The Biden administration is proposing wide ranging infrastructure legislation. The bill includes funding for transportation, communications, energy, workforce development, emergency management and response capabilities, as well as other activities related to supporting the U.S. economy. The cost of the proposed legislation is about $2 trillion over 15 years. While most agree that investing in roads, bridges, electricity grids, communications systems, and other physical infrastructure is essential for a fully productive economy, other systems and resources such as workforce training and population health are equally essential for productivity. Everything that supports economic production is a form of infrastructure. By addressing the range of systems and resources that enable an economy to function and be resilient in the face of the various challenges that inevitably arise, this legislation can help restore and strengthen the economy to thrive in the future.
The U.S. economy is complex. It has supply chains and production processes that reach around the globe. Additionally it needs to be responsive to ever changing markets. The U.S. economy and society have experienced fundamental changes since the last time the federal government undertook infrastructure building. The economy is much more dependent on high speed communications and information processing to support current manufacturing requirements such as “just in time” delivery of intermediate goods and inventory control. Investments in infrastructure such as transportation, communications/information, and power generation will make the economy more efficient. Investments in the appropriate stewardship of important resources such as clean air and water will allow the avoidance of paying for remediation in the future. Investment in emergency management and response capabilities will mitigate the impact of natural disasters or other unforeseen events and facilitate a more rapid recovery.
Societal changes have also caused changes in the economy over time. For example, the role of women has transitioned from a focus on unpaid family care-giving to being integrated into every aspect of the workforce. One result has been the emergence of a care-giving sector for children and elders so women are enabled to participate in the wage economy. There have been demographic changes as well, especially in the trend to smaller families with fewer children. Without more entrants into the U.S. labor force, it will not be possible to sustain economic growth and the financial integrity of the social security retirement system. The current economy incorporates such rapid technological changes that workers need to be able to learn and incorporate new skills within short time-frames. This has created a new requirement for ongoing post-secondary training throughout the life span. Assuring all Americans have access and are equipped to participate and contribute to the economy to the maximum extent of their talents and abilities and no one is limited by bias or discrimination optimizes the productivity of the entire labor force. Population health is another aspect of infrastructure. The fact that the U.S. ranking for most health indicators continues to decline remains a hindrance to economic competitiveness, primarily as lost labor productivity and increased healthcare costs.
All of the sectors included in the proposed legislation are critical components of the current U.S. economy. Federal investment in all aspects of infrastructure will have a positive impact on the economy and future competitiveness.
Although the Pfizer-BioNTech and Moderna COVID-19 vaccines were developed in less than one year, the underlying technology of mRNA vaccines actually dates back to the early 2000s when medical researchers began to formulate a vaccine to treat cancer. As is the case with virus infected cells, cancer cells display antigens on their cell surfaces that are unique to the disease. The immune system can be “trained” to recognize these antigens with a vaccine and kill the affected cells. Scientists reasoned that if they could create a cancer vaccine, it would only target diseased cells and leave the surrounding healthy cells and organs unaffected. This approach would be less damaging to the body than radiation or chemotherapy, which can cause harm to overall health. After some initial experiments, researchers decided to focus their research efforts to develop an mRNA vaccine because it offered advantages that other therapeutic approaches lacked. Several experimental mRNA vaccines have also been developed in recent years for infectious diseases, including Zika, influenza and rabies. The research for mRNA vaccines has demonstrated the products can be safely administered, easily formulated, and manufactured in large quantities
Among the specific advantages of mRNA vaccine technology compared to more traditional vaccine development approaches are the following. First, mRNA proteins can be synthesized in a laboratory, which means the chemical and physical structure of the desired antigen could be manufactured with a high degree of accuracy to correspond to the antigen of interest. Secondly, because of the characteristics of the vaccine mRNA and how it interacts with living cells, there is no possibility of causing any unintended genetic mutations. In fact, the characteristics of the vaccine mRNA are such that it does not enter the cell nucleus, which is where the cellular DNA genetic code exists. Thirdly, the mRNA can be packaged so that it could be easily absorbed into cells (but not the nucleus), perform the necessary function of replicating the antigen, and then degrade as part of normal cellular processes. Lastly, enveloping the mRNA inside a lipid (fat) carrier has proven to be safe to administer. An additional advantage is that the mRNA can be quickly modified to match any antigen changes, which is important since coronaviruses are RNA viruses and prone to rapid mutation.
