Outsmarting the Next Pandemic

What Covid-19 Can Teach Us

Elizabeth Anne Kirley, Deborah Porter, Elizabeth Anne Kirley, Deborah Porter

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000526967
• Edition: 1
• Topic: Medicina
• Subtopic: Sanità, amministrazione e assistenza pubblica

This book examines the role of law and policy in addressing the public health crisis of COVID-19 and offers reforms that could improve pandemic preparedness for future outbreaks.

Focusing on a number of countries most expected to provide agility and organization in their crisis response – the United States, Canada, Australia, the United Kingdom and Taiwan – the book shows how failures in leadership from governments, executives, and institutions created a vacuum that was quickly filled by naysayers, conspiracy theorists, vaccine hucksters, and fake news generators. Through the key themes of healthcare, leadership, security, and education, the chapters address critical questions: Why have masks become such a polarizing force? How do you self-isolate if you don't have a home? How should equitable triage models for overwhelmed frontline healthcare workers be developed? Can we utilize artificial intelligence to educate the public about manipulated information they access concerning the pandemic? The book was written during the pandemic and weaves in to each chapter vignettes with personal revelations from a broad range of countries, including some also grappling with poverty, war, natural disasters, or revolution.

It will appeal to academics, professionals, and policymakers interested in how law and health policy can converge on solutions for global infectious disease. It is suitable for use in upper-level courses.

PART I Healthcare

1 HOW SMART IS COVID?

Elizabeth Anne Kirley and Deborah Porter

DOI: 10.4324/9781003215769-3

To ask strangers to be smart during a catastrophe might seem an impertinence. To ask colleagues might seem to take advantage. To ask it of yourself is to set yourself up for criticism as too ambitious or a know-it-all.

It has been suggested that the virtue we are looking for to deal with the coronavirus is resilience, not smartness. That notion builds on sister virtues of tenacity, courage, and forbearance. Those qualities have been named in the profuse array of publications on this moment to describe the doers (those involved in governance of infrastructures to keep responses systematic), the sufferers (those who succumb), and the adapters (those who service the sufferers and those who wait and recalibrate). Very little about SARS-CoV-2 is uncontested, however. The non-pharmaceutical interventions of masks, handwashing, and isolation have been proven to bend the viral curve, but without more, such as a vaccine, we keep ourselves at the mercy of a transmutating organism that, as we are learning, can be just as smart as we are.

Law, too, is a non-pharmaceutical intervention. It is a smart response in that it looks for long-term solutions to the uncertainty and chaos global pestilence brings, not to situational cessation of risky behavior. The law’s presence has been central in this disease. As one medicolegal study has calculated, in the first half of 2020 alone, more than 1,000 laws and orders were issued by federal, state, and local authorities in the United States to reduce disease transmission.¹ The study’s inventory includes various regulations that touch our own lives, such as stay-at-home orders, mask mandates, travel restrictions, and more particularized rules for business operations, alcohol sales, tax remittances, curfews, and healthcare.

Ideally, we look to “the right mix, intensity, and enforcement approaches” in our laws that control transmission with the least intrusive and unequitable harms.² That might suffice in autocracies or in smaller, more geopolitically contained societies. For the rest of us, looking to law as a way out of this economic and social limbo has accentuated the pluralistic nature of our lives, not its uniformity. The imposition of laws also inevitably brings ethical questions with their own debates: should we force our children, students, healthcare staff, or essential workers to get vaccinated? With limited oxygen or fentanyl, who gets priority treatment?

Choosing “smart” for our title is a bold act, signifying a hope that we can muster intelligence, embolden creativity in the hunt for solutions, and come out of this pandemic dilemma the wiser: more wary of infectious invaders we cannot see, more understanding of societal inequities that health crises bring, and more compassionate towards those too vulnerable to go it alone. One response to a calamity is to work out a strategy, a game plan. It has been done before, of course, with disaster simulations and next-step playbooks. But we shall get into that later. A question at this point is whether we dust off those how-to scenarios and recalibrate or rewrite them with the knowledge and wisdom we have gained from this communal tragedy.

But first, we must start with …

What we know

We know that COVID kills. It seems to prefer adults, although children have been infected as well, sometimes with medically curious symptoms and side effects.³ So for the virus to land in a country with a higher median age, such as Spain or Italy with age medians of 44 and 47 respectively, is to award it an immediate advantage. In fact, we now know that after the age of 30, the chance of dying if one contracts COVID doubles roughly every eight years.⁴ If we subscribe to the wet-market-in-Wuhan version of events, the virus has invaded an intermediate species, such as a bat, pangolin, or a civet cat that has, in turn, infected a human. That person can begin community spread any time after infection, from a day to two weeks, through airborne organisms or possibly by touching surfaces other humans will then touch.

