Lessons in Pandemic Response: Student Perspectives by Texas A&M School of Veterinary Medicine & Biomedical Sciences

TIER ONE PROGRAM “SCIENCE & POLICY” CLASS WHITE PAPER • 2020

Lessons in Pandemic Response: Student Perspectives

The views expressed and opinions presented in this paper are those of the Scowcroft Institute of International Affairs and do not necessarily reflect the positions of The Bush School of Government & Public Service or Texas A&M University.

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from the Scowcroft Institute’s 2019 Pandemic Simulation Contents

LESSONS IN PANDEMIC RESPONSE: STUDENT PERSPECTIVES FROM THE SCOWCROFT INSTITUTE’S 2019 PANDEMIC SIMULATION Tier One Program “Science & Policy” Class White Paper • 2020 Section One: Roles in Pandemic Response................................................................................................................................... 4 Role of Government in Pandemic Response........................................................................................................................... 4 Government Structure.......................................................................................................................................................... 4 Communication Between Agencies..................................................................................................................................... 5 Communication with the Public........................................................................................................................................... 6 Government Strength in Pandemic Response................................................................................................................... 8 Role of Non-governmental and Intergovernmental Organizations..................................................................................... 8 Intergovernmental Communication.................................................................................................................................... 8 Strengths of NGO/IGO Collaboration.................................................................................................................................11 Role of the Private Sector..........................................................................................................................................................11 Communication Between the Private Sector and Government.....................................................................................12 Strengths of Private Sector Collaboration.........................................................................................................................13 Recommendations............................................................................................................................................................... 14 Section Two: Funding Response Efforts...................................................................................................................................... 16 Funding Detection Efforts........................................................................................................................................................ 16 Funding Response Efforts.........................................................................................................................................................17 Mobilization of Funds............................................................................................................................................................... 18 Ensuring Equal Funding for All Citizens............................................................................................................................. 18 Implementation of Funding Framework........................................................................................................................... 18 Allocation of Funds.....................................................................................................................................................................19 Barriers to Allocation............................................................................................................................................................19 Recommendations............................................................................................................................................................... 20 References....................................................................................................................................................................................... 20 Authors............................................................................................................................................................................................ 25 In Memoriam................................................................................................................................................................................... 26 The Scowcroft Vision...................................................................................................................................................................... 26

Tier One Program “Science & Policy” Class White Paper • 2020

Lessons in Pandemic Response: Student Perspectives

SECTION ONE: ROLES IN PANDEMIC RESPONSE Role of Government in Pandemic Response Government Structure

Governments play a large and multi-faceted role in pandemic response. Not only do governments have primary responsibility for coordinating response efforts, communicating to international organizations, and approving containment measures, but they also often inadvertently create barriers to the pandemic response efforts of other organizations. It can be difficult to coordinate the unique responses of federal, state, tribal, and local governments - in the case of the United States - during an outbreak. Furthermore, a national governmentâ&#x20AC;&#x2122;s capacity to respond to a pandemic depends on the respective countryâ&#x20AC;&#x2122;s form of government, societal understandings of government power, and the corresponding ability of the government to enact measures which might inhibit individual liberties in order to help stop a pandemic.

The impact of governance structure was evident in the Scowcroft Pandemic Simulation held in November of 2019. In this simulation, the United States was the origin point of the outbreak of pneumonic plague and the democratic nature of its political system encourages citizen involvement, open press, and excellent funding capabilities. These governmental elements allowed the U.S. to take a more proactive role in the pandemic simulation. However, democracies face greater restraints in imposing mandatory quarantines, compulsory vaccination, or other critical public health measures necessary to contain disease spread. Therefore, democratic governance requires greater transparency with citizens. Conversely, authoritarian governments, such as the Chinese government in the simulation, have greater direct control over the implementation of disease containment measures and can be less transparent

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from the Scowcroft Institute’s 2019 Pandemic Simulation

with the public over the course of the outbreak. An authoritarian government structure allows leaders to forcibly contain people to their homes, as was done with COVID-19 (Cooper, 2020). In the simulation, we also played out the Mexican government’s response, which closely mirrored their real-life response to the 2009 H1N1 response. Overall, the Mexican government struggled with response in the simulation due to a lack of resources and limited bargaining power in international negotiations. However, in the simulation the Mexican government was able to help contain the outbreak through public awareness campaigns and health promotion, similar to how the real-life Government of Mexico responded to the 2009 H1N1 outbreak (Córdova-Villalobos, et al., 2009). Throughout the simulation, all players grappled with questions about what level of government, if any, in a given country had the authority to direct matters such as school cancellation, vaccine distribution, and allocation and distribution of supplies broadly. Time spent trying to determine who had authority over what actions could have been better spent actively responding to the disease. As is true in real-life outbreak response, the simulated outbreak began at the local level with cities working, mostly independently, to contain the spread in the short-term. As outbreaks grow, they become issues of national and international concern, allowing for greater resources to be allocated (Pittman, 2011). Even when disease outbreaks reach the level of national or international concern, the federal governments of democratic countries unlikely to implement more stringent disease control measures that may violate civil liberties and freedom of movement, such as quarantines. In the United States, a federal quarantine had not been enacted for almost 60 years when the 195 Americans were quarantined after evacuation from Hubei Province, China in January 2020 (Grady & Rabin, 2020; "Regulations and Laws That May Apply During a Pandemic", 2016). Understanding the nuances of local, federal, and international pandemic response efforts, along with implications of governmental structure are proved essential to establishing effective pandemic response in the simulation.

