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Tuesday, March 28, 2023

What did we learn from COVID?

Pandemic Center analyzes the lessons of COVID-19

Brown University

In March 2020, the SARS-CoV-2 virus took the nation by storm. The COVID-19 pandemic blindsided leaders and forced hasty decisions that came with long-term repercussions for the health and well-being of Americans, and local, national and global economies.

In 2022, the Brown University School of Public Health launched its Pandemic Center with the goal of reducing the chance for repeat mistakes. There’s no doubt that future public health emergencies will arise, said founding director Jennifer Nuzzo, and the country urgently needs to be better prepared.

“The reality is that we have seen over time an increasing number of new infectious disease threats,” said Nuzzo, an epidemiologist who focuses on global health security, public health preparedness and response, and health systems resilience. 

“That has to do with several factors, including how we've changed our relationship with the environment and how we, as humans, have changed behaviorally. In the future, we could see events that have an even greater potential to negatively impact society than COVID-19.”

At the outset of the pandemic, she said, the nation launched into crisis mode, and leaders made decisions quickly with the best information they had at the time. But the next emergency should come as less of a surprise: “Three years later, we should absolutely be asking what worked and what didn’t, so that next time we can do better.”

Scholars at the Pandemic Center are working not only to ensure the world more fully understands catastrophic threats like viral pandemics, but also to develop tools, policies and practices to mitigate and prevent their harmful impacts. Brown’s commitment to collaboration across disparate fields of study makes it an ideal place to carry out that work, Nuzzo said.

Working with partners toward the center’s mission extends well beyond campus. too. As just one example, the Pandemic Center is collaborating with the COVID Collaborative and the Center for Strategic and International Studies Global Health Policy Center to convene a bipartisan effort focused on unearthing state and community lessons from the pandemic. Beth Cameron, senior advisor to the Pandemic Center and a Brown professor of the practice, is leading that effort for the School of Public Health.

Most recently, that team organized a roundtable of nearly 40 leaders: governors and mayors; officials from red, blue and purple states and from the Biden, Trump, Obama and Bush administrations; and experts in incident management and pandemic inequity. The group produced a report that discusses failures, highlights community successes and, Nuzzo said, points to a path forward.

With the three-year anniversary of COVID’s major impact in the U.S. having arrived this month, Nuzzo and Cameron shared three key takeaways from pandemic, and described how the Pandemic Center will use them to inform realistic strategies for future response.

Lesson 1: A successful public health response does far more than limit the number of disease cases

The impacts of the pandemic have been profoundly far-reaching: it cost the world millions of lives and trillions of dollars, and caused major societal deficits in learning, health and well-being.

“Case numbers didn't represent the totality of how the virus was affecting us,” Nuzzo said.

She pointed out that beyond the individuals directly infected by the virus, the COVID-19 pandemic harmed health and society in multiple ways — for example, by setting back a generation in terms of learning, worsening a national mental health crisis, causing people to forgo necessary medical treatment, and damaging the well-being of workers unable to make a living.

Unintended harmful effects of laser-focused COVID mitigation strategies can erode public support for public health, Nuzzo said, citing stories from people who were prevented by lockdowns from getting medical care or tending to a dying loved one.

“Emergencies touch all aspects of not just public health, but of society,” Nuzzo said. “So we need plans that have a broad scope.”

Nuzzo said that expanding the definition of a public health response means integrating the effects of pandemics on education, the economy and society overall; broadening and updating the concept of how public health operates to protect Americans; and creating stable, consistent mechanisms that are capable of bridging sectors and parties during biomedical crises.

Data is essential to creating those kinds of complex, multi-layered approaches, she added: “We need better, faster data to inform better, faster decision-making.”

In a pandemic, useful data goes beyond case counts, Nuzzo explained — it identifies gradations of risk. She cited masks as an example: Part of the reason there is such an intense and heated debate over mask mandates, she said, is that there aren’t enough good studies that help communities understand how to use masks and masking policies to reduce infections.

Scholars at the Pandemic Center are working not only to ensure the world more fully understands catastrophic threats like viral pandemics, but also to develop tools, policies and practices to mitigate and prevent their harmful impacts. (Photo: David DelPoio)

“My husband works for NASA, so I've gotten to see what it means when a government agency has well-exercised playbooks and implementation plans,” Nuzzo said. “We don't send a rocket to space without having data to understand if that rocket is on course. Unfortunately, in the case of the pandemic, the country didn’t collect the data that was needed in order to understand if our response was having the right impact, or if there were ways the response could be improved.”

