Preparedness and Policy in the Time of Pandemics

The COVID-19 influenza pandemic is upon us, wreaking havoc across the globe. Just weeks after onset, this viral outbreak has already killed tens of thousands, thrown national economies into freefall, and paralyzed modern life as we know it. This scourge promises considerably more social devastation before it runs its course.

Modern societies are increasingly vulnerable to viral pandemics thanks to high population densities with high degrees of social interaction and mobility. Recent viral epidemics such as COVID-19, SARS (2003), avian flu (2005), MERS (2012), and Ebola (2014) were triggered when viruses mutated and jumped from animals to humans following regular exposures with family-owned livestock or at live markets. These viruses surfaced in one geographical region and spread nationally and globally via infected travelers. Viral transmission was facilitated because carriers of the infection were contagious before the onset of observable symptoms.

Government policies for responding to viral pandemics epitomize critical decisions. They play out over months or years, affect large numbers of stakeholders with diverse and often conflicting needs and interests, and carry serious risks of catastrophic social harm. Decisions about responding to pandemics are also complicated; they require significant commitments of funds and careful planning to allocate limited resources and coordinate actions, in this case, across multiple levels of government, NGOs, and the private sector.

Pandemics constitute a highly lethal type of threat. As such, responses fall into familiar categories of risk management decisions:

• Prevention — stop threats from materializing or moderate their intensity
• Mitigation — respond to the consequences from the threat and minimize harm
• Recovery — restore normalcy by rebounding from damage and losses

These categories of threat responses must be mapped into public health decisions tailored to the lifecycle of influenza pandemics, as shown below (adapted from World Health Organization).

The spread of viral infections across a human population is a biological process that occurs in social environments. This means that public health responses must encompass both medical services and changes in social behaviors. Prevention aims to detect the emergence of new viruses in humans as soon as possible and arrest the explosive growth of transmission once the “spark” of sustained infection surfaces through containment: intensive testing of suspect individuals (based on symptoms or travel patterns) and isolating those who test positive (and those who they exposed) until they are no longer contagious. Containment only works at a small scale, when limited public health resources are adequate to trace direct personal contacts of infected (and exposed) individuals.

As outbreaks expand, the number of infected persons whose original contacts are untraceable increases rapidly, signaling the spread of undetected cases across communities. Containment transitions into suppression: testing and quarantines of individuals must be augmented with more socially disruptive policies: restrictions or prohibitions on travel; closures of non-essential businesses, schools, and other public venues; and stringent practices to enhance personal hygiene and minimize interpersonal contacts (e.g., sterilizing hands and work surfaces, social distancing). These broader restrictive policies aim to decelerate viral spread or “flatten the curve” of the outbreak. If successful, these policies moderate the surge of new infections, and more critically, new admissions into hospitals. This buys time to treat more intensely ill patients, given constrained capacity of beds, equipment, and healthcare providers.

The second crucial component of mitigation is medical treatment. Serious coronaviruses such as COVID-19 attack the respiratory tract, producing symptoms including fever, coughing and difficulty breathing, and in severe cases, pneumonia. Seriously ill patients require oxygen, and in cases of acute respiratory failure, machines called ventilators that assist them in breathing.

Antiviral drugs kill viruses or at least inhibit their capability to multiply. If administered promptly, they can shorten illnesses and reduce the severity of symptoms. By lessening the “shedding” of viral residues in coughs, these drugs reduce the likelihood of patients transmitting the infection. They can also be given prophylactically to protect individuals at high risk, such as the elderly, persons with weakened immune systems, and health care workers. No antiviral drugs have been approved for treating COVID-19 (although tests are underway on several candidates). In effect, treatment for novel viruses focuses on keeping patients alive until their immune systems can defeat the infection. Ideally, vaccines can be developed to induce immunity to viruses, effectively preventing new infections. Newer antibody therapies also stimulate patients’ immune responses rapidly, but benefits are often only temporary. Work is underway on both types of treatments targeting the COVID-19 virus.

