The Coming Plague (110 page)
Authors: Laurie Garrett
Minnesota state epidemiologist Dr. Michael Osterholm assisted the CDC's efforts by surveying the policies and scientific capabilities of all fifty state health departments. He discovered that the tremendous variations in outbreak and disease reports reflected not differences in the actual incidence of such occurrences in the respective states, but enormous discrepancies in the policies and capabilities of the health departments.
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In the United States all disease surveillance began at the local level, working its way upward through state capitals and, eventually, to CDC headquarters in Atlanta. If any link in the municipal-to-federal chain was weak, the entire system was compromised. At the least, local weaknesses could lead to a skewed misperception of where problems lay: states with strong reporting networks would appear to be more disease-ridden than those that simply didn't monitor or report any outbreaks. At the extreme, however, the situation could be dangerous, as genuine outbreaks, even deaths, were overlooked.
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In the United States all disease surveillance began at the local level, working its way upward through state capitals and, eventually, to CDC headquarters in Atlanta. If any link in the municipal-to-federal chain was weak, the entire system was compromised. At the least, local weaknesses could lead to a skewed misperception of where problems lay: states with strong reporting networks would appear to be more disease-ridden than those that simply didn't monitor or report any outbreaks. At the extreme, however, the situation could be dangerous, as genuine outbreaks, even deaths, were overlooked.
What Osterholm and Berkelman discovered was that nearly two decades of government belt tightening, coupled with decreased local and state revenues due to both taxation reductions and severe recessions, had rendered most local and regional disease reporting systems horribly deficient, often
completely unreliable. Deaths were going unnoticed. Contagious outbreaks were ignored. Few states really knew what was transpiring in their respective microbial worlds.
completely unreliable. Deaths were going unnoticed. Contagious outbreaks were ignored. Few states really knew what was transpiring in their respective microbial worlds.
“A survey of public health agencies conducted in all states in 1993 documented that only skeletal staff exists in many state and local health departments to conduct surveillance for most infectious diseases,” the research team concluded. The situation was so bad that even diseases which physicians and hospitals were required by law to report to their state agencies, and the states were, in turn, legally obligated to report to CDC, were going unrecorded. AIDS surveillance, which by 1990 was the best-funded and most assiduously followed of all CDC disease programs, was at any given time underreported by a minimum of 20 percent. That being the case, officials could only guess about the real incidences in the fifty states of such ailments as penicillin-resistant gonorrhea, vancomycin-resistant enterococcus,
E. coli
0157 food poisoning, multiply drug-resistant tuberculosis, or Lyme disease. As more disease crises cropped up, such as various antibiotic-resistant bacterial diseases, or new types of epidemic hepatitis, the beleaguered state and local health agencies loudly protested CDC proposals to expand the mandatory disease reporting listâthey just couldn't keep up.
E. coli
0157 food poisoning, multiply drug-resistant tuberculosis, or Lyme disease. As more disease crises cropped up, such as various antibiotic-resistant bacterial diseases, or new types of epidemic hepatitis, the beleaguered state and local health agencies loudly protested CDC proposals to expand the mandatory disease reporting listâthey just couldn't keep up.
Osterholm closely surveyed twenty-three state health department laboratories and found that
all but one had had a hiring freeze in place since 1992
or earlier. Nearly half of the state labs had begun contracting their work out to private companies, and lacked government personnel to monitor the quality of the work.
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In a dozen states there was no qualified scientist on staff to monitor food safety, despite the enormous surge in
E. coli
and
Salmonella
outbreaks that occurred nationwide during the 1980s and early 1990s.
all but one had had a hiring freeze in place since 1992
or earlier. Nearly half of the state labs had begun contracting their work out to private companies, and lacked government personnel to monitor the quality of the work.
29
In a dozen states there was no qualified scientist on staff to monitor food safety, despite the enormous surge in
E. coli
and
Salmonella
outbreaks that occurred nationwide during the 1980s and early 1990s.
At the international level the situation was even worse. The CDC's Jim LeDuc, working out of WHO headquarters in Geneva, in 1993 surveyed the thirty-four disease detection laboratories worldwide that were supposed to alert the global medical community to outbreaks of dangerous viral diseases. (There was no similar laboratory network set up to follow bacterial outbreaks or parasitic disease trends.) He discovered shocking insufficiencies in the laboratories' skills, equipment, and general capabilities. Only half the labs could reliably diagnose yellow fever; the 1993 Kenya epidemic undoubtedly got out of control because of that regional laboratory's failure to diagnose the cause of the outbreak. For other microbes the labs were even less prepared: 53 percent were unable to diagnose Japanese encephalitis; 56 percent couldn't properly identify hantaviruses; 59 percent failed to diagnose Rift Valley fever virus; 82 percent missed California encephalitis. For the less common hemorrhagic disease-producing microbes, such as Ebola, Marburg, Lassa, and Machupo, virtually no labs had the necessary biological reagents to even try to conduct diagnostic tests.
