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From Hubris to Humility: An American Story

BLOG - 8 April 2020

Jeremy Adelman is the Henry Charles Lea Professor of History and Director of the Global History Lab at Princeton University.

Debates are raging everywhere on countries' unpreparedness to cope with Covid-19. The United States has been no exception. The late, often haphazard responses of the federal system are beginning to be dissected. Donald Trump's reversals, in the midst of a pre-electoral climate accentuating the differences between Republican and Democratic states also played their role. Even more than Europe, the US should have benefited from the temporal advance given to it by the rise of the epidemic first in China and then in Europe. We are not yet at the peak of it; even the White House forecasts a mass tragedy.

Jeremy Adelman, Henry Charles Lea Professor of History and Director of the Global History Lab at Princeton University, gives us his take on how the US has managed, and mismanaged, to contain and trace the spread of Covid-19, starting from a central question: why did the system fail to learn its lessons of the Chinese, then the Italian situations in time when experts and senior advisers were ringing the alarm?

Anatomy of a crisis

The Global Health Security Index ranks 195 countries’ preparedness for a health calamity. It relies on an elaborate model of 34 indicators and 140 questions. It is staffed by an international panel of experts and co-coordinated by The Johns Hopkins University Center for Health Security and The Economist Intelligence Unit. In 2019, the United States ranked at the top of the Index, by far out-distancing the number two, the UK. Then came the Netherlands, Australia, and Canada. It’s an elite club of readiness and the United States was the unquestioned leader.

Yet, on March 31, the White House shared estimates that up to a quarter million Americans could die by the end of this year. The following day, the so-called Federal Stockpile of emergency medical supplies of masks, gloves, and gowns was nearly empty while state governors and health care officials pleaded for basics.

On March 31, the White House shared estimates that up to a quarter million Americans could die by the end of this year.

With over 3,000 dead in New York City and empty parking lots filling with refrigerated 18-wheel trucks to operate as makeshift morgues, the State Governor, Andrew Cuomo warned that New York would run out of ventilators in six days, long before the infection rate was expected to peak. American infections now triple Chinese numbers – and one can hear the predictable complaints from some anti-Chinese media corners that Beijing is fudging the numbers in order to make the US look bad. The thing is: Beijing doesn’t have to.

To a runaway pandemic has been added an economic catastrophe. On April 2nd, the Labor Department announced that the American economy saw a staggering 10 million jobs disappear in two weeks. A graph based on Google Trends Data has horrified Americans. It shows seasonally adjusted jobless rates for the past fifteen years. The numbers blip upwards in mid-2008 during the so-called "Great Recession," slowly subsides to 3.5 per cent in January, 2020. Then, the bars surge upwards, pushing the vertical axis off the page. It’s a graphic representation of an economic nightmare.

Covid-19 has been a cascading crisis for Americans who like to comfort themselves as victors of the Cold War, as daring problem-solvers, as the heart of entrepreneurial gusto. But what has made this crisis so dramatic is that it was foretold. Even when the numbers of infections were low, many warned of a massive spread.

How could a country with deep capacity, elaborate plans, and large stockpiles have failed so spectacularly? How did the American luxury of being able to learn from others before them turn into such a catastrophe? In previous transnational disease threats, from SARS to Ebola, the US was an exporter of technologies, knowledge and solutions. This time around, it’s an importer. And much of what could have been learned and applied got stuck in the metaphoric customs warehouse.

This crisis is far from over. But it is not too soon to outline a first draft of current history.

The First Draft

Early assessments of the Trump administration’s response point to two patterns. First, American authorities pursued the virus instead of preventing it. Yet, acting early was clearly necessary and called for. Ignoring the exponential nature of the spread, the Trump administration followed the Italian playbook well after it was deemed disastrous. By the time the crisis was unfolding in Italy, experts were warning of the peril of relying on partial solutions, step by step decrees, and the human toll of denial. But rather than learn from, and cooperate with, others, American officials at the top dampened down the warnings and refused international outreach at a crucial time, when it would have been much easier to contain and to control. Bereft of cooperators and global thinkers, the administration delayed and dithered.

