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The Unique U. S. Failure to Control the Coronavirus
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.
In recent days, Mr. Trump has continued the theme, offering a torrent of misleading statistics in his public appearances that make the situation sound less dire than it is.
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:
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a lack of effective travel restrictions;
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repeated breakdowns in testing;
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confusing advice about masks;
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a misunderstanding of the relationship between the virus and the economy;
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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.
By January, mask wearing in Japan was widespread, as it often had been during a typical flu season. Masks also quickly became the norm in much of South Korea, Thailand, Vietnam, Taiwan and China.
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.”
The Fed’s independence helped it save the US economy in 2008 – the CDC needs the same authority today
The image of scientists standing beside governors, mayors or the president has become common during the pandemic. Even the most cynical politician knows this public health emergency cannot be properly addressed without relying on the scientific knowledge possessed by these experts.
Yet, ultimately, U.S. government health experts have limited power. They work at the discretion of the White House, leaving their guidance subject to the whims of politicians and them less able to take urgent action to contain the pandemic.
The Centers for Disease Control and Prevention has issued guidelines only to later revise them after the White House intervened. The administration has also undermined its top infectious disease expert, Dr. Anthony Fauci, over his blunt warnings that the pandemic is getting worse – a view that contradicts White House talking points.
And most recently, the White House stripped the CDC of control of coronavirus data, alarming health experts who fear it will be politicized or withheld.
In the realm of monetary policy, however, there is an agency with experts trusted to make decisions on their own in the best interests of the U.S. economy: the Federal Reserve. As I describe in my recent book, “Stewards of the Market,” the Fed’s independence allowed it to take politically risky actions that helped rescue the economy during the financial crisis of 2008.
That’s why I believe we should give the CDC the same type of authority as the Fed so that it can effectively guide the public through health emergencies without fear of running afoul of politicians.
The paradox of expertise
There is a paradox inherent in the relationship between political leaders and technical experts in government.
Experts have the training and skill to apply scientific knowledge in complex biological and economic systems, yet democratically elected political leaders may overrule or ignore their advice for ill or good.
This happened in May when the CDC, the federal agency charged with controlling the spread of disease, removed advice regarding the dangers of singing in church choirs from its website. It did not do so because of new evidence. Rather, it was because of political pressure from the White House to water down the guidance for religious groups.
Similarly, the White House undermined the CDC’s guidance on school reopenings and has pressured it to revise them. So far, it seems the CDC has rebuffed the request.
The ability of elected leaders to ignore scientists – or the scientists’ acquiescence to policies they believe are detrimental to public welfare – is facilitated by many politicians’ penchant for confident assertion of knowledge and the scientist’s trained reluctance to do so.
Compare Fauci’s repeated comment that “there is much we don’t know about the virus” with President Donald Trump’s confident assertion that “we have it totally under control.”
Experts with independence
Given these constraints on technical expertise, the performance of the Fed in the financial crisis of 2008 offers an informative example that may be usefully applied to the CDC today.
The Federal Reserve is not an executive agency under the president, though it is chartered and overseen by Congress. It was created in 1913 to provide economic stability, and its powers have expanded to guard against both depression and crippling inflation.
At its founding, the structure of the Fed was a political compromise designed make it independent within the government in order to de-politicize its economic policy decisions. Today its decisions are made by a seven-member board of governors and a 12-member Federal Open Market Committee. The members, almost all Ph.D. economists, have had careers in academia, business and government. They come together to analyze economic data, develop a common understanding of what they believe is happening and create policy that matches their shared analysis. This group policymaking is optimal when circumstances are highly uncertain, such as in 2008 when the global financial system was melting down.
The Fed was the lead actor in preventing the system’s collapse and spent several trillion dollars buying risky financial assets and lending to foreign central banks – decisions that were pivotal in calming financial markets but would have been much harder or may not have happened at all without its independent authority.
The Fed’s independence is sufficiently ingrained in our political culture that its chair can have a running disagreement with the president yet keep his job and authority.
Putting experts at the wheel
A health crisis needs trusted experts to guide decision-making no less than an economic one does. This suggests the CDC or some re-imagined version of it should be made into an independent agency.
