How the US Has Mishandled the Pandemic

John Whyte, MD, MPH; Howard K. Koh, MD, MPH

Disclosures

November 24, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

  • Public health crises like this pandemic need a one-government approach, with federal, state, and local leaders all working together under a coordinated plan. The United States has had little of that during the pandemic, leading to a lot of confusion.

  • Questioning the basic science has been a disturbing part of the pandemic response and has hampered efforts.

  • Universal use of masks across the country is long overdue. Mask wearing actually boosts freedom by allowing businesses and schools to reopen.

  • In 2021, the White House should sponsor a daily briefing about the pandemic, led by scientists who are the top subject matter experts.

  • To combat the current vaccine hesitancy, the vaccine approval process at the US Food and Drug Administration must be held to the highest scientific standards and involve expert advisory committees.

This transcript has been edited for clarity.

John Whyte, MD, MPH: Hi, everyone. You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD.

We have millions of cases of COVID in the United States. Over 250,000 people have died from COVID-19, and we're heading in the wrong direction. To help provide some insight as to what's gone wrong — and how we can stop from getting to 20 million cases — I've asked Dr Howard Koh to join me.

Dr Koh is a professor at the Harvard T.H. Chan School of Public Health in Boston, as well as the Harvard Kennedy School in Cambridge, Massachusetts. He was also a former assistant secretary for health for the US Department of Health and Human Services and a former commissioner of health for the Commonwealth of Massachusetts. Dr Koh, thanks for joining me.

Howard K. Koh, MD, MPH: John, thanks so much for having me.

Whyte: I wanted to put all that bio in there because it shows that you know what you're talking about. You've dealt with public health crises throughout much of your career, particularly in government as the assistant secretary for health.

So, what has gone wrong with COVID? Is it because it's a novel coronavirus, so there's a lot that we don't know? Is the issue a lack of federal coordination? Why are we at millions of cases and developing millions more?

Koh: You're right. These public health emergencies are just part and parcel of the public health landscape in our generation. When I was the Massachusetts commissioner of public health, 9/11 and anthrax occurred on my watch. That was my introduction to public health emergencies and the need for crisis leadership. It was an unforgettable time for me, now almost 20 years ago, which I can't believe.

When I became the assistant secretary in 2009, H1N1 was already on the horizon, the last pandemic our country has faced. I have served in the trenches here at the state and federal level in times like this.

When crises like this arise, what you need first and foremost is for an empowerment of the top public health agencies and scientists. You need regular communication with the general public, coordinated and galvanized by the White House so the messages are consistent. Most important of all, you need a one-government approach where federal, state, and local leaders are all working together.

Now, I've worked for both Republican governors and a Democratic president. At a time of crisis, you need a bipartisan — if not nonpartisan — approach when you try to care for all people, get through the issues, put it behind us, and move forward. So, that's what we need. Unfortunately, we haven't had a lot of that in the current response, and it's led to so much of the confusion that we're witnessing. With the new administration on the horizon, we're hoping that some of those trends can change and that we can move forward as one nation and have a united effort for the United States.

Whyte: When you were leading public health efforts to address some of the crises that you mentioned, was there an attack on science? For instance, people are questioning the facts around the usefulness of the wearing of masks. Did you have to battle that type of misinformation?

Koh: No, we did not. I'll just say it very simply: This confusion about the basic science has been a very disturbing part of the pandemic response this year.

I worked very closely with Dr Anthony Fauci when I was assistant secretary. That was an incredible honor. He's one of the top public health figures in the world and universally respected. Again, in times of crisis, you lean on the top scientists to tell you what the scientific facts are. Then you try to shape the best public health guidance around that science.

It was never put into question, undercut, or sidelined in any way. We've got to get back to a time where we are sending unified messages. And for masks, for example, their universal use is long overdue. I know the president-elect wants to advance that theme from the first day, when he assumes office. This is a way to promote the power of prevention — not just for you, the mask wearer, but for people around you who you care for and love. People say it inhibits freedom, but I often like to point out that it boosts freedom. It allows you to go out and interact with the public, and hopefully get your school and business back on track. So, these are some of the messages that I hope are put forward, sooner rather than later.

Whyte: How do we address that mindset, though, where it's "you have your facts, I have my facts"? They both can't be right. We want people to come along without having to beat people over the head. How do we do it in a way that's respectful of people's opinions but recognizing that everyone can't have their own facts? At times, we have to do things for the good of the community as well as for ourselves.

Koh: Here is where I think the consistent (if not daily) communication, from the highest levels of government, is very important. We've seen that from many governors in the past 10 months and counting, but inconsistently from the federal government. This is the worst public health emergency we've had in a century. We should have a daily briefing sponsored by the White House, but where the scientists take the lead and start with the facts and the data.

Whyte: Should it be the career scientists as opposed to political? Some politicals are physicians and health professionals. Will it make a difference if it's the career scientists who aren't necessarily influenced by the political nature of the events? We haven't heard enough from the career scientists, have we?

Koh: No, we haven't. I guess you could put Dr Fauci in that category, although he is in his own leadership class.

Whyte: But as you know, having worked in the department, there are many top-notch career scientists at very senior levels at the US Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), who have been there a long time and will continue to be there. Is it important to hear from some of them?

I'm just trying to tease it out when we think about communications strategies. For some people, it will simply be one group of politicals replaced by another group of politicals. That can be very divisionary as opposed to, if we focus on the science and the presentation of the science, then we'll do better.

Let's talk about vaccines. In some ways it's a success story of innovation, right? But people are saying, "Hey, hold on; it's too good to be true. I don't believe it, so I won't be standing in line." When we talked about vaccines early on in February and March, people were thinking about how they were going to queue up and line up. Now people are saying, "I'm going to wait. I'm going to wait and see how you do, Howard, before I go." How do we address that? That's science.

