There is a drive under way to change the priorities of the Atlanta-based Centers for Disease Control and Prevention (CDC) to what has until now been unthinkable: a possible nuclear strike is to be raised in a briefing to be given by Dan Sosin, CDC deputy director and chief medical officer in the Office of Public Health Preparedness and Response, on the work the federal, state and local governments in the US are doing for such an eventuality.
The CDC has a public responsibility to deal with all looming health security risks, and the alarming exchanges between North Korea’s Kim Jong-un and US President Donald Trump have accelerated the centre’s focus on the nuclear and radiological domains. "While a nuclear detonation is unlikely … it would have devastating results and there would be limited time to take critical protection steps," the CDC notice read.
The briefing will presumably reveal what the "critical protection steps" would be. The assumption has always been that a limited nuclear war cannot, by its nature, be contained and will inevitably become a global holocaust against which no meaningful protection is possible. On this issue the CDC is expert, so let us hear them out.
Whatever it says, be sure to know that in this and other measures the Trump administration seeks to vacate its global health leadership role and reduce all of its effort to a self-defeating nationalism by taking on merely a defensive posture, as evidenced by its budget proposals and the steady and certain preparations being made to place the US on a war footing.
The implications of these developments are breathtaking. The shift towards nationalistic defence is indicated by Trump’s budget proposals. Mick Mulvaney confirmed in May in the Foreign Service Journal that "the president is using the budget to redefine US foreign policy priorities, focusing on ‘hard power’ by boosting the military, while scaling back ‘soft power’ — a category that includes diplomacy, cultural exchanges and participation in international institutions."
Accordingly, the Trump administration proposed a 6%-9% increase in the hard-power areas of defence and homeland security (and veterans’ affairs) and a significant cut in funding for those departments responsible for advancing US interests abroad through diplomacy, principally the state department (-29%) and Health and Human Services or HHS (-18%) as well as the key agencies involved in supporting diplomacy – USAid and the CDC.
Health funds have always served diplomatic purposes, but this grew to an altogether different level when George W Bush started the President’s Malaria Initiative and, especially, the President’s Emergency Plan for Aids Relief (Pepfar). With $2bn a year to spend at their height, health programmes gained almost equal if not more weight than trade, governance and defence.
In 2014, when HHS secretary Kathleen Sibelius launched the Global Health Security Agenda with a special appropriation injection of $1bn (to be spent over five years), additional funds to deal with health catastrophes were brought into the global health mix, most of it to be used to help developing countries strengthen their capacity to prevent, detect and respond to pandemic disease outbreaks, which are increasing in incidence, severity and scale.
A new professional discipline called health diplomacy emerged. Traditionally, US ambassadors, like most everywhere, steered away from the more technical subjects in health and science
These developments turned the CDC, headquartered in Atlanta, into a truly global agency, with officials stationed in 60 countries worldwide, 2,000 technically trained health specialists employed and — unique internationally — six health science specialists with the rank of health attaches reporting directly to ambassadors stationed in Geneva, Beijing, Brasilia, Mexico, Pretoria and New Delhi.
These attaches advised on the expenditure of health funds at these centres.
A new professional discipline called health diplomacy emerged. Traditionally, US ambassadors, like most everywhere, steered away from the more technical subjects in health and science. But with anywhere between 60% and 85% of embassy bilateral assistance budgets — those located in developing countries — being health-related, the opportunity to forge stronger ties could not be missed.
With good projects to fund, especially in maternal and child health, CDC experts helped ambassadors to leverage additional funds from domestic governments, businesses and global agencies to support interventions, human skill capacity-building and innovative public-private delivery platforms. Embassy governance itself changed, with health-related work involving the CDC, USAid, labour, trade, defence and the Peace Corps becoming more coordinated.
It was CDC health experts who supported the health security assessments and national plans to remedy the weaknesses that were undertaken by the World Health Organisation and Joint External Evaluation alliance.
That the world now has metrics on the preparedness of more than 60 developing countries to deal with infectious disease, biological and radiological health risks and what to do about the weaknesses, amounts to an extraordinary asset in global health. Jimmy Kolker, a former assistant secretary for global affairs at HHS, recently told a Columbia University audience at a seminar organised under the auspices of the Global Health Security and Diplomacy programme that it was the CDC and USAid, the Pentagon and the US embassy in Monrovia that established reporting chains, provided staff security, force protection and specialised ebola training. HHS negotiated the right to practise medicine and prescribe drugs in Liberia, living arrangements for health staff, water supply, the definition of health workers for patient access and treatment protocols.
During the zika outbreak, it was HSS that sent scientists to work with their Brazilian counterparts to overcome barriers in sample sharing, cohort studies and institutional coherence. Kolker cited from his outstanding paper, HHS and Global Health in the Second Obama Administration (Centre for Strategic and International Studies, Washington DC, April 2017), that with Brazil, they developed a highly effective 14-point action plan "that stood the test of time" and of governments.
It is this capable machinery Trump wants to diminish. It is capable because key staff are subject matter experts — scientists — who support and enable generalist career diplomats, bringing two cultures together to take advantage of their complementary assets to fight disease outbreaks. To pull the CDC back from its global role and restrict its capabilities to only support national defence would leave the world, and the US, dangerously exposed.
Leading infectious disease specialist Michael Osterholm and documentary film maker Mark Olshaker recently warned in the New York Times that it was a matter of time before a pathogenic flu strain attacked us. To prevent an outbreak, they argue, requires major investment in developing a universal vaccine that, even with the money, will take time. The only fall-back we have is a capable CDC working with global partners to detect and isolate a novel outbreak.
"We will continue our partnership on critical health initiatives," Trump recently remarked as US Secretary of State Rex Tillerson praised the GHSA two weeks before the November 2017 Kampala Summit, saying that while tremendous progress was made, "considerable work remains. That is why the US advocates extending the GHSA until the year 2024".
They speak with forked tongues, but we shall nevertheless hold them to their word.
• James is a visiting professor in (nonclinical) paediatrics and international affairs at Columbia University and special adviser to the Working Group on Global Health Security and Diplomacy.
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