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Ensuring the Future of the Airline Industry

At this point, with most of the world still in the grip of the COVID-19 pandemic, there is great uncertainty about what the future of the airline industry will look like. It is possible to make some short-term predictions, and some workshop presenters did that, but the long-term shape of the industry will depend in large part on decisions that are made and directions that are taken over the next few years. There was general agreement among workshop participants that it is quite possible, perhaps even likely, that it will not be long before the world experiences another pandemic with similar effects to COVID-19, and no one in the airline industry wants to be as unprepared for that possible next one as they were for this one. Thus many of the speakers offered suggestions for changes that could help the airline industry respond much more quickly and effectively to that next one—and, more generally, make the airline industry more agile and adaptable as it heads into an uncertain future.

DEMAND FOR AIR TRAVEL IN THE IMMEDIATE FUTURE

Several speakers offered predictions—with varying detail—of what the next few years are going to look like for the air travel industry in terms of demand and financial outlook. For example, Laurie Garrow, the co-director of the Center for Urban and Regional Air Mobility at Georgia Institute of Technology, said she did not expect recovery until 2023 or even 2025. “It’s going to be a long haul, and costs are going to be higher,” she said. Many airlines will emerge smaller, and in some cases they will be greener because they have retired older aircraft that were less fuel efficient. Many airlines may not survive, she said, and the financial health of individual airlines is going to be a function of geography and government support.

Ivan Bassato, the executive vice president of operations at Aeroporti di Roma, offered his own predictions for what the future of the airline industry will look like. Showing a figure that offered a “foreseeable scenario” for air travel (Figure 6.1), he said it is possible that it will be sometime in 2024 that air travel volume returns to its pre-COVID-19 levels. It is likely that once the acute phase of the pandemic passes, there will be a chronic phase during which COVID-19 continues to affect society. With the vaccine rollout going as it is, Bassato said that the fourth quarter of 2021 is the earliest time that Italy and the rest of the European Union are likely to see herd immunity; it may be later. And even after that, the virus will likely still be in circulation and will affect society in various ways. Thus until the virus is eradicated, he said, it will be necessary for the air travel industry to have protocols for identifying and dealing with infected passengers. And only after that eradication are air passenger volumes likely to recover completely.

James Wiltshire, the assistant director for external affairs of the International Air Transport Association (IATA), went into a more detailed prediction for the future of the aviation industry. One of the key unknowns, he said, is to what extent demand for air travel will return after the pandemic is beyond its acute stage and into a chronic stage. One hint may be found in places like China and South Korea, which have gotten the virus under control and where domestic air travel has returned to near pre-pandemic levels—and, in the case of South Korea, is actually somewhat higher. “The domestic markets give us some hope,” he said, that the aviation industry could return to normal after the pandemic.

One key concern, he said, is whether governments will pull support for airlines too quickly as the pandemic eases. Many airlines have survived only because of government aid, and the inflection point that comes at the beginning of a recovery “is actually the point of maximum risk.” Unfortunately, he added, support for the airline industry is likely to be to be needed for some time, going forward into 2021 at the very least.

The major factor influencing international air travel now is government travel restrictions. The rising infection rates and the concern about new variants, particularly in the United States and Europe, led to a tightening of travel restrictions in winter 2020–2021, “which means we are back, in some ways, where we were in March 2020,” he said. This is very concerning.

However, on a positive note, there are indications that once travel restrictions are removed, air travel may quickly return to normal or near-normal. Wiltshire showed a graph of air travel between the the United Kingdom and Dubai in the United Arab Emirates. Up to November 2020, there was a quarantine in place for UK travelers visiting Dubai, and air travel between those locations was down 80 percent from a year before. However, when the quarantine was lifted, bookings shot up to levels that were even a little above normal for that time of year. Then, as a new variant of the virus emerged, travel restrictions were put back in place, and bookings plunged. In short, he said, how governments respond to COVID-19 going forward is critical to the outlook of the industry.

A more fundamental factor affecting the future of air travel is the availability and use of vaccines, Wiltshire said. Countries that achieve herd immunity will likely begin to ease travel restrictions, but the vaccine rollout is very uneven around the world. Based on current patterns, it appears that the United States could reach herd immunity in the second quarter of 2021, followed perhaps by Canada, to be joined by the United Kingdom and then the European Union in the third quarter of 2021. But other countries are lagging—Latin America and Japan in the first or second quarter of 2022, China in the third or fourth quarter of 2022, and India not until 2023.

“The pace of rollout is going to be key,” he said. Also, “the trigger points that governments choose for their relaxation of restrictions is going to be key, and that’s going to come down at some point to your appetite to risk.”

One other factor, he said, is what happens with COVID-19 variants. If variants appear that are not susceptible to the current vaccines and time must be spent developing new vaccines to counter these variants—“basically, get into a game of constantly playing catch up and whack-a-mole with the variants”—then the path back to normal levels of air travel will likely be much longer.

Finally, Wiltshire said, health credentials will be a key enabler of recovery. If some sort of internationally accepted vaccine passport becomes available, it could do a great deal to encourage the return of air travel. The World Health Organization (WHO) is working actively on vaccination certificates, he said, IATA has been working on a “travel pass” that would help passengers learn about testing requirements in different travel locations, find testing centers and laboratories that meet the requirements, securely receive test results from those centers, and then create a “digital passport” that would prove to the necessary travel authorities that the passenger has met the relevant requirements. Something of this sort will be crucial, he said, to allowing passengers to satisfy the varying requirements of the countries to which they travel.

On a related note, David Kipp, the vice president of technology services at Burns Engineering, which provides and manages technologies for airport operations, said that a major determining factor in how quickly air travel returns to normal will be consumer confidence. To illustrate how this may play out, he showed a graph from Gensler, a major airport planning and design company, which indicates how quickly passengers expect to be comfortable with air travel (Figure 6.2). “What’s interesting about it,” he said, “is that it takes almost a year to get from where we are now, which is around 50 percent confidence level, to 90 percent confidence level. This is a long sustained recovery, so anyone that’s hoping for the so-called V-shaped recovery in aviation probably is going to be disappointed.” It will take a year or more to get back to normal levels of confidence in air travel.

