Policy & Politics • vol 46 • no 1 • 27–45 • © Policy Press 2018 • #PPjnl @policy_politics

Print ISSN 0305 5736 • Online ISSN 1470 8442 • https://doi.org/10.1332/030557317X14974484611316

Accepted for publication 08 June 2017 • First published online 20 June 2017

article
Indicators, agendas and streams: analysing the
politics of preparedness
Rob A DeLeo, rdeleo@bentley.edu
Bentley University, USA

The multiple streams approach (MSA) emphasises that problem indicators, which refer to numeric
measures of a problem, are an important determinant of policymaker attention. However, few
studies empirically examine the relationship between indicators, agenda setting and policy change.
This study fills this void by modelling the extent to which indicator change induces agenda activity
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in emerging disease domains. It shows that the rate of indicator accumulation – how quickly
indicators amass – is a predictor of agenda activity. Although rapid accumulation almost always
captures policymaker attention, policy change is more likely when indicators slowly amass and
provide ample time for political mobilisation.
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key words agenda setting • indicators • multiple streams approach

To cite this article: DeLeo, R.A. (2018) Indicators, agendas and streams: analysing the politics of
preparedness, Policy & Politics, vol 46, no 1, 27–45,
DOI: 10.1332/030557317X14974484611316

The multiple streams approach (MSA) identifies four mechanisms of problem

identification (Kingdon, 2003; Zahariadis, 2014). Focusing events, including disasters
and personal tragedies, are ‘attention grabbing’ events that come to symbolise a larger
problem. Feedback describes information derived from the monitoring of programmes
that reveals flaws in current policy designs. Indicators are more or less objective measures
of a problem, including counts and statistics (for example, monthly public transit
ridership, drug overdose rates and so on) as well as written reports interpreting these
metrics. Finally, load refers to situations where the number of problems confronting
government is so overwhelming that new issues are crowded out of the agenda.
Jones et al’s (2016) meta-analysis of peer-reviewed articles applying MSA concepts
between the years 2000 and 2013 suggests that indicators play an important role in
stimulating issue attention. Nearly 69 per cent of the articles sampled referenced
the term ‘indicators’ at least once, dwarfing the number of references to ‘focusing
events’ (27 per cent), ‘feedback’ (16 per cent), and ‘load’ (1 per cent). This finding
does not, however, reflect a thriving research agenda. Using QSR’s NVivo content
analysis software, I counted the number of references to term ‘indicator’ in 62 of the
66 indicator-referencing publications cited by Jones et al (2015) (four studies were
not available). The vast majority of these studies (over 90 per cent) make little more
than a passing reference to how a ‘change in cases’ elevated policymaker concern.

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 Rob A DeLeo

Only two papers include indicators within a larger quantitative model (Travis and
Zahariadis, 2002; Rapaport et al, 2009).
Government is increasingly concerned with gathering, disseminating and
interpreting information (Workman, 2015). Some suggest the emergence of an entire
‘indicator industry’ devoted to filtering data into the political system (Lehtonen, 2015,
76). Policy scholars working outside of MSA have been much more sensitive to this
reality and have devised sophisticated understandings of the relationship between
information and policy change (Jones and Baumgartner, 2005; Baumgartner and
Jones, 2015; Workman, 2015). Nor are these debates purely academic. Many local
governments use information technology to track problem indicators in real time
(How Cities Score, 2016). This increased emphasis on data-driven decision making
introduces important questions about government’s capacity to respond to new and
often conflicting information.
MSA has been heralded for its ‘unparalleled empirical richness’ (Jones et al, 2016:
31). It provides an accessible depiction of the policymaking process and has been
cited in more than 1,900 peer reviewed journals from various academic fields since
2000 (Zahariadis, 2014). By distinguishing between three distinct but interrelated
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streams of policymaking activity (the politics, problem and policy streams), MSA allows
for targeted investigations of the specific drivers of agenda setting. Research on focusing
events, for example, helped establish a thriving body of literature on risk, hazards
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and policy change (Birkland, 1997). Similarly, applications of Kingdon’s concept of

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policy entrepreneurship helped demonstrate the importance of individual leadership

during the policymaking process (Mintrom, 2000). In fact, Boswell and Rodrigues
(2016) argue that stream independence makes MSA a particularly useful theory for
investigating policy change via programme implementation, as it ‘allows one to treat
policy as an exogenous variable, developed and imposed by a central or superordinate
authority’ (p 508). MSA thus provides an excellent framework for isolating the agenda
setting power of indicators.
Guided by MSA, the following study considers agenda setting in the United States
Congress in response to two emerging diseases, pandemic influenza and Ebola. The
Ebola and pandemic influenza cases offer fruitful material for analysing indicators.
First, both problems are ‘unambiguously related’ to two very clear indicators, the
number of human cases and deaths (Jones and Baumgartner, 2005: 209). Put differently
cases and deaths are widely believed to be the best measures of changes in influenza
and Ebola. This important feature makes it easier to isolate the relationship between
indicator change and agenda activity because it helps ensure that policymakers are
in fact responsive to these particular measures. Moreover, these indicators are very
well documented by public health agencies, which consistently track outbreaks of
emerging disease (Etheridge, 1992). Third, both diseases have the capacity to be
highly disruptive in nature, as large-scale outbreaks can result in widespread loss of
human life and economy. Indicators thus have the ability to awaken deep rooted fears
and, at times, are fairly well mediatised.
This paper begins by examining the existing literature on indicators, agenda
setting and MSA. While few MSA studies have explicitly examined agenda setting
and indicators, a number of findings can be gleaned from Kingdon’s (2003) theory
as well as the larger literature on policy change. This paper uses negative binomial
regression to analyse the influence of indicators on the congressional agenda. My
models are supplemented with a descriptive analysis of the interplay between the

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 Indicators, agendas and streams

various streams, a dynamic that is difficult to empirically measure. It closes by

considering the theoretical implications of my findings.

