Three Years After

UCLA Health article

In the waning days of autumn in 2019, a coronavirus in Wuhan, China, is believed to have jumped species. It entered its first human host, and a new respiratory illness started to spread. Hospital beds filled with patients, each of them gravely ill with pneumonia-like symptoms. Standard treatments had no effect. As people began to die, doctors became increasingly desperate. Despite their repeated pleas for help, local officials refused to act. In those first critical weeks, instead of issuing public warnings, authorities punished and silenced anyone who dared sound the alarm. By the time Wuhan publicly admitted to 100 coronavirus infections, medical workers put the true number at closer to 10,000. In that close-packed city of 8.5 million people, mere weeks after that first infection, the start of the COVID-19 pandemic was well underway.

For the past three years, humanity has been held hostage by the cluster of genetic code now known as SARS-CoV-2, and it has paid a heavy price. We have witnessed a historic loss of life, with a world - wide death toll that now totals well over 6.6 million people. In the 200- plus nations and regions where COVID-19 still rages today, every aspect of daily life has been transormed. Health care, childcare, education, commerce, family life, social life, social justice — none has been spared.

But we enter the fourth year of COVID-19 armed with a mea - sure of hope. We have effective vaccines that blunt the virus, and also ease the burden on our health care institutions. There are also medical advances to help those who previously would have died. Although infections continue and the virus claims lives, it’s not at the same frenzied pace.

After three difficult and frightening years, the pandemic is easing into an endemic phase. And in these hard-won moments of respite, there comes time to assess and reflect.

For Shangxin Yang, PhD (FEL ’16), assistant medical director of the UCLA Health Clinical Microbiology Laboratory, the appearance of COVID-19 in the U.S. came as no surprise. It was mid-December, well before news of a novel coronavirus had begun to leak out, when he began to hear rumblings that something was amiss. Chinese social media was suddenly filled with posts about a mysterious new pneumonia spreading throughout Wuhan. But details were sketchy, and at first Dr. Yang shrugged it off. “It seemed like it was an exaggeration,” he says. “I thought it was likely that something else was going on, just people being a little bit paranoid, so I really didn’t give it much thought.”

Then, in the final hours of the final day of 2019, his perspective dramatically shifted. “On New Year’s Eve, I got a message through Chinese social media that officials high up in the government in Wuhan had put out a notice about the virus,” Dr. Yang recalls. “That made everything that I had been hearing in the last few weeks more legit.” It was nearly midnight, and Dr. Yang was already in bed. But the nagging unease made sleep impossible. “I just jumped out of bed and got online, doing re - search and chatting with friends and colleagues in China,” he says. Combing through social media, he found a deep trove of information about the growing crisis, panicked chats and posts, frightening videos of overwhelmed hospitals, none of which had yet been made public.

So many people in the city were sick, they were rushing to all of the hospitals, but all of the hospitals had already run out of beds,” Dr. Yang says. “They were setting up tents in the open space outside of hospital buildings in the very cold winter weather. Everything I was reading that night indicated that this was going to be very, very severe.”

Dr. Yang shared what he had learned with colleagues at UCLA. But the clamp-down on informa - tion from Wuhan was so complete he was met with astonishment, skepticism, and even some disbe - lief. By late February, when news of a novel coronavirus had finally been made public, it became a topic of discussion at a town hall meeting in his laboratory. “I remember telling everyone that this would be the last in-person meeting where we have more than 50 people in the room for a very long time,” Dr. Yang says. “I just didn’t expect it to last this long.”

No one did. In the beginning, “it was a bit exhilarating, to be honest,” recalls Dan Uslan, MD, MBA, co-chief infection-preven - tion officer for UCLA Health. “I naively thought that with enough up-front public health efforts we might get by relatively unscathed. I hadn’t experienced anything of this scope before — no one really had. At UCLA, we were well-prepared for an influx of patients with an emerging infection like Ebola, but I didn’t imagine anything of the scope of what we eventually had to deal with, or how rapidly things evolved. Exhilaration rapidly gave way to exhaustion.”

THE VIRUS QUICKLY STARTED ITS GLOBAL SPREAD. In the U.S., clusters of the illness that would soon come to be known as COVID-19 began to appear, first in Washington State and then in New York. Dr. Yang was deeply shocked when, with misinfor - mation and denials, top U.S. government officials mirrored the Chinese response. Even the Centers for Disease Control and Prevention (CDC), the indepen - dent public health agency whose guiding mission is to safeguard the wellbeing of Americans, was subjected to political pressure.

“I truly believed the U.S. would do better than China because here, we are not afraid to speak the truth,” Dr. Yang says. “But then it went the other way. There were denials by the president, and even political interference with the CDC. We lost a whole month when we really could have stopped the spread.”

Meanwhile, federal health agencies in the U.S. were having problems of their own. Slow and unsteady, they took dubious steps to address the looming threat. Omai Garner, PhD (FEL ’12), associate professor of pathology and labora - tory medicine and director of the clinical microbiology lab, knew that to slow the spread of the virus, it was necessary to accurately identify who was infected. Immediate and widespread testing for COVID-19 had to be done. But because this was a new illness, diagnostic tests did not yet exist. That meant not only creating accurate tests, but also arranging for their manufacture. With the virus spreading so quickly and so far, it was clear that hundreds of thousands of tests would be needed right away.

