America is first, and not in a good way. Last week, the United States set a grim record, surpassing all other nations in the reported number of people infected with the coronavirus that causes COVID-19. As of this morning, officials have documented nearly 190,000; the death toll neared 4100. Even President Donald Trump—who just 1 month ago claimed the virus was "very much under control"—has warned that the pandemic is about to get much worse.
To limit the damage, Trump announced on 29 March that federal recommendations to practice physical distancing would remain in place at least through the end of April, dropping his much-criticized push for a faster return to business as usual. In the meantime, officials across the nation are scrambling to find enough ventilators, protective gear, and supplies for hospitals overwhelmed with COVID-19 patients—or about to be. Many state governors ratcheted up restrictions intended to slow the pandemic, imposing stay-at-home orders that some said could last into June.
Despite such actions, the U.S. pandemic response remains a work in progress—fragmented, chaotic, and plagued by contradictory messaging from political leaders. "We don't have a national plan," says epidemiologist Michael Osterholm of the University of Minnesota, Twin Cities. "We are going from press conference to press conference and crisis to crisis … trying to understand our response."
The United States is "in a reactive mode," says Jeremy Konyndyk, a senior policy fellow at the Center for Global Development who headed the U.S. Agency for International Development's disaster response efforts under former President Barack Obama. "This is a virus that punishes delay. … We're still chasing the virus."
To catch up, Osterholm and other researchers have released a flurry of battle plans in the past week. Many officials have welcomed the recommendations and signaled their support. But the question now is whether the United States—a patchwork of more than 50 state and territorial governments marked by political polarization and a history of fierce resistance to centralized authority—can follow through.
The urgency is great. A review of 12 mathematical models conducted by federal scientists concluded the United States is likely to see millions of people infected. The death toll is now likely to exceed 100,000 even with distancing and other measures, Deborah Birx, White House coronavirus response coordinator, has said repeatedly. Some experts fear even those numbers are too optimistic, given that outbreaks are now poised to explode in places—including Louisiana, Michigan, and Florida—that are ill-prepared for the surge of people needing hospitalization.
The new battle plans generally agree several moves need to be taken immediately. Federal, state, and local governments must consistently urge, if not order, most people to stay home and keep their distance from others. Federal officials must take a stronger role in directing medical supplies to areas most in need. Testing for the virus must accelerate and expand so that people who are infected can be quarantined.
But there are numerous obstacles. Testing could soon be hampered by a shortage of reagents, caused in part by the disruption of supply chains in Asia, Osterholm notes. Instead, health officials may have to rely on less precise illness surveillance—documenting the frequency of COVID-19 symptoms to estimate the number of cases.
Persuading more than 320 million people in the United States to take the pandemic seriously, meanwhile, will require a radical change in messaging from political leaders at every level, from the White House to city halls. "Rule one of communication in a pandemic is [to] have a message and stick to it," says political scientist Scott Greer of the University of Michigan, Ann Arbor, who has studied the U.S. response to the 2014 Ebola epidemic. So far, that's been the exception, as Trump and state and local officials have delivered a cacophony of conflicting messages, from indifference to alarm.
"Yesterday, I was supposed to be in church on Easter, and now all of a sudden New York's under quarantine," says biologist Carl Bergstrom of the University of Washington (UW), Seattle, referring to Trump's vacillating messages over the past few weeks. The lack of clarity, he says, is "hemorrhaging that reservoir of trust" needed to persuade the public to immediately adopt nonpharmaceutical interventions (NPIs) such as physical distancing. "When you have a pandemic where you don't have pharmaceuticals or vaccines, you're restricted to NPIs. And you've got this reservoir of trust that you can use to deploy NPIs."
Governors go their own ways
The absence of strong nationwide coordination has highlighted the division of legal power between the federal and state governments, observers say. As the pandemic has deepened, governors have gone their own ways, with some adopting stringent measures and others shrugging off the need for immediate action.
