**4. Coordination challenges/barriers**

Public health emergencies require coordination, but challenges exist. In fact, coordination is a fundamental problem for public health agencies. A challenge for public health agencies is to work with new partners, as well as the challenge to work differently with regular partners. Beginning with the events of 9–11, in addition to providing health services on a routine basis, the federal, state, and local public health agencies are expected to be prepared for natural disasters, terrorist attacks, and pandemics. Public health agencies are well prepared to respond to recurring events, such as food-borne outbreaks. The same can be said for seasonally occurring infectious disease outbreaks of flu and pneumonia Both of these outbreaks have serious health outcomes, but their occurrence is expected and strategies to manage them are programmable. Once these outbreaks are identified, public health agencies mobilize personnel, following well-established and longstanding plans and procedures, to stop the outbreaks and coordinate treatment of those who may have been affected.

Hurricane Katrina has been identified as the worst natural disaster to ever occur in the United States. To classify it as a major disaster is an understatement. Hurricane Katrina attacked the United States over a five-day period, from August 25th to August 29th in 2005. The storm first struck Florida, then intensified and made landfall in Louisiana. Its devastation was spread over several Gulf Coast states, but its primary affect was felt in the City of New Orleans. The failure of the levees in New Orleans resulted in floodwaters over 80% of the city and over 1,500 deaths [36].

Shortly after Hurricane Karina passed through New Orleans and downgraded to a sub-tropical disturbance, it became clear that the storm had overwhelmed public health agencies. Lt. Gen. Russel Honoré testified to the U.S. Senate that Hurricane Katrina "beat us" [37]. A coordinated response was not implemented at first, because of the lack of communications, which were eliminated by the storm. Coordinated responses required command and control functions, which did not exist in the first few days after Hurricane Katrina made landfall. Results of this included: delayed and duplicate efforts by public health and governmental agencies, uncoordinated search and rescue efforts, confusion over delivery of needed supplies, lack of clarity as to who was coordinating hospitals' evaluation of patients, lack of local police protection, and confusion over who was in command [38].

#### *Coordination of Public Health Response: The Role of Leadership in Responding to Public Health… DOI: http://dx.doi.org/10.5772/intechopen.96304*

The absence of command and control was the greatest challenge for the Hurricane Katrina response because it is essential for emergency management. Again, in his testimony to the US Senate, Lt. Gen. Honoré stated that the art of command is to arrive at a situation and unconfuse the people [37]. The effects of the storm eliminated local command centers, either due to facility destruction or loss of communications. Successful coordination occurs when there is a singular command and effort, as well as a well-defined chain of command. There must be one person in command with a clearly defined line of command and control. The different federal, state, and local agencies must be guided by a jointly agreed set of objectives. Coordination is manifested by all agencies working to achieve the same objectives.

To alleviate many of the outcomes of Hurricane Katrina, a Joint Task Force Katrina (JTF-Katrina) was quickly established and lead by Lt. General Russel Honoré, a co-author of his chapter. JTF-Katrina consisted of federal and state military, local law enforcement, and federal, state, and local agencies. Establishing JTF-Katrina resulted in regaining command and control. JTF-Katrina assisted federal, state, and local agencies to provide immediate assistance in search and rescue, emergency medical care, evaluations, restoring infrastructure, damage assessment, and resupplying food and water. The assistance was successful due to a high level of coordination and collaboration.

On January 6, 2021 insurgents rioted and assaulted the US Capitol and American democracy. This insurrection was fueled by falsehoods of unfair election processes and ultimate confirmation of the Electoral College votes for President and Vice President of the US. Uncharacteristically, security at the US Capitol was overwhelmed and resulted in significant property damage and six deaths. Speaker of the House of Representatives, Nancy Pelosi, appointed Lt. Gen. Russel Honoré to lead a review of US Capitol security. A significant part of Lt. Gen. Honoré's review will be to evaluate the coordination of the various federal and local law enforcement agencies with respect to command and control [39]. The reason for his selection was based on past successful leadership in coordinating public health emergency response.

The COVID-19 pandemic is the worst public health emergency in the world since the Influenza Epidemic of 1918. The Influenza Epidemic lasted two years and resulted in 500 million infections worldwide (one-third of the world's population at that time) and 50 million deaths. Nearly 25% of the US population was infected and 675,000 people died [40]. COVID-19 first emerged in late 2019 in Wuhan, China and, at first, seemed to be a problem far away for the other parts of the world. In early January 2020, China announced that Wuhan and other cities were locked down in attempt to stop the spread of the virus. Many countries, including the US, deemed it a China problem and travel to and from China was prohibited. It was thought that this would reduce the risk that the COVID-19 would not become a problem outside of China. This assumption was based on historical information from the severe acute respiratory syndrome (SARS) pandemic of 2003. SARS is a coronavirus which caused respiratory illness, and cases were first seen in Asia. SARS spread to more than 12 countries. In total, across the world, 8,000 people showed symptoms, and 774 of the symptomatic patients died. In the United States eight people who had traveled to infected areas became ill. However, there was no community spread in the United States [41]. But, despite travel restrictions, it soon became evident that the COVID-19 differed from SARS and was spreading throughout the world.

