Lessons Learned With Margaret (Peggy) Hamburg

Monday, March 13, 2023

Former Foreign Secretary, National Academy of Medicine; Former Commissioner, U.S. Food and Drug Administration; Member, Board of Directors, Council on Foreign Relations; Member, CFR Independent Task Force, Improving Pandemic Preparedness: Lessons From COVID-19


Senior Scholar, Associate Professor, Center for Health Security, Johns Hopkins Bloomberg School of Public Health; CFR Member

Lessons Learned

Peggy Hamburg discusses her distinguished career as an internationally recognized leader in science, medicine, and public health. Hamburg served as the twenty-first commissioner of the U.S. Food and Drug Administration, the foreign secretary of the National Academy of Medicine, and the founding vice president and senior scientist at the Nuclear Threat Initiative, and currently chairs the Harvard Medical School board of fellows and serves on numerous other nonprofit boards and advisory councils.

Lessons Learned is a roundtable series, open to term members and younger life members, which features distinguished speakers who reflect on their career experiences, the choices they made along the way, and the lessons they have learned from them.

GRONVALL: Ready to start? Well, welcome, everyone. Thank you so much for being here and joining me with a conversation with Dr. Peggy Hamburg. Her bio is in your materials, so we won’t go too much into that right now because we’re going to talk about Peggy’s career and the various roles that she’s had over her career.

And so let’s start with basic question number one: Peggy, how did you get where you are?

HAMBURG: (Laughs.) Well, I would have to say that I have ended up pursuing a career that I had never imagined when I was either a child growing up or even when I started medical school. You know, I had grown up on a university campus, Stanford University, where my parents were both on the medical school faculty. And I—you know, I could see that medicine and science was an exciting career to pursue. And I sort of expected to be a traditional academic medicine type—teaching, taking care of patients, and doing research. Instead, I ended up really pursuing a career much more focused on public service and working at the intersection of health and medicine, and a much broader set of issues—legal, social, economic, political—and have found it enormously gratifying.

But I think what happened to me was really related to the emergence of an earlier global disease pandemic. People forget, but HIV/AIDS was and continues to be a serious global health challenge, a pandemic. And when I started medical school—and I went to a respectable medical school, Harvard Medical School—we were taught that really the era of infectious diseases was over, thanks to the advent of effective medicines and vaccines. And of course, huge progress had been made, and continues to be made. But the truth is that infectious disease threats persist. And that was strongly brought home to me when we watched, as medical students, the strange, unexpected immune deficiency syndrome appear.

Nobody knew what it was. Nobody knew what caused it. Nobody knew what to call it. And we had nothing to offer in terms of really effective treatment or prevention strategies, management of the symptoms and that was pretty much it. Over the course of my medical school training and then into residency, we learned more and more. And it was, in fact, HIV/AIDS. I did my residency training in New York City, where we saw a lot of HIV/AIDS patients still with this tragedy of having really nothing to offer medically, and seeing so many people—generally people in the prime of their youth—suffering from this devastating disease, and losing their lives, including one of my fellow residents who succumbed to HIV/AIDS.

It really made me think. And it made me realize that I wanted to pursue a different kind of career. It got me interested in, you know, public health much more broadly. It got me interested in working at this intersection of medicine and science with broader health issues and broader social and political challenges, in order to make a real and enduring difference. And I’ve never looked back, but my Great-Aunt Winnie (sp), who’s was sort of like a grandmother to me, couldn’t believe that I was giving up being a real doctor to do things like being health commissioner in New York City. She thought that was just, you know, a great loss of career opportunity. But I disagree. (Laughs.)

GRONVALL: So it wasn’t just HIV/AIDS that was—that influenced your career trajectory. There was another infectious disease that, you know, I guess many people thought we had already taken care of. But tuberculosis that came back. Could you talk a little bit about that?

HAMBURG: Yeah. Well, when I was working as health commissioner in New York City, which I did for six year—three under Mayor Dinkins and three under Mayor Giuliani, so that in and of itself was a learning experience—but I suddenly confronted the fact that we were having a very serious resurgence of tuberculosis in New York City. And not just tuberculosis, but drug-resistant tuberculosis, which is much harder to treat and much more challenging.

