FEBRUARY 2023

American Democracy and Pandemic Security

Strengthening the U.S. Pandemic Response in a Free Society

By the CSIS Global Health Policy Center, Brown University Pandemic Center, and COVID Collaborative

The Covid-19 pandemic imposed unprecedented challenges upon U.S. federal, state, and local officials, and it inspired important and lifesaving successes. Most disturbingly, the pandemic response in the United States featured stark failures in early rapid response, preparedness, execution, and messaging. Leadership was missing in key moments. Those failures eroded confidence not only in public health but also in the ability of leaders and institutions to make decisions that affected every sector of society. The pandemic magnified persistent inequities and exacerbated—and was exacerbated by—polarization, what many now view as a comorbidity that prevented a more unified and effective response. A limited tool kit too often left decisionmakers with blunt, binary, and divisive choices involving stark societal trade-offs: health versus the economy, online versus in-person education, locking down versus lifting restrictions, and individual freedom versus collective responsibility. Compounding the challenge were mixed and confusing messages about what institutions and Americans should do.

And yet, despite enormous challenges, the pandemic yielded important successes. The United States was a global leader in research and development that created multiple safe and effective Covid-19 vaccines and medicines. Government, clinical, and community leaders launched the largest vaccination program in modern history; private sector partners launched the largest public service announcement campaign in U.S. history; and collective efforts from trusted messengers and multiple sectors were ultimately able to vaccinate much of the U.S. population in record time. Targeted, community-based efforts helped narrow racial and ethnic disparities in vaccine uptake. U.S. communities demonstrated resilience in learning how to cope with overwhelmed health systems, shuttered schools and businesses, and restrictions on individual freedoms.

However, major inequities, deficiencies, and divisions remain in how people judge the legitimacy of community, state, and national responses to public health measures. These divisions continue to plague the ongoing Covid-19 response and will make it highly problematic and uncertain for the United States to respond quickly and effectively in future pandemics. In fact, one could argue that these divisions will make many Americans less willing to embrace measures to address serious public health threats in the future and could lead to a further general erosion in popular confidence in countermeasures such as vaccines, not only for Covid-19 but for other viruses such as measles, for which vaccination rates are declining. Now, entering year four of the pandemic, the United States faces the risk that these societal divisions will harden, becoming more permanent barriers to effective pandemic response and bipartisan action.

Going forward, a bipartisan approach is needed to protect public health and work to preserve individual freedom, drawing on the lived experiences of states and localities that did better at reducing deaths and hospitalizations while navigating impacts on education, the economy, and society. Such an effort will be mindful of the politics that have divided Americans during the Covid-19 response and will engage leaders and institutions reflecting the strength and pluralism of the United States to learn from the past and build a better future. A new, pragmatic consensus is needed that bridges deep divides and is fueled by candor, self-criticism, humility, a determined optimism, and civility. Mistakes stretch across every acre, as do quiet successes. Finding new solutions is the challenge. Below is a description of the first convening and major findings of the Democracy and Pandemic Security roundtable.

This document presents a summary of key themes that emerged during the discussion, but it does not necessarily represent unanimous consensus by the meeting participants.

On December 5, 2022, the Brown University School of Public Health Pandemic Center, the Center for Strategic and International Studies (CSIS) Global Health Policy Center, and the COVID Collaborative convened a senior-level roundtable on “Democracy and Pandemic Security.” The roundtable brought together a bipartisan cross-section of the nation’s top pandemic leaders, including state, local, and federal officials, as well as implementers who have served the nation amid numerous disasters (see below). The gathering of leaders and institutions focused on identifying solutions to better protect Americans from pandemic threats and reinforce American values of freedom and democracy. The discussion was divided into four parts: (1) where is the United States now, (2) how did the country

get here, (3) what worked or failed, and (4) what’s next. The group was candid and pragmatic in its assessment of how the nation arrived at this juncture—and how it can do better in the future.

