Statement by the Honorable Mark Dybul, MD, to Hearing of the Senate Foreign Relations Committee
June 30, 2020
Statement, as Submitted, by the Honorable Mark Dybul, MD
Professor of Medicine and Co-Director, Center for Global Health Practice and Impact, Georgetown University Medical Center
Hearing of the Senate Foreign Relations Committee: COVID-19 and US International Pandemic Preparedness, Prevention and Response
Chairman Risch, Ranking Member Menendez and members of the Committee:
It is a privilege to be back before this important body. I would be remiss if I did not thank this Committee and the entire Congress for its steadfast, bipartisan efforts to ensure that the USA has been the unquestioned leader in global health for decades.
Most people living in the USA, Europe and many other countries are experiencing for the first time the devastating impact of a rapidly spreading and deadly global pandemic. There have been scares – SARS, MERS, H1N1 Influenza and Zika, among others. Fortunately, those epidemics were limited in their scope and scale.
COVID-19 has made clear that a global pandemic requires a global response. While we have the outlines of a global response, it needs to be strengthened by reforming existing structures and identifying financing mechanisms that will build on the uneven response to this crisis.
Thank you for taking up the remarkably important issue of controlling this pandemic and focusing on preparedness for the next one.
Unfortunately, it is likely this will not be the last pandemic we will experience. Changes in climate and weather patterns, population growth, increased contact with animals and a highly mobile global population create the conditions conducive to pandemics.
The task before the world is to work to ensure that all countries can respond to the current threat, but also to be ready for the next one.
But there is good news: what is needed is not rocket science. A number of countries that did well in the early stages of COVID-19 were not faster at setting up systems to respond – they already had them.
From the relatively high-tech South Korean to the relatively low-tech Taiwanese approaches taken, the devastating experiences from SARS and/or MERS propelled them to develop, establish and maintain effective systems for sentinel surveillance, testing, contact tracing and quarantine. They performed simulations of outbreaks to identify and fill gaps and to stay alert. They stockpiled key commodities. They were prepared. Therefore, they never had to enforce total lockdowns.
Other countries, for example Germany, rapidly put test, trace and quarantine systems in place. As a result, they were able to safely begin reopening within 6 weeks, identifying and containing additional outbreaks as they occurred – and continue to occur.
I am grateful to the Chairman and his bipartisan co-sponsors, as well as to the Ranking Member for putting forward proposals to help ensure the USA coordinates its international bilateral programs and to ensure complementary, non-duplicative multilateral institutions so the world can be prepared and rapidly detect and respond to continued and new waves of COVID-19, and to future pandemics.
I listened with great interest to the hearing the Committee held on June 18 with Government witnesses, all good people working hard in challenging times.
From my experience as one of the principal architects, and then as the head, of the President’s Emergency Plan for AIDS Relief (PEPFAR) under President George W. Bush, and as someone who has been involved deeply in multilateral organizations, including as the Executive Director who led the transformation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, I would like to offer, with all humility, one perspective on the Chairman’s question: “who is the fire department; whom do we call?”
For those interested in more detail, please refer to a White Paper on the need for a Global Response to COVID-19 published with colleagues from Georgetown University and Dr. Peter Piot. Please also refer to the Report of the CSIS Commission on Strengthening America’s Health Security – co-chaired by a former member of this chamber and former Director of CDC – on which both Ambassador Kolker and I served.
Proposals to create a Coordinator at the Department of State resonate. Perhaps that is not surprising since I served as the US Global AIDS Coordinator in the State Department. From the perspective of Legislative oversight, the Coordinator would be the fire department for bilateral engagement.
When PEPFAR was developed, we struggled with where to house it. A Coordinator at State was, to paraphrase Churchill’s quip on democracy: the worst approach – except for everything else.
Like COVID-19, the HIV pandemic is caused by a virus that jumped from animals to humans. Fortunately, unlike HIV, COVID-19 is not yet wiping out a generation in Sub-Saharan Africa. We knew what this Committee knows, and what the Government panel verified a few weeks ago: to be prepared for and combat a global pandemic, multiple parts of the US Government must be engaged. We also knew from reviewing past experiences that selecting one implementing agency to receive all of the funds and then fully embrace, engage and fund other implementing agencies stretches beyond the bureaucratic breaking point.
USAID is deeply engaged in many aspects of health as well as overall development efforts that impact health, such as education, economic security, agriculture and nutrition, water, sanitation and hygiene (WASH) required for hand-washing to prevent COVID-19 and many deadly diseases. And of course, USAID leads on humanitarian responses.
CDC is the premier government health organization in the world. It is the only agency in the US Government armamentarium that spans domestic and global health and that is engaged with, provides technical support to and is looked to, and respected by, governments and institutions in high-, middle- and low-income countries. These unique characteristics are essential in pandemic preparedness and response. It leads in sentinel surveillance, testing, laboratory capacity and public health capacity. It has already supported countries to implement GHSA that resulted in strong responses to COVID-19. CDC is built for what is most needed for global and national pandemic preparedness and response.
More than with PEPFAR, the national security apparatus is needed for other pandemics. While the Department of Defense is a key part of PEPFAR, it is a relatively small piece of the budget and relates mostly to work with HIV prevention, care and treatment in foreign militaries. For global health security, there is a much bigger role including identification of outbreaks, potential in emergency responses, such as transportation, logistics and deployment of field hospitals as was done with Ebola. The need for significant engagement of the national security departments and agencies complicates full coordination from the Department of State. In that regard, it is important to note that both proposed bills identify the essential role of the National Security Council. Perhaps there is also an opportunity for cross-Committee Authorization and Appropriation legislation, which is not without some precedent.
