The nature of the next pandemic is unpredictable. Therefore, the U.S. and other countries need to develop capabilities that will give them the flexibility to respond to whatever nature throws at them. There are five capabilities in particular: redeployable manufacturing, an expandable health care workforce, decentralized innovation, flexible regulations, and better communications and coordination.
Already, there are calls for the United States and other countries to start taking steps to be better prepared for the next pandemic by developing highly detailed response plans at the local, state, and federal levels. However, based on my experience in helping set up CIC Health to rapidly scale testing in multiple U.S. states and mass vaccination sites in Massachusetts and working on strategy and planning for large corporations for nearly two decades, I have another point of view. While plans are obviously important, those that are overly prescriptive can lead you down the wrong path, because you can never predict exactly what’s going to happen. So instead of trying to spell out all possible actions in excruciating detail, it is better to develop the capability to be nimble.
We can draw a page from the world of business strategy to explain why this is the case. Corporations know that they need to match their strategic approach to their strategic environment. Two important factors to consider are the level of predictability and the ability to reshape the future. In environments in which you can predict the future, winning players are often incumbents who can execute against a plan that makes the best use of their advantaged assets. In environments in which you can reshape the future, winning players are typically innovators who can execute against a visionary plan that disrupts the structure of an industry. However, in environments marked by high uncertainty and a low ability to shape the future, winners are not those with preexisting plans but those who are nimble — who can get out of the starting blocks quickly, shift direction as they learn more, and scale fast.
The United States’ response to the Covid-19 pandemic illustrates this. In 2019, following a multi-year effort, an international team of experts and researchers rated the United States as number one among 195 countries on pandemic preparedness and awarded it a perfect score on “emergency preparedness and response planning.” (They have since docked the United States a few points but still gave it the top spot in their 2021 Global Health Security Index.) Clearly pandemic plans, rated as excellent, were not sufficient. Why? First, while many predicted a pandemic, there were many key features that were unpredictable. For instance, that infected people were contagious before they showed symptoms meant that plans that relied on symptom screening were not going to work. Furthermore, following such plans provided a false sense of security. Second, we had much less control than was expected. For instance, early warning systems did not work as intended.
The next pandemic could also be both unpredictable and hard to control. The diversity of plausible scenarios, encompassing zoonotic viruses to bioterrorism, is just too vast. Meanwhile, trust between nations has eroded, with lingering concerns about the source of this virus, anger about travel restrictions, and inequity in access to vaccines and essential supplies, potentially making it harder in some ways to coordinate a global response. So, faced with the likelihood that the next pandemic will have elements that are both unpredictable and hard to control, the United States needs to turn to an approach that relies not on excruciatingly detailed plans but on adaptive capabilities in at least five key areas.
1. Redeployable Manufacturing
The United States must have manufacturing facilities that can be rapidly deployed to turn out critical items — not just factories that are “warm” (i.e., mothballed) and need to be restarted. It also needs some that are being actively used that can be tapped quickly. This is important both for cutting-edge technologies, such as medicines, and basic low-cost items such as masks, swabs, and syringes.
It’s not just having this capacity that matters; the country also requires a set of principles for marshaling these resources and adjusting how they are deployed across the country as events unfold. A fragmented approach, with states competing against each other as happened this time, is suboptimal for everyone.
2. An Expandable Health Care Workforce
One of the big challenges during a pandemic is that there is a surge in the need for public health and health care workers that far exceeds the demand during normal times. The United States needs to find ways to keep honed the pandemic-related skills of this workforce.
Also, since the country is facing a long-term shortage of doctors and nurses, it needs to find ways to reward and retain (and refresh) the pool of people who have been willing and able to pivot quickly into roles that augment the capacity of its clinical workforce during pandemic-related surges. This could include a range of people, including school nurses, community health workers, and emergency medical technicians (EMTs) who can be organized and trained as a “para-pandemic corps.”
3. Decentralized Innovation
The United States also needs to do more to harness its innovation ecosystem. Sun Microsystems cofounder Bill Joy observed that “no matter who you are, most of the smartest people work for someone else.”
During the early months of the current pandemic, the Centers for Disease Control and Prevention (CDC) held sole responsibility for developing the test for the virus that caused Covid-19. This centralization of an early innovation step resulted in a critical delay of several weeks. In contrast, South Korea was able to quickly develop and deploy high quality tests because it turned to its medical industry to innovate.
The United States needs to be ready to quickly deploy open innovation approaches that draw in innovation talent from outside the government to participate in developing potential solutions.
4. Flexible Regulations
While any innovations (vaccines, drugs, tests, devices, clinical protocols) used for prevention, diagnosis, or treatment should, of course, go through appropriate vetting for efficacy and safety, the United States should eliminate regulations that unnecessarily slow things down.
The Food and Drug Administration’s Emergency Use Authorization (EUA) eventually sped up approvals for labs to run tests, but the EUA process also exposed a lot of red tape that got in the way of commonsense process improvements. For instance, testing organization realized quickly that using prelabeled tubes (instead of labeling tubes after collecting patient samples) could save hours in test turnaround time, but making that simple change, which had nothing to do with the test itself, required an amendment to the EUA, a time-consuming exercise.
Another regulation that did more harm than good was one that mandated that physicians had to authorize Covid-19 PCR tests for patients — a stipulation that impeded what Atul Gawande and I called assurance testing, frequent testing of asymptomatic workers and students as a way of keeping our schools and workplaces open. This requirement added unnecessary cost, time, and complexity.
A consequence of treating pandemic population-level testing the same way as traditional diagnostic testing was that the entire enterprise of testing was loaded with the expensive infrastructure (regulations, health IT, clinical resources) of symptomatic testing. Looking forward, the United States needs to identify areas in which regulations need to be rewritten so they don’t impede a nimble response.
5. Better Communications and Coordination
The many failures in public communication during the pandemic are widely documented. These were particularly problematic given historical misgivings about the federal government’s role in public health and rampant misinformation.
The core challenge is that people are looking for clear direction at the same time as data about the pandemic is being collected. So as the science evolves, public health authorities need to be transparent about what they know and don’t know. This will create an environment in which changing guidance in response to changing information builds, rather the detracts from, the trust needed to achieve broad support for public initiatives based on solid scientific evidence (e.g., for proven vaccinations).
Another prerequisite for an adaptive pandemic response is mechanisms that enable the numerous relevant departments and agencies at the federal, state, and local levels to communicate effectively with each other and coordinate actions. These include better systems for sharing information, knowhow, and concerns. This may be the hardest of these recommendations given how siloed these entities can be and the relatively high level of political polarization in the country.
The Result: A Faster, More Effective Response
Ultimately, investments in building adaptive capabilities in the areas of manufacturing, workforce, innovation, regulations, and communication will put the United States in a much better position to respond to the next pandemic than this one. Those capabilities will be far more valuable than extremely detailed plans.
Some may counter that a better solution would be scenario planning to develop plans that cover many different uncertainties. I strongly support scenario planning but not for the purpose of developing a variety of plans. I support doing them — and engaging in war games and simulations — because such activities can help build the competencies the country needs to be adaptive.
Referring to the fog of war, Dwight D. Eisenhower, the supreme commander of the Allied Expeditionary Force in Europe during World War II and the 34th U.S. president, said, “Plans are worthless, but planning is everything.” Given the inevitable fog that will engulf the next pandemic, let us ensure that our planning results not just in plans but helps build the capacity to be nimble to respond to whatever nature hits us with.