Improving Pandemic Preparedness: Lessons From COVID-19

Improving Pandemic Preparedness
CFR.org
Task Force Report No. 78
Improving Pandemic Preparedness Lessons From COVID-19
Updated October 2020
Findings
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COVID-19 has confirmed the U.S. and global vulnerabilities that were repeatedly identified in high-level reports, commissions, and intelligence assessments on pandemic threats for nearly two decades prior to this pandemic. COVID-19 has underscored several truths about pandemics and revealed important shortcomings in current global and national capacities to prepare for, detect, and respond to them. This pandemic will not be the last one that the United States or the world faces. To better prepare for the next crisis, and future waves of the current one, the United States will need to devote considerable political capital and economic resources to reducing the domestic and global vulnerabilities that jeopardize individual, national, and global health security.

In this first half of this report, the Task Force presents its major findings grouped into three sections: the inevitability of pandemics and the logic of preparedness; the global response to COVID-19, including the performance of WHO, multilateral forums, and the main international legal agreement governing pandemic disease; and the performance of the United States, also drawing lessons from other countries, including several whose outcomes contrast favorably with the U.S. experience.

The Inevitability of Pandemic Threats and the Logic of Preparedness

Pandemics of emerging and reemerging infectious diseases are inevitable, predictable, and costly.

Pandemics are not random events. Pandemics afflict societies through the established relationships that people have created with the environment, other animal species, and each other. The precise timing and location of the coronavirus outbreak that led to this pandemic were difficult to predict, but the emergence of a novel respiratory virus and the threat it would pose to urbanized nations with extensive travel links and underfunded public health systems were not.

Outbreaks of well-known infections and encounters with new diseases occur regularly.5  Global population growth and greater encroachment of settlements, agriculture, and mining activities into animal habitats in forested areas make the occurrence of zoonoses—viruses jumping from animals to humans—more frequent than in the past (see figure below).6

More than forty new infectious diseases in humans have emerged in these past few decades.7  At the same time, overuse of existing drugs and underinvestment in new ones produce drug-resistant strains of fungi, protozoa, and bacteria, making routine medical care more dangerous.

These outbreaks of emerging and treatment-resistant pathogens can easily cross national boundaries, given increases in global trade, faster travel, rapid urbanization, and rising global temperatures (resulting in warmer, more vector- and virus-friendly climates).8  The world is 74 percent urban: 5.4 billion people live in urbanized areas.9  The United Nations estimates that of the nearly 1.5 billion city dwellers added worldwide since 2000, 90 percent live in lower-income countries. Emerging infectious diseases, such as Ebola, are less likely to burn out in rural villages and more likely to reach the crowded cities that are hubs for commerce, travel, and migration, but have limited health systems—ideal incubators for outbreaks. Previous reports have found that many microbes are transmissible before infected individuals exhibit symptoms and could travel far and spread without the knowledge of the infected person.10  In this era of jet travel, with more than 1.4 billion international tourist arrivals each year, new pathogens, such as SARS-CoV-2, can easily hitch a ride on an unwitting human traveler to anywhere in the world in a matter of hours.

As barriers to the global spread of infectious disease are diminishing, multiple factors are increasing societies’ vulnerabilities to emerging and treatment-resistant pathogens. These factors include aging populations, rising numbers of immunocompromised individuals and people living with noncommunicable diseases such as diabetes and chronic respiratory diseases, persistent underfunding of public health systems, widespread adoption of just-in-time supply chains for critical medical supplies, an inability of hospitals to accommodate patient surges, and persistent gaps in adequate health protections for elderly, marginalized,and vulnerable groups.11

Infectious agents have demonstrated an ability to ravage populations, overwhelm health systems and economies, and destabilize governments since antiquity.12  In 2002, the coronavirus causing severe acute respiratory syndrome (SARS) emerged in China and spread to nearly thirty nations, eventually infecting 8,098 people and killing 774 of them, and causing $40 billion in economic losses worldwide in six months.13  Since SARS, the world has been repeatedly rocked by epidemic and pandemic scares, including H5N1 flu outbreaks (2007), the influenza A (H1N1) flu pandemic (2009), the Ebola virus epidemic in West Africa (2013–16), the Zika epidemic in the Americas (2015–16), and the Ebola virus epidemic, again, in the Democratic Republic of Congo (DRC) (2018 to the present). The World Bank estimates that in 2015 the Ebola virus epidemic, in addition to infecting more than twenty-eight thousand and killing eleven thousand people, took $2.2 billion from the combined GDP of Guinea, Liberia, and Sierra Leone, and more than $3.6 billion was spent globally to fight the disease.14  The 2015 outbreak of 153 cases of Middle East respiratory syndrome (MERS), another coronavirus, cost South Korea an estimated $10 to $13 billion.15

Even before recent outbreaks, history had already shown that the societal and economic disruption from a pandemic of a novel respiratory disease could be horrific. In 1918, a lethal influenza strain killed tens of millions of people worldwide. Premature deaths that occur in pandemics of that magnitude can significantly reduce the size of labor forces. Widespread, serious illness also leads to increased absenteeism and reduced productivity. In addition, the treatment, mitigation, and control measures taken to contain and suppress the spread of easily transmissible viruses stress already resource-constrained health-care systems. A 2005 study by the Congressional Budget Office estimated that a severe pandemic could, in the United States alone, infect two hundred million people, leave ninety million clinically ill, and kill two million, resulting in a 5 percent decrease in GDP and total U.S. economic costs of $675 billion, as well as a 3 to 6 percent decline in global output.16

The COVID-19 pandemic has confirmed many of these previously identified systemic risks and vulnerabilities. In the weeks before the Chinese government began restricting movement of its domestic population on January 23, millions traveled to and from the city of Wuhan, China, including thousands of infected individuals. Their destinations spanned the globe. Researchers estimate that 86 percent of infections among those travelers went undocumented.17  A genetic analysis demonstrates that most of the COVID-19 cases in New York City arrived from Europe rather than China, underscoring the rapid spread of the virus.18

Acute shortages of critical drugs and PPE, much of which are made in China and other initially hard-hit areas in Asia, have occurred not just in the United States, but also around the world.19  Lack of international cooperation and deteriorating relations among major powers threaten to undermine the global development and equitable distribution of safe and effective vaccines, therapeutics, and diagnostics for the novel coronavirus.

Pandemics of infectious disease have disparate effects on elderly, low-income, marginalized, and other vulnerable populations within societies. In the current pandemic, infection and mortality rates have been highest among nursing home residents and Black, indigenous, and Latinx communities, especially those inadequately served by the U.S. health-care system and bearing the brunt of socioeconomic disparities.

Health outcomes have been considerably worse for those older than sixty-five and with comorbidities such as diabetes and chronic kidney diseases, but the virus has also spread disproportionately among vulnerable and marginalized populations who are inadequately served by the U.S. health-care system and lack sufficient social protections. Transmission rates have been higher among workers designated as essential, including those in health care, food service, and public transportation, as well as those with crowded living and working conditions for whom social distancing is not possible.20  More broadly, nursing homes, prisons, meatpacking plants, homeless shelters, and psychiatric or developmental care facilities represent nearly all of the one hundred largest clusters of COVID-19 cases that occurred in the United States between January and May 2020.21  As of August 13, more than four hundred thousand residents and employees had been infected in nursing homes and other long-term care facilities, leading to more than sixty-eight thousand fatalities—more than 40 percent of the total deaths from the virus in the United States.22  Residential care facilities in New Jersey, New York, and Pennsylvania were particularly hard hit.

In addition, COVID-19 causes the most severe illnesses in people with preexisting medical conditions such as high blood pressure, diabetes, obesity, and cardiovascular diseases. According to estimates from the Centers for Disease Control and Prevention (CDC), hospitalizations were six times higher and deaths twelve times higher among those with reported underlying medical conditions, compared to those with none reported.23  Such underlying conditions are more prevalent among vulnerable and economically disadvantaged groups and racial and ethnic minorities with inadequate access to nutrition, health care, and a clean environment, helping explain why these populations have suffered so disproportionately from the pandemic.

In the United States, Black Americans have been among the hardest hit (see figure below). They make up 13.4 percent of the U.S. population but, as of July 1, 2020, nearly 23 percent of the deaths from COVID-19. The disparity and the toll are even greater in cities and counties where Black Americans represent a larger share of the population than the national average. The COVID-19 infection rate is three times higher in predominantly Black counties than in predominantly white ones, and the mortality rate is six times higher.24  In cities, such as Chicago, or states, such as Louisiana, Black Americans represent less than one-third of the population but more than two-thirds of the deaths from the disease. Other racial and ethnic minority groups have also been disproportionately affected by COVID-19. In some states, Latinx Americans have more than four times the expected rate of infection based on their share of the population.25  In New Mexico, Native Americans make up about 11 percent of the population but account for 32 percent of COVID-19 cases.26

 
 

 

Investment in international preparedness was consistently too low.

Investment in preparedness is cost effective compared to the high costs of an uncontrolled pandemic, yet international and domestic investments in pandemic preparedness have been consistently low relative to the societal and economic risk of dangerous disease events.

The early evidence suggests that investments in preparedness have mattered during this pandemic. Having learned from its experience with an outbreak of MERS in 2015, South Korea was better prepared than most countries when COVID-19 arrived. South Korea has an infectious disease surveillance system in place that provides investigation and incident management guidelines for a number of different types of infectious diseases. Early, widespread testing, tracing, and isolation of cases, along with evidence-based government advisories on physical distancing, were crucial to getting the disease under control.

South Korea confirmed its first case of COVID-19 on January 20, within a day of the United States. South Korea tested three times as many citizens per capita as the United States, kept reported cases to roughly eleven thousand, and maintained a COVID-19 mortality rate 2.5 times lower than that of the United States in the early months of the outbreak. When confronting a case involving an individual who traveled to multiple night clubs in a single evening in May, South Korea conducted more than sixty-five thousand tests in the area in a week, uncovering 170 infections and stopping the outbreak. Thanks to its pandemic preparedness, the South Korean government not only contained the virus but also managed to avoid applying the stringent lockdowns seen in other countries, such as China, France, Italy, and the United Kingdom.

South Korea was not alone in achieving such success. Diverse nations such as Canada, Germany, New Zealand, Norway, Rwanda, Taiwan, and Vietnam have so far managed a robust, rapid response to the pandemic. In many cases, these countries responded with public health fundamentals: aggressive tracing, isolating, and testing contacts, people whom confirmed or suspected carriers could have encountered before realizing they were, in fact, SARS-CoV-2 carriers. A common factor among many, but not all, of these earliest responding nations was having direct experience with previous outbreaks such as SARS or MERS or a higher level of endemic infectious disease.

The world, however, cannot afford to wait for nations to learn from experience whenever a novel pathogen emerges. As Nobel Laureate Joshua Lederberg once aptly wrote, “The microbe that felled one child in a distant continent yesterday can reach yours today and seed a global pandemic tomorrow.”27

The virtual inevitability and high potential toll of future pandemics make investments in preventive and mitigatory measures both sensible and cost effective. The amount required to prevent and mitigate such incidents pales in comparison to their costs. A National Academy of Medicine commission estimated in 2016, for example, that increasing global expenditures on pandemic preparedness by $4.5 billion per year—a negligible fraction of global output—would provide substantial safety increases.28

WHO defines pandemic preparedness as “having national response plans, resources, and the capacity to support operations in the event of a pandemic.” Preparedness includes prevention, detection, and containment measures as well as programs that respond to and mitigate issues that arise from the spread of pandemics, such as PPE shortages, limited hospital capacity, and acquisition of vaccines and other countermeasures. The International Health Regulations (IHR), a binding international agreement revised in 2005 and signed by 196 state parties, includes rules related to identifying and sharing critical information about epidemics and maintaining core capacities to prevent, detect, and respond to dangerous disease events.

These efforts cost money. To expect nations such as DRC or Somalia, which have total government spending across all sectors of less than $100 per person, to contribute equally to these critical global health security investments is of course unrealistic. Even in high-income countries such as the United States, however, mobilizing sufficient resources to support pandemic preparedness at home or abroad has proved difficult.

Many reports have described support for global pandemic preparedness as prone to the cycle of crisis and complacency, but relative to the economic and health risk, describing funding levels as consistently complacent is more apt. Emerging health threats have claimed many more lives than terrorism but receive nowhere near the global or U.S. funding that counterterrorism efforts do.29

Despite the adoption of IHR, multiple pandemic threats, and numerous reports urging more investment, international assistance for pandemic preparedness has never amounted to more than 1 percent of overall global health assistance (see figure below).

 

 

 

 

 

In 2019, a total of $374 million in global aid, less than 1 percent of total official development assistance for health, was spent on pandemic preparedness in low- and middle-income nations.30  Another $5.2 billion was spent on strengthening health systems, some of which could improve countries’ ability to deal with global epidemics, but even this spending has been shrinking. Since 2003, global aid for health system strengthening has fallen from 22 percent to 14 percent of overall annual development assistance for health.

In 2014, the Barack Obama administration, in collaboration with thirty countries and international organizations, launched the Global Health Security Agenda (GHSA). It was designed to elevate the political importance of pandemic preparedness, and during the West Africa Ebola outbreak was resourced to provide more than $1 billion in surge funding over five years to build capacity in priority low-income countries and to coordinate action to prevent, detect, and respond to biological threats. Despite congressional attempts to repurpose these funds for a response to the 2016 Zika virus epidemic, the focus on prevention and capacity-building was preserved. Several of the countries that took leading roles in GHSA implementation, including Finland, South Korea, and Uganda, are among the nations that have responded most effectively so far to the coronavirus pandemic.

The Donald J. Trump administration maintained the U.S. commitment to advance the GHSA through 2024 but reduced the funding for international capacity-building and cut the number of U.S. personnel assigned to work with international partners, including in CDC country offices.31  Overall budget requests for U.S. pandemic preparedness aid have sunk to pre-2014 levels. U.S. pandemic and emerging infectious disease programs have remained on the back burner relative to the attention and funding devoted to cross-border military and terrorist threats.32

Many other governments have followed the United States’ lead in recognizing pathogens as more than public health problems and in failing to provide the resources to match this insight. In 2018, Group of Seven (G7) foreign ministers recognized that epidemic threats deserve the same level of attention as other serious threats confronting their countries, but fewer than half of all nations were in compliance with their IHR core capacity obligations.33  On four occasions, the G7 has committed to supporting seventy-six countries in building those core capacities but has not monitored countries’ limited follow-up on that commitment.34  Without that monitoring, these multilateral commitments are effectively meaningless.

Preparedness metrics were not predictive of success in this pandemic.

Existing metrics for pandemic preparedness and health system capacity do not reflect the full range of variables, including implementation, that affect a country’s response to a severe pandemic.

Much of the attention paid to pandemic preparedness in recent years, including the Global Health Security Agenda, has focused on building up the capacities of low- and middle-income countries for detection, preparedness, and response, on the grounds that global health security is only as strong as its weakest link. Although that principle remains true, COVID-19 surprised the world by having dramatic effects on prosperous countries with relatively modern health-care infrastructure, including China, the United States, and Italy. The experience of this pandemic has demonstrated that readiness capacity remains shockingly low in most nations, and preparedness is insufficient without timely implementation. Even high-income countries were overwhelmed in this pandemic in ways that existing metrics of international preparedness did not anticipate or capture.

In 2010, WHO identified thirteen core pandemic prevention, detection, and response capacities for the purpose of monitoring capacity-building efforts and compliance with IHR obligations. Countries used these core capacities to complete self-assessments and self-reporting to WHO, but these assessments lacked transparency and accountability and were thus not considered representative of the true capacity for health security within countries.

Following the 2013–16 Ebola epidemic in West Africa, WHO developed, in cooperation with the GHSA and with regional consultation, a voluntary Joint External Evaluation (JEE) process to monitor IHR capacities and assess the ability of a nation to prevent, detect, and respond to a disease of pandemic potential. More than one hundred nations undertook voluntary JEEs, and more than sixty countries developed National Action Plans for Health Security (NAPHSs). The voluntary JEE tool was useful for identifying gaps, but the practical impact of JEEs and NAPHSs on strengthening IHR core capacities has not been apparent in this pandemic.

