6 lessons to learn after more than a year of Covid-19 and more than 500K deaths in the U.S.

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The first cases of Covid-19 in North America were reported in the United States in January 2020. By March 2020, Covid-19 had reached all North American countries, and by December 2020 Covid-19 became the third-leading cause of death in the U.S., behind heart disease and cancer. It caused an unprecedented effort in developing tests and vaccines, and a cascade of scientific activities (estimates vary from 40,000 to 170,000 Covid related publications in 2020).

The Covid pandemic may not be one with the largest global death toll (unlike the bubonic plague in the 14th century) but certainly one of the most impactful pandemics of modern times. Despite all the attention and scientific efforts, after more than a year, there are still several lessons to be learned in order to be better prepared for the next one.

1.   Create an infrastructure, establish processes, and stash material for a health crisis of gigantic size

A new type of “war”

Over decades the United States seemed to be very well prepared in case of a military attack or even the outbreak of an atomic war likely caused by the Soviet Union. For our national defense, we spend more than $700 billion a year, we have a well-trained and well-equipped military, underground bunkers, command centers and (hopefully) well-defined chains of commands in case of war. America’s war on terror has cost taxpayers over $6 trillion since 2001, and fortunately, there was no major terror attack on US soil since then.

In 2020 however, the enemy did not come from an extremist country or in form of a bomb, but as a virus, causing more casualties in the United States within one year than in World War II, Korean War and the Vietnam War combined. America was unprepared and helpless. Any potential effective response was impaired by jurisdiction squabbles between states and the federal government, politicized between two parties, and debilitated by inconsistent communication.

The Defense Production Act (DPA), a Cold War-era law signed in 1950 and amended over the years beyond its military origins, is a powerful tool that was leveraged to secure the production of critical products like PPE and vaccines. However, it needs to be expanded to ensure infrastructure, production, executive processes, and preparedness are ready for the next pandemic or for (equally unavoidable) other disasters. It also needs to include the protection of independence from suppliers outside the US.

Facilities, processes, and equipment

The initial shortage of ventilators and PPE shed a frightening light on our dependence on other countries, especially China. Rescue came in form of vaccines developed by private initiatives, but when it came to distribution, bureaucracy again introduced inefficiencies into the process, vaccinations slowed down due to state-mandated priorities, inconsistent guidelines, and overwhelmed appointment systems. To prepare for next time – and this is not a question of “if” but  “when” – a robust infrastructure needs to be created, processes defined, and material must be stored. One example: Each larger arena in the US can be changed within 24 hours from an ice hockey rink to a basketball court to a concert hall. Just add “hospital” and make it mandatory for all building conversions or new constructions to be also converted to a hospital.

First responders and trained personnel

Personnel to run these facilities can be recruited from retirees, from the military, from the pharmaceutical industry, or from other places where employees with a nursing or medical background can be found. Countries that have a draft system for the military keep civilians regularly trained for a potential operation in a crisis situation. In times when health disasters or pandemics need to be taken into account we can learn from these systems of preparedness by regular training and practice.

Triage and prioritization in times of shortages

In addition to logistical distribution problems of vaccines, the uncertainty about prioritization for vaccinations revealed many challenges which were mostly caused by multiple inconsistent guidelines. There were 50 different frameworks in defining priority groups. On top of an uncertain legislative and executive power of local governments to enforce these, important ethical questions remain open and cause vaccine hesitancy and conflicts. Ethical questions like the prioritization of protecting vulnerable individuals versus reducing the spread by broad vaccination of the active (working) generation need to be clarified. Guidelines need to be developed now to avoid uncertainty and panic-driven decisions in the next crisis.

Need for e new type of ID

Any lockdown measure intended to prevent the spread of an infectious disease has the potential to impede basic human rights which are guaranteed in the constitution. They can only be justified if the larger good, i.e. protection of society, overwhelmingly prevails over individual civil rights. Now, as the vaccination effort in the U.S. has reached a state where about half of the population can be considered a low risk of further spreading the virus, such impediments of basic rights do not seem to be justified anymore in people who are fully vaccinated. They may claim that their constitutional rights are restricted without reason. The CDC recently loosened mask restrictions allowing fully vaccinated individuals to roam indoors and outdoors without a mask, except in certain situations. This immediately raises the question: How can a person can prove her vaccination status?

Therefore, the need for a vaccination pass as an official fake-proof document is obvious. Considering that almost all vaccination scheduling happens electronically and that almost everybody has a cell phone, it is hard to believe that a CDC issued paper card is all what experts could come up with. Proof of vaccination may be required domestically and will be mandatory for many international travels. It should be personalized, as an app, or on paper with unforgeable items, e.g. a hologram or at least a QR code. There is a significant risk that this critical tool will be delayed by lengthy data protection discussions. Therefore, data storage should be decentralized and the passport only be used by a person if she wants to do so.

2.   Use appropriate science and metrics to justify political decisions

Health versus economy

It is challenging to balance lockdown measures intended to protect health versus the immediate and long-term damage caused by shutting down large parts of the economy. Drug development knows how to assess risk versus benefit, efficacy versus safety. Science has learned to differentiate between proof and hypothesis. In addition, an analysis of effects on individuals versus the impact on the large population has to be made during a pandemic. This way of thinking has not yet been adopted by many politicians and other decision makers. In general, decisions that are supposed to have an actual positive effect (efficacy) should be based on scientific proof. Decisions that are intended to protect from a risk (safety) can be based on a strong reasonable hypothesis if the proof is still pending. Both types of decisions, however, require a carefully obtained risk/benefit analysis.

