The Next Pandemic

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April 2, 2023

Nash Weerasekera

When Dr. Neil Vora watched the television show “The Last of Us,” he thought that its zombielike creatures were improbable but the show got one thing right: Climate change is increasing the risks for outbreaks.

Dr. Vora has seen many epidemics up close; he investigated them with the Centers for Disease Control and Prevention. And while he thinks the next pandemic will most likely be viral, he argues in this essay that the changes seen in the natural world, including changes to fungi, are alarming. The World Health Organization agrees. Scientists worry about the long-term impact a warming planet will have on disease, including novel ones. We shouldn’t wait to find out.

— Alexandra Sifferlin

Fungi Are a Public Health Blind Spot

By Neil Vora

“The Last of Us,” a postapocalyptic television thriller, recently concluded its first season with a stunning finale. However, as a physician and horror superfan, I found the show’s beginning more striking: A 1960s talk-show host asks two epidemiologists what keeps them up at night. “Fungus,” one replies.

He’s worried about a real-world species of Ophiocordyceps known to hijack the body and behavior of ants. Fast forward to the show’s central, fictional drama: a pandemic caused by a type of that fungus, which mutated as the world grew warmer. The new version infects humans and turns them into ravenous, zombielike beings whose bodies are overtaken by mushrooms.

Fungal epidemics in humans are infrequent, in part because human-to-human transmission of fungi is rare, and I am not aware of any involving zombielike creatures. It’s far more likely that the next pandemic will come from a virus. But the idea that climate change is making the emergence of new health threats more likely is solid. Could it cause a fungus ubiquitous in the environment to morph into a lethal pathogen in humans? It’s possible.

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Scientists like me worry that climate change and ecosystem destruction may be creating opportunities for fungal pathogens to grow more infectious, spread over larger distances and reach more people. For example, Candida auris, a drug-resistant yeast that can be deadly in hospitalized patients, may have gained the ability to infect people thanks to warmer temperatures, according to some researchers. On March 20, the Centers for Disease Control and Prevention said Candida auris has spread at “an alarming rate” in health care facilities and is “concerning.”

But international efforts to strengthen global health security rarely consider fungal pathogens. Given that the risks are growing, that leaves us unprepared and failing to take adequate steps for their prevention. No fungal vaccines exist, diagnosis is complicated and costly, and there are not enough drugs to combat fungi. Unless governments fund research to better address fungal disease and reverse the environmental factors that fuel their emergence, we will remain vulnerable.

For many plants and animals, fungi are a scourge. Fusarium wilt, which devastates banana plants and for which there are limited treatments, is spreading globally and is a major threat to the multibillion-dollar banana industry. An infection known as white-nose syndrome has killed millions of bats across North America. Ninety amphibian species have gone extinct from chytridiomycosis, a dreadful disease that causes a frog’s skin to fall off.

Humans have largely been exempt from fungal outbreaks because of our warm blood — 98 degrees Fahrenheit, too hot for many fungi to survive. That could be changing. A January study in the journal Proceedings of the National Academy of Sciences found that heat kicked a fungus called Cryptococcus deneoformans — which can infect humans — into evolutionary overdrive, increasing certain genetic mutations fivefold. This means more opportunities to develop dangerous adaptations, such as heat tolerance and drug resistance. In another lab study, a research team grew and heated a type of fungus known to kill insects. After four months, under laboratory conditions, two strains could reproduce at about 98 degrees Fahrenheit, up from a previous limit of about 90 degrees.

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Some microbiologists believe climate change is already accelerating fungal evolution in nature. Their theory is that global warming may have selected for strains of Candida auris in the environment that could survive at higher temperatures. This allowed the yeast to break a thermal barrier that previously limited spread, such that it gained the ability to infect warm-blooded birds — and humans exposed to those birds.

A changing climate may also increase the transmission of fungal disease. These microorganisms are everywhere: kitchen counters, backyard soil and the air we breathe. Typically, systemic fungal infections occur in immunocompromised individuals — cancer patients, organ recipients and others — who have inhaled spores from their environment. But regional outbreaks among healthy people are of increasing concern since flooding, cyclonic winds and wildfire smoke can create conditions for fungi to flourish and spread.

Counterintuitively, so can drought. In the American Southwest, long periods without rain have dried out the earth, leading to dust storms. Reported cases of Valley fever, a once-rare respiratory illness caused by soil-borne fungal spores, have soared nearly tenfold since 1998; the fungus has also spread to new regions, including Washington State.

A warming planet is creating more vulnerability in humans, too. Reduced crop yields, for example, lead to malnutrition, while heat stress causes kidney disease. At the same time, deforestation, inadequate safety measures on farms and commercial wildlife trade increase the risk of so-called spillovers, where viruses like Ebola jump from animals to people. Fungi, nature’s savviest opportunists, will use these disturbances to their advantage. We saw this in the 1980s as fungal infections surged alongside H.I.V., a virus that emerged from spillover. We also saw it more recently when a unique fungal disease affected thousands of people in India who had received immune-suppressing steroids as part of their treatment for Covid-19.

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Last October, the World Health Organization created a list of “fungal priority pathogens” for the first time. “Fungal pathogens are a major threat to public health,” the group wrote. This was an important symbolic gesture, but it does not give doctors what they need: better tools to fight these infections. There are no approved vaccines. Globally, many countries lack the capacity to diagnose certain common fungal diseases. Even in New York City, where I treat patients, it can take weeks for some to receive a diagnosis for fungal infections. Worse yet, many fungal pathogens already are resistant to the few antifungal drugs we do have available.

In part, this is a technical challenge: It’s difficult to develop antifungals that don’t also destroy our cells. But we cannot develop cures if we don’t try — and right now, fungal research output is abysmal. For example, cryptococcal meningitis, a fungal infection, kills more people than bacterial meningitis caused by Neisseria meningitidis, yet the latter receives over three times as much research funding.

Fungal pathogens simply haven’t been on government funders’ radar — they receive just 1.5 percent of all research funding for infectious disease research. Likewise, pharmaceutical companies have little incentive to invest in research and development, because the potential profit is limited.

To help fill this void, the National Institutes of Health must increase support for the study of fungal diseases, as it recently did for Valley fever. The U.S. Biomedical Advanced Research and Development Authority, which helps develop vaccines and drugs for public health emergencies through public-private partnership, must also make them a priority. Currently, none of the 83 initiatives listed on the B.A.R.D.A. medical countermeasures portfolio website are for fungal pathogens, though it has announced its support for the development of novel antifungals.

This moment also calls for humility. In the 1960s, some prominent experts erroneously believed infectious diseases were a diminishing threat. But nature is full of surprises. From 2012 to 2021, I investigated outbreaks with the Centers for Disease Control and Prevention. As my colleagues and I responded to Ebola, rabies, poxviruses and coronaviruses, we saw firsthand how the ways people interact with the environment and animals can surface disease in horrific and unexpected ways. Often, we don’t learn how devastating these diseases are until we are in the midst of a full-blown emergency. With only 5 percent of an estimated 1.5 million fungal species identified to date, fungi are perhaps the great blind spot in public health.

Our health depends on a delicate ecological equilibrium. Maintaining that balance — by weaning ourselves off of fossil fuels to slow climate change and halting the loss of nature to prevent viral spillovers — is perhaps our best hope for avoiding a fungal horror show.

Dr. Neil Vora is the pandemic prevention fellow at Conservation International and led New York City’s Covid-19 contact tracing program from 2020 to 2021.

You Ask, Experts Answer

Dr. Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, responded to reader questions about fungus and other threats.

After reading Ling Ma’s novel “Severance,” Hanya Yanagihara’s “To Paradise” and watching and playing “The Last of Us,” it seems that pandemic-causing fungal infections are making their mark in art and literature. If we ever experience a fungal pandemic, in terms of transmission and potential deadliness, how might that be different from a viral pandemic? What kind of precautionary measures might there be? — Jason, Seattle

Rivers: Fungal pathogens do seem to be having a moment in popular culture, and in this case, art and life echo each other. To answer your question, I called Dr. Tom Chiller, chief of the mycotic disease branch at the Centers for Disease Control and Prevention. “We have emerging fungi discovered every year,” he told me. Some, like Candida auris, do not typically affect healthy people but can cause severe disease and death in people who are immunocompromised. Others, like Valley fever, only spread in certain environmental conditions. With these constraints, fungi are unlikely to cause a pandemic as disruptive as Covid-19.

But Dr. Chiller cautions that we must remain vigilant. The geographic range of Valley fever and other environmental fungi are expanding with climate change. The fungi that cause ringworm and athlete’s foot are evolving to be highly drug-resistant. One fungus common in Brazil, Sporothrix brasiliensis, has gained the ability to easily spread between cats and humans. These developments are reminders that disease surveillance systems must include fungi, and that more research for drugs and vaccines to combat fungal infections is needed.

Considering the current stage of climate change, what kind of microorganisms are potentially most dangerous to humanity? — Helena David, Rio de Janeiro

Rivers: While not microorganisms, mosquitoes and the diseases they carry are leading infectious disease threats, and climate change will likely make matters worse. Globally, vector-borne diseases account for one in six infections and cause hundreds of thousands of deaths each year. Even in the United States, mosquito-borne diseases are growing in importance.

In recent years, Puerto Rico has fought epidemics of chikungunya, Zika and dengue. And earlier this month, the C.D.C. reported the first cases of locally acquired (or autochthonous, for vocabulary enthusiasts) dengue in Maricopa County, Ariz. Milder winters and changes to rainfall and animal migration patterns are projected to expand the range of disease-carrying mosquitoes and put new populations at risk. These are just a few examples of infectious diseases spread by mosquitoes popping up in previously unexpected places.

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April 9, 2023

Ian Cheibub

“You know what’s better than a vaccine mandate?” my colleague Ezra Klein asked last year. “A society that doesn’t need one.”

