New models for pandemic response can be found in existing agencies

As we start the second year of the COVID-19 pandemic under a new administration and we get our country on the road to recovery, it is time to take steps to improve the federal government’s structure for future pandemics. A combination of staffing and structural changes at the White House and the Department of Health and Human Services are needed, as was pointed out by the former White House Ebola response coordinator under President Obama, Ron Klain.

Following the Ebola outbreak of 2014, Klain outlined several measures the federal government should take to combat future pandemics, which he and the current Director of National Intelligence agreed are national security threats of the highest priority.  

One of his primary recommendations was to create the right pandemic prevention and response structure at the White House. A dedicated White House staff directorate made up of cross-functional experts in emergency management, public health, medicine and policy can ensure comprehensive policies and plans that integrate national security needs with science, policy, economics and communications. The Biden administration is on the right track by bringing in a senior director for global health security and biodefense in the National Security Council.

Another noteworthy recommendation by Klain was to create a new Public Health Emergency Management Agency (PhEMA) to mobilize a national response to a major domestic outbreak. A strong operational health agency focused on medical preparedness, response, logistics, supply chain and procurement is essential to an effective domestic response to future pandemics or other health security threats. 

Many of the roles Mr. Klain described are best suited for the congressionally authorized, but relatively unknown, Office of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services. Modeled on the Goldwater Nichols Act and created through the Pandemic and All Hazards Preparedness Act in 2006, ASPR’s mission is to coordinate preparedness, response and recovery activities for all federal health and medical assets to support state and local partners, and to develop policies, strategies, and programs that relate to health security.  

ASPR oversees the National Disaster Medical System, the Hospital Preparedness Program, the Strategic National Stockpile and the Biomedical Advanced Research and Development Authority (BARDA), and chairs the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) interagency coordinating group. BARDA played a central role in the rapid development and manufacturing of safe and effective COVID-19 vaccines in record time.  

The combination of these historically small programs creates a locus of effort worth strengthening. It makes more sense to reform and build out ASPR to achieve its promise rather than to create yet another federal agency.  

For ASPR to reach its full potential, several issues need to be resolved. One is leadership. Currently the head of ASPR is a civilian assistant secretary who may choose to be commissioned as a 2-star admiral in the U.S. Public Health Service. That rank does not reflect the scope and importance of the position. For ASPR to be most influential with its colleagues, the position needs to be administratively elevated to a 4-star rank.  

Second, ASPR should be redesigned to mirror the Department of Defense combatant command structure, in particular the special operations command (SOCOM). SOCOM is the responsible authority for assuring that all service elements (e.g., Army, Navy, Air Force, Marines) are integrated into planning, readiness and execution of operations that require unique multi-element response. 

A federal response to a major domestic health emergency or pandemic requires coordinated assets from different federal agencies. Therefore, senior health officials from the Department of Veterans Affairs, Federal Emergency Management Agency (FEMA), and DoD should represent those agencies within the ASPR structure as full-time advisors to the head of ASPR, all serving asynchronous to presidential terms in order to minimize political impact. This senior leadership structure would enable access to key federal resources much better that the current configuration allows. In times of emergency, the head of ASPR should serve as the disaster health and medical advisor to the White House, much like the FEMA Director.  

Lastly, ASPR should work more closely with state, territorial, tribal and local jurisdictions, as well as the private sector to allow for better understanding of their needs and barriers to preparedness. ASPR should be empowered to establish expanded regional offices providing integrated health and medical support to those jurisdictions, thereby allowing meaningful interactions to occur in a sustainable manner.

Given the national security implications of pandemics and other health security threats, we have no time to waste in improving our federal government posture to prepare for and respond to the next health emergency. The Biden administration has taken some promising initial steps. Building on the PhEMA concept by strengthening the existing ASPR organization and creating a combatant command-type structure would synchronize efforts among the four largest federal agencies responsible for the health and medical response to disasters using a model that has been proven over time.

Craig Vanderwagen, MD, was the founding ASPR from 2006 to 2009 and is now managing director with East West Protection, LLC. Kevin Yeskey, MD, was the founding director of the Office of Preparedness and Emergency Operations in ASPR and most recently served as ASPR principal deputy assistant Secretary in 2020; he is now senior advisor for Emergency Public Health with MDB, Inc. Yeskey and Vanderwagen have been engaged in planning and responding to domestic and international health disaster events including support to civilian, security, and DOD missions since the 1990’s. Jennifer B. Alton, MPP, previously worked for the Senate Committee on Health, Education, Labor and Pensions and drafted the Pandemic and All-Hazards Preparedness Act. She is president of Pathway Policy Group and a center affiliate at the Georgetown University Center for Global Health Science and Security.