If the coronavirus hits America, who’s responsible for protecting you?

What the response to a Covid-19 outbreak in the US could look like.

The outbreak of the coronavirus — and Covid-19, the disease it causes — in mainland China has provoked a response the likes of which the world has never seen. Hundreds of millions of people in the country have had their travel restricted; many have not even been allowed to leave their homes. All of this is aided by the vast Chinese surveillance state.

Meanwhile, though the number of new cases in China dropped to 406 on Wednesday, bringing the total to 78,000, China is ramping up capacity to treat tens of thousands of sick people, with new hospitals going up nearly overnight. Many people still haven’t returned to work, though some of the restrictions are being eased.

Draconian restrictions on movement and the intensive tracking of people potentially exposed to the virus are just some of the ways China — a centralized, authoritarian state — has responded to its outbreak.

What would have happened if the outbreak had started in the US — or if it comes here next?

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The number of confirmed cases in the US is small: just 14, and 12 are related to travel. An additional 45 people who were sickened with Covid-19 abroad have returned to the US for treatment. On Tuesday, the Centers for Disease Control and Prevention shifted its message on the likelihood of the coronavirus spreading in the United States. “Ultimately we expect we will see community spread in this country,” Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, told reporters in a press call. She said it’s a matter of “when,” not “if,” and that “disruption to everyday life might be severe.”

There’s still a lot we don’t about the virus. It’s a novel, fast-spreading disease to which people have no immunity. So far, no vaccines or drugs to treat it exist, though both are being developed. That said, many of the cases of Covid-19 are mild, as Vox’s Julia Belluz reports. The fatality rate — which remains an early estimate that could change — is hovering around 2 percent. A virus of these parameters could spread very quickly.

While there’s much we don’t know about how this could play out with regard to how many people will get sick and how sick they’ll get, what we do know is the United States has dealt with outbreaks — polio, tuberculosis, and H1N1 flu, for starters — before, and many health officials have been anticipating a new one. There are lots of professionals on the federal and local levels who stand ready to try to stymie the spread of coronavirus in the United States.

That’s not to say our system is perfect, or even necessarily prepared for this incoming novel virus. But it’s worth thinking through what responses are possible in the United States and how they might become politicized. There are a few really important things to know.

The biggest one: Public health is a power that’s largely left up to the states, which introduces flexibility into our system. But it also introduces inconsistencies, local politics, and laws, with varying protections for civil liberties. The biggest question remains: Can our health care infrastructure handle an influx of thousands of new patients?

Public health is largely up to the states

The first question to ask about outbreak response in the United States: Who is in charge?

You may think “the White House,” or some arm of the federal government. But per the 10th Amendment of the US Constitution, public health is not a power specifically given to the federal government, and so it rests mainly with the states, as well as large cities with strong public health departments, like New York City.

“It’s important to remember that public health is actually a police power that is delegated to the states,” says Rebecca Katz, director of the Center for Global Health Science and Security at Georgetown.

This may be good news if you’re nervous about the Trump administration’s preparedness for a significant outbreak. The federal government does have some powers, including the right to quarantine travelers coming from abroad (the CDC recently issued its first mandated quarantine on travelers in 50 years due to Covid-19), and to impose travel restrictions. If things get really bad, the federal government “can basically federalize state response if there’s a failure of local control,” says Tom Frieden, former director of the CDC and former New York City health commissioner. But local control comes first.

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The federal government maintains the CDC, the premier disease-tracking and prevention research agency in the world, whose guidance is essential during an outbreak. The agency also maintains a strategic stockpile of medical supplies like respirators to deploy in a wide-ranging pandemic.

The administration could also appoint a person (like a Covid-19 “czar”) to oversee coordination between the many departments of the federal government (Health and Human Services, Agriculture, and others) to aid the response. It hasn’t yet, though Politico reports that President Trump is considering FDA commissioner Scott Gottlieb for the job. “There used to be a White House office in charge of pandemic prevention and response,” says Ron Klain, who led the response to the 2014 Ebola epidemic und the Obama administration. “President Trump abolished the office in 2018.”

How local governments could intervene in an outbreak

Cities and states hold most of the power to act during an outbreak. What could they do?

