S1E31: A Patchwork Pandemic / Ed Yong & Howard Koh

“We all believe that we need a national plan in the face of a national emergency, a United response for the United States… We’re all in these parts of the same country. You can’t control the pandemic without some degree of coordination.” – Ed Yong

What kind of coordinated national response is required for a national health crisis like COVID-19? Today on “Epidemic,” Dr. Celine Gounder speaks with Dr. Howard Koh, Professor of Public Health Leadership at the Harvard School of Public Health, and Ed Yong, staff writer for the Atlantic. They discuss the “patchwork pandemic” we are experiencing, where the country is divided on how it’s responding to — and being impacted by — COVID-19. They’ll examine the degree of federal leadership that is required for an effective COVID-19 response, and the consequences suffered from failing to implement a nationally coordinated plan.

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Celine Gounder: I’m Dr. Celine Gounder. This is “Epidemic.” Today is Friday, June 26th.

Beautiful day in the Rose Garden, I appreciate everyone being here… today I’d like to provide an update to the American people on several decisive… 

Celine Gounder: On March 13th, President Donald Trump addressed the nation.

To unleash the full power of the federal government in this effort, today I am officially declaring a national emergency. Two very big words.  

Celine Gounder: For much of February, Trump had been downplaying the virus’s threat. But this seemed like it could be a change.

The action I am taking will open up access to up to $50 billion of very importantly… very important and a large amount of money for states and territories and localities in our shared fight against this disease. 

Celine Gounder: Sounds good right? A national emergency declaration. Funding to fight a common threat. But unfortunately, that leadership never materialized.

Howard Koh: When the president declared a national emergency on March 13th, that ordinarily means that the national government is taking the lead, and we have not seen that coordination the way we should.

Celine Gounder: This is Dr. Howard Koh.

Howard Koh: In usual times states take the lead in addressing the health crises within their own borders. But these are not usual times. This is a threat that affects every American across the country. And we’ve seen a scramble where we have a patchwork of responses, state by state.

Celine Gounder: Howard is a Professor of Public Health Leadership at the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School.

Howard Koh: We all believe that we need a national plan in the face of a national emergency, a United response for the United States.

Ed Yong: It is about the federal government setting up the conditions under which States can win. And I think it’s very clear that this government has not done that.

Celine Gounder: This is Ed Yong. He’s a staff writer for The Atlantic, and he’s been one of the harshest critics of the government’s response.

Ed Yong: you need that coordination to build trust among people. You need to feel, you need them to see you that the government has their back, and that’s really important because a lot of the measures that we’re asking people to do, like wearing masks, like social distancing, depend on community trust. So do a lot of public health measures. Contact tracing isn’t going to work if people don’t pick up the phone so you need to, you need people to feel as if they’re part of something greater and without some kind of clear coordinated central messaging, that is very difficult.

Celine Gounder: Ed, Howard, and other critics have said this abdication of responsibility by the federal government has created a patchwork pandemic. The experiences with coronavirus and responses to it vary widely from state to state; city to city. In this episode, we’re looking at that patchwork… how it came about, how it has failed us, and why a federally-coordinated response is still our best hope at containing and beating the coronavirus.

Few people understand this better than Howard. Before joining the faculty at Harvard, Howard spent more than two decades guiding state and federal responses to public health emergencies. He was the public health commissioner of Massachusetts from 1997 to 2003, a tenure that included the terrorist and anthrax attacks of 2001.

Howard Koh: The fall of 2001 was a time where the country was terrified like it is now. And it was critically important to see government working as one, to send unified health messages to respond to the threat.

Celine Gounder: The anthrax attacks threatened to become a public health crisis. Envelopes containing anthrax spores were being mailed to government and media offices. Twenty-two people were infected and five died before the threat was contained.

Howard Koh: And during that tragic time, I saw the importance of emergency preparedness and response.

Celine Gounder: In the wake of 9/11 and anthrax, the federal government created the Public Health Emergency Preparedness program. Managed by the Centers for Disease Control, the program created a partnership between the federal government and states to ensure that there was a sufficient and well-coordinated response to future threats. The effort paid off when the H1N1 flu reached the U.S. back in 2009. By that time, Howard was the Assistant Secretary of Health and Human Services, a role that gave him a new perspective on emergency response.

Howard Koh: In federal government, I appreciated what the states were doing because they could always report back what was happening at the local level. And that’s a perspective that many of us in federal government can never have because we’re too far away from the action. So in a time like this, if federal, state, and local officials are all working as one, a one government approach, that’s the only way we can handle a pandemic like this.

