by Andrew Cuomo
3. The leadership of public health organizations tasked to respond to future public health threats must be able to operate free from political interference.
COVID has shown us that political influence can have deadly consequences. While public health governance should have checks and balances, public health leaders—similar to other important positions in government—should be inoculated from political interference so they can express their expert advice without fear of political consequences. Public health leaders should require Senate confirmation and serve in term appointments so they are not subject to political interference by any president or federal administration.
Multiple media reports detail how during the COVID crisis Dr. Fauci, senior leadership at the CDC, and other federal health-care officials were censored by the Trump administration. The HHS secretary and the DHS secretary are presidential political appointees and too often appeared to be clearly charged with political spin over objective dissemination of information to the American people. In a public health emergency, it is paramount the public can trust the information they are receiving. If the American people are called on to take dramatic action, they will cooperate only to the extent they trust and respect the information and those providing it.
We do not need to create another bureaucracy, but we must ensure the competence and integrity of the ones that exist. We must drastically and quickly reform how our federal agencies operate. The CDC is currently a subdivision within the Department of Health and Human Services. HHS is an agency run by political appointees of the president, many of whom have no experience in anything related to health or human services. The CDC should not be a subdivision of an agency directly controlled by the president. In the meantime, Congress should fully investigate whether the CDC did not have the expertise and capacity to detect COVID or if the agency was suppressed in its attempts to communicate the depth of the crisis to the American people by the White House.
As of this writing, we do not know what the CDC and NIH knew about COVID and when they knew it. We do not know what the WHO informed the White House of and when. We do not know the source of information to the White House in January 2020 that led Peter Navarro, a senior aide to the president, to write a memo suggesting apocalyptic consequences from COVID-19. We must demand answers to these basic questions to understand why such an early warning by a senior administration official was ignored at the highest level of the federal government.
President Trump has blamed the World Health Organization for the lack of timely detection of COVID-19. However, the WHO did issue a global alert in late January—around the same time the president’s own senior aide raised a serious warning. Why then didn’t the United States act swiftly and deliberately to protect our citizens? An FDA press release on February 4 said, “At this time, federal health officials continue to believe that the threat to the general American population from this virus is relatively low.”
To ensure the delivery of science-based, expert public health advice, steps must be taken to guarantee that the leadership of public health can do their jobs free from political interference.
4. Government’s response to public health threats must be informed and guided by data.
During the COVID crisis, New York has collected and publicized more data than most other states, and the state’s usage and reliance on data and metrics are something we have done extraordinarily well. Data allowed us to better manage the crisis, understand where to target resources and efforts, and identify and mitigate emerging areas of concern. From the earliest days in the crisis, New York required hospitals and other health-care providers to submit detailed information daily on how many hospital beds were available, the number of ICU beds occupied, how many ventilators were in use and on hand, the amount of PPE available, the number of tests performed, and much more. We tracked how many patients were in hospitals, what communities they were from, and extensive socioeconomic information. In New York, we also collected individual data so we knew what was happening in each community down to the zip code level. This approach to data collection and attention to detail has supported our nation-leading contact tracing program.
The federal government should use New York’s model and build a similar system, and it must be completed quickly. It should share the data that is collected with states, especially states that lack resources or technical capacity to develop their own robust systems. During the COVID-19 crisis, the federal government did not mandate data be collected or reported in any uniform way. Most states did not collect or publicize as detailed information as New York State. As a result, as of this writing, it remains impossible to do a true state-by-state analysis of what happened.
Data must be reliable and transparent to the public. As a starting point, it has to be free from political influence so that the people can have faith in the information they are receiving. Recent media reports have stated the White House is interfering with hospital data, asking hospitals to bypass the CDC and instead report information to HHS. Why would they make this change seven months into the pandemic? It raises serious questions about the accuracy of information being collected, controlled, and released by the federal government.
5. The federal government must build a public health emergency operation team and program with the capacity to coordinate and respond to major health crises.
The Federal Emergency Management Agency was designed to assist in natural disasters such as hurricanes, floods, and fires, but it was wholly ill-suited to be helpful and responsive during the COVID crisis. Public health experts must be central to the response for their epidemiological expertise, but health agencies are largely regulatory bodies and are not equipped with managing a crisis of the magnitude of COVID-19. In essence, public health experts in the federal government need the experience and expertise of emergency operational officials who can execute tasks like building large-scale testing capacity quickly.
