How one of Covid’s deadliest effects is obvious only now

medium nocaption118880750February 2025. A blustery morning. I alight, a little breathless, from the subway at 168th Street and walk the oddly deserted blocks toward the hospital where I work. I hear a distant cough. A windblown plastic bag tumbles along the sidewalk and lodges itself in the skeletal branches of a tree. The familiar, insistent whine of an ambulance rises in the distance.It has been five years since the world was blown into the tumult of a lethal pandemic. Back then, deserted streets and distant coughs, to say nothing of ambulances docking into hospitals, would have carried a very different meaning. But as Proust wrote, the moments of the past do not remain still. We have metabolized a global trauma — millions of deaths, nations brought to their knees, a generation scarred by grief, isolation and loss — so rapidly that it seems, at times, not to have happened at all.As the pandemic rose, I saw my patients get sick and in some cases die, including a 42-year-old mother of two young children whose loss is seared into my soul. As it receded, I served on then-Governor Andrew Cuomo’s commission to rebuild New York’s health infrastructure. Back then, the overwhelming public sentiment was: never again. Today, it seems: never what? large118881051But Covid didn’t just change billions of individual lives. It changed our country’s basic approach to public health, in fundamental ways that are becoming fully visible only now — and that the Trump administration looks likely to render irreversible.It was sometime in the thick of the pandemic, in January 2021, that I reread John M Barry’s superlative book “The Great Influenza,” which tells the story of the 1918 pandemic and the birth of public health as a discipline in the United States. Before that, shielding the population from disease was primarily the domain of either individual heroic doctors such as John Snow (who solved London’s 1854 cholera epidemic by tracking its epicentre to a contaminated water pump — and, so the story goes, breaking off the handle) or civic interventions such as the new sewer system that London installed to address the Great Stink of 1858.That ad hoc approach changed in October 1918, when William Welch inaugurated a school of public health at Johns Hopkins University in Baltimore. Its trainees would learn to dissect patterns of disease in populations, just as a pathologist might perform an autopsy on an individual patient. They would confront future epidemics and health crises systematically, through public institutions, issuing mandates, dispensing carefully vetted information and managing the surveillance and containment of contagion — tools that, as Barry notes, lack the drama of individual heroism but have saved countless millions of lives.Barry has written no fewer than five afterwords for his book, the most recent in 2021, while the world was still adjusting to the novel coronavirus. In it, he wrote that one of the great lessons of the 1918 pandemic is that “public health measures — the nonpharmaceutical interventions of social distancing, proper ventilation” and so on — “work”. I’ve seen it myself, at times of crisis and times of calm, in New York, across the country, around the world.It came as a surprise for me, then, when I heard Dr Céline Gounder, an infectious disease doctor and a member of US President Joe Biden’s Covid-19 Advisory Board, and listened to her pronounce that public health was nearly dead. It was October 2024, and we were seated in a chilly tent at the National Academy of Medicine meeting in Washington.Dr Gounder was referring to what she calls the “unglamorous public infrastructure” — the interlocking institutions that function constantly and invisibly, and don’t depend on private enterprise or personal decisions. Yes, we conquered Covid, but “if we are inclined to think of our victory against Covid as a public health success,” she warned me, “we should really reconsider.”What seemed to succeed, instead, was a deployment of private enterprise (backed by state subsidies): the invention of vaccines by pharmaceutical companies; their delivery in significant measure through private hospitals and clinics; the ascendancy of private decision making by individuals, schools and businesses; and the surveillance of the pandemic by private institutions. large118881135Covid was a privatized pandemic. It is this technocratic, privatized model that is its lasting legacy and that will define our approach to the next pandemic. It solves some problems, but on balance it’s a recipe for disaster. There are some public goods that should never be privatized.Dr Gounder checked off the basic mechanisms by which public health experts confront a pandemic: They create systems to understand and track its cause and spread; they identify the people most at risk; they deploy scaleable mechanisms of protection, like air and water sanitation; they distribute necessary tools, such as vaccines and protective gear; they gather and communicate accurate information; and they try to balance individual freedoms and mass restrictions.In the case of Covid, each of these