Like the Fed, the CDC is run by technical experts who are often among the best minds in their fields. Like the Fed, the CDC is responsible for both analysis and crisis response. Like the Fed, the domain of the CDC is prone to politicization that may interfere with rational response. And like the Fed, the CDC is responsible for decisions that affect fundamental aspects of the quality of life in the United States.
Were the CDC independent right now, we would likely see a centralized crisis management effort that relies on the best science, as opposed to the current patchwork approach that has failed to contain the outbreak nationally. We would also likely see stronger and consistent recommendations on masks, social distancing and the safest way to reopen the economy and schools.
Independence will not eliminate the paradox of technical expertise in government. The Fed itself has at times succumbed to political pressure. And Trump would likely try to undermine an independent CDC’s legitimacy if its policies conflicted with his political agenda – as he has tried to do with the central bank.
But independence provides a strong shield that would make it much more likely that when political calculations are at odds with science, science wins.
Making coronavirus testing easy, accurate and fast is critical to ending the pandemic – the US response is falling far short
For many people in the U.S., getting tested for COVID-19 is a struggle. In Arizona, testing sites have seen lines of hundreds of cars stretching over a mile. In Texas and Florida, some people were waiting for five hours for free testing.
The inconvenience of these long waits alone discourages many people from getting tested. With the surge in cases, many public testing sites have been reaching maximum capacity within hours of opening, leaving many people unable to get tested for days. Those that do get tested often face a week-long wait to get their test results.
Every person who isn’t tested could be spreading COVID-19 unknowingly. These overstretched testing programs are a weak link in the U.S. pandemic response.
I study public health policy to combat infectious disease epidemics. The key to overcoming this pandemic is to slow transmission of the virus by preventing contagious people from infecting others. A widespread quarantine would accomplish this, but is economically and socially burdensome. Testing offers a way to identify contagious people so they can be isolated to prevent the spread of the disease. This is especially important for COVID-19 because an estimated 40% or more of all people infected with SARS-CoV-2 have few or no symptoms so testing is the only way to identify them.
Some states are doing much better than others. But as a whole, the U.S. is falling far short of the amount of testing needed to control the pandemic. What are the challenges the U.S. is facing? And what is the way forward?
Testing should be free, easy, fast and accurate
The ultimate goal of testing is for everyone, regardless of symptoms, to know at all times whether they are infected with the coronavirus. To achieve this level of testing, tests should be free, very easy to perform and provide accurate results quickly.
Ideally, free COVID-19 tests would be delivered to everyone directly. The tests would be simple to perform – like a saliva test – and would give a perfectly accurate result within minutes. Everyone could test themselves weekly or anytime they were going to be in close contact with other people.
In this ideal scenario, most, if not all, contagious people would be detected before they could spread the virus to others. And because of the rapid results, there would be no burden of quarantining between doing the test and getting the result.
Researchers are working on better-quality tests, but access is a problem of infrastructure, not science. Right now, nowhere in the U.S. comes close to meeting surging demand for testing.
One of the worst cases: Texas
The difficulty of getting a COVID-19 test varies by state, but currently, people in Texas face some of the biggest obstacles, which results in far fewer tests being done than is needed to control the pandemic.
First, Houston – which is experiencing a surge in cases – and many testing sites across the state recommend or offer testing only to people who have symptoms, were exposed to a COVID-19 case or are a member of a high-risk group.
Even people recommended for testing still face challenges. It is possible to request an appointment for a free COVID-19 test, but testing facilities can handle only so many patients a day and testing slots fill up quickly. Even if someone gets an appointment, they may face an hours-long wait at the testing site.
Finally, public health experts recommend that people who may have been exposed to COVID-19 should quarantine at home for 14 days or until they receive a negative test result. In Texas, patients are supposed to get results through an online portal in three to five days, but many labs have been taking seven to nine days to return results. These long delays mean people face a much higher burden of quarantining while waiting for results.
All of these challenges make it clear that Texas is simply not testing enough people to keep the spread of COVID-19 in check.
To gauge the success of COVID-19 testing programs, epidemiologists use a measure called test positivity. This is simply the percentage of tests that come back positive. The lower the test positivity, the better, because that means very few cases are going undetected. A high test-positivity rate is usually a sign that only the sickest people are getting tested and many cases are being missed.
