3
The Global Application of Knowledge, Tools, and Technology: Opportunities and Obstacles

Changes in travel and trade and the disruption of economic and cultural norms have accelerated and made it much more difficult to control the emergence and spread of infectious diseases, as described in Chapters 1 and 2 of this report. Even as progress is made, the public health community will likely encounter further setbacks, such as growing antimicrobial resistance. Yet there is a positive side to these developments as well. While globalization intensifies the threat of infectious disease, it also results in stronger tools for addressing that threat. From technological advances in information dissemination (e.g., the Internet) to the growing number of bidirectional infectious disease training programs that are bringing clinicians, scientists, and students from both sides of the equator together, the opportunities made available by globalization appear as endless as the challenges are daunting.

At the same time, the opportunities afforded by globalization do not necessarily come easily. Workshop participants identified obstacles that, if not addressed, may prevent or retard the ability to take full advantage of some of these new global tools. Global surveillance capabilities made possible by advances in information and communications technologies, for example, are still fraught with numerous challenges. This chapter summarizes the workshop presentations and discussions pertaining to some of these opportunities and obstacles.

One of the most enthusiastically discussed opportunities made available by our increasingly interconnected world is the type of transnational public health research, training, and education program exemplified by the Peru-based Gorgas Course in Clinical Tropical Medicine. This program not



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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary 3 The Global Application of Knowledge, Tools, and Technology: Opportunities and Obstacles Changes in travel and trade and the disruption of economic and cultural norms have accelerated and made it much more difficult to control the emergence and spread of infectious diseases, as described in Chapters 1 and 2 of this report. Even as progress is made, the public health community will likely encounter further setbacks, such as growing antimicrobial resistance. Yet there is a positive side to these developments as well. While globalization intensifies the threat of infectious disease, it also results in stronger tools for addressing that threat. From technological advances in information dissemination (e.g., the Internet) to the growing number of bidirectional infectious disease training programs that are bringing clinicians, scientists, and students from both sides of the equator together, the opportunities made available by globalization appear as endless as the challenges are daunting. At the same time, the opportunities afforded by globalization do not necessarily come easily. Workshop participants identified obstacles that, if not addressed, may prevent or retard the ability to take full advantage of some of these new global tools. Global surveillance capabilities made possible by advances in information and communications technologies, for example, are still fraught with numerous challenges. This chapter summarizes the workshop presentations and discussions pertaining to some of these opportunities and obstacles. One of the most enthusiastically discussed opportunities made available by our increasingly interconnected world is the type of transnational public health research, training, and education program exemplified by the Peru-based Gorgas Course in Clinical Tropical Medicine. This program not

