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Garrett on Global Health - July 19, 2016

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July 19, 2016

Garrett on Global Health

Dear Friends and Colleagues,

America’s presidential primaries, also known as the American silly season, have ended, and we are now at the front end of what promises to be a bruising three-and-a-half-month battle between Republican Donald Trump and Democrat Hillary Clinton. Neither candidate is particularly popular among U.S. voters. A June poll found Trump with a -30 percent net favorability rate; Clinton fared only slightly better, at -19 percent favorability. Both parties are counting on their national conventions this month to boost support for their positions and platforms, if not their actual nominees.

In a prior Garrett on Global Health, I detailed the stances of the candidates on global health and development issues—neither Clinton nor Trump have said anything that appears to alter those positions. But we do have information about the running mate of at least one candidate.

On July 15, Donald Trump named Mike Pence, governor of Indiana, as vice president. Pence, a strong social conservative, leads a state that is politically dominated by the right wing of the Republican Party. He has overseen several controversial actions that have affected the health of Hoosiers, as residents of Indiana call themselves. In 2011, the state stripped Planned Parenthood of all financial support, not only for abortion and family planning, but also testing and treatment of sexually transmitted diseases (STDs). This left some rural areas without HIV testing clinics. In 2015, Pence signed the Religious Freedom Restoration Act, under which companies and employers could assert their "religious rights" to deny services or sales to lesbian, gay, bisexual, and transgender (LGBT) people and others whose behavior or "lifestyle" they found objectionable. The act was used by some businesses to ban clients who were in same-sex marriages, and by others to banish Muslims from their premises.

Twenty years previously, the Indiana legislature banned needle-exchange programs that aimed to prevent passage of hepatitis C and HIV among drug users who shared their syringes. By 2008, Indiana had witnessed a surge in illegal pharmaceutical opioid use, especially in rural areas. A year later, both hepatitis C and HIV rates started to soar in Indiana, and the toll of treatment costs rose. By early 2015, the combination of out-of-control opioid and heroin use, lack of HIV testing and STD treatment clinics, and religious objections to LGBT people and non-Christians had created an atmosphere of skyrocketing overdose deaths, HIV and hepatitis spread, and fear of seeking services among drug-using Hoosiers. When it was clear that Indiana had the highest incidence in the nation of new HIV infections, Governor Pence declared a state of emergency on March 25, which temporarily overturned the ban on needle exchanges, opened testing and treatment centers in every county, and ushered a bill through the legislature that granted civil rights to LGBT people in the state.

Since 2007, when he first sponsored a bill in the state legislature banning Planned Parenthood from Indiana, Pence has led the Republican Party’s attack on the organization. That issue is at the core of the standoff between congressional Republicans and the White House over the Obama administration’s requested $1.9 billion in funding for Zika prevention and research. After four months of squabbling, the GOP leadership offered the White House $1.1 billion, with a caveat in their bill that would ban all federal financial support for Planned Parenthood.

Under a law signed by Governor Pence this year, it is illegal in Indiana to have an abortion due to the diagnosed health or deformity of the fetus: it would be against the law to terminate a pregnancy in his state despite the mother’s known Zika infection and clear sonogram evidence of resulting fetal deformity.

Hillary Clinton has not at the time of this writing indicated who her running mate will be.


The Brexit Vote

The Leave victory in the June 23 referendum in the United Kingdom (UK) has shocked the entire world—seemingly including the leadership of the Brexit movement. The fallout of the decision has already been breathtaking, including a change of UK government, striking decline in the value of the pound sterling and UK gross national income (GNI), a rise in anti-immigrant assaults in the country, and calls for a second Scottish vote on its exit from the United Kingdom (perhaps a "Sexit"?). The divisions across the United Kingdom were stark, with England and Wales voting leave while Northern Ireland, London, and Scotland voted to maintain ties to the European Union—a divide Council on Foreign Relations (CFR) President Richard Haass predicts will lead to an independent Scotland and possible Northern Irish unification with Dublin. The divide was also starkly generational, with 73 percent of eighteen- to twenty-four-year-olds voting Remain, according to Lord Ashton Polls, compared to 60 percent of over-sixty-year-olds voting Leave.

