https://www.theatlantic.com/health/archive/2021/09/america-prepared-next-pandemic/620238/?utm_source=STAT+Newsletters&utm_campaign=1d9394f060-MR_COPY_01&utm_medium=email&utm_term=0_8cab1d7961-1d9394f060-152134678
A year after the United States bombed its pandemic performance
in front of the world, the Delta variant opened the stage for a
face-saving encore. If the U.S. had learned from its mishandling of the
original SARS-CoV-2 virus, it would have been better prepared for the
variant that was already ravaging India.
Instead, after a quiet spring, President Joe Biden all but declared victory against SARS-CoV-2. The CDC ended indoor masking for vaccinated people, pitting two of the most effective interventions against each other. As cases fell, Abbott Laboratories, which makes a rapid COVID-19 test, discarded inventory, canceled contracts, and laid off workers, The New York Times reported. Florida and Georgia scaled back on reporting COVID-19 data, according to Kaiser Health News. Models failed to predict Delta’s early arrival. The variant then ripped through the U.S.’s half-vaccinated populace and once again pushed hospitals and health-care workers to the brink.
Delta’s extreme transmissibility would have challenged any nation, but
the U.S. nonetheless set itself up for failure. Delta was an audition
for the next pandemic, and one that America flubbed. How can a country hope to stay 10 steps ahead of tomorrow’s viruses when it can’t stay one step ahead of today’s?
America’s
frustrating inability to learn from the recent past shouldn’t be
surprising to anyone familiar with the history of public health. Almost 20 years ago,
the historians of medicine Elizabeth Fee and Theodore Brown lamented
that the U.S. had “failed to sustain progress in any coherent manner” in
its capacity to handle infectious diseases. With every new
pathogen—cholera in the 1830s, HIV in the 1980s—Americans rediscover the
weaknesses in the country’s health system, briefly attempt to address
the problem, and then “let our interest lapse when the immediate crisis
seems to be over,” Fee and Brown wrote. The result is a Sisyphean cycle
of panic and neglect that is now spinning in its third century. Progress
is always undone; promise, always unfulfilled. Fee died in 2018, two
years before SARS-CoV-2 arose. But in documenting America’s past, she
foresaw its pandemic present—and its likely future.
More Americans have been killed by the new coronavirus than the influenza pandemic of 1918, despite a century of intervening medical advancement. The U.S. was ranked first among nations in pandemic preparedness but has among the highest death rates in the industrialized world. It invests more in medical care
than any comparable country, but its hospitals have been overwhelmed.
It helped develop COVID-19 vaccines at near-miraculous and
record-breaking speed, but its vaccination rates plateaued so quickly that it is now 38th in the world.
COVID-19 revealed that the U.S., despite many superficial strengths, is
alarmingly vulnerable to new diseases—and such diseases are inevitable.
As the global population grows, as the climate changes, and as humans push into spaces occupied by wild animals, future pandemics become more likely. We are not guaranteed the luxury of facing just one a century, or even one at a time.
It might seem ridiculous to think about future pandemics now, as the U.S. is consumed by debates over booster shots, reopened schools, and vaccine mandates. Prepare for the next one? Let’s get through this one first! But
America must do both together, precisely because of the cycle that Fee
and Brown bemoaned. Today’s actions are already writing the opening
chapters of the next pandemic’s history.
Internationally,
Joe Biden has made several important commitments. At the United Nations
General Assembly last week, he called for a new council of national
leaders and a new international fund, both focused on infectious
threats—forward-looking measures that experts had recommended well before COVID-19.
But
domestically, many public-health experts, historians, and legal
scholars worry that the U.S. is lapsing into neglect, that the temporary
wave of investments isn’t being channeled into the right areas, and
that COVID-19 might actually leave the U.S. weaker against
whatever emerges next. Donald Trump’s egregious mismanagement made it
easy to believe that events would have played out differently with a
halfway-competent commander who executed preexisting pandemic plans. But
that ignores the many vulnerabilities
that would have made the U.S. brittle under any administration. Even
without Trump, “we’d still have been in a whole lot of trouble,” Gregg
Gonsalves, a global-health activist and an epidemiologist at Yale, told
me. “The weaknesses were in the rootstock, not high up in the trees.”
