American enterprise institute. Event is hosted by the American Enterprise interested institute. I am a senior fellow at the American Enterprise interested to enterprise institute. Thank you for coming. Thanks to those who are tuning in virtually. What i thought i would do is before getting into our panel, we have a terrific lineup and two excellent panels i am make excited about. I want to start by saying a few words about why we are having this event here now i way of background. I think it would be uncontroversial to say the covid19 crisis was a crisis. We think about it, it is something that we will be grappling with for some time to come and certainly among the most important events of recent times. It was a Public Health crisis, arguably the worst in 100 years, which resulted in unspeakable amount of death and illness. It also has resulted in a set of policy and political decisions which were unprecedented, the effects of which we are grappling with and trying to understand and the effects of covid can be measured now only in terms of the massive amount of carnage but also the secondary effects of the crisis. Thinking in terms of learning loss, Mental Health issues, other sorts of medical problems that were exacerbated by the crisis. Also the affectional crisis had on our social fabric and political life. If you spend time reading the history of epidemics, which is a the marling demoralizing exercise, you will find this is a very frequent pattern and one of the worst effects of the pandemic is the cost social and political conflict and an erosion of social trust and we will be grappling with that for a long time. All of that would be reason enough to have serious reflection on what happened during the covid crisis, what we did well and what we did badly. There is another arguably more important reason which is that covert is not the last Public Health crisis we will face. It is likely not the less pandemic we will face. In the years to come. While recognizing with humility that there are deep patterns that can occur, we are not helpless. We do have tools that we can use and draw on to think about how to grapple with crises like this. One thing we can agree on, we did not handle covid well, the response particular in the u. S. , is not an exemplar of good politics are policy and the question we have to think about today is how we can do better next time, what kinds of lessons we can learn for policy, for thinking about how we use evidence for policymaking, which is the subject of the first panel but also how we think about institutional reform and building resilience into our federal and other institutions which is what we will talk more about in the second panel. As the crisis proceeds, the window in which to learn those lessons, risks closing. This is why we need to have the conversation now and one might have expected a national Blueribbon Commission to look at the covid crisis and to think about what we did well and maybe something akin to what happened after the 9 11 attacks. Demoralizing we demoralizingly, we have seen little action in washington compared to the scale of the crisis and its importance with thinking about the future. As it happens, a group of experts got together in 2021 with the purpose of trying to we ate a commission trying to create a Commission Like the 9 11 commission and had an adequate and had adequate success inadequate success. They formed the Covid Crisis Group which was an independent group of experts which tried to examine what we did well and badly during the crisis and tried to put forward recommendations and these recommendations came together to report a book called lessons from the covid war. Part of what we want to do today is highlight the work of the report and engage with its findings and recommendations so we are fortunate to have a member of the Covid Crisis Group on each of our panels. We hope we will this will be the beginning of a set of conversations, only the start of more to come and we are here to convene and contribute to that so without further ado, i would like to introduce our first panel so weekend here less from me and more from the experts. Joining such as, we have a professor of epidemiology. During the pandemic, he was named the founding codirector of the new center within the center of Disease Control and prevention prevention. We have an independent research scholar, one of the divisions within the National Institute of health where emily leads the epidemiology and Data Management unit. We have the dubious distinction jennifer fuller who has the dubious distinction of being a fellow scholar. He is also a professor and as well as the cofounder and Deputy Editor of the philosophy of medicine. I will like it to pass it over to mark. Thanks for the invitation to be here. I think it is an opportunity opportunity to opportunity Time Opportunity opportune time. I should say although i do hold a parttime i am speaking not as a representative of the cdc. I was one of the people that was on the Covid Crisis Group, which produces this group that many this book many you have seen many of you have seen. Lessons on the covid war. Tony asked me to say words on the process of that. The original idea was to be the groundwork layers for a fullscale Investigative Commission that might be set up by the government or in some other way. That began in 2021 through the efforts of someone who led the 9 11 commission as the director and who work with four foundations, the rock effector the rockefellers are foundation to stand together to try to get diversity of funding and diversity of viewpoints on the planning what was the Covid CommissionPlanning Group and he began assembling that group through a snowball process of surveying people who were involved in the pandemic of various ways, asking some of us after the interviews to come and