How did it come to this? A virus a thousand times smaller than a dust mote has humbled and humiliated the planet’s most powerful nation. America has failed to protect its people, leaving them with illness and financial ruin. It has lost its status as a global leader. It has careened between inaction and ineptitude. The breadth and magnitude of its errors are difficult, in the moment, to truly fathom.
In the first half of 2020, SARS CoV 2—the new coronavirus behind the disease COVID 19—infected 10 million people around the world and killed about half a million. But few countries have been as severely hit as the United States, which has just 4 percent of the world’s population but a quarter of its confirmed COVID 19 cases and deaths. These numbers are estimates. The actual toll, though undoubtedly higher, is unknown, because the richest country in the world still lacks sufficient testing to accurately count its sick citizens.
Despite ample warning, the U.S. squandered every possible opportunity to control the coronavirus. And despite its considerable advantages—immense resources, biomedical might, scientific expertise—it floundered. While countries as different as South Korea, Thailand, Iceland, Slovakia, and Australia acted decisively to bend the curve of infections downward, the U.S. achieved merely a plateau in the spring, which changed to an appalling upward slope in the summer. “The U.S. fundamentally failed in ways that were worse than I ever could have imagined,” Julia Marcus, an infectious-disease epidemiologist at Harvard Medical School, told me.
Since the pandemic began, I have spoken with more than 100 experts in a variety of fields. I’ve learned that almost everything that went wrong with America’s response to the pandemic was predictable and preventable. A sluggish response by a government denuded of expertise allowed the coronavirus to gain a foothold. Chronic underfunding of public health neutered the nation’s ability to prevent the pathogen’s spread. A bloated, inefficient health-care system left hospitals ill-prepared for the ensuing wave of sickness. Racist policies that have endured since the days of colonization and slavery left Indigenous and Black Americans especially vulnerable to COVID 19. The decades-long process of shredding the nation’s social safety net forced millions of essential workers in low-paying jobs to risk their life for their livelihood. The same social-media platforms that sowed partisanship and misinformation during the 2014 Ebola outbreak in Africa and the 2016 U.S. election became vectors for conspiracy theories during the 2020 pandemic.
The U.S. has little excuse for its inattention. In recent decades, epidemics of SARS, MERS, Ebola, H1N1 flu, Zika, and monkeypox showed the havoc that new and reemergent pathogens could wreak. Health experts, business leaders, and even middle schoolers ran simulated exercises to game out the spread of new diseases. In 2018, I wrote an article for The Atlantic arguing that the U.S. was not ready for a pandemic, and sounded warnings about the fragility of the nation’s health-care system and the slow process of creating a vaccine. But the COVID 19 debacle has also touched—and implicated—nearly every other facet of American society: its shortsighted leadership, its disregard for expertise, its racial inequities, its social-media culture, and its fealty to a dangerous strain of individualism.
SARS CoV 2 is something of an anti-Goldilocks virus: just bad enough in every way. Its symptoms can be severe enough to kill millions but are often mild enough to allow infections to move undetected through a population. It spreads quickly enough to overload hospitals, but slowly enough that statistics don’t spike until too late. These traits made the virus harder to control, but they also softened the pandemic’s punch. SARS CoV 2 is neither as lethal as some other coronaviruses, such as SARS and MERS, nor as contagious as measles. Deadlier pathogens almost certainly exist. Wild animals harbor an estimated 40,000 unknown viruses, a quarter of which could potentially jump into humans. How will the U.S. fare when “we can’t even deal with a starter pandemic?,” Zeynep Tufekci, a sociologist at the University of North Carolina and an Atlantic contributing writer, asked me.
Despite its epochal effects, COVID 19 is merely a harbinger of worse plagues to come. The U.S. cannot prepare for these inevitable crises if it returns to normal, as many of its people ache to do. Normal led to this. Normal was a world ever more prone to a pandemic but ever less ready for one. To avert another catastrophe, the U.S. needs to grapple with all the ways normal failed us. It needs a full accounting of every recent misstep and foundational sin, every unattended weakness and unheeded warning, every festering wound and reopened scar.
