Findings and Recommendations
Lighting a Path Forward Amid Pandemic Polarization:
Harnessing State and Local Innovations to Achieve American Health Security
Findings and Recommendations
Lighting a Path Forward Amid Pandemic Polarization:
Harnessing State and Local Innovations to Achieve American Health Security
There are two stories of how America fared during the COVID-19 pandemic, one of struggle and one of innovation.
Both are true.
There are two stories of how America fared during the COVID-19 pandemic, one of struggle and one of innovation.
Both are true.
One story is characterized by national failure, loss, inequity, and polarization. To honor the more than 1 million Americans who have died from this virus and the millions who have suffered from related economic, social, and educational impacts, we must remember that story—and do everything we can to prevent it from recurring.
One story is characterized by national failure, loss, inequity, and polarization. To honor the more than 1 million Americans who have died from this virus and the millions who have suffered from related economic, social, and educational impacts, we must remember that story—and do everything we can to prevent it from recurring.
The second story is one of hope in the darkness — of American ingenuity and state and local innovations that bridged divides across sectors and silos and enabled a more effective response tailored to community needs. These improvisations, and the unifying practices and structures they yielded, must be captured and sustained — now and before the next pandemic or health security crisis strikes.
The second story is one of hope in the darkness — of American ingenuity and state and local innovations that bridged divides across sectors and silos and enabled a more effective response tailored to community needs. These improvisations, and the unifying practices and structures they yielded, must be captured and sustained — now and before the next pandemic or health security crisis strikes.
Bridging health security divides in the United States
Pandemic-related polarization in America has made it likely that our country is less prepared today for a major biological crisis than it was in 2019. This is an existential threat to America’s health, society, economy, and future. To overcome this challenge to our health – and to the health of our democracy – we set out to harness learning across a variety of states and communities with different pandemic experiences, recognizing that each American community is unique, and leaders and state structures vary. When a pandemic meets a system of federalism, you need a whole-country response with states and localities on the frontlines. We have sought to learn lessons from communities and states that represent the diversity of our nation’s response to the pandemic.
We spoke with approximately 75 leaders and experts from different geographies, political ideologies, and critical sectors, including state officials such as former Governors and Mayors; health experts and emergency response officials; community, nonprofit, and faith-based groups; educators; and business leaders.
We did not encounter amnesia or anger in our outreach. Instead, we found self-critical leaders who were candid about what worked and what didn’t and were willing to dispassionately examine their own actions. We found public health experts who recognized their limits and worked within the bounds of a broader socioeconomic response. We found humility on both sides of the aisle. Most of all, we found an intense interest in sustaining lessons that will not only build better preparedness for the next pandemic but will also make communities safer today.
From this exploration, we have identified a set of common-sense actions – borne out of American ingenuity in our darkest moments – that can draw support across political divides and that, if adopted, will strengthen preparedness for inevitable future emergencies and health crises.
We have no illusions. Challenges that plagued our nation during the COVID-19 response persist: data access, health inequities, mental health issues, learning loss, economic impoverishment, lack of trust in science, and political divisiveness. There is no single formula for pandemic leadership that will resolve them. And finding common ground in America is difficult, especially given the crisis in trust – in government, institutions, experts, science, and especially in one another.
But we remain optimistic.
For, despite the many drivers of mistrust during the pandemic—reckless leadership in high places; profound fear; the sheer destructive power of COVID-19 itself; and the pervasive falsehoods of our digital era—the flame of hope still burned.
At the state and local level we saw the spirit of community and ingenuity that are the hallmarks of American democracy at its best. We found leaders across the country who understood that trust isn’t bestowed, it’s earned – earned through operational competence and through partnerships built on pragmatism, transparency, and humility in the face of uncertainty. They earned it by being prepared, mounting a rapid response, acting equitably, admitting mistakes, communicating in plain language, and most of all, listening. As a result, they were able to mount a more nuanced and effective response.
Going forward, we must capture, learn from, and sustain the practices these leaders and lamplighters employed and innovations they inspired to ensure effective, community-informed responses to future American health crises. That is the path to restore trust. We intend the American Democracy and Health Security Initiative to be a living effort, one that can form the basis for a larger bipartisan American endeavor – an endeavor, as one leader urged us, to ensure that in the next crisis – and there will be one – we can transcend red, blue, and purple divides, to mount a response that is simply “red, white, and blue.”
