It has been just over two years since Donald Trump declared a national emergency in the face of the coronavirus pandemic that was rapidly spreading across the United States – and the rest of the world.
Now, even as Covid-19 remains a threat, US public health officials and researchers are looking to the next potential pandemic – whether it’s influenza, another coronavirus, antimicrobial resistance, or a different health threat entirely – as they hope to build on the progress and avoid the pitfalls of the past two years.
Knowledge of how respiratory viruses work – and how to battle them – has increased exponentially during this outbreak. But at the same time, misinformation about infectious diseases, especially vaccines and treatments, has multiplied, presenting new challenges.
Scientists, several of whom have advised Joe Biden, recently released a 136-page “roadmap” for moving from Covid crisis to what they term the “next normal”. These investments include supporting health workers and strengthening health systems, as well as supporting survivors with long-term symptoms.
A new disease forecasting center, the Center for Forecasting and Outbreak Analytics, will become part of the US Centers for Disease Control and Prevention (CDC), aiming to prepare for the next big outbreak. And a new bill with strong bipartisan support would create a 9/11-style commission to investigate the Covid response and learn from it.
But the US was already thought to be prepared for the next pandemic – in fact, in November 2019, the US was ranked first among 195 countries for pandemic preparedness. Even so, the US response has been plagued by failures, including politicization, lack of trust, the individualization of health, and widespread inequality.
And one key reason for the failure may have to do with something that would seem completely unrelated to public health.
Trust – or a lack of it – played a major role in the pandemic’s scope, according to recent research that examined infection and fatality rates in 177 countries. The researchers sought potential connections to democracy, universal healthcare, hospital beds, quality of health services, and economic inequality.
“We were not able to observe a connection between any of those things and how countries actually did,” said Thomas Bollyky, lead author of the study and the director of the global health program at the Council on Foreign Relations. Only one factor seemed to matter: trust in leaders and in one another.
Building trust can play a critical role in preparing for the next pandemic, along with improving data collection and sharing, biomedical advances like vaccines and treatments, and low-tech solutions, like improving ventilation and wearing high-quality masks during respiratory outbreaks.
Making such changes can strengthen a country’s pandemic response even in the midst of an outbreak.
The Ebola outbreak that began in 2014 suffered, at first, from a poor response that prolonged the epidemic. People refused to allow health workers into their homes, or refused to go to clinics, because they were scared of what a diagnosis would mean. Local leaders promoted miracle cures, some of which were poisonous. As clinical trials for an Ebola vaccine ramped up, it was difficult to find volunteers because of skepticism or outright hostility toward first responders.
But then, the response turned a corner – and Bollyky credits the U-turn to steady efforts to build confidence in officials, neighbors and other countries.
National governments and other organizations held parades of Ebola survivors to boost confidence in getting tested, seeking treatment and recovering successfully. Local youth leaders, religious leaders and other community representatives encouraged participation in the vaccine clinical trials. Anthropologists worked with community representatives to develop burial practices that honored tradition while being less likely to spread the virus.
And it was successful, helping end the largest, deadliest outbreak of Ebola.
Applying these same lessons could bring Covid to heel – and it could help prevent or address the next big one, which could be even more dangerous.
“In some ways, we were lucky with this pandemic, which is an odd thing to say. But the fact of the matter is, a future virus or novel influenza could certainly be more transmissible and more virulent,” Bollyky said.
And all of the investments America makes in preparing for the next big one will help address Covid as well, experts said.
“You’re using your present response to start to develop the behaviors, investments and infrastructure in order to be able to do the same response in a future crisis,” Bollyky said.
Ventilation and air filtration are among those important infrastructure investments, said Rick Bright, chief executive of the Pandemic Prevention Institute at the Rockefeller Foundation and a former official for the US Department of Health and Human Services.
“It’s really important for us to continue our investments in upgrading our air filtration systems in public buildings, restaurants, bars, transportation hubs, airplanes, airports, schools – reminding people of the importance of ventilation and filtration, and also being ready and able to be willing to wear the mask when we have high levels of virus prevalent in our community.”
