U.S. Leadership in Global Health:

Preparation Recommendations for Expanded Engagement

CSIS Commission on Smart Global Health Policy - Options for U.S. Support
November 2009

We are now in an era of recurrent and emerging disease threats that argues for a long-term strategic approach to global health preparedness by the United States.

The emergence of SARS, H5N1 (avian) and H1N1 (swine-origin) influenza has raised awareness of the interdependence of human and economic security, of the ethical questions around equitable distribution of critical health commodities, and of the need for more systematic global preparation for sudden public health crises. While the current H1N1 pandemic has demonstrated recent progress in pandemic preparedness, it has also underscored existing inequalities between industrialized and developing countries, and the need to act preemptively to forestall future disease threats.

U.S. engagement in global pandemic preparedness is fundamentally about improving human security. Creating developing country capacities to cope with emerging disease threats not only serves U.S. self interest; it is an investment in the well-being of the world’s poorest individuals. Pandemic preparedness is a smart way of building for the long-term security of vulnerable communities, and is an area where the U.S. has great expertise and can easily expand upon its current efforts.

The 2005 publication of the World Health Organization’s updated International Health Regulations (IHRs)⁽¹⁾ and their entry into force in 2007 signaled a normative shift in the responsibility of states to build both their own and global capacities to respond to emerging disease threats, at least in part by reducing the risk of inter-state spread of disease that could threaten the sovereign interests of other states. Although they contain no enforcement mechanisms, the IHRs do commit states to actively collaborate in creating a collective global welfare and provide an important framework that can facilitate the improvement of public health preparedness on a global scale. That process, however, also requires stronger external incentives for developing countries to invest in building their own capacities.

In addition, concerns about post-9/11 bioterrorism and the global spread of avian influenza spurred the United States to undertake several early steps to begin strengthening global preparedness. Since 2004 the United States has expanded training and improved laboratory capacity in developing countries; accelerated its own domestic preparedness planning at and between federal, state, and local levels; invested diplomatically in shaping a common international approach to avian influenza.

Despite these early advances in responding to emerging disease threats, two looming gaps remain that will require sustained long-range solutions: (1) a need to increase health preparedness capacities, especially disease surveillance in the developing world, where they are weakest; and (2) a need for multilateral mechanisms to arrange more equitable access of countries to medications, vaccines and other public health commodities critical during public health emergencies.

The United States has an important role to play in addressing these gaps and reaching the goal of improving human security in the developing world. Ultimately, decreasing the time required to respond to emerging health problems within developing countries will improve the overall health preparedness of the entire global community. To help reach this goal, the U.S. should utilize its special leadership assets, its domestic preparedness experience, and its expertise in training field epidemiologists and other public health workers. The United States should also ensure that all efforts to improve preparedness capacity in developing countries contribute to the larger goal of strengthening the overall capacities of national health systems.

Taking a long-term perspective will need to be a critical component of U.S. involvement in global health preparedness, as will heavily involving individual countries in all decisions about improving pandemic preparedness within their own borders and paying closer attention to emerging zoonotic diseases.

Options for expanded U.S. engagement in global preparedness over the next 15 years include:

1. Expand assistance programs to help build preparedness capacity in developing countries, particularly through investments in disease surveillance systems, public health laboratory capacity, and the training of key public health workers. Although the long term resource requirements for this expansion have not yet been estimated, current assistance levels in these areas are clearly inadequate and not yet guided by a coherent long-term vision. All future preparedness development programs should be sustainable, self-replicating, and include routine program evaluation. Several existing programs, such as the CDC’s Field Epidemiology Training Programs, can serve as strong models for building capacity in a sustainable way.
2. Work multilaterally with the W.H.O., the European Union and others to develop a common plan for long-term global health preparedness. This should include creating a system for effectively tracking global preparedness capacity building; dividing global capacity building responsibilities among industrialized countries; and adapting national disease control priorities to the needs of each country or region.
3. Give high priority to working within the United Nations and other multilateral institutions to achieve a more predictable and equitable basis for affordable access to medicines, vaccines, and other commodities for use in emergencies.
4. Improve current U.S. government support for this global effort through better coordination and integration of all U.S. government global preparedness activities. A single internal focal point should be created for coordinating U.S. agencies and their operational grantees (e.g., universities and NGOs), utilizing the comparative strengths of each in one unified preparedness strategy. The expertise and technical capacities of the U.S. military should also be better integrated with the global preparedness efforts of U.S. civilian health agencies.

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¹See the International Health Regulations and other supporting documents at www.who.int/ihr/en