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Testimony on Infectious Diseases
by David Satcher, M.D., Ph.D.,
U.S. Surgeon General and Assistant Secretary for Health,
U.S. Department of Health and Human Services

Before the House Committee on International Relation

June 29, 2000

Good morning. I am Dr. David Satcher, U.S. Surgeon General and Assistant Secretary of Health, Department of Health and Human Services. I am pleased to be here to discuss an important issue: the threat that infectious diseases like malaria, HIV/AIDS, and tuberculosis pose to global stability and what this means for the United States, in terms of health, economics, and foreign policy. I will also review recently launched global initiatives and partnerships that aim to address specific disease problems.

Emerging Infectious Diseases as a Global Issue

From a public health point of view–no less than an economic one–the world has become a global village. Modern factors that connect us culturally, commercially, and physically, such as air travel and the food supply, put us at risk of exposure to microbes with epidemic potential, whether we live in large cities or small rural hamlets. Last year, two Boy Scouts acquired malaria, which is not usually contracted in the United States, from mosquitos at a summer camp in a rural part of Suffolk County, New York. In August and September, 6 people in the northeastern United States and a Canadian who visited New York died from West Nile encephalitis, a viral disease transmitted by mosquitoes. The West Nile virus, which is carried by migratory birds in Asia, Africa, and Europe, had never before been reported in the Western Hemisphere. Also from July 1999 to January 2000, 56 persons in South Texas were recognized with dengue fever, 17 of whom acquired their illness in the United States.

The HIV/AIDS pandemic continues to cause the death of children and young adults all over the world, and age-old diseases like malaria and tuberculosis are resurging, often in drug-resistant forms. For instance, a new strain of tuberculosis (strain W), which is multidrug resistant and occurs more frequently in HIV-infected people, has now been reported in twelve states. Additionally, 45 states have reported other strains of multidrug-resistant TB. Moreover, a long list of unforeseen infectious disease problems with global impact have emerged in recent years. To give a few examples: in 1997, an avian strain of influenza that had never before been found in humans caused the death of previously healthy people in Hong Kong. This crisis raised the specter of an influenza pandemic similar to the one that killed more than 20 million people worldwide in 1918-1919. In 1997, we learned that vancomycin–an antibiotic of last resort–has begun to lose its power to cure infections caused by Staphylococcus aureus, a common bacterium that can cause life-threatening illness. And in 1998, a new encephalitic disease of pigs and humans was discovered in Malaysia and found to be caused by a previously unknown virus, which has recently been named Nipah virus.

Disease Outbreaks Affect Global Prosperity and Security

The impact of infectious diseases goes far beyond devastating effects on individuals and families. The cumulative burden of morbidity and mortality caused by infectious diseases like malaria, HIV/AIDS, and multidrug-resistant tuberculosis affects economic growth in many countries and decreases global prosperity and security.

Many countries in Africa, especially those in Sub-Saharan Africa, are experiencing explosive HIV epidemics that are taking an enormous toll in human life and having a profound economic and social impact. It is estimated that 22 million adults and 1 million children are currently living with HIV/AIDS in the Sub-Saharan region of Africa and an estimated four million new infections occur in that area each year. The AIDS death toll is rapidly rising, with an estimated 5,500 funerals occurring each day in the region. The epidemic is wiping out gains in life expectancy. By the year 2010, demographers project that life expectancy will fall from 66 to 33 years in Zambia and from 70 to 40 years in Zimbabwe. By 2005, 61 of every 1,000 infants born in South Africa are expected to die from AIDS before the age of one year.

Outbreaks of infectious disease can interfere with trade, agriculture, tourism, and foreign investment, and epidemic-related trade embargoes and restrictions on travel and immigration can cause friction with trading partners. The 1997-98 Rift Valley Fever (RVF) outbreak in eastern Africa, which killed both humans and livestock, harmed the Kenyan dairy industry, as well as trade in sheep, goats, cows, and camels. In Somalia, where 96% of export income is generated by the sale of sheep, camels, and goats to the nations of the Persian Gulf, the economy was devastated by trade embargoes intended to prevent the spread of RVF via imported animals. The agricultural costs of controlling outbreaks can also be considerable when large numbers of disease-carrying food animals must be slaughtered, such as cows during the "mad cow disease" outbreak in the United Kingdom; chickens during the avian influenza outbreak in Hong Kong; and pigs during the Nipah virus outbreak in Malaysia.