Communication Between Agencies In order for governments to effectively collaborate in pandemic response, it is imperative to have interconnected communication between agencies and organizations. Dynamic interagency communication allows for increased preparedness in an outbreak, whether intentional, accidental, or naturally-occurring. There are a variety of agencies responsible for emergency preparedness and response to pandemics. At the international level there is: the World Health Organization (WHO) Epidemic and Pandemic Alert and Response (EPR) and the Emergency Prevention System for Transboundary Animal and Plant Pest and Diseases (EMPRES). At the US Federal level there is: the Department of Health and Human Services (HHS) which oversees: the Office of Assistant Secretary for Health (ASH), Office of the Assistant Secretary for Public Health Emergency Preparedness (OPHEP), National Vaccine Program Office (NVPO), Office of the General Counsel (OGC), Office of the Assistant Secretary of Public Affairs (ASPA), Office of Global Health Affairs (OGHA), Center for Disease Control and Prevention (CDC), Food Drug Administration (FDA), National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), Centers for Medicare and Medicaid Services (CMS), National Vaccine Advisory Committee (NVAC), Vaccines and Related Biological Products Advisory Committee (VRBPAC) and the Office of the Assistant Secretary for Preparedness and Response (ASPR). Other organizations involved are the Department of Homeland Security (DHS), the Department of Defense (DoD) and Department of Veteran Affairs (VA), Department of Agriculture (USDA), Department of Energy (DOE) and Department of Transportation (DOT), and the Department of Interior (DOI) (Georgetown Law Library 2020). Every agency has its own outline for how they will respond to a pandemic threat. For example, DHS documents state that if the “Emergency Support Function (ESF) for External Affairs is activated, the National Joint Information Center (NJIC) will coordinate with and support the White House, Secretary of Homeland Security, the National Operations Center (NOC), and the National Response Coordination Center

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Lessons in Pandemic Response: Student Perspectives

to coordinate the Federal communications response.” (DHS 2020). The next step would be coordinated messaging with the U.S. Department of Human and Health Services and other international partners if the outbreak stretches beyond the US borders (DHS 2020). The CDC’s Crisis Emergency Risk Communication manual discusses different ways to address chemical, biological, radiological, nuclear or explosive (CBRNE) events. Given that our simulated pandemic was an act of bioterrorism, we will only focus on the elements of the Crisis Emergency Risk Communication framework pertaining to bioterrorist events. The CDC explains how there are increased communication challenges when there is a terrorist attack using Weapons of Mass Destruction (WMDs), of which many bioterrorist agents qualify. In the case of a bioterrorism attack, communication will proceed as follows: “the DHS Secretary and the Attorney General (through the FBI) will be responsible for coordinating information dissemination to the White House, Congress, and other federal, state, and local government officials” (CDC 2014). Congruently, there will be a focal point of coordination on behalf of FEMA: National Incident Management System (NIMS)'s national joint information center (JIC), which would disseminate the public and media information accordingly (CDC 2014).

The distinction between bioterrorism and an emerging infectious disease is important and the CDC explains that “health investigators may not immediately know that an infectious disease outbreak is the result of an international release of germs; selected illnesses and symptoms may result from nature or bioterrorism” (CDCynergy 2012). In the United States government, the White House contains a national security division called the Policy Coordination Committee (PCC), which provides a space for high-level decision makers to communicate regarding a national emergency, threat or crisis of the day. Within this agenda, there are interagency meetings that help the correspondent ministers, deputy assistant secretaries, and other committees that carry out the national security decisions to be taken to the National Security Council. The ongoing COVID-19 pandemic has been a central topic of these conversations. For COVID19-related PCC meetings, 14 agencies have been involved including: the Department of State (DoS), Department of Transportation, Federal Aviation Administration (FAA), DHS, Department of the Interior, U.S. mission in the United Nations Geneva Headquarters, US mission in the WHO, the CDC, U.S. Embassy in Beijing, USAID, DOD, Office of Management and Budget (OMB), and the National Security Council Staff (NSC) (The White House 2020). All the organizations depend on the scientific community's determinations in order to coordinate transportation, economics, and policy to tackle the pandemic. The PCC involvement in COVID-19 response provides insight beyond the lessons learned in the simulation as to how the United States government will address pandemic response.

Communication with the Public Communication with the general public during a crisis can be divided into two dimensions: “hazard” and “outrage.” Hazard refers to the level of real-life threat that is occurring as a result of the crisis. Outrage is the public’s response to the crisis based on their understanding and perceptions. Crises tend to be high hazard, high outrage situations, but the goal of crisis communication is always to make the outrage reflect the hazard. This means that governments want the public to have an accurate understanding of the threat and

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from the Scowcroft Institute’s 2019 Pandemic Simulation

to respond (“outrage”) accordingly. Providing timely, accurate, and consistent information is vital to address a crisis and create the appropriate balance between hazard and outrage (Sandman, 2001). Building a culture of preparedness is a shared responsibility at all levels of government (DHS, 2019). Crisis communication emphasizes the timely dissemination of information to the public. For crisis communication to be most effective, factual information must be disseminated by a credible, singular spokesperson, who can provide insights on the crisis and answer questions from the public (CDC, 2018). The purpose of a credible spokesperson is to provide the public with consistent, accurate information, which helps to reduce panic and increase compliance with disease containment measures. Every word of crisis communication should be intentionally selected. Communications should use neutral words that are readily understood, respectful,

and suitable (CDC, 2018). Additionally, providing the public with simple, tangible actions that they can take to protect themselves increases self-efficacy and overall compliance with containment measures. For example, the suggestion of handwashing during an outbreak gives the public an action that they can take on a regular basis that reduces their chances of infection. Such actionable steps serve to reduce fear and hopelessness among the general public. It is also important to be mindful of audience background, behavior, and culture so that messages can be constructed in the appropriate context. To develop successful crisis communication of the general public, attention must be paid to determining the best route of communication and tailoring the information to reach and be understood by different populations (Zarcadoolas, Pleasant, & Greer 2003; Zarcadoolas, Pleasant, & Greer 2005). Information can be conveyed through a variety of communication channels from verified social media accounts and websites to traditional news media outlets and phone hotline