The
panic-neglect cycle is not inevitable but demands recognition and
resistance. “A pandemic is a course correction to the trajectory of
civilization,” Alex de Waal, of Tufts University and the author of New Pandemics, Old Politics,
told me. “Historical pandemics challenged us to make some fairly
fundamental changes to the way in which society is organized.” Just as
cholera forced our cities to be rebuilt for sanitation, COVID-19 should
make us rethink the way we ventilate our buildings,
as my colleague Sarah Zhang argued. But beyond overhauling its physical
infrastructure, the U.S. must also address its deep social weaknesses—a
health-care system that millions can’t access, a public-health system
that’s been rotting for decades, and extreme inequities that leave large
swaths of society susceptible to a new virus.
Early
last year, some experts suggested to me that America’s COVID-19 failure
stemmed from its modern inexperience with infectious disease; having
now been tested, it might do better next time. But preparedness doesn’t
come automatically, and neither does its absence. “Katrina didn’t happen
because Louisiana never had a hurricane before; it happened because of
policy choices that led to catastrophe,” Gonsalves said. The arc of
history does not automatically bend toward preparedness. It must be
bent.
On September 3, the White House announced
a new strategy to prepare for future pandemics. Drafted by the Office
of Science and Technology Policy, and the National Security Council, the plan
would cost the U.S. $65 billion over the next seven to 10 years. In
return, the country would get new vaccines, medicines, and diagnostic
tests; new ways of spotting and tracking threatening pathogens; better
protective equipment and replenished stockpiles; sturdier supply chains;
and a centralized mission control that would coordinate all the above
across agencies. The plan, in rhetoric and tactics, resembles those that
were written before COVID-19 and never fully enacted. It seems to
suggest all the right things.
But
the response from the health experts I’ve talked with has been
surprisingly mixed. “It’s underwhelming,” Mike Osterholm, an
epidemiologist at the University of Minnesota, told me. “That $65
billion should have been a down payment, not the entire program. It’s a
rounding error for our federal budget, and yet our entire existence
going forward depends on this.” The pandemic plan compares itself to the
Apollo program, but the government spent four times as much, adjusted
for inflation, to put astronauts on the Moon. Meanwhile, the COVID-19 pandemic may end up costing the U.S. an estimated $16 trillion.
“I
completely agree that it will take more investment,” Eric Lander, OSTP
director and Biden’s science adviser, told me; he noted that the
published plan is just one element of a broader pandemic-preparedness
effort that is being developed. But even the $65 billion that the plan
has called for might not fully materialize. Biden originally wanted to ask Congress to immediately invest $30 billion but eventually called for just half that amount, in a compromise with moderate Democrats who sought to slash it even further. The idea of shortchanging pandemic preparedness after the events of 2020 “should be unthinkable,” wrote former CDC Director Tom Frieden and former Senator Tom Daschle in The Hill. But it is already happening.
Others
worry about the way the budget is being distributed. About $24 billion
has been earmarked for technologies that can create vaccines against a
new virus within 100 days. Another $12 billion will go toward new
antiviral drugs, and $5 billion toward diagnostic tests. These goals
are, individually, sensible enough. But devoting two-thirds of the full
budget toward them suggests that COVID-19’s lessons haven’t been
learned.
America failed to test sufficiently throughout the pandemic even though rigorous tests have long been available. Antiviral drugs
played a bit part because they typically provide incremental benefits
over basic medical care, and can be overly expensive even when they
work. And vaccines were already produced far faster than experts had
estimated and were more effective than they had hoped; accelerating that
process won’t help if people can’t or won’t get vaccinated, and
especially if they equate faster development with nefarious
corner-cutting, as many Americans did this year. Every adult in the U.S.
has been eligible for vaccines since mid-April; in that time, more Americans have died of COVID-19 per capita than people in Germany, Canada, Rwanda, Vietnam, or more than 130 other countries did in the pre-vaccine era.
“We’re
so focused on these high-tech solutions because they appear to be what a
high-income country would do,” Alexandra Phelan, an expert on
international law and global health policy at Georgetown University,
told me. And indeed, the Biden administration has gone all in on
vaccines, trading them off against other countermeasures, such as masks
and testing, and blaming “the unvaccinated”
for America’s ongoing pandemic predicament. The promise of biomedical
panaceas is deeply ingrained in the U.S. psyche, but COVID should have
shown that medical magic bullets lose their power when deployed in a
profoundly unequal society. There are other ways of thinking about
preparedness. And there are reasons those ways were lost.