AIRLINES DOING WHAT THEY DO BETTER

Many workshop speakers looking into the future focused on how airlines can do what they do better, whether relative to the COVID-19 pandemic or relative to other sorts of challenges the future is likely to bring. Hassan Shahidi, president of the Flight Safety Foundation, emphasized the importance of international collaboration among different facets of the air travel systems. Valerie Manning, the senior vice president of customer support at Airbus and a member of the workshop planning committee, described the role that Airbus and other original equipment manufacturers (OEMs) can play in helping airlines respond to the COVID-19 pandemic and to prepare for future pandemics. Pinar Keskinocak, director of the Center for Health and Humanitarian Systems at the Georgia Institute of Technology, offered a variety of thoughts on how the airline industry might adapt to the future. And Josh Cohn, the director of airport planning at InterVistas, focused specifically on how airports can adapt for the future.

The Importance of International Collaboration

In his presentation, Shahidi reiterated the importance of the many of risk-reducing strategies that had been discussed by other presenters, but he emphasized in particular the important of international collaboration in restoring the global aviation industry to health. Individual countries such as the United States can implement measures intended to fight the pandemic, he said, but “if those measures are not standardized and they’re not harmonized, it’ll be difficult to get air travel back up and recovery back up, especially internationally.”

A successful strategy for reducing COVID-19 risk in air travel will need to be multi-layered, Shahidi said. It will require airline hygiene practices, airport hygiene practices, ensuring the quality of cabin air quality, passenger actions, and testing and vaccination, and much has been done in each of these areas over the past year, he said, as had been demonstrated in many of the workshop presentations. But equally important to the future of the aviation industry will be the establishment of international standards to ensure that proper actions are being taken around the world. At present, he noted, there are various restrictions and quarantines in different parts of the world, and “while the passenger may feel safe to fly in an airplane, getting there and being quarantined for 2 weeks is not going to work to get recovery and travel back up on a consistent basis.”

Reviewing the various steps that have been taken to deal with the pandemic, Shahidi pointed out a number of areas where international standards will be important. For example, he quickly listed many of the improved airline procedures that other speakers had described—contactless check-in, required masking, improved and more frequent cabin cleaning and disinfection, the use of new technologies, and so on—but added, “while certain airlines have certain practices, if those practices are not harmonized internationally, then we’re going to have issues in those other countries where they don’t have those practices.”

Similarly, concerning the work done by airports, Shahidi said that the Airport Councils International has done significant work over the past year in providing health accreditation program across the world as a standard to help ensure that airport health measures are aligned with international guidelines. “That was very important work, and that work continues,” he said.

Passengers also have a role in reducing the risk of COVID-19, he said, and he mentioned in particular a set of “COVID-19 golden rules” that the Flight Safety Foundation published after working with WHO and the world medical community to define the proper role of the passenger. The rules include such things as “If unwell, do not travel or go to work” and “Comply with personal protective equipment requirements,” and the foundation has offered a number of webinars internationally to discuss the need for heightened awareness by passengers and on what air passengers should be doing.

Concerning COVID-19 testing, Shahidi said that international standards are going to be very important. There needs to be some general agreement on what tests are acceptable for screening passengers for air travel so that passengers do not have to worry about getting different tests for different countries. WHO and other international organizations are now working on test protocols that could be used for international travel.

In particular, he said, there are a number of questions that need to be addressed about both pre-flight and post-flight testing. How close to a flight should a test be given? And what about exposures after the test but before the flight? Should passengers be tested upon arrival, and when? What exactly will be required for arriving passengers to be able to avoid quarantine?

Vaccination has similar issues. Many people have suggested the use of “vaccine passports,” but what will that entail, both domestically and internationally? What will be the requirements? How can the aviation community work with the medical community to create a harmonized and seamless process to facilitate international air travel?

In concluding, Shahidi reiterated that international cooperation is going to be important for the air transportation sector to recover. The Flight Safety Foundation has called for cooperation among governments and health authorities, airlines, airports, manufacturers, aviation professionals, and WHO and the International Civil Aviation Organization “to really work together and have a coherent, coordinated internationally harmonized standard set of protocols to bring all of these different elements of the ecosystem together, so we can get this industry back up into recovery.”

The Role of Original Equipment Manufacturers

Dealing with a pandemic requires an end-to-end approach, Manning said, involving not just the aircraft and airport but also people—passengers, flight crew, ground crews, cleaning crews, and so on—and the broader society. Airlines and airports already had many safety-related procedures in place before the pandemic, she said, but they need to be revised with an eye on what is required for operating in a new reality. And, as priorities have changed for airlines, Airbus and other OEMs have also had to adapt.

It was not just the OEMs, of course, but any other organizations working with the airlines, such as the maintenance, repair, and overhaul organizations, she said, and Airbus has worked to coordinate with these as well. “We tried to develop solutions and agree on things we can all live with,” she said, offering as an example how Airbus and Boeing agreed to standardize the allowable disinfection liquids for both types of aircraft.

In the wake of the pandemic, Airbus has worked to determine exactly role it should play beyond selling its aircraft to airlines. For instance, she said, Airbus does not generally interact with passengers, but it does sometimes offer advice to organizations that seek its views. But it must be careful, she said, as while a U.S. airline might take the advice as one piece of information among others, in some places in the world an Airbus recommendation is treated more like a command. “So we have to be quite careful what we’re proposing.”

The aviation industry as a whole, including OEMs, airlines, airports, and others, must work collectively to ensure that air travel is safe, secure, and healthy. The focus on safety has existed for decades, and security has also been a major focus since at least the 1990s, but the focus on health is relatively recent and has really come to the fore with the COVID-19 pandemic. Thus it requires the aviation industry to engage in new thinking to determine the best approaches for ensuring the health of passengers. Furthermore, she added, it is not enough to be safe, secure, and healthy, but people must believe it. And this is something that requires contributions from the entire industry.

So what role should OEMs play in the overall response to COVID? Manning pointed out that the aircraft designs must take into account how the aircraft interacts with the terminal, with boarding crew processes, with maintenance practices, and so on, so as various practices change in response to the pandemic, Airbus and other OEMs need to be part of it. It will be most effective if decisions are made collectively about what new practices and protocols will work best in preventing COVID transmission during air travel.

People at Airbus strongly believe that the pandemic will change how people fly, and they want to be prepared for those changes, Manning said, but there remain many unknowns. For instance, it will often be other companies developing substances for use in disinfecting aircraft, but Airbus needs to know how they will interact with the aircraft and how, for example, they will affect maintenance procedures.

