Having just participated in the American Frontline Doctors White Coat Summit, I realize more than ever that when all the available pieces of the puzzle are put together, the developing picture is not at all a pretty one. I say this not out of any fear of a virus, but...
Brace for Impact, Responding to COVID-19
It’s been a rough week for the United States. In the space of one week, the country has gone from treating the COVID-19 as something distant and far away, to panic on the verge of having a nervous breakdown.
Travel restrictions from the European Union have been put into place. More will follow. America has gone from a highly mobile society to one that is locking itself down. Every gathering of any size for any reason anywhere has been cancelled. The new term social distancing has emerged onto the scene as a new cultural phenomenon. The markets have collapsed into bear territory reflecting the nervousness of a nation that is not sure exactly what is coming next.
Our pucker factor is intense, which may explain a strange obsession for hoarding toilet paper. We were hoping for containment against a virulent strain, but our national consciousness just realized that is not to be. We are having a human reaction to an inhuman threat. We are reflecting exactly the type of cultural anxiety that was initially seen in China.
The United States experience with COVID-19 will not be like China’s. In China, they isolated the outbreak to a single province that contained 59 million people. The population of the United States is 327 million people.
Within that Hubei province region, the Chinese implemented stringent population lockdown controls limiting mobility to give the government the upper hand to work the problem. The Chinese further implemented even stricter quarantine controls in the epicenter city of Wuhan to further isolate the ability of the virus to propagate. The US is an open society where our ability to come and go as we please is treasured. In a crisis, we adapt not by force, but by a common sense of purpose. Not as mathematically efficient as totalitarian control; but, it’s our way.
Medical Infrastructure Challenges Lie Ahead
The thing to remember about a virus is that it’s not something that hyper-efficient medicine or miracle drugs can cure, not without a precisely targeted tailored drug or vaccine anyway. We don’t have that yet. Until then, treating a virus is primarily a game of treating symptoms; and in critical cases, rapidly deteriorating complex complications. You don’t need specialists for this. You need armies of general practitioners, nurses and medical technicians.
Between affected regions, the indigenous number of physicians per capita is the number to watch. The US has 2.3 physicians per 1,000 people while China has 1.51 physicians per 1,000 people. At the outset, Hubei province had around 89,090 doctors available. The US starting number is 752,100 physicians. Then the surge of critical cases begins; and you start running out of resources. Medical staff gets thin. Facilities with oxygen concentrators and ventilators become fewer than the number of patients that need them. Specialized care for critical ICU patients becomes a matter of there are no more beds.
Here’s an important warning to note. Italy got overwhelmed. This is an important data point for American crisis management planners because Italy started this crisis with 4.2 physicians per 1,000 people, more per capita than either the US or China; but in absolute numbers only 252,000 doctors for the country of 60.48 million population.
What the Chinese were able to do, because they isolated the problem to a single province, was bring in the medical staff from the rest of their country of 1.386 billion people to help the people of Hubei province. They were able to draw from a reserve of 1,990,500 additional physicians to come to the aid of their countrymen, a total of 2,168,360 physicians in the entire nation. They had 22.3 doctors in reserve for each one in Hubei province. Reports indicate around 40,000 doctors volunteered to aid Hubei, bringing the Chinese to 2.18 physicians per capita in the affected province for the outbreak.
This is roughly the same number as the US medical staff statistics for the United States. That’s good news. We may be able to make do with what we have; though, we may need to get creative to manage the surge of cases as they arise; particularly so in our hottest zones, our major urban centers.
There is one rather disheartening statistic for the US. China started their COVID-19 epidemic with 4.2 hospital beds per 1,000 people. They had to build more hospital space and quarantine facilities on an emergency basis when the virus surged.
The United States has 2.9 hospital beds per 1,000 people. We are in this infrastructure configuration because our medical system is full of advanced technology, highly organized for cost efficiency, staffed with specialists, and able to move patients to outpatient care in 1/3 the time.
