The other day I summarized the big-picture global trajectory on #COVID19. Here's an attempt at assessing US readiness.
In short: the big variables are not the virus; they're our political system, our health system, and public trust.
In short: the big variables are not the virus; they're our political system, our health system, and public trust.
But first let's debunk two myths that are showing up a lot in my mentions:
Myth 1: "We're all gonna die!" Nope. This isn't a disease in which most infected people die. Only about 5% of cases are critical; 1-2% die. Most cases will be like this guy:
Myth 1: "We're all gonna die!" Nope. This isn't a disease in which most infected people die. Only about 5% of cases are critical; 1-2% die. Most cases will be like this guy:
Myth 2: "No big deal, it's just like flu"
NO. Much more dangerous. Around twice as contagious, 10-20 times as deadly. And no vaccine or treatment.
Means the plausible high-end risk is big, because spreading <2% fatality across a vastly large number of people would kill many.
NO. Much more dangerous. Around twice as contagious, 10-20 times as deadly. And no vaccine or treatment.
Means the plausible high-end risk is big, because spreading <2% fatality across a vastly large number of people would kill many.
So it's a legitimately dangerous virus.
Fortunately a path is coming into focus: intensive public health efforts have shown progress in China, Malaysia, Hong Kong. But will still be a long war, and may not end until vaccines come on line in 18+ months.
Fortunately a path is coming into focus: intensive public health efforts have shown progress in China, Malaysia, Hong Kong. But will still be a long war, and may not end until vaccines come on line in 18+ months.
What does this mean for the US?
Well, as @LawrenceGostin points out, China's draconian measures won't work here. Not feasible legally or socially.
So we must figure out how to apply the kind of discipline and rigor they have, but in our own system.
Well, as @LawrenceGostin points out, China's draconian measures won't work here. Not feasible legally or socially.
So we must figure out how to apply the kind of discipline and rigor they have, but in our own system.
We will need a different model. As I see it we face (at least) three big challenges to translating China and Malaysia's lessons to the US:
- Our health care system
- Crisis management
- Communication and cooperation
- Our health care system
- Crisis management
- Communication and cooperation
First, our health system. We have a fragmented, profit-driven system that is mostly managed by the private sector, and funded by insurance. The federal government can influence this system, but can't direct it.
At a system level, that makes it harder to implement, much less enforce, a consistent, coherent hospital readiness strategy. The federal govt can issue guidance and give support, but can't just tell a private hospital what do to (as we found on Ebola in 2014).
Our system also impedes the disease surveillance that underpins China's progress.
To interrupt spread of the disease, you need visibility on as many cases as possible, so you know where and how they are spreading and can focus efforts accordingly.
To interrupt spread of the disease, you need visibility on as many cases as possible, so you know where and how they are spreading and can focus efforts accordingly.
But our system provides huge disincentives to seeking care if you are mildly ill or un/under-insured.
Like this guy who returned from China with flu symptoms, only to be charged $1400 out of pocket for his test (he was negative). miamiherald.com/news/health-ca…
Like this guy who returned from China with flu symptoms, only to be charged $1400 out of pocket for his test (he was negative). miamiherald.com/news/health-ca…
Charging people for testing would make large swathes of the population reluctant to come forward if they have only mild symptoms (i.e. 80% of spreaders). They could remain out in the community, invisible to health authorities and spreading the virus to others.
And at a hospital level, tight profit margins mean infection prevention protocols are a consistent weak point (which is how you end up with 124 workers self-quarantined from a single case in California). @SaskiaPopescu is the expert on this aspect. schar.gmu.edu/news-and-event…
Those tight profit margins also mean the US doesn't maintain a lot of spare bed capacity in hospitals. That's good for profits, bad for surge potential - as the US found during the nasty 2017-18 flu season. statnews.com/2018/01/15/flu…
So our health system has some big hurdles built in. That's not insurmountable, but it does highlight the importance of my second big concern: novel crisis management.
This outbreak will be by far the most challenging thing the Trump administration has had to manage.
This outbreak will be by far the most challenging thing the Trump administration has had to manage.
Managing a novel crisis like this one is HARD. Let's not at all minimize the challenge facing the federal government. This is tough and largely uncharted territory.
If you want a sense of what it's like, I wrote about the inside-USG process on Ebola: cgdev.org/publication/st…
If you want a sense of what it's like, I wrote about the inside-USG process on Ebola: cgdev.org/publication/st…
Getting USG novel crisis management right depends on a strong leadership structure, well-informed and rigorous planning, capable people, all operating under a wartime rather than a peacetime mentality. Govt has to push itself beyond its comfort zone.
Closest proxy for that under Trump? Probably Puerto Rico/Maria - another novel crisis that strained govt's normal systems. Not an encouraging precedent, but has some parallels to this one - notably Trump's insistence that he was doing great, despite all evidence to the contrary.
And that gets at the biggest variable on crisis mgmt capacity: not the team around the President, but the President himself.
The team around him is solid. Azar, Fauci, Birx, Redfield are competent; and at career level the same folks will work this regardless of administration.
The team around him is solid. Azar, Fauci, Birx, Redfield are competent; and at career level the same folks will work this regardless of administration.
But as I wrote about on Puerto Rico, the President's role is incredibly important in a novel crisis - he sets the tone for the entire operation. He is the one person who can simultaneously kick the whole federal government beyond business as usual. washingtonpost.com/news/postevery… 
Sadly what we've seen so far reflects weak crisis mgmt. To borrow from @BrendanNyhan, there have been many "brown M&Ms" moments: the debacle with testing kits, infighting between CDC and State over medevac from Japan, the HHS whistleblower complaint, etc.
Those and other things - notably the failure to move aggressively on hospital preparedness, or to request a robust emergency budget package - suggest a response operation operating more on a peacetime than a war-time mentality.
And ultimately the President sets that tone.
And ultimately the President sets that tone.
So the big question on crisis management is this: will an administration renowned for chaotic, slapdash management at the White House be able to devise and lead the kind of rigorous and disciplined response operation it will take to defeat this outbreak?
Final concern: communications and public trust.
The USG cannot coerce Americans into cooperating with potentially disruptive public health measures - it will need to voluntary cooperation, and that in turn requires their trust.
The USG cannot coerce Americans into cooperating with potentially disruptive public health measures - it will need to voluntary cooperation, and that in turn requires their trust.
Maintaining public trust takes disciplined, consistent, transparent messaging.
The message sloppiness of the past few weeks - in which political and economic figures in the administration have been out of step with the scientists - does not augur well.
The message sloppiness of the past few weeks - in which political and economic figures in the administration have been out of step with the scientists - does not augur well.
Nor does the administration's tendency to frame this crisis in terms of the stock market, and the President's electoral prospects.
Much of the public mistrusted Trump already; this kind of thing just reinforces their skepticism.
Much of the public mistrusted Trump already; this kind of thing just reinforces their skepticism.
That mix of baseline mistrust and muddled communication is going to make it much tougher for the federal government to earn public cooperation if/when disruptive outbreak control measures become necessary.
That said, today's press conf set a better tone - if they can sustain it.
That said, today's press conf set a better tone - if they can sustain it.
So - we'll see how this all plays out. The progress in China/Malaysia/Hong Kong leaves me encouraged that mitigating the outbreak is possible. But seeing the shortcomings in our own government's handling of this to date, I'm uncertain they have the discipline to pull that off.
