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How did warning build or develop over time?

The SARS outbreak in 2002 gave the U.S. a glimpse of what could occur during a modern pandemic and would serve as a warning that the next one could be worse. Information leading up to 2020 indicated a pandemic would be disastrous and existing planning was not appropriate. Various government and civilian agencies raised awareness, and some offered solutions and disaster recovery plans. Over time, conceptual scenarios turned into vulnerability warnings making it clear that a pandemic was a question of “when” not “if”.

In our after action or current action review (Coronavirus has not been eradicated) a consistent timeline was drawn from the first NIE in January 2000 through the current period.

How clearly were likelihood and implications communicated?

Many sources stated the likelihood in a clear manner. The implications were consistently determined to be serious. A pandemic was deemed to be likely and high impact.  There were numerous examples across all of the sources as to the potential for a global pandemic and referenced the 1918, 1956, 1968 pandemics as well as the more recent MERS-CoV, Ebola, and SARS outbreaks.  A common theme throughout the sources were the dynamic and rapid evolution of a threat.

How timely? Did policymakers theoretically have time to take appropriate actions?

A pandemic response playbook for the Executive Office of the President was created in 2016. Most recent warnings were mentioned in 2019, with enough warning to create a plan, prepare supplies, and begin looking for indicators.  In fact as far back at 2000 with the NIE in January of 2000 disseminated key issues and implications for an impending pandemic.

What were the key challenges the analysts faced?

Some sources state political issues caused challenges for the analysts. They produced a product that was not used appropriately.  Also, intelligence fusion and integration across the interagency was not consistent as other near-term and current operations competed for policymakers' priorities.

How accurate?

The specific location of an outbreak and specific disease were topics of debate, but the result of an outbreak were similar across most sources. Broadly speaking, there was to be mass disruption across the globe with all elements of daily life disrupted.  Our research indicates many previous pandemics have initiated in the eastern regions of the World however due to changes in climate, migration, and global transportation, no confirmed place of origin could be definitely established.

*Document                                Team member*
2000-NIE                                   Braswell
2003-NIC Report SARS            Saucedo
2016-WHO Report                      -
2016 - Pandemic Playbook      Hap
2016- Ebola Memo                    Girod
2017-USNORTHCOM                Braswell
Branch Plan
2017-G'town Global Health      Hoffman
2018- WHO R&D Blueprint       Girod
2019- Preparedness Index      Hoffman
2019- Statement for the           Girod and Yitzhak
Record US IC
2019- FEMA Assessment         Green
2019- Crimson Contagion        Girod
2019- Congressional                 Follett
Testimony

Summary written by Braswell, Hap, Green, and Saucedo

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NIE 99-17D The Global Infectious Disease Threat and Its Implications for the United States

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NIE 99-17D The Global Infectious Disease Threat and Its Implications for the United States

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(01/2000):
https://www.dni.gov/files/documents/infectiousdiseases_2000.pdf

Warning intelligence at the strategic level-indications intelligence report issued by the National Intelligence Council:  Key Judgements: New and reemerging infectious diseases will pose a rising global health threat and will complicate US and global security over the next 20 years.
"These diseases will endanger US citizens at home and abroad, threaten US armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests."

