WTHC Season 2 Episode 4 Transcript

How Decisions Get Made During Public Health Disasters

In our last episode, we talked about why the work of public health is often invisible to the public. We also discussed how storytelling can be used to illustrate that work and illuminate its importance.

There are moments, however, like in the wake of a natural disaster or in the midst of a pandemic, when the role public health plays is put under a spotlight.

Put simply, crises have a way of pulling back the curtain on society. They test the resourcefulness, generosity and grit of individuals, but also the strength of the systems designed to keep communities safe and healthy. And as disasters become more frequent and more devastating, the question isn’t just how we respond, but whether those systems can keep up.

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From the Center for Public Health Systems at Columbia University, this is “Who the Health Cares,” a podcast about the history, politics and substance of our public health system. I’m your host, Michael Sparer.

On today’s show, we’re zooming in on the role of emergency preparedness and response within our public health system. We’ll discuss how the government responds when the unexpected hits and why some systems break, some bend and some stand strong during a crisis. We’ll also talk about what navigating uncertainty looks like in real time, and why the future of emergency management may depend less on top-down solutions and more on the proactiveness of communities themselves.

Joining me for this conversation is Mitch Stripling, director of the New York City Preparedness and Recovery Institute, also known as PRI. The mission of PRI is to help organizations and communities prepare for and respond to public health threats, ranging from infectious disease to climate-related emergencies.

Mitch first got interested in emergency response while working as a tech consultant in his home state of Florida. Then, in 2004, four hurricanes hit the state in the span of six weeks: Charlie, Francis, Ivan and Jeanne.

It was an all-hands-on-deck situation, and “all hands” included Mitch. Over the course of that summer and fall, he says, he took a deep dive into emergency management that inspired him to pursue a career in disaster response. Since then, he’s helped plan and implement responses to more than 20 federally-declared disasters and public health emergencies.

I’m so pleased to have Mitch for this conversation because, in my view, there is no one who better combines on-the-ground work as an emergency responder with a bigger picture view of our overall emergency response systems.

Mitch: So what we see in crisis is that these are the moments that things change. The world will be bopping along, people think things are stable, there may be currents under the surface that are shifting, but when crisis comes, it's when those things go out into the open when you see them clearly, maybe for the first time in a long time, and where you have to wrestle with them.

So really the course of, of US history has been forged in crisis in different ways. You know, there's a lot of sociology around this. An historian named Walter Scheidel wrote a book called The Four Horsemen, where he said that the only times in human history that we've increased equality within societies have been during crisis, have been during those times where we've decided to wrestle and wrestle well with those questions.

Now in this country, we, we don't necessarily do that. You know, you can see that in the history of Katrina recovery. We, we treat our crises as, as ends. You know, we wanna get back to the way things were the day before. But they are beginnings in some way in that they show us problems in new ways. And if we treat them honestly, we can, we can actually, I think, use them to improve society rather than, um, just watching them sort of weaken society.

Michael: We have a large public health system in the United States, which covers a lot of territory, you know, from septic inspections to restaurant inspections, to dealing with emergency response. How would you define sort of the field of emergency response as a part of the public health system in the United States?

Mitch: So that goes to the definition of a disaster. And it turns out that emergencies, disasters, and catastrophes are different things in the literature. An emergency is actually something that you can respond to by a procedure. So a house fire is an emergency, right? We have a system, it responds to it, it handles it.

A disaster is what happens when that system breaks. So when a local community is overwhelmed by something, that's the technical definition of a disaster. So a county's hit by a tornado, they have to call in state resources, that's when a disaster hits.

A catastrophe is what happens when those systems themselves are overrun. So the safety net doesn't function. In our literature, for example, we say that Hurricane Sandy was a disaster. Hurricane Katrina was a catastrophe because it overwhelmed those systems.

So I don't wanna get all semantic on you, but when I try to answer the question, what I try to throw in there is this idea of a public health disaster, a time when the systems we rely on to keep us healthy, they break, and we've gotta improvise to figure out how to make them work.

Michael: Tell me if I'm wrong, historically, I don’t know, the last 50 years, 75 years, but it seems today I turn on the news and every day there's another earthquake, another massive fire, another tsunami, another emergency breaking out all over the place. Are there more of these sort of crises today than there used to be? Or are we just reporting on them more? They always were there, they just weren't on the news. Are things worse or is it just this is sort of steady state for the last, you know, period of time?