Apandemic can be prevented in two ways: Stop an infection from ever arising, or stop an infection from becoming thousands more. The first way is likely impossible. There are simply too many viruses and too many animals that harbor them. Bats alone could host thousands of unknown coronaviruses; in some Chinese caves, one out of every 20 bats is infected. Many people live near these caves, shelter in them, or collect guano from them for fertilizer. Thousands of bats also fly over these people’s villages and roost in their homes, creating opportunities for the bats’ viral stowaways to spill over into human hosts. Based on antibody testing in rural parts of China, Peter Daszak of EcoHealth Alliance, a nonprofit that studies emerging diseases, estimates that such viruses infect a substantial number of people every year. “Most infected people don’t know about it, and most of the viruses aren’t transmissible,” Daszak says. But it takes just one transmissible virus to start a pandemic.
Sometime in late 2019, the wrong virus left a bat and ended up, perhaps via an intermediate host, in a human—and another, and another. Eventually it found its way to the Huanan seafood market, and jumped into dozens of new hosts in an explosive super-spreading event. The COVID 19 pandemic had begun.
“There is no way to get spillover of everything to zero,” Colin Carlson, an ecologist at Georgetown University, told me. Many conservationists jump on epidemics as opportunities to ban the wildlife trade or the eating of “bush meat,” an exoticized term for “game,” but few diseases have emerged through either route. Carlson said the biggest factors behind spillovers are land-use change and climate change, both of which are hard to control. Our species has relentlessly expanded into previously wild spaces. Through intensive agriculture, habitat destruction, and rising temperatures, we have uprooted the planet’s animals, forcing them into new and narrower ranges that are on our own doorsteps. Humanity has squeezed the world’s wildlife in a crushing grip—and viruses have come bursting out.
Curtailing those viruses after they spill over is more feasible, but requires knowledge, transparency, and decisiveness that were lacking in 2020. Much about coronaviruses is still unknown. There are no surveillance networks for detecting them as there are for influenza. There are no approved treatments or vaccines. Coronaviruses were formerly a niche family, of mainly veterinary importance. Four decades ago, just 60 or so scientists attended the first international meeting on coronaviruses. Their ranks swelled after SARS swept the world in 2003, but quickly dwindled as a spike in funding vanished. The same thing happened after MERS emerged in 2012. This year, the world’s coronavirus experts—and there still aren’t many—had to postpone their triennial conference in the Netherlands because SARS CoV 2 made flying too risky.
In the age of cheap air travel, an outbreak that begins on one continent can easily reach the others. SARS already demonstrated that in 2003, and more than twice as many people now travel by plane every year. To avert a pandemic, affected nations must alert their neighbors quickly. In 2003, China covered up the early spread of SARS, allowing the new disease to gain a foothold, and in 2020, history repeated itself. The Chinese government downplayed the possibility that SARS CoV 2 was spreading among humans, and only confirmed as much on January 20, after millions had traveled around the country for the lunar new year. Doctors who tried to raise the alarm were censured and threatened. One, Li Wenliang, later died of COVID 19. The World Health Organization initially parroted China’s line and did not declare a public-health emergency of international concern until January 30. By then, an estimated 10,000 people in 20 countries had been infected, and the virus was spreading fast.
The United States has correctly castigated China for its duplicity and the WHO for its laxity—but the U.S. has also failed the international community. Under President Donald Trump, the U.S. has withdrawn from several international partnerships and antagonized its allies. It has a seat on the WHO’s executive board, but left that position empty for more than two years, only filling it this May, when the pandemic was in full swing. Since 2017, Trump has pulled more than 30 staffers out of the Centers for Disease Control and Prevention’s office in China, who could have warned about the spreading coronavirus. Last July, he defunded an American epidemiologist embedded within China’s CDC. America First was America oblivious.
