key: cord-323696-0lq8ql6n
authors: Bearman, Gonzalo; Pryor, Rachel; Vokes, Rebecca; Cooper, Kaila; Doll, Michelle; Godbout, Emily J.; Stevens, Michael P.
title: Reflections on the COVID-19 Pandemic in the USA: Will We Better Prepared Next Time?
date: 2020-05-20
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.05.059
sha: 
doc_id: 323696
cord_uid: 0lq8ql6n

Abstract The United States (US) spends more on healthcare than any other country with little evidence of better, or even comparable, outcomes. We reflect on the US and the COVID-19 pandemic and focus on cultural, economic and structural barriers that threaten both current and future responses to infectious diseases emergencies. These include the US healthcare delivery model, the defunding of public health, a scarcity of infectious diseases physicians, the market failure of vaccines and anti-infectives and the concept of American exceptionalism. Without institutionalizing the lessons learned, the US will be positioned to repeat the missteps of COVID-19 with the next pandemic.

The United States (US) spends more on healthcare than any other country with little evidence of better, or even comparable, outcomes. We reflect on the US and the COVID-19 pandemic and focus on cultural, economic and structural barriers that threaten both current and future responses to infectious diseases emergencies. These include the US healthcare delivery model, the defunding of public health, a scarcity of infectious diseases physicians, the market failure of vaccines and anti-infectives and the concept of American exceptionalism. Without institutionalizing the lessons learned, the US will be positioned to repeat the missteps of COVID-19 with the next pandemic. States of America (US) exceeds 1.2 million infections and 78,000 deaths, the greatest count per country worldwide. 1 We reflect on the US and its response to the COVID-19 pandemic and focus on cultural, economic and structural barriers that threaten both current and future responses to infectious diseases emergencies.

The US spends more on healthcare than any other country, with little evidence of better, or even comparable, health outcomes. 2 In most developed nations, governments maintain universal access to healthcare services for citizens and coordinate resources across the span of the healthcare system. This central agency is able to effectively plan healthcare services, reduce inefficiency and develop infrastructure and workforce capacity to meet the population needs. 3 Conversely, the US relies on a patchwork of public and private payors to finance healthcare delivery. 4 The fragmented US healthcare system also produces fragmented self-interests. Health insurance agencies may seek to limit expenditures of insurance plan members in order to remain solvent, will only increase as Americans continue lose their jobs due to the financial impact of COVID-19. 6, 7 Though the federal government has made assurances that healthcare systems will not bill uninsured patients for care related to COVID-19, some uninsured patients have still received bills. 8 Like many issues related to the American healthcare system, much of an uninsured person's bills are subject to the laws of the individual state in which a person resides. 9 A growing pool of unemployed, uninsured persons will almost certainly impact access to COVID-19 testing with negative impact on transmission dynamics. This may result in significant numbers of undiagnosed people with minimal or mild symptoms, not under public health surveillance and contact tracing, transmitting the virus.

The fragmentation, disparities in care and misaligned incentives do not provide a strong foundation for public health emergencies. A for-profit business model strives for maximal efficiency and minimal redundancy in supply chain structure. However, the global supply chain "just-in-time" manufacturing is not positioned to support the needs of Page 5 of 16 J o u r n a l P r e -p r o o f 5 the healthcare system during a pandemic. This system has forced health care providers to resort to pleas on social media to secure personal protective equipment (PPE). 10 Other developed countries, such as Finland; effectively prioritized, funded and maintained adequate PPE stockpiles following the Cold War, better positioning themselves for the threat of infectious diseases. 11 In the US, the federal government's response to COVID-19 including invoking the Defense Production Act (DPA), which requires industries to produce specific products (like PPE) needed to meet critical demands. Yet procurement of raw materials for PPE production continues to be challenging for manufacturers. As the pandemic lengthens, supply management organizations increasingly feel severe disruptions. 12 The US federal government waivered on providing the centralized leadership to maximize the effectiveness of the DPA in obtaining raw materials and getting needed products to locations where they are needed most. 13 Updating policies like the DPA must be a priority in an increasingly complex global economy.

Like most aspects of American governance, public health laws and mandates vary from state to state. The Centers for Disease Control and Prevention (CDC) provides guidance and recommendations to states but does not provide oversight. The CDC is able to enforce isolation and quarantine for specific communicable diseases in certain circumstances like interstate travel, 14 Adequate funding is required to both incentivize ID as a career track and to staff both health departments and infection prevention programs.

Antimicrobial resistance is a public health crisis. Estimates predict that 10 million deaths per year related to antimicrobial resistance will occur beginning in 2050, coming at an enormous economic cost. 18 Compounding this problem is a paucity of new antimicrobials in development against organisms designated by the World Health Organization as priority pathogens. 19 Although government and non-governmental organizations have created incentives to encourage antibiotic research and development, pharmaceutical companies continue to abandon antibiotic discovery and development efforts. This is largely been because of concerns over a poor return on investment. 20 The current COVID-19 pandemic highlights a complex and potentially vulnerable global supply chain for many pharmaceuticals, in addition to PPE. 21 The US has experienced critical supply shortages related to natural disasters in the past. In 2017, In the US, the Food and Drug Administration (FDA) oversees clinical diagnostics.

