Long after the animal source of the novel coronavirus is discovered, the pathogen’s human effects fully catalogued, and the case fatality rate calculated to two significant digits, a bigger mystery might remain: Why wasn’t the United States ready for this? What happened back when SARS-CoV-2 was a cloud on the horizon no bigger than a man’s hand?
Answering that will take a long time and may not even be possible. But, like the search for a vaccine against COVID-19, people in large numbers are already at the task. About $20 million of the $2-trillion CARES Act passed by Congress in March will go for an assessment by the U.S. Government Accountability Office of the federal government’s response. The privately funded Bipartisan Commission on Biodefense, which issued an 82-page report with 33 recommendations in 2015, will also look at the nation’s performance and make additional suggestions. There are undoubtedly books in the works doing the same.
Many people, in and out of the medical world, have been expecting something like COVID-19 for a while. Since the turn of the millennium, the country has experienced a series of invasions that together form a syllabus for a course on biosecurity. Spores of anthrax—a nearly eliminated disease of herbivores—were sent in the mail in 2001 in an act of domestic terrorism. SARS, like COVID-19 caused by a coronavirus, was recognized in China in 2003 and eventually resulted in 774 deaths worldwide (but none in the United States). A strain of H1N1 influenza entered the country from Mexico in 2009, prompting an emergency vaccination campaign. The ghoulish Ebola hemorrhagic fever touched the United States in 2014 when a few patients who’d contracted it in West Africa were evacuated for treatment. Zika virus, which is especially dangerous to pregnant women, briefly circulated in Florida and Texas in 2016 and 2017 after arriving from Latin America and the Caribbean.
The United States has been preparing for these events in earnest at least since the anthrax attacks, and in some ways since the 1918–1920 influenza pandemic. How well that preparation worked depends on what response you examine, how much you expect of government, how tolerant you are of human frailty, and, of course, whom you ask.
The first-pass conclusion, however, would have to be that preparation wasn’t good enough. How else can you explain pictures of citizen seamstresses sewing facemasks for hospital workers—the equivalent of our great-grandmothers rolling bandages for doughboys in the Great War? In the eyes of many people, it was abysmal, and the fault is President Trump’s. That’s also what Martin Alperen thinks. He’s a lawyer in San Francisco and author of Foundations of Homeland Security: Law and Policy, 2nd Edition. He points to the first page of the Trump administration’s National Biodefense Strategy, released in 2018:
The United States actively and effectively prevents, prepares for, responds to, recovers from, and mitigates risk from natural, accidental, or deliberate biological threats. … The mission of the Federal Government during a biological incident is to save lives, reduce human suffering, protect property and the environment, control the spread of disease, and support community efforts to overcome the physical, emotional, environmental, and economic impacts.
“I have no idea why anyone would publish a document that had absolutely no meaning,” Alperen told me. “This is the executive branch telling itself what to do, and not doing it. I don’t think we need to go farther than that.”
But Alperen does go farther than that. On his website, and in interviews, he cites a long roster of Congressional acts and presidential memoranda before the Trump era—16 such documents. Although Alperen doesn’t make the argument, the unavoidable conclusion is that presidents before the current one had more time to prepare the country for COVID-19 than Trump did. Equally clear is that the president’s assertion that he was provided nothing by his predecessors is comically, or tragically, incorrect.
In 2001, the Joint Commission—the nonprofit organization that accredits more than 20,000 hospitals and clinics in the country—for the first time required that hospitals address preparedness for emergencies such as bioterror attacks. In 2005, the George W. Bush administration released its 12-page “National Strategy for Pandemic Influenza” report in response to the outbreak in Asia of H5N1 influenza (“bird flu”), followed the next year by a 227-page “Implementation Plan.”
Addressing these two problems—the release of a biological weapon, and the emergence of a deadly strain of influenza—was the armature on which pandemic planning was built over the past two decades. What followed was a cavalcade of laws (the Pandemic and All-Hazards Preparedness Act of 2006 is one example), presidential directives (such as the one for Public Health and Medical Preparedness, in 2007), and new agencies and offices (HHS’s Biomedical Advanced Research and Development Authority, or BARDA, in 2006). Simultaneously, states and cities were making preparations, as were hospitals and some companies. Various universities and panels occasionally ran pandemic preparedness exercises similar to the military’s war games.
