Alabama’s Unified Command for the COVID Response, Part II: Obstacles Galore

As the former Interagency Coordinator for Alabama’s Unified Command on COVID, I was asked to serve on the Alabama Pandemic Response and Preparedness Commission. The Commission was tasked to study the state's response to the COVID-19 pandemic and to assist the state in preparing for future pandemics. Members of the commission were asked to provide input, including answers to several specific questions. My written input to the Commission explained how the response was organized, key challenges we faced, best practices which aided response efforts and recommendations for the future. My input was a “behind the scenes” look at the response in the Spring of 2020 that most people never saw. It had the good, the bad and the ugly. It is presented here in a series of four articles. This is the second article.?

Alabama’s Unified Command for the COVID Response, Part II: Obstacles Galore??

From July 2021 until January 2022, I served on the Alabama Pandemic Response and Preparedness Commission, tasked to study the state's response to the COVID-19 pandemic and to assist the state in preparing for future pandemics. Members of the commission were asked to provide written input, including answers to several specific questions. The first was “What were the three main obstacles each agency dealt with in terms of response.” We had experienced a host of obstacles inside the Unified Command. Winnowing it down to three was a challenge. However, three obstacles did stand out. The first two are sadly all too common in disaster responses, the lack of pre-event relationships and the lack of reliable information. The third was more unique. The third obstacle was the impact of “novelty.” The novel nature of the pandemic and the state’s use of an unfamiliar command structure in Unified Command both contributed to this obstacle.

While my observations are candid and often critical, we were asked to identify obstacles after all, I want to highlight the fact that most challenges were structural, procedural or at the leadership level. The vast majority of the people I worked with inside the Command from the various state agencies were dedicated professionals, doing their best to serve in a very difficult situation. I was proud to be on a team with them.

Three Main Obstacles Dealt with in Terms of the Response:

Obstacle #1 – Relationship Deficiencies

The first obstacle was the lack of pre-event relationships. Establishing pre-event relationships is a tenet of crisis management. “Don’t exchange business cards at the smoking crater” is the common expression in the emergency management and first responder communities. Sound relationships build trust. They also allow organizations to understand the capabilities of other organizations with whom they will interact during a crisis. Trust and an appreciation for the capabilities of other agencies facilitates interagency cooperation in a crisis and allows better integration.?The lack of relationships on multiple levels was an enormous obstacle in the response.

Because the Alabama Department of Public Health (ADPH) is not a cabinet agency and does not report to the Governor, there was a limited relationship between the Governor’s Office and ADPH prior to the pandemic. While the personal relationship between the State Health Officer, the Governor and her senior staff was cordial and based on mutual respect, the were no “operational level” relationships in place. This resulted in various executive branch staff sending multiple messages, primarily requests for information, to various ADPH staff members. The predictable result was a mix of unanswered questions or conflicting information. Establishing a Unified Command and a single point of contact for information within the Unified Command greatly alleviated this issue. However, early challenges due to the lack of a pre-event relationship could have been avoided.

Additionally, there was a limited relationship between the Alabama Emergency Management Agency (AEMA) and ADPH, the two organizations that would form the Unified Command. There was virtually no relationship at the senior level. What relationships did exist were between operational level AEMA personnel and personnel in ADPH’s “Center for Emergency Preparedness” (CEP). The relatively small size and specific focus of CEP reduced the positive impact of this pre-established relationship. In areas where CEP had a role, the distribution of supplies for example, this pre-established relationship was enormously helpful. In the other areas in which the Unified Command would become involved such as, testing, contact tracing, pharmaceuticals, information management, etc. the lack of pre-event relationships was a handicap.

There were also a limited relationships between the Alabama National Guard (ALNG) and the two agencies in the Unified Command, ADPH and AEMA. The ALNG and AEMA had enjoyed a close relationship for many years. Unfortunately, leadership changes at both agencies had a caused that relationship to atrophy. This caused some friction in coordinating support to the Unified Command from the Guard. This was overcome eventually and the Guard personnel inside the Unified Command headquarters in particular were invaluable to the response.