The mRNA cancer therapy proved to be effective in targeting and destroying cancer cells throughout the body and extended survival for those patients who were treated. After the SARS-CoV-2 coronavirus emerged in late 2019, scientists decided to translate the mRNA vaccine technology in an effort to address the pandemic and resulting social and economic crisis. While health authorities will continue to monitor vaccine recipients for adverse events and long-term efficacy, the vaccine has provided a way to bring the pandemic under control and a return to a more normal life.
February 15, 2021
The arrival of two COVID-19 vaccines authorized for emergency use in the United States is the most significant positive development since the pandemic emerged about a year ago. The U.S. Centers for Disease Control and Prevention (CDC) deployment protocol focuses on two groups who are at greatest risk of illness from exposure to the SARS C0V-2 virus, healthcare personnel and long-term care residents are slated to receive the first doses of a limited supply. Healthcare workers face constant exposure to the virus as they treat COVID-19 patients and long-term care residents are a group that experience the worst outcomes after infection. While a significant reduction COVID-19 mortality is expected for vaccinated persons, the disease will likely continue to continue its spread among other groups and public health measures of mask wearing, physical distancing, and enhanced hand washing remain essential to limit illness and death for everyone else. Notably, healthcare providers and long-term care residents comprise about 24 million people, or only about seven percent of the U.S. population. This percentage is insufficient to control the disease using vaccination alone.
There are multiple challenges facing health officials as they distribute the COVID-19 vaccine but among the most consequential are the logistics of administering doses to individuals. The Pfizer-BioNTech vaccine requires ultra-cold storage and many of the point-of-care healthcare facilities participating in the vaccination drive do not have the equipment to store the vaccine for more than a few hours. Once the Pfizer-BioNTech vaccine is thawed and prepared for use, it must be injected within six hours or discarded. The temperature requirements of the Moderna vaccine are logistically simpler since it can be stored frozen in commonly available medical refrigeration equipment. While the thawed vaccine can only sit at room temperatures for a short period of time before it is spoiled, the thawed but still sealed vaccine vials can remain refrigerated for later use up to the expiration date. It is Imperative, then, that vaccine recipients be in place for the limited time the vaccine has reached the temperature for injection. If insufficient numbers of recipients are not in place during this short timeframe, critical vaccine doses could be lost.
The numbers of new SARS-Cov-2 infections and deaths spiked during December 2020, most likely due to increased interactions among susceptible [i]persons during Thanksgiving holiday celebrations. A similar pattern is emerging now after the year-end holidays. According to the U.S. Department of Transportation Bureau of Transportation Statics (BTS), trips between 50 and 500 miles during Thanksgiving week increased this year by 46.7 million over last year while trips exceeding 500 miles decreased by 3.5 million. The number of COVID-19 hospitalizations reached unprecedented numbers during the first week of January. Holiday travel, the increased transmissibility of the new SARS-CoV-2 variants, and the ever increasing case counts are placing emergency critical care under increasing strain. It is highly likely that demand for health resources will exceed availability and difficult decisions about treatment will become necessary. Such decisions will not only affect treatment of COVID-19 patients but all patient treatment because the number of highly trained medical personnel is constrained.
A newly discovered variant of SARS CoV-2, the so-called U.K. (United Kingdom) variant because it was initially identified there, seems to be more transmissible. It is unclear if this increased transmissibility is due to ability to more easily bind to human cells, faster replication once infection is established, or some other characteristic, but it does spread more easily within communities. A second new variant, the so-called South Africa variant because it was first identified in that country, has also begun to circulate. It is being investigated to identify specific distinguishing characteristics that affect how it transmits within communities. While available information suggests the currently available vaccines will still work against these new variants, the challenge will be for the vaccine program to keep up with an increased number of new cases.
[i] Department of Transportation Bureau of Transportation Statics (BTS) available at https://www.bts.gov/data-spotlight/thanksgiving-travel-long-distance-trips-are-up on January 5, 2021.
The development of the Pfizer-BioNTech and Moderna COVID-19 vaccines during November 2020 is clearly good news. Early clinical trial data indicates the effectiveness of these vaccines for preventing serious disease is over 90 % and no significant safety issues have been noted. It must be stated, however, that there is insufficient data to address the questions of the length of the immunity conferred by the vaccine and whether successful vaccination will prevent someone from spreading the disease to others. These questions are critical for planning the public health policies for disease prevention during the period between vaccine introduction and effectively controlling COVID-19. During the interim period, efforts to prevent disease spread must remain in place to prevent a resurgence of the pandemic.
