The Honolulu war games exercises and the Reston virus incident were pieces in a larger picture of sharply heightened concerns in some scientific circles about preparedness for confronting the emergences of new disease. Five major U.S. government studies addressed the issue between 1988 and 1994.14
In addition, several international agencies and organizations addressed various aspects of the emerging disease preparedness issue.15
These reports, though produced by different groups of scientists and physicians, shared a sense of urgency and despair over the status of public health infrastructures and infectious diseases research in the United States and Europe. The solutions varied strikingly, however, reflecting the agendas of the various institutions involved.
American scientists, particularly virologists and those who were practitioners of the fledgling field of microbial ecology,16 tended to support large-scale monitoring and surveillance schemes. Satellites, biological containment laboratories, computers, and PCR devices were the tools they hoped to use to spot changes in ecologies that might promote microbial emergences. Failing that, they hoped to be equipped to swoop in with a scientific rapid strike force that would identify and destroy emerging microbes before an outbreak progressed to an epidemic.
The most ambitious of these proposals, ProMED,17 sponsored by the Federation of American Scientists, was the brainchild of Stephen Morse. In his claustrophobic, cluttered office at Rockefeller University, the bearded, bespectacled driven Morse burned midnight oil for years searching for answers to how best to help humanity stay one step ahead of the microbes.18 When he and Nobel laureate Joshua Lederberg discussed that matter for hours on end in 1988 while planning the historic 1989 “Emerging Viruses†conference, Morse thought a fairly modest approach would suffice. Resurrecting the old Rockefeller Foundation international network of tropical laboratories would, he then thought, provide adequate protection.
But as the enormity of the scope of the emerging disease problem became apparent, the scale of Morse’s envisioned surveillance net grew. The ProMED scheme involved a vast international network of monitoring systems that would keep an eye on diseases emerging not just in hospitals and clinics but also in agricultural crops, livestock, wild-caught animals, and sampled water supplies. The system Morse imagined would serve as a watchdog not only for natural emergences but also for uses of biological weapons.
Such a far-flung network could only work if supported politically by the United Nations. Accordingly, Morse and his ProMED colleagues, drawn from the ranks of biologists from all over the world, convened at WHO headquarters in Geneva during September 1993 in hopes of mustering more formal support for the initiative.
“The perception is growing that more needs to be done to prevent the emergence of new epidemics,†the Federation of American Scientists’ Dr. Barbara Rosenberg told the gathering. “This perception comes from both the bioweapons and public health communities … . There is a deep worldwide undercurrent of concern about emerging diseases, and an obvious need to develop a comprehensive, global plan.â€
D. A. Henderson, who had once led efforts to eradicate smallpox, told the Geneva gathering that “there is a growing belief that mankind’s wellbeing, and perhaps even our survival as a species, will depend on our ability to detect emerging diseases … . Where would we be today if HIV were to become an airborne pathogen? And what is there to say that a comparable infection might not do so in the future?â€
Years earlier, Karl Johnson had voiced darker concerns. After conversing at length with colleagues at a tropical diseases meeting in Seattle, he pulled Joe McCormick and a reporter aside, drawing the pair into a cranny away from crowds.
“I worry about all this research on virulence,†Johnson had said, his tone deadly serious. “It’s only a matter of months—years, at most—before people nail down the genes for virulence and airborne transmission in influenza, Ebola, Lassa, you name it. And then any crackpot with a few thousand dollars’ worth of equipment and a college biology education under his belt could manufacture bugs that would make Ebola look like a walk around the park.â€
With genetic engineering it was a simple enough matter to insert genes coding for just about anything into the DNA or RNA of a virus.19 Johnson believed that discovery of the Ebola genes for hemorrhagic disease could lead to their insertion into a virus, such as influenza or measles, that was adapted for respiratory transmission. And he wasn’t alone among biologists in expressing that concern.20
By 1993 some 125 nations had signed the Bioweapons Convention,21 yet the agreement had no teeth.
As a result, scientists living in countries with historic border and regional tensions worried that even a poor, backward nation could develop bugs that would produce famine by wiping out crops, cause widespread veterinary or human disease, or target economically crucial commodity crops to cripple a rival’s economy.
“It can easily be done,†Dr. A. N. Mukhopadyay said in Geneva. As dean of agriculture for G. S. Pant University in Pantnagar (Nainital), India, Mukhopadyay was particularly concerned that tensions between India and its neighbors could lead some country in the Indian subcontinent to carry out agricultural sabotage against its enemies. “This is not science fiction,†he said.
