key: cord-285397-rc65rv6r
authors: Comfort, Louise; Kapucu, Naim; Ko, Kilkon; Menoni, Scira; Siciliano, Michael
title: Crisis Decision Making on a Global Scale: Transition from Cognition to Collective Action under Threat of COVID‐19
date: 2020-05-30
journal: Public Adm Rev
DOI: 10.1111/puar.13252
sha: 
doc_id: 285397
cord_uid: rc65rv6r

nan

engage citizens in collective action to reduce risk (WHO 2017 ). Yet, decades of diminished investment by constituent nations and corresponding charges of mismanagement have left the existing international governance mechanisms, such as WHO, Office for the Coordination of Humanitarian Affairs (OCHA) and the Office for Disaster Risk Reduction (UNDRR), without the resources, personnel, monitoring systems or global operational networks necessary to mount an early and effective response. Consequently, the mechanisms for credible search and exchange of valid information to inform decisions and action on multiple scales of operation at the level and speed needed to inform global decision making were limited, leaving nations to chart individual courses of action with widely varying results.

Drawing on research from decision making in complex, dynamic conditions (Hutchins 1995; Comfort 2007; Kahneman 2012) , we examine four basic functions -cognition, communication, coordination, and control-that appear central to governmental decision processes in all countries as public officials grapple with how to recognize, respond, and recover from this deadly, invisible threat. We follow this discussion with comparative vignettes from three nations as they addressed the threat of COVID-19, leading to strikingly different outcomes. We conclude with recommendations to invest in a global information infrastructure to enhance cognition as a first step in managing large-scale, multi-disciplinary threats to the health, economy, and sustainability of the world's community of nations.

Public leaders have quintessential responsibility for protecting the lives and livelihoods of their constituents. In routine times, they may follow time-honored procedures honed over decades of experience, confident that lessons from the past will guide them (Kettl and Fesler 2005) . For public leaders facing unknown risks, decision making is fraught with uncertainty and becomes an adaptive process that has four distinct components: (i) cognition, This article is protected by copyright. All rights reserved.

(ii) communication, (iii) coordination, and (iv) control (Comfort 2007) . Under conditions of COVID-19, how public leaders exercised these four functions proved critical in different contexts.

Cognition. In crisis management, cognition is the "capacity to recognize the degree of emerging risk to which a community is exposed and to act on that information" (Comfort 2007: 189) . Importantly, cognition provides the transition to action. It constitutes not simply the perception of risk to self, but also comprehension of the risk to others (Fligstein and McAdam 2012) . That is, action taken may help oneself, but action not taken may irretrievably harm others. The fundamental component of empathy in cognition creates a human connection to others who share the risk and spurs collective action for the benefit of the community as a whole.

Public leaders had difficulty in recognizing the depth, scale, and lethality of COVID-19. From the first slow, sobering discovery of the virus as it emerged in Wuhan, China to the broad determination that ordinary methods of treating the novel coronavirus were ineffective, cognition came late to public leaders in individual countries as they searched unsuccessfully through old models of dealing with contagion. By the time public leaders recognized the lethality of COVID-19, it was already spreading silently in their communities. While measures to suppress social interaction slowed the spread of the virus, they also created a cruel trade-off by shutting down schools, travel, commerce, and cultural activities that make societies function.

Communication is defined as a process that links sender and receiver in shared comprehension of messages (Luhman 1989) . In doing so, communication creates shared meaning among actors with different roles. It is the means used to inform partner agencies in the global community as well as the public in different nations about the potential risk and rationale for evidence-based mitigation measures and the need for collective response. Effective communication to explain COVID-19 to the public as an invisible, novel, deadly threat requires strong leadership, timely, evidence-based information, and trust to build broad public consensus to support collective action (Ansell, Boin, and Keller 2010; Kapucu 2006) .

Coordination is defined by the degree to which organizations align their resources, tasks, and time to engage in interdependent functions to achieve a shared goal (Comfort 2007) . In complex environments, coordination requires articulation of shared goals among diverse actors in response to shared risk. Coping with the risk of COVID-19, each nation faced decisions on how to align the components of their respective national response systems in ways that would slow or stop transmission of the virus, actions that would also contribute to the global goal. Public leaders build trust with their constituents through timely, informed communication, enabling citizens to accept the validity of proposed actions for both self and community and to act, collectively, under the extraordinary constraints of crises.