Even after warnings reached the U.S., they fell on the wrong ears. Since before his election, Trump has cavalierly dismissed expertise and evidence. He filled his administration with inexperienced newcomers, while depicting career civil servants as part of a “deep state.” In 2018, he dismantled an office that had been assembled specifically to prepare for nascent pandemics. American intelligence agencies warned about the coronavirus threat in January, but Trump habitually disregards intelligence briefings. The secretary of health and human services, Alex Azar, offered similar counsel, and was twice ignored.
Being prepared means being ready to spring into action, “so that when something like this happens, you’re moving quickly,” Ronald Klain, who coordinated the U.S. response to the West African Ebola outbreak in 2014, told me. “By early February, we should have triggered a series of actions, precisely zero of which were taken.” Trump could have spent those crucial early weeks mass-producing tests to detect the virus, asking companies to manufacture protective equipment and ventilators, and otherwise steeling the nation for the worst. Instead, he focused on the border. On January 31, Trump announced that the U.S. would bar entry to foreigners who had recently been in China, and urged Americans to avoid going there.
Travel bans make intuitive sense, because travel obviously enables the spread of a virus. But in practice, travel bans are woefully inefficient at restricting either travel or viruses. They prompt people to seek indirect routes via third-party countries, or to deliberately hide their symptoms. They are often porous: Trump’s included numerous exceptions, and allowed tens of thousands of people to enter from China. Ironically, they create travel: When Trump later announced a ban on flights from continental Europe, a surge of travelers packed America’s airports in a rush to beat the incoming restrictions. Travel bans may sometimes work for remote island nations, but in general they can only delay the spread of an epidemic—not stop it. And they can create a harmful false confidence, so countries “rely on bans to the exclusion of the things they actually need to do—testing, tracing, building up the health system,” says Thomas Bollyky, a global-health expert at the Council on Foreign Relations. “That sounds an awful lot like what happened in the U.S.”
This was predictable. A president who is fixated on an ineffectual border wall, and has portrayed asylum seekers as vectors of disease, was always going to reach for travel bans as a first resort. And Americans who bought into his rhetoric of xenophobia and isolationism were going to be especially susceptible to thinking that simple entry controls were a panacea.
And so the U.S. wasted its best chance of restraining COVID 19. Although the disease first arrived in the U.S. in mid-January, genetic evidence shows that the specific viruses that triggered the first big outbreaks, in Washington State, didn’t land until mid-February. The country could have used that time to prepare. Instead, Trump, who had spent his entire presidency learning that he could say whatever he wanted without consequence, assured Americans that “the coronavirus is very much under control,” and “like a miracle, it will disappear.” With impunity, Trump lied. With impunity, the virus spread.
On February 26, Trump asserted that cases were “going to be down to close to zero.” Over the next two months, at least 1 million Americans were infected.
As the coronavirus established itself in the U.S., it found a nation through which it could spread easily, without being detected. For years, Pardis Sabeti, a virologist at the Broad Institute of Harvard and MIT, has been trying to create a surveillance network that would allow hospitals in every major U.S. city to quickly track new viruses through genetic sequencing. Had that network existed, once Chinese scientists published SARS CoV 2’s genome on January 11, every American hospital would have been able to develop its own diagnostic test in preparation for the virus’s arrival. “I spent a lot of time trying to convince many funders to fund it,” Sabeti told me. “I never got anywhere.”
The CDC developed and distributed its own diagnostic tests in late January. These proved useless because of a faulty chemical component. Tests were in such short supply, and the criteria for getting them were so laughably stringent, that by the end of February, tens of thousands of Americans had likely been infected but only hundreds had been tested. The official data were so clearly wrong that The Atlantic developed its own volunteer-led initiative—the COVID Tracking Project—to count cases.
Diagnostic tests are easy to make, so the U.S. failing to create one seemed inconceivable. Worse, it had no Plan B. Private labs were strangled by FDA bureaucracy. Meanwhile, Sabeti’s lab developed a diagnostic test in mid-January and sent it to colleagues in Nigeria, Sierra Leone, and Senegal. “We had working diagnostics in those countries well before we did in any U.S. states,” she told me.
