How to build a global health security movement

BURLINGTON, Vt. — Supporters of a stronger U.S. role in global health security have long warned that if politicians did not choose to listen to them, they would someday be forced to. As the coronavirus pandemic has brought the world economy to a screeching halt, these same advocates say the time might finally have arrived to escape what experts call the “cycle of crisis and complacency” in pandemic preparedness.

World Health Organization Director-General Tedros Adhanom Ghebreyesus reiterated that message Monday in his opening remarks to the World Health Assembly — convened virtually due to the COVID-19 outbreak.

“The world can no longer afford the short-term amnesia that has characterized its response to health security for too long. The time has come to weave together the disparate strands of global health security into an unbreakable chain — a comprehensive framework for epidemic and pandemic preparedness,” he said.

Despite what many consider a disappointing international response to COVID-19 so far, there are some signs that the U.S. government might try to breathe new life into global health security efforts. If that happens, it will not be the first time advocates have sought to turn an immediate threat into a long-term, sustainable plan for preparedness.

Lawmakers in the U.S. House of Representatives and the Senate have introduced legislation that would establish higher-level leadership for pandemic preparedness at the White House — following the decision by President Donald Trump’s administration to disband the office leading such efforts — and elevate the Global Health Security Agenda, or GHSA — a partnership initiative launched in 2014 during the administration of then-President Barack Obama.

Those efforts have been accompanied by calls to inject significant international funding — a group of Senate Democrats have called for $9 billion — into the next U.S. emergency spending bill, which is still being negotiated.

Some lawmakers have also backed a proposal to put $1 billion in U.S. support behind a global health security challenge fund, which would aim to compel national governments, donor agencies, and the private sector to mobilize funding for pandemic preparedness efforts.

“It’s hard to imagine that, after this experience with coronavirus, there wouldn’t be a realization on a broad scale that countries all over the world have underinvested in global health security and public health,” said Josh Michaud, associate director for global health policy at the Kaiser Family Foundation.

“The question is: How long will our memory last?” he said.

That is the challenge facing advocates for a strengthened and sustained effort to improve pandemic preparedness: ensuring that the damage inflicted by COVID-19 will be seen within the context of an ongoing threat created by the combination of infectious pathogens and weak health systems.

“One of the things we’re betting on is that we can translate this moment of political attention into sustained support,” said Carolyn Reynolds, co-founder of Pandemic Action Network.

That is “very much an open question,” Reynolds added, since all of the money and attention directed toward COVID-19 is still a product of “panic mode.”

“It’s human nature to deal with the crisis in front of you and not the one that you can’t see,” she said.

A basement and a blizzard

When officials in the Obama administration took on the issue of global health security, they drew inspiration from an unlikely source: the president’s agenda-setting speech on nuclear security in Prague in April 2009.

Biosecurity experts realized they needed something similar to what Obama laid out in the Prague speech — a three- or four-point elevator speech for biological threats that could work for both the global health community and the national security community, said Beth Cameron, vice president for global biological policy and programs at the Nuclear Threat Initiative and former senior director for global health security and biodefense at the White House National Security Council.

They referred to what they were looking for as “bio-Prague,” said Laura Holgate, vice president for materials risk management at NTI and former senior director for weapons of mass destruction terrorism and threat reduction at the NSC.

One of the first challenges was bringing together two communities — global health and national security — that tended to look at each other with skepticism.

“There was serious concern among those who approached global health from a development perspective that it would be instrumentalized,” said Gayle Smith, former senior director for development and democracy at the NSC and CEO of the ONE Campaign.

That concern was well founded. The Central Intelligence Agency’s use of fake vaccination campaigns to gather information about Osama bin Laden has resulted in the killing of front-line health workers in Pakistan. Less dramatically, the Department of Defense had taken what Holgate admitted was, at times, a clumsy approach to working with health ministries on biological threat reduction programs.

Mending those divisions required partnership between Holgate on the national security side and Smith on the global health and development side.

“I think it demonstrates what an effective NSC looks like, quite frankly,” Smith said.

They pulled in representatives from the Centers for Disease Control and Prevention, the Department of Health & Human Services, the Department of Agriculture, the Food and Drug Administration, the Environmental Protection Agency, multiple parts of the Department of Defense, and the U.S. Geological Survey, since it oversees water security.

“It absolutely has to be whole-of-government,” Holgate said.

“We couldn’t even house the meetings that Laura and Gayle had to kick off GHSA. The biggest meeting rooms in the [Eisenhower Executive Office Building] couldn’t fit everybody,” Cameron said.

The effort drew pulses of motivation when emerging health threats such as Middle East respiratory syndrome and the H7N9 strain of bird flu popped up in various parts of the world, raising alarm bells and prompting weekly meetings at the NSC.

The agenda also benefited from Obama’s personal interest and celebrity status, which he utilized in conversations with world leaders to put the issue of pandemic preparedness on their radars. That, in turn, gave health ministers in other countries more cachet within their own governments, Cameron said.

