Viral pandemics pose serious threats to our health and prosperity, both as individuals and collectively.
The SARS-Cov-2 virus behind the COVID-19 disease is proving more lethal and socially disruptive than recent pathogens, causing far more extensive sickness, death, and economic devastation. The first piece in our series identified preparedness as the common prerequisite for all critical decisions responding to viral outbreaks across their lifecycle. The second and third articles described two important types of epidemiological models and discussed their strengths and weaknesses in supporting decisions for responding to pandemics. This last installment reviews the decisions facing leaders as the first wave of COVID-19 contagion is cresting in most parts of the world. These decisions cover responses over three time frames: short-, medium-, and long-term.
Short-Term
Most countries that have stemmed the first wave of viral infection did so by instituting public health policies that severely limited personal movement and social interactions, including shutting down non-essential businesses and services. With infection curves flattened, leaders are struggling to relax onerous personal and commercial restrictions and restore their crippled economies. These efforts are being propelled by impatient or angry and often desperate individuals, businesses, and other institutions. This growing pressure must be balanced against the risk of triggering a second and potentially deadlier wave of infection, which would trigger another prolonged societal lockdown starting from a weakened position.
Decision-makers are handicapped by two serious problems: preparedness and the lack of a rigorous methodology for reopening societies and economies safely. Fortunately, control theory holds the answer for relaxing societal shutdowns in a prudent and measured manner. Control theory is a subfield of systems engineering—the design and operation of complex machines such as cars and aircraft and continuous processes in industrial plants that generate power or manufacture chemicals. Control theory defines the mathematics for maintaining stable operations of dynamic systems such as inhibiting runaway behavior caused by feedback effects in aircraft controls or nuclear and chemical reactions. Control theory is tailor-made to guide governments to restart the economy without triggering new surges of COVID-19 infections.
Applying control theory to suppress viral resurgence is much like figuring out how to release and apply the brakes on a car with a stuck accelerator so that you can travel as far as possible without losing control of the car. It presupposes the availability of good indicators to signal when and how to use the brakes such as sensors measuring position, speed, acceleration, and steering. Potential signals for viral contagion include the daily number of new infections, hospitalizations, and transfers into intensive care and metrics for compliance with policies such as social isolation and distancing. As in other phases of decisions to respond to pandemics, preparedness constitutes a crucial prerequisite. Preparedness in this context means that many countries still lack the testing “infrastructure” to produce reliable signals required to detect and squelch infection hot spots before they reignite secondary surges. Infrastructure includes testing components (swabs, reagents), diagnostic kits with low rates of false negatives, accessible locations staffed with trained personnel equipped with personal protective equipment, and test evaluation facilities to turn around results in minutes or hours. It also includes timely reporting from hospitals, nursing homes, and other facilities that handle infected individuals. Deficiencies in reporting, testing capabilities, and capacity represent the Achilles heels to an otherwise proven approach to regulate the reopening of societies safely. At this stage of the pandemic, it is inexcusable for developed countries to lack the wherewithal to gather the data needed to rescue themselves.
Medium-Term
The primary public health objective for responding to pandemics over the medium-term is to suppress secondary surges of viral infection. As this goal is met in a stable manner, it becomes possible to start rebuilding economies and moving toward a new, but sustainable and tolerable social normalcy. Social isolation and distancing protocols, vigorous testing, and hospital capacities must be maintained. Work must continue apace on antiviral treatments and verifying, producing, and delivering vaccines at scale. Reducing uncertainties is a priority. This includes the “blocking and tackling” of improving accuracy and turn-around time for testing kits that confirm infection and recovery. It also encompasses watchfulness for two potential game-changers: monitoring COVID-19 samples for evidence of harmful mutations and tracking the duration of immunity in recovered patients.
Critical policy decisions in this time frame focus on societal recovery, sustaining families and businesses facing financial ruin at levels not seen since the Great Depression as economies reopen. The most novel feature of the economic crisis brought about by COVID-19 is that many sectors and services will have to rethink their core operations and business models. Most businesses and institutions that rely on social density are affected. Density comes in two forms: high concentrations of workers required to produce goods or services (meatpacking, construction, orchestras) or critical masses of customers (transportation, hospitality, tourism, entertainment, sports, religious and cultural institutions, education, and social services). High-density businesses and institutions have fixed levels to achieve economic viability or profitability (e.g., 70% occupancy of seats, 300 customers a day) tied to operating costs and prices. Social distancing rules and aversion to crowding into confined spaces will almost certainly preclude reaching those thresholds. Affected organizations will have to transform themselves to survive, much less to profit and grow, by redesigning their physical facilities and operations and economic models.
