The unique US failure to control the virus

David Leonhardt, The New York Times

Posted at Aug 07 2020 07:58 AM

Shoppers on 34th Street in Manhattan, July 18, 2020. Slowing the coronavirus has been especially difficult for the United States because of its tradition of prioritizing individualism and missteps by the Trump administration. Hiroko Masuike, The New York Times

Nearly every country has struggled to contain the coronavirus and made mistakes along the way.

China committed the first major failure, silencing doctors who tried to raise alarms about the virus and allowing it to escape from Wuhan. Much of Europe went next, failing to avoid enormous outbreaks. Today, many countries — Japan, Canada, France, Australia and more — are coping with new increases in cases after reopening parts of society.

Yet even with all of these problems, one country stands alone as the only affluent nation to have suffered a severe, sustained outbreak for more than 4 months: the United States.

When it comes to the virus, the United States has come to resemble not the wealthy and powerful countries to which it is often compared but instead to far poorer countries or those with large migrant populations.

How did this happen? The New York Times set out to reconstruct the unique failure of the United States through numerous interviews with scientists and public health experts around the world. The reporting points to 2 central themes.

First, the United States faced long-standing challenges in confronting a major pandemic. It is a large country at the nexus of the global economy, with a tradition of prioritizing individualism over government restrictions.

“As an American, I think there is a lot of good to be said about our libertarian tradition,” Dr. Jared Baeten, an epidemiologist and vice dean at the University of Washington School of Public Health, said. “But this is the consequence: We don’t succeed as well as a collective.”

The second major theme is one that public health experts often find uncomfortable to discuss because many try to steer clear of partisan politics. But many agree that the poor results in the United States stem in substantial measure from the performance of the Trump administration.

In no other high-income country — and in only a few countries, period — have political leaders departed from expert advice as frequently and significantly as the Trump administration. President Donald Trump has said the virus was not serious, predicted it would disappear, spent weeks questioning the need for masks, encouraged states to reopen even with large and growing caseloads, and promoted medical disinformation.

“In many of the countries that have been very successful, they had a much crisper strategic direction and really had a vision,” said Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. “I’m not sure we ever really had a plan or a strategy — or at least it wasn’t public.”

Together, the national skepticism toward collective action and the Trump administration’s scattered response to the virus have contributed to several specific failures and missed opportunities, Times reporting shows:

— a lack of effective travel restrictions,

— repeated breakdowns in testing,

— confusing advice about masks,

— a misunderstanding of the relationship between the virus and the economy,

— and inconsistent messages from public officials.

Already, the US death toll is of a different order of magnitude than in most other countries. With only 4 percent of the world’s population, the United States has accounted for 22 percent of coronavirus deaths.

A TRAVEL POLICY THAT FELL SHORT

In retrospect, one of Trump’s first policy responses to the virus appears to have been one of his most promising.

On Jan. 31, his administration announced that it was restricting entry to the United States from China. Many foreign nationals — be they citizens of China or other countries — would not be allowed into the United States if they had been to China in the previous 2 weeks.

But it quickly became clear that the US policy was full of holes. It did not apply to immediate family members of US citizens and permanent residents returning from China, for example. In the two months after the policy went into place, almost 40,000 people arrived in the United States on direct flights from China.

Even more important, the policy failed to take into account that the virus had spread well beyond China by early February. Later data would show that many infected people arriving in the United States came from Europe. (The Trump administration did not restrict travel from Europe until March and exempted Britain from that ban despite a high infection rate there.)

The administration’s policy also did little to create quarantines for people who entered the United States and may have had the virus.

Authorities in some other places took a far more rigorous approach to travel restrictions.

South Korea, Hong Kong and Taiwan largely restricted entry to residents returning home. Those residents then had to quarantine for two weeks upon arrival, with the government keeping close tabs to ensure they did not leave their home or hotel. South Korea and Hong Kong also tested for the virus at the airport and transferred anyone who was positive to a government facility.

The United States imposed few travel restrictions, either for foreigners or U.S. citizens. Individual states did little to enforce the rules they did impose.

Travel restrictions and quarantines were central to the success in controlling the virus in South Korea, Hong Kong, Taiwan and Australia as well as New Zealand, many epidemiologists believe. In Australia, the number of new cases per day fell more than 90 percent in April. It remained near zero through May and early June, even as the virus surged across much of the United States.


