It's fair to say that the U.S. performance in dealing with the pandemic has been disastrous. With the effort led by Donald Trump, this is not surprising. His main, if not only, concern was keeping up appearances. Preventing the spread of the pandemic, and needless death, was obviously not part of his agenda.
Unfortunately, many other wealthy countries, like France, Belgium, and Sweden, have not done much better. They don't have the excuse of having a saboteur in charge who was actively trying to prevent the relevant government agencies from doing their jobs.
Anyhow, I thought it would be worth throwing out a few points about how we should have approached the pandemic. While some of this is 20-20 hindsight, I was making most of these points many months ago. I should add, I claim zero expertise in public health, but I do have some common sense, in spite of my training in economics. Of course, if anyone with expertise in public health wants to correct or expand on any points here, I welcome the opportunity to be educated.
I will break down the discussion into three key areas:
- Measures to reduce spread;
- Efforts to develop effective testing, vaccines, and treatments;
- The distribution of vaccines
The United States has failed horribly in all three areas, but many other countries have not done much better.
Containing the Spread
When I look back at what I have been wrong about since the pandemic started, my biggest mistake was in thinking that we could get the pandemic under control after a two or three month shutdown. (I also expected that we would make more progress in treatment. Unfortunately, the ratio of deaths to infections has not changed much since the summer.)
The idea that the shutdowns, followed by effective containment measures, could control the spread should not seem far-fetched. Several European countries did get their infection rates down to very manageable levels after their shutdowns. For example, Denmark, a country with a population of a bit less than 6 million people, had their daily infections below 20 in the summer. At this level, it is possible to do effective contact tracing and arranging for those who have been exposed to be quarantined and/or tested. Several countries in East Asia, such as Japan and South Korea, did even better.
Unfortunately, Denmark, like other European countries, allowed its people to travel freely over the summer. This resulted in many people becoming infected, and then spreading the virus when they returned.
Anyhow, the idea that we would have shutdowns (which can be much better targeted with what we now know) and then have containment measures and testing in place to prevent large-scale spread is clearly a possibility. We completely failed in this effort in the United States, both because we did not implement containment policies and also because we had grossly inadequate testing.
As far as containment, this would require the Centers for Disease Control (CDC), the Occupational Safety and Health Administration (OSHA) and other agencies giving clear guidance and ideally being able to enforce their rules. This mostly did not happen because the Trump administration did not want it to happen. The most important example here was when the CDC tried to produce rules for safe school re-openings, which Trump administration officials then rewrote because they complained that they required too much work.
In a similar vein, OSHA produced guidance for safe practices in meatpacking plants only after widespread reports of infections and deaths in a number of facilities. Incredibly, it was only last week that OSHA issued general guidance for workplace safety in dealing with the pandemic.
Going along with better guidance on the safe operation of workplaces and businesses, we should have had more aggressive efforts at testing and contact tracing. While some states have taken this effort seriously, the Trump administration was often openly hostile to the idea of more frequent testing. As Donald Trump said on several occasions, if we have less testing, we will identify fewer cases. In an administration in which public appearance was the main priority, not controlling the pandemic, there was little interest in pursuing a policy that would show the problem to be bigger.
In terms of what difference better control can make, Germany has had just over half the death rate (relative to its population) from the pandemic as the United States. Denmark has had less than one third the death rate. Governments that knew what they were doing and took the pandemic seriously kept people from dying.
Open-Sourcing Research on Testing, Vaccines, and Treatments
To my view, the biggest failure of policy in the pandemic has been the fact that we gave patent monopolies to the companies developing new tests, treatments, and vaccines. This has led to higher prices and needless shortages of the essential tools for containing the pandemic. This practice is even more frustrating since, in many cases, the government picked up the tab for much or all of the development costs.
I argued, beginning back in March, that we should see the pandemic as a great opportunity for experimenting with open-source research in a context of international cooperation. The idea is that we would negotiate some commitment of funding from each country, based on their GDP and wealth, which would go to support research on developing tests, treatments, and vaccines. All the research findings would be fully open, as would be the results of clinical trials. And, all patents would be in the public domain so that anyone with the necessary manufacturing facilities could produce any of the items developed.[1]
In principle, this would allow for the most rapid progress possible. It also would remove the incentives that patent monopolies give companies to lie about the safety and effectiveness of their products. And, it means that everything that was developed – new tests, treatments, and vaccines – would be cheap. These items are rarely expensive to manufacture, they are only expensive because drug companies have patent monopolies or other types of government protection.
The failure to go this route is hitting home now that much of the world, including the United States and Europe, are facing shortages of vaccines. In the wake of these shortages, we are hearing the response that there is limited manufacturing capacity. This is true, but that is precisely the problem.
If Moderna or Pfizer can each build one or two factories to produce their vaccines, then it was possible to build ten or twenty. If there were inputs in short supply, we could have ramped up production of these inputs. This is why we have the Defense Production Act.
There is no reason that the United States could not have had stockpiles of 300 or 400 million of any vaccine that went into Phase 3 testing, by the time that it was approved. If we had capacity to produce another 100 million or so per month, we could ensure that supply would never be the limit on our ability to vaccinate people.
