The world has almost approached the one-year mark since the World Health Organization declared COVID-19 a pandemic. In what seems to have been both the longest and shortest year in recent memory, 2020 in the United States was marked not only by lockdowns, hospital capacity emergencies, spikes in case counts, emerging viral variants and high-profile patients, but also historic vaccine development and approval, remarkable resilience, heartwarming stories and creative re-workings of traditions ranging from Inauguration to the Super Bowl.
While declining cases and increasing vaccinations both provide glimmers of hope for a much more promising 2021, work remains to be done.
Much like the challenges that plagued the United States last year, many of the problems we are facing in 2021 will require us to find synergy between systems and perspectives that often clash — including between the public and private sectors, the individual and the greater population, and federal and state governments. Understanding these three sets of dynamics will ensure a better approach toward accelerating pandemic mitigation and recovery.
The Public and the Private
The collaborative dynamic between the public and private sectors over science has been notable in the United States since Vannevar Bush’s The Endless Frontier report in the era of the atomic bomb. This pandemic has been no different. For example, although most of the fundamental research behind the various COVID-19 vaccines has been funded by the public sector over the past few decades, the BioNTech/Pfizer vaccine — unlike funding networks for many other COVID-19 vaccine, therapeutics, and testing programs — was developed without any federal monetary support, before the eventual federal purchase of these assets.
The major biology-related funding arms of the federal government are the National Institutes of Health and Biomedical Advanced Research and Development Authority, both under the Department of Health and Human Services. While both have played a pivotal role in funding biological products for pandemic response, the private sector has made their own share of contributions. These include the altruism of Ginkgo Bioworks’ Concentric testing program for schools and businesses and doctors’ coordinated campaigns to combat vaccine hesitancy, but also the dubious and inequitable self-interest of private individuals such as notable investor Chamath Palihapitiya, who purchased testing machines in order to play poker.
One concern is that these private sector solutions, albeit gap-filling, still lack the ability to make impacts on the scale of potential of the public sector. For instance, emerging viral variants of SARS-CoV-2 (the virus that causes COVID-19) have exposed weaknesses in our national infectious disease genomic surveillance infrastructure. Much of the key work for the United States has been driven by private academia to fill the information void, as opposed to a robust public information program like that of the United Kingdom’s National Health Service.
While private-public partnerships are crucial for managing crises, COVID-19 has raised an important question: Should the government — whether state or federal — have a larger role in tackling such problems that are so fundamentally intertwined with the safety, health, and security of the public? Our national response to COVID-19 may have been hindered thus far primarily by incompetent leadership in government, but the disjointed workflow of responsibility and impact needs to shift more towards the public sector to install more robust, coordinated health and science policy for both domestic and international wellbeing. This can also enable proactive work in these domains, whether for infectious disease surveillance (a virus “weather system”) or pre-development of vaccines and therapeutics. The Centers for Disease Control and Prevention, in recognition of theis deficiency of disease surveillance infrastructure, recently announced a $200 million “down payment” to more effectively track viral variants through a more robust, public operation.
Reconsidering Federalism
Another important consideration for past and future pandemic management strikes at the heart of our nation’s system of governance: federalism. The balance between state and federal power presents both strengths and weaknesses; greater distribution of responsibility and jurisdiction allows for more flexibility and efficiency, while it also runs the risk of seriously curtailing initiatives because of a lack of a strong, standardized framework.
This trade-off has been most notable over the course of vaccine distribution — an area with which the United States has performed poorly. In December, the CDC issued its recommendations for vaccination prioritization, primarily giving preference to healthcare personnel and nursing home residents, followed by the elderly and non-healthcare essential workers. However, it has then been up to each state to implement their vaccination programs as they see fit. Inadequate systems have led to divergence over different allocation frameworks and the question of how strictly to enforce prioritization versus using extra doses that might otherwise be discarded. Many states have failed to vaccinate people fast enough with many unused doses available, while other states have run out of doses. President Joe Biden’s administration recently announced an increase in the number of doses being sent to states and plans to allocate $160 billion toward a nationwide vaccine program.
