Abstract
I
The Department of Health and Human Services (HHS) National Health Security Strategy defines health security as a state in which a nation and its people are prepared for, protected from, and resilient in the face of health threats. Health security is fundamentally composed of the people, programs, and institutions that keep us safe from outbreaks, terrorism, hurricanes, tsunamis, earthquakes, biological and chemical threats, and much more. Although domestic and international work in this area is all too often underfunded and under the radar, we all depend on it when major crises strike. Typhoon Haiyan, the Boston Marathon bombing, the outbreak of the lethal Middle East respiratory virus, the Japanese tsunami and Fukushima nuclear plant accident, and even bad flu seasons are a few examples in recent history. As we plan for the future, we should also anticipate incipient threats from nontraditional sources, such as cyber-attacks to infrastructure (electricity, water, transportation) that could pose major risks to health security.
These diverse, often unpredictable, and potentially dire health emergencies require quick and well-coordinated action. Advance planning before such events is closely tied to health outcomes, and yet we too often assume that help will be on the way when it is needed, regardless of how much attention and funding have been given to preparing ahead of time.
There are too many important health security programs and priorities to describe in one place, so we won't try to do that. But in the spirit of the coming New Year, here are our 7 resolutions to propose for health security:
1. Increase support for public health and hospital preparedness programs.
Largely as a consequence of 9/11 and the subsequent anthrax attacks, the US invested in bolstering local public health programs and hospital preparedness programs through increased federal funding. This investment has more than paid off. New surveillance systems were launched, regional hospitals formed coalitions to better coordinate during crises, and laboratory programs for diagnosing disease were strengthened. These crucial improvements have contributed to making our public health and healthcare systems more resilient to disasters. The commendable performance of hospitals during the Boston bombing highlights the benefits of serious preparedness efforts by hospitals.
Unfortunately, in the past few years, federal support for public health and hospital preparedness programs has dropped sharply, despite the fact that preparedness work is ongoing and will remain vital. Since 2006, funding for public health emergency preparedness is down 20%, and funding for hospital preparedness programs is down by almost 50%. We need to make a commitment to build, fund, and sustain public health and hospital preparedness programs if we expect them to be there to respond to crises and to save lives. The new National Health Security Preparedness Index, launched in December 2013, has created a better way of tracking progress on many of these issues across the country. We were excited to participate in its development process, and we believe this index will help underscore the many critical elements that comprise health security, the potential consequences of losing these programs, and the great value that these and other preparedness programs bring to the country.
2. Bring more technological power and innovation into health security.
If you compare the technological tools being used to protect the public from disasters and epidemics to those being used in the private sector, it is clear that preparedness programs are lagging behind. Public health agencies and disaster response organizations often lack the ability to effectively use some of the technologies that most of us take for granted in our normal lives, such as social media and mobile phone technologies.
According to a 2012 American Red Cross study, many Americans expect disaster response professionals to respond quickly to calls for help made over social media, but it is unclear how many officials actually respond to, let alone monitor, social media networks. Evidence suggests that local health departments could use cell phones and social media to provide real-time updates, rapidly exchange information with the public, and enhance situational awareness during emergencies. But only a small fraction of local health departments use such technology effectively. Many public health officials, concerned about privacy issues or constrained by their organization's financial limits, are unable to use mobile technologies or social media in the way the public would expect. Support should be provided for public health and emergency management adoption of these technologies.
It is unrealistic (and unfair) to ask public health and disaster professionals to protect us in crises without providing them with the necessary tools and supporting their community engagement efforts needed for the job. These professionals are also going to need to collaborate closely with outside technology organizations in new or unexpected ways when disaster strikes. For example, during the Hurricane Sandy response, emergency responders had to get help on the fly from outside technology experts to be able to visualize supply chains, identify the location of people in need, and determine the most time efficient means of delivering supplies. For this kind of collaboration in an emergency to work well, we need to do a better job connecting technologists with those we are counting on to protect us from disasters and epidemics in advance of crisis.
3. Work toward common international expectations for biosafety when there is the potential for epidemic risk.
In recent years, the power of biotechnology has become increasingly evident, and there is a growing awareness of the importance of having adequate biosafety practices in place to protect the public from the serious adverse consequences that could result from laboratory accidents. Perhaps the most important recent example of the critical importance of biosafety in protecting the public from laboratory accidents was the gain of function research intended to transform lethal H5N1 strains into more readily transmissible strains. If such an engineered, lethal, transmissible virus escaped from the lab and had the capacity to spread from person to person, it could lead to an epidemic catastrophe. That kind of virus would belong in a very small group of lethal and human-to-human transmissible viruses that we think should require special biosafety approaches not only in the laboratory itself, but at the national level. These are viruses that could pose extraordinary global risks in the event of laboratory accidents.
There are already generally held expectations regarding biosafety inside laboratories, but there is no widely accepted international biosafety framework for national-level biosafety policy and practice in countries where research with such pathogens is being conducted. Countries that permit research on this special group of viruses should commit to a national approach to biosafety that would include not only ensuring proper biosafety level laboratory procedures and engineering controls, but also clear public notification regarding risks, rigorous nationally approved biosafety training programs for people working on such research, the establishment of a national database of laboratory accidents in labs that work on those pathogens, and the identification of the national official(s) responsible for certifying laboratory safety and inspections in labs doing this work. A contagious disease epidemic started in any country is a potential risk to every country, and our international approach to biosafety should account for that.
