**Health Seminar Series - Emerging Diseases**

**January 14, 2000**

Session 1---Surgeon General's Global Health Priority

Dr. Arnauld Nicogossian, Associate Administrator for the Office of Life
and Microgravity Sciences and Applications at NASA Headquarters,
introduced the Health Seminar Series on Emerging Diseases, the sixth of
a series of continuing education programs sponsored by NASA's
Occupational Health Program, Office of Health Affairs (OHA), in
cooperation with the Uniformed Services University of the Health
Sciences (USUHS). He briefly highlighted the history of the seminar
series, which began in July 1997. It was originally planned for NASA
Field Centers; subsequently, it was expanded internationally. The first
seminar was Occupational Health in the United States---A Federal
Perspective, followed by Public Health Policies from the Federal
Perspective, an Overview on International Public Health Policy,
Bioethics, and International Health Surveillance and Maintenance in the
Workplace. Dr. Nicogossian thanked the planning committee for their
efforts in producing the sixth NASA seminar series and recognized the
other organizations that on are video link: the Medical College of
Virginia; the Institute for Biomedical Problems in Moscow, Russia; the
European de Telemedicine in Toulouse, France; the Robert C. Byrd Health
Sciences Center of West Virginia University, the Uniformed Services
University of the Health Sciences, and all of the NASA Field Centers.

Dr. Nicogossian introduced the speaker, the Honorable David Satcher, MD,
Ph.D., Assistant Secretary for Health, Department of Health and Human
Services and the Surgeon General of the United States. Dr. Satcher
commended NASA for its very timely seminar series on emerging diseases
and noted that it is a very timely topic in many ways throughout the
world. He also commended the Center for Disease Control and Prevention,
where he served as Director for several years (1993-1998). While working
at the CDC, Dr. Satcher chaired a committed that worked with 17
agencies, including NASA, to develop a global strategy of surveillance
and response to emerging infectious diseases. This strategy was approved
by President Clinton in 1996 as a Presidential Decision Directive, which
is now being implemented by an interagency committee of the Federal
government throughout the country and the world. Dr. Satcher also
commended the Institute of Medicine (IOM) for its contribution to this
topic, including a publication in 1992. This week has been an important
one for global health---on Monday, Vice-President Gore made an important
address to the United Nations on the U.S. commitment to work on the
issue of AIDS in Sub-Saharan Africa and throughout the world. It was the
first time in the history of the UN that the Security Council has met on
a health issue. This is significant and points to the recognition of the
relationship between health and security. The AIDS epidemic has infected
over 50 million people in the world and has the ability to cause
significant social, economic, and political instability in Africa and
throughout the world.

The term "Global Health" refers to health problems, issues, and concerns
that transcend national boundaries, may be influenced by circumstances
or experiences in other countries, and are best addressed by cooperative
actions and solutions. This is a very important concept, and recognizes
the continuity among nations. Problems can cross borders; solutions,
ideas, and lessons learned can also cross borders. This is why the
global strategy is so important. Just recently, the Surgeon General
released a report on Mental Health. In preparing to release that report,
Dr. Satcher visited Australia which has developed some models for
dealing with mental health that could be very useful to this country,
e.g., the de-stigmatization model. Global health is important to the
U.S. If we are going to protect Americans at home and overseas, we must
be involved in global health. It is also important to apply lessons from
overseas to the U.S. health program. There is economic value in global
health. The importance of global health to U.S. is most obvious in the
protection of Americans from infections and other diseases abroad. There
is the impact of international transportation and commerce, especially
with respect to food-borne diseases. Our food supply is now a global
food supply. There is also a concern with biological and chemical
terrorism, and there is the issue of environmental degradation (air,
water, or other aspects of the environment that have global
implications). One of the best examples of the economic value is in
prevention. The savings from global smallpox eradication is about \$32
million every 26 days; the savings from the projected global polio
eradication (within the next two or three years) will be \$3 billion per
year by 2015. The direct interest of the American people are best served
when the U.S. acts decisively to promote health around the world.

