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Before the COVID-19 pandemic began, leading health experts viewed the United States as one of the countries best positioned to handle an infectious disease outbreak. The 2019 Global Health Security Index, which benchmarks each nation’s health security preparedness, ranked the United States the number one country out of 195. Now, as the world enters the third year of COVID-19, it is clear the United States was in fact ill-prepared for a real pandemic.
The number of Americans reported to have died from COVID-19 is 63 percent higher than any other high-income country. The U.S. death rate stands at 295 deaths per 100,000 people, compared with 245 per 100,000 in the United Kingdom, 152 per 100,000 in Germany, and 99 per 100,000 in Canada. There are many reasons for the faltering U.S. response, which will be dissected in detail over the coming years. They range from communication challenges, which have fueled an avalanche of misinformation, to a vaccine campaign that trails behind Australia, Canada, and many European countries. The fragmented public health infrastructure in the United States wasn’t built or resourced to withstand or respond to large-scale public health emergencies. And then there are the challenges with the U.S. health care system itself, problems that existed long before COVID showed up: access to care, health inequities, and the underlying health conditions of Americans.
If one surveys the world to see how different countries responded to the multiple waves of COVID-19 over these last two years, there are some practices that shine brighter than the rest. No one country has had a perfect pandemic response. China’s zero-COVID policy, for example, has resulted in low morbidity and mortality rates for the first two years of the pandemic, but it has come at a hefty price. It involves social isolation, a continuous cycle of lockdowns, and curtailment of individual freedoms. And now, with the highly contagious Omicron variant—and all its sublineages, including the more transmissible BA.2 variant—it looks highly unlikely that this strategy will continue to work. Other regions that successfully mitigated the virus throughout the first two years are now dealing with large case counts and increasing deaths, such as in South Korea and Hong Kong. Although the United States can learn a great deal from COVID responses around the world, it should focus on a few important measures that would be politically and legally possible for it to carry out, including addressing misinformation and doing better on science communication, fostering trust in government, and improving the U.S. public health data infrastructure, to name a few.
For most of the pandemic, the United States was not doing enough testing. But with the expansion of manufacturing and the increased distribution of rapid antigen tests, U.S. officials can now credibly claim that anyone who wants a test can get one. That wasn’t the case in November, as the Omicron variant was taking off in the United States and demand soared. That demand has since tapered off, contributing to the abundance of tests now available. Ubiquitous testing, however, was available in most of Europe much earlier, and often at minimal or no cost. The value of rapid testing as a public health tool was recognized much earlier in many European and Asian countries. It was used to identify infected people, cut down on chains of transmission, and reduce quarantine periods for international travelers. This framework for testing, along with removing barriers such as cost and access, made rapid antigen testing as routine as brushing one’s teeth in places such as in Germany, Slovakia, and the United Kingdom. This culture of frequent testing allowed COVID-positive people to quickly limit their exposure to others. If the United States had incorporated frequent rapid antigen testing earlier in the pandemic, and had enabled a faster regulatory approval process for new tests, it may have been able to avert some of the nearly 80 million confirmed COVID-19 cases—which, in turn, would have prevented some of the 969,000 U.S. COVID deaths.
Now, the issue is no longer availability or supply, it’s whether the United States can maintain testing capacity with ongoing funding levels—money that is now on the chopping block in Congress. With vaccines, the United States has been ahead of the rest of the world in terms of supply. But even with three safe and effective COVID-19 vaccines, millions of eligible Americans remain unvaccinated. As of March 21, approximately 18 percent of the population had not yet received a single dose.
The vaccination campaign has been riddled with challenges: vaccine hesitancy, misinformation and disinformation, the politicization of public health, and widespread anti-science attitudes. With 65 percent of the population fully vaccinated, and only 29 percent who are up to date with boosters, the United States ranks in 65th and 70th place in the world. The United Arab Emirates is 98 percent vaccinated and 50 percent boosted; Portugal is 92 percent and 61 percent; and Canada is 83 percent and 48 percent.
No one country has had a perfect pandemic response.
Beyond access barriers, such as time off to get vaccinated or having to travel to get a dose, a main reason the United States is trailing behind in vaccination rates is low trust in the government, as well as lack of community cohesion. A recent exploratory analysis by the COVID-19 National Preparedness Collaborators showed the importance and effect of trust in government and trust in communities, which correlated with high COVID-19 vaccine coverage among middle- and high-income countries.
