'It's totally ad hoc': Why America's coronavirus response looks like a patchwork

David Norton, who helps to run a community centre in this small Rhode Island city, is not a scientist. Neither were the board members who gathered for an emergency meeting last week, to decide whether the risk of contagion meant they should cancel their upcoming events.

They sat together — a nurse, a civil servant, a therapist, an insurance executive — and tried to decode the guidance given by state and federal authorities.

Rhode Island's governor, Gina Raimondo, had urged community leaders to cancel gatherings larger than 250. On the other hand, Pawtucket's public schools were still open. Then again, a private school nearby, the site of the state's first coronavirus outbreak, had closed for two weeks.

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Boston had cancelled its St. Patrick's Day parade, but Newport had not. Movie theatres and malls were open. But Disneyworld was closing. In the end, members threw up their hands and cancelled most everything through the end of April.

"It's totally ad hoc," Norton said. "There's no science behind it, or reasoning. It's not like we were following someone's instructions."

Without clear guidance from the government, "it feels like we've been left on our own to decide what would be best," he said. "There's a lot of room for error. In Singapore or Japan, if it's cancelled, it's cancelled."

Welcome to public health, American style.

The United States, a nation founded on the notion of individual rights and limited federal power, vests key decisions on public health in state and local government. The last week laid bare a dizzying patchwork of local decision-making, as the largest quarantine in recent American history occurred in a juddering, piecemeal fashion.

Limits on public gatherings are being decided by individual counties, school closures by individual school districts. Testing practices vary widely, with some states introducing curbside testing and private testing firms. Although this country has a central public authority for handling infectious disease — the Centres for Disease Control and Prevention — the federal agency cannot get involved on the ground unless invited by states or municipalities.

"We have a completely decentralised public health system," said Michele Barry, senior associate dean for global health at Stanford University. "It is difficult to mobilise a large containment strategy. That's what Singapore did, or what China did. We don't even work from the states up. We work from the counties up."

She said she worried that this has kept the nation from acting swiftly, to enact aggressive controls on social distancing.

"I'm just worried we're going to follow the Italy course, rather than the Singapore course or Hong Kong course, because we're decentralised," she said.

In interviews from all over the country last week, Americans questioned why the government's handling of the coronavirus varied so widely depending on where they lived.

"Every state has their own little different rules," said Linda Dunn, 64, an Uber driver and retired teacher in Orlando, Florida. That morning, she had read in the news that Minnesota had introduced curbside testing for the virus. It made no sense, she said, that Floridians could not get the same service.

"We've got a wildfire on our hands. The way to control it is the testing. Get it out there and get it done," she said. If states could not keep up with one another, she said, the job should be done by the federal government.

"That's one of the reasons we have a federal government," she said. "This is an emergency."

For many parents, school closings sent a message of confusion and chaos.

Tracy Stettner, 44, of Hillsborough, California, said it was difficult to explain to her two children why the younger son's school — which is private — had suspended in-school classes, to guard against spreading infection, while her older son left every morning, spent the day in close quarters with 1200 other teenagers, and returned home.

"It needs to be all or nothing, or else how do we stop the spread?" said Stettler. "The most confusing thing to my kids is, why is the NBA cancelling, and Disneyland, but my school is still open? It doesn't make sense."

She, too, was eager for a higher level of government to step in — in her case, Gov. Gavin Newsom.

"Our public schools are waiting for him to say something," she said. "They need him to say, 'Any kid that's pulled out is an excused absence.' And even more, they need him to say, 'no mass gatherings,'" which would trigger the closings of schools.

In Bellevue, Washington, Geng Tan, 48, wondered why her children's schools remained open, when the schools in the next county over, where some staff and families had come in contact with the virus, had already closed as a precaution.

Tan, an architect who grew up in China, concluded that the hesitation was "really related to the American social structure."

"I think, under special circumstances, we do need a higher level to make dramatic decisions," she said. "Basically, the school hesitated to make that hard decision themselves."

The country's localised approach to public health is no accident: It was built this way.

The system's infrastructure was shaped by the 1892 cholera pandemic, which reached this country with the arrival of infected passengers sent on steamships from Europe, said Howard Markel, a professor of the history of medicine at the University of Michigan.

There was logic to policing the issue locally, since three-quarters of all imported goods entered the country through New York Harbor. After that, sweeping powers were controlled by the state and municipality; New York City's health department had its own police force, and an island used to quarantine infected people.

In more modern times, however, decentralised decision-making has led to a lag in reaction time.

Markel studied the closure of 550 Michigan schools as a response to the 2009 H1N1 virus, and said he found "a great deal of confusion," as well as "political theater" on the part of leaders who, as time passed, felt community pressure to take action.

Eighty-three percent of those schools closed "too late to do anything," said Markel, the author of "Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892."

"It does speak to the need for a national set of guidelines and triggers," he said. Containment strategies serve to slow the growth of the number of cases, so that scientists have time to develop a vaccine or find new therapies.

"They just buy you time," he said. "You've got to do them early, because the virus spreads. Early is better than late. You've got to do more than one school closure, and you've got to do them for a period of time."

But localised policy can also have an upside, encouraging innovation and nimbleness.

"You can be too centralised, and a lot of the problems in China reflected an excessive use of the command-and-control model, in which everything had to run through Beijing for approval," said Robert Dingwall, a British sociologist who has studied responses to pandemics.

The United States, by contrast, has traditionally fallen back on the strength of its community responses. Peer pressure, he said, can achieve a lot.

"It sits uncomfortably with the American tradition of not passing judgment on your neighbours, of not getting too involved," he said. But he added that "local civic-mindedness" is strong in the United States, embodied in robust community organisations, strong mayors and local press, and that these could accomplish much.

"It creates opportunities for those kinds of mutual surveillance, which achieve the same action as the Singapore government might achieve through a different route," he said.

And over the last week, some officials went out of their way to defend the American tradition.

Newsom, the governor of California, said that he preferred not to use his authority to enforce guidelines limiting the size of large gatherings, instead leaving the decision to each of California's 58 counties.

"I have the ability as governor to enforce, but I don't expect we'll need to do that," he said.

Local autonomy, he said, is part of a working system.

"We are many parts but one body," he said. "We are informed by locals and then we supplement our support with the state and federal government. And we work hand in glove, collaboratively."

Likewise, he said he would leave the decision on closing schools to school districts themselves. He called on Californians to use their own judgment. Holding a meeting in a basement, he said, was very different from an event held in a public park.

"Common sense," he said. "It's available to all of us and it's a renewable resource."

Written by: Ellen Barry
Photographs by: Matt Whittaker, Jim Wilson, Andrew Seng
© 2020 THE NEW YORK TIMES