Intended for healthcare professionals


Overcoming “failures of imagination”—rethinking the US covid-19 pandemic response

BMJ 2022; 379 doi: (Published 05 October 2022) Cite this as: BMJ 2022;379:o2397
  1. Ranu Dhillon, instructor of medicine1,
  2. Abraar Karan, infectious disease doctor and researcher2
  1. 1Division of Global Health Equity, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
  2. 2Stanford University, California, USA

We shouldn’t accept doing less than “everything we could” to protect people from covid-19, say Ranu Dhillon and Abraar Karan

“We did everything we could.” As physicians, we have uttered these words to countless families when a loved one of theirs has passed away. In medicine, we do everything we can to save the lives of our patients as long as it is not causing them undue harm. Even when these efforts are sometimes not enough, the people in our care are still afforded the dignity of being given every chance—and their families the solace of knowing this.

Many times in the low income settings in which we have worked, however, we have seen how the deaths of vulnerable or marginalised people are normalised even when there was much more that could have been done to avoid them. The late Paul Farmer, a doctor and medical anthropologist who was a colleague and mentor to us both, described these preventable deaths as “failures of imagination” that are created by being “socialised for scarcity.”1

The same kind of pathological thinking has plagued the US’s response to covid-19. In remarks made in an interview that aired on 18 September, President Joe Biden declared the pandemic “over.”2 Yet his administration has been steadily downsizing its covid-19 response for months now.3 Soon, the only protection US citizens could be left with is an annual vaccine,4 which declines in efficacy after a few months.5 For now, covid-19 vaccines are freely available, but in the future they could be tough or costly to procure for those without health insurance.6 With other mitigations gone, we are left to hope that cumulative immunity will be enough to protect us.

This is the US’s chosen strategy even as more than 400 US citizens are reported to die from covid-19 every day and millions more struggle with symptoms of long covid,7 an epidemic unto itself that we don’t yet fully understand or have effective ways to treat.

Settling for preventable deaths

Instead of settling for where we currently are and knowingly allowing preventable deaths,8 there are several measures we could pursue that could protect lives without requiring people to restrict or change their everyday routines or make other trade-offs or sacrifices. In the same way that doctors will do everything they can—short of causing harm—to help their patients, policy makers need to be doing the same for their communities. So, what would doing everything we could to offset the pandemic look like?

Doing everything we could would mean turning empty calls for better indoor air quality into solid plans, which lay out specific actions, their timeframe, and how they’ll be achieved. We currently don’t even have clear targets for air cleaning that schools, businesses, and other organisations can use as a guidepost. Billions of dollars were made available to schools for them to improve their air quality, but the money has gone unspent.910 A survey from the US Centers for Disease Control and Prevention found that most US public schools haven't made major investments in improving indoor ventilation and filtration, with only 28% of the 420 schools surveyed using portable high efficiency particulate air (HEPA) filtration systems in classrooms.11 We need to understand why these funds remain unused and resolve any bottlenecks.

If we did everything we could, we would not liken the new bivalent vaccine to an annual flu shot and roll it out with the same routine messaging. Only 68% of Americans have received two doses of the covid-19 vaccine and a mere 33% have had the booster dose—including just 66% of those older than 65.12 With vaccine coverage lagging, the new covid-19 vaccine should be pushed with the urgency of averting the hundreds of deaths a day we are seeing now and the thousands a day we could see if there is another surge.

We should be blitzed with messages on television, radio, and other media urging us to get vaccinated. People in high risk groups should be specifically reached out to through community groups and door-to-door follow-up, as some US counties have previously done,13 until they either get vaccinated or make it clear they understand the risks and still don’t want to. Passively hoping for people to make the effort to get the vaccine isn’t enough.

Protecting people where we can

Doing everything we could would mean finding a way to continue funding free rapid tests that can be mailed out to people’s homes and working on having their over-the-counter cost—unchanged since they first debuted14—reduced to a more affordable price. It would mean having N95 masks freely available. These masks should be subsidised by the federal government as they were in the US earlier in the pandemic and in other countries,1516 so that masks are accessible to individuals anytime they’re entering a crowded indoor setting. This would ensure that people who want to protect themselves can.

Finally, doing everything we could would mean changing the government’s tone of false reassurance to mature, clear communication that conveys how the risks posed by covid-19 are still present, people are continuing to die, and there are steps we can all take to stay safer. It would also mean that instead of framing our choices as dichotomous, with outcomes that must either see us lose ground to the virus or be harmed in some other way economically, socially, or educationally, we develop solutions that allow us to circumvent or minimise trade-offs.

If we get better indoor air filtration in shared spaces, increase vaccine coverage, keep tests and N95 masks freely available, and continue finding innovative ways to limit the need to choose between our health and other important aspects of society, we could drive down the number of deaths and cases of long covid. Taking these steps would allow us to more successfully and sustainably navigate this stage of the pandemic.

We wouldn’t accept doing less than “everything we could” to save the life of a patient. We shouldn’t accept the same for saving and protecting lives in our communities.


  • Competing interests: Abraar Karan is funded by the Stanford Center for Innovation in Global Health (CIGH) on a trial investigating the efficacy of air filtration devices to slow covid-19 spread in homes. Ranu Dhillon has no COI to report.

  • Provenance and peer review: commissioned; not externally peer reviewed.