The U.S. was the world’s best prepared nation to confront a pandemic. How did it spiral to ‘almost inconceivable’ failure?

Almost two months had passed since Chinese health officials first described a fast-moving new coronavirus that had jumped the species barrier from animals to humans. By the time President Donald Trump strode into the White House briefing room on the evening of Feb. 26, the virus had killed more than 2,700 people in China and forced the lockdown of 11 million residents in Wuhan. Infections in Italy were rising by an astonishing 40% a day.

That night Trump assured Americans, “We’re very, very ready for this, for anything.”

Then he held aloft a report co-produced by the Johns Hopkins Center for Health Security ranking 195 countries on their readiness to confront a pandemic.

“The United States,” he said, “is rated number one most prepared.”

The nation did indeed rank first on the Global Health Security Index. But the president never mentioned the report’s ominous central finding: “No country is fully prepared for epidemics or pandemics. Collectively, international preparedness is weak.”

Moreover, the index revealed a number of U.S. flaws that have proved crippling in the fight against COVID-19. America received the lowest possible score for public confidence in government; low rankings among the index’s 60 high-income countries for doctors per capita (38th) and hospital beds per capita (40th); and a dismal rating for access to health care — 175th out of 195 countries.

What the index could not have predicted — what stunned the nation’s public health experts as months passed — was America’s lethargic and inconsistent response, and its failure to follow basic precepts of its own pandemic playbook.

“It’s not that the index measured anything inappropriately, it’s that none of it was acted on,” said Joe Smyser, CEO of the national health care nonprofit Public Good Projects. “I don’t think we’ve ever failed on this scale. The level of failure is almost inconceivable.”

The pandemic playbook, passed down from President Barack Obama to President Donald Trump, had been one of the nation’s key planning documents: a 69-page blueprint laying out the decisions to be made and agencies to be mobilized in a health disaster. Throughout its pages, the document stressed the need for an early public health response coordinated by the federal government.

Joe Smyser, CEO of the national health care nonprofit Public Good Projects
It’s not that the index measured anything inappropriately, it’s that none of it was acted on. I don’t think we’ve ever failed on this scale. The level of failure is almost inconceivable.

That did not happen.

Milwaukee Journal Sentinel interviews with public health experts and reviews of numerous studies by government agencies, watchdog groups and scientists reveal a cascade of blunders that contributed to the deaths of more Americans in the pandemic than died in the Korean, Vietnam, Iraq and Afghanistan wars combined.

Among the most serious lapses:

Money for public health had been cut steadily for decades.

The cuts became critical because America’s leaders ignored warnings about the dire consequences should the federal government abandon its central role in a pandemic, and leave states to fend for themselves.

When this scenario occurred, some states were forced to compete with one another in order to purchase scarce medical supplies. Further, in the absence of detailed federal guidelines, states imposed a hodgepodge of lockdown policies, only to have some undermined by politicians, including the president.

Despite more than a decade of scientific warnings about the specific threat posed by coronaviruses, the government and drug companies allowed a potential vaccine to be shelved for three years instead of testing it in human trials.

Trump routinely dismissed the advice of his own health experts, downplaying the severity of the pandemic. The president told journalist Bob Woodward, as recounted in the book “Rage,” that he played down the pandemic to avoid triggering panic.

While leaders of other countries united their citizens behind the idea of collective sacrifice through lockdowns and other measures, U.S. leaders, especially the president, politicized the pandemic.

When Americans most needed to pull together, they slipped deeper into bitter polarization. 

With its pandemic playbook, “The U.S. was very well prepared,” said Eric Toner, senior scholar at the Johns Hopkins Center for Health Security. “What happened is that we didn’t do what we said we’d do. That’s where everything fell apart. We ended up being the best prepared and having one of the worst outcomes.” 

In disasters, Americans have grown accustomed to looking down with pity at other countries that have fared worse and need our help. COVID-19 shattered that image.

Eric Toner, senior scholar at the Johns Hopkins Center for Health Security
What happened is that we didn’t do what we said we’d do. That’s where everything fell apart. We ended up being the best prepared and having one of the worst outcomes.

“The U.S. accounts for less than 5% of the world’s population, but more than 25% of total COVID-19 cases reported across the globe, and it currently ranks among the top 10 countries in COVID-19-related deaths per capita,” wrote the authors of a Sept. 16 commentary in the Journal of the American Medical Association.

