When Even the Best-Laid Plans Get Lost

Maggie Fox 

Hello, and welcome to One World, One Health with the latest ideas to improve the health of our planet and its people. I’m Maggie Fox, our planet and all of us are battling problems, such as pollution, climate change, and new and reemerging infectious diseases. And they’re all linked. This podcast is brought to you by the One Health Trust with bite-sized insights into ways to help. There’s nothing like being prepared, especially if you know something is coming. The likelihood of another pandemic is just about 100%. So, why not be ready for it. Dr. JESSE GOODMAN has spent his career trying to get the world ready for all sorts of awful things from the next flu pandemic to the growing threat of drug resistant superbugs. Dr. Goodman is now the Director of the Center on Medical Product Access, Safety and Stewardship or COMPASS at Georgetown University. He’s also an infectious diseases physician at Georgetown, and the Veterans Administration Hospital. He was the chief scientist of the US Food and Drug Administration, helped lead the response against the 2009 H1N1 flu pandemic, and he co-chaired a task force on antimicrobial resistance which produced an action plan to fight superbugs. Jesse, thanks so much for joining us.

Jesse Goodman 

It’s really a pleasure to be with you today.

Maggie Fox 

That’s a lot of planning you did. As a result, of course, the nation and the world have been perfectly ready for every pandemic, every disaster, and nothing bad’s happened. Just kidding. Because things don’t always go as planned, right?

Jesse Goodman 

No, they don’t. I think it’s safe to say that no matter what you expect it to happen, will not happen exactly as we expected. And you’ll be thrown new challenges.

Maggie Fox 

You were involved in preparations for our pandemic long before COVID ever hit. But your carefully thought out gameplan got thrown out the window when the pandemic did come. Looking back, how do you feel like things went?

Jesse Goodman 

You know, I think it was overall a very difficult and disappointing response that could have been much better. I’d say, first of all, in fairness, it was a terrible pandemic, a terrible virus. And I don’t think from day one, it was likely that it was going to be fully contained. So, I think it was a global public health disaster. But we did not respond to it very well. If you look at some of the statistics, our country had some of the worst outcomes. All of us who lived through this saw the confusion and politicization, and so many of the road bumps that occurred that weren’t necessary. You know, a positive thing was how quickly vaccines were developed. A lot of that was the result of those past investments and pandemic preparedness. That was good. How that was communicated even about vaccines was faltered, and then much of the rest of the response was very problematic. And I think many lives were lost that didn’t have to be. I also feel like we’re now suffering from a crisis in confidence in public health and public health leadership that really could have been much reduced.

Jesse Goodman 

That crisis in confidence, that was something you had planned to prevent, as part of the pandemic preparations. Can you tell us about some of the things that maybe were planned for and should have been done and didn’t get done?

Jesse Goodman 

I think a very big part of what we could have done so much better in COVID was communication and coordination, these very simple sounding things that are quite hard to do. You know, I was reflecting on this a little bit this morning, before we talked. And I remember, you know, I think it was, a little bit like the boy who cried wolf. We had the Ebola outbreak, which was predicted to cause millions of deaths and things like that, you know. And I think, you know, one of the things that’s overlooked a little is that early on, when we first started seeing the cases, and I remember sitting there and talking to colleagues and family and other leaders and physicians and saying, you know, I’m actually really, really worried about this, okay. And yet, even people I respect tremendously in the public sphere were saying “oh, this is, you know, at worst no worse than influenza.” So, we had a tendency to deny all that went on early, and that, at a time when these emergency plans should have been put in place and steps been taken, contributed to things being done very slowly. And you know, one of the things I do know, because of personal and professional context, is that in January, the international organization set up the Coalition for epidemic preparedness and innovation within days of this virus being noted and China began reaching out to vaccine manufacturers and started soliciting requests for funding. When you look at Operation warp speed, it was a big success. But that only started funding these efforts in May.  So, I think there were three to four months of time that could have been gained if we had been very forward leaning in response, rather than sort of having this collective denial. The other thing that contributed to that and was a big feature of this pandemic was its politicization. So among the very people early on in denial were the president of the United States and his closest aides. And if you’ll remember this famous press conference where President Trump said, “it’s going to zero, there’s five cases here, there’s this,” and I remember hearing that and say, “oh, my God.” I think there were delays in weaning forward. For example, the whole response structure we had put into place would have called for getting things like PPE, ventilators, and diagnostic testing ready; not just leaving it to the private sector or one group, but having a coordinated effort and having backup plans in the event of failure. You put that into place, it does take effort, it does take money. And if a month later, there hadn’t been a real pandemic, maybe you overreacted. But that’s what you do. You try to prepare for the worst, you know, while you hope for the best. Instead they compared it with the past, and they lost precious time with that.

Maggie Fox 

Back in the 1990s, you were already planning for disasters, and one was the arrival of antimicrobial resistance, or AMR. It’s what some people call drug resistant superbugs. You had a plan ready to go. And then something happened. It was 9/11. And it threw everything off track. Tell us a little bit about that planning.

