National Intelligence Estimate: The Global Infectious ... · PDF fileNational Intelligence...

33ENVIRONMENTAL CHANGE & SECURITY PROJECT REPORT, ISSUE 6 (SUMMER 2000)

Special Reports

SPECIAL REPORTS

National Intelligence Estimate:The Global Infectious Disease Threat and Its

Implications for the United States

National Intelligence Council, January 2000

Abstract: Infectious diseases are a leading cause of death, accounting for a quarter to a third of all deaths worldwide. The spread of infectiousdiseases results from both human behavior such as lifestyle choices, land-use patterns, increased trade and travel, and inappropriate use ofantibiotic drugs, as well as mutations in pathogens. These excerpts from a January 2000 National Intelligence Estimate highlight the risingglobal health threat of new and reemerging infectious diseases. The National Intelligence Council argues that the infectious disease threatwill complicate U.S. and global security over the next twenty years. These diseases will endanger U.S. citizens at home and abroad, threatenU.S. armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United Stateshas significant interests, according to the report.

PREFACE

This report represents an important initiative on the part of the Intelligence Community to consider thenational security dimension of a nontraditional threat. It responds to a growing concern by senior U.S.leaders about the implications—in terms of health, economics, and national security—of the growing glo-

bal infectious disease threat. The dramatic increase in drug-resistant microbes, combined with the lag in developmentof new antibiotics, the rise of megacities with severe health care deficiencies, environmental degradation, and thegrowing ease and frequency of cross-border movements of people and produce have greatly facilitated the spread ofinfectious diseases.

In June 1996, President Clinton issued a Presidential Decision Directive calling for a more focused U.S. policyon infectious diseases. The State Department’s Strategic Plan for International Affairs lists protecting human health

This National Intelligence Estimate was produced under the auspices of David F. Gordon, National Intelligence Officerfor Economics and Global Issues. The primary drafters were Lt. Col. (Dr.) Donald Noah of the Armed Forces MedicalIntelligence Center and George Fidas, Deputy National Intelligence Officer for Global and Multilateral Issues, NIC. TheEstimate also benefited from a conference on infectious diseases held jointly with the State Department’s Bureau of Intelligenceand Research and was reviewed by several prominent epidemiologists and other health experts in and outside the U.S.Government. Comments and inquiries may be directed to Dr. Gordon at (703) 482-4128 or by e-mail at [email protected] thanks to Dr. Gordon, George Fidas, and Gerald Fields for their assistance in reprinting the excerpts. Please see theMeeting Summaries section for coverage of an ECSP meeting highlighting the release of this National Intelligence Estimate.

ENVIRONMENTAL CHANGE & SECURITY PROJECT REPORT, ISSUE 6 (SUMMER 2000)34

Special Reports

and reducing the spread of infectious diseases as U.S.strategic goals, and Secretary Albright in December 1999announced the second of two major U.S. initiatives tocombat HIV/AIDS. The unprecedented UN SecurityCouncil session devoted exclusively to the threat to Af-rica from HIV/AIDS in January 2000 is a measure ofthe international community’s concern about the infec-tious disease threat.

As part of this new U.S. Government effort, theNational Intelligence Council produced this National

IMPACT WITHIN THE UNITED STATES

Although the infectious disease threat in the UnitedStates remains relatively modest as compared to that ofnoninfectious diseases, the trend is up. Annual infec-tious disease-related death rates in the United States havenearly doubled to some 170,000 annually after reach-ing an historic low in 1980. Many infectiousdiseases—most recently, the West Nile virus—originateoutside U.S. borders and are introduced by internationaltravelers, immigrants, returning U.S. military person-nel, or imported animals and foodstuffs. In the opinionof the U.S. Institute of Medicine, the next major infec-tious disease threat to the United States may be, likeHIV, a previously unrecognized pathogen. Barring that,the most dangerous known infectious diseases likely tothreaten the United States over the next two decadeswill be HIV/AIDS, hepatitis C, TB, and new, more le-thal variants of influenza. Hospital-acquired infectionsand foodborne illnesses also will pose a threat.

• Although multidrug therapies have cut HIV/AIDSdeaths by two-thirds to 17,000 annually since 1995,emerging microbial resistance to such drugs andcontinued new infections will sustain the threat.

• Some four million Americans are chronic carriersof the hepatitis C virus, a significant cause of livercancer and cirrhosis. The U.S. death toll from thevirus may surpass that of HIV/AIDS in the nextfive years.

• TB , exacerbated by multidrug resistant strains andHIV/AIDS co-infection, has made a comeback. Al-though a massive and costly control effort isachieving considerable success, the threat will be sus-tained by the spread of HIV and the growing

Intelligence Estimate. It examines the most lethal dis-eases globally and by region; develops alternativescenarios about their future course; examines nationaland international capacities to deal with them; and as-sesses their national and global social, economic,political, and security impact. It then assesses the infec-tious disease threat from international sources to theUnited States; to U.S. military personnel overseas; andto regions in which the United States has or may de-velop significant equities.

THE GLOBAL INFECTIOUS DISEASE THREAT AND ITS

IMPLICATIONS FOR THE UNITED STATES

New and reemerging infectious diseases will pose arising global health threat and will complicate U.S. andglobal security over the next twenty years. These dis-eases will endanger U.S. citizens at home and abroad,threaten U.S. armed forces deployed overseas, and exac-erbate social and political instability in key countriesand regions in which the United States has significantinterests.

Infectious diseases are a leading cause of death, ac-counting for a quarter to a third of the estimated fifty-four million deaths worldwide in 1998. The spread ofinfectious diseases results as much from changes in hu-man behavior—including lifestyles and land use pat-terns, increased trade and travel, and inappropriate useof antibiotic drugs—as from mutations in pathogens.

• Twenty well-known diseases—including tuberculo-sis (TB), malaria, and cholera—have reemerged orspread geographically since 1973, often in morevirulent and drug-resistant forms.

• At least thirty previously unknown disease agentshave been identified since 1973, including HIV,Ebola, hepatitis C, and Nipah virus, for which nocures are available.

• Of the seven biggest killers worldwide, TB, malaria,hepatitis, and, in particular, HIV/AIDS continueto surge, with HIV/AIDS and TB likely to accountfor the overwhelming majority of deaths from in-fectious diseases in developing countries by 2020.Acute lower respiratory infections—including pneu-monia and influenza—as well as diarrheal diseasesand measles, appear to have peaked at high inci-dence levels.

KEY JUDGMENTS


Special Reports

number of new, particularly illegal, immigrants in-fected with TB.

• Influenza now kills some 30,000 Americans annu-ally, and epidemiologists generally agree that it isnot a question of whether, but when, the next killerpandemic will occur.

• Highly virulent and increasingly antimicrobial re-sistant pathogens, such as Staphylococcus aureus, aremajor sources of hospital-acquired infections thatkill some 14,000 patients annually.

• The doubling of U.S. food imports over the lastfive years is one of the factors contributing to tensof millions of foodborne illnesses and 9,000 deathsthat occur annually, and the trend is up.

REGIONAL TRENDS

Developing and former communist countries willcontinue to experience the greatest impact from infec-tious diseases—because of malnutrition, poor sanitation,poor water quality, and inadequate health care—but de-veloped countries also will be affected:

• Sub-Saharan Africa—accounting for nearly half ofinfectious disease deaths globally—will remain themost vulnerable region. The death rates for manydiseases, including HIV/AIDS and malaria, exceedthose in all other regions. Sub-Saharan Africa’s healthcare capacity—the poorest in the world—will con-tinue to lag.

• Asia and the Pacific, where multidrug resistant TB,malaria, and cholera are rampant, is likely to wit-ness a dramatic increase in infectious disease deaths,largely driven by the spread of HIV/AIDS in Southand Southeast Asia and its likely spread to East Asia.

By 2010, the region could surpass Africa in the num-ber of HIV infections.

• The former Soviet Union (FSU) and, to a lesserextent, Eastern Europe also are likely to see a sub-stantial increase in infectious disease incidence anddeaths. In the FSU especially, the steep deteriora-

tion in health care and other services owing to eco-nomic decline has led to a sharp rise in diphtheria,dysentery, cholera, and hepatitis B and C. TB hasreached epidemic proportions throughout the FSU,while the HIV-infected population in Russia alonecould exceed one million by the end of 2000 anddouble yet again by 2002.

• Latin American countries generally are makingprogress in infectious disease control, including theeradication of polio, but uneven economic devel-opment has contributed to widespread resurgenceof cholera, malaria, TB, and dengue. These diseaseswill continue to take a heavy toll in tropical andpoorer countries.

• The Middle East and North Africa region has sub-stantial TB and hepatitis B and C prevalence, butconservative social mores, climatic factors, and thehigh level of health spending in the oil-producingstates tend to limit some globally prevalent diseases,such as HIV/ AIDS and malaria. The region hasthe lowest HIV infection rate among all regions,although this is probably due in part to above-aver-age underreporting because of the stigma associatedwith the disease in Muslim societies.

• Western Europe faces threats from several infectiousdiseases, such as HIV/AIDS, TB, and hepatitis Band C, as well as from several economically costlyzoonotic diseases (that is, those transmitted fromanimals to humans). The region’s large volume of

“Some of the hardest hit countries in sub-Saharan Africa—and possi-bly later in South and Southeast Asia—will face a demographic up-

heaval as HIV/AIDS and associated diseases reduce human life expect-ancy by as much as thirty years and kill as many as a quarter of theirpopulations over a decade or less, producing a huge orphan cohort.”

National Intelligence Estimate: The Global Infectious Disease Threat and Its Implications for the United States


Special Reports

travel, trade, and immigration increases the risks ofimporting diseases from other regions, but its highlydeveloped health care system will limit their impact.

RESPONSE CAPACITY

Development of an effective global surveillance andresponse system probably is at least a decade or moreaway, owing to inadequate coordination and funding atthe international level and lack of capacity, funds, andcommitment in many developing and former commu-nist states. Although overall global health care capacityhas improved substantially in recent decades, the gapbetween rich and poorer countries in the availability andquality of health care, as illustrated by a typology devel-oped by the Defense Intelligence Agency’s Armed ForcesMedical Intelligence Center (AFMIC), is widening.

ALTERNATIVE SCENARIOS

We have examined three plausible scenarios for thecourse of the infectious disease threat over the nexttwenty years:

Steady ProgressThe least likely scenario projects steady progress

whereby the aging of global populations and decliningfertility rates, socio-economic advances, and improve-ments in health care and medical breakthroughs hastenmovement toward a “health transition” in which suchnoninfectious diseases as heart disease and cancer wouldreplace infectious diseases as the overarching globalhealth challenge. We believe this scenario is unlikelyprimarily because it gives inadequate emphasis to per-sistent demographic and socio-economic challenges inthe developing countries, to increasing microbial resis-tance to existing antibiotics, and because related modelshave already underestimated the force of major killerssuch as HIV/AIDS, TB, and malaria.

Progress StymiedA more pessimistic—and more plausible—scenario

projects little or no progress in countering infectiousdiseases over the duration of this Estimate. Under thisscenario, HIV/AIDS reaches catastrophic proportionsas the virus spreads throughout the vast populations ofIndia, China, the former Soviet Union, and LatinAmerica, while multidrug treatments encounter micro-bial resistance and remain prohibitively expensive fordeveloping countries. Multidrug resistant strains of TB,malaria, and other infectious diseases appear at a faster

pace than new drugs and vaccines, wreaking havoc onworld health. Although more likely than the “steadyprogress” scenario, we judge that this scenario also isunlikely to prevail because it underestimates the pros-pects for socio-economic development, internationalcollaboration, and medical and health care advances toconstrain the spread of at least some widespread infec-tious diseases.

