Throughout this book, the reader will surely recognize a common theme: as modern life grows increasingly complex, humans and pathogens will more and more cross paths. And whatever the emerging infection threat, whether pandemic flu or inhalational anthrax, foodborne illness or insectborne disease, keen surveillance and

rapid response are the answers. Without an exquisitely sensitive disease tracking system—a worldwide web of health care workers and laboratories and communication networks that can register the faintest signal of aberrant infection against background noise—novel diseases will continue to sneak up on us. Such a system must be built not just within the United States but around the world. Although this book has focused on the U.S., there are no national borders against infection.

For many reasons, affluent countries are reawakening to the fact that the growing disparity worldwide in health and wealth imperils all countries. As Laurie Garrett explains in Betrayal of Trust, “Global public health action on an ongoing basis would, if it truly existed, constitute disease prophylaxis for every locality, from rich nation to poor. New York City need not worry about its inability to stop plague at JFK Airport if India’s infrastructure can do the job in Surat, preventing spread beyond that Gujarati city. And Tokyo need not fear Ebola if Congo’s hospitals are sterile environs in which the virus cannot spread. Safety, then, is as much a local as international cause. In public health terms every city is a ‘sister city’ with every other metropolis on earth.”

What would it take to achieve true global health? Though an indepth discussion is beyond the scope of this book, the short answer is, again: sharp surveillance and response. Public health is essentially a rational, step-by-step process that applies to all outbreak investigations: define a problem, recognize it, find out what causes it, figure out how to control and prevent it. Health authorities need to be able to discern unusual clusters of disease, identify the cause of illness, track the geographic and demographic spread of an outbreak, estimate the magnitude of an infection, describe the natural history of a disease, list the factors behind an infection’s emergence, and measure the effectiveness of interventions. Often this logical series of events begins with the hunch of a single physician who senses something amiss. But it also depends on observation posts that actively look for specific diseases and disease syndromes. It depends on laboratories that can run molecular fingerprints to quickly connect the dots between seemingly unrelated cases. And it depends on swift communications networks that

alert far-flung health departments to potential outbreaks. In addition, governments must be willing to underwrite research on the biology and ecology of infectious diseases.

The United States has a long way to go to upgrade its own under-staffed, underequipped, and underfinanced federal, state, and local health departments. Improving public health globally is a much taller order of business. It will mean building sensitive monitoring systems in developing nations—and in many areas of Africa or India, where new infections are likely to originate and where they have historically gone undetected, it will mean first building the most basic health systems. Doctors and nurses around the world must be trained in the practical aspects of public health and be welcomed into an international network of health care colleagues. Independent laboratories and timely electronic reporting systems must operate free of government interference. Meanwhile, researchers must keep tabs on conditions such as altered habitats or large population movements that give rise to emerging infections. How close are we to approaching such a system, a kind of global Epidemic Intelligence Service akin to the CDC’s élite corps of disease detectives? According to one U.S. government estimate, at least ten years away. Others say that goal is wildly optimistic.

No one knows the promise and perils of achieving global health better than William Foege, MD. Bill Foege (pronounced fay'-gy) is a towering figure in public health, and not just because of his lanky 6foot, 7-inch frame. For the past 40 years, he has been at the center of action against many of the most important infections facing humankind and has helped shape national and international counteroffensives. Revered in the profession, Foege has combined practical vision with passionate humanity. His career offers clues not only to where we’ve been but where we must now go.

Son of a Lutheran minister, inspired as a teenager by the writings of theologian and physician Albert Schweitzer, Foege embarked on a medical mission to Nigeria in the 1960s. His assignment began with a disease that was not emerging but disappearing: smallpox. Campaigns to eradicate a single disease underscore the value of nations working cooperatively rather than separately, and this was doubly true during

ers in Marburg, West Germany, began suffering flulike symptoms, progressing to rash, acute diarrhea, painfully peeling skin, and eventually uncontrolled internal bleeding coupled with heart and brain damage. Within a week or two, they were dead. Marburg fever, as it came to be known, had sprung from contact with the African green monkeys shipped from Uganda for cell cultures to help prepare vaccines. So frightening was the epidemic, it prompted U.S. government officials to construct the first maximum containment lab at the CDC. Two years later, at a mission station in Lassa, Nigeria, an American nurse died of a strange malady that began with high fever and throat ulcers and ended with gastrointestinal hemorrhage. The nurse who cared for her died; her nurse, who was stricken but survived, was transported back home to the United States, where a Yale virologist studying the new agent became infected and desperately ill, and a Yale technician working on a separate floor died after being infected with the escaped agent. Lassa fever underscored the virulence and transportability of a previously unknown African virus—but it wasn’t the last shock from Africa. In 1976, a pair of hideous epidemics in Zaire and Sudan—marked by high fever, agonizing headache, vomiting and diarrhea, delirium, bleeding from every orifice, and in Zaire a 90 percent death rate—sent health officials scrambling. Ebola fever looked like a fictional Andromeda strain become real.

