In early December 2013, in the low-lying mountains of Guinea in West Africa, a 2-year-old named Emile Ouamouno had a sudden onset of strange symptoms: high fever, bloody stool, and vomiting. On December 6, the boy died in his home village of Meliandou. Emile’s 4-year-old sister, mother, and grandmother died shortly after, each suffering similar symptoms.

In March, scientists identified the cause of the deaths: the Ebola virus. By then, 82 more people had died. By May, the outbreak had spread to neighboring Liberia and Sierra Leone as the death toll neared 200.

These were the early months of what would become the deadliest Ebola outbreak in history. From 2014 to 2016, the outbreak overwhelmed health systems in Guinea, Liberia, and Sierra Leone. Seven other countries including Italy, Spain, the United Kingdom, and the United States, also reported Ebola cases, primarily among health care workers and travelers who had recently been to West Africa.

In all, more than 11,000 people died.

The epidemic caught the world by surprise, exposing vast weaknesses in the world’s ability to contain and quell infectious diseases. The Centers for Disease Control and Prevention (CDC), Department of Defense, and other diplomatic and development agencies responded immediately, mobilizing one of the largest outbreak response efforts in history.

The Ebola crisis played a role in kickstarting longer-term US government investment in global health security, a broad term that refers to activities needed to prevent, detect, and respond to infectious disease threats, such as training health care personnel and building laboratories equipped to test for a wide range of pathogens.

Though the CDC and other US government agencies were already involved in outbreak response activities globally before 2014, the Ebola crisis cemented a more permanent and sustained approach to building long-term global capacity to address infectious disease threats. In 2014, the CDC solidified its commitment to this by creating a new department: the Division of Global Health Protection, which is solely dedicated to global health security. The US government, alongside more than 70 other countries, also launched the Global Health Security Agenda, which provided a blueprint for bolstering global health security around the world.

Over the past 10 years, the US government has doled out at least $8 billion to the CDC, the United States Agency for International Development (USAID), and the Department of Defense for their global health security programs. (This figure excludes additional emergency funds provided for Zika and Ebola outbreak responses, the Covid-19 pandemic, and support for other infectious diseases such as HIV, tuberculosis, and malaria.) The theory was that an infectious disease anywhere was a threat everywhere, so every country’s global health security capacity needed to improve.

The Ebola crisis, and earlier pandemics such as swine flu in 2009, was a harbinger of crises to come: Zika, Covid-19, monkeypox, a resurgence in dengue, tuberculosis, and other diseases. Despite the influx of funding, we have seen that the world remains unprepared for infectious disease threats.

From 2017 to 2018, I was a contractor at the CDC’s Division of Global Health Protection, and last year, I briefly served as a global health security technical advisor at USAID. Although there have been some strides in the right direction, by and large, the US hasn’t meaningfully reached many of its goals.

Arguably, global health security has faltered because of a lack of solidarity. The US government has approached health security with too much of a traditional national security approach, focusing more on keeping foreign threats out of the US than quelling all threats globally. As such, US government agencies continually fail to understand or address local needs or to develop true partnerships with foreign governments, instead dictating how “partners” in foreign countries should build health security capacity with little to no local buy-in.

Earlier this year, the Biden administration launched a new US Global Health Security Strategy, which outlines the goals for global health security for the next five years. Though the strategy highlights the importance of cooperation, country ownership, and science-based approaches, it doesn’t clearly outline how agencies will achieve those guiding principles. While the continued commitment to global health security is necessary, if the US government does not address fundamental issues underlying its programming, infectious diseases and future epidemics will continue to claim millions of lives each year and cause billions in economic losses.

What if when Emile Ouamouno first showed up at a health clinic in his rural village in Guinea, the doctors there had already been trained to identify symptoms of an Ebola infection? What if they could have immediately put him into an isolation room away from his family and other patients? What if the nurses could have donned hazmat suits and gloves, collected a blood sample from Emile, then sent it down the hall for a laboratory technician to test for a range of potential viruses or bacteria causing his sickness? What if just hours after discovering Ebola virus in his blood, the laboratory technician could have reported this finding to government staff across the country, immediately triggering a response to contain the spread of Ebola to just one village?

To prevent infectious diseases and to rapidly identify early signs of an outbreak and contain its spread, countries need four things, according to David Heymann, a professor of infectious diseases epidemiology at the London School of Hygiene and Tropical Medicine (he also previously supported Ebola outbreak responses in Africa when he worked at the CDC):

Unfortunately, most countries are lacking on all fronts.

