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Illustration: Aïda Amer/Axios

20 months after pandemic lockdowns first began in the U.S., government institutions and the public are still struggling to manage COVID-19 as the emergency it is.

Why it matters: Past crises, from the Great Depression to 9/11, led to lasting changes in American society and governance. But institutional inflexibility has left us at risk of further COVID waves and disruption and unprepared for the inevitable next pandemic.

Driving the news: On Friday, the FDA endorsed booster shots of the Pfizer-BioNTech and Moderna COVID-19 vaccines for anyone 18 and over.

  • That will increase the number of Americans eligible for a booster by tens of millions, but it comes after a number of experts called for the FDA to speed up widespread booster approval and after several states were already moving on their own to expand eligibility.
  • It will also come too late for Americans getting a booster now to have that added protection by the Thanksgiving holiday next week, as it takes one to two weeks for the full effect. COVID cases have risen 20% in the U.S. over the past two weeks.

The big picture: The delay and confusion around booster eligibility is just one example of the institutional inflexibility that has hobbled the U.S. pandemic response beyond better-known problems of political polarization and vaccine refusal.

  • Despite clear evidence of the drawbacks of remote education, Detroit public schools this week announced students would go remote on Fridays in December in an effort to reduce COVID outbreaks.
  • Part of the justification for the switch was to provide more time for deep cleaning facilities, even though it has long been clear the risk of contracting the virus from surfaces is low.
  • Some government officials are recommending Americans who have family and friends over for indoor Thanksgiving celebrations remain masked and socially distant — advice that seems both unrealistic and outdated at this point.

Between the lines: Nowhere has the institutional conservatism toward COVID held back the U.S. more than around testing.

  • While the vaccines are excellent at blunting sickness and death — and spread to a somewhat lesser degree — frequent and rapid diagnostics can identify the sick when they are contagious, making the tests the most highly effective and targeted public health tool in our arsenal.

Yes, but: Though rapid diagnostics are now more available, they still cost as much as $12 per test — far higher than in countries like Germany and the U.K. that have rolled them out widely with government support — and too high for most people to do regular screening.

  • The FDA's decision to evaluate rapid antigen tests as medical devices rather than public health tools greatly slowed their rollout and increased their cost, Michael Mina, a former Harvard epidemiologist who just became chief scientific officer at the biotech software company eMed, told me recently.
  • "The fault really lies in not having the wherewithal to say that this is a public health crisis," he said. "We don't have a strategy or even a legal infrastructure to talk about tests as a public health tool."

Context: There are many reasons the U.S., despite its wealth and expertise, has one of the highest COVID death rates in the world — not least an entrenched and politically polarized antivax movement, fueled in part by social media, that has helped keep full vaccination rates in the U.S. below poorer countries like Ecuador and Sri Lanka.

  • But institutions and experts have also been slow to adjust to a changing reality, sticking to policies even after real-world evidence has undercut them — like the initial discouragement of mask wearing — and ignoring newer, more targeted interventions like widespread rapid testing.
  • "The pandemic has proved to be a nearly two-year stress test that the United States flunked," sociologist Zeynep Tufekci wrote in the New York Times. As a result, when it comes to institutional trust, "America is bankrupt."

What to watch: What if any institutional changes come out of the pandemic.

  • The Great Depression brought forth the New Deal, WWII the postwar system of Western alliances and international agencies, and 9/11 brought the Department of Homeland Security.
  • None were perfect, but the magnitude of the responses underscored a belief that once-in-a-generation crises demand once-in-a-generation change.
  • But there's little indication the pandemic will cause us to fundamentally rethink how to respond to health threats. Current legislative plans call for $10 billion in new funding for public health and pandemic planning, less than what the Biden administration originally wanted and far less than what experts have called for.

The bottom line: The nearly 800,000 Americans who've died so far from COVID-19 are proof we've lost this pandemic, but if the U.S. finally exits it without fundamental change, it'll be set up to lose the next one.

Go deeper

15 hours ago - Health

Pfizer could have vaccine data for children under five by end of 2021, CEO says

A health care worker administers a dose of the Pfizer-BioNTech COVID vaccine to a child at a Salvation Army vaccination clinic in Philadelphia on Nov. 12. Photo: Hannah Beier/Bloomberg via Getty Images

Pfizer could have data on COVID-19 vaccine efficacy for children under five by the end of the year, CEO Albert Bourla said on Friday in an interview with NBC News.

