Chronicle of a pqndemic Foretold Learning From the COVID - 19 Failure -Before the Next Outbreak Arrives

Chronicle of a Pandemic  Foretold
Learning From the COVID-19 Failure—Before the Next Outbreak Arrives

Michael T. Osterholm and Mark Olshaker
MICHAEL T. OSTERHOLM is Regents Professor and Director of the Center for Infectious
Disease Research and Policy at the University of Minnesota.
MARK OLSHAKER is a writer and documentary filmmaker.
They are the authors of Deadliest Enemy: Our War Against Killer Germs.
foreign affai r s 3


“Time is running out to prepare for the next pandemic. We
must act now with decisiveness and purpose. Someday, after
the next pandemic has come and gone, a commission much
like the 9/11 Commission will be charged with determining how well
government, business, and public health leaders prepared the world for
the catastrophe when they had clear warning. What will be the verdict?”
That is from the concluding paragraph of an essay entitled “Preparing
for the Next Pandemic” that one of us, Michael Osterholm, published
in these pages in 2005. The next pandemic has now come, and
even though Covid-19, the disease caused by the new coronavirus that
emerged in late 2019, is far from gone, it is not too soon to reach a verdict
on the world’s collective preparation. That verdict is a damning one.
There are two levels of preparation, long range and short range, and
government, business, and public health leaders largely failed on both.
Failure on the first level is akin to having been warned by meteorologists
that a Category 5 hurricane would one day make a direct hit on
New Orleans and doing nothing to strengthen levies, construct water-
diversion systems, or develop a comprehensive emergency plan. Failure
on the second is akin to knowing that a massive low-pressure
system is moving across the Atlantic toward the Gulf of Mexico and
not promptly issuing evacuation orders or adequately stocking emergency
shelters. When Hurricane Katrina hit New Orleans on August
29, 2005, preparation on both levels was inadequate, and the region
suffered massive losses of life and property as a result. The analogous
failure both over recent decades to prepare for an eventual pandemic
and over recent months to prepare for the spread of this particular
pandemic has had an even steeper toll, on a national and global scale.
The long-term failure by governments and institutions to prepare
for an infectious disease outbreak cannot be blamed on a lack of warning
or an absence of concrete policy options. Nor should resources
have been the constraint. After all, in the past two decades,
the United States alone has spent countless billions on homeland security and
counterterrorism to defend against human enemies, losing sight of
the demonstrably far greater threat posed by microbial enemies; terrorists
don’t have the capacity to bring Americans’ way of life to a
screeching halt, something Covid-19 accomplished handily in a matter
of weeks.

And then, in addition to the preparations that should have
been started many years ago, there are the preparations that should
have started several months ago, as soon as reports of an unknown
communicable disease that could kill started coming out of China.
The public health community has for years known with certainty
that another major pandemic was on the way, and then another one
after that—not if but when. Mother Nature has always had the upper
hand, and now she has at her disposal all the trappings of the modern
world to extend her reach. The current crisis will eventually end, either
when a vaccine is available or when enough of the global population
has developed immunity (if lasting immunity is even possible),
which would likely require some two-thirds of the total population to
become infected. Neither of those ends will come quickly, and the human
and economic costs in the meantime will be enormous.
Yet some future microbial outbreak will be bigger and deadlier
still. In other words, this pandemic is probably not “the Big One,” the
prospect of which haunts the nightmares of epidemiologists and public
health officials everywhere. The next pandemic will most likely be
a novel influenza virus with the same devastating impact as the pandemic
of 1918, which circled the globe two and a half times over the course of
more than a year, in recurring waves, killing many more people than the
brutal and bloody war that preceded it.Examining why the United States
and the world are in this current crisis is thus not simply a matter of
accountability or assigning blame. Just as this pandemic was in many
ways foretold, the next one will be, as well. If the world doesn’t learn the
 right lessons from its failure to prepare and act on them with the speed,
resources, and political and societal commitment they deserve, the toll
 next time could be considerably steeper. Terrible as it is, Covid-19 should
serve as a warning of how much worse a pandemic could be—and spur the necessary action
to contain an outbreak before it is again too late.

