Main Image Credit The U.S President, Donald Trump. Courtesy of whitehouse.gov.
In tackling the pandemic, the US did not perform as badly as frequently claimed, though community-level resilience should not be confused with adroit federal policy.
With US President Donald Trump infected with coronavirus, attention has shifted again to a critical examination of America’s pandemic response.
It is tempting to label the Trump administration’s efforts to contain the pandemic a failure. Indeed, nearly 8 million Americans have been infected and more than 210,000 have tragically died despite nationwide lockdowns for much of the spring and early summer, whereas countries like New Zealand, South Korea and Singapore have managed to mostly suppress two distinct waves. As cases rise in many states and other countries weigh the need for new lockdowns, it is abundantly clear that the pandemic is far from over. Thus, it is worth understanding the successes and failures of the American pandemic response and what features might be applied or avoided by the broader global community.
A Monumental Effort
By some numbers, the US has fared well compared to its counterparts. According to Johns Hopkins University Coronavirus Resource Center, the observed case fatality rate (CFR) in the US is approximately 2.9%, significantly better than 9.4% in the UK, 5.9% in Canada, and 5.4% in France, among other peer countries. Additionally, several early models anticipated the loss of millions of lives, whereas the current toll stands at a fraction of that. More than a 100 million tests have been performed, more than any other country, and millions of units of PPE, equipment, and medicines have been deployed from the Strategic National Stockpile. The US federal government has pre-emptively ramped up production of experimental vaccines with reasonable expectations that at least one will be safely approved. And despite some projections, the vast majority of the country’s more than 6000 hospitals managed their patients without exceeding capacity, and the USNS Comfort and Mercy hospital ships were barely utilised.
Question the Measurement Yardsticks
However, when interpreted in context, these numbers disguise a much dimmer reality. The CFR in the US as a national metric reflects the heroic efforts of community and regional medical centres, which largely operated on internal expertise and donations of equipment and PPE. When broken down by state in May, the US CFR ranged from <1% to more than 14%. Consequently, the CFR should not blindly validate Trump’s approach. Instead, the US claims the third-highest death rate per capita among developed countries and actually lags considerably on the basis of testing per confirmed case of COVID-19. The government celebrates the number of tests performed, but testing must be calibrated to the severity of the outbreak, rather than viewed in absolute or per capita terms. The point being that if one tests and continues to find large numbers of cases, they must continue to test and trace to map the burden of disease and appropriately direct resources. Consistent with active and increasing transmission of disease, the current daily test-positivity rate in the US (4.5%) is actively rising in many communities and overall higher than nearly all of its peers.
Since the start of the pandemic, Oxford University has been semi-quantitatively tracking government responses across a variety of indicators including school and workplace closings, restrictions on public gatherings, income support, contact tracing and testing policies, and new investment in healthcare and research. When comparing the change in these metrics with respect to the relative change in cases per capita over the first 30 days after reaching 100 cases, a rough index of concrete policies respective to the pace of disease transmission, across peers and competitors, the US ranks at the bottom alongside Brazil’s embattled Bolsonaro regime.
It is too soon to tell whether this early response, or lack thereof, will ultimately be responsible for the total number of cases or deaths, but it is likely to have strongly influenced public perception of the pandemic, which undoubtably contributed to these outcomes. From an organisational perspective, this early response period is when the federal government can be most influential in the course of the pandemic.
State Versus Federal Action
The Trump administration’s decision to delegate the pandemic response to governors was not necessarily irresponsible. After all, state officials understand their infrastructure, geography, and supply chains best, and federal administrators do not have the bandwidth to manage a crisis affecting nearly every county nationwide. One can readily imagine a disastrous alternate outcome where Washington, during any of the past several presidencies, attempted to micromanage such a widespread crisis.
However, the executive branch had several unique levers, including managing emergency relief, clearing bureaucratic hurdles, unlocking new funding for research, and controlling the spread of mis- and disinformation, that were not adequately deployed upfront.
To its credit, the Trump administration allocated large sums to vaccine and therapeutics development and secured early production contracts for promising countermeasures. The administration also directed the military to operate testing facilities, deliver acute medical care, and distribute PPE and medical equipment. However, the Food and Drug Administration also initially barred universities and regional laboratories from developing and validating confirmatory diagnostic tests, and millions of kits sent from the Centers for Disease Control and Prevention contained faulty components, prolonging a national shortage of tests early in the crisis.
Additionally, the administration allowed states and federal agencies to compete for contracts of essential supplies, diverting resources from those in need to those with money, as the Strategic National Stockpile remained critically depleted of respirators and masks after the 2009 H1N1 outbreak.
The asynchrony between the president, White House Task Force and federal scientific leadership directly contributed to the proliferation of misinformation about clinical treatment and basic preventative approaches, most notoriously regarding the baseless use and stockpiling of hydroxychloroquine, and indeed the existence and origin of the pandemic itself, as evidenced by the viral conspiracy documentary Plandemic.
Simply put, the US fared as it did because existing community-level resources, infrastructure, expertise and resilience were sufficient ballast against a virus that is neither particularly contagious nor deadly. Yet it is ironic that Americans fared poorly at all because both the possibility of a COVID-like pandemic and the necessary response was well known. In October 2019, around the time COVID-19 may have begun spreading in Hubei province, a group of scholars and public sector officials, including from the US and China, gathered in New York for a coronavirus pandemic simulation. Their recommendations highlight many of the same shortcomings noted in the official US government H1N1 retrospective, written in 2012. Ultimately, there is no singular pandemic playbook to steamroll future outbreaks. Instead, the future of American health security, and that of its allies and neighbours, depends heavily on the resilience of constituent communities and strength of the country.
Dr Ryan Henrici is an associate scholar of Global Health, Lecturer of Microbiology and Infectious Diseases at the University of Pennsylvania School of Medicine Center for Global Health.
The views expressed in this Commentary are the author's, and do not represent those of RUSI or any other institution.