“There are pros and cons to the decentralized way we do public health in the US,” Frieden says. “There’s enough autonomy so that New York City doesn’t need permission from New York state or the CDC or the federal government to announce an outbreak and begin aggressive control measures.”

How aggressive could it get? State governments, as well as some large cities, have the power to order quarantines for people who may have been exposed to an infection. (Quarantine refers to the practice of isolating people who may have been exposed to a virus from other people, to prevent them from spreading the illness before they have symptoms.)

The power is not only to order quarantines, but to enforce them. “Public health is actually a police power that is delegated to the states,” Katz says. “You could end up with someone coming to your door, and saying ‘you’ve been exposed, and you’re either coming with me, or you have to stay in your house.’”

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They could force you to stay at home, or detain you in a facility. “There are still some places in the country where they may put someone with active TB [tuberculosis] in a jail cell,” she says, “because it might be the only place available for negative pressure containment [an air purification scheme].”

To be clear: that’s an extreme scenario. Katz says these detainment powers are rarely, if ever, used. To start, a quarantine order would probably be voluntary, and possibly limited to people who know for sure they have had direct contact with someone who is sick. (Katz suggests, if it comes to it, to think of quarantine as like jury duty: an annoying civic duty you just have to endure.)

Health policy experts also debate the effectiveness of using mass quarantines and shutting cities down to stop or prevent the spread of an outbreak. Generally, the focus is on isolating patients who are actually sick and quarantining contacts who may have been exposed to their disease. But that’s not to say a local government wouldn’t use turn toward quarantines or travel restrictions, despite public health experts advising against them.

During an outbreak, local authorities would likely be taking their guidance from the CDC and the federal government. But it would be up to these local authorities to enact the “disruption to everyday life” that Messonnier mentioned in the press conference.

Quarantine is not the only option for slowing an outbreak. Depending on how the virus spreads, it could be extremely hard to find the people who have been exposed, and to put them in quarantine.

So other measures can be put into place.

These include postponing or canceling mass gatherings like sports events, concerts, or religious gatherings. It could mean closing schools (any local school board could decide to do this independently), and encouraging telework. The CDC calls these measures “social distancing” and they’re designed to slow the spread of a contagious disease. (Other good practices during any outbreak: Stay home if you’re sick, cover your coughs and sneezes, and wash your hands!)

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The CDC’s Messonnier wants people to prepare for the possibility of these social distancing measures, and figure out how they might still live and work around them. “Think about what you’d do for childcare if schools or daycares are closed,” she said. “Is teleworking an option for you? Does your healthcare provider offer a telemedicine option? All of these questions can help you be better prepared for what might happen.” (The CDC maintains a guide for families to prepare for pandemic flu here. The recommendations should also apply to a respiratory illness like Covid-19.)

What’s not going to happen in the US: the wholesale lockdown of a city, like what has occurred in Wuhan, China, where the virus originated.

“It would be impossible to shut down a major city in United States,” Klain says. “You couldn’t feed the people in the city without things coming in and out. You couldn’t remove the garbage. You couldn’t run the health care system. In the end, if you tried to shut down a major city in the United States, more people would die from the impact on the hospitals in that city … then you would save by like slowing the spread of Coronavirus.”

The cons of this system

The pros of our decentralized public health system is that individual communities can be nimble, and decide what’s best for them in dealing with an outbreak. The con is that, we end up with a potential patchwork of responses. Viruses don’t care about state or city boundaries, and people routinely travel among them. That could make it harder to, overall, control the spread of an infection across state and city lines.

Katz has conducted research into the variety of quarantine laws that exist across states. “Most of these laws are really old and haven’t been updated,” she says. “A lot of the state-level regulations have not been updated since the civil rights and individual rights laws of the ‘60s and ‘70s went into effect.” Some laws don’t provide protections like a right to legal counsel when being quarantined. Very few states — only 20 percent — have provisions to keep people from being fired from missing work during a quarantine.

The upshot is this: Because many states haven’t bothered to revise these laws, they haven’t thought through what a modern-day quarantine should look like, and what rights need to be respected.

