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National emergencies result in legislation that institutionalizes organizational structures with the necessary infrastructure for future incidents that rise to the level of a national emergency. Americans expect Congress to act whether the crisis is a war, terrorism, or pandemic.
Two world wars for which America was unprepared resulted in the National Security Act of 1947. The 9/11 attacks were followed by the merging of 22 federal agencies into a centralized agency whose mission is to keep the U.S. secure from foreign threats. However, when the COVID-19 pandemic emerged in the U.S., the lead agency, the Department of Health & Human Services (HHS), was ill-prepared to adequately respond to a highly contagious biological agent, despite two decades of pandemic planning. As a result, more agencies were activated, and the response resulted in a “whole-of-government” approach.
The National Security Act of 1947 legislated federal agencies that unified the military, created the Department of Defense, formalized the Central Intelligence Agency, and established the National Security Agency to advise the president on national security. Today, the commander-in-chief can order special operations to deploy anywhere with the essential supplies, backup, and supply chains to sustain operations.
The COVID-19 Response
Despite two decades of pandemic planning and over $21.2 billion spent on preparedness since 2002, the COVID-19 pandemic created chaotic circumstances worldwide. In addition, COVID-19 revealed some preparedness failures:
- A vaccine was not readily available that could mitigate the SAR-CoV-2 virus.
- A testing program had yet to be conceived.
- Hospital-based ventilators were in short supply.
- Personal protective equipment had not been stockpiled in sufficient quantities, and inventories were dependent on offshore supply chains disrupted by the pandemic.
- Data-gathering systems were either absent or inadequate to capture COVID-19 case rates, hospital fatalities, and testing results.
- The federal response structure was inadequate to manage an infectious disease outbreak that rose to the level of national emergency.
The Trump administration responded with Operation Warp Speed (OWS), which mobilized the private sector in concert with federal agencies and accelerated vaccine production (from ten years to ten months). Furthermore, it engaged the military and its logistics capabilities with HHS to plan the vaccine distribution to 64 Centers for Disease Control and Prevention awardees. The goal of OWS was to produce 300 million doses of the COVID-19 vaccine, with initial doses available by January 2021. In addition, the Federal Emergency Management Agency (FEMA) engaged its local connections to augment mass vaccination and essential supplies such as personal protective equipment and ventilators. Also, new software had to be developed to manage vaccine distribution and track dose administration. The software called Tiberius was made available, but its rollout caused further complications. New, untested, and with a steep training curve, it became too much for an already-overwhelmed healthcare sector.
At the first anniversary of OWS (December 12, 2021), USA Today published that OWS was perhaps “the most successful public-private partnership since World War II.” However, on January 20, 2021, with the transition of administrations, President Joseph Biden dropped the OWS reference and adopted the Countermeasures Acceleration Group to describe the continuous national vaccination campaign. By May 2021, the group became the HHS-DOD COVID-19 Countermeasures Acceleration Group (CAG), and then CAG management transitioned from the U.S. Department of Defense (DOD) to HHS by December 31, 2021. However, the impact of OWS remains. A transparent, non-partisan, and comprehensive analysis comes from the Government Accountability Office dashboard, where OWS facets are explored and presented. For example, the “Looking Ahead” tab of the dashboard includes a comparison of H1N1 (2009 Pandemic) to COVID-19, the various phases of mass vaccination, and how lessons learned carried forward to the COVID-19 response.
The Historical Role of Politics in Response
Politics has played a part in policies that shaped the pandemic response – for example, the renaming conventions of the response structures described above. However, politics in emergency response during national emergencies is not new. To compare, it took two wars before Congress enacted the National Security Act in 1947. In the interim period between the two world wars, preparedness planning did not occur outside the military – either federal organizational structures or industrial mobilization and its linkage to the military. Today this linkage is referred to as the military-industrial complex.
Has the time come to put the country on a warlike footing for pandemic response with a coherent, institutionalized, and tested pandemic policy?
With the U.S. entry into World War I, President Woodrow Wilson created the War Industries Board to manage the economy and mobilize industry to produce the supplies needed in the first national emergency. The nation was not prepared militarily, nor was its industrial base equipped to make the essential munitions the army and navy needed to supply its forces as they shipped to the European theater. General Pershing used French weapons when his troops arrived on the Western front. The U.S. lagged not only industrially but technologically as well. Germany had begun the process of synthetic nitrates used for both gunpowder and fertilizer. Western nations relied on natural sources only available from Chile, but Germany managed to sequester those supplies. Even though a War Industrial College was established in 1924 by Bernard M. Baruch (War Industries Board chairman) and mobilization planning resulted, it remained sequestered in the military to avoid upsetting the public with perceived “sword rattling.”