This is a disease that actually, going back to my medical school days, I had learned about as a disease of historical interest. Never did I think I’d be dealing with the challenges of tuberculosis. But it was a disease

that’s both highly associated with poverty. It’s also associated with flows of people from other countries where the disease is more endemic. And it’s also associated with immune suppression. So the coming together of HIV/AIDS in epidemic numbers in New York City, and pockets of tuberculosis, you know, really created an explosion. And that was an important live lesson for me as well.

And, interestingly, it showed me how much leadership matters and how much the trust of the public matters in terms of important public health decisions. Mayor Dinkins quickly appreciated the fact that this resurgence of tuberculosis was a serious problem for New York City, in terms of New York City as a place that people work in, and the industries there, also as a tourist entity, and basic public safety. And he really—I think his understanding was helped by the fact that one day the New York Post had a headline, you know, a full-page—killer TB on subway. That gets people’s attention.

But he empowered me, as the public health leader in New York City, to put together a strategy to address tuberculosis, to work across all the components of government and engage with the private sector and the not-for-profit sector as well. And he actually gave me the authority to create a comprehensive, integrated TB budget for the city. Initially people were concerned because they thought, of course she’s going to put all of the money into her own department. But that wasn’t the case. Far more went actually to things outside of the traditional health care system because that was what mattered for TB control.

Making sure that we got rid of some of these huge armory-style shelters to more private apartments, so that you could reduce the spread in congregant settings like that. Addressing the problem in the criminal justice system, which was huge in terms of spread amongst people in jails and prisons, but also the failures of the health care system to be able to track people as they move in and out of criminal justice into the community. So we were really able to develop a plan and have it funded, and really make sure that people understood why this was a problem, why we needed to work on it together, who had what roles and responsibilities, and hold people accountable.

And actually, some people had said, when we started this effort, you know, you’re never going to be able to really adequately address TB unless you solve the problem of poverty. And, you know, it is a concern, especially when you look at the continuing problem of tuberculosis and many other serious public health problems around the world. The link to poverty is profound. But it also did show that you can target programs and policies to make a difference and, in the process, you know, create better conditions for everyone.

GRONVALL: So when did you start moving your—the intersection of disease and security. When did that start to come into your career?

HAMBURG: Yeah. Well, certainly when I was working as health commissioner in New York City I began to appreciate the link between public health and public safety. And I think, you know, we have underestimated that and continue to do so. But I also, when I was health commissioner in New York City—which is, you can see, a very formative period in my career—I had, you know, the terrible experience of being in charge of health in the city of New York the first time the World Trade Center was bombed. And people kind of forget about that. We just actually acknowledged the thirty-year anniversary of that event. But for me, it was a profound moment because it made domestic terrorism a very real phenomenon.

And in thinking about all the points of vulnerability that we had as a city in terms of possible future terrorism, I recognized that I needed to think about my role of health commissioner somewhat differently and really begin to address some of those critical gaps. And in that process, I started to learn about issues of the deliberate use of biological agents to do harm—biological weapons as part of state-sponsored programs and also the possibility of biological terrorism.

And it was really, you know, quite an eye-opener for me. I was very fortunate to have a friend and colleague, someone named Dr. Joshua Lederberg, who is, you know, one of the great sort of patriarchs of, I guess, biology writ large, but biosecurity as well. And he was president at Rockefeller University at the time. And so he

brought me under his wing. He taught me a lot about this set of threats and concerns. And it has sort of stuck with me. I’ve always thought about the deliberate use of biological agents to do harm as part of a continuum that includes naturally occurring pandemic and biological threats. And I think we’ve all seen with COVID that mother nature can be a very effective bioterrorist.

But, you know, it was so obvious that we weren’t adequately prepared for a set of naturally occurring disease threats, and then adding on this additional set of concerns, you know, really required both new investments and new capacities, but new partnerships. Really working with law enforcement and the intelligence community in ways that I never had before, and never imagined I would be pursuing as part of my medical and public health career. But, you know, I think that today we recognize that those kinds of interconnections are more important than ever, and still need to be developed, strengthened, and extended.

GRONVALL: So your time as FDA commissioner has a lot of different—there were a lot of different things that happened during that time. What were some of the lessons, you know, that you want to share from that experience?

