The Paris Peace Treaties may have ended World War II, but the Marshall Plan was the defining legacy of the war. A plan that outwardly emphasized economic redevelopment but included plans to halt the spread of communism in Europe. In fact, the start of the Marshall Plan has been cited as the beginning of the Cold War and a key catalyst for future military alliances, including the formation of the North Atlantic Treaty Organization (NATO).
As COVID-19 enters the winter, and the realistic roll-out of the vaccine seems imminent, we must consider how the inevitable militarization of COVID-19 will impact the distribution of vaccines and the future of healthcare. When the military gets involved, multiple agendas get pushed. We saw it with the Marshall Plan, and there are plenty of reasons to believe we will see it again with COVID-19.
Currently, the dominating headlines focus more on the vaccine trials, which seem more like sprints than trials, and inter-departmental battles between various Federal agencies, which is more a battle of words than an actual conflict. Despite the prevailing animus, all government officials and pharmaceutical executives agree that the urgency of the pandemic does not negate the need for proper regulatory oversight. In early September, multiple pharmaceutical company executives pledged to maintain high ethical standards and adhere to stringent FDA review. A sentiment reciprocated by FDA director Dr. Stephen Hahn just days later.
Indeed, despite all the negative press the pharmaceutical industry has received over the years, they remain true to their pledge and have conducted clinical studies while maintaining the high standards of clinical research as per the evaluations of numerous, highly-referenced academic journals.
Yet, surveys of the American public suggest that only 50% would take the vaccine when available – a percentage far lower than the CDC recommendations for other similar viruses – rendering the overall value of the vaccine lower than if more people took it.
Vaccines work based upon the principles of herd immunity, once an agreed upon principle in epidemiology that has now somehow become controversial. But the fundamentals remain the same – in any given population, a certain percentage of people must take the vaccine to build broad, community immunity. Certain parts of the country in recent years have seen Measles outbreaks where the MMR vaccine rates have fallen, suggesting that patients in areas of low vaccination rates are more susceptible – and validating the importance of widespread vaccines.
A premise that has been upheld in the courts, favoring government intervention if necessary.
In 1905, the United States Supreme Court case upheld the authority of states to enforce compulsory vaccination laws in Jacobson v. Massachusetts. The Court’s decision articulated that individual liberty is not absolute and is subject to the police power of the state. Or that the state has the power to enforce vaccination even if people refuse. A ruling that has been reinforced multiple times over the decades and is not likely to be overturned anytime soon.
A precedent that may come into play in the coming months should the public refuse to receive vaccinations.
The government has been extremely sensitive of its perceived shortcomings during the initial phases of the pandemic. And perhaps there is some merit to that sensitivity, since the United States – as recently as 2019 – ranked first in the world in terms of its preparedness for a viral outbreak, as per the Global Health Security Index. Yet, despite all the preparation, all that is highlighted are the missteps, the perceived failures, and disjointed responses among the states and federal government.
The Council on Foreign Relations (CFR) sponsored an independent task force which gave a resoundingly negative outlook on the government’s response:
Amid these problems, too many federal, state, and local officials failed to communicate a clear, science-based, consistent message to the U.S. population; to develop a robust nationwide system for testing, tracing, isolation, and quarantine; or to clarify the respective roles of the national, state, and local governments in pandemic response.
Whether these responses were inevitable aspects of the learning curve, or unforced errors is something only the perspective time can provide. But the perception of failure, and the inevitable reactions it will produce – will define the government response once a vaccine is made available. For legacy obsessed politicians who serve as the decision-makers for public policy, there is a bias towards action – and then more action. Rather than risk being seen as incompetent or flat-footed in their response, politicians would rather be seen as aggressive, quick-to-act since the latter resonates more strongly in the minds of the public, and in the annals of history.
And this is where the military steps in. First gradually, and then suddenly.
First with government issued ad hoc clinics and camps offering vaccines at nearly free or heavily subsidized rates, espousing the civic duty of all Americans to get vaccinated. Followed by long lines in which citizens eagerly wait to receive their vaccine.
Then suddenly with government mandates, military action, and possibly – use of force. We already have seen military action in places like Portland, Oregon, and civil unrest is already elevated. There are plenty of reasons to believe any government mandate met with resistance can escalate suddenly and unexpectedly. There is too much at stake, politically and financially.
