The U.S. government and many other national governments long ago recognized mass outbreaks of infectious disease as a global and national security concern and planned for the inevitability of future pandemics, but they failed to adequately fund and execute those plans in the face of this coronavirus pandemic. Preventing a reoccurrence of these failures in future pandemics will require major policy and institutional changes to bolster the foundations of U.S. national and global health security.
The Task Force finds that pandemics are inevitable, possibly imminent, and likely to be devastating to U.S. health, economic, and strategic interests. World leaders have called the coronavirus pandemic a “once-in-100 year” crisis, but there is no reason to expect that to be true.94 Pathogens frequently emerge; some jump from animal to human and spread swiftly. Those outbreaks can evolve into epidemics, one of which could explode into a pandemic that spreads worldwide and last months or years. As harmful as this coronavirus has been, a novel influenza could be even worse, transmitting even more easily, killing millions more people, and destabilizing governments and economies alike.95
The coronavirus pandemic is a vivid and painful example of the devastation that emerging pathogens can cause to lives and livelihoods worldwide. The global response has exposed the inherent weaknesses and inequalities in pandemic preparedness and response; it should be a transformative moment. The painful lessons learned should make governments wise enough to avoid such costly mistakes and instead take preemptive steps to advance pandemic preparedness in the United States and abroad.
The Task Force has organized its recommendations into four sections: a strategy for improving U.S. and global pandemic preparedness followed by those related to prevention, detection, and response.
This strategy and these recommendations will only succeed with leadership from U.S. policymakers working in concert with their counterparts in foreign governments and multilateral institutions. Without such leadership and partnership, accompanied by institutional reforms and adequate funding, any future pandemic response will be no better than the current, muddled performance, with high human and economic costs.
Adopt a Robust Strategy for Domestic and Global Pandemic Preparedness
This comprehensive and coordinated strategy to advance pandemic preparedness proposes new infrastructure and investments at the national and global levels. At home, the Task Force calls on the United States to elevate pandemic preparedness to a core national economic and security objective and organize and invest accordingly, revitalize the beleaguered CDC, and clarify federal and state authorities and roles for pandemic response. Internationally, we advocate for continued U.S. membership in WHO and support for its lead role on the international health response to pandemics, a more vigorous involvement of the United Nations, the creation of a new Health Security Coordination Committee to mobilize pandemic response on economic and security matters that includes greater involvement of civil society and the private sector, and the establishment of new mechanisms to finance pandemic preparedness and response internationally.
Prioritize U.S. preparedness—and act and invest accordingly.
The Task Force recommends that the United States finally treat pandemics as a serious national security threat, translating its rhetorical support for pandemic preparedness into concrete action.
The United States needs to make pandemic preparedness a national security priority not only in word, but also in deed. COVID-19 has revealed health security to be a core component of national security, critical to the safety and well-being of its citizens.96 The United States should adapt to this reality by approaching pandemic preparedness with the same seriousness of purpose with which it treats national defense. The federal government should formulate and adhere to a nationwide pandemic preparedness strategy and organize itself effectively so that it can rapidly anticipate, prevent, and respond to outbreaks. The United States should also invest more resources in critical institutions and capabilities, at a level commensurate with the threat it faces.
Organizing for success will require bolstering the White House’s leadership role in preparing for and responding to pandemics, improving congressional input into and oversight over executive branch efforts, reforming the CDC so that it can perform more effectively, and clarifying the often confused division of labor across federal, state, and local governments in pandemic preparedness and response.
The Task Force recommends that the U.S. federal government adopt a comprehensive national strategy for pandemic preparedness, organize itself for success, and craft a budget commensurate to the challenge.
Pandemic diseases pose grave and growing risks to Americans that match or exceed those presented by transnational terrorism. The executive branch should acknowledge this reality by elevating the threat of new and reemerging infectious disease in the National Security Strategy mandated by Congress, as well as in the strategic plans of the Departments of State, Homeland Security, Health and Human Services, Defense, and the U.S. Agency for International Development (USAID). These strategies and plans should drive the annual appropriations requests to Congress prepared by the Office of Management and Budget (OMB).
The president should designate a focal point within the White House for global health security, including pandemic preparedness and response. This office would have lead responsibility for coordinating the multiple federal departments and agencies in anticipating, preventing, and responding quickly to major disease outbreaks, as well as for liaising with states and municipalities. It would also be responsible for conducting regular exercises among federal actors, as well as with state and local counterparts, to develop patterns of cooperation and standard operating procedures that correspond as closely as possible to real-world scenarios.
To work in conjunction with HHS leadership on global health diplomacy, the secretary of state should designate an ambassador-level official to help coordinate the U.S. diplomatic response to international public health emergencies, including through U.S. chiefs of mission abroad. Such an appointment, reporting directly to the secretary, would elevate global health security in U.S. foreign policy, put the State Department on a stronger footing to coordinate with foreign governments and international organizations, and help integrate the international activities of HHS with those of its own regional and functional bureaus, as well as USAID. Within the White House, OMB should appoint a senior official to ensure consistency of health security funding and management decisions across all agencies and accounts, domestic and international.
In parallel with these steps, the United States should significantly increase the portion of the federal budget devoted to domestic pandemic preparedness and response. The U.S. government spends $750 billion a year on the U.S. military to deter aggression and to ensure that if war comes, the United States will win. By contrast, the nation spends a relative pittance on domestic and global health security, and it shows. In the case of COVID-19, the lack of adequate preparedness funding placed the United States in an overwhelmingly reactive mode and forced the government to rely on supplementary appropriations for pandemic response.
The Task Force calls on the executive branch agencies to request and Congress to appropriate funds for a comprehensive health security budget commensurate with the threats that the United States faces from pandemic disease and consistent with the needs identified by U.S. public health officials. This budget would include increased funding for the pandemic preparedness programs, projects, and activities of relevant U.S. agencies, including among others the CDC, the office of the HHS assistant secretary for preparedness and response, the National Institutes of Health, the Food and Drug Administration (FDA), the State Department, and USAID, while exempting specific budget line items from Budget Control Act caps, as well as sequesters, in the interest of U.S. public health security.97
Important components of the nation’s health security budget would include increased funding for state and local hospitals, scientific research on emerging and zoonotic diseases, epidemiological surveillance, the Strategic National Stockpile, vulnerable countries around the world, WHO, and other essential multilateral agencies. This new financial mechanism should be accompanied by additional technical support to accelerate planning and implementation and to monitor progress.
