It Ain’t Over Till It’s Over…but It’s Never Over — Emerging and Reemerging Infectious Diseases


As I prepare to step down from my dual positions at the National Institute of Allergy and Infectious Diseases (NIAID), where I spent 54 years as a physician scientist and 38 years as a director, some reflection is inevitable. When I reflect on my career, what stands out most is the striking evolution of the infectious disease field and the changing perception of the importance and relevance of the field by both the academic community and the public.

I completed my residency training in internal medicine in 1968 and decided to pursue a 3-year combined fellowship in infectious disease and clinical immunology at NIAID. Unbeknownst to me as a young doctor, certain scientists and experts in the 1960s believed that with the advent of highly effective vaccines for many childhood illnesses and a growing range of antibiotics, the threat of infectious diseases – and perhaps with it the need for specialists in field of infectious diseases – was quickly disappearing.1 Despite my passion for the field I was entering, I might have reconsidered my choice of a subspecialty had I known about this skepticism about the future of the discipline. Of course, malaria, tuberculosis and other diseases in low- and middle-income countries killed millions of people every year at the time. Unaware of this inherent contradiction, I happily pursued my clinical and research interests in host defenses and infectious diseases.

Several years out of my fellowship, I was somewhat surprised when Dr. Robert Petersdorf, an infectious disease icon, published a provocative article in the log suggesting that infectious diseases as a subspecialty of internal medicine fell into obscurity.2 In an article titled “The Doctors’ Dilemma,” he wrote about the number of young doctors who are training in the various subspecialties of internal medicine: experts, unless they spend their time cultivating each other.

Of course we all want to be part of a dynamic field. Was my chosen field now static? Dr. Petersdorf (who would become my friend and part-time mentor as we and others worked together Harrison’s Principles of Internal Medicine) gave voice to a common position that did not fully appreciate the truly dynamic nature of infectious diseases, especially with regard to the potential for new and re-emerging infections. In the 1960s and 1970s, most physicians were aware of the possibility of pandemics, given the well-known precedent of the historic flu pandemic of 1918 and the more recent flu pandemics of 1957 and 1968. The emergence of a truly new infectious disease that could dramatically change society influence was still a purely hypothetical concept.

That all changed in the summer of 1981 with the recognition of the first cases of what would become known as AIDS. The global impact of this disease is staggering: since the beginning of the pandemic, more than 84 million people have been infected with HIV, the virus that causes AIDS, of whom 40 million have died. In 2021 alone, 650,000 people died from AIDS-related conditions and 1.5 million became re-infected. Today, more than 38 million people live with HIV.

Although a safe and effective HIV vaccine has not yet been developed, scientific advances have led to the development of highly effective antiretroviral drugs that have transformed HIV infection from an almost always fatal disease to a manageable chronic disease associated with an almost normal life expectancy. Given the lack of global justice in the accessibility of these life-saving medicines, HIV/AIDS continues to take a terrible toll in morbidity and mortality, 41 years after it was first recognized.

If there is one bright spot for the rise of HIV/AIDS, it is that the disease has greatly increased interest in infectious diseases among young people entering medicine. Indeed, with the rise of HIV/AIDS, we had those 309 infectious disease interns that Dr. Petersdorf worried about much needed – and more. To his credit, Dr. Petersdorf readily admitted, years after his article was published, that he had not fully recognized the potential impact of emerging infections and that he became something of a cheerleader for young doctors to pursue careers in infectious diseases, and particularly in the HIV/AIDS practice. and research.

Selected milestone events in the emergence of infectious diseases leading up to and during the author’s four-decade tenure as NIAID director.

DRC stands for Democratic Republic of the Congo, MERS Middle East Respiratory Syndrome, SARS Severe Acute Respiratory Syndrome and XDR Highly Drug Resistant.

Of course, the threat and reality of emerging infections did not stop with HIV/AIDS. During my tenure as NIAID Director, we have been challenged with the emergence or re-emergence of numerous infectious diseases with varying degrees of regional or global impact (see timeline). Among these were the first known human cases of H5N1 and H7N9 influenza; the first pandemic of the 21st century (in 2009) caused by H1N1 influenza; multiple outbreaks of Ebola in Africa; Zika in America; severe acute respiratory syndrome (SARS) caused by a novel coronavirus; Middle East respiratory syndrome (MERS) caused by another emerging coronavirus; and, of course, Covid-19, the loudest wake-up call in more than a century for our vulnerability to emerging infectious disease outbreaks.

The devastation Covid-19 has wrought worldwide is truly historic and highlights the overall lack of public health preparedness in the world for an outbreak of this magnitude. However, a highly successful part of the response to Covid-19 has been the rapid development – ​​enabled by years of investment in basic and applied research – of highly adaptable vaccine platforms such as mRNA (among others) and the use of structural biological tools to design vaccine immunogens. The unprecedented speed with which safe and highly effective Covid-19 vaccines were developed, proven effective and distributed resulted in millions of lives being saved.3 Over the years, many subspecialties of medicine have benefited greatly from breathtaking technological advancements. The same can now be said of the infectious disease field, especially with the tools we now have to respond to emerging infectious diseases, such as the rapid and rapid sequencing of viral genomes; the development of rapid, highly specific multiplex diagnostics; and the use of structure-based immunogen design in conjunction with novel vaccine platforms.4

If anyone had any doubts about the dynamic nature of infectious diseases and, by extension, the discipline of infectious diseases, our experience during the four decades since the recognition of AIDS should have completely dispelled this skepticism. Today, there is no reason to believe that the threat of emerging infections will diminish as the underlying causes are present and most likely increasing. The emergence of new infections and the re-emergence of old ones are largely the result of human interactions with and degradation of nature. As human societies expand in an increasingly interconnected world and the human-animal interface is disrupted, opportunities arise, often aided by climate change, for unstable infectious agents to emerge, leap across species and invade adapting some cases to spread among humans.5

An inevitable conclusion from my reflections on the evolution of the infectious disease field is that the experts of years ago were wrong and that the discipline is by no means static; it’s really dynamic. In addition to the obvious need to continue to improve our capabilities to deal with established infectious diseases such as malaria and tuberculosis, among others, it is now clear that emerging infectious diseases are truly an ongoing challenge. As one of my favorite experts, Yogi Berra, once said, “It’s not over until it’s over.” Clearly, we can now extend that axiom: when it comes to emerging infectious diseases, it’s never over. As infectious disease specialists, we must be constantly prepared and able to meet the ongoing challenge.

The Valley Voice
The Valley Voice
Christopher Brito is a social media producer and trending writer for The Valley Voice, with a focus on sports and stories related to race and culture.


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