2
Examining the Consequences: A Changing Landscape

From the transcontinental movement of people to the global flow of capital, the multitude of complex, interacting phenomena described in Chapter 1 will, if left unchecked, continue to shape the global landscape in dramatic and unpredictable ways. This chapter provides a summary of the workshop presentations and discussions focused on some of the ways in which the global landscape is already changing or expected to change in ways that could cause or exacerbate the emergence and global spread of infectious diseases.

Most notably, the growing demographic and economic divides between rich and poor countries, combined with increasing levels of access to information even in the remotest corners of the world, are expected to fuel widespread discontent, armed conflict, and the massive displacement of people, the public health consequences of which are often disastrous. Refugee populations are among the most vulnerable to emerging and reemerging infectious diseases. Summarized here are the presentations and discussions pertaining to these growing economic and demographic gaps, the consequences of armed conflict for public health, and the need for improved screening and surveillance of mobile populations—not just war-displaced refugees, but also all migrant populations.

The surveillance of mobile populations is only one of several types of surveillance urgently in need of development or revamping. As the transcontinental movement of food and commodities has increased, so, too, has the need for improved trade- and food-related surveillance; discussion of this topic is also included here. (Opportunities and obstacles with regard to



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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary 2 Examining the Consequences: A Changing Landscape From the transcontinental movement of people to the global flow of capital, the multitude of complex, interacting phenomena described in Chapter 1 will, if left unchecked, continue to shape the global landscape in dramatic and unpredictable ways. This chapter provides a summary of the workshop presentations and discussions focused on some of the ways in which the global landscape is already changing or expected to change in ways that could cause or exacerbate the emergence and global spread of infectious diseases. Most notably, the growing demographic and economic divides between rich and poor countries, combined with increasing levels of access to information even in the remotest corners of the world, are expected to fuel widespread discontent, armed conflict, and the massive displacement of people, the public health consequences of which are often disastrous. Refugee populations are among the most vulnerable to emerging and reemerging infectious diseases. Summarized here are the presentations and discussions pertaining to these growing economic and demographic gaps, the consequences of armed conflict for public health, and the need for improved screening and surveillance of mobile populations—not just war-displaced refugees, but also all migrant populations. The surveillance of mobile populations is only one of several types of surveillance urgently in need of development or revamping. As the transcontinental movement of food and commodities has increased, so, too, has the need for improved trade- and food-related surveillance; discussion of this topic is also included here. (Opportunities and obstacles with regard to

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary the development of a general global infectious disease surveillance system are discussed in Chapter 3.) Another notable feature of the changing global landscape is the increased perceived and actual threat of bioterrorism, particularly in the United States. In response, the Bush Administration has proposed an unprecedented amount of public health funding—approximately $6 billion—for defense against bioterrorism (biodefense). These funds are expected to have both direct and indirect benefits for the prevention and control of emerging and reemerging infectious diseases in general, whether intentionally or naturally introduced, by strengthening the public health community’s ability to make constructive changes in a way never before possible. The discussion of this topic is summarized here as well. (Presentations and discussions pertaining to increased spending on international health in general, including funds that are not necessarily U.S. biodefense–related, are summarized in Chapter 4.) Finally, this chapter includes summaries of regional case studies presented by representatives of Russia and the European Union. Both provide important insights into the impact of globalization on public health in parts of the developed world outside of the United States. In the case of Russia, the collapse of the cold war political system has led to widespread social and public health problems manifested in multiple ways, most notably a rise in the numbers of people with HIV/AIDS and multidrug-resistant tuberculosis (TB). The current situation illustrates how even an educated population and a plenitude of natural resources cannot guarantee good public health if political and other leaders do not consider health a priority. The situation in the European Union, on the other hand, may provide a useful model for understanding how the public health impacts of the movement of capital, resources, and people across former political boundaries can be managed. It is unclear, however, whether the European model can actually be applied to other, less unified areas of the world. Moreover, despite its successes, the region is still experiencing serious problems with respect to emerging infectious diseases, for example, among migrant populations. ECONOMIC GAPS, GLOBAL DISCONTENT, COMMUNAL CONFLICT, AND FORCED MIGRATION1 Globalizing forces are expected to increase and exacerbate already tense relationships between rich and poor countries, as has been witnessed