“During the years to come,” the authors predicted, “the U.S. undoubtedly will undergo national-level reviews to understand how its strong capabilities were squandered when the country needed them most.” 

When the Journal Sentinel asked the U.S. Department of Health and Human Services to provide evidence that officials used the pandemic playbook, a spokesperson offered none. Instead, she said the Trump administration’s response “was informed” by three more recent plans.

One of those plans, “The National Biodefense Strategy” from 2018 is not a step-by-step guide for responding to a pandemic, but more a list of goals. Trump departed from one of those goals when he chose to downplay the virus rather than provide “accurate, timely and actionable public messaging.”

The other two reports — the Biological Incident Annex (2017) and the Pandemic Crisis Action Plan (2018) — were both found to be flawed during a pandemic preparedness exercise called Crimson Contagion. The simulation took place in August 2019.

More than four months later, when the pandemic was not a simulation, but real, other nations saw the danger, acted quickly and suffered far fewer deaths than did the U.S. Thailand began screening passengers from Wuhan on Jan. 3 — a full two weeks before American airports began doing so.

The Centers for Disease Control and Prevention found no evidence the virus entered the country before airport screening took effect on Jan. 17, according to the HHS spokesperson.

“This administration’s early and decisive action has saved millions of lives,” the spokesperson said, adding, “Dr. Fauci testified to this before Congress.” 

However, a review of testimony by Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, shows he never said millions of lives were saved by the president’s action, only that lives were saved.

A week after the first case reached his country, Vietnamese Prime Minister Nguyen Xuan Phuc told citizens, “Fighting this epidemic means fighting the enemy.” Government posters proclaimed that “to stay home is to love your country.” In contrast, three weeks into the lockdowns of Michigan, Minnesota and Virginia, Trump sent out tweets, urging their governors to “LIBERATE” all three by lifting the stay-at-home orders.

South Korea authorized a diagnostic kit in February and opened drive-through test centers on Feb. 23. The U.S. opened its first public drive-through test facilities more than two weeks later in Seattle and in the New York City suburb of New Rochelle.

In the rankings for pandemic readiness cited by Trump, Thailand, South Korea and Vietnam had finished 6th, 9th and 50th, respectively. In the COVID-19 pandemic, all three have experienced far fewer infections and deaths per capita than did the U.S.

The U.S. accounts for less than 5% of the world’s population, but more than 25% of total COVID-19 cases reported across the globe.

Today the U.S. has seven times more people than South Korea, but 300 times more COVID-19 cases, according to the Johns Hopkins Coronavirus Resource Center. The U.S. has five times more people than Thailand, but 2,000 times more COVID-19 cases. The U.S. has three and a half times more people than Vietnam, but 6,000 times more COVID-19 cases.

Nigeria provides one of the most striking contrasts. Considered to have a weak health care system and ranked only 96th for pandemic preparedness, Nigeria established a Coronavirus Group a full month before the country reported its first case. The group was asked “to activate its incident system to respond to any emergency.” The nation also strengthened surveillance at its main airport.

Nigeria has a population of 196 million — more than half that of the U.S.

On Oct. 12, Nigeria had 128 times fewer COVID-19 cases than the U.S.

Nigeria’s death toll in the pandemic stood at 1,115.

More have died in Wisconsin alone: 1,508 as of Tuesday.

Track COVID-19 in Wisconsin: See the latest numbers and trends

Prelude: Primed for a disaster

The U.S. began heading for trouble a long time ago. Poor decisions by government and the American people primed the U.S. for a pandemic disaster.

For starters, the nation’s public health system has been underfunded for decades.

When adjusted for inflation using 2020 dollars, the CDC’s annual budget for public health emergency preparedness — the money set aside for pandemics and other disasters — dropped by more than half from $1.4 billion in the 2002 fiscal year to $675 million in 2020.

Using the same scale, money for hospital preparedness shrank at an even greater rate — 62% — from $723 million in 2004 to $275.5 million in 2020. 

The Great Recession from 2007 to 2009 resulted in the loss of 50,000 public health jobs at the state and local level, according to John Auerbach, president and CEO of the nonpartisan organization Trust For America’s Health and former associate director of the CDC. Lost jobs in other sectors returned when the recession ended, but the public health jobs never did. “Since then we’ve lost more,” Auerbach said.

