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Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop (2019)

Chapter: 8 Overcoming Impediments to Achieving Greater Preparedness

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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Page 105
Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"8 Overcoming Impediments to Achieving Greater Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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8 Overcoming Impediments to Achieving Greater Preparedness S ession 2 of the workshop focused on identifying potential strategies to systematize and integrate outbreak and pandemic preparedness at the local, national, and global levels. This session was moderated by Kumanan Rasanathan, a board member of Health Systems Global. Panel- ists discussed how to end the cycle of panic and neglect that often occurs between major outbreaks and how to make a business case for sustained political and financial support for preparedness. To illustrate what this cycle entails, Rasanathan described the experience in New Zealand during the 1918 pandemic. Conservative estimates suggest that half as many New Zealanders died from influenza compared to those who died from World War I (Rice, 2005). Despite the significant number of deaths from the 1918 pandemic in the country, he said that New Zealand’s outbreak experience receives little attention in the country today. While after-event analyses of the pandemic spurred important changes in the country, such as the 1920 Health Act, he noted that this type of action is often made from a position of panic right after outbreaks occur; once the panic is quelled, the issues recede from mainstream priorities. Some periods of action have served as opportunities to build institutions, but for Rasanathan, sufficient political and financial support has not yet been mobilized to make preparedness activities mainstream during all seasons. He suggested that breaking this cycle is the key to making pandemic preparedness a stable, integrated, and systematic activity, and he explained that the workshop panel would speak to the heart of these issues. The first panelist, Julie Gerberding, executive vice president and chief patient officer at Merck & Co., Inc., discussed strategies for institutionalizing 101

102 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS the exercise and practice of preparedness as a way to break this cycle of panic and neglect. Jimmy Kolker, visiting scholar at the American Association for the Advancement of Science (AAAS), explored the role of U.S. leader­ hip in s international efforts to advance preparedness. Suzet McKinney, executive ­ director and chief executive officer of the Illinois Medical District, described strategies for strengthening local-level preparedness capacities. Finally, Peter Sands, executive director of The Global Fund to Fight AIDS, Tuberculosis and Malaria, explored the need to broaden the concept of health security and to strengthen day-to-day health systems in order to bolster prepared- ness capacities. The session also featured small-group discussions that allowed the public audience to examine potential priorities for systematiz- ing and integrating outbreak and pandemic preparedness. INSTITUTIONALIZING PREPAREDNESS Julie Gerberding, executive vice president and chief patient officer at Merck & Co., Inc., explored strategies for institutionalizing the exercise and practice of preparedness. She remarked that the preparedness cycle is not always characterized by panic and neglect per se, but the cycle generally features a period of intense focus and attention, investment, planning, collaboration, and coordination that eventually relaxes into a phase of inattention and dispersion. She noted that the after-action reviews that typically occur when the intense response period has settled tend to identify “left-brained” improvement areas for responses to threats, such as collaboration, coordination, capacity, and competency. In contrast, the response during a threat occurs in a “right-brained” environment associated with emotions. Efforts intensify and escalate during an event, but when the action ends, people relax into a state of inattention, and the focused conditions are not sustained. She suggested finding ways to take these left- brained ideas and tools—such as sustained investment, global leadership, and continuity of preparedness over time—and apply right-brained energy to translate them into an action agenda to strengthen preparedness between events. The high water mark of domestic preparedness typically occurs when an entire country is galvanized around preparing for a pandemic, Gerberding said. The challenge is to find ways to encourage members of leadership to engage and invest in preparedness efforts even in the absence of an impending threat. One possible strategy is to institutionalize the exercise and practice of preparedness on an ongoing basis. However, she said, activities such as exercising response plans require resources and budgetary support that are not typically available during interim periods. She suggested communicating the urgent message, to all levels of decision makers, that a budget sustained beyond specific threats is required in order

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 103 to restore the abilities to exercise and to strengthen preparedness both nationally and globally. She added that leaders should use such budgets to establish routine opportunities to plan and to exercise the scenarios that are most likely to threaten the population. Participating in preparedness for response exercises can impress upon leadership and the general public that current preparedness efforts are insufficient to deal with a crisis. Gerberding said, “Even though the threat may not be imminent, they can imagine what it would be like, and they recognize the gap between what they are able to do now and what they need to be able to do.” A stronger coalition of people committed to preparedness would also help to coordinate work that is currently being conducted in silos. Finally, she suggested that one way to support the role of the World Health Organization (WHO) as a strong global leader in preparedness would be through greater investment and greater engagement from national governments, many of which rely on WHO’s coordinating function during a global event. U.S. LEADERSHIP IN ADVANCING GLOBAL PREPAREDNESS In his presentation, Jimmy Kolker, visiting scholar at AAAS, focused on the role of U.S. leadership in overcoming national and global impediments to preparedness. Drawing on his experiences as a former ambassador and as an assistant secretary for global affairs in the United States, he said that people often talk about political will as if it were a switch to be flipped by diplomats or by policy makers who are skilled at inserting their priorities into political agendas. However, a more effective way to build political will and to garner attention for an issue is to publicize data and evidence tailored to local contexts; this makes theoretical problems more relatable and attractive to the people who make decisions. For example, this type of tailoring might involve breaking down disease burden statistics by country, providing comparison data, and employing personal narratives. Kolker explored the role of the United States as a leader in corralling global political and financial support. He noted that the United States is often viewed as a reference point for international discussions about preparedness, despite the fact that its system is far from perfect. However, he added that the experience with The President’s Emergency Plan for AIDS Relief illustrated that presidential leadership, interagency buy-in, sustained financial commit- ment, and global reach are crucial for the U.S. leadership to affect global-level change. Kolker used the global efforts to combat antimicrobial resistance to illustrate how the United States can play a leadership role in preparedness for pandemic threats and how those efforts can be hampered by a lack of global reach and sustained financial commitment (see Box 8-1).

