4

Crisis Standards of Care: From Plans to Reality

While some institutions, cities, and states have been working on crisis standards of care (CSC) plans for several years, most of those efforts have been holding theoretical exercises and hosting community engagement discussions about hypothetical scenarios. Taking written plans and guidelines and putting them into practice during a true emergency is much less common for most jurisdictions. These instances are often when the key facets of a plan are best tested. In this chapter, speakers discussed various case studies of jurisdictions that have CSC plans and the lessons they learned in the process of creating those plans, especially relating to difficult tasks such as triage. This chapter also contains discussions on challenges related to workforce preparation, decision making, and public and stakeholder perceptions.

SETTING THE STAGE

Anuj Mehta, assistant professor of medicine, Denver Health and Hospital Authority, walked through the spectrum of changing needs from the conventional phase to the contingency phase to the crisis phrase and explained the different facets of CSC planning that need to occur in each phase. He explained that the conventional care phase, when there is no emergency, is when authorities and decision makers could identify the core principles on which they will be basing their decisions, as well as the key stakeholders to involve. As needs change and it looks like an emergency is imminent, other considerations include defining what supplies need to be triaged (i.e., what type of disease or emergency is it), who the triage team

will consist of, and how those triage decisions will be made. Once the entity is operating in contingency mode with the potential to shift into crisis mode, he added, efforts move from purely planning to implementation. At this point, types of triage need to be defined, as well as the triggers or what it will take to activate CSC. Finally, Mehta said, once an institution is in crisis mode, there needs to be constant evaluation of equity implications of the protocols, ongoing assessment of data gathering and triage team processes, consideration of appeals, and deciding what will warrant deactivation of CSC.

John Hick, professor of emergency medicine, University of Minnesota, asked about supporting bedside clinicians for decision support, and Mehta noted that CSC does not just mean allocation of care. It could be altering dialysis time frames or putting two people into one room in an ICU. These processes or methods of disrupting care standards need to be identified early on, along with ethical principles that can guide decision making, Mehta said. Without an ethical foundation it will be difficult to ensure that factors unrelated to the patient and underlying disease are not influencing decisions. Mehta added that nonmedical sectors that rely on logistics, such as shipping companies and ride-share companies, know where all of their assets are at any point in time. He observed that health care is decades behind this and may need a better system for situational awareness and recognizing shifts throughout the day.

IMPLEMENTATION CASE STORIES

To provide varied perspectives on how CSC is implemented in different scenarios, this section provides experiences from three states across a range of planning needs, including community engagement, communication and coordination, and managing triage guidelines and workflows.

Incorporating Community Input in Colorado

Gina Febbraro, planning and improvement consultant, Colorado Department of Public Health and Environment (CDPHE), explained that while Colorado had been working on CSC plans when the pandemic began, concerns started to emerge from communities across the state. Many structurally marginalized communities were fearful of discrimination and implicit bias being embedded in the new CSC guidelines. CDPHE set up initiatives during the pandemic to engage communities and hear their equity concerns about what might be incorporated into guidelines. It is important for planners and providers to consider this process, Febbraro said, noting that it requires a different skill set to be able to engage the community in a meaningful way, especially those people who might not understand the

complexity of CSC factors and plans. She highlighted the benefits of having a strong process and people who understand the principles of community engagement.

Describing the process Colorado undertook, Febbraro said her team recruited different community leaders and by the end of March 2020 was convening weekly group meetings and discussing the concerns and fears of each community at each meeting. Her team also developed a survey for community leaders that led to additional website resources being developed, and acknowledged the importance of these conversations both to influence policy and educate the public. She recalled the media highlighting the triaging of ventilators and ICU beds at the time, which is where her team had to focus much of their initial conversations.

Febbraro also remarked on some of the indirect results of this initiative, saying that relationships were formed and expanded beyond just CSC, and these relationships were able to inform other aspects of the entire response, including vaccine rollout at the state level. Some of the strengths of their process included diverse representation and the ability to be nimble, move quickly, and scale up as needed. Because the pandemic was ongoing and very present in people’s lives—sometimes meaning life or death—she also commented that partners were very committed and engaged, which was a huge value. But limitations were also uncovered, such as structural racism being embedded in institutions. Government health care research and algorithms are integrated into CSC planning, so while these limitations were identified, it was difficult to tease out the areas of bias. Finally, Febbraro said that because of the rapid pace of the pandemic, the team had to move very quickly and were not able to use all the best practices of community engagement that would have been ideal during conventional planning phases.

