Pandemics have shaped the course of human history. Barbara W. Tuchman’s masterful history of fourteenth-century Europe, A Distant Mirror, recounts in sweeping detail the myriad ways the Black Death—the deadliest pandemic in recorded history—altered every aspect of human life, from economics and geopolitics to culture and the arts.
However, drawing lessons from a 700-year-old event has limited utility for grappling with the pandemic of today, COVID-19. It’s perhaps more useful to examine the response to more recent pandemics, such as the 1918 influenza pandemic and HIV/AIDS, which bloomed into a global health crisis in the 1980s.
Influenza is no stranger to us, returning year after year with spikes in the fall and spring. The influenza virus rapidly mutates, requiring vaccine manufacturers to update the vaccine every year in an effort to keep cases low and complicated symptoms minimized. Even with a vaccine, influenza causes 12,000 to 61,000 deaths in the United States each year.1
Every flu season carries the risk that a novel and more lethal mutation will occur. When that happens, we may see a pandemic similar to the deadly outbreak during the outbreak of 1918-1920, which was estimated to have killed 20 million to 50 million people.
Public health officials remain cognizant of the likelihood of such an event. Guidelines exist for healthcare officials to respond appropriately, adapted to handle the current and ongoing COVID-19 pandemic.
Similar to influenza—and, likely, COVID-19—HIV/AIDS continues to be an ongoing concern.
In the 1970s, a spillover event happened in the heart of Africa. Spillover is defined as a zoonotic jump of an infectious agent that establishes itself in a new host, like an animal agent such as simian immunodeficiency virus (SIV) from chimpanzees mutating and infecting humans. HIV and SIV are retroviruses that increase treatment complexity and make it more likely for patients to develop severe complications. In HIV, the complexities affect the immune system further, and there is the potential development of acquired immunodeficiency syndrome (AIDS).2,3
In 1982, HIV became a pandemic. Initially, the virus was not considered a serious concern, and the political and public health response was minuscule. It is well documented that homophobia in global politics and culture fueled the outbreak.
Today, we have the tools and resources necessary to closely examine how global pandemics can impact large and small populations. We also have two professions that can better understand populations and their behavior: public health officials and hospital informaticists.
How can lessons learned from prior epidemics and pandemics impact us today? Can we relate our current situation to past events to develop a path forward to resolve a crisis? How do we pave a path that benefits all communities regardless of size or location?
Current headlines and messaging have made it clear that COVID-19 should be feared. While diffusing fear can effectively shift the public’s behavior, this tactic can also open rifts in communities.
The initial push to view the pandemic as something to be feared in order to push people toward mitigation protocols, such as social distancing and mask-wearing, has been moderately effective with some populations.4
However, one of the major downsides of using fear as a public health tactic is its severely limited efficacy as a tool of education and the inability to provide a broader context for the need to make changes.
With a new epidemic or pandemic, developing research fast enough to provide the public with accurate information remains a significant barrier. The way to avoid these conflicts within communities would be broad and thorough education. Adaptive behaviors, such as frequent handwashing, decontamination of surfaces, social distancing, and mask-wearing, should not be difficult for the public to comprehend as long as sufficient education is provided.
If we use the example of the HIV/AIDS pandemic and its progress to help avoid further infections and help those infected, what do we find? Previously, we saw that fear tactics ran rampant, destroying the lives of individuals and complicating things further for those who needed to seek help.
There were widespread fears that AIDS could be transmitted through casual contact. This, in addition to a culture permeated with homophobia, led to significant stigmatization, discrimination, and insufficient care directed to people managing the disease.5
Today, we have better education on HIV. Though we do not fully understand the mechanisms for curing the illness, we know it is a sexually transmitted illness with lifelong persistence. We also know that it is possible to avoid the spread and have developed medication therapy to help offset complications. In the decades since the emergence of HIV, the change in the mindset between fear and education shows a need to bridge the information and the tactics used to modify behavior.
