Assessing blame for an American catastrophe

In "The Big Fail" two journalists offer a wide-ranging critique of the U.S. response to COVID-19. But their condemnation of the nation's beleaguered public health establishment misses the mark.

The following book review appeared first on The Washington Monthly website and will appear in its November/December issue.

By every objective measure, the U.S. mounted one of the world’s worst responses to the COVID-19 pandemic. Its 1.1 million deaths left it with a mortality rate that exceeded all other advanced industrial nations except the United Kingdom.

Official explanations for this catastrophe are in as short supply as ventilators, masks, and hospital gowns were during the pandemic’s first wave. Neither Congress nor the White House has appointed an independent commission to document what went wrong. Federal and state public health officials have offered few recommendations on how the nation could be better prepared for the next pandemic when it strikes, as it certainly will in this crowded and warming world. Even the usually hyperactive network of think tanks and academicians engaged in public health have been relatively silent about the need for changes in U.S. policy to correct the gaps in pandemic preparedness revealed by COVID-19.

Why did a country with the most expensive health care system in the world, an enviable scientific capacity, and a deep bench of public health expertise perform so miserably when confronted by this unique and dangerous pathogen? The short answer, according to a new book by the award-winning journalists Joe Nocera and Bethany McLean, is that it was inevitable given the decades-long trends in every sector of society that must be mobilized to successfully combat a new threat to public health.

Their review of the actions of elected leaders, the government’s health-related bureaucracies, corporate America, health care institutions, and a substantial fraction of the general public claims that each responded in a self-interested manner. A collective response, which requires a commitment by individuals, corporations, and institutions to preserve life (as necessary in combating a public health threat as it is in wartime), never took hold in the U.S. A few countries succeeded in mobilizing their societies around a joint response. Ours did not, in spectacular fashion.

The Big Fail: What the Pandemic Revealed About Who America Protects and Who It Leaves Behind, by Joe Nocera and Bethany McLean

In The Big Fail, the authors provide a comprehensive catalog of the institutional and leadership failures that led to America’s bungled response. Each failure they document reflected organizational and individual behaviors that had been decades in the making. “A central tenet of this book is that we could not have done better, and pretending differently is a dangerous fiction, one that prevents us from taking a much-needed look in the mirror,” the authors write.

It began before Trump

They begin by documenting the missteps of Donald Trump’s administration and the president’s anti-scientific pronouncements. Trump’s early embrace of unproven and dangerous cures was contagious. In the midst of his reelection campaign, he shoved Health and Human Services Secretary Alex Azar to the sidelines. His replacement as head of the government task force, Vice President Mike Pence, promptly took to the pages of The Wall Street Journal to confidently predict that there would be no second wave—which broke with ferocity just after the election.

The authors only briefly mention the prior decade’s defunding of the nation’s pandemic preparedness infrastructure. But those cuts, demanded by the Republican-run Congress in its dealings with Barack Obama’s administration, contributed to the chaos at the outset of the pandemic. Corporations that supplied personal protective equipment had been outsourcing their manufacturing capacity, largely to China, for decades. Their hospital customers helped drive the trend by demanding ever lower prices for PPE in the name of maximizing their own profits. The result? The government’s stockpile—hoarded by the Trump administration—was inadequate. And supply closets were thinly stocked everywhere. The field was ripe for profiteering and fraud when demand exploded at the outset of the pandemic.

Nocera and McLean provide an important history of the growth of anti-vaccine sentiment over the previous two decades. When the vaccine finally arrived—a joint government–private sector endeavor that receives generous praise in the book—once-niche anti-vaxxer sentiment grew to one in seven Americans, one reason why nearly a third of the population remains less than fully vaccinated. The country that helped invent the mRNA vaccine failed to take full advantage of its medical benefits. (Two scientists from the University of Pennsylvania just won this year’s Nobel Prize in Medicine for their work on the vaccine.)

Private equity’s incursion into the health care industry comes in for repeated criticism in the book. More than a fifth of all deaths took place among residents and staff in nursing homes, which private equity firms had purchased in large numbers early in the 2000s but largely abandoned after extracting short-term profits. Those Medicaid-dependent institutions have never been properly funded by Congress, nor have regulators adopted standards for operators that might have protected patients. “Once the pandemic arrived, it was too late,” Nocera and McLean write.

