“Lessons for a Pandemic”

The New England Journal of Medicine has a new article, Lessons for a Pandemic, which presents itself as a high level post mortem of the US pandemic response. While it does include some pointed criticisms, as we’ll soon explain, that appears to have come despite a set-up that looked designed to gloss over problems. And readers will no doubt find it far too generous in its overall assessment, particularly of the Covid vaccines.¹

I would be particularly interested to get the perspective of those who lived in or were knowledgeable about the practices of countries that had much better results that the US, like South Korea, Australia, and New Zealand.

This article is an interview of NEJM editor-in-chief Dr. Eric Rubin and Dr. Harvey Fineberg, former dean of the Harvard School of Public Health. I already find the format dodgy. What standing does a medical journal editor have to comment on Covid responses? He’s not a public health expert nor was he otherwise on the front lines.

Worse, alert readers will recall that Rubin was the author of the NEJM editorial on the Pfizer vaccine safety and efficacy paper. IM Doc shredded that Rubin piece for abdicating the historical and important role of a medical journal editorial, of scrutinizing the material in the paper so as to discuss findings, problems, and conclusions, to instead act as Pfizer tout.²

So why did Rubin have one of his writers interview him, as if he were a pandemic response expert, and Fineberg? Wouldn’t Rubin have gotten enough profile if he’d instead interviewed Fineberg?

By contrast, the article makes clear that Fineberg has the stature to opine beyond being a top public health expert. He published a paper (in the NEJM, ‘natch), on how to organize the pandemic response. It’s very likely he discussed even more detailed versions with any expert or policy-maker who would listen. It’s obvious Rochelle Walensky didn’t.

Fineberg stressed the paramount importance of having good data, and the US did a lousy job, particularly early on:

Harvey Fineberg: What happened is that we failed at the outset to do many of the things that we had to do in order to get ahead of the curve of the pandemic. We failed to organize properly a leadership array with clear guidance, a clear line of authority, clear responsibility, and a clear strategy. We absolutely failed early on diagnostic tests. We had very few diagnostic tests available, we did not mobilize the private sector to work together with government to produce the number of tests that would be required. And so we were basically flying with blinders on in the earliest months of the pandemic, unable to track accurately exactly where it was going, how quickly it was spreading, who was being affected. So that was a very serious deficiency. It became a very great challenge across the states, with lack of coordination, states competing with one another for equipment, and we had many missteps around communication with the public. So if you go down the list of things that we needed to do, frankly, on all fronts, we fell short….

Eric Rubin: Well, we’re simply flying blind. I mean, it’s not that surprising. It would apply to any other problem we were having. If we were a large company and we were trying to make business decisions without the financial data to back them up, we wouldn’t make good decisions. Health is no different from that. We need a lot of information. Now, it’s important to point out that part of the reason that some countries could do better than us is because their health systems lent themselves better to the collection of those data. So it’s not as easy to do some of the things that were done successfully in other countries here in the U.S.

Nevertheless, that doesn’t make it less important. For example, if isolation and quarantine are important to controlling a disease like Covid-19, then you need to know where the disease is. You have to diagnose it. You have to understand the communities in which it’s spreading so that you can apply some sorts of measures to help decrease that rate of transmission. Now, we’re a journal that primarily publishes randomized controlled trials. But in the setting of a health care emergency like this, it takes too long to do those trials to get some answers. And you need answers right away. And so we really rely on observations. For an epidemic like the one we’re talking about, they come from population-based data.
Does a drug work? Does an intervention that everyone’s using already work? We can’t tell that without having some sort of systematically collected data. And I want to emphasize the “systematically” part. If you’re in a country where all the health records are available and where everyone has access to these electronic health records, then there’s the opportunity to collect data on a group of patients where you know a lot about each patient.

This is a great start to the discussion, but then rather than tease these observations out further, it all goes flabby. For instance, you see, “Oh, gee, if we only had decent electronic health care records.” Well, we do, on a large enough scale to have reached conclusions, in the form of VA data. Some academics have made good use of that information and published important studies. But why wasn’t it being mined by officials in real time?

Similarly, one of the most important sources of information early on Covid progression and likely duration of immunity was the Imperial College of London’s REACT study, which took blood samples from 150,00 every month to determine infection rates and spread.³

It’s implied but not stated that the US might have had more success with its lockdowns with better information. I recall here in Alabama the top expert on infectious disease was besides himself, arguing on the eve of their lifting that we needed just another ten days to really dent transmission. Aside from the lockdowns being too leaky (poor masking and ventilation, too many venues kept open), the US again had no data on where they were working so it could determine why. We can’t say they didn’t work; they were successful in South Korea, Australia, New Zealand, and China until each of them threw in the towel. There’s also no mention of contact tracing, which did help in the early stages of the pandemic, again as demonstrated in South Korea.

There was plenty that was not said, perhaps just due to time limits. But the whole feel was unduly collegial.