The measure of effectiveness for the vaccine clinical trials were the prevention of serious disease or death and based on the observed data the vaccines prevented that outcome for more than 90 % of the participants who received them. Determining the length of immunity requires monitoring the study participants over an extended time and measuring the longevity of antibodies and other immune system components. Given the trials were only initiated several months ago, more time is needed to answer that question. Determining if the vaccine prevents both serious disease and disease transmission also requires long-term data collection. The critical issue is whether the vaccine successfully prevented any disease spread from occurring between vaccine recipients and others. Answering this question requires identifying vaccine participants who were exposed to the SARS-CoV-2 virus after vaccination and determining if they transmitted the infection to someone else. Since less than 10 percent of the vaccine recipients became ill with the disease, there is insufficient data to ascertain if anyone who did not display symptoms but was nevertheless infected went on to spread the disease. We have already observed that the SARS-CoV-2 virus can be transmitted by people who are asymptomatic so this is a very important issue for public health planning.
All of this means until there are definitive answers for these questions, preventive measures such as mask-wearing, social distancing and hand-washing will be necessary to ensure COVID-19 does not continue to spread. While a successful vaccine is a great achievement, it will not allow an immediate return to interacting in the same ways as before COVID-19.
Two unexpected anomalies have emerged since early July 2020 with respect to the continuing COVID-19 pandemic. First, the emergence of 97,000 cases among children provided evidence children can become infected, though they may not exhibit serious symptoms of the disease. As we approach the fall and the resumption of primary and secondary education, this poses serious challenges for educators as they plan instruction for the upcoming academic year. Second, the surge in cases, especially in regions and less urban areas that had not seen significant numbers of people afflicted with COVID-19, shows smaller communities are as vulnerable to the spread of COVID-19 as the original outbreak hotspots on the east and west coasts. These two events are reasons why it is critical to expand testing and fully implement preventive measures in all communities to reduce the spread of disease. The management of the pandemic as the summer ends and we move toward the height of influenza season will profoundly affect how and if pre-pandemic levels of economic activity can be achieved in the near-term. It could also have an impact on the costs of the pandemic.
A sharp rise in cases and deaths has been noted recently, often in communities with limited resources and among populations who face significant health disparities and suffer disproportionately with serious illness. When the SARS CoV-2 virus first arrived in the United States in early 2020, the greater New York City region, Seattle, and large metropolitan areas of California were most immediately and severely affected. Once the virus spread to other large cities such as Chicago, state governments began to implement stay-at-home orders and closed all but essential businesses; schools were also closed. This had the effect of reducing the spread of disease, but also precipitated a severe economic decline. By the early summer, the rapid rate of COVID-19 spread had abated in the early hot spots and those areas which had not seen a large number cases began loosening restrictions and re-opening businesses. The two months in which the restrictions limited non-essential commerce created a “pent up” demand for a return to more normal economic and social activities. The arrival of warmer weather and the traditional vacation travel season led to many people to abandon precautionary measures. The surge in the number of new COVID-19 cases began shortly after the Memorial Day holiday and accelerated through the Independence Day holiday. Retrospective analysis of COVID-19 spread since the early summer indicates much of the spread can be traced to clusters of people interacting in close proximity. Anecdotally, there are numerous reports and photographs of crowded events preceding a local spike in cases. Additionally, ongoing research on the pathology of SARS-CoV-2 infection found that a large number of persons, both adults and children, have asymptomatic infections. This complicates the identification of infected people and they unknowingly infect others. Some communities have re-imposed some restrictions in an effort to regain control over COVID-19 spread. However, with more than five million confirmed infections and likely a large number of asymptomatic ones, it will be extremely challenging to limit further spread.
The combination of child susceptibility and the absence of symptoms during infection could drive a significant surge of cases after schools re-open. Without effective diagnostic testing, it is impossible to know if students are infected and at risk of spreading the disease. While the children may not be sick enough to require treatment or hospitalization, without continuous surveillance testing, these children could become silent spreaders of disease to older family members who are more likely to suffer severe effects of COVID-19 disease. The essential elements of controlling the disease are identifying cases and preventing those cases from spreading it to others in all school settings.
