­­The Hidden Pandemic: COVID-19’s Impact on Antimicrobial Resistance

By Theresa Hoang, Biodefense MS Student

Introduction

The COVID-19 global pandemic has threatened public health security by adversely altering the health of patients and overwhelming hospital systems throughout the world. Not only is COVID-19 a global health threat, but antimicrobial resistance (AMR) is a public health crisis too. AMR happens when microbes become resistant to antimicrobials that are designed to kill them.[1] AMR contributes to healthcare-associated infections (HAI)­ in patients, which spreads within healthcare facilities and throughout the community and environment.[2] The CDC reports that “each year in the U.S., at least 2.8 million people are infected with antibiotic-resistant bacteria or fungi, and more than 35,000 people die as a result.”1 AMR is a serious public health concern, especially during the pandemic, because experts have noted that COVID-19 may have reversed the progress on reducing AMR by creating a “perfect storm” for antibiotic-resistant infections in healthcare settings.[3] How has the COVID-19 pandemic impacted AMR in clinical patients, and why is it important? This issue is important because it affects patients, who are undergoing antibiotic treatments, and healthcare systems that are trying to prevent the spread of AMR. The current literature has discussed extensively the direct and indirect effects of the COVID-19 pandemic on AMR. A group of authors focuses on the increase of secondary drug-resistant infections and how they are affecting COVID-19 patients. Another group discusses the deterioration of healthcare systems allowing AMR transmission to escalate. Other authors analyze the disruption of antibiotic stewardship and its adverse effects during the pandemic. To fight against this growing pandemic, patients should work together with their healthcare providers to learn about the troubling effects of AMR and how to prevent it from spreading by practicing enhanced antimicrobial stewardship.

Secondary Drug-Resistant Infections from AMR

The surge in AMR during the pandemic has resulted in a rise of secondary drug-resistant infections. The three drug-resistant microorganisms that will be discussed are methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacterales (CREs), and Candida auris.

Scanning Electron Micrograph of MRSA (from CDC)

Methicillin-resistant Staphylococcus aureus

MRSA is commonly spread in healthcare facilities and communities, and it can cause staphylococcus infections that are usually difficult to treat because of its resistance to some antibiotics.[4] Segala et. al explain that, during the pandemic, MRSA co-infections have increased significantly in COVID-19 patients who were admitted to intensive care units (ICUs).[5] “Up to 86.4% of all COVID-19 patients admitted to the ICU received a wide spectrum antibiotic therapy,” which helps treat against a vast majority of co-infections, including MRSA.5 However, exposing patients to these unnecessary antibiotics in a combination therapy can induce AMR. In another case study completed in Italy on mechanically ventilated patients, researchers compared the proportion of ventilator associated pneumonia (VAP) due to MRSA, between COVID-19 patients and non-COVID-19 patients.5 They found VAP rates were significantly higher in COVID-19 patients due to receiving a broad spectrum antibiotic therapy. Their findings also suggest there is higher rate of MRSA colonization and environmental contamination in COVID-19 ICUs.5 MRSA has not only evolved to become more resistant to antibiotics, but it continues to spread and colonize in healthcare facilities and other communities, in addition to infecting COVID-19 patients at increasing rates.

Infographic of the Risk of CRE Infections (from CDC)

Carbapenem-Resistant Enterobacterales (CREs)

Carbapenem-resistant Enterobacterales (CREs), formerly known as CR Enterobacteriaceae and nicknamed “Nightmare bacteria,” are a large group of different types of Gram-negative bacteria, such as Escherichia coli (E. coli) and Klebsiella pneumoniae, that commonly causes multiple infections in humans and in healthcare settings. CREs also develop resistance to a group of antibiotics called carbapenems.[6] CRE infections are spread from person-to-person by infecting or colonizing people (without causing infections or symptoms), specifically contact with wounds or stool, and through medical devices that have not been properly cleaned.[7]

CREs are a threat to public health because they are difficult to treat and are resistant to almost all available antibiotics.6 Their resistance comes from producing carbapenemases, which are enzymes that spread to other germs and cause resistance in carbapenems, rendering them ineffective.4 The CDC states that high levels of antibiotic resistance in CREs necessitate more toxic and less effective treatments, harming patient outcomes.7

Studies have shown that CRE infections are increasing among COVID-19 patients. According to a recent review on CRE infections during the pandemic, “secondary infections caused by CR-Klebsiella pneumoniae (Cr-Kp) show high prevalence of co-infection in COVID-19 patients.”5 Researchers have noticed that CR-Kp colonization and infections were associated with a high mortality rate in COVID-19 patients and increased use of antimicrobial agents.5 This represents a significant challenge for both infection control and clinical practice because as new antibiotics continue to be overused, CRE infections continue to rise and manifest in healthcare facilities and throughout communities.

Candida auris on CHROMagar Candida after Salt Sab Dulcitol Broth enrichment (from CDC)

Candida auris

Candida auris is an emerging multidrug-resistant (MDR) yeast that brings severe infections and spreads easily between hospitalized patients and nursing home residents through skin-to-skin contact.4 It can also cause invasive infections by entering the bloodstream, and even cause wound and ear infections.[8] Moreover, C. auris can trigger outbreaks in healthcare settings by contaminating hospital surfaces and medical equipment, especially if they are used for COVID-19 critical care. This indicates that patients are at high risk of C. auris colonization and infections.[9]

C. auris is an extreme public health threat to communities, and it has become a more serious concern during the pandemic. Since some patients with severe COVID-19 have required intubation and other invasive devices, they are put at a higher risk of C. auris infections; the pandemic may have contributed to an increase in these cases.[10] In another report from the CDC, 39 cases of C. auris have appeared in Florida during the pandemic that were attributed to “unconventional personal protective equipment (PPE) practices and environmental contamination.”[11] Risk factors like these have caused critically ill COVID-19 patients with C. auris infections to stay longer at ICUs and require antifungal drugs for long periods of time.5 This proves that improper and extended use of PPE has played a role in self-contamination and transmission of C. auris among COVID-19 patients.5 To prevent C. auris from spreading, especially among COVID patients, it must be detected immediately and IPC practices must be implemented.

Overall, the three different pathogens share a common goal, which is to induce AMR and increase secondary infections among patients. These drug-resistant microorganisms are a few out of the many other agents that have impacted patients during the COVID-19 pandemic.

AMR Implications for Healthcare Systems

Additionally, during the COVID-19 pandemic, the exacerbation of healthcare systems has increased transmission of AMR. Studies have shown that the rise of AMR in healthcare facilities was caused by a variety of factors, such as prolonged stays in the ICU,[12] overcrowding,[13] “contaminated PPE, increased workload among hospital staff, and prolonged glove usage.”[14] Furthermore, “shortages of PPE, staff shortages, fatigue, and deployment of inexperienced staff members with only basic training” are other factors that may contribute to the increased risk of AMR.[15] These determinants not only led to a surge in AMR, but also increases in morbidity, mortality, and healthcare costs for patients.14

To reduce AMR from escalating any further, Rawson et. al propose that social distancing, increased hand hygiene practice, and pre-emptive discharge of patients and cancellation of routine procedures are potential interventions that healthcare systems can implement during the pandemic.13 In addition, Knight et. al mention “enhanced infection prevention and PPE usage and control measures, in response to the COVID-19 pandemic, will help prevent infections and limit the spread of AMR.”15 Therefore, better health infrastructure and enhanced IPC measures set in place mean minimization of AMR amongst patients.

Disruption of Antimicrobial Stewardship

Disruption of antibiotic stewardship is another problem that needs to be addressed with the rise of AMR driven by COVID-19. Antimicrobial stewardship (AMS) is “promoting the appropriate use of antimicrobials, improving patient outcomes, reducing AMR, and decreasing spread of infections caused by multidrug-resistant organisms (MDROs).”[16] However, AMS has not been emphasized enough during the pandemic. For instance, researchers are concerned that increased antibiotic use during the pandemic could enhance the long-term threat of AMR.[17] Popescu states that “misuse and overprescribing of antibiotics, poor stewardship, and generalized lack of surveillance,” are some reasons why AMR continues to be a public health problem.[18]

Moreover, misinformation on antibiotic use (whether it is low public awareness or increased consumption of them) is another factor that may enhance the rise and spread of AMR.[19] For example, Arshad et. al explain that 44% of respondents to a population survey in Australia assumed that antibiotics could treat or prevent COVID-19, and university students in Jordan who believed in conspiracy theories around COVID-19 also thought antibiotics can cure it.[20] Additionally, clinical uncertainty about the disease process and pathology of an infection can increase antibiotic use. “When clinicians do not have all the necessary information to truly understand what is happening to the patient, they tend to prescribe more antibiotics.”17 Altogether, these factors can increase the spread of AMR and disrupt AMS.

In contrast, Toro-Alzate et. al argue that “telemedicine consultations could be useful to educate patients on improving antibiotic use.”19 But at the same time, they mention how telemedicine can also increase over-prescription of antibiotics due to physicians’ decision making.19 Because they are not with patients in-person, healthcare providers tend to misdiagnose more often and not order as much lab tests with these remote services.

#BeAntibioticsAware: Do I really need antibiotics? (from CDC)

Another AMS strategy is using social media to manage online media campaigns that combat misinformation of antibiotic use. Some organizations, such as WHO and Nigeria Centre for Disease Control, correct antimicrobial misinformation and discuss ineffectiveness of antibiotics as a treatment for COVID-19 by using their digital platforms.20 Taking everything into consideration and how the pandemic impacted the public health community, AMS must be further improved and emphasized among patients and healthcare providers to reduce AMR.

Are Hospital Stays of COVID-19 Patients (with AMR) Longer than Those of Non-COVID Patients?

The literature does not yet analyze the question of whether the length of hospital stays for COVID-19 patients with AMR are longer compared to hospital stays of non-COVID-19 patients. One study has claimed that AMR has led to adverse consequences for patients, including “more prolonged hospital admissions.”[21] Srinivasan mentions and compares the patient discharge data and AMR rates between patients with influenza-like illness and COVID-19.11 Yet, the data between patients with flu and COVID-19 were collected at different time frames.

Source: CAPT Arjun Srinivasan, MD, USPHS (CDC PowerPoint)

In the current literature, there is no evidence and comparison recorded between hospital stays of COVID-19 and non-COVID patients during the pandemic, over the same time period. Considering that the surge in AMR has been driven by the pandemic, and that it has caused ill patients to stay at hospitals based on their conditions, it is hypothesized that COVID-19 patients with AMR have stayed at the hospitals much longer than non-COVID patients during the pandemic. To examine this gap, further research needs to be conducted by attempting to gather data through a survey and compare hospital stay rates between COVID-19 and non-COVID patients from different hospitals in the Northern Virginia area. This would also explore the critical steps needed to treat patients with AMR and to mitigate its transmission before discharging patients.

