13 December 2016

Biodefense and the next presidency

Laura H. Kahn

How US president-elect Donald Trump will act on many policy matters is still a mystery—sometimes, it even seems, to the man himself. Beyond promising to get “better deals” and  “drain the swamp” in Washington, he didn’t offer much policy detail during his campaign, and rarely if ever touched on the critical issue of biodefense. Nor did he delve into food security or health issues as they relate to national security.

Ignoring these challenges, however, won’t make them any less urgent. As he chooses advisors and policies, the incoming president has an opportunity to make the United States safer against biological threats. Should he opt to do so, there are five priorities he will need to focus on: biotechnology research oversight, antimicrobial resistance, food security, emerging zoonotic diseases, and public health preparedness. As a major supporter of biotechnology research and home to many institutions and companies in the field, the United States has a strong interest in ensuring that this work does not cause harm, as well as a global responsibility to exert leadership that limits the dangers.

Biotechnology research oversight. Biotechnology research involves the study of cellular components, cells, and microbes such as bacteria, viruses, and fungi in order to develop new technologies intended to benefit humanity. Because this research involves living organisms, which are not entirely predictable, the work comes with inherent risks and unintended consequences, requiring stringent oversight in safety, security, and professional ethics.

As a party to the Biological Weapons Convention (BWC) and a participant in regular review conferences, Washington has at times shown leadership in this area, but has also taken actions that have worried the international community and undermined confidence that it is serious about banning biological weapons.

For example, following the anthrax attacks of 2001, in which letters laced with anthrax spores killed five people and sickened 17, the George W. Bush administration implemented biological threat assessment studies that raised global concerns. As part of the studies, researchers created deadly pathogens that could potentially be used as bioweapons, a practice rationalized as necessary to discover what weapons an enemy could be inventing and develop medical countermeasures. Previously, the Clinton administration had conducted mostly transparent but sometimes classified biological threat assessment work. The Bush administration increased the classified work and rejected a draft protocol, six years in the making, to strengthen the BWC with mandatory inspections and declarations. It also expanded the number of high-containment laboratories working on dangerous microbes. This increased the number of accidents involving lethal microbes, a problem that continues to this day. In 2014 and 2015, there occurred multiple lapses in laboratory safety that potentially threatened public health; a March 2016 report from the US Government Accountability Office highlighted the inadequate oversight of high-containment laboratories.

Another area requiring good governance and monitoring is dual-use scientific research, or that which can be used for either good or malevolent purposes. For example, researchers can now easily edit genes using CRISPR-Cas9 technology, altering not only individual organisms but their progeny as well. This could offer tremendous benefits in terms of solving health problems, like reducing the burden of mosquito-borne diseases. But gene editing could also introduce unpredictable and irreversible harm into ecosystems, for example by introducing altered genes into unintended species or increasing the population of one species at the expense of another, ultimately making matters worse for humans. As such, research and implementation of this and other dual-use biotechnology should be carefully monitored.

So-called “gain-of-function” studies, meanwhile, also pose an ethical quandary. They enhance certain capabilities in microbes, such as transmissibility and lethality. The scientists doing the work say it enables them to identify microbes with the potential to cause pandemics, but many biosecurity experts see no legitimate purpose for gain-of-function studies, which could end up releasing deadly new pathogens on human populations.

These areas of research can be made safer—for the United States and the world—if the biotechnology community and government authorities emphasize research transparency, safety standards and protocols, codes of conduct, and ethical standards for all researchers.

Antimicrobial resistance. Antibiotics are the foundation of modern medicine. Without safe and effective antibiotics, many of the treatments that we take for granted such as elective surgeries and cancer chemotherapy would not be possible because the risk of infection would be too great. Unfortunately, as microbes emerge that are impervious to antibiotics, many previously treatable infections are becoming lethal once again.

Modern agriculture, which uses antibiotics to treat disease and encourage growth in livestock, depends on antibiotics as much as modern medicine. Raising hundreds if not thousands of animals together increases disease risks, but stringent sanitation and hygiene on farms should reduce the need for antibiotics. There has been a blame game going on between the fields of medicine and agriculture as to who is more at fault for the rise of antimicrobial resistance. In fact, the relationship is quite complicated, with new findings emerging all the time. For instance (as I write in One Health and the Politics of Antimicrobial Resistance), in Europe a strain of the bacterium Enterococcus faecium resistant to the antibiotic vancomycin (called VRE, for vancomycin-resistant Enterococcus) emerged in human populations in the late 1980s. Denmark relied heavily on the antibiotic avoparcin, which is closely related to vancomycin, in its food animal production, especially pigs. After the country banned avoparcin in 1995, VRE declined by 90 percent in pigs and poultry—but the rate of VRE among humans in Danish hospitals inexplicably increased.

