Title:Weathering the Storm

Only days into 2020, Georgetown Law professor Larry Gostin was already communicating with global health colleagues about a novel virus that had emerged a few weeks earlier in Wuhan City, China. From a few clusters, the new virus—what we now know as COVID-19—spread rapidly in China, then throughout the region.

“I knew we were in real trouble,” Gostin recalls thinking then. That COVID-19 would spread from the region and reach the United States was just a matter of time—like watching a hurricane approach.

Gostin is one among dozens of faculty members from every school at the university with pandemic-related expertise and research. Over the summer, Georgetown Magazine talked with four faculty members about why this virus is causing worldwide devastation and what the future might bring.

Gostin is no stranger to global pandemics. He’s worked in public and global health since the beginning of the AIDS epidemic in the early 1980s. In a March interview with Georgetown President John J. DeGioia in his Georgetown Now series, Gostin told him, “I was in the CDC [Centers for Disease Control and Prevention] war room when the first case of HIV was announced.” Gostin has long worked alongside Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, with whom he is still close friends.

Gostin holds the highest rank of University Professor and is the founding director of the O’Neill Institute for National and Global Health Law at Georgetown Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He is the Global Health Editor of JAMA. Over his career, he has been called on for his expertise on SARS, MERS, H1N1, Ebola, and Zika outbreaks over the last 20 years. He is on the expert panel of the WHO International Health Regulations, which govern global pandemic response. This year, he’s been sought out almost daily by the media as the novel coronavirus, now in its second wave, spreads at a crushing pace.

Within three months of the outbreaks in China, the World Health Organization declared COVID-19 a global pandemic. A month later, Europe was the virus epicenter, and more than 1.1 million cases worldwide had been confirmed. As of November, WHO counts 57 million confirmed cases of the virus worldwide, with 1.4 million deaths. The United States, which confirmed its first case in January, had 12 million cases and 255,000 deaths by October, per the CDC. Beyond the numbers is untold suffering, a strained health care system, economic havoc, lost jobs and homes, upended social and community bonds, and lives hanging in suspension.

If more than 58 million confirmed cases of COVID-19 aren’t frightening enough, best estimates indicate that for every diagnosed infection there are 10 undiagnosed. Death-rate estimates range from about one percent to four percent of those diagnosed with COVID-19. Gostin thinks the death rate is on the low end of the estimates, “but even at one percent, COVID-19 would be 10 times more fatal than the seasonal flu,” he told DeGioia in their March interview.

Tools for decision making

Ten months into the worst global health crisis in a century, there are still so many unknowns: How many people are asymptomatic but able to transmit the virus? For how long? Once you’ve had the virus, do you have lasting immunity, or can you get it more than once? When will a vaccine be available? How many people died from the virus but weren’t counted?

“Figuring out these questions is critical to how we keep our economy going and who can then go back into the workforce,” Rebecca Katz, professor and director of GUMC’s Center for Global Health Science and Security (GHSS), told DeGioia in a March Georgetown Now interview. GHSS has seven faculty, five full-time staff members, more than a dozen students, consultants working around the world, and about 10 active programs in 26 countries. In addition to her work at the Medical Center, Katz teaches global health diplomacy, global health security, and emerging infectious diseases at the School of Foreign Service.

On November 10, Katz was named as an advisor to President-elect Joe Biden’s new coronavirus task force.

Katz’s research focuses on international systems, global governance, and international health regulations. “All of our teaching, research, and service at GHSS has been focused on preparedness and build- ing capacity around the world within governments and by promoting policies for exactly what we’re dealing with right now,” she says.

Since the pandemic’s outbreak, Katz’s expertise has been in high demand from mayors, governors, international organizations, sports organizations, and private industry to inform their policy and response efforts. “I’m helping them think through everything from high-level policy to very operational components, like should there be a thermal scanner at an entrance, and what are the metrics that we should be using to figure out whether we reopen or relax some restrictions,” she says.