Pandemic-related polarization in America has made it likely that our country is less prepared today for a major biological crisis than it was in 2019. This is an existential threat to America’s health, society, economy, and future. To overcome this challenge to our health – and to the health of our democracy – we set out to harness learning across a variety of states and communities with different pandemic experiences, recognizing that each American community is unique, and leaders and state structures vary. When a pandemic meets a system of federalism, you need a whole-country response with states and localities on the frontlines. We have sought to learn lessons from communities and states that represent the diversity of our nation’s response to the pandemic.
We spoke with approximately 75 leaders and experts from different geographies, political ideologies, and critical sectors, including state officials such as former Governors and Mayors; health experts and emergency response officials; community, nonprofit, and faith-based groups; educators; and business leaders.
We did not encounter amnesia or anger in our outreach. Instead, we found self-critical leaders who were candid about what worked and what didn’t and were willing to dispassionately examine their own actions. We found public health experts who recognized their limits and worked within the bounds of a broader socioeconomic response. We found humility on both sides of the aisle. Most of all, we found an intense interest in sustaining lessons that will not only build better preparedness for the next pandemic but will also make communities safer today.
From this exploration, we have identified a set of common-sense actions – borne out of American ingenuity in our darkest moments – that can draw support across political divides and that, if adopted, will strengthen preparedness for inevitable future emergencies and health crises.
We have no illusions. Challenges that plagued our nation during the COVID-19 response persist: data access, health inequities, mental health issues, learning loss, economic impoverishment, lack of trust in science, and political divisiveness. There is no single formula for pandemic leadership that will resolve them. And finding common ground in America is difficult, especially given the crisis in trust – in government, institutions, experts, science, and especially in one another.
But we remain optimistic.
For, despite the many drivers of mistrust during the pandemic—reckless leadership in high places; profound fear; the sheer destructive power of COVID-19 itself; and the pervasive falsehoods of our digital era—the flame of hope still burned.
At the state and local level we saw the spirit of community and ingenuity that are the hallmarks of American democracy at its best. We found leaders across the country who understood that trust isn’t bestowed, it’s earned – earned through operational competence and through partnerships built on pragmatism, transparency, and humility in the face of uncertainty. They earned it by being prepared, mounting a rapid response, acting equitably, admitting mistakes, communicating in plain language, and most of all, listening. As a result, they were able to mount a more nuanced and effective response.
Going forward, we must capture, learn from, and sustain the practices these leaders and lamplighters employed and innovations they inspired to ensure effective, community-informed responses to future American health crises. That is the path to restore trust. We intend the American Democracy and Health Security Initiative to be a living effort, one that can form the basis for a larger bipartisan American endeavor – an endeavor, as one leader urged us, to ensure that in the next crisis – and there will be one – we can transcend red, blue, and purple divides, to mount a response that is simply “red, white, and blue.”
That is our charge. Here are our findings.
That is our charge. Here are our findings.
John Bridgeland
Chief Executive Officer
COVID Collaborative
Beth Cameron
Senior Advisor, The Pandemic Center
Brown University School of Public Health
J. Stephen Morrison
Senior Vice President and Director
CSIS Global Health Policy Center
Gary Edson
President
COVID Collaborative
Jennifer Nuzzo
Executive Director, The Pandemic Center
Brown University School of Public Health
Katherine Bliss
Senior Fellow and Director
Immunizations & Health Systems Resilience
CSIS Global Health Policy Center
John Bridgeland
Chief Executive Officer
COVID Collaborative
Beth Cameron
Senior Advisor, The Pandemic Center
Brown University School of Public Health
J. Stephen Morrison
Senior Vice President and Director
CSIS Global Health Policy Center
Gary Edson
President
COVID Collaborative
Jennifer Nuzzo
Executive Director, The Pandemic Center
Brown University School of Public Health
Katherine Bliss
Senior Fellow and Director
Immunizations & Health Systems Resilience
CSIS Global Health Policy Center
Findings and Recommendations
Findings and Recommendations
Finding 1
In health emergencies, federal support is critical, but states bear most of the operational responsibility. It is with Governors, Mayors, Tribal, and Territorial leaders that the rubber meets the road. Public health authorities should inform the fight, but elected officials should lead it, collaborating with federal partners. 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. Successful leaders appointed an emergency response coordinator with proven operational expertise to oversee a society-wide, multi-sectoral response, informed by quality data, and clear and candid communication. Advance arrangements among states and Tribal governments were crucial. Preserving trust was a top concern.
