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bloated, inefficient health-care system

Racist policies that have endured since the days of colonization and slavery left Indigenous and Black Americans especially vulnerable

decades-long process of shredding the nation’s social safety net

same social-media platforms that sowed partisanship and misinformation during the 2014 Ebola outbreak in Africa and the 2016 U.S. election became vectors for conspiracy theories

the COVID‑19 debacle has also touched—and implicated—nearly every other facet of American society: its shortsighted leadership, its disregard for expertise, its racial inequities, its social-media culture, and its fealty to a dangerous strain of individualism.

SARS‑CoV‑2 is neither as lethal as some other coronaviruses, such as SARS and MERS, nor as contagious as measles. Deadlier pathogens almost certainly exist. Wild animals harbor an estimated 40,000 unknown viruses, a quarter of which could potentially jump into humans. How will the U.S. fare when “we can’t even deal with a starter pandemic?,”

The U.S. cannot prepare for these inevitable crises if it returns to normal, as many of its people ache to do. Normal led to this. Normal was a world ever more prone to a pandemic but ever less ready for one. To avert another catastrophe, the U.S. needs to grapple with all the ways normal failed us

Many conservationists jump on epidemics as opportunities to ban the wildlife trade or the eating of “bush meat,” an exoticized term for “game,” but few diseases have emerged through either route. Carlson said the biggest factors behind spillovers are land-use change and climate change, both of which are hard to control. Our species has relentlessly expanded into previously wild spaces. Through intensive agriculture, habitat destruction, and rising temperatures, we have uprooted the planet’s animals, forcing them into new and narrower ranges that are on our own doorsteps. Humanity has squeezed the world’s wildlife in a crushing grip—and viruses have come bursting out.

This year, the world’s coronavirus experts—and there still aren’t many—had to postpone their triennial conference in the Netherlands because SARS‑CoV‑2 made flying too risky.

In 2003, China covered up the early spread of SARS, allowing the new disease to gain a foothold, and in 2020, history repeated itself. The Chinese government downplayed the possibility that SARS‑CoV‑2 was spreading among humans, and only confirmed as much on January 20, after millions had traveled around the country for the lunar new year. Doctors who tried to raise the alarm were censured and threatened. One, Li Wenliang, later died of COVID‑19. The World Health Organization initially parroted China’s line and did not declare a public-health emergency of international concern until January 30. By then, an estimated 10,000 people in 20 countries had been infected, and the virus was spreading fast.

Even after warnings reached the U.S., they fell on the wrong ears. Since before his election, Trump has cavalierly dismissed expertise and evidence. He filled his administration with inexperienced newcomers, while depicting career civil servants as part of a “deep state.” In 2018, he dismantled an office that had been assembled specifically to prepare for nascent pandemics. American intelligence agencies warned about the coronavirus threat in January, but Trump habitually disregards intelligence briefings. The secretary of health and human services, Alex Azar, offered similar counsel, and was twice ignored.

“By early February, we should have triggered a series of actions, precisely zero of which were taken.”

Travel bans make intuitive sense, because travel obviously enables the spread of a virus. But in practice, travel bans are woefully inefficient at restricting either travel or viruses. They prompt people to seek indirect routes via third-party countries, or to deliberately hide their symptoms. They are often porous: Trump’s included numerous exceptions, and allowed tens of thousands of people to enter from China. Ironically, they create travel: When Trump later announced a ban on flights from continental Europe, a surge of travelers packed America’s airports in a rush to beat the incoming restrictions. Travel bans may sometimes work for remote island nations, but in general they can only delay the spread of an epidemic—not stop it.

countries “rely on bans to the exclusion of the things they actually need to do—testing, tracing, building up the health system,”

genetic evidence shows that the specific viruses that triggered the first big outbreaks, in Washington State, didn’t land until mid-February. The country could have used that time to prepare. Instead, Trump, who had spent his entire presidency learning that he could say whatever he wanted without consequence, assured Americans that “the coronavirus is very much under control,” and “like a miracle, it will disappear.” With impunity, Trump lied. With impunity, the virus spread.