Deterioration, Then Limited ImprovementThe most likely scenario, in our view, is one in which

the infectious disease threat—particularly from HIV/AIDS—worsens during the first half of our time frame,but decreases fitfully after that, owing to better preven-tion and control efforts, new drugs and vaccines, andsocio-economic improvements. In the next decade, un-der this scenario, negative demographic and socialconditions in developing countries, such as continuedurbanization and poor health care capacity, remain con-ducive to the spread of infectious diseases; persistentpoverty sustains the least developed countries as reser-voirs of infection; and microbial resistance continues toincrease faster than the pace of new drug and vaccinedevelopment. During the subsequent decade, more posi-tive demographic changes such as reduced fertility andaging populations; gradual socio-economic improvementin most countries; medical advances against childhoodand vaccine-preventable killers such as diarrheal diseases,neonatal tetanus, and measles; expanded internationalsurveillance and response systems; and improvementsin national health care capacities take hold in all but theleast developed countries. Barring the appearance of adeadly and highly infectious new disease, a catastrophicupward lurch by HIV/AIDS, or the release of a highlycontagious biological agent capable of rapid andwidescale secondary spread, these developments produceat least limited gains against the overall infectious dis-ease threat. However, the remaining group of virulentdiseases, led by HIV/ AIDS and TB, continue to take asignificant toll.

ECONOMIC, SOCIAL, AND POLITICAL IMPACT

The persistent infectious disease burden is likely toaggravate and, in some cases, may even provoke eco-nomic decay, social fragmentation, and politicaldestabilization in the hardest hit countries in the devel-oping and former communist worlds, especially in theworst-case scenario outlined above:

• The economic costs of infectious diseases—espe-


Special Reports

cially HIV/AIDS and malaria—are already signifi-cant, and their increasingly heavy toll onproductivity, profitability, and foreign investmentwill be reflected in growing GDP losses, as well,that could reduce GDP by as much as twenty per-cent or more by 2010 in some sub-Saharan Africancountries, according to recent studies.

• Some of the hardest hit countries in sub-SaharanAfrica—and possibly later in South and SoutheastAsia—will face a demographic upheaval as HIV/

AIDS and associated diseases reduce human lifeexpectancy by as much as thirty years and kill asmany as a quarter of their populations over a de-cade or less, producing a huge orphan cohort. Nearlyforty-two million children in twenty-seven coun-tries will lose one or both parents to AIDS by 2010;nineteen of the hardest hit countries will be in sub-Saharan Africa.

• The relationship between disease and political in-stability is indirect but real. A wide-ranging studyon the causes of state instability suggests that infantmortality—a good indicator of the overall qualityof life—correlates strongly with political instabil-ity, particularly in countries that already haveachieved a measure of democracy. The severe socialand economic impact of infectious diseases is likelyto intensify the struggle for political power to con-trol scarce state resources.

IMPLICATIONS FOR U.S. NATIONAL SECURITY

As a major hub of global travel, immigration, andcommerce with wide-ranging interests and a large civil-ian and military presence overseas, the United States andits equities abroad will remain at risk from infectiousdiseases.

• Emerging and reemerging infectious diseases, manyof which are likely to continue to originate over-seas, will continue to kill at least 170,000 Americansannually. Many more could perish in an epidemic

of influenza or yet-unknown disease or if there is asubstantial decline in the effectiveness of availableHIV/AIDS drugs.

• Infectious diseases are likely to continue to accountfor more military hospital admissions than battle-field injuries. U.S. military personnel deployed atNATO and U.S. bases overseas, will be at low-to-moderate risk. At highest risk will be U.S. militaryforces deployed in support of humanitarian and

peacekeeping operations in developing countries.

• The infectious disease burden will weaken the mili-tary capabilities of some countries—as well asinternational peacekeeping efforts—as their armiesand recruitment pools experience HIV infectionrates ranging from ten to sixty percent. The costwill be highest among officers and the more mod-ernized militaries in sub-Saharan Africa andincreasingly among FSU states and possibly somerogue states.

• Infectious diseases are likely to slow socio-economicdevelopment in the hardest-hit developing andformer communist countries and regions. This willchallenge democratic development and transitionsand possibly contribute to humanitarian emergen-cies and civil conflicts.

• Infectious disease-related embargoes and restrictionson travel and immigration will cause frictions amongand between developed and developing countries.

• The probability of a bioterrorist attack against U.S.civilian and military personnel overseas or in theUnited States also is likely to grow as more statesand groups develop a biological warfare capability.Although there is no evidence that the recent WestNile virus outbreak in New York City was causedby foreign state or non-state actors, the scare andseveral earlier instances of suspected bioterrorismshowed the confusion and fear they can sow regard-less of whether or not they are validated.

“Frequent and often sudden population movements within and acrossborders caused by ethnic conflict, civil war, and famine will continue

to spread diseases rapidly in affected areas, particularly among refugees.”



Special Reports

PATTERNS OF INFECTIOUS DISEASES

Broad advances in controlling or eradicating a grow-ing number of infectious diseases—such as tuberculosis(TB), malaria, and smallpox—in the decades after theSecond World War fueled hopes that the global infec-tious disease threat would be increasingly manageable.Optimism regarding the battle against infectious dis-eases peaked in 1978 when the United Nations (UN)member states signed the “Health for All 2000” accord,which predicted that even the poorest nations wouldundergo a health transition before the millennium,whereby infectious diseases no longer would pose a majordanger to human health. As recently as 1996, a WorldBank/World Health Organization (WHO)–sponsoredstudy by Christopher J.L. Murray and Alan D. Lopez

projected a dramatic reduction in the infectious diseasethreat. This optimism, however, led to complacency andoverlooked the role of such factors as expanded tradeand travel and growing microbial resistance to existingantibiotics in the spread of infectious diseases. Today:

• Infectious diseases remain a leading cause of death(see Figure 1). Of the estimated fifty-four milliondeaths worldwide in 1998, about one-fourth to one-third were due to infectious diseases, most of themin developing countries and among children glo-bally.

• Infectious diseases accounted for forty-one percentof the global disease burden measured in terms ofDisability-Adjusted Life Years (DALYS) that gauge

DISCUSSION

Figure 1Leading Causes of Death, 1998

Percent

Infectious diseases,25 (45 percent in low-income Africanand Asian countries; 63 percent amongchildren under age five globally)

Cardiovascular diseases,31

Cancers,13

Injuries,11

Maternal,5

Respiratory and digestive,9

Other,6

Note: Cancers, cardiovascular, and respiratory/digestive deaths can also be caused by infections and raise the percentage of deaths due to infectious diseases even more.Source: WHO, 1999.

53.9 million from all causes, worldwide.


Special Reports

• These trends are reflected in the United States aswell, where annual infectious disease deaths havenearly doubled to some 170,000 since 1980 afterreaching historic lows that year, while new and ex-isting pathogens, such as HIV and West Nile virus,respectively, continue to enter U.S. borders.

THE DEADLY SEVEN

The seven infectious diseases that caused the high-est number of deaths in 1998, according to WHO andthe Defense Intelligence Agency’s Armed Forces Medi-cal Intelligence Center (AFMIC), will remain threatswell into the next century. HIV/AIDS, TB, malaria, andhepatitis B and C—are either spreading or becomingmore drug-resistant, while lower respiratory infections,

the impact of both deaths and disabilities, as com-pared to forty-three percent for noninfectiousdiseases and sixteen percent for injuries.

• Although there has been continuing progress in con-trolling some vaccine-preventable childhood diseasessuch as polio, neonatal tetanus, and measles, a WhiteHouse–appointed interagency working group iden-tified at least twenty-nine previously unknowndiseases that have appeared globally since 1973,many of them incurable, including HIV/AIDS,Ebola hemorrhagic fever, and hepatitis C. Most re-cently, Nipah encephalitis was identified. Twentywell-known diseases such as malaria, TB, cholera,and dengue have rebounded after a period of de-cline or spread to new regions, often in deadlierforms (see Table 1).

Year Microbe Type Disease1973 Rotavirus Virus Infantile diarrhea1977 Ebola virus Virus Acute hemorrhagic fever1977 Legionella pneumophila Bacterium Legionnaires’ disease1980 Human T-lymphotrophic

virus I (HTLV 1)Virus T-cell lymphoma/leukemia

1981 Toxin-producingStaphylococcus aureus

Bacterium Toxic shock syndrome

1982 Escherichia coli O157:H7 Bacterium Hemorrhagic colitis; hemolyticuremic syndrome

1982 Borrelia burgdorferi Bacterium Lyme disease1983 Human Immunodeficiency

Virus (HIV)Virus Acquired Immuno-Deficiency

Syndrome (AIDS)1983 Helicobacter pylori Bacterium Peptic ulcer disease1989 Hepatitis C Virus Parentally transmitted non-A,

non-B liver infection1992 Vibrio cholerae O139 Bacterium New strain associated with

epidemic cholera1993 Hantavirus Virus Adult respiratory distress

syndrome1994 Cryptosporidium Protozoa Enteric disease1995 Ehrlichiosis Bacterium Severe arthritis?1996 nvCJD Prion New variant Creutzfeldt-Jakob

disease1997 HVN1 Virus Influenza1999 Nipah Virus Severe encephalitis

Table 1. Examples of Pathogenic Microbes and the Diseases They Cause, Identified Since 1973

Source: U.S. Institute of Medicine, 1997; WHO, 1999.



Special Reports

diarrheal diseases, and measles, appear to have at leasttemporarily peaked (see Figure 2).1

HIV/AIDS. Following its identification in 1983, thespread of HIV intensified quickly. Despite progress insome regions, HIV/AIDS shows no signs of abating glo-bally (see Figure 3). Approximately 2.3 million peopledied from AIDS worldwide in 1998, up dramaticallyfrom 0.7 million in 1993, and there were 5.8 millionnew infections. According to WHO, some 33.4 millionpeople were living with HIV by 1998, up from ten mil-lion in 1990, and the number could approach fortymillion by the end of 2000. Although infection and deathrates have slowed considerably in developed countriesowing to the growing use of preventive measures andcostly new multidrug treatment therapies, the pandemiccontinues to spread in much of the developing world,where ninety-five percent of global infections and deathshave occurred. Sub-Saharan Africa currently has the big-

gest regional burden, but the disease is spreading quicklyin India, Russia, China, and much of the rest of Asia.HIV/AIDS probably will cause more deaths than anyother single infectious disease worldwide by 2020 andmay account for up to one-half or more of infectiousdisease deaths in the developing world alone.

TB. WHO declared TB a global emergency in 1993and the threat continues to grow, especially frommultidrug resistant TB (see Figure 4). The disease is es-pecially prevalent in Russia, India, Southeast Asia,sub-Saharan Africa, and parts of Latin America. Morethan 1.5 million people died of TB in 1998, excludingthose infected with HIV/AIDS, and there were up to7.4 million new cases. Although the vast majority of TBinfections and deaths occur in developing regions, thedisease also is encroaching into developed regions dueto increased immigration and travel and less emphasison prevention. Drug resistance is a growing problem;

Figure 2Leading Infectious Disease Killers, 1998

Deaths in millions

a HIV-positive people who died with TB have been included among AIDS deaths.b Figure for hepatitis B is for 1997 and is not broken down by age.Source: WHO, 1998, 1999.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Over age five

Under age five

Hepatitis BbMeaslesMalariaTBDiarrheal diseases

AIDSaAcute respiratory infections

(including pneumonia and influenza)


Special Reports

the WHO has reported that up to fifty percent of peoplewith multidrug resistant TB may die of their infectiondespite treatment, which can be ten to fifty times moreexpensive than that used for drug-sensitive TB. HIV/AIDS also has contributed to the resurgence of TB. One-quarter of the increase in TB incidence involves

co-infection with HIV. TB probably will rank secondonly to HIV/AIDS as a cause of infectious disease deathsby 2020.

Malaria, a mainly tropical disease that seemed tobe coming under control in the 1960s and 1970s, ismaking a deadly comeback—especially in sub-Saharan

I N D I A N O C E A N

N O R T H

A T L A N T I C

O C E A N

S O U T H P A C I F I C O C E A N

SOUTH

ATLANTIC

OCEAN

N O R T H

P A C I F I C

O C E A N

ARCTIC OCEANARCTIC OCEAN

N O R T H

O C E A N

P A C I F I C

Figure 4Estimated TB Incidence, 1997

Boundary representation is not necessarily authoritative.