The World Health Organization guidelines say that if more than 1 out of 20 COVID-19 tests comes back positive – a test positivity of more than 5% – this is an indication that a lot of cases are not diagnosed and the epidemic is not under control.
Texas currently has a test-positivity of around 16%, which means that a lot of infected people are not getting tested and may be unknowingly spreading the disease.
One of the best cases: New Mexico
In stark contrast to Texas is New Mexico, which has one of the strongest testing programs in the U.S.
First, public health officials there encourage everyone to get tested for COVID-19 regardless of symptoms or exposure. The state has also prohibited health providers from charging patients for tests. People seeking a test have the option to walk in or to make an appointment ahead of time, whichever is more convenient.
All of this relatively good access to testing has resulted in one of the highest per capita testing rates in the country, at over 20,000 tests per 100,000 people, and a test-positivity rate of around 4%. New Mexico’s testing program is diagnosing a relatively high proportion of cases despite the state experiencing a recent surge.
New Mexico still has room for improvement. Long lines, wait times and limited capacity are becoming more common as cases surge, but the foundation of a strong testing program has helped the state cope with the increase in cases.
The big-picture problems
The pre-pandemic infectious disease testing capabilities in the U.S. are clearly unable to meet the current demand. A nationwide response is needed, and there are three things that Congress, the federal government and local governments can do to help ensure COVID-19 tests will be easy to get, fast and accurate.
First, Congress can provide funding to stimulate the testing supply chain, scale up existing testing programs and promote innovation in test development.
Second, governments can improve the management and coordination of testing programs to more efficiently use existing resources.
And third, innovative testing methods that reduce the need for lab capacity – like paper-strip tests and pooled testing – need be approved and implemented more quickly.
Every little improvement in testing capabilities means more COVID-19 cases can be caught before the virus is transmitted. And slowing the spread of the virus is the key to overcoming the pandemic.
Test positivity rate: How this one figure explains that the US isn’t doing enough testing yet
The U.S. has performed more coronavirus tests than any other country in the world. Yet, at the same time, the U.S. is notably underperforming in terms of suppressing COVID-19. Confirmed cases – as well as deaths – are surging in many parts of the country. Some people have argued that the increase in cases is solely due to increased testing.
I am a statistician who studies how mathematics and statistics can be used to track diseases. The claim that the increase in cases is only caused by increases in testing is just not true. But how do public health officials know this?
Testing, confirmed cases and total cases
COVID-19 testing has two purposes. The first is to confirm a diagnosis so that medical treatment can be appropriately rendered. The second is to do surveillance for tracking and disease suppression – including finding those who may be asymptomatic or only have mild symptoms – so that individuals and public health officials can take actions to slow the spread of the virus.
At a White House briefing on July 13, the president said, “When you test, you create cases.”
The problem with this statement is that anyone who is infected with the coronavirus is, by definition, a case. Since taking a COVID-19 test does not cause a person to get coronavirus, just like taking a pregnancy test does not cause one to become pregnant, the president’s claim is false. Testing does not create cases.
However, because many COVID-19 cases are asymptomatic, many people are infected and don’t know it. What COVID-19 testing does do is identify unknown cases. And thus it does increase the number of cases that are known, or otherwise called the confirmed case count.
Finding unknown cases is good, not bad, because identifying those who are COVID-19-positive allows individuals and public health officials to take actions that slow the spread of the disease. When public health officials find cases, they can begin contract tracing. When a person finds out they are infected, they will know to quarantine.
Since the beginning of the pandemic, the U.S. has performed more total tests and more tests per capita than any other country, though as of late July the U.K., Russia and Qatar were performing more tests per capita per day. But counting the total number of tests or the tests per capita is not the right way to judge success of a testing program.
As it says on the Johns Hopkins testing comparison page, a country’s “testing program should be scaled to the size of their epidemic, not the size of the population.” Sure, the U.S. might have a big testing program, but it has a massive epidemic. The U.S. needs an equally massive testing program if health officials want to have an accurate picture of what’s really going on.
Test positivity rate
So how do public health officials know if they are doing enough testing?
