I'm William Brangham, and this is "Horizons."

The COVID pandemic overwhelmed our health care system and killed well over a million Americans.

Fast-tracked vaccines saved millions of lives, but missteps in our response and misinformation online has damaged trust.

What is the state of America's public health system today?

And six years on, is the U .S.

prepared to handle another pandemic?

Coming up next.

♪ Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

From the David M. Rubenstein Studio at WETA in Washington, here is William Brangham.

Welcome to "Horizons" from PBS News.

When it comes to the arrival of another pandemic, it's really a question of when, not if.

According to almost all public health experts and epidemiologists, we will see another global contagion emerge that then sweeps across the world.

Six years ago, COVID-19 exploded out of China and rapidly spread to every continent on Earth, even Antarctica.

This brand-new virus brought the world to a standstill and caused untold economic damage.

At least seven million people died.

That's the WHO's official count, but it's considered by many to be a gross underestimate of the real number of people who died.

Well over one million Americans lost their lives to this virus.

We want to look at both the legacy of that pandemic, but also, more importantly, to look at whether we are prepared for the next one.

Joining us for that are two people who spend a lot of time focusing on that potential future.

Josh Sharfstein is with the Johns Hopkins Bloomberg School of Public Health, where he's a distinguished professor of the practice.

Previously, he was the health commissioner for the city of Baltimore, later, the state of Maryland, and also held senior positions at the FDA.

Elizabeth Cameron is a professor and senior advisor to the Pandemic Center at Brown University's School of Public Health.

She previously worked on global health security for the last three presidential administrations.

Welcome to you both.

Thank you so much for being here.

Cameron: Thanks for having us.

Brangham: I want to take, as I mentioned, the given that we think another one of these pandemics will slip through our defenses and end up coming to our shores, and we will have to wrestle with that.

And I want to talk about our vulnerabilities, but I also want to talk about the things that you both believe that maybe we've gotten a little bit better, that might give you some optimism about how we might respond.

So, Beth, I want to start with you.

What gives you optimism when you think about how we might do next time?

Cameron: Yeah, I think there are definitely things that we've learned from the COVID pandemic.

One thing that we've gotten better at over the last several years is targeting different viral families and thinking very systematically in the United States and globally about how we can actually develop countermeasures.

So that's vaccines, that's tests, that's treatments.

That's things that we were really worried about in 2020 that we now do have the ability, especially when we think about new tools like artificial intelligence and machine learning, we can do better to develop those medical countermeasures.

In addition to that, one of the things that I've been doing at the Pandemic Center over the last couple of years is running a project called the American Democracy and Health Security Initiative.

What we found in talking to people in states and cities across sectors is we found... Brangham: A bipartisan group of states.

A bipartisan group of states.

So we looked at red, blue, and purple states, and this was a project with CSIS and the COVID Collaborative.

We had people involved on both sides of the aisle.

And we asked not what went wrong.

That's a really important question.

We decided to ask what went right.

And what we found was that people told us again and again that they had developed playbooks.

They developed tools for doing really hard things like opening schools in North Carolina.

Like figuring out how to get vaccines to tribes in Washington state.

Like figuring out how to deal with masking challenges in Indiana.

And by and large, there was a lot of commonalities and less differences.

The big challenge, of course, is being able to implement those now in practice and to not lose that learning.

Those are all great.

Josh, do you have... Are there things that give you optimism?

Sharfstein: I think that there is a very clear recognition that it is great to have vaccines that work, tests that work.

But that's just part of the story.

People have to be excited about them.

And the system has to be able to communicate clearly, take questions in, answer them.

And what we're seeing is that public health is starting to change.

Less focus on press releases, more focus on community health workers.

And again, this builds on successes, like Beth was saying, from the pandemic.

In Baltimore, for example, which had a pretty high vaccination rate, there were vaccine ambassadors who were drawn from communities of concern.

And they went door-to-door with their neighbors talking to them.