Another significant related challenge of SARS C0V-2 virus infection is long-term effects are not yet well understood. The eight months that COVID-19 has been recognized is not long enough to collect sufficient data for an accurate assessment. However, anecdotal reporting provides important evidence that the long-term effects are significant. Among adults, prolonged lung damage, heart, kidney and neurological damage from blood clotting, and cognitive decline were observed. In some instances, these effects were observed in patients who did not have severe acute disease. Children who experience a Kawasaki-like inflammatory syndrome during the acute phase of COVID-19 infection may also experience long-term effects. As more data is gathered from COVID-19 survivors, still other medical issues may be discovered. At a minimum, patients experiencing prolonged symptoms may be prevented from returning to their normal activities, thus causing economic losses and social consequences. In addition, those patients who experience post-infection cognitive or neurological symptoms will also incur additional medical and rehabilitation costs. The costs of long-term management of these effects could prove expensive. Again, the best strategy for reducing illness, death, and potential future lingering after-effects is identifying cases and preventing further disease spread.
Re-opening schools for in person instruction and businesses for pre-pandemic economic activity in the absence of effective disease transmission control measures would trigger a return to the crisis experienced during the early days of the pandemic. What is required to resume many pre-pandemic activities safely everywhere is to follow the public health recommendations of hand hygiene, masks, crowd avoidance, and social distancing and make the investments that will mitigate COVID-19 spread including physical barriers to block droplets, sufficient diagnostic and surveillance testing, effective contact tracing, and modifying interior ventilation to improve air exchange as required. It will not prevent all deaths, but it will reduce the massive toll of illness that has occurred during 2020 as well as the additional costs associated with addressing the long-term effects of disease. Some of these mitigation measures will also have the advantage of reducing the health consequences of seasonal influenza and other respiratory infections.
During the seven day period ending on June 17, ten states reported a spike in the number of reported COVID-19 cases in the United States. These states were North Carolina, South Carolina, Georgia, Florida, Alabama, Wisconsin, Illinois, Texas, Arizona, and California. Six of these states: North Carolina, Georgia, Florida, Illinois, Texas, and California, have large populations of African Americans. African Americans Latinos, and indigenous Americans experience a variety of health disparities that have made the impact of COVID-19 much worse for them on a population basis than for Caucasians. While all of the reasons why these states have experienced significant increases in the number of COVID-19 cases are not known, increased interactions among people after various states reduced stay-at-home restrictions, and decreased adherence to social distancing and mask wearing are likely to have played a role. Additionally, clinical research indicates some disease transmission occurs when no symptoms are present, so people spread the virus without knowing they are infected. The current challenge is to reduce disease spread, especially among African Americans, and other people of color, who have been shown to be more vulnerable to severe disease. Data from the U.S. Department of Health and Human Services report 55.5 percent of non-Hispanic blacks in comparison to 75.4 percent of non-Hispanic Caucasians used private health insurance during 2017;[i]9.9 percent of non-Hispanic blacks in comparison to 5.9 percent of non-Hispanic Caucasians were uninsured.[ii]Access to health insurance and, by extension healthcare, is one of several significant health disparities that contribute to a higher rate of chronic disease among African Americans. Chronic diseases are associated with more severe COVID-19 outcomes. Similar disparities exist for other marginalized groups.
The SARS-CoV-2 virus will not be eliminated in the near-term. Even if a successful vaccine is developed it requires protection of more than 70 percent of the world’s population to eliminate the disease. Producing enough vaccine doses for more than seven billion people will likely cause bottlenecks which will take time to resolve; perhaps the most significant of these will be the limited vaccine production capacity. Universally applied mitigation strategies that should be implemented to minimize the adverse effects on disadvantaged communities include more diagnostic testing to identify cases and quarantine of newly infected persons to interrupt transmission within populations. Antibody testing in specific geographic areas is needed to determine and understand the how prevalent COVID-19 disease is in specific communities. Improved healthcare access is needed to reduce health conditions that adversely affect the course of disease and provide early treatment to limit health deterioration if infection occurs. Also, more personal protection equipment (PPE) is needed for all workers who have essential and public facing jobs that place them at greater risk for virus exposure.
In the absence of continuation of the strict lockdown measures that allowed the trajectory of the COVID-19 pandemic to be reduced, we can expect that the number of infected persons will continue to increase. While the lockdown prevented the U.S. health system from being overwhelmed, it did not alter the infectiousness of the virus and thus, it continues to spread. The maintenance of social distancing and mask wearing can curb virus exposure and transmission. These measures, especially in those areas having a spike in the number of cases, along with the mitigation strategies mentioned above, and research to find effective treatments and vaccines will improve outcomes for everyone.
[i]See: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61
[ii] Op.cit at 1.
COVID-19 has sparked the most profound economic crisis unrelated to armed conflict since the 1918 influenza pandemic. Fortunately, there is now far more scientific understanding of disease dynamics to inform the best practices for returning to normal activity. Following are some important considerations for a return to the interactions that underpin the economy.
