Pandemic Puzzle: 2022 Roundtable Summary
A future without pandemics is possible
The pandemic’s cost is hard to fathom. In the United States alone, COVID-19 has killed more than one million people, and severely impacted the health and wellbeing of millions more. The global toll is equally staggering, with well more than six million dying. This tragic loss is punctuated by COVID-19’s economic impact, which could cost the U.S. as much as $16 trillion — more than three-fourths of the nation’s total annual economic output.
Were these outcomes inevitable? Can future pandemics be prevented?
On March 29, 2022, following their Pandemic Puzzle Symposium series, Stanford Medicine and Stanford Graduate School of Business convened a panel of faculty and industry experts to address these questions, assess the U.S. pandemic response, and identify where smart, timely action today could pay substantial dividends tomorrow to protect lives and economic livelihoods.
Below is a summary of key areas the group identified for future action and investment: data sharing, designing infection control into buildings, advancing public-private partnerships, and leveraging targeted economic assistance.
Follow the Data
Public health interventions are only as good as the information they’re based on. That has been evident at every stage of the COVID-19 pandemic. Decisionmakers must have unfettered access to high-quality data to effectively coordinate and respond to evolving outbreaks. From viral variant prevalence to supply chain visibility, varied data is essential to seeing the full picture, anticipating threats, and directing resources where they are needed most.
But that’s not what has happened. Data sharing remains our nation’s Achilles’ heel, with information trapped in silos, gathered inconsistently, and shared via a patchwork of digital and analog technologies (including printed and faxed data spreadsheets). Legacy IT and interoperability take blame for these woes, but the underlying issue cuts deeper. In short, while the U.S. has public health infrastructure, it doesn’t operate as a system.
- Where things stand: There are more than 3,000 public health agencies in the U.S., all with varied authority, resources, and leadership structures (answering to mayors, county officials, governors, etc.). Unlike the U.S. military’s command structure, public health is not administered by any single agency or person. Absent stronger central coordination and investment, improving data sharing and public health cooperation will be slow going and inconsistent across the country.
- Structural change would be hard. In the present political environment, local constituents and their policymakers are unlikely to share or concede authority any time soon.
- Still, progress is possible. There are many voluntary steps that could support better data sharing while still allowing for flexibility and local autonomy.
- Rapid response: The Centers for Disease Control and Prevention established the Center for Forecasting and Outbreak Analytics to “enable timely, effective decision-making” earlier in an outbreak by providing models and forecasts to help, at least in part, assess effectiveness of control measures.
The CDC’s Infectious Disease Office has created a core list of the most critical data points that all public health agencies are strongly urged to track and report.
- That simple step would help ensure public health agencies, elected officials, and researchers are at least working with the same basic information.
- Going further: In addition to tracking the same data, equally important is the need for public health departments to define thresholds for action. This would help increase public transparency when new health guidance is issued, add predictability, and reduce the role of local politics in influencing decision making.
Build on what’s working. Further coordination could come by building on existing programs and networks whose work mirrors the systems needed in public health. The Mosquito Control program run by the CDC and U.S. Environmental Protection Agency relies on state and local agencies on the front lines, as well as public education, and might be a model to be emulated or a network to be leveraged. Similarly, the federal anti-terror BioWatch program, launched after the 9/11 attacks, operates a network of monitoring stations for airborne biological agents in more than 30 major metro areas that could be leveraged for public health.
Strengthening our early warning systems. Throughout the pandemic, tracking the spread of COVID-19 in communities — before cases reach the hospital — has been a key challenge. Many solutions have been tried, including getting people to self-report symptoms online and via apps. But in one way or another they’ve fallen short. Being able to monitor populations, whether entire cities, neighborhoods, or nursing homes, is essential to developing early warning systems for infectious disease.
- The value of waste: The CDC launched the National Wastewater Surveillance System in September 2020 to track the prevalence of viruses in wastewater. The World Health Organization has been using this method for decades, and it has been instrumental in helping to eradicate polio and battle many other diseases.