Communication and Coordination in New Mexico

Chris Emory, chief of the Bureau of Health Emergency Management, New Mexico Department of Health, introduced New Mexico as a very large, primarily rural frontier state with very limited resources. He noted the state has one of the lowest number of hospital beds per capita in the country, so they have had to focus on coordination and communication between stakeholders across the state. As a state, New Mexico started CSC planning in 2018 after the Ebola outbreak, which resulted in a living document that was revised continually throughout the COVID-19 response. He explained that the initial planning team to create that document was given the Institute of Medicine CSC workbooks as well as a copy of Dr. Sheri Fink’s book, Five Days at Memorial, to inform their process and set the groundwork for planning. They then held a full-scale exercise for pandemic

influenza in 2018 that allowed for some testing of CSC plans and identifying the gaps in allocating resources across the state. It ended up also being an exercise where they focused on the need to practice “rational care versus rationing care.” In other words, Emory said, they realized that within the state they had a critical need to develop transport capacity and transport pathways as well as surge capacity.

Once the pandemic emerged in early 2020, Emory said they had just finished revisions to the plan and knew they needed to build capacity to implement their plan. They followed a hub-and-spoke model, identifying three core hub facilities in the metro areas of Albuquerque and the regional hubs of Farmington, Santa Fe, Roswell, and Las Cruces to cover the four corners of the large state. These hospitals were selected based on their care capabilities as well as traditional transport pathways used in the state. Emory reported that those hospitals also were on the medical advisory team for the CSC plan, which was expanded during COVID-19. Throughout the response, the chief medical officers and chief operating officers from those facilities reached out to their spoke facilities daily or weekly to maintain their ongoing situational awareness of their needs and priorities, which was a great method for filtering information up to the state level.

They learned a lot throughout the process, making some initial mistakes, but Emory shared some successes as well, such as facilities being able to flex up to 150 percent of their license capacity. New Mexico also achieved statewide load balancing across facilities, had one central call center for the entire state, and maintained a constant continuum of care assessment, using space, staff, and supplies as core components to address the needs of various facilities.

Learning from COVID-19 in New York City

Elizabeth Chuang, Albert Einstein College of Medicine Montefiore Medical Center, focused her comments on the scarce resource triage component of CSC. Beginning in 2018, she conducted focus groups with key clinical stakeholders to solicit feedback on ventilator allocation draft policies and found that clinicians were worried about threats to their roles and identity, including decision making, autonomy, and fiduciary duty to the patient. While the team found their draft protocol to be necessary and acceptable, this early preparation was still challenged significantly by the emergence of COVID-19. The first barrier her team encountered was the lack of infrastructure to manage the implementation of potential triage protocols.

For example, at the time in early 2020, Chuang noted that the sequential organ failure assessment (SOFA) score was still used in many exemplar triage protocols, but in the first few weeks of the pandemic in New York

City, they were not able to obtain an automated SOFA score on patients with respiratory failure and had to calculate hundreds of scores by hand. They also lacked a reliable way to know how many ventilators were actually in use across the hospital system. These are common information infrastructure challenges across the country, she added. Additionally, while they were planning for potential implementation of triage protocols, they were tripling their ICU capacity, so support staff were busy working on those activities, making it difficult to prioritize triage operations.

Turning to workflows, Chuang noted that while guidelines had been available for years, tangible workflow plans, with appropriate levels of detail, were lacking. It was not clear how often the triage team should meet or how decisions would be made or communicated to teams and family members. Decisions also needed to be made about who would serve on the triage teams, since so many providers were desperately needed for direct patient care. There was also a lack of explicit support for public health expertise generally, and triage planning—specifically at the state government level—was a major obstacle to this planning work. It left hospitals uncertain whether triage protocols and workflows would be legitimized, and this disincentivized investment in these critical planning activities. She shared that through interviews with triage planners across the country, her team learned that states with supportive state governments had hospital leadership that was more willing to engage with triage planning and were able to conduct tabletop exercises to make the logistical steps of triage concrete and identify and correct workflow issues. Hospitals in the states without such support were less sure which activities would be sanctioned and had fear that press leaks of these activities would reflect poorly on the hospitals, making it difficult to complete the necessary training activities that would have allowed a smoother implementation.