in the 1   This section is based on the workshop presentations by Gordon (2002), Leaning (2002), and LeDuc (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary intense international debate regarding intellectual property rights and the affordability of antiretroviral agents. A National Intelligence Council report (NIC, 2000) predicts that over the next 15 years, this international economic divergence will probably continue. Although developed countries and some developing countries will continue to enjoy high rates of economic growth, the rates in most developing countries will be very stunted. The situation will be exacerbated by the fact that infectious diseases, particularly HIV/AIDS, will continue to depress economic growth in the hardest-hit countries by as much as one percent of their gross domestic product (GDP) per year; over the course of many years, the impact of this will be huge. Recent massive changes in international trade law are fueling a great deal of discomfort and unhappiness in the developing world, and poorer countries are already pressing harder to gain access to markets in the developed world. One of the most recent, conspicuous changes in international trade fora is the strengthening voice of developing countries. It is no accident that the current round of multilateral trade negotiations has explicitly been named the “Development Round,” to reflect the growing importance of trade to the developing world. The debate over access to antiretroviral drugs for the treatment of HIV infection suggests that these kinds of issues are likely to become increasingly common points of tension in future trade negotiations. Moreover, the tremendous advances and expansions in communication that are being made possible by today’s technology have provided many, although not all, parts of the world with unprecedented access to television. People around the world know how everybody else is living. Greater knowledge and a changing perception of the increasing social and economic disparities between rich and poor countries will likely continue to fuel widespread antiglobalist sentiments and frustration. For some, knowing that they are not living to the same standard as others is a source of great discontent. In many parts of the world, governance is not strong enough to handle the daunting pressure on states’ capacities to adjust to these global shifts in trade, communication, and perception. A relationship with the people, the capacity to be flexible in times of community distress, and the ability to respond to the ongoing resistance posed by the opposition party all require a sophistication and capacity that many of these countries lack. The pressure to respond creates a greater propensity to state failure. From Zimbabwe to Venezuela, this fragility of government in the face of globalization must be kept in mind. State collapse provides the opportunity for an influx of nonstate actors. The regional instability that often ensues increases the risk of armed conflict, which in turn leads to the massive displacement of people and humanitarian and public health crises.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Communal Conflicts and Small Arms Several think tanks worldwide have investigated the issue of small-arms availability. They have examined the magnitude of the problem, the prevalence and production of small arms, the trade routes used, the amount of money circulating in the trade, impacts in countries where the arms are used, and the major players. The majority of wars are waged with small arms.2 Most of these conflicts are communally based fights between racial, ethnic, tribal, or language groups within larger populations. Although local, these wars are aggravated by regional and global factors, including poor leadership, underlying socioeconomic conditions, and communications with the diaspora. Once ignited, these conflicts tend to be long-lived, generally lasting at least 10 years. Some are well into their thirtieth year. Most populations engaged in communal conflicts suffer from irresponsible or malignant leadership, and such conflicts occur in collapsing or failing states where human rights abuses are rampant. Most of the nonstate actors who wage such wars or who cause complex humanitarian emergencies (as the public health community refers to them) are not part of the established power structure. Rather, they tend to be informal armies, militias, and rebels who are not completely contained by a chain of command and typically are unconcerned about international humanitarian law. Their strategy is to target civilians by committing acts of terror or ethnic cleansing or by capturing land and forcing populations to flee. They follow this strategy for two principal reasons: they have not been educated in other strategies, and they have easy access to small arms, the only weapons available to them. The definition of a small arm is constantly evolving, but essentially encompasses any weapon that can be used by one to three people, including submachine guns and assault rifles, mounted grenade launchers, and portable antiaircraft missiles and missile launchers. Of all the key underlying conditions that promote or sustain conflict—poverty, arms availability, communal tensions, and state failure—arms availability is the most directly affected by globalization. 2   Major recent exceptions include the first Gulf War, which involved massive arms used by a first-world power, the United States, and its allies; Kosovo, which involved NATO (North Atlantic Treaty Organization) forces (i.e., not the Kosovo Liberation Army and Serbian forces that were at work in 1998–1999, which used small arms); Ethiopia and Eritrea, where in the 1990s a massive conventional war with large heavy weapons killed 80,000 to 100,000 people; and, most recently but subsequent to this workshop, the Iraq War.