Organizations concerned with economic development, including the World Bank and the World Trade Organization, have concluded that disease reduction efforts are a necessary part of global development strategies. Infectious diseases can sap the strength of a nation’s workforce and deplete its medical resources, making it more difficult to compete in the global economy. Each year, for example, loss of productivity due to malaria has decreased economic growth in Sub-Saharan African countries by as much as 1.3 percent. Had malaria been eliminated 35 years ago, Africa's current annual gross domestic product would be $400 billion, rather than $300 billion–a loss that is nearly five times greater than all development aid provided to Africa last year.

Security experts, including members of the National Intelligence Council, are concerned that large outbreaks like the HIV/AIDS pandemic may devastate poorer nations. In January 2000, a special session of the U.N. Security Council addressed the HIV/AIDS epidemic in Africa as a global security threat. Social and political strains exacerbated by infectious disease problems in developing and former communist countries may challenge democratic development and political transitions and possibly contribute to humanitarian emergencies and military conflicts. The security community is also concerned that an infectious outbreak might be caused intentionally by a terrorist group or as a weapon of war.

U.S. Investment in International Health

Public health programs are wise investments, both domestically and globally. Successful disease eradication programs save significant amounts of money. The eradication of smallpox in 1977, with support from CDC and USAID, proved to be a remarkably good economic investment. A total of $32 million was spent by the United States over a 10-year period in the global campaign to eradicate smallpox. The entire $32 million has been recouped every 2˝ months since 1971 by saving the costs due to smallpox infection including medical care, quarantine, and other costs, and the cost of smallpox prevention including costs of the vaccine and its administration, and other costs. Achievement of global polio eradication will offer similar benefits: More than $230 million will be saved annually in the United States alone in polio vaccine and administration when polio eradication is achieved. Globally, more than $1.5 billion will be saved annually.

In the coming years, the impact of global infectious diseases on the United States is likely to increase. Infectious disease problems may endanger U.S. citizens at home and abroad, threaten U.S. armed forces deployed overseas, and exacerbate social and political instability in countries in which the United States has significant economic and foreign policy interests. U.S. investment in global health may therefore yield multiple benefits, including:

Preserving domestic health. The United States cannot protect the health of its citizens without addressing infectious disease problems that are occurring elsewhere in the world. Helping other countries to control disease outbreaks–Ebola in the Democratic Republic of the Congo, avian influenza in Hong Kong, or dengue fever in Mexico, for example–prevents those diseases from spreading to the United States, saving lives and dollars. It also reinforces our diplomatic efforts in this area by demonstrating U.S. commitment to global health. In addition, U.S. participation in international outbreak investigations provides U.S. scientists with opportunities to focus on new or drug-resistant pathogens and consider how best to control, prevent, and treat them, before they arrive on our shores.

Outbreaks in other countries may affect Americans who travel overseas, as well as U.S. military forces stationed abroad, who have historically experienced higher rates of hospitalization from infectious diseases than from battlefield combat and noncombat injuries.

Enhancing the U.S. Economy. Improvements in global health can enhance the U.S. economy in direct and indirect ways. Domestic health care costs may be reduced by decreasing the number of cases of imported diseases and by eradicating diseases currently included in childhood vaccination programs. Moreover, as noted by Treasury Secretary Lawrence Summers, the United States has an enormous economic stake in the successful human and economic development of the poorest countries. As poor countries grow richer, they tend to become the fastest growing markets for U.S. goods and services. At the present time, developing countries account for 42% of all U.S. exports.

