Podcast: Lessons learned from COVID

The global pandemic: Three years later

Three years after we first began forecasting the trajectory of the COVID pandemic, we bring together IHME experts to discuss the ongoing effects of COVID and where we go from here.

In today’s episode, Dr. Peter Hotez and Dr. Christopher Murray talk with Pauline Chiou about the lessons learned so far.

 Listen as a podcast

Key takeaways:

• One important lesson was the difficulty for public health authorities like WHO to make decisions early on in the pandemic, when there was very little data to use. Reluctance to take quick action also prevented us from getting ahead of the pandemic.
• We should not treat this pandemic as a one-off event. It is quite likely that another pandemic will occur within the decade, and we should prepare for that eventuality.
• All countries need to work together to ensure vaccine equity:
  • Prioritize rollout and scale-up of vaccines as much as their development 
  • Work with vaccine producers in low- and middle-income countries earlier on
  • Rebuild public trust that has been lost to increase vaccine confidence
• The COVID pandemic brought on unprecedented levels of global scientific collaboration. We should continue that energy through widespread data sharing and encouraging a diversity of data collection efforts.

This transcript has been lightly edited for clarity

Pauline Chiou: Welcome to this special edition of Global Health Insights. I’m Pauline Chiou in Media Relations at the Institute for Health Metrics and Evaluation. As we mark three years of the COVID pandemic, we discuss the lessons learned, too, with Dr. Chris Murray, Director of IHME, and Dr. Peter Hotez, Dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston.

Thank you both for being with us for this podcast. Dr. Murray, let me start with you. What are the key lessons that you take away after three years of this pandemic?

Dr. Christopher Murray: That’s a pretty big question. But if I sort of think back to the whole course of the three years that have led to almost 20 million people dying. I think that one of the most important lessons is the difficulty of making decisions that different groups had – governments, public health authorities, WHO. Particularly when early on, the data is very unclear and uncertain.

And initially, huge reluctance to take action and sort of letting the epidemic take over before responding. And then we were constantly, as they say in in some parts, were on the back foot, you know, just not really being able to sort of get back on top of the epidemic. Now, some countries did a pretty good job of that.

But even then, eventually, you know, the high levels of transmissibility of the Omicron variant even made all those countries fare pretty poorly. There are lots and lots of issues on the data front, but I think the biggest level was how do we make the right choices in those difficult circumstances.

Pauline Chiou: So the question is, how do you make the right choices? How do you communicate country to country? And, Dr. Hotez, you published a book titled Preventing the Next Pandemic. And one of the themes, the major theme is vaccine diplomacy. Can you explain what that is? And is that the key to preventing the next big one?

Dr. Peter Hotez: Well, it’s certainly one of them. Two things before I do a deep dive into vaccine diplomacy: first of all, an unsolicited note of support for the Institute for Health Metrics and Evaluation at the University of Washington and how important that institution became during this pandemic. It probably wasn’t set up to monitor the progress of pandemics. But, you know, Chris, you and your team really and your Institute really rose to the occasion and provided really important and timely information on what was going on, on the cable news channels, you know, several times a day and talking with journalists. The first thing I would do in the morning often was was checking the IHME website. So you really provided a lot of critical and timely information. I’m very, very grateful for that. 

I think the other, as Chris points out, is the high variability. The plastic genome of this COVID-19 virus really did make planning difficult. I mean, as soon as you thought you understood the Alpha variant, then how the Delta variant was behaving, you sort of knew where this virus was going. And then nature threw us a pretty rough curveball with these highly variable new Omicron sequences and going to BA.1, BA.2, BA.4, and BA.5.

And then the Scrabble variants, XBB and others that really, really made planning difficult. I think, you know, for me, one of the big lessons that we’ve seen is that the public health impact of this COVID virus was only one aspect because this virus decimated global economies. It really affected international security and affected the the security of the United States.

And I’m still not convinced we’ve learned that lesson of how we have to recognize that pandemic X, we have to treat a pandemic the same way we would treat the the Chinese sending ships into the Straits of Taiwan to take Formosa or take Taiwan again or the Russian invasion of Ukraine.