HAMBURG: Well, again, that was a very formative experience. I have to say that both New York City health commissioner and FDA commissioner were jobs I never imagined I would have, and never wanted to have. (Laughs.) If you had asked me just a few months before I took on either of those jobs I would have said: Never in a million years. You’d have to be crazy to want to have one of those jobs. But they both, you know, were just fantastic experiences in different ways. But, you know, taught me a lot about both leadership and also taught me a lot about making a difference in a complex world.

At the FDA, I came on board at a time when FDA was really suffering a crisis of confidence and trust. There had been a number of, you know, pretty significant issues around drug safety, and recalls, as well as some major food safety issues. FDA was sort of under attack by both the media and Congress. And I think, you know, the public confidence had dropped quite significantly in FDA. Sadly, a cycle of reduced trust in public health agencies that we’re experiencing again with both the CDC and the FDA to some degree. But I came in then. FDA had been chronically underfunded.

So my first job was really both to sort of restore morale within the agency that had sort of circled its wagons and sort of felt like we don’t want to stick our head out for fear that, you know, we’ll get shot out, or our heads will get cut off. So restoring morale and esprit de corps, and the sense of mission within the FDA, but also explaining to the public, to policymakers, and engaging with our stakeholders about what we were doing, how we were doing it, why we were doing it, and why it really mattered. The FDA is such a unique organization. I didn’t fully understand till I got there, and actually every day I learned more and more about it, till the day I left.

But FDA is actually responsible for the oversight and regulatory decision making around, you know, almost twenty-five cents of every dollar that consumers spend on products in this country. And it’s the gold standard around the world. So FDA touches on so many things that matter every day in our lives, and certainly in a crisis as well, you know, whether it’s the food we eat, or the cosmetics we use, or the drugs to treat loved ones, or during my tenure we took on tobacco oversight as well, which is hugely important, really a historic advance as tobacco-related products still represent the largest cause of preventable illness and disease and death in this country and around the world.

So, you know, really regaining support for the FDA and its critical and unique work was one essential issue. Also, really helping people understand where FDA fits within a broader set of concerns in terms of really being able to translate advances in science and technology into real-world products that matter for people, that have an assurance of a certain level of quality, safety, and efficacy. And, you know, really making sure that the incredible advances in science and technology today, you know, would make a difference for people. Because so much research is done in a context where it isn’t really thinking—you know, the academic researchers that I once wanted to be often are doing really important work, but they don’t know the kinds of studies that need to

be done to create a product that really can be scaled up and be evaluated for safety and efficacy, and go out in the world and make a difference.

The kinds of studies that need to be done to really better understand the relationship of food products and components of food and health. The kinds of work that needs to be done to make foodborne illness outbreaks as effective and efficient as possible. And so really advancing regulatory science, the kind of science that enables you to bridge, was really an important focus. And it continues to be an underappreciated and under-resourced component of how we think about the research enterprise, especially as it relates to biomedical product innovation.

And then the last thing that I really was surprised by but ended up focusing on and worked, actually, with the Council on Foreign Relations during my tenure on this issue, was global governance. Many of the challenges that we were facing at the U.S. FDA were mirrored in countries around the world. Many of the products that we were regulating at the FDA were coming, in whole or in part, from countries around the world, and often through complex, multi-country supply chains as well. We didn’t—even as the richest, most well-resourced regulatory agency in the world—we didn’t have the capacity to be everywhere we needed to be in order to protect and oversee adequately the products that American consumers were using. And there was also unnecessary duplication of effort in some instances.

So really thinking about how could we create a more global regulatory community? How could we share information—both scientific information in the review and approval process, but also information about inspections, information about product concerns and risks? And how could we share workload, you know, including inspections, et cetera? And we created a new global governance mechanism, actually, which really came into its own, I think, during COVID. But COVID brought home, without a doubt, that, you know, the regulatory community has to work together around the globe if we’re really going to make a difference and be able to respond to the needs of consumers in a timely and effective way.

GRONVALL: So your discussion of international issues leads me to the Nuclear Threat Initiative. So how did you end up there? And why—you know, how does NTI square with biology?

