5

Coordination, Government, and Leadership

The significance of leadership in influencing how public health measures were supported or opposed became abundantly clear throughout the ongoing changes and dynamic nature of the COVID-19 pandemic. This chapter examines the critical aspects of coordination and leadership during a public health emergency and reviews experiences in the early stages of COVID-19 and as time went on. Speakers discussed numerous elements of governance, including cross-jurisdictional government coordination, federal coordination, public–private partnerships (PPP) for regional coordination, and finally, elected and appointed leaders.

COORDINATION IN WASHINGTON STATE: A CASE STUDY

Steven Mitchell, associate professor of emergency medicine at the University of Washington and medical director of Washington Medical Coordination Center, noted the role of the speakers living and working in Washington State during the pandemic. This section discusses cross-jurisdictional government coordination, beginning with Washington’s experience at the state level when the virus first appeared; outlines the available guidance at the time and the difficulties in coordination across levels of government; and highlights some successful practices that emerged.

Initial COVID-19 Alert and Response in Washington State

John Wiesman, professor of practice in the Department of Health Policy and Management and former Washington State Secretary of Health, provided

an overview of how coordination in governance was supposed to work and his experience in the state that had the first true outbreak of COVID-19 when it came to the United States. Describing Washington, he noted there are 7.5 million people living in 39 counties, and there are 100 acute care hospitals, 300 school districts, and more than 200 skilled nursing facilities, as well as a large migrant and seasonal workforce. There also 29 federally recognized Native American tribes living in the state as sovereign nations. In terms of coordination of governance in the state, he said there are several existing documents that should direct actions. The state comprehensive emergency plan was updated in 2019, and the Department of Health emergency response plan was updated in 2016. In a pandemic, Wiesman explained that their leadership executes a state emergency operations center activation, as well as forming a policy group comprising private-sector representatives, executive-level members, disaster managers, and state agencies that are responsible for policy decisions regarding the allocation of critical resources and strategic messaging. In terms of information sharing, there are many lines demonstrating communication between various levels (see Figure 5-1). Some of these relationships were followed, but some were not, and messages were not always received as intended, he added.

Going back to the beginning of the pandemic, he reminded everyone that the news of the first COVID-19 infection in the United States emerged on January 21, 2020, identified in Washington. From there so much has happened, he noted. But before that day, on January 19, a 35-year-old male showed up at urgent care in Snohomish County with a cough and relevant symptoms. He had been in Wuhan, China, but was not in contact with anyone who was ill and was not at the market where the virus was thought to have originated. The Centers for Disease Control and Prevention (CDC) agreed to test him, so a sample was drawn, flown to CDC in Atlanta over the weekend, and the result was positive (Holshue et al., 2020). By Monday afternoon, Wiesman said they were being briefed and were coordinating their next steps with CDC. “When federal agencies ask if you want any help, you should always say ‘yes,’” he said.

It is important to be on the same page throughout the process, and while the state government is in charge, federal support can bring other knowledge and resources. The very next day people from CDC were on the ground in Washington to help support the state health department, helping to shape the case definition and who was considered a close contact. We were the first state with a known case and did not have all the information we needed to work through all of this, he noted. While they did use the plans that were developed, any plan is usually insufficient on its own and needs to be adapted and pivoted to respond in real life.

Jeffrey Duchin, chief of the Communicable Disease Epidemiology and Immunization Section for Public Health–Seattle & King County, said because of the restrictions in testing in the region, they missed many cases of COVID-19 in their county. Early on, they received a notification that two hospitalized patients in the county had unexplained pneumonia. One had been a resident of a nursing home who had an influenza-like illness. This was the same day that CDC changed its threshold for testing, he said, so we were able to take specimens and submit them. That result came back positive, which brought their total in the county to four patients at that point—but not all of them were connected.

He said they notified CDC of a large outbreak at the long-term care facility, and shortly after that, other outbreaks emerged at other facilities. During the initial outbreak, Public Health–Seattle & King County was the lead for the response in collaboration with state and national partners. While there were existing emergency plans, he said they did not have a plan that spoke directly to the challenges that emerged with this outbreak. They did not have a playbook to respond to a new, poorly characterized respiratory virus. There was a lot of uncertainty around what measures to use, when to implement them, and for how long. Thankfully, there were very good relationships with colleagues at state and local health care systems, as much of the work accomplished was based more on relationships than plans.

Stephen Kutz, chair of the American Indian Health Commission and Suquamish Tribe Health Clinic director, first acknowledged the indigenous land that the workshop was taking place on in Washington, D.C. When the virus first emerged, he was chair of the tribal council and managed the health care system that consisted of a few locations. Their reality of the virus really became grounded when one of their tribal members passed away at the nursing home in Kirkland, Washington.

Prior to the emergence of H1N1, Kutz explained that four county public health jurisdictions and the Cowlitz Tribe had formed a public health regional governing council to jointly stand up a public health incident command to respond to the H1N1 emergency within four counties in southwest Washington. When the H1N1 epidemic occurred, they were able to quickly allocate vaccines, unlike other tribes in the state. At that time, there were really no plans for the distribution of medical countermeasures (MCMs) to the tribes, and there was no understanding of sovereignty, he said, so we started working on that. Tribes deviated from CDC guidelines in terms of what they prioritized, so that did cause conflict with distribution, he noted. Based on that, they started planning and created mutual aid agreements between tribes and jurisdictions.

In 2018, they had additional meetings and exercises about MCM distribution across counties and tribes. Thinking about long-term planning, they based initial plans on what did not work during the H1N1 epidemic in 2009 and moved forward with geopolitical alliances. However, based on relationships in different states, these will not always work, he acknowledged. In August 2020, the tribes hosted a consultation with the American Indian Health Commission to take care of some of these issues. They addressed MCM distribution and worked on the language around sovereign authority into coordination documents. Working with local health jurisdictions and with the state has been very important to us, said Kutz, and I think that is the reason we have been successful.

