American Democracy & Health Security

American Democracy & Health Security

American Democracy & Health Security

American Democracy and Health Security

Lighting a path forward amid pandemic Polarization

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Executive Summary

Executive Summary

The story of how America fared under the pandemic is actually two stories—the well-known one of national failure, loss, and polarization, and the lesser-known one of state and local collaborations and innovations that bridged divides. Both are true. The former eroded trust and fractured faith in democracy. The latter earned trust and leveraged the strengths of our democracy.

American democracy and health security are inextricable: American health security depends on maximizing our ability to live in a free society and manage a public health emergency simultaneously. Likewise, the health of our democracy depends on citizens’ faith in our institutions – our schools, workplaces, and especially our government – to protect them in a crisis.

Somehow, we must find a way forward that both respects the individual freedoms we hold dear and supports the collective good—and do so now, before the next devastating health emergency strikes.

That path forward is illuminated by the state and local leaders – lamplighters – who innovated in the pandemic’s darkest days, and whose efforts reflected the ingenuity, collaboration, debate, and shared decision making that are hallmarks of American democracy.

The story of how America fared under the pandemic is actually two stories—the well-known one of national failure, loss, and polarization, and the lesser-known one of state and local collaborations and innovations that bridged divides. Both are true. The former eroded trust and fractured faith in democracy. The latter earned trust and leveraged the strengths of our democracy.

American democracy and health security are inextricable: American health security depends on maximizing our ability to live in a free society and manage a public health emergency simultaneously. Likewise, the health of our democracy depends on citizens’ faith in our institutions – our schools, workplaces, and especially our government – to protect them in a crisis.

Somehow, we must find a way forward that both respects the individual freedoms we hold dear and supports the collective good—and do so now, before the next devastating health emergency strikes.

That path forward is illuminated by the state and local leaders – lamplighters – who innovated in the pandemic’s darkest days, and whose efforts reflected the ingenuity, collaboration, debate, and shared decision making that are hallmarks of American democracy.

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America at its Worst

America at its Worst

On the one hand, things went colossally wrong.

Early 2020 was unlike anything Americans had ever experienced. Gradually and then all at once, we were faced with a global pandemic—a new and lethal coronavirus upending every aspect of our lives.

We never imagined that our nation would struggle so mightily to meet the moment, spectacularly failing to launch a rapid, effective, equitable response. We didn’t anticipate that public health would become so polarizing, or that the tension between individual freedoms and collective interventions would become so divisive. We didn’t foresee that by 2023, COVID-19 would have claimed more than 1.1 million American lives—a massive loss our nation has neither collectively marked nor mourned—or that our country, among the world’s most technologically and medically advanced and with only 5 percent of the global population, would account for 15 percent of officially reported COVID deaths.

At the local level, the impact of the pandemic—and the interventions intended to slow its spread—reverberated through every aspect of American life. Officials grappled with seemingly diametrical pressures to minimize the multiple tolls of the virus – in health, livelihoods, and learning — and preserve life as we knew it. There was no established method for reaching decisions on interventions from masking to school closures to social distancing to business operations. Decisions to resolve one issue often aggravated challenges elsewhere.

Political rhetoric heightened divisions. Health officials implored the nation to “follow the science,” but it was not always clear what that meant in practice. Scientific uncertainty and pressing societal concerns – economic, educational – had to be factored into urgent political decisions. Too often, valid dissenting views were dismissed and mis- and dis-information flourished.

Every state, local, and Tribal leader faced flashpoints: how to simultaneously protect health, protect jobs, protect school populations, protect the old, protect the young, protect individual freedom, and promote collective responsibility – all against a terrifying set of unknowns.

Confronting COVID-19 threatened more than Americans’ physical and mental health: it intensified divisions and mistrust among us. Faith in governing institutions plummeted; cynicism deepened. Our sense of safety was shaken, our divisions intensified, our faith in our democracy fractured.

On the one hand, things went colossally wrong.

Early 2020 was unlike anything Americans had ever experienced. Gradually and then all at once, we were faced with a global pandemic—a new and lethal coronavirus upending every aspect of our lives.

We never imagined that our nation would struggle so mightily to meet the moment, spectacularly failing to launch a rapid, effective, equitable response. We didn’t anticipate that public health would become so polarizing, or that the tension between individual freedoms and collective interventions would become so divisive. We didn’t foresee that by 2023, COVID-19 would have claimed more than 1.1 million American lives—a massive loss our nation has neither collectively marked nor mourned—or that our country, among the world’s most technologically and medically advanced and with only 5 percent of the global population, would account for 15 percent of officially reported COVID deaths.

