North Carolina’s Pandemic Playbook

by Jessica Weinkle, Department of Public and International Affairs, University of North Carolina Wilmington In North Carolina

Even before the coronavirus pandemic, the North Carolina state government has maintained fairly extensive plans for pandemic response that center on chains of command.  However, the plans don’t include an institutionalized process for science advice to evaluate multiple forms of information and uncertainty.  As a result, precious time was lost at the beginning of the state’s 2020 COVID-19 response as the state assembled from scratch trusted advisers.  Though data and advisory products were made publicly accessible when available, the process of asking and receiving advise was not readily transparent which can undermine public trust. 

In our EsCAPE COVID-19 research project, researchers begin with two initial questions: What formal goals and guidelines were available to governments for COVID-19 pandemic response?  In particular, what goals and guidelines are available to guide their science advisory processes on pandemic response? 

Answers to the questions establish a baseline by which to judge the subsequent strengths and weaknesses of science advisory activities.  That is, it is difficult to say if something worked well or did not work well if you have little idea of how it was intended to work. 

One of my favorite sayings along these lines comes from the children’s classic, Alice in Wonderland.

My contribution to the EsCAPE endeavor is a case study on North Carolina, a state in the Southeastern United States.  North Carolina developed pandemic plans beginning in 2006 under the guidance of the George W. Bush Administration in response to the H5N1 influenza (bird flu) pandemic threat.  The plan has seen periodic updates.  The next major update to the plan occurred in 2009 in response to the H1N1 influenza pandemic (swine flu).  Another update was underway, I’ve been told, but was derailed by the current COVID-19 pandemic response.

Overall, the North Carolina influenza pandemic plans outline a chain of command, processes of resource and information distribution, provide clarification on the legal authority if necessary to restrict people’s freedom of movement and other civil liberties.  Included in the plans is a 2007 report on ethics in pandemic response decision making.  A central message of the report’s authors is the importance of developing ethics guidelines and doing the work needed to build and maintain public trust prior to a pandemic occurrence.  The pre-pandemic work is essential in the public’s willful compliance with public health regulations that infringe on deeply valued liberties. 

In identification of the chain of command, state plans recognize the authority of the WHO to coordinate surveillance at the national and international level.  State plans also make a key assumption about an organized response by Federal government:   

“Counties and local health departments will rely on state guidance, leadership and resources to continue critical functions. In turn, the state will rely on guidance, leadership and resources from the federal government.”

North Carolina also recognizes that the US Centers for Disease Control and Prevention (CDC) will augment local and state resources for a pandemic response in the following areas: 1) disease surveillance, 2) epidemiological response, 3) diagnostic laboratory services and reagents, 4) education and communication, and 5) disease containment and control.

However, the state plans did not include guidelines on how scientific uncertainty could or would be handled, including uncertainty arising from the political context.  The state’s non-inclusion of a recognized role for science advice is likely due to the central assumption that the CDC and Federal government would provide such organized messaging and information.  But due to the politicization of the former and incompetence by the later neither guidance or leadership was provided.  For instance, actions by the Trump Administration created quick and deep uncertainty about the reliability of the CDC. 

This left North Carolina (and pretty much everyone else across the country) on its own to understand the public health threat and how to respond.  In the early days of the pandemic, there was limited knowledge about the virus itself.  Epidemiological models proliferated indicating any number of outcomes- some incredibly dire.   

The lack of infrastructure to deal with scientific uncertainty at the state level may also be in part to changing technological context.  Since the turn of the century, epidemiological modeling has proliferated and become an important avenue of information for policy decisions of all kinds, including pandemics.  But these models have limits- often left unspoken- and require savvy individuals to make practical meaning of the models, embedded assumptions, and output, for policymaker decisions.    

In NC, precious time was spent organizing an informal group of science advisors to provide policy relevant guidance on the epidemiological models relevant to North Carolina. Additional time was spent developing the institutional pathways enabling the state Department of Health and Human Services (NCDHHS) to make COVID-19 data publicly accessible. 

The key assumption that the Federal response would be helpful instead of actively sowing further uncertainty is an appropriate assumption for a state to make.  Still, a February GAO report indicates that the Federal government was not fully prepared to address scientific uncertainty and coordinate multiple avenues of information.  The GAO reported that the 2018 US National Biodefense Strategy has

“no documented methodology or guidance for how data are to be analyzed to help the enterprise identify gaps and opportunities to leverage resources, including no guidance on how nonfederal capabilities are to be accounted for in the analysis.”

Two conclusions arise out of this brief analysis. 

First, from a state perspective there is a need for improved coordination (and depoliticization) of emergency public health information at the Federal level. To this end, Roger Pielke, Jr. (director of the EScAPE COVID-19 research program) and Neal Lane (former science advisor to President Bill Clinton), argue for an elevated role of the White House Office of Science and Technology Policy. 

Second, there is a need for states to be prepared for public health emergencies under uncertainty (and potentially, politicization, something previously not even considered).  North Carolina already makes use of several standing science advisory committees.  For example, one of its longest standing science advisory committee, the Secretaries Science Advisory Board, advises NCDHHS and the state Department of Environmental Quality on toxic substances. 

Formalizing a standing state advisory group that can offer policy relevant advice on the state of scientific knowledge on emergent health issues, would make more efficient use of time in emergencies.  Such a group should draw from multiple areas of expertise: epidemiological, communications, economics and ethics, for example.  The group would also provide periodic updates to NCDHHS about influential technological advances in medical science that require planning updates and data response innovations by NCDHHS and communities.

Rethinking state science advisory committees- how they are constructed and where they are needed- can be a significant contribution to “Build Back Better” as President-Elect Biden seeks to achieve.