Let’s face it. Relative to other industrialized countries, America’s performance during the COVID pandemic was poor. We made mistakes, especially at the beginning with the bungling of the test roll-out and the failure to provide personal protective equipment (PPE). Furthermore, the recognition of asymptomatic spread came much too late. Most other countries outperformed us in the effective deployment of non-pharmaceutical interventions. Evidence of their success is borne out by lower excess mortality rates. South Korea, Japan, and others won the COVID war, while we came in worse than 30 other wealthy countries.
There are many lessons to be learned, from both the good and the bad of our pandemic response. The question is: Are we willing and able to learn those lessons and then apply them in the next pandemic? While some parts of the country may, the response of other states hangs in the balance.
Progress From the COVID Pandemic Response
Now available are several thoughtful reports analyzing our failures and recommending reforms of the nation’s public health infrastructure at all levels of government, and the CDC in particular. We should recognize the potential for progress. We can certainly improve on the early deployment of tests and PPE. Within reach is the development of uniform and centralized data entry and data sharing for COVID testing and contact tracing that is digital, user-friendly, and rapid. Congressional reauthorization of the Pandemic and All-Hazards Preparedness Act would go a long way to making this a reality.
Furthermore, the FDA has recently approved several single swab rapid antigen test kits that cover four respiratory pathogens: respiratory syncytial virus (RSV), COVID-19, and influenza A and B. The science and technology of vaccine development and production continues to advance, boding well for accelerated delivery (e.g., Coalition for Epidemic Preparedness Innovations’ 100 Days Mission). The cooperative arrangements and relationships that naturally evolved during the crisis care years of COVID among a broad array of local health, social service, education, and non-profit actors will, at minimum, reside in institutional memories, at least in the short-run. No doubt, the research sharing relationships built up among scientists from around the globe will continue. We should support the World Health Organization’s International Pathogen Surveillance Network. We can learn from the U.K.’s research platform RECOVERY (Randomized Evaluation of COVID-19 Therapy), which utilized a large-scale pragmatic clinical randomized trial network to test new therapeutics.
Another bright spot is that unobtrusive wastewater testing has expanded to over 1,400 sites around the country as part of the CDC’s National Wastewater Surveillance System. Locally collected samples of sewage are analyzed to provide an early warning snapshot of pathogens circulating in the community that can be compared to trends over time and to clinical data. The findings can be publicly displayed and publicly discussed at the local and state levels, thus providing an important new dashboard indicator and new level of transparency for driving the public health response at the community level. In essence, wastewater testing constitutes a community pathogen “biopsy.” Last month, New York City issued an alert based on a COVID spike in the 14 wastewater sewage testing sites.
The Hindrances to Future Pandemic Response
The bad news is that, even if we make progress on a number of fronts, including the reform of the CDC, it is likely that we will be in worse shape for the next pandemic. The erosion of public trust in public health and the wide-spread roll-back of federal and state emergency preparedness powers will limit our ability to prevent disease from becoming widespread or mitigate already widespread disease. A local public health official has described the situation as: “like having your hands tied in the middle of a boxing match.”
Many state, national, and even local office holders and office seekers have embraced an anti-science or anti-public health position based on an alternative history of the COVID pandemic. To illustrate the bizarre reality of our current condition, anti-vaxxer and conspiracy theorist Robert F. Kennedy Jr. — the son of the New York senator, attorney general, and presidential candidate assassinated in 1968 — is running for President.
Some state governments have already enacted reactionary laws supported by a substantial segment of the population. Florida Gov. Ron DeSantis (R) has signed a bill that prohibits: (1) business and governmental entities from requiring individuals to provide proof of vaccination or post-infection recovery from any disease to gain access to, entry upon, or service from such entities; (2) employers from refusing employment to or discharging, disciplining, demoting, or otherwise discriminating against an individual solely on the basis of vaccination or immunity status; (3) discrimination against Floridians related to COVID vaccination or immunity status, etc.
The fact is that traditional public health efforts to flatten the curve in anticipation of any future vaccine arrival for a possible next pandemic will be limited by an unprecedented set of political constraints. Furthermore, we cannot be optimistic about vaccine uptake. It is not clear how we will factor this new set of constraints into pandemic preparedness planning. Obviously, the political situation in individual states will be a key factor. And the national government will have diminished leverage over what happens at the state level.
Recent research shows wide variation among and within states in rates of COVID infections and excess deaths. Some states (e.g., Hawaii and New Hampshire) compared favorably to European countries. Many variables, in addition to public health practices, accounted for the variation — poverty, insurance coverage, health system capacity, presidential election preferences, racial and ethnic composition — variables that cannot be changed in the short run. This is not to say that innovative program efforts at the local level cannot make a difference. As an example, Florida A&M, a historically Black university, teamed up with the state to test not only the university community, but also the surrounding African American and lower socioeconomic neighborhoods of Tallahassee. Yet, our fear and expectation is that in the current political climate, variation in performance by location will widen significantly during any future pandemic, with political culture becoming an increasingly important factor. In other words, geography will determine our destiny.
Martin A. Strosberg, MPH, PhD, is emeritus professor of healthcare policy and bioethics at Union College and Clarkson University in Schenectady, New York. Daniel Teres, MD, is a critical care physician and clinical instructor in public health and community medicine at Tufts University School of Medicine in Boston.
Please enable JavaScript to view the