Pandemic Preparedness and Response

SARS and Other Coronaviruses: Old and New Lessons

Each pandemic is different in duration, intensity, and impact, yet most pandemics can be traced to a common source—the animal-human interface. When new viruses emerge from animals, “we don’t know their final destiny,” said David Heymann. “Will they not transmit further, like rabies, will they continue transmission and become sporadic, like SARS, or will they become endemic, like HIV?” A review of pandemics past yields valuable lessons that can inform management of the current pandemic and improve preparedness for future outbreaks.

Heymann outlined key takeaways from history, beginning with the recognition that healthcare workers are often unwitting agents of community spread. In the first Ebola outbreak in 1976, “needles and syringes, as well as healthcare workers and their contacts, were the major way that Ebola was driven into communities,” Heymann said. This phenomenon was observed during each subsequent Ebola outbreak, as well as during the 2003 SARS pandemic, when a single ill physician in a Hong Kong hotel transmitted the infection to guests from eight other countries.

SARS became an international threat when a single infected patient at a Hong Kong hotel transmitted the infection to guests from eight different countries.

“It’s impossible to study an outbreak without a diagnostic test,” continued Heymann, describing the critical role of diagnostics in disease surveillance and management. He highlighted the global shortage of testing at the start of the COVID-19 pandemic as a vivid example of this point. While testing access remains an issue in developing countries as well as in the United States, Heymann says that the push to develop rapid, affordable, point-of-care diagnostics may help alleviate this bottleneck.

The 2014 Ebola epidemic in West Africa demonstrated that vaccines can be developed and studied during an active outbreak—a notable lesson for current times, as public and private research teams work furiously to develop COVID-19 vaccines and treatments. Preemptive vaccine research and development is also critical for pandemic preparedness, said Heymann. WHO has voiced support for such initiatives and released a research and development framework for developing vaccines against organisms with pandemic potential in the wake of Ebola.

As vaccines and therapeutics are developed, however, Heymann cautions that inequities in access and distribution must be addressed. The Pandemic Influenza Preparedness Framework, created in the wake of the 2007 H5N1 influenza outbreak, advocates for equitable distribution of medicines developed for pandemic control. As access concerns are even more pressing in today’s geopolitical environment, the World Health Organization, along with nonprofit and philanthropic organizations worldwide, have committed to ensuring access. “Hopefully, as time goes on...there will be mechanisms to ensure that whatever is developed is equitably accessed throughout the world,” Heymann said.

Heymann concluded where most pandemics begin. “Research at the animal-human interface must be innovative and accelerated,” he said, noting that collaborations with local populations in remote areas have long been essential to tracing the source of new pandemics and getting ahead of emerging infections.

Non-Pharmaceutical Interventions in Influenza Pandemics: Lessons Learned for Pandemic Preparedness

Amra Uzicanin reviewed the history of non-pharmaceutical interventions (NPIs) in four influenza pandemics­–1918, 1957, 1968, and 2009. The NPIs, also called “community mitigation,” are often cited as “the first line of defense” in pandemics, as they are particularly important while pandemic vaccines are not yet available. NPIs include a set of behaviors regarding hygiene, physical distance between people, and physical barriers such as facemasks. NPIs are described in detail in the Community Mitigation Guidelines to Prevent Pandemic Influenza published in 2017. Briefly, personal NPIs include everyday preventive actions recommended at all times, such as covering coughs and sneezes, washing hands, and staying home when sick. During pandemics, people may be asked to quarantine themselves voluntarily, i.e., to stay home if they were in contact with a known case, and to wear face masks. Community-level NPIs are all reserved for use in pandemics; they include setting-specific social distancing measures, such as preemptive school closures, mass gathering cancellations and modifications, and social distancing in workplaces and other congregate settings.

Pandemic response during the 1918 Spanish flu focused heavily on strict community mitigation measures because, according to Uzicanin, “the world didn’t have anything else available.” Modern epidemiologic studies of the impact of NPIs during the 1918 pandemic, based on the archival mortality data and historical information on NPI use, concluded that a strategy of “early, layered, and sustained” NPIs was effective at limiting contagion. Cities that implemented multiple NPIs early in the pandemic stalled transmission progression and had lower peak mortality. In a now-famous comparison, St. Louis maintained a relatively low mortality curve by rapidly implementing NPIs just a couple of days after noticing the first influenza cases in October 1918. In contrast, Philadelphia delayed NPI implementation by two weeks and paid the price in skyrocketing death rates.

