We are definitely in a new era now. If you need evidence of that, just look at CDC's most recent listserv message:
For the future, look to the CDC's revised covid data tracking site:
What's mainly missing are the covid community levels. Combined with the knowledge that all jurisdictions have stepped down their level of disease monitoring resulting in significantly fewer data points means we aren't anywhere near the level of infection tracking we had previously, though even that varied with jurisdiction. Wastewater monitoring is likely to be the most reliable early warning of a resurgence in the US, but note that this monitoring is done on a voluntary basis, covering about 40% of the US population but very skewed geographically. Here's the latest CDC wastewater map looking at variant analysis:
Increasingly I will be turning to the World Health Organization to look at what's going on elsewhere. Current "hot spots" include the SE Asia and Western Pacific regions.
I was also reminded of changes more locally for me. My phone told me this week that I would no longer receive notifications from Virginia's COVIDWISE app to tell me if I had been exposed to anyone with covid. Since I never received any notifications anyway, I wonder how effective it was. I probably set it up incorrectly.
My Book Report - Preliminary Thoughts
As promised last week, I've been working on my first book report since elementary school. However, when I took a break to actually find out what a book report is, I'd say what I've done is more like a book review. The book is Lessons from the Covid War,: An Investigative Report, ISBN-10 1541703804, authored by "The Covid Crisis Group" but principally written by University of Virginia history professor Philip Zelikow. I picked up my copy on April 27 and took my time reading it. I wanted both to see what they had to say but also to determine potential sources of bias in the report. The Crisis Group compiled the report given that there is still no federal commission planned to officially dissect the pandemic response. I purposely haven't read other reviews of the book, though I recall from one TV news report that the reviewer felt they were too soft on criticizing the Trump administration.
First, let's drill down on the potential sources of bias, particularly important with a highly charged political topic. Dr. Zelikow certainly is well qualified for the project having served as executive director of the federal 9/11 Commission. He has held several jobs in both Democratic and Republican administrations. The other 33 members of the crisis group include some involved in politics (again from both sides of the aisle) as well as physicians, scientists, and public health specialists. Notably missing from the group was anyone heading the response from either the Trump or Biden administrations, perhaps a good thing though leaving a gap in verifying circumstances or allowing rebuttal. The report itself has a thorough listing of individual and organizational sources of interviews and other materials, as well as 25 pages of fine-print notes for specific statements in the text.
Another potential source of bias is funding source. Four foundations sponsored the group: Schmidt Futures, the Rockefeller Foundation, the Skoll Foundation, and Stand Together. After reviewing their web sites and other commentaries, my best guess is that 3 are slightly left-leaning and 1 is tilted more towards the conservative side. All have excellent records of interest and accomplishments in various international efforts including disaster evaluation and relief. The foundations contributed equal funds and had no role in drafting or writing the report.
So, my final gestalt is that this is about as non-biased a report as can be expected for the topic. I think the only people who could conceivably have major concerns with it would be those who do not accept the scientific method or specific source documentation.
The report itself is well-written, with explanations making it accessible to those without a scientific or medical background. I was a little put-off by the near constant comparisons to war and military strategies, although the comparison of Operation Warp Speed for vaccine development to the 1940s Manhattan Project to develop the atomic bomb was convincing.
The Meat of the Report
Here are some of the points I thought were helpful.
Clearly the Group felt that we were doomed in our response from the start by the state of our public health system in the US, little changed from the late 19th century in their opinion. They describe 3 main cultures in governance: program and process, research and investigation, and operations. We were lacking in all 3 prior to the pandemic, resulting in much higher loss of life and interruption of daily activities than would have occurred if we had invested in this infrastructure previously. They allude to investing billions to save trillions, and this principle still holds.
I learned that the "Communicable Disease Center," precursor of the CDC, wasn't established until 1946. Atlanta supposedly was chosen as the site because more malaria was present in the South, though this tidbit didn't have a footnote so I'm not sure if that is accurate. The Group clearly feels that the decentralization of public health (we have 2800 local public health departments varying widely in expertise, technology access, and operational guidance) needs overhaul in order to have an effective response to wide-scale emergencies. Essentially, we do not have a national public health service, "all operational responsibility [is] at the state, local, territorial, and tribal levels." (page 71).
