Health and Human Services secretary Alex Azar and CDC director Robert Redfield. Photo: OLIVIER DOULIERY/AFP via Getty Images

After new outbreaks of the COVID-19 novel coronavirus in South Korea, Italy, and Iran, many experts are now warning that the coronavirus is passing the pandemic tipping point. “When several countries have widespread transmission, then spillover to other countries is inevitable,” Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, told Vox. “One cannot shut out the rest of the world.”

“Our window of opportunity [for containing the virus] is narrowing, so we need to act quickly before it closes completely,” World Health Organization director-general Tedros Adhanom Ghebreyesus said on Friday. Though there have been just over two dozen confirmed cases of the coronavirus in the U.S., and CDC officials say the risk of exposure for the American public remains low, there continue to be troubling signs that the Trump administration has been mismanaging the U.S. response and may not be adequately prepared for whatever happens next.

While some of the White House’s response has been praised, its approach has also included a mix of xenophobic policy, improvisation, and suddenly sharp turns in decision-making. And long before the first case of COVID-19 was discovered in mainland China, the administration had been putting off years of back-end work which may undermine the government’s ability to prepare for and handle a breakout of the scale that coronavirus may reach.

Current confirmed U.S. cases

Only 25 cases of the COVID-19 coronavirus have been confirmed in the U.S., including 14 Americans who were infected aboard the Diamond Princess cruise ship in Japan. The other confirmed U.S. cases are all linked to travelers from the epicenter of the outbreak in mainland China. According to the CDC, COVID-19 “is NOT currently spreading in the community in the United States,” and it’s currently unlikely that the general public will be exposed to the virus. A pandemic is now likely, however, the CDC also warns — making more cases and person-to-person transmission in the country inevitable.

The Trump administration has temporarily barred entry for any foreigners who have traveled to China in the last 14 days. Americans who have been to mainland China will be subjected to health monitoring and possible quarantine. Those restrictions went against the recommendations of the WHO at the time, however.

Many questions remain unanswered about the coronavirus, such as how many cases of the virus have gone undetected around the world — including in the U.S. — as well as what percentage of the people infected with COVID-19 develop the most severe and dangerous symptoms of the illness (like pneumonia), or experience only mild symptoms (like a common cold), or experience no symptoms at all. There is evidence of asymptomatic transmission from the latter group, but researchers are still trying to determine how widespread it is. The current fatality rate for confirmed cases of COVID-19 is around 2 percent, but that could be high if the total number of actual cases is far higher than the number of detected and confirmed cases. The incubation period of the virus, meanwhile, seems to be no more than 14 days from the point of exposure in most cases — which is why that is the length of most quarantines being put in place around the world for people who may have been exposed to COVID-19.

The potential stakes

How bad could it get? According to Harvard epidemiologist Marc Lipsitch, in the event of a pandemic, 40 to 70 percent of the world’s population could eventually become infected — though not all those infected would get sick, and not all those who get sick would become seriously ill. Whatever happens, the current outbreaks have already begun having economic consequences around the world, as well as potential political consequences in places like Japan.

Other looming problems include the strain on health-care systems and supply chains, in addition to the various ways outbreaks of disease disrupt people’s day-to-day lives, communities, and workplaces. Specific to the U.S., the potential political impact of an outbreak in an election year shouldn’t be underestimated, and it’s something that is already reportedly worrying President Trump. For an example of another question the U.S. may face: How will disinformation about the virus spread in a country where health officials have already been combating a proliferation of unsubstantiated fears about the safety of vaccines?

Undetected U.S. cases, a lack of testing, and problems at the CDC

There have been ongoing questions about whether undetected cases of the coronavirus are being transmitted within the U.S. The current CDC guidance, as well as the total cases reported by the World Health Organization, only reflect the numbers laboratory-confirmed cases. Two weeks ago, Nancy Messonnier, the director of the CDC’s immunization and respiratory-diseases department, announced that local health authorities will begin testing people who have flulike symptoms for coronavirus. The program will be rolled out in major cities including Los Angeles, San Francisco, Seattle, Chicago, and New York.

Very little testing has been done, however. Last week, Politico reported that problems with a CDC-developed coronavirus test delayed the agency’s plans to expand its testing — and thus get a sense of whether or not the virus is already spreading in the U.S.

It’s not clear when the new CDC test will be ready and distributed, but because of the test failure, only three out of 100 public-health labs in the U.S. have been able to test for COVID-19, according to the Association of Public Health Laboratories. In addition, the cost of each test is as much as $250, according to Politico, and the HHS has already been running out of money to pay for its response to the outbreak. A director at the APHL criticized the federal failure: “This is a national-level response, so we would hope the federal government would have an interest in supporting a national-level response.”

Reminder: As of today (Feb 23), the US remains extremely limited in #COVID19 testing. Only 3 of ~100 public health labs have @CDC 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. 1/7 — Michael Mina (@michaelmina_lab) February 23, 2020

Potential housing issues

Some local officials — like the city leadership in Costa Mesa, California — are attempting to block government efforts to place potential patients who have tested positive for coronavirus but don’t have severe symptoms in a state hospital in the area. Meanwhile in Alabama, Senator Richard Shelby was apparently able to undo a government plan to move some quarantined Americans — after talking to the president.