HAMBURG: Yeah. Well, again, another surprise stop along my career path. I never thought I’d work at a place called the Nuclear Threat Initiative. And I continue to be involved with, what we fondly call it, NTI, as a board member now. But I was the founding vice president for biological programs. And from the beginning it always, as you know, had a biological program. It’s a foundation or an organization—it began as a foundation, now it’s sort of a hybrid entity—funded by Ted Turner and Sam Nunn, the former senator from Georgia was an important partner in it. And it was set up to address the threat of weapons of mass destruction, with nuclear obviously as a central focus. And that was really Ted Turner’s main objective as he created this entity.

But Sam Nunn had been working on issues of weapons of mass destruction more broadly when he was a member of the Senate. And he really appreciated the challenge of the biological threat as well. And I’d worked with him some when I was in government, because of both at the Department of Health in New York City, and then I was in the Clinton administration as an assistant secretary in the Department of Health and Human Services, building a bioterrorism preparedness program and beginning things like the national stockpile, and pandemic flu preparedness plan, and trying to really create both an organization and systems to better prepare to respond to both naturally occurring and deliberately paused infectious disease threat.

So they brought me on to help stand up a biological component within the NTI. I said I’d stay for a year to set it up. I ended up staying much longer than that, partly because the second World Trade Center bombing happened, and then the anthrax letters. And it really brought into very crisp focus what our mission was, to reduce the threat of weapons of mass destruction. And, you know, I really saw the value of the organization and the difference that it was making. On the biological side, from the beginning, with the full support of Senator Nunn, we set up a program that recognized the continuum of biological threats. Not just the deliberate use as bioweapons or bioterrorism, but also naturally occurring infectious disease threats.

And so over the years, I think we—NTI has done a lot of really important work, both helping to stand up some important organizations and programs in the biosecurity world, including early support for the Johns Hopkins Center that you are such an important member of, also some of the early work on preparedness planning, some of the early work looking at how do you responsibly address the stewardship of advances in science and technology, enabling important science to go forward but reducing the threats of possible either intended or unintended misuse. And also, supporting fundamental work on trying to strengthen disease surveillance around the globe, and to strengthen some of the programs at the World Health Organization, which serves as a hub for pandemic preparedness and response.

GRONVALL: So my questions have been all about the past, but can you say a little bit about your future plans?

HAMBURG: (Laughs.) Well, you know, after leaving the Food and Drug Administration, where I served for six years—which is a lot longer than the average tenure of an FDA commissioner—and it was a challenging job. And having had a number of important, demanding leadership roles, and doing a lot of institution-building in those roles, I sort of wanted to step back and have a more mixed portfolio of activities, sort of explore some new areas, bring some of my experience and expertise to that work. And just kind of reflect and think about next stages. That has gone on for a while now and continues to be very interesting. I don’t think I’ll probably take on another major leadership job, although I don’t feel that I’m completely ready for retirement; not at all. In fact, I’m probably working just as hard now as I ever have, but because of this portfolio lifestyle I’m spread out more and I don’t have that infrastructure of support that came with some of these other jobs.

One thing, you know, as I sort of am coming towards the latter part of my career, that I recognized is really important and that gives me a lot of gratification, is also trying to help nurture the next generation of leaders and practitioners in public health and, you know, more broadly science, medicine, health, and global issues. It is a great privilege to be able to work with upcoming leaders, like you. To be able to really provide some of my insights and experience to people at earlier stages in their careers. To help, you know, connect people in important ways because networks, you know, still really matter.

And one of the things that I had been struck by earlier in my career, despite the fact that I had grown up in a community of professionals that included men and women, as a woman in medicine, when I was in training, there weren’t a lot of role models for me. And also, in terms of making this transition from a more traditional academic medical career into policy and public service more broadly, there weren’t a lot of role models. In fact, my chairman of medicine when I was leaving New York Hospital Cornell, where I did my residency training, said to me: If you aren’t back in two years to do some specialty training, you will have thrown away your entire medical career. And, at the time, I was a little undone by that. And, of course, I didn’t know how things were going to unfold. But the irony was that not that many years later he called me up and he said: You know, I’m kind of interested in exploring the world of policy. Can you give me some guidance? But I really think it’s so important to help to mentor the next generation and to remind people about the array of opportunities and options that lie before them.

GRONVALL: Well, that’s a wonderful segue to opening it up to members to ask questions. Just a reminder, this—as you know, this meeting is being recorded, but everything is on the record as you ask your questions. I was once a term member myself, and then—and I tried to make it to as many meetings as I could. And then I had a baby, and it was a little bit harder. (Laughter.) But just a wonderful opportunity.

