Public Health in 2020: The Year That Was

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson. On this episode, reflecting on a year marred by a devastating pandemic, lessons for public health, and the way forward against the COVID-19 virus in 2021.

DR. RACHEL LEVINE:
I think what this pandemic has taught us is how interconnected we really all are, is that what happens to one person impacts their family, of course, their community and our state and our nation.

DR. TOM FRIEDEN:
This has been a horrible year for public health in the United States—undermined, ignored, maligned, attacked in many cases, politicized—but hang in there. Because, ultimately, we will all look back on these months for the rest of our lives.

And we'll think about the things we could have done better, but we want to do now the things that we can be proud of—that we spoke the truth, that we provided clear and open information, that we did whatever we could to save lives—because that's ultimately the calling of public health.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, considering a year turned upside down by the COVID-19 pandemic, certain only have what's happened so far as warnings of a dark winter make us uneasy about the days ahead.

No doubt, public health has been impacted by the pandemic, but to what extent? And what lessons have we learned from this tragic virus that continues to spread out of control? Given rising cases of infection and death, what can we expect in 2021?

Two public health leaders join us to address these questions. Dr. Tom Frieden is president and CEO of Resolve to Save Lives, a global health initiative. He's along shortly. Up first, Dr. Rachel Levine, ASTHO's President and Pennsylvania secretary of health.

LEVINE:
Clearly, the global pandemic with COVID-19 has been the biggest public health challenge that Pennsylvania and our nation has faced in 102 years. And so, it has been a very daunting effort, but I think that state health officials remain positive and united in terms of our work to stop the spread of COVID-19 in Pennsylvania and in the United States.

JOHNSON:
Speaking of expectations, there have been some interesting, unusual, maybe even some unfortunate twists this year around things like masks and vaccines. Can you talk about your thoughts as it relates, first of all, to the mask debate?

LEVINE:
Well, I think it is very unfortunate that there has been such controversy about this simple public health measure. It was not clear at the very beginning how much masks would help. And again, it's a novel coronavirus, which means a new virus that healthcare professionals and public health professionals had never seen before.

There were also concerns that people would try to find the N95 masks, which really need to be dedicated to healthcare personnel on the front lines treating patients with COVID-19. But in the spring, you know, it became clear that the simple act of wearing a mask would have significant public health benefits. I think, unfortunately this has become a political issue, in some areas, a partisan issue, and I think that that's very unfortunate because I think that, over and over again, studies have shown the value of mask wearing. I think we're getting our message across now.

Now, we're, of course, in the middle of our fall resurgence with significant rates of increase of COVID-19 throughout the United States. But I think that now the election is over, is that hopefully we can settle this debate, we can take political considerations out of it, and we all can get down to protecting the public health for ourselves, our communities, our states, and our country by all wearing masks whenever we leave our home and are in public, whether it's indoors or outdoors.

JOHNSON:
Do you think the same could be said of the vaccine conversation?

LEVINE:
Well, I think that there was risk that the vaccine could be politicized. I know there were some political discussions about the vaccine, but I think that that has passed. And I think that the vaccine development with Operation Warp Speed in the end did not have a political bias towards it at all. It seems that this is going to be successful with the development of the Pfizer vaccine and the Moderna vaccine up first, hopefully in December and into the beginning of 2021.

So, we now have to work past vaccine hesitancy that exists in our country about this vaccine—and about vaccines in general, whether that's the flu vaccine, the measles vaccine.

And one of our responsibilities as public health officials will be to message that and to communicate the effect of this and the safety of the vaccines once they receive their FDA EUA and recommendations from the CDC. And then, to try to make sure that as many as the public is possible can receive the vaccine, which I think will be very promising as we go through 2021.

JOHNSON:
Many of these issues—masks, vaccines, contact tracing, all of these things—have spilled over into the political realm. We've talked about that already. But beyond that, they have also impacted you and your colleagues—some have even lost their jobs. What do you make of all of that?

LEVINE:
Well, state health officials are used to being in the public eye, we are used to having pressure, and it's a stressful position at all times. But nothing like it has been during the global pandemic of COVID-19. And so, state health officials at the sides of the administrations that they serve and the governors that they serve have been working tirelessly to protect the public health. And, of course, there's going to be a spotlight on their work.

However, that has taken, for many people, a very negative turn, and there has been a partisan and political pressure put on state health officials. And that, you know, has translated into a vocal minority of the public that have pushed back very hard and led to a verbal attacks on state health officials and even protests in front of their house. I had a protest in front of my suburban house and had to have the Pennsylvania state police there.

I think that that's unwarranted, and untoward, and should not occur. State health officials are a dedicated group of people working to protect the public health. And I might say this is exactly true of local county and municipal health officials as well. And so, even though we expect to be held accountable for our work, having personal attacks and protests is unwarranted.

JOHNSON:
I think the fact remains that most Americans appreciate what you and others are doing to try and help them stay healthy through all of this. Do you ever hear from those people?

