Kelly Ayotte and Julie Louise Gerberding, M.D., MPH. "Co-Chair Statement on the December 2020 Commission Meeting." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, December 21, 2020. Accessed January 25, 2021. https://healthsecurity.csis.org/articles/co-chair-statement-on-the-december-2020-commission-meeting/
From the Commission
This commentary was informed by a CSIS Commission on Strengthening America's Health Security meeting held on December 2, 2020.More about this meeting
U.S. Global Health Security in the Covid-19 Era: Momentous Transitions
On December 2, 2020, the CSIS Commission on Strengthening America’s Health Security convened a meeting of its members and expert advisors. We are pleased that the Commission, originally envisaged as a two-year initiative in 2018, will continue its work through the fall of 2022, thanks to the generous support of the Bill & Melinda Gates Foundation. This December 2 meeting marked the beginning of this second two-year effort, during which time the Commission will drive discourse and develop concrete action agendas for U.S. health security policy in the Covid-19 era.
In November 2019, the CSIS Commission on Strengthening America’s Health Security released its major report, Ending the Cycle of Crisis and Complacency in U.S. Global Health Security. In it, the Commission advocated to Congress and the administration seven strategic recommendations needed to establish a doctrine of continuous prevention, protection, and resilience abroad:
- Restore health security leadership at the White House National Security Council.
- Commit to full and sustained multiyear funding for the Global Health Security Agenda to build partner capacity.
- Establish a Pandemic Preparedness Challenge at the World Bank to incentivize countries to invest in their own preparedness.
- Ensure rapid access to resources for health emergencies.
- Establish a U.S. Global Health Crises Response Corps.
- Strengthen the delivery of critical health services in disordered settings.
- Accelerate new vaccines and therapeutics and address the threat of a polluted digital environment.
Since early 2020, the Covid-19 pandemic has profoundly changed our world. The Commission’s seven recommendations remain powerful and relevant, and the Commission will continue to pursue them while recognizing how significantly the context for action has changed. We can no longer presume reliable U.S. baseline preparedness nor presume that most dangerous outbreaks will do their greatest harm outside our borders. Indeed, we are deep into a dangerous and highly uncertain struggle with a pandemic—unlike anything seen in over a century—that poses still-unresolved strategic threats to the United States and the rest of the world.
As we launch this next phase of the Commission and weigh how to advance a strategic U.S. global health security approach, it is essential to define with some specificity the extraordinary moment we find ourselves in. Six dimensions are most vital.
First, the domestic crisis dominates.
The United States today faces an explosive, uncontrolled, and widespread outbreak, one that fuels economic and social instability at home and threatens U.S. national security and standing abroad. At the same time, the United States has moved with unprecedented speed to develop safe and effective vaccines and vaccination campaigns are beginning, a source of renewed hope. These will accelerate in 2021, creating the very real possibility of achieving 75-80 percent vaccine coverage over the course of the year. On the other hand, we have witnessed a significant decline in trust and confidence among Americans in U.S. public health institutions and in science more broadly, which could very well impede uptake of vaccinations.
In 2019, the “cycle of crisis and complacency” was the core problem underlying the United States’ weak and antiquated global health security policy. Today is different. We are experiencing a historic pandemic crisis as we ponder next steps to strengthen U.S. global health security. The United States is facing a winter surge that could lead to more than 400,000 American deaths by February 1, 2021. Policymakers will simultaneously grapple with the complex logistics required to vaccinate at least 75-80 percent of Americans, and with the question of how to ensure vaccines are also available in low- and middle-income countries. Lingering in the background is the very real possibility that Covid-19 could become an endemic threat, one that persists for years even as new infectious diseases emerge.
While the impact of Covid-19 outside our borders remains vitally important to U.S. national interests, making the case for high-level, sustained U.S. engagement internationally remains essential but problematic so long as domestic crises borne of Covid-19 continue unabated. This reality means, in effect, that any revitalized U.S. international agenda will need to be anchored in the domestic response.
Second, bipartisanship is at risk.