At the local level, the impact of the pandemic—and the interventions intended to slow its spread—reverberated through every aspect of American life. Officials grappled with seemingly diametrical pressures to minimize the multiple tolls of the virus – in health, livelihoods, and learning — and preserve life as we knew it. There was no established method for reaching decisions on interventions from masking to school closures to social distancing to business operations. Decisions to resolve one issue often aggravated challenges elsewhere.

Political rhetoric heightened divisions. Health officials implored the nation to “follow the science,” but it was not always clear what that meant in practice. Scientific uncertainty and pressing societal concerns – economic, educational – had to be factored into urgent political decisions. Too often, valid dissenting views were dismissed and mis- and dis-information flourished.

Every state, local, and Tribal leader faced flashpoints: how to simultaneously protect health, protect jobs, protect school populations, protect the old, protect the young, protect individual freedom, and promote collective responsibility – all against a terrifying set of unknowns.

Confronting COVID-19 threatened more than Americans’ physical and mental health: it intensified divisions and mistrust among us. Faith in governing institutions plummeted; cynicism deepened. Our sense of safety was shaken, our divisions intensified, our faith in our democracy fractured.

America at its Best

Yet beneath the national divisiveness and dysfunction, something else – something hopeful and innovative – was happening at the state and local levels.

Across the country, in countless communities and every sector, there were people finding ways to pull together, innovating amid profound uncertainty, transcending divides, and saving lives.

The efforts of these unsung heroes – lamplighters – reflected the spirit of community, ingenuity, and participatory decision making that are the hallmarks of American democracy at its best. They formed ad hoc collaborations, fusion cells, and networks that reached the corporate sector, the vulnerable and marginalized, the faith and school communities. These improvisations broke down silos, welcomed diverse inputs, demonstrated humility in the face of uncertainty, and prioritized listening that met people where they were.

These leaders prized regular, quality communications and deft explanation of evolving data. They were driven by the will to move rapidly and to create inclusive solutions, respecting individual freedoms while promoting the collective good. In so doing, they struggled, and often succeeded, to transform a limited set of blunt, binary tools – open or close, health or jobs – into more surgical instruments, better tailored to community needs, and better able to balance the science with the social, economic, and educational impacts of an effective battle plan to combat COVID.

They joined with willing partners. Businesses helped fill critical gaps, collect data, and improve planning and delivery processes. Hospitals and health systems rose to the challenge, implementing innovative ideas to remedy gaps in care. Universities brought exceptional technological assets and expertise. Community organizations stepped up to provide trusted messengers, making sure needs were made known and voices heard.

This side of the American experience of COVID-19 may have gotten less publicity, but it is no less real. Harvesting the hard-won lessons of what worked and what can be replicated going forward must be a national priority.

Yet beneath the national divisiveness and dysfunction, something else – something hopeful and innovative – was happening at the state and local levels.

Across the country, in countless communities and every sector, there were people finding ways to pull together, innovating amid profound uncertainty, transcending divides, and saving lives.

The efforts of these unsung heroes – lamplighters – reflected the spirit of community, ingenuity, and participatory decision making that are the hallmarks of American democracy at its best. They formed ad hoc collaborations, fusion cells, and networks that reached the corporate sector, the vulnerable and marginalized, the faith and school communities. These improvisations broke down silos, welcomed diverse inputs, demonstrated humility in the face of uncertainty, and prioritized listening that met people where they were.

These leaders prized regular, quality communications and deft explanation of evolving data. They were driven by the will to move rapidly and to create inclusive solutions, respecting individual freedoms while promoting the collective good. In so doing, they struggled, and often succeeded, to transform a limited set of blunt, binary tools – open or close, health or jobs – into more surgical instruments, better tailored to community needs, and better able to balance the science with the social, economic, and educational impacts of an effective battle plan to combat COVID.

They joined with willing partners. Businesses helped fill critical gaps, collect data, and improve planning and delivery processes. Hospitals and health systems rose to the challenge, implementing innovative ideas to remedy gaps in care. Universities brought exceptional technological assets and expertise. Community organizations stepped up to provide trusted messengers, making sure needs were made known and voices heard.

This side of the American experience of COVID-19 may have gotten less publicity, but it is no less real. Harvesting the hard-won lessons of what worked and what can be replicated going forward must be a national priority.

