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PUBLICATIONS :: FOREIGN POLICY INDEX



Worldwide Health and Disease

I. Avian influenza/Pandemic influenza
II. HIV/AIDS
III. Suggested Reading List
IV. Footnotes


Along with economic globalization has come the globalization of disease.  In the post-9/11 era, in which the United States confronts many nontraditional threats to its national security, the global infectious disease threat is no longer limited to the fields of medicine and public health, but elevated to the realm of U.S. foreign and national security policy.  In short, some foreign policy analysts argue that pandemic infectious diseases such as HIV/AIDS and avian flu constitute both a direct threat to American citizens at home and abroad, as well as U.S. armed forces deployed overseas, and an indirect threat to U.S. national security by exacerbating social and political instabilities in countries and regions of strategic interest to the United States.  In this view, pandemic disease produces significant morbidity and mortality within a nation, which in turn causes severe economic retardation, internal displacement and emigration, psychological stress, and social dissolution. With these may come impairment of defense capacities and political institutions, and weakening states’ ability to govern and in extreme cases may lead to the collapse of the states. 


In 2000, the HIV/AIDS pandemic became the first disease or international health risk to receive classification as a national security threat to the United States.1  The elevation of the disease to the realm of national security policy derived not from concerns about the virulence of the AIDS pandemic on sub-Saharan Africa, but alarm at the projected spread of the pandemic to regions of strategic interest to the United States, most notably to Eastern Europe and Asia. In 2003, President George Bush announced, during his State of the Union Address, the most ambitious and comprehensive effort to combat the HIV/AIDS pandemic to date, with the President’s Emergency Plan for AIDS Relief (PEPFAR).  The president proposed that the United States spend $15 billion over five years to combat HIV/AIDS, with a focus on 15 countries in Africa, Asia, Latin America, and the Caribbean. The Emergency Plan also supports efforts to combat infectious tuberculosis (TB) and malaria.  Since the beginning of the president’s initiative, U.S. funding for global HIV/AIDS, TB and malaria activities has more than doubled, with the U.S. spending approximately $4.556 billion in FY 2007.2  As of September 2006, the Emergency Plan supported care for nearly 4.5 million people, including antiretroviral treatment for over one million men, women and children.3


In addition to the global HIV/AIDS, TB and malaria pandemics, American foreign policy has responded to the threat posed by the spread of avian flu and its potential to turn into a human influenza pandemic.  Since its emergence in Southeast Asia in 2003, avian flu has spread rapidly across Asia, Europe, and Africa.  As of November 2007, 334 human cases of avian flu, of which 205 were fatal, have been confirmed in Europe, Asia, and Africa.4  In an effort to contain and prevent further spread of the disease, the Avian Influenza Action Group was established the Department of State, as part of the president’s November 2005 National Strategy for Pandemic Influenza, to enhance coordination between concerned countries, improve surveillance and laboratory capacity, and strengthen international cooperation. 


I. Avian influenza/Pandemic influenza

A. Flu terms defined:

  • Seasonal (or common) flu is a respiratory illness that can be transmitted person to person. Most people have some immunity, and a vaccine is available.

  • Avian (or bird) flu is caused by influenza viruses that occur naturally among wild birds. The H5N1 variant is deadly to domestic fowl and can be transmitted from birds to humans. There is no human immunity and no vaccine is available.

  • Pandemic flu is virulent human flu that causes a global outbreak, or pandemic, of serious illness. Because there is little natural immunity, the disease can spread easily from person to person. Currently, there is no pandemic flu. Source: http://www.pandemicflu.gov.

B. Key Facts about Avian Influenza (Bird Flu) and Avian Influenza A (H5N1),

C. What changes are needed for H5N1 or another avian influenza virus to cause a pandemic?

  • According to the Center for Disease Control and Prevention (CDC), an influenza outbreak will only result in a pandemic if 1) the new influenza virus subtype emerges with little or no human immunity; 2) it infects humans and causes illness; and 3) it spreads easily and without interruption among humans. The H5N1 virus meets the first two conditions, as the H5N1 viruses have never circulated widely among humans, and it has infected more than 190 humans, with a mortality rate of 50 percent.  The third condition, that of, the establishment of efficient and sustained human-to-human transmission of the virus has not yet occurred. For this to take place, the H5N1 virus would need to improve its transmissibility among humans.

    For a fully transmissible pandemic virus to occur, the virus would need to undergo "reassortment" or adaptive mutation.  Reassortment involves the exchange of genetic material between human and avian viruses during infection of a human or another mammal.  Alternatively, a more gradual process of adaptive mutation may result, in which the capability of the virus to bind to human cells increases with human infection.  The result could be a fully transmissible pandemic virus, in which the disease spreads easily and directly between humans.