To facilitate such an integrated health security budget, the Task Force recommends that Congress establish bipartisan select committees or formal working groups in both chambers. Today, jurisdiction over global health matters is fragmented across a dozen committees and subcommittees in the House and Senate. Congressional leaders should rectify this by establishing specialized bodies that can provide a coordinated vision for the regular committees of jurisdiction. In parallel with these federal-level steps, state governors and legislatures should maintain their own pandemic preparedness budgets, which COVID-19 has exposed as wanting.
The Task Force recommends a thorough review of the performance of the Centers for Disease Control and Prevention during the COVID-19 pandemic with an eye toward potential managerial and budgetary reforms.
The Centers for Disease Control and Prevention has a “unique mission—to save lives by deploying effective, proven strategies to prevent, detect, and rapidly respond to outbreaks at their source.” Too often during the early phases of the COVID-19 crisis, the CDC fell short in fulfilling this mandate.98 To this end, the Task Force recommends that Congress appoint an independent commission to review the CDC’s record during the initial months of the pandemic, identify obstacles to its effectiveness, and consider how it could do better in the future. Potential reform priorities could include developing a more sensitive CDC system of surveillance and early warning, strengthening its overseas workforce, enhancing the agency’s ability to sequence and test genetic materials quickly, creating more effective models to project the spread of pandemics, and expanding the CDC’s capacity to scale up nationwide testing and tracing.
Revitalizing the CDC will take money. Between 2002 and 2020, the CDC’s Public Health Emergency Preparedness program to support U.S. states and localities, including for laboratories and contact tracing, declined from $940 million to $675 million, even as the dangers of pandemic disease gathered.99 That trend needs to be reversed, subject to close monitoring of how these additional funds are used. Finally, consistent with the principle that public health specialists should be out in front in communicating with the American people, the Task Force calls on the executive branch, including the White House, to put the CDC front and center in its public health education efforts.
The Task Force recommends that the U.S. government initiate a review of the responsibilities for pandemic preparedness and response among public health authorities at the federal, state, local, and tribal level, so that federalism is an asset rather than a liability to achieving U.S. health security.
The COVID-19 pandemic has tested the U.S. federal system, revealing uncertainty on how authorities, responsibilities, and burdens for pandemic preparedness and response are and should be apportioned among the federal government, fifty states, and 2,634 local and tribal public health departments. The United States cannot afford ambiguities over federal, state, and local responsibilities in the throes of a public health emergency unless it is willing to risk political paralysis and unnecessary deaths. Nor can the country allow pandemic response to devolve into a modern caricature of the Articles of Confederation, in which U.S. states and cities compete frantically for scarce medical supplies, whether from domestic or foreign sources.100 Although many state governors and mayors have acquitted themselves well, adopting innovative and at times successful policies to fill the federal vacuum, few of their constituents would hope to repeat such a frantic and haphazard experience.
To avoid such a prospect, the Task Force recommends that the White House reverse its practice of weakening federal guidance to states, which has resulted in a patchwork response to the current pandemic. This should involve ensuring that all state governors have timely access to the best available evidence from the CDC, providing more presidential support to states and public health officials seeking to implement federal advice even amid local political pressure, and replacing competition that currently exists among states with more coordination of the procurement of scarce medical resources. The current pandemic demonstrates the need for federal officials to initiate a review process to define more clearly the respective roles and responsibilities of public health officials at the federal, state, and local levels amid a nationwide pandemic. The authority to advance this effort should leverage both carrots (the spending power of Congress) and sticks (U.S. federal authority to oversee interstate commerce) if needed to enable more coordination at the national level of state and local responses to public health emergencies.101 Independent bodies, such as the National Academy of Medicine, could be enlisted to advise on this project.
Revamp the multilateral system for preparing and responding to pandemic threats.
The Task Force recommends that the United States remain a member of WHO and work with other nations to strengthen its capacity and effectiveness in preventing, detecting, and responding to epidemic threats. The UN agency is a flawed institution, but there is no multilateral substitute to advance U.S. interests in the current pandemic or the next one.
The Task Force recognizes that WHO is not a perfect institution. Its limitations, bureaucratic processes, and dysfunctions have, at times, been evident in this pandemic. However, no multilateral alternative to WHO in global public health emergencies exists. In many important respects, the performance of WHO in the current epidemic has improved because of the reforms instituted after the West Africa Ebola epidemic. U.S. policy should seek to enhance WHO’s independence and effectiveness, not degrade it during the present crisis or before the next serious disease event. Doing otherwise will only make Americans less safe from this and future pandemics.
The United States can strengthen WHO and advance needed improvements to IHR and pandemic preparedness and response in only one way: remain a WHO member state and advance reform from within the institution. Any new, U.S.-led initiative that seeks to assume the role of WHO on coordinating the health-related activities on global preparedness and outbreak response management would be duplicative and lack the UN agency’s international legal authorities and ties with health ministries. WHO is able to respond to outbreaks and epidemics in nations where the United States cannot or prefers not to become involved, such as Venezuela’s measles outbreak and the Ebola epidemic in civil war–torn Democratic Republic of Congo. The U.S. government has heavily invested in and benefits from WHO activities on polio eradication; efforts to tackle tuberculosis, malaria, and vaccine-preventable diseases; and its global influenza program. Walking away risks reversing the hard-won gains from those U.S. investments and abandoning WHO when that body is most needed—as the epicenter of the pandemic shifts from high-income to low-income nations.
The legitimate concerns about WHO’s performance in this pandemic include its reluctance to push China to allow a robust, on-the-ground WHO team early in the outbreak; its public, unqualified praise of China’s transparency despite WHO staff’s knowledge and sentiments otherwise; and its occasional scientific miscommunications on issues such as travel restrictions, masks, and the asymptomatic spread of the virus.
