10 Lessons Learned From the Pandemic, and a Way Forward: Report

Ken Terry

September 20, 2021

The federal government is taking "steps in the right direction" to help control this pandemic, but there have been many hard lessons learned, according to a new report from the Association of American Medical Colleges (AAMC).

The report's authors call for "coordinated federal leadership to improve the nation's response to the COVID-19 pandemic."

This is among 10 recommendations that address what AAMC views as systemic inadequacies in the nation's COVID-19 response that can help advise policy makers on how to better prepare for the next pandemic.

The recommendations are:

  1. The White House must lead the charge and ensure coordination among departments and agencies.

  2. The federal government must engage industry and research universities at the outset, commit to purchasing needed supplies and therapeutics in advance.

  3. The federal government must ensure an effective supply chain for critical goods and materials.

  4. Congress must appropriate needed funding to meet public health needs.

  5. Federal and state governments must relax regulatory restrictions on clinical care during a national emergency.

  6. Both government and the private sector must invest in needed data infrastructure.

  7. Federal and state policies must increase supply and well-being of physicians and other health professional.

  8. Congress must continue to commit to basic and clinical research.

  9. Federal government should expand and improve health insurance coverage.

  10. Stakeholders must commit to improving equity and patient-centered care through community engagement.

Current Crisis "Avoidable"

Although the Biden administration's COVID-19 strategy is moving in the right direction, says Atul Grover, MD, PhD, executive director of the AAMC Research and Action Institute, the branch of the association that prepared the report, "the severity of this phase of the COVID-19 pandemic was avoidable."

According to the report, only the federal government can provide the level of coordination that is needed across states and international borders to fight the virus successfully. "The response should not rely on a piecemeal approach that varies by locality and region."

In the absence of clear federal leadership during the pandemic's earlier phase, the report states, "key policies were either absent or conflicting across states, counties, and municipalities. Without federal direction and coordination, states were forced to compete against each other (and, sometimes, against the federal government) for supplies."

As a recent Kaiser Health News report shows, the states are still falling short on the COVID-19 front: for example, at least 26 states have restricted the ability of their public health authorities to take action against COVID in various ways.

In an interview with Medscape Medical News, William Schaffner, MD, a professor of preventive medicine and infectious diseases at Vanderbilt University, agrees on the need for the federal government to lead the COVID fight.

Noting that the cooperation of states with each other and with the national government is voluntary, Schaffner asserted that "subcontracting [the COVID response] to the states doesn't work. That results in chaos and a crazy quilt of responses that persists to this day."

Inadequate Control of COVID Effort

Within the federal government, the AAMC report maintains, the White House must be directly in charge of coordinating the fight against the pandemic. The AAMC calls for the establishment of a top-level office or a coordinating team to lead the COVID effort, similar to what was done during the 2014-2015 Ebola outbreak.

Earlier this year, President Biden appointed Jeffrey Zients as White House Coronavirus Response Coordinator, succeeding Deborah Birx, MD, in that role. Medscape asked Grover in an interview why that doesn't meet AAMC's requirements.

"Jeff and his team are doing a good job," Grover said. "But the reason I think we could be doing a better job is that the messaging has not been consistent across agencies and across the federal government.

"Jeff may not have the authority to overrule individual decisions and to ensure that all decisions are integrated across organizations. Maybe that is happening, but it's not clear to those of us who are not in the meetings every day. At a minimum, we've got to get the messaging right, and it needs to be more transparent."

Grover cites a recent press conference by the Centers for Disease Control and Prevention about the national strategy for vaccine booster shots. "No one from the FDA [US Food and Drug Administration] was there," he said. "Theoretically, FDA has signed off on boosters, but their scientists were caught off guard. The administration's messaging needs to be consistent, and that would be more likely if someone were in charge of these agencies overall," Grover said.

Schaffner said he prefers not to comment on this point, "but I won't argue with the observation."

Supplies Still Not Adequate

In light of the medical supply shortages that have plagued the COVID-19 response, the AAMC report recommends that the federal government ensure an effective supply chain for all critical goods and materials, starting with the Strategic National Stockpile (SNS), which was created in 1999 to supplement state and local medical supplies during public health emergencies.

"The SNS should enable the nation to support care for a minimum number of critically ill patients until the federal government can assure an adequate functional supply chain for a short period of time," the AAMC report states.

The SNS was not replenished after the 2009 H1N1 pandemic and wasn't prepared for the COVID-19 emergency, according to the report. "Despite having built up the supply over the last year, the nation is just one major outbreak or incident away from another monumental shortage of very basic needs such as gloves, masks, and gowns."

Grover said the national stockpile now has more gowns and gloves than it did at the pandemic's start. But he's concerned about what might happen if a new type of pathogen emerged. "If we were to face the same kind of COVID surge we're now facing in the unvaccinated communities more broadly across the US — for example, if we got another variant that was even more infectious or deadly — I'm not sure we'd be prepared."

Just-in-Time Purchasing

Hospitals were caught short when COVID struck because of their just-in-time supply chain approach, which relied on punctual deliveries of new supplies and equipment, the report states. Of course, when demand soared and every provider was competing for scarce supplies, that didn't happen.

Now, Grover pointed out, there is still no central system to keep track of where PPE, ventilators, oxygen tanks, and other critical items are in the supply chains of hospitals and physician practices.

So, even if policymakers determined that the nation should use both the SNS and private locations to stockpile enough supplies to care for a certain number of patients for a period of time, there wouldn't be any way to determine what was on hand or where it was stored.

Moreover, while hospitals have built up their stockpiles to prepare for new COVID surges, he expects them to go back to just-in-time purchasing when the pandemic wanes. Although healthcare organizations want to take good care of patients, they have financial and physical constraints on how many supplies they can store, Grover said.

Testing Conundrum

An analogous challenge exists for companies that make COVID-19 tests, Grover said. "The testing companies don't want to produce more than they're going to be able to sell. They're a for-profit industry." Partly as a result, the nation has never had as many tests as it needs, according to the report.

To solve this problem, the report authors suggest that the federal government take an approach similar to that of the Trump administration's Operation Warp Speed (OWS), which used advance funding and vaccine pre-purchases to spur development.

"The CDC is unlikely to meet testing demands in future outbreaks and pandemics using existing public health lab partnerships, even under the best conditions. Industry was reluctant to mass produce testing kits for fear demand would fail to materialize; an OWS-like advance purchasing strategy and investment in private production could have reduced the spread of COVID-19 and will be critical in mitigating a future outbreak or pandemic."

Public Health Infrastructure

The report also calls for Congress to appropriate "robust and continuous funding for public health infrastructure…Chronic underfunding of public health has hurt the nation's emergency preparedness framework and contributes to health inequity."

This applies not only to federal funding, but also to state and local funding, which has primarily been allocated on a crisis-response basis, the report states.

Grover is glad that the fiscal 2022 budget legislation includes $15 billion to finance this infrastructure, but that's only a start, he said.

Schaffner stresses the importance of improving the IT infrastructure of public health agencies. "We need a better, higher-quality mechanism for quickly gathering critical data from doctors' offices and hospitals and sending that information through a public health stream so it can be gathered.

"Today, data come in at the national level, sometimes slowly, sometimes in fragmented fashion, from different jurisdictions around the country, and it's very difficult to make secure statements and plan effectively."

Schaffner agrees with the report's emphasis on the need for long-term planning to prepare for the next pandemic, but is pessimistic about the odds of it occurring.

"This challenges us as Americans. We have notoriously short attention spans. And we like to put difficult things behind us and look to the future," he said.

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