In recent months across the National Academies of Sciences, Engineering, and Medicine, members, staff, and invited experts have been addressing the medical, social, and economic impacts of COVID-19. In addition, entities such as the Roundtable on Black Men and Black Women in Science, Engineering, and Medicine had already been focusing attention on such issues as health disparities and the underrepresentation of people of color in science, technology, engineering, and mathematics (STEM).
This session of the workshop, moderated by Louis Sullivan, M.D. (former secretary of the U.S. Department of Health and Human Services [HHS]), brought together three National Academies leaders: Marcia McNutt, Ph.D., president of the National Academy of Sciences (NAS); Harvey Fineberg, M.D., chair of the Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats; and Cora Marrett, Ph.D., an advisory committee member for the Division of Behavioral and Social Sciences and Education. The objectives of the session were to understand the landscape of COVID-related work at the Academies and to explore synergies between the Roundtable and other National Academies initiatives.
As recovery from COVID-19 occurs, said Dr. McNutt, it is important that the National Academies “step up the game to help the nation recover” and to advance diversity, equity, and inclusion. She stressed these issues are strongly linked and cannot be separated. The pandemic is a “hundred-year event”—more than 2 million Americans have been infected and 120,000 have died to date. But while people everywhere are affected, people of color are most significantly and disproportionately affected. This workshop, she said, is important to understand why and what can be done about it.
When the Roundtable on Black Men and Black Women in Science, Engineering, and Medicine was created in 2019, there was no idea that the pandemic was on its way, but she expressed appreciation that the Roundtable exists to help in this time of crisis. The pandemic is an unprecedented health emergency, as well as a crisis in terms of the economy, jobs, education, and mental health, she noted, and the pandemic is shining a harsh light on long-standing systemic and structural racial and economic inequality in the country. She added that while the pandemic has been going on for a number of months, the crisis of lack of opportunity and access to the American Dream for Blacks and African Americans played out over centuries.
Dr. McNutt recalled an exercise she conducted as a teacher earlier in her career in which she would ask students to consider the advantages and disadvantages they had encountered in their pasts. The exercise revealed privileged and unprivileged groups of students based on these life experiences, and the separation largely divided along racial and socioeconomic lines. If she were to do the exercise today, she added, she would include a question about whether the students had a close relative who died of COVID-19, and she asserted that, too, would mostly divide along racial and socioeconomic lines.
NAS Commitment to Diversity, Equity, and Inclusion
Dr. McNutt issued a public statement after the murder of George Floyd to state that “just as it would have been insufficient for me as president of the National Academy of Sciences to have simply offered words of support to the victims of COVID-19 and carried on our business as usual, so too for this crisis in equality of opportunity, we have to act, not just offer thoughts and prayers.”1 She said she is acting to include diversity, equity, and inclusion in how NAS conducts its business and, most importantly, in how it serves the nation. She continued:
Society is counting on science, engineering, and medicine to find solutions to the pandemic; to inform the reopening of businesses, schools, and other vital operations; and to lay the groundwork for long-term recovery. As we develop immediate solutions and plan for long-term recovery, we also have an opportunity to build back stronger and to create a more just, robust, and resilient nation for all of our citizens.
Getting through the current emergency and ensuring being prepared for the next crises, systemic issues of inequality in society must be addressed, she continued, including in the STEM enterprise, health-care infrastructure, economy, educational system, and communities. To that end, she said, the National Academies is working on policies, procedures, and mechanisms to ensure that all its studies, whether related to the pandemic or not, consider current inequalities, along with the challenges they pose,
1 For the full statement, see http://www.nasonline.org/about-nas/leadership/president/diversity-equity-and-inclusion-statement.html.
along with any possible science-based solutions to reduce inequalities and the benefits that could accrue. This, she said, could result in more robust and actionable advice to policy makers. “Sadly, progress has not always reduced inequality,” she said. “Too often, it has increased inequality. Only by building in the requirement to reduce inequality will it indeed happen.” She noted that the National Academies is accelerating efforts to attract and retain diverse staff, volunteers, and National Academies members who can address these questions and ensure robust solutions.
