Commentary – Two Decades After 9/11: What We’ve Learned About Public Health Preparedness and Leadership

By Lauren Eichberger (Reynolds), Biodefense Certificate Student

September 11th, 2001 is a date the United States will never forget. Following this tragedy, there were calls to improve our national security against “physical” attacks and amend preparedness plans. Now, in 2021, two years into the COVID-19 pandemic, the nation finds itself in a comparable situation with a call for greater biosecurity and health care preparedness. The Association of State and Territorial Health Officials (ASTHO) held a virtual event, “Two Decades After 9/11: What We’ve Learned About Public Health Preparedness and Leadership” that discussed these two calls-to-action.

The first session was a keynote address by Dr. Philip Zelikow, former Executive Director of the 9/11 Commission, who provided his unique insight on the preparedness of the United States for both 9/11 and COVID-19. Dr. Zelikow recalled the events of 9/11 and his role as the director of the 9/11 Commission. He stated, “[the] best learning comes from rigorous investigation.” He envisions a COVID-19 commission tasked with assessing how the United States responded, and identifying what can be improved in future responses.

As a nation, this is not our first pandemic. In the United States alone, 743,452 “excess” (potentially preventable) deaths occurred from COVID-19 between February 2020 and September 4th, 2021, according to the CDC National Center for Health Statistics. Dr. Zelikow stated this figure exceeds the number of excess deaths that occurred during the 1918-19 influenza pandemic, which was caused by an even deadlier virus. Amid our medical and technological advancements, Dr. Zelikow noted that, “our net outcomes are comparable to 100+ years ago!” He also notes that this may be, in part, due to the science being ahead of our ability to apply it in practice. Even so, our science was able to produce a vaccine faster than ever before, yet we are still “losing” to this virus.

The bones of our current health care system, which is employer sponsored, can be dated as far back as the late 1800s and early 1900s when employers of lumberjacks and those who lived in rural settings hired doctors to be on-site (Emanuel, 2020). In the 1930s and 1940s, states began offering health care via Blue Cross Blue Shield with no change in policy until the 1950s when Medicare and Medicaid were introduced at the federal level (Emanuel, 2020). Since then, the healthcare system has not made the sweeping changes needed to best care for the population, which has changed over the last several decades. As Dr. Zelikow stated, we need to redesign our health care system by focusing on “What worked, what is needed, and how do we make the US stronger and safer, besides just terrorist attacks?” A rigorous investigation of the choices the United States made is needed. As Dr. Zelikow put it, “without hindsight; it blinds!”

After 9/11, the nation came together and painfully learned what they could do to prevent a major terrorist attack on the homeland from happening again. Now, scientists, politicians, and the public have a “generational opportunity” to come together and learn from our mistakes with COVID-19.

A Q&A session moderated by ASTHO President Dr. Nirav Shah focused on the preparedness of the Department of Human and Health Services (HHS), which houses the Assistant Secretary for Preparedness Response (ASPR). Answers were provided by two former ASPRs, Dr. Craig Vanderwagen and Dr. Nicole Lurie. Dr. Vanderwagen started the session by addressing the challenges that ASPR faces today, such as adding emerging infectious diseases to the ASPR Health Care Preparedness and Response Capabilities document, which guides hospitals and health care providers on how to properly train and respond to emergencies that stress their systems, such as a mass casualty shooting or infectious disease outbreak. Dr. Vanderwagen also noted that requiring more responsiveness from HHS would improve preparedness by health care providers. Indeed, the ASPR document is updated every few years, with the current document covering 2017-2022. Dr. Lurie agreed, stating that the COVID-19 pandemic was predicted and that, as a nation, we can learn from this pandemic to better prepare for the next.

“Where did we go wrong?” Dr. Shah asked. Answers ranged from policy to science to public opinion. Dr. Lurie first explained how many scientists and leaders forgot that Mother Nature could produce such a horrific virus, even one that could be worse than a biological weapon. For that reason, the world did not take the virus as seriously as it should have. Secondly, she called out scientists for their own pride and ownership of data. In general, science is not published unless every fact has been substantiated. Also, scientists are often prone to competitiveness rather than collaboration. Dr. Lurie opposed this mindset and explained how in dire emergencies, such as a global pandemic, scientists need to work collaboratively with the information available, even if the information is not deemed perfect. However, she also noted that scientists have been under extreme pressure from politicians, leaders, and the public, and may fear backlash. As a trained immunologist and research scientist herself, Dr. Lurie highlighted her concern that science is being silenced.

Where can our nation go from here? Dr. Lurie and Dr. Vanderwagen agreed that our nation’s healthcare system needs to be redesigned with preparedness in mind, starting with an Emergent Infectious Disease Fund. In case of a future pandemic or infectious disease outbreak, this fund could immediately be used when a disease strikes. Perhaps such a fund could have decreased the excess deaths Dr. Zelikow mentioned.

Another Q& A session, moderated by Dr. Leonard J. Marcus, focused on what the 9/11 attacks taught us about preparedness. Panelists Sherry Adams, a registered nurse and Director of the Office of Preparedness and Response for the Maryland Department of Health; Dr. Georges Benjamin, Executive Director of the American Public Health Association; and Dr. Howard Zucker, the Commissioner of Public Health for New York state, provided their unique perspectives on the topic.

The discussion started with a focus on whether or not there was a failure of imagination in the public health system. As Dr. Benjamin pointed out, there is a complacency born of the belief that “the feds [Federal Government] have our back.” Ms. Adams added that she believes the problem stems from the lack of knowledge the current generation has in how the government operates, a lack of acceptance of science, and emotional responses to the pandemic that overwhelmed thoughtful responses.

The panel also addressed the importance of public communication. The 9/11 attacks taught us how important communication is without the “noise” of misinformation and disinformation. Fast forward 20 years and the information overload in this country means there is even more noise that clutters the facts. This led to another important point: tell the truth to educate the public and be coherent. According to Dr. Zucker, in order to tell the truth, we need to start with better education (and the funding to do so) to rebuild the public health workforce. With a solid foundation and understanding across all healthcare workers, the truth can be told.

When asked what will become of public health preparedness, Dr. Zucker recalled that after 9/11, the nation became more focused on security but failed to update our public health system accordingly. Ms. Adams pointed out that strengthening public health is a long-term strategy, but “society is used to a magic bullet, magic pill, etcetera.” Dr. Georges agreed, reminding everyone that, “Prevention works! We can get ahead of these things.” He also asserted that “we must normalize health security.” In order to do so, the panel stressed that the public must take interest in public health to improve our nation’s preparedness.

This ASTHO event highlighted the common challenges faced after 9/11 and during the current pandemic to identify the right lessons to be learned. While this conference featured the perspectives of health policy experts and former public health officials, the issue of improving health security needs to become an everyday conversation if we are going to put in place the right policies to implement these lessons. Just as our nation became stronger after 9/11, the United States can emerge stronger and more resilient after this pandemic.

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