Q: Sonya Stokes, term member at the Council. Thank you, Dr. Hamburg, for this discussion and for your leadership.

My question is about the U.S. health workforce. We are experiencing staffing shortages that are impacting nearly every aspect of medicine. In many ways, we are more fragile and less able to respond at the health system level than prior to COVID. So how do you see the health workforce shortages impacting our national pandemic preparedness and response? What are some of the strategies for addressing any of the associated risks? Thank you.

HAMBURG: Well, thank you for your question. And it’s so important and so fundamental. And of course, addressing the health workforce, both in the medical care delivery setting and in public health, is crucial. And it’s crucial every day in terms of routine needs of people, but it also is the backbone, as you note, of preparedness to respond nimbly and effectively in a crisis. And I think we have to really, right now, be thinking about our health care workforce as a kind of crisis for our nation. We need to really be making sure that we are supporting both the needs of the existing workforce—and, as you know, mental health issues have been enormous. People are stretched terribly, terribly thin. Work conditions are very, very difficult.

We need to address a set of issues in terms of the existing workforce, but we also need to really focus on training and education and bringing, you know, the next generation into the workforce. And not just doctors. We need to think about, you know, the importance of all of the ancillary health services as well. Nursing shortages have plagued our health care delivery system. Public health, you know, really needs and enormous infusion of resources—human resources and, of course, dollar resources as well—to enable public health to do its job every day and respond to a crisis like COVID.

We also need to think about better integration of our health care and public health system. I can’t resist adding that because it is so crucial. And, you know, one of the things that I have certainly learned in the course of my career is that, you know, we historically siloed these two activities and they need to be together in order to be each effective in doing its own job, but also the synergies are profound. So I think the workforce issues are on people’s radar screen, but we have to make sure that that translates into meaningful action. I’m encouraged, I hear that applications to medical schools are actually up. I’m worried in the public health sphere that they’re down. We need to monitor all that. But, you know, really, this is as important to our nation and its future as making sure that we have a robust, well-trained, effective, well-funded military. And I think we need to address it with that seriousness of purpose.

GRONVALL: I think we have a question from the Zoom.

OPERATOR: Our first question from our virtual audience will come from Lucy Cate.

Q: Hi. I want to just thank you so much for this great discussion.

Your career just has had so many incredible successes, but I find that oftentimes I know that I learn a lot more from failures than we do from success. And so I wanted to get a sense from you just if there is a failure in your life that you’ve learned the most from, and kind of what did you do to overcome it?

HAMBURG: Well, you know, I do think it’s really important to recognize the value of failure and what you can learn. And it is something that, as a society, you know, we tend to sort of feel like we got to sweep failures under the rug, rather than address them and learn. You know, that’s the kind of question where as soon as you ask it, then everything flies out of my mind in terms of specifics. But believe me, there have been many, many failures. I think, you know, one failure has been a failure to have confidence in my own instincts and decision making, especially early on in my career. It is essential.

And I did learn, in starting as health commissioner, that, you know, you have to listen to sort of your internal compass and pursue it, because as soon as you start to make too many accommodations, as soon as you start to, you know, sort of doubt yourself and your decisions, life only gets more complicated. On the other hand, I also feel that one of the really important lessons learned over time has been that the best decisions get made by making sure that you have all the information that you need, by making sure that you bring all the people into the room that you really need to hear from—both your supporters and your adversaries. And that you not be afraid to acknowledge, you know, what your shortcomings are in terms of your understanding of an issues at times, and the need to bring the right experts around the table with you.

You know, another important lesson learned that, you know, had some failures associated with it—you know, probably big and small—is also people in leadership roles, in government but external to government as well,

don’t like to be surprised. And so making sure not only that you have a strong structure for decision making and implementing on decisions, but also you know who needs to know about what you’re doing and making sure that whether it’s, you know, the mayor, or the HHS secretary, or the president, aren’t caught unawares. But also, you know, your stakeholders. And that you’re so much better off if you bring people on as partners rather than surprise them with fait accompli. So I hope that sort of gets at your question.

