We Were Warned. We Still Failed

Among the most critical skills for a surgeon is the ability to reflect deeply upon your errors, identifying how you can do better. Practicing that skill is enshrined in weekly morbidity and mortality conferences where surgeons and their peers discuss what has gone wrong, and occasionally right, in caring for their patients. It is no surprise that, reflexively, I have read many of the post-mortems on the handling and mishandling of the COVID-19 pandemic. 

Much like some surgeons excuse their results because the patient was too sick, pundits on both sides of the aisle have argued why they were right rather than what they did wrong. Last week, I read a review in the journal Public Choice by Alex Tabarrok, a professor of Economics at the Mercatus Center. He is remarkably insightful, casting more light on our human frailties than shade about our intentions. 

“In its size and scope the COVID disaster was unique. COVID killed more Americans than World War I, World War II, the Korean War, the Vietnam War, the Gulf War, the Afghanistan War and the Iraq War combined.”

- Alex Tabarrok, Professor of Economics at George Mason University

With this opening, Tabarrok pulls from the economic literature on disaster to identify systematic weaknesses in disaster preparedness.

Why Disaster Preparedness Fails

Lack of preparation despite numerous warnings – including a warning in 2019 by the WHO that “a global pandemic of flu is a matter of “when” and not “if.” And a cover story from Time Magazine in 2017, “Warning: We are Not Ready for the Next Pandemic.” Despite widespread predictions of a COVID-like event, an agency whose primary goal is preparedness — the Strategic National Stockpile — was itself unprepared, holding only 35 million aging rotting N95 masks instead of the 3.5 billion needed.

Voter and politician misalignment - Voters need long-term investments in readiness. Still, their myopic short-term focus, mirrored by politicians facing frequent elections, emphasizes visible, immediate spending rather than invisible, uncertain preparedness. Because voters struggle to evaluate readiness, politicians gain little political reward for investing in it.

The Prophet’s Paradox - the more successful a warning or preventative action is, the less people believe the threat ever existed. When policymakers act early, deploying measures like quarantines, vaccination campaigns, and emergency stockpiling, the very success of these efforts can erode public support, feeding perceptions of overreaction. The prophet is seen not as wise but as alarmist. While prevention is often silent, rescue is dramatic, creating an incentive to manage rather than prevent emergencies. Measles absence, nearly eradicated by vaccination, led to complacency, distrust, and falling immunization rates. Now, measles resurges. Measles demonstrates the Prophet’s Paradox: the better we are at preventing catastrophe, the harder it becomes to justify and sustain the measures that keep us safe.

Fear of Error leading to indecision - Leaders hesitate not from incompetence but because proactive measures carry immediate, obvious political risks, while the costs of inaction are delayed, diffuse, and harder to trace. Political systems are structurally biased toward cautious inaction, a “rational self-preservation” leaving society vulnerable to the very disasters early action might have prevented. The Texas Department of Health first reported two measles cases on January 23^rd. HHS Secretary Kennedy suggested vaccination as a “personal decision” 39 days later, and the CDC’s Epidemic Intelligence Service “rapid response” followed a day later. 

Failure to understand exponential growth – In infections, exponential growth results in a doubling in size or spread over regular intervals; what seems initially small becomes overwhelming. About a month after local reports, China quickly locked down Wuhan and launched massive health measures.  In the US, it was almost two months between the first reported case and the President's declaration of a national emergency. It is rare for leaders to recognize and act forcefully against the early signs of an exponential threat. History shows that slow responses to pandemics are the norm.

Real-World Preparedness

Taking a cue from Yogi Berra, who argued that while “in theory, there is no difference between theory and practice - in practice there is," Tabbarok argues that, 

"Rather than assuming away politics, uncertainty, and slow bureaucracies, we must build institutions that work despite these realities."

He offers far more than the usual political polemics, proposing pragmatic, friction-reducing tools that work with our weaknesses rather than against them. Since political leaders are likely to act slowly due to myopia, fear of error, and difficulties forecasting exponential threats, institutions must be designed to reduce reliance on political decision-making. Inspired by automatic economic stabilizers, e.g., automatic cost-of-living adjustments (COLA) in social security, the goal is to create systems that trigger responses automatically, minimizing costly delays and saving lives and resources even when political action lags.

Tools for Faster, Smarter Responses

Two “automated predictors” overcome the “recognition lags of public actors.” 

Wastewater Surveillance is a robust early warning system detecting disease outbreaks by monitoring genetic material in sewage before people show clinical symptoms without relying on slow political decision-making or delayed clinical reporting. Because it monitors populations passively and continuously, it allows public health officials to quickly allocate resources and implement control measures even when individuals don't seek testing or governments hesitate to act.  

