Dr. David SmithDeputy Assistant Secretary of Defense (Health Affairs)

Health Readiness Policy and Oversight

December 3, 2015

Advances in Global Health Engagement

DoD Global Health Engagement

DoD Global Health Engagement comprises health and medical related actions and programs undertaken by the DoD to improve foreign armed forces’ or foreign civilian authorities’ health system capacity; and to promote and strengthen their human and/or animal health systems in support of national security objectives.

-Global Health Working Group, January 2014

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Why is DoD involved in Global Health Engagement?

A powerful national security instrument that supports USG efforts around the world

STABILITYGHE contributes to social well-being, rule of law, governance,

economics, and security

COOPERATIONGHE enhances collaboration

with foreign ministries and civil structures

CAPACITYGHE is leveraged to develop

partner capabilities to increase self-reliance

Through:

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2015 National Security Strategy

• We will advance the security of the United States, its citizens, and U.S. allies and partners by:– Developing a global capacity to

prevent, detect, and rapidly respond to biological threats like Ebola through the Global Health Security Agenda.

– Leading efforts to reduce extreme poverty, food insecurity, and preventable deaths with initiatives such as Feed the Future and the President’s Emergency Plan for AIDS Relief.”

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Disclosures

Presenter has no interest to disclose.

PESG and AMSUS staff have no interest to disclose.

This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, and all accrediting organization do not support or endorse any product or service mentioned in this activity.

Learning Objectives

At the conclusion of this activity, the participant will be able to:

1. Contextualization of DoD role in global health engagement efforts 2. Insight into the new DoD policies being developed on global health

engagement, and how they will effect the future of DoD involvement in those engagements

3. Greater perspective on the intricacies of coordinating U.S. government global health engagement efforts, and the collaborative work being done to bridge gaps

2015 National Security Strategy (Cont)

• “We will advance an international order that promotes peace, security, and opportunity through stronger cooperation to meet global challenges by…– Strengthening and growing our global

alliances and partnerships, forging diverse coalitions, and leading at the United Nations and other multilateral organizations.

– Rebalancing to Asia and the Pacific through increased diplomacy, stronger alliances and partnerships, expanded trade and investment, and a diverse security posture.

– Building upon the success of the U.S.-Africa Leaders’ Summit by investing in Africa’s economic, agricultural, health, governance, and security capacity. 7

History of DoD and Global Health

DoD has actually been involved in global health issues for over a century• Traditionally viewed global health engagement

through the lens of force health protection

• MAJ Walter Reed pioneered research into diseases like yellow fever

• Theorized and proved transmission by mosquito

• Established first overseas medical research and surveillance laboratories after WWII Major Walter Reed, M.D., U.S. Army

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Evolution of DoD Global Health Engagement

• Over time, DoD has recognized that global health and global security are inextricably linked

• In the last decade, events like infectious disease crises (HIV, SARS, Ebola, MERS) and natural disasters have caused severe disruption and instability across the globe

• Not in our interest to allow that instability to grow, especially when we have capability to mitigate.

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• Partnership building is a significant priority for DoD in its GHE efforts

• Healthy, capable partners are one of the most effective ways to mitigate health security threats

• Security threats from health catastrophes are real; and the spillover effects from breakdowns in health systems can be harder to contain than armed conflicts themselves.

U.S. Army engineers assist the Liberian military in the construction of an Ebola treatment unit during the 2014 West African Ebola epidemic.

Evolution of DoD Global Health Engagement

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DoD Global Health Functions

Force Health Protection

Humanitarian

Assistance & Disaster Response

Preventive Medicine

Medical Research & DevelopmentPublic Health

DHAPPBuilding Coalition &

Partner MilitaryMedical Interoperability

Building PartnerCiv Med Capacity

Building PartnerMil Med Capacity

Operational/Contingency Plans

IMET

Theater SecurityCooperation

SMEEs

Biosurveillance

GHSA

Humanitarian and

Civic Assistance

Medical Support to Stability Ops

Humanitarian Assistance (HA)

Disaster Relief (DR)

Research & Development on Select Agents: Detection,

Countermeasures, Vaccines

CBEP

Ebola Response

Civ-Mil Emergency

Planning

DPP

SMEEs ---- Subject Matter Expert Exchanges

GHSA ----- Global Health Security AgendaDHAPP --- Defense HIV-AIDS

Prevention ProgramCBEP ------ Cooperative Biological

Engagement ProgramDPP ------- Disaster Preparedness

ProgramIMET ----- International Military

Education & Training

LEGEND

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DoD Global Health EngagementAround the World (2014)

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Importance of International Collaboration

“Infectious disease does not respect international borders or government bureaucracies. Identifying and cultivating areas where our cooperation can be strengthened is something that all of us should be focused on.”

