National Academies Press: OpenBook
Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

The Neglected
Dimension of
Global Security

A Framework to Counter
Infectious Disease Crises

COMMISSION ON A GLOBAL HEALTH RISK
FRAMEWORK FOR THE FUTURE

www.nam.edu/GHRF

Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

NOTICE: Statements, recommendations, and opinions expressed are those of the Commission on a Global Health Risk Framework for the Future (GHRF Commission). The National Academy of Medicine served as Secretariat for the GHRF Commission, with support from the following National Academies of Sciences, Engineering, and Medicine staff:

Carmen C. Mundaca-Shah, Project Director

V. Ayano Ogawa, Research Associate

Priyanka Kanal, Intern (until July 2015)

David Garrison, Senior Program Assistant (from December 2015)

Mariah Geiger, Senior Program Assistant (until December 2015)

Faye Hillman, Financial Officer

Patrick W. Kelley, Director, Board on Global Health

Consultants

Anas El Turabi, Doctoral Candidate in Health Policy (Evaluative Science & Statistics), Graduate School of Arts and Sciences, Harvard University

Philip Saynisch, Doctoral Candidate in Health Policy, Harvard Business School and Graduate School of Arts and Sciences, Harvard University

Sponsors

The Commission was supported by the Paul G. Allen Family Foundation, the Ford Foundation, The Bill & Melinda Gates Foundation, Mr. Ming Wai Lau, the Gordon and Betty Moore Foundation, The Rockefeller Foundation, the U.S. Agency for International Development, and the Wellcome Trust.

International Standard Book Number-13: 978-0-309-39093-4
International Standard Book Number-10: 0-309-39093-1
Digital Object Identifier: 10.17226/21891

Copyright 2016 by the Commission on a Global Health Risk Framework for the Future.

Suggested citation: GHRF Commission (Commission on a Global Health Risk Framework for the Future). 2016. The neglected dimension of global security: A framework to counter infectious disease crises. http://nam.edu/GHRFreport. doi: 10.17226/21891.

Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

COMMISSION ON A GLOBAL HEALTH RISK FRAMEWORK FOR THE FUTURE

Peter Sands (Chair), Former Group Chief Executive Officer, Standard Chartered PLC and Senior Fellow, Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School

Oyewale Tomori (Vice Chair), President, Nigerian Academy of Science

Ximena Aguilera, Director, Center of Epidemiology and Public Health Policies, Universidad del Desarrollo, Chile

Irene Akua Agyepong, Greater Accra Regional Health Directorate, Ghana Health Service

Yvette Chesson-Wureh, Establishment Coordinator, Angie Brooks International Centre for Women’s Empowerment, Leadership Development, International Peace & Security, C/O The University of Liberia

Paul Farmer, Kolokotrones University Professor and Chair of the Department of Global Health and Social Medicine, Harvard Medical School and Cofounder of Partners In Health

Maria Freire, President, Foundation for the National Institutes of Health

Julio Frenk, President, University of Miami

Lawrence Gostin, University Professor of Global Health Law, Georgetown University and Faculty Director, O’Neill Institute on National and Global Law

Gabriel Leung, Dean, Li Ka Shing Faculty of Medicine, The University of Hong Kong

Francis Omaswa, Executive Director, African Center for Global Health and Social Transformation

Melissa Parker, Reader in Medical Anthropology, Department of Global Health and Development, London School of Hygiene & Tropical Medicine

Sujatha Rao, Former Secretary, Ministry of Health and Family Welfare of India

Daniel Ryan, Head of R&D–Life & Health and Big Data, Swiss Re

Jeanette Vega, Director, Chilean National Health Fund

Suwit Wibulpolprasert, Vice Chair, International Health Policy Program Foundation, Health Intervention and Technology Assessment, Ministry of Public Health, Thailand

Tadataka Yamada, Venture Partner, Frazier Life Sciences

Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

INTERNATIONAL OVERSIGHT GROUP

Victor J. Dzau (Chair), President, National Academy of Medicine

Judith Rodin (Vice Chair), President, The Rockefeller Foundation

Fazle Hasan Abed, Founder of BRAC and Chairman of BRAC Bank Limited

Arnaud Bernaert, Senior Director, Head of Global Health and Healthcare Industries, World Economic Forum

