2006 Keynote Luncheon
Health, Security, and Globalization: A Dangerous Nexus?
This event is part of the 17th Annual Summer Symposium for Graduate Students In International Affairs. It is sponsored by WIIS with support from Booz Allen Hamilton and the MacArthur Foundation.
Monday, June 12, 2006
Time: 12:00 - 1:30 pm
Location: Root Room, Carnegie Endowment for International Peace, 1779 Massachusetts Avenue, NW, Washington, DC
Cost: $25 for WIIS members; $40 for non-members
Keynote Speaker: Dr. Margaret Hamburg
Margaret A. Hamburg, M.D. is a senior scientist at the Nuclear Threat Initiative (NTI)/Health and Security Initiative in Washington, D.C. NTI is a charitable organization working to reduce the global threats from nuclear, biological, and chemical weapons. Dr. Hamburg began her service with NTI as the founding Vice President for Biological Threats, developing the strategic plan and grant-making portfolio in that area, as well as the creation of the Global Health and Security Initiative to address the broad range of biological threats to health. Before joining NTI, Dr. Hamburg was the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, which includes the role of principal policy advisor to the Secretary. Prior to this, she served for almost six years as the Commissioner of Health for the City of New York. Dr. Hamburg’s accomplishments in that role included the creation of the first public health bioterrorism preparedness program in the nation. She completed her internship and residency in Internal Medicine at the New York Hospital/Cornell University Medical Center and is certified by the American Board of Internal Medicine. She is a graduate of Harvard/Radcliffe College and Harvard Medical School. Dr. Hamburg currently serves on the Harvard College Board of Overseers. She has been elected to membership in the Institute of Medicine, the New York Academy of Medicine, the Council on Foreign Relations, and is a Fellow of the American Association of the Advancement of Science and of the American College of Physicians. She serves on numerous advisory boards and committees, including the Central Intelligence Agency’s Intelligence Science Board, the U.S. Secretary of Health and Human Services’ Council on Public Health Preparedness, and is a member of the Scientific Advisory Committee of the Communicable Disease Surveillance and Response Department of the World Health Organization.
Remarks by Margaret Hamburg, M.D.
I am very pleased to be here, and to have this chance to talk with such an interesting and dynamic group of women about a topic that is very close to my heart: health, security and globalization. This is an important and timely topic…and it is still a relatively new issue in terms of professional dialogue and discourse among policymakers.
For some reason, there has been a long-standing assumption that health and security were two non-overlapping categories of threat: security threats, which are the concern of military and law enforcement specialists, along with experts in diplomacy, and health threats, which are the province of medical professionals and public health officials. The two sets of experts had very little in common. They did not know each other and they didn’t feel they needed to. Their interests, duties and expertise did not seem to intersect.
But in fact this was a false dichotomy. For as far back as recorded history, health and security have intersected in important and far-reaching ways. Looking across the span of civilizations, plagues have killed far more than the toll of battle, and disease pandemics have lead to panic, riots and economic collapse. They have undermined armies; they have destabilized, crippled and even toppled governments. Even using the strictest definition of a security threat, I think one can argue that health threats can and do represent very real and pressing security concerns.
Moreover, as you all well know, the complex, rapidly transforming and often dangerous world we now live in necessitates new ways of thinking about security. New demands and new realities require broadened thinking about what security means and how to achieve it. It is not a coincidence –although I am frankly amazed--that the G-8 summit next week in St. Petersburg, Russia will be addressing infectious disease threats as among its top two priorities. And today’s lunch gives us a wonderful opportunity to take up this issue as well.
The nexus between global health, science and security reveals itself in many ways. I want to talk today about three critical and related domains of activity: First: emerging infections and microbial threats to health; second, the intentional use of biological agents to do harm—particularly biological terrorism; and lastly, the potential uses for science and health as a bridge to a safer world.
Just a few decades ago, there was enormous optimism that the threat of infectious diseases was receding. Scientific and technologic advances, including the development of antibiotics and vaccines, along with improved hygiene, sanitation and vector control enabled the prevention and control of many infectious diseases, particularly in the industrialized world. Many, including a Surgeon General of the United States in testimony to Congress, ventured to say that we could soon “close the book” on infectious diseases. Back then, smallpox was on the verge of eradication, and health officials had targeted measles, malaria, polio and other diseases for elimination as powerful drugs and vaccines were readied to defeat microbial foes. When I began medical school in the late 1970s, we were told that the future of medicine was chronic disease.
