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Preparing for the Next Biothreat: Lessons Not to Forget

In modern history, only the global wars of the last century can compare to the swift deadliness of the COVID-19 pandemic, except, this time, it came with less warning. In the United States, some officials and responder communities were prepared, but many were not. In 2024, the Preparedness Leadership Council Martin (Marty) Masiuk, executive director and founder of DomesticPreparedness.com, invited senior officials from hospital and healthcare, public health, emergency management, and other responder communities to share the lessons they learned at two workshops held in Washington, D.C., and New York City.

Participants shared stories, reflections, and recommendations, illustrating deficiencies and strengths made evident during the nation’s COVID-19 response. Their documented experiences are a platform from which to improve and inform future responses to coming biothreats, from local to federal levels. Following are key takeaways from the panels’ discussions.

Leaders Are Made, not Born

Titles do not make leaders. Regardless of rank, whoever is in the room may be the only one available to make time-sensitive decisions. In critical situations, an effective decision-maker will gather knowledge from available experts, make plans and decisions based on that information, frequently reassess informed decisions, and change them as needed.

This was the experience of Dr. Laura Lavicoli, chief medical officer for New York City Health and Hospitals. She was reassigned to oversee the system’s response to the pandemic. She relied on experts “in the room” and was not afraid to change paths as new information dictated. Based on this approach, she and emergency department (ED) staff transformed the ED into a hot zone. No one could enter or exit without following full personal protective equipment (PPE) protocols. It was not a popular decision with administration, who feared it would alarm patients, but Dr. Lavicoli believed it would be best for her patients and staff.

The Mind Matters

Like the general population, frontline workers who were making life-or-death decisions during the pandemic also lost loved ones, suffered economic hardship, and processed contradictory information. Additionally, they managed supply-chain disruptions, lived in isolation, and often slept at work—when they could sleep. This required the psychological stamina to withstand feelings of denial, fear, anxiety, and other psychological distress, according to Kelly McKinney, emergency manager at New York University Langone Health.

Many overworked frontline workers suffered mental health crises and burnout. Dr. Mary Foote, medical director for the Office of Emergency Preparedness and Response at the New York City Department of Health and Mental Hygiene, considers that loss a national security risk. She recommends shoring up safety nets and creating better reimbursement structures to ensure stable staffing and resources in time for the next biothreat.

Connecting Dots and Minds

People who live in the “disaster world” are familiar with dealing with the dangerous and unknown. People in the “normal world,” however, fear the disaster world—protecting themselves from the unimaginable by denying its possibility. During the pandemic, that perspective was at the root of many problems connecting these two populations, according to McKinney. Disaster professionals must bridge the gap.

Containing a biological threat with an unknown etiology is difficult. Accordingly, in a global society, confirmed human-to-human transmissions should prompt global activation. The adoption of a universal public health intelligence-sharing organization is one way for the public health profession to share early warning information globally.

During initial stages of the pandemic, information sharing across hospital and healthcare systems was particularly challenging. Officials needed to push out information quickly, yet there was no system for developing clinical information rapidly enough, according to Dr. John Redd, U.S. Department of Health and Human Services. One lasting innovation during the pandemic was to hold event planning meetings and virtual emergency operations center (EOC) meetings. Virtual EOCs can be established for common emergencies to facilitate rapid information sharing and response, believes Charles Guddemi, statewide interoperability coordinator for the District of Columbia’s Homeland Security and Emergency Management Agency.

Being prepared for virtual activation and having access to a downstream pipeline for public health information sharing is crucial for keeping the public informed and safe, both from physical harm and harm from misinformation. With accurate and immediate access to critical information, emergency responders must also consider the people from whom communities will trust to receive information. Having sources on hand, such as nurses, doctors, and others the public can relate to and believe, will facilitate the safe transmission of critical information.

In the hands of a good messenger, messages can be safely delivered, but in addition to accuracy must come transparency. To maintain trust, explaining the rationale for new, seemingly contradictory information is essential.

When monoclonal antibody therapy was found effective, Dr. Redd had to navigate the change in directives advising the public not to come to the hospital if they were not that sick, to directives urging the public to come to the hospital before a person became very ill. Likewise, Dr. Redd found that many providers did not know how to use the therapy when available, further confusing the public.

Cooperation Across the Spectrum of Responsibility

While federal, regional, and local agencies were activated and on call when pandemic waves first hit hospitals, they found themselves overlapping each other’s duties, duplicating efforts, and facing related challenges. National command and control needed a process to coordinate resources at the local level. There must be a clear national roadmap to local response to facilitate efficient resource allocation.

In New York, the National Guard’s Civil Support Teams were ready to serve at the onset of the pandemic. However, without training or experience in mass fatality support and decontamination, its services were competing with active-duty state and local government. The services of the Guard should be embedded into local response through plans and procedures.

Another disconnect between stakeholders was that of medical providers and the incident command system onsite. Medical providers should be included in briefings to share the common operating picture with operational staff and avoid conflict from differing opinions based on an incomplete picture on either side.

