In March 2021, Dr. Anthony Fauci spoke with University of Chicago Harris School of Public Policy Dean and health economist Katherine Baicker. Below are my takeaways from their conversation with an emphasis on leadership, decision-making, and healthcare policy.
Do not be afraid to change your decisions based on new information.
From the policymaker's perspective, the COVID-19 pandemic can be thematically described as unraveling the unknown. Knowledge about the virus and pandemic is still evolving, and there's still so much we don't know. And like any crisis dealing with the unknown, it's impossible to know everything at the outset. Still, you have to make policy decisions without enough data, especially with lives on the line.
For example, when first confronted the novel coronavirus, SARS-COV-2, the Center for Disease Control ("CDC") knew it was similar to the original SARS virus (now named SARS-COV-1). Thus, initial policy decisions were based upon that prior knowledge. However, they later figured out that SARS-COV-2 was very effectively spreading from human-to-human. Unlike any virus Dr. Fauci has studied, 40-50% of those infected by SARS-COVD-2 are asymptotic, whereas others experienced life-threatening conditions that have left millions dead. Anywhere to 50-60% of all transmission occurs when asymptomatic or pre-symptomatic, which is not how respiratory viruses have operated historically. These features of SARS-COV-2 that the scientific community soon discovered complicated everything and are directly contrary to what the CDC first thought. As Dr. Fauci said, it's "confounding," "humiliating," and "sobering." Dr. Fauci continued, "if we had known about this asymptomatic cohort, we would have done things very differently."
1. You will need to make decisions when you don't have all the data you need. But, make sure the foundation of everything you do is base on data and evidence—you have to go with the information you have at the time.
2. In a novel or unknown environment, scientific investigation and data collection, and new evidence will naturally have you evolve your stance, opinion, or guideline over time. You must be flexible and humble enough to change your opinion or policies in light of new information.
3. You may be accused of flip-flopping, but decision-making in the face of the unknown relies on making the best decision on the information available at the time. You will accumulate more information over time. You should not feel bad or guilty about changing your position in the face of new information, assuming scientific inquiry is driving the decision-making. As Dean Baicker said, "it's not flip-flopping; it's learning."
"You should be flexible enough and humble enough to know that, in fact, you've got to go with the data that you have—and if that means changing something that you said, you should not feel badly or even guilty about having to do that." - Dr. Anthony Fauci
Beware what's below the "tip of the iceberg."
Dr. Fauci was one of the leading researchers during the HIV/AIDS epidemic in the 1980s. Before they had sensitive tests to screen for infections, the CDC thought that the only people who had HIV or AIDS were those seriously ill or hospitalized. Dr. Fauci described these HIV/AIDS hospitalizations as the "tip of the iceberg." Below the tip—the number of people hospitalized from HIV or AIDS—there were multiples more infected but were not sick enough to be hospitalized and still transmitting the viruses. And since the HIV incubation period was so long, it meant that one person could quickly spread the disease to many people without knowing it. This below the surface cohort quietly spread HIV/AIDS until it became a full-blown epidemic.
As a decision-maker, you must be mindful of what you can and cannot see—beware what's below the tip of the iceberg. You must find ways to see what you cannot currently see. This is why Dr. Fauci initially wanted to flood the system with testing, especially within the asymptotic cohorts, to understand the virus's spread.
Messaging is almost and often is as important as the decision itself.
Messaging has been one of the most challenging parts of the American pandemic response. As Dr. Fauci explained, the United States is in its most divisive time since the American Civil War. Never before has public health policy—in a pandemic no less—needed to account for the underlying political environment or assume a political stance for public health measures.
Policy messaging is always complicated, but even more so in a healthcare setting with very different population subsegments. You need to find a way to effectively communicate the crux of the problem to all those groups. The key feature of the COVID-19 pandemic is that one population segment (young and healthy) is unaffected by the virus but drives an outbreak that is killing another population segment (elderly and those with underlying conditions). Thus, the critical messaging question Dr. Fauci asked: "How do you get people to care about not propagating an outbreak that will almost certainly not likely affect them but has a devastating effect on others?"
Further complicating the problem was the fragmented and different messaging from blue and red states, which worsened the response. We needed a common message and guidelines to ensure everyone is fighting our common enemy, COVID-19.
- You also need to have enough confidence in yourself. And, you must have flexibility and humility, as mentioned earlier, but not so much that it comes off as having a deficiency or appearing like you don't know what you're doing.
- It is impossible to know everything at the outset. Keep the foundation on what you do is based on data. When you don't have the data, make sure you explain that things are "possible" or "we don't know for sure" so that people don't misinterpret your message.
- Without effective messaging, your policy will likely be poorly implemented, if implemented at all.
Equity needs to be understood and taken into account during the decision-making process.
There are extraordinary health disparities in America that the pandemic exacerbated. We found out quickly that certain groups are more vulnerable to SARS-COV-2 than others. People by nature of their work—people who are interfacing with other people—have a significantly higher incidence of infection. Certain racial or demographic groups have higher incidents of comorbidities had a substantially higher risk of hospitalization or death. Many of these comorbidities and disparities are driven by the social determinants of health—poverty, access to quality healthcare, etc.
The CDC's recommendations and guidance took many of these inequities into account. Vaccination prioritization focused on the most vulnerable populations. There are vaccination and testing clinics explicitly placed in underserved communities. For example, many people live in a "pharmacy desert" or don't have a car to get to a testing site. The CDC is also recommending using mobile testing and vaccination units to get into inaccessible areas.
If the CDC did not take the underlying health inequities into account with their policy decisions, health outcomes would be even worse than they already are for many Americans. Decision-makers must understand inequities and take them into account when making policy decisions.
Understand the advantages and limitations within the system you're working within and take those into account.
The American Federalist system leaves a lot of discretion and power to states. A federal organization like the CDC can offer recommendations on prioritizing vaccinations, but states may decide to issue their own guidelines. In theory, that can allow local governments to serve their community better because they know better for their state. However, when you have a common enemy like COVID-19, which doesn't know the difference between Louisiana and New York, you need a more uniform response. The fragmented messaging mentioned earlier and the many different policies implemented by states ultimately created a weakness in the American pandemic response.
Decision-makers need to consider the system they are working within and look for ways to play to the system's strengths and mitigate its weaknesses.
We must not forget what we've learned and ensure we put those learnings into action.
As mentioned earlier, the social determinants of health were a significant driver in the wide range of health outcomes between American demographic groups. Those are not going to be changed overnight. We need to commit—now—for the next few decades to remove race from the equation while enthusiasm is still high.
There have been dozens of significant supply chain issues throughout the pandemic. The U.S. relies heavily on other countries for PPE and other critical supplies, and those countries were also significantly affected by COVID-19. Understandably, those countries wanted to reserve those supplies for their people, which created significant PPE shortages at the beginning of the pandemic. The U.S. needs to become more self-sufficient to be able to handle future healthcare supply chain shocks.
We cannot let either be forgotten when we get out of COVID-19; otherwise, we risk being underprepared for the next public health crisis.
- As Winston Churchill said, "Never let a good crisis go to waste."
- We must start thinking about our preparations for the next pandemic and the future of healthcare while we are exiting the current pandemic.
- Social determinants of health continue to negatively and disproportionally America's overall health and need addressing.