America, the Ill
Photo by Natanael Melchor on Unsplash
As of the time of the writing of this post, the United States has over 2.4 million confirmed cases of COVID-19, resulting in more than 124,000 deaths. In each case, that constitutes over 25% of the world’s totals, even though the US has only 4.25% of the world’s population.
And despite all of the nation’s efforts to date, no end to the virus’s spread appears in sight. While new cases of COVID-19 are declining in the areas which were originally hardest hit (New York, New Jersey, Connecticut and Illinois), they are now rising dramatically in other regions, particularly in the south. Record numbers of new cases are being reported daily in Texas, Florida, Arizona, Georgia, South Carolina, Mississippi and California.
I’m generally hesitant to make predictions, and this is particularly the case with respect to COVID-19, since I am not an epidemiologist and have no expertise in infectious disease. But a lack of actual credentials hasn’t stopped others from publishing their relatively unsupported speculations regarding the coronavirus, so why not me?
So, here’s my prediction. By the end of September, there will have been at least 5 million confirmed cases in the US, and more than 240,000 deaths—more than the number of US and Confederate soldiers who died in combat in the Civil War.
And that will be where we stand before the onset of the usual flu season in the fall. As people spend more time indoors, we can expect accelerated spread, while the combination of seasonal influenza and COVID-19 will challenge the capacity of our healthcare facilities to an unprecedented extent.
If we are facing a war with the coronavirus, America is not winning.
Yet, the outcome could have been different.
Other countries have managed the pandemic much better. That’s not to say it was easy to do so, or even entirely sustainable. Some countries that originally had success in containing the virus are now seeing the development of new hot spots and community transmission. We don’t yet know if they will be able to contain this new spread, or if it will expand. But there is no question that the per capita number of cases and deaths in many other countries has been dramatically lower than in the US.
Our degree of failure has not gone unnoticed. As the EU prepares to permit travelers to return to Europe, the US is one of a handful of countries (including Russia and Brazil) reported to be on the excluded list.
With one of the most technologically advanced health care systems in the world and the resources of a superpower, why is the US failing to contain the spread of the coronavirus? Many factors are contributing to this result, but at this point the patterns seem increasingly clear. An understanding of these reasons is critical, in order to mitigate the continuing loss of life from COVID-19 to the extent we still can, and to prepare for the next pandemic whenever it may arise.
In my view, there are at least six categories of factors that I believe have most impaired America’s ability to successfully combat COVID-19.
1. Poor Implementation of the First Phase Response
As we approach the end of June, we know much more about COVID-19 than we did in the early days of the pandemic. As a result, it is easy to second-guess the recommendations or statements of experts back in the first months of the year. That being said, we can certainly identify some actions that missed critical opportunities or led to policies that had unintended consequences.
The countries that best handled the early stages of the pandemic did so through extensive testing and contact tracing.
In the US, however, the development of an antigen test was botched by the CDC and the FDA, delaying the availability of widespread testing for several months. The failure was largely a result of following established policies, without recognizing that COVID-19 was an unprecedented threat that required much swifter action than had been necessary for other, recent pandemics. Without data on the number and locations of those infected, COVID-19 spread throughout the country unnoticed. Had better information been available earlier, we might have been able to contain hot spots as they emerged and before community transmission began.
Once it was clear that there was some community spread in the US, the health authorities recommended the implementation of strict shelter-at-home restrictions throughout the country, closing businesses and shutting down transportation.
It is almost certain that taking these actions prevented an even faster spread of the virus, protecting hospital capacity and saving lives. However, these policies failed to take into account the substantial diversity and enormous regional variations within the US in terms of population density, mobility, and environment. The move to lock down whole states nearly all at the same time led to markedly disproportionate costs and benefits. The hardest-hit areas needed to immediately enforce stringent measures to stop the spread, and for them, the severe cost of doing so was clearly balanced by the benefit of saving lives. Nearly the same restrictions were imposed on more rural areas, however, where the virus then was largely non-existent. For them, the costs did not seem to be giving rise to any benefits.
This overbroad, heavy-handed approach led to a loss of confidence in experts and decisionmakers. Opposition to the measures grew proportionately. Protesters wearing plate carriers and holding semi-automatic rifles marched on state capitols, and state and local health officials received death threats. The fact that the virus was hitting states that lean Democratic the hardest, while seeming to spare states that lean Republican, exacerbated political tensions and politicized health policy.
Now that many of those Republican-leaning states are experiencing dramatically increasing case numbers, health authorities have little credibility when they propose measures meant to mitigate the spread.