- The challenge: As of February 2022, only 43 jurisdictions, covering just about 16 percent of the U.S. population, were developing or operating surveillance programs.
What if Our Buildings Could Help Us Fight Disease?
If COVID-19 has taught us a lesson, it’s that behavior change is hard. People will adopt public health guidance, especially in the early stages of a crisis, but they won’t tolerate it forever. For reliable infection control, we need other options.
- Smart investment in smart buildings can take behavior out of the equation by creating environments that are primed to stop infectious diseases in their tracks. Healthy building design has proven to be extremely effective in interrupting infectious disease transmission. A healthy building is one that accounts for ventilation, air quality, water quality, dust and pests, safety and security, and optimizes heating, moisture, noise, and lighting.
- Why it matters: The pandemic lockdowns, while necessary given the alternative, caused considerable collateral damage, especially on the mental and physical health and education of children. Moreover, many essential workers — grocery clerks, teachers, and service industry workers — faced the difficult choice between risking infection or losing their income.
- Incremental investment. Retrofitting offices, factories, schools, retail, and government buildings would cost billions of dollars, but it doesn’t have to happen all at once. As buildings are renovated or rebuilt, they can be upgraded, much like fire safety upgrades, earthquake safety standards, and other building code reforms have been handled.
- ROI: Healthy buildings are cost effective, paying for themselves many times over — even if we never face another pandemic. Collateral benefits would be considerable. Improved ventilation and cleaner air would cut down the spread of influenza and the common cold, which together cost the U.S. economy billions of dollars annually in lost productivity.
Learning from Operation Warp Speed
- Giving credit where it’s due: Decades of investment in basic science research set the table for an unprecedented public-private partnership in Operation Warp Speed, helping to catalyze the development and approval of the Pfizer-BioNTech and Moderna mRNA vaccines inside a year.
- By mitigating financial risk for vaccine makers, Operation Warp Speed encouraged industry to accelerate development and dramatically shortened manufacturing and regulatory time frames.
- The free market needs help during a pandemic: Compared to blockbuster drugs that control chronic disease for a lifetime, vaccines have a smaller economic upside. They’re typically administered once, or perhaps just a few times, to each individual. In a crisis, vaccine makers can also expect pressure to give away their life-saving work. The free market is ill-equipped to solve these challenges. Government intervention was essential in de-risking vaccine R&D and in guaranteeing upside through committed purchases, encouraging as many manufacturers to take as many shots on goal as possible.
Therapeutics? Not so fast. Developing therapeutics, such as antiviral pills, is difficult, typically taking more than a decade and costing hundreds of millions of dollars. To wit, despite there being hundreds of viruses, there are drugs to fight just a handful — and half of those drugs are licensed for HIV.
- Why it matters: Antiviral pills can be easier to transport, dispense, and use, and do not suffer the same politicization and public hesitancy as vaccines, making them an especially critical tool in the toolkit.
No time like the present. Given the complexity of the task and the time required, it is imperative that we prioritize sustained programs in antiviral therapy research before the next crisis.
- Pushed to capacity: In the past two years, the FDA hit its upper limits as it tried to manage the tsunami of COVID-19 submissions in its regulatory pipeline. At the same time, many hospitals and health systems were inundated with cases and had less capacity to sponsor clinical trials on-site.
- Betting on success: A few existing antivirals have proven effective against multiple viruses, demonstrating that broad-spectrum antivirals are possible. Such powerful drugs would give public health officials an advantage in preventing an outbreak from becoming an epidemic or a pandemic.
- Finding a signal in the noise: A healthy head start helps, but in the moment, we also need faster ways of focusing our research efforts. Artificial intelligence has shown great potential for identifying encouraging drug options, whether from promising new molecules or in existing drugs to be repurposed, allowing researchers to target resources earlier.
