This is the month when New Yorkers are due to finally receive an official report on the state’s response to the Covid-19 pandemic, one of the deadliest disasters in state history.

The wait has been long. The report is arriving more than four years after the crisis struck, three years after Governor Cuomo lifted the emergency declaration, two years since Hochul first promised a review, 18 months since the state chose a consultant, and six months after the report’s original delivery date.

The stakes are high. New York City proved to be especially vulnerable to the rapidly spreading virus and suffered unusually high fatality rates and economic losses. There was also serious collateral damage from some of the state’s response strategies – particularly in nursing homes and schools.

Only by carefully analyzing what happened – and which official actions went wrong – can the state properly prepare itself for the future outbreaks that are sure to come. Failing to learn from this once-in-a-century experience would be the worst mistake of all.

To conduct this critically important study, the Hochul administration chose the Olson Group, a Virginia-based consulting firm specializing in disaster response. In December 2022, the firm was given a $4.3 million contract with a one-year deadline, later extended by six months.

The firm was not given subpoena power to obtain testimony and documents from uncooperative witnesses, nor did it have the ability to solicit outside input through public hearings.

Still, its report stands to be the first comprehensive account of the coronavirus pandemic in New York, with analysis of the effectiveness of the state’s response and recommendations for bolstering its public health defenses going forward.

To fairly judge the quality of the Olson Group’s work, it’s important to state in advance what the state and its residents need from a study of this kind.

Here is a partial list of the questions and topics that should be addressed as part of a well-done after-action review:

Crisis planning

The state’s Comprehensive Emergency Management Plan is meant to guide official actions during pandemics and other disasters.

• Did the plan as written in early 2020 give appropriate guidance?
• Were there any topics the plan failed to address?
• Was it sufficiently detailed to be useful in a crisis?
• Were state officials aware of and trained for their prescribed roles?
• Did the Cuomo administration follow the plan?
• What updating does the plan need in light of recent history?

Surveillance

It’s apparent in retrospect that the virus reached New York in late January or early February and that its first wave likely peaked in mid- to late March.

Officials were late to understand both of these developments because they were tracking the outbreak mainly through laboratory testing—which was scarce at first and became more abundant over time.

State and city officials had access to alternate surveillance methodologies—such as flu tracking and surveys of emergency room utilization. These either failed to detect the initial Covid-19 outbreak or failed to get adequate attention from decision-makers.

• Did the state’s and city’s surveillance systems show signs of a viral outbreak in early 2020?
• Did the officials monitoring those systems respond appropriately?
• How could those systems be improved?
• How should routine testing of sewage effluent be used to monitor known threats or detect new ones?
• What other surveillance technologies could the state be using for an early warning system?

Stockpiling

Personal protective equipment and other critical supplies predictably ran short as the virus spread around the world—a problem compounded by the fact that PPE manufacturing was concentrated in China, where the crisis began.

New York had established a stockpile in 2006 as a forward-thinking response to avian flu and swine flu outbreaks. However, it lost funding and fell into neglect during the Great Recession. By early 2020, much of the materials in storage had passed their expiration dates—including 70 percent of the face masks, 41 percent of the ventilators and 23 percent of the surgical gowns.

The stockpile nominally included 1,763 ventilators—but many had been loaned out to hospitals, and were not immediately available when needed.

• Which materials and what quantities should the state keep in its pandemic stockpile?
• How can it assure the materials are kept up to date and ready to use?
• How effectively were the available supplies distributed in early 2020?
• How should the state plan for purchasing, maintaining and distributing supplies in the future?

Testing capability

In February 2020, when testing kits produced by the CDC were found to be contaminated and unusable, scientists at the Health Department’s Wadworth Laboratories quickly developed test kits of their own. However, the state had to wait for FDA approval before putting their alternative tests to use.

• What was the timeline of these events?
• Should federal regulations be changed to waive FDA approval for state-developed testing technology in emergencies?
• Should the state be prepared to move forward with its own testing in the absence of federal approval?
• Should the state collaborate with private manufacturers and testing laboratories to speed the distribution and processing of test kits during emergencies?

Cost-effectiveness of interventions

The governor used his emergency authority to implement dozens of interventions to manage the pandemic. These included travel restrictions, limits on gatherings, business closures, school closures, mask mandates, contact tracing, limits on visitors in hospitals and nursing homes and vaccine mandates for health-care personnel, among many others.

Although meant to protect the public’s health, these interventions disrupted normal life, infringed liberties and caused a massive economic slowdown. There is widespread concern that some policies, such as prolonged school closures, did more harm than good.

