Resource allocation in public health and bio-defence

The three-year anniversary of the deadly anthrax mailings in the US is approaching. Coming in the aftermath of the 11 September 2001 attacks, the anthrax assaults created havoc with the postal system and left five people dead. Some analyses have claimed that the 2001 anthrax incidents led to significant psychological trauma in a large number of US citizens, by some estimates on par with 11 September itself. To date no one has been apprehended in connection with one of the largest cases of biological terrorism in modern history.

Despite the millions of dollars spent in the Federal Bureau of Investigation's (FBI's) Amerithrax investigation, and a US$2 million reward, there has not been a single arrest in the case and the perpetrator or perpetrators remain at large.

Since the start of the global war on terror, the anthrax episode, claims of Iraqi weaponised smallpox and discoveries of ricin have riveted the public's attention on the spectre of biological warfare. A palpable fear gripped New York and Washington, DC in late 2001, communities which were still reeling from Al-Qaeda's most brazen assault on the US homeland. In 2001, there was a fear that anyone could be a victim. Even if you had not received an anthrax-loaded letter yourself, if someone in your office did, or even if your mail had mingled with an infected letter, there was the possibility that you could be exposed to a disease that few emergency room physicians had ever seen.

Postal deliveries were suspended. Entire batches of mail were destroyed, and even more were subjected to radiation in order to render inert potentially deadly mailings. Millions of dollars were spent in hazardous clean-up operations at news rooms, congressional offices and at the now infamous Brentwood mail sorting facility. And as yet, US citizens are just as vulnerable to deadly pathogens today as they were on 10 September 2001.

The July 2004 issue of Harper's Magazine featured a powerful article by Ronald J Glasser, MD, entitled 'We Are Not Immune'. Glasser argues that for all the money spent in the US on bio-terrorism defence since the 11 September attacks, the US people are no safer from deadly disease, especially the disease they are most likely to encounter. Moreover, Glasser asserts that the national security of the US has actually been compromised by the shifting of funds from public health to bio-defence. In essence, Glasser's argument is that by reducing the funding for programmes that prevent illnesses and deaths from diseases that are dealt with each year, to bolster the funding for bio-terror scenarios that are largely remote possibilities at best, amounts to waste and, at worst, negligence.

Glasser makes some very serious points in his essay that help place public health and bio-defence in a more appropriate perspective. He notes that each year, 10-20% of the US population suffers from influenza. Of this number, 36,000 US citizens die from influenza every year, despite the existence of a vaccine. While it may or may not be the most likely vaccine to combat each year's influenza strain, it does save lives and reduce influenza's impact. According to Glasser, a virulent strain of avian flu could kill millions in the US alone, and tens of millions more around the world. It must be asked, when we know that millions of people will suffer from an outbreak that occurs each year, why is more money not devoted to fighting the diseases we know?

While a chilling possibility, the likelihood of an intentional release of smallpox seems rather unlikely to many observers. While it would be negligent to discard this threat, it must be placed in proper context. More than a million US citizens contracted a hospital-borne illness in 1995. More than 100,000 in the US and UK are hospitalised each year with MRSA (methicillin-resistant Staphylococcus aureus), the so-called hospital 'super-bug'. Of these nosocomial infections, 15% of MRSA cases in the UK are preventable each year, which would generate a savings to the National Health Service of about £150 million (US$273m) a year.

As for food-borne illnesses, 76 million US citizens fall ill each year due to these pathogens. Water-borne pathogens also cause significant illnesses in industrialised societies. More than 300,000 US citizens are hospitalised each year as a result of food poisoning and 5,000 die from such illnesses. Such culprits as cryptosporidium and e.coli do much damage, and as yet there is no medical treatment.

In fact, according to Laurie Garnett, author of Betrayal of Trust: The Collapse of Global Public Health, less than 4% of total improvements in life expectancy since the 1700s can be attributed to 20th century advances in medicine. As Glasser notes, most progress in public health occurred before the discovery of antibiotics: hand washing, covered sewers, paved streets, safe food and water, for example. Proper hygiene is currently one of the best ways to combat infections such as MRSA - washing hands, covering wounds and avoiding contact are major tools to stem the spread of disease.

