Table 4 Common themes and representative quotes from student responses^a in the COVID-19 elective course

Background knowledge

Public health concepts

“I was shocked to learn that 80% of viral infections and 50% of bacterial infections are zoonotic. […] viruses get passed back and forth between different animal species all the time, which is what leads to their incredible diversity.”

“I’d heard the flatten the curve term and it made sense theoretically, but then sort of seeing some of the projections that came out of Meyer’s lab about […] here’s our capacity in beds and ventilators, etc. And then here’s how if we don’t […] really aggressively flatten the curve, how we’re gonna fly past capacity. That was overwhelming.”^a

COVID-19 clinical and epidemiological knowledge

“The exact combination of SARS-CoV-2’s relatively low case fatality rate (CFR) overall, R0, and possibility of transmission from asymptomatic patients lead [s] to the issues that we are experiencing with COVID-19.”

Public health response

Cultural and social factors in response

“If we consider East Asian countries to be on one end of the scale of individualism/collectivism, and America is on the end, I wonder where a lot of the European countries fall on that scale. […] in France, for example, solidarity is a strong value […] However, their governments are not as authoritarian as the Chinese government, and the European view on civil liberties probably veers closer to the American perspective. […] if the French government imposed such draconian measures on their population, it would not be taken kindly.”

“The online course has allowed me to explore the responses from different countries and compare them to what is happening here to see what is being done well and what is being done poorly. For example, what is being done in the Asian countries such as China, Singapore and South Korea would be much harder to implement here given the differences in culture.”^b

Ethical dilemmas

“As healthcare providers, we often straddle the line between patient autonomy and paternalism […] With the health and well-being of many other people at stake, I wonder if, during this critical period, […] autonomy should take a backseat to the advice of medical professionals and public health officials.”

Comparisons with other viruses and pandemics

“SARS and MERS taught us that hospital systems need to have standardized protocols for dealing with pandemics, and they need those protocols to be set in place before the pandemic hits.”

“The public’s response in China and South Korea, their willingness to engage in government orders may also have to do with fear of the outcomes of the previous pandemic’s experienced in these countries.”^b

Comparisons among countries

“[The village of Vo in] Italy also has what I think is one of the most stunning examples for stopping the epidemic in its tracks. […] Without finding and isolating the asymptomatic cases, there’s no way such a profound decrease in infections could have happened. […] South Korea and Taiwan have shown success with similar strategies. I fear it is too late to implement something of that scale here in the US.”

“After spending the second week of the elective studying Kenya’s response and preparations, I continue to draw correlations to rural America.”^b

Criticism of response

“Prompt response requires resources and a governmental department [not] strapped by low human and financial resources. […] it seems that we have the expertise and structures to have the correct system [s …]. However, [we allow] other interests to get in the way of optimal preparedness and response.”

“I oft find myself reflecting on what could have been if the US prioritized public health and a social safety net like many other developed countries. It’s highly unfortunate that we as a society have come so obsessed with increasing margins and profits that we overlooked critical health infrastructure such as the National Stockpile and PPE. Now, we must pay the cost in human life and in productivity.”^b

Public health solutions

“Early testing, aggressive contact tracing, and quick isolation is our best line of defense […]. I don’t think that Austin as a city is there yet, but […] there are pockets of our community fighting hard for this.”

Public health communication

“It is important to have an idea of what the audience already knows or believes […] add to the audience’s knowledge and correct any misconceptions […]. The Health Belief Model states that people will take into account the perceived severity and risk of a health event, […] barriers to, benefits, and risks of action.”

“more confident in my ability to access helpful resources.[…] I was in [the group] that worked […] on interpersonal communication, they created this really comprehensive, really good blog post. […] if I was in that situation, I would just immediately go to their blog post and read some responses guiding me on that.”^a

“I realized that health literacy was an issue and no one was sure if CDC guidance applied to small, rural towns.”^b

Community impact

Public opinion and behavior

“I think social opinion is in favor of extreme measures to contain the pandemic. However, if the measures are good then we will never know how bad the pandemic could have been, leading to increased speculation as to whether the interventions were appropriate. Already, there are individuals calling for the reopening of the economy, stating that the ‘cure shouldn’t be worse than the disease,’ which seems to downplay the rhetoric of how many people could die or be hospitalized due to this disease. I’m curious to see how public opinion evolves as social distancing, quarantine and isolation continue past novelty.”

“Our family members [in China] are worried about us because they do not believe the US is responding adequately to the crisis, and because they have heard instances of people of Asian descent unfortunately being the target of discrimination and assault due to scapegoating and xenophobia.”

Disparities in impact

“[…] despite the great strides we have made in public health, medicine, and sanitation, many of the structural factors that aided in the spread of influenza still exist today. There are even greater economic disparities, with the lower class living in areas of the city with decreased access to healthcare, poorer social support, and less resources. Practices of social isolation are extremely difficult when they mean that people living paycheck to paycheck will lose their homes. How does someone without a car get around if they cannot use public transportation? And shelter-at-home can be difficult if you do not have access to any kind of stable housing.”

“the impacts that we’re seeing on our most vulnerable communities and how any crisis […]illuminates, […] those inequities arising […] around race and ethnic lines or around being undocumented in this country.”^a

“There is now a growing interest in inequality of cases distribution—disease prevalence overlapping areas with a higher proportion of service workers and lower cost-housing, predominately black communities. The pandemic is revealing much about the US—Inequalities, systemic racism; wage and worker conditions; differences in education and health literacy.”^b

Systemic implications

Economic impact

“The mitigation conversations seem to be playing with this balance of how bad is the virus versus [the] recession. Some [sources] report that not only are the mitigation efforts necessary […] but also that a reopening of the economy at this point would be generally detrimental. I see a lot of talk in politics about ‘the cure being worse than the disease,’ but that talk sounds like profit vs. lives, which is not a responsible conversation to have. However, the argument can be made that, for however much unemployment rises, suicides and/or all cause death rises, so that would complicate the argument for listing restrictions.”

Political and policy implications

“This discussion over protection for financially vulnerable families in Texas is one of policy. Unlike other wealthy, industrialized nations, the United States does not mandate paid sick leave or universal healthcare. In the face of this pandemic, public health experts and policy makers are being asked to create legislat [ion] that allows for a safety net for these populations. Since any legislat [ion] is slow-moving […], public health officials are scrambling to […] meet needs on a daily basis by tapping into philanthropic and non-profit organizations as they wait for federal ordinances […]. I’d be curious how other countries with paid leave and universal healthcare are faring in comparison.”

“This pandemic does raise novel […] and interesting questions about how to evaluate government intervention and balances of power (both between branches of the federal government and between the federal and state governments).”^b

Health system implications

“I would like to think that this public health crisis will be an opportunity for all of America to critically reexamine our existing healthcare system. It is making people aware more than ever before how broken it is and how critically necessary it is to fix it so that we can have a healthcare system that works for us, not against us.”

“Fundamentally, I think medicine will always be the same. But I think this is going to cause us to question a lot of things. Look back at a lot of our policies and practices, the way we do things. And I think a lot of things are going to change by the time we actually get out into the force.”^a