it found a nation through which it could spread easily, without being detected

sluggish response by a government denuded of expertise

In response to the global energy crisis of the 1970s, architects made structures more energy-efficient by sealing them off from outdoor air, reducing ventilation rates. Pollutants and pathogens built up indoors, “ushering in the era of ‘sick buildings,’ ” says Joseph Allen, who studies environmental health at Harvard’s T. H. Chan School of Public Health. Energy efficiency is a pillar of modern climate policy, but there are ways to achieve it without sacrificing well-being. “We lost our way over the years and stopped designing buildings for people,”

As of early July, one in every 1,450 Black Americans had died from COVID‑19—a rate more than twice that of white Americans. That figure is both tragic and wholly expected given the mountain of medical disadvantages that Black people face

The indoor spaces in which Americans spend 87 percent of their time became staging grounds for super-spreading events. One study showed that the odds of catching the virus from an infected person are roughly 19 times higher indoors than in open air. Shielded from the elements and among crowds clustered in prolonged proximity, the coronavirus ran rampant in the conference rooms of a Boston hotel, the cabins of the Diamond Princess cruise ship, and a church hall in Washington State where a choir practiced for just a few hours.

Between harsher punishments doled out in the War on Drugs and a tough-on-crime mindset that prizes retribution over rehabilitation, America’s incarcerated population has swelled sevenfold since the 1970s, to about 2.3 million. The U.S. imprisons five to 18 times more people per capita than other Western democracies. Many American prisons are packed beyond capacity, making social distancing impossible. Soap is often scarce. Inevitably, the coronavirus ran amok. By June, two American prisons each accounted for more cases than all of New Zealand. One, Marion Correctional Institution, in Ohio, had more than 2,000 cases among inmates despite having a capacity of 1,500.

America’s nursing homes and long-term-care facilities house less than 1 percent of its people, but as of mid-June, they accounted for 40 percent of its coronavirus deaths. More than 50,000 residents and staff have died. At least 250,000 more have been infected. These grim figures are a reflection not just of the greater harms that COVID‑19 inflicts upon elderly physiology, but also of the care the elderly receive. Before the pandemic, three in four nursing homes were understaffed, and four in five had recently been cited for failures in infection control. The Trump administration’s policies have exacerbated the problem by reducing the influx of immigrants, who make up a quarter of long-term caregivers.

the Department of Health and Human Services paused nursing-home inspections in March, passing the buck to the states. Some nursing homes avoided the virus because their owners immediately stopped visitations, or paid caregivers to live on-site. But in others, staff stopped working, scared about infecting their charges or becoming infected themselves. In some cases, residents had to be evacuated because no one showed up to care for them.

its problematic attitude toward health: “Get hospitals ready and wait for sick people to show,” as Sheila Davis, the CEO of the nonprofit Partners in Health, puts it. “Especially in the beginning, we catered our entire [COVID‑19] response to the 20 percent of people who required hospitalization, rather than preventing transmission in the community.” The latter is the job of the public-health system, which prevents sickness in populations instead of merely treating it in individuals. That system pairs uneasily with a national temperament that views health as a matter of personal responsibility rather than a collective good.

“As public health did its job, it became a target” of budget cuts,

Today, the U.S. spends just 2.5 percent of its gigantic health-care budget on public health. Underfunded health departments were already struggling to deal with opioid addiction, climbing obesity rates, contaminated water, and easily preventable diseases. Last year saw the most measles cases since 1992. In 2018, the U.S. had 115,000 cases of syphilis and 580,000 cases of gonorrhea—numbers not seen in almost three decades. It has 1.7 million cases of chlamydia, the highest number ever recorded.

In May, Maryland Governor Larry Hogan asserted that his state would soon have enough people to trace 10,000 contacts every day. Last year, as Ebola tore through the Democratic Republic of Congo—a country with a quarter of Maryland’s wealth and an active war zone—local health workers and the WHO traced twice as many people.

