[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]



 
                            THE NEW NORMAL:
                     PREPARING FOR AND ADAPTING TO
                       THE NEXT PHASE OF COVID	19

=======================================================================

                                     
                                     

                                HEARING

                               BEFORE THE

                     SUBCOMMITTEE ON INVESTIGATIONS
                             AND OVERSIGHT

                                 OF THE

                      COMMITTEE ON SCIENCE, SPACE,
                             AND TECHNOLOGY

                                 OF THE

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 31, 2022

                               __________

                           Serial No. 117-51

                               __________

 Printed for the use of the Committee on Science, Space, and Technology

                                     
                                     
                                     
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]   
 
 
 

       Available via the World Wide Web: http://science.house.gov
       
       
                        ______                       


             U.S. GOVERNMENT PUBLISHING OFFICE 
47-330 PDF           WASHINGTON : 2022 
        
       
       
       

              COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY

             HON. EDDIE BERNICE JOHNSON, Texas, Chairwoman
ZOE LOFGREN, California              FRANK LUCAS, Oklahoma, 
SUZANNE BONAMICI, Oregon                 Ranking Member
AMI BERA, California                 MO BROOKS, Alabama
HALEY STEVENS, Michigan,             BILL POSEY, Florida
    Vice Chair                       RANDY WEBER, Texas
MIKIE SHERRILL, New Jersey           BRIAN BABIN, Texas
JAMAAL BOWMAN, New York              ANTHONY GONZALEZ, Ohio
MELANIE A. STANSBURY, New Mexico     MICHAEL WALTZ, Florida
BRAD SHERMAN, California             JAMES R. BAIRD, Indiana
ED PERLMUTTER, Colorado              DANIEL WEBSTER, Florida
JERRY McNERNEY, California           MIKE GARCIA, California
PAUL TONKO, New York                 STEPHANIE I. BICE, Oklahoma
BILL FOSTER, Illinois                YOUNG KIM, California
DONALD NORCROSS, New Jersey          RANDY FEENSTRA, Iowa
DON BEYER, Virginia                  JAKE LaTURNER, Kansas
CHARLIE CRIST, Florida               CARLOS A. GIMENEZ, Florida
SEAN CASTEN, Illinois                JAY OBERNOLTE, California
CONOR LAMB, Pennsylvania             PETER MEIJER, Michigan
DEBORAH ROSS, North Carolina         JAKE ELLZEY, TEXAS
GWEN MOORE, Wisconsin                MIKE CAREY, OHIO
DAN KILDEE, Michigan
SUSAN WILD, Pennsylvania
LIZZIE FLETCHER, Texas
                                 ------                                

              Subcommittee on Investigations and Oversight

                  HON. BILL FOSTER, Illinois, Chairman
ED PERLMUTTER, Colorado              JAY OBERNOLTE, California,
AMI BERA, California                   Ranking Member
GWEN MOORE, Wisconsin                STEPHANIE I. BICE, Oklahoma
SEAN CASTEN, Illinois                MIKE CAREY, OHIO
                         C  O  N  T  E  N  T  S
                         

                             March 31, 2022

                                                                   Page

Hearing Charter..................................................     2

                           Opening Statements

Statement by Representative Bill Foster, Chairman, Subcommittee 
  on Investigations and Oversight, Committee on Science, Space, 
  and Technology, U.S. House of Representatives..................     9
    Written Statement............................................    10

Statement by Representative Jay Obernolte, Ranking Member, 
  Subcommittee on Investigations and Oversight, Committee on 
  Science, Space, and Technology, U.S. House of Representatives..    11
    Written Statement............................................    13

Written statement by Representative Eddie Bernice Johnson, 
  Chairwoman, Committee on Science, Space, and Technology, U.S. 
  House of Representatives.......................................    14

                               Witnesses:

Dr. Ezekiel Emanuel, Vice Provost for Global Initiatives, Co-
  Director of the Healthcare Transformation Institute, and Levy 
  University Professor at the Perelman School of Medicine and The 
  Wharton School of the University of Pennsylvania
    Oral Statement...............................................    16
    Written Statement............................................    19

Ms. Karen Ayala, Executive Director, DuPage County Board of 
  Health
    Oral Statement...............................................    23
    Written Statement............................................    25

Dr. Lucy McBride, Practicing Primary Care Physician in 
  Washington, D.C.
    Oral Statement...............................................    32
    Written Statement............................................    34

Dr. Mariana Matus, CEO and Co-Founder, Biobot Analytics
    Oral Statement...............................................    48
    Written Statement............................................    50

Discussion.......................................................    62

              Appendix: Additional Material for the Record

Report submitted by Dr. Ezekiel Emanuel, Vice Provost for Global 
  Initiatives, Co-Director of the Healthcare Transformation 
  Institute, and Levy University Professor at the Perelman School 
  of Medicine and The Wharton School of the University of 
  Pennsylvania
    ``Getting to and Sustaining the Next Normal: A Roadmap for 
      Living with COVID'' (Executive Summary)....................    80

Letter submitted by the National Association of County and City 
  Health Officials (NACCHO)......................................    83


                            THE NEW NORMAL:



                     PREPARING FOR AND ADAPTING TO



                       THE NEXT PHASE OF COVID-19

                              ----------                              


                        THURSDAY, MARCH 31, 2022

                  House of Representatives,
      Subcommittee on Investigations and Oversight,
               Committee on Science, Space, and Technology,
                                                   Washington, D.C.

    The Subcommittee met, pursuant to notice, at 10:01 a.m., in 
room 2318 of the Rayburn House Office Building and via Zoom, 
Hon. Bill Foster [Chairman of the Subcommittee] presiding.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Chairman Foster. Well, the hearing will now come to order. 
And without objection, the Chair is authorized to declare 
recess at any time.
    Before I deliver my opening remarks, I wanted to note today 
that the Committee is meeting both in person and virtually. And 
I want to announce a couple of reminders to the Members about 
the conduct of this hearing. First, Members and staff who are 
attending in person may choose to be masked, but it is not a 
requirement. However, any individuals with symptoms, a positive 
test, or exposure to someone with COVID-19 should wear a mask 
while present.
    Members who are attending virtually should keep their video 
feed on as long as they are present in the hearing. Members who 
are--are responsible for their own microphones, and so please 
keep your microphones muted unless you are speaking. Finally, 
if Members have documents they wish to submit for the record, 
please email them to the Committee Clerk, whose email address 
was circulated prior to the meeting.
    Well, good morning, and welcome to our Members and to our 
panelists. Thank you for joining us for this hearing on 
preparing for the next phase of COVID-19. Over the past two 
years, this Subcommittee has held a number of hearings on the 
pandemic, often with an eye to how lessons learned can pave an 
easier path through health crises to come. But the current 
fight against COVID-19 looks far different than it did in March 
2020, and we must consistently evaluate how existing tools meet 
our needs as case counts ebb and flow.
    Fortunately, national COVID cases have been going down 
since the January omicron peak. And after a difficult winter, 
where the death rate has surpassed the rate during the delta 
surge, spring has arrived. Around the country, mask mandates 
have relaxed, schools have opened, and now I'm chairing this 
Subcommittee hearing in person for the first time in two years. 
But we learned from previous lulls that we cannot expect this 
period to last forever.
    Now is the time to invest in research and infrastructure 
that can detect the next pandemic variant as early as possible, 
determine what communities will be at high risk of surges, and 
implement protective measures and communication strategies to 
minimize incidence of severe and fatal infection.
    Our witnesses here today exemplify a broad umbrella of 
COVID preparedness and response. Today, we'll discuss the great 
strides that have been made in vaccines and therapeutics to 
prevent and treat COVID-19 and what more research must be done 
to ensure a robust response to future variants. We'll talk 
about public receptiveness to behavioral mitigation measures 
and how these tools can be scaled up or eased back based on the 
best available information. We'll unpack what goes into that 
information, what metrics must be--we must get better at 
collecting, and how we can most effectively analyze these 
metrics to determine the relative risk in our communities. And 
we'll discuss how that information is best communicated at the 
individual level, to ensure that people are empowered with the 
facts and tools that they need to protect themselves and their 
families.
    Entering a new phase of the pandemic does not mean we've 
declared victory over the virus, nor does it mean that we are 
resigning ourselves to a never-ending state of crisis. The 
landscape has changed immensely in the past two years, and that 
is a testament to the incredible research that's been done on 
how the virus and how we behave.
    Unfortunately, as public health guidance shifts to 
incorporate new information, it's all too often interpreted as 
being flaky or unreliable. Changing recommendations regarding 
mask-wearing are looked at with skepticism, and research on 
vaccine efficacy in the face of new variants causes everything 
from cynicism to panic.
    I am often struck by how navigating through this crisis 
resembles the job of an ancient sea captain. A captain should 
not be criticized for changing course as the wind shifts, but 
any captain who deliberately ignores signals of an approaching 
storm has no place at the helm. Today's fair weather may 
indicate the end of the storm, or we may be simply passing 
through the eye of the cyclone. And a captain will receive 
advice from everyone from the grizzled old salts who have 
survived many stormy passages, to young seamen terrified of 
stories of sea monsters and falling off the edge of the Earth. 
And that was even before social media. And the captain must 
also answer both to his investor's desire to get the cargo to 
market on time, and to the mothers and children of every person 
onboard.
    But in the end, what has made sea travel far safer today 
has been science: the tools of navigation, weather forecasting, 
ship construction, understanding and treating the chronic 
vitamin C deficiencies of his crew, and maintaining a proper 
written record of lessons learned.
    And we've learned so much about this virus that reached our 
shores two years ago, but if this knowledge is not thoughtfully 
communicated to the public, misinformation will fill in the 
gaps. It's unlikely that we've seen the last surge of COVID-19. 
And the good news is that we are more prepared than ever to 
confront what comes. We must seize the opportunity to build 
upon what we've learned. It's imperative that we continue to 
invest in data tracking and communication capabilities at every 
level, and to ensure public health decisionmakers have the best 
information to make recommendations. Misinformation must be 
confronted thoughtfully and aggressively.
    Outstanding questions on issues such as long COVID, 
infection-based immunity, and therapeutic cocktails should be 
aggressively pursued by scaling up clinical studies. And while 
we may not be out of the woods yet, we have the opportunity to 
meet future COVID surges with clearer eyes and stronger tools.
    So I look forward to the hearing today from our witnesses, 
and learning about how we can bolster preparedness efforts in 
the next phase of the COVID-19 pandemic.
    [The prepared statement of Chairman Foster follows:]