None of this is an advantage for treating a viral epidemic where what you need is an infrastructure capable of housing and monitoring patients for extended observations times staffed with general skills doctors and ICU personnel.
Medical To-Do’s We Must Do, or Die
The bottom line is that we have a challenge ahead as COVID-19 surges through our population.
We may need to find ways to leverage our 2.3 doctors per capita to deliver care equivalency higher in certain locales at virus peak. There are three ways to create reserves.
We augment hot zones with personnel from less affected areas the way China did. This is probably our best option. Another potential salvation depends on how well our specialty medical professionals, our existing frontline defense leverage, can think out of the box and adapt their technology and tools to the mission of meatball medicine that COVID-19 will demand. We should all wish them well. Our lives do depend on them.
As a last resort, the Italians look to have tapped into medical school and nursing school students and their military medical technicians to augment their civilian infrastructure. This version of reserves is not the fully trained cadre of country doctors like China had. My instinct says that we will probably not have to do this.
We will likely also need to build physical infrastructure like the Chinese did to establish temporary surge care facilities for acute care and quarantine purposes; except we will have to do it everywhere in our country at once. Unlike China, the US hot zones are not isolated to one region of the country. Our more mobile society has already facilitated the propagation of the virus. It is now uniformly distributed throughout the Continental United States (CONUS). Too late. It’s happened. Now we need to focus on the capacity to treat it. There is no alternative. Well, there is letting people die. That’s not a good alternative.
Brace for Impact. Flying at Economic Stall Speed.
The US is now flying flaps down at stall speed trying to not fall out of the sky as we bring our workforces, educational system, and consumer economy to a self-imposed stand still. Our government and society is adapting in a, so far, orderly fashion, even if the noise factor in the mainstream and social media is in denial that the people of the United States actually have real lives and common concerns.
Quite honestly, the noise makers should just really shut up. We have more important things to tend to. We can only sustain slowing the economy for so long and it only gets more difficult if factions are bickering instead of cooperating.
We are presently seeing unprecedented unity and cooperation to a common crisis and it makes me very proud to be an American to see that there is some real hunkering down to get through this going on. That Democrat Governors are praising the President as our levels of government activate is exactly the reserve mobilization strength that the United States needs for this crisis.
We are seeing friction at the local levels as red tape and bureaucracy has not yet completely adapted to crisis mode but that’s to be expected. This is an event we haven’t seen since the Spanish flu a century ago.
It is heartening to see Congress working with the Administration on fiscal matters, even if lingering noise from petty politics must be mitigated by heightened wrangling between the House and Senate to make sure no bill gets to the Presidents desk that won’t be signed. This is old fashioned Washington D.C. working the problem.
The Executive Branch and its agencies are working as well. A case in point is the medical drug supply. The pundit acrimony would make you believe we are going to run out of aspirin because of China. But the U.S. Food and Drug Administration continually publishes updates about its dealings with the global supply chain of drugs. The FDA’s Feb 27 update indicates there is cooperation to keep the system going.
On medical devices, the FDA reported,
“We are aware of 63 manufacturers which represent 72 facilities in China that produce essential medical devices; we have contacted all of them. Essential devices are those that may be prone to potential shortage if there is a supply disruption. We are aware that several of these facilities in China are adversely affected by COVID-19, citing workforce challenges, including the necessary quarantine of workers. While the FDA continues to assess whether manufacturing disruptions will affect overall market availability of these products, there are currently no reported shortages for these types of medical devices within the U.S. market.
Regarding personal protective equipment—surgical gowns, gloves, masks, respirator protective devices, or other medical equipment designed to protect the wearer from injury or the spread of infection or illness—the FDA has heard reports of increased market demand and supply challenges for some of these products. However, the FDA is currently not aware of specific widespread shortages of medical devices, but we are aware of reports from CDC and other U.S. partners of increased ordering of a range of human medical products through distributors as some healthcare facilities in the U.S. are preparing for potential needs if the outbreak becomes severe.”