Compared with the average wealthy nation, America spends nearly twice as much of its national wealth on health care, about a quarter of which is wasted on inefficient care, unnecessary treatments, and administrative chicanery. The U.S. gets little bang for its exorbitant buck. It has the lowest life-expectancy rate of comparable countries, the highest rates of chronic disease, and the fewest doctors per person. This profit-driven system has scant incentive to invest in spare beds, stockpiled supplies, peacetime drills, and layered contingency plans—the essence of pandemic preparedness. America’s hospitals have been pruned and stretched by market forces to run close to full capacity, with little ability to adapt in a crisis.

Sabeti’s lab developed a diagnostic test in mid-January and sent it to colleagues in Nigeria, Sierra Leone, and Senegal. “We had working diagnostics in those countries well before we did in any U.S. states,”

American hospitals operate on a just-in-time economy. They acquire the goods they need in the moment through labyrinthine supply chains that wrap around the world in tangled lines, from countries with cheap labor to richer nations like the U.S. The lines are invisible until they snap. About half of the world’s face masks, for example, are made in China, some of them in Hubei province. When that region became the pandemic epicenter, the mask supply shriveled just as global demand spiked. The Trump administration turned to a larder of medical supplies called the Strategic National Stockpile, only to find that the 100 million respirators and masks that had been dispersed during the 2009 flu pandemic were never replaced. Just 13 million respirators were left.

The supply of nasopharyngeal swabs that are used in every diagnostic test also ran low, because one of the largest manufacturers is based in Lombardy, Italy—initially the COVID‑19 capital of Europe. About 40 percent of critical-care drugs, including antibiotics and painkillers, became scarce because they depend on manufacturing lines that begin in China and India. Once a vaccine is ready, there might not be enough vials to put it in, because of the long-running global shortage of medical-grade glass—literally, a bottle-neck bottleneck.

As usual, health care was a matter of capitalism and connections. In New York, rich hospitals bought their way out of their protective-equipment shortfall, while neighbors in poorer, more diverse parts of the city rationed their supplies.

A study showed that the U.S. could have averted 36,000 COVID‑19 deaths if leaders had enacted social-distancing measures just a week earlier. But better late than never: By collectively reducing the spread of the virus, America flattened the curve. Ventilators didn’t run out, as they had in parts of Italy. Hospitals had time to add extra beds.

the indiscriminate lockdown was necessary only because America’s leaders wasted months of prep time. Deploying this blunt policy instrument came at enormous cost. Unemployment rose to 14.7 percent, the highest level since record-keeping began, in 1948. More than 26 million people lost their jobs, a catastrophe in a country that—uniquely and absurdly—ties health care to employment

In the middle of the greatest health and economic crises in generations, millions of Americans have found themselves disconnected from medical care and impoverished. They join the millions who have always lived that way.

Elderly people, already pushed to the fringes of society, were treated as acceptable losses. Women were more likely to lose jobs than men, and also shouldered extra burdens of child care and domestic work, while facing rising rates of domestic violence. In half of the states, people with dementia and intellectual disabilities faced policies that threatened to deny them access to lifesaving ventilators. Thousands of people endured months of COVID‑19 symptoms that resembled those of chronic postviral illnesses, only to be told that their devastating symptoms were in their head. Latinos were three times as likely to be infected as white people. Asian Americans faced racist abuse. Far from being a “great equalizer,” the pandemic fell unevenly upon the U.S., taking advantage of injustices that had been brewing throughout the nation’s history.

Of the 3.1 million Americans who still cannot afford health insurance in states where Medicaid has not been expanded, more than half are people of color, and 30 percent are Black.* This is no accident. In the decades after the Civil War, the white leaders of former slave states deliberately withheld health care from Black Americans, apportioning medicine more according to the logic of Jim Crow than Hippocrates. They built hospitals away from Black communities, segregated Black patients into separate wings, and blocked Black students from medical school. In the 20th century, they helped construct America’s system of private, employer-based insurance, which has kept many Black people from receiving adequate medical treatment. They fought every attempt to improve Black people’s access to health care, from the creation of Medicare and Medicaid in the ’60s to the passage of the Affordable Care Act in 2010.

A number of former slave states also have among the lowest investments in public health, the lowest quality of medical care, the highest proportions of Black citizens, and the greatest racial divides in health outcomes

“We’re designed for discrete disasters” like mass shootings, traffic pileups, and hurricanes, says Esther Choo, an emergency physician at Oregon Health and Science University. The COVID‑19 pandemic is not a discrete disaster. It is a 50-state catastrophe that will likely continue at least until a vaccine is ready.

