On the surface, I look like the perfect person to effectively respond to COVID-19.  My educational background includes a PhD in Epidemiology, an MPH with an emphasis on Infectious Disease, an MD, Internal Medicine training and 12 years in private practice.  I know inherently that viruses know no boundaries and the concept of a virus “jumping” from animals to humans was not new to me. The fundamental epidemiologic concepts of surveillance, data sharing, and coordination of response were ones that I was confident would be employed to identify and contain the outbreak in the United States.  But none of that happened and the American public has suffered mightily as a result.  In retrospect, it is now obvious to me why our medical system has failed each and every one of us.

My faculty advisor during my graduate studies was the preeminent virologist Dr. Robert Shope. He was the principal author of the groundbreaking 1992 publication Emerging Infections:  Microbial Threats to Health in the United States.  At the time of the publication, Dr. Shope commented “The medical community and society at large have tended to view acute infectious diseases as a problem of the past.  But that assumption is wrong.  We claimed victory too soon.”  

I had really no practical exposure to an infectious disease outbreak until the 2009/2010 H1N1 “swine flu” outbreak.  At the time I had so little clinical experience I assumed that flu season was just normally that bad.  In retrospect, it did strike me as odd that so many of my cases were younger but my ignorance made this unusual and characteristic feature of H1N1 seem simply, well, usual.

Fast forward a decade.  I’m older, greyer and debatably wiser. The 2019/2020 flu season followed its usual pattern with flu cases peaking here in Los Angeles between Christmas and New Years.  However, towards the end of February, I began to see a perplexing number of flu-like illnesses that tested negative on our point of care testing.  Were these Influenza B cases?  Was it an issue with the test itself?  Or was it something else?  A recent LAC+USC study suggests that this may have indeed been COVID-19 as 5.3% of patients to their medical center who presented around that time with influenza-like illness were shown to have the novel coronavirus.

I began following the coronavirus outbreak in China in earnest beginning in mid-February.  I really began paying attention when CDC’s Dr. Nancy Messonnier stated that she expected widespread transmission of the virus in the US.  The first case in the US was reported February 27th and that week I stopped seeing patients with any acute illnesses in the office.  By mid-March, I had closed the office entirely to patients transitioning to telemedicine and a video platform for assessments.

Surveillance systems – preferably global – are the first, and perhaps most critical bulwark of a health system that can rapidly and definitively respond to a pandemic.  As Dr. Shope wrote in his landmark paper, “Surveillance can take many forms, from complex international networks involving sophisticated laboratory and epidemiological investigations, to small, community-based programs or a single astute clinician.”  

So what happened in the United States that our own surveillance system has failed miserably ?  There are many places in which blame can be reasonably placed, but our inability to effectively respond to COVID-19 has exposed the rotten core of our healthcare system, one which is too bureaucratic and top heavy to respond to shifting threats. This system has consolidated around regional hospital systems which have absorbed community based, independent primary care practices.  It has decimated rural and small town medicine under the guise of higher quality care being available in metropolitan health centers.  Health insurance companies then contract with these  large hospital entities, creating a massive administrative complex which provides zero direct patient care.

For the past 10 years, I watched as primary care physicians – our “single astute clinicians”-  have been devalued in our medical community.  As with all skilled gaslighting, this erosive process began innocently enough at the hospital level where doctors used to caring for their own inpatients were replaced by hospitalists. There simultaneously occurred mass consolidation wherein the major hospital groups acquired outpatient practices.  Inherent in these negotiations (brokered by hospital administrators and legal counsel) was the fact that primary care medicine was openly and unabashedly characterized as a  ‘loss leader.’  Its value remained only in patient recruitment, retention and referrals to hospital owned imaging centers and more profitable specialty care. As a result, the profit driven health care system that valued knee replacement over cardiovascular disease prevention left the citizens of the United States with no surveillance network.  

By 2019, for the first time ever, employed physicians exceeded independent physicians. This key component of recognizing an emerging infection, assessing the risk of such and sounding the alarm was left in the hands of hospital administrators – individuals with no formal medical training..  So what did hospitals do?  They pulled inwards – shuttering outpatient clinics, abandoning any community outreach and instead braced for an inevitable tsunami of critical illness due to COVID-19.

Our ill prepared system has failed at every turn in our pandemic response.  We have further experienced a massive failure of data sharing this in spite of  huge expenditures and profits reaped by Electronic Medical Record (EMR) vendors such as Epic. Hospital systems have touted their “patient portals” yet never bothered to seek connections with their local, regional or state health departments. Thus, in the face of a pandemic, the EMR is useless. Instead we are left filling out case report forms and FAXing them to the local health department. 

Senator Kamala Harris has described a “vacuum of leadership” in Washington DC.  This vacuum is also present in our healthcare system.  Into this empty space, the novel coronavirus has swept encountering no resistance as an hospital leadership who only months ago were busy with service lines and maximizing profits are now nowhere to be seen.  Health insurers have provided no guidance, no leadership, no innovation.  Is it any wonder that a system which wastes 25% of its healthcare expenditure has failed us when we needed it most?

But this is the direction the United States has chosen and we are harvesting what we have sown.  We have chosen profits over people and have on our hands a massive, entirely preventable death toll. We are lucky that COVID-19 spares children. We are lucky that it does not have a 100% mortality rate like rabies, 50% like Ebola or 35% its coronavirus cousin, Middle Eastern Respiratory Virus (MERS).  While nature may abhor a vacuum, this single stranded RNA virus has thrived in ours. The next outbreak may have a high mortality rate and may preferentially infect our children. 

This could have been so much worse.

So the next time, our healthcare system had better be up to task.