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Note: This document is from the archive of the Africa Policy E-Journal, published by the Africa Policy Information Center (APIC) from 1995 to 2001 and by Africa Action from 2001 to 2003. APIC was merged into Africa Action in 2001. Please note that many outdated links in this archived document may not work.

USA: Global Infectious Disease Threat
Date distributed (ymd): 000505
Document reposted by APIC

+++++++++++++++++++++Document Profile+++++++++++++++++++++

Region: Continent-Wide
Issue Areas: +economy/development+
Summary Contents:
The posting contains brief excerpts taken from National Intelligence Estimate 99-17D, of January 2000, which frames infectious diseases such as HIV/AIDS as a national security threat to the U.S. For the full text of the unclassified report, see
http://www.cia.gov/cia/publications/nie/report/nie99-17d.html An article in the Washington Post (April 29, 2000) reported that the Clinton administration has now formally determined that HIV/AIDS poses a national security threat.

A related posting today provides updates on malaria, ranked by the report as third most deadly behind HIV/AIDS and TB.

+++++++++++++++++end profile++++++++++++++++++++++++++++++

The Global Infectious Disease Threat and Its Implications for the United States

NIE 99-17D, January 2000

This report represents an important initiative on the part of the Intelligence Community to consider the national security dimension of a nontraditional threat. It responds to a growing concern by senior US leaders about the implications--in terms of health, economics, and national security--of the growing global infectious disease threat. The dramatic increase in drug-resistant microbes, combined with the lag in development of new antibiotics, the rise of megacities with severe health care deficiencies, environmental degradation, and the growing ease and frequency of cross-border movements of people and produce have greatly facilitated the spread of infectious diseases. ...

As part of this new US Government effort, the National Intelligence Council produced this National Intelligence Estimate. It examines the most lethal diseases globally and by region; develops alternative scenarios about their future course; examines national and international capacities to deal with them; and assesses their national and global social, economic, political, and security impact. ...

• Of the seven biggest killers worldwide, TB, malaria, hepatitis, and, in particular, HIV/AIDS continue to surge, with HIV/AIDS and TB likely to account for the overwhelming majority of deaths from infectious diseases in developing countries by 2020. ...
• Sub-Saharan Africa--accounting for nearly half of infectious disease deaths globally--will remain the most vulnerable region. The death rates for many diseases, including HIV/AIDS and malaria, exceed those in all other regions. Sub-Saharan Africa's health care capacity--the poorest in the world--will continue to lag. ...

The 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 prevention and control efforts, new drugs and vaccines, and socioeconomic improvements. In the next decade, under this scenario, negative demographic and social conditions in developing countries, such as continued urbanization and poor health care capacity, remain conducive to the spread of infectious diseases; persistent poverty sustains the least developed countries as reservoirs of infection; and microbial resistance continues to increase faster than the pace of new drug and vaccine development. During the subsequent decade, more positive demographic changes such as reduced fertility and aging populations; gradual socioeconomic improvement in most countries; medical advances against childhood and vaccine-preventable killers such as diarrheal diseases, neonatal tetanus, and measles; expanded international surveillance and response systems; and improvements in national health care capacities take hold in all but the least developed countries. Barring the appearance of a deadly and highly infectious new disease, a catastrophic upward lurch by HIV/AIDS, or the release of a highly contagious biological agent capable of rapid and widescale secondary spread, these developments produce at least limited gains against the overall infectious disease threat. However, the remaining group of virulent diseases, led by HIV/AIDS and TB, continue to take a significant toll. ...

The persistent infectious disease burden is likely to aggravate and, in some cases, may even provoke economic decay, social fragmentation, and political destabilization in the hardest hit countries in the developing and former communist worlds ...

• The economic costs of infectious diseases--especially HIV/AIDS and malaria--are already significant, and their increasingly heavy toll on productivity, profitability, and foreign investment will be reflected in growing GDP losses, as well, that could reduce GDP by as much as 20 percent or more by 2010 in some Sub-Saharan African countries, according to recent studies.
• Some of the hardest hit countries in Sub-Saharan Africa--and possibly later in South and Southeast Asia--will face a demographic upheaval as HIV/AIDS and associated diseases reduce human life expectancy by as much as 30 years and kill as many as a quarter of their populations over a decade or less, producing a huge orphan cohort. Nearly 42 million children in 27 countries will lose one or both parents to AIDS by 2010; 19 of the hardest hit countries will be in Sub-Saharan Africa.

The relationship between disease and political instability is indirect but real. A wide-ranging study on the causes of state instability suggests that infant mortality--a good indicator of the overall quality of life--correlates strongly with political instability, particularly in countries that already have achieved a measure of democracy. The severe social and economic impact of infectious diseases is likely to intensify the struggle for political power to control scarce state resources. ...

