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what the administration should have been doing in January to prepare us for today.

She cites the delay on tests, without which “cases go undetected and people continue to circulate” as a leading issue along with other missed federal government responses—many of which are still not fully operational

The prescient recommendations from experts across disciplines in the period before COVID-19 reached American shores—about testing, equipment, and distancing—make clear that more than any single factor, it was Trump’s squandering of out lead-time which should have been used to prepare for the pandemic that has exacerbated this crisis.

What follows is an annotated timeline revealing the warning signs the administration received and showing how slow the administration was to act on these recommendations.

The Early Years: Warnings Ignored

2017: Trump administrations officials are briefed on an intelligence document titled “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.” That’s right. The administration literally had an actual playbook for what to do in the early stages of a pandemic

February 2018: The Washington Post writes “CDC to cut by 80 percent efforts to prevent global disease outbreak.” The meat of the story is “Countries where the CDC is planning to scale back include some of the world’s hot spots for emerging infectious disease, such as China, Pakistan, Haiti, Rwanda and Congo.”

May 2018: At an event marking the 100 year anniversary of the 1918 pandemic, Borio says “pandemic flu” is the “number 1 health security issue” and that the U.S. is not ready to respond.

One day later her boss, Rear Adm. Timothy Ziemer is pushed out of the administration and the global health security team is disbanded

Beth Cameron, former senior director for global health security on the National Security Council adds: “It is unclear in his absence who at the White House would be in charge of a pandemic,” Cameron said, calling it “a situation that should be immediately rectified.” Note: It was not

January 2019: The director of National Intelligence issues the U.S. Intelligence Community’s assessment of threats to national security. Among its findings:

A novel strain of a virulent microbe that is easily transmissible between humans continues to be a major threat, with pathogens such as H5N1 and H7N9 influenza and Middle East Respiratory Syndrome Coronavirus having pandemic potential if they were to acquire efficient human-to-human transmissibility.”

Page 21: “We assess that the United States and the world will remain vulnerable to the next flu pandemic or large scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.”

September, 2019: The Trump Administration ended the pandemic early warning program, PREDICT, which trained scientists in China and other countries to identify viruses that had the potential to turn into pandemics. According to the Los Angeles Times, “field work ceased when funding ran out in September,” two months before COVID-19 emerged in Wuhan Province, China.

2020: COVID-19 Arrives

anuary 3, 2020: The CDC is first alerted to a public health event in Wuhan, China

January 6, 2020: The CDC issues a travel notice for Wuhan due to the spreading coronavirus

Note: The Trump campaign claims that this marks the beginning of the federal government disease control experts becoming aware of the virus. It was 10 weeks from this point until the week of March 16 when Trump began to change his tone on the threat.

January 10, 2020: Former Trump Homeland Security Advisor Tom Bossert warns that we shouldn’t “jerk around with ego politics” because “we face a global health threat…Coordinate!”

January 18, 2020: After two weeks of attempts, HHS Secretary Alex Azar finally gets the chance to speak to Trump about the virus. The president redirects the conversation to vaping, according to the Washington Post. 

January 21, 2020: Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Disease at the CDC tells reporters, “We do expect additional cases in the United States.”

January 27, 2020: Top White House aides meet with Chief of Staff Mick Mulvaney to encourage greater focus on the threat from the virus. Joe Grogan, head of the White House Domestic Policy Council warns that “dealing with the virus was likely to dominate life in the United States for many months.”

January 28, 2020: Two former Trump administration officials—Gottlieb and Borio—publish an op-ed in the Wall Street Journal imploring the president to “Act Now to Prevent an American Epidemic.” They advocate a 4-point plan to address the coming crisis:

(1) Expand testing to identify and isolate cases. Note: This did not happen for many weeks. The first time more than 2,000 tests were deployed in a single day was not until almost six weeks later, on March 11.

(3) Prepare hospital units for isolation with more gowns and masks. Note: There was no dramatic ramp-up in the production of critical supplies undertaken. As a result, many hospitals quickly experienced shortages of critical PPE materials. Federal agencies waited until Mid-March to begin bulk orders of N95 masks.

January 29, 2020: Trump trade advisor Peter Navarro circulates an internal memo warning that America is “defenseless” in the face of an outbreak which “elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”

January 30, 2020: Dr. James Hamblin publishes another warning about critical PPE materials in the Atlantic, titled “We Don’t Have Enough Masks.”

January 29, 2020: Republican Senator Tom Cotton reaches out to President Trump in private to encourage him to take the virus seriously.

Late January, 2020:  HHS sends a letter asking to use its transfer authority to shift $136 million of department funds into pools that could be tapped for combating the coronavirus. White House budget hawks argued that appropriating too much money at once when there were only a few U.S. cases would be viewed as alarmist.

Trump’s Chinese travel ban only banned “foreign nationals who had been in China in the last 14 days.” This wording did not—at all—stop people from arriving in America from China. In fact, for much of the crisis, flights from China landed in America almost daily filled with people who had been in China, but did not fit the category as Trump’s “travel ban” defined it.

January 31, 2020: On the same day Trump was enacting his fake travel ban, Foreign Policy reports that face masks and latex gloves are sold out on Amazon and at leading stores in New York City and suggests the surge in masks being sold to other countries needs “refereeing” in the face of the coming crisis.

February 4, 2020: Gottlieb and Borio take to the WSJ again, this time to warn the president that “a pandemic seems inevitable” and call on the administration to dramatically expand testing, expand the number of labs for reviewing tests, and change the rules to allow for tests of people even if they don’t have a clear known risk factor.

Note: Some of these recommendations were eventually implemented—25 days later.

February 5, 2020: HHS Secretary Alex Azar requests $2 billion to “buy respirator masks and other supplies for a depleted federal stockpile of emergency medical equipment.” He is rebuffed by Trump and the White House OMB who eventually send Congress a $500 million request weeks later.

February 4 or 5, 2020: Robert Kadlec, the assistant secretary for preparedness and response, and other intelligence officials brief the Senate Intelligence Committee that the virus poses a “serious” threat and that “Americans would need to take actions that could disrupt their daily lives.”

February 5, 2020: Senator Chris Murphy tweets: Just left the Administration briefing on Coronavirus. Bottom line: they aren't taking this seriously enough. Notably, no request for ANY emergency funding, which is a big mistake. Local health systems need supplies, training, screening staff etc. And they need it now.

February 9, 2020: The Washington Post reports that a group of governors participated in a jarring meeting with Dr. Anthony Fauci and Dr. Robert Redfield that was much more alarmist than what they were hearing from Trump. “The doctors and the scientists, they were telling us then exactly what they are saying now,” Maryland Gov. Larry Hogan (R) said.

the administration lifted CDC restrictions on tests. This is a factually true statement. But it elides that fact that they did so on March 3—two critical weeks after the third Borio/Gottlieb op-ed on the topic, during which time the window for intervention had shrunk to a pinhole.

February 20, 2020: Borio and Gottlieb write in the Wall Street Journal that tests must be ramped up immediately “while we can intervene to stop spread.”

February 23, 2020: Harvard School of Public Health professor issues warning on lack of test capability: “As of today, the US remains extremely limited in#COVID19 testing. Only 3 of ~100 public health labs haveCDC test kits working and CDC is not sharing what went wrong with the kits. How to know if COVID19 is spreading here if we are not looking for it.

February 24, 2020: The Trump administration sends a letter to Congress requesting a small dollar amount—between $1.8 billion and $2.5 billion—to help combat the spread of the coronavirus. This is, of course, a pittance

February 25, 2020: Messonier says she expects “community spread” of the virus in the United States and that “disruption to everyday life might be severe.” Trump is reportedly furious and Messonier’s warnings are curtailed in the ensuing weeks.

Trump mocks Congress in a White House briefing, saying “If Congress wants to give us the money so easy—it wasn’t very easy for the wall, but we got that one done. If they want to give us the money, we’ll take the money.”

February 26, 2020: Congress, recognizing the coming threat, offers to give the administration $6 billion more than Trump asked for in order to prepare for the virus.

