Unmasking system hesitancies that aggravated the COVID-19 tragedy

Cincinnati Children's Hospital Medical CenterDec 8 2023

More than 1.2 million people have died in the United States during the COVID-19 pandemic to date, more documented deaths than any other nation on Earth.

While many have attributed the high death toll on widespread personal hesitancy to wear masks, avoid crowded places or receive vaccines once they were developed, there were several "system hesitancies" that contributed to the tragic outcomes that need addressing, according to an analysis published Dec. 6, 2023, in Health Affairs Forefront.

The analysis was written by first author David Hartley, PhD, MPH, and corresponding author Andrew Beck, MD, MPH, at Cincinnati Children's and several co-authors based in Cincinnati and Boston.

"Such hesitancies continue to stand in our way, placing the public at risk for infection, hospitalization, and even death during times of uncertainty and danger. Moreover, disruptive effects of system hesitancies are not shared equally across populations, with disproportionate clinical and economic burdens for the elderly, communities of color, those living with poverty, and children who were forced to see a safe return to school politicized," the co-authors state.

These systemic hesitancies included:

• Hesitancy to comprehend and act on warnings
• Hesitancy to share, integrate, and learn from diverse data streams across sectors
• Hesitancy to coordinate
• Hesitancy to enable and empower local leadership

Newer technology has made near real-time disease surveillance possible on wide scales, but wider adoption is needed. Many lessons learned about coordinated response to natural disasters still need to be translated to public health responses to disease outbreaks.

System improvements should not focus only on top-down command and control, but rather top-down and bottom-up organizational approaches that support flexible, adaptive, and timely responses, the co-authors say.

In previous research about COVID response, several of the co-authors on the Health Affairs Forefront article also co-authored a report in April 2021 in the Mayo Clinic Proceedings that described how a number of organizations collaborated in southwest Ohio to rapidly build a "regional learning health system" to respond to the pandemic.

In southwest Ohio, a history of routine meetings between otherwise disconnected and often competitive hospitals, health departments and other agencies helped cut red tape, speed data sharing, and smooth resource sharing. That experience may serve as a model for other communities, the co-authors suggest.

"We can design a resilient public health system resistant to hesitancies, a system capable of detecting dynamic public health emergencies, and responding nimbly and efficiently," the co-authors say. "To do so, we need an integrated system that works across sectors, approaches leadership in a new way, and enables rapid learning from the top-down and bottom-up."

Co-authors included Peter Margolis, MD, PhD, and Robert Kahn, MD, MPH, from Cincinnati Children's; Steve Miff, PhD, president and CEO at the Parkland Center for Clinical Innovation; Muhammad Zafar, MD, University of Cincinnati; Kate Schroder, president and CEO at Interact for Health in Cincinnati; Tiffany Mattingly, vice president, clinical strategies at The Health Collaborative in Cincinnati; and Pierre Barker, MD, MBChB, chief global partnerships and programs officer for the Institute for Healthcare Improvement in Boston.

More than 1.2 million people have died in the United States during the COVID-19 pandemic to date, more documented deaths than any other nation on Earth.

While many have attributed the high death toll on widespread personal hesitancy to wear masks, avoid crowded places or receive vaccines once they were developed, there were several "system hesitancies" that contributed to the tragic outcomes that need addressing, according to an analysis published Dec. 6, 2023, in Health Affairs Forefront.

The analysis was written by first author David Hartley, PhD, MPH, and corresponding author Andrew Beck, MD, MPH, at Cincinnati Children's and several co-authors based in Cincinnati and Boston.

"Such hesitancies continue to stand in our way, placing the public at risk for infection, hospitalization, and even death during times of uncertainty and danger. Moreover, disruptive effects of system hesitancies are not shared equally across populations, with disproportionate clinical and economic burdens for the elderly, communities of color, those living with poverty, and children who were forced to see a safe return to school politicized," the co-authors state.

These systemic hesitancies included:

• Hesitancy to comprehend and act on warnings
• Hesitancy to share, integrate, and learn from diverse data streams across sectors
• Hesitancy to coordinate
• Hesitancy to enable and empower local leadership

Newer technology has made near real-time disease surveillance possible on wide scales, but wider adoption is needed. Many lessons learned about coordinated response to natural disasters still need to be translated to public health responses to disease outbreaks.

System improvements should not focus only on top-down command and control, but rather top-down and bottom-up organizational approaches that support flexible, adaptive, and timely responses, the co-authors say.

In previous research about COVID response, several of the co-authors on the Health Affairs Forefront article also co-authored a report in April 2021 in the Mayo Clinic Proceedings that described how a number of organizations collaborated in southwest Ohio to rapidly build a "regional learning health system" to respond to the pandemic.

In southwest Ohio, a history of routine meetings between otherwise disconnected and often competitive hospitals, health departments and other agencies helped cut red tape, speed data sharing, and smooth resource sharing. That experience may serve as a model for other communities, the co-authors suggest.

"We can design a resilient public health system resistant to hesitancies, a system capable of detecting dynamic public health emergencies, and responding nimbly and efficiently," the co-authors say. "To do so, we need an integrated system that works across sectors, approaches leadership in a new way, and enables rapid learning from the top-down and bottom-up."

Co-authors included Peter Margolis, MD, PhD, and Robert Kahn, MD, MPH, from Cincinnati Children's; Steve Miff, PhD, president and CEO at the Parkland Center for Clinical Innovation; Muhammad Zafar, MD, University of Cincinnati; Kate Schroder, president and CEO at Interact for Health in Cincinnati; Tiffany Mattingly, vice president, clinical strategies at The Health Collaborative in Cincinnati; and Pierre Barker, MD, MBChB, chief global partnerships and programs officer for the Institute for Healthcare Improvement in Boston.