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March 31, 2020
Public Health COVID-19
Joshua M. Sharfstein
Sep 8, 2021
Apr 15, 2021
Back to The Milbank Quarterly Opinion
Since 2015, I have taught a course at the Johns Hopkins Bloomberg School of Public Health called Crisis and Response in Public Health Policy and Practice. For 2020, I chose to teach the course in the third term, from mid-January to mid-March. At our first session, I noted the reports of a new infectious disease in Wuhan, China. By the end of the term, the coronavirus pandemic had led the school to cancel in-person classes, leaving me to communicate with my students by videoconference.
The experience of teaching about crisis response in the middle of a national public health crisis provided a framework for understanding what was happening around us. The course divides crisis response into four main phases, each of which has become salient in recent days.
The first phase is recognizing the crisis. I teach that, while this awareness is critical for response, a wide range of biases often block understanding of the situation. Indeed, at first, local China leaders apparently hesitated to report cases, apparently waiting for the end of certain political meetings and leading to assurances to the world early in the course of the epidemic that matters were well in hand. Then, in Italy, political leaders pushed back against scientific warnings and downplayed the seriousness of the situation, leading many residents to continue their lives as usual.
Leadership in the United States did little better, relying on rosy projections and blithe assurances that the country was well protected. These messages undermined the potential for more aggressive early responses, such as reaching out to private industry to scale up coronavirus testing quickly as well as speed the manufacture of needed personal protective equipment, such as masks and face shields. The failure to appreciate the crisis also allowed large gatherings, like Mardi Gras in New Orleans, to continue, with major consequences weeks later.
The second phase is managing the crisis. In my course, as in my book, The Public Health Crisis Survival Guide: Leadership and Management in Trying Times, I emphasize the urgency of setting up an effective crisis management structure, which allows vital decisions to be made quickly.
Unfortunately, as my students noted, the federal government provided a master class in how not to manage a public health crisis. Reportedly, daily meetings stretched for hours without decisions. There also has been a lack of clarity about who is in charge, as well as a conspicuous absence of the Centers for Disease Control and Prevention (CDC), our nation’s leading public health agency in many of the proceedings. Moreover, the federal government has yet to take control of the supply chain for critical personal protective equipment and ventilators, leaving states and health systems to scramble for themselves.
Many states and cities have done much better, with several governors and mayors reorganizing their executive structures to support public communications, health system support, and an early public health response. In my course, I recommend the adoption of incident management systems, with clearly designated roles and responsibilities, a plan based on emerging data, and the ability to scale the response by adding liaisons to the federal government and private sector and by developing focused teams to achieve designated goals.
These new management structures are just beginning to be tested, as far greater capacity to suppress disease transmission is urgently needed. Local governments will need to embrace large public-private partnerships, bringing in new resources, such as housing for people who cannot isolate at home, while maintaining an organized response.
I describe the third phase of crisis management as communications and politics. The CDC has published a terrific guidebook on how to speak to the public during a public health crisis; however, to say that the guidebook still sits on the federal shelf would be an understatement. The CDC advises consistent messages from a small number of people who are expert in disease control, with politicians playing a secondary role of offering vision and support. My students could scarcely reconcile their required reading with what they were seeing on the news and in their social media feeds.
A theme in the course is that political considerations often threaten the success of crisis management. Every year, I welcome a guest lecturer, Jennifer Nuzzo from the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health. She walks the students through a global scenario, complete with made-up newscasts, of a broad biological event affecting multiple countries. Within hours, the countries resort to bickering, ignoring opportunities to collaborate to control the spread of the disease. Today, we’re seeing nationalistic considerations play out on the nightly news. President Trump appears at times to be picking partisan fights with Democratic governors, instead of using the tools of the federal government to mount the strongest possible response.
The fourth phase of crisis management in my course is the process of recovery, including taking steps to prevent the next crisis. We discuss the value—even in the middle of a vigorous response to an overwhelming crisis—of putting down markers for topics that will need further discussion later. Among them today: inadequate testing, not enough personal protective equipment or ventilators, insufficient ability to scale up hospital and ICU beds, and—perhaps most important—a weak public health infrastructure. As we make it through the worst of the coronavirus pandemic, there will be a window of opportunity to address these and other deficiencies before people begin to forget and return to other priorities.
Every year, I pick a historical crisis as the basis for the final exam. This year, I chose the topic of the moment, ripped from the headlines. The exam begins:
The date is January 1, 2020. As the lead for emergency preparedness at CDC, you were up late in the emergency operation center “just in case.” The only point of concern was a report that there might be a new respiratory disease in China. Could there be a virus that poses a global threat like SARS? Hard to say……but it’s your job to prepare.
The students wrote memos outlining the need for an urgent crisis response as quickly as possible, including vigorous testing capacity, scaling up public health efforts, and clear and consistent communications. They advised standing up a clear management structure to guide the national response. They suggested that the Department of Health and Human Services, the CDC, and the Food and Drug Administration should acknowledge the initial testing failures and emphasize everything that is being done now to fix the problem. They warned against letting narrow political considerations interfere with what needs to be done to protect the nation and the world.
Over Zoom during our last class, my students and I worked through some of the thornier issues in the crisis response and ended by resolving to keep in close touch. We have since set up an online discussion board, and we exchange messages frequently. Many have jumped in to volunteer in different response efforts through social services organizations, public health departments, and health systems. Their enthusiasm for the tools of crisis response gives me hope that a more robust public health sector will emerge from this catastrophe. Their careers and lives will never be the same. By teaching about crisis at this unprecedented moment, I can add: Nor will mine.
Joshua M. Sharfstein is associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. He served as secretary of the Maryland Department of Health and Mental Hygiene from 2011 to 2014, as principal deputy commissioner of the US Food and Drug Administration from 2009 to 2011, and as the commissioner of health in Baltimore, Maryland, from December 2005 to March 2009. From July 2001 to December 2005, Sharfstein served on the minority staff of the Committee on Government Reform of the US House of Representatives, working for Congressman Henry A. Waxman. He serves on the Board on Population Health and Public Health Practice of the Institute of Medicine and the editorial board of JAMA. He is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Medical Center and Boston Children’s Hospital, and a 2001 graduate of the fellowship program in general pediatrics at the Boston University School of Medicine.
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