One of the most lethal leadership failures in modern times unfolded in South Africa in the early 2000s as AIDS spread there under President Thabo Mbeki.
Mbeki scorned science, embraced conspiracy theories, dithered as the disease spread and rejected lifesaving treatments. His denialism cost about 330,000 lives, a Harvard study found.
None of us who wrote scathingly about that debacle ever dreamed that something similar might unfold in the United States. But today, health experts regularly cite President Trump as an American Mbeki.
“We’re unfortunately in the same place,” said Anne Rimoin, an epidemiologist at U.C.L.A. “Mbeki surrounded himself with sycophants and cost his country hundreds of thousands of lives by ignoring science, and we’re suffering the same fate.”
One role of journalism is to establish accountability, and that’s particularly important before an election. Trump says he deserves an A-plus for his “phenomenal job” handling the coronavirus, but the judgment of history is likely to be far harsher.
“I see it as a colossal failure of leadership,” said Larry Brilliant, a veteran epidemiologist who helped eliminate smallpox in the 1970s. “Of the more than 200,000 people who have died as of today, I don’t think that 50,000 would have died if it hadn’t been for the incompetence.”
America Wrote the Pandemic Playbook, Then Ignored It.
The U.S. spent 15 years preparing for the coronavirus. Why did we handle it so badly?
There is one graph that has to do with the coronavirus that blows my mind. It looks like this. This graph shows coronavirus cases in the United States versus the European Union. Do you see what happens here? Everyone has a surge around the same time, but while the European Union dramatically drops, the United States plateaus for a little bit and then skyrockets. This is shocking to me because the United States is perhaps the most prepared country on earth for a pandemic. The U.S. government has an actual playbook that tells us what we need to do in the case of a pandemic. Not to mention, it’s like the richest country in the world, with the best health institution on earth, the C.D.C., which literally fights pandemics in other countries and teaches even our peers how to do epidemiology. And yet, you look at this graph and you wonder, what happened? I want to piece together a timeline to find out how this happened. How does the country with the most money and experts and the C.D.C. and a literal pandemic playbook end up with so many deaths, and end up with a graph that looks like this? [MUSIC PLAYING] “The countries best and worst prepared for an epidemic, we’re rated No. 1 at being prepared.” “Europe has largely contained the virus.” “Nearly 200,000 Americans dead from Covid.” “We’re doing great. Our country is doing so great.” [MUSIC PLAYING] As I piece together this timeline, I’m going to need some help. And for that, I turned to Nick Kristof. He’s a Pulitzer Prize-winning journalist. He speaks Mandarin. He’s been all around the world, reporting on and explaining public health crises for decades. I’ve always felt that I come from the country that helped invent public health. And now, my own country, arguably the most powerful country in the history of the world, has taken a challenge that we kind of knew what to do with, and just blowing it in ways that cost so many lives so needlessly. So if I want to understand how this all played out and how we got a graph that looks like this, where do we start? Let’s go way back, before we were paying any attention to this. I figured our timeline would start somewhere in January of 2020, but Nick told me to go back even further, way back to 2005. That summer, President George Bush was on vacation at his ranch in Texas when he got ahold of this book. It was about the Spanish flu that killed tens of millions of people back in 1918. This book freaked George Bush out. He got back to Washington, and immediately got to work putting together a plan, a step-by-step guide of what the U.S. should do if a pandemic came to our country. He called it a playbook for pandemic response. President Obama developed a playbook of his own that had very specific plans in place on what the government should do in the case of a disease outbreak, including specifically citing coronaviruses. This pandemic playbook was then passed on to the Trump administration. “We left them the detailed playbook, which specifically cited novel coronaviruses. Short of leaving a flashing neon sign in the Situation Room saying. ‘Watch out for a pandemic,’ I’m not sure what more we could have done. No one knew when the big pandemic would come, what it would look like. But even still, the previous two administrations were obsessed with making sure we were ready. “But if we wait for a pandemic to appear, it will be too late to prepare.” So now let’s fast forward to when the big one did hit. And that part of the story happens on the last day of 2019. On