In 2018, fewer than half of WHO member states were in compliance with their IHR core capacity commitments, and many lacked even rudimentary surveillance and laboratory capacity to detect outbreaks.35  A May 2020 report of the Independent Oversight and Advisory Committee for the WHO Health Emergencies Program observed no clear relation between JEE scores and country preparedness and response to COVID-19.36

The 2019 Global Health Security (GHS) Index includes important and relevant measures for the current pandemic that go beyond the JEE, such as rapid response to and mitigation of the spread of an epidemic, a robust health system to treat the sick and protect health workers, and adherence to norms. As of July 31, The nations that scored among the highest on these and other index measures of pandemic preparedness, such as the United States and United Kingdom, have struggled in their COVID-19 response (see figure below).37  Conversely, countries such as Vietnam, which has relatively low JEE and GHS Index scores, so far have been among the most successful in containing the coronavirus pandemic. Indeed, at the time of writing, many of the countries with higher JEE and GHS Index scores have had higher death rates, even when accounting for national differences in population age structure and in the timing of the first COVID-19 death.

 

 

 

 

 

What Went Wrong Globally

The ultimate source of the weakness of global governance in preventing, detecting, and responding to international health emergencies resides in sovereign states. National governments remain torn between their desire to have a functioning WHO and their disinclination to provide it with authorities and resources to respond aggressively to outbreaks if doing so were to intrude on national prerogatives and sovereignty. Disease outbreaks are complex events, and no established global mechanism coordinates the diplomatic, economic, health, scientific, security, and surveillance resources needed to mobilize an effective response. This pandemic has been characterized by a patchwork of inadequate domestic responses, a breakdown of compliance with IHR, and a disastrous lack of cooperation and coordination across nations in the multilateral settings where an effective response both to the disease and to its massive economic fallout could have materialized.

Effective governance of global health security depends on sovereign states.

IHR, an international agreement dedicated to pandemic preparedness and response, depends on the compliance of states parties to identify and delay or halt the spread of a dangerous novel infection.

In the 2002–2003 SARS outbreak, China’s Ministry of Health was aware for months of a dangerous new type of pneumonia in Guangdong Province before sharing that information with other nations or issuing a nationwide bulletin to hospitals and health professionals on preventing the spread of the disease. That virus spread to twenty-nine countries, sickened thousands of people, and killed 774 before being brought under control in July 2003.

In the wake of this crisis, the World Health Assembly, WHO’s governing body, revised the International Health Regulations in the hopes of preventing another SARS. The revised IHR requires states parties to be transparent; to maintain core capacities to prevent, detect, and respond to outbreaks; and to grant extraordinary powers to WHO. IHR mandates that each state party should notify WHO within twenty-four hours of assessing a serious disease event and continuously communicate to WHO timely, accurate, and sufficiently detailed public health information on the notified event. The WHO director general is empowered to collect information from nongovernmental sources about a potential outbreak and request that states parties verify such information within twenty-four hours. On the basis of information from governmental and nongovernmental sources, the director general can declare an outbreak a public health emergency of international concern, even over the objections of the state or states most directly affected.

The director general can also issue outbreak-specific guidance to inform and influence how other states use trade and travel restrictions, to ensure that those restrictions are science based and do not interfere unnecessarily with international traffic. This trade and travel guidance is nonbinding, but once a PHEIC is declared, the director general must issue it. Like most international organizations, WHO does not have enforcement powers or investigative capabilities, so it relies on creating incentives for countries to cooperate promptly and fully during crises, including, in the last resort, by naming and shaming.

During the early phase of an emerging novel disease, it is not unusual for national authorities to have an imperfect and evolving scientific understanding of the situation. The current evidence, however, suggests that China’s compliance with its IHR obligations was at best flawed, at least in the early days of the outbreak, when transparency was most important.

First, China did not notify WHO in a timely manner of its assessment of the novel coronavirus, though the duration of that delay remains unclear. According to press statements from WHO officials, WHO first learned about the outbreak in Wuhan not directly from Chinese authorities, but rather from press reports posted on December 31, 2019, on the Program for Monitoring Emerging Diseases (ProMED), a U.S.-based open-source platform for early intelligence about infectious disease outbreaks. These press reports concerned an “urgent notice” that the Wuhan Municipal Health Commission issued on December 30, for medical institutions, stating that cases of pneumonia of unknown cause had emerged from the city’s Huanan Seafood Wholesale Market. Zhang Jixian, a respiratory doctor in Wuhan, identified those cases between December 26 and 29 and twice reported those cases to local health authorities.39  Subsequent press reports indicate that the earliest suspected cases began to appear in Chinese hospitals and clinics in early and mid-December.40  No reports indicate that the Chinese government was aware of any of these earlier cases, but a subsequent analysis in the Lancet indicated that the first cases of COVID-19 did not originate at the Huanan Market and date to at least December 1, 2019.41

On January 1, 2020, WHO requested verification from China based on the ProMED post, after which China notified WHO of the potentially serious disease event and began sharing information with WHO on January 3. As a recent Congressional Research Service report observes, WHO’s first formal statement about the outbreak, on January 5, was vague on how the agency was notified about the virus, indicating that its China Country Office “was informed” of cases of pneumonia of unknown cause in Wuhan on December 31, 2019.42

Second, China was slow to share information with WHO and others before January 20, when it began to do so more actively. Indeed, local government officials on January 2 and 3 reportedly threatened and intimidated multiple Chinese health professionals from speaking or posting on social media about the pneumonia cases.43  Wuhan Municipal Health Commission issued no updates during a five-day political meeting in the city from January 6 to 10. On January 11, China shared the genetic sequence of the virus with WHO, after it had been posted online by a researcher at Fudan University in Shanghai.44

Also on January 11, the Wuhan Municipal Health Commission announced the first death from the virus but stated that it had identified no new infections since January 3, and that no evidence indicated person-to-person transmission or infections among health-care workers.45  Wuhan medical personnel began falling ill with symptoms similar to their patients’ in early January, but Chinese authorities did not officially acknowledge this until January 20.46  On January 13, Chinese officials told a delegation of health officials from Hong Kong, Macau, and Taiwan that “limited human-to-human transmission cannot be excluded.”47  For the duration of a second major political meeting in the city, January 12 to 17, the Wuhan Municipal Health Commission issued daily updates but reported no new infections. On January 20, reporting a significant increase in COVID-19 cases and several deaths, China’s National Health Commission publicly confirmed for the first time that the novel coronavirus was transmissible from person to person and that medical personnel had been infected.48

Chinese authorities do not appear to have shared biological samples with WHO or other international partners until January 28, or even possibly later.49  China’s behavior in the early stages of the COVID-19 pandemic widened the cracks in global regimes for information sharing, and its delayed sample sharing undermined international response efforts at a time when specimens were critical for the development and validation of countermeasures.50  The opacity of the Chinese response in the early weeks of the pandemic sowed diplomatic mistrust, undermining international solidarity at a critical juncture.

Even with perfect transparency and compliance with IHR requirements, it is unclear whether the COVID-19 outbreak could have been fully contained early in China. The evidence does suggest, however, that China’s delay in sharing information contributed to the early spread of the virus domestically and internationally. Wuhan’s mayor, Zhou Xianwang, has said the decision to go forward with an annual potluck banquet on January 18 in Wuhan’s Baibuting neighborhood with more than forty thousand households was “based on the judgment that in this epidemic, transmission between people was limited.” A study published in Nature estimated that had China implemented widespread testing, created a cordon sanitaire around Hubei, and imposed other measures a week earlier, it would have reduced China’s caseload by 66 percent. According to that study, acting three weeks earlier would have cut cases by 95 percent.51

From early December until January 23, when China restricted movement, millions of people traveled to and from the city of Wuhan, including thousands who were infected and carried the virus all over the world. For weeks, the global spread went undetected, until January 13, when Thai authorities confirmed the first case of the coronavirus outside China. That first infected individual was a Chinese national who traveled from Wuhan. Nations did not begin imposing travel restrictions against China to stop the spread of COVID-19 until after China restricted domestic movement; the Marshall Islands imposed the first restrictions on travelers from China on January 24.52

WHO lacks authority to enforce IHR and is under-resourced.

The roles and responsibilities that IHR has assigned to the WHO Secretariat and to member states are neither widely understood nor fit for the purpose of preventing, detecting, and responding to a pandemic. The WHO Emergencies Program is under-resourced and lacks a surge capacity to respond to large-scale emergencies.

The WHO Secretariat’s actions are grounded in its duties and responsibilities under IHR. Any evaluation of its performance should consider the limitations of IHR in advancing pandemic prevention, detection, and response and the degree of IHR adherence by member states in their national responses. The COVID-19 experience suggests that WHO lacks sufficient investigative authorities and resources to lead and coordinate coherent international responses to pandemics—in large part because member states are loath to expand those authorities and the budget.