Stark differences in the mortality curves in St. Louis and Philadelphia illustrate the power of early implementation of non-pharmaceutical interventions.

Influenza vaccines were available during the 1957 and 1968 pandemics, albeit in very limited quantities. Both of these pandemics were initially perceived as mild, and public health officials emphasized more the vaccination strategies rather than NPIs. Schools remained open despite widespread infection, and Uzicanin explained that school and work absenteeism rates became important metrics for monitoring the 1968 outbreak.

In contrast, NPIs were included in the public health guidance from the start of the 2009 H1N1 pandemic in late April; personal NPIs were encouraged especially staying home when sick, and school closures were recommended for schools with one or more case among students or staff. However, the school closure recommendation was rescinded in early May, and influenza activity subsided during the summer school recess. School openings during August-September ushered in a large wave of pandemic outbreaks throughout the U.S., and the second pandemic wave peaked in early October, just as the pandemic vaccine rollout was starting. More than 1,900 school closures occurred during the fall semester of 2009. Subsequent epidemiologic studies showed that closures implemented reactively, after many students were already sick, had no effect on transmission.

“Even though the 2009 pandemic is considered “mild,” it had a major impact on children: the influenza-associated pediatric deaths and hospitalizations during the 2009-2010 season at least doubled compared to inter-pandemic years. The “impact on children was the main lesson learned from the 2009 pandemic,” Uzicanin said. This and other lessons learned during the 2009 influenza pandemic were summarized in the 2017 Community Mitigation Guidelines. NPIs were also integrated into the Pandemic Influenza Plan Update of 2017 issued by the U.S. Department of Health and Human Services. However, Uzicanin noted that institutional barriers to NPI implementation, such as a lack of paid sick leave for many workers, remain.

COVID-19: Lessons Forgotten for War Front Preparation

“The best way I can describe Africa’s pandemic preparedness is to say that we’re waiting for the lion to stop yawning before we start running,” said Oyewale Tomori, bringing a bit of dark humor to the difficult topic of infectious disease control on the African continent.

While Africa is “no stranger to epidemics,” including the constant presence of hot spots for diseases such as yellow fever, Lassa fever, and Ebola, Tomori says that nations face multiple challenges in mounting effective response and containment strategies. National health systems are overloaded, and a lack of strong leadership impairs surveillance efforts, patient care, community engagement, and coordination among countries. As COVID-19 threatens the continent, Tomori believes the preparedness lessons learned from previous epidemics, especially the 2014 Ebola outbreak, have gone unheeded.

The African continent is a longstanding hotspot for emerging infectious outbreaks.

Africa has relatively lower rates of COVID-19 than some other continents at the moment, but nations are profoundly unprepared for the inevitable increase in caseloads. Tomori reports that critical care hospital beds and ventilators are scarce to nonexistent in many countries. Co-occurring infections including HIV, tuberculosis, and malaria, as well as widespread malnutrition, further complicate the treatment landscape. “Due to the underlying poor health infrastructure, all the efforts we’re making now are like pouring vanilla icing on a bad cake,” he said. Lockdowns have been haphazard, and Tomori commented that low standards of living in many parts of Africa limit adherence to stay-at-home orders. COVID-19 testing has been minimal, although partnerships between the African CDC and philanthropic organizations are helping to boost access.

While Tomori regrets that Africa has lost the chance to get ahead of COVID-19, he sees opportunities in the road ahead. “COVID-19 should be a time to reflect on improving healthcare and health infrastructures, and to improve on preparedness, response, and community engagement,” he said.

Regional Coordination of Pandemic Preparedness and Response

Infectious disease outbreaks have long highlighted the importance of regional coordination between neighboring countries. Maria Julia Marinissen offered an insider’s perspective on the benefits and challenges of regional partnerships, discussing her experience as the founder of the North American Health Security Working Group, the technical advisory team that developed the North America Plan for Animal and Pandemic Influenza (NAPAPI). First introduced in 2007, this regional partnership between the United States, Mexico, and Canada initially served as a framework for coordinating efforts to fight avian and human influenza outbreaks. H1N1 influenza struck shortly after NAPAPI launched, surprising the world with its point of origin (the United States) and subjecting the framework to a trial by fire. As Marinissen described, the continent faced a myriad of challenges, including the logistical hurdles of sharing virus samples across borders, communications pitfalls, and the difficulties of balancing political partnerships with public health needs in the areas of antiviral and vaccine distribution.

