Pacific Rim nations have demonstrated an uncomfortable fact about the C19 pandemic. It was manageable. Dotted with super-dense cities, close to the original outbreak, with less time to prepare, developed countries in Asia have suffered relatively little from this pandemic.
Eight of the ten countries with the highest C19 death rates are NATO members. The other two are Sweden and Switzerland. Meanwhile among Pacific Rim countries closer to China, death tolls have been small. As of May 15, 2020, the US has suffered 262 C19 deaths per million people. Japan, 5. South Korea, 4. New Zealand, 4. Australia, 4. Singapore, 3. Hong Kong, .5. COVID-19 has demonstrated the degree to which the US has become the center of global political dysfunction, also highlighting the cost to those who depend on us for leadership.
It didn’t have to be this way. Disease is personal. Pandemic is politics.
We know what could have been done to stop this pandemic in its tracks because the people who organized our successful responses to previous emergencies analyzed their results, refined their playbook to incorporate lessons learned, and built a sophisticated infrastructure for the next pandemic. They went so far as to reduce their recommendations to a 70-page flipbook of guidance, submitted by the White House’s office for pandemic response in December 2016.
The guide is simple enough for a layman to follow, a necessity since we don’t count on our Presidents or legislative leaders to be experts in infectious disease. It breaks down threats by type and severity, literally color-coding its categories and required responses into a format that even an intern could have followed and implemented.
How might a competent administration have responded to the C19 pandemic? It’s possible to piece together an answer by consulting this simple guide. More suggestions can be found by analyzing steps taken by other governments in response to this outbreak and those adopted by previous US administrations in response to others. Without resorting to hindsight, it’s still possible to sketch how an administration of average competence might have responded, and how they might have prevented the disaster that’s left us locked in our homes.
Our start date for any review should be January 3, 2020. That’s the day CDC officials were warned by their Chinese colleagues of the coronavirus outbreak in Wuhan. This information was immediately communicated to the HHS Secretary, Alex Azar. The President was not briefed.
Details of that exchange have not been released, but it was publicly known that dozens of people had contracted a novel respiratory virus which was resulting in dangerous pneumonia. Researchers were not yet certain that the virus was being transmitted via human contact and no one had yet died.
Consulting our pandemic playbook, on January 3 we were in category 1c, orange, defined as “credible threat.” We had confirmation of multiple human cases of a PPP (pandemic potential pathogen) somewhere in the world. As a respiratory illness, it would already be suspected of being a Tier 1 pathogen, the most dangerous category which includes such infamous killers as SARS CoV viruses, specifically called out in the playbook for their high attack rates and mortality ratios.
Response requirements at 1c begin on page 19. They include a long list of assessments of the target country’s capabilities, assessments which must be carried out across numerous agencies from Homeland Security to State and beyond.
Here at home, this stage triggers plans for border screening and travel controls outlined on page 21. No single agency can perform the tasks outlined in this playbook, that’s why this playbook was assembled in the White House and stored there for future Administrations. A response as straightforward as screening travelers to the US, for example, requires the CDC determine the nature of the screening. Homeland Security (TSA and Border Control) have to determine the screening process. FAA has to be consulted to handle potential changes to flights and communicate controls to airlines. The State Department has to collaborate with passport screenings and political issues. The list goes on.
There’s only one person in the US Government with the authority to coordinate a response across all of these entities, the President. All pandemic response begins in the White House, usually by the President designating someone to act in their name, usually also accompanied by a task force of relevant experts. We know what that might look like, since we watched it play out just a few years ago.
In the H1N1 pandemic, which was first detected here in the US, response was swift. The CDC received its first report that the disease existed on April 18, 2009, and its first report of transmission on April 21. President Obama was immediately notified. On April 26 the Administration declared a public health emergency and began releasing medical supplies from the national stockpile, including respirators. The FDA and CDC issued the first available public test on April 28. That’s ten days from first known case on the planet to a test available on a mass scale.
We did not get this quality of leadership from the Trump Administration. In response to the January 3 notification of this pandemic, the Administration took no action and the President was not notified. On that date, the US still had almost three weeks before the disease would be detected here, and two months before it began to spread broadly beyond travelers.
Though the Trump Administration did nothing, other countries didn’t wait. On January 3 Singapore and Hong Kong began screening passengers from Wuhan for illness and launching their broader pandemic response.
