Good morning,
This pandemic is a totally new experience for the modern world, so there have inevitably been mistakes in responding to it. When mistakes are made, it is crucial to learn from them and make corrections. One mistake in the U.S. was woefully inadequate preparation with regard to medical supplies, plans to pay for needed supplies, and support for the medical establishment. I wrote about this mistake in the two articles below, and we seem to be making progress in correcting it (although much remains to be done).
Fear is the Greatest Danger
The Path Forward
In the following discussion, there are 4 key mistakes to focus on – and from which it is imperative that we learn important lessons as quickly as we can.
1. Not treating the pandemic seriously
One enormous mistake in responding to this pandemic was not treating it seriously as it began. China delayed giving the world needed information for a month. In the U.S., for two and a half months after China began releasing information, and as the disease spread across the globe (and its seriousness began to be clear to most countries), President Trump downplayed the dangers, saying the whole thing was not serious for the U.S. History will judge this as a major blunder. For comparison, the United States and South Korea both had their first cases around Jan. 20, 2020. Each country suffered its first death in late February. About that time, however, the course of the disease in the two countries diverged dramatically. The reason? South Korea took the pandemic very seriously from the beginning and began a coordinated, nationwide plan for testing and tracing of contacts in early February.
The results in South Korea are impressive: only 5 deaths per 1 million people there as of April 27, even though most restaurants, bars, churches, and airports have remained open. Lockdowns have not been necessary. The number of new deaths in late April has fallen to only one or two each day. In stark contrast, there have already been 167 deaths per million in the U.S., and over two thousand more are being reported every day as of late April. Thus, South Korea’s 5 deaths per million will not go up very much, while our 167 deaths per million will still rise significantly.
It is now clear that while South Korea was mobilizing to do widespread testing, crucial time was being wasted in the United States. In late January, through February, and well into March, various officials inside and outside the government were warning the President about the severity of the virus and the need to take action. Yet Trump rejected all such warnings, saying there was no problem. On Jan. 22 he was asked, “Are there worries about a pandemic at this point?” He responded: “No. Not at all. And we have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine.” On Jan. 24, he tweeted, “It will all work out well.” On Jan. 28, he retweeted a false headline suggesting a vaccine was close at hand. On Jan. 30, during a speech in Michigan, he said: “We have it very well under control. We have very little problem.”
Inaction continued in the U.S., encouraged by such statements. On Feb. 10, Trump said: “Looks like by April, you know, in theory, when it gets a little warmer, it miraculously goes away,” Then on Feb. 19: “I think the numbers are going to get progressively better as we go along.” On Feb. 23 he pronounced the situation “very much under control.” On that same day, the World Health Organization, which had repeatedly warned Trump about the dangers to be faced, announced that the virus was in 30 countries.
His response did not get better even as the disease began to spread rapidly in the U.S. On Feb. 26, when asked about the growing number of cases, Trump insisted on the opposite of the truth, saying: “We’re going down, not up. We’re going very substantially down, not up.” On Feb. 27, he predicted: “It’s going to disappear. One day — it’s like a miracle — it will disappear.” On Feb. 29, he said a vaccine would be available “very quickly,” and “very rapidly.” On March 2 he said, “We’re talking about a much smaller range” of deaths than from the flu. On March 7, “I’m not concerned at all.” On March 10 he promised: “It will go away. Just stay calm. It will go away.”
Obviously, given the above statements, he knew almost nothing about what was going on, yet he claimed to be an expert, and that he knew as much as any scientist: “I really get it. People are surprised that I understand it. Every one of these doctors said, ‘How do you know so much about this?’ Maybe I have a natural ability.”
The unfolding numbers clearly suggest a lack of touch with reality in this statement. On April 27, there are 989,000 confirmed cases in the U.S. – and some observers believe there are as many as 10 times that number, because so few people have been tested, and because in most places in this country only those with severe symptoms were tested until recently. Most depressingly, there have now officially been over 55,000 deaths from Covid-19 in the U.S., and some experts think the actual number is already twice that figure.