Barbara Rosenberg asserted that biological weapons posed special diplomatic problems not encountered with their nuclear or chemical counterparts. “None of the equipment is so high-tech that it could not be homemade by any nation intent on developing BW capacity,†she warned, adding that “no nation is immune to the dangers.â€
Microbiologist Mark Wheelis, of the University of California at Davis, was among those who believed that PCR technology could be used to finger bioweapons culprits.
“It’s the molecular equivalent of finding the murderer’s fingerprints on the gun,†Wheelis said, noting that even as technology was creating new opportunities for bioweaponry, it was also opening up novel options for detection and deterrence.
The ProMED leaders ardently believed that the same international mechanisms that would permit monitoring and verification of bioweapons violations would also be ideal for watchdogging natural emergences of dangerous microbes.
But that made many scientists from developing countries nervous.
“I think a critical aspect of emerging disease questions is global partnership. It is crucial, essential, for people living in developing countries,†Dr. Natth Bhamarapravati, president emeritus of Mahidol University in Bangkok, said. “We must do nothing to undermine that sense of partnership.â€
Japan’s Isao Arita, a former leader of smallpox eradication efforts, felt that it was already extremely difficult to get past nationalist and cultural suspicions in order to carry out entirely beneficial programs, such as vaccination campaigns; if public health efforts were linked with punitive arms enforcement issues, many countries would deny access to both enterprises.
“The efforts must be separated,†Arita concluded.
If public health disease emergence were to be separately executed on a global scale, what might a system look like, and who—what agency—would be at its helm? Arita wasn’t sure.
Neither Arita nor D. A. Henderson were terribly enthusiastic about the obvious solution—namely, handing over control to the World Health Organization. After their experiences leading the smallpox eradication efforts, both men were fed up with WHO.
“We conquered smallpox in spite of WHO,†Henderson said.
“By the time WHO realized there was an AIDS epidemic it already existed on four continents,†Henderson added. “That’s WHO preparedness and emergency response for you.â€
But if WHO wasn’t adequate to the task, who, or what, was?
Henderson felt that the U.S. Centers for Disease Control was best suited for the job.
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sp; “WHO has pathetically few resources of its own,†Henderson said.22 In addition, the Geneva headquarters was often at odds with its scattered regional offices, which, he asserted, were “staffed by one or two [virologists] only. Inevitably, those who staff such units are prized more for their administrative skills in bringing experts together rather than for their own professional expertise … . I therefore see no option but to acknowledge CDC as an international resource, to fund it appropriately, and to acknowledge its mandate in legislation.â€
In Henderson’s view, worldwide preparedness could be coupled structurally with such programs as the South American polio eradication effort and UNICEF’s global campaign to vaccinate the world’s children against the leading preventable pediatric diseases. And active surveillance would best be conducted through a series of fifteen tightly networked tropical outpost laboratories, staffed by CDC scientists, colleagues from local public health institutions in the host country, and academic researchers drawn from some fifty U.S. universities.
Henderson estimated that the entire system would cost $150 million per year to operate, adding, “Can we afford to invest in such a program? A better question is whether we can afford not to invest in a program that could be a determinant in our own survival as a species.â€
The Henderson proposal was similar to one that had been outlined fifteen years earlier by Jordi Casals,23 and had over the years received support from Tom Monath, Robert Shope, Frederick Murphy,24 and most of the scientists who had played roles in outbreaks of hemorrhagic or arboviral diseases.25 It was formally endorsed by the U.S. Institute of Medicine.26
In response to the Institute of Medicine’s report on emerging diseases, the CDC gave Dr. Ruth Berkelman the task of formulating plans for surveillance and rapid response to emerging diseases. For a year and a half Berkelman coordinated an exhaustive effort, identifying weaknesses in CDC systems and outlining a new, improved system of disease surveillance and response.
Berkelman and her collaborators discovered a long list of serious weaknesses and flaws in the CDC’s domestic surveillance system and determined that international monitoring was so haphazard as to be nonexistent. For example, the CDC for the first time in 1990 attempted to keep track of domestic disease outbreaks using a computerized reporting system linking the federal agency to four state health departments. Over a six-month period 233 communicable disease outbreaks were reported. The project revealed two disturbing findings: no federal or state agency routinely kept track of disease outbreaks of any kind, and once the pilot project was underway the ability of the target states to survey such events varied radically. Vermont, for example, reported outbreaks at a rate of 14.1 per one million residents versus Mississippi’s rate of 0.8 per million.27
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.28 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.
“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 list—they 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.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 diseases—at least the viruses—LeDuc 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.30 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.31 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 1992–93 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 outsiders—Médecins Sans Frontieres, in this case—the 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.
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