February 27, 2020: In a leaked audio recording Sen. Richard Burr, chairman of the Intelligence Committee and author of the Pandemic and All-Hazards Preparedness Act (PAHPA) and the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (reauthorization of PAHPA), was telling people that COVID-19 “is probably more akin to the 1918 pandemic.”

March 4, 2020: HHS says they only have 1 percent of respirator masks needed if the virus became a “full-blown pandemic.”

March 3, 2020: Vice President Pence is asked about legislation encouraging companies to produce more masks. He says the Trump administration is “looking at it.”

March 7, 2020: Fox News host Tucker Carlson, flies to Mar-a-Lago to implore Trump to take the virus seriously in private rather than embarrass him on TV. Even after the private meeting, Trump continued to downplay the crisis

March 9, 2020: Tom Bossert, Trump’s former Homeland Security adviser, publishes an op-ed saying it is “now or never” to act. He advocates for social distancing and school closures to slow the spread of the contagion.

Trump says that developments are “good for the consumer” and compares COVID-19 favorably to the common flu.

March 17, 2020: Facing continued shortages of the PPE equipment needed to prevent healthcare providers from succumbing to the virus, Oregon Senators Jeff Merkeley and Ron Wyden call on Trump to use the Defense Production Act to expand supply of medical equipment

March 18, 2020: Trump signs the executive order to activate the Defense Production Act, but declines to use it

At the White House briefing he is asked about Senator Chuck Schumer’s call to urgently produce medical supplies and ventilators. Trump responds: “Well we’re going to know whether or not it’s urgent.” Note: At this point 118 Americans had died from COVID-19.

March 20, 2020: At an April 2nd White House Press Conference, President Trump’s son-in-law Jared Kushner who was made ad hoc point man for the coronavirus response said that on this date he began working with Rear Admiral John Polowczyk to “build a team” that would handle the logistics and supply chain for providing medical supplies to the states. This suggestion was first made by former Trump Administration officials January 28th

March 22, 2020: Six days after calling for a 15-day period of distancing, Trump tweets that this approach “may be worse than the problem itself.”

March 24, 2020: Trump tells Fox News that he wants the country opened up by Easter Sunday (April 12)

As Trump was speaking to Fox, there were 52,145 confirmed cases in the United States and the doubling time for daily new cases was roughly four days.

To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those they’ve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.

That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. “I’m not aware of any simulations that I or others have run where we [considered] a failure of testing,”

The testing fiasco was the original sin of America’s pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country.

With little room to surge during a crisis, America’s health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency.

That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition

Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear.

Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,”

“Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”

it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April

A “massive logistics and supply-chain operation [is] now needed across the country,” says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That can’t be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agency—a 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.

The first and most important is to rapidly produce masks, gloves, and other personal protective equipment

it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems.

This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests.

These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its course—and the nation’s fate—now depends on the third need, which is social distancing.

There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether that’s treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now “flatten the curve” by physically isolating themselves from other people to cut off chains of transmission.

Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.

Persuading a country to voluntarily stay at home is not easy, and without clear guidelines from the White House, mayors, governors, and business owners have been forced to take their own steps.

when the good of all hinges on the sacrifices of many, clear coordination matters—the fourth urgent need

Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a person’s risk, and to somehow wall off the ‘high-risk’ people from the rest of society. It underestimates how badly the virus can hit ‘low-risk’ groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.

A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care.

There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.

If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it won’t be quick. “It could be anywhere from four to six weeks to up to three months,” Fauci said, “but I don’t have great confidence in that range.”

there are three possible endgames: one that’s very unlikely, one that’s very dangerous, and one that’s very long.

The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.

The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting

The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one.  By the end of the summer, the pandemic will have directly killed 2.2 million Americans,

The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.

there are no existing vaccines for coronaviruses—until now, these viruses seemed to cause diseases that were mild or rare—so researchers must start from scratch.

The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the virus’s genes for the first time and doctors injecting a vaccine candidate into a person’s arm. “It’s overwhelmingly the world record,” Fauci said.

The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. They’ll need to do animal tests and large-scale trials to ensure that the vaccine doesn’t cause severe side effects. They’ll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.

No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into people’s arms.

as the status quo returns, so too will the virus. This doesn’t mean that society must be on continuous lockdown until 2022. But “we need to be prepared to do multiple periods of social distancing,” says Stephen Kissler of Harvard.

First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect.

Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer.

scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. They’ll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.

Aspects of America’s identity may need rethinking after COVID-19. Many of the country’s values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs.

“We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.”

The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. “But my hope and expectation is that the severity would decline, and there would be less societal upheaval,”

After infections begin ebbing, a secondary pandemic of mental-health problems will follow.

But “there is also the potential for a much better world after we get through this trauma,”

Testing kits can be widely distributed to catch the virus’s return as quickly as possible. There’s no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be.

Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements.

Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.

Attitudes to health may also change for the better. The rise of HIV and AIDS “completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic,”

Years of isolationist rhetoric had consequences too.

“People believed the rhetoric that containment would work,” says Wendy Parmet, who studies law and public health at Northeastern University. “We keep them out, and we’ll be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, you’re especially vulnerable when a pandemic hits.”

Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.

After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies.

The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audience’s preconceptions.

“The transitions after World War II or 9/11 were not about a bunch of new ideas,” he says. “The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.”

One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation

The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.

On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5—the world’s highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.

Last year, a Chinese scientist he worked with published a specific forecast: “It is highly likely that future SARS- or MERS-like coronavirus outbreaks will originate from bats, and there is an increased probability that this will occur in China.”

Humans today are exposed to more deadly new pathogens than ever. They typically come from animals, as global travel, trade and economic development, such as meat production and deforestation, push people, livestock and wildlife closer together

Scientists knew infectious disease outbreaks were becoming more common, with 2010 having more than six times the outbreaks of pathogens from animal origins than in 1980, according to data in a study by Brown University researchers.

Yet plenty was left undone, in areas including funding, early-warning systems, the role of the WHO and coordination with China. A big chunk of U.S. funding went toward protecting Americans against a bioterror attack. Government funding for pandemics has come largely in emergency, one-time packages to stop an ongoing outbreak.

She said a better solution would be to fund public health more like national defense, with much more guaranteed money, year in, year out.

“Will there be another human influenza pandemic?” Dr. Webster asked in a paper presented at an NIH meeting in 1995. “The certainty is that there will be.”

Experts including Dr. Webster were particularly concerned about the potential for spillover in southern China, where large, densely populated cities were expanding rapidly into forests and agricultural lands, bringing people into closer contact with animals. Two of the three influenza pandemics of the 20th century are thought to have originated in China.

Dr. Webster and others warned it could re-emerge or mutate into something more contagious. With U.S. funding, he set up an animal influenza surveillance center in Hong Kong. The WHO, which hadn’t planned for pandemics before, started compiling protocols for a large-scale outbreak, including contingency plans for vaccines.

At a dinner back in the U.S., he remembers one guest saying, “Oh, you really needed to have someone in the U.S. to be impacted to really galvanize the government.”

That “drove home the reality in my own mind of globalization,” said Dr. Fukuda. SARS showed that viruses can crisscross the globe by plane in hours, making a local epidemic much more dangerous.

The WHO’s director-general, Gro Harlem Brundtland, publicly criticized China. The government under new leaders reversed course. It implemented draconian quarantines and sanitized cities, including a reported 80 million people enlisted to clean streets in Guangdong.

By May 2003, the number of new SARS cases was dwindling. It infected around 8,000 people world-wide, killing nearly 10%.

After SARS, China expanded epidemiologist training and increased budgets for new laboratories. It started working more closely in public health with the U.S., the world’s leader. The U.S. CDC opened an office in Beijing to share expertise and make sure coverups never happened again. U.S. CDC officials visiting a new China CDC campus planted a friendship tree.

In Washington in 2005, a powerful player started driving U.S. efforts to become more prepared. President George W. Bush had read author John M. Barry’s “The Great Influenza,” a history of the 1918 flu pandemic

Mr. Bush leaned toward the group of 10 or so officials and said, “I want to see a plan,” according to Dr. Venkayya. “He had been asking questions and not getting answers,” recalled Dr. Venkayya, now president of Takeda Pharmaceutical Co. ’s global vaccine business unit. “He wanted people to see this as a national threat.”

