Argument and Contribution

At the national level, the United States struggled to effectively respond to the COVID-19 pandemic: federal policy was delayed and inconsistent, supply shortages were widespread, and political pressure undermined accurate public health guidance. At the state and local levels, however, there was a great deal of variation in terms of the capacity to respond to COVID. While indicators of state capacity often focus on “formal” indicators like institutional resources, staffing, and finances, translating formal capacities into effectively implemented policies is neither a simple nor an automatic process. 

In “Building the Plane While Flying,” Didi Kuo and Andrew S. Kelly draw our attention to the importance of informal indicators of public health capacity. These include strong relationships within and across government agencies, the embeddedness of health officers in local communities, and prior experience with responding to disasters, among other factors. The authors argue that local governments with strong informal capacity were better able to communicate with and learn from one another, as well as to gain the trust of community members, during the pandemic. Conversely, localities with otherwise strong formal capacities often failed to respond to the challenges at hand. This is because they were unable to effectively leverage their relationships and organizational networks.
 

Kuo and Kelly’s paper is informed by qualitative analysis of California’s public health institutions as well as in-depth interviews with health officers across seventeen Northern, Central, and Southern California counties. The interviews illuminate the concrete processes by which local governments responded (or struggled to respond) to the COVID-19 pandemic. One of the paper’s key contributions is to push us to conceptualize state capacity more broadly and to focus on the factors that drive not just policy development, but policy implementation. 

The Importance of Informal Capacity

The bulk of the paper disaggregates informal capacity into its various mechanisms and processes. Each of these proves to be crucial in explaining different pandemic outcomes at the local level. One such mechanism is coordination within local governments. To illustrate this, consider public health officers, who enjoy broad legal powers to protect public health as well as financial resources and personnel at their disposal. By law, officers possess significant capacities to mitigate health crises. Yet across the interviews, health officers reported that effectively implementing COVID-19 policy required their cooperation and communication with a host of actors, including the County Counsel (the county’s top lawyer), Chief Administrative Officer, and Board of Supervisors, which is charged with appointing health officers.
 

Closely related to intra-governmental coordination is the importance of autonomy, particularly in the face of political pressure. For example, boards of supervisors sometimes undermined the public guidance provided by health officers. (This guidance could range from the need to close schools to officers simply communicating truthfully with localities about COVID-19 risks.) Overcoming efforts by board members to ignore or muzzle officers required coordination between those actors who were more insulated from political pressure.

Another key component of informal capacity was prior experience responding to emergencies and California’s myriad of natural disasters, such as fires, floods, or mudslides. Health officers from more experienced counties noted their ability to draw upon established emergency procedures and partnerships. For example, some counties had previously cooperated with each other, as well as with independent agencies like the Red Cross, to provide aid and shelter to those affected by wildfires. These experiences — for which no amount of financial resources or personnel can substitute — served as templates to help coordinate COVID-19 policy responses.

Informal capacity also depended upon health departments effectively communicating with the public. Many departments initially lacked the infrastructure to do this, and therefore relied on cooperation with other actors like school superintendents, sheriffs, and community leaders. Some counties created toolkits to improve their community’s understanding of personal protective equipment (PPE) or even produced local TV shows. Still others scheduled conference calls with local hospitals, faith leaders, and nursing homes. Given that many of these communication efforts were improvised, public health officers stressed the importance of formalizing coordination between state and nonstate actors so as to improve emergency preparedness in the future.
 

In addition to coordination within local governments, effective policy-making and communication required coordination across governments. One such institution was the Association of Bay Area Health Officers (ABAHO), founded in the 1980s during the HIV/AIDS epidemic. ABAHO members had also coordinated policy responses to the H1N1 outbreak. These cross-county partnerships enabled early, rapid, and unified responses to the COVID-19 pandemic. By contrast, the authors find that regions without such networks faced greater challenges in developing and implementing public policy.

A final aspect of informal capacity is the social embeddedness of health officials in their communities. This includes partnerships with leaders of businesses and faith groups, teachers, and restaurant owners. Not only did these partnerships increase the scope of outreach, but they also often established relationships that had not existed beforehand. Gaining a foothold in local communities thus increased the likelihood that community members would support policies and enabled local governments to access hard-to-reach populations.
 

