Editor’s Note: David Holtgrave, PhD, is the dean of the University at Albany School of Public Health and SUNY Distinguished Professor. His three-decade career in public health has included senior positions at the Centers for Disease Control and Prevention, Emory University and Johns Hopkins University, and he served on the Presidential Advisory Council on HIV/AIDS during President Obama’s administration. The views expressed in this commentary are his own. View more opinion at CNN.
The White House Office of Science and Technology Policy has just listed “ending the Covid-19 pandemic” as an administration achievement; however, the epidemic continues to worsen.
And a number of administration errors have led to the current dire circumstances.
We all know what a mistake in medicine looks like. A surgeon performs a procedure and leaves an instrument inside a patient; that is an obvious medical error. But in public health, what constitutes a mistake is a bit more elusive since there are often multiple stakeholders and decision makers charting a course for an entire population.
Sometimes you can pinpoint a public health error (the crisis of lead in the drinking water in Flint, Michigan, being a clear example). But mostly the responsibility becomes more diffuse and harder to gauge.
In an academic paper, I’ve offered a possible definition: “a public health error occurs when one or more stakeholders in a public health system commit a cognizant, negligent act of commission or omission that fails to achieve necessary public health outcomes.” Simply being too complacent in the face of a grave public health challenge could be considered an error. Given this definition, the current administration has committed multiple public health errors that have harmed the national Covid-19 response.
First, the Trump administration failed to adequately acknowledge the existence of the Covid-19 challenge publicly early on as evidenced by the President’s comments about the first Americans to be infected such as “… the 15 within a couple days is going to be down to close to zero …” cases, or “it will go away.” This explicit downplaying of Covid-19 was either an act to overtly spread misinformation or it was a reflection of complacency, but in either case it led to an inadequate Covid-19 response.
Second, the administration, and the Centers for Disease Control and Prevention in particular, had difficulty developing and rolling out initial testing strategies leading to serious delays in the necessary uptake of testing for SARS-CoV-2, the virus that causes Covid-19. For weeks, testing in even hard-hit areas was limited to diagnostic tests for hospitalized people or health care workers rather than population-level testing. Diagnostic testing is still too slow in some areas and testing for asymptomatic persons is still insufficient. The US got off to an avoidable slow start in testing, is still catching up, a key administration adviser on Covid-19 is actively arguing against the testing of people who don’t have symptoms, and the President has been known to say, “slow the testing down please.”
Third, the administration provided some personal protective equipment but failed to make supplies of it for health care workers and schools available at the scale necessary to meet the needs. Without sufficient supplies of the basic equipment needed, it is hard to protect yourself from SARS-CoV-2.
Fourth, the administration reportedly pressured for FDA Emergency Use Authorizations of treatments such as hydroxychloroquine without sufficient evidence of potential effectiveness, eventually leading to a withdrawal of the hydroxychloroquine EUA, but not before the interest in this one drug diverted massive efforts in the medical, public health and research communities to focus on a drug that ultimately garnered scant evidence of effectiveness in well conducted studies.
Fifth, even after states like New York showed that physical distancing (in many forms), mask use, avoidance of large gatherings, hand sanitization, staying home when ill, and other basic techniques served to bring down cases, hospitalizations and death rates, the administration encouraged states to abandon such effective strategies even in the face of widespread community transmission (such as in Florida) and if they did not, the President encouraged residents of jurisdictions such as Michigan to “liberate” their state.
Sixth, the President chose to demonize researchers whose findings did not suit him (such as calling the work of researchers finding no benefit to hydroxychloroquine, an “enemy statement”), thereby putting some scientists in the position of not only defending their science but also their motives for conducting urgent and important research in the first place. Such assaults on science and scientists can lead researchers to think twice about engaging in potentially lifesaving work, and can set back the scientific process such that evidence-based answers to pressing societal challenges are slower in their evolution.
Seventh, White House Task Force member Dr. Scott Atlas and Secretary of Health and Human Services Alex Azar have met with and embraced proponents of the Great Barrington Declaration. The Declaration proposes to achieve herd immunity (before a vaccine is available) by protecting older persons yet removing most SARS-CoV-2 preventive measures among young people. Although he did not cite the Declaration, White House Chief of Staff Mark Meadows recently said on CNN that “we are not going to control the pandemic,” a sentiment consistent with the Great Barrington document. This herd immunity approach has been widely criticized by many in the public health community, because by not having in place the necessary preventive precautions, it could yield substantial expansion of Covid-19 cases in the US and induce serious increases in morbidity and mortality.
Eighth, the President interpreted his personal experience of receiving world-class, life-saving, experimental medical care from a single-source, government run and supported program to be the kind of care that everyone in the US can have (especially as he supports the destruction of the Affordable Care Act, the means to health insurance for millions in the US). Further, based on his experience of medical care privilege, he told the residents of the US not to fear Covid and to not let it dominate their lives … clearly dangerous health care advice for many and especially those without access to the same level of health care he enjoyed.
Ninth, the President, his administration and his campaign have held or attended events in which they ignored most if not all public health recommendations for Covid-19 prevention. For instance, the first family brazenly took off their masks at the initial presidential debate despite the rules of the Commission on Presidential Debates and the Cleveland Clinic health care experts on site. One is reminded of celebrity Fernando Lamas saying, “it is better to look good than to feel good.” Well, that ironic phrase is not one we utilize in public health.
Tenth, the devastating disparities of Covid-19 in communities of color are matters of social justice, and yet the President barely seems to notice or acknowledge them. Clearly, to alleviate the suffering from Covid-19 in the US, one must address the injustice of these racial, ethnic and socioeconomic disparities and begin to better build health equity.
Eleventh, if the administration wanted to address these issues, there would be a comprehensive, evidence-based national Covid-19 strategy, but there is no such national plan at this point. Without a plan in place, there can be no tracking of key metrics, no informed mid-course corrections, and little accountability.
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Twelfth, there are instances when members of the administration are giving out risky information, undermining the American public’s ability to inform and protect itself. Just recently, White House adviser Dr. Scott Atlas tweeted “Masks work? NO” (synergistic with the President’s less than enthusiastic attitude toward mask use), despite substantial evidence to the contrary.
It is difficult to assess the precise number of deaths, life years lost, and lives disrupted by this collection of errors of commission, omission and complacency, but it is clear that a large number of the over 225,000 lives lost to Covid-19 could have been saved had these errors been avoided with straightforward, evidence-based precautions in place, delivered at the necessary scale, and provided at the right time.
Going forward, I encourage the administration and all public health decision makers to keep in mind this definition of a public health error, to avoid such serious mistakes, and to accept the responsibility for their errors when they do occur. Just like surgeons go to great lengths to avoid leaving instruments inside of patients, we must avoid errors in public health. With either type of error, the outcomes can be deadly and in public health the devastation can be even more widespread.