Just weeks before the first case of COVID-19 was reported in China, the Global Health Security (GHS) Index, a report created by the Johns Hopkins Center for Health Security, ranked the United States as the most prepared country for a global pandemic. Then COVID-19 hit.
“We failed dismally,” says Amesh Adalja, M.D., an adjunct assistant professor at the Johns Hopkins Bloomberg School of Public Health, who has served on government panels that developed guidelines for infectious disease emergencies. At press time, the United States’ reported cumulative COVID-19 death toll neared 600,000, according to Our World in Data — roughly the population of the city of Baltimore. It currently stands at 1,807 deaths per million people, compared to just 5 deaths per million in New Zealand or 36 deaths per million in Australia. “That tells you there’s something wrong with how [we] evaluated our preparedness,” says Dr. Adalja.
Thankfully, the U.S. government’s Operation Warp Speed program, combined with years of prior research into related viruses and vaccines, led to the development of several highly effective and safe vaccine candidates in record time. Our current vaccination campaign aims to make up for early pandemic management stumbles, with the daily number of COVID-19 cases and deaths in the U.S. falling precipitously since January.
Still, experts are grappling with the takeaways from this deadly experience. We talked to 10 experts across various fields of public health to understand the lessons we’ve learned from this pandemic that we’ll need to collectively remember for the next one—because, unfortunately, there will be more pandemics to come.
1. Health-care workers need better support to avoid burnout.
More than a year after the start of the pandemic, it’s clear that health-care workers are incredible…but not superhuman: A number of studies have shown that the stress and isolation they experienced during the COVID-19 pandemic increased rates of trauma- or stress-related disorders, depression, and anxiety.
Front-line health-care workers have of course been traumatized. “Many people still need to take a step back and are suffering from PTSD from the past year,” Arthur Kim, M.D., director of the Viral Hepatitis Clinic within the Division of Infectious Diseases at Massachusetts General Hospital, tells SELF. “People have considered leaving medicine. They’ve experienced so much first-hand suffering and separation from family. It resembles, from what I can tell, people returning from the battlefield.”
Charlesnika Tyon Evans, Ph.D., MPH, a professor of epidemiology at Northwestern Medicine, is studying the impact of the COVID-19 pandemic on health-care workers in the Northwestern Medicine system. Anecdotally, Dr. Evans says, burnout, stress, and depression have affected her colleagues’ overall health. “People who do hospital and academic epidemiology work and research are overwhelmed,” she says.
The only potential upside here is that the pandemic has put a spotlight on public health that may bolster the field in the future. “For years, when people asked me what I did, I would get a blank look when I said I was an epidemiologist. They would say, ‘So you work on skin.’ Now everyone knows what an epidemiologist does,” says Dr. Evans. She says applications to public health programs are up, and she remains hopeful that awareness will result in greater funding. “It’s one of most underfunded systems in health care, but public health infrastructure is what will make or break us during a pandemic,” she says.
With that funding, researchers say, policymakers and managers should provide health-care workers with a long list of reinforcements to prevent burnout, such as psychotherapy; encouragement to take regular breaks and to engage in relaxation techniques such as yoga and meditation; and stress management and mindfulness training. “I think the military works in rest and relaxation for good reason,” says Dr. Kim. “In retrospect, we’ll hopefully be better prepared to provide respite if this were to happen in the future.”
2. Inclusive community organizations are critical to address health disparities across races.
In April 2020, Michigan authorities noticed a disturbing trend that mirrored a nationwide crisis: higher rates of infections, hospitalizations, and deaths among people of color. Although Black residents make up about 14% of the population in Michigan, they accounted for 40% of COVID-19 deaths. Between March and October 2020, there were 1,833 deaths per million people among Black Michigan residents, compared to 548 per million among white residents. Starting last October, the gap began to narrow. As of May 3, 2021, the Kaiser Family Foundation estimated the rate of cumulative COVID-19 deaths among Black residents at 23% of all deaths. Although this is an improvement compared with the first months of the pandemic, it’s still higher than the proportion of the Black population in the state.
To address Michigan’s glaring inequities, Governor Gretchen Whitmer signed an executive order creating the Michigan Coronavirus Task Force on Racial Disparities last April. The task force studied the causes of these disparities and recommended policies, partnering with dozens of community organizations, businesses, and public figures in weekly conversations. The program provided $20 million in funding to help local grassroots community organizations meet some of the most pressing community needs for the pandemic response, says Debra Furr-Holden, Ph.D., an epidemiologist at Michigan State University who is a member of the task force. Among many other initiatives, the group set up educational and promotional media campaigns to reach diverse audiences on essential topics like masking and testing. Organizers helped people in vulnerable communities connect to health-care providers and sign up for insurance and other support programs.
