As the U.S. moves from responding to the introduction of a new human pathogen to living with ongoing SARS-CoV-2 infections, we must accept the fact that it is no longer March 2020.
In March 2020 the new virus spread like wildfire, wreaking havoc and death in vulnerable populations, in particular the elderly. Now in March 2022, we have highly effective vaccines that prevent severe disease and death, a surveillance system that can detect increases in new reported positive tests across the country and within populations by age, sex, and heritage, inexpensive and accurate rapid tests for home use, safe, available treatments that can greatly reduce the risk of hospitalization and very high population immunity due to the combination of previous infection or vaccination.
There is no going back in time to 2020 when those interventions did not exist.
We can certainly do better in some areas and continue to make sure unvaccinated individuals at risk for severe disease due to the immunosuppressing nature of age, treatments or disease get vaccinated and probably more importantly, that the same group receives timely treatment.
In the recent “Getting to and Sustaining the Next Normal: A Roadmap for Living With COVID-19” authored by a collaborative of 53 scholars including members of President Biden’s COVID-19 Advisory Board, there was at least one glowing omission: how to assure that those who need timely treatment will get it. Unfortunately, the American Medical Association, not exactly known for its focus on equity or accessible healthcare, does not support access to treatment outside of a physician’s office. But during an epidemic, which by definition impacts public health and not solely individual health, that is exactly where treatment must exist.
We need to set up systems whereby reported SARS-CoV-2 positive test results are not only collected and analyzed for trends but result in an active process to follow-up with high-risk cases and assure timely treatment.
As a former director of a large and highly effective disease control program in San Francisco, we put in place policies to never let the sun set on a curable case of reportable disease. Public health workers were authorized to work 24/7 to assure cases were contacted and treatment was made available, even if it meant a public health worker personally delivered medication to that person’s house or chosen meeting place.
I am not certain why the authors of the Roadmap did not include the many practical local public health activities that have been used in the past and could be used in the future. Another example might be the use of grading systems to identify the indoor building air quality as we do in many cities for restaurant food safety with highly visible grades of A, B, or C.
We need to make sure that future COVID-19 and pandemic preparedness policy is informed by local public health practitioners with the necessary experience. As we used to say in the Centers for Disease Control and Prevention’s Epidemic Intelligence Service program, local public health is where the rubber meets the road.
Rebuilding our national, state and local public health infrastructure will take time and substantial investment. The CDC was founded in the immediate post-World War II era in 1946 primarily as a domestic malaria control program. Within five years in 1951, as a response to the emerging Cold War, it added the Epidemic Intelligence Service to train young physicians in epidemiology and the practice of public health, preparing the country for potential bioterrorism events.
More than 75 years later, its scope and mission have changed, but unfortunately, not much of its authority or ability to serve as a responsive public health agency has. While well-known for its careful investigations, identification of public health hazards and evaluations of public health responses, it was never capacitated to respond in real-time to a large public health crisis like COVID-19. While one cannot hold the agency accountable for activities it was never supposed to do, we must recognize and accept its failure and move on.
To move forward, we might need to raze the CDC and rebuild an agency for health security, one empowered with information access, a leader with demonstrated experience and success in the practice of public health, trained professionals in communication and decision science and with the necessary authority to implement interventions at the state and local level.
Jeffrey Klausner, MD, MPH, is a clinical professor of Medicine, Population and Public Health Sciences at the Keck School of Medicine of the University of Southern California and a former CDC medical officer. Twitter: @DrKlausner.