Dr. Makgoba’s first point –– strong political leadership and commitment –– is particularly salient for developing nations where strong governance is critical in allocating funds appropriately to medical and public health needs. At least two presenters at the conference mentioned the examples of Thailand and Uganda, in which heavy government involvement, in areas such as public health care and education, successfully decreased the number of HIV/AIDS cases. One conference attendee, Dr. Aiah Gbakima, Professor of Biology at Morgan State University, highlighted an opposite case scenario in Sierra Leone, where lassa fever, HIV/AIDS, and dysentery have reached epidemic proportions. Sierra Leone’s maternal mortality rate is the highest in the world, and the country’s unstable political environment has resulted in massive numbers of refugees.² Dr. Gbakima, who left his native Sierra Leone after rebels destroyed his lab along with years of research, attributed “corruption and lack of commitment,” in part, to prolonged suffering caused by disease in his country.³

Concern for Global Health Security
The November 2 conference highlighted the dangerous effects that infectious diseases have on the welfare of the global community. Dramatic increases in drug-resistant types of infectious diseases, frequent travel and migration of peoples, and deficient health care systems in many societies have raised alarming concerns for the entire international world, including the United States.⁴ Recognizing infectious diseases as a nontraditional form of threat to U.S. security, President Clinton issued a Presidential Decision Directive, in June 1996, that mandated a stronger U.S. foreign policy on infectious diseases. In an unprecedented move, in January 2000, the U.N. Security Council focused its session exclusively on the topic of HIV/AIDS threat to Africa. Subsequently, in May 2001, President Bush declared U.S. support for a global fund to fight HIV/AIDS, malaria, and tuberculosis, pledging an initial contribution of $200 million.⁵

Implications for the U.S. Public Health System
The concern that infectious diseases can pose an international security threat has been underscored by recent incidences of anthrax mailings in the U.S. Although anthrax is not communicable among humans, contaminated mail has caused great anxiety –– raising alarms of bioterrorism, in which certain infectious diseases, including smallpox, might be used as weapons of mass destruction. In order to increase the nation’s ability to combat such threats, the U.S. government has recently taken a series of measures. The Department of Health and Human Services (HHS) Secretary Tommy G. Thompson announced in late October that the agency will pursue the production of 300 million smallpox vaccines. Additionally, in October, President Bush requested $1.5 billion for HHS as part of the $20 billion emergency relief budget plan. The request is intended to augment the department’s Fiscal Year 2002 budget request of $345 million for bioterrorism preparedness. The proposed funds would supplement the National Pharmaceutical Stockpile and smallpox vaccine supplies; expand research and medical response capabilities; enhance local and state preparedness; and improve food safety.⁶ More recently, the Senate is reviewing proposed legislation to authorize a budget twice the amount of President Bush’s request –– $3.2 billion to support anti-bioterrorism efforts. Key presenters of the bill––Senator Edward M. Kennedy (D-Massachusetts), Senator Bill Frist (R-Tennessee), and Senator Judd Gregg (R-New Hampshire) –– express confidence that the President will support the bill and that it will pass by mid-December 2001.⁷

These recent measures mark a substantial shift in attitude on the part of the public, and by politicians, toward U.S. public health issues. Before the terrorist attacks of September 11 and the subsequent anthrax mailings, little budget was allocated for the nation’s preparedness against bioterrorism. A post-September 11 study by the General Accounting Office revealed that the $343 million anti-bioterrorism budget for Fiscal Year 2001 was insufficient. Of the total amount, approximately $113 million of the budget was reserved for protecting U.S. military troops, leaving less than $1 to safeguard each U.S. civilian.⁸

Recent movement towards strengthening the American public health system suggests that a strong national public health infrastructure would help to ensure overall security by preventing and/or responding quickly to threats of global infectious diseases and bioterrorism. However, many experts warn that having a strong national infrastructure is not enough. Local public health capacity is vital for protecting national security. U.S. Surgeon General David Satcher noted in his presentation at the November 2 conference that human resources and coordination –– the training of local personnel, as well as communication among private practitioners and public health officials –– are crucial in dealing effectively with bioterrorism.⁹ According to Dr. Satcher, the anthrax scare demonstrated the expertise of the American public health system in terms of well-trained epidemiologists and first-rate national laboratories. At the same time, however, the incidents highlighted deficiencies in local responder preparedness and the lack of public awareness and education about risks and the dangers of bioterrorism. Senator Bill Frist expressed similar remarks earlier during the conference: “In truth, the U.S. has not thought enough about mass casualty…now only one out of five hospitals have a bioterror plan.”¹⁰

As Dr. Margaret A. Hamburg, Vice President for Biological Programs at the Nuclear Threat Initiative explained, local and regional preparedness efforts must include adequate capacity in surveillance, detection, investigation, diagnosis, and responses to biological pathogens such as anthrax and smallpox.¹¹ In other words, the ability of front line responders, such as physicians, nurses, and pharmacists, to detect symptoms of infectious diseases and respond to them appropriately is the key to preventing an epidemic. Whether a potential epidemic originates from a natural cause or a bioterrorist attack, the responsibility of the front line responders remains the same.

