WHY WE WEREN'T READY FOR COVID-19: "Voters find policies with up-front prevention costs to be less attractive than more-expensive policies that pay large amounts after the fact.".

• Author: Strach, Patricia
• Position: PUBLIC POLICY

FOR THE PAST DECADE, we have been studying how local governments respond to public health crises: from 19th-century yellow fever and cholera outbreaks to the contemporary opioid epidemic and COVID-19 pandemic. Although the years, elected officials, and particular health problems change, the patterns are strikingly similar. Here are five lessons we have learned:

Public health crises are crises of capacity. Nineteenth-century municipal documents record page after page of deaths due to contagious diseases like yellow fever and cholera. Disease is constant. Capacity to manage disease outbreaks, however, varies significantly across governments and over time.

Capacity means ability. It entails both expertise to know what to do and infrastructure to carry it out. Some 19th-century local governments were able to marshal resources to accomplish basic tasks, like collect trash and install sewers, which prevented disease outbreaks. Others lacked even the most-basic infrastructure and, sometimes, went so far as to rebuff local businessmen when they offered to help at their own expense.

Today, we still rely on local governments to monitor and maintain public health--and, like centuries ago, they have vastly different resources. Los Angeles County, the nation's largest, has huge problems but also substantial resources--from expertise to infrastructure--to assess these problems and target solutions. More common are smaller, rural counties that have limited resources and often lack expertise (like epidemiologists) on hand in times of crisis. These smaller counties may lack basic services, like doctors, hospitals, and access to ICU beds in their communities.

Yet, diseases--from yellow fever to COVID-19--are equally deadly in poorly resourced areas. Federal and state officials need to take into account the capacity that communities have at their disposal when responding to a public health crisis. Large cities have more rapid transmission, but they have more health-care professionals to treat people. Small, rural towns may have slower transmission, but they also have fewer health-care professionals. Many rural communities in states that did not expand Medicaid as part of the Patient Protection and Affordable Care Act have seen hospitals close or services gutted. In short, the community's capacity to address public health problems has been diminished. Now, in the face of a widespread epidemic, it will not be easy for them to ramp up.

To address the current...