Smart investment: Compared to the tremendous economic cost over the past two years, the money needed now to sustain Warp Speed-like momentum for vaccine and antiviral drug research is a sure bet. Developing vaccines and drugs now for the pathogen prototypes mostly likely to spur a pandemic would simply be a cost-effective insurance policy. If we do, vaccines and therapeutics might already be waiting in the medicine cabinet to prevent the next pandemic.
Target economic assistance
Massive federal pandemic assistance programs were effective in helping ease acute financial distress for millions of Americans, but these efforts weren’t without problems — many of which still weigh on the nation’s economy. Public health officials and economists have learned much in the process.
The state of play: Debt relief programs, which allowed borrowers to skip payments on mortgages, as well as student and auto loans and credit card payments, allowed 70 million consumers to forgo $86 billion in payments. The total value of all loans that entered forbearance was more than $2 trillion out of the $14 trillion U.S. consumer credit market. The speed and scope of the programs were unprecedented.
- Putting it in context: During the Great Recession, mortgage failures rose to more than 8 percent from just 2 percent, depressing housing prices and sending shockwaves through the economy. During the pandemic, delinquency rates actually fell, 3 percent to 1.8 percent.
- Bull’s Eye: Debt forbearance was effective in helping financially vulnerable households that were missed by other assistance programs, such as stimulus checks based on income. Studies also showed that debt forbearance programs successfully helped minorities, especially Black Americans, who were disproportionately affected by the pandemic.
Yes, but, the lasting effects will be substantial: Economists fear how businesses and consumers will untangle all of that delayed debt, especially as inflation hits 40-year highs and households face increased costs for nearly everything.
- Economists disagree, of course, about the primary driver of this inflation — the $5 trillion in federal stimulus, supply chain problems, or surging demand — but they will certainly be watching closely to see how inflation woes and forbearance issues play out.
- Peering into the crystal ball: The endemic phase of COVID-19 may be as much or more about festering financial woes as lingering health issues.
The importance of better understanding the complex financial and social impact of the pandemic cannot be understated.
- Public health officials will need more options to mitigate community spread. Citywide lockdowns and shuttered schools should be kept in reserve while more nuanced and targeted options are attempted.
- Greater financial insights would help business and industry sectors be better prepared to weather future surges, dangerous variants, or novel diseases.
We can get even smarter: Marrying future debt forbearance programs and public health mitigation efforts with household information, such as the California community vulnerability Index, might allow officials to even more efficiently and quickly speed relief to those who need it.
- Incorporate socioeconomic data in public mitigation efforts. Patterned on California’s Socioeconomic Vulnerability Index (SEVI), data would allow each state or county to better support its residents in the case of future lockdowns or pandemic mitigation efforts.
- Federal support payments or tax relief could be better targeted to help those who need it most, while at the same time reducing waste and fraud.
While pandemics have repeatedly and profoundly shaped human history, they aren’t inevitable — a point emphasized during the roundtable discussion. We have the resources and technologies necessary to mitigate and prevent pandemics if we act now to lock in the lessons we have paid so dearly to learn.
Matt Craven, MD, Partner, McKinsey
Lloyd Minor, MD, Dean, Stanford School of Medicine
Jonathan Levin, PhD, Dean, Stanford Graduate School of Business
Patrice Harris, MD, Co-founder, CEO, eMed
Bonnie Maldonado, MD, Professor of Global Health and Infectious Diseases, Stanford Medicine, and Senior Associate Dean of Faculty Development and Diversity
Doug Owens, MD, Chair, Department of Health Policy and Professor of Medicine, Stanford Medicine
George Scagnos, President and CEO, Vir Biotechnology
Amit Seru, PhD, Professor of Finance, Stanford Graduate School of Business
Nigam Shah, PhD, Chief Data Scientist, Stanford Health Care, and Professor of Biomedical Informatics, Stanford Medicine
Milana Trounce, MD, Clinical Professor, Emergency Medicine, Stanford Medicine