In 2013, members of the National Security Council convened a meeting to bring together officials working on infectious disease prevention and response from the Departments of State, Defense, Agriculture, Health and Human Services, as well as from the Federal Drug Administration, the Agency for International Development (USAID), and the Centers for Disease Control and Prevention (CDC).
I worked at State at the time, and my portfolio focused on preventing the spread of weapons of mass destruction, as well as terrorism and biosecurity issues. We met because of a growing concern: that despite the work of the United States, other countries, a variety of international organizations, the non-governmental sector, and other institutions to combat infectious disease, there was a steady increase of infectious disease threats. It was clear that infectious diseases would continue to endanger the global community, and that something had to be done.
That discussion was followed by a range of additional meetings to include close engagements with other countries, international organizations, and the non-governmental sector. The result was the February 2014 launch of the Global Health Security Agenda (GHSA) by the U.S. and international partners. The GHSA is an effort to build countries’ capacities to prevent, detect, and respond to infectious disease threats (whether from an accidental, natural, or intentional causes). Over 30 countries, along with international organizations including the World Health Organization (WHO), joined.
Since the launch in 2014, the GHSA has grown to include 67 countries, international organizations, and non-governmental organizations. The GHSA’s long-term, often quiet effort to strengthen capacity continues, and new global pandemics since then have been a stark reminder of why such planning matters. A month after launching the GHSA, the world was hit with Ebola; since then, we have confronted the 2015 Middle East Respiratory Syndrome in South Korea, the 2016 Zika virus, another outbreak of Ebola in 2018, and now, COVID-19.
When new crises hit, there is often a knee-jerk reaction to reinvent the wheel in response. But the global public health capacity embodied in the GHSA provides a strong foundation for addressing the pandemic we face today.
That was then
There were many indications in 2013 that the global community was not ready for a pandemic.
We realized that most countries (possibly as high as 70%) were not compliant with the WHO’s 2005 International Health Regulations, a legally binding instrument that seeks to, among other things, strengthen country capacities and detail a public health response to the spread of disease. There was also rising global awareness at that time of problems posed by the increasing threat of antimicrobial resistance — in other words, when germs develop the ability to defeat the drugs designed to kill them.
The 2001 Anthrax attacks in the U.S. — which infected 21 people, killed 5, and cost more than $1 billion to clean up — were also still on officials’ minds. SARS in 2003 cost the global economy $30 billion in only 4 months. In 2009, the H1N1 influenza pandemic killed 284,000 people in its first year alone. We were acutely aware that with the ease of global travel, a disease could not be easily contained. We also took note of the fact that over 60% of human diseases come from animals, at a time when many people around the world were (and are still) living in closer in proximity to animals.
The importance of infectious disease prevention, detection, and response needed to be elevated globally. We sought to ensure government leadership, urging leaders to dedicate time and resources to the issue, and to work with other countries. We also reminded the global community that infectious disease threats are a national security threat and should be treated that way.
In 2018, the U.S. administration released a Biodefense Strategy that would help with “detecting and containing biothreats at their source.” Following a whole-of-government approach, Congress allocated $1 billion for the GHSA until 2019. In FY2019, funding for global health security was $504 million, which included a one-time transfer of $38 million in unspent emergency Ebola funding. President Trump’s FY2020 request for global health security totaled $482 million.
This is now
The need for such a global initiative on combatting infectious disease is painfully obvious today, with COVID-19, of course. We have learned a great deal in recent years, including about the importance of work around the world from institutions like the CDC, USAID, and other government agencies, as well as the importance of cooperation within the U.S. government.
The GHSA has led to the establishment of the Joint External Evaluation tool (JEE), a peer review process of a country’s capacity to combat infectious disease. It involves a national self-assessment and an external evaluation team with experts in human and animal health, food safety, agriculture, defense and public safety. Some of the results are posted online and are paired with national action plans promoting transparency on what countries need to do to improve their capacities. Many of the ideas that originated in the GHSA, including the JEE and country strategies, were later adopted by the WHO to help promote compliance with health regulations. To date, over 95 JEEs have been done.
In 2017, the countries attending the GHSA Kampala Ministerial decided to extend the Global Health Security Agenda to 2024, and in so doing, reaffirmed several core principles of the initiative and established time-limited task forces.
Another outcome of the GHSA are “Action Packages” though which the 67 countries collaborate around antimicrobial resistance, biosafety and biosecurity, immunization, laboratory systems, sustainable financing, surveillance, workforce development, and zoonotic disease. Through collaboration via the GHSA Steering Committee of country participants, countries have improved their laboratory emergency response systems, strengthened biosecurity and biosafety programs, and enhanced detection of vaccine-preventable diseases. Also, importantly, countries like Finland, Indonesia, South Korea, The Netherlands, Italy, Uganda, Canada, and others have stepped forward to also take leading roles in the GHSA’s implementation.
Despite some progress on the goals of the GHSA, we are still not as prepared as we could be. Funding for the GHSA has been reduced since the launch in 2014, both in the U.S. and globally. While there were increases in CDC staff abroad following the Ebola crisis — a welcome sight for many countries whose capacities have strengthened as a result — CDC staff was significantly reduced in 2018 as a result of decreased funding for the GHSA. The number of countries in which the CDC was working fell from 49 to approximately 10. The decrease in field-based staff working abroad erodes local public health efforts and preparedness capacities, and also reduces critical situational awareness through early detection of disease events.
Finally, leadership positions have been lost: The Trump administration closed the White House’s National Security Council Directorate for Global Health Security and Biodefense in 2018. The GHSA countries must maintain high-level political attention and commitment to the initiative. To do that and to continue to build long-term capacities to prevent, detect, and respond to infectious diseases, the GHSA and national preparedness efforts need sustained funding and an even larger corps of member countries.
Where do we go from here?
In the past week, Congress has been focused on taking immediate action to prop up American households and businesses — a near-term step that is surely needed to bolster the economy amid the COVID-19 outbreak. But more broadly, we cannot lose sight of the fact that strengthening public health capacity takes time, dedication, sustained money, and resources. For instance, last year the House of Representatives passed the Global Health Security Act of 2019 (which would “authorize a comprehensive, strategic approach…to strengthen global health security”), but it has not passed the Senate.
In 2018, the U.S. launched its Health Security Action Plan based on the results of a JEE. We need to now examine what has gone right and what has gone wrong in how we are combating COVID-19 and determine where we may need to adjust (both domestically and globally). Other countries that have had a JEE and are working on their own long-term plans for building capacity should do the same.
We have an opportunity to learn from the COVID-19 crisis. It’s a chance to consider what other issues should be brought into GHSA discussions on building capacities. We should continue engagement with the private sector, which has valuable insights and experiences, and civil society, which has years of expertise in dealing with infectious disease threats.
Most importantly, no country stands alone when it comes to global threats. More countries must join the GHSA so that transparency can be broadened and enhanced — not just during an outbreak, but before an outbreak occurs. We had a sense of teamwork when we developed and implemented the GHSA. There was strong leadership from the White House and engagement from across the U.S. government and beyond. The GHSA provides a foundation for the global community to better meet the challenges of infectious disease threats while working with international partners like the World Health Organization; we do not need to start from scratch in the global battle against COVID-19. We need to work with and strengthen the mechanisms we have in place.
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