Crucial Steps Forward: the National Academies of Science’s 2018 Study, “Enhancing Global Health Security through International Biosecurity and Health Engagement Programs”

By: Alexandra Williams, GMU MS Biodefense ‘18

This past Monday, July 16, 2018, the National Academies of Sciences, Engineering, and Medicine (NASEM) held an important meeting at their headquarters in Washington, D.C. At this meeting, they discussed with U.S. government security and health agencies the future of global health security, disease surveillance, and biosecurity, as well as the challenges and gaps that exist in meeting international and domestic health security missions and mandates. This second and final NASEM committee public meeting was a follow-up to their first meeting in April 2018. In these two meetings, NASEM was charged with examining and better understanding the Cooperative Biological Engagement Program (CBEP) of the U.S. Department of Defense (DoD)’s Cooperative Threat Reduction (CTR) program—CBEP being a forefront program for biosecurity and health security—and other U.S. government stakeholders in health security. An overview of the July 16, 2018 meeting can be found here. Additional information can be found via the National Academies of Sciences project information page.

As challenges continue to arise in timely and accurately detecting and responding to disease outbreaks—as we saw in 2014 with Ebola in West Africa, and in 2016 with Zika—U.S. health and security agencies are working to better meet these challenges, and examine how they need to evolve to meet unforeseen hurdles that lay ahead. This NASEM study is timely and critical because it addresses and examines these issues head-on, and will serve as the launch point for how the U.S. can rethink, reshape, and improve its already critical and successful work in biosecurity and global health security.

Background of CBEP and CTR
To better understand the crucial nature of this NASEM study, the following is provided as a brief background of the CTR and CBEP programs and where they stand today regarding health security. The DoD’s CTR program has existed since the 1990s at the fall and breakup of the Former Soviet Union (FSU). Their mission and purpose was to ensure global safety and prevent the unfettered proliferation of Soviet nuclear, chemical, and biological weapons, technology, knowledge, and scientists throughout the newly created states that once constituted the Soviet Union, as well as the world. As times and international challenges have shifted to also include infectious disease outbreaks—particularly seen with the Ebola and Zika outbreaks—the CTR program and it’s DTRA’s subunit, CBEP, has evolved to meet these challenges, particularly in aiding partner countries in securing diagnostic, research, and reference labs and lab personnel, and ensuring safe handling of and research on disease pathogen samples. CBEP also helps partner countries build enduring capabilities to detect, report and respond to disease outbreaks at their source. This is important to help mitigate and prevent epidemics and pandemics. Despite their success in these endeavors, CBEP faces challenges in how to balance both missions.

As listed below, several challenges to CBEP’s work and U.S. health engagement and biosecurity were highlighted through this NASEM study series, including CBEP balancing both security and health missions, making sure implementation of CBEP work is durable and sustainable, and can work with partner country constraints and needs, and making sure cooperation across U.S. and international agencies is smooth, effective, not duplicated, and engages the correct partners in the correct way.

Challenge 1: Balancing Security and Health Missions
A major challenge CBEP faces is balancing both its traditional and essential security mission of biosecurity and biosafety with its global health mandate to support disease detection capability building. A constraint CBEP faces in this balancing act however, is that they are a security agency and have Congressional appropriation and legal constraints on their line of work. CBEP needs to stay within the security sector. Although CBEP has been effective and aided countries in building disease detection capability, the work of building disease detection and particularly response, lays largely within and the construction of more robust public health systems and sectors. To better understand this problem, the NASEM committee also engaged other U.S agencies and program stakeholders from CBEP, the Office of the Secretary of Defense (OSD) Policy, scientists, and contract implementers on the ground in CBEP partner countries to expand upon this issue.

