If it is true that generals fight the last war and economists fight the last depression, then the COVID-19 pandemic has demonstrated that doctors fight the last pandemic.
Some experts have asserted that we weren’t prepared for the pandemic, but it might be more accurate to say we just weren’t ready for this particular pandemic.
When COVID-19 emerged in the U.S. in late 2019 and early 2020, the public health community responded in a manner similar to how its members did in prior influenza epidemics. Two prior coronavirus outbreaks, SARS and MERS, affected virtually no one in the U.S., and influenza was the best bet for the next major pandemic. That’s what the public health community geared up for.
This was an understandable approach. Alas, like Leo Tolstoy’s unhappy families, each pandemic is different in its own way.
The experts were completely surprised by how COVID-19 behaved. Critically, when COVID-19 first appeared, it was often spread by patients without symptoms (asymptomatic spread) or by patients before they had symptoms (presymptomatic spread). The consequences of not appreciating viral transmission in the absence of symptoms were devastating. The virus spread rapidly in large numbers of unsuspected patients, meaning the number of cases was initially underestimated. Additionally, asymptomatic spread confounded contact tracing, normally an effective mode of controlling disease transmission.
Another surprise was that because influenza spreads through airborne droplets — from coughing, sneezing, for example — and contaminated surfaces, this was where early attention was directed for COVID-19. This diverted awareness from a key source of COVID-19 transmission: small particle aerosols that linger in poorly ventilated indoor areas. In addition, the Food and Drug Administration delayed approval of specific COVID-19 tests, essentially treating them as a doctor-to-patient diagnostic tool rather than promoting wider use for mass screening (which professional sports leagues did successfully).
But as is true of war, past reversals do not mean future defeat. We now have a new array of weapons — preventive, diagnostic and therapeutic — in our arsenal against COVID-19, and just as important, we understand our enemy better than we did in early 2020.
In terms of prevention, there are now four vaccines available in the U.S., and booster shots are becoming an important adjunct. The Centers for Disease Control and Prevention director acted correctly in overruling her advisory panel and recommending broader use of boosters; in Israel, where more than 3 million booster doses have been administered, the protection from severe illness has resulted in Israeli cities being able to reopen.
To facilitate diagnosis, the Biden administration has announced a $1 billion investment in rapid at-home COVID-19 tests and expects that by December, 200 million rapid tests will be available each month. These tests generally identify COVID-19 positive individuals with results available in 15 minutes, and used correctly, may be useful in breaking potential infection chains in schools and businesses and at family events.
While there is still no cure for COVID-19, the most exciting development is in the realm of therapeutics. For severe COVID-19 respiratory disease, corticosteroids and other immune modulators have been demonstrated to reduce deaths. In moderate COVID-19 disease, monoclonal antibodies can forestall disease progression.
Now, in a potentially revolutionary breakthrough, the drug molnupiravir has been developed for early COVID-19 disease. (An unwritten rule in the pharmaceutical industry is that new drugs must come with unpronounceable names.) Molnupiravir, now being examined by the FDA and several Asian countries, is a pill that when taken in the first five days of infection reduces the need for hospitalization. Together, these drugs represent our best hope that in the future COVID-19 will be a manageable disease at all stages.
This requires each of these weapons to be deployed efficiently. Currently, when patients receive rapid tests for influenza, positive results are poorly coordinated with effective oral treatment. To avoid repeating this snafu, the CDC should prepare protocols and indications to test patients with respiratory symptoms and when to administer treatment in patients with mild COVID-19 disease.
Of course, this means better public messaging — and a single, strong voice. To this point in the pandemic, messaging has been shambolic, too many cooks spoiling the broth. (Actually, Chicago has done a better job than federal officials, with the public health commissioner and mayor appearing together and giving coordinated public health recommendations.) The national news media are far from blameless. Too often, they have promoted sensationalism and fear over sober reporting, exacerbating public division.
As we try to recover from our initial pandemic missteps, a good model to draw on would be the Apollo space mission. In early 1967, three astronauts were killed in a launchpad fire that threatened the cancellation of the program and attempts at a moon landing. After a careful review of the tragedy, the lessons learned were instrumental in restarting the project and promoting better spacecraft design. That in turn led to the successful flight to the moon in 1969.
William Gerstenmaier, a longtime NASA engineer, who now works for Elon Musk’s Space X, observed: “What we really learned from the Apollo fire, in the words of former astronaut Frank Borman, was ‘the failure of imagination.’ We couldn’t imagine a simple test on the pad being that catastrophic. The message to the team is to remember how difficult our business is, the importance of staying focused and using our imaginations to envision what can go wrong.”
Perhaps we have finally overcome our failure of imagination with COVID-19.
Dr. Cory Franklin is a retired intensive care physician. Dr. Robert Weinstein is an infectious disease specialist at Rush University Medical Center.
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