Pandemic preparedness has been the subject of numerous national plans dating as far back as 1978. Johns Hopkins alone hosted four major tabletop exercises simulating pandemic situations: Dark Winter in 2001, Atlantic Storm in 2005, Clade X in 2018 and most recently Event 201, which tested officials with a fictional coronavirus in October 2019. 

More to the point, the nation has been tested by actual pandemics: HIV and swine flu.

Over the years, at least some of those assessing the nation’s preparedness were troubled by what they saw.

As recently as 2018, a bipartisan study panel sounded alarms about the federal government’s readiness to take charge in a biological disaster as it had following the 9/11 terrorist attacks. The general rule has been that in such emergencies the federal government assumes control, rather than shifting the burden to states and local communities.   

“Unfortunately, there is grave concern that a large-scale biological event will prove to be the exception to this rule,” wrote the authors of “Holding The Line On Biodefense.” “Devastation could be vast and swift, and local resources would be very quickly depleted. The thousands of state, local, tribal and territorial governments that are the backbone of our nation will have to fend for themselves for far too long until federal assets arrive and Congress can provide emergency supplemental funding.”

The report’s authors, the bipartisan, privately funded Blue Ribbon Study Panel on Biodefense, called on the federal government “to improve the distribution of the Strategic National Stockpile and other stores of pharmaceuticals, equipment and essential supplies.”

Previous pandemic warnings even cited the specific threat posed by coronaviruses, which had produced two outbreaks in the space of a decade: Severe Acute Respiratory Syndrome in 2002 and Middle East Respiratory Syndrome in 2012.

The number of SARS-like viruses lurking in horseshoe bats and human consumption of “exotic mammals” that may have contact with bats amounted to “a time bomb,” according to a 2007 paper in Clinical Microbiology Reviews.

Yet government and drug companies pulled the plug on efforts to develop a coronavirus vaccine that might have worked on multiple coronaviruses. Thousands of doses of a potential SARS vaccine, developed by researchers at the Baylor College of Medicine and manufactured by the U.S. Army, sat for more than three years in a Houston freezer. Because SARS had petered out before becoming a full-scale disaster, so did interest in funding clinical trials using the vials of vaccine.

Then came the 2016 election.

The nation chose a new president, inexperienced in governing and sensitive to negative headlines. He took bad press personally, often dismissing unflattering articles as “fake news.”

In the first year of Trump’s presidency, Hurricane Maria pounded Puerto Rico and the aftermath found the president clashing with local officials over federal assistance. A similarly bitter back-and-forth took place between the president and officials in California following 2019 wildfires.   

“I always feared that the Puerto Rican hurricane response would be the template for what we would see,” said Jeremy Konyndyk, a senior policy fellow at the Center for Global Development. “Trump’s default was to say, ‘We made no mistakes. Everything is fine.’ That means you can’t need this, this and this fixed because there’s nothing wrong.”

From early in his term, the president demonstrated a willingness to dismiss the nation’s best minds in science, medicine, law and foreign intelligence, undermining or muzzling their advice. In the early months of 2020, the president was facing the end of an impeachment trial and the beginning of a fierce battle for reelection. 

As 2020 began, the U.S. had set the table for the greatest public health crisis in generations. 

January: A sluggish response

Although there is not universal agreement among health experts about the precise moment that should have triggered an all-hands-on-deck response from the U.S. government, most cite events in January.

“In the first week of January, we convened our emergency team,” said Nicole Lurie, referring to the team at the Coalition for Epidemic Preparedness Innovations, a global partnership where she is the strategic adviser leading the response to COVID-19. 

Lurie said the coalition had been working with manufacturers developing vaccines for various diseases. 

“We called some of them before the (DNA) sequence for the virus was posted and asked them if they could pivot to COVID,” said Lurie, who served as Obama’s assistant secretary for preparedness and response.

The draft of the new virus’ sequence, its genetic blueprint, was posted Jan.10 by a consortium of scientists. Three days later, Thailand reported the first case outside China.

“By then there had been clustering of an unusual set of pneumonia in Wuhan,” Lurie said, “and it seemed like a variety of sources were saying that this was getting out of hand.”  

At the Johns Hopkins Center for Health Security, Toner said that by mid-January, “We knew the virus was spreading person-to-person and the Chinese government was going to completely unprecedented and drastic measures.

“It was obvious from reading the literature and watching the news that this was alarming. This was likely going to be a pandemic, and a pandemic on the 1918 scale.”

