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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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