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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Flint, Michigan, and the Failure of Public Agencies

On my first day as health commissioner in Baltimore in December 2005, the chief counsel to the city gave me some advice: When you see a problem, fix it. Don’t let your first instinct be to wonder who caused the problem, or to wait for every possible detail, or to defer to others. He said that the most important question the public will ever have about any problem is whether it has been fixed. And then he added, in an unwavering, deep voice, that fixing the problem is the right thing to do.

Joshua M. Sharfstein, MD

After the disastrous decisions that led to contamination of the water supply in Flint, Michigan, public agencies stumbled again by failing to identify the problem and respond quickly. Delays led to brutal assessments of governmental inaction and likely played a role in the resignation of senior state and federal officials. It took the courageous work of a professor and a pediatrician to force public leaders to pay attention to a health crisis.

Whenever government agencies founder, some find fault in their leaders for heartlessness, ignorance, or incompetence (or a combination of all three). Yet there are also reasons why even well-intentioned and otherwise effective government officials may fail to recognize and fix problems. Without excusing any of the failures in Flint, it is worth considering whether these factors may have played a role there.

The blind spot for crisis. It is no secret that public officials, just like everyone else, prefer good news to bad news. A tap of the keyboard sends happy news releases and upbeat emails to the public, the media, and elected representatives. Agencies use positive news to generate internal pride and external momentum.

The emphasis on good news makes it more difficult to acknowledge bad news. Problems require more than words; they require attention, and many underfunded offices are stretched thin just meeting their daily obligations. Responding to a health or environmental challenge means intense focus, rapid decisionmaking, and robust engagement with communities; practically speaking, releasing bad news can require pulling staff from other important activities for days if not weeks or months. As a result, officials are susceptible to wishful thinking that concerns will resolve by themselves. In the case of Flint, some public officials apparently spent time developing reassuring press statements rather than planning a comprehensive response.

The organizational chart trap. Although public agencies can be quite large, any given technical topic is likely to be understood by only a few staff members located in a corner of the organizational chart. This is the group responsible for setting policy on the topic; it is also the group most likely to field questions about concerns that may arise.

If a crisis is brewing in an area of specialized knowledge, such as whether water from a new supply source has received adequate treatment, agency leaders need to assess the facts quickly and effectively. Relying on the same people responsible for having made key decisions in the first place risks falling into a trap of false reassurance. A better approach is to seek outside expert input. This apparently did not happen in Flint until it was too late.

Legal quicksand. When an agency leader is considering a bold course of action to address an unexpected problem, at least one person inside an agency is likely to ask, “Are we allowed to do that?” Legal concerns may be entirely appropriate. What often happens, however, is that leaders hold off on all action, including permissible steps, until the questions are resolved. As some involved in the Flint crisis have now discovered, an extended delay for legal review is impossible to justify after the crisis becomes widely known.

A better approach is for public officials to talk promptly and candidly about the crisis, explaining what options are under consideration. A clear statement setting out the facts about a public health hazard may even lead to voluntary action without the need for the agency to exercise legal authority.

Missing warning signs. Many problems come to light as a result of external investigations—from journalists, auditors, inspectors general, and others. Nearly always, the agency has a chance to spot clues about what is happening during the investigation and move fast to limit the damage. For example, a reporter may confront a health agency with uncomfortable facts or an auditor may ask for an unusual set of records. These are precious opportunities for public officials to recognize whether there is, in fact, a major crisis brewing and respond. Yet few agencies are set up to review these warning signs fairly and systematically and figure out if something is truly awry.

Failing to take advantage of early signals of trouble should be called “GSA moments,” after the epic failure five years ago of the General Services Administration (GSA) to promptly recognize and address management failures that led to lavish parties held at the public’s expense. By the time the Office of the Inspector General released its report, it was too late for the agency. In the case of Flint, concerns expressed by citizens, journalists, and outside scientists provided multiple opportunities for public officials to dig further into the problem, but they led to GSA moments instead.

The responsibility conundrum. An agency taking responsibility for fixing a problem can find itself blamed for having caused it in the first place. Why? The public will assume that the agency is acting to address the consequences of its own making. Countering this assumption can be difficult -- and counterproductive. Moving forward to get a job done is often incompatible with casting blame on others, especially those whose assistance is needed in a collaborative effort. Success may require giving others a pass (as well as, perhaps, an opportunity at redemption).

Yet a common phobia among public officials is the fear of being held accountable for a problem for which others share responsibility. This is not difficult to understand in a world of judgmental journalists, partisan political conflict, and social media. However, when multiple agencies are circling around the same crisis, as in Flint, this phobia can lead to paralysis, without any agency stepping forward and embracing the challenge.

Effective public agencies are able to surmount all of these obstacles. Their leaders keep an eye out for the lurking crisis; they look outside for expert assistance when appropriate; they do not permit legal considerations to sap urgency; they react quickly to warning signs; and they embrace responsibility.

They do so not because they are sure to be rewarded for their actions at the end of the day, because there is no such assurance in public service. They do so because it’s the right thing to do.

About the author: Joshua M. Sharfstein, MD, is Associate Dean for Public Health Practice and Training at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. He is a consultant for Audacious Inquiry, a company that has provided technology services and other support to Maryland’s Health Information Exchange. A pediatrician, he lives with his family in Baltimore.