• US had world’s best pandemic playbook. Why did we toss it?
States’ policy patchwork, experts then undermined
Almost two months had passed since Chinese health officials described a fast-moving new coronavirus that jumped the species barrier from animals to humans. By the time President Donald Trump strode into the White House briefing room on the evening of Feb. 26, the virus had killed more than 2,700 people in China and forced the lockdown of 11 million residents in Wuhan. Infections in Italy were rising by an astonishing 40% a day.
That night, Trump assured Americans, “We’re very, very ready for this, for anything.”
He held aloft a report co-produced by the Johns Hopkins Center for Health Security ranking 195 countries on their readiness to confront a pandemic.
“The United States,” he said, “is rated number one most prepared.”
The nation did indeed rank first on the Global Health Security Index.
But the president never mentioned the report’s ominous central finding: “No country is fully prepared for epidemics or pandemics.”
The index revealed a number of U.S. flaws that proved crippling.
The USA received the lowest possible score for public confidence in government; low rankings among the index’s 60 high-income countries for doctors per capita (38th) and hospital beds per capita (40th); and a dismal rating for access to health care – 175th out of 195 countries.
What the index could not have predicted was America’s lethargic response and failure to follow basic precepts of its own pandemic playbook.
“It’s not that the index measured anything inappropriately, it’s that none of it was acted on,” said Joe Smyser, CEO of Public Good Projects, a national nonprofit health care group. “I don’t think
we’ve ever failed on this scale. The level of failure is almost inconceivable.”
The pandemic playbook, passed down from President Barack Obama to Trump, was a 69-page blueprint laying out the decisions to be made and agencies to be mobilized in a health disaster. The document stressed the need for an early public health response coordinated by the federal government. That did not happen. Milwaukee Journal Sentinel interviews with public health experts and reviews of numerous studies by government agencies, watchdog groups and scientists reveal a cascade of blunders that contributed to the deaths of more Americans in the
“I don’t think we’ve ever failed on this scale. The level of failure is almost inconceivable.” Joe Smyser CEO of Public Good Projects
pandemic than have died in the Korean, Vietnam, Iraq and Afghanistan wars combined.
Money for public health had been cut steadily for decades. The cuts became critical because U.S. leaders didn’t act on warnings about dire consequences should the federal government abandon its central role in a pandemic and leave states to fend for themselves.
Some states had to compete with one another to purchase scarce medical supplies. In the absence of detailed federal guidelines, states imposed a hodgepodge of lockdown policies, only to have some undermined by politicians, including the president.
Trump routinely dismissed the advice of his own health experts, downplaying the severity of the pandemic.
While leaders of other countries united their citizens behind the idea of collective sacrifice through lockdowns and other measures, U.S. leaders politicized the pandemic.
With its pandemic playbook, “the U.S. was very well prepared,” said Eric Toner, senior scholar at the Johns Hopkins Center for Health Security. “What happened is that we didn’t do what we said we’d do. That’s where everything fell apart.”
In disasters, Americans have grown accustomed to pitying other countries that need aid. COVID-19 reversed that.
“The U.S. accounts for less than 5% of the world’s population but more than 25% of total COVID-19 cases reported across the globe, and it currently ranks among the top 10 countries in COVID-19related deaths per capita,” wrote the authors of a commentary in the Journal of the American Medical Association on Sept. 16.
When the Journal Sentinel asked the U.S. Department of Health and Human Services to provide evidence that officials used the pandemic playbook, a spokesperson offered none. She said the Trump administration’s response “was informed” by three more recent plans.
One of those plans, “The National Biodefense Strategy” from 2018, is not a step-by-step guide for responding to a pandemic but a list of goals. Trump departed from one of those goals when he downplayed the virus instead of providing “accurate, timely and actionable public messaging.”
The other two reports the government relied on instead of the playbook – the Biological Incident Annex (2017) and the Pandemic Crisis Action Plan (2018) – were found to be flawed during a pandemic preparedness exercise called Crimson Contagion. The simulation took place in August 2019.
More than four months later, when the pandemic was not a simulation but real, other nations acted quicker than the United States.
In the rankings for pandemic readiness Trump cited, Thailand, South Korea and Vietnam finished sixth, ninth and 50th, respectively. In the COVID-19 pandemic, all three have experienced far fewer infections and deaths per capita than the USA.
Although the USA has three and a half times more people than Vietnam, it has had 6,000 times more COVID-19 cases.
Nigeria provides one of the most striking contrasts. Considered to have a weak health care system and ranked only 96th for pandemic preparedness, Nigeria established a Coronavirus Group a full month before the country reported its first case.
Nigeria has a population of 196 million – more than half that of the USA. Yet on Oct. 12, Nigeria’s death toll in the pandemic stood at 1,115.
That’s less than virtually every state in America.
Prelude: Primed for a disaster
Poor decisions by government and the American people primed the USA for a pandemic disaster.
For starters, the nation’s public health system has been underfunded for decades.
When adjusted for inflation using 2020 dollars, the CDC’s annual budget for public health emergency preparedness – the money set aside for pandemics and other disasters – dropped by more than half from $1.4 billion in the 2002 fiscal year to $675 million in 2020.
Using the same scale, money for hospital preparedness shrank at an even greater rate – 62% – from $723 million in 2004 to $275.5 million in 2020.
The Great Recession from 2007 to 2009 resulted in the loss of 50,000 public health jobs at the state and local level, according to John Auerbach, president and CEO of the nonpartisan organization Trust For America’s Health and former associate director of the CDC. Those jobs have never come back.
Over the years, at least some of those assessing the nation’s preparedness were troubled by what they saw.