Second, instead of an informed and integrated approach, the administration’s piecemeal response worsened the crisis by issuing misleading information, generating a false sense of security, and letting people move around the country long after China, South Korea, and other countries had locked down mobility across the nation to stop the diffusion. To date, there is no general policy on testing, contact tracing, public communication in the United States. Supplies are thin. Ventilators are running out. Every day brings more confusion and alarm.

We are only a few months into what promises to be a long crisis that will go through many phases. But what is starting to become clear is that Americans are confronting the yawning gap between their sense of immunity from world affairs and the reality of global interdependence. They are also faced with the limits of their cherished, exceptionalist, self-understandings.

Early warnings

Americans are confronting the yawning gap between their sense of immunity from world affairs and the reality of global interdependence.

What makes this crisis so stark is that the country had warnings from the rest of the world that it was coming. News came from China that there was a new coronavirus spreading in early winter. Neil Ferguson, one of the leading mathematical modelers and biologists, working at Imperial College London, was warning in January that the world as a whole faced its most serious public health crisis in generations. He prophesized that even the best tracking systems were only able to detect one-tenth of infections crossing borders. Then came Italy, Iran, Spain, and France. And yet, Washington rested on its hands. Covid-19 was a shock to China. It was a surprise in Italy. But it was fully predicted in the United States.

Chinese authorities may have dragged their feet in disclosing the disease. But after December 31, when China informed the World Health Organization officially of the "unknown disease," and after January 9th, when Chinese researchers released the map of the virus’s genetic makeup, and a few days later the first case appeared in Bangkok, the viral implications were clear. By then, reporters from around the world were swarming into Wuhan province as the virus was flowing out.

Dr. Robert Redfield, a noted virologist and the Director of the Center for Disease Control and Prevention (CDC), an organization regularly topping the list of institutions in which Americans have most confidence, had served in the army as medic and became a distinguished AIDS researcher and worked in the field in Africa and Haiti. He got the official news of the Chinese coronavirus on New Year’s Day while he was on vacation with his family. Instead of spending time with his family, he was on the phone day and night. What he learned was dismaying. A few days later, he talked with George F. Gao, the Director of the Chinese Center for Disease Control and Prevention. In the middle of their conversation, Dr. Redfield burst into tears. What alarmed him was the realization of the stealthy exponential power of the virus in the absence of any system for testing and tracking: people could carry the disease without showing symptoms.
 
Redfield immediately informed his staff and superiors. Sure enough, by mid-January, the first cases of infected people without symptoms were showing up in areas north of Seattle. The CDC guidance to medical staff informed them of the fatal threats of asymptomatic infection. At the same time, Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, informed the public that there was no doubt that the disease spread from people who carried it without knowing it. In an interview with Dr Sanjay Gupta, CNN’s Chief Medical Correspondent in mid-February, Redfield confirmed that the CDC was monitoring asymptomatic transmission of the disease. In effect: within one month of the official Chinese disclosure of the virus, the American public health establishment was in full emergency response mode. China’s epidemic was the world’s pandemic.

Weak Link

What needs explaining is what happened, but also, and perhaps more importantly, what did not happen. A complex, prepared, system geared with ample knowledge about the inevitable did not work as it was designed.

On March 31, the White House unveiled grim epidemiological models. Even best-case scenarios predict that the death toll from Covid-19 may reach 240,000 fatalities.

There are two ways to tell the story of systemic failure. One focuses on how one part of the assembly failed – and took down the whole system. It’s a more familiar narrative: find the missing piece, the worn-out cog, the exhausted element that brought the machine to a halt. Right now, that narrative zeroes in on one big part: the management and decision-making style of the White House. It’s certainly the aspect of the narrative that’s on glaring, daily display.