· Implementing comprehensive disease surveillance. This includes adequate clinical testing to provide an accurate knowledge of who and where newly infected persons are and tracing the contacts of confirmed cases. In the United States, this required level of testing has not been reached. Additionally, it is critical to know who has immunity by testing for antibodies. Anecdotal data suggests there is a significant percentage of infections that are not accompanied by symptoms of disease. Antibody tests are essential for anyone returning to a work situation that precludes the possibility of social distancing.
· Collecting and analyzing virus samples over time. This includes genetic analysis of samples both within communities as well as samples from distant places to provide an understanding of how the virus is mutating. The SARS CoV-2 is a pathogen that can mutate quickly and some mutations directly affect whether a recovered person can effectively fight a new exposure to the virus. This is the reason why health officials monitor new influenza virus strains every year. As with seasonal influenza, if the virus mutates in specific ways, it is possible to acquire a new infection even though one has suffered a previous infection.
· Analyzing clinical data to ascertain why certain characteristics predispose some people to more severe disease. Based on the case reporting, we know that African Americans, Hispanics, and those with pre-existing chronic diseases have much higher rates of death and severe illness than others. A comprehensive analysis of patient health status will help protect those who are most vulnerable to serious disease after exposure to COVID-19.
The consequences of the COVID-19 pandemic have caused more economic dislocation than any event other than war since the beginning of industrial age. However, a failure to thoughtfully and adequately plan for a return to economic production will ultimately be more costly in both lives and treasure.
The COVID-19 virus has spread widely, both inside China and to the rest of the world. One possible transmission pathway that should be considered as part of the ongoing epidemiological investigation is the clandestine movement of wildlife and people across international borders.
Illicit international wildlife trade has been documented to occur and China is actively involved in the sale of wildlife in its live animal markets. Other coronavirus outbreaks, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were traced to a wildlife source when those diseases “jumped” to infect humans. A second possibility is the undocumented movement of persons across borders through human trafficking, the illicit drug trade, or other criminal activity. Human trafficking is recognized as a serious problem with many victims being trafficked to provide labor. The illicit drug trade and trade in other controlled products continues to occur because it is highly profitable.
COVID-19 infection has become a significant issue of international concern, both due to its impact on public health as well as on international economics. Investigating how the virus is moving from its source in China should include all possibilities because a thorough understanding of transmission dynamics is essential to controlling the disease.
The exposure to a novel coronavirus in Wuhan, China triggered an outbreak of human disease during December 2019. As of February 10, 2020 there were over 40,000 confirmed cases with over 900 deaths.[i]Genetic sequencing of the novel coronavirus shows it is related to both the severe acute respiratory syndrome (SARS) virus and the Middle East respiratory syndrome (MERS) virus,[ii]which caused human outbreaks in China during 2002 and in the Middle East during 2012. All three coronaviruses have a zoonotic origin. Coronaviruses exist in a variety of wildlife species and the current outbreak is believed to have jumped from animals to humans. In light of the current situation and a history of other coronavirus diseases jumping to humans, the Chinese government ordered the temporary closure of live wildlife markets as a disease control measure. Such markets pose an identifiable risk to human health and the permanent closure of live wildlife markets should be considered.
Close proximity interactions between non-domestic animals of varying species in live markets pose significant human health risks. They provide an opportunity for the spread of infectious diseases between the caged animals and humans who visit the markets. Among the post-outbreak findings from the SARS and MERS outbreaks was that the viruses adapted to humans once it spread within communities. Although much remains uncertain about the current coronavirus outbreak, previous experience suggests a similar human adaptation is possible. Additionally, the fact that the outbreak emerged in a densely populated city such as Wuhan and has spread among people who have not had direct contact with the live wildlife markets raises concerns about its epidemic potential.
Placing several Chinese cities under quarantine, as the government has ordered, could reduce the spread of the novel coronavirus disease outside the most severely affected areas. However, the effectiveness of a quarantine as a control measure is questionable as time passes for logistic (supporting the quarantined population with food and other essential goods) and social/political (the willingness of the population to suspend their usual activities) reasons.
Although it may too late to affect the course of the current outbreak, the permanent closure of live wildlife markets should be considered as a public health policy intervention. Eliminating close interactions among wildlife species and the subsequent exposure of the animals to humans could reduce the risk of another novel disease emerging. History suggests there may be other coronavirus outbreaks with similar characteristics and consequences in the future if no preventive action is taken.
[i]Case counts provided by World Health Organization, available at www.who.inton on February 10, 2020.
