Why Two Decades of Pandemic Planning Failed
At the commencement of the 2020 coronavirus pandemic, the United States government flailed and then failed in its attempt to respond to the crisis. Americans couldn’t help but ask why the government didn’t have a plan for this situation, a situation that was not only predictable, but which many scientists and public officials had predicted numerous times.¹
The truth is the government had a plan. Most commentators forgot that just six months before the current outbreak, Congress passed the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019, which offered funds and planning authority for just such a crisis as we now face.² This act was a reauthorization and an extension of half a dozen similar acts passed over the previous two decades, which acts were themselves extended in countless congressional spending bills, all of which resulted in countless plans.
By the time the virus broke on American shores, the problem was not that the United States didn’t have a single plan for an international pandemic. The problem was it had dozens of plans, totaling thousands of pages, issued by different agencies and by different administrations, apparently with little thought to how they would be combined or who would implement them. In the process of mandating all of these plans, the government had also created an array of competing and often contradictory authorities in different bureaucracies, which often worked at cross-purposes.
The failure of the United States government to respond to the coronavirus was not a failure of foresight. It was a failure to create a coherent strategy and to provide clear lines of authority to implement it. To prepare for the next pandemic, we need to end our current proliferation of planning mandates and overlapping agency authorities (such as that of the Assistant Secretary for Response and Preparedness), strengthen the pandemic response ability of one agency (preferably the Centers for Disease Control and Prevention), and reform our current National Emergency Act to allow clear delegation of emergency power. Only by examining our current failures and rectifying them, most importantly, by combining authority, responsibility, and accountability in the right hands, can we make sure that our next Pandemic Preparedness Act is not an embarrassment to its name.
Pervasive Pandemic Preparedness Planning
After the avian influenza scare of 2005, Congress did the thing it does best, demand that somebody else come up with a plan. With the help of some of the best known names in politics, Congress passed the Pandemic Preparedness and Response Act in December of the following year.³ The act ordered the administration to convene a Pandemic Influenza Preparedness Policy Coordinating Committee, with most of the Cabinet in attendance, to write a plan for a biological catastrophe.⁴ The result was, first, a White House Homeland Security Council National Strategy for Pandemic Influenza, followed the next year by National Strategy for Pandemic Influenza Implementation Plan. The latter plan contained 233 pages of nebulous suggestions, such as recommending that, in a crisis, the government should be “providing anticipatory guidance and dispelling unrealistic expectations about the delivery of health and medical care.”⁵ These general plans in turn birthed numerous individual departments plan, such as the Department of Defense Implementation Plan for Pandemic Influenza.⁶ To supplement these federal plans, the Preparedness Act, and its subsequent iterations, also mandated that states create their own Pandemic Preparedness Plans, which have to be submitted regularly to the Centers for Disease Control and Prevention for approval. These plans total thousands of pages.⁷
Even before the 2006 act passed, however, the Department of Health and Human Services decided to issue its own Pandemic Influenza Plan, in 2005, and it issued one again 2009, and again in 2017, with similar vague exhortations. The subsequent versions of the plan contain no discussion of the National Strategies upon which the coordinating committees labored so diligently.⁸
These specific pandemic plans, usually focused on influenza, but with ramifications beyond it, are only a fraction of the government’s plans for biological crises. After 9/11, the government began writing regular National Response Frameworks, published by the Department of Homeland Security, on how to deal with any national emergency, including a biological attack or pandemic. (Any doubts about the Framework’s importance are dispelled by the opening of one such plan, which introduces the reader to “This important document.”)⁹ As the most recent Response Framework claims, it is “composed of a base document, Emergency Support Function (ESF) Annexes, Support Annexes, and Incident Annexes.” One of those supporting annexes is the Response Federal Agency Interagency Operational Plan, which says it “builds upon” on the National Response Framework in planning to respond to an emergency, but is mainly just a longer version of the Framework.¹⁰ Another of the annexes birthed from the Framework was, of course, a specific Biological Incident Annex.¹¹ The Annex claims that it “serves as the Federal organizing framework for responding and recovering from a range of biological threats,” although what the other plans do is therefore made unclear.¹²
To further add to the confusion, the Department of Health and Human Services (HHS), apparently on its own initiative, created a National Health Security Strategy for the United States in 2009, with updates in 2015 and 2019, describing responses to pandemic and infectious disease outbreaks. Surprisingly, the plan contains no reference to the hundreds of pages of pandemic planning from other departments, or even from other plans written by HHS itself.¹³
