COVID-19: Lessons in Ignorance

Commentary

An online search using the keywords "COVID-19" and "lessons" turns up an astonishing volume and assortment of information: thousands of commentaries, news stories, scholarly articles, book chapters, and monographs. The lessons are intended for vast expert and general audiences: from pediatricians, public health professionals, and other specialized communities of practice to ordinary people and political leaders across the planet. What has been, can be, and should be learned? More lessons loom. Expect a deep dive Congressional investigation and blue-ribbon probes. Storytellers are weighing in with fictional chronicles. Booker Prize winner Ian McEwan's novel, Lessons (New York: Alfred A. Knopf, 2022), is scheduled for September 2022.

From my perspective as a recently retired Centers for Disease Control and Prevention (CDC) branch chief who served in the agency's COVID-19 response from late March through June 2020, the profusion of "lessons learned" reflects the magnitude of the knowledge gaps that impaired America's readiness and undercut its efforts to grapple with a new pathogenic peril, one for which danger signs were long evident. Failures in foresight were followed by fitful attempts at comprehending a lethal contagion's spread and knowing what to do about it.¹Cormac Bryce, Patrick Ring, Simon Ashby, and Jamie K. Wardman, "Resilience in the Face of Uncertainty: Early Lessons From the COVID-19 Pandemic," Journal of Risk Research 23, no. 7–8 (2020): 880–887.

The story of the nation's COVID-19 plight is as much an unfolding epistemological crisis as it is a once-in-a-century epidemiological catastrophe. Among the many lessons to be distilled are how and why ignorance in various forms and places accounts for so much of what went wrong. A thorough and wide-ranging exploration is needed, which calls for contributions from multiple disciplines and approaches. As historian of science Robert Proctor recommends: "We need to think about the conscious, unconscious, and structural production of ignorance, its diverse causes and conformations, whether brought about by neglect, forgetfulness, myopia, extinction, secrecy, or suppression."²Robert N. Proctor, "Agnotology: A Missing Term to Describe the Cultural Production of Ignorance (and Its Study)," in Agnotology: The Making and Unmaking of Ignorance, ed. Robert N. Proctor and Londa Schiebinger (Stanford, CA: Stanford University Press, 2008), 1–33. Further, as sociologist Scott Frickel suggests, we also need to focus on "how, where, and why ignorance, once produced, becomes institutionalized."³Scott Frickel, "Not Here and Everywhere: The Non-production of Scientific Knowledge," in Routledge Handbook of Science, Technology, and Society, ed. Daniel Lee Kleinman and Kelly Moore (New York: Routledge, 2014), 263–276. For example, studies of CDC's shambolic performance should include close scrutiny of institutional obliviousness, under a succession of agency directors and programmatic leaders, to basic gaps in readiness and responsiveness that became glaringly obvious during the pandemic and contributed to numerous missteps in the US response to COVID-19.

If the so-called Spanish influenza of 1918 was, in the words of historian Alfred W. Crosby, America's Forgotten Pandemic, then for the time being the bounty of lessons suggests that COVID-19 is America's Teachable Moment Pandemic.⁴Alfred W. Crosby, America's Forgotten Pandemic: The Influenza of 1918, Second Edition (New York: Cambridge University Press, 2003), 311–328. The largest public health cataclysm in a hundred years has put to the test assumptions, capacities, decisions, practices, and policies. In many ways, the United States has been found wanting, as evidenced by the exceptionally devastating and inequitable toll that COVID-19 has exacted, much of which was averted or more proficiently mitigated by other countries, including nations in the Global South. Vietnam is a prime example.

Events turned US exceptionalism on its head; the nation's heralded public health preeminence ran aground against a novel corona virus. Remarkably, four months before the World Health Organization declared the worldwide spread of COVID-19 a public health emergency, preparedness experts convened by the Nuclear Threat Initiative and Johns Hopkins University reported that the United States was at the top of the heap internationally in terms of its readiness to contend with a pandemic. Scoring 83.5 out of 100 possible points, the US was deemed "best prepared" in the world.⁵Elizabeth E. Cameron, Jennifer B. Nuzzo, Jessica A. Bell, et al, Building Collective Action and Accountability, GHS Index, October 2019, https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf. Yet, when the virus began to spread throughout the nation, political and public health leaders overlooked or failed to respond promptly and effectively to signals of a mounting threat.