According to the CDC, about 500 million people worldwide were infected in the 1918-’19 flu pandemic and at least 50 million died.

People wear protective masks as they line up in a supermarket on Feb. 12 in Wuhan, China.

People wear protective masks as they line up in a supermarket on Feb. 12 in Wuhan, China.
Getty Images

In the fourth week of January, videos from Wuhan showed dozens of excavators building a 1,000-bed hospital in 10 days.

The hospital in Wuhan was still under construction when, according to Woodward’s book, Trump was warned about the virus by his national security adviser: “This will be the biggest national security threat you face in your presidency. This is going to be the roughest thing you face.”

By then, the World Health Organization had offered a stark view of the threat. On Jan. 30, the organization declared a Public Health Emergency of International Concern, a designation for “an extraordinary event” that risks an international spread of disease and requires a coordinated international response. 

Within a week of China’s first announcement, the U.S. pandemic playbook should have been off the shelf and guiding the nation. By Jan. 7, when Chinese researchers reported that the cluster of pneumonia cases in Wuhan had been caused by a novel coronavirus, the situation had advanced from the playbook’s first level of alert, “Elevated Threat,” to become a “Credible Threat.”

At the first level, U.S. agencies including the Department of Health and Human Services and the Federal Emergency Management Agency should have been asking whether states and communities “have diagnostic capacity and capacity sufficient to trace and monitor for an outbreak.”

By Jan. 7, when Chinese researchers reported that the cluster of pneumonia cases in Wuhan had been caused by a novel coronavirus, the situation had advanced from the playbook’s first level of alert, “Elevated Threat,” to become a “Credible Threat.”

Further, agencies should have been evaluating whether states and local communities have plans and the ability “to prevent an outbreak,” whether through lifesaving medicines or other means. The U.S. government is to provide support to states and communities “where gaps exist.”

At the second level, federal agencies should have been determining whether states and communities could increase levels of clinical care to meet a rise in the number of cases. They also should have been increasing production of medicine and supplies “if necessary.”

The HHS spokesperson offered no evidence that the federal government followed the playbook recommendations. 

“What we’ve learned over the last 20 years is that you need to be immediately ready in an emergency,” said Auerbach, who was involved in the U.S. responses to Ebola and Zika during his time as associate director of the CDC. “Everybody needs to know what their responsibilities are. When there’s an emergency, that’s not the time you want to be exchanging business cards.” 

By Jan. 30, COVID-19 had risen to the third level in the playbook: “Initial Response.” The CDC confirmed the first American case of person-to-person transmission of the virus (there already had been cases in China, and the virus was present in 19 countries).

John Auerbach, president and CEO of the nonpartisan organization Trust For America’s Health and former associate director of the CDC
What we’ve learned over the last 20 years is that you need to be immediately ready in an emergency. Everybody needs to know what their responsibilities are. When there’s an emergency, that’s not the time you want to be exchanging business cards.

In the last three days of January, the U.S. government responded to COVID-19 by establishing a task force on the new coronavirus, and ordering restrictions on travelers entering the U.S. from China.

When the White House convened its coronavirus response task force on Jan. 29, the group did not initially include the commissioner of the U.S. Food and Drug Administration, the agency that regulates and approves vaccines, according to Margaret A. Hamburg, who had served in the position from 2009 to 2015.

Concerned, Hamburg said she texted FDA Commissioner Stephen Hahn, urging him to push hard to get on the task force. Hahn was subsequently added.

Asked about the omission, FDA Senior Adviser Jane Hubbard said, “At no point was FDA excluded,” even though the official White House briefing on the task force lists no one from the FDA.

Two days later, the president issued an executive order barring all non-U.S. residents and non-citizens who had been in China in the last 14 days from entering the U.S.

The travel restriction would become the signature action the president would point to and credit with saving “potentially millions of lives.” Some epidemiologists, however, have questioned the restriction’s impact, saying that COVID-19 cases were already entering the U.S. through Europe.

Further, the ban allowed exceptions for U.S. citizens and residents returning from Wuhan and other cities in China.

February: Urging a ‘no regrets’ approach

Writing in The Washington Post on Feb. 4, Konyndyk, the senior policy fellow at the Center for Global Development, called on U.S. leaders to take a “no regrets” approach to the virus.