Better than simply counting total number of tests, the test positivity rate is a useful measure of whether enough tests are being done. The test positivity rate is simply the fraction of tests that come back positive. It is calculated by dividing the number of positive tests by the total number of tests. Generally, a lower test positivity rate is good.
A good way to think about test positivity is to think about fishing with a net. If you catch a fish almost every time you send the net down – high test positivity – that tells you there are probably a lot of fish around that you haven’t caught – there are a lot of undetected cases. On the other hand, if you use a huge net – more testing – and only catch a fish every once in a while – low test positivity – you can be pretty sure that you’ve caught most of the fish in the area.
According to the World Health Organization, before a region can relax restrictions or begin reopening, the test positivity rate from a comprehensive testing program should be at or below 5% for at least 14 days.
There are two ways to lower a test positivity rate: either by decreasing the number of positive tests or by increasing the total number of tests. A comprehensive testing program does both. By conducting a large number of tests, most cases in the community are detected. Then, individual and government actions can be taken that contain the virus. This results in a declining number of positive tests.
Returning to the fishing metaphor, the goal of a comprehensive testing program is to use a huge net to overfish in the coronavirus lake until there are very few COVID-19 cases left. Using the test positivity rate as a measure of success helps ensure that a testing program is appropriately scaled to the size of an epidemic.
As of July 27, the U.S. as a whole had a test positivity rate of 10%. States where testing programs are robust and the virus is fairly well controlled have test positivity rates well below 5%, like Massachusetts at 2.68% and New York at 1.09%. In places like Mississippi and Arizona that are experiencing large outbreaks, test positivity rates are above 20%.
The right amount of testing
The increases in confirmed cases aren’t occurring just because there is more testing. The high test positivity rates in some locations show that the virus is in fact spreading and growing so testing needs to grow with it. I believe that if the U.S. wants to beat back this virus, one of the first things that needs to happen is to increase testing. We need to deploy larger nets to catch more fish. Yes, we’ll find more cases, but that’s the point.
How COVID-19 might increase risk of memory loss and cognitive decline
Of all frightening ways that the SARS-COV-2 virus affects the body, one of the more insidious is the effect of COVID-19 on the brain.
It is now clear that many patients suffering from COVID-19 exhibit neurological symptoms, from loss of smell, to delirium, to an increased risk of stroke. There are also longer-lasting consequences for the brain, including myalgic encephalomyelitis /chronic fatigue syndrome and Guillain-Barre syndrome.
These effects may be caused by direct viral infection of brain tissue. But growing evidence suggests additional indirect actions triggered via the virus’s infection of epithelial cells and the cardiovascular system, or through the immune system and inflammation, contribute to lasting neurological changes after COVID-19.
I am a neuroscientist specializing in how memories are formed, the role of immune cells in the brain and how memory is persistently disrupted after illness and immune activation. As I survey the emerging scientific literature, my question is: Will there be a COVID-19-related wave of memory deficits, cognitive decline and dementia cases in the future?
The immune system and the brain
Many of the symptoms we attribute to an infection are really due to the protective responses of the immune system. A runny nose during a cold is not a direct effect of the virus, but a result of the immune system’s response to the cold virus. This is also true when it comes to feeling sick. The general malaise, tiredness, fever and social withdrawal are caused by activation of specialized immune cells in the brain, called neuroimmune cells, and signals in the brain.
These changes in brain and behavior, although annoying for our everyday lives, are highly adaptive and immensely beneficial. By resting, you allow the energy-demanding immune response to do its thing. A fever makes the body less hospitable to viruses and increases the efficiency of the immune system. Social withdrawal may help decrease spread of the virus.
In addition to changing behavior and regulating physiological responses during illness, the specialized immune system in the brain also plays a number of other roles. It has recently become clear that the neuroimmune cells that sit at the connections between brain cells (synapses), which provide energy and minute quantities of inflammatory signals, are essential for normal memory formation.
Unfortunately, this also provides a way in which illnesses like COVID-19 can cause both acute neurological symptoms and long-lasting issues in the brain.
Microglia are specialized immune cells in the brain. In healthy states, they use their arms to test the environment. During an immune response, microglia change shape to engulf pathogens. But they can also damage neurons and their connections that store memory.
