As the days of the COVID-19 pandemic wear on and we see and learn more about its effects on our society and our economy, I have been thinking more and more about what we will, or should, learn from it. I also have thought a great deal about what we have learned (and sadly, in some cases seemingly unlearned) from previous epidemics and pandemics.
Of course, we are continuing to learn a lot about SARS-CoV-2, the virus that causes COVD-19, its effects on those who become ill, its demographics, and how it spreads.
We have had a lot of experience with contagious respiratory viruses, most of which began with the so-called influenza pandemic of 1918. At the time, we didn’t know anything about viruses, much less that influenza was caused by a virus. There was no treatment, other than supportive care, and of course a vaccine was not a realistic possibility. Military personnel had their throats sprayed with disinfectant as an attempt to prevent infection.1
While there were objections to the wearing of masks, social distancing and limitations on commercial activity in 1918, it seems clear in retrospect that these measures probably had some real benefit. And it seems clear today in the case of the current pandemic. That said, there are enormous pressures to “re-open” the country, even though, so far, we have already seen some alarming results in some areas where enforcement has been lax, or where restrictions have been eased to accommodate school openings.
Limitations on business, sports, worship and other activities that traditionally involve large gatherings of people have led to profound economic consequences2 – both anticipated and unanticipated, viz., millions struggling to afford basic living expenses, despite relatively paltry “stimulus” payments, as contrasted with huge profits in some sectors of big business, in part also related to “stimulus” packages. Then there are the enormous psychological consequences to individuals and families, including domestic violence, increased substance abuse, depression and the potential for suicide. Job losses also have resulted in loss of health insurance for many. All of these phenomena have exposed and amplified already existing fault lines in our society and economy: pre-pandemic increasing income and wealth inequality, lack of universal health care coverage and other safety nets, to name a few. And we should have already had in place a working infrastructure integrating points of care and public health agencies with adequate protections of personal privacy.
The AIDS pandemic presented somewhat different problems, but also similar ones. Even when it became obvious that the bathhouses needed to be closed, there was tremendous resistance, not just from the owners, who had a great economic interest in keeping them open, but from large segments of the gay community who didn’t want their new sexual liberation infringed upon. The facts that the causative agent had not yet been identified and the mode of transmission (although highly suspected) was not clearly identified early on (perhaps in part due to the relatively long incubation period) gave life to this resistance at tremendous cost in human lives.3 Yet today we see ongoing resistance to mask wearing and limitations on social gatherings, even though the mode of virus transmission in COVID-19 is fairly well understood.
A big part of this resistance is due to (I believe) to a mixture of denial and misguided fear of loss of civil liberties, and the failure of people to understand that there are certain situations where a temporary restriction on freedom to which they have become accustomed has value and will only be temporary or at least quite circumscribed so as to minimize disease transmission. Unfortunately, our political climate has allowed and even encouraged this mindset to become an important campaign issue.
As I write this piece, there are well over 100 entities working hard, most with government and/or private venture capital funding, to develop a vaccine, and there is tremendous pressure by the White House to have an effective vaccine before the November elections. At present, there are nine vaccines in phase 3 trials.4 There are accusations of Chinese and Russian hackers5 trying to steal research strategies from U.S. sites. Excuse me, but wouldn’t it be smarter, cheaper, and even safer to share information being developed among a few designated research centers world-wide, perhaps each pursuing different strategies? And it is not even yet clear if an effective vaccine will be developed any time in the near future. Witness the decades-long and so far, largely unsuccessful struggle to develop an HIV vaccine.
The hunt for a vaccine has turned into a political football. And credit for developing an effective vaccine almost seems like an end in itself – a kind of prize in the form of accumulating wealth and/or prestige for whomever wins the race. We witnessed the parallel development of the Salk and Sabin6 vaccines in the 1950s, with each having certain advantages and disadvantages,7 and the subsequent smoldering feud between the two investigators.8 Neither of these men, though, nor their institutions attempted to patent their discoveries. That was probably a good thing, but it was for reasons that are complex, and probably not primarily altruistic, as is widely believed.9 We also witnessed the battle between Luc Montagnier at the Pasteur Institute in France and Robert Gallo of the National Cancer Institute for recognition of who discovered the HIV virus. In the spirit of cooperation, Montagnier had sent the LAV virus (which he correctly believed to be the cause of AIDS) to Gallo in September of 1983, and soon after, Gallo announced that he had discovered the AIDS virus, which he termed HTLV-III,10 but in fact was almost identical to LAV. In an extraordinary chain of events that followed, a lawsuit over patents rights culminated in a settlement, ironically mediated in part by Jonas Salk, and punctuated by a signing between Presidents Reagan and Chirac in which Montagnier and Gallo were named “co-discoverers” of the virus that caused AIDS, henceforth, and as a result of the settlement, known as HIV.