WAKE-UP CALL

For anyone who wasn’t focused on the threat of an infectious disease
pandemic before, the wake-up call should have come with the 2003
outbreak of SARS . A coronavirus—so named because, under an electron
microscope, the proteins projecting out from the virion’s surface resemble
a corona, a halo-like astronomical phenomenon—jumped from
palm civets and ferret badgers in the markets of Guangdong, China,
made its way to Hong Kong, and then spread to countries around the
world. By the time the outbreak was stopped, the animal sources eliminated
from the markets, and infected people isolated, 8,098 cases had
been reported and 774 people had died.

Nine years later, in 2012, another life-threatening coronavirus, MERS,
spread across the Arabian Peninsula. In this instance, the virus originated
in dromedaries, a type of camel. (Since camel owners in the Middle East
understandably will not kill their valuable and culturally important animals,
MERS remains a regional public health challenge.) Both coronaviruses
were harbingers of things to come (as we wrote in our 2017 book,
Deadliest Enemy), even if, unlike COVID -19, which can be transmitted by
carriers not even aware they have it, SARS and MERS tend not to become
highly infectious until the fifth or sixth day of symptomatic illness.
SARS , MERS, and a number of other recent outbreaks—the 2009 H1N1
flu pandemic that started in Mexico, the 2014–16 Ebola epidemic in
West Africa, the 2015–16 spread of the Zika flavivirus from the Pacific
Islands to North and South America—have differed from one another in
a number of ways, including their clinical presentation, their degree of
severity, and their means of transmission. But all have had one notable
thing in common: they all came as surprises, and they shouldn’t have.

For years, epidemiologists and public health experts had been calling
for the development of concrete plans for handling the first months and
years of a pandemic. Such a “detailed operational blueprint,” as “Preparing
for the Next Pandemic” put it in 2005, would have to involve everyone
from private-sector food producers, medical suppliers, and health-care
providers to public-sector health, law enforcement, and emergency-management
officials. And it would have to anticipate “the pandemic-related
collapse of worldwide trade . . . the first real test of the resiliency of the
modern global delivery system.” Similar calls came from experts and officials
around the world, and yet they largely went unheeded.

PREEXISTING CONDITIONS

If anything, despite such warnings, the state of preparedness has
gotten worse rather than better in recent years—especially in the
United States. The problem was not just deteriorating public health
infrastructure but also changes in global trade and production.
During the 2003 SARS outbreak, few people worried about supply
chains. Now, global supply chains are significantly complicating the
U.S. response. The United States has become far more dependent on
China and other nations for critical drugs and medical supplies. The
Center for Infectious Disease Research and Policy at the University
of Minnesota (where one of us, Osterholm, is the director) has identified
156 acute critical drugs frequently used in the United States—the
drugs without which patients would die within hours. All these drugs
are generic; most are now made overseas; and many of them, or their
active pharmaceutical ingredients, are manufactured in China or India.
A pandemic that idles Asian factories or shuts down shipping
routes thus threatens the already strained supply of these drugs to
Western hospitals, and it doesn’t matter how good a modern hospital is
if the bottles and vials on the crash cart are empty. (And in a strategic
showdown with its great-power rival, China might use its ability to
withhold critical drugs to devastating effect.)

Financial pressure on hospitals and health systems has also left
them less able to handle added stress. In any pandemic-level outbreak,
a pernicious ripple effect disturbs the health-care equilibrium.
The stepped-up need for ventilators and the tranquilizing
and paralytic drugs that accompany their use produce a greater need
for kidney dialysis and the therapeutic agents that requires, and so
on down the line. Even speculation that the antimalarial hydroxychloroquine
might be useful in the treatment of Covid-19 caused ashortage of the
drug for patients with rheumatoid arthritis and lupus,
who depend on it for their daily well-being. It remains unclear
what impact Covid-19 has had on the number of deaths due to other
conditions, such as heart attacks. Even if it’s mostly a matter of patients
with severe or life-threatening chronic conditions avoiding
care to minimize their risk of exposure to the virus, this could ultimately
prove to be serious collateral damage of the pandemic.

