American Democracy and Pandemic Security
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.
Major Findings
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 decision making 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 decision making. 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 decision making, 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.