At the start of the pandemic, testing was limited to the CDC, which developed and deployed an approved assay to state labs. State labs were unable to validate the assay, leading to significant delays in testing. Inconsistent funding of public health programs contributed to COVID-19 testing shortages. In late February 2020, the FDA approved Emergency Use Authorization allowing private laboratories to produce testing products to meet their diagnostic needs, but test shortages persist despite gradual increases in public and commercial test capacity.

Both Germany and South Korea mounted COVID-19 responses with more speed, complexity and urgency than the United States. Both countries quickly mounted largescale testing capabilities. This was a function of central oversight, coordinated healthcare delivery, public health infrastructure and public trust. Within the first two months of diagnosing the first case of COVID-19 in South Korea, 600 testing sites had been set up, eventually allowing for 20,000 tests each day. 26 High testing volume allows asymptomatic, COVID-19 individuals to self-isolate. In addition to testing large swaths of the population, South Korean public health officials designed their test to detect the genetic targets recommended by the WHO.

As of May 5, 2020, Germany was able to test 120,000 people daily (population 83 million). 27 Prior to the arrival of the COVID-19 virus in Germany, a German lab created a diagnostic test and published a "how to" online for other labs to use. 28 Publishing the test "blueprint" allowed other German laboratories to create their own COVID-19 tests, maximizing test availability. Germany and South Korea's responses to the COVID-19 pandemic differ in many ways; but widespread, sustained testing allowed for prompt diagnosis, isolation and contact tracing in both countries.

J o u r n a l P r e -p r o o f 10 A country's ability to prepare for a novel infectious disease relies on planning, sustaining and executing emergency response systems. This requires emergency preparedness as a national priority. Within a loosely integrated and complex combination of private and public healthcare payers, commonly under a for-profit model, supply chain emergency response priorities must be uncoupled from business as usual and supported by state and federal funding. Public health systems must be adequately funded and staffed to address both present and future infectious diseases threats.

Healthcare systems must incentivize infectious diseases and epidemiology as careers for graduates to meet current needs and coming plagues. The slow development of antivirals, antibiotics and vaccines is a market failure requiring robust public-private partnerships for sustained enhancement.

Will the US be better prepared for the next pandemic? Resilience and ingenuity are part of the US cultural fabric, most notably demonstrated in the last century during World War II. However, resilience and ingenuity are necessary yet not sufficient.

Without institutionalizing the lessons learned from COVID-19, the US will be positioned to repeat the missteps of COVID-19 with the next pandemic. The future of US emergency preparedness will reflect the wisdom of US political leader, inventor and intellectual Benjamin Franklin: "by failing to prepare, you prepare to fail." All named authors have seen and agreed to the submitted version of the paper. This Editorial is original work and has not been submitted or published elsewhere. We have no conflicts of interest to report nor did we receive any funding for this Editorial. No ethical approval is required by our institution for an Editorial submission.

Higher Spending, Worse Outcomes? The Commonwealth Fund

Mirror, mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Updated July14

Shortages resulted with health care providers often resorting to social media to secure personal protective equipment (PPE)

What happens when our insurance is tied to our jobs, and our jobs vanish? The Washington Post

Up to 43m Americans could lose health insurance amid pandemic, report says. The Guardian

COVID-19 coverage for uninsured is underway, but more is needed. The American Medical Association

Got coronavirus? You may get a surprise medical bill, too. NBC News

With COVID-19, some states reopen the ACA marketplace for uninsured

Health in International Perspective: Shorter Lives, Poorer Health

COVID-19 Survey: Impacts on Global Supply Chains. Institute for Supply Management

Critical Supply Shortages -The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic

Isn't worried About Masks. The New York Times

Legal Authorities for Isolation and Quarantine

Kaiser Family Foundation. State Data and Policy Actions to Address Coronavirus

Ready or Not: Protecting the Public's Health from Diseases, Disasters, and Bioterrorism

Tackling drug-resistant infections globally: Final report and recommendations. Review on Antimicrobial Resistance

Priority pathogens and the antibiotic pipeline: an update

What are the economic barriers of antibiotic R&D and how can we overcome them?

Coronavirus raises fears of U.S. drug supply disruptions. The Washington Post

The Shortage of Normal Saline in the Wake of Hurricane Maria

Developing vaccines for SARS-CoV-2 and future epidemics and pandemics: applying lessons from past outbreaks

American Orientalism and American Exceptionalism: A Critical Rethinking of US Hegemony

How Is COVID-19 Affecting South Korea? What Is Our Current Strategy?

The New York Times. Germany Coronavirus Map and Case Count

Exception? Why the Country's Coronavirus Death Rate Is Low. The New York Times