The development of vaccines and treatments, especially those built on quickly customizable platforms over the past two years, can play another critical role in responding to the next pandemic.
Before Covid, the previous record for developing a vaccine was four years. It took 326 days to create and authorize a Covid mRNA vaccine, followed quickly by several more vaccines put into use around the globe.
“That’s remarkably fast, and we also produced it at a greater scale than we’ve ever seen before,” Bollyky said.
Most of the Covid vaccines are built on platforms that can be changed relatively quickly when new variants or viruses emerge – a very promising development that could change vaccinations for evolving and emerging pathogens.
Technology under development could mean immunizations happen not with needles and syringes but simple skin patches, like Band-Aids, Bright said.
New investments need to be made in the worldwide delivery of vaccines, both in terms of shipping and storing vaccines and educating people about the benefits of vaccination – and those investments will persist for the next outbreak, experts said.
“Our only hope in future pandemics is to contain outbreaks closer to their source,” Bollyky said. “It is in our economic, moral and humanitarian interest to do something about the undervaccination that exists globally.”
Improving faith in health officials and institutions could also prevent growing hesitations around vaccines, Bollyky said. With Covid, “we’ve unfortunately gone the wrong direction” and a new system of misinformation and disinformation could be mobilized in future pandemics as well – a worrying trend that needs to be addressed.
While confidence has declined in the US Centers for Disease Control and Prevention and state governors, it has remained high in health workers, faith leaders and other community representatives, who can help guide current and future pandemic responses.
Some of the mistrust is probably driven by vast inequities in American society, Bollyky said.
“Addressing the sources of economic, social and political alienation in populations seems like the right place to start – in itself a good thing to do, and it does help start to address the long-term trust deficit. And what the pandemic has shown is, our lives depend on that.“
Vaccines and treatments are also most effective the earlier they can be used – which means data collection and sharing is key during a crisis.
“To make them more effective, you have to use them sooner in the game … and the only way to do that was to have an earlier warning signal” of emerging viruses, Bright said. A persistent lack of these early warning systems “has always been this achilles heel in every pandemic we’ve seen in the past,” he said.
“Going into this pandemic, we pretty much relied on a nose swab to get the information we needed to get, to know where the virus was spreading and how it was changing or evolving,” Bright said.
That’s more expensive and slower than other signals, like wastewater monitoring. It also relies on individual behavior, which can be a difficult metric when some people are resistant to getting tested or don’t realize they are sick.
Warning signs can instead be discovered through wastewater surveillance of pathogens like Covid, influenza and drug-resistant bacteria, for instance.
The modern world is “a mosaic of signals”, Bright said. Changes in patterns – new illnesses cropping up in clinics, environmental changes to water and air, satellite images tracking new animal migration patterns – can then prompt epidemiologists to look for outbreaks more quickly and effectively.
“What worries me is that we ignore the signal,” Bright said.
It’s also important to share this information across borders – and not to penalize other countries with travel bans, as several nations did when South Africa and Botswana sounded the alarm on the Omicron variant.
“In some cases, those restrictions actually hindered their ability to get the materials to keep surveilling the outbreak of the new variant,” Bollyky said.
The next Covid variant is probably evolving or spreading now, Bright said.
“I’m concerned, as we dial down more testing and more surveillance, that it’s going to turn the lights off on that battlefield and we’re not going to be able to see this variant as clearly and as quickly,” he said.
“Many people think the pandemic is behind us and it’s over,” Bright said. But “anything and everything we do to prepare for the next surge will make us better for the next pathogen as well.”
The biggest risk is forgetting or ignoring the hard-won lessons on Covid and other disease outbreaks, Bright said.
“We always seem to get through them and then forget. We forget how bad it was, we forget how expensive it was, we forget how disruptive it was, and life goes back to normal. And then we don’t continue to invest in the innovation and technologies that got us through that crisis. And then the next pandemic comes along, and we’re not ready again and we’re starting from scratch.”
But right now, he said, “we have an opportunity in the United States and around the world to continue funding, not let our foot off the gas, and drive these innovations.”
