Without mass testing, contact tracing, and protective equipment for health workers – all in critically short supply – the president’s plan could be disastrous.On Thursday evening, Donald Trump took to the dais in the White House press briefing room and declared that he was leading America in a “historic battle against the invisible enemy” that amounted to the “greatest national mobilisation since world war two”.
Warming to his theme, the US president said the country was now ready to move to the next phase in the war against coronavirus. It was time, he said, “to open up. America wants to be open, and Americans want to be open”.
Unveiling new guidelines for the loosening of the lockdown, he committed his administration to a “science-based reopening”. He added: “We are starting our life again, we are starting rejuvenation of our economy again, in a safe and structured and very responsible fashion.”
Beyond the cloistered confines of the White House an alternative interpretation of events was gathering force. On a day in which the US suffered its highest death toll from Covid-19, with a total of more than 680,000 confirmed cases and 34,000 deaths, public health experts were scrutinising the president’s new guidelines and coming to rather different conclusions.
“This isn’t a plan, it’s barely a PowerPoint,” spluttered Ron Klain on Twitter. Klain, the US government’s Ebola tsar during the last health crisis to test the White House, in 2014, said the proposals contained “no provision to ramp up testing, no standard on levels of disease before opening, no protections for workers or customers”.
On 28 March the Guardian exposed the missing six weeks lost as a result of Trump’s dithering and downplaying of the crisis when the virus first struck. Jeremy Konyndyk, another central figure in the US battle against Ebola, told the Guardian that the Trump administration’s initial response was “one of the greatest failures of basic governance and leadership in modern times”. Now that the US is contemplating a shift into the second phase of the crisis – a tentative reopening of the economy – scientists and public health officials are agreed that three pillars need to be put into place to manage the transition safely.
They are: mass testing to identify those who are infected, contact tracing to isolate other people who may have caught Covid-19 from them, and personal protective equipment (PPE) to shield frontline healthcare workers from any flare-up. A chorus of expert voices has also begun to be heard warning that those three essential pillars remain in critically short supply throughout the US. Less than a month after the Guardian’s exploration of the missing six weeks, the chilling recognition is dawning that the country is heading for a second massive failure of governance under Trump, this time on an even bigger scale.
Unless testing capability is dramatically ramped up and a giant army of health workers assembled to trace the contacts of those infected – right now – the consequences could be devastating.
“I’m fearful,” said Dr Tom Frieden, the former director of the US Centers for Disease Control and Prevention (CDC). “Testing remains scarce in many parts of the country and it’s slow to scale up – we are weeks if not months away from having enough test capacity.”
Frieden, who now heads the global health initiative Resolve to Save Lives, told the Guardian in an interview conducted shortly before Trump released the new reopening guidelines that time was being wasted. The federal government’s misplaced insistence in February that its China travel ban would be enough to make the virus go away had “lost precious weeks” in tackling the first wave of coronavirus.
We wasted February, and I’m worried we’re about to waste April too.
Jeremy Konyndyk, a key figure in the Ebola fight.
Jeremy Konyndyk, a key figure in the Ebola fight.
Now, as the US contemplates reopening, Frieden said he was afraid a repeat performance was imminent.
“I fear there’s an analogous mistaken belief that sheltering in place will make this virus go away, that we can then choose a date and all come out. It’s not about the date, it’s about data and building a national response at scale.”
In a series of tweets posted in reaction to the new White House guidelines, Konyndyk echoed the anxiety about more lost weeks. He said the Trump administration had “wasted February, and the White House guidance on ‘opening up’ leaves me worried that we’re about to waste April too”.
Konyndyk said that for states to reopen before they were ready “would be a disaster. It’s no great insight to say we need more testing, tracing, PPE [protective gear for health workers] – it’s been obvious for a month and a half. But each of those face huge bottlenecks and the document doesn’t acknowledge them, much less propose how to resolve them.”
Trump, launching the new reopening guidelines on Thursday, insisted that the US was in “excellent shape” on testing. “We have great tests. We have done more testing now than any country, in the world, by far.”Trump says we have the best testing, but the US is in the last percentage of tests administered to its population
Michael Greenberger, University of Maryland
The US has so far tested about 3.3 million people, about 1% of its population. Per capita, that is small compared with several countries including Germany and South Korea. Iceland has tested people at 10 times the US rate.
“Testing has been an unnecessary disaster,” said Michael Greenberger, director of the University of Maryland Center for Health and Homeland Security. “Trump says we have the best testing, but the US is in the last percentage of tests administered to its population.”
Not one of the 50 states is currently in a position to carry out tracking of Covid-19 infections on the scale needed, whatever Trump said about their readiness to reopen. Many states, including the hardest hit, New York, are still experiencing testing shortages, 12 weeks after the first US case was recorded.
Individual states continue to have to compete for critical supplies against each other, and against the federal government, driving up prices. Components including nasal swabs, reagents and RNA extraction kits are running short.
Daily testing has flattened out and is now hovering around 150,000 tests a day – vastly below the level that would be needed to detect localized pockets of disease as the economy reopens. Most alarmingly, the number of tests carried out by commercial labs has actually plummeted in recent days due to shortages in test samples, leaving the labs sitting idle.
