Customize your JAMA Network experience by selecting one or more topics from the list below.
As the country tries to make sense of all that has happened during the coronavirus disease 2019 (COVID-19) pandemic, one idea that should cause little controversy is the importance of health to the security of the US, to its economy, and to the well-being of its citizenry. Given health’s fundamental importance to national security, a disaster preparedness and response unit should be reestablished as part of the National Security Council (NSC) and remain there on a permanent basis. This response unit would be in addition to, not a replacement for, the Office of Pandemics and Emerging Threats. The latter currently resides in the Office of Global Affairs in the Department of Health and Human Services (DHHS) and should continue to function there in the future.
The NSC’s Directorate for Global Health Security and Biodefense had been established in 2015 by the Obama administration. When the Trump administration disbanded it in May of 2018 and merged some of its members with other units, critics said this change left the country less prepared for pandemics. What many do not realize is that this move actually followed a pattern established by several previous presidents, including the administrations of both Presidents Barack Obama and George W. Bush, which disbanded similar NSC task forces established by their predecessors and reestablished them, in part or in whole, elsewhere in the government.
Here’s a brief history. RADM Kenneth Bernard, a physician with training in public health who had been assigned to work on international health security issues at the Clinton White House, opened up the first Biodefense and Health Security Office at the NSC. This office was subsequently closed by the George W. Bush administration, but after the September 11, 2001, and 2001 anthrax attacks, Bernard was called back to reopen it (as the White House Health and Security Office) by Tom Ridge, the first director of the NSC’s Office of Homeland Security. The incoming Obama administration closed the office again and dispersed its portfolio over 3 separate NSC directorates, but reestablished it following the 2014 West Africa Ebola outbreak, where it operated until it was disbanded by the Trump administration. The problem with distributing responsibilities for health security and biodefense across multiple offices is that none of these offices have these functions as their primary focus.
One action that has had an effect on the COVID-19 pandemic is the National Strategy for Pandemic Influenza, created in 2005 by the George W. Bush administration. As part of its activities, the federal government was called on to maintain and distribute a national stockpile of medical supplies in case it was ever needed. Some of these supplies have been important, though not nearly sufficient, in dealing with the current pandemic.
The Obama administration faced several health emergencies, although none on the scale of COVID-19. The first case of H1N1 (swine flu) influenza was reported in April 2009 and was declared by Obama as a public health emergency before any US deaths had even been reported. Although the number of cases was high—60 million people—the number of deaths, just over 12 000, was not. The 2014-2016 Ebola outbreak was a significant concern in West Africa, with more than 11 000 deaths, but it did not materially affect the US. Large outbreaks of Zika virus disease in 2016, in contrast, had a much greater effect on the US, with more than 40 000 cases in US states and territories. Around the time that the Zika virus was affecting the US, Obama’s national security advisor, Susan Rice, created the Directorate for Global Health Security and Biodefense as part of the NSC.
Questions about stockpiling medical equipment such as ventilators or personal protective equipment for future epidemics—such as how much equipment should be stockpiled and for how long—are important to consider but should be relatively easy to resolve with the help of expert consultants. Whether it is advisable to rely on countries that have been or may become adversarial for critical medical components or pharmaceutical supplies is a harder question to settle. As an economist, I generally believe that countries specializing in whatever they can produce best and then engaging in trade makes all countries better off. However, a situation in which the US is dependent on countries that control key ingredients for pharmaceuticals or other basic components of care means the US is potentially vulnerable to threats of being denied access to those vital products. These are national security considerations that will need to be carefully considered in the future.
The DHHS is and should remain the primary source of federally provided health care for the country, with the US Centers for Disease Control and Prevention and the US Food and Drug Administration continuing as the entities likely to be most relevant in dealing with future epidemics. There will be many lessons to be learned after emerging from the present crisis as to how the country should position itself before the next pandemic.
But the vital roles played by the relevant departments in the DHHS in no way diminish the importance of having the security apparatus of the country understand the threat that disease can present to the US. People outside health care—in the military and in positions affecting national defense—need to understand that health care and public health are as vital to US health and security as the more traditional components of security, such as diplomacy and weapons training. They need to appreciate that more people died of communicable disease in the 20th century—with at least 50 million deaths worldwide, including 675 000 US deaths, resulting from the 1918 (H1N1 virus) influenza pandemic alone—than from all of the wars of the 20th century.
Military medical services and the military’s senior leadership appreciate the vital role that health care and health care workers play in the military’s well-being. However, the importance of this health care infrastructure to an all-volunteer military as well as to the civilian population is not always well understood by some of the senior members of the national security establishment. One hopes that the country’s recent experience with COVID-19 will have made it clear that safeguarding the nation’s health is an inextricable part of the nation’s security.
Correction: This article was corrected on July 22, 2020, to fix the date from 2011 to 2001 for the anthrax attacks and to revise the name of the armed services’ medical service corps to the military medical services.
Corresponding Author: Gail Wilensky, PhD, Project HOPE, 7500 Old Georgetown Rd, Ste 600, Bethesda, MD 20814 (email@example.com).
Conflict of Interest Disclosures: Dr Wilensky reported receiving personal fees from UnitedHealth Group; serving as a director for UnitedHealth Group, Quest Diagnostics, and ViewRay; receiving retainer payments and deferred stock or stock options from UnitedHealth Group, Quest Diagnostics, and ViewRay; and receiving payments from the UMWA Health and Retirement Fund for serving as a trustee.
Previous Publication: This article was previously published in JAMA Health Forum at jamahealthforum.com.
Wilensky G. The Importance of Reestablishing a Pandemic Preparedness Office at the White House. JAMA. 2020;324(9):830–831. doi:10.1001/jama.2020.15525
Artificial Intelligence Resource Center