    Source: CDC, http://www.cdc.gov/flu/avian/gen-info/qa.htm

D. Vaccination and treatment of H5N1 in Humans

  • There currently is no commercially available vaccine to protect humans against H5N1 virus.  A pandemic vaccine cannot be produced until a new pandemic influenza virus emerges, and scientists identify the strain.  In an effort to meet the challenge, the US Department of Health and Human Services (HHS), in collaboration with industry, has undertaken efforts to develop pre-pandemic vaccines based on the current lethal strains of H5N1 and to increase the US’ vaccine production capacity.  While the H5N1 virus has proved resistant to amantadine and rimantadine, two antiviral medications commonly used for influenza, two other antiviral medications, oseltamavir and zanamavir, may be effective in treating influenza caused by H5N1 virus.  Additional studies, however, must be completed to demonstrate their effectiveness. 

    Source: http://www.pandemicflu.gov/vaccine/#research

E. The threat:

  1. Figure 1: Nations With Confirmed Cases H5N1 Avian Influenza (as of Feb. 2008):

    Nations  With Confirmed Cases H5N1 Avian Influenza (as of Feb. 2008)
     
  2. Figure 2: Global Risk of Avian Influenza Outbreaks

    Global Risk of Avian Influenza Outbreaks

  3. H5N1 avian flu timeline (updated as of 30 January 2008). Available at http://www.who.int/csr/disease/avian_influenza/ai_timeline/
    en/index.html
    .

  4. Potential Economic Impact of Pandemic: According to a Congressional Budget Office assessment, the macroeconomic effects of an avian influenza pandemic (similar to the 1918 pandemic) may result in a 4 percent decline in U.S. GDP, while a milder pandemic (on the order of those that occurred in 1957 and 1968) may cause an approximate 1 percent decline in U.S. GDP. In each case, economic activity would most likely recover once the pandemic ended, and consumers increased spending and businesses increased production to meet demand. http://www.cbo.gov/ftpdocs/72xx/doc7214/05-22-Avian%20Flu.pdf.

  5. Pandemics and Pandemic threats since 1900: See http://www.pandemicflu.gov/general/historicaloverview.html. It is important to note that several previous pandemic threats, including the Swine Influenza and Russia Influenza, never resulted in actual pandemic influenzas. Also, see http://www.cdc.gov/ncidod/EID/vol12no01/05-1254.htm.

F. U.S. Domestic and International Efforts to Respond to the Threat

  1. On November 1, 2005, President Bush announced the National Strategy for Pandemic Influenza, a comprehensive approach for addressing the threat of pandemic influenza, including the avian viruses.  See http://www.whitehouse.gov/homeland/pandemic-influenza.html.  The State Department has established the Avian Influenza Action Group to coordinate the US international effort.  See http://www.state.gov/r/pa/prs/ps/2006/65770.htm.

  2. On September 14, 2006, President Bush announced the International Partnership for Avian and Pandemic Influenza in his remarks at the High-Level Plenary Meeting of the U.N. General Assembly.  As part of the Partnership, member nations and international organization collaborate to enhance international preparedness, prevention, response, and containment activities.  The aim of the Partnership is to:  
    1. Elevate the issue on national agendas
    2. Coordinate efforts among donor and affected nations
    3. Mobilize and leveraging resources
    4. Increase transparency in disease reporting and surveillance
    5. Build capacity to identify, contain, and respond to a pandemic influenza
        See http://www.state.gov/r/pa/scp/2006/64101.htm

  3. As of June 2007, the US Government has allocated $6.3 billion in emergency funding to address the threat of avian and pandemic influenza domestically and internationally.  See http://www.state.gov/r/pa/scp/95835.htm

Avian influenza photo gallery and videos:

II. HIV/AIDS

A. Key Facts about the HIV/AIDS Pandemic

  1. The HIV/AIDS Pandemic (Source: http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf):
    • An estimated 33.2 million people worldwide are infected with HIV, 95% of whom live in developing countries. In 2007, approximately 2.5 million people were newly infected with the virus.

    • Sub-Saharan Africa accounts for 68% of the global HIV/AIDS infection total. Eight countries in the region account for almost one-third of all new HIV infections and AIDS deaths globally.

    • Young people ages 15-24 account for 42 percent of new HIV infections and represent almost one-third of people living with HIV/AIDS worldwide.

    • HIV/AIDS has killed more than 20 million people worldwide. In 2005, an estimated 2.1 million people died of AIDS-related causes, of which 76% occurred in sub-Saharan Africa.

