The U.S. Government and Global Health Security
- Global health security efforts – that is, efforts to help countries prepare for and address pandemic and epidemic diseases – have grown over the past few decades, driven by concerns about emerging infectious diseases such as HIV, SARS, influenza, Ebola, and Zika.
- The U.S. government (U.S.) has supported global health security work for more than two decades and is the single largest donor to such efforts. Currently, the U.S. focuses on providing technical assistance and financial support to build countries’ capacity to prevent, detect, and respond to infectious disease threats. The U.S. is also a supporter of multilateral efforts, such as the Global Health Security Agenda (GHSA), and often plays a key role in international responses to major disease outbreaks.
- U.S. funding for its main global health security programs – activities primarily carried out by the U.S. Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and Department of Defense (DoD) – has waxed and waned over time, with spikes in supplemental funding driven by specific disease events. For example, while funding for global health security generally ranged between $400 million and $500 million per year over the last decade, it spiked to $1.34 billion in FY 2015, reflecting additional, emergency funding provided in response to the Ebola outbreak in West Africa, and was $552 million in FY 2016 in response to Zika.
- Looking ahead, there are ongoing questions about the future of U.S. engagement in global health security, including funding. Almost all of the FY 2015 emergency Ebola funding for global health security, which had provided a funding boost for U.S. programs over the last few years, is now spent or expired and agencies face the prospect of having to reduce their activities if funding returns to pre-FY 2015 levels. Congress and the Administration have signaled strong support for global health security, but it remains unclear if future funding will be sustained at the levels seen in recent years. There are also questions going forward about how the U.S. will engage with and support relevant international institutions in global health security, including the World Health Organization (WHO) and the GHSA.
Global recognition of the threat of epidemic and pandemic diseases has grown over time, with the emergence of the HIV/AIDS epidemic in the 1980s marking a major turning point. Since then, multiple other new human infectious diseases have been identified (e.g., SARS, MERS), while other diseases have “re-emerged,” causing greater numbers of cases than before and/or affecting different populations and regions (e.g., dengue fever and Ebola). Still others have developed resistance to available treatment (e.g., multi-drug resistant tuberculosis) or been newly linked to adverse health outcomes (e.g., Zika) (see Table 1).
While not every emerging infectious disease has major public health implications, some result in significant epidemics or global pandemics. Outbreaks can lead to sizeable economic costs and interruptions in trade and travel. For example, SARS resulted in an estimated $30 billion in economic losses (over $3 million per case) in 2003, primarily from reduced commerce, travel and trade, while the 2014-2015 West Africa Ebola epidemic in Guinea, Liberia, and Sierra Leone resulted in an estimated $53 billion in economic losses. Moreover, it is estimated that an influenza pandemic similar in nature to the 1918 influenza pandemic could kill 100 million people worldwide and lead to a loss of up to 4.8% of global GDP.
|Table 1: Selected Emerging Infectious Diseases|
|Emerging Disease||Year First Identified||Notes|
|Ebola Virus Disease (Ebola)||1976||West Africa epidemic 2014-15 caused 28,616 cases and 11,310 deaths; DRC epidemic 2018-19 has caused more than 3,000 cases and 2,000 deaths|
|HIV/AIDS||1981||37.9 million people worldwide living with HIV/AIDS in 2018|
|H5N1 Influenza (“bird flu”)||1997||850 cases and 449 deaths between 2003-2016|
|Severe Acute Respiratory Syndrome (SARS)||2003||8,096 cases and 774 deaths worldwide|
|H1N1 (2009) Influenza (“swine flu”)||2009||More than 284,000 deaths worldwide|
|Middle East Respiratory Syndrome (MERS)||2012||2,468 cases in 27 countries, and 851 deaths|
|H7N9 Influenza (“bird flu”)||2013||1567 cases and 615 deaths|
|Zika Congenital Syndrome||2015||5-10% of all babies of women with confirmed Zika virus infection in the U.S. had Zika associated birth defects|
|NOTES: Includes selected emerging infectious diseases since 1975. Cases and deaths as of November 18, 2019. DRC: Democratic Republic of the Congo.
SOURCES: West Africa Ebola, DRC Ebola; HIV/AIDS; H5N1 Influenza; SARS; H1N1 (2009) Influenza; MERS; H7N9 Influenza; Zika.