Control is defined as the capacity to respond to an external threat and still maintain regular operations in the society (Comfort 2007; 2019) . In reference to COVID-19, control means achieving a reasonable balance between mitigating the spread of the infection, building healthcare capacity, and managing a safe level of economic and social activity. The global crisis generated by COVID-19 requires coordination not only across jurisdictional boundaries within countries, but also across national boundaries to bring this massive pandemic under effective control. The following section briefly characterizes the policy actions taken by three countries in response to the threat of COVID-19 but focuses on the function of cognition as the initial step toward building effective communication, coordination and control of the pandemic.

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South Korea's previous experience with MERS in 2015 significantly increased the level of cognition of COVID-19 as a severe risk for individuals as well as government agencies. The MERS experience taught Korean decision makers primary lessons regarding prevention and mitigation of community infection, especially at hospitals, clarification of the command center functions, which became the Korean Center for Disease Control and Prevention (KCDC), and information sharing among ministries, local governments, and citizens utilizing advanced information technology (Moon 2020).

Recognizing early the risk of community infection from the progress of COVID-19 in China, the KCDC started to strengthen surveillance for pneumonia cases in health facilities nationwide from January 3, 2020. Moving quickly, the KCDC began to develop analysis and testing methods for COVID-19 on January 13. Private medical companies such as Seegene also started to develop the test kits on January 21. The KCDC issued emergency use authorization on February 12 within a week after the application for the approval of Seegene.

With rapid development of test kits, South Korea reduced the time required for testing for presence of infection from 24 to six hours.

Controversies arose when the KCDC reported the first confirmed patient, a Chinese national traveler who resides in Wuhan. Many citizens, as well as opposition parties, called for banning travelers from China and intensive preventive measures. The KCDC scaled the national alert level from Blue (level 1) to Yellow (level 2) but did not adopt the travel ban policy following the WHO recommendation on January 23. Instead, the Ministry of Foreign Affairs increased the level of travel-alert to level 2 and asked for high caution in traveling to Wuhan. Almost two weeks later (February 4). the Korean government banned entry of travelers from Wuhan, not all of China. Also, the Korean government checked the health status of entrants from overseas and used information and communications technologies (ICT) to deliver information and to identify the contacts. This article is protected by copyright. All rights reserved.

The second outbreak of COVID-19 emerged on February 17 due to the Shincheongji (religious cult group) community infection in Daegu province. Well aware of the risk of escalating the infection, the Korean government raised its national alert level to the highest level (level 4) and tested all religious groups in Daegu province. With the quick development of test kits, the KCDC could test more than 10,000 suspected cases every day and continuously increased the number up to 18,000 tests per day in early March. At the same time, the Korean government and civil society began to coordinate limited medical resources.

While the national health insurance program provides full access to medical services for all people regardless of income, the local government did not have sufficient medical staff and hospital beds. Responding to the immediate challenge, local governments less affected by COVID-19 took patients from Daegu, and hundreds of doctors and nurses volunteered to take care of patients. Private companies and hospitals provided their facilities as special units for taking light-symptom patients. More than 180,000 citizens volunteered to help patients and support local communities between January 20 -March 17. Government agencies worked with pharmacies to distribute masks to the public (The Government of ROK 2020a).

Extensive information-sharing between local governments and citizens developed and maintained collective cognition of the disease as public risk. Before mid-February, the KCDC traced contacts of infected people manually. In early February, the Korean government quickly developed the COVID-19 Smart Management System (SMS), which analyzes data from 28 public as well as private organizations, such as credit card companies and smartphone companies. Using this system, the KCDC could analyze any movement of infected patients within 10 minutes and share that information with citizens through cellphone text messages. The SMS evoked the issue of privacy (Park et al. 2020 On February 19, 2020, the first person from a small town 70 km south of Milan was found severely ill from COVID-19. The Italian Government recognized the severity of this discovery, but several problems affected its capacity to translate such understanding into decisions before issuing a total lockdown of the country. The Italian health care system is very stressed and working to near capacity in ordinary conditions. The buffer for emergencies in Intensive Care Units is practically non-existent (Grasselli et al. 2020 ) and burdened by poor response capacity of peripheral hospitals and lack of emergency plans (Villa et al. 2020) .