Successful leaders appointed pandemic response coordinators who were proven commanders, capable of cutting across sectors and silos–not singularly focused on public health outcomes. Successful leaders established multi-sectoral command structures – networks, collaborations, and fusion cells – that met daily. They put in place formal agreements with Tribes on handling supplies and medical countermeasures. They used data to drive their decisions, and they listened with humility to meet people where they were. Immersed in chaos and faced with a need for speed, many Governors called on outside experts with experience leading on a national scale to coordinate their statewide efforts.
Recommendations for Governors, Mayors, Tribal, and Territorial Leaders
• The buck stops here.
Governors, Mayors, Tribal, and Territorial leaders should be the key decision-makers for states and Tribes during pandemic emergencies. Their decisions should be informed by health and other experts, but elected officials ultimately own the consequences of their crisis decisions. They should create formal agreements with Tribes in advance of health emergencies that outline how coordination and supply sharing will work. Preserving public trust and confidence is the coin of the realm.
• Appoint a proven emergency response coordinator with operational expertise.
At the very start of a health emergency, Governors, Mayors, Tribal, and Territorial leaders should appoint a single pandemic response leader, who is empowered to work across all sectors and silos for every constituency taking into account social impacts of key actions and decisions. The appointed leader must be a recognized expert, who has operational experience in crisis response, strong communications skills, and a ready ability to tap top expertise in science, health, education, and the economy.
• Establish a 24/7 multi-sectoral command structure right away.
The command structure must break down silos and engage not only health but business, education, and civil society representatives. It must integrate medical intelligence with social, educational, and economic data and considerations from local, state, national, and global sources. The command center or network must meet at least daily with the elected official and their pandemic response team, work with modeling experts, and push data to decision-makers. Private sector and community leaders should be active participants.
• Prioritize clear, daily communications, combined with data that is usable by the public.
Leaders should regularly communicate with the public and key leaders across sectors about the status of the pandemic response, driven by data, candor about what is known and not known, and a holistic approach that takes into account the impacts on health, education, the economy, and society. There should also be regular opportunities for the public to provide feedback and voice concerns.
Effective leaders recognized that the science was simultaneously essential and incomplete and that what we knew would change as the pandemic unfolded. They didn’t become paralyzed or polarized by the science; instead, they took it into account, and used it to help communities.
Finally, effective leaders admitted it when they got it wrong.
• Hold annual health emergency exercises.
Leaders should annually conduct an exercise on health emergency response. Crisis learning is quickly forgotten if not regularly practiced. These exercises must become an embedded, budgeted routine, into which the public should provide input. Organizations such as the National Governors Association (NGA), the U.S. Conference of Mayors, National League of Cities, National Congress of American Indians, and National Association of Counties, in concert with the Association of State and Territorial Health Officials (ASTHO), should support these exercises through sharing their knowledge on health emergency learning and practice.
• Insist upon after-action assessments of COVID-19.
All states, Tribes, and Territories should take account of pandemic preparedness in the context of their broader health system, in order to chart a path ahead, identify what worked and what didn’t, and prioritize resources to strengthen capabilities. In states, such as Indiana and Maryland, where public health commissions have been established, enabling communities across states to reconcile loss and identify a common path forward to improve pandemic response and access to health services. In Indiana, the very first commission to be launched and completed successfully resulted in a significant increase in state investments in local health departments.
• The buck stops here.
Governors, Mayors, Tribal, and Territorial leaders should be the key decision-makers for states and Tribes during pandemic emergencies. Their decisions should be informed by health and other experts, but elected officials ultimately own the consequences of their crisis decisions. They should create formal agreements with Tribes in advance of health emergencies that outline how coordination and supply sharing will work. Preserving public trust and confidence is the coin of the realm.