The convening emerged with urgent imperatives to:

1. understand and transcend partisan divides to gain a better and deeper understanding of what worked at the state and local levels in responding to the Covid-19 pandemic and how these efforts interacted with the response system at the national level;

2. empower and engage with states and communities to better respond to public health threats with a more robust menu of pandemic security options that are operationally feasible, equitably protective, and aligned with community values; and

3. create stable, consistent mechanisms that are capable of bridging communities, sectors, and parties during biological crises.

Going forward, policymakers must demonstrate the validity of a bipartisan approach to objectively evaluate and reduce the impact of pandemics on society, harvest local learnings from Covid-19, and empower individuals, communities, and states to transcend partisan divides and improve their

response to future public health threats. Policymakers must prioritize state and community dialogues across the United States in red, blue, and purple states to identify models that worked; devise better tools and playbooks for community response to pandemic threats; and support the development of a bipartisan, multisectoral team that can build civic strength and bridge divides in advance of and during future biological crises. In this work, the group also will remain mindful of the indispensable role of the federal government in pandemic response and what worked and what failed in its response to Covid-19.

AMERICA MISSED THE MOMENT

Covid-19 cost the nation and the world millions of lives and trillions of dollars in economic losses and caused major societal deficits in learning, health, and well-being. The United States faced specific challenges in how its national pandemic response, rooted in its culture and federated system of public health, was organized and executed. As a leading democracy, the United States possessed assets, such as highly sophisticated science and technology traditions, which should have enabled the nation to launch a rapid response and deploy interventions with laser-like focus on managing infectious disease outbreaks and biological events. But while the United States possessed many strengths, the pandemic placed excessive stress on its healthcare system, and the United States had a higher death rate than comparable countries because of leadership failings, because it had insufficient tools in its arsenal of public health measures, and because it used those tools too ineffectively. The response failed to adequately address preexisting social and economic vulnerabilities—compounding the toll of the pandemic and undermining confidence and trust in public health recommendations. The willful absence of a strong, coherent, and trusted federal response early in the pandemic set a course for disorder and confusion that greatly exacerbated these challenges and fueled polarization.

A FAILURE OF LEADERSHIP, A LACK OF UNITY, AND A LOSS OF CONFIDENCE

National crises have historically brought the country together. Yet, the United States was unable to organize cohesive leadership at the national, state, local, and tribal levels, and it failed to rapidly unify its citizens to act in solidarity to suppress the emerging pandemic and overcome preexisting health and other social inequities that exacerbated the toll of the pandemic. This was compounded by a lack of data and a dearth of public engagement to inform community responses to the virus, poor messaging, and the use of blunt tools that ultimately were not well adapted for community realities.

The resulting lack of support for public health across the United States is occurring amid a decline in confidence in government, institutions, and democracy itself. Polling data show that while the country was initially united in its views of the pandemic, community support for the pandemic response eroded over time. These data also now show stark differences in views among Republicans and Democrats, as well as Americans of different races, ethnicities, and backgrounds, on pandemic control measures, such as masks and vaccinations, and trust in government health agencies. A culture of individualism, coupled with the erosion of a shared social contract, has led many Americans to resist public health safety measures. And in year four of the Covid-19 pandemic, with other ongoing health crises such as mpox, Ebola, seasonal influenza, and respiratory syncytial virus (RSV) also challenging U.S. national defenses, the United States faces a weary public and a beleaguered public health community. When the next biological threat emerges, it is unclear how, and whether, many Americans will trust and adhere to public health measures, including guidance on testing, masking, vaccination, and quarantine and isolation. That is an unaffordable threat to the country’s future.

