We’ll lose ‘World War C’ against the coronavirus if we don’t fight the right way
This is war. It is “World War C,” humans against the coronavirus. In a war, a strategy is important and so is organization. For rapid, effective action to fight epidemics, the best practice is to use an incident management system. Every country needs one, but it’s not clear that the U.S. has one today.
As of today, organization of the U.S. response remains unclear. What is the role of the Federal Emergency Management Agency (FEMA) concerning the vice president, the White House Coronavirus Task Force, the chairman of the task force, and the White House Coronavirus coordinator?
The FEMA operation does use an incident management system, but does it feed information to the White House to be the basis of careful assessment of policy options — for example, guidelines for when to relax physical distancing? What role is the U.S. Centers for Disease Control and Prevention (CDC) playing? In every infectious disease response since the CDC was created nearly 75 years ago, it has been central to the U.S. response. Sidelining, the CDC will cost time and lives.
For example, the administration rightly notes that private industry is eager to help with masks, ventilators and other critical supplies. Forcing them to do so may be appealing to some but is probably unnecessary. What the White House seems to fail to understand is that to be effective, industry efforts must be carefully coordinated by the federal government.
Real-time data is essential to make, assess and revise policy decisions and program implementation. The better we understand how the virus spreads and how to stop its spread to health care workers and in the community, the better we limit health and economic harm.
When we know what proportion of infections are spread by pre-symptomatic and asymptomatic people, we can better target contact tracing, isolation of patients, and quarantine of exposed people. If we learn that children rarely spread infection, reopening schools and daycare centers will be an easier decision. The urgent need for real-time, accurate data is one of the reasons the absence of the CDC is so dangerous — the CDC is the part of the federal government that is best placed to answer (and to help others answer) many of the most important questions.
During the 2014-2016 Ebola epidemic, the CDC produced a weekly dashboard of the most important interventions, objectively grading each in every affected country as red, yellow or green. For Ebola, interventions were in five domains: command and control, surveillance and epidemiology, case management (including laboratory testing), essential health services, and effective communication.
The dashboard focused attention on interventions most likely to stop the epidemic. With COVID-19, the same five domains are essential; two additional domains are physical distancing and providing social and economic support. Once the priorities are clear, then data, guidance, and useful tools can be cascaded from national to state, city and community levels.
Details and management matter. Here’s a starter set of 10 areas to be tracked both nationally and in every state and community:
A well-organized emergency management system with empowered incident managers aligned with political leaders.
Testing available for every patient with pneumonia within four hours, every symptomatic person within 12 hours, and capacity for drive-through testing.
Start contact tracing within hours of case identification; identify contacts for >95 percent of cases, track >95 percent of contacts, test 100 percent of symptomatic contacts, and monitor >95 percent of quarantined contacts for 14 days. This is an enormous undertaking, and both trained people and practical digital tools will be essential. China tracked 685,000 contacts — with fewer cases than the U.S. has.
Provide daily briefings with accurate and timely numbers of those infected, ill and deceased, epidemiologic trends and analysis, along with updated guidance from credible spokespeople.
Protect health care workers with policies, training, and personal protective equipment.
Be sure health care systems can safely surge for large numbers of mildly ill patients, a large increase in patients needing intensive care, and patients needing ongoing, non-coronavirus-related care.
Be able to resume targeted or general physical distancing if needed rapidly.
Support nutrition, learning, mental and physical health and well-being, and social needs during isolation and quarantine.
Engage communities, obtaining information from the public through surveys, assessing adherence to physical distancing recommendations, and using findings of these surveys to improve the effectiveness and reduce the disruption of measures taken.
Coordinate with states and localities so guidance and policies are implemented within 24 hours of publication.
Achieving targets such as these through clear, accountable incident management systems will reduce infections and deaths. They also will provide the critical data needed to decide when and how to reopen schools, workplaces and the rest of the economy. When health care is ready to surge and public health can test, isolate, trace and quarantine contacts, then it may be safe to loosen the faucet and begin to resume normal activities gingerly.
The group I lead, Resolve to Save Lives, advises countries around the world on how to prepare for and respond to epidemics. Until the United States has a best-practice incident management structure that organizes operations and supplies information for the decisions of our political leadership, and which fully integrates the CDC, we are not even organized for battle.
Dr. Tom Frieden is the former director of the U.S. Centers for Disease Control and Prevention and former commissioner of the New York City Health Department. He is president and CEO of Resolve to Save Lives, a global non-profit initiative funded by Bloomberg Philanthropies, the Chan Zuckerberg Initiative, and the Bill and Melinda Gates Foundation and is part of the global public health organization Vital Strategies. Resolve to Save Lives works with countries to prevent 100 million deaths and to make the world safer from epidemics. Dr. Frieden is also a senior fellow for global health at the Council on Foreign Relations. Follow him on Twitter @DrTomFrieden.
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