With updated estimates of total pandemic mortality reverberating widely, we have cause to consider the pandemic experience that might have been.
The toll of COVID could have been much, much lower; our pandemic experience far, far better. Those who don’t learn from the follies of history are destined to repeat them, and fractious though we may be, I bet we all agree: we’d rather not.
This is not a case of “if only we knew then what we know now,” but rather a matter of overlooking what we were looking over, and missed opportunity. We did know then what we know now to be most salient, affirmed in 5 glaring and painful lessons, for minimizing pandemic harms.
1) There was always more than one way to get hurt. The virus was dangerous, a fact clear in the early going and indisputable now. The sequelae of our indiscriminate policy responses to the pandemic also harbored many dangers, also clear at the beginning, and equally indisputable now. We could have looked, should have looked, and one can only hope next time will look, both ways before crossing a busy pandemic: at the potential harms of infection, and the potential harms of interdictions. Any which way people get hurt is bad; the good of preventing such harm is non-denominational. We needed, and never had, a clearly articulated objective of total harm minimization. We will need that next time, too.
2) The risks for getting hurt, in more than one way, were never evenly distributed. Some of us were highly prone to severe infection, some of us never so, and others in-between. Similarly, some of us were very vulnerable to the punishments of lockdown, and others much less so. Our failure to match risk variation with risk-stratified policies meant more harm to more people, while damaging the credibility of our public health authorities.
3) Time was never our friend. The longer a pandemic lasts, the more viral generations. Each such generation is a vast mathematical opportunity for mutation randomly advantageous to the unthinking viral mission: replicate and spread. Time itself is the substrate of spread, given those mutations. A policy of flatten the curve” was never more than the pandemic equivalent of treading water. It made sense, briefly, to conduct a situational audit, devise sensible policies, and avoid health system overwhelm. Treading is better than drowning, to be sure, but leaves you in it up to your neck, waiting to tire. We needed policies governing lockdowns and liberations that were linked to time-sensitive objectives (and the incubation period of the virus). Instead, we created the on-going pandemic waves by providing the virus recurring access to the vulnerable populations among us. The earlier we make our way through a pandemic, the lesser the opportunity for the toxic interplay of vast viral numbers and time - to wear us out. The waves in which we tread or drown are much of our own fabrication.
4)Causes have causes, overlooked at our peril. Leaving aside our blinkered responses, the “cause” of all the COVID mayhem is ostensibly a pathogen: SARS-CoV-2, in its now many mutated guises. But the underlying cause of our exposure to this pathogen, native to certain wild animals, is a global food supply riddled with liabilities encompassing waste, deficiency, excess, and maldistribution- to name only a few. We can address these directly, or confront them indirectly in the next pandemic.
The underlying cause of the toll of COVID in the U.S. and many other nations was the prior, neglected pandemic of cardiometabolic disease. The cause of all that cardiometabolic mayhem is, in turn, diet and lifestyle at odds with the requirements of human health. A culture designed to feed corporate profits at the expense of public health underlies all of that.
The pandemic of lifestyle-related chronic disease was, if not altogether fixable during the compressed timeline of the COVID pandemic, at a minimum, addressable to very good effect. A single high-quality meal where junk might have been, a single walk where a couch might have prevailed, can ameliorate key markers of metabolic and immunologic health, from endothelial function to chemotaxis. The accruing effects of multiple walks and better meals are of course far greater, with benefit starting immediately and growing over time. A “let’s get healthy together” campaign would have made sense at any time during the COVID response, reaping benefits both acute and extended. Inattention to this opportunity while instead pushing ever more “boosters” of uncertain performance was benighted policy, and an assault on trust.
We need not, for example, have waited to weigh the human costs of a diabetes/COVID feedback loop. Tallying years of living lost to a pernicious interaction known from the earliest days of this pandemic is not just senseless- it is scandalous, and tragic.
We might, rather, have rapidly expanded access to lifestyle medicine, diabetes prevention and management programming, and for that matter- free fruits and vegetables, nuts and beans, recipes and vouchers, sports and exercise equipment- on the same mobile units dispensing masks (in the very early going), and vaccines later. Instead, “follow the science” devolved to dogma limited to masks and vaccines, while ignoring the causes of causes, constraining vision to its traditionally myopic span, and seemingly disavowing sense.
5) Pandemics are global. Just look at the fate of China’s ‘zero tolerance’ policy, which confronts a virus circulating (and mutating) globally with parochial autocracy. An unseeing virus sees better than we a single, global, extended human family. A pathogen that recognizes the same opportunity in every human organism across the globe invites us to organize a coordinated global response, or suffer the consequences we now know all too well. This would be a good time to situate genuine, reliable authority over pandemic response in the W.H.O. Before COVID19 upended our lives for more than two years- would have been a better time.
Even now the pandemic remains at best a mosaic, at worst, the Rorschach test it has been since the start. That latter prospect implies we may never avow a common view, and that could be where common cause goes to die. The former, however, more hopefully allows the same big picture to come into focus with just a bit of distance. Here’s to that.
The COVID disease; the heavy-handed, one-size-fits all COVID “cures”; competing ideologies where epidemiology ought to have prevailed; and the systematic neglect of the underlying causes of the causes of our woe- contributed, all, to a massive toll of preventable harm. There is a far better pandemic that might have been. If we learn the lessons of this one, maybe next time it will be.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.