The New Global Health Security Strategy

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This transcript is from a CSIS event hosted on April 16, 2024. Watch the full video here.

Julie Gerberding: Good afternoon and welcome to the Center for Strategic and International Studies, where we’re going to be discussing the new Global Health Security Strategy. We are speaking on Wednesday, April 10th, but we’re actually pre-taping today for release next week after the Global Health Security Strategy is formally launched.

I’m Julie Gerberding. I am the CEO of the Foundation for the NIH, but I’m actually wearing a different hat today as the co-chair of the CSIS Bipartisan Alliance for Global Health Security. And I’m joined with my compatriot, Senator Richard Burr, who is also co-chairing this effort. And we are delighted to have an opportunity to discuss the latest evolution of our global security strategy.

Before we begin, I do want to make some thanks. We have an incredible broadcast team here, and I’ll start with Qi Yu, Dhanesh Mahtani, and Eric Ruditskiy; but also, several people from CSIS who are brilliant policy leaders and take care of us in good stead as we move through the alliance work. That includes, of course, Steve Morrison, Katherine Bliss, Allison Viescas, Michaela Simoneau, Carolina Andrada, Sophia Hirshfield, Maclane Speer, and Ella Bergendahl. So, thank you all. We couldn’t do this without you. And your technical as well as your policy expertise is legendary.

So today we are absolutely delighted to be joined by Dr. Stephanie Psaki, who is the deputy senior director for global health security and biodefense at the National Security Council, and the deputy assistant to the president, and the inaugural U.S. coordinator for global health security. How do you fit all that on a business card? I’m not sure. (Laughter.)

Dr. Psaki is a social demographer with extensive expertise in the intersections of gender, health, and education. She has a Ph.D. in public health from Johns Hopkins Bloomberg School of Public Health and a Master of Science degree from the Harvard T.H. Chan School of Public Health in the population and international health domain.

So, Stephanie, thank you for joining us. And we really look forward to getting the scoop on this new global strategy.

So why don’t we just give you a few minutes to set the stage here? This strategy is coming on the back of a number of other policy documents, including the National Biodefense Strategy and Implementation Plan. So that’s mostly focused on the U.S., and what you’re working on is much broader than that, kind of a broader framework.

Stephanie Psaki: That’s right.

Dr. Gerberding: We understand that the strategy aims to improve capabilities to combat bio risks from every source, whether they’re naturally occurring, intentional, or accidental. The opening premise of the strategy is one that motivates all of our work at CSIS and the alliance: new threats continue to proliferate, and we need to be better prepared. We know that the drivers of new outbreaks are increasing in intensity, whether that’s due to human encroachment on animal habitats, the impacts of climate change, global trade and travel, or the spread of emerging and new technologies. The vision and the mission articulated in the new strategy is really to create a world where all people are protected from these health security threats, and that’s certainly one we should and could all get behind.

So, Stephanie, welcome, and congratulations on the new strategy. Please kind of walk us through it. Maybe tell us what motivated it, what’s the origin of it, what’s new and exciting about it from your standpoint, and what are the most important themes that we should be watching for as it rolls out.

Ms. Psaki: Great. Well, thank you so much, Dr. Gerberding, Senator Burr, for taking the time to do this. Thank you to the CSIS team. I won’t run through everyone since you did such a great job with that. It is very exciting to have a chance to talk about this strategy which I have been working on, but more than me the team across the U.S. government has been working on for a long time. So, as you mentioned, it’s coming out officially next week on April 16th. Stay tuned. But I am excited to give a preview of it today.

So, since day one President Biden has focused on ensuring that the United States is better prepared for the next pandemic. He came into office, as we all remember, in the midst of the COVID-19 pandemic. I think we all know here today, but it bears repeating, that U.S. national security and prosperity depend on countries around the world being prepared to prevent outbreaks when possible, and to rapidly detect and respond to emerging infectious-disease threats when they occur. We saw that very acutely in COVID-19, but the threats have continued since that time. So, the goal of the new Global Health Security Strategy is to lay out the Biden-Harris administration’s approach to working with partners across the world to do just that, to make sure that we are better prepared and ideally, we prevent the next pandemic.

You did a great job, Dr. Gerberding, talking about the threat and the increasing threat that we’re facing. So, the COVID pandemic demonstrated the impacts that health-security threats pose not just to individuals and communities, to nations, endangering our health, straining health systems, and disrupting economies and livelihoods. The impacts were everywhere – across the world, across our communities – and we all know that it will not be another hundred years before we see the next pandemic for the reasons you mentioned. And we have – we have been battling recent outbreaks, from mpox to Marburg, cholera, and other diseases that are not just in the headlines, but they are wakeup calls for anyone who thought COVID was a once-in-a-lifetime experience. You did a great job touching on just the different drivers that make the risk actually greater in the years to come than it has been historically. And I will add the challenge of mis- and disinformation that further complicates both preparedness, but also responses to health-security threats around the world.

