The pandemic shows why we're never ready for the big one

We had plenty of warning that something like COVID-19 was coming. But the reality is no country's health care system is built to withstand the kind of rare but consequential event this pandemic represents.

• Historically, deaths from infectious disease — like those from most catastrophes, natural and human-made — tend to cluster in a few big events, rather than being spread evenly from year to year.
• A single pandemic — the 1918 flu — killed at least 25 million people, and perhaps as many as 100 million around the world. The HIV pandemic, though it unfolded much more gradually, has killed more than 30 million people. But most infectious disease events are more like the 2003 SARS outbreak, which ultimately killed fewer than 800 people.
• The same is true for deaths from conflict. At least 108 million people died in wars during the 20th century, and the majority of those died in two events: World War I and World War II.

When it comes to national defense, the U.S. has built a system explicitly prepared for those big but rare events. For decades a pillar of American military strategy has been that the armed forces should be capable of fighting two major conflicts simultaneously — one reason why the Defense Department's budget was $686 billion in 2019.

• But that's not the case for health care, especially infectious disease. The number of hospital beds per 1,000 people in the U.S., for instance, has declined by more than 60% since 1970.
• This hasn't been a huge problem until now, in part because more care could be done on an outpatient basis and in part because health threats shifted away to chronic conditions like cancer.
• "If you're not running your hospital at 85% capacity, you're losing money," says David Hunter, an epidemiologist at the University of Oxford. "So there's no surge capacity."

The big picture: Our health care system is built to respond to known threats. The number of deaths from heart disease or cancer, or even seasonal influenza outbreaks, might rise or fall year to year, but it stays within predictable bounds — bounds our health care system can meet.

• But an explosive, global pandemic like COVID-19 breaks those bounds. The result is precisely what we're seeing now: too many sick people and too few medical resources to meet their need.

• At the same time, supporting a health care system capable of meeting the demands of a global pandemic that might only occur every few decades might be prohibitively expensive.

The ideal solution would be to create a system with plenty of surge capacity, capable of rapidly scaling up to respond to a major outbreak. But while digital systems are largely able to do just that — witness the ability of videoconferencing services like Zoom to meet the demands of tens of millions of new customers over the past month — it's far more difficult to scale up the manufacturing and distribution of physical things like masks, ventilators and beds.

• The shift to telemedicine and automation in health care provides some hope for the future, as does the the growth of 3-D printing, which aims to bring digital scaling to the physical world.
• But health care remains a high-touch, inefficient enterprise — albeit one we count on for our very lives.

The bottom line: Low-probability, high-consequence events like COVID-19 present a fundamental challenge to business as usual. Our preparation for them has largely been not to prepare — and we're seeing the painful results of that flawed strategy in real time.