ABOUT THE REPORT

Recognizing the threat posed by old and new infectious 

diseases, this report examines U.S. policies in support of 

foreign capacity to control the spread of dangerous pathogens. 

It calls for expanding U.S. policies designed to strengthen 

surveillance and response capacity abroad as a frontline 

defense against a potential pandemic and as a peaceful and 

positive dimension of U.S. global health diplomacy.

William J. Long is professor and chair of the Sam Nunn School 

of International Affairs at the Georgia Institute of Technology 

and a Jennings Randolph Senior Fellow with the United States 

Institute of Peace. Jennifer Marsh provided research assistance 

in preparing this report.

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SPECIAL REPORT 244 JULY 2010

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William J. Long

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t The spread of old and new infectious diseases constitutes both a threat to U.S. and 

global security and peace and an opportunity for the United States to burnish its international image through strengthening foreign capacity in infectious disease surveillance and 

response. 

t Despite an increase in overall U.S. expenditures on global public health, U.S. policy is not 

fully meeting this challenge or capturing this opportunity. Little-known policies implemented by the Centers for Disease Control and Prevention, the United States Agency for 

International Development, and the Department of Defense offer cost-effective strategies 

that should be expanded under President Obama’s new Global Health Initiative to improve 

infectious disease control abroad as both a frontline defense against a potential pandemic 

and a peaceful and positive dimension of U.S. global health diplomacy.

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The spread of avian influenza virus and other naturally occurring or man-made biological 

threats poses grave security, economic, and humanitarian risks to U.S. and global interests. 

Dramatic increases in the worldwide movement of people, animals, and goods; growing 

population density; and uneven public health systems worldwide are the driving forces 

behind the heightened vulnerability to old and new infectious diseases. In addition to traditional threats, since the early 1980s scientists have identified dozens of new viruses, many 

of which are capable of global reach.1 With more than one million travelers flying across 

national boundaries every day, it is not an exaggeration to say that a health problem in any 

part of the world can rapidly become a health threat to many or all—what one author calls 

the “microbial unification” of the world.2

The outbreak of severe acute respiratory syndrome (SARS) in 2002–03 demonstrated how 

a largely unknown lethal virus could spread via modern air transport, traveling from Hong 

Kong to Toronto in fifteen hours and eventually reaching twenty-seven countries.3 The 

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CONTENTS

Rhetoric versus Reality in U.S. Policy 2

U.S. Government Programs 3

Recommendations 12
2

relatively benign H1N1 influenza outbreak of 2009 provided an early warning of the danger 

posed by a novel influenza virus against which most people have little or no protection. For 

example, since emerging in 1997, avian influenza virus—which to date has infected more 

than four hundred people and killed half of those infected—could, if it becomes capable 

of human-to-human transmission, as H1N1 influenza virus did, create a global pandemic of 

unprecedented lethality, including an estimated two hundred thousand to sixteen million 

U.S. deaths.4

Global economic and political stability could fall victim to a pandemic, too. Accelerating 

transnational flows, especially of pathogens, can stress and overwhelm a state’s capacity 

to meet its essential functions. Weak states could fail economically or politically, thereby 

creating regional instability and a breeding ground for terrorism or human rights violations. 

Statistical studies reveal that declining public health substantially increases the probability 

of state failure,5 and historical examples of the correlation between disease outbreak and 

political instability and violence extend from the fall of ancient Athens to recent violence 

in Zimbabwe that was fueled by a cholera outbreak.

Reducing the danger of influenza or other infectious diseases requires a focus on preparedness and monitoring. Rapid identification, information sharing, and a coordinated 

response are critical to limiting the threats from pathogens. Although the peril is great, so 

too is the opportunity to build cooperation through strengthening regional and worldwide 

disease surveillance, detection, reporting, and response capacity. Recently, subregional 

networks of cooperation in infectious disease control have sprung up in traditional zones 

of conflict and in resource-constrained regions of the world, including the Middle East, the 

Mekong Basin, East and Southern Africa, and the Balkans.6

Here is the positive potential of globalization: the deployment of health and information 

technology in disease surveillance and response and the sharing of best health practices 

across nations create an unprecedented opportunity for U.S. leadership that could deepen 

bilateral ties, foster regional cooperation and stability, and burnish the nation’s image globally. Simultaneously, such cooperative measures would help secure the health and welfare of 

U.S. citizens. A leader in both medical and information technology, the United States is well 

placed to encourage the strengthening of public health systems abroad as a peaceful and 

positive dimension of its global health diplomacy and as a first line of defense against the 

threat of infectious diseases, whose outbreaks typically begin in the developing world. 

U.S. policy does not go far enough to address the dearth of foreign capacity in infectious 

disease control, however. Although the U.S. government recognizes the importance of the 

threat and opportunity posed by infectious disease spread in its policy pronouncements, 

programs directed toward meeting this challenge are insufficiently funded. Little-known 

policies implemented by the U.S. Centers for Disease Control and Prevention (CDC), the U.S. 

Department of Defense (DoD), and the United States Agency for International Development 

(USAID) currently support infectious disease surveillance and response capacity abroad. 

These cost-effective programs should be expanded to better meet the challenge to U.S. 

interests and the opportunity for enhanced cooperation posed by the emergence and potential global spread of old and new infectious diseases.

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Rhetorically, protecting domestic and foreign populations from old and new infectious diseases has become a national priority. The need to develop foreign capabilities in infectious 

disease detection and response has repeatedly received explicit presidential endorsement. 

In 1996, President Clinton’s Decision Directive NSTC-7 “established a national policy to 

address the threat of emerging infectious diseases through improved domestic and internaThe views expressed in this report do not necessarily 

reflect the views of the United States Institute of Peace, 

which does not advocate specific policy positions.

To request permission to photocopy or reprint materials, 

e-mail: permissions@usip.org

ABOUT THE INSTITUTE

The United States Institute of Peace is an independent, 

nonpartisan institution established and funded by Congress. 

Its goals are to help prevent and resolve violent conflicts, 

promote post-conflict peacebuilding, and increase conflict 

management tools, capacity, and intellectual capital worldwide. The Institute does this by empowering others with 

knowledge, skills, and resources, as well as by its direct 

involvement in conflict zones around the globe.

