The U.S. Federal Response to COVID-19 During the First 3 Months of the Outbreak: Was an Evidence-Based Approach an Option?

The Evidence-Based Approach

In the last 20 years, much emphasis has been placed on evidence-based decision-making in the United States and other advanced nations across all areas of government and science (Hole et al., 2017). Former British Prime Minister Tony Blair is credited as the first public figure to openly endorse the evidence-based approach in government decision-making in modern history. In 1999, Blair explicitly promoted the use of evidence-based practices for an effective approach to lead governments. Some consider this a departure that led to the modernization of the British government (Parsons, 2002). Blair’s reference to the evidence-based approach came from the fields of science and medicine.

The term “evidence-based” was first used by Archie Cochrane in 1972 in the book Effectiveness and Efficiency: Random Reflections on Health Services. Cochrane made the case for distinguishing between the scientific evidence provided by randomized clinical trials and the evidence of clinical practices in medicines, suggesting that evidence generated by the application of a sound scientific method provides findings that can be replicated across populations over time. In other words, while clinical practices can inform scientists, it is data collected through the scientific method that provide evidence that is both reliable and generalizable (Mechanic, 1998).

Reliance on facts and data in governments is perhaps older than Tony Blair’s endorsement and even Cochrane’s 1972 book. When defending the British soldiers on trial for the Boston Massacre in 1770, John Adams pointed out that reliance on facts is important in that facts highlight the actual truth (Cuomo, 2020). In John Adams’s words, “Facts are stubborn things and whatever may be our wishes, our inclinations, or dictates of our passions, they cannot alter the state of facts and evidence” (American History Central, n.d.).

COVID-19 is a new phenomenon, and learning from the evidence provided by an analysis of existing data was rather difficult for any government during the first weeks of the outbreak. A few possibilities, however, were available to the U.S. federal government:

All these possibilities existed; however, the response of the U.S. federal government has relied less on facts and more on political instincts.

Evidence From Previous Pandemics and Disasters in the United States

The first pandemic of the 21st century occurred in 2003, when an outbreak of severe acute respiratory syndrome (SARS) resulting from the spread of a coronavirus affected more than 8,000 people around the world and resulted in a 10% fatality rate. The collaboration between the CDC and other public health institutions around the world led to a successful isolation—and eventually the elimination—of the virus that caused SARS (LeDuc & Barry, 2004). Although SARS was different from COVID-19, the protocol identified by U.S. governmental authorities in 2003 proved to effectively curb the transmission of the virus. It was later assessed that SARS disappeared from the face of the earth (Dezhong et al., 2014).

A second pandemic occurred in 2009. Following an emerging spread of influenza H1N1, first identified in Mexico among workers in direct contact with pigs, the United States declared the state of emergency on April 26, 2009. The first confirmed H1N1-related death in the United States occurred on April 29, 2009. The U.S. State of Emergency was renewed twice, on July 24, 2009, and again on October 1, 2009 (Obama, 2009). The World Health Organization (WHO) declared the H1N1 influenza a global pandemic on June 11, 2009 (WHO, 2009). The CDC estimated that from April 12, 2009, to April 10, 2010, there were 60.8 million H1N1 cases, with 274,304 hospitalizations and 12,469 deaths in the United States alone. The virus infected people worldwide and caused the death of an estimated number of people between 151,700 and 575,400. The virus was more prevalent among the young, with 80% of deaths among individuals younger than 65 years of age (CDC, n.d.).

Much could have been learned from the U.S. federal response to the H1N1 influenza pandemic. The immediate concern of the federal government at that time was to free moneys that would allow for the distribution of antiviral medications. The federal government also acted quickly to coordinate the response with the states, allowing for data collections and monitoring of measures, such as school closures (Health and Human Services [HHS], 2012). The federal government immediately implemented airport screening sites to identify travelers who had been exposed to the virus. Individuals with symptoms were immediately connected with health care providers. The main criticism to the Obama administration’s response to H1N1 was the lag in the distribution of vaccines in the fall of 2009 (Calmes & McNeil, 2009). An analysis of the U.S. response protocol for the H1N1 pandemic, taking into consideration both successes and failures of the federal government interventions, could have been used to inform policy makers during the first weeks of the COVID-19 outbreak about the effectiveness of an emergency management protocol during a pandemic.