I think it’s that serious level. And I don’t think we’ve really quite done that yet. I think we still think this is a one-off event. And what I like to say is, you know, Mother Nature has not been quite with us. She gave us SARS in 2002, severe acute respiratory syndrome. She gave us Middle Eastern respiratory syndrome in 2012.

Now COVID-19, she’s telling us pretty much what the plan is. Every seven years, she’s going to hurl a major coronavirus epidemic/pandemic at us. And I think it’s happening because of this confluence of social determinants such as urbanization and deforestation. Together with climate change, we can get more granular about how that actually happens. The point is, I think we’ll have a fourth major coronavirus pandemic before the end of this decade, based on that every seven year idea. And we still have not put the belts and suspenders and everything in place that that we need for that.

I’m happy to address vaccine equity if that’s where you’d like to go because obviously that’s been my passion.

Pauline Chiou: Yeah, absolutely. In terms of vaccine equity, and this is a question for both of you, we saw certain communities hit the hardest during the pandemic, communities of color and women. And part of that was access to health care, access to vaccines, the distribution and the rollout. So as we have this backdrop that Dr. Hotez set up for us with getting ready for the next one, how do we make sure we have equity for the communities that have been hit the hardest and streamline rollout of vaccines?

Dr. Peter Hotez: I think it’s clear that we also paid a pretty heavy price for not having vaccine equity. Not only of the humanitarian tragedy that resulted from that and loss of life, but also the fact that even it was in our own enlightened self-interest. Remember that the Delta variant arose out of an unvaccinated population out of India and the Omicron variants out of an unvaccinated, under-vaccinated population on the African continent.

So the world paid heavily for that lack of vaccine equity. And what I attribute it to is a certain amount of upstream science policy failure. So I have somewhat an iconoclastic view on this that I think the policymakers were so focused on speed and innovation and getting some really, really interesting vaccines like mRNA and adenovirus vector vaccines and particle vaccines, and really did accelerate the whole field of vaccine biotechnology.

But there was so much emphasis on speed and innovation, nobody at the policy level had the situational awareness to say, well, maybe we should also have, in addition to the shiny new toys, have some older technologies that could be scaled and produced locally by low- and middle-income country (LMIC) vaccine producers. And I think what happened was, as any engineer will tell you, when you have a brand new technology, there’s a learning curve before you go from 0 to 10 or 12 billion doses.

And with a brand new technology, eventually the doses came, but too little too late. And had we worked better with the LMIC vaccine producers that band together, they call themselves the developing country vaccine manufacturing network, I think we could have done a much better job. So we did that. We developed a low-cost recombinant protein COVID vaccine specifically intended to partner with LMIC vaccine producers and transferred the technology with no patent to India that scaled up and made Corbevax and then Indonesia that made IndoVac and got 100 million doses administered pretty quickly.

But we had to do that without the benefit of public funds and without Operation Warp Speed funds and other funds. And so I think the other lesson learned is how we work with LMIC local manufacturing earlier on. I think we still need to learn that lesson because I still think we talk about 100 days and it’s all about speed and innovation.

And  I’m an MD, PhD scientist. I love speed and innovation as much as anyone. But it has to be balanced better. We need to find a way to balance that vaccine production ecosystem to make us less dependent on the multinational pharma companies. I think that the mistake was, in addition to the overemphasis on the innovative technologies, thinking that all the multinational pharma companies had the chops to do this.

And it’s important not to demonize the pharma companies. They did a lot of good. They did a lot of good for the Gavi Alliance in the pandemic. But we have to balance out that ecosystem or, some call it, decolonized ecosystem. And I think we provided a path for doing that. And I hope for the next pandemic we can do a better job.

Pauline Chiou: Dr. Murray, do you see other possible solutions in being able to streamline vaccine equity and access.

Dr. Christopher Murray: You know, the very poor performance of getting vaccines to people in low- and middle-income countries, or particularly low-income countries, had all the elements that Dr. Hotez is talking about. But there’s also the problem that was there and getting worse about lack of confidence or vaccine hesitancy, depending on how you want to describe it. And you know, recent data suggests, that will be coming out hopefully in the next month or so, that we’re in an all-time low for vaccine confidence, that the whole experience of the pandemic has lowered people’s willingness to even vaccinate their children with proven lifesaving vaccines.

