health authorities. Preparedness is a public good, something from which we all benefit but which we don’t purchase individually.
On the other hand, although healthcare has some characteristics of a public good, it can be delivered and financed via private enterprise or hybrid public-private mechanisms, and it is furnished to individuals. Thus healthcare is more like a public utility to be regulated than a government function to be performed.
What is similar between the two is that they are both part of the social contract. Individuals contribute to society and therefore expect to partake of the resultant common good and public goods. Just as we’re all in pandemics together, and we should all have access to essential healthcare together. Both threads weave into the fabric of society, the economy and, yes, politics.
Dr. Emanuel observes that rebuilding pandemic preparedness, like reforming healthcare as a whole, requires societal cohesion, not just technical tweaking.
To . . . respond to future public health threats requires deploying real-time information systems, a public health implementation workforce, flexible health systems [but also] trust in government and public health institutions, and belief in the value of collective action for public good.
As he puts it, without a strategic preparedness plan, more people will unnecessarily sicken and die, disparities will widen, and trillions will be lost from the economy. The same could be said for healthcare reform.
Expert Recommendations – Four Strategies
For starters, Dr. Emanuel and colleagues propose a new “risk threshold” target for endemic COVID-19. No longer do they think that a goal of “zero COVID” tenable. Rather, the goal should be to reduce COVID-19 to a level no higher than the high-severity influenza season of 2017-18. That year saw 41 million cases, 710 thousand hospitalizations, and 52 thousand deaths. Weekly deaths peaked at 3,000 in the U.S.
As of this writing, CDC reports 13,400 weekly deaths associated with the highly transmissible omicron variant. Fortunately, CDC and others now expect a decline in weekly deaths following this peak, but clearly the U.S. is still far above the target threshold.
To reach the goal, the experts identify four groups of strategies – transmission mitigation, therapeutics, pandemic preparedness, and general public health.
Transmission mitigation includes systematic testing and reporting. Results should be collated from all test sites and should include self-reporting of at-home testing. There should be comprehensive tracking of emergency department cases, hospitalizations, ICU admission and deaths. This data will guide non-pharmaceutical interventions such as masking, contact tracing, social separation, and interventions at the community level to stop transmission. Wastewater surveillance should be expanded. OSHA should develop ventilation and filtration standards for workplaces and schools.
Therapeutics includes expedited development and deployment of vaccines as treatments. The massive biology effort against COVID-19 solved the cell-level mechanics of two breakthrough approaches to vaccination – mRNA and adenovirus vector. These two approaches can now be rapidly adapted to future viruses, but additional research is needed to determine how to optimize effectiveness. Vaccination needs to be supported by information systems that are secure and interoperable, and that command public confidence. Likewise, antiviral drugs and monoclonal antibody treatments need ongoing research and development and rapid response to future viruses. Government has a role in accelerating development, production, procurement and distribution of therapies. Treatments need to be tightly linked to testing, since there is a short window for treatment after diagnosis. These challenges run into the dual obstacles to healthcare reform – lack of universal access and resistance to public support.
Pandemic preparedness involves specific biomedical, epidemiological, and public health measures. But it also recognizes structural social and economic factors that increase vulnerability to pandemics and reduce resilient responses. Preparedness includes health system surge capacity, supply chains for critical equipment, and system coordination. Testing and surveillance systems need to be at the ready for rapid response. Social determinants of health need to be addressed, such as availability of less crowded affordable housing. Experts emphasized the need not only for U.S.-based pandemic preparedness but also global coordination of surveillance, manufacturing, and distribution. Underlying it all is the need to foster public trust and cohesion in the U.S. and around the world.
Public health has emerged as a high-level governmental focus, as well. This involves pandemic-specific background work, such as a global system to monitor emerging zoonotic viruses. It also involves legal and administrative structures to foster and fund planning and rapid response to future public health threats.
Experts conclude “zoonotic outbreaks on a pandemic scale are here to stay, and ignoring them is not an option.”
This blog agrees. It recognizes that tackling the twin problems of pandemic preparedness and healthcare reform are “routine” and thus doable, despite being complex. But this blog recognizes that mustering the resolve will require undertaking the much more difficult task of social, civic and political reform.
Now, take action.
Title: Ezekiel Emanuel MD, PhD
By: Samuel Masinter, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons