First, some history.

When America’s “Founding Fathers”, that committee of thoughtful men (and they were all white men, of course) sat down in a steamy Philadelphia hall to draft a constitution for a new, barely functioning nation, they were constantly on guard over the need to separate and share powers among the three branches of the new federal government — as well as the new relationship between the 13 states and this just-being-launched government.

They had a few examples to guide them in creating this system. For them, the only successful republics were miniature ones like the Dutch Republic, Venice, a few of the Greek city-states, early republican Rome, and a Native American federation in what is now upstate New York and nearby Canada. From these observations, they gleaned the worrying idea that a republic always failed, once it grew too large. Accordingly, they remained worried about the possible future of the system they had set in motion.

In response to such fears, they divided the powers of government vertically as well as horizontally. Things like the various states’ legal systems, control of education, and even the electoral system were largely left to the respective states. Meanwhile, things like a national army and navy, the tariff regimen, and a national postal system were reserved for the federal government.

At that time, an area like public health was barely a blip on the horizon and was universally seen as the responsibility of local religious, philanthropic, or civic entities (Alexis de Tocqueville’s famous “voluntary associations”), including limited facilities for the indigent. That was probably to the good since medical best practice at the time probably meant bleeding patients for most diseases, surgery in supremely unhygienic conditions, or locking up the mentally unstable in dreadful circumstances.

Nevertheless, the tradition of local control over public health largely continued through the years and it strongly lives on in our own time. As it evolved historically, the US national healthcare system largely remains a logical extension of the federal system of the country as a whole. 

Post-Civil War, federally run veterans homes and hospitals began to be established, and then the Progressive Era’s revelations about the horrific conditions of meat-packing houses and yet other scandals gave birth to new federal agencies such as the Food and Drug Administration. Years later, the establishment of the National Institutes of Health (focusing on research on a wide roster of diseases) and the Centers for Disease Control (focusing on co-ordinating reporting, analysis, and responses to infectious diseases) largely completed the suite of federal scientific protections and innovation centres.

Meanwhile, in the 1930s, New Deal programmes founded in the midst of the Great Depression expanded federal involvement in health and welfare, most notably the Social Security pension system that eventually gave birth to Medicare health insurance for the elderly in 1965, particularly with the support of organised labour. A parallel programme for poor people, Medicaid, became law as well in that period.

But with the increasing strength of labour unions from the late 1930s onward, one of the key objectives for most unions was to push for industrial contracts that focused on establishing comprehensive health care for union members. It was viewed as one of the most important outcomes of unionisation, in addition to the more obvious ones of improvements in wages and workplace conditions.

With these threads taken together, the health landscape in the US has come to resemble a multi-varied quilt (or a threadbare patchwork, if you are a social reformer supporting expanding Medicare to the entire nation). There are government-run medical systems for veterans and active-duty military personnel, as well as a special health service set up on Native American tribal lands.

Meanwhile, the states, counties and municipalities all have a range of publicly operated hospital clinics. In addition, there are stand-alone and large networks of privately run facilities — either for-profit or by non-profit bodies such as religious organisations and community groups — and often associated with medical schools. Payment for care is generally left to patients to manage, either through their private health insurance or reliance on Medicare, Medicaid, or, in extremis, a fallback on the local emergency clinic. Bringing coverage up to a certain standard for almost everyone through minimum coverage requirements and state-by-state insurance exchanges was a key goal of Obamacare. Even with Republican attempts to gut it, still, around 93% of US citizens have now achieved health coverage.

Meanwhile, research on medical innovations is carried out across the country, in addition to NIH, through a combination of funding from government grants, philanthropic foundation grants, and industry support. As a result of all of these parts, the system has flexibility and the possibilities of US medical care can be state of the art, but the costs of such care continue to rise — a combination of expensive new treatments and medicines, as well as the administrative burden of this system. Accordingly, many in the general population, sector specialist analysts, and social commentators all continue to complain that the US’s health sector is too expensive, too inefficient, and too often fails to reach everyone, contributing to support for the idea of a Medicare-for-all system to replace much of this complex public/private/insurance-driven system.

Under the country’s system for co-ordinating action against and research on disease outbreaks or potential epidemics, the CDC and NIH, working with state and municipal public health authorities, is designed to keep the country prepared to confront such disease outbreaks and then to help manage dealing with it. (If films appeal to readers, then watch Steven Soderbergh’s film Contagion to get a thrill-a-minute version of this cooperative system in action. See this story from Telegraph UK for information on how real science was folded into the film.)

