Crafting successful public health measures depends on the ability of top scientists to gather data and report their findings unrestricted to policymakers.
State of play: But concern has spiked among health experts and physicians over what they see as an assault on key science protections, particularly during a raging pandemic. And a move last week by President Trump, via an executive order, is triggering even more worries.
What’s happening: If implemented, the order creates a “Schedule F” class of federal employees who are policymakers from certain agencies who would no longer have protection against being easily fired— and would likely include some veteran civil service scientists who offer key guidance to Congress and the White House.
- Those agencies might handle the order differently, and it is unclear how many positions could fall under Schedule F — but some say possibly thousands.
- “This much-needed reform will increase accountability in essential policymaking positions within the government,” OMB director Russ Vought tells Axios in a statement.
What they’re saying: Several medical associations, including the Infectious Diseases Society of America, strongly condemned the action, and Democrats on the House oversight panel demanded the administration “immediately cease” implementation.
- “If you take how it’s written at face value, it has the potential to turn every government employee into a political appointee, who can be hired and fired at the whim of a political appointee or even the president,” says University of Colorado Boulder’s Roger Pielke Jr.
- Protections for members of civil service allow them to argue for evidence-based decision-making and enable them to provide the best advice, says CRDF Global’s Julie Fischer, adding that “federal decision-makers really need access to that expertise — quickly and ideally in house.”
Between the lines: Politics plays some role in science, via funding, policymaking and national security issues.
- The public health system is a mix of agency leaders who are political appointees, like HHS Secretary Alex Azar, and career civil servants not dependent on the president’s approval, like NIAID director Anthony Fauci.
- “Public health is inherently political because it has to do with controlling the way human beings move around,” says University of Pennsylvania’s Jonathan Moreno.
Yes, but: The norm is to have a robust discussion — and what has been happening under the Trump administration is not the norm, some say.
- “Schedule F is just remarkable,” Pielke says. “It’s not like political appointees editing a report, [who are] working within the system to kind of subvert the system. This is an effort to completely redefine the system.”
- The Center for Strategic and International Studies’ Stephen Morrison says that the administration has been defying normative practices, including statements denigrating scientists, the CDC and FDA.
The big picture: Public trust in scientists,which tends to be high, is taking a hit, not only due to messaging from the administration but also from public confusion over changes in guidance, which vacillated over masks and other suggestions.
- Public health institutions “need to have the trust of the American people. In order to have the trust of the American people, they can’t have their autonomy and their credibility compromised, and they have to have a voice,” Morrison says.
- “If you deny CDC the ability to have briefings for the public, and you take away control over authoring their guidance, and you attack them and discredit them so public perceptions of them are negative, you are taking them out of the game and leaving the stage completely open for falsehoods,” he adds.
- “All scientists don’t agree on all the evidence, every time. But what we do agree on is that there’s a process. We look at what we know, we decide what we can clearly recommend based on what we know, sometimes when we learn more, we change our recommendations, and that’s the scientific process,” Fischer says.
What’s next: The scientific community is going to need to be proactive on rebuilding public trust in how the scientific process works and being clear when guidance changes and why it has changed, Fischer says.
Private calls and unpublished reports leave many Americans and local officials in the dark.
This is a news analysis from the Center for Public Integrity.
From behind a podium and a black mask, Tulsa mayor G.T. Bynum faced the press. It was late July, and one percent of his city had tested positive for COVID-19 since the beginning of the pandemic.
A reporter had a question: What did Bynum have to say about the newly leaked White House Coronavirus Task Force document that recommended Tulsa close bars and limit gatherings to 10 people?
The “alleged White House document” was “never officially presented to us … by either the federal government or the state government,” the mayor said. But he was familiar with the document’s recommendations, having read them online. “All of that remains very much on the table.”
Indeed, the White House reports — chock full of local data and recommendations — would be useful for many city leaders, many of whom still don’t know what percentage of coronavirus tests in their metro areas are positive. But Bynum and others didn’t have that information. The White House was sending each state’s report directly to its governor and a select group of other officials instead of distributing the documents widely or posting them publicly.
The nation’s coronavirus response must be “locally executed, state managed, federally supported,” White House officials have said repeatedly. In fact, much of their public health advice has been secret, segmented and inconsistent. Federal guidance isn’t always reaching the local officials it’s meant to support. And scattershot messages mean that average citizens weighing visits to grandparents or countless other daily risks have limited — and sometimes conflicting — information from the officials they are expected to trust.
THE SUMMER OF SECRET WARNINGS
In late June, the White House Coronavirus Task Force began sending reports to governors showing how their states were faring in the pandemic. Dr. Deborah Birx, a leader of the task force, held the documents aloft at a press conference July 8, but they weren’t distributed to reporters. Birx said several states were in the coronavirus “red zone” — with high numbers of cases — and should take special precautions, but Vice President Mike Pence delivered the primary message of the press conference: Reopen schools.
Later that month, the Center for Public Integrity obtained a copy of the compiled report for all 50 states and published it, revealing that 18 states were in the red zone. The next morning, presidential adviser Kellyanne Conway suggested Public Integrity, a 30-year-old nonprofit, nonpartisan newsroom, had nefarious motives for disclosing public information: “I don’t know about that particular document, and respectfully the Center for Public Integrity is an outside organization that I’m sure doesn’t support the president’s election,” she told reporters.
A spokesman for Pence, Devin O’Malley, later acknowledged the document’s authenticity. But the White House still didn’t release the reports and stayed mum on why it was keeping them secret. Weeks later, White House spokesman Judd Deere sent an email to Public Integrity that didn’t quite answer the question: “The White House Coronavirus Task Force is providing tailored recommendations weekly to every governor and health commissioner for their states and counties,” he wrote. “Local leaders are best positioned to make on-the-ground decisions for their communities … The United States will not be shut down again.”
Public health experts say the reports should be public. “This is a pandemic,” Harvard epidemiologist Bill Hanage told Public Integrity in July. “You cannot hide it under the carpet.”
Dr. David Rubin, who has provided epidemiological modeling to the task force as director of PolicyLab at the Children’s Hospital of Philadelphia Research Institute, is also befuddled as to why the reports are secret. “I think we’d be in a lot different place today if we had national standards around certain things,” he said. But he doesn’t blame Birx or other scientists working with the White House. “They’re playing the hand that they were dealt.”
CUSTOM-MADE OR CONFUSING?
In mid-March, a 4×6” blue-and-white postcard appeared in mailboxes across the nation, emblazoned with “President Trump’s Coronavirus Guidelines for America” and both the White House and Centers for Disease Control and Prevention logos. On the back were a dozen lines of advice, including: “Even if you are young, or otherwise healthy, you are at risk and your activities can increase the risk for others.”
The postcard appeared in the days when the president, vice president, Birx and National Institute of Allergy and Infectious Diseases Director Anthony Fauci together updated the nation daily on television about the state of the coronavirus. The administration had already pressed the mute button on the CDC (though the agency posted guidance online, it wasn’t giving the regular briefings it had in past epidemics), but the White House was still attempting to send out a cohesive public health message.
Then, as the economy cratered, Trump shifted gears to reopening and pushed responsibility for the pandemic response to the states. After decades of relying on national entities for public health advice and regulation — the CDC, the Food and Drug Administration, the surgeon general and others — America handed responsibility for infectious-disease containment to the states.
Doing so allows governors to respond to their unique virus conditions, defenders of the administration said. The U.S. needs “a decentralized approach” said Heritage Foundation visiting fellow Doug Badger, because states have police powers to enforce lockdowns and because they are “better suited to responding to this pandemic, where there is great variation between and within states. […] There’s no one-size-fits-all policy.” Indeed, epidemics unfold at different rates in different geographies, and it makes sense to adjust advice based on whether people live close together or far apart, and how widely the virus is spreading in their communities.
But experts say that even though some public health warnings should be specific to local areas, many messages, such as the need to wear masks, should be nationally consistent. Contradictory guidance undermines trust, and the virus exploits the communities with weakest defenses. “Diseases don’t care about national or state borders,” said Jessica Malaty Rivera, Science Communication Lead at the Covid Tracking Project, a volunteer organization collecting pandemic data. “You can’t look at this in a fragmented way otherwise we’re going to continue this fragmented progress.”
“Diseases don’t care about national or state borders.”