Biological terrorism defence has received large funding since 11 September 2001. Project Bio-Shield, an ambitious US programme to increase funding for disease research, vaccine development and bio-defence response, has been a very large benefactor of these appropriations (about US$2 billion has been spent so far). However, much more must be spent on this extremely vulnerable portion of homeland security. For comparison, the Iraq conflict costs an average of about US$4 billion per month; meanwhile only US$2 billion has been spent on bio-defence in the two-plus years since 11 September. The extremely ambitious and as yet non-working US ballistic missile defence system has cost US taxpayers US$50 billion so far. Twenty-five times the amount to boost bio-defence and fight infectious diseases has spent on an anti-ballistic missile defence programme that has still to perform the miraculous 'hitting a bullet with a bullet' to defend the US from a threat that many analysts doubt has yet to materialise. While it seems doubtful that a hostile power will launch a ballistic missile strike on the continental US in 2004, it is certain that many people will die from influenza, food poisoning and infections caught in hospitals.

This is not to suggest that there is not a very real biological warfare threat that the US and its allies must prepare against. Al-Qaeda and its affiliates have stated plainly that they seek weapons of mass destruction - including deadly pathogens. They have also stated that if they did possess such weapons, they would not hesitate to use them. Therefore it is vital that while a robust homeland security posture is maintained, the US also plans for contingencies to deal with the possibility of an intentional biological attack. It is possible, and indeed prudent, to buttress the bio-defence posture with a more invigorated civilian public health sector.

A viable public health disease identification and isolation programme would complement bio-defence readiness. The two are not mutually exclusive; rather, disease surveillance systems to warn of influenza outbreaks could also be used to provide early warning for other infectious and suspect outbreaks. Such a system, if organised effectively and in a uniform manner, would mesh the two together to safeguard the civilian population against epidemics, both natural and malicious.

Investing in the public health sector will bolster national security. Some measures that should be taken in the near term include:

  • The creation of a robust and universal emerging disease surveillance and monitoring network. New York has done a remarkable job of implementing this type of system. It should be expanded to collect and analyse emergency room admittances, prescription and over-the-counter medication sales to watch for trends indicative of an emerging medical event.
  • Such a system must be compulsory and must be funded accordingly.

  • Increase funding for 'Function 550' accounts in the US. This is the mechanism by which the federal government funds public health initiatives. In his 2005 budget proposal, President Bush has called for a US$1.1 billion cut in this funding - equivalent to a
  • little over a week of paying the bills in Iraq.

  • Implementing a standardised and compulsory food and meat recall system. In the US the Department of Agriculture (USDA) cannot issue a mandatory recall of contaminated or suspect foodstuffs; the USDA can only issue voluntary recalls, which manufacturers have thus far followed. However, in an emergency situation the federal government - which regulates and tests foodstuffs - must have the power to act unilaterally.
  • Standardise routine testing for mad cow disease and other animal-borne pathogens. Since the discovery of mad cow disease in the US, there is no routine testing for infected animals. In the age of industrialised agriculture, it only takes one sick animal to contaminate tens of thousands of food servings. It is vital to keep the food chain healthy.
  • Increase the investment in new research and technologies to improve existing vaccines and medical treatments. Many that exist today will not work on an increasing portion of the population. Today people are living longer, and those suffering from autoimmune disorders, chemotherapy patients and transplant patients cannot tolerate today's protocols.
  • Moreover, new treatments are needed for the diseases that continue to be discovered. Between 1977 and 1994, 29 previously unknown human pathogens emerged. It is estimated that only 1% of bacteria and less than 5% of the world's viruses have been identified.
  • The world faces many very real threats on the medical front, be they from bio-terror, weaponised agents from a hostile power, or hospital-borne antibiotic-resistant bacteria. The same technologies to combat a hostile attack and mitigate its effects can be used to fight the emergence of the next Severe Acute Respiratory Syndrome (SARS) virus. In fact, SARS was brought under control in large part due to prior investment in disease surveillance and monitoring in the wake of the AIDS crisis. Indeed, investing in the public health system is an integral component of creating a resilient and secure homeland.

    Christopher Boucek is editor of the RUSI/Jane's Homeland Security & Resilience Monitor

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