As was seen with Hurricane Katrina, the COVID-19 pandemic found the world unprepared to address its rapid, deadly, and wide-spread effects. An infectious agent with such high levels of infectivity, pathogenicity, and virulence was never seen before across the world. Majority of COVID-19 deaths (80%) in China was

observed in people 60 years of age and older. Early in the pandemic, most deaths in the United States (80%) occurred in individuals 65 years of age and older, with the highest percentage in those 85 years of age and older [42]. Hospitalization rates were high in the United States, to the point of overcrowding of intensive care units. Hospitals were challenged because they had not planned for the bolus of severely ill patients, and rapid modification of strategic and business plans were mandated. Elective surgeries were eliminated and re-assignment of surgical staff to intensive care units resulted. Additionally, supplies and resources acquisition and supplychain management was a challenge [43].

In March 2020, the Italian National Healthcare Service in COVID-19 hotspot areas was overwhelmed. This was due to years of budget cuts and fragmentation of services. The National Healthcare Service is regionally organized and as a result the national government had little control. This led to no coordination between national, regional and local agencies [44]. For example, in Milan the COVID-19 pandemic response was based on a rapidly developed algorithm for identification of cases and referral for treatment. The algorithm consisted of determining individual's residence, if they had been in close contact with cases or suspected cases, and close contact with anyone with respiratory symptoms who had traveled to Asia. Individual who were screened were triaged to a hospital or home for isolation. The algorithm is continually outdated to align with local directives. This algorithm is now used nationally [45].

The response to the COVID-19 pandemic in Spain also faced many challenges. Spain has been one of the worst affected countries in the world. There was a lack of pandemic preparedness. Spain had insufficient surveillance systems, inadequate supplies of personal protection and critical care equipment. Poor coordination among national and regional agencies resulted in delayed response and slow decision making. The lack of preparedness was also evident in nursing homes [46].

## **5. Lessons learned**

Coordination is a major problem because of the complexity of health-related activities. The lack of evaluations to assess capacity to meet strategic goals, lack of coordinated resources and infrastructure including essential data, and disasters lacking the necessary attention of interagency coordination are major barriers. A systematic focus on public health emergencies and the understanding of the need for managing resources and information must be similar across agencies. Establishing a timely and rigorous evaluation process is needed to have successful continuous quality improvement. Leadership is the essential ingredient for successful coordination. Public health response varies based on the events, so leadership needs to have the ability to be flexible. Command and control must be agile to adjust to the changing circumstances within, and across, public health events [47]. Leaders must be decisive, while being flexible. Leaders also must be a) knowledgeable in public health practice, b) able to maintain situational awareness, c) provide continued situational assessment, d) inspire trust, e) coordinate diverse members of the response team, and g) lead and manage effective, timely communications [48].

Because hurricanes are annual events, federal, state, and local agencies have an opportunity to develop a unified plan. In Louisiana, federal and state military have established a coordination plan in the event of a major storm. The plan consists of: establishment of a pre-event united command and control organizational structure, pre-positioning of unified disaster assessment team, designation of a single point

#### *Coordination of Public Health Response: The Role of Leadership in Responding to Public Health… DOI: http://dx.doi.org/10.5772/intechopen.96304*

of contact for the federal coordinating officer to coordinate activities, implement a local or state employee disaster clause to reassign personnel to fill disaster support gaps, pre-position interoperable communication systems, identify external sources to mitigate common resources shortfalls, pre-assign space in state emergency operations center for integration of federal agencies, develop a plan to sustain governmental operations, pre-arrange support contracts for needed resources, acquire an uninterrupted power supply, and collaborate with industry to receive commitments to re-establish critical services post-storm. This coordination plan requires a dominant and directive leadership style to be successful.

The effects of a pandemic have similar response needs. Coordination is essential to successfully address pandemics. Decentralized and fragmented public health agencies need better coordination and establish a plan for command and control. Capacity for surveillance must be increased to a level at which the magnitude of pandemics do not take countries by surprise. Coordination between private, public, and governmental agencies must be formalized. An example is the initial distribution of the COVID-19 vaccine in the US, which has been less than successful. This is due, in part, to the decentralized, state-controlled distribution strategies, which differ from state to state. Agreements among these entities, as well as industry, must be developed and maintained. Adequate and appropriate resources, including human resources, must be planned and financed for long-term periods. Consistent command and control arrangements are requisite, as well as a firm commitment from political leaders to sustain preparedness over time. It is essential that coordination leadership must be participative, while being decisive, but flexible at the same time, due to the uncertainty of the COVID-19 pandemic.

The National Association of County and City Health Officials summarized the proposed response to pandemics [49]. The response recommended the following measures: isolation of infected and exposed individuals, travel restrictions, prohibiting social gatherings, school closures, rationing of medical supplies, and cancelation of elective surgeries. These recommendations were prophetic because these same measures are being used in the COVID-19 pandemic. An important adjunct to this response is community engagement, which is included in the coordination effort to address the effects of pandemics. Preparedness, response, and recovery capacity on the community level can help to optimize pandemic contingency planning [50].

The United Nations has developed a disaster risk reduction model that aims to align policies across the world. The Sendai Framework for Disaster Risk Reduction, Sustainable Development Goals is a global agreement to assist in risk reduction efforts. The Sendai Framework's core priorities are a) understanding disaster risk, b) strengthening disaster risk governance, c) investment in disaster risk reduction, and d) enhancing disaster preparedness [51]. The Sendai Framework's goal is to reduce the loss of life, injury, health impacts, and the effect of the social determinants of health.