THE DOUBLE TESTING FAILURE

Healthcare workers wait to test people at a COVID-19 testing site in Orlando, Fla., July 28, 2020. In recent weeks, many Americans have had to wait hours for coronavirus tests and then days for results. Eve Edelheit, The New York Times

On Jan. 16, nearly a week before the first announced case of the coronavirus in the United States, a German hospital, Charite, in Berlin, made an announcement. Its researchers had developed a test for the virus, which they described as the world’s first. The researchers posted the formula for the test online and said they expected that countries with strong public health systems would soon be able to produce their own tests.

In the United States, the Centers for Disease Control and Prevention developed its own test 4 days after the German lab did. CDC officials claimed that the US test would be more accurate than the German one, by using 3 genetic sequences to detect the virus rather than 2. The federal government quickly began distributing the US test to state officials.

But the test had a flaw. The third genetic sequence produced inconclusive results, so the CDC told state labs to pause their work.

The flaw took weeks to fix. During that time, the United States had to restrict testing to people who had clear reason to think they had the virus. All the while, the virus was quietly spreading.

By early March, with the testing delays still unresolved, the New York region became a global center of the virus — without people realizing it until weeks later. More widespread testing could have made a major difference, experts said, leading to earlier lockdowns and social distancing and ultimately less sickness and death.

The United States eventually made up ground on tests. In recent weeks, it has been conducting more per capita than any other country, according to Johns Hopkins researchers.

But now there is a new problem: The virus has grown even more rapidly than testing capacity. In recent weeks, Americans have often had to wait in long lines, sometimes in scorching heat, to be tested.

The huge demand for tests has overwhelmed medical laboratories, and many need days — or even up to 2 weeks — to produce results. While people are waiting for their results, many are also spreading the virus.

THE DOUBLE MASK FAILURE

For the first few months of the pandemic, public health experts could not agree on a consistent message about masks. Some said masks reduced the spread of the virus. Many experts, however, discouraged the use of masks, saying — somewhat contradictorily — that their benefits were modest and that they should be reserved for medical workers.

The conflicting advice, echoed by the CDC and others, led to relatively little mask-wearing in many countries early in the pandemic. But several Asian countries were exceptions, partly because they had a tradition of mask-wearing to avoid sickness or minimize the effects of pollution.

In the following months, scientists around the world began to report two strands of evidence that both pointed to the importance of masks: Research showed that the virus could be transmitted through droplets that hang in the air, and several studies found that the virus spread less frequently in places where people were wearing masks.

In many countries, officials reacted to the emerging evidence with a clear message: Wear a mask.

Prime Minister Justin Trudeau of Canada began wearing one in May. During a visit to an elementary school, President Emmanuel Macron of France wore a French-made blue mask that complemented his suit and tie.

In the United States, however, masks did not become a fashion symbol. They became a political symbol.

Trump avoided wearing one in public for months. He poked fun at a reporter who wore one to a news conference, asking the reporter to take it off and saying that wearing one was “politically correct.”

Many other Republicans and conservative news outlets, like Fox News, echoed his position. Mask-wearing, as a result, became yet another partisan divide in a highly polarized country.

Throughout much of the Northeast and the West Coast, more than 80 percent of people wore masks when within 6 feet of someone else. In more conservative areas, like the Southeast, the share was closer to 50 percent.

A March survey found that partisanship was the biggest predictor of whether Americans regularly wore masks. In many places where people adopted a hostile view of masks, the number of virus cases began to soar this spring.

THE FIRST RULE OF VIRUS ECONOMICS

Throughout March and April, Gov. Brian Kemp of Georgia and staff members held two daily conference calls with the public health department, the National Guard and other officials. One of the main subjects of the meetings was when to end Georgia’s lockdown and reopen the state’s economy. By late April, Kemp decided that it was time.

Georgia had not met the reopening criteria laid out by the Trump administration (and many outside health experts considered those criteria too lax). The state was reporting about 700 new cases a day, more than when it shut down April 3.

Nonetheless, Kemp went ahead. He said that Georgia’s economy could not wait any longer, and it became one of the first states to reopen. The stay-at-home order expired at 11:59 p.m. April 30.