GHSS has launched the “COVID-19 Frontline Guide” to provide state and local government leaders and other public officials with a web-based decision support tool and progress indicators to assess COVID-19 in their jurisdictions.

In September, Katz and her GHSS colleague Alexandra Phelan, a global health legal and policy expert, published a report, “Governance Preparedness: Initial Lessons from COVID-19,” which was commissioned by the Global Preparedness Monitoring Board. In it, they wrote that the success of any effort to redress pandemic preparedness failures demonstrated by COVID-19 requires an approach to governance that would include greater accountability, transparency, equity, participation, and the rule of law.

Crossing borders

There are ongoing pandemics of HIV, tuberculosis, and malaria, but most people in the United States don’t have personal experience with a global pandemic, says Mark Dybul (C’85, M’92). While outbreaks of other pandemics have remained localized regionally, the novel coronavirus rapidly moved from its epicenter to the rest of the world.

Co-director of Georgetown’s Center for Global Health Practice and Impact, Dybul has a nonstop CV in infectious diseases. He was an HIV research fellow at the National Institute for Allergy and Infectious Diseases, where he was directed by Fauci, whom Dybul considers a mentor and close friend. He also led the President’s Emergency Fund for AIDS Relief (PEPFAR), founded by President George W. Bush, the largest international health initiative in history and the model for presidential global AIDS programming to this day. Other roles include executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

“There’s been very little conversation yet about a global response. Everyone’s focused on their own domestic epidemic, which is understandable,” Dybul says. But unlike the SARS outbreak of 2002-2004, for example, which did not spread beyond a small number of countries, the new coronavirus quickly reached the United States. For the first time, the U.S. is directly affected by a global pandemic, “which means our interest is personal, not just humanitarian,” Dybul adds.

Amplifying inequality

A global pandemic is also local, and Washington, D.C., provides a lesson in how COVID-19 amplifies long-standing systemic inequalities, including access to health care, especially in historically marginalized communities.

According to estimates published during the summer, African Americans—who make up 45.5 per- cent of the District’s population—have accounted for three-quarters of the deaths associated with COVID-19. This mortality rate is attributable to a range of factors: disproportionate rates of pre-existing health conditions, such as heart disease and cancer, limited access to timely health care services, and socio-economic disparities.

Several years of research at the School of Nursing & Health Studies yields valuable data on the ties between entrenched racial inequity and health disparities. The data collected, analyzed, and published in a new NHS study is pre-pandemic, but it provides a baseline for future comparison analysis of the impact of COVID-19, says its lead author, Christopher J. King, chair of the Department of Health Systems Administration at NHS.

The report, Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia, builds on King’s 2016 study on the same issue.

King’s research gets at a fundamental question: When compared with other cities, the District of Columbia has a healthy profile. However, when health and socio-economic data are stratified by race, why is the narrative vastly different?

Deep-seated systemic issues that disproportionately affect African Americans increase vulnerability for a virus that transmits like COVID-19.

People of color are more likely to have front line and service-industry-essential roles that don’t lend themselves to telework, and often lack paid sick leave. And early in the pandemic, many employers did not have the capacity to provide personal protective equipment, nor did they have work environments with structural barriers. High-density apartment complexes and multigenerational households also increase risk of exposure. And a digital divide precludes residents from accessing timely health information and engaging in virtual activities in the home environment.

“All of these [factors] create a perfect storm that puts residents at risk of not only infection, but also mortality,” King said to DeGioia in an April Georgetown Now interview.

In a wildfire

Mark Dybul wants a global task force on pandemics that is charged with detecting risk and dealing with preparedness, protection, and response—so he designed one. He and several Georgetown Center for Global Health Practice and Impact colleagues, including Katz, authored a white paper, A Global Health Pandemic Deserves a Global Response, which lays out strategies to deal with this pandemic and presents a framework that might prevent—or at least contain—future health pandemics. The white paper addresses both the health crisis and the global economy.