The WHO Secretariat plays a coordinating role and is required to adhere to IHR in its conduct during a novel disease outbreak. It cannot operate in member countries without their permission. WHO lacks independent intelligence-gathering capabilities and cannot compel enforcement of IHR requirements on information sharing and transparency. Although binding on member states, IHR does not provide the WHO Secretariat with authority to impose sanctions against countries for noncompliance other than publicly cajoling recalcitrant governments. IHR stipulates that it is up to member states to adhere to the regulations, and that the WHO Secretariat could offer assistance, but WHO has limited power, authority, and budget in its own right.

WHO has an expansive global mandate under the WHO constitution but an annual budget of just $2.4 billion, smaller than some major U.S. hospitals (see figure below).53  For the 2018–19 biennium, WHO devoted $554 million—less than $300 million per year—to implement its core activities in health emergency management and raised 82 percent of that amount from voluntary contributions.54  This budget is too modest to carry out all the activities needed to support member states in health emergencies and, at the same time, coordinate a global response to pandemics. The WHO Emergencies Program is currently managing, in addition to the COVID-19 pandemic, the international response to the Ebola epidemic in the Democratic Republic of Congo, health emergencies in Syria and Yemen, and the Rohingya crisis in Bangladesh. The program also responds to hundreds of acute health events globally.

 

Especially in light of these limited resources, aspects of the WHO response to COVID-19 are worthy of commendation. On December 31, within twenty-four hours of posting press reports of a cluster of pneumonia cases of unknown origin, WHO used that nonstate information to prompt China to issue a notification of the outbreak, in accordance with its IHR authorities. On January 5, WHO published the information it had available on its website and in its first news announcement, and alerted all IHR national focal points of the outbreak. In this regard, IHR worked as designed.

Despite resource limitations, WHO has also successfully supported coordination of many technical aspects of the COVID-19 challenge. On January 9, WHO reported that the mysterious pneumonia illness in China was a novel coronavirus, the same type of pathogen that had caused the early 2000s SARS epidemic. The next day, it issued a comprehensive package of technical guidance with advice to all countries on how to detect, test, and manage potential cases. WHO issued the first situation report on January 21 and since then has updated the latest epidemiological data on a daily basis. On January 23, the organization held an international news conference, confirming a basic picture of the virus that holds up reasonably well today: a novel coronavirus that spreads from person to person, is more transmissible than seasonal flu, and is much deadlier. Since February 4, WHO Director General Tedros Adhanom Ghebreyesus has provided frequent media briefings. WHO has helped coordinate international research and development for coronavirus vaccines, therapeutics, and diagnostics, including organizing a massive, multicountry “solidarity clinical trial” to assess the most promising treatments.55

WHO is advising ministries of health through its country offices and supplying working test kits, masks, and personal protective equipment to low-income countries that request them. When needed, WHO has deployed doctors and scientists as boots-on-the-ground to assess, advise, and implement control strategies in countries with weak health systems, such as Iran and Egypt.

WHO often defers to affected member states in public health crises.

WHO prizes solidarity in responding to emergencies and has been reluctant to criticize member states in order to improve cooperation and IHR compliance. WHO has also been slow to declare public health emergencies of international concern in outbreaks and epidemics over the objections of the directly affected member states.

WHO has always depended on cooperation from governments to compensate for its limited resources and authority. Yet, despite not having any authority to do so, then Director General Gro Harlem Brundtland used naming and shaming in the 2002–2003 SARS outbreak to induce cooperation from China, convincing it to share its data with WHO. She accused China of withholding information, claiming that the outbreak could have been contained “if the WHO had been able to help at an earlier stage” and exhorting the Chinese to “let us come in as quickly as possible!”56  Similarly, despite having no formal power to do so, WHO issued advice against traveling to affected areas after SARS spread to Canada, Hong Kong, and Vietnam.

The 2005 IHR revisions were meant to institutionalize the authorities that Brundtland exercised and ground them within a set of rules. Since the adoption of the revised IHR, however, subsequent directors general have tended to prize solidarity, defer to member states in crises, and exhibit an increasing reluctance to declare a public health emergency of international concern, the highest level of alarm that WHO is authorized to issue under IHR.

These tendencies are not particular to this pandemic, the current director general, or China. Since the 2009 H1N1 influenza pandemic, in which WHO was criticized for declaring a PHEIC too early, directors general have often been reluctant to declare them. WHO was also criticized in the last two Ebola epidemics for being slow to declare a PHEIC, against the wishes of DRC and the affected West African nations, which are not significant contributors to the WHO budget. In the DRC epidemic, the current director general questioned whether a PHEIC declaration would bring any additional benefits for outbreak response.57  During the COVID-19 pandemic, WHO has refrained from calling out any nation by name for failing to comply with IHR or follow WHO guidance—on travel bans or anything else.

In the current emergency, WHO’s tendency toward deference has manifested itself in some inconsistent communication, a credulous public stance toward Chinese government claims, and unqualified praise for China’s response. Internal WHO emails, later leaked to the press, indicate that officials complained during the week of January 6 that China was sharing “very minimal information,” hindering assessment of the virus’s spread, its risk to the rest of the world, and proper planning to confront it. Yet, WHO officials did not publicize those concerns and instead continued to portray China in the best light, reportedly in hopes of eliciting better cooperation from China.58  For example, Maria Van Kerkhove, acting head of WHO’s emerging diseases unit, acknowledged at a January 14 press conference that “it is certainly possible that there is limited human-to-human transmission.” Later that day, reportedly concerned about getting ahead of the Chinese government, WHO tweeted, “Preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission” of SARS-CoV-2.

On January 22, the director general convened the IHR Emergency Committee to address the outbreak of COVID-19. At the time of that meeting, many commentators believed the criteria for a PHEIC had been met: a novel coronavirus had spread to six countries, three hundred cases were reported in China and globally, the Chinese government had confirmed human-to-human transmission, and numerous Asian and Pacific countries had begun to impose airport screening measures on travelers from China.59  Nevertheless, Emergency Committee members disagreed on whether the outbreak constituted a PHEIC but agreed to reconvene in a matter of days to reexamine the situation. Under IHR, the director general is not required to follow the advice of the Emergency Committee but, as in past epidemics, has consistently done so in this pandemic.

On January 28, the director general traveled to China to assess the situation firsthand. WHO declared the event a PHEIC on January 30. The Emergency Committee reconfirmed human-to-human transmission and recommended comprehensive strategies for country preparedness. The urgency with which member states took action in response to COVID-19 based on the PHEIC designation has varied, both in terms of the timing and the comprehensiveness of public health measures.

Rather than naming and shaming China for delays in sharing information, WHO opted to focus on events after January 20, lauding the extraordinary measures that China took to slow further spread of the outbreak. The “world owes China a great debt,” a WHO official said in late February, suggesting that other nations follow China’s lead in containing the virus.

By late January, the alarms were ringing loudly enough for many Asian nations and territories to move decisively to respond to the coronavirus. Japan, Hong Kong, Singapore, South Korea, Taiwan, and Vietnam all adopted immediate, aggressive public health measures to contain and mitigate the spread of the coronavirus in their communities and health-care systems. Despite having access to the same information, the United States and many European nations responded more slowly, ramping up only after it became apparent that community transmission of the virus was occurring within their borders. The one exception was the issuance of travel restrictions in response to the outbreak in China.

Most WHO member states disregarded WHO guidance on travel restrictions.

Few member states complied with the notification requirements for travel restrictions, and many rejected the WHO Secretariat’s shifting guidance on such restrictions during the pandemic.

The WHO Secretariat issued its first COVID-19 related travel advice on January 10, recommending against nations screening travelers upon entry: “It is generally considered that entry screening offers little benefit, while requiring considerable resources.” The guidance also stated, “From the currently available information, preliminary investigation suggests that there is no significant human-to-human transmission, and no infections among health care workers have occurred.”60  On January 24, WHO updated its travel guidance, still advising against entry screening for travelers but noting that “the majority of exported cases were detected through entry screening.” WHO has repeatedly since softened its technical guidance, advising “that measures to limit the risk of exportation or importation of the disease should be implemented, without unnecessary restrictions of international traffic.”61

President Trump has criticized the issuance of WHO travel guidance as “political gamesmanship,” incorrect on the merits, and responsible for delaying other nations from imposing lifesaving travel restrictions to and from China. However, at least forty-five nations had already imposed restrictions on travel to and from China before the U.S. restriction went into force on February 2.62  As outbreaks spread in Europe and the Middle East, states began widening the scope of their travel restrictions. By March 27, the number of nations that had imposed travel restrictions on one or more countries had increased to 136. Most of these nations failed to notify WHO of the public health rationale and scientific justification for their travel measures until mid-March, long past the forty-eight hour notification requirement under IHR.63

Rules on travel restrictions were included in the revised IHR because, under previous iterations of that agreement, states parties often delayed reporting disease outbreaks to WHO and other nations out of concern that other states would impose unduly strict measures, harming the trade, tourism, and reputation of reporting nations. The new regulations, as revised in 2005, recognize the rights of states parties to implement health-related travel restrictions as long as those measures are based on public health principles and scientific evidence and are not more restrictive of trade and travel than other measures that would achieve the same level of health protection.

