On March 13, 2020, I woke up at home with a dry cough, fatigue and chills, having returned the night before from study abroad in Madrid. I did not know it yet, but I was sick with COVID-19. In a county with a single-digit number of tests, I somehow found one of the few available and was thrust into unexpected weeks of self-quarantine, though fortunately my case was mild.
At the same time, Stanford students fled campus after receiving guidance from the university administration, many believing they would return in the following weeks or months. It is no secret that the U.S. government’s response to COVID-19 was disorganized. We expect our government to prepare for and respond to potential disasters; however, the American government knew it was not prepared for a pandemic long before the first cases of COVID-19 were reported.
I was not prepared for the pandemic. Neither was Stanford, nor was America’s government. Few people expect a college junior to prepare for a once-in-a-lifetime pandemic, but we should demand better from our institutions. Now that case counts and hospitalizations are decreasing and vaccines are increasingly available, we should ask why past preparedness measures were not effective and what must be done to avoid repeating these mistakes in the future.
Intriguingly, preparedness did not fail because experts were unaware of our vulnerabilities. These vulnerabilities had been uncovered by studies and simulations designed by public health experts to both stress-test existing preparedness measures and educate policymakers and business leaders. Since the early 2000s, the Johns Hopkins Center for Health Security has run four major tabletop exercises, disease outbreak simulations that assign experts to key roles in a hypothetical emergency.
The now years-old preparedness reports read like headlines out of our current events. One simulation demonstrated that a lack of central leadership and coordination between federal agencies and state governments hinders effective emergency response. Another report found that there is insufficient surge capacity in the American healthcare and public health systems to develop, manufacture and distribute novel diagnostics, therapeutics and vaccines. Each study made apparent that sustained trust in public health experts and government leaders by the public is essential, but easily undermined by mis- and disinformation.
The central theme of each simulation was a plausible, serious, but unconventional threat. The first two exercises, titled “Dark Winter” and “Atlantic Storm,” explored the potential fallout of international smallpox bioterrorism. Dark Winter, conducted in June 2001, became famous for demonstrating the catastrophic potential of domestic bioterrorism once it spirals out of control. More recently, the “Clade X” simulation in 2018 proposed a bioengineered human parainfluenza virus with no vaccine. And eerily, the “Event 201” exercise from October 2019 forecast global economic turmoil due to a novel coronavirus, having spread to humans from pigs.
Overall, these exercises provided stakeholders with actionable recommendations spanning the range of potential risks. Unfortunately, their recommendations have remained largely unimplemented. Instead, federal preparedness over the past decade reacted to the H1N1 Swine Flu and focused on a grave but narrow threat, pandemic influenza.
But even with this narrow scope, the government knew it would be unprepared for an influenza pandemic. From January through August 2019, the U.S. Department of Health and Human Services (HHS) conducted a joint exercise with 12 other federal departments to assess the government response to a potential influenza pandemic originating in China. Their findings were grim. In the event of an influenza pandemic, HHS concluded they would lack the authority, funding and manufacturing and procurement capabilities to respond effectively.
With the benefit of hindsight, then-Assistant Secretary of HHS for Preparedness and Response Dr. Robert Kadlec believes the focus on pandemic influenza was a mistake. The government wrongly assumed that “all swans are white,” meaning that preparing for an influenza pandemic would enable the U.S. to respond to any potential pandemic. While the U.S. has existing diagnostics, therapeutics and vaccine development programs for influenza, COVID-19 confirmed that we do not have the infrastructure to deploy medical countermeasures against a novel pathogen.
With lessons learned from the COVID-19 pandemic, how do we avoid unpreparedness in the future?
First, we must acknowledge that we live in an age of epidemics. The SARS, MERS, Ebola, and Zika epidemics and H1N1 swine flu pandemics all started within the lifetime of most current Stanford students. Scientists currently believe that SARS-CoV-2 jumped from bats to humans, which makes the virus part of a larger trend. More than 60% of emerging human diseases are zoonotic, meaning pathogens jumped from animals to humans. Over the last century more than two diseases have jumped from animals to humans each year.
We have no expectation that these zoonotic events will end soon. The major drivers — land use changes, wildlife trade, globalization, population growth into wild territories and development of megacities — will only accelerate over the coming years. While we have many known disease threats, zoonotic diseases present many unknown threats. Preparedness should focus on “black swan” outbreaks, or highly improbable but impactful events. A “black swan” pandemic is caused by a novel pathogen that is resistant to existing therapeutics and for which we do not have diagnostics or vaccines — like COVID-19.
Second, we need the political will to implement pandemic preparedness recommendations. Awareness of our disease outbreak vulnerabilities did not help us avoid COVID-19 because there was little incentive for policymakers and business leaders to invest in future risk. While funding is not the whole picture, it is central to pandemic preparedness. For example, we know that the shortage of American doctors is a result of limited Medicare/Medicaid funding. And for most emerging disease threats, there is no market for diagnostics or therapeutics until they are desperately needed.
Unfortunately, funding and support for epidemic preparedness has historically been tied to disease-of-the-year hype — think SARS in 2003 or Zika in 2015. Real solutions — like training more medical staff or developing broad-spectrum diagnostics and therapeutics — are costly. Consistent investment is necessary to address these challenges.
Albert Camus wrote in “The Plague,” “There have been many plagues in the world as there have been wars, yet plagues and wars always find people equally unprepared.” The latter is no longer true in the United States. We have a well-funded and structured Department of Defense because the public understands that preparation saves lives and money. But few know that throughout history more people have died from disease during wars than violence. We are unprepared for infectious disease because it is not considered part of conventional defense. Estimates for the cost of the COVID-19 pandemic approach $16 trillion. A fraction invested in long-term preparedness could mitigate the worst of future disease outbreaks.
The current pandemic is likely not the last of this century. Knowing our country’s vulnerabilities did not alone prepare us for COVID-19. Therefore, suffering through this pandemic does not mean we will be prepared for the next one. We should not forget the vulnerabilities that disease outbreak exercises and COVID-19 confirmed. Solving the political and economic challenges of epidemic preparedness requires sustained public attention. We cannot return to “business as usual.” We must demand change. While the COVID-19 pandemic retreats, it is never too early to prepare for the next pandemic.
The Daily is committed to publishing a diversity of op-eds and letters to the editor. We’d love to hear your thoughts. Email letters to the editor to eic ‘at’ stanforddaily.com and op-ed submissions to opinions ‘at’ stanforddaily.com.