A pandemic is not a war

Deadliest Enemy. Our War Against Killer Germs

Key messages from the book:

To review, our greatest threats are:
1. Pathogens of pandemic potential, which essentially means influenza and the downstream effects of antimicrobial resistance.
2. Pathogens of critical regional importance, which include Ebola, coronaviruses like SARS and MERS, other viruses such as Lassa and Nipah, and Aedes-transmitted diseases such as dengue, yellow fever, and Zika.
3. Bioterrorism and dual-use research of concern (DURC), and gain-of-function research of concern (GOFRC).
4. Endemic diseases that continue to have a major impact on the world’s health, particularly among emerging nations, including malaria, tuberculosis, AIDS, viral hepatitis, childhood diarrheal diseases, and bacterial pneumonia.

Priority 1: Create a Manhattan Project–like program to secure a game-changing influenza vaccine and vaccinate the world.
Priority 2: Establish an international organization to urgently address all aspects of antimicrobial resistance.
Priority 3: Support and substantially expand the mission and scope of the Coalition for Epidemic Preparedness and Innovations (CEPI) to fast-track comprehensive public-private vaccine research, development, manufacturing, and distribution for diseases of current or potential critical regional importance.
Priority 4: Launch the Global Alliance for Control of Aedes-Transmitted Diseases (GAAD) and coordinate with the Bill & Melinda Gates Foundation’s malaria strategy, “Accelerate to Zero.
Priority 5: Fully implement the recommendations of the bipartisan report of the Blue Ribbon Study Panel on Biodefense.
Priority 6: Establish an international organization similar to the National Scientific Advisory Board for Biosecurity (NSABB) to minimize the use of DURC and GOFRC to transmit pathogens of pandemic potential
Priority 7: Recognize that TB, HIV/AIDS, malaria, and other life-threatening infectious diseases remain major global health problems
Priority 8: Anticipate climate-change effects
Priority 9: Adopt a One Health approach to human and animal diseases throughout the world.

Health supplies as strategic asset

China Rx
EXPOSING THE RISKS OF AMERICA'S DEPENDENCE ON CHINA FOR MEDICINE

Key messages from Chapter 14:

China has been one of America's bankers, buying US Treasury bonds, and is now America's drugmaker. The centralization of the global supply of key ingredients for America's medicines in a single country poses enormous risks that must be mitigated.
Free market advocates may contend that the United States is better off outsourcing medicine making to China and allowing Americans to keep more of their money to spend on other goods. But medicines are essential for life. A country needs them to function. Prescription drugs are made by private corporations, but many serve a public purpose. 

Not unlike the manufacture of other consumer products, business decisions about manufacturing essential drugs and their therapeutic ingredients have been left to the invisible hand of the market. Financial and human capital have migrated to countries with the lowest cost of doing business. Corporate executives and their boards have determined that for them, the benefits of dependence on China outweigh the risks.
These decisions are too important to leave to the invisible hand. As China rapidly pursues a determined strategy to become a pharmaceutical power, US dependence on a single country will rise dramatically.

Key prescriptions to consider:

1. CONSIDER MEDICINES A STRATEGIC ASSET, NOT A COMMODITY TO BE BOUGHT AT THE LOWEST PRICE
2. TRACK AND FORECAST VULNERABILITIES IN THE SUPPLY OF AMERICA'S MEDICINES
3. PRIORITIZE A LIST OF MEDICINES FOR WHICH A SUPPLY INTERRUPTION POSES AN IMMEDIATE DANGER TO PUBLIC HEALTH
4. INVESTIGATE CHINESE DRUG CARTELS TO FIND OUT IF THEY CAUSE DRUG SHORTAGES IN THE UNITED STATES
5. PROVIDE INCENTIVES TO BRING DRUG MANUFACTURING HOME
6. ENSURE THE US MILITARY DOES NOT DEPEND ON CHINA FOR ESSENTIAL MEDICINES
7. STRENGTHEN, DON'T WEAKEN GOVERNMENT OVERSIGHT OF DRUG MANUFACTURERS
8. DON'T CEDE US REGULATORY OVERSIGHT OF DRUG MANUFACTURING TO CHINA
9. INCREASE FDA TESTING OF MEDICINES                                                            10. LUCK IS NOT A STRATEGY: IDENTIFY PROBLEM PRODUCTS RAPIDLY

Given the current health crisis, you can change medicines by tests and it fits perfectly. You can apply it to your country.

