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OCR for page 23
Out- T~atio~al interests are inevitably linked to tire Stealth of people
throughout tire wotlcI. Healths, like eclucatio~, is an investment in human
capital fiat can Whelp breath cycles of poverty ant! political instability—
contTibutillg to national alar! global economic development and is of
funcIamental importance in shaping the stability and well-being of a
Elation or r egion. Tire tragecly of HIV/AIDS ifs Africa leas cleeply scarrec!
large regions of the continent, ant! it threatens to undermine economic
progress, institutional strengths, ant! tire survival of family unfits. Although
less visible titan the AIDS epidemic, the Truman toll of economic hardship
acid social instability in Russia leas resulted ilk a 10-year decrease in life
expectancy for men, ant! an over 40 percent decrease in births rate from
tire n~id-80s to tire mid-9Os, far loweT titan tire
replacement rate neeclec! to sustain population
levels, the economy, Alice current sta'~ciarcIs of liv-
ing. These aide only two examples of global healths
events that conic! Create peace, prosperity, amuck
international relatioT1SilipS in tire aecacles to come. Tire global reacts of
emerging infectious cliseases cart be more immediate. Within days of tire
issuance of Microl~ial Threats to Health E'nerge`?ce, Detection, and Response
(2003), the SARS epidemic burst alto WoTidVieW, TemilldiTlg US that a pan-
demic can emerge witty astonishing speed and spread globally in a matter
of weeks. Shortly ti~ereafteT; bovine spongiform encephalopatI~y (Mad
Cow Disease) and monkeypox emerged for tire first time in tire Americas.
He~' lil(e eduCatiOn' is
an inveStnlent In Iluman
.} ~)
Lit
T
a:
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]~RMI.~ I1~< ]~tj~r~_~x 6~rRt i55~s i~ u~-At7~
The IOM contributes to improver! global health trough studies bleat
advise on how to reduce the burdens of disease and disability in developing
countries, that illuminate emerging threats to international anc! global
health, and that emphasize infectious diseases tile most truly global
threats to i~ealtl~.
~ ~ . ..
I-- wIsEAst
I. .. I. .
'1fectious diseases toc/ny ignore geographic nils] political boundaries, airy
t1~`s constitute c' global threat tight places every nations acid every persons at
risk. Foot! prO4tfCtS, livestock, exotic pets, and material goods acid the
'microbes they carry are excha'~gec! as cultt~resfro~n every regions oftI~e
world are explo~-ecI. --Microbial Threats to Health, 2003
Infectious diseases continue to burclen populations around tire world.
Hotly naturally occurring acid intentionally introduced biological threats
lyric! increasing potential to cause clisease, disability, ant! Neatly. Through
botch committee studies and convening activities, tire IOM assesses
emerging threats, the capacity of national and international systems to
respond to tI~ose threats, and tire research and artier investments neces-
sary to molest an adequate response.
Microbial Threats to Heat: Emergence, Detection, ant! Response (2003)
conclucles treat tire public health and mecca communities in tire United
States aloe inadequately prepa~-ec] to clear effectively wield infectious dis-
eases. Tire report extends and expands upon a 1992 IOM
report, Emerging Infections: Microbial TI'reats to Hen/th in
tire United States, which brought taxis issue to national
attention and stimulated research efforts and policy
actions. Tire new report describes scientific, social, and
political tresses that leave influenced infection acid clisease
emergence arid control over the past decade. New or pre-
viously unrecognized! diseases Such as SARS) leave
emerged and known diseases that were tI10UgI1t to be
virtually eradicated in tire U.S. (such as measles and per-
tussis) have reappeared, occasionally in epidemic propor-
tions. The r eport reviews the current state of knowledge
on how infectious diseases emerge and identifies opportunities for public
health actions, Motif domestic and worldwide, to strengthen capabilities
for detecting and responding to microbial threats and preventing tire
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Representative terms from entire chapter:
cleveloping countries
3 t~x
spread of infectious diseases. It calls on tire United States to make sig`~ifi-
cant efforts to enhance the global capacity for responding to microbial
threats, focusing in particular on threats in the developing wapiti. This will
require providing technical ant! financial assistance, expanding research
acid surveillance, ant! shearing I`nowledge ant! best public health practices
across national boundaries. Among othe' ~ecommencIations, tire report
stresses tile need for federal, state, anti local governments to rebuilt! and
sustains the infiast~uctu~^e of the U.S. public health system, which leas suf-
fered From years of neglect.
