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This is the third installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. In part 1 and part 2 of the series, we feature observations from our alumni in China, Mongolia, Myanmar, and Singapore.

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The first case of COVID-19 in the Philippines was reported on January 30, 2020, and local transmission was confirmed on March 7, 2020. As of May 21, the number of cases of COVID-19 has risen to 13,434 and the number of deaths attributed to the virus increased to 846, according to the Philippine Department of Health COVID-19 Case Tracker. It is quite alarming that among the ASEAN countries, the Philippines had the second-highest mortality due to COVID-19, next to Indonesia (as per May 5 date by the WHO COVID-19 Dashboard). This could be attributed to several factors, including whether the country’s health system can handle the overwhelming demand for health care due to the COVID-19 crisis and how effective the government’s response is in stemming the spread of this new pathogen. Inherent in the death statistics is the capacity of a country to conduct COVID-19 tests, which means that there should be a sufficient number of test kits available and that the health workers are properly trained to conduct the tests, trace the contacts, and isolate identified individuals.

The President of the Philippines imposed a total lockdown called enhanced community quarantine (ECQ) for the entire island of Luzon, which encompasses eight administrative regions, including the national capital region, from March 15 to April 30. Other parts of the country have also been under some degree of quarantine at different periods since the appearance of local transmission. Executive Order 112, signed on April 30, 2020, was issued to further extend the ECQ in identified high-risk areas and a general community quarantine (GCQ) in the rest of the country. The inter-agency task force for the management of emerging infectious diseases defines ECQ as the implementation of temporary restrictions on the mobility of people, strict regulations of industries, and a heightened presence of uniformed personnel. GCQ is, in a nutshell, a less strict version of ECQ.

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Image captured from the Center for Strategic and International Studies, Southeast Asia COVID-19 Tracker, May 21, 2020.

The Philippines has faced a lot of challenges during this crisis. First, the health system lacks adequate surge capacity to safely handle a nationwide outbreak of COVID-19 due to shortages of personal protective equipment (PPE), mechanical ventilators, and hospitals with ICUs and isolation beds (see this World Bank report and this Rappler article). More importantly, the insufficient number of health workers, especially in areas outside the metropolitan, is a major concern. Nonetheless, the Department of Health has worked hard to meet the surge in demand due to COVID-19, including partnering with the private sector to repurpose structures and providing data to the public to ensure transparency and accountability. As in other countries, the health workers and those with frontline responsibilities have truly been the new heroes or “bayani” with their tireless efforts and sacrifices. 

Another challenge pertains to the adverse economic impact of COVID-19. The Philippines has a relatively large informal sector and the income of many families depends on daily transactions with no formal job or social security. This has prompted the government to extend cash or in-kind support to vulnerable populations – a response that has posed several challenges, particularly related to the who/what/how framework. First, the Philippine government had to properly identify those in need (who). Second, it had to ensure that sufficient resources can be allocated to the identified groups (what). And third, it had to distribute aid in an efficient, timely, and equitable way (how). The government's social welfare efforts to provide for the vulnerable groups have mixed results: at times, the distribution of aid is organized and efficient, at other times insufficient and disorderly (see these CNN Philippines reports of April 7 and April 30).

COVID-19 in the Philippines – How Filipinos Have Coped

There has been a strong spirit of “bayanihan” or collectivism in the country amidst the COVID-19 crisis. People are volunteering, distributing goods to vulnerable groups, or donating PPE to those with frontline duties. Some enterprises also rose to the occasion by repurposing their businesses to meet the local demand for medical products and PPE.

Different individuals have coped differently: some have welcomed the work hiatus that the quarantine has afforded them, some connected more with friends and family, others become more productive working from home. Staying healthy and being mindful are also factors that contribute to remaining calm and rational in this time of national distress.

Despite the challenges, we will continue to face, especially once the quarantine has eased and the new normal is in effect, we can say that Filipinos have also learned some valuable lessons amid this crisis. For one, Filipinos have become more mindful of the importance of good sanitation and non-pharmaceutical public health measures in mitigating the transmission of the virus. Most Filipinos have also become more proactive in their approach, keeping social distance, wearing masks, and practicing proper handwashing, among others. Furthermore, this crisis has redefined and created new heroes who rose to the challenge – from those staying at home to avoid the further spread of the virus to those on the frontline who have dedicated their time and effort to combat the pandemic, to government and business leaders who have served the country sincerely during this crisis.