Native Americans were similarly vulnerable. A third of the people in the Navajo Nation can’t easily wash their hands, because they’ve been embroiled in long-running negotiations over the rights to the water on their own lands. Those with water must contend with runoff from uranium mines. Most live in cramped multigenerational homes, far from the few hospitals that service a 17-million-acre reservation. As of mid-May, the Navajo Nation had higher rates of COVID‑19 infections than any U.S. state.

Americans often misperceive historical inequities as personal failures

the largely unregulated, social-media-based communications infrastructure of the 21st century almost ensures that misinformation will proliferate fast. “In every outbreak throughout the existence of social media, from Zika to Ebola, conspiratorial communities immediately spread their content about how it’s all caused by some government or pharmaceutical company or Bill Gates,”

Rumors coursed through online platforms that are designed to keep users engaged, even if that means feeding them content that is polarizing or untrue. In a national crisis, when people need to act in concert, this is calamitous. “The social internet as a system is broken,” DiResta told me, and its faults are readily abused.

Like pandemics, infodemics quickly become uncontrollable unless caught early.

In 2016, when DiResta spoke with a CDC team about the threat of misinformation, “their response was: ‘ That’s interesting, but that’s just stuff that happens on the internet.’ ”

The WHO, the CDC, and the U.S. surgeon general urged people not to wear masks, hoping to preserve the limited stocks for health-care workers. These messages were offered without nuance or acknowledgement of uncertainty, so when they were reversed—the virus is worse than the flu; wear masks—the changes seemed like befuddling flip-flops.

Drawn to novelty, journalists gave oxygen to fringe anti-lockdown protests while most Americans quietly stayed home. They wrote up every incremental scientific claim, even those that hadn’t been verified or peer-reviewed.

By tying career advancement to the publishing of papers, academia already creates incentives for scientists to do attention-grabbing but irreproducible work. The pandemic strengthened those incentives by prompting a rush of panicked research and promising ambitious scientists global attention.

In March, a small and severely flawed French study suggested that the antimalarial drug hydroxychloroquine could treat COVID‑19. Published in a minor journal, it likely would have been ignored a decade ago. But in 2020, it wended its way to Donald Trump via a chain of credulity that included Fox News, Elon Musk, and Dr. Oz. Trump spent months touting the drug as a miracle cure despite mounting evidence to the contrary, causing shortages for people who actually needed it to treat lupus and rheumatoid arthritis. The hydroxychloroquine story was muddied even further by a study published in a top medical journal, The Lancet, that claimed the drug was not effective and was potentially harmful. The paper relied on suspect data from a small analytics company called Surgisphere, and was retracted in June.**

Science famously self-corrects. But during the pandemic, the same urgent pace that has produced valuable knowledge at record speed has also sent sloppy claims around the world before anyone could even raise a skeptical eyebrow.

No one should be shocked that a liar who has made almost 20,000 false or misleading claims during his presidency would lie about whether the U.S. had the pandemic under control; that a racist who gave birth to birtherism would do little to stop a virus that was disproportionately killing Black people; that a xenophobe who presided over the creation of new immigrant-detention centers would order meatpacking plants with a substantial immigrant workforce to remain open; that a cruel man devoid of empathy would fail to calm fearful citizens; that a narcissist who cannot stand to be upstaged would refuse to tap the deep well of experts at his disposal; that a scion of nepotism would hand control of a shadow coronavirus task force to his unqualified son-in-law; that an armchair polymath would claim to have a “natural ability” at medicine and display it by wondering out loud about the curative potential of injecting disinfectant; that an egotist incapable of admitting failure would try to distract from his greatest one by blaming China, defunding the WHO, and promoting miracle drugs; or that a president who has been shielded by his party from any shred of accountability would say, when asked about the lack of testing, “I don’t take any responsibility at all.”