The country’s scientists have been especially distressed about Brexit. They have seen great gains in both UK and European basic research and all fields of scientific inquiry as a direct result of EU collaboration. Students and postdocs have freely taken studies all over Europe, top British labs have drawn from the vast all-of-Europe talent pool, and freedom of movement has made it possible for researchers to hop on cheap flights from one laboratory to another.

Across the sciences and academia there has been a collective shudder since Brexit, and genuine concern that the principles of collaboration and open science are now threatened.

Considerably more worrying, in my opinion, is the impact augured by Britain’s withdrawal from Europe, coupled with new Prime Minister Theresa May’s cabinet appointments, for the future of global health, development, climate change efforts, and other initiatives that have generally risen in stature and funding during this century. The United Kingdom, under both Tony Blair’s and Gordon Brown’s Labor Party rule and David Cameron’s Tory leadership, has consistently played a vital leadership and financing role in all areas of global health, development, humanitarian response, peacekeeping, climate change adaptation and mitigation, and reform of the United Nations and other multilateral agencies. This profound commitment has crossed party lines in the United Kingdom, and spawned a parliamentary vote last year pledging the country to spend 0.7 percent of GNI annually on overseas development aid. The United Kingdom has distributed billions of pounds of aid since 2000 through EU mechanisms, as well as directly—bilaterally—through its cabinet-level aid agency, the Department for International Development (DFID).

It would be hard to overstate the importance and scale of London’s historic commitment to global health and development, both financially and as a leadership partner in the Group of Seven (G7), the EU Parliament, and through a range of UN channels. Alongside the U.S. government (under the administrations of Bill Clinton, George W. Bush, and Barack Obama) and the Bill & Melinda Gates Foundation, DFID has been an absolutely crucial political and financial force. I recently crunched the numbers and tried to unravel the complex web of DFID/UK/EU support for such institutions as the World Health Organization (WHO) and Oxfam to understand what is at stake.

Devaluation of the pound sterling has already affected everything from remittances send by UK-resident immigrants to their home countries to assessments leveraged on the United Kingdom for support of the joint UN Agency of HIV/AIDS and other multilateral agencies. The picture emerging is grim: more than $4 billion in remittances evaporated immediately after the Brexit vote, thanks to a drop in the value of the pound, and global agencies are nervously awaiting signals from London regarding Prime Minister May’s plans for funds that London currently passes through the European Union.

The day after my Brexit piece was published, May announced that Brexit leader and former Mayor of London Boris Johnson would be foreign minister, despite his often belligerent comments about other nations and their leaders. And then May named pro-Brexit conservative Priti Patel head of DFID—an agency she has called to eliminate.

Writing in the Telegraph three months ago, Johnson criticized the Cameron government’s foreign aid efforts: "The problem is that David Cameron made a commitment to spend 0.7 per cent of gross national income, come what may, and economic growth has grossly swelled the cash sum committed to aid. DFID has been compelled to spend it abroad—even when there have been crises at home that could have done with extra funds."

How this will ultimately sort out will be up to David Davis, May’s new secretary for exiting the European Union. A leader of the Brexit movement, Davis will now presumably negotiate London’s departure from the European Union, including pulling out of the union’s science, aid, and disaster relief agencies.

Meanwhile, Crises Galore Go Unfunded

Well before the Brexit vote crushed globalization dreams, the World Health Organization was on perilous financial ground. When the agency declared the Zika pandemic a public health emergency of international concern on February 1, Director-General Margaret Chan said WHO needed $26 million to fight the disease. Weeks later, when no Zika dollars had materialized, Chan moved $3.8 million from another WHO account into Zika efforts.

This spring, the Zika epidemic continued to expand (now actively spreading in forty-eight countries) and another crisis emerged: yellow fever. In the absence of adequate vaccine supplies, the WHO urgently called for more resources to combat yellow fever in Angola and Democratic Republic of Congo (DRC). In May, the World Health Assembly, the 194-nation legislative body of WHO, approved increased spending for both Zika and yellow fever, but did not agree to actually allot cash. Today, as a result, the WHO needs nearly $200 million, and is battling both epidemics, operating on fiscal fumes—or what I have dubbed "fairy dust."

The yellow fever outbreak is now the worst in three decades, and the WHO funding gap for yellow fever is $72 million. The gap for the International Federation of Red Cross and Red Crescent Societies is $1.4 million. Lacking sufficient vaccines and unable to lure manufacturers to the problem in the absence of financing, the WHO is diluting existing supplies fivefold, hoping to stretch them far enough to create a blanket of herd immunity across equatorial Africa. Médecins Sans Frontières (MSF), also known as Doctors Without Borders, has put out the alarm, warning that everyone should remain vigilant lest the African epidemic "explode" in coming weeks. As of July 15, Angola has reported 3,625 suspected cases with 357 deaths; the DRC reports 1,798 (a one-week jump from 1,307 cases) with 75 deaths. Both are certainly underreported, as yellow fever can be hard to distinguish from severe malaria and many of the hardest-hit areas lack health and laboratory facilities.

The "fairy dust" problem is part and parcel of a larger issue stemming from the 2014 Ebola epidemic—the lack of global capacity to respond to outbreak emergencies.

In June, the UN General Assembly held a high level meeting on HIV/AIDS. I chaired a UNAIDS meeting, "Addressing Global Health Emergencies: Lessons From AIDS to Ebola, Zika, and Other Emerging Epidemics," which involved an extraordinary panel. The YouTube video is good quality and worth watching.

Related to these issues is the election for the next director-general of the WHO—a process that has formally begun. CFR colleague Yanzhong Huang moderated a podcast with the Rockefeller Foundation’s Michael Myers and me, discussing what is at stake in this election, and why we share great concern about both the new selection process and its likely outcome.

Gauging the Zika Threat

Now that winter has come to Rio de Janeiro, the Zika incidence is dropping, and Brazil’s epidemic is declining—for now. Only fools could imagine that that the virus will disappear; it will certainly return with Amazon springtime.

A new study by Imperial College’s Neil Ferguson and colleagues posits that the Brazilian epidemic peaked in late March (with eight thousand new cases diagnosed each week) and is now waning (down in July to about two hundred diagnoses per week), but will cycle back for about three years before sufficient numbers of Latin Americans have been exposed to the virus and acquired immunity. Then, the study argues, Zika will disappear from Latin America without any further interventions by human beings. "Our analysis suggests that once the current epidemic is over, herd immunity will lead to a delay of at least a decade before large epidemics may recur," Ferguson’s group writes. "The current epidemic is not containable; at best, interventions can mitigate its health impacts. More optimistically, the natural dynamics of the epidemic are now likely to give a multiyear window to develop new interventions before further large-scale outbreaks occur."

I am not sure that I agree with the Ferguson assessment. It is predicated on important assumptions that determine the Ro (infectivity rate) and the Tg (time between outbreak generations)—critical elements of any epidemic calculus. Ferguson determines the Ro and Tg assuming that Zika remains a mosquito-carried virus for the coming years, only rarely passing from one person to another directly.

In a new paper published by, I argue that Zika may well become a sexually transmitted disease—not just a rare example of passage through intercourse, but a full-fledged STD like HIV/AIDS or syphilis. An STD outbreak would have completely different Ro and Tg numbers, with the rate of transmission, or how many people any single infected person might pass the virus to, entirely dependent on that person’s level of sexual activity; and the time between each outbreak generation being essentially zero, as human sex has no seasonality or moments of collective cessation.

The U.S. Centers for Disease Control and Prevention (CDC) shares concern that Zika might behave as an STD in the United States, and has a dashboard that tracks infected pregnant women, miscarriages, and newborn abnormalities. Without any evidence of infected mosquitoes in the United States yet, nine babies have been born with Zika-associated birth defects, and six women have miscarried. The agency is trying to get all pregnant women that might have been exposed to Zika, either sexually or as a result of traveling in endemic areas, to register so that a serious database can be built.

But, as I argue, congressional stalemates on Zika prevention and research funding have left the National Institutes of Health (NIH), the CDC, and research centers all over the country hamstrung, unable to pursue answers to vital questions regarding sexual transmission, damage to fetuses, diagnosis of such damage in utero, and likely long-term outcomes for infected newborns. Without such information, policymakers have no option but to recommend that women simply avoid getting pregnant until the Zika threat has passed. If Ferguson’s group is correct, deliberate pregnancy avoidance across the entire American hemisphere should remain in place until 2019. If his calculus is wrong, and if my fear that Zika is becoming an STD bears out, policymakers would be asking an entire generation of women to remain childless. Obviously, that is impossible.