Perhaps there really is a silver lining in every cloud.

Mongolia, a nation bordered by China and Russia, does not usually attract much public attention. Its success so far in containing COVID-19, however, is well worth considering.

Any of several factors could make Mongolia highly vulnerable to COVID-19: its weak healthcare system, its proximity to China, the first epicenter of the coronavirus, and its close ties to South Korea, which experienced one of the largest initial outbreaks of COVID-19 outside China and which is home to a relatively large population of Mongolian migrant workers. Yet Mongolia’s strategy in fighting the pandemic seems to have worked well thus far for its 3.2 million people.

In the following post, Dr. Gendengarjaa Baigalimaa, a gynecological oncologist at the Mungun Guur Hospital in Ulaanbaatar, Mongolia’s capital, discusses the country’s response to the pandemic and its implications. Baigalimaa was a 2013-14 postdoctoral fellow on developing Asia health policy with APARC’s Asia Health Policy Program.

This is the second installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. You can read the first part in the series, featuring reflections by several former Global Affiliates Program Fellows.

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Dr. Gendengarjaa Baigalimaa

As of May 17, 2020, the number of new coronavirus infections in Mongolia has reached 136. All of them are imported cases, including four foreigners and 132 Mongolians who came from abroad. They have been treated by the National Center for Communicable Diseases and some have been discharged as totally recovered. Most notably, there have been no reports of community transmission.

Following the World Health Organization's recommendation of January 22 that countries begin considering containment measures, Mongolia immediately activated its inter-agency State Emergency Commission in support of the Ministry of Health as a lead agency in the response against the coronavirus outbreak. The Mongolian government made an unprecedented decision to close all schools and kindergartens starting January 25. All classes are now being conducting via TV and the internet.

Already in mid-February, with the pandemic's spreading in China, the Mongolian government’s strategy was to adopt decisive preventative measures, including the cancelation of the national holiday Tsagaan Sar, the Mongolian lunar new year, and closure of all travel between Ulaanbaatar and provinces outside the capital. Mongolia also closed its borders with China and Russia, stopping the inflow and outflow of people, and banned international flights from all airlines. The government has been mobilizing its citizens to return home from countries like South Korea, Japan, Turkey, and Russia. Those arriving are quarantined for an extended 21-day period, with multiple coronavirus screenings.

The use of masks, especially from early November, when flu season starts and air pollution worsens, is already familiar to Mongolians. This season, the government has enforced mask-wearing in public places. In the capital city of Ulaanbaatar, the requirement that all employees at government offices, banks, shops, and markets wear masks was imposed as early as January 25. The State Emergency Commission would issue fines of 150,000₮ (54 USD) for violating the order. At the same time, health professionals and community leaders conveyed the importance of mask-wearing and handwashing and worked to increase sanitation at all public places.    

These steps have helped immensely to contain the spread of COVID-19. They have also had the added benefit of sharply reducing the number of flu infections. At the start of the flu season last year, almost 12.7 percent of all hospital visits were flu-related, compared to 1.8 percent this year. Another unexpected benefit was the drop in gastrointestinal infections among children. Children were staying home and washing their hands properly. As a result, there have been no cases of gastrointestinal infections registered this year so far.

“Not only did Mongolia close its borders early and move promptly, but also did a great job at quarantining evacuees from overseas immediately upon arrival and taking safety measures,” said Mr. Sergey Diorditsa, the WHO representative to Mongolia. He praised the country’s economic stimulus measures and noted that prolonged restrictions may adversely affect its social and economic sectors and that WHO Mongolia is conducting a study on the in-country impacts of COVID-19. Indeed, data provided by the National Statistical Office shows that the country’s economy is expected to decline sharply due to the adverse effects of the pandemic.

