America Is Still Not Ready for the Next Outbreak

With the acute phase of the COVID-19 pandemic barely in the rearview mirror, already a new round of public health threats is facing doctors and epidemiologists. In March, the U.S. Department of Agriculture confirmed that avian influenza A, also known H5N1 and bird flu, had made the leap from wild birds to dairy cattle. The virus has been detected in at least 129 herds across 12 states. Inactivated virus has been found in some 20 percent of commercial milk samples, suggesting that even more herds may be affected. A survey of wastewater data hints at the same conclusion. Already, three dairy workers, two in Michigan and one in Texas, have been confirmed as infected. Thankfully, unlike in previous outbreaks—when approximately half the people infected with H5N1 died—these workers’ illnesses were mild.

At the same time, a new outbreak of mpox is alarming epidemiologists in the Democratic Republic of the Congo. Although the 2022 outbreak in the United States was primarily spread through the sexual networks of gay men, the current outbreak in the DRC seems to be spreading through contact between household members and between heterosexual partners. This is especially concerning because the strain of the virus involved is more deadly than the one that fueled the 2022 outbreak, with an estimated case fatality risk of five to ten percent.

Although neither of these events is dangerous to the American public right now, the future remains opaque. Making matters worse, the United States’ ability to mount an effective response has gotten worse, not better: despite the experience of the COVID-19 pandemic, the country is less equipped to respond to public health challenges than it was five years ago. One of the main problems is the way in which public trust in health authorities plummeted during the pandemic. To regain the trust of the American people, it is time for epidemiology to borrow best practices from other fields where failure is not an option, such as commercial aviation. When there is a disaster onboard a U.S. civilian aircraft, the National Transportation Safety Board immediately investigates and issues recommendations to prevent the same scenario from ever happening again. Through this process, the public maintains its belief that it is safe to fly. Americans need to trust that public health measures are also there to protect them and that failure will not be tolerated.

THE DEMONIZATION OF PUBLIC HEALTH

A poll conducted by the Kaiser Family Foundation found a nearly ten-point drop between December 2020 and April 2022 in the percentage of Americans who say they trust the Centers for Disease Control and Prevention (CDC). Another poll, this one conducted by the Pew Research Center in 2022, found that 46 percent of Americans thought public health officials were unprepared for the COVID-19 outbreak, and 32 percent said that officials were too slow to respond to changes during the outbreak. This state of affairs will make it more difficult to enlist members of the public to do their part in managing the next threat—a scenario that is already evident in the demonization of Anthony Fauci, the former director of the National Institute of Allergy and Infectious Diseases, and the growing antivaccine sentiment among some Americans.

And it is not just trust that is deteriorating. The legal infrastructure and resourcing that makes outbreak response possible is eroding. The U.S. Congress, for its part, has been reluctant to support some important public health measures. The CDC has not been granted the authority to require state and local jurisdictions to report outbreak data, and Congress has not renewed legislation that requires the reporting of hospital admissions for COVID-19. Even amid the unfolding outbreak of H5N1, there is legislation on the House floor that would legalize the sale of raw milk, which is known to carry H5N1 virus as well as a host of other diseases. This attempt to loosen restrictions in the midst of an outbreak underscores how some policymakers are failing to take the threat of epidemics seriously.

Support for funding, too, has been thin. The CDC’s funding for public health preparedness and response has been waning for years; the inflation-adjusted budget shrank by 20 percent between 2003 to 2023. This money supports not just federal public health but also public health activities at the state and local levels. As a result, budget constraints are felt in communities, not just in Atlanta, where the CDC is headquartered.

Moreover, substantial funding that was created during the pandemic response has been rescinded. Genomic epidemiology, for example, was awarded $1.75 billion in the American Rescue Plan. That money was used to track variants of SARS-CoV-2, elevating the United States to the top contributor of genomic sequences in the world. But there is not a plan to sustain this capability once ARP funds are exhausted. And some of the public health funding provided during the COVID emergency was clawed back during the debt ceiling negotiations, to be reallocated by Congress for other purposes.

A new outbreak of mpox is alarming epidemiologists in the Democratic Republic of the Congo.

