The unique US failure to control the novel coronavirus

Nearly every country has struggled to contain the coronavirus and made mistakes along the way.

China committed the first major failure, silencing doctors who tried to raise alarms about the virus and allowing it to escape from Wuhan. Much of Europe went next, failing to avoid enormous outbreaks. Today, many countries — Japan, Canada, France, Australia and more — are coping with new increases in cases after reopening parts of society.

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Yet even with all of these problems, one country stands alone as the only affluent nation to have suffered a severe, sustained outbreak for more than four months: the United States.

When it comes to the virus, the United States has come to resemble not the wealthy and powerful countries to which it is often compared but instead to far poorer countries, like Brazil, Peru and South Africa, or those with large migrant populations, like Bahrain and Oman.

As in several of those other countries, the toll of the virus in the United States has fallen disproportionately on poorer people and groups that have long suffered discrimination. Black and Latino residents of the United States have contracted the virus at roughly three times as high of a rate as white residents.

How did this happen? The New York Times set out to reconstruct the unique failure of the United States through numerous interviews with scientists and public health experts around the world. The reporting points to two central themes.

First, the United States faced long-standing challenges in confronting a major pandemic. It is a large country at the nexus of the global economy, with a tradition of prioritizing individualism over government restrictions. That tradition is one reason the United States suffers from an unequal health care system that has long produced worse medical outcomes — including higher infant mortality and diabetes rates and lower life expectancy — than in most other rich countries.

“As an American, I think there is a lot of good to be said about our libertarian tradition,” Dr. Jared Baeten, an epidemiologist and vice dean at the University of Washington School of Public Health, said. “But this is the consequence: We don’t succeed as well as a collective.”

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The second major theme is one that public health experts often find uncomfortable to discuss because many try to steer clear of partisan politics. But many agree that the poor results in the United States stem in substantial measure from the performance of the Trump administration.

In no other high-income country — and in only a few countries, period — have political leaders departed from expert advice as frequently and significantly as the Trump administration. President Donald Trump has said the virus was not serious, predicted it would disappear, spent weeks questioning the need for masks, encouraged states to reopen even with large and growing caseloads, and promoted medical disinformation.

In recent days, Trump has continued the theme, offering a torrent of misleading statistics in his public appearances that make the situation sound less dire than it is.

Some Republican governors have followed his lead and also played down the virus, while others have largely followed the science. Democratic governors have more reliably heeded scientific advice, but their performance in containing the virus has been uneven.

“In many of the countries that have been very successful, they had a much crisper strategic direction and really had a vision,” said Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security, who wrote a guide to reopening safely for the American Enterprise Institute, a conservative research group. “I’m not sure we ever really had a plan or a strategy — or at least it wasn’t public.”

Together, the national skepticism toward collective action and the Trump administration’s scattered response to the virus have contributed to several specific failures and missed opportunities, Times reporting shows:

— a lack of effective travel restrictions,

— repeated breakdowns in testing,

— confusing advice about masks,

— a misunderstanding of the relationship between the virus and the economy,

— and inconsistent messages from public officials.

Already, the US death toll is of a different order of magnitude than in most other countries. With only 4% of the world’s population, the United States has accounted for 22% of coronavirus deaths. Canada, a rich country that neighbors the United States, has a per capita death rate about half as large. And these gaps may worsen in coming weeks, given the lag between new cases and deaths.

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For many Americans who survive the virus or do not contract it, the future will bring other problems. Many schools will struggle to open. And the normal activities of life — family visits, social gatherings, restaurant meals, sporting events — may be more difficult in the United States than in any other affluent country.

A Travel Policy That Fell Short

In retrospect, one of Trump’s first policy responses to the virus appears to have been one of his most promising.

On Jan. 31, his administration announced that it was restricting entry to the United States from China. Many foreign nationals — be they citizens of China or other countries — would not be allowed into the United States if they had been to China in the previous two weeks.

It was still early in the spread of the virus. The first cases in Wuhan, China, had been diagnosed about a month before, and the first announced case in the United States had come on Jan. 21. In announcing the new travel policy, Alex Azar, the secretary of health and human services, declared that the virus posed “a public health emergency.” Trump described the policy as his “China ban.”