The Lamplighters: Lighting a Path Forward Amid Pandemic Polarization

We interviewed leaders across the health, business, education, government, and civil society sectors who led through the pandemic, seeking to extract replicable solutions to help our nation do better in the future. 

We focused on a cross-section of states that represented wide geographic and socioeconomic diversity, as well as different political contexts and state and local structures. Each of these states improvised, generating a distinct set of lessons. We are not claiming that these states did better or worse than others. While other states developed their own innovations, our resources and remit did not allow for exploring all corners of America. Our intent is not to capture the full universe of creative approaches, but rather to highlight some compelling examples of what was achieved and should be preserved and strengthened.      

The lamplighters we feature are Americans who united and served their communities, rising above rhetoric to meet an impossible moment with humility, grit, grace, and strength. 

In this pivotal moment for our country and the world, the examples we are privileged to share in this report – of leaders who improvised to balance personal freedoms with communal health measures – offer practical and actionable lessons for rebuilding trust and charting a hopeful future.

We interviewed leaders across the health, business, education, government, and civil society sectors who led through the pandemic, seeking to extract replicable solutions to help our nation do better in the future. 

We focused on a cross-section of states that represented wide geographic and socioeconomic diversity, as well as different political contexts and state and local structures. Each of these states improvised, generating a distinct set of lessons. We are not claiming that these states did better or worse than others. While other states developed their own innovations, our resources and remit did not allow for exploring all corners of America. Our intent is not to capture the full universe of creative approaches, but rather to highlight some compelling examples of what was achieved and should be preserved and strengthened.      

The lamplighters we feature are Americans who united and served their communities, rising above rhetoric to meet an impossible moment with humility, grit, grace, and strength. 

In this pivotal moment for our country and the world, the examples we are privileged to share in this report – of leaders who improvised to balance personal freedoms with communal health measures – offer practical and actionable lessons for rebuilding trust and charting a hopeful future.

A Snapshot of our Recommendations

Click here for full Findings & Recommendations

From these findings, we offer a set of urgent recommendations—practical, actionable steps—that should be implemented now to advance America’s health security.

Click here for full Findings & Recommendations

From these findings, we offer a set of urgent recommendations—practical, actionable steps—that should be implemented now to advance America’s health security.

Recommendation 1: Strengthen state, local, Tribal, and Territorial operational leadership for health emergencies, in collaboration with federal partners.

The buck stops here. Public health authorities should inform the fight, but heads of government should lead it, weighing what is known of the science with social, educational, and economic impacts. A familiar refrain during the pandemic was to ‘follow the science,’ but this alone is insufficient. As the pandemic showed, science is often imperfect and evolving, translating science into practice can be challenging, and elected officials have to weigh what is known of the science with social, educational, and economic impacts, as they reach urgent decisions.

Governors, Mayors, Tribal, and Territorial Leaders should:

  • Own the consequences of crisis decisions and bear most of the operational responsibility for health emergencies, collaborating with federal partners. Preserving public trust is the coin of the realm.
  • Create formal coordination and supply sharing arrangements with Tribes in advance of health emergencies.
  • Appoint a single, proven emergency response coordinator with operational expertise, empowered to work across all sectors and silos, at the very start of a health emergency.
  • Establish a 24/7 multi-sectoral command structure immediately when a health emergency strikes, to break down silos and engage not only health, but business, education, and civil society representatives.
  • Prioritize clear, daily communications, combined with data that is usable by the public.
  • Hold annual health emergency exercises, informed by the public and in concert with the National Governors Association (NGA), the Association of State and Territorial Health Officials (ASTHO), and others.
  • Insist on after-action assessments of COVID-19 to chart a path ahead, identify what worked and what didn’t, and prioritize resources to strengthen capabilities.
Recommendation 2: Create locally tailored pandemic playbooks, aligned with community needs.

Pandemic decision-makers should:

  • Create locally tailored pandemic playbooks that can adapt to community needs and values. Tackle the hardest issues around maintaining in-person learning, opening businesses, and vaccine uptake. Develop modules to regularly exercise and update them.
  • Designate an official in the Governor or Tribal leader’s office who is charged with local pandemic planning and exercising health emergency playbooks.
  • Plan carefully to maintain in person learning and to keep businesses open and operating safely in the next emergency.
  • Create formal agreements to cement operational roles among state governments, Tribes, and other key parties in advance of health emergencies.
  • Lay the groundwork now to ensure future rapidly scaled responses through formal agreements among states and community-based organizations and practiced use of statewide call centers, such as 211 programs, for health emergencies.
Recommendation 3: Prioritize vulnerable populations first.