So, these are global challenges that we know we cannot tackle alone. We quickly, during the COVID pandemic, figured out how to work with partners around the world. But what would be even better is to make sure that we have those partnerships and we’re ready to go before the next threat emerges. So investing in health security means that we’re investing not just in saving lives, but also in protecting our future and protecting our economies. We feel very strongly – and I think this is one of the core messages of the strategy – that collectively the actions that we are taking right now will make the United States and the rest of the world safer from the next pandemic.

So, the new strategy is, yes, a government policy document, which I know everyone is excited to curl up with and read through in detail. (Laughter.) It is a blueprint for protecting American interests -o that’s very much how we see it; that’s how it’s designed – for ensuring our national security and advancing global health equity and stability. So, the 2019 version of the Global Health Security Strategy – that’s the last time the U.S. government released one – laid the groundwork that we are building on, and the strategy that we are releasing next week is shaped by the hard-earned lessons of the COVID pandemic. So let me go through the three core goals in the strategy and then try to break it down in terms of what it really means beyond what we have in a government strategy document.

So, the first goal focuses on strengthening health security capacities through bilateral partnerships, which is a very government way to say things, but here’s what that means. The building block of global health security is the ability of each country around the world to effectively prevent, detect, and respond to biological threats within their borders regardless of the origin of those biological threats. So as we launch this strategy – when we formally announce it, but we are there – we have developed formal partnerships with 50 countries around the world to strengthen their global health security capacity. That is a commitment we made in the beginning of the administration, and we have delivered on that commitment.

But these partnerships are not just a vague idea. With each of the 50 countries, we have worked to identify five gaps in their capacity to prevent, detect, or respond to biological threats. And we are working together to measure progress in closing those gaps. When we launch the strategy, we will also launch a public website to transparently show what those gaps are we’re working to fill and progress toward filling those gaps. In many cases, these are existing partnerships that are formalizing, like with Indonesia and DRC. In other cases, they are new partnerships, like with Peru and Cambodia. They will not only help to prevent and detect outbreaks, but when outbreaks occur – which they inevitably will – the existing partnerships will make it easier for us to respond quickly and collaboratively. So that’s the first goal.

The second goal is focused on catalyzing political commitment to financing and leadership to achieve global health security; so, mobilizing the incredible network that the United States has around the world of alliances and partnerships to advance this work. So, we all know here that the United States can be a force for progress globally when we use our power to work with bilateral, regional, and multilateral partners to solve big problems, and this is definitely a big problem facing us. So, building on the U.S. support for 50 countries, we have committed to use our leadership to catalyze support from other countries for an additional 50 countries, to reach at least 100 countries, delivering on a commitment made by the G-7 in 2022. And we are already working through G-7 partnerships right now.

But to realize this goal of closing these global health security gaps, more resources are needed. Some estimate $30 billion annually, two-thirds of which should come from domestic financing and one-third from external financing. So, it requires substantial investment, and we have to have our eyes wide open about that reality and solve that problem. Part of the way we are trying to solve that problem is that during this administration we worked with partners to launch the Pandemic Fund in 2022, which was established to invest in building stronger pandemic prevention, preparedness, and response capacities at national, regional, and global levels with a focus on low- and middle-income countries. So it is reinforcing the work that we are doing through our bilateral partnerships and through our leadership to motivate other donors.

We’re also working on pandemic response financing. So Pandemic Fund is focused on preparedness, response – making sure that countries have access to resources early on in an emergency so that they can procure vaccines, they can get PPE for health workers, they can get the systems in place to distribute diagnostics. This year, the U.S. Development Finance Corporation is partnering with other G-7 development finance institutions to transform their capacity to provide surge financing for the procurement, production, and delivery of medical countermeasures in low- and middle-income countries. This also takes pressure off the United States to find a way to provide countermeasures to countries around the world early on in an emergency.

The third goal of the strategy is focused on maximizing the impact of U.S. government investments in health security and complementary programs, so other programs that the U.S. government is investing in. I think the example that we often think about is the way that the United States and other actors leveraged our PEPFAR investments in the early stages of the COVID pandemic – so lab capacity, supply chain systems, health workers that were there to execute on rapid and effective responses. We are taking a more systematic approach to this to make sure that we find opportunities to integrate global health security across our global health programming.

We are also, though, looking beyond the usual global health programming. So we’re looking at our investments in research and development for medical countermeasures to support more equitable access in an emergency, not just in the United States but also around the world. And this goes beyond health programs. We see an opportunity to integrate with programs addressing the impacts of climate change, with animal health programs, and even with our investments in security and defense. So we saw very clearly during the COVID pandemic that pandemics/outbreaks/health emergencies impact every sector, so it makes sense that every sector would step up to make sure that we are safer.