Conclusion

Antibiotics save lives but any time antibiotics are used, they can induce side effects and lead to AMR.4 Along with the rise in AMR, COVID-19 has compounded this issue, creating more challenges for patients and hospital systems to overcome. The surge of secondary infections among patients, the exacerbation of hospital infrastructures, and the disruption of antimicrobial stewardship are the results of COVID-19’s impact on AMR.

Bibliography

Arshad, Mehreen, Syed Faisal Mahmood, Mishal Khan, and Rumina Hasan. 2020. “COVID-19, Misinformation, and Antimicrobial Resistance.” BMJ371 (November): m4501. https://doi.org/10.1136/bmj.m4501.

CDC. 2021. “Candida auris.” Centers for Disease Control and Prevention. July 19, 2021. https://www.cdc.gov/fungal/candida-auris/index.html.

CDC. 2021. “CRE: Healthcare-Associated Infections (HAI).” Centers for Disease Control and Prevention. April 7, 2021. https://www.cdc.gov/hai/organisms/cre/index.html.

​​CDC. 2021. “Patients | CRE | HAI”. Centers for Disease Control and Prevention. February 18, 2021. https://www.cdc.gov/hai/organisms/cre/cre-patients.html.

CDC. 2020. “What Exactly Is Antibiotic Resistance?” Centers for Disease Control and Prevention. March 13, 2020. https://www.cdc.gov/drugresistance/about.html.

CDC. 2020. “Where Antibiotic Resistance Spreads.” Centers for Disease Control and Prevention. March 10, 2020. https://www.cdc.gov/drugresistance/about/where-resistance-spreads.html.

Centers for Disease Control and Prevention (U.S.). 2019. “Antibiotic Resistance Threats in the United States, 2019.” Centers for Disease Control and Prevention (U.S.). https://doi.org/10.15620/cdc:82532.

Jul 27, Chris Dall | News Reporter | CIDRAP News | and 2021. n.d. “CDC Reports Two Outbreaks of Pan-Resistant Candida Auris.” CIDRAP. Accessed October 6, 2021. https://www.cidrap.umn.edu/news-perspective/2021/07/cdc-reports-two-outbreaks-pan-resistant-candida-auris.

Chowdhary, Anuradha, and Amit Sharma. 2020. “The Lurking Scourge of Multidrug Resistant Candida Auris in Times of COVID-19 Pandemic.” Journal of Global Antimicrobial Resistance 22 (September): 175–76. https://doi.org/10.1016/j.jgar.2020.06.003.

“COVID-19 & Antibiotic Resistance | CDC.” 2021. June 8, 2021. https://www.cdc.gov/drugresistance/covid19.html.

Hsu, Jeremy. “How Covid-19 is Accelerating the Threat of Antimicrobial Resistance.” BMJ: British Medical Journal (Online) 369, (May 18, 2020). http://dx.doi.org.mutex.gmu.edu/10.1136/bmj.m1983.

Knight, Gwenan M., Rebecca E. Glover, McQuaid C. Finn, Ioana D. Olaru, Gallandat Karin, Quentin J. Leclerc, Naomi M. Fuller, et al. 2021. “Antimicrobial Resistance and COVID-19: Intersections and Implications.” ELife 10. http://dx.doi.org/10.7554/eLife.64139.

Majumder, Md Anwarul Azim, Sayeeda Rahman, Damian Cohall, Ambadasu Bharatha, Keerti Singh, Mainul Haque, and Marquita Gittens-St Hilaire. 2020. “Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health.” Infection and Drug Resistance 13: 4713–38. http://dx.doi.org/10.2147/IDR.S290835.

Manning, Mary Lou, Edward J. Septimus, Elizabeth S. Dodds Ashley, Sara E. Cosgrove, Mohamad G. Fakih, Steve J. Schweon, Frank E. Myers, and Julia A. Moody. 2018. “Antimicrobial Stewardship and Infection Prevention—Leveraging the Synergy: A Position Paper Update.” American Journal of Infection Control 46 (4): 364–68. https://doi.org/10.1016/j.ajic.2018.01.001.

Popescu, Saskia. 2019. “The Existential Threat of Antimicrobial Resistance.” Bulletin of the Atomic Scientists 75 (6): 286–89. https://doi.org/10.1080/00963402.2019.1680053.

Rawson, Timothy M, Luke S P Moore, Enrique Castro-Sanchez, Esmita Charani, Frances Davies, Giovanni Satta, Matthew J Ellington, and Alison H Holmes. 2020. “COVID-19 and the Potential Long-Term Impact on Antimicrobial Resistance.” Journal of Antimicrobial Chemotherapy 75 (7): 1681–84. https://doi.org/10.1093/jac/dkaa194.

Segala, Francesco Vladimiro, Davide Fiore Bavaro, Francesco Di Gennaro, Federica Salvati, Claudia Marotta, Annalisa Saracino, Rita Murri, and Massimo Fantoni. 2021. “Impact of SARS-CoV-2 Epidemic on Antimicrobial Resistance: A Literature Review.” Viruses 13 (11): 2110. https://doi.org/10.3390/v13112110.

​​Srinivasan, Arjun. “The Intersection of Antibiotic Resistance (AR), Antibiotic Use (AU), and COVID-19.” Centers for Disease Control and Prevention. February 10, 2021. https://www.hhs.gov/sites/default/files/antibiotic-resistance-antibiotic-use-covid-19-paccarb.pdf.

Sun Jin, Louisa and Fisher, Dale. 2021. “MDRO Transmission in Acute Hospitals during the COVID-19 Pandemic.” Wolters Kluwer Health, Inc. (34) 4: 365–371.

Toro-Alzate, Luisa, Karlijn Hofstraat, and Daniel H de Vries. 2021. “The Pandemic beyond the Pandemic: A Scoping Review on the Social Relationships between COVID-19 and Antimicrobial Resistance.” International Journal of Environmental Research and Public Health 18 (16): 1–20. https://doi.org/10.3390/ijerph18168766.        

Vidyarthi, Ashima Jain, Arghya Das, and Rama Chaudhry. 2021. “Antimicrobial Resistance and COVID-19 Syndemic: Impact on Public Health.” Drug Discoveries & Therapeutics 15 (3): 124–29. https://doi.org/10.5582/ddt.2021.01052.


[1] CDC. 2020. “What Exactly Is Antibiotic Resistance?” Centers for Disease Control and Prevention. March 13, 2020. https://www.cdc.gov/drugresistance/about.html.

[2] CDC. 2020. “Where Antibiotic Resistance Spreads.” Centers for Disease Control and Prevention. March 10, 2020. https://www.cdc.gov/drugresistance/about/where-resistance-spreads.html.

[3] “COVID-19 & Antibiotic Resistance | CDC.” 2021. June 8, 2021. https://www.cdc.gov/drugresistance/covid19.html.

[4] Centers for Disease Control and Prevention (U.S.). 2019. “Antibiotic Resistance Threats in the United States, 2019.” Centers for Disease Control and Prevention (U.S.). https://doi.org/10.15620/cdc:82532.

[5] Segala, Francesco Vladimiro, Davide Fiore Bavaro, Francesco Di Gennaro, Federica Salvati, Claudia Marotta, Annalisa Saracino, Rita Murri, and Massimo Fantoni. 2021. “Impact of SARS-CoV-2 Epidemic on Antimicrobial Resistance: A Literature Review.” Viruses 13 (11): 2110. https://doi.org/10.3390/v13112110.

[6] CDC. 2021. “CRE: Healthcare-Associated Infections (HAI).” Centers for Disease Control and Prevention. April 7, 2021. https://www.cdc.gov/hai/organisms/cre/index.html.

[7] CDC. 2021. “Patients | CRE | HAI”. Centers for Disease Control and Prevention. February 18, 2021. https://www.cdc.gov/hai/organisms/cre/cre-patients.html

[8] CDC. 2021. “Candida auris.” Centers for Disease Control and Prevention. July 19, 2021. https://www.cdc.gov/fungal/candida-auris/index.html.

[9] Chowdhary, Anuradha, and Amit Sharma. 2020. “The Lurking Scourge of Multidrug Resistant Candida Auris in Times of COVID-19 Pandemic.” Journal of Global Antimicrobial Resistance 22 (September): 175–76. https://doi.org/10.1016/j.jgar.2020.06.003.

[10] Jul 27, Chris Dall | News Reporter | CIDRAP News | and 2021. n.d. “CDC Reports Two Outbreaks of Pan-Resistant Candida Auris.” CIDRAP. Accessed October 6, 2021. https://www.cidrap.umn.edu/news-perspective/2021/07/cdc-reports-two-outbreaks-pan-resistant-candida-auris.

[11] Srinivasan, Arjun. “The Intersection of Antibiotic Resistance (AR), Antibiotic Use (AU), and COVID-19.” Centers for Disease Control and Prevention. February 10, 2021. https://www.hhs.gov/sites/default/files/antibiotic-resistance-antibiotic-use-covid-19-paccarb.pdf.

[12] Vidyarthi, Ashima Jain, Arghya Das, and Rama Chaudhry. 2021. “Antimicrobial Resistance and COVID-19 Syndemic: Impact on Public Health.” Drug Discoveries & Therapeutics 15 (3): 124–29. https://doi.org/10.5582/ddt.2021.01052.

[13] Rawson, Timothy M, Luke S P Moore, Enrique Castro-Sanchez, Esmita Charani, Frances Davies, Giovanni Satta, Matthew J Ellington, and Alison H Holmes. 2020. “COVID-19 and the Potential Long-Term Impact on Antimicrobial Resistance.” Journal of Antimicrobial Chemotherapy 75 (7): 1681–84. https://doi.org/10.1093/jac/dkaa194.

[14] Sun Jin, Louisa and Fisher, Dale. 2021. “MDRO Transmission in Acute Hospitals during the COVID-19 Pandemic.” Wolters Kluwer Health, Inc. (34) 4: 365–371.

[15] Knight, Gwenan M., Rebecca E. Glover, McQuaid C. Finn, Ioana D. Olaru, Gallandat Karin, Quentin J. Leclerc, Naomi M. Fuller, et al. 2021. “Antimicrobial Resistance and COVID-19: Intersections and Implications.” ELife 10. http://dx.doi.org/10.7554/eLife.64139.

[16] Manning, Mary Lou, Edward J. Septimus, Elizabeth S. Dodds Ashley, Sara E. Cosgrove, Mohamad G. Fakih, Steve J. Schweon, Frank E. Myers, and Julia A. Moody. 2018. “Antimicrobial Stewardship and Infection Prevention—Leveraging the Synergy: A Position Paper Update.” American Journal of Infection Control 46 (4): 364–68. https://doi.org/10.1016/j.ajic.2018.01.001.