For example, part of CBEP’s legal constraints come from OSD Policy—the group that informs and maintains all DoD policy, which CBEP follows. OSD Policy must ensure that DoD, DTRA, and CBEP, follow and support the U.S. National Defense Strategy and National Biodefense Strategy, and that their work can be justified under these strategies. DoD, DTRA, and CBEP’s work supports these strategies through their efforts to mitigate disease and biosecurity threats around the world, which makes it safer for the U.S. military abroad and U.S. domestic population as well. Their work, however, is always subject to constraint if it cannot be justified under these policies and policies set for by the Secretary of Defense.

A subsidiary issue within this tug of war between security and public health is also displayed in how CBEP coordinates with other U.S. government agencies and programs. CBEP efforts have expanded from its traditional security work within the FSU to work in places such as sub-Saharan Africa and Southeast Asia, that have higher public health system needs. As a result of this expansion, CBEP has varied their approaches in aid based on the security needs of the partner country. These needs can range anywhere from Crisis Management, to building Emergency Operation Centers (EOCs), identifying partner country priorities in addressing country concerns and threats, or lab renovation and advisory support to partner country legislative processes to implement biosecurity and disease detection mechanisms. If priority areas for partner countries stretch more into science and public health, such as training staff on disease case definitions and how to properly diagnosis diseases cases, CBEP will enlist other agencies to address those needs, such as the U.S. Center for Disease Control and Prevention (CDC) on Field Epidemiology Program Training (FEPT), the World Health Organization (WHO), and U.S. Agency for International Development (USAID).

Challenge 2: Durability and Reality on the Ground
CBEP project implementers noted that the topic of biosecurity and disease detection capability and capacity building must be long term investments and not just a one-time action with unformalized or little follow-up or support. Sustainability is the term often used to describe this need for longevity and if the program and projects are successful. When asked by NASEM committee members what “sustainability” looks like however, the project implementers and agency representatives alike answered that it should rather be look at as durability, ownership, and responsibility, rather just sustainability. For example, one project that was being implemented in Kenya to help build better biosecurity work and infrastructure. Upon examining one lab in rural Kenya, which is already a low-resource country, there was not clean nor properly running water that would allow the lab personnel to properly clean themselves after working with pathogens, let alone wash nor clean instruments and protective equipment used during procedures and tests. Not only do U.S. biosecurity and disease detection efforts need to be durable (will they be used properly by the partner country when an outbreak occurs?)—but the efforts and projects need to understand what the partner’s needs, expectations, and resources are, but also what is already there or not there, and if the systems that the implementers need are in already place. Ultimately, building biosecurity capabilities in this rural part of Kenya was hampered because there was no running clean water.

Additionally, implementers urged that ownership be a key part of these projects, wherein partner countries not only have buy-in from the top ministries down to the local implementer level, but also everyone that needs to be involved in these processes must be included. There needs to be an incentive for partner countries to take on such projects/research, and that is met through making sure implementers and the larger CBEP, DTRA, and DoD understand partner needs, priorities, and values. It should not be a hurried process, and should be repeated engagements. There needs to be adaptation to each partner country and local level context, and a sharing lessons learned with all those involved in the process, on repeated basis.

Challenge 3: Cooperation, Coordination, and Communication
            A third major issue addressed at the NASEM meeting was the need for better communication and coordination across U.S. government agencies, interagencies within the DoD, and with partner countries across the world. Several incidences were provided to the NASEM committee wherein agency implementers were on the ground, in partner countries, starting the collaboration process, only to find that several other U.S. government agencies such as the CDC and USAID and their teams were already there working, and these implementers had no prior knowledge of them being there. While this would appear to be a simple communication fix, it is rather difficult to coordinate the efforts of multiple agencies and teams, let alone gathering together multiple partner countries to one meeting. Despite this complexity, it was iterated over and over at the two NASEM study meetings that this collaboration and coordination needs to be handled and conducted more effectively, and this is already happening, but needs much improvement.

As the NASEM study will now close to the public, their work with U.S. security and health agencies and stakeholders is instrumental in the forward movement of global health security, and will help be a guide for CBEP’s work over the next five years.