In addition, the lack of national coordination led to scarcities of PPE, supplies, and medication that were unanticipated. Although her hospital never had to triage ventilators, Chuang said, other shortages required the rapid development of strategies for augmenting or allocating those resources. Given the difficulties of informing triage committees and workflows, Chuang noted the missed opportunity to bring together a formal team to manage difficult allocation decisions such as triaging the use of high-flow nasal cannula or providing fewer hours of dialysis to allow more patients access.

Finally, she highlighted the shortcomings of pre-COVID-19 triage guidelines, which are being documented more and more, such as the increasingly evident notion that SOFA scores are not appropriate for this use. Many concerns emerged from disability and minority communities, resulting in uncertainty and moral distress for those in positions of implementation planning, which was exacerbated by the lack of federal, state, and public

support for these activities. She argued that in the future states should mandate preparedness activities and make resources available ahead of the next disaster in order to better navigate implementation of response activities. She concluded that implementation plans should also be transparent and public so debates on their legitimacy can take place ahead of a crisis.

Discussion

Hick asked for comments on the role of the triage team at a facility versus the regional level, and the best ways to make these roles consistent. Chuang said her medical center based its model on the Institute of Medicine CSC framework, and developed a triage committee internally, but more standardization across the region could be facilitated, especially with strong state government support. Tying in the hub-and-spoke model, Emory added that New Mexico’s central call number has been critical from the standpoint of coordination. In an effort to address standardization across the state, they trained triage officers and those working in the call center to recognize and counter implicit biases. Most stakeholders do not know what CSC plans are, added Febbraro, so there is a job to do at the state level and in partnership with hospitals to continue the education of, and communication with, stakeholders and communities. Even though Colorado never had to activate its plan for triage for devices, she said a vast majority of their discussions with communities concerned the triage of ventilators and ICU beds and what would inform those decisions. The art of this community engagement is bringing diverse groups of people together and being able to speak openly about the principles and trade-offs that may be necessary.

Recalling the comments on moral distress for triage teams, Hick asked about how such distress plays out during exercises and real-world experiences, and how it affects the ability for institutions to operationalize these teams. Chuang responded that it is difficult to find people who recognize this is a real need that demands a system for operationalizing. These critical decisions should not be left to stressed bedside clinicians, she said, but it is also difficult to find people who want to engage in these discussions when there is not a crisis. She added that this type of work is challenging and not popular, and no one wants to add to that moral distress, so there is a need to incentivize it during noncrisis times to ensure it is addressed.

Load balancing across a state can work well until everything is full, noted Hick, and without some type of doubling up, things start to fall apart, and then it becomes very difficult to place patients. He asked whether there are policies in place that ensure fair access once everything is saturated. The first three waves of COVID-19 caused a greater focus on better coordination of transport in New Mexico, said Emory, but the current surge—of COVID-19 and other conditions—has reached the upper limit of state capacity. Data has

been key throughout the response, and the state has been able to stay nimble and determine the critical resources needed, but the state had to declare CSC in October 2021 to provide additional protections through credentialing providers and allowing people to work outside their scope. Emory said they wrote a public health order allowing facilities to declare CSC at an individual facility level, based on lessons from previous waves. It is an ongoing effort, he noted, so it is difficult to say what is working well, but they are working within the hub-and-spoke model to ensure any available resource or space is being used efficiently. He said that right now New Mexico is getting to the point where the system is overly saturated.

While the flexibility of different facilities declaring CSC is nice, it can also lead to pockets of inconsistent or variable care, said Hick. Chuang reported that in New York, the state association helps to coordinate some of these processes to standardize approaches within a region. One area this would help is public trust, she added, so people know they are getting the same level of care regardless of the hospital they are taken to. Febbraro commented that this was a very difficult concept to communicate, because if the state made a CSC declaration, it did not bind hospitals to follow those guidelines; they had discretion to choose how they implemented them. The public often felt like the government at the state level should be able to hold hospitals accountable, but that is not the case. Instead, she suggested having open and honest conversations about how health departments and hospitals implement standards.

EXPLORING CHALLENGES IN CRISIS STANDARDS OF CARE

To highlight challenges from various perspectives, this section features views and opinions from different stakeholders regarding workforce preparation, decision making, and public perceptions regarding CSC.