Similarly, executive leaders and politicians must be provided with operational understanding to be more effective at their jobs and to be a part of a whole community response. Without this integration, many instead interfered during the pandemic without a comprehensive understanding of ongoing processes and resource limitations. Giving politicians access to true subject-matter experts on blue-sky days—perhaps established in a statewide or national task force—creates relationships that will smooth communication issues during an emergency.

Further taxing hospital systems were unrelenting requests for data by all levels of government. Hospitals could not handle these requests as they managed the logistics of acute care on an unprecedented scale. If local governments were designated to collect data from hospitals in their jurisdictions, other levels of government could use the local government as their data resource. Local government should also not overlook first responders as data sources or for detecting and surveilling public health threats.

Public health and healthcare operations should operate their own EOCs. Governmental EOCs should coordinate with local EOCs providing human services and let the separate EOCs manage health services.

Plans Are Worthless, but Planning Is Priceless

Essential to an effective emergency plan is a playbook for future pandemics. Responsible agencies had plans in place—but many could not execute them because they were neither operational nor actionable. Interfering factors in some cases were staff turnover—leaving current staff unaware of in-place resources established by previous staff. Frank DePaolo, retired deputy commissioner of the New York City Office of the Chief Medical Examiner, learned that a critical but missing scenario in his playbook was a section he would call “Political Interference.”

For example, rather than burying people, politicians in touch with DePaolo wanted a massive freezer solution that could freeze bodies for a year and a half. But it was costly and had never been executed on the scale needed for that response. Ultimately, 85 percent of the people were buried, so such an undertaking would have been unjustifiable in the end.

For responders to be able to outline best practices for the next pandemic, they need a national repository of lessons learned nationwide. Britt Lampert, Bio Fellow at the Horizon Institute for Public Service, is working on an initiative to collect such lessons from state and local leaders in response to the COVID-19 pandemic and share them broadly.

Agencies should also assess training needs before a disaster and identify resources to support onsite training during a crisis. The whole community can be incorporated into training plans, involving everyone from policymakers to schoolchildren.

Further recommendations by the PLC panels for effective emergency plans include the following:

  • Local governments need to prioritize preparedness by appropriating sufficient funding of their own. They should not be reliant on federal funding in an emergency.
  • Funding from U.S. Health and Human Services and funding from the Federal Emergency Management Agency are for separate purposes. This distinction must be understood, and training may be necessary.
  • The Government Accountability Office’s Office of the Inspector General, Comptroller’s offices, etc., must ensure the application of documented lessons learned at each level of government and enforce improved emergency planning.
  • Governments and agencies should expand partnerships before the next pandemic to promote predictability.
    • Create memoranda of understanding with private-sector partners.
    • Determine how the private sector can adapt its operations to support the public health sector.
    • Build nonprofit partnerships to identify existing resources and capabilities they can provide.
    • Incorporate international partnerships into emergency planning to mitigate supply-chain shortages and create pathways for information sharing.

 

Stockpiles, Supply Chains, and Distribution

The Defense Production Act of 1950 calls for the federal government to stockpile strategic materials. This act should be understood to include defense against biothreats, and in accordance with the act’s statement of policy, the government needs to assess and evaluate production capabilities of resources needed in a pandemic. A governmental agency should adopt this duty and determine how to allocate excess resources in a dynamic environment.

Of special consideration are assisted living facilities, which are not under federal jurisdiction. States’ public health agencies need to see to it that these facilities have a base stock of PPE.

During the pandemic, local governments and hospitals were counting on the federal government to supplement their deficiencies in critical supplies. With these competing needs, both entities had to improvise and adapt to changing conditions.

Multiagency, multijurisdictional directives and response efforts are most effectively led by someone with authority over these entities, such as the vice president chairing the White House Coronavirus Task Force. However, the panels concurred that vaccine distribution was best led by local governments, coordinating with state agencies. Considering the successful implementation of Narcan distribution, vaccines and therapeutics could be distributed similarly. Paramedics could deliver them locally using a similar process as administering Narcan.

Conclusion

The PLC panels agreed on four core recommendations for agencies who respond to the next biothreat crisis. First, workforce training should include building essential leadership skills at all levels so that even those without a title can make critical decisions. Second, create a national repository from entities nationwide of best practices and after-action reports during the COVID-19 response and of common pitfalls from repeating mistakes. Third, create a playbook based on COVID-19 responses, before staff memory is lost. Fourth, implement exercises based on the playbook, which could include creating a response to the 2019 threat before it became a pandemic.

Public health, human services, emergency management, and governments at all levels were not prepared for a global pandemic. With the hard lessons and innovative solutions from that grueling experience, officials and responders need to codify their experience to better prepare for the next biothreat.

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Christy Anderson

Christy Anderson is the associate editor of the Domestic Preparedness Journal, DomesticPreparedness.com, and The Weekly Brief. She works with writers and other contributors to create new content relevant to emergency preparedness, response, and recovery communities. During her public affairs career, Christy worked in the mayor's office at the City of Renton outside Seattle and participated in the Puget Sound area "Sound Shake," the annual regional earthquake response exercise. She has a bachelor’s degree in visual communications from Calvin University and a public relations certification from the University of Washington.

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