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Lessons in Pandemic Response: Student Perspectives

numbers. Consequently, this also allows feedback for message improvement as well as up-to-date information for an ongoing situation (NATO, 2007). Good communication mitigates fear and panic (Zarcadoolas, Pleasant, & Greer 2003; Zarcadoolas, Pleasant, & Greer 2005). It can also help slow or contain a disease outbreak if the right messages are able to reach the general public. Ultimately, pandemic response cannot be done effectively without well-designed crisis communication and an effort to bring hazard and outrage into alignment (Sandman, 2001).

Government Strength in Pandemic Response Governments have wide authority to develop and implement policies, a power that is only amplified in cases of national emergency. While there are differences in the extent to which democratic vs. authoritarian governments may go in disease containment measures, federal governments remain the most powerful entities in disease containment and overall pandemic response due to their power to quarantine, isolate, and allocate funds.

Role of Non-governmental and Intergovernmental Organizations There are numerous non-governmental organizations (NGOs) and inter-governmental organizations (IGOs) that can be leveraged in a pandemic to provide relief and thwart the spread of diseases. The role of an NGO in a pandemic is dynamic because organizations like the Red Cross, Red Crescent, and Doctors Without Borders/ Médecins Sans Frontières remain neutral, allowing them to provide aid even in conflict zones. NGOs can provide resources and tools that are beneficial to the environment, community health, and advocacy (Nilsson, 2017). Health-oriented IGOs, such as WHO, can utilize the resources of multiple nations and governments to protect the health of the global population. Early involvement of both NGOs and IGOs can be paramount to mounting a successful defense against the spread of disease around the world. During the Scowcroft Institute’s student pandemic simulation, NGOs played a central role, but there were still challenges determining community and NGO needs

due to the lack of communication between groups. The role of NGOs in the simulation could have been more beneficial if there were measures taken to begin surveillance and quarantine of the disease when it first emerged in Mexico. In the simulation, the Mexican government could have utilized Partners in Health Mexico and PCI in Mexico, with Médecins Sans Frontières as a standby, to help contain the disease if groups had more effectively communicated and collaborated. The primary IGOs that play a role in pandemic response are WHO and the World Bank. These organizations are essential for disseminating information globally, declaring a pandemic or a Public Health Emergency of International Concern, and helping to allocate funding, resources, and expertise as the outbreak unfolds. In 2009 Mexico took strong action to prevent the spread of the H1N1 virus by working with IGOs and other agencies to decrease the infection rate by minimizing contact rates and providing prompt and accurate information to the population about the current outbreak (Stern, 2009). IGO’s can develop educational pamphlets and develop media content that can be disseminated to the masses via television, internet, pamphlets, radio, and text message notification in addition to helping set policies and providing resources for disease containment (Stern, 2009). In the simulation, Mexico was the only country that took advantage of the services offered by the IGO community.

Intergovernmental Communication The fluctuating nature of international relations and rapid advancements in biological science has made the need for pandemic preparedness more crucial than ever. Open and effective communication between national governments is essential for rapidly responding to disease and minimizing morbidity and mortality in the event of an infectious disease outbreak, including a bioterrorist attack. The international community should take a multifaceted approach in developing disease containment measures. The first aspect of this approach would be to expand upon and increase funding to major internationally cooperative research efforts to combat and counter bioterrorism. The second aspect would bring together international government leaders to establish a framework for the mobilization of resources

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and personnel that clearly identifies roles and authority in the event of a major international bioterrorism event. The aspects of this multinational approach to biosecurity, which will be expounded upon further in this section, are only feasible if lines of communication remain open. This presents a challenging balancing act as nations must protect their own national security while recognizing that in today’s highly globalized world, cooperation between countries is not just beneficial, but it is necessary. The pandemic simulation highlighted one of the central issues pertaining to international public health preparedness: any government's main priority is the protection of its own populations and interests. Since the catalyst for the pandemic in our simulation was a bioterrorist attack, it highlighted the dizzying pace of biomedical advances that has to be met by preparedness planning on the international stage in order to prevent a potential global catastrophe. Communication between major international players is the only feasible means to facilitate this kind of preparedness. In order to address both the issues of individual governments' self-centric approach and the everchanging landscape of biological threats, a series of research initiatives has to be invested in and implemented long before a global incident occurs. These initiatives must be mulit-national and collaborative. A number of IGOs, as was detailed previously, already exist to provide the framework through which governments can begin this cooperative effort and governments must prioritize the utilization of these frameworks as a means of collaboration and communication in areas of research pertaining to public health and biosecurity. Scientific collaborations have a unique advantage, in that it often persists despite the current geo-politcial landscape. There are countless multi-national research collaborations that focus on all areas of health and technology. It is this collaborative approach to science that has served as the catalyst for the breakthroughs that have come to define the twentieth and twenty-first centuries breakthroughs that are only made possible through effective communication between the scientific bodies within each government. It is an incredible opportunity for governments to utilize the plethora of

talent that is already collaborating with one another to create a system in which already cooperating nations are better prepared for a potential bioterror event. Mutli-national organizations such as the G7 and the European Union (EU) already have mechanisms in place where they are actively investing in collaborative research between groups from different nations (Scientometric, April 2009). This approach needs to be turned towards biosecurity in a more robust manner. A large-scale investment in grants and fellowships focused on topics related to biosecurity, by multiple of the world’s major nations through an impartial IGO source, would attract some truly great scientific minds to the table. Investing in this approach is beneficial in a multitude of ways. This approach promotes scientific progress in areas relevant to biosecurity, creating a more prepared and ultimately safer global stage. It also serves to bring major international powers to the same table in a way that is otherwise incredibly difficult. All of these strategies are only made possible if proper and effective intergovernmental communication fosters their existence. Scientific research is one of the only areas

