Policy for the Next Pandemics

After a year of pandemic, one of the last topics I want to think seriously about is a future of pandemics.

But with pandemics as with so many other problems, not thinking about it doesn't make it go away. Monica de Bolle, Maurice Obstfeld, and Adam S. Posen have edited a short 12-chapter e-book titled Economic Policy for a Pandemic Age: How the World Must Prepare (Peterson Institute for International Economics, April 2021). The book considers the discomfiting possibilities that COVID-19 may be a chronic pandemic for some time to come and what lessons might be learned for future pandemics. 

Several of the essays warn about the emergence of COVID variants around the world, including the UK, Brazilian, and South African variants that are known, but quite possibly others variants that are not yet known. Chad P. Bown, Monica de Bolle, and Maurice Obstfeld tell the story of the Brazilian city of Manaus in their essay, "The pandemic is not under control anywhere unless it is controlled everywhere."

Manaus, a city on the Amazon River of more than 2 million, illustrates the dangers of complacency. During the first wave of the pandemic, Manaus was one of the worst-hit locations in the world. Tests in spring 2020 showed that over 60 percent of the population carried antibodies to SARS-CoV-2. Some policymakers speculated that “herd immunity”—the theory that infection rates fall after large population shares have been infected— had been attained. That belief was a mirage. A resurgence flared less than eight months later, flooding hospitals suffering from shortages of oxygen and other medical supplies. The pandemic’s second wave left more dead than the first. 

Scientists discovered a novel variant in this second wave that went beyond the mutations identified in the United Kingdom and South Africa. This new variant, denominated P.1, has since turned up in the United States, Japan, and Germany. Scientists speculate that a high prevalence of antibodies in the first wave may have helped a more aggressive variant to propagate. The hopes for widespread herd immunity may be dashed by the emergence of more infectious virus variants.

Since the outbreak in Manaus in January 2021, P.1 has now spread throughout Brazil. The variant is much more transmissible than those that had been circulating previously in the country. High transmissibility and the absence of measures and behaviors to stem the dissemination of the virus have led to the worst health system collapse in Brazilian history.

What are some of the lessons that emerge from thinking about the pandemic and its global scope? Here are a few that come up repeatedly in the book. 

1) It seems important to have coordinated collection of genomic data on COVID or other viruses, both within countries and around the world. That's how you know if you are dealing with an existing problem or a new one--and if it's a new one, you can start the process of getting appropriate tests and vaccinations up and running. 

2) If you want to stop a pandemic early, before you need to do large-scale long-term lockdowns or watch people die while a vaccine is being developed and tested, the alternative involves lots of testing and follow up. Martin Chorzempa and Tianlei Huang describe this alternative in "Lessons from East Asia and Pacific on taming the pandemic."

Bloomberg News’ COVID Resilience Rankings evaluate success in handling the pandemic while minimizing the impact on business and society. An astounding ten of the top 15 countries and territories are in East Asia and Pacific. Top performers vary enormously in size, wealth, and political institutions, from small, wealthy, democratic islands like Taiwan and New Zealand to large, middle-income countries under one-party rule like mainland China and Vietnam. Core to their exemplary performance was the use of targeted and less costly mitigation measures that do not require an economic freeze. ... The experience in East Asia and Pacific varies among countries with diverse cultures, geographies, and political systems, but one thing is clear: rigorous masking requirements, testing, contact tracing, selective quarantines, border closings, and clear public health communication all helped to avoid the overwhelming economic dislocations that occurred in the West. ...

One of the most crucial advantages in the early days of a pandemic is testing capacity, which helps identify both individuals to quarantine and where to focus further testing. The contrast between the United States and South Korea, for example, is instructive. Drawing on memories from the MERS outbreak in 2015, South Korean officials pushed for quick approvals of promising tests from multiple manufacturers even before their effectiveness could be rigorously proven. The US Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) required lengthy processes that limited testing supply, blinding their officials to the pathogen’s spread. By March 2020, South Korea had tested 31 times more people per capita than the United States, allowing it to catch many more cases and nip transmission chains in the bud.

In many places, including where I live in Minnesota, the primary method of vaccine distribution for the general non-institutionalized population happens in this way. You go online and fill out a form. The state or local government has a priority list and tells you when it's your turn. At that point, you make an appointment for where and when in the metro area to show up. 

I can see the appeal of this approach to a certain kind of administrative mind. There's a master list on a government-run computer, and priorities can be set. But of course, this approach also assumes that you have internet access and are comfortable navigating the government website, that you receive the follow-up messages and respond, and that you have the transportation and flexibility to keep what may be several vaccination appointments. Some people will be a lot better-positioned to jump through these hoops than others: for example, my elderly parents (who live in their own home) would probably not have been vaccinated except for family members who got them registered, followed up, and transported them to the designated location. And of course, this entire process also assumes that you want the vaccine enough to jump through these hoops. Mary E. Lovely and David Xu discuss some of these topics in their essay, "For a fairer fight against pandemics, ensure universal internet access." 

I remember as a small boy when we had a mass vaccination at school (maybe for what was then called "German measles" and now is called "rubella"?). We were marched out of our classrooms, lined up in the hallways, and then paraded by the nurses. That's not a workable model for the general population in 2021. But we need thinking about how to vaccinate many different ways--via workplaces, pharmacies, maybe roving vaccine-mobiles at familiar places like libraries, churches, and so on. 

As David Wilcox points out in his essay, "US vaccine rollout must solve challenges of equity and hesitancy," one result has been a large and growing backlog of available vaccine doses that have not been distributed. Wilcox writes (footnotes and references to figures omitted): 

For whatever reason, fewer doses were being injected into people’s arms each day, on average, than were being shipped to the states. As a result, the backlog of doses that had been shipped but not injected increased rapidly. By the second week of January, this backlog had moved above 15 million doses. ... During the first week of March, more than 2.1 million doses were administered on average per day—the fastest daily pace yet, but still not as fast as the stepped-up pace of delivery. As a result, the backlog moved above 25 million doses in the first week of March. ... As of late March 2021, the average daily pace of doses administered has increased from 2.2 million to 2.8 million, and the supply of doses to the states and other jurisdictions has stepped up to 3.4 million per day. Because the supply of doses has continued to outrun utilization, the implied backlog of doses in inventory has moved up into the range between 35 million and 40 million.

4) Because COVID spreads around the world and mutates around the world, high-income countries like the United States have a self-interested motive to see that the problem is addressed around the world. Yes, most high-income countries will look to their own populations first. But that can only be seen as a first step. Several of the essays in this book address how to do this, and I discussed a couple of months ago in "Why High-Income Economies Need to Fight COVID Everywhere" (February 2, 2021). 

5) In thinking about future pandemics, we need to think in advance about our ability to scale up production for what is needed. Some of this is physical, like the supply chains for personal protective equipment, for tests, and for developing and producing vaccines even more quickly. Some of this is advance planning so that tasks like contact tracing or distribution of tests and vaccines can go much more briskly. For-profit companies are going to be limited in their willingness to commit large-scale resources to future health risks that are uncertain in their source and timing. Along with a number of other people, I was echoing calls for better pandemic preparedness some  years ago. Although some steps were taken, we turned out to be grossly underprepared when the pandemic came. Today's politicians should be judged in part by their ongoing actions in response to COVID-19, but perhaps should be judged even more by whether they are putting policies in  place for the next pandemic.