Singapore-Malaysia-Indonesia-US Dialogue on Biosecurity

1. Singapore, Malaysia, Indonesia, and the United States will face ongoing serious challenges in addressing biological threats that come across their borders.

Participants acknowledged that there is no plausible way to completely prevent infectious diseases from crossing borders, particularly in Southeast Asia. Of note, the area known as the SIJORI Growth Triangle—a robust economic hub of about 10.1 million inhabitants from Singapore, Johor (in Malaysia), and the Riau Islands (in Indonesia)—reports a high volume of cross-border traffic that is challenging to monitor. Singapore alone receives 300,000 commuters from Malaysia every day, while Jakarta experiences a daily influx of 1.38 million individuals from throughout Indonesia and neighboring countries. ²⁰

Given the porousness of international borders and the implausibility of checking every person traveling for signs of infectious disease, participants agreed that their nations share a collective responsibility to proactively detect and respond to biological threats in their own countries. Much remains to be done in this area. Strategies such as fever screenings were described as useful public confidence measures, but they were understood to be largely ineffective for detecting and isolating people carrying potentially dangerous diseases. Furthermore, agricultural and economic interests, institutionalized corruption, dependence on external resources, and the presence of internally displaced as well as refugee populations are additional factors that discourage or even overwhelm border control screening efforts in the region. Frequent natural disasters in the region have led to increases in the numbers of migrants and refugees, exacerbating these challenges. Resource challenges also undermine efforts for augmenting public health screening at national borders. Health security issues surrounding migrant workers have become more prominent in recent years, due in part to the challenges associated with enforcing border security protocols. Institutional corruption has also enabled illicit border crossings. As a result, verifying the legal status of migrant workers has proven difficult.

Given the heightened risks of infectious disease transmission in migrant and refugee groups, participants engaged in lengthy discussion regarding the benefits and challenges associated with screening migrants, commuters, and travelers as a means of impeding the movement of pathogens across highly porous borders. It would take considerable political will and new initiatives to truly secure the borders in many of the countries in Southeast Asia. This concern was echoed by a participant from Indonesia, where there are large numbers of internally displaced individuals, and by an American attendee, who pointed out that populations recovering from humanitarian catastrophes would be especially vulnerable to the impacts of a biosecurity emergency.

Participants also discussed the economic and security considerations associated with efforts to close borders in response to biosecurity threats. Regarding border closures, one participant recalled that during the 2009 H1N1 influenza pandemic, Singapore was able to slow travel and trade to some extent, but pointed out that as a city state and an island, the country could not close its borders completely. Such concerns were also raised during deliberations over the International Health Regulations (IHRs) in 2005. Given the tensions between maintaining secure borders and sustaining strong economies, participants from all 4 nations agreed that biosecurity constitutes a shared responsibility among regional and international partners. As one Singaporean pointed out, “It's impossible to stop a disease in one country from spreading to others. The responsibility doesn't fall to just any one country.”

2. Intersectoral and interdisciplinary boundaries between entities involved in biosecurity efforts impede national and regional responses to biosecurity threats.

Participants agreed that the health and security sectors in the 4 nations would benefit from increased coordination to prevent, mitigate, and respond to biosecurity threats. The numerous stakeholders, bureaucratic hurdles, and overlapping roles of government agencies have complicated responses to past biosecurity emergencies. Governments often lack policies for coordinating and integrating efforts between stakeholders, or are forced to develop them in the midst of a crisis, as they contend with the challenges of responding to complex biosecurity emergencies. Stakeholders include public- and private-sector players in the health, scientific, defense, intelligence, and law enforcement sectors; the research community; traditional and social media platforms; and members of the public. Additionally, participants noted that inadequate communication across sectoral lines during emergencies has created institutional silos and resulted in eroding public trust in government. Though the health and security communities—which, historically, have operated in their own silos—have made substantial progress in their ability and willingness to collaborate during biosecurity emergencies, there remain gaps in interagency communication and response.

In all 4 nations, entities share some responsibility for responses to a serious biological threat. These include: public health, health care, defense, the research community, law enforcement, intelligence, and the general public. The increasing diversity of these actors reflects the complexity of responding to biological crises. This complexity blurs intersectoral lines and challenges protocols for handling crises, sometimes resulting in disjointed and ineffective institutional responses to biological threats. Participants from all nations agreed that “we still have a long way to go” to achieve the kind of integrated, large-scale response required to handle future biosecurity emergencies.