Governors, Mayors, and Tribal Leaders should:

  • Create advance arrangements with community organizations that prioritize vulnerable, marginalized, and underserved populations, who will be disproportionately impacted by health emergencies.
  • Ensure systems for collecting and reporting data are in place to prioritize those populations that are most at risk during health emergencies.
Recommendation 4: Systematically modernize local outbreak data capabilities for decision-making and ensure the CDC fulfills its mission as the one-stop-shop for data dashboards to support local elected officials.

  • Coordinating with the National Governors Association, state and local elected officials should prioritize modernizing their data capabilities, assessing and overcoming obstacles to secure quality and timely data for decision-making in health emergencies.

  • The U.S. Centers for Disease Control and Prevention (CDC) should fulfill its mission as the one-stop-shop for data dashboards, situation reports, and technical assessments that are timely and useful to state and local leaders, as well as the public. In parallel, the federal government should support partnerships with universities, expert disease modelers, and the private sector to strengthen local data capabilities and to create an integrated national picture.

Recommendation 5: Establish new mechanisms to rapidly secure state and Tribal access to scarce supplies.
  • The White House Office of Pandemic Preparedness and Response (OPPR) should appoint a National Pandemic Supply Coordinator.
  • The OPPR National Pandemic Supply Coordinator should develop a new two-way communication channel for federal, state, Tribal, and Territorial leaders to field urgent queries and post regular reports on supply and demand conditions.
  • In parallel, federal, state, and/or philanthropic leaders should invest in the State and Territorial Alliance for Testing (STAT) Network to ensure its sustainability.
  • Starting with H5N1, OPPR should convene a regular, high-level national meeting to hear from state, county, municipal, and community levels on health emergency medical countermeasures and supply needs.
    Recommendation 6: Stand up a national bipartisan expert forum for health emergency response in America, charged with providing recommendations and composed of politically diverse experts across disciplines and sectors – health, education, and the economy -- and representing the full diversity of America.

    An independent non-governmental body should:

    • Establish a prestigious and enduring national bipartisan expert forum – a standing national council – charged with advising states and localities on health emergency response, both in peacetime and during outbreaks.
    • This new national council should produce regular situational reports and recommendations on outbreaks.
    Recommendation 7: Prepare America’s next generation of pandemic decision-makers for worst-case scenarios and unexpected outcomes.

    Academic leaders and philanthropies should:

    • Overhaul training for future pandemic decision-makers to include planning for worst-case scenarios.
    • Establish, ideally in conjunction with federal support, a national center or consortium of centers for training next-generation leaders focused on health emergency decision-making and communications, worst-case scenario planning, and pandemic equity in the United States.

    Recommendation 1: Strengthen state, local, Tribal, and Territorial operational leadership for health emergencies, in collaboration with federal partners.

    The buck stops here. Public health authorities should inform the fight, but heads of government should lead it, weighing what is known of the science with social, educational, and economic impacts. A familiar refrain during the pandemic was to ‘follow the science,’ but this alone is insufficient. As the pandemic showed, science is often imperfect and evolving, translating science into practice can be challenging, and elected officials have to weigh what is known of the science with social, educational, and economic impacts, as they reach urgent decisions.

    Governors, Mayors, Tribal, and Territorial Leaders should:

    • Own the consequences of crisis decisions and bear most of the operational responsibility for health emergencies, collaborating with federal partners. Preserving public trust is the coin of the realm.
    • Create formal coordination and supply sharing arrangements with Tribes in advance of health emergencies.
    • Appoint a single, proven emergency response coordinator with operational expertise, empowered to work across all sectors and silos, at the very start of a health emergency.
    • Establish a 24/7 multi-sectoral command structure immediately when a health emergency strikes, to break down silos and engage not only health, but business, education, and civil society representatives.
    • Prioritize clear, daily communications, combined with data that is usable by the public.
    • Hold annual health emergency exercises, informed by the public and in concert with the National Governors Association (NGA), the Association of State and Territorial Health Officials (ASTHO), and others.
    • Insist on after-action assessments of COVID-19 to chart a path ahead, identify what worked and what didn’t, and prioritize resources to strengthen capabilities.

