The paralysis of the surveillance system in 2020 is by no means the greatest failure of the public health response to COVID-19. The record is damning. In “Inside America’s COVID-reporting breakdown,” Politico health care reporter Erin Banco wrote:
Covid-19 was spreading rapidly throughout the United States, as cold winter weather began to drive people indoors, but the Centers for Disease Control and Prevention was flying blind: The state agencies that it relied on were way behind in their tracking, with numbers trickling in from labs by fax or even snail mail. (https://politi.co/3Oo82iz)
In an interview with the Wall Street Journal, Centers for Disease Control and Prevention (CDC) director Rochelle Walensky acknowledged the underfunding of the data collection system:
Fewer than 200 health facilities across the U.S. had their electronic-health records linked to CDC data-collection systems before the pandemic. . . . At the start of the pandemic, some states that were unable to electronically report positive COVID-19 cases had to fax PCR [polymerase chain reaction] results to the CDC. . . . Some states were entering positive results first because they didn’t have the capacity to enter all the negative ones . . . so the CDC initially received a skewed view of what fraction of the population was positive. (https://on.wsj.com/3RMgeMd)
The CDC was “flying blind!” To track the progress of a pandemic and whether countermeasures are slowing it down, there is no substitute for collecting data specifically for that purpose. Instead, the government, the public, and the press had to interpret hospital and health center numbers of people who decided to test themselves or were so sick that they ended up in a hospital, where their case was recorded. These samples were highly selective, providing a distorted image of the pandemic’s progression. The sociodemographic data often lacked information on ethnicity and race. The exact picture of the proportion of the population infected, and of the communities most affected, was never assessed. Today, reported counts of home test results substantially underestimate the true numbers of infected.
The absence of a national population-based surveillance system forced hasty decisions on lockdowns and school and business closures and delayed the identification of some of the most affected communities. It must have contributed to the grim side of the pandemic response. The United States has suffered the highest death rate of any wealthy country. Altogether, the impact was unfair and unjust. However, crises reveal failures in the public health system, and immediately after a crisis is typically a good time to remediate and prepare.
What is the state of the US surveillance system? The December 2021 issue of AJPH reviewed it along with ways to prepare for and effectively respond to this and future emergencies (https://ajph.aphapublications.org/toc/ajph/111/12). The set of reports showed that, collectively, federal, state, and city surveillance and survey programs had begun to remedy the defective structures and improved collection, processing, and dissemination plans. Still, despite good intentions and expertise, we are still missing accurate estimates of incidence and fatality rates and comparisons of them across time, people, and places.
The June 2022 issue of AJPH (https://ajph.aphapublications.org/toc/ajph/112/6) reviewed the current state of city dashboards, which have been established to remediate or complement the gaps in existing federal surveillance. They are works in progress, needing sustainable funding and geographical integration.
In this issue we document the gaps in the surveillance systems that are hiding the real inequities in COVID-19’s impact and that jeopardize appropriate responses. The reports add empirical evidence to the theoretical guidance from the recent “Charting a Course for an Equity-Centered Data System” (https://rwjf.ws/3RQHRUo).
AJPH will continue to publish work that addresses the following key questions: (1) Which data are needed? (2) What purpose are they for? (3) Who collected and produced them? Modernizing the public health data infrastructure for the US federal government and state and local health departments has a high cost, but no price is too high for building a foundational tool indispensable for piloting public health.
12. Years Ago
Customizing Survey Instruments and Data Collection to Reach Hispanic/Latino Adults
[T]he attitudes, behaviors, knowledge, and experience of Hispanic and Latino persons residing in the United States regarding tobacco use may differ from those of persons in non-Hispanic groups, which may warrant customized approaches to smoking prevention and cessation programs. . . . [We] examined available survey methods, tobacco-related instruments, and their utility for obtaining information from Hispanic populations. . . . The results support the conclusion that culturally sensitive modifications to survey procedures used to locate and contact specific population groups can result in response rates that far exceed those common in survey work today. . . . Developing instruments for specific population subgroups requires consideration of culture and language, cognitive demands, and potential response errors. Collecting information from specific subpopulations requires community knowledge and specialized training.
From AJPH, Supplement 1, 2010, pp. S159–S162, passim
13. Years Ago
Monitoring Inequities in Self-Rated Health Over the Life Course in Population Surveillance Systems
It is necessary to monitor health inequities in terms of socioeconomic position (SEP), gender, ethnicity, and other indicators to determine whether they are widening or decreasing over time and to design and evaluate policies aimed at reducing these inequities. . . . It is widely acknowledged that SEP across the life course influences health and that observational studies of socially patterned exposures and outcomes should adjust for measures of SEP across the life course, but indicators of early-life SEP have not yet been included in population survey monitoring systems. . . . These results for housing tenure and family financial situation over the life course support the theory that SEP effects accumulate across childhood and adulthood.
From AJPH, April 2009, pp. 680–684, passim
Biography
