Here’s how the US got here — and what to do next.
March 26 marked an unhappy milestone for the United States: It’s now No. 1 in confirmed coronavirus cases.
China, where the novel coronavirus originated, was the previous leader. The country reported 81,782 cases as of Thursday near 6 pm on the coronavirus case counter by the Center for Systems Science and Engineering at Johns Hopkins University. Until now, second place was held by Italy, which has reported 80,589 cases.
Now the US leapfrogged them both with 82,404 cases. And it’s only going to get worse from here.
In late February, there were 80,000 cases in China and nascent outbreaks in Japan, South Korea, Iran, and Italy. But things in the US were still looking pretty good — at least, on the surface. The US on February 20 reported only 15 cases, all travel-related.
But once officials started testing in earnest for Covid-19, the cases started coming — and coming and coming. On March 1, there were 75. On March 7, 435. On March 14, 2,770. On March 21, 24,192. Now it’s at 82,404 — and those numbers are only going to go up in the coming weeks.
How did things go so wrong so fast? Much of the answer is that when the US was reporting very few cases, things were already getting bad under the radar. A disastrously mismanaged February, during which government officials, much of the media, and even some experts assured Americans there was nothing to fear, let the virus spread until it was too big to ignore. By that time, it was also too big to stop without heavy-handed social distancing measures — and their attendant catastrophic economic costs.
Much of the blame lies with the president, who stripped public health agencies of the staffing, resources, and authority they needed to function, and then addressed the crisis in his usual fashion: with misinformation and bluster. It’s worked well for him against many of the scandals of his administration, but the virus was unimpressed.
But the failure wasn’t just the president’s. As Zeynep Tufekci, who has been urging us to do more for months, put it, “a soothing message got widespread traction, not just with Donald Trump and his audience, but among traditional media in the United States, which exhorted us to worry about the flu instead, and warned us against overreaction.” Even with the government sleeping on the job, there were signs from other countries that a catastrophe was arriving on our shores. But very few people said it out loud, and the ones who did were assured they were overreacting. Most people took public health experts’ reassurances at face value and assumed the low numbers of reported cases reflected reality.
Meanwhile, the virus spread.
Now, the world’s most powerful country has one of the world’s worst disasters on its hands. The question now is: Is it too late to turn things around?
The most confirmed cases in the world: What it means and what it doesn’t
The US has more confirmed cases than anywhere else in the world. It’s a sign that our coronavirus situation is very grave indeed. However, it doesn’t necessarily mean that the US has the world’s worst coronavirus outbreak.
For one thing, while the US is still undertesting (people with milder cases are typically told to stay home and not be tested), other countries are probably undertesting by even more. Iran, by some estimates, may have millions of coronavirus cases, most of which the government has not reported.
Other hotspots that worry global development researchers include India and Indonesia — both populous countries with weak health systems and high poverty that are likely underreportingtheir coronavirus outbreaks by a significant margin. One study found that Indonesia is probably reporting around 10 percent of its symptomatic cases, and India between 10 percent and 30 percent.
Another important consideration is population. The US is the third-most populous country in the world. That means that, while our outbreaks are not yet worse per capita than many of the outbreaks in Europe, the top-line numbers look worse. Italy, for example, has reported one case for every 750 citizens. The US has reported one for every 4,000 (though 1 in every 400 New York City residents). Per capita numbers may better reflect how overwhelmed a country’s health system is and how badly it is impacted by the virus.
But overall numbers matter, too. Tens of thousands of people suffering and many of them dying isn’t less tragic if it happens in a large country where they’re a smaller share of the population.
So, while the US situation is very bad news, it’s the combination of a high population, a disastrous outbreak, and high testing capacity (in the past few days, the US has finally — if belatedly — started testing on a large scale) that propelled America into the No. 1 slot. We should take the situation seriously.
But it’s a misinterpretation to claim that America has the worst outbreak in the world just because it has the most reported cases in the world. (To be clear, the US could still end up with the worst outbreak in the world — but we’re not there yet.) When you test more, you’ll get more cases — but testing more is a good thing, and the United States, despite the desperate situation, is in a much better position to turn things around because of all the tests run in the past week.
How coronavirus got a foothold in America
In late January, China locked down the country as hospitals and intensive care units (ICUs) in Wuhan were overwhelmed by coronavirus patients. In response, the United States banned foreign nationals who had recently traveled to China. That “resulted in a significant delay in the number of people coming in with infection,” Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention (CDC), has said. “That bought time in the US to better prepare.”
Then, the US squandered it. “Every other step of the government response was badly fumbled,” Frieden concluded.
Budget cuts and mismanagement by the Trump administration had gutted many of the agencies that were meant to address the crisis. The CDC started work on a test that would identify the novel coronavirus, but shipped the test out to labs with incorrect reagents, meaning that the test didn’t work. Guidance on when there’d be a new test was slow in coming.
