Additional and Dissenting Views

How can the United States prepare for a truly equitable response to the next pandemic?135

First, we should acknowledge that pandemics typically exacerbate preexisting disparities.136 When health and economic crises co-occur, such as with COVID-19, socially disadvantaged groups face a double jeopardy.137 Low-wage workers are less likely to have paid sick and family leave or even minimal savings to pay for essentials such as food, housing, and health care.138 And because of structural racism, Black, Latinx, and other people of color are more likely to be frontline workers, live in overcrowded housing, suffer from chronic diseases, and be denied access to testing, treatment, and personal protective equipment (PPE).139

Second, if it is not measured, it will not be managed. Weeks passed before public health officials recognized and reported that people of color were suffering disproportionately from COVID-19. At the start of pandemics, public health agencies should disaggregate and then publicly report data by age, race, ethnicity, gender, disability, zip code, and other sociodemographic characteristics.140 Disaggregation should extend not only to case, hospitalization, and mortality data, but also to the availability of testing, treatment, PPE, and safe places to isolate when sick; receipt of social and economic supports; and the downstream socioeconomic harm of pandemics.

Third, populations most affected by health and economic challenges should be included in decision-making. Policymakers should consult with community-based organizations to identify barriers to health and social services, disseminate public health guidance in culturally and linguistically appropriate ways, and lift up grassroots policy options.141 These relationships should begin during periods of calm: if the first interaction is during a pandemic, it is too late to build trust and collaboration. States and communities should also establish teams dedicated to promoting racial equity in response efforts. These entities should include leaders of color from the public and private sectors, be integrated into the broader public health and economic response, and be accountable to the public. These teams could ensure that critical health and social supports are distributed fairly and proportionately to need.

Fourth, the United States should improve living conditions and remove barriers to health in good times and advance a robust policy response in times of crisis. Bolstering the U.S. health and social safety net will lead to better, more equitable outcomes in future pandemics and recessions.142 The United States needs a comprehensive public health system, which will require sizable reinvestments from all levels of government.143 In addition, the United States should join other Organization for Economic Cooperation and Development (OECD) nations by ensuring that all residents have paid sick and family leave; living wages; affordable, accessible, high-speed internet; and comprehensive, affordable health insurance.144 In the next few months, the twelve holdout states should expand Medicaid for its proven ability to boost health, reduce disparities, and provide a strong return on investment.145 During pandemics, emergency health, economic, and social supports should be available to all residents regardless of work or immigration status. Such supports should be automatically triggered based on predefined criteria and should continue for the duration of the pandemic or related recession.

—Richard E. Besser
joined by Luciana Borio, William H. Frist, Helene D. Gayle,
Amy Pope, Sonya Stokes, and Rajeev Venkayya

Despite great admiration for the scholarship it reflects and appreciation for many of its findings and recommendations, I am unable to join in endorsing the final report and instead have accepted the Council on Foreign Relations’ invitation to submit dissenting views.

My reservations stem more from the report’s omissions than its conclusions. Among the topics I believe would have improved the report include the following:

  • Despite the frequent references to the need for science-based information, as the pandemic unfolded, much new evidence suggesting alternatives to early lockdown strategies was disregarded, or even actively suppressed. Responsible public health policy should be not just open but also vigorously inquisitive about emerging contrary data, especially in the case of a new and not well-understood pathogen.
  • The rationale given to the public for the policy choices being made sometimes shifted to fit the existing strategy. This engendered public confusion and, too often, cynicism and resistance.
  • Many of the world’s health authorities took too long to identify the starkly different danger of the virus across age and health status categories, or to recognize and react to those facts. This led to thousands of additional deaths, while imposing excessive social, medical, mental health, and economic costs on millions. It would not be necessary to criticize any individuals for decisions made on the imperfect early information in order to still point out the costs of not sooner recognizing and acting upon the disease’s disparate effects.
  • In a related omission, there is no mention of the relative outcomes in nations that chose less restrictive and intrusive approaches; many of them appear to have fared better than the United States and countries with similar, restrictive policies and could look better still over time.
  • The essence of public leadership, especially in a cataclysmic circumstance like COVID-19, is the balancing of multiple risks and interests. A global health system that makes little or no attempt to estimate the inevitable costs and consequences of various medical strategies, but rather focuses one-dimensionally on stopping a disease regardless of costs or downside effects, does not serve as well as it should.
  • The report takes no account of the fiscal challenges that the United States, and in fact a world of heavily indebted governments, faces but rather urges the spending of more money on a host of programs old and new. At a minimum, it would have been useful to suggest some current expenditures in the global health realm that are of lower priority and could serve as a source for some of this flood of new funding.
I regret my inability to embrace the study fully, but deeply appreciate the invitation to take part in the Task Force and the many insights I gained from listening to its stellar assembly of participants.