In a heavily redacted document, the Department of Health and Human Services secured the first 100 million doses of the vaccine developed by Cambridge-based pharmaceutical company, Moderna, for $1.5 billion – with the option to buy up to 400 million more. But most of the contracts have not been released, creating a conspicuous lack of disclosure around the terms of the deals with companies manufacturing the COVID-19 vaccines.
Paul Mango, the deputy chief of staff for policy at the Department of Health and Human Services, assures that the military will not administer the vaccine despite being involved in all aspects of the logistics and distribution of the vaccine.
“The overwhelming majority of Americans will get a vaccine that no federal employee, including the Department of Defense, has touched,” Mango said during a teleconference regarding Operation Warp Speed. “That said … we have the best logisticians in the world at the Department of Defense, working in conjunction with the CDC, to guide … every logistical detail you could possibly think of.”
Operation Warp Speed is a partnership between the Department of Defense and the Department of Health and Human Services, which includes the Centers for Disease Control and Prevention, Food and Drug Administration, and the National Institutes of Health.
For many, the close partnership between the military and healthcare may be disconcerting. But modern healthcare has its origins in warfare, including the concept of patient triaging, which was invented by Napoleon’s field generals during their invasions on the European mainland. The historical legacies of war in healthcare can still be seen today, as the top physician in the country is the surgeon general and the use of the phrase, task force, describes many healthcare collaborations.
Regardless of the historical basis, the typical American patient does not equate healthcare with warfare, nor sees the military undertones within healthcare – creating the perception that the government’s involvement will be an inevitable government overreach, in the eyes of the American public.
Yet the fact remains that we may be headed towards a brutal winter, and despite all our learnings in managing COVID-19, we may still be overwhelmed due to the rapid increase in COVID-19 cases and non-COVID-19 upper respiratory infections, like bacterial pneumonia and influenza.
Perhaps we need a centralized, coordinated response from the military.
Perhaps there should be government mandates to take the vaccine. There is both a medical basis and legal precedent for both.
But will the public see this as a violation of their public rights?
And how far should healthcare go in controlling our lives?
We know healthcare is significantly influenced by the everyday decisions and actions of individuals. Modifiable risk factors, such as obesity, high blood pressure, and smoking, were linked to over $730 billion in in health care spending in the US in 2016, according to Lancet Public Health. And researchers from the Institute for Health Metrics and Evaluation – the developers of the highly-referenced Murray Model which forecasts COVID-19 – found healthcare costs were largely due to five risk factors: overweight and obesity, high blood pressure, high blood sugar, poor diet, and smoking.
If we regulate the administration of vaccines, then why should we not regulate other aspects of our healthcare behavior – if it is for the common good. America’s obsession with individual liberties forms the basis of our culture, and largely the biggest argument against the argument for justifying healthcare mandates.
But something has to give.
The disjointed, poorly coordinated responses of COVID-19 created immense debt burdens on the country and exposed inherent weaknesses in our healthcare system. We have blamed healthcare leaders, politicians, hospital staffing models, and everyone in between, but we have not blamed the cultural ethos of America.
We seem incapable of confronting the balance between the common good and individual liberties in healthcare. We do not even see it as a balance, but as a confrontation of highly visceral beliefs that manifest as incomplete arguments laden with emotions more political than medical.
We need a balance, what the Journal of American Medical Association calls sensible medicine, a balance between intervention and a more libertarian medical policy. An approach to treatment that seeks to balance the strength of evidence, the pace of learning and innovating, and the broader socioeconomic implications of treatment. We tend to favor adoption of the new, accept less rigor in research methods and results if we desperately want a particular outcome, and a glance away from subconscious biases, leaving us exposed to unforced errors. In contrast, those that value individual liberties tend to be highly skeptical of new evidence and disdain government intervention – citing the futility of treatment, and the corrupting influence of financial incentives. A balance is a sensible approach, acknowledging that some interventions are effective but can fall short at times as well. With sensible medicine, the practical implementation of clinical care is appropriately calibrated to the rigor and reasoning of the available evidence and the severity of the outcome to be avoided.
For us to truly make inroads to resolving COVID-19, we must create a balance between the government’s oversight and desire to intervene with the public’s collective responsibilities to their health and individual liberties. A balance that will be defined by the public’s response to the government’s role in administering the COVID-19 vaccine.
World War II changed the global order of power, but the Marshall Plan defined how that new order would look. COVID-19 changed healthcare, but the government’s response to the COVID-19 vaccine will define how the new model of healthcare will look.