  2. Estimated Number of Adults and Children Living with HIV/AIDS:
    Estimated adult (15-49 years) HIV prevalence rate(%) globally and in Sub-Saharan Africa, 1990-2007

  3. The Malaria and HIV/AIDS Nexus
    • Malaria and HIV/AIDS tend to overlap geographically, as in sub-Saharan Africa, Southeast Asia, and South America. Globally, malaria is responsible for more than a million deaths per year, with 90 percent of these deaths in sub-Saharan Africa. According to the CDC, "While infection with either malaria or HIV can cause illness and death, infection with one can make infection with the other worse and/or more difficult to treat."
      Source: http://www.cdc.gov/malaria/features/malaria_hiv.htm.

    • Worldwide distribution of Malaria
      Worldwide distribution of Malaria

  4. The TB and HIV/AIDS Nexus
    • After HIV, TB is the greatest infectious killer of young people and adults in the world today. TB is a major cause of death among people living with HIV/AIDS. An estimated 12% of HIV deaths globally are due to TB. Without treatment, as with any other opportunistic infection, HIV and TB jointly shorten the life of those infected with both diseases. TB is treatable and curable, even in people living with HIV. If TB is left unchecked in the next 20 years, almost one billion people will become newly infected, 200 million will develop the disease, and 35 million will die of it. See WHO, http://www.who.int/tb/challenges/hiv/facts/en/index.html.

B. The Future Threat/Trends-The HIV/AIDS Pandemic moves to Asia

  • While the sub-Saharan Africa remains the most-affected region in the world, HIV prevalence in the region appears to have stabilized.

    Estimated number of people living with HIV in Sub-Saharan Africa, 1990-2007

  • The HIV/AIDS pandemic is projected to spread rapidly in the coming decades within Eastern Europe and Asia, home to the world's most populous nations, including India, China, and Indonesia.

  • HIV/AIDS in Asia:
    • In 2007, the number of Asians with HIV reached 4.9 million, including 440,000 million who became newly infected in the past year. Approximately 300,000 people in Asia died of AIDS-related illnesses in 2007. While the epidemics in Cambodia, Myanmar, and Thailand show declines in HIV-prevalence, those in Indonesia and Vietnam are on the rise. Importantly, national prevention strategies generally fail to address the common modes of transmission-injection drug use and unprotected, commercial sex. As a result, the HIV/AIDS pandemic in Asia is largely in transition, with the window of opportunity for preventative action quickly abating.

      Source: UNAIDS, http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/
      EpiUpdArchive/2007/default.asp
      .

  • HIV/AIDS in Eastern Europe and Central Asia:
    • In 2007, an estimated 1.6 million people were living with HIV in Eastern Europe and Central Asia, including 150,000 who became newly infected in the past year. Nearly 90% of newly reported HIV cases in the region were from Russia (66%) and Ukraine (21%). Of the new HIV cases reported in 2006, nearly two thirds (62%) were attributed to injecting drug use and more than one third (37%) were due to unprotected heterosexual intercourse.

      HIV-infection in Ukrainian Regions, 2007

C. U.S. Domestic and International Efforts to Combat the HIV/AIDS Pandemic

  1. The President's Emergency Plan for AIDS Relief (PEPFAR):
    • On January 28, 2003, during his State of the Union Address, President George Bush proposed that the U.S. spend that the United States spends $15 billion over five years to combat HIV/AIDS through the President's Emergency Plan for AIDS Relief (PEPFAR). The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25) established the office of the Global HIV/AIDS Coordinator (OGAC) at the U.S. Department of State, and made the Coordinator responsible for administering all global HIV/AIDS funds. The initiative focuses on 15 countries in Africa, Asia, Latin America, and the Caribbean. The plan anticipated spending $10 billion of the $15 billion on the 15 focus countries, $4 billion on 108 non-focus countries and international HIV/AIDS research, and an additional $1 billion on contributions to the Global Fund.

      Source: http://www.state.gov/p/af/rls/fs/17033.htm.

    • Table 1: 15 Focus Countries and HIV/AIDS Infection Rate
      Country HIV prevalence among adults aged 15-49 years (%), 2005
      Botswana 24.1
      Cote d'Ivoire 7.1
      Ethiopia N/A
      Guyana 2.5
      Haiti 3.8
      Kenya 6.1
      Mozambique 16.1
      Namibia 19.6
      Nigeria 3.9
      Rwanda 3.1
      South Africa 18.8
      Tanzania N/A
      Uganda 6.7
      Vietnam 0.5
      Zambia 17.0
      Source:
      All HIV prevalence data are from the World Health Organization (WHO) Statistical Information System, http://www3.who.int/whosis/menu.cfm?path=whosis&language=english.