Mr. Bush launched the strategy in November, and Congress approved $6.1 billion in one-time funding.

The CDC began exercises enacting pandemic scenarios and expanded research. The government created the Biomedical Advanced Research and Development Authority to fund companies to develop diagnostics, drugs and vaccines.

A team of researchers also dug into archives of the 1918 pandemic to develop guidelines for mitigating the spread when vaccines aren’t available. The tactics included social distancing, canceling large public gatherings and closing schools—steps adopted this year when Covid-19 struck, though at the time they didn’t include wide-scale lockdowns.

A year after the plan was released, a progress report called for more real-time disease surveillance and preparations for a medical surge to care for large numbers of patients, and stressed strong, coordinated federal planning.

A European vaccine makers’ association said its members had spent around $4 billion on pandemic vaccine research and manufacturing adjustments by 2008.

The $6.1 billion Congress appropriated for Mr. Bush’s pandemic plan was spent mostly to make and stockpile medicines and flu vaccines and to train public-health department staff. The money wasn’t renewed. “The reality is that for any leader it’s really hard to maintain a focus on low-probability high-consequence events, particularly in the health arena,” Dr. Venkayya said.

In the U.S., President Barack Obama’s administration put Mr. Bush’s new plan into action for the first time. By mid-June, swine flu, as it was dubbed, had jumped to 74 countries. The WHO officially labeled it a pandemic, despite some evidence suggesting the sickness was pretty mild in most people.

That put in motion a host of measures, including some “sleeping” contracts with pharmaceutical companies to begin vaccine manufacturing—contracts that countries like the United Kingdom had negotiated ahead of time so they wouldn’t have to scramble during an outbreak.

In August, a panel of scientific advisers to Mr. Obama published a scenario in which as many as 120 million Americans, 40% of the population, could be infected that year, and up to 90,000 people could die.

H1N1 turned out to be much milder. Although it eventually infected more than 60 million Americans, it killed less than 13,000. In Europe, fewer than 5,000 deaths were reported.

The WHO came under fire for labeling the outbreak a pandemic too soon. European lawmakers, health professionals and others suggested the organization may have been pressured by the pharmaceutical industry.

France ordered 94 million doses, but had logged only 1,334 serious cases and 312 deaths as of April 2010. It managed to cancel 50 million doses and sell some to other countries, but it was still stuck with a €365 million tab, or about $520 million at the time, and 25 million extra doses.

The WHO had raised scares for SARS, mad-cow disease, bird flu and now swine flu, and it had been wrong each time, said Paul Flynn, a member of the Council of Europe’s Parliamentary Assembly and a British lawmaker, at a 2010 health committee hearing in Strasbourg.

Ultimately, an investigation by the council’s committee accused the WHO and public-health officials of jumping the gun, wasting money, provoking “unjustified fear” among Europeans and creating risks through vaccines and medications that might not have been sufficiently tested.

“I thought you might have uttered a word of regret or an apology,” Mr. Flynn told Dr. Fukuda, who as a representative of the WHO had been called to testify.

Back in Washington, scientist Dennis Carroll, at the U.S. Agency for International Development, was also convinced that flu wasn’t the only major pandemic threat. In early 2008, Dr. Carroll was intrigued by Dr. Daszak’s newly published research that said viruses from wildlife were a growing threat, and would emerge most frequently where development was bringing people closer to animals.

If most of these viruses spilled over to humans in just a few places, including southern China, USAID could more easily fund an early warning system.

“You didn’t have to look everywhere,” he said he realized. “You could target certain places.” He launched a new USAID effort focused on emerging pandemic threats. One program called Predict had funding of about $20 million a year to identify pathogens in wildlife that have the potential to infect people.

Drs. Daszak, Shi and Wang, supported by funds from Predict, the NIH and China, shifted their focus to Yunnan, a relatively wild and mountainous province that borders Myanmar, Laos and Vietnam.

One key discovery: a coronavirus resembling SARS that lab tests showed could infect human cells. It was the first proof that SARS-like coronaviruses circulating in southern China could hop from bats to people. The scientists warned of their findings in a study published in the journal Nature in 2013.

Evidence grew that showed people in the area were being exposed to coronaviruses. One survey turned up hundreds of villagers who said they recently showed symptoms such as trouble breathing and a fever, suggesting a possible viral infection.

Over the next several years, governments in the U.S. and elsewhere found themselves constantly on the defensive from global viral outbreaks. Time and again, preparedness plans proved insufficient. One, which started sickening people in Saudi Arabia and nearby

On a weekend morning in January 2013, more than a dozen senior Obama administration officials met in a basement family room in the suburban home of a senior National Security Council official. They were brainstorming how to help other countries upgrade their epidemic response capabilities, fueled by bagels and coffee. Emerging disease threats were growing, yet more than 80% of the world’s countries hadn’t met a 2012 International Health Regulations deadline to be able to detect and respond to epidemics.

The session led to the Global Health Security Agenda, launched by the U.S., the WHO and about 30 partners in early 2014, to help nations improve their capabilities within five years.

Money was tight. The U.S. was recovering from the 2008-09 financial crisis, and federal funding to help U.S. states and cities prepare and train for health emergencies was declining. Public-health departments had cut thousands of jobs, and outdated data systems weren’t replaced.

“It was a Hail Mary pass,” said Tom Frieden, who was director of the CDC from 2009 to 2017 and a force behind the creation of the GHSA. “We didn’t have any money.”

At the WHO, Dr. Fukuda was in charge of health security. When the Ebola outbreak was found in March 2014, he and his colleagues were already stretched, after budget cuts and amid other crises.

The United Nations created a special Ebola response mission that assumed the role normally played by the WHO. Mr. Obama sent the U.S. military to Liberia, underscoring the inability of international organizations to fully handle the problem.

It took the WHO until August to raise an international alarm about Ebola. By then, the epidemic was raging. It would become the largest Ebola epidemic in history, with at least 28,600 people infected, and more than 11,300 dead in 10 countries. The largest outbreak before that, in Uganda, had involved 425 cases.

Congress passed a $5.4 billion package in supplemental funds over five years, with about $1 billion going to the GHSA. The flood of money, along with aggressive contact tracing and other steps, helped bring the epidemic to a halt, though it took until mid-2016.

Global health experts and authorities called for changes at the WHO to strengthen epidemic response, and it created an emergencies program. The National Security Council warned that globalization and population growth “will lead to more pandemics,” and called for the U.S. to do more.

r. Carroll of USAID, who had visited West Africa during the crisis, and saw some health workers wrap themselves in garbage bags for protection, started conceiving of a Global Virome Project, to detect and sequence all the unknown viral species in mammals and avian populations on the planet.

Billionaire Bill Gates warned in a TED talk that an infectious disease pandemic posed a greater threat to the world than nuclear war, and urged world leaders to invest more in preparing for one. The Bill & Melinda Gates Foundation helped form a new initiative to finance vaccines for emerging infections, the Coalition for Epidemic Preparedness Innovations.

Congress established a permanent Infectious Diseases Rapid Response Fund for the CDC in fiscal 2019, with $50 million for that year and $85 million in fiscal 2020.

In May 2018, John Bolton, then President Trump’s national security adviser, dismantled an NSC unit that had focused on global health security and biodefense, with staff going to other units. The senior director of the unit left.

It pushed emerging disease threats down one level in the NSC hierarchy, making pandemics compete for attention with issues such as North Korea, said Beth Cameron, a previous senior director of the unit. She is now vice president for global biological policy and programs at the Nuclear Threat Initiative.

Deteriorating relations with China reduced Washington’s activities there just as researchers were becoming more certain of the threat from coronaviruses.

Dr. Carroll had earlier been ordered to suspend his emerging pandemic threats program in China.

Dr. Carroll pitched to USAID his Global Virome Project. USAID wasn’t interested, he said. He left USAID last year. A meeting that Dr. Carroll planned for last August with the Chinese CDC and Chinese Academy of Sciences to form a Chinese National Virome Project was postponed due to a bureaucratic hang-up. Plans to meet are now on hold, due to Covid-19.

Attempting to ease tensions with China to make cooperation on global public health possible won’t work, partly because Beijing cannot credibly commit to being more transparent and cooperative in the future.

