[ED NOTE: Some months ago, bewildered by the amount of oncoming data and information - and its misapplications - I started putting together a coronavirus database. That can be found here. Much of the information in this piece is taken from there.]
Postmortem: Too Early?
by Domingo Soto
PART I
Like the cloud of the upcoming November election - the assessment of this administration’s response to the coronavirus pandemic looms ever large. This scourge has not just maimed the body politic, killing thousands in the process, it may have terminally wounded Donald Trump’s election hopes, its prognosis now grim.
A diagnosis of what amounts to a self-inflicted wound is not just about incompetence borne of inexperience, but a malaise exacerbated by an etiology of inaction, conceit, negligence, petulance, impetuosity gilded with ignorance, penchants for infantile and happy talk, dogged insistence and actions by force of will, an indolence and unwillingness to study or work at the tasks before him, and an imperviousness to harsh and obvious realities.
Prior History
Novice or not, there is little substance to the idea that “no one saw this coming.” In 2004, George W. Bush, while leafing through an advance copy of a book, had an epiphany which soon turned into an obsession; Something like the 1918 pandemic could reoccur, he thought.
It was probably no great leap for the man who had just shepherded the country through 9/11 to imagine yet another doomsday scenario. “It may not happen on our watch, but the nation needs the plan,” he told an aide and set about prioritizing health preparedness at a time when the nation’s attention was focused on terrorism. “If we wait for a pandemic to appear, it will be too late to prepare.”
And it was no half measure. His was a full-court press. By the latter part of 2005, he had instigated a comprehensive and ambitious plan involving the top echelons of government and health officials, the World Health Organization and the United Nations. The President’s plan was essentially war preparedness, calling for international working relationships, the stockpiling of medicines, development of new vaccines and antiviral drugs, and the establishment and placement of federal and state emergency plans.
He signed the Pandemic and All-Hazards Preparedness Act (PAHPA) in 2006, beefing up HHS’ preparedness and response activities and establishing a new Assistant Secretary for Preparedness and Response (ASPR). The act provided new authorities for a number of programs, including the advanced development and acquisition of medical countermeasures and the establishment of a quadrennial National Health Security Strategy.
They also established BARDA (Biomedical Advanced Research and Development Authority), tasking it with securing the nation from chemical, biological, radiological, and nuclear (CBRN) threats, as well as from pandemic influenza (PI) and emerging infectious diseases (EID). That agency supported the transition of medical countermeasures such as vaccines, drugs, and diagnostics from research through advanced development towards consideration for approval by the FDA and inclusion into the Strategic National Stockpile.
Taking responsibility for preparedness was now seriously on the table. Myriad reports and assessments from just about every American sector were generated. Global Trends 2025 the fourth installment in the National Intelligence Council-led effort to identify key drivers and developments likely to shape world events was published in 2008. “The emergence of a novel, highly transmissible, and virulent human respiratory illness for which there are no adequate countermeasures could initiate a global pandemic,” the authors warned. The threat, they added, would likely emerge “in an area marked by high population density and close association between humans and animals, such as many areas of China and Southeast Asia.”
The following year, Dennis Blair, then the Director of National Intelligence (DNI), presented his Annual Threat Assessment to the Senate Select Committee on Intelligence. “The most pressing transnational health challenge for the United States is still the potential for emergence of a severe pandemic, with the primary candidate being a highly lethal influenza virus,” he told them.
Blair reiterated that warning the following year. “Lack of consistent surveillance and diagnostic capability for diseases in animals undermines the United States’ ability to identify, contain, and warn about local outbreaks before they spread.” Two years later and only a few months into the Obama administration’s first term, the Swine Flu (H1N1) pandemic hit, forcing the young President to declare a national emergency later part that year.
The House of Representatives, also, was sounding the alarm. It’s “Subcommittee on Emergency Preparedness, Response, And Communications, Committee on Homeland Security” issued Taking Measure of Countermeasures, Part 3: Protecting the Protectors, a report that set out the parameters then being taken in countermeasure development, including the development of next-generation portable ventilators.
Then-DNI James Clapper's Worldwide Threat Assessment warned the following year that “an easily transmissible, novel respiratory pathogen that kills or incapacitates more than one percent of its victims is among the most disruptive events possible. Such an outbreak would result in a global pandemic....This is not a hypothetical threat,” he warned.
Within a few mere months into his new administration, Obama had been forced to grapple with yet another head on the hydra of major problems. Added to the meltdown of the financial economy and the weight of a costly and ineffective healthcare system, was the issue of an emerging pandemic, the H1N1 (Swine Flu) which took over 1,000 lives. Obama, now totally on board, proceeded to shore up the safety system.