On March 31, the White House unveiled grim epidemiological models. Even best-case scenarios predict that the death toll from Covid-19 may reach 240,000 fatalities.
 
This is an about-face for the White House and its boosters, one that unfolded like a three-act drama. In act one, the response brimmed with suspicion and blame. Chinese reports could not be trusted. To some, it was an exaggerated hoax, concocted by Democrats and liberals to chide the White House. By the end of January, suspicion turned to blame. The first concerted policy out of Washington was not to prepare at home but to ground flights from China. By then, cases were being reported in the United States, most alarmingly in a Seattle nursing home. Still, the Secretary of State Mike Pompeo made a point of calling Covid-19 the "Wuhan Virus". More diplomatically challenged voices called it the "Flu Manchu" after the racist Hollywood movie stereotypes.

If China was to blame in act one, the next act was to dismiss the virus as a menace. Trump declared that it was less lethal than a regular flu. One Fox News host, Jesse Watters, rounded on his co-host and asked "Do I look nervous? No. I’m not afraid of this coronavirus at all." The airwaves were even worse. Rush Limbaugh, one of Trump’s favored voices, bellowed into his microphone about the fear-mongers in the mainstream media, universities, and the "deep state" – like the Center for Disease Control. No one ridiculed the warnings more than Trump’s favorite Fox News anchor (Trump joins him every week on television to an average of 5.6 million viewers), Sean Hannity. As far as Hannity was concerned, this was a trifle, whooped up by Democrats to cloud Trump’s economic genius. As late as March 10, when the Director of the National Institute of Allergy and Infectious Diseases was pleading to Americans to be careful, the firebrand conservative commentator, Candace Owens, snorted at "the mass global mental meltdown". (A month later, she still refuses to admit her irresponsibility). The real threat was believing the "hoax" and not trusting the President.

Denial meant being chirpy in the face of threat. President Trump rushed to announced that his otherwise slow-moving Food and Drug Administration (FDA) had "approved" chloroquine as a treatment for Covid-19. It had not. And scientists, including, very publicly, some of President Trump’s senior medical advisers, dismissed the malaria-prevention drug as a pipedream. While Trump announced that he was "a big fan" of the drug, the FDA Commissioner was forced to confess that it was a "false hope". Days later, Trump tweeted, "hydroxychloroquine & azithromycin, taken together, have a real chance to be one of the biggest game changers in the history of medicine". Trump had said, "If you wanted, you can have a prescription", adding, "What the hell do you have to lose?"

The most recent, third act, of the play, once President Trump admitted the emergency, was to declare war. The White House became the hub of a "battle plan," and "survivors," like the evangelical Nic Brown, got rolled out to relay stories of faith. Stay at home, follow the guidelines – and above all pray.

At the center of this weak link in a complex system is the Oval Office. Instead of building a strong link with a cohesive and capable team, the President added more, smaller, weak, links. In the middle of the panic, on March 6th, Trump fired his acting Chief of Staff, Mick Mulvaney. In his place, Trump named a Congressional loyalist, Representative Mark Meadows. But Meadows took three weeks to resign his congressional seat. To fill the gap, Trump created a task force.

At the outset, he handed it to Alex Azar, Trump’s second Health and Human Services Secretary and former pharmaceutical lobbyist. Azar was confirmed at the beginning of 2018 and immediately pivoted to Mr. Trump’s pet concerns: lowering drug prices and fighting the opioid epidemic. Azar was a loyalist. As the alarms went off, and news leaked out about HSS inaction, Azar became more concerned with the reputation of his department and the administration. His goal: change the message. To no avail. On February 26th, Trump dumped Azar and replaced him as the Covid-19 Task Force head with the Vice President Mike Pence.