BOARD OF DIRECTORS

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of Practice, The George Washington University, Washington, 

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Schlesinger Professor of Strategic Studies, School of Foreign 

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President, Leadership Conference on Civil Rights 

MEMBERS EX OFFICIO

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President, United States Institute of Peace (nonvoting) 


tional surveillance, prevention, and response measures.”7 In introducing the new national 

policy to the public, then vice president Al Gore underscored that the directive instructed 

the U.S. government, particularly the CDC, USAID, and the DoD, to work with other nations 

and international organizations to establish a global infectious disease surveillance and 

response system, based on regional hubs and linked by modern communications technologies.8 Shortly after taking office, President Obama reiterated this commitment in May 2009 

by announcing a new Global Health Initiative that would adopt an integrated approach to 

fighting the spread of infectious diseases while addressing other global health challenges. 

The president emphasized, “We cannot wall ourselves off from the world and hope for the 

best, nor ignore the public health challenges beyond our borders. An outbreak in Indonesia 

can reach Indiana within days, and public health crises abroad can cause widespread suffering, conflict, and economic contraction.”9 The National Security Council’s 2009 document, 

“Strategy for Countering Biological Threats,” reinforces the importance of strengthening foreign capacity in detecting and responding to infectious disease outbreaks, as this capacity 

is of equal importance in combating naturally occurring or man-made biological threats.10

Despite consensus on the importance of the issue and clear recognition that combating 

the threat of infectious diseases requires support for public health systems abroad, U.S. policies designed to bolster foreign capacity in infectious disease control have not kept pace 

with the United States’ burgeoning global public health expenditures in the past decade. 

During that period, U.S. funding for global health programs quintupled, from $1.7 billion 

in fiscal year (FY) 2001 to $8.8 billion in FY 2010. The president’s FY 2011 budget request 

anticipates another increase in funding to $9.6 billion.11 Nonetheless, core support for programs designed exclusively to strengthen international infectious disease surveillance and 

response remains less than $100 million annually, constituting about 1 percent of the total 

U.S. government global health expenditures.12

To understand in what ways U.S. policy is not fully meeting the challenge and opportunity posed by infectious disease spread, it is important to appreciate first what the United 

States is doing to support foreign capacity in infectious disease control. 

64(PWFSONFOU1SPHSBNT

Four programs shared by three federal departments explicitly aim to improve the infectious 

disease detection and response capabilities of other nations and regions:

t the Global Disease Detection Program, operated by the CDC;

t the Field Epidemiological and Laboratory Training Program, administered by the CDC with 

significant support from USAID;

t the Integrated Disease Surveillance and Response Program, funded primarily by USAID and 

administered through the CDC; and

t the Global Emerging Infections Surveillance and Response System of the U.S. DoD.

In addition to these four programs, USAID provides bilateral in-country support to public 

health programs in most of the more than one hundred countries in which it operates. This 

aid was estimated at $14 million in 2006.13

Global Disease Detection Program

Congress appropriated funds for the CDC to create the Global Disease Detection (GDD) 

program in 2004, shortly after the SARS epidemic. Recognizing that a weakness in the 

infectious disease surveillance system of any country potentially imperils U.S. and global 

interests, Congress directed the program to “protect the health of Americans and the 


global community by developing and strengthening public health capacity to rapidly 

detect and respond to emerging infectious diseases and bioterrorist threats.”14 The program draws on the CDC’s long-standing expertise in infectious disease detection and 

response to support overseas public health surveillance, provide training in laboratory 

methods, build investigatory and communications capacity, and enhance rapid response 

to emerging infectious diseases.

The CDC has established six GDD centers, one in each World Health Organization (WHO) 

region, to serve the needs of that country and neighboring states.15 Start-up activities at 

a seventh GDD regional center are under way. The CDC has aspirations to eventually establish eighteen GDD centers worldwide to serve as regional resources to detect, confirm, and 

respond to pathogen spread at the source. 

Funding for the program grew rapidly from $11.6 million at its inception in FY 2004 to 

$32.4 million in FY 2006, then held relatively steady at $31.4 million in FY 2008, $33.7 

million in 2009, and $37.8 million in 2010.16 Staffing for the program includes thirty-three 

CDC employees overseas, locally employed staff, and an oversight team in the CDC’s Atlanta 

headquarters.17 The CDC coordinates the work of the GDD centers with WHO. GDD regional 

centers also function as members of the WHO’s Global Outbreak Alert and Response Network 

during emergencies. The GDD program collaborates and supports the work of numerous NGOs 

and philanthropies working in this policy space. 

The CDC qualitatively and quantitatively monitors the outputs, outcomes, and, where 

possible, the overall impact of the GDD programs with respect to five key capacities: (1) 

outbreak response, (2) surveillance, (3) pathogen discovery, (4) training, and (5) networking. From 2006 through 2009, the CDC reported rapid responses to more than five hundred 

disease outbreaks and other serious public health emergencies, the detection of thirty-four 

new pathogens, public health training of more than 37,000 participants worldwide, and 

successful participation with the WHO as part of the international response to the 2009 

outbreak of H1N1 influenza.18

Field Epidemiological and Laboratory Training Program

The CDC’s Field Epidemiology Training Program (FETP) and Field Epidemiological and Laboratory Training Program (FELTP) are applied epidemiology education programs designed to 

help foreign countries develop, run, and sustain a robust public health infrastructure. The 

programs are established in cooperation with ministries of health around the world and in 

concert with national and international partners.19 The goal is to build host country epidemiological and laboratory capacity and thereby contribute to evidence-based public health 

decision making that will improve the host country’s overall health and safety policies. 

Started in 1980, the programs provide two years of applied training for public health 

leaders to strengthen disease surveillance and assessment skills and to improve health 

interventions. The FELTP program, as the name implies, includes a laboratory training component. Before initiating a program, the CDC requires a serious commitment from the recipient country, including material support, and expects that the recipient country will own 

the program and that the program eventually will become fully self-sustaining. Planning for 

the creation of an FETP or FELTP typically takes up to two years to ensure its initial success 

and to guarantee its long-term adoption and sustainability by the host nation. As one CDC 

official explained, “We go into the project with an exit strategy.”20 The cost to set up an 

FETP or FELTP program is estimated to be in the range of $1 million to $2 million, primarily 

to support an in-country resident adviser and pay for training and materials. 

