Why should all 50 states have an emergency response plan for future influenza pandemics

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.

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.

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

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