By then, the credibility of the White House was in deep trouble. Lashing out at fake news agencies in his daily briefings and calling state governors disrespectful, the frustrated and petulant president turned to his kin. His son-in-law, Jared Kushner, who oversees something called the White House Office of American Innovation, swept into action. Kushner calls his Office the "Impact Team." Federal Emergency Management Agency (FEMA) officials struggling to manage the catastrophe found the glitzy former executives appointed by Kushner to "Impact," like his friend Adam Boehler, head of the US International Development Finance Corporation and erstwhile venture capitalist, meddlesome and confusing. FEMA workers renamed the Impact Team the "Slim Suit Crowd" for the Armanis they wear to the battlefields.

But Kushner fared no better at flipping the narrative of failure. His pet causes – a vaunted national Google-partnered screening website aimed to direct citizens to testing locations and the announcement of drive-through testing sites in shopping mall parking lots – were disastrous. Google was caught off guard by the White House’s jubilant announcement; they had barely launched the site. Meanwhile, the national drive-throughs resulted in five lots outside pharmacies in Pennsylvania with a maximum capability of testing 250 cases a day. Trump normally gives his son-in-law a long leash. This time, according to witnesses, he went volcanic.

The emergency did not play to Mr. Trump’s leadership style, which depends more on jostling between his minions than cohesion and focus.

The emergency did not play to Mr. Trump’s leadership style, which depends more on jostling between his minions than cohesion and focus. It kindled his fury that his world could not lock in at 3.5 per cent unemployment and the Down Jones Industrial Average of stock prices nearing 30,000 as recently as February 12th. Instead, his world fell apart, and the habit of firing and hiring scared officials did nothing to create a strong link at the center of power.

A Failing System

There is a second way of telling the narrative of failure. It requires widening the scope to think about the system as a whole and not the very public malfunctioning part in the White House. Since this is a quick-moving but relentless public health emergency that hits many parts of an interconnected system at once, there were ample occasions for the whole system to go into paralysis.
 
Consider two of them. The first has been the reluctance to think globally as a way to solve systemic blockages. Instead of turning to outsiders for help to make up for the parts of the system that were struggling, officials had a knee-jerk tendency to turn away foreign partners and lessons. Nowhere was this more on display than in the way the United States handled its testing capacity. The ability to test and analyze people is at the heart of the monitoring and tracking system, and vital to the ability to remobilize the economy. And yet, the US is still struggling to create and deploy testing facilities.

Redfield’s office immediately swung into action to create a mechanism to identify the virus. The first CDC test used three small genetic sequences to match up with portions of a virus’s genome extracted from a swab. Meanwhile, a German-developed test used by the World Health Organization (WHO) was being handed out to other countries. It used just two sequences, potentially making it less precise. But at least it was proven. In the end, the CDC’s elaborate test kit ran into problems in the third sequence, known as the "probe." It yielded inconclusive results. The CDC had to instruct state labs to stop testing.

This meant that the US was equipped with only threadbare testing abilities and so could only screen people who had traveled to China or who had been in direct contact with someone known to have the virus. While officials doubled down on trying to fix their own kits and were still processing samples from states, the virus spread. Dr. Anne Schuchat, the CDC principal deputy director, later confessed that the CDC did not think "we needed somebody else’s test". And, since the German-designed WHO test had not been screened by the elaborate American regulatory approval process, it was going to take too much time to start that process in order to get imported kits into the country.

It was not just the CDC that stumbled. So did the sprawling FDA, which regulates everything from Viagra to bird food. As with so many federal agencies, its leadership was in turmoil. Dr. Stephen Hahn, a seasoned radiation oncologist and chief medical executive of the MD Anderson Cancer Center, took over in mid-December. Within a month, all eyes turned on him to approve nationwide testing in academic and private labs. Instead, the FDA, ponderous if methodical at the best of times, became a massive roadblock. Dr. Hahn looked upon private labs skeptically and insisted on extensive screening from his in-house scientists. He was following normal protocols.