[17] Hsu, Jeremy. “How Covid-19 is Accelerating the Threat of Antimicrobial Resistance.” BMJ: British Medical Journal (Online) 369, (May 18, 2020). http://dx.doi.org.mutex.gmu.edu/10.1136/bmj.m1983.

[18] Popescu, Saskia. 2019. “The Existential Threat of Antimicrobial Resistance.” Bulletin of the Atomic Scientists 75 (6): 286–89. https://doi.org/10.1080/00963402.2019.1680053.

[19] Toro-Alzate, Luisa, Karlijn Hofstraat, and Daniel H de Vries. 2021. “The Pandemic beyond the Pandemic: A Scoping Review on the Social Relationships between COVID-19 and Antimicrobial Resistance.” International Journal of Environmental Research and Public Health 18 (16): 1–20. https://doi.org/10.3390/ijerph18168766.          

[20] Arshad, Mehreen, Syed Faisal Mahmood, Mishal Khan, and Rumina Hasan. 2020. “COVID-19, Misinformation, and Antimicrobial Resistance.” BMJ 371 (November): m4501. https://doi.org/10.1136/bmj.m4501.

[21] Majumder, Md Anwarul Azim, Sayeeda Rahman, Damian Cohall, Ambadasu Bharatha, Keerti Singh, Mainul Haque, and Marquita Gittens-St Hilaire. 2020. “Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health.” Infection and Drug Resistance 13: 4713–38. http://dx.doi.org/10.2147/IDR.S290835.

Army Training Emphasizes the Importance of Education in Preventing Chemical and Biological Attacks

By Danyale C. Kellogg, Biodefense PhD Student

In October of 2021, I had the privilege of attending the Medical Management of Chemical and Biological Casualties course (MCBC), offered by the U.S. Army Medical Research Institute of Chemical Defense (USAMRICD) and the U.S. Army Medical Research Institute of Infectious Disease (USAMRIID) at USAMRICD’s facility in Edgewood, MD. I learned from instructors at these two legendary institutions how to identify chemical and biological warfare (CBW) agents, diagnose the conditions they cause, and mitigate their impacts. When I applied to the Biodefense PhD program at the Schar School of Policy and Government at George Mason, I could not have predicted that during the first semester of my doctoral studies I would be cutting a classmate out of Mission Oriented Protective Posture (MOPP) gear in the Maryland woods as part of a hands-on training exercise. This course was an incredibly informative, fascinating, and fun opportunity that was an excellent supplement to my graduate education. As an aspiring scholar-practitioner, understanding how the boots-on-the-ground manage these types of events and how such an event could impact broader operations and foreign policy is invaluable.

As the course was hosted entirely at USAMRICD due to the ongoing COVID-19 pandemic, the course felt a bit more focused on chemical warfare (CW) than biological warfare (BW). However, I found this almost more enjoyable as I had virtually no understanding of CW, making this an excellent opportunity to be immersed in learning about these agents. While I understood major concepts like the supposed chemical weapons taboo and global nonproliferation efforts from my prior studies in international relations, this course offered much more in-depth, niche knowledge. For example, I learned at MCBC that mustard-lewisite (military designation HL), two chemical weapons used together, might be a desirable agent for an actor to use, depending on the target and situation in question. This is because HL has certain properties of both agents, such as a lower freeing temperature, making it better suited for both aerial spraying and ground dispersal. Understanding concepts like these are useful from an academic perspective since it provides a better understanding of how an enemy might think about using chemical weapons and how we might prioritize defensive measures in light of such threats.

Bridging the divide between academia and practice requires scholars to learn what real-world elements of their fields look like, which this course provided through its classroom and practical portions. Though this course is explicitly targeted at healthcare providers, I think the in-depth knowledge I gained about chemical and biological agent identification and attack mitigation will improve my work, which lies at the intersection of global health and defense policy. Because of this course, I now have a deeper understanding of how difficult it is to triage victims in a CBW mass casualty event and how time-consuming and complicated it would be to manage decontamination, evacuation, and treatment of victims. I now know how many autoinjectors personnel usually carry in their gas mask carrier to use for buddy aid, what types of drugs different types of military hospitals normally have supplied, and what that all means for their response capabilities in a mass casualty scenario. While the specific, little details may not be critically important to my work, having this context is extremely helpful and, hopefully, will allow me to conduct more rigorous research and make more-informed recommendations over the course of my career.

Finally, deterrence in the CBW realm is dependent on the existence of effective countermeasures and would-be attackers perceiving that their targets are able to successfully mitigate potential attacks. Having attended this training, I am confident that USAMRICD and USAMRIID are succeeding in helping strengthen that deterrent through this and other courses. While our class had about fifty people (the vast majority military personnel) in it, I constantly heard instructors stressing that this information should be taken back to attendees’ units, shared, and used to improve training back home, increasing the chances for this information to reach those responsible for responding to a chemical or biological attack. I heard numerous encouragements for officers to coordinate more closely with their units’ Chemical Corps folks or request food supply inspections from the Veterinary Corps when in doubt about food safety while deployed. It was reassuring to see instructors encouraging servicemembers to use this information proactively, particularly when so much of what our program focuses on is strong preparedness and prevention as deterrents for CBW attacks.

This course was an excellent opportunity for me to interact with professionals in fields entirely unlike my own while having fun and learning a ton. I enjoyed gaining more hands-on knowledge about CBW agents and military medicine while contemplating what this course represents in overall U.S. biodefense.

Book Review – Toxic: A History of Nerve Agents, from Nazi Germany to Putin’s Russia

By Chris Quillen, Biodefense PhD student

Nerve agents are very much in the news these days. Bashar al-Assad’s government in Syria repeatedly used Sarin against its own people during that country’s civil war. The Putin regime employed Novichoks in both Russia and the United Kingdom against citizens it deemed insufficiently loyal to Moscow. North Korea’s Kim Jong Un utilized VX in the assassination of his brother at an airport in Kuala Lumpur, Malaysia. Across the globe, the use of nerve agents is challenging the international nonproliferation regime in numerous ways.     

Against this backdrop, Dan Kaszeta’s Toxic: A History of Nerve Agents, from Nazi Germany to Putin’s Russia provides welcome background and context on these specific types of chemical weapons. A former Chemical Officer in the US Army with decades of chemical weapons experience including multiple stints at the White House, Kaszeta offers much-needed technical expertise on the invention, production, and investigation into nerve agents. The focus specifically on nerve agents is a welcome change from many other histories that tend to lump all chemical (and sometimes biological) weapons into one amorphous “poison gas” threat with little differentiation between them. While older chemical weapons such as sulfur mustard or phosgene are sometimes mentioned in comparison with nerve agents, the author never loses his focus on his primary subject. This focus also enables Kaszeta to bypass the introduction and extensive use of chemical weapons in World War I that tends to dominate many other similar histories. Instead, Toxic begins with the Nazi discovery of Tabun, Sarin, and Soman in the context of World War II and follows the history of the dissemination of this technology to the present day.

The in-depth discussion of Nazi nerve agents is one of the real strengths of this book.  Kaszeta conducted extensive archival research and revealed numerous interesting new details including insights into why nerve agents were not employed during the war, either on the battlefield or in the gas chambers. Similarly, his discussion of nerve agent development by the US, UK, and USSR during the Cold War is impressive even if it tends to focus heavily on weapon systems (likely reflecting Kaszeta’s military background). The sections on the Syrian Civil War and the Skripal poisoning in the UK are also notable for their impressive detail and valuable discussions into those investigations.

Kaszeta’s best analysis appears in recent events that he investigated as part of his work with the open-source research organization Bellingcat. He directly confronts the disinformation campaigns trying to deny Syria’s use of Sarin. The author correctly points out that much of the effort is not designed to disprove Syria’s actions, but simply muddy the waters enough to make investigators throw up their hands in defeat. Kaszeta similarly attacks Russian disinformation about the Skripal poisoning and uses a combination of technical knowledge and common-sense logic to demonstrate the weakness of Moscow’s denials. One would not expect to find much humor in a history of nerve agents, but Kaszeta’s devilish sense of humor makes several appearances, especially when disproving the lies of the Russian and Syrian governments about their nerve agent use.

That said, the book is inconsistent overall. The sections on the Aum Shinrikyo Sarin project and the VX assassination of Kim Jong Nam, in particular, lack the same level of attention as most of the others. The basics are all there, but the minimal amount of detail and the lack of insights are sometimes striking compared to other chapters. Relatedly, Kaszeta sometimes provides copious details on nerve agent production facilities and weapons systems and then fails to provide sufficient analysis of what it all means. This is nowhere more evident than in his too brief final chapter where he brings the entire history together. He, undoubtedly, has more insight to give and the book would likely be much improved if he shared more of it.

Kaszeta remains focused on nerve agents throughout his book, but he sometimes diverges from the broader historical narrative in distracting ways. The chapter on the psychological effects of nerve agents is a key example of this tendency. Kaszeta raises interesting questions about possible linkages between nerve agents and mental illness, but the topic seems out of place and his argument is underdeveloped. Perhaps lacking the appropriate medical knowledge to pursue on his own, the author simply wanted to raise the issue for others to investigate, but this story seemed a speculative diversion away from the main story.    

While most of Kaszeta’s conclusions are well-reasoned, one in particular stood out as questionable. He argues correctly that nerve agents were brought into being through the ingenuity and hard work of people working for the Nazi regime and every other related discovery builds upon that breakthrough. He then makes somewhat of a leap that without this important contribution, nerve agents never would have been invented at all. This conclusion seems debatable at best. Both sides in the Cold War would have continued their chemical weapons research even without discovering the Nazi nerve agents. The science of chemistry also would have continued to advance even without the military impetus. Investigations into the organophosphate compounds that form the basis of nerve agents would have continued regardless. After all, many nerve agent discoveries were originally based on research of pesticides. While the Nazi contribution cannot be denied, the idea that nerve agents would have remained undiscovered without it seems highly unlikely.      

The greatest contribution of Kaszeta’s Toxic is as a historical and technical reference on nerve agents, an important issue. The appendices, in particular, offer solid scientific descriptions of nerve agent issues and background information on several countries rarely discussed in the literature, such as the former nerve agent programs in France and Yugoslavia. Written in accessible language, the book uses Kaszeta’s scientific knowledge to shed light on important questions. For example, he argues that while Soman is more effective than either Tabun or Sarin, few countries have pursued Soman production because it involves the expensive precursor pinacolyl alcohol. He also uses this knowledge to debunk conspiracy theories. Specifically, some have argued that Sarin was only detected in Syria after a warehouse with the binary precursors of methylphosphonyl difluoride (DF) and isopropyl alcohol was bombed. As Kaszeta rightly argues, the bombing of such a building would create a massive fireball from the two flammable chemicals, which would not magically mix together to create a nerve agent. The author’s ability to apply his knowledge and experience to contemporary issues is invaluable. For anyone interested in the historical impact of chemistry or the role of chemical weapons in world affairs, this book is a worthy addition to their reading list.

