"Preventing and Responding to High-Risk Disease Outbreaks." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, September 13, 2018. Accessed October 01, 2020.

High-risk disease outbreaks are a real and growing threat to U.S. national security at home and abroad.

Photo Credit: Mike Stone/Getty Images

A man dressed in protective hazmat clothing treats the front porch of an apartment where a second person diagnosed with the Ebola virus resides on October 12, 2014 in Dallas, Texas.
A man dressed in protective hazmat clothing treats the front porch of an apartment where a second person diagnosed with the Ebola virus resides on October 12, 2014 in Dallas, Texas. Mike Stone/Getty Images

Key Challenges

Rapidly Changing Nature of Infectious Disease

While pandemic influenza remains among the most grave, persistent disease threats, new infectious diseases are emerging at an unprecedented rate.1 39 new infectious diseases have been detected since the 1970s, including HIV, Ebola fever, Marburg fever, SARS, MERS, avian and swine flus, and Zika.2 That’s not to mention the difficulty of anticipating unknown disease threats (“Disease X”) that cannot be easily identified or characterized.3

Science of Response

At home and abroad, high-risk disease outbreaks pose formidable challenges in prevention, detection and response, and post-outbreak consequences. Even with the advent of genetic sequencing of pathogens, it is often difficult to identify and characterize new threats (“Disease X”), given how fast microbes evolve (nearly 40 million times faster than humans.)4 It is no less challenging to develop, approve, and stockpile new drugs and vaccines. Furthermore, most countries are inadequately equipped to detect, respond, and sustain a response to a health threat.

Limited Domestic Capacity

U.S. public health infrastructure has been neglected. Investment fell dramatically after the Great Recession and never regained ground. In 2002, U.S. health emergency preparedness funding was $940 million.5 By 2016, it decreased to $660 million, and funding for the Hospital Preparedness Program decreased from $515 million in 2004 to $255 million in 2016.6 More recently, the United States has had to cope with the exceptional scope and damage of natural disasters in 2017 – Hurricanes Harvey, Irma and Maria – which further strained already weak public health infrastructure, aggravating health vulnerabilities. The U.S. health system would be quickly overwhelmed in the event of a major infectious disease outbreak, act of bioterror, or catastrophic natural disaster.

Domestically at present, the United States cannot effectively deliver critical medical commodities to affected individuals in a timely manner, in the event of an outbreak. Beyond supply chain constraints, leadership and responsibility are diffused across the U.S. government, and there is no clear person in charge for prevention or response activities. As the 2015 Blue Ribbon Study Panel on Biodefense highlighted, the lack of coherent crisis leadership, institutional fragmentation, and multiple budget lines and authorities limit the government’s ability to control, prioritize, coordinate, and hold agencies accountable in the face of such dangers.7

Economic Cost of Inaction

The estimated economic consequences of major outbreaks, at the national and global level, are enormous. A large-scale outbreak would cause major economic disruptions, especially to the U.S. export economy and American jobs. A hypothetical epidemic spanning nine countries in Asia could cost the United States over $40 billion in export revenues and put more than 1 million American jobs at risk.8

Global Health Security Agenda

The United States and its partners have made considerable progress in outbreak preparedness through the U.S.-facilitated Global Health Security Agenda, launched in February 2014.9 GHSA has helped clarify concrete targets for building capacities in low, middle and even high-income countries that still lag dangerously behind. It has motivated many countries to undertake systematic and independent Joint External Evaluations, develop national action plans, and begin to finance the gaps identified.

In its first four years, GHSA created a coalition of over 64 states, international organizations, and non-governmental stakeholders, with $1 billion in Ebola emergency supplemental funding (2014-2019). The U.S. government through GHSA has prioritized assisting 31 countries (17 in the first phase) to strengthen capabilities to prevent, detect, and rapidly respond to outbreaks.10 This investment is part of a G-7 commitment to help 77 countries meet health security goals.11

Since 2015, significant gains have been achieved, yet much work remains. As the $1 billion in emergency funds is expended by the end of 2018, it will be critical that governments around the world, like our own, invest at higher levels in capacities to deal with outbreaks. There is at present no sustainable financing mechanism, no adequate incentive structure to motivate governments to invest in preparedness (against other competing priorities such as roads and other infrastructure), and no internationally-recognized mechanism for tracking commitments and returns.

Domestic and Global Linkages

Self-reporting by countries revealed that in 2012, five years after the revised International Health Regulations came into force, only 21% of the world’s states possessed the basic capacities to prevent, detect and respond to dangerous outbreaks.12 By 2014, that number reportedly rose to 33%.13 No fewer than 7 major international studies reviewed the mistakes made in the international response to Ebola in West Africa beginning in 2014. All concluded that low-income countries remained overwhelmingly ill-prepared and vulnerable, and require external investments in basic capacity building, as a top donor priority.

Global threats are domestic threats. For example, when Ebola erupted in West Africa in 2014, even though it only resulted in a very small number of cases in the United States, it exposed serious gaps in domestic preparedness and ignited widespread fear, panic and confusion. Had Ebola not been successfully contained in Nigeria, the risk to the United States and other countries would have escalated steeply. We must stop outbreaks where they start.

The 2017 National Security Strategy explicitly states that the U.S. will work with other countries to detect and mitigate outbreaks early to prevent the spread of disease.14 This involves “encouraging other countries to invest in basic health care systems and to strengthen global health security across the intersection of human and animal health to prevent infectious disease outbreaks.”[^15] Naturally-occurring virus outbreaks, including Ebola and SARS, and the deliberate 2001 anthrax attacks were recognized as national security threats that can exact tolls on American public health and economic gains.[^16]

  1. WHO, “The World Health Report 2007: A Safer Future – Global Public Health Security in the 21st Century,” 2007, 

  2. Baylor College of Medicine, “Emerging Infectious Diseases,” 2018, 

  3. WHO, “2018 Annual review of diseases prioritized under the Research and Development Blueprint (Meeting report),” February 6-7, 2018, 

  4. Bryan Walsh, “The World Is Not Ready for the Next Pandemic,” TIME, May 4, 2017, 

  5. The National Academies of Sciences, Engineering, and Medicine, “Global Health and the Future Role of the United States,” The National Academies Press, May 15, 2017, 

  6. Ibid. 

  7. Blue Ribbon Study Panel on Biodefense, “A National Blueprint for Biodefense: Leadership and Major Reform Needed to Optimize Efforts,” October 2015, 

  8. Zoe Bamberry, Cynthia H. Cassell, Rebecca E. Bunnell, Kakoli Roy, Zara Ahmed, Rebecca L. Payne, and Martin I. Meltzer, “Impact of a Hypothetical Infectious Disease Outbreak on US Exports and Export-Based Jobs,” Health Security 16, no. 1 (2018): 1-7, 

  9. GHSA, “Implementing the Global Health Security Agenda: Progress and Impact from U.S. Government Investments,” February 2018, 

  10. Ibid. 

  11. Ibid. 

  12. WHO, “Implementation of the International Health Regulations (2005): Report of the Review Committee on the Role of the International Health Regulations (2005) in the Ebola Outbreak and Response,” May 13, 2016, 

  13. UN High-level Panel on Global Response to Health Crises, “Protecting humanity from future health crises (A/70/723),” February 9, 2016, 

  14. The White House, “National Security Strategy of the United States of America,” December 2017, 

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