    Recommendation 2: Create locally tailored pandemic playbooks, aligned with community needs.

    Pandemic decision-makers should:

    • Create locally tailored pandemic playbooks that can adapt to community needs and values. Tackle the hardest issues around maintaining in-person learning, opening businesses, and vaccine uptake. Develop modules to regularly exercise and update them.
    • Designate an official in the Governor or Tribal leader’s office who is charged with local pandemic planning and exercising health emergency playbooks.
    • Plan carefully to maintain in person learning and to keep businesses open and operating safely in the next emergency.
    • Create formal agreements to cement operational roles among state governments, Tribes, and other key parties in advance of health emergencies.
    • Lay the groundwork now to ensure future rapidly scaled responses through formal agreements among states and community-based organizations and practiced use of statewide call centers, such as 211 programs, for health emergencies.

    Recommendation 3: Prioritize vulnerable populations first.

    Governors, Mayors, and Tribal Leaders should:

    • Create advance arrangements with community organizations that prioritize vulnerable, marginalized, and underserved populations, who will be disproportionately impacted by health emergencies.
    • Ensure systems for collecting and reporting data are in place to prioritize those populations that are most at risk during health emergencies.

    Recommendation 4: Systematically modernize local outbreak data capabilities for decision-making and ensure the CDC fulfills its mission as the one-stop-shop for data dashboards to support local elected officials.

    • Coordinating with the National Governors Association, state and local elected officials should prioritize modernizing their data capabilities, assessing and overcoming obstacles to secure quality and timely data for decision-making in health emergencies.

    • The U.S. Centers for Disease Control and Prevention (CDC) should fulfill its mission as the one-stop-shop for data dashboards, situation reports, and technical assessments that are timely and useful to state and local leaders, as well as the public. In parallel, the federal government should support partnerships with universities, expert disease modelers, and the private sector to strengthen local data capabilities and to create an integrated national picture.

    Recommendation 5: Establish new mechanisms to rapidly secure state and Tribal access to scarce supplies.

    • The White House Office of Pandemic Preparedness and Response (OPPR) should appoint a National Pandemic Supply Coordinator.
    • The OPPR National Pandemic Supply Coordinator should develop a new two-way communication channel for federal, state, Tribal, and Territorial leaders to field urgent queries and post regular reports on supply and demand conditions.
    • In parallel, federal, state, and/or philanthropic leaders should invest in the State and Territorial Alliance for Testing (STAT) Network to ensure its sustainability.
    • Starting with H5N1, OPPR should convene a regular, high-level national meeting to hear from state, county, municipal, and community levels on health emergency medical countermeasures and supply needs.

      Recommendation 6: Stand up a national bipartisan expert forum for health emergency response in America, charged with providing recommendations and composed of politically diverse experts across disciplines and sectors – health, education, and the economy -- and representing the full diversity of America.

      An independent non-governmental body should:

      • Establish a prestigious and enduring national bipartisan expert forum – a standing national council – charged with advising states and localities on health emergency response, both in peacetime and during outbreaks.
      • This new national council should produce regular situational reports and recommendations on outbreaks.

      Recommendation 7: Prepare America’s next generation of pandemic decision-makers for worst-case scenarios and unexpected outcomes.

      Academic leaders and philanthropies should:

      • Overhaul training for future pandemic decision-makers to include planning for worst-case scenarios.
      • Establish, ideally in conjunction with federal support, a national center or consortium of centers for training next-generation leaders focused on health emergency decision-making and communications, worst-case scenario planning, and pandemic equity in the United States.

      If the COVID crisis exposed our nation’s worst failings, it also revealed our greatest strengths. As Americans, we now have a chance to define a path forward, while memories and learning are fresh.

      Our conclusion—and what these lamplighters revealed—is that these promising pathways are within reach. If we choose them in the next pandemic (for, alas, there will be one) the story of how America fares will be one that inspires the world: A story of vision, action, and collaboration—one nation, indivisible—in which we preserve our democratic ideals while protecting people’s lives.

      If the COVID crisis exposed our nation’s worst failings, it also revealed our greatest strengths. As Americans, we now have a chance to define a path forward, while memories and learning are fresh.

      Our conclusion—and what these lamplighters revealed—is that these promising pathways are within reach. If we choose them in the next pandemic (for, alas, there will be one) the story of how America fares will be one that inspires the world: A story of vision, action, and collaboration—one nation, indivisible—in which we preserve our democratic ideals while protecting people’s lives.