His efforts were somewhat stymied by some political back and forth with the sequestration cost cutters. But by the end of 2014, the country now faced a second disease outbreak, the Ebola virus. The dangers and the need for mechanisms with which to deal with airborne diseases was obvious and Obama was firmly on board. “We have to put in place an infrastructure,” he said “that allows us to see it quickly, isolate it quickly, respond to it quickly… "If and when a new strain of flu, like the Spanish flu, crops up five years from now or a decade from now, we've made the investment and we're further along to be able to catch it," he said. "It is a smart investment for us to make. It's not just insurance; it is knowing that down the road we're going to continue to have problems like this - particularly in a globalized world where you move from one side of the world to the other in a day."
Obama’s approach was proactive. He brought the Ebola fight to Africa, its source, and in the process limited its reach and impact here. Prioritizing the effort as one of national security, personnel - international and American, civilians and military - were deployed to West Africa to fight the scourge at its source. Locally, they encouraged and developed prophylactic countermeasures such as screening travelers, diagnoses, isolation, testing and treatment. As a result, only 11 people were treated for Ebola in the U.S. during the 2014-2016 epidemic.
Prepping for Change
Three days prior to the Trump inauguration, Dr. Anthony Fauci, a noted epidemiologist we would all soon come to know, spoke at a forum on pandemic preparedness at Georgetown University and warned that the new administration would not only be challenged by ongoing global health threats such as influenza and HIV, but also by a surprise disease outbreak.
That same week, the outgoing Obama administration held a briefing regarding the real potential for a pandemic and the need to coordinate a simultaneous international and domestic response. The National Security Council (NSC) prepared a 69-page, color-coded document, the Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.
And it was with good cause that they warned the new guys. By the end of his term, the now-not-so-young President knew the full implications of health crises. Obama’s mettle had been tested, forged, along with everything else, in the crucible of two pandemics. It had been a lesson learned the hard way. The H1N1 (Swine Flu) epidemic, like the Asian Flu epidemic of 1957, had cost thousands of lives and impacted the economy but the lessons learned on his watch would guide his successful efforts at stemming the Ebola pandemic years later. Preparedness and action were the keys.
Just some few months into the new Trump regime, experts in health and national security were raising concerns that crucial public health positions across the government were not being filled. The nation was being left “ill-prepared to face one of its greatest potential threats: a pandemic outbreak of a deadly infectious disease,” a report said.
Perhaps sensing where the Administration’s true priorities lay, Daniel Coats, the new DNI, soon highlighted the World Bank’s assessment that a pandemic would cost the world around 5% of GDP. “The United States and the world will remain vulnerable to the next flu pandemic or large-scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.”
The Trump administration’s cost-cutting agenda, a large part of its political mandate, was not lost on the Centers for Disease Control and Prevention (CDC). It started downsizing its epidemic prevention activities in 39 out of 49 countries. The agency would focus on 10 priority countries, including China. Congress would eventually step, avoiding the CDC cuts. But the downsize momentum was having its effect. The government reduced $15 billion in national health spending, cut the global disease-fighting operational budgets, and quashed the government’s $30 million Complex Crises Fund.
Heads, also, would roll. Homeland Security adviser, Tom Bossert, who had called for a comprehensive biodefense strategy against pandemics and biological attacks, was fired. Rear Adm. R. Timothy Ziemer, the Trump administration's senior director for global health security and biodefense at the National Security Council left his post abruptly and the global health security team he oversaw was disbanded as part of a reorganization under national security adviser John Bolton. A few months later, medical epidemiologist Linda Quick’s Beijing position as trainer of Chinese field epidemiologists was eliminated.
To the winners go the spoils. Trump won the election, in no small part by championing cost-cutting and the deregulation of government. Up to this point, the backdrop is merely our bad luck and the misfortune of a failed myopic ideology that can only be criticized using 20/20 hindsight.
The perfect storm included errors by others, initially, the CDC. The Chinese had almost immediately isolated and completed the genome sequencing. The development of a test to detect the presence of the virus was the crucial next step. A German test had been immediately available and shipped to 120 countries. Normal quality control standards, however, called for the US to develop and deploy it’s own, which it rapidly did.
HHS Secretary Alex Azar praised the CDC for developing a coronavirus test in one week. "This was really a historic accomplishment." “That’s our prime mission,” Dr. Redfield of the CDC said, “to get eyes on this thing.” Unfortunately, manufacturing errors delayed the viability of the tests for more than a month.