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary only benefits its northern participants, but also helps build a sustainable public health capacity in the developing world. Historically, the goal of many tropical disease training programs was to strengthen the northern country’s capacity for tropical disease diagnosis and treatment. The trend toward a bidirectional, more egalitarian approach that benefits the developing-country partner as much as its northern collaborator reflects a growing awareness that a sustainable global public health capacity can be achieved only with the full and equal participation of the developing world. Thus, not only are the Gorgas Course and other, similar programs becoming more popular, both politically and among students, but their nature is also changing in significant and telling ways. The shifting focus of many of the international training programs of the Fogarty International Center (FIC) within the National Institutes of Health (NIH) further reflects the increased awareness, funding, and efforts needed to strengthen bidirectional international training in epidemiology, public health, and tropical medicine in particular. Are there enough of these programs to go around, however? In addition, despite the clear and growing need and interest, are U.S. medical and veterinary students receiving enough training in public health, let alone in tropical infectious diseases? The Gorgas Course, FIC programs, and other, similar initiatives are summarized here. The chapter also addresses the need to better incorporate public health training into U.S. medical and veterinary school curricula and ways in which Russian scientists could contribute to a transnational public health education program. Workshop participants identified other opportunities for progress as well. These include worldwide access to antiretroviral agents and vaccines; an increased capacity for global and regional surveillance; and technological advances in information and communications technology, namely, the Internet. Rather than focusing on specific opportunities, several of the presentations and discussions revolved around the various ways in which certain organizations and regions are capitalizing on such opportunities. The Pan American Health Organization (PAHO), for example, is relying on the development of regional political networks to aid in the construction of regional surveillance networks and to facilitate the sharing of diagnostic and treatment techniques across borders. Despite these promising developments, many obstacles impeding regional efforts to strengthen infectious disease control capacity remain. Another regional example is Russia, which, despite its current general state of public health as described in the previous chapter, has experienced some recent achievements and taken advantage of opportunities for the development of international collaborations in infectious disease control. The State Research Center of Virology and Biotechnology (VECTOR) plays a leading role in these efforts, which are summarized here.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary A final example is the relationship between the Massachusetts state public health laboratory system and public health clinics in Peru, whereby sputum specimens and isolates from Peru are sent to Massachusetts on a daily basis for drug resistance testing. This arrangement could serve as a model for a much larger, market-based approach to sharing limited public health resources. TRANSNATIONAL PUBLIC HEALTH TRAINING PARTNERSHIPS1 As noted above, the trend toward bidirectionality in transnational education and training, whereby southern partners have as much to gain as their northern collaborators, reflects a growing awareness that a sustainable global capacity to respond to infectious disease threats requires the full and equal participation of developing countries where infectious diseases are endemic. It is vitally important that the intellectual, technological, and health care workforce capacities of the developing world be strengthened, both for the sake of improving the health of local populations and because so many of the world’s infectious diseases arise in tropical countries and spread via nonindigenous travelers. One-third of all new infectious diseases identified over the past 25 years were discovered in Latin America. The Gorgas Course in Clinical Tropical Medicine and other international training programs offered by the Instituto de Medicina Tropical “Alexander von Humboldt” (IMT) in Lima, Peru, and several of the overseas training programs sponsored by FIC exemplify this trend toward bidirectionality, as described in this section. Nevertheless, in addition to improving the capacity of the developing world, one of the primary goals of these programs remains the education and training of northern students, researchers, and practitioners. Despite the progress made over the past decade in providing increasing numbers of opportunities for U.S. students and health care practitioners to gain experience overseas, including experience with the treatment and control of tropical infectious diseases, much work remains to be done. Efforts of the American Society of Tropical Medicine and Hygiene (ASTMH) and others to improve the training of U.S. students in tropical infectious disease medicine are also summarized here. Workshop participants expressed serious concern that too few medical and veterinary school students receive adequate public health training in general, let alone training in tropical infectious diseases. It is vital for front- 1   This section is based on the workshop presentations by Barry (2002), Demin (2002), and Gardner (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary line practitioners to receive such training. As one participant observed, it was an astute physician who identified inhalational anthrax in Florida in the fall of 2001. This section includes a summary of the discussion pertaining to the need for public health training and the challenges, mainly monetary, that make meeting this need difficult. Although most of the discussion of transnational training partnerships focused on collaborations between the developing and developed worlds, particularly between the United States and Latin America, participants also discussed how a global approach to public health education and training would benefit Russia, especially in light of rapidly developing antiglobalist and xenophobic sentiment in that country. Some examples of ways in which Russia could, in turn, contribute to a mutual exchange of information and skills were also outlined. The Gorgas Course and Other Recent Bidirectional Training Initiatives: A Peruvian Perspective Although U.S. and Latin American scientists have been collaborating for more than two decades, the collaborations have tended to involve only certain U.S. universities interacting with certain Latin American countries. This same colonial attitude has been true of European–African collaborations as well. The situation is changing, however. Developed-world partners are adopting new approaches in their interactions with the developing world and realizing that respecting the decisions made by their developing-country partners is critical to the long-term sustainability of these partnerships. For example, IMT, on the campus of the Universidad Peruana Cayetano Heredia in Lima, where the Gorgas Course in Clinical Tropical Medicine is held, maintains a strong collaboration with the Belgian-run Institute of Tropical Medicine in Antwerp. An important component of this four-year collaboration is the way in which the Belgian partners have respected IMT’s decisions. When the collaboration was initiated, the Belgians asked, “What is your priority? How would you like your Institute to develop?” A workshop ensued, IMT devised a plan, and the Belgians agreed with and supported the plan. Another, more popular example is Peru’s interaction with the University of Alabama (UAB) in support of the Gorgas Course in Clinical Tropical Medicine. This annual nine-week diploma course provides 380 contact hours (in English) and daily bedside teaching. Over the last six years, the Gorgas Course has trained 185 medical doctors from 44 countries. About 50 percent of the participants are from the United States, 17 percent from Canada, 12 percent from Latin America, 10 percent from Europe, six percent from Asia, five percent from Australia and New Zealand, and two percent from Africa. Most of the trainees are midcareer professionals with

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary about 10 to 15 years of experience. Participants range from United Nations Children’s Fund (UNICEF) project officers to missionary physicians, U.N. peacekeeping forces, and vaccine developers (see Figure 3-1). The age range of the participants is from under 30 to over 60. The Gorgas Course does more than train. In two months alone there were some 10,000 visitors to cases published on its website. And since the anthrax attacks in the United States, there have been 7,000 U.S. inquiries regarding the anthrax photos provided by the Gorgas Course case collection. IMT also sponsors several other training programs and courses for professionals and students. For example, small grants are available for U.S. students to go to Peru for three or four months at a time and conduct research; two U.S. students participate each year and together have coauthored six published papers to date. The bidirectional nature of IMT’s relationship with UAB is illustrated by the approximately 20 Peruvian students who have trained at UAB over the last three years. In 2002 there were eight Peruvian residents in the UAB Department of Medicine, and the chief resident was from Peru. IMT also offers its own master’s degree in infectious disease control, although this program is not yet as well supported as others. In recognition of the fact that IMT provides sustainable, credible training and is expected to continue to grow, UAB is undertaking several other new initiatives. In 2003, for example, IMT initiated a separate program for trainees from other Latin American countries, including Bolivia, Paraguay, Ecuador, and Colombia. UAB is also developing a plan to provide clinical training in HIV/AIDS and tuberculosis (TB). Other Peruvian collaborations with the United States include a ten-year partnership with the University of Washington School of Public Health and Community Medicine; some 40 published papers have resulted from this collaboration. Several personnel from the University of Washington have also trained in Peru. Other examples include collaborations with the University of Maryland (cholera and typhoid fever), Johns Hopkins University (cysticercosis), and Harvard-affiliated Partners in Health (TB and multidrug-resistant TB). In addition to respecting the decisions made by participants from the developing world, the adequate transfer of economic support is vital to the continued success of these types of programs. The failure to transfer sufficient funds to developing countries is one of the key issues regarding international partnerships. This is especially true of partnerships with the United States, as about 90 percent of U.S. funds designated for training programs in Latin American developing countries are actually spent in U.S. institutions. This is the case even when the award recipients are Latin Americans. In reality, the amount of funds transferred is very small, as the award money still belongs to U.S. institutions and private companies. The situa-

