U.S. Public Health Service crest
In the face of horrific death tolls and unspeakable trauma, there has been a continued refrain of “never again” through the pandemic. We want the small comfort of knowing that the deaths have not been entirely in vain. Yet history demonstrates that without radical change to the culture in which our infectious disease authorities operate, we are destined to repeat similar if not the same mistakes.
Many have placed the blame for America’s disastrous pandemic response on the atrocious leadership or lack thereof, of former President Donald Trump. While Trump has much to answer for, the blame does not lie solely with him, but also with the public health institutional failures.
Public health decisions regarding infectious disease outbreaks need to be just that, data-backed decisions that prioritize the health and lives of our entire population above all else. They need to be free from political and economic pressures and guided by experts, not the reactions of the public. Public health officials should not live in fear of being fired for making evidence-based but publicly unpopular decisions when the cost is human lives.
Containing an infectious disease outbreak takes swift and courageous decisions, yet the culture that has existed at the CDC for decades is one of complacency and caution which results in reckless endangerment to human lives. The focus is on procedure and precedent when one of the defining characteristics of an infectious disease outbreak is often novelty. They waste precious time trying to reach a consensus when it is often an impossible task. The very fact that the director of the CDC is appointed by and can be fired by the president rather than a council of scientific peers, creates a culture of biased decision making and yes-men.
Those who dare to make risk-based recommendations about infectious disease outbreaks or implement policies that go against the grain of this culture, are not just rebuffed and ignored to the detriment of the population but told that the organization will actively work against them.
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This is the experience of real-life characters in Michael Lewis’s latest nonfiction book The Premonition. The book tells the story of a team of “dissenting doctors” who predict the impact of the Covid-19 pandemic and know what needs to be done to redress the situation yet are roadblocked by institutional dysfunction at each turn.
Lewis writes about the time Dr. Charity Dean, Public Health Officer for Santa Barbara County is investigating multiple cases of Meningitis B on the USCB college campus. Knowing how short the window is for administering prophylaxis and how a few cases could spread, she moves quickly to shut down the college fraternities, and sororities and give 1200 students a prophylactic drug. The CDC disagrees with her decision and threatens to put their disapproval in writing, citing a lack of evidence for her approach (there is only one case every 4 years) and the fact that if she pursues multiple strategies they won’t know which one works. Dr. Dean goes ahead with her plan regardless and the cases cease. Her strategy is listed amongst other best practices in a report by the CDC on how to handle outbreaks of Meningitis on college campuses, published two years later. Despite her track record of success in this and other cases, Dr. Dean continues to butt heads with CDC and remains an outsider. When she tries to raise the alarm in January 2020 predicting the exponential growth of Covid-19, she is told to stop referring to Covid-19 as a pandemic.
I also have personal experience as an outsider whose warnings about another pandemic went unheeded by public health authorities. When AIDS emerged, people were content to think of it as a gay man’s disease, something that happened to “them” and not to “us.” While terror and anxiety gripped those in the gay community in the early 1980s, the rest of the country kept on with the status quo. Similar to how so many believed that Covid-19 would not have a global impact outside of China. I was an outlier in believing that heterosexual individuals could be at risk for HIV/AIDs and publicly attacked in a book published by Journalist Michael Fumento, titled “The Myth of Heterosexual AIDS”.
Early on, I tried to convince major pharmaceutical companies to develop a drug to treat HIV and prevent its spread. I met with the research heads for all the major companies – Bristol-Myers Squibb, Pfizer, Roche, Johnson & Johnson, and others – but I heard the same story everywhere: “Sorry, Bill, funds are already fully budgeted for this year.” Likewise, when I approached the chairs of the infectious disease and microbiology departments at the country’s leading universities, I was told that, “It’s scientifically interesting, but we just don’t have the money.” Worse, I was even told that “AIDS will never be an important enough disease.”
I also advocated for home testing of HIV in the 1980s, given the stigma surrounding HIV/AIDs, it seemed natural that allowing people to test in the privacy of their homes could dramatically reduce new infections. The CDC’s own survey confirmed this hypothesis, revealing that 29% of Americans would get tested for HIV if a home HIV test was available versus just 9% who intended to test using existing alternatives. Yet in meetings with federal health officials, I was laughed at for suggesting such a concept. Federal officials continued to insist that home tests were unsafe and unreliable, but the data from clinical trials summarized in the 1987 submission for premarket approval of a home test unambiguously demonstrated safety and efficacy. Both the FDA and CDC continued to oppose home tests. Again, I can draw parallels between this experience and the fact mass rapid antigen testing has never been adopted in the U.S. as a containment policy for Covid-19.
The price of all this early complacency and ignorance towards containing the HIV/AIDs Pandemic was tens of thousands of lives lost. Like the doctors described in Lewis’s book I experienced the unique agony of understanding the solutions needed to save lives, but meeting roadblocks at every turn.
Countries like Sweden, Italy, France, and the UK who have strong healthcare systems were still subject to multiple waves of infection throughout the pandemic because of sluggish and meek decisions or complacency by their public health authorities. Countries like China, Singapore, and New Zealand implemented swift and bold infectious disease control measures and were rewarded with astonishingly low case numbers and quick return to normal life.
But distressingly, the CDC continues a campaign of complacency announcing a surprising national rollback of mask mandates for vaccinated individuals that is not linked to a case or infection rates but instead seems somewhat random. Many have speculated that this announcement was made to encourage vaccination. But with no way to prove vaccination, this just gives the unvaccinated a dangerous license to spread infection unmasked.
Infectious disease control is a noble yet unrewarding job, successes in containing disease outbreaks go unnoticed but mistakes bear the weight of human lives. The pressure is intense and as discussed warnings often go unheeded. Public health officials often garner little respect and low salaries for their qualifications. Lewis’s book ends with Dr. Charity Dean frustratedly leaving public service and launching a consulting company for infectious disease control, believing she will have a greater impact in the private sector. But infectious disease control is not an issue that should be handled by the private sector and we cannot afford to lose the talent that could help defend ourselves against the next pandemic. We cannot afford to keep making the same mistakes.