“Our customers are going to need to adapt to their passengers’ new and changing expectations,” she said, “so we’re exploring more mid- to long-term concepts that can bring benefits to both passengers and the crew.” For example, in dealing with hygiene issues there is likely to be an increasing emphasis on health as opposed to just cleanliness. “Those aren’t necessarily the same thing.” Airbus’s market insight team is working to understand the likely changes in passenger and society expectations, Manning said, because those changes are likely to have as much effect on air travel as potential new international regulations.

Concerning aircraft design, she said that designers and engineers are working to create a cabin “that essentially it keeps itself clean using new materials, environmental control systems, touchless features, lighting, and design, all working together.” This offers a variety of challenges, she said, mentioning as an example anti-microbial surfaces that require sunlight to be activated. Since aircraft cabins have little sunlight, it requires lighting experts and surface experts working together to find a solution.

Touchless technologies are already in use, but Airbus is looking to incorporate more of them, Manning said. It will be important that they be robust because the worst outcome is to have a new touchless device that is more likely to break down that the device it is replacing.

Adapting to the Future of Air Travel

Keskinocak began by saying that her background and research are in the fields of logistics and supply chain management as well as health systems, particularly in infectious disease modeling, and that she would bring these different perspectives together to offer some insights into the future of air travel and how the industry might adapt to that future.

The COVID-19 pandemic brought variability, uncertainty, disruptions, and complexity to the air travel industry. Historically airlines have depended on various predictable trends—such as higher demand on certain routes during summer months—to plan their operations and achieve a balance between profitability and customer satisfaction over the past decades. To this end, many airlines have become avid users of data, analytics, and systems engineering methods in making decisions in such areas as fleet planning, maintenance, ground operations, flight and crew scheduling, price and revenue management, and disruption management. These sophisticated methods are still likely to be of use to airlines in the long term, Keskinocak said, but they may need to make some significant adaptations. In the wake of the COVID-19 pandemic, for example, passenger preferences might change across markets.

Airlines have typically responded well in the past to disruptions and disease outbreaks, she said, but the disruption caused by the pandemic has been on a scale unlike any that the airline industry—or the world—has seen. The disruption is due mainly to travel restrictions imposed by various countries combined with passengers choosing not to travel because of health and safety concerns, and some changes in preferences may be long-lasting. Perhaps, for instance, there will be a greater demand for nonstop flights because of quarantine rules or worries about contracting disease during stops. There is also the possibility of changes to the larger structure of the industry, she said; it is not clear, for instance, whether the hub-and-spoke network in use today will continue to be profitable in the future.

Then, noting that most of the workshop’s presenters had been focused on the passenger side of the airline industry, Keskinocak turned to the issue of air cargo and, in particular, the implications of the changes in passengers travel patterns on cargo capacity and supply chains.

In the wake of the COVID-19 pandemic, available cargo tonne kilometers—a metric used to measure industry-wide cargo capacity—fell by 23 percent through 2020. Before the pandemic, about 60 percent of total international

cargo capacity was in the bellies of passenger aircraft, but, with the drastic decrease in passenger flights, only around 33 percent of international cargo is now being carried in airline bellies. Some airlines responded by removing seats from passenger craft to turn them into freighters, and there was an increase in dedicated cargo capacity of about 20 percent in 2020. However, Keskinocak said, this did not completely make up for the 53 percent decrease in belly cargo capacity, so total cargo capacity dropped in 2020 (Figure 6.3).

It is important to maintain international air cargo capacity, she said, to keep supply chain lines open during the pandemic and beyond in order to ensure the timely delivery of medical equipment, supplies, and other goods being between different parts of the world. The drop in cargo capacity seen in 2020 led both to high cargo rates and record cargo load factors as well as to some shipping delays during the year.

Even after the pandemic is over, she said, it is likely to take several years for the airline industry to return to the pre-pandemic normal—if that happens at all. According to surveys of companies, business travel for most companies will not return to previous levels for at least 2–3 years, and about a fifth of companies said it would never return to normal. “The impact on the airline industry will be significant,” Keskinocak said, “given that business travel accounted for 55 to 75 percent of their revenues prior to the pandemic.”

The outlook for personal travel is more positive, she added. “People have been stranded in their homes for months and are looking forward to traveling soon.”

Turning to disease modeling, Keskinocak said that such models can aid in decisions in various areas, such as predicting the effects of various intervention on the spread of the disease. In addition to information about the disease itself and its spread, she said it is important to incorporate human behavior into a model. How likely, for example, are people to comply with a mask mandate? What difference can various communication strategies make?

One area in which modeling can play an important role is logistics. Models can be used to estimate the need for various resources, such as personal protective equipment, hospital beds, and ventilators and to identify areas that are likely to experience shortages.

Keskinocak’s group has modeled various aspects of the COVID-19 pandemic, and she offered several lessons learned from such modeling. First, shelter-in-place policies do help slow down the spread of the pandemic, but they do not have a significant effect on the eventual total number of infections. Their best use is to buy time for preparedness. Similarly, school closures buy time, but they are disruptive. Alternating-day schedules are a reasonable way to reopen schools, as the risk with respect to infection for such a reopening are not much worse than keeping the schools closed and keeping children home. She noted that there is a significant difference between reopening schools and reopening restaurants, bars, or air travel. In one case there is the same small group of students gathering in a classroom on alternating days with proper public health measures, while air travel leads to the mixing of pas-

sengers from around the world. The key factors in transmission are the number of contacts, frequency of contacts, proximity of contacts, and duration of contacts, and these factors can be much better controlled in a school setting.

One particular issue that Keskinocak’s group looked at with modeling was the combined effects of vaccines and non-pharmaceutical interventions, such as masks and social distancing. Assuming a 6-month rollout of the vaccines and either the continuation of non-pharmaceutical interventions or the cessation of such interventions, they simulated what would happen under various assumptions about the efficiency and the population coverage of the vaccine. Even when the vaccine had low efficiency and low coverage, a population that kept using the non-pharmaceutical interventions pushed the rate of new infections down to near zero, while the populations that stopped using those interventions saw new waves of infections even with the vaccines (Figure 6.4). And, Keskinocak noted, with the appearance of new variants that may not respond as well to current vaccines, the continuing use of non-pharmaceutical interventions is even more important.