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary FIGURE 3-1 Post–Gorgas course activities I and II. SOURCE: Barry (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary tion is analogous to American travelers who visit Peru but fly American Airlines, stay at the Sheraton or Marriott, and travel with a U.S. tour group. Although the trip may cost the tourist $3,000, only about $20 stays in Peru; the rest goes back to the United States (Gotuzzo, 2002). The transfer of technology, skills, and knowledge gained from research endeavors in the developing world is another key issue. With regard to the transfer of technology, for example, the BACTEC system for drug susceptibility testing of Mycobacterium tuberculosis is available but cannot be used in Peru. With regard to the transfer of knowledge, it is critical that research conducted in developing countries have a significant, positive local impact. Even though European and U.S. countries have spent $1 billion on malaria research in just one African country over the past 50 years, the rates of mortality and morbidity from the disease have not changed, and the quality of life has not improved. This situation must be changed. The Changing Nature of Fogarty International Center’s Transnational Training Partnerships The 35-year-old FIC has a specific mandate to promote and support international scientific research and training in the global health sciences and reduce global health disparities. In its early years, the agency focused largely on the exchange of scientists among developed countries. Over the last 15 years, however, it has increasingly emphasized scientific capacity building and training in developing countries by awarding traditional training grants, mainly to universities within the United States. This shifting programmatic emphasis reflects the changing nature of training partnerships between developed and developing countries. In addition, FIC maintains several mathematical modeling research programs addressing a wide range of issues, from disease prevalence to rates of global mortality from influenza and the biomedical modeling of bioterrorism. FIC’s traditional training grants for capacity building and training have been highly successful. Foreign trainees come to the United States, where they receive clinical, laboratory, and research training in public health and then return to their countries, where they use their new skills in leadership roles. As a measure of FIC’s success, one-quarter of the scientific presentations at the World AIDS Congress in Durbin, South Africa, in 2000 had one or more authors who had been trained with FIC support. In fact, these capacity-building programs have been so successful that they have reached the point at which the foreign sites are now able to assume much more responsibility and autonomy. Because of this success, FIC, in collaboration with its 10 NIH partners and the Centers for Disease Control and Prevention (CDC), has established

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary a new, next-generation grants program known as the International Clinical, Operational, and Health Services Research Training Award for AIDS and Tuberculosis (ICOHRTA-AIDS/TB). There are several important differences between this new approach to training individuals from overseas and the earlier, more traditional grants: Training site—Most significant is that, although the grants still fund collaborations, or partnerships, between sites in the United States and abroad, they are increasingly centered in the low-resource country. In the past, foreign trainees were brought to the United States, where they enrolled in courses and, in some cases, degree programs. Now, the training sites are increasingly located in the developing countries, and the developing-country participants set the agenda, decide whom to work with, and assume much more ownership of their efforts than in the past. This shift in emphasis empowers resource-limited countries to sustain their own health care initiatives without continued reliance on CDC and other outside agencies. Research agenda—In the past, research agendas were set mainly by grant recipients in the United States. The agendas of ICOHRTA-AIDS/TB will increasingly be set by individuals in the developing countries. Faculty mentoring—Faculty mentoring was previously performed mainly by faculty in the developed country. It is now being done increasingly by faculty in the developing country. NIH funding—In the past, NIH funding went to the site in the developed country. NIH funding now goes to sites in both the developing and developed countries; paired grants will include direct funding, including overhead costs, to both countries. Types of awards—The long-term sustainability of the grants program at a foreign site requires a long-term commitment from the United States. Traditional training grants are typically for five years, but these new-generation grants will be 10-year (or longer) cooperative agreement programs. Research emphasis—The earlier grants program focused mainly on epidemiology and prevention, important work without which these new-generation grants would not be possible. One of the primary goals of the new program, however, is to expand this focus and integrate clinical, operational, and health services research in an effort to apply results obtained at the benchtop to the bedside. The emphasis is on the integration of therapy and care with prevention efforts. In addition to FIC’s training grants programs, NIH oversees several other, similar international efforts, including the Prevention Trials Network, the Vaccine Trials Network, the Comprehensive International Program of Research on AIDS, Popular Opinion Leaders, International Cen-

