How to prevent the next.., p.3
How to Prevent the Next Pandemic, page 3
Since early 2020, I’ve been peppering the team at IHME with questions about COVID. What I’ve hoped to find out is what the countries that are dealing most successfully with COVID have in common. What did they all do right? Once we answer that question with some certainty, we’ll understand the best practices and be able to encourage other countries to adopt them.
The first thing you have to do is define success, but that’s not as easy as you might think. You can’t just look at how often people with COVID in a given country went on to die from it. That statistic will be skewed by the fact that older people are more likely to die from COVID than younger people, so countries with especially old populations will almost inevitably look worse. (One country that did particularly well—even though it has the world’s oldest population—is Japan. It had the best compliance with mask mandates of any country, which helps explain some of its success, but other factors were probably also at play.)
What you really look for in a measure of success is a number that captures the overall impact of the disease. People who die of heart attacks because the hospital is too overwhelmed by COVID patients to treat them ought to be counted just as much as people who die of the disease itself.
There’s a measure that does exactly that: It’s called excess mortality, and it includes people who die because of the disease’s ripple effect as well as those who die directly from COVID. (It’s the number of excess deaths per capita, in order to account for the size of a country’s population.) The lower your excess mortality, the better you’re doing. In fact, some countries’ excess mortality is actually negative. That’s because they had relatively few deaths from COVID, and there were also fewer traffic accidents and other fatal incidents because people were staying home so much more.
The true toll of COVID. “Excess deaths” measures the impact of COVID by including people whose deaths were indirectly caused by the pandemic. The top bar shows the number of COVID deaths through December 2021. The bottom bar shows the estimated number of excess deaths, with a range between 16.5 million and 18 million. (IHME)
Toward the end of 2021, America’s excess mortality was more than 3,200 per million people, roughly on par with Brazil’s and Iran’s. Canada’s, by contrast, was around 650, while Russia’s was well over 7,000.
Many of the countries with the lowest excess mortality (near zero or negative)—Australia, Vietnam, New Zealand, South Korea—did three things well early in the pandemic. They tested a large share of the population quickly, isolated people who tested positive or had been exposed, and carried out a plan for detecting, tracing, and managing cases that may have come across their borders.
Containing COVID in Vietnam. Government officials implemented measures for controlling the virus during 2020. Having just thirty-five deaths over an entire year in a country of 97 million people is a major accomplishment. (Exemplars in Global Health program)
Unfortunately, early success can be hard to maintain. Relatively few people in Vietnam were vaccinated for COVID—partly because of the limited supply of vaccines, and partly because vaccines didn’t seem as urgent when the country had done such a good job controlling the virus. So when the much more transmissible Delta variant came along, there were relatively few people in Vietnam who had any immunity, and the country was hit hard. Its rate of excess deaths went from just over 500 per million people in July 2021 to nearly 1,500 per million people in December—though even at the higher rate, Vietnam was still doing better than the United States. Overall, it was better off having taken those early measures.
IHME’s data also suggests that a country’s success against COVID correlates roughly with how much people there trust the government. This makes intuitive sense, since if you have confidence in your government, you’re more likely to follow its guidelines for preventing COVID. On the other hand, trust in government is measured by polls, and if you live under an especially repressive regime, you’re probably not going to tell a random pollster what you really think about the government. And in any case, this finding doesn’t easily translate into practical advice that can be implemented quickly. Building trust between people and their government takes years of painstaking, purposeful work.
Another approach to identifying what works is to look at the problem from the other end: Find exemplars that did individual things especially well and study how they did them so that others can do the same. A group called, appropriately enough, Exemplars in Global Health is doing just that, and they have made some fascinating connections.
For example, all other things being equal, countries whose health systems function well in general were more likely to respond well to COVID. If you have a strong network of health clinics that are well staffed with trained personnel, are trusted by people in their community, have supplies when they’re needed, and so on, you are in a better position to fight off a new disease. This suggests that any pandemic prevention plan needs to include, among other things, helping low- and middle-income countries improve their health systems. We’ll return to this subject in Chapters 8 and 9.
Another example: The data suggests that cross-border trucking was responsible for a fair amount of spread from one country to another. So which places managed it well? Early in the pandemic, Uganda required COVID tests for all truckers coming into the country, and the region of East Africa followed suit soon after. But because the testing process was slow and kits were in short supply, the policy caused major backups at the border—of up to four days—and transmission went up while truckers waited around in cramped quarters.
Uganda and its neighbors did several things to fix the logjam, including dispatching mobile testing labs to border crossings, creating an electronic system to track and share results, and requiring truckers to get tested in the country where they started their route, rather than at the border. Soon, traffic was flowing again, and cases were kept under control.
