Understanding the COVID-19 Pandemic as a Preventable Societal Catastrophe
Patricio V Marquez
“The ideal society in my mind involves a structure of institutions, attitudes, and techniques for promoting a just and prosperous nation.”
William D. Nordhaus, 2018 Nobel Prize Laurate in Economics, and the Sterling Professor of Economics, Yale University
In reading The Spirit of the Green—The Economics of Collisions and Contagions in a Crowded World, a new book by Prof. William D. Nordhaus, I was captivated by the clarity and eloquence of his chapter on pandemics and other societal catastrophes. Although the main focus of the book is on environmental economics, the insights he offers on the ongoing COVID-19 pandemic as a societal catastrophe helped me better grasp some of its dimensions and the lessons for the future. In the next paragraphs I will summarize some key points that Prof. Nordhaus presents in this chapter of his book.
Low-probability, high-consequence events
As a catastrophic viral plague, the COVID-19 pandemic is causing widespread social, economic, and political hardship due to its severity, extent, and speed. These events are rare in modern times as they tend to occur with a frequency of decades, centuries, or even longer. Since they are low-probability, high-consequence events, they pose difficulty for social decision processes concerning detection, prevention, and mitigation. Prevailing attitudes and political institutions are at the core of the difficulty for dealing effectively with these catastrophes, even in countries with the most advanced technologies.
A pandemic such as COVID-19 fits in the category of spillovers or externalities, such as pollution. The most important characteristics of deadly agents, such as the novel coronavirus (SARS-CoV-2) that causes the COVID-19 disease, are their infectiousness and their lethality. Epidemiologic methods allow for their calculation. In terms of infectiousness, the number of people on average than an infected person will infect if there are no measures to prevent the spread of the disease is designated by the term RO. In the case of COVID-19, each infected person is estimated to infect three other people, although some variants may have a higher RO. The other feature is lethality (L), the fraction of people who die after contracting the disease. In the case of COVID-19, the L is still uncertain, but estimates range between 0.5% and 2% of infections, lower than the L for smallpox (30%).
To fully understand the control of pandemics, the effective reproduction rate concept captures the impact of protective measures adopted as shown by a fall in the reproduction rate. Therefore, the key to combating any pandemic is to reduce the effective reproduction rate below RO (for example, in the case that 1,000 people have been infected and the effective reproduction rate has been reduced to 0.5%, the number of infected people will decline by 50% each generation). This concept is easily understood when one realizes that the lack of cases of smallpox, measles, and polio today is the result of the application of effective public health measures. In the case of COVID-19, vaccines and vaccinations are reducing infections, severe illnesses, and death.
Role of governments
Dealing with pandemics, as we have experienced with COVID-19, is extremely challenging as they strike suddenly and unexpectedly and spread swiftly. Besides its high infectiousness and lethality, COVID-19 poses an added danger because it is susceptible to human-to-human transmission and it allows both asymptomatic spread (transmission of the virus by people who have no symptoms and will never have symptoms of their infection, but these infected carriers could still make others sick) and presymptomatic spread (the transmission of SARS-CoV-2 from an infected person, the source patient, to a secondary patient before the source patient developed symptoms, as ascertained by exposure and symptom onset dates, with no evidence that the secondary patient had been exposed to anyone else with COVID-19). Few studies have directly determined the proportion of transmission events that occur before symptom onset, but a modeling study inferred that 44% of secondary cases were infected during presymptomatic stages of disease, and another study found a 75% transmission of SARS-CoV-2 in a cohort of case-patients in their presymptomatic phase, which exceeds transmission rates reported in other studies.
Humans are vulnerable, but not helpless in the face of catastrophes. In such a scenario, where a deadly virus is polluting the air impacting all people, the adoption of precautions protects individuals and families, but also friends and strangers alike. Governments have a central role in dealing with deadly externalities such as infectious diseases. But, as shown by the COVID-19 experience, unless political leaders actively shape public opinion and adopt appropriate policies, scientific expertise cannot by itself stop it. Also, the failure to invest in programs to prevent infectious diseases, to slow their spread, or to mitigate their damage, adds to the difficulty of dealing with them. And as shown by the COVID-19 experience, the failure of institutions to follow existing guidelines and procedures in the face of the pandemic onslaught facilitated the spread of the virus and proved to be lethal for the countries and the world.
