CORONAVIRUS

America Had Several Pandemic Warnings (Re-Upload)

This is Part 1 in a series of articles on the United States COVID-19 public health response. Click here to see the other parts.

This article can also be found in my “Issues Breakdown” section.

Photo by United Nations COVID-19 Response on Unsplash

It is embarrassing that the United States botched the COVID-19 response when you realize that the warnings were all there. Honestly, it would almost be funny if millions of people weren’t suffering because of the pandemic.

In the past few years, we’ve had multiple signs that a pandemic could come our way and wreak havoc if the country didn’t prepare. Let’s run down all the red-flags that the US should have noticed, shall we?

Vocabulary

First, let’s go through a few acronyms that I’m going to use a lot.

1. HHS — the Department of Human Health Services. This is an executive branch department right under the President that oversees public health.
2. CDC — The Centers for Disease Control and Prevention. This is one agency within the HHS.
3. DHS — Department of Homeland Security.
4. FDA — Food and Drug Administration. This is another HHS agency.
5. USDA — The Department of Agriculture.
6. DPA — Defense Production Act. This is a law that allows the President to order manufacturing companies to produce supplies that the country needs in an emergency.
7. BIA 2017 — Biological Incident Annex to the Response and Recovery Federal Interagency Operational Plans. This is a pandemic plan that the Trump administration released in 2017 (This is not a standard acronym, this is just my acronym that I’m using for this plan).
8. PPE — Personal Protective Equipment. This includes masks and gloves — things that people wear to protect themselves from getting infected.

Ok, now let’s talk about the pandemic warnings.

Warnings of the Previous Administration

President Obama talks about the need to establish a response plan for future outbreaks.

Let’s start with what the previous president told us. In 2014, after the Ebola virus outbreak, President Obama warned of the need for an “infrastructure” to detect and stop a disease outbreak quickly to keep Americans safe. After a close-call with the Ebola virus in which 2 Americans died on US soil (unfortunately Africa was not so lucky) along with another close-call with the 2009 swine-flu outbreak, it was clear that epidemics would return in our globalized world.

In response, Obama’s administration released a “Pandemic Playbook” in 2016, which explained what questions need to be asked, what decisions need to be made, and what actions to take at each stage of a pandemic. I should note that — in my view — this playbook is flawed as, while it does explain each government agency’s role, the division of roles is sometimes unclear.

Anyway, that’s not the point here. The point is that Obama gave the warning of a pandemic, and if the Trump administration found flaws in the playbook, they could have improved upon it.

However, the Trump administration discarded the playbook and started from scratch, which uses up valuable time in pandemic preparation.

When the previous administration experiences not one but two outbreaks, then warns that a new one could come along and that they’ve released a plan that you can use, you should heed their advice and get prepared.

Incidentally, that is what the Trump administration did… sort of…

The Crimson Contagion Simulation

To be fair, the Trump administration released a pandemic plan in January 2017, called the Biological Incident Annex to the Response and Recovery Federal Interagency Operational Plans. I’ll call this plan “BIA 2017.”

However, no plan is perfect. So in October 2019, the HHS tested BIA 2017 by performing a simulation of a flu outbreak, called the “Crimson Contagion.” This was NOT a computer simulation. Rather, the HHS devised a scenario in which tourists return to the US with a novel flu strain. The government conducted a “functional exercise” with various agencies, states, hospitals, etc. in which they carried out their plans as if an outbreak occurred in America.

The exercise included 19 government departments and agencies, 12 states, 74 local health departments, 15 Native American tribes, 87 hospitals, and over 100 private sector partners (e.g. labs and manufacturers). The exercise lasted 4 days. During that time, these various groups acted the way they would during a real pandemic — they collected the necessary information, made the necessary communications and key decisions, etc. The 4-day exercise occurred 47 days after the hypothetical entry of the virus into the US.

Throughout the simulation, all parties acted under BIA 2017 to test the efficacy of the protocols listed out.

What did they learn?

