The islands of Qinghai Lake, more than 10,000 feet above sea level in north-western China, are well known to people who study pandemics. Each year they provide a resting point for hundreds of thousands of birds as they migrate along the Central Asian and East Asian flyways. Diseases brought here by birds can travel across these great migration routes, which join other flyways to span the globe.
Laurie Garrett had been at the Council on Foreign Relations for less than a year when, in 2005, she was told that a “mutational event” had occurred on Qinghai Lake. A type of avian influenza was infecting bar-headed geese, a species that migrates thousands of kilometres, crossing the Himalayas from the Tibetan plateau to reach as far as southern India.
The disease killing the geese was the H5N1 influenza virus, which had previously been found only in intensively farmed chickens. “The host range of the virus was greatly expanding,” Garrett tells me from her home in New York. “Instead of just being in a handful of species of migratory birds that stayed within the Asia flyway… suddenly, migratory birds that did east-west pathways, across Siberia and into Europe, could carry the virus.”
A pandemic of H5N1 had apocalyptic potential; when the disease was transmitted to humans, it had a mortality rate of around 60 per cent.
A prominent voice in the discussion of public health crises for many years, Garrett has spent decades warning governments about the danger of pandemics. Her first book, The Coming Plague, was published in 1994. In 1996 she won a Pulitzer for her reporting of the Ebola outbreak in Zaire.
After hearing about the spread of H5N1 in 2005, Garrett immediately requested a meeting with a member of George W Bush’s security council. “I started showing him maps and explaining where those birds went – and what this could mean in terms of introducing this super-lethal virus,” she recalls. “We didn’t have enough data to know – was this the big one?”
Security advisors from the CIA, Defense Intelligence Agency and other interests did not prevaricate over Garrett’s warning: “They went straight to the Oval Office.” Bush ordered the creation of a pandemic preparedness plan, the first to be formulated by the US government.
Garrett had seen what a failure to prepare for disaster could mean when, a week after the terrorist attacks of 11 September, 2001, letters containing the deadly anthrax bacteria began arriving at the offices of politicians and media organisations in the US. As agencies competed and interfered with one another’s work, Garrett saw fist-fights between investigators.
“It laid bare all the frailties of this very complicated set of government agencies’ responses, going from city level all the way up to federal government,” she remembers. The plan drawn up by the Bush administration aimed to unpick this mess. “From then on, governments and administrations built on that framework and used it to adapt to new scientific findings.”
The next big test came in 2009 when, less than three months after Barack Obama was inaugurated, H1N9 influenza – or swine flu – began to spread around the world. Among a number of top civil service jobs that had yet to be filled, the new director of the Centers for Disease Control and Prevention (CDC), Tom Frieden, was still waiting to be approved by Congress. “And all of a sudden, here was this flu, which in six months made it everywhere on the planet.”
Swine flu is a very dangerous disease; the 2009 pandemic may have infected as much as 24 per cent of the global populataion, which at that time was around 6.8 billion.
The Centers for Disease Control and Prevention (CDC) estimate that it killed somewhere between 152,000 and 575,000, and unlike most flu strains it was more lethal to the young. Thankfully, for most people it was less dangerous than was first thought. But the new president was “appalled”, Garrett remembers, by the response to the pandemic in the US. “Swine flu really shook him up.”
In the years that followed, the phrase “health security” came into regular use in American government. By 2013, the US had a health security proposal that Garrett describes as “a scheme to train governments in poor countries in how to do surveillance and response to new diseases”, which was necessary as very few countries – “I think it was… eight countries on the planet” – actually complied with the WHO’s regulations on the resources, training and surveillance necessary to monitor outbreaks of infectious diseases. The responsibility for monitoring diseases in other countries was to be shared by the CDC and the US government’s international development agency, USA-ID (equivalent to DIFID in the UK). Domestically, the US engaged in “thinking exercises… training exercises… outbreak training exercises, in almost every hospital in America”. And still, the US was not prepared.
In July of the following year, a 40-year-old American named Patrick Sawyer boarded a plane from Monrovia, the capital of Liberia, to Lagos, Nigeria. Shortly after getting off the plane, Sawyer collapsed and was taken to a nearby hospital, where he was diagnosed with ebola. He died four days later. The Obama administration, Garrett recalls, “watched in shock… we’d never before seen Ebola in more than one country at a time, we’d never before seen it at international airports, and we’d never run the risk that it would get to some huge hub”. The Lagos metropolitan area is home to 21 million people.
The US, having dedicated years to pandemic preparedness, joined other countries in pressuring the WHO to declare a public health emergency, which it eventually did in August 2014, nine months after the first case was discovered. As soon as this happened, Tom Frieden travelled to Liberia. “He came back and went straight to the White House with his hair on fire. Just completely freaked out, said this is going to be this enormous, catastrophic event.”
