10 May 2020

Beyond status quo: US response to the Covid-19 pandemic

Ibrahim Bakri and Emina Osmandzikovic

With more than 1.23 million confirmed cases[i], 164,000 successfully recovered and more than 72,000 having succumbed to the resulting illnesses, Covid-19 has had a significantly greater impact on the United States compared with China, Italy, France, and Spain combined.

Despite the foresight demonstrated in the comprehensive report detailing the US response to the Ebola outbreak drafted by the Obama administration in 2016, as well as the repeated government simulations of contingency measures for combating a pandemic, the US response to the pandemic has shown a clear lack of coordination between federal and state authorities and absence of strategic vision.

Given the situation that the US finds itself in – meticulously anticipated in 2016 following the country’s failure in taking preemptive action against Ebola – this insight evaluates the Trump administration’s response to the Covid-19 pandemic in the context of the country’s past experiences.

The US is neither unfamiliar with the threat of global pandemics nor aloof to the danger to the health of its citizens and the integrity of its economy that accompanies it. However, the failure to act in a timely manner in the early stages of the spread of Covid-19 might have global repercussions in the post-pandemic period, encompassing a historically unprecedented number of industries across the board, in addition to the threat it poses to the efforts of the World Health Organization (WHO)[ii].

In response to the current crisis, there have been radically conflicting messages from Washington, with President Trump openly supporting right-wing protests against virus restrictions[iii] immediately following the issuance of federal guidelines from the White House[iv] dictating how and when governors should reopen their states. This lack of organization at the highest level perfectly demonstrates the dearth of a coherent response to the Covid-19 outbreak in the US, where responses have varied across state lines.

Beyond the current crisis, there is a consensus among the scientific community that the world will experience more zoonotic[v] pandemics and infectious disease outbreaks in the coming times, which makes assessments of future scenarios and potential ways forward an increasingly urgent task.

The problematic status quo

An array of generally uniform restrictions on businesses, imposed social distancing, school closings, curfews, and alerting messages from local governments encouraging citizens to stay at home have been enacted across 42 states and Washington D.C[vi]. This means that stay-at-home orders have been issued to an astonishing 95 percent of the United States, an unprecedented move in American history. These orders have largely been introduced by governors on their own accord, occasionally in collaboration with neighboring states. Measures to shut down states were rolled out more quickly in areas with more confirmed Covid-19 cases. In Midwestern and Southern states, where outbreaks of Covid-19 have been more scarce, there continue to be holdouts in terms of issuing of stay-at-home orders, with some counties and cities taking measures into their own hands.

Graph for Beyond status quo_US response to the Covid-19 pandemic insight

Graph 1: Number of Covid-19 cases in the United States as of 27 April 2020[vii]

This is most evident in the following states; Arkansas, Iowa, Nebraska, North Dakota, and South Dakota, where there have been no orders whatsoever. This refusal to follow the example of the rest of the nation in these more conservative states comes from a combination of public sentiment favoring a small, decentralized government and fear of infringement of civil liberties, along with fear of the havoc that such measures may take on their economies. This fear, while evidently dangerous as cases of Covid-19 continues to spread across the US, is not completely baseless.

 These different approaches to combating Covid-19 have even led to resentment simmering between neighboring states, with a Tennessee congressman notably writing to the governor of Arkansas[viii] pleading for him to take more aggressive measures against the disease in order for it not to spread next door. President Trump has persisted in attempting to play to both concerns, arguing that his administration has taken the necessary precautions[ix] and is abiding by the advice of scientists and health experts, while also lobbying on behalf of protesters who want a quick end to quarantine measures and a rapid re-opening of the economy.

Graph for Beyond status quo_US response to the Covid-19 pandemic insight

Graph 2: Distribution of Covid-19 cases across the United States as of 27 April 2020[x]

This is the problematic status quo that the United States finds itself in, eerily predicted in 2016 following the US failure to take preemptive action against Ebola. Without a clear, nation-wide plan of action, it becomes the responsibility of governors and state governments to make decisions on the proper course of action[xi]. Though this piece-meal method of fighting a pandemic has been a major contributor to the spread of Covid-19 across the US, it is worth noting that there is also a silver lining.