Keskinocak closed with a look to the future. In the short and medium term, she said, it is likely that the various procedures that have been implemented in response to the pandemic—mask wearing, cleaning and disinfection procedures, air filtration, and so on—will continue, perhaps with an increased use of pre-flight testing and possibly post-flight testing, combined with tracing and isolation as needed. Regular testing and additional protective measures for employees will continue to be very important, she said. And a return to pre-COVID-19 passenger volumes without significant changes to passenger flow simply does not look feasible, she added, at least if airlines wish to maintain physical distance in airports. “So we need some creative designs or technologies to help us transition back to higher volumes and hopefully towards touchless travel,” she said.

Digital passes may come to play a larger role, not just for COVID-19 but possibly for a variety of diseases, she said, with passengers required to show them prior to boarding an airplane or even entering an airport.

And there are likely to be some changes to the network structures and flight schedules. This could motivate new aircraft designs, and if airlines start moving away from hub-and-spoke networks toward a more to end-to-end structure, this will have various implications for access equity, particularly for people in smaller cities, which could also have economic implications for smaller cities.

The Future of Airports

Disruption creates opportunity, Cohn said. In the case of the airline industry, he pointed to such examples as the invention of the modern boarding bridge in 1958, deregulation in 1978, and the introduction of the Airbus A380

in 2005, which led to changes in apron, terminal, and airfield design. And he quoted Clark Gilbert, as assistant professor of business at Harvard Business School, who said, “In every industry changed by disruption, the net effect has been total market growth.” So what opportunities will the response to the COVID-19 pandemic create?

The COVID-19 pandemic, Cohn said, has accelerated the adoption of various trends in the airline industry which otherwise might have taken years to be fully developed and implemented. In particular, various innovations in terminal design, such as automated boarding gates and biometrics, have been accelerated to meet COVID-related demands for a safe and socially distant passenger experience.

Along those lines, Cohn focused on six planning trends that had already gotten started before the pandemic but that are now receiving extra attention as ways to build passenger confidence, speed up processing times, reduce touch points, and improve the airport experience in various other ways.

First is changes to the check-in lobby. “It has been a thorn in the side of airport planners for a long time,” Cohn said. Early terminals had vast check-in halls with long counters and long lines of people waiting to talk with an agent behind the counter. Recently, however, there has been a trend to smaller check-in lobbies as passengers have shifted more to self-service, and in many airports, he said, data suggest that nearly 50 percent of passengers may not even need the check-in hall because they have no luggage to check, they have already checked in on their phones, or some other reason. So the check-in lobby’s importance is changing.

A second evolution is occurring in passenger and baggage screening. It began a couple of years ago with such innovations as automated screening lanes and pre-check, which make it possible to screen passengers more quickly and with less contact. Some new technologies are emerging, he said, that should reduce the amount of items that have to come out of bags by reducing some of the false alarm rates and smoothing out the screening process.

Virtual queuing is another example of ways that airports are trying to flatten peaks and reduce the amount of time that passengers are waiting in line. Airports are examining programs similar to Disney World’s FastPass program that would allow passengers to come to the airport at a specific time and get front-of-the-line access. Some airports, such as Montreal Trudeau, have been doing this for almost 10 years now, he said. More recently, Denver International Airport has introduced a virtual queuing program for health-conscious passengers.

A fourth trend is the use of biometrics. Passengers seem to be more willing now to give up their biometric token as a way to get through a process faster, he said, and biometrics are now being seen at check-in, at security, at boarding, and at immigration as a way to speed up processing times, reduce queuing, and reduce touch points. One of the challenges with biometrics is the lack of a centralized biometric database for such things as U.S. driver’s licenses, but, he said, the challenges will likely be overcome as the airport community collaborates with other agencies on bringing biometric information to the airport community.

There are also various low-tech solutions being implemented, such as making terminal spaces more flexible and dynamic, especially in hold rooms and concessions, which can help mitigate dense terminal areas. “This could take a couple of different forms,” Cohn said. “It could take the form of dynamic seating, for example—high-top tables, low tables, chairs that face each other, chairs the face away, allowing people and their parties to select how they want to sit in the hold room.” Another improvement would be to give passengers access to flight information so that they no longer feel that they must stay close to their gates for fear of missing their flights or some important announcement.

The last trend, Cohn said, is in the area of disinfecting and hygiene. There are various improvements being made in this area, such as dynamic restroom cleaning—that is, cleaning restrooms when they need it instead of on a fixed schedule—as well as virus-resistant surfaces and improved air circulation, which could give passengers the ability to have tabletop workstations and private phone booths. “All of these things are creating opportunities for improvement in the way terminals are designed and function,” Cohn said.

Various entities, and not just airport management, are driving these changes, Cohn said. In the United States, airports do not control as much of the airport environment as one might think; airlines and other stakeholders can wield a fair amount of control. In some airports, for instance, airlines or airline consortiums operate long-term leases and can decide what they wish to do inside their individual terminals.

As an example of the changes being driven by stakeholders other than airports, he pointed to Delta and Jet Blue, which were early adopters of biometric boarding. In Atlanta, Delta’s biometric terminal F is the airline’s curb-to-gate experiment for using a biometric token to allow passengers to depart the airport. Similarly, U.S. Customs

and Border Protection has developed a simplified arrival process using biometrics that is intended to help speed up immigration. Some airlines are starting to use the VeriFLY program which allows health-conscious passengers to have exclusive access to a security lane and a train car to go out to the concourse as a way to encourage social distancing. And some airports are also driving innovation by developing their own innovation teams, Cohn said, mentioning the San Diego airport as a specific example.

