This story is published jointly by the Medill National Security Reporting Project and VICE News. The other story in this series, on the race to prevent the next Ebola-like epidemic, can be found here.
More Medill stories on the subject can be found at this link.
Six years ago, the scientist leading the US government's program to catch diseases before they turn into global pandemics went to Capitol Hill with a map of the world. Dr. Scott Dowell was meeting with key Congressional staffers to warn them about what he believed were gaping holes in the system designed to detect and contain infectious disease outbreaks, before they could kill thousands or potentially millions of people.
In 2010, Dowell was leading the much-touted Global Disease Detection Program at the headquarters of the U.S. Centers for Disease Control in Atlanta. Congress had established the GDD program in 2004, to "protect the health of Americans and the global community by developing and strengthening public health capacity to rapidly detect and respond to emerging infectious diseases and bioterrorist threats."
The centerpiece of GDD was supposed to be 18 regional health centers that the US would establish in nations where endemic diseases like cholera and malaria had long been rampant, and in emerging hotspots where new and potentially catastrophic viruses were spawning.
These centers would establish labs and bio-surveillance capability and conduct training in cooperation with the host countries' health agencies. And they would allow US and World Health Organization officials to create an interconnected network to rapidly detect and respond to isolated incidents of disease before they could turn into full-fledged outbreaks. The idea was to stop diseases like the deadly Severe acute respiratory syndrome, or SARS, that had caused a global panic just a year earlier, in 2003.
But by the time of Dowell's appearance on the Hill, only seven of the 18 centers had been built, and at least some of them weren't fully functional. As Dowell's annotated map showed, there was no coverage in some of the areas most at risk, including West and Central Africa, all of SouthAmerica, and other wide swaths of the world.
Dowell explained the need for more government funding to build the remaining GDD centers, and to fulfill other mandates of the program. His trip had taken on added urgency after a devastating series of deadly infectious disease outbreaks in the years after SARS, including several involving an especially lethal virus, Ebola, in Africa from 2007 to 2009.
"That was the crux of much of our discussions with Congress in those years," said Dowell, an accomplished epidemiologist who left the CDC in 2014 to lead public health surveillance initiatives for the Bill & Melinda Gates Foundation. "We always showed West Africa as a gap in a place where there were epidemic threats but little capacity to respond. Pathogens tend to find those gaps, whether we recognize them or not."
Dowell wasn't the only one sounding the alarm.
A 2010 report by the US Institute of Peace, an independent, bipartisan research institution funded by Congress, warned that the US government's lack of attention to the growth of infectious viral diseases had contributed to a true global security threat.
The report singled out the lack of funding for GDD. "The US government should not wait until after an infectious disease disaster before filling in the gaps in this system," it said.
That warning of disaster came true in 2014. A new variation of the Ebola virus roared through three countries in West Africa, killing more than 11,000 people in one of the worst pandemics in recent history. The cost of the US part of the response alone has been in the billions of dollars.
But the CDC never did build a Global Disease Detection center in West Africa.
"Could we have picked up Ebola earlier? (...)I think you'd had to have your head buried in the sand to say no."
US officials now concede that if they had, the outbreak might have been stopped outright, or certainly contained before so many people were killed.
"If we had a GDD center there, if we had active surveillance, could we have picked up Ebola earlier? And I think you'd had to have your head buried in the sand to say no," said Dr. Joel Montgomery, who oversees GDD as the chief of the Epidemiology, Informatics, Surveillance and Laboratory Branch in the CDC's Division of Global Health Protection. "Of course we would have picked it up earlier."
"There has always been a plan to have 18 centers and one of them would be in West Africa," Montgomery said. "I don't think it was ever proposed and rejected. It just never went forward because of [a lack of] resources."
The lack of a regional center in West Africa is emblematic of bigger structural problems at GDD that have compromised the effectiveness of the CDC's principal program for identifying and containing infectious diseases around the world over the past 12 years, according to documents and more than two dozen current and former CDC officials and other experts interviewed for this story.
