U.S. Homeland Defense Strategic Public Health: An Underutilized but Desperately Needed Concept.

Pandemics have been an integral part of the history of civilizations and the ongoing process of globalization. The advancement of transportation, commerce, and technological development has dramatically fueled interdependence between nation-states. As the world becomes more interdependent, an awareness of how a pandemic can destroy a nation's progress has been seen in the COVID-19 pandemic of the past three years. For example, COVID-19 has ravaged Latin America, "killing 1.3 million people, fueling recession, and unleashing widespread political upheaval." (1) In many countries, protests over inequality, slow growth, and corruption predated the pandemic. Still, during the outbreak, "demonstrations have intensified as people have taken to the streets to demand economic assistance and vaccines." (2) Further, the global COVID-19 pandemic proved that the United States' domestic response was subpar compared to other nations' reactions within their borders, thus undermining the U.S. leadership or a model for other countries to emulate. (3) This article discusses an underutilized but much-needed concept of homeland defense strategic public health within the national security community. The paper is divided into three parts. Part I provides general introduction to the topic. Part II discusses why strategic health diplomacy is more critical than ever in the twenty-first century, yet is a concept underutilized by the national security community. Part III, discusses the political, social, and economic implications of COVID-19. Part IV provides some recommendations that the United States must consider if it is to remain a relevant superpower in the future and not be caught unprepared for another devasting pandemic.

The novel SARS-CoV-2, also known as COVID-19, illustrated that globalization and interdependence among nations today did not exclude any countries from its impact. The COVID-19 pandemic also showed that the pandemic was more than simply a public health crisis. It was also an economic crisis, a social crisis, a crisis of inequality, and a political crisis. Countries that adhered to the earlier guidelines set up by the World Health Organization (WHO) for dealing with the pandemic, including, but not limited to, enforcement of quarantine, social isolation, testing, and vaccination, were better at tackling the pandemic and its after-effects. Most importantly, countries with strong leadership and reliable governments--governments with legitimacy and credibility- were in a much better position to address the pandemic. Countries with coordinated responses to the COVID-19 pandemic have reaped the benefits--Chile and Canada have successfully vaccinated over 90 percent of their population. (4) However, nations with haphazard reactions, such as the United States and Russia, are proving to have higher numbers of unvaccinated citizens. While credibility and legitimacy were fundamental to tackling the pandemic, missing in many countries was what is referred to in this paper, a homeland defense strategic health diplomacy to address a global pandemic in a collective whole-of-government approach. Given that COVID-19 was not the first (nor will be the last) pandemic to wreak havoc on nations around the globe, the United States must be prepared for the next pandemic. It is not a matter of whether it will happen but when--and the answer is sooner than expected. Why is Strategic Health Diplomacy More Important than Ever Today?

If the COVID-19 global pandemic has taught any lesson, it is that governments ignore investing in public health at their peril or believed benefit to their economy or international reputation. However, pandemics devastate a nation's overall economic, social, and political operational environment. Historians have not forgotten this fact. Therefore, today, more than ever, a nation-state should develop strategic health diplomacy to detect, defend, defeat, and protect its citizens against deadly viruses and antimicrobial resistance diseases. Recent outbreaks of potential devasting diseases such as the SARS outbreak in 2003, Monkeypox, the ever-growing threat of antimicrobial resistance (AMIR), the devastation caused by Zika in Brazil, Ebola in Nigeria, Chikungunya Virus in Brazil, and the deadly pandemic of the 1980s HIV/AIDS, which former U.N. General-Secretary Kofi Annan once referred to as the "real weapon of mass destruction." Brazil's first case of Zika virus infection was first reported in May 2015 in the Northeast part of Brazil. Brazil's Northeast region is the poorest region of the Brazilian Federation of States and most dependent on the federal government for public health assistance. The outbreak of this disease in Brazil has led to a generation of orphans born with microcephaly and other congenital malformations of the central nervous system early in the Zika epidemic. (5) The Ebola virus disease outbreak in Nigeria in 2014 was even more devasting than any other pandemic. The first known case of Ebola in Nigeria was in a traveler exposed in Liberia. According to the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR):

