Systemic Aspects Underlying the COVID-19 Coronavirus Pandemic

Revised 1 April 2020

The dynamic behavior of the current COVID-19 pandemic stems from a number of interacting factors that are a consequence of how some key contemporary systems are structured.  This discussion endeavors to describe these systemic factors and how they amplify the societal impacts of the disease, particularly in the United States.  A number of systems aspects lead to recommendations.

 Systemic Factors Influencing the Virus’s Spread

The virus appears to have started its spread from the city of Wuhan, in Hubei Province in China.  Wuhan is a megacity with a population of approximately 11 million.  It is a major transportation hub and many residents travel extensively, both within China and around the world.  The outbreak in Wuhan began shortly before the Chinese New Year, when people are accustomed to travel widely to be with family or to vacation.  So the virus was primed to be spread particularly quickly from its point of origin.

Twenty-first century air travel connects major population centers around the world.  Ground transport links (rail and highway) further connect locations beyond air links.  Few locations of any size in the world are significantly isolated from each other.  Thus a virus can travel today throughout the globe with unprecedented speed.  Attempts to control the spread in the U.S. by restricting travel from China and other early centers of infection have been too late to have much effect.

In today’s world, there are many environments where large numbers of people gather in close proximity for extended periods.  In addition to airliners, these include ground transportation systems (trains, buses, subways, etc.), sporting events, shopping malls, restaurants, religious facilities (churches, mosques, etc.), and many others.  These environments are ideal venues for spreading a respiratory viral infection.

Viral epidemics are characterized by exponential growth behavior, where each contagious person infects multiple other people.  In exponential growth, the absolute numbers of cases increases slowly at the beginning and then increases very rapidly, much quicker than linear growth.  The slow increase at the outset commonly misleads decision makers into not appreciating the severity of the situation and taking decisive action as early as possible.

Systems aspect: Appreciate the implications of exponential growth and the need to respond immediately when a problem is first detected.   

Key Virus Characteristics

The virus appears to have jumped from an animal host (possibly from bats) to humans.  It is brand new to humans, so no one has existing antibody immunity.  It can have a relatively long incubation time before symptoms appear, but is contagious well before a person becomes aware that they are ill.  It appears to spread primarily through airborne droplets produced by sneezing or coughing.  However, there are infection cases where virus particles appear to be ejected by forceful breathing, such as during singing or exercise.  Studies indicate the virus remains infectious on surfaces for periods extending up to three days, with variations depending on the nature of the surface.

While not as lethal as some other contemporary viruses such as Ebola, the novel coronavirus causes serious illness for a portion of those infected, requiring extended hospitalization and extensive medical resources for its care.  This creates serious hazards to medical personnel caring for patients.  Medical personnel can then become disease vectors to infect additional victims, particularly during the period from their infection to exhibiting symptoms or getting tested

The symptoms of the virus have some similarities to influenza.  Testing is essential to confirm whether a person has an ordinary influenza infection or one of the SARS-CoV-2 virus strains.

Systems aspect: Appreciate the implications of a virus being contagious before symptoms appear and guide response policies accordingly.

Infection Testing

Because it is new to humans, no pre-existing tests were available when the virus first became apparent. While tests were developed in a number of laboratories after the virus was identified and characterized, initial test protocols were complex and required specialized laboratory capabilities and equipment and training.  In particular, the tests for the coronavirus require specialized swabs and specialized reagents with few suppliers.  Also, the tests took a significant amount of time before results could be returned.

In order to respond to the epidemic effectively, very large numbers of people have to be tested with rapid reporting of results.  Only in recent weeks have streamlined testing procedures become available, and it is taking time to ramp up the production and distribution of new tests to all the locations that need them.

In the United States, tests available from the World Health Organization (WHO) were rejected in favor of domestically-developed tests.  The initial test systems were flawed, causing a significant delay in testing U.S. patients while the virus was spreading quickly.  Approval procedures for the testing systems by U.S. government agencies further slowed the rollout of testing capabilities.

What is clear now is that accelerated development and distribution of testing resources is essential on a worldwide basis in order to deal with disease epidemics.  This requires international coordination and cooperation on a basis with little precedent.

Systems aspect: Prepare testing capabilities on a sufficient scale in advance, because there will not be time to catch up when a problem such as a pandemic is already underway.    

Medical Resource Supply Chains

The globalization of manufacturing, where production is transferred to locations with the lowest cost and least restrictive regulations, has moved much of the production of pharmaceutical and medical supply items to China and, to a lesser extent, India.  Furthermore, the global supply chain has shifted to a just-in-time model, where users keep very low inventory and depend on the suppliers keeping them stocked.  This model does not easily accommodate huge surges in demand when a crisis such as a viral pandemic appears.  The users quickly exhaust the supplies they have on hand, and cannot get restocked from the distant producers.  In the case of the COVID-19 pandemic, China has its own huge surge in demand at the same time as medical users around the world are calling for vast increases in orders for medical supplies.

