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The JAMA Forum
September 15, 2020

New Rules for the Pandemic Era

Author Affiliations
  • 1Department of Economics and Kennedy School of Government, Harvard University, Cambridge, Massachusetts
JAMA. 2020;324(11):1023-1024. doi:10.1001/jama.2020.15526

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 coronavirus), 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

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.

Previous Publication: This article was previously published in JAMA Health Forum at jamahealthforum.com.

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