Under IHR, the WHO director general can issue guidance on trade and travel measures responding to dangerous disease events and is required to do so after declaring a PHEIC. This guidance is not binding on nations as a matter of international law. However, the widespread adoption of travel restrictions in this pandemic and the failure of member states to notify and explain the reasons for departing from WHO guidance undermines the viability of IHR. If nations do not have confidence that IHR and WHO guidance will restrain nations from imposing unnecessary and unduly strict trade and travel restrictions, those nations could be less likely to report disease outbreaks early in fear of the economic consequences that notification could bring.

Early research and scenario analysis suggest the combination of travel restrictions within China and international travel restrictions against China could have delayed the spread of COVID-19, but were more effective in nations that also used that time to reduce community spread of the virus.64  Many nations, however, did not do so. During the 2014 Ebola virus epidemic, WHO discouraged travel bans, in part, because of their potential to create “a false impression of control”—a misperception that the ban was sufficient to stop the spread of disease.65  The most recent literature on the topic finds limited evidence to support that travel bans helped minimize the spread of four other emerging infections earlier this century, including the coronaviruses MERS and SARS.66

Nations failed to mobilize a multilateral response.

Much of the responsibility for the weak multilateral response falls on national governments, especially the United States, which often bypassed or ignored WHO and failed to mobilize adequate responses within other critical multilateral forums, including the Group of Twenty (G20), the Group of Seven, and the UN Security Council.

Potentially pandemic diseases are a threat to international security, economic prosperity, and global health, but are not treated with sufficient gravity by the multilateral system. There is no established global mechanism charged with coordinating the various diplomatic, economic, health, scientific, security, and surveillance resources needed to mobilize an effective international response to a severe pandemic. What exists instead is a panoply of multilateral institutions, all of which have underperformed in this pandemic, thanks in large part to their member states.

WHO, the ostensible focal point for global health governance, is under siege. Unhappy with its performance, President Trump announced on May 29 that the United States would leave the already beleaguered and resource-strapped agency, depriving it of its most important member and largest funder. Beyond WHO, national governments have failed to use high-level multilateral forums effectively to forge a collective response to COVID-19, due in large part to geopolitical frictions. Strategic rivalry between China and the United States undercut the potential for the G7, G20, and Security Council to provide political direction to the international system, both in orchestrating a robust public health response and in coping with the economic fallout.

The leaders of the G7, representing the world’s leading high-income democracies, did not convene until mid-March, in a meeting devoted to little more than information sharing. Later that month, a meeting of G7 foreign ministers dissolved into acrimony amid disputes between the United States and its partners over whether their joint statement should refer to the Chinese origins of the coronavirus. The G20, which comprises the world’s most important established and emerging economies, convened to discuss the pandemic for the first time in late March, nearly three months into the crisis, with paltry results. The United States blocked agreement on a joint commitment by the G20 to strengthen WHO’s mandate and arm it with additional resources to coordinate the international fight against the disease. The G20 leaders also failed to take several steps that could have expanded global health cooperation, such as lifting export controls on critical medicines, medical supplies, and basic foodstuffs; ending the disruption of supply chains; and agreeing to prioritize the fast disbursement of medicines and vaccines over the rigid protection of intellectual property rights.67  In mid-April, the group finally agreed to suspend the debt obligations of low-income nations through the end of the year, but the United States rejected a major expansion of International Monetary Fund (IMF) special drawing rights. A planned G20 leaders’ meeting later that month collapsed, however, amid continued U.S.-China rancor over WHO.

Even these lackluster efforts, however, outshone the nonexistent response of the UN Security Council, which was paralyzed by geopolitical maneuvering. In March, the United States insisted that any statement from the body mention the Chinese origins of the virus.68  China, which held the Security Council’s rotating presidency, blocked it from considering any resolution regarding the pandemic, arguing that public health matters fell outside the council’s “geopolitical ambit.” The resulting stalemate prevented the Security Council both from issuing a powerful resolution to mobilize UN agencies and the broader multilateral system and from creating a subsidiary body to provide high-level direction, including to help coordinate the international response in fragile and war-torn states. U.S.-Sino competition helped politicize the pandemic and played a major role in derailing the international response to it. Even during the Cold War, the Soviet Union and the United States worked together to fight polio and smallpox.

The poorly coordinated global response to COVID-19 underscores both a fundamental truth and an inescapable reality. The truth is that multilateral institutions do not spring magically into life during crises. Their success depends on the enlightened leadership of powerful member states, who should be willing to put their differences aside and mobilize these bodies behind a collective effort. The contrast with the global financial crisis of 2008–2009, during which world powers rose to the occasion, is instructive.69  The reality is that we live in an age of heightened geopolitical competition that complicates multilateral responses to future pandemics. The return of balance-of-power politics hinders the easy health diplomacy of the immediate post–Cold War years.

Spotlight: An Abbreviated Chronology of the Early Outbreak of COVID-19
  • December 1, 2019: According to a Lancet study published on January 24, the first cases of COVID-19 date to at least December 1, 2019, and did not originate at the Huanan Seafood Wholesale Market.
  • Late December: Hospitals in Wuhan, China, identify cases of pneumonia of unknown origin.
  • December 30: The Wuhan Municipal Health Commission issues urgent notices to city hospitals about cases of atypical pneumonia linked to the city’s Huanan Seafood Wholesale Market. The notices leak online and are reported in the local press.
  • December 31: A Chinese media report about the outbreak is posted to ProMED, a U.S.-based open-access platform for early intelligence about infectious disease outbreaks. WHO headquarters in Geneva sees the ProMED post. WHO China Country Office requests verification of the outbreak from China’s government.
  • December 31: The Wuhan Municipal Health Commission issues its first public statement on the outbreak, saying it has identified twenty-seven cases.
  • January 1, 2020: WHO requests verification of the media reports from China.
  • January 2-3: Local Wuhan police reportedly reprimand several health professionals, including Dr. Li Wenliang, for spreading allegedly false statements about the outbreak online.
  • January 3: China notifies WHO of the potentially serious disease event and begins sharing information. Chinese Center for Disease Control and Prevention (China CDC) Director General Gao Fu tells CDC Director Robert Redfield about the outbreak in Wuhan.
  • January 4: WHO issues first public statement on the outbreak, tweeting, “China has reported to WHO a cluster of pneumonia cases—with no deaths—in Wuhan, Hubei Province.”
  • January 5: WHO issues formal statement indicating that the China Country Office “was informed” of cases of pneumonia of unknown cause in Wuhan on December 31, 2019.
  • January 6: HHS Secretary Alex Azar and CDC Director Redfield offer to send CDC experts to China.
  • January 6-10: Wuhan Municipal Health Commission issues no updates during five-day political meeting.
  • January 7: China completes genetic sequencing of novel coronavirus later named SARS-CoV-2.
  • January 11: Fudan University researchers post the genetic sequence of the virus on an open-access platform. China CDC subsequently also posts genetic sequences and shares sequence with WHO.
  • January 12-17: Wuhan Municipal Health Commission issues daily updates but reports no new infections.
  • January 13: China National Health Commission officials tell a delegation of health officials from Hong Kong, Macau, and Taiwan that “limited human-to-human transmission cannot be excluded.”
  • January 13: Thai authorities confirm the first case of the coronavirus outside China.
  • January 14: The acting head of WHO’s emerging diseases unit tells a press conference, “It is certainly possible that there is limited human-to-human transmission.” WHO later tweets that preliminary investigations by Chinese authorities “have found no clear evidence of human-to-human transmission.”
  • January 20: China confirms person-to-person transmission and infections among medical workers.
  • January 20: Experts from WHO China Country Office conduct a one-day field visit to Wuhan.
  • January 21: CDC announces the first novel coronavirus case in the United States.
  • January 23: Wuhan suspends public transportation and bars residents from leaving the city.