As a first line of defense against emerging diseasesâat least the virusesâLeDuc advocated a modest $1.8 million one-shot program to upgrade all the laboratories and tighten the WHONet voluntary reporting system that linked key hospitals and medical systems worldwide.
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LeDuc's proposal was formally endorsed by WHO and a panel of disease experts chaired by Joshua Lederberg on April 26, 1994. Months after the proposal went out to the wealthy nations of the world LeDuc was still waiting for some dollars, marks, yen, or other solid currency.
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LeDuc's proposal was formally endorsed by WHO and a panel of disease experts chaired by Joshua Lederberg on April 26, 1994. Months after the proposal went out to the wealthy nations of the world LeDuc was still waiting for some dollars, marks, yen, or other solid currency.
Berkelman's plan for bolstering CDC capabilities rested on the successful funding of LeDuc's global program, major improvements in domestic surveillance programs in all tiers of government, and vast advances in federal research, infrastructure, laboratory efforts, training, and general commitment to the problem.
That cost money: perhaps $125 million a year.
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And any requests for funds immediately threw the fate of disease surveillance and preparedness in the hands of politicians. Thus, what began as a scientific concern ended up as fodder for congressional debate at a time when legislators were under public pressure to reduce the huge U.S. national debt.
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And any requests for funds immediately threw the fate of disease surveillance and preparedness in the hands of politicians. Thus, what began as a scientific concern ended up as fodder for congressional debate at a time when legislators were under public pressure to reduce the huge U.S. national debt.
Any vision of global health monitoring that ultimately rested in the hands of a U.S. agency was bound to be controversial in the court of international public opinion. The CDC had a track record of playing that role reasonably well for four decades with everything from Ebola to yellow fever. And when a crisis occurred the first call WHO generally made was to Atlanta.
But Francophile nations were likely to call the Institut Pasteur, which also had an established track record, particularly in West Africa. Members of the Commonwealth were, similarly, likely to contact the London Institute of Hygiene and Tropical Medicine. And nongovernmental organizations, such as Médecins Sans Frontieres, Médecins du Monde, the International Red Cross/Red Crescent, and Oxfam were increasingly playing the role of disease early-warning systems. It was Médecins Sans Frontieres, for example, that spotted the 1992â93 epidemic of extremely lethal visceral leishmaniasis in southern Sudan. With the country in a state of civil war and virtually all public health systems having collapsed, there was no Sudanese agency that was even monitoring the health of people in the rebelheld south, much less reporting disease outbreaks to Khartoum or Geneva. If not for the outsidersâMédecins Sans Frontieres, in this caseâthe epidemic, though it afflicted tens of thousands of people, might well have remained invisible to the global public health community.
Indeed, as the 1990s witnessed an overwhelming number of high-intensity local conflicts between political, ethnic, and religious rivals, it became apparent to organizations most involved in relief work that
no
government-based disease surveillance systems had a prayer of success in regions of conflict. In 1993 alone, a massive measles epidemic swept over war-torn Angola; the Luanda government officially denied its existence. Médecins Sans Frontieres identified ten populations at high risk for starvation
and disease in 1993: non-Muslim Sudanese (700,000 people at risk), Afghani civilians (more than 10 million at risk), Tajikistani Muslims (more than 300,000 of whom were refugees in a bloody, ongoing civil war), Caucasus minorities (numbers not stated), Liberian civilians (some 820,000 at high risk), Angolan civilians (some 8 million imperiled by ongoing civil war), Cambodian noncombatants (millions subject to drug-resistant malaria and TB, as well as famine, in Khmer Rouge-held western parts of the country), Bosnian civilians (more than a million Muslims and Serbs endangered by ongoing civil war), Nagorno-Karabakh (more than 700,000 refugees fleeing war between Armenia and Azerbaijan), and Somalis.
no
government-based disease surveillance systems had a prayer of success in regions of conflict. In 1993 alone, a massive measles epidemic swept over war-torn Angola; the Luanda government officially denied its existence. Médecins Sans Frontieres identified ten populations at high risk for starvation
and disease in 1993: non-Muslim Sudanese (700,000 people at risk), Afghani civilians (more than 10 million at risk), Tajikistani Muslims (more than 300,000 of whom were refugees in a bloody, ongoing civil war), Caucasus minorities (numbers not stated), Liberian civilians (some 820,000 at high risk), Angolan civilians (some 8 million imperiled by ongoing civil war), Cambodian noncombatants (millions subject to drug-resistant malaria and TB, as well as famine, in Khmer Rouge-held western parts of the country), Bosnian civilians (more than a million Muslims and Serbs endangered by ongoing civil war), Nagorno-Karabakh (more than 700,000 refugees fleeing war between Armenia and Azerbaijan), and Somalis.
