Received: 23 April 2020 Revised: 17 May 2020 Accepted: 26 May 2020
DOI: 10.1002/emp2.12155
LETTER TO THE EDITOR
Correspondence
Why the United States failed to contain COVID-19
At the time of writing this article, there have been more than 4.7 million
confirmed cases of the novel coronavirus severe acute respiratory syn-
drome (SAR)S-CoV-2, and approximately 315,000 deaths globally. The
World Health Organization declared a pandemic on March 11, 2020.1
Before and since that announcement as well as other warnings, the
health care response in the United States was insufficient so as to avoid
eventually accounting for 28% of all coronavirus disease 2019 (COVID-
19) deaths, despite comprising only 4.25% of the world population.
There is nothing about the biology of Americans that made this
inevitable. Rather, systemic readiness and our real-time responses
have been major contributors to this outcome. Here we discuss some of
the logistical and cognitive failures that, if understood and addressed
by present and future policymakers, can be improved upon in the
future.
1 LACK OF A RECENT HISTORICAL PRECEDENT
IN THE UNITED STATES
Although outbreaks of dangerous viruses such as Zika, Ebola, Middle
East respiratory syndrome (MERS), and SARS have occurred in recent
years, the effects have been remarkably limited in the United States.
In the case of MERS and SARS, no mortalities occurred in the United
States.2,3 A collective sense of being “immune” to problems appearing
in other nations likely contributed to complacency and an underappre-
ciation of the true severity of the outbreak.
Further, the perceived distance between other nations and the
United States may have been a contributor to the cognitive errors
made here. The full implications of today’s truly global economy appear
not to have been sufficiently apparent.
One modifiable consequence of this was our failure to produce an
adequate supply of testing kits for SARS-CoV-2 despite the availabil-
ity of the virus’ genomic sequence since January 11, 2020.4 This left
us less able to detect outbreaks in many regions; strict guidelines from
the Centers for Disease Control and Prevention (CDC) early in the out-
break created a high bar for “persons under investigation,” and many
patients who met revised PUI definitions were not initially tested. A
second modifiable action relates to insufficient supplies of personal
protective equipment for health care workers. Although the morbidity
and mortality of this unreadiness are difficult to quantify, we do note
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that for the first time in modern American history, the CDC was com-
pelled to release guidance on recycling of personal protective equip-
ment, including the use of bandanas by health care professionals when
other personal protective equipment was not available.5
2 THE VARYING REPORTS ON THE
CHARACTERISTICS OF THE DISEASE
The true number of cases from China and other early affected coun-
tries is likely far higher than reported. Until recently, asymptomatic
transmission was underappreciated and mild cases were frequently
undocumented.6 First, the overall contagiousness of this disease has
been initially understated.7,8 As a result, the need to enact strict
shelter-in-place strategies, as achieved in China, South Korea, and else-
where, may not have been adequately appreciated as necessary.
Suboptimal testing strategies could have contributed to an underes-
timation of the number of cases, include a failure to account for known
rates of false-negative polymerase chain reaction (PCR) tests for SARS-
CoV-2,9,10 low rates of testing of patients with mild symptoms, and, in
some places, even the underreporting of known cases and deaths by
governments.11
Second, the higher calculated case fatality rates cited by the World
Health Organization early in the outbreak may have contributed to a
sense that a disease with a high case fatality rate might behave more
like MERS and SARS, which were geographically contained, and less like
pathogens with lower case fatality rates that may seem more “realistic.”
For example, the previous SARS and Ebola outbreaks had case fatality
rates (CFRs) of 9.6% and between 25% and 90%, respectively.12,13 It
appears that the worse the disease, the less Americans believe it will
affect them. This error, known as normalcy bias, dictates that “because
it has not happened here before, it cannot happen now.”
Moreover, improper comparisons to seasonal influenza may have
contributed to an undue sense of safety. Some used lower CFR esti-
mates of COVID-19 seen in some areas (under 1%), to justify com-
parisons between the seasonal flu (a relatively known pathogen), with
SARS-CoV-2 (an unknown one). Although the true CFR of SARS-CoV-2
is likely to be lower than initial reports, that fact should not have been
used by public officials to make unwise and inappropriate comparisons.
JACEP Open 2020;1:686–688.