• Appoint a proven emergency response coordinator with operational expertise.
At the very start of a health emergency, Governors, Mayors, Tribal, and Territorial leaders should appoint a single pandemic response leader, who is empowered to work across all sectors and silos for every constituency taking into account social impacts of key actions and decisions. The appointed leader must be a recognized expert, who has operational experience in crisis response, strong communications skills, and a ready ability to tap top expertise in science, health, education, and the economy.
• Establish a 24/7 multi-sectoral command structure right away.
The command structure must break down silos and engage not only health but business, education, and civil society representatives. It must integrate medical intelligence with social, educational, and economic data and considerations from local, state, national, and global sources. The command center or network must meet at least daily with the elected official and their pandemic response team, work with modeling experts, and push data to decision-makers. Private sector and community leaders should be active participants.
• Prioritize clear, daily communications, combined with data that is usable by the public.
Leaders should regularly communicate with the public and key leaders across sectors about the status of the pandemic response, driven by data, candor about what is known and not known, and a holistic approach that takes into account the impacts on health, education, the economy, and society. There should also be regular opportunities for the public to provide feedback and voice concerns.
Effective leaders recognized that the science was simultaneously essential and incomplete and that what we knew would change as the pandemic unfolded. They didn’t become paralyzed or polarized by the science; instead, they took it into account, and used it to help communities.
Finally, effective leaders admitted it when they got it wrong.
• Hold annual health emergency exercises.
Leaders should annually conduct an exercise on health emergency response. Crisis learning is quickly forgotten if not regularly practiced. These exercises must become an embedded, budgeted routine, into which the public should provide input. Organizations such as the National Governors Association (NGA), the U.S. Conference of Mayors, National League of Cities, National Congress of American Indians, and National Association of Counties, in concert with the Association of State and Territorial Health Officials (ASTHO), should support these exercises through sharing their knowledge on health emergency learning and practice.
• Insist upon after-action assessments of COVID-19.
All states, Tribes, and Territories should take account of pandemic preparedness in the context of their broader health system, in order to chart a path ahead, identify what worked and what didn’t, and prioritize resources to strengthen capabilities. In states, such as Indiana and Maryland, where public health commissions have been established, enabling communities across states to reconcile loss and identify a common path forward to improve pandemic response and access to health services. In Indiana, the very first commission to be launched and completed successfully resulted in a significant increase in state investments in local health departments.
Finding 2
In our democracy, successful state and local pandemic responses require a locally tailored menu of options that are, by design, highly flexible and adaptable to local community contexts. Without such tools for dealing with societal issues during a pandemic, leaders were often left with blunt, binary, and divisive options for responding: e.g., lock down or open up schools and businesses; prioritize health versus jobs. These rigid approaches failed to sufficiently take account of social, business, and educational impacts and exacerbated inequities.
Pandemic decision-makers didn’t have flexible response playbooks at the ready and frequently created their own after scrambling for weeks. Federal and state public health officials implored the nation to “follow the science,” but it was not always clear what that meant in practice. Successful leaders created their own playbooks to open schools, enable widespread testing and vaccinations, and keep employees safe.
Recommendations for Governors, Mayors, Tribal, and Territorial Leaders
• Create local pandemic playbooks that can adapt to community needs and values. Develop modules to regularly exercise and update them. They should align with community needs, tackle the hardest issues around maintaining in-person learning, opening businesses, vaccine uptake, and other critical items.
These playbooks should be developed and exercised now for different scenarios, while COVID-19 experiences are fresh. A useful example is the Testing Playbook developed by non-governmental experts to identify specific steps for deploying tests in different phases of public health emergencies. These state and local playbooks should take into account worst-case scenarios and be operationally feasible for state, local and Tribal use. Successful approaches will expand equitable access, while building public trust and legitimacy, systematically tapping into networks rooted in diverse ethnic, racial, economic, faith, business, and educator communities. Modules for exercising these playbooks should be developed for states to use for different scenarios and sectors.