Truck driver Naliku Musa waits for the results of his COVID test at the border between Uganda and South Sudan.
Bottom line: In the early days, if you’re able to test a large share of your population, isolate the positive cases and their contacts, and handle possible cases coming from abroad, you’ll be well positioned to keep the caseload manageable. If you don’t do those things quickly, then only extreme measures can prevent a large number of infections and deaths.
Some countries show us what not to do.
I don’t like to dwell on failures, but some are too egregious to ignore. Although there are positive exemplars, most countries handled at least some aspects of their COVID response poorly. I’m calling out the United States here because I know its situation well, and because it should have done so much better than it did, but by no means is it the only country that made a lot of mistakes.
The White House’s response in 2020 was disastrous. The president and his senior aides downplayed the pandemic and gave the public terrible advice. Incredibly, federal agencies refused to share data with one another.
It certainly didn’t help that the director of the Centers for Disease Control and Prevention is a political appointee subject to political pressure, and some of the CDC’s public guidance was clearly influenced by politics. Even worse, the person running the CDC in 2020 wasn’t trained as an epidemiologist. The former CDC directors who are still remembered today for their amazing work—people like Bill Foege and Tom Frieden—were experts who had spent much or all of their careers in the organization. Imagine a general who has never even been through a battle simulation suddenly having to run a war.
One of the worst failures, though, is that the United States never got testing right: Not nearly enough people were tested, and results took far too long to come back. If you’re carrying the virus but don’t know it for another seven days, you’ve just spent a week potentially infecting other people. To me, the most mind-boggling problem—because it would have been so easy to avoid—is that the U.S. government never fully maximized the capacity for testing people, nor did it create a centralized way to both identify those who should be first in line to get quick results and record the outcomes of all tests. Even two years into the pandemic, as Omicron spread rapidly, many people weren’t able to get tested, even when they had symptoms.
In the early months of 2020, any people in America who were worried about having COVID should have been able to go to a government website, answer a few questions about symptoms and risk factors (such as age and location), and find out where they could get tested. Or, if test supplies were limited, the site might determine that their case wasn’t a high enough priority and notify them when they could be tested.
Not only would the site have made sure that testing kits were used most efficiently—for the people most likely to actually test positive—it also would have given the government additional information about parts of the country where too few people were showing an interest in getting tested. With this data, the government could have directed more resources toward getting the word out and expanding testing in those areas. The site would also have provided people with instant eligibility to participate in a clinical trial if they tested positive or were at high risk, and it could later have been used to help make sure that vaccines went to the people at the highest risk of getting severely sick or dying. And the site would also be useful in nonpandemic times for fighting other infectious diseases.
Any software company worth its salt could have built this site in no time,[*3] but instead states and cities were left to their own devices, and the whole process was chaotic. It was like the Wild West. I remember one especially heated call with people from the White House and CDC in which I was quite rude about their refusal to take this basic step. To this day I don’t understand why they wouldn’t let the most innovative country in the world use modern communications technology to fight a deadly disease.
In the face of something the world should have been better prepared for, people did heroic work.
Whenever there’s a disaster, the children’s TV host Fred Rogers used to say, “Look for the helpers. You will always find people who are helping.” During COVID, it takes very little looking to find the helpers. They are everywhere, and I’ve had the pleasure of meeting some of them and learning about many more.
Every day for five months of 2020, as a COVID tester in Bengaluru, India, Shilpashree A.S. would put on a protective gown, goggles, latex gloves, and a mask. (Like many people in India, she uses initials referring to her hometown and her father’s name as her last name.) Then she’d step into a tiny booth with two holes for her arms and spend hours performing nasal swab tests on long lines of patients. To protect her family, she had no physical contact with them—for five months they saw one another only on video calls.
Shilpashree A.S. takes samples in Bengaluru, India, while stationed in a booth and wearing protective gear.
Thabang Seleke was one of 2,000 volunteers in Soweto, South Africa, to participate in a study on the effectiveness of the COVID vaccine developed at Oxford University. The stakes for his country were high: By September 2020, more than 600,000 people had been diagnosed with COVID and more than 13,000 people had died from it. Thabang heard about the trial from a friend and stepped forward to help bring an end to the coronavirus in Africa and beyond.
Sikander Bizenjo went from Karachi to his home province of Balochistan, a dry, mountainous region in southwestern Pakistan where 70 percent of the population lives in poverty. He founded a group called Balochistan Youth Against Corona, which has trained more than 150 young boys and girls to help people across the province. They’re hosting COVID awareness sessions in local languages while also building reading rooms and donating hundreds of thousands of books. They’ve provided medical equipment to 7,000 families and food to 18,000 families.
