Exactly one year ago today, the Centers for Disease Control and Prevention confirmed the first case on U.S. soil of a new coronavirus scientists were then calling 2019-nCoV.
Since then, the country has recorded more than 24 million cases and more than 400,000 deaths, according to data compiled by Johns Hopkins University, and a new president takes office amid warnings that the pandemic will get worse before it improves.
But public health experts, doctors, scientists and leaders from industry and government say the past year has taught us a lot about the virus — and how those lessons can be applied to try to slow the pandemic now.
Their takeaways ranged from findings about the virus itself, and how it spreads — remember when we were all Clorox-wiping our groceries? — to reflections on our own behavior, and how it’s condemned us to ever-increasing infection rates.
Some, from former National Security Council member Dr. Luciana Borio and Operation Warp Speed chief Moncef Slaoui, emphasize the importance of partnering early with industry. Others say the past year proves the promise of our biomedical technologies can be realized quickly — if only they’re funded well enough.
Here are their thoughts.
On the virus
“It is not the winter respiratory virus it was billed to be,” said Dr. Paul Offit, of Children’s Hospital of Philadelphia. “It’s far more far-reaching and damaging than that.”
Predictions in the spring about the virus’s course warned it could resemble the patterns of the 1918 influenza pandemic: a milder first wave, followed by a much deadlier second one in the fall.
The autumn of 2020 did ultimately bring with it a feared larger wave of coronavirus cases, but it wasn’t after a uniform trough through the summer as originally expected. Mid-July saw a peak at about 76,000 cases as the virus swept across Florida, Texas and Arizona.
By that time scientists already had a handle on what makes this virus so damaging, experts said, as learning developed rapidly in the first few months.
“In early January of last year, we were told there wasn’t human-to-human transmission,” said Brown University’s Dr. Megan Ranney. “Once we realized it did spread [person-to-person], we thought it spread like flu … we thought we had to be worried about droplets and fomites.”
That all changed, Ranney said, “by the time we got through that first horrible Northeastern wave.”
The fact that transmission is “more airborne than we originally thought, less surface than we originally thought” has important “implications for prevention recommendations,” said Emory University’s Dr. Carlos del Rio. Hence wearing masks and avoiding large gatherings indoors.
But scientists also learned this virus is trickier than others; the fact that it strikes some fatally while silently infecting others is, in fact, what makes it so dangerous, said Dr. Jeremy Faust of Brigham and Women’s Hospital in Boston.
“Asymptomatic transmission, on one hand, has good news in it: not everyone gets as sick as we thought,” Faust said. “On the other hand, it’s so much more difficult to control because people think, ‘If I feel okay, I’m fine. I must not be a danger to myself or anyone else.'”
Dr. Leana Wen, former health commissioner of Baltimore, said that mindset is what’s driving much of the spread now, when we’re recording an average of almost 200,000 cases per day.
“There is still a degree of magical thinking when it comes to people we know and love who are not in our household,” she said. “We think, ‘Well, this person looks fine; I know them, I trust them that they wouldn’t engage in high-risk behaviors, so I’m going to see them.'”
Because so much spread can happen from people without symptoms — more than half, according to the CDC — the best course is to “regard everyone as if they could have coronavirus,” Wen said.
On human behavior
“We have developed a sense of a shifting baseline,” said the University of Minnesota’s Dr. Michael Osterholm. In April, he said, it felt like the “house was on fire,” with 32,000 cases reported each day. By May, cases were down to about 20,000. “People felt like we’d flattened the curve, we were done,” he said.
By mid-July, that surge through the Sunbelt saw a previously unfathomable new high of more than 70,000 daily cases. Early September saw cases fall back down to 26,000, a figure that was “almost as high as the high in April, but people felt like, ‘Look, see, this is good, it’s under control,'” Osterholm said.
By October, the upper Midwest started to light up with infection, and “by Thanksgiving we had almost 200,000 cases a day,” he said. The country’s most recent peak, Jan. 8, saw more than 300,000 cases reported on a single day.
“Think of 300,000 versus 32,000,” Osterholm said. “In a period of April to January, we became numb to that. Each one of these is a shifting baseline, and suddenly what was happening doesn’t seem so bad.”
It’s part of the human condition to react this way, he said, to “develop a sense of survival.” But it’s a key challenge to turning the tide in the pandemic.
So too, said both Osterholm and Ranney, is addressing the structural issues that put the brunt of the pandemic on the poor, the vulnerable and people of color.
“When designing or implementing public health strategies to combat an epidemic, whether that be structural racism, economic inequality, divisions between high-income and low-income countries, when we don’t pay attention to the drivers of people’s behavior, we will fail,” Ranney said. “Even with good science.”
Borio, who along with Osterholm served as a Covid-19 advisor to the Biden transition, named the importance of leadership as the chief lesson from the past year.
“It must start at the top,” she said. “A nation divided can’t tackle a pandemic. Our government, vast and complex, has tremendous capabilities but doesn’t organize itself.”
But keep politics, as much as possible, out of it, added Slaoui, who resigned last week as chief adviser to Operation Warp Speed, the Trump administration’s effort to develop vaccines and drugs for Covid-19.
