CIA activities in this area include the preparation of National Intelligence Estimates. They examine the most lethal diseases globally and by region; develops alternative scenarios about their future course; examines national and international capacities to deal with them; and assesses their national and global social, economic, political, and security impact. Next, they assess the infectious disease threat from international sources to the United States; to US military personnel overseas; and to regions in which the United States has or may develop significant equities. The DIA's Armed Forces Medical Intelligence Center (AFMIC) is a major contributor to these estimates.
The IC determined that new and reemerging infectious diseases will pose a rising global health threat and will complicate US and global security over the next 20 years. These diseases will endanger US citizens at home and abroad, threaten US armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests.
Infectious diseases are a leading cause of death, accounting for a quarter to a third of the estimated 54 million deaths worldwide in 1998. The spread of infectious diseases results as much from changes in human behavior--including lifestyles and land use patterns, increased trade and travel, and inappropriate use of antibiotic drugs--as from mutations in pathogens.
HIV prevalence will increase in five hard-hit countries, contributing to more instability:
Developing and former communist countries will continue to experience the greatest impact from infectious diseases--because of malnutrition, poor sanitation, poor water quality, and inadequate health care--but developed countries also will be affected.
Although the infectious disease threat in the United States remains relatively modest as compared to that of noninfectious diseases, the trend is up. Annual infectious disease-related death rates in the United States have nearly doubled to some 170,000 annually after reaching an historic low in 1980. Many infectious diseases--most recently, the West Nile virus--originate outside US borders and are introduced by international travelers, immigrants, returning US military personnel, or imported animals and foodstuffs. In the opinion of the US Institute of Medicine, the next major infectious disease threat to the United States may be, like HIV, a previously unrecognized pathogen. Barring that, the most dangerous known infectious diseases likely to threaten the United States over the next two decades will be HIV/AIDS, hepatitis C,tuberculosis, and new, more lethal variants of influenza. Hospital-acquired infections and foodborne illnesses also will pose a threat.
65% of all deaths in Sub-Saharan Africa come from infectious diseases. Rudimentary health care delivery and response systems, the unavailability or misuse of drugs, the lack of funds, and the multiplicity of conflicts are exacerbating the crisis. According to the AFMIC typology, with the exception of southern Africa, most of Sub-Saharan Africa falls in the lowest category. Investment in health care in the region is minimal, less than 40 percent of the people in countries such as Nigeria and the Democratic Republic of the Congo (DRC) have access to basic medical care, and even in relatively well off South Africa, only 50-70%t have such access, with black populations at the low end of the spectrum. It will remain the most vulnerable region. The death rates for many diseases, including HIV/AIDS and malaria, exceed those in all other regions. Sub-Saharan Africa's health care capacity--the poorest in the world--will continue to lag.
Four-fifths of all HIV-related deaths and 70 percent of new infections worldwide in 1998 occurred in the region. Although only a tenth of the world's population lives in the region, 11.5 million of 13.9 million cumulative AIDS deaths have occurred there. Eastern and southern African countries, including South Africa, are the worst affected, with 10-26% of adults infected with the disease.
Sub-Saharan Africa has an estimated 90 percent of the global malaria burden. Cholera, dysentery, and other diarrheal diseases also are major killers in the region, particularly among children, refugees, and internally displaced populations. Forty percent of all childhood deaths from diarrheal diseases occur in Sub-Saharan Africa. The region also has a high rate of hepatitis B and C infections and is the only region with a perennial meningococcal meningitis problem in a "meningitis belt" stretching from west to east. Sub-Saharan Africa also suffers from yellow fever, while trypanosomiasis or "sleeping sickness" is making a comeback in the DROC and Sudan, and the Marburg virus also appeared in DRC for the first time in 1998. Ebola hemorrhagic fever strikes sporadically in countries such as the DRC, Gabon, Cote d'Ivoire, and Sudan.
Expert estimates the actual number of HIV patients may be between 3 and 5 million. Adult prevalence is much higher in cities (13-20%) than in rural areas (5%). Heterosexual transmission is the primary mode of spread, and people with multiple partners—especially those with sexually transmitted diseases (STDs) and prostitutes—have significantly higher infection rates.
