FRIST CALLS FOR MANHATTAN PROJECT FOR THE 21ST CENTURY Speech makes the case for immediate and in-depth research to protect against future epidemics
US Senator William H. Frist, M.D.
August 3rd, 2005
- U.S. Senate Majority Leader William H. Frist, M.D. delivered the
following lecture at the Nantucket Atheneum. The talk titled “The
Manhattan Project for the 21st Century” outlined the global threat of
infectious disease and bioterrorism and the need to better prepare the
United States and the world to respond to epidemics and outbreaks:
Like everyone else, politicians tend to look away from danger, to
hope for the best, and pray that disaster will not arrive on their
watch even as they sleep through it. This is so much a part of human
nature that it often goes unchallenged.
But we will not be able to sleep through what is likely coming soon
-- a front of unchecked and virulent epidemics, the potential of which
should rise above your every other concern. For what the world now
faces, it has not seen even in the most harrowing episodes of the
Middle Ages or the great wars of the last century.
We are unprepared for rampant epidemics. And even worse, we haven’t
taken sufficient note of the fact that though individually each might
be devastating, they are susceptible of either purposeful or accidental
combination, in which case they could be devastating almost beyond
imagination.
*
The history of pathogens advances in parallel with and is no more
static than our own -- with which it is always intertwined, even if at
times invisibly. Sometimes it rushes forward with great speed and
breathtaking evolutionary vigor -- and sometimes it rests in slow
backwaters.
When, in 1967, the U.S. Surgeon General declared that we were
within site of winning the war on infectious diseases, we thought the
slack water would last forever. But that war never ended other than in
wishful thinking.
Today more than a quarter of all deaths -- 15 million each year --
are due to infectious diseases. These include 4 million from
respiratory infections, 3 million from HIV/AIDS, and 2 million from
waterborne diseases such as cholera. This is a continuing and
intolerable holocaust that, while sparing no class, strikes hardest at
the weak, the impoverished, and the young.
Three million children die every year of malaria and diarrheal
diseases alone -- one child every 10 seconds. As sobering as this may
be, we’ve been nonetheless in a quiescent stage of the mutability of
pathogens -- a hiatus from which they are now poised to break out.
When viral diseases evolve normally -- such as in the typical
course of the human influenza virus undergoing small changes in its
antigenicity and killing an average of 500,000 people annually
throughout the world -- it is called an antigenic drift.
When they emerge with the immense power derivative of a jump from
animal to human hosts followed by mutation or recombination with a
human virus -- as in the influenza pandemic of 1918 - 1919 in which 500
million people were infected and 50 million died, including half a
million in the United States -- it is called an antigenic shift.
Antigenic shifts are the result of random, fortuitous, and unavoidable changes.
Human population increase, concentration, and spread,
intensification of animal husbandry, and greater wealth in developing
countries brings animals both wild and domestic into closer contact
with ever larger numbers of people.
War, economic catastrophe, and natural disasters subdue active
measures of public health. The unprecedented societal overuse and
misuse of antibiotics build unprecedented resistance within the
microbial bug universe to our even most powerful ammunition. Travel,
trade, and climate change bring into contact disparate types and
strains of disease.
And as a consequence of all this, microbes evolve, mutate, and find new lives in new hosts.
*
The evidence suggests that we could be at the threshold of a major
shift in the antigenicity of not merely one but several categories of
pathogens -- for rarely if ever have we observed among them such
variety, richness, opportunities for combination, and alacrity to
combine and mutate.
You read the tid bits and pieces in the news. HIV, variant
Creutzfeldt-Jakob disease (mad cow), avian influenzas such as H5N1, and
SARS -- all are merely the advance patrols of a great army forming out
of sight, the lightning that however silent and distant gives rise to
the dread of an approaching storm, a storm for which we are unprepared.
How can that be? How can the richest country in the world, with its
great institutions, experts, and learned commissions, have failed to
make every preparation -- when preparation is all -- for epidemics with
the potential of killing off large segments of its population?
