America has an opportunity to learn from its mistakes during the Covid-19 pandemic — but it is already in danger of missing its chance.
Despite more than 575,000 dead Americans, there is no 9/11 Commission-style governmental inquiry into the mistakes and missteps that doomed the country’s early response to the virus. Congress has moved onto other business. The Biden White House is consumed with the current pandemic. But the next one will come, and sooner than we may think.
Vox reporters recently explored six other countries’ successes in the fight against Covid-19. We found some common themes: Nations that found success acted quickly, often having learned from previous encounters with deadly viruses.
South Korea learned from its mistakes during the MERS outbreak of 2015. After an outcry, the country built a new public health system that snapped into action in early 2020 and successfully contained Covid-19. The Senegalese were forced to shield themselves from Ebola last decade, and applied the same principles of isolating contacts to get a new virus under control.
This could be the moment for the US to examine what went wrong during Covid-19 — how a country considered to be the best-prepared in the world faltered so badly that it missed its chance to contain the virus at all.
“I fear that history will repeat itself and once COVID-19 is behind us, people will be lulled into complacency again,” Wafaa El-Sadr, a Columbia University epidemiologist who focuses on health systems, told me over email recently. “The US had the highest rating in terms of [global health security], yet our performance has been disappointing, if not shocking. Our lack of preparedness was catastrophic.”
But a combination of pandemic fatigue and the success of the US vaccine rollout — a late American triumph in the fight against the virus — threatens to erase any sense of urgency around reform.
The vaccines are phenomenally effective and were delivered in record time, though much of the world is still waiting for them, prolonging the pandemic. In any case, a vaccine alone is not a plan for future pandemics, experts told me. Even a more aggressive timeline likely means months would pass, and potentially thousands would die, before a vaccine was widely distributed enough to end the pathogen.
“We still need tests and treatments while the vaccine is being evaluated and manufactured, and in case the vaccines don’t work,” Harvard’s Marc Lipsitch says. “There was no guarantee that mRNA would work this time, and no guarantee next time either.”
The US has a long list of questions to answer after the last year’s failures. How do we quickly scale up testing? Can we perform comprehensive contact tracing? Why was America so slow in setting up clinical trials for treatments? How did Covid-19 enter the US in the first place and what could have been done to stop it at the border? Were the lockdowns of last spring — the school and business closures — necessary to stop the virus’s spread?
“I am not sure the US has learned much at all — or what it even can learn given the federal nature of the country and the balkanized state of the health care system,” William Hanage, a Harvard epidemiologist, told me.
There are still some clear lessons from more successful aspects of other nation’s responses. The question is whether the US will be able to learn them.
Lesson 1: Act fast
Part of each country’s experience with Covid-19 has been luck, from where the virus landed and when to structural factors like the population’s age.
But bad luck wasn’t determinative. South Korea was one of the first countries to face a serious Covid-19 outbreak. The country controlled it by acting decisively, with mass testing and mandatory contact tracing, having already gamed out what it would do in this scenario. Island nations, like New Zealand and Taiwan, may have enjoyed structural advantages, but they still had the virus introduced into their country multiple times during the last year. They moved quickly to snuff out new clusters and prevent the virus from escaping containment.
As David Wallace-Wells wrote in a New York magazine feature on how Western countries lost to Covid-19: “Speed was probably the most significant factor in determining national outcomes.”
“What we are realizing is you can’t stop pandemics, but you can blunt them,” Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, who is participating in the nongovernment Covid Commission Planning Group, told me. He pointed to those Asia and Oceania countries as models: “You get on top of it right away, early, comprehensively.”
South Korea passed nearly 50 public health reforms after the MERS outbreak, when they experienced the worst outbreak outside the Middle East. They invested in more hospital infection control units and the biotech sector. They ran periodic pandemic war games to walk through different outbreak scenarios and their hypothetical response. Within a week of detecting its first local cluster, in the city of Daegu, South Korea was running the most Covid-19 tests in the world; it quickly established a contact tracing program and opened up isolation centers for infected and exposed patients.