Research during the Covid-19 pandemic suggested that countries that fared better tended to have high levels of social trust. Government and interpersonal trust were associated with more vaccinations and possibly fewer infections.

But how do you build trust in places with untrustworthy leadership? This is a question the science journalist Amy Maxmen explored on a recent reporting trip to Brazil. She makes the case that grass roots efforts in the country’s favelas built trust among citizens and helped protect them. For instance, Brazilians got vaccinated in high numbers despite having a president at the time, Jair Bolsonaro, who undermined Covid-19 vaccination campaigns.

— Alexandra Sifferlin

Brazil’s Favelas Offer Lessons in Building Trust

By Amy Maxmen

RIO DE JANEIRO — Thiago Nascimento expected no help from the government when the coronavirus arrived in his neighborhood. ‌‌He was worried because, as in other favelas — informal settlements throughout the city — people were made vulnerable by a lack of income, safe housing and clean, running water. ‌ A study later showed that people in favelas were twice as likely to die if they had Covid-19 than those in higher-income neighborhoods in the city.

Mr. Nascimento’s faith in government assistance went from bad to worse as the pandemic wore on. Amid a surge of cases in May 2021, the police conducted a drug raid in his favela, Jacarezinho, which caused 28 deaths, injured additional bystanders and terrified residents. When community members built a memorial to honor the dead, police demolished it with a crowbar and an armored vehicle. “This broke any trust,” he told me. ‌

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Thiago Nascimento, the founder of LabJaca.

Experts often cite mistrust of the government as a key reason certain communities ‌have suffered disproportionately during deadly outbreaks, including Ebola and Covid-19. Mistrust is a serious problem in a pandemic if it prevents people from obeying health recommendations, seeking medical care and accepting vaccines.

‌In marginalized communities, ‌‌mistrust is often rooted in a history of discrimination, neglect or abuse at the hands of authorities. The onus to mend those relationships should therefore be on governments that have proved untrustworthy, and that requires political change. But the next pandemic — or another disaster — may strike sooner. In the meantime, health officials and researchers would be wise to learn how to assist the communities that are most in need. That starts with recognizing the grass roots power that has kept them resilient for so long.

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Lessons lie in Brazil’s favelas because, in the face of decades of government neglect, many have created internal systems to support one another. When Covid-19 began to spread and people were out of work, community leaders like Mr. Nascimento raised money to provide ‌food and face masks for those in need. In Jacarezinho, Mr. Nascimento co-founded a collective called LabJaca to report Covid-19 data because ‌he and others suspected that official counts ‌had underestimated ‌case loads. Journalists and community leaders in other favelas were attempting something similar, and soon LabJaca was one of several groups feeding data into a dashboard tracking the disease across 450 favelas in Rio de Janeiro.

Members of LabJaca at the organization’s headquarters in Rio de Janeiro.

In the hilltop favela of Morro dos Prazeres, Janice Delfim, a community leader, printed out lesson plans for children when schools closed because their families didn’t have computers at home. And when the kids complained of hunger, she appealed to non‌governmental‌‌ ‌organizations for donations of food, face masks and hygiene products‌. In other favelas, community leaders installed faucets in heavily trafficked paths so that people without running water could wash their hands.

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‌‌Brazil’s ‌president at the time, Jair Bolsonaro, ‌denied the gravity of Covid-19 as hospitals overflowed. He encouraged mass gatherings and unproven treatments. He disputed the worth of face masks and, later, of vaccines. But even when health authorities broadcast recommendations for people to wash their hands and stay home, Ms. Delfim said their words rang hollow ‌for those ‌living without running water or the ability to work from home. “Our reality is different,” she told me.

Fernando Bozza, a doctor and public health researcher at Fiocruz, a research institute in Rio de Janeiro, realized the need to work at a grass roots level as Covid-19 began to spread in favelas. ‌‌He and other Fiocruz scientists partnered with the non‌‌governmental organization‌‌ Redes da Maré, ‌‌which had long served Rio’s massive Maré favela and residents from the community.

A resident of Complexo da Maré receives care.

Through this coalition, scientists provided free Covid-19 tests. When someone tested positive, a member of the group would offer to deliver food, cleaning supplies and masks to the person’s home, as well as provide check-ins with a health worker over the phone. Residents in the coalition also relayed circulating rumors‌‌ for the scientists ‌‌to correct‌‌. And those who were influential in local WhatsApp groups‌‌ or on Instagram or TikTok created messages to combat the misinformation. “It was a continuous listening process with people from the community leading,” Dr. Bozza says.

Such coalitions emerged around the world. In California’s hard-hit Central Valley, local researchers cooperated with grass roots organizations serving farmworkers to roll out testing and care. In Goa, India, a network of community‌ correspondents‌ that had long been working in rural districts of the country partnered with Lieve Fransen, a doctor and advis‌‌er in global public health based in Belgium. Dr. Fransen held daily video calls with the correspondents about how to treat the severely sick when ‌clinics were overwhelmed or too far away. When Covid-19 vaccines rolled out, she says that uptake was high because of the trust that people had in these correspondents, which had been built over nearly 20 years.

Community-led initiatives should be evaluated with the same rigor as any intervention. In an unpublished report, Dr. Bozza and his colleagues found that weekly Covid-19 deaths dropped by 60 percent in Maré after eight months of their work with the coalition, compared to a 28 percent reduction over the same period‌ among a similar number of people living in similar favelas in Rio.

It’s more complicated to study the impact of community-led work on longer-term problems, like diabetes, poverty and low educational attainment. These issues render people vulnerable to pandemics, so they’re important to tackle. Jason Corburn, a public health researcher at the University of California, Berkeley, who has been trying to improve such metrics ‌‌in nearby Richmond, warned that this work takes time. “Some of these problems are 20 or 80 years in the making, so we need to track them over time, incrementally‌,” he said.

‌Despite a recent push for more community-led efforts in public health, alliances built during the pandemic are dissolving as projects shut down with the decline of Covid cases. Such quick exits breed mistrust because people may feel used by researchers who seem only concerned with a fleeting cause, as opposed to their welfare.

Another problem that befalls public health initiatives meant to include communities is that they often devolve into tokenism as advice from residents is brushed aside. Researchers and health officials don’t easily hand over the reins, said Mr. Corburn. “Letting communities lead goes upstream against the tide of science, expertise and bureaucracy that has been embedded in our institutions for 250 years.”

Nonetheless, the communal spirit survives with or without outside support. ‌Today Mr. Nascimento is connected with community leaders across many favelas and they continue to coordinate efforts. Lately, they’ve tackled police violence and assisted residents rendered hungry or homeless by flooding.

Ms. Delfim’s residents association has grown larger because more people want to help out. There’s no shortage of work to be done, and it comes with mental health benefits that emerged during the pandemic and live on. “We came together,” she said‌‌. “It was like collective therapy.”

Amy Maxmen is a science journalist and a press fellow at the Council on Foreign Relations.

You Ask, Experts Answer

Dr. Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, responds to reader questions about trust and misinformation.

How do we correct for the mistrust and misinformation that circulated during this most recent pandemic? — Jennifer Wallace, Los Angeles

Rivers: I worry about this a lot. Misinformation is pervasive — and it’s not just around pandemics where falsehoods are flourishing, it’s also topics like childhood immunizations, international politics and election integrity. I don’t know how we find our way back, but I do wonder if public health is missing the mark by trying to beat back the torrent of misinformation. There is so much more we must do to strengthen crisis communications and ensure people have access to timely, high-quality information. I would rather see the public health community devote resources to improving that capability, rather than attempting to match manufacturers of misinformation move for move.

Like climate change, pandemic risk awareness and understanding, accompanied by a willingness to take meaningful action, are largely driven by education. But there is such disparity in education in the United States, which is exacerbated by the whims of political and religious extremism, that it seems an unrealistic hope that we can adequately prepare for future pandemics. Are there specific approaches that might address this conundrum? — Michael Schultz, Northern Michigan

I take heart in the solidarity and cohesiveness we saw in the early days of the pandemic. Although mitigation measures like mask use and social distancing became contentious as the pandemic ground on, most people were open to taking steps to keep themselves and their families safe. In June of 2020, for example, 80 percent of people said they wore masks in public some or all of the time. After vaccines became available, 80 percent of adults got vaccinated, including nearly 95 percent of older adults. That is an overwhelming response.

I don’t want to paper over the serious challenges that we face. Confidence in public health officials has eroded, and basic disease control measures have become politicized. Public health has a lot of work to do to rebuild trust. Still, I think it’s instructive that there was robust collective action at the outset. If public health officials communicate clearly, frequently and honestly, people will listen.

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Ibrahim Rayintakath DAVID WALLACE-WELLS How Did No-Mandate Sweden End Up With Such an Average Pandemic? Reconsidering the country’s libertarian Covid response. By David Wallace-Wells

Erin Schaff/The New York Times EZRA KLEIN The Covid Policy That Really Mattered Wasn’t a Policy Public health is rooted in the soil of trust. By Ezra Klein

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April 16, 2023

Nash Weerasekera

Patients have long played a leading role in the medical and social response to outbreaks. One striking example is gay men in the early years of the AIDS crisis. The same group was active against mpox, formerly known as monkeypox, the University of California San Francisco physician Ina Park and the author Dan Savage write in a guest essay. Gay men, they write, raised alarm about the disease that was primarily spreading within their community and helped protect themselves and others with an aggressive vaccination and awareness effort. Examining how this group was able to honestly and forthrightly navigate concerns about stigmatization in order to confront and stamp out the mpox outbreak in the United States can — and should — provide lessons for how to respond to future pandemics.

— Alexandra Sifferlin

How Gay Men Saved Us From Mpox

By Ina Park and Dan Savage

For weeks, the same awkward scene played out again and again in sexually transmitted infection clinics across the United States. Half-naked gay men stood with their pants around their ankles while clinicians crouched between their legs, swabs at the ready. The clinicians were covered head-to-toe in hazmat chic: gowns, gloves, face shields and N95 respirators. The men were covered in something much worse: painful lesions, on their genitals, their anuses and sometimes even their faces and limbs.

