X Series: Emergency Response and COVID-19

An examination of the current relationship between public health officials, leaders, citizens, and the disease itself.

The Emergency Management Field

Once upon a time, the World Health Organization created an epidemic response blueprint. It was developed in order to properly unite disparate agencies and organizations and facilitate the rapid roll-out of equipment, personnel, and information to best maximize survival for the most number of people. On it, diseases of interest like Ebola, Zika, Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and Severe Acute Respiratory Syndrome Virus (SARS-CoV) were specifically called out as potentially huge agents of destruction around the world. There is also, distinctly, a “disease X” retained on the list in the knowledge that many pathogens are novel and that more exist outside of our understanding than within it. Disease X represents that hidden agent of destruction that can happen anywhere at anytime.[1]

COVID-19 is a novel Coronavirus named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and is closely related to MERS-CoV and SARS-CoV-1. We know this because we were prepared for this virus and had been preparing for emergencies for quite a while, not just as local communities, but as a field of management and a discipline of integrated interdisciplinary public health. The public health emergency preparedness utilized for this response is a field, just like rocket scientists and car mechanics. There is a dedicated group of professionals committed to these exact kinds of events. It is a highly developed, regulated, and important component of modern infrastructure and city planning. From disaster to disease, there are public servants thinking about, planning for, and developing strategies to save the most number of people possible under the worst conditions.

These people usually reside in the community planning and health departments within state, local, and federal agencies at all levels of government and they are singularly committed to protecting their communities with whatever resources they have or can build.

And they do it often. The 2009 H1N1 Influenza outbreak and the 2014-2015 Epola epidemic were only the most recent incidents testing our emergency response system and preventing the hands-off, disorganized approach like the 1918-1919 influenza pandemic that killed 50 million people. Officials constantly reexamine their plans, update practices and ready themselves for the next disaster. As the Army says, “The more you sweat in peace, the less you bleed in war.” A truer motto for the field doesn’t exist.[2]

Emergency preparedness and response are tied so closely with public health because any disaster will automatically trigger a medical response and an infrastructure collapse of some kind. Disasters of every kind cost lives, crush basic necessities like food, water, and transportation, and demolish administrative processes that keep resources flowing where they are needed most. Someone has to pay for everything and someone else wants to know what that money is being spent on. It is a defining characteristic of our public health officials that they can promote resilience and creativity in the face of these tremendous obstacles, but it helps to have a plan and structure in place before everything goes wrong to ensure maximum survival.

So. How do we make that plan as public leaders?

There are many kinds of threats. Short-term, long-term, acute, chronic, environmental, social, chemical and every one of them can have widespread impacts on everything it touches. Health effects from environmental hazards, weather emergencies, toxic chemical exposures, global climate change, general infrastructure failure, water pollution, even poor asset management of real property can cause emergencies that destroy the environmental or human health. The PG&E wildfires near Paradise, CA and the water disaster of Flint, MI are excellent examples of when administration goes wrong. As community planners and installation managers, it’s our job to see these threats before hand and do our best to mitigate as many hazards as possible and we must do that for all of our citizens. We do not get to choose who gets protection or what department should be more important than others in the decision-making process. It is not about our own egos or skimming budgets to make the numbers line up. Our mission is to bring together all departments for the benefit of the whole community and forge a single, unified team of disparate responsibilities and technical expertise. Our citizens should never bear the burdens of our obsession with promotion or titles. The poor should not die to feed wealthy, gated communities or financial schemes. There are no individuals here, only the most good for the most people. This mentality of complete and selfless service is integral to all levels of decision-making-from where a wastewater treatment plan is located to how to build streets that allow free citizen movement for all. And, specifically to this section, how to efficiently and effectively roll out a pandemic response plan.

It wasn’t until around 2001 that Public Health, as a proper nomenclature for interdisciplinary operations, was funded as an entity. Before, it was run on a shoe-string budget applied by ingenious and inventive officers, but woefully underfunded and ignored by most political bodies. The War on Terror helped to change that. For the first time, Americans were dealing with Bioterrorism and the threat of real and continuous emergency conditions. In conjunctions with the scale-up of natural disaster impacts due to climate change over the past twenty years, the US needed emergency management plans that worked and kept cities alive.

All of these plans start with the same general method:

1.      Recognize the problem

2.      Gather intelligence about the scope of the problem. Use real-time data and surveillance whenever possible for the most accurate intelligence.