Commentary – Assessing China’s New Biosafety Law

By Sally Huang, Biodefense PhD Student

Introduction

The COVID-19 pandemic, which was first detected in the Chinese city of Wuhan in December 2019, has turned the world upside down. While the origins of the pandemic, either a natural spillover event from animals to humans or the result of an escaped virus from the Wuhan Institute of Virology, remain contested, there is no denying that the virus has served as a focusing event for political leaders. As a rare, sudden event that has inflicted large-scale harm upon the public, the pandemic has also functioned as a powerful catalyst for policymaking [i]. While China had been drafting new biosafety legislation since 2019, the pandemic accelerated its finalization after President Xi Jinping announced his intent to enhance biosafety measures in February 2020. The law’s approval also comes as China recently experienced one of its worst COVID flare-ups in 2021, challenging the country’s success in overcoming the virus.

On October 17, 2020, China’s Standing Committee of the 13th National People’s Congress approved the Biosafety Law of the People’s Republic of China [ii]. This law is the first of its kind, unifying numerous preexisting biosafety policies under a single framework [iii]. Yet, one may be wary of the law’s credibility in effectively addressing biosafety gaps in China’s infectious disease framework given the political drama surrounding China’s response to the pandemic. China is under heightened scrutiny as the international community questions the origin of the pandemic, China’s initial handling of the COVID-19 outbreaks in Wuhan, and whether Chinese institutions and facilities are prepared to counter future infectious disease threats. Thus, even though China proactively initiated the Biosafety Law to address biosafety concerns, its rapid completion could be seen as a reflexive action to ameliorate the international community’s skepticism. The Biosafety Law’s broad and sometimes vague approach to addressing pathogen management, biohazardous agent accountability, capacity-building, and preparedness also highlight that there is much work to be done beyond approval of the law.

China’s Biosafety Law is unlike a highly detailed US law. Rather, it is analogous to a US government-issued strategy, a high-level document setting forth broad principles for subsequent legislative actions and policies. Thus, Chinese ministries will have to subsequently provide additional details to build upon the Biosafety Law. While strategy documents retain a certain amount of ambiguity to set the stage for more prescriptive, future policies, China’s Biosafety Law exhibits a noticeable lack of clarity. An analysis of the Biosafety Law’s key elements will therefore help inform outside parties about how China plans to navigate the infectious disease and biotechnology landscape moving forward.

Prior to diving into China’s Biosafety Law, it is worth taking a few moments to describe the linguistic differences between how Western and Chinese scientific communities use the terms, biosafety and biosecurity. When using these terms, the Western scientific community references two separate, but interrelated disciplines. The Chinese scientific community commonly uses the term shengwu anquan (biosafety) while also presently developing familiarity with shengwu anbao (biosecurity). Due to the widely varying opinions on what biosecurity means depending on where one works, Chinese scientists characterize shengwu anbao (biosecurity)as a subcategory of shengwu anquan (biosafety) as opposed to an independent field of study. An unintended consequence of this is the Chinese scientific community’s tendency to use these terms interchangeably [iv]. This may be a result of China’s intent to grow their biosecurity sector under the aegis of their biosafety policies, which were made more comprehensive following the country’s 2003 SARS outbreak [v]. On the other hand, this may cause confusion to the unbeknownst reader. In an effort to best maintain the Biosafety Law’s context in this article, the evaluation below adopts China’s interpretation of biosafety and biosecurity. Therefore, readers should keep in mind that as biosecurity (as described below) encompasses the security of biotechnologies, it is applied in the context of biosafety.

China’s Biosafety Law: Why Now?

COVID-19 highlighted the absence of a central agency and legal framework in China to provide direction for policies related to the management of threats posed by infectious diseases and biotechnology. Even with nearly a hundred existing biosafety laws and regulations, China has struggled with communicating, coordinating, and enforcing biosafety regulations. This demonstrates that a variety of policies can foster inconsistencies and poor policy oversight [vi]. As a result, China’s regulations are problematically left open to interpretation by all levels of government [vii]. Left unattended, these issues could balloon into long-term complications that could disrupt or contradict efforts to combat infectious diseases. Thus, China’s new Biosafety Law is meant to unify preexisting biosafety policies under one single framework to promote national biosafety standards and regulations, and demonstrate to the world their commitment to improving biosafety practices and infectious disease preparedness.

What Does the Biosafety Law Aim to Do?

Comprised of 88 articles, China’s Biosafety Law aims to bolster prevention and response to the threat of biological agents, nurture responsible laboratory conduct, and promote stable development of biotechnology to ensure the well-being of the ecosystem and population. As a basic, all-encompassing law, it takes a broad approach to formulating supervisory parameters for various issues of concern beyond biosafety and biosecurity. It bestows the Chinese State Council—the executive body of state power in charge of carrying out policy—with the authority to enforce, oversee, and lead investigations for all activities addressed under the law [viii]. With the Biosafety Law serving as the chief blueprint, it will work towards integrating various areas to fortify national and economic security, and social stability as well as set a precedent for future policies. The main components of China’s Biosafety Law include biosafety, biosecurity, public health preparedness, ethics, and biodefense.

Biosafety Prevention and Standards

China defines biosafety as the effective prevention and response to threats of biological agents and related factors to peoples’ lives and the ecosystem, and the stable development of biotechnologies [ix]. Although the law lists various areas in which biosafety would apply, it does not clearly define laboratory safety procedures or implementation of containment principles in the event that accidental outbreaks were to take place. This is interesting as the Western definition of biosafety more clearly lists criterion and values for protecting lab personnel and the public from the threat of biological agents [x]. However, it is worth noting that biosafety is explicitly written as “an important part of national security” within the Law as numerous articles describe the boundaries of biosafety activities and appropriate behavior in China [xi]. Article 6, for example, emphasizes the need to strengthen international cooperation and fulfill biosafety obligations under international treaties. This is especially pertinent to China’s compliance to the Cartagena Protocol on Biosafety in order to improve governance over the movement of pathogens and modified organisms [xii].

Article 8 empowers individuals to report activities endangering biosafety with the goal of preventing government authorities from ignoring early warning signs and valuable information provided by experts. This is a significant provision that could provide protection for whistleblowers. During the earliest stage of the COVID-19 outbreak in Wuhan, for example, Dr. Li Wenliang, a doctor treating patients with the novel coronavirus was detained and reprimanded by Chinese authorities for raising alarms about the hazards of the virus via social media. After his death from contracting COVID-19, he was hailed as the “hero who told the truth” as the Chinese public became outraged over the initial cover-up and number of lives that could have been saved if authorities had heeded the warnings [xiii]. The inclusion of this provision should pose a sanguine outlook for whistleblower protections, but specific assurances are not described. Only time will tell how Chinese government officials will act in the future.

The biosafety-focused articles also promote joint agency collaboration to enhance biosafety capacity-building. Article 42 stipulates that China should formulate a unified biosafety standard for pathogenic microorganisms in laboratories. Article 45 establishes hierarchical management for biosafety laboratories (BSLs) to ensure that research on pathogens is carried out responsibly in appropriate BSLs as categorized by risk level. Expanding upon responsible operation of pathogens, Article 68 calls for construction of a national biosafety infrastructure to accommodate high-grade pathogens and bolster national preparedness and response. As of now, China has only two BSL-4 labs [xiv]. The Biosafety Law does not dictate which types of biocontainment labs will be built. However, China is reportedly planning on building thirty additional BSL-3 labs and at least one BSL-4 lab over the next five years [xv].

Most reflective of the COVID-19 environment is Article 70 which details the State Council’s role in ensuring “the production, supply and deployment of medical rescue equipment, treatment drugs, medical devices and other materials needed for emergency response to biosafety incidents” [xvi]. Like any other country combatting COVID-19, healthcare workers and first responders in China are on the frontlines and require proper protective gear and medical countermeasures to help those in need.

Public Health and One Health

With the pandemic sparking additional concerns about novel infectious disease outbreaks, multiple provisions of the law address public health concerns. Article 18 dictates China will establish a biosafety inventory system to catalogue important biological data, including animal and plant, and other invasive species. Article 15’s biosafety risk investigation and evaluation system, combined with Article 16’s unified national biosafety information sharing system, will then help identify animal and plant epidemic risks that endanger China’s biosafety. China is also poised to streamline communication between government departments to efficiently classify and manage potential outbreaks. Article 47 aims for more controlled management of experimental animal research in laboratories to better protect the public. These articles reflect China’s efforts to amend loopholes in its public health and biosafety systems after SARS escaped Beijing labs twice in 2004. Continued speculation of the origin of COVID-19 also places pressure upon China to straighten their public health systems.

Articles 22, 23, and 27 through 30 have a One Health focus—an interdisciplinary approach that recognizes the intersection between human, plant, and animal health [xvii]—and dedicate attention to the development of monitoring systems to trace and manage epidemics among plants and animals. Article 31 stresses the importance of strengthening capacity building measures for prevention and control of animal and plant agents at borders and ports. Article 32 expresses China’s aim to protect wildlife and prevent the spread of infectious diseases of animal origin. This will be vital for countering infectious diseases that are approximately 60-75% zoonotic [xviii]. To further champion animal and plant epidemic protections, Article 60 sets out to formulate lists of invasive alien species as guides for creating relevant management measures. By taking a One Health approach to recognizing and reducing infectious disease threats, these articles demonstrate China’s hope in preserving biodiversity, ecosystems, and the natural environment.

Security of Biotechnology Research and Applications

The Biosafety Law does not include a definition for biosecurity. Instead, biosecurity is considered a part of biotechnology dual-use research of concern (DURC). China’s singular attention to biosafety after the 2003 SARS outbreak meant that the Chinese scientific and legislative community did not become familiar with biosecurity until later on [xix]. According to Michael Barr, there are widely varying opinions on biosecurity in China and there is a “divergence of awareness” [xx] depending on where one works, but biosecurity is generally considered a subcategory of biosafety. This differs from the Western scientific community’s interpretation of biosecurity, in which biosafety and biosecurity are separate, but complementary, disciplines.

Recognizing the role of DURC in biotechnologies and how it influences pathogen management, Article 34 strengthens the safety management of biotechnology research while prohibiting research activities that endanger public health and damage ecosystems or biodiversity. Article 36 seeks to formulate biotechnology R&D standards and classifies biotechnology R&D activities as high-risk, medium-risk, and low-risk “according to the degree of risk of harm to public health, industrial agriculture, ecological environment, etc” [xxi]. Article 39 emphasizes the importance of regulating the purchase and introduction of biotechnologies and related biological factors in accordance with a control list and prohibits individuals from purchasing or possessing items on this list. The law does not provide any details on the contents of this control list.

