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4
Protecting Our People
U.S. investment in international health has always been based on more than
humanitarian and charitable concerns. Such investment is necessary to protect
Americans from emerging infections, from the threat of biological and chemical
warfare, from violence and its consequences for health, and from the effects of
environmental pollution and mismanagement. This chapter first outlines the
particular threats to Americans from infectious diseases, chemical and biologic
weapons, violence, and spiraling health care costs. It then discusses some
opportunities for the U.S. to reduce these threats.
THREATS TO THE AMERICAN PEOPLE
Infectious Diseases. The U.S. population is vulnerable to a wide array of
infectious diseases. They include common infections that once existed in America,
such as malaria, to rare yet deadly disease such as Ebola and Lassa fevers. For
those who doubt the magnitude of the potential threat, it is well to recall that the
1919 influenza pandemic killed 20 million people worldwide (including 500,000
Americans), a greater death toll than all of World War I. In recent years, America
has witnessed on its own soil the AIDS epidemic, the presence of drug-resistant
tuberculosis in our vulnerable populations, and recent outbreaks of Lyme disease,
Hanta virus, and cryptosporidium.
U.S. investment in global health is necessary to protect the
health of Americans.
America is far from immune to the cross-border transfer of risks discussed in
Chapter 2. We can consider no site too remote, no person too removed to affect us,
and no organism safely isolated elsewhere. In 1993, more than 27 million
Americans and Canadians traveled to developing areas (Garrett, 1996; WHO,
1996b). At the same time, ever-growing numbers of visitors are coming to the
United States. This increased mobility has amplified the threat of both spreading
and contracting infectious diseases to higher levels Han ever before (CISET,
1995~. In addition to human traffic, the trade in goods and services across U.S.
borders also poses risks. In 1985, for example, Aedes albopictus mosquitoes a
25
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26
AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
vector of diseases such as dengue fever, viral encephalitis, and yellow fever were
introduced to the U.S. through tires imported from Asia (IOM, 1992a).
Several other factors are associated with the increased emergence of infectious
diseases (IOM, 1992a). Table 4-1 lists some of them. Prominent among these and
perhaps most relevant for the United States is the excessive and indiscriminate
use of antimicrobials in both developing and industrial nations, a practice Mat has
promoted the selection of drug-resistant organisms. For example, acute respiratory
infections are a major cause of death worldwide. The major causative pathogen,
Streptococcus pneumonias, is estimated to be responsible for 1.9 million deaths a
year, mostly of children, worldwide (WHO, 1996a). Infections caused by this
organism have been effectively treatable by penicillin-like drugs until recently.
Emergent new strains, however, are now showing resistance to these drugs, both in
the U.S. and elsewhere (see Table 4-2~. The Implications of this resistance for
public health, and especially the health of children, have alarmed medical experts
worldwide (CISET, 1995~.
A number of environmental changes have also promoted the emergence of
new diseases. As woodland areas have expanded in the northeast corridor of the
United States, for example, deer populations have increased. Grown in the density
of human habitations In these areas has increased human exposure to Me deer-
bome tick Hat carries Lyme disease. The colonization of rain forests In He
Amazon and He building of He Aswan Dam In Egypt have also been associated
win local disease outbreaks.
Total U.S. expenditures on infectious diseases exceed
$120 billion annually.
TABLE 4-1 Factors Contributing to Disease Reemergence and Examples of
Associated Infections
Contributing Factors
Associated Infectious Diseases
Human demographics and behavior
Technology and industry
Economic development and land use
International travel and commerce
Microbial adaptation and change
Dengue/dengue hemorrhagic fever, sexually
transmitted diseases, giardiasis
Toxic shock syndrome, nosoeomial (hospital
acquired) infections, hemorrhagic colitis/
hemolytic uremic syndrome
Lyme disease, malaria, plague, rabies, yellow
fever, Rift Valley fever, sehistosomiasis
Malaria, cholera, pneumoeoeeal pneumonia
Influenza, HIV/AIDS, malaria, Staphylococcus
aureus infections
Breakdown of public health measures Rabies, tuberculosis, trench fever, diphtheria,
whooping cough (pertussis), cholera
SOURCE: Adapted from CISET, 1995.
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PROTECTING OUR PEOPLE
27
TABLE 4-2 Examples of Drug-Resistant Infectious Agents and Percentage of
Infections that Are Drug Resistant, by Country or Area
Pathogen
Drug
Country/Area
Percentage of
Drug
Resistar~t
Infections
Streptococcus pneumonias Penicillin
Staphylococcus aureus
Mycobacterium tuberculosis
Methicillin
Vancomycin
Any drug
INH+RIF*
Plasm odium falciparum malaria Chloroquine
Shigella dysenteriae
Mephloquine
Multidrug
United States 10-35
Asia, Chile, Spain 20
Hungary 58
United States 32
United States 0
United States 13
New York City 16
United States
New York City
s
Kenya 65
Ghana 45
Zimbabwe 59
Burkina Faso 17
Thailand 40
Burundi, Rwanda 100
*Resistance to isoniazid (INH), rifampcin (RIF), and/or other drugs.