All told, it seemed in 1993 that more than 21 million people on earth were living under conditions ideal for microbial emergence: denied governmental representation that might improve their lot; starving; without safe, permanent housing; lacking nearly all forms of basic health care and sanitation.
The situation only worsened in 1994, as more than two million Rwandans fled their country, most of them ending up in perilous refugee encampments lacking even the most rudimentary sanitation or safe water supplies.
On June 17, 1993, Médecins Sans Frontières filed an official protest with the United Nations Security Council, documenting numerous examples in war-torn areas of relief workers being endangered by local military forces, outlaw gangs, or United Nations troops. Further, the group charged that civilians were routinely denied access to hospitals and medical careâin some cases hospitals were deliberately targeted by warring forces.
By charter the United Nations was proscribed from doing anything that might be viewed as disrespecting national sovereignty. In times of crisis the UN interpreted that to mean that its agenciesâincluding WHOâcould not intervene in a nation without the official invitation of its recognized government. Without such permission, WHO could no more deploy a team of physicians to investigate an unusual disease outbreak in Kigali than it could in Los Angeles or Paris.
For Jonathan Mann, Daniel Tarantola, and most of the other former members of the Global Programme on AIDS, these concerns only heightened their conviction that disease emergence was inextricably bound to human rights. Mann wanted the world community to examine ways to use already existing human rights laws as leverage for UN and WHO access to health-imperiled populations.
During the Cold War there were far fewer such civil wars and nationalistic clashes because the superpowers imposed an overriding layer of control over most global conflict. In the absence of that global supervision, some governments felt free to slaughter their own people, exterminate rival minorities, eliminate all social (including medical) facilities for key population groups, and deny the existence of disease.
While some emerging disease specialists spoke of setting up NASA
satellite networks to monitor rainfall and mosquito populations, red tides, or rain forest destruction in order to keep tabs on the microbes, physicians working in the midst of crises argued that what was needed was far more fundamental.
satellite networks to monitor rainfall and mosquito populations, red tides, or rain forest destruction in order to keep tabs on the microbes, physicians working in the midst of crises argued that what was needed was far more fundamental.
“There will always be a need for an emergency response effort, and that will probably always primarily mean the CDC,” Joe McCormick argued. “But you need people on the ground to spot these things first. You need a health care system. And you need a place to call.”
If the government is your enemyâif you and your people are victims of oppressionâwhom do you call?
“In candor, there is discomfort,” Henderson said. “I'm all too conscious of the constraints that are upon us.”
Former CDC director Dr. William Foege felt that new disease emergence was tightly linked to Thirdworldization: the overall status of health care, immunizations, sanitation, education, and total burden of disease in a society. Working with the Atlanta-based Carter Center for International Peace, Foege argued that structural adjustments ordered by the World Bank and the International Monetary Fund, coupled with a genuine capital crisis following the fall of the Berlin Wall, had severely worsened the human condition and improved odds for the microbes. More than $178 billion a year was flowing from the world's poorest nations to the richest in the form of debt payments, while a third of that amount (just under $60 billion) flowed in the other direction in the forms of loans and foreign aid.
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“This is a public health crisis,” Foege argued. “One trillion dollars is spent on weapons annually. Of the fourteen million kids who died in 1989, nine million [deaths] could have been prevented for two and a half billion dollars. And that's what's spent in the United States annually for cigarette advertising.”
Foege felt that international and domestic American health were so thoroughly integrated by the 1990s due to globalization of the microbes that it was impossible to ensure a disease-free existence for people in North America and Western Europe without providing similar assurances for residents of Azerbaijan, Côte d'Ivoire, and Bangladesh.
As the world, and disease threats, became increasingly complex, McCormick and Fisher-Hoch got fed up with both the CDC and WHO. McCormick decried all the “desk jockeys” and “pencil pushers” in Atlanta, Washington, Paris, and Geneva. After years of battling Lassa, McCormick and Fisher-Hoch saw civil war in Liberia and government instability in Nigeria wash away all their efforts and outbreaks of the rat-borne disease become commonplace. Having logged a lifetime of fighting the microbes both in the laboratory and dead center amid epidemics, McCormick had lost all patience. He thought that the links between poverty, lack of basic health care, ecological disturbances, and the emergence of dangerous microbes were so obvious as to be basic tenets of public health. Yet his kind of global thinkingâand that of Henderson, Johnson, Monath, and Foege
âwas no longer in vogue at CDC and WHO or inside the federal health bureaucracies in Washington, Paris, and London.
âwas no longer in vogue at CDC and WHO or inside the federal health bureaucracies in Washington, Paris, and London.
In the spring of 1993, McCormick and Fisher-Hoch left the CDC, moving to Pakistan to do what they believed was the last hope in the war against the microbes: train people in poor countries to conduct their own microbial search-and-destroy missions.
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