During illness and inflammation, the specialized immune cells in the brain become activated, spewing vast quantities of inflammatory signals, and modifying how they communicate with neurons. For one type of cell, microglia, this means changing shape, withdrawing the spindly arms and becoming blobby, mobile cells that envelop potential pathogens or cell debris in their path. But, in doing so, they also destroy and eat the neuronal connections that are so important for memory storage.
Another type of neuroimmune cell called an astrocyte, typically wraps around the connection between neurons during illness-evoked activation and dumps inflammatory signals on these junctions, effectively preventing the changes in connections between neurons that store memories.
Because COVID-19 involves a massive release of inflammatory signals, the impact of this disease on memory is particularly interesting to me. That is because there are both short-term effects on cognition (delirium), and the potential for long-lasting changes in memory, attention and cognition. There is also an increased risk for cognitive decline and dementia, including Alzheimer’s disease, during aging.
How does inflammation exert long-lasting effects on memory?
If activation of neuroimmune cells is limited to the duration of the illness, then how can inflammation cause long-lasting memory deficits or increase the risk of cognitive decline?
Both the brain and the immune system have specifically evolved to change as a consequence of experience, in order to neutralize danger and maximize survival. In the brain, changes in connections between neurons allows us to store memories and rapidly change behavior to escape threat, or seek food or social opportunities. The immune system has evolved to fine-tune the inflammatory response and antibody production against previously encountered pathogens.
Yet long-lasting changes in the brain after illness are also closely linked to increased risk for age-related cognitive decline and Alzheimer’s disease. The disruptive and destructive actions of neuroimmune cells and inflammatory signaling can permanently impair memory. This can occur through permanent damage to the neuronal connections or neurons themselves and also via more subtle changes in how neurons function.
The potential connection between COVID-19 and persistent effects on memory are based on observations of other illnesses. For example, many patients who recover from heart attack or bypass surgery report lasting cognitive deficits that become exaggerated during aging.
Another major illness with a similar cognitive complications is sepsis – multi-organ dysfunction triggered by inflammation. In animal models of these diseases, we also see impairments of memory, and changes in neuroimmune and neuronal function that persist weeks and months after illness.
Even mild inflammation, including chronic stress, are now recognized as risk factors for dementias and cognitive decline during aging.
In my own laboratory, I and my colleagues have also observed that even without bacterial or viral infection, triggering inflammatory signaling over a short-term period results in long-lasting changes in neuronal function in memory-related brain regions and memory impairments.
Does COVID-19 increase risk for cognitive decline?
It will be many years before we know whether the COVID-19 infection causes an increased risk for cognitive decline or Alzheimer’s disease. But this risk may be decreased or mitigated through prevention and treatment of COVID-19.
Prevention and treatment both rely on the ability to decrease the severity and duration of illness and inflammation. Intriguingly, very new research suggests that common vaccines, including the flu shot and pneumonia vaccines, may reduce risk for Alzheimer’s.
Additionally, several emerging treatments for COVID-19 are drugs that suppress excessive immune activation and inflammatory state. Potentially, these treatments will also reduce the impact of inflammation on the brain, and decrease the impact on long-term brain health.
COVID-19 will continue to impact health and well-being long after the pandemic is over. As such, it will be critical to continue to assess the effects of COVID-19 illness in vulnerability to later cognitive decline and dementias.
In doing so, researchers will likely gain critical new insight into the role of inflammation across the life-span in age-related cognitive decline. This will aid in the development of more effective strategies for prevention and treatment of these debilitating illnesses.
Most Americans Still Aren’t Wearing Face Masks Outdoors, Poll Finds
TOPLINE
Even as the surging Covid-19 pandemic has inspired a broad majority of Americans to start wearing face masks indoors, the practice still remains rare outside, with a new Gallup poll finding that fewer than half of Americans wear face masks outside in non-socially distanced settings, despite many mask-wearing mandates now requiring them to do so.
KEY FACTS
While 81% of poll respondents say they always or usually wear a mask indoors when social distancing isn’t possible, only 47% say they wear a face mask outdoors when they cannot socially distance.
29% say they “always” wear a mask outdoors and 18% say they “usually” do.
The practice is more common among Democrats, with 64% saying they wear a mask outdoors as compared with 43% of Independents and only 23% of Republicans.