However, today we know that such optimism was premature. It did not take into account many critical factors such as:
• the extraordinary increases in international travel, immigration and trade;
• the movement of people into urban settings—many into mega cities, living in shantytowns— where opportunities for disease spread are amplified through crowding, along with poor sanitation and hygiene;
• changing agricultural practices and environmental manipulations that alter disease vectors as well as opportunities for exposure;
• the continuing difficulties of translating existing medical knowledge and tools into action for all who need it, whether because of inadequate resources, ignorance or complacency;
• and, of course, the extraordinary resilience and adaptability of the microbes themselves
As we enter the 21st century, infectious diseases continue to burden populations around the globe. Infectious diseases are responsible for one in every two deaths in developing countries and are the leading cause of death for children and young adults. AIDS, TB and malaria alone cause some half a billion illnesses each year and take the lives of at least six million. It has been estimated that every hour, 1,500 people die from an infectious disease—over half of them are children under 5 years of age. The burden of infectious disease is, of course, greatest in the developing world but extends across all nations and into all communities.
As New York City’s Health Commisioner during the decade of the 90’s I had a chance to experience this first hand. It was a veritable smorgasbord of biological concerns…old disease, new disease, imported disease -- we had it all. We watched new disease emerge and take hold -- HIV/AIDS being the most startling and disturbing, but problems like Legionnaire’s or Lyme disease are examples of diseases that are now part of the landscape, but were unknown just a decade before. I found myself spending huge amounts of time and effort dealing with a disease that in medical school I learned about as being of historical interest only, TB, which had resurged in epidemic proportions and often in new and more dangerous forms because of the development of drug-resistance. Other serious forms of drug-resistant disease as well, which represents an increasingly serious problem worldwide, sometimes rendering a once treatable disease incurable.
Similarly, we saw gains made against sexually transmitted diseases slow or reverse in certain populations. Also, we have seen old diseases that have emerged in new geographic regions, such as West Nile in the United States or hanta virus pulmonary syndrome or malaria. In addition, many diseases once thought unrelated to infectious disease are now known to be the result of chronic infections. Many such examples come from the realm of cancer, such as human papilloma virus and cervical cancer, or liver cancer and hepatitis B and C, but also things like ulcers and coronary heart disease. What is more, we live in an era when we must think seriously about the potential for intentional use of biological agents as weapons to do harm, possibly even with genetically engineered organisms produced to enhance their lethality or infectivity.
Undeniably, diseases with epidemic potential are realities of the modern world. Many were stunned by the sudden appearance of SARS and how quickly it spread around the world, afflicting multiple countries in 2003. Today we watch nervously as the highly pathogenic avian flu (H5N1) makes its way progressively across countries, arising first in Southeast Asia, and in Europe and Africa. But we should not be that surprised. Today’s high-speed international travel, expansive global commerce, environmental degradation and dramatic shifts in population into urban centers are just a few of the multiple factors that lead to the emergence and resurgence of infectious disease. In the words of Dr. Joshua Lederburg, “One could hardly have created a better-calculated recipe for a tinderbox…We have never been more vulnerable…Infection knows no national boundaries, and we will pay dearly if we ignore the smoldering of infection anywhere”
This lesson has not always been obvious, and sometimes it takes a while to sink in. Back in 1994, when I was Health Commissioner in New York and Giuliani was Mayor, I remember an incident that involved an outbreak of a plague in Surat, India. It was a pneumonic form that – like SARS or flu-- could be spread person to person with relative ease. We were worried that, with international travel, someone infected with the plague could slip into our urban center, go unrecognized and untreated, and spark a serious outbreak of disease. We knew just how explosive such things could be, and we were especially worried because there was a major Indian festival being celebrated and it was a time when one might expect more travel between India and the large Indian communities of our city.
So, naturally, we took some precautionary steps. I called over to City Hall and offered to brief them on the situation. Some staffer in the Mayor’s office sent me back a terse message saying, “We don’t need your briefing about something happening in India; we can read the papers.” I sent a message back asking if they were aware that more than 30 flights a day came into JFK Airport with passengers from India. Shortly thereafter, the phone rang in my office, with Mayor Giuliani on the other end asking if we should shut down Kennedy airport. That was not exactly the solution, but he had gotten the message. He understood that a disease in a remote part of the world could be in our backyard tomorrow.