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Small arms can be purchased from a thriving global market that includes about $3–6 billion in legal sales and $2–10 billion in illegal sales annually. There are more than 500 million small-arms weapons in circulation—one for every 12 people on earth. About a third of a million people die each year from wounds caused by the small arms used in war; another 200,000 people die each year from wounds caused by handguns during peacetime. Legal transfer represents a major share of the small-arms trade, one that could be influenced by U.S. policy. Policy changes that affected the legal market would also affect the “gray” market, where sales are possibly legal but either secret or unauthorized in small-arms trade laws. The illegal black market, however, cannot even be monitored because it takes place in remote, inaccessible, or highly dangerous areas and remains overlooked because of corruption. Enormous humanitarian impacts result from the prevalence of these weapons in societies that are already disintegrating because of state collapse and the encroachment of rebel forces operating outside the rule of law. In Afghanistan, for example, virtually every male over the age of nine possesses an AK-47 assault rifle. It can be terrifying to live in a society where the availability of small arms disrupts traditional modes of conflict resolution. Traditionally, for example, if a man’s cow were stolen, he might kill one of the thief’s animals with his knife. Or if a man’s woman were insulted, he might attack someone in the suspect’s family with a long-bore, single-shot rifle. The situation is quite different today, with grenades, land mines, and assault rifles being at everyone’s disposal, and is exacerbated by the escalating cycle of reprisal and action. Many people living in such areas (e.g., Somalia and Sudan) say the situation is out of control. In the postconflict setting, disarmament of a population in which the presence of small arms is so diffuse and pervasive is politically daunting. The persistence of the weapons retards the transition to work, deters investors from the developed world, and leads to the rise of criminal elements, as is currently happening, for example, in Liberia and Sierra Leone. Forced Migration Communal conflicts are characterized by the massive dislocation of populations and extensive destruction of infrastructure. An estimated 50 million people worldwide are forcibly displaced from their homes each year; this displaced population includes migrants who move regularly to find work and refugees who flee to a foreign country to escape danger. The United States alone receives an average of 90,000 refugees annually. Refugee populations are among the most vulnerable to emerging infectious diseases, even more so than migrants (see Chapter 1). For example, on the basis of preliminary data from a 2000 International Organization for Mi-

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary gration assessment of the health of more than 76,000 mobile people (44.7 percent migrants, 55.3 percent refugees), refugees are more likely than migrants to be HIV-positive (representing 65 percent of HIV-positive individuals in the database) (Grondin, 2002). The breakdown of public health systems and the public sector generally in areas that are experiencing war or receiving migrants can be profound. In many war-torn areas, public health systems are so severely affected that they do not have the capacity to provide adequate services. The rates of death and disease in Afghanistan, for example, are among the highest in the world. The maternal mortality rate in Afghanistan is on the order of 1,700 maternal deaths per 10,000 live births—close to what one would expect if there were no health care at all. Fully 25 percent of children in Afghanistan die before the age of five years, and about 20 percent before their first birthday. The country is experiencing a breakdown at all levels of health care, and immunization is almost nonexistent. Although there is little concern about a mass epidemic in Afghanistan since the country is not densely populated, its dire situation illustrates the devastating effects war can have on public health. The situation is often exacerbated by the fact that forced migration can escalate or precipitate further conflict. This occurs especially in regional and host settings in Africa and Central Asia where massive influxes of people fleeing one war feed into a local diaspora that is also part of an unwanted ethnic group in the host country. For example, Georgia, Armenia, Afghanistan, and the surrounding countries are sites of regional tumult where migrants move from one area of distress and sow another in their host country. Because the receiving countries are typically poor and already border the war-torn areas, the refugees tax the host governments even further. Workshop participants noted that refugees are not the only people who serve as infectious disease vectors during wartime. Peacekeepers do so as well. This is especially true for HIV/AIDS, as the parallel progression of the HIV/AIDS epidemic and the peacekeeper movement in many parts of Africa illustrates. Kosovo may be experiencing the beginning of a similar war-related HIV/AIDS epidemic. Before the war in Kosovo and the introduction of peacekeepers, not a single case of HIV/AIDS was known in the area, according to Kosovo’s Institute of Public Health. Since the arrival of peacekeepers, however, the incidence of HIV/AIDS has been increasing. Peacekeepers can be disease vectors for a variety of reasons. Peacekeeping soldiers generally arrive in areas in large numbers, more often engage in sexual activity than does the general population, and frequently behave in a predatory manner; these behaviors among soldiers have been witnessed for centuries. Moreover, a number of studies have shown that when peacekeepers move into an area, the prevalence of HIV/AIDS increases significantly, not only in the host country but in the adjoining countries as well, because of the