Advancing U.S. foreign policy interests. Health is an area of concern for all nations, and international projects that address infectious disease issues can build bridges and ease tensions between the United States and other nations. Protecting human health and reducing the spread of infectious diseases is one of the Secretary of State’s strategic goals for international affairs, recognizing the importance of global health issues to the national interests of the United States. Investments in global health clearly benefit the American people by reducing the threat to public health in the United States, but such investments also pay dividends through improved bilateral relationships, conditions for economic development and trade, and regional stability. Benefits provided by health investments can also accrue to our national security through activities such as redirecting the work of biological weapons scientists in the Russian Federation and Newly Independent States of the former Soviet Union to fight global diseases.

Investing in global health is an area in which global humanitarian needs and U.S. national interests coincide. As the Institute of Medicine stated in its 1997 report, America’s Vital Interest in Global Health, "the direct interests of the American people are best served when the U.S. acts decisively to promote health around the world." In the area of emerging infectious diseases, the United States can lead with its strengths in science and technology to protect American and global health while projecting U.S. influence internationally. While we must continue to respond to other countries’ requests for outbreak assistance, we must also support international efforts to build global public health infrastructure to detect, control, and prevent infectious diseases.

Partnerships and Initiatives

The challenge ahead outstrips the means available to any one agency, organization, or country. To quote Dr. Gro Bruntland, Director-General of the World Health Organization (WHO), when it comes to public health, "solutions, like problems, have to be global in scope." If we pool our talents and resources, a great deal may be accomplished.

Many U.S. agencies are involved in interagency efforts to combat infectious diseases. For example, earlier this month an Interagency Task Force on Antimicrobial Resistance, that is co-chaired by CDC, the Food and Drug Administration (FDA), and the National Institutes of Health (NIH), and includes seven other agencies, published a draft Public Health Action Plan to Combat Antimicrobial Resistance. The Action Plan provides a blueprint for coordinated federal actions and will be used by agencies to develop programs to effectively combat the emergence and spread of antimicrobial resistance through better surveillance, prevention, research, and new products for treatment and diagnosis. The growing threat of resistance is also the topic of a newly released WHO report, Overcoming Antimicrobial Resistance, which outlines WHO’s recommendations for addressing the worldwide problem.

As another example of collaborative efforts, in 1995, I had the honor of chairing a working group on emerging infectious diseases for a committee of the National Science and Technology Council–the Committee on International Science, Engineering, and Technology (CISET)–which was charged with conducting a government-wide review of our ability to protect our citizens from emerging infectious diseases. In September 1995, the Committee issued a report which concluded that existing mechanisms for surveillance, response to, and prevention of outbreaks of new and reemerging infectious diseases were inadequate, both at home and abroad. The report described the seriousness of infectious diseases and problems of antimicrobial resistance in the United States and made specific recommendations that became the basis of a 1996 Presidential Decision Directive (PDD) that established a new national policy. The Directive called for a coordinated U.S. government response to address the growing health threats posed by infectious diseases.

The PDD called for the establishment of an interagency Emerging Infectious Diseases (EID) Task Force, which I co-chaired with Dr. Kerri-Ann Jones, the former Associate Director for National Security and International Affairs of the White House Office of Science and Technology Policy (OSTP). The President charged the EID Task Force with implementing the PDD. U.S. agencies are working through diplomatic channels to make the issue of emerging infectious diseases a priority with other nations, in accord with the PDD and with the State Department’s Strategic Plan for International Affairs. Emerging infectious disease issues are also on the agenda of the Group of Eight Nations and the Asian Pacific Economic Cooperation (APEC). In addition, they are under consideration in bilateral talks with Japan, South Africa, Mexico, the European Union, and the Russian Federation.

