Somewhere, someone has the flu. Dr. David Heymann, assistant director-general for communicable diseases at the World Health Organization (WHO), is talking to the Stanford community about infectious diseases and public health security, and his discussion invariably comes back to just that—influenza, or “the flu.” The Global Influenza Programme at WHO is one of the organization’s most developed, and with good reason: There are 3 to 5 million cases of severe influenza around the world each year, resulting in 250,000 to 500,000 deaths. What Heymann and the WHO influenza surveillance network are on the lookout for are new strains like H5N1 (avian influenza) and seasonal outbreaks in areas not equipped to manage them.

The surveillance network, Heymann explained, is one way that global collective action can reduce vulnerability to infectious diseases—and shows how advances in technology can be used to fill the gaps in official country-by-country reporting. While international health regulations are in place, “they’re outdated,” he said. Often a “first case of a disease occurs, a country either reports late or doesn’t report at all because it doesn’t want to let anyone know, and so there’s a delayed response, the outbreak is uncontrolled, it makes people sick and kills them in the country, and there’s a risk of international spread,” said Heymann.

But in February 1999, the Global Public Health Intelligence Network (GPHIN)— an Internet-based, early-warning system developed by the Canadian Ministry of Health—detected an outbreak of fatal influenza in rural Afghanistan, then under control of the Taliban. It was a perfect example of outbreak verification and response—and one that was entirely independent of formal national reporting. And in 2003, as part of WHO efforts to contain SARS, public health officials mapped out clusters of influenza cases, using software the Hong Kong police ordinarily use to track petty crime, said Heymann, citing another example.

In a world in which increasingly global commerce and rapid contact across national lines have made infectious disease a foreign policy issue, intergovernmental health organizations such as WHO are finding that there are limits to the cooperation and collective sense of responsibility of member countries. After the United States vetoed a revised set of international health regulations in 2006—the last update had been in 1969—Heymann and other public health officials started to redefine the scope of their work. For Heymann, that means continuing to work with countries to develop containment strategies, but using technology to gather and verify information independently.

Heymann concluded two weeks in residence at Stanford on April 12 by giving a 2007 Payne Distinguished Lecture, titled “Infectious Diseases Across Borders: Public Health Security in the 21st Century.” Four weeks later, on May 9, another eminent physician and public health activist also delivered a Payne Distinguished Lecture, “AIDS: Pandemic and Agent for Change,” to the Stanford community—Dr. Peter Piot, executive director of UNAIDS and under secretary-general of the United Nations. Like Heymann, Piot is no stranger to the “globalization of risk,” as he calls it, nor to its implications for international security and development. AIDS is the fourth-leading cause of death worldwide and the number-one killer for 15–59-year-olds. It has infected 65 million people since it was first diagnosed in 1982; 40 million people are living with HIV today.

Dr. Alan Garber, director of the Center for Health Policy and Center for Primary Care and Outcomes Research (CHP/PCOR), described Piot as “perhaps the most important person in the effort to limit the global spread of the HIV virus and to make sure that people have access to treatment.” A major factor in Piot’s effectiveness in securing political and financial support for new programs has been his ability to view—and challenge others to view—AIDS in a political context.

“AIDS ranks with climate change, international terrorism, and the threat of nuclear war,” Piot told his audience. “This is the most important interdisciplinary issue of our time. ...This is not a short-lived phenomenon.”

“Act early. Don’t take that risk. The price the world is paying is now extraordinarily high.”

Unlike almost every other disease and health indicator, Piot said, AIDS is not a disease of poverty. It is a disease marked by its exceptionalism as well as its wideranging implications for security and human well-being; it affects people in their most productive years and “erodes human and social capital, putting development programs into reverse.” In some African countries, teachers are dying faster than new ones can be trained. Other governments struggle to fill institutional and parliamentary positions left vacant after incumbents died of disease. Seventy percent of all military deaths in South Africa are from AIDS.

In the 10 years since UNAIDS was founded, its spending on the developing world has increased 40-fold, from $250 million to $10 billion. Two million people are on antiretroviral treatment in that part of the world. But one of Piot’s challenges as executive director of UNAIDS has been maintaining political focus on the epidemic. In 2001, the U.N. General Assembly held a special session on AIDS—the very first time such a session was held for a public health issue. It was a “watershed,” said Piot. The session concluded with a Declaration of Commitment to Deal with HIV/AIDS; the meeting, according to Piot, put AIDS “on the political map—not just on public health agendas—and world leaders were taking it seriously.”

With their combined years of experience and field work, both men have a clear sense of urgency to respond to public health crises when and as they arise. Piot co-discovered the Ebola virus in Zaire in 1976; Heymann was involved in the initial characterization of Legionnaires’ Disease and worked in Africa to contain the second outbreak of the Ebola virus. But they also understand the ironies that have unfolded in public health management over the last 40 years. Heymann discussed the program to eradicate smallpox in the late 1960s and 1970s and how political will, the availability of a cheap and stable vaccine, easy clinical diagnosis, and face-to-face transmission all favored eradication efforts. Smallpox eradication was certified in 1980, two years before the first case of HIV/AIDS (a virus that makes the smallpox vaccine toxic to the human body) was diagnosed. “Address infectious diseases when you can,” Heymann said. “The window of opportunity may be smaller than anyone realizes.”

Similarly, Piot discussed how HIV/AIDS was underestimated in the early 1980s. Twenty-five years and 65 million HIV cases later, Piot said, we now know to “act early. Don’t take that risk. The price the world is paying is now extraordinarily high.”

Both Heymann and Piot noted that intellectual property protection is necessary for continued production of vaccines despite the challenge it poses to vaccine access: No profit margin means no production. One of the medium-term strategies Heymann offered is to look at industries in developing countries that might have the capacity and include them in the process. In the long term, some combination of technology transfer in an increased market for seasonal vaccines and the development of new technologies that make it easier to develop vaccines will be necessary.

Piot highlighted a number of the changes in international trade agreements and intellectual property systems in the last few years. In 2001 World Trade Organization members (including the United States) signed the TRIPS-Doha agreement, which provides for fair compensation and generic versions of drugs in times of health crisis. “The aim is to make cheaper drugs available to developing countries,” Piot said, “but to still provide fair compensation to patent holders.” He also discussed the trade agreements for health issues, negotiated by Bill Clinton, which had been publicly announced just a few days prior.

Whether a country refuses to release bird-flu samples to WHO for vaccine production, as Indonesia did earlier this year, or suspends a basic childhood vaccination program, as Nigeria did in 2003, public health has become a globally politicized issue that exposes the basic inequalities between developed and developing countries. It also, Piot poignantly argued, exposes inequity in gender relations in much of the world. Half of HIV-positive individuals are women; among teenagers, HIV infection rates are five to six times higher in women. There are biological factors, such as the efficiency of transmission; but many more are social, such as women’s lack of control over their own bodies and gender violence. AIDS, said Piot, “is probably one of the most lethal aspects of inequality between men and women.”

As devastating as AIDS and influenza have been, Piot and Heymann both spoke about areas in which disease has unexpectedly worked as an agent for social change— gay rights, patient-doctor relationships, public debate and activism, public accountability, international governance, development assistance programs, gender relations. The message? There is much work to be done, but there is also progress, and we must stick with it. “The world needs greater intellectual power in the fight against AIDS,” said Piot, “a brilliant alliance of politics, business, trade unions, and churches, so that it’s not just AIDS workers and activists battling the epidemic.”