Thomas R. Cullison and J. Stephen Morrison. "Department of Defense Contributions to the U.S. Covid-19 Response, at Home and Abroad." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, December 16, 2021. Accessed May 11, 2022. https://healthsecurity.csis.org/articles/department-of-defense-contributions-to-the-u-s-covid-19-response-at-home-and-abroad/
The U.S. Department of Defense (DOD) should be systematically incorporated into any U.S. government vision on international global health security. The United States should build on what has been learned and achieved through DOD support at home to the civilian-led Covid-19 response, as well as past DOD contributions to pandemic response overseas, and incorporate long-standing DOD international capabilities against biological threats. DOD should contribute to responding to the acute phase of the pandemic and build long-term preparedness capacities.
DOD has considerable assets in three areas that can and should be included, when appropriate, to support the U.S. civilian-led international response:
- Logistics, lift, and planning;
- Biosurveillance and infectious disease research and development; and
- Relationships built through decades of international collaboration in biosecurity and biosafety, ongoing global health engagements, and work in overseas laboratories.
DOD already is playing a significant role in the procurement and delivery of 1 billion doses of the Pfizer-BioNTech vaccine, which President Biden has pledged to the COVAX vaccine solidarity mechanism to benefit 92 low- and lower-middle-income countries. A process of strategic planning for other likely DOD contributions to contain the global Covid-19 pandemic should begin right away.
The United States has been shaken by a biological agent that originated overseas and arrived through the normal flow of international travel and commerce. Despite previous widespread coronavirus outbreaks, no vaccine was initially available, testing capability was scarce, and the effectiveness of available therapeutics was uncertain. As of December 14, 2021, more than 800,000 U.S. deaths—greater than the population of Denver or Seattle—are attributed to the disease.
Even with vaccines widely available and the promise of therapeutics to mitigate symptoms, the delta and omicron variants fundamentally changed the course of the pandemic and how the United States thinks about how the virus, particularly outside U.S. borders, will impact the security of Americans. It has deepened the awareness that unless SARS-CoV-2 is checked across the board, new, even more virulent strains will proliferate, spreading deadly challenges around the globe. It has led to the realization within the U.S. government that the threat is urgent and must be addressed quickly with effective, coordinated action if the worst is to be avoided and U.S. national interests are to be protected. Deep inequities in global vaccine distribution, access to diagnostics, and therapeutic availability are especially troublesome, particularly in low-income countries already burdened by weak health systems and endemic diseases such as HIV/AIDS, tuberculosis, and malaria. As Covid-19 spreads through these countries, the resulting social instability and humanitarian emergencies will create international crises to which the United States will be called upon to respond.
The United States has stepped forward with a commitment of 1.1 billion vaccine doses for international use, with nearly a quarter already delivered. Renewed U.S. financial and material support for international organizations, including the World Health Organization (WHO) and COVAX (co-led by Gavi, the WHO, and the Coalition for Epidemic Preparedness Innovation), is laudable. So too is the role that DOD assumed in the procurement and delivery of 1 billion doses of the Pfizer-BioNTech vaccine that President Biden pledged to the COVAX vaccine solidarity mechanism to benefit 92 low- and lower-middle-income countries. What remains unaddressed is the need for a strategy and plans to coordinate U.S. involvement in the international response with the efforts of other countries, including China, at a scale necessary to blunt the threat. Based on recent experience, U.S. military participation will be necessary when civilian capabilities are not available or capacities run short. DOD has much to offer in crisis leadership; logistics, lift, and planning; biosurveillance, research, and development; and biosafety and biosecurity. For the U.S. response to be most effective and rapid, DOD should be included in initial planning at all levels.
U.S. military support for the domestic Covid-19 response has been remarkable. As the United States scrambled to respond, thousands of DOD personnel supported civil authorities with logistics, laboratory testing, direct patient care, biosurveillance, and whole genomic sequencing.
The pandemic confirmed that in many places the U.S. healthcare system is not nearly resilient enough and has little to no surge capacity. The U.S. Military Health System (MHS) cares for 9.6 million people around the world while providing expeditionary medical care to support military operations overseas. Since early in the pandemic, military medical personnel have delivered direct patient care in overwhelmed civilian medical facilities throughout the United States without significantly interrupting MHS healthcare delivery or impacting deployments of medical units supporting U.S. military missions worldwide.
DOD also contributed significantly to the remarkably rapid development of SARS-CoV-2 vaccines within months after the disease appeared in the United States. For a decade prior to the pandemic, the Defense Advanced Research Projects Agency (DARPA) sponsored research that supported the development of the messenger ribonucleic acid (mRNA) vaccine platform on which the pharmaceutical industry built the first approved Covid-19 vaccines.