Both South Korea and Vietnam, driven by their leaders’ distrust of the Chinese government, acted before the full threat of the coronavirus was appreciated by the rest of the world. Vietnam started to close its border with China at the beginning of January and, by mid-March, it had sealed itself entirely from foreign travel.
The United Kingdom struggled to contain its epidemic, but ran some of the most effective clinical trials in the world — so much so that American companies chose to test their drugs there as the US struggled to stand up effective trials for short-term treatments. The success of the UK Recovery Trial can also be credited to speed: The program went from brainstorm to reality within just a few weeks, and researchers found the first effective Covid-19 treatment by early summer.
The Trump administration’s response, on the other hand, was marked by indecision and inconsistency. The US was paralyzed, in part because it failed to settle on a plan and a goal beyond “flattening the curve”: Were we just trying to prevent hospitals from being overwhelmed? Or were we aiming for zero Covid?
“An overriding message for me, we as a country next time need to be very clear about what strategy we are deploying,” Leana Wen, former Baltimore city health commissioner, who is participating in the Bipartisan Policy Center’s work evaluating the pandemic response, said. “There was just no strategy.”
Lesson 2: Be flexible and creative
South Korea enlisted its biopharma sector to develop diagnostic tests for Covid-19. The country promised, and delivered, rapid approval for any tests that proved reliable. The United States, on the other hand, centralized its test development to the CDC, discouraging other scientists from developing their own. So when the initial CDC test was found to be unreliable, there was no back-up plan.
We know the virus was spreading in the US in late February, but America lacked the surveillance to detect and track cases because of those testing failures. South Korea, on the other hand, approved multiple tests in the month of February and was running 10,000 tests per day by the end of that month. It wouldn’t be until mid-April that the US would surpass South Korea in per capita testing capacity, long after Korea had contained its outbreak and the US had lost control of its own.
Vietnam, likewise, defied public health orthodoxy and closed its borders at a time when the prevailing expert consensus was that border control measures were ineffective and punitive. Over time, Vietnam seems to have been proven right: Its highest single-day count of recorded cases throughout the pandemic was only 110.
The German state of Jena quickly adopted a mask mandate after one small hospital study suggested they were effective, though the broader expert consensus had not yet embraced mask-wearing.
“In a pandemic, you cannot wait for the evidence,” Mathias Pletz, director of the Institute for Infectious Diseases and Infection Control and a doctor at Jena University Hospital, told Vox’s German Lopez. “Sometimes, you have to make pragmatic decisions.”
There is still, today, much even the experts don’t understand about Covid-19. Countries have to be willing to change their thinking as the facts on the ground change.
“I think the one thing that overlays all of this discussion is humility with regard to this virus,” Osterholm said.
Lesson 3: Suppression is everything
The countries that acted quickly and gave themselves a chance also found it easier to adapt as the pandemic wore on. South Korea and Senegal have seen second and third waves of infections, but they have been able to react and manage them because they’d succeeded in crushing their first wave.
In the US, however, the virus quickly escaped containment, and the country lost its window to suppress it. Covid-19 has been widespread ever since, with the US never recording fewer than 20,000 new daily cases since last April.
It’s easier to be nimble in your response once you’ve gotten the virus somewhat under control. The more virus there is, the harder it is to justify experimenting. And the longer the virus is circulating, the bigger the risk that it will eventually break through even in countries that manage to contain it at first.
Every country we examined with a drawn-out pandemic struggled. Germany initially succeeded in getting the public to accept wearing masks and following social distancing. But as the pandemic dragged on, adherence slacked and cases started to rise. Its response plan only worked if people would follow the guidance. Senegal is now facing another year or more until everyone is fully vaccinated, taxing its grassroots public health campaign.