FELTP and FETP trainees typically take courses in epidemiology, communication, economics, management, and methodology, and they spend most of their time in the field 

The CDC has aspirations to 

eventually establish eighteen 

GDD centers worldwide to 

serve as regional resources to 

detect, confirm, and respond to 

pathogen spread at the source. 


conducting epidemiological investigations and surveys, evaluating surveillance systems and 

prevention practices, and training other health workers. The CDC develops and delivers most 

of the curriculum and assigns an in-country adviser for four to six years to provide training 

and technical assistance.21 Directorship of the program remains the responsibility of the 

host nation, however. 

Over the course of the program, the CDC has supported thirty-one initiatives involving 

forty countries that have produced more than 1,500 graduates. In addition to the nineteen 

self-sustaining FETP programs and twelve ongoing programs involving twenty-three countries, twelve programs engaging seventeen countries are in development.22

Besides the continuation of country programs and their eventual graduation to selfsustainability, there are other measures of long-term impact. A 2007 internal analysis of six 

FETP programs established between 1999 and 2004, for example, revealed that 92 percent of 

the graduates continued to work in public health after graduation.23 With regard to assessment, the CDC has developed and is piloting a self-administered scorecard for FETP and FELTP 

programs to measure progress regarding their quality and sustainability.24

The core CDC budget for the program has been roughly steady since 2005, at approximately $3 million per year. Through leveraging its resources with transfers from other federal 

agencies and programs, particularly funds transferred from USAID and private donors, the 

CDC reported total program expenditures in FY 2010 approaching $25 million.25

Integrated Disease Surveillance and Response Program

The Integrated Disease Surveillance and Response (IDSR) program is a creation of the World 

Health Organization African Regional Office (WHO-AFRO) adopted by its member states 

in 1998 and supported by the CDC. The IDSR strategy focuses on developing surveillance 

systems, monitoring and evaluating those systems, and strengthening laboratory capabilities and workforce training. The emphasis is on a multilevel, multidisease surveillance and 

response system that integrates activities from the district level to the national level. The 

integrated approach strives to develop and maximize the potential of a resource-constrained 

country to promote public health, increase its ability to respond to emerging threats, and 

meet international standards for disease reporting and control. 

The CDC provides expertise in the design, development, implementation, monitoring, 

and evaluation of IDSR activities and tools for disease surveillance and laboratory confirmation. The CDC’s annual budget for the program is about $3 million. 

A participating country begins the implementation of an IDSR program with an assessment of the national surveillance system by a team of national and international experts. 

This team examines the current surveillance, laboratory confirmation, and epidemic preparedness and response activities at all levels of a country’s health system. The ministry 

of health then uses the assessment results to develop a plan of action for creating a fully 

functional IDSR system, including improvements at various levels of the national public 

health system.

The IDSR network grew rapidly from 2001 to 2005, with the number of countries having 

a developed IDSR plan of action increasing during that period from thirteen to forty-one, 

and the number of countries with an established national IDSR committee expanding from 

six to thirty-two.26 Recently, the program has slowed to incorporate new WHO requirements 

for disease detection and reporting. Turnover in personnel at several WHO-AFRO offices has 

also contributed to delays in the program.

The countries themselves are largely responsible for assessing and evaluating their 

respective programs. A WHO-AFRO task force, with input from the CDC and USAID, adopted 

IDSR core indicators in 2003. Participating countries utilize the IDSR core indicators to 

The emphasis is on a multilevel, 

multidisease surveillance and 

response system that integrates 

activities from the district level 

to the national level.


monitor and evaluate their own progress to ensure they maintain effective and functional 

IDSR systems.27

Global Emerging Infections Surveillance and Response System

The U.S. DoD has personnel deployed to at least 147 countries around the world and has a 

presence of more than two hundred personnel in at least twenty-one nations.28 Given this 

widespread dispersion of military forces, the DoD has long had in place systems designed 

to detect and respond to infectious diseases, as a way of maintaining force readiness and 

protecting its employees. In all, more than a dozen different DoD entities and their foreign 

military partners work together on infectious disease detection and control.

Connecting many of these programs and integrating overseas research laboratories 

and humanitarian assistance programs is the Global Emerging Infections Surveillance and 

Response System (GEIS). The DoD created GEIS in response to President Clinton’s Decision 

Directive NSTC-7 “to strengthen the prevention of, surveillance of, and response to infectious disease that (1) are a threat to military personnel and families, (2) reduce medical readiness, or (3) present a risk to U.S. security.”29 The GEIS increasingly interprets this mandate 

broadly to include encouragement of host country capacities in infectious disease control 

capability and compliance with WHO regulations. The GEIS works with various research and 

treatment facilities operated by the DoD to improve local ability to provide early detection of emerging infectious disease threats, share information in disease surveillance and 

research, and enhance response capabilities, with a particular focus on five categories of 

infectious diseases: respiratory disease (particularly influenza), gastroenteritis syndromes, 

febrile illnesses (such as dengue fever and malaria), antimicrobial resistance (a particular 

problem in tuberculosis), and sexually transmitted infections.30

In FY 2009, the DoD obligated approximately $12 million to core surveillance capacity 

building for the GEIS, up from $8 million in 2005. Separately, the GEIS received $40 million 

in supplemental funds as part of the government’s efforts targeted on pandemic and avian 

influenza. These funds help support research laboratories in Egypt, Indonesia, Kenya, Peru, 

and Thailand, as well as other military research units for surveillance projects located in seventy-eight countries.31 Many of these projects are conducted with host country nationals, 

often in the form of military-to-military cooperation, and include establishing or improving 

laboratories, training host country staff in surveillance techniques, and providing advanced 

diagnostic equipment.32 The labs themselves remain DoD assets and belong to particular 

branches of the armed services.