SOURCE: Martin Cetron, Grace Emori, Patrick Kachur, Gloria Kelley, and Robert
Tauxe, U.S. Centers for Disease Control and Prevention, personal communication, 1996.
The economic costs of infectious diseases to the United States are
extraordinarily high, as shown in Table 4-3. Total U.S. expenditures exceed $120
billion annually (CISET, 1995~. Drug-resistant infections greatly amplify these
costs: for example, treatment of conventional tuberculosis in the U.S. costs $25,000
per person, compared with $250,000 for multidrug-resistant tuberculosis.
Biologic and Chemical Weapons. The 199~1991 Persian Gulf War
heightened awareness of the threat of military deployment of chemical and biologic
agents. More recently, the 1995 terrorist release of toxic sarin gas in the Tokyo
subway system converted the civilian risk from abstraction to reality. Authorities
discovered that the Aum Shinrikyo cult in Japan had stockpiles of biologic agents
and bacterial culture media. Thus, a new generation of bioterrorists, with the ability
to strike anywhere and possessing both the requisite knowledge of microbiology
and the willingness to use such weapons, is at hand (Kaplan and Marshall, 1996~.
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28
AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
TABLE 4-3 Estimated Annual Financial Costs to the United States of
Common Infectious Diseases
Disease
Estimated Annual Cost
HIV/AIDS
Tuberculosis
Nosocomial (hospital-acquired)
infections
Sexually transmitted diseases
(excluding AIDS)
Intestinal infections
Drug-resistant infections
Influenza
$3 billion in Public Health Service funds
$343 million in Public Health Service funds,
$700 million in direct treatment costs
$10 billion in direct treatment costs
$5 billion in direct treatment costs
$23 billion in direct medical alla lost productivity
costs
$4 billion (and increasing) in treatment costs
$5 billion in direct treatment costs
$12 billion in lost productivity costs
SOURCE: Adapted from CISET, 1995.
The serious consequences of the use of biologic agents in a terrorist attack are
not limited to direct health effects. Use of a nonfatal, debilitating bioagent could
result in hundreds of millions of dollars in medical costs and lost productivity.
International surveillance and safeguards against man-made infectious outbreaks
are currently inadequate. The technical obstacles to international control are
formidable.
Spiraling Health Care Costs. International studies show that health care
spending varies dramatically between countries.
In 1992, the United States spent just over $3,000 per
head on health care, compared with an OECD average
of $1,374.
An inefficient health system may consume as much as 5 percent more of a
country's national product than an efficient one (World Bank, 19934. Nor is
health care spending alone a reliable predictor of a country's health status as
measured by life expectancy (World Bank, 1993~. In 1992, the United States
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PROTECTING OUR PEOPLE
29
spent just over $3,000 per head on health care, compared with an OECD average
of $1,374 (WHO, 1 996a).
In response to pressures to reduce health care spending and release potential
resources for investments that will have a greater impact on health, public and
private organizations are taking a variety of steps to reduce the use, intensity,
and cost of health services (IOM, 1995a). To guide these steps, what can
America learn from other countries that appear to have better health status and
lower health care costs? To date, there are more questions than answers. Can the
experience of countries that have relied less on specialists and hospitals inform
this country's growing focus on primary and ambulatory care? Can we learn
from the experiences of others which new health care prevention and therapeutic
interventions are most cost-effective? What are the lessons to be learned from
countries that have shifted more responsibility for public health from national to
regional or local governments? What effect does universal or near-universal
health insurance have on the level and distribution of health spending and on the
level and distribution of health within populations? Are there alternative mixes
of market and governmental roles that might be more effective than America's?
These questions merit serious attention.
Violence. The impact of violence on health is considerable; it ranges from
debilitating physical injuries to the psychological suffering caused by post-
traumatic stress disorder (PTSD).
The Vietnam War demonstrated how exposure to violence can have long-term
adverse effects on civilian life. For example, a small but significant proportion of
war veterans continue to suffer from PTSD, and these individuals are more likely
than the general population to commit violent acts, especially acts of family
violence (Stray, 1994~. Veterans of the Persian Gulf War have experienced a range
of physical health problems as well as psychological stress.
