Danielle Carnival: Addressing chronic disease requires an infectious disease strategy

Danielle Carnival, Deputy Assistant to the President for the Cancer Moonshot, shared a post on LinkedIn:

“Some thoughts from my experience leading the White House Cancer Moonshot on why we must not buy into the false choice between a focus on chronic versus infectious disease. Americans deserve research, policy, and health care that drives progress and access to prevent, detect, treat, and support them no matter what the health issue they are facing.

Addressing chronic disease requires an infectious disease strategy

There is a lot of talk right now about the state of American health outcomes. It is true that by many measures, we are on the wrong track for the quality and longevity of life for the American population. In fact, we lost fifteen years of life expectancy gain with the grave impact of and our slow recovery from the COVID-19 pandemic and saw a decline in the number of years of healthy life in the United States over the last two decades.

These health outcomes are not acceptable. However, the solution is not a simple one; this is a problem that developed over time and requires a set of concerted steps to improve disease prevention, early detection, treatment, and support. And, importantly, it is a solution that requires a concerted approach to chronic and infectious diseases, not one at the expense of the other.

There are major evidence-based contributors to longevity and health quality of life that must be a part of a plan to improve American health outcomes.

First, a focus on maintaining health must be prioritized, including individual and societal approaches to improving nutrition, developing a healthy lifestyle, and reducing environmental and toxic exposures.

Second, we must provide widespread access to effective preventative and primary care to directly prevent health issues and detect and treat them when they arise.

Third, we must continue bold investment in research to understand the biological basis of human health and the development of new ways to prevent, detect, and treat diseases and conditions.

Fourth, we must reach more people across the country with the interventions we have and the care they need.  For an example of the effort I led for President Biden that took this comprehensive approach to ending cancer as we know it see our final report here.

While the two top drivers of adult mortality – namely heart disease and cancer – point at the need for an approach to prevent and treat non-infectious diseases, there are several reasons that it would be an egregious mistake to back away from strategies to research and address infectious diseases.

For one, we just came out of a global pandemic from an infectious agent that caused more than 1.2 million deaths in the United States. Additionally, the flu and respiratory viruses directly lead to the loss of up to 50,000 Americans per year. And viral hepatitis and human immunodeficiency virus (HIV) contribute an additional 8,000-10,000 deaths, annually.  These represent just a few examples of the direct impact on mortality driven by infectious diseases in the United States.

Secondly, there is a bi-directional interaction between chronic and infectious disease that we would ignore at our peril. For example, those with chronic conditions succumb to viral infections at a much higher rate than age-matched peers who are otherwise healthy. For a striking recent example, adult death rates from COVID-19 were twelve times higher for people with certain chronic diseases, namely heart disease, diabetes, or a chronic lung disease. Diabetes is a major driver of excess death from influenza, increasing the flu death rate by up to 15%.

This means that with an increasing percentage of the U.S. population living with a chronic condition, infectious disease prevention is even more critical.

Possibly less well known but just as important is that many chronic diseases are contributed to by infectious agents. In fact, infections contribute to many of the leading causes of death – including heart disease, cancer, and chronic lower respiratory diseases, like pneumonia and bronchitis, that altogether contribute 1.5 million deaths per year in the United States.

By some estimates, infectious diseases are responsible for 20% of global cancer cases. This occurs because viruses can insert their genes into human cells, disrupting normal function that can lead to the uncontrollable cell growth that is characteristic of cancer; a suppressed immune system can result from a prior viral infection, preventing the body from being able to detect and kill cancer cells; and chronic inflammation caused by infectious agents disrupts cells and can lead to malignancy.

We know that latent effects of an HPV infection cause up to seven kinds of cancer and the virus is responsible for triggering nearly all cervical cancer cases. Additionally, hepatitis B and C are a leading cause of liver cancer and the majority of upper stomach cancers are linked to the H. pylori bacterium.

Separately, viral infections can reach the heart and cause heart conditions like heart disease, the top driver of deaths in the United States. This happens when the virus damages heart tissue directly, or the immune response to the infection causes damage to the heart. Infectious diseases also contribute to a collection of autoimmune diseases, including rheumatoid arthritis, type-1 diabetes, lupus, and even multiple sclerosis.

The specific mechanisms are still being studied but, generally, this occurs when the body’s response to an infection results in the immune system attacking the person’s own tissue and organs. It may be less surprising that chronic lower respiratory diseases like bronchitis and pneumonia are directly driven by viral and bacterial infections. And long COVID demonstrates the direct link between COVID-19 and a set of chronic neurological, autoimmune, and cardiovascular conditions.

Third, because of publicly-supported scientific discovery and private sector investment, we have prevention measures for many of the most harmful and/or common infectious diseases that either prevent the infection altogether or decrease the severity, longevity, and long-term effects of the infectious agent. Vaccines are the medical intervention with the greatest impact on improving life expectancy, adding, on average, more than 30 years to Americans’ lives over the last century.

National health policy must maintain a balance of focus on the many contributors to disease, other health concerns, and death in this country.  For one, it is dangerous to pose a false choice between addressing infectious or chronic diseases and conditions.  We must continue robust investment in research and development, grow a societal focus on maintaining health, deploy effective prevention and primary care measures, and support a healthcare system that serves all people. American lives are at stake.”