One of the significant concerns about the spread of the virus is that if it spreads too quickly, hospitals will be overwhelmed by patients in need of immediate care, essentially turning hospitals into triage units, choosing who to care for first. During a White House press briefing on Sunday, the Vice President said that the capacity of the US healthcare system is in the forefront of his task force’s conversations on a daily basis.
What is happening in Europe right now is offering little consolation. Italy, Spain, France and even the UK have reported their highest single-day death tolls. A significant part of the problem, particularly in Italy, which saw 368 deaths in one day, has been the stress on the healthcare system.
Alex Azar, the US Health and Human Services Secretary said during the same White House briefing on Sunday that the strategy of cancelling events and public gatherings will help delay and flatten the curve of the virus in order to keep it from spiking beyond what the US healthcare system can handle.
Meanwhile, New York Governor Andrew Cuomo, in The New York Times on Sunday, called for the President to take greater federal actions to speed up testing and task the Army Corps of Engineers to provide further hospital capacity immediately.
After multiple epidemics and pandemics over the past century, what have we learned about how the US healthcare system has responded to outbreaks?
The Cipher Brief spoke with Christopher Nelson, a senior political scientist at the RAND Corporation and a professor at the Pardee RAND Graduate School. He has over 20 years of experience as a policy analyst and evaluator and his work often involves leading multi-disciplinary teams in designing systems (including healthcare systems) for performance measurement, system improvement, and organizational learning. He says part of the problem is the inability to maintain clear and consistent guidance. Let’s start with the facts.
Background:
What is an epidemic and what is a pandemic?
- An epidemic is when a disease is actively spreading, whereas a pandemic relates to a geographic spread that affects an entire country or world.
- Almost all pandemics refer to diseases that extend over wide geographic extension and most imply movement or spread that can be traced from place to place.
- Pandemics typically exhibit high attack rates and spread exponentially with multiple cases appearing within a short time.
- The term ‘pandemic’ most commonly is used to describe new diseases, or at least associated with novel variants of existing organisms. Though not a criterion, it is also often associated with diseases that are infectious, contagious, and severe or fatal.
The most significant modern historical epidemics and pandemics:
- The Flu Pandemic of 1968 - Referred to as the “Hong Kong Flu”, this pandemic was caused by the H3N2 strain in which more than 1,000,000 fatalities were reported. 500,000 of these fatalities took place in Hong Kong which was 15% of the population at the time. It took only 17 days before the outbreak was reported in Singapore and Vietnam and three months for it to spread to the Philippines, India, Europe, Australia, and the United States.
- The Asian Flu (1956-1958) - An outbreak of influenza A of the H2N2 strain. Lasting for two years, the Asian Flu took more than two million lives with 69,800 coming from the U.S. The disease spread to Hong Kong, Singapore and the United States.
- The Flu Pandemic (1918) - Between 1918 and 1920, an estimated 50 million people died from influenza across the globe and infected more than a third of the world’s population. The mortality rate was at 10 to 20 percent with over 25 million deaths in the first 25 weeks. This pandemic was different from others because it targeted perfectly healthy young adults. Previous outbreaks largely took the lives of juveniles or the elderly.
- The H1N1 Pandemic (2009) - A version of Influenza A (H1N1pdm09) that was first detected in the United States. Between 151,700-575,400 people worldwide died and approximately 80% of those deaths were people under the age of 65.
United States Preparedness:
- In 2005, the United States developed a Pandemic Influenza Plan for federal agencies and non-federal organizations to implement measures to control and respond to outbreaks. This strategy contains three key components: preparedness and communication, surveillance and detection, and response and containment. Each component has guidelines for both international and domestic efforts.
- In order to handle the pandemic, agencies and organizations have been assigned specific tasks. The Secretary of Homeland Security is responsible for overall coordination at the Federal level by implementing policies, maintaining cooperation between all federal agencies, and monitoring screening for influenza at the border.
- The Secretary of State is responsible for coordinating with the international community to help slow the outbreak by limiting trade and commerce and assisting other countries with their outbreaks.
The Cipher Brief asked Christopher Nelson about what we should have learned from prior pandemics, particularly when it comes to the two most pressing issues in the US today, testing and hospital system capacity to deal with the virus.
What is your reaction to how the U.S. is handling the testing process for COVID-19?
Testing obviously has been one of the biggest challenges during the COVID-19 response in the US. I expect this will be a major focus of After-Action reports on the outbreak response. But for now, it’s clear that it’s putting us in a situation where we’re flying a bit blind. All the more so because the symptoms are very similar to those of the flu and we’re seeing a fairly active flu season at the same time. This increases the challenges in deciding how to allocate scarce resources and communicate the risk with the public.
It’s also helpful to step back a bit from this specific outbreak and take a broader view. Over the years, I’ve looked at responses to many public health emergencies – not only infectious disease outbreaks but also the health consequences of fires, floods, hurricanes, explosions, and transportation accidents. I’m often struck by the challenges of responding where power and authority are distributed across many different jurisdictions and units.