Midwesterners are the least likely to wear masks outside; only 37% in the Midwest region wear masks outside, versus 55% in the Northeast, 47% in the South and 49% in the West.
Research has shown that Covid-19 appears to be more easily transmitted indoors, though outdoor settings still pose some risk, and Gallup notes the poll findings “could indicate a potential for increased spread of the disease” in outdoor venues like beaches.
Many state or local mask-wearing mandates include outdoor settings where social distancing isn’t possible, and multiple areas, including New Jersey and Oregon, have also imposed additional orders specifying masks must be worn outdoors in many circumstances.
CRUCIAL QUOTE
“We know this virus is a lot less lethal outdoors than indoors, but that does not mean it is not lethal,” New Jersey Gov. Phil Murphy said in a statement about his July executive order requiring masks outdoors. “The hotspots we’re seeing across the nation and certain worrisome transmission trends in New Jersey require us to do more.”
BIG NUMBER
66,740: The number of lives that could be saved in the U.S. by December 1 if 95% of people “were to wear masks when leaving their homes,” as projected Thursday by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine. The IMHE’s model projects 295,011 deaths by December, which would drop by 49% to 228,271 with “consistent mask-wearing.”
KEY BACKGROUND
Mask wearing has become a major point of contention as Covid-19 has rapidly spread across the U.S. Though many states and localities have imposed mask-wearing mandates, the orders have been resisted by many GOP governors, including in states like Florida that have been particularly hard-hit by the virus. While President Donald Trump initially made mask-wearing a partisan debate through his refusal to don a mask, the president has shifted to promoting the practice in recent weeks, tweeting a photo of himself in a mask that called mask-wearing “patriotic” and urging supporters to wear a mask in a recent campaign email. Prominent Republicans including Senate Majority Leader Mitch McConnell have also vocally advocated for mask-wearing, with McConnell saying Thursday on CNBC that wearing a mask is “the single most significant thing everybody in the country can do to help prevent the spread.”
69% Of Americans Are Concerned That The U.S. Is Reopening Too Quickly Amid The Coronavirus Pandemic
TOPLINE
Some 69% of Americans believe that state governments have eased restrictions too soon amid the Covid-19 pandemic, as opposed to opening too slowly, according to a new Pew Research study published on Thursday, as the U.S. grapples with a still-uncontrolled outbreak of the coronavirus.
KEY FACTS
While the Trump administration pushed for states to lift stay-at-home orders throughout the spring to help the battered economy, governors are now being forced to pause or restore some restrictions after a surge in cases this summer.
Around seven-in-ten people believe the most effective way to help economic recovery is to significantly reduce infections across the country, according to the study, and while Trump continues his argument that the U.S. leads the world in cases due to an increase in testing, 60% of Americans believe it’s primarily due to more new infections.
A majority of Democrats and Republicans believe the main reason the outbreak in the U.S. has continued is due to the lack of social distancing and mask wearing, while 58% of adults surveyed believe it’s due to early lifting of restrictions.
A number of wealthy nations that experienced severe outbreaks early in the pandemic have exited their first waves and have less cases than states like California and Florida, with 62% of Americans believing the U.S. response to the coronavirus trails other affluent countries.
The survey comes as the Trump administration continues to pressure Democratic-led states to ease restrictions and demand schools reopen for in-person instruction, even threatening to withhold federal funding if they don’t.
CRUCIAL QUOTE
Dr. Anthony Fauci, the government’s lead infectious disease expert, commented on the rise of infections across the nation: “In the attempt to reopen in some situations states did not abide strictly by the guidelines that the task force and the White House has put out. And others that even did abide by it, the people in the state actually were congregating in crowds and not wearing masks.”
KEY BACKGROUND
While initial hotspots like New York and New Jersey were able to lower the infection rate throughout the spring, cases began exploding in southern and western states before the country as a whole could exit the first wave of its outbreak. Cases are now trending down after a record high of 74,818 on July 24, according to the Centers for Disease Control and Prevention, though deaths have been over 1,000 daily the past week and there are still tens of thousands of cases each day. The U.S. leads all other countries in cases with 4.87 million, as well as reported deaths with 159,864.