So, let me just end with perhaps the most important question from the perspective of the White House, and that is: How does this work protect the health and well-being of the American people? A disease originating in a remote population halfway around the world can travel to the U.S. in as little as 36 hours. That means that in order to ensure the health and safety of Americans, the world must have the capacity to manage infectious disease outbreaks. But let me give four specific ways that this protects Americans.

First, by tackling a problem at its root. Strengthening health systems and health security capacities in other countries, especially in regions where infectious diseases often originate, helps prevent outbreaks, and when they occur it helps to contain them at their source before they come to the United States.

Second, by giving us more time to prepare at home. U.S. government investments to improve disease surveillance around the world and improve capabilities around the world enable earlier detection of potential health threats, allowing for prompt response, including the development of effective medical countermeasures. Investments abroad mean earlier warnings and swifter actions at home.

Third, by fortifying our global defenses we do not need to act alone in times of crisis. Our investments foster collaboration with international partners, including governments, nongovernmental organizations, and multilateral institutions. These partnerships facilitate information sharing, joint research, sharing of samples and data, coordinated response efforts during emergencies, and enhanced global preparedness so that we operate together, and the entire pressure is not on the United States to solve global problems.

And fourth, these investments protect our economy. Our economic security is tied to how well we can prevent epidemics from becoming pandemics. These investments contribute to our economic security by mitigating the impact of global health crises on trade and travel, supporting global economic stability.

As we speak, my colleagues and your former colleagues at CDC are working to stop the next pandemic. This is not just a theoretical long-term approach, as you well know, to building capacities; it also means right now there are CDC, USAID, State Department, and other staff in countries where outbreaks are happening collecting samples, understanding whether viruses have changed, making sure that the countermeasures we have here in the United States will protect Americans. So very directly, very immediately this is protecting American lives.

And the last thing I will say is the best pandemic is the one that never happens. So, a lot of this work happens under the radar, and that means that we are all doing our jobs.

Richard Burr: Well, Stephanie, thank you for what I think is a comprehensive overview of the global health agenda, and congratulations on the completion of the strategy. It’s plain-spoken, clearly presented, and very pragmatic, I will say.

It marks a renewed alignment with the Global Health Security Agenda that dates back to 2014 and that health framework then. It began under the Obama administration and was carried out through the Trump administration and is now in its latest iteration under the Biden administration. That continuity speaks, I think, to the enduring bipartisan foundation of the Global Health Security Agenda.

The strategy continues to adhere to the WHO organization’s standardization of Joint External Evaluation framework for reviewing countries’ readiness and regularly judging progress across 19 indicators such as biosecurity, biosafety, immunization, surveillance, and emergency management. The USG Global Health Security Strategy reaffirms the central goal of building competency in 50 partner countries and in – and in at least five core health-security capabilities, extending the timeline from 2024 to 2028.

This is a smart strategy. It’s focused on what is truly needed, and what we can achieve and understand, and what has enjoyed bipartisan support for, I think, Julie, a decade. I commend that line of thinking.

At the same time, the path the administration has laid out here is fairly cautious and awfully modest. There are no big new goals within the strategy. As we’ll discuss, there are many enduring challenges that require much more thinking and a lot of U.S. leadership on financing, dealing with mis- and disinformation, and creating a coherent strategy on climate and health.

We should also note that this is the first strategy to emerge since several major institutional developments, including the creation of the Office of Pandemic Preparedness and Response, the launch of the new Bureau of Global Health Security and Diplomacy at the U.S. State Department, and your appointment, Stephanie, as the coordinator of the Global Health Security. These new institutions and the continued strengthening of CDC are essential steps in enhancing U.S. capabilities and they’re matched by a gifted, innovative new line of senior leaders, including you, Stephanie, and for that we’re grateful.

The unfortunate reality is that while we’ve had such a wealth of lessons, both good and bad, to learn from our experience in COVID-19, we’ve entered an era of neglect. We see this evidenced by the recent $200 million cut in global health security funds in the 2024 omnibus appropriations package – Julie and I have seen this before – and in continued polarization on COVID interventions.

Stephanie, what’s the core message that this strategy intends to convey to the skeptics on Capitol Hill and beyond?

Ms. Psaki: Yes. I have a lot of thoughts on the other pieces you shared, but let’s start there. So, look, I think the most important message here is that, as you said, this is bipartisan. There’s been support for a long time and this is about protecting the American people. These investments in a very immediate way protect the health of individuals, communities, and our economy. And I do think, even though we have some distance from the COVID pandemic, and the memories start to fade, the American people experienced what the consequences are of not making these investments in a very real way just a few years ago, so I think that message will resonate with people.

