Flying the Plane While Building It: Lessons From the COVID-19 Pandemic

Flying the Plane While Building It: Lessons From the COVID-19 Pandemic

Science is an iterative process. The COVID-19 pandemic dramatically changed the fabric of science and health care, and its effects and the lessons learned will reverberate for decades to come. An important lesson is that implementation of evolving science needs to be contextualized within existing societal values and beliefs. If not, we risk the exacerbation of mistrust in science and health care such as occurred during and after the COVID-19 pandemic (1). Decision making during the pandemic was truly like flying the plane while building it. Information was inconclusive and constantly evolving, yet decisions had to be made quickly to avert a worsening crisis. Retrospection allows us to take an honest look at the process and outcomes with the goal of being better prepared for the inevitable next catastrophic health care crisis (2). The entire health care and public health community must have the humility to reflect on lessons learned to ensure we do better the next time we face a public health catastrophe.

Humans have an innate, robust immune system that is equipped to fight infection, but advances in medicine can optimize this system. One such advance is vaccination, created in the late 1700s when Edward Jenner discovered that inoculation with cowpox could prevent smallpox. When conveying the benefits of vaccination to the public, it is important to contextualize the meaning of “vaccine” and the type of “immunity” generated within the innate characteristics of the organism, including mutation rate and immunity durability (3). Measles vaccine, like other highly impactful childhood disease vaccines, is remarkably effective at preventing the acquisition of disease and is estimated to have averted more than 93 million deaths between 1974 and 2024 (4). The primary COVID-19 vaccines were also remarkably effective. However, due to the high mutation rates and variable community levels of immunity from prior infection, the goal of COVID-19 boosters is primarily to prevent hospitalization and death, particularly in people older than 64 years or with predisposing conditions, the most vulnerable groups (5). Additional benefits of COVID-19 vaccination include reducing the risk for post–COVID-19 sequelae (6). Substantial evidence documents that the consequences of infection are much greater than the potential adverse effects of vaccination (7).

Yet nuanced questions remain about who is most likely to benefit from COVID-19 booster vaccination, and answering these questions requires careful consideration of the individuals. As Prasad and Makary stated in a May 2025 commentary in The New England Journal of Medicine, people older than 64 years should receive COVID-19 booster vaccinations, as should people of any age with immunocompromising medical conditions that predispose them to higher risk (8). We believe that vaccination recommendations should also consider the context of younger, healthy persons who live with, care for, or are in frequent contact with persons at high risk. Although a 50-year-old without medical conditions might experience a mild inconvenience from infection with SARS-CoV-2, that person's circumstances could necessitate protection of an immunocompromised or older person they spend time with. We believe that public health recommendations should allow all people the choice to receive vaccine (and that this choice should be supported with insurance coverage) if their circumstances would enable them and those they interact with to gain benefit, as vaccination is safe and effective in the proper context. Similarly, although routine vaccination of healthy children may have a modest direct protective effect, it can mitigate disease in others, as has been observed with other childhood vaccines (9). Additional concerns about recent recommendations from the U.S. Food and Drug Administration (FDA) and the U.S. Department of Health and Human Services include the feasibility of the clinical trials they mandate and the lack of transparent and collaborative decision making.

Before the 21st century, Americans saw vaccination, such as for polio, as a civic duty and a moral imperative to protect not only themselves but also their fellow citizens. The politicization of science has disrupted the precarious balance between public good and individual freedom. The COVID-19 pandemic overwhelmed our health care systems and gave rise to excessive mortality in the United States compared with other similar countries. The realization that protecting oneself as well as others is paramount to the survival of any society. The ongoing attacks on science and public health and the spread of misinformation about vaccines will erode the safety and health of all of us.

Science must be allowed to exist outside the realm of political influence. In the highly effective contemporary model, the FDA considers the safety and efficacy of vaccines, and the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) considers implementation of vaccination to best protect personal and public health. A risk-based strategy for COVID-19 boosters has merit, but estimation of risk must weigh other factors beyond a person's age and personal health conditions, such as their social circumstances, living situation, work responsibilities, and family dynamics. Providing the opportunity for someone to be vaccinated based on the best available scientific evidence and their personal situation supports the concepts of liberty and choice. Political directives should not prevent people from seeking safe and effective care that they desire and deserve. People in the United States should have agency and autonomy to decide how they should best receive care in the framework of mutual respect and reciprocity of rights so that their actions do not negatively affect others.

Currently, the Patient Protection and Affordable Care Act requires insurers to cover all ACIP-recommended vaccines (10). The FDA's decision to limit the use of COVID-19 booster vaccines, as well as the recent statement from U.S. Secretary of Health and Human Services Robert F. Kennedy Jr. that the CDC no longer recommends COVID-19 vaccines for young children and pregnant women (in advance of ACIP making formal recommendations), places ACIP in the difficult position of potentially approving off-label use of these vaccines. This could jeopardize payment coverage for millions of Americans who could not otherwise afford the vaccine to protect themselves, their families, and their fellow citizens.

Scientists, clinicians, and policymakers must be reflective and willing to accept change when new evidence emerges. At the same time, we must stay true to our primary mission of promoting health for all. History should be our guide, not our captor.

References

1.Kearney A, Sparks G, Hamel L, et al. KFF Tracking Poll on Health Information and Trust: January 2025. 28 January 2025. Accessed at https://www.kff.org/health-information-and-trust/poll-finding/kff-tracking-poll-on-health-information-and-trust-january-2025 on 25 May 2025.Go to CitationGoogle Scholar

2.Halperin DT, Hearst N, Hodgins S, et al. Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here. BMC Public Health. 2021;21:2084. [PMID: 34774012]  doi: 10.1186/s12889-021-12082-zGo to CitationCrossrefPubMedGoogle Scholar

3.Panthagani K. Did public health really tell people COVID vaccines were 100% effective? Yes. You Can Know Things. 21 April 2025. Accessed at https://youcanknowthings.substack.com/p/did-public-health-really-tell-people on 25 May 2025.Go to CitationGoogle Scholar

4.Dattani S, Spooner F. Measles vaccines save millions of lives each year. Our World in Data. 19 May 2025. Accessed at https://ourworldindata.org/measles-vaccines-save-lives#:[APPROX]:text=Fifty%20years%20since%20the%20start,measles%20deaths%20prevented%20every%20year on 25 May 2025.

This article was adapted from a piece originally published by ACP Internist. Read the original version click here…