Future policymakers should take note. Real-time information is critical, so the highest priority must be given to the swift development and availability of testing. With that information, isolating hot spots to prevent community spread is the first line of defense. If that fails, however, the data obtained can be used to implement procedures on a comparatively localized basis. Different areas need to be treated differently, with measures targeted to achieve and maintain an R-naught of less than 1.0, while keeping as much of the economy open as is possible within those goals. Popular support for painful measures will require public confidence that the costs imposed are necessary to save lives.
To an extent, the loss of confidence in medical experts could have been mitigated through strong political leadership, particularly at the presidential level. Which brings us to the next reason the US has failed the test of COVID-19.
2. Political Failure
The failure of presidential leadership during the COVID-19 pandemic has been heavily reported, so there is no need to repeat it in detail here. Shared national sacrifice is hard at the best of times. It is that much harder when the threat is invisible, affects different populations disproportionately, and has no applicable precedent that anyone alive can remember.
The nation needed leadership that accepted the opinions of scientists and health experts, conveyed a consistent message, and expressed the compassion and confidence needed to unify the people in facing the difficult tasks needed to protect the most vulnerable among us.
We did not have such leadership.
The bully pulpit of the president can move the nation. When it is used to disparage the recommendations of experts, to blame the other political party or China or the World Health Organization, and to deflect responsibility, the result is a poison that seeps into the nation’s collective resolve. The further failure to use the power of the office to ensure the swift manufacture and distribution of personal protective equipment and medical supplies put additional burdens on the healthcare system and led to regional competition for equipment and rationing.
But the failure of political will extended beyond the White House. For a brief time, it appeared that the threat of COVID-19 could bring the nation together, as have other crises in the past. In our extraordinarily partisan times, that would have been unlikely under the best circumstances. But instead of joining with their Democratic colleagues, many Republican politicians questioned the qualifications and motivations of the experts, engaged in magical thinking, or gave credence to conspiracy theories. That many Republican-leaning regions remained largely unaffected by the virus for several months made it easier to play to the biases of the party’s base, rather than lead it to an understanding of the need for sacrifice.
That’s not to say that Democratic politicians did not make their own errors that cost lives. Governor Andrew Cuomo of New York and Mayor Bill de Blasio waited at least a week too long to lock down their communities, and orders requiring care facilities to take patients who had tested positive for COVID-19 resulted in terrible outbreaks among an extremely vulnerable population. Those errors, however, were made in the early stages of the pandemic, when the unprecedented threat posed by the virus was just being recognized. Many Republican leaders continue to this day to deny the pandemic’s risks in an effort to avoid imposing new restrictions.
In addition, the legislation necessary to mitigate the economic consequences of the shelter-at-home orders and business closures ran counter to many standard Republican principles concerning the limited role of government and opposition generally to welfare or benefits programs. As a result, the need for compromise and swift action led to economic relief legislation that included poorly considered provisions and compromises that failed to provide sufficient support for an economy forced to shut down nationwide.
In the end, strong political leadership would not have prevented the COVID-19 pandemic, but it could have fortified the nation with the resolve needed to make the sacrifices necessary to minimize its impact. The deaths of an unknown number of Americans can be laid directly on the doorstep of our political class.
3. Loss of Trust in Experts and Statistical Denial
I have already written a blog post about the scientific method. The concept of science remains poorly understood by the American public, which presumes that there should always be a “right” answer to a question. In science, however, there is never a “right” answer; there are just best answers at a time given the best information then available. As new information is obtained, as new studies and analyses are performed or new concepts conceived, the answers may change.
Usually, this process occurs quietly, behind the scenes among scientists. But this time, the process was not just out in the open, it was being covered 24 hours a day by the news media.
Reporters and politicians asked questions and demanded answers. The experts responded the best they could, but often with very little data about the virus and in the absence of peer-reviewed studies. When new information became available, they modified their views. Sometimes, the experts just didn’t agree on how to interpret the data they did have. That’s how science is supposed to work. But to the public, the confusion and changing responses was interpreted as proof that the scientists didn’t know what they were doing, were incompetent, or were engaged in some sort of conspiracy, perhaps against the president or in furtherance of some sort of new world order.
This was exacerbated by the decision of many news outlets and other media, hungry to fill air time, to interview non-experts expressing their own, uninformed views. To those watching, their presence on respected media forums lent credence to their opinions, and further confused good information from bad.