It also brought to mind a story—you know, one of the challenges in terms of lessons learned, of course, always has to do with finding the right balance in life—which is hard. The life work, existential questions. But I’ll never forget, when I was working on the anthrax letters response, my daughter said to me: Why can’t I have a normal mother who drives carpool and doesn’t talk about anthrax all the time? (Laughs.) But I also was very mindful of the fact that, you know, some of my failures weren’t professional but, you know, I tried as hard as I could. But also, you know, the importance of addressing the needs and concerns of family.

Q: Thank you.

GRONVALL: Hi. Jessica, with the Council on Foreign Relations.

During the COVID pandemic we’ve seen a pretty substantial rise in misinformation about public health as well as a decrease in public trust in both domestic and global health institutions. You touched on this a little bit, about your time at the FDA, that there was a crisis in public confidence. Can you talk about—is there anything that you learned during your tenure at the FDA that we could apply now to help restore some of that trust and combat some of that misinformation that we’re seeing and have seen throughout the pandemic?

HAMBURG: Well, you know, your question is such a vital one, and one that I think we’re all grappling with. And there are no easy answers. The surge in misinformation and disinformation has been so huge, and so devastating, I think, to the ability for policymakers, for sure, but providers as well, to undertake important activities to address the COVID crisis and beyond. You know, most of my leadership career in public health was in an earlier era, I have to be honest, when social media wasn’t quite as prominent and all-powerful. And watching social media evolve, I remember the first twenty-four hour cable TV stations were starting as I was health commissioner, both New York 1 in New York and CNN.

And you could even feel how that changed things. You know, stories were unfolding all the time. And so when the health department would do a briefing every day on an unfolding crisis, that worked until the story kept changing over the course of time. And now the sources of information and what’s out there are so vast that it’s hard both to get a clear, consistent message out there, and it’s also hard to overcome some of the misinformation. And of course, we all know some of it has been so deliberate and aggressive, such as the antivax movement, that it really has a lasting ability to undermine information.

How to address it is so tough. I mean, I think part of it is that you have to be very clear and consistent in your messaging. You have to be transparent about what you’re doing, how you’re doing it, and why. I think it is very important in terms of building and sustaining trust to be willing—going back to the other question about, you know, failures—you have to be willing to admit failure, but how you’re addressing it. You have to be willing to say what you don’t know, what the gaps in knowledge are. When there’s an unfolding pandemic, you can’t possibly have certainty about every step you’re taking.

But you also, I think, have to communicate to the public that you recognize this gap in knowledge, you’re addressing it in certain ways, and that you will be updating them and you’ll be updating policy based on new information. But that you will always be driving forward in the best way possible to serve them and their needs. And always trying to get all of the information necessary for the best decision making. I think we have an obligation as a society to continue to try also better inform the public on a routine basis about issues of science, medicine, public health, and technology, so that things don’t emerge out of nowhere and expect people to understand them. And also, helping people to be able to better assess data, what makes sense, how to really know what’s credible and what isn’t.

And then I think we need to make sure that we’re driving out really solid information for people in accessible ways, not making it hard to get to. Not assuming that just because you post something on the website that everybody’s going to read it and understand it. And then, I really think, especially where we are today, we have to engage community leaders in these efforts, people that are trusted in the community. They might not have backgrounds in science, or medicine, or public health, but they’re voices that are known and trusted. And so to engage community leaders in the efforts is also crucially important. And we always say in public health—and we say it because it’s true—that you have to earn trust every single day.

GRONVALL: We have a question from the virtual audience.

OPERATOR: Our next question will come from Amy Maxmen.

Q: Hi. Thanks a lot.

I actually had a follow-up to that question, so that was good timing for me. So about misinformation, so what we saw in this pandemic is that a lot of misinformation actually comes from, you know, within the government. And you saw that at multiple times during the pandemic. I saw just recently that the CDC and the FDA sent a letter to Florida’s surgeon general about sort of the antivaccine misinformation he’s been promoting. Are there any ideas, you know, within the FDA to make sure that it is not kind of falling prey to politicization? You know, like as we saw with hydroxychloroquine? And also moves to make sure that there’s kind of a more one government response in terms of this is—this is what the best science says right now? Because I think that just contributed to so much misinformation and politicization of all sorts of information.