“Here in our lab, we knew that we had the molecular capabilities in-house to develop a COVID-19 test, so we actually started to order the test components before anyone else did,” Dr. Garner says. “And that was one of the reasons why UCLA was among the first hospitals in Southern California to have diagnostic testing.” (To date, Dr. Garner’s lab has performed close to 1.2 million PCR tests.)

But in one of a series of baffling moves, the CDC set extremely limiting criteria for who qualified for COVID-19 testing. At a moment in time when the virus was exploding, a mere fraction of the populace was able to get a test. That allowed countless active cases, including in people with no obvious symptoms, to go undetected. So infected people kept on spreading the virus. The agency further slowed reaction time by limiting who was allowed to create a diagnostic test.

Unlike South Korea, which immediately launched nationwide manufacturing of COVID tests, the CDC required the use of its own test. In an embarrassing turn of events, those first CDC tests contained a faulty reagent, which made them unreliable. By the end of February 2020, South Korean health officials had tested 65,000 people and were expanding their efforts; the U.S., by contrast, had managed to test just 459 people. CDC officials eventually backtracked. The agency expanded its testing guidelines and allowed widespread test manufacturing. However, it proved to be much too late.

“By then, the global supply chain had fallen apart,” Dr. Garner says. “Reagents, testing swabs — none of it was easy to get. And the whole time the virus is spreading. The numbers were just staggering.”

At the same time that the CDC’s decisions hamstrung the scientific community’s virus response, the agency’s public relations arm was engaged in its own struggles. In communicating with the public about the virus, the agency issued guidance that was complicated, often confusing and sometimes downright incoherent. And on an almost-daily basis, that advice also continued to change, which led to a loss of public confidence in its accuracy. This shifting information about COVID-19 and its mitigations stemmed, in large part, from the fact that scientists and medical personnel were learning about the disease in real time.

“This was a new virus that we knew so little about, and as we learned more and more, the public health recommendations kept changing,” says Robert Kim-Farley, MD, MPH, professor-in-residence in the UCLA Fielding School of Public Health and former director of the Division of Communicable Disease Control and Prevention at the Los  Angeles County Department of Public Health. “But from the public perception, it seemed like experts were flip-flopping in their guidance.”

For federal public health agencies to find themselves so unprepared was surprising. “Public health should have been able to do a better job at preparing the public for changes in the guidance over time, as we got to know the virus better and as the virus itself mutated,” Dr. Kim-Farley says. “Perhaps if marketing experts, behavioral scientists, social media experts had been included early on, communications with the public would have been more successful. Unfortunately, that didn’t happen.”

Dr. Uslan agrees. “Early on there were recommendations against wearing masks, and obviously that changed. That’s what science and medicine do — they evolve as research is conducted and as we learn more. It is a part of the normal process, especially with something new like an emerging infectious disease.”

And then, an even bigger shock — the science was beset by politics. Politicians, including the president, began to weaponize basic mitigation measures. Wearing a mask, self-isolating, getting inoculated when vaccines became available, keeping up with boosters, all became Red State versus Blue State issues. Tragically, the COVID-19 data soon reflected that split, with increased infection rates and higher death tolls in the cities and states that rejected COVID-19 precautions. “I didn’t see that coming, and still don’t understand why evidence-based medicine became political,” Dr. Uslan says. “It’s been very sad to see the hostility and anger misdirected against well-intentioned scientists, public health experts and health care workers.”

Communication challenges also led to a misunderstanding of why certain mitigation measures were undertaken, says Annabelle M. de St. Maurice, MD, MPH, associate professor of pediatrics in the Division of Infectious Diseases and co-chief infection-prevention officer for UCLA Health. This includes the shutdowns, which were widely associated with the idea of eliminating transmission of the virus. But the virus continued to spread despite shutdown measures, which were causing enormous hardship. As a result, the measure quickly came to be viewed as useless, and even a failure.

Again, poor messaging was to blame. “The goal of the shutdowns wasn’t to eliminate transmission; it was to reduce transmission so that our hospitals, and our whole medical system, wouldn’t be overwhelmed,” Dr. de St. Maurice says. “Even with the shutdowns, that was an extremely difficult period [for health care institutions]. Without the shutdowns, I really don’t know how we could have functioned.”

ONE OF THE GREAT SUCCESS STORIES OF THE PANDEMIC has been the development of the COVID-19 vaccines. Under normal circumstances, the complex process of vaccine development can take well over a decade. But building on existing research, and thanks to international cooperation, the COVID vaccines were ready for use in under a year. And yet, due once again to misunderstanding, fueled in part by politicization, a large segment of the public has a low opinion of the vaccines.

“The biggest shame of all this is that the vaccines have been viewed as failures because they don’t prevent 100% of transmission of the virus,” Dr. de St. Maurice says. “But the focus should instead be on how effective they have been at lowering the rates of hospitalization. In that regard, the vaccines were, and continue to be, a tremendous success.” (UCLA Health has administered 300,000 doses of the vaccine to date.)