*
To see what might lie on the horizon one need only look to the
relatively recent past. I have a photograph of an emergency hospital in
Kansas during the 1918 influenza pandemic. People lie miserably on cots
in an enormous barn-like room with beams of sunlight streaming through
high windows. It seems more crowded than the main floor of Grand
Central Station at five o’clock on a weekday. In this one room several
hundred people are in the throes of distress.
Think of two thousand such rooms filled with a crush of men, women,
and children -- 500,000 in all -- and imagine that the shafts of
sunlight that illuminate them for us almost a century later are the
last light they will ever see. Then bury them. That is what happened.
How would a nation so greatly moved and touched by the 3,000 dead of
September 11th react to half a million dead?
In 1918 - 1919 the mortality rate was 3 percent, which seems
merciful in comparison to the 50 percent mortality rate of today’s
highly pathogenic H5N1 avian flu. In just the last 18 months, avian flu
has caused the death or destruction of over 140 million birds in 11
Asian nations. And, most alarmingly, in 4 of those nations, H5N1 has
taken the worried jump from birds to infect humans.
Should the virus shift and human-to-human transmission become
sustained, imagine how many human lives avian flu will take. How then
would a nation greatly moved and touched by three thousand dead, react
to 5 or 50 million dead?
*
The new realities of terrorism and suicide bombers pull us one step
further. How would we react to the devastation caused by a virus or
bacteria or other pathogen unleashed not by the forces of nature, but
intentionally by man?
During the Cold War, the Soviet Union, which stockpiled 5,000 tons
annually of biowarfare-engineered anthrax resistant to 16 antibiotics,
also produced massive amounts of weaponized smallpox -- just as the
monumental effort to immunize the world’s children came to a successful
close.
It is impossible to rule out that quantities of this or other
deliberately manufactured pathogens such as pneumonic plague,
tularemia, or botulinum toxin may find or may have found their ways
into the possession of terrorists such as bin Laden and Zarqawi.
Although the United States now has enough smallpox vaccine for the
entire population, we have neither the means of distribution nor the
immunized personnel to administer it in a generalized outbreak nor the
certainty that the vaccine we have would even be relevant to a specific
weaponized strain of the virus.
Hospitals and our long neglected public health infrastructure would
be quickly overwhelmed. Panic, suffering, and the spread of the disease
would intensify as -- because people were dead, sick, or afraid -- the
economy ceased to function, electrical power flickered out, and food
and medical supplies failed to move.
Over months or perhaps years, scores of millions might perish, with
whole families dying in their houses and no one to memorialize them or
remove their corpses. Almost without doubt, the epidemic would spread
to the rest of the world, for in biological warfare an attack upon one
country is an attack upon all.
Every vestige of modernity would be overturned. The continual and
illusory flirtation with immortality that is a hallmark of our
scientific civilization would shatter. And we would find ourselves
looking back upon even the most difficult times of the last century as
a golden age.
*
Despite the common wisdom, humanity has not moved beyond this kind
of scenario. No -- of late it has moved unnecessarily and gratuitously
toward it.
Any number of known and unknown viruses -- for which at present
there is neither immunization nor cure -- are at this very moment
cooking in Asia and Africa -- where they arise in hotbeds of densely
intermingled human and animal populations.
We are in unexplored territory. The brew is stewing in a new, ideal
mixing vessel. Economic and environmental changes in Asia have forced
wilderness-deprived waterfowl to alight to feed amid farm animals -- in
newly dense populations due to recently acquired wealth and dietary
expectations and in a culture in which live poultry is brought to
market.
The reassortment of viral DNA as a result of this mingling is so
frenzied that it is only a matter of time until the emergence of a
virus unequaled in transmissibility and virulence. The epidemiological
calculus of flu is notoriously volatile due to the unknowns of rapid
reassortment. We do know now, however, we are woefully under prepared
even for a virus that we can today foresee -- much less for one that we
cannot.