LETTER TO THE EDITOR
3 THE PRESUMPTION THAT ONLY THE
ELDERLY AND PATIENTS WITH COMORBIDITIES
ARE AT RISK
Elderly patients and those with underlying comorbidities and SARS-
CoV-2 in China were reported to have a higher fatality rate (14.8% in
those 80 years or older) than the younger population (0.6% fatality in
patients under 60 years old).14 In the United States, this observation
may have led younger persons to feel protected, as seen by the pub-
lic gatherings even after officials warned against it.15 Although such
risks assessments are up to the individuals, again we reemphasize that
the rate of asymptomatic spread was underappreciated. Therefore, the
spread from the young and healthy to the old and otherwise vulner-
able may have occurred and contributed to morbidity and mortality,
especially within health care facilities.16 In addition, if we compare this
lower fatality rate in patients under 60, it would still be multiple mag-
nitudes higher than that for the seasonal influenza.17 Thus, the notion
that COVID-19 is a disease of the elderly is also false.
4 FEAR OF ECONOMIC CONSEQUENCES
The fear of the economic impact of a panic caused by a communicable
disease epidemic may have slowed lawmakers and government officials
to respond to the emergence of the COVID-19 threat. Such an impact
was seen earlier in the Asian economic markets because of COVID-
19.18 Perhaps in an effort to contain this fear to prevent similar impact
on the US economy, appropriate information on how to prepare for the
eventual epidemic in the United States was not disseminated to the
public, businesses, and industries. In hindsight, it is all too easy for us
to conclude that any and all aggressive proactive measures required to
contain the outbreak and eventual spread of the disease in the United
States would have been less costly.
5 CONCLUSION
An unusual synergy of viral characteristics (contagiousness, asymp-
tomatic transmission, varying fatality rates, variable time between
infection and contagion) and geopolitical beliefs (the false assump-
tion that the current outbreak would behave like previous well-known
ones) has led to multiple catastrophic drawbacks in the United States’
response to SARS-CoV-2/COVID-19.
Although the uncertainties during a pandemic response always
render “perfect responses” impossible to achieve, there is much to
be learned from the current experience. In the future, most robust
international cooperation on surveillance in particular, especially the
early sharing of data, will likely prove beneficial. In addition, early
and vigorous testing strategies are likely to significantly aid in the
development of proportionate responses in future outbreaks. On the
other hand, future outbreaks are also likely to incite panic sooner
than in the past, stemming from understandable fears of “the next
687
COVID-19.” Governmental officials, international organizations, and
other key experts will have to balance such competing concerns so that
robust early responses are enacted, while preventing global economies
from prematurely grinding to a halt at the first sign of trouble. There
will be another highly contagious respiratory illness in the future. The
question of when it is going to happen is difficult to answer, but we
now know that it is going to happen. We need to rethink our strategies
for production and supply of protective equipment, ventilators, and
medical supplies, and early contact tracing and isolation.19 We could
increase the size of the supplies in the national stockpile considerably
and accommodate for a future pandemic at this scale. We also need
to have strategies in place for the potential rapid production of essen-
tial medical supplies and personal protective equipment inside the
country, in case we lose our chain of supply in similar circumstances.
Armin Nowroozpoor MD1
Esther K. Choo MD, MPH2
Jeremy S. Faust MD, MS3
1 Department of Emergency Medicine, Yale School of Medicine, New Haven,
Connecticut, USA
2 Center for Policy and Research in Emergency Medicine, Department of
Emergency Medicine, Oregon Health and Science University, Portland,
Oregon, USA
3 Department of Emergency Medicine, Division of Health Policy and Public
Policy, Brigham and Women’s Hospital, Harvard Medical School, Boston,
Massachusetts, USA
Correspondence
Armin Nowroozpoor, MD, Postdoctoral Fellow, Dept. of Emergency
Medicine, Yale University School of Medicine, 464 Congress Avenue,
Suite 260, New Haven, CT 06519-1362, USA.
Email: armin.nowroozpoordailami@yale.edu
ORCID
Armin Nowroozpoor MD https://orcid.org/0000-0002-7646-4966
Esther K. Choo MD, MPH https://orcid.org/0000-0001-8847-5745
Jeremy S. Faust MD, MS https://orcid.org/0000-0002-8561-1446
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