The greatest power of the Presidency, as Teddy Roosevelt vividly put it, is to serve as a “bully pulpit.” The President has the ability is to focus the people on key issues and rally them to take important actions. Yet for 2½ months, the time during which many countries were mobilizing to limit the spread of this dangerous disease, Trump was telling us it was not a problem, that it was under control, and that we did not need to worry about it or take protective measures. During this same time, several countries such as Germany, South Korea, Iceland, and Sweden were able to contain the disease while remaining much more open to activities than a lot of the U.S. is now. Each of these countries has managed to contain the disease while at the same time avoiding the most severe closures of their economies and a total disruption of their ways of life. We should have studied what they were doing and tried to learn from them. We didn’t, and it is costing many lives.
Learning from the mistake
The lessons we can learn from all the countries that have dealt with this crisis better than we have come down to the actions that all have taken in common: 1) a commitment to broad testing, 2) tracing contacts of those who have tested positive, and 3) making sure those people stay away from others. There have been many other actions taken in lots of countries, but none have been scientifically shown to be particularly effective, except those listed above. This is what we should have done in the U.S. from the beginning – but didn’t. In contrast, the central government in the successful countries took the lead in developing a plan, implementing it, and paying for it. Although most people in the U.S., as well as the President, are now treating this disease seriously, we still do not have a coordinated plan. The absence of such a plan, and funding for it, is our greatest failure. Dismayingly, the national government under Trump is still not taking the lead in making this happen, which will likely mean that the second and third waves of this disease will be worse in this country than in many others. Can we not come together and mobilize at a national level with a coordinated plan?
2. The Central Importance of Testing
It cannot be emphasized enough that the most important step we should have taken was to develop a widespread testing program to discover where the disease was spreading so we could respond immediately and effectively through further testing, contact tracing, and quarantining of those who might have the disease. Every other developed country in the world did a better job than the U.S. with this – which is the single biggest reason the United States has become the most ravaged country in the world. And the claim that testing should have been done by local governments, by healthcare organizations, or by hospitals, is ludicrous. When an enemy attacks the whole country, it is not up to each city or state to build missiles or decide how many tanks each will need to fight that enemy. And it is certainly not a part of local budgets to pay for tanks and missiles. Nor is it a part of their budgets to pay for the research and development necessary to create tests for new diseases, or to manufacture those tests, or to pay for their administration on the scale required by a national emergency.
Covid-19 is clearly a national emergency, and only a nationally coordinated plan could have mitigated the damage we have already suffered. And only that action will be effective now. This does not mean that each section of the country will do the same thing, but that there needs to be an overall plan within which we are all coordinating efforts. There is no entity in this country that has a mission to prepare for a national pandemic – except the federal government. This is exactly why we have a “national” government – to deal with issues that local areas cannot deal with alone. Each city or state could not develop its own test kits for the coronavirus, or pay to administer them.
As this crisis unfolded, the problem was even worse than a failure to act: not only did the federal government refuse to take the lead in providing a solution to the testing dilemma, it interfered with the development of a solution. For a new disease, a new test has to be created. Several organizations in the U.S. were trying to develop an effective test, or find ones others had developed overseas. But these efforts were thwarted by mistakes and unnecessary requirements of the Trump-led FDA and CDC. For instance, in early February, the World Health Organization produced and shipped 250,000 test kits around the world. At the same time, in the U.S., the CDC had created and shipped only 90 test kits – and these were seriously flawed. When private organizations tried to implement fixes for these flawed CDC tests, or to produce their own, they were prevented by the FDA, which demanded strict control over all testing procedures. The FDA, under Trump’s orders, literally prevented commercial labs that had developed test kits from making and widely distributing them. And, while this testing train wreck was unfolding, Trump kept saying the problem was under control: on March 6, “Anybody that needs a test, gets a test.” That was completely false, and added to the confusion in this country.
The action that would have made a tremendous difference is if the Trump administration had approved and used the test being distributed by the World Health Organization. If the FDA had approved this test early on, and not prevented private hospitals and labs from quickly developing their own tests, we would not be leading the world today in the percentage of our population infected and dying.