For China’s leaders, the pandemic revealed the inexorable decline of the West, confirmed Beijing’s power and capabilities, and created more latitude for the CCP to do as it wished.

But in case cooperation fails, it must have a backup plan to rally allies and partners to provide a much greater share of global public goods, even if that means shouldering more of the costs.

as a number of U.S. embassy officials told the foreign policy analyst Colin Kahl and me for our book Aftershocks, this team’s cooperation with the Chinese government became more challenging as U.S.-Chinese rivalry intensified, largely because of China’s actions.

When COVID-19 hit, the Chinese Communist Party (CCP) maintained near-absolute secrecy. All channels of communication between Beijing and Washington went silent, as they did between Beijing and other governments. Chinese leaders sought to conceal vital information about the emerging epidemic in China from the rest of the world, even attempting to prevent Chinese scientists from sharing the genetic sequence of the virus with scientists in other countries.

It is impossible to say for certain why the Chinese government behaved the way it did, but secrecy and control make sense in light of what the vast majority of China experts believe to be Xi’s top priority: regime survival.

Xi did not want to facilitate an international response to COVID-19 that could have attributed blame to China or isolated it through travel restrictions, either of which might have damaged the regime’s domestic legitimacy. Instead, Xi leveraged the pandemic to his advantage: China’s suppression of the virus became a matter of national pride, held up by Beijing in sharp contrast to the experience of the United States.

according to the UN, the pandemic could force a total of 490 million people into poverty—defined as the loss of access to clean water, adequate food, or shelter—pushing the global poverty rate to around seven percent by 2030, compared with the pre-pandemic target of three percent. 

Contrary to popular belief, some senior Trump administration officials grasped the national security threat posed by the virus faster than their European counterparts did. Top officials in the National Security Council began focusing on the pandemic in early January, just days after news of the outbreak in Wuhan, China, became public.

ven though Pottinger and other NSC officials were wise to the danger, they ultimately failed to persuade Trump to make the necessary preparations to deal with the pandemic when it inevitably reached the United States. 

As the administration began to formulate its response, those who favored a more comprehensive public health approach both at home and abroad were excluded or marginalized at crucial moments. The result was that the Trump administration focused more on holding China responsible for the outbreak and reducing U.S. reliance on Beijing than on the minutiae of global public health policy or the hard work of rallying the world to tackle the pandemic.

the pandemic and China’s response to it helped unify the administration behind a more comprehensive strategy to push back against Beijing. Between March 2020 and the end of the year, the senior official said, the United States put in place more containment measures than it had in the previous three years, including restrictions on Chinese technology firms, sanctions on Chinese officials, looser regulations on diplomatic contacts with Taiwan, and recognition of the repression in Xinjiang as a genocide. In this sense, the pandemic was a pivotal moment in the U.S.-Chinese rivalry. 

Competition between the two countries overwhelmed everything else, including U.S. cooperation with allies on the pandemic, leaving a global leadership vacuum that no one could fill.

The EU tried to step up by increasing funding for the WHO and for COVAX, the global initiative to share vaccines, but it never came close to organizing a global response. China’s assertive foreign policy, and its attempts to use pandemic assistance to advance its interests, aggravated European leaders and convinced them to harden their positions toward China throughout the course of 2020. 

During this period, there was hardly any international cooperation on vaccine development or distribution, no coordination on travel restrictions or the distribution of medical supplies, and limited cooperation on achieving a cessation of hostilities in conflict zones

The United States needs a strategy to address transnational threats under the conditions of great-power competition. It must aim to cooperate with rivals, especially China, to prepare for future pandemics and to tackle climate change

The economic disruption caused by COVID-19 devastated low-income countries, which received little in the way of international assistance. Especially hard hit were countries, such as Bangladesh, that had made significant development gains in the last two decades and were propelling themselves into the lower tier of middle-income economies.

Pandemics are not the only transnational threat that promises to intensify great-power rivalry and diminish the prospects for much-needed cooperation. Climate change could do the same.

the real challenge is determining what to do when cooperation with China and other rivals falls short of what is required. The United States needs a backup plan to tackle shared challenges through coalitions of the willing.

Countries that aggressively decarbonize could place sanctions and other trade restrictions on countries that do not, leading to counterresponses and new trade wars.

the impediments to cooperation between Europe and China on climate change “are becoming higher” and warn that “decision-makers must not underestimate the highly competitive aspects of how China is changing its energy production and consumption.” 

The United States and Europe will both compete with China for access to raw materials and in developing the technology needed to make their economies carbon neutral: magnets, batteries, high-performance ceramics, and light-emitting diodes, among other things

even if the U.S. government remains broadly aligned with Europe on climate policy, the Europeans could still become disaffected if Congress blocks meaningful climate action, such as commitments to cut carbon emissions or invest in clean technology. This, in turn, could diminish Europe’s willingness to help uphold the U.S.-led international order.

If, on the one hand, they mean softening U.S. rhetoric without conceding much of substance to China, they would do well to look to Europe, where governments were much more inclined than the Trump administration to cooperate with China, but China did not take them up on the offer.

If, on the other hand, they mean unilaterally making major geopolitical concessions to China—on its territorial acquisitions in the South China Sea, for instance, or the status of Taiwan—the United States would not only pay an extremely high price but also likely embolden Beijing further without actually securing cooperation on pandemics or climate change beyond what Beijing has already offered.

There is no getting around strategic competition with Beijing: it is deeply embedded in the international order, mainly because China seeks to expand its sphere of influence in Asia at the expense of the United States and its allies, which are in turn committed to thwarting Beijing’s plans.

The United States and China are also engaged in what Jake Sullivan, Biden’s national security adviser, recently called “a competition of models.” China is seeking to make the world safe for the CCP and to demonstrate the effectiveness of its system. This entails pushing back against what it sees as pressure from liberal democratic countries that could thwart its objectives. For its part, the United States worries about the negative externalities of Chinese authoritarianism, such as censorship of international criticism of Beijing or the export of its tools of repression to other countries.

The United States also worries about what would happen to the military balance of power if China secured an enduring advantage in key technologies.

Even in diplomacy, friction will be endemic to the U.S.-Chinese relationship and will affect the broader international order for the foreseeable future. Outright confrontation can be avoided—but competition cannot. 

This competition places real limits on cooperation. Take the arena of global public health: many studies on how to improve pandemic preparedness call on world leaders to dramatically strengthen the WHO, including by giving it the same power to enforce international health regulations as the International Atomic Energy Agency enjoys with nuclear nonproliferation rules

The problem is getting every government to agree to a universally applicable mechanism for sanctions or some other enforcement mechanism. China will not agree to any reform that would involve intrusive inspections of its scientific research facilities.

The need for cooperation on transnational threats must change how the United States competes with China—not whether it competes.

U.S. officials should not give up on China entirely; instead, they should make a good-faith effort to work with Beijing, both bilaterally and in multilateral settings. Recognizing that there are strict limits on U.S.-Chinese cooperation is not the same as saying that no cooperation is possible.

Rather than unite the world around a common purpose, climate change is likely to deepen competition between major powers, especially as the transition away from fossil fuels creates economic winners and losers.

When it comes to pandemic preparedness, this means fully supporting the WHO (including by pressing for needed reforms) but also forging a coalition of like-minded states: a global alliance for pandemic preparedness that would regularly convene at the head-of-state level and work alongside nongovernmental organizations and the private sector.

Crucially, whenever the WHO declared an international public health emergency, alliance members would coordinate on travel and trade restrictions, as well as on public messaging and financial penalties and sanctions. Those penalties and sanctions would be aimed at those states that failed to provide sufficient access to or fully cooperate with the WHO. The alliance would support, not supplant, the WHO.

Sustained, managed competition with China could potentially help the United States build bipartisan support for investments in clean technology that would prevent Beijing from gaining an enduring advantage in this area.

ut the United States and the European Union will also need to build coalitions of the willing to deal with the international security consequences of accelerated climate change, such as extreme weather events that threaten large numbers of people, and to address the foreign policy dimensions of climate action, including managing the risk that a shift away from fossil fuels could destabilize countries and regions that are dependent on oil exports.