Aft effective surveillance system is critical to detect and monitor infec-
tious disease, boric within the U.S. amuck globally. ill 19967 able Executive
Office of else President, acting on advice Cons its National Science acid
Technology Committee, issued a directive Rectal ing that U.S. citizens were
clot being adequately protected fiom emerging infectious diseases. The
directive (NSTC-7) stated tI1at national and international capabilities for
monitoring, respot~ciit~g to, and preventing infectious diseases were insuf-
ficient, ant! it caller! for a more robust national policy to improve Otiose
capabilities. Among actions taken in response, the Department of Defense
in 1997 established tile Global Emerging Infections SurveilIa~ce ant!
Response System (GEIS). After several years of operations, massagers of tire
GEIS asI
[N,~N,!~ 7~--~< /~)~ CKI116~AL ~~.~S Or HEAL11-I
toward achieving its goals in protecting tile heat of U.S. military and civil-
ian populations, as well as global health interests. Tire r effort recommenci-
ec! some refinements—such as increasing tire number of personnel who
leave applied epiclemiological expertise, expanding training pi ograms, and
broadening communications efforts to include public Stealth partners-
and called for tire government to inc' ease financial support fo' the systen~
to help ensure its lo~g-te~~m success
Unlike viruses and microorganisms—tl~e agents of most known infec-
tious cliseases priors are act anally sl~apec! forest of a normal n~a~n-
malian protein. Identified in 1982, pinions appear to be associated wield a
group of uniformly fatal '~euroclegenerative diseases called transmissible
spongiform encepl~alopatI~ies (TSEs), which
include "Mad Cow Disease." Conventional metI~-
octs useful to cliagnose most infectious diseases
fad! to cletect TSEs. Timbre is no cure, prophylaxis
or fail-safe a~temortem diagnostic test for TSEs.
A decacle's worthy of attempts to clevelop effec-
tive prior-detection tests Slave largely failecI.
Consequently, tire lJ.S. Department of Defense
launched tire National Priors Research Program in
2002 with $42.5 million and requester! tire assis-
tance of tire IOM to review scientific I<~owlecige about TSEs ant! to recom-
menc! the highest-priority research for funding. Advancing Prion Science:
Guidance for the Nations! Priors Research Programs? (2003J concludes that
.~-~5 dPi't~ t~ ~
aSSOCiatet! wait ~ Up of
Ally fatal neurt,4~
g0~ti~3 ji50350~8 catle]
~ * o ,"
ranSmIsS' Ule Spongl'l'0~m
encenf'alonat-hies (TSEs)
whith fin cIude~ 'Mad Cow
~ iSeaSe.'
progress il1 developing an antel11ol tem diagnostic test to detect priOllS Will
be slow unless fundamental questions are answered about tire n~olecular
biology of potions and tire normal prion protein from WI1iCl~ it is derived.
TIle committee stressed treat tire infiastructure capability for research on
TSEs in tire U.S. is limited due to constraints in funding, lab facilities, and
Umber of investigators trained ilk taxis Idly specialized area.
International collaboration offers opportunities to expand treat capacity.
A'~`malar'al~s
Malaria remains else leading killer of children in Africa and a significant
cause of morbidity among adults and children in Africa, Asia, and focally,
in ouster parts of tire world. Resistance to inexpensive antimalarial drugs is
widespread, and few effective drugs even expensive ones - exist to fill
tire current need, which is growing. An upcomin`, IOM report will examine
evolving patterns of malaria (including drug resistance) and tire options for
~~Ri\L ~<,4~ AND liNrFT(~?~S ~~45E
controlling it, witty the aim of cleveloping policy strategies, particularly
financing strategies, that couic! leac! to tire greatest goof! for those accost
affected, as well as for tire larger popt'lation at r isI<. The potential for incre-
n~ental in~proven~ent of existing, new antimalarials through pl~ar~naceuti-
cal technology also will be explored.