[ii]Roujian Lu and others, “Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding,” The Lancet, Published online January 29, 2020 https://doi.org/10.1016/S0140-6736(20)30251-8
Revitalizing infrastructure remains an important imperative for the federal government. Legislation to support the rehabilitation and improvement in transportation, power generation, telecommunications and other nationwide systems could facilitate economic growth and improve population welfare. Although health infrastructure does not receive as much attention in discussion of national infrastructure priorities, it is an essential component that will support the national economy and also improve lives. Any policy proposal to fund infrastructure improvements should include health infrastructure, especially in the areas of workforce, data systems, and crisis response; these areas were identified by a federal study as being critical parts of the national health infrastructure.[i]
While the United States spends about one sixth of its GDP on health related expenses, it still does not reap the same level of tangible benefits as other peer developed countries that spend much less on a per capita basis. Additionally, the emergence of climate change and exotic zoonotic diseases challenges to U.S. heath infrastructure in novel ways. A modern U.S. health infrastructure will need to develop capabilities across human and animal health to optimize benefits to the U.S. economy and residents.
Currently, there are workforce shortages in a variety of health fields including physicians[ii]and veterinarians[iii]. As the U.S. population ages, there is increased demands for health services. Also, for reasons that are not yet clear, the health status of younger Americans is worse that it was for previous generations of Americans at the same age and may be an additional cause of increased health service demand. [iv]Climate change has resulted in changes in disease patterns among animal populations. Previously unknown pathogens will likely increase the demand for veterinary clinical services including animal disease surveillance and outbreak management. Further integration of human and animal health, or “one health” infrastructure, will be essential for building additional health capacity.
Modernization and improvements of health systems, particularly in the areas of telecommunications and cybersecurity will support the needs of health infrastructure by improving medical record keeping and information access when patients are treated. Disease patterns will be identified and outbreak response can be occur more quickly. The recent approval for the merger of CVS Pharmacy and Aetna health insurance suggest a shift from large medical practices to retail health settings for routine healthcare. If stand-alone clinics become an increasingly popular source of preventive and well-being health services, more reliable and comprehensive access to individual medical records will facilitate optimal care.
Effective crisis response to health emergencies requires support from other critical infrastructures because the immediate requirement is to deploy resources as quickly as possible for rescue and recovery. Depending on the nature of the health emergency, such as hurricane response for example, rescue workers may need to get to disaster areas quickly to restore basic health services. Affected health infrastructure may require transportation, telecommunications, and electrical power systems as well as possibly erecting temporary clinical facilities to resume operations. A different health crisis may require specialized clinical isolation and treatment facilities be created to contain a widespread infectious disease outbreak. To the extent that a rapid and efficient response will minimize deaths and more severe health consequences, collaborations between various infrastructure stakeholders would ideally include exercise for a variety of health crisis scenarios.
Health systems and infrastructure are an important area of the overall U.S. infrastructure and must be an integral part of planning nationwide updates and modernization.
[i]See Healthy People 2020, Public Health Infrastructure, https://www.healthypeople.gov/2020/topics-objectives/topic/public-health-infrastructure, accessed on June 9, 2019.
[ii]Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physicians and Surgeons,
on the Internet at https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (visited June 06, 2019). See U.S. Department of Health and Human Services, Health Resources and Services Administration, https://data.hrsa.gov/topics/health-workforce/shortage-areas, accessed on June 9, 2019.
[iii]See Journal of the American Veterinary Medical Association, https://www.avma.org/News/JAVMANews/Pages/181215e.aspx?PF=1, accessed on June 9, 2019
[iv] See Blue Cross Blue Shield, “The Health of Millennials,” https://www.bcbs.com/the-health-of-america/reports/the-health-of-millennials accessed June 9, 2019.
An alarming number of new COVID-19 cases are emerging in the United States and the situation remains a major crisis. According to data from the U.S. Centers for Disease Control and Prevention (CDC), the number of new cases per day has almost doubled from around 100,000 to over 181,000 during October 30 to November 13; there were over 1800 deaths on November 10, a daily total that is the highest since June 25. The rapid growth of new cases and deaths began about September 15, when new cases averaged about 37,000 and deaths were in the mid-800 range according to information from CDC. Data from the COVID Tracking Project at the Atlantic Magazine reported 30,328 people were hospitalized with COVID-19 on September 15 and it escalated to 79,410 on November 18. As the number of cases accelerates, it becomes increasingly difficult to control the spread of COVID-19. More people are available to infect others and the ability of contact tracing to identify exposed people and disrupt transmission diminishes. Increasing case counts and deaths are expected to continue as the United States approaches winter. In the absence of an effective and deployed vaccine, there are limited opportunities to resume economic activities safely.
