The Predictable Pandemic: Whose Risk, Whose Responsibility?

The United States finds itself once more confronting a major public health disaster, albeit this time on a scale not experienced since the flu pandemic of 1918. The obvious lack of preparedness on the part of government in regard to the availability of testing kits, personal protective gear and ventilators, as well as the decision-making process underpinning quarantine protocols and the financial stimulus package, will guarantee fueling Congressional inquiries well into the future. And, if history is any guide, the manufacturing and distribution of any COVID-19 vaccine that is created will be a topic of discussion too. The big question will be why the spending of billions of dollars by the Federal government on pandemic planning over the past 15 years has little to show for it despite previous lessons learned.

Predictably, the inquiries will be framed as they were after the bungled government response to Hurricane Katrina in 2005, which focused on the question, “How could this have happened in America, and what must our government do to make sure to the best of our ability that nothing like this national nightmare ever happens again?” The foregone conclusion will be the same, i.e., “All levels of government failed in their obligations.” The inquiries will fail—again—to probe and answer the more fundamental set of questions that need asking if we are to mitigate future crises: What are the government’s, and the American people’s, respective roles and responsibilities in the face of disaster?

Indeed, so predictable is this turn of events that—with some substitutions to match the current crisis—that what follows below is substantially an identical argument to the one I made in April 2006 for IEEE Spectrum following Katrina, and which warned of future events like pandemics.

For example, what is the obligation of government—local, state, and federal—to manage its citizens’ risk? Can the government protect its citizens from all their risks, and even if it can, should it? What are U.S. citizens’ expectations regarding personal choice in management of their risk? What is the nation's risk appetite and risk tolerance? How much risk management is enough? What are the responsibilities of corporations as well as individuals to make preparations? Without addressing these and similar questions, we are likely to end up with more poorly conceived, contradictory and costly strategies that will only increase risk.

A particularly contentious issue has been the lack of intensive care unit (ICU) ventilators available for hospitals. Governors, mayors and other locally elected officials have criticized the Federal government for not having enough ventilators in the Strategic National Stockpile to support the COVID-19 patients in their states’ hospital ICUs. However, the potential lack of ventilators in the event of a national pandemic was fully understood by state health preparedness officials prior to the pandemic.

For instance, in November 2015, New York State Commissioner of Health released its updated ventilator allocation guidelines [PDF] originally released in 2007 which “develop guidance on how to ethically allocate limited resources (i.e., ventilators) during a severe influenza pandemic while saving the most lives.” The guidelines explicitly make it clear that in a severe pandemic, “many more patients will require the use of ventilators than can be accommodated with current supplies.” The guidelines further state that even if New York were to purchase the “vast number” of ventilators needed, a “sufficient number of trained staff would not be available to operate them.”

In the introduction to the guidelines, the Commissioner with obvious pride notes, “The first Guidelines were widely cited and followed by other states. We expect these revised Guidelines to have a similar effect.” Other states who don’t use New York’s guidelines have similar ones of their own.

Given this widespread acknowledgement and acceptance that ICU ventilators and trained personnel would be in short supply in a severe pandemic, state politicians’ feigned surprise and anger over shortages are mere deflections for their own failure to have a robust public discussion about their government’s role, and capability, to manage their state’s citizens’ risk in a pandemic before it occurred. If New York State residents knew, for example, that its public officials were not going to purchase adequate number of ventilators in case of a pandemic, would they have objected and insisted that they should be? Unfortunately, they never were asked.

Similarly, what is the responsibility of the American people to manage their own risks? The Centers for Disease Control and Prevention (CDC) has repeatedly published and widely advertised preparedness guidelines [PDF] for the American people to follow in the case of a severe pandemic. The guidelines recommend that households buy and store two-weeks’ supplies [PDF] of food, water, medicine, face masks and other essentials. Yet, how many families followed these recommendations? (A related question regards how much thought was given to households without the resources or space to accumulate such a cache, particularly in pandemic-prone high-density cities like New York, where housing costs are burdensome and apartments small.)

In both cases, the risk and resources needed to prepare for a pandemic was traded-off against other competing risks, both short-term and long term. While many American households may not have the means to prepare for a pandemic as the CDC recommended, the paucity of ventilators in event of a pandemic was a risk accepted by state government officials with eyes wide-open.

There has been a growing expectation among the American people, as well as state and local governments, that the Federal government be the risk manager of first resort in every crisis. However, there are limits to what any government can realistically accomplish, given the sheer number of disasters possible. Can the government protect all citizens from the effects of pandemics, floods, fires, hurricanes, tornadoes and earthquakes, as well as human follies like oil spills or financial mismanagement?  

If the American people desire the Federal government to be their risk manager of first resort, then there must be an open and honest discussion to decide what its risk management priorities should be. Then allocate tax dollars to mitigate those risks as opposed to others. The government must draw a bright line demarcating which risks it will try to anticipate and act to prevent, and which risks it can only react to. For these latter cases, the government must forcefully convey what it can and cannot reasonably do, and just as forcefully formulate what it expects its citizens to do. Then no one will be under the illusion that the government can control risks that it cannot, nor guarantee a risk-free life where it will make every person “whole” after disasters occur.

A friend of mine who was recovering from his second heart attack remarked to me that his first heart attack got his attention, while the second kept it. Perhaps, after suffering yet another government risk mismanagement heart attack, we can finally have a national debate on the roles, responsibilities, and expectations of government and its citizens in terms of managing risk—and decide which risks and responsibilities are whose. If we don’t, the next heart attack may be the one that kills us.

A version of this post appears in the May 2020 print issue as “Managing Risk and Responsibility During a Crisis.”