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Emerging Public Health Challenges in the United States

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Thomas J. Bollyky, senior fellow for global health, economics, and development, and director of the Global Health Program at CFR, discusses emerging public health challenges in the United States, including vaccine hesitancy and the recent measles outbreaks, as part of CFR’s State and Local Conference Call series.

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Thomas J. Bollyky

Senior Fellow for Global Health, Economics, and Development, and Director of the Global Health Program, Council on Foreign Relations


Irina A. Faskianos

Vice President, National Program and Outreach, Council on Foreign Relations

FASKIANOS: Good afternoon from New York, and welcome to the Council on Foreign Relations State and Local Conference Call Series. I’m Irina Faskianos, vice president for the National Program and Outreach at CFR. We are delighted to have more than eighty of you joining us from twenty-eight states across the country. As you may know, the CFR State and Local Officials Initiative serves as an authoritative politically independent resource on pressing international issues that affect the priorities and agendas of state and local governments. As a reminder, the conversation between our speaker Thomas Bollyky and us is on the record and will be available on our website after the fact. The question and answer portion and comments will be not for attribution. So we will not make those public so we can have a more candid discussion.

So we are delighted to have Tom Bollyky with us. He is the director of the Global Health Program and senior fellow for global health, economics, and development at CFR. He is also an adjunct professor of law at Georgetown University. Tom Bollyky is the author of the book, Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways. And his book, Bill Gates has just listed at the top of his reading list, so I commend it to all of you. Tom has been a consultant to the World Health Organization and the Bill and Melinda Gates Foundation, and he’s served in a variety of roles in the U.S. government. Previously, he represented clients before the International Court of Justice and the U.S. Supreme Court, and was a Fulbright scholar to South Africa, where he worked at the AIDS Law Project. In 2013, the World Economic Forum named Tom Bollyky as one of its global leaders under forty.

Tom, thank you very much for being with us today. It would be great if you could give us an introduction to some of the emerging public health challenges you’re seeing in the United States, such as the recent outbreaks of measles and the anti-vaccination movement. And talk a little bit too about why we should be worried that the world is getting healthier.

BOLLYKY: Sounds good. Thanks, Irina. I appreciate the kind introduction. This is a remarkable group of officials. I had a chance to look at the list of those participating and it’s really an honor for me to have a chance to speak to all of you who are on the frontlines of public health.

The topic I’m going to build my remarks around today is on vaccination and vaccine hesitancy, using measles as a case study in particular. I wouldn’t presume to tell this group what that phenomenon looks like in your—in your towns and states. Instead, what I’m going to do is try to connect what has been happening in the United States domestically and put it in a broader historical context, draw the connection to some international trends, and then present what I see as the opportunities and risks of the current situation from someone who thinks about these issues from a foreign policy and national security perspective.

Let’s start with the historical context. As Irina alluded to, I have a recent book. It’s on the history of the decline of infectious diseases, which is a funny thing to talk about in the midst of an outbreak of measles, but it’s true. For the first time in recorded human history bacteria, viruses, and other infectious agents do not cause the majority of death or disability in any region of the world. Indeed, and in fact in most regions of the world—all regions of the world—infectious diseases cause less than 8 percent—8 percent of the mortality. In the last fifteen years alone, deaths from HIV are down 40 percent. Deaths from malaria, tuberculosis, diarrheal disease are down a quarter. Measles deaths, notably, are down 80 percent globally from 2000. 1950, there were a hundred countries in the world where one out of five children would die before their fifth birthday. Today that doesn’t happen anywhere.

What my book argues is that there’s been no development in the last century—not world wars, not the rise of the internet, or spread of democracy—that has had as transformative an impact on the lived human experience as this decline of infectious diseases. It’s shaped and affected the fortunes of nations’ economies, the geography of cities around the world, and the movement of people. It’s important, and we should continue to invest in global health.