Workforce Preparation

Emily Kidd, medical director for Acadian Ambulance in San Antonio, Texas, provided a local perspective on planning and implementation in a large EMS system in Texas. When it comes to numbers of disasters, Texas is number one, she said, so it has had many opportunities to think about CSC. For those hospitals still developing plans, she emphasized the importance of understanding the state laws and rules related to EMS and medical direction. Some states have an EMS medical director, but some—like Texas—do not, so EMS medical directors have to make decisions for their local agency without state oversight.

Kidd shared examples of medical director involvement in implementing CSC, such as outlining altered standards of care, and noted these are diffi-

cult decisions to make, choosing which patients will get which types of care, similar to the alterations made in an overrun hospital. Medical directors also had to change medications and treatments, especially early in the pandemic before the virus was well understood. Many EMS medical directors altered criteria for terminating resuscitation in the field, or not transporting patients to the hospital and just treating them in the field. Additionally, she explained, there were changes such as varying destinations for transport, altered dispatch protocols, and using EMS personnel in nontraditional roles (e.g., giving vaccines, working in monoclonal antibody centers). All of this has to be under the purview and protocols of the EMS medical director, Kidd stated, so it is important for them to be involved in all aspects of CSC planning well in advance of an emergency event.

Hick asked about the added burden on EMS of interfacility transfers during the pandemic, when there were often longer distances than usual that required additional coordination. Kidd agreed this was a critical issue, and though everyone thinks of 9-1-1 when they consider EMS, interfacility transport of patients is just as important. There were very long times for interfacility transport, she said, because full hospitals resulted in longer transport distances, or because EMS was overwhelmed or having staffing shortages. There is a need to balance having sufficient staff and ambulances to respond to 9-1-1 calls while also being able to complete hospital transfers, but this has been a significant challenge that will likely continue.

Erin Talati Paquette, assistant professor of pediatrics and School of Law at Northwestern University, shared challenges on the pediatric side throughout the pandemic. First, she noted the effect of the illness on pediatric patients and institutions, saying that although children in general have lower rates of infection and severe infection, they still needed to create the same triage preparation for pediatric institutions if the regional system was stressed to maximal capacity. What became challenging in this setting was that the use of ventilators and life-sustaining therapies in small children is not readily translatable to adults, so using the same criteria was not a good method.

There were some algorithms and protocols that had been in development for children that they tried to use to predict and triage supplies, but this proved quite a challenge, Paquette noted. Another consideration was how pediatric institutions can optimize their ability to serve as resources in a setting where there is an overall strain on the medical system. Many served as regional sites for consolidating pediatric care or increased their age eligibility to try and decompress adult facilities, but there were several barriers to consolidation—mirroring many of the adult challenges.

Within the pediatric workforce, Paquette said, there was a drive for providers wanting to work at the top of their license. But in terms of staffing plans, the desire for individuals to work with adults needed to be balanced with contingency planning in case there was a pediatric surge. It

was also critical to ensure that individuals providing services would have adequate coverage if they became ill or had to quarantine. Regarding training, she said it is important to work on calibrating the workforce towards fluidity of resources—trying to have the same person serve in a variety of roles—but this requires coordination across multiple departments and services. Many pediatric providers were used to help with messaging and public health measure compliance, helping to create honest messaging about transmission and risk to children and vaccine hesitancy.

Paquette emphasized the need for coordination beyond one’s own hospital system. Her system relied on the Chicago Bioethics Commission, a voluntary gathering in the Chicago area that worked on trying to have consistent guidelines across hospitals for adult and pediatric populations, she noted. Her system also tried to interface with local public health authorities and follow guidance from relevant associations, but it faced many of the same barriers in terms of communicating the changes in usual practices when trying to coordinate resources across regions and states. To truly have regional coordination, the authorities are important, concluded Paquette, because individual institutions cannot enact any kind of regional standardization, which makes it difficult when working across so many different facilities.

Decision Making

Brian Garibaldi, associate professor of medicine, Johns Hopkins Biocontainment Unit, introduced the general process his health system in Maryland used to approach the difficult decisions of allocating scarce resources. He first emphasized the goals of maximizing treatment benefit and enhancing survival, and any policy that is developed needs to be iterative and tested in an ongoing manner. Garibaldi also highlighted that there is no one correct approach, and decisions and principles will be different and individualized to each hospital or location. Thankfully, in his experience, Johns Hopkins did not have to allocate ventilators or ICU beds, but it did reach a point with therapeutics and extracorporeal membrane oxygenation machines.

