I recently finished reading Uncontrolled Spread, a new book by Scott Gottlieb, MD, which offers an incredible deep dive into what was and is still happening with the U.S. government's pandemic response. I believe Uncontrolled Spread will be the most authoritative book on the COVID-19 pandemic in the U.S. out of the many books that will be written.
From the beginning, Gottlieb has had an outlook on the COVID-19 pandemic that was both prophetic and personal. He carefully tracked the initial spread of the coronavirus from its early days in Wuhan, China, and then in Lombardy, Italy. Most of the country didn't take the pandemic seriously at that point, but Gottlieb -- who left his post as FDA commissioner in 2019 -- sounded the alarm. In January 2020, he warned that the outbreaks in other countries were previews of what would happen in the U.S. It's one of many predictions Gottlieb got right when so many were wrong.
One of the first places in the U.S. hit hard was a hospital where he had trained as a medical resident -- Elmhurst Hospital in Queens, where refrigerator trucks lined up outside to receive some of the earliest COVID-19 victims. He could personally feel the weight of the tragedy. Testing was a mess. In his book, Gottlieb does a root cause analysis. As he writes, the original sin of our pandemic response was relying on government bureaucracies to guide us using legacy systems that no one understood or dared to question.
The U.S. took a top-down approach that created bottlenecks, when what we needed was decentralized action that would allow for a nimble response. It began with a regulation that no doctor or medical center could test a person for COVID-19 -- even though they could easily do so -- unless their test had been authorized by the government. The test the CDC put out was flawed, but that was entirely avoidable. Moreover, any lab that wanted to develop a test needed a sample of the virus, which only the CDC could provide. Without a sample, there was no way to prove that COVID-19 tests would work. But, like an angry librarian who gets mad if you want to borrow a book, the regulators made it hard for labs and public health experts to do their jobs. This hamstrung the U.S. response, causing us to lag far behind other countries in testing. By the time we had testing, the virus was on the run and it was hard to catch up.
Without good information about the number of COVID-19 cases we were flying blind. U.S. public health officials used hospitalizations as a proxy indicator for the epidemic, but this didn't offer a complete or accurate picture of what was going on. Government doctors had been accustomed to relying on hospitalizations as a key indicator in the influenza-like surveillance system. But since it was a mild flu season and COVID-19 hospitalization are a lagging indicator, many, including all of our nation's top physician-public health officials, falsely concluded that we did not have widespread community transmission. But in hindsight, we obviously did. In fact, the coronavirus was seeded all over the country. Like sheep, the media and public health leaders got caught up in the debates, while being myopically dependent on "confirmed cases" on the Johns Hopkins COVID-19 map, as if two cases on a map really meant there were two cases. It didn't. Meanwhile, in the absence of data, political opinions filled the void and became louder over time.
Gottlieb argues that these critical mistakes are not just interesting tidbits of historical trivia. These are structural problems that desperately need to be fixed today. The CDC has consistently delivered tardy and inadequate data throughout this pandemic, leaving both the public and the medical community with few tools to fight it. He attributes this to an agency culture that has historically performed "high-scienced" and "retrospective reviews," as done in Morbidity and Mortality Weekly Report (MMWR).
Remarkably, the CDC, an agency with 21,000 employees, does not have much of a rapid response team. But in a pandemic, we need the CDC to deliver real-time data. Have you ever wondered why so many of our insights about COVID-19 come from Israel, and the best study about masks comes from Bangladesh? We spend more than $100 billion on taxpayer funded medical research each year in the U.S., yet the CDC has failed in its primary function to deliver data to guide our pandemic response.
Even today, as policymakers discuss COVID-19 vaccine booster shots, we don't have the information we need. We currently have about 100,000 Americans in the hospital with COVID-19. The CDC has data on the small subset of those who were vaccinated, including which vaccine they had, how long it's been since their shots, and whether they have any pre-existing conditions. Analyzing and sharing this information would help shape our booster plan and inform vaccinated Americans of their current risk. But sadly, the CDC is not providing this data.
One of Gottlieb's main book themes is that we need to stop treating pandemics as a boutique medical subject. The preparation for the next public health emergency needs to begin right now. Moreover, it needs to recruit our clandestine services to assess threats early. Doing so in Wuhan would have helped us get an important head start. Getting ready for the next crisis may sound esoteric, especially since we're still trying to claw our way out of this one. But it may not be a viral pandemic that's generations away -- it may be a tsunami, antibiotic-resistant bacteria, a mass shooting, or biological warfare. The next crisis could be right around the corner.
In fact, for those wanting to harm masses of people, the pandemic introduced a new weapon. Gottlieb sternly concludes that we must treat labs as sources of biologic weapons and that this activity should be monitored around the world, just as nuclear weapons are monitored globally.
Throughout the pandemic, Gottlieb spoke with the front-line physicians, researchers, and top decision-makers at the highest levels in government. He became a leading voice of reason as the American people tried to make sense of COVID-19, and policymakers and business leaders struggled to protect the public. Every clinician can learn a thing or two from reading his new book and paying attention to his detailed guidance on what needs to change. Now is the time to redesign our healthcare agencies, not in the future when the urgency is forgotten.
There are many books on COVID-19, and there will be more to come. I believe Uncontrolled Spread will emerge as the best of them. It comes from a unique and impeccably qualified vantage point. Gottlieb's comprehensive analysis and take-home messages offer hope and direction that we can only hope our decisionmakers will heed.
Marty Makary, MD, MPH, is editor-in-chief of MedPage Today, a professor at the Johns Hopkins University School of Medicine, and author of The Price We Pay: What Broke American Healthcare -- And How to Fix It.
https://www.medpagetoday.com/opinion/marty-makary/94619