Indicators and agenda setting

MSA argues policy change occurs through the coupling of the problem, politics and
policy streams. The problem stream, which consists of indicators, focusing events,
feedback and load, encompasses the various issues competing for government attention
(Kingdon, 2003). The agenda setting power of indicators is not necessarily derived
from their objective features, but from how these measures are integrated into larger
policy narratives. Indeed, Kingdon notes that the ‘data do not speak for themselves’
and require interpretation (p 94). Measurement discourse strategically uses data to
draw attention to a problem, while advocating for policy solutions. Competition over
the definition of indicators is fierce, as the outcome of these debates often determines
whether an issue cracks the crowded governmental agenda (Innes, 1990; Stone, 2002).
Kingdon (2003) describes the policy stream as a ‘primeval soup’ where different
ideas confront each another, evolve, and, on occasion, inform the design of public
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policies. The viability of any solution will ultimately hinge on the composition of the
politics stream, which includes things like the national mood and the distribution of
political power within government institutions. Mobilising political support is always
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difficult, especially in a system marked by extreme institutional inertia, such as the

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US. In turn, organised interests seek out favourable policy venues or institutional
locations that are most likely to support their policy goals (Pralle, 2006).
MSA also indicates a special role for the policy entrepreneur, individuals or groups
willing to invest a tremendous amount of resources to secure a future policy goal
(Mintrom, 2000). Entrepreneurs work to couple of the streams, in turn opening a
policy window or an opportunity for policy change. Coupling is more likely when
entrepreneurs attach their solutions to ‘higher order’ symbols that evoke intense
and widespread public emotion (Zahariadis, 2014). Windows vary in terms of their
predictability, ranging from fairly recurring windows (for example, windows opened
by budgets) (Howlett, 1998) to random windows (for example, windows opened after
disaster) (Birkland, 1997). Most are fleeting, although some windows cast fairly long
shadows, meaning ‘they leave a legacy through the construction of path-dependent
narrative’ (Zahariadis, 2014: 35).
Lehtonen (2015) distinguishes between three categories of indicators: (1) descriptive
indicators, which monitor and describe existing situations; (2) performance indicators,
which guide the evaluation of agency performance; and (3) composite indicators, which
provide a comprehensive assessment of a programme’s social impact. The concept of
descriptive indicators is consistent with MSA’s definition of indicators as measures
or metrics of a problem (Kingdon, 2003). Still, other theories of policy change,
including the punctuated equilibrium theory and advocacy coalition framework, do
not use the term ‘indicator’ and instead refer to problem measures as ‘information’
(Baumgartner and Jones, 1993; Jenkins-Smith et al, 2014). These distinctions become
more confusing when one looks outside the narrow literature on agenda setting. Far
more than problem measures, the term indicator has been linked to every stage of the
policy process, informing everything from programme design to policy evaluation
(Seaford, 2013). It even holds special meaning in the world of applied policy analysis,

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 Rob A DeLeo

which has seen various indicator movements or attempts to quantify an array of social
problems (Lehtonen, 2015).
Indicators thus have a diffuse intellectual history. Ultimately, they serve a diagnostic
or monitoring function, helping policymakers to make sense of problems (Lehtonen,
2015). An indicator’s power is magnified when there is general consensus that it is the
best measure of a particular problem, a phenomenon called ‘indicator lock’ (Jones and
Baumgartner, 2005). These headline indicators are accepted as a matter of orthodoxy
by policymakers, the media and the general public alike (Seaford, 2013). Robust media
coverage only enhances their legitimacy (Wolfe et al, 2013). Moreover, domains with
strong indicator cultures – domains that emphasise data-driven decision-making – tend
to be more responsive to indicator change than those where the value of different
measures is hotly debated (Turnhout et al, 2007; Bell et al, 2011).
Still, few indicators go uncontested. Indicators with less proximity to a problem
– indicators that do not directly measure a problem but are surrogate measures – are
often scrutinised and tend to have less of an impact on the policy agenda (Bell et al,
2011). Gent’s (2000) study of local needle exchange programmes investigated the
use of HIV/AIDS infections as a surrogate measure of the value of needle sharing
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programmes. Gent found changes in this measure had little impact on local agenda
activity because policymakers failed to grasp the connection between clean needles
and AIDS.
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Policymakers are drawn to changes in indicators. Kingdon (2003) notes ‘people