Mongolia’s urgent response to COVID-19 offers lessons for vulnerable communities on containment of the coronavirus and prevention of its spread. The country is also a relevant case study for the economic repercussions of the pandemic.

COVID-19, combined with the effects of ongoing civil conflicts, hotter and drier weather in many areas, and an unfolding locust invasion in Africa and the Middle East, could cut off access to food for tens of millions of people. The world is “on the brink of a hunger pandemic,” according to World Food Program (WFP) Executive Director David Beasley, who warned the United Nations Security Council recently of the urgent need for action to avert “multiple famines of biblical proportions.”

(Watch Beasley’s conversation on food insecurity as a national security threat with his WFP predecessor, Ertharin Cousin, a visiting scholar with Stanford’s Center of Food Security and the Environment.)

Understanding how these conditions – alone or in combination – might affect crop harvests and food supply chains is essential to finding solutions, according to David Lobell, the Gloria and Richard Kushel Director of the Center on Food Security and the Environment. Below, Lobell discusses the connection between immigration and U.S. food security, a counter-intuitive effect of COVID-19 and more.

How could COVID-19 affect global food security?

I think the biggest effects will probably be related to lost incomes for many low-income people. Even if food prices don’t change, potentially hundreds of millions could be pushed into a much more precarious food situation. I’d be especially worried about remittances – the money immigrants in wealthy nations send home to developing nations – falling, since these are a surprisingly large source of stability for many poor people. Beyond the income effects, there are definitely prospects for reduced supply of foods, but I think these are secondary, especially because global stocks right now are quite large.

Another counter-intuitive effect is that the drop in gasoline demand due to social distancing may be a big driver of changes in food prices. A lot of corn demand is for use in ethanol fuel, and corn prices can affect the prices of many other crops. The price of corn has dropped by about 20 percent since February.

What are the biggest risks in terms of food supply?

Three things come to mind. First, for crops that require a lot of labor, there are some indications that planting and harvest activities are being affected. Even though these are usually included as essential activities, they often rely on migrant populations that can no longer cross state or national borders. California is going to be a prime case study in this.

Second, some countries, like Russia, have started to restrict food exports in an effort to calm domestic consumers worried about food shortages. Even if there is enough global supply, there is a risk that supply for importing countries could be curtailed. This was a big part of the food price spikes a decade ago. Now, we have the added potential that exports will be limited by a lack of mobility to get products to the port – for instance, there are reports from South America that towns won’t let trucks through for fear of the virus.

Third, COVID-19 could really limit the ability of governments and international groups to address other crises that emerge. Nearly every year there are at least a few surprises around the world affecting food that are usually handled before they make big news. Things like livestock diseases and crop pest outbreaks, for example. But without the ability to deploy people to assess and fix problems, there is more scope for issues to go unchecked. Right now, the biggest example of this is the desert locust outbreak in Eastern Africa.

What current and/or likely future weather conditions might have significant impacts on food production?

As the globe warms, we continue to see more “surprises” in most years in terms of record hot or dry growing seasons. It’s a bit too soon to say if and where those will emerge this year. Since global food stocks are high, we have some ability to cope with a shock, but if governments are already nervous it may take less to induce export bans and all of the negative effects those entail.

Ahead of the summer harvest, what is the prospect for controlling locust swarms in threatened countries, and how might the swarms further complicate the global food security picture?

If not for COVID-19, this would likely be the biggest development related to food this year. My understanding is that they are spreading fast in Africa and the Middle East, and while they haven’t yet had big effects in the main production regions, the next couple of months will be critical. The hope is that the winds change and drive them back toward the desert areas they came from. If not, there are at least 20 million people at risk of major food security impacts in the region.

Could we see locust swarms in the U.S.? What can we do to prevent them?

Locusts can occur anywhere. A few years back there was a major outbreak in Israel. They haven’t been a big issue in the U.S. because control methods are available, such as widespread spraying. But again, in a time of COVID-19, these types of responses are harder.

What does history teach us about the situation we are in with multiple threats to food security, and how to deal with it?