Cooperation across this divide should always be the first choice in times of shared crisis, but as the COVID-19 pandemic has demonstrated, the U.S.-led constellation must always have a backup plan. It did not have one in 2020. It needs one for the next crisis

In this spirit, in my FT column I’ve repeatedly harped on questions of global development as particularly glaring examples of the way in which Western governments and their publics fail to rise to the scale of contemporary global challenges.

Conversely, flights from reality, blindspots and structural hypocrisies are profoundly telling as to our actual interests and willingness to summon the will, the power and the resources to act effectively in the world we are actually in.

These questions are not contemplative. They are not posed out of idle curiosity. They are urgent and practical. They are the first step, if we want to claim to be realistically engaged with the world as it is and thus to have any hope of informed and purposive agency.

In previous one column I addressed the failure of rich countries to seize the huge opportunity of investing at scale in global public health

In a world of polycrisis, in which intersecting problems compound each other and there are few easy wins, it is all the more important to recognise those policy choices that are truly obvious. Vaccines are one such investment. Since the 1960s, global vaccination campaigns have eradicated smallpox, suppressed polio and contained measles

. Modest expenditures on public health have saved tens of millions of lives, reduced morbidity and allowed children around the world to develop into adults capable of living healthy and productive lives.  … Unfortunately, in public policy, pandemic preparedness is all too often relegated to the cash-starved budgets of development agencies or squeezed into strained health budgets.

Where such spending properly belongs is under the flag of industrial policy and national security. 

As the IMF declared: “vaccine policy is economic policy.” And pandemic preparedness belongs under national security because there is no more serious threat to a population. A far larger percentage of the UK died of Covid between 2020 and 2023 (225,000 out of 67mn) than were killed by German bombs in the second world war (70,000 out of 50mn)

The annual defence budget of just one of the larger European countries would suffice to pay for a comprehensive global pandemic preparedness programme

The money lavished on just one of the UK’s vainglorious aircraft carriers was enough to have made the world safe against both the ghastly Ebola and Marburg viruses. 

After last week’s Brics meeting in South Africa, the question hangs in the air: what does the west have to offer a new, multipolar world? Nowhere is that question more urgent than in Africa. The Niger coup extends the comprehensive rout of western strategy across the Sahel. The debacle of western military intervention, notably on the part of the French, is embarrassing. But the wave of coups also represents a failure of Europe’s effort to link economic development and security in the programme known as the Sahel Alliance

This multinational group jointly promoted by France and Germany co-ordinated aid and development projects across the region. Launched in July 2017, as of 2023 it counts more than 1,100 projects with a cumulative funding commitment of €22.97bn. For Niger, project commitments under the Sahel Alliance come to over €5.8bn. And this is only a part of the financial assistance that Niger was receiving in the years prior to the coup.

According to OECD data, the combined total of official development assistance for Niger in 2021 came to $1.78bn. These numbers sound impressive until you place them in relation to the scale of the Sahel’s development needs. The western Sahel is home to 100mn of some of the poorest people on Earth. Niger’s population of 25mn has the third-lowest human development index in the world and the highest birth rate. Long hailed as the western bastion in the region, almost two-thirds of the population cannot read. Niger desperately needs investment in education, irrigation and basic health services. To meet these priorities, on a per capita basis foreign aid in 2021 came to just $71 for every inhabitant of Niger, or $1.37 per week. Of this miserly total, roughly 7 cents were spent on education, 15 cents on health, and 30 cents on production and infrastructure. Twenty-six cents were devoted to the basics of keeping alive.

Last month I took up the issue of the prevailing fatalism in the USA when it comes to the question of development in Central America

The attack line from the Republicans is predictable: Kamala Harris was Biden’s border tsar. The crisis on the border with Mexico shows that she failed. So too is the response from the Democrats: No, the vice-president never was in charge of the border. Her role was to address the root causes of migration from El Salvador, Guatemala and Honduras. No one can blame her for failing. It was mission impossible

The striking thing about this retort is not that it is unreasonable, but that it sets such a low bar. Whereas for the Republicans the desperation in Central America is reason to seal the border even more firmly, for the Democrats the deep-seated nature of those problems is an excuse. Apparently, no one expects Harris or anyone else to succeed in addressing the poverty and insecurity in the region. Shrugging its shoulders, the US settles down to live with polycrisis on its doorstep.

I returned to the question of the scale of global aid and European aid in particular for the African continent.

Uncontentious estimates of global development need put the sum of investment required to achieve comprehensive sustainable develoment at between $ 3 and 4 trillion per annum. That is an immense amount, but given the rewards on offer and the fact that global GDP stands at $105 trillion it cannot be dismissed out of hand as “utopian”.

FDI and private lending will do some of the work. But it is highly volatile and not willing to take the risks necessary for comprehensive development. So support and derisking, on carefully managed terms, must come from public balance sheets. Some will come from multilateral development banks like the World Bank. But a substantial amount will depend on concessional loans and aid in the form of grants. The crucial question is, how much is being made available? How far does it reflect the needs of the moment?

According to the OECD, the volume of official development assistance (ODA) in 2023 was 224 billion, a new high. Of that amount only $36 billion went to Africa, the continent with the most dramatic development needs.

So, what might these figures look like, if the West was actually invested in changing the trajectory of Africa’s development through material assistance? To this question, too the OECD data provide an answer.

The upshot is startling: In 2023 money flows to Ukraine classified by the OECD as official development assistance (ODA) exceeded the equivalent flows to the entire African continent.

At this moment, millions in Sudan are at risk of outright famine. The UN’s funding appeal for Sudan famine relief is for $2.6 billion, less than the monthly rate of support for Ukraine in 2023. So far it has raised $1 billion.

This is a stark measure of the difference between a crisis in which the Western donors see their interests directly and urgently engaged and one to which they are relatively indifferent.

It is the difference between a crisis happening to “people just like us”, people who have been welcomed in their millions into their neighboring European countries, and a crisis happening in Africa to black people with whom the donor populations feel on the whole only an abstract form of sympathy and identification.

It is the difference between crises happening on either side of the global colour line.

These discrepancies reveal the extraordinary extent to which, for all the common place talk of globalization, racial hierarchies and geographical division continue to undergird our political discourse and policy.

They are a sad commentary on where we are at and what time we are in. They also force the question of whether and by what means this line will be maintained and at what cost.

Security concerns, moreover, keep most information about stockpile purchases under wraps. Details about the contracts and inventory are rarely made public, and even the storage locations are secret.

Former Emergent employees, government contractors, members of Congress, biodefense experts and current and former officials from agencies that oversee the stockpile described a deeply dysfunctional system that contributed to the shocking shortages last year.

Purchases are supposed to be based on careful assessments by government officials of how best to save lives, but many have also been influenced by Emergent’s bottom line

The stockpile has long been the company’s biggest and most reliable customer for its anthrax vaccines, which expire and need to be replaced every few years.

In the two decades since the repository was created, Emergent’s aggressive tactics, broad political connections and penchant for undercutting competitors have given it remarkable sway over the government’s purchasing decisions related to the vaccines

While national security officials still consider anthrax a threat, it has not received specific mention since 2012 in the intelligence community’s annual public assessment of dangers facing the country, a report that has repeatedly warned of pandemics.

Emergent bought the license for the country’s only approved anthrax vaccine in 1998 from the State of Michigan. Over time, the price per dose the government agreed to pay Emergent increased nearly sixfold, accounting for inflation, contributing to record revenues last year that topped $1.5 billion

The company, whose board is stocked with former federal officials, has deployed a lobbying budget more typical of some big pharmaceutical companies

Competing efforts to develop a better and cheaper anthrax vaccine, for example, collapsed after Emergent outmaneuvered its rivals, the documents and interviews show.

preparations for an outbreak like Covid-19 almost always took a back seat to Emergent’s anthrax vaccines

the government approved a plan in 2015 to buy tens of millions of N95 respirators — lifesaving equipment for medical workers that has been in short supply because of Covid-19 — but the masks repeatedly lost out in the competition for funding over the years leading up to the pandemic

After Dr. Frieden and others in the Obama administration tried but failed to lessen Emergent’s dominance over stockpile purchases, the company’s fortunes rose under Mr. Trump, who appointed a former Emergent consultant with a background in bioterrorism to run the office that now oversees the stockpile

“If I could spend less on anthrax replenishment, I could buy more N95s,” Dr. Kadlec said in an interview shortly after leaving office. “I could buy more ventilators. I could buy more of other things that quite frankly I didn’t have the money to buy.”