Dec. 31, 2019, a report of 44 people with pneumonia comes in from a fish market in China. So at this point, it seems like this is a fairly small deal. It’s 40 people with pneumonia in China. So who in the U.S. would even care or have this on their radar in the first place? `Epidemiologists were on top of this immediately in early January, about the risk this might be something serious. The World Health Organization was communicating with the C.D.C., the C.D.C. was communicating with the administration. And indeed, it appears to have entered the president’s daily brief in early January. “We’re going to begin here with the outbreak of a mystery virus in China that now has the World Health Organization on edge.” I heard that China was concealing information. And didn’t that stop American experts from getting a full picture on what was happening? Yes, absolutely. China behaved irresponsibly and was concealing information. But we had channels into China, into the World Health Organization. We were getting feedback about what was really happening. It’s the middle of January, and coronavirus is potentially a thing of concern. Didn’t President Trump get on a call with President Xi Jinping? Yeah, they did. They had an important phone conversation then. But what they talked about was trade. But it just doesn’t get any bigger than this, not only in terms of a deal. Tell President Xi, I said, President, go out, have a round of golf. This was a huge, huge missed opportunity. OK, so we miss these first two opportunities of taking those early reports really seriously and that call with Xi Jinping, which potentially could have been a health collaboration to stop the virus. But it was still early on. The coronavirus hadn’t even been detected in the United States yet. “Gwen Stefani and Blake Shelton not quite yet engaged, right? Definitely not married.” So while the United States was preparing for the Grammys and the Super Bowl, the coronavirus quietly came into our country. The first case is reported around Seattle on Jan. 21. At this point, Trump has been hearing more and more warnings from his intelligence briefings, as well as from the C.D.C. And as the news breaks of the first case in the U.S., Trump is on his way to Switzerland to speak at the World Economic Forum, where he talks a lot about China, but just not about the virus. “Our relationship with China right now has probably never been better.” Man, just like imagine what could have happened at this moment. End of January, the president reads his briefing. He’s like, oh, whoa, this is real. This is spreading globally. We need to get serious about this. He calls Xi Jinping back, and he’s like, hey, Xi Jinping, I know we’ve been talking a lot about trade, but why don’t we talk about this virus that’s coming from your country to mine? What do we need to do to solve it? And Xi Jinping is like, yeah, you’re right, let’s do it. Trump gets up to tell the nation a pandemic is coming and that we’ve got to be ready for it, but don’t worry because we’re super prepared. We have all the plans. We have a literal pandemic playbook. We have money. We have experts. We can squash this. “Have you been briefed by the C.D.C.?” “I have.” “Are there words about a pandemic at this point?” “No, not at all, and we have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine.” There was some hope that we could have actually eliminated it in early January and avoided this catastrophe for the world. Instead, our leaders, and our citizens, were completely focused on other things. “The Grammy Awards are finally here.” “CNN breaking news.” “Kobe Bryant— Has been killed in a helicopter crash.” “Special coverage of the impeachment trial.” “Did nothing wrong. Did nothing wrong.” [CHEERING AND APPLAUSE] So by the end of January, the virus has now arrived to the United States. There are reported cases here. We are now aware that it is a problem. I guess I’m wondering, like, what is the response? What should the U.S. have done in that moment? The first step in response to a disease like this is to find out where it is, which means you develop a test. “We have 12 cases— 11 cases. And many of them are in good shape now, so.” The United States and South Korea had their first reported case of Covid-19 on the same day. A month later, South Korea, who, by the way, has like a fifth the number of people that the United States has, had tested 13,000 people. Here in the U.S., we had tested 3,000. “I’m not afraid of the coronavirus, and no one else should be that afraid, either.” A reminder that all of these steps, the testing was not a new idea. This was in the old playbooks. Testing and surveillance of where the virus is is like a fundamental step in responding to a pandemic. “It’s mind-blowing that because you can’t get the federal government to improve the testing because they just want to say how great it is.” “And the testing is not going to be a problem at