Here's an unfortunate heads up: The program that helped stop Ebola in its tracks may be gone by next fall. Family physicians should be on notice, because the implications are serious -- both for public health and for our practices.
Ranit Mishori, M.D., M.H.S.
We all take pride in the well-deserved recognition garnered by our family medicine colleagues Kent Brantly, M.D., and Rick Sacra, M.D., who not only treated patients during the international Ebola outbreak in 2014, but also contracted the disease themselves. Their work highlighted the crucial role family physicians may play at the frontlines of efforts to manage and prevent such outbreaks, and to contain them when they threaten to spread internationally.
But now a core global program designed expressly for that purpose is facing, if not elimination, then a profound decrease in funding(www.npr.org) and, consequently, likely in reach and effectiveness. The Global Health Security Agenda, or GHSA, was started in 2014 in response to that year's epidemic as a "multilateral and multisectoral initiative of over 40 countries … to prevent, detect, and rapidly respond to infectious disease threats."
The idea is to stop infectious disease outbreaks at their source, before they hit the United States or other countries around the world, and to do that by bolstering local capacity. This means training local labs and frontline health workers to detect dangerous pathogens and set up systems for surveillance, early warning and emergency response.
That is an ambitious agenda, and yes, achieving it is expensive because it requires marshalling high levels of expertise, along with appropriate resources and meaningful levels of coordination. Not surprisingly, an initiative like this also takes a long time to reach full functionality before it can begin to show success.
Now, however, GHSA may not get that chance. News reports suggest that the program may be facing extraordinarily deep cuts -- as large as 66 percent from current levels. In practical terms, that means that after October 2019, only 10 countries will benefit from the program instead of the current total of about 40. The countries likely to remain in the program are India, Thailand, Vietnam, Jordan, Kenya, Uganda, Liberia, Nigeria, Senegal and Guatemala.
In the countries left out of the program, training may cease, containment efforts will be curtailed, and prevention initiatives will be curbed. As an indication of the risks involved, consider, for example, that in the recent past four of the countries in this cohort -- Haiti, China, Brazil and the Democratic Republic of Congo -- have been the sites of, respectively, a major cholera outbreak, ground zero for the severe acute respiratory syndrome (SARS) epidemic, the place where Zika took root, and the nation where Ebola started and where it occasionally resurfaces.
The implications are obvious. Countries with weaker public health systems will likely backslide in their ability both to detect and contain the next epidemic, making it more likely that smaller, containable outbreaks will spiral out of control as individuals hop on trains, boats or planes.
That's when and how the problem comes home to us.
"An outbreak anywhere is a threat everywhere," the CDC's Division of Global Health Protection, which manages GHSA, says on its website. "We know that a disease can be transported from an isolated rural village to any major city in as little as 36 hours."
As family physicians, even those of us who are not involved directly in global health work must acknowledge that the proposed cuts can directly affect us, our communities, our patients, our national security and our economy. Prevention is almost always the less expensive course because the cost of chasing an epidemic in the United States -- and preparing our clinics and hospitals for such emergencies -- will almost always be greater than the cost of containing outbreaks far from our shores. We have no moat when it comes to disease, and an "America first" mentality, if it means cutting back on the support we give to other countries' control efforts, is highly likely to come back to bite us.
Global health matters to family physicians through direct clinical care, education and train-the-trainer programs and through engagement in prevention and public health projects. Some family physicians may not want to engage in discussions that end up being politicized or that involve global affairs. But this is a case where we must consider that microbes ignore borders and political parties. Middle East respiratory syndrome and SARS and multidrug-resistant TB don't care about right versus left.
These cuts will leave the world unprepared for the next outbreak, and our own citizens -- our patients, our family members, our colleagues, all of us -- vulnerable. In today's interconnected world, a traveler can be in West Africa one day and in a Midwestern town the next. After a particularly rough (and still ongoing) flu season, who's to say where the next flu pandemic may come from? We are far less likely to know if the government allows these budget cuts to take effect.
Ranit Mishori, M.D., M.H.S., is a professor and director of global health initiatives in the Department of Family Medicine at Georgetown University School of Medicine in Washington, D.C. She also is a member of the advisory board of the AAFPs Center for Global Health Initiatives.