One participant noted that confusion over agency roles and responsibilities during an emergency stems from disagreement over the definition of biosecurity itself: “When we use the term ‘biosecurity,’ there's a lot of confusion over what it means. Is it a health or defense sector issue? Many people don't like the idea of securitizing health. But [this work] is actually collective protection against a common threat. When we come at it from that angle, we can get people from different sectors to come to the table.” Participants also discussed how a lack of intragovernmental coordination often gives rise to complicated regulatory processes or duplicative efforts between institutions. One attendee remarked: “Things have improved today. We have gotten a lot better within our stovepipes, but it's not clear if we can coordinate effectively across sectoral lines.”

American participants described how regulatory tensions exist between the US Department of Agriculture and the Food & Drug Administration, which maintain oversight over poultry products and vaccines, respectively. This division of responsibility has complicated recent efforts to contain outbreaks of avian influenza across the country. Participants from all 4 nations shared examples of past challenges related to intragovernmental collaboration and communication, noting that the ministries of home affairs, health, and agriculture in their respective countries can have overlapping jurisdictions, which has led to difficulties in responding to past events.

A Malaysian participant raised the issue of further integrating the defense and intelligence sectors into biosecurity response efforts, citing the Nipah virus outbreak of 1998-99 as an example of how the responsibility of biosecurity emergency response cannot rest with a single health agency. There was wide recognition in the group that effective multiagency approaches are especially important for biosecurity threats, requiring close collaboration between law enforcement and public health authorities. Malaysian authorities are currently developing frameworks for handling the criminal and epidemiologic procedures required during a bioterrorist event. The Indonesian delegation noted that should such threats come to pass in Indonesia, their military and defense agencies would be best suited to lead the response with active participation from the public health sector. They also noted that Indonesia, which maintains a strong track record of handling terrorism writ large, is developing a national strategy for mitigating bioterrorist threats. A number of American participants believed that during future biosecurity emergencies, the Department of Defense (DoD) would likely continue to be involved, although it would not lead those efforts. Another American participant noted that DoD's capabilities in laboratory support, logistics, acquisitions, and research and development may prove more valuable during a crisis than the number of healthcare personnel it could provide.

Intersectoral tensions also exist between regulators and researchers in each of the 4 countries. A Singaporean attendee highlighted the importance of striking an appropriate balance between scientific self-governance and external regulation. A number of participants noted the importance of establishing and maintaining strong biosafety and biosecurity systems, particularly in high-containment labs. Participants discussed the possibility of equipping labs to monitor researchers and security personnel for insider threats, but thought that such a practice would likely be unsustainable in the long term. Some research communities have taken proactive steps to eliminate institutional and intersectoral silos. The University of Indonesia's Faculty of Medicine, for instance, collaborates with the Ministry of Health and 9 national hospitals on issues of biopreparedness and biodetection. Three of its labs serve as national reference labs for HIV, multidrug resistant tuberculosis, and extensively drug-resistant tuberculosis, while its Department of Microbiology serves as the designated regional lab for avian influenza and conducts sentinel surveillance for influenzalike illnesses. The university has also integrated a biosafety and biosecurity module into its clinical microbiology curriculum, which it uses to train outside groups and organizations.

Participants from all 4 nations jointly acknowledged the challenges that the public sector faces in engaging private-sector partners, but they emphasized the value of building such relationships. In Singapore, the private financial sector is generally well-resourced, but it remains vulnerable to the impacts of infectious disease. Following the SARS pandemic, Singaporean banks lost a lot of money and subsequently approached health authorities to conduct industry-wide exercises to prepare for pandemic events. Such successes have encouraged the Singaporean government to continue pursuing private-sector partnerships: “Once you get them interested, they have huge capacities to assist government agencies.”

3. Biosecurity threats that defy existing prediction and detection capabilities present the greatest challenges in terms of preparedness and response.