104 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS BOX 8-1 U.S. Leadership in Global Efforts to Combat Antimicrobial Resistance The U.S. government disseminated data and evidence on antimicrobial resistance in a 2013 report that laid the groundwork for the 2014 U.S. National Strategy for Combating Antibiotic-Resistant Bacteria (National Strategy) (CDC, 2013a). The National Strategy set forth specific requirements for U.S. government agencies to help gain interagency buy-in, but it did not have sustained financial commitment or enough global reach to communicate to other countries the importance of addressing antimicrobial resistance. In 2015, the U.S. Congress appropriated funds for the accompanying U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria, which outlined milestones to implement the National Strategy. The World Health Assembly passed the Global Action Plan on Antimicrobial Resistance (Resolution 68/20) in 2015, for which every country was to develop a national antimicrobial resistance plan; however, the Global Action Plan had no attached funding. In 2018, 52 countries (mostly high-income) enrolled in the World Health Organization’s Global Antimicrobial Surveillance System. Since then, some progress has been made. Forty countries have provided information about national surveillance systems. In addition, 22 countries have provided data on levels of antibiotic resistance, but a much larger number of countries have not provided any information (WHO, 2018c). The United States has maintained the National Strategy under the current presidential administration. Progress against antimicrobial resistance in the United States is evident in the U.S. Food and Drug Administration’s ban on the use of antibiotics to promote growth in livestock. However, U.S. policy has lagged behind Europe in other areas such as failing to prohibit the distribution of antibiotics to healthy animals in a herd with no sick animals. Experiences in Europe suggests that such policy changes could help control antimicrobial resistance. SOURCE: Kolker presentation, November 28, 2018. Kolker said despite the current vacuum of U.S. engagement in many multilateral forums, the U.S. role in combating antimicrobial resistance remains important because efforts made at the local, state, and national levels are scrutinized by other countries as a model of sufficient health and scientific standards. He outlined a set of additional areas in which the United States could play a leadership role on the international front. For example, antibiotic stewardship could be a condition of health coopera- tion with respect to prescription practices, over-the-counter restrictions, and manufacturing practice (particularly related to waste management). Market failures driven by the lack of economic incentives for research cause concerns with specific relevance to outbreaks and epidemics (Heymann et al., 2015). He suggested that better incentive models are needed that

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 105 do not place the onus on the U.S. government or on WHO to finance the development of new antibiotics through an advance market commitment to assume responsibility for the stewardship of those new drugs. Kolker observed there is a similar sense of uncertainty about the responsibility for leadership in ensuring that medical countermeasures will be available for future outbreaks of global significance. Kolker explored the extent to which the Global Health Security Agenda (GHSA) and Joint External Evaluation (JEE) efforts may help end this cycle of panic and neglect in preparedness. He noted that considerations of antibiotic resistance are not explicitly part of the International Health Regulations (IHR) but are part of the GHSA action packages and that the JEE does assess capacity and needs related to combating antimicrobial resistance. He explained that prior to the JEE process, the IHR did not provide assistance in outbreak preparedness and response, but the Ebola outbreak underscored the need for such support. He described the GHSA and JEE efforts as “game changers” that provide a necessary but not sufficient condition to halt the cycle of panic and neglect. However, many countries or partners still fail to fully recognize the programmatic advantages of addressing antimicrobial resistance as part of health security. Kolker concluded by suggesting that the most important action that the U.S. government should take is to increase its investment in global health research and preparedness. Such investment would provide support for global institutions to take a normative, leadership role within an international multilateral system. This would alleviate some of the burden on the United States with respect to both financing and responsibility, he noted. Also, such investment would directly benefit the United States because the alternative ad hoc scenario would place a disproportionate burden on the country to prepare for future crises. MAKING THE CASE FOR LOCAL PREPAREDNESS Suzet McKinney, executive director and chief executive officer of the Illinois Medical District, provided a local-level perspective on preparedness. She said a business case needs to be made for sustainable investment in outbreak preparedness, but this is difficult because of the competing priorities and limited resources at the local and state levels. Although the local level is where the “rubber meets the road” in terms of science, policy, and operational guidance, complacency remains a problem. She noted that the impact of previous outbreaks is quickly forgotten, and during pre- outbreak periods, members of leadership do not have tangible evidence of impending threats. She suggested finding more compelling ways to convey the significance of outbreaks to leaders and stakeholders in terms they can understand and to which they can relate. For example, workshops

106 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS could convene local and state officials and stakeholders from the health care, government, and business sectors. Stories and narratives from actual emergencies and outbreak situations could also be leveraged to emphasize the importance of outbreak preparedness. Champions from industry and philanthropy could also be helpful, especially when they could provide additional financial support. Sustained federal investment in preparedness is important, she added, because it is difficult to make the case that local and state officials should invest in preparedness in the absence of sustained federal investment. McKinney explored strategies to gain political and financial support from high-level stakeholders at the local and state levels. The overarching strategy she recommended was to educate local leaders and stakeholders about how outbreaks in their jurisdictions could affect their abilities to govern and about how investment in preparedness could protect against those challenges. For instance, outbreaks and pandemics could affect the political prospects of elected officials by impacting local economies, disrupting educational systems, and causing civil unrest. Educating local business leaders about the potential effects of outbreaks and pandemics on their bottom lines might also encourage protective investment in preparedness. People who live and work in local communities can help contribute to ending cycles of panic and neglect. However, McKinney said, they need to be equipped with information and knowledge to empower them and to enable them to act. This is a challenge because many communities, especially those with underrepresented or vulnerable groups, continue to mistrust the government. Moving beyond this mistrust will require being more inclusive of communities in preparedness efforts, she remarked. Community engagement is a powerful tool that can help quell panic and chaos during a crisis by increasing compliance with preparedness efforts, such as vaccination, and by helping public health officials understand the unique vulnerabilities within specific communities. McKinney noted that community health workers, faith-based organizations, and community- based organizations are often considered trusted agents that can also play a role in helping communities understand the importance of preparedness. BROADENING THE CONCEPT OF HEALTH SECURITY Peter Sands, executive director of The Global Fund to Fight AIDS, Tuberculosis and Malaria, said the cycle of panic and neglect is unsurprising from an economic standpoint. Behavioral economics has shown that when faced with low-probability, high-impact risks, people tend to overreact or to massively underreact; people also tend to be susceptible to the availability heuristic and to over-optimism. In the context of an infectious disease

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 107 outbreak, this combination of factors drives the cycle of panic and neglect. He suggested breaking that cycle will require structural and institutional efforts to make the risks and the degrees of preparedness more transparent. There have been a fair number of economic analyses of the risk of infectious disease outbreaks, Sands said, but the situation is not ideal in terms of institutionalizing these analyses. Ad hoc economic analyses of the cost of a large-scale influenza epidemic, for example, are not useful unless they are incorporated into the mainstream macroeconomic analyses that drive policy decisions. This tends to happen only after an incident has occurred. He suggested that in order to converge different decision maker perspectives on investment in preparedness, the risk of outbreaks needs to be successfully factored into economic policy making in the same way that other kinds of risks are factored into the economy. Sands remarked that the global health community is currently focused on collaboration to achieve multiple objectives through different institutions with individual mandates (e.g., the Global Action Plan for Healthy Lives and Well-Being for All1). Such collaboration would also benefit global preparedness efforts because response efforts are shaped by context—outbreaks do not occur in isolation. For example, the response to the current Ebola outbreak in the Democratic Republic of the Congo is being impeded not by technical limitations but by violence in the area, which prevents health workers from intervening effectively. He suggested that adopting this broader perspective would also help strengthen local capacity because encouraging local officials and communities to invest in preparedness requires communicating the concept of health security in a way that makes practical sense to them. Sands argued that the concept of health security often promulgated is counterintuitive—from a political perspective or, arguably, from an ethical perspective—because it asks national governments to invest money in diseases that might kill their people instead of asking them to invest sufficiently in diseases that are killing their people in large numbers every day. For example, the current Ebola outbreak in the Democratic Republic of the Congo has killed more than 500 people and has mobilized much effort and attention, but during the same period, 20,000 people died of malaria in the country (WHO, 2018b). He said that given this disparity, convincing officials to prioritize Ebola over malaria is difficult. Sands maintained that a new concept of health security should be developed to directly address the diseases that are currently killing people in 1 Coordinated by WHO, this Global Action Plan unites 12 health and development interna- tional organizations to commit to finding new ways of working together to accelerate progress toward achieving the Sustainable Development Goals. For more information, see https://www. who.int/sdg/global-action-plan (accessed February 26, 2019).