To fight a war, there has to be someone organizing the effort, some organization deciding what supplies might be needed and procuring those supplies in an orderly way. In fact, a committee was created several years ago within the National Security Council to deal with just this kind of issue, including a possible pandemic. Trump not only ignored their plan, but disbanded the department that created it in 2018.
One other step that should have been taken is that, in early 2020, the federal government should have agreed to pay for the production of tests within the U.S. on a broad scale. There was no organization that had a responsibility to pay for the development of Covid-19 tests, and there was certainly no organization or person in a position to pay for the testing of millions of people across the United States. No entity within our health care system has such a responsibility in a global pandemic. The only possible organization that might have assumed this responsibility was the federal government. It did not. And it still has not. No wonder the United States has fallen far behind South Korea, Sweden, Iceland, Germany, Singapore and even China in fighting this disease. “We just twiddled our thumbs as the coronavirus waltzed in,” William Hanage, a Harvard epidemiologist, wrote.
For a clear picture of the testing failures, here are two good articles:
https://www.nytimes.com/2020/03/28/us/testing-coronavirus-pandemic.html
https://www.washingtonpost.com/investigations/2020/04/18/timeline-coronavirus-testing/?arc404=true
Correcting the mistake
The only correction for this mistake is to commit to a coordinated national testing program – as every other developed country in the world has already done. Funded at the national level. By the second week in April, the U.S. had finally ramped up testing to about 145,000 tests a day, but for 3 weeks that number was “frozen-in-place.” Expert opinion varies, but estimates of the number of tests needed each day to manage this pandemic and return to a more normal way of life are between 500,000 and 5 million tests every day. Only these numbers will give a clear picture of where the disease is spreading and how fast, enabling an effective containment policy. (One reason such a high number of tests is necessary is that, if a person tests negative for the virus this week, that person could be infected soon thereafter, so everyone who might have been exposed will have to be testing frequently.)
Until this level of testing is possible, it has been proposed that random sampling for active infections in areas judged to be high risk could give us the information we need. Another suggestion is the use of antibody testing. Effective antibody tests are being developed, and they can be used to identify those in the population who might have developed full or partial immunity to Covid-19. We do not yet know, however, whether someone who has had the disease is immune (it is too early to tell), and because these antibody tests have so far had a high degree of inaccuracy, we haven’t reached the point where such tests can be used to give an all-clear signal to those who have the antibodies. Perhaps that will happen in the future. Until that time, however, the antibody tests that do exist are cheap and easy to manufacture, easy to administer, and the results can be obtained very rapidly (some in 5-10 minutes), so a widespread antibody testing program could quickly be put in place to give us general guidance as to where the disease is and where it is spreading. With that information as a guide, a more effective plan of action for opening up our nation could be implemented.
I am not an epidemiologist or medical research designer, but there are many good ones, who, if given sufficient resources, could design and implement such testing programs rapidly. Because this virus will be with us for years to come, because widespread vaccination is at least 18 months away, and because we can’t keep the country closed down that long, there are only two alternatives if we are to move forward: a) a broad, intelligently designed testing program to guide our actions, or b) we allow the disease to run through the whole population until herd immunity is developed, which would cost between 1 to 2 million lives. (Herd immunity would require approximately 60 percent of the population be infected, and if 0.5 percent of those died, that number would be about 1 million people. If 1.0 percent die, that would be 2 million.) It seems to me that alternative (a) is the much better course. Why aren’t we committing to it – now?
3. Overreacting – and the unintended consequences
The overreactions to this pandemic were discussed at length in my previous essays, ”Fear is the Greatest Danger” and “The Path Froward” (links at the beginning of this essay). In essence, the mistake is thinking that closing everything down for a few weeks will solve the problem of the pandemic, and that using fear to get people to avoid activities and interactions is the only effective way to protect people. We should have stepped into this crisis will resolve, while teaching courage in the face of a problem that we would be dealing with for a long time.
