Not If, but When: A Warning

Last month, my colleagues and I released a series of memos addressed to the Trump Administration and Congress describing the state of national and global health security and our recommendations on how to strengthen it. This is the second set of health security memos to an incoming administration that we’ve written. We write these transition memos to help new staffers navigate the complex biological threat environment, and to understand the programs and concepts that have been developed to address those challenges. As a result, the memos cover a wide range of topics, including public health and healthcare preparedness, the organization and funding of the federal health security enterprise, biosurveillance, community engagement, the security implications of synthetic biology, and others.

I’d like to focus here on a prediction that can be found in our memos, and has also been recently articulated by other subject matter experts. That is the judgment that this administration can expect to face a severe infectious disease emergency at some point during its tenure.

To wit (emphasis mine):

“If history has taught us anything, it is that the new administration is likely to experience at least one infectious disease crisis of significance. We have learned from the past decades that it is important to have strong global surveillance systems; transparency and honest communication with the public; strong public health and health care infrastructure, or capacity building efforts where needed; coordinated and collaborative basic and clinical research; and the development of universal platform technologies to enable the rapid development of vaccines, diagnostics, and therapeutics. We also have learned that it is essential to have a stable and pre-established funding mechanism to utilize during public health emergencies similar to a FEMA-like emergency disaster fund. What we know for certain is that emerging infections will continue to be a perpetual challenge, requiring the attention of all Presidents to come.”

Dr. Anthony Fauci, Director, National Institute for Allergy and Infectious Diseases

“Finally, the near and long term challenge most in need of a global response is that of emerging infectious disease. Terrorism and cyber threats have featured prominently in all three of the transitions on which I worked.  Most recently, in my transition meetings with my successor, I urged that the new administration will need to maintain a third focus when it comes to transregional threats that will keep people up at night: infectious disease.

It is a virtual certainty that the new administration will be challenged by some new pathogen, one that no wall will keep out. Ebola and Zika showed us pandemics need not have a malicious origin to take lives, cause panic, and drain resources. This will take focus, resources and precisely the sort of global cooperation that is difficult when countries feel alienated from American leadership. The Global Health Security Agenda, championed by the Obama Administration and now 50 countries strong, must be sustained. It requires United States investment and leadership to ensure that countries continue transparent, independent health assessments and are accountable for progress.”

Lisa Monaco, Former Assistant to President for Homeland Security and Counterterrorism and Deputy National Security Advisor

“It's not if, but when these events are going to occur again…We need to ramp up our preparedness.”

Dr. Peter Salama, Executive Director, Health Emergencies Programme, World Health Organization

“Each POTUS has faced outbreak crises: AIDS, SARS, Bird flu, swine flu, Ebola. Just a matter of time.”

Jeremy Konyndyk, Former Director, Office of US Foreign Disaster Assistance, USAID

“…it is safe to assume that one or more events that require a national-level response will occur in the near term. As a result, ensuring a high degree of public health preparedness should be a national priority.”

Matthew Watson, Dr. Jennifer Nuzzo, Matthew Shearer, Diane Meyer, JHSPH Center for Health Security

While I’ve highlighted just handful of examples above, I don’t think this is a particularly controversial position. Anyone with a passing familiarity with microbiology or epidemiology would probably agree.

A couple of things strike me as notable. First, the consistency and near-certainty of the message. While the occurrence of infectious disease outbreaks is highly stochastic, the sheer volume of recent, off-normal biological events - to include the 2001 anthrax attacks, biosafety lapses, and major epidemics or pandemics like SARS, H1N1 influenza, MERS, Ebola, Zika, and others - strongly suggests more to come.

Just why these events have been coming at such a rapid clip, and why we should expect more, can be explained by several different factors including environmental degradation, a changing climate, available and affordable international air travel, changes in human behavior and consumption patterns, the mutation rate of pathogens, and the occurrence of spillover events. In some cases, human failings such as malevolence or carelessness have come into play. For me, though, the most important contributing factor is that humanity is getting really good at recognizing cases and clusters of viral, bacterial, and fungal infections. We can now watch epidemics develop in real time, and we are increasingly on the lookout for emerging and re-emerging infectious diseases. The increasing speed and accuracy of surveillance and diagnostic systems makes it critical that we develop a more nuanced appreciation of the risks posed by a given outbreak or pathogen, both in public and in the halls of power.  Some rational setting between indifference and panic would be optimal. 

Second, this warning of outbreaks to come is being sounded by a diverse group of scholars and practitioners from both poles of the health security spectrum. Now, it’s important to remember that individual judgements are just that, and it’s understood that expert judgment is not infallible. But taken in aggregate, I would suggest that these statements can best be understood as a warning that should be taken seriously at the highest levels of our government.

That’s what we know. What we don’t know, and what is probably unknowable, is the source, scale, severity, and nature of the next infectious disease emergency. The past 16 years have seen naturally occurring outbreaks, intentional events that can rightly be characterized as attacks, and accidents.

To ensure that we’re able to meet the next threat when it inevitably arrives, strengthening our national and global health security posture should be a high priority for this administration.