Three Types of Science to Understand COVID-19
Dr. McNutt has outlined a strategy on how to deliver science during the COVID-19 crisis to meet short-term and long-term needs (McNutt, 2020). Drawing on her experience leading the recovery after the Deepwater Horizon oil explosion and spill in the Gulf of Mexico in 2010, she said science in crisis has unique pressures but also opportunities. It requires a different type of science, rather than “science as usual.” To provide the broad array of answers needed, a scientific framework needs to encompass three different time frames and scopes:
- Actionable science provides timely, immediate guidance delivered to decision makers, understood by nonscientists and provided in the context of the decision at hand. It must be based on the highest standards that timeliness allows, meaningful, and rooted in societal values. The Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats, chaired by Dr. Fineberg (see next section of this chapter), has provided actionable science to the U.S. government on such topics as effectiveness of homemade face masks, crisis standards of care, and the seasonality of the virus. They are currently working on a fast-track study about data use. In partnership with the National Science Foundation, the Societal Experts Action Network (SEAN) has been formed to develop evidence-based recommendations to support local, state, and national responses and policies. Dozens of webinars have been held in which top experts share their knowledge on a range of COVID-19 topics. The Based on Science website is directly answering questions in plain English and has seen an increase in traffic since the start of the pandemic.2
- Strategic science will assist with longer-term planning in the months ahead as policy makers and communities make decisions that position them well for an uncertain future. Strategic science involves interdisciplinary teams of scientists, engineers, and medical professionals in scenario planning to consider a range of issues, along with estimates of uncertainties and possible consequences for health, the environment, the economy, and infrastructure. Examples include the possible impacts of a second round of infections in diverse populations, such as in the health of farmworkers that could potentially have ramifications on the food system. Strategic science could also be used to develop scenarios to ensure maintenance of the research enterprise, which serves as a major engine of innovation and economic growth, during times of severe fiscal constraints. Scenario planning helps identify actions that can be taken now to prevent a chain of negative consequences that could ensue.
- Irreplaceable science stems from the crisis itself. “Although no one would wish a pandemic on society, this crisis provides an opportunity to conduct a special kind of research that takes advantage of the unusual conditions existing during the pandemic,” Dr. McNutt said. A scientist could not be able to devise an experiment in which a large segment of the global population is asked to socially distance; now that it has happened, it is important to understand the impacts on mental health, family relationships, and the very fabric of society. Irreplaceable science would also allow for the capture and analysis of data about what is happening on the ground in health-care settings and communities to learn more about how and why COVID-19 is disproportionally affecting minority populations and find solutions to long-term disparities in the health-care system.
Dr. McNutt affirmed her belief that employing actionable, strategic, and irreplaceable science can help society recover from the crisis and also address long-standing, structural racial and economic inequalities that are exacerbating it. She again thanked the Roundtable in helping in the emergence from the pandemic in a stronger position for the future.
To respond to requests by HHS and the White House Office of Science and Technology Policy (OSTP) in March, the National Academies created
a standing committee of experts to respond to specific government requests with actionable science, as described by Dr. McNutt. Dr. Fineberg described the work of the Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats, which he chairs. He noted the speed in which responses were provided is unusual for the Academies. Consensus studies typically begin with an extensive and carefully vetted statement of task, an expert committee, deliberations that go on for several months, and then a report that goes through critique through a report review process.
Instead, the Committee was asked to respond within hours to days on specific questions of concern to OSTP or HHS. In the Committee’s first 28 days, 11 rapid expert consultations took place to respond to such scientific questions as the stability of the virus in the environment, its transmissibility, and the role of face masks and other preventive measures. In the space of a few days, the Committee assembled the available literature, conferred with leading scientists about the status of their work, and produced a document that could be reviewed through an acute review process under the National Academies’ Report Review Committee leadership. The result was delivery of a usable, actionable, relevant, scientifically sound, and timely document delivered into the hands of the government sponsors. It depended on an intensive effort by the staff and Committee members who responded with enthusiasm and alacrity, but also led to a recognition that some of the reports were not fast enough on the one hand nor able to deal with all the relevant questions on the other. To deal with speed, a process of rapid telephonic consultation was developed. Although it would not represent a collective committee view and was not vetted in the usual way, it has allowed government staff to hear directly from experts in the field about the critical issue of that moment.
