A coronavirus is so tiny that 1,000 of them could be stacked in the thickness of a sheet of paper. It is an invisible threat, and it is making vivid the shortcomings of our health care systems.
The world is a “a playground” for viruses like the novel coronavirus that causes Covid-19, infectious disease experts wrote last week in the New England Journal of Medicine. “We must realize that in our crowded world of 7.8 billion people, a combination of altered human behaviors, environmental changes, and inadequate global public health mechanisms now easily turn obscure animal viruses into existential human threats.”
There is still a chance that the outbreak, which has now spread to six continents, will stall out. China’s willingness to impose draconian, unprecedented quarantines has bought everyone time.
But the outbreak should be a wake-up call — one ignored with the less widespread outbreak of SARS in 2003 and the not-so-deadly flu pandemic of 2009 — about infectious threats that we face together and that exploit vulnerabilities associated with income inequality, health disparities, and our slowness to recognize threats.
We don’t ignore all threats. We tend to overreact to problems that are facing us right now but underreact to long-term threats that build slowly. We’re willing to take heroic measures to treat a heart attack, but slower to prevent heart attacks from happening. So, too, we’ve been derelict in spending the money needed to prepare for pandemics. We panic, but we don’t prepare. Take the current run on face masks. They won’t protect you from your neighbor’s coronavirus, but a shortage of masks to protect health care professionals who need to treat sick people means we could all suffer.
The Trump administration’s mistakes have been symptomatic of this larger problem. Officials eliminated White House-level positions aimed at preventing pandemics two years ago, and sought to scale back work to deal with disease outbreaks elsewhere from 49 countries to 10. The administration bungled the roll-out of diagnostic tests. And the Centers for Disease Control and Prevention and the Food and Drug Administration were too slow to adopt a suggestion made by former FDA Commissioner Scott Gottlieb: loop in major academic medical centers so more tests can be run. Only now is testing capacity for coronavirus starting to ramp up.
There is still a chance that cases that have been missed can be identified and controlled with measures like isolation or quarantine. Yet even if that can be done, the question is what happens next when the novel coronavirus comes into widespread contact with our health care system.
To contain the virus, people will need to call health care providers as soon as they develop any flu-like symptoms. But will they do so if it means losing money? Not only do 26 million Americans lack health insurance, but nearly half of those with private insurance — another 60 million people — have high-deductible plans in which they can be on the hook for thousands of dollars. Already, the Miami Herald has reported on a man who was charged $3,270 for getting checked out at a hospital, and the New York Times profiled a man who is facing nearly $4,000 in bills after he and his daughter were quarantined following their return from China.
Later on in the epidemic, when we have a better sense for the prevalence and severity of the disease, it may be better for patients with Covid-19 to stay home and use telemedicine services to see the doctor. But telemedicine, though on the rise, is still hamstrung by state licensing rules and the fact that all insurers don’t pay for it the same way.
When patients arrive at a hospital or doctor’s office, they may face shortages of nurses and physicians, particularly in rural areas. There are concerns about whether there are enough ventilators in the country to care for all the people who could get pneumonia in a worst-case scenario.
Bill Gates, the Microsoft billionaire and co-chair of The Bill & Melinda Gates Foundation, fretted in an editorial in the New England Journal of Medicine that this might be “a once-in-a-century pandemic.” Gates, who has been warning of the dangers of disease outbreaks for decades, prescribed a set of steps to help deal with the current outbreak, including his own donation of as much as $100 million to help efforts in lower- and middle-income countries.
To prevent future pandemics, Gates called for a data surveillance system that would instantly give relevant organizations the information they need about potential outbreaks. The U.S. has seemed to move in the opposite direction: The largest maker of electronic medical records in the U.S., Epic Systems, has been pushing back against rules aimed at allowing different record systems to communicate with each other.
Gates also argued that the government should spend billions of dollars to build manufacturing plants for vaccines that would normally provide routine vaccinations (drug companies now handle this, for profit) but could be refitted during a pandemic.
The idea seems like folly in part because of the scope of the idea. Billions of dollars? The Trump administration’s entire funding request for this emergency is only $2.5 billion, although members of Congress have complained it is too low.
But it’s worth considering one area where Gates’ dreams don’t fall short: the development of drugs and therapeutics. His idea of a plug-and-play vaccine that can immediately be deployed against any new pathogen is, well, far out. But new treatments and vaccines are being tested at a speed that would have until now been unfathomable. Early studies of the first vaccine candidate by Moderna Therapeutics are already beginning. An antiviral drug that was already invented by Gilead is being tested. Regeneron Pharmaceuticals and Vir Biotechnology are working on antibody drugs.
“Our savior here is going to be our technology,” Gottlieb, the former FDA commissioner, said on CBS’s “Face The Nation.” “And we need to make a really robust effort to try to develop a therapeutic.”
Given the low success rate for new drugs, it is possible that all these approaches could hit roadblocks or fail outright. But they exist because the development of drugs can be lucrative and Wall Street is willing to give biotech companies millions of dollars to try out new science.
The facile argument here is that this justifies the high prices of new medicines. That’s not necessarily true. But it’s true that this is a role that has been played better by industry than government in part because government is too cheap, too penny wise, and pound foolish to take the risk.
So take this lesson instead: If we were willing to see investments in health care infrastructure as a defense against terrifying new pathogens, those investments might very well pay off. They’d make the next pandemic a lot less scary, and benefit us in non-pandemic years, too.