By Dr. Joy Calayo
Professor of Microbiology and Public Health Dr. Joy Calayo discusses the use of medical countermeasures during COVID-19, arguing that a “nation’s security depends on its citizens’ health”.
The World Health Organization (WHO) has estimated that between 2020-2023, 12-17% of global deaths are and will be attributed to communicable diseases. Meanwhile in 2021, excess global deaths due to COVID-19 was estimated at 14.9 million. These figures show that, despite the decreasing mortality due to communicable diseases, the potential for a biological threat to cause massive disruption in the population’s health remains substantial.
Expectedly, continued scientific research and innovation led to the development and use of medical countermeasures (MCMs) against biological threats. These range from chemotherapeutic agents, vaccines, detection systems, medical devices, and protective equipment, to other goods and services for health preparedness and response.
Revisiting MCMs During COVID-19
Analyzing MCMs during the recent pandemic is an appropriate starting point for this discussion. These MCMs were subjected to challenges during the early phase and at least up to the peak of the COVID-19 pandemic. From the outset, fear of the novel pathogen prompted the heightened use of MCMs such as personal protective equipment (PPE), chemical disinfectants/germicides, and more. However, several factors disordered the access, distribution, and use of MCMs, including biologic agents, geography, communication, legislation, and people.
What You Do Not Know Can Hurt You
SARS-CoV-2 was designated as a Risk Group (RG)-4 pathogen because of its likelihood to cause serious or lethal human disease for which preventive or therapeutic interventions are not usually available. An RG-4 agent is a high-risk agent for the individual and the community, thus
, warranting the maximum protection of humans and their environment. Moreover, at the outset, limited knowledge and differing understanding of SARS-CoV-2 including but not limited to transmissibility, host range, susceptibility and adaptation characteristics allowed for either an overstated or unassuming use of MCMs. Later, fear of SARS-CoV-2 decreased, and it was eventually characterized as a lower RG-3 human pathogen and an RG-2 animal pathogen.
No Man is an Island
Mitigating the more serious cross-border spread of the disease hampered the distribution and access to MCMs. Geographically isolated and disadvantaged areas (GIDAs) already saturated with COVID-19 suffered the most from closed borders, lockdowns, and restricted transportation. Improvization of protective barriers (such as PPE substitution), repurposing of medicines, use of traditional and alternative medicine, and the use of FDA-unapproved drugs were evident displays of disparity in MCMs, aggravated by trial and error in developing treatments.
The Power of Communication
During the pandemic, communication became a double-edged sword. Despite speedy information technology and dissemination systems, mis- and disinformation deprived individuals and communities of factual and useful health awareness and education. News on hoarding of MCMs, intake of unproven medications, and dubious health practices as well as the disruption of the flow of other goods and supplies, were experienced by countries regardless of socio-economic status. On the other hand, the steady flow and sharing of information enabled countries to create or improve their action steps to further understand the virus and help curb the pandemic. Activities related to this included free-access literature, test methods development, vaccine research and development, epidemiologic surveillance, benchmarking of best practices, networking for resource allocation and sharing, risk communication, and country self-regulation.
No One Size Fits All
Many governments had already crafted policies and procedures governing the implementation of public health emergency preparedness and response, and these local laws and regulations were tested for resilience and vulnerability by the pandemic. As a result, some countries have either modified or added layers to improve their applicability, extending up to the post-pandemic recovery phase. A notable collective reactive measure is the ongoing negotiations on the development of the 2021 International Treaty on Pandemic Prevention, Preparedness and Response, or Pandemic Treaty among WHO member states. It is anticipated that the treaty will be able to “represent a commitment by countries of the world to address the health needs of their citizens to advance their health status and strengthen the socio-economic status of their communities at large”.