The deference of WHO to its member states, and the latter’s insistence on preserving their sovereign prerogatives, is likely to thwart many proposals to strengthen WHO to address these and other concerns. Member states’ opposition would almost certainly extend to proposals for empowering WHO with the investigative authorities akin to the challenge inspections authorized by the Chemical Weapons Convention or the special inspections conducted by the International Atomic Energy Agency.102
However, certain feasible reforms, which this Task Force supports, could help strengthen the independence and effectiveness of WHO.
The United States should work with other WHO member states to ensure adequate dedicated funding of the Health Emergencies Program, which is resource-starved and overstretched. Also deserving of support is the Independent Oversight and Advisory Committee’s recommendation that the WHO Health Emergencies Program better use the deep expertise of its independent WHO collaborating centers to help generate technical recommendations in fast-moving international health crises. Further, increasing assessed member state contributions will not be easy in the current global geopolitical and economic environment, but doing so would enhance WHO independence and reduce the share that voluntary contributions represent of the WHO budget (roughly 80 percent), bringing them closer to levels that existed two decades ago (roughly 50 percent).
The biggest impediment to WHO’s success in this pandemic, however, has been the failure of its member states to respond effectively to the pandemic threat and to comply fully with IHR. The coronavirus pandemic has revealed how resistant member states remain to implementing their commitments and how little leverage WHO has to ensure that they do so.
The Task Force recommends that the UN secretary-general establish a global health security coordinator and the United States work with partner nations to create a Health Security Coordination Committee to facilitate a prompt and coherent multilateral response to global health threats.
The COVID-19 experience reaffirms that though WHO has strong technical attributes, it lacks the political heft to mobilize and lead the multilateral system and struggles to constructively partner with the private sector. It is ill suited to respond to potentially pandemic diseases that are a threat to national and economic security as well as health. That role should ideally fall to the world’s high-level international groupings, including the UN Security Council, the G20, and the G7. The involvement of these apex forums in the current crisis has been episodic at best, thanks in part to geopolitical tensions that could or could not persist.
To begin to correct these deficiencies and break logjams in multilateral cooperation, the Task Force supports the appointment of a permanent global health security coordinator, reporting directly to the UN secretary-general. This coordinator would be charged with leading a coherent response to public health emergencies across the UN system, supporting Security Council involvement in such crises, and maintaining direct links to the leadership of UN member states, as well as WHO, IMF, World Bank, UN agencies, G20, G7, and international nongovernmental organizations such as Médecins Sans Frontières (MSF) and the International Federation of Red Cross and Red Crescent Societies (IFRC). The coordinator would help the UN secretary-general direct and supervise a unified UN response to epidemics, pandemics, and other global health emergencies; provide political cover for the technical work of WHO and other UN agencies; and manage the UN’s collaboration with international financial institutions.103 WHO should maintain its lead role in mobilizing UN collaboration on issues that fall within the scope of the health field.
The Task Force further recommends that the UN secretary-general respond to any PHEIC designation by requesting that the Security Council convene to discuss potential collective responses to the emergency. Such a step would have both symbolic and practical importance. It would reinforce the precedent set in 2014, when the Security Council declared the West African Ebola outbreak to be a threat to international peace and security (UN Security Council Resolution 2177). More practically, should geopolitical tensions permit, it would allow the Security Council to issue declarations and even pass resolutions with the binding force of international law, to throw its political weight behind WHO, and to determine which other multilateral assets are needed to mobilize a unified global response. The global health security coordinator should provide ongoing support to any Security Council authorized actions.
In parallel with the creation of this supporting UN infrastructure, the United States should work with partner nations to lead the charge to create a Health Security Coordination Committee to mobilize and harmonize crisis response for vulnerable communities. The committee would convene leadership of the United States, interested G20 and G7 partners, and other countries and private- and nonprofit-sector representatives in support of the UN coordinator and WHO to ensure a coordinated health and economic response globally, especially with respect to vulnerable countries. The relevant heads of state and government could provide high-level political guidance, and their cabinet ministers for finance, foreign policy, trade, and global health could focus on practical matters such as harmonizing trade policies on essential medical supplies; removing barriers to scientific and technical collaboration; increasing shared access to vaccines, diagnostics, and countermeasures; and working with international financial institutions to provide foreign assistance and craft debt relief packages for the hardest-hit countries. A senior WHO representative and the UN special coordinator should serve as technical advisors to the committee.
The benefits of this separate, flexible structure are that it would reduce dependence on the multilateral bodies and forums that have been paralyzed by geopolitics in responding to this pandemic. It would be open to the inputs of nonstate actors such as civil society, nonprofits, and the private sector, and would support, not duplicate, WHO and UN processes. The committee would be open in principle to participation by all nations that share the purposes of the grouping, which the United States and a core of like-minded governments should seek to define.
No multilateral architecture, of course, can substitute for effective political leadership or guarantee that great powers will subordinate geopolitical rivalry to combat a common microbial foe. Nevertheless, the right institutional framework can make a difference, ensuring that appropriate tools are at hand should governments decide to use them.
The Task Force recommends that the United States and partners increase international assistance and pursue external sources of financing to assist low- and lower-middle-income countries both in coping with the current pandemic and adopting measures to improve lasting capabilities for pandemic preparedness and response. Such aid is not a matter of charity but a strategic investment in U.S. and global health security.
International funding needs for responding to the current pandemic and preparing for future ones are significant. Although strengthening its domestic health safety net needs to be a priority, the United States cannot afford to ignore global health security vulnerabilities anywhere. It has a compelling national interest, as well as a moral responsibility, to help prevent the spread of pandemic threats in low- and middle-income nations. The United States should approach foreign aid to fight COVID-19 the same way it has treated the President’s Emergency Plan for AIDS Relief and other global health programs: as strategic health diplomacy and an investment in U.S. foreign policy, national security, and economic interests.104
The coronavirus pandemic, which struck high-income nations first, is now ravaging nations in Latin America, South Asia, and sub-Saharan Africa, where many people cannot sustain social-distancing measures. The pandemic is overwhelming underfunded and short-staffed health systems and destabilizing fragile economies, threatening to erode decades of economic and social gains and reverse progress on the internationally agreed Sustainable Development Goals.105 Rising unemployment, poverty, hunger, inequality, and instability in the developing world are matters of not only humanitarian but also economic, political, and strategic concern to Americans. The probability is also high that uncontrolled outbreaks abroad of other preventable illnesses amid this pandemic will eventually wash up on U.S. shores, leading to new waves of disease.
