Public Health: The Past Is the Prologue

February 2020, when I expressed hope on these pages that lessons from past epidemics would serve us well as COVID-19 was spreading around the globe,¹ seems like a lifetime ago. We knew that a pathogen can travel from a remote village to major cities on all continents in 36 hours.² We knew that it took 2 years of sustained and massive global efforts until the 2002 epidemic with another coronavirus (SARS) fizzled.³ During those years, the CDC deployed more than 850 people to work on SARS (more than 90 deployed to 12 countries including Taiwan, China, Vietnam, Singapore, and the Philippines). When all was said and done, only 161 possible cases were identified in the United States.³ The containment and control efforts cost the United States approximately $40 billion.

The lessons learned were forgotten, warnings about the increasing threat of a global epidemic increasingly ignored, public health and CDC budgets were cut, the position of a CDC’s front-line person to help detect disease outbreaks in China was eliminated, and national epidemic preparation plans were discarded.^1,2,4,5 As of May 26, 2020, the CDC has been able to deploy around the same number of staff (about 800) to support the COVID-19 response as were deployed for the SARS epidemic.⁶ The U.S. costs have already far exceeded the $40 billion it cost to stop SARS in its tracks; by some estimates the pandemic could cost the U.S. economy $973 billion.⁷ Only a handful of countries have been able to “flatten the curve,” and the number of deaths per 100,000 population continues to increase in, among others, Brazil, the United States, India, Mexico, Chile, Spain, Pakistan, South Africa, Indonesia, and Saudi Arabia.⁸ 

These are “just” the numbers. They do not tell the story of heartbreak, suffering, anxiety, and insecurity, nor the morbidity associated with surviving COVID-19 or excess non-COVID19-related deaths. Information about the latter is starting to become available,⁹ and we are just starting to understand the effects of this pandemic on the short- and long-term outcomes of patients whose care was delayed. Similarly, long-term effects on essential workers, on the front-line health care professionals who bore witness to the suffering while fearing for their own health in the wake of PPE shortages, remain largely unknown. Chances are that, similar to SARS, many will develop post-traumatic stress syndrome.¹⁰ 

There is no magic bullet to prevent or treat COVID-19, but we are starting to get a better handle on how to apply the centuries-old principles of infection control to this pandemic: preventing contamination, screening, and contact tracing. We know that the rate of COVID-19 cases and deaths went down when lockdowns were imposed. If the virus cannot find a new host to live in either because it cannot reach the next victim or is killed on a surface, it will die. Yet, not everyone seems convinced or, perhaps, people are getting impatient. The American Medical Association continues to sound alarm bells that some people believe the pandemic is behind us, reminding them that PPE shortages that jeopardize routine medical care and endanger health care professionals remain.¹¹ Similarly, CDC guidelines to prevent the spread of COVID-19 are widely available yet not followed by some individuals and state governments, and the American Hospital Association is urging the Department of Health and Human Services to extend the current public health emergency, which is set to expire in July.¹² Health care professionals may scratch their heads and wonder why calls to implement relatively simple prevention practices such as social distancing and wearing a face mask are not universally implemented. But, when the history books are written, chances are we will find similar themes to those observed during previous epidemics.

In her award-winning book, published 20 years ago, Lauri Garrett observed that public health is a bond – a trust – between a government and its people: a trust that the government will oversee and protect the collective good health.¹³ Even in 2000, there was ample evidence that, for a variety of reasons, the trust in public health all over the globe was diminished. She also observed that public health is not an ideology, religion, or political perspective and that, indeed, history demonstrates that whenever these forces interfere with or influence public health activities, a general worsening of the populace’s well-being usually followed.¹³ Yet, because public health is funded by the public, its budget and policies are subject to the politics of a particular time. This time, in a world of polarizing distrust, trade tensions, and a history of cuts in public health funding, the spread of COVID-19 was aided and abetted by a lack of clear or outright misinformation.⁵ For example, a U.S. national survey conducted between March 29 and April 13 showed that while knowledge about COVID-19 was very high, significant differences were present.¹⁴ Although the survey oversampled hotspot areas, knowledge of potential fomite spread and COVID-19 symptoms was statistically significantly lower among respondents who were African American, Hispanic, male, younger (18–29 years of age), had a lower income, or self-identified as Republican. The study also found that knowledge scores were highly correlated with behavior. That, finally, are data we can do something about. 

We may feel powerless in the face of this onslaught and persistent worries about our patients and our own health, but we can teach! We can explain how the virus is transmitted and how to prevent that. We can explain why a surge in cases is such a big concern, and how it may affect your ability to provide the care patients need now, let alone when they contract the coronavirus disease. You can build on the trust you established with your patients to make sure they understand, write letters to the editors of local newspapers, and, of course, try to counteract the myriad sources of misinformation in the world of social media. We can do this but it will be a long, long marathon, not a sprint.

Tim Brookes, the author of Behind the Mask,³ dedicated his book to all those who struggled to understand and contain SARS, to those who died trying, and to their families. We already know that this will be the dedication for the COVID-19 history books. Please be safe! 

The opinions and statements expressed herein are specific to the respective authors and not necessarily those of Wound Management & Prevention or HMP. This article was not subject to the Wound Management & Prevention peer-review process.