JESSICA MALATY RIVERA, SCIENCE COMMUNICATION LEAD AT THE COVID TRACKING PROJECT
In addition, Trump’s desire for state leadership has been selective. After weeks of insisting on a governor-led response, in July Trump Tweeted, “SCHOOLS MUST OPEN IN THE FALL!!!” and threatened to withhold federal funding from school districts that did not open their doors.
WHO DO YOU LISTEN TO?
Splitting public health advice into pieces means that some of those fragments don’t line up. On a private call with state and local leaders earlier this month, Birx said colleges should be testing students as they return to campus, and even be prepared to do 5,000 or 10,000 tests in one day. But the CDC hasn’t endorsed such testing because its effectiveness hasn’t been “systematically studied.”
Nowhere has the fractured advice been more evident than on the topic of how to reopen K-12 schools. The CDC in May issued guidelines, but later replaced them with a more lenient version after the president objected. After insisting schools open their doors, Trump acknowledged that some hot spots may need to delay opening. CDC director Robert Redfield said that schools should go virtual if their areas have more than 5 percent test positivity — a threshold that only 17 states and the District of Columbia met as of Aug. 26 according to a New York Times tracker. Birx has stayed noticeably quiet on the topic. The secret reports from her task force recently endorsed West Virginia’s school reopening guidelines, which say schools must switch to virtual learning if daily new cases in a county exceed 25 per 100,000 residents.
All this leaves local officials with a dizzying set of choices and advice, stuck making the decisions others don’t want blame for.
“This really stinks for local health departments,” said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. “Everybody wants to relinquish authority to the local health department. The authority ends up coming and going depending on how hard it is to address the issue. And it just is not fair to them.”
All this has meant that in the first major pandemic in a century, despite the feeble and disjointed efforts of the White House to corral them, the United States were not united, not even in the messages sent to citizens. That has some experts worried about what’s to come in the fall, when the reluctance of some to be vaccinated could mean the nation fails to reach the threshold for herd immunity that would protect everyone. Rivera, of the Covid Tracking Project, is “absolutely terrified” about that possibility; united messaging is key when trying to help people understand the scientific rigor behind a vaccine, she said. “All it takes is one rumor to completely shift public health behavior.”
HELP FROM THE FOURTH ESTATE
In Tulsa, Bynum can now see all the White House reports. That’s because Public Integrity published a recent Oklahoma report, and local journalists pressed the governor on why he hadn’t handed it out. Last week he agreed to post all of the state’s White House reports.
In other parts of the country, people still don’t know what White House experts are saying about their states or counties. The federal map of red, yellow and green zones — an easy-to-understand stoplight that could help people quickly decide whether to cross state lines, for example — remains off limits to the public. President Trump resumed daily coronavirus briefings this month, but Birx remains relegated to private calls and local press briefings on her treks across states. The CDC continues its silence; Fauci is recovering from a vocal cord surgery and can’t speak.
For more than a century, Congress has given the federal government a prominent role in helping stop the spread of disease from state to state. Americans can debate whether governors or the president should make the big decisions in this particular pandemic. But neither statute nor scientific wisdom puts limits on the federal government’s ability to dole out health advice. And there is no national security reason to make such advice secret.
While it battles a virus that can spread quickly via silent carriers, the United States has yet to execute a strategy for testing asymptomatic people. This is a problem — and ProPublica health reporter Caroline Chen explains why.
Dr. Sara Cody, health officer of Santa Clara County, California, was tired of seeing the same thing over and over again. Her contact tracers were telling people exposed to COVID-19 that they needed to get tested, but when some went to testing sites, health care providers turned them away because they didn’t have any symptoms.
This posed a problem for Cody’s work. Knowing if a contact was infected would help her department keep an accurate count of her county’s coronavirus infection rate; also, if a contact tested positive, it’d spur a new round of contact tracing from her staff, to help stop any further transmission from that asymptomatic carrier.
Cody decided to issue a countywide health officer order in June requiring certain health care facilities to provide testing for all close contacts, and also all front-line workers, such as mass transit drivers and retail workers, whether or not they had symptoms.
Then last week, the U.S. Centers for Disease Control and Prevention quietly changed guidelines on its website to say that people without symptoms did not necessarily need to be tested, even if they had been in contact with someone who had COVID-19. Cody was confused. ”Was it because there isn’t enough testing capacity?” she initially wondered. But there was no such explanation from the agency.
The CDC was met with a degree of pushback that was notable in its intensity; several states flat-out said they would not follow the guidelines, including California, where Gov. Gavin Newsom said, “I don’t agree with the new CDC guidance. Period. Full stop.”
The controversy surrounding the CDC guideline change is all just a symptom of a deeper issue that has plagued America’s coronavirus response: Even though we have spent more than half a year battling a virus whose insidious hallmark is its ability to spread through those with no symptoms, the country has not yet articulated a coherent strategy to test these silent carriers.
“The fact that we’re this far into the pandemic and we’re still talking about how to do asymptomatic testing and going back and forth on this is a major part of the reason why we’re struggling to open schools and colleges, and why people are still dying in prisons,” said Dr. Ashish Jha, dean of the Brown University School of Public Health.
The lack of consistent asymptomatic testing guidelines means that from state to state, county to county, a hodgepodge of strategies are being used with varying standards, testing methods and levels of access. Decisions are being made sometimes by people who have been thrust into the role of public-health officer with no training — school principals and college deans, leaders of companies and daycares and churches, who are just trying to do right by the people they are responsible for.
It’s unfair to ask them to have to come up with their own testing strategies, or to have to navigate the maze of their local health authority’s often shifting recommendations. There may be pros and cons to various strategies experts have proposed, with variables to consider like testing technologies, supply chains and federal funding, but perhaps the more urgent need at this point is picking a plan and actually seeing it through.
To understand why, we need to start with a clearer understanding of the pivotal role asymptomatic testing plays in containing this virus, particularly in the absence of a vaccine.
Why Asymptomatic Testing Is Important
Let’s start with the most basic question: Why do we bother testing in the first place? There are, broadly speaking, two reasons to use a test. The first is as a clinical diagnostic; the other is as a public health tool. Both are important, but for different reasons.
Doctors use a clinical diagnostic like a strep test to tell whether a patient is sick with a disease that can be treated with particular medicines. “The purpose of the test is based around doing one thing when it’s negative and doing another thing when it’s positive,” said Dr. Patrick O’Carroll, head of health systems strengthening at the Task Force for Global Health, who previously worked at the CDC for 18 years.
From this perspective, it seems pointless for an asymptomatic person who might have COVID-19 to take a test, because there’s not going to be any difference in how they will be treated — there are no symptoms to medicate. You might have even heard your doctor say, “Don’t bother taking a test if you only have mild symptoms, because I’m not going to tell you do anything different besides drinking fluids, taking Tylenol and resting.”
But from a public health standpoint, testing asymptomatic people can yield actionable information. COVID-19 is unlike many other diseases, in which a patient’s peak contagiousness coincides with the height of their symptoms. With COVID-19, about 40% of patients do not show any symptoms or have such mild ones that it would never have occurred to them that they had been infected. In a recent study of 192 young people with suspected COVID-19 in Boston, only half who tested positive had a fever.
Furthermore, studies have shown that among patients who do develop symptoms, viral load, which correlates with a patient’s contagiousness, is highest right before or at the time when symptoms start appearing. Put together, these features have explained why the coronavirus has been able to spread so perniciously across the globe. It’s one sneaky virus.
If an asymptomatic person tests positive, public health officials can ask them to isolate from others and begin the process of contact tracing in order to break chains of transmission. In the bigger picture, it also helps them keep tabs on where the virus is spreading in their city. (This is what’s known as “surveillance” in public health parlance: They’re not spying on you. They’re tracking the virus.)
“Since the beginning, testing has been the foundation of our response, because it tells us who is positive, where they are, in which demographic, and what the patterns are,” said Dr. Umair Shah, executive director for Harris County Public Health in Texas.
Understanding population prevalence also helps guide public health actions. For example, said O’Carroll, “if testing shows that only 2% of the population is positive, I’m going to call all of those people, interview them, put all of the contacts in quarantine and really try to stamp it out. But if I find that 30% are positive, then I really don’t have the resources to interview and chase down thousands and thousands of people — that’s when spread is too high for contact tracing to be useful.”