No such viruses have yet reached critical mass, or leapt from the
channels imposed by their inherent limitations, environmental
obstacles, and deliberate actions to contain them. But who is to say
they cannot? I certainly won’t. Not with what I’ve seen.
I was in China at the height of the SARS outbreak and witnessed the
government’s confused, deceptive, and miserable initial cover-up and
response. As a doctor on annual medical mission trips, I have treated
patients in the Sudan and, just two weeks ago, in Tanzania. I have seen
a determined epidemic -- HIV/AIDS -- kill millions and hollow out
entire societies on the African continent.
The evidence I have seen as doctor, scientist, and policy maker,
the patterns of history, and new facts -- such as rapid, voluminous,
and essential travel and trade; the decline of staffed hospital beds;
and a now heavily urbanized and suburbanized American population
dependent as never before upon “just in time” but easily disrupted
networks of services and supply -- lead me to believe that such
pathogens could result in the immensely high death tolls to which I
have alluded.
*
Take the virus that is today the gravest threat -- avian flu. A
vaccine would not become available, at best, until six to nine months
after the outbreak of a pandemic. Even then, the vaccine would not be
available in mass quantities. And even then, we do not know if that
vaccine would work. It’s still experimental.
So, in essence, we have no vaccine for avian flu. Nor do we have
enough of the only effective anti-viral agent Tamiflu stockpiled to
treat more than one percent of our population for avian flu.
*
It’s true that neither Avian flu nor these other viruses have yet
spread geometrically -- instantly and irrevocably overcoming health
care systems and pulling us backward across thresholds of darkness that
we long hoped we would never cross again. And yet this they might do --
either entirely on their own in nature or as a result of deliberate,
purposeful human intervention.
No intelligence agency, no matter how astute, and no military, no
matter how powerful and dedicated, can assure that a few technicians of
middling skill using a few thousand dollars worth of readily available
equipment in a small and apparently innocuous setting cannot mount a
first-order biological attack.
It’s possible today to synthesize virulent pathogens from scratch,
or to engineer and manufacture prions that, introduced undetectably
over time into a nation’s food supply, would after a long delay afflict
millions with a terrible and often fatal disease. It’s a new world.
Unfortunately, the permutations are so various that the research
establishment as now constituted cannot set up lines of investigation
to anticipate even a small proportion of them. But is it really
reasonable to assume that anyone might resort to biological warfare?
Indeed it is.
Though Al-Qaida’s leadership has been decimated, it has declared
that, “We have the right to kill four million Americans -- two million
of them children . . . . [and] it is our right to fight them with
chemical and biological weapons.”
It’s hardly necessary, however, to rely upon stated intent. One
need only weigh the logic of terrorism, its evolution, its absolutist
convictions, and the evidence in documents and materials found in
terrorist redoubts.
Though not as initially dramatic as a nuclear blast, biological
warfare is potentially far more destructive than the kind of nuclear
attack feasible at the operational level of the terrorist. And
biological war is itself distressingly easy to wage.
Never have we had to fight such a battle, to protect so many people against so many threats that are so silent and so lethal.
*
So I ask again how it is that we are so unprepared either for
naturally occurring epidemics of newly emergent diseases or those that
will be deliberately and purposefully induced?
I propose that we take the measure of this threat and make
preparations today to engage it with the force and knowledge adequate
to throw it back wherever and however it may strike.
It need not be invincible and we need not fall to our knees before
it. Means adequate to the success of a defensive plan are present in
great profusion. Whereas the approaching biological shift is gathering
force like a massing army, providence has massed an army to meet it.
Having themselves expanded geometrically, the life sciences have
come to the threshold of a great age, and to cross it they need only
encouragement and a signal from the body politic to put their resources
in play.
*
We are not without weapons in this war. They are present in the
stupendous material and intellectual wealth of the civilized world,
which, despite current divisions of action and opinion, has everything
to lose in common.
