More than once, the U.S. response to the COVID-19 pandemic has been called a dumpster fire.
Early test development was bungled, public health messaging was clumsy and undermined by political interference, and glacially slow use of data hampered prompt responses to an evolving epidemic.
What's more, mask-wearing and other pandemic responses were drowned out by deadly politicization while we doubled down on tepid responses to health inequities that we worsened by hoarding vaccines.
In response, half of Americans think the CDC and the country's elected leaders handled the pandemic poorly. And -- more telling than the twitchy court of public opinion -- life expectancy in the U.S. is rebounding more slowly from COVID-19 than in Europe.
Despite that grim news, the dumpster fire of U.S. public health contains more than flames. Peer carefully into those flames, and you will see miracles, heroes, and even some optimism within.
First, we should own responsibility for that fire.
The Chemical Formula of Gasoline
For decades, before COVID-19 became a household name, we repeatedly ignored calls for better funding from public health experts.
In 2017, as Ebola was slipping out of the public eye, a blue-ribbon World Bank panel on pandemic preparedness begged again for better resources:
"As the havoc caused by the last outbreak turns into a fading memory, we become complacent and relegate the case for investing in preparedness on a back burner, only to bring it to the forefront when the next outbreak occurs. The result is that the world remains scarily vulnerable."
It is a brutal irony to blame public health workers for lacking the tools they were repeatedly denied.
Compounding that chronic budgetary hypoxia, political gamesmanship also sabotaged the U.S. public health response, perhaps even to distract from that legacy of neglect.
Exactly when we needed trustworthy messaging about mask-wearing, vaccines, and evidence-based treatments, right-wing extremists undermined masking advice, fueled threats against the nation's leading infectious diseases physician, stoked concerns about vaccine safety, and promoted snake oil. The partisan divide in COVID-19 mortality rates is but one symptom of that sad act of self-sabotage.
Even so, the triumphs of the U.S. public health response also warrant mention.
A Miracle, Under the Flames
In the greatest public health achievement of our lifetimes, lifesaving COVID-19 vaccines developed largely by U.S. scientists and companies were sped to your neighborhood and mine with astonishing speed, saving millions of lives.
With similar alacrity, clinicians treating high risk and severe COVID-19 now have a panoply of proven life-saving treatments developed predominantly in the U.S.
Any assessment of the U.S. public health response to COVID-19 must include those historic successes, diluted though they were.
Not all successes involved new technology. Our grandmothers and uncles are alive today because a highly committed army of public health dweebs counted cases, conducted contact tracing, held vaccine drives, and wrote and re-wrote informational web pages while the rest of the country called them idiots on Twitter. Nobody clanged pots and pans every evening for public health workers, but our frontline public health workers are heroes, too.
Reasons for Optimism
In the words of Rahm Emanuel, former chief of staff to President Obama, "You never want a serious crisis to go to waste. It's an opportunity to do things that you could not do before."
Emanuel repurposed his own 2008 quote to call for better funding for public health. He hoped the crisis of COVID-19 would bring new oxygen to our strangling public health system.
In that spirit, here are three reasons for optimism for public health in the U.S.
New Funding
The silver lining of the COVID-19 crisis is that the death toll appears to have shaken some shekels loose from the world's deepest pockets.
Leaders of the G20 recently announced the formation of a $1.6 billion global fund for pandemic preparedness. While more work remains to grow those funds and spend them wisely, better funding and multi-lateral collaboration on pandemic responses are welcome changes.
Closer to home, the Biden administration has called repeatedly for substantial increases to the nation's public health budget.
If those long-overdue investments come to fruition, there will be real cause for optimism that our best weapon against the next pandemic won't be a dilapidated public health system.
New Leadership
Infectious diseases physician and HIV research powerhouse Rochelle Walensky, MD, MPH, took the helm of the CDC midway through a raging pandemic.
Walensky gets it. She said, "To be frank, we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications."
She has gone far beyond apology. Less than 2 years into her tenure, Walensky has ordered a major restructuring of the CDC and appointed a trusted leader to lead the charge.
That openness to critique, and willingness to make major change, will make new Congressional investments in a nimbler CDC more palatable -- and more likely to save lives.
New Ideas
As much as hope of better funding and structural reform at the CDC are welcome news, the flaws in the nation's public health response went well beyond that much-maligned agency.
To grapple with the wide-reaching inputs into the nation's public health failure, from political sabotage to the pernicious impact of pre-existing health inequities, a coalition of bipartisan senators has called for a national commission to examine pandemic lessons learned.
Meant to emulate the bipartisan 9/11 Commission, this new COVID Commission could give political oomph to improved public health funding, including to fight the health inequities that COVID-19 brought to light and then made worse.
Don't Forget the Realism
Just as the American pandemic response was both a dumpster fire and a miracle, our optimism should be seasoned with some hard-nosed realism.
Biden's calls for better public health funding are not guaranteed to survive our fractious appropriations process. It is also far more difficult to redirect decades of institutional inertia at the CDC than to name the right new direction. The national COVID commission has not yet been greenlit.
Still further, populist anti-public health sentiment remains. Republican presidential frontrunner Ron DeSantis recently proposed an anti-vax tribunal and Twitter's new saboteur-in-chief Elon Musk recently put out a transphobic anti-Fauci tweet.
The million life question is thus: in response to the dumpster fire of the American COVID-19 response, will we use the fire extinguisher of new funding and data-driven systems change, or the gasoline of demagoguery?
I choose hope for the fire extinguisher. Hope is the first step to transformation, and there are real miracles and real heroes worth saving from the fire.
Tim Lahey, MD, MMSc, is an infectious diseases physician and ethicist at the University of Vermont Medical Center, and a professor of medicine at the University of Vermont's Larner College of Medicine.