And so I think that’s a huge issue for us as a community and one for which the road back to building confidence is not so obvious. I think that the debates that have been out there, you know, some of the reaction to vaccine mandates has created a much more entrenched set of doubters in science and in vaccines that we really need to address.

Otherwise, even if we have the low-cost locally produced vaccines, people won’t take them. 

Dr. Peter Hotez: I totally agree. In fact, Chris, I have a new book coming out about this. It’ll be out this summer, also published by Johns Hopkins Press. It’s called The Deadly Rise of Anti-science: A Scientist’s Warning. And it really does a deep dive into, starts with the United States. You know, some estimates say the COVID mRNA vaccines in the US may have saved as many as 3 million lives.

But the flip side of that is 200,000 Americans during the Delta wave, after vaccines were widely available by the last half of 2021, 200,000 Americans needlessly lost their lives because they refused a COVID vaccine. And mostly where I am in Texas and other Southern conservative states and up some of the Mountain West states, which are also very conservative, there was a needless massive loss of life because of a rise in anti-vaccine activism.

And we actually look at the source of where that came from. But now this is not confined to the US. And I think Chris is right. It’s these anti-vaccine activist groups and some of the governments that are linked to the anti-vaccine groups. It’s not like they’re going to fold the tent and go home after COVID-19.

They’re now targeting all childhood vaccinations. And so I’m worried, very worried. There’s been a kind of a tear in the matrix of the whole vaccine ecosystem. And we know that with the social disruptions in the pandemic, our ability to vaccinate kids in general went down. That’s not so surprising. And it is, yes, it’s slowly coming back up.

But here’s what’s happening. It’s not coming back to baseline. And so we seem to have sort of this permanent, or hopefully it’s not permanent, but significant rupture in, whatever you want to call it, the social contract or certainly this disruption that will affect the whole vaccine ecosystem. And I was at WHO at the end of last year talking about this.

I think we have to really start looking at what’s driving this. I think too often we kind of just throw it out there saying it’s some random junk on the Internet. We call it the infodemic, or we call it misinformation. And I think it’s none of those things. I think it’s organized, it’s deliberate, and it’s politically motivated.

And the reason we have to talk about it is that it’s a killer. When you think of 200,000 Americans dying because of anti-vaccine aggression or activism, that’s not a small number. That’s up there with all the other big societal killing forces. And now that it’s globalizing, we’re going to have to really look at this. And I think, and in the book and in my experience, it’s now contaminating the low- and middle-income countries on the African continent and South Asia.

And some of the same forces are doing that. It’s going to affect introduction of new vaccines. Remember, we’re hoping to introduce new RSV vaccines or new malaria vaccines. And I think it’s going to affect that as well, in addition to the existing childhood immunizations.

Pauline Chiou: So this is a troubling picture that you’re painting if we’re trying to prepare for the next pandemic in order to combat that. Dr. Murray, is data sharing and and being more transparent country to country part of the solution here?

Dr. Christopher Murray: It certainly is. And unfortunately, I think we are not really in a better place now than when COVID showed up in terms of the sort of expectations and norms around sharing data and being transparent. You know, we struggled everywhere in the world. Some countries produced very quickly daily numbers on cases and hospitalizations and deaths, and that was great.

But even here in the US, it took until late in the fall of 2020 before hospital admissions were being reported. And it actually took a letter from Vice President Pence at the time to hospitals to report in the first place. And then it took Congress asking HHS to release that to the public late in 2020.

And it’s just been this constant balance where public health authorities have wanted to not share data too much either with their own people or between countries, because they want to control the narrative. And usually I think they’re well-motivated. But I think in the long run, it’s not good for anybody when that happens. And then we see more recently with Omicron and China, a sort of a complete collapse starting in November of any meaningful reporting about what was happening with Omicron.

Dr. Peter Hotez: And now, and not only the data sharing and data availability, but the data analysis that wasn’t really coming from governments. I mean, thank goodness for the Institute for Health Metrics and Evaluation, right? Because you need, just to have the data and collect it is not sufficient, it has to be interpreted. You have to be able to shape a story for the policymakers and help people understand as best you can using current data where this is going.

