On the Near Impossibility of Planning for a Viral Pandemic
Gerald Posner on What Went Wrong and What Comes Next
A lot of people assume that I know a lot more about the coronavirus than I do. That’s because Avid Reader Press published Pharma: Greed, Lies, and the Poisoning of America, a week ago on March 10. Pharma’s penultimate chapter is titled “The Coming Pandemic” and it closes with an infectious disease expert telling me that the next pandemic is “not a question of if, but of when.” The day after publication, the World Health Organization declared the virus a pandemic.
In fact, coronavirus is not mentioned in my book. The manuscript was at the printer by the time China reported two deaths from an unidentified illness in Wuhan in mid-January. Although I may not be an expert on COVID-19, during the past five years of reporting for my book, I have become fully familiar with pandemics, their history, and the successes and failures of responses over time by governments and the medical/pharmaceutical industries.
A question frequently asked is how so many governments, including ours, seemed unprepared from the beginning for this catastrophic public health crisis. My answer surprises many: there is little governments can do in advance for a novel virus. By its very nature, its outbreak is unexpected and it is dangerous precisely because it is a new pathogen that doctors have never seen and for which humans have no natural immunity.The idea that the emergency health care service in America might buckle under the challenge of treating a flood of seriously ill COVID-19 patients, makes everyone feel vulnerable and less safe.
A big reason we are so particularly vulnerable to a COVID-19 is because it is a virus not a bacteria. That distinction is lost on a lot of people. Chicken pox, Smallpox, HIV, Ebola, are all viruses. Typhus, Lyme disease, tuberculosis, cholera and the Middle Ages’ bubonic plague are and were bacterial. Sometimes it is hard to tell since pneumonia and meningitis can be either. Antibiotics can rapidly treat bacterial infections. They are useless against viruses. And the antiviral drugs that offset the severity and duration of viral infections do not yet work against COVID-19.
Many infectious disease experts have worried for decades about a looming pandemic that would catch the world unprepared, resulting in a huge loss of life while savaging the financial system. Their warnings, as I report in Pharma, were focused on bacterial epidemics. The overprescribing of antibiotics for decades and their widespread use in the food chain has allowed many microbes to mutate into versions resistant to those drugs. In 2016 in Nevada, an elderly woman got infected with a supergerm and earned the dubious distinction in American medical history as the first patient on which every known antibiotic failed to stop infection. The microbes that killed her were impervious to pharma’s war chest.
If COVID-19 was bacterial, the answer to “how did we get it so wrong” would be on the drug companies for largely abandoning antibiotic research and development to pursue much more profitable drugs to treat chronic conditions. In 1980, there were 36 American and European drug companies that made antibiotics. Today, there are fewer than six. There was a 31-year stretch that ended in 1999 in which there was no innovation in the field. Chinese drug firms produce the antibiotics today that are consumed in America. The abandonment of antibiotics for drugs with greater returns has left the planet vulnerable for a bacterial plague. COVID-19 does not change that.
Unfortunately, when it comes to viral epidemics, not much has changed in the 102 years since the Spanish flu infected a third of the planet. The 2020 response to a viral pandemic is the same low tech one as back then, isolation and quarantine. Antibiotics are useless. China, with the speed afforded only by an authoritarian government with an enormous military, tried stopping the virus in its tracks by quarantining 30 million people. But that dramatic action to contain microbes by not allowing them to spread beyond Wuhan’s ground zero came far too late. Although governments and the drug industry are almost always reactive to a pandemic, what they do and how they are prepared can make a significant difference in how many people are infected and ultimately die. The problem in China was that it took doctors three weeks last December before they made the connection between several early patients hospitalized for the same symptoms. All the sick were vendors from the same outdoor food market.
One of the treating physicians, Dr. Li Wenliang, warned some colleagues about the new illness on December 31. Instead of spreading the word about the new pathogen and dispatching the country’s top infectious disease detectives to Wuhan, the police arrested Dr. Li and accused him of “spreading rumors.” He died on February 7 from the coronavirus that he contracted while treating patients. It took China’s president Xi Jinping until January 7 to order his top medical officials to investigate the outbreak. They publicly denied it was communicable person-to-person. That allowed Chinese lunar New Year celebrations and holiday breaks to go ahead as planned, sending infected people from Wuhan around the country and across the planet.Unfortunately, when it comes to viral epidemics, not much has changed in the 102 years since the Spanish flu infected a third of the planet.
The Holy Grail to stop a novel virus once it gets out of the origination hot zone as it did with China, is to create some type of basic immunity in as many people as possible. Mother Nature’s way of doing that is allowing the pandemic to run its course. Infectious disease doctors call it herd immunity and it results after the viral surge has peaked. The Spanish Flu only stopped when the lethal microbe had killed between 50 and 100 million, a toll unthinkable today. The last viral pandemic in 2009, a less lethal one called H1NI, infected an estimated billion people. They developed a natural immunity from reinfection.
