Policy Lessons from Our Covid Experience

Perspective

As of August 24, 2020, nearly 5.7 million cases of Covid-19 had been reported in the United States, with more than 176,000 deaths. Although there is debate about the accuracy of these specific numbers — many people with mild symptoms are never tested for Covid, for example, and especially early in the epidemic, the difference between dying from Covid and dying with Covid may not have been accurately captured — the increase in excess mortality rates reported by the Centers for Disease Control and Prevention is consistent with a significant loss of life associated with the disease.

At the same time, the Covid-19 pandemic has led to staggering economic losses in the United States. Closing down the economy has had a devastating impact on the American people, even though the closure was imposed to save lives. The longest economic expansion on record abruptly ended in February, and the country officially entered a recession late that month.

The U.S. unemployment rate in February was 3.5% — a half-century low. By March, it was 4.4%, and by April, 14.7%, with 20.5 million people losing their jobs and more than 20% of the labor force filing for unemployment benefits. Experts predicted that the unemployment rate would approach 20% in May; instead, it was reported as 13.3%, although there’s debate about whether this figure reflected some workers’ self-classification as only temporarily laid off. The June unemployment rate was even lower — 11.1% — but the economy was still operating with 15 million fewer jobs than it had in February, and there was new concern that the economic impact of the pandemic may linger, given the recent resurgence of new cases.

As the country reopens, it’s important to assess how we can be better prepared to stave off such enormous economic losses during the next wave or the next epidemic. In my view, a few key policy changes will be critical.

First, expertise on pandemic related policy and strategy should be located closer to the center of power. I believe that the type of pandemic-preparedness office (the Office of Pandemics and Emerging Threats) that now resides only in the Department of Health and Human Services (HHS) also needs to be reestablished as part of the National Security Council (NSC). Incorporating the office into the NSC doesn’t guarantee that the White House will pay attention to its recommendations, but it helps in commanding the attention of the most senior members of the White House staff. The HHS assistant secretary would continue to serve as the execution arm of the pandemic office.

Since the early 1990s, such an office has repeatedly been established after a national health scare — and then disbanded by the successor administration. The Biodefense and Health Security Office established during the Clinton administration was closed by President George W. Bush, reopened after the anthrax scare, closed by President Barack Obama, and then reopened after the Ebola and Zika scares, at which point the Directorate for Global Health Security and Biodefense was created. The plan prepared in the wake of the Ebola outbreak might have been helpful in preparing a response for the current Covid pandemic, but like his predecessors, former National Security Advisor John Bolton dissolved the office in 2018 Once again, some of the office’s personnel were merged into other NSC units, but the pandemic office itself no longer existed.

Whether as cause or effect of the office’s repeated dissolution or sidelining, neither the defense establishment nor the public seems to appreciate that disease threats are as serious to the country’s security as are wars with our traditional enemies. For example, another airborne disease, smallpox, caused 300 million to 500 million deaths worldwide — more than all 20th-century wars combined.

Second, in planning for unknown future epidemics, federal pandemic-preparedness officials must decide what constitutes a prudent level of supply stockpiling, with an understanding of the inevitable trade-offs between perceived readiness and the cost of equipment and supplies that we hope never to use. They should develop strategies for deploying supplies on an as-needed basis. And they should plan ways to provide surge capacity for beds, operating rooms, and trained personnel, which may involve calling on the National Guard, among other resources. Designation of particular people who will be accountable for these activities will be key to their success.

Third, when an outbreak occurs, determinations about policy and financial responses should be based on accurate epidemiologic knowledge. It is important to establish as quickly as possible who is most vulnerable to a new disease and to respond selectively, with targeted measures directed toward the most vulnerable populations. Older people, particularly those with underlying conditions and compromised immune systems, are especially vulnerable to Covid-19. Some 50,000 deaths from Covid had occurred in nursing homes and other senior care facilities by mid-June. But older people are not always the ones at greatest risk. The “Spanish flu” in 1918 was especially dangerous to infants and 20 to-40-year-olds. We need to understand who is contracting the disease and experiencing serious consequences in order to craft an appropriate and differentiated response.

In a recent study, John Birge and others claim that the economic cost of the U.S. Covid shutdown could have been reduced by 33 to 40% if neighborhoods had been selected for closure more strategically, in line with the infection risk for local residents and workers.1 The authors’ rationale is that living areas are frequently different from the places with the highest concentration of jobs and that it may be possible to keep jobs open as long as many of the employees live in unaffected areas. To calculate the number of people at risk in a given area, however, we need to know who comes into contact with an infected person and be able to track their travel histories. Such work can be done with the type of contact tracing being done in Hong Kong, Germany, and elsewhere, but it may require that people provide detailed information to the authorities, including turning over their cell phones or providing details about their contacts in phone interviews. Many Americans are unlikely to be willing to do so.

Fourth, pandemic-control policies must have logically consistent components. The decision to shut down the U.S. borders to limit the entry of people carrying Covid-19, for example, required thousands of U.S. citizens to quickly reenter the United States, but no plans appeared to have been made for the safe reentry of large numbers of people through a limited number of entry ports. As a result, hundreds of people were crowded into inadequate spaces trying to get through customs and immigration. If any of them were carrying the virus, the crowding would have exacerbated the spread, with serious consequences for public health.

Finally, beyond public policy, individual citizens clearly need to accept responsibility for acting in ways appropriate to fighting pandemics. Though much remains unknown about Covid-19, there is increasing evidence about the efficacy of mask wearing. The refusal of some people to wear face coverings when indoors or to maintain reasonable social distances outdoors increases the burden on all of us. When a safe and effective vaccine becomes available, it will also be incumbent on all who are of an appropriate age and have no contraindications to get vaccinated.

Only time will tell whether the country will be better able to respond to the next health crisis. A key focus now needs to be on reopening the economy in a smart and sensible way. While the economy was shut down, the government provided critical short-term assistance, but I believe we need to ensure that future support is designed to encourage people to return to work as soon as they can do so with relative safety. A stimulus bill was under discussion in Congress but stalled when Congress went into their August recess on July 31. The president signed an executive order on August 10 to provide $400 weekly to unemployed Americans, but it is judged to be on shaky legal grounds. The additional federal spending related to the pandemic has added a huge long-term debt burden to the country. Replacing many Americans’ usual work income with federal funding is not a viable long-term strategy.

Disclosure forms provided by the author are available at NEJM.org. From Project HOPE, Bethesda, MD.

This article was published on August 26, 2020, at NEJM.org.

  1. Birge JR, Candogan O, Feng Y. Controlling epidemic spread: reducing economic losses with targeted closures. Working paper no. 2020-57. Chicago: University of Chicago, Becker Friedman Institute for Economics, May 6, 2020 (https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3590621).

DOI: 10.1056/NEJMp2023204 Copyright © 2020 Massachusetts Medical Society.

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Gail Wilensky, Ph.D.

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