On biologics, the FDA reported,
“The FDA is not aware of any cellular or gene therapies that are made in China for the U.S. market. There are no shortages of biologics to report at this time.”
On animal drug, the FDA reported,
“There are 32 animal drug firms that make finished drugs or source active pharmaceutical ingredients in China for the U.S. The FDA has contacted all 32 firms and no shortages have been reported at this time. However, six of those firms have indicated that they are seeing disruptions in the supply chain that soon could lead to shortages. The FDA is working with these firms to help identify interventions to mitigate potential shortages.”
And the FDA has makeshift recommendations to mitigate shortages, for example,
“Lengthen Expiration Dates to Mitigate Critical Human Drug Shortages: Shortages of certain critical drugs can be exacerbated when drugs must be discarded because they exceed a labeled shelf-life due to unnecessarily short expiration dates. By expanding the FDA’s authority to require, when likely to help prevent or mitigate a shortage, that an applicant evaluate, submit studies to the FDA, and label a product with the longest possible expiration date that the FDA agrees is scientifically justified, there could be more supply available to alleviate the drug shortage or the severity of a shortage.”
I’ve spent extra time here for a reason. It’s important to share that all of these federal agencies are not, as too many in the mainstream media and social media claim, incompetent, or led by incompetents. There is work going on. Boring work. Trench warfare work. Work that isn’t worth turning into click-bait fodder. The kind of work that will get the United States through this crisis. This won’t take a village. It’ll take a nation, a united one. Or we will fail.
As to President Trump’s leadership, it’s really been a steady build focusing on phases of containment in the early stages with a less Draconian hand than how China handled it. Let’s be fair here. The Trump led process was, when you really step back and look at it, balanced to what could be pragmatically accomplished within the societal model of the United States. We are neither totalitarian nor inhumane. We cope. Muddle. It’s our way. Deal with it.
Honestly. It’s best to ignore all the people that couldn’t let go of their political positioning as events unfolded. Tightening border controls bought the US time to prepare the funding, infrastructure and consensus for emergency management operations when the virus exited the containment phase and or nation entered the lockdown phase.
Are we completely ready? No. Who could be? But this is no longer a time to second guess. We are braced for impact. We are about to be forced to remember that what will get us out of this is the one thing punditry and politics cannot buy, American ingenuity and resolve. It’s lead, follow or get out of the way time. Deal with that too.
We can get back to our cultural habits of petty domestic bickering after this has passed. For now, that narrative is counterproductive.
Trump’s Next Challenge, Restart the Engine After the Virus
At some point we are going to reach the plateau of this virus’ attack. Like China, the rate of new cases appearing will level off and decline. When that happens, we need to have our plans in place to restart the economy.
It is presently premature to ask President Trump to begin to explain what the plan is. Like all of the facilitating infrastructure preparations and economic relief action now being made to endure the lockdown phase of this calamity, there will need to be similar preparations and economic incentives set into motion to activate economy as soon as the crisis has passed.
We have shut down our consumer economy and we will need to start it back up. That means people will need to get back to work so that they can again be making the disposable income that they need to have in order to make the nondurable goods and luxury goods portion of our economy come back to life.
This plan, like the shutdown plans being set into motion now, will have to span from the highest levels of federal government to the local levels of municipal implementation. It will cross over into the financial and corporate sector. It will have to incorporate lessons learned about single point global supply chain vulnerabilities and what to do about them. It will have to adapt to the realities of the ingenuity we are about to discover. Medical services. Distance education. How much of what we learn will we keep? What will we set aside? It is likely that many things we assumed a week ago may not be the same in the aftermath of COVID-19.
Restart is as complex, if not more complex, a set of preparations that need to be examined and set into motion with a cool head even as we made. Let’s not fail to complete the job to keep America Great.
Use the code ‘OUTLOUD’ and receive your 20% discount on your first order.