HAMBURG: Yeah. Well, that does build on the last question in important ways. And I think, you know, first to say that we may have failed during COVID from different venues to really help explain that the response was going to depend on an iterative process of the unfolding experience of the pandemic, ongoing studies of what works and what didn’t, understanding the nature of how the virus is transmitted, asymptomatic transmission, long COVID, what kinds of treatments actually were studied and demonstrated to have benefit, et cetera. And so there were a lot of issues that, you know, we weren’t thinking about in the beginning, we didn’t expect, we didn’t fully understand.

But I think that all got sort of muddled up with communications about what people needed to do. And in that moment, a sense of urgency about certain things, which then when new information was available the recommendations changed. But that undermined confidence, and it gave tools to those that wanted to further undermine—with disinformation campaigns or politically, ideologically motivated efforts—undermine leadership or certain kinds of actions. You know, the whole controversy around masks, you know, is certainly one good example.

But I think we’re never going to have everybody all on the same page. There’s no doubt about it. What we can do, though, is both to try to make really good information available easily to people, as I mentioned, so that it will be the sort of go-to sites and go-to resource, rather than spending a lot of time searching the web for information, or listening to your neighbor, or whatever. I think also really engaging, for example—you mentioned the example of the health commissioner in Florida.

Well, I think if instead of having an unfortunate strategy, as COVID unfolded, of every state on its own bottom, so to speak, and decision making and leadership becoming very, very fragmented, if we could have tried, both from an information perspective as well as a resource perspective, to have more coordination, you know, stemming from national leadership but recognizing the autonomy of states, but the value to states of having the integration with national systems, national strategies, and national resources. I think we could have prevented some of the problems that unfolded and, you know, we’re now in a challenging position of how do we roll back from some of the mistakes that have been made.

Q: Hi. Dan Mejia, Associated Press.

I wanted to ask you about the obligation of public health leaders to be candid and forthright to the public. Thinking back to the beginning of the pandemic and the masks, and how masks were initially discouraged, which clearly seemed to have, like, wider reasons for that. Can you kind of, stepping back to that incident, talk about, like, whether you think that that was the right thing for the government to do, and the obligations of public health leaders to be honest with the citizens? Thanks.

HAMBURG: Yeah. Well, I think, you know, it’s always easier to be a Monday morning quarterback than to be on the field making hard decisions. For me, some of what unfolded, you know, was an object lesson in the need for public health officials to be candid and transparent, as I said before, and to be address what is known and what isn’t, and why you’re making the recommendation. I think in the midst of a crisis to err on the side of caution is generally a good strategy. And so, you know, perhaps the mask issue wasn’t adequately addressed early on in terms of just, you know, the precautionary principle that—the recommendation that we’re not sure the value, but there’s likely some harm reduction.

But remember that this is also unfolding at a time of huge gaps in supplies. And so there was a prioritization that was going on as well that you didn’t want the public and companies and others, you know, buying up all the stocks of masks that were clearly most needed in the health care setting and in settings where the most vulnerable populations were being housed and cared for. So, you know, there were a lot of moving parts.

But the other thing I want to mention, which is an indirect answer to your question, is it’s not just the communication about why you’re making recommendations and how they might change over time with more information. It’s I think our country could have done a better job, to be perfectly frank, in terms of assuring the necessary research agenda and its implementation to really affirmatively ask and answer some of the questions that were emerging in terms of policies. I think we could have, in a more targeted way, really addressed the question of, you know, was COVID respiratory droplets or airborne spread? And that has implications for the role of masks. We could have, in a more targeted way, addressed some of the issues as we learned about asymptomatic transmissions. We could have in a more targeted way and earlier begun studying long COVID. We could have and should have really studied ventilation and air quality in a more aggressive way.

I think we were sort of counting on the richness of our academic research universities, the private sector, and government entities, to sort of identify what the critical questions were and do the right studies. But that doesn’t always happen, especially if you don’t completely understand the policy context and needs. And so, you know, I hope that as part of our pandemic preparedness planning going forward we really ensure that there’s a component that’s focused on leadership and coordination of a research agenda that’s a dynamic, living activity that doesn’t necessarily mean that the government is going to do it all, or even that the government’s going to fund it all. But I think that it should be part of a national preparedness strategy. And it should be a situation where there is this blueprint for action with identification of where this work is going to be done, and how it’s going to be done in a coordinated way—you know, presumably with a cross-institutional, cross-sectoral, cross-disciplinary focus. And working with other countries as well.