As of today, significant gaps in the network remain; only 10 of the promised facilities have been built and at least some are still not fully functional. All of South and Central America, for instance, is still covered by one center in Guatemala, despite a broad array of infectious diseases that affect millions of people in the region.
On January 15, the CDC issued an unprecedented travel warning cautioning pregnant women and women planning to become pregnant to postpone travel to a set of Latin American and Caribbean countries and territories experiencing outbreaks of a mosquito-spread disease known as Zika virus. CDC officials said they were concerned that the Zika virus was responsible for skyrocketing numbers of severe birth defects in Brazil.
Also, the program has had little in the way of oversight; there have been no specific audits or reviews of the overall GDD program despite at least $338 million spent on it since 2004. CDC spokesperson Donda Hansen said other oversight efforts are used, including site visits by CDC technical experts and a requirement that most individual GDD overseas grantees, those who receive $300,000 or more, conduct annual independent audits.
The GDD program has never received close to the amount of funding it needed to function effectively, according to these records and officials.
From the GDD's creation, Dowell and other key officials concluded it would take $200 million a year to run the kind of fully functioning public health early warning system that they envisioned. But since 2004, the program has usually received about one-sixth of that, an average of about $35 million a year. That's in part because public health officials never asked for more.
Those officials have long argued that an interconnected global disease detection network was urgently needed.
In 1996, President Clinton established a national policy that called for a system almost identical to GDD, which would "establish a global infectious disease surveillance and response system, based on regional hubs and linked by modern communications."
And in 2001, the Government Accountability Office, an independent, non-partisan federal watchdog agency, cited the need for a similar network of regional health centers to improve overseas laboratory capacity, disease surveillance, and prevention of the spread of diseases in developing countries.
Two years later, SARS hit 27 countries in Asia, Europe and North and South America. The particularly virulent infectious disease, which spread when an infected person coughed or sneezed, ultimately infected 8,098 people, killed 774 of them, and caused $30 billion in economic damage.
SARS prompted US health officials to intensify calls for an effective global disease detection, and the GDD program was born. At the time, CDC's numerous international programs were "somewhat siloed," and the lack of coordination hampered detection and response efforts, senior CDC official Dr. Rohit Chitale said.
At CDC's urging, Congress spent $11.6 million in fiscal year 2004 to establish GDD. Three centers would be built in each of the World Health Organization's six regions, to bolster compliance with international health regulations requiring all countries to build core capacities for epidemic detection, reporting and response.
The centers would link up with a GDD Operations Center, an analytical clearinghouse and coordination point at the Atlanta headquarters.
Thailand was chosen as one of the first centers, along with Kenya, in part because of a promising pilot project there that was run by Dowell, the International Emerging Infections Program. Dowell moved to Atlanta to launch GDD, using the Bangkok project as a model.
Other centers would be established in Guatemala, China and Egypt in 2006, Kazakhstan in 2008, India in 2009, South Africa in 2010, Bangladesh in 2011 and Georgia in 2013.
But from the beginning, there were concerns that a lack of adequate funding made it impossible for GDD officials to create the public health safety net that they and Congress wanted.
Beginning in late 2007, the Ebola virus struck eastern and central Africa, killing about 40 people in Uganda and almost 200 in the Democratic Republic of the Congo.
Other serious outbreaks occurred during the next few years, and in the run-up to the fiscal 2011 budget deliberations, Dowell returned to the Hill. He was armed with a PowerPoint presentation that touted GDD's many successes, including responding to Ebola, all types of contagious influenzas, cholera, and even the plague.
But his presentation, obtained by Medill, also included a map titled, "GDD Regional Centers and Remaining Gaps in Coverage," showing all of the places that remained uncovered.
"Part of our consistent message was that there's an interest in getting more GDD centers in critical parts of the world," especially to close those gaps, Dowell said.
Dowell said that as a CDC official, his job was to educate Congress, not lobby for money. But public health advocates were clamoring for additional funding as well.
The Trust for America's Health, a non-partisan, non-profit organization with many former US health officials on its staff, issued a report each year calling for significantly more funding for GDD. Its budget memos often included a map strikingly similar to Dowell's, showing huge gaps in the coverage, and details about how the existing centers were not achieving the five basic core activities of outbreak response, surveillance, pathogen discovery, training, and networking.
