This blog is a collaborative effort between Global Health Council, Nuclear Threat Initiative (NTI)|bio, the Johns Hopkins Center for Health Security, and PATH.

The U.S. government has been a leader and financier of international action to prevent, detect, and respond to infectious disease threats both prior to and following the 2014 launch of the Global Health Security Agenda (GHSA), a partnership of more than 60 countries, international organizations, and non-governmental stakeholders dedicated to global health security. Due to important progress made possible through the GHSA, the five-year partnership has been extended from 2019-2024.

The Johns Hopkins Center for Health Security, Global Health Council, NTI | bio, and PATH recently hosted Clade X: A Global Health Security Simulation for Congressional staff to demonstrate the need for continued support to prevent serious infectious disease threats. The simulation—an abridged, modified version of the original day-long Clade X pandemic exercise designed and hosted by the Center for Health Security—was conducted to highlight the necessity for effective preventive interventions and the importance of accountability of government agencies during global health crises. The exercise gave Congressional staff a window into the choices government leaders must make during a pandemic.

The exercise highlighted the need for the U.S. to play a leadership role in the global health security community and for countries to work together to develop a robust pipeline of countermeasures to mitigate the impacts of outbreaks; create transparent international action plans that measure progress; and support sustained global health security funding that advances health security preparedness in low- and middle-income counties. Overall, participants emphasized the need for the Administration and Congress to work together to develop and support a comprehensive U.S. strategy for pandemic preparedness.

During the simulation, Dr. Tom Inglesby, Director of the Center for Health Security, played the role of National Security Advisor to the President, with co-facilitation by Carolyn Reynolds, Vice President of Advocacy and Policy at PATH, and Dr. Beth Cameron, Vice President for Global Biological Policy and Programs at NTI. While the scenario was fictional, it gave participants a realistic perspective into what it is like to face multiple reports of disease outbreaks occurring simultaneously in Venezuela and Germany.

(Left to Right): Dr. Tom Inglesby, Carolyn Reynolds, Dr. Beth Cameron, and Dr. Jennifer Nuzzo.

As part of the fictional scenario, Congressional staff were tasked with providing recommendations to the President about whether to, and how the U.S. should respond to the scenario. Among the most significant challenges were: requests for global aid amid an impending national crisis; requests for U.S. military and public health intervention in various geopolitical environments; and processing information about the severity and longevity of the outbreak in the context of a constrained national budget. An additional challenge throughout the exercise was the lack of timely and specific information, mimicking the lack of reliable data that exists to inform leaders during a real global health crisis.

As a result, participants grappled with providing timely resources to affected countries. Delays in aiding highlighted that if previous investments in disease detection and reporting systems had been made, more information would have been available to inform response decisions, and ultimately, fewer people would have died.

In the second half of the simulation, participants discussed the impact of a reported outbreak of Clade X in Niger, as well as a new outbreak in a small college town in the United States. During this session, the conversation focused on the impact of the outbreak on U.S. domestic and foreign policy. Thorny issues also arose regarding the need to protect Americans and military personnel abroad while at the same time contributing to an international response effort.

Following the simulation, the non-governmental sponsors led the group through a “hot wash” discussion about Congressional roles in preparing for and responding to outbreaks, including deployed public health personnel to help with disease  prevention; providing for robust disease-detection data; and identifying channels for coordination and communication across the executive and legislative branches.

The simulation painted a realistic picture of global health security risks in action—the lack of emergency preparedness and planning, absence of clear authorities, and poor communication with the public—and was a reminder that viruses know no borders. Today, more than two-thirds of countries are still not properly prepared to address pandemic threats. A severe infectious disease pandemic could cost more than 1 million U.S. lives and up to $6 trillion to contain*. Although a growing number of countries are taking steps to prepare for the increasing risks of emerging infectious diseases, sustained political commitment, financial support, technical assistance, and partnerships are needed to strengthen the capacity of every country to prevent, detect, and respond to global health threats.

Regarding the original Clade X, from the Johns Hopkins Center for Health Security website:

The original Clade X was a day-long pandemic tabletop exercise hosted by the Johns Hopkins Center for Health Security that simulated a series of National Security Council-convened meetings of 10 U.S. government leaders, played by individuals prominent in the fields of national security or epidemic response. The exercise illustrated high-level strategic decisions and policies needed to prevent a severe pandemic or diminish its consequences should prevention fail.

At the conclusion of the exercise on May 15, 2018, the Center for Health Security presented 6 strategic policy goals needing commitment from the United States to prevent or reduce the worst possible outcomes in future pandemics. Those recommendations are:

  1. Develop capability to produce new vaccines and drugs for novel pathogens within months not years.
  2. Pioneer a strong and sustainable global health security system.
  3. Build a robust, highly capable national public health system that can manage the challenges of pandemic response.
  4. Develop a national plan to effectively harness all US healthcare assets in a catastrophic pandemic.
  5. Implement an international strategy for addressing research that increases pandemic risks.
  6. Ensure the national security community is well prepared to prevent, detect, and respond to infectious disease emergencies.

To learn more about Clade X and access an extensive repository of materials from the exercise, please click here.


*Gostin, L.O., Mundaca-Shah, C.C., & Kelley, P.W. (2016). Neglected Dimensions of Global Security: The Global Health Risk Framework Commission. JAMA, 315(14), 1451-1452