President Trump’s new National Biodefense Strategy contains welcome tactics for protecting the health of Americans when “biological incidents” such as the 2001 anthrax attacks or the 2014 Ebola epidemic in West Africa occur. Some of the plans, however, are at odds with the administration’s policies on health insurance and immigration. Reconciling the two is essential for the strategy to match its promise.
We see three notable positive steps in the strategy. One is the appointment of Alex Azar, secretary of the Department of Health and Human Services, to be biodefense point person. A second is the plan’s recognition that disease “does not respect borders,” an essential principle if this strategy is to succeed. The third is an emphasis on the strategic importance of using diagnostic testing in the response to biological incidents, giving it equal footing with vaccines and drugs.
But the Trump administration’s policies on health insurance and immigration run contrary to the biodefense strategy’s goal of preventing, containing, and treating infectious disease outbreaks.
From a bureaucratic point of view, it makes sense for the strategy to put HHS, our leading national health agency, in charge of biodefense. While there’s no question that biological weapons pose a national security risk, the threats from naturally occurring infectious diseases are likely to put far more Americans in danger than threats from bioterrorism. HHS has skilled leadership in Azar and deep scientific acumen under Francis S. Collins, director of the National Institutes of Health, and Scott Gottlieb, commissioner of the Food and Drug Administration. Both are leaders who know how to harness the capacity of America’s life science research community, including universities and biotechnology companies, both of which will play vital roles in developing new products to detect and treat infectious diseases.
The strategy does not fully acknowledge that once an infectious disease risk emerges, the single best way to contain further spread is to make sure that people exposed to it receive medical care before they infect others. One of the principles of the embattled Affordable Care Act worth highlighting here is increasing access to health insurance. Under the ACA — especially its expansion of the Medicaid program — more U.S. residents have relationships with doctors and a “medical home” than they did before it was signed into law in 2010. The Trump administration’s efforts to weaken the ACA diminish our national biodefense by increasing the number of people without health insurance or coverage. They are less likely to have a regular physician and less likely to see a doctor when they are ill. That means the diagnosis of an infectious disease can be delayed — or completely missed — allowing it to spread through the community.
In several states that did not expand Medicaid, especially those with rural populations, more than one-third of rural residents are uninsured.
A second gap in the National Biodefense Strategy concerns immigration. The administration’s anti-immigration stances may have the unintended effect of increasing the spread of infectious disease. Undocumented immigrants are likely to avoid public health clinics where they may be identified, separated from their families, and deported. The administration’s latest “public charge” proposal, which would restrict green cards and visas for immigrants who use public benefits, could make even legal immigrants afraid of using benefits they are eligible for, including health care.
The biodefense plan does recognize the need for new vaccines and other preventive measures against infectious disease, including the development of diagnostics after a novel virus has been identified, even though that may be too late if it is a rapidly spreading disease, like airborne influenza. It does not, however, embrace what we have learned from previous Ebola and Zika outbreaks: Earlier and accurate detection and diagnosis of novel pathogens is essential to prevent widespread transmission.
Sometimes there is no effective way to test people suspected of having an infectious disease. Experience teaches us that having a simple, inexpensive, point-of-care diagnostic tool in the hands of health care workers in advance of a biological incident can thwart the spread of disease and prevent it from becoming widespread. Such technologies exist today in the form of metagenomic next-generation sequencing platforms. These could be installed in clinics across the country to provide immediate point-of-care diagnostic information during biological incidents with novel pathogens.
We hope that the compelling arguments for Medicaid expansion that go beyond biodefense are heard and more states act to increase access to public health care. We also hope that Congress intervenes to review the adverse consequences of discouraging the use of publicly funded health clinic by immigrant families. Finally, we urge Azar and his team to prioritize the development of clinical point-of-care diagnostic systems for infectious disease.
While the National Biodefense Strategy reflects the expertise of HHS, the administration’s policies on the Affordable Care Act and immigration leave millions of people without ready access to doctors and clinics. That’s dangerous for society, because people without health care coverage are especially vulnerable to the spread of disease.
In the final analysis, we must realize that borders are not just national boundaries. They are also dividing lines between the insured and uninsured in our society, which will have a substantial impact on our ability to respond to biological incidents.
David Beier is a managing director for Bay City Capital, a life sciences venture capital firm based in San Francisco. Devabhaktuni Srikrishna is the founder of Patient Knowhow, which curates patient educational content on YouTube. He worked on the response to the 2014 Ebola outbreak in Guinea.