The critical lesson Dr. Furr-Holden hopes we take away from Michigan’s experience: It’s essential to include people who represent their communities in planning and executing a pandemic response. “The task force was specifically designed to represent all of the major disparate populations in the state,” she says. “We used their expertise and lived experience to inform our decision-making about how to allocate resources and solve our problems. It’s important you do work with people and not on their behalf without their inclusion.”
“A diverse public health force that represents all communities is vital,” agrees Whitney R. Robinson, Ph.D., an associate professor of epidemiology at the University of North Carolina Gillings School of Global Public Health. She lauds several nonprofit organizations in her city for providing critical infrastructure for care, education, and personal protective equipment (PPE) such as masks. “In a crisis, strong existing relationships and community knowledge are incredibly valuable. I’m lucky to be able to provide expert public health advice from a neighbor, tailored to the community, and responsive to the community.”
3. We should assume people who don’t seem sick can still spread respiratory viruses.
Asymptomatic or presymptomatic viral spread shouldn’t have come as a surprise during the pandemic, says Tara Smith, Ph.D., an epidemiologist at Kent State University College of Public Health. “It happens with almost every infection,” she explains, pointing to HIV, HPV, and even the flu. Yet in the case of SARS-CoV-2 (the virus that causes COVID-19), many experts didn’t expect that transmission would occur in people without symptoms. That’s because during the severe acute respiratory (SARS) virus outbreak in 2003, asymptomatic transmission seemed to be pretty rare, and most infections came from people who were showing symptoms, says Dr. Smith. “That’s why masks weren’t emphasized early on” during this pandemic, she adds. “They’re not as important as isolating when ill for a disease that only transmits when one is sick.”
Since then, the evidence overwhelmingly shows that seemingly healthy people can transmit COVID-19 to others. Some studies have suggested that roughly one in five people with COVID-19 are asymptomatic but still potentially contagious. In fact, researchers estimate that at least 50% of COVID-19 transmission stems from people without symptoms, with about 24% coming from asymptomatic people and 35% coming from presymptomatic people.
Asymptomatic and presymptomatic transmission makes it much more difficult to control the spread of an infectious disease, says Dr. Smith, highlighting the importance of wearing masks during any respiratory disease outbreak and handwashing even in normal times. In a future pandemic, experts will likely ask the public to mask and socially distance from the get-go. “In hindsight, we should have assumed asymptomatic or presymptomatic transmission just in case,” says Dr. Smith. “I suspect we will with any other novel respiratory virus that emerges in the future.”
4. Prevention is critical to keeping variants under control—and vaccines effective.
Early in 2021, health experts noticed a worrying global growth in coronavirus variants that seem to spread more easily and quickly, leading to more COVID-19 cases and stress on the health-care system. Theodora Hatziioannou, Ph.D., a Rockefeller University virologist who studies how viruses adapt to our immune system, tells SELF that she wasn’t surprised. She’d conducted a 2020 study that predicted these variants before they arose. “We had data like this all the way back in the summer of last year,” says Dr. Hatziioannou. “What we obtained was a tunnel of mutants that mirror all of the variants we see now.”
When a virus infects you, it attaches to your cells to copy itself and survive. Genetic errors happen during this replication process and are coded into the cell’s genome. Most mutations are harmless, but some create an advantage for the virus—for example, making it easier for the virus to evade human antibodies so it survives for longer. The more people the virus infects, the more chances it has to replicate itself, and the greater the odds are that a mutation benefitting the virus will develop and then become the predominant strain. As long as the virus continues to spread, mutations will occur; new variants will have an increasing number of mutations in the spike protein that’s targeted by the vaccines, explains Dr. Hatziannou. “This will seriously affect vaccine efficacy because the virus will become more and more immune to the antibodies we are producing,” she says.
Pfizer and Moderna are working on booster shots for the variants to be released as early as this fall, but Dr. Hatziioannou worries they may already be too late to address the mutations in new variants if the virus continues infecting people. That’s why we have to stop the virus from replicating now through vaccination, masking, and social distancing. “These variants arose because of our failure to stop the spread,” Dr. Hatziioannou says. “The more we let the virus grow in the face of these ever-increasing antibody responses, the more resistance we’re going to select.”