When testing is restricted to symptomatic patients, health officials will only have limited signals about the extent of the virus’s spread, leaving them to operate partially blind.
Standards Vary From State to State
There are two categories of asymptomatic people to consider: The first includes those who had close contact with someone who has already tested positive for the virus. The second includes people who don’t have any reason to believe they have been exposed. The first group is a higher testing priority, because there’s a far greater chance that they have been infected and can be spreading the virus.
In an ideal world, if testing were abundant and cheap and results were fast, we would test everyone daily and catch all of the asymptomatic carriers. But when there aren’t enough tests to go around, public health officials need to triage.
In the earliest stages of the pandemic, when there were hardly any tests available across the country, public health officials had to limit tests to the most urgent need — people with severe symptoms in hospitals. As tests became more available, they started to widen the criteria, first to people with symptoms, then to asymptomatic people with known exposure. Finally, in some areas of the country, anyone who wanted a test could get one, whether or not they had symptoms.
But to this day, the decisions have been made piecemeal. I reached out to health departments around the country, and found that testing criteria still vary depending on where you live.
In Delaware, close contacts are asked to get tested once, at the end of their 14-day quarantine period. The state lets anyone get tested, whether or not they were exposed or have symptoms. Maryland recommends that people who suspect they’ve been exposed to the virus get a test, whether they are symptomatic or not. Arkansas says it works to facilitate testing for all close contacts of positive cases, and also tries to provide testing for anyone in the state who wants a test, asymptomatic or not.
But Oregon and Wisconsin don’t recommend testing for asymptomatic people who have not had close contact with a confirmed case. (Oregon makes an exception for people in a high-risk category, such as agricultural workers.)
Some states have more nuance to their recommendations. New Jersey said testing is available to all, but noted that if you are asymptomatic, testing is recommended if you are a front-line worker, if you were in a large crowd with difficulty social distancing, if you are a member of a vulnerable population or if you recently traveled somewhere with a high COVID-19 infection rate.
Effective Contact Tracing Can’t Happen Without Efficient Testing
Within each state, however, guidelines aren’t always followed consistently by test providers. Cody, the health officer in California, isn’t the only one whose contact tracers are unable to get asymptomatic people tested.
Rebecca Fischer, an assistant professor at Texas A&M University School of Public Health, said she’s seen the same thing happen in Brazos County. “We call them and say, ‘How did the test go? And they’ll say, ‘They sent me away because I don’t have symptoms.’ and we’ll say, ‘You need to go back and say the health department sent you,’ and often they get turned away again.” Sometimes, Fischer said, the health department would have to give the person a letter to verify that they needed a test.
“We get on the local news station and plead with test providers to help us facilitate widespread testing,” Fischer said.
It’s unclear why providers are turning down asymptomatic patients. It may be, in part, due to the perceived purpose of the test. Dr. Michael Hochman, a primary care doctor and director of the Gehr Family Center for Health Systems Science and Innovation at the University of Southern California, said he thinks the value of testing contacts without symptoms is “modest” and would rather make them stay home for 14 days instead of come into a clinic for a test, “which is bringing them together with other people, the opposite of what you want.”
He worries that a false negative could give patients a misguided sense of security and prompt contacts to leave quarantine before they’re supposed to. Hochman says he sometimes has patients calling who say they have potential exposure and want a test, but when he explains to them that regardless of the result, they still will need to quarantine, the patients often then decide they won’t bother with a test.
Cody countered that many people don’t always adhere to the 14-day guidelines. “We’re not doing legal orders, so there’s not going to be perfect compliance,” she said. Given the opportunity to test and find out that an asymptomatic contact is positive is always preferable, she said, because people are more likely to take precautions and isolate properly, particularly around family members.
Without a Clear National Strategy, Confusion Abounds
Into this already chaotic environment came the CDC’s guidance change on Aug. 24.
Normally, when the agency updates its guidances, it gives a heads-up to state and local health departments, so they can decide how to adjust their own recommendations or how to communicate to the public, said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents large metropolitan health departments.
“Usually at minimum, there’s a big tent call … and normally at the top of the call, they say, we’re going to update this.”
But this time, it didn’t happen. “It was buried in an email,” she said. “If you hadn’t clicked on it, you wouldn’t have known.”
Previously, the CDC recommended testing for all close contacts of people with known COVID-19 infection, specifically noting that “because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts … be quickly identified and tested.” The new guidance, however, said, “If you have been in close contact … you do not necessarily need a test unless you are a vulnerable individual or your health care provider or state or local public health officials recommend you take one.”
The new guidance for asymptomatic people who had no known exposure conveyed a number of different messages, depending on which part of the website you read. On one hand, it said, “If you do not have COVID-19 symptoms and have not been in close contact with an infected person: You do not need a test.”
But farther down the page, the site also said, “If there is significant spread of the virus in your community, state or local public health officials may request to test more asymptomatic ‘healthy people.’”
In the absence of explanation or context, confusion ensued.
Calling the new guidelines “vexing and hard to interpret,” Dr. Jeff Duchin, health officer for public health for Seattle & King County said in a statement that “testing asymptomatic close contacts of COVID-19 cases is important to identify cases and interrupt transmission and we intend to continue to do that pending additional information that would lead us to reconsider.”
When I asked the CDC to explain the change in guidance, it didn’t respond, instead pointing me toward the Department of Health and Human Services.
HHS sent me a statement from Adm. Brett Giroir, the federal testing czar, saying that the updated guidance “places an emphasis on testing individuals with symptomatic illness, those with a significant exposure or for vulnerable populations, including residents and staff in nursing homes or long term care facilities, critical infrastructure workers, healthcare workers and first responders, and those individuals (who may be asymptomatic) when prioritized by public health officials.”
The revised guidance did not appear to be generated internally by the CDC. Giroir later told reporters that the recommendations were approved by members of the White House coronavirus task force, saying, “We all worked together to make sure that there was absolute consensus that reflected the best possible evidence.” Dr. Anthony Fauci, however, said he was undergoing surgery and was not part of the discussion.
A few days later, CDC director Dr. Robert Redfield verbally softened the changes, saying that testing “may be considered” for asymptomatic contacts, though the guidelines online were not changed.
“Ultimately, it may not actually be a huge change,” said Juliano, but in practice it means that the federal government “is really pushing the decision down to states and local.”
“It means when public health says you should get tested, someone could say, ‘well, the CDC says it’s not necessary.’ It leads to public confusion, and you’re really putting state and local in a line of fire that’s not necessary.”
Use the Right Test for the Right Situation
Now that we’ve talked about the reasons it’s important to do asymptomatic testing, it’s time to think about resources. In recent months, many experts have been advocating that different types of tests be used for different purposes, in order to optimize available supplies and avoid testing delays.
The idea goes like this: We should save the most sensitive tests — known as PCR tests — for diagnostic purposes, when we need to be absolutely sure that a patient has COVID-19, because we’re going to be treating them or asking them to isolate, based on the results. So these tests should be used for people with COVID-19 symptoms and people who were known to be exposed to the virus.
But for public health purposes, when it comes to keeping tabs on how broadly the virus is spreading, we could instead be using slightly less sensitive — though not poor quality — rapid tests, known as antigen tests, which typically can provide results in minutes to hours. Such tests should be used for screening people en masse in settings like nursing homes, essential workplaces, and communities that have limited testing resources, proposes a team at Duke University’s Margolis Center for Health Policy. Any positives that turn up could then be confirmed with a PCR test.
The goal is to avoid the long testing turnaround times that the country was plagued with this summer. PCR tests, while highly accurate, usually require at least a day or two to return results even under optimal conditions, and require more specialized equipment, labs and staff. This summer, when the majority of tests were being shoved into the PCR queue, turnaround times stretched out, with some people waiting more than two weeks for test results.
This is not just an annoyance for individuals. It’s a massive public health problem, because a test that takes more than two days to come back is pretty much useless.
“Patients don’t know what to do in those two weeks, and guess what, we can’t do our contact tracing, so we can’t fight the pandemic — all of that gums up the system.” said Shah, of Harris County. Such long turnaround times are “shameful. It makes no sense.”
Dr. Mark McClellan, one of the authors of the Duke paper, said the government must set aside funding to pay for antigen tests in at-risk populations, including low-income, minority and immigrant communities, and public schools and colleges.