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believe the change is symbolic of something larger and find that the new figures do
not conform to their previous experience. Thus indicator change can have exaggerated
effects on policy agendas’ (p 93). Numbers are an especially important measurement
tool, not only because they make it easy to demonstrate change, but also because
of their assumed legitimacy (Stone, 2002). In fact, policymakers have a propensity
to overreact to changes in numerical measures, which are assumed to symbolise
deviations from the status quo (Jones and Baumgartner, 2005).
While it is well established that changes in indicators tend to capture policymaker
attention, it is less clear whether the pace and magnitude of these changes – how
quickly and how much indicators amass – has any bearing on agenda activity. MSA
assumes the sudden aggregation of losses of life or economy compels policy action.
Focusing events are influential precisely because they denote situations where death
and destruction amass rapidly. Birkland (2006) suggests that indicators serve a similar,
but far less dramatic, function noting that ‘problems become known slowly, as indicators
of problems accumulate and become more evident’ (p 7). This logic dictates that
dramatic changes in indicators, which signify deviations from the status quo, should
correspond to equally dramatic changes in agenda activity.
Of course, agenda setting should not be conflated with policy change, which
describes a more substantive reconfiguration of power dynamics often through the
enactment of a new law (Baumgartner and Jones, 1993). Rapaport et al (2009) suggest
that the ‘salience of a policy problem matters, but not on its own. Rather, it matters
in combination with the length of time that a policy problem floats in the policy
stream. Thus, for policy reforms it is not only saliency that matters but also time’
(p 712). The authors show that the policy and politics streams need time to ‘gestate’ or
develop before coupling (and policy change) can occur. Paradoxically, then, whereas
much of the MSA literature argues policymakers are most sensitive to radical changes

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 Indicators, agendas and streams

in problem measures, Rapaport et al imply actual policy change is more likely when
indicators amass slowly and provide ample time for the three streams to converge.
The literature is also conflicted regarding the influence and agenda setting power of
indicators. Kingdon (2003) suggests some problems are not made self-evident through
indicators alone and that sometimes they ‘need a little push to get the attention of
people’ (p 94). Lancaster et al (2014) found focusing events can provide such a ‘push’
by making a once ignored problem relevant to policymakers, the public and the media.
Their study shows that, despite an abundance of indicators of rampant addiction and
abuse, Australia’s methamphetamine epidemic did not reach the government agenda
until ABC News aired an expose investigating the destructive nature of the drug and
describing the social dimensions of the country’s ‘ice epidemic’.
Conversely, Jones and Baumgartner (2005) show that this is not always the case
and that ‘the connection between problem and measurement is not always so
elusive’, adding that ‘some issues are unambiguously related to quantitative indicators’
(p 209). Delshad’s (2012) dynamic agenda setting model of biofuel policymaking
found that changes in economic indicators were the most important predictors of
both congressional and presidential agenda setting. Delshad shows Congress and the
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president have very little influence over each other and are much more likely to be
influenced by exogenous variables, notably indicators. In sum, empirical evidence
suggests indicators are quite adept at capturing policymaker attention and helping
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problems access the agenda.

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Alas, the agenda setting and policy change literature – including MSA – is divided
on the agenda setting function of indicators. Whereas some studies contend dramatic
changes in indicators capture policymaker attention, others imply that small changes
in these measures is enough to induce policy change. Similarly, whereas some studies
suggest indicators alone are a sufficient agenda catalyst, others indicate numbers need
a nudge from an exogenous event before capturing policymaker attention. With an
eye toward these conflicts, the following section outlines this study’s methodology.

Methods and expectations

When does agenda setting occur in response to problem indicators? As noted above,
it is unclear whether the rate or magnitude of indicator accumulation influences
agenda setting and policy change. Still, MSA broadly assumes that indicator change
captures policymaker attention, a testament to the fact that government tends to
overreact to deviations from the status quo (Jones and Baumgartner, 2005; Kingdon,
2003). Indicator change, therefore, should be positively related to agenda activity:

H1: Indicator change captures congressional attention.

H2: As the number of indicators increase, so too does congressional attention.

Second, this paper tests the interplay between indicators and events. Kingdon
(2003) implies indicators often need a nudge from a focusing event before capturing
policymaker attention, but this contention is contradicted by empirical evidence,
which suggests that indicators are, in fact, an important predictor of policymaker
attention (Delshad, 2012). In light of this disconnect, this paper hypothesises:

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 Rob A DeLeo

H3: Focusing events do not facilitate agenda setting in domains where

indicators are unambiguously related to a problem.

As noted previously, emerging diseases, such as Ebola and pandemic influenza, are
unambiguously related to a clear set of indicators. Therefore, focusing events should
be less influential in these cases.
Finally, this paper also investigates policy change. Rapaport et al (2009) note
that policy change is more likely to occur when indicators amass slowly. My final
hypothesis thus contends:

H4: Policy change is more likely when indicators amass gradually over a
period of years than when they amass quickly and sizably over a period
of weeks or months.

This paper uses negative binomial regression analysis, which is appropriate for studies
that rely on count data. My paper borrows from Delshad’s (2012) study, which also
used count data and a negative binomial regression model. While Delshad’s work
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does not specifically test MSA, it is one of only a few studies to empirically measure
the relationship between indicators and agenda setting. Negative binomial regression
is also appropriate for studies where data is not normally distributed (O’Hara and
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Kotze, 2010). My data defied standard normalisation procedures, failing both the
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Kolmogorov-Smirnov and Shapiro-Wilk tests of normality after undergoing log-

transformations. These types of distributions are commonplace in studies of agenda
setting, as policymakers tend to fixate on a limited number of issues before turning
their attention elsewhere (Jones and Baumgartner, 2005).
Despite measuring issue attention, my negative binomial regression models cannot
account for changes in the actual substance of the law. In order to test hypothesis
four, this study considers whether periods of increased agenda activity resulted
in budgetary changes or the enactment of new legislation. Material used for this
descriptive analysis is primarily drawn from Congress.gov, which provides a full
repository of congressional legislation. This paper also considers the various plans
and regulations issued by executive branch departments, which are readily available
on agency websites. This approach is consistent with other quantitative applications
of the MSA, which also use qualitative analysis to more closely investigate findings
generated by a quantitative model (Birkland, 1997).

