The Globalization of Disease
Congo sneezes, will California get a cold?
bold speech in early June marking the 20th anniversary of the first
report of HIV/AIDS, United Nations Secretary General Kofi Annan called
on the private sector as well as donor governments to contribute to a
$7–10 billion global trust fund to combat HIV/AIDS, malaria, and
tuberculosis. His call for action to the business community was based on
a sensible dose of "enlightened self-interest."
warned that AIDS leaches profits out of economies and businesses and
raises new barriers to development and economic growth. He cautioned
that the widening gaps between wealthy and poor, which AIDS and other
diseases are expanding, could accelerate the growing backlash against
globalization. While global markets have created unprecedented economic
opportunities and growth, the benefits have not been equally
distributed, and the risks—especially the health risks—of an
increasingly interlinked and interdependent world have not been
trade, travel, and food sources become more global, humans, animals, and
plants are being exposed to myriad new and ever more resiliant diseases.
Increasingly antibiotics fail to subdue multi-drug-resistant forms of
diseases, such as tuberculosis, that they once nearly eliminated.
Although there is no agreement on what is causing this trend—theories
include climate changes, manipulation of plants and animals, genetic
engineering, increased mobility of humans and food sources, and
terrorism—the fact remains that disease threats are increasing.
Officials in the United States and the internationalcommunity need to
begin containing the threat that diseases and pests pose in an
increasingly globalized world, by putting into place reliable,
cooperative, and responsive systems to anticipate, prevent, detect, and
react to outbreaks—both those caused inadvertently and those caused by
and New Disease Risks
December 1999 the National Intelligence Council released an
unprecedented unclassified assessment of the threat that new and
reemerging diseases pose to the United States and other countries. The
report highlighted a few key facts. First, infectious diseases are a
leading cause of death worldwide, accounting for one-quarter to
one-third of all deaths globally in 1998. Second, 20 diseases that had
been in decline reemerged or spread geographically between 1973 and
1999, including new multiple-drug-resistant strains of tuberculosis,
malaria, and cholera. And third, 29 previously unknown diseases were
identified in the same period, including HIV/AIDS, Ebola, and hepatitis
C. There are no cures for many of these diseases.
United States, despite its sophisticated medical care and
infrastructure, has not been immune to this trend. Between 1980 and
1999, deaths due to infectious diseases doubled. Multiple-drug-resistant
forms of TB and staphylococcus alone kill more than 14,000 Americans
annually. HIV/AIDS is experiencing a resurgence, especially among
minorities and women. In 1999, new HIV infections rose from 40,000
annually to 46,000, according to the Institute of Medicine. However,
only 70 percent of Americans infected with HIV know their sero-status,
and many who do know are failing to protect and educate themselves.
Unprotected sex in some high-risk gay communities has risen to 50
percent, and a survey released by the Centers for Disease Control (CDC)
in December 2000 found that 40 percent of the 5,600 Americans questioned
believed that AIDS could be transmitted by sharing a glass with or being
coughed on by an infected person.
some lessons have been learned from the struggle against HIV/AIDS, the
U.S. health care system is ill equipped to deal with large-scale
outbreaks of new or rare diseases. As evidenced by the outbreak of West
Nile virus in New York in August 1999, an unknown and relatively weak
virus can easily gain a foothold and quickly spread. Although only 82
people had been infected by the end of 2000 and only 8 had died, more
than 4,000 birds and 59 horses had tested positive or died from the
virus. Even though the CDC alone spent nearly $10 million in 1999 and
2000 to contain West Nile virus, it spread from 3 states in 1999 to 12
states and the District of Columbia by the end of 2000, and its spread
and Animals at Risk
risks posed by new and reemerging diseases are not limited to humans.
Crop and livestock diseases can exact steep health and economic costs.