108 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS vulnerable countries. This involves building day-to-day capacities—such as disease surveillance, frontline health workers, and diagnostic laboratories— that simultaneously build the contingency and resiliency capabilities neces- sary to handle outbreaks. He said institutions should focus more keenly on how efforts to fight diseases such as malaria can be used to achieve broader health security objectives. Catalyzing action, Sands reiterated, will require conceptualizing health security in a way that makes sense to people work- ing on the ground. He added that businesses are an under-leveraged point of action because many are unaware of their vulnerabilities to infectious disease risk and of the net impact of outbreaks. Engaging business owners and encouraging them to think more systematically about the nature of their exposures can encourage them to advocate for better preparedness. DISCUSSION Reflecting on the panel presentations, Kumanan Rasanathan, board member of Health Systems Global, highlighted the importance of identify- ing and connecting with people’s specific interests and incentives to ensure adequate preparedness. He said the broad realities of people’s lives need to be considered—at the global level, with the Sustainable Development Goals as a unifying framework—and at the individual level, by identifying the health threats of greatest concern. In 2013, 40,000 children under 5 years of age died in Sierra Leone, but this tragedy was not considered a global health emergency; in contrast, an outbreak that people fear is a global risk can suddenly become a global health priority (UNICEF, 2013). Rasanathan observed that the cycle of panic and neglect is difficult to escape because, in many ways, the habitual framing of outbreaks lends itself to this cycle. He suggested that trying to understand and to address these challenges in particular ways—such as by communicating evidence and risks through narrative strategies that personalize the potential impact of outbreaks—may lead to improvements. Furthermore, the cycle itself could be exploited by capitalizing on any opportunities that arise from the focused attention dur- ing crises in order to build lasting capacities and institutions. He noted that people who participate in exercises on preparedness for response exercises, for example, develop a sense of the potential impact of outbreaks on their lives and their core businesses, which incentivizes their continued focus. In addition, Rasanathan underscored that preparedness work needs to be bridged with other health concerns and with other sectors. Global health has often encouraged “single issue fundamentalists” who focus exclusively on a given issue, in many cases very successfully, but he urged that pan- demic preparedness needs to be situated in the broader context. As Sands suggested, to gain credibility, preparedness should be linked to existing infectious threats (such as malaria), to day-to-day health concerns (such

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 109 as diabetes and cardiovascular disease), and to individuals’ concerns about their personal security in conflict areas. Rasanathan reminded the audience that communities are heterogeneous and diverse, so one-size programs do not, in fact, fit all. To be equitable, he said, more attention must be paid to vulnerable populations that have high levels of risk and that often miss out from government and private-sector interventions. The heterogeneity of society at large should also be recognized, he added, because preparedness is often a government enterprise that does not sufficiently reflect the inputs of communities or of the private sector, which has many resources and capacities to contribute. He added that although investment cases are use- ful, there are so many of them in global health—which tend to be based on models with a large number of assumptions—that they can be difficult for policy makers to bring together. There is rarely a sense of relative prioritiza- tion that examines the tradeoffs involved in different investment strategies. Transcending the Cycle of Panic and Neglect Rasanathan asked panelists if they believed it was possible to transcend the cycle of panic and neglect or if periods of higher and lower priority were inevitable. Gerberding said pandemics and outbreaks are increasingly probable events, but because their geographic spread and timing cannot be predicted, a national defense model is more apt than a probabilistic one. She noted that even the poorest countries seem to be able to find resources and to sustain investments in their defense capabilities, and this mentality should be shifted to the fight against microbial enemies. Kolker remarked that in the near future, the economic impact of infectious diseases will be of similar magnitude to those of terrorism and of climate change; yet, spending on infectious disease preparedness is orders of magnitude lower than spending on other areas. An episodic approach is not appropriate for infectious disease preparedness or any other systemic problems, Kolker said. McKinney maintained that the status quo is unacceptable because outbreaks have become more frequent and severe over time. She suggested a whole-community approach to preparedness, which balances top-down approaches to engage high-level local leaders with bottom-up approaches to engage community members, stakeholders, and faith-based leaders. Sands agreed that outbreaks are increasing and are not the type of events that occur only once in 100 years. Although efforts to deal with the morbidity and mortality impacts of infectious disease outbreaks have improved, complacency is unacceptable because today’s interconnected global economy is more vulnerable to the swift and powerful knock-on eco- nomic impacts of events that occur on the other side of the world. He said preparedness efforts need to improve through a holistic capacity-building approach, which will require building the components of the JEE to be able

