Pandemic Proof: Boosting the US Role in Global Health Security

STEPHANIE PSAKI:
The truth is we don't have a global system right now that can support providing vaccines to everyone in the world as quickly as it needs to support that in a pandemic.

JAVIER GUZMAN:
You're listening to Pandemic Proof from the Center for Global Development. In this podcast, we explore policies and reforms to better prepare and respond to infectious disease threats like COVID-19, but also other nasty viruses, microbes, and fungi that can throw our health, our communities, and our economies into crisis. Join us as we envision ways to better protect our world in the future. I'm your host, Javier Guzman. Let's get started. It has been a year since the United States Public Health Emergency Declaration for COVID-19 expired in May 2023. And even though the focus, the budget, and the overall attention have largely shifted to other crises and a post-pandemic world, the US is continuing to reflect on lessons learned during the pandemic to improve its approach to pandemic prevention, preparedness and response. As you all know, the US has been an early champion and a very important donor to the Pandemic Fund, but the US has also been very active in the negotiations on the pandemic agreement.

It has supported very important global health initiatives like Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations, all to increase rapid and equitable access to medical countermeasures and to improve pandemic preparedness and response. But this year, the United States has taken two specific additional steps to strengthen its ability to prevent, prepare for, and respond to pandemic threats. First, in April, the United States released a new global health security strategy, which sets the course for the next five years. And second, in February, the White House appointed the United States First Coordinator for Global Health Security, a position created by a 2022 bill and designed to help lead the federal government's pandemic preparedness prevention and response efforts. With that, I'm very pleased to have here with me today the coordinator for Global Health Security, Dr Stephanie Psaki. Stephanie has led public health policymaking at senior levels of the United States government, including in her concurrent role with the White House National Security Council.

She has also worked with a range of civil society organizations, including the Population Council and FHI 360. It is a great pleasure to have Stephanie with me today. Stephanie, thanks for coming. It's great to have you here. Thanks for speaking with me today.

STEPHANIE PSAKI:
Thanks so much for having me here. I'm very happy to talk about our work.

JAVIER GUZMAN:
Wonderful. So, let's get started. You know, I was talking about the two big important milestones and I want to ask, can you please reflect on those changes and the changes to the US approach to pandemic preparedness and response, including the creation of your role and including of course the launch of the US Global Health Security Strategy. What does this mean in terms of learning lessons from COVID-19?

STEPHANIE PSAKI:
So, thanks for that question and I really appreciate how you framed where we were a few years ago. You mentioned a couple of the recent changes that have been made, and there are others that have been made within the US government in the last few years. So, first, the office that I work in at the National Security Council on Health Security and Biodefense did not exist at the National Security Council. So, when COVID emerged as a threat, there was not an office at NSC or at the White House that was tracking the emergence of biological threats around the world. President Biden established the National Security Council and recreated this office that I am based in this past August, the White House established the Office of Pandemic Preparedness and Response policy, which is basically the successor to the White House COVID response team to make sure that we have a domestically focused office within the White House that is ensuring that we are prepared for the next pandemic or other biological threats.

So, those two entities within the White House are looking around the world, looking within the United States to make sure that we are prepared and responding to, to threats. And there, there are ongoing threats right now, there are also other changes that have been made in the departments and agencies. So, just as one example, CDC has established the Center for Forecasting and Outbreak Analytics to make sure that they're able to look ahead and come up with an assessment of the broader risk to the American people and to others around the world when a threat emerges. So, a whole range of changes that have been made over the last few years, and also launching our new global health security strategy, which was called for by Congress, but also called for by the president in a national security memorandum earlier in the administration. Part of all of this is making sure that we are learning the lessons from the COVID pandemic and the new global health security strategy that we launched includes a section that talks about what the lessons are that we learned and ties it to how we've formulated this new strategy.