The Roles of Government Agencies and Departments are NOT Clear

The first and most glaring problem was that the roles of government agencies and departments were not distinguished. For example, it was unclear which department should be the “leader” during a pandemic response.

On the one hand, some laws — such as the 1932 Economy Act and the 1944 Public Health Service Act — stated that the HHS should lead a pandemic response effort. However, other laws state that the DHS should lead this effort. “Leadership” in this context entails coordinating the responses of other government agencies, tracking the supplies, tests, and cases within the states, working with manufacturers to acquire supplies, and monitoring hospital capacity. Should the HHS do that, or the DHS?

The question boils down to whether a pandemic should be treated more as a public health issue (HHS) or a homeland security (DHS) issue.

The potential consequence of this is that both departments could end up sharing overlapping responsibilities — both could store data on cases and supply movement through hospitals, for example. That means that the collection and processing of data are spread over multiple departments, making the response decentralized and possibly inefficient. Centralization and efficiency are key in an emergency like a pandemic.

This type of problem also extended down to smaller agencies. For example, state governments didn’t know how the CDC and HHS were dividing responsibilities. They didn’t know what the CDC was doing and what the HHS was doing. This also applies to other agencies — for example, states often sent requests to the FDA that were supposed to be sent to the USDA.

There was confusion about who is in charge of what, which is funny but also terrifying. When an outbreak hits the country, we can’t waste time figuring out who does what. The government should establish those roles ahead of time, and each agency should react in muscle memory fashion.

But that wasn’t the case here.

There was a Lack of Clarity in the Government’s Response Tactics

Another major problem was that while the government had plenty of possible policy responses to take, such policies often lacked a standardized method of implementation. That means there were inconsistencies in how policies were executed. For example, oftentimes, the federal government didn’t set national standards for states to follow, so states all responded to the outbreak in different ways, causing a lack of consistency.

Here are some examples.

1. Each states’ guidelines on school closures differed. There was no standardized national guideline on how schools should close.
2. There was no standardized system for the government to monitor states’ requests for supplies. If states asked for supplies (like masks or syringes), then these orders were monitored both by the CDC and the HHS — there was no centralized database to track this information.
3. Each states’ guidelines on how to define essential versus nonessential workers (in the event of economic closure) were different from each other. There was not a clear standardized definition of essential versus nonessential businesses at the national level.

Maybe these things sound nitpicky, but in an emergency, everyone should agree on what exactly to do so that there’s no confusion or hesitation. Again, a pandemic response should be executed with muscle-memory and clarity.

The Pandemic Response is Disorganized

Let’s just say that there are kinks that the government needed to iron out before they could say they were ready to address an outbreak.

1. Insufficient manufacturing. Domestic manufacturing wouldn’t satisfy our demands for PPE, syringes, etc. Foreign manufacturing wouldn’t be enough either, as foreign countries would likely limit their exports to build up their stockpiles. That’s a clear indication the government would need to stockpile those supplies ahead of time to be prepared.
2. Lack of funding. I mentioned that the HHS is (arguably) the leader during a pandemic. However, the HHS lacked the necessary funding (at the time). It was determined that $6.2 billion would be needed to manufacture vaccines while $3 billion would be needed to ramp up the production of antiviral drugs, PPE, and syringes, totaling $8.2 billion. The Public Health Emergency Fund did not contain enough money at the time.
3. Lack of knowledge. The national government asked states several questions about their local public health systems — questions that the states didn’t know how to answer (e.g. how many ventilators are in use). That’s pretty unfortunate.
4. Poor communication. There were instances in which the federal government communicated with private-sector entities, including hospitals. In doing so, they occasionally provided incorrect information to healthcare workers. Nice.
5. Poor communication (again). Oftentimes, states used different terminology from the federal government regarding vaccines and medical equipment, which led to confusion.
6. Confusion regarding funding. States didn’t know what the regulations were on emergency funds coming from the CDC — they were unclear on how they could use these funds.

Final thoughts on the Crimson Contagion

Ok, so I’ve been beating up on the pandemic plan pretty hard. Some kinks had to be worked out. However, that’s understandable. Simulations like this should be performed so that the government can find flaws in its plans and then fix those plans to prepare themselves for emergencies.

