It has been three years since the first reported Covid-19 case in Wuhan, China, and more than 6.6 million people have died from this disease since. The United States has the highest number of Covid-19 deaths worldwide, with a sixth of the global toll. But despite this devastation, the U.S. may not be ready for the next pandemic: Experts say they can easily imagine a virus that is as infectious (if not more infectious) than the coronavirus but far more deadly. “If this was our test run, I think we mostly failed,” says Bob Wachter, chair of the Department of Medicine at the University of California, San Francisco.
So, what went wrong? No one answer can explain everything, and Amy Acton, former director of the Ohio Department of Health, thinks the U.S. needs to establish a 9/11-style commission to study the pandemic response and improve preparedness going forward. With the country seemingly ready to move on, though, nobody can say when this commission will happen, if ever.
In this absence, we reached out to public health experts to distill six lessons we’ve learned from Covid-19 that could help us fight the next pandemic.
We need to rapidly scale up testing
According to Eric Topol, director of the Scripps Research Translational Institute, the first failure of the pandemic was “not to have a test for almost two months.” As Covid-19 spread across the country between late January and early March 2020, the U.S. was driving blind, unable to track transmission and get ahead of the disease. “That set us down a dark hole that never has been truly dug out,” Topol says.
On January 11, 2020, Chinese scientists uploaded the coronavirus’ genome online, and a week later, German scientists made the first diagnostic test. In the U.S., the Centers for Disease Control and Prevention (CDC) was developing its own test, but the first batch created was defective—and it took weeks to fix the issue. Meanwhile, the U.S. refused to use the World Health Organization (WHO) test, even as almost 60 other countries did, and federal regulations obstructed state, academic and commercial labs from developing their own versions. These regulations were lifted only at the end of February. “One of the biggest missteps we had was lost time,” says Monica Bharel, former commissioner of the Massachusetts Department of Public Health.
Looking around the world, many countries empowered commercial labs to produce Covid-19 tests so that early in the pandemic, they were able to test tens of thousands of people per day, even as the U.S. could test fewer than 100. “One of the real lessons is that the CDC cannot, or—at least based on the way they were two years ago—should not have been trusted to be the only developer for testing,” says Wachter.
In the future, waiving some of the regulatory hurdles and using WHO tests as a temporary measure could help the U.S. rapidly scale up testing while still ensuring quality control and efficacy.
We need to leverage data more effectively
During the pandemic, “follow the science” was a common refrain, but the paucity of quality data made it almost impossible to adhere to this commitment. The initial delay in testing was part of the issue because it left public health officials with inadequate information to guide their state’s response. “If you don’t test, you don’t know what’s there,” Acton says.
That’s true from an equity lens as well. In late March, Bharel saw that Massachusetts wasn’t getting enough reporting of cases, hospitalizations and deaths by race and ethnicity, so she put out a public health executive order requiring this breakdown. And, in short course, race and ethnicity reporting shot up from 28 percent to 98 percent for Covid-19 deaths, Bharel says. That granularity in data allowed Massachusetts to identify health disparities early and proactively work to close them, even as many other states were working in the dark.
Beyond testing and data collection, one of the biggest challenges of the pandemic was that public health departments’ data systems were severely outdated. In Ohio, that meant that the department had to look elsewhere for its data analytics. “We don’t even have the money to afford that,” says Acton, “but we were able to go to Cleveland Clinic and scientists from amazing universities who could run the numbers for us.”
These collaborations were critically important but decentralized, so every state was reporting Covid-19 data in ways that weren’t always compatible nationally. “It was very difficult for me in Massachusetts to say, what can I learn from Illinois or Rhode Island or New York—and compare and contrast,” Bharel says. “There has to be a way for the CDC to obtain information from all states and territories in a standardized way.”
In future pandemics, the CDC should mandate that states collect granular, high-quality data and help build the digital infrastructure to standardize reporting across the U.S. Public health agencies could then share this data with Americans in daily briefings and weekly reports, as opposed to data snapshots that usually come too little, too late, Topol says.
We need to seek out a diversity of voices
Acton says, “when you’re a leader, truth doesn’t always get up to you.” That’s partially by design, because gatekeepers help prevent information overload. But it’s also partially politics: “Bureaucratic systems incentivize, at certain levels, not speaking up,” she adds.
That’s why Acton admires Ohio Governor Mike DeWine, who used to say that “the only decisions he regrets are when he didn’t work hard enough to get all the information he needed.” This relentless information-seeking helped Ohio build a kitchen cabinet of advisers from day one. “Ohio got ahead because we were able to get the information we needed,” Acton says.