Stories from spanish flu epidemic

THE SPANISH FLU EPIDEMIC AND ITS INFLUENCE ON HISTORY.  Stories from the 1918–1920 global flu pandemic

From Chapter 11:

Perhaps the most lasting legacy of Spanish flu is that it barely left a legacy at all. While it has continued to be studied and analysed in niche virology circles, the collective memory seemed to stub it out and hurry to move on. Were it not thanks to a handful of dedicated historians such as Geoff Rice and Richard Collier, who collected personal accounts of the tragedy through the 1970s and 1980s, many first-person testimonies may have been lost. There are a few explanations of this mass memory loss and one of them related to honour. Perhaps in order to dull the painful reality of the loss of a treasured father, husband, brother or son, much pomp was  conveyed onto the memory of those who died in battle. Dying from flu, however, did not convey the same sense of honour. In fact, in a world where eugenics had played a strong role so far, it made otherwise brave men appear weak and flawed.

 Time is a healer, though, and there are lots of good reasons to be interested in Spanish flu now, a hundred years on from the pandemic; to honour the dead, to analyse the medical response, to measure the impact of the virus on the health of the population through the relatively new discipline of
epigenetics … but perhaps the most pressing reason for us to remember the outbreaks from a virology, epidemiology, sociology and historical point of view, is because of the high possibility it could happen again.

 The outbreak of Spanish flu at the start of the twentieth century is considered to be one of the deadliest infections in the history of humanity, affecting a minimum of 30 per cent of the global population, and killing around 5 per cent.

In a previous post you may find additional details.

How pandemics shaped our world

Germs, Genes, & Civilization. How Epidemics Shaped Who We Are Today

From Chapter 11:

In his futuristic work The Shape of Things to Come, published in 1933, H. G. Wells relies on a novel plague to eliminate half the population of Earth in 1955–1956 and usher in a new era. Although this epidemic was largely modeled on the Black Death, Wells had his “maculated fever” waft around the world on the wind instead of spread by fleas. His fictitious disease emerged from captive baboons in the London Zoological Gardens. The Shape of Things to Come was written as a prediction of the future in an age when most scientists foresaw only the eventual eradication of infectious disease, not its resurgence.
So what should we predict? First, let’s consider the global situation. The British Empire was the last great civilization. Improved hygiene, originating from the industrialized West, led to worldwide decreased infant mortality. That, in turn, created a population boom that undermined the profitability of the European colonial empires. Despite poor hygiene and rampant disease relative to the industrial nations, the birth rate still outstrips infant mortality in Third World countries. The ongoing population explosion is the single most important biological trend in today’s world.
Denser populations, coupled with poverty, are promoting the spread of disease. Although tuberculosis is in the lead right now, most of those infected do not fall ill. As the remaining sensitive humans are weeded out, the incidence of TB in the Third World will begin to decline naturally, just as it did in Europe a century ago.
In the advanced nations, AIDS will affect homosexuals and intravenous drug users but have marginal impact on the mainstream. Its major effect, especially in the United States, will be to increase the cost of health care in the inner cities. This will help enlarge the growing gap between rich and poor. In Africa and, to a lesser extent, other third world regions, AIDS will thin out the promiscuous and malnourished, and favor the spread of religious puritanism, particularly, Islamic sects.
Still more serious, in my opinion, are malaria and other insect-borne infections that are spreading in the tropics. Rising world temperatures promote the spread of insects that transmit many tropical or subtropical diseases. Human construction and irrigation projects are helping, as is the steady increase in insecticide resistance among the insect carriers. An ugly long-term threat is the possible adaptation of tropical viruses to be carried by insects that survive in colder climates

