Terrorist attacks on the US that began September 11 may have dealt a mortal blow to a global public health system that was already severely crippled from decades of governments' neglect and mismanagement, say experts in international health and bioterrorism.
From now on, public health will be dominated by national security concerns focused on fighting terrorism and proliferation of biological weapons, David Fidler, professor at the Indiana University School of Law, told a meeting on globalization and infectious disease held in Washington on 6 November 2001. Global efforts to fight infectious disease may suffer badly, according to Fidler, an expert on international law and public health. The recent anthrax attacks on the US postal system have hastened the country's shift from a weak global perspective to a strong national one, from a weak commitment to public health to a strong effort on homeland security, and from tepid concern about naturally occurring disease to serious fear about malevolent international use of microbes, he said.
Pulitzer Prize–winning journalist Laurie Garrett, author of Betrayal of Trust, the book about the collapse of public health, said she cheered on hearing the words "public health infrastructure" coming out of the mouths of politicians for the first time — except that most of them don't know what it means. And most Americans think public health means medicine for poor people, instead of a compact between government and the citizenry to guard it against disease, she noted. The result of the anthrax attacks, she fears, may be reactive measures that make no long-run sense. They are also likely to skew use of resources, diverting attention away from traditional public health measures such as monitoring disease outbreaks and making sure the food supply is safe.
The meeting itself demonstrated the point that bioterrorism is at the forefront of people's concerns. The session on bioterrorism and biowarfare drew the liveliest response and many questions from the audience —even though it came at the end of a long day that had otherwise painted a horrific picture of public health catastrophe all over the globe. Described by Garrett and others, it included the inexorable spread of traditional scourges such as malaria and tuberculosis; out-of-control infant diarrhea and other disorders resulting from lack of clean water, from sharing quarters with livestock, and from untrustworthy food sources; HIV infection, which has generated the worst pandemic since the Black Death in the 14th century; and the fearsome spread of bacteria resistant to the whole panoply of formerly useful antibiotics.
Unless public health workers mobilize, get more sophisticated about playing politics, and make clear the connections between public health and national security, the public health message will be co-opted by the military, Fidler warned.
The medical system is uniquely vulnerable to bioterror, suggested Tara O'Toole, deputy director of the Johns Hopkins Center for Civilian Biodefense Studies. Doctors don't know how to diagnose organisms like anthrax. There is no one to pay for disaster preparedness. Pharmaceutical companies can't ramp up quickly enough to deal with a surge in demand for drugs or vaccines. In a search for financial efficiency, excess capacity has been eliminated, so the system is unable to deal with a sudden flood of patients. In the US, she pointed out, there is no hospital or even group of hospitals that could handle the crush if just a thousand people suddenly needed care.
And the public health system is in even worse shape, she argued. The government has failed to invest in it, and the field does not attract physicians and other medical professionals. Public health is so badly off, she said, that half of US local health departments don't even have connections to the Internet.
Seth Berkley, president and CEO of the International AIDS Vaccine Initiative, urged public health specialists to see the anthrax scare as an opportunity rather than a disaster. Because anthrax has commanded attention, there is more institutional interest in infectious disease, and even more money, although not much. Still, he argued, public health advocates can potentially kill 2 birds with one stone: improve capacity to deal with disease while fighting bioterrorism.
How can bioterrorism become an opportunity to turn around the calamitous decline of public health systems worldwide? Is it possible to leverage the fear and anger to make a change? According to economist Jeffrey Sachs, who directs the Center for International Development, Harvard University, the answer is straightforward: Just point out the links between national security and public health in the developing world.
One of the main predictors of state collapse, he noted, is the two major health indicators: life expectancy and infant mortality. Americans now spend only 1 penny out of every $100 of income on aid to poor countries, even though 16 million people are dying of poverty every year. If rich countries were willing to put up 1 penny for every $10 of income instead, and used it to focus on a relatively small cluster of infectious diseases (such as AIDS, infant diarrhea, malaria and other parasitic diseases), eight million lives could be saved every year, he predicted. The problem is bipartisan; for two decades, every US administration has cut the foreign assistance budget. That makes no moral sense, Sachs argued, but it also doesn't make sense for national security. "We're not taking the most minimal steps to protect our interests," he said.
The anthrax attack has been a small-scale event. It was highly localized, is not contagious, involved comparatively few casualties, and only 2 grams of material. Yet it has led to significant societal disruption, noted Kenneth Alibek, a bioweapons expert now at Advanced Biosystems, Inc. The result, he said, was a lesson for the US. But the terrorists learned a lesson too. They know how the entire country can be affected, and the result is likely to be more bioterrorism, he predicted.
Alibek worked in the Soviet Union's offensive bioweapons program, which focused on smallpox. He defected to the US in 1992, and — like many others — is deeply concerned that highly contagious and incurable smallpox will be the next bioweapon of choice. To prevent Russian bioweapons researchers from going to work for terrorists, and to learn from their expertise, Alibek urged bringing them to the West. O'Toole agreed.
She also pointed out that the 21st century's 'Big Biology' is going to make possible bigger and better bioweapons. Advances in biotechnology and genomics will be able to generate terrifyingly potent organisms, as scientists learn more about the genetics of virulence, antibiotic resistance, new ways to control interaction of human cells and microbes and how to manipulate entire genomes.
Still, O'Toole argued, much can be done to protect people. What is needed is a significant US investment in research and production that should include both Department of Defense and the Department of Health and Human Services, and also the private sector. In the immediate term, the nation should invest in vaccines and existing treatments. In the longer term, hope lies in learning how to modulate immune responses.
If the US invested as it did after the Soviet launch of Sputnik in the 1950s, she urged, that would not only remove bioweapons as threat, but would also give the world a lot of help in dealing with poor countries' burden of infectious disease.