110 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS to deliver on near-term health objectives for a specific community. This approach enables joint benefits: It solves immediate health problems and exercises and tests a system’s capacities prior to a major event. Sands added that health security capacity building should be integrated with efforts to solve communities’ immediate health needs; this type of effort would build trust within communities and would enhance the credibility of health authorities and frontline workers. Peter Daszak, president of EcoHealth Alliance, asked for examples of how the cycle of panic and neglect has been transcended for infectious diseases or other cyclical health threats, perhaps strategies that were insti- tutionalized during one crisis but were designed to last through the next. Kolker reflected on some of the strengths and weakness of the anthrax and Ebola responses. Both were emergency appropriations and did not create a continuum of funding. However, the Biomedical Advanced Research Development Authority (BARDA) and the Assistant Secretary for Pre- paredness and Response (ASPR) within the U.S. Department of Health and Human Services were created in response to the anthrax event, which has institutionalized business–government cooperation. He noted that the Ebola outbreak helped catalyze the GHSA, which, in turn, led to develop- ing the JEE and placing WHO at its lead. Kolker added that after its 2015 reforms, WHO approached the Zika and Ebola outbreaks in the ­ emocratic D R ­ epublic of the Congo in a more coherent way. This included the creation of standing agreements to increase surge capacity with actors that did not previously have organic working relationships with WHO. However, he said, U.S. government agencies such as the U.S. Centers for Disease Control and Prevention (CDC) still tend to have a risk-avoidance mentality rather than a risk-management one, which precludes the agency’s intervention in less secure settings such as Eastern Congo. This risk-avoidance mentality is self-defeating, Kolker said, because it undermines the new approaches to pandemic preparedness that the United States helped establish. He noted that CDC has specialist experts who could be dispatched to help other countries elevate their systems to first-world capacity, but the agency is not structured to do so. Insurance for Preparedness and Response Efforts Bruce Gellin, president of global immunization at Sabin Vaccine Insti- tute, asked about the potential for insurance to mitigate downstream risk and to reduce payouts after an event. Sands responded that the role of insurance is both overstated with respect to countries and understated with respect to the private sector. Insurance related to outbreaks has two functions: (1) it provides cash to respond to an event after it has happened, and (2) it creates incentives for better preparedness if that investment is

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 111 reflected in lower premiums. Among more vulnerable countries in particu- lar, however, money is relatively easier to obtain during a crisis response than during preparedness efforts. Insurance does not create the right type of incentives for this situation, Sands added, because vulnerable countries will not be able to obtain a sensible price for infectious disease risk; fur- thermore, any preparedness efforts that do exist are typically donor-funded. He argued that it is not advantageous to have low-resource countries pay expensive premiums for an insurance product—using money they could be spending on actual risk mitigation—because insurance, in and of itself, does not mitigate any risk. Sands noted two factors about infectious disease outbreaks that make the economics of insurance more difficult. First, because the externalities are so large in relation to the risk borne by the payor, much of the cost and threat of an infectious disease outbreak is not borne by the country in which it first originates. Second, an outbreak is not a discrete event with immediate consequences, such as an earthquake or a flood; because it is an event that unfolds over time, its trigger is much more difficult to define. Sands noted that the only payout from World Bank’s Pandemic Emergency Financing Facility to date was from a component of the mechanism that was not insurance-driven because the insurance component had not been triggered. Sands suggested that more insurance options related to infectious disease outbreaks could be useful in the corporate sector because they would establish the right incentives for businesses to better prepare for outbreaks, and that would be reflected in premiums. However, corporate insurance for outbreaks is not currently available in most places. Building a Political Movement for Preparedness Carolyn Reynolds, vice president of policy and advocacy at PATH, suggested that moving the preparedness agenda forward will require invest- ing directly in building political will. She emphasized that politicians and funders need to be presented with a cogent political argument to garner interest and to convince them to act. Kolker said that obtaining predictable and sustainable funding for preparedness will require creating a politi- cal coalition. McKinney described an innovative local-level approach to building political will that was used in New York City: A one-page threat- response guide was created for local elected officials, which summarized the threat, the impact it could have on the city, and the actions neces- sary to avoid that impact. She suggested that this type of practice could be extrapolated to build political will among other elected officials. For ­ example, guidance could be provided to the members of U.S. Congress who control appropriations, so they are aware of the importance of prepared- ness. Leveraging other existing systems that have already been developed

112 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS could also help to maintain the continuum of preparedness in the face of funding cuts, she added. For example, existing community coalitions could be incorporated into issues around outbreaks and pandemic preparedness. Gerberding noted an additional benefit of strengthening private-sector busi- ness participation in preparedness is that it is a component of building political will. Bridging the Dichotomy Between Pandemic and Day-to-Day Preparedness Rima Khabbaz, director of the National Center for Emerging and Zoonotic Infectious Diseases at CDC, pointed out the perceived dichotomy between investment in preparedness and investment in day-to-day threats. Pandemics receive large amounts of attention and resources in the short term, but these reactions do not build the type of awareness needed to encourage people to invest in capacities for both day-to-day threat response and surge capacity for preparedness. Gerberding said that focusing more attention on preparedness during the interim periods will require drawing on institutions and measures already in place. For example, businesses could integrate and institutionalize preparedness as part of their existing planning processes. Businesses are often required to conduct risk assessment, risk mitigation, and risk planning, so many companies already have approaches that could be expanded to include outbreak risk. Bringing preparedness planning into existing risk assessment structures would highlight the potential impact of an outbreak on the continuity of business and the potential for mitigation. In a health-related business, planning for a health threat becomes even more germane, she added. Not only must the business be protected, she said, but the people who depend on vaccines and medicines must also be protected. Pia MacDonald, senior director of applied public health research at RTI International, said that the business community needs to be better educated about the risk of pandemics. She noted that a recent risk evaluation study of Fortune 500 companies found that many firms that had disclosed significant levels of international sales had not disclosed any risks around disease outbreaks or other public health issues in their 10-K filings. Sands reiterated that much ongoing work could have practical benefits for outbreak preparedness. For example, creating emergency operation centers focused on malaria also builds emergency management capability that can be multipurposed for an outbreak. Some of the JEE’s components may map onto current work, such as Gavi, the Vaccine Alliance’s cold chain distribution systems for vaccines and the Global Fund’s disease surveillance system for tuberculosis, HIV, and malaria. He suggested that systems and capabilities should be implemented in a deliberate, systematic, and forward-thinking way to serve specific purposes while also having the