In 1849, after investigating a devastating outbreak of typhus in what is now Poland, the physician Rudolf Virchow wrote,
“The answer to the question as to how to prevent outbreaks … is quite
simple: education, together with its daughters, freedom and welfare.”
Virchow was one of many 19th-century thinkers who correctly understood
that epidemics were tied to poverty, overcrowding, squalor, and
hazardous working conditions—conditions that inattentive civil servants
and aristocrats had done nothing to address. These social problems
influenced which communities got sick and which stayed healthy. Diseases
exploit society’s cracks, and so “medicine is a social science,”
Virchow famously said. Similar insights dawned across the Atlantic,
where American physicians and politicians tackled the problem of urban
cholera by fixing poor sanitation and dilapidated housing. But as the
19th century gave way to the 20th, this social understanding of disease
was ousted by a new paradigm.
When scientists realized that infectious diseases are caused by microscopic organisms, they gained convenient villains. Germ theory’s pioneers, such as Robert Koch,
put forward “an extraordinarily powerful vision of the pathogen as an
entity that could be vanquished,” Alex de Waal, of Tufts, told me. And
that vision, created at a time when European powers were carving up
other parts of the world, was cloaked in metaphors of imperialism, technocracy, and war.
Microbes were enemies that could be conquered through the technological
subjugation of nature. “The implication was that if we have just the
right weapons, then just as an individual can recover from an illness
and be the same again, so too can a society,” de Waal said. “We didn’t
have to pay attention to the pesky details of the social world, or see
ourselves as part of a continuum that includes the other life-forms or
the natural environment.”
Read: How the pandemic now ends
Germ
theory allowed people to collapse everything about disease into battles
between pathogens and patients. Social matters such as inequality,
housing, education, race, culture, psychology, and politics became
irrelevancies. Ignoring them was noble; it made medicine and science
more apolitical and objective. Ignoring them was also easier; instead of
staring into the abyss of society’s intractable ills, physicians could
simply stare at a bug under a microscope and devise ways of killing it.
Somehow, they even convinced themselves that improved health would
“ultimately reduce poverty and other social inequities,” wrote Allan Brandt and Martha Gardner in 2000.
This
worldview accelerated a growing rift between the fields of medicine
(which cares for sick individuals) and public health (which prevents
sickness in communities). In the 19th century, these disciplines were
overlapping and complementary. In the 20th, they split into distinct
professions, served by different academic schools. Medicine, in
particular, became concentrated in hospitals, separating physicians from
their surrounding communities and further disconnecting them from the
social causes of disease. It also tied them to a profit-driven system
that saw the preventive work of public health as a financial threat.
“Some suggested that if prevention could eliminate all disease, there
would be no need for medicine in the future,” Brandt and Gardner wrote.
This
was a political conflict as much as an ideological one. In the 1920s,
the medical establishment flexed its growing power by lobbying the
Republican-controlled Congress and White House to erode public-health
services including school-based nursing, outpatient dispensaries, and
centers that provided pre- and postnatal care to mothers and infants.
Such services were examples of “socialized medicine,” unnecessary to
those who were convinced that diseases could best be addressed by
individual doctors treating individual patients. Health care
receded from communities and became entrenched in hospitals. Decades
later, these changes influenced America’s response to COVID-19. Both the
Trump and Biden administrations have described the pandemic in military
metaphors. Politicians, physicians, and the public still prioritize
biomedical solutions over social ones. Medicine still overpowers public
health, which never recovered from being “relegated to a secondary
status: less prestigious than clinical medicine [and] less amply
financed,” wrote the sociologist Paul Starr. It stayed that way for a century.
During the pandemic,
many of the public-health experts who appeared in news reports hailed
from wealthy coastal universities, creating a perception of the field as
well funded and elite. That perception is false. In the early 1930s,
the U.S. was spending just 3.3 cents of every medical dollar on public
health, and much of the rest on hospitals, medicines, and private health
care. And despite a 90-year span that saw the creation of the CDC, the
rise and fall of polio, the emergence of HIV, and relentless calls for
more funding, that figure recently stood at … 2.5 cents.
