America’s ability to solve the current and future global pandemics may determine whether we continue to be the world’s leading power. China and Russia are already trying to get into the global health game, and unless we step up our efforts, they may take our place.
It is inevitable that we will have to deal with more pandemics – perhaps with increasing frequency and even more potency. How the United States organizes itself to combat pandemics “over there” is critical because those pandemics will end up “over here.” Given the current crisis, we are right to ask whether the U.S. government needs to be better organized to respond to pandemics.
There is a debate within the Trump administration about who should lead the U.S. government’s international pandemic response. One school of thought is to create a structure at the State Department which would have authority over USAID’s pandemic response – the so called “PIPER/PRO” initiative, modeled on the President’s Emergency Plan for AIDS Relief (PEPFAR). This plan would include the potential for sequestration of existing USAID funding and the interruption of the agency’s proven pandemic-fighting capacities. This plan is a bad idea because it would learn the wrong lessons from PEPFAR and would disregard evidence from past experiences.
Before anything else is moved into the State Department, State’s systems need to be fixed.
The far better solution would be to model U.S. global pandemic response on the President’s Malaria Initiative (PMI), where USAID has been the inter-agency coordinator of all resources and has successfully bent the Malaria disease curve.
The United States – until the emergence of COVID-19 – has very ably responded to global pandemics using the capacity and expertise of USAID, oftentimes in partnership with the U.S. military and the Centers for Disease Control and Prevention (CDC). During the Ebola crisis, USAID controlled the forward response in West Africa, and it was the same in the case of the Zika virus. In both cases, USAID drew upon other U.S. government assets and worked in partnership with allies and friends. The difference with COVID-19 – and part of the reason that we have not led the charge globally – is that from the beginning of the crisis USAID was not at the inter-agency table.
The so-called PIPER/PRO initiative, where State would add layers of bureaucracy to USAID pandemic response capacities, is coming from an understandable desire to have one lead on international pandemics, but it ignores the other dynamics at play. The initiative would create a de facto Undersecretary of Global Health by executive order, a move that is likely to cost precious time and resources that should be put into USAID response measures. Worse yet, we know from past experience that it would not work at building the capacities and systems in developing countries that are needed to respond to pandemics. Finally, PIPER/PRO would take on a number of functions that generally are regarded as the purview of the National Security Council. On that topic, one fix that is needed is that the U.S. should reconstitute the Biosecurity Directorate at NSC that was merged into the WMD Directorate in June of 2018.
It should be noted that the State Department is responsible for setting policy; it is not an operational agency, and at times it struggles to allocate funds where it is responsible for doing so (e.g., the Bureau of Democracy, Human Rights, and Labor (DRL) and the Bureau of International Narcotics and Law Enforcement (INL)). Because State lacks the operational, contracting and field expertise, they would need to either subsume capacity from other agencies or fill new positions, creating the potential for further redundancy and further slowing down USAID operations.
PEPFAR, run out of the State Department for almost 20 years, has been a highly successful stand-alone initiative in terms of bringing down the total number of HIV cases worldwide, at a cost of almost $100 billion. It was not meant to go on indefinitely, though; the “E” which stands for “Emergency” was not meant to mean “Eternal.” Its main failure has been that it did not successfully develop in-country health systems. PIPER/PRO learns this wrong lesson from PEPFAR. We should not be creating a similar global, stand-alone program for pandemics with large, so-called “mortgages” locking up budget flexibility for years to come.
Creating a new unit for the coordination of global health within a weakened State Department would mean three years of a bureaucratic, big government, nightmare, smack in the middle of a pandemic. Global health professionals, trying to respond to this crisis, would be distracted by literally hundreds of interagency meetings on merger issues, coordination issues, and new tracking systems. On top of this, people would be worrying about their roles and responsibilities as opposed to doing their jobs.
The far better approach would be to create a light touch coordinator at USAID similar to the President’s Malaria Initiative.
Years of experience have shown that integrating prevention, detection, and response to broader development efforts is the most effective way of safeguarding U.S. national interests and the world from future pandemics. Pandemics are not just health crises; they begin due to poor governance, a lack of transparency, and weak country health systems. The recent Ebola outbreak in DRC persisted because of weak governance, instability, and a lack of development over many years. And COVID-19 took root in China due to a lack of transparency and accountability.
Functioning health systems are key in responding to pandemics. Strengthening health systems requires more than just solving health issues, but the capacity of a country plan, and an ability to develop and finance its own system. Success requires engagement beyond the health sector: local revenue and finance reforms, a functioning private sector, as well as bringing to the table many stakeholders other than health ministries, such as ministries of finance, national and local governments, parliaments. Taking health out of solving these broader development challenges, isolating health, will not lead to success. USAID with its interconnected relief efforts, is the suitable vehicle for this work.
There are four reasons USAID as the lead for global pandemics response is the best solution. First, USAID would draw on the agency’s experience with leading the inter-agency effort for the President’s Malaria Initiative. Second is that USAID has proven, unmatched skills and experience in responding to complex humanitarian crises, including pandemics, as well as supporting countries in their day-to-day fight against malaria, tuberculosis, and polio. Third, USAID sees global health as part of broader development challenges, naturally linked with agriculture and food security, response to global conflict, promotion of human rights and the rights of girls and women, and other complex economic- and social-development issues. Fourth, USAID is one of the best managed federal agencies in the U.S. Government, according to the invest in America 2019 Federal Standard of Excellence Index.
We need to be able to successfully solve global pandemics, or we may lose our license as a global power.
Overburdening and weakening USAID, the right agency for the job, in the middle of a pandemic is a terrible error. PIPER/PRO is bad development, bad public management, and will weaken our ability to respond to not only pandemics but also all development challenges. USAID should lead our global pandemic response maximizing our chances of not only beating pandemics but maximizing our chances of beating China in the global influence race.