It was July of 2022, just last summer, and an outbreak of mpox — formerly known as monkeypox — was in full swing. From a handful of cases in a few cities in early May, the outbreak surged to more than 16,000 cases in 75 countries and territories just two months later. It was terrifying.

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The sudden appearance of so many mpox cases everywhere and all at once was shocking. Aside from an occasional case among travelers from countries in West or Central Africa, where the virus is endemic, mpox was extremely rare in Europe or North America. The United States had seen only one outbreak, back in 2003, among Midwesterners with pet prairie dogs that had been housed with infected African rodents. There were 47 cases then and no documented cases of human-to-human transmission.

This time was different. In early May of 2022, mpox found its way to gay raves in Spain and Belgium, huge annual parties that draw men from all over the world. Clothing was scant, grinding was plentiful and when the parties were over everyone flew home. Within weeks, mpox cases — resulting from human-to-human transmission — began cropping up in cities worldwide.

While the outbreak caught the public unaware, public health officials had been warned. Five years earlier, Dr. Dimie Ogoina had observed unusual cases in Nigeria, first in an 11-year-old boy and then among young men who’d reported multiple sex partners or encounters with sex workers. He soon realized that this was not “the regular monkeypox we know” and tried to alert the scientific community about the possibility of sexual transmission.

And just as we were grappling with proof that Dr. Ogoina was right about everything — right that something had changed, right that mpox was transmitted sexually and right to raise the alarm — testing revealed that the mpox virus could survive on linens or clothing for more than two weeks. While we were both primarily concerned for those already suffering from mpox and those at highest risk of contracting the virus, we feared what might happen if mpox made its way into hotel rooms and onto cruise ships and college campuses. (Think of all those frat house couches that are rarely cleaned.) This outbreak could become an epidemic, perhaps even a pandemic.

Luckily, we were wrong.

While mpox could live on surfaces, it turned out it didn’t spread that way. The virus required close, sustained contact to spread, which is why it was fanning out overwhelmingly through sex. So this outbreak that started in gay and bisexual communities mostly stayed in those communities, but not for long. On Jan. 31, 2023, the federal government declared an end to the mpox emergency, as average case counts fell from a peak of over 450 per day in early August to less than five during the last week of January. While the outbreak in the United States lasted just under nine months, it caused plenty of damage, resulting in more than 30,000 cases and 42 deaths.

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While the outbreak ended faster than many believed it would, it was far worse than it needed to be, representing both a public health triumph and a public health failure. Both health officials and the media failed to expediently warn and engage the gay community in the outbreak’s crucial first weeks.

When the first cases were reported among gay and bi men in the West, health authorities and the media couldn’t bring themselves to say the word “gay.” To avoid stigmatizing gay and bi men, early reports buried the lead. The Associated Press didn’t mention that this outbreak was being seen almost exclusively in gay men until 15 paragraphs into one report; other reports didn’t mention gay and bi men at all. A gay man scanning headlines in May of last year might have learned of an outbreak — but unless he had traveled to West Africa recently, or had contact with infected rodents or primates, he could have easily concluded that he wasn’t at risk.

While this desire to avoid stigmatizing gay and bisexual men was understandable, it wasn’t helpful. We know gay sex has been unfairly blamed for everything from natural disasters to the fall of Rome. But in their efforts to avoid stigmatizing the community, health authorities and the media failed to effectively warn gay and bi men. Ignorant of the threat as the virus spread, gay and bi men couldn’t take steps to protect themselves and their partners.

Unfortunately, stigma and discrimination found the community anyway. Gay men with mpox were turned away from urgent care clinics and emergency rooms. Phlebotomists refused to draw their blood. Like its predecessors Covid-19 and H.I.V./AIDS, mpox had all the makings of a public health disaster. It took nearly two months into the outbreak for testing to become widely available. A dearth of vaccines created “Hunger Games”-like scenarios in cities throughout the country, with vaccine clinics opening and then shutting their doors for lack of supply. Cases began to appear in a small handful of transgender people and cisgender women and children, raising alarm about wider spread.

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Even after it was evident that this painful, potentially disfiguring or even fatal infection was spreading through gay men’s sexual networks, public health officials and the media were hesitant to give the same advice they had given freely at the beginning of the Covid pandemic: Limit your number of sex partners and express your sexuality in socially distanced ways.

But while health officials and journalists hesitated, gay and bi men sprang into action. Young men with lesions covering their faces took to social and mainstream media, telling the public that they were dealing with “the worst pain I’ve experienced in my life” and perhaps the most telling: “I’d rather have Covid.” Benjamin Ryan, a gay journalist, and Carlton Thomas, a gay doctor, risked cancellation — e.g., being yelled at on Twitter — to dish out what Dr. Thomas referred to as “tough love” advice for their community: Slam the brakes on sex outside of committed relationships; seek immediate medical care for symptoms; and get vaccinated as soon as possible.

And the gay community listened.

Gay party promoters canceled long-planned events and individual gay men temporarily deleted hookup apps from their phones and reduced their sexual contacts. The Centers for Disease Control and Prevention verified these shifts in behavior, reporting that half of gay men surveyed reduced their number of sex partners, one-time sexual encounters and use of dating apps during the outbreak. And gay and bi men got vaccinated in droves; two-thirds of those surveyed by the Pew Research Center in September 2022 reported that they had already received an mpox vaccine or were planning to do so. Gay and bi men endured frustrating attempts to secure appointments for the crucial first dose of the two-dose series and hourslong waits at pop-up vaccination sites. Of the over one million doses of the Jynneos vaccine (protective against smallpox and mpox) administered in the United States since June 2022, more than 90 percent were given to men (presumably gay and bisexual men).

Communications teams at the C.D.C. made great strides during this time. They acknowledged the realities of gay sexuality and its breadth of expression, using the actual language gay men use when discussing sex with each other. The words “fetish gear” appeared on a C.D.C. website for the first time; the clinical term “anus” became the more user-friendly “butthole,” and instead of “public sex environments,” the C.D.C. spoke frankly about “back rooms” and “sex parties” and the risk of contracting mpox in those spaces.

While those warning gay men to cut back on sex until they were vaccinated against mpox experienced accusations of fomenting stigma — echoing pushback experienced by gay men who urged others to avoid bathhouses and start using condoms at the start of the AIDS crisis in the early 1980s — efforts to shoot the messenger were less aggressive than in years past. One key difference between H.I.V./AIDS and mpox: Many of the messengers were gay and bisexual men themselves, including gay journalists, doctors and average citizens with access to social media, plus a generation of gay men who had been inspired to pursue public health careers in the wake of AIDS.

The C.D.C.’s chosen spokesman to lead national conversations on mpox and gay men’s sexual health wasn’t a straight doctor in a lab coat who squirmed at the mention of gay sex. Instead, it was Dr. Demetre Daskalakis, an out gay man who not only attends raves but posts shirtless selfies on social media to prove it. This was a messenger the community would listen to.

Gay and bi men had already written the playbook on activism and advocacy throughout the H.I.V./AIDS epidemic, resulting in more than $7 billion in federal funding for H.I.V. research, prevention, treatment and social services. Furious over the federal government’s initial response to mpox, they mobilized and organized, protesting at local Department of Health and Human Services offices and filing a complaint with the Massachusetts state attorney general over denial of mpox testing and treatment.

So while an early and frankly honest public health response could have blunted the outbreak, resulting in far fewer cases and far less suffering, the swift collective action of gay and bi men prevented catastrophe. If the broader American public had responded to the threat of Covid-19 the way gay and bi men responded to the threat of mpox, we might have seen fewer cases (there have been 100 million to date) and a lower death toll (1.1 million and counting). When the next infectious outbreak strikes (and surely it will), the public would be wise to channel gay and bi men: communicate openly without stigmatization, organize and insist on access to effective prevention, diagnosis and treatment.

There’s another important lesson about the gay community that health officials and journalists need to remember going forward: When it comes to emerging health threats — even ones that can spread sexually — gay men can handle the truth. You can give it to them straight.

Ina Park (@InaParkMD) is a professor of family and community medicine at the University of California San Francisco and the author of “Strange Bedfellows: Adventures in the Science, History and Surprising Secrets of S.T.D.s.” Dan Savage has been writing “Savage Love,” one of the most widely read sex advice columns in the country, for more than 30 years and is also the host of “Savage Lovecast.”

You Ask, Experts Answer

Dr. Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, responds to reader questions.

With both Covid and mpox, health officials took too long to realize that the diseases were not what they expected and missed the opportunity to contain them. What are they going to do differently next time? — Christian Collet, Montreal

I agree with your assessment; it did take too long to understand the epidemic potential of both diseases. Our public health systems are staffed by epidemiologists with deep experience and expertise, but there aren’t reliable mechanisms for implementing protocols and sharing learnings across jurisdictions. I worry we haven’t been able to leverage the lessons from Covid-19 and mpox (formerly monkeypox) to improve our ability to manage the next crisis. We need to develop those mechanisms if we want to improve outbreak response performance.

Based on what we know so far about epidemiology, virology and environmental factors such as climate change, changes in population, etc., what are the most credible hypothesized scenarios for the next pandemic? Is it likely to be airborne, spread through water? — Caitlin Thomas, New York City

The canonical origin story for a pandemic begins with an RNA virus that spills over from an animal reservoir like bats, birds or pigs to humans through close contact. Once it emerges in the human population, the virus travels through social networks, finding more and more hosts who can carry it around the globe. Viruses spread by respiratory transmission have the widest reach and their spread is difficult to interrupt, so droplet and airborne pathogens are especially concerning. Influenza pandemics are thought to begin this way, and so too did SARS in 2003 and now Covid-19.