Kathy Lofy, former state health officer of the Washington State Department of Health, was primarily responsible for providing clinical and scientific technical advice to the governor and health office in her role. When the virus first appeared in early 2020, she said they had fortunately been working for nearly 10 years prior to develop guidelines on crisis standards of care. Thankfully the guidelines included elements like allocation of scarce resources that became very relevant as the pandemic worsened. The other guidance document that was helpful was CDC’s Morbidity and Mortality Weekly Report that was published around community mitigation measures related to community influenza. “We had plans,” she said, “and while they were not perfect, they were helpful and we were glad that we had spent that time developing them.”

Difficulties in Coordination Across Government

Regarding the coordination across various government agencies, Lofy noted that CDC was incredibly helpful with the first case and studied asymptomatic infections and close contacts. The coordination for that event worked wonderfully. But in the month following, she said they were not able to do testing within the state, which made things very difficult. The University of Washington virology lab had developed a polymerase chain reaction (PCR) test, but there were delays in getting the test approved. She advocated for much more robust plans outlining how to very quickly stand up clinical testing, using the huge network of laboratories across the country. Tests can be developed quickly, she said, so we need to learn how to pivot to include the private sector since there is such limited capacity within state public health. After the outbreak was detected in King County, the capacity within public health was very quickly overwhelmed, she continued. There was unrecognized transmission, and as soon as public health officials were able to start testing they were finding cases of COVID-19 everywhere. The resulting tsunami of work then overtook the local and state health departments, which reinforces some of the previous funding comments in Chapter 3.

As an example of the shortage of resources in public health, Lofy said they were uncovering outbreaks in many long-term care facilities. The state-level program staff only has three people in it, and they worked nonstop for months, she said, but it is difficult to pull people from another part of the agency and train them in health-care-associated infections, which puts lots of pressure on those who do have that expertise. Coordination was less of a problem than just lack of resources and human capital to do the work, she admitted, including personal protective equipment (PPE) and testing supplies. But coordination was difficult, as decisions during this time needed to be made quickly. The federal government was not able to give states much information about decisions coming down the pike, and similarly, departments at the state level were not always able to get input from local health departments and then inform them of big policy decisions. That really hurts coordination when people are caught off guard, she noted.

Duchin agreed with Wiesman and Lofy, and said they experienced similar issues locally. There were unrealistic expectations of what public health could handle, overwhelming demands, and challenges for non-CLIA-approved SARS-CoV-2 assays during that first month of the outbreak with a lot of unrecognized transmission.¹ In terms of coordination at their level and

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¹ The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations include federal standards applicable to all U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease.

trying to get a handle on the incidence of cases, Duchin shared challenges from Department of Veterans Affairs (VA) hospitals to report immunization data into the state registry. Additionally, the federal vaccine allocation forecast for state and local jurisdictions was not available until the last minute before delivery, which made the planning of clinics and working with health care very difficult when trying to plan administration of vaccines.

Other challenges were related to situational awareness, such as getting accurate data on hospital bed capacities early on and the need for crisis standards of care. Lastly, it was difficult to coordinate among public and private entities related to acquisition of PPE, masks, respirators, and testing supplies. Over time they transitioned to a more long-term response, he said, shifting responsibilities to other partners, but initially the demand was so high and the sourcing so disjointed that there were many difficulties in getting necessary supplies.

In terms of medical surge, Wiesman outlined the Disaster Medical Coordination Centers described in the plan to assist with patient placement. Health care coalitions are also the primary convener of health care facilities and responders within their region to coordinate sharing of information and resources. Coordination occurred in many ways, with calls happening each month, with state and local health officers, tribal leaders, and various calls with state and local hospital, nursing, and medical associations.

Wiesman agreed that it is critical to coordinate with the private sector and its existing structures and not think government will take on everything from testing to distribution of countermeasures. Another challenge he noted was the formation and execution of the policy committee within the operations center. This was so big and the consequences were so large, such as considering shutting down the economy, he said, it consumed the governor’s time and his team for nearly a year. But the policy making really was happening outside the formal policy group, so the policy piece as planned never really came to fruition, which was frustrating for many. Similar to Lofy’s comments, Wiesman agreed that discussions and ideas moved so quickly and decisions were so consequential that things sometimes happened simultaneously.

For Colonel David Adam, army state surgeon, Washington Army National Guard, the underuse of the National Incident Management System was a pain point. Requests that came outside this process degraded our capability for mission analysis, he said, which then made it difficult to evaluate the response.

From the perspective of Native American tribes, Kutz said, low points included the tribes that lacked trust in the state and attempted to get supplies through Indian Health Services and the federal government. In those cases, things typically took longer, and they watched other tribes who worked closely with their states getting vaccines and supplies. Those tribes then

requested to receive additional vaccines through the state. Also, tribes were generally lacking public health infrastructure, he said, so they ran their response through clinics and medical staff. They had constant coordination calls, sharing vaccines and PPE, while also trying to procure freezers so they would be able to store vials of the Pfizer vaccine at subzero temperatures. Some tribes do not have medical facilities, he explained, so they were not able to be included initially but were able to join local county resources to stand up their vaccination program.

Key Moments and Best Practices at the State Level

Lofy did note several shining moments in the state’s experience, mainly centering around relationships, which were fundamental in this effort and helped with the process and coordination. She noted that she and Wiesman had been in their positions and working in governmental public health for many years. They had built up many relationships and knew what to expect in public health emergencies. They also had strong relationships with the acute health care system, meeting regularly even prior to the pandemic with health care association leaders. In the future, Lofy and Duchin agreed that we need to take advantage of existing supply chains that work quickly in the private sector. Bringing supplies into the state via the government and then having to send them out is a slow process.

Another shining moment was the establishment of the Washington Medical Coordination Center (WMCC). Essentially, it acted as air traffic control for patients throughout the state. “It was agreed early on that we didn’t want one single hospital to have to move into crisis standards of care alone,” said Wiesman, “and we decided that if necessary, the hospitals would do it together across the state.” But that would not have been possible without WMCC, which was able to move patients across the state where needed.

