They are scenarios that national health and security experts have been contemplating for years.

A deadly virus crosses from animal to human triggering another pandemic.

A dangerous microorganism accidentally escapes from a research lab to infect a population.

Or a pathogen is unleashed as a biological weapon by an unhinged dictator.

But three years of battling the Covid-19 pandemic has left us prepared for such emergencies, right?

Maybe not, according to health authorities from around the state and the nation.

While the country has made substantial progress in some areas, they say, it has a long way to go in others, such as communicating information to the public and sustained public health funding.

Where the nation excelled during the pandemic, the experts agree, was in the science.

Dr. Michael D. Sweat, director of the Division of Global and Community Health at the Medical University of South Carolina, points to the rapid development of the mRNA Covid vaccines as an example, calling them “a really big breakthrough for humanity.”

“That was a world class effort … that took an enormous amount of resources and scientific skills. And it’s a huge advantage should we face another … outbreak because we can produce them rather quickly, and they’re easy to adapt to the genetic profile of pathogens,” he said.

“And we have therapeutics now, monoclonal antibodies, and incredible expertise grown through the epidemic, and the sensitization to act quickly,” he added. “We know the damage these global pandemics can cause. It had gotten away from our memory since the 1918 flu epidemic. People are now paying attention.”

The development of a vaccine through public-private partnerships less than a year from the detection of the virus was nothing short of a “medical and scientific miracle,” said Dr. Brannon Traxler, director of public health for the South Carolina Department of Health and Environmental Control. 

“The fact that that occurred … and they produced the amount they did in the time they did, was a real miracle,” she said. “They were able to … accelerate the science that had been in the works since 2003 with the first SARS outbreak. 

“And that undoubtedly saved lives.”

Scientists initially underestimated how quickly the variants could mutate, how impactful they would be, and how long the immune response to vaccines would last, said Dr. Georges Benjamin, executive director of the American Public Health Association.

But they quickly learned more about the new strains, about how the virus enters our bodies, and how it impacts our organs, for example, leading to Long Covid, he said. 

Researchers also learned a lot about doing clinical research and medical management of the sick, Benjamin said, for instance with antiviral agents.

“We are much better prepared on the clinical side of this equation,” he said.  

And thanks to heightened surveillance systems that weren’t in place in 2019, the 2022 monkeypox outbreak was detected and dealt with earlier than it would have been otherwise, said Rachel Nuzum, senior vice president for policy at The Commonwealth Fund and lead of its public health initiative.

But the nation comes up short in other areas, the experts said. And chief among them is communication.

“We hugely need to do better there,” said Benjamin. “There were major blunders.”

Perhaps the best example, he said, was messaging about wearing masks.

At the outset, when there weren’t enough N95 masks amid uncertainty about how Covid was spread, authorities said the public didn’t need to wear them, he said.

“It was a big mistake,” he said, adding that it’s since been addressed. “It’s better to be very honest about a lack of understanding as opposed to making statements that were not grounded in science.”

Nuzum agrees that some of the criticism about messaging was warranted. 

For example, she said, advice about masking changed over time because the science changed, but that wasn’t adequately explained. 

“We were often caught flatfooted,” she said. “Evidence is always evolving, and it could have been presented better.” 

As a result, the public became unsure about the message, said Benjamin. 

“We did not preface it with, ‘This is what we know now and as we learn more, we may give you different advice,’ ” he said. “We need to prepare people for potential change.”

Traxler said transparency is crucial for public trust.

“Being very transparent about what we don’t know and how what we know as science evolves could change would help manage expectations,” she said.

In addition, Nuzum said, there should be one person in the federal government who’s responsible for public health who has ear of the White House and can coordinate with all the agencies to avoid confusion. 

Beyond that, she said, messaging also needs to come from trusted sources for targeted populations. For some, that might be Dr. Anthony Fauci, the recently retired director of the National Institute of Allergy and Infectious Diseases, she said. But someone else might be best for others.

“What we saw loud and clear is that while evidence and messages should be consistent, who you have giving those messages has to depend on the community you want to reach,” she said. “You need to use local resources who are well-regarded.”

The pandemic also pointed up the fractured pattern of public health funding, the experts say.

It’s one of the greatest weaknesses of the system, said Dr. Helmut Albrecht, an infectious disease specialist with Prisma Health Midlands and medical director of the Center of Infectious Disease Research and Policy for Prisma and the University of South Carolina.

Public health should be regarded as a first responder with continuous funding, he said. Instead, he said, it’s viewed as dispensable, leaving the infrastructure to be rebuilt with each new crisis. 

Cities don’t sell their fire trucks when they’re not in use, he said, but public health gets dismantled. Attitudes must change to correct that, he said.