In normal times, the United States’ hospitals have little in the way
of reserves and therefore little to no surge capacity for emergency
situations: not enough beds, not enough emergency equipment such as
mechanical ventilators, not enough N95 masks and other personal protective
equipment (PPE). The result during a pandemic is the equivalent
of sending soldiers into battle without enough helmets or rifles.
The National Pharmaceutical Stockpile was created during the
Clinton administration and renamed the Strategic National Stockpile
in 2003. It has never had sufficient reserves to meet the kind of crisis
underway today, and it is fair to say that no administration has devoted
the resources to make it fully functional in a large-scale emergency.
Even more of an impediment to a rapid and efficient pandemic
response is underinvestment in vaccine research and development. In
2006, Congress established the Biomedical Advanced Research and
Development Authority (BARDA ). Its charge is to provide an integrated
and systematic approach to the development and purchase of
vaccines, drugs, and diagnostic tools that will become critical in public
health emergencies. But it has been chronically underfunded, and the
need to go to Congress and ask for new money every year has all but
killed the possibility of major long-term projects.

Following the 2014–16 West African Ebola outbreak, there was a
clear recognition of the inadequacy of international investment in
new vaccines for regional epidemic diseases such as Ebola, Lassa fever,
Nipah virus disease, and Zika, despite the efforts of BARDA and
other international philanthropic government programs. To address
this hole in preparedness, CEPI, the Coalition for Epidemic Preparedness
Innovations, a foundation that receives support from public, private,
philanthropic, and civil society organizations, was conceived in
2015 and formally launched in 2017. Its purpose is to finance independent
research projects to develop vaccines against emerging infectious
diseases. It was initially supported with $460 million from the Bill &

Melinda Gates Foundation, the Wellcome Trust, and a consortium of
nations, including Germany, Japan, and Norway. Although CEPI has
been a central player since early this year in developing a vaccine for
SARS -CoV-2, the virus that causes COVID -19, the absence of a prior
major coronavirus vaccine initiative highlights the ongoing underinvestment
in global infectious disease preparedness.
Had the requisite financial and pharmaceutical resources gone into
developing a vaccine for SARS in 2003 or MERS in 2012, scientists already
would have done the essential research on how to achieve
coronavirus immunity, and there would likely be a vaccine platform
on which to build (such a platform is a technology or modality that
can be developed for a range of related diseases). Today, that would
have saved many precious months or even years.

FIRST SYMPTOMS

By late 2019, the lack of long-range preparation had gone on for years,
despite persistent warnings. Then, the short-range failure started. Early
surveillance data suggested to epidemiologists that a microbial storm
was brewing. But the action to prepare for that storm came far too slowly.
By the last week of December, reports of a new infectious disease
in the Chinese city of Wuhan and surrounding Hubei Province
were starting to make their way to the United States and
around the world. There is no question that the Chinese government
suppressed information during the first weeks of the outbreak,
evident especially in the shameful attempt to silence the
warnings of Li Wenliang, the 34-year-old opthamologist who tried
to alert the public about the threat. Yet even with such dissembling
and delay, the warning signs were clear enough by the start of this
year. For example, the Center for Infectious Disease Research and
Policy published its first description of the mystery disease on December
31 and publicly identified it as a novel coronavirus on January
8. And by January 11, China had published the complete genetic
sequence for the virus, at which point the World Health Organization
(WHO) immediately began developing a diagnostic test. By the
second half of January, epidemiologists were warning of a potential
pandemic (including one of us, Osterholm, on January 20). Yet the
U.S. government at the time was still dismissing the prospect of a
serious outbreak in the United States—despite valid suspicions
that the Chinese government was suppressing information on the
Wuhan outbreak and underreporting case figures. It was the moment
when preparation for a specific coming storm should have
started in earnest and quickly shifted into high gear.