    Good morning, and welcome to our members and our panelists. 
Thank you for joining us for this hearing on preparing for the 
next phase of COVID-19. Over the past two years, this 
Subcommittee has held a number of hearings on the pandemic, 
often with an eye to how lessons learned now can pave an easier 
path through health crises to come. But the current fight 
against COVID-19 looks far different than it did in March 2020, 
and we must constantly evaluate how existing tools can meet our 
needs as case counts ebb and flow.
    Fortunately, national COVID cases have been going down 
since the January omicron peak. After a difficult winter, where 
the death rate has surpassed the rate during the delta surge, 
spring has arrived.
    Around the country, mask mandates have relaxed, schools 
have opened, and now I'm chairing this subcommittee hearing in 
person for the first time in two years. But we learned from 
previous lulls that we cannot expect this period to last 
forever. Now is the time to invest in research and 
infrastructure that can detect the next problematic variant as 
early as possible, determine what communities will be at high 
risk of surges, and implement protective measures and 
communication strategies to minimize incidence of severe and 
fatal infection.
    Our witnesses here today exemplify the broad umbrella of 
COVID preparedness and response. Today we'll discuss the great 
strides that have been made in vaccines and therapeutics to 
prevent and treat COVID-19, and what more research must be done 
to ensure a robust response to future variants.
    We'll talk about public receptiveness to behavioral 
mitigation measures, and how these tools can be scaled up and 
eased back based on the best available information.
    We'll unpack what goes into that information--what metrics 
we must get better at collecting, and how we can most 
effectively analyze these metrics to determine relative risk 
level in our communities. And we'll discuss how that 
information is best communicated at the individual level, to 
ensure that people are empowered with the facts and tools they 
need to protect themselves and their families.
    Entering a new phase of the pandemic does not mean we've 
declared victory over the virus, nor does it mean we are 
resigning ourselves to a never-ending state of crisis.
    The landscape has changed immensely in the past two years, 
and that is a testament to the incredible research that has 
been done into how the virus--and we--behave. Unfortunately, as 
public health guidance shifts to incorporate new information, 
it's all too often interpreted as being flaky and unreliable.
    Changing recommendations regarding mask-wearing are looked 
at with skepticism, and research on vaccine efficacy in the 
face of new variants causes everything from cynicism to panic.
    I am often struck by how navigating through this crisis 
resembles the job of an ancient sea captain. A Captain should 
not be criticized for changing course as the wind shifts, but 
one who deliberately ignores signals of an approaching storm 
deserves no place at the helm. Today's fair weather may 
indicate the end of the storm, or we may simply be passing 
through the eye of the cyclone.
    A captain will receive the advice of everyone from the 
grizzled old salts who have survived many stormy passages, to 
young seamen terrified of stories of sea monsters and falling 
off the edge of the flat earth.
    And the captain must answer both to his investor's desire 
to get their cargo to market on time, and to the mothers and 
children of every person aboard.
    But in the end, what has made sea travel much safer today 
has been science: the tools of navigation, weather forecasting, 
ship construction, understanding and treating the chronic 
Vitamin-C deficiencies of his crew and maintaining a proper 
written record of lessons learned.
    We've learned so much about this virus that reached our 
shores just two years ago, but if this knowledge is not 
thoughtfully communicated to the public, misinformation will 
fill in the gaps.
    It is unlikely that we've seen the last surge of COVID-19. 
The good news is that we are more prepared than ever to 
confront what comes. We must seize the opportunity to build 
upon what we've learned. It is imperative that we continue to 
invest in data tracking and communication capabilities at every 
level, to ensure public health decision makers have the best 
available information to make recommendations. Misinformation 
must be confronted thoughtfully and aggressively.
    Outstanding questions on issues such as long COVID, 
infection-based immunity, and therapeutics cocktails should be 
aggressively pursued by scaling up clinical studies.
    We may not be out of the woods yet, but we have an 
opportunity to meet a future COVID surge with clearer eyes and 
stronger tools.
    I look forward to hearing from our witnesses today about 
how we can bolster preparedness efforts in the next phase of 
the COVID-19 pandemic.
    I now yield to Ranking Member Obernolte for his remarks.

    Chairman Foster. And I now yield to Ranking Member 
Obernolte for his remarks.
    Mr. Obernolte. Well, thank you very much, Captain Foster.
    Chairman Foster. Aye, aye.
    Mr. Obernolte. And thank you to the Chair for convening 
what as usual is a very timely and I'm sure will be a very 
informative hearing.
    You know, it's--we're here in the Science, Space, and 
Technology Committee, and I think it's, you know, a very timely 
discussion to have to think about the application of science to 
fighting the spread of COVID and to reflect on the lessons that 
we've learned over the past couple of years because, as the 
Chair said, this is not something that's over and done with. 
It's something that we're going to be dealing with for many 
years. And it also is something that we have to learn from 
because this--you know, we would hope that this would be the 
last pandemic the world experiences, but history shows that 
it's probably not going to be. And we certainly would be doing 
society a disservice if we did not apply the lessons that we've 
learned here.
    So I'll tell you a couple of things that I'm looking 
forward to talking about in this hearing. First of all, I think 
that we need to be more holistic about considering what our 
goals are when we institute public health measures in response 
to a pandemic because it seems pretty clear looking at what has 
happened with COVID that focusing on merely containment is 
probably not the right thing to do. Containment proved to be 
impossible with many of the variants of COVID. The countries 
that were the most draconian in trying to contain rather than 
trying to manage the spread of the virus are some of the ones 
that did the worst in terms of healthcare outcomes. So I look 
forward to having that discussion.
    And I also think it's time that we acknowledge the fact 
that when we are contemplating what to do to mitigate the 
spread, that we contemplate all of the societal costs that are 
borne, not just the health costs, and that's something that we 
kind of learned to our more misfortune through the recent 
pandemic is that we've got a lot of societal costs that public 
health officials were not considering when they made some of 
these decisions, for example, things like learning loss in 
children, for example things like behavioral health issues, 
things like substance abuse issues that occur when people are 
not allowed to socialize with each other, and certainly the 
economic costs that are imposed on society by actions like 
lockdowns.
    Not to say that any of those are more important than 
stopping the spread of a variant, but we would be foolish not 
to consider the fact that the actions that we take as a 
government do have societal consequences. And I think that 
we've determined kind of through this process that making these 
decisions is more complex, that we have to kind of weigh all of 
these different factors. And although it is difficult to 
balance something like an economic cost against lives lost, we 
have to somehow parse that metric.
    And to something that the Chairman just mentioned, 
communication I think is something that we've learned is much 
more important than we ever thought it was. The words that we 
use when we communicate with the public about the science of an 
epidemic are critically important and the fact that we need to 
maintain the public's trust. In many cases I think that we 
were--we had kind of a scientific arrogance in our 
communication with our public over the last couple of years, 
and that's something that we need to avoid in the future 
because only through being transparent and honest with the 
public can we get them to trust us when we tell them that a 
certain action is the best thing for society.
    We certainly can't hide things like uncertainty and tell 
people that this is the right thing and then tomorrow tell them 
that the science has shifted and something else is now the 
right thing to do. That's going to shatter their trust. We need 
to be upfront and honest with them when uncertainty exists.
    And then lastly--and I'm--I don't think any of our 
witnesses today would have the sand to tell us this, but, you 
know, we as public leaders, I think we need to learn by 
example, and that's something that we've learned to our 
misfortune over the last couple of years. The words that we use 
are very important, and the actions that we take are very 
important. And I think that events in my home State of 
California and States around the country have proven that when 
public officials are caught not following their own guidance, 
that is incredibly destructive to public trust. So that's 
something I think we need to keep in mind as we not only go 
through this hearing but as we contemplate the way to handle 
epidemics in the future.
    So, Mr. Chairman, I'm looking forward to the hearing with 
you and looking forward to see what our witnesses have to say. 
I yield back.
    [The prepared statement of Mr. Obernolte follows:]

    Good morning. Thank you, Chairman Foster, for convening 
this hearing. And thanks to our witnesses for appearing before 
us today.
    We are here today to discuss ``the New Normal'' and how we 
can best prepare for and adapt to the next phase of COVID-19 
and beyond. I'm glad that we're here today looking forward at 
what's to come, and I believe to be successful we need to 
examine what worked and what didn't over the past two years of 
this pandemic. I think we can all agree that the government's 
response hasn't been perfect. So we need to consider what 
lessons we've learned so that we can avoid making similar 
mistakes in the future.
    First and foremost, to establish a ``new normal'' we need 
to set specific goals for combating COVID-19 to guide the 
implementation of reasonable policies. We can't expect zero 
transmission, so we need commonsense policies that not only 
protect the most vulnerable, but also allow our schools, 
workplaces, and business to return to normal operating status 
as quickly as possible. Containing the virus must be a 
priority, but so is avoiding additional long- term 
consequences, like those being reported in children from mask 
mandates.
    Second, we need public health officials to clearly 
communicate these goals and policies so that Americans know 
what to expect as we move forward. I can't emphasize this 
enough.
    Americans were told to ``trust the science'' but the 
science wasn't being fully and clearly communicated. That led 
to a lot of mistrust and vaccine hesitancy. So we must clearly 
communicate up front what we do and don't yet know about the 
virus itself. And we need to give people the facts on the 
various mitigation measures that are being proposed. Public 
health leaders and the CDC (Centers for Disease Control and 
Prevention) must also avoid missteps of the past two years. 
They should not withhold data from the public due to fear that 
such data could be misinterpreted. This only serves to erode 
trust and create a perception that the government is hiding 
something. Public health decisions aren't based on medical 
factors alone--they must take into account other factors 
including social, economic, or other risks. That should be 
communicated. Only through clear and concise communication 
about what is known, what is unknown, and what is changing can 
we hope to restore Americans' trust in the public health 
apparatus.
    Additionally, we need to look at past COVID relief funding 
to inform future appropriations. There is no doubt that more 
funding is needed for testing, vaccines, therapeutics, and the 
infrastructure necessary to allocate each where it is needed. 
Moving forward, however, we absolutely must be more responsible 
with hard-earned taxpayer dollars, especially given the high 
rate of inflation. This means investing in areas where we can 
get the most bang for our buck. For example, rather than 
blanket handouts to states for things like luxury high-rise 
hotels and minor league baseball stadiums, future COVID relief 
funding should be measured and targeted to ensure that those at 
high risk and our most vulnerable populations get the vaccines, 
treatments, and testing that they need. Indiscriminately 
throwing money at the problem is not a solution-it just creates 
further problems.
    We also need to take a good hard look at various health 
issues that have taken a backseat to COVID-19 during the 
pandemic. We should examine the adverse health consequences- 
physical, social, and mental-that have either cropped up during 
or been exacerbated by our response to COVID over the past two 
years. We are just beginning to see the tip of the iceberg in 
terms of looming mental health challenges, developmental issues 
in young children, and other adverse consequences of COVID-19 
beyond the disease itself. These challenges cannot remain 
unaddressed.
    Finally, we in Congress should lead by example. I'm 
disappointed but not at all surprised that earlier this week 
the Speaker extended the ``covered period,'' allowing remote 
committee proceedings and vote-by-proxy to continue in the 
House until at least May 2022. This was done under auspices of 
a public health ``emergency,'' making the ``new normal'' look 
more and more like the old normal. What's the justification for 
this when our kids are back in school?
    How can we in good faith ask Americans throughout the 
country, in both the private sector and Federal workforce, to 
get back to work when the House refuses to do the same? How can 
we ask the American public to adhere to public health guidance 
and mitigation measures, and to follow CDC recommendations, 
when the Speaker isn't doing that? Throughout the pandemic, 
we've seen far too many examples of ``rules for thee but not 
for me.'' As we move forward to the ``new normal,``public 
leaders must lead by example and adhere to the same rules that 
they expect the American people to follow. This, too, would go 
a long way in restoring Americans' trust in their public health 
officials and elected leaders.
    In closing, we can't move into the new normal without 
reestablishing trust with the American people. We do that by 
establishing specific goals for public health, by clearly 
communicating and empowering Americans to make informed 
decisions about their own health; by spending judiciously, and 
by returning to normal here in Congress. We represent the 
American public here in the House, and we should trust our 
constituents to do what is needed to overcome this pandemic. If 
we do this, just maybe we can begin to reestablish Americans' 
trust in our public health apparatus. If we don't, I'm afraid 
the new normal may be nothing more than the old normal. And 
that is unacceptable.
    Thank you, Chairman Foster, for convening this hearing. And 
thanks again to our witnesses for appearing before us today. I 
look forward to our discussion.
    I yield back the balance of my time.