This is a National Intelligence Estimate so at the strategic level. It represents input and analysis from the IC.  It examines the most lethal diseases globally and by region; develops alternative scenarios about their future course; examines national and international capacities to dealwith them; and assesses their national and global social, economic, political, and security impact. It then assesses the infectious disease threat from international sources to the United States; to US military personnel overseas and to regions in which the United States has or may develop significant equities.c.  The methodology incorporated data analysis in developing a typology used to analyze impact regionally.d. Does it communicate strategic, operational, or tactical warning? The NIE is strategic in nature.e. What are the types and the quality of the intelligence used? DIA/AFMIC (Armed Forces Medical Intelligence Center) analysis incorporated f. Is the argument based on observation, analogy, historical patters, or a combination? A combination of historical patterns and observation are used.   Three potential scenarios. 1. Stead progress 2. progress stymied, and 3. deterioration, the limited improvement.  Factors affecting growth and changes in human behavior are considered key drivers.i.  The NIE presents the probability of a bioterrorist attack against US civilian and military personnel overseas or in the United States also is likely to grow as more states and groups develop a biological warfare capability. It suggests the development of a global surveillance and response system to identify outbreaks and coordinating action without overtly calling it a recommendation.  Alternative Futures Analysis method was used to which included examining three plausible scenarios for the course of the infectious disease threat over the next 20 years (2000-2020).  The scenarios were influenced by three sets of variables. The first is the relationship between increasing microbial resistance and scientific efforts to develop new antibiotics and vaccines. The second is the trajectory of developing and transitional economies, especially concerning the basic quality of life of the poorest groups in these countries. The third is the degree of success of global and national efforts to create effective systems of surveillance and response. The interplay of these drivers will determine the overall outlook.  “New, and reemerging infectious diseases will pose a rising global health threat and will complicate US and global security over the next 20 years.  These diseases will endanger US citizens at home and abroad, threaten US armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests.”  As this NIE is at the strategic level, trends and regions and areas are discussed versus specific instances of potential threat.

This NIE is useful as a strategic warning piece on the breadth of impact a pandemic would have and I found the SAT well developed through the scenario based analysis. I think unless a policymaker had a completed understanding of the problem set this may not reach a wide audience. Note. the impact beyond health and on the economic and security of the U.S. informative.

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NIC Report: SARS: Down But Still a Threat

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NIC Report: SARS: Down But Still a Threat

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(2003): This report was written by an intelligence officer in the IC at the request of the Health and Human Services Secretary and other Health officials. This product serves as a warning of the possible resurgence of SARS and the implications associated with it. The analyst brought in experts from their fields to contribute to the analytical process and achieving a consensus on this judgment. The report communicates a strategic warning identifying SARS as a looming threat that has not been completely irradicated. The report uses data and information gathered from the WHO, CDC, NIH and other health experts. The arguments are based on the history of the SARS epidemic in 2003 and observations on the economic impact and successful ways to slow the progress of the disease. The report identifies 3 different scenarios. The report is objective, clear of any political stance. The assumptions and limitations are clear as well as the warning. The warning itself is very thorough in identifying several issues that could arise due to the possible resurgence of SARS.

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(2016): This is a recommendation to the WHO on a basic outline of emergency preparedness, which includes monitoring, communications, responses, etc.

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Executive Office of the President of the United States -Playbook For Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents AKA "The Pandemic Playbook for Dummies"

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Executive Office of the President of the United States -Playbook For Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents AKA "The Pandemic Playbook for Dummies"

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(2016):
a.      Who wrote it? Is it the product of an individual agency or office, a combination, or a community product? This Playbook is a product of the Executive Office of the President of the United States of America. This document is a product of the Executive branch, likely informed by all source analysis from reports across the Intelligence Community.

b.      What kind of product is it? What is its purpose? (as a product type) This is an Executive Branch Playbook. The purpose is to guide domestic and international decision-making in the event of a pandemic either at home or abroad. It is a decision-making tool that identifies what questions to ask, whom to consult, and the critical decisions which may require deliberation through the National Security Council.

c.       What does it say about the analytical process involved in reaching the judgments? Notably, this is a playbook designed to assist complex national-level decision-making on complex and emerging threats. Per the module 12 lecture, emerging threats are within the six-month time frame. The playbook enables targeted subject matter input from relevant agencies within this emerging threat timeline.

d.      Does it communicate strategic, operational, or tactical warning? This product is designed to help national-level decision-makers digest intelligence and make strategic-level decisions. It specifically highlights that the DOD’s Armed Forces Health Surveillance Center and National Center for Medical Intelligence (in conjunction with the Department of Homeland Security) have the ability to answer questions from decision-makers regarding epidemiology and country-dependent questions (Department of State would assist in the event of a pandemic originating overseas). The document states that the NCMI would “provide assessments of foreign health threats, including pandemic warning, to prevent strategic surprise across the broad threat spectrum.”

