© Win McNamee/Getty ImagesPresident Donald Trump arrives at the White House on October 5 after his stay at Walter Reed National Military Medical Center, where he was treated for Covid-19.
America's Covid-19 epidemic is truly national. Every region has far too many coronavirus cases and deaths, with cases increasing in all 50 states and Washington, DC, for at least some time over the past couple months.
In June, just three states reported daily new coronavirus cases higher than 12 per 100,000 people. Today, every state except Hawaii exceeds that threshold. Some of that is due to greater testing capacity, but the climbing toll of hospitalizations and deaths, which have reached record highs nationally in the last month, show this is not merely a "casedemic" of sick people who might have gone undetected earlier in the year, but a rising tide of Covid-19 across the US.
So how did America get here?
The primary answer lies in President Donald Trump and Republican leaders in Congress, who have collectively abdicated the federal government's role in addressing the outbreak or even acknowledging its severity. From Trump's borderline denialist messaging on Covid-19 to Congress's inability to pass more economic relief, the country has been left in a place where states, local governments, and the public have to fend for themselves - and none of them have the resources to deal with the coronavirus on their own.
Trump and his allies have also actively worked to sideline the Centers for Disease Control and Prevention, crippling the agency's ability to provide guidance to states and others that have now been left out on their own.
At the same time, there are serious structural issues that hindered states' and the public's ability to act. Experts have long argued that the US's public health infrastructure is underresourced and ill prepared for a serious crisis, and the pandemic has exposed this many times over: Nearly a year into the pandemic, no state has capacities for testing and contact tracing that most experts would consider adequate.
And the lack of economic relief has made it much harder for people to stay home and business owners to close down, faced with the decision of mitigating the coronavirus's spread or failing to pay their mortgage and other bills.
"Throughout the whole pandemic, I have never accepted the argument that the problem of America is we have 50 failed governors," Ashish Jha, dean of the Brown University School of Public Health, told me. "That can't possibly be the right answer. The right answer is not we need better governors - the right answer is we need a different structure and a better federal government."
Still, Jha acknowledged, "I don't want to completely let the governors go." They've been limited in what they can do, especially as a weakened economy shrunk their budgets. But over time, as fatigue around the pandemic set in, governors became less proactive toward the coronavirus and more reactive - and they increasingly pushed short-term economic interests over public health concerns.
That was clear as the entire country, over the summer and fall, reopened schools, indoor dining, bars, and other risky indoor spaces, even as experts warned that the consequences could be very dire. Now we're seeing the effects.
That includes states led by both Democrats and Republicans:
- In California, Democratic Gov. Gavin Newsom earned praise in the spring for shutting down the state early, helping avoid the kind of surge that New York saw. But in recent months, he pushed to close down only after the state was reporting tens of thousands of Covid-19 cases a day.
- In New York, Democratic Gov. Andrew Cuomo was praised for his response to an enormous spring surge as he locked down the state, built up testing, and vowed to leave things closed down as long as necessary. But in the summer and fall, he began to open up the state more aggressively - reopening indoor dining in New York City, despite experts' warnings of the dangers involved. The failure is now apparent, as New York City closed down indoor dining again after cases skyrocketed.
- In Ohio, Republican Gov. Mike DeWine originally stood out as one of the few in his political party taking aggressive steps against Covid-19 - only to respond to the ongoing surge with a curfew that's widely seen as a joke to experts. (The coronavirus, it turns out, doesn't keep nighttime hours for spreading from person to person.)
This is only a sampling of states' mistakes. "There have been different versions of not doing this well across the states," Kirsten Bibbins-Domingo, an epidemiologist at the University of California San Francisco, told me.
The public has eased up too. The US has generally gotten better at masking, based on public opinion surveys, but we've also gotten much worse at social and physical distancing than we were in the spring. We've patronized the restaurants, bars, and other risky indoor areas that have reopened. We've gathered with friends and family over Labor Day, Halloween, and Thanksgiving, even as public health officials and experts have pleaded that we don't.