Eileen Bulger, trauma director at Harborview Medical Center in Seattle, asked to expand on the evolution of WMCC and its long-term plan. She saw its work as critical, as hospitals never reached a point where they were overrun, and they were still able to reserve beds and providers for other issues besides COVID-19. Mitchell noted that WMCC was borne out of seeing an outbreak from one nursing home overwhelm a very high functioning and well-resourced hospital in Washington. It engaged people across the state to come up with a plan for distribution, with a key element being the commitment from hospital leadership to not go into crisis standards of care unless everyone was moving into it together.

In the first 18 months we received 200 requests from hospitals, he said, which was a fairly small number, but they were doing it with a spreadsheet file and a cell phone shared between a few people. Then, once the Delta

variant emerged a year later they received 3,600 requests. Overall, the WMCC goal was distributing patients and balancing loads across the state. Nearly 75 percent of the requests it received came from rural, unaffiliated hospitals, he noted. Without an entity like WMCC, who is going to be their voice, he asked? Though the crisis and surge periods of the pandemic have ended, he said WMCC is still operating because we know the importance of maintaining these relationships and the familiarity to allow improved ability to expand better during surges.

Duchin emphasized the excellent working relationships and trust among individuals. He also acknowledged that it was helpful having people in response who had experience working in other agencies at other levels. In King County, emergency medical services and the medical examiner’s office are part of the Public Health Department, which was critical in coordination for those aspects of the response, he explained. King County is also fortunate to have a very mature health care coalition, the Northwest Health Care Response Network, and support of CDC colleagues early in the outbreak. Adam also agreed on the importance of relationships, saying that embedding liaison officers at points of care was one of the shining moments in his experience and influential in refining their plans.

Serino asked for examples of best practices learned from the community. Kutz highlighted telehealth as a huge win as they were able to attract so many different types of patients. Lofy noted that they added a mental health specialist to their coordinating calls and tried to communicate the effects that many would likely feel. Community engagement is critical, she said, but you really need a lot of people to do it. For example, King County has countless different communities, so it takes a lot of people and time to truly engage them all in a meaningful way.

COORDINATION AT THE FEDERAL LEVEL

To open the session, Richard Serino asked federal panelists to describe their role and experience at the early stages of the COVID-19 pandemic.

Federal Emergency Management Agency (FEMA)

“We had lots of plans,” said Pete Gaynor, former acting secretary of the U.S. Department of Homeland Security and former FEMA administrator, “and we used bits and pieces of them but mostly adapted as we went.” He recounted the transition at the start of the pandemic when FEMA became the operational lead of the COVID-19 response. By March 13, 2020, the president declared a national emergency, he said, giving us the power to put things into motion. By that Wednesday, Gaynor continued, we moved the integral parts of the U.S. Department of Health and Human

Services (HHS) to FEMA and made a decision to push power to the 10 FEMA regions so all decisions were not made in Washington, D.C.

He attributed part of FEMA’s success to having that operational capability throughout the nation. The FEMA regions already had existing relationships with governors and city leaders, so they integrated CDC and the Office of the Assistant Secretary of Preparedness and Response (now the Administration for Strategic Preparedness and Response [ASPR]) into those regions and created a unified coordination group that made decisions as a team. No plan anticipated things would go this direction. The magic in getting things done was working directly with the task force, concluded Gaynor. Having the ability to work directly with the vice president and then immediately put things into action cut down on a lot of time and misunderstanding.

Also within the operational role, David Bibo, deputy associate administrator of the Office of Response and Recovery at FEMA, was the acting associate administrator when the pandemic first hit. When he describes FEMA’s role to people, he tries to simplify it to three tasks: gaining and maintaining situational awareness, establishing a federal footprint, and delivering aid to the American people. Since most of FEMA’s responses are limited to certain affected regions of the country, having to apply these tasks to a nationwide incident was a huge challenge, even with the systems they had in place. He agreed they had an advantage over other parts of government by being so distributed around the country, which allowed FEMA to provide the level of support that it did.

FEMA staff also had resources to pull from and inform their actions. The pandemic crisis action plan (PANCAP), developed in 2018, was informed by the 2013–2014 H7N9 influenza virus that never resulted in a pandemic. Around the same time, the Middle East respiratory syndrome (MERS) coronavirus was emerging in different parts of the world, and there was concern it would spread further, so FEMA started to look more closely at what a crisis action approach would look like for this type of event.

He acknowledged that while many things had changed since then, those elements provided some background when the COVID-19 virus first emerged. One noticeable difference between the plans and reality, Bibo commented, was that the documents often said, “You may lose up to 20 percent of your staff for 2 weeks at any point because they are sick.” But sending vast numbers of federal workers home, emptying FEMA headquarters, and bringing in various different operators was unexpected. There has been certain growth from those early assumptions, Bibo said. As a final point, he emphasized the lack of capacity and outright disinvestment in public health infrastructure in so many states as something that demands a fervor like that of post-9/11 to be ready to address the next threat.

Office of the Assistant Secretary for Preparedness and Response (ASPR)

Robert Kadlec, former assistant secretary for preparedness and response, echoed the comments that multiple plans existed and said his role was to be an advisor to the secretary of health on several fronts. However, no plan survived first contact with the virus, he said. But every plan we had to address an event of this nature was based on influenza, which professionals had a good understanding of in terms of how the virus might behave and respond to efforts of containment and immunization. At the time though, they did not realize that this new virus had 40 percent or more asymptomatic transmission, a characteristic much different than influenza. Again, highlighting the underfunding of public health, Kadlec compared the four to six public health staff he had in each region to the several hundred FEMA representatives Gaynor highlighted.

Centers for Disease Control and Prevention (CDC)

Also in public health, Christine Kosmos, director of the Division of State and Local Readiness in the Center for Preparedness and Response at CDC, said they had a major role in coordinating and leading the pandemic response, given where they sit in the public health space. “We like to think of ourselves as a conduit between national and local levels,” she said. “We develop guidance, deploy teams on the ground to help with outbreaks and data collection, and coordinate information sharing.”