GEIS assessment and reporting on particular programs occurs quarterly and annually. As 

in civilian programs, developing metrics for overall effectiveness and impact is difficult in 

this area. Success in terms of disease prevention is hard to quantify, and country baselines 

by which to measure performance can be difficult to obtain. Regarding interagency coordination, a 2008 study by the United States Institute of Medicine encouraged GEIS to enhance 

its coordination and collaboration with its domestic counterparts, particularly the CDC, 

which operates in almost all the countries where DoD laboratories are located.33

Assessment of U.S. Policy 

As far as they go, there is little wrong and much that is right about U.S. programs in support 

of improving foreign capacity in infectious disease surveillance and response. The problem 

is that they do not go far enough. The failure to adequately engage the threat of infectious 

disease outbreaks at the source and to seize the potential opportunity for enduring international collaborations in public health is both a security lapse and a forgone opportunity for 

the effective exercise of U.S. influence.

More than a dozen different 

DoD entities and their foreign 

military partners work together 

on infectious disease detection 

and control.
7

This shortcoming reflects generic problems in U.S. global health policies, including the 

tendency of American global health policy to

t fund treatment for a few targeted diseases rather than strengthen public health systems 

generally to enable them to respond to existing and emerging challenges;

t focus overwhelmingly on treating the problem of infectious disease spread after it has 

reached U.S. shores;

t offer charity rather than make investments in host countries;

t deploy funding in response to the current interests of the donor community and focus on 

near-term impact rather than on recipient needs and sustainable, long-run effects; and 

t support related programs in various agencies without a formal mechanism for interagency 

coordination and collaboration.

Each of these problems, as applied to the issue of controlling infectious disease spread, is 

discussed below.

First, programmatic funding levels are insufficient to meet the threat of infectious disease spread and to capture the promise of improved diplomatic relations through strengthening overseas capacity. Despite a huge increase in U.S. global public health expenditures, 

funding for long-term programs that strengthen global capacity in infectious disease surveillance and response remains small and relatively stagnant, especially for civilian programs 

(figure 1). 

A decade ago, the Government Accountability Office (GAO), an independent assessment 

body of the U.S. Congress, noted the need to strengthen overseas laboratory capacity, 

improve disease surveillance, and prevent the spread of diseases in developing countries 

through greater support of programs like the GDD and the FELTP.34 Nonetheless, core budgets for foreign capacity building have not increased in real terms since 2006.35

The status of the GDD program illustrates the implications of underfunding. The GDD 

aspires to create eighteen linked regional or subregional centers for infectious disease control 

around the world—a network first called for in President Clinton’s 1996 directive. To date, 

however, that network is not in place, and only six centers are completed. To fully implement 

the program, GDD’s budget would need to increase approximately sixfold, to about $200 

million—still less than 2 percent of the U.S. global health budget. The U.S. government 

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Source: Kaiser Family Foundation, "The U.S. Global Health Initiative (GHI) Budget Analysis," December 2009

Funding for long-term programs 

that strengthen global capacity 

in infectious disease surveillance 

and response remains small and 

relatively stagnant, especially 

for civilian programs.

millions of 

dollars
8

should not wait until after an infectious disease disaster before filling in the gaps in this 

system (figure 2). 

In the context of U.S. global health expenditures generally, the core budgets of those 

programs designed to strengthen overseas capacity in infectious disease surveillance and 

response are miniscule. Rather than increasing core budgets to meet a critical, long-run 

need, the agencies and programs with primary responsibility in this crucial domain have 

been given a hunting license to capture funds from disease-specific programs via interagency transfers or to procure donations from international organizations or private philanthropies to meet their programmatic objectives. While these governmental programs have 

been effective and entrepreneurial in augmenting their budgets, an ad hoc, opportunistic 

funding model does not allow for systematic planning and expansion of programs to meet 

a stated national priority.

The increase in U.S. global public health funding has gone overwhelmingly to fighting 

a handful of diseases, and in particular to treating HIV/AIDS. Since the launch of President 

George W. Bush’s President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, more than 

70 percent of U.S. global health funds have been allocated to AIDS programs.36 The proposed 2011 budget would continue this trend, with nearly $7 billion of the proposed $9.6 

billion total going to PEPFAR.37 Not only does an overwhelming percentage of U.S. funding 

go toward treating one disease, during the first five years and $15 billion of the PEPFAR 

initiative, funds were earmarked for treatment largely in the form of antiretroviral drugs 

(55 percent), palliative care (20 percent), prevention (20 percent), and care of HIV/AIDS 

orphans and vulnerable populations (10 percent), leaving little to fund efforts designed to 

strengthen public health capacity in recipient countries.38

PEPFAR has been a powerful impetus for garnering U.S. support for global health programs generally, and the initiative is remarkable for its generosity and the number of lives 

it has saved and enhanced. Focusing on treating one disease, however, leaves other health 

problems unattended39 and neglects capacity building in core areas, such as epidemiology 

and laboratory capacity. Capacity building is critical to combating infectious disease and 

to making the entire health system robust and grounded in sound science and reliable 

data. PEPFAR’s own analysis of its first five years concludes that the program has largely 

ignored the issue of strategic strengthening of health systems in the countries in which 

it operates and has “had both positive and negative impacts on country-level health systems”; the report further notes that programs “did not fully translate to a broader service 

'JHVSF(%%(SPXUI.BUSJY

The increase in U.S. global 

public health funding has gone 

overwhelmingly to fighting a 

handful of diseases, and in 

particular to treating HIV/AIDS.

Increased Capacity

Increased Coverage

Emerging

Infections

Field

Epidemiology

Influenza Zoonoses Health Comm.

& IT

Lab Systems &

Biosafety

Thailand

Kenya

Guatemala

China

Egypt

Kazakhstan

India

TBD*

TBD*

TBD*

TBD*

TBD*

TBD*

FY 2009 FY 2009

18 GDD

Centers

Current

Capability

Partial

Capability *Future GDD sites are selected using a defined set of criteria and a 

thorough selection process.