Emergency management protocols in the United States include a four-phase cycle: preparedness, mitigation, response, and recovery. In the case of a pandemic, preparedness also includes seeking expert advice from well-trained epidemiologists. It is important to have epidemiologists on the ground in other countries to gain firsthand information where it matters when it matters. Such information is of vital importance to prevent the spread of any contagious disease. Unfortunately, in the last 2 years, the Trump Administration cut more than two thirds of the staff at key public health agencies. These included the CDC, the National Science Foundation, and Personnel of the U.S. Department of Agriculture who were transferred out of China, as part of a larger reduction in U.S.-funded health and science experts on the ground whose competencies and capacity were boosted during the previous administration for the prevention of the spread of infectious diseases (Taylor, 2020). One may say that gutting the public health apparatus as a rollback in U.S.-funded public health measures proved to be a mistake. One may also speculate that this decision was politically motivated as it aimed at reversing the course of action of a democratic president who prioritized funding for the prevention of infectious diseases based on the experience of the H1N1 pandemic. Perhaps this concern with politics prevented the current administration from adopting the protocol for emergency management implemented by the Obama administration.

The first step to mitigation put in place to limit the spread of COVID-19 in the United States was a travel ban for people traveling from China issued on January 31, 2020. The ban, however, did not apply to American citizens or permanent residents. Effective February 2, 2020, traveling from China was limited to U.S. citizens and permanent residents coming back home. Flights were redirected to 11 locations around the United States where screening of travelers was available (Bier, 2020). By then, the virus had already spread across Europe, and Italy was now the epicenter of the virus. The Europe travel ban became effective only on March 11, 2020. Travelers returning to the United States had to stay in quarantine for 14 days, but experts point out that this response was rather uncoordinated (Bier, 2020). There was no mention of screening and testing at the airport in the ban. It is possible that the delays in the implementation of coordinated travel restrictions contributed to the spread of COVID-19 in the United States.

A much-needed response from the federal government during the COVID-19 crisis related to the distribution of personal protective equipment (PPE), ventilators, and testing supplies across the country. During the first weeks of the crisis, states were left to compete with one another when ordering materials from companies abroad, limiting states’ capacity in the response to the pandemic (O’Reilly, 2020). The President of the United States can enforce the Defense Production Act as a tool to demand that businesses within the nation produce materials needed to face the crisis (Else, 2009). Targeting specific companies, President Trump wrote two memoranda regarding the Defense Production Act, the first on March 27, 2020, and the second on April 2, 2020 (The White House, 2020). This response to address the needs of states and local communities for the procurement of supplies for frontline workers can be perceived as part of a policy-making approach that is reactive rather than proactive.

Although pandemics are unique in the way they tend to burden the entire health care system, they also present many similarities with natural disasters, such as tsunamis, earthquakes, and floods. In a comparative study of the needs nations developed in response to the 2004 Indonesian Tsunami and the 1918 Spanish flu pandemic, Scanlon et al. (2007) found that both disasters created mass deaths and led to shortage of supplies, shortage of personnel, high demands for volunteers, economic hardship, and cultural barriers that complicated burial procedures. The authors argue that there are no reasons for nations not to be ready to respond to a pandemic once they experience disasters of any type, as the needs for all types of disasters tend to be very similar. The immediate needs relate to a variety of issues, not just health care. A major barrier for a society’s ability to cope with a disaster (either pandemic or not) is the delay in coordination of resources and services (Scanlon et al., 2007). The immediate consequences of pandemics, similar to those following natural disasters, tend to be exacerbated by the presence of socioeconomic inequalities within a given population. Poor people, those with no access to health care, those living in high-density areas, those residing in low-income public housing, and the disabled tend to fare worse during any kind of disaster. COVID-19 is proving to be similar in this regard to any other disaster the United States has experienced in modern history. However, the federal government has not issued any policy that would specifically protect the most vulnerable populations.

Having rejected the protocol put in place by the previous administration left the Trump administration with two other options: learn from the experience of other countries and follow the advice of domestic experts.

The Experience of Other Countries With COVID-19

Since the emergence of global capitalism, nations are connected with one another for more than just economic reasons (Tilly, 1975). This connectivity among nations leads to the spread of information, customs, and also public health troubles. What happens in one place is rarely just the product of a nation alone. In the global village, the development of an event is most often associated with the development of similar events around the world (Wallerstein, 1992). At the same time, the power of intervention and the ability to influence any course of action are in the hands of a powerful social network represented by both individual governments and international organizations. Within network societies, communication becomes the most powerful tool (Castells, 2011).

Information about COVID-19 was already circulating in the global village several weeks before the first U.S. confirmed case. Emergency management protocols from other nations were already in place.

The city of Wuhan identified the first COVID-19 cases in late December 2019. Almost 1 month later, Wuhan went on complete lockdown. Although the virus had affected mostly the city of Wuhan, by January 23, 2020, the lockdown was extended to the whole province, an intervention that helped successfully isolate COVID-19 cases (“The Last Six Weeks . . .,” 2020).