• Designate a leader within the elected official’s office, who is charged with local pandemic planning in advance of a health emergency.
Ensure these plans establish lines of responsibility, the delivery of health services, and how to manage and open businesses and schools. The key to success is refining options that will better protect essential workers exposed to high risks, more clearly allow for safe schooling and opening businesses, and, wherever possible, avoid overly directive guidance in recognition of the specific needs and challenges of a given community.
• Plan carefully to keep schools and businesses open and operating safely in the next emergency.
Future closures may happen; we can’t predict the next pandemic agent’s mortality rates or its impact on children or any other population. Still, the goal should be to maximize in-person work and learning.
• Lay the groundwork now to ensure future rapidly scaled responses.
Formal agreements, in advance of health emergencies, among states and community-based organizations can accelerate future access to and distribution of supplies. Practiced use of statewide call centers, such as 211 programs, for health emergencies can make pandemic information, vaccination scheduling, and access to PPE, tests, and treatments more accessible to all.
• Create local pandemic playbooks that can adapt to community needs and values. Develop modules to regularly exercise and update them. They should align with community needs, tackle the hardest issues around maintaining in-person learning, opening businesses, vaccine uptake, and other critical items.
These playbooks should be developed and exercised now for different scenarios, while COVID-19 experiences are fresh. A useful example is the Testing Playbook developed by non-governmental experts to identify specific steps for deploying tests in different phases of public health emergencies. These state and local playbooks should take into account worst-case scenarios and be operationally feasible for state, local and Tribal use. Successful approaches will expand equitable access, while building public trust and legitimacy, systematically tapping into networks rooted in diverse ethnic, racial, economic, faith, business, and educator communities. Modules for exercising these playbooks should be developed for states to use for different scenarios and sectors.
• Designate a leader within the elected official’s office, who is charged with local pandemic planning in advance of a health emergency.
Ensure these plans establish lines of responsibility, the delivery of health services, and how to manage and open businesses and schools. The key to success is refining options that will better protect essential workers exposed to high risks, more clearly allow for safe schooling and opening businesses, and, wherever possible, avoid overly directive guidance in recognition of the specific needs and challenges of a given community.
• Plan carefully to keep schools and businesses open and operating safely in the next emergency.
Future closures may happen; we can’t predict the next pandemic agent’s mortality rates or its impact on children or any other population. Still, the goal should be to maximize in-person work and learning.
• Lay the groundwork now to ensure future rapidly scaled responses.
Formal agreements, in advance of health emergencies, among states and community-based organizations can accelerate future access to and distribution of supplies. Practiced use of statewide call centers, such as 211 programs, for health emergencies can make pandemic information, vaccination scheduling, and access to PPE, tests, and treatments more accessible to all.
Finding 3
Successful local COVID-19 response approaches prioritized vulnerable populations first. Protecting communities that will be hardest hit is essential for limiting harm, disease spread, and deaths.
New and existing networks and collaborations across the country were essential: the Indiana Minority Health Coalition; Challenge Seattle; LATIN-19 and The ABC Science Collaborative in North Carolina; the American Indian Health Commission in Washington; and Rural Health Matters in Nebraska. They delivered voices from across communities and Tribal lands into the deliberations of Governors and other pandemic leaders. In the post-acute phase of COVID-19, their resources have dwindled, placing their future at risk.
Recommendations for Governors, Mayors, Tribal, and Territorial Leaders
• Create advance arrangements with community organizations that prioritize the vulnerable, marginalized, and underserved populations, who will be disproportionately impacted by health emergencies.
Some states had pre-existing relationships with community groups and understandings with Tribes. Some created relationships from scratch. These must be retained as an integral component of every leader’s health emergency toolkit to reach and gain rapid input from the elderly, frontline workers, and ethnic, Tribal, racial and ethnic communities. These community bodies should be ready in advance of a biological crisis to assist their constituents with food and housing, childcare, mental health support, and access to vaccines, tests, therapies and other critical supplies.
• Ensure systems for collecting and reporting data are in place to prioritize those populations that are most at risk.
