Way back in 2018, Ed Yong wrote a piece for the Atlantic that seems prescient now. It was called “Is America Ready for a Global Pandemic?” The answer to that question was no. Three years and a pandemic later, Yong has published a new story titled “Is America Prepared for the Pandemic After COVID-19?” And you can probably guess his answer to that question: still no. Yong points to two major problems with the U.S. pandemic response: that Americans have thought about this pandemic mostly as an individual problem, not as a community one; and that the government has focused too much on drugs and vaccines and not enough on the social causes of disease. On Wednesday’s episode of What Next, I spoke to Yong about what’s missing from America’s pandemic preparedness plan. Our conversation has been condensed and edited for clarity.
Ed Yong: America, probably more so than other countries, really hews towards technological fixes for social problems. The idea is that we are going to find the new tool, the shiny new object that is going to save us. And in this case, it tends to be vaccines or drugs. And that’s so ingrained that it almost sounds absurd to question it. Like, of course it’s a disease. Of course you’re going to want to treat it with drugs. Of course you’re going to want to vaccinate against it. What else are you going to do?
Well, I think actually the what else is very clear if you look at the history of infectious diseases. If you look at the 19th century, a lot of thinkers then were very clear that epidemics occur and are strongly influenced by social conditions like poverty, like inequality, substandard housing, bad sanitation, and these create the conditions in which epidemics spread easily, and they explain why some communities are badly hit and others aren’t. And if you want to address the problems of epidemics, you need to fix these underlying societal weaknesses.
That perspective fell away in the late 19th and early 20th century because of germ theory, because we understood for the first time that diseases were the work of microbes, and that gave scientists targets, it gave them villains to focus on. And because of that, this idea of the social consequence causes of disease completely fell by the wayside. Instead, researchers got to think of diseases solely as battles between individuals and pathogens, and that again reflects how we think about COVID today. I mean, look at everything from the last year. The Biden administration has absolutely gone in an almost entirely vaccine-only strategy. It has pitted vaccines against things like masks and testing. All of those things should be part of a unified, multilayered approach.
They might say there are limited resources, so we’ve chosen to focus on vaccination because we know it’s the most effective of all of these possible interventions. What would you say to that?
I would say it is theoretically the most effective—for an individual, absolutely. If you pick one thing that gives a person the best chance of resisting this new virus, then yeah, get them vaccinated. But two things in that: The delta variant is transmissible enough that you can’t just rely on vaccinations alone to safeguard a society. You need to layer it with other protections. And also, vaccines are fantastic and almost miraculous in how effective they are. But vaccines are completely useless unless you can get vaccinations.
The U.S. has plateaued very early and at a quite low level of vaccinations compared to other countries that have widespread access. Consider that deaths from COVID per capita in the U.S., after all adults became eligible, are higher than deaths per capita in a hundred-plus other countries before vaccines were ever available. That should alarm us. That should really make us think about what happens when you deploy very, very good medical interventions on a society where millions of people can’t access health care, where public health has been allowed to rot away for over a century, and where there are gross inequities in who gets to make choices that protect their own health.
You say people in public health have noticed the U.S. has cycles of panic and neglect. When there’s a national health crisis, a spigot of funding and public concern opens up. But then, at the first hint that we’re on the other side of that crisis, the spigot shuts off, leaders move on. There was a dramatic example of this in the summer, when President Biden declared the pandemic all but over on July 4. This was just before the delta variant walloped much of the country.
If you really just go in on one countermeasure, you’re very vulnerable when either you can’t get enough compliance, so vaccination rates aren’t high, or if you start getting variants in the future that really start eroding into the protection that vaccines afford. People have been saying since late last year that we needed layered strategies that complement each other. That didn’t stop being true this year, but we kind of acted as if it was true. And to me, that reflects this very strong bias towards biomedical interventions.
There are a couple of roadblocks I see. One is that so much of our public health infrastructure is shouldered by the states. You look at a state like Florida, where when it comes to testing for COVID, they’ve significantly ramped back their reporting and they’ve kind of made a unilateral decision on that. It doesn’t feel like there’s much that the federal government can do when you’re relying on an individual state like that that’s going to go its own way.
The other thing is that in some of these interventions, there’s this optimism. Like with the masks, you talk about how the Biden administration basically said you can rip your mask off if you’re vaccinated, and it created this sense that masks weren’t as important anymore. But that was also meant to be a kind of incentive for people to get vaccinated. There was an intention behind it. And so I could sort of see why they made that decision. I guess what I’m trying to say is these things are pretty complicated.
I agree that it’s complicated, so I think actually we’re sort of in alignment here. Both of these things are examples of the bigger problem that I’m talking about, this panic-neglect cycle. So the idea of scaling back on state-level data in Florida, for example, is a classic example of this. Things start getting better and then you pull back on the same measures that would have protected you in the first place. Same thing with the masking rollback, right? The minute things start improving, we already slalom headfirst into the neglect phase and we erode some of the measures that actually would protect us the next time round.
