Improving Pandemic Preparedness: Lessons From COVID-19

The United States and the world were caught unprepared by the COVID-19 pandemic despite decades of warnings of the threat of global pandemics and years of international planning. The failure to adequately fund and execute these plans has exacted a heavy human and economic price. Hundreds of thousands of lives have already been lost, and the global economy is in the midst of a painful contraction. The crisis—the greatest international public health emergency in more than a century—is not over. It is not too early, however, to begin distilling lessons from this painful experience so that the United States and the world are better positioned to cope with potential future waves of the current pandemic and to avoid disaster when the next one strikes, which it surely will.

This CFR-sponsored Independent Task Force report seeks to do just that, framing pandemic disease as a stark threat to global and national security that neither the United States nor the world can afford to ignore again. It argues that future pandemic threats are inevitable and possibly imminent; policymakers should prepare for them and identify what has gone wrong in the U.S. and multilateral response. One of the most important lessons of this pandemic is that preparation and early execution are essential for detecting, containing, and rapidly responding to and mitigating the spread of potentially dangerous emerging infectious diseases. As harmful as this coronavirus has been, a novel influenza could be even worse, transmitting even more easily, killing millions more people, and doing even more damage to societies and economies alike.

This Task Force proposes a robust strategy consisting of critical institutional reforms and policy innovations to help the United States and the world perform better. Although there is no substitute for effective political leadership, The recommendations proposed here would if implemented place the nation and the world on a firmer footing to confront humanity’s next microbial foe.

The Task Force presents its findings grouped into three sections: the inevitability of pandemics and the logic of preparedness; an assessment of the global response to COVID-19, including the performance of the World Health Organization (WHO), multilateral forums, and the main international legal agreement governing pandemic disease; and the performance of the United States, while also drawing lessons from other countries, including several whose outcomes contrast favorably with the U.S. experience.

Preparation can mitigate the effects of pandemics.

Pandemics are not random events. Outbreaks of well-known infections and new diseases occur regularly. These outbreaks can spread easily on this interconnected planet and impose significant human and economic costs, making preparedness imperative. Since the 1990s, successive U.S. administrations, as well as other governments and international organizations, have acknowledged this reality. In the United States, this recognition has been reflected in multiple national security strategies and intelligence assessments, blue-ribbon commissions, and simulation exercises that anticipated many of the challenges the world encountered in 2020.

• The Task Force finds that U.S. and global efforts to prepare for the inevitability of pandemics provided the illusion—but not the reality—of preparedness. Despite a succession of previous global public health emergencies, the United States and other governments failed to invest adequately in prevention, detection, and response capabilities to protect the populations most vulnerable to infectious disease outbreaks, or to fulfill their multilateral obligations to international organizations and to one another. The COVID-19 pandemic laid bare these failures in global and U.S. domestic preparedness and implementation, exposing important lessons that had not been learned, critical initiatives left unfunded, and solemn obligations that had not been met.
• The Task Force finds that early action and investment in preparedness have mattered in this pandemic. In the early stages, a diverse group of nations was prepared to respond rapidly and aggressively to COVID-19 with public health fundamentals, including testing, contact tracing, isolating, and clear, science-based risk communication to the public. Others, including the United States, were not.

Multiple obstacles thwarted an effective multilateral response.

• The pandemic revealed troubling shortcomings in multilateral arrangements for global health security, including a lack of coordination across nations and a breakdown of compliance with established norms and international agreements, notably the International Health Regulations (IHR), the main international agreement governing dangerous disease events.
• The Task Force finds that primary responsibility for these weaknesses can be laid at the feet of national governments, which remain torn between their desire for effective global health governance and their resistance to expanding the authorities, funding, and capacities of WHO and other international agencies. Rising geopolitical competition—particularly between the United States and China—further frustrated multilateral cooperation at the Group of Twenty (G20), the Group of Seven (G7), and the UN Security Council.
• The Task Force assesses China’s compliance with its reporting and information-sharing obligations under IHR as at best flawed, particularly in the early days of the outbreak, when transparency was most important. As in other recent outbreaks, WHO prioritized solidarity in its international crisis response, proving hesitant to criticize China publicly over these flaws and to declare a public health emergency of international concern (PHEIC) over China’s objections.
• The Task Force finds that WHO has the mandate and expertise to lead global epidemic and pandemic response, but that it is beleaguered, overstretched, and underfunded. WHO prompted China to notify the world of the outbreak of the SARS-CoV-2 virus and has successfully supported international coordination of many technical aspects of the COVID-19 challenge, particularly in low-income nations. Yet WHO also cannot ensure that many member states comply with IHR obligations and fails to constructively coordinate with the private sector. The WHO Emergencies Program is under-resourced and lacks surge capacity. The COVID-19 experience confirms that WHO has an important leadership role in the health aspects of public health emergencies but lacks the geopolitical heft to address the broader diplomatic, economic, and security implications of pandemics. The U.S. decision to pull out of WHO, if it occurs as scheduled in July 2021, threatens to make the agency’s leadership role even more precarious and the United States even more vulnerable to future pandemics.