It’s hard to overstate how thoroughly the testing debacle incapacitated the U.S. People with debilitating symptoms couldn’t find out what was wrong with them. Health officials couldn’t cut off chains of transmission by identifying people who were sick and asking them to isolate themselves.
Water running along a pavement will readily seep into every crack; so, too, did the unchecked coronavirus seep into every fault line in the modern world. Consider our buildings. In response to the global energy crisis of the 1970s, architects made structures more energy-efficient by sealing them off from outdoor air, reducing ventilation rates. Pollutants and pathogens built up indoors, “ushering in the era of ‘sick buildings,’ ” says Joseph Allen, who studies environmental health at Harvard’s T. H. Chan School of Public Health. Energy efficiency is a pillar of modern climate policy, but there are ways to achieve it without sacrificing well-being. “We lost our way over the years and stopped designing buildings for people,” Allen says.
The indoor spaces in which Americans spend 87 percent of their time became staging grounds for super-spreading events. One study showed that the odds of catching the virus from an infected person are roughly 19 times higher indoors than in open air. Shielded from the elements and among crowds clustered in prolonged proximity, the coronavirus ran rampant in the conference rooms of a Boston hotel, the cabins of the Diamond Princess cruise ship, and a church hall in Washington State where a choir practiced for just a few hours.
The hardest-hit buildings were those that had been jammed with people for decades: prisons. Between harsher punishments doled out in the War on Drugs and a tough-on-crime mindset that prizes retribution over rehabilitation, America’s incarcerated population has swelled sevenfold since the 1970s, to about 2.3 million. The U.S. imprisons five to 18 times more people per capita than other Western democracies. Many American prisons are packed beyond capacity, making social distancing impossible. Soap is often scarce. Inevitably, the coronavirus ran amok. By June, two American prisons each accounted for more cases than all of New Zealand. One, Marion Correctional Institution, in Ohio, had more than 2,000 cases among inmates despite having a capacity of 1,500.
Other densely packed facilities were also besieged. America’s nursing homes and long-term-care facilities house less than 1 percent of its people, but as of mid-June, they accounted for 40 percent of its coronavirus deaths. More than 50,000 residents and staff have died. At least 250,000 more have been infected. These grim figures are a reflection not just of the greater harms that COVID 19 inflicts upon elderly physiology, but also of the care the elderly receive. Before the pandemic, three in four nursing homes were understaffed, and four in five had recently been cited for failures in infection control. The Trump administration’s policies have exacerbated the problem by reducing the influx of immigrants, who make up a quarter of long-term caregivers.
Even though a Seattle nursing home was one of the first COVID 19 hot spots in the U.S., similar facilities weren’t provided with tests and protective equipment. Rather than girding these facilities against the pandemic, the Department of Health and Human Services paused nursing-home inspections in March, passing the buck to the states. Some nursing homes avoided the virus because their owners immediately stopped visitations, or paid caregivers to live on-site. But in others, staff stopped working, scared about infecting their charges or becoming infected themselves. In some cases, residents had to be evacuated because no one showed up to care for them.
America’s neglect of nursing homes and prisons, its sick buildings, and its botched deployment of tests are all indicative of its problematic attitude toward health: “Get hospitals ready and wait for sick people to show,” as Sheila Davis, the CEO of the nonprofit Partners in Health, puts it. “Especially in the beginning, we catered our entire [COVID 19] response to the 20 percent of people who required hospitalization, rather than preventing transmission in the community.” The latter is the job of the public-health system, which prevents sickness in populations instead of merely treating it in individuals. That system pairs uneasily with a national temperament that views health as a matter of personal responsibility rather than a collective good.
At the end of the 20th century, public-health improvements meant that Americans were living an average of 30 years longer than they were at the start of it. Maternal mortality had fallen by 99 percent; infant mortality by 90 percent. Fortified foods all but eliminated rickets and goiters. Vaccines eradicated smallpox and polio, and brought measles, diphtheria, and rubella to heel. These measures, coupled with antibiotics and better sanitation, curbed infectious diseases to such a degree that some scientists predicted they would soon pass into history. But instead, these achievements brought complacency. “As public health did its job, it became a target” of budget cuts, says Lori Freeman, the CEO of the National Association of County and City Health Officials.