But just to give a few examples of how this strategy builds on those lessons. There are three goals in the strategy. So, the first goal is investing through our bilateral programs to build stronger global health security capacity in countries around the world. And we announced that we are reaching now 50 countries as what we're calling intensive support partners, which means we have a structured relationship that we've agreed on in partnership with the government of gaps to fill in each country's capacity to prepare, detect, and respond to a biological threat. So, one of the areas that was very clear, I think, in the US and around the world during the COVID pandemic is the importance of having strong capacity for effective risk communication to make sure that the public knows what the risk is, is able to make informed decisions about the risk for their own health and safety. That obviously is something we've been working on within the United States, including the work that CDC has been doing.

But around the world, it's one of the major areas of support through our bilateral programs, primarily through USAID. So, that is a core part and we launched a website alongside the strategy where you can go and see what the 50 countries are and which capacities we're working on and where we are working on stronger risk communication in particular. So, that's one example. The second goal of the strategy, and I'm paraphrasing, is a focus on political leadership and financing addressing the shortage of pandemic financing. I think that it was very clear, again in the United States and around the world that when you have a pandemic or a health crisis of this scope, it's not sufficient to just be working through the Ministry of Health, although they obviously play a central and essential role, but it also becomes just a broader government-wide response from the White House to the State Department to all of the domestic facing agencies. And so, ensuring that we are investing in building strong political leadership by countries around the world, which is part of these partnerships that we're forming, but also the work that we're trying to advance through our multilateral partnerships and some of our bilateral partnerships.

The third example and the third goal on the strategy is making sure that we are better linking our global health security programs to other programs that the US invests in. So, other global health programs is an obvious example, thinking about the PEPFAR investments that were so essential during the COVID pandemic, but there are also animal health programs, there are other security programs, there are climate response programs and there are broader development programs that can be leveraged for global health security and global health security can strengthen those programs. And I think that, again, learn builds on this lesson we learned during COVID. That is, if you don't have a well-functioning health system, if you don't have health workers who are in place paid well-trained, it's very difficult to suddenly drop an emergency response onto a weak health system. So, the need to continue that work even as we prepare for the next pandemic.

JAVIER GUZMAN:
That is wonderful. And thank you very much for summarizing. So, you've got a bit of bilateral work, multilateral work, domestic work that is regional and global in nature. If I ask you about your top two or three priorities as global health security coordinator, what would you say? And also, if you can say what you will not focus on, I mean just to give a bit of a flavor to our audience on what the role is about.

STEPHANIE PSAKI:
So, the role of the coordinator, and this is also the role of the National Security Council more broadly, is to coordinate the work that is happening across federal departments and agencies. So, we do not ourselves and I personally am not making the policy, the job is to really pull on the expertise and the incredible work that's being done by agencies like the State Department, by USAID, by the Department of Health and Human Services, by USDA, many others, and make sure that we are doing it in a coordinated way, that we are responding quickly to threats that we are delivering on the strategy. So, in the actual legislation, largely, the way that the role is described is ensuring we're delivering on the strategy that it also teed up and we just launched. So, that is kind of overarching what the job is. And some pieces of it pushing for political leadership, pushing for financing are very high level. So, thinking about how to actually implement and deliver on that. So, there are a few areas that I am focused on and I will say that this is, and maybe this is part of the answer to what I'm not doing.

This is where we can be and where I can be helpful and complimentary to the work that the departments and agencies are already doing around the world. So, things that where we have clear policy, where we have clear resources, where they're working very well and that is most of what's happening is moving forward and being implemented by the leadership across the agencies. And then the question is where I can be helpful in elevating some of the work we're doing, better coordinating, resolving any questions about what our policy is. So, I would say there are two other areas, maybe three in addition to the strategy itself. One is just emergency response. So, I think that, you know, the primary role is making sure that we are of the White House, but also just of the president and the administration is making sure that we're protecting the American people. And so, to the extent that there are biological threats, whether they are naturally occurring, accidentally occurring or deliberate threats, our responsibility is to make sure we are protected from those threats.