The University of Illinois is requiring all faculty, staff and students to participate in screening testing twice a week, using a rapid saliva-based test. Not every college has the resources to perform these routine tests, but advocates for this kind of testing point to the university to show that it isn’t a fantasy.
“It is feasible,” said Carl Bergstrom, a computational biologist at the University of Washington. “It’s just a matter of will.”
McClellan and his co-authors estimate that about 14 million people are in high-risk settings that need regular screening testing, requiring an average of two tests per week. “There needs to be a lot more financial support to get that capacity up, something like Operation Warp Speed, with the government going in jointly with manufacturers,” he said.
What We Need to Do: Pick a Plan, and See It Through
For now, though, the federal government doesn’t appear to embrace this vision. Testing czar Giroir told reporters in a call on Aug. 13, “I’m really tired of hearing, by people who are not involved in the system, that we need millions of tests every day. … You don’t need this degree of testing. You need strategic testing combined with smart policies.”
Giroir explained that the administration’s focus was testing symptomatic patients as well as vulnerable populations, such as nursing home residents, coupled with policies including mask wearing, social distancing and hand washing. “That plan is being implemented and that plan is working,” he told reporters.
Some public health experts say that approach won’t be enough to curb the pandemic.
“Masks are a very powerful tool for virus control, and they’re not completely off the table, but a lot of our population has not been able to adhere to them because it’s become politicized,” said Dr. Michael Mina, assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health.
And while social distancing is important, said Jha, he doesn’t think that alone will work in places where people are regularly congregating, like schools. “It’s not the real world,” he said. “Do we really think kids will never get close to each other?”
Mina argues for an audacious plan that calls for far more testing than the U.S. has been capable of to date. His testing strategy, particularly when it comes to how it approaches asymptomatics, seems directly at odds with Giroir’s.
Mina envisions tests so cheap ($1 apiece) and so widely available (over the counter) that every American can test themselves at least twice a week. The tests we’d use are paper strips that require only a saliva sample. They would certainly be less sensitive than PCR tests, but sensitive enough to catch people when their viral load is highest, which is exactly when they are most infectious.
The technology for a cheap, rapid antigen test certainly exists: Abbott Laboratories’ $5 test, authorized by the U.S. Food and Drug Administration last week, goes a long way to prove this point. But Abbott’s test is intended to be used on symptomatic patients, and needs to be performed by a doctor. Mina wants people to be able to test themselves.
Mina’s vision has gained broad support in recent weeks by numerous public health experts, but would need buy-in from the federal government, particularly the FDA, to become reality.
Many other plans have been proposed, but at this point, more time has been spent talking about what we should be doing and debating the various options, rather than mustering the necessary regulatory, financial and political power to get any one of the plans fully executed.
“Choosing not to test those who are asymptomatic is like saying we won’t fight the fire until it reaches the second floor,” said Brian Castrucci, chief executive officer of health philanthropy the de Beaumont Foundation.
The pandemic has been raging across America for more than half a year. It’s past time we had a coherent national plan to put out the fire.
The administration has already begun to implement some policies along these lines, according to current and former officials as well as experts, particularly with regard to testing.
The approach’s chief proponent is Scott Atlas, a neuroradiologist from Stanford’s conservative Hoover Institution, who joined the White House earlier this month as a pandemic adviser. He has advocated that the United States adopt the model Sweden has used to respond to the virus outbreak, according to these officials, which relies on lifting restrictions so the healthy can build up immunity to the disease rather than limiting social and business interactions to prevent the virus from spreading.
Sweden’s handling of the pandemic has been heavily criticized by public health officials and infectious-disease experts as reckless — the country has among the highest infection and death rates in the world. It also hasn’t escaped the deep economic problems resulting from the pandemic.
But Sweden’s approach has gained support among some conservatives who argue that social distancing restrictions are crushing the economy and infringing on people’s liberties.
That this approach is even being discussed inside the White House is drawing concern from experts inside and outside the government who note that a herd immunity strategy could lead to the country suffering hundreds of thousands, if not millions, of lost lives.
“The administration faces some pretty serious hurdles in making this argument. One is a lot of people will die, even if you can protect people in nursing homes,” said Paul Romer, a professor at New York University who won the Nobel Prize in economics in 2018. “Once it’s out in the community, we’ve seen over and over again, it ends up spreading everywhere.”
Atlas, who does not have a background in infectious diseases or epidemiology, has expanded his influence inside the White House by advocating policies that appeal to Trump’s desire to move past the pandemic and get the economy going, distressing health officials on the White House coronavirus task force and throughout the administration who worry that their advice is being followed less and less.
Atlas declined several interview requests in recent days. After the publication of this story, he released a statement through the White House: “There is no policy of the President or this administration of achieving herd immunity. There never has been any such policy recommended to the President or to anyone else from me.”
White House communications director Alyssa Farah said there is no change in the White House’s approach toward combatting the pandemic.
“President Trump is fully focused on defeating the virus through therapeutics and ultimately a vaccine. There is no discussion about changing our strategy,” she said in a statement. “We have initiated an unprecedented effort under Operation Warp Speed to safely bring a vaccine to market in record time — ending this virus through medicine is our top focus.”
White House officials said Trump has asked questions about herd immunity but has not formally embraced the strategy. The president, however, has made public comments that advocate a similar approach.
“We are aggressively sheltering those at highest risk, especially the elderly, while allowing lower-risk Americans to safely return to work and to school, and we want to see so many of those great states be open,” he said during his address to the Republican National Convention Thursday night. “We want them to be open. They have to be open. They have to get back to work.”
Atlas has fashioned himself as the “anti-Dr. Fauci,” one senior administration official said, referring to Anthony S. Fauci, the nation’s top infectious-disease official, who has repeatedly been at odds with the president over his public comments about the threat posed by the virus. He has clashed with Fauci as well as Deborah Birx, the White House coronavirus response coordinator, over the administration’s pandemic response.
Atlas has argued both internally and in public that an increased case count will move the nation more quickly to herd immunity and won’t lead to more deaths if the vulnerable are protected. But infectious-disease experts strongly dispute that, noting that more than 25,000 people younger than 65 have died of the virus in the United States. In addition, the United States has a higher number of vulnerable people of all ages because of high rates of heart and lung disease and obesity, and millions of vulnerable people live outside nursing homes — many in the same households with children, whom Atlas believes should return to school.
“When younger, healthier people get the disease, they don’t have a problem with the disease. I’m not sure why that’s so difficult for everyone to acknowledge,” Atlas said in an interview with Fox News’s Brian Kilmeade in July. “These people getting the infection is not really a problem and in fact, as we said months ago, when you isolate everyone, including all the healthy people, you’re prolonging the problem because you’re preventing population immunity. Low-risk groups getting the infection is not a problem.”
Atlas has said that lockdowns and social distancing restrictions during the pandemic have had a health cost as well, noting the problems associated with unemployment and people forgoing health care because they are afraid to visit a doctor.
“From personal communications with neurosurgery colleagues, about half of their patients have not appeared for treatment of disease which, left untreated, risks brain hemorrhage, paralysis or death,” he wrote in The Hill newspaper in May
The White House has left many of the day-to-day decisions regarding the pandemic to governors and local officials, many of whom have disregarded Trump’s advice, making it unclear how many states would embrace the Swedish model, or elements of it, if Trump begins to aggressively push for it to be adopted.
But two senior administration officials and one former official, as well as medical experts, noted that the administration is already taking steps to move the country in this direction.
The Department of Health and Human Services, for instance, invoked the Defense Production Act earlier this month to expedite the shipment of tests to nursing homes — but the administration has not significantly ramped up spending on testing elsewhere, despite persistent shortages. Trump and top White House aides, including Atlas, have also repeatedly pushed to reopen schools and lift lockdown orders, despite outbreaks in several schools that attempted to resume in-person classes.
The Centers for Disease Control and Prevention also updated its testing guidance last week to say that those who are asymptomatic do not necessarily have to be tested. That prompted an outcry from medical groups, infectious-disease experts and local health officials, who said the change meant that asymptomatic people who had contact with an infected person would not be tested. The CDC estimates that about 40 percent of people infected with covid-19, the disease caused by the coronavirus, are asymptomatic, and experts said much of the summer surge in infections was due to asymptomatic spread among young, healthy people.
Trump has previously floated “going herd” before being convinced by Fauci and others that it was not a good idea, according to one official.
