September 23, 2020

The title of a recent JAMA editorial caught my eye the other day - Suboptimal US Response to COVID-19 Despite Robust Capabilities and Resources. Just as I’ve heard from many of our Medical Society’s members, I’ve been frustrated by our country’s seeming inability to mount a consistent, coordinated federal response to this crisis, so I read on.

The article discusses that while the US ranks number one in the world on the Global Health Security (GHS) Index, a framework for benchmarking health security in 195 countries, our response to the COVID-19 pandemic has not been commensurate with that ranking. 

The United States has the largest number of COVID-19 cases to date in the entire world, despite having only 5% of the world’s population, and we have one of the highest per-capita case fatality rates in the world, with now over 200,000 deaths (and counting) at the time of this writing. 

How did the country best prepared to face a pandemic, with the most resources in the world, fare so poorly when it came to our actual response?

The authors suggest a couple of intriguing possibilities. Despite its top overall ranking on the GHS index, the US received a low score on what the editorialists feel is a key factor in how well a country is able to respond to a pandemic – public confidence in government. Our American distrust of government certainly didn’t start with the current federal administration, or with this current pandemic (some might suggest it goes all the way back to the founding of our republic), but the halting, disjointed, and inconsistent federal response to this crisis, along with lack of consistent messaging from our federal government based in fact and science, seems to have worsened what were already historic lows in our trust in government. Without that trust, even if the federal government had been consistently and reliably giving us sound public health advice, Americans would be less likely to follow that advice. Combine that fact with the politicization of simple public health measures, like wearing masks, and you start to see how a country so rich in resources could be faring so poorly in our COVID-19 response. 

Another factor that the authors cited as likely contributing to our disproportionate number of COVID-19 cases and deaths is our lack of universal health care coverage; the GHS index ranked the US at 175th out of 195 countries for access to health care. Just as with other diseases, lack of consistent access to health care for the uninsured and underinsured leads to poorer health outcomes for COVID-19 as well.

Here in New Hampshire, our COVID-19 response has thankfully been much less politicized, and has been consistently based on data, facts, and science. Our public health response, lead by Dr. Benjamin Chan, State Epidemiologist, and his colleagues in the NH Division of Public Health, and Dr. Jonathan Ballard, NH-DHHS Chief Medical Officer, have been driving forces behind COVID-19 policy decisions since the pandemic arrived in our state. If my ‘back of the napkin’ calculations are accurate, NH has about 0.4% of the total US population, but only about 0.12% of the total COVID-19 cases and 0.2% of the COVID-19 attributed deaths, so it appears that our New Hampshire approach is in fact leading to relative success. 

A combination of favorable geography and population density, along with sound public health policy that has been consistently communicated since early March, has allowed us to flatten the curve here in the Granite State and keep case rates relatively low through the summer. But our response has still been limited and to some extent hamstrung by the bungled federal response, whether due to difficulty obtaining PPE, lack of adequate testing supplies, or confusing and at times outright inaccurate messaging coming from Washington.

Could a consistent, coordinated, science-friendly federal approach have improved our response nationally? Undoubtedly. In the richest country with the most resources compared to all other countries in the world, we should have been better prepared to respond to a pandemic, and once it arrived at our shores, our response should have been swift, coordinated, and driven by public health experts.

The federal response may be beyond our current control, but here in New Hampshire we can continue to look to our public health team to drive policy decisions as they relate to our COVID-19 response, and we can personally and professionally continue to promote simple, inexpensive, evidence-based measures to control COVID-19 transmission and save lives – wear a mask, physically distance six or more feet when possible, and wash your hands. In the country with the greatest resources, ironically it may come down to these cheap and easy measures to determine whether we ultimately fail or succeed.

In health,

John Klunk, MD
NHMS President

Please send comments or questions to john.klunk@nhms.org.