Unlike conditions in other next-wave countries, war has significantly contributed to the spread of the disease in Ethiopia. Many soldiers contracted HIV/AIDS during the civil war in the 1980s by having contact with multiple sex partners. When the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading HIV/AIDS in their villages and towns.
Ethiopians, due to result of drought, malnutrition, limited healthcare, and other infectious diseases, have generally poor health. In the HIV-seropositive group, this has caused HIV to progress rapidly to AIDS. Looking ahead, we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government’s limited capacity to respond more actively.
Given the already advanced state of the disease and the government’s limited capacity to respond, the Intelligence Community expects HIV/AIDS to infect as many as 10 to 15 million people by 2010. Nigerian prevalence may be 18 to 26 percent of adults—close to the current rates in some of the hardest hit countries in southern Africa. This graphic is of a second-wave country; Southern Africa is already badly affected by the first wave.
Although the more developed countries of Asia and the Pacific, such as Japan, South Korea, Australia, and New Zealand, have strong records in combating infectious diseases, infectious disease prevalence in South and Southeast Asia is almost as high as in Sub-Saharan Africa. The health care delivery system of the Asia and Pacific region--the majority of which is privately financed--is particularly vulnerable to economic downturns even though this is offset to some degree by much of the region's reliance on traditional medicine from local practitioners. In South and Southeast Asia, reemergent diseases such as TB, malaria, cholera, and dengue fever are rampant, while HIV/AIDS, after a late start, is growing faster than in any other region.
TB caused 1 million deaths in the Asia and Pacific region in 1998, more than any other single disease, with India and China accounting for two-thirds of the total . Several million new cases occur annually--most in India, China and Indonesia--representing as much as 40 percent of the global TB burden. HIV/AIDS is increasing dramatically, especially in India, which leads the world in absolute numbers of HIV/AIDS infections, estimated at 3-5 million. China is better off than most of the countries to its south, but it too has a growing AIDS problem, with HIV infections variously estimated at 100,000 to 4000,000. and spreading rapidly. Regionwide, the number of people infected with HIV could overtake Sub-Saharan Africa in absolute numbers before 2010.
Crowded living conditions are among the causes fueling a TB epidemic in the FSU, especially among prison populations--while surging intravenous drug abuse (IVDA) and rampant prostitution are substantially responsible for a marked increase in HIV/AIDS incidence. There were 111,000 new TB infections and 25,000 deaths in Russia alone in 1996, a growing number of them multidrug resistant. The number of new infections for the entire FSU in 1996 was 188,000, while East European cases totaled 54,000.
Diphtheria reached epidemic proportions in the FSU in the first half of the decade, owing to lapses in vaccination. Cholera and dysentery outbreaks are occurring with increasing frequency in Russian cities, such as St. Petersburg and Moscow, and elsewhere in the FSU, such as in T'bilisi, owing to deteriorating water treatment and sewerage systems. Hepatitis B and C, spread primarily by IVDA and blood transfusions, are on the rise, especially in the non-European part of the FSU. Polio also has reappeared owing to interruptions in vaccination, with 140 new cases in Russia in 1995. .
HIV/AIDS also is increasing in the Russian military services. Up to 33% of prospective conscripts are deemed unfit for service owing to the effects of prior drug use (chronic hepatitis or HIV infection). Enlisted men in the ground troops have the largest number of infections, while strategic military forces and airborne troops have the lowest.
Latin American countries are making considerable progress in infectious disease control, including the eradication of polio and major reductions in the incidence and death rates of measles, neonatal tetanus, some diarrheal diseases, and acute respiratory infections. Nonetheless, infectious diseases are still a major cause of illness and death in the region, and the risk of new and reemerging diseases remains substantial. Widening income disparities, periodic economic shocks, and rampant urbanization have disrupted disease control efforts and contributed to widespread reemergence of cholera, malaria, TB, and dengue, especially in the poorer Central American and Caribbean countries and in the Amazon basin of South America. According to the AFMIC typology, Latin America's health care capacity is substantially more advanced than that of Sub-Saharan Africa and somewhat better than mainland Asia's, with 70-90% of populations having access to basic health care in Chile, Costa Rica, and Cuba on the upper end of the scale. Less than 50 percent have such access in Haiti, most of Central America, and the Amazon basin countries, including the rural populations in Brazil.