We should have developed a nuanced plan for taking actions that were proving effective in other places, which in addition to testing and contact tracing, are a) emphasizing techniques of personal hygiene, b) encouraging anyone with even minor symptoms of a cold or flu to isolate or quarantine themselves until they can be tested, c) cancelling large gatherings, d) cleaning public spaces thoroughly and often, and e) organizing restaurants, stores, and other public spaces so that people can maintain distance from each other while remaining open. Other countries did these things and have had much better results than have we in the U.S.
We could have, we can, do all of these things for 18 months if necessary, while keeping our society operating and saving millions upon millions of jobs. Other countries are following different versions of this kind of path, and they have had many, many fewer infections and deaths – both in total numbers and in percentages of the population infected – than we have had in this country. Those who have taught fear and prescribed overly severe restrictions will end up causing many unintended problems in the long term. For instance, lots of people who need medical care are staying away from hospitals and doctors in the U.S. today. Emergency rooms across the country have about half their normal number of patients, and many heart and stroke units are nearly empty. Some medical experts fear more people are dying from untreated emergencies than from the coronavirus.
Somehow, we have to learn to begin functioning while managing this disease as best we can. It seems to me Sweden is doing much better than we are, and they did not close things down very much. Even though they are having new cases, their economy continues to function, and they have far fewer cases percentage-wise than do we. Here is a view from there:
https://www.businessinsider.com/sweden-says-leaving-businesses-open-might-be-working-2020-4
Sweden has accepted they will have more cases, and more deaths, percentagewise, in the short term, than other countries like Denmark that have imposed a more severe lockdown. However, Sweden is betting that they will not have wave after wave in the future like other countries will have when trying to reopen. They are betting that over 18 months, they will have fewer cases and fewer deaths than other countries, and the advantages they will have over the longer term are that their economy will be in far better shape, they will have continued with more normal life, they will not have instilled fear in their populace, and they will not have resorted to radical state control. It is too early to know, but there is a good chance they are correct, and will have the best possible long-term outcome, given the unavoidable difficulties of the pandemic. I would have chosen a path between theirs and Germany’s.
The reason a nationwide “shelter-in-place” policy in not a good solution is that to be effective it would require our country to close down for at least 18 months – because the virus will be an active among us for at least that long. Thus, if shelter-in-place is the go-to solution, each time we begin to open up, a new outbreak will force us to close down again. People will become afraid again and again, until fear becomes deeply ingrained, and the dramatic destruction of jobs and our economy will be irreparable. (Perhaps as many as 45 million people have lost their jobs or been laid off already, a much greater percentage than in the Great Depression.) “Shelter-in-place” might be necessary in places like New York City in the midst a severe outbreak, but not for places that do not have much disease. Those who have proposed this solution have not thought through how such a policy can end. There will be no all-clear signal, so we have to begin functioning in the face of some risk.
Why? Because as we “shelter-in-place,” our economy is collapsing and millions of peoples’ lives are being destroyed. While the wealthy and some of the middle class can “shelter-in-place” without too great a burden, millions of Americans do not have that luxury. They must have a paycheck each week in order to eat and have a place to sleep. Tens of thousands of small businesses will likely end up filing for bankruptcy because of steps we have already taken. The Pew Research Center recently reported that at least one person in 52 percent of low-income households in the U.S. have lost a job because of the coronavirus. There are the millions of young people who have lost their jobs or were just entering the job market – whose life prospects have abruptly taken a severe nose-dive. Many millions of school-age children do not have computers and thus are being denied the schooling that affluent families can afford. At the same time, we are asking, often demanding, that many low-wage workers take risks to provide the rest of us with our necessities; we are asking them to take risks we are not taking. As Roger Cohen put it in his April 20 column in the NYT, “the underpaid first responders, garbage collectors, farm workers, truckers, supermarket cashiers, delivery people and the rest who have kept people alive and fed while the affluent took to the hills or the beaches have delivered a powerful lesson in the need for greater equity and a different form of globalization.”