    Chairman Foster. Thank you. And if there are Members who 
wish to submit additional opening statements, your statements 
will be added to the record at this point.
     [The prepared statement of Chairwoman Johnson follows:]

    Thank you Chairman Foster for holding this hearing, and 
thank you to all of our esteemed witnesses for appearing before 
the Subcommittee today. The fight against COVID-19 today looks 
much different than it did in March 2020. That progress is 
thanks to the tireless healthcare workers, researchers, public 
health officials, and citizens everywhere working to protect 
their families and communities. We must continue to build on 
our successes and learn from the hardships of the last two 
years. Today's witnesses bring a wealth of experience from many 
facets of pandemic response. I am looking forward to their 
testimonies on how we can best prepare ourselves for the next 
phase of COVID-19.
    As we've discussed before on this Committee, this is a 
global battle. It will not be solved anywhere until progress is 
made everywhere. So long as low- and middle-income countries 
remain under-vaccinated, the virus will continue to circulate 
and mutate. Surveillance of emerging variants requires strong 
international research partnerships, so our world-class 
scientists can offer their expertise and get real-time 
information about variants emerging abroad.
    On a national level, we must position our public health 
authorities to receive and share timely, good quality data. To 
get reliable projections of COVID surges, we need a wealth of 
data. We need to know the test positivity rates, which gets 
more difficult as take-home tests become more common than PCR 
tests. We need insight into how immunized a population is, 
whether their immunization comes from vaccines, natural 
infection, or a combination. We need to know whether hospital 
systems are overwhelmed by dwindling capacity or worker 
shortages. Public health communication is a two-way street. 
Bolstering communication among individuals, healthcare 
facilities, and public health officials will be imperative to 
detect COVID surges early and equip our communities with the 
tools they need.
    So much of the fight happens in the last mile. We've made 
such great strides in answering the grand scientific questions 
of how this virus spreads and kills. And how vaccines and 
therapeutics can save lives. We must also focus on translating 
knowledge to health outcomes. We need more research into how 
misinformation can derail effective public health 
communication, and how we can deliver accurate information to 
counteract these lies. We need to be thoughtful about reaching 
those who remain unvaccinated. We need to learn from past COVID 
surges when it comes to how we implement personal protective 
measures. Researching these issues can help us overcome future 
hurdles in public health messaging.
    It is tragic that we are still battling this virus more 
than two years after it reached the U.S. But it is truly 
remarkable to reflect on the progress that has been made. We 
can now face the next phase of the pandemic building upon the 
knowledge and the infrastructure we've put in place since March 
2020. I thank our witnesses for joining us today and I yield 
back.

    Chairman Foster.  And at this time I'd like to introduce 
our witnesses. Four old salts who have weathered many stormy 
passages. Our first witness is Dr. Ezekiel Emanuel. Dr. Emanuel 
is the Levy University Professor at the Perelman School of 
Medicine at the University of Pennsylvania. He's an oncologist, 
a world leader in health policy and bioethics, and has authored 
or edited over 350 publications and 15 books. Dr. Emanuel is 
currently Special Advisor to the Director General of the World 
Health Organization. He previously served as the founding Chair 
of the Department of Bioethics at the NIH (National Institutes 
of Health) and as a Special Advisor on Health Policy to OMB 
(Office of Management and Budget) and the National Economic 
Council.
    And I will now yield to Mr. Casten to introduce his 
constituent and our next witness.
    Mr. Casten. Thank you, Mr. Chairman. You are not only the 
master of your fate, you are the captain of your soul. It is--
we're going to push this all hearing.
    I'm so grateful and honored to introduce my good friend and 
Illinois Sixth District community health champion and expert 
Dr. Karen Ayala. Dr. Ayala serves as the Executive Director 
with the DuPage County Health Department. Prior to that role, 
she served as the Director of Community Health and Public 
Health Services since 2007. Throughout her career, Dr. Ayala 
has worked in community services and public health, bringing a 
strong commitment to social justice and a creative approach to 
system design.
    I'm particularly proud that Dr. Ayala was responsible for 
the opening and management of a mass testing and vaccination 
facility in the district that allowed DuPage County to be one 
of the most successful examples in the country of why high 
vaccination rates could mean a quicker return to normal for 
businesses and students.
    Just as a personal note, I am--I cannot tell you how 
grateful I am for all your great work, Dr. Ayala. The--you 
know, those moments through the crisis when we had uncertainty 
about the status of the disease, uncertainty about how supplies 
of testing and vaccines were going to be allocated from the 
feds to the States, from the States of the counties, learning 
the science as we went, and of course the growing 
politicization of that and all the slings and arrows that were 
thrown in directions of anybody, including you. You were just 
consistently such a rock and a beacon of strength and you made 
us all look better and I know you made our constituents all 
feel like they were in good hands.
    So thank you, Dr. Ayala, for your service to our State, to 
our country, and I look forward to hearing your testimony.
    Chairman Foster. Thank you. And following Ms. Ayala, our 
next witness is Dr. Lucy McBride. Dr. McBride has worked on--as 
an internal medicine physician in Washington, D.C., for nearly 
two decades. She is also a prominent healthcare educator, 
mental health advocate, and author of a COVID-19 newsletter, as 
well as articles published in The Washington Post, The 
Atlantic, and USA Today. Dr. McBride's work aims to increase 
the awareness of the inseparability of mental health and 
physical health.
    Our final witness is Dr. Mariana Matus. Dr. Matus is a 
computational biologist by training and the CEO (Chief 
Executive Officer) and Co-Founder of Biobot Analytics. Biobot 
won multiple entrepreneurship competitions at MIT 
(Massachusetts Institute of Technology) for its wastewater 
epidemiology platform. The subject initially used its platform 
to track opioid usage patterns before pivoting to COVID-19 
detection at the beginning of the pandemic. They were selected 
by HHS (Health and Human Services) to execute a national COVID-
19 wastewater monitoring project and have expanded their 
platform to analyze wastewater treatment plants across the 
Nation for early warning signs of new COVID outbreaks and 
variants.
    As our witnesses should know, each of you will have five 
minutes for your spoken testimony. Your written testimony will 
be included in its entirety in the record of the hearing. When 
you've all completed your spoken testimony, we will begin with 
questions. Each Member will have five question--five minutes to 
question the panel, and we will attempt, if time permits, to 
have two rounds of questions.
    And we will start with Dr. Emanuel.

               TESTIMONY OF DR. EZEKIEL EMANUEL,

              VICE PROVOST FOR GLOBAL INITIATIVES,

                 CO-DIRECTOR OF THE HEALTHCARE

                   TRANSFORMATION INSTITUTE,

                 AND LEVY UNIVERSITY PROFESSOR

               AT THE PERELMAN SCHOOL OF MEDICINE

                     AND THE WHARTON SCHOOL

               OF THE UNIVERSITY OF PENNSYLVANIA

    Dr. Emanuel. Chairman Foster, Ranking Member Obernolte, 
thank you for having me. It's a privilege to be before this 
Committee at this critical juncture for COVID response in our 
country.
    As you know, this month marks 2 years since our first surge 
and our first lockdown in the country. We've experienced almost 
1 million deaths, 80 million cases, tens of millions of 
students whose learning has been affected, and hundreds of 
millions of Americans who have suffered socially and 
economically because of this pandemic.
    At this moment, we are at a critical juncture, as I 
mentioned. We need to confront the situation with some 
humility. We're certainly going to have another surge. How bad 
it is, no one here in the room knows. We know that we're going 
to confront some waning immunity from the vaccines. We are 
going to confront some resistance from the virus to some of our 
interventions. How bad all of these things are, we don't know. 
The only way to stay ahead of SARS-CoV-2 virus and to get a 
handle and to go into the next normal smoothly is to scale up 
our physical, our virtual, and our human infrastructure to 
combat this.
    As human beings, as a society, we are bad at prevention. 
Prevention does something in the future. It requires investing 
today for a return tomorrow, and we're not constitutionally by 
nature good at that. We always underinvest in prevention. There 
are loads of data about how individually we do that and how 
socially we do that. But we can't do that going forward.
    Over the last few months, I've convened 25 of the country's 
leading experts on COVID to create a strategic roadmap for the 
country. I've submitted that roadmap as written testimony. I 
want to highlight six points from it.
    First, we need a viral dashboard to follow to determine 
when we need to impose public health measures, when we can 
relieve them safely, how to go forward, and when we're going to 
be in the next normal. That dashboard has to include at least 
five critical items: vaccination rates, seroprevalence of the 
virus--of immunity in the community, wastewater testing--and 
you'll hear about that from others--the health system stretch, 
how close to the peak we are, and of course death rates in the 
community. All of those need to be looked at.
    Truth be told, we're not there yet in measuring these five 
elements. We need a surveillance infrastructure that is 
bolstered up to measure four important things on a continuous 
basis: The wastewater in this country, we need standardization 
of that wastewater. We need it for more communities than we 
have it. We need to measure population immunity, which we don't 
do a good job of. We need to measure genetic variants. We don't 
do a good job of that. And we need to measure animal 
reservoirs, zoonotic surveillance, and we need to have a 
platform and have that data available in real-time. We don't 
have that today. That is the second item.
    The third item is we need to invest in vaccines, right? Our 
scientific agencies need to rapidly prioritize different kinds 
of vaccines, mucosal vaccines, different pan-coronavirus 
vaccines. We need a heavy investment in that.
    Fourth, we need to invest in therapeutics. Yes, we have 
Evusheld today, we have Paxlovid, but they're not enough. Our 
virus becomes resistant to these things and will more and more 
as they come out in the community. So we need a heavy 
investment in therapeutics, especially oral therapeutics that 
people can take readily.
    Five, we need an investment in indoor air quality. It was 
good that OSTP (Office of Science and Technology Policy) 
yesterday had a major event--or Tuesday a major event on indoor 
air quality, a first recognition by the government of its 
importance. We need to standardize what good indoor air quality 
is and enforce it. We also need to use some of our rescue funds 
to get indoor air quality in schools and childcare centers up 
immediately using portable filters or improvements in the HVAC 
(heating, ventilation, and air conditioning) systems.
    Finally, we need an urgent, very rapid research into long 
COVID. The NIH and the CDC have not prioritized this. They have 
studies, for example, the NIH RECOVER study, but it's got an 
aim of 40,000 people and it's only enrolled 1,000 people to 
date. We need half a million people studied to get going.
    Let me just remind you, what I've said are investments in 
the future. They're investments in prevention. They are--should 
not be considered spending and wasteful spending. This is how 
we're going to prevent serious complications from the next 
surge or the next virus that comes along. Thank you very much.
    [The prepared statement of Dr. Emanuel follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
        
    Chairman Foster. Thank you. And next is Ms. Ayala.

