The first confirmed case of COVID-19 in the United States was on January 19, 2020, a month after the viral outbreak was identified in Wuhan. By May, the United States had the largest number of deaths resulting from the virus of any country in the world. This failure to control the disease serves as an indictment of the American approach and institutions, which abdicated responsibility in the early stages of the pandemic, avoiding the aggressive measures known to be necessary to clamp down viral spread: mass testing and contact tracing to identify suspected cases and high risk communities, and quarantine to isolate them.
The country is now entering its third month of economically devastating lockdown. The lockdowns were supposed to buy time to spin up a more sustainable approach, but little has been done except a flip of the official narrative from downplaying the effectiveness of masks to ham-fistedly enforcing their use. As resentment to the squandered lockdown grows, states are beginning to open up with no vaccine or alternative containment strategy in sight.
Despite decades of warning about pandemics, the United States was unable to pursue the only approach known to work. Lacking a clear delineation of responsibilities for public health authorities, besides other missing essentials such as competence and an intent to actually solve the problem, contact tracing will not be effectively pursued in the future either. And the next pathogen outbreak is not far off: pandemics are the new normal. The implicit admission is that “herd immunity,” either from letting diseases burn through the population till antibodies are developed or a vaccine is released, is the only strategy we are actually capable of executing.
The problem started with a delayed reaction, resulting from late warnings from the World Health Organization (WHO) and the casual attitude the White House took. When the WHO declared an international emergency at the end of January, it praised China’s efforts to contain the virus, avoided making specific recommendations for travelers, and warned against restricting international travel and trade. The early response of the U.S. Centers for Disease Control and Prevention (CDC) was very narrow, focusing only on those who had traveled to China or come into contact with a traveler until late February, even when it was becoming clear that this was allowing the virus to escape into the community. The White House further inhibited the CDC’s capabilities, preventing CDC representatives from contributing to national communications, refusing to boost early on-the-ground contact tracing efforts, and denying calls to ramp up medical production. The White House declared the coronavirus a national emergency on March 13, and by the third week of March, 48 states had declared emergencies with widespread lockdowns.
National contact tracing efforts led by the CDC were minimal in the early phases of the virus, with state-led efforts only picking up steam in mid-April. States and non-profits are recruiting tracers to call homes and identify those who have come into contact with those who have had or might have had the virus in order to encourage quarantine efforts. The jury remains out on whether traditional contact tracing efforts being undertaken can amass enough manpower to get the job done. Apple and Google have jointly developed a decentralized Bluetooth-powered contact tracing apparatus to aid public health agencies, but adoption has been low from smartphone users in the United States due to consumer privacy concerns and general distrust.
The tragedy of the American response has resulted in lockdowns which disproportionately affect the vulnerable. From the economic insecurity that has fallen on millions of people, to the rise in domestic violence brought about by confining people to their homes, the harms to life and health need to be weighed against the civil liberties concerns of data-driven methods to stamp out the virus.
The social and economic fabric of our globalized world should not melt down every time an outbreak occurs. We cannot afford to shut down until a new vaccine is developed for every disease that proves infectious. Effective testing and contact tracing, with quarantines imposed for those who have come in contact with someone infected, is the only method for containing a virus early.
Contact tracing is essential because it enables the identification and isolation of suspected cases, preventing them from spreading. The social distancing approach, on which the current lockdowns rely, aims to “flatten the curve” of an infection’s spread. This does little to eradicate its presence. The virus always remains in at least a few people who don’t or can’t comply with effective distancing—it just spreads at a slower rate to make it more manageable for the medical system.
But as soon as things open up again, it would rapidly expand. Only by testing aggressively, identifying networks of transmission around confirmed cases, and instituting targeted quarantines and protective measures at a more granular level, can further networks of transmission be intercepted. By doing so, you remove only those who are likely to be infected until they are deemed clear of the virus.
Institutional sclerosis prevented the rollout of contact tracing at the early stage when it could have worked. One of the major barriers was a poor delineation of responsibility. State public health agencies could not act because the FDA limited their independent authority. The FDA delayed in approving private tests for state agencies and until mid-March mandated that the CDC confirm all tests. The FDA’s reliance on the CDC in turn caused problems due to the CDC’s conflict with the White House, which likely resulted from the CDC’s adoption of the vague response language of the WHO. Afterwards, coordination failures between national governments and their public health bodies—both in the U.S. and other countries—prevented them from producing the necessary medical supply stocks, which only intensified our current crisis.
As governments start testing ways to end the lockdowns across North America, there seems to be little indication of a strategy—short of a vaccine or herd immunity—for ensuring that we permanently move past the draconian measures initially put in place to limit the spread of COVID-19. The risk of a spike, or a return of the virus next year, will limit the willingness of many people to return to work and normal life. Lockdown for the entirety of the 12-18 month timeline it takes to develop and test a vaccine isn’t viable. While the cancellation of large gatherings and the encouragement of safe distancing measures are tolerable, the scale of lockdowns currently in place has led to painful social and economic upheaval.
Even before tests were made, there were limited national efforts to identify potential cases. In many developed countries outside of East Asia, the response at the border was weak. Temperature scans at airports were slow to roll out in the United States, while India and nations across Africa made it an early priority. In mid-February, The Lancet, one of the world’s leading medical journals, published a commentary labeling countries who imposed travel restrictions as violating international law for imposing health measures “not supported by science or WHO.” At the end of February, the WHO doubled down on its recommendations against travel restrictions, and many nations mirrored its stance. The countries with the greatest capacity and expertise to respond also deferred the most to the international order.
