It was the nightmare that wasn’t.
On July 20, 2014, as West Africa struggled to quash a historically large outbreak of Ebola, an infected man carried the virus to Lagos, Nigeria—Africa’s largest city. In that dense throng of 21 million people, many of whom travel extensively, it seemed that Ebola would be impossible to track and contain.
But Nigeria was ready. In the previous years, it has been using investments and support from the United States and other countries to boost its efforts to eradicate polio. When Ebola came, it swiftly redirected all of that infrastructure at the problem, including an emergency operations center, a crack team of epidemiologists trained by the U.S. Centers for Disease Control and Prevention (CDC), and GPS systems that could be used to track potential cases. In the end, Nigeria brought Ebola to heel in just three months, with only 19 cases and eight deaths.
The country’s spectacular success is a testament to the decisive actions of its government and health workers. But it also shows how important it is for rich countries to bolster the capacities of poorer ones, where outbreaks are most likely to begin due to weaker health systems and dense populations. No nation can tackle the problem of epidemics alone. In a world in which someone with a deadly virus can fly to any other continent in less than a day, the United States is connected to the entire planet’s diseases. And so, to protect itself, it must protect everyone else. As Rebecca Katz from Georgetown University once said to me, “If your desire is to keep disease out of your country, the best way to do that is to contain it at the source.”
In the years since the Ebola outbreak, the United States has channeled billions toward this goal, and has led other countries in doing the same. But some of that funding is set to disappear. This is a common pattern with epidemics. Diseases flare up and we throw money and resources and troops at them. The crisis ends and peacetime brings complacency. “We’ve got to get out of this cycle of panic and neglect,” says Carolyn Reynolds, vice president for policy and advocacy at PATH, a nonprofit working in global health.
In a new report called Healthier World, Safer America, launched today, PATH calls for the United States to redouble its commitment to global health. The timing is no coincidence: Tomorrow, delegates from 50 countries will gather in Kampala, Uganda, for a ministerial meeting of the Global Health-Security Agenda—a five-year international partnership that aims to improve the health security of developing nations. PATH wants America’s support for the GHSA to continue, and to be backed up by strong leadership and a firm plan.
Barack Obama convened the GHSA in 2014 with strong bipartisan support, and since then, the United States has committed more than $1 billion to the program. These investments have already made tangible differences. As just one example, Cameroon’s response time to recent outbreaks of cholera and bird flu shortened from 8 weeks to just 24 hours. “That’s a really significant change,” says Reynolds, when thinking thinking about whether a disease remains a localized outbreak or flares into a globe-spanning pandemic. “We feel that the Ebola epidemic was a tipping point—a global wake-up call that the world is not prepared.”
This is as uncontroversial a position as exists in public health, and one also shared by many other major organizations. Since the Ebola epidemic, the National Academies of Sciences released a report urging that the “U.S. government should maintain its leadership position in global health as matter of urgent national interest.” The World Bank released its own report saying that “investing in preparedness is not a one-off, but an ongoing requirement” and that “every expert commentary and every analysis in recent years tells us that the costs of inaction are immense.” Meanwhile, an international coalition called CEPI—the Coalition for Epidemic-Preparedness Innovations—has raised $460 million to develop vaccines against potential pandemic diseases. “We have taken some steps, but there’s always another crisis that shifts political attention,” says Reynolds. “We can’t afford to take our eye off the ball.”
America has a long and bipartisan history of supporting global health. In 2003, George W. Bush created the President’s Emergency Plan for AIDS Relief (PEPFAR), which has since used over $72 billion in funding to distribute antiretroviral drugs to almost 11.5 million people in sub-Saharan Africa. In 2014, Barack Obama deployed thousands of troops and health workers to fight Ebola in West Africa, and secured an emergency budget of $5.4 billion to deal with the epidemic.
The Trump administration’s attitudes toward global health have been harder to gauge. The president’s penchant for isolationism, from his America First rhetoric to his thrice-attempted travel ban to his NATO skepticism, sit uneasily with an ethic of international cooperation, and the administration’s proposed budget threatened to slash $2.2 billion from global health programs. But recent signs from administration officials have been more reassuring.
For example, the U.S. delegation at the GHSA meeting in Kampala will be led by Tim Ziemer, a retired rear admiral who led George W. Bush’s President’s Malaria Initiative, and has been described as “one of the most quietly effective leaders in public health.” In July, at the Aspen Security Forum 2017, Thomas Bossert, assistant to the president for homeland security and counterterrorism, said the United States would “continue our full-throated support” of the GHSA. “The weakest country among us with the ... least preventative-care capabilities [is] going to be the patient-zero outbreak source,” he said. “And they're going to end up killing and infecting the world, and so we need to put money into places that don't have the money to do it themselves to prevent loss of life here. So that's it.” Secretary of State Rex Tillerson backed up this rhetoric in early October, saying that “the United States advocates extending the GHSA until the year 2024.”
Reynolds argues that these strong verbal commitments must be backed up by equally strong financial ones. Currently, the United States spends around $450 million on global health security programs—less than 0.1 percent of what it spends on military defense. Congress has averted the worst of Trump’s proposed cuts, but its budget still reduces the total spent by 10 percent in fiscal year 2018.
An even steeper fiscal cliff looms in 2019, when $1 billion, which was diverted from the money allocated to fighting Ebola, runs out. That money has been used well, to train epidemiologists, buy equipment, upgrade labs, and stockpile drugs. If it disappears, progress will halt, and potentially reverse. The CDC, for example, would have to pull back 80 percent of its staff in 35 countries, breaking ties with local ministries of health. “We’re in the middle of substantial capacity-building efforts and it’s the wrong time to pull out,” says Reynolds.
Research and development into drugs, vaccines, and diagnostic tests for neglected diseases has also been underfunded. Until the Ebola money was appropriated, such funding was at its lowest since records began in 2007. It will fall back to that historical nadir unless new commitments are made.
Of course, budgets aren’t infinite, and the United States has any number of domestic health crises too, from environmental catastrophe in Puerto Rico to a nationwide opioid epidemic. But “it can’t be an either/or,” says John Monahan at Georgetown University, a former adviser to the State Department. “We have to do multiple things to protect the health of the American people, and one of them is investing in health security abroad.”
The word “investing” is key. A severe outbreak, equivalent to the flu pandemic of 1918, could cost the world up to $6 trillion and kill between 50 and 80 million people. It is far more cost-effective to prepare for one than to react to it.
Nor does preparedness involve huge amounts of money, doled out in perpetuity. PATH calculates that USAID and CDC could continue the work that was supported by the Ebola money with an extra $250 million over the next three years. That would go a long way toward helping the countries that are assisted by the GHSA to meet development benchmarks laid out by the World Health Organization, and reach a point when they can sustain their own progress.
“The American government, the American people, have done so much in global health,” said Awa Marie Coll-Seck, Senegal’s minister of health, at a recent event hosted by PATH. “It’s important for the United States to understand that supporting our countries to have strong preparedness and response to epidemics will protect the United States. It’s a win-win situation. If we are weak, everything will come. There are no borders, no passports, no visa if it’s a disease.”
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