America Is Not Set Up For This

By the last week of January, Rob DeLeo knew it was going to get bad.

“I was having breakfast with my partner and I said, ‘We should get some extra food because we’re going to be inside for awhile,’” said DeLeo, a Bentley University professor who has been studying America’s political response to pandemics for more than 15 years.

Over the next two weeks, as he began preparing for a lengthy period of self-isolation, he was struck how calm political leaders seemed to be. The coronavirus was never mentioned at the Democratic presidential debate on Feb. 7. Even as cases appeared in major cities and the Centers for Disease Control and Prevention announced that person-to-person transmission was underway, no one seemed interested in warning Americans to get ready for a lockdown.

DeLeo later searched the congressional record and found just six mentions of the word “coronavirus” before Feb. 8.

“I’m a political scientist, not an epidemiologist,” said DeLeo. “If I was freaking out, why wasn’t anyone else?”

Warnings of a global flu pandemic have been appearing in academic papers, government documents, magazine articles and TED Talks for over two decades. A 2015 study estimated that an influenza outbreak could kill up to 300,000 Americans. Last October, the Center for Strategic and International Studies convened a panel of 20 global health experts to run a disaster-preparedness scenario and give advice to policymakers. The catastrophe they chose was a novel strain of coronavirus.

And yet, despite these warnings — not to mention real-life influenza outbreaks in 2009, 2013 and 2017 — the gaps in America’s pandemic response have never been filled. In 2015, researchers found just 56,300 ventilators ready to be deployed in a respiratory disease outbreak. In February, the Government Accountability Office noted that America’s strategy for tackling biological threats included ”no clear processes, roles, or responsibilities” for data gathering or decision making.

“This has been painfully predictable for so long,” DeLeo said. “But still, even I’ve been surprised at how poor the response has been.”

America’s political institutions had all the information they needed to avert disaster. So why didn’t they?

Preparing For the Previous Disaster

The best thinking about disasters, said Davia Downey, a public administration professor at Grand Valley State University, happens only after they’ve ended.

“We’re always looking backward at where the holes are,” said Downey, who has been researching American disaster response for over a decade. “That’s understandable, but over time you lose the ability to respond to events that aren’t like something you’ve seen before.”

Nearly every development in the history of America’s disaster-preparedness tracks this insight. When it was first established in 1999, the Strategic National Stockpile, a store of essential supplies and medications, was an afterthought. The obscure program (then known as the National Pharmaceutical Stockpile) was reportedly created because then-President Bill Clinton read a popular novel about a chemical attack on New York City.

The book turned out to be eerily prescient. After the terror attacks of Sept. 11, the program deployed over 50 tons of medical supplies within hours. Just over a year later, the stockpile delivered post-exposure prophylaxis to hundreds of postal workers who had been exposed to anthrax.

Those early successes set the template for growth. By 2019, the Strategic National Stockpile’s budget had grown from its initial outlay of $50 million to $7 billion. Since 2002, administrators have used the stockpile to deploy emergency medications and equipment in 60 national disasters, including hurricanes Katrina, Sandy and Harvey; flooding in North Dakota; and the 2009 H1N1 influenza outbreak. The stockpile now includes 900 types of pharmaceuticals — from generic antivirals to nerve agent antidotes — as well as 134,000 pallets of equipment and 13,570 portable beds.

Though their specific locations are confidential, the stockpile is stored in shipping containers in regional offices across the country. CHEMPACK, the part of the stockpile designed to respond to chemical attacks, is stored in so many facilities that 90% of the American population lives within one hour of a facility from which they can acquire a dose. The Department of Health and Human services swaps out all the pharmaceuticals within one year of their expiration date, for resale and replacement.

But even as it has expanded in size and sophistication, America’s disaster response system has retained its original focus on chemical weapons and biological attacks. In the early 2000s, DeLeo said, administrators primarily focused on the kinds of highly fatal diseases that would be useful to terrorists. The stockpile included, for example, treatments for the black plague and enough smallpox vaccine to immunize every single American. Diseases with lower fatality rates but higher chances of outbreaks were largely overlooked.

“The concern was a weaponized virus when there were emerging diseases that posed more of a threat,” DeLeo said. “There was a lot of concern in public health that homeland security had co-opted viable public health research.”

Patrick Roberts, a Rand Corporation researcher and the author of “Disasters and the American State,” pointed out that America’s disaster response infrastructure has always conceived of disasters as local, short-term events.

“Our systems were designed to respond to a single disaster in a single place,” Roberts said. “But public health threats are very different from natural disasters and terror attacks. What we’re experiencing now is much closer to a civil defense threat, something the entire country has to be prepared for at once.”

COVID-19 is affecting every state at once, and for months on end. Its global spread has choked supply lines for protective equipment and medications. Even if the federal government could send 50 tons of supplies to every city in the country, that would only offer temporary relief.

“Most disasters we’ve confronted in our lifetimes are short-duration events,” DeLeo said. “The disaster happens, a part of our life gets washed away and then we have time to rebuild. COVID-19 is a long-term event with accumulating consequences. We’ve never had to deal with anything like that before.”

Who Does What, Exactly?

Disasters have reached a scale and frequency never before seen in U.S. history. The number of state and local disaster declarations has roughly tripled since the late 1990s. Between 1980 and 2018, disasters costing more than $1 billion have risen from six per year to 13 per year. Most of these are natural disasters like storms, floods, fires.