Robert Gordon, the economist, cites the decline if infant mortality in the United States between 1890 and 1950 as one of the single most important facts in the history of American economic growth. China, as many of you will know, in the 1950s through the ’70s was one of the poorest countries in the world. When it began an all-out peasant-based war on infectious diseases, that created the conditions for its eventual economic rise. In the U.S., our gains against infectious diseases and the improvements we saw attendant to those declines in those diseases—respiratory diseases like measles played a big part in that.

Measles and other respiratory diseases, infectious diseases, caused nearly 30 percent of U.S. deaths in children under the age of fourteen in 1900. And it was really with the development of a vaccine that advanced and cemented the gains the U.S. had been making against those diseases and helped spread those gains around the world. A 2013 New England Journal of Medicine study estimated that measles vaccination in the U.S. averted thirty-five million cases of measles since 1963 alone. This was a disease that had been killing around five hundred people per year, and about fifty thousand people hospitalized. So that’s a pretty significant gain.

These gains have—through vaccination—have spread globally. The international campaign against smallpox, immunization campaign, succeeded in eradicating that disease—the first disease humankind has eradicated—in 1980. And that campaign became the model for our other global health initiatives. One such campaign, entitled the Child Survival Revolution, managed to vaccinate 70 percent of the world’s children in just a decade. And with that, you’ve seen the health improvements that we described—that I described, and notably, for measles, more than 80 percent decline in deaths, but also just in the incidence of the disease. Measles vaccination over that time is estimated as, say, twenty-one million deaths globally. The disease was eliminated in the U.S. and in its North and South American neighbors. We’ve seen a decline in child deaths by almost half, from ten million to fewer than six million over that last fifteen years.

But these gains are fragile. And that brings us to the topic we’re going to focus on, or I’m going to focus on, the rest of these remarks. And that’s vaccine hesitation and under-vaccination. It’s not a new issue. Opposition to compulsory smallpox vaccination arose in the nineteenth century in Britain and the United States and tended to gain traction with the success of that vaccination campaign, and the decline of smallpox. It was particularly prevalent in insular social groups, primarily immigrant groups and rural groups, but also the urban artisan class—groups that had harbored a distrust of government.

And many—if you look at many of the pamphlets that were traded around by those movements in the 19th century, they bristle with the same ideas around vaccine choice and purity that you read about today. But the impact of those campaigns was variable. There were some nations that needed—that scaled back their compulsory vaccination programs or granted exceptions, but there were lots that didn’t, like France which, for decades, maintained them. And it tends to be very context specific.

The issue of vaccine hesitancy, of course, as you all know, has escalated over the last two decades with the rise of social media. It’s not an accident that Andrew Wakefield in his study in the Lancet on the link between autism and the MMR vaccine happened on the eve of the digital revolution, right around the time when Google opened its doors, followed by Facebook, and YouTube, and rest. He’s not alone. As you well know, there are lots of other players out there who have also embraced social media and have been, in some cases, abusing that resource. The World Economic Forum in 2013 ranked as one of its leading global risks these digital wildfires. And health was the primary reason for that.

Now, vaccines and vaccination tends to be particularly vulnerable to social media advocates against them because, in part, these are products that are produced by the private sector. They’re regulated, in some cases distributed by governments. It involves a science that may seem inaccessible to many who are being vaccinated, or their children. And you know, that’s played a role. There also has been a rise of some elements of this that are new even beyond social media. There was an interesting report that some of you may have seen out of George Washington University about Russian trolls and bots disseminating anti-vaccine messages as a way of sowing dissention.

Internationally, vaccine hesitancy—so to leave aside just the U.S. for a minute, again, to focus on the international context—the World Health Organization now ranks it as one of its top ten global health risks. This is an issue well beyond measles. In Nigeria in 2004, rumors of the polio vaccine being linked to sterility in young girls led to resistance against that vaccine campaign cost the global polio eradication initiatives $500 million and several years to reverse the consequences of that. But other developed countries too—like Japan, Denmark, and Ireland—had resistance to the HPV vaccine. And social media rumors that you’ve seen just a few weeks ago in Pakistan with some concerns being raised over Facebook and YouTube about the polio vaccine killing people. You saw a hundred thousand refusals of vaccinations in Islamabad alone. And that’s up from the normal rate, which would be about two to three hundred.