In 2011, Obama included a section on global health security in his speech to the United Nations General Assembly, calling on countries to “come together to prevent, and detect, and fight every kind of biological danger” and to step up their efforts to meet WHO’s International Health Regulations, or IHR, which reflect an agreement by 196 countries to report public health threats and cooperate to stop their spread.

“One of my biggest victories at the White House was getting that language in there,” Holgate said.

Those regulations had been revised and strengthened in 2005 but still only required countries to self-report their preparedness and lacked much authority to do anything about the gaps they identified. The deadline for meeting them was 2012, but it was clear before then that the majority of countries would fall short, which 80% eventually did.

In the background, the constituency for global health security was growing inside the administration, until Holgate eventually hosted a meeting of more than a dozen senior officials in her own basement, where they began to outline a U.S.-led initiative to kick-start a global effort to fill in the world’s pandemic preparedness gaps.

The core of the GHSA involved translating the IHR into specific metrics to paint a comprehensive picture of pandemic preparedness for every participating country.

“One of my favorite ones is: Can you assemble your emergency operations center in two hours?” Holgate said. “It doesn’t matter if it’s an hour and 50 minutes, or two hours and 10 minutes. The point is: If you can get your people together, then that says a lot. … It says you have a plan.

“We went through each of those IHRs and said, ‘What is an actual, measurable, visible, tangible indication that that IHR is being met?’ That’s what the agenda became.”

In February 2014, as the launch date for the GHSA arrived, a snowstorm descended on Washington, shutting down federal offices and paralyzing the city. The GHSA team dispatched a staffer with a four-wheel-drive vehicle to collect the Ugandan delegation, Holgate recalled, while then-Secretary of Health and Human Services Kathleen Sebelius arrived at the White House in her snow boots to help launch the agenda with Margaret Chan — Tedros’ predecessor as WHO director-general — and 29 initial partner countries, many of them joining virtually.

“This is probably the most comprehensive effort in recent memory to address the problem of infectious disease threats and to bring different parts of the U.S. government and other governments together to try and address it,” Scott Dowell, then-director of global disease detection and emergency response at the CDC Center for Global Health, told Devex at the time.

Frameworks and financing

With the coronavirus now projected to reverse three years of global development progress, plunging tens of millions of people back into extreme poverty and causing immense collateral damage to health and livelihoods, it can be difficult to regard any previous effort to strengthen global health security as anything other than a failure.

Those involved in the creation of the GHSA — which still exists as an international partnership — say that the failing was not in the framework they built to identify gaps in the global health security net, but in not doing enough to support countries’ efforts to fill those gaps.

Cameron said the GHSA achieved something very early that its supporters believed would be nearly impossible: the creation of a system of “joint external evaluations,” or JEEs, which began to shift national preparedness from self-reporting to independent, rigorous analysis of specific global health security metrics. While the World Health Organization was initially wary of that idea, doubting it could garner buy-in from member countries, the JEEs have now been handed off to WHO following an initial pilot in five countries, and 100 of these external evaluations have been completed.

“It’s like everything you would want from a development perspective. It’s a very technical evaluation of all the gaps,” Smith said.

That work has given rise to other assessments, such as the Global Health Security Index, which grades 195 countries on their outbreak preparedness.

“It showed nobody is prepared. Nobody. That’s not a condemnation of the framework; it’s a condemnation of the execution of the framework,” Cameron said.

“Where we haven’t had as much success is on financing,” she added.

Part of the GHSA’s value proposition was that if countries participated in a process to identify gaps in their health preparedness systems, international donors and the private sector would step forward with the financial, technical, and commercial assistance to help fill them. That end of the bargain has not fully materialized, most people involved with the effort readily admit.

Reynolds attributed that financing shortfall in large part to a lack of political advocacy on behalf of global health security. She co-founded the Pandemic Action Network to start building the kind of constituency that has helped other health priorities, such as HIV, garner sustained political support.

Global health security has been “largely in the domain of technical experts,” Reynolds said, and those experts have not always had “the skill set or the capacity to effectively translate that into the political realm.”

With daily briefings and an endless stream of headlines dedicated to the science and epidemiology of the current pandemic, those separate domains may have — at least temporarily — broken down. The cost argument that global health security advocates have been making for years is now front and center.

Smith said that when she left government, the world was investing roughly $5 billion per year in global health security. Now, the U.S. government is negotiating — and passing — emergency spending packages that total in the trillions.

“I think that the development community’s got a vast amount to offer. I think it’s going to be a really important moment for the community,” she said.

The world has also seen the vital role of political leadership, both in prioritizing global health health security and in “leveraging the paper capability that we have,” Cameron said.

While some countries, such as South Korea, have performed as would be expected from the assessments of their preparedness, the U.S. and others have dramatically underperformed.

“If we don’t leverage that capability, we’re gonna all be sitting at home,” Cameron said.