We’re better off when science leads the way

Better Off talks with Harvard Chan School’s Howard Koh about lessons learned from the 2009 H1N1 influenza pandemic, also known as swine flu, and how the incoming administration can use those lessons to respond to COVID-19.

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Episode Transcript


Anna Fisher-Pinkert: From the Harvard T.H. Chan School of Public Health – this is Better Off. A podcast about the biggest public health problems we face today . . .

Howard Koh: Whenever a new vaccine is rolled out to the American public, particularly in a time of emergency and crisis, it raises all these issues of trust and confidence.

Anna Fisher-Pinkert: . . . and the people innovating to create public health solutions.

Howard Koh: The most important thing to remember is that when prevention works, absolutely nothing happens and all you have is the miracle of a perfectly normal, healthy day. That’s what we need right now.

Anna Fisher-Pinkert: I’m your host, Anna Fisher-Pinkert.

On January 20, 2021, Joseph R. Biden will become the 46th President of the United States. No matter who you supported in the 2020 election, I think we can all agree that it’s a big relief to stop seeing all those political ads, to stop watching pundits wave their arms in front of big electoral maps.

But here’s the thing. . . the COVID-19 virus doesn’t care about the election, or politics, or pundits. It just keeps going. One model predicts that the U.S. will see nearly 400,000 deaths from COVID-19 by February.

Biden has laid out a plan that he says will get the pandemic under control. But with numbers like those, it’s hard not to wonder . . . are we too far gone? Is there any action that the U.S. government could take right now that would turn things around? And what would those solutions look like?


So we’re going to talk today about the federal government, the presidential transition, and how to stop the pandemic that just keeps growing. This week, we’re better off with Howard Koh, health policy expert.

Let’s start by going back to June of 2009, when the U.S. was in the middle of another public health crisis.

Reporter 1: The CDC has confirmed America’s first swine flu death, a 23-month-old toddler in Texas. Health officials are preparing for the worst. The CDC expects multiple swine flu deaths . . .

Reporter 2: . . . there have been 130 cases reported in the U.S. at this point. It’s spreading, albeit slowly. . .

Anna Fisher-Pinkert: H1N1, initially called swine flu, was first detected in a 10-year-old patient on April 15, 2009 in California. Barack Obama had been in office for less than 100 days. By June, all 50 states and more than 70 countries had reported cases of H1N1.

Howard Koh: So literally from my first day, that was the issue that was highest on my agenda for many months going forward, so it was an unforgettable time.

Anna Fisher-Pinkert: That’s Dr. Howard Koh, he’s now the Harvey V. Fineberg Professor of the Practice of Public Health Leadership at the Harvard T.H. Chan School of Public Health. In June of 2009, he joined the Department of Health and Human Services as Assistant Secretary for Health. And this was quite a time to start a new job – his office was helping to coordinate the Department’s public health response to the first flu pandemic in 40 years, with a special focus on vaccine safety.

Howard Koh: The big difference between then and now is we already had some candidate vaccines in the pipeline, and we were pretty sure our vaccine would come sooner rather than later.

Anna Fisher-Pinkert: Having a head start on the vaccine was a huge boost to the pandemic response – but just having a vaccine doesn’t halt a pandemic in its tracks. People need to actually go out and get vaccinated. And to get them to do that, you need to earn their trust.

Howard Koh: Whenever a new vaccine is rolled out to the American public, particularly in a time of emergency and crisis, it raises all these issues of trust and confidence. And we knew that if we had an excellent scientific system that was tracking adverse outcomes and safety profiles, that that would go a long way to making that new vaccine acceptable to the American public.

Anna Fisher-Pinkert: Before clinical trials for the H1N1 vaccine began in July of 2009, HHS already had two different vaccine safety monitoring systems – one is a coordinated effort between the CDC and the FDA, the other is a collaboration between the CDC and eight managed care organizations. On top of that, HHS convened an additional safety working group. So, while the vaccines were being developed at top speed, they had all of these safety checks in place.

Howard Koh: When you ask people to take a vaccine, you’re asking otherwise healthy people to take a risk to stay healthy. So the bar has got to be really high, that it’s got to be safe as well as effective.

Anna Fisher-Pinkert: The first vaccines were approved by the FDA in September, and by October, HHS had launched a campaign to encourage Americans to get vaccinated. But after the vaccine was finally ready, a new problem emerged.