Jesse Goodman 

Antimicrobial resistance is really interesting. And it shares many similarities with a pandemic. And I’d say one of the biggest ones is that at least initially, it seems theoretical, it doesn’t seem real to people. So right now, when people get surgery, transplants, a strep throat, an eye infection or something else, they are given antibiotics. They go into the hospital expecting that if an infectious complication develops, the treatments will work. However, in the case of antimicrobial resistance, the slow development and spread of genes and other things make common infections resistant to antibiotics.  While, right now, it doesn’t seem real, it could suddenly become real soon. And even right now, there’s a considerable burden of disease, that as a clinician, I see all the time.  So, we got together all the agency leaderships across the government, and engaged the public and the private sector, especially those who potentially develop new medicines and for resistant organisms. And we came up with a good roadmap for how we make progress in the future. But it did require public sector investment. But, when 9/11 happened, all that investment went into national security and the investment that went into public health was primarily focused on specific threats like anthrax and smallpox. However, the longer term was ignored. That gets to that point of we need longer term commitments. You know, we need five-year budget plans. Can you imagine in the private sector if you said that we’re just going to worry about the next six months and invest in that and in the meantime, if something else comes along, we’ll just change course?

Maggie Fox 

A pandemic affects everybody. And it’s not just government agencies that are involved. We’re now seeing some long term effects. Can you talk about where planning can do a better job and including everybody who’s affected?

Jesse Goodman 

It’s not just all a public health and medical response. It’s also these other impacts on society. So, I don’t think there had been much thinking at all, maybe zero, about the implications of some of the social steps that had to be taken on distancing like school closures and work closures on employment and the way the sick leave system discouraged people from staying at home when they’re sick.   I think we’ve hopefully learned a lot about the social impacts of responding to a public health emergency, especially a long and ongoing one like COVID where we need to be prepared for those impacts. I also think that public health can’t act alone because it will just think about controlling the spread in the case of an outbreak. The measures that can be taken in the early days, such as the closing of schools and offices, to bend the curve may not be appropriate six months down the line, when the educational and social impacts of these shutdowns may, in some ways, be as important as the public health impacts.  While you can’t let the business community, or the education community run the long-term response, you also can’t just say it’s only a public health response because the social impacts are so broad.

Maggie Fox 

I remember sitting in some of those preparations when they were including journalists because communication was part of it. And when COVID hit, I was thinking, “oh, my God, there’s all these people, they’re ready, they know what to do.” And I’m sure you know, you’re one of them, there must be this feeling of deflation. Like we were ready, we knew what to do. We knew how to work together.

Maggie Fox 

I think at this point, rather than blaming X, Y, or Z, we have to understand that those same conditions could occur again, and how can we do better next time.  And I think we can do that. I think we can build on the experience and do that. But I don’t think we can be naive, that just sort of experts knowing what to do, and political attention in 2023 can translate to long term improvements. And there needs to be a lot of thought of not only how to put plans in place, but also how to make sure they’re resourced; how to make sure it’s not just the US, but it’s globally; and how to make sure that the integrity of the process is respected. I don’t think we do that just by saying it. We have to think about structures. For example, we must consider the structures that can protect the FDA and regulatory agencies from undue pressure so that they can make the best decisions. So, there’s a lot of devil in the details. And unless we pay attention to being prepared for the details, the same natural forces that lead people astray during emergencies, whether their politics or emotion, will come into play again. One of the advantages of having more than one agency or sector in the room at the same time is that you’re hearing all the perspectives and discouraging group thinking. And a lot of that is about good leadership. One of the things I’d like to think about is how we can prevent this problem. We need that long term funding, and we also need reserves, both in the US and globally that are significant amounts of funding that in an emergency can be flexibly accessed by public health authorities to do what needs to be done. So, you don’t have to go to Congress on day one and have this debate. But if the public health infrastructure in the US says this is an emergency, there’s a pot of several billion dollars to get this going. I think the same is true globally. The global community cannot compete for vaccines against the ability of the US and Western Europe to buy them. But instead, there needs to be a pandemic fund and billions of dollars put aside that can be used in emergency so that anybody can purchase these vaccines, and that will help drive the market too. So, it’s not like they’re just competing for the same vaccines. It will help ensure more equity. So, those are the kinds of things that can be done ahead of time and should be done. There are a lot of people interested in it. But the political leadership needs to come along and do it. And of course, when something like COVID has been so politicized, you have this whole anti-vaccine stuff. This kind of denial has come back and that could be a real problem. Also, that lack of faith I talked about earlier, that, you know, really leads to a challenge in how we accomplish this. But I still feel somewhat optimistic that we have a window in time where the world and the US can improve our preparedness, but it needs to be done in a longer term and coordinated way.

Maggie Fox 

That was terrific. Thank you.

Jesse Goodman 

Sure. My pleasure. Take care of it.

Maggie Fox 

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