Mask mandates. Remote classes. Outdoor dining.
As 2022 dawns, it’s beginning to look a lot like March 2020 - so much so that President Joe Biden sought to reassure Americans they would not return to those dark days, instead promising a future made safer by vaccines and tests.
Those breakthroughs, along with genomic sequencing that can identify new variants and the promise of powerful antiviral pills, represent a revolutionary assault on the coronavirus. But biomedical advances are only half the battle, experts say.
“We have seen it isn’t enough to have testing and vaccines; you have to have a public health system that can deliver testing and vaccines,” said Joshua Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health.
The country is at a pivotal moment, Sharfstein said, full of opportunity if the lessons of the past two years lead to a new focus on getting shots in arms, swabs up noses and pills into mouths.
But some experts contend that the imbalance between the country’s scientific advances and its public health response is starker than ever, looking back in wonder on spring 2020 when a largely compliant population submitted to wide-ranging restrictions.
“We are going backward,” said Alfred Sommer, an epidemiologist and former dean at Hopkins.
“People are infinitely less responsive now,” said Sommer, who has tackled outbreaks of cholera and smallpox around the world. “This is different from anything that any public health person I know would have predicted in March 2020.”
When the most striking technological achievement of the pandemic - the mRNA vaccines - became available last winter, Sommer and others predicted the pandemic would be brought under control within months.
Instead, a year later, with little more than 60% of the U.S. population fully immunized with two mRNA shots or a single dose of the Johnson & Johnson product, the vaccines are providing huge benefits to individuals while failing to fulfill their public health potential of protecting the entire population.
For anybody who trusts science, this is “vastly different than March 2020,” said Francis S. Collins, who in December stepped down as director of the National Institutes of Health, the nation’s medical research agency. But those who don’t trust science and haven’t been vaccinated are in a vulnerable place, he said, endangering everyone around them.
“People should ask themselves which group they want to be in,” Collins said.
In a recent Washington Post Live interview, Collins warned about the dangers of overlooking the lessons of this pandemic. On the research side, he said, scientists are working toward new vaccines and antivirals that will leave Americans less vulnerable to another pathogen that may come our way.
But that half of the equation needs to be matched by improvements on the delivery side, Collins said, by increasing staffing and funding for local health departments, many of which have been running on a shoestring. Officials in some local health departments still transfer data by fax.
There “needs to be a real reset button for the whole system to try to figure out how to be better prepared,” Collins said.
During the past two years, there has been little appetite for organizational overhauls to keep up with the evolving enemy - or prepare for future pandemics - according to Jay A. Winsten, director of strategic media initiatives at Harvard’s T.H. Chan School of Public Health.
The United States has largely relied on legacy public health systems. One example: The Centers for Disease Control and Prevention’s external advisory board, the Advisory Committee on Immunization Practices, typically makes recommendations for routine vaccines that affect small portions of the population - often children - rather than responding to the minute-by-minute shifts of a worldwide outbreak.
The “processes are designed for a very different moment,” said Ashish K. Jha, a health policy researcher and dean of the Brown University School of Public Health. “They are not functioning well in a pandemic.”
The CDC did not respond to a request for comment.
Those organizational shortcomings are coupled with incomplete and sometimes contradictory messages. There was, for example, the early assertion that the general population would not need to wear masks and, later, a months-long disagreement among federal officials about the importance of booster shots, Winsten recalled.
Officials should speak with greater transparency about what they do and do not know, Winsten said, especially in the face of developments such as omicron, even as scientists scramble to learn more about that variant.
“What’s been missing all along, I think, is a publicly visible contingency-planning process that provides a window into the government thinking and advance planning for a range of possible future scenarios,” Winsten said.
The issue, Winsten said, is that misinformation fills the void, leaving local public health officials reacting on the fly instead of focusing on implementing the innovations that science makes available.
“What we have learned is that science isn’t enough; data isn’t enough; research isn’t enough,” said Jennifer Bacani McKenney, a health official from rural Wilson County, Kan., who has faced growing resistance. “We have learned all the science. How do we reach people is the big part.”