In 2021, I helped establish the CDC’s Center for Forecasting and Outbreak Analytics to help predict and track the course of infectious disease outbreaks. (The center funds work to translate outbreak modeling into public health practice at the Center for Outbreak Response Innovation, where I am director.) Already, CFA anticipated the 2022 Omicron wave and helped guide the mpox response. Now, however, anemic funding has put the center’s mission at risk. Although $55 million was appropriated in the fiscal year 2024 budget, those dollars had to be split with other work at the CDC that allows state and local public health departments to report data on infectious diseases. This puts the center short of the $100 million operating budget that would allow it to grow into an organization that could do for infectious diseases what the National Weather Service does for dangerous storms.

At the state level, the situation is even more precarious. Many state legislatures have stripped legal authorities from their public health departments. For example, according to the Network for Public Health Law, North Dakota no longer allows state health officials to require face masks, even if someone is infected with a deadly disease. Montana no longer allows health officials to mandate quarantines. And Arizona now prohibits hospitals and other employers from requiring vaccination against infectious diseases like influenza and COVID-19.

Perhaps most concerning of all is a palpable lack of urgency and purpose at all levels of government. The H5N1 outbreak began in wild birds in 2020 in Europe and reached North America in 2021. Years have passed in which public health officials could have been preparing to mount a robust response, and yet there is little evidence that such preparations had begun until just recently. For example, the CDC has not updated since 2017 the documents meant to serve as the country’s blueprint for responding to a flu pandemic, and so the plans reflect none of the lessons learned during the COVID-19 pandemic. And officials seem to be doing little to understand and prepare for a scenario in which the strain of mpox affecting people in Congo comes to the United States.

Not all outbreak preparedness and response activities are public. Authorities are likely doing more behind closed doors than is readily evident. But that, too, is reason for pause. Americans and people in the rest of the world rightly demanded transparency during the pandemic, when early reports from China and then Italy foreshadowed the fate that New York City and, later, the rest of the United States suffered. Later, genomic surveillance data reported by other countries was pivotal to identifying and anticipating new variants and their impacts. Public health should continue to facilitate more transparency, not less, in the face of emerging threats.

A NO-FAIL MISSION

There are some simple, if not easy, fixes to these woes. Public health needs durable, flexible government appropriations that can ensure that any response to a public health emergency is funded quickly and generously. There is also a clear need to expand the authority of public health officials in certain areas: for example, Congress ought to allow the CDC to compel and direct data reporting during public health emergencies.

But the bigger problem for public health officials is figuring out how to regain the trust and respect of elected representatives and the U.S. public. In his book The Checklist Manifesto, the surgeon and writer Atul Gawande details the airline industry’s use of checklists to prevent deadly flight errors. Gawande tells the story of a critical incident that nearly led to a disaster involving a Boeing 777 plane carrying 152 passengers. At the end of an uneventful trip from Beijing to London by way of the North Pole, the plane mysteriously lost power to both engines. The pilots were forced to make an emergency crash landing at London’s Heathrow airport. Forty-seven people were injured, one seriously.

Immediately following the incident, the Air Accidents Investigation Branch, the institution charged with aviation safety in the United Kingdom, deployed a team of professional investigators to identify what caused the loss of engine power. The team worked for two years, poring over the aircraft’s components, the electrical system, the fuel lines. At every turn, they came up empty. No signs of damage or malfunction could be found.

Finally, after every plausible cause had been ruled out, the investigators arrived at a seemingly fantastical hypothesis. Perhaps during the polar segment of the flight, the conduit that fed fuel to the engine developed ice crystals. Then, when temperatures rose as the plane descended, the slushy mixture dislodged into the engine and interrupted its workings.

The U.S. Congress has been reluctant to support some important public health measures.

Thousands of flights cross the North Pole each week, and none had ever experienced such a problem. Still, in the aviation industry, the acceptable number of safety incidents is zero. So safety experts set about devising a protocol in the form of a checklist that could keep ice crystals from disrupting the engines, should it ever happen again. The checklist was added to the procedure book that every flight team uses while on a Boeing 777, anywhere in the world.