The cages poser! by infectious diseases clen~anc} concerted and
coordinates! efforts along a number of fronts, from treating inclividual
patients and preventing tire spread of clisease within comn~u~ities to sI~ap-
ing public policies in tire United States anti worIc~wicle. Tile lOM's Forum
on Microbial Threats, creates! in 1996, fosters wicle-ra~gi~g discussions
among tire various parties who square a stake in improving the prevention,
detection, and management of these diseases. Forum workshops provide
timely opportunities for representatives from academia, industry, profes-
sional ant! interest groups, amuck government to cliscuss, in a neutral setting,
critical and sometimes contentious issues. Such cross-sector dialogue leas
helped in establishing priorities for research and public i~ealtl~ policy, iden-
tifying areas in need of greater attention, and illuminating opportunities
for more effective collaboration I'etween else private and public sectors.
Recent wo~
|~IN(i I~E i. brig iR3~ CRI11~AL a... I,\ IDEALS
where tizzy account for I~alf of all cleatl~s. Belt no region is free from con-
cern, and every inI~abitecl continent regularly experiences large outbreaks
of some type of infectious clisease. The lOM report concludes that fighting
tire global spread of infectious diseases will talce political resolve and suf-
ficient financial] resources. The workshop brought together key representa-
tives fi one tire Americas, Afi ice, Asia and the Pacific, and Euro ope. Wiley sur-
veyec! such issues as the factors that contribute to the emergence of infec-
tious diseases, efforts to coordinate surveillance activities and responses
witl~in ant! across borders, and remaining needs for research and
resources. In the report, participants stressed treat the world community
must work toward a set of common goals. Among finest goals are strengti~-
e~ing disease surveillance of l~u~nans and clomestic animals Wick can
pass diseases to humans, fostering good public health practices, expand-
ing training programs, conducting collaborative research in a number of
targetec! areas, a'~c! accelerating vaccine development Alice distribution.
· The Emergence of Zoonotic Diseases: Unclerstancling the Impact on Animal
airy Suntan Health (2002~. Diseases passed to Pumas frown animals-
zoonoses are leaching causes of illness ant! cleated in many nations, ant!
they negatively affect commerce, travel, acid economies woridwicle. Many
factors influence the emergence and spreac! of zoonoses, ranging frown
molecular interactions in microbes to forces that trigger tire growths and
movement of populations ancI changes in the environment. There also is
concern about tire potential use of zoonotic
agents as "bioweapons" by terrorists. The IOM
report explores tire forces that drive zoonotic
diseases and offers some broacl-based strategies
treat will help tire United States arch tire world in
preventing ant! controlling talent. Participants
cited a Bleed to expanc! research in a varied of areas, including tire patI~o-
genesis of zoonotic agents and tire development of vaccines; to entrance
national ant! international laboratory capabilities; to strengthen surveil-
lance systems titan can provide early waving for emerging zoo~oses; acid
to mount education programs to increase public awareness of tire prob-
lems and minimize undue fears. Perhaps tire most funcian~ental neec! is for
improved collaboration and cooperation among government agencies at
all levels, as well as among members of tile Unman health, veterinary,
wildlife healths communities.
There also is co'3~n abot~t
thg potently! use of zoo
noliC a~s aS Lb Jo_
weapo'~' by te`~;~..
· Considerations for Viral Disease Eradication: Lessons Learned clue! Future
Strategies (2002~. Tile success in using vaccines to eradicate smallpox sug-
gests tire possibility of eradicating many officer viral diseases tight once
GLOBAL ~~-ALl~''l.~:) Me- D~-,4~r
were consiclerec! beyond slope. IncleecI, the eradication of several diseases,
including polio and measles, is on tire horizon. This prospect raises tire
importance of aciciressing early on a range of issues likely to surround tire
cessation of immunization and otI~er prevention activities. Tile IOM report
examines the biological challenges, medical interventions, and operational
considerations to be faced and I~igl~ligl~ts efforts titan may facilitate wise
clecision-maki~g in the post-eraclication era. Participants pal ticularly
empl~asizect titan eradication must not beget con~placency. Reemergence of
a virus or its intentional reintroduction will remain a threat, especially
as immunity wanes and tire populations at large grows snore susceptible to
infection. Enough vaccine sl~oulc! be stockpiler! (or provision made foil
emergency replenisI~ment) to cope witty any outbreaks treat might arise,
and surveillance sixfold continue to quickly iclentify local outbreaks before
Riley can spread. Among other actions, it is vital to continue research on
viral biology arm! vaccine tecI~ology, and to make sure tight remaining
viral stocks if it is deemed necessary to maintain such stocks—be secure-
ly contained.
