Gavin Yamey , professor of global health and public policy 1, Gregg Gonsalves , assistant professor of epidemiology 2 1Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA 2Public Health Modeling Unit and Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA Correspondence to: G Yamey gavin.yamey{at}duke.edu

He downplayed the risk and delayed action, costing countless avertable deaths

On 23 January 2020, the World Health Organization told all governments to get ready for the transmission of a novel coronavirus in their countries. “Be prepared,” it said, “for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread.”1 Some countries listened. South Korea, for example, acted swiftly to contain its covid-19 epidemic.2 But US President Donald Trump was unmoved by WHO’s warning, downplaying the threat and calling criticisms of his failure to act “a new hoax.”3

Trump’s anaemic response led the US to become the current epicentre of the global covid-19 pandemic, with almost one third of the world’s cases and a still rising number of new daily cases.4 In our interconnected world, the uncontrolled US epidemic has become an obstacle to tackling the global pandemic. Yet the US crisis was an avertable catastrophe.

Dismissing prescient advice on pandemic preparedness from the outgoing administration of the former president, Barack Obama,5 the Trump administration went on to weaken the nation’s pandemic response capabilities in multiple ways. In May 2018, it eliminated the White House global health security office that Obama established after the 2014-16 Ebola epidemic to foster cross-agency pandemic preparedness.6 In late 2019, it ended a global early warning programme, PREDICT, that identified viruses with pandemic potential.7 There were also cuts to critical programmes at the Centers for Disease Control and Prevention (CDC), part and parcel of Trump’s repeated rejections of evidence based policy making for public health.8

Denial After the US confirmed its first case of covid-19 on 22 January 2020, Trump responded with false reassurances, delayed federal action, and the denigration of science.9 From January to mid-March, he denied that the US faced a serious epidemic risk, comparing the threat to seasonal influenza. He repeatedly reassured Americans that they had nothing to worry about, telling the public: “We think it's going to have a very good ending for us” (30 January),10 “We have it very much under control in this country” (23 February),11 and “The virus will not have a chance against us. No nation is more prepared, or more resilient, than the United States” (11 March).12 China’s quarantine and lockdown measures bought the Trump administration time to scale up its preparedness efforts. It could have used this time to put mass covid-19 testing and contact tracing in place, produce enough personal protective equipment (PPE) for all health workers, expand hospital capacity to manage surges in demand, and establish clear chains of communication between the federal government and state governors. The federal government did none of these things. In the face of PPE shortages, the CDC was left advising health workers to use bandanas.13 Governors have been forced into “an ‘eBay-style’ bidding war” against each other to secure ventilators and PPE.14 The CDC produced a faulty covid-19 test and took weeks to realise and fix the mistake.15 All this time, the US could have used a WHO approved covid-19 test that the organisation was shipping worldwide. Trump’s anti-scientific pronouncements during covid-19 have been particularly perilous. On 28 February, he said that the coronavirus would soon disappear on its own “like a miracle.”9 On 21 March, he promoted the anti-malarial drug hydroxychloroquine for “use immediately” as a treatment, despite the lack of evidence for its effectiveness.16 His promotion triggered “panic-buying, skyrocketing prices, and overdoses in malaria-prone regions in Africa and South Asia,”17 and led to shortages of the drug for those who need it to treat other conditions such as lupus, for which it has proved benefit.18 Rick Bright, the director of the US agency that oversees covid-19 vaccine development, says he was removed from his post because he questioned Trump’s promotion of hydroxychloroquine.19 On the day that the CDC advised the public to wear face masks, Trump said he would not wear one himself. On 23 April, Trump suggested that injecting disinfectant or bringing “light inside the body” could cure covid-19, prompting experts to urgently warn the public against inhaling or ingesting bleach.20 But Trump’s arguably most dangerous act was to call last week for mass public protests by his supporters to “liberate” states from their stay-at-home orders, specifically targeting states with Democratic governors.21 This would also, he said, be “an appropriate time,” to bring up the second amendment, the right of US citizens to bear arms. By encouraging armed insurrection, said Washington state governor Jay Inslee, Trump is “putting millions of people in danger of contracting covid-19. His unhinged rantings and calls for people to ‘liberate’ states could also lead to violence.”21

Blame Now that the US has the world’s worst epidemic, Trump has sought to deflect blame on Obama, Democrats, China, and, most recently, WHO, halting funding to the organisation even though he praised it in February for “working hard and very smart.”22He has refused to acknowledge any failings of his own, famously saying, “I take no responsibility at all.”23 Meanwhile, the death toll mounts (46 851 deaths as of 23 April 20204), with the virus disproportionately killing the most vulnerable in US society. The US is likely to experience years of mass unemployment, multiple cycles of stay-at-home orders, a rise in reported and unreported mental health conditions, other excess deaths otherwise avoided outside of a crisis, and other social dislocations in response to epidemic resurgence. We know that Trump will not—indeed cannot—rescue us. US citizen are “alone against the virus.”24 To get through this, the US will need unprecedented social mobilisation. The dislocations call for a new social movement, inspired by the AIDS movement of the last 40 years—one that pushes local, state, and federal leaders to provide universal health coverage, universal sick pay, and rent and food assistance, focusing particularly on people who are poor, homeless, marginalised and those in jail or juvenile and immigration centres. Trump’s astounding incompetence was a political determinant of the US covid-19 epidemic. A new “politics of care” could be the corrective.24

Footnotes Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: GY has been a technical adviser to WHO, is a registered Democrat, donated to the Presidential campaign of Barack Obama, and supported Senator Elizabeth Warren in the 2020 Democratic Party presidential primary campaign. GG declares that he is a registered Democrat and has donated to the presidential campaign of Senator Elizabeth Warren.

Provenance and peer review: Commissioned; not externally peer reviewed.