Many immigrants have been victimized by warfare, violence in refugee camps,
and culturally sanctioned violent acts in their countries of origin. Rates of PTSD
among refugees range Mom 25 to 75 percent in the groups studied. In addition,
women Dom the Middle East and northern ADica have often been subject to genital
mutilation, and many families from those countries seek such "circumcision" for
their daughters when they settle in the United States. These practices have been
declared a threat to women's health in other countries and have resulted in public
health initiatives directed at their eradication (Desjarlais et al., 1995~.
Violence not only reduces the personal health, security, and well-being of
Americans, but will also adversely affects U.S. economic grown for example, by
contributing to the decline of inner cities and by discouraging tourism from abroad.
OPPORTUNITIES TO PROTECT OUR PEOPLE
Investing in Surveillance and Communication Networks to Save Lives
and Money. The recent outbreaks of Ebola in Zaire, hemorrhagic Dengue fever in
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30
AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
southern Mexico, drug-resistant TB in New York City, plague in India, and E. cold
0157 in Japan and Scotland emphasize the importance of global surveillance
systems that can alert the international community to outbreaks of infectious
diseases. Yet no formal infectious disease surveillance system exists on a global
scale.
The goal of effective disease surveillance is prevention, and experience has
shown prevention to be highly cost-effective. Since smallpox was eradicated in
1977, for example, the total investment of $32 million is resumed to the United
States every 26 days (Brilliant, 1985~. Based on progress to date in the drive to
eradicate poliomyelitis, WHO predicts global savings of $500 million by the year
2000, increasing to $3 billion annually by the year 2015. Every dollar spent on the
vaccine against measles, mumps, and rubella saves $21, and every dollar spent on
the vaccine against diphtheria, tetanus, and pertussis saves $29 (CISET, 1995~.
Prevention is clearly not only the most humane approach to the control of
infectious disease, it is also the most cost-effective.
Since smallpox was eradicated in 1977 the total U.S.
investment of $32 million is returned to the United States
every 26 d_
By the same token, inadequate surveillance can have disastrous consequences,
both human and financial. For example, AIDS was unrecognized until the 1980s.
Its varied clinical expression and prolonged incubation period made detection
difficult in the early stages of the epidemic. If a global surveillance system with the
capacity to identify new diseases had been in place in the 1970s, AIDS might have
been identified earlier, perhaps before it became well established. Epidemiologists
might then have gained a valuable head start in learning how the disease was
transmitted and prevented, and many lives around the world, including in the
United States, might have been saved. Given that the lifetime costs of treatment for
HIV disease in the United States excluding indirect costs have been estimated
to be more than $119,000 per person (Martin in Mann and Tarantola, 1996),
substantial savings might also have been made.
Today, the potential for another AIDS pandemic remains. If a cluster of cases
of a new disease of unknown origin occurs in a remote part of the world lacking
modem communication, the international community may not learn about it until
the disease has spread widely.
If an effective global surveillance system were in place, even small-scale
outbreaks of infectious diseases could be quickly identified. Critical technical
assistance could then be efficiently mobilized in response. For example, global
infectious disease experts, including those from the Centers for Disease Control
and Prevention (CDC) or the U.S. military, could be brought to the site or utilize
modem communication networks to assist in diagnosis and to support local
authorities with their prevention and control measures. Clinical specimens could be
sent to centralized diagnostic laboratories to aid in disease identification and to
strengthen early response measures. In the case of an outbreak of a previously
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PROTECTING OUR PEOPLE
31
unrecognized disease, rapid identification of the causative agent would help
experimental scientists to develop diagnostic tools and, eventually, treatments
(CISET, 19959.
The elements of a global surveillance network already exist, but they need to
be strengthened, broadened, and coordinated. The 1996 Presidential Directive,
which instituted a new national public health policy to deal with the threat of
emerging and resurgent infectious diseases, was an important step in this direction
(CISET, 1995~. Several U.S. government departments and agencies including the
Department of Defense (DoD), the CDC, the National Institutes of Health (NIH),
the U.S. Agency for International Development (USAID), the National Aeronautics
and Space Administration (NASA), and the National Oceanic and Atmospheric
Administration (NOAA - currently maintain field research stations and
laboratories in Africa, the Middle East, Asia, and the Americas. If expanded in
scope and effectively linked through modern information technologies with
international resources such as national health ministries, the World Health
Organization (WHO), WHO collaborating and reference centers, hospitals and
laboratories operated by other nations, and U.S. and foreign private voluntary
organizations, these global surveillance stations could provide the basis for ongoing
monitoring of disease outbreaks and rapid evaluation of disease prevention and
control methods (CISET, 1995~. These same systems could be adapted, for
example, to include early warning systems for any. breakdown in food safety and
for possible terrorist use of chemical and biologic agents.
