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Key Roles for the Department of Defense in Biological
Threat Reduction

KEY MESSAGES

• The Department of Defense (DOD) provides a wide range of direct and indirect support to ensure the nation’s security globally, including biosecurity and biosafety.
• The Biological Threat Reduction Program (BTRP) operates outside of the United States to make positive change possible and, if appropriately synchronized with the rest of DOD and U.S. government agencies as well as other local partners, can be of significant value in reducing the likelihood of surprises in the form of vulnerabilities and threats, including infectious disease or other political, economic, or social events affecting the security environment, all in a cost-effective manner.
• The critical elements of BTRP success are difficult to replicate on a large scale. Appropriate diplomacy and an understanding of human relations significantly improves the likelihood of successful initiatives. BTRP has the potential to combine diplomatic skills with its location in DOD to maximize the impact and cost effectiveness of its efforts.

“The Department of Defense provides the military forces needed to deter war and ensure our nation’s security” (U.S. DOD, 2019c). Under this broad mission, DOD supports U.S. government programs in global health playing multifaceted and evolving roles, which are increasing in scope. Some see DOD’s global health efforts as manifestations of soft power and diplomacy. Others see elements of DOD’s involvement as advancing medical infectious disease research; developing new diagnostics for infectious disease control and prevention; and tracking, preparing for, and responding to infectious outbreaks around the world (KFF, 2019a). DOD’s

work also helps strengthen other countries’ efforts to address infectious diseases (KFF, 2013, 2019a; Michaud et al., 2012a, 2012b). Still others see DOD’s global health efforts as “force health protection and readiness, medical stability operations, and threat reduction” (Michaud et al., 2012a, p. 9). Detailed analyses of DOD’s substantial global health efforts, with a chief focus on infectious disease threats, are recorded in recent reports by the Kaiser Family Foundation (KFF, 2013; Michaud et al., 2012a, 2012b).

The role of BTRP in supporting DOD’s global health missions has traditionally fallen, and will likely continue to fall, under the deterrence part of the DOD’s mission statement. While there may be instances in a post-conflict setting in which BTRP could be asked to engage in securing weapons of mass destruction or helping redirect weapons scientists, the vast majority of its efforts will likely occur in countries struggling to work safely and securely with infectious agents during a local outbreak with global pandemic potential. This may increasingly occur in post-conflict settings, such as in Liberia and Sierra Leone during the Ebola outbreak (2014-2015), or in areas with groups or militias in armed conflict with the local and national government, as in the northeast of the Democratic Republic of Congo at the present time.

Outside Contiguous United States Army and Navy Service Laboratories have been operational for much longer than has the Cooperative Threat Reduction Program (CTR). The mission of the laboratories overlaps with that of BTRP, but has traditionally been built primarily on science and health bases with a secondary focus on biosecurity. The disease surveillance and research conducted in those laboratories has consistently proceeded from the perspective of human or animal health rather than that of infectious agents or laboratory security, unlike the perspective from which BTRP has operated. Yet, these laboratories have, for more than seven decades, contributed significantly to U.S. national security. They have done this through disease surveillance, applied research in regions where important diseases are endemic, and particularly through building strong working relationships of trust with local scientists. These relationships also contribute to the local scientists’ awareness of potential disease threats and risks to their own nation and elsewhere in the world. While individuals deployed to these laboratories frequently turnover every 2 to 3 years, it is the longevity of the initiative that has contributed so much to these personal connections. Less easily measured, but critical nonetheless, good public and human, animal, and plant health in the engaged country also contributes to social, economic, and political stability in the region. These laboratories have

made a clear contribution to U.S. national security from an almost purely health platform.

BTRP engages in health-oriented efforts as well (e.g., diagnostic platforms and disease surveillance systems), but with a greater focus on pathogen and laboratory security, work that reduces the likelihood that often unique endemic pathogens can somehow be obtained and exploited, particularly in the present era, by sub-state actors or groups. Whereas the service laboratories—as well as the Centers for Disease Control and Prevention (CDC), U.S. Agency for International Development, and assistance programs such as the President’s Emergency Plan for AIDS Relief, and the President’s Malaria Initiative—focus primarily on health, BTRP engagements provide a primarily security-oriented perspective.