The discussions come as at least 5.9 million infections have been reported and at least 179,000 have died from the virus this year and as public opinion polls show that Trump’s biggest liability with voters in his contest against Democratic nominee Joe Biden is his handling of the pandemic. The United States leads the world in coronavirus cases and deaths, with far more casualties and infections than any other developed nation.
The nations that have most successfully managed the coronavirus outbreak imposed stringent lockdown measures that a vast majority of the country abided by, quickly ramped up testing and contact tracing, and imposed mask mandates.
Atlas meets with Trump almost every day, far more than any other health official, and inside the White House is viewed as aligned with the president and White House Chief of Staff Mark Meadows on how to handle the outbreak, according to three senior administration officials.
In meetings, Atlas has argued that metropolitan areas such as New York, Chicago and New Orleans have already reached herd immunity, according to two senior administration officials. But Birx and Fauci have disputed that, arguing that even cities that peaked to potential herd immunity levels experience similar levels of infection if they reopen too quickly, the officials said.
Trump asked Birx in a meeting last month whether New York and New Jersey had reached herd immunity, according to a senior administration official. Birx told the president there was not enough data to support that conclusion.
Atlas has supporters who argue that his presence in the White House is a good thing and that he brings a new perspective.
“Epidemiology is not the only discipline that matters for public policy here. That is a fundamentally wrong way to think about this whole situation,” said Avik Roy, president of the Foundation for Research on Equal Opportunity, a think tank that researches market-based solutions to help low-income Americans. “You have to think about what are the costs of lockdowns, what are the trade-offs, and those are fundamentally subjective judgments policymakers have to make.”
It remains unclear how large a percentage of the population must become infected to achieve “herd immunity,” which is when enough people become immune to a disease that it slows its spread, even among those who have not been infected. That can occur either through mass vaccination efforts, or when enough people in the population become infected with coronavirus and develop antibodies that protect them against future infection.
Estimates have ranged from 20 percent to 70 percent for how much of a population would need to be infected. Soumya Swaminathan, the World Health Organization’s chief scientist, said given the transmissibility of the novel coronavirus, it is likely that about 65 to 70 percent of the population would need to become infected for there to be herd immunity.
With a population of 328 million in the United States, it may require 2.13 million deaths to reach a 65 percent threshold of herd immunity, assuming the virus has a 1 percent fatality rate, according to an analysis by The Washington Post.
It also remains unclear whether people who recover from covid-19 have long-term immunity to the virus or can become reinfected, and scientists are still learning who is vulnerable to the disease. From a practical standpoint, it is also nearly impossible to sufficiently isolate people at most risk of dying due to the virus from the younger, healthier population, according to public health experts.
Atlas has argued that the country should only be testing people with symptoms, despite the fact that asymptomatic carriers spread the virus. He has also repeatedly pushed to reopen schools and advocated for college sports to resume. Atlas has said, without evidence, that children do not spread the virus and do not have any real risk from covid-19, arguing that more children die of influenza — an argument he has made in television and radio interviews.
Atlas’s appointment comes after Trump earlier this summer encouraged his White House advisers to find a new doctor who would argue an alternative point of view from Birx and Fauci, whom the president has grown increasingly annoyed with for public comments that he believes contradict his own assertions that the threat of the virus is receding. Advisers sought a doctor with Ivy League or top university credentials who could make the case on television that the virus is a receding threat.
Atlas caught Trump’s attention with a spate of Fox News appearances in recent months, and the president has found a more simpatico figure in the Stanford doctor for his push to reopen the country so he can focus on his reelection. Atlas now often sits in the briefing room with Trump during his coronavirus news conferences, even as other doctors do not. He has given the president somewhat of a medical imprimatur for his statements and regularly helps draft the administration’s coronavirus talking points from his West Wing office as well as the slides that Trump often relies on for his argument of a diminishing threat.
Atlas has also said he is unsure “scientifically” whether masks make sense, despite broad consensus among scientists that they are effective. He has selectively presented research and findings that support his argument for herd immunity and his other ideas, two senior administration officials said.
Fauci and Birx have both said the virus is a threat in every part of the country. They have also put forward policy recommendations that the president views as too draconian, including mask mandates and partial lockdowns in areas experiencing surges of the virus.
Birx has been at odds with Atlas on several occasions, with one disagreement growing so heated at a coronavirus meeting earlier this month that other administration officials grew uncomfortable, according to a senior administration official.
One of the main points of tension between the two is over school reopenings. Atlas has pushed to reopen schools and Birx is more cautious.
“This is really unfortunate to have this fellow Scott Atlas, who was basically recruited to crowd out Tony Fauci and the voice of reason,” said Eric Topol, a cardiologist and head of the Scripps Research Translational Institute in San Diego. “Not only do we not embrace the science, but we repudiate the science by our president, and that has extended by bringing in another unreliable misinformation vector.”
Nearly every country has struggled to contain the coronavirus and made mistakes along the way.
China committed the first major failure, silencing doctors who tried to raise alarms about the virus and allowing it to escape from Wuhan. Much of Europe went next, failing to avoid enormous outbreaks. Today, many countries — Japan, Canada, France, Australia and more — are coping with new increases in cases after reopening parts of society.
Yet even with all of these problems, one country stands alone, as the only affluent nation to have suffered a severe, sustained outbreak for more than four months: the United States.
Over the past month, about 1.9 million Americans have tested positive for the virus.
That’s more than five times as many as in all of Europe, Canada, Japan, South Korea and Australia, combined.
Even though some of these countries saw worrying new outbreaks over the past month, including 50,000 new cases in Spain …
… the outbreaks still pale in comparison to those in the United States. Florida, with a population less than half of Spain, has reported nearly 300,000 cases in the same period.
When it comes to the virus, the United States has come to resemble not the wealthy and powerful countries to which it is often compared but instead far poorer countries, like Brazil, Peru and South Africa, or those with large migrant populations, like Bahrain and Oman.
As in several of those other countries, the toll of the virus in the United States has fallen disproportionately on poorer people and groups that have long suffered discrimination. Black and Latino residents of the United States have contracted the virus at roughly three times as high of a rate as white residents.
How did this happen? The New York Times set out to reconstruct the unique failure of the United States, through numerous interviews with scientists and public health experts around the world. The reporting points to two central themes.
First, the United States faced longstanding challenges in confronting a major pandemic. It is a large country at the nexus of the global economy, with a tradition of prioritizing individualism over government restrictions. That tradition is one reason the United States suffers from an unequal health care system that has long produced worse medical outcomes — including higher infant mortality and diabetes rates and lower life expectancy — than in most other rich countries.
“As an American, I think there is a lot of good to be said about our libertarian tradition,” Dr. Jared Baeten, an epidemiologist and vice dean at the University of Washington School of Public Health, said. “But this is the consequence — we don’t succeed as well as a collective.”
The second major theme is one that public health experts often find uncomfortable to discuss because many try to steer clear of partisan politics. But many agree that the poor results in the United States stem in substantial measure from the performance of the Trump administration.
In no other high-income country — and in only a few countries, period — have political leaders departed from expert advice as frequently and significantly as the Trump administration. President Trump has said the virus was not serious; predicted it would disappear; spent weeks questioning the need for masks; encouraged states to reopen even with large and growing caseloads; and promoted medical disinformation.
Some Republican governors have followed his lead and also played down the virus, while others have largely followed the science. Democratic governors have more reliably heeded scientific advice, but their performance in containing the virus has been uneven.
“In many of the countries that have been very successful they had a much crisper strategic direction and really had a vision,” said Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security, who wrote a guide to reopening safely for the American Enterprise Institute, a conservative research group. “I’m not sure we ever really had a plan or a strategy — or at least it wasn’t public.”
Together, the national skepticism toward collective action and the Trump administration’s scattered response to the virus have contributed to several specific failures and missed opportunities, Times reporting shows:
a lack of effective travel restrictions;
repeated breakdowns in testing;
confusing advice about masks;
a misunderstanding of the relationship between the virus and the economy;
and inconsistent messages from public officials.
Already, the American death toll is of a different order of magnitude than in most other countries. With only 4 percent of the world’s population, the United States has accounted for 22 percent of coronavirus deaths. Canada, a rich country that neighbors the United States, has a per capita death rate about half as large. And these gaps may worsen in coming weeks, given the lag between new cases and deaths.