4. Improve our disease surveillance and management systems.
The sooner a new disease outbreak is discovered and accurately tracked, the faster the effort to control it can begin. The systems needed to do this kind of work are based on well-trained people, good laboratory diagnostics, connections between public health experts and clinical systems where sick people show up, and rapid communication of test results. There are a range of potentially promising surveillance approaches and tools in development that could substantively improve the ability to identify and respond to outbreaks if support is provided for their development. Some of them require linking disparate datasets to each other, such as tracking data required to understand the source of foodborne outbreaks. Others involve better linking of surveillance data to changing practices, such as the practice of linking resistance data to the clinical stewardship of antibiotics. Additional tools depend on discovering patterns of disease in hospitalized patients, which might be possible if public health agencies could have access to records of people infected in an outbreak.
As the practices and institutions of medical care change in the next few years, some current responsibilities of public health agencies are likely to shift to primary care physicians, and in that shift we need to ensure that surveillance systems for diseases like tuberculosis remain strong. This is all occurring at a time when some diseases, like dengue, are reemerging (in November 2013, there was a case of locally transmitted dengue in Long Island, NY). It will be important to start rebuilding the disease surveillance and management systems—for example, vigorous mosquito control programs—that we used to have for these and other reemerging diseases and adapt them for modern times.
5. Strengthen our efforts to cope with the consequences of nuclear and radiation disasters.
The level of public understanding around radiation risks is a lot less than for other kinds of risk or disasters. In part, this may be due to the stronger emphasis put on prevention, as compared to response planning, for such events. While prevention efforts should continue to be the focal point, there does need to be more attention paid to public preparedness for nuclear and radiation events. These are rare, potentially high-consequence events that require a rapid response, possibly on a very large scale. For instance, it is clear that the greatest life-saving intervention after a nuclear detonation would be for survivors to shelter in place in their homes or buildings for perhaps 2 days, but surprisingly few people are aware of this. A public education campaign on this one issue could save tens or hundreds of thousands of lives in the event of a nuclear detonation.
In contrast to nuclear detonation scenarios, much more professional engagement has occurred in terms of nuclear power plant accident response and recovery. But a lot more could be done to share the best practices of the emergency planning that goes on around nuclear plants in the US and abroad. There are localities in the US that still use phonebooks as a primary means to communicate emergency response procedures to the public—a required response to outdated regulatory mandates. There also needs to be more work related to community recovery and reentry after nuclear disasters. It is likely that the relative lag in nuclear and radiation preparedness is in part due to a general reluctance by leaders to discuss nuclear and radiation risks with the public. We need to push past this reluctance if we are committed to protecting people from these risks.
6. Develop new medicines, vaccines, and diagnostics that meet the challenges of biological, chemical, and nuclear threats and epidemics and antibiotic resistance.
Making medicines, vaccines, and diagnostic tests to be used almost solely in the event of national epidemics, bioterrorism or chemical terrorism response, or other disasters is a serious technical and financial challenge. In recent years there has been good progress in the United States against these challenges: There are many new products under development; an active segment of industry is engaged and lending their expertise to the effort; there is increasing focus by the government on ensuring that products would be effective under the conditions in which they would be used; and many positive efforts are under way to streamline the regulatory process. Bioinformatics, synbio, and changes in regulatory science all are likely to provide novel and valuable contributions to drug discovery and development.
Even with this notable progress, we are still years, or potentially decades, away from having vaccines, medicines, and diagnostics against many of the diseases that could seriously threaten health and national security. At the root of this problem, there is no easy way to speed the development of new, innovative medical countermeasures absent the pull of a strong commercial market.
This work will continue to require ingenuity and the experience of industry leaders and, yes, long-term financial commitment and innovative programming from the government. This is true not just for the as-yet-elusive universal flu vaccine and for countermeasures against biological or chemical weapons, but also for new antibiotics or other therapeutic approaches for combating multidrug resistant infections—infections that could literally drag the practice of medicine back to pre-antibiotic days if we do not attend to this growing crisis. We need much greater international dialogue and attention to antimicrobial resistance—especially the serious multidrug resistance occurring in hospitals around the world—a dialogue that should aim to find solutions and commitments for developing the new kinds of antibiotics and other therapies that we all are going to need.
7. Increase international health security collaboration.
There is the oft-repeated adage that disease and natural disasters do not respect national boundaries, which has been shown to be true again and again. And yet, there is relatively little international exchange or sharing of best practices in the area of health security programs and policies. To understand “lessons learned” from a country or city after a health crisis hits now often requires preexisting personal relationships. Networks of personal relationships are crucial for information and technical exchange, and they will always be important. But we should be working to strengthen and regularize our institutional connections as well.
Climate change and related disasters are an increasing worldwide concern, and epidemics and other major health crises are a constant part of the modern world. However, when these events happen in one country, other countries that could be affected are often scrambling to understand and learn from the particular crisis while it is occurring. There would be value in more international technical exchange around health security, more benchmarking of good programs, more collaborating on how to best respond to epidemics and disasters.
In a related vein, it is important for countries to do more to assist other countries in meeting their IHR obligations. As reported in the most recent WHO activity report on the IHR, a majority of countries that signed the IHR have requested extensions to complete their implementation work. These are challenging capacities to build, and those countries that have had success in building them should do more to help those countries that have not. The specific capacities needed vary by country. Some will require support to bolster the skills and experience of their public health professionals; others will require enhanced laboratory capacity. A common need, though, is financial support. Implementing the IHRs requires investment, and low-income countries will need financial support from the developed world to fully implement the IHRs. This requirement of the IHRs—that member states with resources aid those without—is in every country's national interest in an effort to help prevent epidemic surprises from emerging and spreading without notice or a chance to respond early and vigorously.
Can all this be accomplished in 2014? Probably not. But we could make notable progress on many or all of them. If that happens, we will be far more ready to deal with the serious challenges that lie ahead. And that would make for a very good new year.