Mistakes in the US Pandemic Response and Lessons Learned

The United States government mishandled the COVID-19 pandemic long before thousands of Americans succumbed to the virus daily. From the time of the first reports of a mysterious pneumonia in Wuhan, US leadership failed to implement pandemic preparedness measures and made numerous missteps in protecting the country from a critical threat. The most crucial mistakes the US made were what it did not do; it failed to promptly acknowledge the threat the virus posed and implement crucial policies to mitigate its impact. In his book, The Premonition, Michael Lewis crafts a narrative illustrating what the US did wrong and how the government made those mistakes. Lewis tells the story of the local public health officials who saw a pandemic on the horizon and raised the alarm for months before the government took meaningful action. By juxtaposing the actions of these local public health professions with the policies of the Trump administration and CDC, he explains how the country was primed to have such systemic failures in the pandemic response. Lewis describes how an evidence-based pandemic plan gathered dust while people were dying, as the CDC took the wrong lessons out of previous “near misses” like the original SARS and Swine flu outbreaks. Some of the most crucial mistakes Lewis highlights were the government’s delay in acknowledging the risk posed by the virus and the subsequent lagging response. He demonstrates how inadequate testing and delayed social distancing measures altered the trajectory of the pandemic for the worse. Another error in the pandemic response was how the government failed to unite the fragmented US public health system to coordinate infection control measures. Lewis describes this through the stories of local public health heroes. One theme of the failed pandemic response that Lewis does not adequately address is the government’s poor communication with the public, which led to rampant mistrust and thus limited the success of public health measures. The inadequacy of the government’s COVID response demonstrates the US public health system’s weakness and provides insight to better address the next threat. However, as the healthcare system is somehow weaker than it was in 2019, it is possible that the nation will not learn from its mistakes.

The theme of the US pandemic response was inaction and delay. The lagging and inadequate response is arguably the government’s biggest mistake of the crisis because it led to thousands of preventable deaths. The country failed to act in myriad ways stemming from its leadership denying the risk crucial first days of the outbreak. From the CDC to the President, the US government was hesitant to acknowledge that Americans were at risk from COVID. From the first reports of rising cases of a respiratory virus in Wuhan to almost two months later when US citizens started contracting COVID in the community, the government downplayed the seriousness of the situation. Lewis theorizes that this denial resulted from the Trump administration’s assertion that other nations were the sole threat to American well-being (Lewis 163). How could something as microscopic as a virus affect such an impenetrable nation that held its ground against all foreign threats? The inertia of discounting the potential danger of COVID established inaction and delay across all aspects of the pandemic response.

The inadequate urgency of the US government began when the first reports of a mysterious illness came out of Wuhan. The President quickly reassured Americans that the virus was not a danger to them; it was something halfway across the world that would never reach our shores. The government failed to appreciate how the interconnectedness of the world and the nature of communicable diseases would quickly collide and create the perfect viral storm. This denial wasted time that was valuable in minimizing the impact of COVID. While many foreign countries were quickly on alert, Vice President Mike Pence sent an order to the Department of Health and Human prohibiting them from alarming Americans (Lewis 225). As Lewis points out, even scientists at the CDC reiterated that the virus had a slim chance of significantly impacting the US (Lewis 212). The US government downplaying the emerging pathogen was the first misstep in a cascade of errors beginning in the weeks before it reported the first COVID case on American soil.