Independent researchers at Seattle’s Flu Study, a research project studying flu in the Seattle region, sought permission to run their own test. They were denied it.“We felt like we were sitting, waiting for the pandemic to emerge,” said Dr. Helen Chu, who led the project. “We could help. We couldn’t do anything.” Labs around the country sought the Food and Drug Administration’s approval for their own test and met delays.
Strict rules about who could be tested for the virus were put into place. To be tested, someone had to have recently traveled from China or have been exposed to someone who tested positive. In hindsight, it’s easy to spot the Catch-22. If someone got coronavirus while traveling in South Korea, Iran, Italy, or any of the growing number of countries experiencing outbreaks, they could not be tested. If they infected anyone, those people couldn’t be tested either. Because the US had banned travel from China and would only test travelers from China (or those who had been exposed to a person who’d tested positive), it was impossible to determine whether the virus was spreading in America.
It was. Virologist Trevor Bradford estimates by comparing patient genomes that the coronavirus started spreading in Washington state in mid-January. By the end of February, it had been introduced to a nursing home, and patients started rapidly dying.
In the meantime, even people who should have known better took the CDC’s low case numbers at face value. There’s no community spread in the United States, public health officials around the country reassured us.
The risk of coronavirus in the US is “just minuscule,” National Institutes of Health official Anthony Fauci, now one of the most trusted authorities leading the response, said on February 17. “We have more kids dying of flu this year at this time than in the last decade or more,” he added.
People were told that risk in US communities “remains low.” Media outlets wrote articles about how Americans were at greater risk from the flu — a serious mistake in hindsight, to be sure, but an accurate representation of what they were hearing from America’s top public health authorities.
Bedford estimates that there were more than 7,000 cases in the US near the end of February (as opposed to 68 confirmed cases), when a lab in California first detected a community-acquired coronavirus case. If officials had known about them, they could have taken the extensive but not economy-shattering measures that countries like South Korea and Taiwan have taken to stop the virus — testing extensively, aggressively tracing contacts of everyone who tests positive, increasing production of masks and making them widely available.
Instead, the US proceeded as if it were safe, while the least invasive ways to beat back the virus steadily slipped out of our reach.
Always a bit behind the curve
By March, it was obvious that there was community transmission in multiple cities across America. But our response was still slow. The FDA only slowly authorized more labs to conduct testing, and revisions to make their guidelines stricter forced some labs to destroy tests they’d already collected. US testing increased, but the prevalence of the virus was increasing, too.
States, counties, and citieshad to decide one by one whether to shut their schools, declare a state of emergency, urge social distancing measures, or go into lockdowns. They did so haphazardly, with insufficient data because there was still limited testing in their communities. Italy closed all its schools on March 4 and locked down the country when they had fewer than 10,000 cases; the US surpassed the 10,000 case mark (March 19) and the 20,000 case mark (March 21) and the 50,000 case mark (March 24) without any national order to reduce nonessential activities.
Some local and state officials — like San Francisco Mayor London Breed and Ohio Gov. Mike DeWine — acquitted themselves well, taking strong early measures to reduce the spread of the virus. Some didn’t, like Texas Lt. Gov. Dan Patrick, who argued that people shouldn’t take economically damaging measures because if asked “are you willing to take a chance on your survival in exchange for keeping the America that all America loves for your children and grandchildren?” grandparents around the nation would agree to risk letting the virus spread.
Lockdowns are economically devastating, but the death of thousands of Americans in overwhelmed hospitals and the decimation of our health care workforce will not be any less economically devastating for the states that take that route.
In New York, which discovered as they ramped up testing that local cases were terrifyingly out of control, Mayor Bill de Blasio and Gov. Andrew Cuomo sparred over whether the city would have a shelter-in-place order like the one implemented earlier in the California Bay Area. Epidemiologists urged us to employ social distancing, but disorganization, unclear communication from political leaders, and ongoing lack of testing likely reduced compliance rates.
That said, it would be wrong to say that the US hasn’t taken strong measures to stop the virus. School closures were ordered. They were extended to restaurants and bars. California, home to 40 million people and one-fifth of the country’s GDP, ordered its population to stay at home. Nineteen other states have followed. When all the measures go into effect, more than half the country will have been ordered to stay at home (and similar measures may go into effect in more states as the situation worsens).
But the US took these steps belatedly — again, in part because of lack of testing capacity. That meant each measure wasn’t sufficient on its own, and the US had to keep escalating. It is still not clear officials have done enough for situations like New York, New Orleans, and Atlanta, which are already running out of ICU beds.
The US’s ugly start put Americans at an enormous disadvantage for the next phase of the coronavirus fight, and we spent most of March on the defensive while case numbers grew and grew.
So, how does this end?
When every day the news gets worse, it’s easy to start to despair — or to start thinking we should give up, write off 3 percent of our population, and try to, as Bill Gates condemned the idea, “ignore that pile of bodies over in the corner” as we go back to work.