Educating the public should be a straightforward task, though even with comprehensive outreach and over-explanation, segments of the population may disregard the information entirely.
Education of populations begins with a detailed explanation of the scope of the pandemic, including the number of active cases, recovered cases, and mortalities.
The next critical information piece is how the disease spreads—if the agent is sexual, fecal-oral, or respiratory/airborne—and how likely it is to spread. These steps should increase the likelihood that the population will understand why they are being asked to wear masks or adhere to other adaptive measures to mitigate disease spread.
Detail of potential symptoms is always helpful, but insight into specific symptoms and those unique to the illness may help to avoid overwhelming hospitals with patients presenting with a common cold. Models are a helpful tool if used properly, and adaptive models combined with ongoing education that explain why the models have changed—and the implication of those changes—are important.
It’s helpful in all cases to present context with language and terminology that is easy to understand and accessible to laypeople.
Predictions exist of how to curb emerging infectious diseases and spillover agents. Of the recent diseases linked to spillover events, over 335 could have been avoided if we were not pushing the boundaries of nature.
To explain, we must consider the challenges that arise as we expand the boundaries of our populations and footprint on Earth while removing more forestland and pushing wildlife closer and closer together.
First, the biological impact on ecological systems and the trickle-down effects should be studied (e.g., we may push invasive species into new territory as humanity hinders the original ecosystems). Second, and more importantly, the lack of a barrier between humans and these species results in increased spillover events. The probability of an infectious agent mutating and jumping to a new host increases as we continue to remove barriers and relax boundaries between species.
The start of the COVID-19 outbreak has been linked to a wet market in Wuhan, China, where trading of various animal species occurred. As exposure to atypical species increases, we also increase the likelihood of infectious agents spilling over into our population; the authors of a study published in Nature argued that if we prioritize a budget for restoring and maintaining the barrier of these natural habitats, we could minimize the risk of another pandemic.6
Unfortunately, nature’s success persists, and whether it be another coronavirus, a mutated Ebola (filovirus), or influenza, a pandemic will happen again, and the best thing we can do is prepare ourselves.
Geographic location is another significant factor in population outreach. A reconsideration of the mindset regarding the spread of a self-limiting virus is necessary. With the proliferation of a dense and large urban population, we have to acknowledge the difference between more populated communities and their smaller counterparts.
In rural populations, people have lost employment as hospitals were shut down for any care that was not directly related to emergency treatments and COVID-19. While these shutdowns occurred, hospitals saw a hefty impact on their income streams due to a reduction in routine patient visits and emergency visits. A large portion of the income margins that urban hospitals maintain is related to elective surgeries.
We also saw a large shift of treatment moving directly into telehealth and the need to set these treatment channels up almost overnight. While facilities in urban areas have a large workforce that made this transition smoother with less impact, rural hospitals struggled to adopt a technology that was still quite new, particularly in the limited time frame and with limited resources.7
With the insight that small hospitals are bearing the greatest burden due to COVID-19, whether due to the lack of resources or the inability to perform elective surgeries, a better lens to use might be an examination of what can be done to help the impact on communities as a whole. For example, what if patients were incentivized by insurance reductions to adopt a healthy lifestyle or show improvement in health?
On August 26, 2020, the weekly updated report on select demographics and geographic characteristics published by the Centers for Disease Control and Prevention saw an interesting data element that appeared to relate to a patient’s ability to fight a COVID-19 infection: comorbidities. Comorbidities, the underlying issues or other health concerns a person may have, contributed to the frequency at which patients succumbed to the COVID-19 virus. Interestingly, only six percent of COVID-19 fatalities did not have any other conditions contributing to their deaths.