Mitch: Things are worse. There is more reporting. I think that that's true. I think that we often hear now about moderate disasters that 20 or 30 years ago we wouldn't have heard about. But yeah, the data shows that, um, high dollar disasters are going up, and the reason is sort of twofold.

First, climate change is pushing it. We can now see that in the data. You know, climate change doesn't necessarily, uh, create more hurricanes, for example, but it intensifies ones that are there. But the other part is that as humanity grows and we create more centralized systems, there's more harm when one of those systems crack. When there's an earthquake in a more urban area, it's gonna impact more people just because there's more people there. We're, we're building on coastlines, we're building on rivers.

And as the systems scale up and get larger, they get more fragile because they're more connected to these, these underlying harms, right? Like in our field, we say a tsunami is not a disaster. Tsunami's just a wave until it hits poorly built homes on a coastline. And so it's the human choices we make that contribute to the disasters, and unfortunately that's how we're building the world right now. We're building the world fragile, and so we're gonna keep seeing it break.

Michael: You know, when I think about emergency preparedness here in the US and, and certainly beyond as well, it's a complicated environment. When there's an earthquake, when there's a pandemic, I mean, it'll vary I suppose, depending on the crisis, but big picture, how is the system supposed to work, for those who don't really know?

Mitch: Absolutely. Uh, disasters are always local, and so they're always meant to be managed by the, the closest people on the ground. What happens is that a city or county will activate an emergency operation center. so a place where all those folks that you mentioned get in the same room to solve problems together. And that's coupled with an incident command system or incident coordination system, which handles on the ground resources.

So in something like a hurricane, for example, you might have a county and then a state, uh, EOC, and then you would have sort of boots on the ground command systems who were running things like hospital care and triage and other things. So counties, when they get overwhelmed, they ask the state for help. The state, when it gets overwhelmed, it asks the federal government, uh, for help. And all of these EOCs, as we call them, are, are always interfacing, just basically trying to do wicked problem solving together in real time.

Michael: I actually wanna get a little bit into the notion of trust and messaging. And we know there is, certainly since the pandemic but even before the pandemic, there was a growing lack of trust in government, in the public health system, in our ability to respond to crises. Tell me a little about why you think that has, from your perspective as someone who's been in this field for a while, has accelerated and how within the field of emergency preparedness we're trying to deal, we're trying to deal with that issue.

Mitch: I think a lot of people make the mistake of equating trust with communication or with messaging. And what we know from the research is that trust is based on relationships and services. You know, if you're a person who has a primary care doctor, you've been well served by the healthcare system, you have access to healthy food, you have a good house, you have a good education system, your levels of trust will be higher. And if you're a person that hasn't been well served by society, um, you know, you don’t have a primary care doc, you don't have good access to hospitals when you need them, why would you trust the public health system in a moment of crisis, right? Your, your level of trust going in will be low.

Then during a crisis, usually, um, these things stand or fall based on how aligned the perception of the population is of what's happening with what the government's actually doing, like how close those things are together. The farther apart they get, the more screwed you are. And so you have to be able to communicate in a way that builds on trust as a relationship of partnership. Otherwise, that trust gets damaged really quickly and it's hard to build back. Uh, and it's not gonna be built back with a, a pithy slogan or a, a tweet or a, a press release. It's only gonna be built back by ongoing sort of co-design with the people who are surviving the, the catastrophe with you.

Michael: And that has to happen during the crisis itself. You have to build it back almost in real time.

Mitch: Yeah, you know, um, there's a short game and a long game, right? And the short game is you have to be able to pivot your strategy and do some resets. You know, in emergencies, we often run on 12 or 24 hour cycles. You wake up and every day is a new crisis, but you have to be able to plot your strategy over a longer period of time. Now, when you're starting from this place of low trust, it's really hard to grow it in an emergency. But it is, it's easy to kind of knock it down a few pegs.

Michael: I can't help now but transition a little bit to the pandemic, uh, and how we did see in different communities around the country, you know, different levels of rising trust, going up, going down. We've also seen there are certain public sectors, like the fire department, that people still seem to have trust in. Um, when you reflect back on the pandemic a little bit and this issue of trust and what went right, but what went wrong, what are some of the things that you reflect about?

