After an Ebola epidemic devastated West Africa in 2014, many countries took steps to assess their preparedness. But even as the risks of such outbreaks increase, no country — including the United States — is fully prepared to respond to a deliberate or accidental threat with the potential to wipe out humanity, according to a report assessing the efforts of 195 countries.
The report, released Thursday, is the first comprehensive assessment of global health capabilities, giving countries an overall score based on several measures. Unlike existing preparedness assessments, the Global Health Security Index benchmarks health security in the context of other factors critical to fighting outbreaks, such as broad health systems, adherence to global norms, and political and security risks, including public confidence in government.
The United States does well in five of six preparedness categories but ranks 19th — after Australia, Canada, Singapore and more than a half-dozen European countries — in measures that assess the overall risk environment and vulnerability to biological threats. The factors driving down the U.S. score include the risks of social unrest and terrorism, and low public confidence in government. Liechtenstein ranked No. 1 on this measure.
Some other high-income countries also generally score well. But the report found that a number of middle- and low-income countries scored higher than some wealthy countries. Thailand, for example, is the only non-high-income country to rank in the top tier overall. Its overall rank is sixth highest after the United States, United Kingdom, the Netherlands, Australia and Canada.
And some very high-income countries, such as Saudi Arabia and the United Arab Emirates, where experts expected to find better preparedness funding, score below 50 out of a possible highest score of 100. The average overall index score among all 195 countries is 40.2
The index is a project of the Nuclear Threat Initiative, a D.C.-based nonprofit organization, and the Johns Hopkins Center for Health Security. It was developed with guidance from an international panel of experts from 13 countries, with research by the Economist Intelligence Unit. More than 100 researchers spent a year collecting and validating publicly available data.
The project's organizers hope the rankings will galvanize action, coming amid an ongoing Ebola outbreak in Congo that has killed more than 2,000 people.
"Health security is a collective responsibility," said Beth Cameron, vice president for global biological policy and programs at the Nuclear Threat Initiative and one of the index's leaders. "Countries need to know how prepared they are. And they need to know how prepared their neighbors are. Otherwise we'll never improve."
Over the past two decades, decision-makers have focused only sporadically on health security despite concerns after the 2001 anthrax attacks, the emergence of viruses that caused severe acute respiratory syndrome, or SARS, and Middle East respiratory syndrome, or MERS, and the looming threat of a pandemic caused by a novel strain of influenza, the report said.
Since the 2014-2016 Ebola epidemic killed more than 11,000 people, many countries — especially in Africa — have been more willing to report their level of preparedness, said Cameron, formerly senior director for global health security and biodefense at the National Security Council in the Obama administration.
"But in terms of financing to fill the gaps, not enough has been done," she said.
There needs to be a fundamental shift in understanding that biological catastrophes are a major peace and security risk, Cameron said. While health experts have long recognized those risks, finance ministers, heads of states and other decision-makers have not.
Biological threats are catastrophic, yet responsibility for them is "buried in the bowels of health ministries around the world," Cameron said.
During the 2014 Ebola crisis, the Obama administration created an Ebola czar and established a unit on global health security and biodefense, headed at the senior director level, at the National Security Council. That unit was abolished last year under a reorganization by then-national security adviser John Bolton.
In the United States, military readiness is staffed at the level of the chairman of the Joint Chiefs of Staff. Biodefense is currently staffed at the level of assistant secretary at the Health and Human Services Department.
"When heads of states get together, among their five talking points, this isn't always one of them," Cameron said.
Among the report's recommendations: The United Nations secretary general should designate a permanent unit for high-consequence biological threats and call a heads-of-state level summit by 2021 on biological threats that includes a focus on financing and emergency response. Responding to biological threats should also be a priority for the next U.S. president, organizers said.
Tom Frieden, who was director of the U.S. Centers for Disease Control and Prevention during the 2014 Ebola epidemic, said the report underscores the lack of significant action since then to close preparedness gaps. It also provides information on aspects of health security that haven't been previously assessed.
The report also highlights an issue that is too often neglected: protecting front-line health workers, said Frieden, who heads Resolve to Save Lives, a New York-based public health nonprofit. His organization has also developed a tool that spotlights gaps in preparedness, and actions that countries and organizations can take to close them.
Dozens of health workers have been attacked or killed in Congo's Ebola outbreak that began in August 2018, the second-deadliest in history, according to World Health Organization officials.
Among the report's other findings:
- Only 15% of countries score in the highest tier for public confidence in government.
- Only 3% show a commitment to prioritizing services for health-care workers who become sick as a result of participating in a public health response.
- 89% of countries do not demonstrate having a system for dispensing medical countermeasures during health emergencies.
- 92% of countries do not show evidence of requiring security checks for personnel with access to dangerous biological materials or toxins.