join the group that was doing the interview so we assembled in that way. As tony said, the goal had been to put together documents and oral history and some fresh memories for the potential future commission and, as we also also all, that was not adopted in the various pieces of legislation that could have adopted it. So the book was written by philip, which is good because he is a great writer and some of us are not most of us are not as good writers as he. I will go into the details i will not go into the details and one of the things that is good about it is that it is extremely readable and his ability to write well even about bureaucratic and institutional history and we have read books about those topics that are not well written and it is easier to write about personalities and interval stories but the goal was and individual stories with the goal was to write about systemic issues but the goal was to write about systemic issues and why it was decided and why it is yet to be decided in certain ways that lead to less good outcomes then we would have liked. That is part of the value of the book. It does have individual characters. It does have stories. It really focuses on the structures and on the unfortunate fact that had we had the best leadership possible at that time in all parts of government, we would have had a uphill battle. There were clear failures of leadership and they were discussed in the book but the system was not designed it talks about the Grover Cleveland era are of our Public Health system and the analogy between the way we deliver Public Health and the articles of federation. That gives you a taste of the level in which it was written and nonetheless, it is easily readable. I will leave it there and we will come back to some of the topics that are in the book during the course of the discussion. I will now sort of shift to a few perspectives of my own that i think are consistent, probably not all in the book. I think, seriously consistent with what the book tried to lay out. The topic of our panel is the role of science in pandemic decisionmaking. The perspectives i want to bring our thinking about the time evolution of that question. The pandemic was an exercise in decisionmaking under uncertainty and the uncertainty was greatest in the beginning and narrowed as it went on and as we learned more. It persisted. I think it is helpful to think about how you should ask in relation to the science when the science is minimal, when it is somewhat more established and when it is more mature, which we can think of as the beginning, middle and the later phases of the pandemic so in the beginning, there is a need to be cautionary and use shreds of evidence, even shreds up indirect evidence to make policy that will delay the bad outcome. I think there was a process of education that happened at the beginning of the pandemic where people darted to understand what it means to have an exponential growing threat that can be small today and large tomorrow and small is easier to control the large and where delay is at the is the name of the game. If you got covid in february, in april of 2020, you faced overloaded hospitals, very few medical countermeasures, very few evidence of how countermeasures might work. If you got it elite dear later, if you got it a year later, people knew how to treat the disease. There were other procedures in the hospital. You are better off. If it was not new york at the height of its first wave, you are less likely to be in an overcrowded hospital so delay is valuable, flattening the curve, as hackneyed as the term became, really does mean fewer people get affected under the course, as well as those who get affected infected later. You are trying your best as a society to delay the spread. We did not do that as well as we could have. That is one of the biggest issues. It is important to mention the issue of the complementarity of following clients in that environment. I was one of the few people among my friends who was in favor initially of border restrictions. It was not a popular view among many Public Health experts. In retrospect, i made an assumption that was wrong which was if we can delay entry by a month or delay the spread of the virus by a month, we would have time to prepare. In fact, that delay is only useful if you have time to prepare and because we were not doing much preparation in february and march, that delay was not as valuable as it could have been so i think i was right on the principle but wrong in the event. As you get to the end and the precautionary approach means you do a lot of intervention that should be marked with a very big red asterix as temporary and based on our current ignorance and School Closures is a good example. It was a right thing to close schools initially because we do not know the role of children would be in spreading it. It made a big and made a lot of sense given our understanding of how many respiratory viruses spread. They should have had an asterisk saying this is what we know and we will revisit those decisions and that is a general issue i will mention. Evidence accumulated but it is not decisive but the need so they need to eliminate evidence from different sources, from social science, from economics, from biology, from randomized trials, particular interventions becomes more necessary. As we try to figure out how to live with what turned out to be a longterm threat. The goal has to be to make sense of different kinds of evidence, none of which is completely conclusive by itself and to treat it as a multiple input decisionmaking problem. I think emily will talk about this in more detail but in the later stages, what struck me was the importance of observational evidence as opposed to the demised trial evidence as opposed to minimized trial evidence. Most of what we know about