Celine Gounder: Despite the program’s success containing H1N1, it’s often a target of government officials looking to cut federal spending. It took a financial hit during the Great Recession in 2008. In 2017, Senator Mitch McConnell, the Republican from Kentucky and newly-appointed majority leader, attempted to completely defund the program as part of a larger effort to abolish the Affordable Care Act. The program survived the Senate vote, but much of its funding was later reallocated to cancer research and other initiatives. Too many years had passed without an acute public health crisis. Prevention and preparedness were no longer seen as necessary and important.

Howard Koh: People don’t really understand the power of prevention, how critically important it is. But over the last 20 years our interest and commitment to emergency preparedness has gone up and gone down depending on the time.

Celine Gounder: Despite declaring a national emergency, the White House never issued national guidelines for states to follow as they responded to the pandemic. That left states to fend for themselves. Governors and hospital administrators found themselves bidding against each other for supplies, or searching for help. Larry Hogan, the Republican governor of Maryland, organized a shipment of more than 500,000 test kits from South Korea.

The state of Maryland owes an incredible debt of gratitude to the people of South Korea. 

Celine Gounder: Governor Hogan said that acquiring the tests required a month of secret negotiations and credited his wife, who is Korean, with securing the nine-million-dollar deal. The White House criticized him for looking overseas for support. At that point, Governor Hogan pointed out that he was just following the White House’s guidance… or lack thereof.

The administration made it clear over and over again, they want the states to take the lead, we have to go out and get it for ourselves, and so that’s what we did. 

Celine Gounder: Unfortunately, test kits were just the beginning. There was competition over ventilators, too, and protective equipment for health care workers. Here’s Governor Andrew Cuomo of New York in a press conference back in March:

It’s like being on Ebay with 50 other states bidding on a ventilator and you see the bid go up because California bid, Illinois bid, Florida bid, New York bids, California rebids, that’s literally what we’re doing. I mean… how inefficient…  

Howard Koh: To have states and governors using their precious time and energy to scramble for these resources at a time like this is not a good use of anybody’s time.

Celine Gounder: Perhaps the only unified element of the overall response to COVID were stay-at-home orders. They were eventually issued in forty-five states.

Howard Koh: And as time has gone on, we see these trends across the country that should be addressed as a country, but are not so far. So I believe, and I know everyone believes that we need more national coordination of state efforts.

Ed Yong: The federal government has a lot more money than individual states have so they can get testing, they can get protective supplies at economies of scale.

Celine Gounder: Ed Yong again.

Ed Yong: Then, distribution. So they can ensure that those supplies are delivered to different States and different communities according to need rather than according to wealth or connections or to the vagaries of a local leadership, which is what is happening now.

Celine Gounder: On May 20th, Ed published a piece called “We Live in a Patchwork Pandemic Now.” While he’s using the same word as Howard—patchwork—Ed’s article describes a different element of the pandemic. He’s talking about the patchwork of experiences across the country, a patchwork that’s emerging in the absence of federal leadership.

Ed Yong: Different parts of the U.S. are experiencing this pandemic in very different ways. If you look at places like New York that were hit very hard at the start, cases going down, but in other states they are going up. But that overall national pattern masks a huge amount of variation and heterogeneity in how different American states and communities are experiencing this crisis.    It’s not just one crisis. It’s at least 50 interconnected ones and maybe more.

Celine Gounder: That patchwork makes it harder to predict what’s next, and to figure out how to control it. Even within states, communities are experiencing the pandemic in wildly different ways. And this is an issue that goes beyond the lack of a federal response to this particular crisis.

Ed Yong: These new patchworks of COVID-19 are not random. They are laying on top of and emerging from a long histories of discrimination and marginalization that have been parts of American society since the very start. We see, for example, that the Navajo Nation has the highest per capita rates of COVID-19 cases, higher than any state. And that is in large part due to oppression and land theft that has been in that community for centuries. When people don’t have access to running water, they can’t wash their hands. When people live far away from good medical care, they can’t get tests, they can’t get treated. When people don’t have power, they have to heat their homes with wood and coal, irritating their lungs and making them more vulnerable to a respiratory virus.

Celine Gounder: The problem is not unique to the Navajo Nation.

Ed Yong: Today black people and brown people are more likely to be infected by it and to be killed by COVID-19. This is not a new phenomenon, even though the pandemic is new. It is the result of long-standing policies that were specifically intended to push healthcare away from black people and black communities.