The United States should work through the Health Security Coordination Committee to mobilize the United Nations, World Bank, regional development banks, and the IMF, as well as like-minded governments within the G7 and G20, to help ameliorate human suffering, counter economic despair, and mitigate political upheaval in low-income nations. Immediate priorities for international action include expanding issuance of special drawing rights from the IMF, extending debt relief for the lowest-income nations beyond 2020, facilitating renegotiation of debt owed to private creditors, and maintaining and extending preferential trade access to least-developed countries.106
The U.S. Congress has already appropriated more than $2 billion in emergency funding to address global health and development needs associated with COVID-19.107 The IMF has lent more than $20 billion to countries to help with COVID-19 and, with support from Japan and the United Kingdom, has created a special facility to enable countries to miss some debt repayments. The WHO Strategic Preparedness and Response Plan called for $675 million from February to April 2020. The World Bank announced up to $1.9 billion in initial disbursements to assist lower-income countries coping with the health and economic fallout of the global outbreak.108
Much more relief, unfortunately, will be needed given the size of the crisis. The United States should work with multilateral institutions and its allies to increase the assistance necessary to stabilize and preserve human security and welfare in low-income nations, including greater debt forgiveness. Without increased U.S. leadership abroad on pandemic preparedness and response, Americans will be less safe and prosperous at home.
Although immediate relief is obviously a priority, the world should also look beyond the current pandemic and set a goal of fostering enduring pandemic preparedness and resilience in developing countries. This goal will require finding sustainable, external sources of financing for pandemic preparedness that rely less on traditional foreign assistance. One possible financing mechanism would be user fees on international economic activity, such as international travel or financial transactions, that depend particularly on improved pandemic detection, preparedness, and response. Unitaid, a global health fund, is already partially funded by a tax on international air travel levied by several countries.109 Multiple reports also advocate another economic incentive for preparedness: the IMF and the World Bank integrate preparedness into their systematic country risk, policy, and institutional assessments.110
Bolster Pandemic Prevention
Armed with a robust national and global strategy, more effective organization, and adequate funding, the United States and international partners should be better positioned to implement the essential elements of pandemic preparedness and to execute quickly and effectively when the next pandemic erupts. Based on the painful lessons of the current pandemic, the Task Force makes recommendations for improving U.S. and global capacities to deliver each of the three fundamentals of pandemic preparedness: prevention, detection, and response.
To strengthen pandemic prevention, the Task Force recommends revamping the metrics for assessing and monitoring national pandemic preparedness capacity; prioritizing readiness with response triggers, mitigation guidelines, and rehearsals; and strengthening protections for the front lines of the U.S. health-care system and at-risk U.S. populations in future pandemics.
Revamp national preparedness capacity assessments and pair them with strategies to promote readiness and implementation.
The Task Force recommends that the United States work with WHO and with other nations to assess and revise pandemic preparedness capacity measures and to ensure full implementation of mitigation guidelines and regular rehearsals for pandemic response.
It is often said that what gets measured gets done, but the opposite is also true. Countries need to understand where their preparedness gaps lie in order to address them and reduce the likelihood of an outbreak spreading. International organizations should likewise be able to identify where gaps in preparedness exist so that they can target resources to help nations make the necessary improvements. Uncertainty over how to assess accurately a country’s preparedness to prevent, detect, and respond to pandemic threats undermines efforts to convince donors and policymakers to invest more in preparing for future global health security threats.
The Task Force recommends continued efforts during the current pandemic to assess and improve the performance of the JEE, GHS Index, and other preparedness metrics. Such indices remain important tools for measuring and improving the accountability of national capacity to prevent, detect, and respond to epidemic threats. At the same time, these capacity metrics have not been good predictors of performance in this severe global pandemic, suggesting that three other areas merit greater weight in future preparedness assessments.
The first is institutional trust—having a government that citizens trust and listen to. In the months after an outbreak of a novel pathogen and before the development of effective therapeutics and vaccines, nonpharmaceutical strategies, such as contact tracing, isolation, physical distancing, and mask-wearing, are the only way a biological threat can be contained. Accurate, science-based risk communication and strong public confidence in authorities are essential for these nonpharmaceutical strategies to succeed.
Second, investments need to be paired with periodic rehearsals as well as mitigation guidelines, so that governments are in a position to implement their pandemic response capacities quickly when a deadly disease emerges. Countries should prove through exercises that they can actually marshal and effectively use the capacities they possess to prevent, detect, and respond to high-consequence biological threats. The 2019 GHS Index report indicates that 85 percent of countries included showed no evidence of having completed a biological threat–focused IHR simulation exercise with WHO in the prior year, and notably few nations test their emergency operations center annually.111
The United States should work with the proposed UN coordinator and Health Security Coordination Committee, WHO, and other partners to establish comprehensive planning frameworks for pandemic response and to review and rehearse national, regional, and global responses regularly. Each national government should designate an emergency operation center for pandemic response or leverage an existing one to conduct these rehearsals. Internationally, these exercises would be analogous to military preparedness exercises conducted by the North Atlantic Treaty Organization (NATO) but would include a broader range of actors, including manufacturers as well as public health and emergency response agencies.112
The United States should work with WHO, the Africa CDC, and other regional partners to generate community mitigation guidelines and pandemic response triggers, so that national and local policymakers have a road map for early, targeted, and coordinated implementation of nonpharmaceutical interventions. Such guidelines have long informed U.S. and international policies for responding to pandemic influenza, but they were not used in the early COVID-19 response.113 They should be expanded, updated, and improved upon for other epidemic threats. As part of this effort, the United States and other nations should enhance their capacity for just-in-time research on the risk of transmission in different settings, such as schools and workplaces, as well as on the effectiveness of alternative mitigation strategies, based on cross-country comparative studies.