The lesson for future pandemics is to seek out expertise from across the government and country, from theologians to communications experts to medical anthropologists and more. Acton points to Angela Merkel of Germany as a leader who “intentionally surrounded herself with a diversity of minds and thoughts” to make the most informed decisions she could. In a pandemic that cuts across all facets of society, leaders need to deliberately weigh all sides of the situation to make the most effective decisions, she says.
Deliberately seeking out this diversity of voices is also critical for fighting health disparities, Bharel emphasizes. Massachusetts, for instance, formed a health equity advisory group, so community members, health care workers and other experts could counsel the department on where and how to deploy limited resources. The state’s vaccination strategy, widely touted for its high uptake and reach, was probably the most notable example of this advisory group’s success.
Massachusetts started with mass vaccination sites, like most states, but quickly observed that these sites weren’t reaching all residents equally. So, in the state’s most vulnerable regions, the department pursued a hyperlocal strategy, hiring community members to serve as vaccine ambassadors. They would go door to door, answer people’s concerns and walk them over to get vaccinated—familiar faces engaging their communities. “In the United States, if you start to feel unwell, it is your responsibility to physically go to the health care facility,” Bharel says. “What if we flipped that and said we want to come to you in the community, and we want to help you be well?”
Of course, this engagement shouldn’t be transactional—getting shots in arms and then leaving. Public health departments should form interdisciplinary advisory committees that represent their community’s diversity and can help guide their work, whether the threat is lung cancer or the next pandemic. Prioritizing the community’s lived experiences and continuously investing in their success builds trust and equity.
We need to continue making big bets on vaccines
The Covid-19 vaccine was undoubtedly the big success story of the pandemic. “It proved that a concerted public-private partnership is capable of producing at scale a highly effective vaccine in eight to ten months,” Wachter says. This victory was a testament to the unprecedented commitment of federal resources, an expedited Food and Drug Administration approval process, previous research into mRNA vaccines and good fortune that the spike protein was an easy target.
But this success also offers an important lesson. “If you make a big bet, and you’re successful with a program, you should keep making big bets,” Topol says. By removing the risk for pharmaceutical companies, Operation Warp Speed got the U.S. first-generation vaccines, but the government didn’t kick-start a second or third operation to make nasal vaccines or pan-coronavirus vaccines, which could have protected against new variants. This was reportedly because of a lack of political interest and funding. “It’s stupid,” Topol adds. “If this is the best we can do, it’s not good enough.”
Indeed, a big part of the promise of mRNA vaccines is that they can be endlessly tweaked, providing a foundation to tackle all sorts of infectious, autoimmune and neurodegenerative diseases. For future pandemics, the U.S. should take advantage of this iterative nature to develop a series of new vaccines and not put all its eggs in one basket with first-generation vaccines, Topol emphasizes. Furthermore, Congress should be thinking of vaccine development as an instrument of national security, opening up its enormous defense budget to pandemic preparedness. After all, big public-private partnerships will always be needed to continue pushing technological boundaries and protecting American’s health.
We need to actively crowd out bad information
In 1984, HIV was discovered as the cause of AIDS, but almost 40 years later, scientists still haven’t been able to develop an effective vaccine for the virus. For Covid-19, however, “we learned that the biggest problem with vaccines is that people don’t take them,” Wachter says. Despite high-quality scientific evidence that they are essentially riskless, “the misinformation machine is able to elevate any tiny risk, either perceived or real, to feel almost equivalent to the benefit,” he adds.
Part of the challenge is that public health officials are not doing enough to compete for people’s attention. “The network that makes a conspiracy theory go viral is very well worked out and very strategic and intentional,” Wachter says, “whereas [public health] information networks tend to be like, ‘Well, we’re just putting out information. Why do we have to even think about spread?’”
For future pandemics, public health officials need to extensively engage their communities to drown out misinformation. “In Massachusetts, in the first 120 days of the pandemic, our governor had over 100 press events,” Bharel says. “What we really wanted to do was make our information the trusted source of information, because we knew there was a lot else out there.” Consequently, the department worked hard to put out information in different languages, create PSAs with physicians from local communities and creatively engage the public otherwise. In the Commonwealth Fund’s Scorecard, Massachusetts came eighth in the U.S. in its response and management of the Covid-19 pandemic.