“The idea,” he explained, “is that in an unpredictable crisis, we should proactively over-prepare, rather than wait and see. … In the United States and other developed countries, an outbreak with Wuhan’s level of transmission and severity would badly strain hospitals and clinics (just two years ago, a bad seasonal flu cycle forced overstretched U.S. hospitals to treat patients in hallways and tents).” 

Konyndyk called for the federal government to rapidly prepare the nation’s health system, saying, “A vitally important part of this will be efforts to address supply-chain ruptures and accelerate production and availability of critical medical supplies.”

Trump decided on a different approach. In a taped interview, the president told Woodward he had always wanted to downplay the virus to avoid causing a panic.

Asked why HHS did not speak forcefully to correct the president when he downplayed the virus, the spokesperson said only, “HHS has always provided science-based public health guidance to the country.”

In any case, more than a month passed before the U.S. government heeded Konyndyk’s advice.

According to the CDC, “the outbreak appeared contained through February, and then accelerated rapidly.”

Although the CDC began sending out test kits in the first week of February, a week later it was forced to advise all labs across the country to stop using them. An ingredient used in the test was discovered to cause faulty results.

The delays meant that by the end of February, the U.S. had reported fewer than 7,000 test results. On Feb. 29, the official case count in the U.S. stood at 18, including five deaths.

Vietnam, with slightly fewer cases, responded more aggressively. In mid-February, the nation imposed a three-week quarantine on a rural commune of 10,000 people. At the time, only 16 cases of the virus had been reported throughout the country.

On Feb. 23, South Korea, a Democracy, opened drive-through test centers. By March 9, it had produced enough kits to test 522,700 people, about 1% of the population. South Korean law allowed health officials to track the movement of cases using credit cards, cellphones, GPS and security cameras.

HHS stressed that testing to fight the new coronavirus had to be developed “from scratch” and at an unprecedented speed and scale.

March: No federal coordination 

On March 11, the World Health Organization designated the outbreak a pandemic

Two days later, as the U.S. surpassed 3,300 confirmed and probable cases of COVID-19, including 55 deaths, Trump declared a national emergency.

That same day, March 13, House Democrats wrote the president urging that he use the Defense Production Act “to begin the mass production of supplies needed to address the ongoing (COVID-19) pandemic.” The act allows a president to identify businesses capable of producing “scarce and critical material” and compel them to do so. 

Although Trump announced on March 18 that he was invoking the act, he expressed a reluctance to force companies to begin producing masks, ventilators or personal protective equipment. Not until March 27 did he report that he had used the act to “compel General Motors to accept, perform and prioritize federal contracts for ventilators.”

By this point, the U.S. had more than 100,000 cases and a flood of patients had begun to overwhelm hospitals in New York City.

Across the country, governors began locking down their states, imposing stay-at-home orders for non-essential workers and forbidding most mass gatherings. California became the first, going into lockdown on March 19. Wisconsin’s lockdown began March 25.

The U.S. government offered relatively loose guidelines, telling Americans to “listen to and follow” directions from state and local authorities. Directions varied widely from state to state, with some governors waiting until April to order lockdowns, and a handful, including the governors of Arkansas, South Dakota and Iowa, resisting lockdowns entirely.

Even so, for many Americans, it felt as if life had changed all at once. The college basketball season ended with no NCAA tournament. School switched to online teaching. Movie theaters and restaurants shut their doors. Parades and festivals were canceled.

States did not take the stay-at-home measures lightly, knowing they would cause businesses to close, strangle the economy and cost millions of workers their jobs.

“You’ve got a raging fire and you’re trying to deprive it of oxygen,” Konyndyk said. “But when you are depriving it of oxygen you’re also depriving yourself of oxygen.”

Drastic as the measures were, they may have come too late.

Researchers at Columbia University’s Mailman School of Public Health projected that had the U.S. taken the same measures just a week earlier, almost 36,000 deaths could have been prevented. (Their model provided a range of between 28,500 and 41,700 deaths.) 

The research examined data on the movement of people and the spread of the virus across hundreds of counties in the U.S. “The virus grows very aggressively without intervention. It’s an exponential growth process,” said Jeffrey Shaman, one of the study’s authors and director of Columbia University’s Climate and Health Program. “The average infected person will spread it to two people.”

Researchers at Columbia University’s Mailman School of Public Health projected that had the U.S. taken the same measures just a week earlier, almost 36,000 deaths could have been prevented.

Trump dismissed the study, which is still undergoing peer review, calling it a “political hit job.”