Third, policymakers, particularly in the United States, need to understand how critical primary care is for effective pandemic preparedness and response, and rethink how society should value and pay for it, as well as reimburse such expenses. Primary care systems help nations respond to pandemics in multiple ways. They provide a ready infrastructure for disease surveillance. They promote healthier populations by preventing and managing chronic illnesses that often worsen health outcomes from emerging infections. They nurture trust, cultivated in strong patient-provider relationships, which reduces the harm of medical misinformation and disinformation campaigns. Finally, they can bolster surge capacity during pandemics, particularly when patient volume spikes in emergency care settings. These multiple benefits suggest that greater investments in primary care should be a central element of any effort to strengthen the pandemic response capacity of the U.S. health-care system.
Strengthen the front lines of the U.S. health-care system.
The Task Force recommends that the United States adopt national policies and pandemic readiness standards to promote health equity in hospitals and health systems.
Health systems throughout the United States have struggled to survive while fighting to keep their patients safe and healthy during the current pandemic. In areas with exponential surges of COVID-19 cases, hospitals have confronted multiple shortages, including of emergency and critical care specialists, testing kits, essential medicines, ventilators, hospital beds, personal protective equipment, and other critical health resources and services. Simultaneously, a majority of hospitals across the country, including outside COVID-19 epicenters, have suffered severe budget shortfalls, thanks to fluctuations in patient volumes and loss of revenue from foregone elective procedures and surgeries. Although these trends have weakened the entire U.S. health system, the damage has been most acute on emergency departments and ancillary primary care services, which continue to care for the nation’s most vulnerable populations.
During the initial phase of the pandemic, patients seeking medical attention for COVID-19 overwhelmed emergency rooms and urgent clinics, underscoring the urgent need to reinforce and expand the nation’s primary care services. Unfortunately, funding and logistical support for family medicine, trauma surgery, pediatrics, and obstetrics and gynecology has remained stagnant. Simultaneously, many hospitals are reacting to sharpening budgetary constraints by reducing staffing and resources for their emergency departments, in effect, decreasing their frontline capacity in the middle of a pandemic. In addition to endangering frontline responders and patients, these cutbacks render hospitals even less ready to respond to mass casualty incidents, including a second wave of COVID-19.
To reverse these trends and reduce risks to providers and patients alike, the Task Force advocates a national policy to increase the nation’s primary care capacity and to establish and enforce pandemic readiness standards for hospitals and health systems to ensure that these institutions advance both safety and equity. Important elements of such a national policy should include
- investment in telemedicine to improve reach to patient populations in underserved communities;
- national credentialing and onboarding systems to expedite staffing reinforcement during mass casualty incidents;
- support for task-shifting models to rapidly increase staffing in areas with chronic health workforce shortages targeting underserved and rural communities;
- standard bed and spacing requirements with predetermined alternative care sites for emergency departments to reduce the risk of nosocomial transmission; and
- standard stockpiles of personal protective equipment prioritized for the emergency department to safeguard frontline staff.
Identify at-risk populations and reduce their vulnerabilities.
The Task Force recommends that federal and state governments take prompt steps to identify those U.S. citizens most vulnerable to epidemic disease, seek to reduce these disparities, and improve the resilience of these communities before the next pandemic strikes. The Task Force considers this a matter of both social justice and global and U.S. health security.
The COVID-19 pandemic has brought wide attention to gross disparities within American society, including stark inequities in access to quality health care and glaring differences in infection and mortality rates among privileged versus marginalized communities. It has also revealed the extraordinary vulnerability of the country’s elderly population, particularly residents of nursing homes, and of essential workers, whose employment heightens their exposure to disease. Such troubling and persistent differences in health outcomes are not only an affront to social justice, but also a source of national vulnerability. Addressing these long-standing inequities is thus both a moral imperative and a critical dimension of pandemic preparedness and national security.
True health security would entail a system of comprehensive, universal health care that delivers for all U.S. citizens, but the details of such a complex, sweeping reform effort are beyond the scope of this report. However, federal, state, and local governments can take important, immediate steps to reduce the vulnerability of marginalized, at-risk, and underserved groups to epidemic disease.
An immediate priority, if the United States wishes to achieve health equity in its pandemic preparedness and response, concerns data. As of June 2020, the United States lacked information on race or ethnicity for 52 percent of its reported coronavirus cases, and recent federal guidance to begin gathering such data via testing was not scheduled to go into effect until August.114 This is unacceptable. The CDC, in collaboration with states and localities, should make it standard practice to collect and share data on the vulnerability of specific populations—most notably Black Americans, Native Americans, Latinx Americans, those with lower incomes, and the elderly—to pandemic disease. These statistics should be publicly available to permit independent analysis, including of the policy changes needed to produce more equitable outcomes during a pandemic.
Armed with a more disaggregated picture of relative vulnerability, U.S. federal, state, and local governments should craft strategies, programs, budgets, and plans for pandemic preparedness that address the most relevant disparities in health access and outcomes, including making targeted public health investments that increase the resilience to pandemics of traditionally underserved communities, as well as nursing home residents, with full input from the beneficiaries regarding specific needs. These interventions could include establishing early, accessible, convenient, and free testing facilities for communities likely to be hardest hit; universal paid sick leave in declared pandemics; making public facilities available free of charge for those in need of isolation and quarantine; and offering special workplace protections and PPE to essential workers.115
Experience from around the world suggests that such investments can have society-wide benefits. Consider the case of Singapore, where initial success in the response to the pandemic was later imperiled because of outbreaks of COVID-19 among migrant workers especially vulnerable to infection and lacking access to quality health care. In any modern and mobile society, whether Singapore or the United States, health security depends on preventing infectious disease from getting a national foothold.
Improve Pandemic Detection
To improve detection of pandemic threats, the Task Force calls for reforms to improve the functioning of IHR and for the creation of modern global and U.S. systems for dangerous disease event surveillance and forecasting.
Reform the IHR.
The Task Force recommends that the United States and other interested nations consider measures to improve member states’ compliance with the International Health Regulations, focusing on improving information sharing, transparency, and the independence and competence of the Emergency Committee.