Dependent variable
My dependent variable accounts for congressional activity in the pandemic policy case
(N=84) from 1995 through 2015 and the Ebola case (N=88) from 1994 through 2015.
To account for the lag between the onset of indicators and agenda activity as well as
the fragmented legislative schedule, both domains are measured quarterly (every three
months). Congressional activity is a count variable that combines the number of times
the terms ‘pandemic’ or ‘Ebola’ were entered into the Congressional Record as well
as the number of congressional hearings on these topics. The Congressional Record is
an official record of the proceedings and debates of the US Congress. Hearings and
Congressional Record mentions correspond to policymaker concern, and are widely used
as measures of agenda setting (Baumgartner et al, 2002). All data was derived from

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ProQuest Congressional, which provides a comprehensive record of congressional

materials. Data was manually reviewed to ensure its relevance to both cases.

Independent variables
This paper runs two separate types of models. The first model type is best
conceptualised as a ‘dose model’ in that it seeks to capture whether the presence
of any indicators influences agenda activity. This model includes four independent
variables. Onset is a dichotomous variable (1=yes; 2=no) that measures the absence
or presence of any new human cases of pandemic influenza/Ebola. Human cases are
widely utilised as indicators of disease because they offer a straightforward measure
of a disease’s lethality and contagiousness (Webster and Govorkova, 2006).
The second variable, scope, measures whether indicators are representative of a
small scale ‘outbreak’ or a large ‘epidemic/pandemic’ event. This variable measures
whether the World Health Organisation (WHO) declared a current disease event
to be an outbreak or an epidemic/pandemic. There is no numerical threshold that
distinguishes between an outbreak, epidemic or pandemic. These distinctions vary by
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disease, as some diseases spread more rapidly than others. An outbreak occurs when
the number of disease cases exceeds normal expectations. Outbreaks are significant
but are typically confined to an isolated geographic area. An epidemic refers to a
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disease that rapidly spreads across a population, often encompassing a large – but not
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global – geographic area. Finally, a pandemic is a large-scale, global disease event.

This paper assumes an Ebola epidemic and an influenza pandemic are political
equivalents. Unlike pandemic influenza, Ebola cannot be transmitted via air (for
example, a cough or sneeze), which means an Ebola pandemic is extremely unlikely
if not impossible. Still, an Ebola epidemic is an incredibly significant public health
event given the disease’s novelty and lethality (CDC, 2012). Scope is a dichotomous
variable (1=outbreak; 2=pandemic/epidemic).
This paper includes a dichotomous focusing event variable (1=no event; 2=event)
that measures the impact of an exogenous, spillover event on the pandemic and
Ebola domains over a two-year period. While a variety of disasters occurred
during the 20-year period examined in this study, the only event large enough to
produce trans-domain policy activity was the 11 September 2001 terrorist attacks
(September 11 hereafter). September 11 spawned a ‘boundary spanning’ regime
wherein a diverse collection of policy domains (for example, civil defence, disaster
management, transportation, public health) were collectively tasked with securing
the homeland against manmade and naturally occurring hazards (May et al, 2011).
Qualitative evidence suggests that this event influenced agenda setting in the public
health domain, catalysing emerging diseases to the top of the post-September 11
counterterrorism agenda (Avery, 2004). Consistent with other studies of focusing
events, the agenda effects of September 11 are measured for two years after the disaster
occurred (Birkland, 1997).
Presidents can also influence the institutional agenda (Eshbaugh-Soha and Peake,
2010; Delshad, 2012). Their power is especially pronounced in emerging disease
domains, as executive branch officials have historically played an important role in
guiding large-scale public health preparedness efforts (Etheridge, 1992). As such,
although this study focuses on Congress, it also includes a control variable, president,
that measures party control of the presidency (1=Republican; 2=Democrat).

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 Rob A DeLeo

The second model type measures the ‘magnitude’ of the agenda effects of indicators
by dropping the two dichotomous indicator variables (onset and scope) and replacing
them with a continuous variable (rate) that counts Ebola or pandemic influenza cases by
quarter. This model keeps both the focusing event and president variables. All pandemic
influenza data was derived from the WHO’s (2017) situation updates website, which
provides monthly reports of H5N1 avian influenza cases and deaths. Ebola data comes
from the Center for Disease Control and Prevention’s (CDC, 2016) chronology of
Ebola outbreaks. Both variables were transformed to z-scores to ease interpretation.
Both cases were characterised by relatively modest and geographically isolated
outbreaks interrupted by a large epidemic or pandemic event. A smattering of
H5N1 avian influenza outbreaks between 1997 and 2015 caused roughly 832 cases.
These numbers exploded during the 2009 H1N1 swine influenza pandemic, which
infected at least 700,000 people worldwide in a matter of three months. Unlike the
H5N1 virus, which could only be contracted via direct contact with an infected
host, the H1N1 strain was capable of airborne transmission. Similarly, the Ebola
domain experienced 13 separate outbreaks in Zaire, Gabon, Uganda, Congo and
Sudan between 1995 and 2013, totally roughly 1,793 human cases. An acute jump
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in incidences occurred during the 2014 Ebola epidemic, which resulted in 27,580
cases in five African countries as well as a handful of cases in the US and Europe.
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Pandemic policymaking
Table 1 reports the results of both the dose and magnitude negative binomial regression
models. Because it captures the relationship between non-normal variables, negative