When looking at its tools for ventilator allocation, Garibaldi’s unit examined four different elements that underscored the prioritization of who would get a ventilator: short-term survival, long-term survival, clinical trajectory, and random chance. Because these elements could be subjective and variable, his team piloted a project where it created scarce resource allocation teams to examine patients who would be eligible, and had the providers score long-term survival. Garibaldi reported that the allocators did agree on whether someone made it one year or more after their current hospitalization (Ehmann et al., 2021).

When determining these policies, there were a number of outcomes his unit considered, Garibaldi said. The first was patient outcomes and trying to maximize treatment and survival, but he added that it was also important to have patient satisfaction and trust from the family and caregivers. The same is true for care providers, he said, since they were not making direct decisions about scarce resource allocation, but they needed to know the process was fair so they could trust the decisions.

From an organizational standpoint, Garibaldi explained his unit wanted to improve survival and quality of life but wanted to be sure it was maintaining trust and integrity with the community it served, so the community needed to be involved in the process in order to support it. He also reviewed the appeals process for patients and families, saying the process depends on the resource in question. If the decision was made not to offer mechanical ventilation to a patient and the patient wanted to appeal, the person would be given the treatment in question until the appeal could be considered by a special team. He highlighted the importance of testing how these appeals and processes work; his unit is retrospectively looking at COVID-19 patients and evaluating how the allocators and scores would have worked out looking at patient outcomes or potential alternatives. In real time, the reality is that people try the best they can, but now that there is so much data accumulated, he said, there is a need to think more carefully about identifying how the processes and methods for decision making can be improved.

Vikramjit Mukherjee, medical director of the Special Pathogens Program and director of the Medical ICU at Bellevue Hospital Center, shared his perspective from New York City, responding to the COVID-19 pandemic in spring 2020. Unfortunately, he said, most of the patients his hospital saw were those from traditionally underserved communities without good access to health care. He noted that there were mismatches in resources across the board, including staff, space, and supplies, which also took a toll on provider wellness. The effect of this on staff is still unresolved, Mukherjee added, and he expects posttraumatic stress disorder will stick with staff for years to come.

During the first surge, ICU beds filled quickly, he explained, so his ICU had to develop novel spaces or double up on patients in ICU rooms. He noted that while his team did not have to allocate ventilators, other elements of critical care medicine were often in short supply, so the resource mismatch was present across all domains. Unfortunately, he said, decision making was often arbitrary, as there was not clear guidance on who gets the state-of-the-art ventilators versus the old or borrowed ones, or who gets first-line therapy care versus other processes. He lamented that overall the processes and decisions resulted in some inequities.

Communication was another area that could be much improved, Mukherjee shared, as there should have been better communication with

medical operation centers to provide situational awareness and information to the front lines. Working well across health systems was also a challenge, he noted, saying it was painful to see ICU beds totally empty 100 miles north, but New York City was on fire—there was no concept of load balancing. In conclusion, he emphasized that the space between conventional and crisis modes is when they try to do everything they can, coming up with all types of creative solutions to avoid reaching the critical point where resources are rationed. Hick highlighted the delicate balance between waiting too long to activate CSC and actually rationing the resource. Mukherjee agreed that it is a very careful line, but for something like dialysis, it makes more sense to offer half dialysis to 100 patients compared to full dialysis to just 50 patients. Having a clinical eye to inform many of the command center operations is critical in order to make these nuanced calls about resources, he stated.

Public and Stakeholder Perceptions

Julie Reiskin, executive director of the Colorado Cross-Disability Coalition, shared that she represents a community that is distrustful of both medicine and government, so when the pandemic emerged there were some immediate concerns. She highlighted what her coalition did in Colorado to gain community trust in the pandemic response. The historical experiences the people in the coalition have endured has created a perception, she explained, but when there is a significant event that engages community leaders, new perceptions can be formed. Reiskin noted that these changes happened when people at the health department invited leaders from the disability community to come to the meetings to be part of the discussions. As a result of that, changes were made to the CSC plans that removed many of the concerns for people within the disability coalition.

