Years ago I wrote a book on the HIV pandemic in Latin America, which focused on the diversity of epidemics within the region. How could one virus cause such a diversity of outbreaks? Of course it’s impossible to discuss an epidemic without considering human behavior, which we certainly see now with COVID-19. What’s interesting to me is the contrast between Africa, where the death rate has been relatively low, and the severe outbreaks in some Latin American states. Two of my colleagues and I discussed Latin America’s experience with the outbreak in late May, on a panel that focused on Argentina, Brazil and Mexico. Of course, much has happened since then, from the terrible outbreak in Peru, to the mounting challenges faced by Argentina. Still, the broad strokes about how these nations responded to the pandemic has remained similar, such as the populism and denial of Brazil’s President Bolsonaro. You can view our panel here on YouTube.
Like many people, I’ve been struck by the parallels between the current COVID-19 pandemic and the 1918 pandemic. In 1918 many media outlets in Europe and the United States did not initially give the outbreak adequate coverage, because they were censored during the war, or did not want to reveal their nation’s weaknesses. In the United States and Brazil now, populist leaders are dismissive of the news and data on COVID-19, because it reveals their failures. For this reason, their followers tend to view all COVID-19 information through the lens of partisan politics. Indeed, President Bolsonaro of Brazil has called his followers to storm hospitals to take photos and videos to show whether COVID-19 patients are truly filling hospital beds, as the hospitals and state leaders claim. Such denial has caused painful climbs in COVID-19 deaths in both Brazil and the United States. …
In our textbook, the health chapter begins by this comparison of nations: “Chile, Costa Rica, Cyprus, Guadalupe, Hong Kong, Israel, Macau, Malta, Martinique, Singapore, and the United Arab Emirates are a diverse set of nations and territories. Yet they all have one fact in common: their citizens live longer than those of the United States, as do the citizens of many developed countries (United Nations 2006). This truth is unexpected, given the wide gap between the wealth, power, and technology of these countries and that of the United States. But health inevitably becomes linked to broader issues of politics and policy.” This is certainly the case in the United States’ ability to respond to a pandemic.
What have some of the lessons of this pandemic been for the United States? Our health care system has a number of weaknesses during an epidemic:
- A health care system that invests heavily in technology, but less so in people, such as the public health professionals who do contact tracing.
- A lack of recent experience with pandemics, such as South Korea and Canada had with SARS and MERS.
- An inadequate stockpile of personal protective equipment. A failed effort to develop a stockpile of ventilators wasted over a decade, and left the United States undersupplied.
- A popular belief that epidemics are something that happens elsewhere, so that the first and best response is only to put in place border restrictions.
- A sense of hubris, so that outbreaks in China or South Korea are assumed to be something that could not happen here, because our hospitals -with their advanced technologies- would be able to manage the situation.
- A health care system in which peoples’ insurance is tied to their employment. This has meant that when people lose their employment during a pandemic, they also lose health care.
- Deep health inequalities, which mean that case fatality rates may vary widely depending upon class and geography.
- A lack of sick leave for U.S. workers, so that people feel compelled to come to work when they are sick, or to face an immediate financial crisis if they are forced to stay at home.
- A sense of hubris regarding the U.S. medical system, which led U.S. health authorities to reject a German developed test for COVID-19 that the World Health Organization (WHO) endorsed. Instead, the U.S. frittered away precious time developing its own test. When that did not work, the CDC and FDA wasted even more time resolving the situation.
- A CDC and FDA that had become too swamped by bureaucracy and hence struggled to adapt, despite having outstanding and dedicated people. The system’s senior leadership has ossified.
- A U.S. health care system that is too decentralized to respond to a national level emergency, although this decentralization also has some benefits when there are failures at the top.
- An over-reliance on overseas manufacturing for key health goods, for everything from masks to medications.
- A society that undervalues the very people who turn out to be particularly critical during a pandemic: janitors, grocery store clerks, truck drivers, nurses, farmers, and others. As many people have said, it is only during a pandemic you learn whose job really counts. And there is not a good correlation between peoples’ pay and how important their job truly is. The same holds true for respect.
- A high rate of chronic diseases that leave people vulnerable to a disease such as COVID-19. The “diseases of development” such as diabetes, sleep apnea, high blood pressure and morbid obesity have led to higher case fatality rates. Most of these issues connect to the Standard American Diet (SAD) and the U.S. food system. No technology can replace a good diet.
- A chronic underfunding of public health. A good public health system is like a seat belt. You forget that it should be there until you really need it. And it seems kind of basic, but when the moment comes, there is nothing else that can replace it.
- Basic public health relies on people, and salaries are expensive. But not having an adequately funded public health system is what is truly expensive. Contact tracing, outreach, education, follow-up, monitoring, epidemiology, and health communication take time and people. Perhaps because they do not rely as much on technology they are also undervalued in the United States, which always likes to use technology to solve all problems. But there is no substitute for public health professionals.
- The basic systems that are always there in public health -nurses in schools, communication campaigns, testing systems, contract tracing- are the same systems that are needed in a pandemic. So having good public health in ordinary times gives you the tools and the people that are needed during extraordinary times.
As I write these words nurses in Hong Kong are on strike to protest the fact that the Chief Executive, Carrie Lam, will not close the border to China. To be clear, the executive has sharply restricted entry to Hong Kong, closed most crossings, and forbidden entry from the most affected Chinese state, Hubei. But there are still strong calls for a complete border closure coming from within Hong Kong’s medical community. Similarly, the United States has restricted flights from China to U.S. citizens only; some U.S. airlines had already canceled service to China. All such quarantine measures are controversial.
On social media, such as Twitter, and in the press, a number of experts have denounced all quarantines as being not only ineffective but also in violation of WHO guidelines. These authors worried about panic overcoming good judgement, the economic costs of restricting travel, the stigma imposed on those from affected areas (Chinese in particular, but also all Asia), and the importance of upholding International Health Regulations. These are valid and important points. Some authors have also pointed to studies based on computer models showing that quarantines are ineffective with highly contagious respiratory diseases.
Recently the tone has shifted in the discussion, as it has become clear that some cases of the virus are being spread asymptomatically. The number of cases has grown quickly. Some apparent facts (such as no human to human transmission) that seemed true in mid-January are no longer true. So the stridency of the debate about quarantine has declined, but the debate continues.
So is there any role for quarantines to manage such a pandemic? And is there some other way to make a judgement that relies less on computer models? I would suggest that looking at the past history of respiratory pandemics, such as the 1918 influenza pandemic, might be useful. Can history suggest particular circumstances in which quarantines may work? …