By James C. Sherlock

We could see it wasn’t right as it unfolded.

Virginia’s flawed response to COVID was slow for all Virginians.

Fatal for some.

But the public just saw the broad stroke external effects.

• We saw executive orders that seemed sudden, sweeping, and disconnected from the information we had. It turns out that often the governor himself was operating in an information vacuum.
• In the pandemic’s early phases, the Commonwealth finished last or next to last among states in crucial responses like testing and vaccination program rollouts.  Everything seemed to be invented ad hoc rather than from a plan.  It turns out that was true.
• There was a prescient and well-drawn pandemic operations plan that had been produced by a contractor, but virtually no one in the administration knew what it required, and certainly had never practiced it in any meaningful way or fine-tuned it based on realistic exercises.  When BR found and reported on that plan in 2020, it was pulled from public view.

It is important to make sure that doesn’t happen again, whether in another pandemic or in a cyber attack, hurricane, flood, mass shooting, kinetic terrorist attack, nuclear plant emergency, or something else.

In response to my request, a very cooperative Virginia Department of Emergency Management (VDEM) FOIA official has provided a remarkable and profoundly disturbing two-volume series detailing a running history and operations analysis of what happened inside the government.

It is titled “COVID-19 Pandemic History and After Action Report” Vol. 1 (covers 2020) and Vol. 2. (covers 2021) hereafter referred to as the HAAR.

It was compiled and written under contract by CNA, a highly regarded federal contractor, who had people on site in Richmond during the COVID response.

The HAAR describes and assesses a series of widespread and seemingly endless internal and external government breakdowns that compromised the health and lives of Virginia’s citizens.

Management turmoil in the state government during COVID was so extensive as to be almost indescribable by any group with less talent than the CNA team.

The HAAR documents that Virginia’s COVID response was hamstrung by a lack of operations management experience in the leadership.

I understand that with authority comes responsibility.

But the governor, his Secretary of Health and Human Resources, and his Health Commissioner were effectively the chain of decision makers during COVID.  All three were physicians.

But that is one reason we have a civil service.

Virginia’s civil service failed to prepare for its roles in emergency response long before Ralph Northam was governor.  HAAR documents the complete inability of the bureaucracy to plan, organize and equip, train for, exercise and execute emergency plans.

It is clear to me that without capable civil service support, no administration would have fared well.  I hope, by exposing this deadly failure, to prevent the same thing from happening again tomorrow.

I will make strategic recommendations here in this first part of what will be a series on this issue.

I will review those volumes in a series of articles.

Importantly, we will, apparently for the first time, be making HAAR available to citizens and other news organizations through the links above.  It has not heretofore been available on the internet.

Before COVID struck.  The breakdowns represented a failure to prepare.

The National Incident Management System (NIMS) guides all levels of government, nongovernmental organizations and the private sector in working together to prevent, protect against, mitigate, respond to and recover from incidents.

The preparedness cycle of the NIMS is illustrated above.  COVID demonstrated that the preparedness cycle is broken in Virginia.

Virginia had an excellent pandemic response plan on the shelf since 2012, but the events of 2020 and 2021 showed no effective and widespread training for designated participants in that plan.

It appears the plan was never modeled, and the models were never run as simulations in support of exercises, assessments and necessary improvements.

Finally, a comprehensive and full-scale exercise of that plan with the participation of the key participants among leadership and the bureaucracy was never conducted.

Management turmoil March – October 2020.

Unified Command (UC).  The NIMS and Virginia define Unified Command as follows:

When no one jurisdiction, agency or organization has primary authority and/or the resources to manage an incident on its own, Unified Command may be established.

In Unified Command (as defined by the NIMS), there is no one “commander” (though Virginia law makes the governor the state emergency manager with authority to direct state emergency response)

Instead, the Unified Command manages the incident by jointly approved objectives.

A Unified Command allows these participating organizations to set aside issues such as overlapping and competing authorities, jurisdictional boundaries, and resource ownership to focus on setting clear priorities and objectives for the incident.

The resulting unity of effort allows the Unified Command to allocate resources regardless of ownership or location. Unified Command does not affect individual agency authority, responsibility, or accountability.

If only the Commonwealth’s UC had worked that way during COVID.

One example from the HAAR on operational coordination issues

Major transitions of operating structures and processes are fraught with multiple failure modes.  That did not stop constant change.

In the April/May 2020 time frame, the governor reorganized the Unified Command organization actively dealing with COVID to deal with “complex incidents,” like a summer hurricane in addition to COVID. Simultaneously, the governor…

seeing the breakdown of the Unified Command Structure (managed by VDEM) in Virginia… authorized the use of the Commonwealth of Virginia (Incident Management Team) IMT concept (which existed only on paper) on March 16, 2020 to address stovepipes and institute reporting procedures that were more strategic, rather than informational. At the time, the Commonwealth of Virginia IMT consisted of nine personnel representing three state agencies; over the next three months, it grew to more than 130 personnel from eight state agencies.”