In 2018, the bipartisan, privately funded Blue Ribbon Study Panel on Biodefense sounded alarms about the federal government’s readiness to take charge in a biological disaster as it had after the 9/11 terrorist attacks. The general rule has been that in such emergencies, the federal government assumes control.
“Devastation could be vast and swift, and local resources would be very quickly depleted,” wrote the authors of “Holding The Line On Biodefense.”
In 2016, Americans chose a new president, inexperienced in governing and sensitive to negative headlines. He took bad press personally, often dismissing unflattering articles as “fake news.”
In the first year of Trump’s presidency, Hurricane Maria pounded Puerto Rico, and in the aftermath, the president clashed with local officials over federal assistance. A similarly bitter back-andforth took place between the president and officials in California after wildfires in 2019.
“I always feared that the Puerto Rican hurricane response would be the template for what we would see,” said Jeremy Konyndyk, a senior policy fellow at the Center for Global Development. “Trump’s default was to say, ‘ We made no mistakes. Everything is fine.’ That means you can’t need this, this and this fixed because there’s nothing wrong.”
From early in his term, the president demonstrated a willingness to dismiss
the nation’s best minds in science, medicine, law and foreign intelligence, undermining or muzzling their advice.
As 2020 began, the United States had set the table for the greatest public health crisis in generations.
A sluggish response
Although there is no agreement about the precise moment that should have triggered an all-hands-on-deck response from the U.S. government, most health experts cite events in January.
At the Johns Hopkins Center for Health Security, Toner said that by midJanuary, “we knew the virus was spreading person-to-person and the Chinese government was going to completely unprecedented and drastic measures.
By Jan. 7, when Chinese researchers reported that the cluster of pneumonia cases in Wuhan had been caused by a novel coronavirus, U.S. agencies should have been determining whether states and communities could increase levels of clinical care to meet a rise in the number of cases, health experts said. They also should have been increasing production of needed medicine and supplies.
“What we’ve learned over the last 20 years is that you need to be immediately ready in an emergency,” said Auerbach, who was involved in the U.S. responses to Ebola and Zika during his time as associate director of the CDC. “When there’s an emergency, that’s not the time you want to be exchanging business cards.”
On Jan. 29, the White House convened its coronavirus response task force.
Two days later, the president issued an executive order barring all non-U.S. residents and noncitizens who had been in China in the past 14 days from entering the USA.
The travel restriction would become the signature action the president would credit with saving “potentially millions of lives.” Some epidemiologists questioned the restriction’s impact, saying COVID-19 cases were already entering the USA through Europe.
The ban allowed exceptions for U.S. citizens and residents returning from Wuhan and other cities in China.
On March 11, the World Health Organization designated the outbreak a pandemic.
Two days later, as the USA surpassed 3,300 confirmed and probable cases of COVID-19, including 55 deaths, Trump declared a national emergency. House Democrats wrote the president urging that he use the Defense Production Act
“to begin the mass production of supplies needed to address the ongoing (COVID-19) pandemic.”
Although Trump announced March 18 that he would invoke the act, he didn’t use it until March 27 to “compel General Motors to accept, perform and prioritize federal contracts for ventilators.”
By this point, the USA had more than 100,000 cases. Hospitals in New York City were overwhelmed.
Governors began locking down their states, imposing stay-at-home orders for nonessential workers and forbidding mass gatherings. Directions varied widely from state to state, and a handful of the governors resisted lockdowns.
States that imposed stay-at-home measures did not do so lightly.
“You’ve got a raging fire and you’re trying to deprive it of oxygen,” Konyndyk said. “But when you are depriving it of oxygen, you’re also depriving yourself of oxygen.”
Drastic as the measures were, they may have come too late.
Researchers at Columbia University’s Mailman School of Public Health projected that had the USA taken the same measures just a week earlier, almost 36,000 deaths could have been prevented. The research examined data on the movement of people and the spread of the virus across hundreds of counties in the USA.
Trump dismissed the study, which is undergoing peer review, calling it a “political hit job.”
The federal government could have boosted its supply of personal protective equipment and used its buying power to seek better prices, but that didn’t happen. Given far less equipment than needed, states were left to compete with one another on the open market.
“I think it caught everyone off guard the degree to which the federal government and president were not taking ownership of the pandemic,” Konyndyk said. “It would have been unthinkable under virtually any other president. After 9/11, George Bush did not say that counterterrorism was the responsibility of the states.”
The scramble for equipment should never have happened, according to the pandemic playbook.
Availability of lifesaving medicines and supplies, the playbook said, “must be prioritized at high levels of the U.S. Government and mobilized early in any emerging infectious threat incident.” If the supplies are not available, their development “must also be done early.”
A spokesperson for HHS said critical supplies were manufactured overseas, and “unknowns about the virus itself led to overuse of PPE in hospitals and treatment centers.” The spokesperson said the Strategic National Stockpile “was not designed or congressionally funded to respond to a nationwide pandemic.”
The HHS website, by contrast, describes the national stockpile as “organized to support any public health threat.”
By spring, any chance to avert a disaster had passed.
The Institute for Health Metrics and Evaluation, an independent research center that is part of the University of Washington, estimates that by Feb. 1, 2021, America’s death toll from COVID-19 will reach 395,000. Projections by the institute’s model range from 374,000 deaths to 421,000. But there is a note of hope:
The institute’s model projects 79,000 American lives can be saved by Feb. 1 by increasing mask use from the current estimate of 70% to 95%.
Though 95% may sound high, it’s the same level achieved by Singapore, which has 5.8 million people and 27 deaths from COVID-19.