We have to do a good job telling the story to the Hill. You know, we have to make sure that it’s clear what these investments are for; that’s why we’re launching this website to be very transparent about how we are working to build capacities. We all will watch together and see whether there’s progress in building those capacities, and I am certain that if there is not progress we will get questions about why there isn’t progress. We need to talk openly about what we’re doing, what’s working and what’s not working. And some of the challenges, like misinformation and disinformation – they are integrated into the programs we’re doing; they’re integrated into the bilateral support. There are also challenges we’re facing here at home and work that OPPR is doing to address the capacity at home to respond to an outbreak or the next pandemic.

Sen. Burr: It’s striking to me – and I sort of turn to Julie on this one. If we look back over both of our times involved in congressional issues, do you agree the Hill has to be a partner? Not a participant; a partner.

Dr. Gerberding: They absolutely have to be a partner and there is a waxing and waning of the spirit of that partnership, depending on what phase of an outbreak or an event or a threat we’re in. We’ve been fortunate that there have been consistent champions that kind of maintain the focus and were respected in both the House and the Senate – you were one of them – so that people, you know, would be reassured and would pay attention and trust that this really was important. I think another dimension of that were the tabletop exercises, when we brought members of Congress to participate, and what would it be like if we had a very deadly respiratory infection rapidly move through our communities? And that was kind of a wakeup call. It led to some broader interest and hopefully some support for the authorizing legislation. It doesn’t always translate to the budget, but it does translate to the authorities, which are necessary, not sufficient. So, you know, I think it’s – we’ve been working on this theme here at CSIS since 2019, when our very first report from the commission, that was the earlier version of this bipartisan alliance, the title of our first report was, you know, the crisis of – moving from crisis to complacency and how do we stop that cycle? And I think that’s – you know, that’s what we see. We rev up; we relax. We rev up; we relax. But our government can’t really afford to do that. So kudos to the White House for really taking this seriously and putting this effort into it.

I do have a question about – you mentioned 31.1 billion dollars as kind of the aggregate need and about two-thirds of that would be supported by countries’ domestic resources. It’s probably not very likely that that size of budget is going to make it in the United States in the foreseeable future, just given all of the incredible pressures on our budget process. Is this strategy scalable? In other words, if you don’t have what you think you need, can you make substantive, credible progress?

Ms. Psaki: Yeah. So, I mean, I think also, coming back to the senator’s point in terms of level of ambition, I would say there is global ambition to solve this problem and it is largely dependent on the resources available to solve the problem. So we’ve designed it intentionally in a way that we’re meeting 50 countries, we’re reaching 50 countries now, we’re getting other partners on board to reach an additional 50 countries, we’re bringing in the pandemic fund, innovative financing approaches to try to crowd in other resources, but the level of intensity of support we can provide obviously depends on what the support is in the budget, within those 50 countries. And the number of countries we can reach depends on what’s in the budget, not to mention the support we’re providing to multilateral institutions from CEPI to Gavi. I think one of the – so we have this $30 billion number and that is a challenge in itself.

One of the opportunities that also poses a challenge is that we have new technologies that are coming on board that, in many ways, can make us safer and can make the world safer, but they also require additional investment, ahead of time and in the moment. And, you know, thinking about the waxing and waning of interests, as you well know, we are much better off if we’re making investments now in, you know, mRNA-based vaccines that can be adapted quickly in times of crisis or building stronger health systems, building these partnerships, taking an approach to prevention, rather than scrambling in the moment. We got very lucky with the COVID vaccine, but that might not be our experience next time around. So I think it is a real challenge. We are going to throw everything at that challenge. You know, we will have the budget that we have. We will continue to make the case for how important these investments are. We will do everything we can with our budget, bring other partners on board, bring new donors, bring the private sector, use the IMF and the World Bank, having those conversations at the spring meetings next week to try to solve these problems.

Dr. Gerberding: If you’re trying to triage the 50 countries, knowing that it may take a while before you can fully fund all 50, are you thinking of going to the countries that are ahead of the curve and doing, you know, really great and probably don’t need quite as much resource, or are you going to focus on the countries that are really behind and need a lot more help?

Ms. Psaki: That’s a good question. So we are able to support interventions in all 50 countries now and that is helped in part by the fact that we’re still spending the money from the last fiscal year, as you know. So the cut hasn’t taken effect yet.

I think our assessment is that we can continue to support 50 countries albeit at a reduced level of intensity even with the budget cut, although those decisions haven’t been finalized.

I think the strategy is – there’s a few pieces. One is the political will and interest in each country and what they like to tackle – would like to tackle. So biosafety, biosecurity, for example, is a big priority for us. There are a number of countries that are building more and more lab facilities. We want to make sure that they are safe and that we don’t find ourselves in the midst of an accidental pandemic.

I think there also are countries where there are other resources, so back to the complementary programs where there’s substantial PEPFAR investment, for example, in building lab capacity for HIV testing and then it makes it much more cost effective to build on top of those investments to look at testing or surveillance for other outbreaks.

So it’s kind of a piecemeal effect of how can we use the money to get us as far as possible.