all.” “So this struggle to develop a test, wasn’t this more of like an issue with the F.D.A. and the C.D.C. and H.H.S. sort of feuding with each other about who was going to do the test? At one level, the way we fumbled the development of testing in the United States was a result of bureaucratic infighting. But if President Trump had shown the same passion for getting a test that he showed for building a wall or for backing hydroxychloroquine to treat the coronavirus, we would have had a test all ready to go and all around the country by the end of January or beginning of February. “Hydroxychloroquine, we’re just hearing really positive stories. I happen to be taking it. I think it’s good. I’ve heard a lot of good stories.” Sierra Leone in West Africa had an effective test before the United States did. And so as a result, we didn’t know where the virus was. We were blind. “They’re working hard. Looks like, by April, you know, in theory, when it gets a little warmer, it miraculously goes away. Hope that’s true.” And then, Americans started to die. [MUSIC PLAYING] It started with just one in February. But soon one became 10 became 100, and soon it was 100 per day, and then 200 per day, and 500 per day. And now, we’re in the thousands. And then the month of April was here. And in one month, 57,000 Americans died from Covid-19. So was there a moment for you when you realized that this was spiraling out of control? I visited a couple of emergency rooms and I.C.U.s early in the crisis. And this was when people are still talking about how the coronavirus is like the flu. And meanwhile, these emergency rooms are just swamped. The doctors and nurses are traumatized. “I need a vent. I need a vent.” “I need a ventilator.” And the strength of those doctors contrasted with just the fecklessness of our political leadership. “And again, I said last night, we did an interview on Fox last night — You have to be calm. It’ll go away.” [BEEPING] “Many of the places are really in great shape. They really have done a fantastic job. We have to open our country. We cannot let the cure be worse than the problem itself. We’re not going to let the cure be worse than the problem. We have to be calm. It’ll go away.” I’ve seen a lot of grim diseases, but the combination in Covid of such large numbers dying, all alone because their loved ones can’t go with them, saddens me, but it also just enrages me because this was so unnecessary. OK, so let’s realize where we are. It’s April, and we really didn’t get the early response down. We didn’t get testing figured out. But now, we’re in the thick of a crisis. People are dying. There is a crisis in the United States. So the big question here is, what do you do once you’re actually in the thick of this crisis? And in my conversations with Nick, and in all of these playbooks, there’s this one theme that just keeps coming up, which is health communications. Which sort of just sounds like a boring P.S.A. from the government. “Larry, you know this simple exercise can help you stay healthy.” I didn’t even know what that meant to begin with. But as I looked into it, I started to realize that there was something there. In fact, the Bush playbook says that the need for timely, accurate, credible and consistent information that is tailored to specific audiences cannot be overstated. So it turns out that, when a country is devolving into pandemic chaos, one of the most important things, if not the most important thing, a government can do is communicate to its citizens how important and risky this is. “And the 15, within a couple of days, is going to be down to close to zero.” ”Staying at home leads to death also.” “Are you telling the Americans not to change any of their behaviors?” “No, I think you have to always— look, I do it a lot anyway, as you probably heard, wash your hands, stay clean. You don’t have to necessarily grab every handrail, unless you have to. You know, you do certain things that you do when you have the flu. I mean, view this the same as the flu.” “The C.D.C. is recommending that Americans wear a basic cloth or fabric mask. This is voluntary.” “It’s easy to focus just on the failures of President Trump, but look, there is plenty of failure to go around, and it involves blue states as well as red ones. New York was particularly hard hit, in part because New York leaders initially did not take this seriously enough. Mayor Bill de Blasio tweeted that people should get on with their lives and go out on the town. It would be difficult to think of any signal that a leader could possibly send that was more wrong and more lethal than that one. “Tonight, FEMA is bringing in hundreds of ambulances to help with record-breaking 911 calls in New York. This morning, as an emergency field hospital is being built in iconic Central Park —” “All of those beds, all 20,000, will have to be turned into intensive care beds to focus on Covid-19 patients who are