Effectively communicating evolving knowledge about an emerging infectious disease in a way that informs, inspires trust in government, and enables the public to take necessary steps to protect families and communities has become one of the most complicated and difficult aspects of pandemic response. Every country has struggled with this, though some started with stronger trust in government. Other countries benefited from their previous experiences with viral outbreaks. Understanding the danger posed by COVID made them more willing to take rapid action. What has been clear is that honest, regular communication with the public by trusted messengers has been critical. New Zealand and Germany have been particularly successful in their efforts to provide their publics with reliable information grounded in science. With a crisis communication style rooted in empathy, honesty, and openness, the messenger and the message were well received. But as important as this has been, crisis communication remains understudied and few public health officials are sufficiently trained in it, particularly in how to counter disinformation. Prioritizing communication must become a priority for all countries and should be integral to advanced training in every scientific, medical, and public health discipline.
One of the biggest shortfalls of the U.S. pandemic response has been relying on other countries’ clinical and epidemiological data to make localized public health policy decisions, such as who should receive a booster dose. Vaccination data on booster demand from Israel, for example, has been leading the way as a test case for the United States. The lack of standardized data collection and real-time reporting and interpretation in the United States represents one of the country’s gravest pandemic deficiencies, and it was known about for decades. Former directors of the Centers for Disease Control and Prevention wrote earlier this month that “for too long, we have neglected our nation’s public health data infrastructure, much of which is aging, obsolete and insufficient to meet our needs … Progress was limited because of both lack of funds and lack of legal authority.” The different ways in which public health agencies collect and store data combined with privatized health care creates challenges for integrating clinical and epidemiological data. Many public health and health-care systems are not connected, and there is limited interoperability for sharing critical data. In contrast, countries with nationalized health care, such as the United Kingdom, benefited greatly from their standardized procedures and their ability to conduct large-scale clinical trials. Other countries, including Denmark, Israel, and South Korea have also been the frontrunners in sophisticated surveillance systems and real-time reporting. Efforts are underway in the United States to think about how to address this challenge, such as incentivizing and improving data sharing, and devising new strategies for large-scale clinical trials.
Keeping up with the virus as it evolves has been a challenge for the United States. Mike Ryan, executive director of the Health Emergencies Programme at the World Health Organization, said it best: “Speed trumps perfection. Perfection is the enemy of good when it comes to emergency responses.” The United States has often been too late to implement policy measures, including non-pharmaceutical interventions like mask mandates. For example, the initial federal mask mandate for public transportation went into effect in February 2021, shortly after the Biden administration took office, a full year into the pandemic. It has also been slow to facilitate key pandemic products, for example the Food and Drug Administration’s sluggish authorization of rapid at-home tests and its late acknowledgement of their utility as a public health tool. At the same time, the United States has been quick to scale back other measures, like lifting mask ordinances in certain states or reducing surveillance testing. The United States’ bottom-up approach has led an uncoordinated, uncollaborative response, no matter the federal government’s efforts to provide guidance. Instead, the United States has 50 epidemics—a different one in each state.
Places that implemented rapid responses to COVID-19, such as Taiwan, Singapore, and Hong Kong, have prior experience dealing with pandemic threats, such as SARS 20 years ago and the continued threat of avian influenza. This prior outbreak experience built muscle memory about what to do when a pandemic hits and enabled these countries to start with a robust level of trust from the population. One can only hope the United States’ experience with COVID-19 will similarly lead to better instincts the next time it faces an infectious disease threat.
And now, the United States enters the third year of the COVID-19 pandemic, experiencing the equivalent of a mass casualty event every day from COVID-19. Even though many consider this current period a lull, more than 1,000 deaths are still being reported each day. Now is the time to prepare for future surges and to stay ahead of this virus. The Biden administration’s COVID-19 preparedness plan does just that by focusing on four main goals: protect against and treat COVID-19, prepare for variants, prevent economic and educational shutdowns, and continue to vaccinate the world. As promising as this national plan is, funding for it was stripped from the U.S. government’s spending package, and a standalone, supplemental bill is not certain to pass. The consequences of congressional inaction for the American public could be severe.
There is much work to be done in the United States, including revolutionizing and investing in public health infrastructure, bridging data integration from disparate health care systems, and changing the country’s reactive approach. The changes needed are daunting. It will require reestablishing a collective sense of community and a restoration of trust in the government. It will also require a renewed commitment to public health and the health care workforce, which is still reeling from two years on nonstop emergency response with morale at an all-time low. All of this will require political leadership and resources. The United States’ bubble gum and Band-Aid approach to pandemics needs to end with this one.
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