e.      What are the types and the quality of the intelligence used? The Executive Branch would use All Source intelligence from across the IC and US Government. It cites past examples of epidemics and pandemics such as the February 2003, Severe Acute Respiratory Syndrome pandemic which spread across 20 countries before being contained. It also cites the 2014 Ebola outbreak as well as the MERS-CoV and the Zika outbreaks as a sources of information.

f.        Is the argument based on observation, analogy, historical patterns, or a combination? In the event the playbook is implemented, the intelligence would be based on a combination of observation and historical patterns due to pulling intelligence from multiple agencies and sources. For example, the CDC would dispatch officers to the field which would generate field reporting, similarly, the Department of State would receive reporting from Host Nations if the pandemic was abroad.

g.      Does it identify scenarios or multiple hypotheses, drivers, etc? The playbook has example exercises that explore multiple health crisis scenarios (e.g. domestic, foreign, natural, and man-made). It also cites specific viruses that have caused crises in the past such as Bacillus anthracis, hantavirus, West Nile Virus, the Ebola Virus, and most importantly for our purposes “novel coronaviruses.”

h.      Does it refer to indications and indicators? The playbook specifically states that Epidemic Intelligence Service officers working in CDC health departments would be dispatched to investigate epidemics due to both natural and man-made causes. It specifically mentions the ability to be treated through pharmaceutical interventions, whether the pathogen is known scientifically, its mode of transmission, the ability to sterilize surfaces the pathogen comes in contact with, clinical severity, and degree of transmissibility as possible indicators of a potential future health crisis.

i.        Is it objective? Is the analysis imaginative (in the intelligence sense)? The playbook itself is an objective policy document and decision-making tool, informed by past intelligence reporting and Executive operations planning tools.

j.        Does it employ structured reasoning techniques? (SATs or other) Not directly.

k.      Are assumptions and limitations clearly stated? The document contains a significant number of assumptions for the Decision-Making Rubric for Assessment and Response. Assumptions are clearly stated in both foreign and domestic health crisis situations. Of specific interest to intelligence analysts, is the section covering indicators specifically what the document describes as the four areas of risk “ epidemiological indicators, humanitarian/developmental/public health impact indicators, security and political stability indicators, and its [the pathogen’s] transmission/outbreak/potential for public concern in the United States.”

l.        Is the warning clear and explicit? N/A for this document however in the scenarios warnings and threat levels are clearly articulated.

m.    How detailed is the warning and justification? N/A

Overall, the document, while not exactly an intelligence report, adds to the body of USG literature that predicts a future pandemic of national concern. The report specifically highlights novel coronaviruses as a “pathogen of heightened concern.” While the likeliness of a pandemic is not explicitly stated within the text the assumption is that it is nearly inevitable. Moreover, the document implies that a pandemic would be an event with great national security and international security implications. The report itself was designed to be used by the highest levels of the US government and it clearly articulates the threat of epidemics and pandemics.

Reference:
https://stacks.stanford.edu/file/druid:hy459js4845/Pandemic-Playbook.pdf

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Memorandum For Ambassador Susan E. Rice: NSC Lessons Learned Study On Ebola

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Memorandum For Ambassador Susan E. Rice: NSC Lessons Learned Study On Ebola