Department of Defense (DoD)

David Smith, acting principal deputy assistant secretary of defense for health affairs, said he served as a lead for public health policies in the Department of Defense (DoD) during the pandemic. DoD heavily invested in such things as medical research and development for vaccines, testing, treatments, and medical logistics. He outlined the three main priorities set by DoD: protecting our people, maintaining military readiness, and supporting national response by providing whatever assistance is needed. The policies developed continue today, Smith noted, but we try to empower our regions and installations to make their public health decisions based on local conditions working with the states or nations where they are located.

Office of the Surgeon General

Similar to DoD, Brigadier General Carl T. Reese, deputy surgeon general for the Army National Guard at the Office of the Surgeon General,

explained the authorities and timelines within the National Guard, saying there are 54 separate National Guards, under control of the governor or leader of the territory. In times of declared emergency, Title 32 from the U.S. president can activate them as active military. They can also be federalized and fall under control of the president with 10 U.S. Code. Reese described the series of activation and memos that occurred following the emergency declaration on March 13, 2020.

The states of Washington, California, and New York activated their National Guard early in the pandemic since that is where the outbreaks began. But at the peak of the pandemic, there were a total of 55,129 National Guard members mobilized in one form or another. As of May 2022, 14,648 remained activated. Responses were dependent on community needs and changed as the needs arose, he added, and members held roles ranging from driving buses, to staffing nursing homes, to deep cleaning facilities and administering vaccines.

Discussion

When asked about the limitations to federal capabilities, Gaynor recalled the day he realized the pandemic was getting serious: he came into a conference room and people had a ventilator with several different supplies and, owing to the shortage of such equipment, they were trying to turn it into a device that could be used for two to four people instead of just one. This was different than FEMA’s typical role, he said, which is to come in after an acute disaster, once the destruction had already occurred. In this case, he said, we were in the active response mode of trying to save lives. Reese added that this was also a shift for the National Guard, as typically their medical elements are in support of other military entities, but in this case, medical was the supported entity.

Kosmos said that, from her perspective, what seemed so different from previous responses was that no plan she had been a part of ever contemplated something so catastrophic. This was not a public health emergency anymore, she said, it was an economic emergency and a supply chain catastrophe. Kids were out of school, businesses were closed, challenges were piling on top of one another. At the same time, other disasters, such as wildfires and civil unrest and floods, did not stop. Kosmos advocated for understanding the right scale that needs to be planned for, and exercise and train for that. Because clearly, despite best efforts, planners and public health authorities never contemplated the level of crisis caused by the pandemic. “Our systems work really well in a regular sort of emergency,” she said, “when states can call on neighboring states for help, or regions can support an affected area.” This was the first time systems have been tested to their breaking point, she said.

Kadlec added his observations, noting the limitations of federal capabilities and power to respond to an event of this size and scale, and the vital nature of the private sector. We need to more effectively engage them, he said, beyond what is possible within FEMA. Secondly, he recalled a physician from the Department of Homeland Security who was driving across the country visiting various hotspots to report back, since there was no formalized data collection mechanism. When he reached Louisiana, he found they actually needed far fewer ventilators than the models were predicting. Upon talking with the state health officer, Kadlec said, they explained that providers in Louisiana had developed a mechanism to place patients in a prone position and used a high flow nasal canula instead of using ventilators since they were in short supply. The result was that Louisiana was experiencing 20 percent mortality compared to 80 percent in New York because they were able to do this to so many more patients. This was in April 2020, a very critical time, Kadlec said, so once receiving this information, the federal response worked to disseminate the method to health care systems across the country. This highlights how we have to be more poised to “send and receive” from the state and local level, he noted, because it can help the federal responders do their job better and spread best practices faster.

Bibo added that 2 years prior to the workshop, May 18, 2020, there had been 37 alternate care sites set up by the Army Corps of Engineers, complete with technology and advanced capacity. But most of them sat unused, he said, because when talking to hospitals about separating their personnel, you lose medical direction and control. So they were able to get smarter as time went on and create situations that were more efficiently used. For example, he said, today we get clean reports twice a day on the state of hospitalizations across the country, but 2 years ago people were still trying to figure out how to achieve situational awareness.

Chris Shields, City of Chicago, said preparedness is expensive. And the plans were always there, but they were never meant to be static. Instead, they should be dynamic and challenged to result in policy changes and course corrections. But public health funding is paltry when looking at legislative allocations, he said, and is less than 5 percent of the national budget. Sustained funding from Congress is necessary for not only health care infrastructure but public health infrastructure as well. “We can buy widgets all day, but if they spoil because we’re not eligible for sustainment capabilities, then they’re for naught,” Chris said.

When asked how efforts could have been redirected to be more judicious with resources, Gaynor admitted, “Absolutely things could have been done differently, but in the moment we wanted to do the absolute best job we could, with so many uncertainties at the time.” Bibo added that in early February 2020, FEMA did not have $80 billion or $25 billion in the Disaster Relief Fund, so they thought their ability to spend money

might be limited to about $800 million through a particular Stafford Act declaration. Because of this, the spending conversations were much different than they were months later, he noted. The toughest part for Bibo was that they pulled so many people away from their lives for years to work on the response, and even with all of the resources marshaled, more than 1 million American lives were still lost.

Kadlec noted that we now live in a different era, with technological and supply chain advances that demand working with proven partners. He claimed that the only way to address the future is to focus on the two elements of how to exercise systems to see if they will work and how to effectively handle these crises. From a CDC public health perspective, Kosmos added that there is a unique opportunity now to evaluate the level of readiness within the public health system for something that affected the entire country, which is not an opportunity that comes often. In the past she admitted that FEMA has not been the lead in this type of response, but the landscape has changed, and that assumption is no longer accurate.

Gaynor offered two points, first saying that while the federal agency spends a lot of money, there is not enough spent on preparedness. Secondly, there is a deficiency in that many things are not measured, including return on investment. He suggested outlining mandatory things that states need to spend money on for preparedness, with the rest being at their own discretion.