For many Americans who survive the virus or do not contract it, the future will bring other problems. Many schools will struggle to open. And the normal activities of life — family visits, social gatherings, restaurant meals, sporting events — may be more difficult in the United States than in any other affluent country.
A travel policy that fell short
In retrospect, one of Mr. Trump’s first policy responses to the virus appears to have been one of his most promising.
On Jan. 31, his administration announced that it was restricting entry to the United States from China: Many foreign nationals — be they citizens of China or other countries — would not be allowed into the United States if they had been to China in the previous two weeks.
It was still early in the spread of the virus. The first cases in Wuhan, China, had been diagnosed about a month before, and the first announced case in the United States had come on Jan. 21. In announcing the new travel policy, Alex M. Azar II, the secretary of health and human services, declared that the virus posed “a public health emergency.” Mr. Trump described the policy as his “China ban.”
After the Trump administration acted, several other countries quickly announced their own restrictions on travel from China, including Japan, Vietnam and Australia.
But it quickly became clear that the United States’ policy was full of holes. It did not apply to immediate family members of American citizens and permanent residents returning from China, for example. In the two months after the policy went into place, almost 40,000 people arrived in the United States on direct flights from China.
Even more important, the policy failed to take into account that the virus had spread well beyond China by early February. Later data would show that many infected people arriving in the United States came from Europe. (The Trump administration did not restrict travel from Europe until March and exempted Britain from that ban despite a high infection rate there.)
The administration’s policy also did little to create quarantines for people who entered the United States and may have had the virus.
Authorities in some other places took a far more rigorous approach to travel restrictions.
South Korea, Hong Kong and Taiwan largely restricted entry to residents returning home. Those residents then had to quarantine for two weeks upon arrival, with the government keeping close tabs to ensure they did not leave their home or hotel. South Korea and Hong Kong also tested for the virus at the airport and transferred anyone who was positive to a government facility.
Australia offers a telling comparison. Like the United States, it is separated from China by an ocean and is run by a conservative leader — Scott Morrison, the prime minister. Unlike the United States, it put travel restrictions at the center of its virus response.
Australian officials noticed in March that the travel restrictions they had announced on Feb. 1 were not preventing the virus from spreading. So they went further.
On March 27, Mr. Morrison announced that Australia would no longer trust travelers to isolate themselves voluntarily. The country would instead mandate that everyone arriving from overseas, including Australian citizens, spend two weeks quarantined in a hotel.
The protocols were strict. As people arrived at an airport, the authorities transported them directly to hotels nearby. People were not even allowed to leave their hotel to exercise. The Australian military helped enforce the rules.
Around the same time, several Australian states with minor outbreaks shut their own borders to keep out Australians from regions with higher rates of infection. That hardening of internal boundaries had not happened since the 1918 flu pandemic, said Ian Mackay, a virologist in Queensland, one of the first states to block entry from other areas.
The United States, by comparison, imposed few travel restrictions, either for foreigners or American citizens. Individual states did little to enforce the rules they did impose.
“People need a bit more than a suggestion to look after their own health,” said Dr. Mackay, who has been working with Australian officials on their pandemic response. “They need guidelines, they need rules — and they need to be enforced.”
Travel restrictions and quarantines were central to the success in controlling the virus in South Korea, Hong Kong, Taiwan and Australia, as well as New Zealand, many epidemiologists believe. In Australia, the number of new cases per day fell more than 90 percent in April. It remained near zero through May and early June, even as the virus surged across much of the United States.
In the past six weeks, Australia has begun to have a resurgence — which itself points to the importance of travel rules. The latest outbreak stems in large part from problems with the quarantine in the city of Melbourne. Compared with other parts of Australia, Melbourne relied more on private security contractors who employed temporary workers — some of whom lacked training and failed to follow guidelines — to enforce quarantines at local hotels. Officials have responded by banning out-of-state travel again and imposing new lockdowns.
Still, the tolls in Australia and the United States remain vastly different. Fewer than 300 Australians have died of complications from Covid-19, the illness caused by the virus. If the United States had the same per capita death rate, about 3,300 Americans would have died, rather than 158,000.
Enacting tough travel restrictions in the United States would not have been easy. It is more integrated into the global economy than Australia is, has a tradition of local policy decisions and borders two other large countries. But there is a good chance that a different version of Mr. Trump’s restrictions — one with fewer holes and stronger quarantines — would have meaningfully slowed the virus’s spread.
Traditionally, public health experts had not seen travel restrictions as central to fighting a pandemic, given their economic costs and the availability of other options, like testing, quarantining and contact tracing, Dr. Baeten, the University of Washington epidemiologist, said. But he added that travel restrictions had been successful enough in fighting the coronavirus around the world that those views may need to be revisited.
“Travel,” he said, “is the hallmark of the spread of this virus around the world.”
The double testing failure
On Jan. 16, nearly a week before the first announced case of the coronavirus in the United States, a German hospital made an announcement. Its researchers had developed a test for the virus, which they described as the world’s first.
The researchers posted the formula for the test online and said they expected that countries with strong public health systems would soon be able to produce their own tests. “We’re more concerned about labs in countries where it’s not that easy to transport samples, or staff aren’t trained that thoroughly, or if there is a large number of patients who have to be tested,” Dr. Christian Drosten, the director of the Institute for Virology at the hospital, known as Charité, in Berlin.
It turned out, however, that the testing problems would not be limited to less-developed countries.
In the United States, the Centers for Disease Control and Prevention developed their own test four days after the German lab did. C.D.C. officials claimed that the American test would be more accurate than the German one, by using three genetic sequences to detect the virus rather than two. The federal government quickly began distributing the American test to state officials.
But the test had a flaw. The third genetic sequence produced inconclusive results, so the C.D.C. told state labs to pause their work. In meetings of the White House’s coronavirus task force, Dr. Robert R. Redfield, the C.D.C. director, played down the problem and said it would soon be solved.
Instead, it took weeks to fix. During that time, the United States had to restrict testing to people who had clear reason to think they had the virus. All the while, the virus was quietly spreading.
By early March, with the testing delays still unresolved, the New York region became a global center of the virus — without people realizing it until weeks later. More widespread testing could have made a major difference, experts said, leading to earlier lockdowns and social distancing and ultimately less sickness and death.
“You can’t stop it if you can’t see it,” Dr. Bruce Aylward, a senior adviser to the director general at the World Health Organization, said.
While the C.D.C. was struggling to solve its testing flaws, Germany was rapidly building up its ability to test. Chancellor Angela Merkel, a chemist by training, and other political leaders were watching the virus sweep across northern Italy, not far from southern Germany, and pushed for a big expansion of testing.
By the time the virus became a problem in Germany, labs around the country had thousands of test kits ready to use. From the beginning, the government covered the cost of the tests. American laboratories often charge patients about $100 for a test.
Without free tests, Dr. Hendrik Streeck, director of the Institute of Virology at the University Hospital Bonn, said at the time, “a young person with no health insurance and an itchy throat is unlikely to go to the doctor and therefore risks infecting more people.”
Germany was soon far ahead of other countries in testing. It was able to diagnose asymptomatic cases, trace the contacts of new patients and isolate people before they could spread the virus. The country has still suffered a significant outbreak. But it has had many fewer cases per capita than Italy, Spain, France, Britain or Canada — and about one-fifth the rate of the United States.
The United States eventually made up ground on tests. In recent weeks, it has been conducting more per capita than any other country, according to Johns Hopkins researchers.
But now there is a new problem: The virus has grown even more rapidly than testing capacity. In recent weeks, Americans have often had to wait in long lines, sometimes in scorching heat, to be tested.
One measure of the continuing troubles with testing is the percentage of tests that come back positive. In a country that has the virus under control, fewer than 5 percent of tests come back positive, according to World Health Organization guidelines. Many countries have reached that benchmark. The United States, even with the large recent volume of tests, has not.
“We do have a lot of testing,” Ms. Rivers, the Johns Hopkins epidemiologist, said. “The problem is we also have a lot of cases.”
The huge demand for tests has overwhelmed medical laboratories, and many need days — or even up to two weeks — to produce results. “That really is not useful for public health and medical management,” Ms. Rivers added. While people are waiting for their results, many are also spreading the virus.
In Belgium recently, test results have typically come back in 48 to 72 hours. In Germany and Greece, it is two days. In France, the wait is often 24 hours.