· In else wake of September 11 and r ecent anthrax events, our nation's
bioterrorism response capability leas become an imminent priority for pol-
icymakers, researches, public Dealt officials, acac'ae~nia and the private
sector: In a tI~ree-day workshop treat was cap-
turec! in a workshop sun nary titieci Biological
Threats to Terrorism: Assessing the Science a',`/
Response Ca,vabilities (2002), experts from each of
these communities came together to identify,
clarify, and prioritize tire next steps that need to
be tableau in order to prepare and strength
bioterrorism response capabilities. Fron1 the ctis-
cussions, it became clear treat of utmost urgency
is tire neec] to cast tire issue of a response in an appropriate fi-ameworI; to
attract the attention of Congress ant! the public in order to garner suffi-
cient and sustainable support for such initiatives. No matter flow tire issue
is framed, numerous workshop participants agreed that there are many
gaps in tile public healths infrastructure anc'a counter~neastare capabilities
that must be prioritizes! and acIdressec' in order to assure a rapid and effec-
tive response to anotilel big-terrorist attack.
R .~ ~ mini 0~] ~ ~ i ()i ~ (~0 (' ~ t~
respons`~ capab;lillty has
become ~Ln in~minent priors
fly for p`-~cymakers'
re~, public Huh
officials, acaden~ia and the
priV`~-~e Sector.
· The Resistance Phenomenon in Microbes amuck Infectious Disease Vectors:
Implications for Suntan Henith O!?4 Strategies for Containment (20031.
Resistance in bacteria, viruses, al protozoa to therapeutic agents is an
increasing challenge. More microbes are becoming resistant to name
~9
|~,~,~~,~,~~r(~ If ]~3~ CKI]~%AL [.~IfE-S /~ l~
drugs, thereby reducing able power of drugs for combating infectious clis-
eases. Tire IOM report discusses tire causes ant! consequences of drug
resistance in microbes ant] examines current and potential strategies for
mitigating its impact on unman health. Participants stressed treat the emer-
gence of resistance must be recognized as an integral part—not an
aberrant part—of mica obial life. Developing a fuller understa'~cling of flow
'microbes evolve where facet! with drugs Nay leac! to innovative ways to
bring tavern under control. Additionally, tire revolt examines tire influence
of pesticide ant! i~secticicle resistant infectious clisease vectors on control
measures for diseases sucks as malaria. Oliver suggestions for action i~clucle
fully implementing national and international programs being developer!
to contains microbial resistance, expanding surveillance efforts to ensure
early detection of problems, supporting scientific and epicle~niological
studies in targeted areas, strengthening professional education and train-
i~g, and conducting economic studies to both inform policy making amuck
suggest incentives for encouraging individuals ant] institutions to adopt
practices tight will Whelp limit tire spread of antimicrobial resistance.
1
~ RE IN .. DEvEtOPlNG Woken
Brain clisorclers now affect at least 250 million people in tire clevelop-
ng wapiti, amuck taxis number is expected to increase as snore people live to
old age. Brain disorders encompass a wide range of clisabling conditions,
including epilepsy, stroke, schizophrenia, unipolar
depression, bipolar clisorde'; mental retardation, cere-
bral palsy, and autism. Yet public acid private health sys-
tems in cleveloping countries have paid relatively little
attention to brain clisorciers, concentrating instead on
tire major communicable diseases. Neurological,
Psychiatric, and Develoyn1e'~tal Disorders: Meeting the
Challenge in tile Developing World (2001) concludes that
titers are effective amuck affordable ways to treat or even
prevent many brain disorders in developing countries,
and it presents a comprehensive plan designed to Whelp
these countries help their citizens who have or are at risk
of developing epilepsy, schizophrenia, clepression, or other such disorclers.