And the consequences of our actions are spreading out in waves around the world. Because we are the largest economy in the world, the problems caused by severe shutdowns here are multiplying and amplifying the consequences of limitations all over the world. There are perhaps as many as two billion people in the world who live in families that must have a weekly paycheck to eat. Sadly, but not surprisingly, it was recently estimated that an additional 125 million people in the world will be thrown into severe food shortage (and many of those into starvation) because of measures put in place to contain the pandemic. Even though the numbers are not as high in the U.S. as in many other countries, there are several million who fall into that category here.
The article below gives a vivid picture of the dramatic unintended consequences all over the world of shutting things down to deal with the coronavirus:
https://www.nytimes.com/2020/04/22/opinion/coronavirus-pandemics.html
And here are some ways to help:
https://www.nytimes.com/2020/04/25/opinion/sunday/coronavirus-giving-guide.html
Righting the course
We desperately need a nuanced plan now. As Tomislav Mihaljevic, C.E.O. of the world-class Cleveland Clinic health center said in an interview, we need to use “tailored and discriminating solutions” that recognize regional differences. At the moment, “We’re using the methodology from the 14th century to combat the biggest pandemic of the 21st century.” Acknowledging the need for lockdowns in the worst-hit areas. Dr. Mihaljevic says “we cannot hold our breath forever,” and “effective therapies or vaccines may be long in coming.” Covid-19 will be “a disease we have to learn to live with.” This means that public policy must not focus on trying to eliminate the risk of this disease, but to “mitigate, manage and frame expectations for it.”
For instance, in Ohio, where Cleveland Clinic is located, Dr. Mihaljevic says that Covid patients are using just 2 percent of hospital capacity, and the curve of new infections has been flat for more than two weeks. Yet there has been a dramatic decline in people seeking care for heart attacks, strokes, and new cancers, presumably because of fear of going to the hospital. This corresponds with other research showing that fear of Covid-19 is causing parents to postpone well-child checkups, including shots, which will put millions of children at risk of exposure to preventable deadly diseases in the future. All this leads Dr. Mihaljevic to the conclusion that: “The public conversation needs to be about the value of human life in its totality,” which would mean fewer restrictions on activity for some people and in some locations, and much greater activity in some locations than is happening now.
Another important understanding that is emerging is that the more crowded the conditions people have to face, and the longer a person is in crowded conditions, the greater the danger – both of being infected as well as the likely severity of any infection acquired. Thus, encountering the SARS-CoV-2 virus in small numbers provides only a small risk of infection, and if you become infected, having encountered only small numbers of the virus means the disease is less likely to be severe. This is the reason that health care workers dealing with this disease have been the heroes and heroines during this crisis – because they have put themselves at risk of being exposed over and over, and to heavy doses of the virus. This is very likely the reason that otherwise young and healthy medical personnel have had serious infections and even died. The same is true to some degree of all the service people who have continued to keep our country functioning while the rest of us were hiding from this disease. They have risked multiple exposures so the rest of us could stay safe.
Considering this understanding, we can begin to plan our lives to minimize the dangers without having to stay closed in for months and months. Crowded cities will require more careful behavior than less crowded places. Knowing we will all encounter this virus at some point in the next few years, we can minimize the risks we are taking by improving our normal hygiene habits, improving our health in general, minimizing our time in crowded places (although not necessarily avoiding them completely), and coming to understand that this disease is but one of the many risks we have to manage but need not fear – along with riding into automobiles, flying in airplanes, playing sports, visiting foreign countries, or even getting within 6 feet of any other human being because anyone might have a contagious disease of some kind. Somehow, we have to find a way to live our lives fully and without fear, finding the best way to include Covid-19 among the risks we inevitably face as we live full, productive, meaningful lives.
4. Politicizing a life and death crises
The SARS-CoV-2 virus does not have a preference for Democrats or Republicans, for those on the left or the right, and in-so-far as we approach it as a political issue we will preclude an effective response. Treating it as political will cost many lives. Anyone who uses this crisis to promote a political agenda or point-of-view is doing our nation a great disservice, and causing much harm.
The consequences of the disfunction and political in-fighting in this country have been dire, both for this country as well as for the world. As summarized in a recent article in the NYT by Katrin Bennhold:
“As images of America’s overwhelmed hospital wards and snaking jobless lines have flickered across the world, people on the European side of the Atlantic are looking at the richest and most powerful nation in the world with disbelief.