Ethics

The Biosafety Law also covers ethical issues such as how China should improve supervision of Human Genetic Resources (HGRs). The ethical handling of HGRs has become an important issue in China after Dr. He Jiankui used CRISPR technology to produce gene-edited babies in an attempt to reduce their susceptibility to HIV [xxii]. This controversial experiment raised a number of red flags for the international scientific community—not only was it a flagrant flouting of medical and research ethics, but it also evinced China’s ineffective regulations and scientists’ lack of compliance. Therefore, Article 53 calls for strengthened supervision of the collection, preservation, and utilization of HGRs and related biological resources. Article 54, which empowers the State Council to carry out necessary investigations, provides a means of verifying compliance with these new provisions. Details on how the State Council would conduct these investigations, however, are not provided. Nonetheless, the universally negative response to Dr. He’s experiment provided a strong incentive for China to redefine its HGR regulations and reshape its bioethics standards.

Promoting Biodefense

Through Article 61 of the Biosafety Law, China hopes to “take all necessary measures to prevent biological terrorism and the threat of biological weapons”[xxiii]—echoing the Biological Weapons Convention’s (BWC) objective of prohibiting the development, manufacture, acquisition, stockpiling, possession, and utilization of biological weapons [xxiv]. China has already passed legislation for domestic implementation of the BWC and reported its biosecurity policies and enforcement measures to the United Nations Security Council’s 1540 Committee. In 2019, however, the US State Department reported that China was engaged in “biological activities with potential dual-use applications, which raises concerns regarding its compliance with the BWC” [xxv].

Article 62 tasks the State Council with creating China’s own version of the US’s Select Agent and Toxins List which is used to regulate access to dangerous pathogens that could be used by terrorists. Though criteria for this list are not described, a biological agent control list would provide China with a more formal method for managing, monitoring, and investigating suspicious purchases or activities with biological agents at risk of being misused to cause harm. Meanwhile, Article 65 calls for investigations of remnants of biological weapons found within China and the construction of facilities for their storage and disposal. The discovery and disposal of abandoned biological weapons holds historical significance for China as the country was subjected to multiple biological attacks by Japan during the Sino-Japanese War, and Chinese prisoners of war and captured civilians were victims of Japanese BW experiments conducted by Unit 731 in Manchuria during this time [xxvi]. At the end of the war, Japanese abandoned the site and destroyed records. However, recent discoveries of new records and an incubator used for the production of Yersinia pestis (the causative agent for plague) at sites in China indicates that the destruction of Unit 731’s equipment and materials was not completely thorough [xxvii]. Thus, other experimental equipment and biological munitions have the potential to be unearthed. These efforts to clean up the legacy of Japan’s biological weapons program in China complements China’s long-standing effort to safely destroy abandoned Japanese chemical weapons [xxviii].

Penalties for Violating the Biosafety Law

The Biosafety Law concludes with a final chapter on penalties for individuals who violate the law through the abuse of power, neglect of duties, engagement in malpractice for personal gain, fabrication of false information, and/or criminal acts. Penalties for such violations are financial fines that range between thousands to millions of yuan depending on the scope of the violation committed. The law does not delineate any prison time or any other form of penalties distinct from financial fines. With these current penalties, China hopes to influence scientific institutions and personnel to comply with the Biosafety Law. Yet, these articles do not describe pertinent criminal laws that would apply nor does it address whether novel criminal laws will be created to enforce the Biosafety Law—leaving the parameters for legal responsibility and investigations ambiguous.

Conclusion

Even as the Biosafety Law reflects China’s strategic positioning to incorporate biosafety, biosecurity, and biotechnology into its national security system, this ambitious set of laws needs to be accompanied by verification and accountability measures to ensure its proper implementation. What’s more, it will be interesting to see how China’s new expansive benchmarks will hold up, especially as the wording of key articles may be too broad and vague to be interpreted clearly. Nevertheless, countering infectious disease threats will be a balancing act requiring steadfast commitment and investment. COVID-19 has served as a long-awaited wake-up call for China to re-center their policy efforts and develop purposeful strategies to reduce the threats posed by natural and man-made biological threats. As the world continues to face infectious disease threats, the Biosafety Law serves as a preliminary touchstone for Chinese scientists and institutions to elaborate upon. This new law is the beginning of a long process of heightening biosafety from a local concern to a national one and developing the policies, processes, and institutions necessary to implement the law. Only then can the Biosafety Law begin to be the comprehensive and effect


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[xiii] Verna Yu, “‘Hero Who Told the Truth’: Chinese Rage over Coronavirus Death of Whistleblower Doctor,” The Guardian, February 7, 2020, http://www.theguardian.com/global-development/2020/feb/07/coronavirus-chinese-rage-death-whistleblower-doctor-li-wenliang.

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[xxiv] “The Biological Weapons Convention (BWC) At A Glance | Arms Control Association,” Arms Control Association, accessed January 20, 2021, https://www.armscontrol.org/factsheets/bwc.

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Commentary – Systematizing the One Health Approach in Preparedness and Response Efforts for Infectious Disease Outbreaks


By Michelle Grundahl, Biodefense MS Student

We can use a One Health approach to improve our next pandemic response to actually strengthen global health security – and we can choose to systemize and globalize right now.  One Health is a collaborative, multisectoral, and transdisciplinary approach — working at the local, regional, national, and global levels — with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. The objective of this workshop – offered by The Forum on Microbial Threats of the National Academies of Sciences, Engineering, and Medicine – was to confront our emerging health threats through systematizing and integrating the One Health approach. Systematizing is defined as arranging an organized system; to make systematic. Living through the current pandemic required us to perform outbreak detection and response to SARS-CoV-2, but prevention and preparedness is actually what we should be doing prior to outbreaks. Topics in this workshop included integrating One Health into existing coordination mechanisms (into national action plans for health security) and integrating animal and human health surveillance systems.  Essentially, this new paradigm in biodefense will create a framework across sectors and bring order among disparate expertise. The adopters of One Health are ready for the challenge.

Should we create a National Pathogen Surveillance and Forecasting Center for biological threats? Pandemic prediction, prevention, and policies are our next step in responding to the current SARS-CoV-2 pandemic. Medical countermeasures are useful during outbreaks but perhaps it would be better to truly mitigate global health threats, and even prevent them. We can achieve global health security through relationship building and lateral leadership. Two themes were repeated during the workshop: (1) future public-private collaboration must happen and (2) strong health systems are needed (globally and locally).

Day one of the workshop focused on the practices of existing programs and how these could improve the current model for global public health responses. The Africa CDC provided their lessons from COVID-19 and they stressed the continued importance of using a holistic approach to health threats. Specifically, the creation of a new framework for the African continent – Framework for One Health Practice in National Public Health Institutes – recognizes that other countries are frequently hampered by siloed health systems. The African Framework explains that the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), and Sustainable Development Goals (SDGs) call for a One Health approach in order to comply with the 2005 International Health Regulations (IHR).

Back in the United States, we learned about the activities at Harris County (Texas) Public Health office. They explained their operational approach using One Health practices. An example given was the removal of old tires (mosquito breeding grounds) to combat Zika. Another was their response to Hurricane Harvey when they sheltered people and their pets together. Most recently, Harris County did surveillance of SARS-CoV-2 in pets.

On day two, the sessions tackled the urgency of a One Health approach and how it can be applied immediately. The development of a One Health workforce is one path forward. Dr. Lonnie King suggests that we should value a “T-shaped worker who has a deep understanding and high proficiency in one area with the skills to work collaboratively and respectfully across disciplinary lines for synergistic problem-solving.” In fact, USAID has a workforce project to do just this. An example, Africa One Health University Network (the latest effort in this USAID project) is creating a competent future workforce by developing multi-skilled students, who can work outside of silos. Universities can integrate systems thinking and encourage collaboration across disciplines. Woutrina Smith reminded the audience that social context is important, too; we cannot forget to incorporate the social sciences into traditional science to effectively create solutions using the data that we generate. Transdisciplinary thinking is essential.

Day three looked at the future of One Health with the experience of SARS-CoV-2 in mind. Biosurveillance using shared international data would create the ability to better forecast outbreaks. This will require cooperation through public-private partnerships, along with policy changes. The workshop suggested the goal of building a “broad, threat-agnostic global health system.”  This includes learning from the past to determine future capabilities. Collaboration across disciplines, sectors, and communities can enhance the detection of threats. Surveillance is key here. Realistically, it is unfeasible to collect and monitor all global health data.  Local, national, and international epidemiological surveillance systems are still needed though. They should be designed (and refined) with One Health in mind. The session on “Precision Epidemiology, Human Behavior, and the Future of One Health” (led by Jonathan Quick) discussed machine learning, which can sort through the massive amounts of data that we may begin to collect. Intelligence and national security applications of this surveillance data were not obviously addressed in this three-day event. Future conversations to address this sort of data will need to include scientists and intelligence professionals. Regardless, most agree now that global health security is national security.

Many of the topics of this workshop focused on current and future actions; which were reminiscent of the challenges listed in 2016’s Pandemic Prediction and Forecasting Science and Technology Working Group of the National Science and Technology Council. The major theme for this workshop was that collaboration is a must if we want to improve resilience to global health threats. Other groups (outside of this workshop) are collaborating and systemizing at the state level. On March 1st, New Jersey passed a bill (A-1992/S-347) for the ‘New Jersey One Health Task Force’ to operationalize One Health in the state. Looking forward, will we excel in our reaction to the next pandemic? Will we also create multisectoral preparedness that allows us to forecast, or prevent, the next pandemic?

There were many heavy hitters speaking at this NASEM workshop, including: Peter Daszak from EcoHealth Alliance; Laura Kahn from Princeton University; Casey Barton Behravesh, Director of the One Health Office at the US Centers for Disease Control and Prevention; John Nkengasong from the Africa Centres for Disease Control and Prevention; Jonna Mazet, Professor of Epidemiology and Disease Ecology and Executive Director of the One Health Institute School of Veterinary Medicine at University of California, Davis; Tracey McNamara from Western University of Health Sciences; Peter Rabinowitz from University of Washington; Lonnie King, Dean Emeritus for the College of Veterinary Medicine at The Ohio State University; and Jonathan Quick, Managing Director of the Pandemic Response, Preparedness, and Prevention Health Initiative at The Rockefeller Foundation.

