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The US series documents the many complex, inter-related causes of the poor US pandemic response, underpinned by two key contexts. The first is the nation’s pre-existing structural and systemic features, which magnified the pandemic’s impact. These include gaps in healthcare and public health systems, the absence of social safety nets and workplace protections, social inequality, and systemic racism. These same features also contribute to the US’s poor performance on many health indicators compared with other wealthy countries.6 From 2010 to 2019, even before covid-19, US life expectancy stagnated while it rose in its peer high income nations,7 and inequalities in health and healthcare widened.8 Over the same period, the US Centers for Disease Control and Prevention had funding for its core budget and public health emergency preparedness activities reduced.9 From 2010 to 2020, per capita spending for state public health departments fell by 16% and for local health departments by 18%.9 With the Trump government bungling the federal response,10 hollowed-out state and local health departments were poorly equipped to step into the breach.9

ncy preparedness activities reduced.9 From 2010 to 2020, per capita spending for state public health departments fell by 16% and for local health departments by 18%.9 With the Trump government bungling the federal response,10 hollowed-out state and local health departments were poorly equipped to step into the breach.9 Ingrained inequalities contributed to devastating pandemic outcomes. The US has greater income inequality and more limited worker protections than its peers,11 and precarious employment was on the rise even before covid-19.12 These are key reasons why the nation saw higher covid-19 mortality rates than its more equal counterparts,13 and why pandemic death in the US was so closely patterned by social class.14 In addition, a history of pervasive structural racism manifested across many aspects of society, which, unsurprisingly, resulted in stark racial inequalities in the US in who lived and who died.15

lity rates than its more equal counterparts,13 and why pandemic death in the US was so closely patterned by social class.14 In addition, a history of pervasive structural racism manifested across many aspects of society, which, unsurprisingly, resulted in stark racial inequalities in the US in who lived and who died.15 A second context is that while the US had many scientific resources, exemplified by the success of Operation Warp Speed in accelerating vaccine development and the Covid-19 Prevention Trials Network in mobilising critical research, government at many levels showed a surprising inability to generate reliable information, communicate it in a timely and consistent manner, and translate it into sound policy. These failures began at the top. President Trump lied endlessly about the pandemic,10 16 17 with dreadful consequences.18 His suggestion of injecting disinfectant into people infected with covid-19 came to symbolise the chaotic presidential communications in the pandemic’s first year.19 Despite its scientific resources and decades of pandemic preparedness exercises, the country struggled to generate scientific evidence on viral transmission and the coordinated policies needed to prevent such transmission. Poor communication of existing evidence also contributed to confusion and delayed or inappropriate actions, contributing to the partisan difference in how quickly US states instituted public health protections and in excess death rates during the pandemic,20 especially after vaccines became available.21

h transmission. Poor communication of existing evidence also contributed to confusion and delayed or inappropriate actions, contributing to the partisan difference in how quickly US states instituted public health protections and in excess death rates during the pandemic,20 especially after vaccines became available.21 The absence of timely evidence and delayed or incomplete communication of what was known also led to over-reach, which itself had harmful consequences. For example, even after studies had shown that fomite transmission was rare and transmission outdoors was much less common than indoors,22 23 some municipalities and states kept parks, playgrounds, and beaches closed. Even after research had shown that schools could be reopened safely with basic public health measures, too many jurisdictions kept teaching online only.24 Too often, there were failures to learn from evidence based harm reduction approaches that have been successful in curbing other pandemics, such as HIV/AIDS.25 The communication failures were compounded by federalism—the division of power between the national government and the 50 US states—which ensured that the covid-19 response depended on zip code.26

But despite these failures, the pandemic also showed the US how government and society could have a different role in protecting health. In addition to rapid vaccine development, which was publicly funded, many public policies were put in place that helped to support citizens and curb deaths. These included expanded unemployment benefits, food assistance programmes, a moratorium on evictions, expanded child health insurance coverage and Medicaid enrolment, and federal funding for public school upgrades. These strategies had measurable social and health benefits.27 Of special relevance to the 2024 US presidential election, they illustrate how a range of government actions, beyond health insurance, can be critical to protecting health in the next pandemic and beyond. The BMJ series includes articles on the effects of systemic racism and economic inequality; mass incarceration and poor prison health; labour market inequalities; legal infrastructure; and the diminished role of the public sector. The aim of the series is not to assign blame—there is plenty to go around—but to look to the future and lay out the critical steps to transform US public health and preparedness and improve population health more broadly.