Concerns about such outbreaks has fueled efforts to improve local, national, and international capabilities to address emerging diseases. For example, in 2005, WHO member states agreed to revise the International Health Regulations (IHR), a long-standing international agreement that outlines roles and responsibilities for countries and international organizations in global health security (see Box 1). The revised IHR, among other things, requires countries to develop minimum capacities to detect, report, assess, and respond to outbreaks and other public health emergencies. More recently, noting that progress on meeting the IHR requirements has been slow and unequal across regions, in 2014, a group of governments and other stakeholders launched the Global Health Security Agenda (GHSA), a multilateral initiative to speed country progress in identifying and addressing gaps in basic global health security capacities (see Box 2). In addition, growing recognition of the importance of global health security to broader economic and social development has been reflected in the inclusion of a global health security objective under the U.N. Sustainable Development Goals (adopted in 2015) as well as by multiple recent endorsements of global health security efforts by the leaders of the G7 and G20.
|Box 1: Defining Global Health Security|
|Activities supporting epidemic and pandemic preparedness and capabilities at the country and global levels in order to minimize vulnerability to acute public health events that can endanger the health of populations across geographical regions and international boundaries. This includes efforts to improve countries’ capacity to prevent, detect, and respond to infectious disease threats.1|
Despite these and other developments, many countries remain vulnerable to outbreaks. WHO estimates that in 2018, just a third of countries were adequately prepared to detect, report and respond to emerging infectious diseases. Many observers agree that even as the performance of WHO itself in this area has generally improved since its poor response to the 2014-2015 West Africa Ebola epidemic, the organization faces ongoing challenges in its global health security role, such as a broad mandate with limited, inflexible funding and a complex bureaucratic structure that can impede rapid and decisive action (see KFF fact sheet on the U.S. government and WHO).
U.S. Government Efforts
The U.S. has supported global health security efforts for over two decades.2 Specific policy guidance for federal agencies dates back to a 1996 Presidential Decision Directive on emerging diseases (PDD/NSTC-7), and each subsequent Administration has updated or released new policy and strategic guidance. Most recently, the Trump Administration released the National Biodefense Strategy in 2018 and the Global Health Security Strategy (GHS strategy) in 2019. The biodefense strategy outlines a comprehensive U.S. government approach to addressing biological threats domestically and internationally, while the GHS strategy – the first national strategy focused specifically on U.S. global health security efforts and developed at the direction of Congress – guides U.S. government activities aimed at accelerating capacities of targeted countries to prevent, detect, and respond to infectious disease outbreaks.
As outlined in the GHS strategy, the U.S. government invests in these programs in order to “prevent the spread of human and animal infectious diseases and protect populations at home and abroad” and with three overarching goals:
- Strengthened partner country global health security capacities;
- Increased international support for global health security, and
- A homeland prepared for and resilient against global health security threats.
The U.S. approach centers on bilateral financial and technical support for capacity-building programs in certain partner countries. Specifically, since 2014, the U.S. has focused its efforts in 17 GHSA “partner countries,” although the recent GHS strategy suggests that starting in FY 2020, the U.S. geographic focus may shift, leading to some current partner country programs being shrunk or eliminated and/or others being added, and may incorporate regional approaches in some cases.
In addition, the U.S. approach includes active involvement in multilateral efforts related to global health security, including playing leading roles in the multilateral negotiations for the 2005 revision of the IHR and the development and launch of the Global Health Security Agenda (GHSA), a multi-country partnership designed to help coordinate and accelerate progress toward IHR and global health security goals (see Box 2) in 2014. The U.S. also participates in and supports international responses to outbreaks; for example, it was the largest donor to and supporter of the response to the 2014-2015 West Africa Ebola epidemic, which was the largest Ebola outbreak in history, and is a key donor to and responder to the 2018-2019 DRC Ebola response, which is the second largest Ebola outbreak to date.
|Box 2: The Global Health Security Agenda (GHSA)|
|The U.S. played the leading role in developing the Global Health Security Agenda (GHSA), a multilateral initiative that aims to serve as “a catalyst for progress toward the vision of attaining a world safe and secure from global health threats posed by infectious diseases.” Launched in 2014 for an initial 5-year period (2014-2019), it has been extended for a second five-year period through 2024. Among the strategic objectives of the GHSA are to:
–promote international initiatives, instruments, and frameworks relevant for health security; and
-increase domestic and international partner financial support for strengthening and maintaining capacities to prevent, detect and respond to infectious disease outbreaks, including health system strengthening.
There are 67 member countries of the GHSA, including the U.S. The initiative incorporates several multilateral institutions as partners, such as WHO, the United Nations Food and Agriculture Organization (FAO), the World Organization for Animal Health (OIE), the World Bank, and World Trade Organization (WTO). Private sector and non-governmental partners also engage the initiative through forums such as the GHSA Private Sector Roundtable and GHSA Consortium.
GHSA members have agreed to coordinate efforts and mutually work toward goals in defined areas of global health security, known as “action packages.” To assist in this process, the GHSA helped develop a tool for independent evaluation of countries’ preparedness levels, known as the Joint External Evaluation (JEE); these scores are used as benchmarks for country and global progress in global health security. Over 100 countries, including the U.S., have undergone such an evaluation since 2014.