I think it comes down to a combination of investing in science-based solutions to avoid problems to begin with, and then having good social safety nets for when problems arise. At that level, it’s not really any different than dealing with infectious disease. The absence of any problems is our goal. At the same time, that absence always seems to breed complacency and neglect. Hopefully, the experiences of 2020 will help strengthen support for a society based on facts, science and compassion.

Media Contacts

David Lobell, Center on Food Security and the Environment: (650) 721-6207; dlobell@stanford.edu

Rob Jordan, Stanford Woods Institute for the Environment: (650) 721-1881; rjordan@stanford.edu

While Wuhan, China was the first epicenter of the COVID-19 pandemic, every nation in Asia has been deeply affected by the spread of the virus. In a virtual seminar convened by the Freeman Spogli Institute, APARC experts discuss the social and economic impacts of COVID-19 and the various policy responses to the pandemic across Asian nations.

Senior Fellow Xueguang Zhou focuses on the phases of crisis response taken by the PRC in the early stages of the unfolding coronavirus outbreak. Center Fellow and Korea Program Deputy Director Yong Suk Lee discusses the policy responses of the South Korean government. Southeast Asia Program Director Don Emmerson offers a comparison of different governance strategies and actions implemented across Southeast Asian countries, while Karen Eggelston, APARC's deputy director and director of the Asia Health Policy Program, addresses the response of health systems in Japan and South Asia.

Watch the full discussion and Q&A below. You can also read the Stanford Daily's coverage of the event.

WATARU FUKUDA
Chief Representative of the Shizuoka Prefectural Government in Singapore
Global Affiliates Program Fellow, 2014-16

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TSUYOSHI KOSHIKAWA
Chief Advisor, Japan International Cooperation Agency Expert for the Ministry of Planning, Finance, and Industry in Myanmar
Global Affiliates Program Fellow, 2014-15

I currently live in Naypyitaw, Myanmar, though I am originally from Japan. Naypyitaw is currently not under shelter-in-place, though the city of Yangon is. In Naypyitaw, restaurants are serving only take-out meals, and most amusement facilities like movie theaters, karaoke boxes, bars, and beauty salons have been closed. There are still a few big department stores open, as well as the public golf course and tennis courts.

At the time of this writing, the number of known COVID-19 cases in Myanmar is nearly 150, and I am worried about the potential risks because the healthcare and medical information systems here are not as organized as in countries like Japan, the UK, or the United States.

Anyone with a fever of 37.5 degrees C (99.5 F) or higher is being kept from entering Yangon. The Ministry of Health is taking all traveler’s temperatures at the airport, railways stations, and the exits of all highway interchanges throughout Yangon. Foreigners with a fever of 38 degrees C (100.4 F) have been told that they will not be permitted into private hospitals anywhere in Myanmar at present. Isolation wards in general hospitals will accommodate foreigners. The situation is frightening, but with frequent handwashing and hygiene, we are trying to take care of each other.

XIAOYUAN SHI
Deputy General Manager in the Internal Audit Bureau at the Industrial and Commercial Bank of China
Global Affiliates Program Fellow, 2012-13

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Thankfully, our efforts have worked. The new confirmed cases are mostly coming in from foreign travel. Big cities like Beijing and Shanghai have low infection rates, and people feel much less stressed. Social life, work, and production are recovering, and the lockdown of Wuhan City has been lifted. Most schools will continue to use online classes for the time being and restaurants are still not fully open, but I think the most difficult time is behind us.

It’s impossible to spot all of the potential virus carriers, and therefore precautionary measures like avoiding going out unnecessarily, wearing masks in public, and handwashing are still recommended. I’ve not heard of COVID-19 cases or deaths among my acquaintances, thankfully, but the conditions here have proven that this virus is highly infectious and death is possible. I hope our practices here can provide some references for other places where it is spreading.

Most of the stillbirths that occur around the world are among women who live in low- and middle-income countries. Some 2.5 million women suffer the heartbreaking loss each year.

Yet determining the causes and prevention of stillbirths has largely been ignored as a global health priority — the incidence not even included in the WHO Millennium Development Goals.