In 1977, Bill Foege became the CDC’s director. Despite the scares from abroad—news of which, unlike today, stayed within the small public health community—infectious disease in America seemed about to turn the corner. Foege had intended to apply the epidemiology and surveillance methods honed in infectious disease research to what appeared to be America’s next battle: chronic diseases fostered by lifestyle and the environment. But during his six years as director, new homegrown infections unreeled like a public health martial arts flick. Laboratory scientists had just identified the bacterium behind Legionnaires’ disease. In 1980, toxic shock syndrome appeared in menstruating women using extra-absorbent tampons. In 1981, scientists identified the bacterium behind Lyme disease. In 1982, a McDonald’s restaurant

in Oregon was ground zero for the first known E. coli O157:H7 epidemic.

The term “emerging infections” hadn’t yet been coined. “We called them new diseases, knowing they weren’t,” Foege says, “but they were new to us.” He suspected that these infections wouldn’t stay put, and his globalist convictions grew even stronger, in part because he had seen firsthand that infections new and old tend to become entrenched in poor and neglected parts of the world. Experts in other realms of public health harbored their own concerns about the potential for worldwide epidemics. Veterinarians had discovered weird new viruses in Africa and Central and South America that had jumped from animals to people. Military doctors had seen how hard it was to contain infections among troops stationed abroad. These practitioners at the front lines felt a mounting sense of unease that largely went ignored by the mainstream public health community.

In June 1981, the CDC’s Morbidity and Mortality Weekly Report, the tip-sheet known as MMWR, carried the now famous report of a rare pneumonia in gay men, the early rumblings of the acquired immunodeficiency syndrome, or AIDS, pandemic. At first, Foege thought the outbreak would fade. But every week brought alarming new data. “It was a steamroller that just got bigger and bigger,” he told one reporter. “There was nothing like it on this scale. You have to remember that there are not many things that are one hundred percent fatal beyond rabies. AIDS just did not follow the rules in any way.” The Reagan administration refused to adequately fund research. To compensate, Foege quietly shifted monies from other programs within CDC. In 1983, after the Republican administration refused to put warning labels on aspirin bottles despite CDC findings that aspirin can cause potentially fatal Reye’s syndrome in young children, Foege quit.

The Reagan White House’s indifference to AIDS seared into Foege’s brain the realization that every public health decision boils down to a political decision—and that to mold policy, public health experts must become adept in the ways of political influence. From 1984 to 1990, he created and led a partnership of United Nations agencies and nongovernmental organizations that raised worldwide

immunization levels from 20 percent to 80 percent for six major childhood diseases. From 1987 to 1992, he served as executive director of the Carter Center in Alanta, which mounted attacks on two African scourges, Guinea worm and river blindness. Here, too, he observed how public health is powered by politics. “President Carter had access to heads of state,” he says. “In a short meeting, you could end up getting a commitment that would bind the minister of health and the minister of finance and everyone else. This access allowed you to shortcut lots of things.”

But political commitment was scarce as AIDS continued to sweep around the world. No disease would better illustrate emerging pathogens’ global reach and the need for a coordinated response. Today, the United States has arrived at a kind of bleak truce with AIDS. About 40,000 Americans are annually infected with the human immunodeficiency virus, or HIV, which causes AIDS; each year, about 16,000 Americans die. Though the infection first struck white gay men disproportionately, it has since settled among minority populations, primarily blacks and Latinos. The last few years have also seen a resurgence in young gay men. By mid-2001, AIDS had killed more than 450,000 Americans and infected more than a million.