 

My thanks to research assistant Ashley Geleta (@ashley_geleta) for her help in preparing this post.

Developing the Next Generation of Biosecurity Leadership

When I was a new analyst, I thought that the only thing I needed to correctly interpret and make unique contributions to biosecurity policy was the highest possible volume of raw data, facts, figures, statistics and stories that I could shoehorn into my brain. The more well-read I was, I thought, the more sound my research and other output would be. Frankly, younger me was dead wrong. Of course, reading (smartly) in your field on a daily basis is absolutely critical, but there are limits to what information alone can accomplish. To use an old chestnut, it is necessary, but not sufficient, for success.

If I was asked to identify the single most important factor for success, it would take me half a second to answer -- my network. The people who I can bounce my latest crazy idea off of, the people who I continue to learn from, and the people that inspire me to get better day in and day out. Hands down, my coworkers at the Center for Health Security, and my growing ring of colleagues and contacts, have been responsible for more intellectual growth than all of the information I’ve willed myself to absorb over the years. To that end, I'd offer the following recommendations: 

  1. Identify people who are smarter than you

  2. Actively learn from them. This involves asking a lot of questions.

  3. Talk about what you know. Don’t be a knowledge miser.

  4. On occasion, go out for a beer. 

Now here’s the rub. Is this process replicable? While concerns regarding and planning for biological emergencies have been a serious focus of governmental interest since at least the Second World War, what we now call health security (which encompasses biosecurity) is a relatively young and insular area of study, policy and practice. With several exceptions, it’s not taught in graduate schools, and there has not been an obvious path for graduate students or early career professionals to learn about the field, or how they might contribute. That is, until recently.

In 2012, the Center, with support from the Department of Defense, launched the Emerging Leaders in Biosecurity Initiative (ELBI). ELBI’s goal is to provide a path into the biodefense world for young scholars and practitioners from a wide range of backgrounds and expose them to both historical and current issues in biosecurity writ large. To date, we’ve had 81 highly talented alumni go through the one year program, and it’s been gratifying to watch them rise in their respective careers. They either are currently, or in the near future will be, the people whose phones ring when the next crisis erupts. It’s our hope that the nation’s health and security will benefit from their service, and hopefully, from the lasting bonds they’ve created.

Today, we’re opening the application period for the 2016 class. If you’re at all interested in biosecurity as a discipline, I’d encourage you to apply, because sometimes, it’s who you know that matters most.   

Health Security Summer Reading

This summer, I read some great books about infectious diseases and the impacts they’ve had on culture, economics, politics, and, perhaps most importantly, the way people perceive and interact with the world. Tweet me suggestions for other good reads or books you’d like to see reviewed.

The Plague (Albert Camus)

“Ah, if only it had been an earthquake! A good bad shock, and there you are! You count the dead and the living, and that’s an end of it. But this here damned disease – even them who haven’t got it can’t think of anything else.” 

Though Albert Camus published The Plague in 1947, it remains exceptionally relevant even today. While intended primarily as an allegorical commentary on German militarism and moral responsibility, it also provides useful insights into disease dynamics. The novel, which details the spread of bubonic plague in Oran, Algeria and the reactions of its townspeople, is uncanny in its resemblance to recent responses to the Ebola outbreak in West Africa. During the course of the story, the characters experience confusion over the origin of the outbreak, panic about its rapid spread, despair over the lack of effective treatments, and rebel against a government-mandated quarantine intended to contain the plague within Oran’s walls.

While the details of the healthcare and public health responses to the plague are astonishingly accurate, what makes The Plague an especially satisfying read is the detail with which Camus illustrates the psychological and emotional tolls associated with battling deadly diseases. Most importantly, the novel avoids sensationalizing the disease in question, as many popular depictions of outbreaks are inclined to do. As such, The Plague is by far one of the best fictional accounts of an infectious disease epidemic I’ve come across.

 

The War Machine and Global Health (Edited by Merrill Singer & G. Derrick Hodge)

“Directly or indirectly, war touches the lives of most people on the planet, often with enduring and costly health consequences…Immediate casualties, in short, are only the beginning; war-related deaths and injuries are numerous and insidious and last far longer than active combat.”

The War Machine and Global Health is a stunning anthropological analysis of violent conflict and its impacts on population health. The book consists of numerous case studies examining the social, political, and economic drivers of conflict and draws out their associated health consequences, which, unsurprisingly, often persist long after the conflict in question dies down. These case studies explore among other issues, the decimation of Iraq’s healthcare infrastructure, the psychosocial health of child soldiers in Nepal, the forced migration of the Chagossian people, the Honduran government’s transgressions against its poorest citizens, and the challenges of achieving interoperability between US and Guatemalan military medical teams.

Recent acts of violence in places like Israel and Palestine, Nigeria, Pakistan, and Afghanistan underscore a disturbing trend: that the effects of violent conflict increasingly are spilling over into the civilian sector to an unprecedented degree. There is an urgent need for further scholarly analysis of this trend. Some researchers have already examined conflict as a public health problem, but The War Machine and Global Health does an especially impressive job of combining rigorous scholarship with anecdotes, interviews, and ethical analyses to paint a moving and comprehensive picture of what conflict does to people and their health.

