At a public talk in January, Amy Pope, deputy homeland security advisor to President Obama, highlighted what she considered "the most significant threat that we need to be prepared for" in the United States: emerging infectious disease.
"Pandemics don't know borders," she said during a forum hosted by Georgetown University Medical Center. "Border security is an issue I've spent a lot of my time on and I will tell you we have not found an effective way to keep out a pathogen." The best way to protect the homeland, Pope continued, is "to make the investments around the world so that our global partners are able to very quickly detect, prevent and respond to disease. We are only as safe as our partners around the world have the capacity to make us safe."
She also offered a handful of lessons for the new administration as they transitioned into office. The first? "We need to convene leaders early and often," she said, stressing the importance of getting leadership together on all levels to start planning for how to detect and respond to health crises.
Yet as President Trump comes up on 100 days in power, key positions remain unfilled throughout his administration, thus making it difficult for the kind of forward thinking Pope talked about. Two of those roles are the administrator of the U.S. Agency for International Development (USAID) and the director for the Centers for Disease Control and Prevention (CDC)—both agencies working to protect and advance public health.
Public health isn't something the average citizen spends a lot of time thinking about. More often than not, we react to the news of a health crisis—like Ebola or Zika—and then move on with our lives. Yet one could argue the threat of an outbreak of infectious disease is much more immediate than terrorism. Cases of Zika, for example, have been documented in more than 80 countries since 2015.
But it is the job of the CDC and USAID to officially be on the lookout for what's going on around the globe that may impact Americans. Currently, both are helmed by two qualified career professionals—Acting Administrator Wade Warren at USAID and Acting Director Dr. Anne Schuchat at the CDC. But critics say without permanent leaders in place, it's difficult for these agencies to move forward very much. And with the well-being of citizens here and abroad depending on the steadfast work of these organizations, that's a huge concern.
The role of acting leadership "really is making sure the trains keep running," explains Dr. Georges Benjamin, the executive director of the American Public Health Association (APHA). "When you don't have a permanent head, people are very unlikely when they're acting to start new initiatives or to take the kind of risks that a permanent head would take. It's just because you don't want to get something started and someone new shows up and totally undermines everything you started."
"That doesn't mean progress doesn't occur because there are always initiatives that are in place," he adds. "But you don't get the kind of leadership that you want in an organization to really advance a health goal."
Scott Becker, the executive director of the Association of Public Health Laboratories (APHL),says the CDC, which APHL works closely with, is "in good hands" with its acting director. What's more worrisome for him is the sheer number of unfilled positions at the US Department of Health and Human Services (HHS). "Without having assistant secretaries and deputy secretaries and all those other layers … I think that's challenging, especially if we are faced with any kind of outbreak or public health response."
"Think back to the SARS outbreak. It started in Hong Kong and it moved to Toronto and it devastated the economy in Ontario," Becker says, pointing to the long-reaching impact of public health. "It could have been a lot worse." The US was able to avoid an outbreak of SARS because "we had leadership, we had readiness and we had planning," he says. "We were able to deploy tests and get protection strategies out there."
Another concern beyond how simply ill-prepared the government appears right now is the threat to national security. Last month, the White House unveiled its budget blueprint, which included requests for extra spending on defense and money to fund the building of a wall along the southern border. But it also included cuts to the State Department and HHS, which would trickle down to USAID and the CDC.
The work USAID (and to some extent the CDC) does "is designed to empower other nations to strengthen their systems of health, economics and governance," Benjamin says. "Healthy, happy people in other countries are much less likely to become unhappy and much less unlikely to become violent, either in their country or here."
Oklahoma Rep. Tom Cole, who chairs the House Appropriations subcommittee on labor, health and human services, education, and related agencies, told the Washington Post that the country's health agencies are "the front lines of defense for the American people for some pretty awful things. If the idea of a government is to protect the United States and its people, then these people contribute as much as another wing on an F-35 [fighter jet], and actually do more to save tens of thousands of lives."
One immediate issue facing the US today is the Zika virus, especially now that peak mosquito season is rapidly approaching. Before he left his post, former CDC director Tom Frieden stressed to Scientific American his concerns about the mosquito-borne disease that can cause birth defects if a woman is infected during pregnancy: "Zika is not over," he said. "It is likely to spread in Latin America and the Caribbean for months and years to come, and we still don't fully understand the range of birth defects it causes."
One role of the CDC includes acting as a crisis agency and responding to new and emerging disease. "They're always in the mode of managing acute, severe medical problems around the world, not just in the US," Benjamin says.
In January 2016, the CDC's Emergency Operations Center was activated to begin monitoring reports of Zika and coordinating the response, which includes conducting tests for better understanding, educating health care providers and the public, tracking the spread of the disease, and more.
According to the CDC, there were 5,238 Zika virus disease cases reported in the US between January and April 2015. Last year, of 250 US pregnant women who had been infected, one in 10 had a baby or fetus with Zika-related birth defects. Those numbers may increase, now that health officials know the virus can be transmitted sexually. Currently, there is no vaccine or medication for Zika.
USAID is doing its part to help stop the spread of Zika. Perhaps more widely known for administering foreign aid to help end extreme poverty, another one of the agency's key goals is to "strengthen America's efforts to combat global health challenges." One response to the Zika virus has been funding programs in the Dominican Republic, El Salvador, Guatemala, Haiti, and Honduras to help increase awareness about how the disease is spread; the organization has also distributed condoms to help stop the spread by sex, and it's awarded money to developers around the world with new ideas on how to prevent an outbreak.
Both USAID and the CDC are also partners in the Global Health Security Agenda, which aims to bolster the infrastructure for disease detection in countries around the world and help those areas fight infection on a local level.
"Imagine if the ministries of health and health infrastructure in Liberia, Sierra Leone and Guinea had better capacity, they would have been able to handle the Ebola issue locally," Becker says, "and it might not have exploded the way it did in West Africa" and ultimately come into the US by way of a handful of travelers.
Ebola was eventually brought mostly under control, though a few pockets of cases remain. And thanks in part to USAID and CDC's technical assistance in Africa, a much larger humanitarian catastrophe was averted.
The important work involved in striving to eradicate diseases offers a small window into how important USAID and the CDC are. Underscoring the immediacy of bringing on permanent leaders in these agencies is the notion that anything can happen—whether it's an infectious disease like bird flu or a major hurricane like that which ravaged Haiti—at any moment.
Disease and other health risks do not recognize borders, Benjamin says. "We're in a globalized world," he explains. "Our food does not come from one farm in the US. It comes from lots of farms all over the world. Our ability to have good health diplomacy to work with other nations impacts the health of those individuals, our health, our trade position, our economics. Health is a global commodity, whether we're paying for it or someone else is paying for it. This concept that we can lock ourselves inside our borders is absolutely wrong."
That's why it's so important to get the right people in these top roles: people who understand the role of public health and can think strategically about it. "When something bad happens, you want someone who can calm the fears of the American people," Benjamin says. "There's not been a year in the last several years that we've not had some kind public health emergency. Something's going to happen and we're going to need that individual to help lead the national effort."
As of this writing, only 24 nominations for 555 key positions in the administration that need Senate confirmation had been announced, according to the Partnership for Public Service. "Whether people are reluctant to take those jobs at this time, or whether or not [the Trump administration is] having trouble finding the right people, it remains to be seen," Benjamin says. "But they're important jobs to fill and they need to get about doing so."