In addition, statistics are often contrary to our experience. We are not used to geometric growth in our daily lives. The complexity of analyses relating to the pandemic made it hard for the ordinary American to independently understand the implications, and made it easier for those seeking alternative explanations to find data points that permitted them to justify their preferred conclusions. Ultimately, anecdote is often easier to understand. For those who did not know anyone who had contracted COVID-19, or a healthcare professional working in a hospital where cases were handled, the pandemic seemed to be someone else’s problem, or even a false problem manufactured by those who wanted to use it for ulterior ends.
The popular rejection of science is not new, unfortunately. We have seen the same loss of trust in experts with respect to climate change and the acceptance of vaccinations, for example. But in this case, the loss of trust led directly to actions that had an immediate effect on the lives of Americans. As a result, the recommendations of medical and healthcare experts have been discounted or ignored by large portions of the American public.
4. Loss of Confidence in Government
Certain events, such as pandemics, require swift coordination of response across nearly all communities. Reliance on voluntary individual action can be woefully insufficient when population-wide action is needed. Under such circumstances, only government can supply the necessary coordination.
Unfortunately, trust in the government has been on the decline for many years in the US. The Vietnam War and Watergate eroded confidence in what government said, while the Reagan Revolution was based in large part on a belief that government is generally incompetent.
There is also a deep strain of libertarian influence in American policy, supported by business interests. From this perspective, reliance on the free market provides the greatest good to the most people, while government influence is a form of socialism that should be avoided.
It probably goes without saying that some distrust of government has certainly been earned. But in this case, when a coordinated response was critical to mitigating the spread of the virus, this distrust weakened our ability to take the collective actions necessary to confront the pandemic and minimize the economic impact of those actions.
5. Independence, Religious Freedom and the Frontier Mindset
A powerful strain of independence and self-reliance runs through the American mythology. Our traditions tell us that our nation was born in rebellion, and conquered a continent through the hard work of settlers moving westward in covered wagons. We cherish our freedom of speech, our right to bear arms, and our right to worship God in exactly the way we want.
The power of this myth (and a myth it is, partially true, but omitting anything running contrary) is especially strong in the nation’s western states and in the south. The hero is the settler, the farmer, the rancher, the cowboy. The enemy? Often, the government, and in particular the federal government.
As a result, mandates to maintain social distancing and to wear masks were initially suspect. Closing businesses, which threatened livelihoods and legacies, seemed even more contrary to the spirit of America. The strength of these opinions only grew as people wearied of the economic distress from imposed restrictions, and tired of the business of covering our faces, maintaining social distance, and washing our hands.
Forcing churches to close their doors was particularly offensive to certain segments of the US population, which considers the right to religious freedom to be the paramount right enshrined in the US Constitution.
Legal challenges were mounted, some successful (though not on the grounds of the US Constitution), and statements along the lines of “I refuse to live in fear” became commonplace. For many, collective action seemed too much like “socialism” and too little like the American way.
Much like an organism that is particularly susceptible to a specific parasite, the United States is most vulnerable to challenges that require sustained collective action and the sacrifice of individual freedoms. Doing this simply doesn’t come naturally, and is counter to deep traditions in US culture.
6. Failures of our Healthcare System
Finally, the structure of the US healthcare system made confining the spread of COVID-19 much more difficult.
The key to containment is finding those who are infected, quarantining them, and isolating those who they had contact with.
Millions of Americans are uninsured or have insufficient insurance. More than half of the population relies on their employer for health coverage, so losing a job means losing healthcare. And far too many people do not have enough savings to survive if they are not working.
As a result, uniquely in the United States, people who may have symptoms of COVID-19 or know they were exposed may refuse to go to the doctor or get tested, simply because they cannot afford to do so. Nor can they afford to be off work during the typically recommended 14-day quarantine or isolation period. And some who have symptoms may continue to go to work because otherwise they would be unable to pay their bills.
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So, what do we do now?
Some of the factors that have impaired our ability to confront COVID-19 are systemic and will be very hard to change. Some are deeply embedded in the American psyche, and constitute part of our national identity. Others, however, can be addressed with sufficient political will. Our dysfunctional politics, public distrust of science, and inadequate healthcare system, for example, are all within our collective power to change, and doing so will be critical if we are to successfully confront the next pandemic we face.
But there are some lessons we can learn and act on that do not require massive changes in public opinion or realignments of entire industries.
To my mind, it is most critical that future public health recommendations be sufficiently localized so that the costs borne by a community are clearly commensurate with the benefits. This needs to be implemented swiftly but compassionately, based upon the advice of the experts, and supported without qualification by politicians of both parties and at all levels.
But this is just a first step. The next steps require political courage. Those politicians who have denied the threat of COVID-19 or pandered to the prejudices of their party’s base must be held to account. They have cost us an unknown number of unnecessary deaths. They have failed our country in its time of need.