Critical Condition: Healthcare and Public Health Preparedness for Pandemic Response and Health Security
By Frank G. Rando, CBRNE - Protective & Biomedical Countermeasures SME, University of Arizona
The brilliant Nobel laureate and microbial geneticist, Joshua Lederberg, Ph.D. said it best when he stated, "The greatest threat to mankind ... is the virus". What has been dubbed "The Great Coronavirus Pandemic of 2020" has indeed demonstrated that an entity which is one billionth our size can decimate the human population on a global scale.
The SARS - CoV-2 virus is a novel Coronavirus, and a close cousin of the SARS - 1 virus which also originated in China and caused severe febrile respiratory illness in 2003 and caused acute respiratory failure which overtaxed the healthcare infrastructure in Guangdong Province, China, Toronto, Canada, and several other countries. By September 2003, there had been 8,098 cases and 774 deaths reported in 29 countries. SARS - COVID-19 proved to be more than a crisis or emergency. Its impact has been catastrophic and historic rivaling the death rate of the 1918 Spanish influenza pandemic. Over the years, epidemics and pandemics have impacted every sector of society and killed millions around the world.
Emerging and re-emerging infectious diseases are a clear and present danger to the health, security, and prosperity of global populations. Yet, in the U.S., and other countries, the formal recognition of infectious diseases as a security threat did not begin to take form until the 1990s.
Generated and sustained by the HIV / AIDS pandemic, the emergence of Ebola, the reemergence of cholera, the onset of drug - resistant tuberculosis (TB) and other infectious diseases, President Bill Clinton and his Administration issued an assessment in 1996 titled " Addressing the Threat of Emerging Infectious Diseases." The Clinton White House's Presidential Decision Directive (PDD) called for reinforcement of the national bio surveillance system, building a global surveillance and response system, and expanding the mandate of the Department of Defense (DoD) to enhance and improve protective measures for civilian populations.
Also, during the time, the realization that biowarfare, bioterrorism and biocrimes were realistic and feasible threats that could be carried out by nation - states and various terrorist factions led to placing biological threats high on the list of priorities. The year 2000 initiated greater political attention to the relationship of health and international security. In January 2000, the US - based National Intelligence Council released a report titled “The Global Infectious Disease Threat and Its Implications for the United States.”
This report addressed concerns by U.S. government officials that the spread of infectious diseases, whether natural or intentional could severely impact health, economics, and national security. This document affirmed the U.S. intelligence agencies' interest in including infectious diseases as viable nonconventional threats to homeland defense and national security.
On April 29, 2000, the Clinton White House officially recognized infectious diseases as a threat to U.S. national security. In 2002, President George W. Bush released the National Security Strategy (NSS) which was heavily influenced by the 9/11 terrorist attacks and the anthrax letters disseminated via the U.S. Postal Service system in October 2001. In this document, medical preparedness for bioterrorism threats and public health and health promotion are certainly mentioned, briefly but no relation is implied regarding security. The link between infectious disease and global health security is missing.
During the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) -1, the international community was threatened and challenged by both SARS and the public health crisis posed by Highly Pathogenic H5N1 Avian Influenza (A1) in East and Southeast Asia. The Bush administration was concerned regarding the potential spread of A1, which spurred a flurry of governmental activity leading to the development of pandemic preparedness plans as well as an “all- hazards “approach to the US preparedness framework.
In addition, these efforts were enhanced with the establishment of the International Partnership on Avian and Pandemic (IPAPI), in 2005, a U.S. – led effort to strengthen global bio surveillance and response and to mobilize resources.
By 2006, the White House released an NSS that included more language and emphasis on both biological weapons and emerging biohazardous threat agents. The updated strategy explicitly mentioned the need to improve capacity to detect and respond to biological attacks, as well as the need to secure dangerous pathogens, fortify global bio surveillance, develop medical countermeasures, and improve public health infrastructure – all in support of countering a biological attack. When referencing naturally occurring pandemics, the strategy declares that pandemics pose “a catastrophic challenge to national security with risks to social order". In 2009, President Barak Obama had to face an evolving pandemic of H1N1 influenza. The Obama Administration eventually released the 2010 version of the NSS, which further solidified the health- security relationship. In September 2011, the importance of health security was catapulted to new heights.