Every attempt to boost it eventually receded, and every investment saw
an equal and opposite disinvestment. A preparedness fund that was
created in 2002 has lost half its budget, accounting for inflation. Zika money was cannibalized from Ebola money.
America’s historical modus operandi has been to “give responsibility to
the local public-health department but no power, money, or
infrastructure to make change,” Ruqaiijah Yearby, a health-law expert at
Saint Louis University, told me.
Lisa
Macon Harrison, who directs the department that serves Granville and
Vance Counties, in North Carolina, told me that to protect her community
of 100,000 people from infectious diseases—HIV, sexually transmitted
infections, rabies, and more—the state gives her $4,147 a year. That’s
90 times less than what she actually needs. She raises the shortfall
herself through grants and local dollars.
Trifling
budgets mean smaller staff, which turns mandatory services into
optional ones. Public-health workers have to cope with not just
infectious diseases but air and water pollution, food safety, maternal
and child health, the opioid crisis, and tobacco control. But with local
departments having lost 55,000 jobs since the 2008 recession, many had
to pause their usual duties to deal with COVID-19. Even then, they
didn’t have staff to do the most basic version of contact
tracing—calling people up—let alone the ideal form, wherein community
health workers help exposed people find food, services, and places to
isolate. When vaccines were authorized, departments had to scale back on
testing so that overworked staff could focus on getting shots into
arms; even that wasn’t enough, and half of states hired armies of consultants to manage the campaign, The Washington Post reported.
Read: Six rules that will define our pandemic winter
In May, the Biden administration said that it would invest $7.4 billion in recruiting and training public-health workers,
creating tens of thousands of jobs. But those new workers would be
air-dropped into an infrastructure that is quite literally crumbling.
Many public-health departments are housed in buildings that were erected
in the 1940s and ’50s, when polio money was abundant; they are now
falling apart. “There’s a trash can in the hallway in front of my
environmental-health supervisor’s office to catch rain that might come
through the ceiling,” Harrison told me. And between their reliance on fax machines and decades-old data systems, “it feels like we’re using a Rubik’s Cube and an abacus to do pandemic response,” Harrison added.
Last year, America’s data systems proved to be utterly inadequate for tracking a rapidly spreading virus. Volunteer efforts such as the COVID Tracking Project (launched by The Atlantic) had to fill in for the CDC. Academics created a wide range of models, some of which were misleadingly inaccurate.
“For hurricanes, we don’t ask well-intentioned academics to stop their
day jobs and tell us where landfall will happen,” the CDC’s Dylan George
told me. “We turn to the National Hurricane Center.” Similarly, George
hopes that policy makers can eventually turn to the CDC’s newly launched
Center for Forecasting and Outbreak Analytics, where he is director of
operations. With initial funding of about $200 million, the center aims
to accurately track and predict the paths of pathogens, communicate those predictions with nuance, and help leaders make informed decisions quickly.
But
public health’s long-standing neglect means that simply making the
system fit for purpose is a mammoth undertaking that can’t be
accomplished with emergency funds—especially not when those funds go
primarily toward biomedical countermeasures. That’s “a welfare scheme
for university scientists and big organizations, and it’s not
going to trickle down to the West Virginia Department of Health,” Gregg
Gonsalves, the health activist and epidemiologist, told me. What the
U.S. needs, as several reports have recommended and as some senators have proposed, is a stable and protected stream of money that can’t be diverted to the emergency of the day.
That would allow health departments to properly rebuild without
constantly fearing the wrecking ball of complacency. Biden’s $7.4
billion bolus is a welcome start—but just a start. And though his new
pandemic-preparedness plan commits $6.5 billion toward strengthening the
U.S. public-health system over the next decade, it might take $4.5 billion a year to actually do the job.
Read: The coronavirus is here forever. This is how we live with it.
“Nobody
should read that plan as the limit of what needs to be done,” Eric
Lander, the president’s science adviser, told me. “I have no
disagreement that a major effort and very substantial funding are
needed,” and, he noted, the administration’s science and technology advisers
will be developing a more comprehensive strategy. “But is pandemic
preparedness the lens through which to fix public health?” Lander asked.
“I think those issues are bigger—they’re everyday problems, and we need
to shine a spotlight on them every day.”