Less than 10 10 - 24 25 - 49 50 - 99 100 - 250 Greater than 250

Range of rates(per 100,000)

Source: World Health Organization, 1998.


N O R T H

A T L A N T I C

O C E A N


SOUTH

ATLANTIC

OCEAN

N O R T H

P A C I F I C

O C E A N


N O R T H

O C E A N

P A C I F I C


Figure 3Global HIV/AIDS Prevalence, 1998

Source: UNAIDS, 1998.

North America890,000(44,000)

Latin America1,400,000(160,000)

Western Europe500,000(30,000)

33,400,000

(5,800,000)

Total living with HIV/AIDS

Total new HIV infections

North Africa/Middle East

210,000(19,000)

Sub-SaharanAfrica

22,500,000(4,000,000)

Eastern Europe/Central Asia

270,000(80,000)

South Asia/Southeast Asia

6,700,000(1,200,000)

Australia/New Zealand

12,000(600)

East Asia/Pacific560,000

(200,000)Caribbean330,000(45,000)



Special Reports

Africa where infection rates increased by forty percentfrom 1970 to 1997 (see Figure 5). Drug resistance, his-torically a problem only with the most severe form ofthe disease, is now increasingly reported in the mildervariety, while the prospects for an effective vaccine are

poor. In 1998, an estimated 300 million people wereinfected with malaria, and more than 1.1 million diedfrom the disease that year. Most of the deaths occurredin sub-Saharan Africa. According to the U.S. Agencyfor International Development (USAID), sub-Saharan


N O R T H

A T L A N T I C

O C E A N


SOUTH

ATLANTIC

OCEAN

N O R T H

P A C I F I C

O C E A N


N O R T H

O C E A N

P A C I F I C


Figure 6Estimated Hepatitis B Prevalence, 1997

Less than 2 percent 2 - 7 percent Greater than 7 percent No data available

Proportion of population infected



N O R T H

A T L A N T I C

O C E A N


SOUTH

ATLANTIC

OCEAN

N O R T H

P A C I F I C

O C E A N


N O R T H

O C E A N

P A C I F I C


Figure 5Malaria-Endemic Regions, 1997

Source: World Health Organization/CTC, 1997.

Malaria-endemic region


Special Reports

Africa alone is likely to experience a seven to twentypercent annual increase in malaria-related deaths andsevere illnesses over the next several years.

Hepatitis B and C. Hepatitis B, which caused at

least 0.6 million deaths in 1997, is highly endemic inthe developing world, and some 350 million peopleworldwide are chronic carriers (see Figure 6). The lessprevalent but far more lethal hepatitis C identified in


N O R T H

A T L A N T I C

O C E A N


SOUTH

ATLANTIC

OCEAN

N O R T H

P A C I F I C

O C E A N


N O R T H

O C E A N

P A C I F I C

Figure 8Reported Measles Incidence Rates, 1996


0 1 - 9 10 - 100 Greater than 100 No data available

Range of rates(per 100,000)



N O R T H

A T L A N T I C

O C E A N


SOUTH

ATLANTIC

OCEAN

N O R T H

P A C I F I C

O C E A N


N O R T H

O C E A N

P A C I F I C


Figure 7Estimated Hepatitis C Prevalence, 1998


Less than 1.0 percent 1.0 - 2.4 percent 2.5 - 4.9 percent 5 - 10 percent Greater than 10 percent No data available

Proportion of population infected



Special Reports

1989 has grown dramatically and is a significant con-tributor to cirrhosis and liver cancer. WHO estimatedthat three percent of the global population was infectedwith the hepatitis C virus by 1997 (see Figure 7), whichmeans that more than 170 million people were at riskof developing the diseases associated with this virus.Various studies project that up to twenty-five percent ofpeople with chronic hepatitis B and C will die of cir-rhosis of the liver and liver cancer over the next twentyto thirty years.

Lower respiratory infections, especially influenza andpneumonia, killed 3.5 million people in 1998, most ofthem children in developing countries, down from 4.1million in 1993. Owing to immunosuppression from

malnutrition and growing microbial resistance to com-monly used drugs such as penicillin, these children areespecially vulnerable to such diseases and will continueto experience high death rates.

Diarrheal diseases— mainly spread by contaminatedwater or food—accounted for 2.2 million deaths in1998, as compared to three million in 1993, of whichabout sixty percent occurred among children under fiveyears of age in developing countries. The most com-mon cause of death related to diarrheal diseases isinfection with Escherichia coli. Other diarrheal diseasesinclude cholera, dysentery, and rotaviral diarrhea, preva-lent throughout the developing world and, more recently,in many former communist states. Such waterborne andfoodborne diseases will remain highly prevalent in theseregions in the absence of improvements in water qualityand sanitation.

Measles. Despite substantial progress against measlesin recent years, the disease still infects some forty-twomillion children annually and killed about 0.9 millionin 1998, down from 1.2 million in 1993. It is a leadingcause of death among refugees and internally displacedpersons during complex humanitarian emergencies.Measles will continue to pose a major threat in develop-ing countries (see Figure 8), particularly sub-SaharanAfrica, until the still relatively low vaccination rates aresubstantially increased. It also will continue to causeperiodic epidemics in areas such as South America withhigher, but still inadequate, vaccination rates.

FACTORS AFFECTING GROWTH AND SPREAD

With few exceptions, the resurgence of the infec-tious disease threat is due as much to dramatic changesin human behavior and broader social, economic, andtechnological developments as to mutations in patho-gens (see Table 2). Changes in human behavior includepopulation dislocations, living styles, and sexual prac-tices; technology-driven medical procedures entailingsome risks of infection; and land use patterns. They alsoinclude rising international travel and commerce thathasten the spread of infectious diseases; inappropriateuse of antibiotics that leads to the development of mi-crobial resistance; and the breakdown of public healthsystems in some countries owing to war or economicdecline. In addition, climate changes enable diseases andvectors to expand their range. Several of these factorsinteract, exacerbating the spread of infectious diseases.

Human Demographics and BehaviorPopulation growth and urbanization, particularly

Table 2. Factors Contributing to InfectiousDisease Reemergence and AssociatedDiseases

ContributingFactor(s)

Associated InfectiousDiseases

Humandemographics andbehavior

Dengue/denguehemorrhagic fever,sexually transmitteddiseases, giardiasis

Technology andindustry

Toxic shock syndrome,nosocomial (hospital-acquired) infections,hemorrhagiccolitis/hemolytic uremicsyndrome

Economicdevelopment andland use

Lyme disease, malaria,plague, rabies, yellowfever, Rift Valley fever,schistosomiasis

International travelandcommerce

Malaria, cholera,pneumococcalpneumonia

Microbial adaptationand change

Influenza, HIV/AIDS,malaria,Staphylococcus aureusinfections

Breakdown of publichealth measures

Rabies, tuberculosis,trench fever, diphtheria,whooping cough(pertussis), cholera

Climate change Malaria, dengue,cholera, yellow fever

Source: Adapted from U.S. Institute of Medicine, 1997.


Special Reports

in the developing world, will continue to facilitate thetransfer of pathogens among people and regions. Fre-quent and often sudden population movements withinand across borders caused by ethnic conflict, civil war,and famine will continue to spread diseases rapidly inaffected areas, particularly among refugees. As of 1999,there were some twenty-four major humanitarian emer-gencies worldwide involving at least thirty-five millionrefugees and internally displaced people. Refugee camps,found mainly in sub-Saharan Africa and the Middle East,facilitate the spread of TB, HIV, cholera, dysentery, andmalaria. Well over 120 million people lived outside thecountry of their birth in 1998, and millions more willemigrate annually, increasing the spread of diseases glo-bally. Behavioral patterns, such as unprotected sex withmultiple partners and intravenous drug use, will remainkey factors in the spread of HIV/AIDS.

Technology, Medicine, and IndustryAlthough technological breakthroughs will greatly

facilitate the detection, diagnosis, and control of cer-tain infectious and noninfectious illnesses, they also willintroduce new dangers, especially in the developed worldwhere they are used extensively. Invasive medical proce-dures will result in a variety of hospital-acquiredinfections, such as Staphylococcus aureus. The globaliza-tion of the food supply means that non-hygienic foodproduction, preparation, and handling practices in origi-nating countries can introduce pathogens endangeringforeign as well as local populations. Disease outbreaksdue to Cyclospora spp, Escherichia coli, and Salmonellaspp. in several countries, along with the emergence,primarily in Britain, of Bovine Spongiform Encephal-opathy, or “mad cow” disease, and the related new variantCreutzfeldt-Jakob disease (nvCJD) affecting humans,result from such food practices.

Economic Development and Land UseChanges in land and water use patterns will remain

major factors in the spread of infectious diseases. Theemergence of Lyme disease in the United States andEurope has been linked to reforestation and increases inthe deer tick population, which acts as a vector, whileconversion of grasslands to farming in Asia encouragesthe growth of rodent populations carrying hemorrhagicfever and other viral diseases. Human encroachment ontropical forests will bring populations into closer prox-imity with insects and animals carrying diseases such asleishmaniasis, malaria, and yellow fever, as well as here-tofore unknown and potentially dangerous diseases, aswas the case with HIV/AIDS. Close contact betweenhumans and animals in the context of farming will in-

crease the incidence of zoonotic diseases—those trans-mitted from animals to humans. Water managementefforts, such as dambuilding, will encourage the spreadof water-breeding vectors such as mosquitoes and snailsthat have contributed to outbreaks of Rift Valley feverand schistosomiasis in Africa.

International Travel and CommerceThe increase in international air travel, trade, and

tourism will dramatically increase the prospects thatinfectious disease pathogens such as influenza—and vec-tors such as mosquitoes and rodents—will spread quicklyaround the globe, often in less time than the incubationperiod of most diseases. Earlier in the decade, for ex-ample, a multidrug resistant strain of Streptococcuspneumoniae originating in Spain spread throughout theworld in a matter of weeks, according to the director ofWHO’s infectious disease division. The cross-bordermovement of some two million people each day, includ-ing one million between developed and developingcountries each week, and surging global trade ensurethat travel and commerce will remain key factors in thespread of infectious diseases.

Microbial Adaptation and ResistanceInfectious disease microbes are constantly evolving,

oftentimes into new strains that are increasingly resis-tant to available antibiotics. As a result, an expandingnumber of strains of diseases—such as TB, malaria, andpneumonia—will remain difficult or virtually impos-sible to treat. At the same time, large-scale use ofantibiotics in both humans and livestock will continueto encourage development of microbial resistance. Thefirstline drug treatment for malaria is no longer effec-tive in over eighty of the ninety-two countries where thedisease is a major health problem. Penicillin has sub-stantially lost its effectiveness against several diseases,such as pneumonia, meningitis, and gonorrhea, in manycountries. Eighty percent of Staphylococcus aureus iso-lates in the United States, for example, arepenicillin-resistant and thirty-two percent are methicil-lin-resistant. A U.S. Centers for Disease Control andPrevention (USCDC) study found a sixty-fold increasein high-level resistance to penicillin among one groupof Streptococcus pneumoniae cases in the United Statesand significant resistance to multidrug therapy as well.Influenza viruses, in particular, are particularly efficientin their ability to survive and genetically change, some-times into deadly strains. HIV also displays a high rateof genetic mutation that will present significant prob-lems in the development of an effective vaccine or new,affordable therapies.



Special Reports

Breakdown in Public Health CareAlone or in combination, war and natural disasters,

economic collapse, and human complacency are caus-ing a breakdown in health care delivery and facilitatingthe emergence or reemergence of infectious diseases.While sub-Saharan Africa is the area currently most af-fected by these factors, economic problems in Russiaand other former communist states are creating the con-text for a large increase in infectious diseases. Thedeterioration of basic health care services largely accountsfor the reemergence of diphtheria and other vaccine-preventable diseases, as well as TB, as funds forvaccination, sanitation, and water purification have driedup. In developed countries, past inroads against infec-tious diseases led to a relaxation of preventive measuressuch as surveillance and vaccination. Inadequate infec-tion control practices in hospitals will remain a majorsource of disease transmission in developing and devel-oped countries alike.