At the White House briefing, Trump insisted that the phenomenon of the idle labs was a “great thing”, a sign that states were finding local solutions and an “affirmation that testing is growing at a historic rate”.
All of these impediments have put the US on the back foot as it seeks to pull off the daunting feat of getting back to work without risking a renewed surge of contagion.
“We have had cases circulating in communities undetected for several weeks, and because of the delay in the roll-out of testing we never had the chance to be on top of it,” said Anita Cicero. She is joint author of one of the most definitive scientific plans for reopening the US, produced by a team from the Center for Health Security at Johns Hopkins University.
“That means it’s going to require much more ubiquitous testing,” she said.
Estimates vary on how much testing will be needed, but they are all substantially greater than present provision. Even at the lower end, as posited by the former commissioner of the US Food and Drug Administration Scott Gottlieb, some 2m to 3m tests a day are recommended – up to three times the current level.
Harvard’s Safra Center for Ethics argues that is too few. It calls for tens of millions of tests every day, way beyond existing capacity.
The states are not islands. Their borders are not closed.
As the Johns Hopkins plan makes clear, diagnostic testing is only the start. It must be combined with relentless detective work, called “contact tracing”, to track down anyone who has come into contact with an infected person and who may need quarantining to stop the virus spreading again.
The Johns Hopkins plan envisages a nationwide army of 100,000 contact tracers. “That might sound eye-popping, but it’s reasonable and may be a low estimate,” Cicero said, pointing out that in Wuhan, China, the authorities employed a workforce three times the size per capita.
With contact tracing, too, there is no sign that Trump recognizes the urgency of the moment. Frieden told the Guardian that many states were already struggling to ramp up contact tracing to a level that would support reopening. Health departments are overwhelmed, and some have “trouble even conceiving the scale of operations they are going to need”, he said.
Faced with a wide gap between nationwide demand for testing and contact tracing and insufficient supply, Trump has flip-flopped in his positions. He began by insisting that he had “absolute authority” to overrule the states in deciding when to reopen, a posture widely denounced as king-like and anti-American.
On Thursday he effected an about-turn and passed the buck to the 50 states. “You are going to call your own shots,” he told governors on a call on Thursday.
Trump’s sudden switch to offloading federal responsibility to the 50 states has prompted questions about his motive. Current and former senior officials in the Trump administration told the Washington Post that he wanted to “shield himself from blame should there be new outbreaks after states reopen”.
The former head of Medicare and Medicaid from 2015 to 2017, Andy Slavitt, commented on Twitter that the White House guidelines were sending a clear message to the states: “Your state didn’t open, that’s on your governor. Your state opened and people died, that’s on your governor.”
Trump attempted to sell the idea of devolving responsibility by presenting his vision of America as a “beautiful puzzle”. He said: “I call it a beautiful puzzle. You have 50 pieces. All very different. But when it’s done … a very beautiful picture.”
A “beautiful puzzle” may be an appealing concept to the incumbent of the Oval Office in an election year. But it fits uncomfortably with a virus that is highly contagious, relatively deadly, and dismissive of state boundaries.
“The states are not islands, their borders are not closed and they do not have water around them,” Cicero said. “So it will be a bumpy road going forward in terms of managing the virus.”
States still held in the grip of the contagion, such as New York, are finding it difficult to accept the idea that the buck stops with them in a country with the most powerful national government on Earth. New York’s governor, Andrew Cuomo, has repeatedly called on the Trump administration to do more to help.
“I understand that the federal government’s not eager to get involved in testing. But the plain reality here is we have to do it in partnership,” he said on Thursday.
At Trump’s disposal is the formidable wartime power of the Defense Production Act, which allows the administration to order corporations to redirect their efforts to the cause of fighting Covid-19. So far the president has deployed this capability only sparingly.
I’m moved and crushed by what’s happening in New York right now
Tom Frieden, former CDC headThe president said there were 29 states which are in “extremely good shape” and could reopen soon, some “literally tomorrow”. He declined to name them, though it has been reported that several Republican governors are champing at the bit to loosen lockdowns.
Florida, Texas, Alabama and Mississippi are at the head of the line, according to Axios. Florida began to reopen its beaches on Friday, a controversial move given that the late closure of its beaches during spring break helped spread Covid-19 across the US.
The danger of Trump’s “beautiful puzzle” approach is illustrated by New York City, where the death toll is heartwrenching. The probable tally of deaths from Covid-19 in the city now stands at more than 11,000 – more than double the normal monthly loss of life from all other causes.
“I’m moved and crushed by what’s happening in New York right now,” said Frieden, who until 2009 was the city’s health commissioner.
About 10,000 New Yorkers a day are currently being tested for coronavirus. Mark Levine, chair of New York City council’s health committee, told the Guardian that the frequency would need to be stepped up twentyfold were the city to have a fighting chance at reopening.
Yet even now New York is just days away from running out of testing kits.
Levine said he worries that the window for federal action is rapidly closing. “Trump has the authority to order manufacturers to retool to produce test kits. Unless the White House issues the order immediately, we are going to be out of time.”
https://www.theguardian.com/us-news/2020/apr/18/operation-reopen-america-are-we-about-to-witness-a-second-historic-failure-of-leadership-from-trump
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