The US is making the same mistakes with the H5N1 bird flu virus as with Covid, even as the highly pathogenic bird flu continues to spread on US farms and raise alarms that it could mutate to become a pandemic, public health experts argue in the New England Journal of Medicine.
“We close our eyes to both the Covid pandemic and to a possible burgeoning bird flu [pandemic] on the horizon,” says Gregg Gonsalves, associate professor of epidemiology at the Yale School of Public Health and co-author of the article. “Our ability to react quickly and decisively is the big problem.”
Beyond the outbreaks — of Covid, bird flu, mpox, measles and other dangerous pathogens — the inability or refusal to learn the lessons of each crisis is the most pressing health issue facing America, he said. “The social epidemic of forgetting is likely to be the more worrisome public health event of 2024.”
A lack of testing, opaque data, political divisions, poor access to health care and a sense of hubris — all plagued the Covid response, and now these mistakes are playing out over the bird flu response, Gonsalves said.
“We haven’t really done anything to address what’s happening in terms of the further spread of bird flu across the US – we’re back to the same old mistakes,” he said. “At the moment the imminent risk is low and we have not yet seen human-to-human transmission. But the point is, we’re not waiting for that to happen. Right?”
World officials have feared an H5N1 pandemic since the first human case was detected in 1997.
Highly pathogenic influenza viruses have been closely watched for decades for their pandemic potential, and it was in part because of their monitoring for pandemic-potential pathogens such as these that the The US was number 1 for pandemic preparedness in 2019.
But when hit by a new respiratory virus, SARS-CoV-2, the US fared far worse than other countries in the global north, with at least 1.2 million deaths and millions more sickened and disabled by the virus .
Experts are still unraveling the reasons why – and trying to draw attention to these failures before the next avoidable crisis.
A lack of testing and monitoring of the virus has plagued the Covid response, from the limited and flawed tests in the early days to the lack of testing which continued. Likewise, scientists now know that H5N1 circulated in cattle for months before being detected, and reporting indicates that infections among farm workers may also be underreported. Some employers at farms were reluctant to cooperate with health officials — much like the meatpacking industry was with Covid, Gonsalves said.
The confusing and Byzantine structure of federal, state, and local agency responsibility also creates significant challenges. Although there have been calls for the US Centers for Disease Control and Prevention to be given greater powers to lead federal responses to pandemics due to Covid, no such changes have been made.
Agencies still struggle with jurisdiction and cooperation, and there are also significant differences between federal, state, and local approaches. With Covid, “we had a patchwork of state responses, some more robust than others, and we paid for it”, Gonsalves said.
The constraints on public health forces have only worsened due to Covid. At least 26 states new laws introduced to place restrictions on public health authorities during the pandemic.
Iowa and Tennessee, for example, now ban mask requirements in schools, and health officials cannot close schools in Wisconsin.
This is very worrying because the next pandemic could greatly affect school-aged children, which has historically been true of influenza, Gonsalves said. “We are fixated on what just happened, and have no imagination of what a new pandemic might bring.”
The next pandemic virus could spread even faster and be even more deadly — and that’s true even if the virus itself is no longer virulent because of the lack of funding for, trust in, and authority from public health, he said. .
Recent decisions of the US Supreme Court, including invoking the “big questions” doctrine and overturning the Chevron precedentmeans that federal agencies likely need explicit authorization from Congress, which can be divided and slow to act, to act quickly and stop new outbreaks.
“We’re basically being told, ‘Ignore what’s happened just over the last four-plus years, ignore what’s happening now with bird flu, and let’s tie your hands behind your back in terms of being able to respond when the time comes,’” Gonsalves said.
Political fractures have only worsened during the Covid pandemic and threaten to derail efforts to contain infectious disease outbreaks.
Growing anti-vaccine sentiment can block the development and distribution of new and existing pharmaceuticals, such as vaccines, once they have gone through the complicated and expensive process of development. Operation Warp Speed, a massive and successful project to quickly produce Covid vaccines, ended instead of becoming a regular component in pandemic response.
Inequalities have hindered vaccine distribution even now. “We have a broken health care system, which means if you can’t get a vaccine because you don’t have insurance right now, you’re out of luck,” Gonsalves said.
Those who can afford it may have access to quality health care in the US, but serious gaps remain for those who are uninsured or underinsured. The US health system has “the most fancy tertiary care in the world”, he said, but it stumbles on primary care, preventive medicine and public health. “We’re not good at the basics.”
Great inequality meant that some patients were able to access some of the most sophisticated care in the world, while others struggled to find enough masks, ventilators and treatments. While other countries have cushioned the worst of the pandemic’s blows with social safety nets, many Americans have been left to fend for themselves, Gonsalves said. And the focus on individual health overlooks the role of public health, which is by definition collective.
Despite these fatal missteps, the US has never had a Covid commission to analyze what went wrong, as countries like the UK have. There was a two-pronged effort to create a query similar to the 9/11 commission, but it got frustrated.
It was America’s sense of misplaced and continued confidence that it was handling the pandemic as well as it could that may have damaged its response the most, Gonsalves said. “We have a very inflated view of our abilities, capabilities and willingness to do the right thing.”
For example, officials have reiterated that “we have the tools” — yet treatments and vaccines are quickly becoming outdated as the virus evolves, while access issues and misinformation persist and other precautions, such as isolation for the duration of illness, are no longer recommended.
There is still time to correct these mistakes, the experts said.
“Everyone is extremely grateful that we are not caught in a loop of 2020, in which we have hospitals overflowing, morgues overflowing and we have no refuge from the virus,” Gonsalves said. But “we can do a lot more”, from updating respiratory virus guidance with the latest evidence on transmission to improving indoor air quality.
The Covid pandemic was “one of the most important historical events in the United States of the last 100 years, in terms of public health. We all suffered,” Gonsalves said. “The best way to avoid the pain we’ve felt over the past four years is to be prepared.”