In the aftermath of H1N1, representatives from each nation reconvened with a mission to create a new version of NAPAPI better suited to guiding mobilization in future outbreaks. The revised framework launched in 2012, with a broader scope that encompasses regional health security threats beyond influenza.

In recent years, NAPAPI’s North American Health Security Working Group has prioritized the development of an online pandemic supply chain network—“like Amazon.com, but for pandemics,” Marinissen joked. The group was deep into navigating the legal and regulatory hurdles of building an online supply network when reports began to surface of a novel virus circulating in Wuhan, China. “We shifted immediately from preparedness to response,” said Marinissen. The group continues to address a range of needs for the current pandemic, from PPE and testing supplies to reopening strategies and worker safety.

While NAPAPI is a largely successful model of regional coordination, Marinissen believes there is room for continuous improvement. Notably, she commented that all regions must focus on supply chain resilience to minimize competition for essential supplies, and improve protocols for developing and sharing medical countermeasures.

Global Governance for Pandemic Preparedness and Response

Rebecca Katz is not surprised by COVID-19. “We all knew it was coming,” she said, referencing the ample warnings from public health experts about the catastrophic potential of a highly transmissible respiratory pathogen. The world has not seen a pandemic of this magnitude in more than a century, and Katz noted that its arrival powerfully illustrates the importance of taking action in seven key areas to enhance global governance of disease.

Katz advocated for stronger multilateral leadership. This includes defining a clear role for the United Nations in global oversight of infectious outbreaks, especially those that occur among displaced populations and in complex environments, such as conflict zones. She called for broad support for the World Health Organization, which has long been underfunded and struggles to function as intended.

The International Health Regulations have been a guidepost of global health security since 2005. But amid widespread implementation issues, Katz believes a reexamination—and perhaps a renegotiation— of the articles is long overdue. “We need to reframe global governance of disease,” she said, “and make this treaty more fit for purpose.”

She lamented the inadequacy of systems for gathering metrics on countries’ disease prevention, detection, and response capabilities. “Either we are measuring the wrong things, or we are measuring the right things the wrong way,” she said, calling for a reconsideration of the current metrics. Data collection and dissemination are also crucial to decision-making, yet systems for both often fall far short. While Katz acknowledges that there are no easy answers for improving both the quality of data gathered as well as data sharing methods, she commented that “we are not taking advantage of where we need to be in terms of sharing and compiling information.”

Better metrics are needed to accurately assess pandemic preparedness and response capacity.

The current pandemic has spotlighted the role of healthcare workers in responding to health emergencies, and Katz reinforced the importance of a well-resourced healthcare workforce in global health security. She also emphasized the need to ensure that municipal governments are adequately resourced and receive technical guidance in pandemic preparedness and response.

Katz’s final recommendation is the operationalization of a One Health approach to governance. Embracing the interconnectedness between humans, animals, and environment is key to reducing opportunities for zoonotic spillover, as is addressing climate change as a driver of emerging health threats.

Global Coordination of Pandemic Preparedness and Response

Somewhere in the world, a virus emerges. In one scenario, nothing is done to contain it, and the virus circles the globe within months. In other scenarios, nations enact pandemic response plans, restricting travel, and taking other precautions to limit spread. The latter requires international, multisectoral cooperation, evidence-based guidance for leaders and the public, and centralized coordination through an entity like the World Health Organization. As Larry Kerr described, this scenario simulation and these recommendations for global response, among others, were detailed in exercises with top government officials in 2005, amid heightened concerns about H5N1 influenza.

While Kerr admits that “no country is fully prepared,” the current pandemic has laid bare significant gaps in pandemic preparation, response, and global coordination. Kerr identified areas for improvement that are both “realistic and provocative.”

Response to COVID-19 has been hampered by public health gaps, including difficulties implementing the “key, fundamental basic systems” that allow communities to detect and diagnose disease and conduct timely contact tracing. These implementation challenges speak to larger gaps in governance and indicate a lack of multisectoral coordination. Kerr noted that no pandemic response plan can function without the maintenance of essential frontline and medical services, and urged nations to take the strongest precautions to protect health and other essential workers, as well as vulnerable populations, including nursing home and long-term care residents. Knowledge gaps about the virus itself, and particularly about the durability of COVID-19 immunity, are likely to present ongoing difficulties that can only be resolved through global information sharing and collaboration.

