More than three years ago, the coronavirus pandemic officially became an emergency, and much of the world froze in place while politicians and public-health advisers tried to figure out what on Earth to do. Now the emergency is officially over—the World Health Organization declared so on Friday, and the Biden administration will do the same later this week.
Along the way, almost 7 million people died, according to the WHO, and looking back at the decisions made as COVID spread is, for the most part, a demoralizing exercise. It was already possible to see, in January 2020, that America didn’t have enough masks; in February, that misinformation would proliferate; in March, that nursing homes would become death traps, that inequality would widen, that children’s education, patients’ care, and women’s careers would suffer. What would go wrong has been all too clear from the beginning.
Not every lesson has to be a cautionary tale, however, and the end of the COVID-19 emergency may be, if nothing else, a chance to consider which pandemic policies, decisions, and ideas actually worked out for the best. Put another way: In the face of so much suffering, what went right?
To find out, we called up more than a dozen people who have spent the past several years in the thick of pandemic decision making, and asked: When the next pandemic comes, which concrete action would you repeat in exactly the same way?
What they told us is by no means a comprehensive playbook for handling a future public-health crisis. But they did lay out 23 specific tactics—and five big themes—that have kept the past few years from being even worse.
Good information makes everything else possible.
- Start immediate briefings for the public. At the beginning of March 2020, within days of New York City detecting its first case of COVID-19, Governor Andrew Cuomo and Mayor Bill de Blasio began giving daily or near-daily coronavirus press briefings, many of which included health experts along with elected officials. These briefings gave the public a consistent, reliable narrative to follow during the earliest, most uncertain days of the pandemic, and put science at the forefront of the discourse, Jay Varma, a professor of population health at Cornell University and a former adviser to de Blasio, told us.
- Let everyone see the information you have. In Medway, Massachusetts, for instance, the public-school system set up a data dashboard and released daily testing results. This allowed the entire affected community to see the impact of COVID in schools, Armand Pires, the superintendent of Medway Public Schools, told us.
- Be clear that some data streams are better than others. During the first year of the pandemic, COVID-hospitalization rates were more consistent and reliable than, say, case counts and testing data, which varied with testing shortages and holidays, Erin Kissane, the managing editor of the COVID Tracking Project, told us.The project, which grew out of The Atlantic’s reporting on testing data, tracked COVID cases, hospitalizations, and deaths. CTP made a point of explaining where the data came from, what their flaws and shortcomings were, and why they were messy, instead of worrying about how people might react to this kind of information.
- Act quickly on the data. At the University of Illinois Urbana-Champaign, testing made a difference, because the administration acted quickly after cases started rising faster than predicted when students returned in fall of 2020, Rebecca Lee Smith, a UIUC epidemiologist, told us. The university instituted a “stay at home” order, and cases went down—and remained down. Even after the order ended, students and staff continued to be tested every four days so that anyone with COVID could be identified and isolated quickly.
- And use it to target the places that may need the most attention. In California, a social-vulnerability index helped pinpoint areas to focus vaccine campaigns on, Brad Pollock, UC Davis’s Rolkin Chair in Public-Health Sciences and the leader of Healthy Davis Together, told us. In this instance, that meant places with migrant farmworkers and unhoused people, but this kind of precision public health could also work for other populations.
- Engage with skeptics. Rather than ignore misinformation or pick a fight with the people promoting it, Nirav Shah, the former director of Maine’s CDC, decided to hear them out, going on a local call-in radio show with hosts known to be skeptical of vaccines.
A pandemic requires thinking at scale.
- Do pooled testing as early as possible. Medway’s public-school district used this technique, which combines samples from multiple people into one tube and then tests them all at once, to help reopen elementary schools in early 2021, said Pires, the Medway superintendent. Pooled testing made it possible to test large groups of people relatively quickly and cheaply.
- Choose technology that scales up quickly. Pfizer chose to use mRNA-vaccine tech in part because traditional vaccines are scaled up in stainless-steel vats, Jim Cafone, Pfizer’s senior vice president for global supply chain, told us. If the goal is to vaccinate billions of patients, “there’s not enough stainless steel in the world to do what you need to do,” he said. By contrast, mRNA is manufactured using lipid nanoparticle pumps, many more of which can fit into much less physical space.
- Take advantage of existing resources. UC Davis repurposed genomic tools normally used for agriculture for COVID testing, and was able to perform 10,000 tests a day, Pollock, the UC Davis professor, told us.
- Use the Defense Production Act. This Cold War–era law, which allows the U.S. to force companies to prioritize orders from the government, is widely used in the defense sector. During the pandemic, the federal government invoked the DPA to break logjams in vaccine manufacturing, Chad Bown, a fellow at the Peterson Institute for International Economics who tracked the vaccine supply chain, told us. For example, suppliers of equipment used in pharmaceutical manufacturing were compelled to prioritize COVID-vaccine makers, and fill-and-finish facilities were compelled to bottle COVID vaccines first—ensuring that the vaccines the U.S. government had purchased would be delivered quickly.
Vaccines need to work for everyone.