Climate ChangeClimatic shifts are likely to enable some diseases and

associated vectors—particularly mosquito-borne diseasessuch as malaria, yellow fever, and dengue—to spread tonew areas. Warmer temperatures and increased rainfallalready have expanded the geographic range of malariato some highland areas in sub-Saharan Africa and LatinAmerica and could add several million more cases indeveloping country regions over the next two decades.The occurrence of waterborne diseases associated withtemperature-sensitive environments, such as cholera, alsois likely to increase.

REGIONAL TRENDS AND RESPONSE CAPACITY

The overall level of global health care capacity hasimproved substantially in recent decades, but in mostpoorer countries the availability of various types of healthcare—ranging from basic pharmaceuticals and postna-tal care to costly multidrug therapies—remains verylimited. Almost all research and development funds al-located by developed country governments andpharmaceutical companies, moreover, are focused on ad-vancing therapies and drugs relevant to developedcountry maladies, and those that are relevant to devel-oping country needs usually are beyond their financialreach. This is generating a growing controversy betweenrich and poorer nations over such issues as intellectualproperty rights, as some developing countries seek tomeet their pharmaceutical needs with locally producedgeneric products. Malnutrition, poor sanitation, and

poor water quality in developing countries also will con-tinue to add to the disease burden that is overwhelminghealth care infrastructures in many countries. So too,will political instability and conflict and the reluctanceof many governments to confront issues such as thespread of HIV/AIDS.

Sub-Saharan AfricaSub-Saharan Africa will remain the region most af-

fected by the global infectious disease phenomenon—accounting for nearly half of infectious disease-causeddeaths worldwide. Deaths from HIV/AIDS, malaria,cholera, and several lesser known diseases exceed thosein all other regions. Sixty-five percent of all deaths insub-Saharan Africa are caused by 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 thecrisis. According to the AFMIC typology, with the ex-ception of southern Africa, most of sub-Saharan Africafalls in the lowest category. Investment in health care inthe region is minimal, less than forty percent of thepeople in countries such as Nigeria and the DemocraticRepublic of the Congo (DROC) have access to basicmedical care, and even in relatively well off South Af-rica, only fifty to seventy percent have such access, withblack populations at the low end of the spectrum.

Four-fifths of all HIV-related deaths and seventypercent of new infections worldwide in 1998 occurredin the region, totaling 1.8-2 million and four million,respectively. Although only a tenth of the world’s popu-lation lives in the region, 11.5 million of 13.9 millioncumulative AIDS deaths have occurred there. Easternand southern African countries, including South Africa,are the worst affected, with ten to twenty-six percent ofadults infected with the disease. Sub-Saharan Africa hashigh TB prevalence, as well as the highest HIV/TB co-infection rate, with TB deaths totaling 0.55 million in1998. The hardest hit countries are in equatorial andespecially southern Africa. South Africa, in particular, isfacing the biggest increase in the region.

Sub-Saharan Africa accounts for an estimated ninetypercent of the global malaria burden (see Figure 9). Tenpercent of the regional disease burden is attributed tomalaria, with roughly one million deaths in 1998. Chol-era, dysentery, and other diarrheal diseases also are majorkillers in the region, particularly among children, refu-gees, and internally displaced populations. Forty percentof all childhood deaths from diarrheal diseases occur insub-Saharan Africa. The region also has a high rate ofhepatitis B and C infections and is the only region witha perennial meningococcal meningitis problem in a


Special Reports

“meningitis belt” stretching from west to east. Sub-Sa-haran Africa also suffers from yellow fever, whiletrypanasomiasis or “sleeping sickness” is making a come-back in the DROC and Sudan, and the Marburg virusalso appeared in DROC for the first time in 1998. Ebolahemorrhagic fever strikes sporadically in countries suchas the DROC, Gabon, Cote d’Ivoire, and Sudan.

Asia and the PacificAlthough the more developed countries of Asia and

the Pacific, such as Japan, South Korea, Australia, andNew Zealand, have strong records in combating infec-tious diseases, infectious disease prevalence in South andSoutheast Asia is almost as high as in Sub-Saharan Af-rica. The health care delivery system of the Asia andPacific region—the majority of which is privately fi-nanced—is particularly vulnerable to economicdownturns even though this is offset to some degree bymuch of the region’s reliance on traditional medicinefrom local practitioners. According to the AFMIC ty-pology, ninety to one hundred percent of the populations

in the most developed countries, such as Japan and Aus-tralia, have access to high-quality health care. Forty tofifty percent have such access among the large popula-tions of China and South Asia, while southeast Asianhealth care is more varied, with less than forty percentenjoying such access in Burma and Cambodia, and fiftyto seventy percent in Thailand, Malaysia, and the Phil-ippines. In South and Southeast Asia, reemergent diseasessuch as TB, malaria, cholera, and dengue fever are ram-pant, while HIV/AIDS, after a late start, is growing fasterthan in any other region.

TB caused one million deaths in the Asia and Pa-cific region in 1998, more than any other single disease,with India and China accounting for two-thirds of thetotal. Several million new cases occur annually—mostin India, China, and Indonesia—representing as muchas forty percent of the global TB burden. HIV/AIDS isincreasing dramatically, especially in India, which leadsthe world in absolute numbers of HIV/AIDS infections,estimated at three to five million. China is better offthan most of the countries to its south, but it too has a

Figure 10Malaria Mortality Annual Rates Since 1900

Per 100,000 population

Source: WHO, 1999.

0

50

100

150

200

250

199719901970195019301900

World minusSub-Saharan AfricaWorldSub-Saharan Africa

9



Special Reports

growing AIDS problem, with HIV infections variouslyestimated at 0.1-0.4 million and spreading rapidly.Regionwide, the number of people infected with HIVcould overtake Sub-Saharan Africa in absolute numbersbefore 2010.

There were 19.5 million new malaria infections es-timated in the Asia and Pacific region in 1998, many ofthem drug resistant, and 100,000 deaths due to malaria.Acute respiratory infections, such as pneumonia, causeabout 1.8 million childhood deaths annually––over halfof them in India––while dengue (including dengue hem-orrhagic fever/dengue shock syndrome) outbreaks havespread throughout the region in the last five years. Water-borne illnesses such as dysentery and cholera also take aheavy toll in poor and crowded areas. Asian, particu-larly Chinese, agricultural practices place farm animals,fowl, and humans in close proximity and have long fa-cilitated the emergence of new strains of influenza thatcause global pandemics. Hepatitis B is widely prevalentin the region, while hepatitis C is prevalent in Chinaand in parts of southeast Asia. In 1999 the newly recog-nized Nipah virus spread throughout pig populationsin Malaysia, causing more than 100 human deaths thereand a smaller number in nearby Singapore.

Latin AmericaLatin American countries are making considerable

progress in infectious disease control, including the eradi-cation of polio and major reductions in the incidenceand death rates of measles, neonatal tetanus, some diar-rheal diseases, and acute respiratory infections.Nonetheless, infectious diseases are still a major causeof illness and death in the region, and the risk of newand reemerging diseases remains substantial. Wideningincome disparities, periodic economic shocks, and ram-pant urbanization have disrupted disease control effortsand contributed to widespread reemergence of cholera,malaria, TB, and dengue, especially in the poorer Cen-tral American and Caribbean countries and in theAmazon basin of South America. According to theAFMIC typology, Latin America’s health care capacityis substantially more advanced than that of sub-SaharanAfrica and somewhat better than mainland Asia’s, withseventy to ninety percent of populations having accessto basic health care in Chile, Costa Rica, and Cuba onthe upper end of the scale. Less than fifty percent havesuch access in Haiti, most of Central America, and theAmazon basin countries, including the rural populationsin Brazil.

Cholera reemerged with a vengeance in the regionin 1991 for the first time in a century with 400,000new cases, and while dropping to 100,000 cases in 1997,

it still comprises two-thirds of the global cholera bur-den. TB is a growing problem regionwide, especially inBrazil, Peru, Argentina, and the Dominican Republicwhere drug-resistant cases also are on the rise. Haiti doesnot provide data but probably also has a high infectionrate. HIV/AIDS also is spreading rapidly, placing LatinAmerica third behind sub-Saharan Africa and Asia inHIV prevalence. Prevalence is high in Brazil and espe-cially in the Caribbean countries (except Cuba), wheretwo percent of the population is infected. Malaria isprevalent in the Amazon basin. Dengue reemerged inthe region in 1976, and outbreaks have taken place inthe last few years in most Caribbean countries and partsof South America. Hepatitis B and C prevalence is great-est in the Amazon basin, Bolivia, and Central America,while dengue hemorhagic fever is particularly prevalentin Brazil, Colombia, and Venezuela. Yellow fever hasmade a comeback over the last decade throughout theAmazon basin, and there have been several recent out-breaks of gastrointestinal disease attributed to E. coliinfection in Chile and Argentina. Hemorrhagic feversare present in almost all South American countries, andmost hantavirus pulmonary syndrome occurs in thesouthern cone.

Middle East and North AfricaThe region’s conservative social mores, climatic fac-

tors, and high levels of health spending in oil-producingstates tend to limit some globally prevalent diseases, suchas HIV/AIDS and malaria, but others, such as TB andhepatitis B and C, are more prevalent. The region’s ad-vantages are partially offset by the impact of war-relateduprooting of populations, overcrowded cities with poorrefrigeration and sanitation systems, and a dearth ofwater, especially clean drinking water. Health care ca-pacity varies considerably within the region, accordingto the AFMIC typology. Israel and the Arabian Penin-sula states minus Yemen are in far better shape than Iraq,Iran, Syria, and most of North Africa. Ninety to 100percent of the Israeli population and seventy to ninetypercent of the Saudi population have good access tohealth care. Elsewhere, access ranges from less than fortypercent in Yemen to fifty to seventy percent in the smallerGulf states, Jordan and Tunisia, while most North Afri-can states fall into the forty-to fifty-percent category.

The HIV/AIDS impact is far lower than in otherregions, with 210,000 cases, or 0.13 percent of the popu-lation, including 19,000 new cases, in 1998. This owesin part to above-average underreporting because of thestigma associated with the disease in Muslim societiesand the authoritarian nature of most governments inthe region. TB, including multidrug resistant varieties,


Special Reports

is more problematic, especially in Iran, Iraq, Yemen,Libya, and Morocco, with an estimated 140,000 deathsin 1998. Malaria is significant only in Iran, Iraq, andYemen, but diarrheal and childhood diseases caused 0.3million deaths each in 1998. Other prominent or re-emerging diseases in the region include all types ofhepatitis, with Egypt reporting the highest prevalenceworldwide of the C variety. Brucel-losis now infects some 90,000 people;leishmaniasis and sandfly fever alsoare endemic in the region; and vari-ous hemorrhagic fevers occur, as well.

The Former Soviet Union and East-ern Europe

The sharp decline in health careinfrastructure in Russia and else-where in the former Soviet Union(FSU) and, to a lesser extent, in East-ern Europe—owing to economicdifficulties—are causing a dramaticrise in infectious disease incidence.Death rates attributed to infectiousdiseases in the FSU increased fiftypercent from 1990 to 1996, with TB accounting for asubstantial number of such deaths. According to theAFMIC typology, access to health care ranges from fiftyto seventy percent in most European FSU states, includ-ing Russia and Ukraine, and from forty to fifty percentin FSU states located in Central Asia. This is generallysupported by WHO estimates indicating that only fiftyto eighty percent of FSU citizens had regular access toessential drugs in 1997, as compared to more thanninety-five percent a decade earlier as health care bud-gets and government-provided health services wereslashed. Access to health care is generally better in East-ern Europe, particularly in more developed states suchas Poland, the Czech Republic, and Hungary, where itranges from seventy to ninety percent, while only fiftyto seventy percent have access in countries such as Bul-garia and Romania. More than ninety-five percent ofthe population throughout the East European regionhad such access in 1987, according to WHO.