Mitch: So one thing that PRI has been working on for several years is a review of the New York city COVID-19 response. Not, not just the governmental response, but what we did across society. And when we talked to people, and we interviewed hundreds of, of leaders and neighborhood mutual aid groups, uh, for this work, we found that there are actually two kinds of trust that are in play. There's the, the trust of social cohesion, like the neighbor to neighbor trust that we saw. And then there's the trust in government, right? The trust in public health, trust in messaging.

And what we saw, actually, is that that neighbor to neighbor trust actually increased during the pandemic because people were leaning on each other and they were building new relationships. That's a little bit the magic of crisis, that you can create this network of all kinds of responders from all different walks of life who are gonna join hands and work together.

You know, unfortunately, what we saw in a lot of cases, and this isn't at all specific to New York, was that the official response was often working against that energy, and it was trying to work in ways that were sort of very clear, very objective, very evidence-based, which, you know, is often all to the good, but in the fluid case of a crisis, it just will, will hit at trust because you have to be able to open yourselves to these relationships, even when they're imperfect.

You know, I think in public health we often wanna be able to say, here's the evidence-based guidance and then stick to it. And, and in a crisis, first it's hard to come by, there's not a lot of evidence. Second, what you're learning every day is different than the day before. Um, and third, just that the knowledge that people have on the ground, neighborhood by neighborhood, is very different than the knowledge you have in an EOC. And so the more you can mesh those two together, the better you do.

Michael: So not pick on, too much anyway, your former state where you worked, uh, Florida, where you worked on emergency response for years, um, I would guess, and you could tell me if I'm wrong, that during the pandemic and during crisis more generally, the neighbor to neighbor trust probably was still there to a certain extent, but I think the sort of messaging coming from the governor, coming from the government at the time, you also had President Trump, you know, it, it was becoming an increasingly partisan issue. What's your sense of, of, how things played out in, in that kind of context and how – what sort of difference that made in terms of outcomes?

Mitch: Um, one interesting study that I saw that came out recently about something we'd all wondered about for a while did show that counties with higher percentage of Republican voters who were skeptical of vaccines had higher mortality rates over the course of the, the pandemic, especially once the vaccine was available.

And it's, it’s tragic to say that, but the data does show that polarization cost us lives in those moments. And that's the sad thing about Florida. You saw so much good work done, so many brave officials saving a lot of lives. One thing that's tricky, and this is, it’s a little wonky, Michael, you're gonna have to forgive me.

Michael: Oh, we're in, we're in academia, I suppose.

Mitch: That's right. Ivory tower all the way. Is that in a place like Florida, or there’s good work on this in Michigan, for example, the initial crisis that people saw was actually the COVID restrictions and not the virus. What people saw first was ‘I can't open my gym now,’ right? ‘I can't run my small business.’ And in an emergency, it's important both to rank harms but also to note harms. And I think in those early days of COVID, we should've, as, as health officials of all kinds, we should have named that as a harm. It's a harm when you lose your economic livelihood.

Is it the greatest harm? No. The greatest harm is those fatalities that we saw, those illnesses. But you can have a range of harms and problems you're working on in emergencies, and I think if the sort of business supports that we saw come out sometimes several weeks or months later had come out in that early package of initial restrictions, I think that that would've changed the tenor of the response substantially.

Michael: You mentioned briefly the issue of disparities and how we enter a crisis in a society full of disparities and the crisis illuminates those disparities. And we try to adopt policies and procedures that in theory might reduce the disparities that would obviously be felt by, you know, people who were delivering food, by Medicare workers, by people who couldn't be six feet apart in their apartment 'cause there were lots of people in the apartment, by communities that had been, you know, marginalized over the years. And yet, those efforts to reduce the disparities don't seem to quite get the results that we, we hope they should. Maybe talk a little about how we, how we should think about that going forward.

Mitch: I think this is the hardest question in emergency, uh, response. And you have to look at it over the long term. Uh, so there's a sociologist named Christopher Dyer who studied the, uh, Exxon Valdez disaster. I don't know if you remember that one, Michael.

Michael: I sure do.