Chris Elias, President of the Global Development Program, The Bill & Melinda Gates Foundation

Jeremy Farrar, Director, Wellcome Trust

Shigeru Omi, President, Japan Community Health Care Organization

Paul Polman, CEO, Unilever

Mirta Roses, Former Director, Pan American Health Organization

Shen Xiaoming, Professor of Pediatrics, Xin Hua Hospital and Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine

Tan Chorh Chuan, President, National University of Singapore

Miriam Were, Chancellor, Moi University

REVIEWERS

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the Commission in making its published report as sound as possible and to ensure that the report meets International Oversight Group standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Sharon Abramowitz, University of Florida

George Alleyne, Pan American Health Organization (Emeritus) and University of the West Indies

Ramesh Bhat, Indian Institute of Management

Emmanuel d’Harcourt, International Rescue Committee

Mark Feinberg, International AIDS Vaccine Initiative

Mohamed Jalloh, FOCUS 1000

Dean Jamison, University of California, San Francisco

Margaret Kruk, Harvard T.H. Chan School of Public Health

Peter Lamptey, FHI 360

Diop Ndack, University Cheikh Anta Diop

Srinath Reddy, Public Health Foundation of India

Kenji Shibuya, University of Tokyo

Samba Sow, Center for Vaccine Development–Mali

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David Challoner, University of Florida. He was responsible for making certain that an independent examination of this report was carried out in accordance with International Oversight Group procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the Commission.

Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

Preface

“Messieurs, c’est les microbes qui auront le dernier mot.”
(Gentlemen, it is the microbes who will have the last word.)
—Louis Pasteur

While Louis Pasteur, the famed 19th-century microbiologist, may have literally spoken the truth, individuals, communities, and nations expect governments to use all the available tools of science and public policy to combat the threat of infectious disease. And where such tools are lacking, or poorly used, responsible leaders are expected to take action, plugging the gaps and enhancing execution.

Much has been done since the days of Pasteur to mitigate the threat of infectious diseases to individuals and humanity as a whole. Hygiene, water purification, vaccines, and antimicrobials have all contributed to great improvements in well-being and life expectancy. However, despite these advances, we have in the last few decades seen several large-scale outbreaks of infectious diseases, not only old foes—such as cholera and yellow fever—but new threats such as Ebola, severe acute respiratory syndrome (SARS), hantavirus, human immunodeficiency virus (HIV), and novel strains of influenza. A range of factors, including increasing population, economic globalization, environmental degradation, and ever-increasing human interaction across the globe, are changing the dynamics of infectious diseases. As a consequence, we should anticipate a growing frequency of infectious disease threats to global security.

We have not done nearly enough to prevent or prepare for such potential pandemics. While there are certainly gaps in our scientific defenses, the bigger problem is that leaders at all levels have not been giving these threats anything close to the priority they demand. Ebola and other outbreaks revealed gaping holes in preparedness, serious weaknesses in response, and a range of failures of global and local leadership. This is the neglected dimension of global security.

Part of the problem is the way this threat is perceived. Framed as a health problem, building better defenses against the threat of potential pandemics often gets crowded out by more visible and immediate priorities. As a result, many countries have underinvested in their public health infrastructure and capabilities. And global agencies, such as the World Health Organization (WHO) and the rest of the United Nations system, have lacked the focus and capacity to provide the required international support and coordination.

Yet, framed as an issue of human security, the current level of investment in countering this threat to human lives looks even more inadequate. There are very few threats that can compare with infectious diseases in terms of their potential to result in catastrophic loss of life. Yet nations devote only a fraction of the resources spent on national security to prevent and to prepare for pandemics.

Framed as a threat to economic growth and stability, the contrast is equally stark. Both the dynamics of infectious disease and the actions taken to counteract it can cause immense damage to societies and economies. And in a globalized, media-connected world, national borders are no barriers to real or perceived threats. Fears, whether rational or unwarranted, spread even more quickly than infections. And such fears drive changes in behavior and public policy, often leading governments to implement non-scientifically-based actions that exacerbate economic

Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

impact, such as travel bans, quarantines, and blockades on the importation of food, mail, and other items. Yet both at the level of individual countries and at the global level, there has been remarkably little analysis and preparation for potential pandemics as a source of economic risk.