We should not do that.
But we shouldn’t resign ourselves to another year and a half in lockdown, either — though it’s true that it will be a long time before the country or the world returns to normal. There are lots of promising options available, and pursuing some combination of them will likely allow us to ease up on some of the costliest current restrictions.
“Suppression will minimally require a combination of social distancing of the entire population, home isolation of cases and household quarantine of their family members,” an influential report from the Imperial College London argued, and then more than a year of maintaining “this type of intensive intervention package — or something equivalently effective at reducing transmission.” Other researchers have criticized specific assumptions underlying that model, but there’s wider agreement on the general premise that we need to find an “intervention package” that keeps transmission low.
But the details of that intensive intervention package are up to us, and some possibilities could be improvements over the current lockdowns. Countries are exploring a wide range of options for reducing transmission with minimal human costs.
One option, based on South Korea’s success at managing the virus, is called “test and trace.” The idea is to get much much better at testing so that we can identify sick people sooner, isolate them and all of their contacts, and let other people go about their daily lives.
That’s the approach favored by the WHO, based on what’s worked best so far in the countries that have controlled their outbreaks. “To suppress and control the epidemic, countries must isolate, test, treat, and trace,” WHO Director-General Tedros Adhanom Ghebreyesus argued last week.
“Everyone staying home is just a very blunt measure. That’s what you say when you’ve got really nothing else,” Emily Gurley of the Johns Hopkins Bloomberg School of Public Health told NPR. “Being able to test folks is really the linchpin in getting beyond what we’re doing now.”
Accomplishing this will require making testing much more widespread. Tactics like test pooling, which Nebraska has started using and which other states may copy, can be employed to let us test more patients with the same number of tests. Developing tests with faster turnaround time will mean that sick people get answers within an hour instead of waiting for weeks. We’re a long way away from this, but that doesn’t mean that it couldn’t happen fast with enough focused attention and funding.
Another option, serological tests, will let us check who has already recovered from the virus, so some people will know they’ve developed immunity and can return to normal. The UK is aggressively exploring this option and says they plan to make millions of serological tests available within “days rather than weeks or months,” says Sharon Peacock, the director of the national infection service at Public Health England.
Lockdowns affect lots of people who could be at work. Once we have better testing, we can lock down only people who’ve been exposed for the period of time that they’re at risk of spreading the virus (most countries require 14 days of self-quarantine).
Better treatments, too, might change the dynamic of our fight against the coronavirus. Several promising drugs are undergoing trials right now, including a multi-nation, thousands-of-patients, multi-drug randomized trial organized by the WHO called SOLIDARITY. The president has controversially highlighted chloroquine, an antimalarial drug, but others showing promising early results include Japanese flu drug favipiravir, HIV medication remdesivir, and others. If a successful treatment that makes the illness much less dangerous is discovered, we could return sooner to normal life.
To be clear, it’s a mistake to hype any one of these drugs as a cure-all (and please, don’t hoard them at home). And the president certainly hasn’t helped by touting them as miracle cures despite mixed early evidence.
But it’s not unlikely that our treatment options will improve dramatically as we learn more. “We need more data at every level,” UCSF biologist Nevan Krogan, who is researching drug treatments for the disease, said in March.
Finally, our manufacturing can scale up production of personal protective equipment and ventilators, and we can rapidly train more people to care for coronavirus patients, increasing our hospital capacity and our ability to cope with the virus.
“Let’s figure out testing, let’s get enough PPE [personal protective equipment] for first responders,” Tara Smith, who studies infectious disease at Kent State University, told my colleague Brian Resnick. “Let’s get enough swabs. Let’s buy more ventilators, build more ventilators — to have this second chance at not messing things up.”
While all that’s happening, researchers like Stephen Kissler of Harvard have proposedthat we might alternate periods of social distancing, trying to keep society functioning and our mental health acceptable while not overloading our hospitals. “Intermittent social distancing — triggered by trends in disease surveillance — may allow interventions to be relaxed temporarily in relative short time windows, but measures will need to be reintroduced if or when case numbers rebound,” the Imperial College London report concluded.
So while life as normal might be a long way off, we shouldn’t expect to be sitting in lockdown for the next year. This is a painful, temporary, weeks-long (maybe months-long) step while we progress as fast as possible on all of those fronts.
There are now two months of coronavirus response behind us. We spent one of them unaware that we were under attack, and the second trying to figure out how to respond. By the time we had a good picture of the problem in front of us, we had a problem on an unprecedented scale.
But it’s not all hopeless. If the world is at war with the coronavirus, it’s encouraging to remember that the US has historically been incompetent in the early stages of a global war — but unstoppable once we set ourselves to the task at hand. This isn’t over — it is, in fact, barely getting started — and it’s up to all of us to decide how it ends.
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