Are we ready?

A few weeks later, the World Health Organization declared COVID-19 a global pandemic. As the virus continued its march, daily life was disrupted around the world. Schools and businesses shuttered. Many jobs went remote and busy streets in New York City and other sprawling metropolises around the globe stood quiet. By the time the COVID-19 global health emergency had ended more than three years later, the virus had killed 7 million people around the world. At least 1.1 million Americans died of the illness, the most of any country, according to the WHO.

But incredible progress has been made since the early, dark days of the pandemic. For the past five years, public health experts have focused on fortifying the systems that stand between our nation’s people and the next big biothreat.

“We have a lot of the knowledge, tools and systems in place, but they can easily go away if they don’t continue to get the funding and support they need,” Jha warns. “And even if we do sustain these tools and systems, will we actually use them in a crisis? It’s far from clear in today’s landscape.”

Testing and Surveillance

In the first weeks and months of the pandemic, public health officials needed to know how the virus was moving through the American population: Who had it? And how quickly did it spread? In order to find this out, the U.S. needed to test millions of people.

But, as Dean Jha realized, testing was a major failure in the U.S. response. Instead of activating the dozens of academic and commercial labs around the country that were capable of producing diagnostic tests, for weeks the Centers for Disease Control and Prevention, working in concert with the Food and Drug Administration, kept a tight grip on testing approvals: Only CDC’s own proprietary test was allowed to be used. When that test turned out to be flawed, the result was a bottleneck that slowed America’s response at the worst possible moment, leaving officials without the tools to know where the virus was and where it wasn’t.

Other countries, including South Korea and Germany, ramped up testing by leveraging private industry. By the end of February 2020, China had five types of commercial tests and could process 1.6 million tests per week. The U.S., bogged down in regulatory red tape, had tested fewer than 500 people, in total.

Where does U.S. surveillance stand five years later? Nikki Romanik, a distinguished senior fellow in global health security in Brown’s School of Public Health, spent years at the CDC and most recently served as the deputy director and chief of staff at the White House Office of Pandemic Preparedness and Response Policy. She says that in the years since the pandemic, the federal government removed many of the hurdles that initially delayed testing. The CDC now has mechanisms in place to immediately partner with clinical laboratories nationwide, ensuring rapid test development and surge capacity in public health emergencies. These public-private partnerships enable private labs to collaborate with federal scientists in real time, so that the early failures of 2020 aren’t repeated.

Biothreat surveillance has also expanded by leaps and bounds over the past five years, Romanik says. During the height of the pandemic, wastewater surveillance emerged as a critical tool to track the spread of COVID-19 in the U.S. and around the world. Researchers found virus levels in wastewater typically increase roughly four to six days before an area sees an uptick in clinical cases. Communities and medical providers can use this information to anticipate and prepare for local surges of illness.

The CDC’s National Wastewater Surveillance System, which launched in September 2020, has expanded to over 400 sites and today monitors the wastewater of nearly half the U.S. population, detecting influenza, norovirus and measles along with COVID-19. Complementing this federal effort is WastewaterSCAN, a collaboration between Stanford and Emory Universities that covers about 12% of the U.S. population.

Wastewater surveillance efforts have successfully tracked recent outbreaks  of H5N1, or bird flu. In Texas, for example, scientists detected the virus in wastewater weeks before it appeared in cattle in early 2024.

“Instead of just hoping diagnostic tests are available and hoping that sick people show up to use them, the idea is that we can test the environment to help better understand where pathogens are and what trends we are seeing,” says Jennifer Nuzzo, professor of epidemiology and director of Brown’s Pandemic Center. “That’s a critically important innovation to supplement our traditional public health surveillance.”

Despite its success, the National Wastewater Surveillance System’s future is uncertain. Without dedicated funding,  it could be shut down or drastically scaled back if COVID-era grants dry up, warns Nuzzo, who sees wastewater surveillance as part of a broader effort to reshape pandemic preparedness. “We live in a world where these events will happen more and more, but we can find ways to live where we don’t allow them to upend our lives.”

A “New” Vaccine Platform

At the start of the COVID-19 pandemic, the world braced for a years-long wait for a vaccine. Operation Warp Speed—an unprecedented public-private partnership aimed at fast-tracking the development, production and distribution of COVID-19 vaccines—shattered those expectations.