In closing, Cohn offered a look at the future of airports. Clearly COVID-19 has forced the industry to adapt, he said, but many of the changes that are occurring in response to the pandemic are actually changes that have been long desired by passengers. For years surveys have shown that air passengers express interest in things like increased use of technology, increased use of biometrics, being in control of their journey, not having to wait in long lines, and reducing human interaction to the that it is only necessary if there is an issue or a problem. Carrying out such changes is a way to maintain passenger confidence, he said. So understanding passenger expectations could inform design prioritization going forward, he said, “so instead of waiting for the pandemic or something else to drive change,” airlines should realize that what passengers want may actually align with where the industry needs to move

LESSONS FOR THE AIRLINE INDUSTRY FROM OUTSIDE THE INDUSTRY

Looking outside the traditional borders of the air travel industry, several workshop presenters offered insights from other areas that could, they said, be applied by the aviation industry to improve its response to COVID-19 and any future pandemics and, more generally, make the industry stronger, more capable, and more resilient. David Walt, a professor at Harvard Medical School, illustrated the value of collaboration by describing how the Mass General Brigham system adapted to meet the challenges of the COVID-19 pandemic. Leonard Marcus, co-director of the National Preparedness Leadership Institute, spoke about the importance of preparedness and leadership. Celine Gounder, a clinical assistant professor at the New York University Grossman School of Medicine, discussed taking a public health approach to dealing with the COVID-19 pandemic and to use that to prepare for future pandemics. Francesca Manca, a research associate in the Department of Civil and Environmental Engineering at Imperial College London, described some research findings on attitudes toward travel among passengers in the COVID-19 world. And Lindsey Leininger, a clinical professor of business administration at Dartmouth University’s Tuck School of Business, discussed ways to be successful in educating the public about the COVID-19 pandemic or other science-related issues and illustrated that with her own colorful experiences.

The Value of Collaboration

In describing how the Boston clinical research community responded to the COVID-19 pandemic, Walt did not touch on the aviation industry per se, but he said he believed that the lessons learned from that response can be applied in aviation and help accelerate how the community responds the next time.

Boston was an early COVID-19 hotspot in the United States because of a Biogen conference with approximately 125 attendees, which was the first U.S. superspreader event. More than 50,000 infections, both domestic and international, have now been traced to that event, he said. Shortly after that conference, the numbers of COVID-19 patients in Boston hospitals began to increase and stress the system because of shortages in personal protective equipment (PPE), ventilators, and diagnostic testing materials.

In response, leadership of the Mass General Brigham system created the Mass General Brigham Center for COVID Innovation, of which Walt is a co-director. “We felt that we had an advantage,” he said, “because Mass General Hospital and Brigham and Women’s Hospital are two of the largest research hospitals in the country, and the combined MGB System has the most research funding of any medical system in the United States.”

Within a few days of establishing the center, 2,000 people had volunteered to take part. Many of them were willing and able to pivot from what they had been doing to COVID-related work. As an example, Walt said that 8 of the 20 people working in his laboratory volunteered to pivot to COVID diagnostics work even though only two people in the laboratory had infectious disease experience.

The center operated with the following four pillars: a devices pillar that dealt with things like PPE, a diagnostics pillar that dealt with testing issues, a data analytics pillar, and a therapeutics pillar. A key strength was

that there was great collaboration across all four pillars. “Clinicians at this time were encountering problems on a daily, if not hourly basis,” he said, and in addressing those problems, the center took advantage of what Walt called “unprecedented interactions between clinicians, researchers, and engineers.” Typically, scientists, clinicians, and engineers work in silos. “In this case, it was just a seamless interaction between them, with clinicians on a daily basis identifying problems, transferring those to researchers, who then rapidly came up with solutions that could be transferred to engineers, who could implement those solutions.”

Sharing was a crucial aspect of the response to COVID-19, he said, not just at the center but across the broader community. Samples were shared. Protocols were shared. Preprint servers were overwhelmed with researchers and clinicians sharing results. And, Walt added, his group had great interactions with Chinese clinicians and researchers who at the time were a month to 6 weeks ahead of the United States in dealing with the pandemic. That sharing helped clinicians in the United States avoid repeating some of the mistakes that the Chinese had made early in the pandemic.

There was also deep collaboration between academics and industry, he said. Innovations were rapidly transferred between academic institutions and biotechnology companies not only in Cambridge, but also across the rest of the country.

Walt then offered some examples from the diagnostics area, as his specific area of expertise is in novel diagnostics and he runs the diagnostics pillar at the center.

For context, Walt explained that the demand for COVID-19 testing is three times the previous total capacity for all diagnostic testing for all diseases worldwide. How could this shortfall be dealt with? “The first solution that we came up with was to scale central testing.” Specifically the center engaged the Broad Institute in Boston which carried out high-throughput screening for genetic sequencing. The institute turned its robotic systems to sample processing and were able to carry out tens of thousands of samples per week, which has now been scaled to about 200,000 tests per week. But increasing testing capacity was not enough. Delays in collecting samples, transporting them, and reporting the results back to the individuals or their physicians slowed the time from sample to result by at least 24 hours. To deal with this, the center decided to rely on distributed testing using point-of-care platforms, such as could be deployed at urgent care centers or primary care physicians’ offices. And eventually, Walt said, the goal will be to migrate to at-home and at-work tests, so people can do them on their own.

The center set up a laboratory to evaluate and validate the new types of tests that were being developed. To their surprise, Walt said, they found a staggering 2,000 diagnostic test platforms under development globally. Most of them were created by small-scale operations, with virtually no manufacturing capability and no experience with diagnostics, that validated their systems on a small number of samples under ideal conditions and submitted them to the Food and Drug Administration emergency use authorization. This resulted, Walt said, in a number of high-profile failures of diagnostic tests after they began to be used with real samples in populations with much lower prevalence. “There were all these false positives, all these false negatives, and it was frankly a disaster.”

The lesson, he said, is that with diagnostics—but also across the system—it is important to have standards. And scale really matters. Small companies had no capacity to manufacture the numbers of tests needed, he said. “So we really need the scale of the larger companies, and you see companies like Abbott, Becton Dickinson, and Roche beginning to step up because they have not only the diagnostics capacity, but the manufacturing capacity to back it up.”

Looking to the future, Walt said it is not just about the technology and the science. “We need to implement policies, establish protocols, and reduce barriers.” Things needs to be in place beforehand in order to avoid many of the missteps that plagued the early response to COVID-19. And success will also depend on having responsible decision makers—in hospitals or the aviation system—to have a plan in place before the next emergency and to follow that plan.

As an example of the sorts of issues that can be avoided with this sort of planning, Walt described an ongoing problem with COVID-19 tests in the labor and delivery departments of the Mass General Brigham hospitals. Testing in the hospitals is controlled by the infection control staff and the clinical laboratory, and since they want the most accurate test, they require polymerase chain reaction (PCR), which is the gold standard. The problem is that it has a turnaround time of 2 hours under the best of conditions, and there are many women who come into the hospitals and deliver their babies in less than this time. There are rapid tests available, but they are not as accurate as PCR, so the clinical laboratories and the people in infection control resist using them. As a result, health care workers sometimes do not have the information they need to identify infected women quickly and take the necessary precautions.