Christopher Nelson, Senior Political Scientist, RAND Corporation
The U.S. has approximately 2,800 public health departments at the federal, state and local levels. As a result, we have the challenges associated with using a structure originating in the 18thcentury to manage events that happen on the speed and scale of a dynamic, global 21st century economy. To be fair, this decentralization can sometimes be a strength, as it creates opportunities for innovation. But it also can create significant challenges.
For instance, a couple of years ago we had the opportunity to review how the healthcare system responded to past outbreaks (e.g., SARS, H1N1, Zika, etc.). Across all of these we saw challenges in maintaining clear and consistent guidance (e.g., on appropriate use of personal protective equipment) to clinicians from the various relevant federal, state, and local agencies. Similar challenges result from the fact that we often have multiple jurisdictions communicating with the public. School closure decisions, for instance, are often made by the nation’s 14,000-odd school districts. Oftentimes, you have several districts in a single media market, and during H1N1 in 2009, we had situations where parents saw neighboring districts closing while their own district remained open.
What is the difference between the U.S. healthcare system and the public health system?
The healthcare system focuses on providing care at the individual level. In an outbreak like COVID-19 this means diagnosing individual conditions and providing care to people after they’ve become sick – in extreme cases putting them on ventilators, for instance. But it’s important to keep in mind that the “healthcare system” includes not only state-of-the-art academic medical centers, but also small physician practices and urgent care centers and pharmacy chain-based clinics.
The public health system, by contrast, is focused on population-level health. In an outbreak like COVID-19, this means detecting and characterizing clues about new risks, communicating them to the public, and working with state and local governments to implement broad-scale disease control measures like quarantines, school closures, and other forms of social distancing. These functions are provided mostly by governmental public health agencies, including state/local health departments and (at the federal level) the CDC.
The fact that these functions sit in separate organizational “silos” adds to the coordination challenges mentioned above.
And, as the school closure example illustrates, in functional terms, the “public health system” also arguably includes schools, the media, workplaces, and others whose decisions impact the spread of a disease and efforts to respond to it. This was recognized in a widely cited Institute of Medicine report back in 2008 and reflected in the fact that national pandemic preparedness plans have chapters on schools, workplaces, as well as hospitals, health departments, etc.
How is the U.S. healthcare system different than those in other major countries such as France or Italy?
The U.S. certainly isn’t the only country where public health response authority is widely distributed, as was illustrated by the tensions between national and regional leaders in Italy at the onset of the national quarantine. But the U.S. is a continent, not just a country, and the scale and scope of the challenge is that much greater. A great many communities overcome these coordination challenges through joint planning, training, and exercising, and for the past several years the federal government has encouraged the creation of regional healthcare coalitions that include health, public health, schools, EMS, and other partners. But maintaining close working relationships, updating and exercising plans etc. is a constant challenge and takes a lot of sweat equity.
Perhaps the biggest difference, however, is the fact that the U.S. does not have universal access to healthcare and a weaker social safety net than other OECD countries. This has a wide range of impacts, as the sick may hesitate to get the tests and care they need, for fear of huge medical bills and they may be unable to comply with social distancing for fear of loss of income.
What are the major gaps that exist in the US’ ability to combat health pandemics?
To be sure, many aspects of the US public health system are “best in class”, and we are fortunate to have a number of experts who have worked on numerous past outbreaks, including SARS, Zika, Ebola, and many others. But uneven access and coverage is a real concern. According to a survey by the National Association of County and City Health Officers, only half of large communities (more than 500,000 population) have access to a full-service health department; the number is even lower for medium and smaller communities. Pockets of weakness in detection capabilities can allow disease clusters to grow unnoticed. And sick patients do not always show up at the highest-capacity hospitals.
All clinics need to have a minimal competence in triage, infection control, and treatment, even if only to transfer patients to higher capacity hospitals (this was the idea behind the tiered system of care developed during Ebola – and for which, last time I checked, future funding is uncertain). Indeed, our health care system is already under considerable daily stress, with many hospitals and health systems across the US routinely operating near or at capacity. And federal investments in the front-line capabilities of public health response have declined over the years and have been comprised by reductions in staff.
Christopher Nelson, Senior Political Scientist, RAND Corporation
It’s very important to note that these gaps have been around for years. It will be critical to have a robust conversation about public health preparedness after the dust settles on COVID-19, so we’re better prepared the next time around. As we’re seeing, infectious diseases are serious business, not just for the health of our bodies, but for our economies and relationships with other countries. Thucydides knew it. Remember the discussion of the Plague of Athens in the History of Peloponnesian War? It’s still true.
Research conducted by our student partners at The University of Mississippi’s Center for Intelligence and Security Studies.
There were things we should have learned after SARS. Read The Coronavirus is worse than the System Blinking Red by Cipher Brief Expert Norm Roule.
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