Researchers from several NGOs and universities developed The Global Health Security Index, which comprehensively assesses country capacity to prevent, detect, and respond to infectious diseases. In their 2021 report, they found that even after significant investment and effort during the Covid-19 pandemic, “all countries remain dangerously unprepared to meet future epidemic and pandemic threats.”

Of 195 countries included in their index, 126 did not have an overarching national public health emergency response plan, 128 have no plan for testing for novel pathogens during a public health emergency, and 169 countries did not have national health security plans that addressed the risk of zoonotic diseases. Beyond the index, health care systems in developing countries are woefully understaffed. Some 47 countries in Africa face severe shortages of health workers, and 4.5 billion people around the world do not have full access to health services.

There are a lot of complex moving parts within global health security. Sometimes the challenge seems insurmountable. While the CDC, in a statement to Vox, said that it recognizes global public health is a “team effort,” unfortunately the current paternalistic approach alienates its most important partners, according to the experts Vox spoke with.

While the US government’s global health security funding does, in part, fulfill a humanitarian mission to improve the lives and livelihoods of people around the world, experts have accused the US government of pushing too much of a US-centric agenda that is primarily focused on keeping diseases out of the US rather than developing true partnerships and building capacity around the world.

There are several examples of this. The US government invested heavily in developing at least two effective and FDA-approved treatments for Ebola; however, to date, these drugs remain largely siloed away in US stockpiles for national security and biodefense and have not been made readily available in foreign countries during Ebola outbreaks, according to Doctors Without Borders.

Heymann points to the Covid-19 pandemic as another example. While the US and European governments were criticized for not sharing the Covid-19 vaccine, the discourse among public health officials in Africa was vastly different. In 2021, Heymann asked public health leaders from Africa what the most important vaccine was to them. They said it was the malaria vaccine. They reported that they did not need the Covid-19 vaccine because the toll was lower compared to other diseases, perhaps because populations in Africa are generally younger and have fewer comorbidities. (A lack of testing likely also reduced the number of cases and deaths recorded.) In fact, the officials Heymann spoke with saw the vaccination push as “a measure of the North to protect itself by making us get vaccinated,” he said.

There is widespread perception that global health security is an American program pushing an American agenda, or perhaps more broadly an effort devised for the benefit of the Global North. Local officials and organizations do not trust American and European global health security staff, according to Syra Madad, the chief biopreparedness officer at NYC Health + Hospitals.

This perception is one reason why foreign governments do not prioritize global health security and do not dedicate domestic funds to maintaining systems that the US and other donor countries invest in. More than 150 countries included in the 2021 Global Health Security Index did not have domestic funding for epidemic threats. Competing health priorities and a general lack of domestic funds certainly play a role, too.

“The reality is, you can invest money, you can invest resources, but there’s only so much you can do, unless the other country comes to the table and says, ‘You know what, we are going to not only use this funding and resources, but we’re going to now take this on, and it’s going to be our country issue. We’re going to invest in it, we’re going to maintain it.’ And that’s really what’s been the struggle,” Madad added.

Although the US government may have little to show for its massive investment in global health security in the past 10 years, it could be laying an important foundation for future work. Developing the health and public health systems required to prevent, detect, and respond to infectious diseases is certainly a long game.

“The requirements around the world for making substantial progress are huge. The world is very big. It’s very susceptible to infectious disease,” Tom Inglesby, the director of the Johns Hopkins Center for Health Security, said. “So moving the needle on real preparedness is difficult.”

First and foremost, the US government needs to forge true partnerships with foreign governments where ideas are exchanged back and forth and both parties jointly work toward building health security capacity. The US government should also require local buy-in and domestic investment from foreign governments; this would help ensure that the areas where the US is putting taxpayer dollars is a true priority in the country.

“We have to decolonize ourselves,” Heymann explained. “It’s no longer, ‘we’ll give you the money, and you do it.’ It’s ‘you request the money from us, and then you put in your share, and we’ll put in our share,’” he said. “If countries aren’t engaged in wanting to do the job, then why should we be giving the money? That’s just forcing them to do something they don’t want to.”

Madad also recommends that the US government open up more direct funding lines to the frontline clinics and community-based organizations that are knee-deep in responding to epidemics rather than funneling those funds through larger institutions such as the Ministry of Health or World Health Organization. She also recommends focusing on building capacity at the primary health care level, such as those rural clinics like the one Emile Ouamouno visited after he became infected with the Ebola virus.

“A lot of it all starts with primary care,” Madad said. “If you have a good primary care infrastructure and you’re building that workforce around it, then you’re able to really detect cases of a novel or an emerging or reemerging infectious disease much sooner,” she said. “If we’re able to really invest in primary care around the world and provide the resources and the workforce to be able to provide this primary care, then we would be in much, much better shape.”