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In ordinary times, states handle the public health crises that affect their residents. That usually works well, because challenges in California can vastly differ from those in Connecticut. But these are not ordinary times.

Covid-19 does not respect state lines. So without explicit federal coordination of the response to and the recovery from this pandemic, the American people are left largely unaware of health and safety guidelines, unsure of best practices, and unnerved to see states competing against each other for lifesaving resources such as test kits, personal protective equipment, and ventilators.


Instead of 50 states with 50 different strategies, what the country needs now — as states loosen stay-at-home restrictions and try to return to a sense of normal — is a unified Covid-19 response and recovery plan that can be tailored and implemented locally.

President Trump’s declaration of a national emergency on March 13 should mean that the federal government leads the effort. Doing so could support and coordinate states as they apply science-based policies to their own communities.

And that’s because the federal government can establish national guidance and update it as necessary. Only the federal government can leverage its enormous buying power to purchase test kits and personal protective equipment at the most competitive prices, assure that the domestic supply chain can meet demand, and distribute resources equitably to states and laboratories. And only the federal government can establish standards for the country to synchronize state surveillance, establish benchmarks, monitor outcomes, disseminate best practices, and offer consistent health messages that can lead to a healthier and more informed populace.


Governors, who have clamored for cooperation, have formed some regional collaborations. But that is not enough.

As the assistant secretary for health in the Obama administration during the H1N1 crisis, I know that a coherent “one-government” approach is the only way to coordinate national, state, and local officials during a pandemic. Doing so allows the country to concentrate all of its resources, attention, and energy to protect health.

A federally led, nationally coordinated Covid-19 response and recovery plan should, at a minimum, include these five elements:

National standards for controlling Covid-19 outbreaks and reopening society. Standardizing outbreak control has become an increasingly critical issue for high-risk sites such as nursing homes — which currently make up one-third of deaths nationally — prisons, meat packing plants, and homeless shelters, and others.

Federal guidance can provide place-based frameworks to guide states as they respond to these outbreaks while tracking common key indicators such as new cases of Covid-19, deaths, hospitalizations, and hospital capacity. Tracking such indicators through a recovery phase can demonstrate that the pandemic can be contained as sectors reopen.

Explicit national place-based strategies to address Covid-19 in these and other high-risk sites have special urgency for communities of color, including indigenous peoples, who are disproportionately affected. Monitoring comprehensive race/ethnicity data is essential. The Centers for Disease Control and Prevention has begun to offer some detailed recommendations, starting with checklists and other guidance, for reopening schools, businesses, restaurants, and other sectors.

Testing strategies for high-risk populations and communities of color. The country must test smarter and test harder so that current national testing guidelines, which primarily focus on symptomatic people, extend to asymptomatic people as well in the high-risk populations and sites mentioned earlier. Doing so would build upon recent scientific understanding about asymptomatic transmission of Covid-19.

In overall national testing, positivity rates started around 20% and have dropped under 10% in the last two weeks. But they need to go lower still to demonstrate we are casting our net wide enough, finding every case and not missing any. South Korea’s positivity rate of 1% to 2%, is one example of an aggressive national strategy that has kept the country’s death toll at a fraction of the U.S. rate. Current testing in the U.S., about 350,000 tests a day, must rise by at least several fold, and perhaps even further as demand rises.

Testing strategies aren’t as easy as they might seem. We need key expert groups to weigh in now on difficult challenges, such as which diagnostic tests are most valid and reliable, how to reduce false negatives and false positives, and determining the future of antibody testing. These issues will gain further importance as more schools and businesses consider broad-scale testing in their own sites.

A coordinated system for contact tracing. Contact tracing efforts across the states are currently a patchwork. Some states, like New York and California, have begun recruiting “armies” of 17,000 and 20,000 tracers, respectively, while other states have barely begun. The federal government can standardize training and evaluate outcomes, such as the number of contacts who have been exposed to SARS-CoV-2, and whether they successfully followed quarantine recommendations. Such national information will be invaluable as the country tries to onboard the estimated 100,000 to 300,000 professionals needed.

Determining how technology of the kind that Singapore has used might help in contact tracing and must involve some federal coordination. Contact tracers, who can also link individuals needing social support at home to food and other services, represent the foundation for a community health workforce that the country has long needed.

A coordinated plan for supplying the health care system. If we face another Covid-19 surge this fall, it would be tragic if we once again witnessed states bidding against one another for resources. The federal government should lead and coordinate procurement of personal protective equipment, ventilators, and drugs; maximize domestic production of supplies; and expeditiously send supplies to hot spots.

