As the work of this committee draws to an end, none of its members are sanguine about what the future may hold with respect to microbial threats to health. Certainly, it is clear many forces in our complex global village converge to make us more vulnerable to these threats. At the same time, however, this study has identified many opportunities to make a real and enduring difference in preventing disease and improving health.
Today’s outlook with regard to microbial threats to health is bleak on a number of fronts. AIDS is out of control in much of sub-Saharan Africa, India, China, and elsewhere; bioterrorism has become a reality; the relentless rise of antimicrobial resistance continues; we have no viable strategy or acceptance of responsibility for the replacement of obsolescing antibiotics; many disappointments surround efforts to develop vaccines for diseases such as malaria and HIV, as well as the range of new vaccines that may be needed for natural and manmade threats; in some countries a poorly informed popular movement against vaccination has led to a resurgence of common childhood infections; and cholera, drug-resistant malaria, and dengue fever continue to spread to new areas. Moreover, microbial threats present us with new surprises every year.
Yet bright spots on the global scene have also occurred, including the gratifying model of the utility and availability of ivermectin for onchocerciasis in Africa; the containment of H5N1 flu in Hong Kong in 1997, along with ongoing surveillance; and the reduced mortality from HIV/AIDS in the United States, attributable to a combination of behavioral change and the availability of protease inhibitors and combination antiretroviral therapy.
Many developments hold promise for achieving further progress. These include signs of public, philanthropic, and political awareness of the significance of global infectious diseases; a new recognition of the importance of a strong and vital public health infrastructure; the extraordinary advances made in microbial genomics offering enormous potential for new technologies to prevent and cope with infection; the emergence of broad ecological and evolutionary perspectives on the biology of host–microparasite symbiotic interrelationships; and a greater appreciation of the socioeconomic settings of disease emergence.
At the same time, it is essential to recognize that infectious diseases have always been closely interwoven with world history, and the present situation is no exception. The world is changing and in many respects is quite unstable, as evidenced by the realignment of powers with the end of the cold war; the eruption of interethnic hostility in the Balkans and Central Africa, the political and religious conflicts raging in many areas of the world, and the escalation of international terrorism. Such political turbulence is paralleled by the state of the global economy, including the massive burden of third-world debt, currency and banking crises, and the cycling of economic bubbles and collapses—all of which have eroded the resources available for public health and for entrepreneurial investment in antimicrobials and vaccines to counter the microbial threats identified in this report. Not surprisingly, the interdependence of health status and economic and social development is also interwoven with issues of leadership, whether at critical health institutions or in various national regimes.
The developed world has financial and technological resources that should enable the successful application of old and new methods to contain infection. Nevertheless, we live in a society where many competing factors—including market forces, regulatory pressures, and environmental and ethical concerns, to name but a few—influence research and development priorities and portfolios. Inevitably, tensions arise that may override or diminish the potential community health benefits of such measures as the development of pesticides or vaccines adapted to the needs of the developing world.
Thus while dramatic advances in science and medicine have enabled us to make great strides in our struggle to prevent and control infectious diseases, we cannot fall prey to an illusory complacency. We must understand that pathogens—old and new—have ingenious ways of adapting to and breaching our armamentarium of defenses. We must also understand that factors in society, the environment, and our global interconnectedness actually increase the likelihood of the ongoing emergence and spread of infectious diseases. It is a sad irony that today we must also grapple with the intentional use of biological agents to do harm, human against human.
No responsible assessment of microbial threats to health in the twenty-first century, then, could end without a call to action. The magnitude and urgency of the problem demand renewed concern and commitment. We have not done enough—in our own defense or in the defense of others. As we take stock of our prospects with respect to microbial threats in the years ahead, we must recognize the need for a new level of attention, dedication, and sustained resources to ensure the health and safety of the United States—and of the world.