Not to be outdone by the race for a vaccine in its high political profile, are the efforts to produce a treatment. One can hardly pick up a newspaper and not read about the possibility of a “breakthrough” in therapy, from convalescent antibodies, to antivirals, to disinfectants. So far, the only drug (a corticosteroid) shown to be of clear benefit in certain cases is one that has been around for decades and can be produced cheaply. It is perhaps significant that the studies that demonstrated its effectiveness were a large-scale, international cooperative effort,11 and an earlier study in the United Kingdom that was facilitated by a health care and public health infrastructure that is integral to its single payer health care financing system.12 It’s anybody’s guess whether dreams of fame and fortune on the part of individual, institutional, or commercial researchers working separately and in secret will inhibit or stimulate the earliest possible new therapeutic agents when the possibility of lucrative patents is in the mix.
Some have even advocated the approach of letting the disease run free with the expectation of so-called “herd immunity.” This is a dangerous approach for a couple of reasons: It is not clear for how long survivors of the infection will have lasting immunity; and the likely certain massive increases in the incidence of COVID-19 will dangerously strain an already overburdened health care system and the professionals who staff it.
It seems clear from what we have learned already that international cooperation, including the sharing of research data, in the search for therapies and vaccines should be expanded and not contracted, and that public money – and not the need to acquire intellectual property – should be the driving force in such research. Restrictions on behavior and personal liberties, highly tailored (in a scientifically validated way) to suit public health needs are necessary, and some of these restrictions may become a permanent part of our lives. We also have learned that health care financing in the U.S. needs an overhaul that may be viewed as radical in our own country but is in fact rather conservative when viewed through the lens of virtually every other developed country in the world. We also need to take steps to alleviate increasingly obscene wealth and income disparities – again, a conservative idea from the perspective of the mid-twentieth century. The idea of a universal basic income and other increases in the public safety net also should be given serious consideration if we are to avoid the epidemic of hunger, evictions, and catastrophic loss of personal wealth, the worst of which we may not yet have seen. There is a real concern that a “return to normal,” if it occurs, will lead us to forget about some of these measures, just as we did in abandoning the contingency plans developed during the Bush and Obama administrations, that included international cooperation in surveillance and public health preventive measures including preparedness and response.13
The pandemic has taught us, I hope, that we have much to do to protect our public and personal health, and more emphasis and better funding of our public health infrastructure is going to be necessary. At the very least, we should learn that “toughing it out” until there is a vaccine or until the pandemic (may or may not) end and then going “back to normal” simply will not do.
Kolata G, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It, Simon and Shuster, New York, 1999.
Many that will last for years, like ballooning credit card debt with its exorbitant interest rates, and the pre-mature tapping of pensions, including the penalties therefor.
Shilts R, And The Band Played On, St, Martins Griffin, New York 1987, p. 593.
Mankiw N, A Vaccine Subsidy Licks 2 Crises With One Shot, New York Times, 9/13/20.
Barnes J and Venutolo-Mantovani M, Spies Battling To Gain Edge On a Vaccine, New York Times, 9/6/20, https://www.nytimes.com/2020/09/05/us/politics/coronavirus-vaccine-espionage.html.
Sever J, Remembering Albert Sabin and the vaccine that changed the world, https://www.statnews.com/2018/03/01/albert-sabin-polio-vaccine.
Why do we still use the Sabin poliovirus vaccine?, virology blog, 9/10/15, https://www.virology.ws/2015/09/10/why-do-we-still-use-sabin-poliovirus-vaccine/
Reddick J, Polio: The Salk-Sabin Rivalry, Pulitzer Center, 5/11/15, https://pulitzercenter.org/reporting/polio-salk-sabin-rivalry
The Real Reason Why Salk Refused to Patent the Polio Vaccine, https://www.bio.org/blogs/real-reason-why-salk-refused-patent-polio-vaccine.
Earlier work by Gallo had led to the discovery of the HTLV-I and HTLV-II viruses that were really quite different from the AIDS virus.
Writing Committee for the REMAP-CAP Investigators, Effect of Hydrocortisone on Mortality and Organ Support in Patients with Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial, JAMA, Published online September 2, 2020 doi:10.1001/jama.2020.17022, https://jamanetwork.com/journals/jama/fullarticle/2770278.
Kupferschmidt, One U.K. Trial is transforming COVID-19 treatment. Why haven’t others delivered more results?, Science, July 2, 2020, https://www.sciencemag.org/news/2020/07/one-uk-trial-transforming-covid-19-treatment-why-haven-t-others-delivered-more-results.
Homeland Security Council, National Strategy for Pandemic Influenza Implementation Plan, https://georgewbush-whitehouse.archives.gov/homeland/pandemic-influenza-implementation.html; Pandemic Prediction and Forecasting Science and Technology Working Group of the National Science and Technology Council, Towards Epidemic Prediction: Federal Efforts and Opportunities in Outbreak Modeling, 2016, https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/NSTC/towards_epidemic_prediction-federal_efforts_and_opportunities.pdf.