In May 2020, Dr. Rick Bright, former director of BARDA, warned Congress that, without ramped up coronavirus pandemic preparedness, we would face the darkest winter in modern history. His warnings were spot on, however there has been precious little follow through and that will be a problem in 2023.
As a result of previous Dark Winters, 385,433 died during the season in 2020 and another 463,203 the following 2021 season even after vaccines became available. Now we find ourselves facing a third dark winter as we enter 2023. Here are seven considerations that need to be addressed to avoid future dark winter(s).
1. The “Perfect Storm” (Influenza/RSV) will pass; Covid-19 will not.
The well-publicized perfect storm of Covid-19, seasonal influenza and respiratory syncytial virus (RSV) will soon fall from the headlines because infections from the latter two have peaked early. The CDC anticipates an earlier than usual decline in both influenza and RSV infections. What is not going to decline is Covid-19.
A harbinger of what the US will experience comes from the north as 2022 has been Canada’s deadliest year since the pandemic began. A troubling observation is the shift in public attitudes regarding Covid-19 that mirror those of many Americans. Canadian ethicists and medical professionals see their society willing to live with Covid-19 and return to normal lives if the worst effects are confined to specific populations. This attitude is easy to understand, but not so easy to accept.
Those who become seriously ill, and die are largely out of sight and easy to ignore. They are overwhelmingly over 65, immunocompromised, marginalized and poor.
In the US, people over 65 make up 16% of the population but account for 75% of Covid deaths. The Hastings Center asks “How May Covid-19 Deaths Should We Accept?” On December 28, the Johns Hopkins’s 28-day death toll was 47,129.
With China’s relaxation of its Zero Covid policy, hundreds, if not thousands, of travelers are already dispersing the virus worldwide. Fifty percent of passengers arriving in Milan, on two separate flights from China, tested positive for Covid-19. Our 2020 pandemic response taught us that Covid testing visitors will not stop viral spread and travel restrictions even less so.
A new and very worrisome Covid-19 variant is in its ascendancy – XBB.1.5. The variant is a recombinant (fusion) of different Omicron variants and has nearly doubled in prevalence over the past week representing close to 41% of new cases. It is the most immunity-evasive variant to date and no accessible therapies exist to neutralize XBB.1.5.
2. The combination of severe Covid-19 and Sepsis is deadly.
An article appeared in OFID discussing the critical need for new diagnostics that can rapidly distinguish one infection from the other because the two can coexist. This is important because a delay in making an accurate diagnosis means a delay in administering targeted therapy and yields poorer outcomes.
Covid-19 sepsis is deadly. Current laboratory testing methods require days or longer to determine the presence of a secondary pathogen, identify it, and determine its sensitivity to treatment. Delays in administering targeted treatment can have lethal results.
Treating Covid-19 sepsis requires a better understanding of the destructive processes wrought by the dual infections which cause one limb of the immune system (the lectin pathway) to become hyper-activated. Restoring normal function will save countless lives.
3. Our healthcare infrastructure will have a difficult time meeting the challenges of the coming surge in new Covid-19 infections.
RSV infections are currently overwhelming hospitals and their intensive care units raising bed occupancy to over 80% in many regions. As RSV subsides, the winter Covid-19 surge will take over.
Infections are not the only reason patients require hospital care. Other winter-related injuries requiring hospital care include falls, heart attacks, hypothermia and carbon monoxide poisoning.
Add to this list the need to treat chronic lung disease, diabetes, cancer and trauma and the strain becomes all too obvious. Emergency Room wait times are frequently measured in hours. Then, once a decision is made to admit a patient from the ER, it takes hours to find an open bed. In Boston, patients lie on hallway gurneys for 8 hours awaiting transfer to a floor bed. This is what 85% occupancy looks like.
4. Supply chains have not recovered.
The inability to get a new car or major appliance will be seen as inconveniences compared to difficulty accessing basic goods. Just-in-Time works well when supply chains are reliable, but it is not flexible enough to efficiently deal with disruptions.
