COVID shows US needs stronger legislation for effective public health agencies

The Biden administration and Congress have a lot on their plates related to the immediate response to the COVID-19 pandemic. Appointing and confirming strong and collaborative leaders and examining and fixing flaws in the current response system are among the most important actions to be taken. 

Like the reviews undertaken following the 9/11 terrorist attacks in 2001 and Hurricane Katrina in 2005 when systematic government breakdowns occurred, Congress must take stock and ensure we are better equipped to respond to the next crisis.  

As part of that, the legislative framework of the Pandemic and All-Hazards Preparedness Act deserves close review. PAHPA resulted from the disjointed, failed federal medical and public health response to Hurricane Katrina. This act, passed by a bipartisan congressional effort in 2006 and subsequently reauthorized twice, created two little-known but vitally important offices within the U.S. Department of Health and Human Services: the Assistant Secretary for Preparedness and Response and the Biomedical Advanced Research and Development Authority.  

ASPR’s mission is to coordinate the domestic federal public health and medical preparedness for, response to, and recovery from all disasters — natural and otherwise. It also oversees BARDA, whose mission is to work with private industry to rapidly develop medical countermeasures such as vaccines and medications needed to treat a wide variety of health security threats. ASPR also oversees several small but important medical readiness programs such the National Disaster Medical System, the Strategic National Stockpile and the Hospital Preparedness Program, which is the only federal investment in healthcare preparedness.  

ASPR had some quiet early successes in the COVID-19 response. It pushed the envelope on innovative approaches to overcome long-standing capability gaps and played a critical role in establishing and coordinating Operation Warp Speed. But in recent months, its role has also been questioned, overshadowed and criticized. 

There are many reasons why ASPR has not been able to live up to its full potential at coordinating the federal medical and public health response to this emergency. Conflicts between national plans and frameworks, interagency mission creep, political intervention, departmental in-fighting, disregard for the PAHPA framework and insufficient funding over the last decade all contributed to this outcome. A recent Inspector General report also raised concerning questions about allocation of funds dating back to 2010.  These issues all need assessment and potential reform.

In the immediate fog of COVID-19, there may be a sense that ASPR was a failed experiment and its responsibilities and programs should be scaled back, spread across other federal agencies or eliminated altogether. We strongly recommend against that knee-jerk reaction. Our collective experience tells us that a strong legislative framework and ASPR are needed now more than ever.

There are three specific areas for improvement. First, ASPR needs to strengthen its connections with state governments. Like FEMA, ASPR must have greater resources to dedicate to establishing meaningful interactions with its counterparts at the state level. Full-time ASPR personnel must be located within each state to better understand their resource needs and preparedness gaps. A broader clinical response force should also be established and funded to create a “medical national guard,” which functions like the military’s national guard and provides similar benefits.  

Second, roles and responsibilities within HHS for preparedness and response must be clarified. We believe the ASPR position should be elevated to the equivalent of a military four-star flag officer held by a uniformed public health service official. Further, the secretary must be held accountable for resolving interdepartmental friction.  

Third, to keep up with current and future health security threats, ASPR should set an ambitious goal of rapidly developing drugs, vaccines and diagnostics in just months. To meet this goal, BARDA must leverage lessons learned from its role in Operation Warp Speed, invest in innovative technologies and harness game-changing science. ASPR also needs to have the tools to protect those investments and associated intellectual property from foreign bad actors.  

The Biden administration and the 117th Congress have a grave responsibility and great opportunity to fix the near term U.S. response to COVID-19 and ensure we are much better able to respond to the next health crisis. By selecting and supporting a strong leader and following the PAHPA framework, ASPR should play a critical role in both the immediate response, as well as the longer term preparedness for future crises.

Craig Vanderwagen, MD was the founding assistant secretary for Preparedness and Response from 2006 to 2009 and is now managing director with East West Protection, LLC. Kevin Yeskey, MD was the founding director of the Office of Preparedness and Emergency Operations in ASPR and most recently served as ASPR principal deputy assistant secretary in 2020; he is now senior advisor for Emergency Public Health with MDB, Inc. Jennifer B. Alton, MPP, previously worked for the Senate Committee on Health, Education, Labor and Pensions and drafted the Pandemic and All-Hazards Preparedness Act, she is now president of Pathway Policy Group and a center affiliate at the Georgetown University Center for Global Health Science and Security.