Dr. Satcher discussed the global health challenges around the world.
Global health risk can be divided into three categories: (1)
Communicable, maternal, perinatal, and nutritional conditions; (2)
non-communicable diseases; and (3) injuries. In developed countries, the
overwhelming majority of deaths are related to non-communicable
diseases. In developing countries, over 40% of deaths are related to
Group 1, primarily infectious/communicable diseases. The difference in
impact of infectious diseases is significant. Every year, there are
about 51 million deaths in the world. Worldwide, about 1/3 of all deaths
are due to infectious and parasitic diseases. In the U.S., the largest
number (over 40%) are due to cardiovascular disease. Dr. Satcher showed
some projections on global health risks worldwide. In 1990, about 1/3 of
the deaths were from infectious diseases; in 2020, only about 15% of
deaths are project to be due to infectious diseases. Injuries will have
increased and non-communicable diseases will have increased
dramatically. This is due to the fact that all over the world, people
are getting older, and people are dying of chronic illnesses more and
more. However, the emergence and re-emergence of infectious diseases was
not predicted, so if we are not successful at handling these diseases,
the picture will not be what it is projected to be. The World Health
Organization made a major commitment to dealing more effectively with
non-communicable diseases throughout the world while continuing the
strategy against infectious diseases.

What should the global health priorities be? The Surgeon General's three
priorities are: (1) to work toward a preventive health system in this
country; (2) to take a more global approach to public health; (3) and to
eliminate disparities in health. For global health, the IOM recommended
using the global burden of disease methods for setting priorities. The
number one cause of the global burden is cardiovascular diseases; the
second is mental health; and the third is cancer. The IOM recommended
that priorities especially focus on the health and well being of females
and children. There is a significant interrelationship between global
health and the health and well being of women. Another critical area
will be new disease patterns associated with the aging population. Other
generic priorities are: the public health significance of violence; the
persistence of AIDS; health system financing reform; special attention
to Africa; ethical guidelines in setting priorities; and problems from
the triad of poverty-population-environment. Our ethics must be as
sophisticated as our science. The IOM's report on emerging infectious
diseases in 1992 was a landmark report. The definition of "emerging
infections" is: new, reemerging or drug-resistant infections whose
incidence in humans has increased within the past two decades or whose
incidence threatens to increase in the near future.

Throughout the world, there are many examples of new infectious diseases
that have emerged since 1970. For example, those in the U.S. in 1996
include: *Ebola* in non-human primates in Texas, raccoon rabies in Ohio,
*Cyclospora* gastroenteritis in multiple states; malaria in Georgia and
Florida; intrinsic contamination of albumin in multiple states; yellow
fever (imported) in Tennessee; and *E. coli* O157:H7 in apple juice in
multiple states. There are some themes that seem to be common in many of
these outbreaks: (1) many of the outbreaks are multi-state---this has to
do with the nature of our food technology/transportation---and affect
many people over a broad span in a short period of time; (2) people
cross national boundaries (about 2 million per day), leading to global
outbreaks very quickly; and (3) the ability of infectious diseases to
affect the social, economic, and political status of a nation. For
example, there was a small outbreak of the plague in India in 1994. The
response to the plague was dramatic---people fled cities, a team was
sent to India from the CDC, tourism was affected, etc. The reaction cost
India at least \$3 billion, although only about 100 people were actually
affected by the plague. Another example is "mad cow" disease in England
and the impact on the beef industry in Great Britain and across Europe.
If the AIDS epidemic continues to affect Sub-Saharan Africa as it does
now, it will turn back a lot of progress that has been made over the
past 20 years in development in those countries. The biggest event of
1999 was the West Nile encephalitis outbreak in New York, involving 59
cases and 7 fatalities. When microbes enter new ecosystems, they usually
spread very rapidly, especially in birds and mosquitoes, producing
unusual mortality in the migratory bird species. We don't know what will
happen with this virus in 2000. Globally, there were some noteworthy
outbreaks in recent years---in Malaysia, there was the new virus
(jumping from pigs to humans) producing encephalitis in both species;
there was the avian influenza in Hong Kong (the virus jumped directly
from chickens to humans); and there was the return of the marburg virus
(a close relative of Ebola) in Congo, striking with an 85-90% fatality
rate.