A robust public health emergency operations team will be well suited to implement a national public health program that is responsible for building up the nation’s health-care capacity to deal with future crises—an urgent need. It is obvious that the nation was unprepared to handle a viral outbreak on the scale of COVID-19. For instance, the federal government’s own forecast in March estimated that the COVID virus would require between 2.4 million and 21 million hospital beds nationwide, yet the entire country has only 925,000 staffed hospital beds. One can argue that we should have been better prepared after H1N1 swine flu, SARS, Ebola, and other past public health challenges. Whatever the reason, it is clear we were not.
A public health capacity program must start with an early warning detection system as outlined above, but first and foremost it must focus on building a nationwide testing system. The United States has no capacity to quickly ramp up large-scale testing of our population. Other countries such as China and South Korea were much more successful in quickly determining the number of individuals infected with a virus and isolating them to stop the spread. In the United States, testing is a fragmented network of private labs with major national manufacturers selling different equipment and proprietary test kits and approximately seven thousand private laboratories and hospitals capable of conducting tests. It is imperative that the federal government design the necessary requirements to provide mass-scale, nationwide rapid testing—including for new and emerging viruses.
Likewise, the nation needs a contact tracing operation to follow up on those who test positive and help limit viral spread. Like the testing operation, it can be either federally operated or federally designed and delegated to the states. In New York, we set a tracing formula based on the infection rate of regions within the state, and as of this writing we currently have about seven thousand contact tracers. The program has helped the state find and isolate COVID clusters before the virus spreads more broadly in the community.
Staffing was also a challenge nationwide.
On the front lines of the crisis in hospitals and other health-care facilities, nurses and physicians would contract the virus or need a break because of the severe fatigue of working long hours. Given that COVID-19 is a national crisis and that future viruses will likely be as well, the federal government should create a nationwide volunteer portal where health-care professionals across America can offer their services and states and local health-care facilities can access as needed. Such a system will avoid competition of scarce human capital during an emergency.
The federal government must invest in isolation and quarantine facilities, which must be readily available to hold infected people who do not have the ability to self-isolate. In dense and crowded communities, like New York City, a person who tested positive often did not have the ability to self-isolate. We need a public health system that can care for highly infectious individuals who don’t require the acute care of a hospital but should not be sent to a nursing home or a rehabilitation center because such a facility may not be prepared to provide the level of care and isolation a contagious person requires. These convalescent facilities should be designed and identified by the states to be ready for an emergency, with operational and financial support provided by the federal government.
Further, the United States must maintain a real national stockpile of emergency medical equipment and supplies anticipating a future public health emergency. The reliance on China and other countries to supply us on a moment’s notice with vital equipment is a national security risk. The federal government should identify necessary medical supplies and equipment that we may need in an emergency and incentivize private sector companies to increase their capacity to assist, both to build a stockpile now and to help with rapid production during a future emergency. Robust nationwide stockpiles were created under President Bill Clinton’s administration, but recent reports found that the federal stockpile is currently “thin.”
New York State distributed tens of millions of needed supplies during the COVID crisis, and many states undertook similar efforts. This is not normally a state responsibility, but it was a necessity; many health-care facilities were in short supply. To avoid this in the future, states must enact what New York has done: Develop baseline supply and equipment requirements for health-care facilities and mandate that they maintain the supplies necessary. At a minimum, states should require that individual hospitals have a ninety-day capacity of PPE and essential pharmaceuticals on hand during crisis situations. Then states should have an additional thirty days on hand. These supplies will then be supplemented by the federal effort.
6. The country must have a health screening system as part of its border patrol control system.
The original sin in this crisis was that the federal government failed to have an early detection system in place for COVID-19. The result was the virus had moved from Asia to Europe, where it began to spread. Then the federal Department of Homeland Security failed to control the spread from Europe to the United States, when it allowed millions of travelers to come to this nation on tens of thousands of flights throughout the month of February and until mid-March, many carrying the virus. This was confirmed in reports issued by Mount Sinai as well as the CDC, which found that the virus came to New York mainly from Europe and was spreading here in early February. By the time the federal government instituted travel restrictions from Europe, it was too late.
Even after the travel bans were implemented, screening was almost nonexistent. A March 13, 2020, New York Times article, “Travelers from Coronavirus Hot Spots Say They Faced No Screening,” reported, “As thousands of Americans flee from Europe and other centers of the coronavirus outbreak, many travelers are reporting no health screenings upon departure and few impediments at U.S. airports beyond a welcome home greeting.” That must not happen again.