That being said, there are many ways for pathogens to gain a foothold. Cholera, a waterborne disease, is surging in around 20 countries and is now a W.H.O. graded emergency. H.I.V. and mpox spread primarily through sexual contact. New vector-borne diseases are found regularly. I think we have to be alert to the full range of possible scenarios to be truly prepared.

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April 23, 2023

Nash Weerasekera

Bird flu has been a concern among scientists for a very long time. Whether the virus spills over to humans in a significant way remains unknown. But the way it’s behaving in nature — decimating bird populations — is enough of a concern, the journalist David Quammen writes. As Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, also says in an answer to a reader question below, even if the absolute risk for humans is small right now, “we should take the possibility seriously nonetheless and take steps to prepare.”

— Alexandra Sifferlin

Remember the Birds

By David Quammen

Experts are concerned that a new global disease outbreak, possibly worse than Covid-19, might begin any day. The virus that worries them is H5N1, a form of avian influenza, or bird flu. Some researchers have warned that with just a few mutations, or maybe a sudden swapping of gene segments, this deadly flu virus could gain the ability to spread from human to human.

But in fact, the next pandemic has already begun. To use a more accurate term, a panzootic — a widespread outbreak of disease among nonhuman animals — is underway.

To appreciate this catastrophe, we’ve got to move the focus off humans, at least for a bit. H5N1 is devastating the world’s birds. Eagles are dropping dead, as are great horned owls and peregrine falcons and pelicans. Twenty California condors recently died of what’s suspected to be avian flu — 10 are confirmed so far. It’s the worst thing that has happened to wild birds since the pesticide DDT.

Tallying deaths among wildlife in wild places, especially those flying through forests and over oceans, is hard. The Book of Matthew may assert that not one sparrow falls to earth without the knowledge and consent of God, but us mere humans can’t count how many raptors, waterfowl, shorebirds, ravens, parrots and other wild birds may be dying in places beyond notice. The results could be dire for some bird populations, even pushing endangered species closer to extinction. What happens when this killer virus gets into whooping cranes, of which fewer than 900 exist on the planet? What’s next for the California condor, with barely 300 birds alive in the wild?

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Seabirds that nest in great colonies are a little more visible. Such dense nesting also makes them more vulnerable to contagious disease, and many kinds are long-lived, maturing at relatively late ages, which leaves their populations slower to rebound. During nesting season last May, at a colony of sandwich terns on the coast of France, observers counted more than 1,000 tern corpses. France as a whole may have lost 10 percent of its breeding population within a week. At remote island sites in Britain, such as Orkney and the Shetlands, the great skua seems to have suffered die-offs of up to 85 percent.

Any such bird flu, so deadly, is called highly pathogenic avian influenza, or H.P.A.I. That label was once applied to viruses that infect chickens. Until this century, these kinds of viruses were virtually unknown among wild birds. The exception was an event in 1961, when 1,300 common terns showed up dead along the coast of South Africa. The cause was a new avian virus of the general sort that — we now know — wild aquatic birds carry endemically and sometimes spill into domestic birds, pigs and humans. For decades after that tern die-off, though, no other influenza so virulent was detected in wild birds. New influenzas did come from wild birds, yes, but in milder form, usually sickening domestic birds little or not at all. Evolving to become more lethal was something that happened, so far as science could see, mainly among farmed poultry.

A Belgian epidemiologist, Marius Gilbert, led a 2018 study of this phenomenon. Dr. Gilbert and his colleagues reviewed 39 cases in which a mild avian influenza had evolved into a killer virus. All but two of those 39 known conversions occurred among commercial poultry.

Is it going too far, I recently asked Dr. Gilbert, to conclude that commercial poultry farms are what deliver the problem of virulent influenzas upon us humans, and also upon wild birds? “No. I don’t think it’s too far,” he said. “But we have to bring nuance to that statement.”

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“Commercial poultry” can mean there’s a vast and dense aggregation of birds — thousands, or hundreds of thousands, in industrial-scale operations — or it can mean 10 chickens and six ducks in the backyard of a family in a rural village. The ducks share the rice paddy with wild birds passing through, and some of the chickens are sent live to a local market. Viruses flow in every direction, including to the children who tend the ducks.

The currently circulating H5N1 lineage of avian flu emerged back in 1996, among farmed geese in a rural area of Guangdong province in southern China. Its kill rate among those geese was 40 percent, with symptoms that included bleeding and neurological dysfunction. At some point it passed into wild birds, spreading across Asia to Europe and the Mideast, and occasionally into humans and other mammals, though without triggering long chains of transmission.

In December 2021, it was detected among wild birds in Newfoundland and Labrador, and from there it seems to have been carried by migrating waterfowl down the Atlantic Flyway to the Carolinas, Georgia and Florida. That’s where Nicole Nemeth, a wildlife pathologist at the University of Georgia, encountered it, when bald eagles started arriving dead at her laboratory.

Dr. Nemeth and her colleagues found a high rate of bald eagle nest failure (no surviving chicks) and adult deaths, with dead birds brought to the lab and confirmed to be ravaged by the H.P.A.I. virus. “It was very sad and alarming,” Dr. Nemeth told me.

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Adult birds were losing muscle control, shaking their heads, showing signs of weakness or paralysis, keeling over, tumbling from their high nests. Bald eagles are big birds, weighing up to 14 pounds, so when they fall, they land hard. “As a pathologist, I was looking at these birds carefully, and they were clearly dying of a very severe, acute, viral infection,” Dr. Nemeth said. Some were probably dead by the time they hit the ground.

Necropsies revealed organ failure and brain inflammation, but also blunt trauma and bleeding from the long falls. And when the adults became sick and fell, the unfledged young usually died, too, either from the same infection or from orphanhood. In coastal Georgia, during the 2022 season, nesting success for bald eagles was down by 30 percent.

It could get worse. There’s very little, Dr. Nemeth told me, that either science or wildlife management can do. When the bald eagle population declined badly in the 1950s and then the species was declared endangered in 1967, the main cause of reproductive failure — DDT — was banned. The eagle population bounced back, a wondrous conservation success. But you can’t ban a virus like you can a chemical — not a virus that travels everywhere in wild birds and evolves continuously in domestic ones, which are raised in vast numbers on both industrial-scale farms and in backyards.

Our little world contains eight billion humans. It now also contains more than 33 billion chickens. This vast horde of domestic poultry is an important link in the chain of cause and effect that is killing wild birds all over the world. We should consider what can be done about that — if not by wildlife management, maybe by better managing ourselves.

We should think about how our access to cheap supermarket chicken, breasts and legs wrapped in plastic, kindles jeopardy for the hawks, falcons and owls of our forests, the ducks and loons of our wetlands, the vultures that clean away carrion, the crows that amuse us in town, the gulls and terns of our shorelines, the wild geese we enjoy hearing as they honk southward on an autumn night — and jeopardy also for ourselves. We should bear in mind that those 33 billion broilers and roasters represent a great petri dish for the continuing evolution of flu viruses. One such virus could well — just by chance — acquire mutations that make it the next human nightmare. The eagles would still be falling dead off their perches, a tragedy in itself. And the chickens, for us, would come home to roost.

David Quammen is a science writer and the author of “Breathless: The Scientific Race to Defeat a Deadly Virus.”

You Ask, Experts Answer

Dr. Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, responds to reader questions about bird flu.

Avian flu appears to be a top candidate for a pandemic. It is extremely lethal in birds and some animals. How likely is it that this virus will make the jump to humans, with sustained human-to-human transmission? — Steven Downing, Grand Rapids, Mich.

Over the course of the past year, highly pathogenic avian influenza A (H5N1) has caused a record-setting pandemic in birds. Tens of millions of commercial poultry have been culled in the United States, and the virus has been found in every state. The virus has also spilled over into numerous mammals, including dogs, cats, bears, foxes and even marine mammals like sea lions. Although H5N1 does not spread easily from person to person, widespread transmission in animals is giving the virus plenty of opportunities to adapt and evolve — which is something of a specialty for influenza. These factors make it one to watch.

Nobody knows how likely a human H5N1 pandemic is. My feeling is that the absolute risk is probably low, but we should take the possibility seriously nonetheless and take steps to prepare. I would like to see public health officials update their risk assessments, establish metrics and triggers for when to escalate the public health response and create detailed plans for what they will do if those triggers are tripped — just in case.

Since there is infrastructure in place to manufacture flu vaccines, could one be rapidly developed for H5N1 (bird flu) should that virus evolve the capability to spread among the human population? — Tim Rule, Columbia, Md.

There are a few options. As of 2016, the Pandemic Influenza Stockpile contained some 20 million doses of H5N1 vaccine, but it would need to be checked for effectiveness against the currently circulating strain, put into vials and distributed across the country. Even without the stockpile, the research and development pipeline for the influenza vaccine is very robust, since we exercise it every year for the seasonal flu vaccine. Still, it would most likely take several months to get shots in arms. For reference, the 2009 H1N1 pandemic was identified in April and the first doses were given in early October. Public health officials would probably recommend non-pharmaceutical interventions like masking while a vaccine is readied, which is why it’s troubling that those measures have become politicized.

[phkrause]

April 30, 2023

Nash Weerasekera

“Something clearly went wrong. And I don’t know exactly what it was,” Dr. Anthony Fauci recently told my colleague David Wallace-Wells in an interview about the Covid-19 pandemic.

In the earliest days of a pandemic, many decisions are made based on limited information. Ideally, when it’s clear one approach isn’t working, leaders can be nimble enough to switch gears or tweak recommendations based on evolving information. And hopefully we can learn clear lessons from the successes and failures of pandemic response to inform how we’ll handle future outbreaks.

Today’s newsletter looks at what we don’t know about the Covid-19 pandemic — specifically around the data used to understand the virus and to inform mitigations against it. Members of the group behind Johns Hopkins’s coronavirus tracker write about why they had to end operations because nearly all states stopped frequent public reporting of new cases and deaths. The country’s ability to track disease in a systematic way is poor, they argue.