By late March, many states and communities were taking the measures recommended by the pandemic playbook: “Voluntary isolation of the ill and home quarantine of the exposed,” dismissal of students from schools, social distancing and use of personal protective equipment. (It is unclear whether use of protective equipment and social distancing were “widespread” as recommended). 

But the playbook described these as “critical components of early response to an emerging epidemic or pandemic.” With COVID-19, most of the measures did not go into effect until two months after the CDC confirmed the virus had arrived in the country.  

Mid-March brought more bad news as hospitals in states like New York faced a surge of COVID-19 patients. Just as the authors of “Holding The Line On Biodefense” had feared, the federal government failed to meet the demand from states for personal protective equipment, such as N95 masks, gowns, gloves and face shields.

More than a month earlier, the World Health Organization had warned countries about likely shortages of PPE, a message amplified by the Center for Infectious Disease Research and Policy at the University of Minnesota.

“From the WHO’s assessment, demand of PPE is up to 100 times higher than normal and prices are up to 20 times higher,” the center reported.

While the federal government could have boosted its supply of PPE and used its buying power to seek better prices, that’s not what happened. Given far less equipment than needed, many states were left to seek the remainder on the open market.

People speak near a makeshift morgue outside Bellevue Hospital on March 25 in New York City.

People speak near a makeshift morgue outside Bellevue Hospital on March 25 in New York City.
Eduardo Munoz Alvarez / Getty Images

“I think it caught everyone off guard the degree to which the federal government and president were not taking ownership of the pandemic,” said Konyndyk at the Center for Global Development. “It would have been unthinkable under virtually any other president. After 9/11, George Bush did not say that counterterrorism was the responsibility of the states.” 

Konyndyk spent four years as Obama’s director of the USAID Office of Foreign Disaster Assistance and reviewed and contributed to the pandemic playbook passed on to the Trump administration.

Jeremy Konyndyk, a senior policy fellow at the Center for Global Development
I think it caught everyone off guard the degree to which the federal government and president were not taking ownership of the pandemic. It would have been unthinkable under virtually any other president. After 9/11, George Bush did not say that counterterrorism was the responsibility of the states.

“We just left the states to their own devices,” said Thomas Bollyky, a senior fellow for global health, economics and development at the Council for Foreign Relations. “Prices skyrocketed.”

Some states found themselves competing with one another, and even with the federal government, as they sought to buy precious medical supplies. Kentucky was pursuing medical equipment when “FEMA came out and bought it all out from under us,” Gov. Andy Beshear told the Louisville Courier Journal.

Other states banded together, purchasing supplies as a group, or sharing with those facing the most severe shortages. 

Wisconsin fared better on equipment. The state made its first request to FEMA on March 21 (50,000 masks, 10,000 face shields, 11,000 coveralls, 3,000 N95 respirators and 35,000 pairs of gloves). Most of the equipment arrived in April or May.

Wisconsin was on its own, however, when it came to the reagents required to carry out COVID-19 tests. “We were told that the feds were not involved in distribution of those supplies,” said Jennifer Miller, a spokeswoman for the state Department of Health Services.

The scramble for equipment should never have happened, according to the pandemic playbook.

Availability of lifesaving medicines and supplies, the playbook said, “must be prioritized at high levels of the U.S. Government and mobilized early in any emerging infectious threat incident.” If the supplies are not available, their development “must also be done early.”

“While States hold significant power and responsibility related to public health response outside of a declared Public Health Emergency,” the playbook added, “the American public will look to the U.S. government for action when multi-state or other significant public health events occur.”

Asked why the U.S. lacked basic medical supplies and left states to find them on their own, the HHS spokesperson said the Strategic National Stockpile “was not designed or congressionally funded to respond to a nationwide pandemic.”

The HHS website, by contrast, describes the national stockpile as “organized to support any public health threat.”

There were other explanations for the lack of basic medical supplies, according to the HHS spokesperson. Critical supplies were manufactured overseas, the U.S. had difficulty early on ensuring that supplies went to the states that needed them most, and finally, she said, “unknowns about the virus itself led to overuse of PPE in hospitals and treatment centers.”

Lurie, the former assistant secretary for preparedness and response, offered a much harsher view of the federal response to COVID-19.

“I’ve never seen a situation where you are having a national and international emergency and the response is not being coordinated by the federal government,” she said. “For the federal government to virtually abdicate responsibility is unheard of.” 

