Lessons Learned

It’s become very clear that racial and ethnic minority populations and those with low income are bearing a disproportionate burden of this pandemic on a lot of different dimensions, including number of cases, likelihood of being hospitalized and having serious morbidity following infection, and mortality. As somebody who studies health disparities, I was not surprised that the pandemic exacerbated inequities in health and health care, but I was taken aback by the magnitude of the disparities. This shows us how important it is to have rigorous and accurate data on race, ethnicity, and socio-demographic characteristics. It’s very hard to manage a pandemic without essential data. You can’t manage what you can’t measure.

The disproportionate impact of COVID-19 on minority and low-income communities is rooted in systematically racist policies and deep inequalities in American society that have persisted over centuries. We must begin to dismantle these fundamental causes of disparities to avoid further suffering and improve health and well-being for all. This requires work on several fronts. For example, universal access to care is a foundational step in addressing health disparities. It’s hard to address health disparities when large portions of the population, particularly racial and ethnic minorities, are excluded from the health care system. And that access is under threat in more than one way. First, most people in the United States get their health coverage through their employer, and we’ve seen tremendous job losses. At the same time, efforts to overturn the Affordable Care Act could lead to disrupted insurance coverage for tens of millions of Americans. During a pandemic that would be a disaster.

A living wage, including access to paid medical leave, too, is essential. When workers don’t have paid medical leave, they are forced to make a choice between coming to work with a potential infection and staying home and losing income. We also must address food insecurity and housing instability, both important consequences of the pandemic. For our economy to maximize opportunities for all people to live healthy and productive lives, we must repair holes in our safety net that worsen health outcomes.

The pandemic has given me a sense of just how much the health care system can change when there’s an immediate need. I work at the Providence VA, and the whole system has been reorganized for COVID-19. We tend to think that systems are static and unable to change rapidly. This crisis has given me a sense of what can happen when systems need to move.

Finally, I believe this is a moment of clarity where it’s impossible to deny the impact of systemic racism on health. Many people are finally realizing that systemic racism is a public health issue. Given that disparities are embedded in centuries of history, we wouldn’t expect them to be completely reversed by one or more policies in a short period of time. But when it comes to expanding health insurance, changing the health care system to address disparities in care, and addressing social determinants of health, we can move on those quickly. With crisis comes opportunity, and we’re certainly in a crisis. This is an opportunity to seize a moment to make our society more equitable.

In 2014, the Robert Wood Johnson Foundation introduced an initiative to “build a culture of health,” where health is a “shared value” resulting in equitable solutions that address the social, economic, and environmental factors that adversely impact health and well-being. The impetus for the culture of health was driven by the stark inequalities in the health care system as a consequence of social determinants that consistently placed racial/ethnic minority groups, low-wage earners, and the uninsured and underinsured at higher risk for poor health outcomes.

Despite having the highest per capita cost for health care in the world, inequalities have persisted, suggesting that in order to ensure optimal health as defined by the World Health Organization, a culture of health perspective would force us to develop innovative interdisciplinary partnerships across institutions and communities. Within this context, COVID-19 arrived in the US and exposed the underlying fissures in our nation’s health and economic systems. If we do not correct course to be more intentional in our efforts to address the unequal vulnerabilities perpetuated in the US, we will continue to repeat this cycle wherein we struggle to prevent or control adverse health outcomes.

In epidemiology, timely, accurate data plays a central role in the decision-making process. Unfortunately, the politicization of COVID-19 has resulted in less reliance on centralized government sources of data, such as the Centers for Disease Control and Prevention, and more on a hodgepodge of sources, such as academic institutions and the popular press (for example, the Johns Hopkins Coronavirus Resource Center and The Atlantic’s COVID Tracking Project, respectively). Some states, like Rhode Island, have done a good job with not only collecting data in a timely manner, but also following the data and the science and using them in a way that has impact, not that further marginalizes people. For example, when the Rhode Island Department of Health started to see there were high numbers of cases in certain neighborhoods that potentially had challenges with transportation to drive-up testing sites, we set up walk-up sites in those neighborhoods. The sites were possible in part due to existing partnerships with local community health centers. These community-based partnerships are necessary for us to build a culture of health so that we already have established relationships and an understanding of the unique strengths and challenges present in communities to allow us to address adverse health outcomes.

Finally, we in public health need to do a better job of addressing misinformation in a systematic way. We must understand that with the internet and social media, there are many different ways people can be misinformed—and have and continue to be during this pandemic. Why are we still having debates about wearing masks and practicing social distancing? We need to think more about partnerships with colleagues in informatics to track misinformation in real time so that we can counter it promptly and get people to do what they need to do to reduce the spread of disease.

For me, the most important takeaway from this pandemic is that polarized politics endangers public health. When we have had prior public health crises of this magnitude—the Spanish flu, the HIV/AIDS crisis—politics made a difference, but neither time was the public interest so undermined by ideology and political motivations. It is a lesson we need to learn because it will affect public health decisions going forward.