Crowded living conditions are among the causesfueling a TB epidemic in the FSU, especially amongprison populations––while surging intravenous drug useand rampant prostitution are substantially responsiblefor a marked increase in HIV/AIDS incidence. Therewere 111,000 new TB infections in Russia alone in 1996,a growing number of them multidrug resistant, andnearly 25,000 deaths due to TB––numbers that couldincrease significantly following periodic releases of pris-

oners to relieve overcrowding. The number of new in-fections for the entire FSU in 1996 was 188,000, whileEast European cases totaled 54,000. More recent dataindicate that the TB infection rate in Russia more thantripled from 1990 to 1998, with 122,000 new cases re-ported in 1998 and the total number of cases expectedto reach one million by 2002. After a slow and late start,

HIV/AIDS is spreading rapidly throughout the Euro-pean part of the FSU beyond the original cohort ofintravenous drug users, though it is not yet reflected inofficial government reporting. An estimated 270,000people were HIV-positive in 1998, up more than five-fold from 1997. Although Ukraine has been hardest hit,Russia, Belarus, and Moldova have registered major in-creases. Various senior Russian Health Ministry officialspredict that the HIV-positive population in Russia alonecould reach one million by the end of 2000 and couldreach two million by 2002. East European countries willfare better as renewed economic growth facilitates re-covery of their health care systems and better enablesthem to expand preventive and treatment programs.

Diphtheria reached epidemic proportions in theFSU in the first half of the decade, owing to lapses invaccination. Reported annual case totals grew from 600cases in 1989 to more than 40,000 in 1994 in Russia,with another 50,000 to 60,000 in the rest of the FSU.Cholera and dysentery outbreaks are occurring with in-creasing frequency in Russian cities, such as St.Petersburg and Moscow, and elsewhere in the FSU, suchas in T’bilisi, owing to deteriorating water treatmentand sewerage systems. Hepatitis B and C, spread prima-rily by intravenous drug use and blood transfusions, areon the rise, especially in the non-European part of theFSU. Polio also has reappeared owing to interruptionsin vaccination, with 140 new cases in Russia in 1995.

“Infectious diseases are likely to slow socio-economic development in the hardest-hit

developing and former communist countriesand regions. This will challenge democraticdevelopment and transitions and possiblycontribute to humanitarian emergencies andcivil conflicts.”



Special Reports

Western EuropeWestern Europe faces threats from a number of

emerging and reemerging infectious diseases such asHIV/AIDS, TB, and hepatitis B and C, as well as sev-eral zoonotic diseases. Its status as a hub of internationaltravel, commerce, and immigration, moreover, dramati-cally increases the risks of importing new diseases fromother regions. Tens of millions of West Europeans travelto developing countries annually, increasing the pros-pects for the importation of dangerous diseases, asdemonstrated by the importation of typhoid in 1999.Some eighty-eight percent of regional population growthin the first half of the decade was due to immigration;legal immigrants now comprise about six percent of thepopulation, and illegal newcomers number an estimatedsix million. Nonetheless, the region’s highly developedhealth care infrastructure and delivery system tend tolimit the incidence and especially the death rates of mostinfectious diseases, though not the economic costs. Ac-cess to high-quality care is available throughout most ofthe region, although governments are beginning to limitsome heretofore generous health benefits, and a grow-ing anti-vaccination movement in parts of WesternEurope, such as Germany, is causing a rise in measlesand other vaccine-preventable diseases. The AFMIC ty-pology gives somewhat higher marks to northern oversome southern European countries, but the region as awhole is ranked in the highest category, along with NorthAmerica.

After increasing sharply for most of the 1980s and1990s, HIV infections, and particularly HIV/AIDSdeaths, have slowed considerably owing to behavioralchanges among high-risk populations and the availabil-ity and funding for multidrug treatment. Some 0.5 mil-lion people were living with HIV/AIDS in 1998, downslightly from 510,000 the preceding year, and there were30,000 new cases and 12,000 deaths, with prevalencesomewhat higher in much of southern Europe than inthe north. TB, especially its multidrug resistant strains,is on the upswing, as is co-infection with HIV, particu-larly in the larger countries, with some 50,000 TB casesreported in 1996. Hepatitis C prevalence is growing,especially in southern Europe. Western Europe also con-tinues to suffer from several zoonotic diseases, amongwhich is the deadly new variant Creutzfeldt-Jakob dis-ease (nvCJD), linked to the bovine spongiform encepha-lopathy or “mad cow disease” outbreak in the UnitedKingdom in 1995 that has since ebbed following imple-mentation of strict control measures. Other recent dis-ease concerns include meningococcal meningitisoutbreaks in the Benelux countries and leishmaniasis-HIV co-infection, especially in southern Europe.

INTERNATIONAL RESPONSE CAPACITY

International organizations such as WHO and theWorld Bank, institutions in several developed countriessuch as the U.S. CDC, and nongovernmental organiza-tions (NGOs) will continue to play an important rolein strengthening both international and national sur-veillance and response systems for infectious diseases.Nonetheless, progress is likely to be slow, and develop-ment of an integrated global surveillance and responsesystem probably is at least a decade or more away. Thisowes to the magnitude of the challenge; inadequate co-ordination at the international level; and lack of funds,capacity, and, in some cases, cooperation and commit-ment at the national level. Some countries hide orunderstate their infectious disease problems for reasonsof international 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 ofthese countries.

WHOWHO has the broadest health mandate under the

UN system, including establishing health priorities, co-ordinating global health surveillance, and emergencyassistance in the event of disease outbreaks. Health ex-perts give WHO credit for major successes, such as theeradication of smallpox, near eradication of polio, andsubstantial progress in controlling childhood diseases,and in facilitating the expansion of primary health carein developing countries. It also has come under criti-cism for becoming top heavy, unfocused in its mission,and overly optimistic in its health projections. WHOdefenders blame continued member state parsimony thathas kept WHO’s regular biennial budget to roughly $850million for several years and forced it to rely more onvoluntary contributions that often come with stringsattached as the cause of its shortcomings.

The election last year (1998) of Gro HarlemBruntland as Secretary General, along with a series ofreforms, including expansion of the Emerging and OtherCommunicable Diseases Surveillance and Control(EMC) Division, has placed WHO in a better positionto revitalize itself. Internal oversight and transparencyhave been expanded, programs and budgets are under-going closer scrutiny, and management accountabilityis looming larger. Bruntland has moved quickly tostreamline upper-level management and has installednew top managers, mostly from outside the organiza-tion, including from the private sector. She also isworking to strengthen country offices and to make the


Special Reports

regional offices more responsive to central direction.WHO is increasing its focus on the fight against resur-gent malaria, while a better-funded EMC is expandingefforts to establish a global surveillance and responsesystem in cooperation with UNAIDS, UNICEF, andnational entities such as the U.S. CDC, the U.S. DoD,and France’s Pasteur Institute.

The World BankThe growing sense that health is linked inexorably

to socio-economic development, has prompted theWorld Bank to expand its health activities. Accordingto a 1997 study by the U.S. Institute of Medicine, themost significant change in the global health arena overthe past decade has been the growth in both financialand intellectual influence of the World Bank, whosehealth loans have grown to $2.5 billion annually, in-cluding $800 million for infectious diseases. Health

experts generally welcome the Bank’s greater involve-ment in the health sector, viewing it as efficient andresponsive in areas such as health sector financial re-form. Some remain concerned that the Bank’s emphasison fiscal balance can sometimes have a negative healthand social impact in developing countries. Some devel-oping countries resent what they perceive as thedomination of Bank decision-making and priority set-ting by the richer countries.

Nongovernmental OrganizationsAnother major change in the global health arena

over the last decade is the increasingly important role ofNGOs, which provide direct assistance, including emer-gency shelter and aid, as well as long-term domestichealth care delivery. NGOs also build community aware-ness and support for WHO and other international andbilateral surveillance and response efforts. At the same

Number of Countries and Territories

Integrated management of

childhood illnesses

Directly ObservedTreatment Short

Course to control TB

HIV/AIDS education in schools

Routine childhood

immunization

0

50

100

150

200

250

Countries not adopting WHO policies

Countries adopting WHO policies

Figure 12Inadequate Commitment to Infectious Disease Control Policies at Country Level

Source: WHO, 1999.

120 developingcountries only

10



Special Reports

time, health experts note that NGOs, like their govern-mental counterparts, are driven in part by their own selfinterests, which sometimes conflict with those of hostand donor governments.

Bilateral AssistanceThe United States, through USAID, the CDC, the

National Institutes for Health (NIH), and the DefenseDepartment’s overseas laboratories, is a major contribu-tor to international efforts to combat infectious diseases.It is joined increasingly by other developed nations andregional groupings, such as the European Union (EU),that provide assistance bilaterally, as well as through in-ternational organizations and NGOs. The FieldEpidemiology Training Programs––run jointly by theCDC and WHO—as well as the EU-U.S. Task Forceon Emerging Diseases and the U.S.-Japan Common Sci-entific Agenda, are key examples of developed-countryprograms focusing on infectious diseases.

National LimitationsA major obstacle to effective global surveillance and

control of infectious diseases will continue to be pooror inaccurate national health statistical reporting bymany developing countries and lack of both capacityand will to properly direct aid (see Figure 10) and tofollow WHO and other recommended health care prac-tices. Those areas of the world most susceptible toinfectious disease problems are least able to develop andmaintain the sophisticated and costly communicationsequipment needed for effective disease surveillance andreporting. In addition to the barriers dictated by lowlevels of development, revealing an outbreak of a dreadeddisease may harm national prestige, commerce, and tour-ism. For example, nearly every country initially deniedor minimized the extent of the HIV/AIDS virus withinits borders, and even today, some countries known tohave significant rates of HIV infection refuse to cooper-ate with WHO, which can only publish the informationsubmitted by surveying nations. Only a few, such asUganda, Senegal, and Thailand, have launched majorpreventative efforts, while many WHO members do noteven endorse AIDS education in schools. Similarly, somecountries routinely and falsely deny the existence of chol-era within their borders.

Aid programs to prevent and treat infectious dis-eases in developing countries depend largely onindigenous health workers for their success and cannotbe fielded effectively in their absence. Educational pro-grams aimed at preventing disease exposure frequentlydepend on higher literacy levels and assume cultural andsocial factors that often are absent.

1990RankOrder

Disease or Injury 2020RankOrder

1 Lower respiratoryinfections

6

2 Diarrheal diseases 93 Conditions arising

during perinatal period11

4 Unipolar majordepression

2

5 Ischemic heartdisease

1

6 Cerebrovasculardisease

4

7 Tuberculosis 78 Measles 259 Road traffic deaths 310 Congenital

abnormalities13

11 Malaria 2412 Chronic obstructive

pulmonary disease5

13 Falls 1914 Iron-deficiency anemia 3915 Protein-energy

malnutrition37

16 War 817 Self-inflicted injuries 1419 Violence 1228 HIV 1033 Trachea, bronchus,

and lung cancers15

Table 3. Projected Change in the RankOrder of Global Disease Burden forLeading Causes, Worldwide 1990-2020,According to the Optimistic Scenario

aOf the six infectious diseases ranked in 1990, only lower

respiratory infections, diarrheal diseases, and measles are

trending downward as projected, while malaria is increasing

and tuberculosis and HIV are growing far faster than

projected. Nonetheless, more pessimistic experts have not

developed an alternative model and generally adopt the

projections of the Murray and Lopez model.

Source: Adapted from World Bank, WHO, 1996, edited by

Christopher J. L. Murray and Alan D. Lopez.


Special Reports

ALTERNATIVE SCENARIOS AND OUTLOOK FOR

INFECTIOUS DISEASES

The impact of infectious diseases over the nexttwenty years will be heavily influenced by three sets ofvariables. The first is the relationship between increas-ing microbial resistance and scientific efforts to developnew antibiotics and vaccines. The second is the trajec-tory of developing and transitional economies, especiallyconcerning the basic quality of life of the poorest groupsin these countries. The third is the degree of success ofglobal and national efforts to create effective systems ofsurveillance and response. The interplay of these driverswill determine the overall outlook.

