The COVID-19 Outbreak and Epidemic Preparedness in the United States

The COVID-19 Outbreak and Epidemic Preparedness in the United States

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Public Health Threats and Pandemics


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Thomas J. Bollyky, senior fellow for global health, economics, and development, and director of the Global Health Program at CFR, discusses the COVID-19 outbreak and epidemic preparedness in the United States as part of CFR’s State and Local Officials Conference Call series.

Learn more about CFR’s State and Local Officials Initiative.


Thomas J. Bollyky

Senior Fellow for Global Health, Economics, and Development, and Director of the Global Health Program, Council on Foreign Relations


Irina A. Faskianos

Vice President, National Program and Outreach, Council on Foreign Relations

FASKIANOS: Good afternoon from New York, and welcome to the Council on Foreign Relations State and Local Officials Conference Call Series. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR.

We’re delighted to have participants from forty-six states across the country joining us for today’s discussion. As you know, CFR is an independent and nonpartisan organization and think tank focusing on U.S. foreign policy. Through our State and Local Officials Initiative we serve as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics, Foreign Affairs magazine, and briefings with CFR fellows.

We know that many of you on the call are on the frontlines of responding to public health threats in your communities, which is why we are having today’s discussion with Tom Bollyky. We circulated his full bio prior to the call, so I’m just going to give you a few highlights on his distinguished background.

Mr. Thomas Bollyky is senior fellow for global health, economics, and development, and director of the Global Health Program at CFR. He is also an adjunct professor of law at Georgetown University. He is the author of the book Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways. It covers the history of infectious disease control and is on Bill Gates’ reading list. It came out in paperback in October 2019 and I commend it to all of you since there is a specific chapter on the flu I believe from 1918, right, Tom?

BOLLYKY: That’s right.

FASKIANOS: And finally, he is also the founder and managing editor of Think Global Health. The URL is It’s an online magazine that examines the ways health shapes economies, societies, and everyday lives around the world. And again, this is a really important resource, now more than ever, as we are dealing with COVID-19, and Tom can talk a little bit more about that.

So let me talk about the ground rules. We will begin with a few opening remarks from Tom Bollyky that will be on the record. Then we will follow with a question-and-answer portion that will be off the record so we can have a candid discussion, and we really hope that you can share your concerns, ask questions of Tom, maybe exchange best practices as we are in the really early days of this outbreak.

So, Tom, thank you very much for being with us. Why don’t you talk about COVID-19 outbreak and talk about epidemic preparedness in the United States, and then we’ll open up to the group for their questions. So this portion, again, is on the record. Tom, over to you.

BOLLYKY: Great. Thank you for that kind introduction, Irina.

Like Irina, I fully understand that effective response to outbreaks of emerging infections like this novel coronavirus now known as COVID-19 depend on the action and vigilance of public health officials at the state and local level. You are on the frontlines. It’s my great honor to speak with you, and I will do my best to make this call a good use of your very limited time.

Let me begin with what you need to know on the international level what’s happening with this outbreak before moving to the four issues that we’re watching here at the Council on Foreign Relations to get a better sense of what COVID-19 may mean for the United States, and states and localities in particular.

So as you know, COVID-19 until this week, really, has been primarily a China story, and China still has 95 percent of the world’s cases of novel coronavirus. It has—all but sixty-six of the deaths have occurred within the mainland’s borders. Yet, the last few days have shown that COVID-19 is no longer a China story, primarily a China story.

Yesterday, for the first time, the number of new cases of COVID-19 reported outside of China exceeded the number of new cases reported inside of China. That’s something that happened for the first time. Since Sunday alone, eighteen countries have reported their first COVID-19 cases. It’s worth just saying the list because it really is staggering in its geographic diversity: Afghanistan, Algeria, Austria, Bahrain, Brazil, Croatia, Denmark, Estonia, Georgia, Greece, Iraq, Italy, Kuwait, North Macedonia, Oman, Pakistan, and Switzerland—again, just since Sunday. Almost none of these countries’ cases came directly from China.

The U.S. Centers of Disease Control and Prevention, as all of you know well, reported the first suspected case of COVID-19 spreading at the community level in the United States. That happened yesterday in Northern California. Earlier this week the World Health Organization announced that national and local officials need to start behaving like this virus will show up in your community tomorrow because it may very well do just that.