After the Trump administration acted, several other countries quickly announced their own restrictions on travel from China, including Japan, Vietnam and Australia.

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But it quickly became clear that the policy was full of holes. It did not apply to immediate family members of US citizens and permanent residents returning from China, for example. In the two months after the policy went into place, almost 40,000 people arrived in the United States on direct flights from China.

Even more important, the policy failed to take into account that the virus had spread well beyond China by early February. Later data would show that many infected people arriving in the United States came from Europe. (The Trump administration did not restrict travel from Europe until March and exempted Britain from that ban despite a high infection rate there.)

The administration’s policy also did little to create quarantines for people who entered the United States and may have had the virus.

Authorities in some other places took a far more rigorous approach to travel restrictions.

South Korea, Hong Kong and Taiwan largely restricted entry to residents returning home. Those residents then had to quarantine for two weeks upon arrival, with the government keeping close tabs to ensure they did not leave their home or hotel. South Korea and Hong Kong also tested for the virus at the airport and transferred anyone who was positive to a government facility.

Australia offers a telling comparison. Like the United States, it is separated from China by an ocean and is run by a conservative leader: Scott Morrison, the prime minister. Unlike the United States, it put travel restrictions at the center of its virus response.

Australian officials noticed in March that the travel restrictions they had announced Feb. 1 were not preventing the virus from spreading. So they went further.

On March 27, Morrison announced that Australia would no longer trust travelers to isolate themselves voluntarily. The country would instead mandate that everyone arriving from overseas, including Australian citizens, spend two weeks quarantined in a hotel.

The protocols were strict. As people arrived at an airport, authorities transported them directly to hotels nearby. People were not even allowed to leave their hotel to exercise. The Australian military helped enforce the rules.

Around the same time, several Australian states with minor outbreaks shut their own borders to keep out Australians from regions with higher rates of infection. That hardening of internal boundaries had not happened since the 1918 flu pandemic, said Ian Mackay, a virologist in Queensland, one of the first states to block entry from other areas.

The United States, by comparison, imposed few travel restrictions, either for foreigners or US citizens. Individual states did little to enforce the rules they did impose.

“People need a bit more than a suggestion to look after their own health,” said Mackay, who has been working with Australian officials on their pandemic response. “They need guidelines, they need rules — and they need to be enforced.”

Travel restrictions and quarantines were central to the success in controlling the virus in South Korea, Hong Kong, Taiwan and Australia as well as New Zealand, many epidemiologists believe. In Australia, the number of new cases per day fell more than 90% in April. It remained near zero through May and early June, even as the virus surged across much of the United States.

In the past six weeks, Australia has begun to have a resurgence — which itself points to the importance of travel rules. The latest outbreak stems in large part from problems with the quarantine in the city of Melbourne. Compared with other parts of Australia, Melbourne relied more on private security contractors who employed temporary workers — some of whom lacked training and failed to follow guidelines — to enforce quarantines at local hotels. Officials have responded by banning out-of-state travel again and imposing new lockdowns.

Still, the tolls in Australia and the United States remain vastly different. Fewer than 300 Australians have died of complications from COVID-19, the illness caused by the virus. If the United States had the same per capita death rate, about 3,300 Americans would have died rather than 158,000.

Enacting tough travel restrictions in the United States would not have been easy. It is more integrated into the global economy than Australia is, has a tradition of local policy decisions and borders two other large countries. But there is a good chance that a different version of Trump’s restrictions — one with fewer holes and stronger quarantines — would have meaningfully slowed the virus’ spread.

Traditionally, public health experts had not seen travel restrictions as central to fighting a pandemic, given their economic costs and the availability of other options, like testing, quarantining and contact tracing, Baeten, the University of Washington epidemiologist, said. But he added that travel restrictions had been successful enough in fighting the coronavirus around the world that those views may need to be revisited.

“Travel,” he said, “is the hallmark of the spread of this virus around the world.”