New York’s existing plans for pandemics were not enough for the current crisis

Well before “coronavirus” had entered the lexicon of every New Yorker, the state was preparing for the eventuality of a pandemic, whether it was a relatively mild one like the H1N1 flu, which generally had mild symptoms and fairly low hospitalization rates, or a worst-case scenario like current COVID-19 pandemic. Gov. Andrew Cuomo has been widely praised for his response to the crisis in New York, while also receiving some criticism from nurses about an apparent lack of equipment. Some argue Cuomo only appears to be doing well compared to President Donald Trump and New York City Mayor Bill de Blasio, who have both been slow to respond and failed to lead by example. 

Certainly, there is a case to be made that the state could have been better prepared, with plans in place for how and when to close schools and more decisive action taken sooner. The reality of an exploding number of cases – and the strain that’s already putting on downstate hospitals – suggests that despite Cuomo’s therapeutic press conferences, he was caught off-guard. But the state actually had plans in place to respond to a pandemic – it just may not have been enough for the worst case scenario New York is facing.

By and large, Cuomo has been following the guidance of previous pandemic plans. The state laid out the basics of its pandemic response plan in a 2006 state Department of Health document called the Pandemic Influenza Response Plan, which received an update in 2014. City & State could only find the original version, and a request for the 2014 update went unanswered by the state. The guidance, like most pandemic response plans, worked off the assumption that a new virus that can reach pandemic status would most likely be a strain of the flu, unlike the new coronavirus spreading now, but the plans still apply to pandemics in general. In addition to the response plan, the state also has a March 2020 Pandemic Annex to its Comprehensive Emergency Management Plan, put out by the state Department of Homeland Security and Emergency Services, which offers further preparedness plans for interagency coordination. It included the same general timeframe for state action as the 2006 Pandemic Influenza Response Plan.

Cuomo declared a state of emergency in New York on March 7, when the state had only 76 confirmed cases and disease investigators were still attempting to keep track of individual exposures. A week later, on March 11, the World Health Organization declared the new coronavirus a global pandemic. Four days later, Cuomo announced that schools in New York City, Westchester and Long Island would close for at least two weeks to help slow the spread. At the time, the state had a little over 700 confirmed cases, a large number of which were in the city of New Rochelle in Westchester. A day later, the governor closed all bars, restaurants and theaters and asked businesses to reduce in-person workforces by 50%. The number of cases in New York increased rapidly, thanks in part to expansive testing, and on the evening of March 22, after a series of successively more restrictive policies to slow the spread, the state effectively locked down as all nonessential businesses closed and all social gatherings were banned.

Although journalist Ross Barkan in a recent Columbia Journalism Review article questioned why it took Cuomo 22 days after the state’s first confirmed case to take the drastic, but necessary measures, the governor’s timing seemed to follow the state’s Pandemic Influenza Response Plan, which is more of a guide based on CDC recommendations than a step-by-step instruction book on how to deal with a pandemic. For example, it reads that “community-based containment” methods should be enacted – like closing schools and canceling public gatherings – when there is “moderate to extensive disease transmission in the area,” or “many cases cannot be traced to contact with an earlier case.” Cuomo has generally followed that guidance through progressively more restrictive measures as the degree of community spread became more apparent. While hindsight may suggest that moving more quickly would have been prudent, and critics like Barkan are not wrong to point out that the state could have started planning well in advance, the governor has largely kept with best practices determined by state and federal health officials laid out in planning documents.

California had its first confirmed case on January 26, but Gov. Gavin Newsom did not declare a statewide shelter-in-place order until March 20, the same day Cuomo announced his own executive order. Washington state, another hotspot, declared a stay at home order three days later on March 23. While the outbreaks in both states officially began well before New York’s, both still have significantly fewer cases. Although when looking at cases per capita, Seattle still has one of the worst city outbreaks in the country, with the same number of deaths per capita as New York City.

The World Health Organization splits a pandemic into six phases, previous versions of which are detailed in the state’s 2006 response plan, the final stage being a pandemic declared. Those six phases have been updated, according to the 2020 Pandemic Annex, but the updates don't substantially change the points at which various interventions are recommended based on the virus’ spread. About the time the pandemic announcement came, the world at-large was in phase three – comparable to phase five in the old stages – , a point when governments should have been implementing quarantining and social distancing rules, and preparing for more drastic measures. The next phase, whether looking at the old or new version of the stages, is when the most dramatic measures are taken. 