And I think... Brangham; People from that community speaking to their own community.

Exactly.

And it made a big difference.

And I think there's a deep understanding in public health, amidst all the challenges I'm sure we will talk about, that really connecting to people in real life is a really important task.

And that recognition and some extra funds that have been made available are being put to that.

But that fundamental recognition gives me optimism.

Let's just pick up with... what you just left off with there, which is vaccines, because back during COVID, I mean, Operation Warp Speed, we can all agree, was a miraculous success under President Trump's administration.

We got vaccines out quite quickly.

They're the first President Trump's administration.

The second one feels a little bit differently about it, but we'll get to that.

Brangham: Good.

Let's stay on that.

The idea was, these vaccines came out quite quickly.

And although there has been some partisan distinction in who took that vaccine, I think it was still like four out of five Americans got them, even more older populations.

I mean, there was seeming national unanimity about vaccines.

Now, as you're hinting at, in the second Trump administration, there's a lot of skepticism of vaccines.

The childhood vaccination rates are going down.

The measles is up.

Bird flu is up.

Do you think we could reproduce what we did back then now, given the environment we're in?

I think it's worth just sticking on COVID vaccines for a moment.

Now, there were serious disagreements in the first administration and in the Biden administration about mandates and when vaccination should be mandated, but there was a pretty broad understanding these were lifesaving vaccines for many, many people.

The challenge is that that understanding is going away.

And in fact, we have heard that the CDC director has suppressed a report, the acting CDC director, showing the value of these vaccines.

And we know that there are people who have been appointed to key committees who have called for these vaccines to be taken off the market altogether.

So we've gone from national unanimity, like you said, an incredible scientific achievement, to discussion about when is it appropriate to mandate vaccination, to... "Should we take them off the market?"

in the second Trump administration.

That gives you a sense of the kind of challenges we're dealing with now.

Cameron: I might just pick up on two threads there.

I agree totally with you, Josh, about the unanimity going away and the polarization that we're seeing.

But in addition to that, a whole type of vaccines, mRNA vaccines in particular, is under attack.

We saw the mRNA vaccine platform for avian flu, which we had invested in and actually bought advanced doses of if and when it is approved.

We stepped out of that vaccine contract, basically making Americans vulnerable to an avian flu pandemic if and when it arises.

Brangham: Which is one of the biggest potential fears.

Cameron: Absolutely.

In addition to that, one of the things that was really challenging during the COVID pandemic, in addition to making the vaccines, which I agree was a major success, was getting those vaccines to people and then getting those vaccines out in the states into the arms of actual humans.

That was a huge problem in the United States.

It was an even bigger problem around the world.

Those systems were slow, much slower than many of us anticipated during the COVID pandemic, particularly for vaccines that had to be kept cold, very cold in the case of the Pfizer and Moderna vaccines.

That system right now, the Federal Emergency Management Agency was a huge part of that success.

Our CDC officials were a huge part of that success.

There was a major influx of funding that has now been clawed back from the states.

I'm really concerned in addition to even if we could replicate that success, we wouldn't actually be able to get the vaccines to people.

Then as Josh said, people would have to want to take them and we have a big trust deficit there.

Yah, and in a pandemic, time is of the essence.

What makes mRNA vaccines incredible is how quickly they can be made.

You know, traditional flu vaccines are made in eggs and you have to wait for them to grow.

Then you find out whether or not the egg actually grew enough vaccine.

It's a big moment when that happens.

mRNA takes all that guesswork out and shortens the time to a matter of weeks to be able to produce effective vaccines.

When you're dealing with a virus in that first wave that can produce not just hundreds or thousands of deaths, but tens of thousands or hundreds of thousands, every single day that you can shave off to produce an effective vaccine really means lives saved.

That's why there are many, many scientists and panels that have said the mRNA platform is critical for responding to pandemic.

Yet we just cut half a billion dollars for research into those platforms with this administration.

Yeah, that was one of the really shocking things that has happened.