Dr. Gerberding: So I have a question for you.

Sen. Burr: Yeah.

Dr. Gerberding: If you were in the Senate right now, what would you tell your colleagues about this?

Sen. Burr: Well, I’ve been in a similar situation. After I created BARDA I think over the next 14 years three different times we had it on life support and I had to explain the importance of this entity that we created even though we hadn’t had at the time H5N1, which is the reason it was created, and that was on the heels of anthrax and it was while we went through SARS and MERS, Ebola – you know, I can go through the litany – of which any of them could have turned into a pandemic based upon the makeup.

You mentioned technology and I think that’s really, really important. So how does the private sector fit into this architecture that you’ve created for 50 countries that we will be perceived as the leader?

Ms. Psaki: So, you know, we have been working closely with industry on a whole range of issues and, if I may, one of the ones that is near and dear to me and I’m very focused on in 2024 is the access to medicines issue around the world – vaccines, diagnostic therapeutics.

It’s been at the heart of a lot of the multilateral negotiations that we’re immersed in right now and the discussions have been really challenging because we are starting the conversation from completely different starting points including the fact that we have a very robust active industry in the United States that to a large extent was behind the innovation for the COVID vaccines that were useful for the entire world.

Now, that was with investment from the U.S. government and from others but we are invested in making sure that we can protect that innovation in a future pandemic. So the conversations we have been having with industry around access to medical counter measures I think some of them are challenging. Some of them show signs of progress.

But I do see some commitment from them in answering this core issue that we hear over and over again from, I would say, all 50 of these countries which is in the next pandemic how are we going to get access to vaccines because last time around it took way much – too much longer than it should have taken.

So we are integrating them as much as we can. What we have heard from partners and from multilateral institutions is some resistance, honestly, some of which you might have heard, to bringing them into the room. But that’s an important priority for us in the U.S. It’s part of what we’re –

Sen. Burr: And let me say I think this answers Julie’s question.

The Congress, when they see private sector involvement, private sector interest, private sector support, members of Congress are more apt to fund and in the throes of COVID – I’ll tell one story just real quickly – I called an agency that I wanted them to look at a technology that I thought was rather unique, the identification and predictability of infection.

The answer I got was the head of this agency can’t meet with a private sector company. Wrong answer. And I say to you and I say to the other 49 partners that you have to leverage the private sector and what they’re capable of doing so that you’re able to spread those dollars in a much broader way, in a much more effective way, and I realize there’s push back at the beginning but it’s absolutely crucial to make it work and when you look at COVID and our experience it wasn’t just vaccines. It was testing. It was the capability to produce – mass produce portable freezers that were able to store vaccines that had to be kept at a certain temperature and we exported those all around the world.

So, the private sector played in much greater ways than anybody sat down and tried to think and without them you can have the best laid plans, but it only gets so far.

Ms. Psaki: Yeah. And I think that there are opportunities. You know, one, we have to play this role often of a neutral broker, which means we’re going to have tough conversations with basically everyone, as you probably know, from having been in government.

But I think there are opportunities for win-win. So just to give an example, one of the great frustrations that we have experienced both in terms of vaccine donations from the U.S. government and that the private sector has also experienced is regulatory barriers in other countries.

So we have products. You know, right now we’ve been trying to donate vaccines to the Mpox outbreak in DRC. For over a year we’ve had trouble getting the vaccines into the country because they don’t have regulatory approval even though they have FDA approval in the United States.

Overcoming some of these barriers and finding ways for the private sector to fund some of the approaches to overcoming those barriers would solve a major problem that we face over and over again when we’re tackling these outbreaks, but they also resolve an area of tension for industry.

Dr. Gerberding: So, you kind of mentioned the pandemic accord or whatever is the current terminology describing it. Can you share your outlook? Do you think by the World Health Assembly we’re going to actually be able to negotiate our way into something that represents credible progress?

Ms. Psaki: Well, like, I will share the outlook from the U.S. government perspective, which is twofold, one from people who have been through very difficult negotiations like this. They say it’s often darkest before you get to the light so perhaps that’s the moment, we’re in, but also that we are really committed to getting to an agreement.

I think at this point we have very clearly put our positions on the table. We’ve shared them publicly a couple weeks ago through HHS and the State Department. We have conveyed them over and over again to countries on all sides of the discussion.

We’ll have to see if there’s an ability or willingness to get to a place of consensus. We are very committed to operationalizing some of the positions that we’ve put on the table outside of the agreement because we think they’re the right thing to do.

So, we’ll keep moving forward with U.S. leadership. We’re hopeful that other countries will come to the table.

Dr. Gerberding: Does the global health security strategy help you build credibility in the World Health Assembly?

Ms. Psaki: You know, I will say that I don’t know that they’re going to have it printed out and dog eared. I hope so. (Laughter.) Maybe by then.