The one “bright spot” in pre-event relationships was the solid connection between AEMA and the Alabama Forestry Commission. In the earliest days of the Command, AEMA coordinated with Forestry to provide key personnel to support the Planning Section of the Command. These personnel were eventually replaced by ADPH and AEMA personnel, but Forestry’s contributions were invaluable and an exemplar of the benefits of pre-event relationships.?

Obstacle #2 – Information Deficiencies

The second obstacle was the lack of reliable information. Each of the agencies in the Unified Command operated on their own information and knowledge management systems. These systems were not compatible and did not communicate. Interagency communications were completely dependent on emails, phone calls and meetings. Each agency maintained its own externally facing dashboards but could not see each other’s internal dashboards. The lack of a single operating system to create, track and share information and knowledge was a significant obstacle to shared situational awareness. For example, the Unified Command created and maintained an electronic Common Operating Picture. This is a critical element in all response operations and was invaluable to the Interagency Coordinator. However, because it resided on the Alabama National Guard network and could only be shared via static reports sent by email or by visiting the room in the Command in which it was maintained, it was of little value to the Unified Command as a whole. Critical information such as Command messaging themes, priorities of work and operational objectives all had to be communicated by voice or email and this information frequently stopped with agency leadership and was never pushed down to personnel in the response. Challenges related to this lack of interoperability increased workload and created trust issues between agencies.

Compounding the limited methods to share information, was the significant lack of actionable information. ADPH relies heavily on a dated computer software program called the Alabama Incident Management System (AIMS) to monitor critical information reported by hospitals, nursing homes, and ambulance resources during times of disasters. AIMS was designed to facilitate support between hospitals during a local emergency like a hurricane. It was not designed for a state-wide event. AIMS is used to track beds available and occupied, ventilators, ICU beds and other information.

The data in AIMS is dynamic and the numbers change daily. Several factors impact the reported numbers.??All hospital data is manually entered, so human error is a factor.?The hospitals report “staffed beds,” a number that can change daily based on staffing availability and required patient-staff ratios.?Some hospitals simply do not report information daily, despite being requested to do so. For example, at the time, there were then 109 acute care hospitals reporting in AIMS. All hospitals were requested to report information using AIMS daily. This did not happen. There was not a single day that all 109 acute care hospitals reported while the Unified Command was activated. The single day high was 105 hospitals reporting. ?It was never clear why the hospitals failed to report uniformly.

Additionally, there was no way to verify the numbers in AIMS. Therefore, AIMS generally provided a “rough number” of hospital beds, ventilators, ICU beds and other information. In a typical localized disaster, this “close enough” information is “good enough” as resources are reallocated around the state to address the needs of an area in crisis. In this scenario where a communicable disease resulted in a pandemic affecting the entire state, AIMS did not provide decision-makers with the fidelity of data needed to conduct a meticulous analysis and make precision decisions. For example, the Command was never able to tell the Governor’s Office exactly how many beds were available at any time. An approximate number was the best the Command could do.

AIMS was also the system that hospitals used to identify shortfalls in personnel protective equipment (PPE) and other supplies. PPE includes, but is not limited to, face masks, face shields, coveralls, gloves, and disposable gowns. However, AIMS only allowed hospitals to input the desired number of these items. There was no way for the Command to know how many of any item was currently on hand in the hospitals or assess the urgency of the need. Again, AIMS completely lacked the level of data needed to conduct analysis and make decisions on the allocation of resources.

Finally, there was no designated procedure for users without access AIMS to ask the hospitals or nursing homes for information. This resulted in communication barriers and a complete reliance on AIMS operators in ADPH to pass information back and forth often resulting in miscommunications.

Obstacle #3 – Novelty Overload

The third obstacle was the impact of “novelty.” The novel nature of the pandemic and the state’s use of an unfamiliar command structure in Unified Command both contributed to this obstacle.

