President Donald Trump revealed a grim projection in the coronavirus pandemic on Tuesday: Even with the social distancing the US is doing now, 100,000 to 200,000 Americans will likely die as a result of the ongoing outbreak. “When you see 100,000 people, that’s a minimum number,” Trump said.

It’s a horrifying figure. That’s more people than ever died in a single year from HIV/AIDS, drug overdoses, gun violence, or car crashes in the US. It’s more than American casualties during the entire Vietnam War.

But it’s also a horrifying number, in part, because much of it was likely preventable. If the US — including the Trump administration — had better prepared for pandemics, the country likely could have avoided ever talking about 100,000 to 200,000 deaths.

The estimated death toll “was not inevitable,” Céline Gounder, an epidemiologist at New York University, told me. “If we’d jumped into contract tracing and testing, social distancing, and health system preparedness as soon as we heard reports from China, we’d be in a very different situation now.”

Under Trump, the US had years to prepare. With warnings from President Barack Obama’s administration and activists like Bill Gates, it was always clear that America was vulnerable to a pandemic. (Vox did a whole episode about it for Netflix.) For many, the 2014-’16 Ebola outbreak exposed the threat; Jeremy Konyndyk, who worked in the Obama administration during the Ebola outbreak, told me he “came away from that experience just completely horrified at how unready we would be for something more dangerous than Ebola,” which, thankfully, was relatively hard to transmit.

In the years leading to the coronavirus outbreak, though, Trump did not take the concerns seriously. His administration shut down the White House office, set up after the Ebola outbreak, that oversaw disease outbreaks and pandemics. It repeatedly proposed cuts to the Centers for Disease Control and Prevention (CDC) and other public health agencies (although Congress largely rejected those cuts). The administration cut a public health position that was meant to help detect disease outbreaks in China, where the coronavirus outbreak began.

By the time it became clear that the world was facing a serious threat in January and February, Trump and his administration were again slow to act. Despite declaring a public health emergency, the administration failed to establish the infrastructure for nationwide testing — holding up private testing labs with bureaucratic and regulatory hurdles while sending out its own faulty test kits. The administration did nothing of substance to really scale up the production of personal protective equipment (PPE) for health care workers, allowing a shortage to take root. Trump still hasn’t leveraged the full might of the Defense Production Act to get medical supplies to hospitals and clinics that need them to fight the outbreak.

The failure on testing alone is massive — one that remains today. As Johns Hopkins University epidemiologist Jennifer Nuzzo told the New York Times, “Had we had done more testing from the very beginning and caught cases earlier, we would be in a far different place.”

The result is an outbreak that looks very different in the US than in the few countries, like South Korea and Taiwan, that have better contained Covid-19, the disease caused by the SARS-CoV-2 coronavirus.

This isn’t solely on Trump. Some of it comes down to chance — that the coronavirus is popping up now and is so deadly and contagious is obviously not under any president’s control. Konyndyk’s experience under Obama shows the previous administration wasn’t ready for a pandemic either. Experts and advocates argue that pandemic preparedness, along with public health more broadly, is notoriously underfunded not just in the US but around the world. Some local and state officials, such as in New York City and Florida, have also underreacted to the crisis, making it worse.

But Trump, perhaps more than any other president, had plenty of warning about what was to come. He squandered all the opportunities given to him to do better, leaving much of the aggressive action that has reduced the death toll — down from the millions the White House and experts say is possible without interventions — to local and state officials who simply don’t have the reach of the federal government.

So now 100,000 to 200,000 Americans are likely to die.

Trump failed to prepare, then downplayed the coronavirus outbreak

Every step of the way, the Trump administration failed to take the threat of a pandemic seriously.

The threat was long well-known, including to the federal government. Government simulations and exercises before the outbreak revealed that there were a lot of problems, from the lack of sufficient PPE to simple confusion between the cities, states, and many federal agencies about who’s in charge during a crisis.

Trump reacted to the risks by deprioritizing pandemic preparedness. In 2018, then–National Security Adviser John Bolton fired Tom Bossert, a homeland security adviser who, the Washington Post reported, “had called for a comprehensive biodefense strategy against pandemics and biological attacks.” Then Bolton let go the head of pandemic response, Rear Adm. Timothy Ziemer, and his global health security team. The team, the Directorate for Global Health Security and Biodefense, was the main group within the White House for pandemic preparedness — and it was never replaced.

At the time, the Trump administration and Bolton said the cuts were needed to streamline the National Security Council. But what it did, experts have told me, is leave the US unready for a crisis of the magnitude it’s facing now.

“The basic systems need to be in place for global, state, and local responses,” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, previously told me. “When you don’t shore those up, you’re not starting from scratch, but you’re catching up every single time.”

