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January 6, 2022

The Pandemic Preparedness Program: Reimagining Public Health

Author Affiliations
  • 1Department of Medical Science, Brown University, Providence, Rhode Island
  • 2Harvard Law, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard University, Cambridge, Massachusetts
JAMA. 2022;327(3):219-220. doi:10.1001/jama.2021.23656

On September 2, 2021, the White House released its long-awaited pandemic preparedness proposal titled American Pandemic Preparedness: Transforming Our Capabilities.1 Called for by presidential executive order 13987 and National Security Memorandum 1, the proposal, 8 months in the making, comprises a whole-of-government review and update of US national biopreparedness policies.2,3 The pandemic preparedness proposal is ambitious and all-encompassing and acknowledges that the transformation of “our medical defenses” will require “extensive scientific and technological efforts.”1 In this Viewpoint, we review the leading objectives of the pandemic preparedness proposal, discuss the outcome of comparable past federal efforts, and emphasize the imperative of intragovernmental coordination.

Addressing vaccines, the pandemic preparedness proposal seeks the “ability to rapidly make effective vaccines against any virus family.”1 To realize this goal, the proposal calls for the design, testing, and authorization of vaccines “within 100 days after the recognition of a potential emerging pandemic threat” and vaccine production for the “entire United States population within 130 days.” Commensurate advances in vaccine distribution (eg, eliminating the need for cold storage) is to follow suit. Simplified, rapid, large-scale vaccine administration is to be addressed as well. Replacing the need for sterile injection with skin patches or nasal sprays is to be explored. Efforts must also be directed at replacing “the need for multiple doses with time-released formulation.” The all-important capacity “to rapidly adapt, test, and review modified vaccines to keep pace with changes in the virus” is similarly emphasized.

For therapeutics, the pandemic preparedness proposal aims to have at hand a “range of therapeutics suitable for any virus family, available before a pandemic or readily created during a pandemic.”1 Hoped-for therapeutics are to include inhibitors of viral functions of the “small-molecule” and “programmable RNA” varieties. Yet other therapeutics are to comprise neutralizing monoclonal antibodies, the rapid and large-scale application of which to infected individuals is projected to be impactful. Additional consideration is being given to therapeutics that would “limit damage from infectious diseases caused by over- or under-active responses of the human body to infection.”1

Seeking to maximize the utility of vaccines and of therapeutics, the pandemic preparedness proposal also argues for “simple, inexpensive, high-performance diagnostic tests [to become] available at large scale within weeks after the recognition of an emerging pandemic threat.”1 Such diagnostics are to “be deployed in a range of settings and use cases, including home, point of care, and central labs.” Used in the context of a pandemic, these diagnostics are to “enable routine testing for circulating viruses, including in home settings.” The combination of high-performance diagnostic tests and contact tracing is called for if the spread of a future pandemic is to be arrested.

Apart and distinct from shoring up the medical defenses against a pandemic, the pandemic preparedness proposal aims to ensure situational awareness (eg, early warning systems) that would “detect viruses that pose a pandemic threat soon after they emerge in humans and produce and publicly share the full genome sequence.”1 The capability to “monitor the spread and evolution of the virus” in real time is similarly emphasized. Above and beyond the preceding considerations, the proposal calls for strengthening the US public health system (eg, modernizing the extant infrastructure) and for building core capabilities (eg, personal protective equipment as well as stockpiles and supply chains). Also, the proposal notes the imperative of managing the mission in a manner befitting an “Apollo program.”

The success of the pandemic preparedness proposal is contingent upon its ability to break with a troubling historic record of well-meaning if ineffectual national preparation for public health emergencies.4 Decades of federal planning for a future pandemic such as the COVID-19 pandemic failed to live up to expectations.4 Legislative inaction was not at fault. Indeed, 4 US presidents, faced with outbreaks of influenza A (H1N1), Ebola, Zika, and SARS, signed into law a total of 9 significant bills over the last 20 years with the next pandemic in mind.4 Moreover, authorized funds made their way to states and to hospitals, the position of Assistant Secretary for Preparedness and Response was created, and key organizations such as BARDA (Biomedical Advanced Research and Development Authority) and the US Department of Health and Human Services’ Centers for Innovation in Advanced Development and Manufacturing were established.4 What may have been missing was continuous leadership across administrations and a sense of urgency. Without these key elements, the death toll, the societal disruption, and the economic dislocation caused by the COVID-19 pandemic were all but predictable.4

In another nod to the “Apollo program,” the pandemic preparedness proposal calls for the establishment of “a strong, unified Mission Control to manage, integrate, and ensure accountability for all aspects of the U.S. pandemic preparedness program.”1 It would appear, however, that the pandemic preparedness proposal fails to note several key governmental constructs of central consequence to pandemic readiness. Examples include but are not limited to the Antiviral Program for Pandemics (APP), the Accelerating COVID-19 Therapeutics and Vaccines (ACTIV), and the Antiviral Drug Discovery (AViDD) Centers for Pathogens of Pandemic Concern.5-7 Ensuring the success of the pandemic preparedness proposal will require impeccable inclusivity such that no meaningful governmental program is left behind.