Source: Division of Global Disease Detection and Emergency Response, Center for Global Health, CDC, March 5, 2010. Source: Division of Global Disease Detection and Emergency Response, Center for Global Health, CDC, March 5, 2010


delivery impact across the health sector.”40 The consequence, health analyst Julie Fischer 

concludes, is that “U.S. support for disease-specific programs [saves] lives but leaves most 

of the population without essential services [and] does little to free human capital for economic development, or to accomplish either public health or soft diplomacy goals.”41 Other 

disease-specific programs that have grown more gradually have had a greater opportunity 

to balance short-run treatment with long-run system building and sustainability. In time, 

this outcome may prove true of PEPFAR too, as discussed below.

U.S. disease-specific support in the case of pandemic influenza illustrates a second 

problem with the focus of U.S. funding: the tendency to spend funds overwhelmingly on 

domestic preparedness rather than creating a front line of defense by detecting and controlling infectious disease outbreaks at the source, that is to say, primarily in Africa and Asia 

(figure 3).42

When the United States responded to the H1N1 influenza outbreak with a supplemental 

appropriation of more than $6.5 billion in 2009, for example, only $190 million went to 

global programs, with the balance spent largely on domestic defensive countermeasures.43

Of course, domestic programs such as vaccine stockpiling are essential to protect those 

residing in the United States, but the issue is whether an ounce of protection achieved by 

putting a higher priority on global overseas surveillance and response capacity is worth a 

pound of domestic medical cure. 

The failure to strengthen foreign capacity reflects the United States’ tendency to give 

support for the treatment of particular diseases rather than invest for the long term in public 

health infrastructure abroad.44 The approach persists even though viable health systems 

are the key to curtailing the spread of infectious disease and improving the overall health 

of the recipient country.

There are several reasons for limited investment in foreign public health capacity, but 

they are not particularly sound policy reasons. First, demonstrating the direct, quantifiable 

impact of bolstering overseas public health systems is difficult. Lives not lost to disease, 

infections prevented by early detection, and pandemics avoided by rapid containment at the 

source are not as easily calculated or as compelling as the immediate, measurable effects of 

a program that vaccinates or treats thousands or millions of patients for a particular illness. 

This public relations problem would be solved, of course, after a deadly pandemic, but surely 

'JHVSF*OGFDUJPVT%JTFBTF%FBUITCZ3FHJPO

Source: World Health Organization (WHO), “Global Burden of Disease 2004,” 54-55, accessed at http://whqlibdoc.who.

int/publications/2008/9789241563710_eng.pdf, February 27, 2010
10

we do not need to learn that lesson the hard way. Second, system strengthening takes time 

to realize and appreciate. Most analysts recommend a time frame of ten to fifteen years or 

more for measuring systemic health impacts.45 Policymakers in donor countries rarely think 

beyond the current budget or electoral cycle, however, and are unlikely to make such patient 

investments. Third, because funding for global health primarily reflects the popular interests 

of the donor rather than the needs of the recipient, U.S. foreign health expenditures do 

not always align with the recipient’s national health plans or support the recipient’s overall 

public health and treatment infrastructures to maximize long-run returns on foreign investment through a true partnership. Finally, despite rhetoric to the contrary, U.S. policy still 

reflects an insufficient appreciation of global interconnectedness. U.S. interests defined in 

security, welfare, diplomatic, and humanitarian terms require significant investment abroad, 

not just at home. 

The Obama administration has heard some of these critiques. Its early policy planning, as 

reflected in PEPFAR’s second five-year strategy document and the President’s Global Health 

Initiative Consultative Document, appears responsive. For example, in its second five-year 

cycle, PEPFAR aims to “focus on transitioning from an emergency response to promoting 

sustainable country programs” that serve a broader health and development context.46 Similarly, the Global Health Initiative sets out a broader set of global health priorities. Rather 

than focusing just on particular diseases, the initiative emphasizes upgrading the health 

care systems and infrastructure of recipient countries. The vision statement for the policy 

explains, “The GHI will help partner countries improve health outcomes through strengthened health systems with a particular focus on improving the health of women, newborns, 

and children through programs including infectious disease, nutrition, maternal and child 

health, and safe water.” Although not focused on infectious disease per se, the Global Health 

Initiative recognizes that “Building functioning systems will, in some cases, require a new 

way of thinking about health investments, with increased attention to the appropriate 

deployment of health professionals, improved distribution of medical supplies, and improved 

functioning of information and logistic systems.”47 The new approach articulated in the 

initiative calls explicitly for a business model that encourages country ownership, invests in 

country-led plans, and creates sustainability through health systems improvements. 

The rhetoric is right, but time will tell if resources follow. Changing the orientation of 

U.S. policy and implementing a system-strengthening approach to global health challenges 

will be a slow and uneven process. Notably, under President Obama’s proposed FY 2011 budget for global health, the FETP and FELTP programs would receive significant new funding 

but the GDD program would receive $37.8 million, a steady-state budget and far short of 

what is needed to make meaningful strides toward reaching the program’s full potential.48

Many believe that a fragmented bureaucracy and a lack of harmony among competing 

interests in U.S. global health policy create a major challenge to developing a new approach 

to global health in general and to expanding support for foreign capacity in infectious 

disease surveillance and response in particular. The prevailing wisdom calls for greater interagency consultation in global health policy and centralization of strategy under the National 

Security Council or other White House office.49

True, there is no overarching coordinating mechanism across the major agencies, no plan 

for creating an integrated, interagency structure, and, until the Global Health Initiative, 

no government wide plan for meeting global health challenges. Although various agencies 

meet and discuss programs frequently, no one office or individual resolves conclusively which 

agency will lead on which issue. Coordination mechanisms do exist for particular disease initiatives, however.50 These disease-specific coordination bodies generally receive high marks 

for giving a strategic focus to the programs under their jurisdiction. Further, each of the major 

agencies involved in shaping global health policy has its own mechanism for coordination. 

