U.S.

Reimagining America’s Infectious-Disease Defense

A health worker works with blood samples during a coronavirus vaccination study at the Research Centers of America in Hollywood, Fla., September 24, 2020. (Marco Bello/Reuters)
The steps we need to take now to be ready for the next pandemic

For several decades, health experts have warned about the potential for an infectious pandemic sweeping the globe. After the Spanish flu ravaged the globe in 1917–18, resulting in upwards of 50 million deaths worldwide, the countries of the world tried to stay vigilant. The death of 675,000 Americans alone in that pandemic left a deep imprint on the American psyche through the middle of the 20th century.

Over the years, multiple epidemics have hit the world, with varying degrees of severity. The 1957 Asian influenza (H2N2) virus killed over one million worldwide, including over 100,000 in the U.S. alone. In 1968 the Hong Kong flu (H3N2) resulted in similar number of deaths, and that strain was so virulent that even today the H3N2 subtype reigns as one of the most common and troublesome influenza viral strains. In 2003, a coronavirus jumped from palm civets and ferret badgers in markets in Guangdong, China (sound familiar?). The virus spread to Hong Kong, and throughout the world. That virus, SARS, was relatively small in comparison, only killing around eight hundred people. But then, in 2009, we received a warning shot across the bow here at home, when the H1N1 virus (more commonly known as the swine flu) originated in Mexico and swept across the globe. In a year, 60 million Americans alone were infected, with over 12,000 deaths.

The warnings were common and consistent. However, even then, the countries of the world didn’t truly comprehend the scope of the threat. In 2005, Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, wrote the following:

Time is running out to prepare for the next pandemic. We must act now with decisiveness and purpose. Someday, after the next pandemic has come and gone, a commission much like the 9/11 Commission will be charged with determining how well government, business, and public health leaders prepared the world for the catastrophe when they had clear warning. What will be the verdict?

The COVID-19 virus showed that even with those numerous frightening warnings, we were not ready for this eventuality. The ultimate verdict was that we failed as a species to protect our own.

The failure did not originate with the American government establishment, however. China failed the world community by not being honest and transparent from the very beginning. After the SARS outbreak, China had promised the world, especially the World Health Organization (WHO), that it would provide full transparency in the event of future outbreaks.

They clearly broke their promise. The Communist Party’s innate fear of appearing incompetent to its own citizens — or worse, impotent to protect the people — has always driven its decision making. As has been repeatedly documented, China knew about the threat of a potential epidemic and pandemic very early in December of 2019. Random news reports out of China to newspapers in India and Singapore hinted at massive numbers of dead. Western intelligence agencies also had at least some suspicion of a major outbreak even earlier than that.

To compound matters, the WHO also appears to have completely failed in its duty as the key surveillance organization on biological threats. Founded in 1948, the WHO has a wide mission to ensure the physical, mental, and social well-being of all humans. However, viral threats have seemed to evade the WHO’s ability. This was true with SARS in 2003, and with Ebola on several occasions.

The Wuhan novel coronavirus, however, had unique characteristics that helped it avoid detection by the WHO. First and foremost, it originated in western China, away from the centers of power in Beijing and Shanghai. As the Communist Chinese sought to obfuscate and hamper efforts to investigate the threat, the WHO largely allowed them to do so, blindly keeping the faith that the Chinese would be fully honest with them. Local officials had informed the Chinese central government of the threat, but in response, the central government did little other than send a bulletin to hospitals. Internet medical chat rooms from Hubei province whispered about a new, untreatable pneumonia spreading around the region. In response, the Communist Party called these physicians agitators and rumormongers.

By the time China finally admitted the scope of the threat, it was already far too late for the rest of the world. Italy already was seeing community spread. England and France likely saw their earliest cases in December and never knew it. And gene studies in the U.S. show some cases as early as December, and likely large-scale community spread in New York City as early as the end of January. The window of opportunity to shut the door on the COVID threat had closed.

This is when the failures of the U.S. federal government come into play. The American Centers for Disease Control and Prevention (CDC) is considered the preeminent disease-protection entity in the world, bar none. Most countries have copied our organization and built their own versions of disease protection after our own CDC. But in this time of crisis, it is quite clear the CDC was not fully up to the job.

In January, after the virus had spread outside of China, the WHO and CDC were still refusing to accept that they had a full pandemic on their hands. The Trump administration was also divided. As early as January 29, Trump’s trade adviser, Peter Navarro, wrote an extensive memo detailing the risk of COVID to the U.S., saying the lives of millions were at stake. On that very same day, HHS secretary Alex Azar claimed the disease was well under control. The inadequate response by the federal government to the exponential growth of the virus was catastrophic. That lost time was critical in ramping up production of critical items, such as medical personal protective equipment (PPE), ventilators, and various critical drugs and supplies.