Cholera reemerged with a vengeance in the region in 1991 for the first time in a century with 400,000 new cases, and while dropping to 100,000 cases in 1997, it still comprises two-thirds of the global cholera burden. TB is a growing problem regionwide, especially in Brazil, Peru, Argentina, and the Dominican Republic where drug-resistant cases also are on the rise. Haiti does not provide data but probably also has a high infection rate. HIV/AIDS also is spreading rapidly, placing Latin America third behind Sub-Saharan Africa and Asia in HIV prevalence. Prevalence is high in Brazil and especially in the Caribbean countries (except Cuba), where 2 percent of the population is infected. Malaria is prevalent in the Amazon basin. Dengue reemerged in the region in 1976, presenting both as the usual form and the more lethal dengue hemorrhagic fever (DHF). Hepatitis B and C prevalence is greatest in the Amazon basin, Bolivia, and Central America, while DHF is particularly prevalent in Brazil, Colombia, and Venezuela. Yellow fever has made a comeback over the last decade throughout the Amazon basin, and there have been several recent outbreaks of gastrointestinal disease attributed to E. coli infection in Chile, Argentina, Bolivia and Peru Hemorrhagic fevers are present in almost all South American countries, and most hantavirus pulmonary syndrome occurs in the southern cone.
The region's conservative social mores, climatic factors, and high levels of health spending in oil-producing states tend to limit some globally prevalent diseases, such as HIV/AIDS and malaria, but others, such as TB and hepatitis B and C, are more prevalent. The region's advantages are partially offset by the impact of war-related uprooting of populations, overcrowded cities with poor refrigeration and sanitation systems, and a dearth of water, especially clean drinking water. Health care capacity varies considerably within the region, according to the AFMIC typology. Israel and the Arabian Peninsula states minus Yemen are in far better shape than Iraq, Iran, Syria, and most of North Africa. Ninety to 100 percent of the Israeli population and 70 to 90 percent of the Saudi population have good access to health care. Elsewhere, access ranges from less than 40 percent in Yemen to 50 to 70 percent in the smaller Gulf states, Jordan and Tunisia, while most North African states fall into the 40- to 50-percent category.
Its status as a hub of international travel, commerce, and immigration, moreover, dramatically increases the risks of importing new diseases from other regions. Tens of millions of West Europeans travel to developing countries annually, increasing the prospects for the importation of dangerous diseases, as demonstrated by the importation of typhoid in 1999. Some 88 percent of regional population growth in the first half of the decade was due to immigration; legal immigrants now comprise about 6 percent of the population, and illegal newcomers number an estimated 6 million. Nonetheless, the region's highly developed health care infrastructure and delivery system tend to limit the incidence and especially the death rates of most infectious diseases, though not the economic costs. Access to high-quality care is available throughout most of the region, although governments are beginning to limit some heretofore generous health benefits, and a growing antivaccination movement in parts of Western Europe, such as Germany, is causing a rise in measles and other vaccine-preventable diseases. The AFMIC typology gives somewhat higher marks to northern over some southern European countries, but the region as a whole is ranked in the highest category, along with North America.
TB, especially its multidrug resistant strains, is on the upswing, as is co-infection with HIV, particularly in the larger countries, with some 50,000 TB cases reported in 1996. Hepatitis C prevalence is growing, especially in southern Europe. Western Europe also continues to suffer from several zoonotic diseases, among which is the deadly new variant Creutzfeldt-Jakob disease (nvCJD), linked to the bovine spongiform encephalopathy or "mad cow disease" outbreak in the United Kingdom in 1995 that has since ebbed following implementation of strict control measures. Other recent disease concerns include meningococcal meningitis outbreaks in the Benelux countries and leishmaniasis-HIV co-infection, especially in southern Europe.
