Vectors Without Borders
The Spread of Global Pathogens Can Imperil Us All
By Jennifer Brower and Peter Chalk
Jennifer Brower is a science and technology policy analyst. Peter Chalk is a political scientist.
This year's outbreak of severe acute respiratory syndrome (SARS) in Beijing, Hong Kong, Taipei, and Toronto is only one of the more recent examples of the challenge posed by infectious diseases. Highly resilient varieties of age-old ailments— as well as virulent emerging pathogens—are now prevalent throughout the world. These illnesses include cholera, pneumonia, malaria, and dysentery in the former case and Legionnaires' disease, acquired immune deficiency syndrome (AIDS), Ebola, and SARS in the latter. In the United States, West Nile virus entered New York in 2000 and then spread to 44 states by 2002, and monkeypox struck the Midwest this June.
In the latter half of the 20th century, almost 30 new human diseases were identified. The spread of several of them has been expedited by the growth of antibiotic and drug resistance. Globalization, modern medical practices, urbanization, climate change, sexual promiscuity, intravenous drug use, and acts of bioterrorism further increase the likelihood that people will come into contact with potentially fatal diseases.
The transnational threat of infectious disease deserves more attention from national governments than it has received thus far. Beyond impairing the health of individuals, the spread of disease can damage the economy, weaken public confidence in government, undermine social order, catalyze regional instability, and intensify the threat posed by bioterrorism or biowarfare.
Currently, the United States is managing the infectious disease threat; however, there are many indications that, if left unchecked, pathogens could present a serious hazard to the smooth functioning of the country. In the face of the microbial threat, the federal government could take several actions to defend the American people. Federal initiatives such as those listed below should be considered to address the vulnerabilities in the U.S. public health, medical, pharmaceutical, and biotechnological infrastructure:
- Coordinate public health authorities at all levels of government for greater interaction across state borders and local boundaries.
- Integrate private research, development, and manufacturing of vaccines and antibiotics into overall public health efforts.
- Undertake a large-scale education and information campaign highlighting disease prevention.
- Augment the supply of health care workers.
- Mobilize hospitals and emergency health facilities to develop appropriate emergency plans to respond to new diseases and large patient influxes.
- Invest more resources in foreign governments to help them enhance their internal disease prevention efforts.
Beyond these health-oriented initiatives, the United States also needs to rethink how it protects the American people from external dangers. Increased cooperation among agencies and departments that have historically had little to do with one another—including those involved with defense, justice, intelligence, public health, agriculture, and the environment—will be required, as will new executive actions to coordinate such multidimensional policy efforts.
How Disease Can Cripple a Country
The AIDS crisis in South Africa provides a disturbing example of how a pervasive infectious pathogenic organism can affect a nation at the individual, local, and national levels and even disrupt its regional and international affairs. About one-quarter of the adult population in South Africa tests positive for the human immunodeficiency virus (HIV), the virus that causes AIDS, with a disproportionate burden falling on the most productive age group in society. The full impact of the epidemic is yet to be felt. Deaths from fullblown AIDS are not projected to peak until the period between 2009 and 2012, and the number of HIV infections is still rising.
The disease is responsible for undermining social and economic stability, weakening military preparedness, contributing to increases in crime (and the lack of a capability to respond to it), weakening regional stability, and limiting South Africa's ability to participate in international peacekeeping missions. More than two million South Africans under the age of 15 will have lost their parents to AIDS by 2010 (see Figure 1), adding to the social instability. The disease is expected to remove about $22 billion from South Africa's economy through the year 2015.
Many factors have played a role in the development of the crisis, including promiscuous heterosexual sex, the low status of women, prostitution, sexual abuse and violence, a popular attitude that dismisses risk, and the failure to acknowledge the magnitude of the problem in the early and middle stages of the epidemic. Thus far, the South African government has made only a small effort to curb the epidemic, due in large part to President Thabo Mbeki's ongoing questioning of the link between HIV and AIDS and his skepticism of the benefits of western-developed antiretroviral treatments.
This policy orientation has had devastating results, something that has been acknowledged by the United States, independent nongovernmental organizations, and the international health community. The South African example serves as a pertinent lesson to other nations: If unaddressed, infectious disease can overwhelm the capabilities of a country to respond and, in so doing, detrimentally affect its future socioeconomic and human development. Indeed, HIV has already weakened the militaries and internal security structures of several sub-Saharan African nations (see Figure 2).
How Americans Are at Risk
Many of the global factors that serve to increase the threat from pathogenic microbes are particularly relevant for the United States. As American citizens continue to travel, import food and goods globally, engage in high-risk sex, use illegal intravenous drugs, and encroach on new habitats, they will inevitably expose themselves to virulent organisms.
Despite this reality, public health has been accorded a low priority in the United States for the last 30 years—in part because of the belief that technological advances would solve the challenges posed by microbes. Reflecting this inattention, several critical weaknesses are currently undermining the effectiveness of the country's disease prevention and mitigation efforts. Principal areas of concern include (1) the inadequacy of surveillance mechanisms, (2) fiscal neglect, (3) a lack of personnel with experience in recognizing and treating emerging infections, (4) a shrinking capacity to produce needed vaccines and therapeutics, and (5) a lack of coordination for many of these functions.