Table 1: Congressional activity and pandemic influenza

Independent Model 1 (Dose) Model 2 (Magnitude)
variables Any indicators Change in indicators
Indicators
Onset (yes=reference category) 1.979(.3313)*** –
Scope (Pandemic=reference category) 1.868(.4752)*** –
Rate – 0.646(0.1806)***
Focusing Event
9/11 (9/11=reference category) -0.734(0.5504) -2.606(0.4618)***
President (control variable)
Republican (reference category) 1.464(0.3015)*** 1.768(0.2650)***
Intercept -0.093(0.2646) 1.585(0.1559)
N 84 84
Mean 12.3214 12.3214
Deviance goodness-of-fit (value/df) 1.245 1.836
Log likelihood -235.155 -259.453
Chi-square likelihood ratio 126.235*** 77.639***

Note: Estimated coefficients for Rate variable are z-scores. All others are unstandardised negative
binomial coefficients. Standard errors are in parentheses.

*p <0.10, ** p <0.05, *** p <0.01; two-sided tests of significance.

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 Indicators, agendas and streams

binomial regression lacks typical measures of explained variance, like Pseudo R2.
Deviance goodness-of-fit tests, which measure how well the observed data correspond
to a model, imply a very strong fit for the dose (any indicators) model (Goodness of
fit=1.245) and a slightly weaker fit for the magnitude (change in indicators) model
(Goodness of fit=1.836). (A reading of ‘1’ indicates a perfect fit.) Significant chi-square
likelihood ratios for the dose (Chi-square likelihood ratio=126.235) and magnitude
models (Chi-square likelihood ratio=77.639) suggest an improvement over the null.
Both the emergence of new indicators (onset) and significant spikes in cases (scope)
induced changes in congressional activity. Consistent with my hypotheses, model one
shows Congress was quite sensitive to indicator change. The control variable (president)
had both a statistically significant and positive effect on agenda activity, indicating
that the Bush administration played an important role in stewarding pandemic
influenza policy. In the second model (the magnitude model), rate indicates a positive
relationship between increases in indicator accumulation and congressional activity.
Specifically, a one-standard deviation increase in the number of pandemic influenza
cases (roughly 43,087 cases) increases congressional activity by about 65 per cent. Once
again, the Bush administration had a significant and positive effect on agenda setting,
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increasing congressional activity by close to 200 per cent.

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Figure 1: Congressional activity and pandemic influenza

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250
Hearings and Congressional Record

200

H1N1 Swine Flu

150 Pandemic
H5N1 Avian
100 Influenza Outbreak

50

0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year

Figure 1 charts congressional activity by year and suggests two distinct but interrelated
agenda setting stages, the first occurring between 2004 and 2007 and the second
in 2009. The first stage coincided with the outbreak of H5N1 avian influenza in
Southeast Asia. The outbreak was modest, never infecting more than 120 people in
a given year and never spreading to the US. However, H5N1 was quite lethal, fairly
novel and many worried that its capacity to infect both animals and humans portended
a pandemic event, hence the relationship between onset and congressional activity.
The Bush administration played an important role in guiding this policy process.
In 2003, President George Bush requested roughly $100 million from Congress
to support the development of a pandemic influenza vaccine. A number of factors
contributed to the President’s noticeably proactive approach. For one, there was
general consensus among public health leaders, many of whom regularly appeared
before Congress during this period, that the next great pandemic was long overdue

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 Rob A DeLeo

and large-scale preparedness actions were needed (see United States Congress, 2005).
Second, all-hazards preparedness was an important theme in the Bush Administration,
which, in the wake of September 11, was determined to protect the country against
an array of man-made and naturally occurring threats (May et al, 2011). In some
respects, avian influenza represented a test of the all-hazards regime, as the gradual
accumulation of cases and deaths meant that policymakers could both detect and
prepare for a larger, culminating event. What is more, the perceived urgency to
act was likely heightened for the Bush Administration in 2005 after Hurricane
Katrina barrelled into the Gulf Coast, killing close to 2,000 people and once again
demonstrating the danger of being unprepared for disaster (Gorman, 2005).
Perhaps most importantly, Secretary of Health and Human Services Michael Leavitt
served as a policy entrepreneur during this period. He regularly appeared before
Congress and even disseminated copies of John Barry’s 2005 bestseller The Great
Influenza: The Story of the Deadliest Pandemic in History, which described the horrors
of the 1918 influenza pandemic, to legislative leaders (Simonson, 2010). Leavitt also
played an important role in advocating for, devising, and eventually implementing
various executive branch planning efforts, like HHS’s (HHS, 2005) Pandemic Influenza
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Plan and the White House’s (White House Homeland Security Council, 2005)
National Strategy for Pandemic Influenza. Leavitt’s efforts paid off and in 2005 and
2006 the pandemic policy domain experienced major policy change, including the
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enactment of the Pandemic and All-Hazards Preparedness Act (PAHPA) (PL 109-
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417), which authorises the Secretary of HHS to lead federal emergency response
efforts during a public health emergency, and the Public Readiness and Emergency
Preparedness Act (PREPA) (PL 109-148), which shields vaccine manufacturers
from tort liability for damages arising from disease countermeasures (Cooper, 2006).
Moreover, between FY 2004 to FY 2009, Congress appropriated roughly $7 billion
for avian influenza-related programmes.
The second round of policymaking coincided with the 2009 H1N1 swine influenza
pandemic. The swine influenza was not an emerging threat, but a real public health
crisis that infected hundreds of thousands of people worldwide. Unlike the first agenda
setting stage, which spanned close to four years, the 2009 pandemic bowled its way
onto the legislative agenda, as reflected in the strong relationship between scope and
congressional activity. However, this period did not see policy change and Congress
spent most of its time overseeing the Obama administration’s management of the
crisis, as opposed to devising new legislation (Shear and Stine, 2009).
The significant but negative relationship between September 11 (focusing event) and
congressional activity reported in my model two is also notable. September 11 created
avenues for agenda setting in a number of public health issue areas, especially when
policymakers were able to link a disease to bioterrorism (Avery, 2004). Yet, there
was no significant influenza activity in 2001 – the virus did not reemerge until 2004.
Thus, indicators of novel influenza did not coincide with September 11, in turn
mitigating the likelihood that this exogenous event could somehow push a totally
unrelated issue onto the policy agenda.

