Weekly Article

Looking back on the past three years since COVID-19 came to the US, it is hard to measure the impact of this pandemic.  There are the statistics; more than half a billion cases worldwide and almost seven million deaths; although actuarial models based on estimated “excess global mortality” place the number closer to 20 million deaths. Numbers allow us to compare and analyze tragic events, but they are an incomplete measure. To put things in perspective it is estimated that the bubonic plague of the 1300s resulted in close to 200 million deaths, wiping out half of the European population. In terms of deaths, COVID-19 doesn’t even rank in the top five deadliest plagues.  Just in recent times HIV claimed more than 36 million lives. 

It is empowering to think that our knowledge, and technology helped to reduce mortality from COVID. It certainly did. But COVID highlighted our vulnerabilities, and if we are to learn from this experience we must acknowledge our flaws. History teaches us that another pandemic will occur. We just don’t know when. The question is, can we be better prepared from our experience with COVID-19? Here is my personal list of lessons learned:

Lesson 1: Transformation of the vaccine development paradigm. A major success story of COVID-19 was the development of an effective vaccine. In 326 days, we were able to move from discovery of a new genomic sequence to authorization of a COVID-19 vaccine by a stringent regulatory authority. Subsequent to the initial roll out, the industry has quickly developed and delivered modified vaccines with high efficacy against new severe COVID-19 variants. All of this with an outstanding safety profile. This would not have been possible without investment in research on mRNA and genome sequencing technology decades ago. We should not minimize the incredible impact vaccination had on our ability to respond to the COVID pandemic. It is remarkable that despite a series of mutations that increased the transmissibility, COVID has become a very manageable illness for most of society. In large part this is a result of an effective vaccine and our commitment to invest in basic research. In anticipation of the next pandemic, the industry needs to build on this success and develop an even more efficient process to identify emerging viruses before they spread and then have the infrastructure and processes in place to develop, test, and distribute new vaccines in under 100 days.

Lesson 2: We have a remarkable ability to innovate and adapt in a crisis. The early phase of the COVID-19 response was a period of tremendous innovation. Seemingly overnight we shifted to remote work, education, and worship. Zoom became part of the everyday vernacular. Disrupted supply chains spawned new sources of products and resources. We began 3D printing of personal protective devices such as face shields and masks. Distilleries shifted from vodka to hand sanitizer. Virtual doctor visits — a concept that for years was bogged down by regulatory and financial bureaucracy and poor IT infrastructure — became widely available in a matter of weeks. New technologies were adapted for surveillance of local outbreaks. Thermometers linked to a web-based platform were shown to be able to predict local outbreaks several weeks before there was a rise in positive cases and hospitalizations. Wastewater treatment plants began testing for viral antigens to identify early introduction of new variants into communities. In the later stages of the pandemic technologies for home testing were developed and became widely available.  

A common theme that drove this innovation was that it came from the bottom up, through interdisciplinary teams that were motivated to cooperate to solve common problems. Barriers were removed and those most closely involved with the problem were empowered to create solutions. We need to find ways to encourage and sustain that spirit of positive innovation, creativity, and collaboration. We live in times of rapid change that will continue to challenge our ability to adapt and respond to emerging challenges.

Lesson 3: Trust forms the basis for an effective pandemic response.  Trust is the social contract that allows individuals to work collectively to achieve the level of commitment and resilience necessary to persist through the challenges of an ongoing pandemic. In a 2022 study published in the journal Nature researchers found that all countries where more than 40% of survey respondents agreed with the statement “most people can be trusted” achieved a near complete reduction of new cases and deaths following the first peak in COVID-19 cases. More trusting societies were able to bring down cases and deaths faster and implement containment efforts more effectively. Societal trust is more closely correlated with better COVID-19 outcomes than a country’s wealth or public health infrastructure. 

In reflecting on our own response, a decline in public trust in science and government impaired our public health preparedness and response. The politicization of our response to COVID-19 led to mistrust in vaccination and public health policies. The low level of health literacy in the US population compounded the problem as even major media outlets were challenged to differentiate data produced by rigorous science from poorly substantiated or false claims. The scientific community must be more transparent in communicating the science that drives policy and rigorously review the outcomes of policy decisions based on prior assumptions. Oftentimes in hindsight well intentioned policy can be wrong. 

