On the afternoon of New Year’s Eve, just hours from when 2019 was going to segue into 2020, I read an email about some unusual pneumonia cases in China’s Hubei province. Over the past couple of decades, China has been a wellspring of dangerous zoonotic diseases — SARS, H5N1 bird flu, and H7N9 bird flu. Better keep an eye on this, I thought to myself.
Fast-forward two years. We’re entering the third year of the Covid-19 pandemic. So much has happened in the intervening months. Some things have gone surprisingly well, notably the rapid development of Covid vaccines and some therapeutics. But far more things have gone horribly wrong.
Multiple commissions and panels have been set up to learn the lessons of this pandemic so that we don’t repeat the same mistakes next time. (Yes, sadly, there will be a next time.) More commissions and panels are likely to follow. But already, some things have become abundantly clear.
Here are 10 lessons I’ve learned in the past two years.
You gotta act fast
For reasons I may never understand, in January and February of 2020 much of the world seemed not to grasp that the new virus that was spreading so rapidly in China wouldn’t stay in China.
Some experts I spoke to early on thought that the new coronavirus would be controlled because two others in that family — the SARS virus from 2003 and MERS, a camel virus that sometimes spreads to people — didn’t manage to ignite pandemics. But by late January, early February the virus had been found in a number of other countries. If the world ever truly had a chance to contain it, the moment had passed.
The guiding principle of outbreak response is hope for the best but prepare for the worst. It has felt too often in this pandemic that people are forgetting about the second part of that maxim. We’re seeing it even now with responses to the surging wave of Omicron cases.
It is true that public health authorities can get hammered if they sound the alarm for something that turns out not to merit it. The World Health Organization was pilloried by the European Parliament after the 2009 H1N1 flu pandemic ultimately proved not to be particularly deadly.
But with fast-developing disease outbreaks, if you wait until you’re sure that something is going to be a disaster before seizing every opportunity to alter its trajectory, you’ve made the outbreak much, much worse.
In the summer and early autumn of 2020, when Phase 3 clinical trials of Covid vaccines were still underway, two groups in the United States set out to determine who should have first access when vaccine doses became available.
The National Academies of Science, Engineering and Medicine established an expert panel that created a priority list. The Advisory Committee on Immunization Practices, an independent group that advises the Centers for Disease Control and Prevention on vaccine policy, devised its own.
Both groups prioritized health care workers and the elderly, who were at the highest risk of dying if they contracted the new virus. The schemes were not identical, but both emphasized that people with serious health conditions and essential workers — people whose lives were at risk because they were doing jobs that kept society functioning — should have early access to vaccine doses.
But who were essential workers? Does everyone who works in a hospital qualify as a health care worker? Could we realistically expect people administering the jabs to check whether the person before them actually had diabetes? Or that they taught elementary school, not spin classes? (In a word: No.)
Though well-intentioned, the schemes were too complex to operationalize. A number of states junked them in favor of calling people forward by age strata, after they’d vaccinated health care workers.
The same problem arose with the rollout of Covid boosters this fall, which happened in a stepwise fashion where eligibility was linked to age, health status, and the level of individual risk, because of where people lived or worked. Eventually Nirav Shah, president of the Association of State and Territorial Health Officials, pleaded with ACIP to simplify the system, saying it was hampering booster shot uptake because people couldn’t figure out whether they were eligible.
The calculus for kids is just different
One of the few blessings of this pandemic is that Covid-19 isn’t nearly as hard on children as it is on adults, at least not in terms of illness and deaths. (It has been terrible for children in myriad other ways, particularly the disruption of in-person schooling and the educational and social consequences of that.)
To date, there have only been 790 Covid deaths in children 18 years old and younger in the U.S., data from the Centers for Disease Control and Prevention suggest. Children and teens make up only 0.1% of the more than 800,000 deaths the country has incurred.
Covid has been seen to induce a post-infection condition in some children called MIS-C — short for multisystem inflammatory syndrome in children. According to the CDC, there have been nearly 6,000 reported cases in the U.S. Most children who develop MIS-C recover, but there have been 52 deaths.
In the main, though, children experience milder disease when they catch Covid. And because of their far lower risk of death, the WHO has suggested children should be vaccinated later, after health workers and older adults the world over have been protected.
Logically, the WHO is correct. Prioritizing vaccine doses for older adults would save more lives. But the agency’s pleas have fallen on deaf ears.
Societies may accept large numbers of deaths in the elderly, but even small numbers of deaths in children are deemed to be too many. There was never a meaningful debate in this country about the ethics of vaccinating American kids before vaccinating African health workers. There were no public proponents arguing for putting kids here behind adults elsewhere.