Why is a rapid response important? With a novel disease, testing and tracing is the only means of containment. Unlike a bacteria which might live, breed and thrive on surfaces on in the environment, a virus (like SARS and MERS previously) can be eradicated by cutting off its capacity to spread among humans. The SARS virus that killed hundreds of people has been eradicated. It was eliminated by identifying and isolating its hosts and tracking down all potential infections. There isn’t another way. Testing and tracing get harder the longer you wait, but the requirement never goes away. It will remain the only method of eradicating C19 even after a vaccine is developed. Vaccines merely make this testing and tracking process easier. Fail to isolate the disease and a pathogen can become so widespread as to be endemic, a background element of the microbial biome which will roam and kill at will, indefinitely.
Five days later, on January 8, the source of the infection was identified as a novel coronavirus. Though Chinese authorities were still hedging on whether widespread human-to-human transmission was possible, and no deaths had yet been tied to the disease, it was becoming clear that this was a more serious outbreak than previously acknowledged. By that date, researchers who work with coronaviruses were already sounding the alarm over human transmission. Still, without demonstrated, sustained human-human spread, our pandemic playbook would leave us at 1c, where the President should have been notified and initial planning begun, including airport and border screenings and preparation for testing and tracing. The President was not notified and we did nothing.
On January 10, China announced its first death from the coronavirus. A Chinese researcher released the full genome of the virus on January 11. Also on January 11, a German scientist made available the first reliable mass test for the virus, which was immediately and successfully deployed in Taiwan. Our government had still taken no action.
On January 15, authorities in Thailand and Japan announced they had detected C19 cases in travelers from China who had not visited the Wuhan market. This is the date when a reasonably competent Administration would escalate its response to Phase 2a, as human-human transmission was confirmed. Some of the questions faced by the President at 2a (pages 26-30) for an outbreak abroad include whether an overseas military deployment should accompany the civilian response, how to implement stringent screening requirements, what potential medivac operations might be necessary for US citizens abroad and whether a disaster declaration would be appropriate. The Administration took no action and the President was not informed.
On January 17, the CDC issued its first public briefing on the virus, announcing temperature screenings for passengers at only 3 US airports. Those screenings were only intermittent, with no effort to track travelers who has been to Wuhan, and were never widely deployed. When efforts were made to tighten screenings they were so chaotic that they were quickly abandoned.
On January 18, President Trump was notified of the outbreak by HHS Secretary Alex Azar. The President’s response was to change the subject, asking when limits on the sale of vaping products would be removed.
Our first domestic case of C19 was detected on January 20 in the Seattle area, in a patient who had recently traveled to China. The Administration took no action. This is the same date that the first case was detected in South Korea. There, leaders were notified immediately. A meeting was organized between the South Korean government and pharmaceutical CEOs a week later. South Korea deployed their public testing regimen the following week, on February 3. Other Asian governments, not waiting on leadership from the US, were already deploying their response.
By the discovery of a US case of C19 on January 20, any administration of average competence, even if they’d missed every signal up to that point, would have snapped to attention. The only means to contain a novel virus is testing, isolation and contact tracing. It’s a formula our CDC has honed since the 1980’s into a powerful machine. It should have begun in force on January 20, but it takes a President to coordinate this multi-agency response, and our President did nothing.
The first known case of local transmission of C19 in the US was identified on January 30 in Chicago, in a family with a member who had traveled to China. There were now at least two US geographies with potential spread. With the disease spreading in the US, by January 30, 2020 the playbook moves to its domestic section, still at Phase 2a, starting on page 36. Everything at this stage assumes a robust network of testing and contact tracing.
When the events of January 30 unfolded, even a weak and chaotic administration should have been spurred to action. The most important next steps would have been the deployment of thousands of tests to the affected areas. CDC contact tracers would have been mobilized, both to trace those potentially exposed and to begin training the hundreds or even thousands of new contact tracers who would potentially be needed later.
Our playbook would also dictate new travel and border controls, along with mobilization of emergency stockpiles of medical equipment. Page 37 references the workforce protections that would need to be assessed, leveraging OSHA and the Institute for Occupational Safety to make sure workers were safe. The playbook also reminds us that coordination with Tribal authorities would be necessary for any capable response.
Page 45 describes methods for imposing a lockdown, including work-from-home rules requirements for the use of protective devices. These are practically a footnote. Lockdowns do not stop a pandemic, they merely buy time for a country that’s fallen behind the curve to set in place the testing and contact tracing necessary for a competent response. If the government fails to implement testing and tracing, then the lockdown and all its damage will have been squandered.
On January 30 there was still time to contain this pandemic. New York City didn’t get its first cases until likely mid-February. Though it was probably present, still undetected, in many locations, contact tracing could have isolated it in major cities, buying time for a response elsewhere. A response launched on January 30 might still have required interruptions in air travel and brief, localized lockdowns while the CDC ramped up testing and tracing. It’s likely that hundreds of people might still have been infected and some might have died, but we might have experienced nothing like what actually unfolded.
