COVID-19: A pandemic spells out needs for infectious diseases, global health security investments and leadership

It is 10 pm Eastern Standard Time, and an exhausted 79-year old man, who has managed to keep the façade of a 50-year-old man, with a sterling infectious disease career is on CNN fielding questions from a world thirsty for knowledge. The public and media like thirsty desert travelers who have exhausted their water supplies hold out big empty cups for knowledge. They are begging for these cups to be filled. The world is facing a crisis and some leaders are stepping up to the plate as shining examples of what leadership should look like  -- firm, consistent, unwavering, credible and able to read the future to meet the needs of today.

Dr. Anthony Fauci is one such leader. With decades of experience and knowledge in infectious diseases he fills these cups with a calm confidence. His voice strikes a chord of confidence with the public, media and politicians. Dr. Fauci heads the United States National Institute of Allergy and Infectious Diseases. He has allowed himself to be a window through which the world can understand the many facets of the mysterious illness, COVID-19, which seems to have turned our lives upside down.

He has placed a spotlight on the field of infectious diseases. This is a field of medicine known to most physicians but unknown to the average layperson. It is easy to know what a surgeon does. “What does an infectious disease specialist do?” I have often heard that question. I smile and attempt to answer. A picture is worth a thousand words. A look at Dr. Fauci’s role in this pandemic would speak volumes to all those who have wondered. The caps that infectious disease doctors wear in any organization are so many that they defy a list -- from acting as antibiotic gatekeepers, to ensuring that the hospitals environment poses little risk of infection as well as taking care of complex infectious disease problems when they are consulted. The fun part for most of these specialists is the art of being disease detectives. Doctors who figure out what is the root cause of a fever and other diagnostic dilemmas. Sometimes our work unveils cancer or a connective tissue disorder. In any hospital they may be the busiest physicians because they will dig for every little piece of information in every nook and cranny to come up with a diagnosis. The COVID-19 pandemic has shed light on an important facet of these physicians -- leading the world with calm direction in the face of a noisy epidemic. Dr. Fauci is showing the world the value of training and investing in infectious diseases education.

For about five years in a row, the field of infectious diseases has seen fewer internal medicine graduates applying for fellowships for a myriad of reasons which include the amount of knowledge that has to be acquired, lower remuneration since Medicare did away with consultation fees, the pull of the hospitalist track which promises more rewards without the need for another two to three years invested in an infectious disease fellowship. COVID-19 and the leadership Dr. Fauci has exhibited maybe what the world needs to understand the value of infectious disease training and maybe a game changer in convincing young medical trainees to consider infectious diseases as a specialty. Across the nation and in other parts of the world, infectious disease doctors have become invaluable as the leaders in the COVID-19 planning and training.

In a March 3 post on this blog, I indicated how the COVID-19 storm that had blown across Asia and Europe was threatening to pull the rug of calmness from under America’s approach to the spread of SARS-CoV-2. It did more than that. It has completely overwhelmed our hospitals and stretched our resources thin. I did not think I would live to see the day when healthcare workers would be asked to reuse N95 masks, not for one patient, but for multiple patients over several days. COVID-19 has managed to do that. Today America has overtaken Asia and European countries in the disease burden after testing only 1 million of its 300 million people. On March 30, after 1 million tests had been performed America boasted a case load of 136,000 -- more than any country in the world and clearly overtaking China in sheer numbers and in density of cases considering that China’s case load of 82,000 is in the context of a 1.4 billion population, which is almost five times the population of the United States. Italy’s case load of almost 100,000 in the context of a population of 62 million contrasted against China’s 1.4 billion population all speak to the need for leadership to act quickly and decisively in these epidemics. Beyond the numbers are families who have lost parents, parents who have lost children and loss of talent, like the death of the President of Northern Italy’s medical association- Medical Guild of Varese. The 67-year old man, Dr. Roberto Stella died on March 10, a day after the country went on lock down.

In Africa, the disease is slowly taking root. The African myth that people of color cannot be infected with the virus has quickly evaporated in the heat of the steady trend of increasing daily cases. The myth that the warm equatorial temperature will melt the fragile envelope of the single stranded enveloped virus has also quickly vanished into thin air. Most African countries are in the exact place Europe was about a month ago, A few countries like South Africa, Rwanda, Nigeria and Ghana have restricted internal movement and a travel while implementing all the formal strategies like identifying cases, testing, isolation, and case management, contact tracing and protecting healthcare workers. Without these population-based measures that largely reduce importation of new cases and limit spread, Africa will struggle. It is at a tipping point; any more disease transmission and its cases will skyrocket. The living conditions and the dynamics and kinetics of the thronging markets and overloaded public transportation that marks the daily interaction in most of sub-Saharan Africa will yield a basic reproduction number of close to 15 instead of the expected 2.5-3. It would therefore see a surge sooner than most western nations. Its African Union is gearing up to follow the example of the European Union in coming up with a concerted continental strategy to reduce death, harm and limit the impact of the disease. Its average hospital bed to patient population ratio according to World Bank data is 1.2 to a 1000 population, lower than the world average of 2.7 and much lower than Italy’s value of 3.4 and America’s value of 2.9. It cannot fully handle the demands of a surge of cases which this outbreak demands. In some of the African states the ratio is as low as 0.7 and 0.9.