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 113 potential to strengthen preparedness efforts. If the more general elements of preparedness are achieved through multipurpose programs in pursuit of the broader health systems development agenda, he added, then efforts specific to health security will become narrower in scope and easier to achieve. Integrating Health Security Capabilities into the Health Agenda Rafael Obregon, chief of communication for development at the United Nations Children’s Fund, asked about practical entry points for integrating health security capabilities into the broader health agenda, given that the donor community and ministries of health tend to be issue-driven and to support vertical programming. Sands said one point of integration could be one of the indicators (3d) of Sustainable Development Goal 3 (SDG3), which states the importance of strengthening the capacities of all countries, in particular developing countries, for early warning risk reduction and for management of national and global health risks.2 The significance of the Global Action Plan for Healthy Lives and Well-Being for All is that the participants will not only pursue their individual mandates but also work together to help other countries deliver on the SDG3 agenda. Kolker noted that the SDGs, while important, have encroached somewhat on the integrated global health agenda because they do not directly address health security. As a result, health security is not being prioritized in spending decisions or being measured to the extent that it should. Sands said though they are far from perfect, the SDGs reflect the frame through which major donors and health multilaterals think. He argued that a broader concept of health security with greater political and ethical legitimacy is needed. The current narrative around health security is that “poor, vulnerable countries should invest in things that might kill them, rather than the things that are killing them . . . this has not worked, and it is not going to work,” Sands said. Shifting from Threat Protection to Health Promotion Keiji Fukuda, director and clinical professor, School of Public Health, The University of Hong Kong, observed that public health focus has expanded to include noncommunicable diseases as well as infectious dis- eases, which has driven a fundamental shift toward promoting wellness in addition to reducing health threats and fighting diseases. He wondered if the traditional threat-reduction approach will be abandoned because many people perceive infectious disease outbreaks as irrelevant, distant events. 2 For more information on the other SDG3 indicators, see https://sustainabledevelopment. un.org/sdg3 (accessed February 11, 2019).

114 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS Similar concerns apply to the current focus on catalytic funding rather than sustainable funding for capacity building. Fukuda asked if the mes- sage should be changed or if shifting the narrative would undermine the effort. Gerberding remarked that local and state tools have been updated to include measures of how many people are optimally well in a given population. Such updates could allow health to be reconceptualized as a community good that warrants investment, like any other natural resource, through the “health in all policies” approach. McKinney suggested com- municating how the lack of appropriate pandemic preparedness may undo advancements in health and wellness and create even greater disparities and inequities in health. Potential Technological Advances and Considerations Avital Percher, AAAS fellow at the National Science Foundation, asked about technological advancements that may enhance response to an out- break or pandemic. Kolker replied with an example from the Ebola and H1N1 outbreaks. Before surveillance systems were implemented, Internet search terms about symptoms were predictors of where outbreaks would occur. He suggested finding ways to systematize social media to help iden- tify problems and to respond to them. Sands highlighted several types of technologies that he believed would be impactful, including • inexpensive, point-of-care diagnostic technologies that can be used by relatively unskilled workers to support response to any disease; • advanced geospatial mapping tools that could be used in resource- poor environments as a basis for contact tracing and incidence mapping, which would allow interventions to be targeted effectively; and • modern communication technologies that could be used to build rather than to undermine trust, which would allow governments to maintain a voice of authority and credibility. Monique Mansoura, executive director for global health security and biotechnology of MITRE, asked panelists about the sustainability of the business model for companies that make vaccines or other medical countermeasures. Gerberding reported that Merck’s experimental Ebola vaccine, which is currently being used in the Democratic Republic of the Congo, was not developed as a commercial opportunity. Because it cost far more money to produce than the company would ever recover, Merck did not consider it to be a sustainable solution. She suggested that the Coalition for Epidemic Preparedness Innovations (CEPI), a global alliance that finances

