Medical Examiner


Why a deadly disease might be coming your way soon.

Last week’s announcement of a mysterious deadly disease resurrected Hot Zone-like fears of a killer bug assaulting the human race. Dubbed “severe acute respiratory syndrome,” SARS has so far spread to more than a dozen countries and hospitalized more than 300 people, killing at least 10. SARS did not drop from the sky: It’s likely that the bug behind it has jumped from animals into humans for eons and that this outbreak simply signals that it has better evolved to copy itself in humans and spread. To researchers who specialize in such emerging infectious diseases, the wake-up call rings loud and clear. As the University of Texas’s C.J. Peters, a renowned researcher of debutante bugs puts it, “Some viruses are part way there; if we continue to fart around, they might adapt.”

And when it comes to infectious diseases we’re not doing much more than farting around, as was made abundantly clear in a massive report issued this week by the U.S. Institute of Medicine, “Microbial Threats to Health: Emergence, Detection, and Response.” It might as well have the subtitle: “How We’re Blowing It.”

If one were to rate the “Microbial Threats to Health” report according to the Office of Homeland Security’s color scheme, it would merit a red-plus alert. The report unsparingly finds fault with almost every aspect of the world’s response to dangerous bugs. Surveillance systems that aim to detect outbreaks of diseases in the United States “remain fragmented” and have not “evolved at the same rate” as advances in electronic technology. On a global level, matters are worse still, with systems rated as “skeletal.” Only the sketchiest cooperation exists among nations to track and communicate outbreaks of hazardous new diseases. Underscoring this point: China appears to have kept mum about its outbreak of SARS, which dates back to November. The report rings further alarms about the ability of doctors to identify the agents that cause disease in the first place, stressing that detection efforts have actually “declined significantly” during the past decade.

But “Microbial Threats to Health” saves its ear-piercing air-raid sirens for the state of drug and vaccine research and the cumbersome process that turns scientific leads into products. As microbiologists have shouted for more than a decade, the world desperately needs antibiotics that can deal with the increasing number of drug-resistant bacteria in circulation. But only one large pharmaceutical company has what the report calls a “robust” antibiotic research program. Currently, every new antibiotic under development, save one, works by the same mechanisms as those already on the market—meaning that even the newest antibiotics will face the same resistance dilemmas as the old, at a time when inappropriate use of antibiotics has led to an ever more rapid emergence of drug-defying bugs. This has created “an imminent crisis” in the control of bacterial diseases.

Drugs against specific viruses are “largely lacking,” and in contrast to antibiotics only a few anti-virals exist that work against more than one disease. Viruses, small pieces of DNA and RNA, have long defied drug developers because, unlike bacteria, they are not living things, and they so closely resemble our own genetic material that attacking them can easily harm us. Viruses also evolve rapidly, quickly learning how to dodge almost any drug thrown at them. To the green-eyeshaders at drug companies, that means investing in anti-viral research often presents great financial risk. Little surprise, then, that few new anti-virals are in development.

Matters on the vaccine front may be even worse. Owing to the economic reality of the business—low profit, high liability risks, expensive R&D—only four big pharmaceuticals still make vaccines. What does this mean? Even shortages of existing preparations have become commonplace. Last year, the United States ran out of eight of the 11 childhood vaccines. Influenza is one of the most devastating infectious diseases on the planet; the industry had tremendous difficulty producing enough influenza vaccine during 2000 and 2001, when mild strains circulated. The report warns that this “signals a potential disaster” should a particularly nasty flu bug hit the United States or the world: “The reality is that the infrastructure does not exist to produce even a sufficient supply of currently licensed vaccines, let alone to develop new vaccines against emerging microbial threats.”

During the past five years, several progressive attempts have surfaced to confront this microbial mess. The Bill and Melinda Gates Foundation, with a $24 billion endowment and a mission to reduce global health inequities, has done nothing less than redraw the edges of the public health universe, quickly pouring hundreds of millions of dollars into campaigns to thwart malaria, TB, HIV, meningitis, dracunculiasis, and other diseases rampaging the world’s poor. Last year, after U.N. Secretary-General Kofi Annan made a call to arms, the Global Fund To Fight AIDS, Tuberculosis, and Malaria was born; the fund takes a radical new approach to helping the hardest-hit countries confront these problems. (Unfortunately, the fund remains financially strapped, in part because donor countries—and in particular the United States—have yet to contribute anywhere near the $12 billion a year required to make such a sweeping approach effective.)

Humans will never win the war on bugs. But we can, with the help of aggressive programs, win many more battles that now go entirely unfought. As the Institute of Medicine report laments, without “leaps of political will and public understanding” humans will suffer “many burdens whose alleviation is scandalously within our technical grasp.”

The main obstacle preventing new anti-bug drugs and vaccines from moving forward? Money. If we want to thwart infectious diseases most effectively, we cannot rely on the marketplace. Rich countries need to fund and plan an organized international public health program. What might happen if the U.S. government decided to protect the world from dangerous bugs with the fervor that it now reserves for terrorists and potentates? Government-owned manufacturing plants could produce vaccines for those diseases that scientists believe they can outfox. The United States could distribute them to the world (which, among other things, would help build international goodwill). And when scientists identify new bugs, like the one that causes SARS, crash programs could immediately begin vaccine R&D, immunizing people in the most vulnerable regions. Similar efforts could bolster the pharmaceutical industry’s lackluster programs to develop new antibiotics and anti-virals. A decade’s worth of funding for such an ambitious approach likely would cost less than what the U.S. government will spend in its attack on Iraq.

This is less pie-in-the-sky than it may sound. The Institute of Medicine has repeatedly gathered experts who urged the U.S. government either to invest in manufacturing plants or to contract directly with companies to develop vaccines. The new report implies that the same thing would work for drug development. (As for the nuts and bolts of how to organize such an effort, the lack of a viable marketplace for biodefense vaccines has long forced the U.S. Department of Defense to address these issues in great detail.)

In all likelihood, scientists will soon deduce conclusively the cause of SARS (top candidate: a paromyxovirus, a cousin of measles). New treatment and prevention strategies will come forward; the disease will receive a proper name; it will disappear from news headlines. Like Nipah, Hendra, Hanta, Ebola, Marburg, monkeypox, and H5N1 (bird flu), SARS will become just one more poster bug—a brief reminder that scary pathogens continue to emerge. Medicine will appear to have triumphed once again. Except for one ominous detail: Development of medicine for emerging infectious diseases remains at the tail end of a very long line. You can almost hear SARS threatening, Schwarzenegger voce, “I’ll be back.”

[Update, Monday, March 24: The Centers for Disease Control and Prevention today reported that their researchers announced a new “leading hypothesis” for the cause: coronaviruses, which infect many species and typically cause the common cold in humans.]