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary ters for Excellence in Research, and Partnerships for HIV/AIDS Research in Africa. FIC also helps foster many major U.S. government and other international AIDS research efforts, including those of CDC’s Global AIDS Program; the U.S Agency for International Development’s Rapid Response Initiative; the Bill and Melinda Gates Foundation; the American Foundation for AIDS Research; the Elizabeth Glaser Pediatric AIDS Foundation; the Academic Alliance for AIDS Care and Prevention in Africa; and the Global AIDS, Tuberculosis, and Malaria Fund. One of the most recently established FIC programs is the Global Health Research Initiative Program for New Foreign Investigators, a reentry grant program with the aim of reversing the “brain drain” from foreign countries that occurs when scientists come to the United States for graduate school and NIH training and do not return home. The program provides five years of support at $50,000 a year to scientists who reenter their home country after receiving training in the United States. Also relevant is the International Training and Research Program in Emerging Infectious Diseases, a traditional program carried out at university sites conducting research overseas. In addition, FIC has partnered with the National Science Foundation and created the Ecology of Infectious Disease program. The purpose of this program is to support efforts toward understanding the ecological and biological mechanisms that govern the relationships between human-induced environmental changes and the emergence and transmission of infectious disease. Finally, FIC funds the International Studies on Health and Economic Development program, which supports projects examining the effects of health on microeconomic agents (individuals, households, and enterprises) and aggregate growth, as well as the effects of health finance and delivery systems on health outcomes. Russia’s Potential Contributions to Transnational Training Although most of the discussion of international bidirectional training programs during the workshop focused on north–south collaborations, and U.S.–Latin American partnerships in particular, some participants commented on the need for a transnational public health research and education agenda in Russia, especially with regard to infectious disease control in migrant populations. Many Russian experts are capable of participating in such international collaborative programs, and Russia could contribute to this type of program in many ways: Russia’s unique experience with protecting its population from extremely dangerous infections as part of the former Soviet Union’s so-called “counterplot service” could be a very useful source of information for other countries.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Russia could play a leading role in prevention and control programs for HIV/AIDS and other infectious diseases throughout Eastern Europe. Russia’s stored smallpox specimens—one of the world’s two supplies of wild virus—could be used for international collaborative research. Russian experts who are developing a register of sites in Russia where anthrax (Bacillus anthracis) spores are stored could contribute to an international effort to register and monitor anthrax sites around the world. Such a registry could be used in bioterrorism prevention and control, for example, to differentiate between bioterrorist and natural outbreaks. Russian experts could also aid in the development of a register of infectious disease carriers for use in preventing the dissemination of infectious diseases beyond national borders as a result of migration. Recent Overseas Training Initiatives: A U.S. Perspective After the Institute of Medicine (IOM) announced in a 1987 report, U.S. Capacity to Address Tropical Infectious Disease Problems, that only 300 people in the United States had the capability to diagnose and treat tropical diseases, ASTMH formed a committee to formulate recommendations for remedying the situation (IOM, 1987).2 It was clear that the United States had no truly excellent program offering the kind of diploma training course, including laboratory and overseas experiences, called for by the IOM report. The ASTMH committee recommended that an examination in clinical tropic medicine be administered and that a diploma in tropical medicine and hygiene be offered. ASTMH distributed a request for proposal to 370 U.S. and Canadian medical schools; 22 schools responded, and the proposals from seven U.S. and five overseas medical schools were accepted. Today, there are strict requirements for a diploma course and a separate two-month overseas course. Since 1995, 619 individuals have taken the examination, 412 have passed, and 387 have had the overseas experience. The Gorgas Course, which prepares students for the ASTMH examination, is an excellent example of the type of training program in tropical medicine and hygiene envisioned by ASTMH. In addition to the Gorgas Course, other ASTMH-accredited diploma courses are offered at the following universities: Bernard Nocht Institute (Germany), Case Western Re- 2   ASTMH, a 1951 merger between the American Society of Tropical Medicine (formed in 1903) and the National Malaria Society (1940), is a major U.S.-based organization dedicated to the advancement of the study of tropical diseases and international health. Its goals are to promote and stimulate science-based policy in international health, professional interest and career development, and basic and operational research in tropical diseases.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary serve University, Humboldt University (Germany), Johns Hopkins University, Liverpool School of Tropical Medicine, London School of Hygiene and Tropical Medicine, Mahidol University (Thailand), Tulane University, University of Virginia, West Virginia University, and Uniformed Services University of the Health Sciences. A number of other ASTMH training initiatives were inspired by the 1987 IOM report. These include the Ben H. Kean Traveling Fellowships in Tropical Medicine (for clinical or research experiences for medical students and residents); the Centennial Fellowship (for senior undergraduate and graduate students to work on immunomolecular parasitology with colleagues in the developing world); the Burroughs-Wellcome Fund Fellowship (for overseas projects at collaborating field sites); the Gorgas Memorial Research Award (for Latin American and Caribbean scientists to work with their North American colleagues on collaborative projects); and travel awards for overseas colleagues to present their research at ASTMH annual meetings. Many non-ASTMH educational initiatives have also emerged recently worldwide. They include the Yale World Fellows Program and the Yale/ Johnson & Johnson Physician Scholars Program. The former attempts to bring together midcareer professional leaders from academia, government, nongovernmental organizations, business, and media from throughout the world in an effort to create an international dialogue and network among fellows and broaden the general understanding of globalization. Participants receive a generous stipend for themselves and their families so they can attend Yale for a semester or a full year. Fellows participate in seminars and independent studies during an initial visit; they revisit the campus after having worked back at their home sites for two years. The Yale/Johnson & Johnson Physician Scholars program, which started in 1981, sends physicians-in-training in a variety of subspecialties to 16 sites around the world for overseas rotations. In 2002, when the program was broadened to include a national competition, it funded 65 scholars, including senior midcareer physicians. The goal is to place physicians in underserved areas where they can learn to recognize tropical diseases and develop long-standing bilateral relationships between their home school or hospital and the host area. Not only there is a need for more training in tropical infectious diseases among health care providers in the United States and other countries in the developed world, but there is also a strong student demand for such training. By going abroad, students learn about and encounter diseases and conditions, such as measles, that do not occur regularly or at all in the United States. In 1984, just four percent of graduating medical students participated in overseas training. This percentage has risen dramatically. According to an unpublished 2002 study of nearly 400 internal medicine

