Editor’s Note: This post reflects on a speech on pandemic preparedness Dr. Fauci gave on January 10, 2017 in Washington, DC, hosted by The Center for Global Health Science and Security at Georgetown University Medical Center, the Harvard Global Health Institute, and Health Affairs.
One of the most important challenges facing the new Administration is preparedness for the pandemic outbreak of an infectious disease. Infectious diseases will continue to pose a significant threat to public health and the economies of countries worldwide. The U.S. government will need to continue its investment to combat these diseases wherever they emerge, and to conduct crucial research and development of medical countermeasures in the form of vaccines, treatments, and diagnostics to rapidly respond to emerging infectious disease threats.
In the 1960s, many notable physicians and scientists expressed the belief that the availability of antibiotics and vaccines meant that infectious diseases would not pose a serious threat in the future. However, these individuals failed to look beyond the borders of resource-rich countries or to recognize that new diseases would continue to emerge, and diseases would re-emerge in new locations and geographic areas where they had been previously eliminated. Today, infectious diseases cause approximately 15 percent of all deaths around the world, accounting for approximately 8.4 million deaths in 2015.
In 1984, I became the director of the National Institute of Allergy and Infectious Diseases (NIAID), beginning in a position that has now spanned more than 30 years. During my tenure, I have advised five presidents and testified more than 250 times before Congress. Over this time span the US has faced a multitude of threats, from the HIV/AIDS pandemic to bioterrorism. The lessons learned have shaped how the scientific community responds to escalating public health crises and will inform the future response to the next inevitable threat.
The Reagan Years: HIV/AIDS Emerges As A Threat To Public Health
In the early 1980s, NIAID’s greatest concern was HIV/AIDS, which was initially reported as an undefined disease in homosexual men in New York and California. In June 1982, at the very early phase of the pandemic, I stated in an article that I published in the Annals of Internal Medicine, “… because we do not know the cause of this syndrome, any assumption that the syndrome will remain restricted to a particular segment of our society is truly an assumption without scientific basis.”
Sadly, this prediction proved correct. According to the latest worldwide statistics from UNAIDS, there had been cumulatively more than 70 million cases of HIV infection throughout the world and in 2015 there were more than 36 million people living with HIV, 1.1 million AIDS deaths, and 2.1 million new HIV infections. The activist community criticized President Reagan for not using the office of the President to call attention to this burgeoning pandemic. Nonetheless, modest increases in research funding for HIV/AIDS were enacted during the latter part of the Reagan administration, largely due to Congressional support.
George H.W. Bush: HIV/AIDS Draws Political Attention As Treatment Advances
When George H.W. Bush became President in 1989, public health leaders began to understand the global scope of the HIV/AIDS pandemic. President Bush reached out to the National Institutes of Health (NIH) and other health professionals, met with HIV-infected patients, and facilitated a massive increase in funding for HIV/AIDS research.
The financial commitment to research and development enabled the early development of treatment that would eventually culminate in effective combination antiretroviral therapy (ART). ART has contributed to a dramatic increase in life expectancy for persons living with HIV/AIDS.
During these years, we came to appreciate the substantial and sustained resource commitment needed to combat an emerging infectious disease. We also learned that it is crucial to engage affected communities, and foster collaborations with industry, academia, global organizations, philanthropies, and non-governmental organizations.
William J. Clinton: HIV/AIDS Continues To Spread While New Threats Emerge
The Clinton presidency saw not only the continued growth of the HIV/AIDS pandemic, but also the appearance of West Nile virus in the U.S. for the first time, the first wave of H5N1 Influenza in Southeast Asia, and the growing problem of microbial resistance to antibiotics. NIH continued the development and testing of medical countermeasures, as a first step to an effective response strategy to each of these emerging public health threats.
The growing threat of antimicrobial resistance (AMR) required the development of a new multi-sectoral response strategy. Years later I wrote about AMR in an article published in the Journal of the American Medical Association, “…biomedical innovation combined with improved surveillance, prevention efforts, rapid diagnosis, market incentives to drive technology development, and curtailed misuse can meet the continual threat of antimicrobial resistance.”
