Global Policy Forum

National Council for International Health

Aviation Health and Security Act, 1997

No matter how selfish our motives, we can no longer be indifferent to the suffering of others. The microbe that felled one child in a distant continent yesterday can reach yours today, and seed a global pandemic tomorrow. -Joshua Lederberg, Nobel laureate

Summary: To establish a small user fee ($3 - $5) on airline fares for international travel into and out of the US that will guarantee a generation of funds to provide consistent and predictable protection against the spread of infectious diseases for the benefit of healthier US and world communities.

Problem: The spread of infectious diseases across national borders is increasing as well as the potential for dramatic consequences. The dangers are significantly influenced by increasingly frequent and faster air travel between countries, combined with reductions in aid directed at international human health and development efforts.

Given the unpopular, expensive and impractical solution of increasing travel restrictions, the concept of early prevention holds great promise. In the past, the financial costs associated with prevention efforts has lead to the neglect of these problems until an epidemic or outbreak has occurred. Considering the potential health and economic costs of a future crisis, early and effective preventive strategies are essential.

Charged with reviewing the US role in fighting the emergence of infectious diseases, an interagency working group under the Committee on International Science, Engineering and Technology (CISET) was established in 1994. The CISET report recommended that the US government work with other countries, the World Health Organization (WHO), and other international organizations to improve four areas deemed essential for containing the emergence and spread of infectious diseases: prevention, surveillance, response, research and development. The report concluded that no single nation has the capabilities or resources to fight infectious diseases, rather a coordinated multilateral effort is required.

The health of tomorrow's economy depends on the investments that we make today. Financial priorities must be placed on the above four recommendations.

Solution: Implement a small per flight/per ticket fee on all international air travel to and from the US to increase revenue for investment in effective infectious disease control efforts at both national and international levels.

Benefits: The potential to annually raise between $240 - $400 million from international travelers would make great strides in fighting infectious diseases, without burdening Congressional budgets. Minor investments in prevention will pay enormous dividends in protecting the health of all populations as well as saving American lives and money.

Background: Modern air travel makes national borders and the traveling distance between any two nations irrelevant in regards to infectious diseases. Each year millions of Americans travel to foreign countries for business, religion, pleasure and study while millions of foreigners come to the US for the same. Many previously remote areas are now less than a day of air travel away from US communities. According to the International Air Travel Association, there were an estimated 78.8 million scheduled passengers between international destinations and the United States in 1993. By the year 2010, this figure is expected to reach 226 million, an increase of 187% over the 1993 figure.

Frequently, travelers unknowingly import diseases that were previously not present in the US. This creates new challenges for health care professionals, additional threats to our safety and welfare, and a drain on US health resources.

In the US, infectious diseases directly account for 3 and indirectly for 5 of the 10 leading causes of death, while 25% of all visits to physicians are due to these diseases. The death rate from infectious diseases has increased by more than 50% since 1980.

Infectious diseases are draining this country of $120 billion a year, which accounts for approximately 15% of the nation's total health-care expenditure. Despite the vast amount of spending allotted for the treatment of infectious diseases, agencies involved in prevention, like CDC, NIH, USAID and other organizations are underfunded and understaffed.

The CDC, among other international health organizations, reports recent incidences of disease introduced into the US by air travel as follows:

Cholera, an acute diarrheal illness caused by infection of the intestine, was recently diagnosed in 75 persons in California, one of whom subsequently died. In addition, several incidents of cholera have been reported following air travel from South America. The CDC has recently warned that cholera vaccinations are not protective against all strains of the disease.

Dengue Fever is a potentially lethal mosquito-borne disease which has swept across Latin America in epidemic proportions in recent years. From 1993 to 1994, there were 148 suspected cases of dengue fever in the United States, the majority of which were imported by travelers.

HIV/AIDS was unknown in the United States twenty years ago. After most probably being brought into this country via air transport, the virus has caused one of the most devastating epidemics in American history. By June of 1996, there were an estimated 630,000 to 900,000 cases of HIV in this country, 540,806 cases of AIDS, and 338,831 deaths. For the 1996 fiscal year, HIV/AIDS prevention and treatment alone required $7.4 billion in federal spending.

Leishmaniasis, a vector borne blood disease, was diagnosed in troops returning from the Persian Gulf War. Cases came from 5 different military units and the majority of stricken soldiers became symptomatic in the US.

Malaria has been diagnosed in every region of the US. In recent years, approximately 1000 annual cases of malaria have been reported in the US, the majority of which were imported. The CDC has found that in recent cases a staggering 84% of US civilians who have acquired malaria overseas had not used or had incorrectly used chemoprophylaxis.

Measles, once thought to be close to eradication in North America, has made a comeback, with 309 cases since 1993. Virtually all infected persons acquired the disease outside of the United States. Between 1989-1991 a measles epidemic struck over 55,000 Americans, causing 123 deaths.