I just got off the phone with the President. He told me that his administration will not be sending any victims of the Coronavirus from the Diamond Princess cruise ship to Anniston, Alabama. Thank you, @POTUS, for working with us to ensure the safety of all Alabamians. — Richard Shelby (@SenShelby) February 23, 2020

The impact of the Trump administration’s budget and personnel cuts

On Monday, the White House asked Congress for $2.5 billion in emergency funds to handle coronavirus in the United States. (To compare to a recent health crisis, the Obama administration requested $6 billion in emergency funding for the 2014 Ebola outbreak and eventually received $5.4 billion.) Though Democrats in Congress have pushed the administration to call for emergency coronavirus funding since early February, Politico states that “White House officials have been hesitant to press Congress for additional funding, with some hoping that the virus would burn itself out by the summer.”

But as Foreign Policy’s Laurie Garrett recently explained, the administration has spent years enacting policies and putting forth budgets that have weakened the U.S. government’s ability to prepare for and respond to an outbreak like this one, both in the U.S. and abroad. In addition, as Garrett highlights, the administration’s notoriously dysfunctional personnel drama and haphazard efforts to reduce the size of the government haven’t helped either:

In May 2018, Trump ordered the NSC’s entire global health security unit shut down, calling for reassignment of Rear Adm. Timothy Ziemer and dissolution of his team inside the agency. The month before, then-White House National Security Advisor John Bolton pressured Ziemer’s DHS counterpart, Tom Bossert, to resign along with his team. Neither the NSC nor DHS epidemic teams have been replaced. The global health section of the CDC was so drastically cut in 2018 that much of its staff was laid off and the number of countries it was working in was reduced from 49 to merely 10. Meanwhile, throughout 2018, the U.S. Agency for International Development and its director, Mark Green, came repeatedly under fire from both the White House and Secretary of State Mike Pompeo. And though Congress has so far managed to block Trump administration plans to cut the U.S. Public Health Service Commissioned Corps by 40 percent, the disease-fighting cadres have steadily eroded as retiring officers go unreplaced.

The cruise-ship crisis

Just as concerning as the big-picture oversight is an individual case of mismanagement reported by the Washington Post last week, in which the State Department overruled a recommendation from the Centers for Disease Control and Prevention stating that 14 Americans infected with coronavirus should not be flown home from Tokyo after disembarking the quarantined Diamond Princess:

The State Department and a top Trump administration health official wanted to forge ahead. The infected passengers had no symptoms and could be segregated on the plane in a plastic-lined enclosure. But officials at the Centers for Disease Control and Prevention disagreed, contending they could still spread the virus. The CDC believed the 14 should not be flown back with uninfected passengers …

The State Department won the argument. But unhappy CDC officials demanded to be left out of the news release that explained that infected people were being flown back to the United States — a move that would nearly double the number of known coronavirus cases in this country.

Questions also remain over the evacuation of the MS Westerdam in Cambodia a week ago. It had been denied docking for two weeks after visiting Hong Kong. Cambodia’s authoritarian leader, Prime Minister Hun Sen, let the Westerdam, which had more than 600 U.S. passengers aboard, dock in his country — earning praise from both the U.S. ambassador and President Trump. The cruise line said no passengers exhibited any symptoms of the virus, but only 20 people were given laboratory tests before being allowed off. Hundreds of others left the ship after a health screening and temperature check via thermal scanner. They were not placed in quarantine. Two days later, an American woman from the ship developed symptoms on her chartered flight to Malaysia and tested positive for COVID-19 when she landed. No other passengers or crew from the ship have tested positive for the virus as of yet, but many other symptom-free Americans were still allowed to fly home that same day, and don’t appear to have faced any quarantines since. The U.S. managed at least part of this process, and appears to have managed it badly.

Trump’s public response and political fears

In White House meetings, Trump’s deputies have been reportedly urging him to have some restraint in his public statements related to outbreak and the U.S. response. So far, at least, the president has offered relatively few comments about the coronavirus compared to other topics, but that relative restraint may not hold if the threat grows and the government’s response dominates media coverage, and particularly if Trump takes any resulting criticism personally. According to Politico, Trump’s advisers also fear the president could create false hopes of a quick solution to the crisis, or offer questionable predictions like when he tweeted on February 7 that “as the weather starts to warm … the virus hopefully becomes weaker, and then gone.” (He repeated that claim to a group of governors, suggesting that spring temperatures would take care of the problem naturally.)

As administration officials reportedly share concerns that coronavirus is spreading undetected inside the U.S., the possibility of political blowback could soon affect the White House’s response to the outbreak. “The biggest current threat to the president’s reelection is this thing getting out of control and creating a health and economic impact,” Chris Meekins, a former Trump administration HHS emergency-preparedness official, told Politico. At the point of a substantial outbreak, Democratic messaging on the administration’s mismanagement could be equally as concerning to the Trump campaign. If a health crisis emerges, expect Democratic candidates to easily and effectively hit the president on proposed CDC cuts — the White House 2021 budget proposed this month suggested a 19 percent reduction — and administration policies designed to undermine scientific research.

This post has been updated throughout to include additional details, analysis, and commentary.