The U.S. performance in this pandemic was deeply flawed.

• The Task Force assesses the U.S. performance during the COVID-19 pandemic as deeply flawed. The United States has declared pandemics to be a national security threat but has not acted or organized itself accordingly. The federal government lacks a strong focal point and expertise at the White House for ensuring pandemic readiness and coordinating an effective response. Despite intelligence and public health warnings of an imminent pandemic, the United States did not act quickly enough in mobilizing a coherent nationwide response, wasting precious weeks that could otherwise have been used to implement a nationwide strategy and capacity for testing and contact tracing to identify new infections and reduce their spread. These failures had grievous economic and health consequences, forcing states, localities, and employers to resort to blunt interventions, including imposing severe limits on human movement and shuttering businesses and public places. Without clear federal guidance, many states relaxed these public health measures prematurely, resulting in new spikes.
• The Task Force finds that the United States compounded these early mistakes with other unforced errors on public health risk communication. Elected U.S. officials, including President Donald J. Trump himself, often fell short as communicators, failing to offer the American people clear, reliable, and science-based information about the risk of infection; to adequately defend public health officials against harassment and personal attacks; and to release timely guidance on the utility of the public health measures implemented to combat the spread of the disease.
• The pandemic also exposed the nation’s inadequate investment in state and local health systems, many of which were quickly overwhelmed. The failure to maintain an adequate Strategic National Stockpile (SNS)—and to clarify the rules governing its use—led to shortages of essential medical supplies and competition among states over scarce medical equipment. More generally, COVID-19 revealed tremendous confusion over the respective responsibilities of federal, state, local, and tribal governments, resulting in blame-shifting and an incoherent U.S. approach to this public health emergency.
• The COVID-19 pandemic has also revealed the lack of coordination in U.S. and global pandemic preparedness and response in three areas. It has illustrated the risks of overdependence on a single nation, such as China, for essential medicines and medical equipment in a global pandemic. It has exposed the lack of a multilateral mechanism to encourage the joint development and globally equitable distribution of lifesaving vaccines, therapeutics, and diagnostics. Finally, it has revealed the limitations of existing national and global systems of epidemic threat surveillance and assessment, which left public health officials and researchers without access to timely data.

The coronavirus pandemic has spread to nearly every nation, caused a global economic recession, and, as of August 31, 2020, killed more than 850,000 people worldwide. As harmful as COVID-19 has been, a future pandemic of novel influenza could be even more catastrophic, killing millions more people and destabilizing governments and economies alike. To prevent that possibility, the United States and other nations need to learn from their recent, costly mistakes.

This Task Force organizes its recommendations into four sections. We first outline a comprehensive and coordinated strategy and propose new infrastructure and investments to advance pandemic preparedness in the United States and abroad. We then organize the remaining recommendations for responding to the hard lessons learned in this pandemic according to the three fundamental elements of pandemic preparedness: prevention, detection, and response.

Treat pandemic preparedness as a serious national and global security threat—and invest accordingly.