Explaining CSC and triage is hard, she said, as most people in this community have been told they will not survive something, so the concept of survivability causes suspicion. As a result, members of the coalition needed messaging in a way that was clear and not patronizing. One thing that built trust more than anything else, she said, was that people from the health department were willing to answer questions throughout the pandemic. She gave the example of a household in a rural community with two severely disabled people who were trying to navigate how to manage caregivers going in and out. Through these discussions, they had access to people who were knowledgeable and connected, and they were able to get the right PPE for the caregivers and follow the right public health measures, allowing trust to be built while those individuals stayed in their own home. Consequently, she shared that there was very little vaccine hesitancy in the disability community. Inviting community members in, listening to their

concerns, and making changes where reasonable is critical for community trust, Reiskin concluded.

Elizabeth Lee Daugherty, chief wellness officer and associate professor of medicine at Johns Hopkins School of Medicine, shared a project from Maryland that was conducted, beginning in 2013, to better understand the issues in the community related to allocation of resources. Her team gathered participants from the community and general public and held 4-hour meetings using deliberative democracy methods to explain complex issues to attendees, giving them time to work through them and talk with colleagues about what might happen. Over the course of the year, the project engaged with 235 participants to discuss who would be prioritized if there were shortages of certain resources. Key messages included a community right to know and hope for a technological fix, such as sharing ventilators or using other technologies. But additionally, she noted that people were pragmatic and saw the need to be prepared against ad hoc approaches. They also did not want providers to be coming up with decisions as the needs arose. Finally, she said the participants held discussions around objective methods to combat biases, recognizing that biases can be ingrained within providers and systems, so community members wanted to ensure they were not embedded into any processes or decisions.

Will Stone, science reporter at National Public Radio, noted that most people had never heard of CSC before the pandemic emerged in early 2020. Once they did, early discussions focused on such extreme scenarios as having enough ventilators or beds for patients. The public opinion of CSC amounts to the assumption that people will be dying in the streets, he said. Headlines and language play a large role in this, and some evoke more fear than others. There is always a tension with how you describe the pandemic and current needs, he said, as you want to be concrete but also risk being reductive.

Reporting on the dire health care needs is difficult because it is not always clear to journalists when CSC is being activated, Stone noted. The media has to talk about this responsibly, but they are also very reliant on health officials to be clear about what is happening. There were many stories of full hospitals and shortages of workers, he explained, but it was never clear if that translated to CSC, so overall transparency to the press was lacking. Without that, it can be hard to get a nuanced portrait of what is truly happening in hospitals. People end up making CSC very black and white, stated Stone, even though it is not a light switch. Hick added that the field has struggled with triggers and understanding when the activations or details on shortages or changes in standards should be clearly communicated to the public.

REFLECTIONS

Mehta noted that these discussions highlight how complex CSC plans are and the immense amount of work that goes into avoiding these situations. He highlighted the need to reflect on how to engage with the community, how to think about equity, and how to deal with systemic imbalances within the health system. He also shared that he had not heard much of CSC until the pandemic emerged, but he realized as an intensivist there were many important allocation questions that would quickly emerge in his department if there were too many patients. Erin Serino, deputy chief of staff, Boston Emergency Medical Services, commented that she saw the trends in discussions as coordination and communication across systems and at state and regional levels. She pondered how to continue to drive that coordination and collaboration across states and at the national level. Shandiin Wood, health systems epidemiologist and tribal liaison, New Mexico Department of Health, agreed with coordination and collaboration being key, especially among disparate organizations across levels and geographies. He noted that to make these collaborations more effective, there is a clear need for better-integrated communication channels so that institutions are not geographically restricted when negotiating difficult questions about lack of resources.

Megan Jehn, associate professor, Arizona State University, added that as a nonclinician, most of her experience in CSC has been with community engagement. She reiterated the need to communicate in clear and consistent terms the differences in the needs of the various phases—conventional versus contingency versus crisis. In addition to the stress of living through a pandemic, she said, many communities carried the fear and stress of being on the receiving end of biases in these formalized processes and system protocols. She asked how to find best practices for gaining the public’s trust. She noted there is also a need to maintain transparency and communicate to patients as they enter hospital systems so they are comfortable and trust that they are in a safe and just place. With all of the work that has happened in the last 18 months, Mehta concluded, this should reinvigorate stakeholders to push for these changes to be implemented in time for the next crisis. Given globalization and the movement of people across the world, there will certainly be another pandemic, but this is an opportunity to be better prepared.

This page intentionally left blank.