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 Indicators, agendas and streams

Ebola policymaking
Table 2 reports the results of my Ebola models. Deviance goodness-of-fit tests indicate
a very strong fit for both the dose (any indicators) (Goodness of fit=1.153) and
the magnitude (change in indicators) (Goodness of fit=1.308) models. Significant
chi-square likelihood ratios for the dose (Chi-square likelihood ratio=102.065) and
magnitude models (Chi-square likelihood ratio=87.933) indicate an improvement
over the null.

Table 2: Congressional activity and Ebola

Independent Model 1 (Dose) Model 2 (Magnitude)
variables Any indicators Change in indicators
Indicators
Onset (yes=reference category) 0.212(0.3218) –
Scope (Pandemic=reference category) 2.892(0.4707)*** –
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Rate – 0.848(0.1808)***
Focusing Event
9/11 (9/11=reference category) 1.074(.4722)** 1.165(0.4530)**
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President (control variable)

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Republican (reference category) 0.027(0.3266) -0.360(0.3173)

Intercept 0.298(0.2085) 0.893(0.1640)***
N 88 88
Mean 4.3656 4.3636
Deviance goodness-of-fit (value/df) 1.153 1.308
Log likelihood -176.009 -183.075
Chi-square likelihood ratio 102.065*** 87.933***

Note: Estimated coefficients for Rate variable are z-scores. All others are unstandardised negative
binomial coefficients. Standard errors are in parentheses.

*p <0.10, ** p <0.05, *** p <0.01; two-sided tests of significance.

Changes in the party control of the presidency (president) did not influence congressional
activity. Congress was quite responsive to the 2014 Ebola epidemic (scope), an event that
had significant and strong effects on congressional activity (see Table 2). However, unlike
the pandemic case, the mere presence of new indicators (onset) was not enough to
attract policymaker attention, while September 11 (focusing event) played an important
role in stimulating policymaker attention in both models. This finding obviously
challenges the proposition that focusing events do not influence agenda setting in
indicator-driven domains. And as the number of indicators (rate) increased so too
did congressional activity. Specifically, a one-standard deviation increase in the number
of Ebola cases (roughly 1,645 cases) increases agenda activity by about 85 per cent.
Similar to the pandemic influenza case, these findings are demonstrative of a two-
staged agenda setting process (see Figure 2). There was a modest, but not statistically
significant, increase in congressional activity in 1995 in response to an Ebola outbreak

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in the Democratic Republic of the Congo, which infected more than 300 people.
This was the largest outbreak since the first Ebola outbreaks in Zaire and Sudan in
1976, which infected 318 and 284 people respectively. Indeed, save modest outbreaks
in Sudan in 1979 (34 cases) and Gabon in 1994 (52 cases) most of the outbreaks
occurring between 1976 and 1995 were limited to no more than four human cases.
The observed increased in policymaker attention therefore reflects the fact that Ebola
reemerged after close to two decades of near dormancy.

Figure 2: Congressional activity and Ebola

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Unlike the pandemic influenza case, however, the mere presence of new Ebola
indicators was not enough to trigger a statistically significant increase in congressional
activity. This is partially a testament to the fact that, at least prior to 2014, few
policymakers believed Ebola was a legitimate threat to the US. Whereas influenza
viruses can easily mutate into an airborne strain and transmit via a simple cough or
sneeze, Ebola can only be spread through direct contact with an infected host. Ebola
tends to exploit weaker public health systems, but is not necessarily a threat to the
US (Shrivastava et al, 2015). Thus, although many public health experts argue that
the US is behooved – even obligated – to help reduce the global burden of emerging
diseases regardless of whether or not they pose an immediate risk to national security,
Ebola did not trigger the sort of widespread mobilisation and policy entrepreneurship
observed in the influenza case (Garrett, 2001).
September 11 quickly changed this dynamic, as evidenced in the statistically
significant relationship between the focusing event and congressional activity variables.
While few policymakers were overly concerned with the possibility of a naturally
occurring Ebola outbreak in the US, September 11 raised the spectre that Ebola, as
well as a number of other viruses (for example, smallpox, anthrax, camelpox), could be
used as a biological weapon (Avery, 2004). These fears were magnified by the anthrax
attacks of 2001, which occurred weeks after September 11 and killed five people. And
unlike the pandemic influenza case, the September 11 attacks coincided with a fairly
significant Ebola outbreak in Uganda in 2000–01, which killed more than 400 people.
Ultimately, the increase in policymaker attention after September 11 is an outgrowth