On the positive side, reduced fertility and the agingof the population, continued economic development,and improved health care capacity in many countries,especially the more developed, will increase the progresstoward a health transition by 2020 whereby the impactof infectious diseases ebbs, as compared to noninfec-tious diseases. On the negative side, continued rapidpopulation growth, urbanization, and persistent pov-erty in much of the developing world, and the paradoxin which some aspects of socio-economic development––such as increased trade and travel––actually foster thespread of infectious diseases, could slow or derail thattransition. So, too, will growing microbial resistanceamong resurgent diseases, such as malaria and TB, andthe proliferation or intensification of new ones, such asHIV/AIDS.

Two scenarios—one optimistic and one pessimis-tic—reflect differences in the international healthcommunity concerning the global outlook for infectiousdiseases. We present and critically assess these scenarios,elaborate on the pessimistic scenario, and develop a third,combining some elements of each, that we judge as morelikely to prevail over the period of this Estimate.

The Optimistic Scenario: Steady ProgressAccording to a key 1996 World Bank/WHO study

cited earlier that articulated the optimistic scenario, ahealth transition––resulting from key drivers, such asaging populations, socio-economic development, andmedical advances—already is under way in developedcountries and also in much of Asia and Latin Americathat is likely to produce a dramatic reduction in the in-fectious disease threat. The study projects that deathscaused primarily by infectious diseases will fall steadilyfrom thirty-four percent of the total disease burden in1990 to fifteen percent in 2020. Those from noninfec-tious diseases are likely to climb from fifty-five percentof the total disease burden to seventy-three percent, with

the remainder of deaths due to accidents and other typesof injuries. According to the study’s ranking of majordisease threats over this thirty-year time frame, nonin-fectious diseases generally will rise in importance, ledby heart disease and mental illness, as will accidentalinjuries. TB will remain in seventh place in 2020, andHIV/AIDS will move from twenty-eighth place to tenth,with the two combined accounting for more than ninetypercent of infectious disease-caused deaths among adults,almost all of them in developing countries. Lower respi-ratory infections will fall from the top spot to sixth place,however, while measles and malaria will drop precipi-tously from eighth and eleventh place to twenty-fourthand twenty-fifth, respectively (see Figures 11 and 12).

Scenario Assessment. Our overall judgment is thatthe “steady progress” scenario is very unlikely to tran-spire over the time period of this Estimate. Althoughthe scenario captures some real trends, it overstates theprogress achievable, while underestimating the risks.

• The global life expectancy increases projected bythe optimists are likely to be substantially offsetby HIV/AIDS and related diseases, such as TB,which are already causing a major reduction in lifeexpectancy in the most heavily affected sub-Saharan African countries and will be spreadingextensively throughout heavily populated Asiaduring the time period of the Estimate. Optimistsacknowledge that HIV/ AIDS and TB will be theoverarching infectious disease threats by 2020, butthey understate the magnitude of that threat,while their projections of a steep decline inmalaria deaths is belied by the disease’s resurgenceand growing death toll.

• The picture of steady socio-economic progress isnot consistent with the most recent surveys of con-ditions in developing countries undertaken by theUnited Nations, the World Bank, and other inter-national agencies. These studies point to a slowingof progress in basic social indicators in much of thedeveloping world, even before the recent global fi-nancial crisis.

• Although we judge that economic growth is likelyto continue, we are less confident that the dramaticreductions in poverty achieved in many countriesin the last generation will be sustained. Growth islikely to be halting in many countries, owing tostructural economic problems and the impact ofrecurring developing world economic crises.



Special Reports

Figure 13Projected Changes in the Global Distribution ofDeaths and DALYS by Causes According to theOptimistic Scenario, 1990-2020

Percent

Sources: Adapted from World Bank; WHO; The Global Burden of Disease, edited by Christopher J. L. Murray and Alan D. Lopez, 1996.

Projected Deaths

Projected DALYS (Disability-Adjusted Life Years)

DALYS provide a broader measure of the disease burden by including disabilities as well as deaths. One DALY is equivalent to one lost year of healthy life.

Noninfectious diseases

Infectious diseases

Injuries

55 7334

11

15

12

4742

11

6917

14

1990 2020

1990 2020

11

• The rapidly expanding costs of many drugs, espe-cially those that attack critical infectious diseases,such as HIV/AIDS and multidrug resistant TB andmalaria, threaten to limit the sustainability of im-proved health care. Furthermore, despite economicgrowth, pressures on government budgets, especially

from rising pension and other costs, may limit theprospects for increased health financing.

• The optimists may place too much emphasis on thesteady progress of science, which is inconsistent withthe demonstrated difficulty of developing new drugs


Special Reports

and vaccines for complex pathogens such as HIVand malaria.

The Pessimistic Scenario: Progress StymiedSurprisingly, even the most pessimistic epidemiolo-

gists have done little to project the long-term implica-tions of their analysis and simply adopt the longer termprojections of the World Bank/WHO model in the ab-sence of a worst-case model. We have developed a worstcase scenario culled from a variety of epidemiological

Figure 14Various Projected HIV/AIDS Death RatesPer 1,000 People, by Region, 1990-2020

Sources: Adapted from World Bank, Confronting AIDS, 1997.

All three of the above projections on HIV/AIDSdeath rates have underestimated the number of deaths thus far, and their future estimates also are likely to be exceeded, in our view. The three sets of projections are by Murray and Lopez (1996), Bongaarts (1996), and the Global AIDS Policy Coalition (Mann and Tarantola 1996). Since the Global AIDS Policy Coalition (GAPC) does not explicitly project an adult death rate, the projection for 2005 used here is derived from itsestimate of the number of new HIV infections in 1995 by using Bongaarts' rule of thumb that AIDS deaths in any given year will approximately equal the number of people infected with HIV during the year 10 years before. According to this formula, the 5.8 million new HIV infections in 1998 will result in 5.8 million deaths in 2008.

Asia

AIDS death rate per 1,000

Latin America and Caribbean


Eastern Europe and Central Asia


Established Market Economies


Sub-Saharan Africa


0

0.2

0.4

0.6

0.8

201510052000951990 0

0.2

0.4

0.6

0.8

201510052000951990

0

0.2

0.4

0.6

0.8

201510052000951990 0

0.2

0.4

0.6

0.8

201510052000951990

0

0.5

1.0

1.5

2.0

2.5

3.0

201510052000951990

Note scale change

Murray and Lopez

BongaartsGlobal AIDS PolicyCoalition

12



Special Reports

and broader health studies. This scenario highlights thedangers posed by microbial resistance among reemergentdiseases such as TB and malaria. It takes a more con-cerned view of new diseases and of the HIV/AIDSpandemic, in particular, and is skeptical about the ad-equacy of world health care capacity to confront thesechallenges. It emphasizes continuing and difficult-to-address poverty challenges in developing countries andprojects an incomplete health transition that prolongsthe heavy infectious disease burden in the least devel-oped countries and sustains their role as reservoirs ofinfection for the rest of the world.

Scenario Assessment. Our overall judgment is thatthe “progress stymied” scenario, while more plausiblethan the optimistic scenario, is also unlikely to developover the period of this Estimate. Although the pessimis-tic scenario provides an important counterpoint to theassumptions in the “steady progress” scenario, it under-states the likely longer term impact of economicdevelopment, scientific progress, and political pressuresin responding to the infectious disease threat.

• The demographic projections understate the likelyimpact of continued progress in reducing infantmortality.

• Improvements in the economic conditions of poorcountries and the poorest within countries are prob-ably more important for the infectious diseaseoutlook than the widening “prosperity gap” bothbetween countries and within countries. Althoughthe outlook for sub-Saharan Africa remains bleak,for the rest of the world progress against infectiousdiseases would stall only under the most dire globaleconomic scenario.

• The negative impact on health care delivery ofprivatization and the transitions in former commu-nist states is likely to be most heavily felt in theimmediate future. Free market reforms eventuallywill improve health care delivery.

• The current success of the “mutating microbes” inthe race against scientific innovation will, in and ofitself, call forth a greater research effort that will,over time, increase the likelihood of a reversal ofthis trend.

• The rapid spread of HIV/AIDS in developing andformer communist countries is likely to reinvigo-rate international efforts to address the virus throughboth medical and behavioral approaches. It will es-

pecially give impetus to the search for a more cost-effective approach than at present.

• While growth in surveillance and response capabili-ties are slow, they are real and are unlikely to bereversed.

The Most Likely Scenario: Deterioration, Then LimitedImprovement

According to this scenario, continued deteriorationduring the first half of our time frame—led by hardcore killers such as HIV/AIDS, TB, and malaria—is fol-lowed by limited improvement in the second half, owingprimarily to gains against childhood and vaccine-pre-ventable diseases such as diarrheal diseases, neonataltetanus, and measles. The scale and scope of the overallinfectious disease threat diminishes, but the remainingthreat consists of especially deadly or incurable diseasessuch as HIV/AIDS, TB, hepatitis C, and possibly, here-tofore unknown diseases, with HIV/AIDS and TB likelycomprising the overwhelming majority of infectiousdisease deaths in developing countries alone by 2020.

Scenario Assessment Because some elements of boththe optimistic and pessimistic scenarios cited above arelikely to appear during the twenty-year time frame ofthis Estimate, we are likely to witness neither steadyprogress against the infectious disease threat nor its un-abated intensification. Instead, progress is likely to beslow and uneven, with advances, such as the recent de-velopment of a new type of antibiotic drug against certainhospital-acquired infections, frequently offset by re-newed setbacks, such as new signs of growing microbialresistance among available HIV/AIDS drugs and with-drawal of a promising new vaccine against rotavirusbecause of adverse side effects. On balance, negative driv-ers, such as microbial resistance, are likely to prevail overthe next decade, but given time, positive ones, such asgradual socio-economic development and improvedhealth care capacity, will likely come to the fore in thesecond decade.

• The negative trends cited in the pessimistic scenarioabove, such as persistent poverty in much of thedeveloping world, growing microbial resistance anda dearth of new replacement drugs, inadequate dis-ease surveillance and control capacity, and the highprevalence and continued spread of major killerssuch as HIV/AIDS, TB, and malaria, are likely toremain ascendant and worsen the overall problemduring the first half of our time frame.

• Sub-Saharan Africa, India, and Southeast Asia will


Special Reports

remain the hardest hit by these diseases. The Euro-pean FSU states and China are likely to experiencea surge in HIV/AIDS and related diseases such asTB. The developed countries will be threatenedprincipally by the real possibility of a resurgence ofthe HIV/AIDS threat owing to growing microbialresistance to the current spectrum of multidrugtherapies and to a wide array of other drugs used tocombat infectious diseases.

• The broadly positive trends cited in the more opti-mistic scenario, such as aging populations, globalsocio-economic development, improved health carecapacity, and medical advances, are likely to cometo the fore during the second half of our time framein all but the least developed countries, and eventhe least developed will experience a measure ofimprovement.

• Aging populations and expected continued declinesin fertility throughout Asia, Latin America, theformer FSU states, and sub-Saharan Africa willsharply reduce the size of age cohorts that are par-ticularly susceptible to infectious diseases owing toenvironmental or behavioral factors.

• Socio-economic development, however fitful, andresulting improvements in water quality, sanitation,nutrition, and education in most developing coun-tries will enable the most susceptible populationcohorts to better withstand infectious diseases bothphysically and behaviorally.

• The worsening infectious disease threat we posit forthe first decade of our time frame is likely to furtherenergize the international community and mostcountries to devote more attention and resources toimproved infectious disease surveillance, response,and control capacity. The WHO’s new campaignagainst malaria, recent developed country consid-eration of tying debt forgiveness for the poorestcountries in part to their undertaking stronger com-mitments to combat disease, self-initiated efforts bysub-Saharan African governments to confront HIV/AIDS, and greater pharmaceutical industry willing-ness to provide more drugs to poor countries ataffordable prices are likely to be harbingers of moresuch efforts as the infectious disease threat becomesmore acute.

