by Mary Bryna Sanger, coauthor of After the Cure: Managing AIDS and Other Public Health Crises
When After the Cure was published, the nation was just recovering from numerous public health threats and crises. Now we find ourselves in the midst of a new and serious one with the emergence of the COVID-19 pandemic. Our experiences in both the policy and management levels and at the federal and local levels have proved uneven at best. Even in areas where the science and effective treatments are clear, public health success often eludes us, even when the stakes are high as they are with COVID-19. Large-scale public health initiatives are complicated, and managing their implementation requires skillful leadership in the face of competing political, organizational, and economic forces. But, as we found in our research, the obstacles to success are often knowable, and “strategic skepticism” of effective public managers can improve the odds.
The history of COVID-19 and the needless death and suffering experienced will surely be seen as a new reminder of what is needed to face these challenges head-on—and how leaders can plan. This will not be the last pandemic.
The lessons we identified in After the Cure bear careful attention today. And it is a failure to heed them that explains much of the chaos and fear we are observing. The COVID-19 crisis, despite its broad spread and massive economic impact, is not so different from many of the public health crises the United States has faced over the years. But the current environment of political denial, weak and uneven policy response, poor and confusing communication, and contentious intergovernmental relations are predictable and typical threats to effective response. They are, in many ways, challenges of management and competence more than they are failures of science or public health. As we analyzed the successes and failures of past efforts in previous US public health crises, we found that management played an outsized role in predicting outcomes. And several key dimensions of management appear crucial.
The lessons of our book seem more relevant today than ever. We considered the discovery and implementation of the polio vaccine initiative, the swine flu vaccine implementation program, reemerging multidrug resistant tuberculosis, the childhood immunization crisis, and the early responses to the AIDS epidemic. All of these efforts faced serious obstacles and challenges, and their successes or failures when they occurred were the result in large part of the quality and nature of executive management by government actors faced with responding to these crises. All major public health crises by their very nature pose a complex combination of social, political, economic, and governance challenges. Failure to identify these challenges and develop a plan to address them in advance explains much of the historical failure in government response to public health emergencies.
Many of the dimensions of the public management challenges we found most important in both the disastrous swine flu debacle and the success of the reemerging tuberculosis epidemic in New York City are key to understanding the COVID-19 story. We documented market failures for important medical supplies, political fights over the implications of scientific findings, the politicization of government research, interagency conflicts, tensions between the federal government and the states, coordination challenges, imperfect dissemination of information through the news media, and questions of distributional equity relating to treatment of different groups and communities. These are all too familiar to our current experience.
Effective responses in past crises featured actors who were able to anticipate and deal with each of these areas—in the case of the COVID-19 response, little or no attention was directed, in advance, to anticipating and developing plans to manage these areas. COVID-19 is not the first time that governments faced challenges with supply chains or disagreements between federal and state actors. But this crisis is remarkable for a lack of planning for how to resolve such inevitable challenges.
But as the pandemic rages on, it is not too late to learn lessons from the past.
Common solutions can be found through the study of historic public health cases. They are as meaningful now as they were then. The overarching lesson is to acknowledge and anticipate these dimensions of resistance and to plan for them. Creative anticipatory responses are needed and facing the challenges with initial skepticism and planning for contingencies is key. New York City’s health commissioner Margaret Hamburg faced multidrug resistant tuberculosis through a carefully orchestrated collaboration with numerous organizational and political stakeholders. She managed the conflict between client advocates and public health nurses who met their homeless patients daily to ensure the administration of directly observed therapy—a key determinant of success among a population spreading the disease. This is not unlike the need to plan for developing a corps of contact tracers to contain virus spread of COVID-19.
Arming executive managers with alternative responses in the face of obstacles takes preparation. Indeed, it requires a way of thinking: learning from the past and anticipating the future. Program design and implementation needs to anticipate what can go wrong and plan for it, such as by sourcing and distributing protective equipment, ventilators, and testing kits. Complex logistics with a global supply chain should have been anticipated and federal leadership to support the states could have provided rational distribution chains to where they were needed. Some of the demands on executive leadership are daunting, but not all of what is needed is rocket science. Some generic types of responses can be built in advance, as the childhood immunization crisis did through legislation that provided cost sharing and indemnification.
Executive management needs to embrace the inevitability of threats to success and approach the design and implementation role with strategic skepticism. Scenario-building is a powerful way to engage in this kind of thinking and planning. Stakeholder mapping, for example, helped in early AIDS response to identify and to plan for the opposition from conservative groups and the Christian coalition. The process helped public health officials neutralize their impact of aggressive early investments in treatments. While the threats of dangerous diseases face complex forces, some unique and idiosyncratic, there is a striking similarity in the obstacles that threaten to derail them. Anticipation can help. Sometimes merely envisioning negative consequences mobilizes ideas and resources to counter them in advance. What Albert Hirschman called “an action-arousing gloomy vision” can and does serve to galvanize executives about impending danger and thus produce strenuous effort to overcome it.
COVID-19 is a reminder of all that can go wrong without planning and executive leadership. Now is a time to revisit the lessons of the past, lest we are forced to repeat them.
Mary Bryna Sanger is professor of urban policy analysis and management and the Deputy Provost and SR. VP for Academic Affairs at the New School University. She is a coauthor of Making Government Work: How Entrepreneurial Executives Turn Bright Ideas into Real Results.