Mitch: From the late eighties, you know, millions of gallons of oil in Prince William Sound. And what he did was he studied the disparities in the health outcomes of the indigenous villages that were impacted there. Now, most of them weren't impacted in the initial response. Uh, they didn't get oil all over themselves, right. But in the recovery, the funds that came in turned them into outsourced, hourly sort of wage laborers.

And year by year this money poured in, but it was money that had to be spent and used in certain ways that the federal government was mandating. None of it was done in consultation with that culture, and it weakened them. And, uh, you know, then they had a series of floods. They had sort of mini tsunamis. They had these other fires and other disasters. And Christopher Dyer watched each of those subsequent hits weaken the cohesion of their society until finally it dissolved and they don't exist anymore.

His conclusion was that when you had a disaster and you put resources in, in a way that was not linked to the needs of the most local groups, that will, regardless of your intent, weaken the underlying structures of society and will make disparities worse because the, the values aren't aligned. You don't have that initial values alignment.

So in COVID, we saw a lot of really well intentioned work that was targeted at disparities like they were big bullseye, right? Rather than the fact of what we know they are, based on the social determinants of health, which is baked into the underlying structures of our society. We treated them as an externality rather than as something that we were kind of creating as we went along.

And in disasters over and over, we see people try to do that, and what happens is it ends up making them worse because they get sort of calcified, they get locked in as a part of society because you never quite have enough resources and people don't quite wanna do it. And so the misalignment between the, the money on the ground and the needs of the people kind of gets wider and wider as that goes along.

Michael: So, sitting here in 2026, are we better prepared or worse prepared for the next pandemic right now?

Mitch: It's a hard question because it assumes there's one us, and I don't think there's one us.

Michael: Yeah. Okay.

Mitch: At the moment. I think that as a nation, I think that we are less well prepared because we've lost a lot of institutional knowledg and we have this deficit of trust that we've talked about. And we have a deficit, actually, of operational readiness. As an emergency person, you, you throw around the term operator a lot, you know, uh, a person who's an operator is a person that you throw into chaos and they're gonna get the job done somehow.

And right now, we have some people who are sort of timid, who are kind of trying to hide behind evidence with a door shut. And then we have people who are breaking stuff and disrupting it. And what we need are some operators who are willing to get in there and do what's best for the community.

I will say that we see better prepared communities right now. We have, through COVID, there are a lot of neighborhoods, there are a lot of cities, there are a lot of counties who said, you know what? We know how to do this now. We have the right muscles, we have the right relationships. And they're kind of ready to stand up at a local level in a way that some of the big structures aren’t.

Michael: Got it. I read recently where you noted that two of the biggest changes that are taking place in emergency response these days are, one, accelerating adoption of AI, uh, and two, the increasing importance of what you called community response. Can you talk a little about both AI and where that will help, where it'll hurt, you know, what, what AI sort of means for emergency response? And sort of what you meant by the increasing importance of community response?

Mitch: Yeah. Let me take the second one first. You know, I think that it's a cliche now to talk about the 20th century as this time of creating huge institutional structures, you know, massive corporations, massive military scale. And the 21st century has been about decentralization. It's been about creating networks that are empowered without command structures.

After 9/11, lower Manhattan had 800,000 people that needed to be evacuated and a group of Mariners around New York Bay saw that issue and without any command structure, they all moved as one to evacuate 350, 400,000 people over the next, uh, 48 hours from Manhattan to New Jersey. And it was because they saw a clear mission and they had a, a value proposition in making it work and they had the skillset to do it.

And if we had waited for a plan with an incident command structure and so on to get that done, it would never have happened, right? And so we need to be able to trust people in emergencies to work in that kind of community supporting ways. And my bet is, if we were willing to do that, if we were willing to funnel money directly to neighborhood communities for these times, to do things, even things like coordinate testing, coordinate how vaccination will happen with local communities. Do they need more resources to do that? Yes. But the command structures, the decision making power, they have that in spades and they know their communities best.

Now, that's hard to convince senior executives. Alright? We never, to my knowledge, wrote an evacuation plan for New York City that included all those mariners in it because it's too hard to control. It's too hard to get that through a command structure. But if we trust it, it will help us. That's what's important.