When the Commission released its major report in 2019, global health security enjoyed a promising level of bipartisan support. That is no longer a given. Covid-19 has been politicized to such a degree that today there is a troubling lack of a national consensus: over how seriously to take the disease; whether to adhere to masking, social distancing, and other measures; whether there should be a national approach to testing and investment in local capacities; whether the federal level has an essential leadership responsibility; and what level of U.S. international engagement and commitments are warranted. This polarization has given rise to false choices, pitting public health against the economy and the domestic response against the international response. We now need to find a way to transcend these false choices and understand how they are interlinked to one another.
Compounding these divisions is the spread of misinformation and disinformation about Covid-19 across the internet and social media platforms, fueling hesitation about vaccines, public health, and science more broadly. U.S. leaders will have to make a convincing bipartisan case to the American people for U.S. leadership in global health security in the absence of a solid domestic consensus on Covid-19.
Third, the Covid-19 crisis at home has shaken the standing of the United States abroad.
We are now grappling with the question of whether and how the United States can recover from Covid-19 and restore its leadership position in the world. U.S. membership in the World Health Organization (WHO) has been severed, and there is no formal U.S. participation in promising new coalitions such as the Access to COVID-19 Tools (ACT) Accelerator, which seeks affordable access to Covid-19 vaccines, therapies, and tests for low- and middle-income countries. We also face the reality that while the United States and other Western powers struggle with their own outbreaks, China has largely succeeded in containing the spread of Covid-19 and restarting its economy and is in a position to expand its influence rapidly. This emerging new form of geostrategic competition will have to be incorporated into any future vision of U.S. global health leadership.
Fourth, the epidemic countermeasure product development landscape has fundamentally changed.
One of the greatest successes of 2020 has been the extraordinary acceleration in the development timelines for Covid-19 vaccines, therapeutics, and diagnostics. This is in part thanks to the successes of the Biomedical Advanced Research and Development Authority (BARDA) and the Coalition for Epidemic Preparedness Innovations (CEPI), the latter an alliance established in the aftermath of the 2014-2016 West Africa Ebola outbreak to coordinate and accelerate the development of new vaccines for infectious disease epidemics. These and companion scientific advances helped to ensure, for example, that vaccine platforms were in place to rapidly develop RNA vaccines—two of which are being rolled out in the United States and overseas less than one year after the pandemic began.
Operation Warp Speed has proved a successful model for a concerted, integrated, public-private effort to drive accelerated biotechnological research and development. Operation Warp Speed sets a precedent for a U.S. government approach to developing tools amid a dangerous outbreak. In the coming years, there will be an expectation that the accelerated development of vaccines, diagnostics, and treatments will continue as a central dimension of the initial, rapid response to public health emergencies—not as a later add-on. This also raises issues of equitable access, both domestically and globally, to the essential new products that result.
Fifth, the scale of action and investment required at home and abroad are vastly higher than what the Commission proposed in 2019. Selling a costly international agenda will require a concerted effort.
Covid-19 has infected over 76 million people globally and has killed over 1.6 million people, including over 317,000 Americans. The pandemic has cost the global economy $11 trillion, according to the International Monetary Fund (IMF), triggering the worst recession since the Great Depression. In March and April, Congress approved nearly $3 trillion to support the Covid-19 response at home and stem its economic impact, matched by an estimated $3-4 trillion in unprecedented support provided through the Federal Reserve. On December 20, Senate leaders announced they had reached an agreement on another $900 billion aid package. These are staggering numbers. And likely, Congress will pass additional stimulus packages in 2021.
To stabilize the U.S. society and economy, beat back the virus, and accelerate the procurement and delivery of vaccines—two doses to at least 70-85 percent of the United States’ 328 million citizens—are tasks of unthinkable complexity and costs. U.S. leadership in shaping the global response, including guaranteeing access to vaccines in low- and middle-income countries, will be essential to reopening the global economy. International leadership will require expanded and sustained investments—on top of the domestic response.
In 2019, the Commission’s recommendations for enhanced U.S. international engagement had a price tag of less than $1 billion. Today, we know the investments required will be many times greater. We have no choice but to focus on the international response in order to protect Americans. If we do not undertake an effective global response, the risk to U.S. citizens will remain high; as we know, Covid-19 and all pandemics do not respect borders.