Beyond the massive economic disruption, there’s also the question of how to finance the response to the pandemic—from the costs of testing kits and patient care to the logistics of running the health supply chain, getting ventilators and other medical devices in place, distributing an eventual vaccine, and providing education to share best practices. The task force Dybul lays out would be global, with national and regional equivalents. Such a task force would not only need national governments, but also the private sector, nongovernmental organizations, and militaries globally to respond quickly.

One of the biggest issues in effective response is global interconnectedness. “We have two choices,” Dybul says. “We can basically become island states and never move around and never have risk of infection—which would destroy all our economies—or we can figure out how we work together.”
This kind of systematic preparedness is crucial, Dybul says, because domestic and international connectedness, population growth, and climate change will lead to more pandemics. “We need to be prepared for the long haul,” he says.

“The pandemic is a relatively straightforward public health problem,” Dybul adds. “If you had these technical responses and the financing in place now, you could have a rapid response to prevent the spread,”

The United States would normally be leading such an effort, Dybul says, but the Trump Administration has chosen not to play that traditional role. While Germany, South Korea, and New Zealand among other countries effectively contained COVID-19’s spread, the Trump Administration dismissed the severity of the threat and the guidance of scientists and its own coronavirus task force, he says. With 8.1 million cases and 219,000 deaths (as of October), the U.S. has the most cases globally.

“The U.S. objectively has had one the worst responses in the world in this pandemic,” Dybul says. “All the more aggravating is that we had a head start, because COVID-19 came to us later. We blew it all.”

Dybul notes that the Administration has announced that it will leave WHO in 2021, even though “we need global organizations like WHO more than ever.” Dybul is part of an independent panel to review WHO’s pandemic response, with the first report released in September.

“Even the strongest health system will fail without leadership,” Georgetown Law professor Gostin says. “This could have been stopped right at the beginning if we got tests out and did contact tracing immediately. Now we need to mask-up and maintain social distance. There were other opportunities to stop or slow the spread, but those are long exhausted,” Gostin adds.

“It’s like we’re now in a wildfire, and the fire department is overwhelmed. The fire will have to burn itself out,’” he says.

Holy Grail

Developing a safe and effective COVID-19 vaccine is the Holy Grail, and is likely to be considered the most valuable medical resource ever. Several promising vaccine candidates are in the final stages of testing, but none are approved yet. A vaccine developed by the U.S. may just have to take longer. “We have institutional guard-rails like the FDA and the CDC,” Gostin says. “These are robust agencies—they may need to bend to [pressure from] this Administration for speed, but they won’t break. We will end up with a safe and effective vaccine.”

When a vaccine is developed, it will be in limited supply, and it could require regular reformulation, like the flu shot, which has to be adjusted every year to attack new mutations in the virus. And manufacturing and distribution will need to accommodate global need. “There has to be justice and equity for people around the world to have a chance to live,” Gostin says. “A lack of equity will undermine global solidarity.” A U.S. Advisory Panel has been convened to monitor distribution, ensuring that health care workers and first responders have early access and that vaccines are distributed in a socially just way.

‘Don’t let hope be a casualty’

Despite a focus on the devastation, disruption, and death that COVID-19 has left in its wake, the faculty members interviewed in this article all see reasons to hope—and not just on the disease management front.

King is excited by the interest of fellow NHS faculty members and especially students. “Our students have an appetite for delving into the root causes of racial differences in health outcomes. Using our own city as a laboratory for experiential learning, they are able to make sense of the data and unearth opportunities for a brighter future,” he says.

Dybul urges that we not let hope become a casualty of the pandemic, pointing to the vast amount of progress made in treating AIDS worldwide over the last 20 years through a combination of science, leadership, and global cooperation. “We can look backward and inward with fear, or we can look outward and forward with hope,” he said in an April interview Georgetown President DeGioia. “It’s inspiring because if we all work together globally, we can solve this problem.”

Looking forward, Gostin already thinks about what we as a society will want to be like when the pandemic is over. “I think we will come through stronger because we’ve been here for each other.”