GHSA and the IHR are meant to be complementary, with GHSA action packages designed to support countries’ progress toward meeting IHR core capacity requirements. While the GHSA and the IHR facilitate cooperative efforts among countries, ultimately country governments are responsible for ensuring capacity to prevent, identify, and respond to emerging diseases within their own borders.
Multiple U.S. agencies are engaged in global health security efforts. The National Security Council (NSC) is responsible for overall coordination and review of U.S. strategy and activities in global health security, including its international response. Three main U.S. agencies implement programs in partner countries: USAID, CDC, and DoD.
The USAID Global Health Bureau’s global health security program helps countries build capacity to identify and respond to dangerous pathogens in animals and humans and to be prepared for outbreaks, including pandemics. Additionally, other USAID global health programs support health systems strengthening, including building surveillance and laboratory capacities that have applications for global health security. In addition, the Office of Foreign Disaster Assistance (OFDA) has often been involved when the U.S. engages in large-scale international outbreak responses.
The CDC Center for Global Health’s Division of Global Health Protection provides capacity-building, training, and educational support to other countries through its Global Disease Detection Program (GDD), Emergency Response and Recovery Branch (ERRB), and Field Epidemiology Training Program (FETP). Other CDC global health programs help build surveillance, laboratory, and other capacities relevant to global health security. CDC has also created a cross-agency rapid response team for international deployment, and CDC staff are often involved in international response efforts for Ebola and other outbreaks.
The Department of Defense (DoD) Defense Threat Reduction Agency’s Biological Threat Reduction Program (BTRP), previously known as the Cooperative Biological Engagement Program (CBEP), funds capacity-building efforts to strengthen partner countries’ biosecurity, surveillance, and response capabilities and is a component of the DoD’s broader Cooperative Threat Reduction (CTR) program. The DoD’s Global Emerging Infections Surveillance and Response System (GEIS) provides technical and funding support for DoD and partner organizations’ surveillance, research and development, outbreak response, and local capacity-building and helps support Army and Navy laboratories that are located in multiple foreign countries.
Other U.S. Efforts
The Department of Health and Human Services (HHS) is the official U.S. point of contact with WHO for IHR purposes and often represents the U.S. at multilateral meetings on emerging disease topics and helps coordinate U.S. global health security efforts. HHS supports research and development for emerging disease countermeasures (e.g. drugs and vaccines) through the National Institutes of Health (NIH) and the Biodefense Advanced Research and Development Authority (BARDA), while the Food and Drug Administration (FDA) is responsible for regulatory review and approval. The Department of State engages in diplomacy and coordination in support of global health security and is home to the Biological Engagement Program (BEP), a biological security assistance and capacity building effort. The Department of Agriculture (USDA) engages in capacity building for animal health and food safety and supports surveillance and research on animal diseases overseas.
U.S. funding for its main global health security programs has waxed and waned over time, with occasional spikes driven by supplemental funding connected to specific disease events. For example, while funding for global health security generally ranged between $400 million and $500 million over the last decade, it spiked to $1.34 billion in FY 2015, reflecting additional, emergency funding provided in response to the Ebola outbreak in West Africa, and was $552 million in FY 2016 in response to Zika (see Figure 1). The Trump Administration requested $482 million for FY 2020, which would represent a decrease of $22 million (4%) compared to FY 2019.
U.S. funding for global health security is provided primarily through accounts at USAID, CDC, and DoD (see Figure 2 and Table 2; also see KFF budget fact sheet):
- USAID: USAID funding for global health security activities has fluctuated over the last 10 years, with occasional increases in connection with outbreak events. For example, the agency received $140 million in FY 2009 and $201 million in FY 2010 in connection with 2009 H1N1 influenza, $385 million in FY 2015 in connection with Ebola, and $218 million in FY 2016 in connection with Zika.3 Congress reprogrammed some unspent FY 2015 emergency Ebola response funding in FY 2018 and FY 2019, resulting in USAID funding in those years of $172.6 million and $138 million, respectively.4 In most other years, funding for the agency was less than $75 million. Congress also provided $70 million for an “emergency reserve fund” in FY 2017, to be made available to support future responses to any “emerging health threat that poses severe threats to human health” (this funding is not included in the global health security total). The Trump Administration requested $90 million for USAID in FY 2020.
- CDC: CDC funding for global health security activities has also fluctuated over time. After receiving less than $63 million each year from FY 2009 through FY 2014, funding spiked to $652.1 million in FY 2015, including $597 million in emergency Ebola funding that was made available for use through FY 2019. Then, after two fiscal years with less than $60 million, funding rose to $108.2 million in FY 2018 and FY 2019, partly in response to the decline in funding from the dwindling pot of emergency Ebola funding that eventually expired at the end of FY 2019. Congress also established an Infectious Diseases Rapid Response Reserve Fund with $50 million in FY 2019, which allows use of the funds by CDC and certain parts of HHS to prevent, prepare for, or respond to “an infectious disease emergency” in the U.S. or abroad (this funding is not included in the global health security total). The Trump Administration requested $149.8 million for CDC in FY 2020.