Developed within 11 months of the virus being genetically sequenced, vaccines from Pfizer and Moderna were found to be widely successful in preventing severe disease and death. Before this, the fastest vaccine ever developed—the mumps vaccine—took four years. The Ebola vaccine, which became available in 2019, took five years. On average, most vaccines take about double that time.

The COVID-19 vaccine’s quick turnaround was genuinely shocking to most Americans. But while the vaccine technology was news to the public, mRNA vaccines had been in development for decades.

Many traditional vaccines rely on weakened or inactivated viruses to trigger an immune response, but developing and modifying them can be lengthy and expensive. The COVID-19 vaccines were built on the mRNA platform, a biotechnology that uses synthetic molecules to prompt cells to produce proteins that train the immune system to recognize and f ight disease. This “plug-and-play” approach allows for faster development, easier adaptation to new variants and lower production costs, making mRNA vaccines a powerful tool in pandemic preparedness and a shining example of a long-term medical investment paying off.

“We had invested in the mRNA platform for 10+ years across multiple parts of the federal government, and that allowed us to develop and scale the fastest vaccine in history,” Romanik says.

Recent policy shifts in the U.S., however, have raised concerns about the nation’s commitment to investing in vaccine preparedness—especially in the mRNA platform. Earlier this year, the Trump administration debated whether to withdraw $590 million in federal funding for Moderna’s mRNA-based bird flu vaccine while the FDA canceled a key meeting with experts set to select flu strains for next season’s vaccine, prompting warnings from scientists that production delays could follow.

“The systems we built, the lessons we learned and the science we advanced will be the foundation for how we tackle the next pandemic or biothreat,” Jha says. “We should be investing in more options, not less.”

Telehealth

An area of massive investment during the pandemic was telemedicine. Use of the “electronic housecall” had been steadily increasing for years, but when Congress, in response to the pandemic crisis, toppled numerous  telemedicine regulations, the floodgates opened to virtual health care. Today, telehealth has profoundly reshaped health care delivery and gained traction with both patients and care providers. Patients in remote areas or those with chronic conditions can connect with care from home. And new technologies, like remote monitoring tools, allow health care providers to track patients’ health in real time and to adjust treatment when needed.

But Dr. Ateev Mehrotra, professor and chair of the Department of Health Services, Policy and Practice warns of the “great unwinding” of pandemic-era health policies that expanded Medicaid and public health infrastructure. One of his primary concerns: the future of telehealth.

During natural disasters like hurricanes or floods, Mehrotra says, “we naturally focus on those directly affected—those who lost their homes or lives. But it’s also about ensuring people with chronic conditions, like cancer or other medical needs, continue receiving care. That’s why telehealth is so vital. It allows for people to get care without putting themselves or the clinicians at risk.”

During the pandemic, telehealth proved itself as an alternative care delivery option that could be scaled widely, with visits increasing from about 5 million to more than 53 million among Medicare recipients alone, according to the U.S. Government Accountability Office. This helped ease the burden on hospitals and allowed patients access to routine care for non-urgent health needs including chronic conditions, mental health counseling and routine follow-ups.

Still, policymakers hesitate to make long-term investments in telehealth and instead have only voted to extend flexibilities for months at a time. This constant state of limbo has Mehrotra worried. “We’re still in pandemic mode with all these short-term extensions on telehealth,” he says. “We’re seeing telehealth wither on the vine a little bit when we should be creating permanent policy around it and lifting it up.”

The Health Care Workforce

The significant challenges facing the nation’s health care workforce, from shortages to burnout, long preceded March of 2020, but they were brought to a breaking point under the strains of the pandemic. In urban centers, like New York City, where Dr. Craig Spencer, associate professor of the practice of health services, policy and practice, was working as an emergency room physician, hospital overcrowding soon had ERs spilling out onto sidewalks.

“It was impossible to go, some days, an hour or two without having a patient die,” he says of the earliest days of COVID19. “For my friends who were battle-hardened emergency physicians for a decade or more in some of the toughest places in New York City, this just really jolted them.”