We don’t know, but some suspect either that the virus has escaped the confines of a biomedical laboratory, is a specimen smarter than its creators, or, like birds that enter your open window, is a serendipitous result of opportune circumstances. Right place, right time. Or for the human patient zero, wrong place and time. Either way, it takes up residence inside millions of people in all countries save a few tiny islands of the world. It can duplicate out of sight, undisturbed, for several days.⁵

In any contest with a killer, a human’s first strategic step is to size up the comparative advantages of the opponent.⁶ That would involve assessing the viral fitness of the coronavirus against the physical fitness of the host; learning the genetic sequencing of the virus considering the patient’s genetic viability; and gauging the pathogen’s ability to transmutate in light of our human inability to do so. Intelligence and inventiveness also enter the calculus, as does the patient’s will to live. A palliative care team from Lausanne, Switzerland, defines the will to live as the knack of existing in the present, of resisting focusing on the future. The team asks, “[D]oes the person, at the present moment, have an existential motivation to live?” That capability is frequently associated with factors such as resilience and quality of life.⁷ Again, resilience is not enough: the viral enemy must be routed and undone for the human to prevail.

In terms of virulence, we are told that the novel coronavirus is not as strong as its predecessor SARS or its cousin MERS.⁸ The new microbe is also about 10,000 times smaller than the width of a human hair⁹ or 5 million times smaller than you or me.¹⁰ So what’s the contest, then? First, the pathogen knows to start its onslaught with the human breath of life: it attacks the epithelial layer of cells covering our throat, airway passages, and our lungs. Our Achilles’ heel, as it were, is the ACE-2 receptor in that epithelial layer of cells that accommodates the spike formation on the novel virus, pairing much like a key fitting a lock. As well as the lungs, we have recently learned that smoking, or being exposed to second-smoke, increases the receptivity of ACE-2 receptors in the lining of our noses and mouths, thereby increasing the entry points into our bodies for the coronavirus.¹¹ With an estimated 1.3 billion tobacco smokers in the world, that strategy seems a sound one for the virus.¹² Once the lungs are infected, the virus can similarly infect most other major organs in the torso.¹³

How we are attacked

That entry technique is only the beginning of the destruction. Once inside, the coronavirus induces the production of proteins,¹⁴ an act that can trigger a massive response from our body’s immune system, known as a cytokine storm. The virus has now highjacked our body. It has been called a tightrope balancing act, with our body trying to rein in that immune response and at the same time using it to fight the virus. Apparently, either process can kill us.¹⁵

At the same time, once activated, the ACE-2 receptors expel a hormone that narrows our blood vessels and increases our blood pressure. One of the risks of that action is heart damage and even a stroke. Medical treatment of the ACE-2 receptor either reduces their number and so reduces the available entry points into our cells or increases the number but confuses the virus. Having entered the lungs and replicated, the new virus then spreads to other vital organs as it continues to replicate.

The novel virus can live without sustenance, outside our body, for up to 17 days, according to a study of infestation aboard the cruise ship Diamond Princess.¹⁶ That floating laboratory has also taught us that 18% of all infected people on the ship had no symptoms, that quarantine could have reduced the rate of infection from about 7% to less than 1%, but that the rate of infection could work in the virus’ favor if we have preexisting vulnerabilities, such as being black or brown in certain societies, being poor, possessing medical conditions, being a smoker, or any combination of those factors.¹⁷

External factors that can help or hinder

Factors outside our bodily invasion could also contribute to the rate of transmission of the virus. Heat and cold factors in the environment have proven to affect the rate of spread. A recent study found that warmer and humid climates might slow transmission of the SARS-CoV-2 virus. Cold and dry weather conditions, on the other hand, facilitate the spread of all coronaviruses.¹⁸ This is a critical factor when choosing which vaccine to use under certain temperature conditions. For example, the Pfizer and BioNTech vaccine uses a novel tool, strands of messenger RNA held within lipid particles, that can degrade at room temperature and so require doses to be frozen at −70°C (−158°F) for transportation and then thawed for use. The doses can be kept in the freezer for five days before they start to degrade. Newer vials of Pfizer, however, can now be stored at 2°C–8°C (35°F–46°F) for up to one month if undiluted and thawed.¹⁹ While that method provides more flexibility and will reduce the former destruction rate of doses, the ideal time between the first and second shots is still 12 weeks, or three months, as particularly recommended for older people by a UK study.²⁰

The Moderna vaccine, also a messenger RNA variety, has a slight edge: it can tolerate a much warmer environment of −20°C (68°F), which is standard for most hospital and pharmacy freezers, and it remains stable at that temperature for up to 30 days.²¹ That difference becomes particularly useful in rural areas and lower-to middle-income countries that lack ultracold freezers or have other vulnerabilities that break the cold chain.²² The fact that Pfizer and Moderna require two shots for highest efficacy is another complicating factor in the effort to encourage uptake by populations and hence reduce our risk of infection. Another vaccine, Johnson & Johnson, does not face those temperature-related challenges and only requires one shot. However, that brand is proving more effective in men as blood-clotting conditions have been diagnosed in a few women as a response to the vaccine.²³ If we...