The US was poised in many ways to handle a public health emergency, but the attempt was largely a failure. What happened and how can we push forward?
This article is part of Contagion’s one-year COVID-19 series, which will run in 3 parts, March 17-19. You can share your thoughts, questions, reflections, and concerns from this last year in the pandemic through our channels on Facebook, Twitter, and LinkedIn.
When news of a possible viral outbreak began early last year, not many countries were fully prepared for what was to come, if any were at all.
The public health community has long sounded the alarm that there was potential for a pandemic of high-consequence. They went as far as penning a report in September of 2019 urging political leaders around the globe to take the necessary precautions and ensure that resources were available in the case of such an event.
Just one short month later, the Global Health Security (GHS) Index found that not a single country was completely ready for a substantial health emergency. Though some ranked higher than others, more steps needed to be taken by everyone.
The United States, the world’s largest GDP and one of the most powerful technological and scientific nations, ranked number one on that list. The country was the global example for health emergency preparedness—at least on paper.
“The US has high-quality laboratories, trained epidemiologists, and a stockpile along with plans to distribute personal protective equipment in public health emergencies. The US also has an emergency operations center and risk communication plans,” Jennifer B. Nuzzo, DrPH, wrote in a viewpoint published online in the journal JAMA.
“In addition, there is the world-renowned US Centers for Disease Control and Prevention (CDC) that works across the globe to improve the ability of other countries to detect and respond to infectious disease threats.”
Yet, a year into COVID-19 and the US topples the charts with nearly 30 million cases and more than 500,000 deaths due to the disease—both far and away the most out of any country on the planet.
Even now, many people are asking how this happened and what can be done in the future to prevent a similar outcome.
In the Beginning
On January 21, 2020, the CDC announced the first confirmed case of COVID-19 in the US. The case was a Washington state resident who had returned from Wuhan, China, where the virus had initially originated.
In a quick call to action, the CDC deployed a team to aid in the investigation and start the process of contact tracing. This eventually turned out to be much more difficult than initially anticipated, for numerous reasons.
Throughout the course of the pandemic, it would prove extremely difficult finding people to hire as contact tracers, let alone having the capability to organize them efficiently. Worsening the situation further, many of those who were traced reported no contacts and countless others could not even be reached. Public health officials have stated that this is not surprising, placing the blame on a mistrust of authorities in certain communities.
“That the United States [failed] such a simple test of its capacity to protect public health is shocking,” Eric C. Schneider wrote in a perspective published in The New England Journal of Medicine. “The United States was once a leader in collecting systematic federal data on population health.”
In the ensuing days and weeks, the World Health Organization (WHO) issued a global health emergency, as both the death and case tolls were rising in many East Asian nations. The United States began restricting global air travel, formed a coronavirus task force, and began directing funds towards a response and vaccine development.
Finally, on March 13, a national emergency was declared.
Although measures were being put into place, the month of February, a critical point in the timeline, was mostly lost. Looking back, it is now clear that the virus was spreading more than was thought between the first confirmed case and the national emergency announcement.
Officials did encourage people to stay home during this time and practice good hand hygiene but they failed to acknowledge and explain that the virus could be exhaled or individuals could be asymptomatic, allowing it to spread widely.
Despite the CDC asserting that the country was heading toward a pandemic status, and while other countries began taking extreme courses of action, the federal government and most state and local governments did little to disrupt normal economic and social life.
Following the declaration, the federal government began to comprehensively undertake the necessary efforts to quicken mass testing, improve medical supply availability, and encourage citizens to altogether change their behavior in hopes of stopping the spread of the virus.
However, because of the federalist system of public health governance within the country, in which most of the responsibility fell to the states—coupled with the lack of a clear, unified message—whatever attempts the federal government made were not sufficient.
“The missteps and miscommunications that have stymied a more effective…response to the COVID-19 pandemic bring into sharp focus the deficiencies in governance systems of the US public health and scientific institutions,” K.M. Venkat Narayan, MD, MSc, wrote in a viewpoint published in the journal JAMA.