The point is, while antibiotic resistance is an enormous potential danger facing humanity, vastly more research is required to understand and hopefully prevent it. Research into antimicrobial resistance and new antibacterial treatments must be a national priority.

Food security. Agriculture and food security are the foundation of civilization. Climate change is the greatest threat to food security, so in one sense, Trump did touch on food security in his presidential campaign, by denying that human-caused climate change exists. Unfortunately the head-in-the-sand approach will not make it go away. Farmers need a stable, predictable climate to know when to plant seeds and when to harvest. Climate change increases the impact of droughts, which can have terrible ecological and socioeconomic consequences in the United States and elsewhere. Given that climate change threatens the US agriculture and food industries, it would be surprising if companies in these sectors did not join forces with environmental groups to demand that the Trump administration take this existential threat seriously and address it.

When food security disappears, civil society breaks down. The Syrian civil war was preceded by three years of devastating drought that led to crop failures. As more countries face diminished food security with a warming climate, we can anticipate more wars and refugees fleeing to less-affected nations, prompting further xenophobic backlashes.

The second-greatest threat to food security is disease, which can be caused by natural or man-made forces. Currently, the US federal government is building the National Bio and Agro-Defense Facility in Manhattan, Kansas, replacing New York’s Plum Island Animal Disease Center, moving research of deadly livestock diseases to the middle of livestock country. This is a big mistake, as even with the best biosafety policies and oversight, accidents happen. The smartest move would be to halt construction and reassess the location of the laboratory.

More generally, research on preventing microbes that threaten the food supply is vital—and should be conducted in laboratories far from farms to reduce the dangers of accidents or breaches.

Emerging zoonotic diseases. Zoonotic diseases are animal ailments that can affect humans. Many deadly illnesses—like Ebola, Nipah, MERS, SARS, avian influenza, and some that are still emerging—are either direct or indirect results of humanity’s quest for meat and other animal proteins. Deforestation to clear land for farms contributes to the emergence of new human diseases because displaced wildlife, in particular bats, harbor some of the world’s deadliest viruses. And as humans encroach into forests to hunt, consuming wild animals like bats and monkeys leads to disease transmission.

The question is: Can we feed ourselves sustainably in a warming climate without destroying the natural world and unleashing deadly diseases onto ourselves?

Our current strategy, if one can call it that, is to conduct surveillance and put out the “fires”—new disease outbreaks—when they appear. This approach relies on robust medical and public health infrastructures, which do not exist everywhere—even within the United States. That brings me to my final topic.

Public health preparedness. In the preamble to the US Constitution, the authors included “…promote the general Welfare…” as part of the government’s responsibility. Health is certainly necessary for general welfare, and requires access to healthcare. Doctors and nurses are the eyes and ears of public health surveillance, but their effectiveness depends upon whether they are available. If someone doesn’t have access to healthcare, but has a deadly, communicable disease, then the risk of an outbreak spreading unchecked increases.

During the Ebola outbreak in West Africa in 2014, a poor Liberian showed up at a Texas emergency room with a non-specific fever. He was given antibiotics and sent home, and ultimately died of Ebola. Fortunately this incident didn’t lead to a widespread Ebola outbreak in Texas, but it’s the kind of thing that could.

Obamacare may have its faults, but one thing it does right is provide millions of Americans with health insurance who would not have it otherwise. From a public health perspective, access to healthcare is absolutely critical for pandemic preparedness. During the election, candidate Trump repeatedly stated that Obamacare was a “disaster” and should be repealed. More recently, president-elect Trump announced that he might keep parts of the Affordable Care Act. It’s hard to know what he believes or wants to do. But one thing is clear: If he repeals it, and we get hit with a deadly pandemic, the public should hold him and the Republican Congress accountable. Better to avoid that outcome, and keep in place a system that ensures more Americans have access to doctors. The health of the nation literally depends on it.