“The rapid tests aren’t perfect,” Walt said, “but they’d be better than no information.” So 12 months into the COVID-19 pandemic, the different parties are still working out things that should have been worked out well in advance. “We’re now finally getting all the parties together to figure this out,” he said, “but, as I said, it would have been better to have these procedures in place prior to the pandemic.”

The lessons from this experience can be applied in all sectors, including aviation, Walt said. Collaboration, openness, innovation, and sharing can make it possible to go from problem identification to implemented solutions in significantly compressed timeframes. “Yes, there are some institutional barriers,” he said, “but the lessons learned—rapid pivoting, market pull rather than tech push, and deep and seamless cooperation, collaboration—can benefit the aviation community and can be broadly applied across all sectors.”

Preparedness and Leadership

Dealing with crises such as the COVID-19 pandemic requires appropriate preparedness and leaders, and Marcus told the workshop about an initiative formed to deal with that pandemic and some of the broader lessons that initiative offers concerning preparedness and leadership.

In July 2020, the Aviation Public Health Initiative was formed by Airlines for America and a coalition of airport operators, airlines, and aircraft and equipment managers. It includes a team of faculty and associates from Harvard University’s T.H. Chan School of Public Health, including experts in infectious diseases, medical and industrial hygiene, epidemiology, and the social sciences. The project, Marcus said, takes a systems approach to problem assessment and solution building, engaging a wide variety of key aviation industry stakeholders. The goal of the initiative was to form a comprehensive understanding of the intersection between science informing COVID-19 transmission and the operations within the aviation environment.

For context, Marcus explained that what is taught at the National Preparedness Leadership Institute is done in the framework of “meta-leadership.” A person who thinks in terms of meta-leadership looks at problems from a very, very broad perspective and attempts to create connectivity of effort among all the different stakeholders who are involved. For crisis leadership in particular, it is crucial that the different stakeholders are oriented toward helping one another to be a success, he said. “That is a critical principle of meta-leadership.”

Turning to the COVID-19 pandemic, Marcus said that it is useful to think of a crisis proceeding through an arc of time. “Every crisis has a beginning, a middle, and an end,” and each part of the crisis requires a different approach. One can, for example, think of the COVID-19 crisis as “a simple series of events, each of them distinct, that require their own attention.” One arc of the COVID crisis can be seen in the surge that began around Thanksgiving and was beginning to subside around the time of the workshop. The vaccination phase is another arc, and in the future there will be an arc of time where the country—and the aviation industry—starts to recover.

In looking at leadership through this lens, he said, it becomes clear that one should not wait until being in the middle of the arc to prepare. “So the point here for the aviation industry,” he said, is “we can anticipate that there will be a future arc of time in which the vaccination program is beginning to subside, it has vaccinated a good portion of the population, and we have that herd immunity.” Now is the time to start thinking about how to approach that post-pandemic period with its various measures that need to be put in place to reduce the risk of disease spread over the long haul.

Marcus explained that the Aviation Public Health Initiative not only consists of a collaboration among many pieces of the aviation industry, but it is also in dialogue with a variety of government agencies, including the Centers for Disease Control and Prevention, the Transportation Security Administration, the White House Coronavirus Task Force, and others. This makes it possible for the initiative to share data widely and to have an ongoing dialogue with many different players in the airline industry and the response to COVID-19. This is in line with the idea of meta-leadership, which calls for building good situational awareness and as much connectivity as possible.

A Public Health Approach to the COVID-19 Pandemic and Beyond

In thinking about the best ways to deal with the COVID-19 pandemic and other such pandemics in the future, Gounder said, it is useful to think about them from a public health perspective. Looking at it from that angle, she

continued, it is clear that COVID-19 points toward a world that is facing unprecedented public health challenges. The combination of increased global travel, climate change, overpopulation, deforestation, and other factors is accelerating the emergence of infectious diseases, some of which will become epidemic and some of which will become even pandemic. Just in the past 10 years, she said, the world has seen the emergence of MERS, SARS, Ebola, Zika, and COVID-19 as well as resurgences of polio and measles. Much of this can be traced to the fact that travelers can go from isolated rural villages to any major city worldwide in less than 36 hours, so it is easy for people to travel from areas of disease outbreak and seed their infections elsewhere. And indeed, she noted, much of the focus of the 2-day workshop had been on how to reduce the risk of COVID-19 and other infectious diseases at airports as well as in flight.

However, she added, it is important to recognize that the window of risk for transmission is not just during travel and that the incubation period for many infectious diseases is longer than the time it takes to travel around the world. Furthermore, many infected travelers are allowed to board planes and travel around the world because they show no symptoms, either because they are still incubating the infection or because it is an asymptomatic infection. Thus the real risk from travel arises from people from different places mixing together, regardless of how they traveled from one place to another. “If there is anything that COVID has taught us,” Gounder said, “it is that it’s the people we trust the most—our family, our friends—who are most likely to infect us and who we’re most likely to infect.” Thus the virus is able to “hitch a ride on our love for family and trust of family and friends.”

Thus it is important to think about more than just what happens in airports and on flights and to look beyond the current pandemic and consider the pandemic and its lessons from a public health perspective. “I think we need to rethink our public health surveillance and infrastructure for a modern globalized world,” Gounder said. Furthermore, “we should be thinking of transportation systems and hubs, including our airports and plane flights, as active agents in our global public health system.”

As an example of how the transportation system could be thought of as a part of the public health system, she suggested that airports could function as sites of public health surveillance, particularly in resource-limited settings. “They could serve as sentinel sites for what might emerge and spread elsewhere,” she said, “complete with laboratory testing capabilities or, at the very least, the ability to collect specimens.” Locating such testing resources in airports would make it much easier to service the laboratory equipment and deliver the necessary supplies and reagents.

Continuing, Gounder suggested that wastewater- and vector-based surveillance could also be located at airports, providing information that could help public health specialists anticipate which emerging infections might be most likely to spread via travel elsewhere in the world. Such an approach could be particularly valuable in resource-poor areas, she said. Furthermore, passengers could also be subjected to random screening for viruses, just as airports conduct random bag checks today, although such screening would need to done in a way that respected passenger privacy and civil liberties.