                 TESTIMONY OF MS. KAREN AYALA,

       EXECUTIVE DIRECTOR, DuPAGE COUNTY BOARD OF HEALTH

    Ms. Ayala. Good morning, and thank you for this opportunity 
to share testimony and for the warm welcome.
    DuPage County Health Department is considered a large 
suburban local health department serving nearly 1 million 
residents in northeast Illinois. Incredibly, today marks the 
800th day on the frontlines of our local public health COVID 
response. Since January of 2020, we have based our local 
response on the best available public health data. What are the 
best data to communicate to our residents? As a local public 
health official who routinely interacts with residents, 
community leaders, healthcare partners, the best data are those 
that are locally and consistently available as near to real-
time as possible.
    Early on at the health department we invested in developing 
interactive dashboards and easy-to-use platforms for sharing 
information that was available within our county. Still, we 
know being able to describe and analyze detailed in-depth 
information about who is becoming affected and potential 
outcomes and opportunities for treatment is critical to allow 
us to intervene more effectively and strategically.
    Unfortunately, due to lingering data system and 
interoperability issues, we are yet to meaningfully respond to 
these reasonable expectations of our constituents. A new 
challenge around data infrastructure is related to the rapid 
rise in at-home tests in the absence of a robust reporting and 
surveillance system to capture these results and information 
about those testing positive. As a result, we once again risk 
creating ad hoc, uncoordinated, inefficient efforts that will 
ultimately limit our ability to analyze broader trends and 
waste precious resources in the absence of a coordinated 
effort.
    We request investments in electronic data-sharing practices 
across healthcare and Federal leadership to promote the 
development of data-sharing standards. Those are critical to 
our ability to collect, analyze, and report back to our 
communities in standardized ways.
    We have repeatedly learned that when communicating with the 
public, it is critical for public health agencies to be 
speaking in a coordinated fashion with one voice. While the 
CDC, the executive branch, and our other Federal agencies are 
responsible for formulating national guidelines across our 
response efforts, many of these announcements were made 
suddenly or unexpectedly. Local health officials were left in 
an avoidable position of scrambling to evaluate and develop 
local messaging that would assist our residents both to 
understand as well as to implement those guidelines. What is, 
after all, the value of even the most sound public health 
guidance if no one can explain what it means or how it applies 
to me? We must refocus our collective work to coordinate 
communication between local, State, and Federal agencies now in 
order to be better prepared for the next surge and the next 
public health emergency by rebuilding that structure.
    Finally, I'd like to highlight the need for sustained 
investment in local public health departments and the public 
health infrastructure to enable us to address the ongoing 
public health challenges that already existed, as well as to be 
prepared to respond to future emergencies. We know there is a 
huge chasm between the per capita spending for public health 
services when compared with spending for traditional healthcare 
services.
    Now is the time, however, I believe we can agree that our 
priorities for preventing severe disease, illness, and death 
can be and must be in closer alignment with the priority of 
simply treating those conditions through our funding decisions. 
Local public health departments need sustained, predictable 
disease-agnostic funding that can be used to support poor 
public health infrastructure activities upon which disease-
specific funding can build when the situation and the need 
further arises. Investing in these core public health 
capabilities will strengthen and support all the work done by 
local health departments, and it will also assure more 
effective use of all healthcare resources.
    Thank you so much to Chairman Foster, to Congressman 
Casten, and all of the other esteemed Committee Members for the 
opportunity to share my perspective and for your work to ensure 
that we are better prepared tomorrow to protect the health, 
safety, and security of our residents.
    [The prepared statement of Ms. Ayala follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    Chairman Foster. Thank you. And after Ms. Ayala is Dr. 
McBride.

                 TESTIMONY OF DR. LUCY McBRIDE,

     PRACTICING PRIMARY CARE PHYSICIAN IN WASHINGTON, D.C.

    Dr. McBride. Good morning, and thank you to Chairs Johnson 
and Foster and Ranking Members Lucas and Obernolte for inviting 
me today. My name is Lucy McBride. I'm a practicing primary 
care doctor here in Washington, D.C. I've been practicing for 
over 20 years. I see patients from teenagers to 90-year-olds, 
and I've dedicated my life and my career to helping people 
understand the inseparability of mental and physical health.
    As we inevitably face more COVID waves and variants, I 
worry about the ongoing devastation from the virus itself and 
about the collateral damage from the mitigations. But perhaps 
most of all I worry about the ongoing confusion and anxiety 
from not knowing--for people not knowing who to trust in a 
global health crisis.
    I'm not here today with any political agenda but rather to 
share with you what I've learned firsthand caring for patients 
almost every day during COVID, patients who are real people on 
the receiving end of often confusing guidance and the 
unfortunate politicization of science.
    In patient care, trust is the glue. To help patients manage 
everything from mental and behavioral health to end-of-life 
care, I first have to establish a relationship and a rapport. 
But unfortunately, trust in medicine and public health hangs in 
the balance, as is our ability to help people get the 
information and services they need because we have not 
appropriately acknowledged uncertainty and we've lost sight of 
what I see is the four fundamental pandemic truths: No. 1, the 
effectiveness of the extraordinary vaccines; No. 2, the 
sophistication of the human immune system; three, the ability 
of patients and the public to understand nuance; and four, the 
complexity of human behavior.
    I'll give you some examples of how trust has been 
threatened. The mixed messaging around school safety, booster 
shots, masks, and infection-acquired immunity has inadvertently 
sparked confusion, fear, and vaccine hesitancy. We've scared 
parents by suggesting that schools are inherently unsafe. We've 
terrified vaccinated folks about breakthroughs when the primary 
three-shot series continues to hold up beautifully against 
death and hospitalization for most people. We've alienated 
recovered patients by not validating their prior immunity until 
recently. And we've accelerated mask culture wars by not 
adequately explaining the difference between a mask mandate and 
the benefits to an individual of one-way masking when they need 
added protection. We should have more appropriately 
acknowledged the realities of the vaccines, of the immune 
system, and of human beings' ability to live in a constant 
state of emergency to better manage people's expectations and 
to build trust. People are more likely to take in information 
and follow guidance when the advice is nuanced, when it's not 
rooted in fear, and we don't moralize human behavior, also when 
we communicate uncertainty with humility and candor and provide 
reassurance when appropriate.
    Just to be clear, I don't blame the CDC or any one person 
or political party for these challenges. Had our prior 
President, for example, messaged vaccine competence, we could 
have saved countless lives. But when we don't talk straight 
with the American public and when people lack a trusted guide, 
the vacuum of trust gets filled with the cacophony of political 
opportunism, lots of media opinions, and celebrities and 
internet influencers. And that's exactly what's happened. I see 
the effects every day in my patients.
    So how do we build back trust? First, we must acknowledge 
our past mistakes and abandon mitigations whose harms outweigh 
the benefits like school closures, mask mandates, and 
asymptomatic testing in schools.
    Second, we must be honest about ongoing uncertainties about 
COVID like about long COVID, while reassuring people about how 
well the vaccines and therapeutics drop the risk of serious 
outcomes.
    Third, we need to ramp up public health measures that we 
know work from ventilating public buildings and scaling up 
outpatient treatments to legislating paid sick leave. We must 
surge resources like vaccines and rapid tests to our most 
vulnerable populations.
    And last, we must arm people with the tools and guidance 
they need to manage the future variants and a myriad other 
health issues that are--that plagued us before the pandemic and 
that only got worse during COVID, specifically the epidemics of 
obesity, substance use disorders, and the worsening mental 
health crisis, particularly among young people.
    To that end, we must allow every American unfettered access 
to a primary care hub with integrated behavioral and mental 
health services. We should heavily invest in school-based 
health centers, starting with marginalized communities to meet 
teens and kids where they are, exactly like the ones run by my 
pediatrician friend Dr. Ana Caskin here in D.C., clinics that 
are annexed to those high schools that serve our highest-risk 
teens.
    Primary care providers specialize in building trust and 
rapport. We get the medical vulnerabilities of our unique 
patients. We get their biases and beliefs. We understand their 
unique resources and risk tolerance. Being human is risky. 
Eliminating risk is impossible. It is the job of public health 
and primary care to help people manage the everyday risk they 
inevitably face.
    COVID is here to stay, and we are not done. We'll never be 
done protecting the most vulnerable. We must give people a 
place to go, someone to trust. By investing in primary care, 
we're investing in people, and that is the workplace of trust. 
Thank you very much.
    [The prepared statement of Dr. McBride follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
        
    Chairman Foster. Well, thank you. And next is Dr. Matus.