Something else that is happening throughout the world is the growing
microbial resistance to antibiotics and antivirals, in part due to the
misuse and overuse of antibiotics and in part due to the ability of
micro-organisms to mutate and become resistant. Not enough attention is
being given to this. For example, there has been a dramatic increase in
drug resistant staphylococcus aureus infections in hospitals, the
pneumococcal bacteria resistant to penicillin, etc. We need a strategy
for the growing microbial resistance to drugs.

What are the factors involve in the emergence of infectious diseases?
The IOM cites a number of factors. There are a number of changes in
human demographics and behavior---the most obvious is that we are
getting older. Without question, drug use and abuse and homelessness
have been major factors in the reemergence of tuberculosis. Technology
and industry create problems in terms of allowing infections to move
rapidly (e.g., the food-borne technology/transport). With the invasion
of the rainforest we are encountering viruses that we have not seen
before. Other factors are international travel and commerce, the ability
of micro-organisms to adapt and change, and the breakdown of public
health measures. With the development of vaccines and antibiotics, there
was so much success that some people felt we should close the book. We
let our guard down; we underestimated micro-organisms and their ability
to change and adapt; we allowed the public health infrastructure to
deteriorate (e.g., the public laboratories at the state level); now we
are trying to catch up. We are funding states to develop stronger public
health laboratories and we are trying to bring some of our best
technology to bear in terms of surveillance, monitoring, and response.
One of the government programs nominated for a top award in innovation
was the "Pulsenet", a system using DNA and digital fingerprinting to
diagnose the cause of an outbreak and to rapidly communicate that
information and respond. During the time that Dr. Satcher was at
Director at the CDC, that organization developed a strategy for
responding to emerging diseases. There were four components:
strengthened surveillance and response (the development of sentinel
networks of primary care physicians reporting to CDC and sending
samples, networks of emergency rooms in a system of surveillance, etc.);
applied research (a balanced research approach including prevention,
behavioral research, microbiology, molecular genetics, etc., to put in
place stronger systems for detection and response); prevention and
control (e.g., hand washing after using the toilet, when preparing food,
etc.); and public health infrastructure (including training people).

The CISET Working Group developed priority recommendations on emerging
and re-emerging infectious diseases: establish global infectious disease
surveillance and response system; enhance domestic infectious disease
surveillance; strengthen the response capacity through collaboration
with the private sector; assist other countries in strengthening
national infectious disease systems; establish the authority of the U.S.
agencies to make most effective use of their expertise; and establish an
Interagency Task Force to facilitate implementation of recommendations
(the Task Force is in place working to implement these recommendations).
"The United States should lead from its strengths in medical science and
technology" (a recommendation from the IOM in 1997). The U.S. can also
lead in saying that it has a moral responsibility for the orphans in
Sub-Saharan Africa within the next several years if we do not do
something globally. Many of the UN colleagues have responded. A major
front against this epidemic will be mounted.

Dr. Satcher noted other areas of health concern: childhood and adult
obesity is at an all time high; physical activity has decreased in the
last decade; too many teenagers are initiating a smoking habit every
year. We must get people more physically active; we have to convince
more people not to start smoking and convince smokers to stop; we have
to be more responsible in our sexual behavior. All of these things are
critical in enhancing the health of people in this country and
throughout the world.

Questions:

Dr. Nicogossian noted that these seminar courses are very important to
NASA. NASA has global health issues due to landing sites around the
world, crew health in orbit, the health of NASA specialists and
contractors traveling and living in other countries, and the health of
NASA's international allies and partners who visit and live in the U.S.

Dr. Asrar/NASA HQ: Regarding the use of technology towards eradicating
some of the food-borne diseases---Europe has been using radiation and
some of the other nations around the world as a means to eradicate some
of the food-borne diseases. There seems to be a resistance for our
nation to use radiation. What are your views on this? Do you see any
problems? How do you envision technology such as radiation helping us?