A Word About Data

All data concerning global disease incidence, including WHO data, should be treated as broadly indicative of trends rather than accurate measures of disease prevalence. Much disease incidence in developing countries, in particular, is either unreported or under-reported ... Since much morbidity and mortality are multicausal, moreover, diagnosis and reporting of diseases can vary and further distort comparisons. WHO and other international entities are dependent on such data despite its weaknesses and are often forced to extrapolate or build models based on relatively small samples, as in the case of HIV/AIDS. ...

The Deadly Seven

The seven infectious diseases that caused the highest number of deaths in 1998, according to WHO and DIA's Armed Forces Medical Intelligence Center (AFMIC), will remain threats well into the next century. HIV/AIDS, TB, malaria, and hepatitis B and C--are either spreading or becoming more drug-resistant, while lower respiratory infections, diarrheal diseases, and measles, appear to have at least temporarily peaked ...

HIV/AIDS. Following its identification in 1983, the spread of HIV intensified quickly. Despite progress in some regions, HIV/AIDS shows no signs of abating globally (see figure 3). Approximately 2.3 million people died from AIDS worldwide in 1998, up dramatically from 0.7 million in 1993, and there were 5.8 million new infections. According to WHO, some 33.4 million people were living with HIV by 1998, up from 10 million in 1990, and the number could approach 40 million by the end of 2000. Although infection and death rates have slowed considerably in developed countries owing to the growing use of preventive measures and costly new multidrug treatment therapies, the pandemic continues to spread in much of the developing world, where 95 percent of global infections and deaths have occurred. Sub-Saharan Africa currently has the biggest regional burden, but the disease is spreading quickly in India, Russia, China, and much of the rest of Asia. ...

TB. WHO declared TB a global emergency in 1993 and the threat continues to grow, especially from multidrug resistant TB (see figure 4). The disease is especially prevalent in Russia, India, Southeast Asia, Sub-Saharan Africa, and parts of Latin America. More than 1.5 million people died of TB in 1998, excluding those infected with HIV/AIDS, and there were up to 7.4 million new cases. Although the vast majority of TB infections and deaths occur in developing regions, the disease also is encroaching into developed regions due to increased immigration and travel and less emphasis on prevention. Drug resistance is a growing problem; the WHO has reported that up to 50 percent of people with multidrug resistant TB may die of their infection despite treatment, which can be 10 to 50 times more expensive 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 second only to HIV/AIDS as a cause of infectious disease deaths by 2020.

Malaria, a mainly tropical disease that seemed to be coming under control in the 1960s and 1970s, is making a deadly comeback--especially in Sub-Saharan Africa where infection rates increased by 40 percent from 1970 to 1997 (see figure 5). Drug resistance, historically a problem only with the most severe form of the disease, is now increasingly reported in the milder variety, while the prospects for an effective vaccine are poor. In 1998, an estimated 300 million people were infected with malaria, and more than 1.1 million died from the disease that year. Most of the deaths occurred in Sub-Saharan Africa. According to the US Agency for International Development (USAID), Sub-Saharan Africa alone is likely to experience a 7- to 20-percent annual increase in malaria-related deaths and severe illnesses over the next several years. ...

Sub-Saharan Africa will remain the region most affected by the global infectious disease phenomenon--accounting for nearly half of infectious disease-caused deaths worldwide. Deaths from HIV/AIDS, malaria, cholera, and several lesser known diseases exceed those in all other regions. Sixty-five percent of all deaths in Sub-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 the crisis. According to the AFMIC typology, with the exception of southern Africa, most of Sub-Saharan Africa falls in the lowest category. Investment in health care in the region is minimal, less than 40 percent of the people in countries such as Nigeria and the Democratic Republic of the Congo (DROC) have access to basic medical care, and even in relatively well off South Africa, only 50 to 70 percent have such access, with black populations at the low end of the spectrum.

Four-fifths of all HIV-related deaths and 70 percent of new infections worldwide in 1998 occurred in the region, totaling 1.8-2 million and 4 million, respectively. Although only a tenth of the world's population lives in the region, 11.5 million of 13.9 million cumulative AIDS deaths have occurred there. Eastern and southern African countries, including South Africa, are the worst affected, with 10 to 26 percent of adults infected with the disease. Sub-Saharan Africa has high TB prevalence, as well as the highest HIV/TB co-infection rate, with TB deaths totaling 0.55 million in 1998. The hardest hit countries are in equatorial and especially southern Africa. South Africa, in particular, is facing the biggest increase in the region.

Sub-Saharan Africa accounts for an estimated 90 percent of the global malaria burden (see figure 10). Ten percent of the regional disease burden is attributed to malaria, with roughly 1 million deaths in 1998. Cholera, dysentery, and other diarrheal diseases also are major killers in the region, particularly among children, refugees, and internally displaced populations. Forty percent of all childhood deaths from diarrheal diseases occur in Sub-Saharan Africa. The region also has a high rate of hepatitis B and C infections and is the only region with a perennial meningococcal meningitis problem in a "meningitis belt" stretching from west to east. ...