As the nation’s governors, mayors, and local leaders took action in initiating shutdowns and quarantines, these same leaders are also the ones with the authority to lift restrictions once the data on the virus transmission permits it. Though this is contrary to President Trump’s claim that he alone has the constitutional authority to force states to reopen[xii], constitutional scholars have since refuted his declaration. In reality, the American state-level response to Covid-19 has shed light on the immense power of state governments, particularly when the federal government is unable to provide clarity and a course forward. This has been particularly relevant and pertinent to the current Covid-19 crisis, as President Trump’s ‘whole of government’ response has left much of the government sidelined and awaiting orders.

While the US government has largely failed to tackle the Covid-19 crisis effectively, many of its agencies that had been ready were left on the sidelines, waiting for directions to execute measures. For instance, hospital ships stayed in port, and veterans’ hospitals awaited orders, and requests for help went unanswered as many government agencies across all the 50 states remained on the sidelines at the crucial early moments of the crisis.

Many Americans continue to ignore stay-at-home orders even in less conservative areas[xiii], with an average of only 35 percent effectively voicing their support for social distancing. Whether it is a lack of respect for the science behind the orders, necessity or gig-based work, or the psychological pressures of isolation without a clear end[xiv], it is quite difficult for even local governments to enforce the stay-at-home measures required for rates of Covid-19 to decrease to the extent needed to relax measures.

Although quarantine is aimed primarily toward keeping rates of infection low enough for hospitals to be able to treat patients effectively[xv], it is not a solution that will eradicate the disease completely. Nor will herd immunity provide protection against Covid-19 once the number of infected reaches a high enough point, as scientists have confirmed that the virus mutates regularly enough for herd immunity to prove ineffective.

Graph for Beyond status quo_US response to the Covid-19 pandemic insight

Graph 3: US healthcare capacity and predictions as of 27 April 2020[xvi]

Epidemiological models across the board have continued to point to a trend that Tomas Pueyo dubbed “the hammer and the dance”[xvii], with inevitable surges in deaths causing steep rises and falls in modeling. These surges will likely become commonplace as the US begins to slowly reopen its economy, with deaths decreasing and periods between enforced lockdowns increasing slowly over time. Even Donald Trump’s “Opening Up America Again” guidelines recommend different levels of social distancing continuing over long periods of time[xviii], even after measures to reopen the American economy begin.

It is this prediction of sustained contact with Covid-19 and its persistence in the foreseeable future that makes it overwhelmingly clear that the disjointed US approach to battling the pandemic must come to an immediate, swift end; otherwise, there is a risk of an indefinite postponement of a return to normalcy.

The historical context

In the immediate aftermath of the First World War, the second wave of the 1918 influenza outbreak[xix], popularly known as the “Spanish Flu”, ravaged the US, causing more than 675,000 deaths. Nearly 200,000 people died from the disease in October of 1918 alone, making it the deadliest month in American history, within a global pandemic that led to 20-50 million people being killed worldwide in a span of two years following one of the world’s bloodiest wars.

Lacking a vaccine or even knowledge of the actual cause of the outbreak, mayors and city health officials across the US had to implement a countrywide response. The rapid spread of the Spanish flu in the fall of 1918, however, was at least partially to blame on the unwillingness of public health officials to impose wartime quarantines. For example, a 2007 analysis found that if San Francisco had kept anti-flu protections in place through the spring of 1919, deaths could have been reduced by 90 percent.

More recently, the Ebola outbreak happened in West Africa in 2014 and threatened all countries around the world. Despite the significant successes of the US mission in West Africa, Ebola reached Dallas and New York, wherein the lack of an effective federal government incident-command structure contributed to mistakes in personal protective equipment use, disinfection, the collection, transport, and disposal of hazardous waste, the provision of social services for those placed under quarantine, and post-event monitoring and travel restrictions for potentially exposed health workers. In the early stages, the management of Ebola was distributed across many bureaus with no obvious centralized body to coordinate responses[xx].