Health metrics

On the health side of this analysis, we got used to metrics like seven-day incidence of positive tests or number of deaths per day. However, these metrics lack the perspective of population density which is crucial when it comes to infectious diseases (e.g. number of infectious people per square mile) per state or per city. Furthermore, the local risk of encountering an infectious person in an office, a supermarket, or indoor restaurant has not been established ( e.g. number of potentially infectious people per 1000 sqft). Instead of considering the individual risk, whole industries have been shut down without consideration of the individual size and local infection risk of a business location. Better and more targeted health metrics need to be used!

Economy metrics

Almost no metrics have been used to assess the negative side effects of lockdowns on the economy. The times when share prices reflected the actual intrinsic value or a reasonably assessed earnings potential of a company are long over. Nowadays share prices and a respective stock index represent much more the fantasies, expectations, and paranoia of greedy speculators rather than professional valuations assessed by financial experts. Therefore, Dow Jones, NASDAQ, or S&P 500 are inadequate to assess the economy during a health crisis. In addition, many traditional key measures of economic performance (for example GDP and inflation) have a lagging time which is too long to indicate the effect of lockdown measures. Furthermore, it is not the impact on “the market” or on large companies which has to be measured, but also eventually it is individual people who suffer the most from any restrictions on the economy, especially the middle and lower class. Therefore such metrics must reflect the impact on individuals, expressed by, for example, unemployment rate, credit card debt, private consumption, credit scores, number of individual bankruptcies.

3.   Leverage the power of big data

Since many health care systems in the world are fully digitized, all the data needed for natural history studies of diseases, observational trials or to learn about risk profiles, are available in electronic format, including those about Covid. Real-world data (RWD) from millions of people could easily be run through artificial intelligence algorithms to discover patterns for profiling of patients who may be more likely to survive an infection with no or low symptoms versus those who may become more severely sick.

“Big Data” would also allow to provide information about the infection situation in certain areas. This could be much more precise than the incidence rate per state or per county which is still used to define “risk areas”.

Almost every person who gets a virus test has a smartphone that is used either for scheduling or for communicating the test result. Thus, it would be easy to generate a life map of SARS-CoV-2 infections, similar to traffic patterns in Google Maps or a weather radar in meteorological maps. As nobody is interested in individual test results but just looks at aggregated anonymized data, privacy rules should not be an obstacle. In addition, smartphone apps with Bluetooth and geo-data work faster and more efficiently than an army of human tracers.

4.   Collaborate and consolidate activities across various jurisdictions in a consistent way

Despite the CDC, which can be considered as one nationwide science-based source of recommendations, rules and regulations regarding business closures and face mask mandates vary not only from state to state but can also differ within a state, based upon county or city. This type of diversity undermines the credibility of authorities (“does county A know better than county B?”) and leads to confusion. In addition, it is highly inefficient, because local executives have to analyze information and make decisions that have already been done multiple times elsewhere, a redundant waste of activities. If regionally different rules are deemed necessary, then they should be based on regional distribution of infections and on population density, but not based on borders of towns or states.

5.   De-politicize mainstream media but fully honor 1st amendment

Covid-19 happened around the 2020 U.S. presidential campaigns and election. It sounds extremely unreasonable why a global pandemic as a medical emergency should be drawn into political debates, as if the virus could possibly discriminate between Democrats and Republicans, and if party preference was the main determinator of an immune response.

However, what humans, politicians, and journalists made out of it, their reactions, statements, or executive orders became subject of intense political debates. Media, chief among them CNN and FOX, abandoned the very basic rules of journalism, i.e. the separation of news, interpretation and opinion, thus significantly contributing to the US becoming very divisive. Together with social media, which had run completely out of control, an overall incoherence was created that is about to split our country apart.

The First Amendment ensuring freedom of speech and freedom of the press is interpreted widely and allows expression of opinions to a far extent. However, it is often forgotten that a right usually comes with responsibilities. Institutions and persons who exercise their right of free speech often forget that they are responsible for the consequences of their actions, including the way how their speech is interpreted by others.

6.   Simplify messages to the public, but be honest

The usual language among scientists contains many assumptions and theories. This way of communicating is driven by the desire in science to only state hard facts which are significant and statistically proven; Otherwise, they are considered hypotheses. This caution in scientific communication may originate from the fear of later being blamed for wrong statements, having to withdraw a paper, or in the worst case being sued.

What may be adequate among scientists can have a detrimental effect if such a communication style is carried over to the public. Statements that are full of uncertainties and disclaimers create anxiety and mistrust in the public.  Rather than confidence, such a style builds a climate of suspicion and eventually supports the generation of conspiracy theories. Therefore, the “nation’s top scientists”, when speaking to the public, need to be clear, simple, and honest. They must not forget that their audience is not a group of academics living in their theoretical world, but a population that is deeply concerned, anxious, actually impacted and in desperate need of reliable information.

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