“We must never again politicize public health issues,” Slaoui said. “I am sure this has cost tens of thousands of lives.”
On government and industry
Both Slaoui and Borio, as well as former FDA Commissioner Dr. Scott Gottlieb, who is now a CNBC contributor and board member of Pfizer and Illumina, said the first year of the pandemic demonstrated the importance of public-private partnerships and of acting on them quickly.
“The refusal of CDC to pivot early to engage commercial labs and commercial test kits left us blind to the early spread,” Gottlieb said.
The U.S.’ ability to detect the virus was hampered in the early weeks by a test from the CDC that turned out to be faulty.
“The virus was able to get deeply rooted in our communities,” he added. “It was a historic failure.”
Borio pointed to the importance of data systems created by Palantir, gene-sequencing partnerships with companies such as Illumina, diagnostic testing through Quest and LabCorp and vaccine distribution through CVS and Walgreens.
“A truly modern public health-care system requires a public-private partnership,” she said.
But Borio emphasized the importance of rigor in the regulatory process as well and the dangers of “premature issuance” of Emergency Use Authorization, “before data from adequate and well-controlled trials are available, as have occurred for many of the therapeutics.”
Hydroxychloroquine, in particular, was a black eye for the Food and Drug Administration. The FDA revoked its Emergency Use Authorization for Covid-19 in June after finding hydroxychloroquine was unlikely to be effective.
That, Borio said, “doesn’t help patients.”
Slaoui, who oversaw scientific development at one of the largest public-private partnerships in medical history through Operation Warp Speed, also emphasized the need to be able to run better clinical trials. He said at points during the last year, there were more than 400 trials running in the U.S., most without placebo control, which is considered the gold standard for testing new therapies. Many were also enrolling just a handful of patients.
“That is hugely inefficient and carries a big opportunity cost,” Slaoui said.
What well-controlled trials did prove, though, was that “mRNA vaccines work,” Ranney said. “The fact that we have not one but two mRNA vaccines that have been effectively deployed in humans that are both safe and effective in preventing the disease is just huge.”
They wouldn’t have been possible, though, Borio said, “without early investments by the U.S. government many years ago; these technologies take years to develop.”
She called them the “most exciting innovation in vaccine technology in decades.”
The outbreak also proved the speed and utility of a second technology, vaccines that use harmless viruses to ferry genetic material from the coronavirus to the body’s cells to induce an immune response, Slaoui said. “There are at least two very fast vaccine platforms that can be used to develop vaccines in months” instead of years, he added.
“What we missed,” he said, “is manufacturing capacity and capabilities.”
Slaoui said the answer is something he’s proposed called a biopreparedness organization that would develop new vaccines against emerging threats and be able to provide help immediately if those threats materialized. He first raised the idea in 2016 when he was chairman of vaccines at GlaxoSmithKline, and he said it didn’t take off, “but we must revive it now.”
Borio cited the appointment of Eric Lander as Biden’s top science advisor, in a newly elevated Cabinet-level position, as a signal of a new era where science “will be integral to the policymaking process.”
Offit, an expert in vaccine science, put it most bluntly: “We have it in us to make and test a vaccine very quickly,” he said, “if we’re willing to spend the money.”
Despite the lessons from the Covid-19 pandemic’s first year, public health experts warned of a difficult path forward.
“What strikes me most is how much we still don’t know,” said Dr. Kayvon Modjarrad, director of the Emerging Infectious Diseases Branch at the Walter Reed Army Institute of Research.
Questions such as: How does this virus behave differently from other respiratory viruses? How does it evolve? Why does it cause such severe disease in some but infect asymptomatically in others?
“In science, the first major step toward solving one of nature’s puzzles is understanding how large the puzzle is and what questions to ask,” Modjarrad said. “We’re only now reaching that point.”
One of the most pressing challenges is that a variant known as B.1.1.7, thought to be more transmissible than earlier forms of the coronavirus, is likely to “take off in the next couple weeks to months,” said Osterholm. That means “we could see the worst days of the pandemic ahead of us, even with the vaccine.”
Among the Biden administration’s most urgent tasks is managing distribution of coronavirus vaccines, for which it’s set a goal of 100 million doses administered in his first 100 days.
Osterholm noted, though, at that pace — even with an additional vaccine cleared for use that requires just one dose, as Johnson & Johnson‘s is expected to be within the next few months — only about 14% of the U.S. population would be fully vaccinated by the end of April.
Combined with an estimated 30% of the population that’s already been infected and may have immunity, that’s less than half the country protected heading into May, “far from any kind of herd immunity,” Osterholm said.
“Vaccines don’t matter, only vaccinations do,” Modjarrad said. “We cannot congratulate ourselves too much or declare victory too soon.”
Dr. Anthony Fauci, the nation’s top infectious disease scientist, said this week he expected that 75% to 80% of the country’s population could be vaccinated by the fall.
“If we do that efficiently from April, May, June, July, August,” he told the hosts of a Harvard Business Review livestream, “by the time we get to the beginning of the fall, we should have that degree of protection that I think can get us back to some form of normality.”