A participant highlighted the differing information coming out on policies around masking, vaccination, and other response issues, and asked if there was a united front to coordinate communications across federal agencies. Kosmos admitted one of the more challenging things was that they needed to repeat over and over that guidance is going to change. People took that the wrong way, but she emphasized how the dynamic nature of the evolving pandemic needed to be communicated better so people understand and expect that the science will change. Gaynor agreed that there needs to be a much better system. Smith noted that one of the things done now is having a regular coordination meeting led by the White House. Whenever there is interagency coordination needed, the domestic policy council or the National Security Council needs to be involved, he said, because there is not another mechanism with that functionality to bring together so many agencies.

Bibo acknowledged the disproportionate effects of the pandemic on certain populations, and the challenge that brings for FEMA and other responding agencies about where the line is between the baseline challenges that are persistent in the United States and the emergency. “We’ve struggled to answer that question,” he said, “and it’s not a perfect line, but we attempt to go as far up to the line as possible.” A participant brought up the differences in death rates across counties and asked if it were pos-

sible to standardize those differences within a regional response. Smith suggested that those outcomes may be related to other disparities, such as the access to trauma care, especially between urban and rural areas. Much of what we see in terms of access to care, vaccines, and antivirals should be our way forward, said Kadlec, and could even be a metric to work toward the future.

Adding to this, Kosmos said there were also lessons learned about health equity and social determinants of health that clearly influenced differences across community outcomes. Those elements and that perspective need to be baked into everything we do, she concluded. Regarding workforce, Kosmos reminded participants that the current presidential administration has pledged to invest and fund 100,000 people in the public health workforce, to help sustain some of the gains that have been made. It will not solve everything, she acknowledged, but it is an investment in the public health workforce that we have not seen in modern history.

Kadlec said that FEMA is a strong system, with mechanisms that have proved to be adaptable and flexible, but he admitted that it needs to be optimized for the public health and medical components of a crisis. He sees an opportunity for ASPR to be integrated fully with FEMA at the national and local levels. Smith also added that there is a need for more examination of biosurveillance around COVID-19 and applying that to be more predictive and understanding of the next threats that will appear.

Kosmos brought up the term whole of government and said it is a phrase that has been thrown around for years, but this crisis was the first time everyone really experienced what it meant. She suggested taking time to reflect on that and rewrite playbooks where needed in order to do better next time, and take more time to contemplate truly catastrophic planning.

In conclusion, Gaynor noted two critical things necessary when planning for the next catastrophe. First, he advocated for an integrated and easily analyzed data set that supports decision making and can turn the mountains of available data into more actionable support. Secondly, supply chain expertise is critical for the next catastrophe, he said, especially when managing a lack of resources.

PUBLIC–PRIVATE PARTNERSHIPS

Eileen Bulger, chair of the Committee on Trauma for the American College of Surgeons, invited panelists from a state health department, a university hospital system, a nonprofit health care coalition, and a private health care system to share their experience during the pandemic with PPPs.

HCA Healthcare

Melissa Harvey, assistant vice president for Enterprise Emergency Operations for HCA Healthcare, shared that the health care resilience task force, where she led the hospital team, was truly an interagency, diverse effort. As a past example of a successful PPP, Harvey highlighted the response from the health care coalition in Philadelphia following the 2015 Amtrak train derailment. They used their coalition to rapidly gauge situational awareness and see where the bed and operating room availability was. They communicated this information to emergency medical services while rescue was ongoing to ensure that no single hospital was overwhelmed, and all patients needing emergency surgery were able to get it. They reflected on this experience once the pandemic emerged, and they set up multiple medical operations coordination cells (MOCCs) at various levels of government.

One lesson she offered was to reflect on what your health care pattern looks like every day and make sure that you can coordinate with all of the nearby hospitals. It is also important to have a clinician inside each MOCC to help prioritize patients and make sure the right patients end up at the right facilities. Some places may only have a few intensive care unit beds, so they should be reserved for the most critical patients. From there, Harvey noted the expectation that the local communities were going to be overwhelmed, so the same amount of coordination needs to happen at the state level as well, and there will likely be the need to transfer patients across state lines.

Even 2 years into the pandemic, MOCCs have only been stood up in approximately 15 to 20 different states, said Harvey. Some are run by public health departments and some by an emergency medical services (EMS) agency, health care agency, or coordination center. But she emphasized that who is running it or what form it is in does not matter. What is important is that the function is operational for all of the partners involved. This is something that really demands focus going forward, Harvey argued, to enable the right authorities so that this type of center can operate the most effectively and efficiently.

As a final example of how her organization runs PPPs, she highlighted a surge year in Northern Virginia, during a recent time where 80,000 Afghan evacuees came in through Dulles Expo Center in just a few months. Initially it was not well coordinated, she admitted, so Reston Hospital, which is within their network, was processing nearly every evacuee that needed to go to the emergency department because they were the closest hospital. But the regional health care coalition stood up and started a rotational basis where they all took turns receiving Afghan evacuee patients to balance the load.

Northwest Healthcare Response Network

Onora Lien, executive director of the Northwest Healthcare Response Network, shared some experiences from her coalition, which serves most of western Washington and comprises 64 hospitals and hundreds of other health care and emergency response organizations. When the pandemic began, the coalition had recently expanded from three counties to serving all of western Washington. Although the coalition was established in 2005, its recent growth provided both challenges and opportunities to connect and coordinate across many more health care organizations across the state. It was challenging, Lien explained, because many relationships were still new, and the concept of a regional emergency was still unique at that scale. However, there were also many long-term relationships that aided in this work, she said.

Lien shared four primary anchors of the coalition’s role: information sharing and coordination, resource supports, operational planning support, and convening leaders and planners to develop the model for the Washington Medical Coordination Center, described previously. She highlighted the role of the coalition as serving at the intersection of what is happening in the health care system and across sectors, while helping to shape state policy and strategy. Lien said the coalition also found itself as a neutral broker, bringing together competitive organizations, subject-matter experts, and advocates for what health care needed. This is a unique role that health care coalitions can play and is one of the successes of the PPP, she concluded.

