Covid-19: A Compounding Crisis

by Elisabeth M. Eittreim, author of Teaching Empire; Native Americans, Filipinos, and US Imperial Education, 1879–1918

CNN ran a devastating though not surprising headline on Monday, May 18, 2020: “Navajo Nation surpasses New York state for the highest Covid-19 infection rate in the US.” Two months earlier, the New York City region had shut down, including life in the small suburban town where I live. Schools, businesses, and life in general was (and continues to be) quarantined, and daily news briefings counted the highest number of lives lost and rates of community transmission in the country. Only recently have analyses of nationwide statistics regarding the virus revealed the known but often ignored inequities that plague our nation, as higher rates of COVID-19 infection and death are found among African American, Latino, and other minority communities, disproportionately burdening the most oppressed in the land of the free. Perhaps some of the most ignored and neglected among us are the more than 6 million indigenous peoples living in the United States today.

Despite high rates of compliance to some of the strictest stay-at-home orders in the country, CNN reports multiple risk factors that the Navajo nation faces with the advent of COVID-19: 30-40% of households without running water, multi-generational family units, and limited numbers of grocery stores. Disproportionately high rates of disease and poverty also plague the Navajo and other Native American peoples, increasing susceptibility to the virus.

The Navajo nation’s vulnerabilities today are not indicative of history repeating itself. Today’s vulnerabilities—and those of other minority communities—are historical inequities compounded. Moments of crisis, like this 2020 pandemic, exponentially exacerbate existing inequities: inadequate access to food, health care, medicine, living wages, and safety. Many Americans like to tell themselves that they have worked hard and have thus earned their salaries, their homes, and their lifestyles. And yes, many have worked hard, although most have not been burdened by centuries of generational poverty.

Historically, disease and European then American greed—conquest, warfare, forced removal, and enforced reservation life—decimated the indigenous population of North America. Between 1492 and 1900, more than 85 percent of the population was lost. Assaults on native lives, livelihoods, and culture continued into the twentieth and twenty-first centuries, including through institutions that many Americans considered the great equalizer: school.

While missionaries had sought to reeducate American Indians since early contact, by the late 1800s the US government increasingly invested in schooling to resolve the so-called “Indian problem”—that posed by Native Americans who continued to insist on their autonomy despite US expansion. In 1879, the US government opened the first off-reservation Indian boarding school: the Carlisle Indian Industrial School in Pennsylvania. Established in the east, far from most Native American communities, Carlisle and other schools for Indian education sought to “save the Indian” both from their presumed “backwardness” and from extinction itself. Indigenous families were largely coerced into sending their children to such schools, and too many families would never see their children alive again.

From the Carlisle Indian School’s earliest days, disease stole the lives of native children. A Cheyenne child was the first to die in January 1880. Weeks later, an Iowan child died after only three weeks at the school. Diseases like consumption, measles, tuberculosis, and trachoma plagued all Indian schools. Children died of pneumonia, meningitis, and influenza. In the almost forty years that Carlisle was open, more than two hundred student deaths were officially reported, most from disease, though the actual number is much higher, as sick children were often sent home and not counted.

Government-sponsored Indian schools continue to exist today, though their missions now celebrate indigenous heritage and diversity rather than try to squelch it. Still, education alone cannot remedy the poverty plaguing the Navajo nation and other indigenous communities. Education, however well-intended, does not guarantee that households have running water; such children and their families are acutely vulnerable to COVID-19 as they literally cannot wash away the virus.

Most Americans prefer to celebrate the promise of American democracy rather than admit its flaws. We revel in historic victories but minimize the atrocities. We elevate the stories and events of the past that show our best side but ignore those that expose our worst. Such selective storytelling about who we are impacts the policies and perspectives that we hold today. The Navajo nation’s access to running water today may seem disconnected from historic wrongs, but it is the cumulative result of centuries of disease, displacement, deceit, and denial. In fact, most non-native Americans ignore the existence of modern-day indigenous peoples. We confine native peoples to the past, dress up as pilgrims and Indians in kindergarten classroom Thanksgiving celebrations or cheer on a team mascot embodying the bravery and strength of an Indian warrior, but we do not see the plight or resolve of Native Americans today. We do not burden ourselves with the fact that almost half of Navajo households lack running water.

It is now, in times of crisis, that drastic inequities are revealed and worsened. Let us make it a time where we begin to acknowledge our sins of the past and present, where we strive toward understanding, and where we listen. It is not our job to assume that we have all of the answers, but it is our responsibility to respect and hear native voices.

Elisabeth Eittreim is a lecturer in the History Department at Rutgers University and an adjunct in the Women’s Studies Department at Georgian Court University.

COVID-19: Lest We are Forced to Repeat Past Mistakes

by Mary Bryna Sanger, coauthor of After the Cure: Managing AIDS and Other Public Health Crises

When After the Cure was published, the nation was just recovering from numerous public health threats and crises. Now we find ourselves in the midst of a new and serious one with the emergence of the COVID-19 pandemic. Our experiences in both the policy and management levels and at the federal and local levels have proved uneven at best. Even in areas where the science and effective treatments are clear, public health success often eludes us, even when the stakes are high as they are with COVID-19. Large-scale public health initiatives are complicated, and managing their implementation requires skillful leadership in the face of competing political, organizational, and economic forces. But, as we found in our research, the obstacles to success are often knowable, and “strategic skepticism” of effective public managers can improve the odds.

