How can we know more earlier?

Critics of President Trump have taken him to task for not giving this pandemic proper urgency earlier. After this crisis is over, a nonpartisan Commission should be appointed to assess everything that was done or could have been done, in order to avoid having a disaster of this magnitude happen again.

I have never believed that focus on stopping the spread of this virus should have been so high a priority that nothing else mattered. The President and the state Governors have to address multiple additional issues: the health and wellbeing implications of people losing their jobs (today, we learned that 6.6 million Americans filed unemployment claims, a staggeringly high number), the chronic disease risks of prolonged, indefinite isolation, stress and reduced outdoor physical activity, and irrational fear.

However, it is beyond dispute that it would have been beneficial for every decision maker to have understood the risks of this pandemic and to have acted earlier. Some people have sent me clips of remarks the President made in January, February and early March and contrasted them with the disaster that has unfolded since then. Their comments are understandable, but their logic is deeply flawed. If the response to the pandemic has to take all four factors into account, not just disease containment, then we can only judge decision makers on what they did, based on what they knew at the time they spoke or acted. At all times, they were having to make trade-offs between the risks of disease spread and the risks of acting precipitously that made other health, well-being and economic problems worse. Juxtaposing a February 20 comment by President Trump along side a tragic posting from Elmhurst Hospital in late March is neither useful, nor rational.

However, it is fair to ask what our government should have known earlier. What has emerged in the last two weeks is that Dr. Birx and others relied heavily on the data they were receiving from China about the scope of the disease in Wuhan. Dr. Birx freely admits that the reporting of 50,000 cases in a province with a population of 80 million people gave her the false sense of confidence that this virus was serious, but not at a pandemic level. She was led to believe that it was similar in scope to SARS, which we were able to keep contained. She did not realize the rapid and significant contagiousness of this virus, and would have made different recommendations if she did.

Clearly, what we now know and had confirmed in the last few days is that the Chinese government significantly understated the scope of the problem. We and others were misled and delayed acting for too long, based on what now looks like deeply-flawed information. Our intelligence services have concluded that this understatement by China was deliberate and a gross violation of world health norms. Whether that is the case is not something we will fully be able to understand because the investigative activity supporting it is top secret.

What should have given us more skepticism at the time was the degree to which the Chinese government actively persecuted the physician who attempted to talk publicly about this virus. We need not know why they did this, but their unwillingness to let the World Health Organization and others get better information earlier should have set alarm bells ringing. We would have begun development of diagnostic tests earlier than we did.

The other known fact is the contrast between what we did and what South Korea did at the earliest stages of the pandemic. South Korea, which had been badly burned by its slow response to the MERS virus in 2015, convened its large private sector companies when it had only four cases, and agreed that it would develop a Covid19 test kit as quickly as possible. It also agreed that speed of deployment and use was of the essence. The Government decided that the private sector would take the lead.

The South Korean made another critical decision: it was prepared to accept the risks of more inaccurate test results, because it lacked all the information it would normally have wanted before developing and deploying the test. Government-approved drugs, medical devices, and lab tests have safety risks and effectiveness risks. For diagnostic tests, there can be either "false positives" (a test incorrectly indicates the presence of a condition that is not there) or "false negatives" (a test fails to indicate a condition that is present). Fortunately for South Korea, it appears that the error rate was tolerable, despite the incomplete information available at the time the test process and equipment was developed.

Either error is bad. "False positives" cause medical resources to be misallocated and spread fear faster. "False negatives" cause individuals who need medical help not to get it. No test is perfect. As a result, some error rate is tolerated. How much is a policy decision, as well as a clinical or public health decision.

As a father whose daughter was diagnosed with chronic Lyme disease, I entered a world in which diagnostic testing is flawed and the correct protocols for diagnoses are hotly debated. The CDC has now taken the position that there is no definitive, error-proof diagnostic test and warns people visiting its site of that. The anger directed at doctors, researchers, and the CDC from imperfect diagnostic tests was beyond anything I could have imagined.

Whereas the South Koreans made a national government decision to accept a test process that had significant error risk built into it, the CDC set out to build a test kit that would have very few errors, but it traded off delay to achieve that result. Unfortunately, despite taking additional time and having better information, its first test kit was flawed and unusable.

Would the Trump Administration have let CDC make the trade-off it did if it had known about the contagious of the virus? No one knows the answer to this, because that was not the evidence available to it? In late February, President Trump convened the private sector and ordered multiple companies to work with LabCorp and Quest to develop test kits that could be deployed quickly and achieve the best results. The work was done in record time, and test kits were produced in record time.

Unfortunately, the supply chains to get these kits out and the training of healthcare and lab workers was another challenge. We found that clinicians and lab workers were a bit slow in using something new and incorporating it into their processes.

With the benefit of hindsight, we are likely to find many ways in which we could have discovered and correctly evaluated the risk of this virus earlier. However, at this point, we should be focused on what we do now and in the near term. The recent revelations about China also remind us that doing "Monday morning quarterbacking" may be premature, since we may learn things that change how we assess what we could have done differently a few months ago.