Conspiracies, Contagion, and Convergence: Troubling Trends and COVID-19

By Stevie Kiesel, Biodefense PhD Student

For hundreds (if not thousands) of years, disease outbreaks have been accompanied by exaggerated or downright false claims of origin, spread, and treatment. Some of these claims are misinformation—incorrect information spread without an intent to mislead. For example, shortly after COVID-19 was declared a pandemic, claims that garlic could cure COVID-19 spread across social media. The majority of posters did not appear to have malicious intent in sharing this content, making these claims misinformation. On the other hand, disinformation is deliberately misleading or biased information. Far-right Telegram users planned to weaponize disinformation when they urged followers to spread inaccurate information about COVID-19 safety precautions via flyers in certain neighborhoods. While misinformation and disinformation are both dangerous, disinformation is more insidious. Throughout history, both mis- and dis-information have spread prolifically during pandemics. This article provides a brief history of conspiracy theories during pandemics, discusses some popular COVID-19 conspiracies, and examines a potential convergence of various communities spreading similar conspiracy theories.

Fear of disease occupies a special place in the human psyche—an invisible threat that can cause physical deterioration and possibly death. Though science has come a long way in understanding pathogens and the human body, even today “much remains unknown in medicine, creating fertile ground for fear.” While this is certainly true of the novel coronavirus SARS-CoV-2, conspiracy theories have accompanied disease outbreaks for millennia. Susceptibility to conspiracism is present in every country and can gain traction at any time, though it is more common around unprecedented events. Disease outbreaks are certainly one example, but the attacks of September 11th and the 2010 Deepwater Horizon industrial accident show that conspiracies often accompany newsworthy events.

The influenza pandemic of 1918 saw its fair share of myths, often aimed at rival countries. For example, the United States and United Kingdom initially linked the outbreak to intentionally adulterated aspirin from Bayer, a German company. These accusations reflected a post-World War I mistrust of Germany. Similarly, a rumor circulated throughout Brazil that the 1918 influenza virus was intentionally spread around the world by German submarines in an act of biological warfare. Though Americans often call this pandemic the Spanish flu, many countries had other regional names for it based on their particular prejudices. Conspiracy theories commonly lay blame on specific groups in an attempt to turn public opinion, even going so far as to claim that an outbreak is the result of biological warfare. For instance, a pernicious rumor in 14th century France claimed that a Muslim prince enlisted help from France’s Jewish population to bribe lepers to contaminate public water sources and kill Christians. A few hundred years later, conspiracy theories around yellow fever eventually led to the genre American Gothic. The father of American Gothic, Charles Brockden Brown, caught the disease himself, and though he recovered, others in his life did not survive it. His writings often used disease as a “conventional vehicle of terror.” His style was also deeply paranoid, including “hidden voices, secret societies…[and] fears of the Illuminati.” These themes, as well as a fearful fascination with the Illuminati, reverberated in American popular culture and religious life as yellow fever continued to spread.

Conspiracies accompany nearly every significant outbreak of disease. Some believed that the SARS outbreak of 2002 was caused by a virus created in a Chinese weapons lab (sound familiar?). During the H1N1 (swine flu) outbreak of 2009, rumors circulated that the World Health Organization and pharmaceutical companies conspired to manufacture the outbreak so that they could profit from vaccine distribution (a theme that appears with many outbreaks). And the current outbreak of novel coronavirus is a case study in how the internet and political tensions can exacerbate conspiracism in the United States.

Because SARS-CoV-2 is a novel virus, misinformation and disinformation have provided many people with answers where science could not yet do so. The World Health Organization labeled this phenomenon an “infodemic,” where technology and social media are used on a massive scale. While technology provides new mechanisms for keeping people safe and informed, it can also result in an overabundance of information, as well as the proliferation of incorrect and potentially harmful narratives. The pandemic has spawned countless conspiracy theories, but the most widespread can be generally grouped into four buckets:

  • Virus origins and spread. There is a great deal of theories about how the virus came into existence and how it is spread. Members of the Trump administration, as well as the former POTUS himself, have claimed that the Wuhan Institute of Virology is responsible for bioengineering SARS-CoV-2. Some adherents of this theory claim the virus was then intentionally released, while others say it escaped the lab accidentally. Another popular theory is that 5G networks are acting as super-spreaders for the virus. This theory has been linked to several acts of vandalism against 5G towers and an increased propensity for violence.
  • Preventative measures. Claims that preventative measures like mask wearing and social distancing are ineffective got a lot of traction on social media and were amplified by the Trump administration’s words and actions. This is not a uniquely American phenomenon: for example, Moldova’s former President was routinely photographed violating social distancing and mask mandates in his country. And in the US as well as Germany, the United Kingdom, and other countries, these preventative measures were met with angry protests by those who believe the lockdowns were a pretense for increased government control. And unfortunately, recent studies have proven that belief in COVID-19 conspiracy theories reduces willingness to engage in these preventative measures and protect communities.
  • Vaccines. No other preventative measure has spurred quite as many conspiracy theories as the COVID-19 vaccine. The theories range from mundane (the vaccine actually gives you COVID-19) to bizarre (the vaccine will alter your DNA) to absolutely wild (the vaccine contains a microchip that will allow Bill Gates to track your every movement and implement a New World Order). Others are simply concerned about the safety and effectiveness of the vaccine because they perceive the approval process as rushed and/or they mistrust the government and pharmaceutical companies. As of December 2020, only 60% of Americans surveyed said they intended to get the vaccine, while 20% said they were fairly certain they would under no circumstances get the vaccine.
  • Treatments. At the start of the pandemic, home remedies for COVID-19 were extremely popular on social media. Other bad information about COVID-19 cures came and went throughout 2020. Some of the most popular “cures” include garlic, saline nasal wash, exposure to high temperatures or sunlight, antibiotics, and hydroxychloroquine. None of these are effective against COVID-19.

Bad actors often encourage and amplify the spread of these narratives, twisting them for their own purposes. Extremists have latched onto many of these conspiracy theories and used them to recruit and radicalize followers. Social distancing, lockdowns, and online school and work have moved many people indoors, online, and looking for answers. When scientists, doctors, and public officials cannot provide the answers people are looking for, they become incredibly susceptible to messengers that claim to have a simple answer.

Conspiracism ebbs and flows, and though it is not a uniquely American phenomenon, we are currently living through a peak in what Richard Hofstadter has called the “paranoid style in American politics.” Understanding all the factors that have led to this crescendo is beyond the scope of this article, but political turmoil, increasing inequality, and a global pandemic play a significant role, exacerbated by the rapid spread of information and a waning trust in institutions. While much of the focus is on the political right, particularly given the recent siege of the Capitol, there is evidence of a convergence of conspiratorial thinking among those on both ends of the political spectrum, as well as those with few political beliefs who find answers in these ways of thinking. COVID-19 misinformation has been rampant on the right as well as within wellness and spirituality communities that are traditionally uninterested in politics or lean left. Liberal and leftist activists have also spread similar misinformation rooted in suspicion of pharmaceutical companies, the “medical industrial complex,” and the government.

The QAnon conspiracy is another recent example of this convergence. Declared a domestic terrorism threat by the FBI in 2019, adherents of the theory have been linked to at least a dozen alleged crimes. This statistic does not take into account any crimes committed during the Capitol siege, but QAnon adherents had a sizeable presence there. While many Q followers approve of Donald Trump because they believe that he has been trying to dismantle the deep state cabal of pedophiles and Satanists that run the US government, QAnon has appealed to people across the political spectrum. Though at its core, the QAnon conspiracy is based on an old antisemitic trope of the Blood Libel, the core belief has been laundered through movements such as #SaveOurChildren (claiming to be fighting child sex trafficking) and by social media influencers that put a gentle exterior on an extreme ideology. Much like multi-level marketing schemes, this rebranding targets potential marks by constructing a façade to hide the ugly reality and consequences. The subreddit QAnonCasualties is full of stories from former Q adherents as well as their friends and family. These stories show how conspiracism can consume someone’s life, leading them down a path to extremism that often ends in ostracism and sometimes even violence against their loved ones. The subreddit also shows the many different communities that can lead to Q, from churches to the wellness community to other conspiracy communities to right-wing politics and in countries outside the US.

Conspiracy theories and extremism will remain a potent threat for years to come, and currently disparate communities may converge in ways predictable or surprising. Conspiratorial thinking is often black and white, an “us versus them” mentality that can erode a person’s aversion to violence. Terrorist groups can (and have) taken advantage of this shift in mindset and used conspiracy theories as an opening to eventually introduce more extreme ideas. The Capitol siege and subsequent crackdown on inflammatory rhetoric on the major social media platforms may be pushing people toward sources such as Gab, Telegram, and Bitchute where extreme ideas flourish. The Biden administration has suggested several actions to combat the threat of domestic extremism, including a threat assessment and capacity-building to disrupt extremist networks. These are positive steps that must include experts outside of government and from a variety of disciplines, including those experienced in successful cult deprogramming and deradicalization. While promoters of and participants in extremist violence should be held fully accountable under the law for their actions, we should not lose sight of the structural and systematic failures that have made these conspiracy theories so appealing today.

Commentary – Incorporating One Health into Global Security: Educating the Public and Governments

By Maddie Roty, Biodefense MS Student

The Global Health Security Agenda Annual Ministerial Meeting, held 18-20 November 2020, focused on addressing gaps in global health security by promoting international and multidisciplinary engagement, coordination, and funding. Leading up to this event, there were side meetings addressing various topics related to global health. On 27 October, the United States Department of Agriculture (USDA) hosted the side meeting “Incorporating One Health into Global Security: Educating the Public and Governments.” One Health is an important topic that promotes a multisectoral approach needed to address global health security issues from climate change to zoonotic spillover events, and to improve the human and planetary conditions. Dr. Jennifer Rowland, an AAAS Science and Technology Policy Fellow at USDA, moderated two panels, one made up of One Health educators and the other of government officials with a role in One Health. The panels addressed how to educate students about One Health and how to implement One Health initiatives in US government agencies.

The One Health education panel included: Dr. Laura Kahn from Princeton University and the Founder of One Health Initiative; Dr. Deborah Thomson, Founder of OneHealthLessons.com; and Dr. Olga Pena, Mitacs Canadian Science Policy Fellow. Dr. Rowland asked each panelist a series of questions regarding the value of teaching students about One Health, how it helps support the goals of international organizations, and the challenges we face.

The most sobering point during this panel was made by Dr. Pena, who said “One Health disrupts human-centric views.” Too often, we are blinded to the interconnectedness of the human, plant, animal, and environmental conditions. What humans do affect the health of the rest of the planet, and what happens in Mother Nature affects the health of humans. Maintaining human-centric views will not only be harmful to the planetary condition but to humanity as well.