As a result, the US is now among the worst performers on Covid-19 in the world. Despite recent surges in Europe and elsewhere - which were largely the result of similar failures - America remains within the top 20 percent for most coronavirus deaths per person among developed nations, with more than twice the death rate as the median developed country. If the US managed the same Covid-19 death rate as Canada, nearly 190,000 Americans would likely be alive today.
While the story behind those numbers lies mostly in what Trump and much of the federal government have wrought, it's also on the rest of the US. From the president to governors to mayors to the public, America has failed on Covid-19 - and only by learning from those mistakes can we ensure they don't happen again.
All states are doing very badly on Covid-19
Since early on in the pandemic, I've tracked a range of metrics for each state's Covid-19 outbreak. Taken together, these metrics - daily new cases per capita, the infection rate, and the test positive rate - provide a sense of how well a state is controlling its epidemic.
As of now, no state is doing well. For the past few weeks, not a single state has met all three benchmarks in the state-by-state tracker. In fact, for most of the past several weeks, not one state has met even two of three benchmarks.
The map for cases per capita used to have a diversity of colors, but now it's almost all purple. The coronavirus has overwhelmed every single state. Even Hawaii and Vermont, which are performing the best, have case levels that suggest the epidemic is spreading out of control.
© Provided by Vox.com Covid-19 hospitalizations and deaths have also steadily increased for more than a month nationwide now. The increase in cases isn't just the result of more tests - more people are genuinely getting sick and dying as a result of the coronavirus. The US is quickly approaching a daily Covid-19 death toll that matches that of the 9/11 attacks, every day, with no sign of slowing.
This was preventable and predictable. Part of the problem is the US never truly suppressed the coronavirus. "We've never gotten cases down to a really low point - ever - even in the best states," Bibbins-Domingo said. So there's always been a lot of virus out there, waiting to spread to new hosts the moment the public and governments eased up.
By contrast, the countries that have done better against Covid-19 - including Australia, Japan, South Korea, and Vietnam but also, to a lesser degree, Canada and Germany - suppressed the virus at one point. So when they did see a rise in cases, it was a rise that was much more manageable.
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That's why it was so dangerous for states to reopen as early and as quickly as all of them did at some point this year - before they and their neighbors had real control of the coronavirus through low cases, widespread masking, and scaled-up systems to test and contact trace. Reopening created an environment in which the coronavirus could quickly spread out of control as people went back to private gatherings, parties, restaurants, and bars.
Now states face another crisis: With holiday gatherings around Thanksgiving, Christmas, and New Year's Eve, as well as the cold weather making outdoor activities much harder for much of the country, public health experts always expected that cases would rise in the fall and winter. But because states had already squandered any gains they made by the time Thanksgiving rolled around, the fall surges are surges on top of surges, shattering records set during the spring's initial outbreaks.
This is truly national, with no state spared. The best thing one can say is that Hawaii, which could use its geographical advantage to take stronger steps to restrict travel from other states, is suffering less. But it still has far more than 8 cases per 100,000 a day on average, more than double the threshold of about 4 cases per 100,000 a day that experts rely on as a sign of having the coronavirus under control. The best in the US is still quite bad.
Trump and Congress's failure is mostly to blame
When a failure in the US is nationwide, chances are the problem is rooted in a common variable - a systemic factor that's influencing the behavior of leaders across the country.
Particularly with an infectious disease, a big failure in one part of the country is typically going to result in some level of spread to others. It's just too difficult, if not impossible, to restrict travel among states, due to the social, legal, and political issues involved. That's what made a federal strategy so important for every single state - but such a federal plan never came, and the Trump administration and Congress actually pulled back from offering aid to states, counties, and cities as the pandemic progressed.
At the top of the list of problems is the failure to pass a second economic relief bill. Democrats have pushed for a bill in Congress, passing multiple versions of one in the House. But Trump made clear the bill was less of a priority than getting his Supreme Court nominee through the Senate. And Senate Majority Leader Mitch McConnell has continuously resisted a stimulus package on both fiscal grounds and to push for legal protections for employers so they're not held legally liable for Covid-19 spread in their workplace.