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Lessons in Pandemic Response: Student Perspectives

where geo-political agendas donâ&#x20AC;&#x2122;t hold major influence, as researchers are often much more devoted to scientific progress than to political ideology. (AAAS, CSD 2015). A multinational investment in scientific research related to biosecurity allows each nation to take an active role in their own level of preparedness through their degree of involvement. Any countryâ&#x20AC;&#x2122;s propensity to protect themselves will involve investment in a strategy such as this because it keeps them in the loop on the international biosecurity stage while advancing initiatives that will protect the homefront. The cooperation of nations in advancing biosecurity through collaborative investment in research will rely on, as well as foster, communication between major global powers. This, inturn, will help to perpetuate a cycle in which channels of scientific communication between nations grow, lead to greater global security, and reduce the threat of bioterrorism. Lastly, an area that must not be overlooked is the role of low-income countries in global health security. As previously discussed, investments through IGOs in multinational collaborative research focused on biosecurity would serve to open lines of communication in a way that often proves difficult in both real-life and

our simulation. Low-income nations do not financially contribute to IGOs on the same scale of their wealthier counterparts, but this does not mean that these nations should be excluded from the conversation on global health security. They also risk serving as an epicenter for an outbreak while sometimes having less adequate laboratory biosafety measures and health infrastructure to contain it. Excluding low-income nations from the conversation creates health security voids. Instead, leading global governments should seek to not only include, but invest in the research programs contributed by low-income nations, who have a number of talented scientists and innovative perspectives, but lack the resources to project their voices sufficiently loudly on grander international platforms (Nature, April 2019). This form of science diplomacy would bring new scientists into the fold and, over time, the support and encouragement of their home nations. This approach, through scientific engagement, would open lines of communication that many nations would never consider possible to exist otherwise and would increase global biosecurity preparedness overall. The increased ability and effectiveness of communication between governments as a result of collaborative effort and investment in pandemic preparedness and response research could serve to strengthen diplomatic relationships between nations. As is often the case within biomedical and technology research, committees would be formed to determine best practices and realistic application of research efforts. If biosecurity prevention was invested in as previously outlined, the formation of committees and working groups, with members from all actively participating nations, would serve to establish a framework through which support and resources could be offered to any nation affected by an infectious disease outbreak, whether an act of bioterrorism or naturally occurring. The key distinction in this approach is that currently in the event of any major incident (bioterrorism, natural disasters, etc.) time is wasted during the critical acute period following the event and decisions are often made by individuals not intimately involved with the situation at hand. This oftentimes results in a delayed, inadequate response. The formation of a set of guidelines or a

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framework through which those nations, and their researchers who have been involved in the preparedness effort can effectively and timely deploy their developed resources would be paramount. Communication between governments must be fostered over time and cannot be expected to manifest simply in times of crisis. Through investment in international scientific research collaborations focused on global health security, governments can more effectively communicate and therefore increase overall global health security.

Strengths of NGO/IGO Collaboration According to the U.S. Department of State, there are 1.5 million NGOs in the United States (U.S. Department of State, n.d.). They are vital actors within any community but become even more important when a disaster happens. NGOs often play important logistical roles in outbreak response, shipping supplies and coordinating the delivery of medications. This was demonstrated during the Scowcroft Institute pandemic simulation when NGOs such as the Red Cross set up medical clinics and helped keep communities informed as the outbreak progressed. Communication with affected communities is essential because people are often misinformed about the facts of an outbreak or how they can protect themselves from infection. Despite these strengths, one of the limitations for NGOs is funding. Many NGOs and IGOs receive their funds through donations, making funding sometimes unpredictable. The lack of funding is where the private sector comes into play.

Role of the Private Sector The role of private companies in pandemic preparedness and response, though often overshadowed by that of the public sector, is necessary to quickly mitigate the impacts of a disease outbreak. The private sector already has much of the infrastructure needed for production and distribution of vaccines and other medical supplies. This offers governments the opportunity to capitalize on pre-existing resources in order to increase preparation and strengthen response capabilities. Public-private partnerships do not come without challenges, however, and these challenges must be addressed to increase private sector involvement. Developing a vaccine, for example, can cost several billion U.S. dollars (Dimasi et al., 2016) and the profit

margin for pharmaceutical companies in this field can be thin (Kieny & Girard, 2005). Vaccines can take 10 or more years to develop (Struck, 1996), which is longer than the period in which the vaccine would be the most useful in an ongoing outbreak. Adding that there is not a guaranteed market between outbreaks. These considerations deter many companies from taking the risks of diverting funding, resources, and personnel to vaccine development and production from their ongoing projects (Bipartisan Commission on Biodefense, 2015). Generally, private companies develop and produce products for a profit. It’s unlikely under normal circumstances for them to veer from this model and unrealistic to expect them to. As pointed out by Dr. Jean Lang, associate vice president of R&D for Sanofi Pasteur, the investment risk involved with development expenses and opportunity cost of other projects, coupled with a lack of visible return, poses a serious problem for the private sector (Oger & Austin, 2018). In the Scowcroft Institute pandemic simulation, for example, the group representing the Mexican government had trouble

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finding ways to encourage private companies to take on these risks without help from the government as it faced its own funding limitations. This market is even more scarce in the â&#x20AC;&#x2DC;peacefulâ&#x20AC;&#x2122; times between pandemics since there is no immediate demand for the research or products and no urgency to encourage taking on the risk and opportunity costs involved. Yet, this is exactly the time that can be best utilized for these purposes. The research and innovation canâ&#x20AC;&#x2122;t be put off until the next pandemic arrives. It must happen in the times of non-crisis.

currently unknown how fast CEPI and other researchers may be able to produce a vaccine for SARS-CoV-2, however, this outbreak demonstrates their ability to partner with entities like the WHO and respond.