Not surprisingly, a study published in JAMA last year found that many overburdened health care workers left their jobs during the pandemic. Employers in all economic sectors have reported difficulty hiring and retaining workers since the pandemic, but in the health care sector, workers faced unique risks. Through 2021, they were still quitting at  higher-than-normal rates and the Association of American Medical Colleges warns that the U.S. could see a shortage of between 37,800 and 124,000 physicians by 2034.

Spencer says the health care workforce is now in some ways actually worse off than during the pandemic. “At least then we had people cheering us on, even if there weren’t enough of us,” he says. “We still have provider shortages throughout the country, and the COVID experience has scarred a whole generation of health care workers. But the patients keep coming, the struggles with pre-approvals and other insurance headaches have only returned stronger, and the public has largely moved past the sacrifices health care workers made at the outset of the pandemic.”

At a time when the public health workforce needs bolstering to recover from the last global pandemic and prepare for  the next, we are instead seeing cuts to vital programming. The National Institutes of Health, the CDC and the Food and Drug Administration face funding cuts and a brain drain  of world-class experts. With measles, bird flu and other pathogens spreading, the nation announced plans to withdraw  from the WHO, signaling the U.S. taking a step back from  the global health stage and hindering our public health workforce’s ability to respond to ongoing and future outbreaks.

“The U.S. is actively dismantling decades of support for global health security,” Spencer says. “By abdicating our traditional leadership role, we leave the whole world—including Americans—dramatically less safe.”

A Question of Trust

In moments of crisis, people are often ready to  offer their support, whether that’s cheering on first responders or rolling up their sleeves and helping out, says Nuzzo. “We saw this happen during COVID,” she says, “but it didn’t last.”

In the early days, people clapped for health care workers from their balconies, sewed masks for strangers and formed groups to deliver groceries to the elderly. Communities rallied behind small businesses and most people followed public health guidance and stay-at-home orders to “flatten the curve,” seeing it as a shared responsibility.

But as the pandemic wore on, that goodwill began to erode. A Pew Research Center survey found that Americans’ confidence in scientists, which was at 87% in April 2020, dropped to 73% by October 2023 before settling at 76% in late 2024.

For Jha, rebuilding public trust is a priority. He says before the next biothreat starts, scientists and public health experts must consider changing how science is communicated.

Recalling mistakes of the pandemic—like keeping schools closed in the fall of 2020 despite evidence suggesting they were safe to open—Jha says, “We all would have done better if we had explained what the scientific process is, how it’s self-updating, how it’s self-correcting, how you get stuff wrong and that’s okay because you get better over time. If we had done that, a lot of the mistakes of the pandemic would have been avoided.”

Spencer believes that while the lessons of the pandemic are vast, public health too often takes the blame for falling levels of trust. “If you look at trust in the Supreme Court, in the presidency, in any of our political institutions, in any of the things that we’ve long considered true and dear, they have plummeted over the past 50 years, from highs to incredible lows,” he says.

“I’m worried that so much of the finger pointing goes at public health, when it turns out, we all need to do better. We need to have really difficult conversations with people we don’t agree with and figure out the places that we do agree, and move forward on that. The polarization in every single aspect of our life is going to make it harder for us, not just to move forward politically, but as a field in public health.”

All Eyes on Washington

In today’s world, regardless of what side of the aisle someone stands on, the next biological threat is not a matter of if,  but when, according to many experts at Brown and beyond. This reality is underscored by the growing number of biothreats, even within our own borders. A measles outbreak  in West Texas that started in January 2025 has proved fatal. The nation continues to confront a growing bird flu epidemic among wild birds, poultry and dairy cattle while more than 60 cases have been confirmed in humans with at least one of those cases resulting in death. The 2024-2025 flu season was the worst in a decade. And, all the while, COVID-19 persists, though at lower rates of infection, severity and death than in previous years.

These ongoing, evolving and overlapping epidemics, five years after the start of the COVID-19 pandemic, reinforce why preparedness must not only continue, but intensify.

“Policymakers need to think about this in the way they  think about any other national security threat,” Jha says. “We don’t wait until someone launches a nuclear weapon to start figuring out how to prevent a nuclear attack on the U.S. In the same way, we shouldn’t wait for the next biological emergency to decide to invest in preparedness. We should be making sure we’re investing in readiness now. That actually reduces the likelihood that we’re going to have serious consequences from biological threats. We cannot pull back from that. We have to do more.”