Researchers at Stanford University, meanwhile, developed their own working test based on the German-WHO model. They ran into resistance at the FDA. Led by Dr. Benjamin Pinsky, the Stanford lab ultimately decided not to apply for permission to test the test. It was not until early March that they got the green light to begin testing. The same happened to the French diagnostics firm, bioMérieux. Their BioFire is a countertop testing system used to assess respiratory illnesses and provide results in 45 minutes. It works in 1,700 hospitals around the country. But it was not approved for Covid-19 testing. It took six weeks for the FDA to get emergency approval for the BioFire to begin testing its test. That was on March 24th.

To blame provincialism is too simple. There were many other sources of inertia: red tape, weak teamwork, panicked leadership.

To blame provincialism is too simple. There were many other sources of inertia: red tape, weak teamwork, panicked leadership. But access to the world was treated as the problem, the threat, not the solution or the alternative. The failed testing system produced a monumental gap in the American ability to contain and to trace the virus. This has meant that lock downs have to be more severe and prolonged, inflicting further economic damage. But it did not have to unfold this way. Just as the affliction was foretold in the way it ravaged China and Europe, so too there were solutions and practices to be learned by foreign experience.

If an inability to seek out foreign partners was one systemic problem, a second systemic failure has been the way in which federalism became quicksand. One of the mainstays of American constitutionalism, the distribution of power among national and state tiers creates lots of checks and balances against overgrown government authority. It is better at braking state power than mobilizing power. It was designed that way. In fast-moving, mobile, emergencies, however, it can make things worse.

In such a heterogeneous country, some regions got hit harder and earlier than others. It would have been hard enough to muster national resolve and unity. But in the hands of a President who wins by dividing and pitting, this was not going to fly. Much of the Trump base has been skeptical of federal authority anyway, and touts a tradition of decentralized "state’s rights." This meant that the first and most afflicted states tended to be those in the hands of Democratic governors. In the rancor between Democratic states and a Republican White House, the two tiers of government, states and federal authority, stalled any concerted action.

Federalism has paralyzed government between Democratic state needs and Republican state rights. The result: the White House has resisted mandated, national, behavior, preferring to leave that to states, even if the virus crosses state lines. States are left to jostle with each other for scarce supplies. Even members of the Covid-19 Task Force, like Dr. Anthony Fauci, are flummoxed. Dr. Fauci has almost singlehandedly been the purveyor of trust in federal authority. An immunologist who has spent most of his career in public service, his gravelly voice and straight talk have made him a media darling. He noted to CNN on April 2nd that "the tension between federally mandated versus states’ rights to do what they want is something I don’t want to get into". Yet, he could not resist the conclusion: "But if you look at what’s going on in this country, I just don’t understand why we’re not doing that".

The White House also refuses to use its own powers to repurpose the private sector to produce much needed emergency protective equipment, ventilators, and the laundry list of medical supplies. President Trump has at his disposal a piece of legislation from the Korean War era, the Defense Production Act (DPA). It empowers the federal government to order industrialists to shift to producing vital goods. When asked why he did not want to use the DPA to prime the production of much needed supplies, the President celebrated the efforts of the private sector and firms like General Electric and Baxter. "We have tremendous numbers of companies also making equipment", he said, adding for good measure "we’re not a country based on nationalizing our business". He continued: "go ask a person over in Venezuela; ask them how did nationalization of their businesses work out. Not too well". But this, as many have pointed out, is a wanton misunderstanding of the legislation, which merely empowers the federal government to require businesses to accept and to prioritize contracts for supplies that are necessary for national defense. Companies still get paid; they still own their assets.

It remains unclear why the White House remains committed to a misreading of its own powers, especially when the opportunity to play the role of hero riding to the rescue lies so clearly before a President who relishes the role.
 
Meanwhile, President Trump opted for the optically friendly gesture of sending off the USNS Comfort, a Navy hospital ship with 1,000 beds, from its base in Norfolk, Virginia. It sailed into New York harbor but immediately refused to admit any Covid-19 patients because they cannot pass Navy protocols. Instead, the big white ship floats nearly empty in the harbor, a symbol of paralysis in the middle of a disaster.

 

 

Copyright: Angela Weiss / AFP

 

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