3.      Provide surge capacity in the healthcare system to handle sick and injured.

4.      Mitigate the problem by identifying and removing  sources.

5.      Provide clean-up and recovery plans to restart communities safely and as soon as possible.

Though terrorism got the attention of political leaders and provided a jumpstart for resources, emergency managers have been grappling with these problems and this method for a long time. Infectious disease, in particular, has been the greatest fear of leaders and city planners for thousands of years. Vitruvius, in his Ten Books on Architecture, talks about the importance of city siting, cleanliness, waste removal, and disease mitigation as early as 1st century B.C.E.[3] Ancient water engineers from the Mayans to the Greeks warned of the devastating effect of disease on crowded cities that did not design appropriate public health infrastructure. Installations of hygiene and health protection are a key factor of decent standards of living and economic prosperity. And while most of these cultures focused on water treatment and distribution, this was only because the ideas and implementation of germ theory and true infection mediums had yet to be discovered and were poorly understood.[4] With the increased understanding of microbial and viral transmission, the first developments of vaccines, and the first established medical standards, public health evolved to include not just civil and environmental engineering, but actual medical prevention and treatment options.

This infrastructure was first tested properly in 2005 with the development of the first national influenza plan. It was an attempt to unify resources and develop an integrated response for all federal, state, and county public health utilities in the event of an epidemic. In 2009, the H1N1 pandemic was its first implementation.[5] Now, it should be noted that while this plan was developed for influenza (since that was evaluated as the greatest disease threat-event at the time), the infrastructure and processes it developed were applicable to any wide-spread respiratory infectious disease, right down to the vaccine development protocols. In this case, the epidemic burned out relatively quickly, but a vaccine was produced in record time and it cost only about 13,000 lives, all-told. The response relied heavily on social distances and community behavior changes, like school closures.[6]  

The plan they developed has seven sections:

1.      Surveillance

2.      Community mitigation measures

3.      Medical countermeasures

a.       Diagnostic devices- use, sale, production

b.      Vaccines

c.       Theraputics

d.      Respiratory devices

4.      Healthcare System Preparedness and Response Activities

5.      Communication and public outreach

6.      Scientific infrastructure and preparedness

7.      Domestic and international response policy, incident management global partnerships and capacity building[7]

This is a good planning tool designed to unify departments, get people immediate, life-saving care, vaccinate the healthy, and prevent spread as much as physically possible. Public health departments all over the world, engineers, scientists, hospitals, and leaders at all levels have to work together to follow this plan as much as possible to make reasonable decisions and protect their citizens.

This approach method allows for an organized way to track disease cases, hospitalizations, deaths, facilitate containment, study viral epidemiology, and implement community mitigation measures. Just because the regular civilian in the United States had never thought about a pandemic or what to do in such a global emergency does not mean that the emergency responders and public health departments didn’t. In fact, it’s just the opposite.

But at this point, we come to something rather unexpected. Emergency response leaders and public health utilities seem to have a blind spot. One that this COVID-19 response highlighted in stunning detail. These leaders assume that people in danger want to be helped by the people they pay to do exactly that. Firefighters go into burning buildings because they assume the people in them don’t want to die. They don’t take a poll or ask for permission slips or vote on whether they should save or not save those people. It’s their job to make sure anyone alive stays that way and they behave accordingly. Water engineers assume people don’t want to drink poisonous, contaminated water, so they spend huge amounts of money to repair lines and build water treatment systems. Again, rarely do they ask for people’s permission or consent. Not many people can understand water treatment toxicology and they don’t have to. The water engineers are there to protect communities and make good, sound technical decisions all for the protection of the public good. All of this is done without fuss or fanfare. It usually goes completely unnoticed by community members, exactly as it should. Public infrastructure is at its best when it is working so smoothly no one notices it. However, it is based on a certain degree of trust from the community that its civil servants are competent, committed, and interested in preserving life. This is the base assumption emergency planners and community leaders operate on: that their people want to live, want others around them to live, and will allow technical specialists to do what is necessary to keep the most possible alive at all times, regardless of how bad it gets.

In this pandemic, some community members seem to be actively rejecting that assumption. 30%, plus or minus, of the United States is actively opposing emergency managers from doing their jobs.

They cite lack of evidence, personal freedoms, individual bodily autonomy, etc. But when the firefighter carries a victim out of a burning building or the engineer shuts off a city’s water temporarily, it is not done for politics or personal gain or anything other than a dedication to service and protection of that public good. But as the illusion grows that somehow shadowy doctors and emergency managers are implanting microchips and killing sperm and targeting conservative, Christian groups for some sort of ethnic cleansing, most of the public works infrastructure technical support staff is left staring at their communities in uncomprehending shock. Here they are, holding battle plans hard-fought, tested, proven strategies that require citizens to cooperate in their own rescue and people are punching the firefighters to go back and sit in the flames, ‘since there are still a couple rooms not on fire, so that proves the fire is a hoax.’ What else can you do but let them die and hope to contain whatever you can of the fire?

COVID-19 (SARS-CoV-2) is the most significant public health emergency event since 1918. As of this writing, there are over 45 million cases and 735,000 deaths in the U.S. alone.[8] But many people seem unconvinced that this is an actual emergency and describe political machinations and conspiracy theories instead of actual facts about the virus.