I will say that what helps us build credibility, and this has been true along the way, is the way that the United States has showed up in the global health space for the last few decades. PEPFAR, to come back to it again, is a huge example in the Africa region. You know, we are stuck in these negotiations with the Africa group of countries, among others.

But they have reiterated over and over again that they have seen that the United States shows up through our investments through PEPFAR, our investment through the Global Fund, and it has saved lives – 25 million lives across the world.

And so, our commitment is clear and I think in a way that no other country has showed up around the world. So, I think there is an expectation and understanding that the U.S. will continue to play that kind of leadership role and I hope that we do.

They also are following what is happening in the United States right now. They follow the debates about PEPFAR reauthorization and that, unfortunately, starts to shake some of their confidence in our willingness to show up in the future.

So, the history of the U.S. showing up is what builds credibility. I think it does give us – it gives us a runway, but we have to – we’re in a new moment now and we have to ask tough questions about how we’re going to deliver in a different way.

Sen. Burr: Well, let’s get to some real fun stuff.

Dr. Gerberding: Great.

Sen. Burr: I already said, you know, to some degree you were cautious and conservative in what you structured, and, quite honestly, it lacks boldness. There’s a limited reference to building, manufacturing capabilities in low and moderate income countries.

If there’s one takeaway that we learned in COVID and we saw again in Ukraine is logistics is everything and there’s really no reference to the geopolitical competitors like China. The United States has reinstated multiple working groups with China on critical sensitive matters – security, trade, cyber, climate, fentanyl precursors – but none on health security and there’s minimal discussions about misinformation and disinformation, which quite honestly was a collapse of public trust in this entire process.

How do you intend, through this effort, to move forward in those areas?

Ms. Psaki: Yeah. Those are some big questions. Let me tackle them.

So, you know, I think that it is important for us to draw a distinction from our geopolitical competitors in terms of how we show up in the world, particularly how we show up on global health, global health security, and some of these other areas.

When we are partnering with countries we’re partnering with countries where China is also very present, where China is investing heavily in infrastructure and taking other actions, and it is important that we convey clearly that we are partnering for the benefit of the bilateral partnership and for the people in their country, not for a geopolitical competitiveness benefit to us, which these countries are very sensitive to as they are watching what is happening around the world.

So, I think these investments are critical for that reason anyway. You know, again, to come back to PEPFAR, I think the fear of stepping back from PEPFAR in the Africa region is a gift to China if they want to get a stronger foothold in the region. That is the reality, whether that is the intention behind it or not.

But I think in these global health security partnerships we really come to the table with an interest and willingness in closing gaps to protect the people in those countries and there are secondary and tertiary benefits to that work. I think, more broadly, the way that we are showing up in multilateral spaces in some of these negotiations where China and others are a party to the negotiations, is that we are showing the leadership position. China continues to negotiate with developing countries, which is interesting given their economic growth. (Laughs.) And we are negotiating on the side of developed countries and trying to find solutions and put resources on the table and solve the problems that we saw during COVID. So I think it is evident what the difference is, and what we bring to the table, and what China brings to the table, without us having to point to it. But sometimes we also do point to it in multilateral settings, as I’m sure you know.

On the manufacturing front, you know, I think this is partly not captured in this strategy – not at all because this is – you know, not as a reflection of it not being an area of interest or priority, but perhaps because we don’t – you know, to come back to the government bureaucracy part of it – we don’t have an investing in manufacturing budget line, you know? There is a lot of – there are a lot of different pieces of work that we are doing across the U.S. government to address this issue. And, in fact, last week – I think, the weeks flow together, but I think it was last week – we posted a factsheet on the White House website about the work we are doing in this area broadly of expanding access to medical countermeasures. And a big portion of that is investing in diversifying manufacturing capacity.

There are, as I’m sure you know, all sorts of initiatives that have sprung up on this topic in the wake of COVID, and a lot of interests that have been put on the table. What we are very focused on, and this is why I think the investments through DFC, for example, are exciting, is making investments that are sustainable, where there is a market for the product that is going to be built, where the government is able to stand up and not just invest in building a facility but also invest in maintaining the facility, invest in training and paying the workers in that facility, and then where the product will be sold in the country or in the region. And so that is how we are thinking about our investments in manufacturing. It does – it means it take smore time. It means it’s going to be somewhat more incremental. But that’s the approach we’re taking.

Now, if we had a budget line item – (laughs) – again, on building and diversifying manufacturing capacity, I think there is much more we could do. And we could benefit from having a cohesive strategy in that space. I think that’s probably an area we will go in the future.