Celine Gounder: The pandemic is bringing this on-going public health crisis, and the costs of health care inequities, into the spotlight in a catastrophic way.

Ed Yong: Racism is a public health crisis in the U.S. COVID-19 is a public health crisis. And, and I think the two are inextricably linked and related to this patchwork idea. You know, we, we give advice to people in public health that is meant to apply to everyone, but there are so many publics, who may or may not be able to benefit from the same advice.  We tell people that they should isolate themselves at home to stay safe. Breonna Taylor was killed in her own home.

Celine Gounder: Breonna Taylor was a 27-year-old woman who was killed by police after they entered her Louisville home. They were looking for someone who did not live in the house. Kentucky’s attorney general and the FBI have opened investigations into Breonna Taylor’s death.

Ed Yong: We tell people that they’ll be safe from the virus if they go out running. Ahmaud Arbery was killed while on a run.

Celine Gounder: Two white men shot Ahmaud Arbery while he was running through their Georgia neighborhood earlier this year. This week, a grand jury indicted three men on murder charges in the case.

Ed Yong: Different people in this country vary in their capacity to carry out this public health advice, not because of their own personal choices or their decisions, but because of structural racism that has been part of America for the longest time. And I think, unless we truly grapple with that, we cannot get the pandemic under control, but the patchwork will continue.

Celine Gounder: And yet, when left to their own devices, state governors are not grappling with these long-standing issues. They’re just following the usual course of healthcare in the United States: basically, you can have it if you can afford it. On May 27th, NPR released a map of testing sites in Texas. The map showed more sites available in whiter, more affluent communities—despite data showing that low-income neighborhoods are at highest risk.

Ed Yong: We need some sort of coordination so that the entire country is operating on a shared playbook. And one state might well say based on what our community is experiencing we can start to reopen while another state might want to continue shutting down. But it’s important that those decisions are made in a consistent way, according to the same framework. Because we’re all stuck in the same place. We’re all in these parts of the same country. We share loads of borders. People move about freely. You can’t control the pandemic without some degree of coordination.

Celine Gounder: As COVID spiked in New York City, and cases increased across the country throughout April, it briefly seemed as though the federal government might change course. In an April 16th press conference, the White House announced a three-phase framework for states to follow as they considered reopening.

Our team of experts now agrees that we can begin the next front in our war, which we’re calling, “Opening Up America Again.” And that’s what we’re doing: We’re opening up our country. 

Celine Gounder: At long last, there would be a national strategy…

Trump: Therefore, my administration is issuing new federal guidelines that will allow governors to take a phased and deliberate approach to reopening their individual states. 

Celine Gounder: The plan held promise.

Howard Koh: Those were good principles. High level, but very sound, and the White House Task Force stressed that states should not consider reopening until cases were declining over a steady period of time, that hospital capacity was improved so that professionals could take care of both COVID and non-COVID patients. We wanted also signs of robust contact tracing in every state so that public health could improve. We wanted positivity of test rates going down. So those are some high level principles. If there was constant tracking of that, and calling out of best practices and encouraging states that were falling behind to be supported by other states, allocation of resources from one part of the country to another to address hot spots, that’s the national coordinated response that we need right now.

Celine Gounder: But despite the fanfare, the White House’s Opening Up America Again didn’t do much.

Howard Koh: Every state went off and made their own decision and there was no coordination of implementing those principles at the national level.

Celine Gounder: And it’s not going well. On the day this episode was recorded, the United States hit an all-time record for the highest number of new reported cases of coronavirus in a single day. But it’s a patchwork… this time hitting the South and West hardest. In Houston, for example, ICU beds were 97% full. It’s how things looked in NYC a couple months ago.

Ed Yong: We’re in a dangerous position right now where different States have opened up at different times and where a lot of leaders and the federal government, the White House, are repeatedly providing misinformation to people, and stoking the fires of political partisanship. That being said, it does seem like across the board, even in a lot of very heavily red-leaning States, people have been reluctant to go back to some degree of normal and a lot of people are still being very cautious. And that suggests that some of that shared experience is holding despite the patchwork that has ensued.

Celine Gounder: Americans may not necessarily have a shared experience with COVID, but many people are developing a shared attitude about it.

Ed Yong: As the virus has spread to rural areas, to suburban areas, to states in the heartland that were not originally affected, I think more and more people are coming to terms with what COVID-19 actually means. We are seeing a growth in people taking the threat seriously and a reduction in partisanship.

Celine Gounder: And at least some of the public health messaging is reaching the general public, regardless of where they live.

