After the successful containment of Ebola in the United States and West Africa, President Barack Obama’s administration recognized the challenges of coordinating all the agencies of federal, state, and local governments and civic institutions to address a sudden and potentially global public health emergency. Best practices call for an all-of government – or better yet, an all-of-society – response. 

Given the risks to national security that global disease outbreaks represent, President Obama gave this responsibility to the National Security Council, which is the President’s, “principal forum for national security and foreign policy decision making with… senior national security advisors and cabinet officials.”

What is more important for our purposes, though, is that the National Security Council is, “the President’s principal arm for coordinating… policies across federal agencies.”

In 2016, the National Security Council established the Directorate for Global Health Security and Biodefense. Its task, according to the first head of that directorate, Dr. Beth Cameron, was:

“… to do everything possible within the vast powers and resources of the U.S. government to prepare for the next disease outbreak and prevent it from becoming an epidemic or pandemic.”

In a 2020 Op-Ed in the Washington Post, Cameron described the rationale for establishing the directorate:

“The U.S. government worked hard to fight the 2014 Ebola epidemic. Unlike Central Africa, Ebola was not a usual occurrence in West Africa; the necessary elements of community trust and public health decision-making weren’t in place to detect and stop it. Guinea, Liberia and Sierra Leone were blind spots for disease surveillance. The cost was thousands of lives, billions of dollars and years of economic recovery for countries already torn by decades of war.”

The work of the directorate was to coordinate the intricate patchwork of public health and medical intelligence capabilities and to help inform federal policy and response.

Cameron described the essential work of the directorate this way:

“It would identify needs among state and local officials, and advise and facilitate regular, focused communication from federal health and scientific experts to provide states and the public with fact-based tools to minimize the virus’s spread. The White House is uniquely positioned to take into account broader U.S. and global security considerations associated with health emergencies, including their impact on deployed citizens, troops and regional economies, as well as peace and stability.” 

As important, the directorate would be able to move with far greater speed than an ordinary government agency. Cameron explained,

“A White House office would… elevate urgent issues fast, so they didn’t linger or devolve to inaction… It would be in charge of sharing information and coordinating our public health and humanitarian response with partners and allies. And it would work now to prepare the United States and the world for the next pandemic, including by developing incentives for global leaders and governments to rapidly finance and fill identified gaps.”

Cameron reported to both the president’s National Security Advisor and his Homeland Security Advisor. Her and her team’s work was coordinated with the senior-level National Security Council response coordinator who could rally the government at the highest levels. 

Cameron noted: 

“This high-level domestic and global reporting structure wasn’t an accident. It was a recognition that epidemics know no borders and that a serious, fast response is crucial. Our job was to be the smoke alarm – keeping watch to get ahead of emergencies, sounding a warning at the earliest sign of fire – all with the goal of avoiding a six-alarm blaze.”

This early warning/rapid response capability is the key to preventing a disease outbreak from becoming a pandemic. Cameron described the challenge this way:

“In a health security crisis, speed is essential… the specter of rapid community transmission and exponential growth is real and daunting.”

One significant role of the directorate, in the event of an outbreak, was:

“… to get ahead: to accelerate the response, empower experts, anticipate failures, and act quickly and transparently to solve problems… We were to prepare for and, if possible, prevent the next outbreak from becoming an epidemic or pandemic… We partnered with federal departments and agencies as they monitored evolving outbreaks, triggering alarms for decision-makers when those outbreaks began to take on unusual or worrisome characteristics.”

Cameron noted both the severity and complexity that pandemics represent:

“Pandemics, like weapons of mass destruction and climate change, are transnational threats with potentially existential consequences. No single department or agency can be responsible for handling them. Pandemic threats may not arise every year, but the White House should constantly prepare for them.”

The directorate became operational in the last year of the Obama presidency.

When the Obama administration came to a close, the directorate handed off to the Trump transition team a detailed playbook to coordinate government resources in the event of, “high-consequence emerging infectious disease threats and biological incidents.” 