The hospital industry’s inadequate response to COVID was similarly skewed by inadequate funding—for some hospitals, not all. People who are poor or low-income are more likely to suffer from one or more chronic medical conditions and therefore were the ones most vulnerable to serious consequences when stricken with COVID. They were more likely to wind up in one of the nation’s safety net hospitals, which get most of their funding from Medicare and Medicaid, which pay less than private insurance. Hospitals in well-off neighborhoods, meanwhile, took care of fewer COVID patients, yet they received a disproportionate share of hospital emergency funds, which were distributed based on pre-COVID revenue. As a result, hospitals with the least resources bore the brunt of the fight against the disease.

The authors aim their fire for this sorry situation at privately owned chains like HCA Healthcare; at private equity’s incursion into the hospital sector (still a very small share of hospitals); and at the outsized salaries of top hospital officials. It’s important to note that major nonprofit chains, often religiously affiliated, benefited just as much during COVID from the government’s failure to channel most of its emergency aid to frontline institutions.

“We have met the enemy and he is us”

While their far-ranging critique may sound Pogo-esque—the 20th-century newspaper cartoon character’s most famous aphorism was “We have met the enemy and he is us”—Nocera and McLean repeatedly cite the politicization of science as a major cause of the U.S.’s pathetic performance. That’s true. But rather than lambast opportunistic politicians or the growth of anti-science among the general public, they reserve their sharpest barbs for the arrogance of career government officials at the National Institutes of Health and the Centers for Disease Control and Prevention. This may come as a shock to those (like me) who saw the primary threats to a coherent, science-based response coming from followers of Donald Trump, who early on championed quack cures like hydroxychloroquine and ivermectin; from anti-vaxxers; and from conservative politicians like the governors of Florida and Texas, who actively encouraged resistance to masking, social distancing, and economic lockdowns.

Nocera and McLean instead focus on the flip-flopping by the government’s physician-leaders, who were the trusted figures to whom most Americans initially turned for advice. Anthony Fauci, the director of the National Institutes for Allergy and Infectious Diseases, comes in for repeated opprobrium. He first said there was no reason for people to be walking around with masks. A month later, the CDC recommended masking and social distancing, which Fauci promptly endorsed. “Follow the science,” he said repeatedly during his television appearances. After Joe Biden’s new administration installed Rochelle Walensky as head of the CDC, she switched her position on social distancing without explaining why six feet of separation was now required instead of the three feet she had recommended when she was a hospital official in Massachusetts. She and Fauci initially encouraged using cloth masks to protect against catching or spreading the disease, but a year later, the CDC admitted that cloth masks without an N-95 rating afforded little protection.

“That kind of grudging change didn’t inspire confidence,” the authors write. “The problem with ‘following the science’ is that science, particularly in the early stages of discovery, is not an immutable thing. It rarely offers certainties. It offers theories and models and probabilities, which are then supposed to be tested against real-world evidence. But self-righteousness does not easily acknowledge uncertainty.”

Acknowledging uncertainty and seeking real-world evidence are sound principles. One wishes that Fauci and others had been more forthright about their recommendations being based on the best available science at the time; that researchers were learning more every day about what worked and what didn’t; and that there would inevitably be twists and turns in recommended actions.

But the authors should have followed their own advice as they issued a harsh indictment of the scientists and state public health officials who supported the federal government’s endorsement of economic and school lockdowns. Yes, those actions had serious consequences for small businesses, schoolchildren, and any working American not a member of the educated Zoom class that could work from home. But the goal of public health officials is preserving human life. They judge the value of lockdowns, like all prevention strategies, with that measure.

Heroes?

Nocera and McLean make the incorrect claim that Fauci “had to know that lockdowns as a mitigation measure had no basis in science.” They follow the lead of the epidemiologists Martin Kulldorff at Harvard and Jay Bhattacharya at Stanford, who are portrayed in near-heroic terms in the book. Both were fierce opponents of lockdowns. They first articulated their position in an op-ed in The Wall Street Journal, and then helped organize the Great Barrington Declaration of October 2020, which eventually gathered nearly a million online signatures. The declaration emphasized the enormous collateral damage when you shut down a society: Kids fall behind in school; domestic violence soars; businesses shut down; people die when hospitals stop performing surgeries and patients postpone routine preventive care.