A fundamental tension exists between an international infectious disease control regime predicated on national sovereignty and the scientific reality that epidemic threats know no national borders. IHR respects the rights of its states parties to determine their own public health responses, but also establishes rules, obligations, and procedures that reflect an understanding that national and collective outcomes are best advanced by governments working together, sharing information, and relying on the best available scientific evidence. Without more significant consequences for violating the agreement, however, the balance tilts toward sovereignty over safety.
IHR cannot effectively improve global health security unless governments promptly identify and report dangerous novel infections so that countries can delay, or halt, their spread. The sooner health authorities know about a novel event, the more quickly they can mount an effective response. Nations fear that once an outbreak of an emerging infection is disclosed, other governments and private-sector actors could impose travel and trade restrictions, which could have severe economic consequences. The widespread adoption of travel restrictions in the present coronavirus pandemic, over WHO guidance to the contrary, only reinforces that impulse.
More contagious than the Ebola virus and more deadly than influenza H1N1, COVID-19 has exposed the dangerous consequences of this system, but problems with IHR compliance have long been recognized. There were delays in notification and a lack of transparency in West Africa during the Ebola epidemic and in Saudi Arabia during MERS.116 In 2011, the IHR Review Committee, considering the functioning of the agreement in the H1N1 pandemic, stated that “the most important structural shortcoming of the IHR is the lack of enforceable sanctions.”117 In 2015, the Ebola Interim Assessment Panel came to similar conclusions, stating that nations did not “take seriously” their IHR obligations and recommending that the IHR Review Committee “examine options for sanctions” against in cases of noncompliance.118
WHO has potential tools to improve compliance, but implementing them would require revising IHR and seeking approval from the World Health Assembly. IHR could, for example, be amended to make it mandatory for WHO to share with all states parties when a state party does not respond within twenty-four hours to a verification request of a potentially serious disease event or accept WHO’s offer of collaboration. Alternatively, WHO could seek to expand Article 7 of WHO’s constitution, which provides that member states that fail to meet obligations could have their voting privileges or other services suspended. The WHO director general could seek World Health Assembly approval to invoke Article 7 in cases of severe noncompliance with IHR. However, the World Health Assembly comprises member states that are unlikely to grant that authority, lest it be applied to them, and WHO, given its preference for solidarity and deference to member states, would be unlikely to exercise it.
Whether to reopen the text of IHR to improve its effectiveness is worth considering, but reform would likely necessitate a multiyear negotiating process at a time when many governments have expressed hostility toward multilateral institutions and international treaties. Fortunately, the United States, working with other WHO member states, could pursue other measures to improve the functioning of IHR in the interim that do not require reopening the entire text to renegotiation.
The Task Force recommends that WHO member states establish an IHR Review Conference to discuss how IHR has been used during this pandemic; to consider issuing interpretive guidance to inform WHO and member states’ actions on information sharing, particularly of pathogen samples and genetic sequence data; and to improve the effectiveness of how the Emergency Committee advises on the declaration of a public health emergency of international concern.119 Similar review mechanisms have been used in arms control treaties to agree on interpretation and treaty implementation and improve state party compliance.120
IHR requires nations to provide relevant public health information to WHO following a potential PHEIC notification, including case definitions; laboratory results; case and death counts; and information concerning the source and risk posed by the epidemic threat, the conditions affecting its spread, and the health measures that have been deployed. The text of IHR does not explicitly include genetic sequences or isolates, and neither does WHO policy, but the phrase “public health information” could be broadly interpreted to do so.121 Extending the scope of IHR in this manner would not address all information-sharing concerns that have arisen in the present pandemic but would help increase genetic sequence and sample sharing, and that alone would markedly improve global health security.122
In deciding not to declare the coronavirus a PHEIC on January 23, WHO Director General Tedros cited the divided views of the Emergency Committee, which ultimately advised it was “too early” for the declaration and that there were “a limited number of cases abroad.”123 The WHO director general has sole power to declare a PHEIC, and acceptance of the advice of the Emergency Committee is not mandatory, but no director general has departed from the committee’s recommendation in the thirteen years since the revised IHR entered into force. The competence and lack of transparency of the Emergency Committee have long been criticized, and a recent assessment found considerable inconsistencies in the Emergency Committee’s statements regarding the application of PHEIC criteria and among the body’s recommendations of whether they had been met.124 The procedures, independence, and functioning of the Emergency Committee could and should be improved via the Review Committee process, even without renegotiating IHR.
Build global surveillance and forecasting capabilities.
The Task Force recommends that the United States lead international efforts to build a modern national and global epidemic surveillance and forecasting capacity.
In a global crisis involving a highly transmissible novel pathogen, some heterogeneity in national responses is to be expected. Yet the current pandemic demonstrates that an international framework for pandemic detection and response that relies so heavily on the transparency, judgment, and discretion of individual national governments leaves too many opportunities for failure. The Task Force recommends the following measures to improve the availability and reliability of early epidemic threat surveillance and to enable rapid identification, characterization, and tracking of emerging infectious diseases.
First, the United States should work with other governments and civil society partners to build and integrate national and global epidemic surveillance systems, which would detect, share, and publicize early signs of an outbreak in near real time. This framework should establish a voluntary, international sentinel surveillance network, founded on health-care facilities around the world that regularly share hospitalization data, using anonymized patient information, to identify unusual trends. National voluntary sentinel surveillance systems could target vulnerable communities—such as nursing homes or low-income neighborhoods—which could allow for the detection of new, dangerous outbreaks within these groups before they became unstoppable. Participation in these international and national sentinel networks should be incentivized with grants and technology transfers.
Other surveillance methods being used in this and previous outbreaks are worth expanding. Wastewater surveillance to detect the presence of certain viruses was pioneered in polio eradication and is now being harnessed in some settings to track coronavirus trends. Kinsa, which uses internet-connected thermometers to predict the spread of the flu, has been used to identify anomalous fever spikes that could be COVID-19 related. These and similar methods, known as syndromic surveillance, could be used more broadly to identify presence of pathogens with outbreak potential, even before people start becoming sick.