And this is what makes things frustrating — the government botched its COVID-19 response in 2020. There was clear evidence that the pandemic plan needed tweaks, but the government still wasted its window of opportunity. For example, I mentioned that the HHS was underfunded. However, at the time of the Crimson Contagion Simulation, the H.R. 2740 bill was going through Congress. This bill would have appropriated $1.1 billion into the Public Health Emergency Fund — $566.7 million of which would support R&D. There was also $735 million for procuring security countermeasures, $920 million for building up the Strategic National Stockpile, and $270 million for other expenses.

But the bill didn’t pass, forcing the government to play catch up in 2020 by re-attempting to fund the Strategic National Stockpile, among other things. The government missed its opportunity to prepare. Maybe you would say “well, the government should not have passed H.R. 2740 because it was too much money and it would have increased the debt.” Alright, but the government ended up spending tons of money anyway in March. For example, the government passed a $2 trillion stimulus package to revive the economy, but if the government had spent a few billion dollars earlier (e.g. in January), then we could have saved money and contained the virus.

Anyway, we’re not done yet, boys and girls.

Congressional Briefing in December 2019

In December 2019, the HHS Assistant Secretary of Preparedness and Response briefed Congress on the possibility of a pandemic. They said:

1. Global economic damages could range from $413 billion to $3.79 trillion.
2. 500,000 Americans could die if preventative measures aren’t taken.
3. Between 670,000 and 4.3 million Americans could require hospitalization.
4. China’s monopolies over the drug supply and PPE supply are problematic. During a pandemic, PPE and medicinal supplies are hard to come by. Thus, stockpiling beforehand would be an absolute necessity for being prepared.
5. They also reiterated the results of the Crimson Contagion simulation.

There’s nothing unexpected here, but it’s clear that the government was warned about the consequences of dragging its feet.

Warnings from China, the WHO, and the President’s Cabinet

Let’s run through a quick timeline of January 2020:

1. January 3rd — the HHS secretary is informed of the outbreak.
2. January 4th — WHO announces mysterious cases of pneumonia in China.
3. January 15th — the CDC authorizes screenings at airports in New York, LA, and San Francisco.
4. January 20th — A Chinese scientist reports that the virus undergoes human-to-human transmission.
5. January 21st — the CDC introduces screenings in Chicago and Atlanta.
6. January 23rd — China puts 11 million people under quarantine.
7. January 25th — Chinese president Xi Jinping calls the outbreak a “grave situation.”
8. January 29th — A Chinese research paper is published and supports human-to-human transmission. It also reports that the infected population doubles every 7.4 days. It warned of an outbreak. (the paper was republished in March but initially published in January).
9. January 31st — the HHS secretary declares a “public health emergency.”

In January, the HHS secretary declared an emergency while China quarantined millions, so something was wrong. I will say that the US response in January was not that bad — the CDC did begin to screen airports as I mentioned, and the wheels were set in motion to allocate emergency funding.

But February was wasted. The President could have invoked the Defense Production Act to mandate that companies make supplies. The government could have begun testing to trace disease hotspots. But the Defense Production Act wasn’t invoked until March 18, and the CDC didn’t release tests until February 26, while testing didn’t ramp up until mid-March. This was partly due to the CDC finding flaws in their initial tests. However, this could have been avoided if the CDC had used the WHO-approved test template (as South Korea did) rather than develop tests from scratch.

Anyway, January had warnings that the outbreak could be serious, but the government didn’t prepare until March — it wasted its opportunity.

Conclusion

The fact is that there were warning signs all along the way that (1) the coronavirus would spread quickly and could become an epidemic, (2) that the US would need to prepare for it efficiently, and (3) the US government’s previously established plans were not adequate to handle an outbreak. So yeah, the Trump administration didn’t take the hints. The result was a botched pandemic response, which I discuss in the below article.

What Other Countries’ Pandemic Responses Can Show Us (Re-Upload)

Remember to Stay Cynical guys.