For future pandemics, Dr. Hatziioannou hopes that governments worldwide will institute coordinated social distancing, masking, testing, and tracing measures early on—and stick to them. “We should be more proactive in imposing actions earlier and keeping them up. We’re not out of this pandemic yet, so this is a lesson for the next wave,” she says.
5. Government officials need to trust and believe in science—and communicate that science clearly to the public.
The human tendency to try to make sense of chaos in a crisis gave COVID-19 conspiracy theories an enduring stronghold. Perhaps the most pervasive myth of all was that hydroxychloroquine sulfate (HCQ), which is used to treat malaria, lupus, and rheumatoid arthritis, could be a miracle cure for COVID-19.
The belief that HCQ could treat and even prevent COVID-19 spread like wildfire among Americans thanks to mixed messaging from leadership including former president Trump himself—who said last May that he was taking the drug preemptively to avoid getting COVID-19. At the height of the hype, many Americans were reportedly self-medicating with a combination of HCQ and the antibiotic azithromycin in an attempt to prevent infection, resulting in multiple deaths and hospitalizations. Like any drug, HCQ has risks, especially if it’s not taken under the supervision of a doctor: It can block how electricity is conducted in the heart, leading to sedation, coma, seizures, abnormal heart rhythms, and cardiac arrest.
At first, there were certainly reasons to be hopeful about HCQ. “Many places were touting HCQ because data from experiments in the lab suggested it could serve a dual purpose of dampening the immune response and working against the virus,” says Dr. Kim. With a lack of data and treatment options, the U.S. Food & Drug Administration granted emergency-use authorization (EUA) of chloroquine phosphate and HCQ last March to treat hospitalized COVID-19 patients when involving them in a clinical study isn’t feasible. By June the EUA was revoked when data showed the drug was not only ineffective but could lead to serious heart-rhythm problems. But that didn’t stop some politicians and even health officials from continuing to guarantee that HCQ was an effective COVID-19 treatment.
“We know what works in the lab doesn’t always work in people,” Dr. Kim says. Even doctors struggle to make treatment decisions during a pandemic—which is why caution and consistency in public health communication are critical.
Dr. Kim, who was also a member of the NIH’s COVID-19 Treatment Guidelines Panel, led a group of epidemiologists, infectious disease physicians, cardiologists, neurologists, hepatologists, oncologists, and rheumatologists from Mass General in regular meetings to analyze a dizzying flood of information on COVID-19, then create, update, and post the hospital’s treatment guidelines online. “There’s a firehose of information, with hundreds of papers coming out every day. We were just trying to make sense of it all,” he says.
Across the country, Dr. Kim says, other hospitals have similar procedures to share and learn from their peers. This communication and collaboration helped experts to come up with methodologies that have truly improved how we manage the virus. “A silver lining has emerged of interdisciplinary cooperation and forging of local, regional, national, and international relationships that I hope will be built on after COVID-19 and prepare us for the next pandemic,” says Dr. Kim.
As recently as this April, rumors about HCQ’s effectiveness as a COVID-19 treatment have continued to circulate in the general public, while debunked and unproven therapies still surface on social media, says Dr. Kim. But experts are much more confident in their ability to manage COVID-19. “Our arsenal is limited, but at least we know [these treatments] are helpful,” he says. “We now rely on better-quality data to make treatment decisions, which is a much better place to be than we were early on in the pandemic.”
6. Pandemics won’t end without global cooperation.
India became yet another country to face a COVID-19 crisis this May, with around 350,000 new diagnoses and 3,500 deaths every day by mid-month. “We aren’t going to be able to treat our way out of disease. We need to prevent more infections from happening,” Amita Gupta, M.D., MHS, the deputy director of Johns Hopkins University Center for Clinical Global Health Education and a member of the Johns Hopkins COVID-19 Precision Medicine Center of Excellence, tells SELF. Mass vaccination is the proposed solution. Yet even though India is the world’s largest vaccine producer, it’s facing a COVID-19 vaccine shortage: Only about 3% of its 1.37 billion people have been fully vaccinated as of late May. “It’s not a question of being able to make enough vaccine,” says Dr. Gupta. “There’s an issue globally.”
