The United States’ Response to COVID-19: A Case Study CHAIR CASE STUDY COMMITTEE Ari Hoffman, MD Associate Professor of Clinical Jaime Sepúlveda, MD, MPH, Dean Jamison, PhD, MS Medicine, Department of Medicine, MSc, DrSc Edward A Clarkson Professor, University of California, San Executive Director, Institute for Emeritus, Institute for Global Health Francisco; Affiliated Faculty, Philip Global Health Sciences, University Sciences, University of California, R. Lee Institute for Health Policy of California, San Francisco; Haile San Francisco Studies T. Debas Distinguished Professor of Carlos del Rio, MD Global Health, Institute for Global Andrew Kim, MD, MPhil Distinguished Professor of Health Sciences, University of Resident Physician in Internal Medicine, Division of Infectious California, San Francisco Medicine, School of Medicine, Diseases and Executive Associate University of California, San Dean at Grady Hospital, Emory Francisco University School of Medicine; AUTHORS Professor of Epidemiology and Jane Fieldhouse, MS Neelam Sekhri Feachem, MHA Global Health, Rollins School of Doctoral Student in Global Health, Associate Professor, Institute for Public Health of Emory University Institute for Global Health Sciences, Global Health Sciences, University University of California, San Jeremy Alberga, MA of California, San Francisco Francisco Director of Program Development Kelly Sanders, MD, MS and Strategy, Institute for Global Sarah Gallalee, MPH Technical Lead, Pandemic Health Sciences, University of Doctoral Student in Global Health, Response Initiative, Institute for California, San Francisco Institute for Global Health Sciences, Global Health Sciences, University University of California, San Katy Bradford Vosburg, MPH of California, San Francisco; Clinical Francisco Associate Director, Pandemic Instructor, Lucile Packard Children’s Response Initiative, Institute for Hospital at Stanford University Global Health Sciences, University Forrest Barker of California, San Francisco Master of Science Student in Global Arian Hatefi, MD Health, Institute for Global Health Associate Professor, Department of Sciences, University of California, Medicine, University of California, San Francisco San Francisco The United States’ Response to COVID-19: A Case Study | B Contents Preface ii Chapter 6: Communications, Trust and 35 Engagement Abbreviations iii Building and Maintaining Trust 35 Executive Summary 1 Communicating Clearly 36 Chapter 1: Introduction and Epidemiology 5 Empowering Communities 38 The Context 5 Chapter 7: Health System Resilience 39 This Report 6 Hospital and Primary Care Capacity: 39 How Did the U.S. Get Here? 6 Overflow and Spillover Effects The Story in Numbers 6 Human Resources for Health: Shortages, 42 The Bottom Line 14 Attrition & Mental Health Impact Essential Supplies for the Healthcare System 44 Chapter 2: Framework for Assessing the 15 U.S. Response Vaccine Deployment: an Operational Challenge 44 Domestic Leadership 16 Investing in Global Immunologic Equity 46 Global Leadership 18 Chapter 8: Scientific Innovation 48 Chapter 4: Economics and Finance 20 Research and Development 48 Economic Impact 20 Basic Science & Clinical Innovation 49 Fragmented Health System Financing & 24 Global Health Security Research 50 Lack of Universal Health Coverage Chapter 10: Conclusions and 51 Chapter 5: Public Health Measures 26 Recommendations Know the Enemy 26 Post-Script: The Biden-Harris National 56 The Blunt Instrument 28 Strategy Lockdown Replacement Package 30 References 57 Genomic Surveillance 33 Appendix 75 The Importance of a One Health Approach 34 Acknowledgements 78 The United States’ Response to COVID-19: A Case Study | Contents | i Preface One year ago, the WHO declared COVID-19 a The second is good communication. This pandemic. History will surely consider 2020 as means communication from leaders that is clear, the most calamitous year in health since 1918, accurate and honest and builds trust between the when influenza swept the globe. It will also be government and its people. The third lesson is remembered as the worst economic crisis since that as a global community, we can trust science. the Great Depression. The social consequences of With COVID-19, science has once again come this pandemic will be felt for a long time to come. to the rescue, delivering innovative vaccines in record time. The pandemic has affected everyone on the planet, directly or indirectly. So far over 10% of Perhaps the most important lesson from this the global population has been infected. With pandemic is that “no country will be safe until all over 10,000 deaths per week, COVID-19 is now countries are safe.” Global immunologic equity the third main cause of death globally; and an should not only be a humanitarian