We need the federal government to develop a comprehensive screening system and protocol so viruses cannot enter our nation undetected. Ports of entry are a federal responsibility, and the national government must develop a screening process for the next virus. Customs and Border Protection is tasked with securing our country’s borders, but they must also have public health screening safeguards in addition to verifying citizenship or checking for contraband. Let us not waste a crisis, and let’s take this opportunity to retool Customs and Border Protection to expand its role and expertise.
7. State governments must reinvent the public health capacity.
In New York, we have one of the best health-care systems in the world with world-class physicians, nurses, and other health-care workers. But the COVID-19 situation demonstrated that we don’t have one coherent health-care system, but rather a patchwork of different health-care institutions, both private and public, with varying capacities. The hospitals that faced the greatest stress during the crisis were the public municipal hospitals, yet nearby were other hospitals with more capacity and resources to help.
Under an innovative Surge & Flex program described in more detail later in this appendix, New York built and managed a centralized system where patients were transferred from one burdened hospital to a different one with more capacity—regardless of which system a hospital was part of. In the end, the state’s program assisted in transferring approximately sixteen hundred patients from overwhelmed hospitals to hospitals with capacity. States should use their regulatory authority to institutionalize a similar program so various health-care institutions can be run as a single coherent system during an emergency.
Also under the Surge & Flex program, New York helped health-care facilities with ample surplus share supplies and equipment with other facilities that were running low. This was an effective strategy that states should adopt and institutionalize.
8. Citizen action is essential.
We have learned once again that social action is the essence of political power and social change. All government action during COVID was dependent on individual action. The individual action forged the collective movement that protected society. People bent the curve in New York. In states where the virus spread, it was the people’s actions that caused the spread. COVID illustrated clearly the strength and limitations of government as well as the power of individual action. Individual actions determine an individual’s health. Individual social and political participation determines government action. Inform yourself, protect yourself, act responsibly, and participate in democracy. On a micro level, follow the individual rules of responsibility that I include in this appendix. On a macro level, participate, advocate, vote, protest, make social change. We did and we can. Be an American in the truest sense of the word.
* * *
—
COVID-19 HAS ILLUSTRATED this country’s weakness and vulnerability. The only thing worse than having lost the lives of thousands of Americans would be for them to have died in vain. We must learn the lessons of this experience in order to do better. We owe it to the front-line workers who sacrificed so much and above all to those who lost their lives and the loved ones they left behind.
* * *
—
THE FOLLOWING ARE SUMMARIES of “game plan” protocols the state of New York implemented during COVID—one for testing, and the other for our Surge & Flex program. I hope these program details can be helpful to other states or to federal policy makers in the fight against COVID and in preparation for the next pandemic.
NEW YORK STATE SURGE & FLEX HEALTH COORDINATION SYSTEM
In early March, New York State’s 213 private, public, and independent hospitals had approximately 53,000 total beds, of course many occupied by patients receiving care for non-COVID reasons. Starting early in the COVID crisis, to determine the effect of the virus on New York’s hospital system, the State Department of Health required every hospital in the state to report daily how many beds in its facility were available, as well as how many were occupied, including by patients with COVID, those in the ICU, and patients requiring int
ubation.
Normally, these hospitals operate individually, competing with one another for patients, and rarely coordinating, particularly with hospitals outside of their “system.” (Most hospitals are part of a network, such as Columbia-Presbyterian, Mount Sinai, Northwell, NYC Health + Hospitals [H&H], and the University of Rochester Medical Center). There has never been a single statewide public hospital system or even a coordinating entity to help these 213 individual facilities work together in times of crisis. The situation at Elmhurst hospital in Queens during the third week of March demonstrated that a new, innovative coordinating system would be needed to bring every hospital in the state under one true statewide public health system that effectively balanced patients, staff, supplies, and equipment across all facilities.
Elmhurst is a public hospital operated by the New York City Health + Hospitals system. Early in the fourth week of March, Elmhurst was overwhelmed with COVID patients experiencing serious symptoms—a startling situation that happened very quickly and was well documented in the media. However, at the time Elmhurst was under siege, there were only about 4,000 patients hospitalized with COVID-19 in the entire state—just one-fifth of what our eventual peak would be, at nearly 19,000. At the same time, the H&H system reported to New York State having 900 open hospital beds across the eleven hospitals in its network. Likewise, of the more than 21,000 total hospital beds in New York City, including all hospitals, more than 3,500 beds were vacant. Why were patients from Elmhurst not transferred to these nearby vacant beds? The situation at Elmhurst made clear that coordination between hospitals and hospital systems was just as important as—if not more important than—increasing hospital capacity.