Operation Warp Speed’s (OWS) success in developing, manufacturing, and distributing multiple vaccines approved by the U.S. Food and Drug Administration (FDA) was due in large part to the strong leadership of its chief operating officer, U.S. Army general Gustave Perna, who motivated a team of widely diverse organizations and individuals with a single-minded purpose to save lives by:
- Advocating for calculated risks in concurrent research and development as well as animal and human trials;
- Underwriting the manufacture of millions of doses of promising vaccine candidates to be ready upon FDA approval;
- Organizing military logisticians, planners, information technology specialists, and acquisition experts who identified and coordinated innumerable details critical to success;
- Quickly executing expansive contracts to keep pace with developments; and
- Employing the Defense Production Act to ensure raw material availability.
OWS achieved a remarkable degree of institutional flexibility, allowing all agencies to work together pragmatically in a new institutional structure. This collaborative approach and lack of rigidity provides a powerful set of lessons on which to model similar U.S. government efforts outside U.S. borders in the future.
As the United States contributes to efforts to counter the pandemic globally, it is very likely that the U.S. military will be requested to assist civilian-led efforts. DOD routinely supports overseas disaster relief under the direction of the U.S. Agency for International Development’s (USAID) Bureau of Humanitarian Assistance (BHA) when all other efforts are insufficient. For example, when the 2014 West African Ebola outbreak killed nearly half of those infected, health workers were on the brink of losing control of the situation throughout the region. The Liberian president’s request for assistance resulted in the first U.S. military operation specifically to support a disease-driven foreign humanitarian mission, primarily via logistical and transportation assistance. U.S. military personnel constructed Ebola treatment units and medical facilities to treat infected caregivers and flew vertical lift air transport missions for staff and supplies. DOD scientists also deployed with mobile laboratories to assist in diagnostic testing. Perhaps even more important, the entry of U.S. troops into Liberia and the creation of an air bridge had profound psychic impacts in breaking the panic that had accelerated in August and September 2014 and restored hope.
What Is Required Now?
The worldwide Covid-19 pandemic demands a response of another magnitude than what has been seen thus far if the multilateral confusion and deep and destabilizing inequities are to be surmounted.
In September 2021, President Biden convened the Global Covid-19 Summit, challenging the world to come together by introducing ambitious targets, along with significant U.S. commitments, in three critical areas: vaccinate the world, save lives now, and build back better. The White House in its statement said that all countries “need the capacity to prevent, detect, and respond to biological threats, including future pandemics.”
Overcoming the threat of human suffering and economic devastation in low-income countries will certainly require massive external support. The Global Preparedness Monitoring Board’s recent report underscores that at the current pace, low-income countries’ Covid-19 vaccination rates will be far below the 70 percent vaccine coverage target for September 2022. The expected continued spread of disease and societal disruption will likely fall to the United States to address, partially in the context of enlightened self-interest.
DOD rightfully responds to foreign disasters only when other means are inadequate. Unlike geographically and time-limited events, such as tropical storms or earthquakes, this pandemic requires massive, coordinated support from all nations if it is to be contained. In some ways, the Covid-19 pandemic can be viewed as a relatively slow-moving disaster. There is time, but not much, to plan how the leadership of these efforts will be aligned, how U.S. overseas involvement will be organized, and to develop likely scenarios for how and where U.S. military support will be required.
In the short term, the U.S. military might provide logistical, lift, and planning support to U.S. and international agencies involved in vaccine procurement and distribution. In particular, DOD may assist with bulk transport and even “last-mile” delivery—particularly when the host nation’s military plays a major role in the process.
In the longer term, DOD will need to continue to work closely with other federal agencies, notably the Department of State, the Department of Health and Human Services (particularly the U.S. Centers for Disease Control and Prevention), Department of Agriculture, USAID, and the National Institute of Allergy and Infectious Diseases, to strengthen health systems around the world to prevent, detect, and respond to infectious disease as outlined in the Global Health Security Agenda (GHSA). Although DOD is not specifically mandated or funded to perform GHSA activities, GHSA provides an excellent framework for numerous U.S. military global health and global health security engagement activities.
The extensive DOD biosurveillance, biological research and development, public health, biosecurity, and biosafety enterprises are essential elements of overall U.S. warning and assessment capabilities. They exist both to ensure the health and safety of U.S. military forces and to protect the United States against biological agents, whether released naturally, accidentally, or intentionally. Capacity building supported by the Cooperative Threat Reduction Program’s Biological Threat Reduction Program fills essential gaps when well-coordinated through a robust interagency approach while still being tailored to meet specific DOD needs. Military infectious disease research laboratories located around the world and long-standing efforts such as the Defense HIV/AIDS Prevention Program develop established relationships and strengthen host-nation health capacities that are critical in times of crisis.
Historically, DOD organizations dealing with biological agents derive from one of two tracks: (1) concerns regarding biological weapons, and (2) protecting against naturally occurring diseases. Although many areas of overlap exist between these groups, separate chains of command, authorities, and funding streams have historically led to “stovepiping”—isolated and narrow chains of communications. This situation has improved in recent years, and there is reason to expect that progress will continue.
Several key considerations should be front of mind in weighing concrete recommendations for DOD’s contributions, at home and abroad, for both the immediate response to the acute pandemic and strengthening future preparedness.