Timely cognition was hampered by the mixed patterns of communication to the public regarding measures to suppress the infection and the chaotic, puzzling debate they generated. This article is protected by copyright. All rights reserved.

Public leaders at all levels issued opposing opinions and statements. Lombardia region proved to be the epicenter of the contagion, with 75,134 cases as of April 29 (Manca 2020).

By mid-May, the plan for reopening the country mainly consists of a calendar for gradual reactivation of businesses. Confusion still persists regarding the many guidelines circulating within individual organizations and among regions that are not always consistent.

Information regarding reopening is provided late, as has occurred with all preceding decrees.

Decree 33 issued on May 16 provides indications regarding mobility within regions and internationally, but specific norms are not provided for businesses (Dwyer 2020) . The report prepared for the Italian Government to support the entrance into reopening is not publicly available and only partial and fragmented elements of it have been reported by newspapers.

Still lacking is a strategy that connects economic rebooting, technical and financial support to enact the many restrictions that will impact business productivity, monitoring and surveillance indicators, and practical tools to be used for tracing new surges and mapping the epidemic through a testing plan.

The US response to COVID-19 was slow in comparison to other countries. Only in mid-March 2020 did the federal government and the general public began to acknowledge the seriousness of the disease and act in accordance. Cognition and the subsequent response were hampered by three interrelated issues. First, the Trump administration downplayed the gravity of the situation. Both through press conferences and through conservative media outlets, the early talking points were that the US had the virus under control and that it posed no more threat than the flu (Leonhardt 2020) . Second, the US capacity to identify and respond to global pandemics had been dramatically reduced over the past two years (Sun 2018) . The White House National Security Council's Directorate for Global Health Security and Biodefense was disbanded, and a key homeland security advisor focused on biodefense strategies against pandemics was removed (Lopez 2020). These key actors in the pandemic response system have not been replaced. Third, and most critically, the US lacked the testing capacity needed to understand the extent, and contain the spread, of the virus. Initial concerns of community spread in the US were confirmed on February 29 when the first known US resident died. Because the individual had not been exposed through travel, health officials feared that community spread was occurring across the country.

Despite these concerns, testing capacity lagged. By mid-March, US testing capacity ranked last among eight developed nations (Resnick and Scott 2020) . Reasons for the lack of testing capacity in the US were numerous and include the initially faulty CDC tests produced in February. As testing capacity slowly became available, only those who traveled to China were eligible to be tested. Despite ongoing community transmission, most citizens, even those experiencing symptoms, could not be tested under CDC guidelines. Those guidelines were not updated to facilitate wider testing until March 4 (CDC, 2020). At that time, the US had conducted fewer than 2,000 tests; in comparison, South Korea, a country one-sixth its size, had conducted 140,000 (Meyer and Madrigal 2020) . Without adequate capacity to test, the disease spread relatively undetected and hampered cognition. The artificially low case count provided many public officials with false assurance that COVID-19 was not a serious threat. On March 25, WHO indicated that the US, with roughly 65,000 cases, would become the global epicenter of the pandemic (Quinn 2020). By early April, the country had over 250,000 confirmed cases and 5,000 deaths.

The initial federal response focused on travel restrictions to China and Europe but lacked a broader national coordinated effort to mitigate the spread. In mid-March, the CDC released guidelines advocating for all events of 50 or more people to be canceled and the This article is protected by copyright. All rights reserved.

Accepted Article president advised people to avoid gatherings of 10 or more. Given the federal structure of government, and without national stay-at-home orders, states varied considerably in the timing and extent of interventions used to combat the spread of COVID-19 (Science News Staff 2020). By March 13, several states, including Pennsylvania and Michigan, announced plans to close their schools. On March 19, California became the first state to issue a statewide stay-at-home order. Several states quickly followed, while others delayed decisions until April. Eight states, all with Republican governors, chose not to issue stay-at-home orders for all residents (John 2020 ). Lack of federal-level interventions and mixed communication from the Trump administration culminated in a patchwork of policies that varied from state to state and even within states.

Extreme differences in state policy response created confusion and frustration among the public regarding the risk posed by COVID-19. Protests were held in several states by citizens demanding that the stay-at-home order be lifted (Bosman et al. 2020) . Despite warnings by public health officials, several states decided to reopen their economies by the end of April, much earlier than recommended. Public health officials as well as the WHO warned that reopening the economy and lifting stay-at-home orders early is likely to escalate infections (Chiu 2020) . Lack of federal interventions coupled with an absence of national testing and equipment sourcing strategies pushed states to coordinate response efforts on their own (Science News Staff 2020; Segers et al. 2020 ).