For example, in the AIDS crisis that began in the early 1980s, the Republican Party was more conservative about homosexuality, giving needles to drug abusers, and funding drug treatment clinics. They were opposed to those things ideologically and so were resistant to doing things that would help not only treat people who were getting AIDS, but also keep it from spreading. It was not until 1988, with the bipartisan leadership of Orrin Hatch (R-UT) and Ted Kennedy (D-MA), that Congress finally passed its first comprehensive AIDS funding bill. We lost time. In public health, political conflict costs lives.

We have a two-party system, so we are always going to be divided in a binary way. But what you can do is take public health off the table. You can insist that elected officials rely on science and not sacrifice people’s health for their political agenda. The only way to protect public health and take it out of the hands of politics, ironically, is through politics: by voting elected officials into office who care about science. People have to demand of government that they not put lives in danger because of ideology. The silver lining to COVID politically is that it is the loudest wake-up call the Democrats have ever had. Complaining on your favorite social media outlet is not going to change the world. You have to get out there and advocate for what you believe: March, campaign, volunteer, fundraise, and stand up for science in both private and public arenas. Make your voice heard.

I’ve been involved in leading parts of Rhode Island’s coronavirus response since the beginning, and never before have I seen such coordination between the clinical sector, public health departments, the governor’s office, academics, education, and commerce. All these sectors have come together across our state to address COVID-19.

At the Department of Health, every day we synthesize the onslaught of incoming data, including surveillance data from across the state, research from the scientific community, and data from the federal government and CDC. Governor Gina Raimondo and the director of the Rhode Island Department of Health, Dr. Alexander-Scott, MPH’11, are both very data-driven, so the state’s response has been data driven, too: We’re using what the evidence shows works to determine what we’re going to do. We base all our decisions on rapidly evolving evidence and work to educate the broader community about how to effectively address COVID-19.

There’s been a lot of miscommunication and misinformation in this pandemic. When you start taking the focus away from the science and what’s been shown to be effective, it’s a disaster. At the end of the day, when you go see your doctor, you don’t want them to be acting on what they believe, you want them to be taking an evidence-based approach. That’s what we should be doing for public health as well. If I had to point to one thing that was most concerning about this pandemic, it’s the challenge to science by politics.

While this country has the best science and medical care in the world, our normal process of evaluation and approvals can sometimes delay the innovation needed to address a pandemic. This is a new lesson I think we are all learning. We knew about this disease at the end of December 2019, but three months later, still lacked reliable testing. It was like that with PPE, too: We had time to prepare but still faced huge shortages. All of a sudden, the pandemic was here and we were fighting it with both hands tied behind our backs. That cost lives. Should this happen again, we must do better. That said, we’ve employed tried-and-true public health actions like isolation and quarantine, and though the scale has been unprecedented, the measures we’ve taken were the right ones.

A pandemic really shows that individual efforts impact the wider community. We all have to do our part. We also must work to build up our public health infrastructure again, investing in public health research at the state and federal levels so we can understand these diseases. We spend a lot of money on defense and other things. I think that should be funneled toward public health efforts so the losses we’ve seen don’t happen again. Funding could have been used earlier for new testing technologies, for understanding transmission and the epidemiology of COVID-19 to optimize mitigation approaches, for modeling to understand how the virus spreads and how to prevent it, for improving computer systems to capture and synthesize incoming data, and for developing new treatments and vaccines.

I’ve been doing work on de-politicizing discussions of public health for a while, specifically around firearm injury prevention. The lessons I learned through years of trying to get firearm injury prevention research refunded by the Center for Disease Control and Prevention apply to the discussions that we’re having around COVID-19: A segment of society tries to make it political, but the vast majority of Americans are just scared and want to be able to have a normal life.

As scientists, physicians, and public health professionals, our challenge is to provide evidence-based guidance in a way that is not political. There are moments when that is difficult, but when we give in to that political instinct, doing our job becomes even harder. And when we only talk about the politics, we fail our communities. For me, this pandemic has reemphasized both the value of the public health approach and the importance of joining it to effective public communication strategies. Of course there are times when we need to do advocacy or engage legislators, but there is also a lot we can do independent of policy.

Mask-wearing is a great example. Back in February, many of us were saying not to wear masks in public because we didn’t have enough of them and we didn’t think cloth masks were adequate. Within a couple of months we had evidence that good-quality cloth masks are adequate to stop the spread of COVID-19, and that if we all wore them in public, we would decrease virus transmission by between 60 and 90 percent. So while universal mask mandates would be helpful, we don’t have to wait for them to wear masks. Policy alone is not everything.

Another vital thing for us to do is to step out of the hospital, research lab, or virtual lecture hall and engage with the public. We at Brown are at the forefront of really important COVID-19 research, but we are national leaders in communicating about the latest science and public health strategies, as well. A number of us have been proactive in not just doing the scientific work to develop knowledge and evidence-based strategies, but also in reaching out to the media and to communities at risk to engage them in understanding and applying the science. Dr. Ashish Jha and I have gone before Congress multiple times. Much of our work has been extensively covered by national news sources. We’ve emerged as trusted voices nationally for a nonpartisan approach to preventing and reducing the impact of COVID-19, and we’re actively thinking about how best to inspire our students to engage in public communication about public health and medicine. Most Americans aren’t reading the New England Journal of Medicine. The science has to be interpreted. So it’s essential that we be comfortable doing that interpretation.