The HHS National Health Security Strategy was an annex of sorts to the more comprehensive National Security Strategy, issued by the White House National Security Council, which itself also includes plans to deal with an epidemic, and demands the government “detect and contain biothreats at their source.”¹⁴ But the White House also issued numerous specific plans to deal with biological threats outside of the so-called NHSS and the NSS. As a sampling, there was the 2006 Homeland Security Presidential Directive-10, “Biodefense for the 21st Century,” and the 2009 National Strategy for Countering Biological Threats (featuring the peerless “Objective Seven,” which demanded that the government “Transform the international dialogue on biological threats”) and the 2016 National Security Council’s Playbook for Early Response to High-Consequence Infectious Disease.¹⁵ In the National Defense Authorization Act of 2017, Congress mandated that the White House convene a group of interagency officials to write a specific National Biodefense Strategy, which was released to understandably little fanfare the following year. The strategy offers such inimitable insights as “Biological Threats Originate from Multiple Sources,” including “naturally occurring outbreaks.” Its relation to previous pandemic plans is not clear, since none of them are cited.¹⁶
The United States has also made league with international organizations in creating new plans. In 2005, the U.S. and the World Health Organization encouraged all WHO member nations to create their own pandemic response plans.¹⁷ One might imagine that the innumerable plans already issued by the United States would satisfy this requirement. Instead, the US Assistant Secretary for Preparedness and Response at HHS created a United States Health Security National Action Plan, which at least admits it “derives from, maintains alignment with, underscores, and supports the goals and implementation plans of other federal statutory and policy obligations, including the United States’ National Security Strategy, the National Health Security Strategy (NHSS), the National Biodefense Strategy (NBS), and other important federal initiatives and partnerships.”¹⁸ It also notes that the Plan was a supplement of sorts to North American Plan for Animal and Pandemic Influenza, written with the help of the health administrations of Canada and Mexico, and released in 2007 and again 2012, whose details I will not bore you with.¹⁹
In summary, the acronyms for existing federal pandemic response plans include, but are not limited to, NSPI, NSPIIP, PIP, NRF, RFIOP, BIA, NHSNAP, NSS, NHSS, NBS, NAPAPI, along with assorted other incidents, annexes and iterations, to use the language favored by their authors.
Such a farrago of mismatched plans does have consequences. Because of the piles of unreadable PDFs, nobody can be held responsible to any of them, and different departments of government, with their own, often-contradictory plans, continue to work at cross-purposes. When Politico noted that the Trump administration was not following the National Security Council’s Playbook for Early Response to High-Consequence Infectious Disease, the administration responded that they weren’t working with that plan anymore, but with some combination of the Biological Incident Annex to the National Response Framework, the Biodefense Strategy, and something called the Pandemic Crisis Action Plan (or PanCAP), whose provenance and even existence outside of this discussion I have not been able to discover.²⁰ Inevitably, the Trump administration has now written its own hundred-plus page plan specifically for the COVID-19 pandemic. After decades of pandemic planning for just such a crisis, only one previous plan is even referenced in it.²¹
Who’s in Charge?
Another question not infrequently asked during the crisis is, who is supposed to be in charge of the response? It may surprise the reader to know that, at least according to the 2006 Pandemic Preparedness Act, someone named Robert Kadlec, the Assistant Secretary for Pandemic Preparedness and Response, is supposed to “coordinate the Federal interagency response to a pandemic.”²² Kadlec seems like a qualified individual. He spent 20 years as an Air Force physician, and was a staff director of a subcommittee on bioterrorism in the Senate, and a director of biodefense on Homeland Security Council from 2002 to 2005, before becoming special assistant to the President from 2007 to 2009.²³ His name, or even existence, however, may surprise the public, because they haven’t heard a word from him in the three weeks since the HHS said they were delegating him to lead the response, at least at their own department, seemingly counter to the express words of the statute putting him in charge across all agencies.²⁴
But one can’t blame HHS for limiting the Assistant Secretary’s mandate, since other statutes give other agencies authority to coordinate pandemic response. The Centers for Disease Control and Prevention by its very title would seem to lead the response to a pandemic, and indeed, its empowering law says that “Congress finds that the Centers for Disease Control and Prevention has an essential role in defending against and combatting public health threats domestically and abroad,” so that the director should appropriately “maintain capabilities related to bioterrorism and other public health emergencies, sufficient to enable such Centers to conduct this important mission.”²⁵ Thus, Robert Redfield, the CDC’s director and a former professor at the University of Maryland, would seem to be in charge as well.²⁶ The CDC contains a Division of Global Migration and Quarantine, with authority to implement quarantines and stop the spread of diseases, and a National Center for Emerging and Zoonotic Infectious Diseases (affectionally called by no one the NCEZID).²⁷ But how these agencies relate to other agencies is not clear.²⁸
The job of quarantining and controlling such diseases is further muddied because Congress has also given such authority to the Surgeon General of the United States, now occupied by Jerome Adams, a former assistant professor of anesthesiology at Indiana University and Indiana State Health Commissioner. Adams oversees the Public Health Service, whose originating law gives him authority to “make and enforce such regulations as in his judgment are necessary to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession.” How this authority squares with those of the CDC or other agencies is not clear.²⁹