Moreover, while economic or financial problems in fragile or failed states pose very little direct risk to the rest of the world, infectious disease outbreaks in such states represent a direct threat. The lack of health care and public health capacity in these countries is both a disaster for their own populations and an acute vulnerability for the world as a whole. The recent Ebola outbreak showed how fragile post-civil-war nations can serve as incubators for infections of global pandemic potential. Guinea, Liberia, and Sierra Leone are far from being major engines of the African economy, let alone the global economy, but the sparks that came out of their remote jungles ignited an enormously expensive global reaction. Moreover, it could have been much worse. If Ebola had spread to much bigger, more globally integrated cities, such as Lagos, Nairobi, or Kinshasa-Brazzaville, it would have been a very different story. Indeed, we saw the impact of an infectious disease spreading rapidly through urban centers around the world in 2003 when SARS emerged from China.

It was against the backdrop of the Ebola outbreak that the Commission on a Global Health Risk Framework for the Future was conceived. While Ebola was the catalyst, the aim of this exercise was to look to the future, taking a broad view of the potential threats from infectious diseases, without putting particular emphasis on a single outbreak or agent. Indeed, our objective was to set out a framework of institutions, policy, and finance that would be resilient to a wide range of such potential threats, whether known—such as influenzas, coronaviruses, and haemorrhagic fevers—or as yet unknown.

The Commission was established in response to an urgent need. Eight philanthropic and government sponsors recognized the crisis of Ebola, the underlying neglect of health systems around the globe, and the associated peril for economies and security. Because of its extensive history of managing complex advisory studies, these sponsors asked the U.S. National Academy of Medicine (NAM, formerly the Institute of Medicine) to provide staff to support the Commission in carrying out its task in a comprehensive, rigorous, and objective manner. While the NAM provided staff expertise, the Commission’s report should be regarded as independent of the NAM and all other organizations. The Commission’s task was to provide peer-reviewed consensus recommendations based on evidence and expert opinion. The 17 members of the Commission include citizens of a dozen countries, and its peer reviewers are similarly balanced. Rather than following the well-established procedures of the NAM, the process and policies of the Commission were informed by them and customized to reflect the international nature of this effort and the constrained timeframe. An Independent Oversight Group, composed of 12 eminent and diverse leaders from Africa, the Americas, Asia, and Europe, provided oversight. To ensure that the Commission drew on insights and expertise across the globe, it was informed through a total of 11 days of public meetings held in Accra, Ghana; Hong Kong; London; and Washington, DC. More than 250 invited presenters offered their perspectives at these events.

The Commission’s recommendations encompass three broad areas: first, reinforcing national public health capabilities and infrastructure as the foundation of a country’s health system and the first line of defense against potential pandemics; second, reinforcing international leadership and coordination for preparedness and response; and third, accelerating research and development in the infectious disease arena. Together, these recommendations amount to a comprehensive, costed, and coherent framework to make the world much safer against the threat of infectious disease.

Inevitably, there will be discussion as to which of the Commission’s recommendations are most important and which are the hardest to implement. Four observations are perhaps worth making in this context. First, a policy framework is most effective when the various elements combine to complement each other. Partial implementation makes even those elements that are put in place less efficacious. Second, we should heed the oft-learned lesson that, in this arena as in others, investment in prevention and preparation is worth much more than spending on response, and that the best response is a well-prepared response. Third, ultimately the fight against infectious disease outbreaks will be fought on the ground within specific communities, and the battle will only be won if these communities are engaged with and part of the response. Finally, science is our most powerful weapon in combating infectious diseases,

Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

but the development of tools such as vaccines and diagnostics must be begun before the crisis occurs. Otherwise, the time it takes to deploy scientific tools effectively could be immensely costly in terms of lives and livelihoods.

So, while we should reinforce international mechanisms to lead, coordinate, and resource the response to infectious disease crises, including strengthening WHO’s capabilities and creating contingency financing mechanisms through WHO and the World Bank, we should avoid the temptation to see such initiatives as being in any respect a complete answer. These may be the most visible actions, and perhaps the least difficult to achieve, but that does not mean they are the most important.