GRONVALL: Mmm hmm. Was there a country that you thought did a better job in that respect?

HAMBURG: Well, I think the U.K. did. As you know, many of the important breakthroughs about important treatment interventions came from U.K. studies that were done in a very targeted way. They also had the advantage of the National Health Service to implement. But their science advisor did actually have a strategy that involved identifying some of these critical gaps. And he brought in some external advisors. And I briefly, you know, served in that role, to help identify areas that might need study as well. So I think that is one example.

They also did some interesting work that I only just learned about thanks to a CFR panel earlier this month looking at three years of pandemic experience that Lu Borio mentioned, a study done at Heathrow Airport looking at wastewater surveillance. And looking at it during a period of very tight travel restrictions and a perio

really making much difference. Which is important information to know in terms of policymaking and what kinds of interventions matter. So I think—I think I would say that the U.K. provides some lessons for us going forward. But I think we can also figure out some of what we can do better next time.

GRONVALL: One of the things that—I know we just have a few more minutes—what are the, like, surprises that you have? What do you think is going to get fixed? You know, what are the problems that you saw during COVID and what do you think is most likely to get fixed?

HAMBURG: Well, you know, certainly there were a lot of problems. And we tend to talk more about the problems. One of the great bright spots was the way the scientific enterprise came together to advance vaccine development. And it really was because of taking this sort of ecosystem approach and thinking about all the components of vaccine development that need to happen to move, you know, from a good idea in a lab to a real-world vaccine in people’s arms.

And trying to see how those things can be aligned more efficiently, how you could reduce some of the periods of study without compromising the quality of the science, and thinking about making certain kinds of investments much earlier, such as in manufacturing, even when you didn’t know for sure—it was a financial risk—whether the vaccine was going to make it over the finish line, in terms of the assessments of safety and efficacy. And I think that the rapid development of the mRNA vaccines, you know, really has been a powerful lesson that we can do things better, we need to do things better, and it shouldn’t only be in a crisis but it should be to address critical unmet medical care and public health needs.

But also, recognizing that, of course, things don’t naturally always come together when there isn’t a crisis. So how can we mobilize the kinds of political and public support to continue to accelerate scientific innovation and access to new products in ways that will make a difference for routine needs? We still have huge unmet public health and medical care needs. But also, of course, in a crisis. So that’s one of the pluses. And I think, you know, we will be thinking about these issues differently going forward.

I think in other ways, I’m very, very worried. Coming back to this issue of trust, one of the surprises to me was how much trust mattered. I actually think—maybe it’s wishful thinking—but that our country was much better prepared to respond to a crisis like COVID-19 than we demonstrated in the actual response. And I think a lot of that was an inadequate mobilization of the tools that we had at hand, but it was also that some of this came at a time when already there was an undermining of the value of science, and scientific expertise, overlaid on a very divisive political environment and, you know, some early failures that further undermined confidence, and some deliberate campaigns of misinformation, disinformation.

So that, you know, the failure of trust in government and critical institutions in our country was a surprise to me. And it, I think, resulted in a failure to actually respond as meaningfully and effectively as we could have, and should have, and, hopefully, as we will in the future.

GRONVALL: So now we’re thirty seconds to end on an optimistic note. Can you say what gives you hope for the future in this area?

HAMBURG: Well, I guess what gives me hope is that we have had an experience that has demonstrated, without question, the critical importance of advancing science and technology to serve critical public needs. We have seen how failure to address public health and health care issues not only matters for the health of individuals, and families, and communities, but the health of our economy, our society, our national and international security. And I think we have seen that we are in the middle of a lot of complexity in our modern world, competing priorities, and many, many serious threats.

But that we have to have health as a centerpiece of so many activities, whether it’s responding to biological threats and pandemics, or climate change and its impacts on health, or food and energy and water security. All of these things have a health component. And we need to press on that. We need to engage all of our various

stakeholders and partners. And, you know, we have huge opportunities in terms of where we are in terms of advancements in science and technology that can be applied to find solutions to the greatest problems before us.

GRONVALL: Wonderful. Please join me in thanking Dr. Peggy Hamburg. (Applause.)


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