A full recovery in U.S. economic activity and employment is contingent on slowing the further spread of disease. Expanding federal support to address the pandemic will be essential to achieving that outcome. The most immediate challenge is to disrupt transmission now that daily new cases approach 200,000. First and foremost, there should be renewed emphasis on achieving universal compliance with good public health practices. While the federal government cannot impose mask and social distancing mandates outside federal property, messages from federal officials should consistently and repeatedly remind the public that masks and distance help protect everyone and hasten the day when such measures will no longer be required. Local governments need additional resources so they can add staff for effective contact tracing. The federal government can direct additional manufacturing of critical health related products such as diagnostic tests and personal protective equipment and act as a central purchasing agent when buying such goods. The federal government can provide technical support and funding to businesses that want reduce transmission risk with workplace mitigations such as enhanced air filtration and physical barriers. Another area of economic concern for the workforce is the impact of long-term health consequences from COVID-19 infection. Early evidence indicates a significant percent of SARS CoV-2 survivors experience long-term and debilitating effects. As more people become infected, more people may be affected by this phenomenon. Without such federal actions, it may be necessary to re-impose activity restrictions as case counts continue to skyrocket. Another federal assistance package is expected before the end of this year and economic assistance to support these efforts should be a priority. Rapid legislative action is critical because the continued exponential growth in cases could sideline more workers and discourage people from engaging in any economic activity that is not online due to safety concerns.
Unlike it was in the earliest stages of the pandemic, in recent weeks COVID-19 has spread nationwide and affected rural areas and small towns, especially in the central part of the United States. Many of these areas do not have similar access to medical facilities as the largest cities, in large part due to the loss of their community hospitals. The most common reasons for the closure of these facilities were difficulties in recruiting doctors and other medical professionals and the inability of the hospitals to cover their costs. In addition, people living in non-metropolitan urban areas tend to be older and less healthy than urban residents. As the pandemic spreads in these areas, local healthcare systems and even the larger regional medical centers are far less well-equipped to cope with extremely ill COVID-19 patients. As was demonstrated during the spring of 2020 when medical resources of the largest U.S. cities were overwhelmed, there is a limit to how many patients can be successfully managed when demand inundates capacity. U.S. healthcare resources, particularly highly trained personnel, are constrained and the continued rapid increase in the number of new cases will overwhelm the system if disease transmission remains out of control. Healthcare workers remain uniquely vulnerable to COVID-19 infection due to close patient contact and continuing shortages in personal protective equipment. Evidence of the fragility of adequate staffing during the current upsurge is the November 9 order by the North Dakota governor that allows infected but still asymptomatic nurses to remain on the job. Clearly this presents a hazard for all hospitalized patients as well as other hospital staff. In such instances there are insufficient personnel resources to care for hospitalized patients even though there may be more critical care beds. The federal government can assist states and localities by acting as a clearinghouse for efficient sharing of medical personnel resources between states and, if necessary, sharing any available resources from the Department of Veterans Affairs medical system, the largest integrated healthcare system in the country, for the duration of the emergency. Such actions will provide respite for over stretched staffs.
The increasing positivity rate measured by the Johns Hopkins University COVID Resource Center, the number of positive diagnostic results divided by the number of tests, is another indication of the increasing spread of disease. The increase in the positivity rate over the last month indicates some states are capturing only the most severe cases and many mild or asymptomatic cases are being missed. Given that COVID-19 causes a significant percentage of asymptomatic cases, it is almost certain there is more transmission than is being detected by the current testing programs. For economic recovery to be sustained, there must be a high level of assurance the probability of catching the disease has been drastically reduced and it is safe to return to schools, workplaces, and various other activity venues. Even in those states that have imposed movement restrictions to control the pandemic, many remain reluctant to venture outside their homes for nonessential activities. Improved testing programs that quickly and accurately identify asymptomatic infections will give the public increased confidence that they can return to previous activities without fearing for their personal health.