In all pandemics, “evidence-based, transparent communication that speaks to all levels of society” is critical, said Kerr, but public health communications surrounding COVID-19 face a decidedly 21-century challenge—misinformation, often disseminated through social media. Kerr stressed the importance of using all means possible to counter misinformation with truth. “We must use communication as a tool of public trust—to understand exactly where we are, what we know, and what we do not know,” he said.

The real-time economic devastation of the COVID-19 pandemic has galvanized the financial community's attention in ways that no simulation ever could. This recognition has resulted in the initiation of financial impact analyses of pandemic scenarios to inform future response measures and, Kerr hopes, major sustainable investments in preparedness. “We are in a cycle of panic right now,” he said, “but we should never enter a cycle of neglect where we forget that critical investments [in preparedness] pay off in volumes.”

Kerr echoed his peers’ concerns about supply chain gaps, not only for PPE and testing equipment, but for delivery of vaccines and therapeutics. As the pandemic progresses, nations will need to improve supply chain and logistics systems to prioritize and move resources to areas of greatest need.

Applying Public Sector Lessons in the Private Sector

Decades of experience leading outbreak response within the U.S. government gave Nicole Lurie a unique perspective when she began working with the Coalition for Epidemic Preparedness Innovation (CEPI), a non-governmental organization that accelerates vaccine development against pathogens with epidemic potential. The lessons Lurie learned during multiple outbreaks guide her approach at CEPI and her insights into pandemic preparedness strategies.

Lessons learned through government response to infectious outbreaks can be applied in the private sector.

“Start early and prepare for the worst,” Lurie said, commenting that once a potentially dangerous new pathogen is identified, “you can always stop [response efforts], but you can’t make up for lost time.” CEPI activated its response to SARS CoV-2 on January 7, preparing its preexisting MERS vaccine development platform to pivot to work on the new coronavirus. The planning paid off. “The day the viral sequence was posted, we had at least four developers downloading it and beginning to work on vaccine candidates,” said Lurie.

Pre-positioning as much as possible saves precious time in the earliest days of an outbreak, explained Lurie. She described the various supply chain shortages experienced during the H1N1 and Ebola outbreaks, which continue to make headlines in the fight against COVID-19. For CEPI, planning also meant fortifying the entire supply chain for vaccine development, including adjuvants, glass vials, and equipment for distribution and delivery. Pre-established scientific partnerships can also aid in the development of testing assays and standards, as well as with collecting serum for antibody studies and accessing animal models for testing. Lurie commented that prearranging financial and contracting agreements before an outbreak enables teams to immediately begin investing in research when an outbreak begins.

Development and deployment of countermeasures in the U.S. occur within a unified, federally funded system that supports the process “end-to-end,” said Lurie, from basic science through vaccine manufacturing, purchasing, and distribution. “But the global ecosystem isn’t put together like that at all,” she said, noting that CEPI is working closely with WHO, Gavi, and private sector partners to replicate an end-to-end response system and allocate responsibilities—including manufacturing– within a global ecosystem.

“Plans, policies, procedures, and expertise do no good if they’re not used,” Lurie said, closing with commentary on the importance of leadership above all else. She noted that exemplary leadership is essential for navigating the current pandemic and preparing for the next one, “so we’re not making it up as we go,” she said.

Lessons Observed, Not Always Applied

Gerald Parker shifted the discussion to recurrent challenges in infectious disease outbreaks. “It seems we’re not always taking stock of our lessons observed and turning them into lessons learned,” he said. Amid the noise of “an ever-increasing drumbeat of emerging infectious diseases,” the COVID-19 pandemic can hardly be considered a surprise—but Parker hopes its scope and impact motivate progress in historically stubborn areas of preparedness and response.

Outbreaks of both novel and re-emerging infectious diseases have increased in the past decade.

Reviewing the response to four recent outbreaks, Parker cited common challenges including the lack of an effective vaccine; vaccine manufacturing and deployment issues; a shortage of diagnostics and lab capacity; inadequate research surge capabilities; lack of healthcare surge capacity; supply chain issues; and challenges with disease surveillance and community mitigation.