Just as national security agencies have expanded their activities to include and rely on data surveillance expertise, so should public health communities. Since 2013, the CDC has fostered an open collaboration, called FluSight, to improve the science and usability of epidemic forecasts of influenza for public health decision-making. Proposals to create similar systems for sharing data on epidemic threats are worthy of support.125
This data should feed into an integrated global disease surveillance data platform, created under the auspices of the Health Security Coordination Committee. This platform should enlist participating government agencies and relevant nongovernmental agencies to standardize assessment of data and characterization of threats. It should share the results of those assessments and raise the alarm over any unusual trends with the UN coordinator, WHO Emergency Program, and the general public. This global surveillance architecture should be linked to public health agencies in participating nations, including the CDC, so that the data can be used to directly inform preparedness and response activities to both global and domestic threats.
Within the United States, disease surveillance is a responsibility that has been split across multiple federal agencies without a true national system for consolidating reporting and assessment. A consolidated U.S. government office for epidemic threat surveillance and forecasting should be established, the most obvious location being within the CDC.
Strengthen Pandemic Response
Finally, the Task Force recommends improvements in U.S. and global pandemic response. These include insisting that U.S. officials deliver clear, science-driven communications on public health matters; creating a nationwide U.S. strategy and capacity for testing, tracing, and isolation; adopting policies to improve the resilience of global supply chains for essential medicines and equipment; and establishing a global framework to ensure the equitable allocation of vaccines.
Deliver clear, science-based communication.
The United States should build and execute on its capacity to deliver clear, transparent, and science-based communication with the American people as a critical dimension of successful pandemic preparedness and a fundamental obligation for all public officials.
Given the societal challenges that pandemics pose, educating the public will be critical to effective preparedness and response. Public officials from the president on down need to ensure that when they communicate with the American people, they are clear and credible and that their public health guidance on current and future risks and necessary policy measures is grounded in the best available science and the most up-to-date information. The United States cannot afford to have public health messages muddled or discounted because they are couched in partisan messaging that seeks to downplay or exaggerate the dangers the country faces or the precautions needed to address these threats.
To help prevent domestic and global health security from becoming a political football, public officials at all levels, from the White House to state houses to city halls, should place physicians, epidemiologists, and other public health professionals front and center in public briefings, and they should showcase their expertise when describing the pandemic to the American people. Political authorities should be prepared to adjust their public health guidance as scientific evidence emerges and pandemics themselves evolve, for instance, in response to new research on the effectiveness of nonpharmaceutical measures or to unexpected spikes or recurrent waves of infection.
Develop a national strategy for testing and tracing.
The Task Force recommends that the United States immediately develop a national strategy and capability to support testing and contact tracing by states and localities that can be rapidly scaled up in any public health emergency.
No factor undercut the early U.S. response to COVID-19 more than the lack of a comprehensive nationwide strategy and capability for timely and accurate testing, tracing, and isolation. Without reliable, daily estimates of the number of people infected across U.S. states and localities, public officials cannot know how quickly a pathogen is spreading, when a lockdown is required, or when resuming normal activities is safe. To avoid such debilitating knowledge gaps from recurring in the future, the executive branch and Congress should develop a coherent national strategy and capability, accompanied by sufficient funds, to help state and local health departments—with guidance from the CDC—bolster their existing systems for testing, reporting, and contact tracing.126 The resulting system should deliver both speed and accuracy. It should be capable of being rapidly scaled up during public health emergencies and should leverage the latest digital technologies, including (with adequate U.S. privacy protections) contact tracing apps.127
To be successful, any nationwide scheme for testing and tracing needs to meet several hurdles. First, it should incentivize and expedite the development and manufacture of quality diagnostics by the private sector and university researchers, so that millions of individuals can be quickly tested to determine not only who is infected but also who has been exposed to the virus. Second, it should involve testing on a far more ambitious pace and scale than anything attempted during the first half of 2020 in the United States, including by mobilizing smaller labs rather than relying on a few large companies, streamlining supply chains for laboratory equipment, developing and deploying low-cost rapid tests for home use, and making broad community screening free for all individuals.128 Third, testing should be accompanied from the start by a robust system of contact tracing, involving the training of tens, and potentially hundreds, of thousands of individuals in the complex skills needed to perform this task, based on national guidelines.129
The proposal for a federally funded National Public Health Corps staffed by hundreds of thousands of trained contact tracers, which has attracted bipartisan congressional support, is an idea worth exploring, even in a post-COVID world.130 The Task Force believes, however, that any such initiative should ideally build on existing infrastructure, such as the U.S. Public Health Service Commissioned Corps, a six thousand–strong corps of uniformed public health professionals, or the Federally Qualified Health Centers, a nationwide network of community-based primary health-care providers that focuses on underserved areas.
Finally, patients who test positive need to have the ability to isolate themselves, in accordance with CDC guidelines, not only from their communities, but also from families and loved ones. Many Americans currently do not have the available lodging, requisite income, or child and elder care support to isolate effectively.
Maintain a dependable national stockpile.
The Task Force recommends that the executive branch and Congress work together to ensure that the Strategic National Stockpile is appropriately resourced and stocked for future pandemics, and that there is no confusion between federal and state governments as to its purpose.
The United States cannot be caught in the same position it was in early April 2020, when 90 percent of the stockpile’s protective equipment was already gone, leading to a free-for-all by states and cities to try to obtain such materials themselves. To avoid such a scenario in the future, the government should fully fund the SNS and ensure that its contents are sufficient to provide U.S. states confronting an urgent public health emergency (whether a pandemic or bioterror event) with indispensable medicines and equipment before the private sector can be mobilized to meet local needs. The most critical products required for any such emergency should be prioritized over highly specialized products. These include, for example, antibiotics, emergency medical devices, PPE, and other essential materials.
The federal government should adopt a policy of transparency with respect to the contents of the SNS so that both federal and state officials are aware of what it does and does not contain, and institute clear procedures for fulfilling requests from states based on need and urgency during moments of crises. To improve the reliability and timeliness of the SNS distribution capacity, the executive branch and Congress should consider creating a public-private partnership that has the ability to ship drugs and medical equipment directly to health systems based on their daily or weekly needs. Such an entity should also have the ability to balance total supply against demands across the nation. The SNS should be prepared to address demand surges and shortages of essential medicines during a pandemic, including by careful management of inventory for drugs and equipment routinely sold to health systems through normal distribution channels to avoid the waste associated with letting SNS products expire. In an extended pandemic crisis, the SNS system should be prepared to act as a central purchasing agent on behalf of state governments to prevent competition from driving up prices and leading to unnecessary shortages of PPE and essential medical supplies.