U.S. President Donald Trump would later proffer the twin assertions
that he “felt it was a pandemic long before it was called a pandemic”
and that “nobody knew there’d be a pandemic or an epidemic of
this proportion.” But on January 29, Peter Navarro, Trump’s trade adviser,
wrote a memo to the National Security Council warning that when
the coronavirus in China reached U.S. soil, it could risk the health or
lives of millions and cost the economy trillions of dollars. That same day,
as reported by The Wall Street Journal, Alex Azar, the health and human
services secretary, told the president that the potential epidemic was well
under control. Navarro sent an even more urgent memo on February 23,
according to The New York Times, pointing to an “increasing probability
of a full-blown COVID -19 pandemic that could infect as many as 100
million Americans, with a loss of life of as many as 1–2 million souls.”
Washington’s lack of an adequate response to such warnings is by
now a matter of public record. Viewing the initially low numbers of
clinically recognized cases outside China, key U.S. officials were either
unaware of or in denial about the risks of exponential viral spread. If
an infectious disease spreads from person to person and each individual
case causes two more, the total numbers will remain low for a
while—and then take off. (It’s like the old demonstration: if you start
out with a penny and double it every day, you’ll have just 64 cents after
a week and $81.92 after two weeks, and then more than $5 million by
the end of a month.) Covid-19 cases do not typically double overnight,
but every five days is a pretty good benchmark, allowing for rapid
growth even from just a few cases. Once the virus had spread outside
East Asia, Iran and Italy were the first to experience this effect.
Even with the lack of long-range planning and investment, there was
much that the U.S. government could and should have done by way of
a short-range response. As soon as the novel and deadly coronavirus
was identified, Washington could have conducted a quick but comprehensive
review of national PPE requirements, which would have
led to the immediate ramping up of production for N95 masks and
protective gowns and gloves and plans to produce more mechanical
ventilators. Relying on the experience of other countries, it should
have put in place a comprehensive test-manufacturing capability
and been ready to institute testing and contact tracing while the number
of cases was still low, containing the virus as much as possible
wherever it cropped up. It could have appointed a supply chain coordinator
to work with governors, on a nonpartisan basis, to allocate and
distribute resources. At the same time, Congress could have been
drafting emergency-funding legislation for hospitals, to prepare them
for both the onslaught of Covid-19 patients and the sharp drop in
elective surgeries, routine hospitalizations, and visits by foreign visitors,
essential sources of revenue for many institutions.

Instead, the administration resisted calls to advise people to stay at
home and practice social distancing and was unable or unwilling to
coordinate a government-wide effort among relevant agencies and
departments.The Centers for Disease Control and Prevention initially
shipped its own version of a test to state public health labs, only to
find that it didn’t work. This should have immediately triggered an
elevation of the issue to a crisis-driven priority for both the CDC
and the U.S. Food and Drug Administration, including bringing
the private clinical laboratory industry into the process to help manufacture
test kits. Instead, the problem languished, and the FDA took
until the end of February to approve any independent tests. At that
point, the United States had 100 or so recognized cases of Covid-19.
A little over a week later, the number would break 1,000, and after
that, the president declared a national emergency.
In 1918, cities that reacted to the flu early, preventing public gatherings
and advising citizens to stay home, suffered far fewer casualties
overall. But for this approach to work, they had to have reliable information
from central authorities in public health and government,
which requires honesty, responsiveness, and credibility from the beginning.
In the current crisis, the output from the White House was
instead—and continues to be—a stream of self-congratulatory tweets,
mixed messages, and contradictory daily briefings in which Trump
simultaneously asserted far-reaching authority and control and denied
responsibility for anything that went wrong or didn’t get done.
Everything was the governors’ responsibility and fault—including
not planning ahead, the very thing the administration refused to do.
Two years earlier, it had even disbanded the pandemic-readiness arm
of the National Security Council.

