Ominous pathogens seem to arrive every few years: SARS in 2003, swine flu in 2009, Ebola in 2014, Zika in 2016, COVID-19 in 2019. The World Health Organization calls these viral threats “Disease X,” both to encourage policy makers to think broadly about what the next pandemic might be, and because it could be anything. At this rate, 2025 is not looking good.
After an inept coronavirus response, will the United States do better when the next pandemic strikes? Experts generally agree that America learned from the past year, and that the next public-health crisis won’t be quite as bewildering. But America’s pandemic preparedness still has major gaps, some of which are too big for any one administration to fix. In recent weeks, I’ve called back many of the experts I interviewed over the past 18 months about masks, testing, contact tracing, quarantine, and more. I asked them, “Are we ready for another one?” The short answer is “Not quite.” The long answer is that being truly “ready” will be harder than anyone realizes.
The U.S. is notorious for spending oodles on health care, but health care has little to do with stopping the spread of infectious diseases. When a person has strep throat, they go to the doctor; when a nation faces an epidemic, it turns to public-health workers. But one major reason the U.S. struggled to contact tracewas that budget cuts following the 2008 recession had eviscerated the nation’s public-health departments. Spending on state and local public-health departments has declined by 16 and 18 percent, respectively, since 2010, according to an analysis by Kaiser Health News and the Associated Press. Public-health departments’ data systems are especially outdated, which means that public-health workers have trouble tracking people’s vaccine status, counting COVID-19 deaths, or sharing data across state lines.
The American Rescue Plan, which was signed by President Joe Biden in March, dedicates $7.7 billion to hiring and training more public-health workers to perform tasks such as contact tracing and vaccination. Several experts commended this cash infusion, but they said what’s really needed is a larger annual public-health budget. Public-health departments can’t hire people based on a onetime surge of money. Just like businesses, they need annual revenue in order to make payroll. “A lot of states are not going to hire people unless they know that there’s a secure, ongoing level of funding,” Marcus Plescia, the chief medical officer at the Association of State and Territorial Health Officials, told me. That would need to come from Congress, a body that is not known for acting swiftly and boldly.
In March of last year, I explained that the U.S. was behind on coronavirus testing because the FDA’s authorization process for new types of lab tests—called an emergency use authorization, or EUA—was too slow. “The speed of this virus versus the speed of the FDA and the EUA process is mismatched,” Alex Greninger, the assistant director of the virology division at the University of Washington Medical Center, told me at the time.
After these early testing bungles, the FDA changed its authorization process so that labs could spin up tests more quickly. But testing for Disease X is not guaranteed to go more smoothly. The FDA is answerable to whichever administration is in charge at the moment, and the next pandemic might happen under the watch of President Donald Trump Jr., not President Biden. A president might be incentivized to slow testing so that the overall rates of infection look better—and indeed, President Donald Trump reportedly did this.
Another challenge that labs faced this time was getting a sample of the coronavirus out of China, where it originated and where controls on viral-sample shipping are strict. When I called Greninger back recently, he said he hopes that whoever is at the helm of the FDA during the next crisis will allow labs to use the virus’s genetic sequence, which is easier to obtain than a live sample, as the initial way of proving that their test works. (In response to a request for comment, an FDA spokesperson said that in the future, “if there are no available clinical specimens, FDA will consider the best approach to allow for validation with the most appropriate means available, for a limited time until clinical specimens become available.”)
Other testing reforms would be helpful too. The Health and Human Services Department needs to do a better job of coordinating testing among public-health labs, academic labs, and commercial labs, all of which were working on different kinds of tests at the beginning of this pandemic, Scott Becker, the CEO of the Association of Public Health Laboratories, told me. The federal government should also be proactively monitoring wastewater for signs of an emerging virus, not relying on people to volunteer for testing, says Ralph Catalano, a public-health professor at UC Berkeley. These steps would be wise, but they hinge on the wisdom of the people in power when Disease X hits.