As a result, the lessons of WWI had not been acted upon by Congress when Pearl Harbor was attacked. The U.S. responded with a declaration of war for which the nation and its military were unprepared. President Franklin D. Roosevelt, through executive action, hesitated to prepare before the attacks and to mobilize emergency committee structures once the war was declared. There was no adopted industrial mobilization plan, nor were organizational structures in place that could respond to the national emergency. The War Production Board was established in January 1942. However, each mobilization crisis brought on by the U.S. engagement in the European continent and the Pacific expanded the needs. New agencies also were created, such as the Office of Economic Stabilization in October 1942, followed by the Office of War Mobilization in May 1943, each overlapping the mission of its predecessor. Meanwhile, time was lost as the economy converted from peacetime to wartime mobilization.
A hospital in Kansas during the Spanish flu epidemic in 1918 (Source: Otis Historical Archives, National Museum of Health and Medicine, Public domain, via Wikimedia Commons).
The federally supported California State University Community Vaccination Center is equipped to administer up to 6,000 vaccinations per day (Source: FEMA, February 2021).
COVID-19 strained the nation’s resources beyond the healthcare sector, workforce, and vaccine manufacturers. Mass vaccination planning for venues and vaccinators was inadequate. Supply-chain issues, limited personal protective equipment, the absence of an established testing program, controversial non-pharmaceutical interventions, politically-laden protocols, and mandates all required tremendous effort to surge response capacity. Contact tracing, a long-time public health tool virtually unknown outside of public health, became a household name after January 1, 2020, as a non-pharmaceutical intervention method – coupled with isolation and quarantine measures – to track the spread of COVID-19. Isolation and quarantine measures resulted in both physical and mental consequences. For example, dietary changes and lack of physical activity exacerbated health conditions, while the mental health impacts resulted in social isolation, depression, and the stigma associated with it. Equally noteworthy is that federalism played out in the courts as states took the White House to court over state’s rights while federal authority for a lead agency lacked clarity between HHS, FEMA, and the Department of Homeland Security. The public’s response was vaccine hesitancy and apprehensiveness about whose “science” to follow.
Next Steps for Pandemic Response
Given 20 years of pandemic planning, is it not surprising when people ask, “Why were we not ready?” Given the persistent emergence of novel infectious diseases and the performance of the nation’s lead health agency, this question should be explored whether the time has come to put the country on a warlike footing for pandemic response with a coherent, institutionalized, and tested pandemic policy. For example, the pandemic response should mimic an enhanced, robust seasonal influenza vaccination campaign – a policy and model depicted in the aftermath of the 2009 H1N1 Pandemic.
A January 2022 Government Accountability Office report designated HHS’s leadership of public health emergencies as high-risk and stated that it is a federal program requiring a transformation. The rationale for a warlike footing for pandemics is that the nation needs emergency structures that are established legislatively rather than leave it to the whims of administrations and partisan politics. With COVID-19 and the transition of White House occupants, the changing of response structures (OWS versus CAG) is reminiscent of Roosevelt and his reluctance to mobilize the nation for WWII and the naming of WWII emergency structures. Pandemic organizational structures should be legislated through congressional action as well as defining the lead federal agency in the whole-of-government approach. The executive office executes responses through existing structures rather than fashion new structures with titles that mimic pop culture. It became apparent the effective response took on a vast logistics operation that integrated the medical response. A logistics model then supplanted the medical model – a model the nation had depended upon for its planning scenarios since the 1950s.
The passage of the National Security Act demonstrated that the nation needed continuity with its security institutions to provide the commander-in-chief with an informed council required in emergencies. From these concerns came the National Security Act in 1947 and the Defense Production Act of 1950, used in 2019-2020 to acquire pandemic supplies during the national crisis.
In a June 9, 2020 white paper by the U.S. Senate Committee on Health, Education, Labor, and Pensions, referring to the coordination of federal agencies, it states:
It is Congress’ responsibility to provide a foundational structure that administration after administration can build on instead of creating a new structure with each new emergency. The laws that Congress passed do not seem to have anticipated fully the scope of a pandemic such as COVID-19 and the need for a whole-of-government approach.
Legislated actions on the order of the National Security Act of 1947 would build essential resilience to public health emergencies of national significance. Resilience could be achieved by a sustained public-private partnership that brings offshore critical supply chains onshore and supplements vaccine production. This partnership brought pharmaceutical manufacturers onshore after 2009 and illustrated federal government efforts to accomplish these feats. In 2009, only one onshore manufacturer produced vaccines. Today, four pharmaceuticals produce vaccines from U.S.-based facilities. Resilience will be realized when pandemic preparedness is a sustained, systematic process at all levels of government, not an afterthought amid a crisis that permits politics to create temporary emergency response structures.