Since its evolution into CTR 2.0 much of the BTRP mission has been focused on engaging people to promote professional/technical capabilities to address current and future biothreats, naturally occurring, accidentally caused, or intentionally introduced. Specifically, such engagement can connect infectious disease laboratories around the globe, usually government supported and run, to facilitate sharing of principles, values, ethics, proper procedures, and awareness of threats and risks that can change the way those responsible think about their jobs and responsibilities to their own nation and to the global community. BTRP is in many ways a unique program, focused on a specific spectrum of challenges, working as part of the broader DOD to seek to deter conflict while always preparing for it. BTRP operates outside of the United States to make positive change possible and, if appropriately synchronized with the rest of DOD and U.S. government agencies as well as other local partners, can be of significant value in reducing the likelihood of surprises in the form of infectious disease vulnerabilities and threats or other political, economic, or social events affecting the security environment, all in a cost-effective manner.

Numerous opportunities exist for DOD to deter hostilities and contribute to national security and global health, and some are precisely aligned with the work of BTRP, including the following:

• Effectively engage military medical expertise in other countries
• Draw on U.S. military medical capabilities and special expertise in microbiological threats within the U.S.-based and at overseas DOD medical research laboratories
• Promote consolidation of infectious disease archives/sample libraries
• Focus on security for agent and clinical sample repositories, facilities, and workers

• Provide logistics and support for response when DOD’s capabilities are unique (regardless of the size of BTRP’s contribution relative to the overall challenge)
• Fill gaps between U.S. government programs in response to emerging threats
• Provide funds to implementing agencies
• Access funds designated as security-related versus funds allocated for foreign assistance
• Respond rapidly to arising global health security needs
• Engage with partner countries through sustained scientific programs

Given these opportunities, it seems very likely that BTRP will continue to play important roles in identifying and rapidly responding to emerging biological threats, especially when they threaten the stability of local and regional partners, and have potential to impact the United States.

BTRP must anticipate the complex array of diverse, modern biological threats and have the latitude to partner with other U.S. agencies to seize opportunities worldwide to mitigate these threats and risks. This means, in part, identifying locations vulnerable to emergent biological threats, vectors for transmission, and technologies that introduce new capabilities that can be used for positive or negative purposes. Perhaps most important, anticipating threats, means engaging with the local people who can help prevent, counter, and respond. Those professionals, whether government, military, or academic, are important partners, and cooperation needs to be nurtured and sustained over time.

To address such emergent threats and risks, the Office of the Under Secretary of Defense for Policy and BTRP must monitor and, when possible, anticipate future vulnerabilities. BTRP is in a position to assess security as well as training needs and develop and implement a plan to prepare and bolster local capabilities to detect and respond to biothreats whether they be natural, accidental, or intentional. In order for BTRP to respond more quickly and effectively, it will need broader authority and flexibility to tailor engagements to the current, anticipated, and novel new biothreats.

Because such threats do not respect bureaucratic or geographic boundaries, programs, such as BTRP, that counter those threats need flexibility. BTRP needs the ability to work beyond the U.S. government’s Select Agents and Toxins List (CDC, 2017) because serious natural, accidental, and intentional biological threats may arise from pathogens not designated as selected agents. Given the broad geographic and topical

scope of potential biothreats, BTRP, in collaboration with others, should have the flexibility to determine where to work and what efforts to undertake, rather than being unduly limited by restrictions that do not consider emerging novel pathogen threats that often appear in unexpected places. This does not mean that BTRP can or should take on every part of DOD’s larger global health security mission, or engage in every place from which a biothreat might emerge. Rather, strong interagency discussions should determine which agency, within the U.S. government and internationally, is best able to address newly identified needs and has the optimal ability to work with a given country. However, BTRP needs to be flexible enough to fill the inevitable gaps when and where its unique capabilities are needed.