The new approach articulated 

in the initiative calls explicitly 

for a business model that 

encourages country ownership, 

invests in country-led plans, and 

creates sustainability through 

health systems improvements.
11

Improved interagency coordination is something all can agree on in principle. In practice, however, there are many competing notions of how best to achieve broad coordination 

of U.S. global health policy and where best to locate the authority to resolve issues concerning overlapping agency jurisdiction. More important, centralized policymaking might help 

with disputes concerning interagency power sharing in Washington, but it is unlikely to be 

a panacea for improving support for, or the operational effectiveness of, overseas capacity 

with regard to infectious disease control. Moreover, centralization of policy and a common 

strategic framework issuing from the White House, National Security Council, or Homeland 

Security Council would not be without its potential pitfalls. It risks pulling authority farther 

away from those experts who know the medical, technical, and in-country dynamics best. 

These experts are more likely located in Atlanta and around the world, rather than inside the 

Beltway. They possess superior knowledge of programs and possibilities, an understanding 

of what works in different settings, and an appreciation for cost-effectiveness and sustainability. Public health professionals also stay with the issue for the long term and have 

fewer short-term or political motivations for the actions they recommend. Furthermore, 

these specialists have real, robust, and efficacious networks across governmental agencies, 

within the countries they operate in, and in multilateral institutions involved in the same 

issue area. These networks are essential to the success of health initiatives. Interagency 

coordination in this area is probably better “in the field,” that is, in-country, rather than in 

Washington. Most long-time infectious disease experts, be they in the DoD, CDC, or USAID, 

are mission-oriented and committed to finding ways to get the job done efficiently.51 Both 

civilian and military officials point to the effective teamwork between their co-located disease detection programs in the Middle East and South America, for example.52 Admittedly, 

the level of coordination varies from one country or region to the next and may turn on 

personal and professional relationships, but edicts from Washington are unlikely to change 

this reality. Coordinated reporting mechanisms would likely go farther toward promoting the 

adoption of the most effective practices and the elimination of redundancies.

Ironically, greater centralization and politicization of global health policy also run the 

risk of reducing the political effectiveness of U.S. policy designed to improve foreign capacity in infectious disease control. One of the great advantages possessed by global health 

professionals in this field is that they generally are not viewed as political actors. Most 

people implementing U.S. infectious disease control policy are medical and public health 

specialists and scientists who see the first order of business as “doing good public health.”53

Because of their reputation for doing good work well, U.S. public health officials working 

this issue can play a critical and early role in many conflict or postconflict situations, as they 

are doing in Iraq and Afghanistan, and can enhance relations with difficult countries that 

would reject a more openly political overture, as is happening in Yemen and Sudan. In short, 

centralization could further exclude from strategy those who know the issues the best, and 

could compromise some of the delicate but important political dividends associated with 

global disease control initiatives.

Harmonization in this area should not mean that U.S. policy has a single voice, only that 

it works coherently. U.S. infectious disease control policies are not meant to serve one policy 

goal but several: national security, economic development, human rights, public diplomacy, 

commercial, and other goals. It is both natural and inevitable that different agencies should 

pursue different goals consistent with their respective core missions. For example, the DoD’s 

greatest concerns are ensuring the health of its troops, protecting American borders from 

foreign (microbial) invasion, and promoting stability in foreign nations in which the troops 

operate. Capacity building in public health is a means to these ends. The CDC, in contrast, 

gives pride of place to building sound medical practices and capacity abroad, thereby promoting healthy lives and indirectly serving national security as a consequence. Each agency 

One of the great advantages 

possessed by global health 

professionals in this field is that 

they generally are not viewed as 

political actors. 
12

has unique strengths in health, too. The CDC is considered to have set the gold standard 

in epidemiological practice and is viewed as a prestigious international partner. The DoD, 

by virtue of its logistical abilities, can deliver health services and build capacity in regions 

that might be difficult or dangerous for civilians to enter. USAID knows best how infectious 

disease control fits within a country’s overall development objectives. Complementary mandates leverage different skills and perspectives to extend the scope and performance of U.S. 

policies designed to improve foreign capacity in infectious disease control, even at the risk 

of some duplication of efforts and jurisdictional disputes at the margin.

3FDPNNFOEBUJPOT

Several recommendations for strengthening the U.S. role in global infectious disease control 

emerge from this discussion. These recommendations are consonant with the dual goal of 

defending against a potential pandemic, thus securing the health of U.S. citizens, and promoting a positive dimension of U.S. global health diplomacy.

t .BUDI64HMPCBMIFBMUIQPMJDZSIFUPSJDUPSFBMJUZJOSFHBSEUPTUSFOHUIFOJOHPWFSTFBTDBQBDJUZJOJOGFDUJPVTEJTFBTFTVSWFJMMBODFBOESFTQPOTF Programs such as the 

GDD, FETP and FELTP, and IDSR are precisely the type of long-term, system-strengthening 

initiatives that are the aspiration of the president’s Global Health Initiative. These programs help contain disease outbreaks; transfer technical skills in epidemiology, surveillance, and health promotion to partner countries in the developing world; and establish 

evidence-based technical standards and procedures that make possible regional or global 

collaboration. Many of these programs have operated quietly and effectively for years. In 

addition to their successes in controlling disease spread, they generate political goodwill 

and promote a favorable image of the United States.54 However, their base funding needs 

to be increased over existing levels.

t %FTJHOBUFBQFSDFOUBHFPGEJTFBTFTQFDJGJDGVOEJOHUPCFVTFEGPSJNQSPWJOHQVCMJD

IFBMUIJOGSBTUSVDUVSFJOUIFEFWFMPQJOHXPSMEBecause the United States dedicates considerable funding to particular diseases, a near-term transition to a system-strengthening 

perspective might entail allocating a percentage of disease-specific funding for use in 

improving core competencies in the public health infrastructure in developing areas. Such 

core competencies would include infectious disease control and laboratory capacity. These 

systems will help ensure the long-run success of disease-specific initiatives. This set-aside 

would assist programs such as PEPFAR to move in the directions enunciated in their strategic plans and would contribute toward realizing the aims of the Global Health Initiative.