The double mask failure
For the first few months of the pandemic, public health experts could not agree on a consistent message about masks. Some said masks reduced the spread of the virus. Many experts, however, discouraged the use of masks, saying — somewhat contradictorily — that their benefits were modest and that they should be reserved for medical workers.
“We don’t generally recommend the wearing of masks in public by otherwise well individuals because it has not been up to now associated with any particular benefit,” Dr. Michael Ryan, a World Health Organization official, said at a March 30 news conference.
His colleague Dr. Maria Van Kerkhove explained that it was important to “prioritize the use of masks for those who need them most.”
The conflicting advice, echoed by the C.D.C. and others, led to relatively little mask wearing in many countries early in the pandemic. But several Asian countries were exceptions, partly because they had a tradition of mask wearing to avoid sickness or minimize the effects of pollution.
In the following months, scientists around the world began to report two strands of evidence that both pointed to the importance of masks: Research showed that the virus could be transmitted through droplets that hang in the air, and several studies found that the virus spread less frequently in places where people were wearing masks.
On one cruise ship that gave passengers masks after somebody got sick, for example, many fewer people became ill than on a different cruise where people did not wear masks.
Consistent with that evidence was Asia’s success in holding down the number of cases (after China’s initial failure to do so). In South Korea, the per capita death rate is about one-eightieth as large as in the United States; Japan, despite being slow to enact social distancing, has a death rate about one-sixtieth as large.
“We should have told people to wear cloth masks right off the bat,” Dr. George Rutherford of the University of California, San Francisco, said.
In many countries, officials reacted to the emerging evidence with a clear message: Wear a mask.
Prime Minister Justin Trudeau of Canada began wearing one in May. During a visit to an elementary school, President Emmanuel Macron of France wore a French-made blue mask that complemented his suit and tie. Zuzana Caputova, the president of Slovakia, created a social media sensation by wearing a fuchsia-colored mask that matched her dress.
In the United States, however, masks did not become a fashion symbol. They became a political symbol.
Mr. Trump avoided wearing one in public for months. He poked fun at a reporter who wore one to a news conference, asking the reporter to take it off and saying that wearing one was “politically correct.” He described former Vice President Joseph R. Biden Jr.’s decision to wear one outdoors as “very unusual.”
Many other Republicans and conservative news outlets, like Fox News, echoed his position. Mask wearing, as a result, became yet another partisan divide in a highly polarized country.
Throughout much of the Northeast and the West Coast, more than 80 percent of people wore masks when within six feet of someone else. In more conservative areas, like the Southeast, the share was closer to 50 percent.
A March survey found that partisanship was the biggest predictor of whether Americans regularly wore masks — bigger than their age or whether they lived in a region with a high number of virus cases. In many of the places where people adopted a hostile view of masks, including Texas and the Southeast, the number of virus cases began to soar this spring.
The first rule of virus economics
Throughout March and April, Gov. Brian Kemp of Georgia and staff members held long meetings inside a conference room at the State Capitol in Atlanta. They ordered takeout lunches from local restaurants like the Varsity and held two daily conference calls with the public health department, the National Guard and other officials.
One of the main subjects of the meetings was when to end Georgia’s lockdown and reopen the state’s economy. By late April, Mr. Kemp decided that it was time.
Georgia had not met the reopening criteria laid out by the Trump administration (and many outside health experts considered those criteria too lax). The state was reporting about 700 new cases a day, more than when it shut down on April 3.
Nonetheless, Mr. Kemp went ahead. He said that Georgia’s economy could not wait any longer, and it became one of the first states to reopen.
“I don’t give a damn about politics right now,” he said at an April 20 news conference announcing the reopening. He went on to describe business owners with employees at home who were “going broke, worried about whether they can feed their children, make the mortgage payment.”
Four days later, across Georgia, barbers returned to their chairs, wearing face masks and latex gloves. Gyms and bowling alleys were allowed to reopen, followed by restaurants on April 27. The stay-at-home order expired at 11:59 p.m. on April 30.
Mr. Kemp’s decision was part of a pattern: Across the United States, caseloads were typically much higher when the economy reopened than in other countries.
As the United States endured weeks of closed stores and rising unemployment this spring, many politicians — particularly Republicans, like Mr. Kemp — argued that there was an unavoidable trade-off between public health and economic health. And if crushing the virus meant ruining the economy, maybe the side effects of the treatment were worse than the disease.
Dan Patrick, the Republican lieutenant governor of Texas, put the case most bluntly, and became an object of scorn, especially from the political left, for doing so. “There are more important things than living,” Mr. Patrick said in a television interview the same week that Mr. Kemp reopened Georgia.
It may have been an inartful line, but Mr. Patrick’s full argument was not wholly dismissive of human life. He was instead suggesting that the human costs of shutting down the economy — the losses of jobs and income and the associated damages to living standards and people’s health — were greater than the costs of a virus that kills only a small percentage of people who get it.
“We are crushing the economy,” he said, citing the damage to his own children and grandchildren. “We’ve got to take some risks and get back in the game and get this country back up and running.”
The trouble with the argument, epidemiologists and economists agree, was that public health and the economy’s health were not really in conflict.
Early in the pandemic, Austan Goolsbee, a University of Chicago economist and former Obama administration official, proposed what he called the first rule of virus economics: “The best way to fix the economy is to get control of the virus,” he said. Until the virus was under control, many people would be afraid to resume normal life and the economy would not function normally.
The events of the last few months have borne out Mr. Goolsbee’s prediction. Even before states announced shutdown orders in the spring, many families began sharply reducing their spending. They were responding to their own worries about the virus, not any official government policy.
And the end of lockdowns, like Georgia’s, did not fix the economy’s problems. It instead led to a brief increase in spending and hiring that soon faded.
In the weeks after states reopened, the virus began surging. Those that opened earliest tended to have worse outbreaks, according to a Times analysis. The Southeast fared especially badly.
In June and July, Georgia reported more than 125,000 new virus cases, turning it into one of the globe’s new hot spots. That was more new cases than Canada, France, Germany, Italy, Japan and Australia combined during that time frame.
Americans, frightened by the virus’s resurgence, responded by visiting restaurants and stores less often. The number of Americans filing new claims for unemployment benefits has stopped falling. The economy’s brief recovery in April and May seems to have petered out in June and July.
In large parts of the United States, officials chose to reopen before medical experts thought it wise, in an attempt to put people back to work and spark the economy. Instead, the United States sparked a huge new virus outbreak — and the economy did not seem to benefit.
“Politicians are not in control,” Mr. Goolsbee said. “They got all the illness and still didn’t fix their economies.”
The situation is different in the European Union and other regions that have had more success reducing new virus cases. Their economies have begun showing some promising signs, albeit tentative ones. In Germany, retail sales and industrial production have risen, and the most recent unemployment rate was 6.4 percent. In the United States, it was 11.1 percent.
The message is the response
The United States has not performed uniquely poorly on every measure of the virus response.
Mask wearing is more common than throughout much of Scandinavia and Australia, according to surveys by YouGov and Imperial College London. The total death rate is still higher in Spain, Italy and Britain.
But there is one way — in addition to the scale of the continuing outbreaks and deaths — that the United States stands apart: In no other high-income country have the messages from political leaders been nearly so mixed and confusing.
These messages, in turn, have been amplified by television stations and websites friendly to the Republican Party, especially Fox News and the Sinclair Broadcast Group, which operates almost 200 local stations. To anybody listening to the country’s politicians or watching these television stations, it would have been difficult to know how to respond to the virus.
Mr. Trump’s comments, in particular, have regularly contradicted the views of scientists and medical experts.
The day after the first American case was diagnosed, he said, “We have it totally under control.” In late February, he said: “It’s going to disappear. One day — it’s like a miracle — it will disappear.” Later, he incorrectly stated that any American who wanted a test could get one. On July 28, he falsely proclaimed that “large portions of our country” were “corona-free.”
He has also promoted medical misinformation about the virus. In March, Mr. Trump called it “very mild” and suggested it was less deadly than the common flu. He has encouraged Americans to treat it with the antimalarial drug hydroxychloroquine, despite a lack of evidence about its effectiveness and concerns about its safety. At one White House briefing, he mused aloud about injecting people with disinfectant to treat the virus.