“Of course, it costs money,” Albrecht said. “But an ounce of prevention is as effective as a ton of treatment. We’re always doing treatment, and then we have to throw a ton more money at it to even catch up. Given how connected the world now is and how quickly these things can (spread), we don’t have the luxury to wait until the new threat comes. Covid showed us that.”

To be ready for the next crisis, the health care workforce must be maintained and trained and technology needs to be modernized, he said.

“There will be pandemic influenza one of these days again,” he said. “We need to keep the system up and running.”

Benjamin characterizes the situation as “boom and bust funding.”

For example, he said, billions were earmarked to battle the pandemic, but it’s one-time funding that won’t build a sustainable system.

Technology needs to be updated regularly and be interoperable with other federal and state agencies, he said, and there must be standardized and secure data reporting systems.

“We still have health departments collecting data by pen … and sending by fax,” he said. “The only thing worse would be if we were still using carbon paper.”

Sweat said the initial response to Covid clearly illustrated how public health has suffered from decades of underfunding. 

“We need to put more money into public health on a regular basis,” he said. “If we face another outbreak, we will need that.”

And, he adds, another outbreak will come.

One of the biggest lessons from Covid is the importance of continuous public health funding at all levels –  not just during emergencies – because it’s critical that the nation’s biodefense strategy is built on a strong foundation of public health, Nuzum said.

For example, she said, there was no infrastructure in place to do surveillance, data collection, or vaccine rollout on such a scale before Covid. 

“It’s like monitoring for terrorist activity. We don’t just do that when there’s a threat. We do that all the time,” she said. “We’re at a critical decision point now. Public health is limping along in the background, and no one thinks about it until we have a crisis. 

“You don’t want to fix the boat when you’re already sailing.”

All the experts assailed the politicization of science and the pandemic, saying it impacted how people regard public health overall.

“Covid has become so politicized and therefore public health has become politicized,” said Nuzum. “If you’ve made up your mind that government doesn’t know what it’s talking about, you’re not likely to listen. It will take some time for that to sort itself out.”

Health care and science were historically exempt from politicization, but that’s no longer the case, Albrecht said. 

“Everybody is so divided politically that it spills over into this evaluation of science,” he said. “We have to explain that the world is round, that vaccines that save millions of lives are good for you.”

Though DHEC got expert advice about communications and politics regularly the year the vaccine was rolled out, Traxler said that by that point the pandemic was already so politicized they were behind the eight ball.

“There are two populations – those receptive to messaging and can have their minds changed and those who (are) … convinced without a doubt that they’re not going to trust the vaccines and won’t get them,” she said.

“But we know from a study that just came out that roughly 3 million lives were saved because of the vaccine,” she added. “I wonder how many more we could have saved if more (people) took the vaccine.”

The politicization even extended to demonizing Fauci, and that’s had some unexpected repercussions, Albrecht said, noting that 56 percent of infectious disease fellowship slots in hospitals were not filled this year compared with 90 percent historically.

“Nobody wants to do this anymore after what just happened,” he said. “You work harder, get paid less – and at least you have the coolest job on the planet – but now you get hunted for that. Or threatened. It’s a fallout that’s not going to serve us well.”

Sweat agrees about the politicization, noting he needed personal security because of death threats and other harassment directed at him during his public talks. 

“If we were to suddenly get a new coronavirus next month, or another pathogen, our ability to mobilize the public and nimbly implement mitigation activities might be compromised,” he said. 

In addition, he said, the stress of Covid has driven others away from public health professions. 

Another serious challenge, the experts say, is managing misinformation and disinformation, which snowballed during the pandemic fanned by social media and other sources.

“Scientists weren’t perfect and mistakes were made, but lack of trust is a problem we need to deal with as a society. And these extremist movements,” Sweat said. “It’s a tall order, but it has to be addressed.” 

The proliferation of misinformation and disinformation during the pandemic was unlike anything seen before, leaving everyone with “their own set of facts,” Nuzum said. 

Largely produced by bots from sources hostile to the U.S, it can reach millions of people in a flash, Albrecht said, so public health must do better at combating it and getting out the facts.

Misinformation also fueled anti-vaxx sentiments overall, leading to outbreaks of diseases like measles, he said. 

“Vaccinations for kids, and other routine vaccinations, are down for the first time,” adds Nuzum. 

Benjamin said that federal agencies need to strengthen their risk and science communication skills generally so the public and policymakers understand how science works.

And Nuzum agrees that the nation has a long way to go to make the public more aware of what a local health department does.

Supply chain problems were one of the biggest obstacles at outset of the pandemic, Sweat said, noting hospitals didn’t have masks, ventilators and reagents for PCR testing among other things in the early months. 

