With more than 600 000 confirmed cases and close to 27 000 deaths, the USA has become the current centre of the global coronavirus disease 2019 (COVID-19) pandemic. Fewer than 3 months have elapsed since the first severe acute respiratory syndrome coronavirus 2 infection in Washington State was confirmed by the US Centers for Disease Control and Prevention (CDC). Initially appearing slow moving and constrained in contrast to the scale of outbreaks in China and Italy, COVID-19 has given way to a nationwide public health catastrophe. For the first time in US history, a disaster declaration has been put in place for all 50 states and most US territories, and 95% of Americans are at least temporarily under some form of stay at home order. The increasing gravity of the situation in the USA has drawn public health and infectious disease experts, policy makers, and partisans across state and federal government into a fitful clash for control and direction of the COVID-19 response. Putting the USA at odds with the international community and global pandemic strategy efforts, President Trump announced his intention to withdraw funding from WHO (about 22% of its budget). Caught amid the chaos are the American people grappling with the fear of a deadly and poorly understood virus, conflicting messaging around their protection and safety, fear of financial fallout, absence of a cohesive national strategy, and volatile, incompetent leadership.
As Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has suggested, sluggish decision making by the federal government at the outset of the COVID-19 crisis lost precious time: had “you started mitigation earlier, you could have saved lives”. It was not until late February, 2020, after local transmission of COVID-19 was established in additional clusters in Oregon and New York states, that the CDC updated guidance to authorise testing for individuals who had not travelled recently, substantially widening the scope of cases that could be detected. During the brief window when containment of the virus might have been a possibility, the CDC retained control of all testing, preventing external academic and commercial test development, and processing only about 100 samples per day. The US Food and Drug Administration has also created barriers through its requisite approval scheme for all diagnostics. Even with the slow scale-up of testing, private facilities and laboratories tasked with processing samples have been severely overwhelmed with thousands of backlogged cases. Point-of-care and clinic testing for active infections is still pressing, especially in regions where outbreaks are predicted to occur, but there must now be a shift in urgency to develop and expand testing capacity for previous COVID-19 infections.
Testing might rely on the ability to innovate, but simple and effective prophylaxis against COVID-19 has been hampered and delayed by Trump's prevarication. Dynamic models predicting the rates of mortality and hospital admission, such as the IHME COVID-19 projections as well as previous pandemic preparedness plans, have been available to help states get ready for surge responses, through increasing the number of hospital beds and ventilators available. Yet shortages and inadequate personal protective equipment have and continue to put front-line health-care workers at great risk. After sparring with governors over access to the Strategic National Stockpile, Trump has not invoked the Defense Production Act, ordering private businesses to manufacture needed goods, leaving states, philanthropists, and health-care advocacy groups to source equipment, often directly competing with the federal government for goods. Anticipating a protracted fight against COVID-19 that could involve multiple waves of outbreak, reinforcing that availability and equitable distribution of essential medical supplies should be the priority of existing federal agencies.
In hard-hit states such as New York, although hundreds of COVID-19 deaths are still occurring daily, hospital admissions appear to have plateaued. Credit might be due to effective physical distancing measures that limit community mobility. But progress in preventing the spread of COVID-19 has come with economic havoc—at least 17 million Americans are unemployed, a number that could ultimately surpass the Great Depression, and take years to correct. A new impasse is forming around the Trump administration's eagerness to boost the economy by lifting restrictions, just as mitigation efforts by the states are yielding results. The degree to which the USA stalled in taking aggressive action to curtail the spread of COVID-19 is directly the product of an administration marked by consistently poor timing, intent on making decisions in favour of economic interests instead of those that are guided by science and to protect health. The rush to reopen the country puts dollars over deaths.