Kuo and Kelly’s analysis of informal capacity should give us pause when considering existing indices of public health preparedness; some of these have ranked the United States quite high despite its often ineffective responses to the COVID-19 pandemic. That this mismatch occurs is arguably a function of observers prioritizing formal capacities. For federal, decentralized countries like the US, informal capacities and relationships are essential not only for delivering services but for generating legitimacy and trust among those receiving services.

*Research-in-Brief prepared by Adam Fefer.

It’s always great to see the work of one of our researchers shouted out in the New York Times. It’s even better when it becomes the scientific basis of an argument thrown into the mix of a presidential campaign.

Nicholas Kristof asserted in his column on Sunday that when women are involved in the political process and given the capacity to shape public policy, everyone benefits, particularly when it comes to health.

Kristof, who covers human rights, women’s rights, health and global affairs for the Times, wrote in his column:

Put aside your feelings about Hillary Clinton: I understand that many Americans distrust her and would welcome a woman in the White House if it were someone else. But whatever one thinks of Clinton, her nomination is a milestone, and a lesson of history is that when women advance, humanity advances.

Grant Miller of Stanford University found that when states, one by one, gave women the right to vote at the local level in the 19th and early 20th centuries, politicians scrambled to find favor with female voters and allocated more funds to public health and child health. The upshot was that child mortality rates dropped sharply and 20,000 children’s lives were saved each year.

Many of those whose lives were saved were boys. Today, some are still alive, elderly men perhaps disgruntled by the cavalcade of women at the podium in Philadelphia. But they should remember that when women gained power at the voting booth, they used it to benefit boys as well as girls.

Miller, an associate professor of medicine and core faculty member of Stanford Health Policy, first wrote about this issue in the Quarterly Journal of Economics in 2008, arguing that women’s choices appear to emphasize child welfare more than those of men.

He presented evidence on how state-to-state suffrage rights for U.S. women from 1869 to the adoption of the 19th Amendment in 1920, which gave all women the right to vote, helped children benefit from scientific breakthroughs.

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Simple hygienic practices — including hand and food washing, boiling water and milk, refrigerating meat and the renewed emphasis on breastfeeding — were among the most important innovations in the 19th and early 20th centuries to help protect children from often-fatal diseases such typhoid fever, smallpox, measles and scarlet fever.

“Communicating their importance to the American public required large-scale door-to-door hygiene campaigns, which women championed at first through voluntary organizations and then through government,” explained Miller, who is also a senior fellow at the Freeman Spogli Institute for International Studies and the Stanford Institute for Economic Policy Research.

As women became more and more involved in state and federal politics, Miller found, child mortality declined by 8 to 15 percent, or 20,000 fewer child deaths each year.

“Public health historians clearly link the success of hygiene campaigns to the rising influence of women,” Miller wrote, citing examples with data and graphs.

That women have been — and can be — so influential seems like a no-brainer, but it’s nice to have the science to back it up.

Stanford students belong to the first generation that could witness the end of extreme global poverty — in what would be one of humankind's greatest achievements — the head of the World Bank said during a recent talk on campus.

But their generation, he said, is also likely to experience the first global pandemic since the 1918 influenza that killed more than 50 million people.

Jim Yong Kim, president of the World Bank, said innovations in health, education and finance are behind the World Bank's twin goals of ending extreme poverty and boosting shared prosperity for the bottom 40 percent of the global population.

Speaking at the inaugural conference of the Stanford Global Development and Poverty Initiative on Oct. 29, Kim lauded faculty and students for their multidisciplinary approach in tackling poverty and improving public health. He is an infectious disease physician who oversaw World Health Organization initiatives on HIV/AIDS.

"Seeking transformative solutions to challenges of development and poverty that are necessarily cross-disciplinary is exactly what a great university should be doing," Kim said in his speech at Stanford.

The World Bank announced last month that the number of people living on less than $1.90 a day is expected to drop to 9.6 percent of the global population by the end of the year. That is down from 36 percent in 1990.

The bank has pledged to cut that rate to 3 percent by 2030.