WHAT WORKED, WHAT FAILED, AND HOW TO REPAIR AND REBUILD

Against this backdrop, the roundtable asked senior leaders to share their candid views on what worked, what failed, and what concrete next steps should be taken to repair and rebuild—so that the country emerges from the Covid-19 pandemic better prepared for the next threat that comes its way. Lack of clear guidance, community-focused tool kits, and well-communicated game plans plagued the U.S. response from the start of the pandemic. These were coupled with errors in decisionmaking from both elected and public health officials, as well as a proliferation of mis- and disinformation and fear. Taken together, these exacerbated a polarization of the Covid-19 response in the United States and challenged adherence and trust on key issues such as Covid-safe schools, masking on planes, testing in the workplace, and vaccine confidence and readiness. To better prepare the United States for a more unified and effective response to pandemic threats, and to do a more effective job at empowering the American people and U.S. institutions to make reasoned choices, it will be essential to tackle this underlying polarization, which itself became a comorbidity of Covid-19, and establish mechanisms to bridge divides during, and in advance of, biological crises.

Participants highlighted the following lessons:

• Understand what worked and empower those actions for states and communities closest to the challenge. The shock of federal abandonment in 2020 still lingers in the minds of state officials from both sides of the aisle. While federal leadership, competency, and commitment are indispensable and were highlighted by the group as vital for pandemic response, the group also emphasized that the U.S. federalist approach to public health requires vesting more ownership and flexibility for key decisions in those who are charged with making it work on the ground. These were the state and community leaders who frequently found ways to quietly right the ship during this pandemic. More must be done to empower communities by providing a larger menu of options for responding to pandemics that can be tailored to their specific needs and values and that provide feedback loops from the public to adjust the response over time. As one participant noted, “We need to demonstrate authority without being authoritarian.” Central to this is providing support and encouragement to leaders to engage with their communities and help define pandemic response approaches that are operationally feasible for communities and aligned with their values.

• Address equity head-on and listen to the perspectives of different populations. Participants raised the need to engage different populations early on to understand their perspectives, concerns, and how to engage most effectively. Participants highlighted, for example, the historical trauma in the Black community from the Tuskegee Syphilis Study on 400 Black Americans over five decades that needed to be addressed to build confidence in Covid-19 vaccines; the importance of messages from Latino officials; how rates of vaccination among Native Hawaiians and Pacific Islanders significantly lagged behind those of Asian Americans; and how Indigenous populations were among those most devastated early on in the pandemic and had much to teach other communities about how to build trust, empower local communities to lead, and expand distribution to reach the most vulnerable populations. In addition, participants highlighted major preexisting inequities as a significant factor in poor responses. As the pandemic progressed, it became clear that low-income communities and communities of color were disproportionately harmed by the virus. Lack of paid sick leave, adequate housing, and access to healthcare combined with systemic bias and low levels of trust contribute to these disproportionate impacts and undermine pandemic response efforts. Poor data, inadequate training for public health leaders, and lack of a unified public health infrastructure in the United States also contributed to local failures to tailor the pandemic response to address evident disparities. Equity was at the center of discussion and should remain central.

• Create options for pandemic response that balance impacts on health, education, economy, and society. An effective pandemic response requires more than following the science of public health. Participants noted that the science itself is often uncertain, and officeholders have to meld the “practical” with the science, weighing societal cost-benefit trade-offs and disparate social and economic contexts within communities. Federal and state authorities had limited tools that were sometimes viewed as blunt, binary, and divisive. There was no clear framework for leaders and communities to balance interventions based on the epidemiology of the disease and emerging science against social, economic, and political realities. This contributed to polarization.

• Provide better data for better decisionmaking. Participants emphasized that state and local officials did not always have access to all of the data and information necessary to make decisions. The lack of data interoperability was flagged as the twenty-first-century equivalent of the nineteenth-century railroad gauge dilemma. This was compounded by a disjointed method of data collection, with multiple agencies collecting different sets of related data. Participants also highlighted the need for disaggregated data by demographics, localized and detailed data, and intelligible data that can be easily understood. This is vital to enable better decisionmaking, to allow people to see themselves reflected in the data, and to enable people to better engage with public health data, similar to how they engage with weather data. As one participant noted, “People want to see the ‘me’ in the ‘we.’”

