The U.S. Government and Global Health Security
- Attention to and support for global health security efforts, activities to help countries prepare for and develop capacities to address epidemic and pandemic diseases, have grown over the past few decades, driven by concerns about emerging infectious diseases such as HIV, SARS, influenza, Ebola, Zika, and now, SARS-CoV-2 (COVID-19).
- The U.S. government (U.S.) has supported global health security work for more than two decades and is the single largest government donor to such efforts, providing financial support and technical assistance to help build countries’ capacity to prevent, detect, and respond to infectious disease threats. The U.S. also was instrumental in creating the international “Global Health Security Agenda” (GHSA) initiative in 2014.
- Historically, U.S. funding for global health security has waxed and waned over time, with spikes in funding driven almost entirely by specific disease events, often through emergency spending measures. For example, while funding for global health security generally ranged between $400 million and $500 million per year in the last decade, it spiked to $1.34 billion in FY 2015, due to an influx of emergency Ebola funding. It is expected that some emergency COVID-19 funding appropriated in FY 2021 will also be directed to global health security.
- The COVID-19 pandemic has led to an intensified focus in the U.S. and elsewhere on the importance of addressing global health security going forward. Several global health security bills have been introduced in Congress calling for more funding and U.S. action. President Biden’s initial FY 2022 budget request includes nearly $1 billion for global health security, and the administration has also taken several steps to bolster U.S. global health security efforts including:
- reinstating the National Security Council’s Global Health Security and Biodefense Directorate,
- creating a Coordinator for Global COVID Response and Health Security at the Department of State,
- reversing the prior administration’s decision to withdraw the U.S. from membership in the World Health Organization (WHO), and
- affirming that the current administration “will treat epidemic and pandemic preparedness, health security, and global health as top national security priorities,” per a January 2021 national security memorandum on advancing global health security.
Global recognition of the threat of epidemic and pandemic diseases has grown over time, starting with the emergence of HIV in the 1980s, which marked a major turning point. Since then, multiple other new human infectious diseases have been identified (e.g., SARS, MERS, SARS-CoV-2 (COVID-19)), 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).
|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 2018-20 caused 3,481 cases and 2,299 deaths|
|HIV/AIDS||1981||38 million people worldwide living with HIV/AIDS in 2019; 32.7 million people have died from AIDS-related illness since the beginning of the epidemic (as of the end of 2019)|
|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||1,568 cases and 616 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|
|Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) / Coronavirus Disease 2019 (COVID-19)||2020||155 million cases and 3.2 million deaths worldwide|
|NOTES: Includes selected emerging infectious diseases since 1975. Cases and deaths as of Dec. 17, 2020, except COVID-19 is as of May 6, 2020. DRC: Democratic Republic of the Congo.
SOURCES: West Africa Ebola, DRC Ebola; HIV/AIDS; H5N1 Influenza; SARS; H1N1 (2009) Influenza; MERS; H7N9 Influenza; Zika; COVID-19.
While not every emerging infectious disease has major public health implications, some result in significant epidemics or global pandemics. Beyond their toll on health, these diseases can lead to severe disruptions in human activity, and even smaller scale outbreaks can lead to sizeable economic costs due to interruptions in commerce. For example, the original SARS outbreak 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. A full economic accounting of the impact of COVID-19 has yet to be calculated but in the U.S. in 2020 alone the cost has been estimated at $16 trillion – a number four times as large as the lost economic output from the ‘Great Recession’ of 2008 – and the pandemic has led to a severe global recession with an expected 3 percent decline in worldwide GDP through 2024.
Concerns about such outbreaks, therefore, 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. In 2014, noting that progress on meeting the IHR requirements had been slow and unequal across regions, a group of governments – with the U.S. playing an instrumental role – 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
Global health security as defined here does not include U.S. support for research and development for infectious disease countermeasures (such as diagnostics, drugs, and vaccines), nor does it include support for acute epidemic response in other countries (such as funding for COVID-19 vaccine procurement and distribution or direct assistance for Ebola responses in other countries).