To make a truly significant impact in reducing the risks to humanity and to human prosperity, we must catalyze the building of stronger public health capabilities and infrastructure at a national level, even in failed and fragile states, and do so in a way that establishes effective community engagement. We do not underestimate the difficulties in achieving this, because it requires leadership at multiple levels and sustained financing. Yet this must be the top priority.

Neither do we underestimate the challenges of mobilizing additional funds for research and development in the infectious disease arena, or of achieving greater harmonization and efficiency in development and approval processes. Yet ultimately, we depend on science to enable us to counter potential pandemics. So we need to find the money and make our processes less complex and cumbersome.

Infectious disease pandemics represent one of the potent threats to humankind, both in terms of potential lives lost and in terms of potential economic disruption. The Commission’s recommendations represent a framework for making the world much safer. Now the challenge is to make them happen.

Peter Sands, Chair
Commission on a Global Health Risk
Framework for the Future

Page viii Cite
Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
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Acknowledgments

The Commission wishes to thank colleagues, organizations, and agencies that shared their expertise throughout the course of the study. Their contributions informed the Commission and enhanced the quality of the report.

First, we would like to thank the study sponsors whose support made this initiative a reality: the Paul G. Allen Family Foundation, the Ford Foundation, The Bill & Melinda Gates Foundation, Mr. Ming Wai Lau, the Gordon and Betty Moore Foundation, The Rockefeller Foundation, the U.S. Agency for International Development, and the Wellcome Trust. We especially thank The Rockefeller Foundation for hosting the report launch event at their headquarters in New York City.

We are grateful for the participation of more than 250 experts who volunteered their time and shared a wealth of information with the Commission at the four international Institute of Medicine (IOM) Global Health Risk Framework workshops on finance, governance, health systems, and research and development (R&D), as well as in two R&D consultations. Their rich discussions and contributions were critically considered by the Commission in their deliberations. Details on the workshops are provided in Chapter 1 of this report and will be published as IOM workshop summaries this year. We would like to express our gratitude to the stakeholders who participated in the R&D consultations: Manica Balasegaram, Beth Bell, Seth Berkley, Luciana Borio, Robert Califf, Edward Cox, Anthony Fauci, Peter Horby, Philip Krause, Cliff Lane, Nicole Lurie, Rohit Malpani, Gary Nabel, Judit Rius, Susan Sherman, Moncef Slaoui, Patrick Vallance, Charlie Weller, and David Wood. We would also like to thank Margaret Chan, Tom Frieden, and Jim Kim, who shared their expertise with the Commission and Secretariat through individual consultations. Olga Jonas from the World Bank also provided invaluable insight into the costings for country-level pandemic prevention and response activities. We also appreciate input from Marc Lipsitch from the Harvard T.H. Chan School of Public Health.

Collaboration with other relevant efforts was critical to the Commission’s work. We are especially grateful to Ramesh Rajasingham with the Secretariat at the United Nations (UN) High-Level Panel on Global Response to Health Crises, and Elil Renganathan with the Secretariat at the WHO Ebola Interim Assessment Panel.

We are appreciative of the support and advice on the dissemination strategy that we received from the Brunswick group, with particular gratitude to Jennifer Banks, Charis Gresser, and David Seldin. We are also very grateful to Casey Weeks for his creative work with the cover design. In addition, we want to thank Attaya Limwattanayingyong for her technical support to the Commission during the second Commission meeting.

The Commission also thanks Anas El Turabi and Philip Saynisch for their technical expertise in pandemic financing and for modeling the business case for investing in preparedness for global health events. Their contributions were critical to the Commission’s deliberations.

We would like to thank the staff in various offices of the National Academies of Sciences, Engineering, and Medicine who were crucial for the success of this project. We thank the staff who organized and conducted the IOM workshops: Allison Berger, Gillian Buckley, Eileen Choffnes, Anne Claiborne, Jack Herrmann, Kathryn Howell, Benjamin Kahn, Michelle Mancher, Rachel Pittluck, Megan Reeve, Joanna Roberts, and Annalyn Welp. We are very grateful to Katharine Bothner and Morgan Kanarek, who coordinated the critical role that the International Oversight Group played along the course of the study. We thank Laura DeStefano for successfully organizing the launch

Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
×

event of the report, as well as Jennifer Walsh, for coordinating the release of the report to the public. We also thank Megan Slavish for leading the administrative process that supported the peer review of the report. The project also received valuable assistance from Faye Hillman (Office of Financial Administration) and Rebecca Morgan (National Academies Research Center).