Closing borders with countries or other jurisdictions where the outbreak has already escaped control applies the logic of contact tracing and quarantine to the geopolitical level. China shut internal borders with Hubei, and most countries eventually implemented some kind of border restrictions—although mostly with exceptions for citizens and essential trade.
Building new tools for preparation would fail without a clearer remit for public health agencies, including in the U.S. The world had over a decade of warning about the risks of bat-borne coronaviruses, yet public health agencies shrugged their shoulders when the time came for them to act. This cannot be blamed on bad data. Despite the unreliable information released by China about the outbreak in Wuhan, epidemiological tools, such as the infectious disease tracker built by BlueDot, sounded the alarm that something was going awry.
And yet, Western countries didn’t do much until the threat of the virus became a domestic reality. Even after Iran and South Korea experienced outbreaks, North American policymakers largely demurred until Italy’s outbreak proved uncontainable. Even with abundant information, there was a failure of coordination between organizations that had valuable data on the nature and spread of COVID-19.
Some nations acted quickly and did not go down the route of widespread lockdown, in contrast to North America and much of Europe. Sharpened by their experiences with SARS, Singapore, Hong Kong, and Taiwan leaped into action in mid-January, aware of just how close the epicenter of the outbreak was. They instituted an array of travel restrictions, contact tracing, and mandatory quarantines of those suspected to be infected. These efforts proved invaluable.
East Asian nations not only learned from past outbreaks about what tools were needed to help control outbreaks, but also how they should be used. These tools, from influenza-like illness trackers to telecommunications-based contract tracing, exist everywhere. But few are able to use them to their fullest extent. Surviving an epidemic does not mean all the right lessons will be internalized. In 2003, Toronto experienced the worst outbreak of SARS outside of Asia, killing dozens and causing over a billion dollars in economic damage. Recognized as a “dress rehearsal” for the next pandemic, the SARS postmortem report noted the failure of Canada’s largest province to coordinate the mobilization of testing capacity beyond state-run labs. But the province stumbled again during the COVID pandemic on testing and other basic measures.
Had authorities acted earlier by sharing essential information and rerouting resources based on their predictions of potential points of outbreak, generalized and destructive social distancing measures may have proved unnecessary. Locking everyone inside to limit the possibility of infectious spread is a response of desperation. Even our medieval predecessors were wise enough during plagues to focus on quarantining those likely to be affected, while maintaining a sense of normalcy and order in most citizens’ lives. Identifying and isolating the sick, which is the only effective way known to contain outbreaks, requires a radically different mindset and more institutional competence than what we have now.
One of the greatest strategic failures of national governments during COVID-19 was the attempt to maintain a false sense of security, even while the pandemic’s potential became apparent. The WHO, while vital for information gathering and sharing, is not a substitute for local expertise when crafting domestic strategies. International organizations serve as a useful reference for state action, but should not be a barrier to it. New Zealand, Taiwan, and Singapore quickly put in place travel restrictions, even as these drew ire from the WHO and the international medical community.
The lesson here is that clearly delineating the responsibilities of public health bodies is essential for effective pandemic response. The CDC, while sensitive to the threat of pathogens, did not have the legislative remit to be vigilant and prepare actionable strategies for containment. The culture of the CDC—and of American public health authorities more generally—is to have a high degree of trust in international institutions. It trusted these international institutions enough to take their information and recommendations as a guide for decision-making. In the case of the current pandemic, the America has misplaced this trust. The result has been institutional passivity.
Unlike in the United States, in South Korean, Taiwan, and Singapore, public health agencies were empowered to contain outbreaks and play a clear role in mobilizing resources, ramping up medical production, sharing information between local agencies, and creating unified and effective public messaging. The last of these points is particularly important. Having national bodies as the linchpin of communication was vital for encouraging compliance in Singapore and Taiwan. Poorer messaging led to widespread flouting of the rules created in Italy and the mass confusion that reigns in the United States.
Sub-national bodies are most effective when empowered to direct and coordinate laboratory and testing resources between state, hospital, and private laboratories. This strategy is embodied by the success of the Canadian province of Alberta’s muscular centralized health authority in deploying testing across the province. American states, hampered by the FDA’s emergency regulations limiting test production, were not able to act early on independent of the CDC.
At the local level, public health authorities, which wield extraordinary powers in times of emergency, should be small enough to be attentive to local concerns but large enough to attract a critical mass of resources and talent to act effectively. The failure seen in cities like Detroit, which has had an astonishing death toll from COVID-19 (over a thousand dead in a city of less than a million), reveals the necessity of local capacity. The city was not able to acquire sufficient tests from state bodies. Testing facilities were inaccessible to those without a car. Some hospitals denied admission to infected locals who weren’t showing severe enough symptoms because the hospital lacked testing capacity. Non-profit efforts to independently acquire tests and open up mobile testing sites are frantically aiming at improving the city’s ability to respond. Decentralizing the administration of testing and the development of isolation units allows these local bodies to devote their resources to the most pressing needs of their communities. But lacking central coordination, they can’t be as effective as a real state-driven response.
As it stands, the murkiness concerning responsibility and accountability in pandemic response has led to a failure of ownership. This has made it too easy to pass the blame and too difficult to determine where the fault lines lie in our capacity to respond to present and future threats from infectious diseases. Everyone has suffered. Another pandemic is only a matter of time, and unless particular authorities are empowered to identify and isolate swiftly, the same institutional failure will rear its head again.