America has one of the world's worst coronavirus responses
The U.S. is doing everything wrong. Taiwan is doing everything right.
The world is gripped by the coronavirus pandemic. At time of writing there were about 225,000 confirmed cases in total, and 9,300 deaths. Europe is for the moment the epicenter of the outbreak, particularly in Italy where the virus has overwhelmed the health care system, but dozens of other countries are only a week or two behind on a similar track, including the United States.
However, there are major divergences between the performance of different countries. Rich and middle-income East Asian countries like Taiwan, Vietnam, and Singapore have managed to nearly halt the outbreak in its tracks, while more ramshackle countries like the U.S. and U.K. have botched it almost beyond belief.
While it is obviously too early to conduct a full accounting of what works and what doesn't, some broad lessons about best practices are still apparent. America will need to learn these lessons quickly if it wants to save itself from potentially horrifying outcomes, both now and in future pandemics.
It's fair to say there are three broad levels to any pandemic response, each built on top of the other. The foundation is the national health care system, which provides the necessary broad access to testing and treatment. The second is the state's administrative bureaucracy and welfare state, which coordinates additional response measures. That means stuff like setting up mass testing checkpoints at border crossings and around the country, securing stockpiles of necessary medical supplies, constructing emergency hospitals, and so on. It also means deploying income support to individuals and businesses should mass lockdowns or quarantines become necessary, to keep people from being ruined financially and the economy ticking over. The third is citizen awareness: The population must be ready to upgrade their hygiene habits, accept drastic restrictions on movement, and avoid gathering together, so transmission is limited.
Of all these, mass testing deserves special emphasis, because without it any emergency response is all but hamstrung. A nation cannot fight an epidemic without knowing where the disease actually is.
The best-performing countries, however, excelled on all three levels. Taiwan has a Medicare-style single-payer system (indeed, it was actually based initially on America's Medicare system, except made universal), which allowed them to deploy testing, treatment, and quarantine without any fuss. They also had pandemic response plans drawn up after the SARS outbreak in 2002, which had been regularly reviewed and practiced. Finally, their citizens had been educated and prepared to take any epidemic seriously, so that people did not try to escape lockdowns and spread the disease further.
Even middle-income countries can manage this. Vietnam, whose per-capita GDP was only about $6,600 in 2018 (or about 12 percent as much as the U.S.), squelched its initial epidemic with a lightning-fast deployment of mass testing, contact-tracking, quarantine, and public education measures (though it has since been dealing with new infections from foreign travelers). If the state is on top of the situation, mass lockdowns and the associated economic devastation can be limited or avoided.
European countries were considerably behind the curve. Most have good enough or better medical systems, but their bureaucracies were caught flat-footed on the response. Italy has a world-class health care system, and the state actually moved quite quickly to put through testing, lockdown, and quarantine measures, but it simply wasn't fast enough to halt the outbreak. Worse, Italian citizens initially did not take the crisis seriously enough. Many resisted social distancing advisories and continued going out to public gatherings when the epidemic was in its early stages — encouraged by mixed messages from some authorities. Notice of a mass lockdown in northern Italy leaked before it could be implemented, and thousands fled to the south, where they spread the disease. And once an outbreak has gotten out of hand, even the best health care system in the world will be overwhelmed, because none are prepared to treat such gigantic surges of critically ill patients.
Still, Italy is now working to the absolute utmost to fight the crisis, and appears to have slowed the growth of new cases. Other European countries, belatedly jolted into action by the Italian example, are taking drastic steps to limit disease transmission, build up their testing and treatment capacity, and keep their populations protected in the meantime. Here the famously generous European welfare states come in handy — countries like Denmark and Norway already have generous sick leave so infected people do not have to come to work, plus unemployment benefits to catch people who lose their job, and so on. These countries were also quick to pass business support measures to limit layoffs and prevent bankruptcies until the crisis passes.
The United States, by contrast, has faceplanted on every single aspect of the response. Our health care system is a bitter joke by Taiwanese or Italian standards. We do not even have universal coverage, and what coverage we have is a usurious, fragmented, Kafkaesque nightmare that routinely bankrupts people who get sick. President Trump's direct response has also been horrifically bungled. We still do not have enough tests at least two months after we should have had them. He has not secured supplies of vital equipment like masks and ventilators, and hospitals are already running short. He did not even start activating the Army Corps of Engineers until a couple days ago. Hospital ships that Trump boasted were on their way turned out to be docked for maintenance and will take days to get moving. An economic support measure (which contains some emergency paid leave and unemployment insurance provisions that are worse than what most European countries have in normal times) is bogged down in Congress.
Perhaps worst of all, Trump, Republican politicians, and right-wing media consistently downplayed the epidemic for weeks as it gathered strength. As the virus quietly spread through the population, Trump was still claiming "The coronavirus is very much under control in the USA," and conservative media was claiming it was no worse than the flu. Just in the last few days, Republican hack propagandists like Sean Hannity have pivoted on a dime from "I see it, again, as like, let's bludgeon Trump with this new hoax," to "this program has always taken the coronavirus seriously. We've never called the virus a hoax." The result is a persistent partisan split in how likely Americans are to understand the threat posed by the outbreak.
At any rate, this all suggests the sketch of a broad policy agenda to fix this outbreak and head off future ones. First, the wretched American health care system needs to be sharply augmented on an emergency basis and eventually replaced with something that actually works, like Medicare-for-all. Second, the federal government is in shambles and needs a total overhaul. To start with, we should copy Taiwan's pandemic systems so that response teams and supplies are always ready to go on a moment's notice. More broadly, state capacity, which has been gutted by decades of conservative austerity, anti-science, and anti-expertise dogmatism, must be rebuilt across the board. Conservatives have insisted for decades that the government is all but useless, and today we are all paying the price. Third, Trump should be turfed out of office and the conservative movement should be comprehensively defeated politically. It turns out there are some serious downsides to having a narcissistic reality TV host in charge of the country.
I have little hope that very much of this will come to pass. But in a crisis, sometimes what seemed impossible can happen very quickly. Let's hope somebody is trying to learn the lessons Taiwan and other Asian democracies are teaching us.
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