“As the calamity unfolds, President Trump and state governors are not only arguing over what to do, but also over who has the authority to do it.
“The pandemic sweeping the globe has done more than take lives and livelihoods from New Delhi to New York. It is shaking fundamental assumptions about America’s role in the world — the special role the United States played for decades after World War II as the reach of its values and power made it a global leader and example to the world. Today it is leading in a different way: More than 840,000 Americans have been diagnosed with Covid-19 and at least 46,784 have died from it, more than anywhere else in the world.”
The article quotes Henrik Enderlein, president of the Berlin-based Hertie School, about the disaster unfolding in New York City, saying, “How can this happen? How is this possible? We are all stunned. Look at the jobless lines. Twenty-two million” (jobless claims). Timothy Garton Ash, a professor of European history at Oxford University and a lifelong fan of the United States says, “I feel a desperate sadness.” And Dominique Moïsi, a political scientist and senior adviser at the Paris-based Institut Montaigne sums up a common view: “The pandemic has exposed the strengths and weaknesses of just about every society. It has demonstrated the strength of, and suppression of information by, an authoritarian Chinese state as it imposed a lockdown in the city of Wuhan. It has shown the value of Germany’s deep well of public trust.” And, “America has not done badly, it has done exceptionally badly.”
These worldwide consequences are made vivid by Roger Cohen in his column mentioned above, in which he says there is a battle going on for the survival of democratic values, and that “the great 21st century democracy-dictatorship battle is far from over. Emergencies serve autocrats but can also demonstrate the failings of their systems and provoke radical rethinking.” Cohen fears that because of the failure of leadership in the U.S. during this crisis, an American-led world “is gone.” And if the United States does not recover its sense of decency and principle on the world stage, autocrats will likely prevail. Carl Bildt, the former Swedish prime minister told him: “The virus is attacking an incoherent, deglobalized world. And as long as that is the case, the virus wins.”
The solution – a coordinated, unified response
How much we should keep things closed down in any given location in the U.S. is a guessing game. No one knows the right path – doing too little will cost lives in the short term, while doing too much will cost lives and set in motion other harmful consequences in the longer term. We will inevitably make mistakes in each direction, and the mistakes will vary from region to region. But if we can find a way to work together in facing this crisis, this in itself will be a giant step in the right direction. Thus, perhaps the most important thing our leaders could do is lead us into a coordinated, unified response to this great crisis.
Australia has a very conservative government right now, and New Zealand a liberal one, but each has been able to implement a broadly supported national program to contain and manage the pandemic. Both countries have very competitive parties on the left and the right, but each country has been able to develop a united response to this common enemy – making clear that this is not an issue of left versus right, but one of life and death. Many other democratic countries such as Germany and South Korea, which have fiercely competitive political parties, have been able to develop a strong national consensus on a path forward, and although different, both are having success. What their plans have in common is a coordinated, nationally organized testing program and a committed acceptance by a majority of the people in each country. These are the key ingredients for any country to find a path to a healthy and well-functioning post Covid-19 world. This in turn depends on effective leadership that can enlist the acceptance and support of a large majority of the people.
In the United States we must begin to open up our country while at the same time working together to overcome this disease. And we must do this in a way that encourages a less fearful way of living. To politicize the issue of the steps we should take is extremely dangerous and destructive. No one knows the right pace for reopening – we must simply start making efforts in that direction, without blaming and criticizing each other to score political points. If we cannot find a way to do this together as a country, it will be another severe blow to the future health and prosperity of the United States. Germany, Australia, Sweden, New Zealand, South Korea, Iceland, and many other democracies have managed to pull their people together and forge plans for reopening that, although different, have widespread support, and thus are likely to work to at least some degree. Can we not get beyond our political divisions and come together as a country to solve a great problem, the way we did during World War II, when conquering space, or in overcoming polio and other major disease?
That is our hope and our challenge.
May we all somehow find a way to solve this great crisis together,
David