- ASD(HA) Dr. Jonathan Woodson, Asia Pacific Military Health Exchange 2015 13

Senior leader engagements between USPACOM and thePeoples Liberation Army/Navy have opened up new opportunities for collaboration with

China

Military-to-Military Health Engagement

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Bi-lateral and multi-lateral military exercises provide opportunities to practice and test interoperability in battlefield and disaster medicine

processes and procedures

Interoperability Health Engagement

USNS Comfort anchors off Haiti for Continuing Promise 2015, during which its personnel conducted medical training exercises

and exchanges with partner nations in Latin America.

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Humanitarian Assistance & Disaster Relief

Nepalese service members offload supplies from a U.S. Marine Corps MV-22 Osprey in the aftermath of the 2015 Nepal earthquake 16

Pacific Partnership 2015

• 4-month Deployment

• US lead multinational command-and control structure including a deputy mission commander from the Australian Defense Force and a mission chief of staff from the New Zealand Defense Force

• First visit by a U.S. Navy vessel to Fiji in 9 years.

• Visit to Vietnam was in conjunction with the 20th anniversary of the normalization of diplomatic relations between the United States and Vietnam

• First PP mission to use a joint high speed vessel (JHSV)

To date, PP missions have provided:

• Medical care to 270,000 patients

• Veterinary care to 38,000 animals

• 180 engineering projects to Host Nations

“Pacific Partnership strengthensrelationships that are critical to deterconflict while increasing regionalstability and security - the crux of theU.S. strategic “rebalance” to the Indo-Asia-Pacific.”

Partner Nations:

Host Nations:

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Continuing Promise 2015

• 6-month Deployment

• Joint training mission, with units from Army, Navy, Air Force, and Marines participating

• Mission: to remain Forward, Engaged and Ready in support of US Naval Forces SOUTHCOM/US Fourth Fleet; Commander, US SOUTHCOM; US national objectives; and US Global Maritime Strategy

• Delivered deliberate, sustainable and transparent method to enhance host nation capabilities

• Includes uniformed and civilian health providers (NGOs)

CP’15 anticipated:

• Medical/dental care to 133,00 patients ashore

• 1000 surgeries aboard USNS Comfort

• 800 subject matter expert exchanges

“Continuing Promise 2015 will enable us to strengthen ties in support of our enduring partnerships with the people of Central America, South America and the Caribbean – a partnership that will enhance our shared values, interests and commitment to unity, security and stability within the region.”

Host Nations:

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Value of Global PartnershipIn A More Connected World

• Our research / Your research demands greater public-private, and national/ international partnerships– Strengthens medical

research– Strengthens long-term

partnerships– Strengthens national

security

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Global Health EngagementWhole of Government Approach

3D (Diplomacy, Development, and Defense)Global Health Group

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Global Health Security Agenda

A world safe and secure from global health threats posed by infectious diseases, whether naturally occurring, deliberate or

accidental

PREVENTDETECT

RESPOND21

A Role for Military Medicine in GHSA

Biological threats, both natural and intentional, jeopardize our national security, mission assurance, and force health DoD has a long-time focus on bio threats, even prior to the GHS Agenda Increased understanding and awareness improves force health protection for force Activities within force health protection, countering weapons of mass destruction, threat

reduction, building partner capacity, and supporting Science & Technology programs complement GHS Agenda objectives

Prevention, detection and response require holistic solutions through strengthened relationships with health services, other government and industry partners, and academia Cooperation is a force multiplier; cross-cutting collaboration is required at the national as well as

the international level The GHS Agenda offers DoD and other militaries a framework within which to engage and better

coordinate with interagency (other ministries) and international partners

MULTI-SECTORAL: IN US, DOD is in SUPPORTIVE ROLE with other elements of our government

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Defense Programs in Support of GHSA

DoD Cooperative Threat Reduction (CTR)/Cooperative Biological Engagement Program (CBEP) Enhance partners’ biosafety and biosecurity systems to consolidate and secure collections of

pathogens and diseases of security concern to prevent the diversion or accidental release of such pathogens