In most poorer countries, health care--ranging from basic pharmaceuticals and postnatal care to costly multidrug therapies--remains very limited. Market forces drive private pharmaceutical companies, and many developed country government research programs, to focus on drugs needed in their environment, not necessarily those of the poorer countries. This is generating a growing controversy between rich and poorer nations over such issues as intellectual property rights, as some developing countries make their own copies, not always with permission, of drugs under patent protection. Developing countries also are less willing to make microbial samples available to companies that will make commercial vaccines from them, which may be too costly for the country that provided the sample.
A global composite measure of health care infrastructure devised by DIA's Armed Forces Medical Intelligence Center (AFMIC) assesses factors such as the priority attributed to health care, health expenditures, the quality of health care delivery and access to drugs, and the extent of surveillance and response systems.
A major obstacle to effective global surveillance and control of infectious diseases will continue to be the quality of national health statistical reporting by many developing countries and lack of followthrough to properly direct aid and to follow recommended health care practices. Those areas of the world most susceptible to infectious disease problems are least able to develop and maintain the sophisticated and costly communications equipment needed for effective disease surveillance and reporting. In addition to the barriers dictated by low levels of development, revealing a disease outbreakmay harm national prestige, commerce, and tourism. For example, nearly every country initially denied or minimized the extent of the HIV/AIDS virus within its borders, and even today, some countries known to have significant rates of HIV infection refuse to cooperate with WHO. Only a few, such as Uganda, Senegal, and Thailand, have launched major preventative efforts, while many WHO members do not even endorse AIDS education in schools. Similarly, some countries deny the existence of cholera within their borders.
Aid programs to prevent and treat infectious diseases in developing countries depend largely on indigenous health workers for their success and cannot be fielded effectively in their absence. Training indigenous workers appears more effective than educating the general public of these countries.
International organizations such as WHO and the World Bank, institutions in several developed countries such as the US CDC, and Nongovernmental Organizations (NGOs) will continue to play an important role in strengthening both international and national surveillance and response systems for infectious diseases. Development of an integrated global surveillance and response system probably is at least a decade or more away. This owes to the magnitude of the challenge; inadequate coordination at the international level; and lack of funds, capacity, and, in some cases, cooperation and commitment at the national level. Some countries hide or understate their infectious disease problems for reasons of prestige and fear of economic losses. Total international health-related aid to low- and middle-income countries--some $2-3 billion annually--remains a fraction of the $250 billion health bill of these countries.
WHO has the broadest health mandate under the UN system, including setting priorities, coordinating global health surveillance, and emergency assistance in the event of disease outbreaks. Health experts give WHO credit for major successes, such as the eradication of smallpox, near eradication of polio, and substantial progress in controlling childhood diseases, and in expanding primary health care in developing countries. WHO defenders blame continued member state parsimony that has kept WHO's regular biennial budget to roughly $850 million for several years and forced it to rely more on voluntary contributions that often come with strings attached as the cause of its shortcomings. This situation led to lack of focus at the top level as well as overly optimistic forecasts.
The 1998 election of Gro Harlem Brundtland as Secretary General, along with a series of reforms, including expansion of the Emerging and other Communicable Diseases Surveillance and Control (EMC) Division, has placed WHO in a better position to revitalize itself. Internal oversight and transparency have been expanded, programs and budgets are undergoing closer scrutiny, and management accountability is looming larger. Bruntland has moved quickly to revitalize top management, mostly from outside the organization, including from the private sector. She also strengthened country offices and to made the regional offices more responsive to central direction. WHO is increasing its focus on the fight against resurgent malaria, while a better-funded EMC is expanding efforts to establish a global surveillance and response system in cooperation with UNAIDS, UNICEF, and national entities such as the US CDC, the US DoD, and France's Pasteur Institute. Margaret Chan, the current Director-General, is still being assessed; there were questions about her performance as chief of public health for Hong Kong.
