May 1998
| Shalala's Worldwide Challenges Against Infectious Diseases |
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ATLANTA - Speaking at the International Conference on Emerging Infectious Diseases, Donna E. Shalala, PhD, warned physicians that they must not become complacent in their attitudes about infectious diseases.
"It's easy to assume that modern medicine has defeated this enemy once and for all," said the Secretary of the Department of Health and Human Services (HHS). "Our comfort is a natural byproduct of our progress and success - the remarkable breakthroughs in antibiotics and vaccines, thanks to the work of scientists and researchers at the Centers for Disease Control and Prevention [CDC], National Institutes of Health [NIH] and worldwide."
Although there have been some victories, most notably the eradication of smallpox, infectious disease remains the leading cause of death worldwide and the third leading cause of death in the United States. "While we may be winning some old battles, we're struggling with some new adversaries - emerging infectious diseases such as Ebola, Hantavirus, resistant tuberculosis, HIV and AIDS, and Lassa fever, to name a few. In fact, the World Health Organization [WHO] has labeled the growing threat of infectious disease a global crisis."
A global crisis needs a global effort. History and progress have created what Shalala termed an "ironic contradiction." The same forces that invite pandemics can be used to fight pandemics.
Thanks to global travel and trade, immigration, communication and industrialization, the world is smaller and its borders more porous. "So the bad news is we have fewer barriers against the spread of infectious disease. Yet, the good news is, those fewer barriers mean new avenues to progress and the potential for sharing information and efforts to stop infectious disease," she said.
Shalala said that if governments, public health systems and industry worked together, they could "push infectious diseases off the world stage." But a global exit strategy is required.
The answer may be found in the 1918 influenza pandemic, which killed 24 million people in about 11 months. "The 1918 pandemic provides three important lessons - lessons that are also challenges for all of us."
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Lesson one: assume that a pandemic can occur. Whether it is the emergence of a virulent influenza strain, a re-emerging or emerging disease, or a man-made threat such as antibiotic resistance or biological terrorism, a pandemic is possible.
"Antibiotic resistance isn't just a medical problem, it's also a behavioral problem," she said. Physicians overprescribe antibiotics or prescribe a broad-spectrum agent when a narrower one would due, and patients demand antibiotics for viral infections and don't finish the full course. In addition, there is widespread use of antibiotics in farm animals.
"Given the consequences, we must act now to combat the diminishing effectiveness of antibiotics. That's why the CDC is strengthening surveillance and implementing education campaigns about the problem; why NIH is studying resistance; and why the Food and Drug Administration [FDA] is promoting judicious antibiotic use. But this isn't a job for government agencies alone. Each and every one of us who understand the risks needs to spread the message that antibiotics are being misused, abused and overused," Shalala said.
Bioterrorism is another challenge. "If a specific threat is issued - perhaps someone claims to have released a toxic agent in a public place - then it's trained public health officials who must first verify that an incident has actually occurred. And they may need to decontaminate the area; identify exposed populations; and deliver preventive measures and treatments. But, too often, a threat isn't issued - no warning is given. In such a situation, public health officials must first quickly determine the deadly agent, the route of exposure and the likely source," she said.
HHS is coordinating with other agencies and the military to ensure the training of state and local health officials; the availability of vaccines and drugs; and the enhancement of surveillance capacity and expertise. There's also an administration effort to train emergency response teams and health care providers in 120 cities.
Lesson two is to be prepared. "We cannot wait until the next deadly microbe appears on the world stage," she said mentioning the pandemic influenza plan that was just developed.
The same commitment that has been shown against a potential influenza pandemic is needed in response to all emerging infections. "What we need, and what the CDC has championed, is the creation of a worldwide surveillance and response network that can identify and stop an outbreak," she said.
The groundwork for such a network is already being laid. In 1997, eight industrialized nations pledged to develop a surveillance network. In addition, the United States and the European Union have begun to share surveillance data on Salmonella infections, and the United States is working with South Africa to train South Africans in surveillance and applied epidemiology.
The CDC and WHO jointly run 12 world monitoring stations for influenza alone. "Perhaps the best example of the kind of monitoring and surveillance system we need to have, worldwide, is the excellent system that stopped the avian flu outbreak in Hong Kong," she said.
"Hong Kong's surveillance system proved that early detection of infectious diseases can prevent their spread. David Heymann of WHO once asked a pro vocative question: What would have happened if we had had an excellent surveillance system in place in Africa when the AIDS outbreak first occurred? Perhaps we could also have halted that virus in its tracks."
The lesson learned from AIDS, Shalala said, was that people cannot afford to hesitate in their efforts to defeat infectious diseases. "But we cannot simply deal with each potential pandemic as it arises. In this age of wonder and change, we must also look over the horizon and seize new possibilities to head off infectious diseases before they can occur."
Besides a truly global surveillance and monitoring network, more research is needed to find ways "to prevent, stop, overcome and cure infectious disease," she said.
President Clinton proposed the 21st Century Research Fund to spur the best minds to uncover scientific advances. The research fund will provide a $1.1 billion budget increase for the NIH next year. Shalala called it "the first down payment on an unprecedented 50% expansion of NIH over the next five years." And it should enable the agency to develop new ways to diagnose, treat and prevent disease.
In addition, Shalala is asking for an increase in CDC funding to increase its ability to identify and investigate infectious disease outbreaks both here and abroad.
"This new American investment in fighting infectious disease will not only pay off in America. Because in this world without borders, a discovery by any one nation will benefit us all - and brings us a little closer to preventing the next pandemic."
Lesson three is to work together. "We have the power to prevent the next pandemic, and defeat emerging infectious diseases, but only if our nations step up the fight together. Because diseases recognize no borders, in our fight against them, neither can we.
"Let us pit our wits - and our will - to this battle, together, to heed the lessons of the great pandemic, and so ensure that it does not happen again; that we are prepared; and that we always work together. And if we do, then our children - the children of the millennium - will remember the 21st century as a time of health and hope ... a time of promise and possibility ... a time of medical miracles and scientific marvels," Shalala said.
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