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December 12, 2023
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We are likely still too close to the Covid pandemic, too enmeshed in its ongoing risks, to fully evaluate what we did right and what we did wrong these past years, and how we can best plan for future pandemics. Yet we have learned enough for a general sense of where our priorities should lie as we work to shape a world that is resistant to pandemics. Expert groups have been publishing early commentary—the best so far is “Lessons from the Covid War: An Investigative Report” by The Covid Crisis Group. This report was a response to Congress’s failure to authorize a 9/11 type report for the Covid pandemic. We applaud their work, and offer five questions, some of which underscore the Group’s observations. Engaging the wider public on these questions may, we think, increase the likelihood of addressing them and, consequently, minimize the damage of future pandemics.
The primary challenge with the US response to any epidemic (or other disaster) is identifying who is in charge of recognizing the threat and leading the response. Politics, including the lack of a coherent public health plan at the federal level, has sometimes meant that the public health lead must be taken by the President, as was the case in the swine flu scare of 1976 and after Hurricane Katrina. This has historically been disastrous. At least one reason why no federal official has been designated the “Public Health Czar” is our system of federalism in which the states retain their inherent “police powers” under the Constitution. This means that, in the context of a new communicable disease or natural disaster, the individual states are responsible for protecting their own citizens. The federal government does, however, have authority to deal with an incident (including one involving a biologic entity) threatening national security or people traveling interstate. During Covid, this led—from the very early days of the pandemic—to substantial confusion about who was in charge and hampered a coherent national response. Disentangling this conflicting set of responsibilities will require a serious engagement with difficult statutory questions. The importance of a clearly designated—and empowered—point person to lead coordinated response efforts nationally in future pandemics cannot be overstated, as the window to respond early and effectively during a crisis can narrow quickly. Similar points can be made about constructing a transparent and effective international oversight structure for dangerous biological research.
The injustices and inequalities in health care featured in the pandemic were disgraceful and unacceptable. Black and brown people, people living in poverty, persons with lower levels of education, among other populations, have long had worse health than others in the United States. Their disadvantages were reflected during the pandemic in their disproportionate burden of Covid morbidity and mortality. As arguably the richest and most influential country in the world, the United States might have taken the lead in an approach to Covid that anticipated the greater health burden borne by these populations. But we failed to do so because the underlying challenges were far too great for us to even contemplate addressing them fully during the time of crisis. The role that non-medical factors play in determining health has been the subject of ample scholarship over the past decades. However, discussions about the “social and economic determinants of health” often happen in academic isolation from the $4.3 trillion annual endeavor that is the US health care system. In addition, less than 3% of our health spending is estimated to focus on matters related to public health. This financial disproportionality should motivate a genuine reconsideration of our national priorities on health investment. This challenge eludes easy solutions, making it an important area for thoughtful engagement in the years to come.
A substantial, perhaps even primary, motivation for much of the action undertaken early in the pandemic in the United States was the concern that hospitals would be overrun and that we would have to ration in-hospital care for people who were severely ill. Commonly known as “flattening the curve,” the goal of preventing hospital overcrowding motivated decisions on mitigation strategies from lockdowns to masking mandates. The concern that there would be major shortages in at least some parts of the country in hospital staff, nurses, and physicians, as well as in Intensive Care Unit beds and equipment such as ventilators, has been a feature in disaster planning since at least Hurricane Katrina. However, it was soon recognized that while indeed there were shortages of personnel and resources in some parts of the country (albeit at a much smaller scale than feared), pandemic rationing schemes were not evidence-based. Instead of helping to distribute scarce resources fairly they led to discrimination on the basis of age, disability, and race. This is because the rationing scheme itself, known as “crisis standards of care,” was based primarily on the incorrect premise that physicians and nurses would not show up for work at hospitals unless they were granted legal immunity from lawsuits for making rationing decisions that harmed their patients. This turned out to be false—personal protection equipment was (shamefully) often in short supply, but dedication to patients was not. We need a rethinking of the assumptions behind rationing of care, when and why it might happen, and how best to deal with it in a fair and nondiscriminatory way if it becomes necessary.
Many hospitals and long-term care facilities were overwhelmed at the beginning of the pandemic and took drastic steps, including prohibiting visitors to Covid patients. While this may have been appropriate in cases of extreme hospital overcrowding, it was not appropriate for every facility, and even where it was, it should have been the rule that immediate family members could always be with their loved ones at the end of life. It is especially discouraging that all of the ethics work done on end-of-life care over the past 50 years, including advance directives and hospice care, seemed to be discarded as not an integral part of critical care at the outset of the pandemic. The pandemic made it clear that we need better plans, including for the widespread availability of personal protective equipment, to routinize continued visitation. It is an unacceptable premise that patients must check their human rights and dignity at the hospital door during a pandemic.
There are some observations that emerged from the Covid pandemic that can set the foundation for a re-imagining of future pandemic communication. We entered the pandemic with an assumption that the public needed clarity of authoritative communication. Unfortunately, as pandemic realities evolved rapidly, this communication devolved into false certitude that contributed to eroded public trust in government. We now know that we must deal more effectively with uncertainty in our communication, but also with willful efforts to sabotage public health communication through misinformation, false information, and the politicization of public health recommendations. The government’s choice of language, including metaphors, matters. The Covid Crisis Group, for example, strongly urges the state to employ the war metaphor in describing the Covid pandemic as “the Covid war.” This is recommended even though the war metaphor has been strongly criticized as, among other things, turning the patient’s body into a battlefield. An alternative metaphor could suggest concepts like diversity, renewal, sustainable, community, and conservation. Likewise, not everything is a “public health emergency,” and there are times—even during a pandemic—when levels of caution change. Overusing crisis labels ultimately trivializes them and makes them useless for explaining the importance of a policy. This points to a central need to consider reforms in both the language of science and the language of politics during a pandemic.
It is too early to articulate the definitive approach to pandemic response without the tint of recency bias. It is not, however, too early to start thinking about the areas where we clearly fell short during Covid, to catalyze critical thinking that can lead to needed reforms in national preparedness and response. We suggest that, amidst a myriad of pandemic challenges, these five questions would benefit from earnest reconsideration in the years to come. The pandemic did not cause the shortcomings of our public health and health care systems, but it did expose them by tearing off a bandage that had covered them—making it, hopefully, impossible for public health and medicine to any longer turn away.
Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. He has published extensively in the peer-reviewed literature, and is a regular contributor to a range of public media, about the social causes of health, mental health, and the consequences of trauma. He has been listed as one of the most widely cited scholars in the social sciences. He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow. His book Within Reason was published by University of Chicago Press on December 1, 2023.
George J Annas, JD, is the William Fairfield Warren distinguished professor and director of the Center for Health Law, Ethics & Human Rights at the Boston University School of Public Health, School of Medicine, and School of Law.
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