And Dr. Jennifer Nuzzo, the director of the Pandemic Center at Brown University School of Public Health, argues in the essay below that we need higher-quality studies to better understand how well efforts like mask mandates and school closings worked.

— Alexandra Sifferlin

How Well Does Masking Work? And Other Pandemic Questions We Need to Answer

By Jennifer B. Nuzzo

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When the coronavirus took off in 2020, the unknowns were immense, as was the urgency. It was clear that the virus was novel, that it was spreading widely and that it was killing many of the people it infected. And there was no vaccine or proven drug treatment. This was the context in which states first mandated masks, issued stay-at-home orders and closed schools, among other measures — an emergency.

But now we should have more data from this pandemic to guide our decisions. We don’t send rockets into space without collecting data to monitor their progress and detect if they are veering off course. And yet we witnessed more than one million Covid-19 deaths in the United States without a clear plan to assess whether we were doing all we could to prevent more.

We should be systematically studying pandemic mitigation efforts in order to ‌learn which interventions are effective and how best to employ them. ‌Just as important: We should ‌‌do so with the understanding that the absence of evidence of effectiveness is not the same as having evidence of ineffectiveness.

Questions about masking‌‌, for example, were recently revived by a Cochrane ‌study reporting that masking (with surgical ones or respirators like N95) makes “little or no difference” in reducing infection at the population level, such as among health care workers or in communities. ‌Some mask opponents‌‌ claim this validates their assertions that masks don’t work. ‌‌Some mask supporters‌ are raising questions about the study’s authors and attempting to discredit their conclusions. Which side is right? ‌

‌As with most things about th‌e Covid pandemic, the answer is most likely somewhere in between. ‌

There is good evidence that masks can protect ‌‌people who use them correctly and consistently. Laboratory studies clearly show that wearing a mask properly, when in the presence of the virus, will reduce ‌a person’s exposure to ‌‌it. Other studies show that higher-quality masks, such as N95 respirators, are better able to keep the virus out than less well-fitting surgical masks or cloth masks.

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The confusion occurs when we shift from‌ showing that masks work in a laboratory or for individual people to finding evidence that masking works at the population level‌ and what interventions work to encourage it. At the population level, compliance and mask quality may vary, making it ‌difficult to find evidence to review on the effectiveness of masking in reducing the number of respiratory infections. ‌‌The Cochrane review tried to ‌‌untangle the evidence in one analysis. ‌And according to that limited evidence, masking at the population level did not have a clear impact on reducing infections.

How can this be? Part of the reason has to do with the quality of studies on masking. Though there have been studies observing differences in disease rates between places with masking policies and those without, evidence from these observational studies isn’t of the highest quality because it doesn’t fully account for other differences between masking and nonmasking populations.

To address the quality issue of these studies, the Cochrane review looked only at randomized trials evaluating the effectiveness of masking. Randomized trials are particularly helpful for studying the impact of health interventions within populations because they help to minimize bias and confusion caused by other factors besides the one you are trying to evaluate. For example, if you looked at infections among people who choose to mask versus those who don’t, you may be observing not just the effect of masking but also the effects of other protective decisions that people who are inclined to mask may also take, such as ‌avoiding crowded indoor spaces.

‌There have been only a few randomized trials specific to masking, and most of the ones included in the Cochrane review were not conducted during the ‌Covid-19 pandemic or in the United States. ‌‌Many of the studies that the Cochrane review included looked at the spread of influenza.

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This is important because while we think there are some similarities between how ‌the novel coronavirus and other respiratory viruses are spread, there also are likely to be important differences. ‌Covid proved to be deadlier than seasonal influenza, which may have influenced how often and well people wore masks. Masking for Covid was also mandated throughout much of the United States, which most likely also influenced masking behavior.

The pertinent question isn’t whether masks work but why ‌‌masking didn’t prove to be highly effective in the most rigorous studies. Was it because adherence to masking, not the masks themselves, was the problem? Is it because the population studied‌‌‌‌ wore masks when around infected people but then got infected from family members? Maybe people didn’t wear masks properly because they weren’t comfortable or they didn’t fit. Knowing the answers to these questions will help us know how best to use masks and help us better control the spread of infections. The Cochrane review authors say their examination was limited to whether interventions to promote mask wearing help to slow the spread of respiratory viruses. It’s important to note that masks only work when people wear them, so adherence will always be key.

In early 2020, when we knew little about the virus but saw its toll, masks were a reasonable step because they had few harms. Considering the rapid spread of the virus and its deadly impact, we could not wait until we had all the data to understand how best to use them. And if a new, deadly respiratory disease emerged tomorrow, we’d have few tools besides masks to prevent spread and protect ourselves.

But we should have put into place efforts to rapidly collect and assess high-quality data to understand whether masks were having optimal effectiveness and, if not, how to increase that effectiveness. We should have done this for other mitigations, too, like school and business closings and policies that required exposed contacts of cases to quarantine. ‌Pandemic measures like masking and vaccination have been challenged by political leaders and in the courts. Without clear evidence at the population level that mitigation measures meaningfully change transmission rates, it will be harder to meet challenges that could block effective, life‌saving interventions.

We ‌need to develop clear plans for ‌randomized and other well-designed studies and get them funded. A review of research by investigators affiliated with U.S. governmental public health entities during the pandemic found very few studies that evaluated the impact of measures to control the spread of disease. It is ludicrous to simply hope academic researchers will spontaneously choose and muster the resources necessary to address the most pressing pandemic response questions. Just as we have established research networks and protocols to conduct the highest-quality evaluations of the effectiveness of vaccines, we should have the same for nonpharmaceutical interventions, like masking. We can and must identify the highest-priority research questions and the funding to systematically and rigorously investigate them.

Jennifer Nuzzo is the director of the Pandemic Center at Brown University School of Public Health and a senior fellow for global health at the Council on Foreign Relations.

READ MORE

Antoine d'Agata/Magnum Photos GUEST ESSAY Our Covid Data Project Is Over, but the Need for Timely Data Is Not Three years ago we were caught flat-footed, and many people died. By Beth Blauer, Lauren Gardner, Sheri Lewis and Lainie Rutkow

You Ask, Experts Answer

Jason Abaluck, a professor of economics at the Yale University School of Management, conducted one of the most rigorous studies on masking during the Covid pandemic. He responds to reader questions about masks.

Do masks work, yes or no? — Laurie Birch, Dubuque, Iowa

Yes, although saying that masks work is different from saying everyone should wear them (see below for more on that). The studies of policies that actually get people to wear masks tend to find reductions in Covid. Wearing a mask probably reduces your likelihood of contracting respiratory diseases and makes you less likely to infect others if you are infected. The evidence is stronger for higher-quality masks with greater filtration efficiency.

Evaluating public health initiatives is more complicated, because these initiatives will be successful only if they get more people to wear masks. In places where many people are dying of Covid, mask mandates can probably save many lives. If an airline steward or teacher or preacher asks people to please put on a mask, a few will resist but most will comply.

Should people keep wearing masks in public even if Covid is endemic? — Jara Cimrman, Chicago

The average person probably does not need to wear a mask currently, although symptomatic people should certainly wear masks to avoid infecting others (with the coronavirus, influenza or the common cold virus).

One way to quantify the risk from Covid and the reduction in risk from wearing a mask is to consider how much money a person or government would need to spend to improve people’s health by an equivalent amount. Typically, economists think it costs about $100,000 in the United States to reduce your risk of dying by one percentage point. My very rough back-of-the-envelope calculation suggests that the average person faces about $3 worth of mortality risk from Covid. A surgical mask worn in crowded public areas may eliminate one-third of that, and a higher-quality mask perhaps half or more. For most people, I nonetheless suspect that the discomfort of wearing a mask exceeds the $1.50 worth of health benefit.

This calculation looks different for people with pre-existing conditions and the elderly. For people over the age of 75, the risk is about eight times higher. Wearing a mask might be worth $8 to $12 right now. For people over the age of 85, it roughly doubles again to something like $16 to $24 a day. That may be enough to make it worthwhile for most people over the age of 85 to wear a mask in public.

Of course, if the mortality rate from Covid were to increase again, the conclusion of this calculation would change. Additionally, there are many factors not accounted for. We still do not have a great sense of the risk of long Covid and how this is affected by masking; a natural guess is that this risk is proportional to the mortality risk, although it is hard to know given existing evidence. A bottom line: If you find being sick especially unpleasant and find wearing a mask unobtrusive, then by all means, continue wearing masks and you will probably get sick less.

MORE ABOUT DR. FAUCI’S RECENT TIMES INTERVIEW

Ibrahim Rayintakath DAVID WALLACE-WELLS Who’s to Blame for a Million Deaths? While fingers are pointed at Trump and Fauci, the virus was an unbeaten foe. By David Wallace-Wells

Philip Montgomery for The New York Times Dr. Fauci Looks Back: ‘Something Clearly Went Wrong’ In his most extensive interview yet, Anthony Fauci wrestles with the hard lessons of the pandemic — and the decisions that will define his legacy. By David Wallace-Wells

[phkrause]

May 7, 2023

Nash Weerasekera

Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention, announced on Friday that she would step down from the agency at the end of June. She acknowledged last year that the agency made mistakes during the Covid-19 pandemic (some under her leadership, others under her predecessor) and had begun an agency reorganization. Internal and external reviews of the agency concluded that its challenges are not new and require long-term, structural change to address.

This week’s newsletter looks at what some of those changes should be, which will now need to be implemented by a successor. Two authors of an independent report on the C.D.C. share their findings, and three former C.D.C. directors discuss the agency’s past and future. Thoughts? Email us at next-pandemic@nytimes.com.

— Alexandra Sifferlin

How to Overhaul the C.D.C.