• The United States should finally treat pandemics as a serious national security and economic threat by translating its rhetoric into concrete action. The Task Force recommends that the president designate a White House senior official as a focal point for global health, including for pandemic preparedness and response. The secretary of state should designate an ambassador-level official to help coordinate the U.S. diplomatic response to international public health emergencies, in support of the Department of Health and Human Services (HHS), including through U.S. chiefs of mission abroad. The U.S. government should also initiate a review of the responsibilities for pandemic preparedness and response among public health authorities at the federal, state, local, and tribal level, so that U.S. federalism is an asset rather than a liability to achieving U.S. health security.
• In parallel with these domestic reforms, the Task Force recommends that the United States revamp its current approach to pandemic preparedness and response internationally. To start, the United States should remain a member of WHO, working with other nations to strengthen it from within. The UN agency is not a perfect institution, but no multilateral substitute exists to advance U.S. interests in the current pandemic or the next one. The United States should collaborate with other member states to ensure adequate, dedicated funding for WHO’s Health Emergencies Program.
• To coordinate diplomatic, economic, and security responses to future pandemics and additional waves of the current one, the Task Force recommends that the United Nations establish a permanent global health security coordinator. This UN coordinator, reporting directly to the UN secretary-general, should be charged with leading a coherent response to global health threats across the UN system, supporting any activity by the Security Council in pandemic response, and maintaining direct links to the leadership of the International Monetary Fund (IMF), World Bank, World Trade Organization (WTO), and other relevant multilateral forums, such as the G20 and G7. WHO should maintain its lead role in mobilizing UN and international collaboration on the health-related aspects of pandemic emergencies.
• UN infrastructure alone will not resolve the geopolitical gridlock that has undermined effective pandemic preparedness and response, nor will it help mobilize more private-sector participation. Accordingly, this Task Force recommends that the United States spearhead the establishment of a Global Health Security Coordination Committee to better mobilize and harmonize broader multilateral economic and emergency responses to pandemic threats. Such a flexible coalition, based on a core of like-minded states but open to critical input from civil society and private-sector actors, would allow national ministers to focus on practical matters, such as coordinating trade policies on essential medical supplies; removing barriers to scientific and technical collaboration; increasing equitable access to vaccines, diagnostics, and therapeutics; and working with international financial institutions to assist hard-hit countries and to help incentivize countries to invest in future pandemic preparedness. A senior WHO representative and the UN special coordinator should serve as technical advisors to the committee.
• The Task Force calls on the executive branch to request and Congress to appropriate funds for a comprehensive health security budget that is commensurate with the pandemic threats the United States faces and that reflects the professional judgment of U.S. public health officials. This federal funding should include increased money for global and domestic epidemiological threat surveillance and assessment, pandemic preparedness at state and local hospitals, the SNS, assistance for vulnerable countries around the world, and pandemic response capabilities of WHO and other essential multilateral agencies, and it should exempt critical budget line items from any future budget caps and sequesters.
• The Task Force further recommends that Congress appoint an independent commission to review the Centers for Disease Control and Prevention’s (CDC) record during the initial months of the pandemic, identify obstacles to the CDC’s effectiveness, and consider how it could do better in the future, including on surveillance, data transparency, and capacity to scale up nationwide testing and tracing.

Adopt strategies for better prevention.

• The leading metrics of pandemic preparedness have not been good predictors of performance during the current pandemic, and many countries were not ready to implement the capacities they had. It is often said that what gets measured gets done, but the opposite is also true. Countries need to understand where their preparedness gaps are in order to rectify them to better prevent future outbreaks from evolving into pandemics. The Task Force recommends that the United States work with WHO, the Africa CDC, and other international partners to revamp national preparedness capacity assessments and pair them with strategies to promote readiness and implementation. The objective should be to generate community mitigation guidelines and pandemic response triggers so that national and local policymakers have a roadmap for early, targeted, and coordinated implementation of surveillance, nonpharmaceutical interventions, and measures to reinforce medical and public health capacities.
• This pandemic has exposed the failure of the United States to invest adequately in the public health of the U.S. population or to provide sufficient protections to marginalized, at-risk, and underserved groups to prevent outbreaks from accelerating into epidemics. The Task Force recommends that the United States adopt a national policy establishing and enforcing pandemic readiness standards for hospitals and health systems and ensuring that these institutions respect and promote health equity. The CDC, in collaboration with states and localities, should make it standard practice to collect and share data on the vulnerability of specific populations, most notably Black Americans, Native Americans, Latinx Americans, low-income families, and the elderly, to pandemic disease. The U.S. federal, state, and local governments should craft strategies, programs, budgets, and plans for targeted public health investments that increase the resilience of these communities, as well as nursing home residents and essential workers. The Task Force considers this a matter of both social justice and global and U.S. health security.

Improve detection of epidemic threats.