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary sex trade. Sex workers flock to where the peacekeepers are located, moving back and forth across borders and spreading disease. In addition, biological evidence suggests that the infectivity rate is highest during the early phases of HIV infection, when the viral load is very high; therefore, newly infected soldiers with many sexual partners initiate spirals of disease propagation. One participant asked whether, when peacekeeping forces are assembled, deferred compensation is ever considered as a means of constraining the social impact of the economic imbalance between the peacekeeping forces and the general population, especially since this economic imbalance is what drives the sex trade. For example, the much higher per diem of the United Nations Transitional Authority in Cambodia relative to the average daily wage of Cambodians led to an explosion of the prostitution industry in that country and the movement of HIV into Cambodia from Vietnam. In response to this question, a participant stated that, although a great deal of attention is being focused on the prevalence of HIV infection among peacekeeping forces, the issue is very politically charged. Many countries that provide peacekeeping forces do so because they receive a small amount of money from the United Nations to augment their military budgets; these countries are too poor to provide treatment for their soldiers and thus refuse to have them tested for HIV. Those countries that do test their forces and treat their HIV-positive soldiers, including Great Britain, the United States, Canada, and some western European countries, are less likely to provide forces for peacekeeping missions. Another participant pointed out that the economic imbalance existing in war-torn areas is not limited to peacekeepers. The United Nations and other nongovernmental organizations and bilateral agencies pay their international staff five to 20 times more than is customary in the local economy, creating massive economic distortion. Anyone who can speak English or the most common language in the given location is drawn from the local labor market, a talent drain that can take years to redress. This is happening in the Balkans, for example, as well as in Afghanistan, and has occurred in the past in many parts of Africa, including Angola and Sudan. A participant suggested that perhaps the United Nations could address this issue if and when the humanitarian community becomes more organized. SURVEILLANCE OF MOBILE POPULATIONS3 The incidence rates of TB and multidrug-resistant TB in migrant populations (see Chapter 1) illustrate the tremendous risk of acquiring and 3   This section is based on the workshop presentations by Barry (2002), Cetron (2002), Grondin (2002), and LeDuc (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary transmitting infectious diseases among mobile populations, especially those originating in poor countries with a high prevalence of disease. Preventing and controlling the emergence and spread of TB and other infectious diseases among mobile populations will require that gaps in public health infrastructure among countries be bridged, particularly gaps between countries that generate and receive migrants. Although mobility, technologies, and economies may no longer be constrained by borders, political boundaries still limit public health infrastructure. This is perhaps nowhere more evident than in the surveillance of mobile populations. There is an urgent need to shift away from traditionally fragmented provincial, state, or local health department–based surveillance infrastructures toward a more global approach to data acquisition and information sharing. At the same time, the need for a new, borderless approach to managing the health of mobile populations should not detract from the continuing need for strong domestic medical training programs. In particular, the medical staff in receiving countries, including the United States, need to be better trained to treat migrants. Physicians should be able to recognize and treat those infectious diseases, such as multidrug-resistant TB, that are most likely to affect migrants. Migrant Screening Criteria The procedures used to screen mobile populations vary among countries. Countries that have traditionally received large numbers of migrants—including the United States, Australia, Canada, and New Zealand—conduct prearrival medical screening for migrants with active and infective TB and mandatory testing for HIV. The criteria used to determine who will be screened before arrival include the incidence rates of specific infectious diseases in the country of origin, the category of the applicant (e.g., refugee vs. migrant), and the individual’s occupation and expected length of stay in the receiving country. European and other countries with more recent immigration histories rely on postarrival screening, as demanded by work permits or refugee immigration statutes. Prearrival screening may appear to be the ideal model for preventing the importation of TB and other infectious diseases. In reality, however, it is truly effective only in the case of well-organized, well-managed, and well-planned migration movements; it could not possibly be used to manage today’s global mobile population. Moreover, prearrival screening based on immigration status is not necessarily the most effective way to manage migrant health. According to the above-mentioned 2000 International Organization for Migration assessment of the health of mobile people, in contrast with the case of HIV, the incidence of TB was about eight percent higher among migrants than among refugees (Grondin, 2002). This finding