Ethel Branch, a member of the Navajo Nation and its former attorney general, left her law firm to help form the Navajo & Hopi Families COVID-19 Relief Fund, an organization that delivers water, food, and other necessities to people in need throughout the Navajo and Hopi nations. She and her colleagues have raised millions of dollars (some of it through one of the top five GoFundMe campaigns of 2020) and organized hundreds of young volunteers who have helped tens of thousands of families from both nations.
The stories of people who are making sacrifices to help others during this crisis could fill an entire book. Around the world, health care workers put themselves at risk to treat sick people—according to the WHO, more than 115,000 had lost their lives taking care of COVID patients by May 2021. First responders and frontline workers kept showing up and doing their jobs. People checked in on neighbors and bought groceries for them when they couldn’t leave home. Countless people followed the mask mandates and stayed home as much as possible. Scientists worked around the clock, using all their brainpower to stop the virus and save lives. Politicians made decisions based on data and evidence, even though these decisions weren’t always the popular choice.
Not everyone did the right thing, of course. Some people have refused to wear masks or get vaccinated. Some politicians have denied the severity of the disease, shut down attempts to limit its spread, and even implied that there’s something sinister in the vaccines. It’s impossible to ignore the impact their choices are having on millions of people, and there’s no better proof of those old political clichés: Elections have consequences, and leadership matters.
Expect variants, surges, and breakthrough cases.
Unless you work on infectious diseases, you had probably never heard of variants until COVID. The idea may have seemed new and scary, but there’s nothing particularly unusual about variants. Influenza viruses, for instance, can quickly mutate into new variants—which is why flu vaccines are reviewed each year and frequently updated. Variants of concern are the ones that are more transmissible than others, or better at evading the human immune system.
Early in the pandemic, there was a broad belief in the scientific community that, although there would be some mutations of COVID, they wouldn’t cause a big problem. By early 2021, scientists knew that variants were emerging, but they appeared to be evolving in similar ways, leading some scientists to hope that the world had already seen the worst mutations that the virus was capable of. But the Delta variant proved otherwise—its genome had evolved to make it far more transmissible. The arrival of Delta was a bad surprise, but it convinced everyone that even more variants could show up. As I finish this book, the world is facing a sweeping wave of Omicron, the fastest-spreading variant to date—and in fact the fastest-spreading virus we’ve ever seen.
Viral variants are always a possibility. In future outbreaks, scientists will monitor variants closely to make sure that whatever new tools come out will still work on them. But, because every time a virus jumps from one person to another is an opportunity for it to mutate, the most important thing will be to keep doing the things that definitely reduce transmission: Follow the experts’ recommendations on masks, social distancing, and vaccines, and make sure low-income countries get vaccines and the other tools they need to fight the pathogen.
Just as the rise of variants wasn’t a surprise, neither were so-called breakthrough cases, in which people who have been vaccinated end up getting infected anyway. Until vaccines or drugs can block infections perfectly, some vaccinated people will still become infected. As more people get vaccinated in a given population, the total number of cases will go down, and a growing percentage of the cases that do occur will be breakthroughs.
Here’s one way to think about it. Imagine that COVID starts spreading through a town with a fairly low vaccination rate. A thousand people get so sick that they end up in the hospital. Out of those 1,000 severe cases, 10 are breakthroughs.
Then the virus spreads to the next town over, which has a high vaccination rate. That town sees only 100 severe cases, of which 8 are breakthroughs.
In the first town, breakthroughs represented 10 out of 1,000 severe cases, or one percent. In the second, they made up 8 out of 100, or 8 percent of the total. Eight percent sounds like bad news for town #2, right?
But remember, the important number is not the breakthrough rate. It’s the total number of severe cases, and that number went from 1,000 in the first town to just 100 in the next. That is progress by any definition. You’re safer by far in town #2, where lots of people are vaccinated, and if you’re one of them.
Along with variants and breakthrough cases, waves—big spikes in the number of cases—were not a surprise in and of themselves. We know from the history of previous pandemics that waves occur, yet countries in every region of the world were caught off guard by them. I admit to having been surprised, as many people were, by the size of the Delta wave in India in mid-2021. It was partly the result of wishful thinking—the mistaken idea that the country could relax because it had contained the virus in the early days of 2020. Another explanation is sadly ironic: Countries that do the best job of suppressing the virus early on will often be susceptible to later surges, because their suppression measures kept people from getting sick and developing natural immunity. The aim is to use suppression to delay widespread infection, prevent hospitals from getting overloaded, and buy time for vaccines to protect people. But if an especially transmissible variant shows up before vaccines are widely distributed, and if suppression measures are ended, then a big wave is almost inevitable. India did learn these lessons quite rapidly and ran a successful COVID vaccination campaign later in 2021.
