Research, ideas, and leadership for a more secure, peaceful world
Author
Flavia Chen
As a child, I was awed by airport baggage claim. Having flown to see loved ones half a planet away, I’d wiggle in as close to the chute as possible to spot our suitcases arriving after many hours of travel. We hadn’t schlepped them through our tight transfers, and yet, voila!
Airport personnel, concurrent planning, international data standards, and below-wing services didn’t enter my imagination. Intricacies and technologies remained invisible. We take systems that work reliably for granted. I trusted that a bag dropped off at the origin would show up at the destination.
For others, baggage claim may conjure memories of that panic-stricken moment when the last item of luggage has been unloaded, and yours is still nowhere to be found. Your mind races for an alternative to showing up to your meeting in sweat pants. The system, however reliable, may go unnoticed only until the moment it fails.
The COVID-19 pandemic has highlighted our reliance on many key systems, including public health. Parts of the system, already stretched thin and underfunded before the pandemic, failed the public during COVID. If there is a silver lining, it lies in the opportunity to bring these lessons to bear when we one day build our post-pandemic public health future.
As compared with clinical medicine, which focuses on an individual patient, public health is concerned with the health of populations. Interventions that result in beneficial outcomes for wide swaths of the population are generally undervalued. The benefits of a public health intervention may not be seen until months or years in the future.
The public health system is comprised of actors and agencies at the federal, state, local, and territorial levels, along with private sector and academic partners. The Centers for Disease Control and Prevention is the flagship public health agency at the federal level. Although the legal authority to conduct public health surveillance is charged to the states, the CDC can respond to disease outbreaks with interstate implications. Data collection and reporting practices within states and territories are specific to their laws and regulations.
Attempts have been made for many years to establish and improve public health data sharing practices between the states, the CDC, and other agencies – particularly following the terrorist attacks of 9/11 in context of a heightened concern for bioterrorism. Development of electronic health records as part of the Health Information and Technology for Economic and Clinical Health (HITECH) Act also has implications for public health surveillance, however implementation is incomplete.
On February 14, 2020, nearly a month after confirming the first U.S. COVID-19 case, the CDC announced collaborations with public health labs in five cities – Los Angeles, San Francisco, Seattle, Chicago, and New York City – to modify and use “existing influenza and viral respiratory surveillance systems” for COVID-19 tracking. The existing influenza surveillance system, a collaboration between CDC, state, local, and territorial health departments, public health and clinical laboratories, vital statistics offices, healthcare providers, and emergency departments, aggregates and analyzes information, producing a weekly report. Although the CDC planned to expand the COVID-19/influenza surveillance systems to achieve national surveillance, it noted that each site “is a little bit different, so it’s not exactly the same operations”. Mobilizing for COVID-19 would undoubtedly take valuable time. Setbacks in the deployment of the CDC-developed test kits further hampered the federal response.
By early March, the White House had taken over communications, and the CDC stepped back from holding media telebriefings, leading journalists to ask whether the agency was being sidelined – an assertion CDC Director Dr. Robert Redfield dismissed. “But you’re invisible now, sir. Your agency is invisible,” STAT journalist Helen Branswell probed, in her April 4, 2020 interview. Dr. Redfield responded, “You may see it as invisible on the nightly news, but it’s sure not invisible in terms of operationalizing this response. And all you have to do to find that is go talk to your state and territorial health departments. Go out and look at the outbreaks. Go look in the field. So I guess it depends on how you define visibility.”
On March 3rd, The Atlantic journalist Alexis Madrigal published an article, “The Official Coronavirus Numbers Are Wrong, and Everybody Knows It,” noting incorrect COVID-19 case numbers, “simmering public unease,” and “the public health system stuck in neutral.”
As harmonized data from the CDC was not forthcoming, Madrigal and fellow Atlantic journalist Robinson Meyer launched The COVID Tracking Project. The project was only meant to be a stopgap for “maybe a week – until the federal data emerged.” It instead assumed an essential public role – part data journalism, part science communication, explaining the uncertainties and nuances in the data presented.
Omissions of data were also noted. In late March, Senator Elizabeth Warren and Representative Ayanna Pressley wrote to Health and Human Services Secretary Alex Azar calling for reported COVID-19 testing data to include data on individuals’ race/ethnicity, noting that its absence would “exacerbate existing health disparities and result in loss of lives in vulnerable communities”. As more comprehensive data emerged, Ibram X. Kendi’s worry that, “the virus is disproportionately infecting and killing people of color right now – and we don’t even know,” was borne out.
Public health experts Joshua Sharfstein and Georges Benjamin minced no words, calling the U.S. experience with COVID, “a master class in the impotence of leadership from the top during a crisis, demonstrated by its absence.” When official processes fail others rise to fill the gap. The contributions of groups like The COVID Tracking Project, along with academic institutions, and the private sector, have taken on outsized roles in what one might have assumed would be a public sector response
Our public health system is a core institution, and the pandemic has shaken us awake and shown how weak the infrastructure has become. Sustained increased investment will be required. Any updated plan proposed to modernize public health surveillance should demonstrate that lessons learned from the past 50 years of proposals has been synthesized, and that the proposal addresses key questions on data handling, privacy, security, rapid dissemination, and data standards, among other issues.
Although data governance will be vital to the 21st century public health infrastructure, the statements above highlight that the most egregious failures in COVID-19 public health response were not technical issues but issues of policy priorities, leadership, cooperation, and representation.
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In future posts I plan to explore several of the “Lessons” above in greater depth, including public health surveillance modernization proposals and public health equity.
Comments welcome! Flavia_Chen@hks.harvard.edu
Chen, Flavia . “Systems Made Visible .” December 16, 2020