 

Cherokee Medicine, Colonial Germs (Paul Kelton)

“I am much gratified at the good sense manifested by the Cherokee Indians. Who would have thought that vaccination would already have found its way into the wilds of America?”

Edward Jenner, 1802

The story of how British forces used smallpox-contaminated blankets to decimate Native American populations during the French and Indian War is an oft-cited example of early biological warfare. The story exemplifies the “virgin soil thesis,” or the idea that Native tribes’ primitive medical practices and lack of immunity were responsible for the disastrous impacts of smallpox among indigenous populations. In Cherokee Medicine, Colonial Germs, however, Paul Kelton delivers a meticulously researched rebuttal to the virgin soil thesis. Drawing from firsthand accounts, he argues that brutal treatment at the hands of colonizers was the main driving force behind Native American deaths, which in turn amplified the already deadly effects of smallpox. Focusing primarily on Cherokee populations, Kelton examines how commercial interests, cultural differences, and political tensions between colonists and tribes often gave rise to armed conflicts that were far more ruinous than any epidemic.

Of note, Kelton also acknowledges the agency of Cherokee tribes in responding to smallpox outbreaks and describes in detail the practice of Cherokee medicine. Though typically dismissed by colonists, Cherokee medicine was deeply rooted in extensive cosmological belief systems. Its practitioners embraced both quarantine strategies and inoculation as protective measures against smallpox. Cherokee Medicine, Colonial Germs is a valuable read for anyone interested in understanding the impacts of colonialism and disease from the perspective of indigenous populations, the challenges associated with conducting epidemiological analyses, and the roles of culture and politics in shaping the course of and responses to infectious disease epidemics.

 

Rabid: A Cultural History of the World's Most Diabolical Virus (Bill Wasik and Monica Murphy)

“Rabies is a scourge as old as human civilization, and the terror of its manifestation is a fundamental human fear, because it challenges the boundary of humanity itself. That is, it troubles the line where man ends and animal begins – for the rabid bite is the visible symbol of the animal infecting the human, of an illness in a creature metamorphosing demonstrably into that same illness in a person.”

Rabid traces the proliferation and impacts of the rabies virus through human history, from ancient Babylon to a recent episode of The Office (“There’s no such thing as a rabies doctor.”). Despite being one of the best-documented infectious diseases in human history, rabies today remains, paradoxically, both a mystery and a very real public health threat. Rabies infections give rise to a terrifying constellation of symptoms with a near 100% fatality rate: hydrophobia, paralysis, hallucinations, and paranoia. Tens of thousands of cases are reported every year, but – as is the case with many neglected diseases – rabies research and prevention efforts nonetheless attract little funding.

Rabid is compelling and accessible synopsis of rabies’ etiology, including its symbolic and psychological links to vampires, werewolves, and zombies, prevention and eradication efforts around the world, and recent therapeutic breakthroughs. Wasik and Murphy also offer detailed portraits of the scientists who contributed to our understanding of the disease: Louis Pasteur, Rodney Willoughby, and Benjamin Rush. Most importantly, Rabid underscores the importance of understanding the dynamics of disease transmission at the human-animal interface.

Health Security and the State of the Union

The annual State of the Union Address is a chance for the President to present his domestic and foreign policy priorities. Often, the President will reflect on the most difficult challenges facing the country. Last night was no different. In his speech, President Obama took a moment to acknowledge the Americans who are responding to Ebola in West Africa, an epidemic that appears to be moving from apocalyptic to “merely” severe.

Because the State of the Union reflects Presidential priorities, even a mention carries a lot of weight. Below are the best examples of where health security issues have been mentioned in the State of the Union during the Obama presidency.  

2015 - “In West Africa, our troops, our scientists, our doctors, our nurses and healthcare workers are rolling back Ebola — saving countless lives and stopping the spread of disease. I couldn’t be prouder of them, and I thank this Congress for your bipartisan support of their efforts. But the job is not yet done — and the world needs to use this lesson to build a more effective global effort to prevent the spread of future pandemics, invest in smart development, and eradicate extreme poverty.”

2014 – “American diplomacy, backed by the threat of force, is why Syria’s chemical weapons are being eliminated, and we will continue to work with the international community to usher in the future the Syrian people deserve – a future free of dictatorship, terror and fear.”

2013 –  “We can choose to believe that Superstorm Sandy, and the most severe drought in decades, and the worst wildfires some states have ever seen were all just a freak coincidence.  Or we can choose to believe in the overwhelming judgment of science -- and act before it’s too late.”

2010 – “…we are launching a new initiative that will give us the capacity to respond faster and more effectively to bioterrorism or an infectious disease -– a plan that will counter threats at home and strengthen public health abroad.”

These excerpts remind us that health security issues occur frequently, ranging from emerging infectious disease epidemics, natural disasters, and the use of WMD, and often necessitate a response by the President of the United States. That trend is not likely to change any time soon, which speaks to the need for continued awareness of the myriad threats and continued investment in America’s preparedness and response infrastructure.