Throughout the COVID-19 pandemic, social media has played different roles. It helps people connect with each other in a time of social distancing and allows governments and organizations to communicate with the public. Misinformation has also found a foothold on social media, including misinformation about unproven treatments for COVID-19, viral spread in community transmission, and concern over actions or policies that governmental or international health authorities have taken (Brennen, Simon, Howard, & Nielsen, 2020). One study showed that 59 percent of misinformation in the COVID-19 pandemic has occurred by the information being reconfigured in some fashion with a small proportion of misinformation being contrived (Brennen et al., 2020). In a separate study, participants were willing to knowingly share an inaccurate COVID-19 headline (Pennycook et al., 2020). This suggests that misinformation may be driven by attention seeking social media users (Pennycook et al., 2020).

Private organizations outside of a national government may have resources to respond in ways that governments cannot, which makes communication and collaboration between the private sector and governments particularly important during crises. There are different preparedness protocols that both private organizations and governments can develop in anticipation of a pandemic or other public health emergency. One such example is Executive Order 13527 by President Obama in 2009. A component within the Order was the directive to create a National United States Postal Service (USPS) Medical Countermeasures (MCM) model (U.S. Department of Health & Human Services, 2011). Through the MCM, in the event of a biological outbreak or attack, USPS can deliver medical countermeasures to residents, including vaccines and or therapeutics. Although USPS is a component of the U.S. federal government, it is an independent agency and has the resources to deliver MCMs to every resident in the U.S. Private companies also have the ability to respond in emergencies. The United Parcel Service (UPS) mobilized their resources across the United States to assist the COVID-19 response in multiple ways (UPS, 2020). In their press release on March 30, 2020, UPS outlined their collaboration efforts. UPS will be helping transport new FDA approved rapid response test kits to testing sites across the United States, medical devices to help support public safety, and to distribute personal protective equipment (PPE) (UPS, 2020).

Regarding the positive uses of social media, platforms like Facebook and Twitter have also been used by public health entities to disseminate accurate information. The WHO Director General, Tedros Adhanom Ghebreyesus, expressed support for Coalition for Epidemic Preparedness Innovations (CEPI), an organization created in 2017 to collaborate with global partners to develop vaccines for emerging diseases, for leveraging research to accelerate work on vaccines for COVID-19. CEPI designed a platform that allows them to take a novel pathogen to clinical trial in 16 weeks (CEPI, 2020). It is

Prior to the COVID-19 pandemic, UPS had already created a UPS Healthcare sub-branch within their organization. Similarly, other organizations can adapt protocols that may be tailored to their group to enhance preparedness measures. The American College of Occupational and Environmental Medicine (ACOEM) works with corporations, governments, universities and the military to give guidance for pandemic events (ACOEM, 2011). These organizations can communicate with ACOEM to ensure that their employees are prepared and communicate the preparedness plans with the public.

Communication Between the Private Sector and Government

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Corporations can tailor their websites, blogs, and social media posts to fit their stories for different stakeholders (Kim & Liu, 2012). Studies comparing past communication between corporations and government showed that governments were more likely to disseminate information that was directly in the public’s interest and transparency on pandemic preparedness (Kim & Liu, 2012). A limitation of those studies is that they generalize to the small number of corporations that were included in the review compared to the millions of corporations worldwide. Improving the accuracy of information that is spread online may allow for more successful public health interventions and less resistance to policies enacted by local, state, or federal governments. Pennycook and colleagues suggested a scalable accuracy nudge intervention. In this intervention, individuals are prompted to judge the accuracy of information prior to sharing it (Pennycook et al., 2020). This intervention could

be implemented on all social media platforms including those that are solely on smartphones like Snapchat. In addition, news outlets and social media organizations could pin links to reliable information on the pandemic including the Centers for Disease Control (CDC) and WHO sites.

Strengths of Private Sector Collaboration The global scale of many corporate operations gives them understanding and resources in locations throughout the world. Additionally, in comparison to NGOs or government agencies, the private sector typically has more financial resources to allocate to a response. Some companies make it part of their mission to have charitable programs, both nationally and internationally. HSBC Bank located in London, England and the Western Union Corporation located in the U.S., are two such examples in disaster responses. Both companies have money and resources to help communities focus on disasters and bridge gaps left in

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government and NGO responses. Another company, Zipline, builds drones that deliver products such as blood products. This philanthropic infrastructure helps contribute to global health security even in the time between pandemics. When a pandemic does occur, it facilitates part of the private sectorâ&#x20AC;&#x2122;s role in the response. The other facet of the private sector response occurs when companies pivot their typical operations to meet the more immediate needs of responders. Such examples are U.S. Ford and 3M, who have decided to work together to produce a new kind of powered airpurifying respirator while Ford helps 3M increase their production current respirator devices (Valdes-Dapena, 2020).

RECOMMENDATIONS 1) Emergency drills for better coordination and communication during a crisis. State, local, tribal, and territorial jurisdictions should conduct emergency drills, with pre- and post-evaluation reports to identify gaps in current procedures, areas for improvement, opportunities to incorporate suitable new communication technologies, and review current training standards. They should also assess their existing communication procedures during a crisis. There should be an established spokesperson or center of command to coordinate communication, a way to provide communication oversight, and coordination between

governance structures. The drills should encourage intraState, multi-State, and trans-jurisdictional partnerships with an emphasis on regional coordination to enhance preparedness for incidents that exceed traditional boundaries.

