In many ways, modern advancements stole the show in the COVID-19 pandemic. With unprecedented speed, researchers decoded and shared the genetic blueprints of SARS-CoV-2. They developed highly effective, safe vaccines and treatments. Near real-time epidemiological data were at people's fingertips, and global genetic surveillance for viral variants reached unrivaled heights.

But while the marvels of modern medicine and biotechnology wowed, the US struggled with the basics. Health departments were chronically underfunded and understaffed. Behind slick COVID-19 dashboards, health workers shared data in basic spreadsheets via email—and even fax machines. Long-standing weaknesses in primary care deepened health inequities. And useful pandemic prevention tools, like masks, became maligned in the disconnect between communities and local health departments.

At our Ars Frontiers conference this year, I virtually sat down with two leading experts in pandemic preparedness, who talked through these takeaways from the COVID-19 pandemic. I spoke with: Dr. Jennifer Nuzzo, the director of the Pandemic Center and a Professor of Epidemiology at Brown University’s School of Public Health, and Dr. Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security and founding associate director of the Center for Forecasting and Outbreak Analytics at the Centers for Disease Control and Prevention.

More health workers

The conversation started with a big-picture question fielded by Nuzzo on how we generally did with COVID-19. She went through some high points: We all became familiar with pandemic tools, which will be helpful to draw upon in the future; we got real-time data collection going, setting the bar for the next pandemic; and we bulked up health departments with contractors.

But, this last point was also a point of concern because the staff that was hired during the pandemic was brought on with emergency funding—and those positions lapsed when the emergency funding did.

"This is a thing that I'm really, really worried about, probably, perhaps most of all," Nuzzo said. "If you remember three years ago, when we started this pandemic, we didn't have anywhere near the kind of public health infrastructure, the public health defenses that we need in terms of people working in health departments to help us make sense of the data and tell us what to do to help us live, you know, healthier, safer lives. … They're the infrastructure that should be in our communities to help keep us perpetually safe."

Better data infrastructure

While the state of the people-based infrastructure at the foundation of our response is a big problem, so too is our data infrastructure, Rivers explained. With the public health emergency, the federal government gave the CDC authority to compel states and jurisdictions to share COVID-19-related data, setting the stage for near real-time pandemic tracking at a national level. But, without an emergency declaration, the agency doesn't have that power. And to get basic disease data from individual states and jurisdictions, the agency has to hammer out individual legal agreements with each state and jurisdiction for each disease, resulting in non-standardized data.

"These are not blanket agreements," Rivers explained. "They're disease-specific about when and how and what data will flow. And as you can imagine, it takes weeks, if not months, to organize a single agreement. We're talking hundreds of agreements altogether, and it's a very slow process." The burden of negotiating these "is one of the real challenges that we have with our public health data infrastructure."

Another is the anachronistic way health departments collect and share data—often in basic spreadsheets, shared via email or archaic fax machines.

"There's a lot of manual data entry. There's a lot of faxing. There's a lot of emailing spreadsheets. And if we could claw back some of that manpower and put it towards public health practice, put it towards actually keeping people healthier, that's going to be a huge win," Rivers said.

While she was very optimistic about the new funding Congress has approved for data modernization, she noted that "when you're starting from fax machines, it's gonna be a long road back."

Address inequities and build trust

While our infrastructure needs revamping, we could also be doing more to prepare the public to respond to pandemic threats, Nuzzo said. She noted an example of pandemic drills in Taiwan, where they've used mass vaccination of seasonal flu vaccines as practice for emergency vaccinations. The drills help people know what to do and where to go, while officials can test how quickly they can roll out shots and reach high-risk populations like the elderly.

While the US was able to get mass vaccination set up, there were "deep inequities" in who knew where to go and what to do.

"I think one of the biggest lessons of this pandemic is that our underlying social vulnerabilities turned out to be our biggest pandemic vulnerabilities," Nuzzo said, adding it will take "community-based participation" and policies, like paid sick leave, to address.

Building trust between health experts and communities, particularly vulnerable communities, is critical to responding to the next threat, Nuzzo and Rivers noted.

"One of the things that the pandemic has really exposed is how much of a primary health care crisis we have in this country and that if people can't regularly access medicine, such that they can build those trusted relationships … I think we're gonna have a hard time," Nuzzo said.

Rivers made a similar point, noting that the pandemic responses lacked trusted, known sources for health information. "I'm not sure the public ever had an opportunity to really get to know an epidemiologist or a public health official that could talk to them regularly, day over day, about what is happening and what they should be doing," she said. The next crisis, she said, needs a "warm face."

Listing image by Ars Frontiers