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July 23, 2020

New Rules for the Pandemic Era

Author Affiliations
  • 1Department of Economics and Kennedy School of Government, Harvard University, Cambridge, Massachusetts
JAMA Health Forum. 2020;1(7):e200945. doi:10.1001/jamahealthforum.2020.0945

Coronavirus disease 2019 (COVID-19) is not the world’s first pandemic, and it is unlikely to be the last. In recent years, there have been actual or potential pandemics in 2002 (severe acute respiratory syndrome), 2009 (H1N1 influenza), 2012 (Middle East respiratory syndrome coronavirus), and 2014 (Ebola). The new normal seems to be an actual or potential epidemic every 2 to 3 years.

Loss of life is one devastating effect of regular pandemics and economic damage is another. Consider what happens to the economy if pandemics occur regularly. Close association of individuals with different perspectives is a key to productivity. Large, dense cities are the most innovative areas, and the most innovative companies are those that bring disparate people together. If cities become ground zero for pandemics, fewer people will probably choose to live in them. And with that will come a decline in national vitality.

Preventing recurrent pandemics is a major public health challenge. To meet this challenge, society will need to act domestically and globally.

Changes in the US

In many ways, it is remarkable that COVID-19 is the first pandemic with major loss of life to hit the US in a century. The administrations of George W. Bush and Barack Obama both felt they got lucky in not facing an epidemic. Both were sufficiently worried to put in place monitoring systems to detect pandemics and to develop playbooks for what to do in response (and the Trump administration dismantled the monitoring systems and ignored the playbooks). But neither the Bush nor the Obama administration was able to significantly increase funding for pandemic preparedness.

The US budget for countering pandemics is woefully inadequate. The entire public health infrastructure in the US—including state, local, and federal activities—was less than $300 per person in 2018. In contrast, annual Medicare spending is more than $2000 per person in the US population and more than $12 000 per person enrolled in the program.

With a razor-thin margin, any slipup becomes catastrophic. When the US Centers for Disease Control and Prevention’s first diagnostic test for COVID-19 became contaminated, there was no backup. Instead, weeks were lost and clinicians were unable to test for the disease. It would be as if there were only 1 cardiac facility in New York City and the power to that hospital went out. Similarly, the US does not allocate enough funding to regularly employ contact tracers. Thus, when a pandemic strikes, the ability to limit damage is constrained. An overarching new rule for the pandemic era is to allocate more money for public health, which will be essential to prepare for ongoing pandemics.

COVID-19 also shows that new sources of leadership are needed. The federal response to COVID-19 has been abysmal and it is clear that presidential administrations can no longer be trusted to handle matters of public health. In response, alternatives will need to be created. Think about the way the American Heart Association and the American Cancer Society gather and disseminate information on those diseases. If some future administration tried to deny the science on heart disease or cancer, one hopes those organizations would push back vigorously. Similar institutions are needed for public health.

The obvious groups to turn to are medical professional societies, including the American Medical Association. Although their clinical response to COVID-19 has been impressive and their public health advice has been sound, medical groups have not been as quick to point out the idiocy of incorrect public health advice as they might have been. The COVID-19 experience calls into question the current approach to public debate.

Global Institutions

Preventing pandemics is far better than dealing with them ex post. The speed of global travel has created a weakest link principle in that failure anywhere in the world is dangerous to people everywhere in the world. Thus, society needs to strengthen all of the links in the preparedness chain.

Although not a complete agenda for how to accomplish this, here is a start. First, the world will need much greater public health capability. This involves training people in all countries in public health preparedness and having global monitors everywhere to pick up on outbreaks of disease. Rich countries will need to pay for this—though the cost is trivial relative to the cost of repeated pandemics. Second, an international playbook is needed anytime an outbreak is detected. China delayed telling the world when the severe acute respiratory syndrome coronavirus 2 emerged, and that kind of behavior must be made unacceptable. Third, some cities need to be removed from the international grid. The obvious first set of cities are those—like Wuhan, China, the initial epicenter of COVID-19—with so-called wet markets that sell meat, poultry, seafood, and sometimes live animals, including wildlife located there or nearby. Airlines could be directed not to provide international service directly to or from those areas.

One would hope that organizations like the World Health Organization would be able to write international rules for the pandemic era. But there is uncertainty that these types of organizations can. Many international organizations work off a lowest common denominator standard in that all must agree before anything is agreed. This type of system does not work when tough decisions need to be made.