Meanwhile, the economic relief measure Congress passed in the spring has dwindled, as its measures have expired or are set to expire in the coming weeks. Thanks to the US's weak social safety net, this has left people with little to no relief as they lose their jobs due to the weakened economy or are asked to, in effect, give up income as they stay home to avoid spreading the virus.
This obviously hurts people's financial well-being. But it also makes it much harder to actually do what's right for getting Covid-19 under control. If you're a bar owner, you're likely going to be much more resistant to closing down your business if it means you'll lose your source of income without anything to make up for it. The same thing goes for any employee in that bar or any other business who's being told to stay home and avoid the same risky indoor spaces where they work - many of them simply can't afford to do it.
Congress is now reportedly working toward a second relief bill. But even if the legislature passes a bill, it would arguably come too late: The fall and winter Covid-19 surge is already in full effect, people have languished financially for months, and benefits could take weeks to roll out to people even after the measure is enacted.
Trump has also deliberately acted as a bullhorn for Covid-19 denialism over the past several months. The result is a large segment of the country who believes in Trump has hung on to his every word, arguing that their local and state leaders should not take the coronavirus so seriously.
The problem isn't limited to deep-red states. For one, more people voted for Trump in California than in Texas, Florida, or any other state, and those constituencies have been apparently vocal enough to get local officials to step back from stronger restrictions. In a particularly extreme case, Orange County's chief health officer resigned after working on a mask-wearing order and facing public backlash, including death threats.
That's on top of large segments of the public who are simply tired of dealing with Covid-19, and have eased up on precautions like social distancing as the pandemic has dragged on.
"We often think leaders decide things based on what they think is right," Jha said, referring to his own discussions with governors. "But there is a political space they need to act."
On top of his denialism, Trump muzzled those in the federal government who could have provided better guidance and leadership. That applies especially to the Centers for Disease Control and Prevention, which for months didn't hold its own press conferences even as the epidemic rapidly worsened. When agencies like the CDC did try to provide cautionary guidance, Trump, Vice President Mike Pence, and other administration officials often got in the way - an effort to stop anything that could be read as suggesting that Covid-19 is a real problem and that the president isn't doing enough to stop it.
Trump also pulled the federal government out of many Covid-19 efforts. In April, the White House put out a "blueprint" that effectively abdicated the federal government's role in building up coronavirus testing - instead arguing that local, state, and private entities should be in charge as the feds act merely as a "supplier of last resort." In practice, this left the states fighting for a limited number of supplies for tests while no one did anywhere near enough to fix the chokepoints along the supply chain that led to shortages in the first place. The approval process for testing was flawed from the start and continues to be plagued with problems.
Other structural problems preceded Trump. In 2019, a ranking released by the Johns Hopkins Center for Health Security and Nuclear Threat Initiative put the US at the top for disease outbreak preparedness, but also concluded that "no country is fully prepared for epidemics or pandemics." Public health infrastructure in the US, as well as every other country in the world, has long been insufficiently funded to handle a major crisis like the coronavirus.
Combined, all of these structural failures and barriers can help explain how every state now has Covid-19 epidemics that are completely out of control.
But there have been genuine failures by local and state leaders
At the same time, experts cautioned that you can't let local, state, and other non-federal leaders off the hook. There are obvious examples like 12 states still not mandating masks, but there are more controversial actions that local and state leaders could have taken.
Some experts argue states should have simply shut down much earlier this fall - if not entirely, at least close risky indoor spaces like restaurants, bars, casinos, and gyms. This would have involved short-term economic pain largely thanks to the lack of federal economic relief. But it would have saved a lot of lives and, based on the research and experience of other countries, could have actually helped the economy in the long term.
"Lives cannot be rebuilt; other things can be," Daniel Goldberg, a medical historian and public health ethicist at the University of Colorado, told me. He acknowledged the short-term economic pain that closing down would bring, but said it was simply the better of a set of bad options.