Middle East and North Africa

The region's conservative social mores, climatic factors, and high levels of health spending in oil-producing states tend to limit some globally prevalent diseases, such as HIV/AIDS and malaria, but others, such as TB and hepatitis B and C, are more prevalent. The region's advantages are partially offset by the impact of war-related uprooting of populations, overcrowded cities with poor refrigeration and sanitation systems, and a dearth of water, especially clean drinking water. ...

The HIV/AIDS impact is far lower than in other regions, with 210,000 cases, or 0.13 percent of the population, including 19,000 new cases, in 1998. This owes in part to above-average underreporting because of the stigma associated with the disease in Muslim societies and the authoritarian nature of most governments in the region. ...

International Response Capacity

International organizations such as WHO and the World Bank, institutions in several developed countries such as the US CDC, and Nongovernmental Organizations (NGOs) will continue to play an important role in strengthening both international and national surveillance and response systems for infectious diseases. Nonetheless, progress is likely to be slow, and development of an integrated global surveillance and response system probably is at least a decade or more away. This owes to the magnitude of the challenge; inadequate coordination at the international level; and lack of funds, capacity, and, in some cases, cooperation and commitment at the national level. Some countries hide or understate their infectious disease problems for reasons of 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 of these countries. ...

Macroeconomic Impact The macroeconomic costs of the infectious disease burden are increasingly significant for the most seriously affected countries despite the partially offsetting impact of declines in population growth, and they will take an even greater toll on productivity, profitability, and foreign investment in the future. A senior World Bank official considers AIDS to be the single biggest threat to economic development in Sub-Saharan Africa. A growing number of studies suggest that AIDS and malaria alone will reduce GDP in several Sub-Saharan African countries by 20 percent or more by 2010.

• The impact of infectious diseases on annual GDP growth in heavily affected countries already amounts to as much as a 1-percentage point reduction in the case of HIV/AIDS on average and 1 to 2 percentage points for malaria, according to World Bank studies. A recent Namibian study concluded that AIDS cost the country nearly 8 percent of GDP in 1996, while a study of Kenya projected that GDP will be 14.5 percent smaller in 2005 than it otherwise would have been without the cumulative impact of AIDS. The annual cost of malaria to Kenya's GDP was estimated at 2 to 6 percent and at 1 to 5 percent for Nigeria. ...
• Public health spending on AIDS and related diseases threatens to crowd out other types of health care and social spending. ... In Kenya, HIV/AIDS treatment costs are projected to account for 50 percent of health spending by 2005. In South Africa, such costs could account for 35 to 84 percent of public health expenditures by 2005, according to one projection.

Disruptive Social Impact

At least some of the hardest-hit countries, initially in Sub-Saharan Africa and later in other regions, will face a demographic catastrophe as HIV/AIDS and associated diseases reduce human life expectancy dramatically and kill up to a quarter of their populations over the period of this Estimate (see table 5). ...

Life Expectancy and Population Growth. Until the early 1990s, economic development and improved health care had raised the life expectancy in developing countries to 64 years, with prospects that it would go higher still. The growing number of deaths from new and reemergent diseases such as AIDS, however, will slow or reverse this trend toward longer life spans in heavily affected countries by as much as 30 years or more by 2010, according to the US Census Bureau. For example, life expectancy will be reduced by 30 years in Botswana and Zimbabwe, by 20 years in Nigeria and South Africa, by 13 years in Honduras, by eight years in Brazil, by four years in Haiti, and by three years in Thailand. ...

Family Structure. The degradation of nuclear and extended families across all classes will produce severe social and economic dislocations with political consequences, as well. Nearly 35 million children in 27 countries will have lost one or both parents to AIDS by 2000; by 2010, this number will increase to 41.6 million. Nineteen of the hardest hit countries are in Sub-Saharan Africa, where HIV/AIDS has been prevalent across all social sectors. ... With as much as a third of the children under 15 in hardest-hit countries expected to comprise a "lost orphaned generation" by 2010 with little hope of educational or employment opportunities, these countries will be at risk of further economic decay, increased crime, and political instability as such young people become radicalized or are exploited by various political groups for their own ends; the pervasive child soldier phenomenon may be one example.

Destabilizing Political and Security Impact In our view, the infectious disease burden will add to political instability and slow democratic development in Sub-Saharan Africa, parts of Asia, and the former Soviet Union, while also increasing political tensions in and among some developed countries.

The severe social and economic impact of infectious diseases, particularly HIV/AIDS, and the infiltration of these diseases into the ruling political and military elites and middle classes of developing countries are likely to intensify the struggle for political power to control scarce state resources. This will hamper the development of a civil society and other underpinnings of democracy and will increase pressure on democratic transitions in regions such as the FSU and Sub-Saharan Africa where the infectious disease burden will add to economic misery and political polarization.