It’s 2021! What’s going to happen next?

There are some pathways emerging that could take us to the end of the pandemic, but a lot of uncertainty remains. We’re trying to stick with the core lesson of COVID-19 so far (humility) and won’t aim to make any specific predictions. There are some broader themes, however, that we think will be important in the coming weeks and months:

• Vaccination 2.0: This is about the act of providing vaccinations -- shots in arms, as distinguished from vaccines themselves (the material in the syringe). Vaccination 2.0 will require more nimble, accessible services to reach people where they are for equitable distribution and coverage. Prioritization for COVID vaccination so far has been transparent, with reasonable discussions and conclusions, although there are many alternative scenarios and rollout has not followed recommendations with complete fidelity. We know some lower priority individuals have been vaccinated during phase 1a, and we know some vaccine has gone to waste -- although it seems these have been small quantities, fortunately. With limited supply, prioritization phases remain too wide and further specifics within phases are needed for practical vaccine rollout. An equitable, just, and effective prioritization approach requires more detail, and resources for vaccination campaigns that have not yet materialized. The U.S. is not comfortable with the concept of resource constraints faced by most of the rest of the world, but it is our current reality. Our technological gains are offset by our failures to support the more routine: for example, the U.S. developed but has not been able to effectively implement the antibody treatments that can keep people out of the hospital. It feels like a theme: we excel on the cutting edge of science and technology, but fall short on the fundamentals. What to do in 2021: Quickly develop more detailed vaccination prioritization, incorporating equity and impact with transparent and inclusive approaches. Incorporate years of life lost as part of the prioritization discussion, not just total number of deaths. Acknowledge that our health care delivery is falling short, and take action such as vaccinating and mobilizing volunteer medical corps members, and looking for non-traditional access points to care, such as using plasma donation centers to administer antibody treatments to liberate capacity in health systems for vaccine administration.
  

• Avoidable unknowns: We will continue to miss fundamental signals about this pandemic. Our understanding of COVID epidemiology has key gaps that are attributable to our ongoing failure to invest in public health infrastructure. COVID testing and sequencing are illustrative examples. Testing with timely results at the scale and coverage we would need to routinely track asymptomatic and undiagnosed cases remains out of reach in the United States. Genetic sequencing of the COVID virus is likewise limited in the U.S., which is why we missed the circulating strain that may confer increased infectivity (the first official detection, on Dec 29 in a Colorado individual with no history of travel is consistent with widespread circulation that went undetected). What we miss next about this pandemic may be related to testing or sequencing, or another as-yet unidentified area where our current capability is substandard. We remain without a common set of data variables and key indicators to track COVID, and contact tracing was functionally abandoned early in the pandemic, without any clear sign this basic public health function will be brought back online. To illustrate shortcomings, the thanksgiving surge may have been a large spike among those who traveled and gathered, diluted to appear smaller due to a decrease in cases among a larger segment of the population that remained COVID safe over the holiday, is unknown. What to do in 2021: Implement better standards for data collection and reporting. As the unknowns emerge and become known, have SNL make a sequel to a comedic bright spot.
  

• Flat learning curve: Slow learning and adaptation is an issue for public health institutions that have been under-resourced for so long. Steep learning curves for institutions that safeguard the public followed the Sept. 11, 2001 attacks and the H1N1 influenza pandemic of 2009. In both cases, events fit a “worst case scenario,” but the scenarios had been neither unimaginable nor unpredictable. 2,977 died in the attacks of 2001, and 2,117 died of confirmed influenza in the 2009 pandemic although the total death toll was estimated to be more than 12,000. What followed 2001 was a complete overhaul of air travel security, in the form of the Transportation Security Administration (TSA). What followed in 2009 were strong efforts to update pandemic response plans, some brief attention to pandemic stockpiles, and a nearly 10% budget reduction for public health between 2008 and 2014. This is one demonstration of a repeated pattern of failure to build robust, durable public health institutions in the United States. What to do about it in 2021: If the TSA was “air travel security 2.0,” let’s see the next generation of public health infrastructure emerge from the COVID pandemic.

The image for 2021 that we think should be emerging is one of seeing the mountain peak in front of you, and realizing that it may be the final peak, or it may be a false peak: Beyond mountains, there are mountains. We still don’t know how far we are from the summit. Vaccines provide a real pathway for hope, but just because you know summer will eventually arrive doesn’t mean it’s time to take off your winter gear. It’s 15 degrees fahrenheit; don’t take off your jacket just because it’s going to warm up in 6 months. Between now and then there’s going to be a lot more ups and downs.