The response to the coronavirus pandemic in the United States and other countries has been hobbled by a host of factors, many involving political and regulatory officials. Resistance to social distancing measures, testing debacles, and longtime failures to prepare for the possibility of a pandemic all played a role.
But a subtler, less-recognized factor contributed to the wasting of precious weeks in January and February, when preparations to try to stop the virus should have kicked immediately into high gear.
Magical thinking — you could call it denial — hampered the ability of even some of the most seasoned infectious diseases experts to recognize the full threat of what was bearing down on the world.
As China was seeking to rid itself of the SARS-CoV-2 virus, a number of leading infectious diseases scientists mused that the outbreak would be controlled or might burn itself out. Yes, there were cases outside China — just over 100 had been reported to the World Health Organization by Jan. 31 — but they were spread out in relatively small numbers in 19 countries. The virus, the thinking went, didn’t appear to be behaving as explosively outside of China as it had inside it.
In hindsight, that argument, from a biological point of view, didn’t make any sense — and it ignored a soon-to-be-apparent Epidemiology 101 lesson: It takes time for a virus that spreads from person to person to hit an exponential growth phase in transmission, even if every new case was infecting on average two to three other people.
It wasn’t that the virus was behaving differently; we simply hadn’t yet seen what it was doing as it moved beyond China. When large outbreaks exploded in Iran and then Northern Italy in late February, the reality became abundantly evident. And then it was too late.
“Everybody was in denial of this coming, including the U.S. And everybody got hit — just as simple as that,” Gary Kobinger, director of the Infectious Disease Research Center at Laval University in Quebec, told STAT.
Kobinger himself thought the WHO’s immediate move to a war footing on the virus — the day after China made its first official report on it on Dec. 31 — was probably an overreaction. The rapid rise in cases in the city of Wuhan brought him around.
“After that I changed my mind and I said, ‘No, this is not an overreaction. This is what we need,'” said Kobinger, who is on an expert committee that advises WHO’s health emergencies program.
It’s not that infectious disease experts didn’t take notice of what was happening. When something that might be a new infectious disease emerges from China, spines tend to stiffen in this community. China has a track record of being a source of some scary new infections — SARS in 2002-2003; H5N1 bird flu, for about a dozen years starting from 2004; and H7N9 bird flu, from 2013 to 2018. And yet the immediate reaction this time was, perhaps, fairly cautious.
On Jan. 5, a day after STAT published its first story on what would become the novel coronavirus, Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota, told me he didn’t think the new outbreak would turn into a pandemic.
At that point Wuhan, the epicenter of the outbreak, was reporting 59 cases. The disease didn’t yet have a name. It would be three more days until China even announced the cause was a new coronavirus, and five days until it posted the genetic sequence of the virus in a global database.
Osterholm, co-author of the 2017 book “Deadliest Enemy: Our War Against Killer Germs,” thought China was going to get a handle on whatever was responsible for the outbreak. Even if the cause was a new coronavirus — as was rumored from the first emerging word of the outbreak — the world had experience controlling coronavirus outbreaks. The SARS virus had been vanquished, and MERS, a related camel virus that causes sporadic human cases on the Arabian Peninsula, had never spread widely beyond it, except for one outbreak in South Korea in 2015.
Within days, Osterholm’s thinking shifted. By Jan. 20, he was warning the 3M Company — which makes N95 respirators — that the virus, in his opinion, would cause a pandemic. The company immediately moved to increase production.
Osterholm was nonetheless seen by some colleagues as too quick to pull the alarm, especially after he published an opinion piece in the New York Times on Feb. 24 with the headline: “Is It A Pandemic Yet?” (The WHO didn’t declare the outbreak a pandemic until March 11.)
“I was getting the same heat from people. ‘Oh, there you go again, you’re scaring everybody,’” Osterholm recalled recently. “I said, no, you don’t get it. This one’s real. This is it. And they didn’t get it.”
In late January, Wang Linfa, who co- discovered SARS, told STAT the virus was not as dangerous as its earlier cousin had been. “It’s too early to say if a SARS-like event will happen. But I have a gut feeling it won’t,” said Wang, director of the program in emerging infectious diseases at Duke-NUS Medical School in Singapore.
That interview occurred on Jan. 27, after China had taken the extraordinary step of quarantining tens of millions of people in Wuhan — a measure it never resorted to during the SARS outbreak. By that point, more than 2,700 cases had been diagnosed, most still in China. SARS-CoV-2 had infected in less than one month more than one-third of the cases recorded in the entire months-long SARS outbreak.
Through January and beyond, the WHO was exhorting countries to be ready to find and stop spread of the virus, championing a containment plan aimed at halting transmission. The agency made clear the virus was an extremely serious threat, but still hoped the new coronavirus could be relegated to the history books.
“There’s enough evidence to suggest that this virus can still be contained,” Mike Ryan, head of the WHO’s health emergencies program, told STAT on Feb. 1.
Like the WHO, the Centers for Diseases Control and Prevention quickly recognized that the situation in Wuhan might spell trouble. On Jan. 7, the agency stood up an incident management structure for its Covid-19 response. The next day, it issued a notice to health care providers and state and local public health departments to be on the lookout for illness in people who had recently been in Wuhan.