The state’s after-action review should include each intervention, including:

• Travel restrictions
• Limits on gatherings
• Business closures
• Designation of “essential workers”
• School closures
• Mask mandates
• Contact tracing
• Limits on visitation in hospitals and nursing homes
• Suspension of elective procedures in hospitals
• Liability waivers for health-care providers
• Testing mandates for health personnel
• Vaccine mandates for health-care personnel

In each case, the review should answer the following:

• What were the costs and benefits? 
• Were these interventions implemented in a timely and effective manner?
• Which of these steps should be taken during future pandemics, and under what conditions? 
• How can the harms of emergency measures be mitigated?

Internal communication and chain of command

During the early weeks of the crisis, state and local officials repeatedly clashed over policymaking. On several occasions, then-Mayor de Blasio would announce a policy—such as closing schools or urging people to shelter in place—only to be overruled by Governor Cuomo, who would issue his own similar order a few days later.

Behind the scenes, state Health Department officials have said they were blocked from sharing information with their counterparts in New York City and other local authorities.

• What was the proper division of responsibility and authority between state and local officials during this pandemic?
• Were these rules clear to state and local officials and did they follow them?
• Why were the city and state unable to work together more cooperatively?
• What harm was caused by these conflicts over policy and limits on communication?
• Should the division of responsibilities be modified in the future?

Expert consultation

Officials in the Health Department, including then-Commissioner Howard Zucker, have said they had little input into pandemic management—and sometimes learned of policy changes by watching the governor’s daily briefings.

Instead, the governor appears to have relied on other sources, such as consulting firms, to guide his decision-making. During some of his briefings in late March 2020, Cuomo showed projections by consultants indicating that the state’s hospital system would soon be overwhelmed by infected patients—a possibility that appears to have driven subsequent decisions, such as a scramble to open temporary hospital facilities and an order sending infected patients from hospitals into nursing homes.

• What expertise and experience did Health Department personnel have with respect to managing pandemics?
• What led the governor to look elsewhere for advice?
• What resources did the governor and other officials use to guide their decision-making?
• What was the quality of information and analysis those resources provided?
• Should the state prepare for future pandemics by developing better in-house capabilities or continue relying on outside help?

External communication

While the governor’s daily briefings received wide attention, both from the public and the press, the state did relatively little to communicate with those who were not tuning in or following media reports.

The state Health Department was slow to produce public service announcements for television and radio. The resulting spots were often poorly produced and included out-of-date guidance.

• How effectively did the state communicate its public health guidance to the general public?
• Did the state use the full range of communication systems, such as billboards, posters, text messaging, social media and automated highway signs?
• What was the quality of the state’s guidance and messaging?
• Does the state have a plan for quickly producing effective public service advertisements in emergencies?
• Should the state work with professional advertising agencies to improve its public health communications, both routinely and during pandemics?

Hospital capacity

During the worst of New York City’s first wave, some hospitals were filled to capacity with Covid patients, leading to crowded conditions and over-stressed staff, while others had empty beds due to a drop in non-emergency procedures—at first due to fear of infection, and later because of state restrictions. As Cuomo noted at the time, a hospital system run by multiple independent owners was poorly equipped to reallocate patients from one facility to another.

State officials also became concerned about models indicating the need for hospital beds might peak at a level that far exceeded the available supply. Although the models proved incorrect, they caused officials to scramble for additional beds.

• To what extent did hospital crowding contribute to New York’s unusually high mortality rates?
• Which hospitals ran low on space and why?
• How close did New York City’s overall hospital system come to running out of beds?
• What are the logistical obstacles to transferring a sick patient from one hospital to another?
• How well did the Cuomo administration’s “surge and flex” system work to alleviate pressure on crowded facilities?
• What can be done in the future to reallocate patients from overcrowded hospitals to other facilities with more space?
• How likely is New York to run critically short of hospital beds in a future pandemic?
• How can the state prepare in advance to quickly create temporary hospital capacity?

Underused emergency hospitals

Concerned about a looming shortage of hospital space, officials rushed to create an emergency hospital at the Javits Convention Center and to deploy the U.S.N.S Comfort, a Navy hospital ship, to Manhattan. Both of these facilities went largely unused, even as thousands of patients were transferred into nursing homes.

• What contingency plans had been prepared before the crisis for responding to overcrowding of hospitals?
• Were those plans followed?
• Why weren’t more patients relocated to the Javits facility or the Comfort?
• What protocols should be established to assure better utilization of temporary hospital capacity in the future?

Health Department structure and performance

A state-operated system for tracking infectious disease outbreaks in nursing homes failed to provide an early-warning of the Covid crisis because of widespread non-compliance by operators. A comptroller’s audit found that the Health Department had been aware of these problems for years but had done nothing to fix them.