• Ensure consistent information from credible messengers. The U.S. public was faced with changing, and sometimes conflicting, information, which made it difficult to make informed decisions and contributed to an erosion of trust in public health leaders. Consistent messaging and trusted spokespeople are essential, as are opportunities for the public to engage in conversation with their public health officials. Additionally, health messengers need better training in how to communicate effectively, especially in the face of uncertainty. Former state officials also recognized the lack of planning relating to messaging, noting, “Work on messaging [was] unbelievably deficient [and] clumsy . . . are we proud of messaging terms like ‘lockdown?’” It is vital to invest now in educating state and local leaders and building networks to mobilize messaging.

• Be transparent about what is known and what is unknown. Sometimes, officeholders and public health experts made mistakes—office holders did not always listen to the science, or all of the science, and scientists were not always transparent about the uncertainties. Often, these mistakes were not openly acknowledged. Participants provided examples of increased vaccine uptake among skeptical audiences in situations where leaders were transparent about what was known and what was unknown.

• Use dialogue and engagement from the bottom up as the path to rebuild trust. Data collected during the pandemic showed a steep drop-off of trust in government, and participants highlighted that regaining trust—organically and authentically—is urgently necessary but will take time and is driven by such things as demonstrated competence in execution. At the same time, that trust may necessarily come through locally led dialogues, tools, and engagements rather than through interventions that start at the national or federal level.

• Engage the public in vigorous and open debate to help define priorities and foster partnerships. The role of, and engagement with, the public was underplayed in the U.S. national response to Covid-19, and experts acknowledged the need to “understand where Americans are and how to engage them in preserving their own safety.” Further, they stressed: “We could not agree on the gravity or uniformity of the response or the routine of the response—things like making testing widely available and free, or providing access to adequate personal protective equipment.” One participant said the inquiry was ultimately “How do we most effectively influence the decisions of 300 million Americans in Covid-19 response?” Some participants felt that legitimate debate about the science, the virus, and the pandemic response was too quickly labeled as misinformation and that civil society did not always allow for enough dissent on scientific questions. Playing to U.S. strengths, including encouraging free and open debate, is important for community buy-in.

• Use incident command structures for executing pandemic response. Participants emphasized the best practice of utilizing an incident command system—a standardized organizational structure at the local level for managing major emergencies such as hurricanes and floods—as a platform for pandemic response, building from the National Incident Management System. Surge capacity that can flex for pandemic crises was also identified as a vital need.

• Foster mechanisms for unified response. Especially early in the pandemic, states, tribes, and localities within the United States did not have unified operational approaches for maintaining supplies and responding to the pandemic as it crossed borders and city, state, county, and tribal boundaries. Strong federal engagement, regional compacts, and interstate collaboration are essential to provide and share clear and consistent messaging, data, supplies, tests, vaccines, and treatments.

As the country enters year four of the Covid-19 pandemic, it is clear that U.S. pandemic security is interlinked with democratic and civic strength. The pandemic has resulted in devastating loss of life and illness to individuals and families, overwhelmed health systems, negatively impacted schools and businesses and other places where Americans gather, and contributed to a further loss of trust in each other as well as leaders and institutions. These are all concerns that affect U.S. democracy. It is also clear that the United States has not sufficiently defined concrete next steps and solutions that can be enacted to improve community and state responses, including initiatives that could be launched to reinvigorate public health and pandemic readiness at the local level and efforts to overcome societal divisions before they harden further.

While there is a long road ahead to better prepare the United States for the next pandemic threat, the work outlined below is an essential part of the journey:

1. Create mechanisms to engage in bipartisan, multisector, pluralistic, and candid dialogues at the local level in order to better understand what happened, what worked, and how to overcome pandemic divides across red, blue, and purple states. It will be essential to hold structured and bipartisan forums across the United States for public engagement, multistakeholder dialogues, and community listening. This will be vital for understanding what worked, addressing preexisting inequities that greatly impact pandemic response, empowering local authorities, and creating pandemic plans that align with community values and will have their support. As one participant noted, “We are quick to zone in on communication, messaging, and combatting misinformation, but we should start with listening.”