Nancy Messonnier, director of the CDC’s Center for Immunization and Respiratory Diseases, may have been among the first top U.S. health experts to publicly acknowledge the new coronavirus might cause a pandemic.
“If you were here at CDC in the emergency operations center, you would see us stood up just like we had been planning to do for a pandemic,” she told me in an interview on Jan. 24.
“I think the real question is whether other countries are going to see sustained transmission. And on hours where I’m feeling optimistic, I think about the fact that none of the other countries, including the U.S., have seen significant sustained chains of transmission,’’ Messonnier said. “But that doesn’t mean that it’s not coming.”
A week later, on Jan. 31, she told reporters who dialed into a CDC Covid-19 briefing: “We are preparing as if this were the next pandemic, but we are hopeful still that this is not and will not be the case.”
In the second week of February, Kobinger traveled to Geneva for a scientific meeting at the WHO that was attended by experts from around the world. The Asian scientists were all extremely nervous, Kobinger recalled, mentioning that a South Korean scientist he knew was shaky.
“I’ve never seen him like this, and I’ve known him for 15 years,” he said, without naming the scientist.
But a number of the Europeans at the meeting expressed the belief the virus would not come to Europe in a big way, noting they’d been testing and not finding anything at that point.
“In Europe, they … are convinced it’s going to die off, that it won’t come to Europe,” Kobinger said after the meeting. Looking back on it recently, he said: “I could not understand that rationale of saying ‘It’s not going to come here.'”
At that point, of the nearly 45,000 cases globally, about 450 were from outside of China, and the places with the most cases — Singapore, Japan, and South Korea — appeared to be containing the virus.
About the time Kobinger was in Geneva, I was in Washington moderating a panel on the new coronavirus at the Aspen Institute. On the panel were Messonnier from the CDC; Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases and a key member of the White House’s coronavirus response team; and Ron Klain, who served as President Obama’s Ebola czar during the 2014-2016 Ebola crisis.
Even in mid-February, Fauci was describing the risk to Americans as “relatively low,” saying that he hoped sustained human-to-human spread might not occur in the United States.
He and Messonnier both noted that there were only 13 cases in the United States — surely a major underestimate at the time. Health departments were monitoring the contacts of known cases, but weren’t seeing illnesses among those contacts, Messonnier said.
I pressed Fauci on his assessment the risk was low, pointing out there was no force field around China. “Is there a risk that this is going to turn into a global pandemic? Absolutely yes! There is. There is,” he acknowledged.
The following week I interviewed a number of infectious diseases experts in the U.S. and Europe. I was working on a story exploring why the virus seemed not to be spreading as much outside of China as it had in Wuhan and Hubei province. Several of the people I spoke to were puzzled. Then Caitlin Rivers, an assistant professor of epidemiology at the Johns Hopkins Center for Health Security, gave me that Epidemiology 101 lesson: It takes time, she explained, for an outbreak to build to the exponential growth phase, where cases appear to mushroom and hospitals get overrun.
Before I had time to write the article, Iran and then Italy proved her right. A pandemic was clearly underway.
Anne Schuchat, principal deputy director of the CDC, agrees that there was a kind of unreal quality to the emerging evidence as cases continued to climb, though she, like Messonnier, said the agency’s response was early and aggressive. Schuchat is now leading the CDC’s day-to-day response.
Schuchat, who ran Messonnier’s center before being named the agency’s No. 2, spent years involved in planning for pandemic influenza — planning that was deployed during the 2009 H1N1 pandemic. That event was mild, by pandemic standards.
“There’s a sense for all of us pandemic influenza planners and responders and respiratory virus folks that look back at [the Spanish flu pandemic of] 1918 and say, ‘Well, we always need to prepare and be ready for that.’ But in the back of your mind it’s sort of ‘Yeah, but I’m not going to have to go through it,’” she told me last week.
Initially, information out of China was at times murky. The death rate seemed high, but it wasn’t clear if that was because milder cases were simply being underreported.
“I think many of us doubted the severity. The sense of well, OK, it’s a few percent, but that’s because you’re only keeping up with what’s in the hospital,” Schuchat said. It’s become clear since “it’s a severe pandemic. There’s no question about that.”
Schuchat recalled the moment when she realized what the country and the world might be facing. In a Feb. 27 meeting with modelers who had been working on estimates of what might happen in the U.S., the scenario that seemed the most plausible projected 2 million Americans would die, if actions to slow spread weren’t taken.
“I remember sitting in that room and saying … ‘We’ve got to go on a pause. People have to stay home,’” Schuchat said. “This seems like the time for mitigation.”
The Trump administration has resisted calls for a national shelter-in-place order, leaving it to state and local health authorities to act on their own. California issued the first mandatory stay-at-home order on March 19, followed closely thereafter by Washington state. Many, though not all other states followed suit.
“Whether it’s wishful thinking or magical thinking, I think we were taking it seriously, acting aggressively,” Schuchat said. “But in the back of our minds, there’s that human nature of denial, that ‘Could it really be as severe as it is?'”
An earlier version of this story misstated the date on which China confirmed the Wuhan outbreak was caused by a new coronavirus. It was Jan. 8.