What Went Wrong Domestically

The Task Force assesses the U.S. domestic performance in responding to COVID-19 as deeply flawed. Despite having declared the threat of pandemics to be a national security priority for over two decades, the United States was unprepared for COVID-19, having failed to integrate and implement the lessons of earlier epidemics and multiple training exercises, to designate a strong focal point for interagency coordination, to allocate resources commensurate with the magnitude of the threat, or to maintain an adequate Strategic National Stockpile (SNS) and an adequate public health infrastructure.

Once the crisis was upon the country, the federal government and many U.S. states compounded these weaknesses by acting too slowly to mobilize an effective response and adopting ill-conceived and haphazard approaches to balancing public health and economic concerns, which produced suboptimal health outcomes and devastating consequences for the economy. Amid these problems, too many federal, state, and local officials failed to communicate a clear, science-based, consistent message to the U.S. population; to develop a robust nationwide system for testing, tracing, isolation and quarantine; or to clarify the respective roles of the national, state, and local governments in pandemic response.

The Task Force appreciates that COVID-19, the greatest public health crisis since the influenza pandemic of 1918, posed extraordinary challenges to the United States. Nevertheless, the nation and its leaders could—and should—have done much better.

Action came too late.

The United States did not act early enough in mobilizing a federal response to COVID-19, and the delay increased both the human and economic toll of the disease.

The Trump administration did not heed multiple warnings from the U.S. intelligence community and WHO of an impending pandemic in early 2020 and was slow to mobilize a vigorous federal response to the virus, despite the pleas of senior U.S. public health officials. Even after WHO declared COVID-19 a public health emergency of international concern, the White House continued to downplay the seriousness of the epidemic during February and into early March, and, other than its imposition of international travel restrictions against China, the administration did not launch a major response to impede and mitigate the domestic spread of the virus until it was well established across the country.

The federal government and many states wasted precious weeks that could otherwise have been used to implement aggressive testing and tracing, social-distancing policies, and isolation, quarantine, and other public health interventions to dampen the rate of new infections. Two prominent epidemiologists estimate that if the government had issued social-distancing guidelines two weeks earlier in March, the United States could have cut death rates by 83 percent in the first months of the pandemic (see figure below).70  Had the guidelines been issued just one week earlier, according to these researchers, mortality would have still dropped by 55 percent.71

 

The failure to support travel restrictions with nationwide surveillance and prompt, targeted containment measures on testing, contract tracing, and isolation of infected individuals facilitated the spread of the disease in the United States. It compelled the nation to adopt more drastic and sweeping public health measures to promote physical distancing and suppress the spread of the virus, incurring profound economic dislocation and pain in the process. This pain was compounded in the summer when, following the hasty decision of many U.S. states to relax social distancing and reopen economically, U.S. infection levels spiked again, forcing many state governments to reimpose restrictive measures to mitigate transmission.

Lessons were not learned.

The United States has declared pandemics to be a national security threat but has not acted accordingly, failing to integrate the lessons of past epidemics, multiple crisis simulations, and blue-ribbon reports underscoring the need for pandemic response capabilities, or to organize itself effectively to coordinate such a response.

For more than two decades, through both Republican and Democratic administrations, the U.S. government has explicitly recognized infectious disease as a growing threat to national and international security, a reality reinforced by multiple past epidemics, from SARS to H1N1 to Ebola. The executive branch has drafted numerous detailed strategy documents underscoring these risks, including the George W. Bush administration’s National Strategy for Pandemic Influenza (2005) and the Obama administration’s National Strategy for Countering Biological Threats (2009) and Executive Order on the Global Health Security Agenda (2016). More recently, the Trump administration issued the National Biodefense Strategy (2018) and Global Health Security Strategy (2019).72  Congress, meanwhile, has held multiple relevant hearings, including on the reauthorization of the Pandemic and All-Hazards Preparedness Act, first signed into law by George W. Bush in 2006, as well as the quadrennial National Health Security Strategy.73

Despite this avowed concern, the Task Force sees a repeated lack of urgency, resources, and political will to prepare the nation for the risks.74  Rather than developing a standing capacity to prevent, respond to, and mitigate pandemics, the United States has too often paid lip service to readiness, resulting in a pattern of crisis response followed by policy drift. This lack of prioritization is clear in the U.S. federal budget, which devoted $750 billion to the U.S. military in fiscal year (FY) 2020, but a paltry $547 million to secure itself from global health security threats of the sort that brought the nation to its knees in early 2020.75  Breaking this pattern will require elevating pandemics in U.S. national security strategy and making decades-long investments in pertinent resources and institutional structures, rather than reinventing the wheel in response to each new emergency.

Although the specific timing, origin, and epidemiology of COVID-19 were impossible to predict, the U.S. government was well aware of the need for pandemic preparedness. In the years and even months before the current emergency, U.S. government agencies and outside groups organized multiple crisis simulations and issued prominent reports highlighting not only the inevitability of future pandemics but also the multiple public health and other policy challenges such crises would present to the United States.76  In 2016, the Obama administration sought to distill the lessons learned from the Ebola experience, and, in early 2017, prepared for the incoming administration a sixty-nine-page “Playbook for Early Response to High Consequence Emerging Infectious Disease Threats and Biological Incidents.”77  From January to August 2019, the Trump administration’s Department of Health and Human Services (HHS) ran an ambitious simulation of a pandemic influenza outbreak in the United States. That scenario, dubbed Crimson Contagion, concluded that the national response to such a major public health emergency would be hindered by dangerous gaps in funding and inadequate coordination across government agencies.

Outside government, multiple commissions published reports, including the Bipartisan Commission on Biodefense, the National Academies of Science, Engineering, and Medicine, and the Center for Strategic and International Studies (CSIS), stressing the need to end the complacency in U.S. pandemic preparedness.78  The slow and haphazard U.S. response to COVID-19 demonstrated that the United States had failed to internalize these warnings and the lessons of past crises, and to develop the standing capabilities and institutional tripwires needed to galvanize a rapid and integrated government response.

The federal government was poorly organized in early 2020 to coordinate a national pandemic response, an undertaking that requires it to marshal the unique competencies and resources of multiple federal agencies. Experience suggests that the best way to accomplish this goal is to designate a senior official to serve as the focal point for policy coordination within the White House and to charge that person with supervising the design and implementation of a comprehensive, government-wide strategy.

The lack of such a strong central coordinating node in the White House appears to have undercut U.S. performance during the first months of the COVID-19 pandemic. Prior to May 2018, responsibility for coordinating interagency pandemic response fell to the National Security Council (NSC) directorate for Global Health Security and Biodefense. The Trump administration merged that directorate with the counterproliferation directorate, which led to an erosion in expertise and the number of personnel dedicated to global health security at the NSC.79  At the State Department, the lead for pandemics was assigned to the Office of International Health and Biodefense, a small part of the Bureau of Oceans and International Environmental and Scientific Affairs—the only State Department bureau never to have an assistant secretary nominated by the Trump administration. Lacking a strong focal point in the NSC, the president initially assigned responsibility for coordinating the U.S. government response to a single cabinet department, HHS, before shifting that role to a committee chaired by the vice president, an official with another day job and many other competing demands on his time.

U.S. capacity to monitor and influence health developments in China has also diminished in recent years. The staffing in CDC’s China office was cut from forty-seven in 2017 to fourteen, including only three Americans, before the coronavirus outbreak occurred. The bilateral agreement that HHS and the CDC had with the China CDC expired in 2017, and the bilateral protocol between the two nations on sharing information about emerging infectious diseases expired in June 2020.

Although the importance of bureaucratic wiring diagrams is prone to exaggeration, institutional position, staffing, and competencies do matter. Coordinating a whole-of-government response is much more difficult from lower-level department offices than from the beating heart of the executive branch.

Communications were unclear, inconsistent, and often politicized.

Communicating clear, credible, and timely information is essential during pandemics. During the first months of the COVID-19 pandemic, U.S. communication campaigns were scattered, inconsistent, and too often politicized rather than grounded in science and public health.

