Nathan A. Paxton, Ph.D.
Senior Director, Global Biological Policy and Programs
Famines are not “natural disasters.” They are policy failures to manage the effects of a drought or a flood. Likewise, pandemics are not natural disasters—only policy failures to manage the effects of an infectious disease outbreak.
Economists and philosophers Amartya Sen and Jean Drèze helped shed light on this distinction three decades ago, raising awareness that most of the human effects of “natural disasters” are policy choices. Political and social decisions are at the heart of how adverse events affect societies. What we know is that the worst of disasters are avoidable.
In 2021, during the heart of the COVID-19 pandemic, the Covid Crisis Group (originally the Covid Commission Planning Group) was created by four foundations (Schmidt Futures, the Skoll Foundation, Stand Together, and The Rockefeller Foundation) to lay the foundation for a National Covid Commission. That national commission would have studied the American preparation and response to COVID-19, in similar fashion to the 9/11 Commission.
The CCG released a report in April—“Lessons from the COVID War”—that argues the upheaval that COVID caused in the United States was the result of basic failures in governance that were bipartisan in both origin and execution, and the fact that Americans have lost confidence in policy governance and problem-solving. While the CCG authors make some specific and action-oriented suggestions for reform, they could have more explicitly engaged with the vital question of the present: how we can use democratic collaboration to improve pandemic security.
(As a U.S. Senate staffer during the pandemic, I worked with members of the CCG’s previous iteration, the COVID Commission Planning Group, as we attempted to write and pass legislation to set up a 9/11 Commission-style study of the national response.)
As the pandemic began, the U.S. government and society lacked several technical features that would have vastly improved the country’s ability to respond. The problem was not intense, red-versus-blue polarization. Even more important to the next two years, the CCG authors argue, the United States lacked a purpose-designed, modern, public-health system. “The United States faced a twenty-first-century challenge with a system designed for nineteenth-century threats.”
The problem is not that our public health system is old but that the system lacks coherent organization to coordinate actions. There are about 2800 local public health departments in the United States. “Half report to a centralized board of health; half do not. Some have carve-outs and carve-ins, where animal health is excluded but environmental health is included, and vice versa. No two are the same.” [emphasis added] They vary too much in size, resources, and quality, and no entity oversees helping them to create or execute policy.
Executing—on policies, plans, or problem-solving—constitutes another lacking feature of the response to COVID in the United States. This is the “how people actually do the substantive public problem-solving” that allows for identifying problems, coming up with actions to solve them, evaluating and course-correcting on those actions, and remembering what was done. The CCG argues that the apogee of American problem-solving lay in a mid-20th century engineering-oriented business culture that extended to academia and government.
If we dig into some of the detailed indicators of the Global Health Security Index that NTI has previously produced in partnership with the Johns Hopkins University Center for Health Security and Economist Impact, we see evidence of this weakness. In 2021, the United States scored 25 out of 100 on whether a country is exercising its infectious disease outbreak plans—and this was in the middle of a pandemic. In terms of prevention, the United States’ score also fell quite considerably between 2019 and 2021 on the indicator that examines preparation for dealing with zoonotic diseases.
I should note that the GHS Index wasn’t designed to predict the specifics of a country’s response to a global health crisis. In the Index, we can measure the capacities of a country, but we are restricted to data that are publicly available or published and that we can collect for the 195 states-parties to the World Health Organization International Health Regulations. Like any other quantitative measure across 195 locations, the GHS Index has to transform some very detailed qualitative data to a numerical scale. In the case of the GHS Index, this is needed to make cross-sectional comparisons. The Index partners designed it to address national-level characteristics, and it does not look at the policies and solutions implemented on local or regional levels within a country. The Index does make its methodologies transparent and public so that those who wish to do subnational or local measures could implement their own.
The CCG report drills down on precisely the sort of questions that the GHS Index was not designed to address—questions of governance, “culture,” and how local, provincial, and national authorities interact and relate. By providing that subnational detail and texture, CCG’s report dovetails the work of the Index and drills down into the health security response of one country.
That said, I wish the CCG report had addressed one aspect of the pandemic response more clearly. The United States lacked pandemic and health security strength because the United States lacks democratic strength. It is necessary to increase democratic strength and functioning if we are to increase security for the next pandemic that we know will come. If we continue to lack democratic strength, we will not be able to gain pandemic security.
The “operational culture” that CCG says has been lost in American governance does not live only in government agencies or health authorities. It can be a democratic culture, rooted in applied, everyday customs of practice. Americans engineer forms of government and political compromises from the material at hand, with regard for “what works” rather than for consistency.
The CCG notes that the U.S. response to COVID was not uniformly awful: there were local responses in some cities and states (they highlight San Antonio, Texas and Massachusetts) that balanced the varied imperatives to prevent illness, preserve an economy, keep children in school, and so forth. Even when analyzing successes in testing, return to school, or crisis communication, the CCG weights a little heavily toward the side of engaging with experts and less about how to bring people into participation.
The greater success of democratic participation bubbles up every so often, most obviously in the section of the report on school closings. In San Antonio, local civic leaders and businesspeople provided funding for a robust school testing program; in Massachusetts, the Commonwealth provided the funding. In all cases where school testing efforts were successful, the CCG argues that the combination of voluntary participation, public-private partnerships, and community volunteers were key elements.
These successful approaches relied on a relatively broad concept of democratic involvement of the “people” as participants in decisions and actions, rather than as spectators or recipients of decisions. The CCG is largely correct in noting that partisan divides in the policy responses to COVID were less the cause of policy failure than the result of those failures. What opinion polls, news articles that talk to the denizens of small-town diners, and social science research all tell us is that many Americans want closer connections to the processes that mediate and govern their lives. Much of contemporary American governance, particularly at “higher” levels of government, reduces the citizen to observer.
Creating incident command structures, crisis response and communication training for officials, or a coherent health security structure—these depend on mobilizing people who are already highly skilled, trained, or invested in the pandemic security process. They may be necessary, but they are likely insufficient. It is not clear how this helps to create buy-in from people who are not already officials and policymakers. Such solutions are technocratic and even oligarchic. Unless we all work to find ways to make them more democratic, we will fail to achieve preparation for the next pandemic that will occur.
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