Sustainability is a challenge for One Health. Historically, the health sector has been reactive to threats, not proactive. Once a threat subsides, so does interest and funding. Dr. Thomson emphasized the best way to sustain efforts is to talk to the people who are most curious, most interested, and most willing to learn: children. If we want to change policies in the future, we need to reach the future politicians. For efforts to be sustainable, One Health education must also be tailored to the local community, traditions, and beliefs. Partnerships at the local level must be developed, and community leaders must be taught and empowered so they can continue teaching.

Unfortunately, providing education about One Health is challenging without the appropriate funding and resources. The panelists stated frustrations with finding funding for something as interdisciplinary as One Health, and even less funding for education because “education is not a product.” Building synergistic relationships that exchange funding for expertise, such as government agencies partnering with organizations and universities, is one way around this challenge, but it is not common enough to be a sufficient solution.

The One Health government panel included: Dr. Casey Barton Behravesh from CDC; Dr. Jane Rooney from USDA; and Mr. John Haynes from NASA. They answered a series of questions about how One Health is incorporated into the agencies, how agencies can work together, and how agencies can empower One Health work.

The most important takeaway from this panel was that One Health relies on partnerships. Despite the name, One Health is a team sport and no one person or one agency can accomplish its objectives. Like the education panel, this panel was concerned about funding and resources in the government for One Health, showing that interest and investment must come from the highest levels of government. In December 2017, there was an interagency workshop with subject matter experts and high-level agency voting members to come up with priority zoonotic diseases and generate recommendations on how to move One Health forward. Coronaviruses were on the list, and the workshop included suggestions for how to prepare for coronaviruses. Unfortunately, the resources were not there to follow through with the recommendations. Two years later, the COVID-19 pandemic has obviated the consequences of this lack of commitment and resources.

Of all the panel members in this meeting, Mr. Haynes impressed me the most, perhaps because he was the most surprising participant. Prior to the meeting, I had no understanding of how NASA would be involved in One Health, let alone serve as one of the leading agencies promoting the concept. Apparently, I was not alone; Mr. Haynes elaborated on how NASA attends public health and other medical conferences to raise awareness about what NASA is doing and how it should be incorporated into the health sector. NASA has an air and health quality applications program, and it has been very active during the COVID-19 pandemic. One program, for example, is modeling how the Saharan dust plume impacts public health, and specifically if the plume is associated with greater morbidity and mortality from COVID-19. There is no public health school in the United States that includes environmental remote sensing observations like those that this program offers in its curriculum. Mr. Haynes believes, and I am convinced, that this is a problem as most public health students and professionals have no idea these data are there and how valuable they can be for disease issues.

The main lessons from both panels were that One Health is extremely interdisciplinary and requires increased commitment and funding from educators, government agencies and leaders, and the public to protect the human and planetary conditions. The COVID-19 pandemic – occurring at the same time as compounding disasters like wildfires, hurricanes, and famines – show just how interconnected all of these issues are, and, hopefully, will stimulate increased and sustained dedication to One Health principles. 

Now more than ever, it is important to be actively engaged in global health security. If you would like to watch any of the side meetings or the Ministerial Meeting, click here.

Commentary – Recent Congressional Testimony: Worldwide Threats to the Homeland

By Stevie Kiesel, Biodefense PhD Student

As we gleaned very little useful information from the most recent presidential debate, it is worth taking a look at a more serious forum to understand how the US government perceives today’s most pressing threats. On September 17th, FBI Director Christopher Wray testified about “Worldwide Threats to the Homeland” to the House Committee on Homeland Security. Wray acknowledges the “unique and unprecedented challenges” brought about by COVID-19, as well as important “aggressive and sophisticated threats on many fronts,” but in his opening statement he focuses on five main topics: cyber, China, lawful access, election security, and counterterrorism. This article reviews the FBI Director’s depiction of these topics and provides additional characterizations of them, based on recent reports, legislation, and strategic guidance.

Wray discussed a “diverse array of threats from [US] cyber adversaries,” including state-sponsored cyber intrusions, economic espionage, and the increasing sophistication of cyber-crime. While Wray highlights ongoing work on cyber issues, he can only hope that these efforts will be enough before “we have some truly apocalyptic cyber crisis.” The Trump administration released a National Cyber Strategy in 2018, containing four pillars: protect the American people, the homeland, and the American way of life; promote American prosperity; preserve peace through strength; and advance American influence. These are the exact same pillars as the National Security Strategy released in 2017, tailored to address the cyber realm. The Government Accountability Office (GAO) released a report last month finding that since the National Cyber Strategy’s release, “it is still unclear which executive branch official is ultimately responsible for not only coordinating implementing of the strategy, but also holding federal agencies accountable once activities are implemented” (GAO-20-629). The constant jostling within federal agencies to determine who is ultimately responsible for emerging, high-priority threats is not a new theme. In just one relevant and timely example, the Department of Homeland Security (DHS) Office of Inspector General recently found that DHS is failing to coordinate efforts to defend against terrorism aimed at food, agriculture, and veterinary systems. The root cause? The DHS Countering Weapons of Mass Destruction Office (CWMD) is directed, via the Securing Our Agriculture and Food Act, to carry out the relevant program, but CWMD believes the DHS Secretary has not clearly delineated this authority to CWMD. Whether it is agroterrorism, cybersecurity, biotechnology, unmanned aerial systems, or the host of other fast-emerging threats the US faces, federal agencies need to improve their ability to absorb and act on a newly-assigned mission.

Wray also argues that “the greatest long-term threat to [the US’s] information and intellectual property and…economic vitality is the counterintelligence and economic espionage threat from China.” Understanding and countering this threat has become increasingly important in the wake of a Department of Justice indictment that found the Chinese government has sponsored hackers to target, in part, US labs working on COVID-19 vaccine research. Though the indictment is from July 2020, the two men had been involved in illicit cyber activities for more than a decade, targeting a wide range of industries in multiple countries. They most commonly targeted the high-tech manufacturing, engineering, software, pharmaceutical, and defense industries. Yet even as the US needs to take a firm stance on a host of issues related to China, the need to cooperate on issues such as biosecurity and infectious disease has never been greater. Rather than pulling out of international institutions such as the World Health Organization (WHO), the US should leverage international partnerships to increase transparency on health security issues and bring multilateral pressure to bear where appropriate.

A third issue of concern to Wray is lawful access, which refers to law enforcement’s inability to access data that utilizes end-to-end encryption, even with a warrant or court order. The Department of Justice and FBI have argued for years that this inability to access encrypted communications has led to a “decline in [law enforcement’s] ability to gain access to the content of both domestic and international terrorist communications.” Senator Lindsay Graham (R-SC) even introduced Senate Bill 4051, the Lawful Access to Encrypted Data Act, to make it easier for law enforcement agencies to access encrypted data. The bill was introduced in June 2020 and referred to the Committee on the Judiciary, where it now sits. Opponents of bills like this argue that the characterization of the issue as a balance between privacy and security is disingenuous, and, in fact, private, encrypted communications are a matter of security. Strong encryption serves many security functions: preventing cyber intrusions into critical services, protecting financial and health information from cyber criminals, and keeping constitutionally protected speech safe from abuses of power. An additional argument against lawful access is practical: if law enforcement is granted a way around encryption, that method will eventually be identified by nefarious cyber actors and exploited.

A fourth issue the Committee expressed great interest in is election security. The lead organization for election security is the Cybersecurity and Infrastructure Security Agency (CISA, formerly NPPD) within DHS. Wray characterized the FBI’s role as “working closely with…federal, state, and local partners, as well as the private sector, to share information, bolster security, and identify and disrupt any threats.” In a recent example of this collaboration, the FBI has worked with Facebook and Twitter to remove accounts created as part of a Russian disinformation campaign. In his testimony, Wray confirmed that Russia is primarily trying to influence the 2020 election through “malign foreign influence,” with fewer attempts to target election infrastructure than were seen in 2016. Russia is not the only actor targeting US elections; the National Counterintelligence Security Center Director recently stated that China and Iran were similarly looking to influence the election.

The FBI also recently issued guidance for the public on combating foreign influence in the election. This guidance focuses on applying critical thinking to information you see online before sharing it—by considering where information comes from and who is posting it and why before sharing that information. Additionally, in 2017, the FBI stood up the Foreign Influence Task Force to “counteract malign foreign influence operations targeting the United States.” The Task Force’s mission is to increase communication and coordination within the FBI and with its partners, through investigations and operations, information and intelligence sharing, and relationships with the private sector.

The final topic, and that which consumed most of Wray’s testimony before the Committee, was on counterterrorism. According to Wray, the greatest terrorist threat to the US today comes from “lone actors radicalized online who look to attack soft targets with easily accessible weapons.” The FBI distinguishes between two groups within this threat space: (1) domestic violent extremists (DVEs), whose ideological goals stem from domestic influences (e.g., racial bias, anti-government sentiment) and (2) homegrown violent extremists (HVEs), who are radicalized in the US but inspired ideologically by foreign terrorist organizations (e.g., the Islamic State). Wray points out that 2019 was the deadliest year for domestic extremist violence since 1995 and the Oklahoma City bombing that killed 168 people. The top threat from DVEs comes from what the FBI calls racially/ethnically motivated violent extremists, or RMVEs. While this moniker can apply to any flavor of racially or ethnically motivated extremism, in practice the threat is largely emanating from white supremacist ideologies. Though Wray provided clear and measured statements during the hearing, politicians’ grandstanding and attempts to score political points on this issue underscored how leaders’ rhetoric can only serve to inflame the issue of domestic violent extremism.

Commentary – Agri-Pulse’s Harvesting Perspectives: Agriculture and Food Policy Summit

By Michelle Grundahl, Biodefense MS Student

“We never could have imagined how the critical connections between food security and national security would be generating headlines when we first planned this Summit in 2019.”

– Sara Wyant, Agri-Pulse Editor and Founder

This virtual 2020 Ag & Food Policy Summit highlighted the links between food security and national security. We are reminded of Alfred Henry Lewis’s words, “There are only nine meals between mankind and anarchy.” This might be new information for some, but our intelligence community is well aware. To set the stage here, an issue in agricultural security is the misunderstanding of the term “food security” as food insecurity, and all definitions should include securing the food supply. Food security is national security. Food insecurity – resulting from a pandemic, a contaminated supply chain, an intentional biological attack, or an animal disease outbreak – can lead to national instability. Imagine the horror if an additional food supply problem arose while much of the US was panic buying groceries in March 2020. Sheltering-in-place is only possible if citizens have enough safe food with which to hunker down.