Within the next few years, the Obama administration worked to develop the Global Health Security Agenda and contributed to projects, like the Global Health Security Initiative. The Administration’s final NSS listed severe global infectious disease outbreaks as a top strategic risk to the United States.
How does health impact national security? There are both direct and indirect connections between infectious diseases, national and international security. The most obvious are the proliferation and use of strategic militarized biological agents or the intentional dissemination and spread of disease among specific population targets. The impact of epidemics and pandemics on military personnel assets can leave nations vulnerable to attack. Military readiness, troop mobilizations and deployments can become severely affected and disabled greatly in their fighting strength and capabilities. Prior to World War II, infectious diseases outweighed battlefield injuries in the causes of morbidity and mortality. Even to this present day, infectious diseases impact troop readiness and effectiveness worldwide, and account for more hospital admissions than injuries and wounds during military deployments.
As a result, national military biomedical research and development resources and assets have been vastly expanded, as have building global diagnostic laboratory capacity, disease surveillance infrastructure and vaccine development. Indirectly, infectious diseases threaten national security by creating crises and emergencies in supply and distribution chains, economic upheaval, social disruption, panic, and civil unrest as well as mass traumatic stress.
Clearly, to prevent, mitigate and effectively respond to the evolving spectrum of health security threats posed by infectious and biohazardous threat agents, nations must invest greatly in medical and public health preparedness efforts. Medical defense against global infectious disease threats requires robust, highly prepared, and responsive health care delivery systems and public health infrastructure.
Planning and preparedness are key elements that must be prioritized accordingly and afforded the utmost in funding and resources. Efforts, such as training, education, exercises, and national strategic stockpiles including medical supplies, equipment and pharmaceuticals must be consistent, ongoing, adaptable, and readily available. Stockpile assets must be regularly audited, rotated, and replenished. Critical components of these assets should be strategically pre- deployed to towns, municipalities, health departments and healthcare facilities (HCFs). Local, state, regional, national, and international healthcare - medical, and public health strike teams must be trained and ready to rapidly deploy to affected areas with short notice. Vaccine production capacities and capabilities must be prepared to meet the challenges of novel pathogens and variant strains and be able to ramp up the availability of vaccines. Medical resources such as mechanical ventilators and other critical care equipment must also be rapidly deployable to hot areas as these items reach critical use levels quickly, as happened with COVID-19, where medical staff were placing 4 patients to share one ventilator. This is totally unacceptable. Appropriate triage protocols to determine scarce resource allocation must be in place.
In short, “Stuff, Staff and Space are the three main and generic cornerstones of medical surge capacity and capabilities at HCFs. Dependable, accurate and updated public information and evidence-based risk communication efforts are essential. Behavioral health assets need to be integrated into the healthcare and public health emergency management efforts to address both pre-existing and event induced behaviorally health issues, such as traumatic stress.
Diagnostic laboratory capacity and newer detection and diagnostic technologies such as saliva-based PCR testing must be integrated into strategic planning, preparedness and medical response to public health emergencies involving infectious diseases.
In the U.S., Homeland Security Presidential Directive 21 (October 2007) defines four critical areas of medical/ healthcare and public health preparedness:
- A robust and integrated bio surveillance system.
- The ability to stockpile and distribute medical countermeasures (MCMs).
- The capacity to engage in mass casualty care in emergency situations.
- Building resilient communities at the state and local levels.
The looming mosaic of infectious disease threats that can induce worldwide morbidity and mortality and destabilize entire nations, continues to unfold. We must learn from the deadly and tragic legacy of COVID-19. We must continue our vigilance and be prepared to meet the challenges posed by the next pandemic.
Author: Frank G.Rando
Frank G.Rando is a clinician, educator, researcher, author, first responder and Subject Matter Expert in crisis, emergency and disaster management, medical management of CBRNE and hazardous materials casualties, emerging infectious diseases, pandemic planning and preparedness, tactical, disaster and special operations medicine and environmental health and safety.