At the same time, states should devote a greater share of their budgets to maintaining emergency stockpiles of certain essential materials of their own at levels adequate for their respective populations. The SNS is designed to support and supplement, not supplant, these state-level stockpiles. Federal and state governments should collaborate in the negotiation of standing contracts with private-sector corporations to surge production of essential medicines, equipment, and materials that could become quickly depleted during emergencies. To help ensure both the efficiency of the national stockpile and its accountable use, relevant congressional committees should hold regular hearings on the adequacy of its contents and provisions for its deployment, as well as on defining potential triggers for invoking the Defense Production Act to meet critical needs in public health emergencies.
Diversify global supply chains.
The Task Force recommends that the United States diversify its global supply chains of critical medical supplies and protective equipment for resilience and reliability without unduly distorting international trade.
The COVID-19 pandemic has shown the need to strengthen and diversify global supply chains for medicines so that the United States is not left vulnerable to disruptions, shortages, price volatility, and quality questions when it comes to pharmaceuticals and other critical medical supplies.131 Today, most of the active ingredients in the pharmaceuticals used by U.S. consumers are manufactured abroad. An estimated one-third of these supplies come from China and India. During the early months of the pandemic, China discontinued production and India restricted exports of certain medicines.
The United States should adopt a multifaceted approach to reducing its exposure to such shocks in the future, with the objectives of protecting against supply chain disruption. Important steps to reduce U.S. vulnerabilities would include
- creating an essential medicines list to set priorities for policy, investments, and regulatory reviews;
- improving the transparency of global supply chains, including enhanced data on the sourcing, pricing, and quality of drugs;
- diversifying overseas sources of production;
- expanding domestic production of critical medicines through government incentives for building new U.S. manufacturing capacities;
- increasing U.S. stockpiles of critical medicines, including within the SNS;
- enhancing crisis cooperation on global supply chains among close U.S. partners and allies, including through emergency sharing arrangements; and
- strengthening multilateral regulatory cooperation among major producer nations to ensure common standards and quality control, including during emergencies.132
Support multilateral mechanisms for the equitable allocation of vaccines.
The Task Force recommends that the United States support multilateral mechanisms to manufacture, allocate, and deliver COVID-19 vaccines, therapeutics, and diagnostics in a globally fair manner consistent with public health needs.
Development of COVID-19 vaccines is progressing rapidly around the world. Numerous trials are also under way to find effective therapeutics to treat the disease and with several promising candidates even further advanced than the potential vaccines. This Task Force recommends that the global allocation and delivery of COVID-19 therapeutics, diagnostics, and vaccines should be equitable, public health–driven, and globally coordinated.
Absent global coordination, countries could bid against one another, driving up the price of vaccines, therapeutics, diagnostics, and related materials. The result could be not only an unnecessary loss of life and economic costs for already suffering economies, but also a legacy of resentment against vaccine-hoarding nations. That resentment would undermine the global cooperation required to tackle future outbreaks and have ongoing, adverse economic, diplomatic, and strategic consequences for U.S. interests.133
If, for example, early doses of COVID-19 vaccines were fairly distributed to protect health workers and those most likely to die or become hospitalized, the human and economic toll of the disease globally would be significantly reduced, allowing many economies to begin recovering. In the interim, additional doses of the vaccine should be manufactured and made available to the less vulnerable over time. Developing a globally fair, public health–driven allocation system for the earliest available vaccine doses is critical for preparing and responding to the next pandemic.
CEPI, Gavi, and WHO are developing a globally fair allocation system to ensure that the limited early doses of any COVID-19 vaccines are equitably distributed. The Task Force recommends that the United States work with a coalition of political leaders from countries representing the majority of global vaccine-manufacturing capacity to support these organizations and help fund their efforts on distribution and allocation. Building a globally fair allocation system requires commitments from the pharmaceutical industry to make their early doses available for purchase through that global procurement facility and commitments from countries to buy their first doses through the facility. Countries should enter into a COVID-19 trade and investment agreement, which articulates the conditions for sharing vaccine supplies and includes commitments to forgo export bans and expropriation of those supplies against other parties to the agreement.134 This enforceable infrastructure would facilitate country sharing of vaccines and could be developed and expanded for potential use for therapeutics, diagnostics, and other essential medical supplies and in future pandemics.
The COVID-19 pandemic is not over. It continues its deadly march, and the specter of new waves of the disease will haunt us until scientists develop a vaccine. The only thing that is certain is that when this virus is vanquished, another will take its place. This report is intended to ensure that in future waves of the current pandemic and when the next one occurs, the United States and the world are better prepared to avoid at least some of the missteps that have cost humanity so dearly.
Pandemics are inevitable, but the systemic policy failures that have accompanied the spread of this coronavirus were not. As this report documents, the United States, other nations, and international organizations have failed to prepare for the inevitability of pandemic disease, neglecting to invest in the national and multilateral public health institutions and systems required to respond quickly when a novel pathogen strikes. The cost of such complacency can be tallied in the lives lost and livelihoods upended.
The recommendations in this report are designed to ensure that such a tragedy of this magnitude never happens again. The Task Force stresses that the national and international dimensions of the pandemic are mutually reinforcing and cannot be considered in isolation. This is true above all when it comes to the role of the United States. If the COVID-19 pandemic has revealed anything, it is that strong and sustained U.S. global leadership remains essential for effective multilateral cooperation. There is simply no substitute. When the United States adopts an insular posture, rather than working to rally the world behind a common objective, there is nobody to pick up the baton. The result is more likely to be a haphazard and disjointed international response, as nations go their own way, regardless of the formal and informal organizational structures that exist.
A world without U.S. leadership, in which the United States eschews any responsibility for what occurs beyond its borders, is a less safe and prosperous place, not least for Americans.