Not only did the Trump administration fail to declare the threat of COVID before it arrived, but the denial continued even when the virus reached the US. When the CDC reported the first US COVID case on January 24th, the government still showed little alarm; all the CDC did was issue an alert to screen for fever in travelers from China (Lewis 167). Meanwhile, other countries have already implemented more extreme measures, such as testing and quarantining all citizens entering from Wuhan (Lewis 175). The US government did not act with the same urgency, and Americans were unprepared to do what was necessary to control the virus. On January 31st, the CDC finally required travelers from China to quarantine upon return, but it was far too late for this measure to have an impact. Lewis argues that there were signs that the virus was already widespread inside the US at this point, so focusing on travelers was futile (Lewis 179). Still, the CDC persistently avoided and denied the term “pandemic” despite warnings from scientists attempting to convince the Trump administration of the potential impact of the coronavirus (Lewis 183). One cannot argue that the government was unaware of the outbreak’s potential costs because pandemic experts like Dr. Carter Mecher prepared for this event (Lewis 176). Dr. Mecher estimated, based on the earliest data, that COVID would cause between 900,000 and 1.8 million deaths in the US alone. Based on the pandemic plan he and other scientists under the Bush administration, this Category 5 threat warranted the CDC to take all available infection control measures (Lewis 177). Lewis reveals that the government was aware of the destruction the US faced but still lacked the necessary urgency.

The nearly two months of denial and inaction primed the response for failure. Another crucial mistake that stemmed from the early action was the lagging testing for the virus in the US. Implementing early and widespread testing would have likely altered the trajectory of the pandemic, but US testing was abysmal. Many countries, even those with fewer resources, tested far more efficiently. Lewis acknowledges that the limited testing capacity early in the outbreak left the country blind to the true impact of the virus (Lewis 181). The CDC did not prioritize testing, which was an appalling oversight. Although the organization promised a quick test, it did not follow through with enough testing capacity. As a result of the limited capacity, testing was sparse. Due to the asymptomatic nature of many infections, the lack of testing permitted unidentified viral spread across the US. The CDC developed a test by January 20th, but the organization immediately halted its use because one of three sequences gave inconclusive results (Shear et al., 2020). While they recalled the CDC-developed test, the CDC and FDA stood in the way of private companies willing to contribute. FDA regulations made it impossible for private companies to implement independently developed diagnostic tests, even though they could mass-produce them (Shear et al., 2020). Robert Redfield, the CDC director, said that tests made by independent labs could not be utilized without approval, even if people wanted the test (Lewis 176). Additionally, the CDC did not allow the use of the WHO-approved test (Shear et al., 2020). Lewis argues that by failing to relax these prohibitive regulations in a time of crisis when the government lacked the capabilities of testing, the CDC and FDA stood in the way of a robust COVID-19 testing system.

As a result of the limited testing capacity, the criteria for testing were very narrow; initially, only those in an ICU with a travel history to China could get swabbed (Lewis 210). In mid-February, the US only ran around 100 samples daily (Shear et al., 2020). With a limited flow of tests, state and local public health officials were stuck waiting for the CDC and could not independently track growing cases. The CDC slowly expanded the eligibility criteria, but not rapidly enough. By early March, testing ramped up when the CDC released its tests, the FDA relaxed regulations allowing independently developed tests, and President Trump appointed a COVID planning official (Shear et al., 2020). However, at this time, it was just too late; the virus silently spread across the US during the lag. Furthermore, even when testing capacity increased, it was still nearly impossible for the average American to access one, especially if they were asymptomatic. Results from a PCR test took days to a week to get back, which was essentially useless as a positive person could go on to infect more people. The delayed, inefficient, and inadequate testing system led to the virus spreading unchecked and becoming pervasive throughout the country.

A final mistake of inaction was the delay in implementing social distancing and masking requirements. Lewis demonstrates that scientists knew the importance of social distancing measures in controlling a pandemic, yet the government did not use this knowledge early in the COVID crisis. He explains how the experts who developed the pandemic preparedness plan used the influenza pandemic of 1918 as proof that these measures save lives. Initially, data did not support social distancing because Philadelphia, the city hardest hit by the pandemic, implemented social infection control measures to no avail; the city had some of the highest infections and deaths in the nation (Lewis 100). Other cities that instituted social distancing and mask requirements earlier than Philadelphia saw much lower death and infection rates (Lewis 103). Pandemic planners Carter Meter and Richard Hatchett recognized that implementing social distancing early in an outbreak resulted in less disease and fewer deaths. These measures became integral to the pandemic plan they developed during the Bush administration.