On July 17, 2014, while under observation in a Monrovia, Liberia, hospital for Ebola, the patient developed a fever and, while symptomatic, left the hospital against medical advice. Despite advice against travel, on July 20, he flew by commercial airline from Monrovia via Accra, Ghana, to Lome, Togo, then changed aircraft and flew to Lagos. On arrival on the afternoon of July 20, he was acutely ill and immediately transported to a private hospital, where he was noted to have fever, vomiting, and diarrhea. During hospital admission, the patient was queried about Ebola and said he had no known exposure; he was initially treated for presumed malaria. Nigerian doctors, realizing that the patient did not respond well to the initial treatment for malaria, shifted gears and began treating the patient for Ebola. The Nigerian public health system also activated the Emergency Operations Center (EOC) and the Incident Management System (IMS), resulting in a "rapid, effective, and coordinated outbreak response." (6)

Chikungunya is a life-threatening and disabling infectious disease caused by an Alphavirus transmitted by Aedes mosquitoes. This disease has been prevalent in Brazil's Northeast. The first reported outbreak of Chikungunya was in 2013. According to Nunes et al., "the outbreak has since spread to 38 regions in the Americas. By September 2014, the first autochthonous CHIKV infections were confirmed in Oiapoque, North Brazil, and Feira de Santana, Northeast Brazil." (7)

Antimicrobial resistance is an equal concern on the global scale as any other disease. Illnesses such as tuberculosis, HIV, and malaria are treated with antibiotics widely used and distributed internationally. However, overuse and misuse of antibiotics make these diseases less responsive and more prone to mutation, leading to higher mortality. (8) While the World Health Organization has published a 5-objective Global Action Plan to combat AMIR, each nation must prepare accordingly. (9)

Respiratory illnesses, such as the SARS outbreak in 2003 and COVID-19, are also devastating illnesses on a global scale due to the interconnectedness of nations through rapid air travel. According to theoretical physicist Dirk Brockmann, "Our transportation network... shapes the pandemic more than our physical geography." (10) In 2013, Brockmann studied the distributions of a modern pandemic of influenza worldwide. Without air travel, he found the pattern would be "chaotic and formless." However, with air travel, the distribution is a "series of waves, radiating outward one by one." While the wet markets of China served as the ideal conditions for initiating a flu-like disease such as COVID-19, the ability to spread to other continents quickly was the launch pad for a global pandemic.

The destructive impact of disease on nation-states' preparedness and readiness has been known for centuries. In his magnum opus, The Peloponnesian War, the great Greek historian Thucydides reports how the plague twice devasted and destabilized the Athenians' forces and society during the second and fifth years of the conflict. (11) As Thucydides says, during the first year of the plague, which lasted two years:

People in good health were suddenly attacked by violent heat in the head, redness and inflammation in the eyes, and the inward parts, such as the throat or tongue, becoming bloody and emitting an unnatural and fetid breath. These symptoms were followed by sneezing and hoarseness, after which the pain soon reached the chest and produced a hard cough. (12) During the fifth year of the Peloponnesian War, the plague returned to Athens. The second plague returned, lasting less than a year, but its effects were just as devasting to the Athenians' forces and society. Thucydides reports, "No less than four thousand four hundred hoplites in the ranks died of it [the plague] and three hundred cavalry, besides a number of the multitude that was never ascertained." (13) Recently, U.S. government personnel assigned to embassies in Cuba, Russia, China, India, Austria, Germany, Switzerland, and the U.S. complained of debilitating headaches, vertigo, and ringing ears. After an extensive interdisciplinary examination by physicians, psychiatrists, and psychologists, the conditions became known as Anomalous Health Incidents (AHI) or Havana Syndrome (14) due to where the original incidents occurred. While the number of individuals impacted by Havana syndrome is small compared to the...