2) Transparency is necessary for effective response. During the Scowcroft Institute pandemic simulation, all nations continued to withhold information throughout the exercise. Withholding information, particularly as it pertains to morbidity and mortality numbers, transmission, and other essential biological information, makes it impossible to mount a global response to a pandemic. Government entities must be transparent and knowledgeable about the availability of resources for disease containment.

3) Incentives should be implemented to encourage private companies to produce medical supplies in and for times of crisis. Providing incentives to increase production of medical supplies in the times between crises - when production would normally decrease due to lack of demand would increase the size of the national stockpile. The COVID-19 pandemic has shown that some manufacturing companies in other industries can switch production in order to fill the demand for medical supplies, such as automakers producing ventilators and face masks. Providing incentives to capable companies during crises would encourage voluntary shifts in production to essential medical supplies. Both the incentives between and during crises would alleviate some of the pressure on manufacturers and increase access to necessary medical supplies for healthcare workers.

4) Incentives should be provided in times between crises for biopharmaceutical companies to continue development and production of vaccines. Outbreaks can more effectively be fought through better preparation in addition to a strong response, but this can be difficult to do since the vaccine market decreases significantly in the time between outbreaks. This makes development and production less profitable, but that in-between time is critical to fighting diseases. Novel epidemics often wind down before a vaccine is

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developed, but epidemics can have multiple waves of outbreaks in the short and long term as well as become endemic. Providing incentives to biopharmaceutical companies to continue vaccine development and production in the times between crises would prepare the country to fight diseases over time and help to prevent future crises.

5) The distributions systems already in place within the private sector should be capitalized upon, and funding should be allocated to incentivize companies to participate. Private companies like UPS should be considered as potential partners for distribution of medical supplies and vaccines. It has already been shown that these companies can deliver items quickly and effectively to locations all over the world. The infrastructure is already established and could be easily taken advantage of in

times of disease outbreaks. Drone deliveries, as can be seen with Amazon’s recent service, to reach isolated and highly infected regions should also be considered.

6) Build on the business roundtable model by expanding it to include annual roundtables on pandemic preparedness where corporations and government entities will be at the same table discussing protocols. Roundtables would allow companies to collaborate on preparedness plans and policies, as well as update on new technologies and surveillance tools. During the current COVID-19 pandemic, as of this writing, one USPS worker in Washington State has contracted COVID-19. It is believed that they contracted the disease through fomites in the mail sorting room (Mazhukhina, 2020). This incident demonstrates the importance of establishing guidelines prior to a disease outbreak.

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Lessons in Pandemic Response: Student Perspectives

SECTION TWO: FUNDING RESPONSE EFFORTS Surveillance is essential to detecting the emergence of infectious diseases that have the potential to cause significant harm to global health. Ideally, countries should have surveillance programs in place even when there is not an imminent threat of pandemic, in order to track circulating diseases and make eventual response efforts more effective. The traditional method of disease surveillance is done through laboratory-based methods and can be costly and difficult to use on a large scale, however research towards using electronic medical records as a large-scale surveillance tool is progressing. For a surveillance tool to be effective, it must have sufficient granularity to show disease patterns on a local scale, so that preventive and response measures can be tailored to the local outbreak. The CDC has the National Notifiable Diseases Surveillance System (NNDSS), which monitors diseases relevant to public health in order to prevent outbreaks. This system is supported by the CDC

Division of Health Informatics and Surveillance (DHIS), which also supports local, state, and territorial public health departments as they gather data about infectious diseases for NNDSS.

Funding Detection Efforts Once precautionary procedures have been established, detection efforts need to be put in place to mitigate a global pandemic. Unfortunately, funding for such efforts is often neglected and lack of a streamlined donation process can limit the amount of funding that goes towards pandemic preparedness and response. According to Jain (2019), overhead costs for donors increase when donations are uncoordinated. Streamlining the donation process is important for the effective allocation of funds to pandemic preparedness, and there is no area that could benefit more than that of pandemic detection.

Scowcroft Institute of International Affairs

from the Scowcroft Institute’s 2019 Pandemic Simulation

Testing as a method of disease detection can have farreaching consequences on disease outcome. Testing availability and accuracy is one of the biggest problems faced during a global pandemic, especially in countries with weak health care infrastructure. Compounding this problem is the decreasing funding available for public health infrastructure aid in low-income countries. A paper by Bogich et al. (2012) reported that the Organization for Economic Co-operation and Development (OECD) found that aid commitment for infectious disease control increased from 8 percent to 16 percent from 1990 and 2008; however, public health infrastructure aid has decreased from 11 percent to 5 percent in this same time period. This lack of funding contributes to the inability to detect diseases early, thus allowing them to gain a foothold in the community. Inadequate public health infrastructure also cannot implement necessary containment measures, allowing a disease with pandemic-potential to reach a pandemiclevel (Bogich et al., 2012). Stronger public health infrastructure could allow for more disease outbreaks to be detected rapidly and helps contain the spread of disease.

and social distancing with vaccines or antiviral drugs is more effective in disease control than using vaccines and antiviral drugs alone during pandemics, and thus must be considered in pandemic preparedness and response (Velasco et al., 2012). Social distancing in the form of school closures, was also shown to be effective when combined with either antiviral prophylaxis or vaccination for the general population or household contacts. This has proven to be a cost-effective measure for containing disease in all countries (Velasco et al., 2012). In a case report conducted about the SARS outbreak in Toronto in 2003, quarantine was found to be cost saving because it decreased direct and indirect medical costs (Gupta et al., 2004). One limitation is that most of the information with regards to the cost and benefits of different pandemic mitigation strategies comes from data obtained from higher-income countries (Jamison et al., 2018). This means that the effects of quarantine on lower income countries may be different than what is described for higher-income countries. However, it remains possible that quarantine would be a cost-effective measure in lower income countries also, especially as it relates to the mitigation of mortality.