The IMT was demobilized July 1, 2020.

Again from the HAAR.

Management turmoil – the vaccine rollout.

Perhaps the government had learned its lesson.  Perhaps the vaccination program, with plenty of lead time, would go well.

Statewide planning for vaccination went on for months in 2020.  VDH hosted state agencies for a seminar on October 8, 2020 and a table-top exercise on October 14, only to face-plant upon execution.

I have no idea what they think they learned.

But the UC structure was completely overhauled again after the exercise.

A new chain of command went from the governor, through the Cabinet Secretaries within the Policy Group, and to the VDEM State Coordinator and VDH State Commissioner and the rest of the VDH and VDE.

The Policy Group was yet another new organization not present in the state Emergency Operations Plan.

In January 2021, the IMT was re-activated, restructured and given a new mission.  IT supported the VDEM regions in the build-out of the state-run Community Vaccination Clinics (CVCs) and mobile vaccination clinics.

With all of that, and arguably because of it, from the HAAR:

In terms of total tests performed divided by population size, Virginia ranked 49th among US states on April 5, 2020, and ranked between 48th and 50th on all days between April 13 and April 30, 2020.

You get the point.

Recommendations.  

Structure of government.

Governments operate in two modes: normal and emergency.

The governor is by law the Commonwealth’s Director of Emergency Management.  He had sweeping authority to deal with COVID.

His executive branch proved utterly unprepared to do so.

The structure of that government only supports normal operations, ensuring that emergency operations have little chance to function well.

The responsibility for emergency preparedness resides in an office within an agency, the Virginia Department of Emergency Management, itself an agency within the Office of the Secretary of Public Safety and Homeland Security.

The Secretary oversees nine agencies, of which VDEM is but one.

Emergency management cannot be buried that deep in the governance structure and be expected to function on demand.

The current bureaucratic positioning not only did not work when needed in COVID, it will never work broadly across the government.  People who have key roles in emergency plans, even if training is held and competently structured exercises are conducted and assessed, which they have not been in Virginia, will not feel compelled to attend.

Many of a governor’s cabinet secretaries have active roles depending on the emergency.  Emergency management thus needs direct representation in his office.

Systems of Government.

One key to the emergency functioning of government is to make normal operations resemble as closely as possible coordinated whole-of-government emergency operations.

Virginia’s government is a forest of agency stovepipes.

I have seen no evidence in Virginia government that any managed attempt has ever been made to align the day-to-day government enterprise with the emergency operations enterprise in Virginia.  Imagine if the military had different management structures for peacetime and war.

It is no coincidence that perhaps the only institution in Virginia government that emerged from the HAAR with its reputation enhanced was the National Guard.

Normal/emergency process and technology alignments are necessary not only among agencies in Richmond, but also between Richmond and the federal government, with state agency components across the state and with local governments.

There will never be perfect alignment, but what we have does not even try.

The NIMS preparedness cycle.

The NIMS cycle shown above must be lived, not pointed at.  In a learning organization, it is a cycle without end.

There is no reason whatever to expect Virginia government response to be any better next time.  Every element of the preparedness cycle is broken.

Virginia government has no idea how to create a plan, conduct and learn from an exercise, revise plans, and continue forward.

There is no functioning system in place to even incorporate these lessons learned from COVID response.

In another FOIA request, I asked VDEM if ANNEX 4 to the emergency operations plan, the pandemic emergency annex, is still the state’s active plan.

The answer was yes.

I asked if they intended to update the current pandemic plan, the one that was not implemented, based on the HAAR.

The answer was no.

Bottom line. Emergency preparedness and response is not just about government executives looking silly in hard hats.

We had no reason to expect from his background that Governor Northam had any knowledge of, much less experience in, management or emergency management.

He was out of his depth.

But the HAAR has left us with well-founded doubts about state preparedness for hazards to public safety regardless of the governor. It left me with no faith at all in VDEM as currently structured and positioned.  The agency has preparedness responsibilities without the authority or resources to carry them out.

As for the media, we government watchdogs, I urge each organization to go back and see what it reported, now that we know what actually happened.  For most, it will not be a pretty exercise.  We need to do much better.

The executive and legislative branches of government need to work together to fundamentally restructure, manage and fund emergency preparedness in the Commonwealth.

They will need outside help to do it.  CNA has earned a spot on that team.  I have other suggestions for later articles.

The fatally flawed COVID response in Virginia is guaranteed to be repeated in any emergency future response at scale if we don’t make fundamental changes.

It is past time to start.