And now, as some members of Congress push for larger reserves of ventilators, masks and other equipment needed in a pandemic, a trade group led in part by a top Emergent lobbyist has warned that the purchases could endanger companies focused on threats like anthrax and smallpox by drawing down limited funds.

Last year, as the pandemic raced across the country, the government paid Emergent $626 million for products that included vaccines to fight an entirely different threat: a terrorist attack using anthrax.

“I think it’s pretty clear that the benefit of the vaccine is marginal,” he said in an interview

“They’re very vicious in their behavior toward anybody they perceive as having a different point of view,” said Dr. Tara O’Toole, a former Homeland Security official who says she ran afoul of Emergent in 2010 after telling Congress that the nation needed a newer and better anthrax vaccine.

That year, the company that would become Emergent — then known as BioPort — paid Michigan $25 million to buy the license for a government-developed anthrax vaccine and an aging manufacturing plant.

The company opened its doors with one product, called BioThrax, and one customer, the Defense Department, which required the vaccine for service members.

Emergent’s anthrax vaccine was not the government’s first choice. It was more than 30 years old and plagued by manufacturing challenges and complaints about side effects. Officials instead backed a company named VaxGen, which was developing a vaccine using newer technology licensed from the military.

Emergent’s successful campaign against VaxGen — deploying a battalion of lobbyists, publicly attacking its rival and warning that it might cease production of its own vaccine if the government didn’t buy it — established its formidable reputation. By 2006, VaxGen had lost its contract and the government had turned to Emergent to supply BioThrax.

“They were totally feared by everybody,” Dr. Philip Russell, a top health official in the administration of President George W. Bush, said in an interview. He said that he clashed with Emergent when he backed VaxGen, and that his reputation came under attack, which was documented by The Times in 2006. (Dr. Russell died this January.)

the group of federal officials who make decisions about the stockpile and other emergency preparations — known as the Phemce, for the Public Health Emergency Medical Countermeasures Enterprise — ordered up a study. It found in 2010 that the government could not afford to devote so much of its budget to a single threat.

Instead, the review concluded, the government should invest more in products with multiple applications, like diagnostic tests, ventilators, reusable respirator masks and “plug and play” platforms that can rapidly develop vaccines for a range of outbreaks.

from 2010 through 2018, the anthrax vaccine consumed more than 40 percent of the stockpile’s budget, which averaged $560 million during those years.

Emergent and the government have withheld details of the stockpile contracts, including how much the company has charged for each dose of BioThrax, but executives have shared some of the missing information with investors.

The company in 1998 agreed to charge the government an average of about $3.35 per dose, documents show. By 2010, the price had risen to about $28, according to financial disclosures and statements by Emergent executives, and now it is about $30

Over the past 15 years, the company recorded a gross profit margin of about 75 percent for the vaccine, in an arrangement that one Emergent vice president called a “monopoly.”

Emergent’s rise is the stuff of lore in biodefense circles — a tale of savvy dealings, fortuitous timing and tough, competitive tactics.

One afternoon in October 2010, Wall Street investors gathered at the Millennium Broadway Hotel in Manhattan for a presentation by Mr. Burrows. He shared with them a secret number: 75 million.That was how many BioThrax doses the government had committed to stockpiling, and it was the backbone of Emergent’s thriving business. In pursuit of that goal, the government had already spent more than $900 million, and it continued to buy virtually every dose Emergent could produce. It had even awarded the company more than $100 million to expand its Michigan factory.

“The best approach toward anthrax is antimicrobial therapy,” Dr. Anthony S. Fauci, the government’s top infectious-disease expert, told Congress as early as 2007.

In an analysis published in 2007, the firm determined that giving antibiotics immediately after a large outdoor anthrax attack was likely to reduce serious illnesses by more than 80 percent. Administering the vaccine would then cut serious illnesses only by an additional 4 percent.

Dr. Ali S. Khan, who ran the C.D.C. office managing the stockpile until 2014, said bluntly: “We overpaid.”

“A bunch of people, including myself, were sitting in a room and asking what kind of attack might happen,” said Dr. Kenneth Bernard, a top biodefense adviser to Mr. Bush, recalling a meeting in the months after the 2001 attacks.

“And somebody said, ‘Well, I can’t imagine anyone attacking more than three cities at once,’” he said. “So we took the population of a major U.S. city and multiplied by three.”

A team of Homeland Security and health officials began doing just that in 2013. The group determined, in a previously undisclosed analysis, that the government could stockpile less BioThrax and still be prepared for a range of plausible attacks, according to two people involved in the assessment. Separately, government researchers concluded that two doses of BioThrax provided virtually the same protection as three.

the National Intelligence Council, which helped draft the assessments during Mr. Obama’s second term, said in an interview that the idea of a three-city attack affecting 25 million people was “straining credulity.”

“If you talk to the head of the House Intelligence Committee,” Don Elsey, Emergent’s chief financial officer, told investors in 2011, “and you say, ‘What are you most worried about?’ he’ll say, ‘Let me see: Number one, anthrax; number two, anthrax; number three, anthrax.’”

Emergent’s sales strategy was to address that fear by promising the federal government peace of mind with its vaccine.

“There’s a political element involved,” Mr. Burrows, the company’s vice president of investor relations, said at an industry conference in 2016. “I don’t have a marketing expense. I have lobbying expense.”

Since 2010, the company has spent an average of $3 million a year on lobbying — far outspending similarly sized biotech firms, and roughly matching the outlays of two pharmaceutical companies with annual revenues at least 17 times greater, AstraZeneca and Bristol Myers Squibb

In 2015, as stockpile managers questioned the large purchases of BioThrax, the spending topped $4 million

“They were pouring it on — how poor they were and how this was going to ruin the company, and they’d have to close down factories, and America was going to be left without anthrax vaccine,”

“Their revolving door is moving at 60 miles per hour,” said former Senator Claire McCaskill, a Democrat from Missouri who had questioned spending on the vaccine while in the Senate. “There is really a lot of incestuousness because it’s such a specialized field.”

Ms. DeLorenzo, the Emergent spokeswoman, said the lobbying was necessary because government investment “in biodefense and other public health threats has not been as strongly prioritized as it should be.”

Over the past 10 years, Emergent’s political action committee has spread almost $1.4 million in campaign contributions among members of both partie

The move followed a yearslong pattern of retaining a bipartisan lobbying corps of former agency officials, staff members and congressmen, including Pete Hoekstra of Michigan, Tom Latham of Iowa and Jim Saxton of New Jersey.

“You have people coming and saying, ‘There’s no market for this — nobody’s going to produce this unless you buy enough of it to keep the production line open,’” he said. “It’s an absolutely appropriate argument to make.”

Emergent’s campaign proved effective. Despite the 2015 recommendation by the stockpile managers, Senate overseers made clear they opposed the reduction, and the government went ahead and bought $300 million worth of BioThrax.

Emergent executives, meanwhile, warned that there could be job losses at the factory in Lansing, Mich. — the capital of a swing state at the center of a contentious presidential campaign between Mr. Trump and Hillary Clinton.

Because Emergent was the sole manufacturer of a product deemed critical to national security, the company has played what one former executive described to The Times as “the we’re-going-to-go-bankrupt card.”

Dr. Hatchett said the idea gave him pause. But, he explained in an interview, “if there’s only one partner that can provide a product and only one customer for that product, the customer needs the partner to survive.”

Just a year later, Emergent spent about $200 million in cash, and made other financial commitments, to acquire Sanofi’s smallpox vaccine and GlaxoSmithKline’s anthrax treatment, two products with established pipelines to the stockpile. The purchases expanded Emergent’s hold over the reserve.