Ten months later, disaster struck again. A flight team piloting a jet from Shanghai to Atlanta lost power to both engines during its descent after a trip over the North Pole. They pulled out their protocol book, located the checklist devised after the Boeing incident, followed the recommended procedure, and restored power to the engines. The passengers aboard never knew anything was amiss. They did not need to. Everything was under control.

Gawande used this story to illustrate the power of checklists to help even experienced experts execute complex protocols without relying on the frailties of human memory. But the story reveals something else, as well. Outbreak response, like aviation safety, must be a no-fail mission. Just as planes cannot be allowed to fall out of the sky, disease outbreaks cannot grow unchecked. Every avoidable error should be investigated and accounted for.

But what the aviation industry has, epidemiology does not: a process by which to improve. After the Boeing accident, professional investigators worked relentlessly to diagnose the problem, and then a permanent fix was disseminated and universally adopted by all crews on Boeing aircraft. In outbreak epidemiology, there are no similar mechanisms. At best, the epidemiologists involved conduct their own after-action review, the results of which inevitably languish on a shelf. In the worst (and most common) case, there are no opportunities for learning or reflection after outbreaks at all.

The results speak for themselves. In 2020, across nearly 4.4 million flights totaling 8.3 million flight hours, there were zero aviation fatalities in the United States. In fact, there have been no aviation fatalities in seven of the last ten years. In contrast, more than a million Americans have died from COVID-19, leaving the United States with a higher death toll than that of any other country. Mpox, a disease for which the United States stockpiles vaccines, tests, and therapeutics, has infected over 32,000 people domestically. H5N1 is disrupting the dairy and poultry industries, and epidemiologists fear it may someday adapt to humans. Although these outbreaks likely could not have been prevented entirely, they should never have been allowed to grow so large.

THE SURGICAL PAUSE

Epidemiologists should commit to a plan of action to transform outbreak response from an ad hoc, reactionary enterprise to one more akin to fields such as aviation, where the tolerance for accident and error is zero, and where there are reliable processes in place to drive continual improvements. This concept, known to systems engineers as “high reliability operations,” should guide the changes epidemiology needs to make in the months, years, and decades ahead.

High-reliability industries such as aviation, aircraft carrier operations, and surgery are generally organized around at least one organization that identifies and disseminates best practices, provides trainings, and has an oversight or independent investigation function. The National Transportation Safety Board, for example, is an independent government agency tasked with investigating transportation accidents. The board does not have an any regulatory or implementation authorities but simply makes recommendations based on its findings. The Marine Spill Response Corporation, founded in 1990 after the oil tanker Exxon Valdez dumped 11 million gallons of oil into Alaska’s Prince William Sound, is a nonprofit organization that was established to meet congressional requirements for high reliability in the oil and gas industry. These examples, and others that are similar, could be models for an organization that could drive epidemiology’s transformation.

The benefits of a high-reliability approach would be myriad. Regaining the trust of the American people hinges on excellence. Embracing this approach could also restore the confidence of those hesitant to increase the CDC’s funding and authority because of doubts about the agency’s performance. And high reliability could facilitate outbreak responses that are faster, more effective, and less disruptive to the people affected.

Public health is not a patient the United States can afford to lose.

Longtime public health practitioners will note that the laws and regulatory infrastructure differ greatly between public health and commercial aviation. Public health is primarily governed at the state and local levels, whereas aviation is federally regulated. Moreover, public health depends on the behaviors and choices of the public, which is diverse and autonomous; aviation safety, in contrast, relies only on professionals such as pilots and air traffic controllers. These differences are substantial, but they do not override the enormous benefits that could be gained from a new approach.

Like aviation, surgery also underwent a transformation in recent decades with the introduction of checklists, standard operating procedures to prevent errors and complications, and other principles of high reliability. In an operating room, for example, anyone can call a time-out. From the attending physician wielding the scalpel to the circulating nurse handling the documentation, every member of the team has not just the permission but also the obligation to halt proceedings if they think something is amiss.

During the pause, the surgical team confirms the basics of the task at hand: Is it the right procedure, on the right body part, for the right patient? Does anyone on the team have concerns that must be addressed? What more needs to happen to ensure the best outcome?

Epidemiology has no equivalent of a time-out. But it needs a pause right now so that officials can learn from the experience of the past five years. Public health is not a patient the United States can afford to lose.