I somehow missed or didn't remember that the White House Council of Economic Advisors issued a report in September 2019 estimating that a pandemic would cost trillions and kill more than 500,000 people in the US. It was based more on influenza and sadly turned out to be an underestimate. I was also unaware of Crimson Contagion, a pandemic exercise conducted in early 2019 that identified many coordination problems in responding to an influenza-like pandemic. The death toll in the exercise was in the hundreds of thousands.
Regardless of our preparedness prior to the pandemic, it is clear that our responses once it started contributed to greater hardship and loss of life. Early in 2020, so many mistakes were made it would almost be comic without the tragic results. Virtually everyone in the US failed to realize key differences between an influenza pandemic and covid (or coronaviruses in general). These include the presence of asymptomatic infection with effective human transmission from those individuals, the nature of aerosol spread and use of mask, social distancing, etc., the ability of the virus to rapidly produce variants resulting in multiple disease waves, poor development and deployment of resources and distribution systems, and, critically, effective communications.
Operation Warp Speed is one of the few successes of the US response. Prior to reading this report, I had credited the government of China with posting the genomic sequence of the virus early in January, 2020, but I learned that the sequence was posted by a Chinese scientist without government permission. This sequence was a necessary precursor for covid vaccine and test research. Thankfully, investment in basic research in coronaviruses and mRNA technology allowed for a rapid response to produce effective vaccines in record time. Still, we failed miserably in vaccine distribution and communications about benefits and risks to the general public.
Needless to say, it is the communication issues where the Trump administration, the president in particular, derailed effective vaccine uptake early on and continues to contribute to the anti-vax movement and almost total covid vaccine refusal in some groups. Any chance at herd immunity was lost fairly early in the pandemic. In April and May 2020 "Trump poured acid on the strained bonds" (p. 209) trying to hold together all the different parts of the US pandemic response, effectively eroding trust and confidence in public health.
The US also did not have a system to detect variants quickly. Instead, we relied on Israel, Denmark, the United Kingdom, and later South Africa to give us early warning. The Report also is critical of President Biden and his administration, especially in 2021; no one gets off cleanly.
The good guys for pandemic response globally appear to be South Korea and Germany; the Group implies we can learn a great deal from them.
It isn't until page 253 of the 288-page Report that we start to see concrete considerations for going forward. As you might expect, it takes money, authorized by Congress on a multi-year basis, to start to prepare for the next pandemic. This holds whether it be covid, another coronavirus, influenza, or something we haven't yet identified. We also need to partner globally; we've all seen how closely tied together we are with fellow world citizens, not only with pandemics but with localized outbreaks (remember Ebola?) that can spill into other parts of the world very easily. Today, the Middle East has no covid vaccine manufacturing sites. Sub-Saharan Africa has only one. Abandoning the World Health Organization and adopting the America First strategy early in the Trump Administration really hurt the pandemic response.
I counted 13 different lessons from the final chapter. (I was disappointed that the Report was almost devoid of tables and graphs, so I made my own.)
- Develop systems to govern highly risky biologic research
- Build worldwide early warning systems for early threats
- Develop systems for ongoing evidence gathering during a crisis
- Develop basic vaccine designs for each category of potential pandemic agents and create vaccine libraries with resources to manufacture and distribute vaccines at high scale
- Plan similarly for development, distribution, and use of diagnostic tests
- Ditto for therapeutics
- Advance investment and access to emergency funding
- Plan for proactive partnerships with private industry to meet public needs
- Create effective global coalitions
- Develop effective non-medical interventions to buy time early in health emergencies
- Crisis communication - need I say more?
- Develop a "coherent national health security enterprise" (p. 284)
- Perhaps not a separate point, but I think very important. The White House should not be the center of crisis management (corollary: the President is not the central guide for large operation management); we need a new structure as in #12.
I realize I've now detailed only about 1/3 of the underlinings, highlights, and margin notes I made in my copy of the Report. I won't bore you with all that. Suffice to say that I highly recommend reading this Report if you want a better understanding of the US role in the pandemic. It's certainly not the final word, but I hope Congress and high-ranking officials in the federal government pay attention to it.
And, to be fair, it's not like the feds are doing nothing. As I mentioned last week, CDC has a planned overhaul, though maybe at risk with a change in leadership. HHS just announced a new plan. FDA is trying to evolve based on pandemic lessons learned. All we need now is political consensus and funding!
Thanks for putting up with my long-winded book report/review. Now I can dig into "Maigret in Retirement."