• The likely eventual approval of new drugs and vac-cines—now in the developmental stage—for major

killers such as dengue, diarrheal diseases, and possi-bly even malaria will further ease the infectiousdisease burden and help counter the microbial re-sistance phenomenon.

Together, these developments are likely to set thestage for at least a limited improvement in infectiousdisease control, particularly against childhood and vac-cine-preventable diseases, such as respiratory infections,diarrheal diseases, neonatal tetanus, and measles in mostdeveloping and former communist countries. Giventime––and barring the appearance of a deadly and highlyinfectious new disease, a catastrophic expansion of theHIV/AIDS pandemic, or the release of a highly conta-gious biological agent capable of rapid and widescalesecondary spread—such medical advances, behavioralchanges, and improving national and international sur-veillance and response capacities will eventually producesubstantial gains against the overall infectious diseasethreat. In the event that HIV/AIDS takes a catastrophicturn for the worse in both developed and developingcountries, even the authors of the optimistic WorldBank/WHO model concur that all bets are off.

ECONOMIC, SOCIAL, AND POLITICAL IMPACTS

The persistent infectious disease burden is likely toaggravate and, in extreme cases, may even provoke so-cial fragmentation, economic decay, and politicalpolarization in the hardest hit countries in the develop-ing and former communist worlds in particular,especially in the worst-case scenario outlined above. This,in turn, will hamper progress against infectious diseases.Even under the most likely scenario that posits someattenuation of the infectious disease threat in the sec-ond half of our time frame, new and reemergentinfectious diseases are likely to have a disruptive impacton global economic, social, and political dynamics.

Economic Impact Likely To Grow Macroeconomic Im-pact

The macroeconomic costs of the infectious diseaseburden are increasingly significant for the most seriouslyaffected countries despite the partially offsetting impactof declines in population growth, and they will take aneven greater toll on productivity, profitability, and for-eign investment in the future. A senior World Bankofficial considers AIDS to be the single biggest threat toeconomic development in sub-Saharan Africa. A grow-ing number of studies suggest that AIDS and malariaalone will reduce GDP in several sub-Saharan African



Special Reports

countries by twenty percent or more by 2010.• The impact of infectious diseases on annual GDP

growth in heavily affected countries already amountsto as much as a one-percentage point reduction inthe case of HIV/AIDS on average and one to twopercentage points for malaria, according to WorldBank studies. A recent Namibian study concludedthat AIDS cost the country nearly eight percent ofGDP in 1996, while a study of Kenya projectedthat GDP will be 14.5 percent smaller in 2005 thanit otherwise would have been without the cumula-tive impact of AIDS. The annual cost of malaria toKenya’s GDP was estimated at two to six percentand at one to five percent for Nigeria.

Microeconomic ImpactThe impact of infectious diseases—especially HIV/

AIDS––at the sector and firm level already appears tobe substantial and growing and will be reflected eventu-ally in higher GDP losses (see Figure 13), especially inthe more advanced developing countries with special-ized work force needs.

• A recent study by the Zimbabwe Commercial Farm-ers’ Union estimated that production losses due toHIV/AIDS in the communal and resettlement ar-eas—the African farm-holder sector—is close to fiftypercent.

• WHO estimates that small farmers in Nigeria andKenya spend thirteen and five percent, respectively,of total household income on malaria treatment thatwould otherwise go to other forms of consumptionof more benefit to the economy.

Although a 1996 World Bank–sponsored study ofnearly 1,000 firms in four African countries focusingsolely on the impact of AIDS-related employee turn-over concluded that it was not likely to substantiallyaffect firm profits, several individual firms and theirAIDS consultants paint a much bleaker picture by 1999.Using broader measures of AIDS-related costs, such asabsenteeism, productivity declines, health and insurancepayments, and recruitment and training, they projectedprofits to drop by six to eight percent or more andproductivity to decline by five percent. They are espe-cially troubled by the high rate of loss of middle-andupper-level managers to AIDS and the dearth of replace-ments, as well as the loss of large numbers of skilledworkers to AIDS in the mining and other key sectors.According to one expert, South African companies willbegin to feel the full impact of the AIDS epidemic by2005. One study of the projected impact of AIDS onemployee benefit costs in South Africa concludes thatbenefit costs would nearly triple to nineteen percent ofsalaries from 1995 to 2005, substantially eroding cor-porate profits.

Fiscal Impact. Infectious diseases will increase pres-sure on national health bills that already consume someseven to fourteen percent of GDP in developed coun-tries, up to five percent in the better off developingcountries, but currently less than two percent in leastdeveloped states.

• By 2000, the cumulative direct and indirect costsof AIDS alone are likely to have topped $500 bil-lion, according to estimates by the Global AIDSPolicy Coalition at Harvard University. In LatinAmerica, the Pan-American Health Organization in1994 estimated it would take a decade and $200billion to bring the cholera pandemic in the regionunder control through a massive water cleanup ef-fort, or nearly eighty percent of total developingcountry health spending for that year. The directcosts of fighting malaria in sub-Saharan Africa in-

Figure 15Projected Impact of AIDSon GDP of Selected Countriesin Sub-Saharan Africa

Source: USAID, 1999.

-25

-20

-15

-10

-5

0

Tanzania 2010

Kenya 2005

Zambia 2000

Zimbabwe 2000

Percent reduction in GDP

13


Special Reports

creased from $800 million in 1989 to $2.2 billionin 1997, largely owing to the far higher cost of treat-ing the growing number of drug-resistant cases, andthe trend toward higher costs is likely to continue.

AIDS, along with TB and malaria—particularly thedrug-resistant varieties––makes large budgetary claimson national health systems’ resources (see Figure 14).Policy choices will continue to be required along at leastthree dimensions: spending for health versus spendingfor other objectives; spending more on prevention inorder to spend less on treatment; and treating burgeon-ing AIDS-infected populations versus treating otherillnesses.

• Although prevention is cost-efficient––the eradica-tion of smallpox has shaved $20 billion off the globalhealth bill, and polio eradication would save as muchas $3 billion annually by 2015––most countries willnot be able to afford even basic care for those in-fected with diseases such as TB and HIV/AIDS. InZimbabwe, for example, more than half the meagerhealth budget is spent on treating AIDS. Yet, treat-ing one AIDS patient for a year in sub-SaharanAfrica costs as much as educating ten primary schoolstudents for one year.

• Public health spending on AIDS and related dis-eases threatens to crowd out other types of healthcare and social spending. In India, for example,simulated annual government health expendituresin the context of a severe AIDS epidemic in whichtotal expenditures, including AIDS costs, are subsi-dized at twenty-one percent would add $2 billionannually to the government’s health bill through2010 and $5 billion with a government subsidy offifty-one percent. In Kenya, HIV/AIDS treatmentcosts are projected to account for fifty percent ofhealth spending by 2005. In South Africa, such costscould account for thirty-five to eighty-four percentof public health expenditures by 2005, accordingto one projection.

• Even given the budgetary dominance of AIDS, careis likely to be limited to the most basic of therapies.Few countries will be able to afford the high cost ofmultidrug treatment for HIV/AIDS—or for drug-resistant TB and malaria—ensuring that suchdiseases will continue to be highly prevalent. Onlyabout one percent of HIV/AIDS patients even inrelatively well off South Africa currently undergomultidrug treatment, for example, while it would

cost Russia several billion dollars annually to pro-vide such treatment for its surging HIV/AIDS caseload—which is unlikely given its fiscal difficulties.In addition to the cost of the drugs, few countriescan afford to build and maintain the health careinfrastructure that makes effective treatment pos-sible.

Disruptive Social ImpactAt least some of the hardest-hit countries, initially

in sub-Saharan Africa and later in other regions, willface a demographic catastrophe as HIV/ AIDS and as-sociated diseases reduce human life expectancydramatically and kill up to a quarter of their popula-tions over the period of this Estimate (see Table 4). Thiswill further impoverish the poor and often the middleclass and produce a huge and impoverished orphan co-hort unable to cope and vulnerable to exploitation andradicalization.

Life Expectancy and Population Growth. Until theearly 1990s, economic development and improved healthcare had raised the life expectancy in developing coun-

Figure 16Potential AIDS Treatment Costsin Selected Countries in Sub-Saharan Africa

Source: USAID, 1999.

0

10

20

30

40

50

60

70

Zimbabwe 2005

Kenya 2005

Ethiopia 2014

Percent of Ministry of Health Budget

Note: The number of AIDS patients seeking careis already overwhelming health care systems. Inmany hospitals in Sub-Saharan Africa, half of hospital beds are now occupied by AIDS patients.

14



Special Reports

tries to sixty-four years, with prospects that it would gohigher still. The growing number of deaths from newand reemergent diseases such as AIDS, however, will slowor reverse this trend toward longer life spans in heavilyaffected countries by as much as thirty years or more by2010, according to the U.S. Census Bureau. For example,life expectancy will be reduced by thirty years in

Botswana and Zimbabwe, by twenty years in Nigeriaand South Africa, by thirteen years in Honduras, by eightyears in Brazil, by four years in Haiti, and by three yearsin Thailand.

Family Structure. The degradation of nuclear andextended families across all classes will produce severesocial and economic dislocations with political conse-

Country Projected Child Mortality1 Per 1,000Live Births, 2010

Projected Life Expectancy, 2010

With AIDS Without With AIDS WithoutSub-SaharanAfricaBotswana 120 38 38 66Burkina Faso 145 109 46 61Burundi 129 91 45 61Cameroon 108 78 50 63Cote d’Ivoire 121 84 47 62Dem. Rep. ofCongo

116 97 52 60

Ethiopia 183 137 39 55Kenya 105 45 44 69Lesotho 122 71 45 66Malawi 203 136 35 57Namibia 119 38 39 70Nigeria 113 68 46 65Rwanda 166 106 38 59South Africa 100 49 48 68Swaziland 152 78 37 63Tanzania 131 96 46 61Uganda 121 92 48 60Zambia 161 97 38 60Zimbabwe 116 32 39 70Latin AmericaBrazil 31 21 68 76Haiti 129 119 54 59Honduras 55 29 60 73Southeast AsiaBurma 80 70 59 63Cambodia 134 124 53 57Thailand 25 21 73 75

1Probable deaths before age 5.

Table 4. Projected Demographic Indicators for 2010 in Selected Countries With andWithout AIDS

Source: Adapted from United States Bureau of the Census, 1998.

,


Special Reports

quences, as well. Nearly thirty-five million children intwenty-seven countries will have lost one or both par-ents to AIDS by 2000; by 2010, this number will increaseto 41.6 million. Nineteen of the hardest hit countriesare in sub-Saharan Africa, where HIV/AIDS has beenprevalent across all social sectors. Children are increas-ingly acquiring HIV from their mothers duringpregnancy or through breast-feeding, ensuring prolon-gation and intensification of the epidemic and itseconomic reverberations. With as much as a third ofthe children under fifteen in hardest-hit countries ex-pected to comprise a “lost orphaned generation” by 2010with little hope of educational or employment oppor-tunities, these countries will be at risk of furthereconomic decay, increased crime, and political instabil-ity as such young people become radicalized or areexploited by various political groups for their own ends;the pervasive child soldier phenomenon may be oneexample.

Destabilizing Political and Security ImpactIn our view, the infectious disease burden will add

to political instability and slow democratic developmentin sub-Saharan Africa, parts of Asia, and the formerSoviet Union, while also increasing political tensions inand among some developed countries.

• The severe social and economic impact of infectiousdiseases, particularly HIV/AIDS, and the infiltra-tion of these diseases into the ruling political andmilitary elites and middle classes of developing coun-tries are likely to intensify the struggle for politicalpower to control scarce state resources. This willhamper the development of a civil society and otherunderpinnings of democracy and will increase pres-sure on democratic transitions in regions such asthe FSU and sub-Saharan Africa where the infec-tious disease burden will add to economic miseryand political polarization.