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of the fact that Ebola was discussed within the context of various counterterrorism
statutes, including the Uniting and Strengthening America by Providing Appropriate
Tools Required to Intercept and Obstruct Terrorism (USA PATRIOT) Act (PL
107-26); the Public Health Security and Bioterrorism Preparedness and Response
Act of 2002 (PL 107-188); and the Project BioShield Act of 2004 (PL 108-276).
The second-round policymaking activity followed a different trajectory (Figure 2).
The 2014 Ebola epidemic was a public health crisis, infecting thousands of people
in a matter of months. A handful of Ebola cases in the US, coupled with a political
battle over the efficacy of CDC’s screening protocols, heightened policymaker concern
(Schnirring, 2014). Ebola skyrocketed to the top of the policy agenda and congressional
activity during this period eclipsed the post-September 11 levels.
This period also saw Congress pass the Adding Ebola to the FDA Priority Review
Voucher Program Act (PL 113-233) (‘Voucher Program’ hereafter), which incentivised
drug makers to create Ebola vaccines and other treatments by promising them an
expedited Food and Drug Administration (FDA) review process. The Voucher
Program symbolised a shift in Congress’s thinking about Ebola. No longer merely
a weapon of mass destruction, Ebola was now one of a number of diseases worthy
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of special review. Still, although the Voucher Program was undoubtedly a victory
for the global public health community, its significance paled in comparison to the
kinds of large-scale policy changes observed in the Ebola domain in the wake of
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September 11 and in the pandemic influenza domain during the avian influenza
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outbreak. In fact, many observers believed this change was overdue, as the FDA was
criticised for its prior refusal to add Ebola to the priority list (Wechsler, 2014). The
Voucher Program was an example of policy maintenance in that it saw an existing
statute undergo fairly minor alterations in light of new circumstances (Parsons, 1995).
It should not, however, be equated to the substantive changes observed in the wake
of September 11.

Analysis and discussion

This study identifies two patterns of indicator accumulation: gradual versus rapid
indicator accumulation (see Figures 3 and 4). Whereas the MSA literature broadly
assumes policymakers are attracted to indicator change, the concept of indicator
accumulation provides a more nuanced depiction of the complex interplay between
indicators and agenda setting (Kingdon, 2003). Specifically, the way in which
indicators reveal themselves to policymakers – how quickly and how much they amass
– can shape the trajectory of issue attention, agenda setting and even policy change.
Gradual indicator accumulation sees indicators amass slowly over a period of several
years. Gradually accumulating indicators are often forward looking, suggesting the
possibility of a larger culminating event. Additionally, Lehtonen (2015) notes ‘the ways
in which [descriptive indicators] enter into policymaking are largely unpredictable’
(p 80). This is an apt description of gradual indicator accumulation, as the issue
attention patterns associated with the Ebola and pandemic influenza cases were quite
different and very unpredictable. Policymakers all but ignored the various Ebola
outbreaks of the 1990s until September 11 heightened concerns about bioterrorism.
Conversely, policymakers were incredibly sensitive to small changes in avian influenza
cases, as evidenced in the marked increase in agenda activity between 2005 and 2007.

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 Rob A DeLeo

Figure 3: Distribution of novel and pandemic influenza (H5N1/H1N1) cases worldwide by

year

> 700,000 in 2009

Case Distribution

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Figure 4: Distribution of Ebola cases worldwide by year

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>27,000 cases in 2014/2015

Case Distribution

<2,000 cases b/t 1994-2013

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Despite differences in issue attention, both the Ebola and pandemic influenza domains
experienced policy change during periods of gradual indicator accumulation.
The gradual accumulation of cases stoked policymaker concern but provided
sufficient time for the development of acceptable solutions, the cobbling together of
political coalitions, and, in the pandemic influenza case, the emergence of a policy
entrepreneur. In other words, the various streams did, in fact, need time to gestate
(Rapaport et al, 2009)
Rapid indicator accumulation, by contrast, sees a sizable amassing of indicators
transform a once emergent hazard into a manifest crisis. Rapid accumulation
allows issues to quickly access the legislative agenda, and significant increases in
congressional activity occurred in both cases. While Kingdon (2003) is careful to note
that policymakers are attracted to deviations from the status quo, the rapid indicator
accumulation process documented in this paper is far more dramatic than the MSA

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literature describes. The 2014 Ebola outbreak was 15 times larger than all previous
Ebola outbreaks combined. The 2009 swine influenza pandemic was hundreds of
times larger than the avian influenza outbreak.
This finding raises important questions about the conceptual distinction between
indicators and focusing events. Focusing events are depicted as rapid onset disasters
that emerge without perceptual cues (Birkland, 1997; Nohrstedt, 2008). Neither the
Ebola epidemic nor the swine influenza pandemic perfectly match this description,
as they spanned a several months. Yet, both incidents met many of the other criteria
ascribed to focusing events: they were relatively rare, sudden, inflicted a great deal
harm and, for the most part, became ‘known to policy makers and the public virtually
simultaneously’ (Birkland, 1997: 22). What is more important is that rapid indicator
accumulation has important implications for the agenda setting process. Indeed, the
2014 Ebola outbreak and the 2009 influenza pandemic exemplify Kingdon’s (2003
depiction of events that ‘bowl over everything standing in their way of prominence
on the agenda’ (p 96).
Rapid indicator accumulation is unequivocally more likely to capture policymaker
attention than gradual accumulation, but it is not necessarily a recipe for policy change.
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Save perhaps the Voucher Program, which is best characterised as an example of

