A mass casualty occurs when the destructive effects of nature or human-made forces overwhelm the ability to meet the demand for health care. During the twentieth century, humans and pathogens caused mass casualties that killed over 271M people worldwide. Most countries prepare for human-perpetrated mass violence through their national defense structure. Such has not been the case with pathogen-caused mass casualties. COVID-19 demonstrated the existential threat an uncontrolled pathogen presents, capable of scale beyond that of human conflict.
Just before COVID-19 (SARS-COV-2) hit the United States in 2020, the nation’s level of health security (ability to prevent or respond to acute threats that endanger health) received the highest index score in the world from the Center for Health Security at Johns Hopkins. No nation was better prepared for a pandemic, yet with over 1.1 Million deaths (40% higher than Europe), a staggering $16 trillion ($5 trillion in direct Federal expense) in full economic impact, and a profound sense of Federal Government failure, no nation performed worse than the U.S. at protecting its people from loss. Despite two decades of mass casualty preparation, the government’s response displayed collective national incompetence manifested in systemic inadequacies at nearly all levels of preparedness response; for example, public health surveillance, health (bio, medical, and public health) system integration, testing, response funding, national stockpile management, foreign supply chains, medical and public health staffing, and above all, leadership. I left many to seek pandemic information from non-government sources, where mis and disinformation abounded, diminishing the value of an important pandemic response tool… informed citizens.
It wasn’t as if the U.S. was caught unaware or flat-footed. In 2005, President George W. Bush, having experienced two mass casualty events (9/11 and Hurricane Katrina) and aware of an increasing probability of an epidemic/pandemic, addressed the National Institutes of Health, where he presented a $7.1 billion strategy to get America prepared for imminent mass casualty events, human or nature caused. Specific to epidemic preparedness, he called for increased epidemiological research, improved vaccine technology, detailed quarantine plans, and stockpiling everything from vaccines to personal protective gear. Subsequent Administrations’ did not afford mass casualty preparedness the same commitment. For example, the Obama administration utilized the stockpile during the 2009 influenza and 2016 Zika outbreaks but did not replenish it. The Trump administration also did not fund replenishment, leaving a depleted federal stockpile critical to the fight against COVID-19.
After-action findings assessed the U.S. government’s COVID-19 mass casualty response as lacking focused strategy, actionable policy, sufficient prepositioned resources, and means and methods to immediately augment and backfill initial responses with capability and capacity. Preparedness requires a commitment to operational readiness designed to respond rapidly to untoward events of specific causal source types. In a pandemic, the enemy will be a pathogen. Best policy building blocks are knowledge compiled from operational expertise organic to government. For example, the government’s Center for Disease Control and the Department of Defense developed and executed the successful Operation Warp Speed. The challenge inherent in preparedness policy is twofold. Leadership’s commitment to readiness capability and capacity. Simply this means preparedness is an investment that may never provide a return but, when needed, is worth much more than the cost to respond if unprepared, hence the characterization of preparedness as “spending billions to save trillions.” Second is the regular exercise of policy readiness for relevance and sufficiency against ever-changing threat assessments. In an emergency, governments either have the necessary resources or they don’t. The COVID-19 response demonstrated the latter.
Although national leaders recently ended the three-year-old pandemic state of emergency, COVID-19 remains a threat with weekly tolls of approximately 70,000 infections and 700-1,000 deaths. Viral mutations put Coronaviruses in a similar category as other human cross-over viral forms (for example, influenza), which can mutate into strains with heightened transmissibility and infection ability; for instance, Coronavirus was first identified in 1962 when it caused the common cold. In later years, it mutated into lethal strains, SARS-CoV1 in 2002, MERS in 2012, and SARS-CoV-2 in 2019. Lethality and transmissibility are public health concerns with pathogens. For example, the influenza virus of 1918 was four times more lethal per infection but less transmissible, and CoV1 of 2002 was twenty times more lethal but also less transmissible. Slow transmissibility benefited medical and non-medical control actions. What accentuated CoV2’s lethality was its rapid asymptomatic transmissibility, unexpected virus behavior not immediately identified by epidemiologists impacting response effectiveness.
We live in an era where a lethal virus can emerge suddenly and spread rapidly, requiring vaccine and therapeutic mitigation. Genetic research affords the understanding necessary for developing effective vaccines and therapeutic responses. An essential capability in response preparation. This importance was demonstrated during COVID-19 when researchers used genetic codes from SARS-CoV1 and MERS to accelerate (cut in half) COVID-19 vaccine development, saving thousands of lives.
Dr. Stephen M. Wolfe, an Instructor and Health Service Administrator, combines 30 years of experience as a graduate-level educator with 26 years of healthcare leadership, including a role as a Colonel in the USAF Medical Service Corp. His career also spans 13 years of leadership in County Government probation and mental health. He holds a Doctorate in Business Administration, specializing in Health Service Administration.