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The United States takes a federalist approach to pandemic responses while the bulk of pandemic powers sits at the state level. Thus, comprehensive accounts of how state health officials managed the crisis and how the federal government affected those efforts are needed to better understand the governmental response to the COVID-19 pandemic. This article reports the results of semistructured interviews with 29 state-level policy actors from 16 US states. Interviewees discussed multiple aspects of the US federal COVID-19 response that affected the response in their states, including communications with the public, intergovernmental communications, and federal actions regarding various aspects of health service preparedness including emergency funding, procurement, testing capacity, vaccine development and distribution, and data systems. This research enriches the discussion about US pandemic preparedness and response, and indicates that alignment of public communications across government levels, enhanced intergovernmental communication, inclusion of rural perspectives, and federal investment in and sustainment of health service preparedness are key factors that can improve future US pandemic responses. 

Abstract ObjectivesWe conducted interviews with state epidemiologists involved in the state-level COVID-19 response to understand the challenges and opportunities that state epidemiologists and state health departments faced during COVID-19 and consider the implications for future pandemic responses. MethodsAs part of a broader study on policymaking during COVID-19, we analyzed 12 qualitative interviews with state-epidemiologists from 11 US states regarding the challenges and opportunities they experienced during the COVID-19 response. ResultsInterviewees described the unprecedented demands COVID-19 placed on them, including increased workloads as well as political and public scrutiny. Decades of under-funding and constraints posed particular challenges for meeting these demands and compromised state responses. Emergency funding contributed to ameliorating some challenges. However, state health departments were unable to absorb the funds quickly, which created added pressure for employees. The emergency funding also did not resolve longstanding resource deficits. ConclusionsState health departments were not equipped to meet the demands of a comprehensive COVID-19 response, and increased funding failed to address shortfalls. Effective future pandemic responses will require sustained investment and adequate support to manage on-going and surge capacity needs. Increased public interest and skepticism complicated the COVID-19 response, and additional measures are needed to address these factors. 

Many policies were put in place during the COVID-19 pandemic in the United States to manage the negative impact of the coronavirus. Limiting severe illness and death was one important objective of these policies, but it is widely acknowledged by public health ethicists that pandemic policies needed to consider other factors. Drawing on semi-structured interviews with 38 people across 17 states who participated in the state-level COVID-19 pandemic policy process, we examine how those actors recounted their engagement with four different objectives over the course of the pandemic: protecting public health with respect to COVID-19 (which we refer to as pathogen-focused disease prevention), protecting the economy, promoting the public’s broader health and wellbeing, and preserving and restoring individual freedoms. We describe the different ways that pathogen-focused disease prevention was thought to have conflicted with, or to have been coherent with, the other three policy objectives over the course of the pandemic. In tracing the shifting relationships between objectives, we highlight four reasons put forward by the participants for why policy changes occurred throughout the pandemic: a change on the part of decisionmaker(s) regarding the perceived acceptability of the negative effects of a policy on one or more policy objectives; a change in the epistemic context; a change in the ‘tools in the toolbox’; and a change in the public’s attitudes that affected the feasibility of a policy. We conclude by considering the ethical implications of the shifting relationships that were described between objectives over the course of the pandemic. 

The state‐level COVID‐19 response in the United States necessitated collaboration between governor' offices, health departments and numerous other departments and outside experts. To gain insight into how health officials and experts contributed to advising on COVID‐19 policies, we conducted semi‐structured interviews with 25 individuals with a health specialisation who were involved in COVID‐19 policymaking, taking place between February and December 2022. We found two diverging understandings of the role of health officials and experts in COVID‐19 policymaking: the role of ‘staying in the lane’ of public health in terms of the information that they collected, their advocacy for policies and their area of expertise and the role of engaging in the balancing of multiple considerations, such as public health, feasibility and competing objectives (such as the economy) in the crafting of pandemic policy. We draw on the concept of boundary‐work to examine how these roles were constructed. We conclude by considering the appropriateness as well as the ethical implications of these two approaches to public health policymaking.