“You go to war with the army you have, not the army you might
want or wish to have at a later time,” U.S. Secretary of Defense
Donald Rumsfeld famously declared in 2004, addressing U.S. troops
on the way to Iraq, where the military’s vehicles lacked armor that
could protect the service members inside from explosive devices. That grim
message could apply to the pandemic response, too, with, for example,
frontline health-care workers going to war against COVID -19
without PPE. But in many ways, the current situation is even worse.
The United States and other countries went to war against a rapidly
spreading infectious disease without a battle plan, sufficient personnel,
adequate facilities or stocks of equipment and supplies, a reliable
supply chain, centralized command, or a public educated about or
prepared for the struggle ahead.

In the absence of strong and consistent federal leadership, state
governors and many large-city mayors have taken the primary responsibility
of pandemic response on themselves, as they had to, given
that the White House had even advised them to find their own ventilators
and testing supplies. (And health-care workers, forced into
frontline treatment situations without adequate respiratory protection,
are of course the hero-soldiers of this war.) But fighting the virus
effectively demands that decision-makers start thinking strategically—
to determine whether the actions being taken right now are
effective and evidence-based—or else little will be accomplished despite
the best of intentions. In this regard, it is not too late for the
United States to take on its traditional leadership role and be an example
in this fight, rather than lagging behind, as it has so far, places
such as Germany, Hong Kong, Singapore, and South Korea, and even,
despite its initial missteps, China.

THE BIG ONE

Why did so many policymakers ignore the virus until it was too late
to slow it down? It’s not a failure of imagination that prevented them
from understanding the dimensions and impact of a mass infectious
disease outbreak. In the United States, numerous high-level simulated
bioterror and pandemic tabletop exercises—from Dark Winter
in 2001 through Clade X in 2018 and Event 201 in 2019—have demonstrated
the confusion, poor decision-making, and lack of coordination
of resources and messaging that can undermine a response in the
absence of crisis contingency planning and preparation. The problem
is mainly structural, one that behavioral economists call “hyperbolic
discounting.” Because of hyperbolic discounting, explains Eric Dezenhall,
a crisis manager and one-time Reagan White House staffer who has long
studied the organizational reasons for action and inaction in government
and business, leaders “do what is easy and pays immediate
dividends rather than doing what is hard, where the dividends
seem remote. . . . With something like a pandemic, which sounds like
a phenomenon from another century, it seems too remote to plan for.”
The phenomenon is hardly new. Daniel Defoe relates in A Journal
of the Plague Year that in 1665, municipal authorities in London first
refused to accept that anything unusual was happening, then tried to
keep information from the public, until the spike in deaths made it
impossible to deny the much-feared bubonic plague. By that point, all
they could do was lock victims and their families in their homes in a
vain attempt to stop the spread.

Short of a global thermonuclear war and the long-term impact of
climate change, an infectious disease pandemic has the greatest potential
to devastate health and economic stability across the globe. All
other types of disasters and calamities are limited in geography and
duration—whether a hurricane, an earthquake, or a terrorist attack. A
pandemic can occur everywhere at once and last for months or years.
Worldwide mortality estimates for the 1918 influenza pandemic
range as high as 100 million—as a percentage of the global population,
equivalent to more than 400 million people today—making it easily
the worst natural disaster in modern times. So profound were the pandemic’s
effects that average life expectancy in the United States immediately
fell by more than ten years. Unlike a century ago, the world
today has four times the population; more than a billion international
border crossings each year; air travel that can connect almost any two
points on the globe in a matter of hours; wide-scale human encroachment
on forests and wildlife habitats; developing-world megacities in
which impoverished people live in close confines with others and
without adequate nutrition, sanitation, or medical care; industrial
farming in which animals are kept packed together; a significant overuse
of antibiotics in both human and animal populations; millions of
people living cheek by jowl with domestic birds and livestock (creating
what are essentially genetic reassortment laboratories); and a dependence
on international just-in-time supply chains with much of the
critical production concentrated in China.