But Topol thinks holding press conferences and engaging the public isn’t enough. “You have to take on the anti-science community, aggressively,” he says, “because if you don’t neutralize it, it just grows and gets more organized and sponsored and funded.” But what would this takedown actually look like? Topol envisions a fact-checking team at the White House or U.S. Department Health and Human Services (HHS) that would be responsible for publicly calling out public health lies spread on major media networks. “These bad actors, whoever they are, need to be identified so that the public knows that these people are making stuff up or lying—and they’re twisting and distorting things,” Topol says.
Whether or not this fact-checking crew could actually work is an open question, but Topol is emphatic that public health cannot take a hands-off approach to misinformation going forward. “It’s harmed millions of people, maybe cost hundreds of thousands of lives in this country already,” he says. “And we just let it happen.”
We need to infuse public health communication with vulnerability
Although misinformation was certainly deadly, the problems with pandemic communication were so much broader. With shifting guidance on issues such as isolation length and booster eligibility, public health agencies lost the American people’s credibility. “When the vaccines first came out and they began saying breakthrough infections are rare, everyone looked around and said, ‘No, they’re not. Half of my family has one,’” Wachter says. According to a poll published in May 2021 by the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, only half of the public reported a great deal of trust in the CDC, and only a third in HHS.
Some of these failures in communication were to be expected because, as Bharel put it, “we were flying the plane at the same time as were building it.” In the context of a novel virus, of course scientific understandings evolve, but communicating this shift to the public proved to be more difficult, with the federal government faltering again and again. For instance, the CDC’s masking recommendation in April 2020 was seen as arbitrary and capricious rather than reflecting greater evidence for airborne transmission and asymptomatic spread.
For future pandemics, the U.S. should consider taking a page out of Ohio’s playbook. In 2020, New York Times producers watched seven weeks of Acton’s press briefings and released an opinion documentary titled “The Leader We Wish We All Had,” focusing on her vulnerability, brutal honesty and empowerment. She acknowledged Ohioans’ pain and made them feel less alone. She openly projected her own uncertainty instead of providing static, irrevocable answers. When testing was in short supply in April 2020, she confessed that the Department of Health didn’t know how much Covid-19 had spread. “I have to be very clear and transparent with you. All of these numbers are a gross underestimation,” Acton said at the time, “and we have no real idea of the prevalence of this infection yet.”
Acton reflects back and says, “We would directly lay truth on the table, and once you do, more truth will spread.”
Bharel echoes similar points about transparency and flexible messaging. “This is what we know now. This is what we don’t know. And this is how we’re trying to find out more information,” she parcels out. Public health experts say that the public can handle—and in fact appreciates—difficult truths, as well as learning what specific work is being done to provide more clarity.
But perhaps one of the most important lessons for public health messaging is unity. During her wildly popular press briefings, Acton would share everything from Michael Stipe’s song “No Time for Love Like Now,” to the story of Bonnie Bowen, a 93-year-old Ohioan who’s made watercolor paintings every day since March 2020. When Bowen got Covid-19, she received 250,000 prayer messages—and ended up surviving. “We had to build a life raft where people were pulling one another up, and in Ohio, we ended up creating this movement of people helping people,” Acton says. “Kindness is an age-old, enduring principle. It’s about having the hard conversations but holding space and seeing the humanity in one another.”
Before the next pandemic, Wachter says “there should be a postmortem of the communication effort by the federal government about what the lessons learned were.” After cleaning house accordingly, HHS should establish an integrated system for public health communication, like the U.S. has for extreme weather and homeland security threats, and promulgate best practices for science communication to state and local leaders.
We need to question whether we’ve learned our lessons
We discussed the six biggest takeaways from Covid that will help us fight the next pandemic, but we could have mentioned so many other lessons, from improving ventilation to reforming contact tracing to depoliticizing public health. And that’s why Acton, Bharel, Topol and Wachter all emphasized the need to fully reckon with the failures of the Covid-19 pandemic and ensure that we are actually learning from our mistakes.
But Topol says there’s no guarantee that we will. And Wachter paints a similarly bleak picture about the future of public health: “We will underinvest in it because that’s what everybody always does when the acute threat passes. There’s always some other threat to take its place in the public attention and priorities.”
But experts stress that we can’t let this moment go by, especially after the past three years have brought unimaginable suffering, fear and loss to every pocket of the U.S. “We need to mourn, memorialize and then move forward,” Acton says. “We have to make meaning out of things we’ve endured.”
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