Q&A: Chronicling the failures of the U.S. response to Covid

A new book on the U.S. response to the Covid-19 pandemic paints a picture of a country ill-prepared to cope with a dangerous biological foe, riven by partisan politics, and led by people who saw little political gain in taking ownership of managing the crisis.

It also describes a country that remains ill-equipped to battle the next pandemic or major disease threat, though it lays out changes that could strengthen the country’s position.

“Lessons From the Covid War: An Investigative Report,” which will be published Tuesday, was written by a consortium of scientific and public health experts, many intimately involved in the pandemic response. The group’s members originally came together to do the spade work for what they thought would be an eventual independent commission tasked with investigating the response to Covid. That inquiry, which they thought would mirror the well-regarded 9/11 Commission, never came into being. So the Covid Crisis Group, as it calls itself, has published its analysis of what went wrong and what needs to be done to fix it.

It makes for disheartening reading in spots. The group’s members note, for instance, that in the first two years of the pandemic, U.S. excess mortality — deaths over and above what would normally be expected — was 40% higher than what European countries experienced. Spain, they wrote, performed 50% better than Florida in preventing premature deaths among its citizens.

The group lauds the performance of Operation Warp Speed, the U.S. program that hastened the creation and production of Covid vaccines, and of COVAX, the international effort to procure vaccines for low-income countries. But it questions why Warp Speed-like efforts weren’t conducted to develop Covid drugs, or mass-produce Covid tests and masks.

For the Q&A that follows, STAT spoke separately to two of the group’s members: Philip Zelikow, executive director of the 9/11 Commission, a history professor at the University of Virginia, and the person who “held the pen”; and Carter Mecher, a former senior medical adviser in the Department of Veterans Affairs who served as director of medical preparedness policy in the George W. Bush administration.

Their answers to STAT’s questions have been edited for length and clarity.

Your group expected there to be a 9/11-style commission set up to study the nation’s response to the Covid-19 pandemic. It was never established. Do you understand why?

Zelikow: Not for sure but I have some sense. The Congress side of the story I do know a little bit about. And that was that the partisans in Congress already had their stories. And to put it in shorthand, the Republicans blame China and [former National Institute of Allergy and Infectious Diseases Director Anthony] Fauci, and the Democrats blamed [former President Donald] Trump.

But the big reason, the deeper reason is because the Biden administration decided it didn’t want a commission. There were some very senior officials who were supportive. I think the view that carried the day could be summarized as: more trouble than it’s worth. … What’s our political interest in this?

They didn’t really know what they wanted to do. They didn’t have an agenda in mind. They could not articulate even to themselves internally as to how the system should change.

Was there any discussion ever about a responsibility to tell the story for posterity?

Zelikow: Yes, and some people believed in that. But it just didn’t carry the day among the key people who made these decisions in the White House staff.

I remember when I first read Albert Crosby’s book on the 1918 Spanish flu, “America’s Forgotten Pandemic.” It struck me as so inconceivable that people could have forgotten an event of that magnitude. But having come through Covid, and now watching how quickly people are trying to put it in the rearview mirror, maybe it’s easier to understand?

Mecher: That’s one of the things that has surprised me through this pandemic, our reaction to mass death. I think back to the headline in the New York Times in late May of 2020, when we surpassed the threshold of 100,000 deaths in the United States, and the headline was “An Incalculable Loss.” Well, since May of 2020, we’ve had 10 more incalculable losses. I think it’s become almost numbing.

I think these large numbers, they lose all sense of meaning. And that’s been the most surprising thing to me is how we pretty much have gotten to a point where we just shrug our shoulders at these types of numbers.

The report says that the members of your group are “angry” because Americans were let down. My overwhelming reaction to reading this report was a sense of … almost despair.

Some of the problems it identifies don’t seem like they can be fixed. The disconnect between chronically under-funded public health operations and private health care delivery. The country’s data collection quagmire. Do you see reason for hope that there’s a commitment to try to learn from the mistakes of the Covid response?

Zelikow: It’s funny you have that reaction. I was talking with a member of our group last week and she said that she was re-reading the report, and she said she found that really encouraging and empowering. She said: “It’s impossible to read the report and not see all this stuff we could do.”

Let’s take the data problem, for instance. A lot of the data we need actually is already being collected. The private health care system actually has really first-class data systems that are proprietary data. And there are ways to anonymize it for privacy purposes. But it’s awkward for them to share their proprietary information with their competitors or with their regulators.

This is not a new problem for our government. It’s come up in a couple of places, like electric utilities and civil aviation, where airlines and aircraft companies want to share safety information or technical information, but they need a safe way to do that. So they create nonprofit intermediaries that do the data sharing.

So what we propose, for example, is you create an intermediary that then pools all this data and then in turn helps provide inputs for a network that we think probably the Centers for Disease Control and Prevention should run.

Something from the report that does not seem doable is the idea that there should be global governance of laboratory security and regulation of what risky research can be done.