After the acute period of the first month, the Committee took a step back to consider the questions that would be important over the next weeks and months, as distinct from the very short-term questions. They identified four levels of questions related to (1) the virus and its attributes; (2) clinical issues of care; (3) individual-, community- and population-level issues, including differences in susceptibility and burden of illness; and (4) crosscutting issues related to equity, the law, and ethics. Looking ahead, the Committee will organize to undertake the most salient topics to develop scientific guidance. The Committee is establishing ground rules for data systems related to the virus, as well as an effort to outline a roadmap for diagnostic testing. Dr. Fineberg particularly requested input from the Roundtable and individual workshop participants:
What are the scientific questions around which research is needed to reveal the reasons why this particular virus has demonstrated such a predilection for differential burden on African Americans in the United States? We all have reasons we can raise for understanding and explaining this…. The question I am raising is…what a research agenda would be that would lead to increased confidence about the relevant causes.
Dr. Fineberg reflected on the 1980s and 1990s when HIV was identified as a new, emerging infection. One result that came out of that crisis was to rethink the role of the patient in research and the nature of the research that would be done by the government. He expressed hope that similar advantage could be taken to learn about the experience, reality, and hardship of COVID-19 to produce new knowledge and ways to obtain knowledge that will help people become healthier and better able to cope. In particular, the reasons for the disparity in the burden of disease across racial differences should be learned, he said. In conclusion, he noted the Committee remains ready to respond to rapid questions but will also focus on intermediate-term strategic questions that will be valuable for COVID-19 and other health threats.
In transitioning from Dr. Fineberg to the next presenter, Dr. Sullivan reflected that the HIV challenge produced a strong advocacy group that did not trust the government. Over time, the advocates became involved with HHS, and especially the National Institutes of Health, and developed a consensus to use resources that resulted in HIV being held in check from a fatal disease to a chronic condition. Rocky relationships turned out to become positive. With this case in mind, he commented that the minority community most impacted by COVID-19 can play a similarly active role.
Dr. Marrett focused on the role of the social, behavioral, and economic sciences and their influence on disease patterns. She said she did so for three reasons. First, they play a role in illuminating conditions associated with COVID-19, as discussed throughout the workshop. Second is the attention paid to these fields within the National Academies. Third is the outreach of the Roundtable to all areas relevant to COVID-19 problems and challenges, including these fields.
A first theme to emphasize, Dr. Marrett said, is the importance of high-quality data. As Dr. Cato Laurencin and Dr. Clyde Yancy pointed out
in their presentations (see Chapter 3), it is often difficult to acquire these data. “There is a lot of noise…noise is not always the same thing as data, and we need evidence-based information to proceed,” she said. An interest in the social inequities related to coronavirus, including long-term inequities, is also important to consider. These long-standing issues precede the current pandemic. There is interest in the National Academies to address and redress these inequities, she noted. Partnerships across fields and entities can produce resilient communities.
Related to the first concern about data availability and quality, she said the Social Experts Action Network (SEAN), as earlier described by Dr. Fineberg, has been set up to respond quickly. SEAN’s work has centered on pointing out the limitations and shortcomings of the data being collected. This is in part because some states are not producing or providing data on a regular basis. Beyond access and availability, SEAN has identified problems with particular measures. For example, “confirmed cases” only covers reported cases. Measures on hospitalizations only capture severe cases, but not asymptomatic individuals, while data on confirmed deaths have a lag time. Notwithstanding these problems on a national level, there is more than sufficient information to show disparities between groups. For example, in her home of Dane County, Wisconsin, Blacks are 5 percent of the population but 18 percent of known cases and 12 percent of deaths.