Participants from all 4 nations underscored the considerable threat posed by so-called “black swan” events ²¹ —rare, consequential, and unexpected events that could deal severe blows to the health systems, security capabilities, and social fabrics of affected communities. Previous “black swan” events, including the 1998-99 outbreak of Nipah virus, the Amerithrax attacks of 2001, the SARS outbreak of 2002-03, and the 2014 Ebola outbreak, galvanized public interest in preparedness and encouraged governments to be more proactive in their preparedness and response efforts. Dialogue participants noted several categories of biological threats that could have destabilizing impacts: emergence of new zoonoses at the human-animal-ecosystem interface, disease outbreaks de novo or following humanitarian catastrophes, and acts of deliberate bioterrorism. There was concern that refugee or migrant populations in the region would be particularly vulnerable to such threats and that disease could spread especially quickly among such groups. Concerns were also raised regarding “next-generation bioterrorism,” including the genetic manipulation of pathogens to increase their virulence and/or transmissibility. “Next-gen bioterrorism” could also include “gain-of-function” research involving pathogens of pandemic potential. Participants identified several technologies and capabilities required to counter an ever-evolving range of biological threats: field-deployable genetic tests, reliable diagnostics and screening strategies, enhanced surveillance systems and containment measures, rapid pathogen identification techniques, and new antibiotics and antivirals.

Dialogue participants raised and returned repeatedly to the topic of biological threats involving “unknown unknowns.” All participants felt that their countries are vulnerable to both newly emerging and bioengineered pathogens, and they expressed concern that current diagnostic tools will not be effective in providing early warning of such threats. Southeast Asian countries were severely affected by the SARS pandemic of 2002-03 and fear that another SARS-like disease could spread even more rapidly in the populated region before authorities could detect the outbreak and devise an effective response strategy.

A Malaysian participant suggested that the 4 delegations address the many limitations of current “early warning” systems. He noted that new pathogens, when tested with existing diagnostics, will result in many “negative samples,” and that governments require a strategy for resolving this issue. A Singaporean participant echoed this concern and agreed that current screening strategies may fail to provide early warning of a newly emerged threat.

The group discussed recent gain-of-function mutation experiments with pathogens that have pandemic potential. It was acknowledged that scientists would continue developing new techniques and experiments that could increase the lethality or transmissibility of pathogens. Participants recognized the challenges in both the science and security communities regarding how to manage such research endeavors, as well as how to create effective approaches for early detection of engineered pathogens, whether accidentally or deliberately released. Concerns were raised regarding “next-generation bioterrorism”—specifically, intentional genetic manipulation of pathogens to increase their virulence and/or transmissibility. Participants discussed whether an all-hazards approach to preparedness would be effective in the face of an “unknown unknown,” but they were not confident that existing preparedness structures would be sufficient to prevent or mitigate such threats. All agreed that much more thought and dialogue in this area are needed.

Attendees also discussed the challenges associated with investing in biosecurity prevention and response capabilities. Participants from Singapore, Malaysia, and Indonesia also highlighted the conundrum that they face when confronted with the issue of investing in biosecurity capabilities: well-resourced countries like the United States that invest considerable sums in research and development have brought relatively few medical countermeasures to market, so there are few perceived incentives for nations like Singapore, Malaysia, and Indonesia (and their entrepreneurs) to follow suit. Attendees from all 4 countries agreed that nations should explore new ways of incentivizing investment, networking, and sharing best practices in biosecurity among regional and international partners.

4. Regional coordination and information sharing during biosecurity emergencies are generally acknowledged to be desirable goals, but they remain challenging in practice.

Dialogue participants affirmed the value of regional coordination in the face of transnational biosecurity threats. However, all agreed that the lack of trust and a lack of effective working relationships between neighboring states can often preclude such cooperation. Though Singapore, Malaysia, and Indonesia are all members of the Association of Southeast Asian Nations (ASEAN) and understand the potential benefits of a regional approach to biosecurity, one participant stated, “We have not trusted our neighbors enough to prepare outside of our borders.” Another participant noted that when real biosecurity issues arise, “countries fall back on bureaucracies and national thinking” rather than turn to their neighbors to provide information or to request help. Participants from all 4 countries also discussed the very common phenomenon that takes place in intragovernment dynamics. Many countries, for example, are proficient at collecting information before and during biosecurity emergencies but often fail to share that information effectively among their own intranational agencies and stakeholders, let alone with other regional partners.