Ms. DeLorenzo said the acquisitions did not suggest the company was better off than it had claimed, but Dr. Bright said he and others involved in the bailout felt used.

a plan five years earlier to create an emergency supply of N95 respirators was simply not funded. A team of experts had proposed buying tens of millions of the masks to fill the gap during an outbreak until domestic manufacturing could ramp up, according to five officials involved in the assessment, which has not been previously disclosed.

By the time the novel coronavirus emerged, the stockpile had only 12 million of the respirators. The stockpile has since set a goal of amassing 300 million.

Dr. Kadlec, the Trump administration official overseeing the stockpile, said he used the previous administration’s mask recommendation to raise alarms as early as 2018.

Dr. Annie De Groot, chief executive of the small vaccine company EpiVax, spoke about the need to break Emergent’s lock on research dollars at a biodefense forum in 2015.

“Politicians want to look like they’ve addressed the problem,” she said. “But we need to actually listen to the scientists.”

Over the last five years, Emergent has received nearly a half-billion dollars in federal research and development funding, the company said in its financial disclosures.

“We know ahead of time when funding opportunities are going to come out,” Barbara Solow, a senior vice president, told investors in 2017. “When we talk to the government, we know how to speak the government’s language around contracting.”

The company used federal money to make improvements to BioThrax, and also found a way to earn government money from a competing anthrax vaccine it had excoriated. After the demise of VaxGen in 2006, Emergent bought the company’s unfinished vaccine and in 2010 persuaded the federal government to continue paying for research on it

By the time the research contract was canceled in 2016, Emergent had collected about $85 million, records show. The company then shelved the vaccine. “If the U.S. government withdraws funding, we re-evaluate whether there is any business case for continuing,” Ms. DeLorenzo said.

For more than 30 years, the government had been encouraging the development of a BioThrax replacement. In 2002, the Institute of Medicine had concluded that an alternative based on more modern technology was “urgently needed.” By 2019, there were three leading candidates, including one made by Emergent, known as AV7909.

Emergent’s candidate was hardly the breakthrough the government was seeking, former health officials said. AV7909 was essentially an enhanced version of BioThrax. The competitors were using more modern technology that could produce doses more rapidly and consistently, and were promising significant cost savings for the stockpile.

To qualify for emergency authorization, a vaccine must be at an advanced stage of development with no approved alternatives. Emergent acknowledged in its financial disclosures that there was “considerable uncertainty” whether the new vaccine met those requirements.

The election of Mr. Trump as president was good news for Emergent.

Dr. Lurie, the senior health official in the Obama administration who had tried to scale back BioThrax purchases, was out. Mr. Trump’s pick to replace her was Dr. Kadlec, a career Air Force physician and top biodefense official in the Bush administration who was fixated on bioterrorism threats, especially anthrax, current and former officials said

Soon after entering the Trump administration in 2017, Dr. Kadlec took a series of actions that he characterized as streamlining a cumbersome bureaucracy but that had the effect of benefiting Emergent.

He assumed greater control of purchasing decisions, diminishing the authority of the Phemce, the oversight group that had proposed buying less BioThrax. And in 2018, he backed a decision to move control of the stockpile to his office in the Department of Health and Human Services and away from the C.D.C., which is based in Atlanta and prides itself on being insulated from the influence of lobbyists.

Dr. Frieden, the former C.D.C. director, was strongly opposed. The move, he said, “had almost as an explicit goal to give the lobbyists more say in what got purchased.”

That July, the government made the announcement Emergent had been banking on, committing to buying millions of doses. Separately, it said it would stop funding Emergent’s competitors.

The decision to side with Emergent did not surprise Dr. Khan, the former C.D.C. official overseeing the stockpile.“Again and again, we seem unable to move past an old technology that’s bankrupting the stockpile,” he said.

Last month, as the death toll from Covid-19 neared a half-million, Mr. Kramer, the company’s chief executive, told analysts there had been no “evidence of a slowdown or a delay or a deprioritization,” and echoed a statement he had made in April when asked whether the pandemic might interrupt Emergent’s sales to the stockpile.“It’s pretty much business as usual,” he said then.

The result was a perfect storm: A U.S. government not well prepared for a pandemic, run by a president who was slow to act after his intelligence community and public health advisers were warning about the dangers.

U.S. government over 20 years of successive administrations and Congresses failed to heed the warnings by taking basic steps that would have made it easier to quickly respond to a fast spreading and lethal pathogen. They didn't set up and fund a large volunteer medical reserve corps, for example, or build surplus hospital capacity, or create a system to quickly produce and deploy virus tests.

elected officials from both parties have never fully geared up for the biological threat, former officials and public health experts told NBC News. Each new White House deprioritized the issue, only to elevate it later after some defining event led to a presidential revelation. They then belatedly scrambled to respond with ambitious plans and initiatives, which faded after a few years.

"Here's the problem: In 10 years, if there's no pandemic, then everybody starts getting a bit relaxed," said Michael Leavitt, a former Utah governor who served as secretary of Health and Human Services in the Bush administration.

officials deserved "at least a B-plus," and Mount Sinai virologist Peter Palese called the overall response "excellent." Republicans in Congress praised the CDC for developing a vaccine in six months.

But after 9/11 and the subsequent anthrax attacks, the newly created Department of Homeland Security hired Bernard back, with added staff, to run a bio-preparedness unit.

After Bush read a book about the 1918 influenza pandemic in 2005, he forced his administration to double down on pandemic preparation, replenishing the stockpile and creating an early warning system.

When President George W. Bush took office in 2001, Bernard wrote a transition memo. He soon learned the Bush team had eliminated his job as White House biodefense czar.

When Ebola erupted in Africa in 2014, Obama brought in an outsider, Ron Klain, to run the federal response. The effort was widely praised, as was Obama's response to the 2016 Zika virus outbreak. But afterward, the Obama administration failed to fully replenish the federal stockpiles, according to research by ProPublica and USA Today.

Under Obama and a mostly Republican-controlled Congress, public health spending declined. Per capita public health spending, adjusted for inflation, rose from $39 in 1960 to $281 in 2008, and fell by 9.3 percent from 2008 to 2016, according to a 2016 study published in the American Journal of Public Health. It has fallen further under the Trump administration, records show.

During the transition from Obama to Trump, Obama officials conducted a tabletop exercise based on a pandemic with incoming Trump aides. But in his second year as president, Trump fired his top official in charge of pandemic response, Tom Bossert, and did not replace him. Trump then allowed his national security adviser to disband the NSC's global health unit. As a result, when alerts about coronavirus began to emanate from the intelligence and public health communities, there was no senior official in the White House to coordinate a response.

"Every administration has at some point in time gotten religion and realized there is a program and dusted it off and used it," Clarke told NBC News."Except this one."

"The disease-causing microbes of the planet," wrote Garrett, "far from having been defeated, [are] posing ever greater threats to humanity."

The exercise predicted many of the problems besetting the coronavirus response – confused lines of authority, shortages of medical gear, controversies over social distancing.

They failed to set up a system that would insure the rapid deployment of tests for a novel virus. And they failed to replenish a federal stockpile that hospital officials say is both insufficiently stocked and rife with defective gear.

Those failures — and the late start on gear purchases by the Trump administration — have severely hampered the U.S. response to coronavirus, said Scott Gottlieb, who ran the FDA from 2017 to 2019.

"In no way, shape or form can anyone say that we weren't warned, that the information wasn't available and shared with them," he said. "We've known about the risk of pandemics, and war gamed them literally going back some 30 years."

Even before the pandemic struck, local public health agencies had lost almost a quarter of their overall workforce since 2008 — a reduction of almost 60,000 workers

The agencies’ main source of federal funding — the Centers for Disease Control and Prevention’s emergency preparedness budget — had been cut 30 percent since 2003. The Trump administration had proposed slicing even deeper.

According to David Himmelstein of the CUNY School of Public Health, global consensus is that, at minimum, 6 percent of a nation’s health spending should be devoted to public health efforts. The United States, he said, has never spent more than half that much.

the problems have been left to fester.

Delaware County, Pa., a heavily populated Philadelphia suburb, did not even have a public health department when the pandemic struck and had to rely on a neighbor to mount a response.

With plunging tax receipts straining local government budgets, public health agencies confront the possibility of further cuts in an economy gutted by the coronavirus. It is happening at a time when health departments are being asked to do more than ever.