Eggs, toilet paper and produce rely on a fragile system of distribution. Basic medicines and therapeutics do as well. Children’s Tylenol is in short supply. Some regional pharmacy shelves are empty, and physicians are having to be creative in addressing the problem.
Supply chain disruption has already caused a shortage of common medications like Adderall and the antibiotic amoxicillin. The FDA lists nearly 125 medications and medical devices that are currently in shortage. Disruptions increase the price of medications creating problems for individuals who are uninsured or who have high deductibles and copays.
5. Inflation is a threat to our economy and our health.
Inflation exposed the weaknesses of our fragile economy. Food prices are 12% higher than a year ago while wages increased by only 5.2% over the same period.
Federal subsidies for therapeutics like Paxlovid and vaccines are to expire in January. Currently, the government pays $530 per course of Paxlovid and $30 per dose of Covid-19 vaccine.
When the agreement expires, the projected out-of-pocket cost is expected to exceed $530 per course of Paxlovid treatment. Similarly, the cost of a single dose of vaccine is expected to quadruple to $120. Americans facing inflationary forces will be unlikely to spend their money on therapeutics.
That response will be costly. The ill will become sicker, miss work and may require hospitalization. Those with little or no sick leave may lose their jobs. People without jobs will lose health insurance. Incurred health care costs will drive some to bankruptcy and leave society holding the bag. This is not sustainable.
6. We have never understood how to work with China.
Any dealings with China are complex and challenging. China is the undeniable other major global player with a large and diverse economy, a significant military presence, and a unique political system. To date, we have followed an incoherent plan that seesaws between trade agreements and sanctions because we have failed to listen to, much less understand, China’s goals. In simple terms, China seeks to be engaged as a co-equal in the economic, diplomatic and societal arenas.
Despite undeniable cultural differences, we must recognize China’s great potential as a collaborator if we expect to contain the ravages of Covid-19. It may seem like a cliché, but Covid-19 infections anywhere mean Covid-19 infections everywhere and this is especially true if they occur in China.
7. America is Unhealthy.
America is already among the unhealthiest of industrialized nations and is getting sicker. We lost 26 years’ worth of progress on life expectancy according to a recent report due to Covid-19 and drug overdose deaths.
Comorbidities increase the risk of death from both Covid-19 and Covid-19/sepsis infections. Over 40% of our population is either overweight or obese. A decade ago, no state had an adult obesity rate over 35%. Today, 19 states do. Pandemic quarantine and isolation practices led to poor eating and exercise habits. Both contributed to weight gain.
Isolation and quarantine fueled depression which led to alcohol and substance abuse. Unsurprisingly. deaths from liver failure (cirrhosis) and suicide increased.
Covid-19 precautions caused the unintended consequences of delayed medical care. Postponed checkups for cancer screening, blood pressure monitoring, diabetes control and a host of other maladies resulted in avoidable disease progression and death.
Before we consider reversing this trend, we must stop its progression. A good place to start would be recognizing obesity as a disease rather than a character flaw. Multiple diseases are either caused by or are worsened by being overweight.
Adding to America’s poor health are patients who survive acute Covid-19 infection only to be burdened with post-acute sequalae of SARS-CoV-2 (PASC) or long-Covid. At least 1 in 13 US adults (7.5% of the population) have long-Covid. We do not understand long-Covid or how to treat it. We do know that long-Covid can be debilitating and long lasting. Reinfection with Covid-19 for a second, third, or fourth time, increases the chance of developing long Covid.
Conclusion: We can pay now or pay dearly later.
The attack on and erosion of American health has never been greater. Yet when we need their incentivization and funding the most, the public and the private sectors are not fully supporting innovation.
We cannot afford to ignore the warnings of Dr. Bright, who might also encourage us to heed the motto of House Stark – “Winter is Coming,” so that we prepare. If stakeholders fail to mount a vigorous response to incentivize and support diagnostic and therapeutic innovation, we will enter another Long Night that might have been avoided.