While different groups will be at particular risk depending on the emergency, ensuring real-time identification of those most affected will be essential to an effective, equitable response. Ongoing engagement with community groups to ensure on-the-ground perspectives is critical as are data systems that capture factors such as race, ethnicity, health status, and occupation. The information can be used to refine messaging and surge resources to those at higher risk.
• Create advance arrangements with community organizations that prioritize the vulnerable, marginalized, and underserved populations, who will be disproportionately impacted by health emergencies.
Some states had pre-existing relationships with community groups and understandings with Tribes. Some created relationships from scratch. These must be retained as an integral component of every leader’s health emergency toolkit to reach and gain rapid input from the elderly, frontline workers, and ethnic, Tribal, racial and ethnic communities. These community bodies should be ready in advance of a biological crisis to assist their constituents with food and housing, childcare, mental health support, and access to vaccines, tests, therapies and other critical supplies.
• Ensure systems for collecting and reporting data are in place to prioritize those populations that are most at risk.
While different groups will be at particular risk depending on the emergency, ensuring real-time identification of those most affected will be essential to an effective, equitable response. Ongoing engagement with community groups to ensure on-the-ground perspectives is critical as are data systems that capture factors such as race, ethnicity, health status, and occupation. The information can be used to refine messaging and surge resources to those at higher risk.
Finding 4
The absence of quality, actionable data motivated state and local pandemic leaders to create their own data dashboards to track key outcomes, adapting information from local universities, the private sector, and national non-governmental data efforts.
Quality data was the single most important commodity during the pandemic. Yet, despite leading the world in developing new technologies, American pandemic leaders and the public didn’t have wide access to modeling, testing, and hospital data. Access to data often became a politically charged issue of personal privacy. Sharing of data was often a bureaucratic and political challenge. When data did become available, it often wasn’t in a usable format to inform decisions to avert healthcare system collapse or safely reopen schools and businesses. There was an over-emphasis on COVID case numbers and insufficient emphasis on actionable metrics like COVID hospitalizations, deaths, and disparities. In the future, leaders across America–from states to cities, Tribes, and Territories–must have timely access to quality, actionable data.
Recommendations for Governors, Mayors, Tribal, and Territorial Leaders
• Coordinating with the National Governors Association, state and local elected officials should accelerate efforts to modernize state and other data capabilities, assessing and overcoming obstacles to securing quality and timely data for decision-making in health emergencies.
Without reliable, standardized data about the virus, governors were often flying blind on critical decisions from stay-at-home directives, to masking, to school closures. States, cities, Tribes and Territories will need technical assistance as they modernize the way they collect and report public health data. Across the country, this effort would benefit from the support of the National Governors Association, the Association of State and Territorial Health Officials (ASTHO), and local organizations.
• The U.S. Centers for Disease Control and Prevention 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.
The data upon which technical recommendations are based should be transparent. These data and analyses should be easy to interpret and actionable. They should be the go-to-source for Governors, municipal leaders, Tribal and Territorial authorities, and the general public as they seek accurate, intelligible information about outbreaks. The one-stop-shop should get input from outbreak modeling centers from states across the country. In parallel, the federal government should support a network of partnerships with universities, expert disease modelers, and the private sector to strengthen local data capabilities and to create an integrated national picture.
• Coordinating with the National Governors Association, state and local elected officials should accelerate efforts to modernize state and other data capabilities, assessing and overcoming obstacles to securing quality and timely data for decision-making in health emergencies.
Without reliable, standardized data about the virus, governors were often flying blind on critical decisions from stay-at-home directives, to masking, to school closures. States, cities, Tribes and Territories will need technical assistance as they modernize the way they collect and report public health data. Across the country, this effort would benefit from the support of the National Governors Association, the Association of State and Territorial Health Officials (ASTHO), and local organizations.
• The U.S. Centers for Disease Control and Prevention 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.
The data upon which technical recommendations are based should be transparent. These data and analyses should be easy to interpret and actionable. They should be the go-to-source for Governors, municipal leaders, Tribal and Territorial authorities, and the general public as they seek accurate, intelligible information about outbreaks. The one-stop-shop should get input from outbreak modeling centers from states across the country. In parallel, the federal government should support a network of partnerships with universities, expert disease modelers, and the private sector to strengthen local data capabilities and to create an integrated national picture.