Prediction Markets harness the Wisdom of the Crowd, tapping into the knowledge of many individuals, often outperforming expert consensus, especially when timely, decentralized insight is critical. In pandemic situations, where official information can be slow or politically filtered, prediction markets could provide faster, more accurate signals about threats and outcomes, helping to guide better decision-making under uncertainty. 

Vaccine Libraries and Viral Research Hedge Our Bet because vaccine development is slowed by testing and regulatory delays rather than scientific failures. On January 11, 2020, the genetic code for COVID-19 was uploaded to the internet; two days later, a vaccine had been designed in the US. The near-year wait for public release was almost entirely due to testing. The rapid development of a vaccine was due to previous research on SARS and MERS, which identified the “spike protein” as the vaccine target. Foundational basic research on common features and mechanisms of pathogens reduces the time necessary for scientific development. A vaccine library of pre-developed vaccines, tested for safety and efficacy, would allow scientists to move directly into late-stage testing when a new threat emerges, hedging against the inevitable slowness of an emergency response, ensuring a running start when the next virus emerges.

A Pandemic Trust Fund (PTF) Operation Warp Speed, arguably the most successful program in fighting COVID-19, struggled to secure funding. It scrounged resources from other programs, relying on creative accounting and legal maneuvers. The problem wasn’t an available budget but the political optics of diverting money from existing programs. A PTF that clearly denotes pre-authorized pandemic spending rights avoids costly and divisive budget battles when rapid action is needed most. It would operate as a drawdown account, triggered automatically by public health criteria, providing immediate resources for vaccine development, emergency responses, and mitigation efforts, and replenished later. A PTF, as with Tabarrok’s other recommendations, accepts the realities of political behavior and designs around them.

The remaining two of his recommendations gave me significant pause. Let me quickly describe each, along with my concerns. 

Ethical and Political Tradeoffs in Acting Quickly

Human challenge trials involve intentionally infecting volunteers with a pathogen to quickly test the effectiveness of vaccines or treatments. Unlike traditional randomized controlled trials (RCTs), which rely on participants naturally encountering the disease, challenge trials can deliver faster, clearer results, a decided advantage when delay costs lives. Human challenge trials raise serious ethical concerns, particularly around intentionally exposing individuals to risk, as was the case with the Tuskegee syphilis experiments.

The ethical dilemma facing physicians stems from our foundational principle of "first, do no harm." Physicians have a fiduciary duty to prioritize the immediate well-being of their patients, making the deliberate exposure of healthy volunteers to pathogens, even for vital research, feel fundamentally wrong. This conflict is amplified by competing obligations to the patient’s immediate community and society. Tabarrok suggests a more utilitarian calculus, emblematic of military leaders, who weigh individual sacrifice against collective benefit. Yet this overlooks the immediacy of emotional consequences both professions face when harm occurs. To navigate these challenges, he proposes shifting oversight of human challenge trials to institutions like the military, which are experienced in balancing individual and societal risks and creating a bureaucracy that spreads rather than apportions guilt. In the context of a pandemic, when speed is critical, ethically structured challenge trials might enable faster, more balanced policy responses.

Public-private partnerships - Operation Warp Speed proved critical during the COVID-19 pandemic by combining government funding and authority with private sector speed and innovation. It is a pragmatic solution, accepting that existing institutions are too slow in a crisis and that building entirely new ones is politically and practically unrealistic. However, there is a natural tension between the need for rapid action and the risk of political favoritism, misallocation, or corruption, raising concerns about accountability, oversight, and potential waste when speed and flexibility override standard safeguards. 

For example, concerns have been expressed over the “Department of Government Efficiency” (DOGE), where emergency power and funding have resulted in opaque decision-making and speculation about political favoritism in the face of unchecked urgency. They serve as a cautionary tale showing that without strict limits and transparency, rapid-response programs, whatever the intent, can breed inefficiency and public mistrust. Unlike what we are seeing with DOGE, effective public-private partnerships must be narrowly structured, time-limited, and rigorously monitored to harness the strengths of both sectors while containing, but not eliminating, the risks that inevitably arise. 

Moving Beyond Illusion

Actual preparedness requires more than expert committees and ambitious declarations; it demands institutional designs un-reliant on political bravery or perfect foresight. Tabarrok’s proposals accept the structural realities of governance rather than wishing them away. In a system built around short-term incentives and fear of blame, the most effective reforms will act automatically when human nature hesitates. If we are serious about facing future threats, and we must be, Tabarrok makes a strong case to abandon the romance of heroic leadership and invest in the quiet, often invisible work that keeps catastrophe at bay.

Source: Pandemic preparation without romance: insights from public choice Public Choice DOI 10.1007/s11127-025-01277-2