t $POOFDU UFDIOJDBM TQFDJBMJTUT BOE BHFODJFT LOPXMFEHFBCMF JO EJTFBTF XJUI UIPTF

LOPXMFEHFBCMFJODPVOUSZDPOEJUJPOTUPEFWJTFCSPBE
PWFSBSDIJOHTUSBUFHJFT The creation of an interagency committee to provide greater harmony in U.S. global health policy 

is potentially useful, but undue centralization may impede promoting infectious disease 

control systems abroad. In developing broad strategies, then, any new coordinating body 

should find ways to tap the expertise of those technical specialists and agencies (particularly the CDC and USAID) knowledgeable in the diseases and the country conditions. 

t "WPJEQPMJUJDJ[JOHUIFXPSLPGEJTFBTFDPOUSPMTQFDJBMJTUTBOEQSPHSBNT Many disease 

control programs and experts have, over the years, fostered goodwill as nonpolitical actors 

in the countries where they work. Coordination efforts should refrain from introducing an 

overtly political tone to these programs.

t 3FGSBJOGSPNDPOUSJWJOHBPOFEJNFOTJPOBM8BTIJOHUPOQPMJDZDPOTFOTVTUIBUGBJMT

UPSFDPHOJ[FUIFEJWFSTFPCKFDUJWFTTFSWFECZ64QPMJDJFTJOTVQQPSUPGJOGFDUJPVT

EJTFBTFDPOUSPMA centralized policy conducted under the aegis of the White House should 


avoid subjecting complex and diffuse networks of interagency and international coordination in infectious disease control to a Washington-based political compromise. Such a 

compromise, while producing policies more uniform in content, would likely prove less 

effective in practice in serving the many distinctive but interrelated goals pursued through 

U.S. disease control policies.


/PUFT

1. Lincoln Chen, Tim Evans, and Richard Cash, “Health as a Global Public Good,” in Global Public Goods: International 

Cooperation in the 21st Century, ed. Inge Kaul, Isabelle Grunberg, and Mark A. Sterns, 284–305 (New York: Oxford 

University Press, 1999), 288. 

2. Giovanni Berlinguer, “Health and Equity as a Primary Global Goal,” Development 42, no. 2 (1999): 12–16.

3. Kelley Lee and Derek Yach, “Globalization and Health,” in International Public Health: Disease, Programs, Systems 

and Policies, ed. Michael H. Merson, Robert E. Black, and Anne J. Mills, 681–708 (Sudbury, MA: Jones and Bartlett, 

2006), 690. 

4. World Health Organization, Global Alert and Response, “Pandemic Preparedness,” www.who.int/csr/disease/

influenza/pandemic/en. 

5. See Gary King and Langche Zang, “Improving Forecasts of State Failure,” World Politics 53 (July 2001): 623–58.

6. See William J. Long, Pandemic Peace: Transnational Cooperation and Governance in Controlling Disease

(Washington, DC: United States Institute of Peace Press, forthcoming).

7. White House, Office of Science and Technology Policy, “Addressing the Threat of Emerging Infectious Diseases,” 

June 12, 1996, http://www.fas.org/irp/offdocs/pdd_ntsc7.htm.

8. White House, Office of the Vice President, “Vice President Announces Policy on Infectious Diseases, New 

Presidential Policy Calls for Coordinated Approach to Global Issue,” June 12, 1996, http://www.fas.org/irp/

offdocs/pdd_ntsc7.htm.

9. White House, “Statement by the President on Global Health Initiative,” May 5, 2009, http://www.whitehouse.

gov/the_press_office/Statement-by-the-President-On-Global-Health-Initiative.

10. National Security Council Presidential Directive, “National Strategy for Countering Biological Threats,” letter of 

transmittal, November 2009.

11. Jen Kates, “The U.S. Global Health Initiative: Overview and Budget Analysis,” Kaiser Family Foundation, December 

2009, http://kff.org/globalhealth/upload/8009.pdf.

12. This figure is necessarily an estimate because the U.S. government has no agreed-upon definition across agencies 

of what programs constitute “global health activities” and which expenditures are rightly categorized as in 

support of infectious disease surveillance and response rather than a related public health goal. In addition, 

U.S. programs and funding are directed overwhelmingly toward particular diseases or themes rather than more 

general objectives, such as strengthening overseas infectious disease control systems. Julie Fisher, Eric Lief, Vidal 

Seegobin, and Jen Kates, “U.S. Global Health Policies: Mapping the United States Engagement in Global Public 

Health,” Kaiser Family Foundation, August 2009, 1, http://www.kff.org/globalhealth/upload/7958.pdf.

13. Statement by David Grootnik, director of International Affairs and Trade, October 4, 2007, in U.S. Government 

Accountability Office, “Global Health: U.S. Agencies Support Programs to Build Overseas Capacity for Infectious 

Disease Surveillance,” http://www.gao.gov/new.items/d08138t.pdf.

14. Centers for Disease Control and Prevention, “Global Disease Detection,” policy paper, June 2008, http://www.cdc.

gov/cogh/pdf/GDD_at_a_Glance_2008.pdf. 

15. The centers are located in Thailand (2004), Kenya (2004), Guatemala (2006), Egypt (2006), China (2006), and 

Kazakhstan (2008). A seventh center, in India, is in the planning phases.

16. Tiaji Salaam-Blyther, “Centers for Disease Control and Prevention Global Health Programs: FY2001–FY2010,” 

Congressional Research Service Report, Washington, DC, August 2009, http://fpc.state.gov/documents/

organization/128822.pdf.

17. Centers for Disease Control, “Global Disease and Detection Program: Monitoring and Evaluation Report 

2006–2008,” 4, http://www.cdc.gov/globalhealth/GDD/pdf/GDD_m&e.pdf.

18. Ibid. See also Centers for Disease Control, “Global Disease Detection Accomplishments,” http://www.cdc.gov/

print.do?url=http%3A//www.cdc.gov/cogh/gdd.html.

19. Centers for Disease Control, “Global Health: Field Epidemiology Training Program,” http://www.cdc.gov/

globalhealth/FETP. 

20. CDC official, interview by author, Atlanta, GA, January 29, 2010. 

21. Centers for Disease Control, “Division of Global Public Health Capacity Development 2008 Annual Report,” http://

www.cdc.gov/globalhealth/FETP/pdf/2008_annual_report_508.pdf.