This event consisted of topics in food trade, farming practices, agricultural technology, biosecurity, food contamination, and national stability. Kip Tom, US Representative to the United Nations Agencies for Food and Agriculture, was the opening presenter. He led by saying that food insecurity can lead to civil unrest. Political conflict in food insecure countries is, unfortunately, very common. When the US intervenes with food aid in other countries, it is for the purpose of creating stability, but it is not simply for altruism. Early on in COVID-19, several industries were forced to shut down, creating food insecurity issues in many nations. Tom reminded the audience about the UN’s Sustainable Development Goals (SDG’s), which include goals to reduce hunger. He then explained that the European Union’s agroecology plan is an “ideological indulgence” for rich countries since some agroecology practices include manual labor instead of high production machinery. The methods of the EU (using agroecology and highly sustainable practices) are not as highly mechanized or efficient as implemented in the US. These practices could take years to implement, but could lead to local sustainable food supplies. Producing less food (and less efficiently) than the US is what seemed to be condemned here. Perhaps this is just our tendency as Americans to always want “bigger, more, faster.”

Tom suggested that the use of CRISPR, hybrid seeds, and similar technologies are the only path forward and he disparaged the EU for diverging. Helping farmers become more productive through innovation and technology, he insisted again, is the only way forward. Tom called upon the need for political will to uphold the environmental, social, and economic pillars of stability. William “Kip” Ward, a Retired US Army General who served as Commander of the United States Africa Command (USAFRICOM), is also concerned about stability. Stability is a key factor for the security of a nation. Creating stability always includes the food system, so unrest due to a lack of food security can lead to leadership instability. He explained that the national security of the US benefits when other nations are fed. 

As politics are certainly involved, Sonny Purdue, the Secretary of Agriculture, asserted the political side of trade and that feeding people requires technology and innovation. His statements seemed to echo Tom’s in that implementing agroecology (as in the EU and Africa) creates a national security risk to the US. Would US influence be diminished if these nations have food trade based on systems that the US is not using? Ted McKinney, the Under Secretary of Agriculture for Trade and Foreign Agricultural Affairs, remarked that having productive agriculture is important. He stated that our “Innovation Agenda” embraces technology, but it is being rejected by some countries and that the EU has “misguided” Africa with their ideas. It was implied that that there will be trade implications if other countries do not grow food at sufficient rate. My takeaway from this was that a slow rate of growth toward stability and sustainability in some countries might be too slow for an impatient US. If countries are growing just what they need, they will need to import less. Right now, the US produces more food than we need, putting us in a good trade position.

The US, and the world, needs the diversity of small and mid-sized farms, as well as major corporations. The current US paradigm of farm monocropping can be seen as a national security risk to some people. Creating huge farms of just one crop is “not natural.” A lack of biodiversity is not congruent with a healthy ecosystem, and McKinney’s opinion is that diverse American farms are an insurance policy. But McKinney also stated that we use less insecticides, fungicides, and pesticides when we use GMO seeds. While this might be technically true, Chef José Andrés, Founder of World Central Kitchen, might disagree.

Andres noted that patented seeds are a risk to the American people. If small farms cannot grow food for their local communities, especially after a major disaster, then they are not truly resilient. Natural seeds should be accessible to small farmers, because patented GMO seeds are costly. Having only patented seeds available causes the control of food production to be in the hands of just a few corporations. Andrés’ example is that the US primarily grows five crops, so we are at risk of an incident (intentional or natural) that compromises our ability to feed the population, let alone trade with the rest of the world. Corn, wheat, soybeans, cotton and hay seem to be what the US specializes in. His comments bring to mind the government’s suggested Victory Gardens of 1917 and 1942. During WWI and WWII, US citizens were encouraged to plant food as “war gardens” and “food gardens for defense.” This reduced pressure on the food supply.

Andrés went on to describe the challenges of the food boxes provided by the USDA in response to COVID-19. Andres was dismayed at the long lines and empty food banks. The chef said that when people are in need, they need food and water immediately.  Having US citizens wait in line for food, while some food was being destroyed (milk), was the result of inefficient delivery systems. Andres encouraged creativity, such as accepting SNAP subsidies at local restaurants (using local food), which could alleviate many supply chain issues.

The chef then stated his main concern that “at any moment, we could experience a terror attack on the American food supply.” Mike Conaway, a ranking member of the House Committee on Agriculture, had concerns with possible contamination of the food supply, too. He stated that the supply chain worked well during COVID-19 early on. People could get food, even if they had to buy items that they did not prefer or had to wait in long lines to get groceries. We need to maintain a secure supply chain. Conaway said that the US needs to consider our food security interests and rank them at the same level as our military defense interests and spending.

In the panel “Is the US food supply really secure? A closer look at the biggest challenges in agriculture biosecurity at home and abroad,” Everett Hoekstra, President of Boehringer Ingelheim Animal Health, reminded the audience that animal health and human health are intertwined, especially regarding the protein supply on which humans depend. Dr. Liz Wagstrom, the Chief Veterinarian of the National Pork Producers Council, reflected on biosecurity gaps. These gaps are on farms as well as at international borders and places in between. Considering that some diseases can cause severe economic and trade impacts, farms need to be ready for diseases like African Swine Fever. Another panelist, Dr. Alan Rudolph, Vice President for Research at Colorado State University, suggested using biosurveillance systems and a One Health approach to ecosystem science. We need One Health solutions for resiliency to future outbreaks as we rebuild our infrastructure after COVID-19.

Securing America’s farms and food systems will pave the way to viable strategies for food production beyond today’s systems. Defending the food supply will include supporting international systems. The world’s projected population growth will impact land use as people cause changes in land that affect whole ecosystems. Food security also includes supporting indigenous people’s right to eat and regulating the illegal wildlife trade. Considering the root causes of certain novel emerging infectious disease can inform improvements for the American food system.  For now, the focus should be on designing secure systems, ones that consider how even the smallest livestock – honeybees – supports an increasing population’s demand for protein.  In the biodefense of food, a wholistic bipartisan policy is needed if we want to sustain a stable world where we collaborate with nature and science. And where we can always have enough to eat.



Commentary – Event: Building Pandemic Preparedness and Resilience to Confront Future Pandemics

By Sally Huang, Biodefense PhD Student

With the current COVID-19 pandemic revealing major gaps in national readiness, the Bipartisan Commission on Biodefense brought together members of the legislative and scientific community for a virtual discussion on the need to increase and optimize resource investments to promote changes in US policy and strengthen national pandemic preparedness and response. Even as the nation continues to respond to the COVID-19 crisis, the various panelists unanimously acknowledged that the world will most likely face future pandemics. After having adapted to telework, decisionmakers are determined to enhance and enact new policies and guidelines to better position the nation to effectively respond to future infectious disease threats. Areas requiring the nation’s attention were addressed in three separate panel discussions; emerging biological threats and innovative technology for biodefense, emerging biological risks, and the future of biodefense. The recording of the virtual discussion held by the Commission, “The Biological Event Horizon: No Return or Total Resilience,” can be found here.

Representatives Susan Brooks (R-IN) and Diana DeGette (D-CO) discussed the responsibility the US has to its people to take advantage of lessons learned so far from the COVID-19 pandemic to integrate into pandemic preparedness and response policies. After all, as much as governments monitor indicators of possible biological attack, there is no set method to predict or foretell events of Mother Nature, “the world’s worst bioterrorist” and how it may further increase infectious disease threats. The US, operating from a privileged position as a world power, had a heightened belief of preparedness partly brought on by availability of advanced biotechnologies, but quickly realized the scope of their unpreparedness as private and public sectors were overwhelmed. The shock that resulted from COVID-19 demonstrates that the government not only has to invest meaningfully in CBRN programs, but also speaks to the need to translate scientific research into solutions in order to be well-equipped. For example, expanding and improving management of the Strategic National Stockpile and establishing a national forecasting system of infectious diseases analogous to the National Weather Service. This also includes revamping trainings and imparting institutions with flexible working styles in recognition that teleworking and digital platforms are transforming the working landscape. This is much needed for government institutions as COVID-19 caused a significant interruption in government operations and its ability to provide services to the people. More importantly, with the November election approaching, the nation requires clear leadership from the White House during this critical time to steer pandemic and biodefense progress in the right direction.

These policy additions and enhancements are also backed by advice given by experts, including Jaime Yassif, PhD, Sohini Ramachandran, PhD, and Nita Madhav, MSPH, about emerging biological risks. There is an evident need to close the gap between science and policy to enrich pandemic preparedness and foster a culture of cooperation, coordination, and resilience. As the panelists mention, numbers of infectious diseases will increase over time, meaning that complex contagion will inevitably become a reality the US and international community have to battle with. Thus, this further highlights the urgent need to fund interdisciplinary research to enhance analytical tools for infectious disease modeling and sheds light on the national forecasting suggestion brought up by the first set of panelists to better coordinate infectious disease analytics and information more efficiently. Proactive preparedness will help ensure proactive and effective reaction.

That being said, all the more reason to pay attention and invest strategically in the future of biodefense. Private and public sectors need to be effectively incorporated into a national strategy in order to improve foundational capabilities and compensate for the noticeable gaps during the COVID-19 pandemic. This includes enhancing and providing support to the supply chain, a critical building block for addressing America’s material needs. Additionally, analytic and scientific models should account for modern globalization trends and climate change effects to heighten awareness and response. The recent wildfires spreading across California, Oregon, and Washington serve as an example where unpredictable events have the potential to set up ideal conditions for further disease transmission. Not to mention, natural events cause ecological shifts that also contribute to a changed infectious disease landscape. Decisionmakers have no doubt that this feat will require a strong united front to address these concerns.

The recommendations raised during this virtual discussion led to congressional members underscoring the significance of the Apollo Project for Biodefense. Noted as a vital step to building the nation’s resilience, this initiative will examine the nation’s track record of dealing with infectious diseases, and assess how to better invest and coordinate science and technology efforts and innovation. Extending the ambitions, values, and characteristics of the original Apollo mission,—with the goal of landing the first humans on the moon, to the current COVID-19 pandemic—the legislative and scientific community are hopeful that the bipartisan Apollo Project for Biodefense will champion public and private sector partnership, and galvanize public support to achieve prevention and mitigation of infectious disease threats. Legislative and scientific communities are optimistic that this initiative will push the country in the right direction to better understand, prepare for, and anticipate future pandemics.

This three-paneled virtual discussion echoes the notion that positive policy change in the realm of infectious diseases is a dynamic and all-inclusive process in which various sectors have to participate and cooperate, and integrate expert advice with legislative detail to properly enact long-term change. Even from a virtual distance, it is clear that members of the legislative and scientific community are ready to take collaborative action to ensure that the world doesn’t come to another standstill in the face of future pandemics. As the country continues to struggle and recover from the COVID-19 pandemic, the right policies governed by suitable leadership will determine a nation’s future plan, response, and resilience towards infectious diseases. While the Apollo Project for Biodefense emphasizes a united and hopeful front, the panelists are aware that a great deal of coordination is still required before strategies can be translated into action. There will have to be steadfast commitment from various sectors and stakeholders in order to foster preparedness, resilience, and response during this opportune window of time.