Pandemic Preparedness - Now and Forever

 For the next current events session here at MonteCedro, the group wanted to discuss pandemic preparedness. Since both Margan and I are infectious disease physicians and epidemiologists who were involved in preparedness planning for many years in both military and civilian organizations, this will probably be fairly easy. I thought it might be useful to write a little about how this important topic came to be and, in light of the Covid-19 pandemic, what went wrong.

Pandemics are a relatively recent problem. In human history, only in the last 10,000 years have we had the conjunction of agriculture, which fostered larger populations of more sedentary humans, along with constant contact with domesticated animals, whose microorganisms we came to share in a variety of ways. Tuberculosis and measles originated in bovine animals. Influenza is primarily a disease of fowl and pigs. Human immunodeficiency virus (HIV) arose in nonhuman primates in Africa and likely spread to humans through consumption of bushmeat (meaning, consumption of monkeys and other simians). It seems to have festered in what was then the Belgian Congo (now Democratic Republic of Congo) for decades, with the advent of railroads and roads, an imbalanced burgeoning urban population comprised of single males, and the sex trade allowing it to spread from the early part of the 20th century to other locales. Two coronavirus epidemics in the early 21st century, SARS and MERS, had zoonotic origins but petered out. SARS-CoV-2, the cause of Covid-19, unfortunately did not. Also of zoonotic origin, it has caused more than 2.5 million deaths worldwide to date. 

I believe it was with the threat of biowarfare and bioterrorism that the concern about pandemic disease finally gained attention in the late 20th century. When Saddam Hussein was confronted by an Allied coalition in 1990 after his forces seized Kuwait, concern over Iraqi capabilities for both chemical and biological warfare surfaced. Saddam had developed anthrax and other biological weapons and weaponized them during the prelude to war in January 1991. There is no evidence they were used. Anthrax was sent through the mails after the 9/11 terrorist attacks; it is likely this was domestic terrorism. But the publication of the book Biohazard: The Chilling True Story of the Largest Covert Biological Weapons Program in the World -- Told from the Inside by the Man Who Ran It may have set alarm bells off at the national security level. The book’s author, Ken Alibek, was a physician and colonel in charge of the Soviet Union’s massive bioweapons program that operated from the mid-1980s until several years after the collapse of the USSR. I met Alibek when I was the Surgeon for Joint Task Force Civil Support in 2000. The book and his presentation certainly conjured up nightmares.

But man-made terror is perhaps the least of civilization’s worries. I have often said that Mother Nature is the preeminent bioterrorist. There are good recent articles on some of the many pandemics that have ravaged humanity in the past several thousand years. Bill Clinton directed his administration to enhance preparedness against microbiological threats after reading The Cobra Event, a novel by Richard Preston; the novel “scared the bejesus out of him.” While George W. Bush initially pooh-poohed the need for expenditures for preparedness, the post-9/11 anthrax attacks combined with concern about terrorist use of smallpox virus and Bush’s reading of John M. Barry’s The Great Influenza made him more of a believer in the power of massive infectious disease outbreaks. To his credit,

Thus was born the nation's most comprehensive pandemic plan -- a playbook that included diagrams for a global early warning system, funding to develop new, rapid vaccine technology, and a robust national stockpile of critical supplies, such as face masks and ventilators, Townsend said.

President Obama struggled with a GOP-controlled Congress for the last six years of his Presidency. The high for public health funding (which includes pandemic preparedness and everything else) peaked in 2008 and then fell 9.3% by 2014. And then came Donald Trump. In 2017, Trump proposed a budget that slashed expenditures for public health. This continued throughout his failed administration. Not only that, he ignored the pandemic playbook and exercise that the Obama administration left for him and dissolved the White House National Security Council Directorate for Global Health Security and Biodefense. While Clinton, Bush, and Obama took the threat of pandemics seriously, Trump was more interested in providing trillion-dollar-plus tax cuts to his plutocratic friends and playing golf. His predecessors understood the threat and were willing to fund the resources to prepare for it. Trump fiddled while Covid-19 surged. 

The price of this inattention is staggering, not only to the United States but to the world as a whole. Economically, we would have better spent billions preparing for Covid-19 rather than an estimated $16 trillion globally. The cost in suffering and mortality as noted is overwhelming, with more than 2.5 million deaths across the planet. And Covid-19 is quite possibly a threat to democracy. 

As an infectious disease physician and epidemiologist (yes, retired but not dead) I am appalled that we came to this point with coronavirus. Even if we could not have prevented the pandemic, it is obvious that we missed a big opportunity to do better. The political disaster that the United States has undergone (and that sadly continues) is one factor. I hope anyone reading this realizes why I have a visceral negative response to the Republican Party. But there are many other reasons as well. We as Americans, in our fealty to unfettered capitalism, bear blame collectively and individually. Americans still believe that we remain blissfully isolated from the rest of the world and still supreme on the world’s stage as we were after World War II. We’re not. We can blame China if we want for Covid-19. Viruses can emerge from anyplace on the globe that humans and animals mix. Preparation takes work and money and perseverance. It takes understanding science and investing in that. Preparedness requires an open mind and control of selfish impulses. We are still in the midst of taming Covid-19. H5N8, a novel avian influenza virus, has just been reported in humans in Russia -- a first. Covid-19 will certainly not be the last pandemic that humanity has to deal with.