really, really sick.” We simply blew it. And the result was that Americans did not take the virus as seriously as they did in other countries. OK, so the U.S. blew it when it came to health communications, whereas Europe and many countries around the world got it right. I want to know what the actual proof is that that’s the key to fixing it. Is it just because the playbook said it or because Nick said it? Well, I got my hands on some data that really helped me understand this. Google collected data from a bunch of people’s phones to track before the pandemic and during the pandemic how people’s movement changed. If you assemble that data onto a map, you see something really interesting. If you look over here, you can see these dark blue areas, which represent countries that shut down by up to 80 to 100 percent. This means they weren’t going out, they weren’t shopping, they weren’t going to cinemas. They were staying home like the government implored them to. Austria shut down by 64 percent, France by 80 percent, Ireland by 83 percent. All of this movement shut down in the name of beating the virus. Meanwhile, over here in the United States, we’re at about 39 percent on this same day in late April. We never really shut down. One of the basic things about this pandemic is that, if people really do take it seriously, and for four weeks or six weeks do adhere to stay-at-home orders in the way Europe did, with 90 percent of the travel shut down, then the virus is stopped in its tracks. Other countries did it, one after the other. The U.S. was never able to do that. We fought the virus, and the virus won. Again, I can’t help but think of what could have happened if our president got up and said — “My fellow Americans —” This is going to be very difficult. We have to shut down our entire country. Not just the urban spots, the entire country. It’s going to be painful, but it will help us reopen our economy quicker and it will help save American lives. But that didn’t happen. I remember looking at the graphs in April and watching daily deaths climb so rapidly, just skyrocketing. The natural response would’ve been to say, whoa, slow down, we need to really tighten things up and learn from other countries that have done better. But instead, the very next day — The president, remarkably, attacks stay-at-home orders in states around the country and encouraged supporters to liberate states like Michigan. This was an obliviousness to science and public health advice, a lack of empathy for those who were dying. I don’t know what to call that failure except an example of extraordinary incompetence. I find that truly heartbreaking. This is where the graph starts to blow my mind, and really starts to get to the heart of my big question of why these lines look so different. Watch how the Covid cases sort of plateau in the U.S., but in Europe, cases start to look like this. Our peers buckled down and did the hard work to get ahead of the virus by following basic pandemic measures articulated in all of the plans, including our own playbooks. They saw the results of that. The U.S., on the other hand, plateaus for a bit, and by mid-June, starts to skyrocket again. “In the nation’s three most populous states, things are going from bad to worse.” “California, Texas and Florida are in crisis.” “Today, reporting more than 5,000 Covid-related hospitalizations.” And even though Europe is having an uptick now, you need to look at this gap. This gap represents a lot of unnecessary suffering, and the death of tens of thousands of Americans. I understand that we’re going to make mistakes. This is hard stuff. Lots of countries made mistakes. But what has troubled me is that we just didn’t learn from them. We weren’t self-correcting. Instead, we doubled down on mistakes. And then, we just gave up. OK, so I now feel like I have a much better understanding of why our graph looks like this compared to other countries. It has a little bit to do with those early mistakes and whatever, but those are sort of forgivable. Instead, it’s what happened once the pandemic was here and raging and killing Americans. Instead of having leaders who told us what we needed to do to make it through this risky and uncertain time, we had leaders that denied that this was even a big deal, and then who eventually just gave up on the whole thing. The death certificates of more than 150,000 Americans will say something like Covid-19. In a larger sense, what should be written on those death certificates as the cause of death is “incompetence.”
There’s plenty of blame to go around, involving Democrats as well as Republicans, but Trump in particular “recklessly squandered lives,” in the words of an unusual editorial this month in the New England Journal of Medicine. Death certificates may record the coronavirus as the cause of death, but in a larger sense vast numbers of Americans died because their government was incompetent.