In any public health emergency, the onus is on senior federal, state, and local government officials to communicate with the American people in an honest, transparent, and timely manner about the pertinent pathogen and the danger it poses. The federal government did not meet this obligation in the initial months of the pandemic. President Trump and officials in his administration offered inconsistent opinions about the gravity of the coronavirus, as well as contradictory public health guidance to states, municipalities, and individuals. Administration officials delayed and limited outreach from experts at agencies such as the CDC, which should have been front and center in sharing the latest data and offering timely, unvarnished guidance to the American people.80  Some state and municipal officials likewise failed to provide consistent messages to the public about the gravity of the threat and the need for evidence-based policy responses.

Within American society more generally, intense ideological divisions often complicated a common understanding among U.S. citizens of the risks of COVID-19 and the most effective strategies to combat it. Individuals and groups retreated to their partisan corners, and the pandemic became a political football. Federal, state, and local public health officials were subjected to harassment and personal attacks.81  Many people questioned the reality of COVID-19 and the value of basic measures such as masks and testing, clearly an unacceptable outcome from scientific and public health perspectives.

The experience with COVID-19 underscores the importance of U.S. government officials, from the White House on down, providing U.S. citizens, residents, and visitors with clear, up-to-date, reliable information about the risk of infection and the public health measures needed to combat the spread of the disease. Such education is particularly important given the prevalence of misinformation in the public discourse and its magnification on social media, as well as the dangers posed by foreign state-sponsored information warfare.

Finally, in any pandemic, the government should be prepared to update and fine-tune its public health message as the situation evolves. Mask-wearing provides a case in point. Initially, U.S. public health officials suggested that masks should be reserved for health workers and that only sick members of the general public should wear them. Those officials updated their guidance as evidence emerged on the importance of mask-wearing for reducing community transmission of this virus, but many of the country’s political leaders muddled that message.

More testing and tracing were needed.

The U.S. response to COVID-19 was undermined by the failure to rapidly stand up a reliable nationwide system of testing and tracing. Without a way to accurately identify infected people and those with whom they had been in recent contact, public health authorities were too often operating without crucial information.

A core component of any effective pandemic response is a timely and reliable system for testing and tracing that allows public health officials to identify and isolate sick people, as well as find those with whom the infected have been in recent contact. From the outset of the pandemic, the United States has struggled to meet this objective. Between the release of the genetic sequence of the coronavirus on January 10 and March 1, U.S. public health departments conducted fewer than one hundred tests for coronavirus infection. Without more testing or even systems for testing in place, local, state, and national authorities faced an uphill battle in gauging the disease’s prevalence and rate of transmission, as well as crafting public health interventions that would allow healthy people to continue to go about their lives as the infected and vulnerable were isolated. As late as the end of August 2020, when this report went to press, the United States had failed to develop an accurate, reliable national system for coronavirus testing, to its great cost.

Most countries that have successfully grappled with the pandemic have done two things right: embraced social-distancing policies and implemented an effective nationwide system of testing and tracing. By failing to achieve the latter, the United States allowed the virus to spread and compounded the resulting economic pain. A comparison with South Korea is striking (see figure below). Within a week of the first reported case of community transmission in late February, South Korea had tested more than sixty-six thousand people. The United States, whose population is more than six times as large, did not perform a similar number of tests until nearly a month later, exacerbating an already late start.82  The lack of clear data about who was infected and who was not had economic as well as public health ramifications because it forced states, localities, and employers to implement blunt interventions that effectively shut down social mobility and market activity, rather than separate those infected from the remainder of the population.

 

After many delays, the availability of testing gradually improved. By early May, some nine million Americans, or 2.7 percent of the country, had been tested, and daily tests had ramped up to three hundred thousand, a figure still below the level needed to make informed decisions about opening schools, businesses, sporting events, summer camps, and social gathering spots. On May 11, the White House announced that it would devote $11 billion from the funds Congress had previously appropriated for coronavirus relief to assist states in testing.83  As of mid-August, however, just $121 million of those funds had been used, and much of an additional $8 billion appropriated to HHS for expanding testing and developing contact tracing had not been distributed, despite a nationwide spike in COVID-19 cases.84

The federal government underinvested in local preparedness.

Years of federal underinvestment in pandemic preparedness at the local and hospital level undercut the U.S. response to COVID-19.

Pandemics are global, but the battle against them is won and lost in local trenches. Over the past two decades, federal support for state and local public health emergency preparedness and response has declined by hundreds of millions of dollars. Despite multiple congressional reauthorizations, funding for the CDC’s Public Health Emergency Preparedness cooperative agreements has decreased by more than 25 percent since 2002, reducing an essential source of support for core public health capabilities in states, territories, and local areas (see figure below).

 

It was not supposed to be this way. In response to the 9/11 terrorist attacks, Congress created the Hospital Preparedness Program (HPP) to mobilize health-care organizations and hospitals with significant federal support in the event of a regional or national emergency. Managed by the HHS office of the assistant secretary for preparedness and response, the HPP program works with 360 health-care coalitions and was involved in the response to the 2009 H1N1 pandemic, the Boston Marathon bombings, and, more recently, Hurricanes Harvey, Maria, and Irma. Since 2004, however, successive administrations and Congresses have halved the HPP budget, reducing the single source of federal funding to help regional health-care systems prepare for emergencies such as pandemics.85

In FY 2018, twenty-nine states received 50 percent or more of their public health funding from the federal government. Over the last decade, local public health departments have cut an estimated 56,360 staff positions due to funding issues.86

The Coronavirus Preparedness and Response Supplemental Appropriations Act (H.R. 6074, P.L. 116-123), enacted on March 5, 2020, began to address the shortfall in funding to states. It provided $2.2 billion to the CDC to fund prevention, preparedness, and response efforts, of which $950 million was allocated to state, local, territorial, and tribal public health response; $300 million would replenish the Infectious Disease Rapid Response Reserve Fund.

The U.S. stockpile was not well stocked.

The pandemic has exposed shortcomings in—and disagreements over the purposes of—the Strategic National Stockpile.

COVID-19 presented the first major test since H1N1 in 2009 of the SNS, an emergency repository of antibiotics, antitoxins, vaccines, protective gear, and other essential medical equipment for public health emergencies, under the auspices of the assistant secretary for preparedness and response at the Department of Health and Human Services since 2018.87  The stockpile was created to provide state and municipal (as well as tribal and territorial) governments with essential medicines and supplies not otherwise immediately available or which could become quickly depleted during emergencies.88  During the early phases of the pandemic, the SNS struggled to meet heavy demand from states, exacerbating shortages of pandemic response materials in many areas of the country. The experience exposed several weaknesses in the SNS system: insufficient funding, oversight, maintenance, and transparency; a flawed procurement and distribution system that struggled to fill, in a timely manner, the ongoing inventory needs from the front lines of the health system; and lingering uncertainties about the respective responsibilities of the states vis-à-vis the federal government during emergencies.

The SNS contains around $8 billion worth of supplies, but insufficient appropriations had left its pandemic response materials under-replenished since their deployment in 2009 to combat H1N1.89  The coronavirus pandemic placed heavy demands on the stockpile, revealing to the public the extent of the shortages of protective masks, ventilators, and other materials. By April 1, only a few weeks into the pandemic, the Department of Homeland Security acknowledged that the supply of personal protective equipment in the SNS had been almost entirely depleted. Lack of transparency and oversight have also emerged as concerns, including on Capitol Hill. The Trump administration exercised considerable discretion over the distribution of supplies from the stockpile, prioritizing some states over others and eliciting concerns about the motives behind these distributions.90  More generally, the pandemic revealed a lack of clarity over the purposes of the SNS and the expectations that states should have for it: many governors argued that the SNS should be the states’ first port of call in an emergency, whereas the White House contended that it was designed merely to supplement and resupply inventories of medicines and supplies during emergencies severe enough to exhaust the states’ stockpiles, which the crisis had revealed to be minimal.

The Task Force finds that the SNS was not at full strength when the pandemic hit the United States, complicating emergency response. At the same time, the Task Force recognizes that the stockpile was never intended to be a permanent solution to any public health emergency. Rather, it was designed as a temporary, stopgap mechanism, to tide the nation over until private-sector supply chains could respond to demand, or until the president invoked the Defense Production Act (DPA). Many states failed to maintain adequate stockpiles, however, leaving them unprepared when the pandemic struck. Although a better-funded SNS, as well as a more rapid invocation of the DPA, could have ameliorated the situation, the shortages of essential medicines and medical equipment that the nation experienced in early 2020 also reflected more fundamental failures of the U.S. health-care sector, which is based on a model of just-in-time replenishment of inventories in the interest of economic efficiency but at the expense of resilience and preparedness.91

Lines of authority in the United States were unclear.