Despite such efforts to date, countries remain vulnerable to outbreaks. According to a WHO review, in 2018 most countries still had “low to moderate” levels of national preparedness for emerging diseases and did not meet IHR core capacity requirements. An independent review of global health security in 2019 found “no country is fully prepared for epidemics or pandemics.” The world’s experience with COVID-19 has put the lack of preparedness and response capacity in stark relief, shining a spotlight on major gaps in financing for strong public health systems, social protection programs, international cooperation, and other aspects of global health security. It also, according to the Independent Panel for Pandemic Preparedness and Response, showed that existing measures of preparedness “failed to account sufficiently for the impact on responses of political leadership, trust in government institutions and country ability to mount fast and adaptable responses.”
Even as much of the world continues to struggle with COVID-19, efforts are already underway to identify the weaknesses exposed by the pandemic and the steps that could address them. A number of proposals have already been put forward to improve country and international systems for global health security in light of COVID-19, including calls for a new international treaty, increased governmental and donor financial support including a new global funding mechanism, and more empowered leadership at national and international levels. The ultimate impact the pandemic will have on shaping global health security efforts going forward remains to be determined, as debates and negotiations on these and other topics are likely to continue to play out for months and years to come.
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. The Trump administration released the Global Health Security Strategy (GHS strategy) in 2019 – the first national strategy focused specifically on U.S. global health security efforts and developed at the direction of Congress – guided U.S. government activities aimed at accelerating capacities of targeted countries to prevent, detect, and respond to infectious disease outbreaks protect populations at home and abroad.” Still, during the Trump administration, the NSC Directorate on Global Health Security and Biodefense (first established during the Obama administration) was eliminated, and in mid-2020, the administration initiated the process of withdrawing the U.S. from WHO membership within a year and also halted U.S. contributions to WHO.
In January 2021, the Biden administration took immediate steps to reorient the U.S. response to COVID-19 overseas and to reinvigorate and revamp U.S. global health security efforts. On his first day in office, President Biden issued an executive order that, among other things, restored the NSC Directorate on Global Health Security and Biodefense and directed that the NSC Principals Committee to coordinate the government’s efforts to address biological threats and pandemics and to advise the president on global response to and recovery from COVID-19, including matters related to global health security and WHO. At that time, President Biden issued a national security memorandum on U.S. global leadership regarding the global COVID-19 response and global health security, which states that the current administration “will treat epidemic and pandemic preparedness, health security, and global health as top national security priorities” and reversed the prior administration’s decision to withdraw the U.S. from WHO membership. The administration also released the National Strategy for the COVID-19 Response and Pandemic Preparedness, which states that it is a U.S. goal to “restore U.S. leadership globally, advance health security, and build better preparedness for future threats” and affirmed that the U.S. will restore its funding to WHO and work to strengthen and reform the agency, including through its role as a member of the WHO Executive Board (see the KFF fact sheet on the U.S. government and WHO and KFF brief on the Biden administration’s global health agenda for more information).
The U.S. approach centers on bilateral financial and technical support for capacity-building programs in certain partner countries. Specifically, in FY 2020, the U.S. focused its efforts in 19 GHSA “partner countries” and supported additional efforts in at least 16 other countries; the U.S. geographic focus may incorporate regional approaches in some cases.3 It has also included 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 GHSA (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. Under the Biden administration the U.S. has already re-engaged with and restored funding to WHO and stated that it will take steps to strengthen U.S. leadership in the global COVID-19 response and elevate U.S. efforts in support of GHSA.4
|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; its Global Health Security and Biodefense Directorate, which was first established during the Obama administration but disbanded during the Trump administration, has been restored under the Biden administration. 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 Operations Center (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 outbreak response efforts.
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 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 current administration has created a new role within the department, Coordinator for Global COVID Response and Health Security, charged with leading the U.S. response to the pandemic overseas and ensuring that U.S. global health security efforts adequately equip partner countries for future global health threats.5 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 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 generally ranged between $400 million and $500 million over the last decade, it spiked to $1.34 billion in FY 2015, due to an influx of emergency funding provided to address the Ebola outbreak in West Africa and support future preparedness efforts. Additional funding for global health security was also provided in FY 2016 in response to Zika (see Figure 1). It is likely that some FY 2021 emergency funding for COVID-19 will be designated for global health security efforts as well.7,8 The administration’s initial FY 2022 budget request includes nearly $1 billion for global health security via the Department of State/USAID, an increase of approximately $800 million compared to FY 2021.