This is happening against the backdrop where in some countries you have corruption and conflict leading to under-vaccination rates, like in the Ukraine, or Yemen, or Venezuela, or Madagascar. And these pockets of under-vaccinated populations tend to be a way in which outbreaks of measles in particular have spread internationally. So out of the eighty-three thousand cases of measles that were reported in Europe last year, in 2018, fifty-five are—or, I guess close to fifty-five thousand cases originated in Ukraine, or fifty-five thousand of those cases were in Ukraine. And many of them are credited with spreading to other regions. They were able to do this, of course, because of the rise of vaccine hesitancy in some of these other European nations. So cases in Greece doubled in a year. Cases in France grew nearly six fold in a year, and those cases, again, it’s people declining to vaccinate their children.

In the U.S. context, this—the way this international dynamic interacts is, of course, many of the outbreaks we’ve seen over the past five years have all followed similar patterns. Unvaccinated international travelers coming to communities where you have a disruption in herd immunity, where you have under-vaccinated populations here, and that leads to outbreaks. That was true with the Disneyland outbreak in 2015, which originated from an unvaccinated individual from the Philippines. But more—almost all of the—or all of the outbreaks we really have seen started with an international traveler—an unvaccinated international traveler ending up in these clusters of vaccine hesitancy in groups.

And we’re seeing that—there’s, of course, half of the nearly thousand measles cases—or, over a thousand measles cases we now have in the United States are in New York. Tends to be a significant portion that are in Rockland County, and linked in particular to the Orthodox community there. But that has also been a way—through other Orthodox communities you’ve seen it spread to other states. But that’s not the only way. Of course, there’s also people that have been hesitant to vaccinate. And Washington state declared a state of emergency around this, and you’ve seen other states with a fairly high number as well.

This all has echoes of what we saw in the nineteenth century, where you have outbreaks occurring in trusted communities, or vaccine hesitation, rather, occurring in trusted communities, where it’s really around—less around religious reasons per se, but that within a trusted community and network, shared beliefs get quickly accepted by other members of that network. And, again, that’s what you saw—what we’ve always seen around vaccine hesitancy. And, you know, shared community ties lead, sadly, to shared viruses. And communities with a diaspora tend to spread those viruses both nationally and internationally.

So here’s what I see as the, again, someone who thinks about these things in a foreign policy and a national security context, what I see as the risks and opportunities. And let’s focus on the positive for a moment in terms of the opportunities. Vaccination has been a vehicle by which we’ve drawn nations together historically. That Child Survival Revolution I mentioned, it is, as I know, the only initiative that has led to a ceasefire, which occurred in El Salvador in their fourteen-year civil war, for the purposes of immunizing children, for the purposes of health.

So vaccines in the face of an understanding of the risks of not being vaccinated are a vehicle for building trust in societies and among an international community. I saw it as quite positive that President Trump has made an unequivocal statement about the need to vaccinate, particularly around measles, and that you’re starting to see some thinking happening in social media terms about what can be done to address the share of the population—and it’s probably a minority of the vaccine hesitant community—how many of them are using these websites nefariously. But social media firms are thinking about how to address that.

The other opportunity I see here is really for physicians and the medical community and public health community to take a greater role than it even is now. I think people turn to social media because they need to have a space to have discussions over their anxieties. And, you know, there’s an absence of opportunity to do that. We’ve seen around HPV in the past, though, a federal effort to try to encourage and empower the physician community and dissuade them from avoiding what can be sometimes difficult communities that people don’t have—or, difficult conversations that busy health professionals don’t have time for. Encouraging them and trying to empower them to give them space to have those difficult conversations, this is a vehicle with which in other circumstances we’ve been able to address. Even already around the measles outbreaks, you see how it’s drawn some pro-vaccine parents out of the closet, so to speak, and be a lot more vocal. And I think that’s helpful.