However, although the political class failed in this regard, the onus for recognizing the threat really should lie with entities such as the CDC, and they too failed the American people. Leaders including CDC director Robert Redfield and Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, also failed to alert the country to the massive threat, downplaying it for weeks.

Its biggest early failure, by far, was the failure to quickly develop and scale up testing for this novel coronavirus. Microbiologist Stephen Lindstrom was in charge of the CDC’s effort to develop a test. Early development was promising; however, decisions were made by the CDC as well as the FDA to produce lab-created RNA fragments of the virus, as well as reagents for testing, in-house instead of with a private contractor. This proved to be fatal, as the testing kits were fundamentally flawed and ultimately had to be discarded.

The CDC and FDA failure to provide the country with a rapid test early in the pandemic was a mistake from which the U.S. still hasn’t totally recovered. By May the government was rapidly expanding testing facilities, but the eight- to twelve-week gap had done incalculable damage to public-health-department response to the viral pandemic.

Questions persist: Why was there no backup plan? How come SARS-CoV-2 circulation in many parts of the United States remained undetected by the CDC’s early-warning systems for at least several weeks in early January and February? Why did the CDC not take the lead in developing, or at least systematically collating, projection models for the pandemic’s spread, which would have decreased confusion among decision-makers and the public?

These failures were then compounded by resistance from localities. As the virus proliferated through New York and the West Coast in early January, little was done to slow the spread. It is likely that the virus had spread to over 35 states by the end of February. At this point, most states had not issued even the earliest of warnings. Transportation hubs such as airports, railway stations, and subways should have been closed weeks earlier but remained open through the middle of March. This helped seed the virus, first reaching community spread in New York and surrounding regions and then spreading outward throughout the rest of the country. Local mayors and governors did not want to take courageous stands that could have saved lives. In short, state and local leaders compounded the already dismal federal response by worrying about their own political pet causes.

The Trump administration definitely worsened this politicization by using the CDC as a scapegoat for its early failures. As has been well documented, White House officials constantly interfered with CDC recommendations and guidance in order to please various political bedfellows. The constant dodging and weaving by the CDC further undermined the already weakened public trust in the organization.

One clear problem that arose was the dependency of the federal government on private industry. Private companies are the backbone of American ingenuity and production, but they are not always fleet-footed when it comes to responding to disasters and emergencies. These entities simply aren’t built for responding to unexpected, unpredictable events. As much as possible, the health-care infrastructure should work with private companies to coordinate planning and logistics in order to work seamlessly in an emergency. The federal government should not have to search for solutions from the private sector; those solutions should be readily available to them at a moment’s notice. If the federal government can provide the planning, blueprints, and methodology, our private industry is up to the challenge of actual production of these materials.

Even in the best-case scenario, however, the government must maintain more of its basic emergency reserves, especially those that the private sector cannot readily provide. This is especially true with the Strategic National Stockpile, which was greatly depleted after the swine-flu epidemic and never fully restored afterwards.

These problems will surely be investigated and challenged well into the future. Congress should consider a nonpartisan commission, much like the 9/11 Commission, to study what went right and wrong with America’s response to the virus. Only then can politicians and organizations at all levels be held to account. But knowing what we know now, what are some steps we can take the next time we are confronted with such a threat?

First, we must somehow get rid of many of our current biases within government, the medical community, and the public-health sector. There are many examples of this. Maybe most apparent is our reluctance to call for the institution of travel bans and regional and national quarantines. Simply put, in this instance that bias resulted in a grave mistake. More and more evidence shows that early travel restrictions in Asia and Europe clearly decreased the damage caused by the first wave of the pandemic. To this date, the successes of island nations such as Taiwan and New Zealand first and foremost relied on their natural geographic barriers to entry. In Europe, while nations in the western part of the continent were being ravaged by the virus by April, Eastern European nations were largely spared the peak impact of the first wave. It was only this fall, after most of the travel restrictions had been lifted throughout the EU, that many of these countries were hit with large case numbers.

Additionally, numerous studies now show that New York was the first region to have community spread, and exponential growth was likely taking place there by early February (far earlier than predicted by experts). The virus clearly crossed the ocean from foreign sources, and nothing but a travel ban could have stopped it.

Many leaders were resistant to even the most gentle of travel bans. When Trump instituted travel restrictions from China on January 31, there was an uproar from opponents that this was an ignorant, and even bigoted, policy move. In hindsight it is clear that Trump’s travel ban, if anything, was not restrictive enough. Legally, the president could stop the entry of any foreign visitors. However, Trump likely did not have the legal power to restrict U.S. citizens and legal residents from reentering the country. In retrospect, it is quite likely that those who did reenter helped seed the virus.