The natural tendency might be to reassuringly assume that a century’s
worth of medical progress will make up for such added vulnerabilities.
(The human influenza virus wasn’t even discovered until1933, when the
virologists Wilson Smith, Christopher Andrewes, and Patrick Laidlaw,
working at London’s National Institute for Medical Research, first isolated
the influenza A virus from the nasal secretions and throat washings of
infected patients.) That would be a grave misconception. Even in a nonpandemic
year, aggregated infectious diseases—including malaria, tuberculosis,
HIV/aIDS, seasonal influenza,and diarrheal and other vector-borne illnesses—
represent one of themajor causes of death worldwide and by far the leading
cause of deathin low-income countries, according to the WHO.

In fact, given those realities of modern life, a similarly virulent influenza
pandemic would be exponentially more devastating than the
one a century ago—as the current pandemic makes clear. In the absence
of a reliable vaccine produced in sufficient quantities to immunize
much of the planet, all the significant countermeasures to
prevent the spread of COVID -19 have been nonmedical: avoiding public
gatherings, sheltering in place, social distancing, wearing masks of
variable effectiveness, washing hands frequently. As of this writing,
scientists and policymakers don’t even have a good handle on how
many of the RT-PCR tests that determine whether an individual has the
virus and how many of the serology tests that detect antibodies and
determine whether someone has already had it are even reliable. Meanwhile,
international demand for reagents—the chemicals that make
both kinds of tests work—and sampling swabs is already outstripping
supply and production. It is hard to conclude that the world today is
much better equipped to combat a massive pandemic than doctors,
public health personnel, and policymakers were 100 years ago.
Some are calling the Covid-19 pandemic a once-in-100-year event,
comparable to 100-year floods or earthquakes. But the fact that the
world is enduring a pandemic right now is no more predictive of when
the next one will occur than one roll of dice is of the result of the next
roll. (Although the 1918 flu was the most devastating influenza pandemic
in history, an 1830–32 outbreak was similarly severe, only in a
world with around half of 1918’s population.) The next roll, or the one
after that, could really be “the Big One,” and it could make even the
current pandemic seem minor by comparison.

When it comes, a novel influenza pandemic could truly bring the
entire world to its knees—killing hundreds of millions or more, devastating
commerce, destabilizing governments, skewing the course of history for generations
to come. Unlike Covid-19, which tends to most seriously affect older people and those
with preexisting medical problems, the 1918 influenza took a particularly heavy toll on otherwise
healthy men and women between the ages of 18 and 40 (thought to be a result of their
more robust immune systems overreacting to the threat through a “cytokine storm”).
There is no reason to think that the next big novel influenza pandemic couldn’t have similar results.

PLANS VS. PLANNING

Humans do not have the power to prevent all epidemics or pandemics.
But with the sufficient will, resources, and commitment, we do have
the power to mitigate their awesome potential for causing premature
deaths and attendant misery.
To begin with, Americans must change how they think about the
challenge. Although many people in the public health sphere don’t like
associating themselves with the military—they heal rather than kill, the
thinking goes—there is much that they can learn from military planning.
The military focuses on flexibility, logistics, and maintaining
readiness for any foreseeable situation. As U.S. General Dwight Eisenhower
noted, “Peace-time plans are of no particular value, but peacetime
planning is indispensable.”

The starting point should be to prioritize health threats in terms of
their likelihood and potential consequences if unchecked. First on
that list is a deadly virus that spreads by respiratory transmission
(coughing, sneezing, even simple breathing). By far the most likely
candidate would be another high-mortality influenza strain, like the
1918 one, although as revealed by SARS , MERS, Zika, and Covid-19,
new and deadly noninfluenza microbes are emerging or mutating in
unpredictable and dangerous ways.

