America's experience with COVID-19 left us with an odd result. We pulled off something scientifically extraordinary and came out of it with less confidence in many of the institutions responsible for making it happen.
In less than a year, scientists, regulators and manufacturers developed, tested, reviewed and began distributing vaccines against a virus that medicine hadn't even known existed. That wasn't a shortcut. It was the payoff from decades of work in mRNA, immunology, viral vectors and related technologies, coupled with a willingness by government and industry to dispense with some of the usual bureaucratic dawdling. We moved fast because we were able to move fast.
A lot of Americans saw it differently. Speed looked suspicious. Emergency Use Authorization sounded like government-speak for “experimental.” When public-health recommendations changed, people quite reasonably asked why something they had been told with great confidence in March was no longer the advice in September. We didn't do a particularly good job answering them.
In The Illusion of Over, our new book, we discuss the dangerous tendency to confuse being finished with a pandemic with a pandemic being finished with us. Viruses don't care that we've moved on. Biology doesn't operate according to election cycles, news cycles or public-opinion polls. Declaring victory has never been a particularly effective strategy against infectious disease. Influenza should be reminding us of that right now.
Last year's flu season was classified by the CDC as highly severe across every age group, with an estimated 51 million illnesses, 710,000 hospitalizations and 45,000 deaths. It was the first high-severity season since 2017-18. Those are serious numbers. Yet flu has become part of the scenery. It comes back every year, we have vaccines and treatments for it, and most people don't give it much thought until they or somebody they know gets sick. We've become accustomed to flu. That doesn't make it less dangerous.
Washington traditionally thinks about pandemic preparedness in terms of things we can count: laboratories, surveillance systems, stockpiles, manufacturing capacity, clinical-trial networks and regulatory readiness. We need all of them. COVID demonstrated why.
But COVID also exposed a weakness that can't be solved by buying another million doses of vaccine. People have to trust the institutions asking them to take it. And here's where public health needs to own part of the problem.
During COVID, public-health officials sometimes spoke with more certainty than the evidence warranted. When the evidence changed, the recommendations changed. To scientists, that's normal. Science changes when the facts change. To a person sitting at home, however, the message was simpler: You told me something different six months ago.
We shouldn't wave away that reaction as ignorance or misinformation. Sometimes people misunderstood what public-health officials were saying. Sometimes public-health officials didn't explain themselves very well. And sometimes government got it wrong.
Social media certainly made matters worse. Preliminary studies were presented as established fact. Legitimate disagreements among scientists were turned almost instantly into political arguments. There was no shortage of self-appointed experts willing to provide certainty where none existed. But blaming social media is also a convenient way for government institutions to avoid looking in the mirror.
FDA, CDC and other public-health agencies need to get more comfortable saying, “We don't know yet.” They need to explain what they know, what they don't know, why a decision was made and what new information might cause that decision to change.
That's basic regulatory science.
The same applies when an agency makes a mistake. Admit it, explain it and correct it. Americans can handle uncertainty. What they don't handle particularly well is being assured that there isn't any.
Scientific independence matters too. Every White House wants answers during an emergency. So does Congress. That's understandable. But regulators aren't there to produce the answer somebody wants. Their job is to tell us what the evidence supports, even when the answer is inconvenient.
Medicine is moving toward gene editing, engineered cell therapies, AI-assisted diagnostics, individualized cancer vaccines and treatments for smaller and more precisely defined patient populations. These are enormously promising technologies. They're also difficult to explain. Try doing that in a 20-second television interview.
At the same time, confidence in scientific institutions has become more fragile. That's a problem we should be working on now, rather than discovering it again in the middle of the next emergency. We need vaccines, diagnostics, surveillance, manufacturing capacity and stockpiles. But we also need an FDA, CDC and other public-health institutions with enough credibility that when they tell Americans something important, people are willing to listen.
That kind of credibility takes time to build. It can't be ordered up when the emergency starts.
Flu season gives us a chance to work on it every year. COVID does too. Neither attracts much attention anymore, which may be precisely the problem. There will be another serious infectious-disease threat. I don't know what it will be, and neither does anyone else. But when it arrives, American science will again be asked to move quickly. I'm confident that we can. What worries us more is what happens after the scientists do their job.
We can develop a vaccine in record time. We can have sophisticated diagnostics, enormous manufacturing capacity and some of the best regulatory scientists in the world. But none of that gets us very far if a significant portion of the country doesn't believe the people telling them why those tools matter.
That's part of what we mean by The Illusion of Over. COVID may no longer dominate the headlines, but the damage it did to public trust didn't disappear with it. We have time to repair some of that damage before the next pandemic. We shouldn't waste it.
Peter J. Pitts, a former FDA Associate Commissioner, is President of the Center for Medicine in the Public Interest.
Gregory Poland, MD, is the Mary Lowell Leary Emeritus Professor of Medicine, Infectious Diseases, and Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic.