WHO competes for resources with other UN agencies that are involved in health care. The United Nations Children's Fund (UNICEF) focuses on children's health. The United Nations AIDS Program (UNAIDS) focuses on improving the response capacity toward HIV/AIDS at the country, regional, and global levels in cooperation with other UN agencies. Other UN agencies involved in health care issues include the UN Development Program (UNDP); the UN Family Planning Agency (UNFPA); the UN High Commissioner for Refugees (UNHCR); the UN Educational, Scientific and Cultural Organization (UNESCO); the International Labor Organization (ILO); the Food and Agricultural Organization (FAO); and the World Food Program (WFP).
The persistent infectious disease burden is likely to aggravate and, in some cases, may even provoke economic decay, social fragmentation, and political destabilization in the hardest hit countries in the developing and former communist worlds, especially in the worst case scenario outlined above:
The relationship between disease and political instability is indirect but real. A wide-ranging study on the causes of state instability suggests that infant mortality--a good indicator of the overall quality of life--correlates strongly with political instability, particularly in countries that already have achieved a measure of democracy. The severe social and economic impact of infectious diseases is likely to intensify the struggle for political power to control scarce state resources.
As a major hub of global travel, immigration, and commerce with wide-ranging interests and a large civilian and military presence overseas, the United States and its equities abroad will remain at risk from infectious diseases.
Broad advances in controlling or eradicating a growing number of infectious diseases--such as tuberculosis (TB), malaria, and smallpox--in the decades after WWII fueled hopes that the global infectious disease threat would be increasingly manageable. This optimism, however, led to complacency and overlooked the role of such factors as expanded trade and travel and growing microbial resistance to existing antibiotics in the spread of infectious diseases. According to the 1999 NIE,
One of the challenges of detecting bioterrorism is that while automated aerosol detection equipment exists, it can cover only limited physical areas, such as high-value targets or troop concentration. In a civilian population, the first warning of covert terrorism is apt to come from clinicians that can compare many cases. An emergency room is one obvious place for comparison, but the availability of electronic health records, from which data from many office encounters can be extracted, with due regard for privacy, and searched for patterns.
War and other factors are spreading resistant forms. In the US, Acinetobacter strains were previously seen only in immunosuppressed patients, but Acinetobacter baumanii has been a common, and drug-resistant, infection in military patients from Iraq and Afghanistan.
In response to these practices and attendant problems, several organizations (e.g. The American Society for Microbiology (ASM), American Public Health Association (APHA) and the American Medical Association (AMA)) have called for restrictions on antibiotic use in food animal production and an end to all non-therapeutic uses. The European Parliament called for phasing out of antibiotics for non-medical use in feed animals with a total ban as of 1 January 2006. However, delays in regulatory and legislative actions to limit the use of antibiotics are common, and may include resistance to these changes by industries using or selling antibiotics, as well as time spend on research to establish causal links between antibiotic use and emergence of untreatable bacterial diseases.
The magnitude of the global movement of animals is staggering. In terms of sheer numbers, 37,858,179 individually counted live amphibians, birds, mammals, and reptiles were legally imported to the United States from 163 countries in 2000–2004.
Animals are legally imported into the United States for many reasons. They are used for exhibitions at zoos; scientific education, research, and conservation programs; food and products; and in the case of companion animals, tourism and immigration. Increasingly, however, animals are being imported for a thriving commercial pet trade. In many cases the animals that are imported and traded are of species that are considered exotic (here defined as non-native species, animals not traditionally kept as pets, or both). This can be a risky business, as many shipments include a high volume of wild-caught versus captive raised. For most of these animals, there are no requirements for zoonotic disease screening either before or after arrival into the United States. There have been anecdotal reports of high rates of death among animals in these shipments.
Animals imported for commercial trade represent a substantial risk to human health. In 2003, monkeypox was introduced into the United States when a shipment of African rodents was distributed to various US exotic pet dealers, one of whom housed these animals with prairie dogs. The prairie dogs subsequently became ill and transmitted the infection to 47 humans, including prairie dog owners and veterinary staff caring for the ill animals. In addition to monkeypox, human tularemia and salmonellosis outbreaks have been traced back to contact with prairie dogs and hedgehogs.