• COVID-19 has revealed the downsides of relying on a weak IHR system that does not motivate governments to promptly report and share timely, relevant information about public health risks. The Task Force recommends that WHO member states establish an IHR review conference to discuss how to improve member states’ compliance with IHR, increase information sharing and transparency, and enhance the competence and consistency of WHO’s Emergency Committee when advising on the declaration of PHEICs.
• The current pandemic also demonstrates the inherent vulnerability of an international system of pandemic detection that relies so heavily on the transparency, judgment, and discretion of individual national governments. The Task Force thus recommends that the United States work with other governments and civil society partners to build and integrate national and global epidemic surveillance systems. This voluntary, international sentinel surveillance network should incentivize health-care facilities around the world to regularly share hospitalization data, using anonymized patient information, to improve the availability and reliability of early epidemic threat surveillance and to enable rapid identification, characterization, and tracking of emerging infectious diseases. This data should feed into an integrated global disease surveillance data and assessment platform, created under the auspices of the Health Security Coordination Committee. It should share the results of its assessments with participating government agencies and relevant nongovernmental organizations and raise the alarm over any unusual trends with the UN coordinator, WHO, and the general public. Within the United States, the CDC is the logical home for such a consolidated epidemic threat surveillance and forecasting office.

Strengthen U.S. and global pandemic response.

• No factor undercut the early U.S. response to COVID-19 more than the lack of a comprehensive, nationwide strategy and capability for testing, tracing, and isolation. To avoid a reoccurrence of those failures in future pandemics, the Task Force recommends that the United States immediately develop and adequately fund a coherent national strategy and capability to support testing and contact tracing by states and localities, following CDC guidance, that can be rapidly scaled up in any public health emergency, including by leveraging the latest digital technologies, incentivizing research and development of diagnostics such as low-cost rapid tests, and training tens of thousands of contact tracers.
• The United States cannot afford to have public health messages muddled or discounted because they are couched in partisan messaging that seeks to downplay or exaggerate the dangers the country faces or the precautions needed to address these threats. The Task Force calls on all U.S. public officials to accept, as a critical dimension of successful pandemic preparedness and a fundamental obligation of their positions, the responsibility of communicating with the American people in a clear, transparent, and science-based manner. This should include increased reliance on public health experts—including from the CDC, HHS, National Institutes of Health, Food and Drug Administration (FDA), and other technical agencies—to provide briefings and timely guidance to the American people.
• To ensure that the nation possesses sufficient quantities of essential medicines and equipment in an urgent public health emergency (whether a pandemic or bioterror event), the executive branch and Congress should work together to ensure that the Strategic National Stockpile is appropriately resourced and stocked for future pandemics, and that there is no confusion between federal and state governments as to its purpose. In an extended pandemic crisis, the SNS system should be prepared to act as a central purchasing agent on behalf of state governments.
• In parallel with this step, the United States should use incentives to diversify its global supply chains of critical medical supplies and protective equipment for resilience and reliability, without unduly distorting international trade and running afoul of WTO commitments. This approach could include pursuing emergency sharing arrangements among close U.S. partners and allies and strengthening multilateral regulatory cooperation among major producer nations to ensure common standards and quality control, especially during emergencies. The FDA should produce regular updates on supply chain vulnerabilities.
• Finally, the Task Force urges the United States to support multilateral mechanisms to develop, manufacture, allocate, and deliver COVID-19 vaccines, therapeutics, and diagnostics in a globally fair manner consistent with public health needs. Absent such global coordination, countries have been bidding against one another, driving up the price of vaccines and related materials. The resulting arms race threatens to prolong the pandemic, generate resentment against vaccine-hoarding nations, and undermine U.S. economic, diplomatic, and strategic interests. The Task Force recommends that the United States work with political leaders from countries representing the majority of global vaccine-manufacturing capacity to support the Coalition for Epidemic Preparedness Innovations (CEPI); Gavi, the Vaccine Alliance; and WHO in developing a globally fair allocation system that can be expanded for potential use in future pandemics.

The only certain thing is that when this pandemic is brought under control, another will eventually take its place. Pandemic threats are inevitable, but the systemic U.S. and global policy failures that have accompanied the spread of this coronavirus were not. This report is intended to ensure that in future waves of the current pandemic and when the next pandemic threat occurs, the United States and the world are better prepared to avoid at least some of the missteps that have cost humanity so dearly. Although the recommendations in this report stand on their own, the Task Force stresses that the national and international dimensions of the pandemic challenges are mutually reinforcing, above all when it comes to the role of the United States. If the COVID-19 pandemic has revealed anything, it is that strong and sustained U.S. global leadership remains essential.