Books COVID-19

Book Review: Uncontrolled Spread

If you want to learn more about what went wrong for America’s response to the COVID-19 pandemic, a great book to read is Scott Gottlieb’s Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic. Gottlieb is a physician, a former FDA commissioner, and a member of the National Academy of Medicine and is well-placed to evaluate what went wrong.

One of the key issues he highlights is that the CDC was well-prepared for a flu epidemic, but not well-prepared for the spread of other viruses, like SARS-CoV-2. For instance, why were we wiping down surfaces and then later did not have to? Because the wiping down of surfaces is helpful for fighting flu, not COVID-19.

One of the key failures Gottlieb highlights relates to the rollout of COVID-19 tests.

The CDC’s single biggest breakdown in its response to COVID was the abortive rollout of its COVID test….once the agency ran into challenges with their development of that initial test for SARS-CoV-2, for weeks afer, there still wasn’t another test being pursued in the US…When Secretary Azar asked the CDC why the agency wasn’t shipping its test kits to private hospitals, CDC officials had to tell him that the agency never provided test kits to the private sector, only to state labs. But in this case, the CDC was expected, for the first time, to supply test kits directly to commercial and academic labs.

What should have happened? Gottlieb argues that there should be a variety of COVId tests to suit different needs. There should be laboratory-developed tests that get be used in the field; PCR tests for high-throughout testing to test hospitalized and severely ill patients; point of care tests for patients showing symptoms but not severely ill that can be administered quickly in physicians offices where patients can find out if they are COVID-positive before they spread the disease, and low-cost antigen tests to for population-based screening of asymptomatic individuals. While we are now at a point where all these different tests are available, it took months for them to be approved.

Another interesting point was vendor stockpiling. When you think of stockpiling, you think of a warehouse where extra medicines and PPE could reside. In practice, however, the medicines will expire and the PPE decay. Thus, you need a vendor-managed stockpiling where goods are manufactured, a share of recently manufactured goods to into the stockpile, and then goods from the stockpile sent out to current customers. That way, the stockpile is consistently replenished with fresh medicines and PPE.

One item the CDC did embark on later for COVID-19 monitoring was to use the US wastewater system.

The CDC launched a project called the National Wastewater Surveillance System (NWSS) that is monitoring for variants of SARS-CoV-2, but also starting to look for new viruses that may be circulating in the population. Because we shed many viruses into our feces, city wastewater can serve as a “liquid biopsy” to help inform us of emerging outbreaks.

Overall the book is very interesting and worth a read. I did note, however, that while there is significant criticism leveled at the CDC, very little criticism was aimed at the FDA. As a former commissioner at the FDA, I think Gottlieb largely omitted many FDA issues with the COVID-19 response. Nevertheless, the book is interesting throughout and worth a read.

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