The Assistant Secretary for Preparedness and Response, the CDC Director, and the Surgeon General all serve in the Department of Health and Human Services. And thus the Secretary of HHS, now Alex Azar, a former Deputy Secretary of HHS during the Bush administration, should clearly have some authority. In fact, according to law, he seems to have all of it. As one HHS website declares, “The Secretary of the Department of Health and Human Services has statutory responsibility for preventing the introduction, transmission, and spread of communicable diseases in the United States.” Some of this he has delegated to CDC and their Division of Global Migration and Quarantine, but it is not clear how that fits with statutory authority carried by the Surgeon General and Assistant Secretary for Preparedness or other agencies.³⁰
There are other agencies outside of HHS which are also supposed to lead the response to a pandemic. The Federal Emergency Management Agency would seem to be the lead responder, since, in FEMA’s own words, the agency was created due to a “lack of coordination [in emergency situations] and the fact that, at the Federal level, no single entity was responsible for coordinating Federal response and recovery efforts during large-scale disasters and emergencies.”³¹ So today, FEMA, led by Administrator Peter Gaynor, who was director of the Providence and then Rhode Island emergency management agencies, says it “coordinates the federal government’s role in preparing for, preventing, mitigating the effects of, responding to, and recovering from all domestic disasters, whether natural or man-made.”³² How it is supposed to enforce this coordination with the other agencies is not clear.
Besides those agencies given direct emergency authority, many others seem to have a crucial job in disease response, but their authority is not integrated with other disaster response “coordinators.” The Food and Drug Administration, under Steven Hahn, former head of the University of Texas MD Anderson Cancer Center, has significant power to approve drugs and tests that deal with a disease outbreak.³³ The National Institute of Allergy and Infectious Diseases, under Anthony Fauci, former recipient of the Presidential Medal of Freedom in 2008 for his role in combating the AIDs epidemic, has a role in sponsoring the research into new cures and responses to epidemics.³⁴ Other agencies also have claimed and appear to have some authority in responding to infectious diseases, as well as planning for them, including the Department of Defense and the Department of Homeland Security.³⁵ For the reader’s sake, I will not got into such seeming tertiary organizations as the National Pandemic Influenza Economics Advisory Committee. (This committee has apparently not met in years.)³⁶
The White House itself is supposed to organize disaster response under the National Security Council, and it is not surprising that in this case it has also created a Coronavirus Task Force, composed of most major members of the US Cabinet and other officials, although the task force surprisingly excludes many officials the law themselves designated as “coordinators,” such as the Assistant Secretary of Preparedness and the FEMA Administrator. The newly created “response coordinator” for the task force is Deborah Birx, the US Global AIDS Coordinator under the past two presidents, although exactly what authority she has to “coordinate” with other departments is also not clear.³⁷
To summarize, the acronyms of those agencies that are supposed to organize a response to a communicable disease crisis include, but are not limited to, the ASPR, CDC, DGMQ, NCEZID, USSG, HHS, FEMA, FDA, NIAID, DOD, DHS, NSC, CTF, and associated sub-agencies and divisions and offices. Inside these agencies, there are dozens of intelligent and accomplished individuals, often from bipartisan or civil service backgrounds, who are supposed to lead in a crisis. The problem is that those people have no clear lines of authority about who is supposed to coordinate them or be in charge, and no clear plan to follow even if such authority were provided.
A Failure of Government and A Partial Solution
The haphazard, confused, and contradictory response of the US government to the coronavirus pandemic perfectly illustrates what political scientist Steven Teles calls our “kludgeocracy.”³⁸ Since the United States government, unlike the parliamentary governments of many other developed nations, does not have a unified system of executive and legislative control, its reforms tended to be more slow and sporadic. Our relative slowness in changing policy is one of the geniuses of American government, in that it ensures policy changes are enacted more deliberately, and with more broad-based support, than other nations’. But there are costs beyond mere sluggishness. The fact that the US government also has a proliferation of “veto-points,” from congressional committees to agency regulators to judges to presidential task forces, means most new policies are awkward “kludges,” or fixes layered on top of more pervasive problems. Many new policies, such as Pandemic Preparedness Act, just layer new agencies on top of old, or demand more of what has been called the kudzu of bureaucracy, interagency committees. Such fixes often further exacerbate the existing confusion, and lead to new awkward kludges and more problems, such as the proliferation of coordinators without clear authority, who in fact create more veto-points preventing action.³⁹ The proliferating bureaucracies, in turn, lead to an increasing desire to enlarge the powers of the presidency itself to corral competing fiefdoms. The failures of such a habit in the present crisis are too obvious to require elaboration.
