A perfect storm. This analogy has come to symbolize a series of events or factors that converge in a powerful way, often with a catastrophic outcome. As people seek answers about the trajectory of the COVID-19 pandemic — where it started, how it spread, when the curve will flatten, and how the world will navigate the long-term impact — some have suggested that the virus is the epidemiological equivalent of a perfect storm. But is that an accurate characterization?
In the April 16, 2020 issue of the New England Journal of Medicine, an editorial titled “Not a Perfect Storm — COVID-19 and the Importance of Language” was published. This opinion piece was written by two medical historians affiliated with Harvard University, Allan M. Brandt and Alyssa Botelho. These co-authors suggest that COVID-19 was not a random event, but rather one that was shaped in a very significant way by human actions. I find myself in agreement with their persuasive argument. They write: “This language creates a public health discourse that seems reactive rather than proactive, reductive rather than holistic, disempowering rather than empowering. Though its inherent drama may be appealing, the term ‘perfect storm’ invokes notions of randomness and volatility that may actually undermine our ability to address the Covid-19 pandemic and future disease outbreaks.”
With all “inherent drama” held firmly in check, I would like to take a logical look at five aspects of health care that I believe will change as a result of the COVID-19 global pandemic.
1. Pandemics, Redefined: The world has become more populated with people densely packed into large cities. Pollution, an environmental factor that negatively impacts the immune system, has increased. Global mobility — the ease with which we travel across countries and continents — fuels the transmission and spread of viral illnesses. In the last two decades, we have seen bird flu, swine flu, and Ebola become global health issues. Now we have COVID-19, and there is every indication that we will see more infectious disease pandemics in the future, perhaps with even greater frequency. People will need to adapt to this new reality that ignores borders and crosses cultural boundaries. In 2018, Bill Gates, tech pioneer and co-founder of the Bill & Melinda Gates Foundation, published an article in the New England Journal of Medicine that was titled “Innovation for Pandemics.” Presciently, Mr. Gates suggested that a large-scale and lethal pandemic was a very real possibility. He was using historical precedent to guide his thinking about probability as well as preparedness. He wrote: “What the world needs is a coordinated global approach to pandemics that will work regardless of whether the next pandemic is a product of humans or of nature. Specifically, we need better tools, an early detection system, and a global response system.” How will pandemics be redefined? As an issue that connects humanity, not divides us.
2. Public Health, Redefined: Sanitation, hygiene, outreach programs, and awareness campaigns are the pillars that defined public health in the 20th century. But all of these efforts are broad brush — their effectiveness relies on averages and statistical models. Through better data analytics and a focus on personal health-related determinants that interrelate and amplify risk to infectious disease, we are going to see public health become much more precise in its application. The Institute for Health Metrics and Evaluation (IHME) has come to be recognized as the global leader in the field known as health metrics science. IHME’s work is powered by technological innovation and a worldwide collaborative network of research professionals. The value of this data-driven approach has already been demonstrated in a multitude of ways, and I feel it will revolutionize our ability to understand the potential impact of a pandemic by quantifying both the biological and social determinants of disease at a local level (an early warning system for every community in every nation). Data will guide decision-making about the allocation of resources to improve health and lower the risk to infection. At the same time, it will help with the early identification of sources and potential vectors that could trigger outbreaks. How will public health be redefined? It will become more precise, responsive, and targeted as a result of new data tools and technology.
3. Prevention, Redefined: Prevention, which has historically been identified with public health initiatives, has always been linked to population-based concepts such as immunization and the establishment of risk criteria for diseases. While these are important areas of concern, they are not adequate to prevent a pandemic, as our experience with COVID-19 clearly demonstrates. Another fact that is now indisputable is that the severity of response to a viral infection is highly variable among people who are exposed. Although the COVID-19 story is still unfolding, it did not take long to see patterns emerge with regard to incidence of infection. A wide range of possible outcomes also quickly became apparent. Men, older-age individuals, people with pre-existing diseases, and socioeconomically disadvantaged populations all appear to be more vulnerable than other segments of society.
I offer a theory in the form of three questions:
· Could compromised immune resilience be a public health crisis that is not yet adequately measured or tracked in a way that encourages individuals to engage deeply and personally with this critical biological system?
· Is our current health care system responsible for this knowledge gap?
· Could awareness and self-monitoring of immune function save lives?
In 2010, the Affordable Health Care Act mapped out a sequence of first steps that would move prevention from the public health arena to the individual in the United States. By 2016, actionable efforts were underway. That same year, President Barack Obama published an article in the Journal of the American Medical Association that carried this title: “United States Health Care Reform: Progress to Date and Next Steps.” In an editorial also published in that same issue of JAMA, Stuart M. Butler, PhD, a Senior Fellow in Economic Studies at the Brookings Institution, wrote: “The health sector increasingly recognizes that it should focus more on ‘upstream’ determinants of health, not just medical services.” We have learned through our COVID-19 experience that compromised function of the immune system is a state that may be present in many people who appear otherwise healthy. How will prevention be redefined? Medicine will take a closer look at those “upstream” determinants of health. We will see new ways of assessing immune system function in development, and this focus will become incorporated into the standard of care that providers deliver to patients. The word “prevention” will no longer be disproportionately linked to a reduction of risk factors, but rather will encompass immune function and the management of lifestyle factors that can strengthen immune resilience.