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 the KFF budget fact sheet):
- USAID: USAID funding for global health security activities has generally risen each year over the past 10 years, from $47.9 million in FY 2011 to $190 million in FY 2021, with occasional spikes in connection with outbreak events or reprogrammed funding from such events. For example, the agency received $385 million in FY 2015 in connection with Ebola, $218 million in FY 2016 in connection with Zika, and some reprogrammed unspent FY 2015 Ebola funding in FY 2018 and FY 2019.9,10
- CDC: CDC funding for global health security activities has also generally risen over the past 10 years, from $51.2 million in FY 2011 to $203.2 million in FY 2021, with occasional spikes in connection with outbreak events. For example, the agency received $597 million in connection with Ebola funding, which was made available for use through FY 2019; partly in response to the anticipated decline in program funding upon expiration of this emergency funding, base funding at CDC rose sharply in FY 2020. Additionally, some FY 2021 emergency funding for the COVID-19 response will be designated for global health security (the amount is not yet known).11,12
- DoD: BTRP received $203.6 million in FY 2020 and $225.4 million in FY 2021, down from a peak of $320 million in FY 2014. GEIS received between $42 to $59.8 million each year from FY 2011 through FY 2021.
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, FY 2011 – FY 2021
(in $ millions)
|USAID Global Health Security^||47.9||58.1||55.2||72.6||384.5||218.0||72.5||172.6||138.0||100.0||190.0|
|Global Health Programs||47.9||58.0||55.2||72.5||72.5||72.5||72.5||72.6||100.0||100.0||190.0|
|Economic Support Fund||—||0.1||0.1||0.1||—||—||—||—||—||—||—|
|CDC Global Health Protection^~||51.2||55.6||54.3||62.6||652.1||55.2||58.2||108.2||108.2||183.2||203.2|
|Global Public Health Protection||51.2||55.6||54.3||62.6||55.1||55.2||58.2||108.2||108.2||183.2||203.2|
|NOTES: Totals include base and supplemental funding. — means $0/not applicable. FY13 includes the effects of sequestration. 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 FY20 and FY 21, Congress provided emergency COVID-19 funding to address the COVID-19 pandemic globally; it is expected that some of the FY 21 funding provided through CDC may be designated for global health security (the amount is not yet known).* GEIS funding for FY21 assumes level funding based on FY20 level.
SOURCES: KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, U.S. Foreign Assistance Dashboard [website], available at: http://www.foreignassistance.gov, GEIS and AFHSC/AFHSB annual reports, and personal communication with DoD. See also KFF, Global Funding Across U.S. COVID-19 Supplemental Funding Bills.
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, Zika in 2015-2016, and now COVID-19. Despite the efforts of the U.S. and others to date, global preparedness for epidemics and pandemics remains weak, as evidenced by the degree to which countries, including the U.S., and global response systems demonstrated vulnerabilities to COVID-19 over the past year and a half.
This has in turn resulted in an intensified U.S. and global focus on the importance of global health security and lent greater urgency to an overarching question for U.S. policymakers: how best to expand U.S. support for global health security activities and engage with global efforts to shape the international system to address health security threats from here on. Several bills to advance and improve U.S. global health security efforts have been introduced by members of Congress since the pandemic began, which call for greater investment and more leadership from the U.S. in this area. This, coupled with the prominence being placed on global health security by the Biden administration, could result in expanded efforts and funding for global health security, which could become a dominant frame for U.S. global health engagement going forward. Key areas to watch will include:
- the funding levels the Biden administration proposes for global health security efforts, including funding the administration has requested to support the creation of the newly conceptualized global financing mechanism for global health security, and the amounts ultimately appropriated for these efforts by Congress; and, whether more consistent and sustained funding is made available instead of the episodic funding patterns of the past;
- congressional consideration of and potential passage of proposed legislation related to global health security, and how these bills frame the organization, coordination, leadership, and authorized funding of U.S. efforts (see the KFF global health legislation tracker);
- changes in the U.S. approach to and organization of its global health security efforts including whether new U.S. structures or mechanisms will be created;
- the extent of U.S. engagement with partners and multilateral organizations, including WHO, on global health security through various avenues, such as GHSA, the World Health Assembly and the WHO Executive Board, including whether the U.S. will support a new international treaty for pandemic preparedness and response and what the U.S. position will be regarding the location and functions of a new global financing mechanism for these efforts; and
- the implications of a greater focus on U.S. global health security for the “unfinished business of global health, including core U.S. programs such as PEPFAR and PMI.