As seen during recent disease outbreaks in Europe, global trade's
transfer of products, animals, and people around the world can speed the
spread of infection. The British government anticipates paying around 1
billion pounds to farmers in compensation for culling animals
potentially exposed to foot-and-mouth disease. With large parts of the
countryside closed to both foot and vehicle traffic, losses to Britain's
tourism industry are expected to top 5 billion pounds. More than 4.5
million animals in Britain have been slaughtered, and others have been
killed in France, the Netherlands, and other European countries where
the disease spread. Likewise, in Britain, bovine spongiform
encephalopathy (BSE or "mad cow" disease) killed nearly 200,000 cattle.
Nearly 5 million more were preemptively slaughtered. As of last
November, 90 people had died from variant Creutzfeldt-Jakob Disease (vCJD),
a malady linked to eating animals infected with BSE. By December, the
cost of BSE in the United Kingdom alone was estimated by the British
government to exceed 1.5 billion pounds.
United States is the world's largest food producer and exporter.
Agricultural products contributed more than $97.2 billion to the U.S.
economy in 1997, and the Agriculture Department estimates that farm
exports alone contributed more than $49 billion to the U.S. economy in
1999. The potential for harm to the nation's agricultural industry from
alien pests and diseases is enormous.
Tourists and Cargo?
According to the Agriculture Department, the number of passengers
traveling to the United States increased from 27 million in 1984 to 66
million in 1996. More than 400 million U.S. border crossings were
recorded in 1996, and in 1998 more than 422,000 cargo-bearing aircraft
were inspected on landing in the United States. This flood of people and
goods has exacerbated the already difficult job of controlling who and
what enters and exits the nation. Each incoming passenger and cargo load
could harbor new and deadly diseases or pests. With the increasing
globalization of American food sources, including snow peas from
Guatemala, apples from Chile, and mangoes from India, the threat from
diseases and pests to American crops and people is growing. According to
the Department of Commerce, farm imports into the United States
increased 65 percent between 1991 and 1999, and that trend is expected
to continue as the food supply becomes more global.
addition, invasive species—both plant and animal—that are controlled or
balanced in their native environments increasingly threaten indigenous
species in the United States. Conservation researchers cited by the
Agriculture Department have found that invasive alien plant infestations
cover more than 100 million acres in the United States and are spreading
at the rate of 14 percent a year. The department estimates that its
agents intercept more than 1.8 million illegal agricultural products a
year, stopping more than 52,000 plant and animal pests and diseases from
entering the United States. But inspecting bags and cargo and destroying
their contents may not keep out viruses and bacteria. Carried by humans,
animals, plants, soil, foodstuffs, water, and the very planes and ships
that bring foreign people and products to the United States, some
diseases do not wait to pass inspection.
Diseases Gaining the Upper Hand?
Scientists working on human, animal, and plant diseases all agree that
the number of new diseases, the increasing resistance of known diseases,
and the rapid geographic spread of both are on the rise. What they do
not agree on is why. Theories include climate changes, human
manipulation of plant and animal food and genetics, increasing travel of
humans and some animals (especially animals used for food), as well as
deliberate introduction. No one theory has been proven or eliminated,
but policymakers must take seriously the threat posed by the spread of
disease to human, plant, and animal health, as well as the implications
for economies and food security. Putting in place prevention,
mitigation, and disaster-response systems now may help avoid a
United States Prepared?
would happen to America's economy and health care infrastructure if a
virulent and communicable human, animal, or plant disease entered the
United States and gained a foothold? The worst-case scenario would be
the introduction of a devastating disease by a terrorist group.
2000, three mid-size U.S. cities (Portsmouth, New Hampshire; Denver,
Colorado; and Washington, D.C.) took part in a large-scale exercise
spanning several days to see how local, state, and national emergency
systems would respond to three potential disasters—nuclear, biological,
and chemical attacks by terrorists. The biological attack scenario,
played out in Denver, showed that most local and regional authorities,
even those who had been specially trained, were underprepared to deal
with a large communicable disease outbreak and were overwhelmed by the
complex coordination, decisionmaking, and management needed to contain
and control the spread of disease. When the scenario ended (after four
days), between 950 and 2,000 people had "died" and the disease had
spread throughout the United States and to other countries.
being prepared for a possible terrorist attack is important, the more
insidious threat to the American economy and the safety of its citizens
is the daily, routine transportation of goods, products, and people,
along with the diseases and pests they carry, across borders.