This pandemic has deepened the relationships between the School of Public Health, the Medical School, and the University at large. It has highlighted the degree to which our schools have complementary expertise and the fact that all of our perspectives are stronger when we work together. It has also strengthened our relationship with the Rhode Island Department of Health (DOH). A number of our faculty are essential members of the DOH’s COVID-19 response team. Many of us were pulled in early on and many are staying involved.

From a scientific standpoint, a lot of the great things we’ve been able to do in this state are possible because of years and years of work by our faculty to develop both relationships and great scientific techniques for addressing epidemics or pandemics. Whether it’s for gun violence or opioids or HIV and sexually transmitted infections, we have the science and the datasets.

Science and public health are incremental and then have inflection points. If it weren’t for those incremental gains and those years of hard work to set up systems and methods and intervention strategies for different problems, we wouldn’t have had the resources or the know-how to respond to COVID-19 the way we did.

It’s an unavoidable fact that the U.S. has 4 percent of the global population, yet roughly 20 percent of the global cases of COVID-19 and 21 percent of the global deaths. We are contributing much more than we should be to the overall proportion of deaths and cases globally. If we were doing as well as the average country, we would have had, through the third week in October, 6.5 million fewer infections and 175,000 fewer deaths.

Two Brown doctoral students, two faculty members, and I recently published a paper where we investigated the impact of the first stay-at-home order, through the end of April. The outcome measure we looked at is called “doubling time”: how quickly it takes for the number of cases to double. When we compared the period before shutdowns to the stay-at-home period, we found—not surprisingly—that there were significant differences. On average, COVID-19 was taking 2.68 days to double before the shutdowns, but during the shutdown, that increased by more than 400% to 15 days. We found that the initial shutdown was associated with a large reduction in the number of new infections. So we know that stay-at-home orders work. The problem is, many states eased orders too quickly. With numbers of new infections rising as winter approached, many states were required to re-impose some restrictions. One of the biggest issues we face in this phase of the pandemic is that complete lockdowns are no longer feasible. This forces us to consider smart, targeted lockdowns. The problem is, we don’t really know which restrictions are most effective.

COVID-19 is a scientific problem, but it’s probably more than anything a behavioral and a political problem. We know what public health tools work if we use them well and consistently: social distancing, hand washing, wearing a mask, and limiting contacts. Yet over the past few years, science, knowledge, and truth have been labeled by some as absurd elitism. As a result, the public’s trust in science has significantly eroded. That’s an extremely difficult social problem to overcome. So when we are lucky enough to have a vaccine, it won’t be effective if there’s such extreme skepticism that a large proportion of people decide not to take it. The best way to overcome this is for politicians to stay out of the debate and for health agencies to be transparent about their reviews of vaccine candidates, about the results of the vaccine trials, and about unfolding plans for fair and equitable vaccine distribution.

In the U.S., we have suffered from inconsistent, factually challenged, and politicized messages from our government. We’ve pulled out of international bodies. But in the global community of people who are working on the coronavirus, I don’t think that is getting in the way of the exchange of scientific evidence and ideas. We’ve seen some unprecedented scientific accomplishments—for example, days after the virus was discovered, we had a record of the full genome of the virus itself, which offered a potential roadmap for understanding the dynamics of COVID-19 spread and potential efforts at mitigation. A highly active group of scientists are sharing their data, hypotheses, and discoveries—much of that in real time.

Indeed, in some ways, working on the virus has made communication and collaboration easier and faster. We used to have to wait for a paper to be published in a peer-reviewed journal. Today, ongoing COVID-related research is published online. Of course, this has both pros and cons. On the positive side, rapid dissemination of research findings enables scientists to learn about new ideas in real-time, and this new knowledge will in turn inform their own work. On the other hand, rapid dissemination often means that studies are available prior to being peer-reviewed—a critical step in ensuring the integrity of scientific research.

COVID-19 has brought about so many changes that we have yet to comprehend its full impact. For my own classroom teaching, it has been a case study about how we construct, use, and interpret epidemiological data. Much of my teaching has focused on critiquing these measures that we read about daily — infection rates, case fatality rates, and the like. And COVID-19 is an excellent example of the folly of calculating these rates in real time when complete data is not readily available, when the epidemic is moving so fast that a place largely untouched a few months ago, can now be a major epicenter, and when associations that appeared strong at the beginning of the epidemic may fade as more information is gathered and more cases occur. Never has our job teaching the next generation of public health scientists taken on such importance and urgency. As a society, we desperately need well-trained public health scientists who can help us learn from the mistakes of the current pandemic and contribute to the more effective handling of the next pandemic.