Once the U.S. became seeded with the virus, the policy shift should have been more about isolating the disease to those geographical locations and minimizing spread. Once again, our experts failed the nation. First and foremost, the testing failures documented above hampered our efforts to provide real-time data to our policy experts. Second, we had a severe lack of personal protective equipment (PPE) for our health-care workers. The Strategic National Stockpile had been woefully drained of materials during the swine-flu epidemic a decade before, and because of various missteps and failures, had never truly been replenished. This was especially true of PPE such as N95 masks, which neither the Obama nor the Trump administration ever bothered to replenish. Other items, such as ventilators, simply were not intended to be stocked in numbers sufficient for our early need.

A system of constant re-analysis of stockpile quantities and potential health-sector requirements by some central federal authority is essential to ensure preparedness. This should be done frequently, coordinating with the CDC, HHS, FEMA, and state authorities to establish what the national need would be if another widespread pandemic arose. As for ventilators and other more expensive equipment, it might behoove the government to form more public–private alliances before the crisis erupts, so that in the case of a sudden need, production of such items can occur as fast as possible. General Motors, for example, helped produce thousands of ventilators and was able to start manufacturing in a matter of weeks. This was without any pre-planning; imagine what a system that was thoughtfully planned could have done.

Furthermore, the American public-health establishment must change its focus. For too long, we ignored the specific steps needed to confront the threats posed by pandemic-level infectious diseases. The CDC and other entities must approach the problem in ways similar to how the U.S. military approaches threats of attack and invasion from foreign enemies. The key leaders in infectious-disease and public-health policy must be able to regularly game-plan for the unwelcome eventuality of a new biological threat. These entities need to build up technology, logistics, and materials necessary to rapidly scale up production of vaccine and therapeutics when needed. Funding research into the repurposing and rapid response of new treatments must be a constant consideration for the FDA. And to avoid catastrophes like the testing debacle with COVID, federal authorities should have redundancies built in for the most critical issues.

One complaint in recent years is that the CDC’s mission and breadth of scope have been tremendously broadened. The organization now studies diverse ailments ranging from birth defects to obesity and even repercussions from gun crime (both physical and mental). Although these are all relevant issues to the health and well-being of Americans, whether they should be included in the CDC’s mission is highly dubious.

Most supporters of the CDC will instantaneously revert to the usual: More funding. It is the obvious knee-jerk reaction to “reforming” any government entity.

We don’t necessarily disagree about the necessity for more funding. Relative to inflation, funding for these programs has been steadily declining for years. Expanding the various surveillance systems to warn of rising threats would be helpful for future preparation. Increasing funding for the Public Health Emergency Preparedness (PHEP) program is also critical. The Epidemic Intelligence Service (EIS), a key program providing postdoctoral training for CDC scientists, needs to be modernized as well.

And our focus on these viral threats from all over the globe needs to increase so we can speed up the process of creating new therapeutics and vaccines. If over the past several decades we had spent the requisite amount of money on developing more cures and treatments for diseases such as SARS, MERS, etc., we would have been in a far better position to quickly produce and distribute similar treatments against COVID-19. The time lost because of this lapse was critical.

However, if the only response from Congress is to send a bigger check to the CDC, these lapses are unlikely to ever be solved. For years, the CDC has been another bloated, politicized agency, more worried about pleasing members of Congress than about its scientific goals. The CDC campus is littered with buildings named after pork-barrel-loving members of Congress, from the Arlen Specter Headquarters and Emergency Operations Center to the Tom Harkin Communications Center. This politicization must come to an end.

The only way to stop the intervention of politics into these matters, as well as provide the health-policy community with enough freedom and tools to handle these challenges, is for there to be a more autonomous organization to handle these issues. This would not necessarily require a larger organization than the CDC, but it would require congressional reforms to allow the CDC to be insulated from micromanagement by Congress and the president. A semi-autonomous organization, along the lines of the Federal Reserve, with a steady funding stream would be the ideal solution. The head of this entity could be appointed for six- to ten-year terms, much as the FBI director is today, to provide even greater separation from the political maelstrom of Washington, D.C.

This kind of reform would require strong bipartisan support and trust that the future organization would not be biased, politically or scientifically. It can be done, but it will not be easy. Some will say this is too much power and autonomy to give to one agency, while others will argue it is not enough. In the end, we need a health-policy entity that cannot be misused for partisan intent (such as studies on gun crime or repercussions of abortion), but will have the sole responsibility to warn the country of future biological threats.

In many ways, this was the medical and scientific community’s version of 9/11. The COVID-19 virus and the ensuing pandemic have shaken the medical community’s faith in the system to its very core. Only by reexamining how we approach these threats and building a new generation of infectious-disease leaders and organizations can both medical professionals and the public at large gain confidence that their government is ready and able to handle any future threats.

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