For example, a recent 2023 systematic review of 12 randomized clinical trials with 276,917 participants was unable to demonstrate that masking made any difference in the transmission of respiratory viruses. Systematic reviews of randomized clinical trials are generally regarded as the highest level of evidence in measuring the effect of an intervention, and this one was published in the Cochrane Library, generally regarded as the gold standard for systematic reviews. Science can be humbling. Some may say that these results indicate masking mandates were flawed, which may be true. A critical review of the original studies used in the analysis highlights how difficult it is to perform a rigorous experiment on mask effectiveness. Unlike a drug trial where you can measure drug levels, it is difficult to ensure people are following the experimental protocol and actually wearing (or not wearing) a mask.  

The important lesson to be learned is that science is not truth. It is an ongoing formal process that gets us closer to the truth. If we are to be more successful in the next pandemic, we must improve scientific literacy in the population, be humble, and be honest and transparent in communicating the results. Having mutual respect, understanding, and the humility to accept results that may challenge our personal biases is a critical first step in developing trust as we navigate the next pandemic response.

Lesson 4: We lack justice in delivery of healthcare. COVID-19 highlighted the impact of social determinants of health tied to the longstanding impact of poverty and racism.  With the exception of the first COVID-19 surge, U.S. counties with the lowest median income had death rates at least two times higher than that of the counties with the highest income. Individuals in poorer communities were more likely to be uninsured and have less access to high quality health care.  They are more likely to have conditions that increase the risk of death from COVID-19 such as obesity, diabetes, heart disease, and pulmonary issues. They were more likely to have occupations that made it more challenging to adopt behaviors that reduced exposure, such as remote work.  

Significant disparity in COVID-19 outcomes were correlated with race.  Data from the CDC show that Black, Hispanic, American Indian and Alaska Native (AIAN), and Native Hawaiian, and Other Pacific Islander people experienced higher rates of COVID-19 cases and deaths than White people when data are adjusted to account for differences in age by race and ethnicity. Globally disparities in wealth and public health infrastructure led to persistent pockets of high virus transmission contributing to new more transmissible and virulent variants of the SARS-CoV-2 virus that then returned to reinfect wealthier countries that seemingly had the pandemic under control. A key lesson from the pandemic is we are all as vulnerable as the least among us.  

Lesson 5: Adjusting to the long-term impact of the pandemic will be challenging.  COVID will have long-term socioeconomic consequences that will remain with us for many years to come. Humanity has been traumatized and we will need to accept that the recovery will be slow. The social isolation of the pandemic has strained our support networks and social norms. It has brought to the surface the strain on mental health in modern society. Many are suffering from the effects of burnout, depression, addiction, and other mental health problems. It has forced us to reconsider our relationships to work and society, and reset our expectations of what is normal. Whether it is the “great resignation”, “quiet quitting”, or early retirements, 2021 and 2022 saw close to 100 million Americans quit their jobs.  Inflation resulting from higher competition for trained employees and supply costs seems to have temporarily peaked, but we will continue to feel the impact of these factors in many industries reliant on a trained workforce.  

Health care has been particularly hard hit. A survey by the consulting firm Morning Consult reported that one in five healthcare workers quit their job since the start of the pandemic, and that up to 47% of healthcare workers plan to leave their positions by 2025. This is resulting in substantial staffing shortages in many rural and underserved urban hospitals. Data from the HHS Department indicates 25% of Pennsylvania hospitals are facing critical staffing shortages leading to reduction or closure of patient services. Given the aging population of the healthcare workforce and smaller numbers of individuals entering the profession, these staffing shortages will likely worsen at a time where the demand from healthcare is increasing. Time will tell how these factors will impact future access to healthcare.  

As with many life changing events, COVID-19 brought out the best and worst of humanity. Hopefully we can build on our successes and find the resolve to fix our flaws. There are several themes in the lessons learned from COVID-19.  We must have mercy for each other, even those with whom we have disagreement. We must practice justice and compassion for the most vulnerable in our society. We must be humble. These are not new lessons. They have been with humanity throughout time. The lessons from COVID-19 are written in Micah 6:8 “what does the Lord require of you? To act justly and to love mercy, and to walk humbly with your God.” Hopefully when faced with the next pandemic we will practice justice, mercy, and humility. That will prepare us well.