Myriad displays of ignorance in preparedness and response cast a spotlight on areas of knowledge, most visible in America's contributions to pathogen genomics and vaccine development, that were the rarity rather than the rule. As historian Peter Burke predicts, much will be said about ignorance when we look back on the pandemic.⁶Ana R. Rego and Marialva Barbosa, "Interview With Peter Burke: About Ignorance Nowadays," Revista Famecos—Midia, Cultura e Tecnologia 28 (2021): 1–7. The United States will provide many examples for review. "The coronavirus is very much under control in our country," President Donald Trump claimed without justification in February 2020.⁷"Trump Says Coronavirus Is 'Very Well Under Control' in U.S.," Bloomberg, February 25, 2020, Video, 1:26, https://www.bloomberg.com/news/videos/2020-02-25/trump-says-coronavirus-is-very-well-under-control-in-u-s-video. When cases and deaths surged, corporate America chimed in with commercials proclaiming "we are all in this together," a slogan that blithely disregarded systemic, inequitable differences in exposures, resources, and outcomes.⁸"Every Covid-19 Commercial is Exactly the Same," Microsoft Sam, April 15, 2020, YouTube video, 3:40, https://www.youtube.com/watch?v=vM3J9jDoaTA. As COVID-19 variants emerged and disease waves swelled, public health officials justified shifts in their response guidance with the catchphrase "follow the science," in effect denying knowledge gaps and glossing over judgment calls that informed their decisions.⁹Nason Maani and Sandro Galea, "What Science Can and Cannot Do in a Time of Pandemic," Scientific American, February 2, 2021, https://www.scientificamerican.com/article/what-science-can-and-cannot-do-in-a-time-of-pandemic/. Sports celebrities and other influencers joined in; some publicly declined vaccinations for spurious or unspoken reasons. In one widely publicized instance, a National Football League Most Valuable Player invoked vaccine misinformation to justify his decision to remain unvaccinated.¹⁰Ken Belson and Emily Anthes, "Scientists Fight a New Source of Vaccine Misinformation: Aaron Rodgers," New York Times, November 14, 2021, https://www.nytimes.com/2021/11/08/sports/football/aaron-rodgers-vaccine.html. These displays of ignorance, from the individual to the federal levels, almost certainly will be among the major topics covered when histories of America's recent past are written and discussed.

To a large extent, first drafts of our national COVID-19 history have been assembled, produced in near real-time amid an evolving pandemic. Among the lengthier accounts are books by Nicholas Christakis, Scott Gottlieb, Michael Lewis, Andy Slavitt, and Lawrence Wright.¹¹Nicholas A. Christakis, Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live (New York: Little, Brown Spark 2020);  Scott Gottlieb, Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic (New York: HarperCollins, 2021); Michael Lewis, The Premonition: A Pandemic Story (New York: W.W. Norton, 2021); Andy Slavitt, Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response (New York: St. Martin’s Press, 2021); Lawrence Wright, The Plague Year: America in the Time of Covid (New York: Alfred A. Knopf, 2021). Their narratives and additional reports, published across a wide variety of media platforms and outlets, recount a now familiar cascade of main events: warning signals missed or ignored. Contagion risks initially misunderstood or minimized. Testing bungled. Weaknesses in public health infrastructure and operations laid bare. Guidance delayed, shifted, and politicized. Mandates and masks applied, albeit unevenly. Healthcare stretched to the breaking point. Inequalities exposed. Supply chains disrupted. The economy slackened. Government spending skyrocketed, then dipped. Red-Blue divides widened. Vaccines produced in record time received mixed receptions. COVID-19’s impact surged, subsided, and swelled again—repeatedly. The pandemic dragged on and left its mark virtually everywhere and on everyone.