South Korea was able to curb the spread of the virus by following two strategies. First, the country imposed a strict travel ban for everyone traveling from the Hubei province of China. Second, South Korea employed rapid scale testing with 5,500 tests per 1 million residents. Testing was readily available in South Korea. Tests were free with physician’s prescription; tests were also available through private practice with the opportunity of reimbursement from the government if the patient tested positive. Furthermore, South Korea implemented tracing, targeted testing of those exposed to the virus, and monitoring of patients who tested positive through the use of electronic applications (Cowlin & Lim, 2020).

Germany became a model Western European nation for its response to the COVID-19 pandemic. The production of tests ramped up weeks before the first case of COVID-19 became known to German officials, and by mid-January, Germany had already established an efficient testing system (Bennhold, 2020). The country went on lockdown within a couple of days after reporting the first known COVID-19 case (“The Last Six Weeks . . .,” 2020). When the first COVID-19 fatality was reported, on March 9, 2020, Germany’s public health system was prepared to face the challenges of the pandemic (Bennhold, 2020). Germany used data from other nations experiencing the outbreak to implement measures that would curb the spread of the virus. Testing was free in Germany, and this contributed to people’s willingness to participate in government-led interventions (Bennhold, 2020). Germany benefits from a strong national health care system with a robust social safety net. From the beginning of the outbreak, medics’ home visits and hospitalization granted also to people showing mild symptoms helped reduce the number of fatalities across the nation. Throughout Germany, hospitals were equipped with as many as 35 beds with ventilators per 100,000 people, compared with 12 per 100,000 in Italy and 7 per 100,000 in the Netherlands (Bennhold, 2020). Germany’s ability to face the challenges caused by the virus resulted in a far lower mortality rate than in other European nations (Lab24, 2020).

In contrast to the German response to COVID-19, the response of the Italian government was delayed. Italy went on lockdown 6 days after the first COVID-19 case was reported to the national health care system (“The Last Six Weeks . . .,” 2020). This delay contributed to the rapid spread of the virus across the Northern region of the Italian peninsula. In addition, on February 19, 2020, a large crowd of soccer fans gathered in a Bergamo stadium (in the region of Lombardy) for a Champions League match. It was later reported that roughly 35% of those who attended the match tested positive for COVID-19. The match was later considered the catalyst for the spread of infections in the Lombardy region, which became the epicenter of the infection in Europe (Berizzi & Griseri, 2020; Robinson, 2020). The Italian experience demonstrated that a country lockdown and social distancing strategies could have been more effective if implemented sooner.

Although Italy has historically benefited from a highly competent state-run health care system (Boccia et al., 2020), the system became quickly overwhelmed because of the number of patients referred to the hospitals. This also contributed to the widespread transmission of infections among medical personnel. As of April 24, 2020, almost 20,000 medical personnel were found positive to COVID-19 in Italy (Istituto Superiore di Sanita, 2020). Despite its delayed response which was in part responsible for making Italy the European epicenter of the virus throughout the months of February and March, Italy also provided positive examples to other nations. When the first COVID-19 death was reported on February 22, 2020, in the town of Vo’ Euganeo, in the Veneto region, the local government ordered that all the 3,000 residents be tested for COVID-19 (Crisanti & Cassone, 2020). This strategy allowed health care authorities in Vo’ Euganeo to quarantine people even before they showed symptoms and eradicate COVID-19 in only 2 weeks. Researchers found that—at the time of testing—roughly 3.0% of the town’s population had already been infected. The study provided important information as it revealed that the rate of individuals infected by the virus was very high, with many of them being asymptomatic. Isolating asymptomatic patients became the most important strategy in the town (La Repubblica, 2020). The study also showed that social distancing is an important mitigation strategy that works to reduce the infection rate in a community. In Vo’ Euganeo, the number of people infected with COVID-19 rapidly declined after the first 7 days of isolation (La Repubblica, 2020).

An analysis of COVID-19 cases in Italy also suggested that elderly patients and those with comorbid disorders, such as hypertension, ischemic heart disorder, and chronic obstructive pulmonary disease, were at higher risks of dying from the disease. The median age of those infected with COVID-19 in Italy is 62 years. Among those who died from COVID-19, 98.8% suffered from at least another disease and 48.6% had three or more comorbidities (Boccia et al., 2020). The Italian experience indicated that at-risk populations had to be protected from exposure to the virus.

Data on COVID-19 cases provided by Italy, Germany, South Korea, and China were relevant to the implementation of policies that could have protected Americans from a widespread contagion. Social isolation and mass testing proved to be the most successful tools in other countries. Unfortunately, President Trump did not declare COVID-19 a National Emergency until March 13, 2020, 45 days after the first confirmed cases of infections in the country (“The Last Six Weeks . . .,” 2020) and 1 day after WHO declared the COVID-19 outbreak a pandemic (WHO, 2009).