Trump is a comorbidity of the COVID‑19 pandemic. He isn’t solely responsible for America’s fiasco, but he is central to it. A pandemic demands the coordinated efforts of dozens of agencies. “In the best circumstances, it’s hard to make the bureaucracy move quickly,” Ron Klain said. “It moves if the president stands on a table and says, ‘Move quickly.’ But it really doesn’t move if he’s sitting at his desk saying it’s not a big deal.”

everyday Americans did more than the White House. By voluntarily agreeing to months of social distancing, they bought the country time, at substantial cost to their financial and mental well-being. Their sacrifice came with an implicit social contract—that the government would use the valuable time to mobilize an extraordinary, energetic effort to suppress the virus, as did the likes of Germany and Singapore. But the government did not, to the bafflement of health experts. “There are instances in history where humanity has really moved mountains to defeat infectious diseases,” says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. “It’s appalling that we in the U.S. have not summoned that energy around COVID‑19.”

People suffered all the debilitating effects of a lockdown with few of the benefits. Most states felt compelled to reopen without accruing enough tests or contact tracers. In April and May, the nation was stuck on a terrible plateau, averaging 20,000 to 30,000 new cases every day. In June, the plateau again became an upward slope, soaring to record-breaking heights.

It is no coincidence that other powerful nations that elected populist leaders—Brazil, Russia, India, and the United Kingdom—also fumbled their response to COVID‑19. “When you have people elected based on undermining trust in the government, what happens when trust is what you need the most?”

the United States underperformed across the board, and its errors compounded. The dearth of tests allowed unconfirmed cases to create still more cases, which flooded the hospitals, which ran out of masks, which are necessary to limit the virus’s spread. Twitter amplified Trump’s misleading messages, which raised fear and anxiety among people, which led them to spend more time scouring for information on Twitter.

The virus was never beaten in the spring, but many people, including Trump, pretended that it was. Every state reopened to varying degrees, and many subsequently saw record numbers of cases. After Arizona’s cases started climbing sharply at the end of May, Cara Christ, the director of the state’s health-services department, said, “We are not going to be able to stop the spread. And so we can’t stop living as well.” The virus may beg to differ.

The long wait for a vaccine will likely culminate in a predictable way: Many Americans will refuse to get it, and among those who want it, the most vulnerable will be last in line.

It is almost unheard-of for a public-health measure to go from zero to majority acceptance in less than half a year. But pandemics are rare situations when “people are desperate for guidelines and rules,” says Zoë McLaren, a health-policy professor at the University of Maryland at Baltimore County. The closest analogy is pregnancy, she says, which is “a time when women’s lives are changing, and they can absorb a ton of information. A pandemic is similar: People are actually paying attention, and learning.”

As the economy nose-dived, the health-care system ailed, and the government fumbled, belief in American exceptionalism declined. “Times of big social disruption call into question things we thought were normal and standard,” Redbird told me. “If our institutions fail us here, in what ways are they failing elsewhere?” And whom are they failing the most?

It is hard to stare directly at the biggest problems of our age. Pandemics, climate change, the sixth extinction of wildlife, food and water shortages—their scope is planetary, and their stakes are overwhelming. We have no choice, though, but to grapple with them. It is now abundantly clear what happens when global disasters collide with historical negligence.

America would be wise to help reverse the ruination of the natural world, a process that continues to shunt animal diseases into human bodies. It should strive to prevent sickness instead of profiting from it. It should build a health-care system that prizes resilience over brittle efficiency, and an information system that favors light over heat. It should rebuild its international alliances, its social safety net, and its trust in empiricism. It should address the health inequities that flow from its history. Not least, it should elect leaders with sound judgment, high character, and respect for science, logic, and reason.

