Will Microbes Finally Force Modernization of the American Health Care System?

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Mike Magee MD

Science has a way of punishing humans for their arrogance.

In 1996, Dr. Michael Osterholm found himself rather lonely and isolated in medical research circles. This was the adrenaline-infused decade of blockbuster pharmaceuticals focused squarely on chronic debilitating diseases of aging.

And yet, there was Osterholm, in Congressional testimony delivering this message: “I am here to bring you the sobering and unfortunate news that our ability to detect and monitor infectious disease threats to health in this country is in serious jeopardy…For 12 of the States or territories, there is no one who is responsible for food or water-borne surveillance. You could sink the Titanic in their back yard and they would not know they had water.”

Osterholm’s choice of metaphor perhaps reflected his own frustration and inability to alter the course of the medical-industrial complex despite microbial icebergs directly ahead.

For nearly a half-century, America’s scientists had been declaring victory over infectious diseases. General George Marshall got the ball rolling when he declared in 1948 that we now had the means to eradicate infectious disease. Seven years later, Rockefeller Foundation scientist Paul Russell, who along with Fred Soper had championed the use of DDT, published “Mastery of Malaria”, recommending a global spraying campaign. Eight years after that in 1963, Johns Hopkins scientist, Aidan Cockburn, published his seminal piece, “The Evolution and Eradication of Infectious Diseases”, in which he memorably declared , “With science progressing so rapidly, such an endpoint (of infectious diseases) is almost inevitable.” And finally, in 1969, Surgeon General William H. Stewart, declared with complete confidence that it was time to “close the book on infectious diseases.”

Yale historian Frank M. Snowden explained in his book, Epidemics and Society, that the two decades following the end of WW II were years of “social uplift.” This was a period that marked progress (for the fortunate) in housing, wages, diet, and education. In infrastructure as well – from roads to sewers, to water treatment plants, and safer manufacturing equipment – there was some justification for the self-congratulatory waves in the air.

The infectious diseases themselves seemed stalled, static, relatively benign, and historic. The plague had yielded to sanitary cordons, isolation, and quarantine. Water and sewer management had neutralized the threat of cholera in most locations. DDT, paired with quinine, had defanged malaria. And vaccines for just about every nasty childhood disease were now required for school entry. As Snowden describes, we “fell victim to historical amnesia.”

When HIV arrived in the early 1980s, it proved every stereotype about the manageability of infectious diseases false. Here was a brand new infection, impacting both the developed and developing world, which spread rapidly far and wide, had a devastating and tortuous kill rate, and ignited a wide range of associated opportunistic infections.

In its wake, the scientific community was forced to reverse course. In 1992, the IOM served notice with the publication of “Emerging Infections: Microbial Threats to Health in The United States.” Two years later, in 1994, the CDC declared “The public health infrastructure of this country is poorly prepared for the emerging disease problems of a rapidly changing world.”

In 1998, the Department of Defense weighed in. saying “Historians in the next millennium may find that the 20th century’s greatest fallacy was the belief that infectious diseases were nearing elimination. The resultant complacency has actually increased the threat.”

They personified the threat of these organisms as the enemy of mankind, explaining that there were “powerful evolutionary pressures on these micro-parasites.” Their analysis revealed intense mixing of microbes gene pools, highly crowded and impoverished non-immune urbanized populations, growing high-speed travel (including almost 2 billion air passengers worldwide that year), populations displaced and vulnerable due to warfare, the absence of health care services in many areas, and growing environmental degradation. And in the middle of this human mess were tens of thousands of different viruses and some 300,000 different bacterial species capable of attacking humans.

In a JAMA article in 1996, Nobel Laureate Joshua Lederberg alerted the public that our fight with microbes was far from over and that the odds were severely tipped in the microbes’ favor. The IOM 1992 report had noted that they outnumber us by a billion-fold, and mutate a billion times more quickly than us. “Pitted against microbial genes”, Lederberg wrote, “we have mainly our wits.” He coined the term “emerging and reemerging diseases” to encompass historic infectious diseases as well as newcomers like HIV/AIDS.

Eradication of infectious diseases was now a dream of the past. We had been warned and re-warned. But as Ebola and SARS arrived in the early days of the new millennium, the scientific community in the U.S. and around the world were anything but sure-footed. Slowly policy leaders were awakening to the global nature of the threat. The George W. Bush administration in 2003 created the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI).

The WHO promoted early detection and notification obligations after China delayed notifying the world of its detection of SARS for almost four months. In 2019, they repeated the offense, but this time with a much more capable microbial foe, COVID-19. 

The microbe encountered weak defenses on arriving rapidly in the US. The health care system was spotty at best, unable to respond to the challenge with adequate material or manpower to manage the surge of morbidity and mortality. Trump denied, delayed, and distorted at every turn. And the disease deftly mutated, seemingly at will.

With U.S. deaths now approaching 1 million, confidence and trust in science have been grossly maligned. Our democratic institutions have been severely weakened. Our health care system remains porous and highly variable. 

The challenges are stark and the solutions somewhat obvious. We need universal health coverage, forward-looking and coordinated national public health leadership, active participation in the global health community, policies that address income inequality, sound environmental policy, and modernization of our physical infrastructure.

The only question that remains is this – Do we, as Americans, now have the wisdom and determination to do what needs to be done?

Mike Magee, MD is a Medical Historian and Health Economist, and author of “CodeBlue: Inside the Medical Industrial Complex.“