desire, but a estimated 4 million deaths from this pathogen national security concern. To ensure the world is are expected by July of this year. These numbers prepared for the next pandemic, we will require are likely to be a significant underestimate of the more than just a plan; we will require global and morbidity and mortality and caused during this national public health institutions to be well-funded disease. with the authority and ability to move nimbly and forcefully in the face of uncertainty. And it will Not all regions of the world have been similarly mean that we must think about human health as affected. Some countries have performed much part of a broader ecologic system that includes better than others. Understanding what elements the health of our planet, and all the species that made a difference and what lessons can be live on it. derived is the object of our case study. In our research of how the U.S. has responded to this pandemic, we find that there are four areas of particular importance. Each of these is highlighted in detail in our report. Jaime Sepúlveda, MD, MPH, MSc, DrSc Chair, Case Study Committee First is good governance, which includes institutional strength and effective leadership. The United States’ Response to COVID-19: A Case Study | Preface | ii Abbreviations ACA Affordable Care Act AI/AN American Indians and Alaska Natives BARDA Biomedical Advanced Research and Development Authority CARES Coronavirus Aid, Relief, and Economic Security Act CDC Centers for Disease Control and Prevention CMS Centers for Medicare and Medicaid EU European Union FDA Food and Drug Administration FEMA Federal Emergency Management Agency GDP Gross Domestic Product HHS Health and Human Services ICU Intensive Care Unit IHR International Health Regulations IHS Indian Health Services IPPR Independent Panel for Pandemic Preparedness and Response JHE Joint External Evaluation LTCF Long-term Care Facilities MERS Middle East Respiratory Syndrome mRNA Messenger Ribonucleic Acid NGO Non-governmental Organization NIH National Institutes for Health NPI Non-pharmaceutical Interventions NSC National Security Council OECD Organization for Economic Co-operation and Development OWS Operation Warp Speed PCR Polymerase Chain Reaction PPE Personal Protective Equipment RCEP14 Regional Comprehensive Economic Partnership 14 SARS Severe Acute Respiratory Syndrome SPAR Self-Assessment Annual Reporting U.K. United Kingdom U.S. United States USCIS U.S. Citizenship and Immigration Service WHO World Health Organization The United States’ Response to COVID-19: A Case Study | Abbreviations | iii Executive Summary The story of COVID-19 in the United States is one of and scientific capacity. Much like the patchwork U.S. daunting scale. The U.S. epidemic dwarfs that of any health system – the most expensive on the planet – the other country. At the time of writing, the U.S. reports pandemic response has been fragmented and deeply almost 30 million cases and over 500,000 deaths, flawed. With new variants arising worldwide, bringing accounting for 25% of global cases and 20% of global the epidemic under control requires transformational deaths, despite comprising only 4% of the world’s leadership, with swift and competent execution of population. Life expectancy in the U.S. shrank by a sound policies, backed by significant investments. full year in 2020. Had the U.S. responded with the swiftness and effectiveness of East Asia, over 428,000 This case study of the U.S. response to the COVID-19 American lives could have been saved. pandemic was commissioned by the World Health Or- ganization Independent Panel for Pandemic Prepared- The story is also one of great inequity. The pandemic ness and Response (IPPR). A multidisciplinary team, has laid bare existing socioeconomic, health, and under the leadership of the University of California, San healthcare access disparities, with Black and Francisco, Institute for Global Health Sciences, ana- Latinx Americans dying at over 2.6 times the rate of lyzed and synthesized the work of academics, journal- White Americans. In 2020, life expectancy for Black ists, non-profit organizations, national, state and local Americans is expected to have dropped by over two government agencies, and private industry, studying years, with Latinx Americans suffering a drop of over hundreds of academic and media articles, government three years. While experiencing lower mortality rates reports, press releases, blogs, and websites. The team from the virus itself, the economic and social conse- also conducted 23 key stakeholder interviews to ensure quences have been particularly severe for women, a diversity of viewpoints. notably women of color. Record numbers of women have left the labor force since the pandemic began.