Today headlines scream about the potential threat of avian flu. Experts have long worried about the next flu pandemic—a worldwide outbreak of disease caused by human-to human transmission of a flu viruses like H5N1 (or so-called avian flu) or another variation of the flu virus. Most would say that it is a question of when, not if, although it has certainly taken a long while to get policymakers and the public to take this issue seriously. As a senior official in the Clinton Administration I tried to get FEMA engaged in the planning we were doing to prepare for pandemic flu. They simply said “no….we don’t do disease epidemics…they aren’t real disasters…we do things like hurricanes.” That response wasn’t too reassuring—then or now. We did persuade FEMA to participate in a tabletop exercise with a scenario modeled on a flu epidemic similar in nature to that seen in 1918 (Spanish Flu). It quickly became obvious that whether they liked it or not, a disease outbreak of that kind would constitute a natural disaster requiring their involvement…big time!
The 1918 flu infected half the world and between 40 and 50 million people died. Flu pandemics tend to occur in cycles, and they can vary considerably in intensity depending on the flu strain involved. The other two flu pandemics of the last century—in 1957 and in 1968—were less severe. If H5N1 were to modify into a form with rapid human-to-human transmissible spread, we cannot predict the exact numbers, but we know that it would sicken and claim human lives at levels beyond anything we have experienced in our lifetimes and would disrupt society and the economy here at home and on a global level in an unprecedented way. Obviously we must do everything we can to prevent such a circumstance from unfolding and prepare the most effective response possible should it occur. This will require a massive effort across agencies of government, levels of government and sectors of society. As President Bush is reported to have said, we do not want a “Bio-Katrina.”
Much activity is now underway, and much, much more remains to be done. What are some of the elements that need to be in place if we are to better protect against the threat of pandemic flu as well as the other biological threats before us?
First of all let me stress, the best defense against any infectious disease outbreak is a robust and global system for public health—both its science and its practice. Broad-based strategies to improve our ability to prevent, detect, and control emerging, as well as resurging, microbial threats to health will be, in the long run, among the most effective approaches to improve our defense against biological events, whatever their origin. As current events once again underscore, several critical elements must be urgently addressed. First, we must dramatically improve capacity for global disease surveillance and reporting, linked to a rapid investigation and response capability, including adequate and appropriate diagnostic laboratory capacity. We must also strengthen institutional public health capacity, from the local to the global level, as well as integrated and functioning systems for health care delivery, whether in the context of routine or catastrophic events. Future preparedness will also depend on a well educated and trained clinical and public health workforce.
Furthermore, a key to future disease prevention and health protection is a sound research agenda addressing near and longer term requirements for new insights into the nature of infectious disease threats, human host responses, and the opportunities to develop new diagnostics, drugs and vaccines. Current events also remind us of the need to examine the role and use of age-old public health measures such as travel restrictions, isolation, quarantine and even such basics as hand-washing and hygiene. And beyond simply research, we desperately need to develop new and innovative strategies to more fully engage the private sector—both the pharmaceutical industry and the health care system --in the drug development and delivery process, as well as in strategies for care. And of course, the public must be partners in all we do, for they are critical players in a crisis, and valuable advocates to ensure that we do the right things before a crisis occurs.
Given our significant and growing vulnerabilities, markedly greater attention and resources must be devoted toward these problems. We must understand that pathogens—old and new—are endlessly resourceful in adapting to and breaching our defenses. We must also understand that factors relating to society, the environment, and our increasing global interconnectedness actually enhance the likelihood of disease emergence and spread. Moreover, it is a sad reality that today we must also grapple with the intentional use of biological agents to do harm, human against human. The magnitude and urgency of the situation demand renewed commitment, and we must recognize that effective strategies will require greater coordination and cooperation with partners around the globe. Without question, we must work now to create systems that really work so that we can more effectively prevent or protect against the infectious disease threats before us, whether it is mother nature or an act of bioterrorism
I want to turn now to the topic of bioweapons and bioterrorism—always a great thing to talk about over lunch—for these issues represent an important illustration of the nexus of science, security and globalization, and in my view, a very real and growing threat. For a long time, bioterrorism was thought to be the stuff of science fiction. Few took the threat of terrorism in this country very seriously, and especially not the possibility of biological agents being intentionally released to cause widespread panic, disruption, disease and death. Few are so complacent today. World events have forced the realization that neither technical barriers nor moral repugnance will protect us from their use. In the near term, “conventional” attacks such as bombs may remain the most likely mode of terrorism, yet there are many reasons to believe that biological agents may be an increasingly attractive approach.
Certainly, they can produce large numbers of casualties, potentially on a scale to devastate whole cities, regions and possibly the entire nation and beyond. Even without large numbers, attacks with biological agents—especially covert ones—can produce enormous disruption, feelings of vulnerability and possibly panic and terror as people struggle to understand who is at risk and what can be done. Outbreaks with contagious diseases, that spread person to person, are especially frightening.