Although resources have been infused into the public health system in the two years since the anthrax attacks of 2001, the public health and medical infrastructure across the United States remains variable today and inadequate in many cases to deal with naturally occurring or manmade outbreaks of infectious disease. This infrastructure includes hospitals, clinics, public health laboratories, vaccine production, veterinarians, universities, and research groups. Resources and responsibilities for responding to outbreaks lie mainly with the states, further contributing to the variability. The Centers for Disease Control and Prevention acts as the lead federal entity for public health threats, with the exception of bioterrorism, which falls under the jurisdiction of the U.S. Department of Homeland Security.
Certainly, the anthrax attacks have focused attention on the need for a strong public health infrastructure. Policymakers have begun to make funds available to address some of the shortcomings. However, this investment must be sustained, and there is considerable work to do in enhancing overall policy coordination, management, and development.
The U.S. federal government should consider playing a more concerted role in providing resources and instituting uniform standards for the national defense against infectious diseases, while allowing state and local authorities flexibility in meeting these standards. Increased federal investment could provide the basis from which to develop a functional, coherent national policy for combating infectious diseases. We elaborate here on the six kinds of initiatives mentioned previously that federal officials could pursue.
First, coordination among public health authorities at all levels of government needs to be enhanced substantially to allow for greater interaction across state borders and local boundaries. Progress in this area should proceed in conjunction with steps to improve the integration of surveillance systems and data formats and to expand research capabilities for detecting and identifying infectious diseases.
Second, the private sector needs to be integrated into overall public health efforts, particularly in relation to the research, development, and manufacture of vaccines and antibiotics and the development of microbial surveillance technology. The federal government might wish to subsidize the market for new products by agreeing to guarantee minimum purchasing contracts.
Third, a large-scale education and information campaign should be undertaken, explaining the need for regular vaccination and highlighting the dangers of unprotected sex, needle-sharing by drug users, and excessive antibiotic use. These programs must be conceived in such a way that their meaning is not lost on the layperson (as has occurred with an AIDS publicity campaign in South Africa).
Fourth, efforts should be made to augment the supply of health care workers currently available in the country. One way to achieve this would be to create a dedicated public health service reserve that could be activated in case of an emergency. This force could be trained for duties such as administering drugs and vaccinations and trained on a schedule similar to that of military reservists—one weekend a month and two weeks a year. Over the longer term, money will be needed to support public health education components at universities and to facilitate ongoing professional training. Some progress has been made in this area, including the Nurse Reinvestment Act of 2002.
Fifth, hospitals and emergency health facilities need to develop appropriate emergency plans to respond to new diseases and large patient influxes, such as those that might occur in the aftermath of a bioterrorist attack or the introduction of a serious infectious agent—for instance, the Ebola virus—through airplane travel. Medical receiving facilities should be able to provide surge capacity in hospital beds and have auxiliary communication systems and power networks in place.
Sixth, more resources need to be invested in foreign governments to help them increase the effectiveness of their internal disease prevention efforts. There could be mutual aid agreements for the sharing of biological intelligence, research, diagnostics, personnel, vaccines, antibiotics, medical devices, and treatment and prevention techniques. The United States could help to create dedicated regional health surveillance networks, to promote sustainable urban development schemes, and to focus efforts against disease-promoting catalysts, such as unprotected sex.
How the Field of Public Health Can Play a Larger Role
Beyond these specific recommendations, general assessments and forecasts of emerging biological dangers need to be strengthened. Analyses that inform government decisionmaking should be more thoroughly grounded on scientifically formulated models that integrate epidemiological literature with medical research on new and reemerging diseases. Overseas monitoring activities should also be expanded to include such things as the effectiveness of national medical screening systems; the geopolitical, social, economic, and environmental conditions that affect disease incidence; and a state's compliance with international health conventions and agreements.
Given the influence that the United States retains in a variety of international organizations, Washington could play a leading role in adapting them for a global health role. In this regard, the United States could capitalize on efforts that have already been established within some of these institutions to perform collective political, military, and humanitarian missions around the world.
Measures such as these will require political leadership and sustained financial commitment. Considerable attention and resources are now flowing to build defenses against the unlikely scenario of a large-scale bioterrorist attack. Yet responses to more commonly occurring and currently more taxing natural outbreaks of disease remain relatively underfunded.
This policy lacuna is worrisome. Not only have deadly and previously unimagined illnesses emerged in recent years, but established diseases that were thought to have been tamed just a few decades ago are also returning, many in virulent, drug-resistant varieties (see Figure 3).
State-centric efforts to safeguard citizens are clearly unable to deal with influences such as infectious diseases, the effects of which transcend international boundaries to affect the security and welfare of people worldwide. The unique challenges posed by microbial threats cannot be territorially bounded. They need to be understood and addressed in a larger global context.
The Global Threat of New and Reemerging Infectious Diseases: Reconciling
U.S. National Security and Public Health Policy
Jennifer Brower, Peter Chalk, RAND/MR-1602-RC, 2003, 173 pp., ISBN 0-8330-3293-3.