Even in the face of a deadly pandemic, politics override public health
Call me naive, but it never occurred to me before this pandemic that political leaders would put the lives of their citizens at risk by downplaying or downright lying about a disease outbreak, just because telling the truth might jeopardize their political fortunes.
It never dawned on me that political leaders would oppose policies designed to save the lives of their citizenry and mitigate the personal and economic damage an outbreak was causing — things like rules about wearing masks or getting vaccinated.
If that thought had occurred to me, I would have assumed such leaders would have been punished by their followers when it became clear a path taken for political expediency was costing tens of thousands of lives. I wouldn’t have dreamed that instead, those same followers would embrace the bad advice and reject public health guidance.
I didn’t anticipate the havoc polarized politics would wreak on a pandemic response. I thought everyone would have the same goal: Keep as many people from dying as possible.
But so much of the U.S. response has broken down along political lines. Uptake of vaccine is higher in blue counties than it is in red. Mask mandate opposition is higher in parts of the country that vote Republican.
The virus doesn’t vote and it doesn’t care how we do. It’s only looking for respiratory tracts to infect. I assumed we’d all understand that.
Most people have no clue how science works. And that’s a problem
Science education in this and a number of countries is woefully inadequate. As a result, people do not understand the iterative nature of science.
With a brand new pathogen, it takes time to figure out things like how infectious it is or the means by which it best spreads. When vaccines are developed and first put into use, it takes time to see how well they’ll work and for how long they’ll protect. Some vaccines protect for years, others only months. (I’m thinking about flu vaccine here.) The only way to determine where Covid vaccines fall on the spectrum is to give them and watch for breakthrough infections to start to occur. There’s no way around this, but people have found it frustrating.
We saw the lack of understanding of how science works in calls from some quarters to use prototype vaccines before they’d even been tested for safety and efficacy. (The risks would have been huge, and such a move would have been ethically indefensible.) We saw it repeatedly when new knowledge was acquired and WHO or CDC guidance was updated accordingly. Instead of recognizing changes as a reflection that more had been learned about the virus, many people seemed to feel they’d been deliberately misled by the earlier advice. At a time when there is so little trust in public figures and institutions, this lack of understanding contributed to the erosion of confidence in agencies and authorities leading the pandemic response and further undermined support for the Covid control measures they recommended.
Downplaying what lies ahead helps no one
In early 2020, country after country followed China’s lead and instituted some form of “lockdown” to try to slow spread of a virus that was rapidly overwhelming hospitals wherever it went.
When then-President Trump followed suit on March 16, he announced that if people stayed home for 15 days, that would be enough to slow the virus’ spread. Trump spoke of a return to normal by Easter, which fell on April 4.
There was no talk about the fact that the need to reduce transmission of the virus wasn’t a one-time thing — that there was nothing miraculous about a 15-day pause. If people returned to life as normal immediately thereafter, the gains of the pause would quickly evaporate.
Which is exactly what happened. People thought they’d done their bit, taken their lumps — only to find out much more sacrifice lay ahead.
Winning the vaccine race really does matter. So does experience
Pfizer and BioNTech were the first of the Western pharmaceutical companies to prove they had produced an efficacious Covid-19 vaccine. The Food and Drug Administration granted it an emergency use authorization on Dec. 11, 2020 — 11 months after the genetic code for the SARS-2 virus was shared with the world.
Hot on their heels was Moderna, a brash Cambridge, Mass.-based biotech, with an equally efficacious vaccine that was made the same way, using messenger RNA. The FDA granted it an EUA one week later, on Dec. 18.
No one has ever accused the leadership of Moderna of being shrinking violets. But Pfizer has been speedier and, well, pushier in the vaccine development race, consistently beating competitors to become the first — and in the U.S., still the only — vaccine that is fully licensed.
The Pfizer vaccine is the only vaccine in this country that can be used in teens under the age of 18. It is the first to be authorized for use in children; it is now available for kids aged 5 and up. It was the first to be granted an EUA for a booster shot. It’s currently the only vaccine recommended as a booster for people who were vaccinated outside the U.S. with a vaccine not authorized for use here (in other words, a vaccine like the AstraZeneca jab) or for people who took part in U.S. trials of vaccines that haven’t been authorized here (AstraZeneca, Novavax).
By dint of its many firsts and its eye-popping initial vaccine efficacy, Pfizer has created the perception that it is the premier Covid vaccine, even though Moderna’s vaccine, which uses three times the antigen contained in the Pfizer’s shot, may in the end be the better vaccine.