Sixth, the Covid-19 pandemic has exposed gross inequities both at home and abroad that define today’s landscape.
Geographic, racial, ethnic, gender-based, and socioeconomic disparities have all worsened under the force of Covid-19. In the United States, the virus continues to hit Black, Latino, and Native American communities the hardest. At home and abroad, women and girls are far more likely to lose their income as their unpaid care and domestic work burdens have spiked, and face increasing incidents of gender-based violence.
Fragile low- and middle-income countries under pressure from Covid-19 face cascading crises of famine, the resurgence of preventable diseases, and civil unrest. Many of these countries face excessive debt, fiscal insolvency, and economic instability that require a new framework for a negotiated debt relief, and forgiveness in extreme cases, coupled with enhanced commitments to invest in health and health security preparedness. In the race for a Covid-19 vaccine, wealthy and powerful countries are securing millions of Covid-19 vaccine doses for their own populations, while lower- and middle-income countries are at risk of being left behind. It is that looming, destabilizing inequity that prompted the European Union, WHO, foundations, and others to launch the ACT Accelerator in April 2020.
In sum, while the Covid-19 environment is politically charged and challenging, progress is possible.
The pandemic will change governance, ideas, and institutions—and create opportunities. A successful vision for U.S. leadership will have to address issues of scale and scope; consciously preserve bipartisanship and build domestic consensus and trust; manage a domestic crisis while restoring U.S. leadership and engagement abroad; prioritize equity and access in new, enduring ways; and meet both urgent immediate needs and long-term requirements.
The December 2 Commission meeting was marked by a shared sense of energy, optimism, and urgency in moving forward a strengthened U.S. global health security agenda. Despite the polarized politics that dominate today, the Commission is confident that a bipartisan path can be forged. There is consensus that the enormity of the challenges we face today provide an opportunity for a fundamental reset in the U.S. approach to global health security.
At the same time, the Commission called for caution, particularly regarding the role of vaccines in controlling and ending the pandemic. Members pointed to several areas of continued concern: the challenges in procuring, financing, and ensuring equitable access to Covid-19 vaccines in low- and middle-income countries; the scientific unknowns around the duration of immunity and whether vaccines can stop Covid-19 transmission; and the unabated spread of misinformation and disinformation about vaccines and science, fueling vaccine hesitancy.
Over the next two years, the CSIS Commission on Strengthening America’s Health Security will shape a new U.S. global health security agenda grounded in these realities.
The core issues of international engagement that the Commission addressed in 2019 remain valid—U.S. leadership, financing for global health security, global partnerships and diplomacy, and science and technology. But the issues facing the United States today are more politically charged, urgent, and expansive. Building a strong domestic consensus among Americans will require a deliberate, concerted bipartisan effort.
Over the next two years, the Commission will attempt to answer the question, what is a U.S. global health security agenda in the Covid-19 era?
The Commission will take up this question across three thematic areas, enumerated below.
(1) U.S. Leadership in the Covid-19 Era
U.S. leadership is essential in shaping and supporting diplomatic and multilateral efforts in response to health security emergencies outside our borders. That is true for the Covid-19 response and recovery efforts, including Covid-19 vaccine distribution and the economic recovery. The Commission will map out how U.S. leadership can be strengthened, with what priorities, and through what concrete steps, both during and after the pandemic.
The Commission will reexamine key U.S. public health institutions and their evolving role in global health security, particularly the U.S. Department of State, the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration, and White House offices.
There may be an active debate in Congress and elsewhere on the merits and scope of a 9/11-type Commission. The CSIS Commission will work to shape those deliberations to ensure that a future group is bipartisan and forward-looking, and incorporates the issues surrounding U.S. international leadership. It is critical that any such commission not become a forum for blame, but one that forges a consensus across party lines on how to ensure that the United States and the world are prepared for the next pandemic.
The Commission will reexamine the unique capacities that the U.S. military can bring to global health security issues, and how that role should evolve in the Covid-19 era.
In rethinking U.S. leadership, the Commission will focus on how to better promote health security through immunizations and the growing recognition of the essential role played by the primary health care system in disease prevention and outbreak response.