Sen. Burr: Yeah, I mentioned private sector partnership earlier. The West really has to look at contract drug manufacturing organizations, CDMOs, and ask ourselves if we’re going to let China dominate the rest of the globe with CDMOs? Where that’s our choice, because we can’t muster the money to do it ourselves at any given time. And I guess I’m curious, in tabletop exercises, have you looked at how the private sector can fill that gap on manufacturing? I think of companies like Resilience, where not only are they domestic but they’re now global. And in those same tabletops did you take into account the havoc that China and others can play to disrupt this partnership of 50 and maybe an additional 50 countries?

Ms. Psaki: Yeah. So, I think that there is a broader problem that is very China-relevant right now, which is how do you maintain a warm base of manufacturing in the U.S. or in allied countries in between pandemics? And how do we also maintain U.S. leadership in spaces like biotech? It involves – now this is, you know, touching on the work of my colleagues in OPPR – but there is a decision to be made about how deeply we are going to invest in those areas in the U.S., and make sure that we maintain our leadership role.

Which is important for many, many reasons, but one of the reasons it’s important is that if there is an outbreak or a pandemic and we need to access an antiviral, for example, that is only produced in China, or if there is a deliberate threat and we need to access an antiviral that is only produced in China, we could find ourselves in a very difficult situation. Again, this is a decision that needs to be made in terms of how we invest our resources in the short term in anticipation of potential or likely threats in the future.

Dr. Gerberding: Sometimes I feel frustrated, because I feel like this is national security. And when we have conversations about our national defense budget, we know we’re investing intensely in creating weapons and countermeasures that we hope we never have to use. But the order of magnitude in what we’re willing to invest in those spaces and what we seem to be willing to invest in this space is not even close. So, is there anything we can learn from that model?

Ms. Psaki: Well, I would say that, you know, DOD certainly is part of, I would say, indirectly supporting a lot of what we’re trying to do through this strategy. And we certainly have been in situations where there’s an outbreak somewhere in the world, and only DOD can access or transport goods. They also have systems in place like bio surveillance systems that are beneficial in terms of tracking threats. So, I do think that there are ways that even with existing resources even used, you know, in alignment with their authorities, they can support this work.

You know, I think one of the challenges is maybe shifting the mindset or, better, combining the mindset of the health space and the national security space. And that is a conversation we’re having more and more. That, yes, there are investments to be made right now for known threats for issues that we’re dealing with right now. But there are also our investments that are national security and defense investments, for many reasons that are not known, you know, to the broader American public or even to parts of the U.S. government. And I think making that case is perhaps a harder case to make. But, again, it’s part of the conversation we need to have with our colleagues on the Hill as well.

Sen. Burr: Listen, there are multiple – and this playing off of exactly what you said – there are multiple convergent competitive replenishment efforts currently going on – Gave, Global Fund, Pandemic Fund, and the WHO. Reality is that many will fall short of what we would define as success, and certainly aspirations. The delta between the aspirations and the expected levels of available funding is quite significant.

And Julie and I talk about the level of debt and the availability in the out years that we see. The budgets are tight war. The war in Ukraine, Middle East demanding high humanitarian outlays, climate’s risen significantly as a global priority and that requires funding. And the interest in global health and health security has declined, really, as a result of these other issues sort of crowding out the funds. What is our strategy to navigate this in reality?

Ms. Psaki: Well, I was hoping you would have one – (laughter) – but let me share a few pieces? You know, I –

Sen. Burr: I can give you one, but I don’t count anymore. (Laughter.)

Ms. Psaki: Yes. I agree with the way that you have characterized the situation that we are in. I think it is clear that ODA funding from the same small set of donors is not going to be sufficient to meet the multiple replenishment needs when we are thinking about the actual needs of those budgets. So there is – you know, just as we are going to have to prioritize within our global health security budget in the U.S. government, there’s also going to need to be a process within those institutions of prioritizing based on the available resources. That is just where we are in this moment.

I think a few pieces of it that I know those organizations are all thinking about are, one, you know, bringing other donors to the table. I mean, to come back to China for a moment, it would be great to see China step up and fund some of these institutions anywhere close to the level of U.S. funding. That would be a great diplomatic tool for them and beneficial to people around the world. So I recommend that approach. I think there are also a number of other donors in the Middle East and elsewhere who are taking a more active role. And we’re hopeful that they will in these replenishments.

Comes back also to the private sector. What are the opportunities to bring the private sector to the table, either because they see a benefit for their bottom line because it is an issue that resonates with the audience – you know, I think that we have to be creative about that. In terms of the Pandemic Fund, which we are very focused on since it was a day-one priority for the president to establish the Pandemic Fund and we’re headed in, again, to a resource mobilization round, the idea was that it would be ODA funding coupled with innovative financing. That was the promise from the beginning. And that is what we have in mind going into the next year of replenishment. So, we have to demonstrate what that looks like.