On a more optimistic note, he reported several areas of progress, including the founding of the World Health Organization’s Health Emergency Program in 2016, and the joint establishment of Emergency Operations Centers by WHO and the World Organization for Animal Health (OIE). These hubs for day-to-day information sharing and crisis operations form a vital bridge between human and animal health. Parker also pointed to the Ebola vaccine as proof of the power of surge research and clinical trial capacity, paired with unprecedented levels of international collaboration. “Things are evolving, and there is improvement,” Parker said, although, as COVID-19 has clearly shown, many nations remain “dangerously vulnerable.”

Parker hesitates to cast blame for missteps amid an escalating crisis but acknowledges that after-action analysis of COVID-19 is essential to ensure that the lessons of this pandemic are not lost.  To promote an objective, thoughtful review, Parker advocated for appointing a COVID-19 pandemic commission, similar to the 9/11 commission. Much the way the world changed following 9/11, Parker hopes that approaches to preparedness will be transformed in a post-COVID world. “We need to make this a national security priority and provide sustained resources...not just when there’s a crisis,” he said.

Healthcare Biopreparedness and Response at NYC Health + Hospitals

Ebola. Zika. Measles. Pandemic influenza. “You don’t have to look too far to see what New York has faced,” said Syra Madad, beginning an overview of the city’s experiences with infectious disease outbreaks and its efforts to prepare and respond to new ones, including COVID-19.

Madad referred to the 2014 arrival of Ebola in New York as a “wake up call” that fundamentally changed the city’s approach to pandemic preparedness. Hospitals throughout the United States received congressional funding to ramp up their response capacity for high consequence infectious diseases, with several in New York City designated as Ebola treatment centers. Post-Ebola, the city continued to conduct PPE trainings, highly realistic outbreak simulation and response drills, and preparedness workshops for frontline health workers. “These outbreaks are not one-off incidents, and we realized we should expect more of them,” Madad said. “Ready or not, patients will present—we don’t have control over when or how often... but we do have control over how we respond.”

New York City maintains a robust schedule of outbreak simulation and training activities.

That preparation paid off when the first COVID-19 cases arrived in New York, triggering a cascade of pre-planned response measures. With no time to waste and no clinical guidelines for treating a novel pathogen, clinicians and public health partners in New York tapped a “brain bank” of international partners in Singapore to learn about their experiences treating COVID-19 and gather best practices to prepare for the coming storm.

Madad says that many of the difficulties that stymied hospitals’ ability to respond to previous outbreaks, including supply chain issues, also surfaced in the city’s response to COVID-19, but that new lessons have already emerged. “We’ve seen that hospitals are not just where the rubber meets the road in terms of caring for patients—they play a vital role in surveillance and reporting,” she said, noting that hospital and ICU admissions are leading indicators of the trajectory of the COVID-19 pandemic. As the city moves past the current crisis stage, Madad says hospitals are examining how to further adapt operations in a “new normal” of social distancing, PPE, and other changes in patient care.

NYC Health Department Response to COVID-19

The New York City Department of Health and Mental Hygiene’s response to COVID-19 has been “unprecedented,” according to Beth Maldin, “but the foundation of the response is very familiar.” For more than 150 years, DOH has responded to countless outbreaks and other health emergencies, but as Maldin described, COVID-19 has presented unique challenges as well as opportunities for triumph.

When the first case of COVID-19 was reported in New York on March 1, 2020, DOH sprang into action, conducting surveillance, case investigations, and contact tracing to contain the virus. Within two weeks, case numbers exploded— “first hundreds, then thousands,” said Maldin, forcing the implementation of mitigation strategies to flatten the curve. Maldin reported that the city’s public health labs were among the first to report problems with the CDC’s diagnostic assay, and quickly transitioned to a New York State assay that had been granted emergency use authorization. As reagents and testing supplies ran short, the labs validated a variety of specimen samples, including saliva and nasal swabs, on multiple testing platforms.

Nearly two decades of capacity-building allowed DOH to receive and distribute PPE and other medical supplies from the strategic national stockpile and allocate it to every New York City hospital, nursing home, and adult care facility. Maldin counts the distribution of more than 50 million masks and other PPE items, along with 3200 ventilators, as a significant success at a time of great need. “This is a great example of how preparedness pays back huge dividends during response,” she said.