U.S. INTERESTS ABROAD

In addition to protecting the homeland, DOD plays a critical role in protecting U.S. interests abroad. U.S. military forces are deployed in more than 165 countries around the world, with more than 170,000 of its active-duty personnel serving outside the United States and its territories (U.S. DOD, 2019b).

U.S. men and women in uniform are not only at risk of combat and new and diverse terrorist threats, but are also at risk of exposure to common as well as exotic and endemic infectious diseases. In addition, some of these diseases could be highly contagious and/or resistant to current treatment, given the increasing threat of antimicrobial resistance around the world. Moving personnel in and out of regions of disease endemicity puts the homeland at risk from highly contagious viruses, which might affect human or animal populations, either of which could have devastating effects on the economy. Recent, vaccine-preventable infectious diseases have reappeared in the United States, largely due to reduced immunization rates in some U.S. communities, as occurred in 2019 with measles when there were 1,282 individual confirmed cases of measles in 31 states, which was the largest number reported in the United States since 1991, primarily in communities where large numbers of people are unvaccinated (CDC, 2019; Statistica, 2019). The introduction of drug-resistant pathogens represent a similar concern (White House, 2019).

A recent review of the medical literature for the years 1955 to 2018 has documented how thousands of U.S. or other nations’ military service

members have acquired infectious diseases during their deployments and transmitted, or at least had the potential to transmit, these pathogens to their peers, other contacts in deployed settings, and sometimes close contacts upon returning home (Zemke et al., 2019). Examples of military personnel-associated pathogen transmission include a large cholera outbreak, to movement of pandemic influenza to new regions, and importations of malaria, antibiotic-resistant enteric pathogens, pediatric diseases, and sexually transmitted diseases. Although perhaps not always a primary concern, moving military personnel in and out of regions of novel pathogen endemicity always puts them, their military colleagues, and family and friends, and ultimately the homeland, at potential risk, especially in the case of highly contagious pathogens. Even if secondary transmission is uncommon, exposure can result in many infections and considerable morbidity and possible mortality. It is beyond prudent that BTRP remain deeply engaged in understanding and anticipating such novel pathogen transmission risk where troops are or are likely to be deployed.

Military personnel and other travelers also have the potential to unknowingly serve as transmitters of pathogens that infect domestic animals or food agriculture, which could pose a threat to the economy and to food security. As was discussed in Chapter 2, there is great potential today for an international traveler to unknowingly import a pathogen such as African Swine Fever (ASF) virus into the United States or another susceptible country, which could result in a disaster for pork industries.

BTRP currently contributes to U.S. and international biosecurity by assisting countries through training for laboratory staff in improving laboratory diagnostics, disease surveillance, and early-warning capabilities, and by helping countries secure collections of pathogens or tissues. BTRP is engaged in such activities in many parts of the world, thus helping to protect deployed U.S. military personnel, U.S. diplomatic corps, and less directly, the locally resident American population most of whom travel back to the United States on a regular basis and represent potential microbial transport hosts. It was evident in the West Africa Ebola outbreak that the repatriation of a small number of known infected American residents represented a grave and possibly disruptive concern to many communities, even though highly effective precautions against secondary transmission were in place. In fact, the two transmission events to nurses in Texas (Hennessy-Fiske et al., 2014)—which involved a Liberian national index case not known to be infected with Ebola when he arrived in the United States, who then became ill, was hospitalized, and

died of Ebola infection—should have been prevented by better infection control and communication among hospital staff.

Because BTRP’s work requires close relationships with senior foreign government representatives, as well as technical and professional staff, there are opportunities to build long-term relationships of trust. Where relationships of trust exist, honest communication of both good and bad news is more likely. This is evident, for example, where the U.S. Army and Navy service laboratories have been running for decades in collaboration with military counterparts in various countries around the world. Trusted relationships are also important to the success of mid-term projects supported by BTRP, although the benefit is likely to be less direct when the projects are conducted by individuals without a depth of experience and/or without continuity in staffing.

