By the most basic of measurements — rates of illness and death — the U.S. response to the Covid-19 pandemic has been catastrophic. So it seems inevitable that there will be an independent, bipartisan commission to evaluate the nation’s preparedness and response to the pandemic, in the style of the famous 9/11 commission empaneled in 2002. Already, many experts are calling for such a panel.
The response to Covid-19 leaves behind a target-rich environment for any pandemic commission. Nearly 130,000 Americans have died of the respiratory disease since February. Over 2.5 million have become sick. And perhaps most jarringly, in states like Arizona, Texas, California, and Florida, the situation appears to be getting worse, not better: New coronavirus cases and deaths are skyrocketing amid substantial resistance to basic public health measures like social distancing and wearing masks.
The country’s long list of missteps includes decisions from President Trump, governors, local officials, and even activists who have vocally resisted mitigation measures like wearing masks and maintaining social distancing. Looking more broadly any examination could begin with the country’s failure to build infrastructure for testing and contact tracing in early 2020, Trump’s consistent downplaying of the virus even amid mass death, and the Centers for Disease Control and Prevention’s highly publicized testing debacle.
STAT asked five reporters who have covered Covid-19 for nearly six months to lay out the 10 most important issues that a pandemic commission would undoubtedly seek to investigate. Below, a look at the decisions that defined the U.S. government’s coronavirus response and that, in retrospect, held thousands of lives in the balance:
— Lev Facher
The sidelining of the CDC
In previous major disease outbreaks, the CDC would take a lead role, both in the running of the response and communicating to the public about it. This time, the world’s preeminent disease response agency has been largely silenced.
In early March, the Department of Health and Human Services stopped giving the CDC clearance to hold press briefings. During the worst disease outbreak in a century, the CDC went 95 days without holding a Covid-19 related press conference. Chaotic and often facts-light press conferences featuring Trump and a coterie of officials named to a White House coronavirus task force took their place.
The CDC director, Robert Redfield, often took a backseat to the more assertive Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and struggled to stay on message. Fauci is an infectious diseases expert, to be sure. But a public health practitioner he is not.
The politicization of evidence-based decision-making
Of myriad failures in the U.S. response to Covid-19, future historians will likely save their most scathing assessments for the way the response to this pandemic was politicized, including by a president who repeatedly insisted the virus would likely just go away.
Evidence-based public health advice has been routinely ignored, watered down, or overridden by top U.S. officials. The release of the agency’s guidance on how schools, businesses, and other organizations could reopen was delayed by a month as it went through vetting in Washington. The final guidance offered far more latitude than in earlier versions.
Case in point: The CDC initially suggested choirs be temporarily sidelined as churches began to again hold in-person services. Several large outbreaks have been associated with choirs; the act of singing propels virus from infected throats towards those in the singer’s vicinity. The CDC posted its advice, but it was instructed by the White House to take out the advice against choirs.
Airport screening and restrictions on foreign travel
The president banned most travel from China on Jan. 31 as Covid-19 raged through Hubei province. And in the months since, he’s repeatedly cited that action, and a subsequent European travel ban in March, as evidence the federal government acted swiftly and dramatically to prevent the coronavirus from spreading through the U.S.
Public health officials including Fauci, the country’s infectious diseases research chief, have acknowledged the move bought the government valuable time to prepare for an onslaught of cases by building up testing and contact-tracing capacity, preparing mobile hospital facilities, and stockpiling protective gear for medical workers.
Despite the restriction, roughly 40,000 people entered the U.S. from China in February and March. Many were American citizens or permanent residents excluded from the ban (but, of course, no less likely than Chinese citizens to be carrying the virus.) More troubling was that American airports employed inconsistent and spotty screening procedures. And though travelers were asked to self-quarantine for 14 days after arrival, the guidance wasn’t enforced. The same is true for Trump’s Europe travel ban, after which Americans scurrying home on transatlantic flights likely seeded outbreaks in major U.S. cities.
Even if the travel ban did buy the government time, it wasn’t put to use: American health care workers were under-resourced in terms of testing kits and protective gear even once the pandemic arrived in earnest in March.
Guidance for Americans traveling overseas and boarding cruise ships
By the end of February, it was clear the SARS-CoV-2 virus was spreading rapidly far beyond China. But with spring breaks coming, countless Americans had already booked international travel — and there was evidence that cruise ships were becoming hotbeds of transmission.
The CDC’s quarantine and migration division pumped out alert after alert, first telling travelers bound for affected areas to be cautious, then urging people at high risk to reconsider travel.
The group drafted two extraordinary Level 3 travel alerts. A Level 3 is the highest warning the CDC can issue. It means: Do not travel unless it is absolutely necessary. One Level 3 urged Americans not to take cruises because of the risk of Covid-19. The other told Americans to avoid all international travel.
But approval from HHS took time. The Trump administration declared the pandemic a national emergency on March 13. But the Level 3 for cruises wasn’t issued until March 17. And inexplicably, the CDC wasn’t cleared to post the Level 3 alert warning against international travel until March 27, 11 days after the administration asked Americans to shelter in place to try to slow the spread of the virus. The latter was in the works “for weeks,” a source familiar with the situation told STAT.
The testing debacle
The original sin of the U.S.’s coronavirus response is a botched approach to testing in the early days of the pandemic, marked by scattershot leadership, mixed messages, and sluggish bureaucracy.
In February, as Covid-19 crept into coastal states, the CDC rejected a widely used test from the WHO in favor of its own. That test soon proved problematic, leading to unreliable results stemming from a rushed manufacturing process. Because of constrained supply, the CDC was processing only around 100 tests per day by mid-February, dramatically undercounting the number of infected people around the country.