The Forces That Drive People
The people – from the individual to the community – are the greatest influencers of the success or failure of any or all measures against public health emergencies and biological risks or threats. Humanity’s intrinsic nature of adaptability and self-preservation were stimulated by the fear of the unknown virus, mobility restriction, mis- and disinformation, acute onset of unemployment, and profit loss. Individuals and communities were apportioned into two distinct groups based on biological and health risk perceptions: risk averse or risk tolerant. Risk averseness was further subdivided into varying degrees. They included, in general, the frontline responders and those providing non-stop essential goods and services. In other words, they are the main consumers of MCMs, particularly PPE and disinfectants. They were also the first COVID-19 vaccine recipients.
On the other hand, the risk tolerant ones were driven by the need to sustain themselves and their families or dependents, as their income sources became impaired. This is especially true in low- and low-middle income countries with many earners being employed or belonging to small and mid-size enterprises. These people became economically displaced largely due to mobility restrictions.
As a result, this group shrugged off the perils of pathogen exposure and infection in a strong attempt to sustain their needs with little to no MCMs to hand. They often opted to disregard or turned a blind eye to national policies and local ordinances. This is an example of what in my country is known as “kapit sa patalim”. This is a Filipino expression describing the life of someone who is clinging to a knife’s edge, i.e., demonstrating a willingness to risk death or injury despite knowing that it is dangerous to do. In this case, breaking public health safety protocols and in worst cases hostility among citizens had been reported.
Of Heroes and Villains
It is difficult to measure people’s intentions during a pandemic. One individual’s loss could be another person’s gain. In a pandemic situation, those who think ahead win the game. The COVID-19 pandemic was sensational because of discussions that the agent, SARS-COV-2, may have been a laboratory product and beyond that of gain-of-function research. It was termed a Robot Bioweapon and an Unrestricted Bioweapon by Li-Meng Yan and Adrian David Cheok based on in-depth analysis of the viral genomic sequence, which is discordant with what they called “fabricated” sequences.
Similarly, in a 2020 article in Forbes, Dr. Mark Kortepeter, a former U.S. Army physician and biodefense expert, described some criteria which would make COVID-19 a good biological weapon. These are ease of access, ease of manufacture, stability in the atmosphere, a low infectious dose, a high percentage of people becoming ill, users of the bioweapon possessing an antidote, widespread enough to cause public panic, and contagiousness. SARS-CoV-2 appears to meet some of these criteria. It leaves an open discussion on whether defensive biological research on COVID-19 will be practical and benevolent to pursue.
The definite heroes of the war against COVID-19 were primarily the health workers and other essential workforce members, including military personnel. They were sent to the proverbial battlefield equipped with several combinations of MCMs: PPE, protected by secondary barriers, administered with early-design vaccines, and regularly tested as part of disease surveillance, and health monitoring.
The Way Forward: MCMs in the Future
It is not a matter of “if” but a question of “when”. Regardless of the origin, whether natural or man-made, the ability of a biological agent to threaten the safety and security of mankind and the environment are unpredictable. It is up to governments to review current priorities and consider the magnitude and impact of bio-threats. How can an epidemic or global serious public health emergency paralyze socio-economies of nations? Can S&T keep up with well-adapting bio-bugs?
Countries and governments are continuously trying to improve systems to address public health emergencies and CBRN threats by using an “all-hazards” approach. Within this context, the indispensability of the MCM component warrants its sustained development and improvement. MCMs will evolve as a mixture of modern and traditional medicines to explore the most plausible options for treatment and management. The benefits must maximally outweigh the risks and the choice of MCMs should be as appropriate as possible to protect a country’s citizens, because, as I said at the NCT APAC 2023 conference in Kuala Lumpur, “a nation’s security depends on its citizens’ health”.
Dr. Joy Calayo is a professor of Microbiology and Public Health at the Faculty of Pharmacy, Medical Technology and Biochemistry at the University of Santo Tomas, Manila, Philippines. She is also the Chief Medical Technologist at the San Lazaro Hospital (SLH), National Referral Center for Infectious Diseases under the Department of Health. She is the point person for the SLH-Nagasaki University Research Collaboration laboratory.