Even before a specific threat has arisen, a broad group of actors
should be brought together to develop a comprehensive strategy—
with enough built-in flexibility that it can evolve as conditions demand—
and then they should repeatedly review and rehearse it. That
effort should involve everyone from high-level government and public
health officials to emergency responders, law enforcement, medical
experts and suppliers, food providers, manufacturers, and specialists
in transportation and communications. (As emergency planners are
fond of saying, you don’t want to be exchanging business cards at a
disaster site.) The strategy should offer an operational blueprint for how to get
hrough the one or two years a pandemic would likely last;
among the benefits of such a blueprint would be helping ensure that
leaders are psychologically prepared for what they might face in a
crisis, just as military training does for soldiers anticipating battlefield
conditions. The Bipartisan Commission on Biodefense—jointly
chaired by Tom Ridge, the first secretary of homeland security, under
President George W. Bush, and a former Pennsylvania governor,
and Joseph Lieberman, a former Democratic senator from
Connecticut—has suggested that the operation could be located in the
Office of the Vice President, with direct reporting to the president.
Wherever it is based, it must be run by a smart and responsible coordinator,
experienced in the mechanics of government and able to
communicate effectively with all parties—as Ron Klain was as Ebola
czar in the Obama administration.

In addition to the gaming out of various potential scenarios, adequate
preparation must include a military-like model of procurement
and production. The military doesn’t wait until war is declared to start
building aircraft carriers, fighter jets, or other weapons systems. It
develops weapons over a period of years, with congressional funding
projected over the entire development span. The same type of approach
is needed to develop the weapons systems to fight potential
pandemics. Relying solely on the market and the private sector to
take care of this is a recipe for failure, because in many cases, there
will be no viable customer other than the government to fund both
the development and the manufacturing process.

That has proved particularly true when it comes to drug development,
even when there is no pandemic. For many of the most critical
drugs, a market-driven approach that relies on private pharmaceutical
companies simply doesn’t work. The problem is evident, for example,
in the production of antibiotics. Because of the growing problem of
antimicrobial resistance—which threatens to bring back a pre-antibiotic
dark age, in which a cut or a scrape could kill and surgery was a
risk-filled nightmare—it makes little sense for pharmaceutical companies
to devote enormous human and financial resources to developing
a powerful new antibiotic that might subsequently be restricted to use
in only the most extreme cases. But in a flu pandemic, such highly
effective antibiotics would be essential, since a primary cause of death
in recent flu outbreaks has been secondary bacterial pneumonia infecting
lungs weakened by the virus.


The same holds for developing vaccines or treatments for diseases
such as Ebola. Such drugs have virtually no sales most of the time but
are critical to averting an epidemic when an outbreak strikes. Governments
must be willing to subsidize the research, development, clinical
trials, and manufacturing capacity for such drugs the same way they
subsidize the development and manufacture of fighter planes and tanks.
Preparation for pandemics and for the necessary surge of medical
countermeasures will also require being more attentive to where drugs
and medical supplies are produced. In times of pandemic, every nation
will be competing for the same critical drugs and medical supplies at the
same time, so it is entirely reasonable to expect that each will prioritize
its own needs when distributing what it produces and controls. There is
also the ongoing threat that a localized infectious hot spot will close down
a manufacturing facility that produces critical drugs or medical supplies.
Despite the higher costs that it would involve, it is absolutely essential
that the United States lessen its dependence on China and India for its
lifesaving drugs and develop additional manufacturing capacity in the
United States itself and in reliably friendly Western nations.
The U.S. government must also get more strategic in overseeing
the Strategic National Stockpile. Not only does it need to perform
realistic evaluations of what should be on hand to meet surges in
demand at any given time, in order to avoid repeating the current
shame of not having enough PPE for health-care workers and first
responders; supplies should also be rotated in and out on a regular
basis, so that, for instance, the store doesn’t end up including masks
with degraded rubber bands or expired medications.