By Tom Inglesby and J. Stephen Morrison

Long recognized as the nation’s leading public health institution and widely respected around the world, the Centers for Disease Control and Prevention has recently seen its reputation shaken and its performance compromised. As a result, public trust in the institution has eroded‌.

Amid that backdrop, we recently conducted an independent and bipartisan investigation of the C.D.C.’s pandemic preparedness and response during the Covid-19 pandemic. And we concluded that the agency needs a serious reset — urgently so. The health and resilience of the country hangs in the balance.

Our study was based on interviews ‌with dozens of experts, including politically diverse policymakers, public health officials‌‌ and state and local leaders; data the C.D.C. provided in briefings and reports; and a review of previous outside assessments. The takeaway is that the decline in the C.D.C.’s performance and public trust stemmed from errant leadership decisions, operational mistakes, chronic structural weaknesses and attacks from a hostile White House during the first year of the pandemic. Because of this, the agency was unable to meet the most essential demands of the crisis.

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The C.D.C. stumbled terribly at the beginning of the pandemic, when it could not meet the urgent imperative to distribute Covid tests widely across the country. ‌It then struggled to clearly and quickly communicate its changing guidance on vaccines, masks and precautions for workplaces and schools. State and local public health agencies, ‌‌as well as the private sector, became exceedingly frustrated in their attempts to engage ‌with the agency. Governors and congressional leaders lost patience, stopped listening and made their own choices. This fed a chaotic national response that put people at risk and further eroded public confidence.

The Trump administration’s brutal treatment of the C.D.C. also took a heavy toll. ‌Agency leadership found themselves traumatized‌‌, sidelined and ill-equipped to stand their ground.

‌There’s ‌so much that makes the agency crucial and worth saving and strengthening. The C.D.C. continues to be a critical technical and scientific resource to public health authorities around the country and the world. In the acute phase of the pandemic, the C.D.C. dispatched hundreds of emergency response workers to help local health leaders. The agency played an integral role in the planning and execution of the ‌‌national vaccine rollout. It also responded rapidly to requests for help from many vulnerable low- and middle-income countries. In 2021, ‌the C.D.C. also started work on a promising new Center for Forecasting and Outbreak Analytics‌‌, which now has begun to provide state-of-the-art modeling, forecasting and prediction for new outbreaks that can help leaders make more informed decisions.

But the C.D.C.’s structural weaknesses are many, and the following solutions are needed right away.

‌Redesign the work force‌

It’s a problem that the C.D.C.’s Washington presence is skeletal. If the ‌agency is to be effective inside the federal government, it needs to engage with key members of Congress, and that requires operational power in the capital. That doesn’t mean relocating C.D.C. headquarters from Atlanta‌‌, but it does mean‌‌ creating a competent Washington team of senior, seasoned C.D.C. officials with gravitas, policy expertise‌ and an understanding of the foreign policy and security context in which C.D.C.’s special contributions fit.

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‌‌‌Beyond that, the agency’s work force ‌‌needs a redesign. The C.D.C.’s incentive structures have rewarded scientific excellence, but ‌the agency needs more operational leaders with the skills to manage national and international epidemic control. The C.D.C. director Dr. Rochelle Walensky, who is stepping down at the end of June, was working to change that. This included requiring a substantial portion of C.D.C. staff to be trained in emergency outbreak response — an important step. ‌‌The agency also needs to reform its systems of hiring and retaining new talent if it is to compete with the private sector and research universities. Other government agencies are able to bring on new hires within days during a crisis, but the C.D.C. must follow hiring processes that can take many months. This should change.

More C.D.C. employees should also ‌be much closer to the front lines of fighting dangerous outbreaks across America. The agency should embed young talent ‌‌ — upward of 1,000 people‌ — within state, tribal, local‌ and territorial partners. This would strengthen the outbreak response of these places, build knowledge among C.D.C. staff around the challenges facing these jurisdictions‌‌ and generate long-term allegiances.

Overhaul communications‌

‌ “The C.D.C.’s communications are terrible‌‌” is a common refrain we’ve heard from senior elected officials. The agency is responsible for communicating new information and analysis to the public and the private sector, its assessment of the latest infectious disease threats to congressional leaders, ‌its recommendations to the Department of Health and Human Services and the White House, and ‌more. ‌It also remains imperative for the agency to speak directly and meaningfully to skeptical Americans‌, in part by combating pervasive conspiracy thinking and dis- and misinformation. Right now these major communication demands exceed ‌the C.D.C.’s capacities. ‌

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Big changes are needed, including the hiring of a larger‌ work force with the‌ skills and bandwidth to communicate with all of these groups successfully.

Revising the way the C.D.C. develops guidance ‌for Americans has to be a top priority. ‌ There must be more consultation with outside experts and civic leaders before announcing guidance decisions that ‌will have a major impact on U.S. society. For example, when making guidance decisions affecting schools, input from educational and political leaders ‌‌should be essential.

Give more authority and budgetary flexibility‌

‌ The C.D.C. is responsible for providing an up-to-the-minute picture of a pandemic across the country, but it doesn’t have the authorities needed to collect basic, anonymized outbreak data from state and local entities. ‌If a number of states don’t provide data, or they do so too slowly, how can ‌the C.D.C. determine the number of cases that occurred on a given day, how many people were hospitalized or died ‌‌in a particular week, or what new risks and trends are emerging‌? Congress should provide the C.D.C. with the authority to collect that data.

Similarly, the C.D.C.’s budget process is byzantine. It has about 160 individual budget lines, and little to no ability to move funds to where they are needed in a crisis. That is not how FEMA and the Department of Defense operate amid a crisis. Congress has the power to grant the C.D.C. the essential flexibility it requires, and it should.

‌‌Congress and U.S. leadership need to act‌

‌ Last summer, the C.D.C. ‌director publicly acknowledged ‌‌the agency’s mistakes‌‌. She also initiated internal changes ‌‌‌to improve the speed, quality and communications of both guidance and emergency response, as well as the agency’s relationship with Americans. As the summer of 2023 approaches, ‌the agency needs to show how it has put promised reforms into place. This will now fall to Dr. Walensky’s successor, and will be key for persuading ‌‌leaders in Washington to consider making the changes that the C.D.C. is seeking more broadly.

Much of the responsibility to change the C.D.C.’s culture and capacities rests with C.D.C. leadership. But ‌even greater power to reset ‌the agency lies with the White House, Congress and the H.H.S. ‌secretary. This historic opportunity for change cannot be squandered, and Congress must take action to improve the C.D.C.’s performance and rebuild trust.

Leaders in the Biden administration and Congress‌ ‌ need to‌‌ seize this moment. They have ‌an opportunity to build bipartisan consensus around pragmatic reforms that will restore the C.D.C. to high performance and high trust, and ensure the safety of Americans into the future.

Tom Inglesby is the director of the Johns Hopkins Center for Health Security and has advised the C.D.C. in the past. J. Stephen Morrison is a senior vice president at the Center for Strategic and International Studies and directs its Global Health Policy Center.

3 Former C.D.C. Directors on the Agency’s Future

Times Opinion hosted an online conversation about the C.D.C. with three of its former directors: Dr. Tom Frieden (2009-17), Dr. Julie Gerberding (2002-09) and Dr. David Satcher (1993-98).

The C.D.C. said it will undergo a reorganization after acknowledging that it made “pretty dramatic” mistakes during the Covid-19 pandemic. What kinds of changes should be top priorities?

Julie Gerberding: I don’t believe reorganization per se solves many problems. The C.D.C. needs support to modernize its public health sciences in Atlanta and within the state and local front lines. That will take investment and time. What does need to be reorganized is the apparatus in the Department of Health and Human Services and the White House for creating and releasing timely, credible, science-based guidance — free from political interference.

Tom Frieden: The most important change for the C.D.C. is to drastically increase the number of staff embedded in state, city and local public health agencies, and to have those staff rotate to C.D.C. in the coming years. This will increase the number of people at C.D.C. with frontline experience and the ability to provide quick, practical guidance and support.

Dr. Satcher, the United States saw major gaps in vaccine uptake as well as deaths from Covid-19, especially early on. How could this have been avoided?

David Satcher: Better communication. Health disparities are real and well documented, and trust will not become real until it is very clear that we have concern for all people across the country. A study of health disparities prior to the outbreak of Covid-19 would have better prepared us to appropriately respond to any distrust.

Dr. Gerberding, you led the C.D.C. through the 2003 SARS outbreak. And yet the United States wasn’t prepared for another coronavirus. What would you like to see going forward, especially when it comes to respiratory viruses?

Gerberding: Since the AIDS pandemic, our country has lurched from one crisis to another and consistently failed to truly invest in long-term progressive infectious diseases preparedness. Once the crisis resolves, we relax back into our baseline complacency. I see that happening right now. I don’t know what it will take for us to embrace the truth that health security is a critical pillar of our national security, and we need to approach it with the same sustained strategic engagement and investment as we do our Department of Defense.

There are also pragmatic issues we can address. The science of airborne disease transmission and how to effectively prevent it must be a priority. Vaccine innovation, especially alternative routes of administration and global manufacturing capability, supply chain and uptake capacity, is key. Antiviral medicines are also a key area for research investment. The list is long.

Some have argued that the scope of the C.D.C. should be narrower to focus on infectious diseases. Dr. Frieden, what do you think about that?

Frieden: This idea is the public health equivalent of a quack cure and would eliminate programs that prevent cancer, heart attack, stroke and other leading causes of death. The C.D.C.’s core mission is to save lives and protect people from health threats. Period. If we limit C.D.C.’s reach to only infectious disease — an idea favored by the tobacco, alcohol and junk-food industries — more Americans will die. Asking the C.D.C. to work on only some of the things killing Americans is like asking the military to defend against only some parts of the world.

Does the C.D.C. need more authority to act in a crisis?