According to the Ethics and Ebola report[xxi] published in 2015 by the US Presidential Commission for the Study of Bioethical Issues, “in response to the arrival of Ebola on US shores (…) some responses in the United States – such as calls for travel bans, quarantine of health care workers, and stigmatization of and discrimination against western Africans (or anyone thought to be associated with Ebola) – merit scrutiny, both in relation to this ongoing epidemic and to prepare for future public health emergencies.”

 At the time, one of the most fundamental requirements within the overall response was keeping track of where the virus is and where it was going. Identifying key indicators that would reveal the trajectory of the disease in a timely manner was a priority of White House decision-makers. Data integration challenges and the time lag of data flow meant that epidemiological indicators often provided a trailing rather than a leading indicator of where to effectively direct the medical response.

The Ebola epidemic showcased substantial deficiencies in global preparedness and capacity for infectious disease response. When the US mobilized in West Africa, even prior to the virus touching the US shores, such shortcomings were evident in every major US government agency covering health and security.

While the US Agency for International Development (USAID) has been well-practiced at responding in conjunction with the military to natural disasters, the public health challenges presented by Ebola were altogether different. And while the Ebola response is considered a success, merely maintaining the current scale of response activities as a standing capability has proven to be insufficient against Covid-19. Rather than being a point event that happens once, enabling disaster management to be essentially a linear exercise in assessing and managing consequences, the tendency of epidemics, pandemics, and viral outbreaks grow and mutate among the world populace underscores the importance of preparedness.

Simulations and preparations

 The US has attempted to simulate a response to an outbreak at least twice since the early 2000s, albeit with a focus on a potential bio-terrorist viral spread on US soil. Operation Dark Winter was the code name for a senior-level bio-terrorist attack simulation[xxii] conducted in June 2001 and designed to carry out a mock version of a covert and widespread smallpox attack on the US.

The essential purpose of the simulation was to tackle the inadequacies of the national emergency response against a bio-terrorist attack on the US population. In their roles as National Security Council (NSC) members responding to the smallpox crisis, exercise participants were given information about unfolding events through briefings, memos, newspaper summaries, and video news clips.

One of the major findings of the exercise was that the US government organizational structures at the time were not suited for the management of a viral outbreak[xxiii]. The resulting study emphasized that “major fault lines exist between different levels of government (federal, state and local), between government and private sector, among different institutions and agencies, and within the public and private sector.”

Such incongruences had the potential to deteriorate overall situational awareness and compromise the ability to limit the loss of life, suffering, and economic damage. Moreover, the exercise concluded that the US healthcare sector, state-level public health systems, and the pharmaceutical industries had no surge capability. The exercise scenario also predicted a severely strained relationship with the media and overall information management would further impede an effective crisis response.

Nevertheless, little was done to alleviate the potential crisis governance failings identified in Operation Dark Winter. In 2019, a new exercise Operation, Crimson Contagion, simulated an influenza-like pandemic in a series of public health exercises designed to map out preparedness and capacities across a range of government agencies. During the exercise, federal inter-agency partners conducted a crisis action planning session to model key leadership decisions and identify critical information requirements and other essential elements needed to produce an appropriate, whole-of-government response.

Among the key conclusions of the exercise, it was noted, that the global medical countermeasure supply chain and production capacity could not respond to the demand imposed by distressed nations during a global influenza pandemic. Within the US, a large number of states would experience multiple challenges when requesting resources from the federal government due to the absence of a standardized, comprehensive, and properly executed resource request process. Moreover, potential miscommunication was identified as one of the key issues, with the likelihood that the application of resource scarcity mitigation measures would not be clearly communicated across states.

While the exercise revealed much inherent strength in the structure for collaborative efforts between federal and state-level agencies, there was little anticipated progress evident from the previous exercise in the early 2000s. While the exercise provided all levels of government and non-government organizations, with an opportunity to practice the implementation of response procedures in case of an influenza outbreak, the inadequacies of the executive branch and statutory authorities to provide various bodies with appropriate mechanisms to contain the crisis left many questions unanswered.