In 2018, the Trump administration tried to bring order to this tangle with the National Biodefense Strategy and an accompanying presidential memorandum, NSPM-14. In January 2019, the Pacific Northwest National Laboratory created the “Biodefense Policy Landscape Analysis Tool” (renamed the “spaghetti monster”), which graphically outlines 414 responsibilities assigned to 22 agencies in the National Biodefense Strategy. The GAO released a report about the progress of this lumbering behemoth, and its authors testified before a congressional committee just before the lockdown began.
Still, there’s a seductive simplicity to Alperen’s view that the federal government’s statement proclaiming its readiness was untrue. The problem is that there are 89,004 local governments in the United States, according to the 2010 Census, and it’s unrealistic to think the federal government could get them all ready for COVID-19. Nor was that ever the expectation. From the start, pandemic planning was a shared responsibility between governments; in the last decade “public-private partnerships” were increasingly invoked as essential elements, too. The mission statement of Trump’s National Biodefense Strategy is exaggerated for effect—as is Alperen’s blanket condemnation.
People who’ve been watching pandemic plans take shape over the past 15 years point to things that did work.
“The degree of innovation around surge capacity was incredible,” Eric Toner, a physician trained in internal medicine, told me. He’s a senior scholar at the Johns Hopkins Center for Health Security, where he’s been since 2004. “I never thought that places like New York would be able to accommodate the volume of incredibly sick people that they did,” he said. “I think that went really well.”
The person who’s combined useful analysis and shrill warning better than anyone is Michael T. Osterholm, a former Minnesota state epidemiologist who founded and heads the Center for Infectious Disease Research and Policy at the University of Minnesota. (He co-authored an article in the current issue of Foreign Affairs, “Chronicle of a Pandemic Foretold,” that’s the best historical perspective on the present outbreak I’ve seen.) What’s most impressed him is the work on vaccines and therapeutics that began within a month of SARS-CoV-2’s discovery. At least 28 vaccines are in development, and 250 clinical trials of treatments registered.
“It wasn’t planned as such,” Osterholm said to me. “But it’s been remarkable how we’ve been able to bring this research enterprise together in rapid order.”
The failure, as plain as the nose on your face, is the shortage of masks and other personal protective equipment. The Strategic National Stockpile—a cache of medical supplies and drugs distributed among 12 secret locations round the country—had only 13 million N-95 masks at the time of the outbreak, a fraction of what was needed. In mid-March it had about 13,000 ventilators (not all of them working); it subsequently shipped at least 7,000 to states. “One of the weaknesses in many [pandemic] plans is this assumption there will simply be enough stuff—gloves, masks, vials, needles—and if we don’t have enough, we can get it someplace,” Asha M. George, executive director of the Bipartisan Commission, told me. “COVID-19 shows the fallacy there.”
The PPE shortage emphasizes two problems repeated across the COVID-19 response. The first is the fragility of American medicine, which is now part of the just-in-time economy, dependent on daily shipments from global suppliers. The second is that many essential items are made overseas by countries that, to put it delicately, may not love us as much as we love ourselves.
Osterholm was among the first to explore the second-order effects of pandemics—for example, when diabetics run out of insulin and dialysis centers experience shortages of dialysate. His organization’s website lists 156 generic drugs with supplies that could shrink or disappear during a pandemic because they, or their active ingredients, are made in China or India.
“Are we willing to put ourselves in this situation?” Osterholm asked. “Imagine if we outsourced all of our munitions to China?” After COVID-19, these are no longer rhetorical concerns.
So, what’s the final verdict on two decades of planning going to be? “That’s like trying to call a nine-inning game after three innings,” Osterholm told me. But then he added: “Surely at the outset we were not prepared.”
But is preparation the only variable? Might human factors also be involved? A few of those come to mind.
