Postmortems, or autopsies, which were common practice until well into the 20th-century but have recently become more rare, are conducted to determine a cause of death. The Greeks pioneered them three thousand years ago, and famous scientists from Virchow to Harvey extolled their necessity. The purpose of a post-mortem is quality control, to see if diagnoses made while patients were alive were correct. As Dr. Brendan Reilly, former Executive Vice Chair of Medicine at New York-Presbyterian Hospital/Weill Cornell Medical Center, wrote in a 2017 article, “a high autopsy rate strengthened a hospital’s reputation; it indicated that the medical staff wanted to learn as much as possible […] in an effort to improve doctors’ diagnostic capabilities, perhaps gain scientific insights, and avoid error in the future.”
For the same reasons, America needs a national postmortem on our response to the COVID-19 pandemic—to learn from our mistakes and improve responses to the next pandemic. Policy quality control, as it were. An honest postmortem can only occur, however, if Congress finds the will to create and fund a bipartisan commission that will bring in outside experts to analyze data and use the commission’s subpoena power to question policy makers.
With blame and embarrassment undoubtedly belonging on both sides of the aisle, it is not surprising that there is insufficient appetite for setting one up. A few senators have tried to get a bill to the floor to approve a COVID-19 commission, but so far have not succeeded. In the absence of such a commission, we will simply have more of what we have now: tribes of people yelling at each other furiously, both sides convinced that all could have been different and turned out better if only someone else had been in charge or some other set of experts had been listened to.
The House, under control of the Republicans, recently conducted a hearing, the Select Subcommittee Roundtable: Examining Covid Policy Decisions, led by Chairman Wenstrup (R-OH), which he said in opening remarks aimed to be bipartisan and which did contain members from both parties. The sole witness called by the Democrats, Dr. Georges Benjamin, the Executive Dir. of the American Public Health Assoc., said explicitly, as did Dr. Jay Bhattacharya, one of the three witnesses called by the Republicans, that U.S. citizens deserve a bipartisan commission. He referenced the 9/11 Commission as a key step in reforming U.S. national security policies.
Unfortunately, while the committee did raise important questions, for example about school closures and children’s mental health, it in no way mirrored the lengthy, deliberate, and thoughtful processes of a bipartisan commission. There was no extended fact finding phase nor did the committee have subpoena power, although experts were called, including three authors of an eighty page report on the U.S. pandemic response that was released in February. As coauthors on this report, our hope was that a pandemic commission could use it as a blueprint to help inform an extensive investigation into what went wrong–and what went right–and craft a set of recommendations to improve the next pandemic response. So far, this has not happened and numerous attempts to launch such a commission have been squelched.
This is unacceptable. Americans need their lawmakers to finally put the health of citizens above politics and fund a bipartisan commission to devise recommendations for reforming the agencies and policies that failed us, under both administrations.
Some policies and responses were good and should be studied to apply their lessons in the future, like Operation Warp Speed, which brought highly successful vaccines to vulnerable people in record time, and the NIH ACTIV trials which attempted to quickly identify new and existing drugs, such as antivirals and monoclonal antibodies, to fight infection. But many U.S. government policies were unhelpful, some even harmful, and agencies that should have acted quickly instead were slow, politicized, and often hampered by bureaucratic quagmires. For example, while other countries quickly established working PCR assays to test for SARS-CoV-2, laboratories in the U.S. were not permitted to replicate these tests. Instead, they had to get FDA approval to run tests, or send samples to the CDC, severely delaying early case identification and allowing COVID-19 to spread undetected in vulnerable communities such as nursing homes. Why were pathways to deliver testing not smoothed quickly, nor regulatory burdens removed? These are some of the many important questions that have never been adequately addressed or answered. In another example of poorly executed policy, data from Australia and South Korea in August 2020 showed that secondary infection rates were very low in schools. The U.K., as well as Norway and other Scandinavian countries, also showed that in-school spread was low and that teachers were not at higher risk of infection than the general population. Why, then, did many U.S. policy makers and the CDC push guidelines that suggested that schools could not be safely opened in fall of 2020 and beyond?
After the 9/11 commission released its findings, many agencies were reformed and some improvements were made to inter-agency communications, the Department of Homeland Security was created, and major overhauls were made in who could obtain a visa to enter the country. Similar reforms could be made to improve our pandemic preparedness, such as improving communication and data sharing among agencies, removing barriers to innovation, creating proactive pathways to ease testing regulations, and changing leadership structures to make public health officials more impervious to political pressures. For example, the Federal Trade Commission is headed by five commissioners nominated by the president and confirmed by the U.S. Senate and no more than three may be from a single political party. Why not the CDC?
There is an old joke in medicine that surgeons know nothing and do everything; internists know everything and do nothing; and pathologists know everything but it’s too late. The punch line relies on the fact that the pathologist’s job, of course, is not to save the patient but to help doctors prepare for the future–to do better by their next patient. In this case, we are the patients, and we need our elected officials to step up and create a COVID-19 commission to act as the pathologists–to demand answers to the hard questions, assess the harms and benefits of pandemic policies, and gain scientific insights to avoid repeating the same errors. Americans deserve some policy quality control.
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