The United States Needs a Director of National Health Security

By Andrew Kilianski

The US response to the COVID-19 pandemic and the recent monkeypox virus outbreaks has been severely hampered by a lack of a central authority over health security, a concept that encompasses a range of activities focused on protecting the health of citizens from natural, accidental, or human-caused threats. Funding levels are often blamed for poor outcomes, but US spending on health security is high by global standards, with an average annual spending of nearly $11 billion on health security-related programs in the five years leading up to the pandemic.

This spending, however, has failed to translate into results, with the United States reporting 16% of global COVID-19 deaths despite being home to just 4.3% of the global population. Subsequently, in response to the outbreak of monkeypox, the government has struggled to provide equitable and timely access to diagnostics, therapeutics, and an approved vaccine. Congressional efforts (including the proposed PREVENT Pandemics Act), the president’s budget (which seeks to address gaps highlighted in the Biden administration’s pandemic preparedness plan), and the National Biodefense Strategy have focused on financial resources. But before allocating more money to preparedness and response, policymakers should create a unified organizational structure that can coordinate funding, work, and communication across multiple government agencies while being accountable to leadership and taxpayers.  

On paper, the government’s responsibility for preparing for a pandemic is diffuse, spread through multiple agencies within the Departments of Health and Human Services (HHS), Homeland Security (DHS), Defense (DOD), and Agriculture (USDA). Two agencies—the Administration for Strategic Preparedness and Response (ASPR) within HHS and the Federal Emergency Management Agency (FEMA) within DHS—are specified as lead coordinators by the government’s National Response Framework. However, when these coordination roles were activated in 2020, their performance was suboptimal in the face of the complex situation posed by COVID-19. These agencies lacked both the resources and the political and whole-of-government authority to lead the US federal response. 

The lack of unified authority and decisionmaking reduced preparedness before the pandemic and severely hampered both the Trump and Biden administrations’ responses. Without central leadership focused on health security, structural issues prevented coordination across multiple chains of command; the many discreet offices responsible for pandemic and emerging threat medical countermeasure development; and numerous appropriations categories for different departments and agencies. In this leadership void, Operation Warp Speed (OWS) was created as a quick fix for federal vaccine development. As successful as OWS eventually proved to be, it took months to begin operating in early July 2020. And today, vaccines and boosters prevent hospitalizations and deaths—but global waves of infection continue. 

Without central leadership focused on health security, structural issues prevented coordination across multiple chains of command.

The US health security enterprise needs foundational change. To successfully coordinate health security resources and response requires a consolidated leadership structure that can communicate with the White House and Congress, justify and manage appropriations targeting health security improvements, and integrate the mission across departments and agencies. 

Policymakers should use this moment to fundamentally restructure the government’s approach to health security. Central to this would be the creation of a new cabinet-level position, staffed by an official who would be senior advisor to the president on health security, coordinating communication, funding, and activity across multiple agencies while providing accountability to Congress and the American people. This position might be analogous to the Director of National Intelligence (DNI), which was created after the terrorist attacks of 9/11 to focus on integrating activities across the government and avoiding duplication of effort. Similarly, a Director of National Health Security (DNHS) could coordinate communication, streamline budgeting and appropriations, and integrate the health security mission across agencies. Like the Office of the Director of National Intelligence, which hosts several mission centers, the DNHS would also be an ideal home for smaller functional offices, such as the National Center for Medical Intelligence or the National Biosurveillance Integration Center, to ensure that their shared missions become integrated and answer to the principal authority for health security within the US government. 

