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Almost a century ago, a new and deadly strain of influenza spread around the world, shutting down schools and businesses and filling hospitals well beyond their capacity. In the end, the 1918 flu pandemic claimed the lives of approximately 50 to 100 million people, and it infected about one-third of the global population. Since then, medical care has vastly improved, and science has made major gains in vaccines and medicines. Yet the potential remains for a lethal strain of influenza or other contagious pathogen to overwhelm global health care systems by spreading at a rate that outpaces our ability to respond. In such a calamitous scenario, neither the United States nor other countries would be well enough equipped to contain it, increasing the potential for a true national or global catastrophe.
Consider the current H7N9 bird flu epidemic in China. It has infected more than 1,600 people since 2013, with a fatality rate of 40 percent. Although humans have contracted it mostly through contact with infected poultry, it is possible that limited person-to-person transmission has taken place but has yet to be detected. The great concern at the moment is that the virus will adapt, allowing for more efficient transmission; this would enable it to transform from a local outbreak to a global one.
Modern conditions make the scenario of a global pandemic more likely. Humans are encroaching on animal environments, raising chances for pathogens to adapt from animals to people. An increasing share of the planet lives in megacities, heightening the likelihood of person-to-person transmission of pathogens. The movement of people and microbes around the globe is more efficient than ever. The recent outbreaks of SARS, MERS, and Ebola are only small glimpses of how quickly a deadly virus can spread. Imagine if it were to happen with an even more fatal and more contagious pathogen.
Beyond these naturally occurring events, there is also the potential for terrorists or rogue nations to deliberately release dangerous microbes and trigger lethal epidemics or even pandemics. It is easier and cheaper than ever to create biological weapons. New bioengineering tools will make possible various kinds of previously unforeseen changes to pathogens. They could be manipulated to be more communicable among humans or more resistant to vaccines. Animal viruses could be modified to infect humans. Benign viruses could be engineered to be lethal or to transmit cancers.
So what has the U.S. government done to prepare for such scenarios? Since 2003–4, when the H5N1 bird flu spread around the globe, the American response to these health threats has been to establish a range of preparedness programs intended to prevent and respond to pandemics and other biological dangers. For instance, the U.S. government funded research by the National Institutes of Health (NIH) into threatening pathogens, which is crucial for the development of new medicines and vaccines. To aid this effort, the government created a body called BARDA (Biomedical Advanced Research and Development Authority) to focus on finding treatments. The federal government fortified its Strategic National Stockpile, a storehouse for vaccines, antidotes, antibiotics, and other critical medicines, and developed procedures for distributing these supplies to cities in the event of a crisis. It launched an initiative at the Food and Drug Administration to help untangle the regulatory issues that complicate the delivery of these medicines and vaccines to the public. It also established a range of preparedness programs at the local and federal levels and strengthened their ability to detect threats early on and issue appropriate warnings.
Unfortunately, President Donald Trump has not indicated so far that his administration takes this issue seriously. Initially, his 2018 budget proposed slashed funding for such programs by nine percent, or $1.25 billion, from the preceding year, which would be the largest reduction in over a decade. If this budget had been enacted, it would have imposed a 13 percent cut to the Centers for Disease Control and Prevention’s (CDC) preparedness and response programs, an 11 percent cut to the hospital-preparedness program, and hundreds of millions of dollars in cuts to state grants from the Federal Emergency Management Agency. Other cuts would have hurt or entirely eliminated related programs at the Department of Homeland Security, the NIH, the FBI, and USAID, among others. Fortunately, Congress reversed many of the proposed cuts during its appropriations process.
Although the civil-servant workforce has continued to make progress in important programs, it remains to be seen whether the administration’s political leadership will push biosecurity efforts forward in a meaningful way. In the months ahead, there are four elements to look for in evaluating just how seriously the Trump administration will pursue these issues: its budget priorities for the new fiscal year, its impending biodefense strategy, its approach to overseeing research on novel and highly dangerous pathogens, and its level of engagement in the Biological Weapons Convention (BWC) process.