Finally, recovery reprises actions drawn from prevention and mitigation phases of response: identifying and containing any follow-on waves of contagion, and developing vaccines and therapies to blunt or suppress future outbreaks.

Parallel to public health measures, governments must make decisions to intervene in other ways during viral pandemics. They must assure production of necessary supplies, medicines, and equipment to meet the needs of healthcare providers, maintain critical infrastructure networks required for modern societies to function, (e.g., transportation, energy, communication, agriculture and food, public safety), and support populations and businesses from financial hardships created by restrictive social isolation policies. (The scale of economic losses puts government policies to facilitate economic recovery in uncharted waters.)

The most critical decisions for responding to viral pandemics relate to preparedness. Each pandemic is unique insofar as it is caused by a novel viral pathogen with distinctive biology and disease progression, geographic origin, and levels of infectiousness and lethality. This means that antiviral treatments and vaccines must be tailored for each new pathogen, which currently requires months or years to develop, test, and produce and distribute at scale. This crucial lag impedes all strategies for responding to pandemics — prevention, mitigation, and recovery.

That said, pandemics also have strong commonalities, such as non-linear growth rates of contagion and a small set of possible modes of transmission. This means that decision-makers can draw upon an array of policies, practices, and medical technologies that have proven successful in prior outbreaks. It follows that governments must have certain prerequisites in place prior to outbreaks, to facilitate orderly responses.

One obvious prerequisite is assuring adequate institutional capacities: locations to administer diagnostic tests and labs to evaluate those tests at scale, and hospitals and clinics for delivering medical treatment, outfitted with appropriate equipment and supplies such as hospital beds, oxygen, and ventilators. As a corollary, health care providers and support teams sufficient to test individuals and provide medical treatment including intensive care are needed to staff these locations and facilities. COVID-19 has highlighted two further prerequisites: adequate stockpiles of protective personal equipment for front-line health care and public safety workers (e.g., masks, gloves, gowns, and face shields), and of components required for diagnostic tests such as swabs and reagents.

Preparedness also includes assuring adequate capacity to replenish material and sustain services, including maintenance of critical equipment and reliable supply chains designed with back-up sources. Finally, decision-makers must anticipate regulatory obstacles to extraordinary surge conditions, and be prepared to expedite emergency exemptions and certifications (e.g. of new tests, drugs, medical equipment and treatments, reserve health care providers). Finally, preparedness encompasses pre-arranged cooperative agreements, between governments, institutions, and the private sector. Sharing works because viral hot spots arise (and abate) in different locations at different times, allowing constrained resources and supplies to be shifted around to meet localized demand.

Viral pandemics spread rapidly with cascading effects, much like wildfires. In both cases, inadequate preparation constitutes a cardinal sin that compromises prevention, fosters cascading consequences, and escalates the difficulties of mitigation and recovery efforts. With a few exceptions such as Singapore and South Korea, COVID-19 caught most governments unprepared, resulting in missed opportunities to either forestall the pandemic or dampen its progression. For example, US Government agencies weren’t prepared technically, logistically, or bureaucratically to produce, conduct and evaluate diagnostic kits at scale, causing a month’s delay that precluded effective detection and containment. Meanwhile, severe shortages of protective gear are producing high rates of infection in medical staff, depleting previous capacity for treatment. Barring highly creative solutions, the current national shortage of beds and ventilators will lead to tragic shortfalls in treatment capacity.

Decisions to prepare for viral outbreaks constitute insurance policies for societies; they are resented and stinted because they produce no tangible benefits until disaster actually strikes. Governments neglected or declined to make the necessary investments despite forewarnings from prior viral threats. COVID-19 is demonstrating the unintended but predictable consequences: unnecessary suffering and deaths, accompanied by traumatic economic and social disruptions. The dynamics that propel pandemic spread are swift and unforgiving (as described in my next post). Preparedness for pandemics is no less critical for national security than robust armed forces. Hopefully, governments will recognize this fact and do better the next time.