Airports and other transportation hubs could also serve as community health sites, Gounder suggested, complete with community health workers who specialize in the needs of different kinds of travelers. These airport-based community health sites might also offer many of the health care services available at a typical urgent care center; thus a site might offer diagnosis and treatment of a traveler who is presenting with allergies or upper respiratory infections or perhaps a gastrointestinal illness such as nausea, vomiting, or diarrhea. It could also be value to travelers, Gounder continued, if these airport-based community health sites offered such things as vaccines for influenza and other travel-related infection, malaria prophylaxis, testing for HIV and other sexually transmitted diseases, and contraception. In addition to helping travelers with such health care issues, the sites could deliver essential preventive public health services and, at the same time, collect data on symptoms and diagnoses that could be fed into public health surveillance systems.

Some airports are already hosting community-based COVID-19 testing, Gounder said, and these could be the basis on which to build airport-based community health sites. In New York City, the Test & Trace Corps, a partnership between the New York City Department of Health and NYC Health + Hospitals, is currently offering free walk-in rapid COVID-19 testing at all New York City area airports. Anyone who tests positive is connected with a contact tracer for accelerated contact tracing and is also told about a program that offers free resources for individuals to safely isolate at home or in a free hotel room with wraparound services, including food and medical

support and monitoring. This sort of housing and wraparound services may also be important in the future in cases where some countries have a lower threshold for implementing travel restrictions during infectious disease outbreaks.

Finally, Gounder suggested, airports could help in changing social norms concerning what are considered to be reasonable universal precautions, such as mask wearing and hand hygiene. “Just as every passenger is given a drink and a snack, perhaps in the long term post-COVID we should be giving every passenger a surgical mask and hand sanitizer when they’re checking in for a flight or clearing security or boarding an aircraft.”

In closing, Gounder reiterated that her goal is to reframe people’s thinking. Instead of simply thinking about how COVID will affect the commercial airline industry,” she told the workshop audience, “I’d like to ask us to think a bit bigger: What role do our transportation systems have to play as global public health agents?”

Attitudes Toward Air Travel in the COVID-19 Era

Manca spoke about consumer attitudes to air travel in four cities around the world: London, New York, Shanghai, and Sao Paolo. His research is part of a broader project called ACCLAIM, which is funded by the UK’s Engineering and Physical Sciences Research Council and whose aim is to understand and model air traveler behavior and choices. There were two rounds of web-based surveys, one in 2019 and one in 2020, with the latter adding questions about attitudes toward COVID-19.

The main objective of the part of the survey that Manca described was to investigate how people make decisions about air travel in the context of the COVID-19 pandemic and to see if and how those decisions and attitudes might vary from city to city and country to country. The respondents to the survey were given hypothetical scenarios that might take place once flying was once again feasible, and they were asked about their preferences in those situations. Manca noted that the survey was given to residents of the different cities on different weeks and that the cities were in different phases of the pandemic when the survey was given. For instance, when the survey was given to people in Shanghai, the pandemic had been under control for several months, while Brazil was just coming down from a major peak when the survey was given to those in Sao Paolo.

The survey asked respondents about six hypothetical trips that varied in several ways: short-haul versus medium-haul versus long flights, cost of the flight, whether there was a transfer between planes, total time spent at the departure airport, and total time spent at the arrival airport. The respondents were told that the various differences were due to measures that the airports and airlines had taken to ensure safety in the face of the pandemic. For example, the fare might be higher because of the reduced demand for flights or the reduced capacity of the aircraft, and the time spent at the airport could be higher because of longer queues caused by social distancing or the need for passengers to take a test.

The survey also included a number of attitudinal questions on such things as safety concerns during traveling and the frequency of video calls made with family and friends living in other cities or for work before, during, and after the pandemic. The survey also included items designed to test for the “Big Five” personality traits: extraversion, agreeableness, conscientiousness, neuroticism, and openness.

Discussing the results of the survey, Manca first reported that there had been a significant change between the 2019 and 2020 survey in how likely people said they were to choose to fly instead of just communicate with people via video calls. In Sao Paolo, London, and particularly New York City, significant percentages of people—almost half in New York City—said they would be less likely to fly after than pandemic than before it. A much smaller percentage of those in Shanghai said that, which was probably related, Manca said, to the fact that at the point when the 2020 survey was taken, the pandemic seemed to be under control in China.

Not surprisingly, the survey found that respondents in all four cities reported having used video calls, both for business and personal reasons, during the pandemic than before it. When the respondents were asked how much they expected to use video calls instead of travel after the pandemic compared with before, large percentages of people in London and New York said their use would be about the same, while those in Shanghai and Sao Paolo were more likely to say that they would be using video calls more often.

To understand the factors behind individuals’ choices, Manca’s group analyzed the decisions individuals indicated that they would make versus their answers to questions about safety. Three explanatory factors emerged:

individuals’ worries about COVID-19—that is, their concerns about catching of passing on the virus); attitudes toward safety measures, such as how safe they felt when wearing a mask; and attitudes toward quarantines, such as not traveling in the case of a quarantine.

Next Manca described some of the trade-off choices that passengers make. For example, passengers in all cities were more sensitive to the cost of air travel when it was personal travel than when it was for business. London and New York travelers were the most sensitive to cost, especially for personal travel, while Shanghai travelers were less sensitive.

Concerning attitudes and perceptions, Manca found that London and Sao Paolo travelers who were more concerned about catching COVID-19 at the airports or on board the plane were less likely to travel; the other two factors—attitudes toward safety measures and attitudes toward quarantines—did not make a significant difference among these travelers. By contrast, it was the safety measures factor that was significant among New York travelers, with those who said they would comply with mask mandates at the airport and on the airplane and would prefer an empty seat next to them being less likely to travel in general. Finally, quarantine issues were most important to Shanghai travelers, with a significant number saying they would be less likely to travel if they might face a quarantine upon arrival or return. “Again,” Manca said, “this is because in China the quarantine has been very strict since the beginning of the pandemic.”