There is of course the risk that we would have produced 400 million doses of a vaccine that was not approved by the Food and Drug Administration, but so what? With the cost of production around $2 per shot, this would mean throwing $800 million in the garbage. In a context where the pandemic has cost us close to 500,000 lives, and trillions of dollars of lost output, the risk of wasting $800 million looks pretty trivial.
In fact, we should be thinking about the issue on a world scale. That means that we should have been looking to have 1-2 billion doses available when vaccines first were approved by regulatory authorities. This is where international cooperation really would be hugely valuable. In addition to the U.S.-European manufacturers, China, Russia, and India have also developed vaccines.
Two of China's vaccines have been approved by other countries' regulatory authorities. Russia's vaccine has also been approved by regulatory authorities in a number of countries and a recently published article shows it to be highly effective. Russia is currently submitting for approval by the European Union's regulatory agency. Germany has already expressed a willingness to use the Russian vaccine, if it is approved. Russia indicated it could provide 100 million doses to Europe in the spring.
It is great that these other countries have developed vaccines, but unfortunately, they have not been very forthcoming with their results. The Chinese vaccines seem to be less effective than the vaccines developed by Pfizer and Moderna, but they may nonetheless still be very useful in slowing the spread of pandemic, and perhaps even more importantly, preventing severe cases requiring hospitalization and possibly leading to death.
If we had gone the route of full open-source research, the trial data for these vaccines would be freely available to researchers and clinicians throughout the world. This would both allow governments to make informed choices about which vaccines might be best for their populations (several of the vaccines have the advantage of not requiring freezing, which makes delivery and storage far easier, especially in developing countries) and also for doctors and patients to weigh the relative risks and benefits of the available vaccines.
It is also important to point out in this context that we have a very concrete reason for wanting a quick and successful worldwide vaccine program. We know that the more the virus spreads, the more it mutates. There is a great risk that if the pandemic is allowed to spread unchecked in large parts of the world, that there will be mutations for which the current vaccines are not effective. Even if the vaccines can be adjusted to make them effective, as some scientists have claimed, this would still require the production and distribution of hundreds of millions of new doses of a revised vaccine, with the pandemic spreading widely in the meantime.
We really really do not want to be in a situation where we have to go through this thing a second time. That means we should be very serious about getting the whole world inoculated as quickly as possible, even apart from the humanitarian interest that we should not want to see preventable illness and death anywhere.
Distributing the Vaccines
Perhaps the most mind-boggling aspect of the policy response to the pandemic has been the failure of the vaccine distribution process. In the United States we have a fairly straightforward explanation: Donald Trump. Trump made it clear that, under his leadership, the federal government was taking no responsibility for distributing the vaccine. However, even without the leadership of the federal government, it is disturbing that states have not been better in stepping up and filling in the gap.
Even more striking is the fact that United States is actually doing better in its vaccine rollout than countries like France and Germany, which do have national health care systems and generally competent governments. It is astounding that they seem to have been unprepared to deliver vaccines once they had been approved by regulatory authorities. It is striking that these countries did not seem to have plans in place to quickly deliver whatever vaccines they had available.
This means having concrete plans to distribute the vaccine immediately after the regulatory authorities gave the green light. That would mean having stockpiles available near distribution centers. It means picking locations – nursing homes, hospitals, pharmacies, or mass inoculation points at sports stadiums or other facilities – and then ensuring that the necessary personnel are at the site.
We have heard reports of shortages of everything from syringes to personnel trained in giving the shots. We had all fall to ensue that we had plenty of syringes. If enough people had not been trained to administer the shots (we give two million flu shots a day during flu season), then we should have trained more people.[2]
It is truly incredible that states did not make these preparations. Again, having a federal government that was completely AWOL on the vaccine distribution effort was a big handicap, but it is still surprising how most states seem to have fallen down so badly.[3] And, it is very hard to understand how competent governments in Europe seem to have also been unprepared to quickly deliver the vaccine doses that were available.
Conclusion – The World Has Messed Up Big Time in Dealing with the Pandemic
It is hard to look at the track record over the last year and not conclude that governments failed badly in their efforts to control the pandemic. This is partly due to corruption and a failure of imagination, as in the decision not to open-source the development of vaccines, treatments and tests, and partly to a lack of competence, as in the failure to prepare in advance for the distribution of vaccines.
Some countries, especially those in East Asia, have done very well in limiting the spread of the virus and thereby minimizing deaths and economic damage. But few countries elsewhere have much to brag about. Donald Trump is of course a big part of the problem in the United States, but the failure goes well beyond Trump. There should be some real accountability once the pandemic is contained, which hopefully will be soon, if we start doing things right.
[1] I outline a system of publicly funded drug research in chapter 5 of Rigged.
[2] One of the amazing stories I've heard from public health people is that the coronavirus shots take longer to deliver because the shot giver has to make arrangements for a second appointment. If this is actually true, it is incredible that we would waste the time of a person giving shots, by having them make these arrangements, rather than having a separate person who checks people in doing this work.
[3] One explanation that I have heard is that states delayed making plans because they assumed there would be money for distribution logistics in the second pandemic rescue package that eventually passed at the end of December. The idea was that if they spent funds before the bill passed, they wouldn't be reimbursed, but if they waited, they could then have the Feds pick up the tab. If this explanation is right, then it shows the enormous cost of the long delay in passing this bill.
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