After a long time of practicing, our work will become natural, skillful, swift, and steady. —Bruce Lee
Think back to the reports last spring from New York City, describing frantic efforts to deliver care at overwhelmed hospitals. Ships were used to add inpatient beds. Refrigerator trucks were provisioned as temporary morgues.
Consider the idea of a vaccination surge. Per Zeynep Tufekci, that means “setting up vaccination tents in vulnerable, undervaccinated neighborhoods—street by street if necessary—and having mobile vaccination crews knock on doors wherever possible. It means directing supply to places where variants are surging.”
Picture a border patrol station at an international airport. Rapid diagnostic testing for arriving passengers (something that before we would have thought invasive and unfair) should obviously be de rigueur. The tests will vary with the country of origin. Zika tests from blood may be appropriate for arrivals from Brazil, while flu testing from saliva may be desired from arrivals from China. Testing volume will vary too, as anyone could attest who has seen an immigration queue suddenly jump from empty to jammed.
One more. Imagine the logistics of sequencing disease variants around the world. You’d need to gather data on disease hotspots, direct resources to the highest-risk locations, and gather animal and patient samples in rustic—often dangerous—conditions.
What these scenarios share is their unpredictability. As a result, they also share a sort of impracticality: there is no reason to train the average medical professional how to handle them. Medical training is supposed to be scalable. We train doctors, nurses, and administrators to provide the best care to the most people. We train specialists to treat the tricky diseases, then disseminate their discoveries and methods through scientific communication and apprenticeship. One-off catastrophes and oddball environments have no scale. Each one is a pop-up production, where success requires rapid decision-making, improvisation, and personal courage.
The military has a term for this: operational medicine. It refers to care delivered on ships and planes, after disasters, while traveling, in combat. In the wake of COVID-19, it seems past time to expand the definition to include temporary clinics, mass vaccination sites, mobile labs for diagnosis and sequencing, street medicine, and group living settings like military bases, universities, prisons, and nursing homes.
It’s past time, too, that we figure out how to deliver operational medicine when and were we need it. For all our success rapidly developing new diagnostics and therapeutics in response to COVID-19, the pandemic response has made it painfully obvious how ill-equipped we were to use these tools to deliver timely, effective care.
In the US, we lost the first battle against COVID-19 by failing to test, failing to trace, failing to lock down, and failing to mask. We won the second battle with a human miracle: not one, but four supremely effective vaccines, developed in under a year, approved by the EU and US, and delivered to patients in record time.
We will lose the war. SARS-CoV-2 is now endemic throughout the world, and there is no realistic path to fully beating it as we have with, say, small pox. (Count me skeptical that there’s a short path to deploying universal vaccines.)
As losses go, this one will end up being middling. On the one hand, the casualties in the first battle were millions higher than they needed to be. On the other, the efficacy of our vaccines, and our shambolic but inevitable push into vaccine diplomacy, will prevent millions more deaths. Without vaccines, it might have been several years before SARS decayed into a seasonal nuisance: highly infectious but only occasionally deadly, like influenza.
The test we now face is whether we will adapt in the ways we need to win the next war. Vaccines alone won’t get the job done. They don’t prevent a new disease from emerging. They can’t deliver care to patients spreading and suffering from disease. They don’t inject themselves into anyone’s arms.
If pandemic response is a war, vaccines aren’t an army, they’re merely weapons. It is health providers, performing operational medicine, that form the fighting force. Unfortunately, our operational medicine force is a ragtag militia.
To fight the next pandemic, we need a standing army, permanently funded with non-discretionary federal spending. Call it the MediCorps: a permanent staff with expertise in clinical medicine, medical research, logistics, and disaster response, who train specifically to deliver operational medicine. Like the military, MediCorps would define and execute missions, deploy staff, and procure new tools.
The military brings the fight to our geopolitical adversaries. MediCorps would bring the fight to our biological adversaries.
Last year saw the advent of a powerful new vaccine platform. MediCorps could put it to use, running drug trials and administering inoculations overseas. They could sequence whole villages for Lassa virus. They could stand up field hospitals and train nurses from among the local population.
If this sounds hard and expensive, that’s because it is. But so is maintaining a standing army, an expense that in living memory we’ve always been willing to bear. If we were routinely engaged in outbreak response over there, we’d be much more effective at outbreak response over here.
Our soldiers are effective and prepared to fight our geopolitical adversaries because they fight all around the world, all the time. Our medical professionals are effective and prepared to care for the diseases we already know about. Fighting emerging biothreats requires a new kind of force—one that medicine was never designed to field. The only way to get the force we need will be to build it from scratch.