- Recruit diverse populations for clinical trials. Late-stage studies on new drugs and vaccines have a long history of underrepresenting people from marginalized backgrounds, including people of color. That trend, as researchers have repeatedly pointed out, runs two risks: overlooking differences in effectiveness that might not appear until after a product has been administered en masse, and worsening the distrust built up after decades of medical racism and outright abuse. The COVID-vaccine trials didn’t do a perfect job of enrolling participants that fully represent the diversity of America, but they did better than many prior Phase 3 clinical trials despite having to rapidly enroll 30,000 to 40,000 adults, Grace Lee, the chair of CDC’s Advisory Committee on Immunization Practices, told us. That meant the trials were able to provide promising evidence that the shots were safe and effective across populations—and, potentially, convince wider swaths of the public that the shots worked for people like them.
- Try out multiple vaccines. No one can say for sure which vaccines might work or what problems each might run into. So drug companies tested several candidates at once in Phase I trials, Annaliesa Anderson, the chief scientific officer for vaccine research and development at Pfizer, told us; similarly, Operation Warp Speed placed big bets on six different options, Bown, the Peterson Institute fellow, pointed out.
- Be ready to vet vaccine safety—fast. The rarest COVID-vaccine side effects weren’t picked up in clinical trials. But the United States’ multipronged vaccine-safety surveillance program was sensitive and speedy enough that within months of the shots’ debut, researchers found a clotting issue linked to Johnson & Johnson, and a myocarditis risk associated with Pfizer’s and Moderna’s mRNA shots. They were also able to confidently weigh those risks against the immunizations’ many benefits. With these data in hand, the CDC and its advisory groups were able to throw their weight behind the new vaccines without reservations, said Lee, the ACIP chair.
- Make the rollout simple. When Maine was determining eligibility for the first round of COVID-19 vaccines, the state prioritized health-care workers and then green-lighted residents based solely on age—one of the most straightforward eligibility criteria in the country. Shah, the former head of Maine’s CDC, told us that he and other local officials credit the easy-to-follow system with Maine’s sky-high immunization rates, which have consistently ranked the state among the nation’s most vaccinated regions.
- Create vaccine pop-ups. For many older adults and people with limited mobility, getting vaccinated was largely a logistical challenge. Setting up temporary clinics where they lived—at senior centers or low-income housing, as in East Boston, for instance—helped ensure that transportation would not be an obstacle for them, said Josh Barocas, an infectious-diseases doctor at the University of Colorado School of Medicine.
- Give out boosters while people still want them. When boosters were first broadly authorized and recommended in the fall of 2021, there was a mad rush to immunization lines. In Maine, Shah said, local officials discovered that pharmacies were so low on staff and supplies that they were canceling appointments or turning people away. In response, the state’s CDC set up a massive vaccination center in Augusta. Within days, they’d given out thousands of shots, including both boosters and the newly authorized pediatric shots.
Also, spend money.
- Basic research spending matters. The COVID vaccines wouldn’t have been ready for the public nearly as quickly without a number of existing advances in immunology, Anthony Fauci, the former head of the National Institute of Allergy and Infectious Diseases, told us. Scientists had known for years that mRNA had immense potential as a delivery platform for vaccines, but before SARS-CoV-2 appeared, they hadn’t had quite the means or urgency to move the shots to market. And research into vaccines against other viruses, such as RSV and MERS, had already offered hints about the sorts of genetic modifications that might be needed to stabilize the coronavirus’s spike protein into a form that would marshal a strong, lasting immune response.
- Pour money into making vaccines before knowing they work. Manufacturing millions of doses of a vaccine candidate that might ultimately prove useless wouldn’t usually be a wise business decision. But Operation Warp Speed’s massive subsidies helped persuade manufacturers to begin making and stockpiling doses early on, Bown said. OWS also made additional investments to ensure that the U.S. had enough syringes and factories to bottle vaccines. So when the vaccines were given the green light, tens of millions of doses were almost immediately available.
- Invest in worker safety. The entertainment industry poured a massive amount of funds into getting COVID mitigations—testing, masking, ventilation, sick leave—off the ground so that it could resume work earlier than many other sectors. That showed what mitigation tools can accomplish if companies are willing to put funds toward them, Saskia Popescu, an infection-prevention expert in Arizona affiliated with George Mason University, told us.
Lastly, consider the context.
- Rely on local relationships. To distribute vaccines to nursing homes, West Virginia initially eschewed the federal pharmacy program with CVS and Walgreens, Clay Marsh, West Virginia’s COVID czar, told us. Instead, the state partnered with local, family-run pharmacies that already provided these nursing homes with medication and flu vaccines. This approach might not have worked everywhere, but it worked for West Virginia.
- Don’t shy away from public-private partnerships. In Davis, California, a hotelier provided empty units for quarantine housing, Pollock said. In New York City, the robotics firm Opentrons helped NYU scale up testing capacity; the resulting partnership, called the Pandemic Response Lab, quickly slashed wait times for results, Varma, the former de Blasio adviser, said.
- Create spaces for vulnerable people to get help. People experiencing homelessness, individuals with substance-abuse disorders, and survivors of domestic violence require care tailored to their needs. In Boston, for example, a hospital recuperation unit built specifically for homeless people with COVID who were unable to self-isolate helped bring down hospitalizations in the community overall, Barocas said.
- Frame the pandemic response as a social movement. Involve not just public-health officials but also schools, religious groups, political leaders, and other sectors. For example, Matt Willis, the public-health officer for Marin County, California, told us, his county formed larger “community response teams” that agreed on and disseminated unified messages.