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(07/11/2016): This memorandum was written as a means of relaying the assessments of several researchers into one summarizing document. The author is Dr. Christopher Kirchhoff, a political scientists who has worked for the Department of Defense, the White House, and the National Security Council (NSC). At the time the report was written, Dr. Kirchhoff was the Director fo Strategic Planning at the NSC during the Obama administration. The recipient, Susan Rice, was the US National Security Advisor. Contributions to the report were made by various agencies, including ODNI. While some contributions were quite large and include interviews from hundreds of employees, the assessment is ultimately made by Dr. Kirchhoff’s individual evaluation of the outbreak and the materials provided to him by other agencies. The report states that prominent points of issue when trying to contain the Ebola outbreak were problems with inter-agency communications, limits of authority, and timeliness. Dr. Kirchhoff warns that more frequent pandemics are imminent and that the weaknesses articulated in the document must be addressed to mitigate future tragedy. He identifies factors such as globalization, urbanization, and increased international travel as increasing the likelihood of a future outbreak.  The memorandum is largely a summary of events that took place during the Ebola outbreak and identifies successes and failures at each step, making it mostly reflective in nature, though it could be argued that identifying failures is a method of imagining hypothetical alternative outcomes. The document highlights the importance of handling public response to and news coverage of domestic outbreaks, limiting hysteria, and maintaining trust. It also praises innovations like electronic health records and contact tracing apps for reducing the spread of disease. The report emphasizes the need for improved preparedness and protocol and stresses the likelihood of another pandemic occurring in the near future.

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USNORTHCOM Branch Plan for Pandemic Influenza and Infectious Disease Response 06

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USNORTHCOM Branch Plan for Pandemic Influenza and Infectious Disease Response 06

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(01/06/2017):
https://irp.fas.org/agency/dod/northcom-influenza.pdf
Operational Plan incorporating strategic and operational warning intelligence report.
Warning intelligence at the strategic level or indications intelligence:  DOD, NORTHCOM, a CONUS US Component Command drafted this branch plan which is a sequel representing an evolution of planning based on analysis of a potential or future threat to the strategic and operational interests of the US. While NORTHCOM developed the plan it incorporated input from across the US interagency.  This branch plan was designed to provide guidance for operational actions in response to a “significant infectious disease outbreak.” While it is an operational guidance is the overall intent of this product, it also presents dilemmas that could be future challenges.  The analytical process is very much scripted using a defined methodology. This is not to say it is not useful. The process while highly regimented allows for factor analysis of potential threats as well as opportunities as it relates to the strategic and operational interests of in this case, NORTHCOM.  This plan and warning assessment of the operational environment intelligence assessment as part of the overall operational plan.  The assessment is based on historical patterns or examples such as the 2009 H1N1 Pandemic Influenza, 2012 MERS-CoV), 2013 H7N9 Avian Influenza, 2014 Ebola Virus Disease (EVD), and 2015 Zika Virus outbreaks in addition to “Spanish Flu” (which may have come from US soldiers going to Europe during WW1, 1957 Asian Flu, and the 1968 “Hong Kong Flu.” The plan outlines significant factors and drivers versus scenarios although the assessment does present artificial and natural risks from potential human-made and naturally developing disease.  I&W including biosurveillance consisting of biosphere data and identifying disease activity and threats to humans or animal health.  The causation while an important aspect of the assessment, the link between animals and humans is the most imaginative in that it draws possible impact based on potential infection. The intelligence assessment to the branch plan utilizes a cone of plausibility technique developed by the intelligence analysts assigned to the J2 branch of NORTHCOM to identify key tripwires and conditions that would provide indications that the threat from a virus is likely imminent.  In this plan it is the priority intelligence requirements that present the nature of the threat and drivers which includes scenarios informed by the historical cases I’ve listed above. The failure of imagination may not be as applicable in this case since this assessment informs an operational approach.  The assumptions presented suggest some initial warning and building of indicators that would suggest that an outbreak or pandemic is likely. If those tripwires and conditions are met then the likelihood of a pandemic increases.  There is a clear warning on the potential however the reality that viruses such as Coronavirus are dynamic and morph, highlighting the uncertainty in pinpointing what type of virus and where the epicenter will be change the intent of this plan and the intelligence assessment to the plan is not designed as a tactical warning product. It does provide several recommendations including support to and by the NCMI, CDC, NBIC.

This report "specifically identified coronaviruses as a potential threat" and the lack of preparedness that would exacerbate a potential infectious disease pandemic.

The report does not however provide an alternative of analysis on how a foreign actor could or may try to use a pandemic to threaten the strategic interests of the US or allies.