In the US, though most people did wear masks and practice social distancing at first, those habits became more and more politically polarized over the year. In April, Democrats and Republicans were almost equally likely to say the coronavirus was a major threat to the US. But by August, there was a chasm, according to the Pew Research Center: While 85 percent of Democrats said it was a major threat, just 46 percent of Republicans agreed.
People’s resolve faltered as the pandemic dragged on. A raging outbreak exacerbated political divisions.
“The next pandemic is going to be just as vulnerable to the response of human behavior as this one,” Osterholm said.
Competence builds trust. South Koreans had lived through SARS-1 and MERS, and they largely trusted the government’s plan to get the new virus under control, even if they had to sacrifice some privacy. Senegal relied on a grassroots campaign that involved community leaders going into people’s homes, explaining to them the nature of the threat and what must be done to try to mitigate their risk. British patients largely approve of the National Health Service and, when asked to take part in an experimental trial when hospitalized with Covid-19, more than 35,000 of them said yes.
The lack of any clear plan or goal made it hard to maintain cohesion in the US. (Contrast that with Australia, too, where a more explicit “zero Covid” roadmap found success.)
“Having that kind of leadership and the buy-in from at least the vast majority of the country on a goal, that should be the lesson No. 1,” Wen said.
The US is capable of decisive action. Inaction is not inevitable.
Some experts are quietly trying to do the work of figuring out what went wrong.
The Covid Commission Planning Group is being led by Philip Zelikow, who was executive director of the 9/11 Commission, supported by a number of top philanthropic groups and advised by many of the top public health experts in academia. Their goal is to do some of the legwork necessary to set up a national Covid-19 commission if Congress or the White House decides to authorize it, or to continue that work on their own if the government does not take up the task.
Groups like the Bipartisan Policy Center and Trust for America’s Health are working with experts and state and local health officials to evaluate America’s response and offer their recommendations for better preparedness.
Some of the experts I spoke with believe the US does need an official body, something similar to the 9/11 Commission, with subpoena power and the ability to act on its findings.
“An important retrospective needs to be done. Why did this fail?” Albert Ko, dean of the Yale School of Public Health, told me.
He added that it should be “done with authority.”
“We have to hold people responsible,” Columbia’s El-Sadr told me. “We owe it to the hundreds of thousands of people who lost their lives or their loved ones, as well as the horrific indirect effects of this pandemic.”
The US has successfully tackled public health challenges before, though “it takes us time and it’s slow,” as Ko put it to me. The progress on HIV/AIDS, after a disastrous initial response in the 1980s, is a testament to America’s ability to get its act together on a major public health problem, Ko said.
Even during this pandemic, the United States has been capable of decisive and ambitious actions — to save the economy. As Dylan Matthews wrote in the final story of the Pandemic Playbook series:
A detailed comparison suggests that the US had the strongest economic response to the pandemic, in terms of providing income to its citizens during lockdown and ensuring a strong, rapid recovery as the economy began to reopen.
“The US will come out of this economically better than any country that was similarly affected by the virus,” Jason Furman, an economist at Harvard and former chair of Obama’s Council of Economic Advisers, says.
But that economic success does not erase the pain of 575,000 lives lost. That same audacity that cut poverty and hunger in the middle of a pandemic might also be harnessed the next time to better control an outbreak in the first place. Such drastic fiscal measures might not be necessary — as Vietnam, one of the standout economic performers of 2020, found — and more people would survive.
This work would not be easy. America is a massive and politically divided country, with a complex federalist system of government. Structural problems — a lack of universal health care, pervasive chronic health problems, and a decentralized health system — could end up weakening our resistance to new diseases no matter what containment protocols are put in place.
But the cost of inaction is too high. The current pandemic is not over, and, already, the US risks doing too little to stamp out the coronavirus elsewhere. But there should also be an urgency about preparing for the next outbreak because we don’t know when it will come. In South Korea, less than five years passed between MERS and Covid-19.
“The biggest mistake we can make,” Ko said, “is to think we’ve defeated Covid, so we pack our bags and move on.”