November 24, 2020 – In mid-March, public health officials across the San Francisco area issued the first U.S. regional shelter-in-place order in response to the emerging COVID-19 pandemic. A “field report” on the crisis decision-making approach followed in that effective early response is featured in a special COVID-19 supplement to the Journal of Public Health Management and Practice. The journal is published in the Lippincott portfolio by Wolters Kluwer.

“With the benefit of hindsight and reflection, we recount our story through the lens of public health legal authority, meta-leadership, and decision intelligence,” according to the new article, authored by Tomás J. Aragón, MD, DrPH, of the San Francisco Department of Public Health along with local health officers (LHOs) from six other Bay Area jurisdictions. Their paper appears as part of a JPHMP supplement titled “COVID-19 and Public Health: Looking Back, Moving Forward.”

On March 15, 2020, LHOs in Alameda, Contra Costa, Marin, San Francisco, San Mateo, and Santa Clara Counties and the City of Berkeley issued legal orders for 6.7 million residents to shelter-in-place to prevent the spread of SARS-CoV-2. Within days, other regions issued similar orders. Studies have confirmed that early shelter-in-place orders prevented many COVID-19 cases, hospitalizations, and deaths across the United States.

But even in a crisis, outcomes can’t determine whether a decision was good or bad. “The quality of a decision depends only on the quality of the decision-making process at the time the decision was made,” Dr. Aragón and coauthors write. They review key elements of good crisis decision making during complex public health emergencies:

  • Crisis Decision Making. Public health decision makers bring epidemiologic (causal and probabilistic) reasoning and the ability to balance tradeoffs from competing objectives to tackle a health crisis. In the face of “volatility, uncertainty, complexity, and ambiguity,” team deliberations must be built on trust-based, collaborative relationships and approached with “genuine intellectual humility … embrac[ing] curiosity over certainty.”
  • Legal Authority. In California, LHOs are authorized to take measures as necessary to control the spread of communicable diseases. This enabled the Bay Area LHOs to act “quickly and decisively” to issue shelter-in-place orders to protect the public health and healthcare system from a COVID-19 surge like that occurring at the time in New York City.
  • Meta-Leadership. Longstanding state and regional health official networks have played an important role in responding, adapting, and scaling to public health threats. In the Bay Area, years of experience in preparing for pandemic influenza, and responding to other microbial threats, enabled the spontaneous activation of “swarm leadership”–a key characteristic of good disaster responses where a group, without formal hierarchical authority, coalesces to tackle effectively a complex emergency.
  • Decision Intelligence. Dr. Aragón and colleagues define decision intelligence as “the integration of problem-solving and decision quality within a performance improvement framework, ensuring quality and continuous improvement in crisis decision making.” While recognizing that a shelter-in-place order was a “drastic measure,” the LHOs agreed that immediate action would maximize the benefits of interrupting transmission: “flattening the curve” of COVID-19 cases, hospitalizations, and deaths while providing time to ensure public health systems readiness and to learn about SARS-CoV-2 biology and transmission.

The Bay Area LHOs hope their experience will draw attention to the elements of crisis decision making – throughout the pandemic and in preparing for future public health emergencies. “Decision intelligence provides practical tools to improve crisis decision making,” Dr. Aragon and coauthors conclude. “We hope that with experimentation and practice, public health officials will improve their routine team decisions, and thereby be capable and ready to make better decisions in new crisis situations.”


The supplement presents 18 original research papers and commentaries, focusing on the early phases of the public health response to COVID-19. In an introduction, guest editors Chrissie Juliano, MPP; Michael Fraser, PhD, CAE; and Brian C. Castrucci, DrPH, MA; write: “The knowledge shared in this supplement can be instantly applied to the current public health response to COVID-19 and to help protect the health of all Americans.”

The supplement is sponsored by the de Beaumont Foundation, the Association of State and Territorial Health Officials, and the Big Cities Health Coalition.

Click here to read “Crisis Decision-Making at the Speed of COVID-19: Field Report on Issuing the First Regional Shelter-in-Place Orders in the United States.”

DOI: 10.1097/PHH.0000000000001292

About Journal of Public Health Management and Practice

Journal of Public Health Management and Practice publishes articles which focus on evidence-based public health practice and research. The journal is a bi-monthly peer-reviewed publication guided by a multidisciplinary editorial board of administrators, practitioners, and scientists. Journal of Public Health Management and Practice publishes in a wide range of population health topics including research to practice; emergency preparedness; bioterrorism; infectious disease surveillance; environmental health; community health assessment; chronic disease prevention and health promotion; and academic-practice linkages.

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