Saturday, March 21, 2020

The Most Predicted Global Crisis of the 21st Century

Credit Wikipedia


This weekend, as the world slips deeper into a pandemic winter of unknown duration - and nations desperately try to cobble together some kind of coherent response - the sobering fact is this critical  junction in history has been predicted for decades.
Not so much by this humble blogger, but by thousands of scientists, researchers, emergency planners, and yes . . . even the bean counters at Lloyds of London. 
While everyone knew that another pandemic was `inevitable', and that it was just a matter of time, our politicians and leaders somehow convinced themselves that - if it happens, it won't be as bad as predicted.  And even if it is, it probably won't happen on my watch. 
And so we've let decades go by without seriously preparing for this day. 
Although our current crop of leaders will undoubtedly take the bulk of the blame, this has been a systemic failure of long duration by governments all around the world. And because of that, we don't have the PPEs, the ventilators, or the hospital and public health surge capacity that we so desperately need right now. 
If I sound just a bit angry over this. I am.  
I get emails from all around the country from nurses telling me they either don't have N95 respirators, or have so few they will have to reuse them.  Some are even being told not to wear surgical masks - not because they don't help - but because their facilities don't have enough of them. 

We've spent billions of dollars on high-tech `pandemic solutions', but we've neglected the most basic of preps. Personal Protective Equipment (PPEs) for those on the front line.  And it isn't as if this shortage wasn't widely anticipated.

More than a decade ago, during the opening weeks of the 2009 H1N1 pandemic - many hospitals had an inadequate supply of PPEs on hand - and that led to a number of protests (see Nurses Protest Lack Of PPE’s , Report: Nurses File Complaint Over Lack Of PPE).

  • In some cases nurses reported they were issued only one N95 mask to be used for an entire 8 hour shift, and told to don it only when in direct contact with a potentially infected patient.
  • In other venues, HCWs were issued surgical masks in lieu of N95s, despite the recommendation at the time from the CDC that N95 masks were the preferred level of protection.
Our Strategic National Stockpile reportedly contains more than 100 million N95 and surgical masks (see Caught With Our Masks Down), but more than 10 years ago the HHS estimated the nation would need 30 billion masks (27 billion surgical, 5 Billion N95) to deal with a major pandemic (see Time Magazine A New Pandemic Fear: A Shortage of Surgical Masks).
We have less than 1% of what we would require during a severe pandemic.  And since we buy most of our PPEs from other countries, our ability to replenish supplies in the middle of a pandemic is in serious doubt.
In late 2011 a study published in the journal Infection Control and Hospital Epidemiology showed that the inadequate use of masks by healthcare workers during the opening days of the 2009 pandemic put them at greater risk of contracting the virus (and spreading it to patients).

Still, nobody did anything about it.  Sure, many of our leaders talked about the problem.  But they assumed there would be time, and besides, there were always `sexier' things to spend money on.  Preparedness is boring. 
As a result, some HCWs are going to die for a lack of proper PPEs (including N95s, gowns, gloves, and face shields) during this pandemic, while others may find it too risky to work without them (see  HCWs Willingness To Work During A Pandemic)
A problem which has been predicted - and discussed ad nauseam - for more than a decade.  But largely ignored. 
In Italy, a shortage of ICU beds and ventilators - and specialized HCWS to use them -  is believed largely responsible for their stunning number of deaths from COVID-19 over the past 3 weeks.  Yesterday Italy reported over 600 new deaths, or about 1 every 4 minutes.

Once again, this was predicted, and rather than invest in more ventilators - countries, including the United States - decided instead to create a triage plan on how to allocate vents (ie. decide who will live, and who will die)  during a pandemic. 
Harsh?  Perhaps, but true. 
The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) recently published guidelines for doctors to use in triaging patients during this emergency, but we've also published similar guidelines in the United States.