The city has entered the suppression phase of pandemic response, with DOH supporting testing and contact tracing efforts to stamp out flare-ups, as well as providing support for communities disproportionately impacted by COVID-19. Many experts anticipate a second wave of infection this fall, and Maldin says planning is underway for that possibility, as well as for an eventual vaccination campaign.

Different support strategies are required as a pandemic progresses through containment, mitigation, and suppression.

COVID-19 is often described as a once-in-a-century pandemic. With the spotlight on the often-hidden work of the public health community, Maldin also believes it’s a “once-in-a-lifetime opportunity to reimagine what public health and healthcare look like,” and to advocate for greater funding and support.

COVID-19: Future Considerations 

For Michael Osterholm, the future of COVID-19 starts now. In this fast-evolving pandemic, each day brings new challenges that only time and additional research can address. As some countries that had successfully suppressed the virus now face surging infection rates and others, including the United States, reach all-time highs, Osterholm admits that the shapeshifting course of this outbreak poses many questions that elude easy answers. One certainty, he says, is that with infection rates totaling roughly 5%-7% of the population of any given nation, the world remains far from herd immunity. Until 60%-70% of the population acquires natural or vaccine-induced immunity, “this virus will continue to attack us,” Osterholm said.

While planning can be challenging with so many unknowns– including if or when we will have a vaccine and the durability of immunity against COVID-19– Osterholm stressed that nations and communities must expect to grapple with this virus for “months, perhaps even years” to come. He observed that pandemic response at the state and local levels has been hampered by a previously unimaginable degree of partisanship, as well as ongoing supply chain challenges that complicate already-strained healthcare and social support systems.

Looking to the future requires “a sense of creative imagination,” said Osterholm, who struck a hopeful note despite the difficulties ahead. “We’ll get through this, and without question, our great-grandchildren will study 2020 the way we study 1918,” he said. “It’s our job to come out of this in a way that [makes us] proud of how we responded to this very serious situation, not with regrets about what we did or didn’t do.”

The Future of Preparedness

Pre-COVID-19, all indicators placed the United States among the best-equipped countries to respond to a pandemic. But six months into the outbreak, Luciana Borio said, “somehow we’ve lost our way.” Planning for the future requires a “back to basics” approach, according to Borio, who recommends returning our collective focus to the three core elements of epidemic response: diagnostic tests, contact tracing, and non-pharmaceutical interventions, especially social distancing.

Testing has been an ongoing struggle in COVID-19, and Borio believes that any testing strategy that relies on public labs is bound to be crippled by limited capacity and long turnaround times. In the future, Borio believes that “big labs in the private sector should be part of the response from day one.” She encouraged government collaboration and investment to help private labs build capacity and validate tests, as well as support for innovation in non-PCR testing platforms. Point-of-care and rapid diagnostics will facilitate broader testing across the healthcare system, and ultimately bring testing into patients’ homes.

Contact tracing is another area ripe for technology innovation. This time-and resource-intensive public health measure “has never been attempted on a scale of this magnitude,” explained Borio. Contact tracing teams face high levels of non-compliance among citizens reticent to disclose their recent contacts. “There’s no question we need to incorporate technologies to assist in the workflow...and they have to conform with our culture and values, especially around privacy,” Borio said. She recommends a centralized approach to developing privacy-conscious tracing technologies, with guidance and participation across the federal government. “We need contact tracing for the 21^st century, for 21^st-century pandemics,” she said.

Borio cites the “huge communications challenge” surrounding NPIs, especially social distancing, as a major barrier to containing COVID-19. While these interventions can be “quite magical” in their impact, little guidance has been offered regarding how to reap the benefits of NPIs without economic ruin. Absent this nuance, a binary emerges—states either close down completely to flatten the curve, or reopen and brace for surging caseloads. Borio “firmly believes there’s a better way” to implement targeted distancing with minimal disruption.

Borio concluded with comments on the importance of fortifying the supply chain to ensure supportive care for patients while awaiting novel drugs and therapeutics. She also praised the expansion of telemedicine in the U.S. as an essential step in improving access to medical care. In a final, sobering reminder, Borio spotlighted the widespread health disparities exposed by the COVID-19 pandemic. “We’ll never have a robust response if we leave so many behind,” she said. “Hopefully this won’t be forgotten, and will be addressed as we move forward.”