For instance, even though making clear the US was stumbling about early on, the article implies the US redeemed itself with the vaccines. Huh? We have one of the worst performances in the world in per capita case counts and deaths. Why, by contrast, has comparatively poor Southeast Asia done so much better?

Similarly, there’s no admission that Covid is not over and even the comparatively mild (in death terms) Omicron is a disease of disability. They have a bully pulpit with which to criticize the cutbacks in data collection now. Why aren’t they making noise?

The vaccine cheerleading, predictably, comes at the expense of discussing non-pharmaceutical interventions.

The defeatism on getting public cooperation is also striking:

The second big takeaway is that it is very difficult to do social engineering on a large scale for a very sustained period of time.

Huh? The US is actually very good at this sort of thing, witness the inculcation of Russia hatred, and the sudden, non-organic, fairly successful proselytization for trans rights. No doubt there would be some “because freedom” resistance, but the public health community did an abjectly poor job of listening to and trying to address concerns and questions. A little bit more respect would have reduced the pushback.⁴

Finally, a bit like Anthony Blinken looking ahead to what Ukraine does after the war when there may not be much in the way of Ukraine by then, the pair discusses how the US should prepare for the next infectious disease crisis. Oddly, they fail to mention an urgent task, rebuilding nursing and doctor staffing in light of Covid-related resignations. It’s hard to fathom how they can discuss implementing ambitious and badly needed programs when the foundations are rotting.

Even worse, the praise of the vaccines has a whistling-past-the-graveyard air about it, even though they may be so well ensconced in Blue America not to recognize it. From UNICEF, in April:

The State of the World’s Children 2023: For Every Child, Vaccination reveals the perception of the importance of vaccines for children declined by more than a third in the Republic of Korea, Papua New Guinea, Ghana, Senegal and Japan after the start of the pandemic. In the new data, collected by The Vaccine Confidence Project and published today by UNICEF, China, India and Mexico were the only countries studied where the data indicates the perception of the importance of vaccines held firm or even improved. In most countries, people under 35 and women were more likely to report less confidence about vaccines for children after the start of the pandemic.

Lower vaccination rates are a public health disaster in the making. Yet that blowback is hardly a surprise given the level of vaccine injuries. IM Doc has described how his father was a public health official during the swine flu vaccine debacle, which was yanked based on a level of injuries that was puny compared to Covid. He has said, contrary to widely-touted stereotypes, that the parents in his practice now rejecting all vaccines for their children are avocado-toast health fetishists. This is consistent with the pre-existent anti-vax movement having deep roots in the wealthy parts of Northern California.

So the Covid response was not only deeply flawed, but it managed to set the US up for even worse performance down the road. But typically, there’s no willingness to admit the need for major course corrections by the people who steered this car into a ditch.

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¹ I for one find it disturbing that Novavax, a late entrant because developing more conventional vaccines is slower than using mRNA, has been marginalized despite having excellent efficacy and can be presumed to score better on safety.

² From IM Doc’s post:

In medicine, especially in top-tier journals like NEJM, landmark papers are always accompanied by an editorial. These editorials are written by a national expert who almost always has “peer-reviewed” the source material as well. This is how the reader knows that an expert in the field has looked over the source material and that it supports the conclusions in the paper. My mentor did this all the time. The binders all over his office were the actual underlying data that he scrutinized to confirm the findings….

My first lesson from him: READ THE EDITORIAL FIRST. It gets the problems in your head before you read the statistics and methods, etc. in the actual paper. It gives you the context of the study in history. It often includes a vigorous discussion of why the study is important…

So I read the editorial first. You can find it on the NEJM webpage, in the top right corner.

And, amazingly, it is basically a recitation of the same whiz-bang Pfizer puffery that we have all been reading for the past few weeks. There really is not much new. Furthermore, it is filled with words like “triumph” and “dramatic success”. Those accolades have yet to be earned. This vaccine has not yet even been released. Surely, “triumph” is a bit premature. Those words would NEVER have been used by my mentor or similar researchers in his generation. They would have been focused on the good, the bad and the ugly. A generation ago, editorial reviewers saw their job as informing the reader and making certain the clinicians that were reading knew of any limitations or problems.

³ Your humble blogger was far from alone in reading the results of every REACT survey when it was released. Why couldn’t the US organize something like this, if nothing else, through the VA? From the gov.uk site:

REACT-1 is the largest population surveillance study being undertaken in England that examines the prevalence of the virus causing COVID-19 in the general population. It uses test results and feedback from over 150,000 participants each month.

The study focuses on national, regional and local areas, as well as:

• age
• sex
• ethnicity
• socio-economic factors
• employment type
• contact with known cases
• symptoms
• other factors

The findings will provide the government with a better understanding of the virus’s transmission and the risks associated with different population subgroups throughout England. This will inform government policies to protect health and save lives.

⁴ I am assuming, perhaps charitably, that the “social engineering” remarks are about practices like lockdowns, masking, work at home. The coercion around vaccination, when they do little or nothing to reduce transmission of Delta and later variants, generated great mistrust of public health officials in some communities.