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary consider the market conditions for vaccine products may drive even these few remaining vaccine manufacturers out of business. The same situation applies to companies that sell products for both the prevention and treatment of the same disease. If it is more cost-effective, from a public health standpoint, to take preventive measures for a given disease, these companies will make more money by developing and producing preventive products and will have less incentive to develop and produce the corresponding treatment products. Finally, it was noted that when these issues are discussed, people often start thinking immediately about the need for new drugs. However, the 23 percent rate of implementation of DOTS noted several times during the workshop illustrates that, at least in the case of multidrug-resistant TB, the main problem is not the production of new drugs but the implementation of the therapy. Even if the pharmaceutical industry produces a new anti-TB drug every year, multidrug-resistant TB is going to continue to emerge worldwide unless the implementation of DOTS is improved. As anti-HIV therapies are introduced into countries, it must be kept in mind that for many reasons, there may be fewer innovative efforts to develop new therapies in the future. The same is true of antibiotics. Thus it is crucial that the first steps taken be the right ones. OPPORTUNITIES FOR AND OBSTACLES TO GLOBAL SURVEILLANCE7 Effective in-country surveillance systems are one of the many reasons smallpox was and remains eradicated.8 As noted throughout this report, however, emerging infectious diseases are no longer geographically contained; therefore, effective in-country surveillance systems alone cannot prevent and control their global spread. A global surveillance system is necessary to better protect against infectious diseases through a collaborative response. An effective global surveillance and response system has four key components: accurate surveillance, appropriate information dissemination, a 7   This section is based on the workshop presentations by Cash (2002), Cleghorn (2002), Corber (2002), and LeDuc (2002). 8   A number of additional factors contributed to the successful eradication campaign: the epidemiology of the disease was understood; the disease could be easily recognized; a low-cost, effective technology (i.e., the bifurcated needle and a vaccine) was available; there was a clear political commitment and an understanding that eradication had local and global benefits; and there was a willingness to help those countries that were too poor to conduct eradication efforts by themselves.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary reasonable international response, and adequate enforcement by multilateral agencies. Ideally, clinical identification of an infectious disease in the field would be followed by diagnostic laboratory support, and finally diagnostic confirmation by a regional, national, or international laboratory, such as WHO, which would also establish an international strategy appropriate for the situation. The international response would involve WHO or another agency that would disseminate the information and coordinate the support. Nations would then institute their own control procedures on the basis of their national policies, international regulations, WTO policies, and, if necessary, Codex Alimentarius Commission food standards. Eventually, the outbreak would be controlled with minimal international spread and disruption of trade. However, there are several impediments to the establishment of such a global surveillance and response system. Perhaps most important, regional and local health officials sometimes face strong political pressure to suppress outbreak reports so as to protect the country from the potentially damaging economic and political costs that often ensue. These costs stem in part from the lack of dissemination of information or the dissemination of inappropriate information by health officials and the media, as well as the limited diagnostic, treatment, and prevention capacities available in developing countries. The media are often prone to sensationalism when reporting on outbreaks. Other nations may issue travel advisories or impose trade sanctions, even when such measures are unnecessary, in an effort to protect their populations, public confidence, political interests, and industries. Indeed, the measures taken all too often are far more stringent than is necessary or appropriate. The 1994 outbreak of plague in India serves as a disturbing example of what can happen when a country reports an outbreak. The outbreak, which caused 56–60 deaths, occurred in the town of Surat, which at the time was experiencing economic and environmental conditions among the worst in the country. India’s diagnostic capacity was not very good at the time, and there was some question as to whether the outbreak actually involved plague. On the basis of its assessment that the outbreak was plague, however, India responded in accordance with WHO health regulations and ensured the adequate monitoring of both people and goods. Nonetheless, when the public was informed of the outbreak, many people fled from Surat, including physicians, who were among the first to leave (after treating suspected cases and instituting control measures such as the distribution of antibiotics). Although WHO recommended that there be no restrictions on trade and travel, trade restrictions were imposed by Qatar, the United Arab Emirates, Bangladesh, Oman, Italy, Sweden, and others. Moreover, Italy, France, Germany, Canada, the United Kingdom, the United States, and other countries restricted travel to India, and more than 2.2 million