University of Texas Health San Antonio

Ronald Stewart, chair of the Department of Surgery at the University of Texas Health San Antonio, echoed Lien’s comments, saying that his coalition, Southwest Texas Regional Advisory Council (STRAC), played a very similar role in their region. “We come at this from the trauma system point of view,” he said, “and it’s become very clear in my experience that cooperation and communication save lives.” In any wide-scale event, acute health care and EMS have to integrate and work with public health, all within the emergency management system. As an analogy, he said, we are missing a central nervous system with respect to disaster response—missing the neural network that provides situational awareness and allows communication and quick exchange of resources where needed.

Arizona Department of Health Services

Lisa Villarroel, medical director for the Division of Preparedness at the Arizona Department of Health Services, presented the Arizona Surge

Line, which is the statewide transfer system for COVID-19 patients. It was created to balance the patient load at hospitals and postpone hospital use of crisis standards of care and expedite transfers. It was designed, funded, and administered by the state health department, she explained, and it worked with a hospital steering committee comprising public, private, federal, county, and tribal representatives. They partnered with the Health Information Exchange to create a real-time statewide bed board, and it ran continuously for 2 years during the pandemic, successfully transferring nearly 10,000 patients to the right level of care.

Discussion

Bulger asked panelists to reflect on the strengths and weaknesses of PPPs. Harvey cited their strengths being built on the day-to-day system. There were several successful MOCCs that stood up during the pandemic that were built on foundational relationships and did not need to go out and meet their partners for the first time. But there were also a number of challenges, she continued. It can be really difficult in some areas to get competitors to come to the table and work together. Some regions have struggled to develop coalitions even since the guidance came out in 2012, and they are now the same ones saying they would never be able to operate an MOCC.

She also recounted difficulties in information sharing early in the pandemic but noted that once the Centers for Medicare & Medicaid Services (CMS) made information sharing conditional to receiving COVID-19 funding, information started to come forward very quickly. So CMS carries the proverbial stick, she said, but it has still been difficult to get CMS to partner and understand that it can have such an influence in fostering the information sharing and rotation of patients in a region. Lastly, she noted malpractice laws as a challenge as well. For many MOCCs that activated within a health department rather than being based out of a hospital where the clinician was already provided coverage through their malpractice insurance, there was concern that if the lead clinician prioritized patients in a way that people did not agree with, they could be sued. These are just a few areas that need to be solved before the next major crisis so these PPPs can continue to be developed, Harvey said.

Lien added that the hospital preparedness program investments over the past decade or more have built and fostered PPPs in a way that has created the relationships and given time to build trust, and we really need to recognize that it takes time and resources to sustain and cultivate these models. She also highlighted PPPs as a great space for innovation. In her experience in Washington State, even early in the pandemic they realized their tools for situational awareness and capacity were going to be insuf-

ficient for the demand. To address this, they worked with Microsoft and developed a local prototype that was eventually expanded to a statewide tool, and created new solutions for crisis standards of care, building on clinical relationships. Lastly, Lien brought up the policy environment and framework needed for the desired outcomes, calling for better alignment between policy at the federal and state level with what coalitions and health care institutions are trying to achieve operationally.

Stewart added that the biggest success in his experience is people working together in the region across disciplines, organizations, and geography. He offered four principles that, if adhered to, can guide a coalition or coordination center to success. First, be maximally inclusive of all stakeholders, so all are involved in decision making and problem solving. Next, intentionally focus the dialogue on what is the right thing for the patient or population. Then commit to making decisions by consensus and have cooperation and communication values embedded into systems to facilitate communication. Finally, have a bias for action, and do not default to waiting for more information. Villarroel added the principle of transparency to her list as well. For the Arizona Surge Line, she shared that PPPs really had an effect in implementation and innovation. But in terms of weaknesses, she cautioned that relying exclusively on collaboration in partnerships can be insufficient, especially as the situation worsened in some places and went on for longer periods than many had hoped.

When asked about strategies to encourage private-sector participation, Stewart said that having the structure of a 501(c)(3) that is regionally based with a set of standards can allow for interfacing with government but still let the entity be more entrepreneurial. He suggested a national trauma and emergency preparedness system that functions in this way. He also emphasized the importance of being a trusted neutral party. Villarroel added that through the Arizona Surge Line, they did mandate participation through a governor’s executive order and learned some key strategies. First, she said, align with the values of the partners, including financial drivers. Second, provide data requested as quickly as possible. They found nearly every tense situation in the state was ended by rapidly providing those hospitals with the relevant data. Third, they realized that they really needed a conflict resolution pathway in place. As the pandemic progressed there were times when there was a lack of consensus between systems, and it was unclear who held final decision-making power.

Harvey commented that given the competitive nature of partners involved in a health care coalition, there is a need to provide value to those members, even on a day-to-day basis. She also highlighted the challenge in incentivizing data sharing among competitive partners, saying there have been some great initiatives to do this better. The same data being used by technology companies, taken from large health systems

and repackaging it in an anonymized fashion to enable faster research, can also be used for situational awareness, she said. That in itself could bring people to the table, combining research and emergency preparedness in one platform.

Lien also noted that they saw significant challenges in long-term care during the surge response and had the opportunity to adapt some of the data collection to better characterize discharge dispositions. During the peak of the Omicron variant surge in western Washington, where there are 7,000 to 8,000 staffed beds, more than 1,000 of them were occupied by patients who were medically cleared for discharge but had no place to go, she said. To really work on fixing the system, we need to be more deliberate about bringing in the postacute care environment and relevant stakeholders. Lien also offered another strategy to engage private-sector companies rather than getting CMS or others to mandate participation. She suggested aligning to a shared vision and having consistency across a federal grant. Across all relevant agencies, within grants and funding awards, there are different ways of referring to participation, or coalitions, or different organizations assigned to be coordinators, and without that consistency at the federal level it is difficult to get more buy-in at the local level.