responsibilities became increasingly relegated to the private sphere. In one of US President Trump’s first national speeches about Covid, he told the nation, “You’re going to be hearing from some of the largest companies and greatest retailers and medical companies in the world.” And so we did.As the new administration engulfs Washington, we are witnessing the further, and perhaps final, phase of this retreat. In its first weeks, the Trump administration announced far-reaching cuts in the Centres for Disease Control and Prevention as well as reportedly severe restrictions on the kind of research its employees can conduct. It moved to dismantle the USAID, even though the agency funds crucial health efforts around the world, including an early detection system for epidemics. The president proposed slashing funding for medical research at universities. And of course, to lead the Department of Health and Human Services, he chose Robert F Kennedy Jr, who might have done more than anyone else alive to recast the miracle of vaccines as a dark and dangerous conspiracy.The mechanisms that Dr Gounder identified may no longer function at all. Their time of death will be this chaotic political moment. But the illness set in during the pandemic.Let’s begin with vaccination. The fight against Covid has been repeatedly told as a technological story and a story of corporate heroism. In record time, four major pharmaceutical companies — Pfizer, Moderna, AstraZeneca and Johnson & Johnson — created the vaccines that were used most to vaccinate the world. Pfizer’s and Moderna’s, in particular, are triumphs of science: Building on the prior work of academic scientists, they established the use of mRNA as a platform for vaccination. Drew Weissman and Katalin Karikó deservedly shared the 2023 Nobel Prize in Medicine for their research on mRNA; it is notable, however, that while they receive wide mention in the story of vaccine development, the decades-long funding of their science by public institutions such as the National Institutes of Health (which has also funded some of my research) is often left out. The “Moderna vaccine” is as much the “NIH vaccine”. medium118881195The first Trump administration deserves fair praise for accelerating the development of these vaccines through Operation Warp Speed, a public-private partnership. But it was the private sector that prevailed and will be remembered.In the United States, vaccines were delivered through an often ad hoc and chaotic system managed nominally by the government — but almost entirely run by private hospitals, clinics, pharmacies and district-run vaccination centers that relied on private-public partnerships. There was no federal system for scheduling the shots. Instead, countless different systems bloomed, many created by enterprising software companies, each seeking to simplify, but overall contributing to more chaos. Vaccine-hunting felt, at times, like a “Hunger Games” challenge, replete with illusory hopes and disappearing screens. In New York City, you stayed up late in order to pounce when the next tranche of appointments opened up. Then just as you clicked to claim a spot, it vanished — presumably to someone who had hit it a nanosecond before you had.And remember the early days of testing? Public testing sites could take a couple of weeks to offer results. Anything quicker might require booking an appointment at a private facility, some of which charged hundreds of dollars. Other options arose, and soon the streets of major cities were lined with custom-outfitted vans and tents, the innovation of quick-thinking entrepreneurs who rushed in to meet a public need.large118881299The collection and dissemination of facts during a pandemic is typically considered an essential public good and therefore best controlled through validated, state-endorsed channels. But it took three months for the Centres for Disease Control and Prevention to produce a national testing database. Rick Bright, the former head of the Biomedical Advanced Research and Development Authority, or BARDA, told me that the most important surveillance data “were generally reported by universities, such as Johns Hopkins, or the Covid Tracking Project, a private project coordinated by The Atlantic. The US eventually adopted these dashboards, as did most news and media outlets, over any efforts that the government tried to produce.”As for the responsibility to provide more than data at a moment of mass panic and obfuscation, many Americans looked to the government for answers. Dr Anthony Fauci, the former director of the National Institute of Allergy and Infectious Diseases, became for many a hero for shouldering the near-impossible task of dispensing information in the midst of a sandstorm of unknown unknowns. It was dangerous work. But as Zeynep Tufekci wrote here in June, “under questioning by a congressional subcommittee,” officials later “acknowledged that some key parts of the public health guidance their agencies promoted during the first year of the Covid-19 pandemic were not backed up by solid science. What’s more, inconvenient information was kept from the public.”The lack of