Early in the COVID-19 pandemic, the World Health Organization identified three necessary conditions to contain the outbreak:

1. An unusual and unprecedented speed of decision-making by top leaders;

2. Operational thoroughness by public health systems; and

3. Engagement of society.

These are consistent with the standards of the U.S. Centers for Disease Control and Prevention (CDC). 

The United States did none of these. In all three respects, the U.S. did the opposite. 

In late January 2020, a week after the first confirmed U.S. case, former Food and Drug Administration chief Scott Gottlieb and former National Security Council director for medical and biodefense preparedness policy Luciana Borio warned in the Wall Street Journal: 

“If public-health authorities don’t interrupt the spread soon, the virus could infect many thousands more around the globe, disrupt air travel, overwhelm health-care systems, and, worst of all, claim more lives. The good news: There’s still an opening to prevent a grim outcome.”

But the United States missed that opening. It was a lost opportunity.

Tilting at Windmills Over Masks

One proven way to interrupt the spread of COVID-19 is to wear a mask. 

At the time that COVID-19 first broke out, the government official in charge of securing supplies to protect the nation in the event of an infectious disease outbreak was Dr. Rick Bright, the Deputy Assistant Secretary for Preparedness and Response at the Department of Health and Human Services (HHS). 

Bright, a 25-year career HHS administrator, began advocating for the federal government to acquire N95 masks and other critical supplies in mid-January 2020. But his persistent pleas fell on deaf ears, including Health and Human Services Secretary Alex Azar. 

An August 2019 pandemic simulation, in which Bright had taken part, had revealed that the United States would need 3.5 billion N95 masks just to protect healthcare workers. That number doesn’t include the billions more masks that would be needed to protect ordinary citizens.

In late January, leaders in the medical supply industry, including companies that manufacture N95 masks, told Bright that the supply chain was strained, and that other countries from which the U.S. had previously acquired the masks were blocking exports to the U.S. Some were even buying up the available American supply. Bright forwarded those alerts to HHS senior political leadership. His warnings were met with indifference. 

On January 22, Bright received an email from an executive at a Texas-based company that is the largest American manufacturer of surgical masks. The company had four unused N95 manufacturing lines. The executive said: 

“Reactivating these machines would be very difficult and very expensive but could be achieved in a dire situation and with government help.”

The same executive followed up:

“We are the last major domestic mask company… My phones are ringing now, so I don’t ‘need’ government business. I’m just letting you know that I can help you preserve our infrastructure if things ever get really bad.”

On January 23, three days after the first confirmed COVID-19 case in the U.S., Bright made the case to surge manufacturing of N95 masks to HHS’s senior leadership. He presented the anticipated needs and the likely costs. Bright testified to a congressional committee later in the spring that in this meeting Secretary Alex Azar seemed taken aback by the need for more funds. Bright explained:

“My request was met with a bit of surprise and puzzlement. I remember Secretary Azar looking around the room and saying ‘Money? You need money? Maybe there’s money somewhere.’ I mean, it was just something that I can tell hadn’t been thought of.”

After the meeting, Bright’s boss’s chief of staff admonished him that he had caused “quite a shit storm” by asking for money in front of Secretary Azar.

Two days later, the mask manufacturing executive wrote that he was getting lots of requests from China and Hong Kong for masks. Bright worried that American hospitals would run out of masks if the U.S. did not start manufacturing its own. But once again, he found HHS leadership unresponsive. It was another missed opportunity.

The mask manufacturing executive wrote again on January 27:

“I think we’re in deep shit. The world.”

On February 7 Bright attended a meeting with HHS senior leadership. He repeated his view that the nation needed to ramp up production of masks. The leaders’ proposed solution if masks should be in short supply: Limit who could receive the masks. Bright later told a Congressional hearing,

“They informed me that they did not believe there was a critical urgency to produce masks [sic]… I indicated that we know there will be a critical shortage of these supplies, we need to do something to ramp up production. They indicated that if we notice there is a shortage that we will simply change the CDC guidelines to better inform people who should not be wearing those masks, so that would [sic] save those masks for our healthcare workers. My response was, I cannot believe you can sit and say that with a straight face. That was absurd [sic].”

On February 25, 2020, in testimony before the Senate Appropriations Committee, HHS Secretary Azar said that the Strategic National Stockpile had 30 million N95 masks. But earlier in the day, HHS Assistant Secretary for Preparedness and Response Dr. Robert Kadlec had told the committee that the nation would need 300 million N95s just for healthcare workers. This did not equate at all to the pandemic simulation’s conclusion of 3.5 billion N95 masks needed to protect just healthcare workers in a pandemic. 

In other words, the pandemic simulation had concluded that the nation needed more than ten times the N95s than what Kadlec had told the committee was needed, and more than 100 times what Secretary Azar said was in the Strategic National Stockpile. Just to protect healthcare workers.

At the time the U.S. was not surging the supply of masks. Another missed opportunity. 

And the nation was running out of masks.

As Dr. Bright had feared, in late February the federal government began rationing the masks for healthcare workers and discouraging the public from wearing masks. 

On February 27, CDC Director Robert Redfield told a House of Representatives committee hearing that healthy people did not need to wear masks. 

In the first week of April, the World Health Organization advised that prevention starts with wearing a mask to limit the spread of breathing droplets released by oneself or by others:

“Wearing a medical mask is one of the prevention measures that can limit the spread of certain respiratory viral diseases, including COVID-19.”

After months of the U.S. government saying that masks were not necessary for most people, on April 3, 2020, the CDC finally recommended the wearing of masks to prevent transmission of the virus. 

Dr. Robert Redfield, director of the CDC, told The New Yorker that this reversal was awkward:

“When you have to change the message, the second message doesn’t always stick.”

And indeed, for millions of Americans, the second message did not stick. Yet another missed opportunity.

One major reason: the leaders they trusted did not deliver the message to wear a mask. They did the opposite. President Trump, who did not wear a mask, made it even less likely that people would wear them. He told the American people:

“This is voluntary. I don’t think I’m going to be doing it.”

It remained very difficult to find masks, even if people wanted to use them, because of HHS inaction in January when Rick Bright had tried to surge protective equipment. 

An encyclopedic account of the first year of the pandemic in the U.S. by The New Yorker’s Lawrence Wright traced the consequences of Trump’s modeling of behavior that was contrary to public health recommendations:

“Some anti-maskers called the coronavirus a hoax; others believed that it wasn’t all that dangerous. But the image of the maskless President spoke to people, especially his base. He appeared defiant, masculine, invulnerable. He knew that the virus was dangerous… Yet he dared the virus to touch him, like Lear raging against the storm.”

That reliance on Trump’s example had real human consequence that continues to this day. Says Wright:

“Tens of millions of Americans emulated the President’s bravado, and the unchecked virus prolonged unemployment, upended efforts to reopen the economy, and caused many more fatalities. ‘I’m not buying a fucking mask,’ Richard Rose, a thirty-seven-year-old Army veteran from Ohio, posted on Facebook on April 28. ‘I’ve made it this far by not buying into that damn hype.’ He tested positive on July 1st and died three days later. There are many similar stories.”