Exotic pet ownership brings unanticipated risks to agribusiness, wildlife conservation, and the ecosystem. For example, giant African land snails released into farmlands have become agricultural pests. They reproduce rapidly, consume large amounts of vegetation, and are hosts for parasites such as Angiostrongylus cantonensis. The illegal trade of exotic wildlife, with promises of considerable financial return in the underground markets, has disastrous implications for many endangered or threatened species.
Intelligence estimates of infection rates and their likely trajectories go beyond the official statistics by incorporating the assessments of academics and NGOs with field experience. The numbers cited in the estimages should be considered rough estimates with a relatively high margin of error. Infection surveillance of women attending prenatal clinics is considered the most reliable indicator of adult Human Immunodeficiency Virus (HIV) prevalence in the general population. But even these statistics can be affected by poor clinic attendance when fee for services or mandatory HIV testing is instituted.
The number of people with HIV/AIDS will grow significantly by the end of the decade. The increase will be driven by the spread of the disease in five populous countries—Nigeria, Ethiopia, Russia, India, and China—where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010. This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic. China will have 10 to 15 million HIV/AIDS cases, and India is likely to have 20 to 25 million by 2010—the highest estimate for any country. By 2010, Nigeria will have 10 to 15 million cases, Ethiopia 7 to 10 million, and Russia 5 to 8 million.
HIV/AIDS is spreading at different rates in the five countries, with the epidemic the most advanced in Nigeria and Ethiopia. In all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate.
It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. Government leaders will have trouble maintaining a priority on HIV/AIDS—which has been key to stemming the disease in Uganda, Thailand, and Brazil—because of other pressing issues and the lack of AIDS advocacy groups.
The rise of HIV/AIDS in the next-wave countries is likely to have significant economic, social, political, and military implications. The impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles.
The growing AIDS problem in the next-wave countries probably will spark calls for more financial and technical support from donor countries. It may lead to growing tensions over how to disburse international funds, such as the Global Fund for AIDS, TB and Malaria.
The cost of antiretroviral drugs—which can prolong the lives of infected people—has plunged in recent years but still may be prohibitively high for low-income countries. More importantly, the drug costs are only a portion of HIV/AIDS treatment costs. Drug-resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs.
Governments often do not spend enough money to get quality infection surveillance because they have other budget priorities, do not want to acknowledge the extent of the epidemic, and the drug users and prostitutes at high risk of infection are not key political constituencies.
Even if testing is available, many people do not get tested because of denial, stigma, discrimination, or resignation.
To make each year's version of the influenza vaccine, samples of that year's mutations are necessary. Typically, the new virus strains start in Asia. Indonesia's decision to withhold samples of avian influenza virus A (H5N1) from the World Health Organization for much of 2007 caused a crisis in global health. The World Health Assembly produced a resolution to try to address the crisis at its May 2007 meeting. Indonesia refused to make samples of a virus in a local outbreak available, based on international legal principle of sovereignty and its appeal to rules on the protection of biological and genetic resources found in the Convention on Biological Diversity. The incident involving Indonesia's actions with virus samples illustrates both the importance and the limitations of international law in global health diplomacy.
Control of fecal–orally transmitted pathogens is inadequate in many developing countries, in particular, in sub-Saharan Africa. Acquired resistance to antimicrobial drugs is becoming more prevalent among Vibrio cholerae, Salmonella enteritidis, diarrheagenic Escherichia coli, and other pathogens in this region. The poor, who experience most of the infections caused by these organisms, bear the brunt of extended illness and exacerbated proportion of deaths brought about by resistance. Improved antimicrobial drug stewardship is an often cited, but inadequately implemented, intervention for resistance control. Resistance containment also requires improvements in infectious disease control, access to and quality assurance of antimicrobial agents, as well as diagnostic facilities. Structural improvements along these lines will also enhance disease prevention and control as well as rational antimicrobial drug use. Additionally, more research is needed to identify low-cost, high-impact interventions for resistance control.
Oral rehydration therapy was an enormous step in treating these diseases, based on the seemingly simple, but long missed, idea that sugar is necessary for the absorption of salts and water. The availability of oral rehydration solution, which can be improvised under Third World conditions, broke through the probability of needing the skills and materials for intravenous rehydration.