So, that means that we are tracking, we have global biosurveillance to make sure that we know when there are threats emerging that may or may not pose a risk to Americans. We are clear as we see threats emerging on whether we have the right medical countermeasures in place, whether we have sufficient medical countermeasures and we have the public health system in place to respond and protect Americans. So, that is going to be always the first priority. There are some threats that we are always tracking around the world. So, we're, of course, working with our colleagues in OPPR to pay attention to the Avian influenza outbreaks domestically. But we are also looking globally at mpox in DRC and some of the surrounding countries and a few other areas. So, that's number one. On top of that, I am very focused on looking at where we can make progress on the financing landscape in 2024. So, you mentioned the pandemic fund. This is going to be an important year for resource mobilization for the pandemic fund.

We want to make sure that it's on very solid footing, it's well resourced by the end of this term. I think the US as well as many other countries who are the primary contributors in terms of ODA funding is in a difficult budget situation. We heard that from our counterparts in France, we've heard it from many others. And the vision of the pandemic fund was to not just pull on ODA funding but also to have a more innovative financing model. So, this year, we are going to push for $2 billion for funding for the pandemic fund from ODA funding. That includes expanding beyond the current donor base to bring in other government donors. But we are also going to push for what we're hoping will be a match to that at least. So, another $2 billion from private sector partners or from innovative financing sources. We are also pushing some, some work on surge financing through Development Finance Corporation in the US and the other DFIs for the rest of the G7 through the G7 process. So, those discussions are ongoing right now we just hosted a meeting at the White House with other DFI to try to talk about what's possible on the surge financing front to make sure that the DFIs can provide resources early on in an emergency for the procurement of medical countermeasures.

And we're continuing the work on MDB evolution to make sure that the multilateral development banks are better prepared to respond to some of the ongoing crises or threats including pandemics, but also climate and conflict. So, those are a few areas of opportunity on the financing front, but we are also going to continue pushing other traditional donor countries to make sure that, that we are not the only ones who are stepping up in terms of resourcing for for global health. And then the third priority area, equitable access to medical countermeasures, which I think is broadly a challenge across the global health spectrum, but specifically is one that has been really acutely top of mind for low and middle-income countries after the COVID pandemic. This is not a short-term solution. There are a lot of discussions that are on the table in the pandemic accord negotiations about how we make sure that we can reassure everyone that there will be sufficient countermeasures available. The truth is we don't have a global system right now that can support providing vaccines to everyone in the world as quickly as it needs to support that in a pandemic.

In terms of things I will not focus on, you know, I think there is a lot of frustration even for us in terms of where the FY24 budget landed and some cuts that were made to the global health security line among others. As you know, well, Congress ultimately makes a decision about what the funding looks like, and then we implement what we can implement with that funding. So, I think re-litigating or worrying about that or for those who are concerned about the budget, it did not land in a way that aligns with the president's priorities based on the budget he put out. But I think the best thing we can do to try to find ourselves in a better place a year from now is to make the case really clearly about why these investments are essential to protect the American people and why global health security is part of national security. So, that's what we'll be focused on doing.

JAVIER GUZMAN:
Thank you for that. I think the financing is extremely important. And clearly, it is a difficult period. I mean fiscal crisis, you know, ODA is not increasing but plateauing and we've got a lot of elections, but I think what you have to do is, is very hard. Can you tell us a bit how you make the case both within the US but with other countries to invest in something that people feel is not longer an acute threat?