"We expect the extreme poverty rate to drop below 10 percent for the first time in human history," he said. "This is the best news in the world today. And this is the first generation in human history that has been able to see that potential outcome." 

Promoting prosperity

One of the co-founders of Partners in Health, Kim was the keynote speaker at the daylong conference, "Shared Prosperity and Health," which drew together Stanford faculty and researchers, plus government and NGO officials from around the world.

Stanford's global development and poverty effort is a university-wide initiative of the Stanford Institute for Innovation in Developing Economies, known as Stanford Seed, and the Freeman Spogli Institute for International Studies. The conference was held at Stanford's Graduate School of Business, which was a partner in the event.

Kim's talk was optimistic about the newly adopted U.N. Sustainable Development Goals, with an ambitious agenda to end poverty and hunger, ensure healthy lives, empower women and girls and attain quality education for all children by 2030.

While those goals seem lofty, Kim pointed to the accomplishment of bringing down extreme poverty to 10 percent, a figure many had once said was impossible.

Ninety-one percent of children in developing countries now attend primary school, up from 83 percent in 2000, he said. And the number of people on antiretroviral drugs for treatment of HIV in sub-Saharan Africa has increased eightfold in the last decade.

"But we're humbled by the challenges ahead," Kim said. "Rising global temperatures will have devastating impacts on poor countries and poor people – and, as we saw with Ebola, major pandemics are likely to disproportionately affect the poor."

Pandemic threats

Kim said that most virologists and infectious disease experts are certain a pandemic will sweep the world in the next 30 years. He said that would lead to more than 30 million deaths and anywhere from 5 to 10 percent of lost GDP.

He blasted the global community for taking eight months to respond to the Ebola crisis in West Africa, noting that Guinea, Sierra Leone and Liberia had among the fastest growing economies in Africa before the outbreak killed more than 11,000 people – most of whom were poor.

In an effort to speed up financial aid the next time such an outbreak occurs, the World Bank is developing the Pandemic Emergency Facility, which would disburse funding immediately to national governments and responding agencies.

Rajiv Shah, the administrator for the U.S. Agency for International Development from 2010-2015, spoke earlier at the conference about his work leading the U.S. efforts to contain Ebola.

"Three small countries with total population of maybe 30 million people had such weak health systems with so little domestic investment – in one country $6 per capita health investment per year – that when Ebola became a crisis there was no first-line of defense," he said.

By October 2014, the U.S. was pouring hundreds of millions of dollars into containment efforts, including the establishment of a 2,500-personnel military deployment to hit Ebola on the ground. Shah said President Obama "stayed extraordinarily true to the science" of containment at the source.

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Stunted children 

Moving beyond containment of epidemics, Kim said the most important investment developing countries could make in their people starts when a woman becomes pregnant. Using a combination of health, nutrition and education will have lifelong benefits for each child, as well as for the country in which each prospers.

The World Bank estimates that 26 percent of all children under age 5 in developing countries are stunted, which means they are malnourished and under-stimulated, risking a loss of cognitive abilities that lasts a lifetime. The number climbs to 36 percent in sub-Saharan Africa, giving those children limited prospects in life."This is a disgrace, a global scandal and, in my view, akin to a medical emergency," Kim said. "Children who are stunted by age 5 will not have an equal opportunity in life. If your brain won't let you learn and adapt in a fast-changing world, you won't prosper and, neither will society. All of us lose."

From 2001 to 2013, the World Bank invested $3.3 billion in early childhood development programs in poor countries. Kim said innovative policymaking and financial tools allowed the bank to help Peru cut its rate of child stunting in half to 14 percent in just eight years.

"Progress is possible – and it can happen quickly. But we must do even more,"he said.

Kim said the world set a target in 2012 to reduce stunting in children by 40 percent. But that would still leave 100 million children malnourished and undereducated. The bank and world leaders should pledge to end stunting for all children by 2030, he said.

"With partners like the Global Development and Poverty Initiative and the entire Stanford community, I'm full of hope that we can indeed be the first generation in human history to end extreme poverty and create a more just and prosperous world for everyone on the planet."

Read more here about another innovation to improve health in the developing world.