Paradigm Shift: Moving from a Crisis-Based System to Prevention.
Illustration: Fien Jorissen, Heart Agency
Paradigm Shift: Moving from a Crisis-Based System to Prevention
The toll COVID-19 has taken on so many has been thoroughly chronicled since the start of the pandemic, with the number of those who died being the saddest metric. As that number climbs steadily—the nation is currently now at more than 1 million COVID-19 deaths, a figure that is likely significantly higher based on recent SPH research—it’s clear that the disease has had the largest and most visible effects where we convene: our cities, our workplaces, our recreation spaces, and our schools.
As we climb out of a third pandemic year, public health researchers have begun to document various strategies for containing and mitigating the disease that has driven so much recent inquiry and policy action. At SPH, teams of researchers collected voluminous data on workplace and municipal policies to figure out what worked and what didn’t. Clinicians have studied vaccine hesitancy, mask acceptance, and other procedures that were designed to increase safety in gatherings.
But as COVID and its variants continue, many SPH researchers have subtly shifted their focus from fighting the current pandemic to figuring out how to prevent the next one.
Learning from the Past, Planning for the Future
How schools of public health approach training the next generation of public health professionals in pandemic response is likely to become a critical issue in coming years. At an SPH symposium in April 2022, presenters discussed the dual problem public health educators face of applying what we learned during the past three years to the next pandemic, while at the same time adapting to the shifting environment as real-time changes occur.
According to Matthew Fox (SPH’02,’07), professor of epidemiology and global health, “If we train the next generation of public health professionals the same way we’ve trained the previous generation, presumably we’re going to end up with the same response.”
One takeaway: educators may need to reassess the current public health approaches to messy, complex situations—such as pandemic response—and put greater emphasis on interdisciplinary training across multiple fields rather than adopting the current trend toward specialization.
“The overarching structure of how we train public health students is actually one of the things that made me decide to move my primary affiliation from a med school to a school of public health,” says Megan Ranney, professor of emergency medicine, Alpert Medical School, and academic dean, School of Public Health, Brown University.
Beyond COVID
This is not just about COVID, Ranney says, even though discussions may be center around prevention of the next pandemic. “It’s also about preventing all of those other societal effects that have happened downstream—sometimes in the margins, sometimes as a secondary effect of the very necessary measures that we put in place to control this pandemic.”
A Stanford University study published in The Lancet in July 2022 found that in 2020, cases of fatal opioid overdose in California spiked 44 percent over the number of 2019 deaths, with disproportionate increases among structurally marginalized populations in many major urban areas. In Boston, Jonathan Jay, an assistant professor of community health sciences at BUSPH, coauthored a study whose findings suggest that “the unprecedented measures implemented to mitigate the spread of COVID-19 were associated with an increase in gun violence.”
In the study, published in The Journal of the American Medical Association in February 2022, Jay and a team of researchers looked at 2,383 patients treated at Boston Medical Center in 2020 for “violent penetrating injury” and found that while the number of stabbings was relatively constant over the previous five years, there was a significant increase in shootings that started while Massachusetts was still under a stay-at-home advisory and before large-scale racial justice protests began. “As the pandemic abates,” the researchers wrote, “efforts at community violence prevention and intervention must be redoubled to defend communities against the epidemic of violence.”
While epidemiologists may have received much of the COVID press, both positive and negative, the entire health community will likely need to be involved in all aspects of preparation and planning for the next pandemic. According to the Centers for Disease Control and Prevention (CDC), anxiety and depression rates among US adults were about four times higher between April 2020 and August 2021 than they were in 2019. The World Health Organization estimates that global prevalence of anxiety and depression increased by as much as 25 percent during the same time span.
However, at least in the US, the feared widespread increases of multiple types of self-harm, including suicide, were not realized. “We have not seen dramatic increases in suicide rates, which I think is important to call out because there’s a popular narrative to the contrary,” Ranney says.
A future pandemic is likely to cause ripples throughout the heath care system that will extend far beyond the COVID-specific immediate care delivered to patients. COVID shutdowns stifled normal operations of many healthcare functions, including preventive screenings for numerous conditions. Throughout much of 2020 and part of 2021, healthcare providers saw declining rates of mammograms, colonoscopies, women’s reproductive health screenings, childhood vaccinations, elective surgeries, and dental care.
These gaps in health care must be anticipated in the policy development process before any major closures in the future, with an eye toward improving equity. It is also important to consider the hidden populations who may be particularly at risk from policies that don’t adequately consider their needs. For example, the CDC estimates about 2.5 to 3 percent of the US population—nearly 8 million people—may be moderately to severely immunocompromised and potentially at higher risk of serious illness and hospitalization if they contract COVID-19, even if vaccinated. Any future virus may have the same effect.
Creating Better Pandemic Response Systems
Jeffrey Shaman, professor of environmental health sciences at the Columbia University Mailman School of Public Health, hopes that developing better pandemic preparedness and improving our ability to respond will include issues associated with population-scale modeling analytics and forecasting.
This will require improved data collection, archiving, and sharing, as well as a commitment to better communication protocols with an emphasis on evidence-based approaches.
“I’ve been very heartened to see that the CDC has founded a center for forecast and outbreaks analytics,” Shaman says. “This is not a panacea. It’s not going to solve everything. It’s an idea that’s been kicking around for nearly a decade and almost came to fruition during the Obama administration, but unfortunately didn’t. Now it has been launched with obvious impetus because of the events of the last few years.”
Shaman believes that this center, and several others like it around the country—or possibly, the world—can provide the kinds of modeling analytics and forecasting that “can be used to understand at an epidemiological and population scale what makes a particular virus tick.”