The White House, for its part, has signaled it will let governors make their own decisions, in part because they have greater control of on-the-ground actions. For example, governors, not federal officials, typically hold police powers to shut businesses and enforce curfews. But many governors and local officials are reluctant to invoke those powers and suffer the political costs without clear direction from above, Greer says. Political division over the pandemic has also hampered decisive action: Polls show Republicans perceive the threat as less serious than Democrats and independents.
To see the consequences of such divides, Greer points to Florida, where Governor Ron DeSantis (R) delayed ordering a statewide closure of beaches and other facilities, apparently unwilling to cross the powerful tourism industry—and his political base. DeSantis "is dependent on a large bloc of voters who are Republicans and many are very pro-Trump. If I've got Donald Trump saying essentially, 'Don't lockdown,' what political cover do I have?" Greer says. (Yesterday, DeSantis said the White House coronavirus task force had not sent him specific recommendations, but, "If they do, that's something that would carry a lot of weight with me." Epidemiologists predict the dithering will worsen the outbreak in Florida, which now has more than 7000 cases.)
New research suggests partisan leanings might be influencing pandemic response in other states, too. In a preprint released on 28 March, researchers at UW found that states with a Republican governor or where Trump fared better in the 2016 election were less likely to have instituted a range of social distancing measures than states led or dominated by Democrats. Although that study comes with plenty of caveats, it is clear that, with a few exceptions, Republican governors have been more reluctant to impose strict restrictions.
Bridging such divisions will be essential if the United States is to defeat the coronavirus, says Harvard University epidemiologist William Hanage. "The closest comparison here, in terms of national mobilization, is a war. And there is no way the United States would fight a war as 50 separate states."
Some public health experts are dismayed that the U.S. Centers for Disease Control and Prevention (CDC), which has prominently provided national leadership in past outbreaks, hasn't been more visible. "In every other public health emergency this country has faced since the CDC was created 75 years ago, it has played a central role," says Thomas Frieden, a former director of the agency under Obama. "Not having a central role here is like fighting with one hand tied behind your back. I'll feel much safer if and when it becomes clear that [CDC] is playing a key role in developing policy options based on science and communicating the reasons for those policy decisions to the public," Frieden says.
Julie Gerberding, who led CDC between 2002 and 2009, notes that "when you poll Americans about who they trust, CDC still ranks as the most trusted source of this kind of information. … That's something we should use at a time when people are frightened and really want to get reliable information firsthand."
What happens after the pandemic slows?
Even if lockdowns succeed at halting the virus, as they have in China, the country will next have to marshal massive resources to monitor for new outbreaks and quickly contain them, Konyndyk says. Identifying cases and contacts and isolating them will require a huge increase in public health workers at the local level. "Most of what we would need to do to transition away from large-scale social distancing is not in place, and there don't appear to be plans to put it in place," he says.
Those measures would include intensive testing to monitor for new cases, swift quarantines, and tools such as cellphone tracking to find anyone who has crossed paths with an infected person. "Contact tracing has been assumed to be something you can't take to scale," Konyndyk says. "I think the lesson of South Korea and China is you have to find some way to scale that."
Although state and local governments employ most of the public health workers on the front lines, the challenge is too big to leave it to them, Konyndyk says. He recently spoke with an official in rural Georgia who described having one public health worker for the entire county. "This is something that purely from a resource perspective cannot be left to the states," he says. "This needs to look more like a domestic Peace Corps or AmeriCorps or Teach for America." (Some have suggested governors could assign the tracing task to National Guard troops.)
Ann Bostrom, a risk communications expert at UW, believes government officials will need to become more transparent. She's concerned that some U.S. counties haven't been releasing even basic information about new COVID-19 cases, such as the patient's city of residence. (In contrast, countries such as South Korea sent cellphone alerts to the public informing them of new cases in their neighborhoods.) "People need to judge their exposure," Bostrom says. "They need to know what's going on."
With reporting by Warren Cornwall, Jocelyn Kaiser, Kai Kupferschmidt, David Malakoff, and Kelly Servick.