Although many lessons have been learned from Ebola and other infectious diseases, planning needs are quickly diverted when the previous threat is overshadowed by another emerging or re-emerging disease, or other homeland security threat. However, without adequate prioritization, planning, and preparedness, the nation may be set for failure when the next unexpected threat presents.
In October 2015, the Blue Ribbon Study Panel on Biodefense issued its critical and detailed report entitled A National Blueprint for Biodefense: Leadership and Major Reform Needed to Optimize Efforts. The report is comprehensive and thought provoking byentifying and reinforcing numerous vulnerabilities and inadequacies regarding planning and preparedness for a myriad of biosecurity, biodefense, and public health threats.
The blue ribbon panel reportentified 33 recommendations for national leaders and policy makers to consider and implement, but any coordinated national response to them remains to be seen. The importance of these recommendations can be best measured by a post-analysis of the Ebola virus outbreak and its impact on the United States in 2014. A year after the significant outbreak, more interest appears focused on the lessons learned regarding individual rights and tactical concerns rather than strategic planning and the apparent inadequacies of federal, state, and local biodefense preparedness.
From the blue ribbon panel report to several other important year-end public health studies and findings addressing the Ebola virus and other outbreaks, it remains apparent that a whole of community approach is required to plan and prepare for these biosecurity threats. With the assistance of these reports, the threats and vulnerabilities are restated but lead to the question, “What will be the impact?”
Blue Ribbon Panel Report The blue ribbon panel was established in 2014 to assess gaps and provide recommendations to improve biodefense in the United States. The panel obtained information from all levels of government, academia, and the private sector pertaining to biological attacks and emerging and re-emerging infectious diseases. The panel began with Homeland Security Presidential Directive 10 – Biodefense for the 21st Century (2004) for the pillars of biodefense and then expanded well beyond it for an extensive analysis.
According to the report, the nation does not afford the biological threat the same level of attention as it does other threats:
There is no centralized leader for biodefense;
There is no comprehensive national strategic plan for biodefense;
There is no all-inclusive dedicated budget for biodefense; and
There is no single leader to control, prioritize, coordinate, and hold agencies accountable for working toward common national biodefense.
The report reinforced the well-documented concerns that the nation lacks leadership, coordination, collaboration, and innovation to respond to a biological crisis. This failure was noted in the report as being magnified due to the responsibility for biodefense being so dispersed throughout the federal government. The panel members developed a unique concept of an overarching leader who recognizes the severity of the biological threat and possesses the authority and political will to defend against it – the vice president of the United States.
Panel Recommendations The blue ribbon panel recommendations and their action items present a clear pathway to improve, enhance, and unify national biodefense preparedness. From the empowerment of the vice president to the encouragement for a unified congressional budget, a framework has been established with short-, medium-, and long-term goals. The framework is a whole of community approach for biodefense involving defense, medical services, animal health, law enforcement, public health, and other biosurveillance partners.
The report stressed the need for national leadership to elevate collaboration since biodefense is obviously not solely a federal function. The panel believed that the federal government must aid state, local, territorial, and tribal governments in enhancing their capabilities and support improved training. Intergovernmental and multidisciplinary efforts are needed to adequately defend the nation against biological threats.
Unfortunately, if history is a guide, this report may not gain full traction until after a serious or catastrophic biosecurity incident. Fortunately, the report can be utilized as a foundation or framework for future congressional hearings and legislation in a fashion such as the post-9/11 terrorist attack report. Until then, the after action analysis of the recent Ebola virus outbreak may also assist in driving discussions, planning, and change.
Lessons Learned (or Not) From Ebola As the Ebola virus recedes back into its unconfirmed reservoir in Africa and no further new patients are encountered in the United States, the nation is able to focus on other pressing homeland security and public health issues. Regrettably, there is no shortage of emerging and expanding political and security issues throughout the nation and world. Unfortunately, this refocus has permitted the redirection of priorities and resources away from the lessons learned during the Ebola outbreak.
The disappearance of the Ebola virus from the United States has permitted the analysis of quarantine and isolation authorities, plans, and practices through an individual rights lens rather than a larger strategic perspective for the next greater pathogenic threat. As an example, a December 2015 article in the New York Timesentified the persisting questions regarding quarantine enforcement a year after Ebola in the United States. The article described the quarantine challenges ranging from personal hygiene to psychological support to legal notices. The execution of the state quarantines demonstrated a lack of planning and preparedness by all of the parties with few clear answers.
Closely following this article, the New York Times posted an editorial on 5 December 2015 about the unfair treatment of Ebola healthcare workers. The editorial stated that, “Instead of helping, quarantines actually made the fight against Ebola more difficult by discouraging health care workers from going to Africa. Quarantines and monitoring also needlessly strain state and local health budgets without making the public any safer than self-monitoring would.”
This editorial opinion was successfully expressed due to the very limited effect of Ebola in the United States in 2014. The editorial concluded that, “Health officials in the United States should study our own response to the epidemic for lessons about what should – and should not – be done when the next germ threatens to hit these shores.” If the Ebola public health and homeland security threat expanded beyond its very few locations and affected more people in the United States, both of the New York Times postings would likely have stressed a different perspective regarding personal rights as compared to greater public health issues.