 Future scenarios and a crisis management roadmap

 The dynamics of globalization and population growth will lead to more pandemics and viral outbreaks, which ought to be considered among the largest national security threats around the world. With anti-lockdown protests spreading across the United States[xxiv], many endorsed and encouraged by the president, the country’s response to the novel Covid-19 virus spread across all 50 states gives a mixed picture thus far. As noted in the previous section, without a clear, nation-wide plan, the leadership of state governments will likely become a permanent fixture of US contingency planning and responses for pandemic prevention in the future.

However, it has been shown prominently over the last few months that without assigning funding and policy responsibility to specific government organizations, the absence of a unified federal government plan that states can implement across the board and without widely-accessible testing mechanisms being made available to citizens as soon as physically possible, state governments are unable to do significantly more than contain the spread of disease. The on-ground repercussions of the discord in communication channels on various levels of governance are seen in anti-lockdown protests that could potentially exacerbate the risk to the lives of hundreds of thousands of US citizens and residents.

This insight argues that future US responses require better-coordinated and well-rehearsed measures. Both a coordinated response and preventative measures will, however, be problematic to execute, given that there is insufficient coordination between military, humanitarian, and health responders. In this respect, exercising, table-tops, training, liaison officers, regular detailing of personnel, and senior management exchanges are needed as demonstrated by Operation Dark Winter and Operation Crimson Contagion. However, a strong central direction is needed to build an immediate response to proactive and preventative contingency exercises for future pandemics given the likelihood they will recur in the future.

Given that the most optimal response requires effective collaboration across borders, the US will benefit from more thorough exposure to international crisis response and pandemic management efforts. In view of the world’s contemporary experiences with viral outbreaks, the Global Health Agenda[xxv] was launched in 2014 with a vision to create a world that is safer and more secure from global health threats under the principle of shared responsibility. One of the GHSA’s key objectives is to enhance countries’ capabilities for preventing, detecting, and responding to infectious diseases and viral outbreaks.

Because of the work of the GHSA, there is more information available in the current Covid-19 crisis than there has been in any previous outbreak regarding which countries have the best preparedness and where the international community needs to direct assistance. Such knowledge can potentially enhance the US’s own situational awareness and the national-level responses of governments worldwide. In other words, health and non-health agencies need a common approach to monitoring emerging pandemic threats.

In devising recovery and potential prevention efforts, the US and the global community must acknowledge the substantial gaps that the Ebola epidemic revealed in preparedness and capacity for infectious disease response. When the US mobilized after the WHO had failed to contain the Ebola epidemic in 2015, the deficiencies that surfaced in every major agency tasked with health and security in the US government indicated the importance of timely and rapid responses in the early stages of an outbreak across federal and state levels.

Merely maintaining the current scale of response capacity as a standing capability will most likely be insufficient. For the sake of US citizens and the international community that looks to the US for guidance and leadership, a new approach is urgently needed.

 

References:

[i] “ United States Covid-19 Cases.” Worldometer, www.worldometers.info/coronavirus/country/us/.

[ii] Shear, Michael D. “Trump Attacks W.H.O. Over Criticisms of U.S. Approach to Coronavirus.” The New York Times, 8 Apr. 2020, www.nytimes.com/2020/04/07/us/politics/coronavirus-trump-who.html.

[iii] Official Twitter  Account of the President of the United States of America, 8 Apr. 2020, https://twitter.com/realDonaldTrump/status/1251169217531056130

[iv] Press Release. The White House, The United States Government, www.whitehouse.gov/openingamerica/.

[v] Monaco, Lisa, and Vin Gupta. “The Next Pandemic Will Be Arriving Shortly.” Foreign Policy, 28 Sept. 2018, www.foreignpolicy.com/2018/09/28/the-next-pandemic-will-be-arriving-shortly-global-health-infectious-avian-flu-ebola-zoonotic-diseases-trump/.

[vi] Mervosh, Sarah, et al. “See Which States and Cities Have Told Residents to Stay at Home.” The New York Times, 24 Mar. 2020, www.nytimes.com/interactive/2020/us/coronavirus-stay-at-home-order.html.

[vii] Jin, Beatrice. “How Many Coronavirus Cases Have Been Found in Each U.S. State.” POLITICO, 16 Mar. 2020, www.politico.com/interactives/2020/coronavirus-testing-by-state-chart-of-new-cases/.