These numbers pale compared to the toll in the rest of the world. At the end of 2000, an estimated 36 million people worldwide were living with HIV, and nearly 22 million had died. Each year, 5.5 million people are newly infected with the virus: more than 10,000 a day. Ninetyfive percent of victims live in developing nations. In sub-Saharan Africa—where AIDS is the leading cause of death, and where three-quarters of global AIDS deaths occur— the numbers prefigure social

catastrophe. By 2010, life expectancy in Botswana will be 29; in Swaziland, 30; in South Africa, 36. And Africa is just the first great wave. By 2010, predicts a U.S. government National Intelligence Estimate, the number of HIV infections in Asia and the Pacific could easily surpass those in Africa. The Caribbean continues to suffer steep rates of infection. And in countries of the former Soviet Union, AIDS is spreading faster than anywhere else in the world, mostly through intravenous drug use. “There is nothing to suggest that HIV will plateau,” noted Nature in 2001, “or that it will not reach 1 billion cases before 2050.” A UN fact sheet starkly sums up the situation: “HIV will kill at least a third of the young men and women of countries where it has its firmest hold, and in some places up to two-thirds. Despite millennia of epidemics, wars and famine, never before in history have death rates of this magnitude been seen among young adults of both sexes and from all walks of life.” By 2020, the AIDS virus will have caused more deaths than any disease outbreak in history—including the Black Death in fourteenth-century Europe, which mowed down one-third of the population.

Another disease erupted in the wake of the AIDS pandemic: tuberculosis, the nineteenth-century “white plague.” The AIDS virus lowers resistance to infections and can ignite a latent case of TB into an active and contagious one. Today, more than two billion people—about a third of humanity—are infected with the TB bacillus, and each year two million die. The most menacing reservoir is Russia, where prisons—crowded, filthy, windowless—have become “pumps” for multidrug-resistant strains. What public health officials most fear are potentially untreatable TB strains that could emerge in Russia and Eastern Europe and race unchecked through the rest of the world, including the United States.

The great historic scourge malaria is another emerging infection, both because the mosquitoes that carry it resist pesticides and because the parasite itself is impervious to once-effective drugs. Over the last 25 years, the death rate of children with severe malaria in developing countries has not budged. Each year sees 300 to 500 million new malaria infections and one to three million deaths.

AIDS, TB, malaria: the top three infectious killers worldwide exemplify how poverty is a cauldron for disease. “The microbe is nothing; the terrain, everything,” Pasteur wrote. Today, one in five people globally resides in poverty. Outside the privileged domain of American affluence, people contend daily with malnourishment, tainted drinking water, untreated waste, and ramshackle housing. Consider subSaharan Africa, where only half of the children are vaccinated against diphtheria, polio, and tetanus; sex education is rare; doctors or nurses are in short supply, as are laboratories to analyze blood samples; and many villages lie miles from the nearest passable road—a knot of problems that public health officials dryly refer to as inadequate “infrastructure.” However it’s described, it’s a colossal barrier to disease prevention and treatment.

Poverty breeds compound infections and a vicious cycle of suffering. “It’s possible to list causes of death in Africa,” says Bill Foege. “But when a child dies of measles in West Africa, it in no way depicts the truth that that child was malnourished, that child also had malaria, probably had schistosomiasis and onchocerciasis and lymphatic filariasis and hookworms and roundworms and whipworms and repeated episodes of diarrhea. All of those things together allowed measles to be the final assault. We miss the point if we think that child had one disease. People in Africa with AIDS and tuberculosis—many of them were malnourished to start with. Many of them had malaria and all of the other parasites and STDs and so forth. So AIDS and tuberculosis come on top of that. When you look at combinations, you can’t discount the role of poverty and illiteracy and fatalism. It’s one big mess.”

This mess has prompted physician and anthropologist Paul Farmer to question the very concept of “emerging” infections. Tuberculosis, he points out, has always had its tentacles in poor people. Hemorrhagic fevers and malaria have long been quotidian dangers in tropical countries. Deadly respiratory and diarrheal infections are a fact of life in Africa and much of Asia and Latin America. Even Ebola, when it ventures out of hiding, tends to strike people who rely on subsistence agriculture, and is amplified in rural hospitals that practice substandard medicine. “If certain populations have long been afflicted by these

disorders,” Farmer writes, “why are the diseases considered ‘new’ or ‘emerging’? Is it simply because they have come to affect more visible—read, more ‘valuable’—persons?”

Traditionally, leaders in the West felt they had to fix the “hard” problems in poor countries—problems such as lagging economic development and totalitarian regimes—before they could look at issues such as disease, which seemed merely a secondary complication. As a result, the status of global health today is utterly depressing. Yet paradoxical as it may seem, the pragmatic Bill Foege feels more optimistic than ever about its prospects. With newly forged links between governments, philanthropies, and private industry, the planets seem to be aligning in an auspicious formation.