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary is of note, given that certain classes of migrants, such as long-term visitors in the United States, are usually excluded from the screening requirements. A 2001 study of TB incidence in Tarrant County, Texas, for example, found that nonimmigrant, long-term visitors had a higher rate of TB and multidrug-resistant TB than immigrants (Weis et al., 2001). In this light, there is a need to revisit migration health surveillance programs targeting only refugees or permanent residents. Refugee health in particular is complicated by the inability to track refugee departures, transit times, and arrivals accurately, making it difficult both to acquire prescreening information and to transmit that information to government resettlement programs before refugees report for postarrival screening. Moreover, in many countries the multidrug-resistant TB detection rate from the screening of migrants is suboptimal at best, and basic supervision of sputum collection procedures is often lacking. In some developed countries, applicants are told to conduct sputum testing at home, without proper supervision. In addition, patients with active TB can have smear-negative sputa if they are being treated. Despite the difficulties of screening mobile populations, many programs are undergoing significant changes that will likely have positive effects on the health of these populations. The International Organization for Migration is sponsoring the development of a pilot electronic notification system that will receive health screening data and provide swift electronic notification of all patients with infectious smear-positive (class A) TB, as well as those who are smear negative but still require follow-up and those with latent TB infection (LTBI) who require prophylactic follow-up. A recent Institute of Medicine report (IOM, 2000) called for the institution of procedures for the screening of migrants with LTBI before they leave their home country, an enormous task extending beyond traditional entry requirements. However, with the realization that reliable partners in other countries are capable of much more sophisticated predeparture management, more challenging goals are being set. This is true not just for patients with TB, but also for those with other infectious diseases. Before departure, for example, African refugees are treated with antimalarial agents in an effort to relieve some of the extra burden on countries that cannot readily recognize or diagnose malaria. Because sputum smears can be converted so readily, efforts are under way to develop more sensitive and appropriate screening algorithms, including culture-based approaches, polymerase chain reaction–based methods, and the addition of adjuvants to sputum for testing purposes. Workshop participants offered several additional ideas for effecting positive change. One participant suggested that recent dramatic discussion

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary in the media about calls from some political leaders to abolish the Immigration and Naturalization Service (INS)4 indicated an opportunity to work toward making changes in that agency to better address the migrant and refugee health issues described above. Another proposed that recent advances in telemedicine may provide innovative opportunities for migrant health screening. Finally, as discussed earlier, it was emphasized that U.S. health care providers need to be better informed and prepared to deal with the health needs of mobile populations. To this end, a health education curriculum addressing migrants/refugees should perhaps be established for U.S. physicians. One participant expressed concern that there is no uniform procedure for refugee screening and that, currently, refugees can be prescreened up to a year before entering the United States. The suggestion was made that the prescreening interval be shortened to less than one year. In response, it was noted that technical instructions for overseas medical screening of refugee populations are being rewritten to shorten the duration from one year to 6 months. Another participant suggested that a centralized website for geographic surveillance of refugee populations be established. In response, it was noted that GeoSentinel, a global network of 22 travel/tropical medicine clinics (14 in the United States and eight in other countries) that monitor the health status of mobile populations, has increasingly focused on refugee health clinics. When the network was established in 1996, its initial emphasis was on collecting disease- or syndrome-specific diagnoses on returning travelers, immigrants, and foreign visitors (Freedman et al., 1999). The network now includes about 25 refugee health clinics as well. There is some concern, however, that GeoSentinel may not be comprehensive since (with variation from one site to another) refugees are not required to visit a refugee (or travel) clinic, are very broadly dispersed, and are also unlikely to see any local provider (Cetron, 2002). Depending on how a country spends its local resources for refugee health, national health departments may or may not be able to accommodate refugee health care, which tends to be distributed mainly among local providers, not refugee clinics. This is true even though GeoSentinel clinics are not required to be based in national health departments and can be in the private sector. Another concern regarding GeoSentinel is that its website—which posts surveillance data for tourist, refugee, and immigrant movements—needs to be further developed and 4   The INS ceased to exist on November 25, 2002, when the last of its functions were transferred to the new Department of Homeland Security.