Warnings Unheeded
Intentional or not, Trump ignored the foundational work of his predecessors and in many ways worked at cross purposes with the safeguards, standards, systems, and protocols that had been put in place by past administrations. With Obama as his wolf bane, that’s not surprising. But the warnings weren’t limited to those of prior administrations. There were ruminations from those within his own administration, the medical community, of course, but also the intelligence community and, even, the military. The warnings were constant and continuous and consisted of reports from every sector of the government and, even, from his closest advisors.
The White House itself had issued National Biodefense Strategy and Presidential Memorandum on the Support for National Biodefense, warning that “the evolving biological threat landscape requires a comprehensive approach.” The Worldwide Threat Assessment issued in early 2019 warned - For the third year in a row - that the U.S. will “remain vulnerable to the next flu pandemic or large-scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.”
“We assess that the United States and the world will remain vulnerable to the next flu pandemic or large-scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support,”
That was followed a few months later by a Biodefense Summit. Attended by Azar and Tim Morrison, then a Special Assistant to the President and Senior Director for Weapons of Mass Destruction and Biodefense on the National Security Council. The meeting’s agenda was to “engage the biodefense stakeholder community to inform national biodefense enterprise efforts to counter biological threats, reduce risk, prevent, prepare for, respond to, and recover from biological incidents.”
"Of course, the thing that people ask: 'What keeps you most up at night in the biodefense world?' Pandemic flu, of course. I think everyone in this room probably shares that concern," Azar said, before listing efforts to mitigate the impact of flu outbreaks.
The year was replete with more of these conferences and internal reports, all warning of the need to be prepared. FEMA, for example issued a National Threat and Hazard Identification and Risk Assessment, identifying the “greatest threats and hazards” to the United States and warning concerning the social, economic and personal devastation that a pandemic could cause, foreseeing current impacts, including overwhelmed hospitals and disruptions in essential services.
Some short time later, HHS concluded its last phase of an 8-month-long simulated pandemic exercise. The exercise, code named “Crimson Contagion,” had eerie and prophetic similarities to the current real-life coronavirus pandemic. Officials from more than a dozen federal agencies, several states and hospitals were engaged in a scenario in which a pandemic flu had begun in China, was being spread by international tourists and was deemed a pandemic 47 days after the first outbreak.
The simulation’s report concluded that the federal government lacked sufficient funding to respond to a severe pandemic; that agencies lacked clarity on the roles of different federal agencies, and what information was important to pass along to its federal partners; that there was confusion in the chain of command; that production capacity to meet the demands for protective equipment and medical devices such as masks and ventilators imposed by a pandemic was insufficient; and that states were unable to efficiently request resources due to the lack of a standardized request process.
Even the White House Council of Economic Advisers joined the harpy chorus, estimating that 500,000 deaths and economic devastation could flow from an influenza-like pandemic.
In November, just a few months before the world would be turned upside down, a bipartisan group of lawmakers and experts were worried enough to formally recommend that the health security leadership on the NSC be restored. It is perhaps no accident that the first case of the coronavirus had been reported that week. Indeed, our military was apprised of the situation, issuing a confidential report warning of a contagion sweeping through Wuhan, China and assessing it as a possibly “cataclysmic” event. According to media accounts, that report was briefed to the National Security Council, the Pentagon and the White House, but the Defense Secretary, Mark Esper, denies any awareness of it.
It’s even harder to buy the idea that the crisis was a complete surprise. There are media reports of repeated warnings posted in the President’s Daily Brief, warnings relayed by the Office of the DNI, the CIA and other intelligence agencies, warnings that especially started heating up at the end of January.
One week after the first reported US case of the coronavirus,
DNI Coats testified at the Senate Intelligence committee’s annual worldwide threats hearing. That very day, Peter Navarro, Trump’s trade adviser, wrote a memo warning that the coronavirus crisis could cost the United States trillions of dollars and put millions of Americans at risk of illness or death. He called for "an immediate travel ban on China."
“The lack of immune protection or an existing cure or vaccine would leave Americans defenseless in the case of a full-blown coronavirus outbreak on U.S. soil....This lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”
He would follow up with another memo a few weeks later in which he warned that "There is an increasing probability of a full-blown COVID-19 pandemic that could infect as many as 100 million Americans, with a loss of life of as many as 1-2 million souls."
He set out the need for an "immediate supplemental appropriation of at least $3 billion", anticipating the need for "Personal Protective Equipment" for health care workers. "We can expect to need at least a billion face masks, 200,000 Tyvek suits, and 11,000 ventilator circuits, and 25,000 PAPRs (powered air-purifying respirators)”, he said.