Those phases were playing out as well on a smaller scale in New York and the United States, as Cuomo followed the guides to attempt to contain the virus through more targeted quarantine and isolation before wide community spread occured. When many of the state’s cases were concentrated in the Westchester city of New Rochelle, for example, Cuomo announced a “containment zone” on March 12 within a one-mile radius of a synagogue believed to be the source of the spread. In that limited space, schools were closed and large gatherings were banned. This aligns with a recommendation in the updated 2020 Pandemic Annex, which said that “schools and public gatherings in the area of concern may be cancelled or closed” prior to the most extreme measures when statewide spread is apparent. Arguably, Cuomo could have instituted similar interventions sooner in New York City, which was increasingly becoming an “area of concern.”

The most extreme measures detailed in both plans include community quarantine and social distancing measures statewide, which have been enacted, and setting up triage and treatment centers at non-traditional sites, like the state has done with the Javits Center and other locations.

As COVID-19 spread, Cuomo continually adjusted the restrictiveness of his mandates in ways that seemed aligned with the state response plan, particularly given the speed of new infections and the unprecedented nature of the new coronavirus outbreak. “As soon as you have an event happening, your plan needs to change and be flexible to respond,” Birkhead said. “You can’t plan for every eventuality.”

One example of that is criticism that Cuomo has received from nurses on the ground about a lack of personal protective equipment and from President Donald Trump about not having enough ventilators. Trump said that the state had the ability to buy 15,000 ventilators years ago, referring to a 2015 task force report issuing guidelines if ventilator triage was necessary. That report said that with the current stockpile, the state would not be prepared for a pandemic outbreak comparable to the infamous 1918 flu. But that represented a worst-case scenario, which one might say the state should have prepared for, but no other state has prepared for either. “I’d say we’re as prepared as anyone else was,” Stu Sherman, a New York City Council candidate and bioethicist who was the executive director of the task force that released that report, told City & State. “But it's always difficult prior to the occurrence of a crisis to get attention and resources and preparation for that.” Birkhead said that New York had a fairly large stockpile of ventilators before this current outbreak – Cuomo says the state currently has about 14,000 ventilators between those in use, those sent by the feds and those in a state stockpile  – but it’s uncommon to spend large amounts of money for the off-chance that the worst possibility will come to pass. “At the national level, that stockpile is not prepared for the worst case scenario either,” Birkhead said. The Strategic National Stockpile has only 16,600 ventilators, a number that pales in comparison to the nearly 750,000 ventilators health experts say the country might need if the COVID-19 pandemic is as bad as the 1918 Spanish flu. 

With that in mind, Trump doesn’t seem to have much moral authority with which to criticize Cuomo, especially considering the poor review that his own response has received from media and public health experts alike. That makes it even harder on the state and local responses, particularly when it comes to equipment shortages. “We have great plans that have been developed and refined with each new pandemic event… but we depend on the federal government when response overwhelms local capabilities – which is what is happening now,” Dr. Robyn Gershon, a clinical professor of epidemiology at New York University, wrote in an email to City & State. “The problem is that the federal response was poorly managed.”

Where Cuomo perhaps did not follow the best guidelines was in the preparations before mandates, such as planning for school closures. Americans knew since January that COVID-19 was ravaging China and that health experts expected it to spread internationally. This was a period when the state’s pandemic response plan said that the state should be coordinating with localities to plan for the likely eventuality of a school closure. When Cuomo announced that schools would shut down, he gave New York City and neighboring counties just days to supply him with a plan for providing necessary services such as childcare and food distribution. Both Cuomo and de Blasio received criticism for not taking quicker, more decisive action to close schools. Cuomo originally wanted to leave the decision to the counties.

De Blasio attributed his reluctance in part to the essential role that schools play in feeding children and uncertainty about how to continue this service, a problem that in theory should have been discussed weeks, if not years, before. The pattern could be seen in other mandates as well – the orders came at the same time as the demand for plans, when that planning should have been taking place in the pandemic alert period. The governor’s office and the Department of Health did not respond to inquiries for this story about the state’s adherence to previously established pandemic plans. 

