Ryan's Reviews > Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic

This is the best book about COVID-19 and the response to it. It's also one of the best post-mortems of a public policy fiasco I've ever read -- on par with Richard Feynman's post-mortem of the Challenger shuttle disaster. There's a common element -- the author in each was a highly intelligent expert in the domain, but not directly involved in a leadership position at the time of the incident, so as to be a truly impartial expert. Gottlieb was formerly head of FDA, one of the government entities key to the response, and intimately familiar with the strengths and challenges of different parts of the US Government, yet was willing and able to point out these issues publicly.

Essentially, there are a few specific problems with the USG (and to some extent, world) Covid response which are now clear, and which unfortunately still exist and are likely to contribute to a future pandemic (likely much worse).

1) China's ongoing secrecy, control of WHO, lax domestic controls, and generally being a bad actor seems to be increasing
2) CDC is not operational -- they are largely backward-looking and focused on producing academic after-the-fact papers on rock-solid science, rather than providing as-needed surveillance and actionable information in an uncertain environment. CDC either needs to be completely reprogrammed, or all operational aspects of CDC moved to another entity. When even FDA is faster and more responsive (itself a too-slow and too-cautious regulator), you know you're doing it wrong.
3) No "JSOC-equivalent" entity in USG for pandemic response which could coordinate across all of government (and industry, and society) and which actually had expertise and experience in dealing with these threats. (To extend this analogy -- we were similarly unprepared for counterterrorism on 9/11, and only developed this capacity through 20 years of war.)

And specific flaws:
1) China failing to share data, and local authorities in China likely not releasing information to the central government -- strong possibility of spread late 2019 well before it was announced. China still hasn't provided early samples to anyone (and the way we got the DNA sequence was likely an unsanctioned release by a scientist)
2) The politicization of response, especially in the US (and to some extent, Europe), and differential costs/benefits to the population (younger, healthy, small business owners suffered, minorities suffered, but the "public policy class" who could work by Zoom didn't to the same degree.)
3) The CDC testing fiasco -- for which individuals probably should be removed, in addition to regulatory and organizational changes -- which largely precluded any possibility of US containment of covid, forcing us to costly mitigations. We burned through public goodwill by doing nationwide lockdowns early when spread was much more localized, such that no public willingness for NPIs existed in other areas by the time they were needed there. The root causes of this were CDC being basically organizationally unsuited for the task, but specific decisions to try for a perfect test vs something adequate, a slow contracting process which encouraged them to do things in-house (which they didn't know how to do well at large scale), rather than contracting efficiently to expert companies, and poor oversight leading to continued delays rather than working on multiple solutions in parallel. We could have simply guaranteed purchase of tests in a certain quantity from private manufacturers early on who would have produced them -- instead there were intellectual property issues with CDC, unwillingness to share information, production problems, and a risk that the CDC tests would eliminate demand for private tests. These private companies had been burned during Zika a few years earlier.
4) US response was largely designed for influenza rather than covid, and covid accelerated timelines for a lot of things. There was some lingering post 9/11 biowarfare defense capability from DOD/DHS which was also not general enough for this. Absent more specific data, we made bad decisions (focus on surface spread/fomites vs. aerosols, weird focus on rules like 6' separation for droplets for far too long)
5) CDC being an active impediment to various efforts by other entities throughout the crisis - restricting independently developed tests, etc

And new concerns:
1) Countries are now highly likely to delay reporting any new infectious disease outbreaks due to risk (well, certainty) of being isolated with travel bans and other economic hardships
2) Now that we've seen how much a relatively low fatality respiratory disease can wreck a country, and this is specifically worst in the US and Western democracies, the risk of a terrorist or military employment of a future pathogen is higher -- way easier to re-create something after you know it's possible, and all the components are out there already.

The one bright spot appears to be vaccine technology and genetic/molecular medicine (i.e. things largely in the private sector). I'm not particularly convinced we'll get better US Government (or international governmental) pandemic preparedness, although the need for a better response is clear.