Tire report outlines strategies that can be implementer! i~nmecliately in
developing countries, such as increasing public and professional awareness
and unclerstanding of brain clisorclers, extending ant! strengthening sys-
tems of primary care to cleliver health services for brain disorders, and
30
GLOI3AL ~~-AL7W ,4..~D i.~( ~~?~ ~~-,] SE
making cost-effective interventions available to patients who will benefit.
It also proposes strategies for creating better options for tire future.
Actions inclucle assessing the cost-effectiveness of specific treatments ant!
health services ill local settings and monitoring tire incicler~ce, prevalence,
anct burden of brain ctisorciers in cleveloping countries; creating national
centers in developing, countries to carry out to aini'~g acid ~ essay Cal on be ain
diso~-cie~s, ant! li~ki~g these centers with institutions in I~igh-income coun-
t~ies; ant! crafting anal funding global programs devoted to improving
understanding of brain disorclers in tire developing world.
Tire Neatly of a motley; fetus, or newborns is tragic wherever it occurs.
WI~ile relatively r are in tile inclustrializec! world, Rinse Teals are consicier-
ably more common in cleveloping countries, accounting for tile vast major-
ity of the 515 000 maternal Beatles; 4 million late fetal cheaters; and 4 mil-
lion ~~eo~atal Beatles conservatively estimated to occur Tacit year. Most of
these deaths occur between late pregnancy and tire enc! of the first week
of a cluing s life. Each yeas; snore than 4 nonillion children are born with bi~-tl~
defects one of the major causes of death in newborns. A set of companion
reports, Improving Filth Outcomes: Meeting the Chal/enges in the Deve/opi'~g
WON// (2003) ant! Reducing the Impact of Birth Defects: Meeting t/~e Cha//e`?ges
in the Developing World (2003) review tile eviclence on interventions treat
can improve birth outcomes ant! reduce birth clefects. Tire Outcomes report
recognizes tire important role of women s education social and econon~-
ic status on birth outcomes. It also reviews the available statistics on n~ajor
causes of 'maternal and neonatal mortality acid morbidity and of fetal loss
summarizes cur r ent knowledge ant! practice with regarc! to a heartily preg-
nancy anal identifies cost-effective opportunities for in~provi'~g births out-
comes. Three adverse births outcomes are addressed in more cletail: low
birtI~weigI,t; births clefects; and perinatal t~ans~nissio'~ of HIV/AIDS. Tile
report concludes treat a sI
Selected' Recommendations for Health Sciences Research
The Role of Large-Scale Science: NIH and other federal funding agencies that sup-
port ~arge-sca~e biomedical science should develop a more open and systematic
Inethoc] for assessing important new research opportunities emerging from Else sci-
entific community in which a ~arge-scale approach is likely to achieve the scientific
goals more effectively or efficiently than tracl itional research efforts (Large-Sea/e
Biomedical Science: Exploring Strategies for Future Research, 2003)
Protecting Research Participants: Feclera~ regulations Aloud be extended to
include every research project that involves human participants regardless of the
source of funding or the setting.
The Institutional Review Board (IRB) as the principal representative of tine interests
of potential research participants should focus on tire ethical aspects of protecting
participants with other organizational units taking responsibility for risk management
and regulatory compliance.
The informed consent process should be an ongoing interactive clia~ogue between
research stain acid research participants that inclucles an assessment of participants
unJerstancling of the discussion. (Responsible Research: A Systems Approach to
Protecting Research Participants, 2002)
Focus on Integrity in Research: Funding agencies should] establish research grant
programs to identify measure ant] assess those factors that influence integrity in
research. Also each research institution should develop anc3 implement a compre-
hensive program designee] to promote integrity in research using multiple
approaches adapted to the specific environments within each institution.
Institutions should implement effective educational programs that enhance the
responsible COIldUCt of research. (integrity in Scientific Research, 2002)
Expanding Research on the Role of Sex in Human Health: Promote research on
sex at tile cellular level; study sex differences over a ~ifetin1e; and examine genetic
variability disorclers of sex differentiation reproductive status and environmental
influences to better unclerstand human health. Alsoj expand research on sex cliffer-
ences in brain organization and function. Monitor sex differences and similarities for
all human diseases that affect both sexes. (Exploring the Biological Contributions to
Hun1an Health: Does Sex Matter.?, 2001 ~