On November 16, Moderna announced preliminary phase three clinical trial data that indicates its vaccine was about 94 percent effective. This news comes on the heels of a November 9 announcement by Pfiizer-BioNTech that its phase three vaccine clinical trials showed more than 90 percent effectiveness. Thus, there are at least two vaccine candidates that could provide protection to the U.S. population in the coming months if approved by the U.S. Food and Drug Administration for emergency use. It remains to be seen if the immunity conferred by the vaccines prevents both illness and disease transmission. Among the other hurdles to controlling the spread of SARS-CoV-2 through vaccination in the near term are producing sufficient doses and deploying the vaccine throughout the country. Both vaccines require two doses to be effective. The logistics of vaccinating the over 300 million people in the United States are daunting given the strict timing of the required doses. Additionally the Pfizer-BioNTech vaccine requires ultra-cold storage and the equipment to maintain such temperatures is not common or widespread. Other vaccine candidates are in clinical trials and may provide more opportunities to control COVID-19.
The upcoming winter holidays are the greatest immediate obstacle to reducing the spread of COVID-19 and continuing the economic recovery. By several significant epidemiological measures, the disease is spreading at an ever increasing rate and infecting more Americans. The combination of cold temperatures forcing groups to gather in enclosed spaces for extended periods and people traveling for holiday celebrations could drive the disease to spread much farther and faster than was observed earlier. This puts the economic recovery at risk. While we know more about how to prevent death for the most severe cases, only adherence to good public health practices will keep the disease at bay.
As the United States approaches fall 2020 it faces four major crises (COVID-19, the precipitous drop in GDP, western wildfires, and numerous hurricanes in the southeast) in addition to the impact of seasonal flu. The intersection of these events and the impact of housing loss will strain the ability to curb further spread of COVID-19. One model predicts an additional 100,000 deaths by the end of 2020, which would raise the death toll to over 300,000 since the beginning of 2020. The key to controlling the pandemic before an effective vaccine is available is minimizing COVID-19 transmission. The keys to mitigating the effects of these multiple disasters is providing economic support to those affected by the economic downturn, along with measures to re-house those who have been displaced by the hurricanes and wildfires in a way that limits both COVID-19 and flu infections. The key to reviving the economy is to control the pandemic.
The economic downturn caused by COVID-19 has had wide ranging effects on health and limited the ability of many Americans to protect themselves from being infected. Many initially furloughed workers became unemployed when their employers were forced to shutter. The loss of income causes food insecurity, which has a direct impact on health and the ability to resist infections. Loss of housing or loss of utilities (such as water and electricity) which are essential for maintaining health and hygiene increases the risk of exposure to COVID-19 because people are forced to live in more crowded circumstances or they do not have the resources to maintain a clean and sanitary living environment. The loss of health insurance affects the medical management of chronic diseases and the wherewithal to seek healthcare for new illnesses, including COVID-19. The wildfires in California, Oregon, and Washington present similar challenges inasmuch as they also cause job losses and destroy housing, health facilities and other infrastructure. Media reports 5500 homes and businesses and 3.4 million acres have burned during 2020 in California alone. All three states will need to find temporary shelter that will also protect thousands of people from COVID-19. Destruction of homes will complicate responding to the housing crisis for displaced people because COVID-19 demands temporary housing that limits the number of persons living in close quarters. There must also be additional facilities to identify and isolate people who become infected until they recover and can return to their temporary homes
The 2020 hurricane season has been active, with serious storms affecting both the Gulf and Atlantic coasts. Damage to health facilities and other infrastructure has affected health resource availability for COVID response. Destruction of homes will require also responding to a housing crisis. The necessity of housing displaced people in small family groups will exacerbate the already difficult problem of providing temporary homes in the aftermath of hurricanes.
The ongoing COVID-19 pandemic shows no signs of slowing down; the number of cases in the United States now exceeds seven million as of September 29, 2020. Infection control has not been effective for several reasons: less than universal compliance with wearing face masks and social distancing recommendations, and re-opening of education institutions and some commercial activities for in-person interactions without strict adherence to physical separation precautions. The change of seasons will affect risk of respiratory disease transmission because people will spend more time indoors as it becomes colder in northern parts of the United States. The arrival of seasonal flu in autumn always raises concern about widespread transmission of respiratory disease and co-infection with COVID-19 is likely to have serious health consequences for anyone who becomes infected with both.
Once the spread of the coronavirus is brought under control by adherence to recommended public health measures, it will be possible to re-open many of the activities closed earlier in the year. While public health investments such as personal protective equipment and modifications to indoor environments to increase air exchange will be needed to protect people from continued circulation of the SARS CoV-2 virus, industrial facilities, schools, and other institutions which require in person interactions will be made safer for gatherings and some group activities can resume. Once an effective vaccine is developed and widely distributed, it will be possible to return to pre-COVID life and the downturn should abate.