The DOD Biodefense Posture Review currently underway presents an excellent opportunity to align efforts against biological agents from any source. It also is a chance to inform the upcoming versions of the National Defense Strategy and National Military Strategy on the role for DOD relative to biological threats, providing clear guidance for policy, structure, and budget considerations.
Funding must be aligned with function. Funding mechanisms are needed that allow DOD access to emergency funding authorizations for international disease response. Also, if DOD is asked to support capacity-building efforts in foreign nations’ civilian or military health systems, appropriate global health engagement funding authorities with multiyear authorizations are necessary for uninterrupted, sequential programs.
Finally, the past and future success of all DOD biological programs is due to highly skilled, dedicated people in and out of uniform. Thousands of outstanding researchers, clinicians, planners, logisticians, and support personnel represent years of education and training, guidance by outstanding role models, and dedication to a job that defines success by avoiding disastrous consequences and ensuring nothing goes wrong. It is extremely shortsighted to believe that these skills are fungible and can be obtained on intermittent, short-term contracts. A realistic assessment of personnel requirements is appropriate, of course, but decisions should be made with long-term outcomes and capabilities in mind, not short-term cost savings.
- Identify a lead federal agency for U.S. international Covid-19 response and future health security crises. DOD should have permanent, sustained involvement in integrating and planning from the beginning.
Strategic direction must come from the White House with the identification of a lead federal agency for operational coordination, preferably the U.S. Department of State. A federal clearing house and coordinating authority is needed to execute guidance from the president and the National Security Council. This authority must understand DOD’s considerable capabilities to give clear direction on when and how to implement these valuable resources to avoid late response and bigger expenditures.
- More closely coordinate and synchronize DOD capabilities dealing with biological threats within DOD and with external partners.
Numerous DOD activities, both within the United States and overseas, have a long history of excellence in biosurveillance; research and development of diagnostics, therapeutics, and vaccines; counterproliferation; and clinical care. The professional expertise and long-term international partnerships developed by existing DOD organizations such as military overseas infectious disease laboratories can be leveraged to complement host-nation health system strengthening, guided by GHSA principles.
Fortunately, DOD has reduced many internal barriers related to organizational structure, funding authorities, and other roadblocks, yet there is still room for improvement. The current Biodefense Posture Review provides an excellent opportunity to expand on the work of working groups within DOD and with other agencies, expanding areas of common interest to create a holistic view of biological threats from any source.
- Align funding authorities with desired outcomes.
DOD should not supplant U.S. international development efforts. However, appropriate funding authorities at DOD are necessary to allow for immediate crisis response and longer-term host-nation health system strengthening, in concert with other federal agencies.
Specifically, 10 U.S.C. § 333 details the authority to provide training and equipment to national security forces of foreign countries for the purpose of building capacity against threats that could impact the United States. That authority should now be expanded to include global health risks in a manner that does not compete with existing purposes of the statute.
Emergency authorizations for pandemic relief should include DOD as a recipient to cover costs above and beyond routine funding levels.
Additionally, a global health engagement funding line with multiyear appropriations should be established to support ongoing DOD military-to-military and military-to-civilian health system-strengthening activities. Those activities should be complementary with those of other U.S. agencies in support of GHSA goals while supporting U.S. strategic interests as reflected in regional security cooperation and nonproliferation efforts. This mechanism could also be used to receive emergency funding in a manner similar to that employed in other federal agencies.
Funding priority should be given to the Cooperative Threat Reduction Program, which will become increasingly important in addressing the global Covid-19 pandemic as well as other biological threats.
- Maintain military medical and scientific expertise.
Potential military personnel reductions in health and the biological sciences must be very carefully balanced against the irrevocable negative impact on this highly successful enterprise. Success in preventing, detecting, and treating infectious disease threats is possible only because of the highly skilled people dedicated to this effort. The combination of career professionals and those who serve for a few years then move to the civilian sector has worked well to develop and sustain the unique military public health, clinical, research, and counterproliferation capabilities that support a healthy and fit military force while also making significant contributions in areas not of commercial interest to the overall U.S. health system or pharmaceutical industry. Advances in malaria, Ebola, and other hemorrhagic fevers; research establishing the mRNA vaccine platform; early success toward an HIV vaccine; protection against vector-borne diseases; and advances in biosafety and biosecurity against especially dangerous pathogens have all resulted from the work of relatively unknown DOD laboratories and scientists.
U.S. leadership on both the global response to the acute phase of the pandemic and strengthening preparedness is essential if the world is to move beyond the current disorder and destabilizing inequities that threaten U.S. national interests. The quality and impact of U.S. engagement, led by civilian institutions, will be significantly amplified if DOD’s unique assets are systematically integrated into a coherent U.S. global strategy that sets priorities, concrete quantifiable targets, a plan of action, and an adequate budget. The arrival of the omicron variant, while its true dangers are still to be determined, serves as a reminder of the unpredictable times and the urgency with which action must be taken.
Thomas R. Cullison is a senior associate with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. J. Stephen Morrison is senior vice president at CSIS and director of its Global Health Policy Center.
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