Funding from the Cares Act, the economic stimulus legislation passed in 2020, and other sources of pandemic-related federal support have helped with outreach, but the future of those funds is uncertain.
Nilesh Kalyanaraman, who became health officer in Maryland’s Anne Arundel County a couple of months before the pandemic hit, has seen the benefits of investing in delivery systems. The county has partnered with community organizations to provide health ambassadors who knock on doors in census tracts with the highest rates of infection to educate residents about vaccines and other public health measures.
A successful pilot program that was launched in May allowed the initiative to continue through next July. Kalyanaraman would like to make it permanent, bolstering public health measures for chronic conditions and positioning the country to respond more effectively to omicron or any other variant, by reducing the inequities that have characterized the pandemic.
“The question is funding,” Kalyanaraman said. Public health departments still haven’t fully recovered from the financial collapse of 2008, leaving them in a precarious financial position when the pandemic hit, he said.
“That’s what we are looking at - how to invest in the long term. I don’t have the answer for that,” Kalyanaraman said.
While the pandemic’s first two years raised awareness of public health’s antiquated infrastructure, those systems still had not been adequately revamped in time for omicron, according to Sara Cody, the Santa Clara County, Calif., health officer, who described developing homegrown databases to track cases.
“We are the health department in Silicon Valley, and we still get information about hospitalized cases faxed to us,” she said.
The biggest - and fastest-growing - impediment involves staffing. The politicization of the pandemic has exacted personal and professional tolls, even in Maryland, where elected officials have largely supported public health measures. Kalyanaraman said county health officers have been worn down by threats - and that he has endured verbal attacks in public.
Cody received police protection after a man was charged with stalking and threatening her.
After a particularly contentious meeting on masks in a school gym, McKenney, the Kansas health officer, was surprised when the sheriff’s department offered to escort her, concerned for her safety.
“This is my hometown, wow,” McKenney recalled thinking. “I kind of thought I might be shielded from that in my hometown.”
Beth A. Resnick, assistant dean for public health practice at the Hopkins School of Public Health, who testified before Congress in September, said her team of researchers identified at least 1,500 incidents of harassment and violence against public health workers nationally between March 2020 and January 2021. That included sharing private information on the Internet, death threats, protests, intimidation, even shots fired at employees’ homes.
By September 2021, Resnick said, more than 300 state and local public health leaders nationally had retired, resigned or been fired.
Complaints include fatigue and frustration with the hobbled infrastructure and the political attacks on public health, which limited emergency powers in some parts of the country, or shifted authority from health departments to elected officials or other entities, such as schools boards.
“They have their hands tied,” Resnick said of public health officials.
McKenney said she sees reason for hope - though not in time to respond to the threats a new variant may bring.
She spoke recently at a conference of the Association of Schools and Programs of Public Health, where she was struck by the number of students who came up to ask about her work in public health. Their enthusiasm is reflected by a 40% increase in applicants to 2021 graduate-level degree programs compared with March 2020, according to the association.
But turning students’ academic aspirations into jobs in local public health departments will depend on sustained funding.
“Everybody gets it. They know that’s where the work needs to be done,” McKenney said. “The upcoming generation is willing to take on that challenge.”
For now, the short-term challenges keep mounting as fresh gaps emerge between biomedical innovations and delivering them to where they are needed.
Shantanu Nundy, a primary care physician who works with low-income populations, has been listening with concern to praise being heaped on the potential benefits of antiviral pills. He anticipates the next problem will be getting pills into mouths. Nundy saw something similar play out with self-administered tests, which he began advocating in March 2020 only to see tests remain difficult to access and often expensive.
The new antiviral medication should be taken within three to five days of onset of symptoms. And it requires a prescription - an almost insurmountable barrier for the 25% of the U.S. population who don’t have a primary care physician and others who would have trouble making a prompt appointment, particularly given the wait time for many test results.
“There is an implicit assumption that biomedical innovation will infuse its way into where it’s needed. And we absolutely know that’s not true,” Nundy said.
“Have we not learned anything in the past two years?”