As Americans were learning about the coronavirus pandemic, they also learned of something called “the national stockpile,” which held a strategic reserve of N95 masks. Or at least it was supposed to. It turned out that the federal government had distributed 85 million N95s during the 2009 swine-flu pandemic, and that supply was never replenished. That led to a shortage of masks in 2020 just as health-care workers needed them most.
For now, that shortage has been alleviated. Last year, the federal government bought 325 million more N95s, said Dan Glucksman, the senior director for policy at the International Safety Equipment Association, which develops standards for personal protective equipment.
In general, the Biden administration has shown “a commitment to a very data-driven, scientific approach to planning,” Charles Johnson, the president of the ISEA, said. But Glucksman and Johnson told me the administration could improve the stockpile further by having mask manufacturers rotate out the mask supply regularly so that it never expires. (N95 masks expire after about five years.) And to combat the hoards of N95 counterfeiters, Biden would do well to establish a White House–level office to fight fakes, they said.
Americans were supposed to stay home for two weeks if they tested positive for COVID-19 or were exposed to it, but months into the pandemic, it became clearthat they weren’t actually quarantining. The reason many people didn’t quarantine was sad and banal: They didn’t have paid time off from work. “We hear people say, ‘I have to work; I have to have my income,’” Ray Przybelski, the director of the Portage County Health and Human Services Department, in Wisconsin, told me in December.
Throughout the pandemic, the federal government did pass several laws that allowed Americans to stay home from work if they were sick with COVID-19 or had to take care of children who were home from school. The concept of paid time off was so new to Americans that many didn’t realize they could take it. But those provisions have now expired, and that leaves America as, once again, the only industrialized country without mandatory, national paid leave. If paid leave isn’t established through legislation before the next pandemic, Americans will find themselves in the same situation, dragging themselves into work and spreading pathogens behind them.
Americans’ experience of the pandemic was largely determined by the state they lived in. Texans were allowed to stop wearing masks on March 10, 2021, when less than 10 percent of the U.S. population had been fully vaccinated. Hawaiians, meanwhile, were required to keep wearing masks indoors as of May 26, when 40 percent of Americans had been fully vaccinated. Last April, a New Yorker might have huddled alone in her tiny apartment while her relatives in South Dakota, which never issued a stay-at-home order, sat in a casino as though it were a normal spring day. The entire pandemic was a bizarro choose-your-own-adventure story in which governors did most of the choosing.
The Trump administration’s unwillingness to have the federal government take the lead made local public-health officials’ job harder. Contact tracing became a brand-new, massive undertaking thrust on each state overnight. “States were left to figure out contact tracing themselves,” said Steve Waters, the head of Contrace, which helps connect contact tracers with health departments.
The Biden administration believes that the federal government is a necessary leader in pandemic response, and will therefore be better positioned to coordinate state actions if Disease X arrives on its watch. But the ability of the government—any government—to handle a pandemic will be limited in a country where federalism and individualism are prized. Other countries have a minister of health; the U.S. has a weak CDC that makes suggestions states can follow or not. “The public-health response has to be unified across the country, must be guided by national leadership and national direction,” Wafaa El-Sadr, a professor of epidemiology and medicine at Columbia University, told me. “This is almost impossible in the face of limited authority of the CDC over states and the autonomy of states in making their own decisions, often due to political imperatives.”
El-Sadr suggested that, in emergencies such as pandemics, perhaps the CDC could temporarily take on a more “directive” role, telling state leaders exactly what to do. But given the politicization of even cloth face masks and free vaccines, that’s highly unlikely to happen.
She also brought up something that will take more than one presidential administration to fix: A lot of Americans died because “we don’t have a healthy population overall,” El-Sadr said. America has a high rate of obesity, a high rate of poverty, a high rate of uninsurance, and now, a high rate of anti-vaccine conspiracism. Pandemics exploit the vulnerabilities that we’ve never bothered to shore up. We may not know what Disease X will be, but it knows exactly where to hit us.