There are a few that really qualify to that really shocking category, but we're talking about a platform that incredibly came out, you know, nobody was sure until the big studies that were done, whether it would work.

We now know how effective it can be.

And then to kind of unilaterally disarm at this moment while those viruses are out there makes no sense.

We asked the White House for comment about this.

I mean, there's also been criticism that the pandemic preparedness team within the White House has basically been reduced to one or two individuals.

We asked the White House for comment on this, and they said that multiple different federal agencies are tasked with pandemic prep, that the administration would avoid things that they argue were damaging, like lockdowns and vaccine mandates.

They also said this, quote, "The Trump administration "remains committed to the principles outlined "in the State Department's America First "Global Health Strategy "to prioritize the interests of Americans "and make America safer, stronger and more prosperous."

Do you believe that, again, given all of the things we're talking about, both the setbacks in research, but also the latent distrust that COVID engendered, that we could mount a communication strategy that would help people think, "Well, this next round of vaccines for the next pandemic would be lifesaving."?

Could we get back to that moment?

Cameron: I think we can get back to that moment eventually.

I think it's going to be really challenging with the policies that are being enacted by this administration.

I am very worried about the lack of just people who are tasked with this within the federal government.

There are many excellent civil servants that remain and they're doing great work across the federal agencies.

But there is real chaos in understanding who would be on first during a pandemic threat.

The office that I have now established twice, once for President Obama and once for President Biden, I also transitioned that office successfully to President Trump in his first term.

And it was maintained until 2018 when it was disbanded.

That office was tasked with bringing together all of those agencies really quickly during any emerging threat to try to figure out how to get ahead of it as best we could and how to communicate about it.

I don't see any evidence that that's going to happen quickly.

I hope that we can get back to that.

We need to get back to that in order to make America safer, stronger and more prosperous.

Sharfstein: I would just add that that's true for the whole of government.

It's also true within individual agencies.

When I was at FDA, when the H1N1 pandemic, if you remember that one, happened and the very, you know, right at the beginning, I heard from the acting CDC director, Rich Besser, for example, "We need a dose of Tamiflu," the anti-flu medicine for babies.

It's not on the label.

We don't know what to dose it.

You know, we're just going to pick one unless you guys can get us a dose.

And we set up an incident response system at FDA for the first time.

We got all the experts together.

And by Monday, they had come up with the best information because they're the total experts what that right dose was.

And it went around the world.

And what U.S.

agencies can do is tremendous.

But the leadership is absolutely essential.

Do you think that the public, we were talking before about the unanimity that we all felt collectively as a nation, that people agreed to stay home from work and keep their kids out of school and do all the things, we recognized essential workers for what they were.

But now the polling shows that people are increasingly distrustful of public health authorities.

They don't trust the guidance that they're getting.

People are reluctant to take vaccines.

Do you think that the public could be brought back around if the next time came around?

Cameron: I think that we can do a lot more.

And Josh was alluding to this earlier, to bring health, public health, health care and community health.

So including community health workers, as Josh mentioned, much closer together.

One of the things that I'm really happy to be able to do now is work a little bit with the Common Health Coalition.

This is a group that exists to do that, to try to knit together those people so that public health isn't just an ethereal idea.

We're going to help populations be healthy, especially during an outbreak.

It is instead about how do we actually bring guidance that is coming to us about what we should do into communities that can then translate it into action that works for them.

And so, for example, there aren't great approaches right now for states and cities, people who are responsible for responding to pandemic threats, to take that federal guidance from CDC or from FEMA and actually turn it into actions for any type of outbreak.

We'd love to see AI-enabled public health assistance in every state and local health department that help them do that with trusted playbooks.

But in order to get there, we need to have a reckoning that it is actually important to be prepared for these kinds of shocks.

Sharfstein: We also have to recognize what we're up against.

There's sort of a traditional metaphor that's used for communications in an emergency in public health, and it's you're sitting watching your favorite TV show, and it says, "There's a tornado coming.