Stanford Health Policy’s Rosenkranz Prize Winner, Ashley Styczynski, MD, MPH, discovered the alarmingly high level of stillbirths while working in Bangladesh as a 2019-2020 Fogarty Fellow, studying antimicrobial resistance in newborns in the hospitals there.

The $100,000 Rosenkranz Prize is awarded to a Stanford researcher who is doing innovative work to improve health in the developing world.

“I was surprised to learn that the rates of stillbirths were comparable to sub-Saharan Africa and that in many cases they had no idea of the cause,” Styczynski said in a Skype call from Dhaka, where she has been living for eight months while conducting her antimicrobial resistance research.

Rosenkranz Prize Winner Ashley Styczynski takes specimen samples with women in Dhaka, Bangladesh, for her research on antimicrobial resistance in newborns. This research led to her prize-winning proposal to investigate the alarmingly high rate of stillbirths in the South Asian nation.

The South Asian nation is among the top 10 countries with the highest number of stillbirths, with an average of 25.4 stillbirths per 1,000 births. Studies have implicated maternal infections as the cause; one ongoing study in Bangladesh has recovered bacteria from blood samples in stillborn babies in whom no prior maternal infection was suspected.

Styczynski believes intrauterine infections may be an underrecognized factor contributing to the excess stillbirths in Bangladesh. She intends to perform metagenomic sequencing on placental tissues of stillborn babies, a process that will allow her to examine the genes in the organisms of those tissues and evaluate the bacterial diversity.

“The alternative hypothesis would be that stillbirths are caused by non-infectious etiologies, which I will be assessing through interviews,” Styczynski wrote in her Rosenkranz application.

Those interviews will be with mothers to evaluate for frequency of infectious symptoms during pregnancy, including fever, rash, cough, dysuria and diarrhea, as well as possible toxin exposures. She will compare the findings with the metagenomic sequencing results to determine how frequently potential pathogens may be presenting as subclinical infections.

“By applying advanced technologies and software platforms, this research will not only enhance our understanding of causes of stillbirths in Bangladesh, but it may also provide insights into causes of early neonatal deaths," Styczynski said.

Bangladesh, one of the poorest and most densely populated nations in the world, offers a rich variety of emerging and known diseases that go undetected.

“The panoply of infections that could contribute to stillbirths is really unknown,” Styczynski said. “That’s why metagenomics is a great tool here. It just hasn’t been accessible here because of the expense. Now this tool will begin to unpack what’s causing these stillbirths.”

The Rosenkranz Prize was started and endowed by the family of the late Dr. George Rosenkranz, who devoted his career to improving health-care access across the world and helped synthesize the active ingredient for the first oral birth control pill.

“No one is more deserving of the Rosenkranz Prize than Dr. Ashley Styczynski”, said Dr. Ricardo Rosenkranz. “Because of her tenacity, originality and focus, Dr. Styczynski exemplifies the ideal Rosenkranz Prize recipient. She has chosen an often overlooked adverse outcome that may prove to be mitigated by her findings. As a neonatologist interested in health disparities, I fully realize the potential relevance and urgency of her work and am excited to see it come to fruition. As the son of George Rosenkranz, for whom this prize is lovingly named, I know that my father would appreciate Dr. Styczynski’s pioneering spirit as well as her desire to affect global positive change by improving medical outcomes in vulnerable communities. We can’t wait to celebrate her work back at Stanford in the near future."

Sheltering in Place

Styczynski spoke from her flat in Dhaka, where she has been confined for three weeks as the world’s third-most populated city prepares for the onslaught of the coronavirus. The country is on lockdown; no international flights in or out.

As of Thursday, there were 1,572 cases in Bangladesh and 60 deaths, according to the widely used Johns Hopkins Coronavirus Map.

But Styczynski believes that’s about 1% of the actual disease activity in the country because testing was so slow to start. She said there is great stigma in the country over testing — red flags are put on the homes of those who have been diagnosed with COVID-19 — because it breaks up the unity of families and the surrounding community. Health-care workers are being kicked out of apartments by frightened landlords and people are afraid to use the health-care system for fear of infection.

“So, the hospitals are quite empty — more so than they’ve ever been,” she said.