STEPHANIE PSAKI:
The president's budget that he puts out every year lays out the priorities for the administration in terms of the resources that we think are needed. So, for the global health security strategy and the work that we're hoping to do in this space, that budget captures the resources needed. And as I mentioned, the FY24 budget where it landed, cut those resources. So, there is a reality that we have to grapple with here in terms of trade-offs, but also as we engage with other countries, it is difficult to put pressure on other countries to show up and support some of these issues if they see that we're making cuts to our own budget in this area. So, that is a real challenge and I think it's important for us to remember that one of the ways that we show leadership is by demonstrating through the budget that we finalize, where we're investing and where we're not investing, and it has a secondary effect. Exactly. That said, there are a lot of hard problems in the world right now. These are some of those hard problems and, you know, grappling with insufficient resources to solve enormous challenges is sort of the name of the game (LAUGHS) in this moment that we're in.

So, there are a few ways that we are trying to do it. One is we announced that we are reaching 50 countries through our bilateral programs. We are sharing very transparently for anyone to see what these countries are, where we're working, what we're doing, and tracking our success in reaching some of the targets. In 2022, the G7 committed to reaching 100 countries. So, the next step is going to our G7 partners and saying, here are the 50 countries that the United States is putting on the table, how do we get to an additional 50 countries? And again, I think this is a really important way for us to show our leadership that if we just push people to invest in global health security through vague language, it's not as compelling as saying, this is what we're doing, what are you doing? What else can you do? So, I hope that that will be powerful. And our goal is to get to that 100 number by the end of 2024, at least in terms of having a clear idea of which countries we're investing in and then we will track progress toward closing those gaps.

I think another, another area which I mentioned already is through the pandemic fund and again, needing to demonstrate, and this is where I think CGD staff and audience can be really helpful, needing to be creative about the ways that we bring resources in to demonstrate this innovative financing approach. So, just to give an example, one of the perpetual areas of frustration that we've heard from pharmaceutical companies is the lack of regulatory systems outside of the United States, but specifically, in the Africa region to get their products into those markets. And when there is a demand for products, the question is, can we come up with a better process to streamline and make it easier? So, for example, with the mpox outbreak in DRC for over a year, we have been trying to donate vaccines from our stockpile to the response in DRC. We have not been able to get them in because there is not regulatory approval in DRC for a product that FDA has approved in the United States. So, can we think about investments to pull in the private sector and reduce some of these barriers that both make Americans and the rest of the world safer when there's an emergency, but also take some pressure off of the ODA funding, which is in a difficult position for many countries.

So, welcome any creative ideas on the best way to do that. We will be rolling that out in the coming months. I think similarly, the pandemic response financing that we're working on through the DFIs and the work that we are doing with MDBs, with the World Bank and with the IMF to think more creatively about finding ourselves in a COVID like situation or the next pandemic, which will probably in all sorts of ways be different from COVID. We need to have a better approach to making sure that we can very quickly ramp up manufacturing around the world for medical countermeasures. We may or may not have a vaccine within a year. So, how do we surge production of PPE, for example, around the world and how do we provide a mechanism for low and middle-income countries to be able to directly get in line to procure vaccines or other medical countermeasures perhaps even before they have received regulatory approval or completed the research. So, similar to warp speed in the United States, is there a way that we can provide financing so other countries can buy in and be in line when those products are available?

So again, I think there are a lot of creative ways we can get at this, but we do need to move beyond the model of just relying on the same set of donors and the same ODA funding to solve all of these problems.

JAVIER GUZMAN:
OK. So, we'll see more of that this year. But you talked a bit about the pandemic agreement and I just wanted to ask a bit about that. Of course, this is really top of mind for the US, for a lot of US partners, low and middle-income countries as well. And it's coming up because the World Health Assembly is just around the corner. What can you say about where we are and what can you say about how you see the pandemic agreement materializing or not?

