of Health and Human Services, 1992). Senior NIH and CDC officials are devoting more attention to the disease, in the form of research and public education. In April 1992, the Food and Drug Administration (FDA) arranged for a limited supply of streptomycin and para-aminosalicylic acid manufactured outside the United States to be available through the CDC under an investigational new drug agreement (Centers for Disease Control, 1992a). The FDA has also recently identified U.S. pharmaceutical companies that have agreed to manufacture these drugs and make them commercially available by late 1992 (Centers for Disease Control, 1992a). In addition, the FDA has promised to expedite the review process for TB-related products (Fox, 1992). Most recently, the CDC published a National Action Plan to Combat Multidrug-Resistant Tuberculosis. The plan lays out a series of specific activities (with organizational responsibility and time frames for action) that address nine objectives identified by the federal task force (National MDR-TB Task Force, 1992).

These responses, like those related to the resurgence of measles, are potentially of value in resolving the current problems with TB and MDRTB but they are reactive, not proactive. It is the committee's view that prevention of infectious diseases must be continually stressed if the U.S. public health system is to be maintained or, preferably, improved. Efforts directed at the recognition of and responses to emerging public health problems, particularly emerging infectious diseases, would help to achieve this goal. The country's recent episodes of measles and TB resurgence should reinforce the importance of upgrading and maintaining the U.S. public health system at all levels. Experience has taught that, in the long run, preventive action is generally more cost-effective than reactive response. For example, the current cholera epidemic, as of mid-1991, had cost Peru's economy an estimated $43 million in medical costs alone. Had that amount been spent over the past few years to provide clean water and adequate sanitation to the people of Peru, it is likely that the epidemic would not have progressed to its current state (Misch, 1991). Other examples of cost effectiveness include measles vaccination and the global eradication of smallpox. The benefit-cost ratio for measles prevention ranges from 11.9:1 to 14.4:1, depending on whether the vaccine administered is measles antigen alone or a combined vaccine (measles, mumps, and rubella) (Hinman et al., 1985). It has been estimated that, in 1967, global expenditures on smallpox annually were $1.35 billion. The 13-year (1967-1979) global smallpox eradication campaign totaled $299 million ($23 million per year), almost a 60-fold annual savings (Fenner et al., 1988).

Microbial disease assessment is a shared function. State and local health departments; the CDC; health care providers; private laboratories; schools of medicine, public health, and veterinary medicine; the FDA; the U.S. Department of Agriculture (USDA); and the NIH all contribute. The existing



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