A better model may be the North Atlantic Treaty Organization (NATO). After World War II, the rich countries of the world agreed to take all measures to defend the world against nuclear war. NATO was expensive but it succeeded spectacularly; a nuclear war never happened. As Microsoft cofounder Bill Gates noted 5 years ago, the nuclear era has now given way to the pandemic era. Does society have the capacity to adapt?

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: David Cutler, PhD, Department of Economics and Kennedy School of Government, Harvard University, 79 John F. Kennedy St, Cambridge, MA 02138 (dcutler@fas.harvard.edu).

Conflict of Interest Disclosures: Dr Cutler reported receiving nonfinancial support from the Health Policy Commission of Massachusetts and Mercer; receiving personal fees and nonfinancial support from the American Medical Association, Brookings, and the Colorado Center for Nursing Excellence; receiving personal fees from Fidelity (for serving on a scientific advisory board and for multidistrict litigation); serving on academic and policy advisory boards for Kyruus Inc and Firefly Health; and holding unpaid positions at the National Academy of Medicine, the National Bureau of Economic Research, the National Academy of Social Insurance, and the Center for American Progress.

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    2 Comments for this article
    COVID-19 Not The First Pandemic with Major Loss of Life in a Century
    Raymond Wesley, M.D. | Private Practice
    Covid -19 is not the first pandemic in the last 100 years to kill a large number of people in the United States or the World.

    World Deaths
    Asian Flu 1957–1958 1.5 to 2 million
    Hong Kong Flu 1968–1969 1 million

    United States Deaths
    Asian Flu 116,000 estimated as low as 80,000 /> Hong Kong Flu 100,000 to 110,000 estimated

    The World and US populations were much smaller.
    1957 US 172 million
    1968 US 200.2 million

    1957 World 2.891 billion
    1968 World 3.534 billion

    I lived during these times, reading the Louisville Courier Journal at age 13. The Courier was then a reliable and inquisitive newspaper with an international outlook. The "Courier" did not report or imply the need for a national paralysis. The 50's and 60's populace did not worry, excessively, about the influenza epidemics. People continued with their work. The economic impact and fear factor was minimal.

    1968 saw my first year as a Medicine Intern. I had up close and personal exposure, daily. The hysteria and fear did not exist.

    Covid-19 is not the only severe influenza attack within a 100 years. The response to the Asian and Hong Kong flu needed more public awareness.

    The planning does need to be more thorough and not detrimental financially as is currently. But current popular channels of communication, warring political parties, and others have created the anxiety, stress, and economic depression.

    Thank you for your excellent opinion and suggestions.
    From "Traumatic Epidemic" to "Disease Epidemic "
    Anatoly Zhirkov, Professor | Saint Petersburg State University
    I read Dr. Cutler's article with great interest. The author raises an important topic of interdisciplinary analysis in health care. In the second half of the 19th century, the famous anatomist, surgeon, and founder of nursing in Russia Nikolai Pirogov called the Franco-Prussian war a traumatic epidemic (1). It is interesting that Florence Nightingale expressed similar thoughts about the role of caring for the wounded in her famous book Notes of Nursing. From the analysis of Pirogov, it followed that the tactics of providing medical care in the theater of operations should depend both on the development of medical science and on changes in the impact of the enemy's damaging factor. Today, his ideas can be rethought in relation to the scientific and technological revolution of the early 21st century. It is thanks to the rapid development of science and technology that the level of medical care in economically developed countries has changed significantly. So in ICD-10, about 11,000 medical diagnoses are taken into account, and in ICD -11, about 55,000. At the same time, the scientific and technological revolution at the beginning of the 21st century led to serious changes in the physical parameters of the environment and the modification of social processes. In the United States in 2018, about 70K people died from drug use (2), and as a result of medical errors against the background of the intensification of medical manipulations, according to unofficial data, only in 2015 more than 250K (3). The COVID-19 pandemic has claimed more than 160K lives in the United States (4). All of these factors make it possible to propose the term "disease epidemic" to characterize the situation in medicine at the beginning of the 21st century. By this term, we understood the increase in the number and nomenclature of diseases associated with the consequences of the scientific and technological revolution at the beginning of the 21st century.

    1. Н. Пирогов. Военно-врачебное дело. Частная помощь на театре войны в Болгарии. В тылу действующей армии в 1877 – 1878 гг. С. Петербург. Издание главного управления Общества попечения о раненых и больных воинах. 1879 (in Russian)
    2. Drug Overdose Deaths in the United States, 1999–2018. https://www.cdc.gov/nchs/products/databriefs/db356.htm#:~:tex
    3. Makary M A, Daniel M. Medical error—the third leading cause of death in the US. BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2139
    4. https://coronavirus.jhu.edu/map.html 08/09/2020