Finding 5
Facing an acute scarcity of supplies, state and local leaders competed with one another in a “pandemic hunger games.” Some established independent procurement pathways; others partnered with neighboring states.
The federal government wasn’t a reliable “shipping clerk” and still lacks routine ways to secure rapid, orderly, transparent, and equitable access to scarce essential supplies during health emergencies. This was true for vital personal protective equipment (PPE), testing, treatments, vaccines, and related supplies. Today there is still no single, dedicated official channel for state-federal collaboration to jointly solve problems on urgent supply challenges arising during health emergencies. This must change.
State and local leaders didn’t have well-exercised or defined ways to connect with the federal government to resolve supply access problems in real time. At the start of the pandemic, political leaders made scattershot efforts to link state and federal officials – a far cry from the tried-and-true hurricane response channels built on years of post-Katrina experience. The Federal Emergency Management Agency’s (FEMA’s) eventual involvement in March 2020 as the federal logistical coordinator for COVID-19 supplies was welcome, but FEMA wasn’t adapted for simultaneous emergencies like pandemics that are experienced by every state at the same time. Some states banded together to pool purchasing and share best practices for testing through the Governors’ compact with COVID Collaborative and the State and Territory Alliance for Testing (STAT) Network, which was launched with the support of The Rockefeller Foundation.
Recommendations for Federal Leaders and Philanthropies
• The White House Office of Pandemic Preparedness and Response (OPPR) should appoint a permanent National Pandemic Supply Coordinator. That person should develop a formal two-way communication channel for federal, state, Tribal, and Territorial leaders to field urgent queries and post regular reports on supply and demand conditions.
OPPR – working with National Security Council staff, the Department of Health and Human Services, and FEMA – should create a formal channel to work through operational challenges and supply shortages with these leaders. This channel should include material requests, allocations, and distribution of medical countermeasures and related supplies.
• In parallel, federal, state, and/or philanthropic leaders should make the State and Territory Alliance for Testing (STAT) Network a sustainable entity.
While there are many different communication links among federal, state, and local officials around supplies, there isn’t a dedicated channel for state and local leaders to work through operational challenges around pandemic supplies in real-time. STAT is currently a peer network and could be sustained and expanded to help fill this gap.
• 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.
The outcome of the meetings should be to facilitate operational contact and regular communication and to identify bottlenecks and set timelines to fix them.
• The White House Office of Pandemic Preparedness and Response (OPPR) should appoint a permanent National Pandemic Supply Coordinator. That person should develop a formal two-way communication channel for federal, state, Tribal, and Territorial leaders to field urgent queries and post regular reports on supply and demand conditions.
OPPR – working with National Security Council staff, the Department of Health and Human Services, and FEMA – should create a formal channel to work through operational challenges and supply shortages with these leaders. This channel should include material requests, allocations, and distribution of medical countermeasures and related supplies.
• In parallel, federal, state, and/or philanthropic leaders should make the State and Territory Alliance for Testing (STAT) Network a sustainable entity.
While there are many different communication links among federal, state, and local officials around supplies, there isn’t a dedicated channel for state and local leaders to work through operational challenges around pandemic supplies in real-time. STAT is currently a peer network and could be sustained and expanded to help fill this gap.
• 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.
The outcome of the meetings should be to facilitate operational contact and regular communication and to identify bottlenecks and set timelines to fix them.
Finding 6
A critical gap is the lack of a national expert forum for American health emergency response. Pandemic leaders would have benefited from access to an enduring, bipartisan, non-governmental experts’ group that represents the full diversity of America. It should be charged with providing consensus recommendations and advice, composed of respected experts from health, education, economic, disaster response, the business sector, the faith community, and the media. Such a council can foster civil public debate, encourage the application of guidance in vastly divergent local contexts, and work towards restoring trust and confidence.