The United States has the potential to improve global health by leading the
effort to develop an effective surveillance network, using its industrial expertise in
the information and communications technologies. Harnessing the global potential
of these technologies will require collaboration among the industries that will build,
operate, provide, and use the services and information that will become available
over evolving national networks. It will also require cooperative efforts among all
countries bilaterally, regionally, and through multilateral organizations to
facilitate the interconnection of their respective networks and the sharing of
information.
A special challenge is how to help developing countries to advance their
capacities in the fields of information and communications. The United States,
particularly the corporate sector, has much to offer in this enterprise. To foster such
involvement, the U.S. government, along with its counterparts throughout the
world, must ensure that the regulatory, legislative, and market conditions necessary
to attract private investment in telecommunications, information technology, and
information services are in place.
Sharing Information for Better Health Services. The international
comparative study of health service delivery and financing offers lessons about
how we might better achieve improved health and more effective, affordable,
and equitable health services for all Americans. Efforts are now under way to
develop networks that would gather the information to address these issues
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32
AMERICA 'S VITAL INTE~STIN GLOBAL HEALTH
(WHO, 1996a). It is in the direct interests of the United States to be an active
participant in such efforts.
Obtaining Value for Money in Acquiring Knowledge from Internation-
al Research and Clinical Trials. U.S. investment in research and development
overseas has benefited the American people in unique ways. American
collaboration in the eradication of smallpox, for example, obviates the global need
to spend $1 billion annually to vaccinate travelers and other citizens. Paralytic
poliomyelitis transmission no longer occurs in the Western Hemisphere, and the
campaign to eliminate polio and measles worldwide will save millions of lives and
enormous resources. The resulting increases in the numbers of persons susceptible
to these diseases will, however, require careful surveillance to ensure that these
infections do not resurge in the fixture. This will require continued cooperation with
other countries.
Trials of drugs and vaccines that benefit Americans are
often not possible without collaboration between countries.
Medical research into the control of infectious diseases is often not possible
without collaboration between nations. Many potentially threatening diseases, such
as malaria and cholera, must be studied abroad among populations in which the
diseases are common. In the United States, trials of vaccines and drugs against such
diseases would not be statistically feasible, even though U.S. citizens have much to
gain from the resulting products. Tests of new drugs and vaccines can also be
undertaken more cost-effectively in populations in which disease rates are high. For
example, whooping cough (pertussis) is much more common in Scandinavian
countries than in the United States, allowing the efficient evaluation of multiple
new acellular pertussis vaccines there. Thus, although trials of the vaccine have
been conducted abroad, their findings will benefit U.S. vaccine policy and safety.
Research collaborations between countries have other health benefits too.
Some genetic diseases and cancers can only be studied internationally, either
because the number of people affected in the United States is relatively small or
because the appropriate registries and databases are not always available. As one
example, Finland has extraordinary registries of health statistics on large
populations that make detailed analyses of risks for conditions such as cancer, heart
disease, and depressive disorders readily accessible. Examples of other
international collaborative research activities that have been shown to be cost-
effective and productive are included in Table 4-4.
In order to maintain the necessary flow of knowledge to prevent diseases
and save money, the U.S. must continue to invest in research collaborations with
its partners abroad. Failure to maintain such links is likely to have damaging
long-term consequences for health.
Preventing Violence. Cross-cultural and cross-national studies of the
contributing causes of violence and its effects, both short-and long-term, on the
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PROTECTING OUR PEOPLE
33
health of U.S. citizens are needed. In other countries, community interventions
have been used to prevent or minimize violence with some effect (Counts et al.,
1992; Levinson, 1989; Messner, 19899. Such interventions, systematically
documented, may bolster programs to prevent domestic and other violence In the
United States. Reducing rates of violence in America will not only Improve the
health and security of Americans, but will also benefit the economy for
example, in attracting business back into the inner cities and in fostering tourism.
SUMMARY OF RECOMMENDATIONS FOR PROTECTING OUR PEOPLE
The board recommends that the U.S. government, together with the
corporate sector, should:
.
act to facilitate the development of an effective global network for
surveillance of infectious diseases, using the full potential of the information and
communications revolution and fostering the capacity of developing countries in
both biomedical surveillance and communications
. further develop and extend the network to provide an early warning
system for possible biological or chemical attacks
· take an active role in global efforts to share information between
countries on the most effective means of financing and delivering health care in
order to maximize efficiency and equity
. invest in continued collaborative health research with other nations to
increase the flow of new products (e.g., vaccines and drugs) and knowledge that
will benefit Americans
increase cross-national and cross-cultural studies of the prevention of
.
violence.
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34
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