In its 2010 report, the US Institute of Peace urged GDD funding at the full $200 million a year called for by Dowell and other GDD officials, noting that even that figure, a sixfold increase over its existing budget, was "still less than 2 percent of the US global health budget."
The report praised GDD officials for coming up with creative solutions, like getting donations from international organizations and private philanthropists. But it also said that "an ad hoc, opportunistic funding model does not allow for systematic planning and expansion of programs to meet a stated national priority."
Each year, however, CDC and HHS requested a far lower figure from Congress, usually around the $35 million average that was ultimately approved, according to documents and interviews.
Dowell and other GDD officials hoped for much more each year, but their annual funding requests were sharply reduced by more senior officials at CDC and HHS, and then again by Bush and Obama administration health and budget officials, who cited many competing budgetary priorities.
CDC officials said their budget deliberation process is confidential and that they could not discuss specifics. But Denise Beauvais, the policy lead for CDC's Division of Global Health Protection, confirmed that GDD "internal budget estimates" of $200 million were rejected as part of the overall budget request by higher-ups within CDC and HHS or by the White House and "never presented to Congress."
"It was because of internal CDC negotiations with HHS and the Office of Management and Budget that a request of $200 million was never made," as part of the President's budget, Beauvais said.
Adrienne Hallett, a senior staffer on the Senate Appropriations Committee, recalled Dowell making a compelling case year after year for why more GDD centers were needed in places like West Africa. But she said GDD was hurt by being forced to compete for scarce federal dollars with key domestic public health programs like the Head Start early childhood health and education initiative.
Hallett also said things got much worse for CDC and the GDD program when the Tea Party conservatives came into Congress and, later, due to sequestration. "They lost a lot of money... I mean, like $1 billion," Hallett said of the overall CDC budget.
In 2011, budget cuts forced CDC to reduce functionality at its center in Kazakhstan, a hotbed of infectious diseases, to the point where "the center no longer serves as a GDD regional center," according to a report that year by the Congressional Research Service. In a statement, CDC said, the Kazakhstan center was still "under development" in 2011.
But Congress is only partly to blame. Records and interviews show that CDC and HHS didn't make GDD a priority even when they were flush with funding.
Funding for global health initiatives, in fact, increased fivefold during the Bush and Obama administrations, from $1.7 billion in fiscal year 2001 to $8.8 billion in fiscal 2010, according to the USIP report. Most of that money was directed to fighting high-profile individual diseases like AIDS and malaria, with just one percent allocated for programs like GDD, designed to strengthen prevention-based international infectious disease surveillance and response efforts, the report said.
GDD senior official Leonard Peruski said it has always been difficult getting support for GDD because its focus is not on saving peoples' lives but preventing them from getting sick in the first place. "It's hard to sell," he said. "It's not something that's easily quantifiable."
Even within GDD, there were differences of opinion about where to put the centers, and which locations were the highest priorities.
Several CDC officials said they used a complex risk-based assessment process to identify the locations with the most urgent need – like West Africa – but that they also required significant political and financial support from the host country in order to build up the local public health capacity. And that wasn't easy to come by, especially in destabilized regions.
The placement of regional centers also hinged on existing partnerships between the US and host countries.
"You can't just plunk a Global Disease Detection Program anywhere," said Hallett.
Despite its many financial challenges, the Global Disease Detection program has had its share of successes.
Between 2006 and 2014, the GDD program detected 77 new and potentially dangerous pathogens. It also responded to 1,735 outbreaks around the world, saving lives and preventing the spread of disease. And the program provided short-term public health training for more than 97,000 participants and established 243 new diagnostic tests in 59 countries, CDC officials said in response to Medill questions.
"Those countries now have more trained epidemiologists, they have experience with detecting outbreaks and characterizing pathogens that they didn't have before," Dowell said. "So, it didn't solve all the problems with the world's epidemic response. But I think it made some important steps forward in clarifying what needed to be done."
