60 International The EconomistFebruary 22nd 2020
2 agency. America’s supply all comes from
the cdcin Atlanta. It will be several months
before commercial tests are available.
Tests could soon run short if other
countries experience covid-19 epidemics
like China’s. Delays in getting the results
would increase. A lab technician must first
prepare the samples. After that, processing
each test through a molecular-analysis
machine can take an hour and a half. These
machines also run tests for the seasonal flu
and other diseases. A covid-19 epidemic in
the middle of winter—peak season for the
common flu—would quickly overwhelm
laboratories in most countries. Rapid diag-
nostic tests for the new virus that are as
quick to carry out in doctors’ offices as
pregnancy tests were at the top of the wish-
list at a whomeeting about research priori-
ties for covid-19 in February.
Once an epidemic is in full swing, ex-
tensive testing to find everyone who might
have the disease is less useful, says John
Hick, an emergency co-ordinator at the
Hennepin County Medical Centre in Min-
neapolis. At that point, he says, doctors will
start to diagnose probable cases by symp-
toms alone—which is common practice for
many illnesses, including the flu. Medics
in parts of China are already doing this.
As with other contagious diseases, co-
vid-19 patients in hospitals must be isolat-
ed to prevent its spread. When patients be-
come too numerous to contain in isolation
rooms, shared rooms, wings or entire
floors may be set aside for covid-19 patients
only. The Vrije University hospital in Am-
sterdam has dusted off its plans for doing
this, including where to put “do not cross”
lines to separate such sections, says Rosa
van Mansfeld, who oversees infection pre-
vention there. When all Dutch hospitals are
overwhelmed, the lights will be turned on
at the country’s “calamity hospital”, a fully
equipped facility in Utrecht that is other-
wise shut (it last opened to care for the vic-
tims of a terrorist shooting in 2019). In Kin-
shasa, Congo’s capital, an empty Ebola
treatment centre will be used when co-
vid-19 cases are identified.
Dr Hick says the biggest challenge if the
disease starts to circulate widely in Minne-
apolis will be staffing. With no vaccine to
protect them, many doctors and nurses
will be infected. Others will need to stay at
home to look after their children because
schools may be closed. In its disaster plan-
ning, the hospital where Dr Hick works
considered offering child care on-site for
its staff. But he admits that people may be
reluctant to bring their offspring to a hos-
pital during an epidemic.
Hospitals will encourage people who do
not seem to be seriously ill to stay away, as
they do during the peak of seasonal flu. In
part, that is to prevent them from straining
the capacity of hospitals that are already
overwhelmed. Doctors have no treatmentto offer those with mild symptoms but in a
hospital they can infect other patients or
medics. Such people will be advised to iso-
late themselves at home. Others with mild
symptoms may in fact have a different
bug—but if they flock to hospitals, they
may contract covid-19 for real.
Hospitals in both rich and poor coun-
tries are worried that in the event of an epi-
demic they will quickly run out of masks,
gowns and gloves. Guidelines by the ecdc
say that 24 disposable sets per day may be
needed for a covid-19 patient in an inten-
sive-care unit. The whosays that a global
shortage is already occurring, with a 20-
fold rise in prices for some types of equip-
ment. Surging demand in Asia, stockpiling
by hospitals and disrupted production in
China have all contributed to shortages of
surgical masks.
Some hospitals are trying to conserve
supplies. Dr van Mansfeld says that nurses
in her hospital in Amsterdam are being re-
minded not to use the high-protection res-
pirator masks if they are caring for patients
for whom the guidelines say ordinary sur-
gical masks suffice. At some point, says Dr
Hick, medics may have to start reusing res-
pirator masks judiciously. Instead of
throwing them away after each patient,
they could remove them, handling them
particularly carefully so that any germs on
the outer surfaces are not transferred to
their mouths or noses, and re-use them.
The swine-flu pandemic, which was
caused by the h 1 n1 virus and infected 16%
of the world’s population in 2009, brought
home the message that doctors would have
to make such tough decisions when big
epidemics strike, says Dan Hanfling of In-
Q-Tel, an American organisation that in-
vests in national-security technology. Be-
tween the first and the second wave of h 1 n 1
infections in America, the country’s Na-tional Academies of Sciences developed a
set of “crisis standards of care”. These spec-
ify what doctors should do as shortages of
medical supplies become worse.
One course of action is to substitute
treatments with near-equivalents, such as
drugs that have a similar effect. Another is
to adapt what is available for different uses.
For example, simpler breathing machines
from ambulances may be used as substi-
tutes for the sophisticated machines in in-
tensive-care units. Medics may have to
clean and re-use equipment, such as cathe-
ters, rather than throw it away after each
use (as doctors in poor countries do every
day, Dr Hanfling points out).
The hardest decisions would come
when all these options are exhausted. Few
countries have discussed how doctors
would choose which patients get ventila-
tors when there are not enough for every-
one who needs one. If doctors have one pa-
tient who is on a ventilator but clearly
getting worse, and another who is healthier
and more likely to survive, they can justify
reallocating the ventilator to the second
patient. But such decisions would be par-
ticularly hard to make with covid-19, based
on what doctors already know about the
disease. A patient may be on a ventilator for
several weeks and show little improve-
ment but still make a good recovery.Be prepared
America is ahead of most countries in
planning for such things, says Dr Hanfling.
Disasters such as Hurricane Katrina—
when many patients died in hospitals that
were unprepared for disaster—laid bare
the need to prepare for the worst. Each year
the federal government gives states and
hospitals about $1bn specifically for disas-
ter preparedness. That is more than the na-
tional health budget of many African coun-
tries. Other countries’ recent experience
may help them. Kerala, the only state in In-
dia to have confirmed cases of covid-19,
swiftly contained an outbreak of Nipah, a
nasty virus, in 2018 and has since bolstered
its health system. Uganda has held back the
spread of Ebola from next-door Congo and
in the process built up stocks of protective
clothing for health-care workers.
But poor countries would be hit particu-
larly hard by outbreaks of covid-19. Uganda
is used to dealing with diseases transmit-
ted through blood, mosquitoes or para-
sites. Covid-19, if it comes, could spread
quickly and unpredictably, which would
test a cash-strapped health-care system.
Ian Clarke, chair of a private health federa-
tion based in Uganda, worries that the mor-
tality rates could be higher in Africa than
they are in China because many people al-
ready have weakened immune systems as a
result of hivor poor nutrition. sarsmostly
skipped Africa; the continent may not be so
lucky with the new virus. 7