(2) Building a New Order
Throughout the course of the pandemic, there has been limited contribution by such key institutions as the UN Security Council, the G7, and G20, including a conspicuous dearth of high-level diplomacy on global health security issues. The United States should expand and elevate its diplomatic leadership, particularly since China and Russia have expanded their influence. The Commission will focus on how U.S. action can bring about stronger international coordination in the response to the pandemic and preparedness for future events.
One major focus will be the ACT Accelerator, a new international coalition formed in April 2020 to advance equitable access by low- and middle-income countries to vaccines, therapies, and diagnostics, along with other critical inputs, such as protective gear. The Commission will give special priority to the ACT Accelerator’s vaccine pillar, COVAX, and the COVAX Facility, exploring what forms of U.S. support—diplomatic, political, financial, in-kind—are possible. Most pivotal in this regard will be strengthening the U.S. relationship with COVAX’s coordinating institutions, CEPI and Gavi, the Vaccine Alliance.
The Commission will weigh in on the Independent Panel for Pandemic Preparedness and Response (IPPR) and related efforts to reform the current global health, development, and health security institutions and partnerships. That will include the reestablishment of U.S. membership in the WHO, with support for the reform agenda to strengthen and improve the organization, and revitalizing the Global Health Security Agenda. Part of that will include deliberations on how concretely the United States can restore its relationship with the European Union and other key partners and allies to achieve a united reform effort and ensure that China does not have undue influence.
The Commission will also examine the U.S.-China strategic competition and identify options for achieving a more effective and pragmatic interaction with China on shared health security threats. The Commission will examine options to secure markets and supply chains and address overreliance on foreign manufacturing (particularly Chinese manufacturing) for critical medical supplies and equipment.
(3) Science and Anti-Science
We live in a paradoxical moment of both scientific renaissance and burgeoning assaults upon the legitimacy and credibility of science.
We are in the midst of an accelerating revolution in the life sciences. The bioeconomy has graduated to become front and center in U.S. national security priorities and policies. This momentous shift—accelerated by the Covid-19 pandemic—will create new opportunities for gains in public and global health, along with challenges of equity and access and increased risks in biosecurity and biosafety. It will rest on new partnerships with industry.
The Commission will strive to illuminate these trends; assess what the implications are for global health security; and identify what new U.S. policies, capacities, and programs are required.
At the same time, the rapid spread of misinformation and disinformation has weakened public trust and confidence in science and public health institutions. The misuse and weaponization of social media have helped to fuel a resurgence of vaccine preventable disease and could significantly impede the introduction of Covid-19 vaccines, both domestically and globally. The Commission will consider what is required to strengthen the CDC—rebuilding trust and confidence in it; enhancing protections against political interference; strengthening its internal systems; and pressing for it to have the budgets and presence in Washington to be an effective lead agency, at home and abroad, in health security.
Over the next three to six months, the Commission will focus on five priority workstreams:
- Mitigating the Looming Crisis: Fiscal Space in the Covid-19 Era;
- Ensuring Equitable Covid-19 Vaccine Distribution Globally;
- Restoring the Independence of U.S. Public Health Agencies;
- Defining the Role of the Military in Health Security in the Covid-19 Era; and
- Evolving a Diplomatic Strategy for the Covid-19 Era.
Through these workstreams it is our goal to lay out concrete action agendas for the administration and Congress to address current gaps in U.S. health security policy and the Covid-19 response.
We have entered momentous transitions, points of peril and hope, of risk and opportunity. Humility and caution are the watchwords. Our nation at home faces unprecedented crises and deep internal divisions, and yet has spearheaded unprecedented biotechnological breakthroughs and demonstrated stamina and determination. Abroad, a world that faces its own mounting risks and perils looks for renewed and sustained U.S. leadership and partnership.
2020 was a year unlike any other in modern time, closest in its feel to wartime. 2021 and 2022 hold the promise of recovery and healing. The CSIS Commission, in its own modest way, strives to contribute to that renewal of our lives and improved biosecurity for all.
Executive Vice President and Chief Patient Officer, Merck
Former Senator (R-NH)
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