2. Develop new, flexible tools and playbooks for pandemic response that empower communities and local leaders. Pandemic response approaches that are operationally feasible and can be tailored to community needs are essential, and these should be developed now, while learning from Covid-19 is fresh and can be built upon. Creating these tools will require new evidence and options for protecting essential workers, allowing for safe schooling, and transcending rigid, absolutist decisionmaking between “opening” and “closing,” wherever possible. These tools must be easy to use and rooted in existing community systems—such as those put in place in conjunction with healthcare, churches, community organizations, and employers to empower people to get tested and vaccinated.

3. Identify, sustain, and replicate networks that can support local pandemic response. Identifying, mobilizing, and sustaining local networks of health leaders, community stakeholders, and technical experts is key to an effective pandemic response. These stakeholders must be ready in advance of a biological crisis to assist communities with core pandemic challenges, such as food insecurity, childcare, and mental health. Public health leaders cannot work in a vacuum and must make common cause with leaders in education, business, and other sectors of society.

4. Foster community and public engagement with public health data. Public engagement with data is essential for risk communication and shared decisionmaking. As with weather applications on smartphones, people might feel more invested if they could engage more personally and regularly with public health data. In turn, that kind of regular engagement would also necessitate continual improvements in data and a better understanding of data gaps.

5. Create better career training for pandemic decisionmakers. Appointed health officials should have standard training competencies, but many public health officials are not formally trained in crisis response. Training should include incident command, decisionmaking in the face of uncertainty, communications, and high-level systems thinking. It should also account for new realities facing public health leaders, such as skepticism and hostility. To improve responders’ understanding of government functions, career training should allow for rotations through federal agencies.

6. Champion predictable, routine federal incident command structures for pandemic response. The United States needs greater clarity as to which federal agencies are in charge of which aspects of pandemic response. While much of the discussion was focused on state and community pandemic response, strong federal leadership remains essential. Yet, several federal agencies—including the Federal Emergency Management Agency, the Administration for Strategic Preparedness and Response, and the U.S. Centers for Disease Control and Prevention—have overlapping domestic pandemic response missions, and there is not yet clarity on which of those agencies will lead in which circumstances when an outbreak arises.

The group remains optimistic about the work ahead but clear-eyed about the seriousness of the challenge as it looks toward markedly improving U.S. preparedness for future pandemic threats. The United States remains at risk of hardening existing polarization, further eroding preparedness, and decreasing the odds that the country will muster the collective, decisive action and community support needed to tackle the next threat. To bridge these divides, the country needs a new, creative, and bipartisan dialogue that rests on a spirit of humility, self-criticism, determined optimism, and civility.

That approach needs to take careful and nuanced account of the harsh lessons from the U.S. response to Covid-19; develop a more robust menu of pandemic security options for communities; integrate the effects of pandemics on education, the economy, and society; broaden and update the concept of how public health operates to protect Americans; and create stable, consistent mechanisms that are capable of bridging sectors and parties during biological crises.

This analysis was authored jointly by experts based at the Brown University School of Public Health Pandemic Center (Brown University), the Global Health Policy Center at the Center for Strategic and International Studies (CSIS), and the COVID Collaborative. This document presents a summary of key themes that emerged during the discussion, but it does not necessarily represent unanimous consensus by the meeting participants (listed below).

This report is made possible by general support to CSIS. No external sponsorship contributed to this report.

This report is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2023 by the Center for Strategic and International Studies. All rights reserved.

Democracy and Pandemics: Can Free Societies Remain Safe?