Dr. Satcher: The role of radiation is important in protecting us from
food-borne diseases. It is effective in many cases. I have testified on
this issue before Congress. We have clearly made the point the we have
the ability, using radiation, to significantly increase the safety of
our food supply and there is no evidence of any ill effects of that.
From a scientific perspective, we have tried to make the safety of
radiation very clear. We are dealing with the fears of people, and
sometimes science cannot overcome that very rapidly. Right now, we are
struggling with genetically produced foods and the implications of that.
We have the ability to save a lot of lives and help starving children
with genetically-engineered rice that has all of the additional
nutrients. The question is: How do you do due diligence to make sure it
is safe (the monitoring never ends) and how do you communicate this to
the public and deal with the fears and concerns that people have. We
have to get better at doing that.

Dr. Gregory, NASA HQ (comment): We have been using radiated food in the
space program for years and have never had any adverse effects on the
astronauts.

Dr. Barry/KSC: You had mentioned the plague epidemic in India. This
raises two questions: Were there any lessons learned in the use of
modern technology? How would the US respond if that happened here?

Dr. Satcher: When the first cases were identified, about 1000 physicians
fled the city of outbreak because of their own fears. One of the
critical challenges that we face is communication---how do we
communicate open and honestly with the general public so that they
understand the magnitude of the threat, but that they don't overreact
and do more harm to themselves and others because of their reaction. We
face that every time there is some kind of outbreak in this country. It
is a delicate balance. The Office for Health Communications was started
at the CDC. In public health, communication is so important that it
needs to be a specialty area. We need sophisticated health
communication, technology as well as basic principles and philosophies.
How can the information be shared so that people without a scientific
background can understand it and use it?

Moscow: What do you think about the Baruch Brody Ethics Commission and
its relationship with Russia?

Comment from Dr. Nicogossian: Dr. Baruch Brody (Baylor College of
Medicine) is leading NASA's Committee on Bioethics and has been working
with the Russian Academy of Sciences on international bioethical issues
in research and medical practice. NASA will be more than happy to
entertain the continuation of the work.

Dr. Satcher: There is an important bilateral agreement between the
former Soviet states and the US (it started out as the Gore-Chernomyrdin
agreement). It is an agreement to work together in several areas of
public health, e.g., infectious diseases, tuberculosis, environmental
health issues (lead levels), occupational health, substance abuse, and
injury prevention. The US is committed to continuing this agreement and
looks forward to continuing the work with Russia. In all of these
things, our ethics must be as sophisticated as our science.

Dr. Mulville/NASA HQ: In the information age, where a lot of medical
records are stored in data bases, concerns have been raised about the
security of those records and the potential to ensure privacy in the
future. What is the public health service's view on the future of
medical records and this issue.

Dr. Satcher: Issues related to privacy and confidentially are critical.
The Department of Health and Human Services and the President have
proposed to Congress some interventions for protecting the privacy and
confidentiality of medical records. Hopefully, we will make significant
progress in this area in 2000. It does recognize that we have enhanced
technology. One of the major concerns has been that physicians did not
know where their patients were on the immunization schedule. We have
tried to strengthen the immunization system by having registers; this
will allow the physician to know where the child is in the schedule.
This system has made a big difference in immunizing children. On the
other side, information can be misused and used against people, e.g., in
employment. There is a lot of concern in this country about the
employer/employee relationship. We need to protect the privacy and
confidentiality of medical information on the one hand, but make sure
that it is available to people that we want it to be available to. There
is a delicate balance to maximize the technology to protect health in
this country and all over the world and to protect the individuals'
privacy and confidentiality.

Dr. Pool/JSC: In Houston, there are some policy issues that affect us.
We have a very highly selected population in the astronaut corps. One of
the factors in their selection is medical---astronauts must meet certain
medical standards in order to function effectively as astronauts. Some
of the initiatives (either by Congress or the Administration) tend to
paint issues of medical confidentiality with a broad brush and in an
effort to protect individuals, it could affect space program from a
policy point of view, e.g., to say that anybody with a wide range of
medical problems can have any Federal job without exclusions for certain
functions, such as astronauts. What are your thoughts on that?