As discussed throughout the workshop, Dr. Marrett said attention is needed on inequities that have an impact on health, including economic opportunities, housing insecurity, and educational access, among others. Social and behavioral scientists have given a lot of attention to these issues and many groups within the National Academies are studying and reporting on them. She reiterated Dr. Fineberg’s call for input on research to understand the gaps in knowledge. The coronavirus has illuminated new areas of inquiry. “What are the matters warranting attention if we are to have an agenda appropriate for our common time?” she queried participants.
The idea of resilience and generating strong communities resonates within the National Academies, including within the Roundtable, Dr. Marrett said.
When we say resilience, we don’t mean to imply that communities should only be prepared merely to adjust. It is not saying, “Have the worst of conditions and your resilience should help you adjust.” No, it’s talking about the strength of communities to provide the kinds of resources and engagements that are going to be important.
The emphasis on resilience appears in many programs at the National Academies, she said. She agreed with Dr. McNutt’s call to look for change through bold vision. For example, the Gulf Research Program—supported by the settlement that followed the Deepwater Horizon oil spill—has noted the historical inequities, deep pockets of poverty, and poor educational and health outcomes that have plagued the region. The program has issued a call for the development, translation, and application of approaches that empower communities. This program indicates the interest from other parts of the National Academies in the building of strong communities, and also illustrates the kinds of partnerships that can be forged by the Roundtable and other groups. As another example, the Transportation Research Board (TRB) has noted the consequences of COVID-19 for the transportation industry, because bus drivers and other workers are on the front line. In New York City alone, according to the TRB, 120 transit employees have died of COVID-19 to date.
Dr. Marrett closed by commenting that the National Academies assembles thousands of experts to advise the nation on matters affecting human welfare. The Roundtable, she said, is prepared to partner with committees and staff throughout the organization on work related to COVID-19. She welcomed mobilization of engagement not just within academia, corporations, professional associations, and the policy world, but also from the National Academies’ committed and talented staff. She expressed appreciation in hearing from Dr. Victor Dzau (see Chapter 1) and Dr. McNutt (see above) about the level of staff engagement to forge partnerships and interactions to build resilient communities.
Dr. Sullivan launched the discussion by noting that health has become a political issue, when it should be seen as a social good. The United States has the strongest history of scientific discovery in the world, he noted, yet the country has failed to deliver the benefits of these investments to the entire population. With the attention given to the health-care system from COVID-19, he asked the presenters for their perspectives on how to place more attention on the connections between the health of people and of the economy, so health is viewed as a social good with a strong return on investment. Dr. Fineberg agreed that COVID-19 has exposed and exacerbated shortcomings that preexisted the crisis. It has demonstrated that access to health care has been set back because of the country’s dependence
on employer-based insurance. People who have lost their jobs have been put in jeopardy of loss of insurance. COVID-19 has also demonstrated that the health-care system is not prepared for a surge. The country must redouble its efforts and face honestly and effectively the capacity of the medical system to provide needed care to every patient who requires it, he said. There is also a disparity of investment in public health capacity in different communities, counties, and states across the nation, and to accomplish this challenge as a scientific and health matter, apart from politics, requires legislative and executive leadership. He questioned whether Congress and the administration could come together in a national service enterprise, setting aside political differences, to accomplish a health-focused, scientifically sound response to stand apart from political interests.
Dr. Sullivan added that the business community also needs to be involved and mobilized to tackle the challenge. Dr. McNutt added that the United States is 1st in the world in terms of spending on health care, but 15th on issues related to health equity, choice, and other measures, which she termed a national tragedy. Other sectors of the economy have been disrupted over the last 20 to 30 years through innovation, which she said that the health-care system needs.