The history of COVID-19 and the needless death and suffering experienced will surely be seen as a new reminder of what is needed to face these challenges head-on—and how leaders can plan. This will not be the last pandemic.

The lessons we identified in After the Cure bear careful attention today. And it is a failure to heed them that explains much of the chaos and fear we are observing. The COVID-19 crisis, despite its broad spread and massive economic impact, is not so different from many of the public health crises the United States has faced over the years. But the current environment of political denial, weak and uneven policy response, poor and confusing communication, and contentious intergovernmental relations are predictable and typical threats to effective response. They are, in many ways, challenges of management and competence more than they are failures of science or public health. As we analyzed the successes and failures of past efforts in previous US public health crises, we found that management played an outsized role in predicting outcomes. And several key dimensions of management appear crucial.

The lessons of our book seem more relevant today than ever. We considered the discovery and implementation of the polio vaccine initiative, the swine flu vaccine implementation program, reemerging multidrug resistant tuberculosis, the childhood immunization crisis, and the early responses to the AIDS epidemic. All of these efforts faced serious obstacles and challenges, and their successes or failures when they occurred were the result in large part of the quality and nature of executive management by government actors faced with responding to these crises. All major public health crises by their very nature pose a complex combination of social, political, economic, and governance challenges. Failure to identify these challenges and develop a plan to address them in advance explains much of the historical failure in government response to public health emergencies.

Many of the dimensions of the public management challenges we found most important in both the disastrous swine flu debacle and the success of the reemerging tuberculosis epidemic in New York City are key to understanding the COVID-19 story. We documented market failures for important medical supplies, political fights over the implications of scientific findings, the politicization of government research, interagency conflicts, tensions between the federal government and the states, coordination challenges, imperfect dissemination of information through the news media, and questions of distributional equity relating to treatment of different groups and communities. These are all too familiar to our current experience.

Effective responses in past crises featured actors who were able to anticipate and deal with each of these areas—in the case of the COVID-19 response, little or no attention was directed, in advance, to anticipating and developing plans to manage these areas. COVID-19 is not the first time that governments faced challenges with supply chains or disagreements between federal and state actors. But this crisis is remarkable for a lack of planning for how to resolve such inevitable challenges.

But as the pandemic rages on, it is not too late to learn lessons from the past.

Common solutions can be found through the study of historic public health cases. They are as meaningful now as they were then. The overarching lesson is to acknowledge and anticipate these dimensions of resistance and to plan for them. Creative anticipatory responses are needed and facing the challenges with initial skepticism and planning for contingencies is key. New York City’s health commissioner Margaret Hamburg faced multidrug resistant tuberculosis through a carefully orchestrated collaboration with numerous organizational and political stakeholders. She managed the conflict between client advocates and public health nurses who met their homeless patients daily to ensure the administration of directly observed therapy—a key determinant of success among a population spreading the disease. This is not unlike the need to plan for developing a corps of contact tracers to contain virus spread of COVID-19.

Arming executive managers with alternative responses in the face of obstacles takes preparation. Indeed, it requires a way of thinking: learning from the past and anticipating the future. Program design and implementation needs to anticipate what can go wrong and plan for it, such as by sourcing and distributing protective equipment, ventilators, and testing kits. Complex logistics with a global supply chain should have been anticipated and federal leadership to support the states could have provided rational distribution chains to where they were needed. Some of the demands on executive leadership are daunting, but not all of what is needed is rocket science. Some generic types of responses can be built in advance, as the childhood immunization crisis did through legislation that provided cost sharing and indemnification.

Executive management needs to embrace the inevitability of threats to success and approach the design and implementation role with strategic skepticism. Scenario-building is a powerful way to engage in this kind of thinking and planning. Stakeholder mapping, for example, helped in early AIDS response to identify and to plan for the opposition from conservative groups and the Christian coalition. The process helped public health officials neutralize their impact of aggressive early investments in treatments. While the threats of dangerous diseases face complex forces, some unique and idiosyncratic, there is a striking similarity in the obstacles that threaten to derail them. Anticipation can help. Sometimes merely envisioning negative consequences mobilizes ideas and resources to counter them in advance. What Albert Hirschman called “an action-arousing gloomy vision” can and does serve to galvanize executives about impending danger and thus produce strenuous effort to overcome it.

COVID-19 is a reminder of all that can go wrong without planning and executive leadership. Now is a time to revisit the lessons of the past, lest we are forced to repeat them.

Mary Bryna Sanger is professor of urban policy analysis and management and the Deputy Provost and SR. VP for Academic Affairs at the New School University. She is a coauthor of Making Government Work: How Entrepreneurial Executives Turn Bright Ideas into Real Results.