It has been a weird roller coaster of emotions for many of us here in the US as a seemingly distant viral infection has morphed into a pandemic. It should not be surprising as the Spanish Flu of 1918 killed nearly 50 million people in a world of 1.8 billion inhabitants, while we live today in ever-increasing proximity and global connectivity. In the past two decades as a world citizenry, we have had some near pandemics with SARS, MERS-CoV, and avian influenza missing out on global domination. I was half expecting the Covid-19 outbreak to reach the same fate, but it seems to be more resilient, able to remain viable on surfaces, spread over longer distances, and remain asymptomatic in hosts while infecting unsuspecting new hosts.
As I write this, I am preparing for the start of my night shifts in the intensive care unit (ICU) where the sickest patients, including Covid-19 suspected and confirmed cases on ventilators, will be housed. My wife is assigned to manage a similar cohort of patients, who are not critical but infected. An estimated 20% of patients with Covid-19 will need hospitalization with 5% of those infected likely going to the ICU. The more people get sick the more limited our resources will become. While the death rate of the seasonal flu here in the US is between 0.1-0.15%, the 2% (1-3%) death rate quoted would overwhelm our last lines of care in the ICU. It is not just machines, but also the lack of availability of trained clinicians to manage both Covid-19 and non-Covid-19 patients. My concern here is somewhat overshadowed by news from my homeland, Malaysia, with the highest rate of infection in Southeast Asia (as of 3/20/2020) and limited ventilators, which will require difficult decisions about withholding care to the elderly. I realize our concern for this coronavirus may be overblown in retrospect. Yet, a few things will likely hold true: experts are rushing to catch up with this disease and the centralization (top-down) of pandemic management cuts both ways.
We Are In This Together, Blame Games Are Unhelpful
A natural inclination is to point an accusatory finger at China and its wet markets, along with the initial reaction by the local government attempting to suppress news of the emergence of a novel coronavirus. While I appreciate the sentiment to avoid public panic without strong evidence, the authoritarian steps taken leaves a bad taste in the mouth of healthcare workers all over – RIP Dr. Li Wenliang. China’s subsequent steps were a show in strength of its centralized planning, as evidenced by the tapering of new cases and deaths, leading to a flattened curve of new infections.Similar intensive steps by Singapore, Hong Kong, and South Korea, with contact tracing, enforced quarantine and mass testing – albeit with concerns of the loss of individual privacy – seem to have flattened the curve. South Korea and Singapore’s tracking of infected individuals and their contacts using CCTV and cell phone signal is both exciting (from an epidemiology perspective) and eerily intrusive in a Big Brother sort of way.
As we applaud these top-down moves, I realize that here in the US some of these steps would fly in the face of infringement of individual liberty, even when society benefits. Yet it is these very individuals (in Asia and the US) who have taken to social media and chat apps to share insights and to shed light on the inaction of public health officials that has been fascinating to observe. What if such freedom of information was available to the Chinese public at the start of this pandemic?
Personal Privacy Is Trumped By Personal Safety
The federal and state response to Covid-19 in the United States has been excruciatingly slow, stemming from the initial ‘wait and hope this blows over’ approach. We had fair warning yet did not put into place effective steps such as those instituted in Asia. Many, including myself, have been critical of the slow steps in the US to deal with Covid-19; what makes the US unique also makes it a nightmare to manage a coordinated response. From state by state regulation of health care to a strong sense of individual liberty, and from private health care companies to a non-existent public health system, the US has its own set of challenges. Frequent contradictions between the White House and health experts, without a clear national Covid-19 strategy, was in stark contrast to Singapore PM Lee Hsien Loong’s reassuring message to the public in early February.