Despite these structural problems, the question remains, are there potential solutions in preparing for the next, inevitable, crisis? Absent a radical change of our system of government, which would neither be warranted or wise, there are limits to what we can accomplish. Nothing would be more futile than to demand a new true plan for responding to a viral outbreak, and a new true coordinator to organize it. This would only create something like the Director of National Intelligence, which Congress created in the wake of 9/11 to synchronize the work of proliferating intelligence agencies, but which has had little authority and less power in the subsequent years. It has only added one more layer of bureaucracy to many.⁴⁰
The first recommendation to Congress in trying to prepare for the next crisis is simple: Do No Harm. They should not respond to the coronavirus by creating one more administrator or director or interagency committee to organize pandemic response. Whatever one thinks of our existing agencies, there are great reservoirs of talent and expertise in them that can be brought to bear with the right direction.
If anything, consolidating existing agencies, or even eliminating many positions, would be more productive. The Assistant Secretary of Preparedness and Response has proven to be a paper tiger, without authority across different agencies and without a voice in the executive offices. It should be eliminated. HHS’s pandemic response should be taken away from both the Assistant Secretary and the Surgeon General and should be centralized in the CDC.⁴¹ If anything, outside agencies like FEMA should be forced to defer to the CDC in a biological crisis, while the CDC’s more research-oriented activities would best be hived off into the National Institutes of Health, which are nimbler in producing innovative breakthroughs. Philip Howard’s group Common Good has long advocated combining public authority and responsibility in a handful of clearly-defined positions, and we should heed them now.⁴² Fewer bureaucracies with more consistent lines of authority would create the accountability we need in a crisis.
Congress also should not respond to the coronavirus by mandating any more plans. While generic planning can be a productive exercise, as Helmuth von Moltke said over a century ago, “No plan survives first contact with the enemy.” As we also learned from the most extensive economic planning exercises of the 20th century, the “Five Year Plans” created by many developing nations, conditions on the ground are inevitably changed by the time the plan itself is finished.⁴³
Instead of plans, disaster exercises, such as the Crimson Contagion pandemic response exercise run in 2016, at least require concrete decisions and steps, and demand analysis of potential failures and new avenues. Such exercises, at least if their lessons are heeded, offer better food for thought and create better institutional knowledge than one more unreadable plan.⁴⁴
Finally, Congress should look at amending the one act that is supposed to govern all national crises, the National Emergency Act of 1976. Right now, the act gives only limited authority to cut through existing rules and bureaucracies.⁴⁵ A renewed National Emergency Act, one which provided some ability to establish clear lines of authority for certain agencies and bureaucracies and override contradictory laws in a crisis, would improve our ability to respond to a pervasive disaster such as our current one. An amended emergency act should also separate the declaration of emergency from the exercise of power under it. Right now, the President both declares the national emergency and then wields emergency power. Instead, the President should have power to declare the emergency, but then, at least in in the case of a pandemic, that authority should be transferred to the CDC, which is best prepared to implement any presidential directive. As long as the CDC director is still answerable to the President, this reform would maintain political accountability, while removing concerns about power grabs in an emergency.⁴⁶
Finally, after this crisis we should continue to strengthen one of the existing assets of American democracy, our federal system. Although the overlapping authority of local, state, and federal governments would seem to be one more example of our “kludgeocracy,” America’s unparalleled decentralized system allows politicians and officials on the ground to respond to a crisis even when the federal government lags.⁴⁷ Although some cities and states have responded slowly, others acted with appropriate dispatch, and demonstrated the value of rapid action in curbing the worst effects of the pandemic.⁴⁸ We should remove any existing laws that preempt the state and local ability to respond in a crisis, and make sure national actions remain a floor, and not a ceiling, on action.⁴⁹ Differing state and local responses will demonstrate the value of the best policies and allow them to spread.
The sad truth is that the U.S. government did plan for just such a crisis as the one we now face. But we cannot count on planning to solve a future crisis. We need to simplify and clarify our federal bureaucracy so it can respond more nimbly to such a crisis in the future, even while we continue to rely on the wisdom of many thousands of Americans in state and local governments to lead.
Bill helps alleviate doctor shortage