Left to Their Own Devices
To those who have been paying any attention, it is blatantly clear that the patchwork reaction to the pandemic among the varying states across the country has been an absolute failure.
States like California, Washington and New York, some of the first and most severely hit by outbreaks, enacted policies and closures in the early phases of the pandemic and kept them stringent with the waxing and waning of numbers.
Stay-at-home orders were implemented in those states before March 24, with mask mandates and business closures not far behind.
In comparison, states like Florida, Texas and Oklahoma were slow to react, imposing hardly any policies until after April. In point of fact, Utah and North Dakota did not impose a mask mandate until November and continued to allow bars, gyms and schools to operate normally, 8 months into the pandemic.
Infectious disease experts repeatedly called on state officials to ramp up the restrictions, but their pleas fell on deaf ears.
Fueling the fire, these states were quick to pull the trigger on rolling back strategies, suffering larger outbreaks as a consequence.
For example, in one of the most egregious acts of defiance and negligence, the small city of Sturgis, South Dakota welcomed over 460,000 motorcycle riders to its annual 10-day rally in August of 2020 with no social distancing or mask requirements in place. A subsequent investigation by the CDC found that the gathering led to 51 primary cases of COVID-19, with an additional 35 secondary cases.
This was at a time when other states were reversing course on re-opening, and rightly so, as case numbers were found to be increasing due to the easing of restrictions during the summer months.
Compounding the issue further, the consequences of these states’ ineptitude was not contained within their boundaries.
Spillover caused by those with more relaxed policies to their neighbors has been clearly established. One study demonstrated that bordering counties of Iowa, a state which at the time the study was conducted had not enacted any stay-at-home orders, had an increased rate of cases in comparison to bordering counties of Illinois, who did implement such an order.
Even within states, leaders were coming to blows. In Georgia, the mayor of Atlanta and the governor continually butted heads on how to handle the increasingly dire situation.
Without the federal government enforcing protocols, states were free to do as they saw fit, leading to the reckless and irresponsible actions like that of Sturgis.
“The US approach contrasts strikingly with those of South Korea and Taiwan, which…prevented widespread community transmission by rapidly implementing a centralized national strategy,” Rebecca L. Haffajee, JD, PhD, wrote for The New England Journal of Medicine. “Lacking strong federal leadership to guide a uniform response, the United States quickly fulfilled the World Health Organization’s prediction that it would become the new epicenter of COVID-19.”
Policies imposed from higher up would have almost certainly slowed the spread of the virus and avoided innumerable deaths.
A study showed that If the federal government had enacted a face mask mandate by mid-March, 183,000 deaths could have been evaded, with an additional 110,000 being saved if a federal lockdown had been put into place in late Mach as was done in California.
In simple terms, the absence of comprehensible, national protocols cost lives.
Falling Short of Our GHS Standing
The response to COVID-19 in the US has exposed key failures and weaknesses in the systems which are intended to protect and promote personal and public health within the country.
It is obvious that the mistakes that were made throughout the course of the pandemic must be taken as a learning experience and that those who are responsible ensure that they do not occur again in the future.
In the face of another COVID-19 scenario, if which history has shown anything will surely happen again, the federal government needs to employ emergency declarations and have a unified, national response.
Encouraging states to follow consistent strategies and enforce public health orders could lead to far greater community mitigation than when they are given the lee-way to react how they choose. Using incentives, such as constraining funds in relief packages to states who adhere to the measures, could be a defensible step.
Making use of our technical and scientific expertise was botched this time around. Utilizing epidemiological data to inform forecast models and conducting rigorous analyses will be key moving forward. Agencies such as the CDC and FDA need to be able to divulge all of the information they have at their disposal and be unconstrained in their discussions with the media and public.
Furthermore, gearing our public health system towards prevention and more proactive approach measures will make certain that the country is in the best possible position to deal with another pandemic.
“Learning is difficult in the midst of an emergency,” Haffajee wrote. “One lesson from the COVID-19 epidemic is already clear: when epidemiologists warn that a pathogen has pandemic potential, the time to fly the flag of local freedom is over.”