In response to a question about using the MOCC model as an instrument for equity, Villarroel replied that the Arizona Surge Line was an equity-enhancing initiative. First, she explained, it removed insurance as a barrier through the executive order. Second, it disproportionately benefited the smaller rural hospitals in the state. Sixty-four percent of patients came from rural facilities, she noted. More than 70 percent of patients coming in through the Arizona Surge Line actually came from a zip code in the highest social vulnerability indices. Now that the rural hospitals have seen how this process can be done, they are trying to set up a permanent rural transfer system for all patients, not just COVID-19 patients. Bulger agreed that without this type of system in place, rural communities are severely disadvantaged.

Stewart added that Texas and Arizona are doing similar things with respect to mental health. Most patients in a mental health crisis are either going to jail or an emergency department, he said. But working through the regional medical operations center, they are able to get the patient reliably taken to a mental health treatment facility initially, which is beneficial for the family and removes the burden from the emergency department.

John Armstrong, division director of the University of South Florida Morsani College of Medicine and member of the American College of Surgeons Committee on Trauma, said the concept of an MOCC makes sense, but he asked how supporters can encourage states to get on board and create them so more states can activate these critical centers. Lien responded that there needs to be more storytelling and sharing of the suc-

cesses of the MOCCs that have been activated. She also suggested embedding this concept not only in disaster spaces but in the professional societies and other environments to broaden the scope and audience. Harvey added that the last 2 decades have demonstrated that you cannot grant fund your way to preparedness, but the hospital preparedness program is revising its capabilities in the next year, and it should really focus on how to figure out load balancing of patients. Previous hospital preparedness program capabilities may have been too prescriptive, she added, so instead of prescribing a coalition, an alternative is to simply tell the state recipients to figure out the best way to achieve the function, whatever form it may take.

Revisiting the conversation on postacute care, a participant asked how to include those facilities in these coalitions to ensure that patients are evenly distributed when being discharged. Harvey replied that in her previous experience in a health system they were often backed up—even prior to the pandemic—because no one knew where there was a nursing home bed available. So when talking about how to bring value to partners through coalitions, she said, there is value in knowing where the nursing home beds are available. Bringing in long-term care facilities would aid in this awareness and could provide value for all members.

Lien commented that some of the long-term care facilities are in far worse condition than hospitals. She advocated for investing in that system and building one that is set up for success from a policy, resource, and regulatory perspective. Villarroel added that they created something called the Postacute Care Capacity Tracker as an adjunct to the Arizona Surge Line, which was a web portal where all the care coordinators from every hospital in the state could see where postacute care beds were available. Those data were provided on a daily basis by postacute care facilities through a mandate from an executive order. This was rapidly done at low cost and was very well received, she noted. But it ended when the state of emergency ended, so now hospitals are asking for that same level of visibility on a day-to-day basis.

LEADERSHIP

Michael Fraser, chief executive officer at the Association of State and Territorial Health Officials, introduced the discussion inviting panelists from the state legislature, as well as state and county health departments, to comment on their role in the pandemic, and whether people have leadership in their plans, or if it is just an assumption that those who are responding become the default leaders. Panelists also provided insights on communication challenges and whether the pandemic became a failure of leadership.

Alaska Department of Health and Social Services

Anne Zink, chief medical officer for the state of Alaska, said that her role at the state level is balanced by her work as a practicing emergency medicine physician, so she is able to see the problems from very different levels. She first learned about the pandemic when her predecessor got a call and told her things could get very bad. While people talk about how public health should not be political, she said, that is very difficult as governmental public health is inherently political. Public health only becomes problematic when it is partisan, Zink added, which is what happened during the pandemic. “I think we do harm in leadership when we do not recognize both sides and the political nature of policies and public health,” she said. Throughout the pandemic she wished for people to understand laws and the constitution, as well as denominators.

States run things differently because of the way they are set up. For example, Alaska is a home rule state. In Alaska they declared crisis standards of care not because they used that specific guidance, but because there was no public health emergency order within the state constitution, and they only had disaster declarations. To provide liability protection for clinicians they had to declare crisis standards of care. There is also a huge divide between public health and health care, she noted, and those sectors need to be brought together. Further, leadership needs better two-way communication. In Alaska they set up a two-way Zoom meeting every week to get questions from the public and to share information back, and even now in 2022, she said, there are hundreds of people who still show up and ask questions. Finally, she commented on tribal health and the 229 tribes in Alaska, who set themselves up into coalitions and have been one of the strongest allies of the state because of the way they have partnered.

Washington State Health Department

Umair Shah, secretary of health at the Washington State Health Department, said he had been a practicing emergency department physician in Houston, Texas, and was also on the front lines as the executive director for Harris County Public Health, just outside Houston. As the pandemic emerged, he was on the front lines fighting the virus, while also sometimes fighting politics and what was happening at state and local levels in Texas. Five days after vaccines arrived in the state of Washington, he transitioned to his new role in a new state. In public health, we have the problem of an invisibility crisis, he explained, and when we do our jobs well nothing happens, which makes it difficult to understand the value proposition. To address this, Shah offered the three Vs: increasing visibility of public health, which leads to people seeing value, and then people are able to validate the

work. But he never realized the fourth V of violence toward public health officials that has occurred over the past few years.

He and Zink are both active on Twitter but are often vilified for the work they are trying to do. Our public health officials and leadership have not been given the tools to understand how to speak the language of the people we are trying to reach, he said. Our biggest challenge is that when we as providers divorce ourselves from the patient or the community, then they do not see us as part of the conversation, Shah continued. That connection has been lost, but that is what leadership is about, trying to find a way for public health leaders to be part of the community so they can increase trust moving forward.

