Last week The Wall Street Journal reported that the US CDC intends to scale back its overseas work to strengthen countries’ capacities to prevent, detect, and respond to infectious disease outbreaks. Representatives from the CDC said that the agency expects to reduce the number of countries in which it is working from 49 to 10 due to a decrease in funding for the Global Health Security Agenda (GHSA), which supported their work in those countries. One of the reasons why we created the Outbreak Observatory was to improve the evidence-based understanding of the public health resources and infrastructure required for maintaining and enhancing preparedness and response programs. In this post, we examine the potential impact of CDC’s reduced footprint on outbreak response across the globe.

What is the CDC Planning to Do?

The CDC has said that, faced with the “anticipated fiscal reality” of not receiving additional GHSA funding to support its overseas work, it has had “to make some very difficult decisions.” CDC officials announced the intention to “plan for the completion of…country-based programs” in 39 countries, including the Democratic Republic of the Congo, which has experienced multiple Ebola outbreaks, including one last year.

What is the GHSA, and How Does it Support Outbreak Response?

As we discussed in a previous Outbreak Thursday post, the GHSA is a multilateral initiative to increase national governments’ progress toward “a world safe and secure from infectious disease threats.” The initiative, which began in 2014 as a US-led effort, has since grown into a partnership of more than 60 countries. A key focus of this collaborative effort is supporting—financially and technically—efforts to develop and maintain public health capacities to prevent, detect, and respond to infectious disease threats.

As staff from our Center wrote in a recent JAMA commentary, political and financial commitments by the US have been critical to the success to the GHSA. In 2015, the US committed to contribute more than $1 billion to the GHSA, providing direct financial support and technical assistance to countries across the globe. In addition to directly supporting capacity building efforts like these, US financial contributions set a precedent that has encouraged other countries to follow. Following US financial commitments for GHSA, other G-7 nations have pledged contributions to support more than 60 countries. For example, South Korea, Japan, and Australia pledged $100 million, $40 million, and $100 million, respectively, to support capacity building in other countries.

In a previous Outbreak Thursday post, we discussed how investments made in boosting countries’ capacities to prevent, detect and respond to infectious disease threats can lead to tangible benefits in outbreak response. For example, GHSA funding has supported US efforts in Kenya to train epidemiologists and veterinary professionals, improving their ability to rapidly detect and contain an anthrax outbreak, and equip public health laboratories, providing the capability to test for more than 50 deadly pathogens. In Sierra Leone, GHSA funds provide public health capacity that enabled the identification of 4,000 previously undetected cases of measles, which then allowed the targeting of vaccination of for more than 2.8 million children.

What Could Reduced US Financial Support Mean for Outbreak Response Globally?

Our Center contends that continued US support is critical to furthering and sustaining the important capacity-building work that the GHSA has enabled to date. The CDC has said that, without a clear signal that additional funds are forthcoming, it will have to use GHSA-related monies to begin the expensive work of shutting down its overseas capacity building initiatives—including recalling US personnel who have been working overseas and dismissing local administrative staff who facilitate US work on the ground in other countries. Shut-down operations will lead to an 80% decrease in field-based staff working abroad, which will effectively erode current progress efforts to strengthen local public health and preparedness capacities.

What Does this Mean for Domestic Preparedness Programs and Efforts?

In addition to indirectly protecting the US by improving other countries’ outbreak detection and response capacities, stopping disease transmission before outbreaks can spread across borders, capacity building and partnerships with other countries provide direct benefits to the US. Importantly, maintaining operational programs in other countries provides critical situational awareness through early detection of disease events that could signal the beginning of a worrisome outbreak, epidemic, or pandemic.

At the onset of the 2009 H1N1 influenza pandemic, it became clear that the relationships between US health officials and their counterparts in Mexico hindered early efforts to characterize the disease. Early data on disease severity in the US were sparse and not yet fully understood, so initial reports of cases of severe influenza-like illnesses in Mexico prompted concern that the pandemic strain of the virus was causing severe illness. At the time, the US did not have well-established relationships with Mexican health authorities and struggled to send teams to Mexico to assist with epidemiologic investigations necessary to obtain critical information about the virus and disease. At a CDC press conference held in the early days of the pandemic, acting CDC Director Dr. Richard Besser commented on the CDC’s challenges in conducting investigations in Mexico:

While we are now working with health officials in Mexico, we’re very early on in those efforts. We’ve only tested a very limited number of samples from Mexico, and we do not have enough information to fully assess the health threat posed by this swine flu virus…we have not sent a team to Mexico yet. We're still in discussions with Mexico but we anticipate that we will have folks there very soon.

Bottom Line

While there has not yet been a public accounting of what specific capacities will be lost if the US shutters its overseas programs in close to 40 countries, there are good reasons to worry that such a move could erode outbreak response both domestically and abroad. Some may argue that, given the considerable financial investments that the US has already made, it is now time for other countries to take the reins to support the GHSA. While increased investments from other countries would obviously be desirable, stepping back from the support for the GHSA is not in the US’s best interest. Continued support for the CDC’s overseas programs is a net win for everyone, providing not only local preparedness and response capacity in the affected countries but also improving domestic response capabilities in the US.


Photo: GHSA meeting in Kinshasa, DRC between US and Congolese health officials; courtesy of CDC/Jessie Blount.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly in near-real time to allow others to learn from these experiences in order to improve global outbreak response capabilities.