Systemic US reforms needed to prevent mass death in the next pandemic

Ahead of the 2024 US presidential election, The BMJ has launched a forward-looking series that highlights the lessons that can be learned from the US’s COVID-19 experience and the actions that are needed to prevent the loss of another million citizens in the next pandemic and improve and protect population health.

The articles, written by leading clinicians and researchers across the US, explore topics such as how systemic racism and economic inequality contributed to COVID-19 disparities; mass incarceration and poor prison health as a driver of the pandemic; labor market inequalities; and the impact of “the hollowing of the state” (the diminished role of the public sector).

The authors call for a set of crucial systemic reforms, which they believe should be central to the manifestos of the 2024 US presidential candidates.

Importantly, the aim of the series is not to assign blame—there is plenty to go around—but to look to the future and lay out critical steps that need to be taken to transform US public health and preparedness and improve population health more broadly.

In an editorial to launch the series, guest editors Gavin Yamey at the Duke Global Health Institute, Duke University and Ana V. Diez Roux at Drexel University Urban Health Collaborative explain how during the devastating global COVID-19 pandemic, the United States suffered “eye-wateringly high” death rates compared to its peer nations.

The 1.16 million Americans killed by COVID-19 represent 16% of global deaths in a nation with 4% of the world’s population, they write. About 300,000 children are estimated to have lost one or both parents, and there is a substantial burden of long COVID.

The series documents the many complex, inter-related causes of the poor US pandemic response, underpinned by two key contexts.

The first is the nation’s pre-existing structural and systemic features, which contributed to devastating pandemic outcomes. These include gaps in health care and public health systems, the absence of social safety nets and workplace protections, ingrained social inequality, and systemic racism.

“These are key reasons why the nation suffered higher COVID-19 mortality rates than its more equal counterparts, and why pandemic death in the US was so closely patterned by social class and race,” write the authors.

The second is that while the US had many scientific resources, the government showed a troubling inability to generate reliable information, communicate it in a timely and consistent manner, and translate it into sound policy.

These failures began at the top, argue Yamey and Diez Roux. President Trump lied frequently about the pandemic, and his suggestion of using bleach to fight COVID-19 “came to symbolize the chaotic presidential communications in the pandemic’s first year.”

Poor communication of existing evidence also contributed to confusion and delayed actions. Such communication missteps is one reason for the partisan difference in how quickly states acted to institute public health protections and in excess death rates during the pandemic, especially in the period since vaccines became available.

Poor communication of evidence also led to inappropriate actions, they add.