That’s where places like the Pandemic Center can play a role, Nuzzo said. A major goal of the center is for its scholars to generate, synthesize and translate evidence. 

To that end, its leaders are currently building and integrating better global, national and local data systems for detecting and responding to pandemic threats and mitigating their impacts. 

A new satellite office in Washington, D.C., will soon open, enabling close partnership with the Brown in Washington program, where students will have opportunities to complete internships, and where Brown researchers will have more direct access to policymakers.

“Our goal is to do actionable research at the Pandemic Center and then ensure it gets translated to policymakers and quickly and efficiently implemented in communities,” Nuzzo said.

Lesson 2: Pandemic planning needs to reflect the political and social realities of the country as it is

Not long into the pandemic, it became clear that the zero-COVID approach adopted by China’s government would not work in the U.S. Instead of expecting the country to change so drastically, Nuzzo said, an effective response needs to engage people in defining the response strategy, to ensure that approaches work for communities and align with their values. Crucially, she added, it’s important that future pandemic response efforts are equitable and don’t leave behind the most vulnerable.

Organizing the conversation and report — titled “American Democracy and Pandemic Security” — with the COVID Collaborative and the Global Health Policy Center is one way the Pandemic Center is trying to understand what that means and engage a diverse group of leaders in identifying new solutions. 

The conveners of the roundtable discussion said they were struck by how much agreement there was around the fact that the country doesn’t have enough tools for communities to be able to function even somewhat normally in a pandemic.

According to the report, many leaders felt that pandemic responses put Americans in a position of choosing between health or the economy, online or in-person education, locking down or lifting restrictions, and individual freedom or collective responsibility. 

These blunt, binary options created divisions within and among political parties and forced some Americans to take sides, Cameron said. The choices also weren’t adaptable for the wide range of communities in the country, from rural to urban to tribal.

“What we need are tools that allow communities to stay as safe as possible while preventing spread, so that they don’t always have to make impossible choices and can more easily open schools and businesses, scale community testing, and improve equitable access to vaccines and treatments,” Cameron said.

To that end, and to engage people in solution-planning, Pandemic Center leaders plan to work with partner organizations to host a series of discussions in communities with a wide variety of political demographics to capture experiences and local successes, and to understand when communities had to make do and what worked for them. 

The plan is to combine the feedback from those discussions with additional research to create playbooks that give communities what Nuzzo has referred to as “a menu of options” to prepare for and respond to future pandemics.

"We plan to define different measures and when they can or should be used,” Nuzzo said.

She added that lockdowns and shutdowns made many Americans equate public health with restrictions and mandates. “It’s time to get back to that point where the public is engaged in public health, and sees it as helping them do the things they care about in a safer and healthier way.”

Lesson 3: Social vulnerabilities are pandemic vulnerabilities

Early on, many experts believed that simply sharing science with the public would be enough to change human behavior. The problem, Nuzzo said, is that even when people understood the science, they weren’t always able to act upon it.

For example, while many Americans were able to avoid large groups by working remotely, others had jobs that required them to report to work in-person; they couldn’t “Zoom in” to the nursing home, the warehouse or to a restaurant shift. 

Then there were those who worked in-person and didn’t have paid sick leave, which meant that following public health recommendations and staying home after testing positive would mean forfeiting compensation. 

Nuzzo also cited the high cost of high-quality N95 and KN95 respirator masks, which meant that many people weren’t able to wear them as health experts advised.

She stressed that social vulnerabilities exacerbated the pandemic’s effects.

“We saw that social vulnerabilities like having a low income, being uninsured, and lacking a safe place to isolate were associated with a higher risk of getting sick,” Nuzzo said. 

“Vulnerable populations can’t be considered a special case; we need to recognize that these individuals should be the highest priority to attend to. Protecting our vulnerable populations is central to the goal of protecting society and keeping the public safe.”

Moving forward, Nuzzo said, equity needs to be a focus of pandemic preparedness plans, not an addendum. Future interventions need to recognize where society falls short; and sick leave policies, housing policies, childcare availability and transportation options all need to be factored into a pandemic response strategy.

Nuzzo pointed toward the Biden administration’s equity-focused COVID-19 vaccination program as a public health success story. When the administration made efforts to engage underrepresented communities in planning and organizing, vaccination rates among Black and Hispanic populations increased significantly, and as a result, the racial gap in death rates disappeared.

“That’s the kind of lesson we can learn from,” Nuzzo said.