PS. Further reading

Fascinating classics written long ago that are still good reading:
Defoe, Daniel. Journal of the Plague Year. New York: New American Library, 1960. (Original edition 1723.)
Although a work of fiction, the author lived in times when the bubonic plague was still around.
Nightingale, Florence. Notes on Nursing: What It Is and What It Is Not. New York: Dover Publications, 1969. (Original edition 1859.)
For a nice little old lady, Florence Nightingale was amazingly blunt and opinionated. She made generals tremble in their shoes. She would have made Hillary Clinton wilt!
Most important modern works:
Ewald, Paul W. Evolution of Infectious Disease. Oxford: Oxford University Press, 1994.
Seminal work on the evolution of infectious disease from the modern genetic and evolutionary viewpoint. Rather academic.
Herlihy, David. The Black Death and the Transformation of the West. Cambridge, MA: Harvard University Press, 1997.
Expounds the idea that the Black Death was responsible for the emergence of Western democracy.
McNeill, W. H. Plagues and Peoples. Garden City, NY: Anchor Press, 1976.
The most important single source that summarizes and explains the idea that epidemics affected human history.
Zinsser, Hans. Rats, Lice & History. Boston: Little, Brown and Company, 1934. (Reprinted quite frequently.)
Classic on typhus fever and history from the viewpoint of a microbiologist.
Narrow in focus, yet fascinating:
Cantor, Norman F. In the Wake of the Plague. New York: Free Press, 2001.
How the Black Death remodeled European society.
Cockburn, Aidan, and Eve Cockburn. Mummies, Disease and Ancient Cultures. Cambridge, U.K.: Cambridge University Press, 1980.
Grmek, Mirko D. Diseases in the Ancient Greek World. Baltimore: Johns Hopkins University Press, 1989.
A selection of other interesting books:
Cartwright, Frederick F., and Michael D. Biddiss. Disease and History. New York: Dorset Press, 1972.
Crawford, Dorothy H. Deadly Companions. Oxford: Oxford University Press, 2007.
Diamond, Jared. Guns, Germs and Steel. New York: W. W. Norton, 1998.
Garrett, Laurie. The Coming Plague. New York: Penguin Books, 1995.
Oldstone, Michael B. A. Viruses, Plagues, and History. New York: Oxford University Press, 1998.
Preston, Richard. The Hot Zone. New York: Random House, 1994.
Wills, Christopher. Yellow Fever, Black Goddess: The Coevolution of People and Plagues. Reading, MA: Addison-Wesley, 1996. (First published in the United Kingdom by HarperCollins as Plagues: Their Origins, History and Future.)

PS. The exit of the lockdown

Contagion

Now is the time to watch this great film:

And you'll get convinced that unless we have a vaccine soon, all things will be very dificult to manage...

Understanding COVID-19

How Will COVID-19 Affect the Health Care Economy?

COVID-19 and risks to the supply and quality of tests, drugs, and vaccines

Virtual health care in the era of COVID-19

Daily briefing: This is the state of COVID-19 vaccine development now

Disease Control, Civil Liberties, and Mass Testing — Calibrating Restrictions during the Covid-19 Pandemic

Thousands of coronavirus tests are going unused in US labs

Selected links on COVID-19.

From NEJM

Consider, for example, a policy in which people seeking to return to work, school, or social activities are asked to undergo baseline testing for infection and antibodies. Positive tests for infection would trigger self-isolation. Negative tests would certify freedom of movement for a defined period — say, 2 or 3 weeks — after which additional negative tests would renew the certification. If antibodies are determined to provide long-term protection against both reinfection and transmission — which is plausible but not yet established — a positive serologic test would warrant longer-term certification.
Aggregating test results at community and state levels would support a reliable disease-surveillance system. A testing regimen’s stringency could then be dialed up or down, depending on community prevalence of Covid-19. China is following a version of this approach by grading community risk on a four-tier, color-coded scale.