The “novelty” of the SARS-CoV-2 virus itself and the length of time since the last pandemic (Spanish Flu, over 100 years prior) led to what can be called a “paralysis by analysis.” Despite each of the agencies having previously published pandemic influenza plans, these plans were never referenced, utilized, or updated during the Unified Command phase of the response.?“This is a novel virus” was the general justification for this. Agencies failed to execute proven crisis management principles and spent countless hours discussing the “novelty” of the situation and failing to take decisive actions. The virus was novel, however crisis management principles still applied. Despite the novel nature of the pandemic, it was still really just a slow moving disaster. Alabama has considerable experience responding to disasters. Rather than treating the pandemic as a disaster, proven plans, techniques, and procedures were ignored.

In addition to the “novelty” of the pandemic, Alabama employed a Unified Command structure in the first months of the pandemic. Prior to establishing Unified Command, ADPH was the lead agency on the state’s pandemic response. This likely seemed logical as the threat was related to public health. However, the response to the pandemic was in fact a large-scale operation more like a disaster response than a public health issue like HIV, Zika or even the limited Ebola threat had been in the United States. The response required collecting and tracking an enormous amount of data, purchasing, and shipping huge amounts of supplies and coordinating with numerous local, state, and federal agencies to name only a few required functions. These functions were far outside the training, experience, structure, and staffing of ADPH. ADPH was simply not designed to conduct that type of operation.

However, historically AEMA is capable of executing these functions and is typically the agency charged with coordinating disaster responses in Alabama. Once an emergency declaration was signed, AEMA should have been the lead agency in an Incident Command structure with ADPH in support on the public health aspects. Prior to establishing a Unified Command, this was reversed with ADPH in the lead of an Incident Command structure and AEMA in support. Charged with a mission outside of their capabilities, ADPH struggled to coordinate the response.

In an attempt to correct this, with approval from the Governor, ADPH and AEMA established a Unified Command on March 30, 2020.?A “Unified Command” is an authority structure under the Incident Command System (ICS) in which the role of incident commander is shared by two or more individuals, each already having authority in a different responding agency. Unified command is one way to carry out command?in which responding agencies and/or jurisdictions with responsibility for the incident share incident management. Under the Unified Command, the executives of ADPH and AEMA shared equal authority. However, this caused new challenges because Alabama had never attempted a Unified Command at this level in the past. Lack of familiarity with Unified Command and the lack of pre-event relationships described above made the first days of the Unified Command difficult and largely unproductive.

On April 6th, the Governor assigned an Interagency Coordinator (IC) to lead the Unified Command on her behalf. While still a “Unified Command” on paper, this basically created a single incident commander with a combined staff from AEMA, ADPH and supported by the ALNG. This was a structure more familiar to the participants, resembling an Incident Command structure in practice and helped ease the “novelty” of Unified Command at the time.

Unfortunately, the Interagency Coordinator was a volunteer that had to return to the private sector after 90 days. Chaffing under the oversight of an Interagency Coordinator and desirous of more autonomy, ADPH and AEMA both lobbied for a return to an Incident Command structure with ADPH in the lead. Rather than appoint a new Interagency Coordinator and continue Unified Command, this plan was adopted. This was extremely unfortunate as it returned the response to the deeply challenged structure in place before the Unified Command was established.

Author’s Note:

Being fully prepared to deal with the continuing pandemic and future challenges requires capturing the lessons learned from the struggles and successes of Alabama’s COVID-19 response thus far. As that was in part the purpose of this Commission, I was pleased to participate. My input in response to the Commission’s emailed questions of August 3, 2021, was based on my observations during my volunteer involvement, in various roles, from late March through the end of June as well as my years of experience in disaster response and crisis management in the Alabama National Guard. My observations, opinions and input were and are mine alone and do not reflect those of my employer, Dynamis, Inc. or any elected or appointed officials of Alabama government.

?Jim Hawkins, Colonel (USA Retired) - Alabama Interagency Coordinator for COVID-19 Response Unified Command, 4/6/20-6/30/20