Today, the U.S. spends just 2.5 percent of its gigantic health-care budget on public health. Underfunded health departments were already struggling to deal with opioid addiction, climbing obesity rates, contaminated water, and easily preventable diseases. Last year saw the most measles cases since 1992. In 2018, the U.S. had 115,000 cases of syphilis and 580,000 cases of gonorrhea—numbers not seen in almost three decades. It has 1.7 million cases of chlamydia, the highest number ever recorded.
Since the last recession, in 2009, chronically strapped local health departments have lost 55,000 jobs—a quarter of their workforce. When COVID 19 arrived, the economic downturn forced overstretched departments to furlough more employees. When states needed battalions of public-health workers to find infected people and trace their contacts, they had to hire and train people from scratch. In May, Maryland Governor Larry Hogan asserted that his state would soon have enough people to trace 10,000 contacts every day. Last year, as Ebola tore through the Democratic Republic of Congo—a country with a quarter of Maryland’s wealth and an active war zone—local health workers and the WHO traced twice as many people.
Ripping unimpeded through American communities, the coronavirus created thousands of sickly hosts that it then rode into America’s hospitals. It should have found facilities armed with state-of-the-art medical technologies, detailed pandemic plans, and ample supplies of protective equipment and life-saving medicines. Instead, it found a brittle system in danger of collapse.
Compared with the average wealthy nation, America spends nearly twice as much of its national wealth on health care, about a quarter of which is wasted on inefficient care, unnecessary treatments, and administrative chicanery. The U.S. gets little bang for its exorbitant buck. It has the lowest life-expectancy rate of comparable countries, the highest rates of chronic disease, and the fewest doctors per person. This profit-driven system has scant incentive to invest in spare beds, stockpiled supplies, peacetime drills, and layered contingency plans—the essence of pandemic preparedness. America’s hospitals have been pruned and stretched by market forces to run close to full capacity, with little ability to adapt in a crisis.
When hospitals do create pandemic plans, they tend to fight the last war. After 2014, several centers created specialized treatment units designed for Ebola—a highly lethal but not very contagious disease. These units were all but useless against a highly transmissible airborne virus like SARS CoV 2. Nor were hospitals ready for an outbreak to drag on for months. Emergency plans assumed that staff could endure a few days of exhausting conditions, that supplies would hold, and that hard-hit centers could be supported by unaffected neighbors. “We’re designed for discrete disasters” like mass shootings, traffic pileups, and hurricanes, says Esther Choo, an emergency physician at Oregon Health and Science University. The COVID 19 pandemic is not a discrete disaster. It is a 50-state catastrophe that will likely continue at least until a vaccine is ready.
Wherever the coronavirus arrived, hospitals reeled. Several states asked medical students to graduate early, reenlisted retired doctors, and deployed dermatologists to emergency departments. Doctors and nurses endured grueling shifts, their faces chapped and bloody when they finally doffed their protective equipment. Soon, that equipment—masks, respirators, gowns, gloves—started running out.
In the middle of the greatest health and economic crises in generations, millions of Americans have found themselves impoverished and disconnected from medical care.
American hospitals operate on a just-in-time economy. They acquire the goods they need in the moment through labyrinthine supply chains that wrap around the world in tangled lines, from countries with cheap labor to richer nations like the U.S. The lines are invisible until they snap. About half of the world’s face masks, for example, are made in China, some of them in Hubei province. When that region became the pandemic epicenter, the mask supply shriveled just as global demand spiked. The Trump administration turned to a larder of medical supplies called the Strategic National Stockpile, only to find that the 100 million respirators and masks that had been dispersed during the 2009 flu pandemic were never replaced. Just 13 million respirators were left.