The leading comorbidity, at 42 percent, was influenza/pneumonia, which is not a hereditary illness. The ability of the body to combat the virus can be attributed to overall health. We also see a few other health issues that can be impacted by lifestyle changes: obesity, heart issues, and diabetes (type 2). These conditions, and other potential comorbidities, can be mitigated by adopting a healthier diet and routine physical activity regimens. These changes can help improve lung health, heart health, memory, mental health, immune system health, and other conditions.
In 2007, Porter and Teisberg pushed out a second article reviewing how physicians could revolutionize patient care.8 A big driving point was the shift to patient-driven care. This is not to say that patient care isn’t an important part of healthcare, but that the focus and relationship between physician and patient should shift.
The historic model has left the patients disconnected from their care plans, where a more inclusive treatment plan incorporating patient concerns could lead to improved outcomes. We should shift to the development of better systems with patients at the forefront of their care plan and a deeper understanding of their care. This push would help with the aforementioned comorbidities. As physicians move to a more patient-driven system, insurance providers could give both providers and patients better incentives to help mitigate any potential loss of revenues. These extra incentives, along with physicians’ help, could further drive patients to develop better diets and increase physical activity in ways that would prevent many health issues. An increase in the population’s general health lowers the complications a novel agent may have on the population.
The most important part of these considerations is found in the information we get from the data itself. Examining the possibilities and using models to mitigate the chances of another spillover event may help us avoid another novel pandemic. The development of educational materials and methods and a review of which behavioral patterns need to shift can be found in that data.
So, what does this mean for the world and businesses today?
The data-gathering methods and applications become more and more important; however, it is essential to use data appropriately, as it is possible to skew data in ways that affect the understanding and implications of those data.
Above all, it is essential to find ways to invest in the data analysts, be it for public health and its large-scale outlook or for the hospitals and for hospital informatics, so that the information may be used to approach changes within individual communities.
A disconnect exists between the large-scale and small-scale mindsets. Laying the groundwork for appropriate communications between the two could improve the lives of everyone, both in this country and globally.
- 1. Centers for Disease Control and Prevention. Disease Burden of Influenza. October 5, 2020. cdc.gov/flu/about/burden/index.html#:~:text=CDC%20estimates%20that%20influenza%20has,61%2C000%20deaths%20annually%20since%202010.
- Avert. History of HIV and AIDS Overview. https://www.avert.org/professionals/history-hiv-aids/overview.
- Avert. Homophobia and HIV. www.avert.org/professionals/hiv-social-issues/homophobia.
- Stolow, Jeni A., Moses, Lina M., and Alyssa M. Lederer. “How Fear Appeal Approaches in COVID-19 Health Communication May be Harming the Global Community.” Health Education and Behavior. June 11, 2020. https://doi.org/10.1177/1090198120935073.
- Fairchild, Amy Lauren et al. “The Two Faces of Fear: A History of Hard-Hitting Public Health Campaigns Against Tobacco and Aids.” American Journal of Public Health. April 16, 2018. https://doi.org/10.2105/AJPH.2018.304516.
- Jones, Kate E., Patel et al. “Global trends in emerging infectious diseases.” Nature. February 21, 2008. https://www.nature.com/articles/nature06536.
- Melvin, Sandra C. et al. “The Role of Public Health in COVID-19 Emergency Response Efforts From a Rural Health Perspective.” Preventing Chronic Disease. July 23, 2020. https://www.cdc.gov/pcd/issues/2020/20_0256.htm.
- Porter, Michael E., Teisberg, and Elizabeth Olmstead. “How Physicians Can Change the Future of Health Care.” JAMA. March 14, 2007. https://jamanetwork.com/journals/jama/article-abstract/206039.
David T. Marc (firstname.lastname@example.org) is chair of the department of health informatics and information management at The College of St. Scholastica in Duluth, Minnesota.
Matthew Blow (email@example.com) is pursuing a masters of health informatics at the College of Saint Scholastica.
Shauna Overgaard (firstname.lastname@example.org) is an assistant professor of health informatics at the College of Saint Scholastica.