The next pandemic is coming. We don’t know when it will hit or what it will be, but we do know that risk factors for the spread of infectious disease are worsening. An increasingly interconnected world means that diseases can circle the globe faster than ever before. Industrial-scale livestock practices, and the encroachment of human settlements into animal habitats, can facilitate the emergence of new pathogens. Anti-microbial resistance threatens to reinvigorate diseases we could otherwise easily contain with antibiotics. And advances in bioengineering make it possible to create dangerous new disease strains.
The 2014–15 Ebola outbreak in West Africa provides a useful microcosm of the challenges a pandemic would pose: it spread at a far greater speed and scale than previously thought possible, reaching multiple countries and highlighting the limits of global public health preparedness. Experimental (but effective) medical countermeasures had negligible effect on the containment operation—they could not be trialed, approved, and produced fast enough. And while the world had a good understanding of Ebola’s basic characteristics, and possessed other effective tactics for containing it on a small scale, neither this knowledge nor those tools provided a roadmap for containing a mass-scale outbreak of the disease.
My new report explores how policymakers navigated the policy and operational challenges of rolling out a large-scale outbreak response with no strategic or operational blueprint. The report recounts how US and UN policymakers contended with the challenge of elaborating a strategy and building a response—and how their differing approaches show the importance of iterating from existing systems rather than constructing brand-new structures in the heat of a response. It also looks into two key US policy challenges: how to manage border and travel controls, and how to scope the role of the US military in an outbreak response.
Three big lessons for the next pandemic response
Outbreak response strategy does not scale in a linear way. Certain tools, particularly medical countermeasures and clinically intensive tools like rigorous isolation in treatment centers, are slow, expensive, and laborious to scale up. Other classic epidemiological tools, like case-finding and contact tracing, are somewhat more scalable but can still be overwhelmed if transmission accelerates rapidly. Response strategies for a major outbreak must better anticipate when elements of an initial approach will hit their ceilings and become difficult to further expand. Alternate options for breaking transmission—likely focused on mass behavioral change—must become more central. This means a much greater emphasis on community engagement and local cultural factors. One important wrinkle is that it is not always obvious when an outbreak has passed a significant scale threshold and requires a strategic realignment. Trigger indicators should be developed to help responders identify and proactively address a response strategy that is falling behind the outbreak.
An evolving response strategy requires a different configuration of actors and capabilities. The initial Ebola response in West Africa centered on traditional public health actors—ministries of health, the World Health Organization, the Centers for Disease Control, and specialized aid agencies like Doctors Without Borders. The eventual response involved a much wider array of players— aid donors, militaries, humanitarian agencies, biomedical researchers, and of course local leaders and influencers in the countries themselves. These players were new to outbreak response and lacked both a common language and relationship networks with the global public health community. This led to a rocky partnership at times, as multiple professional communities went from meeting on a blind date to entering an arranged marriage. Far more work is needed to map the universe of actors that may engage in future pandemic emergencies, develop a common understanding of their prospective roles and responsibilities, and build the institutional and personal relationships that underpin real-time response effectiveness.
Response at scale requires different leadership structures and competencies. A major outbreak or pandemic is not simply a public health crisis—it is a complex emergency with major operational, diplomatic, political, and policy dimensions. Both the US government and the United Nations were slow to recognize this—but both ultimately shifted from responses led by subject-matter-experts (at CDC and WHO) to operations led by senior political figures with direct access to the president and secretary-general. While the Obama administration faced criticism (and late-night satire) for appointing someone without health training to run the response, “Ebola Czar” Ron Klain’s expertise in government process and policy proved to be a far more important asset. A large multi-agency operation requires leadership that serves an honest-broker function, aligning stakeholders around a clear strategy, holding them accountable for delivering, and clearing political and policy bottlenecks that threaten response effectiveness.
The Ebola experience also suggests that this kind of diverse operation performs best under a unity-of-effort leadership model rather than a unity-of-command model. The US government coordination structure under Klain empowered him to facilitate and align government agencies but did not create a new chain of command. The UN applied a different approach, merging all UN agency roles into UNMEER, a new unity-of-command structure modeled on a peacekeeping mission. While this brought greater alignment, it also brought confusion—agencies were unaccustomed to working under a peacekeeping mission configuration and UNMEER lost critically important weeks acclimating UN agencies to this different way of working. Importantly, both the US and UN approaches were ad hoc innovations whose lessons have yet to be sufficiently institutionalized. A future pandemic will leave little margin for error, so the US government and the international system need to put in the legwork now to better articulate the leadership structures they would deploy.
All this and much more is covered in the report—I hope you enjoy it.