Why it matters: Omicron has raised concerns that young children are becoming more vulnerable to the virus. Tshwane, the epicenter of South Africa's Omicron outbreak, has seen a high number of hospital admissions for children under two in the last few weeks, though scientists have not confirmed a link to the variant, Reuters reports.

Updated Dec 2, 2021 - Axios Events

Watch: A conversation on health equity in 2022

On Thursday, December 2nd, Axios health care reporter Tina Reed and congressional reporter Alayna Treene examined persisting health equity issues and the work underway to close gaps in access, featuring Rep. Robin Kelly (D-Ill.), Baltimore City Health Department Commissioner Letitia Dzirasa, and Brown University dean of the School of Public Health & Professor of Health Services, Policy, & Practice Dr. Ashish K. Jha.

Dr. Ashish K. Jha identified the assumptions policymakers should be making about coronavirus through the winter season, what the pandemic highlighted in terms of health equity issues, and the most powerful tools to funding health inequity solutions.

  • On what policymakers should consider for coronavirus next year: “The big picture point I would make to policymakers is 2022 really should be our pivot year, the year we take this acute phase of the pandemic and turn it into something that we’re going to manage more chronically over the long run. What do we need to do that? Obviously, we need to continue to get more Americans vaccinated.”
  • On the pandemic’s exposure of longstanding health inequities: “It’s taken all of the challenges we’ve had, all of the longstanding inequities we’ve had in our country and really exposed them in a way and made them worse. It hasn’t created new inequities. I would say these inequities have existed for a long time, what it has really done is just highlight them in a way that is now hard to ignore.”

Rep. Robin Kelly discussed the health care initiatives in the Build Back Better agenda, the obstacles to health equity progress, and the policy provisions shaping next year’s health care agenda.

  • On obstacles standing in the way of progress: “People have different lenses, and I think that people know we need to get these things done. There’s no excuse for our maternal mortality rates, the health care disparities. COVID put a great big spotlight on the inequities and the disparities in this country.”
  • On upcoming health care policy priorities: “I think the Build Back Better Act is a great first step, but we’ll still be discussing maternal mortality, we’ll still be looking at health equity, we’ll still be looking at diversifying the health care pipeline, diversifying clinical trials, lowering prescription drug costs.”

Letitia Dzirasa explained potential impacts of the new Omicron variant on public health messaging, addressing health equity issues at a local level, and the public health challenges at the forefront for next year.

  • On looking at data and community input to inform health equity interventions: “I think it’s very important that we look at the data, that we understand the disparities and where they exist. But as we’re planning interventions and how best to implement a particular program or outreach method, we have to be community informed, so we’re looking to the community to plan alongside us.”
  • On the public health challenges defining the year ahead: “I think the important thing to note is that all of our other public health challenges did not go away because COVID came along, and so we’re going to be playing catch up in other public health areas for quite some time. I am encouraged by the increased federal funding going towards public health, but you have to remember this is an area that has been chronically underfunded.”

Axios Chief People Officer Dominique Taylor hosted a View from the Top segment with UnitedHealth Group senior vice president and chief health equity officer U. Michael Currie, who emphasized how addressing social determinants of health helps to advance health equity.

  • “You can’t have a conversation about achieving or advancing health equity and best addressing health disparities without having a real appreciation for what these social factors or social determinants of health have on individuals achieving their best possible health.”

Thank you UnitedHealth Group for sponsoring this event.

Dec 2, 2021 - Health

Biden administration moves to make insurance cover at-home COVID tests

President Biden speaks at the Eisenhower Executive Office Building in Washington, D.C. on Dec. 1. Photo: Ting Shen/Bloomberg via Getty Images

The federal government will issue guidance to allow people with private health insurance to seek reimbursement for the cost of at-home COVID tests, President Biden will announce Thursday.

Why it matters: The move — which comes amid growing concern about the Omicron variant and as part of the administration's larger strategy to mitigate the spread of COVID this winter — will expand access to at-home testing for over 150 million people.