According to the World Health Organization and partner agencies, there has been success with reducing the incidence of measles in Africa.; the 1999 NIE may have been overly passimistic about Africa. WHO sees South Asia as the priority: "Large countries with high numbers of measles deaths, such as India and Pakistan, need to fully implement the proven control strategy. Currently, about 74% of measles deaths globally occur in South Asia."
In 2000 polio was officially eradicated in 36 Western Pacific countries, including China and Australia.
Europe was declared polio-free in 2002.
The major concerns include:
The emergence of SARS illustrates the challenge of battling infectious diseases in an increasingly globalized world. Global links have sped the geographic spread of the disease and amplified the economic and political impact.
Outside China, the first clue of the outbreak appears to be November 27, 2002 when Canada's Global Public Health Intelligence Network (GPHIN), an electronic warning system which is part of the World Health Organization's (WHO) Global Outbreak and Alert Response Network (GOARN), picked up reports of a "flu outbreak" in China through internet media monitoring and analysis and sent them to the WHO.
Subsequently, the WHO requested information from Chinese authorities on December 5 and 11. Importantly, while GPHIN's capability had recently been upgraded to enable Arabic, Chinese, English, French, Russian and Spanish translation, the system was limited to English or French in presenting this information. Thus, while the first reports of an unusual outbreak were in Chinese, an English report was not generated until January 21, 2003.
In late April, revelations occurred as the PRC government admitted to underreporting the number of cases of SARS due to the problems inherent in the healthcare system. Dr. Jiang Yanyong exposed the coverup that was occurring in China, at great personal risk. A number of PRC officials were fired from their posts, including the health minister and mayor of Beijing, and systems were set up to improve reporting and control in the SARS crisis. Since then, the PRC has taken a much more active and transparent role in combating the SARS epidemic.
Political leadership has been a key variable in managing the epidemic. China’s efforts to hide the initial outbreak allowed SARS to build up dangerous momentum before Chinese officials became more open, while Vietnam’s willingness to promptly highlight the threat and seek international assistance helped offset the country’s weak healthcare system. The more SARS spread, the tougher countries became in implementing control measures, including quarantining and isolating people to stop its transmission.
The intense focus on SARS has opened a window of opportunity for the United States and the WHO to pursue longer-term bilateral and multilateral cooperation on health issues.
The first scenarion is "SARS Simmers": SARS could resurface but be limited to random outbreaks in a few countries, rendering it more of a public health nuisance than a crisis. Political and economic reverberations still would occur, with some companies and investors looking to reduce their exposure in East Asia, particularly China.
The next alternative is that "SARS Gains a Foothold in Poor Countries, Regions. SARS could spread to poor countries in Africa or Asia, potentially generating more infections and deaths than before but with relatively little international economic impact. The risk of spread would continue, however, even if SARS emerged in poor countries or isolated regions of Russia and China with weak healthcare systems. WHO and CDC probably would come under intense pressure to provide money and technical assistance to compensate for weak healthcare systems.
Some isolated countries such as North Korea probably would resist outside assistance, even at the risk of putting their own citizens at risk and requiring the US to improve its medical intelligence collection to protect its own and allied forces. Some repressive regimes hit by SARS are likely to employ brutal tactics to quarantine and isolate people, possibly sowing division among outside countries and multilateral organizations over how to respond to apparent human rights violations.
The worst case is a full resurgence of SARS could come back in the places it hit before—such as China, Taiwan, Canada, and Singapore—or hit harder in other well-connected places like the United States, Japan, Europe, India, or Brazil. Even if the number of infected persons were not significantly greater, the resurgence of the disease in globally linked countries probably would generate a significant impact again. The return of SARS to Asia is likely to cause somewhat less disruption the second time as citizens learn to live with the disease, but more multinational companies probably would reduce their exposure in the region if they concluded that SARS posed a long-term health challenge. Bigger outbreaks in Europe or the United States would hit a whole new set of business and government players, potentially doing serious damage to trade and growth.
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