INTRODUCTION:
In spring 2007, Andrew Speaker confounded public health, homeland security, customs and border protection, transportation safety, and other federal, state, and local agency officials when, having been diagnosed with a multiple-drug-resistant strain of tuberculosis (MDR-TB), he travelled from Atlanta, Georgia to Paris, Athens, Mykonos Island, Rome, and then returned to the United States by way of Prague, Montreal, and the Champlain, New York border crossing. Speaker’s ability to evade authorities created a sobering awareness of the fault lines in U.S. strategy to contain the global spread of an infectious disease. An examination of the Speaker case, therefore, provides the Project on National Security Reform with key observations regarding U.S. strategy, interagency capabilities, and resources aimed at preventing and containing the emergence and spread of public health risks from natural or deliberate events.

STRATEGY:
Within the United States, there is no national system of public health: the organization, mission, and funding (whether from federal, state, or other sources) of public health is under the authority of the governors of the 50 states. At the federal level, the Centers for Disease Control and Prevention (CDC), U.S. Customs and Border Protection, the Transportation Security Administration, and other key agencies—acting under the guidance of national security framing documents such as Emergency Support Function 8 of the National Response Plan (and now the National Response Framework) and Homeland Security Presidential Directive 21—play a critical role in and share the burden of responsibility for preventing the introduction, transmission, and spread of communicable diseases, such as MDR-TB, across U.S. borders. The Speaker case, however, demonstrated critical seams in this structure, particularly the absence of an integrated strategy for infectious disease detection.

Without such a strategy, health and homeland security processes were implemented in an ad hoc manner during the Speaker response. The principal U.S. agencies involved in the response were slow to recognize the problem and were ineffective in quickly preparing a coherent strategy to manage the Speaker case. They also relied heavily on interpersonal, informal relationships rather than formal processes and mechanisms that might have more rapidly and effectively coordinated response efforts.

INTEGRATED ELEMENTS OF NATIONAL POWER:
When Speaker boarded a plane bound for Europe, he left in his wake numerous state, local, and federal health, homeland security, and transportation officials bereft of abilities to communicate, garner consensus, and act decisively to resolve the situation. Untimely, information sharing among local, state, and federal public health authorities caused confusion regarding the nature and risk of Speaker’s disease and delayed prompt and effective medical intervention. These and other shortcomings led to delays in the rapid and effective implementation of appropriate public health strategies that would have minimized the risk of disease transmission.

EVALUATION:
The Speaker case was a public health threat that required a high level of public health decision making, multi-sector support, and coordination with international bodies—all of which were sorely lacking. Failures in interagency communication and coordination, decision making, and understanding of legal policies and protocols for implementing public health control measures; imprecise use of border control watch lists; confusion over jurisdictional and cross-agency standard operating procedures and protocols; inadequately trained and equipped interagency workforces; and ineffective patient risk communication and management policies all contributed to the inefficient implementation of disease control policies and strategies. The Speaker case also demonstrated that the state-based public health sector is inconsistently backed by its federal consultant, the CDC. These difficulties were exacerbated by the fact that public health professionals have little to no experience working collaboratively with the defense, law enforcement, and intelligence sectors.

RESULTS:
The lack of interagency coordination and the overall ineffective response during the Speaker incident not only unnecessarily placed hundreds of individuals at risk of contracting MDR-TB, but also threatened the public’s confidence in the U.S. government’s ability to protect its citizens from public health risks. Trust that American authorities have resolved systemic failures remains low. The absence of an integrated strategy and the failure to establish effective operating procedures also called into question Washington’s commitment, credibility, and ability to fulfill its legal responsibilities under the International Health Regulations (2005) as a World Health Organization member state, thus undermining American prestige and likely America’s ability to ensure other nations’ compliance with regulations and cooperation in dealing with future biological threats. Critically, the Speaker incident heightened international awareness and, it is safe to infer, terrorists’ knowledge of America’s fault lines in dealing with issues at the nexus of health and homeland security. This result could have grave security consequences should those wishing the United States harm successfully exploit these seams in the future.

CONCLUSION:
Despite some recent improvements, the task of preparing the United States for major health emergencies that pose a threat to national security is not nearly done. The epidemiological consequences of the Speaker incident were manageable and have been contained. However, the introduction of a new or emerging communicable disease with higher virulence, infectivity, and pathogenicity—one that presents a novel threat to public health—could place far greater demands on U.S. civil, political, and economic infrastructures and could pose a far more devastating hazard to American national security. Correcting the institutional inefficiencies that are readily apparent in the Speaker case can offer a springboard from which to improve the federal government’s role in preventing and containing the emergence and spread of public health risks.