consistent messaging left ordinary people looking for answers elsewhere. They got them, or believed they did, from private echo chambers, conspiracy theorists, social media influencers and home remedy peddlers. All of a sudden, Joe Rogan and Dr Fauci were seemingly equal authorities on virology, immunology and vaccine efficacy. That shift has had the lasting effect of greatly diminishing public trust in scientific authorities and science as a whole.What does this mean for future pandemics? The good news is the pharmaceutical companies have already demonstrated that they can develop effective vaccines in record time. But it’s not hard to imagine downsides of giving corporations total control of this arena.When the government withdraws from the private-public partnerships that have produced recent vaccine innovations, it also diminishes its ability to negotiate prices. High consumer cost would deepen healthcare inequities and decrease compliance. As the virus multiplied in unvaccinated people, it would get more chances to mutate, further endangering everyone, even those who got the shot. Private companies might well “donate” some number of doses or negotiate a lower price — but that would be a decision left to executives trying to optimize the shareholders’ interests, not to people making choices in the public’s interest.And as imperfect as our distribution and reporting system has already proved to be, the government-run Vaccine Adverse Event reporting system has been an invaluable repository of nationwide reports that can be rapidly cross-searched by physicians and public health agencies. The degeneration of that vital infrastructure, or its transfer to private management, would have cascading effects. Imagine an adverse-event reporting system managed by the suppliers of vaccines. For a public already suspicious of the process, a conflict of interest like that could be a fatal blow to trust.The same goes for the surveillance of pandemics. The CDC monitors diseases worldwide and publishes the Morbidity and Mortality Weekly Report, a publicly accessible report that acts as a weather vane of the status of diseases across the United States. Will it continue to do so? Infectious disease surveillance companies abound, and Google Trends and Apple Health have a lot more money to throw at this project, if they choose to, than Congress would be likely to allocate.But training matters, and low-tech networks, built and nourished over decades, are powerful. In March 2023, the Marburg virus — an extraordinarily deadly contagion similar to Ebola — broke out in the Kagera region of Tanzania. The news of an unknown infection reached a local CDC-trained health worker named Vedestina Shumbusho through a group chat. She informed the Tanzanian Ministry of Health, which swiftly moved to test and isolate the sick patients. A potential international disaster was averted. I don’t think that the patients were sitting at home on their iPhones, searching “What do I do when I have Marburg virus?”The shift of surveillance to privately owned, profit-minded subscription services (with stated commitment to the public good but obvious obligations to the bottom line) should also raise alarm. Would premium clients get early access to surveillance data? Would they, or the company itself, use it for private gain? Could these sources always be trusted not to put a finger on the scale? What if one of their major funders is a big pharmaceutical company? A private entity looking to break into a new market might want to skew a country’s data to curry favor with its government. A company might even be incentivized to dramatize a far-off danger to increase user engagement on its platform.Is this what we really want — handing off increasing levels of decision-making power to the private sphere? Americans may not agree about much, but it’s clear they are angry about the degree to which corporations constrain our choices about our health and our bodies. (Look, for instance, at the gleeful response to the coldblooded murder of a health insurance executive.) But just when we should be demanding more public accountability and reliability, we seem to be turning away from the idea that health is a collective endeavor, a public good at all, and retreating into the rhetoric of personal responsibility. The deeper message is that we’re all on our own, fighting our private battles. I fear we will come to regret it.Later that afternoon, as I returned home to Chelsea, I walked past the triangular park that marks the AIDS memorial. I doubt New York City will build a Covid memorial park any time soon, but if it does, it will probably be “sponsored.” Perhaps some of the “largest companies and greatest retailers” would chip in, and maybe they’d charge admission (with a percentage no doubt donated to a good cause of their choosing). No names of the deceased would be carved in stone. The memorial sculpture would be some rendition of a strand of mRNA. Or a great glass bubble representing, simultaneously, the lipid nanoparticles within which some of the vaccines were suspended and the ultimate separation of the public air outside and the private air inside.