Finally, the Commission could not have done its work without the extraordinary efforts of the staff of the National Academy of Medicine (NAM) Secretariat, including Carmen C. Mundaca-Shah, project director; V. Ayano Ogawa, research associate; Mariah Geiger and David Garrison, senior program assistants; and Patrick Kelley, director, Board on Global Health, at the IOM. Their work was invaluable.

Page xiii Cite
Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
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Acronyms and Abbreviations

AMR antimicrobial resistance

CDC

U.S. Centers for Disease Control and Prevention

CERF United Nations Central Emergency Response Fund
CFE Contingency Fund for Emergencies
CHEPR Center for Health Emergency Preparedness and Response
CHW community health worker
CSO civil society organization

DG

Director-General (World Health Organization)

DHIS-2 District Health Information System
DOD U.S. Department of Defense
DTF district task force

ED

executive director

EIS event information site

FAO

Food and Agriculture Organization

FENSA Framework for Engaging with Non-State Actors
FETP Field Epidemiology Training Program

GDP

gross domestic product

GHRF Commission on a Global Health Risk Framework for the Future
GHSA Global Health Security Agenda
GOARN Global Outbreak Alert and Response Network

HIV/AIDS

human immunodeficiency virus/acquired immune deficiency syndrome

IASC

Inter-Agency Standing Committee

ICMRA International Coalition of Medical Regulatory Authorities
IHR International Health Regulations
IMF International Monetary Fund
IOG International Oversight Group for the GHRF Commission
IOM U.S. Institute of Medicine
IP intellectual property

MERS

Middle East respiratory syndrome

MOH Ministry of Health
Suggested Citation:"Front Matter." National Academy of Medicine. 2016. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC: The National Academies Press. doi: 10.17226/21891.
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NAM U.S. National Academy of Medicine
NATO North Atlantic Treaty Organization
NFP national focal point
NGO nongovernmental organization
NIH U.S. National Institutes of Health
NTF National Task Force

OCHA

United Nations Office for the Coordination of Humanitarian Affairs

OIE World Organisation for Animal Health

PEF

Pandemic Emergency Financing Facility

PEPFAR U.S. President’s Emergency Plan for AIDS Relief
PHEIC Public Health Emergency of International Concern
PHEOC public health emergency operations center
PPDC Pandemic Product Development Committee
PPE personal protective equipment

R&D

research & development

RCF Rapid Credit Facility
RCT randomized controlled trial

SARS

severe acute respiratory syndrome

SDG Sustainable Development Goal
SMS short message service

TGB

Technical Governing Board

TLAC total loss absorbing capacity

UN

United Nations

UNICEF United Nations Children’s Fund
UNMEER United Nations Mission for Ebola Emergency Response
UNSG United Nations Secretary-General
USAID U.S. Agency for International Development
UVRI Uganda Virus Research Initiative

WEF

World Economic Forum

WHA World Health Assembly
WHO World Health Organization
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Since the 2014 Ebola outbreak many public- and private-sector leaders have seen a need for improved management of global public health emergencies. The effects of the Ebola epidemic go well beyond the three hardest-hit countries and beyond the health sector. Education, child protection, commerce, transportation, and human rights have all suffered. The consequences and lethality of Ebola have increased interest in coordinated global response to infectious threats, many of which could disrupt global health and commerce far more than the recent outbreak.

In order to explore the potential for improving international management and response to outbreaks the National Academy of Medicine agreed to manage an international, independent, evidence-based, authoritative, multistakeholder expert commission. As part of this effort, the Institute of Medicine convened four workshops in summer of 2015. This commission report considers the evidence supplied by these workshops and offers conclusions and actionable recommendations to guide policy makers, international funders, civil society organizations, and the private sector.

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