"Go to the basement."

And you get a text message, and it says, "There's a tornado coming.

Go to the basement."

And then your phone rings, and it's your mom, and she says, "There's a tornado coming.

"Are you in the basement?"

You know, nobody wants to get up when they're watching their favorite TV show, but if you hear the same message multiple places, you'll go to the basement.

Now imagine you're watching your favorite TV show, you've got your favorite snack, and it says, "There's a tornado.

Go to the basement."

But then you get a text message saying, "There's a big lie coming around.

"Don't believe it.

"There's no tornado coming."

And then your mom calls and says, "Big weather is talking about tornadoes again.

"You know, there they go.

That is just a complete lie.

"That's never going to happen."

You're much less likely to go to the basement, you know?

And that's kind of what we're seeing.

So, I think public health does have a recipe for getting to people, but how hard it is depends on these obstacles and whether we can make some progress against them.

And, frankly, one of the biggest obstacles right now is the administration, particularly at HHS, that is undermining effective communication about vaccines.

I mean, putting that genie back in the bottle that you're describing is incredibly difficult to do.

I mean, even when you look at what I think you both would argue were well-meaning communications about the COVID vaccine, when I look back on this, there was still not, I think, effective enough communication about the fact that this virus is ever evolving.

And so that first shot gave you a level of protection.

But Omicron and Delta will be coming along, because we know how viruses operate.

And that shot may not be as effective.

The communication is so difficult.

Sharfstein: I think there's an interesting relationship with trust here, because if you have a lot of trust in other countries, of course, this virus is mutating in other countries too, there was a greater degree of baseline trust.

And when the public health authorities said, "Okay, looks like the virus has changed, we've got to do something different," they're like, "Okay, we trust you for that."

The US, that wasn't the case.

We're a polarized society.

There was a lot of stuff going on before the pandemic.

And pandemics exploit social divisions.

They always have.

And so we wound up in a situation where it's like, how come you didn't anticipate everything right at the beginning?

Or how come you misstated something right at the beginning?

And we're going to hold you accountable for that.

We're saying that caused the distrust.

And I think that's a little bit of an oversimplification.

Cameron: I think there's also the case, just more broadly, with the health care system in the United States, where people don't always feel as close to their primary care physician.

And we know that... Brangham: If they even have such a person.

If they even have insurance, if they can even access the health care system.

And without that day-to-day personal connection to someone in their community that they trust, that's where people were getting trusted information about vaccines.

And so the communication is important at the federal level.

It's important at the state level.

It's really important for people to hear from the people that they trust.

And our health system is not functioning in that way for many, many, many years.

Sharfstein: It's even worse than that.

There's a great book by Sarah Gorman which talks about how the health care system can be an engine of distrust, that people get these bills, they don't know where they're coming from, and they get frustrated, and they get angry, and they are now susceptible to believe that their doctors are in cahoots with the pharmaceutical industry to take their money.

There's actually... Brangham: Which was a thread that was picked up by conspiracists.

Right.

And there's actually an example in her book of a woman who totally distrusts medicine, won't get care for her conditions, moves to Norway, national health system, goes to the doctor, gets care, comes back to the United States, doesn't trust any physician, won't go again.

It was what we would call like a challenge, re-challenge study of the U .S.

health care system.

And this is, again, part of those headwinds for a public health effort for a pandemic.

And we've got all kinds of challenges.

We have a major piece of legislation that's going to push a lot of people out of health coverage, and that's going to make this challenge worse.

Brangham: I mean, you are talking about addressing some foundational issues about American society, the lack of universal health care, the lack of paid sick leave.

Those things, we think of them as societal issues, bigger, broader issues, but they are also pandemic preparation.

I mean, how do you... Again, I'm asking you how we fix these insurmountable problems.

But the argument is that this is essential to how we prepare for a pandemic as well.

Cameron: Absolutely.

Having baseline levels of societal protection are absolutely critical for any major shock, including a pandemic.