The comptroller’s office said this and other shortcomings in the department’s oversight of nursing homes raised questions about the department’s “control environment”—a reference to effectiveness and integrity of its top-level management.

Since the 1990s, when the Health Department took charge of Medicaid, the challenge of managing that massive safety-net health plan has increasingly overshadowed the department’s traditional public health functions. Funding and staffing for some of these functions, such as the Wadsworth laboratories, has either decreased or lost ground to inflation.

• Has the department’s system for tracking outbreaks in nursing homes been fixed?
• Why wasn’t the issue addressed earlier?
• What if anything has been done to improve the department’s control environment?
• Should the department be restructured to separate Medicaid management from its other duties?
• Is the state providing adequate resources for the Wadsworth laboratories and other public health functions?

The March 25 order

In another effort to avoid hospital crowding, the Cuomo administration on March 25, 2020, directed nursing homes to accept the transfer of recovering Covid patients from hospitals without waiting for them to test negative—or even to be tested at all. 

More than 9,000 patients were transferred under that order before it was ended the following May 10.

Although there were other ways that Covid-19 found its way into nursing homes, those transfers likely contributed to what became high rates of illness and death among residents.

• How did the March 25 order come to be issued?
• What was the role of the Greater New York Hospital Association in crafting the order?
• To what extent did state officials consult nursing home officials or other experts before issuing the order?
• When and how was the order communicated to the nursing home industry?
• What accommodations were made for facilities that were reluctant to accept infected patients?
• What financial incentives, if any, existed for hospitals to discharge the patients or for nursing homes to admit them? To what extent did those incentives influence the facilities’ decisions?
• To what extent did the order provide useful relief for hospitals experiencing critical levels of crowding?
• Since the crowding was concentrated in New York City, why was the order extended statewide?
• Why did the order remain in place for weeks after hospitalizations started to decline?

Ventilator utilization

During the early weeks of New York’s first wave, doctors noticed a high fatality rate for patients on ventilators and found that positioning patients on their stomachs—or “proning”—was more effective.

The same practice was soon adopted by doctors across the country and around the world.

• To what extent did ventilator use early in the outbreak contribute to New York’s unusually high fatality rate?
• When were the advantages of proning discovered and which doctors and hospitals were the first to try it?
• How quickly was news about this alternative treatment shared with other providers?
• What role did public health officials play in vetting the new procedure and promulgating its benefits?
• How should the state foster the speedy development and promulgation of best treatment practices in future pandemics?

Scandals

During the pandemic, the governor and other officials were accused of abusing their authority in various ways related to the crisis.

Early on, friends and family members of the governor and other prominent officials reportedly received special access to Covid testing that was otherwise scarce. In some cases, the VIPs received house calls from a high-ranking Health Department doctor and their samples were transported by state troopers.

After the crisis in nursing homes made headlines, the administration was accused of withholding complete data about resident deaths through early 2021—when the attorney general issued a critical report and the Empire Center won a lawsuit under the Freedom of Information Law.

The governor’s office also reportedly intervened to alter a July 2020 report by the Health Department, removing key data and manipulating findings to minimize the impact of the March 25 order.

At some point in the spring of 2020, Governor Cuomo and his staff began working on a memoir that he later sold for $5.2 million – and which he apparently produced with extensive use of government personnel and other public resources.

In the spring of 2021, a longtime Cuomo associate who was in charge of vaccine distribution reportedly called county officials to check their loyalty to the governor – which some took as an implied threat to withhold vaccine supplies.

To clear the air, the review should establish the truth about each of these pandemic-related scandals.

• Who received preferential testing?
• How were their samples and results handled?
• What motivated the administration to withhold accurate information about the death toll in nursing homes?
• How was the Health Department’s July 2020 report altered and by whom?
• What were the actual effects of the March 25 order? Did it worsen conditions in the homes that admitted Covid-positive patients?
• What can be done to prevent manipulation and misreporting of data in future public health crises?
• When did work begin on the governor’s memoir?
• To what extent was the book produced with the help of state employees and other government resources?
• To what extent did the book project distract from government duties or influence decision-making?
• Was the governor’s control over vaccine distribution used to improperly pressure county leaders?
• Were any laws broken and by whom?
• Should laws be strengthened to prevent similar wrongdoing in the future?

During the legislative session that ended last week, lawmakers missed the chance to establish an independent commission on the pandemic response which, unlike the Olson Group, would have had the power to subpoena witnesses and conduct public hearings. The proposal‘s supporters should keep that idea alive for future sessions, especially if the Olson Group’s report leaves any of the above questions unanswered.