The U.S. policy process—if there is one—has been driven by public health experts. Their input is important, but governments must balance their advice with input from other sectors.
FROM FOREIGN POLICY | MAY 5, 2020
Since the coronavirus pandemic began, public health officials across the globe have emerged as the most influential drivers of public policy. In the United States, the most visible authorities are Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, and Deborah Birx, the White House coronavirus response coordinator. At the state level, governors such as New York’s Andrew Cuomo and California’s Gavin Newsom have stressed how their efforts are driven by science and by the counsel of public health experts.
In many respects, that is precisely as it should be during a pandemic. But it also reveals a problem in how the United States has handled the crisis so far: A policy vacuum is being filled by one set of experts rather than a more comprehensive approach that balances risks and shifts when necessary.
The Cuban missile crisis is often held up as Exhibit A for how sound policy should be made. For 13 fraught days in October 1962, U.S. President John F. Kennedy huddled with rotating groups of advisors in order to assess the potential threat of Soviet missiles in Cuba and come up with a response that would simultaneously neutralize the threat without triggering an even more damaging war. JFK heard from hard-line voices urging him to be more confrontational and from those suggesting a far more passive course. Generals, Defense Department officials, diplomats, private citizens, and intelligence officers added their own distinct voices, each speaking from a perch of expertise. Their positions were not always compatible. The military officers, viewing the crisis through the lens of missiles and casualties and years of scenario planning, advocated for different policies than the diplomats who were steeped in Soviet psychology and attuned to the shifting rhythms of the Kremlin. In the end, JFK steered a narrow course between military confrontation and acquiescence.
Just how policy is made in the White House today is opaque, but between the deconstruction of the National Security Council staff and the apparent disinclination of the president to read his own intelligence briefings—or even attend regular meetings of the coronavirus task force—the process is clearly haphazard at best and close to nonexistent at worst. The coronavirus task force headed by Vice President Mike Pence includes most cabinet officials, but it is unclear what that task force does other than react when pressure mounts. And even then, it appears to do little besides offer vague guidelines and exhort states and the private sector to do more. It would be as if JFK had managed the Cuban missile crisis via daily press briefings, leaving it to each agency and department to determine its own course, hoping that somehow it would all come out for the best.
The failings of having little to no policy process have been long been obvious. But the chaos in Washington amid the current crisis has a less noticed unintended consequence: Public health experts have largely filled the void, and thus national policy about both locking down and opening up, insofar as there is any, is being shaped almost entirely by their voices. For sure, the Centers for Disease Control and Prevention (CDC) only has the power to set guidelines, not enforce them. But those guidelines have become the governing strictures for most large companies, for universities, for local businesses, and for many states. Large companies, in particular, that have begun to plan for “return to work” have been following almost to the letter the CDC guidelines. They have an incentive to do so based on possible legal liability if they do not, which is one reason Republicans in Congress are pushing for new laws to alleviate that legal burden if and when businesses resume. Cuomo in his briefings has firmly grounded the path to the state’s reopening on CDC guidelines, such as social distancing measures and rates of infection. States including Ohio, Washington, and California have done much the same.
Yet something as central to all aspects of life as how to reopen economies needs more voices around the policy table. Not having that would be as if the generals had been the primary drivers of how to prevent the Kremlin from installing nuclear missiles in Cuba. JFK’s military advisors were the strongest advocates for using force. During the crisis, the Joint Chiefs of Staff urged JFK to bomb Cuba before the missiles were operational—despite the fact that doing so would likely have pushed the United States and the Soviet Union into a war that might have gone nuclear.
JFK steered clear of that route thanks to a policy process that demanded input from multiple viewpoints. President Donald Trump needs to do something similar today. Public health officials must remain the preeminent voices. These doctors and scientists have spent their whole careers preparing for precisely this moment. They have gamed out scenarios, tested thousands of models, and run through numerous simulations. They have prepared scripts for how to communicate to the public and precise plans for when to shut things down, how to shut things down, and when and how to start things up.
But one silo of expertise cannot dictate all policy—regardless of the crisis. The nature of expertise is not to see the big picture but to comprehend the particular as fully as possible. If, in a vacuum, public health expertise is the only voice, it is as if the generals became the sole arbiters of military strategy and policy.
How might a more coherent process have altered the arc of the United States’ lockdown decisions? There is, and likely will continue to be in the future, debate over whether the level and extent of lockdowns in the United States as well as Western Europe and India were the right response. Already, there is the looming question of whether Sweden’s more hybrid response, relying on its high-trust culture to keep coronavirus numbers down, would have been a preferable path given the massive harms that a lockdown causes. Even as Sweden will suffer economically and with higher mortality than its neighbors, it is not suffering the same level of societal ruptures that lockdowns generate.
Sweden is certainly being guided by public health wisdom, but in its case, a different path was chosen by those health officials. In the United States, dissenting views within the public health profession do not seem evident, which suggests that there is no coherent process. Until two months ago, there was a wider range of views about the virtues of locking down. Until March, for instance, the World Health Organization’s guidelines, developed over years by experts in many countries, strongly advised against closing borders and halting travel, let alone societywide quarantines. In a matter of weeks, many public health officials worldwide shifted gears, but as Sweden at least demonstrates, there were and are countervailing voices. It is unclear if those voices are getting a hearing in the United States at the state or national level, but given the paucity of policy process, it is clear that there is no Team B charged with assessing alternate courses. Certainly, at the federal level, that would allow for weighing different options within the epidemiological and scientific community. Without a better set of processes in the United States, it is unclear how minority and dissenting views within the public health community can or have gotten a fair hearing.
Even if policy driven by the public health playbook were in broad terms absolutely the right call, a process that involved a more coherent measuring of supply chain risks, health care risks, and economic risks might have led to better policies that flattened the curve, did not eviscerate the economy, and maintained vital services more effectively.
For instance, the closing and emptying of hospitals was based on projections of overwhelmed systems. For a period in March, it seemed as if that was a real risk, especially in New York. But emptying out hospitals preemptively also has life-and-death costs that could have been better measured had there been coherent policy processes that weighed risks generated by halting everything at once and planned accordingly and had more coherent recommendations and organization come from Washington. Or there could have been early recognition that food processing plants were susceptible to the spread of infections but also vital to keep open. These policy failures are numerous and go far beyond the failings of testing and using the National Defense Act for supply production. They speak to a larger inability to measure actions and consequences that public health officials cannot and should not be expected to solve for.
As the United States moves forward, the country will need voices not bound entirely by pandemic scripts but that take into consideration the mounting problems that those scripts create. It may be too late for a White House bereft of process to change course, but all of us—individually, in the private sector, in universities, in whatever public forums exist—can at least start listening to other voices, just as JFK listened to not just military experts but diplomats, economic advisors, and his own trusted councilors. Is that a guarantee of good choices? Of course not, but it is the only path to them.