How to confront emerging pathogens

Outbreaks of emerging pathogens, whether natural or manmade, are not just health issues. They present challenges along several other dimensions—legal, political, economic, and military. Improved disease surveillance is at the heart of meeting many of these challenges.

Disease surveillance entails gathering information about the current and past prevalence of diseases in specific countries and regions and provides context necessary for understanding new disease outbreaks and determining, among other things, if they are natural or manmade. Such information is gathered, for the most part, by national health organizations, which forward it to entities such as the World Health Organization, the Pan American Health Organization, and the Centers for Disease Control and Prevention. There, information is compiled into databases and published. But it's not always good information.

I have worked closely with disease statistics for more than a decade. Sadly, I have found that information about disease prevalence, whether in the developed or developing worlds, often contains discrepancies. For example, Argentina, Brazil, and Bolivia were reporting cases of dengue fever some years ago at a time when Paraguay was not. From a geographical and disease-transmission perspective, this was impossible. The discrepancy was not resolved until Paraguay provided updated numbers.

Faulty disease statistics are quite troubling in a world where international travel is easy and controls on passenger health are loose. They are troubling because urbanization has created very poor areas where crowding, inadequate hygiene, and low-nutrition diets allow diseases to flourish. Inaccurate statistics also represent a major impediment to national initiatives in both public health and defense. If you cannot say with confidence which diseases exist in your country, how can you develop a strategic plan to fight disease? How can you gauge the impact of diseases on your population? How can you prevent malevolent individuals from doing harm with deadly pathogens? Better data about the prevalence of disease are also essential for helping researchers perform their jobs more effectively and fulfilling commitments to instruments such as the Biological and Toxin Weapons Convention. If more effective systems for disease surveillance are to be established, improvements are necessary in two main areas: the legal and institutional realm, and the educational realm.

An international legal and institutional framework already exists for emerging diseases, comprising a health component and a weapons component. On the health side, the World Health Organization oversees efforts to combat many diseases. On the weapons side, the Biological and Toxin Weapons Convention, the Geneva Protocol, and the Australia Group (an informal export-control entity) are intended to inhibit the development of biological weapons. But there is considerable overlap between the two realms—for example, yellow fever and dengue fever are relevant both to the health side and the weapons side. This leads to much duplicated effort, as individuals and institutions responsible for disease reporting often must report data to multiple entities. Thus the odds increase that data discrepancies will appear. These problems could be remedied if international health and weapons institutions came to regard disease surveillance as a natural point of contact between their respective endeavors.

But no matter how close the coordination might be between health-oriented and weapons-oriented organizations, data on disease outbreaks will remain flawed if—as is often the case—local health professionals lack the education and training they need to fulfill their duties in disease surveillance. Nations and individual health professionals sometimes lack the ability to identify diseases. Sometimes they don't clearly understand which diseases to report, or whether to report individual cases or only major outbreaks. They may be unsure whether to report all cases or only fatalities. And there may be confusion about whether reports should be filed yearly, monthly, or whenever a worrisome event occurs.

The good news is that these problems can be resolved through improved education for health professionals and officials. The bad news is that little is being done at the international or national levels to improve education. Entities such as the World Health Organization should develop educational programs to address these problems, monitor their performance, and coordinate their efforts with related national initiatives. But bottom-up efforts can also be useful. For example, the University of Bradford has developed excellent tools that can be used to train health care professionals on issues such as reporting data to the Biological and Toxin Weapons Convention. Creating a world safer from emerging pathogens requires that players at all levels—from municipal to national governments, and from regional organizations to global ones—do their part to improve systems for disease surveillance and reporting.

Pathogens do not respect borders. Efforts to control outbreaks of disease—including those caused by emerging pathogens, whether natural or manmade—require that local and national responses be synchronized and that mechanisms for international cooperation be established. At both the national and international levels, scientists play an important role.

Scientists, because of their engagement with pathogens in daily research and their immersion in the literature that surrounds them, are well positioned to act as an early warning system for disease outbreaks. Their involvement in, and endorsement of, measures for biosafety, biosecurity, and dual-use control are vital to confronting the threats posed by emerging pathogens. ("Biosafety," in simple terms, refers to preventing unintentional exposure to pathogens, or their unintentional release. "Biosecurity" means protecting pathogens from theft, loss, or diversion. "Dual-use" research is legitimate research that could be misused to threaten public health or national security.)

In their role as a first line of defense, scientists often find themselves enthusiastically embraced by those who care about pathogen control. But serious questions surround the education that scientists receive in the ethics of biosafety, biosecurity, and dual-use research, and in associated standards for responsibility, professionalism, and good conduct. Ethics education often fails to prepare scientists to meet the expectations that are placed on them, and indeed numerous studies indicate that ethics education, on a global level, remains patchy and unstandardized. Until international ethics education becomes more comprehensive, it is difficult to see how scientists can be cast with real confidence as first-line defenders.

Ethics education for scientists must be focused so that scientists can see value in the topics under discussion—that is, ethics education requires buy-in from the scientists. Without buy-in, ethics education can aspire to little more than providing scientists with information about the risks associated with biosafety, biosecurity, and dual-use issues. It cannot encourage scientists to engage in critical reflection about the misuse of research and to practice ethical decision making.

Getting buy-in from scientists is not so difficult when it comes to biosafety. The biosafety risks associated with research, and scientists' responsibility to address these risks, are a fairly straightforward and generally manageable element of the ethics curriculum. But making scientists properly aware of security risks—whether these risks fall into the biosecurity or the dual-use category—is a far more complicated process. Scientists often perceive these risks as quite removed from their daily research practices (and in most cases there is little that scientists can actually do to reduce the risk that their work will be misused). If scientists are presented with responsibility for reducing risks that they perceive as unfounded, the efficacy of ethics education can be severely undermined. Thus ethics education must walk a fine line—encouraging ethical decision making and critical reflection without exaggerating the security risks inherent in research.