In its 2019 budget proposal, the administration will have an opportunity to support programs that prepare hospitals to care for large numbers of infected people. It could seek funding for public health programs to detect and respond to new outbreaks. It can request money to help accelerate research and development of new medical countermeasures for epidemic threats, including continued research into a universal flu vaccine. It can use the budget to support law enforcement and intelligence efforts to find and prevent threats as well as forensics programs aimed at identifying those responsible for biological attacks. Furthermore, it can back programs intended to strengthen Defense and State Department efforts to address biological threats overseas. It is important that the administration consider these options carefully. Even if Congress can again rescue key programs next year, an administration budget proposal that cuts initiatives designed to protect against pandemic and biological risks will serve as a statement of the administration’s priorities and values—one that will resonate among professionals working diligently on these issues.
One program that should be a funding priority is the Global Health Security Agenda (GHSA). This multinational program was established in 2014 and now involves over 50 countries that collaborate to enhance the detection, prevention, and response to biological threats. To this end, it has provided funding and technical assistance to build labs for disease detection, to train public health officials, to establish emergency operation centers, and to improve vaccination programs and other key capabilities needed to prepare for and respond to biological threats in countries around the world. The U.S. government initially supported the GHSA with a pledge of more than $1 billion. But that source of money is quickly disappearing, and without a 2019 budget commitment or a supplemental bill sometime over the next year, U.S. programs supporting the international initiative will soon need to start shutting down. Although several administration leaders—including the CDC director, the secretary of State, and senior officials from the National Security Council—have made clear that they support the GHSA, it has not been confirmed that sufficient funding for the effort will continue beyond its initial allotment.
The yet to be released national biodefense strategy, which was called for in the 2017 National Defense Authorization Act, is required to address natural, deliberate, and accidental pandemic threats, international and domestic. The administration has publicly committed to establishing this strategy. But the key here, too, will be whether the administration provides the financial resources to successfully implement it. Otherwise, it will be a plan with a set of unreachable goals.
Another test of the administration’s commitment is its approach to certain types of scientific research that can increase pandemic risks. In the last month of President Barack Obama’s administration, the White House Office of Science and Technology Policy published guidance on how the U.S. government should handle the creation of novel and dangerous pathogens for research purposes. For example, it advised scientists to conduct special biosafety reviews and risk-benefit assessments for experiments that could jeopardize public health. Proponents argue that such efforts are worth the risk because they help prepare for pandemics. Opponents, on the other hand, are concerned that this type of research could lead to the accidental or deliberate spread of pandemic pathogens. The Obama administration’s guidance helped clarify the debate and proposed additional controls. The Trump administration, however, has so far remained silent on the issue.
A final indicator of the White House’s commitment to preparing for pandemic threats is how it deals with the BWC, the international treaty banning biological weapons. The vast majority of countries are parties or signatories to it, and the agreement offers the most significant global norm against biological threats. Last year’s Review Conference was a setback, with no forward movement in considering new and emerging biological risks. When the state parties convene in December, the international community will need to push for progress on this front. But it will be difficult to do so without key U.S. representatives. At the U.S. State Department, offices that cover issues related to the treaty—and other key arms-control agreements—still await senior appointees. It is important for the Trump administration to fill these posts, installing leaders who will champion vital interests within the U.S. government and in international channels.
The administration has opportunities to make substantial headway on pandemic risks at the national and international levels. Its budget, biodefense strategy, approach to high-consequence research, and engagement on the BWC are all key. The means exist to diminish the spread of pandemics—through science, intelligence, medical and public health preparedness, diplomacy, and smart governance. For the national security and health of the country, the Trump administration should fully commit to these efforts.
Correction Appended (November 22, 2017): An earlier version of this article incorrectly stated that the H7N9 virus had infected more than 1,600 people this year when it had in fact infected that amount over the last four years.