Katz’s co-authored 2018 paper on this sums it up starkly:

Fewer than half of state laws even include right to counsel during a quarantine, and many fewer have written protections for being able to choose a medical provider or receive compensation for damages that may occur. While half of the states have granted explicit police powers to enforce public health actions during a quarantine, half do not. And only 20% provide any employment protection for individuals forced to stay away from work for the betterment of society. More worrisome, less than half of the states have language in their laws and regulations related to providing safe and humane quarantines.

“We believe the variation between states and the inclusion of curious rules creates an environment across the country that will result in unease, confusion, and possibly civil unrest if large-scale quarantines are ever required,” the paper concluded.

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The patchwork also introduces politics into the mix. Governors, mayors, school boards, and other local officials are politicians. And we know politicians don’t always heed the best available advice of scientific experts. A few weeks ago, during a House hearing on the emerging coronavirus outbreak, Johns Hopkins University infectious disease expert Jennifer Nuzzo testified before a House Subcommittee, saying that international travel bans during outbreaks don’t really work, and are unproductive. Congressman Brian Mast (R-Fl.) responded that her testimony “does not pass the test of common sense.”

Political responses to the outbreak may be wide-ranging. Some may fear acting will hurt their local economy. Others may overreact. In 2014, a teacher in Maine was placed on leave because he had traveled to Dallas, a city where an Ebola patient died in a hospital (the teacher had not visited the hospital). During the Ebola outbreak, then New Jersey Governor Chris Christie forced a nurse who had treated Ebola patients in Africa into quarantine. She never exhibited symptoms of the disease, and experts concluded she posed no risk. But the governor held her in isolation anyway. The nurse ended up suing the state, arguing her rights were infringed on.

Already, we have seen some ways in which local politics can influence the US response to Covid-19. The city of Cosa Mesa, California has gone to court trying to block federally quarantined patients from going to a facility there. The Trump administration scrapped plans to send quarantined people from the Diamond Princess cruise ship to a facility in Alabama after local outcry.

Another fear: That Trump undermines the advice and messaging of the CDC, for political or personal reason. The “sharpiegate” incident where the Trump displayed an altered version of a NOAA hurricane forecast map for the press. Trump has previously erroneously tweeted that Alabama had been at risk for the storm. The altered map made Trump seem like he was correct all along.

The White House is getting moving on a coronavirus response, requesting Congress for $1.25 billion in emergency funding to prepare (though they request the money be sourced from funds that go to work on the Ebola virus). Trump, so far, has been downplaying the risk of the coronavirus taking hold here, but is reportedly “furious” about how the news of the disease is impacting the US stock market.

Are hospitals ready?

The scariest what-if to think through is this: What if a disease like Covid-19 does start to spread widely here, sending thousands or more to hospitals across the country. One of the worries here is also that transmission would likely begin in a big, urban environment with international travel hubs. Could our institutions handle that?

“No,” Klain says bluntly. “That’s one of the most dangerous things about this. It could overwhelm a local healthcare system.”

“We don’t have extra hospitals just sitting around with doctors and nurses and beds with no patients in them,” he says. That’s not the way our healthcare system works, right? Underperforming hospitals are shut down. Generally hospitals run pretty full. What if all of a sudden 10,000 sick people needed hospitalization in a major city? There’s no 10,000 extra beds sitting around someplace.”

(It bears mentioning another concern: this is the American health care system; where sick people are known to avoid care due to fears of high medical bills.)

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We’d have to build tent hospitals to triage patients, and possibly cancel elective surgeries to free up beds in facilities. “You’ll find patients backed up in the emergency room, you will find patients on gurneys because there aren’t enough beds,” says William Schaffner, a professor of preventive medicine and infectious diseases at Vanderbilt. He says all hospitals will have a pandemic preparedness plan, which is often rehearsed. But even the best plans have flaws.

During the 2009 H1N1 flu pandemic, Schaffner says that caregivers in their pediatric emergency department were getting fatigued. But “we didn’t have kind of a team on the bench who were emergency pediatric emergency room certified to go in. So we got volunteers from the rest of the pediatric physician staff.” These staff members had to quickly be trained for the emergency room.

Diseases are chaotic by nature. Outbreaks test the system, and will reveal its flaws. Just how unprepared is the US medical system for a big outbreak? Hopefully we won’t have to find out.