The lessons not fully learned or implemented from the Ebola outbreak are not limited to the quarantine of healthcare workers, but to another interrelated sector that is crucial for this subject matter – air transportation, travel, and trade.
Plan Still Needed for Air Travel A Government Accountability Office (GAO) report issued in December 2015entified the continued need for a comprehensive federal preparedness plan for the U.S. aviation system to address communicable diseases. GAO was requested to analyze this subject due to the many challenges encountered during the Ebola virus outbreak. GAO found that the 14 airports and three airlines that they reviewed possessed high-level plans for responding to communicable diseases, but there was no comprehensive national preparedness plan.
Beyond the human impact and public health threat, there can be enormous economic consequences of a serious emerging pathogenic threat. According to the GAO report, the International Air Transport Association estimated the overall cost at 33 billion dollars of global gross domestic product in 2003 for the Severe Acute Respiratory Syndrome (SARS) outbreak. Since 2003, other novel or re-emerging pathogens, such as H5N1, H1N1, H7N9, and Middle East Respiratory Syndrome (MERS), have affected air travel and global economics. The establishment of a national preparedness plan, with a whole of community approach, remains critical for many reasons to include the consequences for the national economy.
The GAO report concluded with the following recommendation:
“To help improve the U.S. aviation sector’s preparedness for future communicable disease threats from abroad, we recommend that the Secretary of Transportation work with relevant stakeholders, such as the Department of Health and Human Services, to develop a national aviation-preparedness plan for communicable disease outbreaks. Such a plan could establish a mechanism for coordination between the aviation and public health sectors and provides clear and transparent planning assumptions for a variety of types and levels of communicable disease threats.”
The speed and ease of air travel compounds the challenges of preparedness by shortening reaction time toentify and interdict a biosecurity or public health threat. A review of the previous outbreaks and epidemics can be startling enough, but there are surely additional known and unknown concerns looming on the international horizon asentified by governments and health organizations.
Top Emerging Diseases In December 2015, the World Health Organization (WHO) published a list of the top emerging diseases likely to cause major epidemics. A panel of scientists and public health experts convened by WHO met to prioritize the top emerging pathogens likely to cause severe outbreaks in the near future, and for which few or no medical countermeasures exist. These diseases will provide the basis for work on the WHO blueprint for preparedness to help control potential future outbreaks.
The initial WHO list of disease priorities needing urgent research and development attention includes: Crimean Congo haemorrhagic fever, Ebola virus disease, Marburg, Lassa fever, MERS and SARS coronavirus diseases, Nipah, and Rift Valley fever. According to WHO, the list will be reviewed annually or when new diseases emerge. It is very likely that these and other infectious diseases shall emerge, re-emerge, or mutate in the future and threaten countries, regions, and the world with little or no notice.
Protecting From Infectious Diseases Also in December 2015, the Trust for America’s Health and Robert Wood Johnson Foundation issued Outbreaks: Protecting Americans From Infectious Disease 2015. The report stressed that the nation does not sufficiently invest in basic protections that could help avoid significant numbers of outbreaks and save billions of dollars in unnecessary healthcare costs, to include concerns such as MERS, Ebola, and influenza.
The report encourages an increase in resources to maintain and modernize public health capabilities and to have consistent and science-based policies across the country. One of the many areasentified for attention was quarantine enforcement with a whole of community focus:
“Movement and monitoring guidance, and its appropriate application to at-risk persons is essential to containing potential infectious outbreaks. Federal, state and local public health and policy leaders should come together and agree on a common decision-making framework ahead of the next outbreak to help states make movement and monitoring decisions that (1) are based upon the best available scientific and medical evidence; (2) preserve social and economic continuity to the greatest extent possible; and (3) are in the best interest of public health.”
The above statement is a common theme that can be found in other after action reports and studies without many observable and easily measurable results. These notices and warnings should be clearly received from the recent outbreaks. However, these warnings appear to be ignored when the threat recedes and are overtaken by other events.
The Future Impact From the blue ribbon panel report to other important year-end public health studies and findings addressing the Ebola virus and other disease outbreaks, the importance of a whole of community approach is reconfirmed for the planning and preparing for biosecurity and public health threats. Although extremely important, especially to subject matter experts and interested policy makers, the lasting impact is uncertain: Will these after actions reports and studies affect change for planning and preparedness or just be re-read after the next significant biodefense, biosecurity or public health incident?
Time shall tell if the nation chooses to be proactive or reactive for biodefense, biosecurity, and public health threats. The blueprints and frameworks surely exist to educate, support, and prepare the nation for the next black swan event. Therefore, failures shall not be from a lack of knowledge or warning, but from a lack of prioritization, planning, and preparedness.
The opinions expressed herein are solely those of the author in his individual capacity, and do not necessarily represent the views of his agency, department or the United States government.
Robert C. Hutchinson is a Deputy Special Agent in Charge (DSAC) with the U.S. Department of Homeland Security, U.S. Immigration and Customs Enforcement’s Homeland Security Investigations in Miami, Florida. He was previously the deputy director and acting director for the agency’s national emergency preparedness division. His writings, media interviews, and presentations often address the important need for coordination and collaboration between the field