Truth is, probably no single terrorist attack, no matter how horrifying and catastrophic, could threaten the very stability of our society and institutions in the way that biological weapons could…. except, perhaps, for a nuclear attack. Yet compared to nuclear weapons, biological weapons are relatively inexpensive and easy to produce, and significant damage can be done even in the absence of large quantities of material or an elaborate delivery mechanism. What is more, information about how to obtain and prepare bioweapons is increasingly available through the internet, the open scientific literature and other sources. Also, opportunities for access to dangerous pathogens can be fairly routine; certain of these organisms are commonly found in nature, as well as legitimately studied in government, academic and industry labs. Furthermore, bioweapons facilities can be hidden within routine research laboratories or pharmaceutical manufacturing sites.
And we must recognize that while extraordinary advances in modern biology offer great hope to improve health and prevent disease, they also offer the tools -- through malevolence, misapplication or sheer inadvertence -- to create new and more dangerous organisms, as well as improved mechanisms for delivery. Overall, the reality is that access to the materials and know-how to produce potentially very serious biological threats becomes easier and more sophisticated every day. This has profound implications for both national security and for science.
As we mobilize to respond to the threat of bioterrorism, it should be recognized that biological warfare is not new. Documented attacks date back centuries, including the catapulting of plague victims over the city walls during the Tatar siege of Kaffa, or the “gifts” of smallpox contaminated blankets to Native Americans during the French and Indian War. Modern history confirms that biological weapons were explored by many nations, although most programs were officially terminated with the Biological Weapons Convention (BWC) treaty, developed in 1972 and now ratified by more than 140 nations. The BWC prohibits the possession, stockpiling or use of biological weapons, although it contains no provisions for monitoring, inspection and enforcement.
But these days it is not state programs that really worry us. We know that today terrorist groups are working hard to get these weapons. Osama bin Laden is reported to have described it as “a religious duty.” Disturbingly, a recent confidential report by a UN Panel of Experts said that the only thing holding back Al Qaeda from using biological weapons is its lack of technical know-how. Yet, we know that the knowledge and tools to produce and deliver biological agents as weapons are becoming more and more accessible and available, all over the world.
There’s an old quote that my mother had up on the refrigerator when I was growing up. You all have probably heard it. It was a quote from Margaret Mead, the renowned anthropologist. It read, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
When I was growing up, I saw only the positive side of that quote. Now I see the darker side. Today, smaller and smaller groups—often living in remote places-- can do bigger and bigger damage. The entire nature of terrorism has grown more deadly. Former CIA Director James Woolsey has said that terrorists used to be seeking a place at the table; now they want to blow up the table. Recently, one extremist Muslim cleric chillingly told a U.S. newspaper: “we don’t want to change your mind, we want to destroy you.”
In theory, a wide range of biological agents could be intentionally used to cause harm. With advances in biomedical science, including synthetic biology, recombinant DNA techniques, genomics and the like, the possibilities get much greater. The explosion of knowledge about the fundamental building blocks of life—and how to manipulate them—gives new understandings of staggering and unpredictable power. Along with this comes the global spread of expertise and equipment to support biotechnology and biological manufacturing processes. All of this is changing the research and development landscape in the life sciences, but also raises new concerns about the potential for harm, either through deliberate misuse or inadvertence.
This is all very frightening, and from a security perspective the natural reaction is to try to figure out how to limit the kinds of research that may be misused and distorted in these damaging ways. Yet it is quickly apparent that while the potential for misapplication is resoundingly real, this same research holds great potential for good and, in fact, may be essential to the development of the new medicines, vaccines, and technologies needed to counter bioterrorism, as well as to protect against naturally occurring disease.
As it turns out, it is very difficult—if not impossible-- to define dangerous science and it is certainly impossible to monitor all aspects of research that might have destructive applications. So the challenge must be seen, not as how to stop the advance of dangerous science, but how to constrain the misapplication of scientific knowledge and capability without damaging the advancement of science.
There are no easy or complete solutions, but there are ways to approach this problem. Strategies will not mirror traditional approaches to arms control. It will require new systems of governance, and it will require individual, community and government driven strategies. Science is at once the practice and product of individual scientists, and the outgrowth of scientist-to-scientist collaborations. It is an inherently global enterprise. Important life sciences research today is as likely to occur in a private biotech company or in an academic lab, as in a government facility. An effective approach cannot reflect a model based solely on top down government regulations and legal requirements; nor can international treaties solve the problem. Meaningful solutions will require the full engagement of the scientific community, and will require a mix of strategies, including legal regulations, professional standards and codes of conduct, international guidelines and agreements, and a fundamental shift in awareness and accountability about how science is done, the so-called “ethos of science.”
