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Pandemic shows need to overhaul public health system, experts say

In the third installment of “The Pandemic Puzzle: Lessons from COVID-19,” leaders and experts in government, academia, health care and business said the U.S. government must step up to build and coordinate a true, robust public health system.

- By Stephan Benzkofer

Two days after the White House declared a national emergency on March 13, 2020, because of the COVID-19 pandemic, Rear Admiral John Polowczyk was called in to help. The emergency stockpile of key medical supplies had been emptied. The world’s economies were shutting down. Cases and deaths were rising.

Polowcyzk immediately realized he was flying blind. He outlined the problem in a meeting with the nation’s largest providers of medical supplies.

“Next thing I know,” Polowczyk said, “I had their daily transactional business information.” He said the mass of information was dumped in the cloud at the Federal Emergency Management Agency, and using a Defense Department supply chain visualization tool, he and his team  were up and running by mid-April.

In a frantic four weeks, Polowczyk had eyes on the complex web of transactions that supplied hospitals and clinics across the United States. “I could see orders from every hospital, every nursing home, every first responder,” Polowczyk said. “I could see the volumes of material delivered to fill those orders. I could see the material moving from manufacturing overseas.”

Still, Polowczyk, who retired from the Navy last year and is now a managing director at the professional services firm EY, said it was four weeks the United States did not have. While those private-public partnerships were critical to later success, the fact they needed to be created from scratch meant a major delay.

“Time was not in our favor,” he said. “I couldn’t immediately start to say, ‘National demand for a mask is X. Go build X.’ We were essentially behind from the get-go.”

That “supply chain control tower,” as Polowczyk called it, is just one of the infrastructure investments the nation desperately needs before the next pandemic strikes, according to leaders and experts in public health, medicine, academia, business and government who spoke during the third installment of “The Pandemic Puzzle: Lessons from COVID-19,” a symposium series hosted by the Stanford School of Medicine and Stanford Graduate School of Business

Lloyd Minor, MD, the Carl and Elizabeth Naumann Professor and dean of the School of Medicine, said it is critical that the nation build the capabilities and tools needed to combat the next pandemic. Jonathan Levin, PhD, the Philip H. Knight Professor and dean of the Graduate School of Business, called the vulnerabilities and problems in the system sobering.

But unlike the community-based solutions to equity problems that were widely touted at the conference’s second session, the consensus at this one was that the federal government needs to step up. 

Indeed, the deficits in the system are numerous, but a major problem is that there really isn’t a system, said Robert Redfield, MD, former director of the Centers for Disease Control and Prevention.

“We don’t have a public health system,” Redfield said, noting that state governments have public health agencies and that many states also have entities at the local level dedicated to public health. “You have multiple health departments that aren’t really systematically linked.”

Doug Owens, MD, chair of Stanford’s Department of Health Policy and the Henry J. Kaiser, Jr. Professor, detailed the devastating cost of the pandemic — about 750,000 deaths and an estimated $16 trillion hit to the economy — and said it underscored “the consequences of allowing our public health system to atrophy.”  

Because the local health departments are essentially working individually, they can’t see threats rising or how their colleagues might be reacting to those threats, said Charity Dean, MD, CEO and co-founder of Public Health Company. “A real theme is that individual vigilance and individual heroic efforts will always fail when facing off with a novel, fast-moving pathogen,” she said. “We have this linear response, but the threat is exponential.”

Sara Cody, MD, public health director of Santa Clara County, which includes San Jose and Palo Alto, described what the early days of the pandemic felt like without that vital data.

“The month of February was an extremely eerie and terrifying time,” she said, explaining that she and her team knew the virus was spreading but didn’t know how and where. “We didn’t have enough information to know what steps we needed to take to protect the public.”

Robust data vital

“The one thing we need is data infrastructure,” said Nigam Shah, PhD, professor of biomedical informatics at Stanford. “We can’t be sending faxes. Layering those data pipes and upgrading our national infrastructure so that data are treated as a first-class citizen is an essential baseline.”