Mounting an effective U.S. response to pandemics and other major crises requires clear delineation of authority and responsibility among local, state, and national officials and agencies, as well as strong coordination at the federal level. In the absence of such clarity, U.S. political authorities often worked at cross purposes, increasing the human and economic toll of the pandemic.

The United States has lacked a unified response to COVID-19, given that states have diverged in their strategies for addressing the pandemic amid a paucity of coordination and guidance at the federal level. States such as Washington were quick to implement mitigatory measures such as shelter-in-place orders, whereas states such as Florida tarried in adopting large-scale responsive measures to outbreaks within their borders and eased those social mandates sooner than other states. States competed with one another and even the federal government for essential medical and other supplies, and governors formed regional coalitions to secure pandemic response materials and coordinate policy.

Although the federal government has taken several important measures to respond to COVID-19—including implementing restrictions on international travel, forming a national coronavirus task force, and distributing limited supplies—guidance to subnational authorities has often been lacking or in contradiction to state-level policies, particularly in relation to business and movement restrictions. The Trump administration has disavowed primary responsibility for supplying states with medical and protective equipment, even as disputes have arisen between states and federal agencies, such as the Federal Emergency Management Agency (FEMA), over pertinent shipments. In the absence of federal government support, states scrambled to improvise. In the case of Maryland, the governor relied on his wife (a U.S. citizen of South Korean heritage) for help in securing five hundred thousand coronavirus test kits from the Republic of Korea.92

Lack of adequate coordination has led to tensions between authorities at subnational and national levels and highly varied policies and outcomes across U.S. jurisdictions. It has also increased the risk of subsequent spikes in infection rates, given that state lines remain porous to travelers and the pathogens they carry.

Generally speaking, federalism has many benefits for U.S. politics and society, not least in permitting policy experimentation tailored to state circumstances. In the midst of a raging pandemic, however, it can complicate a coherent public health response and impose economic costs, pitting state and local jurisdictions against the federal government and one another, as well as forcing subnational authorities to assume responsibilities and build capacities on the fly.

The United States lacks adequate mechanisms to coordinate its domestic and international activities on supply chains, vaccine development, and disease surveillance.

The United States cannot afford to develop and implement domestic preparedness policies and initiatives in isolation, without considering international factors that will help determine their success. The COVID-19 pandemic has exposed the risks of depending on fragile, overextended global supply chains for essential medicines and critical supplies; of relying on purely national efforts to develop disease countermeasures, without a multilateral mechanism to ensure their global manufacturing and equitable distribution; and of failing to link national systems of disease surveillance with an effective global surveillance system.

Complex and opaque globalized supply chains, including for critical medicines and medical equipment, pose major vulnerabilities to the United States and other countries during pandemics.

As the world economy has in recent decades become more integrated, supply chains have become more complex and far-flung, reliant on offshore manufacturing, often spanning multiple countries, and just-in-time modes of production that prioritize quick turnarounds on orders and warehousing as few goods as possible.93  This new, globalized economic geography has afforded significant consumer savings and other benefits at the cost of decreased national autonomy and greater vulnerability to exogenous and geopolitical shocks, with a single broken link capable of interrupting the entire chain.

COVID-19 has underscored how both crises and political responses to them can disrupt supply chains and exacerbate shortages of crucial goods. Shutdowns in China in January and February highlighted how economic decisions at the national level can reverberate across global markets when production is highly concentrated within a particular country. Decreased exports of medicines, PPE, and other critical supplies led to shortages in the United States, European Union, and elsewhere, reducing pertinent countries’ capacity to respond to the spread of the disease within their borders while heightening geopolitical tensions and undermining international coordination. Policymakers, given their limited knowledge of the structure of these supply chains and little initial recourse to domestic manufacturers, face significant constraints in their ability to ensure adequate supplies of goods in times of crisis.

The international system lacks a widely supported multilateral mechanism to encourage the joint development of and equitable, public health–driven distribution of lifesaving vaccines and treatments. Further, no adequate mechanism is in place for national and global epidemic surveillance and forecasting.

The development and widespread distribution of COVID-19 medical treatments, particularly vaccines, are a common global interest. COVID-19 has already caused scarcity of medical resources in health systems and severely hurt the global economy. Until effective vaccines are developed and widely deployed, SARS-CoV-2 will circulate in human populations unabated, threatening health and economic security.

Vaccine research and development (R&D) is an element of U.S. and global pandemic response that moved extraordinarily quickly. On January 10, scientists from the National Institute of Allergy and Infectious Diseases received the genetic sequence for the coronavirus and four days later had already begun development of several vaccine candidates, working with partners from the Coalition for Epidemic Preparedness Innovations (CEPI). The first U.S. vaccine entered clinical trials sixty-six days after the virus was sequenced. Scientists from across the globe are now racing to develop effective vaccines and therapeutics for COVID-19. Once clinical trials demonstrate which vaccines are safe and effective, doses need to be manufactured to scale. Now is the time to plan for augmenting the manufacturing capacity, financing, and distribution infrastructure necessary to produce sufficient quantities to meet global needs in a fair, public health–driven manner.

Unfortunately, at the time of writing, no adequate financial, legal, and regulatory mechanisms are in place to ensure the equitable, public health–driven distribution of vaccines, therapeutics, and diagnostics for COVID-19 worldwide. Neither does an adequate mechanism exist to provide the predictable, multiyear financing for the manufacturing and global deployment of these products. Manufacturers will also be hesitant to participate in a global vaccine allocation arrangement without indemnification, product liability insurance, or a capped injury compensation program to mitigate risk. There is no transparent regulatory pathway for approval of COVID-19 products that can instill global confidence, reduce development costs, and expedite access in less remunerative markets. At the time of writing, the European Commission–backed Access to COVID-19 Tools Accelerator—an initiative devoted to rapid development, procurement, and equitable deployment of therapeutics, vaccines, and diagnostics—is promising. It has yet, however, to attract the full participation of major pharmaceutical powers such as the United States, China, India, and even some European nations.

Absent a commitment to such a global plan, governments are likely to prioritize providing early doses to members of their populations—even to low-risk individuals—over international initiatives to end the crisis sooner. Even within those countries, the distribution of treatments could be inequitable. During the 2009 (H1N1) pandemic, high-income nations bought virtually all vaccine supplies. Even after WHO appealed for donations, supplies for low- and middle-income countries were limited. Reportedly, some governments have sought exclusive access to a promising COVID-19 vaccine candidate. European and Asian countries have imposed export controls on PPE and ventilators, and similar export controls are likely to extend to COVID-19 vaccine and therapeutic stocks. The United States, meanwhile, has sought to lock up the global supply of the therapeutic remdesivir to ensure that its own population is covered.

These are dangerous precedents. Over the last decade, R&D and manufacturing capabilities have become more globally distributed. The best treatments and vaccines against COVID-19 could well be developed and manufactured outside traditional centers of pharmaceutical innovation. High-income countries cannot count on outbidding competitors if vaccine and therapeutic stocks are kept by countries that manufacture these therapies. Cooperation thus remains a matter of necessity for all nations, and within nations, to ensure equitable distribution of therapies.

Global and national surveillance and monitoring of epidemic threats are still lacking.

This pandemic has demonstrated the potential and limitations of the existing systems for epidemic surveillance and monitoring. The world first learned of the coronavirus outbreak in December 2019 thanks to a report posted on ProMED, a nongovernmental emerging disease monitoring program established by the Federation of American Scientists in 1994. A flu surveillance program, the Seattle Flu Study, was the first to detect community transmission of SARS-CoV-2 in the United States.

At the same time, the pandemic has revealed crucial gaps in data collection during an emerging outbreak. In the early weeks of this pandemic, there was no single repository at the CDC or WHO for standardized, open-source data where public health officials and researchers could access and analyze cases.

U.S. disease surveillance has long been the job of multiple federal agencies that operate without a true national system for consolidating reporting from states, ensuring its consistency, and sharing and collecting that same data internationally. Differences of measures on infections, COVID-attributable hospitalizations and deaths, and testing have hindered the ability of the U.S. national and local governments to detect threats and to learn from the experience of other national and subnational governments. A similar situation exists internationally, where no universal or standardized way of collecting and reporting epidemiological data across countries has been established. Public health agencies often provide data to the public via their websites and situational reports, but delays in reporting are common, and incompatible formats across reports complicate quantitative analysis.

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