As many Americans are dying every 10 days of Covid-19 as U.S. troops died during 19 years of war in Iraq and Afghanistan, and the economists David Cutler and Lawrence Summers estimate that the economic cost of the pandemic in the United States will be $16 trillion, or about $125,000 per American household — far more than the median family’s net worth. Then there’s an immeasurable cost in soft power as the United States is humbled before the world.
“It’s really sad to see the U.S. presidency fall from being the champion of global health to being the laughingstock of the world,” said Devi Sridhar, an American who is a professor of global health at the University of Edinburgh. “It was a tragedy of history that Donald Trump was president when this hit.”
The United States has made other terrible mistakes over the decades, including the Iraq war and the war on drugs. But in terms of destruction of American lives, treasure and well-being, this pandemic may be the greatest failure of governance in the United States since the Vietnam War.
America Was the Leader in Pandemic Preparedness.
The paradox is that a year ago, the United States seemed particularly well positioned to handle this kind of crisis. A 324-page study by Johns Hopkins found last October that the United States was the country best prepared for a pandemic.
Credit for that goes to President George W. Bush, who in the summer of 2005 read an advance copy of “The Great Influenza,” a history of the 1918 flu pandemic. Shaken, Bush pushed aides to develop a strategy to prepare for another great contagion, and the result was an excellent 396-page playbook for managing such a health crisis.
The Obama administration updated this playbook and in the presidential transition in 2016, Obama aides cautioned the Trump administration that one of the big risks to national security was a contagion. Private experts repeated similar warnings. “Of all the things that could kill 10 million people or more, by far the most likely is an epidemic,” Bill Gates warned in 2015.
Trump has accused the Obama administration of depleting stockpiles of medical supplies so that “the cupboard was bare.” It’s true that the Obama administration did not do enough to refill the national stockpile with N95 masks, but Republicans in Congress wouldn’t provide even the modest sums that Obama requested for replenishment. And the Trump administration itself did nothing in its first three years to rebuild stockpiles.
We in the media also blew it: We didn’t do enough to warn about the risks of pandemics.
Trump argues that no one could have anticipated the pandemic, but it’s what Bush warned about, what Obama aides tried to tell their successors about, and what Joe Biden referred to in a blunt tweet in October 2019 lamenting Trump’s cuts to health security programs and adding: “We are not prepared for a pandemic.”
The First Alarm Bells From Wuhan
When the health commission of Wuhan, China, announced on Dec. 31 that it had identified 27 cases of a puzzling pneumonia, Taiwan acted with lightning speed. Concerned that this might be an outbreak of SARS, Taiwan dispatched health inspectors to board flights arriving from Wuhan and screen passengers before allowing them to disembark. Anyone showing signs of ill health was quarantined.
If either China or the rest of the world had shown the same urgency, the pandemic might never have happened.
In the United States, the Centers for Disease Control and Prevention issued a notice about the Wuhan outbreak on Jan. 1, but not much else happened for a time. In China, President Xi Jinping issued orders on Jan. 7 for handling the coronavirus, but they were inadequate. If, at that time or soon after, Xi had ordered a more modest version of the Wuhan lockdown that was to come, it is possible that the virus could have been stifled before it spread around the globe.
Instead, Wuhan held a banquet for 40,000 people on Jan. 18, and by the time the lockdown was ordered on Jan. 23, some five million people had already left Wuhan for the Chinese New Year. In hindsight, two points seem clear: First, China initially covered up the scale of the outbreak. Second, even so, the United States and other countries had enough information to act as Taiwan did. The first two countries to impose travel restrictions on China were North Korea and the Marshall Islands, neither of which had inside information.
That first half of January represents a huge missed opportunity for the world. If the United States, the World Health Organization and the world media had raised enough questions and pressed China, then perhaps the Chinese central government would have intervened in Wuhan earlier. And if Wuhan had been locked down just two weeks earlier, it’s conceivable that this entire global catastrophe could have been averted.
The Defiance of Science
Perhaps the original sin of America’s response to the coronavirus came with the bungling of testing.