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 115 and coordinates the development of vaccines against infectious diseases, is important because it facilitates the development of priority countermeasures to known threats. However, she added, CEPI will likely require partnership with existing companies because they are unlikely to have experience in the domain of approval and licensure. Vaccines and vaccine technology also remain a global concern; there are daily shortages due to difficulties with manufacturing and to the decreasing number of manufacturers. Gerberding predicted market failure will become increasingly inevitable and will require a change in strategy toward a biodefense mentality. Reflections on Overcoming Impediments to Pandemic Preparedness In summary, Rasanathan underscored the need to think about preparedness in a “big picture” way by reflecting on successes in past responses and on why the cycle of panic and neglect is difficult to escape. As Rudolf Virchow (2006) said in his report on the 1848 typhus epidemic in Upper Silesia, “medicine is a social science, and politics is nothing else but medicine on a large scale.” Rasanathan noted that the same challenge persists today: integrating public health evidence and science with efforts to address psychology, behavioral economics, and personal incentives and emotions. According to Rasanathan, the panelists seemed to agree that the cycle of panic and neglect can be escaped, but it will be difficult. When approaches to outbreak preparedness and to non-disease threats, such as war or terrorism, are compared, stark differences in the investments and their sustainability emerge. However, given the advancements in outbreak preparedness over the past century, Rasanathan noted that today’s scenario could be much better. He suggested that in order to motivate people— from a village in Liberia to high-level policy makers in Switzerland—to engage in the preparedness endeavor, stakeholders need to understand how preparedness relates to their daily lives and how it connects with other challenges and threats they encounter on a daily basis. Additionally, the preparedness community needs to focus on attaining a continuum of funding, Rasanathan said. He noted that even the health sector does not appear to be convinced that preparedness warrants significant investment. Garnering investment in preparedness should be feasible, he said, given that $10 trillion is available in the global health sector within the broader frame of the integrated global health agenda. At the same time, other relatively low-probability, high-impact events, such as war or terrorism, have been able to garner continuous funding. He observed that one reason for this trend may be people’s ability to relate to stories about war and terrorism. Similar stories are not typically told about outbreaks, but heroic stories abound during crises. For instance,

116 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS in a village in Liberia, Rasanathan heard tales of heroism, such as stories about people who decided to care for their fellow villagers and who did not touch their own children for 3 months. But these stories, he reiterated, are quickly forgotten and seem to disappear from the public consciousness in a way that stories of war and terrorism do not. Rasanathan suggested the public health community should be proud about some of the achievements in preparedness, but the community should also reflect on how to improve current efforts. Although the efforts might not always proceed in a straight line, he concluded, it is important to leverage the inflection points at which efforts might be intensified and institutions might be built. SMALL-GROUP DISCUSSIONS: POTENTIAL STRATEGIES TO SYSTEMATIZE AND INTEGRATE PREPAREDNESS For the second half of the session, the audience members assembled in small-table groups to reflect on specific actions and strategies that could be prioritized so outbreak preparedness could become a routine—and not extraordinary—part of governmental and other organizational activities at the local, national, global, and private-sector levels. To help spark these discussions, the moderator Jonna Mazet, professor of epidemiology and disease ecology and director of the One Health Institute at University of California, Davis, summarized some key points for ending the cycle of panic and neglect that she captured from the panelists during the first half of the session (see Box 8-2). After the table-group discussions, members of the audience shared some of their reflections from the session. Audience members discussed issues that ranged from bolstering preparedness capacities of governments and communities to creating effective messaging and educational tools for relevant stakeholders. First, David Fidler, professor of law at Indiana University Bloomington, highlighted the importance of accepting and embracing the window of panic as an inevitable component of preparedness. He added that every policy area experiences this cycle of panic and neglect; it is not exclusive to global health. Panic should be construed as a process to be studied in order to find ways to leverage the opportunities that a crisis provides and to work more effectively with decision makers in panic situations, he said. Approaching panic as a process can provide opportunities to reduce the political elasticity seen in global health and to make it more like other areas of policy, which are more inelastic with regard to the cycle of panic and neglect. Jay Siegel, retired chief biotechnology officer and head of scientific strategy and policy for Johnson & Johnson, said that his group discussed whether adequate governmental organizational structure and leadership is

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 117 BOX 8-2 Potential Priorities for Ending the Cycle of Panic and Neglect Jonna Mazet, executive director of the One Health Institute and professor of epidemiology and disease ecology at the University of California, Davis, presented some takeaways she captured from panel discussions about strategies at local, national, global, and private-sector levels that may help end the cycle of panic and neglect for pandemic preparedness: • Conceptualize health security and preparedness in ways that make sense not only at global but also at local and national levels. • Establish a sustained budget for preparedness efforts so that institutionalized capacities and systems can be built. • Build local- and national-level political will for preparedness. • Convene forums and workshops focused on preparedness at the local and state levels. • Educate, equip, and empower local communities, using trusted community agents, with the information and knowledge to act. • Fight day-to-day endemic diseases by building health system capacity and by engendering trust among communities so that systems are in place—and community members are willing to use them—when an emergency strikes. • Publicize data, evidence, and narratives about preparedness in a more compelling way. • Effectively leverage social media to coordinate preparedness efforts. • Support the strengthening of the World Health Organization and other global institutions in order to facilitate preparedness efforts. SOURCE: Mazet presentation, November 28, 2018. in place for preparedness in the United States. He noted that government responses to disasters over the past few decades (e.g., the sulfanilamide and thalidomide disasters) have led to the creation of legislation and infrastructure that are able to deal with and prevent many problems. He reported that some members of the group wondered whether BARDA and ASPR are adequately resourced and staffed to drive behavioral changes throughout different levels of government and across society as a whole. Julie Pavlin, director of the Board on Global Health at the National Academies of Sciences, Engineering, and Medicine, reported that her group discussed institutional capabilities to create a broad interagency organiza- tion in the United States. Ideally, this agency would have the authority and budget necessary to unify the different capabilities in a sustainable and expandable way in times of international disaster. A model like the U.S.