At the Kenya GDD center, lab director Barry Fields worked with the University of Virginia to develop and deploy an innovative diagnostic test for various key diseases in 2010. The Taqman Array Card can screen many more patients, and much more quickly, for a wide variety of deadly pathogens. That has helped health officials quickly differentiate those with Ebola or highly contagious respiratory diseases from those who have less contagious illnesses that look similar, and quarantine those who are infected, GDD chief Montgomery said.
Fields also helped set up the first diagnostic laboratory in Liberia in 2014 at the height of the Ebola outbreak, delivering 700 pounds of equipment and testing 1,000 samples in the first few weeks.
The GDD center in Thailand has been instrumental in building capacity in Southeast Asia, and keeping an eye on emerging zoonotic diseases — those that cross over from animals to humans. And the GDD's one center for all of Central and South America is a case study in how officials have been forced to do more with less.
The center, located on a university campus in Guatemala City, serves as the safety net to stop potentially dozens of diseases from spreading throughout South America and elsewhere, including the United States. Miami is just two and a half hours away by jet.
Peruski, the center director until late last year, said he was especially concerned about mosquito-borne diseases like dengue fever, Zika virus and chikungunya – known as arboviruses – that he says are mutating and "have rapidly blanketed the globe."
Colombia alone has gone from zero arbovirus cases to 500,000 just over the past year, he said. "And while they're not as sexy or as dramatic as SARS, they are affecting a lot more people globally."
But the Guatemala center has suffered significant budget cuts since 2010, forcing Peruski to slash by half the staff of its flagship Field Epidemiology Training Program. He also said he couldn't fill key veterinarian, laboratory and administrative positions at the center, limiting its ability to cover the many countries it oversees.
Despite those challenges, the Guatemala center has become a model for developing and exporting innovative and cost-effective public health programs that are now being used around the world, said GDD chief Montgomery.
In the aftermath of the 2014 Ebola crisis, critics assailed the US government and world health community for being unprepared to detect and contain the virus before it got out of hand. In interviews, current and former GDD officials said Ebola was just the kind of outbreak that GDD was established to prevent, in part through building up surveillance and detection capacity in host countries.
"If not, then why are we doing any of this?" Montgomery said, adding that such preventive response measures would have cost s small fraction of the billions spent on emergency response.
Now, President Obama's administration is dedicating potentially billions of additional dollars for public health measures.
In February 2014, Obama joined the leaders of dozens of countries in launching an ambitious new program called the Global Health Security Agenda.
"It's predicated on funding (...) and right now funding is limited."
The United States said it would pledge more than $1 billion to the effort. More than half of the funding, according to a White House statement, would focus on Africa. Most of the funds are meant to help stop future infectious disease outbreaks by strengthening health infrastructure and laboratory systems and employing "an interconnected global network that can respond rapidly and effectively."
And in November last year the CDC announced that it would create a new Global Rapid Response Team to serve as a "deployable asset" to help the US respond to public health outbreaks in Africa, the Middle East and Asia. The 50-person on-call staff, based at CDC headquarters, is supposed to offer assistance with capacity building, epidemiology, and surveillance.
Privately, some GDD officials expressed concern that the GDD will have to compete with these new, and often similar, Obama administration-sponsored initiatives for funding and attention. They noted that the new Rapid Response initiative is not part of their program, and declined to comment on whether it was designed to plug holes in the GDD network.
Montgomery said he is optimistic that GDD will play a significant role in the US government's post-Ebola expansion of its global disease detection network.
In many ways, he said, the program laid the groundwork for the new Global Health Security Agenda, and its successes will help ensure that it stays funded and relevant for the rest of the Obama administration and well into the future, no matter who takes the White House in November.
But there still are no plans to build the eight remaining centers to complete the GDD network promised back in 2004.
In November, Montgomery ran into Dowell, the GDD founder and former director, at a World Bank meeting in Senegal. They talked about the program's shortcomings: "We agree, it's not finished. West Africa, South America — there are clearly areas where we don't have visibility," Montgomery said. That includes countries where Ebola recently struck.
The problem remains the same: The government is not spending enough.
"It's predicated on funding," Montgomery said, "and I would say right now funding is limited."