There’s no international entity that owns those issues, that could entice or cajole countries to allow outside inspectors to assess their competence or limit what their scientists can do. And there’s no motivation for countries to cooperate on this. China’s not going to be interested in having the U.S. tell it what its scientists can do. Likewise the United States would not allow its labs to be subject to spot inspections by outside authorities. Do you realistically think this can be done?

Zelikow: I think the first thing to establish is we have to look at this issue. You can’t just look away and say, “Well …”

Is it impossible? It’s really hard. But there is now a sensitivity to the dangers here — partly because of the Covid origins controversy — that is really exceptional. So we need to capitalize on this.

If you develop some guidelines, and there becomes broad consensus around them, there are ways to try to encourage compliance with those guidelines that don’t necessarily require formal global regulation. If there was a common understanding — you don’t do this, it crosses a line — you can create norms in biology of what’s acceptable and what’s not acceptable that biologists know about and that have broad public acceptance. And then that has some impact on what gets published and what gets marketed.

What were the worst mistakes the U.S. made?

Mecher: I think one of the biggest mistakes early on was the time it took to recognize the threat that we faced, and the amount of time it took for us to get on a war footing. And so we spent January and February, when it was clear that this was moving pretty quickly, and this was a significant event, to really get on a war footing and to get moving.

I think what made things even worse was what happened with our testing. The problems with our testing just meant that during that period of time we really were flying blind.

Zelikow: We were unprepared to do stuff. Everybody knows the story is the CDC botched the test. But even if the CDC test had been perfect, we still would have had the testing calamity. And even if we had had a lot of tests, we still would have screwed up because we had no idea what to do with them.

Should we use the test for biomedical surveillance? Should we use the tests to create 3,000 drive-thru testing centers? Should we use the test to set up point-of-care testing in nursing homes? Should we use them to help us reopen schools? And then how many tests do we need for each of these functions, deployed with what protocols? We didn’t do any of that.

Everybody has it in their heads that the CDC screwed up. But the deep problem is that we actually weren’t really ready to enact a testing program because we had no strategy for what to do even if we had the tests.

You’ve been working on pandemic preparedness since the George W. Bush administration, when you worked in the White House on a pandemic preparedness plan. Did you anticipate that the U.S. response was going to be as disastrous as it was?

Mecher: In writing the National Implementation Plan, I think one of the things we did anticipate was some of the confusion about authority and some of the potential overlap between, for example, Health and Human Services and the Department of Homeland Services and the CDC. We anticipated that there wasn’t clear identification of responsibilities.

We knew that there was a lot that needed to be done to enhance our surveillance capabilities to be able to track what would happen with a pandemic. I think there was a lot of concern about the second- and third-order consequences of implementing non-pharmaceutical interventions. One thing I think that people lost track of is the title in that guidance was “Early, Targeted, and Layered Non-Pharmaceutical Interventions.” And those three words were critically important.

How do you feel about the way the non-pharmaceutical interventions — things like school closures, masking, and social distance — were used?

Mecher: The whole purpose behind NPIs is to try to slow community transmission. And if you’re going to try to slow community transmission, what you want to do is identify those people who are infected and infectious, and you want to prevent them from infecting people who aren’t. And so the key is testing. And if you can’t test, and if you can’t distinguish between who’s infected, and who’s not infected, the only choice you have is to use a sledgehammer. You pretty much assume everyone is potentially infected.

We really were hamstrung at the very beginning in terms of how we could selectively implement the NPIs, and I think we didn’t really have much of a choice at that point. If you wanted to slow it down, you were now backed into a corner of really using the most blunt instruments.

Should contact tracing efforts have been abandoned much sooner than they were?

Mecher: The problem with contact tracing is the selective bias in the sense of who comes to attention, the people who have symptoms who get tested. And you’re missing all the people who have no symptoms who are flying below the radar screen. If you’re only focusing on those who are symptomatic, who are now presenting to get tested, you’re missing that below the water part of that iceberg.

Something I found dismaying is the report’s assertion that the U.S. government has lost the know-how to mount and operationalize responses. “The Covid war revealed a collective national incompetence in governance,” the report says. How does that get fixed?

Zelikow: First of all, you call it out.

And actually it’s fixable. Once people know that in big cities before blizzards, big city mayors buy snow plows, then you get in trouble if you don’t buy snow plows. And you hold people to a certain standard that you didn’t hold them to before we had snow plows.

And that’s the thing that a book like this can do.

People seem to have cast this pandemic as the equivalent of a 100-year storm, which implies we have decades before we’re going to have to face another biological threat as serious as Covid. That’s a dangerous assumption.

I would think the best time to make progress towards being better prepared for the next time is while the event is fresh in people’s minds. Is your group worried this opportunity is being squandered?

Mecher: The book refers to a cycle of panic and neglect. That we go through panic, and then we kind of blot it from our minds, and we move on. There’s always that risk.

Zelikow: That’s why this report is in your hands. That fear. That’s why we produced it on such a crash basis. People said to us “Why, don’t you wait till this whole thing is over, and then do this in a laborious way, and this will come out in 2026 and it’ll be really thorough and careful?”

We’re in our window now, for just the reasons you articulated. And if we miss this window, shame on us.