Another notable difference among states is the prioritization of teachers for vaccination. This clash has occurred not between political parties, but rather between the federal and state governments. In concordance with demonstrated efficacy of non-pharmaceutical interventions such as masks and social distancing, CDC director Dr. Rochelle Walensky has stated that vaccinated teachers are not a prerequisite for schools reopening for in-person learning, and part of Biden’s American Rescue Plan is to return to in-person classes for most kindergarten through eighth grade schools. Meanwhile, in keeping with conversations with teachers’ unions, the Biden administration has prioritized teachers for vaccination. This, however, is clearly not the case at the individual state level and has been more of an ideal vision than a reality. In addition, while there is little evidence of student-to-teacher transmission in primary education, there is comparatively less research and certainty on this phenomenon for secondary schools, underscoring the importance of increased coordination and better implementation of plans to vaccinate teachers and re-open schools.
Governor Gavin Newsom has particularly come under fire for lagging vaccination rates in California, as data difficulties have plagued the state’s effort to immunize as many people as possible. In tandem, vaccination criteria have been expanding beyond healthcare and other essential frontline workers, even as the state is grappling with a shortage in vaccine supply. This has an important equity component, especially as many frontline agricultural workers in California are Latinx and have been disproportionately impacted by COVID-19. These problems are not unique to California, and they beg the question: Amidst the backdrop of the dynamics of federalism, how do we reach the individual?
Beyond Individualized Solutions for a Population Problem
A pandemic is a population-wide problem that requires a public health-based approach to manage it. However, the disease behind a pandemic still afflicts individuals, each of whom requires clinical care. Unfortunately, these two sets of differing scales — population and individual, public health and clinical — are sometimes at odds if evaluated as an either-or situation. One of the biggest shortcomings of the United States’ pandemic response has been this inability to wield multiple tools to target the various dimensions of each problem posed by COVID-19.
For example, vaccination is very much a population-level endeavor. However, Black and Brown communities have been some of the most afflicted by COVID-19 (in part because they tend to work in frontline jobs) and yet have the highest rates of vaccine hesitancy because of a history of necessary mistrust with the medical system. There is a difficult trade-off: How do we build the most efficient, high-level vaccination program possible and yet still tailor messaging, outreach, transportation, infrastructure and availability to ensure that individuals from these specific populations have enough trust in the system to be vaccinated? Vaccine hesitancy is a complex issue that is often rooted in different sources depending on the individual; thus, an approach to vaccination that is enabled by technology and accompanied by a personal approach for each individual through strong community and grassroots outreach is essential to reconcile these two scales as effectively as possible.
The population versus individual trade-off has also been a focal point of the discussion around testing. Biden’s American Rescue Plan has allocated $50 billion to expand testing, especially those with faster turnaround times and lower costs — what are commonly referred to as “rapid tests.” While these tests are not as sensitive as the gold-standard PCR test, they are highly effective in their intended use as a population-level public health tool that can break chains of disease transmission by identifying only infectious individuals. The answer here is not just either individual or population-focused testing; it is both.
Until we do a better job of reconciling these interests — the population versus the individual, the private versus public sector, and the federal versus state governments — management of the pandemic will remain woefully inadequate. Whether it be a lack of robust financial technology infrastructure to deliver relief checks to working families (a population-level endeavor that is still highly individual), or an effort to test or vaccinate individuals, the United States federal government needs to answer these questions of implementation now, rather than depending on private sector platforms to fill this “void” or watching divergent approaches between it and state governments lead to disarray.
Despite notable room for improvement, our national response to COVID-19 is progressing in the right direction. As vaccination continues, schools reopen, testing expands and weather warms, the world is surely but slowly re-orienting itself towards a “new” new normal. The open question? The degree of our complacency: whether or not we do enough to ensure that such a global catastrophe never happens again.
Image by Jakayla Toney is licensed under the Unsplashed License.
