Three urgent priorities for the National Security Council to strengthen global health security and biodefense

In a planned transition, Beth Cameron, the Biden administration’s top official for global health security and biodefense, leaves her post at the White House National Security Council this month. After more than a decade spearheading biosecurity and pandemic preparedness, she will be replaced by U.S. global malaria coordinator Raj Panjabi — a primary care physician who has been a stalwart advocate for community-based health care programs as the former CEO of Last Mile Health.

Panjabi’s appointment could signal a potential shift in U.S. health security policy.

He takes over as the NSC’s senior director for global health security and biodefense at an uncertain and pivotal moment for public health. Covid-19 has exposed many of the blind spots in standard resilience measures. The transition from vaccine supply to in-country delivery has highlighted that chronic gaps in health systems pose significant barriers to getting shots in arms. International negotiations to bolster pandemic preparedness have been delayed by contested normative and pragmatic approaches to health security. And rising threats from climate change and socioeconomic inequities have fueled increasing concerns for infectious disease spread.

The National Security Council and, by extension, its senior director for global health security and biodefense, plays a key role in mounting a coordinated response to these complex challenges.

Panjabi has an unprecedented opportunity to redefine how the U.S. addresses Covid-19 today and the public health threats of tomorrow. Here are three urgent priorities he should focus on:

Move from diseases to systems

The traditionally narrow focus of health security on infectious disease control has meant it often fails to live up to its own objectives. Covid-19 is the latest in a long history of health emergencies that disrupted essential health services, with 90% of countries still reporting delayed or shuttered health care services. A lack of basic health system capacity has contributed to the deaths of more than 180,000 health workers and millions of unusable vaccine doses. Narrowing the scope of what is included in health security planning to just one-off interventions to temporarily stop disease transmission obscures the wider drivers of health insecurity.

Although robust health security interventions are essential, the inconvenient truth is that they alone will fail to prevent outbreaks unless they rest on a strong foundation of functioning health systems.

Rather than hyper-focusing on infectious disease control, Panjabi’s office should take a systems approach to health security coordination. What does this look like? It means going beyond epidemiologist and surge staffing during crises to support a diverse, well-trained, and protected health workforce. It means sustaining primary health care and essential health services through health security mechanisms like the U.S.-backed Pandemic Preparedness and Response Fund. And it means developing risk communication and public health campaigns that partner with communities and civil society to build trust long before outbreaks occur.

Moving from vulnerability to equity

The coronavirus pandemic disproportionately affected already vulnerable populations. Racial and gender inequities, crowded housing, low economic status, and social stigmatization heightened susceptibility to Covid-19 outbreaks. Each year, health costs push 90 million people into extreme poverty. With Oxfam reporting that inequality directly causes one death every four seconds, the routine exclusion of underlying determinants of health from U.S. health security strategies perpetuates a self-defeating approach to preparedness.

The Biden Administration has committed to “address gender inequities and inequalities health workers face globally.” That rhetoric, however, is not reflected by the U.S.’s lack of funding for the World Health Organization’s Gender Equal Health and Care Workforce Initiative, and a promised White House-led health workforce initiative has yet to materialize. The NSC’s incoming senior director for global health security and biodefense should catalyze these efforts to strengthen equitable access to local health care as a way to bolster health security.

With the U.S. co-chairing the WHO’s Working Group for Preparedness and Response, the NSC should recommend that social protection, primary health care, and universal health coverage be included in negotiations for the WHO’s pandemic treaty and reform of international health regulations.

Panjabi should use the upcoming White House Covid-19 Summit in March to build momentum for equitable health security, such as empowering low-income countries to manufacture medical countermeasures to public health crises, collecting gender-disaggregated data on the impacts of Covid-19, diversifying leadership and governance for the Access to Covid-19 Tools (ACT) Accelerator and the proposed Global Health Threats Board.

Moving from fragmentation to integration

A recent report by the U.S. Government Accountability Office characterized the U.S. Department of Health and Human Service’s leadership and coordination for public health emergencies as “high-risk.” This reflects pervasive fragmentation across global health security initiatives, often fueled by siloed disease programs.

While the American Pandemic Preparedness Plan calls for a “mission control” to streamline domestic preparedness capacities, no similar effort has been proposed to effectively coordinate the various U.S. agencies responsible for global health security and biodefense.

The National Security Council is uniquely positioned within the White House to lead a clear, integrated approach to preparedness and response, including coordinating infectious disease and emergency risk capacities alongside essential public health functions and primary health care. U.S. agencies focused on global health security such as the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), the Centers for Disease Control and Prevention, and others should integrate cross-cutting health systems interventions — community health workers, surveillance networks, and the like — and align with the United States Agency for International Development’s (USAID) Health System Strengthening Vision.

Finally, the NSC’s incoming senior director for global health security and biodefense should tie Covid-19 investments to local health systems that include incentives for domestic financing for adaptable health services (while disincentivizing user fees), supporting regional pooled procurement mechanisms to expand access to medicines and supplies, and directing unrestricted funding toward multilateral organizations like the WHO that can advance cross-cutting sustainable development goals.

As the NSC’s new director for global health security and biodefense, Panjabi should take a long-term, holistic approach to pandemic preparedness and response that is underpinned by broader efforts to strengthen health systems such as sustaining primary care, training community health workers, creating resilient supply chains, and reducing financial barriers to health care.

Fears that a comprehensive approach to disease prevention coordinated by the White House would fuel mission creep take a myopic view of how complex public health threats evolve. The virus that causes Covid-19 is not disappearing — it is adapting. The U.S. approach to global health security must do the same — starting with the National Security Council.

Arush Lal is the board vice chair for Women in Global Health, a community and civil society representative for the Access to Covid-19 Tools (ACT) Accelerator, and a doctoral candidate in health policy at the London School of Economics and Political Science.