We’re now 6 months or 9 months into the Covid-19 pandemic, depending on whether you count from the recognition of the first cases in China in January or the decision to begin locking down the United States in March. More than 200,000 Americans have died—nearly 25 percent of the deaths worldwide—and almost 7 million others have either tested positive or fallen ill and recovered.
In that time, parts of the US health establishment have published guidelines for how to prevent the disease and treat it, along with some documents—though not many—about how the White House has been tracking the illness. But one thing is still missing from the US coronavirus response: a comprehensive national strategy for how to combat Covid-19.
This is unusual. In the past, the US government has produced thorough plans for handling epidemics, both for outbreaks we were already in the middle of and for ones we could envision arriving, such as pandemic flu. Now a group of HIV researchers, impatient with the delay, has proposed taking one of those plans, the National HIV/AIDS Strategy, as the basis of a comprehensive Covid-19 response, one that would define what it means to beat back this disease, and set out the steps to get there.
It’s an innovative idea, and public health people not involved in this specific proposal agree a plan is desperately needed. But no one, including the proposers, can figure out how to counter a critical flaw: the Trump White House’s refusal to engage with the things that are needed to end the pandemic. It’s hard to figure out how to have a national plan if the leadership of the nation it addresses declines to take a role.
“Given the severity of the epidemic, we thought there's a real need for a truly comprehensive plan as urgently as possible,” says David Holtgrave, dean of the public health school at the University at Albany, State University of New York, who was the first author on the proposal (published in the journal AIDS and Behavior). “We felt that where we are now is similar in circumstance to HIV: Before the national strategy was written, different federal agencies had handled elements of a plan, but nothing had pulled them together. It's bringing it all together in one comprehensive place that we're calling for.”
The earliest US cases of HIV were recorded in 1981, but it took until 2010 for the then-new Obama administration to write a strategy for countering the disease. By that point, the virus had already been identified (in 1984), the first versions of the drug cocktails that kept AIDS from being rapidly fatal had been announced (in 1996), and the Food and Drug Administration had approved the first rapid diagnostic test for the virus (in 2002).
But before 2010, no entity had set goals for what HIV testing and treatment of infections were intended to achieve. The innovation in the original national strategy (it was updated in 2015) was to set numeric targets, such as lowering new infections by 25 percent, raising the number of people getting into care within three months of diagnosis to 85 percent, and setting specific objectives for HIV treatment among members of marginalized groups. Then, starting from those goals, the plan’s authors worked backward to specify the steps that federal agencies, state and urban governments, and nongovernmental organizations would have to take to meet them. It also, touchingly, started with a statement of intent: “The United States will become a place where new HIV infections are rare.”
That could not be more different than the current situation with Covid-19—which, if trends don’t change, will be the third-leading cause of death in the US by the end of the year, behind only heart disease and cancer. Though the federal government is putting effort behind vaccine development with Operation Warp Speed, there is still no comprehensive top-down public health response, no agreed-upon steps to get us out of this, and no targets that would help us judge how well we are doing.
There isn’t even a list of things to avoid because they will make the pandemic worse—which is why, for instance, Florida governor Ron DeSantis could announce Friday that he is fully opening his state’s economy, despite the likelihood that cases will increase. “Unbelievable. This is precisely why we need a nationally coordinated Covid-19 response,” Steffanie Strathdee, a longtime HIV epidemiologist and associate dean of global health at the University of California San Diego School of Medicine, responded in exasperation on Twitter.
She followed up in an email to WIRED: “When the US developed a bipartisan national AIDS strategy, policymakers put their differences aside and realized that we should be fighting the virus instead of each other,” she wrote. “We're now facing another pandemic that has already infected more than 7 million Americans, and yet we have no national coordinated plan. As a result, states are left to make policy decisions in a vacuum, and it is costing us thousands of lives."
To date, the closest the US has come to a national plan is one proposed in July by Peter Hotez, a pediatric infectious disease physician and vaccine researcher who is founding dean of the National School of Tropical Medicine at Baylor College of Medicine. His “October Plan” set containment benchmarks, adjusted to local conditions, that would force cases to low enough numbers that contact tracing could become feasible—and which would allow schools and economies to reopen safely by October 1.
