Want To See What Your City's Pandemic Plan Says? Good Luck.

The response to the growing threat of the coronavirus has varied widely in cities and counties across the country. Some are sheltering in place; others aren't. Some have closed public parks entirely, while others have opted to keep parks open but close playgrounds.

So are things going according to plan? It's difficult to say.

That's because many of the largest cities in the United States keep their local pandemic response plans under lock and key, preventing the public from knowing — or critiquing — how their governments will respond to a public health emergency.

NPR reached out to the public health departments responsible for serving the most populous cities in the United States. We could confirm that only one of the 15 largest cities had their most current pandemic response plan posted publicly online: San Diego. Other cities sent NPR their plans directly, but seven denied NPR immediate access, some saying their plans are not public documents. Of the plans NPR was able to obtain or find, some were last updated nearly a decade ago.

Several cities cited security concerns as a reason for not posting their pandemic response plans publicly. For example, a spokesperson for Columbus, Ohio, said "disclosure of some information in this plan could compromise the security of essential equipment, personnel, services, and systems of Columbus Public Health." A spokesperson for Jacksonville, Fla., said the city's plan "contains sensitive information that could put the health and safety of citizens at risk if disclosed." In response to a request made by NPR under the Florida Sunshine Law, the city released a plan with the majority of pages redacted.

"I can imagine that some of their thinking on these issues was formed back in the early years of this century when a good deal of the public health response and the response at county levels and state levels was formed around concerns about public health emergencies arising from terrorist attacks, including bioterrorism," says Alex Capron, a professor of law and medicine, specializing in healthcare policy and ethics, at the University of Southern California.

Funding — or lack thereof — may be another reason local governments struggle to post updated plans, or keep them current in the first place. According to a 2016 study, government public health spending fell by nearly 10 percent per person since 2008.

Capron says these plans aren't just bureaucratic documents: If shared, they can help lay a foundation of trust, so the public will actually follow key guidance, like social distancing. Keeping these local plans confidential, he says, does not give the public a chance to understand why certain decisions are being made. The stakes of these decisions, Capron says, can literally be ones of life or death.

"Overall, it seems to me that it's the exact opposite of what we need," Capron says. "If we get to the point, which we are likely to get to in some areas, that our hospitals are overwhelmed with acute cases of respiratory distress arising from the novel coronavirus, we're going to have situations in which not all patients will be able to get the highest level of care and some of them will die because they're not getting that care... The sooner public health officials acknowledge that there are going to be these choices and share how they're approaching them, the better."

The 2017 pandemic response plan from the Centers for Disease Control and Prevention, which provides public health guidance to state and local governments, specifically urges clear communication during a pandemic, saying "timely and strong lines of communication will ensure the consistency and effectiveness of information and local decision making before and during a pandemic." The World Health Organization, in its 2017 guidance on pandemic influenza risk management, also highlights the importance of local transparency, saying the objective is to "develop and maintain public trust in local and national health systems and to convey realistic expectations about capacities" for emergency risk management.

"Stopping the speed of community transmission, mitigating the effects, that's still possible, but it depends upon the public having faith in the people who are telling them what they should do," says Capron. "I think we have to trust the public if we're going to call on the public to be a huge part of the response."

A lot of the decisions that get made in a public health crisis are local ones: When to cancel events, when to close schools, bars and restaurants. Local pandemic plans can be useful in guiding those decisions, but they can also help serve as a set of instructions for how to keep critical infrastructure like water and electricity working, says David Brett-Major, an infectious disease physician at the University of Nebraska Medical Center who has worked with the World Health Organization on crises like the 2014 Ebola epidemic in West Africa.

Brett-Major says local plans can help lay out how a city government will tackle the ripple effects of a pandemic, like what happens if hospitals run out of masks or no longer have enough health care workers.

"If I have a dollar for emergency response," Brett-Major says. "And I give that dollar to somebody. Can she then go actually hire someone to help? Or buy the gear?"

He says money suddenly might not be that useful if there isn't any more gear to buy in the first place. And he says even just writing down what could go wrong can help lawmakers think through those scenarios before they happen.

"Plans provide a framework for how people might work together," says Brett-Major. "And so the existential value of doing these plans is that people suddenly realize what their interests are. They've had time to think about it. And they've also started to realize who else they might have to reach in order to be able to attain those interests."

But if a community member wanted to see what those considerations were in their city, in some cases they'd be out of luck. Of the 15 cities NPR reached out to, several local governments had plans posted publicly that were out of date.

In Texas, the city of Austin published its last preparedness and response plan — which instructs city officials to communicate by distributing CD-ROMs — in 2006. Its internal plans, a city official says, were updated in 2011, but can only be requested via the state's public records act. A spokesperson for Houston also said its plans need to be requested through the state's public information act, while acknowledging that the plans currently on its website, which were from 2006, were out of date. After NPR asked about the old plans, the city removed them from its website.

Two other large cities in Texas, Dallas and Fort Worth, could not be reached at all regarding their pandemic plans. In California, Los Angeles and San Jose also did not respond to requests for the city's most updated pandemic plan.

Brett-Major says that ideally, local public health departments would update their pandemic response plans — and practice them — regularly. Instead, he says, plans are often updated after a public health scare, like SARS in the early 2000's.

"They happen in fits and spurts when really they ought to be dynamic," Brett-Major says. "Our attention follows the news cycle."

Of the 15 cities we looked at, only six told NPR they have an infectious disease or pandemic plan that's been updated in the past two years.

One key reason to keep plans up to date is how rapidly communication can change over time, says Krutika Kuppalli, an infectious disease physician and an emerging leader in biosecurity fellow at the Johns Hopkins Center for Health Security.

"One of the things that has been astounding to me and my colleagues in this outbreak is the amount of communication that's happening over social media. And even if I think back to the 2014 Ebola outbreak, there was communication over social media, but not to the extent that is happening now," Kuppalli says.

She said if plans aren't updated regularly, they might miss key ways to communicate, like social media and smartphone push alerts. Take the publicly posted plans from Austin, which are from 2006: Twitter was founded that year and Facebook two years prior, but neither had reached anywhere near the level of cultural importance they hold now.

"Preparedness and responses are things that we don't unfortunately think about a lot in this society that we live in," Kuppalli says. "And so we tend to be more reactive than proactive. And so then when something happens, like what we're dealing with now, we are trying to scramble and put things together."

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