Trust is also an important issue that affects health outcomes, Dr. Sullivan added. Many individuals do not trust the system, for example, as shown when they do not use vaccines. Dr. Marrett said that trust is built by and within communities. Evidence has shown that communities can come together to create change and fight illogic. She urged the Roundtable and others in the National Academies not to assume that “things will not change,” but rather to find ways to support communities and fight illogic, such as the assertion by one state legislator that migrant workers in meat-packing plants “prefer” to live in crowded conditions. She suggested the Standing Committee chaired by Dr. Fineberg look for ways to channel information to wider communities to disrupt such illogic. She pointed out that some have also seen education as a private gain, rather than as a public investment. Dr. Sullivan identified several leaders in the past, from both political parties, who saw health as a great investment. Now, he said, individual citizens and organizations must undertake the task as a societal, nonpartisan issue. The economic damage of the pandemic makes the argument that all have a stake in better health, rather than viewing it as a zero-sum game. Global health is important, too, he added. Healthy populations will have more productive societies and economies that will benefit the United States.
Dr. Camara Jones responded to Dr. Fineberg’s query about the research questions that still need to be asked. She suggested the Standing Committee propose intervention research. What would happen, she posed, if there were massive investment in communities of color in terms of housing, education, environment, and other areas? Currently, documentation of impacts takes place as a type of natural history of the impact of racism or continued disinvestment. With knowledge about the social determinants of health, she posed, are there interventions to invest into the well-being of communities so that the next pandemic or crisis would be less likely to hit so hard? Another idea she suggested would be for the National Academies to provide guidance to conduct public health surveillance to collect real-time estimates of the prevalence of infection that would allow predictions 2 weeks hence, which would better mobilize resources. Dr. McNutt said there is work being done to improve early warning systems, such as monitoring effluence in sewage treatment plants as an indicator. She said she found research on the impact of community investment to be intriguing, but noted that a scientific experiment would need to have control communities (no or little investment), which would not be an option that a community would volunteer for.
Dr. Fineberg noted that Dr. Jones’s questions are important and challenging. In regard to a research strategy, he differentiated three levels of studies: those that are descriptive in stating the burden, those that analyze the causes or determinants of the burden, and those that test interventions. One of the challenges in studying social interventions is the time frame for the action to have an effect: the experiment must be designed with a time frame that is suited to detect an effect. A second critical challenge is the difficulty in designing a controlled experiment, as Dr. McNutt had noted. However, this year’s Nobel Prize in Economics recognized the fundamental contribution of recipients Abhijit Banerjee, Esther Duflo, and Michael Kremer in conducting randomized controlled experiments for economic impact, mostly in developing countries, in which the units of analysis were whole communities. Out of their experience, Dr. Fineberg said, come potential lessons for the design of social intervention experiments that are revealing and scientifically sound. All three levels of study—descriptive, causal, and interventional—are important to conduct, he said. Dr. Marrett added that many studies in the social, behavioral, and economic sciences have been controlled experiments, but the design and goals must be clearly articulated. She referred to the Gulf Research Program, mentioned above, as an example of how to design experiments to effect change in communities.
In her view, the National Academies are key to pulling together ways to rigorously study these issues to address broad questions.
A participant asked the panel members how to work to implement the many issues discussed during the workshop and the immediate actions to which the public can contribute. Dr. Sullivan replied that there is no single outcome, but multiple actions are needed, given the systemic problems affecting society. Dr. Marrett noted that the traditional idea of leadership centers on people who are in positions of authority, but this is not what leadership is about. She commented that Dr. Sullivan’s experiences working with the HIV/AIDS community provides an example. She cited the work of Dr. Vanessa Gamble (professor of medical humanities at George Washington University), who has studied how communities come together to make change and not just become victims of a given political climate. Dr. Sullivan suggested each person think of the change they can do and work toward that change. “Don’t look to others; you should be the catalyst,” he urged participants. “We need ideas coupled with actions. It can start with us as individuals coming up with an idea and working with others to get that idea implemented.”
McNutt, M. 2020. The coronavirus pandemic: Delivering science in a crisis. Issues in Science and Technology. https://issues.org/mcnutt-actionable-strategic-irreplaceable-data-delivering-science-in-a-crisis.