At the beginning of September 2014, Garrett was asked to brief the Joint Chiefs of Staff, the board that advises the President on security and defence, on how the US military could help on the ground in the countries worst affected by Ebola – Liberia, Sierra Leone and Guinea. This was an idea “unprecedented in US history; we’d never mobilised US military for a medical response like that before”.
And still, what Garrett saw on the ground in West Africa was “a lot of jockeying for power and money… a lot of competition between agencies, not just between US agencies but between UN agencies, NGOs, and on and on. It was really chaos at first.” Again, the administration moved to clarify the chains of command, to work effectively with other agencies and governments, to avoid confusion. When a case did make its way to a hospital in Dallas, Texas, a co-ordinated domestic response meant that “it went no further than that, largely because they mobilised swiftly and responded correctly”.
All the same, the 2014 Ebola outbreak was another shock. It alerted the US to the urgent need for a health security infrastructure that extended far beyond its own borders. By 2016, America had co-ordinated“an all-of-government response” to the next epidemic, in the knowledge that “if it hit America, every agency would be taxed, from US Treasury Department to Commerce to USDA. It wouldn’t just be the health agencies”.
Garrett briefly sums up the infrastructure created to provide this response as “special elite corps inside of the National Security Council, the Department of Homeland Security, Health and Human Services and CDC, amongst others… an emergency capacity for surge drug approval at FDA… a lot of co-ordination with the states… a whole division that was doing nothing but training hospitals in infection control and appropriate epidemic responses… and a lot of study on how to surge hospital beds, how to surge physicians out of retirement, and so on.”
No country, least of all a vast land mass with 149 international airports, can ever be fully prepared for a pandemic – but in 2016, the US was, domestically and internationally, more prepared than it had ever been.
On 8 May 2018, Donald Trump signed Rescission Proposal R18-1, asking the US government to take back $15bn in spending. At the time, coverage of these cuts focussed on the $7bn that would be taken from the Children’s Health Insurance Program. But the 38-page proposal details a swathe of other cuts. Among these was the removal of the remaining $252m budget for International Disaster Assistance that had been committed in 2015 as part of the Ebola response, and the State Department’s $30m Complex Crises Fund. The CDC, in response to previous funding cuts, had already reduced its pandemic preparedness activity in 39 countries. On the day R18-1 was signed, the WHO announced a new outbreak of Ebola in the Democratic Republic of Congo.
Two days later the newly appointed National Security Advisor, John Bolton, dissolved the Global Health Security team within the NSC. Timothy Ziemer, the most senior White House official in charge of responses to pandemics or bioterrorism, left that day and was not replaced.
The issue with these programmes was not that they were expensive – the $282m saved on pandemic preparedness by R18-1 represents less than 0.007 per cent of US government spending in 2018 – but that they were connected to the health security agenda, which had been an Obama project.
Donald Trump owes his political career to his predecessor. Having previously failed to gain any momentum as a politician, in 2008 Trump became the most prominent member of the “birther” movement, a loose network of pundits dedicated to circulating the racist conspiracy theory that Barack Obama was not African-American but African. The fringe issue of Obama’s provenance allowed Trump to become a constant presence on social media, and to grow in stature among those in the Republican Party who shared that view. Perhaps for this reason, almost the only stable theme in Donald Trump’s policy as President has been his desire to undo the work of Barack Obama.
Whether this is based on a real personal animosity, or the knowledge that it appeals to his base, the removal of America’s ability to protect itself and the wider world from pandemics of infectious disease appears to have been driven by this impulse. “It was really,” says Garrett, “just about getting rid of things that had Obama’s name on them.”
The Trump administration is not solely to blame. Successive administrations have failed to regulate the consolidation of the pharmaceutical industry, which Garrett says has all but disregarded “curative medicine” such as vaccines and the treatment of infectious disease in favour of longer-term therapies with greater market potential. “We had warning in the form of SARS in 2003 and MERS in 2013, signalling to us there is this whole family of viruses called coronaviruses, that we haven’t been taking seriously… we had the warnings, but we don’t have vaccines for either of those. We don’t have effective treatments for either of those.”
The damage done by America’s failure to prepare for or even acknowledge the threat of Covid-19 is only beginning to become apparent. Last week, the US had conducted fewer than 350 tests per million people. On Saturday night, Laurie Garrett recorded the sound of sirens from her home in New York. “The last time I heard this many ambulance sirens piercing the NYC night was 9/11,” she wrote.
On Sunday, the governor of Louisiana announced a statewide stay-at-home order following the publication of statistics that showed the state to have the fastest growth of Covid-19 cases of any state or country. America is waking up to a disaster which it has forfeited the capability to address, and the impacts of this decision will be felt around the world for many years to come.