The organization of WHO regional offices in Southeast Asia contributes to the communication challenges between countries. Singapore and Malaysia belong to WHO's Western Pacific Regional Office, while Indonesia falls under the Southeast Asian Regional Office. This division has, in the past, complicated regional collaboration.

When asked about the potential for ASEAN to serve as an arbiter of future biosecurity-strengthening efforts in the region, some participants stated that their countries' participation in ASEAN has yet to significantly increase information sharing or regional coordination on biological threats, and that the outside perception of ASEAN's influence seems to be greater than its actual role in the realm of biosecurity. The organization has not developed a regional approach to biosecurity or biosafety, and countries do not jointly prepare for, develop common policies related to, or share information regarding biological threats through ASEAN. Participants agreed that the spirit of ASEAN in promoting a “one community” approach exists, but the organization currently does not have the unified political will to drive regional cooperation in biosecurity.

5. As biological threats continue to persist, emerge, and evolve, there is a need for new models of risk assessment, risk communication, and public engagement.

Participants examined the need for new models of risk assessment, risk communication, and public engagement to enhance responses to future biosecurity emergencies. The communication barriers that exist between scientists and policymakers affect countries' abilities to effectively prepare for biological threats. As one participant observed, “Part of our problem is the issue of how to inform leaders during a crisis. It takes effort to create products for a policymaker's decision-making process. Scientists don't like putting judgment on findings. We need better ways of getting information into the communication delivery mechanisms used to inform policymakers.” A Singaporean participant agreed, noting, “We as medical professionals can agree on certain measures based on scientific evidence. But for policymakers, it's going to be a question of rival epistemologies and sources of knowledge. NGOs and other groups have very different conceptions of public health and standards. Policymakers will have a hard time making sense of all this information.” Others pointed out that understanding a threat scientifically has not always equated to good decision making in a crisis, when political pressure is high.

Participants examined the challenges associated with evaluating information about biosecurity threats, noting that while technology has facilitated information sharing, authorities lack guidance for accessing and using such information to respond effectively to biological threats. An American participant remarked, “There will not be less information in the future, but much more. So, how do we manage it? There is great faith that we will automatically know what to do with big data. But we haven't thought enough about how to build systems to manage the data we have and will continue to generate. To do so will require enormous political will. Information already moves across agencies, institutions, and borders, albeit very inefficiently.” Additionally, attendees agreed that different sectors must make efforts to learn from each other, considering that they are likely to take different approaches to making sense of information about a given threat.

In addition to exploring varying biological threat perceptions between different sectors, participants also examined how such perceptions might vary in different ethical and political contexts. A few participants suggested drawing from the risk assessment methodologies used in the nuclear security world, but an American participant countered this idea, contending that biosecurity is not analogous to nuclear arms control given the range of sources of risk and the very different responses that would be required. This participant also asserted that nations think about health differently than they do about nuclear arms, citing cooperation among Palestine, Jordan, and Israel on issues of healthcare delivery despite ongoing conflict in other realms.

Gaps in institutional approaches to risk assessment and mitigation often translate into ineffective public engagement during emergencies, as illustrated by the participants' debate over the merits of screening travelers for disease. Some asserted that such measures engendered public confidence in government efforts to contain and counter biological threats, but others maintained that these practices were largely inefficient and ineffective. One Singaporean participant asserted, for example, that “a lot of the measures we try to put out are designed for a very singular purpose. For example, if I know the US is screening travelers for Ebola, I could take a fever reducer and not admit to having a fever, so the system has failed. You can have the best screening tools, but you have to have public cooperation as well. We need to ask how to minimize individual errors in reporting illness.” Participants also underscored the importance of tailoring public health interventions to the cultural context in question. One Indonesian participant noted, “Cultural competence—or incompetence—in biosecurity is a huge issue. We found a huge cluster of avian influenza in a part of Indonesia where, after a festival with a close human-chicken interface, 9 people became sick. There may also be bats in Indonesia infected with Ebola, but these bats are traditionally consumed as a delicacy. We need a lot of capacities and efforts to improve awareness among the public, since such traditions have gone on for many years.” Others maintained that even excellent communication and cultural competence cannot overcome the overall lack of scientific awareness and understanding among the general public, a fundamental challenge that exists in wealthy and resource-poor nations alike.