With the development of anti-microbial agents in the early 20th century, public health leaders were initially hopeful that all disease would be destroyed within their lifetimes. However, we now realize that what we call general disease is a complex ecosystem of co-evolving microbes, fungi, viruses, and parasitic agents, as well as malfunctioning internal cellular systems and immune responses. Changes in environmental and social conditions spurred by longer life-spans, increased globalization, agronomical revolution, land-use alterations, climate change and many others have triggered a vast array of pathogenic organisms and biochemical reactions.

The world of disease is much more complex than previously understood. Per Madoff and Kasper:

“Ebola virus, human metapneumovirus, Anaplasma phagocytophilia (the agent of human granulocytotropic ehrlichosis) and retroviruses such as HIV humble us, despite our deepening understanding of pathogenesis at the most basic molecular level.”[9]

In our attempt to keep people live longer, immunocompromised people now make up larger and larger proportions of our populations, making disease impacts more severe and widespread. The innate immunity we depend on primarily only works with pathogenic organisms that are genetically ‘recognizable’ to us. Common pathogens present in low-level infections from birth that allow us to build up immunity through long-term exposure and genetic contributions from our mothers. Adaptive immunity that can respond to intracellular invaders can be activated against new pathogens to a limited extent. It works through ‘tagging’ invaders with foreign antigens using the body’s own histocompatibility complex to recognize ‘us’ v. ‘them.’ Sometimes, these cells can’t identify pathogens or an over-stimulation of the immune response can essentially nuke the body, creating a huge inflammatory response, but one without an actual target. This leads to septic shock or toxic shock syndrome or other ‘cytokine storm’ syndromes.[10]

Vaccines work by exposing the immune system to the specific invader in a deactivated, limited quantity. This allows the adaptive immunity cells to register the protein shapes, ‘tag’ them as foreign and place it in the ‘known’ category of destructive pathogens preventing that massive, target-less cytokine storm or skyrocketing infection rate.

The SARS viruses are retroviruses. This means that they hijack and use the cells’ own DNA to reproduce and spread within the body. These coronaviruses are very diverse and very difficult to vaccinate for, since they are morphologically flexible and very adaptable to human and animal systems and seem to have no trouble bouncing between genetically disparate species. Our COVID-19 is the latest in this family. About 80% of COVID cases are asymptomatic, but both the asymptomatic and symptomatic cases seem to show the same high viral load that can be passed by stool, air, saliva, and urine. This easy and effective transmittal makes case tracking and isolation of the infected hugely important and extremely challenging. It is particularly effective at using the body’s own cellular receptors (ACE2 enzyme, specifically) in coopting cellular machinery for reproduction, survival, and spread. The development of an overexpressed RBD amino acid in COVID patients (which is an amino acid that facilitates COVID binding to ACE2 and penetrating cellular nuclei) may help explain the poor immune response, increased recovery time, and long incubation period. The body is essentially seeing itself and can’t find the invader until the infection load is much too high to effectively respond to and by that time, it’s too late. The virus has destroyed huge swaths of cellular function everywhere from the lungs to the heart and kidneys. Even the central nervous system (spine and brain) isn’t safe. COVID can penetrate the blood-brain-barrier and coopt brain cells to suicide and hemorrhage more virus throughout the system.

This means there are too few antibodies available, too many cellular deaths, and too high a viral load on the body leading to death or a dreary, long illness full of unexplainable or unusual symptoms, including additional infections as immune cells can also be hijacked and destroyed in the viral propagation cycle. Heart disease, kidney failure, even brain and spinal cord infections can cause mortality separate from COVID symptoms or possibly as a result from the cytokine storm of immune response overwhelming normal, healthy cells accidently.[11]

And this is what people are saying is political? This is the fire they insist on running back into? This is a public health emergency on a vast scale. Let the emergency managers and public health officials to their job and save the most they can. Come out of the flames. It’s ok. There’s a nice firefighter with some cocoa here to help.

[1] Birkhead, Guthrie. et. al. ed. Riegelman, Richard. 2021. Essentials of Public Health. Burlington, MA: Jones and Bartlet Learning, Loc. #13894.

[2] Ibid.

[3] Morgan, Hickey Morris. Trans. 1914. Vitruvius: Ten Books On Architecture. Harvard University Press.

[4] Mays, Larry. Ancient Water Technologies. Springer, 2010. Pp. 77-85.

[5] Birkhead, et. al. Loc. #13946

[6] Ibid, #13953.

[7] Ibid, #13977

[8] CDC.gov. Accessed 10/24/2021.

[9] Kasper, Dennis. Et. al. Harrison’s Principles of Internal Medicine. Vol. 1. 2005. McGraw-Hill Medical Publishing. New York, NY: 695.

[10] Kasper, 696.

[11] Alipoor, Shamila et. al. “COVID-19: Molecular and cellular response.” Fron. Cell. Infect. Microbiol. 11 February 2021. https://doi.org/10.3389/fcimb.2021.563085.