Constructing robust, multi-agency systems to identify, eliminate, and
control "normal" disease and pest outbreaks will lower that quotidian
threat, while at the same time building a foundation of skilled
individuals and systems to help prevent and respond rapidly to a
potential biological terrorism event.
Needs to Be Done?
Recognizing and assessing U.S. vulnerabilities in protecting against,
containing, and treating diseases is the first step toward building a
comprehensive system to lower the risk of disease outbreaks. The Denver
exercise, for example, was part of an ongoing training effort that
exposed the need for greater coordination in decisionmaking,
communication, and emergency relief efforts. The West Nile virus has
likewise proved the value of increased training and coordination among
health, animal, and plant disease authorities. After people started
falling sick from a mysterious encephalitis infection, animal control
authorities began investigating increased crow deaths in the same
region. They discovered that crows also die from the West Nile virus and
may facilitate its spread. The Agriculture Department has begun to
assess its own infrastructure and training gaps, and its Animal and
Plant Health Inspection Service is now constructing an emergency
management center to handle disease outbreaks in U.S. plants and
efforts, however, are but the first steps to put in place a strengthened
system to detect and deter both deliberate terrorist attacks and
unintentional transmission. Increased training in diagnostic techniques,
better communication networks between and among health and emergency
response personnel and the scientific community, and increased resources
for enforcement, protection, prevention, and education programs are
threat to the United States does not, however, end at the border. Many
diseases originate overseas. The EU, the United States, and other
concerned nations should begin to work with international organizations
on a range of efforts to identify, contain, and control new and
drug-resistant diseases in humans, animals, and plants, and to mitigate
the damage they cause. In the long term, an international effort should
include agreements on disease identification, containment, and
treatment, and standard protocols and cost-sharing structures to ensure
that poor and rich countries alike can control outbreaks of the most
deadly diseases. A global surveillance network to help identify and
eliminate diseases in their countries of origin should also be
considered. Cooperative efforts must also be undertaken to construct
functioning primary health care systems and infrastructure in developing
countries so that diseases originating in the tropics can be identified
and eradicated before they spread. Such an effort, through improving
access to primary care and vaccinations, would improve the health of
children and their chances of obtaining an education. Better education,
better health, and other opportunities could spur development and
economic growth over the long term.
Short-term international efforts should focus on immediate threats and
build foundations for long-term efforts. World health leaders could set
up internationally recognized and endorsed standard protocols for human
vaccine development and testing for HIV/AIDS, malaria, and other killer
diseases, along with systematic plans for comparative trials of multiple
vaccines against them. They should commit to the rapid eradication of
diseases that have not yet developed resistance to standard treatments,
including polio, measles, river blindness, and Guinea worm. (Polio cases
have fallen 99 percent in the past 13 years since the launch of the
Global Polio Eradication Initiative, but polio must be eliminated in the
20 countries where it still exists.) Public-private partnerships could
accelerate development of new disease treatments. (Some possibilities
include tax incentives to encourage companies to manufacture medications
for diseases that affect primarily poor countries, and trust funds to
guarantee a profit for the manufacturers of medicines to treat
third-world diseases.) International intellectual property rights
regimes should be reformed to ensure that essential drugs and medicines
are more affordable for all people. Genetically diverse plant and animal
species should be preserved to increase the genetic pool on which
researchers can draw to find disease-resistant qualities. Scientists,
medical professionals, and disease specialists should have better access
to distance learning, training, and exchange programs to increase
understanding of and best treatments for diseases.
fight against diseases was largely considered over as recently as the
1970s, but as fast as health professionals learn to treat them, diseases
are fighting back. Increased travel and trade are accelerating these
trends. Winning the fight against disease and protecting the world's
health, economies, and food supplies will require coordination,
cooperation, and resources. As has been shown time and again during
vaccination campaigns in war zones, even people trying to kill each
other will agree to a temporary cease-fire to save their children from
disease. If the world can build on that model of cooperation, perhaps
there is a chance to win this war-and in the process create the hope of
cooperation in other areas as well.