Health Emergencies
Countries around the world face a perfect storm of converging threats. Covid is the latest but far from the last health emergency the world will face.
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Countries around the world face a perfect storm of converging threats. Covid is the latest but far from the last health emergency the world will face.
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Covid is the most recent health emergency, but one of only a many in recent years. On average, one new pathogen with substantial potential for human harm is discovered every year.
The Global Health Security Agenda is an important initiative to reduce global risk. But outbreaks and epidemics of HIV, Zika, Ebola, drug-resistant bacteria, cholera, and more demonstrate our ongoing vulnerability to microbial onslaught and sneak attack. The articles in this section outline some of those risks - and some succesful responses that are important to learn from.
For the first time in history, the world has an in-depth understanding of how prepared most countries are to deal with epidemic diseases and of what must be done to improve preparedness. To save lives, funded, prioritised, well-planned actions must be implemented at scale as soon as possible, supported by a network of partners working together to support countries to step up their capacities to prevent, detect and respond to public health threats and make the world safer.
We reviewed experience from 2009 through 20017, drawing lessons from the H1N1 influenza pandemic, Ebola, Zika, and many tother emergencies. Our fundamental conclusion: the best emergency preparation is getting everyday systems to work well to find, stop, and prevent health threats, with the ability to scale these systems up quickly and robustly.
The Zika epidemic was the most complex emergency CDC had faced. It required involvement of a broad range of expertise: virology, entomology, vector control, reproductive health, birth defects, laboratory development, pathology, and more. We're still learning about how to control it, and why the impact was so different in different places.
This collection of artilces outlines the rationale and needs for the Global Health Security Agenda. The world now has a good sense of what is needed, where, how to address these needs, and how much it will cost to do so. What's lacking is action to meet these needs - with money, technical support, and strengthening operational capacities.
In 2005, I called for the application of public health principles to the HIV epidemic (table below). This was highly controversial at the time. Since then, the view has been widely accepted and applied, and we review the substantial, although far from complete progress, since, and concluded that, "The combination of patient empowerment, community engagement, clinical excellence, and public health focus on outcomes and impact could make management of HIV infection a model for combating other chronic diseases."
Delay in diagnosis of HIV results in both avoidable illness in the person diagnosed, and increased risk of spread to others. Addressing the root causes of delayed diagnosis and treatment is essential to controlling the HIV epidemic.
The Ebola epidemic was the most challenging emergency of my 15 years leading public health programs. Thousands of CDC staff worked for years in West Africa to help end the epidemic. Although as I said publicly early on, it was never "in the cards" for Ebola to spread widely in the United States, the epidemic caused a degree of fear and politicization in the public and by politicians that foreshadowed the deadly errors made in the US response to Covid in 2020.
Martin Meltzer's model of Ebola is one of the greatest modeling stories in public health history - and not widely enough known. Samantha Power's book outlines the impact his worst-case scenario had within the United States government and global community. But less well appreciated is the fact that his projection of what would happen with fast, effective action matched what did happen stunningly well, as shown in this figure below.
About Ebola, we made one specific and one general conclusion.
"The Ebola virus is a formidable enemy. If a single case is missed, a single contact becomes ill and isn't isolated, or a single lapse in infection control or funeral-practice safety occurs, another chain of transmission can start."
"We believe that stopping outbreaks in a way that leaves behind stronger systems to identify, stop, and prevent future health threats is a moral imperative."
It's possible to eliminate cholera from Haiti and the Dominican Republic - but requires persistence and political commitment.
The earthquake and cholera epidemic were devastating, and even before these events, Haiti had, by far, the worst health status of any country in the hemisphere. But it would be a mistake to fail to recognize the many areas where dedicated health workers and community volunteers have made substantial progress. This progress demonstrates that more progress is definitely possible.
Antibiotics have saved millions of lives, but drug-resistance threatens to usher in a post-antibiotic time. In April of 1991, acting on a tip from an alert clinician, I conducted a study of every patient in New York City with tuberculosis. The results were alarming, and resulted in a substantial increase in funding and attention. We were ultimately able to control the outbreak, which was largely driven by spread in hospitals, and was the largest outbreak of multi-drug resistant tuberculosis the United States has experienced. Another bacteria, vancomycin-resistant enterocci, didn't spread widely. In 1990, while an infectious disease fellow, I wrote of the widespread inappropriate use of antibiotics.
Writing with Dr. Tedros, now WHO Director General, and others, we outlined a way forward to control of malaria, tuberculosis, and HIV.
I became health commissioner in January, 2002, when the World Trade Center remains were still burning. We established a registry to track health effects and facilitate benefits for survivors and those suffering from the health, including mental health, complications. Rapid creation of health registries to better understand and support those effected by health emergencies is an important public health function, and must be done quickly and sensitively.
There's a long and interesting history of the interaction of nutrition and infection. In the early 1900s, anti-tuberculosis activists helped to create milk stations so children could receive wholesome milk as a nutritional supplement. During my training as an Epidemic Intelligence Service Officer of the Centers for Disease Control, I documented that vitamin A levels were low among children in New York City with measles. This resulted in a new recommendation to provide vitamin A to young children with measles in the United States.
While working in India, we gradually realized that tuberculosis has substantial seasonality: there is a much higher rate in cold weather in the north of the country, but no seasonality in the south of the country which doesn't have a winter season. (I was memorably informed that Chennai has three seaons: hot, hotter, and hottest.) The figure below is striking in showing this. Very high seasonality in the cold winter months in the north, and none in the hot winter months in the south. The reasons for this seasonality are not yet definitively known, but vitamin D deficiency in the colder months, when people are inside more, is a leading and plausible hypothesis, for which there is increasing evidence.
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Health cannot be protected by Ministries of Health alone. Many sectors need to be involved in order to increase and sustain investment, build long-term capacity and implement policies affecting health in the food, security and animal sectors. In many countries, the JEE was the first opportunity for these sectors to work together. This group should continue to collaborate in order to prioritise which gaps to fill first, begin implementation, increase domestic financing and monitor progress. High-level support (eg, from presidential or prime minister offices) is essential for countries to take action. Engagement by journalists and civil society can convey that increased health security is essential. This support can help counter the pattern of a temporary surge of activity followed by waning interest, as typically seen after a major outbreak.
I outlined this in a brief (2 minute) that I wish more people would watch - because models have been so poorly understood and used during the Covid pandemic.
Note: The earthquake also resulted in the death of , a dedicated and inspiring CDC staffer who was in the country on a short-term assignment to help improve prevention and control of HIV. This was the one death in the line of duty which occurred in my time as CDC director from 2009-2017. I will never forget meeting with her family to inform them. We established an award to recognize staff early in their career.
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