But it’s not just the number and size of disasters that explains America’s sluggish response to the coronavirus. It is their increasing complexity.

Federal disaster relief is split between 17 agencies and 300 programs. The response to Superstorm Sandy in 2012 — to pick just one recent emergency — involved 12 states, dozens of cities, and hundreds of local utilities, transportation authorities and government offices. Each of those bodies is responsible for getting its own share of relief.

“There’s this myth that the [Centers for Disease Control and Prevention] just magically rides in on a white horse, but most of the responsibility actually goes down to local jurisdictions,” DeLeo said.

America’s emergency management system was not designed to handle disasters on its own. It is first and foremost a resource for states. To get relief, governors have to issue an emergency declaration within strictly defined legal limits. Within 12 hours, they should receive a ”push package” — a caravan of roughly 100 specialized shipping containers filled with medical supplies.

After that comes “managed inventory,” a steady trickle of equipment, staff and pharmaceuticals targeted to each state’s needs. In some cases, the Department of Health and Human Services can also send a Federal Medical Station, a MASH-style compound of portable tents capable of treating up to 250 patients.

All of these activities depend on well-greased coordination between federal, state and local officials. To be eligible for relief from the Federal Emergency Management Agency, counties have to document that they sustained damage of at least $3.68 per person. Federal administrators require states to spend 25% of their own funds to get relief grants. All of these bureaucratic hurdles cost local officials precious time and resources when they have the least to spare.

“There’s this huge concern about waste, fraud and abuse, which leads agencies to micromanage for people getting too much help rather than getting no help at all,” said Sarah Labowitz, a former administrator for Hurricane Harvey relief in Houston. Before the floodwaters had fully receded, she was already locked in bureaucratic combat with other government bodies.

“First we engaged in a months-long battle about whether the city or the state should administer the money,” she said. “Then, we fought with federal and state agencies about obscure questions like whether we were allowed to rebuild a three-bedroom home for a single person. The amount of time we spent in administrative fights where no oversight agency would take a definitive stand was unbelievable.”

This bureaucratic labyrinth is particularly ill-suited to a pandemic, which affects all levels of government and nearly every administrative agency all at once. Political officials who want to move quickly may find themselves tangled in a briar patch of permissions and legal barriers.

As an example, Downey noted that many American airports are administered as their own jurisdictions. That means that even if they wanted to, governors may not be able to restrict air travel into and out of their states without an FAA declaration.

“Bureaucracy has its benefits because we get predictability,” she said, “but in the middle of natural disaster it means you end up spending a lot of time just figuring out who’s in charge.”

Less Money, More Problems

Despite years of warnings and dozens of critical reports, politicians have never had a reason to fix the problems in America’s disaster preparedness systems.

The problem, DeLeo said, is that preparing for disasters doesn’t have a built-in political constituency. Unlike cutting taxes or preserving national parks, stockpiling equipment for pandemics doesn’t have a group of vocal supporters.

Politicians who make investments in disaster preparedness barely see a bump in their vote share. Mayors and governors who manage disasters poorly do see a decline in their popularity, but the effect is small and short-lived.

It makes more sense, DeLeo said, for politicians to allow disasters to happen and then deliver huge federal relief funds to their districts.

“We have this perverse electoral incentive structure,” DeLeo said. “You get rewarded for distributing relief, but not for preventing disasters.”

And yet preparing for hurricanes, earthquakes and pandemics is one of the best investments cities can make. According to a 2017 study, every dollar spent preparing for catastrophe saves roughly $6 in relief. Up to 80% of the damage caused by Hurricane Katrina, for example, could have been prevented with stricter building codes.

But America still spends orders of magnitude more on post-disaster relief than pre-disaster preparedness. Between 2011 and 2014, the federal government spent $3.2 billion fixing damage from disasters and just $222 million preparing for them. In 2016, FEMA had just $100 million set aside for major disasters — less than one-tenth the cost of just the first month of Hurricane Sandy relief.

“There’s not much fat left to trim,” W. Craig Fugate, a former FEMA administrator, told a congressional hearing in 2009.

The situation is even worse at the state level. In 2018, Pew attempted to survey states on their disaster preparedness spending. Only 23 states answered the survey. Of those that did, just eight could provide detailed accounting. None had spent more than $11 million of their own funds over a five-year period.

“We track every single Medicaid dollar in this country,” DeLeo said. “We know it a year ahead of time. But most states can’t even tell you what they’re spending on disaster preparedness, much less whether it’s adequate. It’s such a tertiary issue.”

And that’s disaster preparedness in general. Pandemic preparedness is even harder to track due to its intersection with America’s for-profit health care system. As market competitors, hospitals have little reason to collaborate on stockpiles or staff training. Due to the lack of centralized data, federal officials don’t know which clinics have which equipment. In 2015, researchers warned that no centralized body had a clear idea of how many ventilators the U.S. had or how they could be deployed in an emergency.

All of this fragmentation has resulted in a system with significant inequalities in the equipment, staff and training necessary to tackle a pandemic.

“Some counties have robust public health departments, while others have no health department at all and may rely on neighboring counties,” Roberts said. “Someone called me the other day and said, ‘I’m in a fire department and I’m being asked to write our social distancing plan. I need help.’”

All of these problems have been clear for years, according to Roberts.

“We’ve always had the same unresolved questions,” he said. “I remember working on Ebola [in 2014] and thinking, ‘Something like this is going to happen again and it’s going to be even worse.’”