Gerberding: We have to be realistic about the federation defined by our Constitution in which we operate. Having said that, in the context of a public health emergency, it makes sense to me that we have the authority to obtain essential information about the epidemiology and impact of the crisis from state and local governments and the health systems they oversee. This may be a tall order in our current polarized political climate, so establishing broad emergency data use agreements in advance of the crisis and eliminating the delays imposed by the paperwork reduction act would certainly be helpful.

Frieden: The C.D.C. also needs new authorities to act more nimbly during an emergency, for example, more flexibility with hiring, contracting and use of funds. But the C.D.C. doesn’t and shouldn’t generally issue mandates for individuals or most businesses. In the United States, most health issues remain primarily the domain of state and local governments.

Covid mitigations like masks and vaccines became so politicized in the United States. How could that be avoided in the future?

Gerberding: Some form of politicization has characterized every public health event I’ve studied. What is different now is the extreme polarization, and that one’s political affiliation seems to dictate one’s beliefs about factual matters of science and evidence-based health decisions. Understanding and respecting people’s values and beliefs is also critical, because they form the basis for how people do or do not accept health guidance. Trusted community leaders are really important in influencing how people interpret information.

Satcher: There needs to be better communication before decisions are made. The C.D.C. made decisions that it saw as best at the time, and that was understandable; however, we need to hear the voices of all groups that are most affected by the problem at hand. We have to listen and respond appropriately.

When it comes to potential future pandemics, what keeps you up at night? And what keeps you hopeful?

Satcher: What keeps me up at night is the extent to which political decisions are increasingly interfering with the best science. Whatever else we do, we must continue to encourage young minds to take on these challenges and develop better strategies. Even though there are reasons for some despair, there is also reason for hope when we critically examine our public health experience to date. What keeps me hopeful is the work that’s been done globally against smallpox and polio.

Gerberding: Climate change, war and terrorism, social disruption and displacement, urbanization and incursion into previously remote areas, antimicrobial resistance, travel involving mass movements and rapid mixing of people around the world — all are interacting to create the ideal conditions for killer pathogens to emerge and rapidly spread. Imagine a coronavirus that spreads as fast as SARS-CoV-2 but has the mortality of SARS-1, about 10 percent, or MERS, about 35 percent. What makes me hopeful is the potential for leaders to rise to the occasion and invest in the creation of the countermeasures we need to protect people in advance of an outbreak.

Frieden: I worry about microbes — especially influenza — and I worry about people — especially the panic-and-neglect cycle. It seems that Covid is already fading quickly into the rearview window. But if we don’t strengthen public health systems’ ability to find, stop and prevent health threats when and where they emerge around the world, we’ll be just as vulnerable to the next pandemic. The mRNA technology and other innovations are exciting developments that, if shaped for the public good, offer hope in the response to future pandemics. And I hope that the world will learn the lessons of Covid, Ebola and other outbreaks to invest substantial and sustained resources in public health in order to create a world for our children and our children’s children that makes vanishingly small the risk of another deadly pandemic.

[phkrause]

May 14, 2023

Nash Weerasekera

There’s unlikely to be a moment of true closure to the Covid-19 pandemic. But the history books will likely cite May 2023 as an important milestone. In the course of one week, the World Health Organization declared the emergency phase of the pandemic over, and the United States ended its Covid-19 public health emergency. However, “Covid is still certainly a public health situation of international concern,” the journalist David Quammen writes. “We’ll be living with it, and dying from it, some of us, forever.”

In the essay below, Jeneen Interlandi of the Times editorial board writes about the crucial policy lessons the United States should have learned from the emergency phase of the pandemic. She outlines the ways the country bolstered its social safety net — and the ways it’s now dismantling it. “We have to start putting the lessons of the past three years to use now,” she writes.

— Alexandra Sifferlin

What Has America Learned?

By Jeneen Interlandi Staff Writer, Editorial Board Writer

The coronavirus pandemic is here to stay, but the national and global emergencies it set off are, by all official declarations, over. On May 5, the World Health Organization declared an end to its “public health emergency of international concern,” and on Thursday, the public health emergency designation in the United States expired. It’s a good time for the country to absorb the crisis’ many lessons. Instead, we seem to be actively forgetting them.

Despite the United States’ many failures — to develop coronavirus tests, deploy vaccines and communicate effectively about the pandemic and our response to it — it still got several things right. Lawmakers beefed up the social safety net with expanded tax credits, more generous unemployment benefits, a federal paid sick leave policy and stimulus checks that together kept millions fed and housed even as the economy plummeted. They also poured billions of dollars into Medicaid and suspended policies under which people are routinely purged from its rolls — a critical move during a health crisis.

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Health departments rallied as well. Decimated by decades of funding cuts, understaffed and working with woefully inadequate technology, they still managed to gather and share reams of data about where and how the virus was spreading, which academics then worked heroically to analyze and publish. And even amid a rash of protests over shutdowns, a silent majority of citizens donned masks and obeyed social distancing edicts.

Perhaps most striking of all: Scientists developed a new and highly effective coronavirus vaccine with unprecedented speed. And yet vaccine hesitancy has reached a high.

The reprieve that kept people on Medicaid has expired, and the 15 million or so Americans who benefited from it are expected to find themselves among the uninsured in the coming months. More than five million of them will be children. A disproportionate number will be Black or Hispanic — the groups that proved most vulnerable to Covid.

Other safety net expansions have also ended, and whatever lessons leaders learned about the importance of public health appear to have been forgotten: Lawmakers in at least 30 states have moved to limit — rather than expand — the power of public health authorities. A surprising number of health experts say that they would opt to do less in the next crisis, even if it involved a more deadly virus. And in the face of low pay and constant harassment, and with resources once again dwindling, those doing public health work are now leaving the field in droves.

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Such sweeping reversals of progress and policy are sure to leave us as woefully unprepared for the next health crisis as we were for this one. But there is still time to change course.

A strong social safety net is crucial in a pandemic. The expansion of social benefit programs like unemployment, food stamps, Medicaid and paid sick leave was one of the great triumphs of the pandemic response. It not only helped more people stay fed and housed during the pandemic and its attendant economic crisis but also helped the economy rebound quickly once the crisis passed.

Rather than cut these programs now, Congress should be doing everything in its power to maintain the ground that has been gained. As experience tells us and study after study shows, pathogens thrive in the gaps between a society’s haves and have-nots, and a nation bereft of food security, health care access and other social supports will be that much more vulnerable to the next pandemic.

Border policies need to truly account for viruses. The current administration erred almost as badly as the previous one in its continued use of Title 42, an emergency order that allowed the federal government to turn away migrants during a pandemic. The stated goal of this policy, which ended on Thursday night, was to prevent the spread of disease.

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But that rationale defies all logic. Forcing people into overcrowded detention centers where they are denied basic preventive health care (including vaccination), is a recipe for ensuring viral spread, not preventing it. President Biden is wise to finally end this policy. But much more work remains: Only a fully modern immigration system can balance the demands of border security, human rights and pandemic preparedness.

Public health is at least as important as clinical medicine. The United States has a long history of granting primacy to private medicine and neglecting public health. In the years preceding the pandemic, less than 3 percent of the country’s $3.6 trillion total annual health care bill was spent on public health; a vast majority of the rest goes to clinical medicine.

We need to correct this imbalance. Public health agencies need modern computer systems and equipment, more and better-trained staff members and the resources to conduct urgently needed research. How well did mask wearing, social distancing, school closings and quarantine protocols work? When and where and why did they fail? The nation cannot prepare for the next pandemic unless its scientists and public health experts answer these questions.

Likewise, curbing public health powers and cutting funds for community health workers, as state and federal officials are now doing, are shortsighted moves that the nation will come to regret.

Smarter partnerships would play to the country’s strengths. Strong collaborations and clear agreements among government, industry, academia and nonprofits are the keys to ensuring that the nation is prepared to develop and deploy tests, vaccines and new drugs, that its national stockpile is adequately stocked and that some semblance of equity is maintained between wealthy nations and their less wealthy neighbors.

To that end, lawmakers should review — and, ideally, amend — the agreements they made with vaccine makers and test developers, especially. As a recent report on the U.S. response to the Covid pandemic makes clear, deaths could have been avoided, and companies could have profited even more than they did with better, stronger policies for collaboration.

Public health requires public trust. If the pandemic taught us anything, it’s that the most advanced technology in the world is no match for the suspicions of the fearful or the skepticism of the misinformed. Several studies indicate that the communities most mired in this kind of mistrust were among those with the worst pandemic outcomes. That’s not surprising, but rebuilding trust between the government and its constituents will take time, effort and a careful rethinking of what it means to follow the science in a time of crisis.

Promises of science free from politics will always ring hollow because decision-making always reflects a society’s values, culture and politics as much as hard evidence. Instead, proponents of sound public health should promote the import of collective action and shared sacrifice in a crisis. To be better prepared for the next pandemic, we will have to think critically about what we expect from one another and about what kind of society we want to live in.

With fresh viral threats looming, it’s clear that the world will not get another century to make these course corrections. The coronavirus pandemic has cost millions of lives and trillions of dollars, has upended the economy and has exposed and aggravated a grim roster of disparities and societal fissures. Though it’s hard to imagine, the next pandemic could be far worse. We have the tools to prevent that from happening, but we have to start putting the lessons of the past three years to use now.

Jeneen Interlandi is a member of the New York Times editorial board and a staff writer at The New York Times Magazine. She writes primarily about public health.

READ MORE ABOUT THE END OF THE PANDEMIC EMERGENCY

Illustration by Sam Whitney/The New York Times GUEST ESSAY If the Pandemic Is No Longer a Public Health Emergency, Then What Is It? The world needs to move from response to preparedness mode. By David Quammen

Dukai/Getty GUEST ESSAY We Worked on the U.S. Pandemic Response. Here Are 13 Takeaways for the Next Health Emergency. Honest reflection is essential to ensure that the nation’s response to the next pandemic is better. By Ezekiel J. Emanuel, Luciana Borio, Rick Bright, Michael T. Osterholm, Jill Jim and David Michaels

You Ask, Experts Answer

Dr. Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, responds to a reader’s question.