Despite this knowledge and the recommendations in the pandemic plan, the US government did not follow this guidance; social distancing measures began when the virus was already widespread across the country. Undoubtedly, social distancing has social and economic consequences, and the CDC feared backlash from the public and the President. However, the organization is obligated to protect the health of Americans. Unfortunately, the CDC and the Trump administration neglected evidence-based recommendations in favor of political strategy. The US became Philadelphia; the government implemented social distancing and masking requirements far too late to have the intended magnitude of impact. In fact, the CDC was not the first organization to begin social distancing; many universities sent students home in the first week of March, and governors issued stay-at-home orders before the CDC posted its first guidance (Lewis 218). On March 15th, the CDC suggested people avoid gatherings of >50 people for eight weeks but allowed and encouraged schools to remain open (Lewis 218). Lewis points out that these recommendations were not only too late but inadequate. It defies common sense to keep schools open while limiting public gatherings because hundreds of thousands of Americans are in close contact for prolonged periods each school day. Eventually, the Trump administration introduced social distancing policies too, but it was too late. It was no longer possible to contain the virus with social distancing because the government failed to act when it mattered most. From not recognizing the threat to inadequate testing and implementing social distancing, the government’s inaction allowed the virus to firmly establish itself across the country. This set the US apart as a nation with perhaps the largest explosion of COVID cases.

Another characteristic of the US pandemic response was a lack of coordination; the US did not live up to its name as it was not united. The government failed to integrate the pandemic response at all levels of the healthcare system, which altered the trajectory of the pandemic for the worse. The cohesion that is instrumental to a successful public health response was absent as the federal government and CDC failed to fulfill their responsibility of directing the actions of public health officials across the nation. As a result, the measures to control COVID in one state differed from the next. This is not how a successful public health system operates; action must be coordinated in a top-down approach because it matters to one state what surrounding states do. Lewis illustrates this hamartia of the US public health system through Dr. Charity Dean’s story. In her career as a public health officer, Dr. Dean saw how the CDC is disconnected from communities. She says, “the US doesn’t really have a public health system. It has 5,000 dots, and each one of those dots serves at the will of an elected official” (Lewis 36). In theory, the CDC commands the public health system and provides guidance for local health officials, but this is not true in practice. Dr. Dean’s story demonstrates how the CDC distances itself and avoids responsibility, deferring it to local public health officials who technically have significant legal power but lack social influence (Lewis, 15). Lewis argues that few people know what a public health officer can do, and few are willing to listen to officials when they use this power because the CDC does not back them.

The CDC was not the leader that the US needed during the pandemic, and although local officials took action to control the virus, they lacked the support they needed. For instance, on March 18th, Governor Newsom of California was the first to issue a stay-at-home order (Lewis, 232). However, this type of response is wholly inadequate; California alone could not control a pandemic, and a coordinated response required the participation of the whole country. Other states followed California’s early lead, but the system remained disjointed. Lewis points to the lack of direction from the federal government gravely impacting the testing rollout and distribution of PPE (Lewis 242). The CDC was obligated to unify the pandemic response but failed, leaving the fragmented public health system unprepared. Additionally, President Trump believed it was “every state for itself” and supported the governors in being autonomous in their infection control measures (Lewis 224). This led to significant inconsistency in each state’s approach throughout the pandemic. The lack of coordination in the US COVID response was an appalling mistake that led to the government’s failure to minimize the virus’s spread.