But Pfizer’s success is not just about being first. The company has a deep well of experience in commercial-scale production and in navigating regulatory processes — something Moderna, which had never commercialized a product before, did not. The differences in regulatory experience may explain why Pfizer was awarded a full license for its vaccine 3.5 months after initiating its application for one. Moderna, on the other hand, took 2.8 months just to complete its application for a full license; four months later, it is still waiting for the license.
Being first on its own might not have positioned Pfizer to be the dominant vaccine provider of the pandemic; by all practical measures, Moderna tied with the Pfizer vaccine getting across the initial finish line. And the vaccines were virtually identical in efficacy outcomes — 95% (Pfizer) and 94% (Moderna) against symptomatic Covid infections. But being first and having the know-how to turn a good prototype into massive amounts of vaccine while at the same time successfully navigating regulatory processes has been a winning combination for the Pfizer-BioNTech partnership.
In a pandemic, it’s pretty much every country for itself
I hate that this is true. But I fear that it is.
The world has suffered from the fact that we are not working together to try to end the pandemic. Rich countries buying up most of the available vaccines, pharmaceutical companies refusing to share vaccine formulas and production know-how, countries blocking exports of oxygen and personal protective equipment — all this has drawn out the pandemic and made it more difficult to endure.
It’s no surprise that vaccine nationalism has reigned, or that borders have closed, often on scientifically indefensible grounds. (See: The Biden administration’s month-long ban on travel from eight southern African countries, even though the Omicron variant is already the dominant virus in this country.) Next time, it will be worse. Borders will close more quickly, keeping people out and critical matériel in, because countries will know what lies ahead.
It’s ugly and it’s counterproductive but it may be inevitable. I would like to be wrong on this.
Conducting clinical trials during a pandemic is doable, but it takes coordination
It is enormously challenging to plan and conduct clinical trials during a disease crisis — especially trials large enough to come to a solid conclusion about whether the drug or vaccine being tested actually works. Time and again, trials conducted during previous outbreaks were too small, were conducted without a control arm (i.e. the thing being tested wasn’t compared to a placebo), or were still struggling to reach an answer when the outbreak ended.
This time has been different. Sort of.
In a true story fit for the big screen, Sir Jeremy Farrar, director of the Wellcome Trust, and British scientist Martin Landray mapped out a plan for what has proven to be an enormously successful trial of Covid treatments while riding a London bus.
The Recovery trial, as it came to be called, told the world the steroid dexamethasone improved survival in people seriously ill with Covid. It proved two HIV drugs, lopinavir and ritonavir, didn’t change Covid outcomes. It also showed that hydroxychloroquine, an antimalarial drug, was ineffective against the new virus.
Recovery harnessed the power of the United Kingdom’s single-payer health care delivery system, the NHS, to enroll sufficient numbers of Covid patients in the early days of the pandemic to come up with much needed answers rapidly. In a separate endeavor, the WHO’s Solidarity trial arrived at some needed answers by drawing in data from around the world.
In the U.S., Operation Warp Speed helped design and run some clinical trials that quickly tested the efficacy of Covid vaccines it helped to fund.
But when it came to testing existing drugs to see if they could be repurposed for Covid, much of the U.S. effort was a bust. Scores and scores to too-small studies came to inconclusive results. Lack of coordination meant that trials continued to study whether hydroxychloroquine acted against Covid even after there was a wealth of evidence that it did not.
Americans are willing to put up with a lot of death
The official Covid death toll in the United States is nearing 820,000, a figure that is certainly an underestimate, though by how much remains unclear.
A truly stunning fact about those deaths is that more of them occurred in 2021 than in 2020. Covid vaccine doses were in short supply in the first quarter of 2021, but soon thereafter anyone who wanted to be vaccinated could get jabbed. And this fall, anyone 16 years and older who wanted to get boosted could get a third shot.
And still, more people died from Covid in 2021 than died from Covid in 2020. In 2021, swaths of the country fought mask mandates, opposed vaccination mandates, objected to any measure designed to slow the spread of Covid that they perceived as an impediment on their ability to resume pre-pandemic activities.
This insistence on returning to life as normal came at an unfathomable cost — the loss of hundreds of thousands of parents, grandparents, great-grandparents. Aunts and great-aunts, uncles, and great uncles. Cousins. Friends. Coworkers and supervisors. And still, big chunks of the population refused to get vaccinated, refused to wear masks, insisted SARS-2 was a hoax, or was no more threatening than the flu.
“It almost is inexplicable,” Anthony Fauci, director of the National Institutes of Allergy and Infectious Diseases, told me when I asked him about this last month.
For me, it is incomprehensible.
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