Koh: First and foremost, whenever any health challenge comes up, you ask, Who are the top subject matter experts?" Let's hear from them.

John, you and I have been in so many briefings in government and outside. You would start any briefing hearing from the top subject matter expert. You give them the stage for the opening minutes, so that you can put the basic facts out there, and then you discuss the options and the implications. With respect to the very important issue you're raising about trust and confidence in a future COVID vaccine, we're all really concerned about vaccine hesitancy and resistance — not just from the general public, but it's documented increasingly in health professionals.

We've got to reverse that immediately, and one major way to do it is to make sure that the FDA approval or authorization process is held at the highest scientific standards, involves outside expert advisory committees, and makes sure that the results from the phase 3 trials are transparent and published in high-profile medical journals. That's the only way to do it. In fact, that's the history and legacy of FDA ─ they've done that many times. We have to have that happen again and try to restore the public trust and confidence, so that vaccines can be accepted and we can get this pandemic behind us.

Whyte: What do you say, though, to people who will argue that there's been a lot of science that's been politicized? Birth control pills and whether or not there should be over-the-counter PrEP for HIV — those are just some of the examples. Are those valid comparisons?

Koh: I don't think so because this is a time of historic importance. We also know that the science has been evolving rapidly over the past number of months, and we know so much more about this virus than we did 10-plus months ago.

As the science evolves, we have to embrace the new learning. Again, defer to the top scientists, the top subject matter experts. And then keep shaping and updating our guidance based on the best science and stressing it to the American people. That's the only way we're going to get this behind us.

Otherwise, we're going to be in this for much longer, and there's been way too much suffering so far. So much of it could have been prevented if we didn't have so much confusion. We've got to rally around and do this as one nation. That's my overriding thought about this whole response so far.

Whyte: How long is it going to take to restore trust in some of the previously most trusted institutions, such as CDC and FDA? Let's be honest: There have been some missteps along the way. You helped oversee those agencies during your time at the department. What do they have to do to recover from the missteps — some serious — that they've taken over the past few months?

Koh: I'm hoping that when the new president gets inaugurated, he will empower his top public health agencies and scientists and let them do their job. In recent weeks, we have actually seen the CDC become a little more forward about their guidance and the Morbidity and Mortality Weekly Report. We didn't see that through the summer and other times when some of their messages got very confusing and started rattling some of the longstanding confidence we've had in that agency.

That's traditionally been one of the best public health agencies in the world, and I respect so many of my colleagues who are still working there day and night. I'm hoping that in the right leadership environment, the science can shine and people can feel empowered to say what the scientific truth is, as uncomfortable as it might be.

Having served in these emergencies, and having done many press conferences through these crises, the first thing to do is get up and tell the public what you know and what you don't know. Lots of times that data has information that you wish didn't exist and is not good news. The challenge of any leader is to speak the unvarnished truth and put it out directly. And then say, " Here's a challenge for all of us, and now we've got to rise up and face this together as one nation." That's what I'm hoping we can do. And then restore science and credibility for these agencies at the same time.

Whyte: Tell us your prediction of how things look 6 months from now.

Koh: I think and hope that things will substantially improve. First of all, we are hoping that these two vaccine candidates can pass the FDA standards. I don't want to get ahead of the FDA; we have to let them do their job. Assuming we have at least two vaccine candidates authorized by the end of the year, and perhaps more, then this is rolled out according to the criteria that have been crafted by the Advisory Committee on Immunization Practices for the CDC, the National Academy of Medicine, and others.

We have the greatest good for the greatest number at the beginning — try to get the supply to meet the demand as much as possible — and then keep emphasizing the need for the power of prevention. Elevate mask usage so it's universally done across the country under our new president, so that that message is loud and clear and not confusing. And then, have all of us working together to support all of those aspects of prevention and care.

I would like to think that by sometime next year we will be back much closer to normal than where we are now. This is so complicated. We have all been humbled by this, but we can get through it. That's where science, prevention, and public health are so important.

Whyte: How do we get more physicians, nurses, other health professionals, pharmacists interested in public health? It's going to be a challenge. We wish we had more contact tracers; we wish we had more people going into public health. Do we have a challenge ahead of us, given what's been going on the past few months, to continue to recruit young people to enter the field of public health?

Koh: On one hand, it's not easy. Public health is a tough field; the pay is low and the pressure is high. I'm very concerned for my colleagues at the state and local level who are tremendous public servants and are getting criticized and pushback for promoting mask usage and other prevention recommendations.

On the other hand, you're looking at a guy who started his medical career wanting to be the best clinician in the world. I trained in multiple areas and had several decades of caring directly for patients, which I was privileged and honored to do. But very early on in my career, I saw too many of my patients suffering from preventable illness, and it really pushed me to think more broadly about the importance of policy and then, ultimately, prevention. That's why you're talking to me from this vantage point right now.

I can tell you that this is the most fascinating and rewarding field in the world. Not easy, often frustrating, but you can't have a more rewarding career than in public health. I am passionate about this field and about prevention. I'm passionate about public service and good government. All of my students would tell you that. I think this is an area that's going to hopefully attract even more attention in the future, despite how challenging it is, because everyone sees the need. We're not going to have a better, healthier society and world unless we have more professionals like the two of us and many others spending more time and making a commitment for a better future. That's my hope.

Whyte: Well, Dr Koh, I want to thank you for your optimism. I want to thank you for your service at the federal, state, and community level, and for training the next group of leaders as well. We certainly owe you a debt of gratitude, so thank you.

Koh: Thanks so much for having me.

Whyte: And thank you for watching Coronavirus in Context.

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