                TESTIMONY OF DR. MARIANA MATUS,

              CEO AND CO-FOUNDER, BIOBOT ANALYTICS

    Dr. Matus. Good morning, Chairman Foster and Ranking Member 
Obernolte. I am Mariana Matus. I'm the CEO and Co-Founder of 
Biobot Analytics, a wastewater epidemiology company based in 
Cambridge, Massachusetts. It is an honor to testify before you 
today about how wastewater epidemiology can help the United 
States and the world better manage the next phase of the COVID-
19 pandemic.
    Biobot was founded in 2017 with a mission to transform 
wastewater into actionable public health data. Just yesterday, 
we had the honor of being recognized as one of the most 
influential companies of 2022 by Time magazine for our novel 
approach to COVID-19 tracking. Everything we eat, the 
infectious pathogens in our bodies, and the medicines we use 
are all excreted in our urine and stool and end up in the 
wastewater. Biobot collects this data in order to understand 
population health trends.
    In March 2020, our team was the first in the United States 
to successfully report the detection and quantification of 
SARS-CoV-2 in the wastewater. To date, we have tested samples 
from more than 700 communities across all 50 States, including 
U.S. territories and tribal nations, helping local officials 
track the spread of the virus, as well as variants of concern. 
In fact, our work includes analysis from wastewater from almost 
every congressional district represented by this Subcommittee.
    Wastewater data is a leading indicator of new COVID-19 
cases because infected individuals shed the virus in their 
waste several days before they develop symptoms. And this type 
of monitoring is holistic and it's equitable. It captures 
anyone who uses the bathroom, including people who are 
asymptomatic or lack access to healthcare. This means that 
wastewater data allows us to better understand the presence of 
COVID, regardless of socioeconomic status or racial 
composition.
    Another advantage is that it preserves individual privacy 
as wastewater represents an aggregate sample of all human waste 
in a community. One sample drawn from a wastewater treatment 
plant is representative of tens of thousands of people, and 
testing wastewater is much cheaper than the alternative of 
testing each of those persons individually.
    At this stage of the pandemic, we are witnessing fewer 
reported COVID-19 cases because at-home antigen tests are now 
widely available, and vaccination has boosted the population's 
immunity. As a result, clinical testing data has become less 
reliable, and public health officials are forced to rely on 
lagging indicators of the disease such as hospitalizations and 
deaths.
    That is why we believe wastewater monitoring will play an 
even more important role in containing the spread of the virus 
as life returns to the new normal. Our work in Massachusetts 
has already demonstrated how powerful this data can be to 
inform decisionmaking. Our data is public. From Governor Baker 
receiving weekly briefings on wastewater data, to a Chief 
Medical Officer at Boston Children's Hospital, down to me as a 
new mom to a baby, we all review these data to determine how to 
manage our little piece of the world.
    To help facilitate the adoption of this new type of data, 
Biobot recommends Congress and the Administration take the 
following steps: First, assist States and localities who have 
started their own wastewater monitoring programs through 
consistent funding. Second, empower relevant Federal agencies 
to support wastewater monitoring efforts across the country, 
especially by standardizing testing and data collection 
methods. Third, align Federal support behind wastewater as a 
pathogen-agnostic technology that can monitor for many 
different public health threats beyond COVID-19, for example, 
the seasonal influenza. It can be as simple as a health map 
similar to a weather map or as complicated as an electronic 
health record. It's up to us to decide how to handle this new 
resource.
    I look forward to answering your questions, and thank you 
again for this opportunity.
    [The prepared statement of Dr. Matus follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    Chairman Foster. Well, thank you. And at this point we will 
begin our first round of questions. The Chair will now 
recognize himself for five minutes.
    Dr. Emanuel, to oversimplify a bit, transitioning into the 
new normal for COVID-19 means assessing the risk level to a 
particular individual or community at a given time and 
adjusting the precautions accordingly. While the COVID-19 
pandemic puts this calculation on a massive scale, this is an 
exercise that the public health community must conduct in real-
time on myriad issues. So what are the lessons that we can draw 
from past public health crises and even just ongoing public 
health risk? And when considering the level of risk that might 
be considered acceptable by the general population, and how do 
we quantify at what point increased mitigation measures are 
actually worth the cost?
    Dr. Emanuel. I keep forgetting to unmute myself. Chairman 
Foster, that is an excellent question. And as I said, there's 
not one indicator we can follow. We need five indicators at 
least, and we need thresholds on those indicators. Again, they 
need to be vaccination rates, population immunity in the 
community, we need to have wastewater testing, we need to look 
at hospital and health system overload, and we need to look at 
the death rate.
    But, as you point out and actually as Ms.--Dr. Matus--sorry 
if I mispronounce your name--has just pointed out we need to 
bring it down to the local level, and we can do that because 
each one of those metrics can be done on a population basis, 
and we need the information in each community and be able to 
give them a dashboard for the country but a dashboard for the 
community. And they need to see where the lines are where we 
need to take added protections and where we can ease off the 
protections. And I think adding in population immunity and 
wastewater testing will give us a very good handle--not a 
perfect handle but a good handle on what's coming down the pike 
in a week or 2 weeks so that people can prepare.
    I think this is something that's going to be critical going 
forward for having that kind of dashboard, and I do appreciate 
the CDC's new dashboard. I don't think it encompasses 
everything we want. But remember, the dashboard is only as good 
as the data, and as you've heard from others on this panel, 
which I totally support, is we need an upgrade in those data, 
more real-time data, more standardization, and getting all 
communities to give it. And the Federal Government needs to 
give funding in exchange for people collecting the data in a 
reliable way and giving it to the Federal Government and 
localities to use.
    Chairman Foster. Thank you. And I guess, Dr. McBride, how 
do we deal with recognizing that different costs are imposed on 
different segments of the population and different benefits? 
You know, we ran into this with one of the major reasons to get 
younger people--young, healthy people vaccinated was simply to 
protect the elderly in our society. And so you couldn't argue 
this only on an individual basis but for a population which may 
be different than your own group. So what is--what are the 
lessons learned and the best approaches to trying to deal with 
that?
    Dr. McBride. Well, I think we have to realize, first of 
all, that in the panicked spring of March 2020 it made sense to 
treat children and elderly people the same because we didn't 
know exactly who was most at risk for severe outcomes from 
COVID. But we're now in March 2022. We have abundant data to 
show exactly who is at highest risk for poor outcomes. It's 
older patients, it's patients with immune-compromised states, 
it's people with underlying health conditions, and it's people 
in marginalized communities who don't have the access to needed 
information and resources to protect themselves and their 
families and their communities.
    So I think what we need to do is, as Dr. Emanuel was just 
saying, make sure we have evidence and data on hospitalizations 
that's stratified by age, by vaccination status, race so that 
we understand exactly who's at higher risk so that we can surge 
our limited resources to the most vulnerable populations and 
then appropriately calibrate the mitigation measures to the 
level of actually--actual risk in that population. For example, 
subjecting young, healthy college kids to mandates for boosters 
when they, for example, had COVID-19 and have had two or three 
shots already, does it make sense? It does make sense, though, 
to focus on surging the fourth shots to people who have, A, not 
had recent COVID, and B, who are at highest risk, and of course 
getting first shots, second shots in first and foremost.
    But I think the larger question here is really how do we 
message to various populations? How do you tell my 
immunocompromised patient, you know, one piece of advice and a 
college student whose risk for depression and anxiety is more 
than their risk of COVID, and that is ultimately the job of the 
primary care doctor to help take broad public health advice and 
marry it to the person in front of us.
    Chairman Foster. Thank you. And my time is expired, and I 
will now recognize the Ranking Member for five minutes.
    Mr. Obernolte. Well, thank you very much, Mr. Chairman.
    You know, I'm fascinated by this discussion about the data 
necessary to make good decisions in the future and how those 
decisions are made. And so let me start with Dr. Emanuel. You 
in your testimony talked about the need for a viral dashboard 
with reliable data on things like vaccination rates, wastewater 
testing, community immunity, things like that. And I agree that 
all of those are things that we need better data on. But, you 
know, as scientists sometimes we pretend that if we had all the 
right data, we can make the perfect decisions, and I think 
everyone would acknowledge that in the case of decisions about 
COVID, the decisionmaking process is more complicated. And some 
of the things that we did not consider over the last couple of 
years are the societal costs that are concomitant to the 
decisions that we make about things like shutdowns and 
mandatory vaccination and things like that.
    So I'm fascinated because your background in bioethics, I 
think this is something you've probably thought about. You 
know, how do you navigate that space, and don't you need data 
about when you're considering a shutdown what the economic 
costs are, what are the costs on behavioral health? You know, 
how do you parse all that?
    Dr. Emanuel. So, first of all, I think you're 100 percent 
right. We are making tradeoffs, and we're making tradeoffs on 
major things that don't look, as we say in the field, 
commensurable, mental health versus, you know, getting kids 
back to school or mental health versus putting people into 
poverty because we've shut down businesses. I don't want to 
look self-interested, but I think understanding better and 
trying to create more models about how we do as human beings 
make those decisions is something that is worth thinking about 
and investing in.
    But I would tell you, I do think there was a false 
narrative out there that, well, the public health people 
weren't considering these other factors like education or the 
economy. We saw from the public when rates went way up of 
COVID, they themselves, before any public health measures were 
introduced, stepped back from engaging in commercial activity, 
not being social, keeping their kids home from school. And so 
there was a very close correlation between fighting the 
infection and getting the economy going. It's very hard to get 
the economy fully going until we've got this fully under 
control, and the risks to us of COVID and other respiratory 
illnesses are at a low enough threshold that we think they're 
worth taking.
    I don't think we're quite there in large measure in my 
opinion because we don't know anything really about long COVID, 
and we need to get understanding of long COVID. We know that if 
you're vaccinated with three doses--three shots, your chance of 
dying are about 1 in 30,000. That's a very low risk, and we go 
back to normal if there were no long COVID. The long COVID 
element to it, unknown, unknown who gets it, unknown what the 
risks actually are I think complicates this and complicates 
weighing all the things you said.
    Let me finish with one point. I think going forward it's 
quite clear to all of us here that closing the schools was a 
mistake, that we could put in better indoor air quality, 
wearing masks, and have in-person learning, which would have 
been so important for the students. Schools should be the last 
thing we close, and they should stay open as long as possible. 
We shouldn't be opening restaurants before we open schools. 
That seems like we have our values quite wrong.
    Mr. Obernolte. Yeah, thank you. Yeah, I mean, I think 
you've illustrated some of the fundamental problems there. And, 
you know, the economic decision is actually, as you say, the 
most difficult. But, I mean, even in the space of public health 
when you talk about the effect on something like a future 
substance abuser, domestic violence, you know, I think it's 
really hard to--you know, to make decisions just based on 
stopping the spread of a contagion.
    Let me ask one last question of Ms. Ayala. You know, in 
your testimony you were talking about the need for the 
availability of more of the at-home testing information. And 
I'm of the opinion that we actually made some bad decisions 
early in the pandemic about prioritizing PCR testing over 
antigen testing because PCR testing we know to be more 
reliable. But in reality antigen testing, we would've gotten a 
lot more data about that. I'm curious, do you think that that 
was a bad decision? And then if you could also address the 
privacy issues involved with gathering the data, I'd appreciate 
it.
    Ms. Ayala. Thanks so much for those questions. Yes, I think 
that acknowledging that PCR testing has unique components and 