Is it hard for the federal government to do very much when states are opposing them? Yes, and that is part of the problem. I will point out that Rochelle Walensky at the CDC did specifically say that their change in in guidance was not, in fact, an attempt to incentivize people to get vaccines. So let’s just take that as given. Even if that’s not the case, it is still trading off vaccines against masks, two of our best possible interventions in this pandemic. And it’s a move that is relevant to our discussions about the social causes of disease because it was a move that privileged people who had easiest and earliest access to vaccines, the least vulnerable in our society, while also creating conditions that disadvantaged people who had a harder time.
If you look at people who are unvaccinated, they are disproportionately likely to live in rural areas. They are disproportionately likely to have food insecurity, to have eviction risk, to work in grocery stores and agricultural settings, people who are in a more vulnerable state. And those are the people who public health should be centering always. The core of public health is equity. That is what the field should be thinking of at all times. And that is the thing that is often lost. It is often seen as a sidebar to prevention rather than its central mission.
The Biden administration recently released a plan for pandemic preparedness, asking Congress for $65 billion over the next 10 years. But even that is still well below what public health experts say they need.
One thing that a few people mentioned to me was that that $65 billion, two-thirds of it is going into vaccines, therapeutics, diagnostics, which again seems so eminently reasonable given the way we think about pandemics and what it means to be prepared for them. But I would argue, as would several of the public health folks I’ve spoken to, that that is insufficient. That is the wrong skew, given everything we’ve learned so far.
One of the experts you spoke to said this is “a welfare scheme for university scientists and big organizations, and it’s not going to trickle down” to the people at the individual public health level. I thought that was a really interesting way to frame it: This is bolstering people who want to make a vaccine real fast, but then the people who have to get the vaccine into arms potentially, like, where are those guys?
Absolutely. It is almost unbelievable to me for anyone to look at what has happened over the last two years and think the solution to this is make vaccines faster. That just feels like people are stuck in this very old, deep-rooted way of thinking about the problem and not actually looking at what has happened. Do we honestly think that getting vaccines faster would have fixed things for America, especially given that so many people said that the rapid development of the vaccine was a reason for them to doubt that safety had been properly considered, that the right checks and balances were in place? Fast development was actually a reason for vaccine hesitation in a lot of people. …
Let’s give full credit to the vaccine development process. This was the one area in which America’s response completely exceeded expectations. And I don’t mean to undersell the vaccine development process, but what I want to do is to reframe how important that is as part of this bigger picture of preparedness. So the interesting thing about the Biden administration’s moves is that it has pandemic preparedness stuff that isn’t billed as such.
What do you mean by that?
So the American Rescue Plan, in my view and in the view of several of the public health people I spoke to, is a pandemic preparedness bill. It’s just that almost everyone would not talk about it in that way.
Because it has some stuff that is directly relevant to pandemics or seemingly is directly relevant to pandemics. It has provisions for strengthening the public health infrastructure, which are much needed, but it also includes things like child tax credits. It includes things that have been estimated to lift millions of people out of poverty this year. And my argument is that that is crucial to pandemic preparedness, whether you think about it in that way or not, and you should do. It is the case that if you make large groups of people less socially vulnerable, they will be better able to resist a new spreading virus. And that means thinking of preparedness not just in terms of vaccines or drugs, but also in terms of things like paid sick leave, in terms of food assistance, in terms of safe, decent housing for people. It involves thinking about things like decarceration in our prison system, universal health care.
So now you’re getting into social welfare stuff, where I think some people would begin to feel uncomfortable, and it’s where we hit this impasse. Joe Manchin, senator of West Virginia, says he wants to prevent us from living in an entitlement state, which to me means looking at those social welfare programs and saying we don’t need all of that.
A lot of America already lives in an entitlement state. A lot of America lives very privileged lives that affords them the ability to look after themselves and their health in the event of a pandemic, and frankly are blissfully oblivious about the centuries of social discrimination that allowed them to be able to do so, expanding that ability to care for yourself and to care for your community in the event of a new disease. Saying that is entitlement, when you yourself have benefited from the fruits of centuries of institutional privilege, is frankly absurd, and it’s looking at that problem in the wrong way.
It’s not politically expedient to do the right thing here, especially for someone like Biden, who’s been in Washington such a long time. It requires saying out loud, “Me and my colleagues have been fleecing the public health system for decades at this point, and we need to get it back to a healthy baseline.” And it’s much easier to say “Republicans did this wrong” or “Trump did it wrong” or “let’s just go back to quote-unquote normal, the way it was a few years back.” I wonder if you think that political problem gets in the way here.
I do, and I think that is a problem for all of us beyond just policymakers. To really think about why we have been dealt such a heavy blow by COVID requires much more than pointing at, say, Trump or any one actor or any one party or any specific group of people. It requires actually grappling with a century-plus of racism, of classism, of terrible policies, of a normal state that we have all collectively internalized and agreed to accept and that we are all complicit in. People so badly want to return to normal without grappling with the fact that normal led to this. The world that we built was a world of intense inequality and therefore a world that was intensely vulnerable to a new pandemic. And if we just revert back to that world, we are going to be in the same situation. And look, I know it’s really hard to think about this stuff. It keeps me up at night. I don’t love thinking about it because it raises some very hard questions about who we are as a society and what we have allowed ourselves to tolerate. To really think about it is like staring straight into the sun. But what choice do we have?