Shah illustrated how laborious data collection proved to be as the nation scrambled to understand the threat it faced. Stanford Health Care treats patients from multiple counties and needed to report cases to their public health officials. Shah said each used a different form. Some still used fax machines. But worse was that they didn’t even define a day in the same way.

Kevin Ban, MD, chief medical officer at Walgreens, said the pharmacy chain operates under a dizzying number of jurisdictions with different rules for testing and vaccinations. He said centralized guidance would ease operations and be less confusing for the public.

A robust public health system would be able to rapidly develop diagnostic testing, run those tests, interpret the data and share that data, the speakers agreed. Shah envisioned a system that not only has the capacity to test individuals but also includes a surveillance system to capture what is happening in communities, such as through a municipal sewer system.

The speakers agreed that the federal government was in the best position to build, coordinate and fund the system, but noted that support was hard to come by and even more difficult to sustain.

Redfield said the nation needed to invest in public health with the same rigor it invests in the military. “This is a multi-aircraft-carrier investment,” he said.

Milana Boukhman Trounce, MD, clinical professor of emergency medicine at Stanford, also used a military analogy, saying that the nation needed to treat pandemics like “a special kind of war,” and that it should take a page from the military in organizing a system in which multiple federal departments and agencies are involved and senior command and control come at the highest levels of government.

“Pandemics are not simply public health crises,” she said. “They affect every aspect of society. They have massive consequences — economic, social, personal — and I think they should be treated as such.”

Public health workers on front lines

After nearly two years on the front lines of the pandemic, public health workers also found themselves on the front lines of the nation’s social divide. The harassment and intimidation, on top of burnout and fatigue, is resulting in a national exodus of public health workers, Owens said.

“There’s no excuse for harassment,” said Paul Farmer, MD, PhD, chair of the Department of Global Health and Social Medicine and the Kolokotrones University Professor at Harvard. “Public health officials have been on the front lines and don’t get all the support that they deserve.”

Panelists pointed to an explosion of health misinformation that’s fueling the problem, and suggested that federal regulation of social media companies was needed.

The internet can target millions of people with a million messages, and it has been weaponized, said Kara Swisher, an opinion writer for The New York Times and host of the “Sway” podcast.

“There’s very little oversight about any of it,” she said of the giant social media companies. “There’s a lot of noncontent things they can do to mitigate what’s happening here, and they don’t because it doesn’t make as much money, and engagement is enragement.”

Though propaganda is as old as society, the scale, hyper-partisan nature of the content and speed with which misinformation can travel is making the situation worse, said Kasisomayajula “Vish” Viswanath, PhD, the Lee Kum Kee Professor of Health Communication at Harvard’s T.H. Chan School of Public Health.

Bonnie Maldonado, MD, the Taube Professor in Global Health and Infectious Diseases at Stanford, said that the issue really escalated during the pandemic, and that the disinformation was preying on people who had serious concerns. “There are a lot of vulnerable people out there,” she said.

With so much misinformation swirling around, it is difficult for the public to know whom to trust, so they turn to people and organizations they already know. When the pandemic hit, it was unlikely that most Americans knew a local public health official they could turn to because of the atrophied nature of the system.

Building that trust will be just as vital a part of any future national public health system as data and a workforce, many speakers said.

“Trust has been so critical in our response,” said Mandy Cohen, MD, secretary of North Carolina’s Department of Health and Human Services, who added that she thinks much has been accomplished to build the capabilities and relationships needed to effectively battle a pandemic.

“We learned a ton,” she said. “We have really deepened partnerships between public health and the health care system, which I think are essential if we are going to be able to react at scale to this sort of massive thing happening to us.”

The fourth installment of the four-part symposium, scheduled for Nov. 19, will focus on advancing vaccine’s, treatments and cures. Register here.

Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu.

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