Tuberculosis kills more people a year (3 million) than all other infectious diseases combined. In the mid-1990s, approximately 25,000 Americans suffered from the TB virus, costing over $700 million to treat in 1991 alone. In 1994, JAMA concluded that a flight attendant was responsible for the transmission of 'M' TB to other flight crew and possibly passengers. The CDC does not recommend routine tuberculosis screening for airline workers as an occupational group.

The above case contributes to the list of diseases that may be transmitted on planes. The documented transmission of diseases includes: cholera (due to food served), staphylococcal food poisoning, foodborne salmonella and shigellosis, influenza, and gastroenteritis.

In addition to these rare diseases, frequent episodes of influenza, trypanisoma cruzi, yellow fever, hepatitis, and other, often drug resistant viral infections have also been associated with international travel.

The detection of new infectious diseases such as Ebola and HIV/AIDS poses several unanswered questions about causes, treatment, and costs. The increase in drug-resistance only makes treating these newly emerging and re-emerging diseases more difficult and costly. According to the aforementioned CISET report, since 1973 more than 30 new disease have been identified.

Antibiotic-resistant bacterial infections are responsible for $ 4 billion a year in treatment costs, and the prevalence of this affliction is on the rise. The proliferation of resistant microbes is fueled, both in the US and abroad, by overuse and misuse of drugs, and by the unrealistic expectations of many patients and unquestioning habits of some doctors.

The spread of disease is often rapid, quiet, and with little regard for cultural or ethnic background, socio-economic status, or lifestyle. They are considered to be immediate threats to children, blood supply, crowded areas, our food supply and the health and welfare of all Americans.

The threat of an epidemic has not been motivation enough in the past to obtain necessary funding for thorough implementation of preventive strategies. Inadequate global and domestic "early warning" surveillance systems forces health authorities to respond to an outbreak only after it has been detected. Routine mass screening is not always affordable, feasible or available to identify these diseases when passengers arrive at national airports, and infected individuals are often asymptomatic upon entry. In addition, U.S. physicians are poorly trained to diagnose endemic diseases, and travelers frequently neglect to investigate preventive measures before going abroad (see malaria example above). Immigrants are required to have medical examinations prior to issuance of travel visas, however these procedures also remain imperfect. The wisdom of prevention has changed little while microbes are constantly evolving. Currently, the US system is inadequately prepared to recognize, treat, or control many of these diseases.

Great pressure will remain to find new sources of funding to alleviate the expenses that endemic diseases may place on the US in the future. A small fee charged on airline travel to and from the United States can be beneficial in three major ways. It would:

1. Provide an alternate source of funding for preventive control of disease threats to our nation.
2. Be 'user-fee' based and only charged to people that travel (from) abroad.
3. Initiate global enthusiasm to provide more effective programs and funding to prevent the spread of infectious disease due to the importation of products and animals, and the migration of people.

Other benefits include:

1. Saving of lives internationally.
2. Improving health conditions internationally.
3. Improving economic conditions abroad which will help increase US exports and related jobs.

This proposal is NOT:

1) To be misunderstood as an effort to curb international travel or to promote quarantine of travelers.
2) A replacement source of funding for international or domestic health efforts. It is to supplement them in a reliable and stable manner.

Basic Intent: To enable Americans and foreigners alike to travel more freely, knowing they have reduced the health risks to themselves, their loved ones and others who have limited access to health and medical attention.

Today, guaranteeing national security means more than just defending our borders at home and our values abroad...there is no more menacing threat to our global health today than emerging infectious diseases. -Vice President Al Gore

For more information contact: Chuck Woolery, Director of Membership
and Advocacy, National Council for International Health
202-833-5900 x206, Fax 202-833-0075 Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

The most significant questions arising thus far around this proposal is a) what entity will manage the distribution of revenues and b) what programs or institutions would receive the resources.

At present we are leaning toward an existing (or yet to be created entity) under the direction of the Dept. of Health and Human Services or the State Department.

For a balanced distribution of revenues we have two mechanisms to consider (outlined below).

Plan A: Divide generated revenues into 3 sectors (40/40/20):
40% Domestic Health care services (refugee, immigrant, low income focus)
40% International Health and Development (primary health, water, sanitation, basic education, nutrition, housing).
20% Budget Deficit Reduction.

Plan B: Divide revenues (25/25/25/25) between 4 sectors (based on CISET report)
A. Surveillance (Global health network of trained health workers and adequate clinics with access to global internet).
B. Response (Trained and supplied WHO/CDC/DoD teams)
C. Research and Development. (sufficient knowledge base, research and production capacity.)
D. Prevention (primary health, water, sanitation, basic education, nutrition, housing).
USAID
Not-for Profits
US based
Indigenous
UN
UNDP
UNICEF
WHO

Plan C: Some combination of Plan A and B.

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