On Thursday, the United States officially ended its covid-19 health emergency. In public, many policymakers shy away from acknowledging their pandemic missteps and calling out the need for solutions that are politically complicated, such as raising low wages. But in private, they speak. After dozens of such conversations over the past few years, I compiled this to-do list.
These fixes are neither exhaustive nor simple — it is a mistake to think that any could be. But they are urgent because the drumbeats of epidemics seems to be increasing.
Put tests everywhere
Testing is the cornerstone to containing outbreaks before they explode. Researchers developed diagnostic tests for the coronavirus SARS-CoV-2 not long after its genomic sequence was posted online Jan. 10, 2020. But these weren’t widely available in the United States for several months.
First, the Centers for Disease Control and Prevention insisted on using only its limited — and initially flawed — tests. Next, the Food and Drug Administration was slow to evaluate tests developed by universities and the private sector. Finally, bureaucratic and logistical hurdles stopped tests from being done outside of hospitals. Once drive-through and walk-up testing centers opened across the United States toward the end of 2020, lines spoke to the demand.
Rather than shut these centers, the government should expand them to test for flu and sexually transmitted diseases. This would curb the spread of these illnesses while strengthening the testing system for the next pandemic.
Nursing homes and medical centers were overwhelmed during surges of covid-19. This harmed patients and made conditions grueling and risky for health-care workers, causing burnout that continues. Nurses and doctors are flooding out of the profession, while fewer are entering. Researchers warn of a national deficit of more than 900,000 nurses within the decade.
This trend makes jobs even harder, perpetuating the exodus. Patients face a higher risk of death and poor outcomes as the ratio of nurses to patients drops. Two years after California required a minimum ratio of 1 to 5 in general wards, nurses reported less burnout.
Congress should adopt a bill introduced in March to set nursing ratio standards around the country.
The United States couldn’t compile detailed data. It had to rely largely on South Korea, Britain and other countries to answer key questions, such as those on airborne transmission or the spread of the virus among vaccinated people.
In 2020, the CDC launched a data modernization initiative to unify the patchwork of information collected by states, hospitals and health departments. Still, the agency cannot force entities to share data, so officials must find ways to encourage sharing. Making the process less risky is a start. For example, data on outbreaks at businesses could be encrypted and anonymized to limit reputational damage. The agency should also incorporate unofficial sources of data, including from media outlets and wastewater testing.
Globally, the World Health Organization must better incentivize openness from countries. Low- and middle-income nations, for example, are asking for faster access to drugs and vaccines in return for sharing genomic data on viruses that’s used to create these therapies.
Poverty was a key determinant of how states and counties fared and of how likely people were to suffer serious illness from covid-19. This is largely due to the risks essential workers faced in factories, farms, warehouses and health-care facilities. Without savings and paid sick leave, many had to work when ill. Labor conditions and low wages help account for why Black and Hispanic people suffered three times as many covid cases in 2020 and 2021 than White people.
The United States must guarantee sick leave for all — it is the only wealthy nation that does not — and raise wages for the lowest earners. Further, workplaces should be required to take steps to protect employees from airborne infectious diseases, such as upgrading ventilation systems and stockpiling high-quality masks.
There are lessons in how the Occupational Safety and Health Administration (OSHA) responded during the epidemics of HIV and hepatitis B, diseases spread through bodily fluids. OSHA required health-care workers to wear gloves and hospitals to have sharps containers in every room. These measures later protected health workers from Ebola when that virus landed in the United States in 2014.
The largest concentrated outbreaks in the United States in 2020 were in jails and other correctional facilities. Overcrowding turned prisons into tinderboxes, sparking outbreaks in surrounding communities, raising the country’s toll. A 2021 study estimated there would have been a 2 percent reduction in daily coronavirus case growth rates had the U.S. rate of incarceration been the global average rather than the highest in the world.
State prisons released some 200,000 people to save lives. But releases were often chaotic, inconsistent and biased in favor of White inmates, amplifying racial disparities in incarceration. Diagnostic tests and high-quality masks alone will not curb the next fast-moving pathogen if jails remain overcrowded. The airborne disease tuberculosis regularly plagues U.S. prisons.
The criminal justice system must figure out how to reduce incarceration strategically, safely and equitably. Options include bail assistance or allowing sentences for certain offenses, such as drug possession, to be served at home. Some states and counties that have tried such measures have not seen a rise in violent crime. Notably, a report from the Bureau of Prisons found that fewer than 1 percent of people released early during the pandemic committed new crimes.
Develop and distribute drugs and vaccines
Everyone everywhere battled the coronavirus with few treatments and no vaccines for nearly a year. Those in poor countries suffered without for longer. By the end of 2021, the lack of vaccines in the Global South contributed to more than 1 million deaths, and arguably led to the emergence of variants that went on to wreak havoc in the rich world, too.
Researchers now need to develop tools to broadly target each of some 22 virus families with pandemic potential. Influenza is one priority, with the bird flu virus H5N1 that has killed millions of birds worldwide now showing up in mammals — from farmed minks to New England seals.
Strategies to ensure speedy vaccine and drug distribution are just as important. The U.S. government should add conditions to its research grants to bring down costs and encourage widespread manufacturing. It should also support myriad initiatives to build manufacturing capabilities in countries such as South Africa, Senegal and Brazil.
Commit to international solidarity
The United States’ repeated flirtation with an isolationist approach to pandemics in an interconnected world is folly. SARS-CoV-2 had spread to at least 19 countries within a month of the first reported cases in China on Dec. 29, 2019.
First, the United States should insure itself against shortages of masks and other protective equipment by strengthening supply chains within the Americas. A reliance on Asia for many of these items rendered the region vulnerable as factories in China closed due to the pandemic.
Second, the United States must help to develop international agreements on public health emergencies, despite rising geopolitical tensions. When officials meet at the World Health Assembly in Geneva this month, U.S. diplomats should play an active role in revising the WHO health regulations and in shaping a pandemic treaty or accord that facilitates the sharing of data, drugs and vaccines among nations.
If the United States fails to defend itself in the seven ways set out here, the toll of the next emergency could dwarf that of covid, as climate change, urbanization, migration and political instability make outbreaks of infectious diseases bigger and more frequent — from cholera to avian influenza to viruses yet unknown.