The 69-page playbook’s purpose was:

“… to assist U.S. Government experts and leaders in coordinating a complex U.S. Government response to a high-consequence emerging disease threat anywhere in the world with the potential to cause an epidemic, pandemic, or other significant public health event, by providing a decision-making tool that identifies: (1) questions to ask; (2) agency counterparts to consult for answers to each; and (3) key decisions which may require deliberation through the Presidential Policy Directive (PPD)-1 process or its successor National Security Council process.”

In other words, the directorate provided a roadmap for the complex coordination needed to manage a whole-of-government response to an infectious disease outbreak. The playbook included sample documents, templates, and key resources.

But the Trump administration ignored the playbook and did not use it in their response to COVID-19. 

On May 7, 2018, Luciana Borio, then the Director of Medical and Biodefense Preparedness Policy at the National Security Council, warned that the United States was unprepared to respond effectively to an infectious disease outbreak until it improves its vaccines, health care infrastructure, and coordination with other countries. She told a symposium hosted by Atlanta’s Emory University and the Centers for Disease Control and Prevention, 

“Influenza is a top priority to the White House, and represents both a health security and a national security threat… Today, however, we cannot respond with the speed that we need to.”

The next day, Trump’s National Security Advisor John Bolton dissolved the National Security Council’s Directorate for Global Health Security and Biodefense, just two years after it had been established. 

The Washington Post reported at the time that the dissolution of the directorate and the departure of its head, Rear Admiral Timothy Ziemer, from the National Security Council, “means that no senior administration official is now focused solely on health security.”

The Post noted that the dissolution of the directorate,

“… comes at a time when many experts say the country is already underprepared for the increasing risk of a pandemic or bioterrorism attack.”

The Post quoted J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies, saying:

“Health security is very fragmented, with many different agencies… It means coordination and direction from the White House is terribly important.”

Crimson Contagion: Pandemic War Game

The reality of just how complex and difficult a national response to a pandemic can be was made clear in August 2019, three months before COVID-19 broke out in China.

The United States conducted an extensive pandemic war game called Crimson Contagion. The exercise involved nearly 20 federal government agencies, 12 states, and dozens of local health agencies in a four-day exercise to test how the government would handle a deadly global outbreak. 

The simulated crisis involved a fictional outbreak in China that entered the United States and then spread quickly. 

The results were not encouraging. There was a lack of clarity about which federal agency was in charge. Also, “policies [were] often in conflict with each other, which resulted in confusion among exercise participants.”

The New York Times characterized the consequences of that confusion:

“Federal agencies jockeyed over who was in charge. State officials and hospitals struggled to figure out what kind of equipment was stockpiled or available. Cities and states went their own ways on school closings.”

The exercise’s after-action report uncovered gaps in the nation’s readiness, including:

• “Different government information systems prevented a common sense of the reality of the situation at any given time.

• There was spotty understanding of how the Centers for Disease Control and Prevention (CDC) shared data.

• There was an insufficient supply chain to provide supplies and equipment in the event of a national outbreak.

• There was confusion about the ability to use the Defense Production Act to mitigate supply shortages.

• States had difficulty understanding how to request federal resources, due to ‘lack of standardized, well-understood, and properly executed resource request processes.’”

In other words, many of the very challenges the National Security Council’s recently discontinued Directorate for Global Health Security and Biodefense had been charged to coordinate were not coordinated. The federal and state agencies were essentially on their own, left to figure things out in their own ways, often competing with each other without a central coordinating authority. 

This left a gaping hole in the nation’s preparedness for an actual infectious disease outbreak.

Note also that the Trump administration had ignored the very playbook for coordination that the Directorate of Health Security and Biodefense had provided it during the transition.

In the months following Crimson Contagion, all these challenges would become real as an actual pandemic began.

Indeed, in September 2019, one month after Crimson Contagion and two months before the COVID-19 outbreak began, the Global Preparedness Monitoring Board, convened by both the World Health Organization and the World Bank, emphasized the significance of having robust coordination in a whole-of-government response to an infectious disease outbreak:

“Heads of government must appoint a national high-level coordinator with authority and political accountability to lead whole-of-government and whole-of-society approaches, and routinely conduct multisectoral simulation exercises to establish and maintain effective preparedness.

At the time, the United States was without such a high-level coordinator. 

And we didn’t have one again until the very first day of President Joe Biden’s term, when he re-established the National Security Council Directorate for Global Health Security and Biodefense.