Gail Wilensky: We Need a Better Policy Infrastructure to Prepare for the Next Pandemic
In a new Perspective op-ed in The New England Journal of Medicine, Gail Wilensky, Ph.D. argues that the United States needs a new policy infrastructure in order to prepare for the next pandemic that might emerge. Wilensky, an economist and senior fellow at Project HOPE, an international health foundation, was Administrator from 1990 to 1992 of what was then called HCFA—the Health Care Financing Administration—and has since become the Centers for Medicare & Medicaid Services (CMS); she served as Administrator of the agency under President George H.W. Bush.
In her article, entitled “Policy Lessons from Our Covid Experience,” and published online in the NEJM on August 26, Wilensky first looks at the overall impact of the pandemic from a public health perspective and also from an economic perspective, noting that “[T]he Covid-19 pandemic has led to staggering economic losses in the United States. Closing down the economy has had a devastating impact on the American people, even though the closure was imposed to save lives. The longest economic expansion on record abruptly ended in February, and the country officially entered a recession late that month.”
Wilensky writes that, “As the country reopens, it’s important to assess how we can be better prepared to stave off such enormous economic losses during the next wave or the next epidemic. In my view, a few key policy changes will be critical.”
In that context, Wilensky says, “First, expertise on pandemic-related policy and strategy should be located closer to the center of power. I believe that the type of pandemic-preparedness office (the Office of Pandemics and Emerging Threats) that now resides only in the Department of Health and Human Services (HHS) also needs to be reestablished as part of the National Security Council (NSC). Incorporating the office into the NSC doesn’t guarantee that the White House will pay attention to its recommendations, but it helps in commanding the attention of the most senior members of the White House staff. The HHS assistant secretary would continue to serve as the execution arm of the pandemic office.”
Indeed, she notes, “Since the early 1990s, such an office has repeatedly been established after a national health scare — and then disbanded by the successor administration. The Biodefense and Health Security Office established during the Clinton administration was closed by President George W. Bush, reopened after the anthrax scare, closed by President Barack Obama, and then reopened after the Ebola and Zika scares, at which point the Directorate for Global Health Security and Biodefense was created. The plan prepared in the wake of the Ebola outbreak might have been helpful in preparing a response for the current Covid pandemic, but like his predecessors, former National Security Advisor John Bolton dissolved the office in 2018. Once again, some of the office’s personnel were merged into other NSC units, but the pandemic office itself no longer existed. Whether as cause or effect of the office’s repeated dissolution or sidelining, neither the defense establishment nor the public seems to appreciate that disease threats are as serious to the country’s security as are wars with our traditional enemies. For example, another airborne disease, smallpox, caused 300 million to 500 million deaths worldwide — more than all 20th-century wars combined,” she notes.
“Second, in planning for unknown future epidemics,” Wilensky urges, “federal pandemic-preparedness officials must decide what constitutes a prudent level of supply stockpiling, with an understanding of the inevitable trade-offs between perceived readiness and the cost of equipment and supplies that we hope never to use. They should develop strategies for deploying supplies on an as-needed basis. And they should plan ways to provide surge capacity for beds, operating rooms, and trained personnel, which may involve calling on the National Guard, among other resources. Designation of particular people who will be accountable for these activities will be key to their success.”
And, she writes, “Third, when an outbreak occurs, determinations about policy and financial responses should be based on accurate epidemiologic knowledge. It is important to establish as quickly as possible who is most vulnerable to a new disease and to respond selectively, with targeted measures directed toward the most vulnerable populations. Older people, particularly those with underlying conditions and compromised immune systems, are especially vulnerable to Covid-19. Some 50,000 deaths from Covid had occurred in nursing homes and other senior care facilities by mid-June. But older people are not always the ones at greatest risk. The “Spanish flu” in 1918 was especially dangerous to infants and 20-to-40-year-olds. We need to understand who is contracting the disease and experiencing serious consequences in order to craft an appropriate and differentiated response.”
Wilensky references research, writing that, “In a recent study, John Birge and others claim that the economic cost of the U.S. Covid shutdown could have been reduced by 33 to 40 percent if neighborhoods had been selected for closure more strategically, in line with the infection risk for local residents and workers.1 The authors’ rationale is that living areas are frequently different from the places with the highest concentration of jobs and that it may be possible to keep jobs open as long as many of the employees live in unaffected areas. To calculate the number of people at risk in a given area, however, we need to know who comes into contact with an infected person and be able to track their travel histories. Such work can be done with the type of contact tracing being done in Hong Kong, Germany, and elsewhere, but it may require that people provide detailed information to the authorities, including turning over their cell phones or providing details about their contacts in phone interviews. Many Americans are unlikely to be willing to do so.”