And Foege is once again at the center of action, as the senior global health adviser to the Bill & Melinda Gates Foundation. By pouring billions of dollars into global health in a few short years, the Gates Foundation has become a powerful catalyst for change, creating a newfound sense of urgency about the international health crisis and shaming governments into action. “This is unprecedented,” says Donald Hopkins, a Carter Center official and longtime public health leader, who has directed the worldwide campaign to eradicate Guinea worm. “Their flexibility and willingness to go where others haven’t gone and get there fast, and the amount of money they have at their disposal, is transforming the field. Fifty years from now, maybe other organizations and official donors—governments and international agencies—will see that the way the Gates Foundation attacked these problems is the way they should move.”

Not since the titanic era of Rockefeller, Carnegie, Morgan, and Ford has the United States witnessed such philanthropic largesse. The Microsoft founder’s commitment to global health began in 1998, when he donated $100 million to create a children’s vaccine program for respiratory and diarrheal infections, two of the biggest killers in developing countries. In 1999, the Gates Foundation donated $750 million to launch the Global Alliance for Vaccines and Immunizations, a coalition of international public health agencies, philanthropists, and drug

companies that will work together to develop and deliver not only childhood vaccines for poor countries, but also vaccines for HIV and malaria and an improved vaccine for tuberculosis. In 2000, the foundation spent more than $1 billion on health projects around the world. The next year, it pledged $100 million to a United Nations fund to stop AIDS, malaria, and TB.

The foundation has channeled most of its contributions to improving access to existing and newly developing medical technologies. It pushes the use of simple tools such as vaccines, nutritional supplements, contraceptives, and diagnostic tests. In doing so, it straddles the old “vertical vs. horizontal” argument in public health over which is the best way to use scarce resources in poor countries: focusing on a specific disease or upgrading the public health system in general. Today, with a plethora of cheap and effective interventions, the answer is: both. “Deliver what you can deliver,” Foege says, “and build the infrastructure as you’re doing it.”

The Gates’ generosity has partly stimulated, partly complemented, other commitments to stopping disease. Even before the Gates Foundation began making its mark, media entrepreneur Ted Turner pledged $1 billion to a United Nations fund promoting global public health. In 2001, the UN General Assembly approved an extraordinary “Declaration of Commitment,” outlining a worldwide campaign against AIDS. Late that same year, the World Health Organization teamed up with businessman George Soros to create a detailed $9.3 billion plan to reduce tuberculosis in countries hardest hit by the infection. The World Bank is exploring ways to convert debt relief to health grants, and has offered low-interest loans for HIV-related projects. The European Union and the G8 group of major industrialized nations are raising cash for health in developing nations. Coca-Cola, the largest private-sector employer in Africa, plans to use its fleet of trucks to distribute AIDS prevention and treatment literature and supplies to towns and villages where they are needed. Auto giant DaimlerChrysler will provide free AIDS drugs to help its South African employees and families combat the disease. Perhaps most important, current and

former heads of state—from UN secretary-general Kofi Annan to former U.S. president Jimmy Carter—are leading the charge.

Even the traditional holdouts are starting to come around. Drug companies have often been averse to making vaccines or treatments for diseases in nations where people can’t afford to pay (recent noble exceptions have included donated treatments for river blindness, lymphatic filariasis, and other diseases). These firms prefer to focus on ailments most prevalent in rich countries—as can be seen in the speedy commercialization of the Lyme disease vaccine, which has little use globally and is not even fully reliable here. “A corporation with stockholders can’t stoke up a laboratory that will focus on Third World diseases, because it will go broke,” Roy Vagelos, former CEO of Merck & Co., once observed. “That’s a social problem and industry shouldn’t be expected to solve it.” But the bottom line may be starting to shift. Merck has donated $50 million for a pilot project to improve care and treatment in AIDS-ravaged Botswana. Pfizer has pledged $11 million for an AIDS care center in Uganda, and has offered to provide an AIDS treatment drug free to developing countries. And though manufacturers have long argued that the production of generic AIDS drugs violates their patents, international pharmaceutical companies in 2001 decided to allow South Africa to import and sell generic versions of expensive AIDS treatments; India and Brazil are making their own nonbrand versions of AIDS drugs. And the Gates foundation is working with drug manufacturers and developing countries to speed promising AIDS vaccines into clinical trials; while the companies will be expected to provide the vaccine at low cost in poor countries, in the United States they will be able to charge whatever the market can bear. “In the long run,” says Barry Bloom, dean of the Harvard School of Public Health, “what’s in it for the pharmaceutical industry is to have developing countries develop health care infrastructure for delivering any kind of drug.”