The way that science and pharmaceuticals can provide people with an immunity from COVID-19 is a vaccine. That is why a couple of dozen pharma and biotech companies are in a frantic race to find one (winning the race in the world of pharma translates to a year to 18 months). Infectious disease experts with whom I speak daily are convinced that a vaccine for COVID-19 is only a matter of time. That is not always the case with viruses. The FDA only approved an Ebola vaccine last year. That was 43 years after the first outbreak in the Democratic Republic of the Congo. There is still no vaccine for HIV/AIDS, coming on 40 years since it was identified.
If there is no effective treatment for a novel virus such as COVID-19, why all the obsession in the past couple weeks on testing? And on the failure of the CDC to have many more kits widely distributed early on? Testing is undoubtedly important because it allows epidemiologists to determine in real-world numbers whether the mathematical models for calculating the virus’s infection and mortality rates are accurate. More important, federal, state and local governments need real-time data that pinpoints possible hot zones with spikes in community spread. Government authorities and health departments can then ratchet up the level of enforcement for isolation and social distancing, as in the case of six northern California counties on yesterday with an unprecedented “shelter in place” order.
The lack of widespread testing in the US—only a few thousand Americans got tested while the virus was spreading around the country—is in sharp contrast to what happened in South Korea. That country had taken steps after it got hit in 2015 with Middle East Respiratory Syndrome, a microbial cousin to COVID-19. In that outbreak, Korea did not have adequate tests and it forced sick patients to visit different clinics and hospitals hoping to determine whether they had MERS. Thirty-eight died from MERS in South Korea and its economy tumbled into a recession. Only later did health authorities realize that half those who got sick were infected at the clinics and hospitals they had visited for testing. To avoid that happening again, the country enacted regulations that permitted near instant approvals of tests for outbreaks of contagion.
Only a few weeks after the first reports from China, South Korea used a WHO formula to manufacture 10,000 tests daily. As of March 10, South Korea had tested a quarter million citizens (in contrast to fewer than 10,000 in the US). Relying on extraordinarily broad powers granted under a public health emergency, South Korea used the extensive testing data to keep those infected from spreading it.
In February they began posting information about everyone who had tested positive, save their names. Able under the emergency health decree to collect all cellphone data and credit card information, it was possible on government websites to find not just the neighborhoods where someone who tested positive lived and worked, but where they sat at restaurants and cinemas and public spaces. International health experts praise the Koreans for an aggressive approach that has paid off in one of the lowest death rates (0.9 percent versus Italy’s near 6 percent).
“I think the number of tests has become the metric of success,” said Dr. Sanjay Gupta on CNN, “and I know why because we have been talking about it for weeks. The increase in testing should have happened weeks ago. Now there is evidence that since you have such significant spread within communities that the focus really has to be on what comes next.”
What is “next” is an effort to keep the virus from spiking at once and crushing the nation’s emergency health care system, as has happened with deadly consequences in Italy. New York Governor Andrew Cuomo warned yesrterday he thought it likely that would happen no matter how much information governments had about local hotspots. Instead of “flattening the curve”—spreading out the infection rate so it does not peak in a single surge—Cuomo said he sees it coming in waves and that the health care system is all but certain to be overwhelmed. No private- or government-run health system could afford, he said, to build overcapacity for expensive hospital beds and intensive care units and then leave them unused in case a pandemic should develop. In a remarkably frank press conference, Cuomo laid out the grim numbers. He said the infection rate could be in a range “between 40 percent and 60 percent of the population. Take that number of 18 million (New York state’s population), take a hospitalization rate of our sample of about 17 percent and then compare that to 50,000 hospital beds (the number in the state). You will then break out in a sweat, maybe hives, you will feel great anxiety, panic attack, and you will be right.”
The idea that the emergency health care service in America might buckle under the challenge of treating a flood of seriously ill COVID-19 patients, makes everyone feel vulnerable and less safe. The government’s rush of billions of dollars into vaccines and treatments as well as the crash effort to find needed supplies such as ventilators, oxygen, and masks, is necessary. But it will not stop what is coming. We are past the containment stage and now can only try and mitigate the fallout.
COVID-19 is a real life lesson of what the Martians learned in H.G. Wells War of the Worlds. We might think of ourselves as the planet’s most evolved and dominant species. We boast of our technology and know-how, traveling to the moon and planning for Mars. But COVID reminds us we cannot control microbes, the smallest living organisms. Tomorrow, March 18, marks one week since the WHO declared COVID-19 a pandemic. It is remarkable how in a single week, pandemics have replaced climate change as the world’s leading existential threat. Most sobering is the knowledge that it will not be the last pandemic in human history.