Across the weeks after January 20, while Asian countries rushed to build the testing and tracing infrastructure necessary for a capable response, our President continued to deny the threat, characterize it as a political hoax, and even carry on campaign rallies. Individual agencies tried to act, but without coordination from the White House and crippled by the appointment of corrupt and incompetent leadership, they accomplished little.
The CDC activated their response structure on January 17. Border control made halting and frankly pathetic attempts to screen passengers starting in earnest in early February. The FDA took erratic and uncoordinated steps to remove testing constraints, steps which had the perverse result of blocking development of tests, then unleashing a wave of unvetted and unreliable testing. When the Administration formed its task force it was stacked with campaign donors and outright grifters. The President’s corrupt son-in-law ran a shadow response that favored the family’s interests at the expense of the country.
As late as the final week in February the US outbreak of the disease was still contained mostly in the Seattle area. Even that late, a full test and trace scheme, augmented by limited lockdowns in major cities, might have been enough to contain the spread and spare us from what followed. A thoroughly incompetent regime that had disregarded all warnings up to that point might still have cut off a disaster, but it would have required a massive effort, probably calling for the training of thousands of contact tracers, deployment on a spectacular scale of a uniform testing infrastructure, and a lockdown lasting many weeks to dampen spread and buy time. That didn’t happen.
Overseas, as late as mid-February Italy still hadn’t experienced a single known C19 death. NATO members were still looking for leadership from their once-reliable ally, leadership that would never arrive. Accustomed to leaning on the US for guidance, and for crucial test and trace infrastructure in a pandemic, NATO countries would suffer a terrible toll that hasn’t yet abated.
Blame China all you want for their early missteps. They contained the virus. Neighboring countries facing the harshest, earliest exposures to China’s failures all contained the virus. C19 is on its way to becoming a lasting threat to the world thanks to collapse of US leadership, and the resulting conversion of our Atlantic alliance into a giant petri dish.
Where does this failure leave us now? Our pandemic playbook has no colors for the condition we find ourselves in. No one considered the possibility that an American President would blow through 70 pages of warning lights and sirens without lifting one of his stubby little fingers. Nevertheless, the core of traditional pandemic response, testing and tracing, remains our only path out of this crisis. A virus depends on its hosts to spread. You stop a virus by containing its spread, identifying and isolating infected hosts. Do that, the virus may not only abate, but disappear.
No vaccine or treatment will save us from the need to isolate and contain C19. Now that we’ve spread the disease broadly in US and European populations, a vaccine can only be an augment to the testing and contact tracing that will ultimately bring the disease to heel. Talk of “herd immunity” is pathetic. Do you manage malaria by infecting everyone? Is that how sane, rational governments manage tuberculosis or measles? C19 is not a cold. It appears that its pneumonia symptoms may be one manifestation of a much more dangerous immune disorder, one that seems capable of remaining a health threat to patients long after any initial flu-like symptoms have passed.
Even with vaccines, we’ve developed no herd immunity to influenza, the common cold, or previous coronavirus infections. We’ve simply been forced to tolerate their annual death toll. Just as an immunity to the flu is brief, we have no reason to expect that patients cannot contract C19 more than once over a long enough timeframe. How many times have you had a flu vaccine? How many times have you had the flu? There will be no magic cure.
America sits, today, right where we were in January and February and every moment since, still waiting on a competent response from an incompetent President. We will make no progress toward an end to this disaster until capable leadership takes the necessary steps. Those steps get harder and the toll of our incompetence more deadly with each passing day.
Containing this epidemic now will require a moonshot. Fail, and we risk becoming one of those “shithole countries” travelers are warned not to visit, one of those sad, disorganized places where travel requires a dozen immunizations and you can’t drink the water.
It didn’t have to be this way.
Hong Kong hasn’t recorded a local C19 transmission in almost a month. Their citizens are now able to travel in the region with few restrictions. Australia and New Zealand are creating a “bubble” to allow international travel among their lightly effected nations. Well-governed countries with responsible populations are moving past this pandemic, many of them having only experienced very light restrictions on business or movement. They are the new “developed world,” emerging ahead of us into a global hierarchy defined by its resilience and capacity to leverage science.
Meanwhile the US, the nation once regarded as the leader of the free world, leads the world in C19 infections and deaths, with no relief in sight. The disease continues to accelerate outside the big coastal cities, but instead of insisting on a robust response, organized resistance to the pandemic is falling apart. Instead of scientists and doctors leading our response, our future is being dictated by idiots marching with guns to complain about wearing masks. We were warned that “everything Trump touches dies,” but we didn’t imagine it would be so literal.