This apparent lack of preparedness could be partly attributed to the severity of the outbreak and its quick spread in the state. The pandemic response plan for the state offers no timeframes for when such steps might be necessary, as it’s impossible to know how a new virus strain might act. Gershon also pointed out that potential shortcomings with the state response would not fall squarely on Cuomo, as localities must also work closely with the state and adhere to best practices themselves when it comes to planning and training.

But given New York’s status as the U.S. epicenter of the COVID-19 outbreak, it would seem that even if Cuomo largely followed established planning, it was still not enough to curb the virus’ spread. With an expected apex rapidly approaching that will push hospitals well past capacity, Cuomo has followed recommended guidance of mandating hospitals increase capacity while searching for more bed space at other health care facilities, as well as hotels and dorms. He’s rapidly identifying and setting up large facilities downstate that can hold 1,000 beds apiece to ease the stress on hospitals. 

Despite Cuomo’s assurances that the state has enough personal protective equipment for frontline workers, including N-95 respirators and plastic face guards, reports from the ground suggest otherwise. Nurses at Mount Sinai West in Manhattan, posted pictures of themselves decked out in garbage bags because they ran out of protective gowns. One nurse has already died there, which coworkers attributed to a lack of supplies. Elsewhere, doctors are reporting that they are forced to reuse masks.

The Cuomo administration has also said that it has not begun shipping ventilators from the state stockpile because the need has not arisen yet. New ventilators “are being deployed on an 'as needed' basis so that they are not being hoarded and can reach the hospitals that need them in real time AS THEY ARE NEEDED,” Cuomo’s second-in-command Melissa DeRosa wrote on Twitter on Friday. Yet The New York Times reports that NewYork-Presbyterian Hospital in New York City is already splitting ventilators, a risky and drastic measure. 

Cuomo himself admitted at a recent press conference that the state is currently failing to flatten the curve of the outbreak, meaning that the spread has not been slowed sufficiently to ease the expected burden on the health care system. This all reflects poorly on New York’s response and preparedness, even if Cuomo attempted to follow established plans.

One area in which the state was well-prepared was its capacity to conduct tests for COVID-19. The devastating lag on that crucial component of the response was the federal government’s fault, not the state’s. 

New York was uniquely prepared to ramp up testing capacity when public and private labs in the state, including the public Wadsworth Center in Albany, got federal approval to perform tests. “The Wadsworth (Center) at the Health Department is probably the premiere public health laboratory in the country outside the CDC,” Dr. Gus Birkhead, a former top official at the state Department of Health until 2015, who was involved in state emergency preparedness and response, told City & State. “They were prepared to begin testing when the CDC distributed the test kits that were faulty.”

Those faulty kits were shipped out at the beginning of February. Wadsworth immediately began developing its own test kits once the faults in the federal kits were discovered. The state kits received Food and Drug Administration approval on February 29 and sent it to other labs across the state. A day later, the state confirmed its first case through a test done at the Wadsworth Center. Since then, New York is performing more tests in total and per capita than anywhere else in the country, with the exception of Washington state. California, another hotspot in the U.S with a population of nearly 40 million, had performed only 78,659 tests as of Friday, which constituted a sharp increase. New York, which has a population of roughly 19.5 million, had performed about 145,753 tests by then. On the national level, the federal government continues struggling to increase testing capacity as well.

Disparity in testing numbers and in the testing information each state releases can lead to confusion among health experts about where hotspots are actually located, and could contribute to New York’s disproportionately high number of positive cases. But for New York as a state, the high volume of testing it has managed to perform has provided the state with valuable data to help inform decision making. Recently, as the state prepares for the surge of patients that will overwhelm current hospital capacity, Cuomo provided updated estimates on necessary hospital beds and ventilators based on that data as the rate of new cases clearly increased.

As the situation grows more dire, perhaps that flexibility that Birkhead spoke of should have come early in the game, with Cuomo choosing to impose stricter mandates than existing plans may have suggested.

Corrections: This article originally misstated the number of ventilators New York has stored, when Washington state issued a stay-at-home order and the date the WHO declared a pandemic. A previous version of this story incorrectly described Stu Sherman's role with the 2015 task force on ventilators.

Clarification: This article has been updated to reflect that the 2006 pandemic plan contained some outdated information about the stages of a pandemic, but which did not affect the overall recommendations of when intervention should be taken based on descriptions of the updated stages.