And I think if we demonstrate what that looks like, whether it’s bringing industry in for a round that’s focused on addressing regulatory barriers, whether it’s bringing in IFIs or other actors, I think if we can demonstrate it not just with the Pandemic Fund but other institutions, it will also bring more donors to the table. So that is part of our approach. I also think we need to think about the medium-to-long term in terms of what the global health space broadly – global health security space being, I would say, a part of it – looks like in five, 10, 15 years, when we get to the end of SDGs. What happens next? What is the next phase? Are we going to continue to focus on disease-specific programs, on investing in health systems, some combination of the two?

There are really important conversations that need to happen right now. And I would say we already have heard questions about that from the Hill in the context of PEPFAR reauthorization. So those are discussions as a community that I think we need to have right now so we don’t find ourselves in a situation in five or 10 years where we see a huge cut collectively to the global health budgets.

Sen. Burr: I hate to harp on the private sector, but I see the private sector is a crucial component to the overall success. And Julie was in government, I think, at the time when H5N1 first appeared as a potential pandemic threat. And we did something in government that I don’t think everybody thought we could do. (Laughter.) We actually partnered with private companies to build vaccine capacity in three different locations, where the government funded two-thirds and the private sector funded a third with an agreement that if it ever became a pandemic, we could take over the facilities, we could mass produce for the American people, and for probably the global population if there was a need for it. But if that was never triggered, then we operated in a seasonal flu vaccine.

One of the challenges was in the switch of administrations and companies wanting to sell and diverse into other things, we forgot the real foundational reason we created these partnerships. And when COVID came, two of them we couldn’t stand up for COVID. And the third one was still designed as vaccine manufacturing, and we didn’t want to do away with seasonal vaccines. The only reason I point it out is there is a history of successful private sector partnerships, even on the manufacturing side, that I think there’s every reason to look at how we structure it, figure it out – figure out what we got wrong over the years, and make sure we’re insulated from the downside. But I believe that the private sector is a key to congressional participation, because it’s their constituents that work at those facilities.

What do you think, Julie?

Dr. Gerberding: I agree with you. I mean, I think flu is exceptional because of dual purpose. You know, because pandemic influenza versus seasonal influenza is basically chicken and eggs, or in the case of North Carolina it was a different technology. (Laughter.) But it was complicated. And yet, we need to be thinking about platforms of countermeasure development, so that you can more vastly sub in the vaccine or the countermeasure, the antiviral, that you need to make now, recognizing that, you know, we have a long way to go before we’re there, because we don’t really have those platforms quite yet.

Sen. Burr: And this is a, you know, tremendous opportunity to look at the assets we have within the USG. I’m thinking of Renee at ARPA-H, where their focus is on technology platforms and tasking them for certain things that help provide you leverage in this overall architecture. Well –

Ms. Psaki: I will say, just on that – on that topic, in the – you know, again in the Pandemic Accord negotiations, but in this discussion about how to get countermeasures to the rest of the world more quickly, one of the pieces that the private sector has said over and over again is that they need a clear signal that there will be demand for a larger supply. You know, there is the supply that they know high-income countries will pay for. And then there’s a question mark about supply after that. So, they’ve laid that out in the Berlin Declaration.

And look, there certainly are skeptics about whether that is really something they are going to deliver on. But part of our position has been, let’s put systems in place so that we can signal very early on in a pandemic that we have an intention to procure and distribute vaccines to low- and middle-income countries, because it creates an incentive then to scale up manufacturing capacity more quickly, which in theory would mean that there is more of a supply for Americans more quickly, and then more of a supply for the rest of the world. So, again, I do think this dialogue – we have to hold each other accountable on both sides, for sure. But having this dialogue and saying this is what you put on the table, here it is, now let’s watch you scale up the capacity and deliver.

Sen. Burr: Good.

Dr. Gerberding: But we’re at our time. I want to make sure that if you have a last word that you really want to make sure that you either summarize or bring up that we haven’t brought up, that you have a chance to close us out.

Ms. Psaki: Well, I will – I will close us where we started, which is that these investments in global health security are essential to protect the American people. That is how we see it from the White House. That is, we hope, how our colleagues on the Hill will see it. And that is the vision that we are going to be driving toward in the next five years.

Dr. Gerberding: Thank you. Richard, you want to take us home?

Sen. Burr: Stephanie, thanks for sharing this preview. Again, I think that there’s a tremendous amount of positive in this for us to work with. And I want to thank CSIS for making this opportunity available today, and for your willingness to come out before it’s going to be released. But this will be held until it is released. And we can share with folks that see this exactly the challenges that we’re faced with to try to be ahead of the curve, and to really respond in a way that the American people would want us to from a security – a health security standpoint.


Dr. Gerberding: I would just thank you. Thank you for taking on the responsibility. I’m sure you have some sleepless nights, either behind you or ahead of you. But this has been a tremendously robust conversation, extremely thoughtful, and we’re just lucky that you’re in the White House. Thank you.

Ms. Psaki: Thank you so much. Thank you for your time. I appreciate it.

Sen. Burr: Thank you.