- DoD: The highest-funded U.S. global health security program, BTRP received $172.8 million in FY 2018 and $197.6 million in FY 2019, down from a peak of $320 million in FY 2014. GEIS received between $42 to $59.8 million each year from FY 2009 through FY 2019. The Trump Administration requested $183.6 million for BTRP and $58.7 million for GEIS in FY 2020.
In addition to these key accounts, other funds may be used for global health security activities, though public information about them is often limited. For example, DoD provides some funding to support Army and Navy overseas labs, and the Department of State, USDA, and other agencies’ budgets support additional global health security activities.
|Table 2: U.S. Funding for Global Health Security (GHS), FY 2009 – FY 2020 Request (in $ millions)|
|USAID Global Health Security^||140.0||201.5||47.9||58.1||55.2||72.6||384.5||218.0||72.5||172.6||138.0||90.0|
|Global Health Programs||140.0||201.0||47.9||58.0||55.2||72.5||72.5||72.5||72.5||72.6||100.0||90.0|
|Economic Support Fund||—||0.5||—||0.1||0.1||0.1||—||—||—||—||—||—|
|CDC Global Health Protection^~||47.5||61.9||51.2||55.6||54.3||62.6||652.1||55.2||58.2||108.2||108.2||149.8|
|Global Public Health Protection||47.5||61.9||51.2||55.6||54.3||62.6||55.1||55.2||58.2||108.2||108.2||149.8|
|NOTES: Totals include base and supplemental funding. — means $0/not applicable. FY13 includes the effects of sequestration. FY19 is based on funding provided in the “Consolidated Appropriations Act, 2019” (P.L. 116-6) and is a preliminary estimate. BTRP is the Biological Threat Reduction Program, formerly known as the Cooperative Biological Engagement Program (CBEP). GEIS is the Global Emerging Infections Surveillance & Response System.
^ In FY15, Congress provided $5.4 billion in emergency funding to address the Ebola outbreak, of which $909.0 million was specifically designated for global health security at USAID and CDC. In FY16, Congress provided $1.1 billion in emergency funding to address the Zika outbreak, of which $145.5 million was specifically designated for global health security at USAID. In FY18, Congress provided $100 million in unspent Emergency Ebola response funding for “programs to accelerate the capabilities of targeted countries to prevent, detect, and respond to infectious disease outbreaks” at USAID. In FY19, Congress provided $38 million in unspent Emergency Ebola response funding for “programs to accelerate the capacities of targeted countries to prevent, detect, and respond to infectious disease outbreaks” at USAID.~ In the CDC FY20 congressional justification, the “Global Public Health Protection” funding line is titled “Global Disease Detection and Other Programs.”
SOURCES: Kaiser Family Foundation analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard [website], available at: http://www.foreignassistance.gov.
Key Issues for the U.S.
The U.S. has supported global health security activities for more than two decades and remains the single largest contributor to international capacity building. Still, U.S. attention to and funding for global health security have waxed and waned over time, with occasional spikes driven by specific disease events such as Ebola in 2014-2015 and Zika in 2015-2016. Despite the efforts of the U.S. and others to date, global preparedness for epidemics and pandemics remains weak, and therefore, the overarching question for U.S. policymakers is whether the U.S. will sustain or expand its support for global health security activities going forward. The following policy issues are particularly important for the U.S.:
- In recent years U.S. global health security programs, especially those at CDC and USAID, have been bolstered by FY 2015 supplementary funding initially provided in response to Ebola. As this emergency Ebola funding is exhausted (as it had been by CDC at the end of FY 2019), agencies face the prospect of having to reduce their activities if funding returns to pre-FY 2015 levels. While Congress and the Administration have signaled strong support for global health security, it remains unclear if future funding will be sustained at the levels seen in recent years.
- GHSA and the U.S. Role. As the GHSA enters its second five-year phase, the level of international support for this multilateral effort will be important to observe. Support from the Trump Administration for this multilateral effort will be particularly vital in light of the central role the U.S. played in initially launching and developing the GHSA.
- U.S. Engagement with WHO. The U.S. recognizes that WHO plays a key role in global epidemic preparedness and response efforts, but the organization faces a number of challenges including limited, inflexible funding for global health security and a complex bureaucratic and political structure. U.S. support for and engagement with WHO as it seeks to address these challenges will continue to be important, given that the U.S. is its largest contributor and deeply involved in the governance of the institution.