Michael: You know, and we'll come back to AI in a minute, I wanna follow up on this for a minute. Um, as part of this effort to sort of bridge communities with health systems, et cetera, there's been a growing use of what we call community health workers. They're sort of part of the health system, but they're also part of the community. Um, tell me about where you think community health workers sort of fit in emergency preparedness.

Mitch: I honestly think that this push could be the most important thing for mass scale disasters in the next five or 10 years. Um, we have partners in Puerto Rico, we work a lot with the Puerto Rico Public Health Trust, and they have funded these incredible community health workers across a range of issues for disaster preparedness, for chronic health concerns, for HIV testing, for cancer care. And when you embed these folks in a community, they're not there just to make sure somebody gets their meds that day. They're there to help craft this holistic pathway towards both individual and community functioning at the same time.

I really feel like if we had embedded community health workers in every neighborhood, really on every block, every one of New York city's 120,000 city blocks, if we had that army of community health workers out there, that would be a low cost way to increase human flourishing and lower our disaster vulnerability all at the same time.

Here's the problem. The problem is, it's hard to find people that will fund them because what you're doing is you're creating a new DNA, right, of health in the city. And the outcomes are slow. You've gotta have that DNA in place for a few years to watch your CMS burden drop, to watch your, your Medicaid costs drop, but it's there. And I'm hoping we can find people who will fund it consistently so that we can see those benefits arrive.

Michael: Yeah, I mean, I think the evidence, as you said, I think is there, that they could make a huge difference. Um, but at this point, it's still a relatively low paid occupation for people. Um, it's a hard job and it's, uh, something I, I agree with you, we really need to work on.

Mitch: What we see in some other countries, um, New Zealand's done this, Japan's done this, is that they have similar models where it's not ever meant to be a person's full-time job, right. They have other ways and, and they're doing some other things, but they're a person with a heart for community service, a heart for public health. And so they take it on in a, sort of a, a stipend fashion. You wanna make sure that that's economically livable, especially in this town. But, there are programs like that that have shown success around the world.

Michael: Let's talk about AI for a minute. Um, what's AI gonna mean for, for emergency response going forward?

Mitch: You know, let's go back to what I said about crisis. I think that the world flips in crisis, and right now we're at a place where AI is one of those things that's bubbling along below the surface, people are using it all the time. Maybe they're not admitting it all the time, right? But it's, it's right there in all of our structures, but it hasn't been fully adopted by government. There's a lot of talk about regulation.

In my experience, what happens with a technology like this is some big crisis is gonna happen and everybody is gonna say, we don't have enough resources. We're gonna mass deploy AI. You know, that's how the telephone, the telegraph, looking back at these technologies, people needed to bring them to bear suddenly and without a lot of thought because something unexpected happened.

So for AI, what I think is important first is that people who are interested in preparedness and response, take it seriously right now, learn how to use the basic tools, um, figure out how to build it into, to your processes. It's uncomfortable, um, but I think it's better to learn now than to have it thrust on you during a crisis.

But the other part is, I think that it's very important that we have both ethical and operational guardrails on it. AI is most likely to be wrong during a crisis because in a crisis we're learning new information. So large language models, they can't handle crisis right now. They would give you wrong answers. They would give you bad questions. They would give you incorrect assumptions. Um, I did an AI, uh, scenario recently, uh, that was a flood, and we got back from AI research three or four different numbers as to the level of water which would sweep a car off the road.

Michael: Wow.

Mitch: Right? What, what the right number of inches is.

Michael: That’s kind of scary.

Mitch: Right. And so you think, well, that's only one small data point.

Michael: Yeah.

Mitch: But that's what responses are built on. And right now, you can't trust AI in those situations.

Michael: You're here, you're part of the mailman school, you'll actually be teaching a course for us on emergency response. You interact with students all the time. What are the kind of the messages that you're trying to convey, uh, to students both in the classroom, but just in general when you talk to students about the issues that you deal with? What's, what’s the advice you're giving to students these days?

Mitch: You know, it's fascinating teaching folks right now and getting to have those relationships, it’s a new experience for me. And what I've seen happen in a lot of public health rooms in particular, it can be very hard to make a choice. And that seems simple, but just to make a, a choice between A and B when things are moving fast, because you can never predict it, you can't control it.