is considered to be the gold standard for testing--for viral 
testing is a no-brainer. However, if the goal is to get as many 
people tested as possible and results turned around as quickly 
as possible, then antigen testing is something that we probably 
should have explored and built systems to support much earlier.
    The idea of privacy issues surrounding testing is something 
that public health has centuries of addressing in much--with 
much more sensitive kinds of disease and virus activity, so I 
think that even if we did a--an opt-in type of opportunity for 
individuals who were getting antigen tested and using their at-
home tests, we still would be further ahead than we are right 
now.
    Mr. Obernolte. Right. Well, thank you. I see my time is 
over. Thank you for the indulgence, Mr. Chair. I yield back.
    Chairman Foster. Thank you, and we will now recognize 
Representative Dr. Bera for five minutes of questions.
    Mr. Bera. Great, thank you, Mr. Chairman. And again, I 
really appreciate the panel and the witnesses, super important 
information.
    I'll plug a piece of legislation that we've just 
reintroduced, the Tracking Pathogens Act, which would, you 
know, plus-up the budget for both gene sequencing but also for 
what you've talked about in terms of wastewater surveillance, 
you know, throughout the country. So, you know, it's a good 
bill. Folks should sign on to it.
    Dr. Emanuel, let me ask you a question, and this is--maybe 
a one-off, but something that we talked about a little bit 
previously, one of my biggest concerns is we obviously have 
seen vaccine hesitancy, you know, spring up around the COVID 
vaccines and so forth. And, you know, in my home State of 
California, you know, we previously did have, you know, an 
anti-vax movement, but it was really largely a small percentage 
of the population. I have a big fear as, you know, we come out 
of COVID or we go into this next phase what that spillover 
effect may be. We know COVID, you know, does minimal harm to 
our children, but if the anti-vax movement now spills over into 
routine childhood vaccines like measles and so forth, I really, 
you know, worry very much about what may happen. And that, 
again, are you seeing any of that trend in terms of routine 
vaccination rates?
    Dr. Emanuel. You're 100 percent right, Dr. Bera, which is 
we have seen in the country a substantial drop in childhood 
vaccinations. Some of that is being able to get to the doctor, 
feeling safe going to the pediatrician's office, some of that 
is a spillover effect of the anti-vax movement. And I do think 
this is something that we have to confront dramatically. We 
need to make it clear that this is both a personal and--a 
responsibility and a community responsibility, and that these 
vaccines are very safe. They're very safe whether they're COVID 
vaccines or DPT (diphtheria, pertussis, and tetanus) or MMR 
(measles, mumps, and rubella) compared to almost anything else 
we do like driving a car, going swimming. And we have to change 
the mental attitude in this country that vaccines are something 
we have to do and we're obliged to ourselves, our family, and 
our community to do. We care about all of that, and people have 
to see these vaccines as helping make a healthy community.
    Mr. Bera. Dr. McBride, you're on the frontlines still 
practicing, and I'd be curious what you're seeing in your 
practice with your patients and then, you know, again, what we 
should be thinking about from the congressional perspective to 
change this narrative in the most effective way.
    Dr. McBride. Thank you, Dr. Bera. I really appreciate the 
question because I have a lot of patients--most of my patients 
are vaccinated and firm believers in vaccines, as I am. I have 
a handful, though, who are vaccine-hesitant. And the way I've 
been able to convince my patients to get vaccinated or even 
consider getting vaccinated is by using that trust and rapport 
that I've built over time, by listening to their understanding. 
I mean, let's face it, people in the United States have 
historical and ongoing real reasons for distrusting the medical 
institution, and that needs to be heard. People need to be 
seen, and they need to be understood and not shamed or blamed 
for not getting vaccinated.
    The second thing I would say is that there's a recent study 
in JAMA (Journal of the American Medical Association) from last 
month showing that vaccination rates increased with the number 
of PCPs (primary care physicians) per capita. So, again, I'm a 
little biased, I'm a primary care doctor, but that is what we 
do. You know, I can't--I can have the best vaccine in the world 
like we do now, but if I don't have the trust of my patients 
and I can't convey nuanced information and meet people where 
they are, respecting their lived experience and their biases 
and beliefs, then I really can't make headway or deliver the 
services that person needs. And so, again, I think we need 
primary care to help meet people where they are.
    Mr. Bera. Well, I'm a primary care internist, so--I'm not 
practicing right now, so I hear that. I guess in the short time 
that have left--and maybe I'll throw it back to you, Dr. 
Emanuel--with regards to long COVID, it is something that, you 
know, we're concerned about, we're thinking about allocating 
the resources and trying to better understand it. Where would 
you want Congress to focus right now in terms of better 
understanding long COVID?
    Dr. Emanuel. So first thing is we need to make sure that 
the NIH and the CDC understand this is an emergency and not 
usual academic research. And I can say that as an academic. 
This has to be turbocharged.
    Second, we knew to expand their trials. The estimate by the 
GAO (Government Accountability Office) is at least 8 million 
people have long COVID, 10 percent of the people who've gotten 
COVID, maybe as high as 23 or 24 million. There are many 
millions of people we can enroll. We need to enroll them in 
studies to find out what the actual rate is, what the risk 
factors, what increases the chance of long COVID, what 
decreases it? Do vaccines protect? Does Evusheld protect? Do 
other treatments protect?
    The last thing we need to do is we need to start 
immediately doing clinical trials. We don't understand the 
biology. That doesn't prevent us from trying things like, you 
know, steroids or statins or SSRI (selective serotonin reuptake 
inhibitors) inhibitors, things that have been shown or 
suggested to lower the risk of COVID, maybe they lower the risk 
of long COVID. Immune modulators, those three things, what's 
the risk of COVID, what affects your risk of COVID, improves or 
reduces your risk of long COVID, and finally, starting clinical 
trials for therapeutics that might curtail long COVID, all very 
important and need to be done immediately. Before the end of 
2022 we should begin to have answers.
    Mr. Bera. Great. I see my time is expired, so I will yield.
    Chairman Foster. Thank you. And I will now recognize 
Representative Bice for five minutes of questions.
    Mrs. Bice. Thank you so much. Dr. McBride, did you want to 
comment on that really quickly?
    Dr. McBride. I just want to comment on the fact that what I 
see in my patients and what I see in the public square is 
necessary and real concern about long COVID. I have patients 
with long COVID. I have a nurse who got COVID back in 2020 and 
is still suffering from the fallout, loss of taste and smell, 
brain fog. It's real. It is absolutely real.
    At the same time, I think in the public, based on what I'm 
observing and what I understand based on the studies that have 
been done that are not well-controlled--they're not well-
controlled studies, is that there seems to be an outsized fear 
of long COVID that, again, this is not to dismiss people's 
fears, this is not to dismiss people's lived experiences, this 
is not to dismiss people who are living with long COVID. My 
point is about the messaging and the difficult threading of the 
needle that we need to do as clinicians and that we need to do 
as public health leaders, reassuring people where reassurance 
is warranted because we see, based on the data so far, that 
vaccines do reduce the risk of long COVID. We need more 
research. We also can reassure people and not scare people 
unnecessarily when they've been vaccinated.
    Mrs. Bice. So on that note, first of all, I want to thank 
Dr. Emanuel for mentioning not, you know, sending kids home 
from school. I think that's incredibly important. And we have 
seen the detriments of that across the country. Every 
socioeconomic demographic is being affected by kids being home, 
so I appreciate your comments on that.
    Dr. McBride, I want to ask you this question. I had a 
conversation with a pediatrician recently who was asked--
obviously is very interested in these conversations, and she 
asked the question, do you think a fourth booster is going to 
be required or recommended by the CDC? And I said, you know, I 
doubt it. But her concern was the virus that we're seeing 
today, these sort of mutations that we're seeing today are 
vastly different than what we saw 2 years ago. And her concern 
is that the vaccines have not been modified at all to be able 
to affect that. What are your thoughts on that?
    Dr. McBride. So lots of thoughts. One is that I think we 
need to do a better job of managing people's expectations of 
what the vaccines can do. The vaccines are no doubt the 
clearest way forward through the pandemic and through the next 
waves and set of variants. But we also need to make clear to 
the general public that vaccines are not magic force fields and 
that they don't protect us against infection like they did pre-
delta. So we shouldn't be surprised, for example, if someone 
has a breakthrough infection despite three or even four shots. 
But the fact that they're not in the hospital, they're not 
severely ill is a vaccine success.
    And that messaging is the nuance that has unfortunately I 
think been lost so that people like in my practice have been 
terrified by getting a breakthrough infection saying, oh my 
gosh, my vaccine doesn't work when actually if you're at home 
with the flu, not that it's the flu, it's a different virus 
altogether, that is your vaccine working.
    So to answer your question, I don't have a crystal ball, 
and I would be lying if I knew what was happening in the 
future, but I do think we will see new variants and we will see 
more waves. And I think ultimately what we'll end up seeing is 
new formulations of the vaccine to target the variant at hand 
not unlike what we do with the flu.
    Mrs. Bice. Right. And that's, I think, what her point was. 
The flu is an annual mutation or variant, and we're having to 
re-create those vaccines every year. We should be looking at 
that for COVID as well because we are seeing these mutations as 
we move through time and they may change.
    I also want to say I agree 100 percent with your assessment 
about communication. I thought from the very beginning it 
should have been OK for the CDC, NIH, and others to say we 
don't know yet, we don't know yet, we're still doing research. 
But instead of that, we heard a lot of information that ended 
up being either incorrect or modified later on, no masking, 
double masking, no masking if you're vaccinated. And I think to 
your very well-made point, people become distrusting if the 
message is constantly being changed, right?
    And so one of the things I want to see from our health 
officials here is, you know, understand that you can say I 
don't know. This was a disease that we had never seen before 
and we didn't know--if you think back to March 2020, people 
thought that you could get it by touching, you know, your 
groceries at the grocery store. I mean, it was really sort of 
kind of crazy times. But now we know a lot more about it, and I 
think that messaging builds confidence in the medical community 
so that people will be more comfortable taking the vaccine, 
being, you know, willing to get a booster if necessary. But 
this constant shift in that messaging makes people incredibly 
distrusting, and that's why we're seeing, I think, such high 
numbers.
    The other thing I'll quickly add, too, is we mentioned 
vaccination rates. I think there are two reasons. Certainly not 
having access is a big deal, especially for low-income families 
when you have health departments that have been closed or 
clinics that have been closed only to COVID vaccines, that 
becomes a problem for children. And then the other piece of it 
is educating these parents that the vaccines that we've been 
taking, you know, DPT, the MMR vaccines are safe and effective 
and that's why we don't have those diseases across the country.
    So, my time is expired. I appreciate your indulgence. And 
at this time I yield back, Mr. Chairman.
    Chairman Foster. Thank you. And for our Members, there will 
be a second brief round of questions as well.
    And we'll now recognize Mr. Casten for five minutes.
    Mr. Casten. Thank you, Mr. Chairman.
    Dr. Ayala, I have to start with a confession. I've never 
admitted this publicly, so bear with me. The Harvard School of 
Public Health has maintained a list throughout the whole COVID 
pandemic showing the vaccination rate by congressional 
district, and I have taken sole credit for the fact that the 
Sixth District of Illinois has consistently been the most 
vaccinated district in the State, and I really don't deserve 
that. You're 50 percent of my constituents, so credit where 
credit is due. You deserve credit for that. And of course 
you've led on testing as well, and it's--and I--you know, I 
meant everything I said about how fortunate we are to have you 
there. I also don't think I'm putting any words in your mouth 
when I say that both of us probably wish those numbers were 
higher.
    And I want to start just by asking you to reflect a little 
bit. Throughout--certainly through the first year of this 
pandemic, there was a--the demand for everything exceeded the 
supply, whether that was the demand for PPE (personal 
protective equipment) or for ventilators and then for testing 
and then for vaccines. And in theory there's an optimal public-