But
here is public health’s bind: Though it is so fundamental that it can’t
(and arguably shouldn’t) be tied to any one type of emergency,
emergencies are also the one force that can provide enough urgency to
strengthen a system that, under normal circumstances, is allowed to rot.
When a doctor saves a patient, that person is grateful. When an epidemiologist prevents someone from catching a virus, that person never knows. Public
health “is invisible if successful, which can make it a target for
policy makers,” Ruqaiijah Yearby, the health-law expert, told me. And
during this pandemic, the target has widened, as overworked and under-resourced officials face aggressive protests.
“Our workforce is doing 15-hour days and rather than being glorified,
they’re being vilified and threatened with bodily harm and death,”
Harrison told me. According to an ongoing investigation by the Associated Press and Kaiser Health News, the U.S. has lost at least 303 state or local public-health leaders since April 2020, many because of burnout and harassment.
Even though 62 percent of Americans believe that pandemic-related restrictions were worth the cost, Republican legislators
in 26 states have passed laws that curtail the possibility of
quarantines and mask mandates, as Lauren Weber and Anna Maria
Barry-Jester of KHN have reported. Supporters characterize these
laws as checks on executive power, but several do the opposite, allowing
states to block local officials or schools from making decisions to
protect their communities. Come the next pandemic (or the next variant),
“there’s a real risk that we are going into the worst of all worlds,”
Alex Phelan, of Georgetown University, told me. “We’re removing
emergency actions without the preventive care that would allow people to
protect their own health.” This would be dangerous for any community,
let alone those in the U.S. that are structurally vulnerable to
infectious disease in ways that are still being ignored.
Biden’s new pandemic plan
contains another telling detail about how the U.S. thinks about
preparedness. The parts about vaccines and therapeutics contain several
detailed and explicit strategies. The part about vulnerable communities
is a single bullet point that calls for strategies to be developed.
This isn’t a new bias. In 2008, Philip Blumenshine and his colleagues argued that America’s flu-pandemic plans overlooked the disproportionate toll that such a disaster would take on socially
disadvantaged people. Low-income and minority groups would be more
exposed to airborne viruses because they’re more likely to live in
crowded housing, use public transportation, and hold low-wage jobs that
don’t allow them to work from home or take time off when sick. When
exposed, they’d be more susceptible to disease because their baseline
health is poorer, and they’re less likely to be vaccinated. With less
access to health insurance or primary care, they’d die in greater
numbers. These predictions all came to pass during the H1N1 swine-flu pandemic of 2009.
When SARS-CoV-2 arrived a decade later, history repeated itself.
The new coronavirus disproportionately infected essential workers, who
were forced to risk exposure for the sake of their livelihood;
disproportionately killed Pacific Islander, Latino, Indigenous, and Black Americans;
and struck people who’d been packed into settings at society’s
margins—prisons, nursing homes, meatpacking facilities. “We’ve built a
system in which many people are living on the edge, and pandemics prey
on those vulnerabilities,” Julia Raifman, a health-policy researcher at
Boston University, told me.
Such
patterns are not inevitable. “It is very clear, from evidence and
history, that robust public-health systems rely on provision of social
services,” Eric Reinhart, a political anthropologist and physician at
Northwestern University, told me. “That should just be a political
given, and it is not. You have Democrats who don’t even say this, let
alone Republicans.” America’s ethos of rugged individualism pushes
people across the political spectrum to see social vulnerability as a
personal failure rather than the consequence of centuries of racist and
classist policy, and as a problem for each person to solve on their own
rather than a societal responsibility. And America’s biomedical bias
fosters the seductive belief that these sorts of social inequities won’t
matter if a vaccine can be made quickly enough.
But inequity reduction is not a side quest of pandemic preparedness. It is arguably the central pillar—if not for moral reasons, then for basic epidemiological ones. Infectious diseases can spread, from the vulnerable to the privileged. “Our inequality makes me
vulnerable,” Mary Bassett, who studies health equity at Harvard, told
me. “And that’s not a necessary feature of our lives. It can be
changed.”