But these issues continue to an extent because so many products aren’t made domestically, and that poses a national security risk, he said.

“The supply chain issues we are all still feeling show how interconnected the world is,” adds Albrecht. 

In addition, Sweat said, the national stockpile must be maintained so supplies don’t degrade like they did during Covid. And while that takes money, he said, support slacks off when the nation isn’t faced with a crisis.

So where do we go from here?

Benjamin said there’s broad national consensus on what needs to be done to fix the system, and the U.S. is up to it. But he wonders about the political will to do it. 

“We know exactly what needs to get done. It’s not rocket science. And even if it was, we’ve got smart people who know about this,” he said. “Political will, turf wars ought not to play a role when people’s lives are at stake.”

Other areas that still need to be addressed, he said, include sharing of real-time data, giving the U.S. Centers for Disease Control and Prevention the authority to require disease reporting beyond infectious diseases, and chain of command issues.  

“We’ve had a public health emergency every year in this country for almost 10 years and we still have not built an incident command system that works,” he said. “Is it the CDC, is it the FDA? We don’t know. And we tie CDC’s hands and then blame them when something goes wrong.”

Albrecht gives the nation a grade of C in overall preparedness, saying we haven’t made enough progress. 

“In one way, we’re in a good place because we are the U.S. and we have more technology and more money and more specialists. But we haven’t learned enough to be prepared for the next one,” he said. “To get to an A is probably too expensive, but I think we should be a B at least.”

Sweat says he’d give the technology and science sectors an A in terms of readiness, but the nation overall gets a C-plus.

Surveillance of circulating pathogens has become more difficult because of at-home testing so case count data isn’t as accurate, and genetic sequencing of the virus isn’t being done as much as it should be, he said.

“It’s a weak area,” he said. “Even here in the U.S., the picking up of variants is dropping off. We’re flying in the dark a little bit.”

Also, animal surveillance needs to step up because the virus, already found in about 40 percent of white-tailed deer, among other creatures, can mutate in animals and cross back over to people, he said.

Traxler gives South Carolina’s preparedness a B-minus.

“We’ve learned a tremendous amount. We have made significant strides,” she said in December. “My goal is for us to be an A within the next six months, and we are on target for that.”

The Biden Administration last October released a National Biodefense Strategy, which calls for a variety of efforts to protect against bioterrorism, a laboratory leak, or another pandemic.

But a review of the report by the Commonwealth Fund Commission on a National Public Health System published in the Journal of the American Medical Association concludes that while some of the strategies outlined are “essential to detect and stop diseases in their tracks worldwide,” it falls short of recommending ways to bolster public health.

Major investments are needed to modernize public health systems, the commission said, and the workforce should be enhanced across all sectors, including epidemiologists, outreach workers and communications experts.

“The Covid-19 pandemic brought a surge of funding to public health agencies. But without regular, sustainable funding — what experts have estimated to be about $4.5 billion each year — it is often impossible to create permanent positions,” the commission wrote. “Reliable readiness for emergencies should be built on the foundation of excellent day-to-day public health work.” 

Traxler said the state contracted for an after-action review of DHEC’s pandemic efforts and is working on a plan to improve readiness that will have measurable objectives.

DHEC recently got a five-year CDC grant for infrastructure improvement and workforce development, she said. It will include building workforce pipelines with industry and schools, she said, and tuition reimbursement in return for service to address the nursing shortage, which worsened during the pandemic, she said. 

There’s also a data modernization initiative, she said. 

“Plenty of people knew during the pandemic that we could not provide the data or statistics we wanted to,” she said. “It came down to systems talking to each other. Our vaccine registry can’t talk to our case database. And it was never designed to handle millions of cases like with Covid. Some of this will go to make sure we have the IT personnel support, even more to modernizing data systems.”

That project will also streamline data sharing with CDC, which is modernizing its systems as well, Traxler said.

DHEC also plans to expand a community health worker program that uses trained lay people to communicate with the public, for instance, about the importance of vaccines, she said.  

And DHEC is developing a respiratory pandemic plan for the next outbreak that’s more generic than the flu plan already in effect, she said. 

“We assumed we knew how the virus was spread, that we already had testing in place and plenty of it, and that we had the basics for a vaccine to be produced very quickly. Those things weren’t true for Covid,” she said. “We need a flexible plan … as part of the state’s emergency response.”

Overall, Benjamin said, the nation has “learned a lot about what not to do for sure.” 

Nuzum says the U.S. will eventually learn from the pandemic and make changes. 

“But I don’t think it will be immediate,” she said. “The effects of Covid will be felt for generations to come.”