Styczynski likened it to waiting for the tsunami that you know is coming.

“That’s why I wanted to jump in to stave off the morbidity and mortality that will be inundating one of the most populated countries in the world,” she said. Some 165 million people are packed into 50,250 square miles — a land mass about the same size as New York State, which has some 19.5 million people.

Ashley Styczynski goes through a thermoscanner was when I was testing out the triage system at an upazila health complex.

The Centers for Disease Control and Prevention (CDC) has a small team of four people working in Bangladesh. Having spent two years as an Epidemic Intelligence Service Officer at the CDC, Styczynski has now joined its Bangladesh team and is also working with the infection prevention and control team of the International Centre for Diarrhoeal Disease Research, Bangladesh.

“Many people here in Dhaka live in high-density apartments with six to 12 people living in the same room,” she said. “How do you isolate when you have a one-room home?”

Ninety percent of the population are daily wage earners, Styczynski noted, who say they’d rather take their chances with coronavirus than die of starvation.

They take those chances at great risk. There is one ventilator for every 100,000 people in Bangladesh and the district hospitals have maybe one to two days of oxygen supply, Styczynski said.

They started out training military hospitals on medical triage, quarantine and isolation, and infection prevention strategies.

“We’ve also been going to some district hospitals to assess some of the challenges they are facing and to identify some of the gaps in preparedness so that we can communicate back to the Ministry of Health how they can better support these district hospitals,” she said.

Her pandemic travels to the district hospitals and preparedness work has allowed her to gather contextual data for her colleagues back at Stanford who are working to address the lack of personal protective equipment (PPE) in low-resourced countries.

“We hope we can generate some evidence very quickly so that we can share some of this information to better protect health-care workers in other low-resource countries,” she said.

Despite her research being temporarily sidelined, Styczynski is upbeat.

“This is what I signed up for as a Fogarty fellow, to help build local capacity,” she said. “But I am also an infectious disease specialist, and these are the types of situations we run towards rather than away from. We build our career for moments like these.”

The novel coronavirus (COVID-19) is a global public health disaster of almost biblical proportions. It is a once-in-a-century occurrence that threatens to destroy countless lives, ruin economies, and stress national and international institutions to their breaking point. And, even after the virus recedes, the geopolitical wreckage it leaves in its wake could be profound.

Many have understandably drawn comparisons to the influenza pandemic of 1918 and 1919. That pandemic, which began in the final months of World War I, may have infected 500 million people and killed 50 million people around the globe. As the grim toll of COVID-19 mounts, it remains to be seen if that comparison will prove apt in terms of the human cost.

But, if we want to understand the even darker direction in which the world may be headed, leaders and policymakers ought to pay more attention to the two decades after the influenza pandemic swept the globe. This period, often referred to as the interwar years, was characterized by rising nationalism and xenophobia, the grinding halt of globalization in favor of beggar-thy-neighbor policies, and the collapse of the world economy in the Great Depression. Revolution, civil war, and political instability rocked important nations. The world’s reigning liberal hegemon — Great Britain — struggled and other democracies buckled while rising authoritarian states sought to aggressively reshape the international order in accordance with their interests and values. Arms races, imperial competition, and territorial aggression ensued, culminating in World War II — the greatest calamity in modern times.

In the United States, the interwar years also saw the emergence of the “America First” movement. Hundreds of thousands rallied to the cause of the America First Committee, pressing U.S. leaders to seek the false security of isolationism as the world burned around them. President Franklin Delano Roosevelt pushed back, arguing that rising global interdependence meant no nation — not even one as powerful and geographically distant as the United States — could wall itself off from growing dangers overseas. His warning proved prescient. The war eventually came to America’s shores in the form of the attack on Pearl Harbor.

Even before COVID-19, shadows of the interwar years were beginning to re-emerge. The virus, however, has brought these dynamics into sharper relief. And the pandemic seems likely to greatly amplify them as economic and political upheaval follows, great-power rivalry deepens, institutions meant to encourage international cooperation fail, and American leadership falters. In this respect, as Richard Haas notes, the COVID-19 pandemic and the aftershocks it will produce seem poised to “accelerate history,” returning the world to a much more dangerous time.