So what are the four issues we’re watching to get a sense of where this spreads? And currently there are several outbreaks, just to say where these cases are coming from. Italy is in the midst of—went from having no cases last week to 528 cases and fourteen deaths. The Middle East cases seem to all be coming from Iran, which has now diagnosed 245 cases, twenty-six of them fatal. South Korea went from thirty cases at the beginning of last week to now eighteen hundred cases, which is the second-highest or the highest outside of China.

So the four things that we are watching to get a sense of how this outbreak progresses.

First, what is the fatality and severity of COVID-19 as it spreads to other countries? Roughly one out of seven people in China—this is according to a report from the Chinese CDC—suffer severe disease, often serious pneumonia or shortness of breath. Five percent of patients have a critical condition, like respiratory failure or septic shock. And between 3 and 4 percent are suffering fatalities. Now, as all of you know there may be many things affecting that case-fatality rate. It could be underreporting of mild cases, although the WHO has said this week it doesn’t think that’s the case. It could be overwhelmed health systems, and it is true that Hubei province in China has a much higher case-fatality rate than other provinces in China. But you know, even if the case-fatality rate of COVID-19 drops to 1 to 2 percent, as all of you know the average flu has a case-fatality rate of .1 percent, so a 2 percent case-fatality rate is twenty times more deadly. And flu kills between—as, again, all of you will know—twenty-nine thousand Americans to as many as sixty thousand Americans in an average year. So that could be quite significant.

All right. The second thing we’re watching: diagnostics and the development of point-of-care diagnostics. This is important because given that—I read that list of countries to you for a reason. It’s geographically distributed and it is many. There are now forty-seven countries with cases against—cases of COVID-19. It is quickly becoming infeasible to expect travel restrictions to keep these cases out of the United States. It will become more important to be able to rapidly diagnose people coming back from areas of interest. That’s particularly true because there is evidence that COVID-19 spread asymptomatically, or can spread asymptomatically, meaning people won’t necessarily exhibit symptoms. So if we don’t have an effective point-of-care diagnostic, it’s going to be very difficult to identify those with the virus and try to slow the spread of this outbreak. South Korea has been able—part of the reason cases have jumped there is South Korea has been able to diagnose many people using diagnostics. We have—as you all will know, have struggled with that in the United States, and that played an issue with this case of community spread in Northern California where there were several days of delay in terms of getting that patient diagnosed.

Third thing we’re watching, we are watching China. The Communist Party is anxious for success, and to get the world’s second-largest economy running again, and anxious to restart life in that nation. Currently there are still 760 million people under restrictions of movement. Do you see a spike in cases as life starts to return to normal in China? Do we see more evidence that the decline in cases in China are just a matter of underreporting?

Last thing we’re watching, of course, is the U.S. government response, particularly in an election year, to COVID-19. As some of you may have seen, yesterday the president announced a czar—Vice President Mike Pence—to oversee the response to the—to the outbreak. Earlier, the administration made a request for $2.5 billion to respond to the outbreak. You know, in past requests to respond to emerging dangerous disease events they’ve really focused on three areas: stopping the disease where it’s spreading, strengthening the U.S. public health system, and reducing risks going forward that arise from global health security concerns like this one. Really, only one element of that is included so far in the funding request. It really has focused on the U.S. protection. Only $1.25 billion of that money is new; the rest of it is repurposed, potentially, from elsewhere. And there really hasn’t been a lot of a response either by the U.S. or other governments in terms of trying to slow this outbreak down in other countries. That will be important because if this takes hold in low- and middle-income countries with limited health systems, watch out in terms of the number of cases that will arrive here.

FASKIANOS: Tom Bollyky, thank you very much. Tom is on Twitter at @TomBollyky. Again, there’s some good lessons in his book, Plagues and the Paradox of Progress. He has a global tracker for COVID-19 on the online website that I talked about at the beginning, So go there. We’re going to be publishing things on our website, And we’re going to be standing up another call like this with a different health expert. We’re going to shoot for next week, so that we can continue to be a resource for you as we—you know, as we’re all trying to navigate through these days.

So, again, if you have any questions or comments and you want to send an email, you can send it to [email protected]. We’ll see what we can do. And we’ll also work on—Tom will go back to the CDC about the poster. And we’ll look to see if there is any other place where such a thing exists. So thank you all for being on this call. Thank you for being on the frontlines. And I guess everybody should be washing their hands.

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