The NEW ENGLAND JOURNAL of MEDICINE

Perspective April 1, 2021

A HALF-CENTURY OF PROGRESS IN HEALTH: THE NATIONAL ACADEMY OF MEDICINE AT 50 Emerging Infectious Diseases — Learning from the Past and Looking to the Future Christopher Elias, M.D., M.P.H., John N. Nkengasong, Ph.D., and Firdausi Qadri, Ph.D.​​

Emerging Infectious Diseases ince the start of the 20th century, there have AIDS, Tuberculosis, and , been substantial reductions in deaths from as well as to the U.S. president’s AIDS and malaria initiatives. Sinfectious diseases in high-income countries. These efforts are as vital as ever, In the United States, infectious disease mortality fell since health inequities are ubiqui- tous and all countries face new from about 800 per 100,000 peo- than 40%. now stands threats, including antimicrobial ple in 1900 (accounting for near- on the brink of eradication. resistance. As Covid-19 has made ly 50% of all deaths) to 50 per Many factors account for this clear, emerging infectious diseas- 100,000 people in 1950 (account- remarkable progress, including in- es also present important chal- ing for about 6% of deaths).1 creased investment in health sys- lenges for global health security, Over the past three decades, tems and infra- and the same conditions that a similar transformation has oc- structure; improvements in the have fueled broad-based gains in curred in low- and middle-income prevention, diagnosis, and treat- health and wealth — including countries (LMICs) in Asia and sub- ment of infection; and the devel- increased trade, travel, and labor Saharan Africa. As opment and distribution of safe migration — have made humans coverage of children increased to and effective (see time- increasingly vulnerable to pan- 80% worldwide, deaths among line). Much of the credit for scal- demics. children younger than 5 years of ing up global access to lifesaving In recent decades, previously age in these countries decreased interventions belongs to multi- isolated zoonotic have by more than 50%. Global ma- lateral organizations and partner- regularly infected and been trans- ternal mortality has also dropped ships such as the World Health mitted between humans, and by nearly 50% during this peri- Organization (WHO); UNICEF; some have spread rapidly among od, deaths from malaria have de- Gavi, the Alliance; the people and across borders. Be- creased by 60%, and the HIV in- Global Eradication Initiative; tween 1980 and 2017, outbreaks fection rate has fallen by more and the Global Fund to Fight of more than two dozen such

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diseases were reported worldwide.2 1961–1975: Seventh cholera takes place Years before the emergence of 1960s 1968–1970: 1968 influenza (H3N2) pandemic (the third influenza pandemic Covid-19, many observers cited a of the 20th century) takes place growing risk of a once-in-a-cen- 1980s 1976: Ebola is first detected in what is now the Democratic Republic of Congo tury pandemic caused by a fast- 1981: The AIDS is first recognized in the United States moving . The National Acad- emy of Medicine (NAM, formerly known as the Institute of Medi- cine) has long worked to raise 1992: Cholera , caused by a new serogroup of Vibrio cholerae, emerge awareness of emerging infectious in the Bay of Bengal diseases, including by means of its Forum on Microbial Threats, launched in 1996, and the Com- 1990s mission on a Global Health Risk Framework for the Future, con- 1996: The IOM hosts the Forum on Microbial Threats vened in response to the 2014– 1997: FluNet, a Web-based influenza surveillance tool, is launched by the WHO 2016 Ebola virus outbreak in West Africa.3 Given other acute needs, however, it proved difficult to 1999: The WHO publishes its first pandemic planning framework sustain public attention, political Nipah virus is first detected in and Singapore will, and funding in the area of pandemic preparedness, even af-