118 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS Federal Emergency Management Agency (FEMA) could be useful—one that delegates responsibility and decision making for preparedness and response but also has a complementary international focus. Pavlin also noted the importance of educating politicians, the public, and other governments about the risks of seasonal influenza, which are often poorly understood, and how to use seasonal influenza response capacity to build a platform of knowledge and capacity to respond during a pandemic event. Other participants also proposed adopting a FEMA-like model. Elizabeth Hermsen, head of global antimicrobial stewardship at Merck & Co., Inc., reported that some of her group members discussed the need to develop a FEMA-style playbook for preparedness that clearly outlines leadership roles and actions for specific situations and that details back-up plans. This playbook should extend beyond the health-specific response components to include a more multisectoral and whole-community response, she said. In conjunction with the playbook, the group discussed the idea of creating a credit line on reserve to expedite access to funding and to avoid the lengthy negotiations typically required for appropriations. Ashley Grant, lead biotechnologist at MITRE, added that members of her group also discussed the potential of a FEMA-style model for preparedness. In addition to strengthening government-level capacities for prepared- ness, Eva Harris, professor of infectious diseases and vaccinology at the University of California, Berkeley, commented on the need to embrace communities. The concept of community is heterogeneous. In some settings, communities are already unified, and in others, they are fragmented—but there is always some level of organization already in place. She said the task should be to recognize and strengthen existing elements and to create linkages to health and preparedness. Similarly, Emily Erbelding, director of the Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Dis- eases, reported that her group focused on the importance of strengthening local capacities, particularly the surge capacity of local health departments, because many departments lack sufficient capacity to conduct day-to-day work. She also noted that some participants in the group discussed day-to- day surveillance for infectious diseases, outbreak response, and outbreak prevention and debated whether health departments would be better pre- pared for a crisis if systems were in place to collect metrics from more ­ ypical outbreaks. These metrics could be monitored to identify deficits and t to apply resources to address them. Furthermore, some group members also discussed the need for structural interventions, such as advance purchase agreements, to reduce the need to procure large quantities of vaccines and/or antivirals during a crisis. Further highlighting the role of communities, Obregon also argued for the need to strengthen local capacities and community preparedness, with

OVERCOMING IMPEDIMENTS TO ACHIEVING GREATER PREPAREDNESS 119 an emphasis on preparedness exercises. He said that to build community resilience and the capacities necessary to prepare for and respond to outbreaks, a broad set of stakeholders and community actors should be included in the process. This process might include, for example, templates or approaches developed for influenza that would also cover a number of other critical elements for strengthening local capacities. A broader public health perspective should be adopted, he added, to ensure that the approach is flexible and adaptable to other kinds of outbreaks or situations that are priorities for the community on a day-to-day basis. He stressed that efforts should also focus on coalition building and on bringing actors from beyond the health sector to the table for discussions—for example, engaging with local politicians and decision makers to communicate the benefits of investing in preparedness for that particular community. Finally, Obregon noted the need to use targeted messaging and communication strategies to raise awareness about the potential impact of outbreaks on local communities. Care should be taken to frame messages positively, he said, and to avoid negative framing that may be amplified by social media and other communication channels. For instance, in the event of a vaccine failure, it would be helpful to focus on the lives that were saved rather than on the failure itself. In a similar vein, Hermsen suggested focusing on education about pandemics and implementing non- pharmaceutical interventions at the local level—such as infection prevention in school-age children—to ensure that community-level preparedness functions are better engrained. Amanda McClelland, senior vice president of Prevent Epidemics at Resolve to Save Lives, added that work is needed to determine how strategies for risk communications should be put together for the community level, particularly in the United States where social media plays such a central role in public life.

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In November 2018, an ad hoc planning committee at the National Academies of Sciences, Engineering, and Medicine planned two sister workshops held in Washington, DC, to examine the lessons from influenza pandemics and other major outbreaks, understand the extent to which the lessons have been learned, and discuss how they could be applied further to ensure that countries are sufficiently ready for future pandemics. This publication summarizes the presentations and discussions from both workshops.

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