This is the first essay in Civic Way’s series on the pandemic and the lessons to be learned from our successes and failures. In this essay, we summarize what has happened thus far during the pandemic. In our next essay, we address the political pandemic. In a future essay, we will discuss the lessons that could help prepare us for the next crisis. The author, Bob Melville, is the founder of Civic Way, a nonprofit dedicated to good government, and a management consultant with over 45 years of experience improving government agencies.

Highlights:

• The Covid-19 virus has infected over 254 million and killed over five million worldwide
• In the US, the Covid-19 virus has infected at least 46.5 million and killed nearly 760,000
• Despite high expectations and prior successes, the US responded poorly to the Covid-19 pandemic, leading the world in reported infections and deaths and failing to chart a unified pandemic response
• America’s failure is attributable to several factors, including a fragile public health system, a disjointed health care system, second-rate testing, inadequate contact tracing and slow vaccine distribution

The Pandemic’s Wrath

Worldwide, the Covid-19 virus has infected over 254 million people and caused over 5.1 million deaths. The global economic impact has been incalculable.

In the US, the Covid-19 virus has infected at least 46.5 million and killed nearly 760,000, more than the combined American deaths for World War I, World War II and the Vietnam War. Economically, the pandemic has cost our nation an estimated $16 trillion (about 90 percent of our annual Gross Domestic Product), four times the economic impact of the Great Recession.

Perhaps even more dispiriting is the pandemic’s persistence. Every time we seem to be turning a corner, we are slammed by another surge. Changing temperatures, contagious variants and relaxed public health measures—among other factors—fuel more surges. Just this week, after several weeks of decline, cases began rising once again. As we approach the holiday season, public health experts fear a fifth wave. Rising infections. Reinstated restrictions. Another season of discontent.

Given the presence of vaccines, this fifth wave should wreak less havoc than prior surges. Still, many public officials are taking sensible precautions. Some nations are reimposing restrictions while expanding vaccine eligibility. In the US, after New York City announced plans to open its Times Square New Year’s Eve celebration to the vaccinated, Governor Hochul warned that another surge could require  another round of restrictions.

America’s Shame

In 2019, most experts expected the US to lead the global fight against the next pandemic. The Johns Hopkins Center for Health Security ranked the US first in pandemic readiness. The world’s wealthiest nation. The most expensive and advanced health care system. A proven global leader during prior pandemics like Ebola.

The US did some things well. Early in the pandemic, its efforts to flatten the curve—while uneven—protected its health care system and saved thousands of lives. The Trump Administration’s Operation Warp Speed spurred a heroic public-private vaccine venture. The Biden Administration has expedited vaccine distribution. Both administrations approved stimulus packages. Covid-19 treatment pills are coming. Several states leveraged federal waivers to grant temporary insurance coverage and expand services (e.g., remote and home care).

Despite such successes, the US pandemic response was too little too late. The US leads the world in total reported infections and deaths. It owns one of the world’s highest per capita death rates. During 2020, it failed to chart a unified pandemic response among its 50 states, let alone lead a global response. Early in the pandemic, supply shortages hampered treatment (e.g., protective equipment).

Several critical factors contributed to our failure. A fragile public health system. An ill-prepared health system. Frayed testing and contact tracing programs. Slow vaccine distribution. Vacillating leadership. Polarized politics. Widespread misinformation. We discuss these factors in more detail below and in our next essay.

Our Fragmented, Resource-Starved Public Health System

Much will be written about our lack of planning and preparation for the Covid-19 pandemic. In the meantime, we can only highlight a few examples of what went wrong.

At the federal level, before the pandemic began, the Trump Administration disbanded the National Security Council’s pandemic team and cut funding for several public health programs. The Obama Administration depleted the Strategic National Stockpile (respirators and masks) during the 2009 flu pandemic, but Congress failed to fund its replenishment. Our limited strategic manufacturing capacity hindered our access to vital drugs (e.g., antibiotics) and other supplies (e.g., vaccine vials).

In the absence of strong federal leadership, our state and local governments floundered. Some states traded the long-term public interest for short-term political advantage. Some governors defied national guidelines. Some legislatures banned local governments from protecting their citizens. Many citizens were left to the treacherous mercies of social media sites that spewed lies and misinformation. Vulnerable populations (e.g., minorities) were left to suffer. The pandemic became fiercely politicized.

Our public health system was weakened by severe fragmentation and years of fiscal neglect long before the pandemic. With 50 states and over 3,000 public health agencies, the system has become far too fragmented to mount a cohesive, coordinated response to emerging pandemics. With ever-shrinking budgets, it lacks the resources to prevent or control the spread of infectious diseases. It is no wonder that, in 2019, the Johns Hopkins Center for Health Security ranked the US 19th in public health infrastructure quality.

Our High-Cost, Disconnected Health Care System

In psychology, there is something called the Cinderella effect. It uses the fairy tale character—more specifically, her neglect and mistreatment by her stepsisters—to explain and understand the oft-unhealthy situation of a stepchild. America’s health care system is the stepsister to the public health system’s Cinderella.