George W. Bush: The Fight Against HIV/AIDS Goes Global As Bioterrorism Presents A New Danger
By 2001, it was clear that all presidents would be forced to address a disease emergence or analogous biological event during their term. Facing the continuing HIV/AIDS pandemic, President George W. Bush established the life-saving President’s Emergency Plan for AIDS Relief (PEPFAR). His administration developed the Pandemic Influenza Preparedness plan that is still in use today. During his tenure, we also saw the emergence of a frightening new virus, known as SARS-CoV, in China, necessitating a global public health response to contain its spread.
Unlike his predecessors, this President also had to respond to the threat of bioterrorism in the form of the anthrax letters in 2001, in the immediate wake of the terrorist attack of 9/11. Funding for biodefense research was immediately increased and NIAID developed strategic plans for research and development of medical countermeasures for a range of biological agents that potentially could be used as weapons. Throughout his presidency, NIAID continued to make groundbreaking advances in new medical countermeasures, developing exciting new technologies for influenza vaccines, and shortening the time between virus identification and countermeasure development.
Barack H. Obama: Ebola, Zika, and Other Viruses Test the Scientific and Public Health Infrastructure
Recent years have seen a range of disease threats, each posing a new challenge to the Obama administration. Just after taking office in 2009, a new pandemic strain of influenza, H1N1, emerged requiring mitigation plans concurrent with the rapid development and then distribution of a vaccine. Unfortunately, the availability of the vaccine came later than the peak of the pandemic underscoring the need for a universal vaccine that would be ready to address any emerging strain of the virus. Several years later in 2013, Chikungunya—a vector-borne disease previously seen in Asia and Africa—emerged for the first time in the Western Hemisphere, leading to NIH-sponsored vaccine development.
At the end of 2013, an outbreak of Ebola erupted in West Africa that would eventually infect more than 28,000 people, and kill more than 11,000. The outbreak was “the perfect storm” — a communicable disease in a highly mobile population, moving into overcrowded urban environments with poor health care infrastructure, few clinicians, a population distrustful of its formerly oppressive governments, and cultural practices that facilitated the spread of disease. NIAID again played a leading role in the research and development of potential therapeutic and vaccine candidates, developing lasting research partnerships with colleagues in Liberia, Sierra Leone, and Guinea. In addition, NIAID provided clinical care to two Ebola-infected individuals in the NIH Clinical Center, and helped educate the American public about the risks of Ebola and the types of dedicated high-containment treatment facilities available to care for Ebola-infected patients in the United States.
Most recently, the Obama administration has responded to the spread of Zika to the Americas. Once again, various factors lined up to create a “perfect storm” for the spread of disease. In Brazil, where most of the initial cases in the West were found, a high density of mosquito vectors combined with dense population centers. The Brazilian public health system led to a striking discovery: the link between Zika infection of pregnant women and microcephaly and other congenital anomalies in fetuses and newborns. Once again, the essential steps of the response required basic and clinical research and the development and testing of medical countermeasures. NIH-funded researchers are developing and testing at least five vaccine candidates, as well as conducting studies to better understand the risks to the fetus.
What Comes Next?
If history has taught us anything, it is that the new administration is likely to experience at least one infectious disease crisis of significance. We have learned from the past decades that it is important to have strong global surveillance systems; transparency and honest communication with the public; strong public health and health care infrastructure, or capacity building efforts where needed; coordinated and collaborative basic and clinical research; and the development of universal platform technologies to enable the rapid development of vaccines, diagnostics, and therapeutics. We also have learned that it is essential to have a stable and pre-established funding mechanism to utilize during public health emergencies similar to a FEMA-like emergency disaster fund. What we know for certain is that emerging infections will continue to be a perpetual challenge, requiring the attention of all Presidents to come.