The United States’ Response to COVID-19: A Case Study of the First Year 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 Abbreviations iii Chapter 7: Health System Resilience 38 Executive Summary 1 Hospital and Primary Care Capacity: Overflow 38 and Spillover Effects Chapter 1: Introduction and Epidemiology 5 Human Resources for Health: Shortages, 41 The Context 5 Attrition & Mental Health Impact This Report 6 Essential Supplies for the Healthcare System 43 How Did the U.S. Get Here? 6 Vaccine Deployment: an Operational Challenge 43 The Story in Numbers 6 Investing in Global Immunologic Equity 45 The Bottom Line 14 Chapter 8: Scientific Innovation 47 Chapter 2: Framework for Assessing the U.S. 15 Research and Development 47 Response Basic Science & Clinical Innovation 48 Domestic Leadership 16 Global Health Security Research 49 Global Leadership 18 Chapter 10: Conclusions and 50 Chapter 4: Economics and Finance 20 Recommendations Economic Impact 20 Post-Script: The Biden-Harris National 55 Fragmented Health System Financing & Lack 24 Strategy of Universal Health Coverage References 56 Chapter 5: Public Health Measures 26 Appendix 74 Know the Enemy 26 The Blunt Instrument 28 Acknowledgements 77 Lockdown Replacement Package 28 Genomic Surveillance 32 The Importance of a One Health Approach 32 Chapter 6: Communications, Trust and 34 Engagement Building and Maintaining Trust 34 Communicating Clearly 35 Empowering Communities 37 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 over 28 million cases and 500,000 deaths, accounting flawed. With new variants arising worldwide, bringing for 25% of global cases and 20% of global deaths, the epidemic under control requires strong and capable despite comprising only 4% of the world’s population. leadership, with competent execution of sound policies, Life expectancy in the U.S. shrank by a full year in backed by significant investments. 2020. Had the U.S. responded with the swiftness and effectiveness of East Asia, over 428,000 American lives The World Health Organization Independent Panel on could have been saved. Pandemic Preparedness and Response (IPPR) invited the University of California, San Francisco Institute for The story is also one of great inequity. The pandemic Global Health Sciences to develop a case study on has laid bare existing socioeconomic, health, and the US response to the COVID-19 pandemic. A multi- healthcare access disparities, with Black and Latinx disciplinary team analyzed and synthesized the work Americans dying at over 2.6 times the rate of of academics, journalists, non-profit organizations, White Americans. In 2020, life expectancy for Black national, state and local government agencies, and Americans is expected to have dropped by over two private industry, studying hundreds of academic and years, with Latinx Americans suffering a drop of over media articles, government reports, press releases, three years. While experiencing lower mortality rates blogs, and websites. The team also conducted 23 from the virus itself, the economic and social conse- key stakeholder interviews to ensure a diversity of quences have been particularly severe for women, viewpoints. notably women of color. Record numbers of women have left the labor force since the pandemic began. This report assesses the U.S. experience one