Hospitals and private laboratories around the country had come up with tests of their own, but a slow-footed FDA process kept them from being put to use. The FDA didn’t relax its regulations until the end of February, delaying widespread testing until well into March. By then, the virus had silently taken root in major metropolitan areas.
Those squandered early weeks of pandemic response left public health officials flying blind. Constrained supplies forced them to ration tests for patients with the most severe symptoms, making it impossible to get a broad sense of the virus’s prevalence. As other countries used widespread testing and contact tracing to isolate outbreaks, the U.S. was scrambling to discern the scope of the crisis.
The FDA’s decision to green-light an unproven drug
In March, the Food and Drug Administration took the controversial step of granting emergency authorization for the use of the malaria drug, hydroxychloroquine, to treat Covid-19 — despite a dearth of evidence that the drug was actually an effective treatment for the infection. As studies piled up showing that the drug, in fact, did not work and might be harmful, the FDA was forced to reverse course: It revoked the emergency authorization in June.
Already, there are signs that the FDA issued this authorization under pressure from President Trump, who personally promoted the drug and took it for two weeks in hopes it would prevent Covid-19. Rick Bright, a vaccine expert and now a federal whistleblower, has alleged that the emergency authorization orders for the unproven drug came directly from the White House and HHS leadership, despite the fact that top FDA regulators were concerned about allowing widespread use.
Following the FDA’s authorization, a number of states amassed their own massive stockpiles of the drug, potentially wasting taxpayer money. And it’s still not known exactly how much public health damage was done by the FDA’s decision. How many patients, for example, were unsuccessfully treated with the drug, experienced serious side effects, or had to forgo access to other, more promising, treatments?
Oversight of the Strategic National Stockpile and distribution of personal protective equipment
The U.S. has an emergency stash of medical gear for situations precisely like 2020, when a pandemic meant that hospitals and health care workers across the country needed protective gear and other medical equipment that, suddenly, was in short supply.
The majority of the 13 million N95 respirators in the stockpile were expired when the pandemic began. Much of the mask supply had not been replenished since 2009, when the H1N1 influenza pandemic forced the Obama administration to bulk up on supplies. Facing severe shortages, federal officials quickly announced plans to buy 500 million N95 masks over a period of several months — as well as a dramatic mobilization to acquire and manufacture ventilators, though a feared shortage has not materialized.
The widespread shortfall of protective gear like masks, face shields, and medical gowns eventually pitted states against one another in a bidding war that left governors to fend for themselves. Charlie Baker, the governor of Massachusetts, called in a personal favor and used the New England Patriots team plane to ferry N95 masks from China. Larry Hogan, Maryland’s governor, was so concerned about federal interference that he deployed state police to guard 500,000 test kits he had flown in from South Korea.
The supply issues also came in the wake of a behind-the-scenes turf battle through which the Trump administration wrested the stockpile from the CDC’s control and placed it, instead, under the purview of Robert Kadlec, the assistant health secretary for preparedness and response. The stockpile that’s supposed to backstop U.S. health officials even in the most dire of situations, by most accounts, failed its first test under new ownership.
The chaotic rollout of the first drug approved to treat Covid-19
In May it seemed there was finally a breakthrough in treating serious Covid-19 infections. Clinical trials were proving that Gilead’s remdesivir was effective in shortening recovery time for patients, the company had committed to donating its stockpile of the drug, and the FDA had issued an emergency authorization to allow nationwide distribution. But then the federal government bungled the distribution of the drug, forcing hospitals, public health officials, and families to scramble to track down doses of the treatment before dying patients ran out of time.
In May, STAT reported that just two dozen hospitals were selected to receive the first tranche of remdesivir, and not even hospital administrators who received the drug could determine how those distribution decisions were made. Gilead scrounged up more doses of the drug to donate to U.S. hospitals and the Trump administration set up a clearer system hospitals could use to request the drug, but those chaotic few days in the midst of the height of the pandemic likely had life-and-death consequences.
The decision to reopen non-essential business
Trump started to talk about reopening the U.S. economy well before public health officials had successfully contained Covid-19. On May 7, a day the country recorded roughly 28,000 new cases, he unveiled a phased, state-by-state reopening plan that would allow governors and local officials to restart their economies after hitting certain benchmarks in terms of new cases and trends in how the virus spread through communities.
Even then, the president acknowledged the move might lead to additional deaths, saying at a roundtable: “Will some people be affected? Yes. Will some people be affected badly? Yes. But we have to get our country opened and we have to get it open soon.”
Trump’s remarks, along with that of governors who aggressively pushed to reopen in states like Colorado, Texas, and Florida against the advice of many public health experts, helped to set the tone for a country frustrated with weeks of lockdown.
The reversal on guidance on whether to wear masks
As the virus gained steam in the U.S. in February and March, federal officials were resolute in their advice: Healthy people shouldn’t wear face masks. “Seriously people- STOP BUYING MASKS!” Surgeon General Jerome Adams tweeted on Feb. 29. The rationale behind the recommendation, echoed by the WHO, was twofold: Surgical masks needed to be reserved for health care workers, and there wasn’t good data on the effectiveness of the many different types of cloth masks suddenly in high demand.
But as the outbreak spread and research shed light on the transmission of the virus, federal officials began to reassess that recommendation, as did the WHO. On April 3, the Trump administration reversed its previous position: Actually, Americans should wear cloth masks in public places, like grocery stores, where it’s hard to socially distance from other people.
Now, some states and municipalities mandate masks in certain public places, and face coverings are seen as one of the most promising ways to reopen society without accelerating the spread of the virus.
But the decision-making process sowed distrust and confusion along the way, and questions remain about whether the turnabout happened as quickly as it should have.
Helen Branswell, Lev Facher, Nick Florko, Damian Garde, and Rebecca Robbins contributed reporting.