4. Reimbursement for Medical Services, Redefined: When social distancing abruptly became our new normal, businesses — even the business of medical care — had to adjust quickly. Before COVID-19, the effectiveness of existing care models was already being called into question. Post-COVID-19, we need to find innovative ways of delivering care and streamlining reimbursement for medical services. Successfully preventing and managing future pandemics may depend on the evolution of the therapeutic relationship. A pre-COVID-19 statistic: more than 70% of medical expenditures in the US are for the diagnosis and treatment of chronic diseases. Chronic diseases, as I have already stated, may negatively impact immune resilience, making those who are living with these conditions high-risk candidates for infectious diseases. These chronic diseases have historically been treated with medications, although numerous studies have indicated that lifestyle interventions related to diet, exercise, sleep, and stress management may be more effective than pharmaceutical treatments. Designating primary care providers as gatekeepers who grant patients access to specialty medicine services may not only be inefficient, but also ineffective. COVID-19 definitively showed us that chronic conditions can be linked to poor outcomes in a pandemic crisis. How will reimbursement models for medical services be redefined? We will see more emphasis on personalized lifestyle health care and how it can be effectively delivered in novel ways. This will include reimbursement for health coaching, group medical visits, and telemedicine. These are three care models that support people in making positive health changes that may translate into the reduction of risk to infectious disease.
5. Planetary Health, New Awareness: While the world was in lockdown for COVID-19, together we marked the 50th anniversary of Earth Day on April 22, 2020. Way back in 1966, Kenneth Boulding, who was an unusual combination of both economist and interdisciplinary philosopher, wrote about a concept of global connectiveness in which he referred to our planet as “Spaceship Earth.” Could there be a better and more profound example of how connected the biophysical web of Spaceship Earth is than a worldwide pandemic that has united us not through fear, but through the collective experience of slowing down and supporting one another through an event that has impacted each and every one of us?
There seems to be a greater recognition now that the resources of Spaceship Earth are not infinite. We all share the same water, air, and energy from the sun. COVID-19 has reminded us of the vulnerability of the human species and how our very survival depends upon the resources derived from our planet. You would be hard-pressed to find anyone who does not now appreciate the importance of our food supply and the global relationships that drive its production and distribution. There are currently 7.8 billion people inhabiting Spaceship Earth, and our crew is projected to grow to 12 billion by the end of the 21st century. The importance of our climate, soils, water, and plant diversity cannot be overstated.
Is there a silver lining to the COVID-19 pandemic? Are people now asking more questions about climate change, pollution, our reliance on ultra-processed foods, our sedentary lifestyles, our excessive alcohol intake, our use of medications and drugs, and our stress — SO MUCH STRESS — from being overscheduled and dependent on smart-devices? In 2017, an article titled “Planetary Health: Protecting Human Health on a Rapidly Changing Planet” was published in The Lancet. It was written by Samuel S. Myers, MD, who is a member of the faculty of the Harvard University Center for the Environment and also Director of the Planetary Health Alliance. Dr. Myers wrote: “The impact of human activities on our planet’s natural systems has been intensifying rapidly in the past several decades, leading to disruption and transformation of most natural systems. These disruptions in the atmosphere, oceans, and across terrestrial land surfaces pose serious threats to our health and survival and require a paradigm shift in how we deal with them.”
This is a field that I have an intense interest in. More than 40 years ago, I began my career as a professor of environmental science. My advocacy has remained strong over the decades, and earlier this year I was proud to co-author a paper with my colleague, Susan Prescott, MD, PhD, that appeared in the International Journal of Environmental Research and Public Health. Dr. Prescott and I wrote about the impact of the planetary health movement, and this is what we had to say: “In restoring human connectedness to the natural world, a sense of community and shared purpose must occur in tandem with technological solutions, and will enhance individual empowerment for personal well-being, as well as our collective potential to overcome our grand challenges. Such knowledge can help shape the use of metaphor and re-imagine solutions and novel ways for restoration or rewilding of ecosystems, and the values, behaviors and attitudes to light the path toward exiting the Anthropocene.” How will COVID-19 result in a new awareness of planetary health? What is a worldwide pandemic if not a “grand challenge”? Spaceship Earth keeps spinning. On its beautiful surface, many of us are still in quarantine, awaiting humanity’s next chapter. Let’s write it collectively. Let’s get it right. We’re in this together.
 Brandt AM, Botelho A. Not a Perfect Storm — Covid-19 and the Importance of Language. N Engl J Med. 2020 Apr 16;382:1493–1495.
 Gates B. Innovation for Pandemics. N Engl J Med. 2018 May 31;378(22):2057–2060.
 Obama B. United States Health Care Reform Progress to Date and Next Steps. JAMA. 2016 Aug 2;316(5):525–532.
 Butler SM. The Future of the Affordable Care Act Reassessment and Revision. JAMA. 2016 Aug 2;316(5):495–497.
 Myers SS. Planetary health: protecting human health on a rapidly changing planet. Lancet. 2018 Dec 23;390(10114):2860–2868.
 Prescott SL, Bland JS. Spaceship Earth Revisited: The Co-Benefits of Overcoming Biological Extinction of Experience at the Level of Person, Place and Planet. Int J Environ Res Public Health. 2020 Feb 21;17(4). pii: E1407.