STEPHANIE PSAKI:
So, this is the pandemic agreement and the International Health Regulations Negotiations, which are wrapping up or perhaps will be paused to continue later. And then the pandemic accord negotiations start. These are very much top of mind. We have laid out clearly and actually in recent weeks been pushing to share publicly what the US positions are in the pandemic accord and also what our goals are, both to clarify what it is we're trying to accomplish for a domestic audience because there's a lot of myths and disinformation out there. But also, to lay our cards on the table for a global audience where we have been able to get in the US positions and the policy commitments we are willing to make is truly progress. And we really believe that it will make the world safer if we can get to an agreement based on this. We're, of course, not at agreement and this is always the case in negotiations. No one gets exactly what they want. And I think everyone will collectively be a little frustrated and a little disappointed if we manage to land on an agreement.

But when you are looking for agreement from all WHO member states, it is going to be more incremental progress than we all would like for it to be. And we believe that there is a possibility to make real progress. So, let me just restate what the US objectives are for both of these negotiations because this is what is kind of top of mind for us as we think about whether we've gotten there or not in terms of where the text lands. So, we have three objectives for both negotiations. The first is to enhance the capacity of countries around the world to prevent, prepare for and respond to pandemic emergencies and to provide clear, credible, consistent information to their citizens. And some of this, of course, has echoes of what we're doing through our bilateral work as well and through some of the multilateral work we're doing. The second objective is to ensure that all countries share data and laboratory samples from emerging outbreaks quickly, safely and transparently to facilitate response efforts and inform public health decision-making regarding effective disease control measures, including the rapid creation and safe and effective vaccines diagnostic tests and treatments.

So, this is one of the areas of concern that has emerged since the COVID pandemic, but has increasingly become a challenge, which is the difficulty in accessing data and samples in a timely manner to make sure that we are prepared either to support a response in another country or prepared for a response in the United States. The third priority is to support more equitable and timely access to and delivery of vaccines, diagnostic tests, treatments, and other mitigation measures to quickly contain outbreaks, reduce illness and death, and minimize impacts on the economic and national security of people around the world. So, this connects to the work that I mentioned before as one of the priority areas I'm focused on of equitable access to medical countermeasures between emergencies but also during emergencies. So, in terms of where the negotiations are, I think that there will be a collective question about whether we feel comfortable that we have arrived at a consensus based product that makes enough progress that we should agree to it now and then continue ironing out the details in the coming months and possibly years.

I think there will be some follow on work by necessity because these agreements are very complex or there is a preference to delay the negotiations continue for a year, maybe more than a year and see if we can get to a more detailed agreement. We are very committed and pushing for an agreement by May. As originally envisioned, we think we are several years out already from the start of the COVID pandemic. We don't know when the next pandemic or emergency will hit. And even if we can't get to a perfect product, we have a collective responsibility to get as much as we can in terms of progress in the short term. So, we'll see how it plays out, but that's what we are hoping for. On the International Health Regulations negotiations, and these have become tied together, you know, they are topically related of course, but also just politically I think there's a lot of tug of war, in terms of what is going to land in the IHR amendments and what is going to land in the pandemic accord. My understanding is that those have been fairly productive.

I don't think we are at agreement, but we are hopeful that we will be able to get to agreement and there might be some issues that are paused until the other side of this round of the pandemic accord negotiations. But on that, as I'm sure everyone knows, the IHRs will exist and be in place regardless of where those negotiations land. But again, we have put forward some amendments and others have put forward amendments that we really feel will make us safer. So, one of the top priorities for the US in those negotiations is a tiered alert system. So, right now, WHO just puts out an alert when there's a public health emergency of international concern. We find that it's insufficient for a number of reasons. One, the COVID pandemic went beyond that. So, we think there's a need for a pandemic emergency alert when we are at a full pandemic risk, but we also think there's a need for an earlier alert which we call an early action alert to say there is a risk that's emerging that has the potential to become a pandemic or potential to become a PHEIC, but we are not there yet.

And that really from a prevention standpoint is the most important alert in a lot of ways because that is the time when we can all surge our resources and make sure that we're responding quickly to contain an outbreak. So, hopefully, we'll get there on those amendments and the pandemic accord, but regardless of where those land, we're going to keep moving forward with these priorities through WHO and through other fora.