I’ve never seen a situation where you are having a national and international emergency and the response is not being coordinated by the federal government. For the federal government to virtually abdicate responsibility is unheard of.

April: Mixed messages from the top 

By early April, most states had issued stay-at-home orders and the nation braced itself for the consequences. That month, 20.5 million American workers lost their jobs, sending unemployment rocketing from 4.4% in March to 14.7% — the largest one-month increase since the U.S. began keeping the data in 1948. 

The virus was now thriving in the U.S. During April, infections rose more than five-fold to a total of more than 1 million; deaths rose more than 10-fold surpassing 59,000. 

Throughout the month, Americans saw photographs they’d seldom seen from hospitals in their own country: overwhelmed doctors and nurses, hospital hallways crowded with beds and refrigeration trucks parked outside for use as makeshift morgues.

Under its list of “assumptions,” the pandemic playbook offered a very different picture from the one Americans were seeing.

The playbook said: “The U.S. Government will use all powers at its disposal to prevent, slow or mitigate the spread of an emerging infectious disease by 1: Limiting the spread of disease 2: Mitigating the impact of illness, suffering and death, and 3: Sustaining critical infrastructure and key resources in the United States.”

Americans saw little in the way of a coordinated response to the pandemic from Washington, only mixed messages from the highest levels.

On April 3, the CDC changed its guidance to the public, recommending that people wear cloth masks. Until then, health officials had feared that recommending masks would trigger a run on equipment at a time when it was in short supply for the frontline medical workers who needed it most. Some public health experts had previously suggested that masks offered relatively little protection for the wearer.

The shift in the CDC’s thinking had much to do with the troubling news that people could contract and spread the virus without showing symptoms. The mask now represented protection for everyone around the wearer. Infectious droplets were less likely to pass from an infected person who was coughing or sneezing into a mask. 

Just a day after announcing the new CDC recommendations, Trump told Americans that when it came to mask-wearing, “I won’t be doing it personally.”

In the coming weeks and months, decisions to wear or not wear a mask, to obey or defy a state lockdown, became fresh symbols of the nation’s political divide. The president and millions of his supporters increasingly ignored the CDC’s guidance.

“I was stunned, actually, because the CDC is among the top disease control and prevention agencies in the world,” said Wilmot James, a senior research scholar at Columbia University’s Institute for Social and Economic Research and Policy.

“To undermine your own institutions in that manner is just absolutely stunning and destructive.”

James, a former member of parliament in South Africa, served on the international panel that helped produce the index that ranked the U.S. first in pandemic preparedness.

He said the disconnect between a world leader and his top health advisers is highly unusual but not unprecedented.

From 2000 to 2005, South African President Thabo Mbeki disputed the scientific consensus that HIV caused AIDS, questioned the usefulness of all antiretroviral drugs in fighting the AIDS epidemic and blocked access to these medicines.

These policies resulted in 330,000 deaths and 35,000 babies born with HIV in South Africa, according to a 2008 study in The Journal of Acquired Immune Deficiency Syndromes.

The HHS spokesperson denied any disagreement between the CDC and the president, saying, “Since the CDC updated its guidelines to recommend face coverings to reduce the spread of the virus, this Administration has been consistent in recommending them for all Americans when they are not able to socially distance.”

However, Trump has questioned the use of masks frequently, accusing a reporter of wearing one “to be politically correct,” mocking former Vice President Joe Biden for wearing “the biggest mask I’ve ever seen” and telling a televised town hall, “There are a lot of people (who) think masks are not good.

May: Repeating the mistakes of Spanish flu

By the first of May, tens of millions of Americans were hunkered down in their homes, many jobless, others working at a kitchen or dining room desk. They were growing restless. Many had been under stay-at-home orders for more than a month.

The U.S. was poised to repeat a crucial mistake from the 1918-’19 Spanish flu pandemic.

A 2005 report, commissioned by the U.S. military and written by researchers at the University of Michigan, examined seven communities that had succeeded in keeping out the Spanish flu by closing off their populations.

Gunnison County in Colorado, for example, closed its borders on Oct. 31, 1918, for all but those willing to be placed in quarantine. During this period only two people came down with the flu. But the quarantine ended Feb. 5, and in little more than a month, county officials reported 140 cases of flu.

“It is important to recall that the most successful protective sequestrations were maintained for a period of months to ensure that the pandemic was well on the wane,” the University of Michigan researchers noted.