Another failure of the pandemic response was the poor communication that primed the rampant misinformation and questioning of authority for which this crisis will be known. Lewis touches upon the general misunderstanding of the virus amongst the public but does not discuss the eroding trust in public health. Lewis acknowledges that it is difficult for the average person to understand infection statistics, which news outlets frequently highlighted in the early days of the outbreak. He argues that people cannot comprehend the exponential nature of viral spread; it is hard to envision how rapidly a few cases can turn into thousands (Lewis 104). There was a discrepancy between the CDC saying that the situation was dire and the experience of people seeing very few cases in their communities. The phrase “flatten the curve” was thrown around in the early days, but many people did not understand what this meant. There was also confusion about the meaning of case fatality rates. When someone hears that “80% of people have mild disease” and the “case fatality rate is around .5%”, they equate this to mean that the disease is not much of a threat (Lewis 217). However, these seemingly small numbers have a large-scale effect in a country of hundreds of millions. This lack of understanding early on led to the polarizing of the public; some believed that the government was overreacting, and others that it was not doing enough. Those who could not resolve this dissonance hesitated to comply with social distancing and masking. The government did not adequately inform people and emphasize that intervention is to stop the spread before it becomes uncontrollable.

Lewis does not directly address the loss of trust in public health and how it altered the pandemic’s trajectory. However, author Sandro Galea identifies this as a significant takeaway from this crisis. He claims that much of this mistrust came from President Trump's “inconsistent, often dishonest” words (Galea, 2021). Trump’s administration was erratic in giving information to the public and made many inconsistent statements. For instance, the President first minimized the virus and then switched to the view that the threat was uncontrollable. Lewis describes how CDC was also inconsistent in its response, but he did not explain how this led to the erosion of trust in public health institutions. Like the Trump administration, the CDC flipped its position on the magnitude of the threat, as well as masking and quarantine, and isolation guidelines. Many of the organization’s statements came without solid evidence to support them. The conflicting information primed the downfall of trust in institutions that was already at an all-time low.

The government did not prioritize effective communication from the onset, leading to a cascade of misinformation and questioning of authority. Just like exponential viral spread, misinformation is best dealt with proximal to its onset, and its attempts to intervene to address misinformation after it was rampant were futile.

There are many lessons from the mistakes in the US COVID-19 response that can inform the response to future outbreaks of communicable diseases. The denial of the virus’ threat and resulting explosive outbreak renews the importance of a prompt response to an infectious threat. The country’s leadership must immediately recognize the seriousness of a threat and use all available systems to coordinate a response. Testing and social distancing measures must be employed early on to be effective. In addition to taking threats seriously, the best way to mitigate the consequences of an outbreak is to have a plan and follow through with it. The US had a pandemic plan for an outbreak like COVID, but as Lewis demonstrated, it failed to translate that plan into action.

Another takeaway from this crisis is that a fragmented public health system that can not work cohesively will fail to stop a pandemic. Throughout the pandemic, the federal government deferred action to the states, which had devastating consequences. In the future, leaders must coordinate action at all levels, trickling down from the highest authorities in the government and CDC to local public health officials in communities. The government must direct the response because an “each state for themselves” approach makes no sense when a virus does not care to see state lines. A pandemic response must be united from the onset in order to be effective.

Finally, better communication with people regarding public health must start long before the onset of a crisis and continue throughout. Misinformation and distrust of public health authorities polarized the country and weakened the pandemic response efforts. Public health education needs to be more robust, from the media to the education system. People need to know how to get the information they need from trustworthy sources. The leaders of the pandemic response must adequately engage the public by informing people in a way they will understand. The CDC must demonstrate its commitment to the health of the country in order to gain the public as a partner in its response. The government should prioritize effective communication, emphasizing honest information about risk and explaining how it plans to mitigate it. The disappointing COVID pandemic response cannot be forgotten like the other mishandled outbreaks that gather dust in the collective memory. An ongoing discussion of the country’s failures should better prepare the US for the next viral outbreak.

References

Galea, S. (2021). What stories will we tell about COVID-19? The Healthiest Goldfish. Retrieved October 29, 2022, from https://sandrogalea.substack.c...

Lewis, M. (2021). The Premonition. W. W. Norton and Company.

Shear, M., Goodnough, A., Kaplan, S., Fink, S., Thomas, K., & Weiland, N. (2020). The lost month: How a failure to test blinded the U.S. to covid-19. New York Times.