During a normal year, a total of approximately 4 billion vaccine doses are manufactured worldwide to inoculate people against many diseases, says Dr. Gupta. This year we’ll likely need more than 14 billion doses for COVID-19 alone, requiring a huge increase in raw materials, she explains. India can only currently make about 80 million doses per month due to a lack of raw materials required to ramp up production. “If raw materials are the issue, it’s a global issue, not specific to India. The amount of vaccine that can be made for everybody needs to be carefully thought through,” says Dr. Gupta.
Supply issues mainly affect middle- and lower-income countries worldwide, such as Brazil and areas of sub-Saharan Africa, says Dr. Gupta. Supplying these areas with vaccines will require major international coordination. Dr. Gupta says we need to look not only at FDA-approved vaccines but other vaccines developed in Russia and China. “What’s efficacious and can be rapidly scaled up? And really think about where it’s going to be needed given the population numbers and the risk of rapid transmission,” she says.
Business and political leaders of key countries are also joining forces to find innovative ways to more equitably dole out supply, she says. The World Health Organization’s COVAX program is distributing vaccines to lower-income countries, for example, while the World Trade Organization is working to temporarily waive intellectual property rights on vaccines to secure faster equitable access worldwide to COVID-19 vaccines. On June 10, President Biden announced that his administration would buy 500 million doses of the Pfizer-BioNTech vaccine to distribute to 100 countries over the next year. This is in addition to an already-promised 60 million doses of the AstraZeneca vaccine for export, if it meets FDA approval, and a $4 billion pledge to support WHO’s COVAX program. But these efforts are not without their criticisms—namely, the idea that a wealthy country like the United States could still do more to help address this crisis globally.
Beyond saving lives, we all have selfish reasons to keep the virus in check through global vaccination. “Allowing the virus to be transmitted and evolve into variants has the potential to undermine vaccine efficacy,” says Dr. Gupta. “Wherever COVID is occurring matters to the world. The virus knows no boundaries.” Yet she remains hopeful: She points out that China quickly released the viral sequence for other studies to use in their own pandemic preparations, scientists had already been studying coronaviruses for years prior to COVID-19, and many vaccine companies jumped at the opportunity to find a solution with government funding. “That all took a fair amount of collaboration among many different partners. Those are examples we should use to prepare for the next pandemic,” she says.
7. Funding for public health is essential, even when we’re not in a pandemic.
Early on in the pandemic, hospitals reported shortages of key equipment needed to care for COVID-19 patients, including ventilators and personal protective equipment for medical staff. Dr. Adalja, with the Johns Hopkins Center for Health Security, explains that hospitals are run to maximize profits while public health institutions scrape by on bare-bones budgets—a formula for a shortfall in a pandemic.
“Hospital administrations…don’t really think about excess capacity,” says Dr. Adalja. “They’ve implemented just-in-time inventory management.” A lack of resourcing for public health departments compounded the issue. In 2018, the Centers for Disease Control and Prevention was forced to cut 80% of its overseas epidemic prevention activities. And the U.S. Strategic National Stockpile, which was created following the anthrax attacks to supplement state and local medical equipment during public health emergencies, hadn’t been replenished after the 2009 H1N1 pandemic, says Dr. Adalja. “It’s hard to make the business case to say, ‘Yes, nothing has happened, but we still need to maintain this PPE in case of.’ This was the ‘in case of,’” says Dr. Evans, with Northwestern Medicine.
“In this country, we had disinvested in public health…. We rely much more on private medical systems,” says Dr. Gupta, with the Johns Hopkins COVID-19 Precision Medicine Center of Excellence. “I think that will be one of the biggest lessons we learned from the COVID pandemic. We have to invest for the long haul so we can test, detect, and act early.”
Dr. Adalja stresses that we have to make sure public health agencies don’t go through “boom-and-bust cycles of panic and neglect.” Does this bring to mind the 2008 financial panic? Banking is all too familiar with boom-and-bust cycles, leading the U.S. government to pass financial regulatory reforms in 2010 that force banks to set aside money to better weather downturns and to undergo yearly stress tests to ensure they’re able to withstand a rare crisis. Perhaps similar regulations and funding are necessary to ensure our hospitals and public health systems are prepared to manage long-term risks.
Fortunately, efforts are underway. “There’s going to be a COVID commission, similar to the 9/11 commission. There are also a lot of efforts on Capitol Hill to increase funding for certain agencies,” says Dr. Adalja. “I do think there is a major concerted effort to never let this happen again. We just have to keep the momentum going until we actually get legislation in place.”