They are present in the great stores of science and technology
amassed over thousands of years of civilization -- in the many hundreds
of universities, advanced research institutions, and hospitals -- yes,
in the United States and Europe, but also in Latin America, India,
China, and dozens of other countries on six continents.
They are present in the revolution spawned by information
technology and our vast, instant and interconnected ability to
communicate and share information. They are present in the private
sector’s ruthless focus, which, though frequently condemned for its
lack of humanity, could well be the instrument that saves us in the
end.
They are present in the special temperament and brilliance of
individual scientists; in the magnificent light that comes of the
surprising and ingenious application of new technologies; and in the
vigor, intelligence, and decency of free and unoppressed peoples.
*
So what must we do?
I propose an unprecedented effort -- a “Manhattan Project for the
21st Century” -- not with the goal of creating a destructive new
weapon, but to defend against destruction wreaked by infectious disease
and biological weapons.
I speak of substantial increases in support for fundamental
research, medical education, emergency capacity, and public health
infrastructure. I speak of an unleashing of the private sector and
unprecedented collaboration between government and industry and
academia. I speak of the creation of secure stores of treatments and
vaccines and vast networks of distribution.
Above all, I speak not of the creation of a forest of bureaucratic
organization charts and the repetition of a hundred million Latinate
words in a hundred million meetings that substitute for action, but
action itself -- without excuses, without exceptions -- with the goal
of protecting every American and the capability to help protect the
people of the world.
I call for the creation of the ability to detect, identify, and
model any emerging or newly emerging infection, present or future,
natural or otherwise -- for the ability to engineer the immunization
and cure, and to manufacture, distribute, and administer what we need
to get it done and to get it done in time.
*
This is a bold vision. But it is the kind of thing that, once
accomplished, is done. And it is the kind of thing that calls out to be
done -- and that, if not done, will indict us forever in the eyes of
history.
In diverting a portion of our vast resources to protect nothing
less than our lives, the lives of our children, and the life of our
civilization, many benefits other than survival would follow in train
-- not least the satisfaction of having done right.
If the process of scientific discovery proceeds as usually it does,
we will come to understand diseases that we do not now understand and
find the cures for diseases that we cannot now cure.
And, as always, disciplined and decisive action in facing an
emergency can, even in the short run, compensate for its costs -- by
adding to the economy both a potent principle of organization and a
stimulus like war, but war’s opposite in effect.
This would power the productive life of the country into new
fields, transforming the information age with unexpected rapidity into
the biotechnical age that is to come. All this, if the nation can be
properly inspired in its own defense and protection -- perhaps just in
time.
We must open our eyes to face the single greatest threat to our
safety and security today, but also to seize our greatest single
opportunity.
*
Allow a conservative Senator from Tennessee who is by nature
skeptical of overzealous government action to affirm the root
conservative principle that if the life of the nation is potentially at
risk, no effort should be judged too ambitious, no price too high to
pay, no division too wide to breach.
I’m aware of the difficulties. But the United States is as blessed
today as it has been since its beginnings. We are the wealthiest,
free-est, and most scientifically advanced of all societies, the first
republican democracy, and the first modern state.
And although we as a nation have suffered criticism of late, we’ve
been willing since our Founding, and are willing still, to pursue
certain ideals. Though not infrequently condemned from the precincts of
cynicism, America has mostly left cynics in its wake -- sometimes after
saving them from floods that they themselves have unleashed.
Today I’ve tried to impress upon you the urgency I feel in a matter
concerning not only America but the world -- for pandemics whether
natural or intentional know neither borders, nor race, nor who is rich
nor who is poor. They know only what is human, and it is this that they
strike, casting aside the vain definitions that otherwise divide us.
It is my pre-eminent obligation as a public servant and my sacred
duty as a physician to ask you to support the essence of this proposal.
In respect of human mortality, for the sake of your own families and
children, for the honor and satisfaction of doing right, I bid you join
in this effort.
May God preserve us all, and may our actions and foresight make us worthy of His preservation.
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