Enhance partners’ capability to survey, detect, diagnose, and report outbreaks of pathogens of security concern in accordance with international reporting requirements

In FY2014, DoD CBEP leveraged collaboration with the Centers for Disease Control and Prevention in ten countries to enable more efficient threat reduction efforts

Armed Forces Health Surveillance Center/Global Emerging Infections Surveillance and Response System Division (GEIS) Conducts public health research and surveillance for force health protection Supports timely, effective, agile response to outbreaks and emerging threats Develops, disseminates and coordinates new surveillance capabilities in the DoD overseas

laboratories Facilitates interagency, intergovernmental and NGO collaborations Facilitating the “multi-sectoral” aspect of the GHSA; bring MoDs to the table

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DoD HIV-AIDS Prevention Program (DHAPP)

• HIV prevention and education program involved in over 80 countries

• Why is the DoD concerned about HIV?– We send our service members into environments

where HIV is a major risk

– But foreign strains of the virus are not an area of focus for National Institutes of Health (NIH)

– DoD is thus a natural actor to tackle the issue in a global context

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Infectious Disease Vaccine Research

US Military HIV Research Program led first HIV vaccine to show efficacy

– RV144 was international collaboration involving NIH, Thai government, and private industry

– 16,000 Thai volunteers– Showed a preventive vaccine IS possible

Advancing three Ebola vaccine candidates – MHRP sites in Africa leveraged for Ebola vaccine research– Conducted first Ebola vaccine study in Africa– Ongoing trials in Uganda and Nigeria– US trial of VSV-EBOV candidate at Walter Reed Army

Institute of Research (WRAIR)

Key capabilities for responding to the next infectious diseases crisis

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Artemisinin-resistant malaria

• We have seen a 50% decline in malaria prevalence in Africa—amazing global health success story

• Artemisinin-resistant malaria, however, remains major concern in Mekong Delta/Southeast Asia

• DoD is already working closely to coordinate malaria control efforts with President’s Malaria Initiative (PMI), Global Fund for Tuberculosis, Aids, & Malaria (GFTAM), and the Bill and Melinda Gates Foundation

• But If ARM were to expand to vulnerable regions like Africa, could undo decades of progress in malaria control

• DoD needs analogue to DHAPP to combat spread of ARM—partner with foreign militaries to create an environment for effective surveillance, prevention, and treatment of disease

• Just as HIV threatened global stability and we needed DHAPP, malaria represents a similar threat

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Combatting Antibiotic Resistance

• Whole of Government / Whole of Nation Responsibilities (Government and Private Sector engagement) • White House – led conference

• Federal Leadership -- HHS / Agriculture / DoD

• Presidential Action Plan

• DoD Role – Antimicrobial Stewardship• Multi-drug Resistant Organism Repository and Surveillance Network

(MRSN)

• Bioinformatics pipeline – 25 genomes per week

• Medical research and development in infectious disease

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Protection Against Infections Disease ThreatsGlobal Infectious Disease Forecasting

Major interagency initiative from White House Office of Science & Technology Policy (OSTP)

• Improved forecasting is a national security imperative…highlighted by West African Ebola outbreak

• The Armed Forces Health Surveillance Center (AFHSC) leads public health / infectious disease surveillance efforts for DoD, and is positioned to support the OSTP effort.

• Research and development funding may be needed to augment the AFHSC effort to apply transformative forecasting approaches to real-world crises of DoD and national security relevance.

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Protection Against Infections Disease ThreatsGlobal Infectious Disease Forecasting

• Infectious disease forecasting must:

– Incorporate the traditional components of traditional forecasting models

– Along with the more challenging elements of anticipating human behavior on a global scale • across multiple cultures • and types of government

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DoD Global Health Engagement Council (MORE TO COME)

• Update with relevant info in late fall

• Add GHE consortium as details jell

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USUHS Center for Global Health Engagement

• Developing center of gravity for GHE-related work

• Fill out details post-establishment

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The Future of GHE

• Health engagement is going to be the major pillar supporting the DoD’s vision and effort to partner around the world.

• Doing this right better supports the US Government, DoD, and our partner nations in developing capability and capacity.

• This not only makes our partners more secure, but it makes the world more secure.

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BACK-UP / HOLD

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CE/CME Credit

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