And...if antibodies and infection are negative? What do you do? And... if this affects to 85% of population?. As is the case of Heinberg in Germany?

I would like to highlight the last one, how spply and demand for lab test doesn't match, in US and elsewhere...

Economics of pandemics (3)

Economics of coronavirus: COVID-19 impact and policy interventions

La salida: Retomar el trabajo (Fugong Fuchan)

Selected readings from Barcelona GSE.
You'll find there our yesterday article and on AES Blog: La salida: Retomar el trabajo (Fugong Fuchan)

Health system responses to COVID-19

Beyond Containment:Health systems responses to COVID-19 in the OECD

From OECD report:

The main focus of this brief is on the policiesaimed at providing effective care and managing the pressure on health systems. Four key measures health systems are putting in place in response to the epidemic are considered: 1)ensuring access of the vulnerable to diagnostics and treatment; 2)strengthening and optimising health system capacity to respond to the rapid increase in caseloads; 3)how to leverage digital solutions and data to improve surveillance and care; and 4)how to improve R&D for accelerated development of diagnostics, treatments and vaccines

PS: From Francesca Colombo

Economics of pandemics (2)

Mitigating the COVID Economic Crisis: Act Fast and Do Whatever It Takes

Crucial contribution from key economists. A must read.

Outline:

Introduction
Richard Baldwin and Beatrice Weder di Mauro

1 So far, so good:  And now don't be afraid of moral hazard
2 Flattening the pandemic and recession curves
3 Limiting the economic fallout of the coronavirus with large targeted policies
4 Italy, the ECB, and the need to avoid another euro crisis
5 The EU must support the member at the centre of the COVID-19 crisis
6 Helicopter money: The time is now
7 What the stock market tells us about the consequences of COVID-19
8 Ten keys to beating back COVID-19 and the associated economic pandemic
9 Saving China from the coronavirus and economic meltdown: Experiences and lessons
10 China's changing economic priorities and the impact of COVID-19
11 Singapore's policy response to COVID-19
12 The experience of South Korea with COVID-19
13 COVID-19: Europe needs a catastrophe relief plan
14 The COVID-19 bazooka for jobs in Europe
15 The monetary policy package: An analytical framework
16 Bold policies needed to counter the coronavirus recession
17 Europe ís ground zero
18 Economic implications of the COVID-19 crisis for Germany and economic policy measures
19 Finance in the times of COVID-19: What next?
20 How COVID-19 could be like the Global Financial Crisis (or worse)
21 Protecting people now, helping the economy rebound later
22 Policy in the time of coronavirus
23 Containing the economic nationalist virus through global coordination
24 The case for permanent stimulus

Security policies in front of a new molecular vision of life

Pandemics, Pills, and Politics. Governing Global Health Security

The goal of this book in one sentence:

This volume reveals the major challenges involved in securing populations pharmaceutically and explores how governments are designing extensive new medical countermeasure regimes to overcome those challenges. At the heart of this pharmaceutical turn in security policy, I argue, lies something deeper: the rise of a new molecular vision of life that is reshaping the world we live in—including the way we now imagine and practice security.

The author explains the pharmaceutical defenses for a global pandemic, and specially describes the case of Tamiflu.

 The idea of “medical countermeasures” is also fascinating, secondly, because of the terminology it musters. The concept textually embodies the progressive epistemic fusion of the two professional fields of medicine (“medical”) and security (“countermeasures”), attempting to seamlessly blend key vocabularies from both communities into a single notion. Here the term begins to form a fascinating intersection, or bridge, between these two different social fields, giving rise in the process to a fascinating new and interdisciplinary policy space where the respective concerns of pharmaceuticals and security begin to interpenetrate each other, and can also come into direct tension with one another.

The chapter 4 is specially of interest: The Margin Call for Regulatory Agencies and explains what was done in the Tamiflu case.