Kemp’s decision was part of a pattern: Across the United States, caseloads were typically much higher when the economy reopened than in other countries.

As the United States endured weeks of closed stores and rising unemployment this spring, many politicians — particularly Republicans, like Kemp — argued that there was an unavoidable trade-off between public health and economic health. And if crushing the virus meant ruining the economy, maybe the side effects of the treatment were worse than the disease.

Early in the pandemic, Austan Goolsbee, a University of Chicago economist and former Obama administration official, proposed what he called the first rule of virus economics: “The best way to fix the economy is to get control of the virus,” he said. Until the virus was under control, many people would be afraid to resume normal life, and the economy would not function normally.

The events of the last few months have borne out Goolsbee’s prediction. Even before states announced shutdown orders in the spring, many families began sharply reducing their spending. They were responding to their own worries about the virus, not any official government policy.

And the end of lockdowns, like Georgia’s, did not fix the economy’s problems. It instead led to a brief increase in spending and hiring that soon faded.

In the weeks after states reopened, the virus began surging. Those that opened earliest tended to have worse outbreaks, according to a Times analysis.

In June and July, Georgia reported more than 125,000 new virus cases, turning it into one of the globe’s new hot spots. That was more new cases than Canada, France, Germany, Italy, Japan and Australia combined during that time frame.

Americans, frightened by the virus’s resurgence, responded by visiting restaurants and stores less often. The economy’s brief recovery in April and May seems to have petered out in June and July.

In large parts of the United States, officials chose to reopen before medical experts thought it wise, in an attempt to put people back to work and spark the economy. Instead, the United States sparked a huge new virus outbreak — and the economy did not seem to benefit.

THE MESSAGE IS THE RESPONSE

President Donald Trump is shown on a screen as he speaks during a Fourth of July celebration at Mount Rushmore in South Dakota, July 3, 2020. Slowing the coronavirus has been especially difficult for the United States because of its tradition of prioritizing individualism and missteps by the Trump administration. Anna Moneymaker, The New York Times

The United States has not performed uniquely poorly on every measure of the virus response. But in no other high-income country have the messages from political leaders been nearly so mixed and confusing.

These messages, in turn, have been amplified by television stations and websites friendly to the Republican Party, especially Fox News and the Sinclair Broadcast Group. To anybody listening to the country’s politicians or watching these television stations, it would have been difficult to know how to respond to the virus.

Trump’s comments in particular have regularly contradicted the views of scientists and medical experts.

The day after the first US case was diagnosed, he said, “We have it totally under control.” In late February, he said, “It’s going to disappear. One day — it’s like a miracle — it will disappear.” Later, he incorrectly stated that any American who wanted a test could get one. On July 28, he falsely proclaimed that “large portions of our country” were “corona-free.”

He has also promoted medical misinformation about the virus. He has encouraged Americans to treat it with the anti-malarial drug hydroxychloroquine, despite a lack of evidence about its effectiveness and concerns about its safety. At one White House briefing, he mused aloud about injecting people with disinfectant to treat the virus.

These comments have helped create a large partisan divide in the country, with Republican-leaning voters less willing to wear masks or remain socially distant.

“If you had to summarize our approach, it’s really poor federal leadership — disorganization and denial,” said Andy Slavitt, who ran Medicare and Medicaid from 2015 to 2017.

For all of the continuing uncertainty about how this new coronavirus is transmitted and how it affects the human body, much has become clear. It often spreads indoors, with close human contact. Talking, singing, sneezing and coughing play a major role in transmission. Masks reduce the risk. Restarting normal activity almost always leads to new cases that require quick action — testing, tracing of patients and quarantining — to keep the virus in check.

When countries and cities have heeded these lessons, they have rapidly reduced the spread of the virus and been able to move back, gingerly, toward normal life. In South Korea, fans have been able to attend baseball games in recent weeks. In Denmark, Italy and other parts of Europe, children have returned to school.

In the United States, the virus continues to overwhelm daily life.

“This isn’t actually rocket science,” said Dr. Thomas Frieden, who ran the New York City health department and the CDC for a combined 15 years. “We know what to do, and we’re not doing it.”

 

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