Now let’s talk about the risks. The risks on the measles side are—many of you are going to be very familiar with. But in case there are a few of you that are not, of course, 1-3 percent of those that contract the disease will die of neurological complications. My book opens—the chapter that talks about measles opens with a discussion of Roald Dahl, who is the author of Charlie and the Chocolate Factory and James and the Giant Peach, and a lot of these other wonderfully dark children’s stories, he tells a story about his daughter when she was seven. And coming from, you know, making pipe cleaner animals for her when she was in bed with the measles to her passing from encephalitis just hours later. And it’s tragic.

And there is a risk of neurological complications, of course. And some percentage of the people who have these have—who are suffering from the current outbreak will get them. And—but also, it suppresses the immune system in ways that makes people at risks to other infections. The fact that we do have vaccination campaigns now means that the outbreaks occur in different ways. Where it used to be just with small children, it’s happening in older children and adults. And there’s a risk even to pregnant women. You know, there’s a story in Shanghai about a measles outbreak that spread in the pediatric oncology ward and ended up in resulting in a more than 20 percent case fatality rate from that outbreak. So it’s scary.

JAMA recently tried to do an estimate of the financial costs, which they argue have been in the past as high as $142,000 per case, depending on how much work up needed to occur, around contract tracing and post-exposure prophylaxis. But certainly what we’re seeing now is costing in the millions, in addition to its tragic health toll, and disrupts health systems in other ways. So that’s on the measles side. The broader risks that I see, and one that really keeps me up at night, is that vaccine hesitancy undermines our ability to confront emerging infections. There’s a lot of investment now, particularly after the 2014 outbreak of Ebola in West Africa, to try to anticipate the diseases that might be leading to epidemics and pandemics in the future.

There’s enormous investment going into trying to develop the universal vaccine for influenza, because avian influenza is one of the few things that can legitimate kill tens of millions of people in a matter of months. And my concern is that the hesitancy we have around vaccines and the breakdown that we’ve seeing around measles makes us more vulnerable in this space. I mean, last year alone, even on influenza, we saw in the United States eighty thousand people die of seasonable influenza. A truly pathogenic strain could do much, much worse. Obviously in 1919 Spanish flu outbreak. Estimates vary from fifty to a hundred million people who perished there. And you could see something similar. So the stakes here are—go well-beyond just measles.

Where I would end is just saying that the history—to tie this back to where I started—the history of the decline of infectious diseases is still very much being written. It’s been transformative both socially and economically, both in the United States and abroad. And there’s still much more to be done. This is certainly not a time for a plot twist or a reversal in that history. And let me stop there and see if people have questions.

FASKIANOS: Tom, thank you very much. One final thing for you to leave us with, just talk a little bit about the Emerging Crisis Noncommunicable Disease Tracker that you have just released on

BOLLYKY: Great. So we have a number of—we have all sorts of materials. Obviously there’s the book, so available at reputable and probably disreputable booksellers near you. We also have interactives on CFR that—a number of them. We have in the past looked at the rate of vaccine-preventable outbreaks. So that’s something institutionally we’ve done. We have one now that looks at how changing demographics internationally are shaping the global health environment. We also have one that looks at the tie to urban environments that we’ve been talking about, and how the future of global health is urban—necessarily because now most of the population, even in low and middle-income countries live in urban areas. We just did one recently on democracy and health. So lots of great materials on the website. I hope you make use of them. And to the extent anybody who is shy about asking a question today wants to follow up individually, I’d be very happy for that too. So I’m easy to find on the CFR website.

FASKIANOS: Wonderful. Tom, thank you very much for sharing your insights with us today, and to all of you for being on the call, and for your questions. We appreciate it. As Tom Bollyky mentioned, you can email questions to him. You can go through us, emailing us at [email protected], as well as feedback and other topics you might want to cover. Tom also tweets. His handle on Twitter is @TomBollyky. So we have a lot of amazing resources that we hope you will take advantage of. If you have specific questions, please feel free to call upon us. And thank you for all that you’re doing in your communities.

BOLLYKY: Thank you for the opportunity. It really is an honor to speak to all of you. And good luck.


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