Federalism and the challenge of a swift public response to COVID-19

Like many residents in California, I am living through the COVID-19 epidemic, learning as we go along on how to best protect ourselves and our communities. We are also concerned about how to protect strangers, outside our friends and neighbors, whom we may be putting at risk by spreading the disease. My University took swift action, moving to an online learning model, avoiding travel, promoting simple guidelines of personal hygiene, and practicing social distancing. Our School District, instead, followed CDC and County protocols, keeping our children attending school for two weeks, on the grounds that they were not susceptible to the same risks as other members of our community. My public schools have only announced today their closing for a month. The rationale is compelling: Santa Clara County currently has 66 confirmed cases and one death, and the epidemic is growing at an exponential rate. Shouldn’t there be a more unified response to the crisis, shared by Universities, Schools and other social spaces of potential contagion?

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Confirmed cases of COVID-19 follow an exponential curve as noted by the blue dots denoting a hypothetical doubling of cases every 4 days after February 27.

More broadly, what is the proper response to a new epidemic in a democratic nation? Measures taken in China are probably not a good guide to how the US or other democratic countries should respond to this crisis. But the way things are going, at least in California, we unfortunately might heading towards a scenario like Italy’s, where COVID-19 has overrun the capacity of highly sophisticated and developed health system.

The problem with making a case for aggressive measures that may arrest contagion is that there are still many unknowns regarding the future of the disease, notwithstanding the sophisticated models simulated by epidemiologists. We do not know how or why children are less susceptible to the disease. We are barely beginning to understand whether warm weather may reduce the rate of infection in the coming months. It is still quite unclear what the actual death rate is. But in addition to the crucial evidence that science is providing to chart a course of action, the US has a structural challenge in facing this epidemic, emerging from its form of government, namely federalism.

Federal systems of government have the peculiarity of being less capable of acting in unison for a threat such as a pandemic. Federalism protects diverse interests creating veto points that empower local actors. But in so doing, it is also less able to transmit centralized decisions to subnational levels of government. There is quite a bit of evidence suggesting that for those same reasons, countries organized along federal lines are more unequal than unitary systems. The national State in federal regimes has less capacity to compensate and equalize when local and state actors block efforts at redistribution. Of course some federal systems are more unequal than others, with the US and the Latin American federations being more unequal than the European ones. But the general point is that in federal systems it is harder to shift resources to where they are most needed or to create solidarity among various territorial units, because of an in built feature in the arrangement that leads towards uncoordinated decision making.

Therefore, one of the complications in the response to COVID-19 in the US, and presumably in other federal systems, is that national strategic responses are harder to put together. This may be one of the elements that explains why Italy, though not strictly federal but characterized by a highly decentralized system of government, could not react in the same way as Taiwan or Japan did. The Italian regions are analogous to the US in their response to the COVID-19 crisis, because they initially were characterized by uncoordinated responses, particularly in what regarded aggressive testing. The Veneto region, as seen below, tested almost 5 per 1000 inhabitants, while Emilia Romagna only a third of that rate. Positive confirmed cases depended on the prevalence of testing, but there might have been an important insight in the authorities of some regions that may have been more able to prevent deaths by slowing down the spread in their jurisdictions.

Prevalence of testing by Italian region. Information from Dipartimento della Protezione Civile (March 12, 2020)

Provincial level data from Italy provide some additional insight, although it is very important to clarify that any claims regarding causal chains or an explanation are invalid with the information we have thus far. There is, however, a greater prevalence of cases in places where there is more jurisdictional fragmentation. The scatterplot is by no means a “smoking gun”, in the sense of providing definitive evidence, but it is suggestive, and a cross sectional regression model shows that the positive correlation is a statistically significant (a slope different from zero) positive one. The provinces in Italy also show what may be a climatic North — South gradient, although it is too soon to know whether this might be a consequence of temperature (we do not yet know how susceptible the virus is to those environmental conditions) or simply a confounding factor related to the way contagion progressed over the Italian territory.

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Own calculations with data from Dipartimento della Protezione Civile (March 12, 2020)

The argument regarding federal dis-coordination does not explain, however, why Germany seems to have been able to respond quite effectively to its first cases. The German case perhaps helps in a different way, by showing why leadership matters: if the federal level of government is oblivious and pandering to its voters, instead of facing the evidence and reacting to a real and urgent threat, its coordinating role is lost, and the pandemic will take hold. The federal government in Germany did not wait to see how the pandemic would evolve, but took very swift action identifying and following up in contact and surveillance of the first cases.

An additional experience of decisive action by a federal government in the face of a pandemic is Mexico. When Mexico went through the H1NI pandemic in 2009, many critics felt that its response was excessive. Schools were closed, all public gatherings cancelled, people stayed at home, bringing Mexico City to a standstill for almost three weeks. The H1N1 turned out to be highly contagious, but no more deadly than other flu viruses. This led to strong critique to the government action, which with hindsight, was perceived by some critics as having been too costly in economic terms.

However, the Mexican response was not just judicious but timely. While the cases may not have been any different from a seasonal flu, the health care resources reacted immediately, and were able to cope with the new epidemic. Part of the reason why the Mexican health system could deal with the H1N1 outbreak the way it did was that, due to a peculiarity in the architecture of Mexico’s health infrastructure, the first case was identified on April 11 2009, by an IMSS clinic in a remote clinic in Veracruz. It was immediately sent to the central authorities, as part of the epidemiological surveillance system. I happened to be with the IMSS-Oportunidades Director that day, and remember distinctly her concern. Within days the leaders of IMSS knew of a suspicious, possibly a new strain of influenza, that had been analyzed by the CDC. These were probably the first cases, circulating in California since March. The Mexican authorities acted according to the seriousness of the threat, with advise and support from WHO, PAHO and CDC. Within a few days Mexico City was keeping close track of an anomalous pattern in influenza cases, and by April 23 all schools in the country were closed.

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Echevarria-Zuno et al. 2010. Infection and death from influenza A H1N1 virus in Mexico: a retrospective analysis. Lancet 2009; 374: 2072–79

I am sure that countless deaths were avoided, particularly among poor Mexicans who may have otherwise been most vulnerable and not receive the care they needed. And also Mexicans learned, thanks to concerted public service campaigns coordinated from the federal level, to protect themselves through hand-washing, sanitizer and prudent social distancing. The response and preparedness by the federal government in Mexico has been more erratic this time, as the President seems to have different “facts” from what most of the epidemiology and public health community sees as an inexorable process that is unfolding already.

The US is at a threshold of a decisive moment. In the worst-case scenario, inaction will lead to the unnecessary loss of many lives, an unsustainable burden on the health system, and eventually huge economic costs that will not be averted by delayed action. This is what is happening in Italy. If the administrations at the county, state and federal level continue muddling through, this seems to be a more likely scenario, unless by sheer luck, temperatures rise, the virus takes on an evolutionary turn becoming less deadly, or people collectively take on social distancing when their governments have failed them.

This is ultimately a question of leadership and trust. Not about political institutions, parties, elections or campaign promises. Whether Mr. Trump is capable of rising to the occasion, and do what is right, is still to be seen. For the sake of so many lives that are at stake, I wish him the best of luck in this turning point. I wish that he may listen to the advise from the best scientists, epidemiologists, virologists and public health experts that are already available to him. And that US citizens can trust their governments in their coordinated efforts, notwithstanding fragmentation and polarization. It is a high call in a country where so many citizens believe government is not to be trusted. But this is a time when only public action, decisive and swift, even if painful in the short run, will be the only thing that can help us all.

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