Dr. Satcher: This is an excellent example of the complexity of the
issue. In the military, when we send people places, e.g., the Person
Gulf, we face some of these same issues. If you want to become and
astronaut, then certainly you know what the requirements are going to
be, i.e., that you will have to share information that a person pursuing
another occupation would not have to share. It gets down to how much
responsibility we place on the individual in terms of providing access
to his or her records with whatever profession her or she wants to
pursue. It is appropriate for you to require certain information that is
critical to the safety of other astronauts. We will not come up with any
polices that will not take into account the needs of NASA and others to
carry out their programs and protect the people involved in them.

Dr. Williams/NASA HQ: Given the high cost of medical education, as well
as the need in economically deprived areas for medical doctors, how is
this being addressed and do we foresee this as a major problem in the
U.S.?

Dr. Satcher: The cost of medical education is high and we need more
physicians, particularly for underserved communities. There is a major
shortage of minority physicians. However, the major problem today is not
financial---through many scholarship programs, a student who does well
and makes a commitment to serve in underserved communities will find a
way to pay their way. The major problems were are facing now are getting
more students interested at an early age and making sure they have the
preparation they need to compete for medical school. We are working hard
with the American Association of Medical Colleges and others to try to
deal with those issues. Another problem is getting information to
minority students early; they sometimes give up early because they
believe they cannot access an education in a particular area. We must
make it clear to students that if they stay in school and do well, we
are rapidly removing financial barriers to their education.

Dr. Long/KSC: You mentioned smoking and its impacts on public health. It
is well known now that the rate of smoking is increasing exponentially
in the eastern European countries and the new states of the former
Soviet Union. How can we deal with this on our side of the world in a
cooperative way?

Dr. Satcher: Smoking is a global problem, and will become worse. In
1999, somewhere between 3 1/2 and 4 million people in the world died
from smoking (about 500,000 in this country). If the present trend
continues in both developing and developed countries, we estimate that
by 2025, 10 million people will be dying every year from smoking-related
illnesses. If there is any example of a global issue that we should be
concerned about, this deserves our attention. This issue deserves as
much time as emerging diseases. There have been 28 reports on smoking
and health in this country, and we have made progress---about 43% of the
American people were smokers in 1964; it is down now to about 25-25%.
What worries us is that more teenagers are smoking---it is up to about
30-35%. This is a global concern and we need a global strategy and the
WHO is taking leadership in that. There will be a major international
meeting on smoking and health sometime within the next two years. We
have to be concerned about all of the exporting of tobacco that we have
done and are doing.

Dr. Charles/Library of Congress (NASA HQ): You have spoken about the
deterioration of the infrastructure of public health and you have also
talked about prevention of injuries. One of your goals is prevention
control with communication and education. Has any thought being given to
placing some new emphasis on collaboration and cooperation among
occupational units within the Federal agencies?

Dr. Satcher: Yes, thought is being given to collaboration among
occupational units within the Federal government. NIOSH is a part of CDC
and works closely with OSHA in developing the science base for OSHA
recommendations. Many major employers work with NIOSH and allow research
on job hazards and implementation of practices that help protect the
health of employees. We are getting ready to announce the launch of
"Healthy People 2010." In looking back at the last decade, some of the
greatest progress has been made at the workplace, e.g., in smoking,
nutrition, etc. The work site has been one of the most successful sites
(better than schools) for health---education, interventions to protect
people from hazards and physical stress, etc.

Dr. Doarn/MCV: The space agency has done a tremendous amount of activity
in telemedicine and medical informatics and these kinds of activities,
as well as data mining, become part of medical care worldwide as we go
into the next century. How do you see these disciplines assisting the
people of the world in accessing medical care? Do you see telemedicine
as useful tool or more of an encumbrance?

Dr. Satcher: Telemedicine is without question a useful tool. Obviously,
it has to be carefully applied and not wastefully applied. I prefer to
call it "telehelp." This will continue to grow and technologies will be
brought to bear in detection of infectious diseases and to better share
ideas and technology. When we put together the CISET report it was with
the recognition that one of the important tools will be "telehelp"---we
can bring people in communication with each other around the world and
can bring the best technology to bear in remote places and to share
ideas and strategies.

Dr. Mulville concluded the session by thanking Dr. Satcher on behalf of
the NASA Administrator for communicating with NASA and the Centers and
NASA's international partners about emerging diseases, and for sharing
his thoughts about public health and the impact on the future