HOLISTIC TREATMENT

To make progress on either a specific vaccine or a vaccine platform for
diseases of pandemic potential, governments have to play a central
role. That includes funding basic research, development, and the
Phase 3 clinical trials necessary for validation and licensing. (This
phase is often referred to as “the valley of death,” because it is the
point at which many drugs with early laboratory promise don’t pan
out in real-world applications.) It is also imperative that governments
commit to purchasing these vaccines.
With its current concentration on the development of a vaccine for
COVID -19 and other medical countermeasures, BARDA has had to put
other projects on the back burner. For all the complaints about its cumbersome
contracting process and tight oversight controls (said by critics to stifle outside-the-box
thinking and experimentation), BARDA   is the closest thing the U.S. government has
to a venture capital firm for epidemic response. Covid-19 should spur a commitment
to upgrading it, and a panel of experts should undertake a review of
BARDA ’s annual budget and scope to determine what the agency needs
to meet and respond to future biomedical challenges.

Of all the vaccines that deserve priority, at the very top of the list
should be a “universal” influenza vaccine, which would be game changing.
Twice a year, once for the Northern Hemisphere and once for the
Southern Hemisphere, through an observational and not very precise
committee process, international public health officials try to guess which
flu strains are likely to flare up the next fall, and then they rush a new
vaccine based on these guesstimates into production and distribution.
The problem is that influenza can mutate and reassort its genes with
maddening ease as it passes from one living animal or human host to the
next, so each year’s seasonal flu vaccine is usually only partly effective—
better than nothing, but not a precise and directly targeted bullet like the
smallpox or the measles vaccine. The holy grail of influenza immunity
would be to develop a vaccine that targets the conserved elements of the
virus—that is, the parts that don’t change from one flu strain to the next,
no matter how many mutations or iterations the virus goes through.
A universal influenza vaccine would require a monumental scientific
effort, on the scale of the billion-dollar annual investment that
has gone into fighting HIV/AIDS . The price tag would be enormous,
but since another population-devouring flu pandemic will surely
visit itself on the globe at some point, the expense would be justified
many times over. Such a vaccine would be the greatest public health
triumph since the eradication of smallpox.

Of course, no single nation can fight a pandemic on its own. Microbes
do not respect borders, and they manage to figure out workarounds
to restrictions on international air travel. As the Nobel
Prize–winning molecular biologist Joshua Lederberg warned, “The
microbe that felled one child in a distant continent yesterday can reach
yours today and seed a global pandemic tomorrow.” With that insight
in mind, there should be a major, carefully coordinated disaster drill
every year, similar to the military exercises the United States holds
with its allies, but with a much broader range of partners. These should
involve governments, public health and emergency-response institutions,
and the major medically related manufacturing industries of
various nations that will need to work together quickly when worldwide
disease surveillance—another vital component of pandemic preparedness—
recognizes an outbreak.

The world was able to eradicate smallpox, one of the great
scourges of history, because the two superpowers, the United States
and the Soviet Union, both committed to doing so, following an appeal
at the 1958 convening of the World Health Assembly, the decision-
making body of the WHO. Today’s tense geopolitics makes such
a common commitment hard to achieve. But without it, there is
little chance of adequate preparation for the next pandemic. The
current global health architecture is far from sufficient. It has little
hope of containing an even more threatening outbreak. Instead,
something along the lines of NATO will be necessary—a public-health
oriented treaty organization with prepositioned supplies, a deployment
blueprint, and an agreement among signatories that an epidemic outbreak
in one country will be met with a coordinated and equally vigorous
response by all. Such an organization could work in concert with the
WHO and other existing institutions but act with greater speed, efficiency, and resources.

It is easy enough to dismiss warnings of another 1918 - like pandemic:
the next pandemic might not arise in our lifetimes, and by
the time it does, science may have come up with robust medical
countermeasures to contain it at lower human and economic cost.
These are reasonable possibilities. But reasonable enough to collectively
bet our lives on? History says otherwise.∂