2002: The Global Fund to Fight AIDS, Tuberculosis, and Malaria is launched ter the Ebola outbreak demon- as an international financing and partnership organization strated the extent to which the 2003: SARS is discovered in Asia and spreads to more than two dozen countries world was unprepared to respond PEPFAR is launched to address the pandemic of HIV/AIDS 2000s to a transnational health emer- 4 2005: The International Health Regulations (IHR) are revised to clarify the responsibilities gency. of countries and the role of the WHO in declaring and managing a Public Health One important response to the Emergency of International Concern The U.S. government’s National Strategy for Pandemic Influenza is published Ebola crisis was the creation of the Coalition for Epidemic Pre- 2007: The AVMA establishes the One Health Initiative task force and the AMA calls for increased collaboration between human and veterinary medical communities paredness Innovations (CEPI) in 2016. CEPI was designed as a 2009: The H1N1 swine flu pandemic, first detected in North America, prompts the first public–private partnership to ac- activation of provisions under the IHR celerate the discovery and devel- 2012: MERS coronavirus is first detected in Saudi Arabia opment of “just-in-case” vaccines against known pathogens such as 2014: The WHO reports the first cases of Ebola virus disease in , part of what would become the largest Ebola epidemic in history Ebola, Nipah virus, Middle East 2015: Zika virus is detected in Brazil 2016: The WHO declares a Public Health Emergency of International Concern for the Selected Events Related to Emerging Zika virus Infectious Diseases and Pandemic 2010s The NAM convenes the Commission on a Global Health Risk Framework Preparedness during the Past 60 Years. for the Future The WHO R&D Blueprint, a global strategy and preparedness plan, is announced AMA denotes the American Medical Asso- The UN secretary-general forms the Global Health Crises Task Force ciation, AVMA the American Veterinary 2017: The Coalition for Epidemic Preparedness Innovations is launched to stimulate and Medical Association, IOM the Institute accelerate the development of vaccines against emerging infectious diseases of Medicine, MERS Middle East respira- and to enable access during outbreaks tory syndrome, NAM the National Acad- 2018: The WHO and the World Bank Group establish the Global Preparedness emy of Medicine, NASEM the National Monitoring Board Academies of Sciences, Engineering, 2019: The first human cases of Covid-19 are reported in and Medicine, PEPFAR the President’s 2020s 2020: A NASEM committee develops an overarching framework for vaccine allocation Emergency Plan for AIDS Relief, SARS to assist policymakers in planning for equitable allocation of Covid-19 vaccines severe acute respiratory syndrome, UN 2021: Global distribution of Covid-19 vaccines begins the United Nations, and WHO the World Health Organization.

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respiratory syndrome, and SARS. and response seriously.”5 In re- peutics required to end the acute Innovative vaccine-development flecting on lessons from Covid-19, phase of . In this case, platforms supported by CEPI — the board noted that conventional the most important market fail- including messenger RNA (mRNA) standards for national pandemic ure has been the lack of access to and DNA constructs — were preparedness — such as having vaccines in LMICs. The discon- used to quickly develop vaccines strong disease-detection capacity, nect between the existence of against Covid-19 and could be well-funded public health sys- global public goods and industry mobilized in the future to pro- tems, and the ability to safely incentives to deliver such goods duce just-in-time vaccines against treat and isolate infected people must be bridged; doing so will newly discovered pathogens. CEPI’s — failed to predict how coun- require innovative public–private greatest challenge has involved tries would fare during a major partnerships. needing to rely on a pass-the-hat outbreak. When national leaders As world leaders develop strat- type of funding strategy, rather ignored public health guidance egies for ending the Covid-19 than having appropriate funding and residents proved unwilling pandemic, we believe they should secured before an emergency. Al- to adapt their behavior to reduce abandon the cyclical phases of though many high-income coun- risk, Covid-19 inci- “panic and neglect” that have tries have provided financial sup- dence spiked. characterized reactions to health port for vaccine research and Another important lesson out- emergencies. Instead, leaders development, major donors such lined in the 2020 report is that should commit to a new frame- as the United States remained out- planning for future pandemics work of prevention, detection, and side the coalition until recently. should include stakeholders out- response. Such an approach would A second important step was side the health sector. The severe involve focusing more resources the launch of the Global Prepared- effects of Covid-19 on national on detecting emerging zoonotic ness Monitoring Board (GPMB) economies and household in- threats and finding and contain- by the WHO and the World Bank comes demonstrate the degree to ing these threats while they are Group in 2018 in response to rec- which countries must be willing localized and manageable. ommendations from the United to mobilize emergency funding Implementing this type of ini- Nations secretary-general’s Global to mitigate financial shocks and tiative would require strengthen- Health Crises Task Force. Com- deliver social protection to peo- ing national, regional, and global posed of political leaders, multi- ple who are most at risk of seri- institutions and scaling up devel- lateral agency heads, and scien- ous health outcomes or impover- opment of the public health work- tific experts, the GPMB was ishment because of social and force, including increasing the established to appraise the steps economic disruption. As the GPMB number of community health care required to prepare the world to described, pandemic preparedness workers. Such efforts would bol- respond quickly and decisively should move from being a re- ster surveillance systems, enable to global health emergencies. The sponsibility financed and led by countries to report threats early, board issued its first set of rec- health ministries to one that is and help countries respond quick- ommendations in a 2019 report, prioritized by finance ministers ly — which they were unable to A World at Risk, then updated these and involves all affected sectors do for Covid-19. recommendations in its 2020 re- as part of a government-wide ap- As part of these efforts, we port, A World in Disorder.5 Despite proach. Under such a strategy, need robust research-and-devel- positive steps by CEPI and the budgets for preparedness would opment capacity that can be rap- GPMB, the Covid-19 pandemic ar- increase at least 10-fold and non- idly activated on a global scale. rived before global leaders could health sectors would have an ex- Private-sector producers must have fully act on these recommenda- plicit stake in national readiness. adequate financial guarantees tions. The speed with which the phar- from governments to reduce the In the 2020 report, the co- maceutical industry responded to risks associated with investing in chairs of the GPMB wrote, “The the Covid-19 pandemic empha- pandemic preparedness and re- Covid-19 pandemic has revealed sizes its capacity to develop and sponse, and preclinical and clini- a collective failure to take pan- scale up manufacturing of the cal research capacity should be demic prevention, preparedness vaccines, diagnostics, and thera- developed at both the national