Ed Yong: Social scientists I’ve spoken to note that upwards of 70% of Americans are united in thinking that social distancing is important, in wanting to reopen cautiously, and thinking that masks are a good idea. These are incredible numbers. You can’t really get 70% of Americans to agree on basically anything. But they are oddly united in this. Now, whether that unity can last… I, I don’t know.

Celine Gounder: In the absence of leadership, people are turning to whatever sources they can find for information. Those who are lucky enough to know Howard have not been shy.

Howard Koh: I’ve been inundated by friends and colleagues who are school leaders and business leaders and members of houses of worship, even judges who are contacting me and saying, Howard, you’re a public health professional, please guide me, because I don’t know where to return safely in my workplace or my school or, or my quarter, my place place of worship. The CDC finally put out some guidance. It should have come out a long time ago. It needs to be as detailed as possible as science-based as possible, and then updated on a regular basis. The confusion we’re seeing about how to safely reopen state by state is very unfortunate and is unnecessary too.

Celine Gounder: The limits of a state-by-state public health response will be tested again when a vaccine becomes available. Original projections predicted we’d have a vaccine by the end of 2021. As we’ve heard in previous episodes of “Epidemic,” an influx of funding is speeding up that timeline. But whenever that vaccine or another preventative treatment becomes available, the planning to distribute it needs to start now.

Howard Koh: If the vaccine arrives when everyone hopes it will, we need to start now to talk about priority groups for receiving that vaccine who are at highest  risk, because there are always issues about supply and demand. So that proactive strategy should be started now.

Celine Gounder: Remember, Howard is speaking from experience. He was the U.S. Assistant Secretary of Health and Human Services when the H1N1 vaccine became available.

Howard Koh: Every time a new vaccine is proposed, there are always questions about the safety profile. And we spend a lot of time coordinating our data monitoring systems to, to have data and present that on a regular basis and show the American people that it was worth the very, very low risk to take it. And since always with new vaccines supply does not meet demand, there were lots of proactive meetings and discussions about how to identify the highest risk groups.

Celine Gounder: Preparation was key.

Howard Koh: And when that vaccine arrived, there were a lot of efforts by so many of my wonderful colleagues to get that vaccine up and out, and then distributed around the country.  And we got through 2009, 2010, there were some 12,000 deaths, which we regretted, but it was a pandemic that was in hindsight, milder than we thought it might be. So, some of those themes I’m hoping can be applied now.

Celine Gounder: Still, it’s not too late for a plan.

Howard Koh: We are in a critical phase right now with the pandemic, because with the summer arriving and states re-opening, it’s very easy to let down our guard. I believe so strongly that if anything, we should be increasing our efforts in terms of caution and promoting science-based policies like social distancing and mask wearing. We are going into a future, especially with the fall where a second wave of COVID may be coming on top of seasonal flu, and that could be incredibly challenging for the country. And there’s increasing indications that this coronavirus may be here to stay even when a vaccine might arrive or better therapeutics. So we have to take the long view here. We just cannot take the short term view, the reactive view that we’ve had up to date. We need to start strategies now.

Celine Gounder: For Howard, one of the most important lessons from this patchwork pandemic is an old one. Sure, local authorities should have the flexibility to respond to different situations on the ground… that’s part of the strength of a federal system. But there will continue to be other epidemics and pandemics that are bigger than any one city or state. And without the resources of a nationwide approach—national leadership, coordination, science, guidelines, and funding—we’re going to continue to see more debacles like COVID.

Howard Koh: I like to say that our good health is a gift, it’s precious and it’s fragile. What public health does is it protects that gift every day. And when prevention, public health has overlooked, we have some of the outcomes that we’re witnessing today. That’s just unacceptable. We can’t let this ever happen again. We’d have to build forward and build a stronger prevention, preparedness and public health system.

Celine Gounder: “Epidemic” is brought to you by Just Human Productions. We’re funded in part by listeners like you. We’re powered and distributed by Simplecast.

Today’s episode was produced by Zach Dyer, Danielle Elliot, and me. Our music is by the Blue Dot Sessions. Our interns are Sonya Bharadwa, Annabel Chen, Claire Halverson, and Julie Levey.

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And check out our sister podcast “American Diagnosis.” You can find it wherever you listen to podcasts or at americandiagnosis.fm. On “American Diagnosis,” we cover some of the biggest public health challenges affecting the nation today. In Season 1, we covered youth and mental health; in season 2, the opioid overdose crisis; and in season 3, gun violence in America.

I’m Dr. Celine Gounder. Thanks for listening to “Epidemic.”