However, history is not destiny. While COVID-19 worsens or sets in motion events that may increasingly resemble this harrowing past, we are not fated to repeat it. Humans have agency. Our leaders have real choices. The United States remains the world’s most powerful democracy. It has a proud legacy of transformational leaps in human progress, including advances that have eradicated infectious diseases. It is still capable of taking urgent steps to ensure the health, prosperity, and security of millions of Americans while also leading the world to navigate this crisis and build something better in its aftermath. America can fight for a better future. Doing so effectively, however, requires understanding the full scope of the challenges it is likely to face.

Read the rest at War on the Rocks

As the deaths and detected cases from the COVID-19 epidemic continue to rise globally, government planners and policymakers require projections of its future course and impacts. They also need to understand how potential interventions might “flatten the curve.”

“It’s important to understand these overall effects by geographic area, demographic group, and for special populations like health-care workers,” says Stanford Health Policy’s Jeremy Goldhaber-Fiebert, who will be teaching a new class in the spring on infectious disease modeling with Stanford Medicine’s Jason Andrews. “Doing this requires mathematical models that incorporate the best available clinical, epidemiological, and policy data along with their associated uncertainties — the state-of-the-art of infectious disease modeling.”

Goldhaber-Fiebert and Andrews will debut the new course, Models for Understanding and Controlling Global Infectious Diseases (HUMBIO 154D for undergrads and HRP204 for graduate students) in the upcoming spring quarter. Stanford Provost Persis Drell announced last week that all spring courses at the university will now be taught online and pushed the start of the new quarter April 6.

Andrews is an infectious disease physician and assistant professor of medicine and Goldhaber-Fiebert, an associate professor of medicine, is a decision scientist.

The class will enable students to become critical consumers of studies using infectious disease modeling and to learn the building blocks for constructing infectious disease models themselves.

Despite the course being new and listed in the middle of winter quarter, they have seen enrollment rise from eight — prior to the rise of COVID-19 in the U.S. and its direct impacts on Stanford’s operations — to nearly 30 students as of March 22.

“Together Jason and I are leading one of several efforts on COVID-19 modeling here in Stanford,” said Goldhaber-Fiebert. “And we anticipate that the course will increase the number of Stanford students with the necessary skills to contribute to Stanford’s leadership in this area.”

Controversies over the lack of diagnostic testing for the COVID-19 virus have dominated U.S headlines for weeks. Technical challenges with the first test developed by the Centers for Disease Control and Prevention (CDC) left the nation with minimal diagnostic capacity during the first few weeks of the epidemic, according to a new paper published today in the Journal of the American Medical Association by Michelle Mello, a professor of medicine at Stanford Health Policy and professor of law at Stanford Law School.

On February 29, the Food and Drug Administration (FDA) began allowing high-complexity labs across the country to use tests they developed in-house. On March 5, the Stanford Clinical Virology Lab deployed its own test for patients at Stanford Health Care and Stanford Children’s Health.

We asked Mello to answer some questions about the federal rollout of diagnostic testing.

You write that in the early stages, COVID-19 “spread beyond the nation’s ability to detect it.” Is there anything the U.S. government could or should have done weeks ago to get out ahead of the spread?

Adopting broader testing criteria and allowing use of a wider range of tests would have been helpful in identifying the first U.S. cases and containing the spread. Manufacturing problems like the one that arose with CDC’s test are always a risk, but the fact that CDC put all its eggs in that one basket made the manufacturing snafu highly consequential.

Also, the public messaging from Washington about the seriousness of the problem has been neither consistent nor accurate, and I worry it may have led Americans to take fewer steps to prevent community transmission than we should have. Containment was not “pretty close to airtight.” A vaccine was never going to be ready in “three to four months,” as the Trump administration claimed. The case fatality rate is not “way under 1 percent.” Part of the problem here is that as the stock market continues to plunge, the president and the task force he appointed appear to be more concerned about calming investors than stopping the virus.

We seem to be between a rock and a hard place: You write that remedying gaps in testing is imperative, yet “more testing is not always better.” How do we determine the happy middle ground?