"A lot of what I do in public health ethics is thinking about the fact that often there isn't a good option," he said. "So what we have to do is pick the least bad one. It's not good. I'm not going to tell you it's a good thing. It's terrible. But it's still the least bad thing we have to do."
But just about everyone reopened too aggressively following spring and summer surges of Covid-19, and they have been far too slow to close down since - as the surges in previously proactive states like California and Ohio indicate.
There are some partisan differences. The states that haven't enacted mask mandates, which the research increasingly supports, are all led by Republicans. Many Republican-led states resisted any sort of restrictions at all - with South Dakota, as one example, sticking to a "personal responsibility" strategy even as the state suffered one of the worst Covid-19 outbreaks in the world at the time.
But it's not entirely a red-or-blue issue. Democratic leaders in California, New York, and elsewhere have also softened their approach to Covid-19, resisting stronger action until after their states reached or neared new highs in coronavirus cases or deaths this fall. According to the New York Times, businesses are mostly or largely open in 41 states, and none has a stay-at-home order statewide.
Governors will point to the structural problems. Jha told me that in his own conversations with governors, they've argued that they essentially have to choose between public health and the economy, thanks to the lack of federal aid. "They really don't like those choices," he said.
While that might make the problems local and state officials face more understandable, it doesn't fully justify what followed. Before the fall, most experts warned of the growing risk of Covid-19 as the holidays arrived, temperatures dropped, and states reopened. Michael Osterholm, director of the Center for Infectious Disease Research and Policy, told me that "this fall is going to be the biggest spike of all" - a message echoed by others in the field, publicly and privately. It was genuinely hard to avoid the warnings that more cases and deaths were coming without proper action.
This created a clear choice for states: You can continue to reopen or keep places open, leading to thousands of deaths and, potentially, not avoiding any economic harm if a new surge leads the public to voluntarily lock down anyway. Or you can impose restrictions, save as many lives as possible through the fall and winter, and come out on the other side with the likely prospects of a vaccine reaching the general public, all with at worst a short-term hit to the economy.
Every state opted to roll the dice on a risky reopening, gambling on the possibility that things wouldn't get too bad and the economy would remain afloat. Now things are bad, with record numbers of Americans getting sick and dying.
Meanwhile, the economy continues to struggle anyway, as much of the public keeps cutting back socializing and spending as the Covid-19 epidemic spirals. According to restaurant data from OpenTable, seated dining from online, phone, and walk-in reservations are now down 71 percent compared to the same time last year before. By contrast, places that have controlled the coronavirus have stronger economies: In Australia, dining in is actually up 58 percent from last year. The problem US leaders sought to avoid by reopening and staying open hasn't been avoided.
"It feels like we have the worst of both worlds," Bibbins-Domingo said, speaking to her experience in California. "You can see that now with the backlash and fatigue and latest reaction [to new restrictions]."
In response, leaders have called on individuals to take steps to mitigate the risk of spread - to cancel or reduce their holiday plans. It hasn't worked, with cases, hospitalizations, and deaths still trending up, and much-feared Christmas and New Year's surges looking more and more likely. The American public simply isn't listening, leading to surges on surges.
Some government leaders have exemplified the failure of this approach. New York Gov. Andrew Cuomo has spent many of his press conferences warning people of the risks of holiday gatherings, advising people to simply not do them. Yet until a public backlash, Cuomo planned to hold a Thanksgiving dinner with his 89-year-old mom and two of his adult daughters.
This kind of example is why experts have called for more government action. While it's true that holiday gatherings can and have led to the spread of Covid-19, and individuals should reconsider any big plans this year, the reality is many people are going to do these kinds of things anyway. But if all levels of government had done a better job controlling the coronavirus before the US got to its holiday season, the risk wouldn't have been as large as it is now - there may have been much less virus out there, waiting to spread over dinner on Christmas Eve.
That's mostly Trump and his Republican allies' fault, but not entirely. The country's Covid-19 horrible epidemic is an American failure - and we have to learn from that.