In April, four in five frontline nurses said they didn’t have enough protective equipment. Some solicited donations from the public, or navigated a morass of back-alley deals and internet scams. Others fashioned their own surgical masks from bandannas and gowns from garbage bags. The supply of nasopharyngeal swabs that are used in every diagnostic test also ran low, because one of the largest manufacturers is based in Lombardy, Italy—initially the COVID 19 capital of Europe. About 40 percent of critical-care drugs, including antibiotics and painkillers, became scarce because they depend on manufacturing lines that begin in China and India. Once a vaccine is ready, there might not be enough vials to put it in, because of the long-running global shortage of medical-grade glass—literally, a bottle-neck bottleneck.
The federal government could have mitigated those problems by buying supplies at economies of scale and distributing them according to need. Instead, in March, Trump told America’s governors to “try getting it yourselves.” As usual, health care was a matter of capitalism and connections. In New York, rich hospitals bought their way out of their protective-equipment shortfall, while neighbors in poorer, more diverse parts of the city rationed their supplies.
While the president prevaricated, Americans acted. Businesses sent their employees home. People practiced social distancing, even before Trump finally declared a national emergency on March 13, and before governors and mayors subsequently issued formal stay-at-home orders, or closed schools, shops, and restaurants. A study showed that the U.S. could have averted 36,000 COVID 19 deaths if leaders had enacted social-distancing measures just a week earlier. But better late than never: By collectively reducing the spread of the virus, America flattened the curve. Ventilators didn’t run out, as they had in parts of Italy. Hospitals had time to add extra beds.
Social distancing worked. But the indiscriminate lockdown was necessary only because America’s leaders wasted months of prep time. Deploying this blunt policy instrument came at enormous cost. Unemployment rose to 14.7 percent, the highest level since record-keeping began, in 1948. More than 26 million people lost their jobs, a catastrophe in a country that—uniquely and absurdly—ties health care to employment. Some COVID 19 survivors have been hit with seven-figure medical bills. In the middle of the greatest health and economic crises in generations, millions of Americans have found themselves disconnected from medical care and impoverished. They join the millions who have always lived that way.
The coronavirus found, exploited, and widened every inequity that the U.S. had to offer. Elderly people, already pushed to the fringes of society, were treated as acceptable losses. Women were more likely to lose jobs than men, and also shouldered extra burdens of child care and domestic work, while facing rising rates of domestic violence. In half of the states, people with dementia and intellectual disabilities faced policies that threatened to deny them access to lifesaving ventilators. Thousands of people endured months of COVID 19 symptoms that resembled those of chronic postviral illnesses, only to be told that their devastating symptoms were in their head. Latinos were three times as likely to be infected as white people. Asian Americans faced racist abuse. Far from being a “great equalizer,” the pandemic fell unevenly upon the U.S., taking advantage of injustices that had been brewing throughout the nation’s history.
Of the 3.1 million Americans who still cannot afford health insurance in states where Medicaid has not been expanded, more than half are people of color, and 30 percent are Black.* This is no accident. In the decades after the Civil War, the white leaders of former slave states deliberately withheld health care from Black Americans, apportioning medicine more according to the logic of Jim Crow than Hippocrates. They built hospitals away from Black communities, segregated Black patients into separate wings, and blocked Black students from medical school. In the 20th century, they helped construct America’s system of private, employer-based insurance, which has kept many Black people from receiving adequate medical treatment. They fought every attempt to improve Black people’s access to health care, from the creation of Medicare and Medicaid in the ’60s to the passage of the Affordable Care Act in 2010.
A number of former slave states also have among the lowest investments in public health, the lowest quality of medical care, the highest proportions of Black citizens, and the greatest racial divides in health outcomes. As the COVID 19 pandemic wore on, they were among the quickest to lift social-distancing restrictions and reexpose their citizens to the coronavirus. The harms of these moves were unduly foisted upon the poor and the Black.
As of early July, one in every 1,450 Black Americans had died from COVID 19—a rate more than twice that of white Americans. That figure is both tragic and wholly expected given the mountain of medical disadvantages that Black people face. Compa
theatlantic.com, 4 August 2020
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