Concerns about local preparedness have been expressed by many other experts in the U.S. prior to the attacks of September 11 and prior to the bioterrorism scare. Earlier this year, governmental and private studies, as well as crisis simulation exercises (such as “Dark Winter”), revealed insufficient capacity to contend with bioterrorism at all levels of government –– federal, state, and local. Many critics argued that not enough funds were being allocated to prepare local and state responders. Clearly, over the past two months, efforts have been underway to increase local preparedness as well as public awareness. For example, the National Institutes of Health (NIH) published a physicians’ guide in November 2001 to review techniques for distinguishing symptoms of anthrax from common infections such as the flu.¹² The American Medical Association posted numerous articles on bioterrorism on the organization’s Internet Web site and in its journals. Similarly, newspaper articles about anthrax and notices from the U.S. Postal Service about handling mail attempted to increase levels of public awareness. Furthermore, the new Office of Homeland Security, in coordination with FEMA and several other federal agencies, plans to review the emergency plans of all fifty states to improve local preparedness.¹³ Yet, initiatives to combat terrorism have begun only recently, and the U.S. still faces enormous challenges ahead.

Conclusion
Despite the urgency to enhance measures against bioterrorism, experts at the November 2 conference emphasized the crucial need for sustained international commitment to fight against the existing threats already posed by HIV/AIDS, malaria, and tuberculosis. This message is critical not only for the U.S. government and the private healthcare sector, but also for every other nation. It is important to recognize that the battle to combat existing infectious diseases goes hand-in-hand with the struggle against bioterrorism. The battle cannot be successful without a robust public health infrastructure at all levels –– local, national, and international. In order to ensure global health and security, the pillars of every public health system must be rebuilt to overcome the challenges posed by ongoing disease threats as well as emergency threats of bioterrorism.

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¹*This approach is challenged frequently by medical experts in other countries. Malegapuru William Makgoba, President, Medical Research Council of South Africa: “The Reality of Infectious Disease.” Conference on Global Infectious Disease and U.S. Foreign Policy – U.S. Department of State; Secretary’s Open Forum. Washington, D.C. November 2, 2001.
²Linda Carroll. “Afghan Women Plagued by Health Ills.” MSNBC Internet Web site. November 15, 2001.
³Aiah Gbakima, Professor of Biology, Morgan State University: On-site Interview on November 2, 2001.
⁴National Intelligence Council. The Global Infectious Disease Threat and Its Implications for the United States. January 2000.
⁵“Fact Sheet: U.S. Leadership on Global Disease Fund.” U.S. Department of State Internet Web site. July 20, 2001.
⁶“Additional $1.5 Billion Proposed to Combat Bioterrorism.” Department of Health and Human Services press release. HHS Internet Web site. October 17, 2001.
⁷Helen Dewar. “Senate Bioterrorism Bill Doubles Bush’s Request.” The Washington Post. November 16, 2001. p. A15.
⁸Ceci Connolly. “Bioterrorism Vulnerability Cited.” The Washington Post. September 28, 2001. p. A10.
⁹David Satcher, U.S. Surgeon General: “Emerging Threats and Responses.” Conference on Global Infectious Disease and U.S. Foreign Policy – U.S. Department of State; Secretary’s Open Forum. Washington, D.C. November 2, 2001.
¹⁰Bill Frist, Senator (R-Tennessee): “Globalization and Infectious Disease.” Conference on Global Infectious Disease and U.S. Foreign Policy – U.S. Department of State; Secretary’s Open Forum. Washington, D.C. November 2, 2001.
¹¹Margaret A. Hamburg, Vice President for Biological Programs, Nuclear Threat Initiative: “Emerging Threats and Responses.” Conference on Global Infectious Disease and U.S. Foreign Policy – U.S. Department of State; Secretary’s Open Forum. Washington, D.C. November 2, 2001.
¹²“NIH Publishes Anthrax Findings.” U.S. Department of State Internet Web site. November 14, 2001.
¹³“FEMA Director Announces State Capability Assessment for Terrorism and Weapons of Mass Destruction.” FEMA Internet Web site. October 25, 2001.