22. Centers for Disease Control, “2010 Field Epidemiology and Management Capacity Building Programs,” January 

2010, unpublished internal document.

23. The six programs examined were those in Brazil, Central Asia, Central America, India, Jordan, and Kenya. U.S. 

Government Accountability Office, “Global Health: U.S. Agencies Support Programs to Build Overseas Capacity for 

Infectious Disease Surveillance.”

24. Centers for Disease Control, “Capacity Development News,” Spring 2009, http://www.cdc.gov/globalhealth/FETP/

pdf/2009_newsletter_508.pdf.

25. CDC official, interview by author, Atlanta, GA, January 29, 2010.

26. Centers for Disease Control, “Integrated Disease Surveillance and Response,” http://www.cdc.gov/idsr.

27. Ibid.

28. Lawrence Kapp and Don J. Jansen, “The Role of the Department of Defense during a Flu Pandemic,” Congressional 

Research Service Report, June 2009, 3, 4. http://www.fas.org/sgp/crs/natsec/R40619.pdf.

29. Eugene V. Bonventre, Kathleen H. Hicks, and Stacy M Okutani, “U.S. National Security and Global Health: An 

Analysis of Global Health Engagement by the U.S. Department of Defense” (Washington, DC: Center for Strategic 

and International Studies, April 2009), http://csis.org/files/publication/090421_Bonventre_USNationalSecurity_

Rev.pdf. 

30. U.S. Department of Defense, Global Emerging Infections Surveillance and Response System, “Fiscal Year 2008 

Annual Report,” 6, http://afhsc.mil/viewDocument?file=GEIS/GEISAnnRpt08.pdf.

31. Ibid.


32. U.S. Government Accountability Office, “Global Health: U.S. Agencies Support Programs to Build Overseas 

Capacity for Infectious Disease Surveillance,” 13.

33. United States Institute of Medicine, Review of the DoD-GEIS Influenza Programs (Washington, DC: National 

Academies Press, 2008), 12.

34. U.S. Government Accountability Office, “Challenges in Improving Infectious Disease Surveillance Systems,” 

August 2001, 35, http://www.gao.gov/new.items/d01722.pdf.

35. See Salaam-Blyther, “Centers for Disease Control and Prevention Global Health Programs: FY2001–FY2010.”

36. U.S. National Academies, “Global Health Should Be a Key Component of U.S. Foreign Policy,” press release, 

December 15, 2008, http://www8.nationalacademies.org/opinews/newsitem.aspx?.

37. This amount includes $1 billion committed through the Global Fund. 

38. Ruth Levine, “Healthy Foreign Policy: Bringing Coherence to the Global Health Agenda,” in The White House and 

the World: A Global Development Agenda for the Next U.S. President, ed. Nancy Birdsall, 43–61 (Washington, DC: 

Center for Global Development, 2008), 49.

39. Colleen C. Denny and Ezekial J. Emanuel, “U.S. Health Aid Beyond PEPFAR: The Mother and Child Campaign,” 

JAMA 300, no.17 (November 5, 2008): 2048–51; Eduardo Gomez, “Stop Fighting Viruses, Start Treating People,” 

Foreign Policy, January 27, 2010, http://foreignpolicy.com/articles/2010/01/27/stop_fighting; C. D. Mathers and 

D. Loncar, “Projections of Global Mortality and Burden of Disease for 2002 to 2030,” PLOSMedicine 3, no. 11 

(2006): 2111–30.

40. U.S. Department of State, “The U.S. President’s Emergency Plan for AIDS Relief: Five-Year Strategy,” December 

2009, 8, 12, http://www.pepfar.gov/strategy/document/index.htm.

41. Julie E. Fischer, “Silos within Silos: Unknotting U.S. Global Health Initiatives,” December 15, 2009, http://

budgetinsight.wordpress.com/2009/12/15/silos-within-silos-unknotting-u-s-global-health-initiatives/.

42. Levine, “Healthy Foreign Policy,” 46.

43. Sarah A. Lister and C. Stephen Redhead, “The 2009 Influenza Pandemic: An Overview,” Congressional Research 

Service Report, September 10, 2009, http://assets.opencrs.com/rpts/R40554_20090910.pdf.

44. Laurie Garrett and Kammerle Schneider, “Global Health: Getting It Right,” in Health and Development, ed. Anna 

Gati and Andrea Boggio, 3–15 (New York: Palgrave Macmillan, 2009) 11.

45. Levine, “Healthy Foreign Policy,” 47. 

46. U.S. Department of State, “The U.S. President’s Emergency Plan for AIDS Relief: Five-Year Strategy,” 8.

47. U.S. Department of State, “Implementation of the Global Health Initiative: Consultation Document,” February 

2010, 4–5, http://www.pepfar.gov/documents/organization/136504.pdf.

48. Kaiser Family Foundation, “Budget Tracker: Status of U.S. FY 11 Funding for Key Global Health and 

Related Accounts,” February 17, 2010, http://globalhealth.kff.org/Policy-Tracker/Administration/Actions/2010/

February/01/FY11-Budget-Request.aspx.

49. See U.S. Institute of Medicine, The U.S. Commitment to Global Health: Recommendations for the New Administration

(Washington, DC: National Academies Press, 2009); Levine, “Healthy Foreign Policy”; U.S. National Academies, 

“Global Health Should Be a Key Component of U.S. Foreign Policy.”

50. The State Department’s Office of Global Aid Coordinator is the guiding agency for the many HIV/AIDS-related 

programs, and USAID leads in the implementation of the President’s Malaria Initiative, for example.

51. CDC official, interview by author, Atlanta, GA, and Washington, DC, January 29, 2010, and March 2, 2010.

52. Ibid.

53. CDC official, interview by author, Atlanta, GA, January 29, 2010.

54. Centers for Disease Control, “Robert Fontaine Received the Friendship Award,” Newsletter, October 2007.
6OJUFE4UBUFT

*OTUJUVUFPG1FBDF

1200 17th Street NW

Washington, DC 20036

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An online edition of this and related 

reports can be found on our Web site 

(www.usip.org), together with additional 

information on the subject.

0G3FMBUFE*OUFSFTU

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