Our Decentralized Response To Covid-19
Probably not surprising, Silicon Valley (and other biotech hubs) with its build and iterate ethos has led the way with the Palo Alto Project (a play on the Manhattan Project – a term coined by Balaji Srinivasan, who at one time was rumored to be in contention for the top job at the US FDA). Credit is certainly due to our private citizens having showcased a full-throttled bottom-up response from mobilizing on Twitter to disseminate information, propose ideas, and challenge theories, to engaging in robust discussions on Reddit and Facebook and from tech and biotech companies developing low-cost ventilators, synthesizing vaccines and creating direct to consumer tests to laboratories providing resources to develop test kits. Some may question the profit motives of these corporations, yet physicians get paid to work and are still deemed altruistic in such circumstances. Large and small companies have instituted ‘work from home’ programs and local governments have closed schools in favor of home-based teaching curriculum, to mitigate the spread of the disease through social distancing. As a result of these steps, remote work and home schooling may be at its tipping point of moving mainstream – along with telehealth.
Regulations introduced during peacetime, with good intentions (and often bad consequences), and regulatory capture have hamstrung a more cohesive, faster top-down and bottom-up approach to this pandemic. The ability for biotech companies and independent testing laboratories to receive virus specimens to create tests and vaccines has been held up, leading to a severe bottleneck at federal, state, and local levels. Restrictive certification rules for suppliers have laid bare our supply chain here in the US, especially from Asia, having also been blamed for our frequent drug shortages and price escalations as limited suppliers have the ability to game the system and monopolize the market. It is vital that we utilize our collective intelligence to bring to fore effective solutions. The government must harness the public-private relationship to be a vital asset in the fight against the next pandemic.
Federal And State Response
As new data emerges, our opinions and analyses must adapt accordingly. It has been encouraging to witness the Department of Health & and Human Services (HHS) and some private healthcare institutions embracing Twitter and Reddit to keep abreast of new information and to reach out to the public. Information vacuums get filled by rumors and illegitimate theories. Hospitals and healthcare departments are finally taking steps to mitigate the spread of this disease by creating clinical pathways to testing and treatment, though with over 15,000 confirmed cases in the US we still face limited testing ability. To improve access to care, telehealth rules to service the Medicare population and privately insured patients have been relaxed. Another positive measure by the HHS was to suspend state-based medical licensure allowing free movement of medical personnel across state lines to ensure that the supply of healthcare personnel meets local demands. It has required a state of emergency to remove archaic protectionist rules. Next, we should provide more autonomy to our nurse practitioners (NP) to screen and treat patients.
We Shall Not Let This Sneak Up On Us Again, Ever.
My hope is that, when this all blows over, we will ask ourselves “what did we do wrong?” and perhaps “how can we learn from the experience and strategies of other countries, both good and bad”. Understanding what went right for Asia and wrong for the rest of us here in the West may be a good place to start, as Italy has officially more Covid-19 deaths than China. Every crisis is an opportunity, and there will be many possibilities in the mix. Forcing more regulations on healthcare institutions to be ‘pandemic-certified’ will only give us the illusion of safety yet do little to protect us from another Black Swan. Crowdsourcing data and leveraging technology should be the new strategy for arming healthcare epidemiology with all the tools available in the 21st century. We need to grant more biotech companies and laboratories access to develop tests and vaccines to create a responsive, responsible and productive pandemic-prepared biotech sector.
In the meantime, hold on tight to your toilet roll (or bidet), stay indoors, stay sane and safe – this roller coaster is just starting.
PSA: Stop stealing our masks, make DIY sanitizer. Use sunscreen.
Avinesh Bhar, MD MBA
Asia 21, Class of 2016 – Asia Society
ABOUT THE AUTHOR – DR. AVINESH BHAR
Dr. Bhar is fellowship-trained and board-certified in sleep and pulmonary medicine. He has been in practice for over seven years. Our excellent sleep and respiratory doctor, Dr. Bhar, believes that high-quality care only comes from a trustful physician-patient relationship. To find out more about sleep and pulmonary telemedicine services, get in touch with us today and visit sliiip.com, or call 478-238-3552.
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