Systems aspect: Create supply chains for critical functions that are resilient under stress.    

Over-Optimization of the U.S. Medical System Capacity

In the United States, there is a strong emphasis in all aspects of the health care system on efficiency, profit maximization, and the creation of shareholder value.  This drive has caused a systematic reduction in spare capacity in the whole medical environment—hospital beds, medical staff, equipment such as ventilators, etc.  The system is sized for the conditions experienced in normal times with anticipatable seasonal variations (e.g., flu season).  But the extra capacity to respond to extraordinary circumstances such as a respiratory disease pandemic has been systematically trimmed away.

Systems aspect: Recreate the U.S. medical system to maximize serving public health care needs rather than maximize wealth creation for system owners.    

Potential Overwhelm of the U.S. Health Care System

The great risk is that the COVID-19 pandemic will grow far beyond the capability of the U.S. health care system to accommodate all the patients who are sick.  Particularly because of the drastic shortage of personal protective equipment, first-line medical personnel and other first responders are catching the virus and many will die.  Others may regard their risks as too great and will leave their jobs.  Thus patients who would otherwise be treated and recover will not get care.

Systems aspect: Protect health care personnel and first responders as a top system priority.    

Citizen Access to Testing and Treatment

Unique among the developed nations in the world, the United States has an extremely fragmented system for the financing of health care.  Only a fraction of citizens have publicly-paid health care (through Medicare, Medicaid, the Veterans Administration, etc.).  Others have private health care insurance, at high cost, through their employment that is dependent on them remaining in their jobs. And a large portion of the population, particularly those lower on the income scale, has no insurance to cover health care at all.  Those with public and private insurance have negotiated discounted rates for health care services, drugs, etc.  Those without insurance pay much higher undiscounted rates for the same things.

The consequence is that many people without insurance simply can’t afford to seek testing and treatment when they exhibit symptoms that could indicate infection with the coronavirus. They will not get isolated, but will remain in the general population to spread the virus to others.

Systems aspect: Remove the financial barriers to people getting tested and treated.  

Isolation and Social Distancing

The virus spread widely in societies around the world before cases could be detected and patients isolated before they passed the disease to others.  As a consequence, authorities determined that it was necessary to drastically limit close contact between people.  People were instructed to stay home as much as possible, not gather in groups, and distance themselves in when public.  Only essential functions were permitted to continue to operate.  Where possible, people were told to work from home.  Many businesses and functions closed down.  Unfortunately, this meant that large fractions of the population lost their source of income.  Many people simply could not afford to follow this guidance and felt they had to continue to work so they could buy food, pay rent and mortgages, and service their debts, even if working exposed them to infection and possibly giving the virus to others they came in contact with.

Because there can be a significant delay between SARS-CoV-2 infection and the initial symptoms, it takes time for contact minimization measures to show a substantial reduction in the number of new cases even when the measures are working effectively.  Decision makers need to commit to staying the difficult course and not relaxing the measures prematurely because early results are not apparent.

Systems aspect: To the greatest extent practical, mitigate the financial effects to businesses suspending operations and people staying home from work to enable compliance. 

Systems aspect: Maintain contact minimization measures long enough to be fully effective.

 Preparation for Responding to a Pandemic

Epidemiology is a well-studied subject.  Many academic and government agency institutions in the United States have considered what would be necessary to respond in a rapid and effective manner to a viral pandemic.  Unfortunately, the current U.S, administration under President Trump dismissed advice on these preparations and reduced the federal government infrastructure to carry out such a response.  When the scope of the epidemic first became apparent, the response from the federal government was seriously delayed.  The messaging to the public was very fragmented, confusing, and contradictory, so people were slow to mobilize to take sufficient actions to be effective, as were done in many other countries around the world.

The Trump Administration was extremely slow in invoking the Defense Production Act to require domestic manufacturers to produce medical equipment such as ventilators and supplies as personal protective equipment to meet emergency medical system needs for the COVID-19 pandemic.

Systems aspect: Listen to the best scientific expertise about the necessary preparations for a problem and take action proactively.  

The Need for Policy Simulators

I believe the COVID-19 pandemic points to the urgent need to develop simulators that decision-makers can use to explore the possible consequences of policy decisions, particularly the consequences in the longer run.  Just as pilots practice how to respond to emergency conditions in flight simulators, decision-makers need to be exposed to realistic potential emergency conditions in their fields in a simulated environment.  They can then see how different alternatives would likely work out, to help guide the best choices.

Systems aspect: Give decision makers better tools to understand emergency conditions and select appropriate responses.