These comments have helped create a large partisan divide in the country, with Republican-leaning voters less willing to wear masks or remain socially distant. Some Democratic-leaning voters and less political Americans, in turn, have decided that if everybody is not taking the virus seriously, they will not either. State leaders from both parties have sometimes created so many exceptions about which workplaces can continue operating normally that their stay-at-home orders have had only modest effects.
“It doesn’t seem we have had the same unity of purpose that I would have expected,” Ms. Rivers, the Johns Hopkins epidemiologist, said. “You need everyone to come together to accomplish something big.”
Across much of Europe and Asia, as well as in Canada, Australia and elsewhere, leaders have delivered a consistent message: The world is facing a deadly virus, and only careful, consistent action will protect people.
Many of those leaders have then pursued aggressive action. Mr. Trump and his top aides, by contrast, persuaded themselves in April that the virus was fading. They have also declined to design a national strategy for testing or other virus responses, leading to a chaotic mix of state policies.
“If you had to summarize our approach, it’s really poor federal leadership — disorganization and denial,” said Andy Slavitt, who ran Medicare and Medicaid from 2015 to 2017. “Watch Angela Merkel. Watch how she communicates with the public. Watch how Jacinda Ardern in New Zealand does it. They’re very clear. They’re very consistent about what the most important priorities are.”
New York — both the city and the state — offers a useful case study. Like much of Europe, New York responded too slowly to the first wave of the virus. As late as March 15, Mayor Bill de Blasio encouraged people to go to their neighborhood bar.
Soon, the city and state were overwhelmed. Ambulances wailed day and night. Hospitals filled to the breaking point. Gov. Andrew M. Cuomo — a Democrat, like Mr. de Blasio — was slow to protect nursing home residents, and thousands died. Earlier action in New York could have saved a significant number of lives, epidemiologists say.
By late March, however, New York’s leaders understood the threat, and they reversed course.
They insisted that people stay home. They repeated the message every day, often on television. When other states began reopening, New York did not. “You look at the states that opened fast without metrics, without guardrails, it’s a boomerang,” Mr. Cuomo said on June 4.
The lockdowns and the consistent messages had a big effect. By June, New York and surrounding states had some of the lowest rates of virus spread in the country. Across much of the Southeast, Southwest and West Coast, on the other hand, the pandemic was raging.
Many experts now say that the most disappointing part of the country’s failure is that the outcome was avoidable.
What may not have been avoidable was the initial surge of the virus: The world’s success in containing previous viruses, like SARS, had lulled many people into thinking a devastating pandemic was unlikely. That complacency helps explains China’s early mistakes, as well as the terrible death tolls in the New York region, Italy, Spain, Belgium, Britain and other parts of Europe.
But these countries and dozens more — as well as New York — have since shown that keeping the virus in check is feasible.
For all of the continuing uncertainty about how this new coronavirus is transmitted and how it affects the human body, much has become clear. It often spreads indoors, with close human contact. Talking, singing, sneezing and coughing play a major role in transmission. Masks reduce the risk. Restarting normal activity almost always leads to new cases that require quick action — testing, tracing of patients and quarantining — to keep the virus in check.
When countries and cities have heeded these lessons, they have rapidly reduced the spread of the virus and been able to move back, gingerly, toward normal life. In South Korea, fans have been able to attend baseball games in recent weeks. In Denmark, Italy and other parts of Europe, children have returned to school.
In the United States, the virus continues to overwhelm daily life.
“This isn’t actually rocket science,” said Dr. Thomas R. Frieden, who ran the New York City health department and the C.D.C. for a combined 15 years. “We know what to do, and we’re not doing it.”
Led by physicians, scientists and epidemiologists, the US Centers for Disease Control and Prevention (CDC) is one of the most reliable sources of knowledge during disease outbreaks. But now, with the world in desperate need of authoritative information, one of the foremost agencies for fighting infectious disease has gone conspicuously silent.
For the first time since 1946, when the CDC came to life in a cramped Atlanta office to fight malaria, the agency is not at the front line of a public health emergency.
On April 22, CDC director Robert Redfield stood at the White House briefing room lectern and conceded that the coronavirus pandemic had “overwhelmed” the United States. Following Redfield at the podium, President Donald Trump said the CDC director had been “totally misquoted” in his warning that COVID-19 would continue to pose serious difficulties as the US moved into its winter ‘flu season in late 2020.
Invited to clarify, Redfield confirmed he had been quoted correctly in giving his opinion that there were potentially “difficult and complicated” times ahead.
Trump tried a different tack. “You may not even have corona coming back,” the president said, once again contradicting the career virologist. “Just so you understand.”
The exchange was interpreted by some pundits as confirmation that the CDC’s venerated expertise had been sidelined as the coronavirus continued to ravage the US.
In the latest development, the New York Times reported this week the CDC has even been bypassed in its data collection, with the Trump administration ordering hospitals to send COVID-19 data directly to the White House.
When facing previous public health emergencies the CDC was a hive of activity, holding regular press briefings and developing guidance that was followed by governments around the world. But during the greatest public health emergency in a century, it appears the CDC has been almost entirely erased by the White House as the public face of the COVID-19 pandemic response.
This diminished role is obvious to former leaders of the CDC, who say their scientific advice has never before been politicised to this extent.
As the COVID-19 crisis was unfolding, several CDC officials issued warnings, only to promptly disappear from public view. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, predicted on February 25 that the virus was not contained and would grow into a pandemic.
The stock market plunged and Messonnier was removed from future White House press briefings. Between March 9 and June 12 there was no CDC presence at White House press briefings on COVID-19.
The CDC has erred during the pandemic, most significantly in its initial efforts to develop a test for COVID-19. The testing kits proved to be faulty – a problem compounded by sluggish efforts to rectify the situation – and then by severe delays in distributing enough tests to the public.
But many public health specialists are nevertheless baffled by the CDC’s low profile as the pandemic continues to sweep the globe.
“They have been sidelined,” said Howard Koh, former US assistant secretary for health. “We need their scientific leadership right now.”
What does it mean for the world?
The CDC being bypassed in the collection of COVID-19 data is another body blow to the agency’s standing.
Hospitals have instead been ordered to send all COVID-19 patient information to a central database in Washington DC.
This will have a range of likely knock-on effects. For starters, the new database will not be available to the public, prompting inevitable questions over the accuracy and transparency of data which will now be interpreted and shared by the White House.
The Department of Health and Human Services, which issued the new order, says the change will help the White House’s coronavirus task force allocate resources. But epidemiologists and public health experts around the world fear the new system will make it harder for people outside the White House to track the pandemic or access information.
This affects all nations, because one of the CDC’s roles is to provide sound, independent public health guidance on issues such as infectious diseases, healthy living, travel health, emergency and disaster preparedness, and drug efficacy. Other jurisdictions can then adapt this information to their local context — expertise that has become even more essential during a pandemic, when uncertainty is the norm.
It is difficult to recall a previous public health emergency when political pressure led to a change in the interpretation of scientific evidence.
What happens next?
Despite the inevitable challenges that come with tackling a pandemic in real time, the CDC remains the best-positioned agency – not just in the US but the entire world – to help us manage this crisis as safely as possible.
In the absence of US leadership, nations should start thinking about developing their own national centres for disease control. In Australia’s case, these discussions have been ongoing since the 1990s, stymied by cost and lack of political will.
COVID-19, and the current sidelining of the CDC, may be the impetus needed to finally dust off those plans and make them a reality.
Hospitals will begin sending coronavirus-related information directly to the Department of Health and Human Services (HHS), not the Centers for Disease Control and Prevention (CDC), under new instructions from the Trump administration.
The move will take effect on Wednesday, according to a new guidance and FAQ document for hospitals and clinical labs quietly posted on the HHS website.
Previously, hospitals reported to the CDC’s National Healthcare Safety Network, which the agency describes as the nation’s most widely used health care-associated infection tracking system.
The CDC tracked information including how many beds are available, the number of ventilators available and how many COVID-19 patients the hospitals have.
Beginning Wednesday, hospitals will report the same data but will bypass the CDC and send it to HHS directly.
According to HHS, the goal is to streamline data collection, which will be used to inform decisions at the federal level such as allocation of supplies, treatments and other resources.
But the move comes amid concerns that the White House has been sidelining the CDC and after Trump administration officials attacked Anthony Fauci, the nation’s top infectious disease expert and a member of the White House coronavirus task force.