A bevy of initial accounts present a broad historical outline of what happened—to date. However, potential pitfalls arise when these first reports go beyond chronicling pandemic events and enter the realm of causal interpretations and lessons learned. There, the authors of quick-to-publication stories should tread particularly carefully, recognize uncertainties, and avoid unjustified or imbalanced explanations. Possible missteps include ignoring explanatory information or information sources and failing to acknowledge, or minimizing, the limits of their evidence. The risks of missing the mark are substantial. Causal interpretations skewed towards the unequivocal and unnuanced provide unreliable takeaway lessons and often obscure deeper etiologic factors. Revisions may be forthcoming, but inaugural versions can exert an outsized influence on what endures as the conventional understanding of what happened and why.

A case in point and cause for concern is Michael Lewis's bestselling The Premonition: A Pandemic Story (New York: W.W. Norton, 2021), a fast-paced narrative—a Hollywood movie version reportedly is on the way—that tells the tale of several outside experts who tried to spur CDC insiders to recognize and respond rapidly in early 2020 to signals of the brewing COVID-19 calamity. CDC's performance leaves little doubt that the agency was ill-prepared for the pandemic and made multiple mistakes in its response, including its botched diagnostic testing roll out, guidance fiascos, and acquiescence to political pressures from the White House. The open questions that Lewis takes on are what accounts for these failures and, more broadly, the poor showing by the United States compared with its lofty, pre-pandemic preparedness ranking. His answers are uncomplicated and unequivocal: the talents and recommendations of experts, represented by a small but heroic crew of scientists and physicians whom he profiles, were ignored, and the underlying cause was a lack of public health leadership, exemplified by the failings of the Trump-appointed CDC Director. According to Lewis, Donald Trump himself bears little responsibility for America's anemic response. "As one of my characters puts it," Lewis reports, "Trump was a comorbidity."¹²Michael Lewis, The Premonition: A Pandemic Story (New York: W.W. Norton, 2021), xiv.

I read Lewis's book closely, concentrating on his account of CDC's poor performance and the lessons to be learned. Notwithstanding his mystifying minimization of Trump's baleful role, Lewis's The Premonition offers a glimmer of hope for revelatory explanations and guidance. "After a catastrophic season, management always huddles up to figure out what needs to be changed," he suggests in his introduction, invoking a football analogy that promises a line of sight into the gap between reputation and results.¹³Lewis, xv. However, the front office managers are the target rather than the truth tellers in Lewis's narrative.

To tell his story, Lewis mainly relies on a small coterie of outside experts, most prominently a retired Sandia National Laboratories senior scientist who studied the effects of social distancing on mitigation of pandemic influenza, a former assistant director of the California Department of Public Health who warned state officials about the mounting COVID-19 threat during the pandemic's initial phase, and two physicians who helped write a national pandemic preparedness and response plan during the George W. Bush administration and raised early alarms about COVID-19's potentially devastating impact on the United States. High among their recommendations for thwarting a rapidly spreading contagion were school closures, which Lewis describes as one of the "truths" that his informants had discovered long ago.¹⁴Lewis, 211. Yet, considering the downsides of school shutdowns and remote learning, cleaving to that plan and putting it into practice in the COVID-19 pandemic was far from an unequivocal success, an important lesson that eludes Lewis and warrants much further attention.     

Lewis doesn't make clear whether he sought or used information from CDC responders about the agency's performance. Notably, he doesn't mention any contact efforts or interviews with insiders about CDC's emergency operations. The enormously harmful effects of Trump and his minions were clear to me and many CDC colleagues, as were major internal weaknesses in the agency's response, which Lewis largely ignores. Some of CDC's shortcomings were due to acute managerial and resourcing problems, often recurring or persistent despite multiple attempts at remediation; others reflected longstanding internal and external assumptions, refuted by the agency's woeful performance, about institutional readiness, proficiency, and sustainability in a pandemic. We need fuller accounts of what went wrong and why, including contributions by CDC insiders, to correctly cull lessons and put them to good use.