Lessons for the future
Prof. Nordhaus concludes the chapter on pandemics by advising that when catastrophes occur, we need to look back and assess the success and failures of policies. To this end, he highlights four key attitudes and policies that are necessary to deal with catastrophes like pandemics:
- Adequacy of relevant scientific and technological expertise. As differing from the state of knowledge a century ago, when influenza was thought to be bacterial rather than viral, the world had at hand in 2020 great scientific and technological resources. These not only allowed the current coronavirus to be sequenced and published for the world in less than two weeks after Chines doctors identified it as a new viral strain, but also the stunning scientific achievement of developing, testing, and gaining emergency use authorization for several vaccines to prevent COVID-19 illness. Vaccines and vaccination, if done across the world, are now offering the real possibility of returning the global economy and society to normal conditions, with people travelling, mingling, and having socially close interactions.
- Level of preparedness. The world knew of the dangers of pandemics, particularly after the Ebola epidemic in West Africa in 2014-2016. Countries had plans that included most of the interventions that began to be used over the course of the pandemic (testing, contact tracing, social distancing, border controls, and surveillance), but in most cases they lacked or had little resources to fund the necessary staff and programs to implement these key public health measures. Indeed, as attested by the experience in the United States, the lack of preparation was reflected in the limited amount of budgetary resources allocated for pandemic planning: while the 2021 federal budget allocated $741 billion to the military, the allocation for the CDC, the agency is charge of tracking pandemics, was $12.6 billion, and only $40 million of that was targeted for pandemic planning for influenza. This dire fiscal reality for essential public health functions is commonplace in most countries of the world.
- Effective execution. Besides sustainable and predictable allocations of appropriate fiscal resources for pandemic preparedness, implementation capacity is of critical importance to deal with pandemics. The failed initial rollout of COVID-19 testing by the CDC in the United States, although it has the facilities and expertise to manage this task, is a good example of poor implementation. The initial COVID-19 tests developed by the CDC were defective, and the agency took weeks to correct the failure. The CDC refused to allow other entities such as hospitals to devise their own tests; did not allow widespread population testing to determine the overall prevalence of COVID-19; and, reflecting scientific conservatism and over-centralization, prohibited pooled testing (tests that combine the samples of different individuals), which is most valuable when the prevalence is small and the availability of tests are extremely limited.
- Effective communication by leaders in the public and private sector. Another major failure in the United States and other countries was lack of clear, effective, coordinated, and timely risk communication by credible government spokespersons. The intrusion of politics into public health prevented the formation of national consensus on taking critical steps to tackle the pandemic (e.g., slowing the spread by universally using face masks). This factor has also helped fuel anti-vaccination perceptions.
Looking forward, the painful lessons accumulated during the COVID-19 pandemic need to be remembered, and they must serve to inform and guide efforts during the post-pandemic period. The likelihood of new public health catastrophes in the future cannot be discounted or their risks ignored, except at our own peril. Globally, all countries need to be prepared, and governments need to be held accountable for pandemic preparedness. Domestic resource mobilization, coupled with international contributions, are needed to ensure that funding for pandemic preparedness and implementation is prioritized in national budgets and sustained over the medium and long terms, and compliance by countries needs to be monitored by international organizations such as the World Bank Group and the IMF as part of investment and credit rating exercises.
At the end of the day, if pandemic preparedness is not assumed as a national security priority and thus as a political and fiscal responsibility of governments in each country across the world, no amount of good intentions and proposals at the international level will guarantee global health security. Indeed, the existence of strong and resilient public health systems that can prevent, detect, and respond to infectious disease threats, wherever they occur in the world, should be seen as a collective responsibility that no country is exempt from and a critical element of a well-managed society—the kind of society that we all should desire and wish to live in.