• A study by Ted Robert Gurr, et al., on the causes ofstate instability in 127 cases over a forty-year pe-riod ending in 1996 suggests that infant mortalityis a good indicator of the overall quality of life, whichcorrelates strongly with political instability. Accord-ing to the research, three variables out ofseventy-five––high infant mortality—which in de-veloping countries owes substantially to infectiousdiseases; low openness to trade; and incomplete de-mocratization accounted for two-thirds ofdemonstrated instability. The study defined “insta-bility” as revolutionary wars, ethnic wars, genocides,

and disruptive regime transitions. High infant mor-tality has a particularly strong correlation with thelikelihood of state failure in partial democracies.

Infectious diseases also will affect national securityand international peacekeeping efforts as militaries andmilitary recruitment pools experience increased deathsand disabilities from infectious diseases. The greatestimpact will be among hard-to-replace officers, noncom-missioned officers, and enlisted soldiers with specializedskills and among militaries with advanced weapons andweapons platforms of all kinds.

• HIV/AIDS prevalence in selected militaries, mostlyin sub-Saharan Africa, generally ranges from ten tosixty percent (see Table 5). This is considerablyhigher than their civilian populations and owes torisky lifestyles and deployment away from home.Commencement of testing and exclusion of HIV-positive recruits in the militaries of a few countries,is reducing HIV prevalence but it continues to growin most militaries.

• Militaries in key FSU states are increasingly experi-encing the impact of negative health developmentswithin their countries, such as deteriorating healthinfrastructure and reduced funding. One in threeRussian draftees currently is rejected for varioushealth reasons, as compared to one in twenty in1985, according to one Russian newspaper report.

• Mounting infectious disease-caused deaths amongthe military officer corps in military-dominated anddemocratizing polities also may contribute to the

Table 5. HIV Prevalence in SelectedMilitaries in Sub-Saharan Africa

Country Estimated HIVPrevalence(percent)

Angola 40 to 60Congo (Brazzaville) 10 to 25Cote d’Ivoire 10 to 20Democratic Republic of theCongo

40 to 60

Eritrea 10Nigeria 10 to 20Tanzania 15 to 30

Source: DIA/AFMIC, 1999.



Special Reports

deprivation, insecurity, and political machinationsthat incline some to launch coups and counter-coupsaimed, more often than not, at plundering statecoffers.

It is difficult to make a direct connection betweenhigh HIV/AIDS and other infectious disease prevalencein military forces and performance in battle. But, giventhat a large number of officers and other key personnelare dying or becoming disabled, combat readiness andcapability of such military forces is bound to deterio-rate.

• Infectious disease-related deaths and disabilities arelikely to have the greatest impact on the capabilitiesof sub-Saharan militaries, particularly those thathave achieved at least a modest level of moderniza-

tion in weapons systems and platforms. Over thelonger term, the consequences of the continuingspread of deadly diseases such as HIV/AIDS on thecapabilities of the more modernized militaries inFSU states and possibly China and certain roguestates with large armies and modern weapons arse-nals may be severe as well.

The negative impact of high infectious disease preva-lence on national militaries also is likely to be felt ininternational and regional peacekeeping operations, lim-iting their effectiveness and also making them vectorsfor the further spread of diseases among coalition peace-keepers and local populations.

• Although the United Nations officially requires thatprospective peacekeeping troops be “disease free,”

• International travel. More than fifty-seven mil-lion Americans traveled outside the United Statesfor recreational and business purposes in 1998—often to high risk countries—more than doublethe number just a decade before. In addition,tens of millions of foreign-born travelers enterthe United States every year. Travelers on com-mercial flights can reach most U.S. cities fromany part of the world within thirty-six hours—which is shorter than the incubation periods ofmany infectious diseases.

• Immigration. Approximately one million immi-grants and refugees enter the United States legallyeach year, often from countries with high infec-tious disease prevalence, while several hundredthousand enter illegally. The U.S.CDC has theauthority to detain, isolate, or provisionally re-lease persons at U.S. ports of entry showingsymptoms of any one of seven diseases (yellowfever, cholera, diphtheria, infectious TB, plague,suspected smallpox, and viral hemorrhagic fe-vers). Although each individual must undergo amedical examination before entering the coun-try, potentially excludable conditions may be inthe incubating and therefore less detectablestages.

Moreover, U.S. law prohibits the Immigrationand Naturalization Service from returning refu-gees who have credible reasons to fear politicalpersecution, including those refugees afflictedwith infectious diseases.

• Returning U.S. military forces. Although U.S.military populations are immunized against manyinfectious diseases and are especially sensitizedto detecting any symptoms before or after theirreturn to the United States, not all cases are likelyto be detected, especially among NationalGuardsmen and Reservists, who are far morelikely to enter the civilian health care system andmay not associate a later-developing illness withtheir overseas travel.

• The globalization of food supplies. Foodborne ill-nesses have become more common as the numberof food imports has doubled over the past fiveyears, owing to changing consumer preferencesand increased trade. At certain times of the year,more than seventy-five percent of the fruits andvegetables available in grocery stores and restau-rants are imported and, therefore, potentiallymore likely to be infected with pathogenic mi-croorganisms, according to a foodborne diseaseexpert.

Mechanisms of Disease Entry Into the United States

The following are a few prominent methods of pathogen entry into the United States:


Special Reports

Figure 17Trends in Infectious Disease-Related Mortality Rates in the United States

Deaths per year per 100,00

0

500

1,000

1,500

2,000

Infectious disease mortality in the United States has generally declined since1900, but the trend has been up since 1980 when deaths reached a low of 36per 100,000, as compared to 59 per 100,000 in 1996. Most of the increase owes to HIV/AIDS and, to a lesser extent, to pneumonia and influenza.

Infectious Disease Mortality in the United States

0

10

20

30

40

1970 1980 1990 1996

Deaths per year per 100,000

Pneumonia, Influenza, and AIDS Mortality

0

15

30

45

60

1985 1990 1995 1998

Thousands deaths

AIDS Deaths in the United States

Multidrug therapy has dramatically reducedHIV/AIDS deaths in the United States fromtheir peak in 1995, but the rate is slowing as preventive measures ebb and microbial resistance increases.

All diseases

Noninfectious diseases

Infectious diseases

Pneumoniaand influenza

AIDS

1996198019600

30

60

19961900 1980196019401920

Source: Adapted from Journal of the American Medical Association, January 6, 1999; CDC 1999.

Note scale change15



Special Reports

it is difficult to enforce this rule with such methodsas HIV testing, given the paucity of available troopsand the potential noncompliance of many contrib-uting states.

• Healthy peacekeeping forces will remain at risk ofbeing infected by disease-carrying forces and localpopulations, as well as by high-risk behavior andinadequate medical care.

In developed countries, the political debate overAIDS and other infectious diseases is likely to focus onbudgetary issues and negligence in the handling of bloodand foodstuffs, as well as on treatment of infectious dis-eases.

• HIV blood and other controversies in several Euro-pean countries have sparked political uproars andled to the dismissal or prosecution of governmentofficials, and have even contributed to the fall ofsome governments.

Infectious diseases also will loom larger in global

interstate relations as related embargoes and boycotts toprevent their spread create trade frictions and contro-versy over culpability, such as in the recently endedthree-year EU embargo of British beef, which was im-posed to stop the spread of “mad cow disease”. Developedcountries, moreover, will come under pressure from in-ternational and nongovernmental organizations, as wellas from developing countries, to deal with infectiousdisease-related instability and economic and medicalneeds in the hardest-hit countries. A growing contro-versy, in this regard, will be over drug-related intellectualproperty rights, in which developing countries will pressfor more and cheaper drugs from developed countrypharmaceutical firms and resort to producing their owngeneric brands if they are rebuffed. States will remainconcerned, as well, about the growing biological war-fare threat from rogue states and terrorist groups.

INFECTIOUS DISEASES AND U.S.NATIONAL SECURITY

As a major hub of global travel, immigration, and

Figure 18US Army Hospital Admissions During War

Percent

Source: DIA AFMIC, 1999.

0

10

20

30

40

50

60

70

80

90

DiseasesInjuriesWounds

Persian GulfVietnamKoreaWWII

16


Special Reports

commerce, along with having a large civilian and mili-tary presence and wide-ranging interests overseas, theUnited States will remain at risk from global infectiousdisease outbreaks, or even a bioterrorist incident usinginfectious disease microbes. Infectious diseases will con-tinue to kill nearly 170,000 Americans annually andmany more in the event of an epidemic of influenza oryet-unknown disease or a steep decline in the effective-ness of available HIV/AIDS drugs. Although severalemerging infectious diseases, such as HIV/AIDS, werefirst identified in the United States, most, includingHIV/AIDS, originate outside U.S. borders, with theentry of the West Nile virus in 1999 a case in point.

Threats to the U.S. Civilian PopulationThe U.S. civilian population will remain directly

vulnerable to a wide variety of infectious diseases, fromresurgent ones such as multidrug resistant TB to deadlynewer ones such as HIV/AIDS and hepatitis C. Infec-tious disease-related deaths in the United States haveincreased by about 4.8 percent per year since 1980 tofifty-nine deaths per 100,000 people by 1996, or roughly170,000 deaths annually, as compared to an annual de-crease of 2.3 percent in the preceding fifteen years andan alltime low of thirty-six deaths per 100,000 in 1980(see Figure 15). The U.S. CDC estimates that the totaldirect and indirect medical costs from infectious dis-eases comprise some fifteen percent of all U.S. healthcare expenditures or $120 billion in 1995 dollars.

Threats to Deployed Military ForcesDeployed U.S. military forces have historically ex-

perienced higher rates of hospital admission frominfectious diseases than from battlefield combat and non-combat injuries (see Figure 16). In addition to diseasetransmission between deployed troops and indigenouspopulations, warfare-related social disruption often cre-ates refugees and internally displaced persons that canpass infections along to U.S. military forces. Allied coa-lition forces may themselves bring infectious diseasesinto an area for the first time and transmit them to U.S.forces and the indigenous population.

Impact on U.S. Interests AbroadIn addition to their impact on the U.S. population,

infectious diseases will add to the social, economic, andpolitical strains in key regions and countries in whichthe United States has significant interests or may be calledupon to provide assistance:

• Infectious diseases are likely to slow socio-economicdevelopment in developing and former communist

countries and regions of interest to the United States.This will challenge democratic development andtransitions and possibly contribute to humanitar-ian emergencies and military conflicts to which theUnited States may need to respond.

• Infectious disease-related trade embargoes and re-strictions on travel and immigration also will causefrictions among and with key trading partners andother selected states.

The Biological Warfare ThreatThe biological warfare and terrorism threat to U.S.

national security is on the rise as rogue states and terror-ist groups also exploit the ease of global travel andcommunication in pursuit of their goals:

• The ability of such foreign-based groups and indi-viduals to enter and operate within the United Stateshas already been demonstrated and could recur. TheWest Nile virus scare, and several earlier instancesof suspected bioterrorism, showed, as well, the con-fusion and fear they can sow regardless of whetheror not they are validated.

• The threat to U.S. forces and interests overseas alsowill continue to increase as more nations develop acapability to field at least limited numbers of bio-logical weapons, and nihilistic and religiouslymotivated groups contemplate opting for them tocause maximum casualties.

1 All data concerning global disease incidence, includingthe World Health Organization (WHO) data, should betreated as broadly indicative of trends rather than accuratemeasures of disease prevalence. Much disease incidence indeveloping countries, in particular, is either unreported orunder-reported due to a lack of adequate medical and admin-istrative personnel, the stigma associated with many diseases,or the reluctance of countries to incur the trade, tourism, andother losses that such revelations might produce. Since muchmorbidity and mortality are multicausal, moreover, diagnosisand reporting of diseases can vary and further distort com-parisons. WHO and other international entities are dependenton such data despite its weaknesses and are often forced toextrapolate or build models based on relatively small samples,as in the case of HIV/AIDS. Changes in methodologies, more-over, can produce differing results.

NOTES


National Intelligence Estimate: The Global Infectious ... · PDF fileNational Intelligence...

Documents

Transcript of National Intelligence Estimate: The Global Infectious ... · PDF fileNational Intelligence...