health way to allocate those scarce resources. In practice, as 
you and I know too well, some of those decisions were 
political. There were situations where, you know, we certainly 
got in a challenge here as far as intrastate allocations, and 
then once they were at the State level on the county 
allocations.
    And I wonder now that we're sort of, you know, hopefully on 
the back end of this, was all of that tension completely 
inevitable, or do you think there are things that we could have 
done better at the Federal or State level to ensure that that 
scarce resource allocation was done collaboratively rather than 
competitively?
    Ms. Ayala. So that's a very provocative question. And I 
think that to a certain extent when you're allocating limited 
resources, there will inevitably be contentiousness and 
unhappiness. However, I think the lesson learned--and I 
remember the conversations that you and I had--transparency 
around those decisions at the time, as well as benchmarks or 
metrics for how the decisions are being made, I think those are 
the tools that could not eliminate but certainly reduce some of 
that unnecessary angst.
    Mr. Casten. Well, hear, hear. We could talk for a long time 
about that. I want to shift, though, if we can to the mental 
health issue that's come up a couple times. I think we're all 
keenly aware of how much we as a people need social engagement 
and how much we've become a little bit sort of socially 
crippled for lack of a better word as we've been in our bubbles 
over the last year.
    At the same time, there's a part of me as an American that 
gets confused and in some ways angry at the fact that the same 
country that was willing to completely transform the way we 
travel, our rights to data privacy, enter into 20-year wars 
after 9/11 is not even talking about the fact that we lost two 
9/11's last week. Almost a million Americans. And somehow we've 
either at best decided that we're just inured to it and, at 
worst, decided that that's an acceptable price to pay so that 
somebody's kid doesn't have to wear a mask or that somebody can 
have the freedom not to get vaccinated because that's more 
important.
    And I don't want to trivialize those mental health issues, 
but you of course oversee a pretty robust mental health 
division as well out in Wheaton, and I wonder how you think 
about the tradeoff between the public health issues of saving 
lives and the real mental health issues you see, how you think 
about that, how you communicate it, how we should think about 
it.
    Ms. Ayala. Sure. So when we talked about--earlier in this 
hearing when we talked about the impact of COVID on children, I 
think one of the opportunities that we did not take full 
advantage of from the public health standpoint in working with 
families around the need for children to get vaccinated, as 
well as the importance of masking and some of the others is the 
impact of the loss of someone close to them. When we look at 
the reports around children who have been orphaned and lost 
that primary caregiver, again, the most dramatic losses have 
occurred in our marginalized, underserved populations. Those 
children--not that any child needs to, you know, experience 
trauma to build any sort of character going forward, but those 
are kids who absolutely need people in their lives who are 
steady and supportive for them.
    I think that--I share your concern that when we talk about 
the numbers--and in DuPage County alone we have nearly 2,000 
deaths that have occurred over the last 2 years in large part 
unnecessarily and tragically too soon and preventable now that 
we know that there's--this is a vaccine-preventable disease. I 
think that to us in public health and health, the most tragic 
outcome is having a death in an otherwise healthy individual.
    And so when we talk about the concerns of economics and 
concerns about restaurants and bars staying open, I think that 
we need to take a really deep look at what is important from a 
community standpoint. And I know I'm over, but one of the 
issues that we've all talked about is the need for schools to 
have been open. Without a doubt. However, when we had other 
facets of our society who were unwilling to abide by some of 
the prevention strategies so that we could get back--kids back 
in school, I think that's when we--that's when the priorities 
of a community are felt more than they're heard.
    Mr. Casten. Thank you. I yield back.
    Chairman Foster. Thank you. And at this point we'll start a 
second round of questions for Members who are interested. And 
I'll now recognize myself for five minutes.
    Dr. Emanuel, you mentioned three interesting technologies 
that you thought we should--that we should pursue actively, 
seroprevalence surveillance, mucosal vaccines, and antiviral 
cocktails. So, first, in terms of the seroprevalence 
surveillance, does technology exist to really, you know, take 
one of these little blood spot tests where you, you know, you 
prick your finger and put it on something that looks like a 
business card, you mail the business card back in, and then 
that can be analyzed for antibodies, for example, that may be 
present? But is there a way--does technology exist to actually 
use that sort of test to predict whether or not you're actually 
immune to a specific variant?
    Dr. Emanuel. It can't predict whether you're immune to a 
specific variant. You can predict whether you've got antibodies 
to variants and you don't need to get people to actively prick 
necessarily. We can use what's called the excess blood from 
laboratory tests. We do millions of tests every day in this 
country, and we can use some of that excess blood to monitor 
these antibodies.
    The other problem I would mention with that is that we have 
cellular immunity, which is what gives us our long-term 
immunity against COVID, and that's much harder to monitor in 
the way that you suggest. But the other technologies we need, 
mucosal vaccines, pan-coronavirus vaccines, multidrug 
cocktails, those are all very important and we're doing 
research. We need to, again, turbocharge the research.
    Let me just conclude with one other item, which is not a 
technology so much as research. You can't tell me, I can't tell 
you, and no one in the country can tell you what the optimal 
vaccine schedule is. We have different kinds of vaccines. We 
probably know that mRNA first and mRNA repeatedly is probably 
not optimal, but we can't tell you is having J&J (Johnson & 
Johnson) first and then an mRNA optimal? Is maybe having the 
new Novavax vaccine, assuming it gets approved, with mRNA, is 
that optimal? We need research on that, too, because we may 
actually get better community protection and immunity with a 
different schedule of just the vaccines we have. And we just 
don't know what's optimal out there, again, another research 
hole that we need to fill.
    Chairman Foster. And one thing that's not really a 
technical issue but I've been very struck, as all of us have, 
trying--you know, we're trying to convince people who are 
hesitant to get vaccinated. And we've all spent hours and hours 
doing that. And very often at the end of the discussion you 
haven't succeeded. And then one of the things that I have tried 
doing is to ask people that if instead of a vaccine it was 
simply a pill that you took, almost universally people say, oh, 
yes, sure, I'd take a pill. And so even though it's not a 
technical issue on the performance of such a vaccine, it seems 
to me that if we prioritize the development of, say, an oral 
vaccine or one of these, you know, nasal spritzer things, I 
think that there might be a huge increase in vaccine 
acceptance. And is there anything--do any of our witnesses 
know, has that sort of thing been studied as a technique to get 
past vaccine hesitancy?
    Dr. Emanuel. I totally agree with you. It's--that's why I 
call for mucosal vaccines. Having a variety of approaches for 
people is absolutely pivotal, and you're 100 percent right. 
People are more inclined to do a pill or a spritz in the nose 
than they are--for whatever reason, shots have very, very bad 
overtones for people.
    Chairman Foster. Yes, I think we're kind of built that way. 
You know, I recently became a granddad, and so babies will 
often put stuff in their mouth with no hesitation at all, and 
I've never seen a baby eager to be injected with something.
    Now, in terms of the antiviral cocktails, this is something 
I've been frustrated by because I don't see, frankly, much 
Federal action on this. We led a bipartisan letter a while ago 
that doesn't seem to have had much effect. There--one of the 
problems, there is no real commercial incentive for the 
manufacturer of a reasonably successful antiviral to be 
enthusiastic about sponsoring a cocktail in clinical trials. 
And it's my understanding that actually held back the 
development of HIV cocktails for actually years. And so is 
there any observations that any of our witnesses have about the 
importance there or what Congress might do to encourage the 
development of antiviral cocktails?
    Dr. McBride. I would just say if I could that I think the 
development of Paxlovid, for example, as an oral antiviral is 
really a gamechanger. And I applaud Biden's test-to-treat 
initiative, and I think we need to really surge resources there 
so that people, as you said, who are either vaccine-hesitant or 
unvaccinated or vaccinated and still get COVID and are at 
higher risk for poor outcomes can quickly get a rapid test, 
show that they're positive, and get the appropriate antiviral 
treatment to further reduce their risk for serious outcomes 
from COVID-19.
    Chairman Foster. Thank you.
    Dr. Emanuel. I do think advanced purchase agreements could 
incentivize us, and specifically allocating money to conduct 
rapid trials on multidrug regimens is something we have to 
prioritize. And I think when you allocate money or appropriate 
money to the NIH, that's something you ought to put in to force 
them to do it. They have been resistant to these oral 
medications right from the start. I can tell you that having 
had discussions. And that's been a mistake. We have hundreds 
now in either preclinical or clinical trials of antiviral 
medications, and we need to turbocharge that, too.
    Chairman Foster. Thank you. And my time is up. I will now 
recognize the Ranking Member for five minutes.
    Mr. Obernolte. Well, thank you, Mr. Chair. This is a really 
fascinating discussion we're having, and I'd like to continue 
the line of questioning about vaccines and vaccine hesitancy. 
But let me just lead by saying that perhaps one of the things 
that this has taught us is that we need to think more out-of-
the-box when it comes to widespread vaccine availability for 
people because although I will agree that an oral vaccine would 
be more accepted than an injectable vaccine, convenience is 
also important. And I know it's--as people in the space of 
public health, it horrifies us to say this, but for a lot of 
people, the necessity of having to go to a healthcare provider 
to get vaccinated, that's a big step for them. I mean, if you 
got just--if your insurance company just sent you in the mail 
the next vaccine dose, was an oral vaccine and they said scan 
this QR code when you've taken it so that we know you've taken 
it, we can update your medical records, and by the way, you 
shouldn't take it if you have the symptoms, you know, I 
actually think that would go a lot further toward making sure 
that we have good vaccine penetration.
    So, you know, let me ask, you know, along those lines, Dr. 
McBride, I'll pick on you again here. You said some really 
interesting things about vaccine hesitancy and the anti-vax 
movement. And I'll be provocative and say I actually think that 
the government and government action throughout the health 
crisis has greatly contributed to the rise of the anti-vax 
movement. I think that if we had just been more open and 
transparent with the public about the fact that vaccines are 
very effective, they're overall safe but they do have risks, 
and I also think that if we had been more respective of 
people's own ability to decide for themselves whether or not 
vaccines were right for them, that people would be less 
hesitant here. Do you agree or disagree with that? And what 
mistakes do you think that we made during the crisis that might 
have resulted in greater vaccine hesitancy?
    Dr. McBride. So thanks for that question. I don't ascribe 
ill intent to our Federal Government. I think we've been 
building an airplane in the air----
    Mr. Obernolte. Well, I can. You don't have to----
    Dr. McBride [continuing]. But I do think----
    Mr. Obernolte [continuing]. But I do.
    Dr. McBride. Oh, OK. Fine. Fair enough. And as I said in my 
written testimony, had our prior President, you know, gotten 
the vaccine as he did and told people about it, that would have 
done a lot of good.
    I think what--this goes back to, again, messaging and 
acknowledging uncertainty, acknowledging the truth that we know 
about the vaccine, and then allowing ourselves, giving 
ourselves permission to give the public permission to have--to 
feel reassured. So I have so many patients who are vaccinated 
and boosted and walking around terrified to see their 
grandkids, to go back to work when they need to know that COVID 
isn't going away, tragically, but that the vaccine has taken 
the fangs and claws away from the virus and that they can then 
focus on their broad human needs. For example, my patients with 
obesity, hypertension, substance use disorders, we need to be 
focusing on those issues and take fear out of the driver's seat 
from--the way they think about COVID while protecting 
themselves and their families from this virus.
    So the other thing I think we missed the opportunity of 
doing is we didn't get the vaccines into primary care doctors' 
offices. Again, trust is the ground game in primary care. And 
if I had the ability to check--see a patient for their annual 
checkup and say, oh, hey, by the way, there's this COVID shot, 
it's excellent, what are your concerns and then have them go 
get their lab work and their vaccine at the same moment, that 