The challenge, of course, is how to change those perceptions going forward. It is not an easy task, as the public response to the twists and turns of the pandemic has proven. “It seems that some people begin with the conclusion that they feel most comfortable with, and then it’s confirmation bias — they seek out the arguments that agree with that,” Dr. de St. Maurice says. “I wasn’t on Twitter before the pandemic, but now I try to at least talk to people [on Twitter] about the vaccines in an evidence-based fashion. But it’s challenging.”

Another viral phenomenon that emerged during the pandemic has been the glut of conspiracy theories. Fueled by the still-unknown origins of the novel coronavirus and amplified by both humans and bots on social media, new theories continue to pop up almost every day. Some of the most outlandish — and popular — have centered on 5G cellular technology, evil billionaires, mass enslavement and the presence of surveillance microchips in COVID vaccines. Things went so far off the rails that the director of the World Health Organization proclaimed an “infodemic.”

Though not nearly as farfetched in its particulars, a parallel discussion about whether or not the SARS-CoV-2 virus may be lab-made continues to pop up in scientific circles. A recent scientific paper circulated as a preprint — research that has not yet undergone peer review — by a team of scientists in Germany created an uproar when the authors claimed to prove that the virus is entirely synthetic. Others have opined that the presence of certain genetic sequences in the virus shows signs of human intervention.

Otto O. Yang, MD, associate chief of the Division of Infectious Diseases, doesn’t give any of these theories credence. “None of the se - rious virologists who have looked at the genetic sequence of the virus have found any convincing evidence of human manipulation that makes it look in any way unnatural,” Dr. Yang says.

He has examined the code of the virus himself and has not seen any persuasive evidence of human interference. “Most of the scientific community is of the opinion that this is a natural virus, and that it has not been genetically engineered.”

As for the lab-leak theory, that SARS-CoV-2 was accidentally released in a biosafety incident at a Wuhan research facility, Dr. Yang says that while it’s possible, we likely will never know. “Not unless there’s some kind of smoking-gun evidence, like written records or a sample,” he says.

What is of greater concern than any of these conspiracy theories is whether or not the U.S. has learned from the COVID-19 epidemic and is thus better prepared for the next one. “In part, COVID spread so fast because it was a completely new virus and there was no immunity in the population, but it also was because of the disorganized and, frankly, ineffective response of our public health agencies,” Dr.  Yang says.

The recent outbreak in the U.S. of mpox — formerly called human monkey pox — in which public health agencies once again fumbled testing, contact tracing and medical care, did little to bolster confidence. “How much better of a situation can you have than a virus for which there is already a vaccine, there’s an effective treatment, it’s spreading in a very defined group of people, and you have advance warning that it’s coming?” Dr. Yang asks. “We had every advantage, and still there was an outbreak.”

LOOKING TO THE FUTURE, Nisha Viswanathan, MD, assistant professor of medicine, worries about the effects of the pandemic on her colleagues, and more broadly on the health care profes - sion in general. The co-director of the UCLA Health COVID-19 ambulatory monitoring program and director of the long-COVID program, Dr. Viswanathan works with, and coordinates the care of, medically complex patients.

“A lot of health care workers have come out of the pandemic burned out and demoralized. And now we’re seeing a decrease in respect for the health care profession itself,” she says. “The work that we do is constantly questioned by people who have become really distrustful of us, and of the health care industry.”

The problem is even worse in areas where COVID-19 denialism has become ingrained. Dr. Viswanathan says the region of the country where a health care worker practices can play a role in how the pandemic unfolded, and how they were personally affected. “Being in L.A., we had a population that took the pandemic more seriously. Living here protected me from some of the worst of the politicization,” she says. “I’m originally from Arkansas, and I previously worked in rural Arkansas, and the health care community there felt the dichotomy far more starkly than we did.”

PANDEMIC PREPAREDNESS HAS BEEN A FOCAL POINT OF PUBLIC HEALTH EXPERTS like Anne Rimoin, MD, MPH. A professor of epidemiology and the Gordon-Levin Endowed Chair in Infectious Diseases and Public Health in the UCLA Fielding school of Public Health, Dr. Rimoin is an internationally recognized expert on emerging infections, global health, surveillance systems and vaccination. She worries that, rather than improve future response, widespread pandemic fatigue may leave the U.S. similarly ill-equipped for a new threat in the future.

“We are at such an important crossroads right now, and I worry that in some ways, we are even less prepared for another surge or another pathogen,” she says. “I think that we’ve learned some things, in particular about the complexity of science communication and the importance of being able to let people know what’s happening,” but even as vaccines and natural immunity lead to an easing of the pandemic, systemic challenges remain.

The health care community continues to combat misinformation, disinformation and a growing disregard for fact-based science. Each plays a role in hindering response to the inevitable next pathogen, Dr. Rimoin says. “I always go back to what my fa - ther-in-law, Dr. Morris Claman, who was a urologist at UCLA, used to say: ‘It is much easier to stay out of trouble than it is to get out of trouble,’” she says. “The problem is, this is a lesson that we seem to keep having to learn over and over again.”