Without testing, health officials fight an opponent while blindfolded. They don’t know where the virus lurks, and they can’t isolate those infected or trace their contacts.
But the C.D.C. devised a faulty test, and turf wars in the federal government prevented the use of other tests. South Korea, Germany and other countries quickly developed tests that did work, and these were distributed around the world. Sierra Leone in West Africa had effective tests before the United States did.
Trump supporters note, correctly, that within the United States, the states with the highest mortality rates have been Democrat-led: New Jersey has had the most deaths per capita, followed by New York. It’s true that local politicians, Democrats and Republicans alike, made disastrous decisions, as when Mayor Bill de Blasio of New York City urged people in March to “get out on the town despite coronavirus.” But local officials erred in part because of the failure of testing: Without tests, they didn’t know what they faced.
It’s unfair to blame the testing catastrophe entirely on Trump, for the failures unfolded several pay grades below him. Partly that’s because Trump appointees, like Robert Redfield, director of the C.D.C., simply aren’t the A team.
In any case, presidents set priorities for lower officials. If Trump had pushed aides as hard to get accurate tests as he pushed to repel refugees and migrants, then America almost certainly would have had an effective test by the beginning of February and tens of thousands of lives would have been saved.
Still, testing isn’t essential if a country gets backup steps right. Japan is a densely populated country that did not test much and yet has only 2 percent as many deaths per capita as the United States. One reason is that Japanese have long embraced face masks, which Dr. Redfield has noted can be at least as effective as a vaccine in fighting the pandemic. A country doesn’t have to do everything, if it does some things right.
Yet in retrospect, Trump did almost everything wrong. He discouraged mask wearing. The administration never rolled out contact tracing, missed opportunities to isolate the infected and exposed, didn’t adequately protect nursing homes, issued advice that confused the issues more than clarified them, and handed responsibilities to states and localities that were unprepared to act. Trump did do a good job of accelerating a vaccine, but that won’t help significantly until next year.
Trump’s missteps arose in part because he channeled an anti-intellectual current that runs deep in the United States, as he sidelined scientific experts and responded to the virus with a sunny optimism apparently meant to bolster the financial markets.
The Coronavirus Outbreak ›
Words to Know About Testing
Confused by the terms about coronavirus testing? Let us help:
- Antibody: A protein produced by the immune system that can recognize and attach precisely to specific kinds of viruses, bacteria, or other invaders.
- Antibody test/serology test: A test that detects antibodies specific to the coronavirus. Antibodies begin to appear in the blood about a week after the coronavirus has infected the body. Because antibodies take so long to develop, an antibody test can’t reliably diagnose an ongoing infection. But it can identify people who have been exposed to the coronavirus in the past.
- Antigen test: This test detects bits of coronavirus proteins called antigens. Antigen tests are fast, taking as little as five minutes, but are less accurate than tests that detect genetic material from the virus.
- Coronavirus: Any virus that belongs to the Orthocoronavirinae family of viruses. The coronavirus that causes Covid-19 is known as SARS-CoV-2.
- Covid-19: The disease caused by the new coronavirus. The name is short for coronavirus disease 2019.
- Isolation and quarantine: Isolation is the separation of people who know they are sick with a contagious disease from those who are not sick. Quarantine refers to restricting the movement of people who have been exposed to a virus.
- Nasopharyngeal swab: A long, flexible stick, tipped with a soft swab, that is inserted deep into the nose to get samples from the space where the nasal cavity meets the throat. Samples for coronavirus tests can also be collected with swabs that do not go as deep into the nose — sometimes called nasal swabs — or oral or throat swabs.
- Polymerase Chain Reaction (PCR): Scientists use PCR to make millions of copies of genetic material in a sample. Tests that use PCR enable researchers to detect the coronavirus even when it is scarce.
- Viral load: The amount of virus in a person’s body. In people infected by the coronavirus, the viral load may peak before they start to show symptoms, if symptoms appear at all.
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