The current crisis

Historically, in dealing with new outbreaks of deadly diseases, the system has generally worked well. The system dealt particularly well with the Ebola virus several years ago, preventing virtually any infection in the US and only one recorded fatality, and in bringing the weight of US public health resources to bear on the disease in West Africa. But, so far, this same system – or most of it – let the country down in the newest viral epidemic. Badly.

It is obvious there is significant blame to go around. When the Trump administration first came into office, they had been briefed on a sobering, perhaps even terrifying, epidemic simulation that explored how a new virus could bring the country low, absent proper proactive decision-making and advance preparation. But soon afterwards, the new administration disbanded the pandemic threat team of specialists on the National Security Council staff (and essentially dustbinned all their staff work), thereby rendering the government largely leaderless in the immediate event of an incipient pandemic.

As one of the authors of that work, Christopher Kirchoff, wrote in Foreign Affairs just the other day, “In international crises, policymakers and politicians rarely have a dress rehearsal before their debut on the main stage. Yet in retrospect, the Ebola outbreak of 2013-15 amounts to exactly that – a real-life test of Washington’s ability to detect and contain an infectious disease that threatens global security.

“Precisely because those who fought the spread of the Ebola virus knew how close we came to global catastrophe, the National Security Council initiated a detailed study of the successes and failures of the international and domestic responses. Starting in February 2015, 26 departments and agencies across the US government participated in a ‘lessons learned’ process headed by the White House that produced a 73-page analysis with 21 findings and recommendations. I led this effort, under the stewardship of National Security Adviser Susan Rice and Ebola Czar Ron Klain, and I authored the NSC report recently made public by The New York Times.

“It was clear to those who responded to the Ebola outbreak that the response system of the United States and the international response system would risk collapse if faced with a more dire scenario. It was equally clear that a more dire scenario taking place was a question of when, not if. As the NSC report concluded, ‘future epidemics, especially those that are airborne and transmissible before symptoms appear, are plausibly far more dangerous.’ It continued: ‘An appropriate minimum planning benchmark… might be an epidemic an order of magnitude or two more difficult… with much more significant domestic spread.’ ”

In fact, the intelligence community had been warning about this for years as well. This happened despite repeated studies by the intelligence community’s own think tank evaluations noting that pandemics would be one of the key international threats to the country in the years to come, noting, “increased travel and poor health infrastructure will make infectious diseases harder to manage”. In some ways, the obdurate refusal to pay attention to these warnings evolved out of Trump’s visible dislike for government experts, preferring, as he often said, to trust his (non-scientifically trained) gut much more.

Then, when the first warnings of a new virus from China began to surface, the president chose to downplay its seriousness, in spite of experts’ concerns, preferring instead to describe the concerns as – yet again – “a hoax”. Even as the Chinese government’s Wuhan city total lockdown began, the president refused to embrace the idea that this was going to evolve into a major public health crisis for the US. Not even the multiple deaths at a nursing home in Washington state were enough to move his administration.

Although the president decided to close access to the US by Chinese arriving from their affected nation, the precious weeks needed for preparation, supplies stockpiling and prepositioning, broad national co-ordination across geographical and hierarchical levels, and replenishment of the supplies stocks that would almost inevitably be needed were lost. This crucial time was frittered away in bloviating about overestimating the disease for Democratic Party political gain.

Instead, dealing with the new disease became a decentralised effort as cities and states all adopted different, sometimes conflicting approaches. The testing regimen itself for the presence of the disease became a fiasco inside the greater chaos. Despite the president’s insistence that anyone who wanted a test to confirm the presence or absence of the disease could have one, there were never sufficient tests (unlike South Korea or Singapore), the organisation and management of the testing nationally was scattershot and disorganised, and some of the earliest versions of the test even turned out to be flawed, or the reagents needed to make them work properly were contaminated.

As the disease began to take hold in the US, with regard to the prevention and cure side of the crisis, the president continued to contradict his own medical advisers, repeatedly telling the public a vaccine was coming soon and that the virus would lose its potency in April, or that he hoped versions of chloroquine (a medicine developed to deal with malaria) would become a miracle drug to treat Covid-19. Moreover, he continued to insist Democratic state governors were overdramatising the crisis, and that they actually didn’t need the equipment they were publicly pleading for – even as the infection rate and the death rate continued to rise, as the mathematicians say, exponentially.