In public health, you know, we're sort of taught this question of, well, how do you make sure that what you're doing is the right answer? And in emergencies, there's not a right answer. There's just a, an ongoing series of improvisations that try to get you closer and closer to helping society, and that's all you got. So there's never gonna be a right answer. And trying to get people to feel comfortable to take that first step, you know, is a hard thing to do.

Michael: Acting under uncertainty you know?

Mitch: That's right. And I think for public health in particular, that's been difficult throughout my career, and I think it's hard for students to learn that too. Especially students who have grown up in a testing environment where the answer is either A, B, C, or D.

Michael: Yeah, I noticed in your classroom, you've told students they can't have their phones in the classroom because you’ve said, I think, in an emergency you often don't even have your phone.

Mitch: Well, one thing we've heard from our partners is that their recent hires in the last three or four years seem to have lost the ability to communicate in emergencies. Because in an emergency, you have to do this level of face-to-face, okay, Michael, here's the mission, it's A, B, C, and D, and you've gotta do it by five o'clock and then you repeat it back and that's all you have time for.

And it seems that in recent hires, and we've heard this from several groups, that's a skillset that people have found to, to be lacking. And I'm trying in my classroom to sort of make sure it happens, to have people do work face-to-face with each other because that human element becomes so critical when all your systems are down.

Michael: Mitch, thank you so much for coming. This was really just an amazing period of time that we're living in, but I think the work that you are doing and the work that the community of emergency responders around this country doing is just so important, so powerful, and so needed. So I really want to end by, by thanking you.

Mitch: Thank you, Michael.

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Big thanks to Mitch Stripling, Executive Director of the Pandemic Response Institute, for providing such a clear, thoughtful, and fascinating overview of the world of emergency response.

If you found this conversation interesting, you might also enjoy Mitch’s new book The Epistemology of Disasters and Social Change. You can find it wherever you get your books.

Let me now highlight a few things that stood out for me in our conversation.

First, in this podcast, and in the public health community more generally, we talk a lot about trust, and the problems created by the declining trust in government and the declining trust in science. Mitch added important nuance to this conversation when he distinguished between what he calls “neighborhood trust” and “government trust.”

During a catastrophe, we typically have less trust in government because there’s often a gap between what is needed on the ground and the services our government is providing. To increase trust in government, we need to improve the services that government provides.

Second, much like our prior guests this season, Mitch is a firm believer in the importance of community health workers. As he noted, in the next 5-10 years, Community Health Workers could become the most important part of our emergency response system, but only if we figure out how to hire, train, and deploy them effectively.

Third, AI does not hold up well in a crisis. Why? Because the situation on the ground is constantly evolving, and so too is the appropriate response. It was scary to hear that an AI simulation of how much flood water would cause a car to float away yielded several different answers. For the time being at least, the job of an emergency planner and responder seems pretty future-proofed.

Fourth, it was important and challenging to hear that our public health students need to better understand that in a crisis there is not always a right answer, that they need to make decisions in times of uncertainty, that they need to learn to work face-to-face with colleagues and complete the task before them. We in public health academia need to take that lesson to heart.

Finally, I was deeply struck by Mitch’s comment that we are “Building the world fragile and we keep seeing it break,” by which he meant that we are making ourselves more and more vulnerable by our own actions, whether it’s building homes along a shoreline or by downplaying the role of climate change in intensifying hurricanes. Another lesson that is so important but under discussed.

Indeed, this last point is a call to me, and to all of us, to do what we can to build a world less fragile and less likely to keep breaking.

Join us again in two weeks for a discussion about why the U.S. is unprepared to deal with its growing elderly population, and what it’ll take to get prepared. This is another important public health issue that I would argue gets far too little attention on our policy agenda.

Till then, this is Michael Sparer, signing off from the Center for Public Health Systems, at

Columbia University.

This episode was produced by Grace Rubin.

Our sound engineer is Zoe Denckla.

Alex Weaver is our social producer. He also composed our theme music.

Fact-checking by Monica Stanovic.

Rachel Ferat is the Program Manager for the Center for Public Health Systems

And Rebecca Sale is the Head of Strategy and Partnerships for the Center for Public Health Systems.

Thanks to all of you!

Resources:

Mitch Stripling, MPA - ICAP at Columbia University

What We Do - NYC Preparedness & Recovery Institute