policy maintenance, rapid indicator accumulation did not result in substantive policy
change. This finding further substantiates Rapaport et al’s (2009) contention that
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the streams need time to converge. It is also plausible that the lack of policy activity
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observed in the wake of these events pays testament to the perceived strength of the
policies put in place years prior. Existing preparedness regimes helped ensure that
the 2009 pandemic and 2014 Ebola outbreak did not come to represent examples
government failure, thus mitigating the likelihood of further policy change after
disaster (Birkland, 1997).
Finally, this study demonstrates the importance of spillover events or situations
where ‘The appearance of a window for one subject increases the probability that a
window will open for another subject’ (Kingdon, 2003: 190). Spillovers help establish
new principles or narratives that reframe an existing problem. Once a principle gets its
proverbial ‘foot in the door’ it is very hard to prevent policy change in the long run,
as the status quo has already been disavowed. September 11 established all-hazards
preparedness as a new principle, in turn facilitating widespread policy change across
a number of issue areas (May et al, 2011).
This mandate was especially pronounced in the public health domain. The
anthrax attacks only strengthened the perceived connection between public health
and counterterrorism (Avery, 2004). Given their temporal proximity, it is obviously
impossible to disaggregate the agenda effects of September 11 and the anthrax attacks.
Avery (2004) suggests that, even in the absence of the anthrax attacks, Ebola would still
have been swept up by the post-September 11 policy agenda. The emerging disease
domain was primed for change. In fact, the movement to bolster the US’s public
health infrastructure can be traced to the 1990s, as various bioterror attacks, like Aum
Shinrikyo’s use of Sarin in Tokyo in 1995, underscored the dangers of weaponised
diseases. Issue advocates were thus poised to capitalise on the post-September 11
policy window regardless of the anthrax attacks.
Yet interaction between indicators and events is by no means a foregone conclusion.
In order for a spillover event to trigger trans-domain issue attention, gradual indicator
accumulation must coincide with the onset of the focusing event. September 11

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occurred months after a very sizable Ebola outbreak, but during a period of dormancy
for novel influenza. In turn, September 11 was positively related to agenda activity in
the Ebola, but not the pandemic influenza case. This finding helps clarify Kingdon’s
(2003) contention that indicators need a little push and suggests that some degree of
‘indicator-event’ overlap is needed before an exogenous event can have spillover effects.

Conclusions
The findings outlined above suggest a number of additional research avenues. First,
closer analysis of the international and global dimensions of indicator tracking and
interpretation is needed. International agencies play an important role in monitoring
diseases and the patterns observed in the US are by no means representative of all
governments. Relatedly, the Ebola and pandemic influenza cases are not representative
of all problems. Public risk domains, including emerging diseases, are distinctive in
that they are devoid of a competitive public, meaning private interest groups do not
readily mobilise against these types of programme and policymaking is dominated by
individuals with a great deal of technical expertise (May and Koski, 2013). Scholars
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should consider investigating non-public risk domains. For example, the substance
abuse or even climate change domains are much more politicised but still maintain
a fairly unambiguous connection to a clear set of indicators (for example, overdose
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rates and annual average temperatures).

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Second, whereas most MSA studies rely on a broad conceptualisation of indicators,

this study shows that different rates of indicator accumulation induce discernable
patterns of agenda setting. Not only is further analysis of the distinction between
gradual and rapid indicator accumulation needed, but scholars should consider other
‘types’ of indicators and their relationship to the agenda setting process. For example,
the distinction between surrogate indicators and direct measures warrants closer
investigation (Gent, 2000). Do surrogate indicators hold more weight in certain
domains? And when and under what conditions will an indicator become accepted
as the best measure of a problem? The last decade has also seen a proliferation of
indicators emanating from non-governmental sources, including unauthorised data
breaches and the online tracking of social behaviour. This data introduces important
questions about what, exactly, constitutes a ‘viable’ policy indicator. To what extent
can, for lack of a better term, non-governmental indicators influence the agenda
setting process? And does the scope and trajectory of political mobilisation differ
when indicators are derived from non-traditional sources?
Finally, this paper implies indicators and events align along a continuum. When
indicators rapidly accumulate, agenda setting becomes more emblematic of a post-
event response than an exercise in anticipation. Are crises inextricably linked to
focusing events or can indicators inform the governance of hazards? Does the presence
of conceptual cues affect the policymaking process? And while large-scale public
health crises are more the exception than the rule, rapid indicator accumulation is by
no means unprecedented. The Great Recession of 2007–09, for example, triggered
a precipitous decline in a host of economic indicators, ranging from gross domestic
product (GDP) to monthly job loss.
From the identification of emergent hazards to the routine monitoring of ongoing
social ills, indicators are central to every major theory of policy change. MSA is no
exception and indicators are referenced more than any other element of the problem

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stream. This paper demonstrates their importance and highlights the extent to which
changes in quantitative measures influence the agenda setting process. Still, much
work remains to be done and MSA stands to gain enormously from studying this
important component of the problem stream.

Acknowledgements
A draft of this paper was presented at the International Symposium on Ambiguity and
Crisis: Disasters, Governance and Social Risk at North Carolina State University, which
was sponsored by the Policy & Politics International Panel Fund. The author would
also like to thank the Bentley University Health Thought Leadership Network for their
support throughout the writing and revision process as well as the anonymous reviewers
for their thoughtful comments and feedback.

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