Even once it became clear that the coronavirus pandemic was a real threat, Trump downplayed the outbreak. He compared the novel coronavirus to the seasonal flu, when the coronavirus is in fact much deadlier and more contagious than the flu. He called concerns about the virus a “hoax.” He said on national television that, based on nothing more than a self-admitted “hunch,” the death rate of the disease was much lower than public health officials projected. Even after his administration invoked social distancing guidelines, Trump talked up the idea of doing away with them by Easter to allow for “packed churches.”

Ashish Jha, director of the Harvard Global Health Institute, described the administration’s early messaging as “deeply disturbing,” adding that it’s “left the country far less prepared than it needs to be for what is a very substantial challenge ahead.”

Trump’s tone has changed in recent weeks. He ultimately extended his task force’s social distancing guidelines through April. On Tuesday, he went after the claim — that, again, he repeatedly made before — that coronavirus is like flu: “It’s not the flu. It’s vicious,” he said.

But however Trump may feel now, his administration’s failure to take this threat seriously early on left the country in a much worse place.

A recent investigation by the New York Times exposed how the Trump administration failed to scale up testing. The CDC developed its own test for coronavirus — seemingly to make a more accurate test than what was available from other places — but the test turned out to be faulty, and the CDC took weeks to provide a fix. Meanwhile, the administration put up all sorts of regulatory hurdles that prevented private labs from rolling out their own tests.

The result: The US was only testing about 100 samples a day by mid-February, according to the Times.

The Times concluded, “Across the government, [experts] said, three agencies responsible for detecting and combating threats like the coronavirus failed to prepare quickly enough. Even as scientists looked at China and sounded alarms, none of the agencies’ directors conveyed the urgency required to spur a no-holds-barred defense.”

This failure alone doomed the US to a much bigger outbreak, forcing Americans to rely far more on social distancing and suffer many more deaths. That’s because testing is crucial, especially in the early stages, to curtailing an outbreak: First, it lets public health officials identify sick people, isolate them, and trace their recent contacts to make sure those people aren’t sick and get them into quarantine as well. Second, testing lets officials detect which places are hardest hit and, therefore, require the most attention and help.

Yet, even today, testing remains a problem. Maryland Gov. Larry Hogan (R) said this week that Trump’s claim that testing is no longer a problem is “just not true” and states are still “flying blind” due to insufficient testing.

Testing is only one example among many. The country is also experiencing a shortage of PPE for health care workers and ventilators for treatment. Both problems were repeatedly raised in pandemic simulations, but the federal government failed to replenish its Strategic National Stockpile and failed to scale up domestic production and supply chains. Even now, Trump has refused to use the full powers of the Defense Production Act, which would allow the federal government to demand more domestic production of these goods (although it’d likely take at least weeks for this production to scale up).

The lack of medical supplies is one reason experts worry the US won’t have the health care capacity to deal with a flood of Covid-19 patients, leading to sickness, suffering, and death due to insufficient treatment.

Again, a lot of this goes back to poor preparation in the years before the Covid-19 pandemic — and, indeed, the years before Trump was in office — but Trump and his administration failed to prepare even once the threat of the coronavirus became clear.

There’s another way this could have gone

These outcomes weren’t inevitable. Other countries that were more aggressive earlier seemed to reduce their potential death tolls.

Just take a look at this chart comparing Covid-19 cases between different countries and places:

The US’s trajectory in this chart is exponential: The number of cases is clearly rising every single day. But while US cases seemed to explode about two weeks after the 100th case, a few places — like South Korea, Taiwan, and Hong Kong — managed to flatten their curves with early, aggressive action around the same time.

South Korea did this, as Max Fisher and Choe Sang-Hun reported at the New York Times, with a lot of testing. While the US was still doing at most 100 tests a day, South Korea was pumping them out in the thousands, if not tens of thousands, a day. This allowed officials in South Korea to detect where outbreaks were happening and contain them — particularly by getting people to isolate and quarantine, along with some restrictions on movement, travel, and socializing — before things got too out of control.

The US is obviously not South Korea. It’s much bigger, more sprawling, and more populous. But the South Korean experience shows that aggressive testing, as one example, could help contain coronavirus. The US, due largely to the Trump administration’s failures, just didn’t have the capabilities South Korea did here.

There’s plenty of other evidence that early, aggressive action can help contain epidemics. During the 1918 flu pandemic, some US cities took quick, decisive action while others didn’t. A 2007 study in PNAS exposed the different outcomes in St. Louis, which quickly imposed restrictions to force social distancing, and Philadelphia, which didn’t, in this telling chart:

The study concluded that “cities in which multiple interventions were implemented at an early phase of the epidemic had peak death rates ≈50% lower than those that did not and had less-steep epidemic curves. Cities in which multiple interventions were implemented at an early phase of the epidemic also showed a trend toward lower cumulative excess mortality, but the difference was smaller (≈20%) and less statistically significant than that for peak death rates.”

If Trump had acted sooner, the US could have had a better chance at replicating the results from St. Louis in 1918 or South Korea in 2020. But that moment has passed — and Americans are now facing the deaths of potentially hundreds of thousands of their friends, family, and peers as a result.