With all that we have learned from COVID-19, are we better prepared for the next pandemic? One would hope the answer is a resounding “Yes.”
Sadly, this may not be the case. Given the ongoing widespread circulation of H5N1 influenza, population growth and migration, climate change and the ability of pathogens to disseminate widely and quickly with modern travel, the next pandemic of consequence may occur sooner than you might think and hope.1 We know one is coming but do not know when.
We learned so much from the COVID-19 pandemic. From investment in cutting-edge science, we learned that we could develop, mass produce and distribute highly effective vaccines against a novel virus in record-breaking time and develop effective antiviral medications. We advanced the science of disease transmission and learned that the long-held dichotomy of airborne vs. droplet transmission of respiratory pathogens was overly simplistic and inaccurate. We learned that masks could reduce transmission of multiple respiratory viruses. We advanced the science on the critical role of the physical plant, including ventilation systems, in reducing disease transmission. We improved systems to ensure supply chains, refined processes to move patients to where care is available and improved our ability to manage unexpected surges of patients.
We made major strides in using video and other electronic technologies for remote learning, patient care and work. We saw that disparities in health outcomes are magnified by pandemic conditions and refocused efforts to reduce such disparities. We learned about the critical importance of effective communication, as much from the failures as from successes. We learned that strategic stockpiles are costly to maintain, procuring large number of supplies quickly may not be possible and that sustaining domestic production capacity is challenging. As a result of long-standing underinvestment in our public health infrastructure, we learned the hard lesson that having a robust public health system is essential.
So with all that we have learned, why are we not better prepared?
In the best of circumstances, communication of public health recommendations in a pandemic setting is challenging. Recommendations are based on incomplete knowledge and are subject to change as the pandemic evolves and as more is learned. A message that should have been repeated over and over throughout the pandemic was to expect recommendations to change – and that these changes do not imply that the previous ones were not appropriate for the time, even if they subsequently prove to be incorrect.
For this message to succeed, there must be trust in public health officials. The nefarious disinformation campaigns during the pandemic did tremendous harm, contributing to the erosion of trust in public health and other leaders.
While there were missteps in our pandemic response, many of us underestimated the extent to which people were willing to undermine public health institutions and leaders, inflict harm by promoting dubious treatments and sow mistrust for financial or political gain. This loss of trust will be hard to overcome.
Hopefully, the next pandemic will be sufficiently far in the future for this era of mistrust to be a footnote. However, real consequences, such as increased vaccine hesitancy and politization of masking, may have a lingering impact.
In the future there should be open dialog between public health organizations, scientists/academic medicine, politicians and the public. Guidelines based on preliminary evidence should not be viewed as holy gospel; expectations should be set that recommendations will change and the rationale for change should for clear. Transparency in all operations will help regain and maintain public trust.
In 2018, the Centers for Disease Control and Prevention and the Rollins School of Public Health held a symposium on the centenary of the influenza pandemic of 1918. During that symposium, we participated in a panel discussing the response of Atlanta-area hospitals to the 2017-18 seasonal influenza, the worst non-pandemic flu season in decades. We noted that hospitals were mostly full, often on diversion and were facing significant staffing shortages prior to that flu season and that the severe flu season further compromised patient care and patient flow.
The challenges we noted in 2018 were dwarfed by the COVID-19 pandemic. In the aftermath of COVID-19, financial stress has precipitated more hospital closures, and persistent severe staffing shortages have forced hospitals to develop alternative care models to compensate for physician, nursing and other healthcare worker shortages. In addition, there has been significant turnover of staff along with the loss of their expertise. From a financial and manpower perspective, our healthcare systems are less resilient now than they were prior to the pandemic. In addition to hospital closures, many hospitals have closed unprofitable service lines, even those that are essential for patient care such as emergency rooms. Hospitals in central Atlanta are still suffering under the strain of the closure of Atlanta Medical Center.
Implementation of solutions to many of the lessons we learned will require money that health systems do not have. Construction of flexible spaces and better ventilation systems, for example, are costly for new construction and likely prohibitively expensive for retrofitting existing spaces.2 Given the current financial pressure facing many health systems, it is unlikely that financially strapped hospital systems will incorporate costly design features including having excess bed capacity whose benefit is primarily for an event that may not occur for decades.
As healthcare systems do not have the resources nor incentives to properly prepare for a pandemic and state-specific ownership would lead to a fragmented response, there needs to be a strong federal role in our pandemic response. This federal role includes overall leadership and coordination of the pandemic response, improved surveillance systems and improved partnership with industry in areas where governmental capacity is limited, such as scaling up diagnostic testing and therapeutics.
While the need for partnering with industry was evident with the slow roll-out of diagnostic testing, the public-private coordination worked exceedingly well for the development of novel COVID-19 vaccines, boosted by over $17 billion in federal funding for vaccine research and development.3 When hospitals were overrun during the COVID-19 pandemic and had to defer elective procedures whose margins are necessary for financial viability, the federal government provided $175 billion in subsidies to hospitals primarily through the Provider Relief Fund.4
Learning from the implementation of these and other programs, our hospitals, particularly safety-net hospitals, will need secure finances to assist them during the next pandemic and to ensure their fiscal health afterwards. Also important is replenishment of key stockpiles and maintenance of supplies, such as N95 masks, that will likely be in high demand during a pandemic.
So while we are not currently prepared for the next pandemic, we have the potential to be in a much improved position if we act on the lessons learned from the COVID-19 pandemic. Although every healthcare system needs a preparedness plan, it is not realistic to expect robust investments at the hospital or healthcare system level. There is an ongoing national debate on the overall role of the federal government, but pandemic preparation is one area where broad and thoughtful federal leadership and federal financial backing is essential.
References
1. Baker, RE et al. Infectious disease in an era of global change. Nat. Rev. Microiol. 20:193-200, 2022
2. https://www.hfmmagazine.com/articles/4429-building-hospitals-in-the-pandemic-era
3. Williams, BA, et all. Outlook of pandemic preparedness in a post-COVID-19 world NPJ Vacines. Nov 20;8:178, 2023