This outbreak has elucidated the need to train and invest more in infectious disease capacity in a world where the business environment and global economy is exquisitely sensitive to global pandemics. Most of the financial gains of the last ten years have been wiped clean in three months like a dog licking a plate. African countries which touted the fastest GDP growth rates will report a slowing economy next year. For the first time in history the Olympic Games has been cancelled and Wimbledon has been called off. All this signals the need for every country to be concerned about global health security. Now we know that what happens in a small market in Wuhan city or any laboratory for that matter is everyone’s business. Diseases are impudent to borders.

The office of Global Affairs of the Health and Human Services is the diplomatic voice of the department tasked with liaising with multilateral organizations, foreign governments, and ministries of health, civil societies and the private sector to gain pertinent information and apply policies that can be used to keep Americans safe. Its Global Health Security Agenda mostly focuses on disease detection and sharing of knowledge and expertise and laboratory capacity building. At the Centers for Disease Control, its Division of Global Health Protection  works with partner countries to quickly identify and contain outbreaks to avoid the economic instability that COVID-19 has left its wake. CDC partners with 33 countries, China is not one of them. The U.S. is one of 67 countries who have signed up to be part of the Global Health Security Agenda. This agenda is to prepare these countries to detect epidemics and reduce the impact of nations who have signed up. On March 17, in an interview transcribed on their website, the chairperson, Roland Driece of the Netherlands, noted that in the midst of this pandemic the voices of their members have remained silent as each member tried to focus on containing the disease in their respective countries. He noted, though, that these countries were better prepared by virtue of signing up as members. Given the far-ranging effects of this pandemic it appears that mandating that every country sign up for this agenda begs the question. This would have given rise to a more coordinated global response than the status quo which allowed the virus to move around the world in waves because it knew there was not a unified global plan to arrest it in its path. The extent of this pandemic is a wake-up call for a review of all the Global Health strategies that are currently in place.

This COVID-19 pandemic has taught us the need to add infrastructure development to all these global initiatives and agenda. Specifically we need to invest in infectious disease hospitals in this country and around the world. At the very rudimentary level hospitals struggle to prevent nosocomial infections due to MRSA, VRE and ESBL organisms. It will be useful to keep patients with these infections in a separate hospital to reduce nosocomial infection rates. The unwelcome appearance SARS-CoV-2 on the world scene has created a situation where COVID-19 patients are being cared for in hospitals with single intensive care units. It creates conditions where a patient with COVID-19 would be managed next to a patient who does not have it. While all health authorities recommend social distancing in our public lives when it comes to persons with unknown COVID-19 status, hospitals are compelled to care for vulnerable patients right next to them totally devoid of any social distancing, separated only by a wall. Nosocomial COVID-19 infections will be inevitable and unfortunate. Healthcare worker death and morbidity is occurring right here on American soil. As navy ships are deployed to New York and convention centers are opened up to house more patients, it is a stark revelation that the need for infectious disease hospitals is a consideration that must be a top agenda item in every state and country. Just as the Ebola outbreak led to the investment in biocontainment units in selected hospitals around the nation, COVID-19’s demand and lesson will be the need to invest in specialized infectious disease hospitals like China and Nigeria built. It is a novel idea, but we need to learn some lessons from this evil scourge on the human population. We cannot predict when this outbreak will end but it is already stretching our intensive care unit bed capacity.

Infectious disease doctors who have mostly focused inwardly on patient care and consults will have to make global health their business now that we know that an infection in a market in faraway Wuhan City will place the life of an emergency physician in the balance in New York and take the life of an eminent neurosurgeon Dr. James Goodrich. It is time to step out of the cocoons of safety in the hospitals and assume global leadership in a world that is asking us to lead.

There has been such a global shortage of ventilators that we need to also focus on rapid mobilization of resources and manpower to handle pandemics. This will not be the world’s last one, we should learn as much we can from it. Next time we will not be caught flat-footed.