Reporter 3: The government has ordered 250 million doses of the H1N1 vaccine, which it anticipates will be enough to cover demand in the United States. But the CDC admits that getting the vaccine out will be bumpy at first.

Anna Fisher-Pinkert: HHS had to figure out how to get enough vaccine doses out to the American public.

Howard Koh: Those opening months were very difficult because the good news was a vaccine became available. The bad news was – and this happens with any new vaccine rollout – initially, supply did not meet the demand. So there were at least several months where trying to meet that demand was very, very stressful for everybody in public health.


Anna Fisher-Pinkert: And yet, by the end of February 2010, 10 months into the pandemic, the CDC estimated that 24-27% of Americans had received the H1N1 vaccine. Kids were one of the groups most vulnerable to H1N1, and 40% of American kids got the vaccine. Fortunately, cases of H1N1 were already on the decline in the U.S. by the time the vaccine was in wide distribution. By August of 2010, WHO announced that the H1N1 pandemic was over.

Reporter 4: Medical associations across the country and around the world now seem to be speaking with one voice on the swine flu. They’re reporting steep declines in the number of new cases.

Howard Koh: When I look back, what I’m proud of, despite the fact it was so challenging and we had some 12,000 deaths, which were very difficult to endure, was that we all worked together as a one government approach: federal, state and local colleagues. When it was over, we learned a lot in terms of trying to prepare for the next one. And now here we are in the middle of the next one, and the outcomes are so much worse this time.

Anna Fisher-Pinkert: All told, H1N1 was responsible for the deaths of 12,500 Americans and 284,000 people worldwide. It was a terrible, terrifying disease. But when I hear those numbers, it almost seems like there should be another word to describe the type of pandemic we’re living through now. At the time of this recording, more than 250,000 people have died of COVID-19 in the U.S., and 1.3 million people have died around the world.

There were a lot of factors working in the U.S. government’s favor when it came to responding to H1N1 – There was a vaccine already in the pipeline, older adults had some immunity to H1N1 because of previous exposure to similar flu strains, and H1N1 responded well to already available treatments like Tamiflu. But when he looks back, Howard Koh thinks there’s more to it than that – some of the success in combating H1N1 can’t just be attributed to the nature of the virus itself. So I asked him, as someone who formerly worked in the federal government, what exactly went wrong when it came to our response to COVID-19?

Howard Koh: So we are into the 10th month and counting of our pandemic response here in 2020. And, Anna, we can already look back and say there’s so many aspects of this response that we wish had gone differently. You know, a major overriding theme is we still don’t have a national plan for the country for this national emergency.

Anna Fisher-Pinkert: He says there was a lot of collaboration and communication between local, state, and federal governments during H1N1 that just did not happen at the start of the COVID-19 pandemic.

Howard Koh: So if we think back to where we were in April, you remember that we had a national shutdown. And then there were plans to reopen the country and certain criteria were put forward to the country and to the states about what indicators to follow as states decided to open back up. Numbers of new cases, test positivity, numbers of deaths, whether those trends were going up or going down. And so those are in general, good guiding principles back then, but the problem was that those were followed in very inconsistent fashion. The decision to proceed was left up to the states, which is on one hand fine, but there has to be some coordination and tracking of how each state is doing.

Anna Fisher-Pinkert: And, unlike during H1N1, communications from government, at least from the federal government, have been largely led by politicians, not by public health experts. And Howard Koh says that led to a lot of confusion about the science behind the COVID-19 response.

Howard Koh: The national communication to the public was very inconsistent. The White House briefings came and went. Sometimes health officials were there or sometimes they weren’t. We all know that in a time of emergencies, what the American people want to hear is scientific information from scientists, because if anybody else is putting forth that information, they don’t have the credibility and trust.

Anna Fisher-Pinkert: Trust seems to be the missing ingredient in the COVID-19 battle. Science itself has become politicized – whether it’s mask-wearing or getting vaccinated. Can we even hope to put science back in the center of the conversation around the pandemic?

Howard Koh: So I know that’s a question I think about regularly, because I’m a public health professional who has had the privilege of serving multiple Republican governors and then a Democratic president, so I have always viewed public health as a bipartisan, if not nonpartisan issue, particularly in the midst of a pandemic, and we should just put aside those partisan differences and just focus on conquering this virus and getting us to the other side of this terrible, terrible emergency. The president-elect has said repeatedly that when he begins, he will empower his top public health agencies and empower his top public health scientists.

