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January 31, 2020

Weekly line: The 'recurring themes' of disease outbreaks

Daily Briefing

    There's a lot we still don't know about the new coronavirus that's been spreading rapidly throughout China and other countries—and has begun spreading in the United States. But as University of Michigan law professor Nicholas Bagley pointed out last week on Twitter, there are some things we do know—at least in terms of government and public response—if we look back at previous disease outbreaks.

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    The 'recurring themes' of disease outbreaks

    Last week, Bagley resurfaced a 2016 list of "themes" that he and his wife, who is also a law professor, found recur when governments and the public respond to disease outbreaks.

    The list was born from a seminar they gave focused on outbreaks of cholera, Spanish flu, polio, AIDS, SARS, and Ebola. Bagley wrote that while "[e]very disease provoke[d] its own unique dread and its own complex public reaction," there were "themes [that] recurred across outbreaks."

    And as Bagley pointed out, many of those themes are "[n]ewly relevant" today, given the ways governments and providers have responded to the new coronavirus outbreak. He told Daily Briefing's Ashley Fuoco Antonelli, "I think it's safe to say that there's a sense that we've seen this movie before, and that history offers us some resources for thinking about how this is likely to play out."

    The difficult balance of government response

    Bagley's 2016 list features several recurring themes that center on governments' responses to disease outbreaks. For instance, three themes that he highlighted are:

    • "Governments are typically unprepared, disorganized, and resistant to taking steps necessary to contain infectious diseases, especially in their early phases";
    • "Public officials are reluctant to publicize infections for fear of devastating the economy"; and
    • "Local, state, federal, and global governing bodies are apt to point fingers at one another over who's responsible for taking action. Clear lines of authority are lacking."

    Each of those themes certainly holds true today. Media outlets have reported that China was slow to report the new coronavirus outbreak and implement measures to contain it. And some observers have questioned whether Chinese officials downplayed the outbreak's severity.

    For example, the New York Times's Li Yuan writes that, as the first cases of the virus emerged, officials "insisted that it was controlled and treatable," and "the [Chinese] government took pains to keep up appearances." For example, she notes, "[T]wo days before Wuhan told the world about the severity of the outbreak, it hosted a potluck banquet attended by more than 40,000 families so the city could apply for a world record for most dishes served at an event."

    Media reports also have highlighted complications and conflict between local and central officials in China regarding what information could be shared with the public. For instance, the Wall Street Journal's Josh Chin writes that Wuhan Mayor Zhou Xianwang has cited rules set by leaders in Beijing for "limit[ing] what he could disclose about the threat posed by the pathogen."

    But it's worth noting that some experts say Chinese officials might have delayed reporting on the virus because they were scrambling to understand its severity before alerting, and possibly unnecessarily alarming, the public. And Bagley told Fuoco Antonelli that while concerns about the outbreak's potential impact on the country's economy might have affected Chinese officials' decisions on announcing the outbreak, China "was actually much more forthcoming about this new coronavirus than it was about" the 2003 SARS outbreak. He added, "And to the extent that we look for progress, not perfection, I think that's good."

    Still, China may not have acted quickly enough to dispel public mistrust in the government's ability to control the outbreak—and that mistrust has further complicated officials' later containment efforts. And that leads us to Bagley's last recurring theme centered on government responses to disease outbreaks: "Calibrating the right governmental response is devilishly hard. Do too much and you squander public trust (Swine flu), do too little and people die unnecessarily (AIDS)."

    When specifically thinking about the current outbreak, Bagley told Fuoco Antonelli, "Calibrating the right response to [this outbreak] can be extraordinarily difficult, because there's a lot more that's unknown about this coronavirus than that's known."

    The challenges of providing effective care

    Bagley's list also highlighted three recurring themes related to medical care during disease outbreaks:

    • "Doctors rarely have good treatment options. Nursing care is often what's needed most. Medical professionals of all kinds work themselves to the bone in the face of extraordinary danger";
    • "In the absence of an effective treatment, the public will reach for unscientific remedies"; and
    • "No matter what the route of transmission or the effectiveness of quarantine, there's a desire to physically separate infected people."

    And that appears to be the case today.

    Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has said there currently "is no proven therapy for coronavirus infection." That means while providers wait for a proven treatment, they are experimenting with existing therapies intended to treat other conditions, all while also dealing with an onslaught of patients.

    Bagley told Fuoco Antonelli that medical professionals "have been working themselves to the bone trying to care for people with" the virus. And the Times' Sui-Lee Wee reported, "Videos circulating on Chinese social media show doctors straining to handle the enormous workload and hospital corridors loaded with patients."

    With little known information and no proven treatment, misinformation about the new coronavirus has flourished online. For example, the Times' Daniel Victor cites recent articles "recommending that people counter the virus by rinsing their mouths with salt water," and "that setting off fireworks would sterilize germs in the air"—claims that have no scientific backing.

    The lack of an effective treatment and information about the virus also contributes to another one of Bagley's themes: "No matter what the route of transmission or the effectiveness of quarantine, there's a desire to physically separate infected people."

    As we've seen in the past, quarantine has become a go-to care option for providers and public health officials looking to control the new coronavirus' spread. But China has shocked experts around the globe by implementing unprecedented travel restrictions in various cities that essentially quarantined tens of millions of people.

    Bagley told Fuoco Antonelli, "There is a temptation to reach for interventions that separate out sick people from the rest of the population, even when doing so is counterproductive. And the quarantines in China may have been."

    A revolving door of disease outbreaks

    Ultimately, some of Bagley's remaining themes foreshadowed these recurring events: "We plan, to the extent we plan at all, for the last pandemic. We don't do enough to plan for the next one." He added, "Historical memory is short. When diseases fall from the headlines, the public forgets and preparation falters."

    Those themes, too, are evident today in China. He Qinghua, an expert with China's National Health Commission, said the SARS outbreak in the early 2000s helped prepare China's cities for dealing with infectious diseases, but China's "rural population has no experience in combating SARS." Qinghua added, "Therefore, their awareness of epidemic prevention is still low."

    And, unfortunately, waiting until an outbreak happens to address the issue doesn't typically fare well for governments and health care providers. "This is not the time we should be building up our capacity, this is the time we're graded on the capacity that we've built up," Bagley told Fuoco Antonelli.

    But the new coronavirus outbreak at the very least gives governments, providers, and public health officials another opportunity to learn best practices for combating infectious diseases in the future. And Bagley told Fuoco Antonelli that lesson largely centers around investing in prevention and preparedness—even after the outbreak falls from the news media's headlines.

    Stakeholders should "[i]nvest now in the infrastructure we need to cope with outbreaks. That means we need to finance disease surveillance. We need to invest in the CDC. It means we need to undertake more exhaustive surveys of the capacities of state and local governments to respond in real time to emerging threats. We need to invest in our ability to quickly create and then manufacture vaccines. And we need to do all of this when the coronavirus is out of the headlines," he said.

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