More broadly, the flaws in Lewis's assessment serve as a reminder that knowledge claims presented as takeaway lessons do not necessarily undo our ignorance. Some "lessons learned" ignore or minimize more compelling understandings of what went wrong and obscure what we ought to know better. The epistemological crisis that compounded the epidemiological calamity threatens to continue in new forms with the writing of pandemic histories and production of Hollywood dramatizations. Still, COVID-19 has the potential to propel high-value learning and positive changes at the individual, organizational, and societal levels.

Among the nation's earliest and most important pandemic lessons is the immense toll that ignorance can take on human lives. As I write this conclusion, American COVID-19 deaths are fast approaching the one million mark, and untold numbers of people who survived the acute phase of their infections are affected by long-term sequelae. Perhaps we now know better the enormity and implications of what was missing in the national efforts to contend with the pandemic, and we will address collectively what science and technology scholar Manjari Mahajan aptly describes as the "complex political and social determinants that anchor a country's public health response and that are critical in ensuring the sustained well-being of a population."¹⁵Manjari Mahajan, "Casualties of preparedness: the Global Health Security Index and COVID-19," International Journal of Law in Context 17, no. 2 (2021): 204–214. COVID-19's impact also has been evident in other, more individual lessons and actions. For many Americans, the pandemic has prompted a personal reckoning and welcome revisions in how they take care of themselves and other people in their lives. However, many COVID-19 lessons and changes are likely to fade, including some that are well worth preserving. America's Forgotten Pandemic of 1918 is a prime example of the finite limits on attention spans and memories. In our time, military conflict and other crises or preoccupations are likely sources of competition for mindfulness, efforts at sense making, and shifts in priorities and routines. "Information is no longer a scarce resource," notes sociologist Sheldon Ungar, "attention and interest are."¹⁶Sheldon Ungar, "Ignorance as an Under-Identified Social Problem," British Journal of Sociology 59, no. 2 (2008): 301–326. As a result, America's COVID-19 lessons, including those that are forthcoming, are at risk of diminution or disappearance regardless of their value.

The pandemic is a uniquely teachable moment in our history; we can learn from our ignorance and act accordingly. As political scientist Eric Stern reminds us, despite the formidable obstacles to learning from a crisis, great benefits can accrue from lessons that are deeply reflective, methodologically sound, and highly pragmatic.¹⁷Eric Stern, "Bridging the Crisis Learning Gap: From Theory to Practice," in Organizing After Crisis: The Challenge of Learning, ed. Nathalie Schiffino, Laurent Taskin, Céline Donis, and Julien  Raone (Brussels: P.I.E. Peter Lang, 2015), 257–272. COVID-19 has made ignorance and its negative consequences more visible in America. Fortuitously, at least for the time being, our lessons in ignorance also provide an impetus for new knowledge and, hopefully, momentum towards a more equitable society, stronger commitments to public health and healthcare, and a much greater responsiveness to planet-wide threats. 

About the Author

After completing the CDC's Epidemic Intelligence Service training program in 1986, Daniel Pollock worked as a medical epidemiologist at the agency for 35 years. Dr. Pollock led the CDC unit responsible for national surveillance of healthcare-associated infections from 2004–2021, and he served in CDC's COVID-19 emergency response in the spring of 2020 as the Deputy Incident Manager for data and surveillance.

Public Health in the US and Global South is a collection of interdisciplinary, multimedia publications examining the relationship between public health and specific geographies—both real and imagined—in and across the US and Global South. These essays raise questions about the origin, replication, and entrenchment of health disparities; the ways that race and gender shape and are shaped by health policy; and the inseparable connection between health justice and health advocacy.

Beginning in 2022, the series expands to include 1000-word blog posts, as well as longer commentaries, essays, articles and media productions that address the public health and political implications of the COVID-19 pandemic from multiple viewpoints. The series editor for Public Health in the US and Global South is Mary E. Frederickson.

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