A cursory review of the FDA approval processes for Tamiflu paints a fairly uneventful picture. In fact, the sequence of events leading up to FDA approval for Tamiflu can be quickly summarized. A month after the Swiss approval, on 27 October 1999, the FDA approved Tamiflu for “the treatment of uncomplicated acute illness due to influenza infection in  adults who have been symptomatic for no more than 2 days” (FDA 1999b). This marketing approval process unfolded rapidly according to the priority review procedure—within six months—following Roche’s initial application for FDA approval on 29 April 1999.

 Again, the case of Tamiflu has been highly instructive. It showed that this new pharmaceutical intervention could only be designed after scientists had first gained a much better understanding of the precise molecular processes involved in viral replication unfolding inside the human body—especially the role played by the influenza virus’s surface proteins such as neuraminidase. Once scientists had understood the vital role played by the neuraminidase and decoded its precise molecular structure, they discovered a “static” site that could form the basis for a new drug target. Scientists could then set about the task of deliberately designing an “artificial” molecule that would bind to that critical site in the neuraminidase and that could inhibit its key role in the process of viral replication. In that sense, our technical ability to develop new pharmaceutical defenses is itself  dependent upon a prior—and deeper—scientific understanding of the life processes unfolding at the scale of the molecular.

The case of covid-19 began without any countermeasure, because molecular knowledge started mid-January once it was sequenced. Nowadays, we can only wait for a successful vaccine and therapy.

Protect yourself and you protect others

PANDEMICS: WHAT EVERYONE NEEDS TO KNOW

Selected messages from a descriptive and useful and concise book by the winner of the Nobel Prize for Medicine, 1996 :

• Our capacity to deal with and live through pandemic situations is continually improving. We should not be fearful, but we should be aware, watchful and prepared. 
• There are steps that we can take to protect ourselves, our families, and our communities, but these need to be thought through ahead of time. Fostering sound personal habits related to cough etiquette, hand/face contact, and hand sanitation is a good place to start.
• As with any form of defense, it takes political will and financial resources (both public and private) to maintain the integrity of national borders (quarantine), support the professionals who serve in the public health field services and laboratories, and fund the research that leads to greater diagnostic

Safeguarding our lives and our livelihoods

Covid-19 Briefing Materials

Great report by McKinsey, for the files. A must read

ePandemic

Digital Health And The Fight Against The COVID-19 Pandemic

Pandemic storytelling

Pandemics, Publics, and Narrative

How people interpret messages to guide action during a pandemic. This is the topic of this book. The effects of storytelling in health communication are crucial and the book starts with the presumed contagion of swine flu by David Cameron.

Our analysis placed engagements with pandemic storytelling across public life in dialogue with the narratives on the enactment of expert advice. This dual approach helped to establish perspectives on how narratives influence publics to take action, or not. We took the view that narrative does not simply mediate pandemic knowledge and advice by helping to structure it intelligibly and meaningfully. We also questioned the idea that narratives persuade in and of themselves in ways that are not very far removed from now discredited notions of linear, hypodermic communications on matters
of health. We adopted the view that media are thoroughly entangled with experience and that pandemic narratives found there help to constitute subjects and the relationships they have with the expert knowledge systems that underpin public health efforts to manage microbial threats

 Unlike states of illness, which depend on determinate biomedical diagnosis and the related transformation of identity and relationality, pandemic experience was most often indeterminate due to the infrequency with which influenza infection is diagnosed in a laboratory and the great variation in influenza symptoms between people, between influenza outbreaks, and even over the course of a particular influenza pandemic.

 Pandemic narratives are placeholders for rich metaphors of life under threat. The metaphorical properties of contagion and immunity give pandemic narratives biopolitical resonance, connecting as they do: political imperatives to do with the production of life; the self defined and protected against the other; the milieu interieur scene for commune with microbial invaders and friends; the tensions implied in proximity and distance; and the coconstruction of narrative and knowledge.

Somebody will have to write a book about current covid-19 pandemic and the title could be: "We are all soldiers against covid". Nothing to add.