Iraq has struggled to recover from the battle against Islamic State of Iraq and the Levant (ISIL) group between 2014 and 2017. Its infrastructure has been laid to waste by decades of sectarian civil war, foreign occupation, two US invasions, UN sanctions and war against its neighbours.

some of the continent’s more democratic states have failed to end corruption or deliver high levels of economic growth. On the other hand, Ethiopia and Rwanda achieved impressive successes, attracting international praise for reducing poverty and unemployment while consistently securing high economic growth

Ethiopia received almost $5 billion in foreign aid in 2018, while Rwanda received just over $1 billion. The figure for Rwanda is particularly striking when one considers that democratic Malawi, which saw a peaceful transfer of power to the opposition in June 2020, receives considerably less aid per person: $70 for each Malawian in 2018, compared with almost $91 for every Rwandan

recent trends in academic and policy research have played an important role in the rise of authoritarian development. These trends provided donors with an intellectual foundation for investing in countries that, on the basis of their human rights records, the EU and the UK might have been expected to avoid.

researchers suggested that when patrimonial systems are tightly controlled, waste can be minimized and resources channeled toward productive investments to support developmental outcomes

The combination of the rise of China, democratic malaise in the West, and the economic struggles of many African democracies has led citizens and political elites to increasingly question the value of democracy for development

there is some evidence that the empirical data used to identify Ethiopia and Rwanda as success stories may not be as impressive as it was first thought

official figures are part of a broader propaganda campaign designed to sell the regime both at home and abroad

The Tiger economies of East Asia, such as South Korea and Taiwan, entrenched the economic progress they achieved in the 1970s and 1980s by undergoing relatively smooth transitions to more open and inclusive—and hence legitimate and stable—political systems in the 1990s. The prospects for such transitions have always seemed less likely in Ethiopia and Rwanda, where opposition parties are not allowed to operate effectively and limited social and political cohesion remains a cause for concern.

While the jury is still out on Rwanda, the political foundations of economic development in Ethiopia appear to be crumbling. When the Ethiopian People’s Revolutionary Democratic Front (EPRDF) came to power in 1991, it initially appeared to have broken out of Ethiopia’s damaging cycle of repression and rebellion. Rather than seeking to enforce one ethnic identity over the others, the EPRDF committed to giving the country’s different communities the freedom and self-respect they had always desired. The government enshrined a right to self-determination in the Ethiopian constitution. However, the reality was very different

the ruling party kept itself in power by rigging elections and repressing opponents. As a result, many ethnoregional groups felt that in addition to being politically marginalized, they were denied the opportunity to press their concerns through democratic channels.

although he quickly won the 2019 Nobel Peace Prize for moving to end a long-running dispute with Eritrea and promising a raft of democratic reforms, Abiy was unable to return Ethiopia to political stability. Most notably, the growing political marginalization of the TPLF left the former dominant clique increasingly frustrated. Tigrayan leaders ultimately quit the government, while Abiy disbanded the EPRDF and replaced it with his own political vehicle, the Prosperity Party. From that moment on, civil conflict between the federal government and the TPLF, whose role was now limited to control over the Tigrayan regional government, became increasingly likely.

Since civil conflict began in November 2020, Ethiopia has had a new set of developmental challenges. Hundreds of thousands of citizens have been displaced, major infrastructure has been destroyed, and Abiy’s reputation as a reformer has been undermined. Moreover, there is a serious risk that even though federal government troops have regained overall control of Tigray, the TPLF will be able to wage guerrilla attacks that will continue to weaken political stability and investor confidence.

Abiy, like his predecessors, will use coercion to maintain political control, building up more problems for the future. Although negotiated and smooth political transitions are not impossible, they are less likely in heavily divided societies and have been rare in sub-Saharan Africa.

Although Ethiopia and Rwanda are often mentioned in the same sentence, Ethiopia is the more important example for the argument that authoritarian government models would serve Africa better than democratic ones. With a small population, a distinctive history, and an intensely authoritarian government, Rwanda is not a promising case from which to generalize. By contrast, Ethiopia, with a large and extremely ethnically diverse population, provides a more compelling example.

The empirical evidence in favor of authoritarian development models in Africa has always been remarkably thin. The vast majority of African states were authoritarian in the 1970s and 1980s, and almost all had poor economic growth. Fast-forward to today, and there are very few authoritarian regimes with the potential to join Ethiopia and Rwanda as notable success stories. Instead, most studies have found that democratic governments perform better when it comes to providing public services or economic growth.

On its own, Rwanda’s small and aid-dependent economy cannot sustain the narrative that authoritarian regimes perform better on development—and if it does not, there is no justification at all for supporting repressive regimes.