There was a time not so long ago when preventing epidemic disease was a cause ordinary people embraced and celebrated. When President Franklin D. Roosevelt called on Americans to join the fight against polio, for instance, he reported that envelopes containing “dimes and quarters and even dollar bills” arrived by the truckload at the White House, “from children who want to help other children to get well.” The March of Dimes went on to fund the development of polio vaccines. When one of them, the Salk vaccine, proved effective, in April 1955, church bells rang out nationwide.
Likewise, in the mid-1960s, when the World Health Organization announced its wildly ambitious plan to eradicate smallpox in just 10 years, people rose to the challenge. Small teams bearing vaccines and a simple lancet called the bifurcated needle were soon moving through the afflicted parts of the planet — by camel across the desert in Sudan, by elephant to ford rivers in India, and by all the more familiar modes of travel. People everywhere lined up to get the peculiar dimpled mark of smallpox vaccination, freeing them from the scourge that had been maiming and killing their families for as long as they could remember.
As many as 150,000 men and women at a time worked on the campaign, and with a final naturally occurring case discovered in Somalia in October 1977, they eradicated smallpox in the wild. For veterans of the “order of the bifurcated needle,” as they called themselves, it was the proudest hour of their lives.
It may seem unlikely that we could ever recapture that determination and excitement about standing up together against a deadly disease. Instead of presenting a unified front against Covid-19, we fought bitterly, and three years on, our shared response seems to be a shellshocked unwillingness to even think about epidemic diseases.
Politicians have become particularly skittish about what ought to be common-sense steps to protect basic public health. The Pasteur Act, for instance, would address the antibiotic resistance crisis that threatens our entire system of medical care, but it’s been stalled in Congress for years. Funding for federal pandemic preparedness programs comes up for reauthorization in September, but its passage is in doubt.
Given the catastrophic losses caused by the Covid-19 pandemic, this type of inaction is baffling. Are emerging and evolving pathogens too elusive a target? Is the political payoff for these actions too small? Is the desperate desire to move on from the nightmare of the pandemic leading us to avoid the difficult realities of prevention?
I believe that the way to ease us as a nation back into the essential business of preventing infectious diseases is by focusing on pathogens we already know perfectly well, and for which we have new tools to reduce or eliminate sickness worldwide. I’m thinking in particular of the very winnable fights against three diseases with a long history of maiming, crippling and killing humans: tuberculosis, malaria and polio.
The dark star of the three is tuberculosis. We haven’t seen it much in the developed world since the arrival of antibiotic therapies in the 1940s, but as Covid deaths wane, tuberculosis has resumed its place as the deadliest infectious disease, killing some 1.5 million people a year, mostly in the developing world. The ability to cut that number dramatically is within our reach. The development of diagnostic technologies like GeneXpert has brought testing times for TB down from weeks to hours — a crucial difference because at present, 40 percent of TB victims don’t get diagnosed or treated. This failure doesn’t just put people at risk, it also spreads the disease to those around them.
Treatment of tuberculosis with a regimen of antibiotics has also gotten easier, shortened from two years down to just six months for antibiotic-resistant cases. For normal drug-sensitive cases, treatment time is also likely to drop soon, from six months to four. Shorter is better because the multi-drug regimen is complicated and prone to side effects, and many patients give up. George Orwell experienced it in its crudest form at the start of the antibiotic era and likened it to “sinking the ship to get rid of the rats.” (His own ship sank just 20 months later, killing him at age 46.) Promising new vaccines are also in the works.
As with so many infectious diseases, lack of determination is the real stumbling block. The United States and other donor nations could argue that we already do more than our share, contributing billions annually to the fight against TB and other infectious diseases. But donors still fall short by more than half on the funding the W.H.O. says it needs to end the TB epidemic by 2030. Until we get the job done, we need to have a broader sense of what “our share” could yet entail: Up to 13 million Americans currently live with latent TB infection, according to estimates from the Centers for Disease Control and Prevention. The realities of modern travel mean that none of us is protected from a TB resurgence until we have protected people everywhere.
It’s the same story with malaria, which used to sicken and kill Americans as far north as the Great Lakes until a well-funded federal initiative protected us. Consciously or otherwise, we then set malaria aside as a “Third World” disease. In June, however, for the first time in two decades, homegrown malaria cases turned up in Texas and Florida, raising the specter that it might again become endemic in the United States.
That ought to serve as a reminder that an estimated 247 million cases of malaria occurred worldwide in 2021, and 619,000 people died. The vast majority of them were children under the age of 5 in sub-Saharan Africa and South Asia. Malaria prevention has stumbled at times because of rapidly evolving resistance to drugs and insecticides. But we are now making major progress with a variety of new tools and a more coordinated and agile response.
Sixteen nations, from El Salvador to China, with efforts coordinated by the World Health Organization, have eliminated malaria since 2000, with another 10 countries aiming to stamp it out in the next two years. Moreover, public health agencies for the first time now have a vaccine against malaria, and about 1.7 million young children across three countries in Africa — Ghana, Kenya and Malawi — have already received at least one dose since the start of a pilot program in 2019. The vaccine is only moderately effective, but by preventing about 40 percent of cases of Plasmodium falciparum, the deadliest malaria variety, it’s expected to save tens of thousands of children every year. With proper funding to develop other necessary tools and get them into the field, the W.H.O. goal for this decade is to drive the annual malaria death toll down to well under 100,000 — en route to eradication.
Polio, finally, offers the most immediate opportunity for a major success over infectious disease. In 1988, when international agencies, national governments and nonprofits launched an eradication campaign, polio was still endemic in 125 countries and every year paralyzed an estimated 350,000 people, mostly young children. This year, there have been just seven cases of wild poliovirus, all in one small, mountainous area on the border between Pakistan and Afghanistan, the last two countries where the virus remains endemic. Both countries are now cooperating to stop it. They have eliminated wild poliovirus from major cities and Taliban-dominated regions where it was still circulating just a few years ago. Border crossings between the two countries now require polio vaccination. And vaccination teams, often with women taking the lead, routinely travel to remote and sometimes dangerous border villages to finish the job.
This is our moment to get rid of polio for good. If we fail, we could return to a time when polio paralyzed 350,000 people a year worldwide, some of them in the United States. Last summer’s brief, horrifying reappearance of polio in New York State was a potent reminder of that threat. Americans may not have much interest in what happens outside our borders. But it makes sense to give till it hurts to the fight against these three diseases — because not giving could ultimately hurt so much worse.
Politicians motivated by protecting their own popularity and legacies should also take note. Even Americans who loathe former President George W. Bush still honor him as a hero for launching the President’s Emergency Plan for AIDS Relief. It slowed the spread of the disease and has saved 25 million lives so far.
Appealing only to our selfishness, though, is a mistake. What we need is a powerful sense of our shared humanity in the fight against some of our most ancient killers, and the courage and determination to win this fight now.
Richard Conniff is the author of “Ending Epidemics: A History of Escape From Contagion.”
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