It was not adopted.
“The fact that we haven't had a national strategy is a major reason why we've been the epicenter of the pandemic for most of 2020,” Hotez says. “And there's no end in sight. Now we have 200,000 deaths. We'll be at 300,000 deaths by the end of the year. We could be at 400,000 deaths by the time of the inauguration.”
Only a top-down national strategy, flexibly administered from within the federal government, can adjust to the variability of the pandemic across the country, he says. That encompasses not just responding to current caseloads, but parcelling out vaccines in response to local epidemics in the near future. “The White House basically left Covid response to the states, and we've already seen leaving it to the states doesn't work,” he points out. ‘They don’t have the epidemiologic horsepower to know how to do this—and also, they don’t have the political cover” that a federally created plan could give them.
To be fair, some states have tried to work together for good. Witness the banding together of three Western states and six Northeastern states in the spring in separate joint agreements over data-sharing and purchasing supplies, or the compact announced earlier this month in which 10 states will collectively buy new rapid Covid tests. All of those actions were proactive and, simultaneously, desperate. They addressed issues that a federal plan might have provided for—except the feds are absent.
There are questions circulating among public health experts over whether the national HIV strategy is the right model for responding to Covid-19. The two are, after all, very different diseases, with different modes of infection and progression of illness. What they have in common is their size—in 2018, the last year tabulated, 770,000 people around the world died as a result of AIDS. And as with HIV/AIDS, Covid-19 overwhelmingly affects minorities and other marginalized groups.
But if HIV is not the right model, other existing national plans could be drawn upon. There is also the National Strategy for Combating Antibiotic-Resistant Bacteria, written by staffers in the Obama White House in 2014 (and largely abandoned after the Trump administration took office), and the National Pandemic Influenza Strategy, first drafted in 2005 by personnel in the Department of Homeland Security under the George W. Bush White House, after H5N1 avian flu began to spread around the globe. (It was updated in 2009 and 2017.)
The procedures that would be necessary to block pandemic flu, such as rapidly achieving and equitably distributing a vaccine, might be a closer fit for Covid-19. To Tom Frieden, the former director of the Centers for Disease Control and Prevention—whose nonprofit Resolve to Save Lives has tried to develop a civilian version of a plan, offering 15 numeric indicators for controlling Covid-19—the most important issue for a national plan is to develop one as fast as possible.
“What's really striking about the US situation is that there has been a just stunning absence of applying basic principles of how we deal with health emergencies, ranging from incident management to a clear line of command to strategic goals,” he says. “It’s never too late for the response to do better.”
The problem is, how? To this point, every comprehensive national plan for a disease has emerged from the government and been overseen by it. The Trump administration has stepped up to do neither.
Holtgrave, the lead author of the proposal to use the HIV strategy, said he and his fellow framers are trying to recruit support. “It’s better if this is done by the federal government,” he says. “But if it’s not done by the government, perhaps it could be done under the auspices of the National Academy of Medicine. Another possibility could be having a coalition of organizations come together. Or perhaps a major foundation that’s very interested in public health.”
But getting foundation support could be tricky, since taking on an effort that the Trump administration has neglected could be interpreted as opposition or disrespect. As one indicator of how dicey it might be, a spokesperson from one foundation, asked if the organization would take on something like this, asked to stay off the record, and then expressed concerns about appearing to take a political stand close to the election.
To be clear, nonprofits and academic groups have tried to fill the power vacuum. Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security, helped draft a “road map to reopening” put forth in March by the American Enterprise Institute that set out tiered guidance for suppressing cases and opening schools and commerce. Since then, there have been many such proposals, from researchers and organizations. But none of them, she points out, can summon the force that a government initiative would automatically wield. “The drawback is that it’s all dependent on buy-in,” she says. “With the federal government, it’s policy.”
This is the hole at the heart of the US response to Covid-19. Past plans show that a response is possible—but only the force of the federal government can make the implementation of a plan succeed. Without that power, a plan can be written. It can even, as with the state compacts, be implemented. But it will not take care of the entire population, which is the federal government’s job.
“The question we’re really asking is: Can you run a country without the executive branch of the federal government?” Hotez asks. “I don't know. We've never tried that before. But it may be we’re going to find out.”