Overall, the impact of the virus on the US economy has been devastating. In the first quarter of 2020, the US stock market experienced one of its worst declines. As the stock market plummeted, so too did employment rates. Data from the US Department of Labor indicated that in a five-week period from March 14 to April 18, more than 26 million unemployment claims were filed. On March 27, the president signed a $2.2 trillion stimulus bill to assist families and companies suffering from the pandemic. By May 17, the number of This article is protected by copyright. All rights reserved.

Accepted Article cases surged to over 1,474,127 with 88,898 deaths (JHU Coronavirus Resource Center 2020).

Slow cognition of the risk led to mixed patterns of communication and lack of coordination at the national level, resulting in devastating losses in lives and economic costs. 

The dilemma between public health and economic functions remains at both global and national scales. The global pandemic unleashed on the world by COVID-19 creates a fundamental test of public values for leaders and decision makers both within and between This article is protected by copyright. All rights reserved.

nations. This harsh test reveals the collective responsibility that we share for self and others in uncertain situations of shared risk and the critical role of of leadership in decision making and mobilizing collective action. It demonstrates the critical role of cognition in precipitating action, as the three countries revealed very different patterns of performance after identifying their first cases of the disease. South Korea already had plans in place after the 2015 MERS threat and quickly devised new programs and policies to strengthen existing capacity in response to COVID-19. Italy identified the threat of the pandemic early but had several weaknesses in preparedness and healthcare capacity that did not allow its early recognition to translate into effective practical interventions. The United States faced a critical fragmentation in cognition between scientific experts and political leaders that delayed substantive action at the federal level for over two months, leading to exponential increases in both cases and deaths. These divergent degrees of cognition led to mixed patterns of communication at the federal level and fractured efforts at coordination across a large country, while leadership at state and municipal levels gained the trust and support of their citizens and the large majority, 70%, of U.S. residents, supported stay-at-home policies (Wise 2020 ).

The three cases show that cognition alone does not achieve collective action and control within countries in a global pandemic crisis. Rather, cognition needs to be supported by a rigorous technical capacity and actionable management frameworks for national and international communication and coordination with respect to collecting data, sharing good practices, and monitoring levels of coping capacity. Each nation has a responsibility not only to its own citizens, but also toward other nations in the global community by implementing preparedness plans and making investments to strengthen their health care systems and the system of international organizations.

The COVID-19 pandemic reveals a rare opportunity to redesign global and national systems for managing deadly risks, using science-based evidence and information communication technology, to identify, track, search, and share timely, valid data among nations, triggering innovation and collective action to build a resilient international community. Bold redesign of existing international organizations -WHO, OCHA, and UNDRRthat monitor and compare the status of global risk would reinforce cognition in facilitating effective crisis response across the globe by partnering with nations to work with their local communities.

Enhanced coordination and exchange of good practices among member nations of the global community would save not only hundreds of thousands of lives, but forego trillions of dollars in economic losses, anguish, and pain. It would mean expanding networks of research, collaboration, and knowledge sharing among the world's scientists, scholars, public managers, and students in shared exploration of means for identifying and reducing emerging risks. It would include building and maintaining a global information infrastructure to support continuous learning and adaptation to a changing environment for both professional practitioners and researchers. It would involve designing and implementing plans for a global health infrastructure and training the personnel who would staff and maintain it, with secure funding sustained by responsible international contributions and oversight.

Building a global information infrastructure to support timely, coordinated decision making and iterative learning in public health is not an easy task, but the world's nations designed the United Nations, Marshall Plan, Organization for Economic Cooperation and Development, and security alliances after WWII. With insight gained from the precedentshattering experience of this pandemic and bold public leadership, nations of the world have a unique policy window for transforming global governance capacity to strengthen and maintain public health and, reciprocally, sustain the global economy. and overall situation day by day can be found on the site of the National Department of Civil Protection also in English: http://www.protezionecivile.gov.it/home 2. Data are reported to the Johns Hopkins University Coronavirus Resource Center from multiple credible sources, including the WHO, and represent the best sources available. Yet, the data likely include errors and undercount the extent of actual cases and deaths, due to inadequate reporting in separate nations and states.

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