This branch plan serves as an operational level warning and plan to identify key drivers that may contribute to an outbreak and coordinate response to a pandemic. The level of imagination is fairly limited given the intent of this product. A more effective document may be the intelligence assessment itself of the threat coronavirus and warning tripwires that would inform a policymaker.

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Georgetown Global Health Security Assessment

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Georgetown Global Health Security Assessment

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(2017): A 2017 Georgetown assessment (based off of a symposium in 2016) about the world could have better handled an "explosive pandemic". The assessment mentions potential damages of large virus outbreaks such as SARS, influenza, or zika, and discusses the potential impact on a range of topics, to include social, political, economic, security, etc. Many of the predictions for a major pandemic outbreak line up with the outbreak of COVID-19 that we saw starting in early 2020 and onwards.

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WHO Research and Development Blueprint 8 Prioritized Diseases

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WHO Research and Development Blueprint 8 Prioritized Diseases

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(2018): WHO’s 2018 Research and Development Blueprint consists of the 8 diseases most likely to cause a public health emergency. This list is updated every year as a way of documenting potential health threats that demand greater attention. This list is sparse in information and gives little detail on why each disease is chosen. The stated requirements are “epidemic potential and/or whether there is no or insufficient countermeasures.” There is little to say about the quality or content of the warning and it is more science-focused than intelligence-focused. While COVID-19 is not specified by name (it is included on the now-updated list), the Blueprint leaves a designated spot on the list for “Disease X.” This is meant to represent the threat of an unknown disease to the world as a whole. Not a warning for a specific type of disease or outbreak, this list still shows the need for constant vigilance and preparedness.

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(01/29/2019): In 2019 BMJ Global posted this extensive article with lots of well sourced material. It assessed that "Estimates of epidemic preparedness drawing on Joint External Evaluation (JEE) data show that many countries are unready for a major outbreak." It further went on to develop and "Epidemic Preparedness Index", which was accompanied by framework for global proper preparedness and response.

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Statement For The Record Worldwide Threat Assessment Of The Us Intelligence Community

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Statement For The Record Worldwide Threat Assessment Of The Us Intelligence Community

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(01/29/2019):
Girod: This document provides information on threats to the US in all areas, including public health. Presented by the Director of National Intelligence, Daniel Coats, this is the product of the Senate Select Committee on Intelligence. Public health threats make up a small portion of this report and are mostly focused on already-documented diseases like malaria and Ebola. However, brief blurbs mention the vulnerability of the US to a pandemic and high mortality rates. The report hypothesizes a reliance on US resources and damage to the global economy should such an outbreak occur. Areas of identified risk were countries in South America, Central/Eastern Asia (not China), and the Middle East. These countries were identified by their current regional conflicts and rates of displacement, as well as neighboring countries. The report also mentions the growing risk of human proximity to animals. COVID-19 was erroneously attributed to contact with bats, but the source of SARS-CoV-2 has not yet been identified. While the warning highlights the possible disastrous impacts of a pandemic, the true risk of an incoming pandemic is not articulated. Political turbulence is identified as the most likely driver as it had affected the mitigation of known diseases at that time.

Yitzhak: This report assess and warns of the following:
"The United States and the world will remain vulnerable to the next flu pandemic or largescale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support."
The report also adds that improvements to global health security will be "inadequate to address the challenge of what we anticipate will be more frequent outbreaks of infectious diseases because of rapid unplanned urbanization, prolonged humanitarian crises, human incursion into previously unsettled land, expansion of international travel and trade, and regional climate change."