Many diseases with pandemic potential mimic other endemic pathogens in areas where emerging diseases are common. Thus, accurate diagnostics are necessary for early disease detection. These important diagnostic measures are costly. (Jamison et al., 2018). The global diagnostics market for bacterial diseases is estimated to be worth $40-45 billion with the bulk concentrated in wealthy countries (Morel et al., 2016). There are few diagnostic markets that see more than $100 million in revenue and, as such, are more influenced by global markets than other parts of the healthcare system (Morel et al., 2016). Many diagnostic companies also rely on government funding to pay for scientific research (Morel et al., 2016), so cuts in government expenditure can have a direct effect on the quality and number of diagnostic tests produced. All of these issues influence the availability of diagnostic tests.

Funding Response Efforts

A combination of pharmaceutical and nonpharmaceutical interventions have proven most effective in influenza pandemic control (Velasco et al., 2012). Combining containment measures such as quarantine

Once appropriate detection measures are in place, the next step is to prepare materials and resources for defense against potential outbreaks. In order to mount an effective response, funding becomes critical. Currently, there are deficiencies in the mobilization and allocation of funds. Two main factors affect the probability for pandemic outbreak: the first is the rate of disease emergence and the second is the chance that those diseases increase virulence and evolve into more widespread outbreaks. Those two factors have both increased over the last several decades. Compared to the previous century, during which we saw three large pandemics, the 21st century has already experienced outbreaks of SARS, MERS, swine flu, avian flu, and the current COVID-19 pandemic. This marked increase in the rates of disease emergence and virulence in the 21st century is predicted to continue to increase due to international travel and trade, the need for rapid response is necessary to prevent widespread outbreak. As such, the necessity to develop a streamlined funding

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plan for response to outbreaks is of critical importance.

Mobilization of Funds

Establishing a Funding Framework The International Health Regulations (IHR) was formed underneath the World Health Organization in 2005 and includes 196 countries. It is a voluntary agreement made by countries to build their capacities to detect, assess, and report public health events. The goal is to allow countries around the world to detain infectious disease outbreaks more quickly.

United States The Department of Defense allocates a small part of its budget towards global health. It produces its budget request every two years through a process known as the Planning, Programming, Budgeting, and Execution (PPBE) system.

Asia In response to the IHR of 2005, the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED) reported: “Progress has been achieved in a number of areas: event-based surveillance (EBS) systems; rapid response teams (RRTs); the Field Epidemiology Training Programme (FETP); laboratory capacity for diagnosis of known and unknown pathogens, and

referral networks; public health emergency contingency plans for points of entry (POE); risk communication; National IHR Focal Point (NFP) capacities; animal– human health coordination; regional surveillance; and monitoring and evaluation (M&E)” (WHO, 2017). Previous work has estimated the economic loss that occurred as a result of each of the 20th-century pandemics as 0.7–4.8 percent of global gross domestic product (GDP) (Turbai & Saynisch, 2016). The speed of response and funding on the part of Western countries, such as the United States, lagged behind those of highly developed Asian countries such as Singapore and Taiwan in combating the recent COVID-19 outbreak. For many countries in Asia, quick mobilization of resources and funding was essential in their ability to flatten the curve. Moving forward, countries across the globe should initiate measures to allocate more funds towards global health and infectious disease prevention tactics.

Ensuring Equal Funding for All Citizens Although a globalized framework is required to establish overarching guidelines in the case of a pandemic outbreak, it is also necessary to recognize the socioeconomic differences among various countries and their ability to attain resources for the health of their citizens. The World Bank currently has the Pandemic Emergency Financing Facility (PEF) in place to supply funding to the poorest countries of the world in the case of transborder disease outbreak. The countries receive funding through both insurance and cash payments during the early stages of outbreak directly to their governments or front-line responder organizations such as UNICEF or WHO. Countries can apply for insurance and can still receive cash payments if they are not accepted (World Bank, 2017). The insurance premiums for the PEF have already been paid by donor countries, most notably Japan and Germany, for three years following the outbreak (World Bank, 2017).

Implementation of Funding Framework Although IHR has a set of recommendations, it has remained the responsibility of individual countries to implement and enforce the guidelines set in place by the WHO. Lack of implementation continues to be a

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from the Scowcroft Institute’s 2019 Pandemic Simulation

barrier to ensuring effective, proactive defense against disease outbreak. Unfortunately, according to the last Geneva convention, approximately one-third of countries fulfilled the recommendations suggested by the WHO for pandemic disease prevention. The lack of movement on part of member states may indicate their lack of prioritization of the next impending pandemic. The PEF has already demonstrated its effectiveness when it made its first distribution of $11.4 million in funds in 2018 to the Democratic Republic of the Congo to combat the Ebola outbreak. The approval of the grant occurred only one day after the DRC formulated a response plan of its own, and the speed of this type of mobilization and allocation is highly desirable in volatile situations. Because the PEF is available in both cash as well as insurance handouts, the cash component could immediately be distributed to the country as needed. Other countries should aim to mimic this type of speed and flexibility moving forward in pandemic relief efforts. Of course, the other socioeconomic components that are affected by the pandemic still need to be addressed.