The ability to openly debate ideas is a strength of our democracy, yet there is no widely respected national body – no national ‘Team B’ – dedicated to developing consensus recommendations in the context of a national health emergency. Nor is there any prospect in the future for the formation of a national commission to examine the response to COVID-19 and the way forward for the future. During the COVID-19 pandemic, decision-makers and the American public were bombarded with disparate, inconsistent analyses and recommendations from a wide, confusing, and often conflicting array of different sources and institutions. Misinformation and conspiracies abounded. What was needed was an authoritative, bipartisan, and multi-sectoral experts’ forum, akin to the COVID Collaborative, to debate and sift through the cacophony of conflicting information and develop consensus advice and actionable recommendations in real time.
Recommendations for Non-Governmental Leaders
• An independent non-governmental body should launch a prestigious and enduring high-level, bipartisan expert forum on health emergency response in America, that cuts across sectors – health, education, and the economy – and represents the diversity of America.
This standing national council should be independent, charged with advising states and localities on health emergency response, both in peacetime and during outbreaks. It should draw support and opinion from across the political spectrum. Special care should be taken to bestow this group with gravitas and ensure its sustainability over time.
• This council should comprise prominent American experts and leaders – spanning pandemic security, public health, disaster response, public policy, media and communications, business, education, the faith sector, and community leaders – and reflect the diversity of America.
It should offer a platform for ongoing debate during peacetime and quick thinking and consensus situational reports as outbreaks appear. It should be an instrument for countering misinformation and restoring trust and confidence.
• An independent non-governmental body should launch a prestigious and enduring high-level, bipartisan expert forum on health emergency response in America, that cuts across sectors – health, education, and the economy – and represents the diversity of America.
This standing national council should be independent, charged with advising states and localities on health emergency response, both in peacetime and during outbreaks. It should draw support and opinion from across the political spectrum. Special care should be taken to bestow this group with gravitas and ensure its sustainability over time.
• This council should comprise prominent American experts and leaders – spanning pandemic security, public health, disaster response, public policy, media and communications, business, education, the faith sector, and community leaders – and reflect the diversity of America.
It should offer a platform for ongoing debate during peacetime and quick thinking and consensus situational reports as outbreaks appear. It should be an instrument for countering misinformation and restoring trust and confidence.
Finding 7
The COVID-19 pandemic revealed the need for more systematic training for the next generation of pandemic decision-makers, equipping them to “look around corners” and prepare for unexpected or worst-case scenarios. The United States was caught flat-footed again and again on issues ranging from testing to masking to vaccine distribution to the mutation rate of the virus itself. The leaders interviewed stressed the need to be prepared for all possible outcomes, no matter how unlikely it was thought to be.
There is no “worst case scenario” track for training the generation of decision-makers who will serve during the next pandemic. Public health leaders, national security professionals, and disaster response officials still speak different languages, whether they are meeting in the White House Situation Room or in Governors’ and Mayors’ chambers. Many public health officials and other health security decision-makers are not formally trained in crisis response, and appointed health officials lack standard training competencies. Developing and implementing standardized training that crosses the disciplines of public health, crisis response, policymaking, and biosecurity will enable current and next-generation pandemic leaders to respond more rapidly and effectively.
Recommendations for Academic Leaders and Philanthropies
• Overhaul training for future pandemic decision-makers to include planning for worst-case scenarios.
Many public health officials are not formally trained in crisis response and don’t have practical experience with worst-case decision-making. Training should include incident command, decision-making in the face of uncertainty, communications, and high-level systems thinking. It should also account for new realities facing public health leaders, such as skepticism, hostility, and mis- and dis-information regarding pandemic measures. To improve responders’ understanding of government functions, career training should allow for rotations through federal agencies.
• 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.
The training center could be launched in coordination with the Association of State and Territorial Health Officials (ASTHO), universities, and other relevant institutions.
• Overhaul training for future pandemic decision-makers to include planning for worst-case scenarios.
Many public health officials are not formally trained in crisis response and don’t have practical experience with worst-case decision-making. Training should include incident command, decision-making in the face of uncertainty, communications, and high-level systems thinking. It should also account for new realities facing public health leaders, such as skepticism, hostility, and mis- and dis-information regarding pandemic measures. To improve responders’ understanding of government functions, career training should allow for rotations through federal agencies.
• 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.
The training center could be launched in coordination with the Association of State and Territorial Health Officials (ASTHO), universities, and other relevant institutions.