I have talked mainly about the dark side of modern science. But we are in a race. The magnitude of the bioterrorism threat—and the power of the science that surrounds it—compels us to better harness the extraordinary talents and capabilities of the bioscience world for good, and to get out in front for our protection and biodefense, and it is true for naturally occurring diseases as it is for bioterrorism.
Certainly, as we teeter on the brink of the next pandemic of influenza, we are painfully aware that we do not have the tools to effectively cope. We have inadequate supplies of vaccine and antiviral drugs, an antiquated vaccine methodology, huge gaps in national preparedness and planning, and even bigger gaps when you look to preparedness efforts on a global scale.
As we take stock of our prospects with respect to microbial threats in the years ahead, we must recognize the need for a new level of attention, dedication, and sustained resources to ensure the health and safety of this nation, and of the world. We must make this a fundamental pillar of our security and an essential element of our foreign affairs agenda.
And as I come to the end, I want to make one last point. As a relative newcomer to the world of international relations, foreign affairs, development, and international security, I have been surprised by how often health is left out of the conversation in important ways and how often true health or science expertise is missing from the table when decisions are made that either directly or indirectly impact these issues.
For example, health is widely understood to be a goal of development, an important outcome of development aid. Yet it is only recently that the importance of health in promoting economic development and poverty reduction has begun to be appreciated.
It is widely recognized that health – or rather disease, disability, and death -- is an outcome of war and violent conflict, yet the potential importance of investing in health and health programs to help reduce conditions that may foster conflict, violence, and war has not been adequately explored.
In addressing the threat of terrorism, the recent 9/11 Commission and others have looked at the causes and conditions that may foster terrorism and allow it to take hold. An array of factors have been cited. The 9/11 Commission outlined an “Agenda of Opportunity” to make a difference in changing the environment in which terrorism breeds, noting such things as education, social programs, and institution building – all good things – but they forgot about health.
Certainly, a lot of different strategies and domains of professional activity will have to be brought to bear if we are to make a difference in responding to the many challenges that confront us with respect to international relations and security today. But, as a health professional, I have a certain bias. In our complex world, I think health may have a special role to play as a mechanism for constructive engagement and as a tool of diplomacy:
First, health is a shared value. It is deeply important to people around the world. A survey conducted by the Pew Research Center in 2002 (but likely no less relevant today) showed that people in a majority of countries – both developed and developing – listed health as one of their top two concerns. They cited infectious diseases more than any other threat (including war and terrorism), as the world’s greatest danger.
Secondly, health interventions can make an immediate impact on people’s lives, as well as having long-term benefits. They can inspire trust and confidence, and a sense that someone cares.
When done correctly, it is non-ideological; health care doesn’t carry with it the same political, emotional, and ideological charge that education or social welfare programs may in certain parts of the world (although it can be made ideological and unfortunately the Bush administration has shown us how).
I suspect that most of us would agree that health is more than just the absence of disease and that health is a key building block to well being, prosperity, and productivity in any society. Health is a concern for all nations, and international collaborative health programs can serve as a valuable pathway to new hope and opportunity in communities impoverished of hope, as well as a bridge to new trust and partnership among communities or nations formerly at odds. On both a group and a governmental level, programs designed to address health issues can open avenues of communication between people who have major disagreements in other areas.
We have witnessed the unifying power of health when conflicts have been stopped in order to allow vaccination campaigns to move forward – the so-called “days of tranquility.” We have also seen the tensions and suspicions that arise between nations when unexpected serious outbreaks of disease occur, or, as in Iraq today, we can see how the presence of health problems both reflects and exacerbates serious issues of infrastructure breakdown, social instability and loss of hope.
While health programs certainly represent an intrinsic good, they may also help foster broader foreign policy and diplomatic goals in important and sometimes unique ways. They may help in:
• reducing regional tensions/conflict
• strengthening cooperation at the community level
• strengthening working relationships between national governments.
• Promoting social stability and economic progress.
• Maybe they could even help foster cooperation and peace.
All things considered, for a relatively manageable investment, a global partnership of developing and developed countries committed to improving health would make a huge difference, both to health but also more broadly.
We all know that there is no “magic bullet.” It is going to take a long time and a lot of work to improve the current world situation, but in a world fraught with tragedy, war, terror, danger, and disease, we have an extraordinary opportunity to lead with strength – not military – but through biomedical science and health. And if we do so, we can truly make the world a safer place for all.
Thank you.