Allocation of Funds After funding has been approved and mobilized, it is necessary to establish a protocol for appropriate allocation. Allocating funds presents an additional issue for pandemic response efforts. Even after funding is secured, insufficient budgeting and unorganized disbursement can pose further complications. As seen with the ongoing HIV/AIDS pandemic, many countries still lack the appropriate infrastructure and financial resources necessary to build effective budgets and strategically plan resource allocation (Forsythe & Semini, 2019). This threatens the efficiency, accountability, and efficacy of aid disbursement

Barriers to Allocation In the case of many outbreaks, increase in donor agencies adds to chaos rather than organization. While donations play a significant role in pandemic response, large influxes of funding combined with ineffective methods of disbursement often create fragmentation in response agencies (Congressional Research Service, 2013). Many agencies rely on mathematical modeling to strategically plan and distribute aid, as mathematical

models are a valuable metric to estimate cost burdens of disease (Heesterbeek et al., 2015). However, models have several limitations and can often splinter allocation. The nature of a disease outbreak is both dynamic and nonlinear in character. Accurate information and rapid updates are necessary to build real-time models for an outbreak. The 2014-2015 Ebola outbreak showed how reliant models are on updated information. A lack of timely data can skew predictions and subvert appropriate responses. Additionally, emergence of novel human pathogens and zoonoses cannot be predicted with models and simple extrapolation from prior outbreaks is ineffective (Heesterbeek et al., 2015). Even for known pathogens, every disease requires different response methods, has different research needs, and receives different levels of media attention that models often fail to characterize (Jain, 2019). International organizations like the World Bank’s Pandemic Emergency Financing Facility and UNICEF provide substantial funding for low- and middle-income nations, especially for pandemic response. These funds aid in the direct response and control of disease outbreaks. Similar organizations, like Gavi, organize funding for vaccine development and dispersal for both prevention and control of outbreaks in impoverished

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countries (Gavi, 2020). However, economic repair of these nations, during and post-pandemic, is neither prioritized nor guaranteed by such organizations (World Bank, 2020). Economic instability, especially as a result of a pandemic, is difficult to remedy when it is not prioritized in global funding. Increase in antimicrobial resistance, trade, and travel facilitate disease emergence and global spread. Participation from every country is necessary to assemble task forces and allocate resources toward pandemic preparedness and response. Additionally, there must be a metric for estimating the funding needs of various diseases - one that has global access capabilities. Though sources of donor funding and collaboration with pandemic response agencies, like the World Bank’s PEF and WHO’s R&D Blueprint have appeared in recent years, there is still much work to be done.

RECOMMENDATIONS 1) Consolidate global funding for pandemic response. During the Scowcroft Institute simulation, the Mexican government had difficulty controlling the spread of disease and recovering economically because it did not have access to the same resources as the other two G7 nations. Aid allocation and disbursement from WHO and other multinational and nongovernmental organizations

was logistically challenging. Lack of preparation for the simulated outbreak led to inconsistent and inefficient allocation of funds. Consolidating global emergency funding for pandemic response and giving a multinational organization like WHO authority to plan and oversee allocation will improve organization and productivity. Although not a law-making organization, WHO is the global leader in pandemic response and has access to first-hand disease surveillance and response strategy. Consolidating global funding to a central location and placing WHO in charge will increase efficiency of aid disbursement and efficacy.

2) Develop a set of core capacities in each country’s healthcare system. The current organizational methods that are in place compartmentalize the various sectors of healthcare, which require time and participation of various departments in order to approve and enact change. In order to optimize the speed and efficiency of response efforts we recommend that areas within the public health, clinical care, and research sectors are merged into a single initiative. This way, the requirements and implementation for pandemic relief can be established at the federal and state levels. Using the R&D Blueprint established by WHO as a guide, we can customize pandemic response based on the characteristics of each infectious disease and distribute funding appropriately.

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AUTHORS

Adriel Arguelles

Elena Crouch

Texas A&M University

Uniformed Services University of the Health Sciences

Alyssa McNulty Texas A&M University

Jazmin Shawell

Amanda Day

Uniformed Services University of the Health Sciences

Texas A&M University

Angelica Allegro

Romyssa Hashim Texas A&M University

Texas A&M University

Breda Jenkins Uniformed Services University of the Health Sciences

Crystal Burrus Texas A&M University

Danyale Kellogg Texas A&M University

DJ Bradshaw

*All authors contributed equally to this white paper

About “Science & Policy” “Science & Policy” is a class funded through the Tier One Program by the Office of the President at Texas A&M University. It’s an interdisciplinary graduate level course designed to bring together Masters and PhD students from the social sciences and sciences from across the university. Students are challenged to work together over the course of the semester on a research topic within the scope of the course.

Uniformed Services University of the Health Sciences

The George H.W. Bush Presidential Library & Museum and The Bush School of Government & Public Service at Texas A&M University, College Station, Texas, USA

Tier One Program “Science & Policy” Class White Paper • 2020

Lessons in Pandemic Response: Student Perspectives

In Memoriam Lieutenant General

Brent Scowcroft (March 19, 1925 - August 6, 2020)

President George H.W. Bush & Lt. Gen. Brent Scowcroft “We live in an era of tremendous global change. Policy makers will confront unfamiliar challenges, new opportunities, and difficult choices in the years ahead. I look forward to the Scowcroft Institute supporting policy-relevant research that will contribute to our understanding of these changes, illuminating their implications for our national interest, and fostering lively exchanges about how the United States can help shape a world that best serves our interests and reflects our values.”

— Lt. Gen. Brent Scowcroft, USAF (Ret.)

Scowcroft Institute of International Affairs

from the Scowcroft Institute’s 2019 Pandemic Simulation

Tier One Program “Science & Policy” Class White Paper • 2020