Keeping Secrets
As the year 2019 closed, a vector loomed in China. Health authorities were now aware of a mysterious and stealthy disease centered in the metropolitan city of Wuman. The World Health Organization issued a warning. By New Year’s day, Chinese authorities would order the closing and cleaning of the Wuhan Seafood Market, the suspected source.
The Chinese bear some measure of complicity for the spread of the virus beyond it’s borders. Instead of treating the matters as a health crisis with global implications, it was handled preliminarily as a political matter, a treatment plan that is eerily reminiscent of the approach taken by Trump. As the disease progressed alarmingly, the Wuhan health officials had dutifully reported their findings. The head of China’s disease control agency immediately informed his US counterpart CDC Director Robert Redfield of the rampaging disease.
Their candor was rewarded by authorities with an information lock-down. China’s Institute of Virology reminded the Wuhan lab; disclosure of information is prohibited. Eight doctors, including the first whistle blower, were punished for “rumor-mongering” via a broadcast on China’s national television. As it has here, the counterproductive interplay between the apparatchiks and the health officials continued. A People's Liberation Army biological weapons expert soon assumed control of Wuhan's P4 lab.
Behind closed doors, the highest levels of government pondered the situation, finally reaching the assessment that it was grim with far-reaching implications. In typical fashion for a government with complete control of the apparatus of authority, they sent out medical shock troops, assigned top health officials to working groups, trained health workers, collected data, did field investigations and supervised laboratories. Soon thereafter, they ordered a complete shutdown of the city and built two treatment hospitals nearly overnight.
As insular and secretive as they are, though, the country’s outbreak had been hard to underplay. There were people dying, literally, on their streets. The cat had been belled. Asia went on full alert. The Lunar New Year, they all worried, would see many workers going back to their home cities. Taiwan, Hong Kong, South Korea, Thailand and the Philippines set up quarantine and scanning zones for passengers from China.
But the Chinese health officials had not abandoned their Hippocratic duties. By the first week of the year, they had isolated and completed the genome sequencing, reported it to the National Health Commission, suggested preventative measure recommendations, and sent a genetic map of the viral DNA to the world community.
The WHO, caught, perhaps as Trump insists, in a political undertow, cautioned caution. Like the Chinese playing their cards too close to their chests, they added to the problem. With a world view not tethered to one country, they advised against travel restrictions to China “based on the current information available on this event." Although internal documents show that the higher echelons of the Chinese government were concerned that the disease had human-to-human transmission capabilities, they fudged on that. As late as January 23, a few days after the first reports of a case in the United States and other world centers, the head of the WHO still resisted calling the outbreak a public health emergency of international concern.
It would not be until the end of January, now facing the harsh realities of a worldwide meltdown, that the WHO would reconvene to consider whether the outbreak amounted to a global health emergency. Declaring it now a pandemic, Dr. Mike Ryan, head of the WHO's Health Emergencies Programme, said, "The whole world needs to be on alert now. The whole world needs to take action and be ready for any cases that come from the epicenter or other epicenter that becomes established." The WHO's Tedros announced that the outbreak had become a "public health emergency of international concern over the global outbreak of novel coronavirus."
The agency advised countermeasures. "Countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of 2019-nCoV infection, and to share full data with WHO.”
In early January, the CDC had created an “Incident Management System” for the coronavirus and advised travelers to Wuhan to take precautions. That was followed by a warning from the Chinese President himself that the outbreak “must be taken seriously” and every possible measure pursued. On January 21, the same day the WHO declared the virus risk as globally “high”, the first US case was reported. If a pandemic “Operation Overlord” had been envisioned by other administrations - whatever systems, protocols, or actions might have been prescribed - they were MIA, allowing the disease essentially unfettered entry.
Instead of an affirmative and measured response, the administration acted in a dilatory, inept, and counterproductive fashion. The coronavirus had us up the creek; Trump not only threw away the paddles, he shot holes in the bottom of the boat. Those lynchpins of pandemic prophylaxis, the standards and protocols recommended by the WHO, the CDC, and others, were not just ignored, they were countermanded. Missing was the steady and firm hand at the till, there were no actions borne of competence and confidence. Instead, it was a reverse play book - testing, contract tracing, quarantines, travel lock downs, the placement of respected medical professions, isolating the process from the appearance of political interference, working to instill public confidence - were all upended. Medical knowledge and its experts was impugned and ultimately sidelined in favor of fanciful elixirs, shamans, mendacity, and magical thinking.
No comments:
Post a Comment