“To be ready for
the next pandemic, we need to make sure that there’s an even footing in
our societal structures,” Seema Mohapatra, a health-law expert at
Southern Methodist University, in Dallas, told me. That vision of
preparedness is closer to what 19th-century thinkers lobbied for, and
what the 20th century swept aside. It means shifting the spotlight away
from pathogens themselves and onto the living and working conditions
that allow pathogens to flourish. It means measuring preparedness not
just in terms of syringes, sequencers, and supply chains but also in
terms of paid sick leave, safe public housing, eviction moratoriums, decarceration, food assistance, and universal health care. It
means accompanying mandates for social distancing and the like with
financial assistance for those who might lose work, or free
accommodation where exposed people can quarantine from their family. It
means rebuilding the health policies that Ronald Reagan began shredding
in the 1980s and that later administrations further frayed. It means
restoring trust in government and community through public services.
“It’s very hard to achieve effective containment when the people you’re
working with don’t think you care about them,” Arrianna Marie Planey, a
medical geographer at the University of North Carolina at Chapel Hill,
told me.
In
this light, the American Rescue Plan—the $1.9 trillion
economic-stimulus bill that Biden signed in March—is secretly a
pandemic-preparedness bill. Beyond specifically funding public health, it also includes unemployment insurance, food-stamp benefits, child tax credits, and other policies that are projected to cut the poverty rate for 2021 by a third,
and by even more for Black and Hispanic people. These measures aren’t
billed as ways of steeling America against future pandemics—but they
are. Also on the horizon is a set of recommendations from the COVID-19
Health Equity Task Force, which Biden established on his first full day
of office. “The president has told many of us privately, and said
publicly, that equity has to be at the heart of what we do in this
pandemic,” Vivek Murthy, the surgeon general, told me.
Some of the American Rescue Plan’s measures are temporary, and their future depends on the $3.5 trillion social-policy bill
that Democrats are now struggling to pass, drawing opposition from
within their own party. “Health equity requires multiple generations of
work, and politicians want outcomes that can be achieved in time to be
recognized by an electorate,” Planey told me. That electorate is tiring
of the pandemic, and of the lessons it revealed.
Last
year, “for a moment, we were able to see the invisible infrastructure
of society,” Sarah Willen, an anthropologist at the University of
Connecticut who studies Americans’ conceptions of health equity, told
me. “But that seismic effect has passed.” Socially privileged people now
also enjoy the privilege of immunity, while those with low incomes,
food insecurity, eviction risk, and jobs in grocery stores and
agricultural settings are disproportionately likely to be unvaccinated.
Once, they were deemed “essential”; now they’re treated as obstinate
annoyances who stand between vaccinated America and a normal life.
The
pull of the normal is strong, and our metaphors accentuate it. We
describe the pandemic’s course in terms of “waves,” which crest and then
collapse to baseline. We bill COVID-19 as a “crisis”—a word that evokes
decisive moments and turning points, “and that, whether you want to or
not, indexes itself against normality,”
Reinhart told me. “The idea that something new can be born out of it is
lost,” because people long to claw their way back to a precrisis state,
forgetting that the crisis was itself born of those conditions.
Better
ideas might come from communities for whom “normal” was something to
survive, not revert to. Many Puerto Ricans, for example, face multiple
daily crises including violence, poverty, power outages, and storms,
Mónica Feliú-Mójer, of the nonprofit Ciencia Puerto Rico, told me.
“They’re always preparing,” she said, “and they’ve built support
networks and mutual-aid systems to take care of each other.” Over the
past year, Ciencia PR has given small grants to local leaders
to fortify their communities against COVID-19. While some set up
testing and vaccination clinics, others organized food deliveries or
educational events. One cleaned up a dilapidated children’s park to
create a low-risk outdoor space where people could safely reconnect.
Such efforts recognize that resisting pandemics is about solidarity as
well as science, Feliú-Mójer told me.
The
panic-neglect cycle is not irresistible. Some of the people I spoke
with expressed hope that the U.S. can defy it, just not through the
obvious means of temporarily increased biomedical funding. Instead, they
placed their faith in grassroots activists who are pushing for fair
labor policies, better housing, health-care access, and other issues of
social equity. Such people would probably never think of their work as a
way of buffering against a pandemic, but it very much is—and against
other health problems, natural disasters, and climate change besides.
These threats are varied, but they all wreak their effects on the same
society. And that society can be as susceptible as it allows itself to
be.