In closing, Manca offered some basic conclusions that can be drawn from the study. A future increase in fare could affect demand much more in London and New York than in Sao Paolo or Shanghai. Long waits at the airport, e.g., for testing, would be more acceptable upon arrival for people from New York and upon departure for those from London and Shanghai. In all cities, but especially in Shanghai, the willingness to pay for nonstop flights is much higher than it was before the pandemic; this seems related to the fact that a transfer between flights or even just a stop with people getting on or off means more social contacts and a greater risk of contracting the virus. And safety perception plays a big role in air travel decisions. Thus, Manca said, he recommends that airlines consider targeted campaigns to inform potential travelers about safety measures in order to convince more skeptical travelers that it is once again safe to travel.

Educating the Public

Leininger described to the workshop her experiences with a group of “nerdy girls” explaining COVID-related science to the public. It began, she said, when she and a group of friends and colleagues realized that they all had a commonality—that they were getting many COVID-related questions from friends and family and their professional networks. The questions were things like, “Should I be wiping down my groceries?” or, “Should I be scared to walk in a park again?” So, thinking it would be more efficient, they banded together to create a Facebook page and answer the questions there.

That initiative grew into their current, called Dear Pandemic—a play off of the old Dear Abby columns—which publishes two posts a day answering questions from the community. It is run by an all-female team, with 14 Ph.D. and M.D. scientists with a wide range of disciplinary expertise, including health policy, social and infectious epidemiology, immunology, family medicine, and behavioral health. They now have 67,000 community members on Facebook, and nearing 11,000 on Instagram. “So here we are, the nerdy girls explaining the pandemic to America,” she said. “Three hundred traditional media appearances later, talks everywhere from K-12 classrooms to the halls of Congress, it’s been a true honor.”

One of the things she has learned from the experience, Leininger said, is that there are three types of personas that one sees again and again when talking about risk, when related to COVID-19 or in some other area. There is Nervous Ned who is quite cautious: “Oh, my goodness, I am not interested in the vaccine. That’s a new technology. No, thank you.” Ned requires plenty of talking and hand holding. Then there is On-the-Fence Fern, who is perhaps persuadable but wants more information. And then there is No Biggie Ben. He doesn’t worry about anything: “Okay, fine, that’s great.”

To illustrate, Leininger offered a quote from one of 70 Dartmouth M.B.A. students whom she surveyed about attitudes toward flying. These students are familiar with air travel, she said, “and in better times they travel frequently for leisure, and many of them go work for consulting firms who have them on the road for 5 days a week.”

One of them, a Nervous Ned, said, “I won’t be ready until after I get the vaccine and the U.S. achieves herd immunity. I feel fear. Every flight is a possible super spreader.” It is not a representative, stratified sample, she acknowledged, but it does illustrate the sort of attitudes that she has found in her work with Dear Pandemic.

In her work as a public risk communicator and health educator, Leininger said she has faced a variety of challenges. The first, she said, is that trust is fragmented and fragile. “We are no longer living in a world where everyone gets their information from Walter Cronkite. There’s no single source of truth, and in fact the digital revolution and all the social media has taken a sledgehammer to that monolith of trust.” Instead, the trust that exists today is decentralized and spread out over different players in the information ecosystem. This is something she said that she wishes she had been more savvy about when she started her communication efforts—the way that misinformation and the fragmented trust were going to wreak havoc with the nation’s pandemic response.

Furthermore, confusion rules the day. There is so much information floating around—some of it true, some of it not—that people get confused. They feel as if they are operating in a fog. WHO refers to this crisis of too much information as an “infodemic.” As a journalist, Leininger said, she often finds it difficult to get to a single source of truth.

Another issue is the common presence of fear, anxiety, and panic in today’s world. It is important to embrace this, Leininger said, and to “lead with empathy.” This is similar to advice found in the public health crisis communication playbook from the Centers for Disease Control and Prevention that states that it is important to contend with people’s fears and their emotions because “that is really what rules the day.”

Different audiences require different messages and different messengers, Leininger said. She mentioned one student who felt comforted that information was coming from the Mayo Clinic. “Some people want to hear from a medical authority at a high-prestige institution.” On the other hand, she has found that many of the people who come to Dear Pandemic look to a school nurse. People who work at schools and families who have children in school have a history of getting advice from the school nurse. As a result, she said, “school nurses throughout this whole pandemic have been one of the most important sources; messengers of trust and public health advice.”

With these factors in mind, Leininger described the ideals that she and the other nerdy girls at Dear Pandemic ascribe to in their educational and community-facing work. First, listen and connect. Keep in mind what the other person may be experiencing—fear and heightened anxiety and uncertainty, which can make it difficult for people to think and act logically and which need to be embraced and explicitly managed. As part of that, Leininger said, it is important to be authentic. She naturally speaks in a casual tone, while others of the nerdy girls have more formal tones. Neither is better. What is important is that each of them is her authentic self, Leininger said, because “I feel like the public just can sniff somebody being inauthentic in a second.”

Second, it is important to map and engage the relevant information ecosystem, she said, and the key to do this is forming partnerships. The need for this has its roots in the fragmented nature of where different people get their information today. For instance, she said, most of the people she talks to will not trust anything that comes from an industry stakeholder. “They’re just distrustful, and so they want to hear it from someone else,” she said, “and so we have to empower an entirely new information ecosystem and think about things like micro influencers or grassroots educators.” She offered an example from her Dear Pandemic experience. He group has partnered with an epidemiologist, Emily Smith from Baylor University, who is married to a Baptist preacher and so reaches a very different community than Dear Pandemic. A second partner who is also a Texas-based epidemiologist with 150,000 followers on Facebook, she has a huge reach on Facebook. Together the Dear Pandemic group and the two epidemiologist serve almost 300,000 community members on Facebook. “We are a team, and, collectively, people have started calling us the Gal Pal squad,” she said. “So you need to put together your Gal Pal squad, whatever that looks like,” but it will need to involve both institutional actors as well as more micro influencers.

Third, transparency is crucial. “You cannot lie, you must say when you’re wrong, and you may not cherry pick the data,” she said.

Fourth, be sure to source and vet data from the best sources. Be an open, humble, voracious learner.

Finally, learning science should help guide the content. Be guided by what is known about the best ways to present information—use visuals, simple language, and other best practices.

“I hope we build out a communications educational infrastructure that is new and innovative,” Leininger concluded, “because it’s truly going to take a whole new system to get out good information, especially to drown out the bad.”