—Mitchell E. Daniels Jr.

Compliance with International Health Regulations (IHR) obligations will inevitably conflict with the sovereignty of participating nations. Understandably, member states will be inclined to put the needs and rights of their respective governments and citizens above global health prerogatives without appropriate incentives and disincentives. The expectation for the World Health Organization (WHO) to compel cooperation from a given country is irrational and antithetical to the institution’s basic mandate; WHO cannot serve the dual roles of advisor and enforcer without compromising one for the other. It is therefore prudent to maximize intelligence gathering and operational capabilities through means and methods that bypass sovereignty.

As we seek out and embrace newer, more efficient models to prevent, detect, and respond to pandemics, we should recall that in the many weeks preceding the Public Health Emergency of International Concern (PHEIC) declaration, clinicians were connecting through back channels on social media and communicating urgent findings to their colleagues and, eventually, to the world. We should remember that it was an ophthalmologist in Wuhan, China, and later an intensive care specialist in Bergamo, Italy, who sounded the alarms forcing their countries to listen and act. Perhaps these warnings came too late, but there is a strong argument that the major inflection points in the pandemic came from health-care providers on the front lines raising their voices at great professional and personal risk.

Information sharing and response coordination across tenuous trust networks can be strengthened by placing these front-line providers in central roles of epidemiologic surveillance. Front-line providers already possess the prerequisite access and expertise, and their primary responsibility is to the safety and well-being of their patients above all other concerns, including sovereign interests. With the right resources and authority, they can become leaders in the early detection and rapid response to any future pandemic. And putting power in the hands of front-line providers creates a mutually reinforcing system that also empowers WHO with leverage that prioritizes the health and security of all nations before the individual sovereignty of one.

—Sonya Stokes
joined by Rajeev Venkayya

The progress we have made in developing vaccines, therapeutics, and diagnostics for COVID-19 creates an opportunity to change the trajectory of the next pandemic. Three factors make this possible: a clearer understanding of the pandemic threat; advances in biomedical science, product development, and manufacturing platforms; and an enduring concern that could motivate unprecedented investment and action. While the following recommendation goes beyond the scope of the Task Force report, it is relevant to future preparedness.

Prior to COVID-19, experts assumed an influenza virus would cause the next pandemic, and that assumption was the basis for planning and investments. The world faced one mild influenza pandemic in 2009, but two other threats came from the coronavirus family: SARS (2003) and MERS (2012) before the emergence of SARS-CoV-2. Between COVID-19 and the discovery of more than fifty SARS-related viruses in bats alone, we can reasonably conclude that coronaviruses have joined influenza viruses as the greatest pandemic threats.146 And given the frequency of recent outbreaks, we could confront the next pandemic within the next five to ten years.

By early 2021, we will have massively expanded our understanding of coronavirus biology, targets for drug and vaccine interventions, the viability of new vaccine platforms to rapidly develop and manufacture effective vaccines, the effectiveness and safety of several new adjuvants, and the most promising rapid diagnostics. These advances could drive a renaissance in virology, vaccinology, vaccine manufacturing, and antiviral development that would make it possible to develop broadly protective antivirals, monoclonal antibodies, and vaccines for future threats. When combined with innovations in clinical development and regulatory science, as well as advances in diagnostics, we could envision creating a robust toolkit of countermeasures for coronaviruses and influenza viruses before the next pandemic.147

Now is the time for a “Mars Shot” public-private partnership to take coronaviruses and influenza viruses off the table as future pandemic threats. Governments, the biopharmaceutical industry, and the scientific community should commit to developing a suite of universal countermeasures for these two families of viruses, targeting common antigens and pathways, with a high likelihood of efficacy against a broad range of potential pandemic viruses identified in animal populations. The utility of this initiative would not be limited to pandemic preparedness. Seasonal influenza and coronavirus infections cause a substantial global burden of illness that would benefit from better tools.

Thousands of industry and academic groups that are working on COVID-19 could be enlisted in this effort, and there will be no shortage of talent. The pandemic will leave an indelible mark on a generation of students and young professionals who will commit themselves to careers in science, public health, medicine, and biotechnology, just as happened with the space race in the 1960s.

In 1980, the world eradicated smallpox after millennia of illness, suffering, and death. We have an extraordinary opportunity to develop the right tools for the next pandemic before the first person is infected by an as-yet-unknown virus. This is the challenge before us, and one that we should accept.

—Rajeev Venkayya
joined by Helene D. Gayle and Sonya Stokes