And that didn’t happen a lot. I was fairly critical of the CDC early on in the pandemic. I think they are righting the ship. But, why wasn’t the CDC doing this and why weren’t more of the major government public health entities doing this?

Ultimately, fortunately, we had really strong university-based organizations that came to the rescue. But I think there’s some lessons that need to be learned from that as well.

Dr. Christopher Murray: Yeah. And I think in the setting of a national global crisis, you want the data sharing. But as Peter said, I think you really want a plurality of voices. You don’t want to count on one monolithic group, wherever they are, to tell you this is what it means. I think we’re all better off if we get some diversity in viewpoints out there.

And so, what can we do to make that happen in the future and right the ship, is really very urgent for us to address as a country and globally.

Dr. Peter Hotez: I think another issue is, we really, now that there’s hearings going around COVID origins, and I’m of the strong belief that it came from bats to people likely through a second intermediate animal host, meaning natural origins. But beyond that, we don’t really understand it on a very granular level. We really don’t know it at a very detailed level.

You know, how this virus, how the coronaviruses are jumping from bats to people probably hundreds or thousands of times every day. And then every few years one catches fire and gains critical mass. We’ve never really done the outbreak investigation in central China that needs to be done where people are going into central China and collecting samples from bats and livestock and people and exotic intermediate animal hosts to really understand that.

And I think we’re going to condemn ourselves to the fourth one since we haven’t really done that. I get frustrated sometimes about the gain of function conspiracies or even the lab leak because I think it’s a distraction because it takes away from the focus where it really needs to be and understanding at a very granular level.

I’m worried that the outcome of some of these hearings is going to tie up the virologists to make it harder for them to work at a time when we need our virologists and bat ecologists and epidemiologists out there really helping us understand how this evolved and telling us when the next one is coming, whether it’s out of China or elsewhere in Southeast Asia. We know bats are infected with coronavirus in a belt going all the way from China to Cambodia and up into Japan and throughout other continents as well. That’s the example of Middle Eastern respiratory syndrome.

And we’re not doing that. If anything, we’re trying to put in place a new set of rules to make it harder for us to make that happen.

Pauline Chiou: But in the absence of that granular authority that you’re looking for, Dr. Hotez, as we prepare because this podcast is what have we learned and how do we prepare for the next one, what are the best next steps?

Dr. Peter Hotez: Well, I’ll say this, it’s also unfair to say we’ve learned nothing and we haven’t done anything. I mean, after every epidemic, pandemic, things do get a little better. I mean, right after the surge in 2002, we put in IHR 2005, International Health Regulations. After H1N1 flu, we put in Global Health Security Agenda, after Ebola, we put in CEPI.

And then I’m sure there will be some positive things that happen after this pandemic. It’s the depth and breadth and scope that’s missing to really bring in the leaders of the G20 countries to want to take this on at a more substantive level. And I think some really positive things happened.

It’s hard to see a lot of silver linings here, but one of them is the fact the way the scientists did work together in unprecedented ways and sharing data and putting it up on Bio Archive or Med Archive and being quite selfless in how they shared data and getting the journal editors to to put up papers in a timely manner without generally sacrificing quality.

So I think in terms of the community of scientists, we worked together at unprecedented levels. And you know, I would think nothing of picking up the phone to call Chris or Ali Mokdad or whatever, say, hey, what the heck do you think’s going on there? We were doing regular Zoom calls with colleagues. So there were positive interactions as well.

Pauline Chiou: And Dr. Murray, do you share that positivity that there have been some silver linings as we’re trying to prepare for the next pandemic?

Dr. Christopher Murray: I think there’s definitely some silver linings. I think the ebb and flow of concern about pandemics is to be expected. I guess I’ve been surprised at how quickly many politicians are wanting to forget about COVID. It was such a nightmare politically. I think the normal process of such a huge cataclysm and then the sort of learnings that will come from it, I think it may take some time.

Dr. Peter Hotez: Yeah, well, even worse, what we’re seeing also is a lot of efforts at revisionist history. You’re seeing this play out in the House hearings, that all of a sudden, it’s not the virus that killed people, it’s the vaccine that killed people, which is utter nonsense. Or using the word lockdown when generally speaking, there weren’t really lockdowns. There were efforts for social distancing and forgetting how scary it was for teachers and everything else.