Is it even really possible for us to plan for the next pandemic, considering the failure of the American people in the pandemic we are currently in? Vaccine uptake, the politicization of almost everything, the lack of available current data, the confusion of C.D.C. messaging. — Ellen C. Campbell, New Jersey

Rivers: A lot went wrong in our response to the Covid-19 pandemic, but a lot also went right. I agree that politicization, data troubles and confused messaging were persistent problems. But the race to develop safe and effective vaccines will appear in history books for generations. So, too, will the successful mass vaccination campaigns, the diagnostic infrastructure scaled to handle hundreds of millions of tests and the ascension of genomic epidemiology.

We need to capitalize on those strengths while shoring up our weaknesses. I would like to see innovations like wastewater surveillance, at-home testing and rapid vaccine development become permanent fixtures. Failings, like poor communication and devastating inequities, must be appraised with an unflinching eye so we can make necessary changes. I believe we can be prepared for the next pandemic, but it will take reflection and sustained hard work. It won’t be easy, but it must be done.

[phkrause]

May 21, 2023

Nash Weerasekera

If you were to go back in time to the start of the Covid-19 pandemic, is there anything that you would do differently? Or anything you have learned from the last three years that would inform your response to future outbreaks? These are questions we posed to Times readers. Many of you shared your responses with us, a selection of which are shared below.

Something that stuck out to me when reading the messages was feelings of betrayal, whether they resulted from the government’s response or from individuals. We got messages from people who think the government’s response was not aggressive enough and from those who think too much was sacrificed for too little. It’s clear that many readers feel a sense of immense and lingering loss.

As natural as it might be to assign blame for what happened, it can also prove to be a hollow experience. The Times Opinion contributing writer Daniela Lamas explores that topic in the essay below.

— Alexandra Sifferlin

Not Every Pandemic Needs Someone to Blame

By Daniela J. Lamas

Three years ago, as I stood at the bedside of my first patient with the coronavirus, I struggled to understand why someone relatively young and healthy had become so sick. The unknown of the virus was frightening enough — to think that severe illness could strike at random was untenable. Even in my personal protective equipment, I held my breath, suddenly aware of my own vulnerability. The air itself felt dangerous.

A couple of months ago, my father called me to let me know that he had tested positive for the virus. I barely reacted — until I realized that a positive test meant that he would not travel to visit my infant as planned. He had been vaccinated and boosted, so I was not worried about his health, but I was frustrated. Quickly I felt my disappointment turn to judgment. He could have been more careful.

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As I reflected on my reaction — and on the shift from the coronavirus as mortal threat to inconvenience — I found myself thinking not just about the early days of the pandemic in the intensive care unit, but also about how this virus has become intertwined with morality.

From the earliest reports, the public conversation has so often assigned blame for the spread of the coronavirus, based on ethnicity or underlying health conditions or political party. It is tempting to believe that health care workers are immune to such reactions. After all, we care for all patients, regardless of their culpability in their own illnesses. But looking forward to the inevitability of another pandemic, we must acknowledge that when faced with fear and uncertainty, those of us working at the bedsides are not entirely different.

Disease has long been weaponized against those who are perceived as “other.” From the bubonic plague of the 14th century to tuberculosis and H.I.V., the examples echo throughout the history of medicine. When people are frightened, they seek someone to blame, to create a narrative — even if that narrative is false — in which disease is punishment rather than a random unlucky event.

Of course, health care workers frequently care for patients who are suffering, either directly or indirectly, as a result of actions they have taken. We transplant organs for those with liver failure after cirrhosis after years of alcohol abuse, with heart failure after decades of poor diet and little exercise. So much of what we do in the hospital is about second chances, about care without judgment.

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And yet the idea of culpability, whether our patients are blameless in their diseases, is still present. When we see patients with lung cancer, for instance, we mention whether they had a history of cigarette smoking. The young mother with a lung mass who has never smoked represents a tragedy; an older man who develops cancer after 50 years of smoking elicits a different response. That’s not to say that the medicine we offer is different, not in any way that’s measurable. But the distinction matters. It affects the way we frame the story, the way we understand the world.

Disease that has no explanation in behavior is terrifying. It is a reminder that no matter what we do, no matter how careful we are, any of us could fall ill and die. It is a reminder that none of us are safe. Which is one reason the coronavirus was so frightening to those of us in health care. The disease did not just break through the boundaries between doctor and patient, it decimated them. We were all vulnerable. And at first I thought that vulnerability might increase empathy, but then, as time went on, that empathy waned. And we, too, began to find an “us” and a “them.”

It happened first with masks. Patients who did not wear masks were, in some ways, responsible for their own illness. We became even more frustrated, and more comfortable with openly discussing that frustration, when it came to patients who were not vaccinated. There were health care workers who railed against the idea of offering advanced and scarce resources like a lung bypass or transplantation to unvaccinated patients with life-threatening disease.

Even when there was no question of medical resources, the stigma of the unvaccinated was clearly present in the way we discussed a case. When we talked about patients on rounds, we would mention in the first sentence whether they had been vaccinated. As in the case of the patient with lung cancer, this knowledge would not affect treatment, but it did change the way we framed the story. The people in front of us had made a choice, and they were sick and even dying as a result. They were not blameless, and so perhaps they were deserving of less of our sympathy.

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This pandemic is waning, but there will be another one. I want to say that we will learn and we will be different, both at the bedside and out in the world. I want to say that we will give grace, that we know how assigning blame only tears us further apart, but then I look at history. I think about our perception of the unvaccinated. I think of the stigma that so many diseases bring with them, how little we want to acknowledge the role of luck and random chance. And I have to wonder: When the next pandemic comes, who will we blame?

Daniela J. Lamas (@danielalamasmd), a contributing Opinion writer, is a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.

We Asked, You Answered

Times Opinion asked readers two questions about pandemic life. A selection of their responses, edited for length and clarity, follows.

What did you learn from the Covid-19 pandemic?

I learned how quickly we forget those whom we briefly cheered in the streets, even though they are still suffering from what they endured. And that beyond their utility to us, we don’t see the grocery clerks, teachers or child care workers who enable all of us to function. — Ruth Feiertag, 60, Lafayette, Colo.

The shocking reality that people have completely different perceptions of what is scientifically proven and how the internet contributes to those perceptions was a hard lesson to learn. Covid took things from me that can never be replaced: my personality and my perception of the world. — Luis Eggert, 17, Darmstadt, Germany

That as individuals we have far less control than we would like to think we do over our own safety. We are interdependent and our survival and ability to thrive depends on our willingness to cooperate. — Caitlin Thomas, 36, New York, N.Y.

I learned to be alone and to be patient. The fear and disbelief that this was actually happening in our world, today, seemed surreal. Now I think anything is possible. — Tanya Hill, 58, Sugar Land, Texas

I learned to process trauma. I learned that family and friends really are everything in a crisis. I learned that we as a global community seem woefully unprepared for this kind of thing. — Elissa Szymanczyk, 47, Portland, Ore.

I learned how deep the desire is to pretend that nothing is wrong, to turn away when people are suffering and dying. The world was in a better position to deal with this pandemic than it has ever been before. And to a large extent, both science and public health stepped up to the challenge. But politicians and much of the public did not. — Monica H. Green, 66, Phoenix

How will your experience with Covid-19 shape your approach to the next pandemic?

I will not rely on political partisans to influence my decisions in a health emergency. Although the advice from the scientific community may not be spot on with rapid onset health emergencies it is still better than politically motivated criticisms or strategies. In most cases a scientific misstep is more prone to course correction than political propaganda. — Bob Taormina, 84, Gardnerville, Nev.

I am an epidemiologist. I will understand that human behavior is much less predictable than infectious disease processes, and ultimately more important to understand. — Karen Levy, 49, Seattle

I will work harder to engage with others and maintain my mental health, particularly by recreating outdoors. And, as a woodwind musician, I will not allow isolation to compel me to stop working on my art and making music. — Sally Schlichting, 56, Juneau, Alaska

I will spend less (none at all) time on social media trying to convince people to act in their own interest. — Ben Leaf, 58, San Diego, Calif.

I learned a lot about empathy during Covid, even if I didn’t see the direct consequences of my actions. For example, at a college town during the peak of Covid, it became common culture for people to think: We’re just going to get Covid anyway, so why not disregard the restrictions? And sometimes it was hard to think bigger picture, outside my bubble, about people who rely on herd immunity or are immunocompromised. — Jamie Martin, 21, Athens, Ga.

The impact of isolation can be just as deadly as an airborne respiratory virus, and in my extended family, it took the life of someone really wonderful. Next time, I will be prepared to make routine check-ins on the people I love. — Katherine Reed, 63, Columbia, Mo.

[phkrause]

on the edge

The next deadly pandemic is just a forest clearing away. But we’re not even trying to prevent it.

https://www.propublica.org/article/pandemic-spillover-outbreak-guinea-forest-clearing?

[phkrause]

Seeding Hope

They set out to save rainforests — and stumbled upon a way to help prevent the world’s next deadly pandemic.

https://www.propublica.org/article/pandemic-spillover-madagascar-health-in-harmony?

[phkrause]

The next pandemic could spring from the US meat supply, new report finds

The next global pandemic could come from the United States.

https://www.usatoday.com/story/news/health/2023/07/22/deadly-covid-style-pandemic-could-easily-start-in-us-report-finds/70442786007/?

[phkrause]

Biden administration announces new partnership with 50 countries to stifle future pandemics

WASHINGTON (AP) — President Joe Biden’s administration will help 50 countries identify and respond to infectious diseases, with the goal of preventing pandemics like the COVID-19 outbreak that suddenly halted normal life around the globe in 2020.

https://apnews.com/article/biden-pandemics-virus-outbreak-mpox-global-worldwide-11571e564eda19f091bdad50d367cbcd?