First, the testing criteria have to be calibrated to our actual testing capacity. You can’t announce that any American who wants a coronavirus test can get one and then, within hours, announce that there aren’t enough test kits to make that possible. High priorities for testing include patients with serious, unexplained respiratory illness and contacts of known cases. From there, testing can be expanded, beginning with other high-risk groups, as capacity permits.

Second, we should consider unintended side effects of mass testing. The problem with this virus is that it doesn’t have signature symptoms. It looks like the common cold or the flu. If everyone with a cough or fever, or who has been around someone with a cough or fever, shows up in their doctor’s office demanding a test, it will quickly overwhelm care facilities that should be focusing on patients with a higher likelihood of being infected or and those who are infected and are seriously ill. It may also work against the social distancing measures that public health officials are trying to encourage, because crowded waiting rooms may spread the virus.

The CDC announced Monday it now has the testing capacity in 78 state and local public health labs across 50 states to test for the virus. There are now 75,000 lab kits cumulatively to test for COVID-19 with more coming on board by mid-March. But is there anything we could have done to roll this out earlier?

The alternative would have been to allow laboratories to deploy their own tests from the beginning, using the primers and protocols made publicly available by the World Health Organization. That’s what other countries have done. RT-PCR is a mature technology and high-complexity labs around the country are well-qualified to conduct this type of testing.

There is a public health argument for not going that route: perhaps those labs wouldn’t have done as good a job as CDC’s own lab and the state labs that it handpicked early in the outbreak. What if there were erroneous test results? We could miss cases, or we could put people into isolation, with huge social consequences, based on false-positive results. There is also a worry that some labs aren’t consistent about reporting positive test results to CDC, and underreporting could compromise disease surveillance efforts.

The counterargument is that high-complexity labs have that certification for a reason—they’re good at what they do. And of course, surveillance is also compromised when you miss cases because you don’t test.

You write in your paper that testing for COVID-19 “highlights a controversial area of public policy—the regulation of laboratory-developed tests—in which there has long been tension between the goals of access and quality.” Who should be in charge of regulating these tests?

Laboratory-developed tests are largely unregulated outside of emergencies. The FDA proposed draft guidance in 2014 that, if implemented, would have required labs to make certain showings to FDA about tests they developed in-house, with the particular evidence calibrated to the risks involved in having a wrong test result. Contrary to President Trump’s claim that an Obama-era policy constrained coronavirus testing, the guidance did not relate to emergency situations. During declared emergencies, another statute and set of regulations apply, and the FDA has broad discretion to allow or disallow use of novel diagnostics and therapies as emergency countermeasures.

As a general matter, it makes good sense to require labs to submit evidence that their in-house tests work. It’s odd that laboratory-developed tests are carved out of requirements that apply to other kinds of medical devices. It’s also sensible that our legal framework allows FDA’s regular rules to be relaxed during emergencies so we can tailor our response to the difficult and changing circumstances.

You write that diagnostic testing is critical to an effective response to the novel coronavirus. What sort of policies and guidelines should be put into place to prevent such a sluggish rollout during an emerging epidemic the next time one comes around?

The legal framework for an effective emergency response is in place. Because giving agency heads the discretion to act as potentially unforeseeable circumstances require is a linchpin of this legal framework, it only works if leaders make smart choices. Every emergency is different, and there is a danger of Monday-morning quarterbacking. But we should learn from every misstep we make, and I think the lesson here is to make better use of already developed networks of highly qualified labs to make sure we have adequate testing capacity to isolate cases and trace their contacts very early in an outbreak.

What are some innovative approaches we could be taking to speed up testing for those who really need it?

The South Koreans have set up drive-through testing stations in parking lots to avoid concentrating crowds of people indoors. Of course, that requires that you have plenty of test kits, which we don’t yet – but we should also be thinking about creative ways to address the epidemic. For example, how could video calls be used to monitor the health of people confined at home after being exposed to the virus? How can social media be used to connect neighbors to help one another when some are isolated at home? Hopefully we can find new ways for technology to bring us together when pathogens drive us apart.