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FEMA Threat and Hazard Identification and Risk Assessment

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FEMA Threat and Hazard Identification and Risk Assessment

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(07/25/2019): The product was created by the Federal Emergency Management Agency. This is a product of a single agency but “The intended audience is emergency management officials engaged in risk assessment at the community and Federal level, as well as other practitioners in the private sector or academia.” Other agencies provided expertise and were involved in this report. It is intended to build a broadly applicable plan that can be adapted to various high impact situations. They scenarios were chose because they could “realistically occur and challenge the core capabilities of the Nation.”(p.16) It should be seen as a warning that states problems exist and planning is needed. They developed a four-step process that involves a literature review, SME consultation, development of 29- standardized impacts, and the creation of 22 specific capabilities targets. Each element of the process is discussed in detail with examples, charts, and descriptions. Each conclusion is validated with evidence. The issues at hand have significant implications and require warning so appropriate preparations can be made. This is a product designed for application at the National Level (p.13)

The report uses prior disasters as case studies. Analysis of those case studies provide lessons learned and provided indicators based on previous events.

Historical patterns are used as a baseline for building responses. The single hypothetical scenario offers a timeline and discusses the impact of a pandemic. The CDC is relied upon for warning and this report discusses the second and third order effects of a pandemic. Multiple scenario generation is used. This is done for the purpose of creating a standardized response. Structured reasoning is discussed in detail so each scenario can be used to generate a broadly applicable response that can be easily adapted to specific issues. Warnings are not explicitly discussed but the report highlights shortcomings in preparations and lists considerations. Specific to a pandemic, the report details areas that are likely to be impacted and problems that will likely occur.

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(10/2019): Crimson Contagion was an exercise, or series of exercies, conducted by the Department of Health and Human Services to assess vulnerabilities the US might experience in the case of an influenza pandemic. Thus, the report was produced by HHS, specifically the Office of the Assistant Secretary for Preparedness and Response. This document reviews the results of the exercise. The exercise deemed US preparedness to be “insufficient” to handle such a pandemic. Such insufficient preparedness applies to the authorities provided to HHS in the case of a pandemic as well as the funding for federal government response. Crimson Contagion was a single hypothetical simulation in which a strain of influenza infected a US traveler while in East Asia. This traveler then stopped in multiple Asian countries before returning to the US and infecting family members. Those family members then attended public events, causing the disease to spread quickly. Chicago was used as the epicenter. Though only one possible event, the simulation found that a significant exacerbator of negative conditions was the lack of communication protocol between different agencies. Local and state health agencies were unsure what to report, CDC data sharing guidelines were not clear, HHS information management system was not sufficient for handling the task at hand, and variance in terminology furthered confusion. In a sense, the “warnings,” or identified vulnerabilities, are very clear. The report identifies explicit antagonizing factors. Each claim is backed with explanation/evidence in a generally analytical format. However, it does not seem to provide flexibility in the possible scenario and how changes might affect the outcomes. Given the structure of the exercise, the findings are based on the application of a variety of SATs, though perhaps not by name, as representatives from various states and agencies played through the four-day simulation brainstorming, comparing hypotheses and possible outcomes, etc. The report does not focus on the limitations of the findings but points to areas for further investigation. The overall message to the federal government and participating entities is that the US is unprepared for an influenza pandemic.

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Flu Season Preparedness Congressional Testimony

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Flu Season Preparedness Congressional Testimony

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(12/04/2019): In this 2019 Congressional testimony Dr. Robert Kadlec discussed the partnership between the Assistant Secretary for Preparedness and Response (ASRP) was partnering with the private sector to prepare for an influenza epidemic. It assessed the R&D accomplishments of the ASRP so far and other projects being worked on as well. The report touches on two main gaps in preparedness as seen from the Crimson Contagion 2019 Function Exercise : 1. inadequate funding 2. and supply chain limitations. Supply chain issues are noted as the biggest obstacle with the U.S. being "dependent on receipt of active ingredients in America’s pharmaceutical and over the counter drugs come from China and India; this dependency also extends beyond pharmaceuticals and includes auxiliary medical supplies such as syringes and gloves" (9). Additionally, these issues are tied back to the importance of vaccine development in the case of a pandemic leading Dr. Kadlec to hone in on the inability of the U.S. to meet medical demand in the event of a pandemic. Ultimately, there is a call to action for greater investment to ensure preparedness but the consequences of not investing are not emphasized to a very high extent.