While the country spends roughly $3.6 trillion every year on health, less than 3 percent of that spending goes to public health and prevention

“Why an ongoing government function should depend on episodic grants rather than consistent funding, I don’t know,” he added. “That would be like seeing that the military is going to apply for a grant for its regular ongoing activities.”

Compared with Canada, the United Kingdom and northern European countries, the United States — with a less generous social safety net and no universal health care — is investing less in a system that its people rely on more.

Himmelstein said that the United States has never placed much emphasis on public health spending but that the investment began to decline even further in the early 2000s. The Great Recession fueled further cuts.

Plus, the U.S. public health system relies heavily on federal grants.

“That’s the way we run much of our public health activity for local health departments. You apply to the CDC, which is the major conduit for federal funding to state and local health departments,” Himmelstein said. “You apply to them for funding for particular functions, and if you don’t get the grant, you don’t have the funding for that.”

Many public health officials say a lack of a national message and approach to the pandemic has undermined their credibility and opened them up to criticism.

Few places were less prepared for covid-19’s arrival than Delaware County, Pa., where Republican leaders had decided they did not need a public health department at all

At the same time, many countries that invest more in public health infrastructure also provide universal medical coverage that enables them to provide many common public health services as part of their main health-care-delivery system.

Taylor and other elected officials worked out a deal with neighboring Chester County in which Delaware County paid affluent Chester County’s health department to handle coronavirus operations for both counties for now.

One reason health departments are so often neglected is their work focuses on prevention — of outbreaks, sexually transmitted diseases, smoking-related illnesses. Local health departments describe a frustrating cycle: The more successful they are, the less visible problems are and the less funding they receive. Often, that sets the stage for problems to explode again — as infectious diseases often do.

It has taken years for many agencies to rebuild budgets and staffing from deep cuts made during the last recessio

During the past decade, many local health departments have seen annual rounds of cuts, punctuated with one-time infusions of money following crises such as outbreaks of Zika, Ebola, measles and hepatitis. The problem with that cycle of feast or famine funding is that the short-term money quickly dries up and does nothing to address long-term preparedness.

“It’s a silly strategic approach when you think about what’s needed to protect us long term,”

She compared the country’s public health system to a house with deep cracks in the foundation. The emergency surges of funding are superficial repairs that leave those cracks unaddressed.

“We came into this pandemic at a severe deficit and are still without a strategic goal to build back that infrastructure. We need to learn from our mistakes,”

With the economy tanking, the tax bases for cities and counties have shrunken dramatically — payroll taxes, sales taxes, city taxes. Many departments have started cutting staff. Federal grants are no sure thing.

80 percent of counties have reported their budget was affected in the current fiscal year because of the crisis. Prospects are even more dire for future budget periods, when the full impact of reduced tax revenue will become evident.

Christine Hahn, medical director for Idaho’s division of public health and a 25-year public health veteran, has seen the state make progress in coronavirus testing and awareness. But like so many public health officials across the country taking local steps to deal with what has become a national problem, she is limited by how much government leaders say she can do and by what citizens are willing to do.

“I’ve been through SARS, the 2009 pandemic, the anthrax attacks, and of course I’m in rural Idaho, not New York City and California,” Hahn said. “But I will say this is way beyond anything I’ve ever experienced as far as stress, workload, complexity, frustration, media and public interest, individual citizens really feeling very strongly about what we’re doing and not doing.”

“I think the general population didn’t really realize we didn’t have a health department. They just kind of assumed that was one of those government agencies we had,” Taylor said. “Then the pandemic hit, and everyone was like, ‘Wait, hold on — we don’t have a health department? Why don’t we have a health department?’ ”

“People locally are looking to see what’s happening in other states, and we’re constantly having to talk about that and address that,”

“I’m mindful of the credibility of our messaging as people say, ‘What about what they’re doing in this place? Why are we not doing what they’re doing?’ ”

Many health experts worry the challenges will multiply in the fall with the arrival of flu season.

“The unfolding tragedy here is we need people to see local public health officials as heroes in the same way that we laud heart surgeons and emergency room doctors,” Westergaard, the Wisconsin epidemiologist, said. “The work keeps getting higher, and they’re falling behind — and not feeling appreciated by their communities.”

It is past time for the nation to make the investments we need to prevent, detect and respond quickly to emerging infectious diseases, like the coronavirus, before they sicken Americans and force catastrophic economic shutdowns.

authorities are too often flying blind, uncertain of the trajectory of the disease, slow to identify hot spots and unable to stop the spread of the virus through targeted measures that do not require shutting down entire communities and economies.

The success of public health measures like contact tracing, mask-wearing, and social distancing depends on individuals and communities trusting and adhering to advice from medical professionals and scientists, sometimes delivered by elected and other officials

That public trust must be earned and sustained.

Elected US officials, including the President, often have fallen short as communicators in this pandemic.

The pandemic has taken a grievous toll on the elderly and nursing home residents specifically. It has also hit essential workers hard, and Black, Latino, Native and low-income Americans suffer disproportionately. As of the end of September, according to the Atlantic, Black Americans have died from Covid-19 at 2.3 times the rate of White Americans, comprising 21% of all US deaths from the disease

US government authorities at all levels should target public health investments to increase the resilience of these communities, including universal paid sick leave in declared pandemics, accessible and free testing, and workplace protections and personal protective equipment for essential workers. Social justice and equity in our existing health care system is not just a moral mandate -- it is a matter of basic pandemic preparedness.

The smarter choice is to reform and strengthen the WHO as an essential cornerstone of global pandemic preparedness

The coronavirus demonstrates that an international framework for pandemic detection and response that relies so heavily on the transparency, judgment and discretion of individual national governments leaves too many opportunities for failure.

Alerts from that network should, in turn, notify national public health agencies and the WHO -- and trigger an international response.

Finally, the next president must resist the siren song of vaccine nationalism

So far, the US has chosen not to join COVAX, a groundbreaking consortium of more than 150 countries created not only to develop a vaccine but to ensure that when one emerges it is shared equitably, rather than hoarded by individual countries. We hope that the next president -- whoever he may be -- will reconsider this decision.

When it comes to pandemics, we all sink or swim together,

years of painstakingly worded treaties, high-level visits and cutting-edge disease surveillance—all meant to encourage good-faith cooperation—have only bitten around the edges of the problem.

“It can’t demand entry into a country because they think something bad is happening.”

Nearly 200 countries were counting on an agency whose budget—roughly $2.4 billion in 2020—is less than a sixth of the Maryland Department of Health’s. Its donors, largely Western governments, earmark most of that money for causes other than pandemic preparedness.

In 2018 and 2019, about 8% of the WHO’s budget went to activities related to pandemic preparedness

It took those experts more than four months to agree that widespread mask-wearing helps, and that people who are talking, shouting or singing can expel the virus through tiny particles that linger in the air. In that time, about half a million people died.

To write its recommendations, the WHO solicits outside experts, which can be a slow process.

the agency’s bureaucratic structure, diplomatic protocol and funding were no match for a pandemic as widespread and fast-moving as Covid-19.

As months rolled on, it became clear that governments were reluctant to allow the U.N. to scold, shame or investigate them.

In particular, The Wall Street Journal found:

* China appears to have violated international law requiring governments to swiftly inform the WHO and keep it in the loop about an alarming infectious-disease cluster

—there are no clear consequences for violations

* The WHO lost a critical week waiting for an advisory panel to recommend a global public-health emergency, because some of its members were overly hopeful that the new disease wasn’t easily transmissible from one person to another.

* The institution overestimated how prepared some wealthy countries were, while focusing on developing countries, where much of its ordinary assistance is directed

Public-health leaders say the WHO plays a critical role in global health, leading responses to epidemics and setting health policies and standards for the world. It coordinates a multinational effort every year to pick the exact strains that go into the seasonal flu vaccine, and has provided public guidance and advice on Covid-19 when many governments were silent.

The world’s public-health agency was born weak, created in 1948 over U.S. and U.K. reluctance. For decades, it was legally barred from responding to diseases that it learned about from the news. Countries were required to report outbreaks of only four diseases to the WHO: yellow fever, plague, cholera and smallpox, which was eradicated in 1980.