Low- and middle-income countries often suffer from a persistent lack of formalized ethics education. The majority of the ethics education that scientists receive in these nations is made available because funding requirements or collaboration agreements require that it be provided (or else it comes in the form of online courses). Scientists therefore receive ethics education that is highly generalized—or, if specific, is specific to the research context of a high-income country. These decontextualized ethics initiatives often discuss types of research that are outside the national research remit of low- or middle-income countries—and scientists often struggle to see the point in discussing risks that fall outside their frames of reference. Moreover, highly visible problems such as poor health care provision may overshadow security concerns in low- or middle-income countries, further complicating ethics education.

Another problem facing education initiatives in low- and middle-income countries is that these nations do not have, nor are they likely to develop soon, comprehensive structures allowing scientists to report concerns about biosafety, biosecurity, and dual-use issues. Such structures in wealthier nations may not be perfect, and they remain the subject of considerable discussion, but they do exist. So those involved in ethics education must be very careful not to present developing-world scientists with responsibilities that they have no way of fulfilling. Initiatives in ethics education must strike the right balance between responsibility and risk; otherwise, scientists will see biosecurity and dual-use issues as simply not pertinent to their research.

An important step toward confronting the threat of emerging pathogens is to develop improved educational approaches for life science ethics. As such approaches are developed, it must be continually reiterated that one size cannot fit all—any successful model for ethics education must contend with issues such as the cultural environment in which the model is to be applied and the practicalities of specific research environments. (Then again, the international harmonization of ethics education is an important issue in its own right.) Until ethics education can overcome such challenges, it will be very difficult to establish an international community of scientists—scientists appropriately aware of biosafety, biosecurity, and dual-use issues—who truly can act as a united first line of defense against emerging pathogens.

Governments and scientific communities in the developed world devote considerable attention and study to the emergence and re-emergence of pathogens. But in resource-constrained countries, this is often not the case. Africa is a region especially prone to outbreaks of the diseases naturally transmitted between vertebrate animals and humans (zoonotic diseases); these include Ebola, Rift Valley Fever, and plague. All countries in the region are at risk from these diseases, and cross-border outbreaks are frequent. But African nations are often characterized by a failure or inability to effectively address the emergence of new diseases or the re-emergence of endemic ones.

Several reasons for this stand out. Africa's systems for disease surveillance are weak and laboratory support is poor, making it difficult to produce data needed for assessing disease burdens and responding with appropriate priorities. When good information is unavailable, the emergence of new pathogens is often met with denial—until a disease outbreak reaches epidemic proportions. Once an epidemic is under way, an affected country is invaded by international health agencies, but they operate in panic and crisis-response mode, and their efforts amount to too little, too late. Pathogen outbreaks ultimately become opportunities for foreign researchers and health agencies to fine-tune their skills, leaving scientists in resource-poor countries permanently dependent on outsiders—reduced to mere sample collectors, unable to control the next pathogen outbreak on their own.

How can these challenges be overcome? The first step involves focusing on local processes of pathogen emergence. Pathogens emerge under widely varying environmental, demographic, and socioeconomic circumstances. A pathogen's ability to emerge or re-emerge depends on factors including genetic changes or adaptation in the pathogen itself; environmental conditions associated with climate, economic development, and land use patterns; and issues related to pathogens' human hosts, including demographics, international trade patterns, misuse of antibiotics, people's occupational exposure, the neglect of public health services, and bioterrorism. These factors and conditions interact differently in different parts of the world—therefore, the first step toward preventing and controlling outbreaks of emerging and re-emerging diseases is to gain a thorough understanding of local processes of pathogen emergence. Once such an understanding is gained, governments, institutions, and professionals—especially in the developing world—must commit themselves to clearly defined, proactive roles in the fight against emerging and re-emerging diseases.

At the national level, in particular, it is essential that each country take "ownership" of systems for disease surveillance, prevention, and control; this allows country-specific response measures to be formulated. Taking ownership of these systems entails making a genuine political commitment to them, and requires that adequate resources, financial and human, be provided for disease surveillance and for laboratory support systems. It is crucial that nations maintain systems capable of detecting, identifying, and containing pathogens that have epidemic potential before they spread too widely.

For governments, taking a proactive role in combating disease also entails implementing appropriate emergency response plans; coordinating collaborative interactions between human and veterinary health surveillance systems; building and sustaining the disease-fighting capacity of local health personnel by providing them training, opportunities to update their skills, and an empowering work environment; and establishing a multidisciplinary approach to disease control, one that allows individuals from diverse fields to bring their expertise to bear on the control of emerging or re-emerging diseases. (Engagement from the private sector, for example, ought to be forthcoming because disease outbreaks threaten everyone's economic security.)

Making the world safer from emerging and re-emerging pathogens also requires a great deal of global collaboration. Nations should collaboratively implement policies, for example, that control pathogens' ability to spread via modern transportation systems. They should participate in regional surveillance and response activities. They should share real-time surveillance information in order to detect zoonotic diseases in animal populations before they appear in human populations. Meanwhile, researchers all over the world should collaborate to strengthen surveillance of human populations that are at high risk of contracting zoonotic diseases. Science-based nongovernmental organizations, because of their wide geographic reach and their field expertise, should be engaged as partners to help provide comprehensive surveillance and response capabilities. Meanwhile, innovative mechanisms could be established that would ensure adequate funding for sustain­able global disease surveillance systems. The struggle against emerging and re-emerging disease is a complex and difficult challenge that requires full-scale effort at both the national and international levels.