The US needs an urgent refocus on health security

We live in an age of epidemics: SARS-1, bird flu, H1N1, Ebola, Zika, COVID-19, monkeypox, even a highly pathogenic avian strain of influenza threatening the US poultry industry — all emerging over the last 20 years with devastating Consequences to human life and economic prosperity. More than 1 million Americans have died, and counting, from the COVID-19 crisis. And yet, by the looks of it, the US government reaction is by and large muted. The COVID-19 pandemic exposed the failures of our current system. The national response was halting, hyper-politicized, and ineffective. It exposed massive disparities in access to effective care, gaps in our federal data collection and sharing system, and deep-seated mistrust with our political and scientific establishments. So, what are we intending to do about it?

The US has set a precedent around structural reorganization and institutional innovation after crisis strikes. After World War II, the US was first to modernize its military and intelligence communities for the new era with the National Security Act of 1947. After 9/11, the Homeland Security Act of 2002 addressed many of the coordination issues that hampered our ability to foresee and respond to the 9/11 attacks. We appear to have reached a similar moment worthy of national reflection today. There is a looming surge of yet more COVID-19 cases potentially coming this fall and winter, bringing more deaths and the threat of a health care system collapse. There are the known risks posed by post-COVID conditions or “long-COVID,” which affects about 30 percent of those who fall ill with COVID-19, contributing to a crisis affecting long term health that has not yet been fully contemplated. And then there are the as yet unidentified, future emerging threats leading to a category of infectious disease — unknown unknowns — as well as risks emanating from the threat of radiological, nuclear, chemical and ever present catastrophic natural disaster events.

It is clear that the US government must act. Now is the time to coalesce around the ability to prepare, respond and recover from the large-scale health emergencies that threaten our future. An important step in that direction is to create a stand-alone Health Security Council, akin to the National Security Council and Domestic Policy Council, convened by the White House under executive leadership.

Health security is an interdisciplinary field of public policy that links together health care, national security, public health and emergency management with a clear focus on protecting the health of the nation. Creation of a Health Security Council will help to coalesce the gaps that exist between these disparate fields and will demonstrate how important health systems and our public health agencies are to both our daily experience and ability to live and work through life-threatening emergencies. Doing so will acknowledge that health system preparedness, sustainability and economic viability are all key components of national preparedness, and the concentration of expertise and leadership will offer local and federal officials with a playbook on how to respond when things go awry.

In response to many of the same challenges, the UK replaced Public Health England (the US government equivalent is the Department of Health and Human Services) with the UK Health Security Agency. The new agency inherited many of its original functions, such as contact tracing and genomic surveillance. In addition, the Health Security Agency was designated as the lead UK agency for predictive pandemic analytics and coordination with foreign governments and international bodies, establishing a single point of responsibility for these critical functions. While the initial response to the creation of the Health Security Agency was mixed, it streamlined lanes of responsibility and addressed many of the bureaucratic inefficiencies that led to failures during the pandemic itself.

In the US, on the other hand, health security remains a field of far-flung and poorly coordinated federal and state agencies with broadly overlapping lanes of responsibility and no clear mandate to play nice when the next pandemic or public health emergency strikes. This generates a range of surprising and disheartening policy outcomes. For example, the Centers for Disease Control and Prevention (CDC) cannot legally require states or health care providers to provide them with the critical data needed to drive insights and inform the president on disease propagation in our communities.

The intelligence community, in charge of detecting threats to the nation, often does not have access to the CDC’s reports on emerging epidemics until they are public. Several agencies, from the Department of State to United States Agency for International Development (USAID), Health and Human Services (HHS), and CDC, hold responsibility for coordination with international bodies and foreign governments. CDC’s Epidemic Intelligence Service and its associated analytic center have a similar mission as the Department of Defense’s Global Emerging Infections Surveillance program, but there is no pre-defined touchpoint for coordination. Meanwhile, the legal authority for resource mobilization and crisis reaction is inherently local and driven by county public health commissioners, city mayors and the local and state budgetary authorities.

We need centralized and coordinated leadership. The creation of a Health Security Council within the White House is a tangible and achievable immediate next step that ought to be implemented now. It can begin the process of aligning and coordinating the disparate elements now scattered throughout US government agencies and echoing a decade of recommendations for hands-on executive office leadership, tied directly to expert input and leadership. Taking this action will demonstrate the Biden administration’s commitment to making health security the priority it needs to be.

Michael Auten recently completed six years of active duty with the US Marine Corps, and he is an incoming medical student at the Mount Sinai School of Medicine.

Dan Hanfling, MD, is an emergency physician and a national expert on health care system and public health preparedness and response. He is a member of the National Academy of Medicine’s Forum on Medical and Public Health Preparedness for Large Scale Emergencies and Disasters.

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