[viii] Klar, Rebecca. “Memphis Congressman Asks Tennessee, Neighboring States to Issue Shelter-in-Place Orders.” TheHill, 31 Mar. 2020, www.thehill.com/homenews/house/490405-memphis-congressman-asks-tennessee-neighboring-states-to-issue-shelter-in.

[ix] Kumar, Anita. “Trump Works to Rewrite Narrative on Coronavirus Response.” POLITICO, 24 Mar. 2020, www.politico.com/news/2020/03/24/trump-coronavirus-campaign-reelection-145007.

[x] “Coronavirus in the U.S.: Latest Map and Case Count.” The New York Times, The New York Times, 3 Mar. 2020, www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html.

[xi] Philip Rucker, Josh Dawsey. “As Testing Outcry Mounts, Trump Cedes to States in Announcing Guidelines for Slow Reopening.” The Washington Post, WP Company, 16 Apr. 2020, www.washingtonpost.com/politics/as-testing-outcry-mounts-trump-cedes-to-states-in-announcing-guidelines-for-slow-reopening/2020/04/16/202ec300-7ffa-11ea-8013-1b6da0e4a2b7_story.html.

[xii] Baker, Peter, and Maggie Haberman. “Trump Leaps to Call Shots on Reopening Nation, Setting Up Standoff With Governors.” The New York Times, 14 Apr. 2020, www.nytimes.com/2020/04/13/us/politics/trump-coronavirus-governors.html.

[xiii] “University of Maryland COVID-19 Impact Analysis Platform.” University of Maryland COVID-19 Impact Analysis Platform, www.data.covid.umd.edu/.

[xiv] “Mental Health and Coping During COVID-19.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Apr. 2020, www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html.

[xv] Specktor, Brandon. “Coronavirus: What Is ‘Flattening the Curve,’ and Will It Work?” LiveScience, Purch, 16 Mar. 2020, www.livescience.com/coronavirus-flatten-the-curve.html.

[xvi] “COVID-19 Projections.” Institute for Health Metrics and Evaluation, www.covid19.healthdata.org/united-states-of-america.

[xvii] Pueyo, Tomas. “Coronavirus: The Hammer and the Dance.” Medium, Medium, 3 May 2020, medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56.

[xviii]Press Release. The White House, The United States Government, www.whitehouse.gov/openingamerica/.

[xix] Roos, Dave. “How U.S. Cities Tried to Halt the Spread of the 1918 Spanish Flu.” History.com, A&E Television Networks, 11 Mar. 2020, www.history.com/news/spanish-flu-pandemic-response-cities.

[xx] Kirchhoff, Christopher M. “NSC Lessons Learned: Study on Ebola.” Memorandum for Ambassador Susan E. Rice, 11 July 2016, www.int.nyt.com/data/documenthelper/6823-national-security-counci-ebola/05bd797500ea55be0724/optimized/full.pdf#page=1.

[xxi] Presidential Commission for the Study of Bioethical Issues, “Ethics and Ebola – Public health planning response,” Feb. 2015, https://bioethicsarchive.georgetown.edu/pcsbi/sites/default/files/Ethics-and-Ebola_PCSBI_508.pdf.

[xxii] “Dark Winter Exercise.” Johns Hopkins Center for Health Security, Center for Biosecurity, 13 Dec. 2019, www.centerforhealthsecurity.org/our-work/events-archive/2001_dark-winter/about.html.

[xxiii] “Dark Winter Exercise.” Johns Hopkins Center for Health Security, Center for Biosecurity, 13 Dec. 2019, www.centerforhealthsecurity.org/our-work/events-archive/2001_dark-winter/about.html.

[xxiv] Waldmeir, Patti, and David Crow. “US Anti-Lockdown Protests: ‘If You Are Paranoid about Getting Sick, Just Don’t Go out’” Financial Times, 22 Apr. 2020, www.ft.com/content/15ca3a5f-bc5c-44a3-99a8-c446f6f6881c.

[xxv] “Global Health Security Agenda.” Global Health Security Agenda, 19 Aug. 2019, www.ghsagenda.org/home/about-the-ghsa/.

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