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary tourist trips to the country were canceled. Overall, the reported outbreak cost India an estimated $2.3 billion in lost trade and travel; the country experienced a record trade deficit in 1994. Why was the response to India’s reporting so extreme, given that its actions were appropriate according to the recommendations of WHO, and especially given that it was unclear whether the outbreak was in fact plague? Ironically, a small, confirmed outbreak of plague occurred in the western United States at the same time. The cholera epidemic in Peru in 1991 serves as another example of the negative repercussions of outbreak reporting. The epidemic began on the Peruvian coast and then traveled south through the Amazon basin into Brazil (even though the reported mortality rate was less than one percent, which may have been due to underreporting). Peruvians made the diagnoses, informed the public, treated suspected cases, and instituted control measures. Signs indicating that people should treat their food and water to prevent cholera were posted throughout Peru and the rest of Latin America. Despite these measures, several of Peru’s neighbors, including Bolivia, Ecuador, Chile, and Argentina, imposed trade restrictions (although the epidemic spread to Ecuador and Chile anyway). The European Union also imposed trade restrictions. Peru lost more than $700 million in trade, and Chile lost $330 million. Travel from North America and the European Union was restricted, and half of all tourists scheduled to travel to the region canceled their plans. These travel restrictions were instituted even though both CDC and WHO stated that “on no account should travel be restricted because of cholera.” The United States implemented testing procedures and placed restrictions on imported food, despite the claim of the UN Food and Agriculture Organization that “there are no documented outbreaks of cholera resulting from commercially imported food. Epidemiological data suggest that the risk from contaminated imported food is negligible.” The trade restrictions, lost tourism, and increased inspection that resulted from the reported cholera outbreak cost Peru more than $1.5 billion. Other examples of the economic costs of outbreak reporting include the shift in coffee prices and subsequent trade-related economic losses that occurred as a result of the 1998 cholera outbreak in Ethiopia. Similarly, the 1998 Nipah virus outbreak in Malaysia, which led to trade and travel restrictions, as well as the loss of the local swine production–related infrastructure, cost the country hundreds of millions of dollars. The current situation with regard to tourism in the Caribbean is another good example of the tension between reporting an outbreak and withholding information to avert economic loss. Because tourism is such a significant industry in the Caribbean—more than 50 million people visit the region each year, many of whom arrive on massive cruise ships—the economic impact of outbreak

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary reporting would likely be quite significant. For this and other reasons, much remains to be done to develop an effective regional surveillance system in the Caribbean. Anecdotal evidence suggests that many countries suppress the reporting of information on outbreaks. Pakistan, for example, has experienced many cholera outbreaks over the past 35 years, none of which have been reported. HIV/AIDS is commonly underreported or not reported at all in many countries, while known plague outbreaks in Africa and elsewhere have gone unreported as well. This is not surprising, as there is no reason to expect that a farmer raising livestock in Argentina, for example, would let it be known that his cattle are dying from what appears to be bovine spongiform encephalopathy. To encourage the rapid and accurate reporting of outbreaks and to strengthen global surveillance and response capacities, three main challenges must be met: The economic and political costs of outbreak reporting must be minimized: Governments and trade associations must be better educated. WTO and WHO need to be proactive in preventing inappropriate economic responses. Economic aid should be granted to countries that are treated unfairly. Mechanisms for the rapid redress of inappropriate responses need to be developed. Decision makers and policy makers need to be aware that if such a situation is not resolved quickly, individuals may lose their livelihoods through the loss of their perishable products. The dissemination of inaccurate information must be remedied: Transmitting accurate information early in an outbreak is critical to a prompt and appropriate response. Press releases and other reporting information (e.g., from WHO, CDC, national health organizations, and nongovernmental organizations) need to be reliable and credible. The media (television, print, and radio, as well as the Internet and the World Wide Web) need to be better educated with regard to their role in outbreak reporting, and it must be determined who is responsible (e.g., the government or schools of public health) for educating those who are doing the reporting. Reporters need to be educated in the principles of surveillance, the true threat of outbreaks, the importance of transmitting accurate information, and the impact of stigmatization and sensationalism. The last point is especially important: too often the victim is blamed, and too often the victim is a poor person in a poor country.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary The limited assistance available for diagnostic, treatment, and prevention capabilities must be rectified. The ability to diagnose, treat, and prevent outbreaks locally must be strengthened by improving the training of local field staff; strengthening national and local laboratory capacities; supporting research on inexpensive, easy-to-use detection methods and equipment; and increasing the transfer of existing biotechnology and genomics. For example, the Sustainable Sciences Institute in San Francisco, California, teaches investigators throughout Latin American about simple, inexpensive polymerase chain reaction techniques. Such programs need to be expanded and further supported, and the transfer of biotechnology and genomics needs to increase. Countries must be empowered to make diagnoses themselves rather than depending on CDC and others. Such dependency is not sustainable and does not give countries the capacity to deal with future outbreaks. In addition to meeting the above challenges, workshop participants suggested a few other steps that could be taken to improve global surveillance. For example, clinical microbiology laboratories, which lie at the foundation of the U.S. laboratory response network and are the recipients of some of the recent biodefense funding, could be considered potential sources of surveillance data. Thus even if the tens of thousands of tests conducted in these laboratories each day failed to yield data that could be used for research purposes, they could be used to save lives and treat patients. Quality assurance tests could be used to monitor the data as necessary. In fact, global surveillance efforts would benefit from tighter links to all components of the clinical arena, including health care providers and physicians. Because of the increasing opportunities for animal–human disease transmission resulting from globalization, a participant suggested that programs be established to encourage and facilitate the exchange of information between the animal and human disease surveillance communities. This information exchange would be of great benefit for disease detection, at least in the United States. Foot-and-mouth disease, for example, could be introduced into the United States with frightening ease, especially if it were done intentionally. Rapid detection, containment, and eradication would require shared intelligence between the animal and human disease surveillance communities. Obstacles to Regional Surveillance: The Caribbean Region as a Case Study Development of the PAHO-administered Caribbean Surveillance System (CARISURV), based at the Caribbean Epidemiology Center in Port of Spain, Trinidad and Tobago, represents an attempt to regionalize infectious

