Emergency measures are most appropriate at the earliest stages of a disease outbreak, before a pandemic begins. This is when the government and the public health system have the most leverage to prevent sickness, death, and economic disruption. Since pathogens are not only deadly but wily, a smart system for preventing pandemics must include multiple layers of defense.
Looking at the results of the Covid pandemic in the United States — millions of cases, over 750,000 deaths, and trillions of dollars in economic costs — one might think that before 2020 the U.S. had not developed such a multi-layered defense system. This conclusion is wrong. In 2005, President George W. Bush read John Barry’s book The Great Influenza on the 1918 Spanish Flu, which led Bush to demand that the U.S. government bolster its preparedness to prevent a similar pandemic in the future. At the heart of the government’s plan was the development of three layers of defense against outbreaks:
1. International monitoring of emerging pathogens;
2. Domestic infection-control through testing, tracing, and isolating the sick; and
3. Rapid deployment of stockpiled countermeasures in case the first two lines of defense falter.
In theory, all three layers of defense existed in January 2020. In practice, each of them failed.
The first layer of defense, international monitoring, was designed to ensure that U.S. health officials had advance warning of dangerous pathogens, which would provide time to prepare the public health system for the challenge. This kind of monitoring relies both on international cooperation and on active monitoring by U.S. officials in case certain governments are less than forthcoming.
Indeed, as we now know, the Chinese government did downplay the danger of the emerging coronavirus to international officials, and concealed information about its person-to-person transmission until late in January 2020. The United States should have been prepared for this dishonesty, especially considering how China downplayed the SARS coronavirus in 2002. Yet there was a sense among health officials that the Chinese government had learned its lesson from SARS, which killed 800 people and cost the global economy upwards of $50 billion. This sense was bolstered by Chinese health officials collaborating with the international community during the 2013 avian flu outbreak, which infected 139 people. But when it came to a much more contagious virus, the Chinese government reverted to its non-cooperative ways, and America was caught unprepared.
The second layer of defense is a robust testing system that allows public health officials to isolate infectious people, and trace and potentially isolate others that may have been infected. These capabilities helped prevent the spread of Ebola in 2014.
But the system failed in 2020, when, instead of using existing tests, the Centers for Disease Control and Prevention insisted on developing its own test, and blocked private labs from participating in the effort. This move was problematic on multiple levels. First, the CDC developed a flawed test. Second, even if the test had not been flawed, the CDC is not equipped to do mass-scale manufacturing of tests. And third, keeping the private sector on the sidelines prevented the participation of America’s best resource for combatting disease: the whole of its robust scientific community. Without effective tests, it was impossible to monitor and limit the spread of infection.
The third layer of defense is a Strategic National Stockpile (SNS) that stores countermeasures and can deploy them anywhere in the country within twenty-four hours. The SNS is incredibly useful, but it is only as effective as the countermeasures in it. Despite warnings — including from myself — that we needed to develop countermeasures for coronavirus, when this one struck, the SNS had neither vaccines nor antivirals that could help.
These failures raise the obvious question of why this multi-layered defense failed. Part of the problem is with the CDC, which has some but not all responsibility for each of the three layers. The CIA also helps with intelligence gathering and disease monitoring. The FDA approves tests, so it is at least partly responsible. And the countermeasures that the SNS is supposed to deploy are procured by the Biomedical Advanced Research and Development Authority and developed by the NIH. Furthermore, the idea of the three layers of defense has not fully caught on within the government, and is virtually unknown to the public. One solution would be to have some higher-level entity within the government oversee pandemic preparedness government-wide, a step that has been recommended by the Bipartisan Commission on Biodefense (of which I am a member).
The failure of these three layers of defense is not the whole story. Covid-19 has also been a challenging virus, with asymptomatic infection and aerosol transmission, that wreaked havoc around the world. But the United States could and should have done better — and would have, had it deployed the three layers of defense. There is, however, some reason for hope, because the poor responses at the early stage of the pandemic, when Covid-19 could have been stopped, were operational rather than strategic failures. Each layer of defense can work in the future, with the proper improvements.
Going forward, America will have to be both more aggressive in doing its own monitoring and more skeptical of foreign claims about outbreaks, especially from authoritarian governments. The CDC must be reformed to focus more on communicable diseases rather than on behavioral challenges, and must work more effectively with the private sector on developing technologies such as tests. And America must do better at incorporating more nimble platforms in the SNS that can address a broad array of threats, rather than static countermeasures that require officials to correctly guess what the next pathogen might be.
These are all achievable goals, and would go a long way to preventing the next pathogen from being as disruptive and deadly as this one has been. Defense is the best strategy in dealing with pandemic threats, and much more protective of our freedoms than extreme measures like lockdowns, mandates, and travel bans after the pandemic threat has emerged. To prepare for potential future outbreaks that may not come again for a generation, America should bolster these three existing defenses, rather than promote large-scale, freedom-diminishing strategies that would reshape the entire country.
We Had a Plan