“The landscape for international health has changed dramatically,” adds Dr. Gro Harlem Brundtland, director-general of WHO. But can the enthusiasm and goodwill last? Some scientists claim that the massive new funding for AIDS, TB, and malaria has siphoned research

money from other pressing diseases that are currently out of the limelight. Public health underwriting, they suggest, is still a zero-sum game. Others say this massive new infusion of money could go to waste if the programs they support don’t have clearcut and measurable targets in reducing disease. Yet others believe all this frenetic activity is just the new-scrubbed face of affluent nations’ timeless self-interest—an updated version of colonial powers’ desire to control tropical disease for their own motives. “Tie the needs of the poor with the fears of the rich,” Foege says. “When the rich lose their fear, they are not willing to invest in the problems of the poor.” Is the United States motivated to help Africa so that the continent will be a market for American products or a producer of cheap goods for America? Or is the American stake primarily political? In 2001, a report prepared by the International Crisis Group, an organization founded by former senator George Mitchell, warned that unless wealthy nations declare war on AIDS they will likely find themselves embroiled in conflicts fought by orphans in countries whose most productive adults died in the epidemic. According to one official in the group, “It’s like you’ve got an army waiting to be recruited for drugs, for crime, for militias.”

“Ideally, I would like people to understand that there is no other way—that we’re all so tied together globally that you have to think as a globalist,” Foege says. “But if people don’t believe that and for selfinterest reasons do the right thing, I’m pleased to accept that.”

Having started out as a medical missionary and ascended to the top of government agencies and having quit those for private foundations, Bill Foege has come to believe that each niche is only part of the solution. “The answer to health today and in the future is the development of coalitions,” he says. “They turn out to be more important than the formal structure. The health leader is not necessarily the director of WHO—it’s the person who could put together a proper coalition. We’re seeing public–private approaches to global health problems that we have not seen in the past. If you’re willing to think one hundred years in the future and ask, ‘What will people wish we had done?’ then you get a perspective of what global citizenship actually means.”

At the end of 2001, the suddenly magnified threat of bioterrorism

lent momentum to this process. As World Health Organization official J. W. Lee said of the newly unveiled global plan to combat tuberculosis, “Before September eleventh, many people thought that a nine billion dollar plan was impossible. But September eleventh proved money is not the issue. The issue is political will.” Added Jim Yong Kim, a Harvard University physician long involved in fighting disease in impoverished nations, “The fear we feel now with anthrax is what people in the developing countries, TB-endemic areas, have been feeling every single day.”

The price of not doing anything is incalculable—in part because we can’t see the future. When smallpox was officially declared eradicated in 1980, no one knew that the AIDS pandemic was already afoot. People infected with HIV can’t be vaccinated against smallpox because the vaccine decimates their weakened immune system. If smallpox hadn’t been wiped out just in time, AIDS would have ensured that it never could be.

Discovering a method that hastened the end of smallpox was one of Bill Foege’s great achievements. Yet when the WHO proudly announced that the disease was history, Foege felt no thrill. “When smallpox disappeared, I seemed to have none of the urge that a lot of people did to celebrate it. Not that I wasn’t pleased that this had happened. But somehow my greatest high, my greatest reward, was at the beginning when I mentally came to the conclusion this could be done.” Lately, Foege says, he has come to that conclusion about global health in general. Though it took 20 years for the AIDS pandemic to bring the world to its senses, Foege is convinced this heightened awareness won’t soon dissipate. “I feel that we have just ended the incubation period for global response,” Foege says. “Now the corner has been turned and people can never back off again. We’re going to look back and think the AIDS problem is what finally caused us to see disease as the surrogate for an alien invasion, which required that the whole world figure out how to get together and respond.”

Emerging infections are among the “thousand secret ties,” in the words of Victorian physician William Budd, that bind the world into an organic whole. In rich nations such as the United States, the need

for public health isn’t always self-evident, because its product is invisible: when it works right, nothing happens. But here and abroad, public health systems must operate with the same constancy and efficiency as microbial evolution itself. It may take the worst emerging infection of all time to stir us into preparing for the next.