Awareness of Potential Emergent Infectious Disease and Biothreats

When communication, particularly resulting from relationships of respect and trust among professionals is ongoing, BTRP personnel are more likely to obtain an understanding of potential risks and threats before they become severe. In certain situations, the host country may not want to share detailed epidemiological information with DOD or other foreign entities, including the World Health Organization (WHO), even though the International Health Regulations (IHR) (2005) require that countries detect, assess, and report public health events to WHO. The threat to local trade, tourism, and reputation may readily suppress sharing of critical information, and overwhelm the duty to report. Therefore, much of the work of BTRP has been undertaking to forge relationships between the host country’s public health professionals, military officers, and WHO professionals, in support of IHR (2005). If BTRP can encourage sharing of data, whether with the United States or with WHO or with the World Organisation for Animal Health, BTRP will enhance the likelihood that the international community can engage to help countries respond and more rapidly control an outbreak. Compared with CDC’s international programs, BTRP is unique in that it has: (1) a natural common language with foreign military forces; and (2) a fundamental interest in biological security as well as the broader health mission. While global health is important, and may be a shared concern with counterparts in other countries, military partners share a common concern for biosecurity.

Although the Department of State Biosecurity Engagement Program conducts similar biosecurity and biosafety training, it has neither the compatibility with foreign militaries nor the diagnostics and health surveillance expertise that characterizes the engagement of BTRP with its foreign partners.

Coordination and Synchronization to Maximize Bioengagement Efforts

Working closely with American embassies, BTRP plays an important role in the broad spectrum of the U.S. government’s global health security diplomacy. The U.S. government and the international community cannot effectively reduce the threat of, and respond to, outbreaks without the cooperation of the host country. Effective engagement skills are essential for BTRP professionals who interact with counterparts from foreign governments on biosecurity concerns, and such skills need to be a critical part of the hiring/assignment process.

There is an increasing number of infectious disease outbreaks occurring worldwide (e.g. hemorrhagic fevers, flaviviruses, novel coronaviruses, influenza A viruses, and ASF), which highlights the significant role BTRP can play in the U.S. government’s global health preparedness and response efforts. However, the committee has observed that senior DOD officials as well as those from other U.S. government agencies are frequently not fully aware of BTRP’s international capabilities. With senior DOD leadership support, BTRP’s capabilities and resources could be more widely known. CDC often promotes its accomplishments more effectively than BTRP. While publication in scientific literature is not a primary goal for BTRP, BTRP professionals should continue to document accomplishments and publicize more widely, in furtherance of the mission to enhance biosecurity. Such occasions may include a regular newsletter, a more robust website, and greater conference attendance.

SUPPORT TO AND COORDINATION WITH DOD AND BEYOND

The next crisis might be a natural epidemic or pandemic to which DOD is called to provide support, or the next crisis might emanate from the biological weapons program in a failed state, analogous to the agreement to destroy Syrian chemical weapons as recently as late 2013. While the Assistant Secretary of Defense for Special Operations/Low-Intensity Conflict may continue to be the first to respond, when the President calls on DOD to respond, as was observed in the Ebola 2014 outbreak in West Africa, BTRP knows, communicates with, supports, and even deploys DOD medical and non-medical biodefense Research Development Test and Evaluation assets necessary for a DOD response in times of biological crisis.

BTRP’s budget is relatively small and the global challenges it seeks to address are enormous. The important work with which BTRP is charged requires not only requisite technical knowledge, but also the preexisting interpersonal relationships that create trust. The critical elements of BTRP success are difficult to replicate on a large scale; just hiring contractors and providing a project budget is insufficient. Appropriate diplomacy and an understanding of human relations significantly improves the likelihood of successful initiatives. In Chapter 3 of this report, the committee discusses the need for and relevance of staff training in diplomacy, and the human relations skills necessary in situations as fraught and politically delicate as those encountered by BTRP professionals. BTRP, existing within DOD, has the potential to combine diplomatic skills and its location in DOD to maximize the impact and cost effectiveness of its efforts.

BTRP professionals who engage in negotiations to implement partnerships would benefit from opportunities to enhance their skills in the tradecraft of health diplomacy. For example, BTRP could take advantage of the 3-day course on Global Health Diplomacy offered by the State Department’s Foreign Service Institute. The course is described as follows: