CHAPTER 21

Battle Plan for Survival

“Before I draw nearer to that stone to which you point,” said Scrooge, “answer me one question. Are these the shadows of the things that Will be, or are they shadows of things that May be, only?”

Still the Ghost pointed downward to the grave by which it stood.

“Men’s courses will foreshadow certain ends, to which, if persevered in, they must lead,” said Scrooge. “But if the courses be departed from, the ends will change. Say it is thus with what you show me!”

—CHARLES DICKENS, A Christmas Carol

We have no illusions about what is likely to be accomplished on our Crisis Agenda in a world divided on so many levels. But we also have no illusions about what must be done if we are to make our world a safer and healthier place for our children and grandchildren, where pandemics do not threaten our way of life on every level imaginable, where infections caused by drug-resistant microbes do not kill for lack of an effective treatment, where drinking water does not become a vehicle of death, and where the emergence of new infectious diseases does not become a public health crisis because we are not prepared to rapidly stop them. If we do not do what we collectively need to do, the shadows of things that may be are almost certain to become the harsh reality of what will be.

With this book, we have intended to present the face of infectious disease in the modern world. We have tried to connect as many dots as possible, especially from science to policy. Moving toward our conclusion, we’ve surveyed the ideas and observations of some of the best minds in public health and public policy. I have used all the lessons that I have learned from my forty-plus years of fighting to prevent and control infectious diseases. This final chapter lays out, in order of priority, what we must do to alter the otherwise catastrophic potential of infectious diseases on humans and animals.

To review, our greatest threats are:

1. Pathogens of pandemic potential, which essentially means influenza and the downstream effects of antimicrobial resistance.

2. Pathogens of critical regional importance, which include Ebola, coronaviruses like SARS and MERS, other viruses such as Lassa and Nipah, and Aedes-transmitted diseases such as dengue, yellow fever, and Zika.

3. Bioterrorism and dual-use research of concern (DURC), and gain-of-function research of concern (GOFRC).

4. Endemic diseases that continue to have a major impact on the world’s health, particularly among emerging nations, including malaria, tuberculosis, AIDS, viral hepatitis, childhood diarrheal diseases, and bacterial pneumonia.

We must consider these threats within the context of certain factors. The most critical of these are climate change, availability of water for drinking and irrigation, global governance and fragile state status, economic disparity, and the ongoing struggle to empower women.

We address these four threats with a nine-point Crisis Agenda. We provide specific program recommendations that largely have not been addressed by the federal government, public health organizations, or even recent formal reviews of the global public health response to the West African Ebola epidemic.

These priorities are listed in order of importance, that is, their potential impact on overall global public health and early, avoidable death.

The Crisis Agenda

Priority 1: Create a Manhattan Project–like program to secure a game-changing influenza vaccine and vaccinate the world.

The single most consequential action that we can take to limit, and possibly even prevent, a catastrophic global influenza pandemic is to develop a game-changing influenza vaccine and vaccinate the world’s population. This is scientifically attainable, though the CCIVI report concluded that only the US government has the necessary infrastructure and resources. We need only the creative imagination of our best scientists, the visionary support of our policy leaders, the technological and financial commitment, and the necessary project-management structure. We would hope other national governments, philanthropic organizations, vaccine manufacturers, and the WHO would readily join the effort. Our best guess is that we would need to invest $1 billion per year for seven to ten years to make this happen. This is about what we currently invest each year in HIV vaccine research, and I believe we’d have a greater chance of the influenza vaccine working. Vaccinating most of the world before another catastrophic pandemic has a chance to begin could save more lives in just a few months than all the emergency rooms in the United States have done in the last fifty years.

Priority 2: Establish an international organization to urgently address all aspects of antimicrobial resistance.

The Intergovernmental Panel on Climate Change (IPCC) was created in 1988 by the World Meteorological Organization and the United Nations Environment Program “to prepare, based on available scientific information, assessments on all aspects of climate change and its impacts, with a view of formulating realistic response strategies.” Since then, the IPCC has served as the scientific authority and moral conscience of all aspects of climate change capably. We must have a similar model for antimicrobial resistance. Like climate change, it is a global crisis in that no one country or region of the world can solve it. And like the greenhouse gases that settle in the atmosphere around the entire planet no matter where they originate, antimicrobial-resistant viruses, bacteria, and parasites will spread around the world no matter where they evolve. The establishment of a panel like the IPCC, under UN authority, will require support and resources from the developed countries to effectively counter the issue of antimicrobial resistance.

Priority 3: Support and substantially expand the mission and scope of the Coalition for Epidemic Preparedness and Innovations (CEPI) to fast-track comprehensive public-private vaccine research, development, manufacturing, and distribution for diseases of current or potential critical regional importance.

The urgent need for vaccines to protect against pathogens of critical regional importance should be obvious. What hasn’t been obvious to those outside a small group of public health professionals and vaccine industry experts is that the international system for researching, developing, and distributing these vaccines is broken and desperately near collapse. We should be far beyond the debate about why governments and philanthropic organizations must provide substantial support to private pharmaceutical companies to have these vaccines when and where we need them.

CEPI represents the first real advance in securing such vaccines. It is a novel partnership of the governments of the United States, the European Union, India, the Gates Foundation, the Wellcome Trust, Gavi: The Vaccine Alliance, the World Economic Forum, and leading vaccine manufacturers. Aside from its EU connection, Norway has its own separate partnership with CEPI.

My biggest concern is that CEPI is not thinking big enough. Annual funding under consideration for the first several years is in the range of $200 million. When I look at the portfolio of critically needed vaccines and the resources that will be required to bring them to licensure, purchase, and distribution, I believe an annual $1 billion infusion of support will provide a huge return on investment in terms of both lives saved and direct and indirect economic costs. All the parties are at the table to make this happen. It will be up to them to embrace and support this more aggressive approach. Once we have these vaccines, we need to use them in advance of potentially devastating epidemics. This is where Gavi and the WHO need to step forward to extend the CEPI mission. Imagine if we could launch a massive Ebola vaccine campaign today targeting all those in Africa at potential risk, including healthcare workers, ambulance drivers, public safety workers, and burial team members. Or how about vaccinating healthcare workers and camel herders on the Arabian Peninsula against MERS? In both examples, we may be able to stop emerging, large outbreaks from ever occurring.

While we are addressing the lack of critical vaccines, we also need to take on the lack of critical diagnostic tests, particularly for those infectious diseases that can cause sudden, regional epidemics. Diagnostic tests, especially those that can be done quickly and reliably at the patient bedside, are necessary for recognizing and controlling outbreaks of infectious disease. For example, our inability to reliably and quickly diagnose patients with Ebola infection in West Africa was a contributing factor in the rapid spread of the virus. Unless there is a near-term financial incentive for diagnostic test research and development companies to create and market tests for Ebola, Zika, or other possible agents that might emerge one day, such tests won’t be available for the next crisis. We need a comprehensive international CEPI-like initiative to address this major shortcoming if we are to improve our public health and medical care aspects of emerging infections.

Priority 4: Launch the Global Alliance for Control of Aedes-Transmitted Diseases (GAAD) and coordinate with the Bill & Melinda Gates Foundation’s malaria strategy, “Accelerate to Zero.”

There is urgent need to bring mosquito-control science and practice into the twenty-first century. The past forty years have seen the dramatic emergence of epidemic arboviral diseases transmitted by Ae. aegypti. During that same time, the prior high level of investment in, and commitment to, Aedes-related control research and professional training has virtually disappeared. There is an immediate need for experts in mosquito-control science and policy to develop an effective overall strategy for Aedes-control tools and begin to research new ones such as pesticides. To provide this leadership, world experts in Aedes biology and control have proposed the creation of a global alliance of international institutions with a vested interest in preventing Aedes-transmitted diseases, to be known as the Global Alliance for Control of Aedes-Transmitted Diseases (GAAD). Members would include national governments, nongovernmental organizations, international funding agencies, and foundations. The alliance would be established under a charter with a committee consisting of representatives from each member organization.

A coordinated source of funding would be needed to develop, manage, and implement the program. We believe an initial investment of $100 million annually would be effective. The US government should lead the way with this support, with other countries in the “Aedes belt” also making sizable investments. GAAD would need to coordinate its activities closely with the WHO; however, as noted previously, the WHO has no major vector-borne-disease resources or expertise.

The Gates Foundation has already launched a major initiative called “Accelerate to Zero” against malaria, a disease transmitted by the Anopheles mosquito. To date, its results have been impressive. While the biology of Aedes and Anopheles mosquitoes, and thus subsequent control measures, is quite different, coordination of the GAAD and Gates Foundation activities would capitalize on shared research activities such as the development of new, effective, and safe pesticides.

Priority 5: Fully implement the recommendations of the bipartisan report of the Blue Ribbon Study Panel on Biodefense.

The October 2015 report is a landmark document that provides the road map for what we must do to maximize our preparedness for a bioterrorist attack, in the United States or elsewhere in the world. It concludes, “The United States is underprepared for biological threats. Nation states and unaffiliated terrorists (via biological terrorism) and nature itself (via emerging and reemerging infectious diseases) threaten us. While biological events may be inevitable, their level of impact on our country is not.”

Today, I’m afraid, the report is accumulating dust on the shelves of the Washington bureaucracy. The next administration and Congress should rank the implementation of the report’s thirty-three recommendations of the highest priority. As former secretary of the navy Richard Danzig told the panel, “We don’t really get to choose what we have to prepare for.”

Priority 6: Establish an international organization similar to the National Scientific Advisory Board for Biosecurity (NSABB) to minimize the use of DURC and GOFRC to transmit pathogens of pandemic potential.

While we have been critical of the accomplishments of the NSABB, it is nonetheless leading the world in addressing the current and future challenges of dual-use research of concern and gain-of-function research of concern. It is my hope that the NSABB can take the next step and follow through on the recommendations made in chapter 10 regarding additional issues they must address. Meanwhile DURC and GOFRC work will continue in countries throughout the world.

Further, an international NSABB-like organization needs to be set up to manage a mutually agreed-upon approach for where and how DURC and GOFRC work should be done globally. This international organization should draw upon the guidance of experts in this area, not simply from the United States, but from around the world. We are under no illusions that such an approach would stop all intentional or unintentional misuse of newly emerging technologies. But to not try to stop it is irresponsible.

Priority 7: Recognize that TB, HIV/AIDS, malaria, and other life-threatening infectious diseases remain major global health problems.

The world can’t afford to take its collective eye off of TB, HIV/AIDS, and malaria. In 2014, there were an estimated 36.9 million people living with HIV worldwide, resulting in 1.2 million deaths from AIDS. There were an estimated 9.6 million cases of tuberculosis, leading to 1.1 million deaths, according to 2015 statistics. And there were 214 million cases of malaria, with 438,000 deaths the same year. I fear the world hasn’t fully come to grips with why it will become even more challenging to control, let alone dramatically reduce, the number of future TB and HIV/AIDS cases.

In 2014, it was estimated that only 63 percent of active TB cases were reported to the WHO, suggesting that more than 3 million infected and potentially infectious people were undiagnosed or unreported. The fact that TB control programs—often in HIV-infected populations—have been unable to get adequate funding, as well as the growing issue of antibiotic-resistant TB infections, does not bode well for global control. As we have painfully learned with the return of the Aedes-related diseases, public health gains from the past can quickly be lost if we let up on our efforts. The megacities of the developing world will only make the challenge of TB control more difficult.

The same forces are at play with HIV/AIDS, particularly in the developing world. A movement known as AIDS Free World looks to a day when there are effective vaccines and a cure for HIV. That is a wonderful aspiration, but if it inspires false hope that we are about to defeat HIV, that could cause a reduced sense of urgency among national governments and even possibly some philanthropic organizations to fund HIV/AIDS programs sufficiently.

Recent reports from countries in Asia—in particular, the Philippines—that new HIV infections are at an all-time high, as well as reports that the increasing number of new HIV cases in Africa outstrips treatment access provided by PEPFAR, speak to the enormity of the challenge. There is nothing in our public health playbook today that supports the UN target date of ending AIDS by 2030.

I feel more optimistic about the potential to control malaria because of the Gates Foundation’s aggressive initiative, “Accelerate to Zero.” Time will tell. But again, we must also remember the lessons of Aedes, playing out in Venezuela as we write this. In 1961, it was the first country in the world to be certified malaria-free. As a result of the collapse of the national economy, many thousands of financially desperate people migrated to the jungle mining areas in search of gold. The swampy mines where they work is a perfect breeding ground for malaria-transmitting Anopheles mosquitoes. Those who become ill with malaria return to their homes in the cities. There they spread the disease in squalid urban settings where there is no money for medicine or healthcare or spraying and mosquito control. In 2016, malaria has come roaring back. This is a vivid reminder that public health is intertwined with every aspect of life.

Priority 8: Anticipate climate-change effects.

As we detailed in chapter 4, climate change and a catastrophic pandemic are two of the four events that have the power to affect the entire planet. While climate change may not influence the likelihood of a pandemic, it surely will have a major impact on the incidence of other infectious diseases. Think of infectious diseases as fire and climate change as fuel. With climate change, some infections such as vector-borne diseases will put a substantially greater number of humans at potential risk as mosquito and tick populations grow in areas where they did not previously exist.

Climate change will also influence precipitation patterns, causing flooding and droughts, resulting in critical shortages of potable water and water used for crop irrigation. Rising sea levels will require the mass migration of densely packed groups of humans and animals from coastal lowlands, particularly in places like Bangladesh. Insufficient safe water and food will combine to create the perfect recipe for increasing the risk of infectious diseases.

We are only just beginning to understand the potential impact of climate change on infectious diseases in both humans and animals. We must maintain robust research and disease-surveillance programs to better understand and respond to this new normal.

Priority 9: Adopt a One Health approach to human and animal diseases throughout the world.

Throughout this book we have stressed the importance of the human-animal interface to the emergence and spread of infectious diseases. The time has come to address almost all human and animal infectious diseases as one continuum of risk and potential prevention and control. In the public health community this movement has become known as One Health. Today, we have the WHO for human health and the OIE, the World Organisation for Animal Health. The OIE’s primary responsibility is to coordinate, support, and promote animal disease control. There are legitimate reasons from an animal health standpoint to have separate organizations—for example, some infectious diseases have major economic implications in food-production animals and not in humans. But until we recognize human and animal infectious diseases as one discipline, we will be disadvantaged in trying to prevent and control these diseases. We recommend that the WHO and OIE, as well as national government human health and animal health agencies, establish joint priority programs in One Health.

Now we come to the critical question of what kind of leadership, command, and control structure we need to make all this achievable—to be able to deal efficiently and effectively with the critical who, what, when, where, why, and how questions we enumerated at the beginning of this book.

One of the premises of our Crisis Agenda is that the United States will have to bear both the primary leadership responsibilities and the bulk of the financial burden. The G20 should provide substantial support, but given the relative lack of international support for global public health programs, this is unlikely to happen. Most of the G20 countries have provided only limited financial support for the WHO, have been largely absent in responding to critical regional outbreaks, and have undertaken minimal efforts in new vaccine and antimicrobial drug research and development.

The internal and external reviews of the WHO performance during the 2014–16 West African Ebola outbreak serve as important assessments of the capability of the international public health community and the WHO to respond to such a crisis. They should be considered seriously in discussions about reorganizing our global public health strategy. But the recommendations in these reports should be seen as just the beginning, not the complete agenda. For example, none of the reports addressed any of the highest-priority Crisis Agenda items we have identified.

We must clearly articulate what we need for global public health leadership and consider alternative approaches. Just as Lincoln had to go through a number of generals before he found one to lead the Union troops to victory, we may have to go through several iterations of an international public health infrastructure before we get it right.

In order to save ourselves as well as the rest of the world, we in the United States will have to step up. But the world, too, will have to realize a new level of public health leadership, organization, and accountability that will involve governments, the private sector, and philanthropic and nongovernmental organizations. It is one thing to say we need to commit x billions of dollars to fight our war against killer germs. But as anyone who has actually fought a war can tell you, all the resources in the world won’t achieve much without leadership, accountability, and an effective command-and-control structure.

We strongly believe there must be a major overhaul of the WHO, beginning with its governance and financial support by member nations, for there to be any effective public health response to the twenty-first-century world of infectious diseases. If that cannot be accomplished, we need to start over and come up with a new international organization or agency that can do the job. The hallmark of such an agency would be its ability to strategically and tactically address the Crisis Agenda we’ve laid out. The US government must look carefully at both reprioritizing and reorganizing our own public health programs if we are to make meaningful change in how to prevent and control infectious diseases.

Laurie Garrett, the author of two important books, The Coming Plague: Newly Emerging Diseases in a World Out of Balance and Betrayal of Trust: The Collapse of Global Public Health, said to us, “I don’t think that most of the people involved in global health today have adjusted to a twenty-first-century perspective on the problem sets and the solution sets. I think we’re still looking at twentieth-century political realities, twentieth-century technologies, and twentieth-century perspectives on the scale of the problems. I think we’ll be mired in paradigms that just as easily could have been taught in a school of public health in 1970 as in 2017.”

The WHO is charged by the United Nations with promoting and protecting global health. But there are 194 member states, constituted as the World Health Assembly, and every single one of them gets an equal vote. As Bill Foege commented to us, “Imagine being the CEO of a corporation that had a 194-member board of directors!”

Despite the equal voting, most of the member nations provide little financial support, and authority is shared in a complex and uncomfortable tension between the director-general in Geneva and the regional headquarters around the world. With funding static for many years now and the virtual inability to get out ahead of an outbreak, it is no wonder the WHO was so roundly criticized for its response to the 2014–16 West African Ebola epidemic. Despite the lessons supposedly learned from the Ebola experience, the WHO has been criticized in 2016 both by African countries and by NGOs on the ground for its response to the yellow fever outbreak in Angola and the DRC.

Garrett expressed little optimism when she told us, “I’ve actually come to the point of feeling like it can’t be reformed effectively. But we can make it a little better. We probably can’t do without the WHO. But in the end, for the sorts of responses we really need, the sorts of capacities we desperately need to save lives worldwide, we need a completely, totally different ‘think’ about what we’re up to.”

Or as Bill Gates puts it, “WHO is not funded to do much. How many planes does it have; how many vaccine factories? We shouldn’t think it’s going to do things it was never intended to do.”

Then there is accountability. The WHO is accountable to the World Health Assembly, which essentially means it is accountable to itself, or, no one.

Garrett notes, “All of the existing systems are without any concrete approach to accountability. There’s no ‘punishment.’ There’s no ‘name and shame.’ There’s no price to be paid for failure or for screw-ups, for deliberate lying and cover-up. None of that will get you in serious trouble. If there’s a court of adjudication of any kind, it’s the court of public opinion. But the problem with the court of public opinion is that it was once fairly wide when it operated at the pace of newspapers. But the age of Twitter and Instagram has an attention span of ten seconds, so we don’t have a mechanism where ‘name and shame’ results in a lasting reform.”

If anyone outside the traditional scientific and political establishments has earned the right to be heard and listened to, it is Bill Gates, and more recently, Dr. Jeremy Farrar. The Bill & Melinda Gates Foundation and the US government together account for 23 percent of the WHO’s budget, so that gives some idea of how influential the Gates Foundation is on the international public health stage. Jeremy Farrar has recently moved the Wellcome Trust into a similarly consequential global health role.

It is evident from even a brief conversation with Gates that he spends an enormous amount of time keeping up on the latest developments in the field, and not only in areas the foundation supports. Equally important, to reverse the old saying, he puts his mouth where his money is. Bill Gates has become a frequent and articulate commentator, analyst, and interpreter in the public health space in venues that range from TED Talks to the New England Journal of Medicine.

When we met with him, he offered a practical and sensible plan for using human and material resources already on the ground as the first assault wave against any emerging outbreak or epidemic.

People aren’t willing to pay for standby capacity [in public health]. They are in the military. They are in fire. I wish they would for epidemics, but they probably won’t. And with standby capacity, you’re never sure how good it is. We’re starting this malaria-eradication effort, which is going to be region by region, and what I’ve decided is we should formalize the idea that as you’re doing this disease eradication—let’s just talk about malaria as an example—you have lots of good people on the ground. These guys know how to set up emergency operations centers, they know how to think about logistics, they know about messaging, they know about panic.

We should say: Of these few thousand people, they are actually standby people for an epidemic. Because the malaria eradication is a super-important thing—I’m the biggest fan of it and will be very involved in it—but the nice thing is you can interrupt it.

Worst case: You interrupt it for a year. Okay, the spread’s back and it’s bad. But it’s got the people doing the kinds of things that you would need for an epidemic. So you can explicitly say, “Look, when we see problems, let’s let thirty of those people look into it.” “Okay, it looks real? Let’s get all of them.”

That happened with polio [eradication efforts during the 2014–15 West African Ebola outbreak]. People don’t acknowledge it and it wasn’t formal. Nigeria is the place where you saw it most specifically. Yes, the Lagos [public health] people did a good job. But it was bolstered by the polio people [already working in the area] who came down and worked all throughout the system that had a major impact on Ebola.

By tying these two functions together—the ongoing disease eradication programs and the emergency capacity—I think it will give visibility to both and maybe—net—get more resources.

As useful as this approach might be, it is not a substitute for an organization that can respond quickly and effectively to any infectious threat around the world.

Since the WHO can’t fit this bill, who can?

In 2014, the US government launched the Global Health Security Agenda (GHSA) as a partnership among nations, international organizations, and nongovernmental stakeholders with the expressed aim “to help build countries’ capacity to help create a world safe and secure from infectious disease threats and elevate global health security as a national and global priority.” It now numbers fifty nations and is supposed to be supported by voluntary national assessments. A number of organizations, including the WHO, serve as advisers.

Like the WHO itself, I don’t see how the GHSA can make a real difference in the Crisis Agenda. It may strengthen a country’s healthcare delivery system and, potentially, its emergency response capability. But the GHSA has limited ability to impact diseases of pandemic potential or even of regional critical importance. Look no further than the public health emergencies of Zika and yellow fever: The GHSA has had little to no impact on the global response to these situations. It offers little leadership and support for global priorities such as vaccine research and development and the rapidly growing challenge of antimicrobial resistance.

Having spoken with numerous experts throughout the fields of public health and national and international governance, we believe a NATO-type treaty organization would be the best model to empower response to infectious disease crises. Member nations would precommit resources, personnel, and financial support so that the organization would be ready to react as soon as the threat becomes clear.

The most difficult part might be simply keeping politics out of it. “A treaty organization is good if you can get the kind of authority within it that’s not going to be obstructionist,” Tony Fauci comments. “I’ve got to tell you: That is really tough.”

On the American domestic front, we have our own challenges in establishing effective public health governance and practice to meet the challenges of the twenty-first century. As a nation, we need to empower the leadership with resources and decision-making capacity as we do our military command structure, which makes decisions knowing their orders will be carried out and that resources needed to accomplish the mission are available. Just as important, the general officers know they are directly accountable for every decision they make.

Says Stewart Simonson, who served effectively under two HHS secretaries and had frequent interactions with the Oval Office, “There is a much more mature dialogue concerning national defense than there is for national preparedness.”

Simonson cites the example of former governor Tom Ridge, when he was appointed by President George W. Bush to be the first secretary of Homeland Security after the 9/11 attacks. Ridge wanted to establish a functional operating model and set up regional commands, each headed by an officer—from FEMA, the coast guard, or a number of other agencies—who would be authorized to make decisions and move personnel, equipment, and funds to rapidly deal with an emergency.

Ridge’s idea went nowhere, because no government agency wanted to subsume its own authority.

The most effective model for the kind of national entity we are talking about would likely require a governmental reorganization. We may now need a Department of Public Health, with its own cabinet secretary who can pull together the resources of the Department of Health and Human Services, including the Public Health Service, the NIH, the CDC, the FDA, and relevant parts of the Departments of Agriculture, Homeland Security, State, Defense, Interior, and Commerce. That office would have a much more focused set of responsibilities than the HHS secretary has today. For example, the Centers for Medicare and Medicaid Services, the organization within HHS that oversees nonmilitary healthcare services, had a fiscal year 2017 budget of approximately $1,012,765,000,000, while the combined CDC (infectious and noninfectious diseases) and National Institute of Allergy and Infectious Diseases (NIAID) of the NIH had a budget of $16,616,000,000. The CDC and NIAID budget is just 1.6 percent of the budget for Medicare and Medicaid, so it is easy to see where the HHS secretary has to direct a great deal of his or her attention. The new agency would also have a mandate and capacity for advance planning and quick global response, just like the Defense Department.

At a background briefing I gave members of the House of Representatives on Zika virus, one senior congressman commented that if we could show that each mosquito was actually a miniature drone controlled by ISIS, we could get all the funding we wanted.

Critical components of our military response are personnel, weapon systems, logistical support, intelligence, and diplomacy. We would not think of being without these resources or waiting to procure them until they are needed. If we have a crisis in the Mediterranean, we’re prepared to send in a Sixth Fleet battle group. We don’t start to requisition funds to build an aircraft carrier, two destroyers, a fleet of jet fighters, and everything else we would need.

To maintain the same level of preparedness in our ongoing war against infectious disease threats, we need to have personnel in place and ready to react: public health epidemiologists, physicians, nurses, veterinarians, sanitarians, statisticians, surveillance technicians, field-workers, lab personnel, and the support positions they all need.

Weapon systems include vaccines, antibiotics, pesticides, point-of-care laboratory tests, environmental health tools (wells, plumbing, and sewers), bed nets, and comprehensive global disease surveillance systems.

As far as leadership, I do not believe traditional public health professionals will be able to lead us out of our current infectious disease complacency. We need to have people who can see—and foresee—the big picture and know how to marshal the resources of government, science, and the private sector to face our challenges. These Crisis Agenda leaders need a unique understanding and practical expertise in global, regional, and national politics, as well as a critical working knowledge of the science behind the agenda. They need some of the same organizational talent that characterized Brigadier General Leslie Groves, the US Army Corps of Engineers officer who directed the Manhattan Project in World War II. They have to motivate governments and the public to support the Crisis Agenda, just as President Kennedy motivated the United States to get to the moon.

We know what we are suggesting will be difficult to implement and will require significant commitments of money, personnel, diplomacy, political power, and courage. That doesn’t make it any less necessary. We shouldn’t have to wait for something to happen before we react. The dots are there to be connected. When we say we were surprised by Zika, we shouldn’t have been. When we say we were surprised by Ebola, or yellow fever, or chikungunya, or so many others, we shouldn’t have been. And we shouldn’t be surprised if tomorrow’s crisis is caused by Mayaro virus, Nipah, Lassa, Rift Valley fever, or a new coronavirus.

And if, in the future, we are unprepared for a pandemic of a deadly strain of influenza, or antibiotics that no longer prevent common infections from causing serious or fatal illness, we certainly won’t be able to say we weren’t warned. Because we’ve had the warning and we have the solutions; we just need to act on them.

What can the average citizen do? Practically speaking, these are big, global problems that require big, global responses by powerful leaders and policy makers. But the average citizen can demand action. Our legislators, for instance, should never have been able to escape Capitol Hill in the summer of 2016 without passing bipartisan Zika funding. We’ve got to hold their feet to the fire and let them know in no uncertain terms that partisan politics has no place in public health policy or action. This will require the same kind of grassroots political action that it has taken to sway Congress on other issues.

CIDRAP advocates for the best science to implement proactive and nonpartisan public policy. I like to believe we are the citizens’ representative on these issues. If you want to stay current and learn more about them, you can follow CIDRAP News and the other information on our website: www.cidrap.umn.edu. There is no charge, the information is updated daily, and you don’t have to be a physician or scientist to understand it.

If we do start questioning and demanding as we should, and our leaders do start rising to their responsibilities in public health, will everything we’ve proposed and endorsed completely neutralize the threat of infectious diseases and the severe, even terrifying impact on modern life around the world? Of course not. But what we can do, with the necessary collective will and commitment of resources, is to give many more people throughout the world, particularly our children and grandchildren, the chance to live out normal, happy, and productive lives. And we can trade innumerable bad deaths for good ones.

And that is all we’ve ever hoped for.