Additionally, the demographics of COVID-19 have illuminated the deadly consequences of longstanding social, economic, and legal disparities. As countries start to recover, they have unique opportunities to look beyond restructuring business sectors and consider redressing broader social inequities for disenfranchised populations (e.g. the elderly, the disabled, the homeless, mentally ill, and impoverished). Decision-making along these lines will, of necessity, spill over into the long-term horizon.
Long-Term
Long-term in this context corresponds to a year or more into the future. Assume that countries have succeeded in restoring a new form of social normalcy in this interval, thanks to anti-viral treatments that reduce suffering and mortality and vaccines that offer immunity for at least a few years. Suppose, additionally, that mid-term policies have set countries back on the road to economic growth and recovery. Having survived the initial devastation brought about by COVID-19, societies must ensure that they don’t get caught napping again when the next novel virus emerges. That is, institutionalizing preparedness will be a critical long-term decision.
Institutionalizing preparedness goes far beyond the basic blocking and tackling of replenishing national emergency stockpiles of supplies such as personal protective equipment, generic supplies such as swabs and reagents for tests, and ventilators for patients with acute respiratory failure. Additional decisions are necessary to promote (or restore) pandemic preparedness to a first-class strategic national priority.
Enhance global pandemic surveillance capabilities
Revive dedicated domestic production capabilities and supporting supply chains for critical medical material and equipment
Strengthen oversight of the national emergency stockpiles for pandemics to avoid reserve shortfalls
Restore funding for international healthcare organizations such as WHO and aid groups
Commit to pooling investment and resources in international collaborations to develop vaccines
Reinstate an independent pandemic advisory team in the executive national security apparatus
Reestablish CDC's preeminent role as the nation’s public healthcare authority
Provide direction (and resources) to FDA to certify all diagnostic and immunity tests and treatments for novel viruses.
Revise national pandemic plans by adding formal surveillance alarms to trigger immediate national actions to contain incipient viral contagion and clarifying national vs. state responsibilities
Pass federal legislation to implement these measures, including guaranteed funding mechanisms.
The obvious drivers of long-term decisions are to capture and preserve lessons learned from our sluggishness, politicization, and other errors responding to COVID-19. This job is incomplete until any improvements are made sustainable—or capable of withstanding the short memories, complacency, and miserliness of future leaders, legislators, and the public.
Leaders face two constants across all three time-horizons for responding to the COVID-19 pandemic: imperfect data and uncertainty about future events, trends, and forces. Given these harsh facts and the high stakes, leaders must try to avoid decision options for preparing for and responding to pandemics that depend on narrow assumptions about future events, conditions, and execution results. Such options are brittle, and almost invariably trigger unintended consequences. Instead, decision-makers should pursue a more prudent strategy: envisage a range of plausible future, formulate decision options that take this range into account, and evaluate and compare the projected outcomes of those options across that spectrum. The “best” decision is the option that avoids “train wreck” outcomes and produces the most attractive results relative to other alternatives across a diverse set of alternative predictions. I call this method a decision test drive because it resembles the road tests that consumers perform before choosing which car or truck to buy. The test drive method doesn’t guarantee optimal decisions and rosy outcomes; however, it tends to produce a satisfactory result that is robust in the face of our uncertainty about the future and imperfect scientific knowledge about viruses, their likely progression, and the effects of implementing complex, large-scale strategies to suppress infections and rebuild our societies.
The COVID-19 virus may be novel, but viral pandemics and the science and public health practices to combat it are not. Countries such as South Korea, Singapore, and New Zealand have shown that prompt, deliberate, and concerted action can contain viral outbreaks and minimize suffering, death, and economic calamity. Failure to prepare for pandemics is like a poor start in a swim meet or track race. It makes it nearly impossible to catch up, much less win. We need to up our game as a nation to survive and thrive.