  2. Impact of PEPFAR?
    • By September 30, 2007, PEPFAR achieved the following in the 15 focus countries:
      • Supported community outreach activities to over 61.5 million people to prevent sexual transmission of HIV
      • Supported prevention of mother-to-child transmission for women during more than 10 million pregnancies, including antiretroviral prophylaxis for over 827,000 pregnancies, and prevented an estimated 157,000 infant HIV infections
      • Supported antiretroviral treatment for approximately 1,445,500 men, women and children.
      • Supported training or retraining of over 52,000 health care workers in the provision of prevention services
      • Supported care for more than 6.6 million people.
      • Supported over 33 million counseling and testing sessions for men, women and children.
             Source: http://www.pepfar.gov/about/c19785.htm

    • Where does PEPFAR funding go? Importantly, over 80 percent of PEPFAR partners are local.

  3. Analyses of PEPFAR
    • Two principal criticisms of the U.S. program have been offered. First is the under-funding or lack of actual spending of appropriated funds, and the minimal cooperation with the U.N. joint efforts. Second is the emphasis on abstinence over other means of prevention or treatment. A criticism, related to the second, is that anti-viral drugs that have been successful in suppressing AIDS in HIV-infected people in the developed countries are too expensive for the regions of the world where the disease is most prevalent, due to the insistence on intellectual property rights-patents-by pharmaceutical corporations. All these shortcomings, critics say, impede the fight against the disease.
      See:

III. Suggested Reading List

Avian Influenza/Pandemic Influenza

Danielle Langton, Avian Flu Pandemic: Potential Impact of Trade Disruptions (Washington, DC: Congressional Research Service, June 9, 2006).  Available at http://fpc.state.gov/documents/organization/68827.pdf.


Tiaji Salaam-Blyther and Emma Chanlett-Avery, U.S. and International Responses to the Global Spread of Avian Flu: Issues for Congress (Washington, D.C.: Congressional Research Service, January 9, 2006).  Available at http://fpc.state.gov/documents/organization/59025.pdf


Michael T. Osterholm, "Preparing for the Next Pandemic," Foreign Affairs, July/August 2005. 

Laurie Garrett, "The Next Pandemic?," Foreign Affairs, July/August 2005. 

Mark Hillman and Fenella Sirkisoon, AMR Research: Pandemic Readiness Study (AMR Research Inc., March 2006), http://www.amrresearch.com/research/reports/
images/2006/0605AMR-A-19413.pdf


Peter Chalk, Hitting America’s Soft Underbelly: The Potential Threat of Deliberate Biological Attacks against the US Agricultural and Food Industry (Santa Monica, CA: RAND, 2004), http://www.rand.org/pubs/monographs/2004/RAND_MG135.pdf

HIV/AIDS Pandemic

Global Fund to Fight AIDS, Tuberculosis and Malaria, the joint effort led by the United Nations.


Nicolas Cook, AIDS in Africa (Washington, D.C.: Congressional Research Service, January 30, 2006).  Available at http://fpc.state.gov/documents/organization/61502.pdf


Stefan Elbe, "AIDS, Security, Biopolitics," International Relations, 2005, Vol. 19, No. 4, pp. 403-419. 


Stefan Elbe, "Strategic Implications of HIV/AIDS," Adelphi Paper, 2003, No. 357, pp. 1-78.


Helen Epstein, The Invisible Cure: Africa, the West, and the Fight Against AIDS (New York: Farrar, Straus and Giroux, 2007).


Nicholas Eberstadt, "The Future of AIDS," Foreign Affairs, 2002, Vol. 81, No. 6, pp. 22-45. 


Paolo Tripodi and Preeti Patel, "The Global Impact of HIV/AIDS on Peace Support Operations," International Peacekeeping, 2003, Vol. 9, No. 3, pp. 51-66.


Kimberly Hamilton, "The HIV and AIDS Pandemic as a Foreign Policy Concern," Washington Quarterly, 1994, Vol. 17, No. 1, p. 201. 


John C. Gannon, "The Global Infectious Disease Threat and Its Implications for the United State," National Intelligence Estimate, NIE 99-17D, January 2000, http://www.fas.org/irp/threat/nie99-17d.htm


Action Today, A Foundation For Tomorrow: Second Annual Report to Congress on the President's Emergency Plan for AIDS Relief (Washington, DC: Congressional Research Service, February 8, 2006).  Available at http://www.state.gov/documents/organization/60950.pdf

IV. Footnotes

1. National Intelligence Council. United States. The global infectious disease threat and its implications for the US, 2000. Available at http://www.fas.org/irp/threat/nie99-17d.htm


2. The U.S. President's Emergency Plan for AIDS, "Relief: Fiscal Year 2007" Operational Plan (June 2007 Update).  Available at http://www.pepfar.gov/about/82481.htm


3. Ibid.


 
Massachusetts Institute of Technology