vaccines are based on observational studies because we did not do trials with this variant. There are a lot of things we cannot do trials on. We have to understand the value of observational evidence and take steps to make it better. I want to finish by saying a couple things i think we can learn from other countries responses and how they integrate science. The u. S. Has among the most informal processes at major industrialized countries were integrating scientific input into government Decision Making on Public Health and putting aside the fda, for four decisions of the sort of many kinds during the pandemic, there was no centralized group of effort of experts who filtered signs from policymaking and contracts to the u. K. In contrast to the u. K. It is a formal structure to filter evidence and provide decisionmakers with a sense of what the Scientific Community believes. Another lesson, and i think that happened informally, physically in many states, there were advisors assembled but no structure. I was on the one in massachusetts, several in massachusetts and because it was informally assembled, it was a week Time Commitment not a many hour a week Time Commitment. We couldnt respond to formal requests for evidence, for example. Another thing that u. K. Did well. I focus on the u. K. Because it was one of the best in terms of evidence was to put in place structures together evidence. They put surveillance studies that made them understand what was going on at a regional level at all times in a very comparable way across jurisdictions that we never had. There is the preparedness aspects of putting in place data structures and data authorities for the federal agencies to collect data from the states and structures for reporting from states and from health care to be more effective, and there is a discussion to be had about that but i will leave it as a teaser. Thank you so much for having me here. I am an infectious i am also here in a personal capacity to give my and my opinions are my own. I am here to talk about data. A lot of what mark said, having to get that evidence, having a lot of misunderstanding and uncertainty as we moved through the pandemic, how we answer those questions, how we become certain is gathering data and doing research and having Surveillance Systems. Unfortunately, data is difficult to collect and manage even at the best of times but it is made more difficult during an epidemic or pandemic. I want to talk about some of the things that went wrong, some of things you could have done better during we could have done better during the pandemic in terms of Data Collection and survey and research. There is a difference in the reasons on why we collect data and how we collected and based where we collected based on where we understand we want to know how many cases of infection are in certain locations and it is different from how well vaccine works. We need to set right surveillance and research and other data needs because it is not just all a one size its all Data Collection. Not all data will collect every question so that is what i want to talk about. My expertise is in design and conduction of critical studies, not observational studies and how and why we collect data and how we use it and how we manage it so that is what i am hoping to bring to this discussion. I had the opportunity to work at a state health department. I work in Academic Year and i work with cdc programs. I had a unique opportunity to understand Data Collection from a wide variety of different areas. Couple of problems that i want to highlight that we ran into during the covid pandemic, although are not surprises to anyone who has done research or the surveillance, it is difficult to collect large amounts of data, particularly sensitive data. In a pandemic, you are collecting information on peoples health, on who is sick, and demographic information. We learn a lot about people through the illnesses they have and that information can get reported and people can have various feelings about that. Some of us dont mind having that information shared and other people may have reasons why they dont want that data to be shared so we need to make sure we are doing collecting data in a sensitive manner. We are doing it in a way that protects peoples privacy. That is difficult to do, especially when you collect data through different platforms. We need to collect data in a realtime fashion, so having data from three weeks ago doesnt help us if we are trying to respond to our pandemic so we need to have data on how many people are getting tested. Are people able to get treatment . Are they taking those treatments . We need them in real time to understand how the situation is evolving and how to understand how we can respond to it and how the responses are working. Otherwise, why are we investings in investing in these interventions . There is the Economic Situation to making sure we are using the speed and Health Reform how we are doing in the Public Health response. We need a debt a standardization so just having a bunch of data instead of is better than having no data but it takes a lot of time to manage data. In this the data science world, we joe, we spent a lot of time cleaning data people handouts and only doing 30 of handling it. We get Surveillance Data from Health Departments and Health Care Companies and medicare services. None of these data systems are standardized. Thats not how our system works in the u. S. It is problematic when it comes time to the pandemic. We need that data to be interoperable to join together so we can say, we may not have one federal system of data but we have a different date at that can coverage and manage what we need. We need to be able to collect the data in realtime and be able to have a standardized and interoperable and we need to have people who cant an