And so now what you’re seeing are groups that are rewriting this history to fit their own political agenda and at the expense of the scientists.

Dr. Christopher Murray: On the revisionist history front, I’m worried that it’s going to take away from our response arsenal some things that really did work like social distancing and mask wearing. And then the next time around, people say, well, you know, there’s all this evidence they didn’t do anything. You just have to look at flu to recognize that flu went away because social distancing and mask wearing works.

But it’s incredible. And we’ll see more of this revisionist history. I think it won’t go away quickly. And I think it’s very important to try to put all sides together and not to let that revision of what happened become the dominant narrative. Back to what we can do, I think even just having a more open and transparent threat monitoring and having the data reported to everybody who cares in the scientific community and any of the public who care to know is so important.

If we don’t become more vigilant about these threats, then we’re going to once again lose the first two or three months when a threat emerges. And that’s just catastrophic.

Pauline Chiou: And in terms of that threat monitoring, Dr. Murray, you’ve mentioned that it’s important to have vehicles that are not tied to governments in order to have that kind of data sharing. So what does that look like? Is that private organizations, scientists collaborating together?

Dr. Christopher Murray: Well, you definitely want the strongest possible government, public health sector, and lab-based surveillance, but you need more than that. I don’t think that what went wrong with COVID was we didn’t have enough invested in labs. The investments are good. But what went wrong was, you know, really slow decision-making. So if you leave it strictly to behind closed doors, committees, governments are making the choices.

We could easily end up with a two- to three-month delay again. And that’s why I’m in favor of a pluralistic model of threat surveillance, public discourse, so that it’s not so easy to ignore threats the next time around.

Dr. Peter Hotez: You mean create something like a network of organizations.

Dr. Christopher Murray: A network of science-based organizations that supplement what governments are reporting and doing, so that there’s a vigorous discussion of what is the risks and benefits of acting now versus waiting for a particular pathogen. If you’ve got a matter or one of the existing alert systems, you know, there’s five or ten a day now and we can’t respond to all of those, but we need to figure out which ones have what sort of risk and then start to know when you bump it up to a higher level of concern based on extra data that’s coming in.

But we don’t have that sort of system in place. And what systems do exist is very much not in the public domain.

Dr. Peter Hotez: I think the other companion to that is how we communicate threats and communicate the changing nature of the pandemic. Chris, listening to you and Ali and others from IHME, and what I tried to do is we did something a little different from what the HHS agencies often did, which is, somebody told them that they have to talk to the American people like they’re in the fourth grade or the sixth grade.

And that’s sort of an old fashioned way of communicating science. What I found, which was very successful and I think you did this as well, is realize that the American people are willing to tolerate a pretty high level of complexity if their lives depended on it, or the lives of the loved ones did. And that’s one of the things that I think we did is we gave them our assumptions and said, here’s how we came to this conclusion based on X, Y, and Z.

And I think very many people find that very helpful in terms of helping them decide what was best for them and their families. And I think too often what we saw in the agencies in both administrations, although again, it’s getting better, was sort of summary statements saying, we’re this agency, here’s what we think.

I think that fell flat often. And I think part of it was because at least in the US, you had two very different types of populations. You had one group that was all in and hey, doc, just tell me what I need to do to keep myself and my family safe. And then you had another that was full down the rabbit hole of Fox News every night as documented by Media Matters, and they were sending misinformation on it every night and they weren’t listening to anyone.

And I think what the agencies did, the federal agencies, including CDC, was to try to reach the American people with one voice. And it came out like baby talk and turned out that nobody liked it.

I think figuring out how we can keep that kind of communication at a high level and a consistent level and based on scientific principles is going to be really important.

Pauline Chiou: One thing that’s for certain is there was this huge hunger for information during this whole pandemic. And to your point, Dr. Hotez, about this complexity and this desire to learn more about the complexity of what we were going through, that was certainly reflected in in how people were just researching everything. You know, RNA was not in most people’s vocabulary before this pandemic.

So well. Dr. Peter Hotez and Dr. Chris Murray, thank you so much for this very insightful conversation. We really appreciate it.

Dr. Peter Hotez: Thank you. I appreciate the opportunity.