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary disease surveillance in the Caribbean. However, the system faces multiple challenges, both financial and organizational. For example, very little money is being spent on dengue surveillance, even though recent economic analyses suggest that the economic impact of dengue in the Caribbean exceeds that of the common cold. Perhaps one of the greatest challenges is that the Caribbean, like many developing regions, is a large area with diverse characteristics. It comprises about 35 countries whose people speak six different languages and have allegiances to different previous colonial powers. Moreover, although most nations in the region are characterized as middle-income developing countries where public health and other problems are generally not as acute as in poorer countries, there are exceptions. Haiti’s annual per capita GDP is about $700, the lowest in the hemisphere; other nations, such as Honduras, are also quite poor. Even among the so-called middle-income Caribbean countries, most governments lack sufficient resources to implement the public health measures that are considered their primary responsibility and for which they generally do not receive assistance from the private sector. The region has very limited human resources devoted to the reporting of infectious diseases, and the statistics produced are notoriously unreliable. In most countries in the region, only a single person is responsible for reporting all infectious diseases, including HIV/AIDS. Laboratory capacity and technology support are also underdeveloped. This situation poses a great challenge for the region’s foreign collaborators, including the United States. The capacity to conduct U.S. Food and Drug Administration– certified clinical trials for HIV vaccines in places such as Jamaica and Trinidad is limited by the fact that very few laboratories meet the criteria of the certifying agencies in the United States. Strengthening of the regional surveillance capacity will require, among other things, the establishment of long-lasting training programs of the type described earlier in this chapter. Because there is a very limited number of trained personnel in the Caribbean—a situation typical of most countries in the developing world—training is extremely important for strengthening not just surveillance capacity, but also public health capacity in general. Surveillance Success Stories Although most observers would acknowledge the considerable challenges to meeting the need for an effective global surveillance system, there are some success stories that serve as good models for what can be achieved. The successes of polio and influenza surveillance efforts, for example, are attributed primarily to clear-cut goals and rewards (eradication, improved health for all). When attempts are made to enforce surveillance in places where there

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary is no clear benefit—for example, where reporting creates a significant economic backlash—the challenges can be more difficult to overcome. It was also pointed out that although the 1994 plague outbreak in India had a devastating economic impact, illustrating the negative global reaction that can result from sensationalized media reporting, few people are aware that India experienced another, more recent plague outbreak that was handled quietly, professionally, and appropriately. There was very little backlash in the form of international sanctions and the like. The pathogen was recognized, isolated, and confirmed within Indian laboratories using modern, state-of-the art resources; there was no need for international assistance. This success was due largely to extended collaborations with CDC and others aimed at improving India’s surveillance and response capabilities. INFORMATION AND COMMUNICATIONS TECHNOLOGY9 Workshop participants emphasized the potential of the Internet and the World Wide Web to change the way the work of public health is conducted, enabling enormous strides in the ability to understand, track, and fight infectious diseases. ProMED, e-mail, electronic chat rooms, the Global Outbreak Alert and Response Network (GOARN), and the Global Atlas of Infectious Diseases are just a few of the ways the Internet is being exploited for infectious disease control on a global scale. ProMED, for example, is a global public health information network that scans English, French, and Spanish media worldwide for reports of infectious disease outbreaks. Although not all ProMED reports are accurate, they allow investigations to begin more rapidly. Furthermore, ProMED reports are more public than country reports, and in many countries the press has a better surveillance capacity than the government. Reports can be obtained either by accessing the ProMED website or by subscribing to receive regular e-mails. (GOARN and the Global Atlas of Infectious Diseases are discussed below.) Because the Internet and other communications technologies can be used to raise general awareness of the fundamental problems of global health, a participant suggested that they could also be used as leverage to ensure that those who can alleviate problems remain accountable—for example, governments that fail to provide resources for the Global Fund. Thus far, the groups that have used the Internet most effectively for such leverage have been targeting pharmaceutical companies, not governments. Finally, although not discussed in detail during the workshop, telemedi- 9   This section is based on the workshop presentations by Corber (2002) and Klaucke (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary cine was mentioned as a new, potentially very powerful tool. Telemedicine is the use of telecommunications technologies to deliver medical information and services when the provider and patient are separated by distance. It was suggested, for example, that recent advances in telemedicine may provide innovative solutions for improved screening of migrants. (See Chapter 2 for a discussion of migrant health.) The Global Outbreak Alert and Response Network In 2000, because the new International Health Regulations (IHRs) were not expected to be finalized and approved for another couple of years, WHO developed GOARN as the framework for some of the organizational activities necessary to be able to respond to urgent public health problems on a global level. GOARN is a technical partnership of 110 institutions and networks that work together to mobilize and pool resources for outbreak alerts and responses. Its purpose is to contain outbreaks by rapidly identifying, verifying, and communicating threats; to deliver appropriate technical assistance to affected areas; and to contribute to long-term outbreak preparedness. GOARN is coordinated by a WHO operational team in Geneva, Switzerland, which works closely with WHO’s six regional offices, 141 country offices, and liaison offices. The network’s outbreak event management system has four main components: intelligence, verification, response, and follow-up. Information is gathered from various sources, both formal (e.g., WHO laboratory networks and regional and subregional networks) and informal (e.g., nongovernmental organizations and the media). The information is then verified by WHO offices and the countries involved, after which a risk assessment is conducted and the appropriate response determined. The appropriate response could include an investigation, preventive measures, case management, and/or the provision of information to the public. Much (39 percent) of the information gathered by the network is transmitted to WHO from the Global Public Health Intelligence Network in cooperation with Health Canada. This real-time early-warning system scans more than a million Internet websites daily for news and other reports of infectious disease events. Other sources of intelligence include WHO (33 percent); ProMED (six percent); and various other sources, such as laboratories and nongovernmental organizations (22 percent). To avoid the spread of rumors, information is not made available to the public until after it has been verified. Verification is a systematic process by which WHO confirms the occurrence of an outbreak, its etiology, and the need for assistance in an affected state(s). The network monitors only events of potential international public concern. The criteria used to determine