LEVINE:
Yes. So, I get very frequent cards and letters and emails from the public in support of all of our work and in appreciation of our work, and that's just wonderful. And I think that means a lot. I think it means a lot to me and to state health officials in general. And I think it is a minority, but it is a vocal minority that has been not just critical, but having verbal attacks, threats, and protests, and that just makes our job much harder.

JOHNSON:
What lessons have you learned from the pandemic and the response so far? Anything you've taken note of?

LEVINE:
Well, I think what this pandemic has taught us is how interconnected we really all are, is that what happens to one person impacts their family, of course, their community, and our state, and our nation. And the actions, the decisions and the actions, that people take also have consequences that reverberate through the community, and our commonwealth, and our country.

And so I think that, to me, freedom is one of the blessings that we all share in the United States, but with freedom comes responsibility. That is not a new concept. That has been discussed since the beginning of our nation. And I strongly feel that there is a collective responsibility that we all have to work towards the common good.

And I think that we demonstrate that collective responsibility when we take simple public health measures, such as wearing a mask, as we discussed, such as washing our hands, such as social distancing. And that's how we show respect to our neighbors, to our communities, and to our states and our nation. And that's certainly one of the lessons of 2020.

JOHNSON:
What obstacles could get in the way of realizing those goals in the new year?

LEVINE:
Well, I think that the continued politicalization of public health is a threat. I think that partisanship is a threat—and not just a regular partisanship, but contentious and toxic partisanship—is a threat in Washington. I think the economy, the state of the economy—so, certainly if funding levels have been severely curtailed because of the economy, then that would threaten spending levels.

JOHNSON:
Whatever the case, public health soldiers on.

LEVINE:
COVID-19 is right there in front of us everyday. So, the challenges for public health continue. And COVID-19 is not the only public health issue that we're dealing with—there is the opioid crisis, there's maternal child health issues, there's environmental health issues.

So, the rest of our department soldiers on. Many of us are concentrated on the threat of COVID-19, but I have public health professionals in my department working on all of those issues all the time. So, public health soldiers on, and it is our mission to protect the public health. Our vision of the Pennsylvania Department of Health is a healthy Pennsylvania for all, and that's what I'm going to spend my time working on.

JOHNSON:
From 2009 until 2017, Dr. Tom Frieden was director of the Centers for Disease Control and Prevention, appointed to the post by President Barack Obama. During those years, he oversaw the nation's response to the H1N1, Ebola, and Zika emergencies. Today, he's president and CEO of Resolve to Save Lives, a global health initiative.

FRIEDEN:
Really, this has been a horrible year for public health. Not only have we had the most disruptive health event of a century, but we've seen the CDC in particular, but also public health more generally, maligned, subverted, and, in some cases, even debased.

JOHNSON:
The response has been as much as a political challenge as a public health challenge, and I am wondering what you think about whether we could have ever anticipated the type of revolt that has occurred against things like masks, or contact tracing, or even vaccines?

FRIEDEN:
It's really been surprising and disappointing.

The way I think of it, Senator Moynihan used to say that you're entitled to your own opinion, but not to your own facts. And it feels like we've gone one level further in this society when people are now entitled to their own facts. But that's actually not a good way to try to fight a health risk because facts are stubborn things.

And we're seeing the spread of coronavirus all over the country, explosively, especially in communities that have been in denial. If you ignore this virus, it will come back to bite you.

JOHNSON:
The new year does hold some promising developments that we have started to hear about in the news. But to get there, we're also being told, we have got some darker days ahead. What are some of the challenges you see facing public health here as we go into the next two or three or four months of this pandemic?

FRIEDEN:
The next couple of months are going to be really hard. And the more we work together but stay physically separated, the safer we'll be, the less hard the next few months will be, and the sooner we'll emerge from what will be, I'm afraid, a dark winter.

You are looking at the likelihood of more than 200,000 diagnosed cases a day, and that's probably only a third or less the total number of infections per day.

We're looking at the likelihood that there will be well over 300,000 deaths in the U.S. by Inauguration Day, which happens to be exactly one year from the first case of coronavirus—January 20th, 2020.

And you are looking at the likelihood that many hospitals will have a great deal of difficulty with the number of patients, the complexity of care, keeping healthcare workers safe.

This is a difficult time. And it's coming just at a very unprecedentedly complex transition between administrations—one administration that's trying not to hand over power, really for the first time in American history, and another administration that has been denied access to basic information so they can hit the ground running. A presidential transition is like a relay race. You want to make sure that the baton is passed and there is no stumble, there is no delay, particularly because we have to do two things.

One is ramp up the most effective public health programs, things like mask wearing and contact tracing and strategic testing; and second, get ready for the most complicated vaccination program that the United States has ever done. And that's going to be hard. It's not going to be quick, it's not going to be easy, and it's going to require moving at the speed of trust. And that means communicating openly and being clear about what needs to happen when, what we know, when we know it.