The CDC is now carrying out an urgent investigation alongside Utah authorities because an elderly man who had travelled in a Zika-endemic area recently died of the disease—and now one of his family members has contracted Zika. According to a July 18 statement from the Utah Department of Health, “The new case is the eighth Utah resident to be diagnosed with Zika. Based on what is known now, the person has not recently traveled to an area with Zika and has not had sex with someone who is infected with Zika or who has traveled to an area with Zika. In addition, there is no evidence at this time that mosquitoes that commonly spread Zika (aedes species) virus are in Utah.” The Utah case presents the possibility of contact transmission via virally contaminated bodily fluids: tears, saliva, blood or urine.

The End of the Geneva Convention

Recently at the Council on Foreign Relations, I had the honor of moderating a session, "Losing Lives to Save Lives: Targeting Humanitarian Workers in Conflict Zones," featuring Jason Cone from MSF, Len Rubenstein from Johns Hopkins School of Medicine, and Yves Daccord, director-general of the International Committee of the Red Cross. A transcript can be read or the session can be viewed here.

Health-care workers, hospitals, humanitarian relief convoys, food shipments, refugees, and journalists are, with horrifying frequency, coming under attack by militias, terrorists, and, most alarmingly, national governments. The WHO is now tracking attacks on health workers and facilities, listing 959 murders in 2014–15. Rubenstein and colleagues from multiple institutions recently released a report demonstrating state-ordered targeting of health facilities in nineteen countries, with the worst actions taken by Syria’s Bashar al-Assad regime. No party has been prosecuted for war crimes, having targeted health-care facilities, doctors, nurses, or patients.

CRISPR and Beyond

The revolution in synthetic biology is so extraordinary that the speed, ease, and declining cost of genetic sequencing and manipulation has far outpaced Moore’s Law for declining cost and increasing power in computers. There is serious discussion now of making a human genome, entirely synthetic—a prospect rife with ethical concern. Recently, CFR member Rob Nichols moderated a discussion, "Biotechnology: The Potential and Perils of Innovation," with Stanford University’s Drew Endy, Merck’s Julie Gerberding, and me—available as both a transcript and video.

Endy asked, "How do we transition our civilization from living on Earth to living with Earth? And what is the role of advanced biology and biotechnology in navigating and realizing that transition?"

I asserted: "Now we have this massive cybersecurity crisis, where nobody in the world feels like their data is secure, that their very personality, their very thoughts are accessible, whether it’s to their own government or to some hacker somewhere out there, or to a foreign government. And so we’re squarely in the realm of all aspects national security. And I think this biology revolution is taking the genome to the place where the cyber has been. It’ll have different dimensions, but it’s similarly so diffuse and distributed across so many national boundaries and involves so many different legal systems that essentially it’s beyond regulation."

Gerberding added, "I totally agree that we need a system of risk assessment and of the rulebook, so to speak, that applies globally, although I also believe that’s going to be a very hard energy to harness."

The online tech site Gizmodo just published its top ten list of future prospects "that should scare the hell out of you." The number one threat:

"1. Virtually anyone will be able to create their own pandemic

Earlier this year, Oxford’s Global Priorities Project compiled a list of catastrophes that could kill off 10 percent or more of the human population. High on the list was a deliberately engineered pandemic, and the authors warned that it could happen in as few as five years.

Many of the technologies for this prospect are starting to appear, including the CRISPR/cas9 gene-editing system and 3D-bioprinters. What’s more, the blueprints for this kind of destruction are being made available. A decade ago, futurist Ray Kurzweil and technologist Bill Joy scolded the US Department of Health for publishing the full genome of the 1918 influenza virus, calling it "extremely foolish." More recently, a number of scientists spoke out when Nature decided to publish a so-called "gain of function" study explaining how the bird flu could be mutated into something even deadlier.

The fear is that a rogue state, terrorist group, or a malign individual might create their own virus and unleash it. Natural selection is good at creating nasty and highly prolific viruses, but imagine what intentional design could concoct."

I hope Gizmodo is paranoid.

As always, I will keep you informed about these and other global health events of special interest.



Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations

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