The president’s announcement to rebuild the Strategic National Stockpile must be followed by a coordinated, real-time distribution plan that states view as fair. And we should start now to consider how to equitably distribute emerging therapeutic agents such as remdesivir based on state need, and create an immunization strategy focusing on high-risk groups that the country can implement once an effective vaccine is approved.

Funding for health care and public health. Initial rounds of congressional funding, including the CARES Act, have sent $175 billion to hospitals and doctors. While Congress has allocated $26 billion for testing, supplies, and contact tracing, more is needed to revitalize state and local public health infrastructure, which has been overlooked and underfunded for too long.

A national plan for Covid-19 response and recovery can better protect all Americans, who have endured so much as the pandemic has swept across the country. It’s time to implement a coherent approach that brings together national, state, and local officials: a united plan for a United States.

Howard K. Koh is a physician, the former assistant secretary for health in the Obama administration, and professor of the practice of public health leadership at the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School.

  • The US is too large and too diverse for a ‘one size fits all’ solution. The state and local governments are much better aware of their situation than a bureaucrat in Washington DC.

    Also remember that the tried and tested disaster response doctrine in the US is that local governments are in charge with the state and federal levels providing support. It works and works well – no reason to change it.

    • The “tried and tested” disaster response doctrine was based on hurricanes and earthquakes, sometimes wildfires. They can certainly effect large areas but they are not infectious diseases, and all of them are are least confined to regions.
      They can recur, but not because the people who got flooded out last time are still carrying “flood germs” – there is no good comparison between infectious disease and natural disasters.

      And, unlike the natural disasters, a bad response – or maybe not even “bad” just one leading to more infected people – can easily effect a neighboring state – my state is medium infected now- many states worse off, many better – but the trend is for my state to get worse, but so far only moderately worse – but if a bunch of people come here from states which were not cautious, they will infect us.
      I want a good national response – at the least, to make sure everyone get’s needed supplies, without hogging them.

    • People are not ‘hogging’ supplies. The fact of the matter is that Trump was right when he told stated to buy stuff themselves and ask for reimbursement later – because they would get the stuff faster that way.

      The procurement process for the US govrenment is slow and the primary goal of the people running it is to not make a decision (because no decision is safer than making a decision and risking being wrong).

      And the pandemic is striking as a series of localized disasters. And the Federal govrenment generally has no good idea as to the exact situation on the ground. In fact this is why US disaster doctrine makes the local officials the decision makers – because they have a much better understanding of the situation than anybody else.

      And in case you haven’t noticed the disease is already everywhere. And there was no realistic chance of preventing the spread in the first place. So your idea of a region infecting another is a moot point.

      Also remember that the national news does not know what the situation is in a state-by-state basis, much less a county basis. And guess what level the fight against the coronavirus is being fought at – the county level.

      Also remember that the CDC screwed things up from day one. We are fortunate that we had state and county health departments that stepped forward and took charge of the response.

      And do you really think that it’s even possible for the CDC to supervise every county in every state? They can’t. All they can do is come up with policies aimed at the median. Which means that they will be excessive for about 40% of the counties and ineffective for another 40%.

  • I am hoping the author can respond to my question:

    Has the value of contact tracing been proven in a situation very similar to this one?

    I am very skeptical it will make much difference. It seems like public health people, who are so accustomed to doing this with other diseases, are very avidly for more of it, but they never give solid reasons.

    I know VD tracing was a thing at one point – may still be – but VD is not at all like this coronavirus. VD is very low in infectivity and will persist in a carrier for years, even decades.

    CoV2 is very highly infective, so it is very hard to identify who could have been infected – many will never be detected – and when you do find them, if it has been more than a few weeks since they got infected, they are either already better, or got so sick they were tested already.

    I understand other countries who have done much better successfully did contact tracing. I am not convinced it made a big difference, it seems like willingness to distance and wear face masks could account for almost all the difference.

    • IMO – masks and people keeping their distance is the primary reason the cases in the US have dropped. What we need is for the govrenment to make PSAs about masks and distancing. And we need the commercial sector to step up to the plate and implement ‘no mask – no entry’ policies.

      Of course the mask issue was something else the CDC screwed up. Because they wanted all the N-95 masks to go to hospitals the put out messaging that masks were useless. Now that they want people to wear masks – a lot of people simply remember the ‘masks are useless’ line and not use them.

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