Decisions are being made in the shadow of President Trump, who in addition to his other evident flaws is turning out to be among the more intimidating presidents in American history. That would seem to explain one especially regrettable episode of the past few months—the March 6 visit to the Centers for Disease Control and Prevention by the president, CDC Director Robert Redfield, HHS Secretary Alex Azar, and an entourage of lesser lights. Trump wore a red “Keep America Great” hat and a black bomber jacket. During his nearly hour-long recorded visit, Trump made his famous assertion that “anybody that needs a test can have a test.” The more extraordinary statement, however, came from Redfield.
“I think at this point, again — and we’ve said this before and the Secretary can add — you know, the overall risk to the American public does remain low,” Redfield said. He repeated the idea a few seconds later: “We’re going to see more cases because we’re getting more diagnostics out there. But I would say that — again, what I said before that — that, at the present time, the general risk to the American public remains low.”
This assertion is as if the director of the National Weather Service had stood on Canal Street on August 26, 2005, and declared that the risk to New Orleanians from Hurricane Katrina “does remain low.” Such a statement is true only in the most immediate and temporary sense. The storm hit Louisiana three days later, killing more than 1,800 people. At the time of the president’s CDC visit, the United States had recorded 250 COVID-19 cases and 15 deaths. As of this writing, there’ve been almost two million cases and 110,514 deaths. It’s hard to believe that Redfield’s comments were directed at anyone other than the man in the red hat.
But even if President Trump weren’t in the picture, one has to consider the natural reluctance to declare something a disaster before it actually is. The difference between a fast, near-perfect response to a disease outbreak and a late, ineffectual one is about six weeks. For actions such as securing more ventilators, buying or making more gowns, masks, face shields, and gloves, and the creation of a laboratory test on an industrial scale, six weeks is almost nothing. Unfortunately, for a transmissible virus it’s an age. A study from Columbia University suggested that if the lockdown and social distancing had begun on March 8 rather than March 15, as it did in many places, 55 percent of the deaths reported through May 3 might have been averted.
Small delays can have big consequences. That’s the first, and will almost certainly be the biggest, lesson of this pandemic.
At the same time, we haven’t heard much about the fact that in two threatened or actual pandemics of the past 50 years, government overreaction was the problem in many experts’ eyes. The first was the swine flu outbreak of 1976, in which the federal government rushed to make and distribute a vaccine against a new strain of influenza. Today, the conventional wisdom is that distribution of the vaccine—about 25 percent of the population ultimately got it—should have been stopped once it was clear the illness was neither as deadly nor as transmissible as it seemed when it broke out at Fort Dix in New Jersey. The immunization campaign was finally aborted when more than 50 cases of Guillain-Barré Syndrome occurred.
The second pandemic was a real one—the H1N1 influenza of 2009. Today, many experts think the World Health Organization shouldn’t have declared it a pandemic (even though it met the definition) because the illness was so mild. Further, the push to vaccinate people after the outbreak started to wane was medically pointless and needlessly alarmist, these experts believe.
Harvey V. Fineberg, former dean of the Harvard School of Public Health, wrote a monograph about the 1976 outbreak called The Epidemic That Never Was. He and other experts concluded that the response was mishandled. In an interview in the Bulletin of the World Health Organization during the H1N1 pandemic, he made some interesting observations.
In the decision-making, the fundamental strategic flaw was combining all aspects of response into a single “go or no-go” decision—the decision to proceed with characterizing the virus into a vaccine, to produce the vaccine, to test it and to deliver it to every man, woman and child in the USA—that was all decided and announced in March ’76 in one fell swoop. This big lesson has been absorbed by policy-makers: separate what needs to be done to prepare for future decisions from reaching conclusions and announcing them, before relevant information is at hand …
From technical, political and policy points of view, it is very difficult to deal with low probability-high consequence events—events that are relatively unlikely, but that would have catastrophic consequences should they occur. When you have such an event in prospect, the naysayer who argues that you are over-reacting is more likely to be right than wrong.
That’s worth repeating. A former dean of one of the most respected schools of public health in the world said: “The naysayer who argues that you are over-reacting is more likely to be right than wrong.”
It’s a matter of judgment whether, and when, to pull the alarm that dispatches trucks from every firehouse in the country. It’s certain the Trump administration waited too long. But the delay isn’t hard to understand, as much as we might hate to admit it.