JOHNSON:
How would you assess the job the state and local officials have been doing in dealing with all of this? The federal government has its approach, but so much of this work, if not almost all of it, is being done at the local level. What do you have to say about how that's gone?

FRIEDEN:
I think there's a lot of excellent work being done in many different states and many local levels. The problem is that, without national coordination, without a national framework, it's very difficult or impossible to have an optimal response at the state or local level, even for something as simple as how to track the virus and how to report publicly.

At Resolve to Save Lives, we assessed this in July and again in October. We saw a lot of creativity, a lot of hard work, but, because of the absence of federal standards, really a complete absence of standardization and leaving much of the country really blind to the most important indicators of what's happening with the virus and what's happening with our response.

JOHNSON:
Has that varied response made the problem worse in your view?

FRIEDEN:
Oh, there is no question that the lack of federal leadership has meant that we have had a much less effective response to this pandemic than we would have otherwise. Now, in fairness, it's a really hard pandemic to fight. So, even a really competent federal response would have struggled with this.

JOHNSON:
Of course, on the Hill, there is a lot of talk about this, and that's been the case from the beginning. Trillions of dollars have been spent already——we suspect more will be spent eventually here, once those negotiations get ironed out.

How would you rate the job of our federal lawmakers as they work through these issues, coordinating both with the federal government and with their own states?

FRIEDEN:
Well, on the one hand, I think the CARES Act was done quickly and well and provided a lifeline for human health and for economic recovery. So, that's a real success story.

Unfortunately, that money is running out. And, unless more resources are appropriated soon for vaccination, for rebuilding public health, for supporting our primary care providers—because family doctors and health centers are facing a huge crisis with this pandemic—unless that's done by Congress soon, we're going to see avoidable death and avoidable economic harm.

JOHNSON:
What do you look forward to in the new year with this new administration? What are you expecting the Biden-Harris team to do?

FRIEDEN:
We've heard three things consistently that are encouraging: first, that they will follow science; second, that they will be organized in their approach and have a clear plan; and third, that they will communicate openly and transparently. Those three things are crucially important to fight an epidemic well, and those three things have been lacking so far.

JOHNSON:
What are some of the lessons that have been learned?

FRIEDEN:
I think the single most important lesson has been the importance of being guided by and fully supporting public health. And places around the country and around the world that have done that have done better. They've had fewer cases, fewer deaths, and less economic devastation.

Also, we've learned that we really have to handle this as a one-two punch. First, knock the virus down, and that needs to be done with more nuanced and strategic closures. We should do everything in our power to keep schools open for in-person learning, especially K-8.

We probably can keep things like retail open if we're really careful and we make sure that we have universal masking, paid sick leave, people don't go out if they're sick, you have more ventilation and less crowding.

We've learned what people care about, and one of the things that people care a lot about—haircuts. So, if we can keep personal services open, I think we'd keep people happier.

But we've also realized that indoor dining, bars, socializing—even at people's homes with two or three families—this is a formula for rapid spread of the virus. So, that kind of nuance in the first of the one-two punch is very important to knock the virus down.

The second of our one-two punch—which is test, trace, isolate, quarantine—we've really done badly with. We've flailed on that despite enormous effort and lots of hard work. We haven't done it in a quick, strategic, patient, focused way that allows us to quickly find people who are infectious, get them isolated effectively fast, find out who their contacts are, warn the contacts, make sure the contacts are quarantined so that the virus stops spreading.

The reason we're seeing such explosive spread now around the U.S. is that we never really crushed the curve. It never went down to the kind of low levels it should have But, if you look at the northeast, the parts of the U.S. that got numbers lower, are taking longer to come back and having less explosive increases.

So, it's very important that we have this one-two punch of a well-timed, nuanced, strategic set of closures, and then a much more effective system to isolate people quickly so that we stop the spread and can really keep the infections down to as low a number as possible until we get a vaccine with the hope—not a certainty, with a hope—that we'll have a safe, effective, long-lasting vaccine.

JOHNSON:
Public health professionals at the state and local level listen to these interviews. They are listening to this conversation. What sort of encouragement can you give them as we move into 2021 with this pandemic still hanging over us?

FRIEDEN:
This has been a horrible year for public health in the United States—undermined, ignored, maligned, attacked in many cases, politicized—but hang in there. Because, ultimately, we will all look back on these months for the rest of our lives.

And we'll think about the things we could have done better, but we want to do now the things that we can be proud of—that we spoke the truth, that we provided clear and open information, that we did whatever we could to save lives—because that's ultimately the calling of public health.

And, even more importantly, this is the moment. This is the moment at the county, city, state, federal, and global level to insist on a step function change in our support for public health systems because public health system are the best buy.

We can promote a healthier, safer society in which children grow to reach their full potential, in which we reduce addiction, improve primary care, protect people from health threats that are avoidable. This is the role of public health and, difficult as this past year has been, I hope that we can show that public health can make all of the difference.

JOHNSON:
You can find links to resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And, if you have comments or questions, we'd like to hear from you. Email us pr@astho.org, that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.