An effective program to ensure that the US is prepared for future pandemics and other major biological threats will require significant annual investments over a sustained period.1 The annualized costs are nevertheless likely to be far less in comparison with those associated with missile defense ($20 billion per year) or with terrorism prevention ($170 billion per year).1 The attendant opportunity cost is likely to be substantial as well. The Global Preparedness Monitoring Board, an expert group convened by the World Bank and the World Health Organization, estimates that a “pandemic akin to the scale and virulence of the 1918 influenza pandemic could cost the global economy $3 trillion in Gross Domestic Product and cause 50-80 million deaths.”8 As per the pandemic preparedness proposal, the total investment called for is $65.3 billion over 7 to 10 years.1 A recent proposal of the White House called for the authorization of $15 billion for the pandemic preparedness program in fiscal year 2022. As of December 13, 2021, however, the fiscal year 2022 outlay for the pandemic preparedness program in the Build Back Better Act (HR 5376) is capped at $10 billion. Passed by the House on November 19, 2021, the Build Back Better Act has yet to be voted on by the Senate. Limiting important funding in efforts involving preparation for the next pandemic would be unwise and shortsighted.

Zoonotic outbreaks on a pandemic scale are here to stay, and ignoring this reality is not an option. Viewed in this light, the American Pandemic Preparedness proposal is a critically important initiative for responding effectively to pandemics and other biological threats in the future.

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Article Information

Corresponding Author: Eli Y. Adashi, MD, MS, Department of Medical Science, Brown University, 222 Richmond St, Providence, RI 02903 (

Published Online: January 6, 2022. doi:10.1001/jama.2021.23656

Conflict of Interest Disclosures: None reported.

The White House. American pandemic preparedness: transforming our capabilities. Published September 2, 2021. Accessed October 9, 2021.
The White House. Executive order on organizing and mobilizing the united states government to provide a unified and effective response to combat COVID-19 and to provide United States leadership on global health and security. Published January 20, 2021. Accessed October 9, 2021.
The White House. National security memorandum on united states global leadership to strengthen the international COVID-19 response and to advance global health security and biological preparedness. Published January 20, 2021. Accessed October 9, 2021.
Alexander L. Preparing for the next pandemic: a white paper. Published June 9, 2020. Accessed October 9, 2021.
National Institute of Allergy and Infectious Disease. Antiviral program for pandemics. Published July 8, 2021. Accessed October 9, 2021.
National Institutes of Health. Accelerating COVID-19 therapeutic interventions and vaccines (ACTIV). Accessed October 9, 2021.
National Institute of Allergy and Infectious Diseases. Antiviral drug discovery (AViDD) centers for pathogens of pandemic concern. Accessed October 9, 2021.
Congressional Research Service. US global health assistance: FY2017-FY2021 funding. Published February 5, 2021. Accessed October 9, 2021.
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    1 Comment for this article
    What About Preparedness Beyond the Healthcare System?
    Dominique Sprumont, JD, PhD | Institute of Health Law, University of Neuchâtel, Switerland
    Adashi and Cohen rightfully raise the key issues in a medical perspective to improve our capacity to prevent, resist and cope with the next pandemic. A new approach to preparedness program in the US and the rest of the world is needed based on the latest experiences acquired during the COVID-19 pandemic. All the elements they address are important and require a rapid answer with adequate resources. Yet it would be a terrible mistake if the preparedness program remain focused on medical solutions and reinforcement of the healthcare systems.

    In the countries that were most effective at mitigating the
    impact of the first waves prior to the availability of the vaccines, the measures that proved the most efficient were not medical but behavioral and social. They mostly relied on the governments’ capacities to provide to their population the necessary means to adopt the proper protective and preventive measures. For instance, before ordering a lockdown, the people need to be reassured that their revenues are guaranteed. Likewise, requiring students and children to study from home requires that the courses are provided online and that no one is left behind in terms of computer and internet access, and for the children that their parents can care for them at home.

    If COVID-19 has taught the world an essential lesson is that under a pandemic inequities become even more inequitable and that poverty is a more deadly factor than the virus itself. It is time to admit that social, economic and legal actions are as important if not more important to cope with the emergence of a pandemic than so-called pharmaceutical measures. It is time to abandon the concept of "non-pharmaceutical interventions" to designate all the measures that are beyond the healthcare system. It is dangerously creating biases within the public health community and the decision makers that those measures are secondary compared to strictly medical ones. Everyone should be worried if the management of the next pandemic relies on the same medical paradigm of the current preparedness approach. This is not to say that we should step away from science. To the contrary, this would be a step toward implementing at last all the knowledge and science available on the social determinants of health.