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and regional levels in LMICs. We an average of $5 per person From the Bill and Melinda Gates Founda- tion, Seattle (C.E.); the Africa Centres for also need broadly distributed sites worldwide each year. In compari- Disease Control and Prevention, Addis Ababa, for manufacturing products to son, economists estimate that the (J.N.N.); and the International Cen- meet global needs and regulatory world has already spent more than tre for Diarrhoeal Disease Research, Dhaka, (F.Q.). systems that are prepared to pro- $11 trillion fighting Covid-19 and vide emergency approval of new that the pandemic will exact an- This article was published on March 27, 2021, products and ensure their rational other $10 trillion in lost future at NEJM.org.

allocation by prioritizing distri- earnings. The NAM will continue 1. Hansen V, Oren E, Dennis LK, Brown bution to regions where products to play an important role in these HE. Infectious disease mortality trends in can be most effective in stopping debates. Recently, for example, the the United States, 1980-2014. JAMA 2016;​ 5 316:2149-51.​ progression of a pandemic. National Academies of Sciences, 2. Ndow G, Ambe JR, Tomori O. Emerging Finally, in an era of nearly Engineering, and Medicine pub- infectious diseases:​ a historical and scientific limitless digital potential, we can lished a consensus study report, review. Socio-cultural Dimensions of Emerg- ing Infectious Diseases in Africa 2019;​31-40. harness the tools of the informa- Framework for Equitable Allocation of 3. National Academies of Sciences, Engi- tion age to share essential data Covid-19 Vaccine. neering, and Medicine. Global health risk for detecting new pathogens, We believe it’s time for world framework:​ resilient and sustainable health systems to respond to global infectious dis- accelerating product leaders to heed warning signs, An audio interview ease outbreaks:​ workshop summary. Wash- with Dr. Elias is development, and en- abandon half-measures, and com- ington, DC: ​The National Academies Press, 2016 (https://doi​.­org/​­10​.­17226/​­21856). available at NEJM.org hancing pandemic re- mit to the global system we need 4. Institute of Medicine. Emerging viral sponse efforts. Coun- to respond to the ever-present diseases:​ the one health connection:​ work- tries should work together to danger of emerging infectious dis- shop summary. Washington, DC:​ The Na- break down barriers to data shar- eases. We simply cannot afford tional Academies Press, 2015 (https://doi​.­org/​ ­10​.­17226/​­18975). ing while taking steps to protect the alternative. 5. Global Preparedness Monitoring Board. privacy and prevent misuse. A world in disorder: Global Preparedness The annual cost of making The series editors are Victor J. Dzau, M.D., Monitoring Board annual report 2020. Gene- va:​ World Health Organization, 2020 (https:// these investments would be bil- Harvey V. Fineberg, M.D., Ph.D., Kenneth I. Shine, M.D., Samuel O. Thier, M.D., Debra apps.​ who­ .​ int/­ gpmb/​­ assets/​­ annual_report/​­ ​ lions of dollars. The GPMB has Malina, Ph.D., and Stephen Morrissey, Ph.D. GPMB_AR_2020_EN­ .​ pdf).­ reported that adequate investment Disclosure forms provided by the authors DOI: 10.1056/NEJMp2034517

in preparedness would require are available at NEJM.org. CopyrightEmerging Infectious Diseases © 2021 Massachusetts Medical Society.

Ensuring That LGBTQI+ People Count

Ensuring That LGBTQI+ People Count — Collecting Data on Sexual Orientation, Gender Identity, and Intersex Status Kellan E. Baker, Ph.D., M.P.H., Carl G. Streed, Jr., M.D., M.P.H., and Laura E. Durso, Ph.D.​​

ost national surveys in the outlined in a comprehensive new and well-being whose contours MUnited States, including the report on LGBTQI+ populations we have mapped, the widespread decennial census, do not collect from the National Academies of lack of comprehensive data col- demographic data on sexual orien- Sciences, Engineering, and Medi- lection means that many more tation, gender identity, or inter- cine, the data that do exist point disparities — and the policy and sex status. As a result, despite to epidemics of depression, sub- programmatic interventions that improvements in the social and stance use, HIV infection, violence, might address them — remain legal standing of lesbian, gay, bi- homelessness, and other adverse unknown. sexual, transgender, queer, inter- outcomes driven by the discrim- Data are fundamentally politi- sex, and other sexual and gender- ination and social and econom- cal: decisions about which data diverse (LGBTQI+) populations, ic marginalization that many are collected and which are over- many simple facts about these LGBTQI+ people continue to ex- looked both reflect and shape communities remain elusive. As perience.1 For every gap in health policy and program priorities. At

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