Oklahoma City County Health Department

Phil Maytubby, deputy chief executive officer of the Oklahoma City County Health Department, said that when the pandemic started he was the chief operating officer at the health department and the deputy incident commander for its response. He described his role early on in the pandemic when his team started seeing some cases in Oklahoma related to travel directly to Wuhan and to Washington State. A defining moment for Maytubby was on March 11, 2020, during a basketball game, when a basketball player tested positive for COVID-19 right when the game was about to start. Maytubby’s medical team swabbed all of the staff at the game that were not yet tested, and then the entire health department spent the night figuring out what to do next. They knew communication was going to be really important from the outset of the pandemic, so they spent a lot of time crafting a strategy, he said. Each morning they would have a hot wash of current science, data statistics, news updates, and political reports, working from morning to night each day. “We chose to lead though and not follow,” he acknowledged, and because of that, we started getting threats at the local level. They were chased out of meetings but were resolute in their efforts and had the support of elected officials. But his biggest lesson was that if you do not already have trust going into an emergency like this, there will be trouble.

San Francisco Department of Health

As an emergency department physician, Andrea Tenner, director of Public Health Emergency Preparedness and Response at the San Francisco Department of Public Health, recalled the initial fear of frontline workers when the pandemic began in the United States, and there was a lot of concern that if workers stopped coming in they would not be able to serve the community. She strongly emphasized the need to support workers and

those in essential positions. But the hardest piece of leadership at any level in a crisis like this is threading the needle between showing your humanity, acknowledging what people are going through, and showing confidence and reassuring the public. There is a difference between confidence and certainty, she noted, which is hard for people to process, but an important piece to learn. It is reassuring for people to know what you are doing, that you are in it together, and someone is working on the problem, even if there is no certainty in outcomes.

Massachusetts State Legislature

Bill Driscoll, Massachusetts state representative and chair of the Joint Committee on COVID-19 and Emergency Preparedness and Management, explained that prior to being elected in 2016 he had spent 11 years in disaster response and recovery with nonprofits, especially through the National Volunteer Organizations Active in Disaster. He was notified of the pandemic beginning on Twitter, following reports out of China. He started talking about it in the House of Representatives and tried to socialize the conversation about things being shut down and what that might mean. They started a working group within the House and found a template for a continuity of operations plan for the state of Massachusetts, asking if there was already one developed. That was the last time they met in person for over a year, he remarked. As a part of the working group quickly set up in March 2020, he brought in the National Preparedness Leadership Initiative to talk about how to speak confidently and lead. He also echoed the importance of two-way communication, so there is trust already built.

Discussion

Fraser asked about challenges for leaders in crisis and emergency risk communication and how panelists managed such challenges. One of the things that was not mentioned when crisis standards of care language and guidance first came out around 2009–2010, said Shah, is that decisions will be made that will seem like “irrational behavior.” The vast majority of decision makers will have good intentions, he continued, but their views may be diametrically opposed to those of others, and they may hold on dearly to their principles. This makes it difficult to have a dialogue when it is really a debate, or even two sides screaming at each other. This was the biggest challenge he encountered because it made it harder for everyone to do their jobs.

Maytubby commented that things need to be done smarter now. In Oklahoma City, they surveyed their population before and after the vaccine

campaign, working with social media and influencers choosing specific key words, and they found the word vaccinate to be very negative. However, using the word choose helped the campaign become more positive. So just that small difference likely had an effect on thousands in their population deciding to get the vaccine, he said.

Zink commented that in health care over the last few decades, the sector has moved to more of a shared decision-making model with patients, but public health has not yet made that shift. But in order to do that, she said, you need information that can be shared, and make sure it can be understood by individuals and how it applies to them. Different regions and cultures will also lean on different leaders. For example, she said a community in northern Alaska relies on their whaling captains for decision making and guidance. So the health department started meeting with them to answer questions and share information. They also changed the wording in those places from masks to breath catchers, and that made a difference for the people wearing them. The last thing she wanted to highlight was inequity, and she argued for more investment in understanding historical and structural inequities that lead to people lacking trust in government and messaging.

Driscoll added that an important addition to follow being first, right, and credible when messaging should include empathy, respect, and providing actions to take. But the context is so important and being first may not even be possible in the age of information. Tenner also noted, related to the idea of irrational behavior, that every time she thought someone was making an irrational decision, it was actually very rational, and they had just come from a different starting point than she had. As humans, we make rational decisions and follow a linear train of thought, she said, but when starting from a different truth or belief, those trains can diverge very quickly. Improving the ability to understand where people are coming from can be a key facet of managing the wildly divergent opinions.

Reflecting on leadership, Zink said she struggles with the idea that COVID-19 has been a failure of leadership. People have put their heart and soul into this response, she said, with so much money spent at so many levels, but at the same time more than 1 million Americans have died. She shared frustration that so many people are talking about the next pandemic, when her next shift in the emergency department will include missing supplies, mothers needing formula, and overloaded behavioral health patients with nowhere to go. “Our system had failed prior to this point,” she said, “we are just recognizing it now because of the pandemic.”

There are two ways to end a pandemic, said Shah—transactional and transformational. With the first, he said, we simply acknowledge that we got through 2 years, did a good job, and move on to the next headline. The other option is to look back at the last 2 years and think about the chal-

lenges and inequities and address them to transform the system. Lastly, he concluded, “we cannot go alone in this effort, and yet we are losing people every day in this field but simultaneously need to think about what the future looks like for the workforce. We have an opportunity to be transformational here, but I worry it’s slipping through our fingers.” Maytubby agreed that there has not been a failure of leadership, but if there is no follow-up and fixing of the processes and funding, that will be the failure. Additionally, he continued, all leaders need to be better prepared.

Tenner agreed with much of the discussion and noted the systemic nature of the things that failed or could have been improved. Many of the successes that did occur were often attributable to exceptional leaders who were transformational, she said. They were inspiring and brought out the mission to people, but this can only be sustained for so long. Driscoll added that in Massachusetts from a governance perspective, they held a listening tour with the legislative committee and tried to solicit feedback from health professionals, hospitals, and elected leaders. They often heard that there were preparedness budgets but not response budgets, so it was difficult to decentralize the top-down command for decisions to be made more locally. While response plans are going to change, he said, they need to be transparent and well communicated with the best information at the time.

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