U.S. agencies are also providing advice and technical support to global health initiatives that involve foreign governments, WHO, development banks, foundations, non-governmental organizations (NGOs), and private companies. The aim of these initiatives is to use the combined expertise, experience, and resources of many partners to identify and implement the most efficient and effective methods for detecting, controlling, and preventing infectious diseases. Global collaborations include:

  • HIV/AIDS Initiatives. The U.S. Government has joined the International Partnership Against HIV/AIDS in Africa to mitigate the effects of the growing HIV/AIDS pandemic. The Partnership, coordinated by UNAIDS, includes African governments, NGOs, USAID, CDC, and other U.S. Federal agencies, aid agencies representing major donor governments, and the private sector. In July 1999, as part of this effort, the Clinton Administration launched the Leadership and Investment in Fighting an Epidemic (LIFE) initiative, which provides support to fourteen countries in Africa and India for reducing HIV transmission, improving treatment of HIV/AIDS and opportunistic infections, and strengthening national capacities to collect disease surveillance data and manage national HIV/AIDS programs.

  • Malaria Initiatives. WHO’s Roll Back Malaria program aims to reduce deaths form malaria by 50% by 2010. This will be accomplished by increasing access to treatment, promoting bednet protection against malaria-carrying mosquitoes, and developing new products for the prevention and treatment of malaria. Specific U.S.-backed initiatives that contribute to the Roll Back Malaria partnership include:

  • Malaria Vaccine Initiative, which accelerates the development and field-testing of promising malaria vaccine candidates. This initiative was created through a grant from the Bill and Melinda Gates Foundation to the Program for Appropriate Technology in Health.

  • Medicines for Malaria Venture, a public-private sector initiative that develops antimalarial drugs and drug combinations for distribution in poor countries.

  • Multilateral Initiative on Malaria, currently led by NIH’s Fogarty International Center, is a multi-partner effort which fosters global collaboration and coordination to maximize the impact of scientific research against malaria in Africa.

  • The African Integrated Malaria Initiative, a USAID-sponsored initiative that enhances integrated malaria treatment and prevention in Kenya, Malawi, Zambia, and Benin.

  • Vaccine Research Plan, the NIAID has developed a research plan for malaria vaccine development.

  • Tuberculosis Initiatives. The goal of the STOP TB Initiative is to accelerate social and political action to stop the spread of tuberculosis around the world. One of its objectives is to promote the implementation of the Directly Observed Treatment Short-course strategy (DOTS). The effective implementation of DOT in NYC, in response to the epidemic in the late 1980s - early 1990s, has served as a model nationally and internationally. The STOP TB Initiative includes research institutions, private companies, donor organizations, government agencies, and NGOs.

  • Vaccine Initiatives. The elimination of malaria, HIV/AIDS, and tuberculosis will ultimately depend on the development of effective and inexpensive vaccines. Research on the development of vaccines against these three important infectious diseases is a priority of the NIH. In his State of the Union message, President Clinton announced the Millennium Initiative, a public-private sector collaboration to overcome technical and economic barriers to the development and delivery of such vaccines for use in developing countries. This Initiative involves new partnerships among the world’s major pharmaceutical and vaccine companies, foundations, and international organizations.

A global effort is also underway to strengthen childhood immunization programs and to bring a new generation of recently licensed vaccines into use in developing countries. These include vaccines against hepatitis B and childhood meningitis and against respiratory infections, which are the leading cause of death in children under five. Substantial resources for this purpose have been pledged by the Bill and Melinda Gates Foundation and by the Global Alliance for Vaccines and Immunization (GAVI).

  • Polio Initiatives. The Global Polio Eradication Initiative, spearheaded by WHO, Rotary International, CDC, and UNICEF, is a good example of protecting the Nation’s health by addressing infectious disease problems elsewhere in the world. Widely endemic in 125 countries on 5 continents in 1988, polio is now concentrated only in parts of sub-Saharan Africa and South Asia. At the end of 1999, there were 30 remaining polio-infected countries. However, no country can be free of the fear of polio until all are free.

  • Measles Initiatives. The United States, through CDC and USAID, is also participating as a partner with the Pan American Health Organization in the elimination of measles from the Western Hemisphere by the end of 2000. Measles is at record low levels in the Americas, with approximately 300 cases reported from only 8 countries so far in 2000. Through this effort, in combination with ongoing success in increasing measles immunization levels in the United States to their highest levels ever, interruption of measles transmission has been achieved in the United States and the health of U.S. citizens protected.