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary whether an event is of international public concern include an unknown etiology, unexpectedly high morbidity or mortality rates, the need for assistance, the potential effect on international travel and trade, the current status of the outbreak relative to the IHRs, and any suspicion that the event was caused by an intentionally released biological agent. Between March 2001 and March 2002, GOARN verified 195 events, most of which occurred in Africa (47 percent); some occurred in Asia and a very few in the Americas. The geographic distribution of the events reflects in part the quality of the public health infrastructure in these regions and the capacity to identify the events and respond appropriately at the national level. The response component of GOARN involves providing rapid, appropriate, and effective assistance to the affected state(s); ensuring a level of response geared to the needs of the affected state(s); meeting daily to verify new intelligence and coordinate any responses; providing a field presence and coordination when needed; and maintaining systematic information management. From 1998 to 2001 there were more than 20 WHO-facilitated epidemic response missions, for which WHO was only one of several response partners. CDC, for example, was involved in more than half of these missions. All responses are tracked in a computerized outbreak event management system. WHO is currently developing a secure website for the network at which network members will be able to find timely information about ongoing responses. Global Atlas of Infectious Diseases The Global Atlas of Infectious Diseases is intended to be a web-based information and interactive mapping system that will support the global surveillance of infectious diseases. It will be used to provide access to infectious disease data and related information; standardized analyses of diseases, including maps, charts, and tables; a standardized dissemination mechanism; and an interactive data entry system for all partners. At the website, one can find information about a disease in any particular area of the world or even a certain region within a larger geographic area. For HIV/AIDS, for example, one could select the African region of WHO and then find places where sentinel surveillance for HIV/AIDS was conducted for pregnant women in 1998. One could then select a particular country and locate the different sentinel sites within that country, or find a report identifying the sites by name. One could also develop charts that would enable comparisons across sites or over time, as well as link to other sources of information, such as epidemiology fact sheets for particular diseases.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary REFERENCES Barry M. 2002 (April 16). Considering the Resources and Capacity for the Response. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Cash R. 2002 (April 16). Impediments to Global Surveillance and Open Reporting of Infectious Diseases. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Cleghorn F. 2002 (April 16). Considering the Resources and Capacity for the Response. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Corber S. 2002 (April 16). A Response to Shifting Threats. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Demin A. 2002 (April 16). Social Aspects of Public Health Challenges in a Period of Globalization: The Case of Russia. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Gardner P. 2002 (April 17). New Directions in Capacity Building. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Gotuzzo E. 2002 (April 17). The Global Application of Tools, Technology, and Knowledge to Counter the Consequences of Infectious Diseases: A Discussion of Priorities and Options. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. 1999. The International Health Program: The fifteen-year experience with Yale University’s Internal Medicine Residency Program. Am J Trop Med Hyg 61(6):1019–1023. Henderson DA. 1998. Smallpox eradication—A cold war story. In: World Health Forum. Vol. 19. Baltimore, MD: Johns Hopkins School of Hygiene and Public Health. P. 113. IOM (Institute of Medicine). 1985. Vaccine Supply and Innovation. Health Promotion and Disease Prevention. Washington, DC: National Academy Press. IOM. 1987. The U.S. Capacity to Address Tropical Infectious Disease Problems. Report by a steering committee of the Board on Science and Technology for International Development. Washington, DC: National Academy Press. IOM. 2005. Scaling Up Treatment for the Global AIDS Pandemic. Report by the Board on Global Health. Washington, DC: The National Academies Press. Klaucke D. 2002. Globalization and Health: A Framework for Analysis and Action. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary LeDuc J. 2002 (April 17). The Global Application of Tools, Technology, and Knowledge to Counter the Consequences of Infectious Diseases: A Discussion of Priorities and Options. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Miller M. 2002 (April 17). Considerations for Shaping the Agenda. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Netesov S. 2002 (April 17). The Current Situation and Perspectives of International Collaboration in the Field of Biomedical Sciences: The Example of the State Research Center of Virology and Biotechnology, VECTOR. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Paterson D, Swindels S, Mohr J. 1999 (Unpublished Data). How Much Adherence is Enough? A Prospective Study of Adherence to Protease Inhibitor Therapy Using MEMSCaps. Poster presented at 6th Conference on Retroviruses and Opportunistic Infections. Chicago, IL, Abstract 92. Redfield R. 2002 (April 16). Considerations for Drug Access and Delivery in the Developing World. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Timperi R. 2002 (April 17). Considerations for Shaping the Agenda. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections.