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‘It’s Totally Ad Hoc’: Why America’s Virus Response Looks Like a Patchwork

For centuries, the United States has resisted a centralized public health policy. This week, as protective measures against the coronavirus varied county to county, Americans saw the cost.

Nursing students Soledad Lupian, left, and Edwin Gituma instructed first graders at Ethel Phillips Elementary School in Sacramento, Calif., on how to properly wash their hands.Credit...Max Whittaker for The New York Times

PAWTUCKET, R.I. — David Norton, who helps to run a community center 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.

Boston had canceled its St. Patrick’s Day parade, but Newport had not. Movie theaters and malls were open. But Disney World was closing. In the end, members threw up their hands and canceled most everything through the end of April.

“It’s totally ad hoc,” Mr. 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 canceled, it’s canceled.”

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 states and 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 Centers for Disease Control and Prevention — the federal agency cannot get involved on the ground unless invited by states or municipalities.

“We have a completely decentralized public health system,” said Michele Barry, senior associate dean for global health at Stanford University. “It is difficult to mobilize 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.

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Michele Barry, senior associate dean for global health at Stanford University. Credit...Jim Wilson/The New York Times

“I’m just worried we’re going to follow the Italy course, rather than the Singapore course or Hong Kong course, because we’re decentralized,” 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, Fla. 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, Calif., 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 1,200 other teenagers, and returned home.

“It needs to be all or nothing, or else how do we stop the spread?” said Ms. Stettler. “The most confusing thing to my kids is, why is the N.B.A. canceling, 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, Wash., Geng Tan, 48, wondered why her children’s schools remained open, when the schools in the next county over had already closed as a precaution.

Ms. 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.”

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A testing center in New Rochelle, N.Y., where the National Guard was deployed.Credit...Andrew Seng for The New York Times

The country’s localized 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, decentralized decision-making has led to a lag in reaction time.

Dr. 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 Dr. 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 localized policy can also have an upside, encouraging innovation and nimbleness.

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Geng Tan wondered why her children’s schools remained open when the schools in the next county were not.Credit...Grant Hindsley for The New York Times

“You can be too centralized, 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 neighbors, of not getting too involved,” he said. But he added that “local civic-mindedness” is strong in the United States, embodied in robust community organizations, 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.

Mr. 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.

On Sunday, he announced more guidelines — among them that everyone over 65 should be isolated at home, and that bars, nightclubs and wineries should close — and said once again that he could make them mandatory but did not think that he would need to.

Local autonomy, he said during the week, 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.”

Thomas Fuller contributed to this report from San Francisco, and Karen Weise from Seattle.

Ellen Barry is The Times's New England bureau chief. She has previously served as The Times's Russia and South Asia bureau chief and was part of a team that won the 2011 Pulitzer Prize for International Reporting. More about Ellen Barry

A version of this article appears in print on  , Section A, Page 9 of the New York edition with the headline: Crisis Response Is Coming From Your Town, or State, or School District. Order Reprints | Today’s Paper | Subscribe

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