A high-level convening to identify solutions to better prepare the United States and other democracies for pandemic threats

Hosted by the Center for Strategic and International Studies (CSIS), the Pandemic Center at Brown University, and the COVID Collaborative

Monday, December 5, 2022 | 2:00 – 5:00pm ET | CSIS

PARTICIPANTS

• Danielle Allen, Director, Edmond & Lily Safra Center for Ethics and James Bryant Conant University Professor, Harvard University

• David Bibo, Former FEMA Deputy Associate Administrator and Expert Associate Partner, McKinsey & Co.

• Katherine E. Bliss, Senior Fellow & Director, Immunizations and Health Systems Resilience, CSIS Global Health Policy Center

• Timothy Blute, Director, Center for Best Practices, National Governors Association

• John Bridgeland, Founder and Chief Executive Officer, COVID Collaborative

• Mollyann Brodie, Executive Vice President, Chief Operating Officer, and Director of KFF’s Public Opinion and Survey Research Program, Kaiser Family Foundation

• Elizabeth (Beth) Cameron, Professor and Senior Advisor, Brown University Pandemic Center

• Michael Carney, Senior Vice President, Emerging Issues, U.S. Chamber of Commerce Foundation

• Chris Christie, Former Governor of New Jersey

• Mandy Cohen, Former Secretary, North Carolina Department of Health and Human Services and Chief Executive Officer, Aledade Care Solutions

• Richard Danzig, Former Secretary of the Navy; Member, CNAS Board of Directors; and Senior Fellow, Johns Hopkins Applied Physics Laboratory

• Aaron Dowd, Special Advisor to the Chancellor, University of Nebraska Medical Center

• Jenny Durkan, Former Mayor, City of Seattle, Washington State

• Gary Edson, President, COVID Collaborative

• Mary Margaret Fill, Deputy State Epidemiologist, State of Tennessee

• Cary Funk, Director of Science and Society Research, Pew Research Center

• Bruce Gellin, Chief, Global Public Health Strategy and Senior Vice President, Health, The Rockefeller Foundation

• Julie Gerberding, Chief Executive Officer, Foundation for the National Institutes of Health

• Jeffrey Gold, Chancellor, University of Nebraska Medical Center

• Joe Grogan, Former Assistant to the President and Director, White House Domestic Policy Council

• Wilmot James, Senior Research Scholar, Institute for Social and Economic Research and Policy, Columbia University

• Juliette Kayyem, Belfer Senior Lecturer in International Security, Harvard Kennedy School

• Jack Leslie, Senior Advisor and Former Chairman, Weber Shandwick

• Jenny Lurray, Vice President of Strategy and Communications, Research!America

• Mark McClellan, Robert J. Margolis Professor of Business, Medicine, and Policy and Founding Director, Duke-Margolis Center for Health Policy, Duke University

• Judy Monroe, Cochair of the Indiana Governor's Public Health Commission and President and Chief Executive Officer, CDC Foundation

• J. Stephen Morrison, Senior Vice President and Director, CSIS Global Health Policy Center

• Jennifer Nuzzo, Professor and Director, Brown University Pandemic Center

• Deval Patrick, Former Governor of Massachusetts

• Aquielle Person, Research Associate, Brown University Pandemic Center

• Megan Ranney, Academic Dean, Brown University School of Public Health

• Scott Rivkees, Former State Health Officer, State of Florida and Professor, Brown University

• Morgan Romine, Chief of Staff, Duke-Margolis Center for Health Policy, Duke University

• Monica Schoch-Spana, Senior Scientist, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health and Senior Scholar, Johns Hopkins Center for Health Security

• Dennis Schrader, Secretary of Health, State of Maryland

• Michaela Simoneau, Associate Fellow, CSIS Global Health Policy Center

• Reed Tuckson*, Managing Director, Tuckson Health Connections

• Anne Zink, President, Association of State and Territorial Health Officials (ASTHO) and Chief Medical Officer, Alaska Department of Health

*Could not attend the meeting but is providing thought partnership.