The world has come together and created the Global Health Security Agenda (GSHA), including 67 countries, international organizations, the private sector, communities and others. It provides a good framework and sensible “action packages”. However, GHSA it is not the fire department.
In the limited time available, I would like to focus on two organizations that I believe are needed: the fire department and the fire hydrant.
The Fire Department: A Global Emergency Operations Center
GHSA provides an action plan for every country to have an Emergency Operations Center (EOC) capable of mounting a multi-sectoral response to an outbreak within two hours. At least in my view, the EOC must also be responsible for continual surveillance down to the community level with systematic reporting to rapidly detect an outbreak at the earliest possible stage.
We need a global EOC as the fire department. This is not a new concept. Bill Gates, myself and others have been calling for some version of this – often called a Task-Force – for a number of years. Of course, there is a lot involved in a global EOC. Managing the many viewpoints and equities will not be easy. But neither was creating PEPFAR, Gavi (the Vaccine Alliance) or the Global Fund. It is time to exert the energy to get it done.
The global EOC should be multi-sectoral, including key organizations for health, economics, security and include the private sector and civil society communities, including the faith community. In the end, everything will work or fall apart at the community level. The principal functions of the EOC would be similar to national EOCs:
– Learn from the past: what has worked and not worked at the global, regional and national levels during previous epidemics and pandemics (as South Korea, Taiwan and others did after their SARS and/or MERS epidemics);
– Conduct regular simulations of local outbreaks with national, regional and global responses to them, rigorously interrogating gaps and weakness;
– Use the knowledge gained from the past and regular simulations to evolve the global EOC to be maximally effective and to support regional and national EOCs to be fully operational, and;
– Coordinate with a financing mechanism, the fire hydrant, to help ensure optimal use of resources.
The Central Role of WHO
It has been said “If WHO didn’t exist, we would create it.” Perhaps as with the PEPFAR coordinator it is the worst approach – except for every other option. But a global effort on pandemics, and a global EOC, cannot be effective without the deep engagement of WHO. It is a necessary, although not sufficient, player.
In my view, WHO has done a good job under the circumstances. And it has significantly improved. There is no real comparison between the deeply flawed response to Ebola and the initially flawed, but overall improved performance of WHO during COVID-19.
The current Director General, Dr. Tedros Adhanom Ghebreyesus, is a committed public health servant and diplomat. I have known Tedros since 2004 when he was the newly installed junior Minister of Health and I was the US Deputy Global AIDS Coordinator. I watched him systematically transform one of the worst performing ministries of health in the world to one of the best performers. He has been a steadfast partner and ally of the USA in global health. He has taken on the difficult task of reforming WHO and, only a few years in, has made significant strides, including reorienting an institution resistant to change from headquarters to the countries.
As the first African Director General, he also has the unwavering support of African countries, who for the first time voted in a block to elect him. As the second most populous continent, Africa’s total engagement is essential for pandemic detection and control.
Finally, as an official of the Bush Administration, including preparation for G7 Summits, and then as Executive Director of the Global Fund, on WHO: “I know that the USA can be most effective in reforming institutions when it is fully engaged,” says Dybul. In part because we bring deep expertise and financial resources, and in part because I know from experience that you can’t place a bet if you aren’t in the game. And if we are not at the table, others are ready to step in and take our seat: China and Russia.
The Fire Hydrant: A Financing Mechanism
The significant progress on childhood vaccinations, HIV, Tuberculosis and Malaria has demonstrated that a financing mechanism separated from normative and deep-bench technical functions can be highly valuable. In my view, a financing facility related to, buy organizationally separate from, a global EOC would create the optimal conditions for success. One already exists to procure vaccines for low- and low-middle income countries: Gavi, the Vaccine Alliance. It was wonderful to see the significant pledge made by the USA at the recent Gavi replenishment conference.
However, there is a great deal of preparedness, detection and response that needs to be funded before and after a vaccine becomes available.
The principal function of the financing mechanism – the fire hydrant – would be to finance the priorities identified by the global, regional and national EOCs – the fire departments.
I appreciated the discussion of the Gavi and Global Fund models during the Government panel hearing. Of course, the World Bank houses catalytic and trust funds. And something new could be created. All have pros and cons. Again, similar to the PEPFAR Coordinator, and for that matter the structure of many organizations, we might have to settle for the least bad option.
It seems to me that the best approach would be for the Administration to play a leadership role working with key governments and stakeholders in a time-bound way and with direction and parameters set by Congress, to identify the most likely mechanism to succeed now and for the future in attracting funds and implementing pandemic preparedness, detection and response. This was the approach taken with the creation of the Global Fund, in which the US Government was deeply involved, and Gavi.
Global and American partners are looking for a sign that the US will, once again, demonstrate its commitment to a comprehensive global response. It is in our national security interest to do so. Investing in the immediate response now and laying the foundation for the future will require leadership and resources. This Committee has a long history of supporting both. Including at least $12 billion in the Heroes Act before Congress will save lives, help protect the US from additional waves of the pandemic and send an important message abroad as well as here at home. A recent poll conducted by the US Global Leadership Coalition found that 72 percent of Americans support including $10 to $15 billion for international assistance in the next emergency package.
We know from the massively destructive global pandemics of history what, sadly, we needed to learn again from COVID-19. No country, and no one is safe until everyone is safe.
But there is good news. This is one of the most solvable problems facing the world – as countries who activated systems they built after their SARS and MERS epidemics, and those who rapidly built those systems and controlled the outbreak in 6-10 weeks and are now safely reopening have shown.
Throughout history, we have seen that when we come together and look forward, outward and with hope there is no problem we cannot solve. And in particular, the USA has shown that when we take a leadership role, it is a blessing of enlightened self-interest serving others while protecting and promoting our interests – and our lives. I thank the committee for what you are doing to lead – again.