The study’s authors warned that “Internecine rivalries or disagreements between local, state, and federal agencies have a strong potential to detract from pandemic influenza prevention and containment.

“More broadly, this is one of the strongest themes in the history of epidemics and disasters in the United States over the past two centuries.”

In the 2020 pandemic, the president announced in April plans for a phased reopening of states and assured governors it would be safe to do so on May 1. In the week leading up to that day, the country hit daily averages of 24,000 new infections and 1,600 deaths. 

On May 22, the president pushed harder, telling states that if they did not reopen places of worship by the weekend, “I will override the governors.”

Protesters in states across the country, including Wisconsin, kept up the pressure, framing COVID-19 closures as a violation of their freedom and challenging the measures in court.

“The messaging put governors in a very difficult position. It undermined their authority,” said Toner at the Johns Hopkins Center for Health Security. “The governors were getting calls from business owners saying, ‘I need to reopen and the president is telling me to. I’m going bankrupt.’ That puts the governors in a terrible bind.”

By the end of May, 44 states were open; the number included the few states that had never closed.

The four main vaccination types and how they’re used

The four main vaccination types and how they’re used

Lou Saldivar, Milwaukee Journal Sentinel

Meanwhile, a new front opened in the battle between the White House and health experts.

In mid-May, the federal government launched “Operation Warp Speed,” a joint effort by the CDC, the U.S. Food and Drug Administration and other federal agencies to accelerate development, testing and approval of a vaccine. The process often takes 10 to 15 years.

The U.S. government set a goal of getting 300 million doses of a safe, approved COVID-19 vaccine to Americans by January 2021, a mere year after the virus was first identified. With the presidential campaign well underway, the arrival date for a vaccine threatened to become more a matter of political strategy than of safety.

At various times since launching Operation Warp Speed, Trump forecast that the vaccine could be ready by October, before Election Day or by the end of the year.

Experts in public health and vaccine development have dismissed all of these dates as unrealistic.

“It’s been very damaging,” said Hamburg, the former FDA commissioner. “There is a process for how vaccines need to be made. There has been an effort made to accelerate that process, but it is absolutely essential that scientific rigor be the driving force, not political pressure.”

“The government has appropriately invested heavily in vaccine development, but its rhetoric has politicized the development process and led to growing public distrust,” editors of The New England Journal of Medicine wrote last week. Their withering editorial declared that in dealing with the new coronavirus, America’s leaders had “failed at almost every step” and “taken a crisis and turned it into a tragedy.”

By the end of May, there was no evidence to suggest the virus would soon disappear. In 31 days, infections had risen by 600,000, deaths by 39,000.

The chance to act quickly and avert disaster had passed.

Epilogue: Too many missteps, too many deaths

As it unfolded, the U.S. response to COVID-19 became simply another symptom of the nation’s polarization.

Trump has defended the actions his administration took, especially the travel restrictions, saying the measures saved an ever-shifting number of lives. 

Others speak not of lives saved, but those lost due to delays and missteps. 

“It has to be in the tens of thousands,” said Lurie at the Coalition for Epidemic Preparedness Innovations.

She pointed to reporting by the Institute for Health Metrics and Evaluation, which has produced estimates of the lives that could be saved simply through consistent mask-wearing.

The institute, an independent research center that is part of the University of Washington, projects that by Feb. 1, 2021, the U.S. death toll from COVID-19 will have reached 395,000. Projections by the institute’s model range from 374,000 deaths to 421,000. 

But the institute also struck a note of hope:

Its model projects 79,000 American lives can be saved by Feb. 1 by increasing mask use from the current estimate of 70% to 95%.

While 95% mask use may seem unprecedented, it isn’t. It’s the same level achieved by the nation of Singapore.

Singapore, which has 5.8 million people, roughly the same as the state of Wisconsin, has reported 27 deaths from COVID-19.  

Eric Litke from the Journal Sentinel and Brett Murphy from USA Today contributed to this report.

Mark Johnson has written in-depth stories about health, science and research for the Journal Sentinel since 2000. He is a three-time Pulitzer Prize finalist and, in addition, was part of a team that won the 2011 Pulitzer Prize in Explanatory Reporting for a series of reports on the groundbreaking use of genetic technology to save a 4-year-old boy.

Email him at; follow him on Twitter: @majohnso.

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