Even here, politics was never far from the president’s responses. As The Washington Post reported, “Florida [with a Republican governor and a place as a key state for the 2020 election] has been an exception in its dealings with the stockpile: The state submitted a request on March 11 for 430,000 surgical masks, 180,000 N95 respirators, 82,000 face shields and 238,000 gloves, among other supplies – and received a shipment with everything three days later, according to figures from the state’s Division of Emergency Management. It received an identical shipment on March 23, according to the division, and is awaiting a third. ‘The governor has spoken to the president daily, and the entire congressional delegation has been working as one for the betterment of the state of Florida,’ said Jared Moskowitz, the emergency management division’s director. ‘We are leaving no stone unturned.’ ”

The president continues to use the disease as a political club, insisting on calling it the China virus, rather than its standard name, Covid-19. In evaluating this word usage, The Economist was not kind, saying, “While the disease was concentrated in China, Mr Trump called it by its approved name, coronavirus. Since its arrival in America he has referred to it, in daily tweets and briefings, as the ‘China virus’. Others in his administration use ‘Wuhan virus’, including Mike Pompeo, the secretary of state. He is reported to have demanded the G7 group of industrial countries call it by that name. A White House staffer is said to prefer the phrase ‘kung flu’.

“It is easy to see what Mr Trump is about. He wants to distract from his administration’s failure to contain the disease – such that America, despite having had months to prepare for it, will soon have more Covid-19 cases than China. He also sees in the issue an opportunity to own the libs. A note circulated by Mr Trump’s re-election campaign last week suggests that it plans to make the president’s fearlessness in uttering the phrase ‘China virus’ a defining difference between him and his presumed Democratic opponent, Joe Biden. In 2016 Mr Trump portrayed Hillary Clinton’s aversion to the unhelpful phrase ‘radical Islamic terrorism’ as weak; he has updated the tactic.”

Even as this sad tale was spooling out, the president has continued to undermine the science, arguing strenuously that, on the one hand, the greater New York City metropolitan area from northern New Jersey to southern Connecticut should be quarantined off. But then, on the other hand, he changed his mind and said that the still-limited national shutdown (schools and workplaces closed, restrictions on large public events) on crowds should be rescinded in time to let millions fill up the churches for the imminent holiday of Easter, and then get back to work making America great again. 

Ominously, over the weekend, Dr Anthony Fauci, the country’s most public virologist, told CNN that if the restraints on public gatherings are rolled back too soon, Covid-19 fatalities could reach 100,000 to 200,000, and that the CDC is deliberating on further travel restrictions. Nowhere in all of the presidential gabble has there been anything approaching a call to citizens to work together to beat this epidemic, despite his insistence he is now a “war president”.

Meanwhile, New York Democratic Governor Andrew Cuomo, a man whose media briefings have made him a television star, has explained that his state and the others are now, invidiously, bidding against each other for the scarce national supply of surgical masks, personal protection visors, hospital gowns, ventilators and related equipment, and remonstrating that this was not the rational way to conduct the country’s healthcare in a crisis. 

To deal with the growing demand for hospital care as this state and its biggest city are now ground zero for the infection, the state has been effectively commandeering large buildings throughout New York City to turn into alternative emergency care hospitals to ease the strain on existing hospital infrastructure. (The federal government has also sent a naval hospital ship, now docked in New York harbour.)

The president eventually agreed to invoke the US Defense Production Act to allow for the ordering of companies to manufacture the needed equipment, but as he dallied, it remained clear the gap in supply is slowly being filled by improvisational efforts – up to and including doctors buying welder’s masks. Really.

In the midst of all this, Americans, transfixed, have been watching the disaster on continuing national television coverage as well as following it online, even as they could also see the exposure and death tolls in nations around the world such as Italy kept climbing. The picture of the US unable to lead, or apparently unwilling to do so in a global fight against Covid-19 continues to do inestimable harm to the nation’s reputation, even as China, Cuba, and Russia have stepped up instead with doctors, supplies and equipment for places like Italy.

As it stands now, the virus is certainly not under control in the US, now that the country is the repository for the largest number of reported cases on the planet, and there is no clear indication the rising curve is starting to level off. The national co-ordination to fight it remains slack, and the president continues to battle against the idea that some kind of nationally enforced shutdown is needed, let alone enforcing the current less stringent measures in much of the country now in place. Epidemiologists warn that too early a relaxation of restrictions will provide opportunities for the virus to stage a resurgence as the transmission blossoms yet again.

And of course, even the spotty restrictions on movement have led to a dramatic economic slide, on the stock markets as well as in the actual economy, as an unprecedented more than three million people filed for unemployment compensation in the previous week. By the end of the week, the Congress had passed, and the president had signed, an emergency financial package of $2-trillion (more than double the funds appropriated during the financial crisis of 2008-9). It included major amounts to support flailing businesses (although not Trump family enterprises), enhanced funding to support individual states at this time, funds for medical supplies, and payment to most individuals in the country who earn/ed below a certain minimum in order to re-inflate consumer demand and thus help reinvigorate industrial production.

In medical language, then, the prognosis for the national patient remains guarded, while the intensive care ward awaits if things do not make a dramatic turn soon. DM