Introduction: The COVID-19 pandemic was an unprecedented, catastrophic public health emergency. With an absent executive branch, all fifty states scrambled to respond to a crisis that had broad, far reaching impacts. Fiercely bitter partisanship was often blamed for causing inadequate, variable US pandemic response efforts. But what explains why the United States, despite its wealth of resources and strong institutions, had a slow, fragmented, and highly politicized pandemic response? A lack of policy alignment, or propensity toward misalignment, in the United States contributed to its uniquely disappointing pandemic outcomes. Methods: Using a qualitative approach, they conducted (a) elite interviews of bureaucrats at the state-level in public health agencies, emergency management agencies, and the governor’s office (n=47) and (b) a historical analysis of the development of disaster and pandemic policy in the United States. Results: Three main variables within a fragmented institutional structure explain alignment and misalignment in the US pandemic response: (1) authority, (2) bureaucratic structures, and (3) capacity. These three variables interact within the greater overlapping fabric of federalism and state-specific contexts that are impacted by prior policy decisions (path dependency), institutional design, and inter- and intra-governmental relations. Conclusion: These findings have broad implications for future US disaster response and public health emergency response capacities and capabilities. They also help further our understanding of federalism: its impact on disaster response and public health emergencies, the intersection of public health and emergency management, and the importance of governors in a federalist system experiencing a crisis.
Katarzyna Klasa (Sun,) studied this question.