JAVIER GUZMAN:
I think it's a window of opportunity that we will not have again. So, I hope, I really hope that member states that countries do agree on something that is ambitious, but feasible and enforceable. Before we finish, we always ask one question, which is, if you could prioritize one change in the global architecture for pandemic preparedness and response, what would that be?

STEPHANIE PSAKI:
I've heard from a lot of people within the US government and from others outside of the US government, there still is not a sufficiently clear picture of what are we talking about when we say the global health architecture. I think it would be so much easier to answer this question if we all had an agreement about what is out there, what are the problems that we are effectively solving, and what are the clear gaps? So, I genuinely feel like one of the biggest struggles we are having in policy conversations is just that clear picture of what we're talking about. There are a lot of vested interest in keeping things the way that they are. So, it's hard to get that clear picture unless it's from an outside source. So, that's the pre-work that I think... (LAUGHS).

JAVIER GUZMAN:
That's doable. That's doable.

STEPHANIE PSAKI:
Yeah, doable. That's doable. That said, you know, I think once you have that clear picture, and this is I think a reality that a lot of the institutions that are part of this infrastructure are grappling with, which is there is a tendency often to expand the scope of work. There are a lot of important problems. You know, when, when you have key institutions that are important actors and they're present on the ground in many countries, they understandably want to expand the scope of their work. I think there's a question about do these institutions combine efforts? Do they narrow the scope of work to make sure that it's clearly complimentary and there's not overlap? Or does it make sense for all of them to expand work? And perhaps, you know, everyone is working on building stronger health systems and investing in primary healthcare, which we know will benefit the broader system. So, once we have the pre-work, then I think the question is how do we take a step back, take a step back from the vested interest in keeping things the way they are and say, what is the rational version of this system?

And how do we get it there? Whether we like it or not, that is the direction we are going to have to go in because there are insufficient resources to support all of the institutions and the scope that all of these institutions have. My top priority vision would be that, you know, I think I come from a broader global health background, not explicitly global health security. And I think in the wake of the COVID pandemic, there are a lot of new voices at the table and new participants in the discussion about global health, which is very welcome. It's good to expand the tent. But again, some of these basics, like you can't drop an emergency response onto a health system that's not functioning, sometimes get lost in the conversation. And to me, it doesn't make sense to have parallel systems for global health and global health security. It makes sense to have one system that is investing at every level. So, we build a strong foundation. We make sure that health workers are in place and paid and well-trained.

We make sure that routine childhood vaccinations are happening. We make sure that services are high quality, that there is access to services. And then you can much more easily build a response, whether it's rolling out countermeasures, sharing information, getting information about pathogens or emerging threats. The best way we can do that is to have strong health systems. So, I think, there is also a tug on this in both directions from the sort of global health and global health security space. My view is that this needs to be one system and we need to be really clear about which parts of the system are moving forward on which objectives.

JAVIER GUZMAN:
OK. That is ambitious and it might not be doable, (STEPHANIE PSAKI LAUGHS) but I hear you, I hear you. So, I guess the question that we finish this with is how do we strengthen health systems with the current architecture? And how do we move forward on that very important aspiration for global health, but also for global health security? Thank you very much, Stephanie, for being with us today. It's a pleasure, and we'll talk soon.

STEPHANIE PSAKI:
Thank you so much for having me. ('CONCENTRATE' BY SPOQ PLAYS)

JAVIER GUZMAN:
Thanks for listening to Pandemic Proof from the Center for Global Development. Very special thanks to the CGD podcast team Morgan Pincomb, Sophia Greenhoe, Stephanie Donohoe, and Soundeazy for making it happen. Pandemic Proof is available on the CGD podcast stream. So, make sure you are subscribed to the CGD Podcast on Apple, Spotify, or wherever you're listening to podcasts. And remember, you can check out all of our work on pandemic preparedness and beyond at cgd.org or on X @CGDev.