I'm a national security professional by training now and a biologist before that.

I hadn't spent nearly enough time on all of the larger safety nets that we need in our society and the ways that we need to be ready for a major shock like the COVID pandemic or worse.

And when I came into the Biden administration, that was the most important thing, was making sure that people could have paid leave, that people could take off of work, that people were protected, that they were able to access care when they needed it in ways that were different than we had before because people weren't able to as easily come in person.

All of those things need to be handled now before the next major pandemic.

And we're really sliding backwards.

I should also say just one second about rising risk, pandemic risk.

We don't know when it's going to happen.

You said this at the very beginning, but we do see an increase in the likelihood that we could have an accidental or deliberate release of a pandemic.

As a national security professional, I spend a lot of time worried about that.

Accidental or deliberate, meaning a terrorist act or... Cameron: Or a state-based biological weapons use.

So either way, a weapon that is intentionally made or a lab leak that is accidentally released.

And as we see artificial intelligence helping us get better countermeasures, which is a great thing, we also see it increasing the access to information about dangerous pathogens and the ability to actually design pathogens that could be more deadly or more transmissible.

And we have to watch that too.

And there too, we are not getting ahead of the guardrails that we need to make sure that these systems are able to be used for the good things, but not easily accessible for misuse.

So rising risk, lack of safety net, we're in a really precarious situation.

Brangham: Huh.

We only have a couple of minutes left, Josh, so I'm going to put you back into a position of leadership.

What would you like to see done from a very basic policy perspective to help move the ball a little bit down the field the way you would like to see?

Well, first, I think it's important to stop the confusion that has been created and bring... Brangham: About the efficacy of vaccines... The efficacy of vaccines, the importance of reliable science, put back the funds to the National Institute of Health that's supporting critical research and recognize that.

I do think at the same time, we have to find a different and better national conversation to have about these things, because just doing that will feel like a ping pong game to a lot of people, right?

There's a new group here and they're back.

It's the science team that's back.

Brangham: "We trust the science people."

Yeah.

And we have to get out of that.

I think we have to find people and I think they exist in faith communities, in the business community who are willing to say, "Let's talk about the importance of health to our economy.

"Let's talk about how we can find "a path together as a community.

"Let's have that conversation about mandates "and under what circumstances, "in a way that we all can "at least contribute to, if not fully agree."

So I think we have to have the policy discussion and a more of a step back from the brink of all this polarization.

I also think we have to be honest about what the online world is doing to us and how there are actually state actors who are trying to, you know, there were, I think, reports about people undermining vaccine confidence from other countries on purpose.

We have to be honest about that and try to find a better way through this horrible information environment that we're in.

So there's a lot of work to be done, but I do think it's possible.

And I do think there are bright spots.

And every day I see, you know, a student, for example, who's super excited to do the work.

So that... Brangham: And you're not discouraging them from the field.

Sharfstein: I am not discouraging them from the field.

I actually think, you know, if anything, with the measles outbreak we have now, with all these challenges in health care, we need public health more than ever.

And it's the need that is going to drive the future of the field.

Brangham: Just in the last few seconds we have, I mean, do you some people argue that the MAHA movement, with its focus on better eating and maybe focus on pesticides, might be a moment to help bring this together.

Do you have any... Are you optimistic about that?

Yeah, I mean, I think it's really important to talk about all types of threats that we're facing in public health.

And so it's great that we're focused on healthy eating and healthy environment.

I think what's really also important is that shocks to the system, like a major pandemic, are part of that.

And we lose our ability to focus on all of those other things when we are rocked by a pandemic threat.

So they're part and parcel.

Brangham: Beth Cameron, Josh Sharfstein, thank you both so much for being here.

Really appreciate it.

- Thanks, William.

- Thanks for having us.

And that is it for this episode of "Horizons."

You can find us on YouTube and wherever you get your podcasts.

Thanks so much for watching.

We'll see you next week.

Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

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