Today I’ll discuss the approach to the pandemic in the United States, and all the factors which contributed to our very high case load during the pandemic.  This article ended up being longer than I thought, so I’ll have a separate post later in the week about how we can prepare for the next pandemic. I have a PhD in molecular biology, and I specialize in infectious disease testing. I am not a physician or epidemiologist. I have an informed but not expert opinion.

The COVID-19 pandemic finally seems to be drawing to a close.  For most of the pandemic, the US had the highest number of daily cases, and has had the most cases over all.  As I write this on May 17th, 2022, the US has 82,629,736 total confirmed cases, approximately 25% of the population, and an unknown but likely very large number of unconfirmed infections.

Meanwhile, the US has the most technologically advanced and well funded medical system in the world.  So what happened? This is a very important question because answering it correctly will help us respond to the next pandemic.

First, we can ask what policies the US had in place, and contrast them with policies that were successful.

Countries that initially did well were Taiwan, Japan, Singapore, and South Korea.  These countries are right next to China, which is the natural source for the seasonal flu.  This is because flu viruses exist natively in aquatic birds from southern China, and there is no practical way to eradicate the flu. We can expect dangerous respiratory viruses to arise from China from time to time.  Neighboring countries know this and are naturally vigilant.  The citizens of Asian countries are used to wearing a mask whenever they have the sniffles, and they are prepared for local epidemics. 

South Korea had the following strategy:

• Early free testing for anyone who wanted a test.
• Contact tracing of people exposed to infected individuals. Cell phone and credit card data was used to track residents and produce contact information for infected people.
• Quarantine COVID positive patients at home, fines imposed for breaking quarantine.
• Nearly all citizens wore masks in public.
• Treatment of patients with moderate symptoms.
• No “Lockdowns”, that is quarantining COVID negative individuals, but schools, cinemas, and gyms were closed. Most stores were open.  Vaccine passports allowed access to high risk areas during the Fall and Winter of 2021/22.

By contrast, the US, and most of the Western world, had the following policies:

• Testing only for symptomatic people.
• Treatment only for severe cases.
• Early “Lockdowns” of all but essential workers.
• Contact tracing applied too late to be effective.
• Early communication on masks was incorrect and even deceptive to avoid a run on N95s which happened anyway.  Mask wearing remained controversial and unevenly applied, medical grade respirators unavailable or rarely used for most of the pandemic.

I will point out that most countries, even Japan, South Korea, and Taiwan, had major outbreaks during the Omicron wave.  These countries did have some COVID related restrictions during the Winter of 2020/21 and during the Omicron wave.  I leave China out of the analysis because I don’t trust their data.

Most respiratory viruses like cold and flu are spread by droplet or contact transmission.  However, SARS-2 is spread by aerosol transmission.  Droplets and aerosols are similar, but an aerosolized droplet is much smaller and can linger in the air for much longer than a droplet, more like a cloud than a spray.

Several precautions than became common and even required are designed to prevent droplet transmission rather than aerosol transmission.  These precautions include 6 foot distancing, cloth and blue surgical masks, and those plastic shields at the store.  These measures are mostly ineffective at preventing the spread of aerosols because they do not prevent the movement of small particles.  As you know, I was a strong advocate of masks indoors during the pandemic, but only the medical grade respirators like N95s, KN95s and KF94s.

Peculiarities of the US:
In addition to prevention policies, the US has several cultural and demographic factors which contribute to our high infection numbers. 

Population: Americans know that the 2 most populace countries in the world are China and India, with about 1 billion people each.  These populations appear to dwarf our own estimated population of 330 million.  But we forget that the US is the 3^rd most populace country in the world, with number 4 being Indonesia at 272 million. Japan has 125 million, and the most populace European country, aside from Russia is Germany at only 82 million.

Mobility: The US is an enormous country, and Americans are used to traveling much more than other peoples.  We may not fly to other continents as much as the Germans do, but we don’t hesitate to drive several hours for the weekend, or fly across the continent. I was having lunch with an Englishman once who said they might plan for weeks to take a trip that would involve a 3 hour drive.  Many Americans may only plan for a few hours for such a trip. Our high mobility certainly contributed to our high COVID numbers.

Independence:  Our independent nature has been an enormously useful quality, contributing to our high innovation, personal freedom, and economic prosperity.  So I’m certainly not arguing against American individualism.  But I have to acknowledge that our fierce sense of independence did contribute to non-compliance with government recommendations.  And yes, I totally understand that many official recommendations were ineffective or unlawful. But this factor is part of the equation that we will need to consider in order to deal with future pandemics.

Federalism: The US Government has a lot less power than most people think.  The 10^th amendment states:

The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.

This means that the only powers the federal government has are those expressly given to it in the Constitution. Much of what the US government does now goes beyond the powers given by the Constitution, and is only done because no one has stopped them.  New federal powers are often popular, so they go forward unchecked. 

The pandemic has caused many to lose trust in several previously trusted federal agencies, and States have started to pull back power from the US.  Many were surprised to discover how limited the President’s power was during the pandemic, limited to suggesting guidelines and creating regulation for federal property and interstate travel.  The vaccine mandate attempted to use private companies to enforce vaccination, but even this was struck down by the Supreme Court. 

Emergency powers outlined in the Constitution only apply in the case of an insurrection or invasion. Unless a Constitutional amendment is passed, the Federal Government can only impose martial law if an emergency forces the courts to close (Duncan v. Kahanamoku, 1946).

States have much broader powers.  In California, the Emergency Services Act allows the Governor to declare a state of emergency at any time, a state which grants him broad powers, including the power to suspend certain laws.  Some have said that this state can only last 90 days without approval from the Assembly, but the ESA allows the Governor to end the state of emergency whenever he deems it necessary, “at the earliest possible date that conditions warrant.” (§8629).

All this to say, the states have much more power to address a pandemic than does the federal government.  Whether you find this good or bad news depends on your own political leanings, and the state you live in!

Manufacturing:
The national shortage of N95 masks early on in the pandemic painfully revealed that our domestic capacity for manufacturing certain necessary items fell woefully short. Other items in short supply were hospital gowns, gloves, disinfectant, certain medications, and yes, even toilet paper. 

This shortage meant that almost no-one had effective masks early on.  In addition, confused messaging from Dr. Fauci and the CDC later produced a condition in which ineffective masks were common in public areas.  This certainly had a big negative impact on our case load.

Misinformation and freedom of speech:
I have written on this before, so I won’t repeat this now.  Suffice it to say that many Americans lost confidence in government agencies, including the CDC and FDA during the pandemic.  Lost trust is hard to regain and it can take a long time to get back.  I’ll discuss this more in my next post.

Political polarization:
Similar to the erosion of trust in government agencies, the response to the pandemic quickly became a “team sport” with some responses being typical of the “blue team” and others typical of the “red team”.  Unfortunately, both sides often opposed reasonable ideas simply because they came from the other side.  Also, some terrible ideas had a longer life span than they should have because they were favored by certain political groups.  As I’ve said many times before, science and politics are a terrible combination.  When politics gets involved in science, the results are usually terrible. 

Frankly, things have become so polarized that I am pessimistic about the future.  Republicans and Democrats seem to disagree strongly about nearly everything these days, having fundamental worldview differences, not just differences in approach. I know lots of people who lost contact with friends and even family during the pandemic, as have I myself.

Let me know in the comments what factors you think contributed to our response. Later this week, I’ll post on the next pandemic, and how we can prepare.

Don’t fear, but be smart,
Erik