What is the United States’ single greatest weakness in its pandemic preparedness?
WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, declared COVID-19 a pandemic on March 11, citing “alarming levels of spread and severity” and “the alarming level of inaction.”
Healio Primary Care asked experts in infectious disease, public health and epidemiology what the greatest weakness is in the country’s capacity to counter an infectious disease threat like COVID-19. – by Janel Miller
POINT. Our lack of capacity to meet increasing health care demands is our greatest weakness.
The imbalance between the demand for health care services and the capacity that is available may be the United States’ greatest weakness during this pandemic. Think about how much time is spent in the ED, how long it takes to make an appointment with a health care provider, and how long you spend in the waiting room once you actually go for your appointment. The demand for medical services will only surge because of the pandemic.
With COVID-19, there may be many people who are infected but are not showing any symptoms and are unknowingly spreading the infection. In the absence of widespread testing, this is analogous to trying to keep a fire under control without seeing exactly where the fire is. It is a serious weakness.
Health systems, insurance companies, and the government need to take action now to handle this increased demand from patients, including those who are not insured. How do you expand capacity and flexibility to handle the increased demand for services and claims? How do you prioritize who will receive the COVID-19 tests, treatment or vaccine when they become available on a greater scale but not yet in ample supply?
Pinar Keskinocak, MS, PhD, is the director of the Center for Health and Humanitarian Systems and a professor in the H. Milton Stewart School of Industrial and Systems Engineering at Georgia Institute of Technology. Disclosure: Keskinocak reports no relevant financial disclosures.
COUNTER. Our greatest weakness is unequal access to care.
The United States’ greatest weakness to pandemic preparedness is access to health care. Access is dependent on who you are, where you live and what you make, which should not be the case. In the case of COVID-19 testing and management of cases, the uninsured, rural, young, minorities, those living in the Southern United States, the less educated and single parents could be hit the hardest by lack of tests and access to care — all because they are at a disadvantage for access.
Good primary care systems and paying mechanisms form the foundation of equitable, effective and efficient health care systems. We falter in almost all these dimensions. Access ensures primary care, prevention, screening and testing, and proper referral, diagnosis and treatment. As of today, 10% to 15% of Americans, or more than 35 million individuals, are uninsured or underinsured. These individuals will not go for COVID-19 testing. Why? Access. Will those who are insured find qualified COVID-19 providers in rural America? No. Do we have enough beds in such places? No.
Despite the fact that the majority of the Nobel prize winners in medicine are from the U.S., it is the only industrialized nation with such dire conditions that depend on who people are and where they live. All other industrialized nations have some sort of safety net or universal health care system.
Jagdish Khubchandani, PhD, MPH, MBBS, is a professor of health science in the department of nutrition and health science at Ball State University in Muncie, Indiana. Disclosure: Khubchandani reports no relevant financial disclosures.
POINT. Lack of testing is the U.S.’ greatest weakness.
The lack of testing and inability to prepare for the large number of tests that we're going to need to track and identify COVID-19 cases and prevent its spread is perhaps the United States’ greatest weakness when it comes to pandemic preparedness.
Though the United States had sufficient time from the outbreaks in China and the Far East to ensure that it had everything in place and to plan and prepare for COVID-19 reaching America, and though there were experts available for the United States to consult with as it coordinated its response to COVID-19, it doesn't appear that the U.S. did enough planning.
Our response to the coronavirus is much different than the response to the novel H1N1 pandemic in 2009. Back then, the situation was handled much more aggressively. There was rapid development of a vaccine. There was rapid development of diagnostic tests that were specific to the new H1N1 strain. The country appeared to proceed with much greater emphasis on planning and execution than during the current pandemic.
The predictions are that the COVID-19 pandemic will result both in significant numbers of lives lost — from 0.6% of the population in South Korea where they've done an enormous amount of testing, to 4.6% of the population in Italy. Approximately 80% of the mortality in the United States is occurring among those aged 60 years and older. The pandemic may also trigger enormous economic losses throughout the world that, unfortunately, will be felt disproportionately in different populations. These numbers are not catastrophic, but they are quite alarming.
Alan Lesse, MD, is associate professor of medicine with a specialization in infectious disease and senior associate dean for medical curriculum at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo. Disclosure: Lesse reports no relevant financial disclosures.
COUNTER. Socioeconomic inequities constitute the greatest weakness in pandemic preparedness.
The United States’ greatest weakness to pandemic preparedness is the socioeconomic inequities that exist in our country. Socioeconomic disadvantage is a key determinant of many of the chronic health conditions that we are seeing put people at greater risk for poor outcomes once infected with coronavirus. Living in socioeconomic disadvantage also creates extra barriers to participate in the public health measures being recommended.
For example, low-income families face extra challenges engaging in one of the most important things we can do to slow the COVID-19 outbreak: social distancing. Lack of paid sick leave, which is typical of many hourly, low-paying positions, as well as the inability to cope with loss of wages, may give people no choice but to continue working, even if they or family members become ill. In addition, many workers at lower paying service industry jobs, if the job isn’t being lost to business closure, require social contact and do not have the option to work from home. The living conditions experienced by many disadvantaged individuals in our country, such as overcrowded housing and homelessness, also make social distancing difficult.
Without immediate legislation that serves to strengthen the social safety net such as the expansion of unemployment benefits and paid sick leave, as well as longer term efforts aimed at improving conditions for disadvantaged populations, our ability to manage COVID-19 and future pandemics will be limited.
Amanda M. Simanek, MPH, PhD, is associate professor of epidemiology at the Joseph J. Zilber School of Public Health University of Wisconsin-Milwaukee. Disclosure: Simanek reports no relevant financial disclosures.