For a variety of reasons, the US spends far more on treating illness than preventing it. To illustrate, our nation spends over 97 percent of its health budget on hospitals and other components of our health care system (treatment), but less than three percent on public health (prevention). It is no coincidence that most health care providers are private entities, detached from public health agencies (mostly county agencies).

Largely profit-driven, our health care system has little financial incentive to invest in pandemic preparedness. Many hospitals can accommodate short-term disasters like hurricanes, but not extended pandemics. Pandemic planning receives scant attention and pandemic supplies—like protective equipment and face masks—aren’t stockpiled. We should not have been surprised by the ICU bed shortages.

The US’ outmoded, tottering health insurance system further undermines our ability to fight pandemics. Despite the ACA and Medicaid, coverage gaps leave many citizens exposed. In 2018, for instance, over 27 million Americans lacked health insurance (the COVID-19 pandemic may have doubled the uncovered). The lack of universal health care coverage has severely inhibited our efforts to control the pandemic.

A Frayed Testing Program

Our diagnostic testing capabilities for Covid-19 remain a work in progress. After several early missteps (e.g., the CDC’s first flawed test kit and the delayed approval of commercial lab tests), the US eventually developed two tests—an antigen test and PCR test. The antigen test is quick and cheap. The PCR test is more costly and accurate (it also can confirm a positive antigen test).

The US’ testing performance lagged that of other nations. For example, it took 46 days for the CDC to deploy a Covid-19 test after receiving the WHO’s initial guidance, but Thailand did so within hours. By March 2020, the US administered fewer daily tests than South Korea (the US is six times larger). It also trailed its own targets. By June 2020, the US only administered 700,000 daily tests against a target of at least 1.2 million. Rapid tests remain in short supply in many areas.

As the pandemic continued, the US’ testing capacities improved. By October 2020, the federal government had shipped about 200 million antigen test kits to states and other entities. Testing sites proliferated and test processing improved. The FDA approved several over-the-counter Covids-19 antigen test for home use. The US Department of Health and Human Services (DHHS) recently announced plans to invest $650 million in increasing its manufacturing capacity for rapid point-of-care molecular tests.

The sad truth is that we lacked adequate testing capacity when we needed it most, before the vaccine rollout. Why did our testing fail when it could have done the most good? A weak public health system. Confusing health care reimbursements. Last-mile test collection logistics. Unused test processing capacity. Lab delays. Uncertain test reliability. Inconsistent reporting. And without adequate testing, a return to normalcy proved elusive.

Haphazard Contact Tracing

Contact tracing has long been an indispensable public health tool for tracking infectious disease outbreaks and informing public containment strategies. It was effectively deployed by the US to control many viruses—Smallpox, Ebola, H1N1 and SARS—and by many nations to control Covid-19. The US, however, failed to deploy it in a meaningful way during the Covid-19 pandemic.

Contact tracing relies heavily on people. Tracer teams must move at warp speed to locate potential patients, identify close contacts and, if necessary, support isolation. In the US, the decentralized state and local public health system, with its highly fragmented workforce and sparse resources, inhibits contact tracing efforts. During the pandemic, ramping up to a workforce of 300,000 contact tracers proved impossible.

The nation’s contact tracing encountered other obstacles as well. Unwieldy, inconsistent contact tracing reports and serious data gaps. And perhaps the biggest impediment of all—widespread distrust of public health officials and any measures that could be construed as an invasion of privacy or a threat to personal freedom.

A Slow, Uneven Vaccine Rollout

We know that a vaccinated population and herd immunity can slash infections, hospitalizations and death. Safe, effective vaccines were developed in record time, an extraordinary achievement for which the Trump Administration deserves credit (it allocated Operation Warp Speed nearly $18 billion). The decision by Moderna and Pfizer to bet the house on a mRNA platform also merits praise.

However, our vaccine rollout has been far less impressive. Poor planning undermined coordination. The FDA’s bureaucratic caution delayed approval. Initial vaccine supplies didn’t satisfy demand. The lack of a national vaccine distribution system forced us to overcome huge logistical challenges on the fly (e.g., remote rural communities and urban pharmacy deserts). Inadequate reporting systems made it hard to align vaccines with needs. Fragmented outreach and mixed messaging did little to counter high vaccine hesitancy rates.

The US has not been the only nation struggling to efficiently distribute vaccines. Several European nations, for example, experienced messy vaccination rollouts. Canada’s rollout was a disappointment. The most successful vaccination campaigns have been in nations with top-down coordination, centralized registration systems and universal health coverage (e.g., Israel and Great Britain).

Back in the US, the vaccine rollout has varied significantly by state. Many states delegated decisions to local health officials, sowing confusion. Over time, the correlation between state politics and state vaccination rates appears to have grown. The states with the lowest vaccination rates tend to have GOP-controlled legislatures while the states with the highest vaccination rates tend to have Democratic legislatures.

Conclusion

Our national response to the pandemic has been plagued by several problems—a fragile public health system, an ill-prepared health system, weak testing and contact tracing programs and slow vaccine distribution—to name a few. More perplexing causal factors, like myopic leadership, divisive politics and misinformation, will be discussed in our next essay. All have profound public policy implications.