Howard Koh: The current administration has done that inconsistently up to now, if I can say, and then the president-elect has also pledged that we may even hear this on the opening day or two of the new administration to put forward efforts to have a national mask requirement. President-elect Biden always wears a mask in public and his events are always socially distanced, according to the science. And I think when the president acts consistently based on science, people follow; when a president acts and speaks, millions pay attention and follow. So I think that change alone hopefully will make a big difference.

Anna Fisher-Pinkert: Another area where Howard Koh would like to see Biden break from Trump’s approach is how his administration works with civil servants – the people who work in federal agencies like HHS, but are not political appointees. Trump has been openly hostile to career scientists and administrators in HHS, CDC, and NIH . . . But Howard Koh has a different perspective on the people who work in those jobs.

Howard Koh: I’ve had the privilege of serving at the state and federal level and public health departments. And the overwhelming majority of my colleagues are civil servants. At HHS, for example, there are 80,000 employees and about 79,500 or more are career civil servants. They stay regardless of what the administration is. Their mission is to get up every morning and protect the American people and help them be as healthy as possible, regardless of the political party involved and regardless of what the threat is. So, when you work shoulder to shoulder with colleagues like that, it really humbles you because they are working really hard. My time in federal government was just the most inspiring time. I met so many incredible people who cared so much about our society, which is why I love this field of public health.

I encourage all my students to at least do a rotation in government, even if it’s just a summer internship to see what it’s like. Understand the challenges and the opportunities and get a big picture view of what public health is all about. These experiences make you absolutely passionate about good government and making sure the right people are in there doing the right job at the right time.

Anna Fisher-Pinkert: When Joe Biden takes office, the biggest and most immediate concern will be the rollout of a successful COVID-19 vaccine. Just like in 2009, there are two big concerns around the vaccine: one, that there may not be enough vaccine for those who want to get vaccinated right away, and two, that there will be some who should get the vaccine and don’t trust that it’s safe. This is of particular concern in communities of color, where rates of COVID-19 deaths are disproportionately high – but polls show that Black Americans are less likely to want to get vaccinated.

Howard Koh: This is where coordination between the federal, state and local health authorities is key. Right now, every state has, in fact, put in a distribution plan to HHS and those are being reviewed and coordinated going forward. And then each state and local public health organization has got to identify high risk groups within their own locales and make sure that those communities are engaged. So particularly at the local level, and let’s say for communities of color, making sure local leaders are engaged in this effort is absolutely important. This is where building the strongest non-traditional partnerships is key.

Anna Fisher-Pinkert: If Howard Koh were back in DC today, he’d have a few words of advice for the incoming administration. First on the agenda? Prevention, prevention, prevention.

Howard Koh: If we take the biggest picture and ask, how did we get here? Why are we seeing such devastating outcomes, particularly for at-risk populations for communities of color, for older people with preexisting conditions? It’s because as a nation, we have just not supported the concept of disease prevention the way we could and should. Only two to three cents on a health care dollar is spent on disease prevention. So much of this could have and should have been prevented looking back. I often reflect, Anna, that after 9/11 and anthrax in 2002, Congress also set up a public health emergency preparedness programs and hospital preparedness programs and said, OK, we’re going to give you funds for planning and coordination and tracking and surveillance. But over time, everyone became more concerned about other issues and then the funding for all those efforts went down. The most important thing to remember is that when prevention works, absolutely nothing happens. And all you have is the miracle of a perfectly normal, healthy day. And that’s what we need right now.

Anna Fisher-Pinkert: It will likely take years before we can fully understand all the different actions and reactions that caused the COVID-19 pandemic to become “the big one,” the pandemic that dwarfed all others in recent memory. We just have to hope that our leaders take those hard lessons and use them to prevent the next “big one.”

We’re going to take a short holiday break – but when we come back, we’ll be bringing you episodes about mental health, sexual health, vaccines and more. Subscribe to Better Off in your favorite podcast app to get episodes every other Wednesday. If you like the show so far, rate and review us – and tell your friends about the podcast, too.

You can find us on Twitter and Instagram @HarvardChanSPH.

We’re better off with our team:

Chief Communications Officer: Todd Datz

Senior Digital Designer: Ben Wallace

Production Assistant: Brian Le

I’m Anna Fisher-Pinkert, host and producer of Better Off, a podcast of the Harvard T.H. Chan School of Public Health.

Music in this episode:

Ketsa – Sabre

Blue Dot Sessions – St. Augustine Red

Blue Dot Sessions – Pxl Eventuat

Ketsa – Onwards Upwards