The major concern among experts and local government authorities in the United States was related to lack of information. Testing would have provided the necessary information for the implementation of evidence-based decisions. However, testing was very limited as the U.S. federal government had attempted to brand a new COVID-19 test that was initially deemed to be defective. By March 8, 2020, the United States had tested only 3,000 people (1 per 100,000 residents). In comparison, South Korea had already tested 342 per 100,000 of its residents (“The Last Six Weeks . . .,” 2020).

Failing to observe the example provided by other countries during the first weeks of the COVID-19 outbreak, after rejecting the protocol put in place by the Obama administration, the U.S. federal government was left only with the option to follow the expert advice of its own domestic scientists.

Evidence Disseminated by U.S. Scientists and Researchers

On January 29, 2020, President Trump appointed a White House Coronavirus Task Force that would comprise expert epidemiologists and other official authorities of the White House with the goal of providing guidelines, interpreting data, and giving advice on policy-making (Shear, 2020). While this effort seemed like a necessary step to keep the country informed, on several occasions, the President dismissed the expert advice of his own Task Force (Wise, 2020). On more than one occasion, the federal government denied the evidence from data to enforce decisions. Three examples are particularly relevant in this context:

During the month of March 2020, President Trump openly endorsed and promoted the use of anti-malaria medications to cure COVID-19 patients, despite the expert advice of the scientists appointed to the White House Task Force. Later, on April 22, 2020, the news was released that Dr. Rick Bright had been removed from the positions as the Director of the Biomedical Advanced Research and Development Authority and HHS Deputy Assistant Secretary for the Preparedness and Response by the Administration and involuntarily transferred to another less impactful position at the National Institutes of Health (Shear & Haberman, 2020). In a letter issued by the law firm representing him, Dr. Bright openly clarified that he believed his transfer was in response to his insistence that Congress approve COVID-19 pandemic solutions vetted by scientific studies rather than prioritize treatments that—like anti-malaria drugs—lack scientific merit. This story is important as it highlights that not only was the current federal government averse to using an evidence-based approach, it opted for removing competent employees who followed their scientific training and demonstrated to be loyal to science. In early May 2020, the news that Dr. Bright filed a whistleblower complaint was revealed (Durrell & Severin, 2020).

Similarly, the U.S. federal administration rejected the findings of a study conducted by the Department of Health and Human Services’ Office of the Inspector General on the availability of resources among U.S. hospitals. The study, designed and coordinated by Deputy Inspector General Christi Grimm, included data from 300 participating hospitals. Its findings, published on April 6, 2020, highlighted a widespread lack of available PPE among frontline workers and a severe shortage of hand sanitizing products. President Trump voiced his rejection of the study’s results condemning the use of the report as a political tool. Later, on May 2, 2020, Christi Grimm was removed from the position (Slotkin, 2020).

A last example refers to the persistent rhetoric endorsed by the White House Task Force (with the exception of Dr. Fauci) that the United States has tested more than any other nation on earth for COVID-19. According to researchers at the Our World in Data, the United States currently ranks 19 in the number of COVID-19 tests per confirmed case. As of May 12, 2020, the United States reported seven tests per confirmed case, compared with 126.4 tests per confirmed case in South Korea, 17 tests per confirmed case in Germany, and 7.9 tests per confirmed case in Italy (Ritchie et al., 2020). Once again, the Trump administration opted for spreading false information to boost their political agenda.

All these examples show that, during the first 3 months of the COVID-19 outbreak, the federal government rejected all the opportunities to follow an evidence-based approach on which previous federal administrations and current state and local administrations have consistently built their own crisis management protocols.

Conclusion

This commentary points out that throughout the first 3 months of the COVID-19 public health crisis, the U.S. federal government manifested a proclivity to distort the truth and drift away from evidence provided by available data. The current year 2020 is a presidential election year. Because President Trump is the presidential incumbent, one may ask whether the situation would be different during a nonelection year. Indeed, President Trump and his supporters within the White House and among the Republican Party have appeared more preoccupied about the presidential elections than following evidence from the data and guidelines provided by other countries, previous pandemics, and current data collected by U.S. institutions and agencies where highly skilled and well-trained experts reside. This analysis of the federal government’s inability or unwillingness to pursue an evidence-based action is concerning at different levels. First, a coordinated response across the various levels of government (local, state, and federal) during the first 3 months of the outbreak became impossible. Second, confusion in the general public became evident as many people struggled to follow social distancing guidelines, whereas others clearly considered COVID-19 a hoax of the Democratic Party (Appiah, 2020). Third, lack of transparency and the dissemination of false information may have contributed to the erosion of trust in public institutions, which can have a lasting damage.