Without such leadership, new investments and additions will only compound the existing structural issues that currently hamper health security responses. For example, in the Senate, the proposed PREVENT Pandemics Act would give the Centers for Disease Control and Prevention (CDC), an HHS agency, considerably more health security authority. Likewise, the White House’s American Pandemic Preparedness Plan and recent update call for additional funding for medical countermeasures, but they place the “mission control” office within HHS. A recent memo from HHS suggests that the functions of the office of the Administration for Strategic Preparedness and Response (ASPR) should be elevated to an “operating division” on par with other HHS agencies like the CDC, Food and Drug Administration, and National Institutes of Health. But while this might be helpful within HHS, it fails to address existing intra-departmental issues, including competition with and confusion about ASPR’s operating authority. Finally, new organizations designed to be central to early warning of potential pandemic outbreaks, such as the CDC’s Center for Forecasting and Outbreak Analytics and the renamed National Counterproliferation and Biosecurity Center within DNI are disconnected from the government leadership responsible for preparedness.

Policymakers should use this moment to fundamentally restructure the government’s approach to health security.

By contrast, a Director of National Health Security would be able to integrate functional capabilities to support the overall health security mission across the federal government as well as at the state and county levels. In particular, DNHS should organize around five capability areas, crafting budget justifications and allocation of appropriations and synchronizing work across other agencies. 

First, the office can help solve current problems related to medical intelligence and pandemic warning. The newly formulated DNHS would have an increased ability to not only detect emerging threats, but to translate that knowledge in ways that can assist decisionmaking at all levels of government. 

Second, DNHS can synchronize development of biomedical responses, including coordinating research, development, and acquisition of future pandemic preparedness vaccines, therapeutics, and diagnostics. It could replicate the best parts of Operation Warp Speed and other existing government-wide efforts while eliminating the need for ad hoc structures during an emergency.   

A Director of National Health Security would be able to integrate functional capabilities to support the overall health security mission across the federal government as well as at the state and county levels.

Third, DNHS could focus on creating a standing collaborative environment to manage current health security crises and prepare for the future. This requires situational awareness and command and control authorities that do not currently exist within one governmental agency. Emergency response capabilities require consistent resourcing and continual exercising, and cannot be turned on rapidly without operating at a constant “warm state” where activities can be initiated immediately. 

Fourth, the office can build better domestic and international capacity. This includes everything from addressing very basic health security failures—such as fax machines being used to transmit COVID-19 testing data and a lack of deep freezer storage for mRNA vaccines, both of which were noted during the height of the COVID-19 pandemic—to larger issues like connecting front-line public health practitioners to the federal enterprise. DNHS can act as a liaison between state and local public health departments and the federal government to coordinate efforts. In addition to building domestic capacity, coordinating with foreign public health authorities and international organizations such as the World Health Organization is essential. Given the global footprint of the US health security enterprise and the presence of health security-related offices such as the CDC and USDA at many embassies, greater coordination is needed to ensure US activities abroad are best positioned to help protect the world from health security threats.

Finally, DNHS would be the health security liaison to the health care sector, which in the United States is largely private and needs to be better integrated into national planning and response efforts. The strain on health care providers writ large has been plain to see throughout COVID-19. DNHS could help bring federal resources to provide preparedness incentives and training and exercise execution across the private health care sector.

Greater coordination is needed to ensure US activities abroad are best positioned to help protect the world from health security threats.

While this approach is intended to streamline US government coordination around all things considered “health security,” it needs to be constructed carefully so as not to add the additional government bureaucracy and duplication of mission that is seen in other federal sectors. This has been a criticism of an analogous organizational structure created under the Director of National Intelligence. However, these risks can be mitigated by learning lessons from how the Office of the Director of National Intelligence was set up, how it operates today, and what improvements to organizational structure can be integrated into the creation of the Director of National Health Security. This is aided by the Government Accountability Office, which maintains Open Priority Recommendations for improving the function of the Office of the Director of National Intelligence. 

Before spending more money on health security or changing org charts within the current structure, policymakers should examine the role of whole-of-government organization and management in the COVID-19 pandemic failures. To bring meaningful benefit to the American people requires fundamental, systemic change to the health security enterprise. A Director of National Health Security will create dedicated management, cross-government coordination, and budget and mission accountability to the White House and Congress that does not currently exist. This central authority, sitting as a cabinet member and the senior advisor to the president on health security, will drastically increase the capabilities of the United States to anticipate, prevent, and respond to health security threats.