  • APEC Initiative. On July 16, CDC and DOD will host a meeting of APEC representatives from developed and developing countries to consider the establishment of a regional system that integrates capacities for disease surveillance, laboratory diagnosis, outbreak response, research and training, and disease prevention. This initiative was proposed by the interagency CISET Task Force on Emerging Infections.

The West Nile Encephalitis Outbreak

Before I conclude, I would like to touch again on last year’s West Nile virus (WNV) outbreak as an example of the domestic health benefits that accrue when U.S. scientists focus on diseases that occur in other countries. Because several agencies had done work on WNV or closely related viruses, diagnostic tools and information on disease prevention were readily available when the outbreak occurred.

CDC and its partners on the WNV interagency coordination committee have issued guidelines to help local health departments address WNV this summer and in the future. In the short run, the guidelines recommend intensified monitoring to determine when and where WNV is circulating in local birds and mosquitoes. Over the short and long run, they recommend the development of emergency mosquito control plans and implementation of integrated pest management techniques. In addition, NIH will continue to explore the potential public health use of new vaccines or antiviral drugs to prevent or treat WNV infections in humans and animals.

The 1999 outbreak epicenter was in the New York City area with infected birds or mosquitoes also identified in Long Island, upstate New York, Connecticut, New Jersey, and Maryland. As the major bird migration routes from this area run south along the Atlantic and Gulf Coasts, this virus poses a threat to humans, wildlife, and domestic animals in coastal states that are either adjacent to or south of the New York City/Connecticut/New Jersey area. Ultimately the virus could appear in other parts of the country as well.

CDC, in coordination with U.S. Department of Agriculture, the Department of Interior, and the Environmental Protection Agency continue to monitor for WNV activity and seek ways to prevent future outbreaks. CDC is working with State and local health departments in this geographic area of risk to develop and implement surveillance for West Nile and other arboviruses so that they can identify and rapidly respond to outbreaks of WNV should they occur. CDC is providing $4.1 million to 19 state and local health departments on the eastern seaboard and Gulf of Mexico to assist in planning and implementing a program for WNV surveillance and laboratory diagnosis. An additional $3.1 million will be awarded to enable other parts of the country to diagnose WNV infection if needed.

As with many emerging infectious disease problems, addressing the WNV outbreak requires a strong partnership between public health and veterinary agencies and the public. There are things that individuals can do to reduce their risk of exposure to WNV. These include eliminating any areas of standing water around the house; minimizing outdoor activities at dawn, dusk, and in the early evening; wearing long-sleeved shirts and pants when outdoors; applying insect repellent sparingly to exposed skin and clothing; and reporting sightings of dead birds to the local health department.

Conclusion

Addressing the threat of emerging infectious diseases depends on international cooperation. Our confidence that nations can come together to improve global health is reinforced by the success of the effort to eradicate smallpox, and the substantial progress made toward the worldwide eradication of polio and guinea worm disease.

We do not underestimate the difficulty of this work, especially when it involves countries that cope with civil unrest, refugee camps, internal migrations, troop movements, or malnutrition. Helping these countries participate in global efforts to combat infectious diseases is a challenging task–one that requires a sustained effort over many years and a willingness to persist in the face of repeated setbacks. It requires strategic investments that build on host countries’ strengths and encourage multi-national assistance.

We must not stop now. The potential for saving human lives by preventing infectious diseases overseas is tremendous. Although U.S. agencies participate in international health projects in many parts of the world, much more could be done, at relatively low cost, if we have the political will, the national leadership, and the support of the American people. Promoting the international effort to combat emerging diseases is a natural role for the United States, and one that benefits both the United States and the global community. We do not know where the next emergency will arise or what its cause will be, but we can be assured that global health emergencies will continue, and we must have the flexibility to be prepared to respond accordingly.

Thank you for the opportunity to testify before the Committee. I will be happy to answer any questions you may have.


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