Why Global Health Security Is Imperative

By Thomas R. Frieden

When he opened the box, André Berro was wearing surgical gloves, mask, and eye protection—routine protocol for a CDC quarantine public health officer, but this was not a routine package. A U.S. Customs scan of the airmail package that arrived at the San Francisco airport from the Philippines showed an outline of what looked like several human skulls.

Or non-human skulls. When Berro lifted the lid, he found himself staring into the empty sockets of a skull with huge horns connected to each temple with leather straps. He found other skulls strapped together with plant-based ropes in triangular and other shapes. One skull, attached to a spine of unknown species, was wrapped with ropes which had animal teeth inserted. Many of the skulls were decorated with feathers or cloth. Some still had remnants of decaying flesh.

Had the package reached its U.S. destination, any of these objects could have been the source of a disease outbreak. The objects apparently came from different remote regions of the South Pacific. The human remains could have carried bloodborne pathogens; the leather and animal skins could have carried anthrax; the feathers could have come from birds infected with deadly influenza; the cloth might have been burial shrouds from people who died of hemorrhagic fever.

All of these alarming materials were confiscated by CDC before they could do any harm. But Berro’s grim discovery was the exception, not the rule. Real health threats usually look innocuous. They arrive every day, along with millions of people and millions of tons of cargo that enter the U.S. from all parts of the globe. Berro’s San Francisco station is one of 20 CDC Quarantine Stations that monitor U.S. ports of entry by air, land, and sea.

This is one line of defense. The front line is wherever diseases break out. With the globalization of travel and trade of foods and drugs, dangerous pathogens that arise anywhere in the world are just a plane ride away. U.S. national health security depends on global health security, because a threat anywhere is a threat everywhere.

That is why this morning, the Centers for Disease Control, working in partnership with the Department of Defense, announced that we will be committing $40 million to 10 additional countries to continue this kind of initial rapid response and increase progress toward global health security.

These threats come from three directions. Emerging diseases don’t just happen in the movies. Every day the CDC starts a new investigation; on average we turn up one new disease-causing organism every year. In 2011 we found three. As I write, the second wave of the deadly H7N9 avian flu is hitting China. We’ve been lucky that this strain hasn’t, yet, learned to pass easily from person to person. New diseases are inevitable, but new epidemics aren’t.

Drug-resistant infections are the second and perhaps most pernicious threat we face. Already the nightmare bacteria called CRE (carbapenem-resistant enterobacteriaceae), resistant to most or all antibiotics, have gone from a single patient in one state in the U.S. to at least 47 states and thousands of patients. Extensively drug-resistant tuberculosis bacteria are another example of why the end of the antibiotic era is already close for some infections. When I was in charge of tuberculosis control in New York City in the early 1990s, I cared for a man with extensively drug-resistant tuberculosis. It took two years, surgery, extended periods of intravenous antibiotics, and more than $100,000 to cure him. A few years later, I helped his village in India set up a treatment program that would have prevented his resistant infection for less than $10.

A third threat is the intentional creation and intentional or accidental dissemination of genetically altered infectious agents. We’ve already seen anthrax deployed in domestic terrorism. An inevitable but unfortunate downside to recent scientific advancements is that there now exist both high-tech and low-tech ways to create more virulent, drug-resistant, potentially vaccine-evading, highly contagious organisms. And the costs of creating such agents are dropping fast.

No single country can achieve global health security by itself. Ensuring national health security means working with international partners.

CDC partners with nations all over the world to detect and respond to disease outbreaks and natural disasters. Holding the front line are more than 1,600 CDC staff in more than 60 countries, leveraging their expertise by working with ministries of health to train new public health experts in fields ranging from community health to laboratory science.

These people, working in their own countries, hold the front line against global health threats. We need more of them, and need more tools and training to offer them. We’ve made excellent progress over the past few years, with support from the U.S. Congress, and now countries around the world conduct hundreds of investigations a year.

Thus today’s announcement for a major push for global health security (GHS). And next year the president will propose adding $45 million to the CDC budget to further expand the initiative, working toward a five-year goal of making sure that at least 30 countries not currently protected with some 4 billion citizens, can improve their capacity to prevent, detect, and effectively respond to disease threats. We are confident that with international partners, every country in the world can improve its own health security, and thereby the world’s. The vision is for host nations to establish their own laboratory networks, emergency operations centers, and prevention capabilities to create a new, globally interconnected line of defense.

Why now? Because not only are the threats greater than ever, our chances of stopping them are better than ever too. There is unprecedented political commitment around the world. We have exciting new technologies. And we’ve seen encouraging successes to build on.

There’s renewed commitment to health security among leaders around the world. Recent experience with SARS, which cost the world $30 billion in just a few months, and pandemic flu has been a wake-up call. Most of the world’s nations have signed on to the World Health Organization’s International Health Regulations (IHRs). These regulations call for every country in the world to establish minimum capabilities. These include laboratory standards and field personnel trained and equipped to find and stop new health threats. However, fewer than 20 percent of nations report meeting IHR goals. The new U.S. government commitment to global health security will help more countries meet these and other important goals, such as building and maintaining national emergency operations centers.

New laboratory technologies make it possible to identify disease threats in hours instead of the days or weeks it used to take. Each nation will be equipped with modern biosurveillance and diagnostics to perform at least five of 10 core tests in at least 80 percent of the country.

New communication technologies—as shown in a recent CDC demonstration project in Uganda—make it possible for health workers to report their findings to a centralized emergency operations center (EOC) even from the most remote parts of the world. I was able to see this system in action in Uganda last year, and it was impressive. There are clinical facilities operating all over the country in remote areas which had previously been shipping specimens to Kampala, the capital, to test of infants born to mothers who are HIV-positive. Health care workers now give the specimens to motorcycle carriers who go to the provincial capital and send the samples by overnight mail to a high-quality lab in Kampala. Within a day or two of collection, test results are reported back to these remote rural clinics via a GSM printer. This terrific technology and cooperation is now being used not just for HIV but also for cholera, Ebola and other viral hemorrhagic fevers, drug-resistant tuberculosis, and other potentially epidemic infections endemic in Uganda including Zika virus, Crimean-Congo hemorrhagic fever virus, hepatitis E, meningitis, and yellow fever. If there’s even a single case, the emergency operations center can track and improve the local response.

That last part is important. The new U.S. GHS plan calls for nations to maintain rapid response teams and an EOC that can activate a coordinated response within two hours of a public health emergency.

CDC is only one part of the U.S. government’s commitment to global health security. Other agencies include the Food and Drug Administration, the State Department, the U.S. Department of Agriculture, the Department of Defense, and the U.S. Agency for International Development.

Can the U.S. afford to support GHS? A deadly flu pandemic such as the one in 1918 would cost hundreds of billions to the world economy as well as an unthinkable toll in human misery and death. And healthy populations mean healthy economies.

André Berro and his colleagues at CDC Quarantine Stations don’t find boxes of skulls every day. But it is an everyday experience for them to screen people and products carrying potentially infectious diseases. The odds against diseases breaching our borders will be much more in our favor when more nations become capable of maintaining their own health security.

This article available online at:

http://www.theatlantic.com/health/archive/2014/02/why-global-health-security-is-imperative/283765/