Three years ago, in Pandemic Realities: Ventilator Shortages, we looked at a study of the number of ventilators and ICU beds available in the United States, that envisioned a `severe scenario' -  albeit, one likely less severe than we are seeing with COVID-19 - that warned:
. . . Without the unlikely rapid addition of 35,000 to 60,500 ventilators (and trained staff, oxygen, drugs, and electricity to run them) - 200,000 to 300,000 Americans that might otherwise be saved, would die for the lack of ventilator resources.
The CDC's 2011 document Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency spends 27 pages looking at a myriad of legal and ethical considerations, but concludes that `policy decisions need to be set and implemented by the responsible public health officials.'
Is it possible to have on hand enough ventilators to cover every possible pandemic contingency?   Of course not. 
But a even a modest increase in our National Strategic Stockpile over the past 10 years would be paying big dividends today. 
Over the next few months, it won't just be N95s, and ventilators that we run short of. Almost all of the IV equipment, drugs, and medical devices used in our hospitals - all of which are produced in other countries - are going to become precious commodities. 
Fifteen years ago Dr. Michael Osterholm, director of CIDRAP, priescently likened a severe pandemic to an 18-month global blizzard, where nearly everything is shut down. Many will find themselves without a paycheck, either due to their refusal to work and risk exposure, or because their jobs are simply no longer available (see Baby, it's Cold Outside).
Pretty much what we are seeing unfold around the world today. 
More recently, in his 2017 book Deadliest Enemy (see my Review: Deadliest Enemy: Our War Against Killer Germs), Dr. Osterholm revisits the idea of our JIT economy, and writes:
Ironically, the ways we have organized the modern world for efficiency, economic development, and for enhanced lifestyle -- the largely successful attempts to transform the planet into a global village -- have made us more susceptible to the effects of infectious disease than we were in 1918.
And the more sophisticated, complex, and technologically integrated the world becomes, the more vulnerable we will be to one disastrous element devastating the entire system.

In 2008, in Lloyd's: A Pandemic Is Inevitable and in The Lloyds Report: A Closer Lookwe looked at their predictions for the next pandemic. 

1. A PANDEMIC IS INEVITABLE With historic recurrence rates of 30-50 years it is prudent to assume that a pandemic will occur at some point in the future. The severity of such events is highly variable; some estimates suggest the most severe to date, in 1918, killed up to 100m. Many pandemics affect the old and young; but some (including the 1918 event) can, perversely, affect the most healthy.

2. 1918 MAY NOT BE THE WORST CASE It is certainly true that the 1918 event was extreme relative to other pandemics in history. However many published “worst case” scenarios take 1918 as a base. There is a danger that we over optimise to this one scenario. There are other forms of pandemic than influenza, some have higher case mortality. Pandemic preparedness should consider a range of scenarios to ensure plans are appropriately flexible.

3. ECONOMIC IMPACTS MAY BE SIGNIFICANT A repeat of the 1918 event is expected to cause a global recession with estimated impacts ranging from 1% to 10% of global GDP. Most industries will be affected, some more than others. In particular, industries with significant face to face contact will be impacted significantly. Insurers investment assets may be affected depending on the mix held. Wider economic and social effects may lead to secondary forms of loss for insurers.

4. MANY INSURANCE LOSSES ARE POSSIBLE For some classes of business such as, life and health it is clear that the impact will be adverse. For other classes of business it is less clear but many forms of liability covers including general liability, D&O, Medical Malpractice as well as specific products offering business interruption and event cancellation could be triggered. Inner limits for Pandemic losses (vertical and sideways) may help to contain exposure.

5. SECONDARY IMPACTS MAY OCCUR Events causing significant global and societal turmoil can give rise to considerable secondary impacts. It is far from clear which of these, if any, would occur; but for resilience planning purposes it is worth considering them. For example the lawlessness experienced in New Orleans after Katrina could be repeated if police services are affected. Traditional claims such as fire loss may be exacerbated if fire emergency services have depleted efficiency and if tradesmen are in short supply.
I could list hundreds more reports, studys, table top exercises ( EVENT 201, CLADE X), and clarion calls (WHO/World Bank GPMB Pandemic Report : `A World At Risk) - all warning of our vulnerability to a severe pandemic - and urging greater preparedness.
And while some progress has been made, it hasn't been near enough. 
When this COVID-19 crisis is over - after we mourn our losses and start to put society back together again - I hope we remember that we had plenty of warning, and countless opportunities to blunt its impact over the past 15 years.

We simply had other priorities.  We put most of our time and resources into more immediately gratifying projects, and now find ourselves badly unprepared.  While we can't undo that legacy of inaction, we can change it going forward.
We can decide to treat pandemic - and `All Threats' - preparedness as the national security issue that it is.  We can vow never to be caught short, and unprepared again. 
Because this won't be the last time we are tested.