Everyone thought the U.S. was well prepared to battle a pandemic. The country ranked first worldwide on the 2019 Global Health Security Index, an effort explicitly created to track abilities to address infectious disease outbreaks that was widely touted by the Trump administration in the early days of the pandemic. It was near the top of the World Health Organization’s Joint External Evaluation Exercise, designed to do the same thing. And yet, America ended 2020 the world leader in reported COVID-19 deaths.
It would be tempting to place the entire blame on the incompetent response of the Trump administration, but that would obscure important lessons that we need absorb if we are going to reduce the death toll from the next pandemic. The capacities required to respond to an outbreak vary considerably depending on the nature of the microbe involved, and existing indicators of preparedness missed some key capacities required to respond to COVID-19. For next time — and there will be a next time — America and the world need to ensure we’re prepared for a new infection that looks like COVID-19 as well as ones that look nothing like it.
Not only did the U.S. come first overall in the Global Health Security Index, it was ranked first in four of the six sub-categories, including the ability to detect and report on epidemics; a sufficient and robust health sector to treat the sick and protect health workers; and commitment to improving national capacity and international norms. It came second on its ability to mount a rapid response and mitigate the spread of an epidemic. That suggests either the index didn’t reflect the most important capacities for responding to COVID-19, or those capacities weren’t used. The index creators have leaned in on the second explanation — “The United States’s response to the COVID-19 outbreak to date shows that capacity alone is insufficient if that capacity isn’t fully leveraged.” — though they add that the U.S. scored low in health care access and public trust in government on the index.
But it is worth looking at some of the other top performers on the Index. The United Kingdom was in second place, and ranked first worldwide on its ability to mount a rapid response and mitigate the spread of an epidemic. And yet, as of Jan. 26, it was fourth worst out of 179 worldwide in terms of COVID-19 deaths as a proportion of the population, six places ahead of the U.S. The Netherlands, third in the security index, was 37th worldwide in terms of deaths. Singapore and South Korea were both in the top 10 on the security index and the bottom 50 in terms of deaths, but other countries that were successful in keeping COVID-19 out were ranked far lower: Vietnam ranked 50th, for example.
On average, countries that scored higher on the index have seen more deaths than countries lower on the index. And that same perverse result holds true looking at the World Health Organization’s Joint External Evaluation exercise. There is simply a big gap between countries we thought were prepared for an outbreak and countries that have performed relatively well during the pandemic.
That suggests more to the story than poor leadership. Many countries in Africa have seen a relatively low COVID-19 burden so far, thanks to some combination of an early policy response and behavioral differences (including wearing masks), young populations, climate and perhaps greater pre-existing immunity. A number of East Asian countries with recent experience from the 2003 SARS pandemic rapidly rolled out systems to test, trace and isolate on a large scale, and that may have been the most important mechanism to flatten the curve before COVID-19 spread out of control.
Meanwhile, a lot of the indicators that went into the Global Health Security Index weighed plans, coordination mechanisms and questions about the existence of capacity over the speed, flexibility and scale of that capacity. The U.S. had world-leading labs and detection mechanisms, and some of the most secure isolation wards, but it failed to scale public health measures to respond rapidly to the threat of an pathogen that could be spread through the air by people showing no symptoms.
And that speaks to a broader problem with any single measure of pandemic preparedness: How well a country is prepared to deal with an outbreak considerably depends on the nature of the infection. The U.S. had the kind of high-level isolation capacity that made dealing with the threat of a disease such as Ebola a minor one. It had the finances and health and research capacity to bend the curve on AIDS deaths ahead of much of the world, although far too late and at too high a price. COVID-19 was no Ebola, nor was it like AIDS. The required toolkit for response was markedly different.
In turn, that suggests a lesson for the future: If “pandemic preparedness” in the aftermath of COVID-19 becomes “preparing for resurgent COVID-19,” we may fall short again. The next outbreak may involve a very different type of infection. Massive and rapid response was vital in the case of COVID-19, and in the U.S. both were extensively absent. But even allowing for that, America wasn’t prepared, and nor was much of the rest of the world. Next time, no matter the specific threat, we need to do better.
Humanity’s responses to infectious diseases can be grouped into the categories of exclusion, sanitation and medicine: keeping distant, keeping clean and using drugs and treatments. Between them, they can control any outbreak. The secret of robust, nimble preparedness to a range of infectious threats will be to ensure that all three can be rolled out rapidly, sustainably and at scale. That capacity involves a lot more than just health care systems: the ability to institute quarantines and ensure livelihoods during lockdowns alongside methods to speed research such as challenge trials, for example. And we should go through the exercise of asking, “Are we prepared against any type of outbreak, whatever its (plausible) characteristics?” — will our distancing, sanitation and medical infrastructures be able to respond at sufficient scale in each case?
Where we used to run a war game playing through our response to a particular disease outbreak, we should run 50 against 50 different outbreaks — and apply that same lesson to our global measures of preparedness.
And competent, multifaceted preparation is vital, as Americans and people around the world have painfully learned. Because if there’s one thing the past year has demonstrated, we can’t rely on leadership alone to get us through.
Charles Kenny is a senior fellow at the Center for Global Development and the author of “The Plague Cycle: The Unending War Between Humanity and Infectious Disease.” Follow him on Twitter @charlesjkenny.