However, the declaration drew immediate fire from the more than 7,000 scientists, physicians, nurses, health care executives, and others who signed the John Snow Memorandum (named after the founding father of epidemiology, who identified the well water source of a mid-19th-century cholera outbreak in London). The memorandum is never mentioned in The Big Fail, an inexcusable oversight. Those signatories argued that lockdowns were “essential to reduce mortality, prevent health-care services from being overwhelmed, and buy time to set up pandemic response systems to suppress transmission following lockdown … In the absence of adequate provisions to manage the pandemic and its society impacts, these countries have faced continuing restrictions.” That’s exactly what happened in the U.S.

But rather than report both sides of a debate then raging in the medical literature and in the press, Nocera and McLean take the side of those pushing what amounted to a herd immunity strategy. What does the science say? To this day, the academic literature is filled with conflicting studies of the impact of economic lockdowns. One study rejecting their use relied on cost-benefit analysis, which places a lesser value on the lives of seniors because they have fewer “quality-adjusted” years left to live. But another study that looked primarily at the mortality benefit (rather than the economic cost) estimated, conservatively, that the 1 million lives saved through lockdowns outweighed the number of lives lost due to economic dislocation by a factor of four to one.

School lockdowns and their support from teachers’ unions are given a similar one-sided treatment. The risk to kids was “minuscule” and the harms were without historical precedent, they write, quoting at length from an Atlantic magazine article. “The fight over schools was an early sign of how stupidly polarized the country had become, and in this case it wasn’t the red states refusing to follow the science,” Nocera and McLean conclude. “It was blue state Democrats who valued their political affiliation over common sense.”

There’s no doubt educational achievement suffered during the pandemic. Parents were stressed, low-income parents most of all. But you will not learn from this account that more than 800 children under 18 died from COVID in the year that most of the age group became eligible for vaccination, which was two-thirds of all the children who died from the disease during the pandemic. Moreover, student suicides dropped, and a recent review of studies found “both school closures and in-school mitigations (like masking) were associated with reduced COVID-19 transmission, morbidity and mortality in the community.” Was there no validity to teachers’ concern about their own and their pupils’ safety, and were the school lockdowns ordered by mostly Democratic politicians mere catering to a favored constituency? This issue deserved a more evenhanded evaluation.

Near the end of this overly long book (do readers really need eight pages on the failed campaign to recall California Governor Gavin Newsom, whose outcome even the authors admit did not hinge on the state’s pandemic response?), Nocera and McLean wonder if modern communications and its reliance on sound bites isn’t suited to getting people through a pandemic. “When ‘maybe’ or ‘we don’t know’ isn’t allowed; when reputable scientists who hold dissenting views are banned from social media and described as ‘fringe’; when error is never acknowledged; and when the lived experience of people is ignored—it is inevitable that people will lose faith in experts telling them how to behave.”

Some people in the public health community did act dismissively toward their critics. But a fairer account would have put those attitudes, especially during the pandemic’s first year, in the context of a presidential election where the incumbent embraced fake science and stoked resistance to the recommendations of the agencies he ostensibly led.

Should lost faith in public officials be ranked among the major causes of the U.S.’s world-worst response to COVID-19? What is missing from that conclusion is any recognition of what it takes for any strategy designed to prevent the spread of disease to succeed. It requires broad public acceptance, which in turn requires social solidarity with those most harmed by the outbreak. It requires a common commitment to the idea that while the science may be uncertain, there is such a thing as the best available evidence. It requires an understanding that society-wide actions may have to shift as more evidence is acquired.

Social solidarity is in short supply in 21st-century America. In a book that seeks to document the multiple causes of America’s failed response to the COVID-19 pandemic, I wouldn’t give the missteps of harried civil servants and government scientists trying to instruct a divided, misinformed, and politically manipulated public a prominent place on the list.