would be great. The problem is, as you know, 80 million 
Americans, according to a recent study, don't have access to a 
primary care medical home, which is why, again, I think we need 
to invest in primary care and allow people to have that place 
to get nuanced information. Because the CDC, even if it was 
doing the best of jobs in the best of times, can't possibly 
speak to every American. It can't possibly speak to a vaccine-
hesitant person and a vaccinated-anxious person. That's our 
job, to be the lieutenants of the CDC, to help people get what 
they need and to get the resources and information they need 
that reflect their unique vulnerabilities and their unique risk 
tolerances because there's really no one-size-fits-all 
prescription for how to manage risk.
    Mr. Obernolte. Sure. I completely agree. And I also think--
I mean, you've raised an interesting issue, which is we need to 
be cognizant of behavioral science when we're making decisions 
about how to increase vaccine adoption. And that's one of the 
mistakes I think we made. You know, it's--we have a long 
tradition of anti-authoritarianism here in the United States. 
In fact, it's kind of part of our national ethos. And, as a 
parent who's raised a couple of kids, I can tell you if I 
wanted them to eat broccoli, the last thing I should do is tell 
them they have to eat broccoli, right? If I instead say, well, 
OK, you cannot eat the broccoli but you're going to miss out on 
something good, they're a lot more likely to eat the broccoli 
on their own. And, I mean, I really think that there are 
lessons to be learned there in addressing vaccine hesitancy 
because those are some of the mistakes I think that we made 
during this process.
    But it's been a fascinating discussion. Thank you, 
everyone.
    Chairman Foster. Thank you. And we will now recognize 
Representative Casten for five minutes of questions.
    Mr. Casten. Thank you. Two questions, first, one more for 
Dr. Ayala and I want to get to Dr. Matus before we wrap up 
here, who has been far too lonely on the screen. The--when this 
pandemic first started, we had some experts come in--Dr. 
Emanuel, you may have been one--advising us on how to talk to 
the public through a crisis and the message that stuck in my 
head was, for goodness sake, don't be the elected official who 
some significant number of people didn't vote for and say I'm 
the one who's right. Get the public health officials to stand 
up next you and speak to that. And I certainly availed myself 
of your skills in that department more than once, Dr. Ayala.
    The trouble was that when we got home and social media was 
ablaze with all sorts of completely garbage information that 
was running contrary to that and we weren't sitting there with 
the expert on hand. And I'm curious, Dr. Ayala, you must've 
felt that as someone who was communicating this in your soul, 
I'm curious what you think we can do better for future 
pandemics about that role of social media and communication and 
what advice you'd give to us if we were going in now about how 
to anticipate that sort of nonsense in the future and inoculate 
the public against it.
    Ms. Ayala. Sure, sure. So I think that although I feel it 
in my soul, I think one of the ways that I've survived the last 
two years is to completely divorce myself from reading any 
social media posts or many social media posts. However, I think 
that as far as communication goes, I think that when we stay 
silent around misinformation and disinformation from a public 
health or a healthcare legitimacy, we undermine ourselves. And 
so I think that, no, we can't possibly address all of the 
issues that are brought up on social media. However, some of 
the points that Dr. McBride, Dr. Emanuel have made about 
communicating the nuances around vaccinations, around 
communicating the nuances around the need to--for layered 
mitigation that, just like there's no one metric, there's no 
one prevention strategy that is going to be the silver bullet, 
I think those would have gone a long way. And instead I think 
we just took, I don't know, high road or didn't want to get 
involved in those kinds of discussions. But I think it really 
worked against us. And that would be definitely a lesson 
learned going forward.
    Dr. Emanuel. Can I raise one--or a few points? First, we 
have to talk about misinformation. It's not just the government 
giving information that might not be clear. There was plenty of 
misinformation out there, intentional deception of people. 
That--some of it came from foreign actors. We know that, and we 
need to see this as a national security threat when they can 
spread misinformation that compromises the public health of the 
country. And I don't think we've done that and taken it on 
seriously.
    Second, the academic studies at least that I've seen trace 
almost all of this back to Fox News and to the misinformation 
Fox News started, then gets amplified by social media, then 
comes back to Fox News, and it's a vicious negative circle 
there. And I think we have to be very clear.
    Third, we have to change those algorithms and prevent 
people from staying in an information bubble. You have the 
power to do it. It's not infringement of First Amendment rights 
that people--that the companies just can't give you a loop of 
the same misinformation you get, that you have to be open to 
information. Those algorithms are quite dangerous to public 
health, but they're also quite dangerous to democracy. And I 
think it's very important for you to take seriously those 
algorithms. They don't infringe the public free speech rights, 
but they do allow us to be more in a democracy so we can hear 
the opposing and alternative views very freely, just as freely 
as we hear----
    Mr. Casten. So, Dr. Emanuel, thank you, and I completely 
agree. It's a rich conversation. I do just want to get to Dr. 
Matus, and I'm seeing my time run down here.
    We had a whole lot of complication early on, to some degree 
probably still do, with data-sharing. Different hospitals have 
different data systems. They didn't necessarily communicate 
properly with the community health centers, with the public 
health departments. And I realize that sewage testing is not 
the entirety of that, but I'm curious to what degree your data, 
which is aggregated, can tie some of that together just from a 
data perspective.
    And then, secondarily, to what degree have you been able to 
work with that diversity of public health systems to use your 
data to interface and maybe spot gaps and coordinate data 
between those if that makes sense in the time we've got left.
    Dr. Matus. Absolutely. Wastewater data has grown from being 
this very obscure novelty that people found interesting or even 
funny, to suddenly becoming the new pillar, the most trusted 
source of truth about what's happening in the pandemic. Just 
earlier this year during the omicron wave, the wastewater data 
which we make publicly available took everybody just through 
our website and social media indicated when the peak of the 
clinical cases would happen 2 weeks ahead of time. It gave 
hospitals, especially in the Boston area where there's lots of 
awareness about this type of information, a 2-week leading time 
to prepare for the peak. And it was equally useful to know when 
the peak would happened, as well as to when it would end. And 
that's the promise. That data can be communicated real-time to 
everybody involved. And, as you say, the data is seen by the 
Governor. It's seen by the State's public health department. 
It's seen by the city-level public health departments from 
Boston, Cambridge, Chelsea. It's seen by the hospitals in the 
area. It's seen by the public and commented by the public on 
social media. And as I see it--and I will just end with that. 
You know, the poop data doesn't lie. And it's that trust, we 
need to go back to the basics, and wastewater provides that to 
the public, a public engagement tool.
    Mr. Casten. Yes. Ending with a comment about the poop deck 
is a great way to yield back to our captain.
    Chairman Foster. All right. Enough of that. I will now 
recognize Representative Bice for five minutes.
    Mrs. Bice. Thank you so much. And I actually just want to 
pivot back to Dr. Matus. You haven't had the opportunity to 
talk about some of these other topics. I just want to maybe 
talk--ask you if you can maybe elaborate on communities that 
you're utilizing these resources in across the country and how 
we can educate municipalities and States to really invest in 
the type of research and technology that you are currently 
providing.
    Dr. Matus. Absolutely. Something to mention is that of all 
of the communities that currently do wastewater epidemiology, 
there is a very big fraction of them that are small towns, 
rural communities, tribal nations. And we work with them. 
That's part of the beauty of this technology. All that you need 
is the wastewater. You don't need any pre-existing 
infrastructure in those areas in order to understand what 
happening. In the State of Oklahoma, as well as in others, we 
have done plenty of work with those communities. And what we're 
seeing, what seems to be the most resonating with them is 
feeling part of this story, telling part of it.
    Mrs. Bice. Sure. Is there--what is the opportunity for us 
to utilize wastewater research in other areas, maybe, you know, 
are you able to identify variants of COVID? Are you--is it 
parts per million that you can see the amount of, you know, per 
capita maybe exposure? Like how does that technology really 
move us forward?
    Dr. Matus. Yes. The wastewater allows you to understand the 
level of disease activity in an area, so the trend. You can see 
if it's going up, if it's going down. Right now, the COVID-19 
levels nationwide are quite stable at a low level, fortunately. 
There's a little bit of an uptick happening but nothing yet too 
concerning. At the same time and from the same sample we also 
analyze for the variants of concern, so we do genomics 
sequencing, which was mentioned earlier today as one of very 
important tools to pandemic preparedness, and we can understand 
which mutations are circulating of the known variants, as well 
as new mutations that we don't understand yet.
    And there's very interesting work there, not to mention 
influenza, other infectious diseases, antibiotic resistance, 
and something that has been mentioned multiple times during 
this hearing, mental health. Mental health can also be 
understood through wastewater, both the opioid side, the 
stimulant side is all of information that can be collected from 
the same source.
    Mrs. Bice. That's fascinating. And I think that the comment 
that you made that you can look at variants I think is 
incredibly important as I think everybody on the panel can 
agree. This isn't going away, and so being able to recognize 
that's important--and can you tell us how long it takes you to 
analyze this to be able to provide the data back to the 
municipalities?
    Dr. Matus. We provide it, yes, next business day.
    Mrs. Bice. Wow.
    Dr. Matus. Wastewater is a leading indicator for what's 
coming. We have been--you know, it has been officially reported 
by economic groups, by the CDC how wastewater gives you an 
early warning about what you're going to see in the clinic when 
it comes to the spikes but also to the variants. Omicron was 
detected in wastewater before it was in the clinic in the 
United States in the last wave.
    Mrs. Bice. Why we are not utilizing these types of 
technologies holistically I think is sort of beyond me, so I'm 
glad to connect with you, and I appreciate you being on the 
panel.
    Dr. McBride, did you want to maybe chime in there?
    Dr. McBride. I just wanted to say how impressed I am by 
what--your presentation, Dr. Matus, and just to say how 
excellent a resource wastewater management can be, particularly 
when we see the harms of all of the--the potential harms of, 
for example, asymptomatic testing in schools. When we have 
these technologies like wastewater testing and we have the 
ability to ventilate buildings, these are invisible and 
private--they preserve the privacy of the public while, you 
know, alerting people in advance of their risk and mitigating 
the risk, whereas when you test someone, for example, an 
asymptomatic child in the school and then send them home for a 
quarantine when they aren't even sick, then, you know, 
particularly in low-resource communities, you put that kid at 
risk for everything from missed school altogether because they 
don't have access to the internet to, you know, not getting fed 
where they--so these invisible interventions, paired with 
access to primary care to get the nuanced information that you 
need for your individual risk, when Mariana Matus's wastewater 
tests go up, I mean, that's really to me the wave of the 
future.
    Mrs. Bice. I love it. Well, thank you so much for our panel 
being here today and, Mr. Chairman, I yield back.
    Chairman Foster. Thank you. And I'm struck by the amount of 
interest in this technology here in a very bipartisan manner, 
and I'm wondering at some point if you may be asked to actually 
predict the results of elections based on wastewater samples.
    But before we bring this hearing to a close, I want to 
thank our witnesses for testifying before the Committee today. 
The record will remain open for two weeks for any additional 
statements from Members and any additional questions the 
Committee may ask of the witnesses. And this hearing is now 
adjourned.
    [Whereupon, at 11:32 a.m., the Subcommittee was adjourned.]

                                Appendix

                              ----------                              


                   Additional Material for the Record




     Executive Summary of a report submitted by Dr. Ezekiel Emanuel
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]     
     



    [For full report, see https://www.covidroadmap.org]
    
                 Letter submitted by the National Association
              of County and City Health Officials (NACCHO)
              
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]