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary better surveillance information needs to be gathered and made more readily available (Cetron, 2002). Recommendations of the International Organization for Migration for Improved TB Screening of Mobile Populations Despite the obvious challenges, improved TB control programs for mobile populations are possible. Such programs will need to involve both predeparture screening in countries of origin and postarrival screening in receiving countries. The greatest challenge is probably faced by policy makers and researchers; this is true not only for TB, but also for HIV/AIDS and other infectious diseases. The International Organization for Migration has made the following recommendations for TB control programs: Even in the country of origin, it is essential that sputum collection be supervised, laboratory personnel be comprehensively trained, a consistent system of quality control and quality assurance be implemented, and complete treatment be conducted under observation (i.e., using directly observed therapy). Countries that receive migrants must share information and public health tools with and provide feedback to countries of origin. Faster, more efficient information systems are needed for communication between countries of origin and receiving countries. Existing surveillance systems must be strengthened, and an international surveillance system linking countries of origin and host countries must be implemented. A public health justification for providing all migrants access to health care, particularly those who do not have legal status, must be formulated. Vulnerability to infection must be reduced by improving the living conditions of migrant populations. Disease prevention strategies for mobile populations must be developed to decrease stigmatization and discrimination within both host countries and receiving local communities. One of the most important issues with regard to screening for TB is the need to formulate screening criteria that are replicable, reliable, and affordable in terms of laboratory support. For example, even individuals who have positive skin tests but do not develop active TB may benefit from prophylactic therapy, and even those who test negative may still be infected and require ongoing treatment.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary sis of packages sent through the mail during the anthrax attacks in the United States; none of the packages was positive, and some even contained no white powder. The Question of the Smallpox Vaccine Stockpile Participants noted that international management of the smallpox vaccine stockpile is an important policy question that must be resolved. The United States is spending a large amount of money on the acquisition of smallpox vaccine, and other countries want to know whether they will have access to those supplies should the need arise. To many people in the developing world, much of the U.S. effort is considered self-serving. In the view of one workshop participant, not only is it untenable that a dose will be made available for every U.S. citizen, but the United States has no clear policy on intervening should smallpox occur elsewhere in the world. CDC has repeatedly said that any outbreak of smallpox anywhere in the world would be a global emergency requiring a U.S. response, but there needs to be greater clarity regarding exactly what this response would entail. Scientific Freedom and Privacy Issues Participants expressed concern regarding the impact of biodefense on scientific freedom. In particular, preventing the proliferation of biological weapons entails controlling technologies that may have multiple uses and may put scientific freedom at risk. How can the United States develop a nonproliferation regimen that provides security while also supporting scientific openness? Privacy is also becoming a more serious issue as individual genome sequencing technologies become more sophisticated. Although information about personal genomes may be necessary for prophylaxis or treatment in the event of a bioterrorist attack, the use of such information raises questions about ownership and fair use. EFFECTS OF THE DISSOLUTION OF THE FORMER SOVIET UNION ON PUBLIC HEALTH IN RUSSIA8 The post–cold war situation in Russia illustrates the public health impact of rapid socioeconomic change induced by globalizing forces in a country where state social programs were previously the sole provider of 8   This section is based on the workshop presentations by Demin (2002) and Netesov (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary health and social safety nets. The dissolution of the Soviet Union in 1991 and the shift away from a bipolar world had public health repercussions not only in Russia, but also in Eastern Europe and worldwide. Although the situation in Russia is unique, it reflects what is happening globally in both the developed and the developing worlds: funding for public health and the public health infrastructure are failing, the health of migrants has become a key issue, and something must be done. In the mid-1960s, the Soviet Union’s public health and social security systems were comparable to those of many western countries. Until 1992, industry, the economy, and state social programs were all fueled largely by state exports of national resources, not manufacturing, and the labor population was of only secondary importance. Nevertheless, under the old Soviet “social contract,” the social security of Soviet citizens was more comprehensive than was the case in most developed welfare states. When Russia began the process of liberalization in the early 1990s, however, the country was experiencing the peak of a major political and socioeconomic crisis. The hasty and unreasoned opening of the country to globalization processes during that difficult time has been identified as a key causal factor in the current public health crisis. The implementation of so-called “shock therapy” wiped out savings. The abolition of the state monopoly on foreign trade, natural resources, and alcohol turnover, as well as biased privatization of state property, created a small, deindustrialized economy oriented toward the export of raw materials that was beneficial for only a small segment of the population. The bulk of the population was deprived of economic power and was thus considered “excessive” during this early stage of post-Soviet reform (Demin, 2002). The state abrogated its role in social security policy, the ruling elite overlooked the need for new approaches to social security, and privatization and the new market economy failed to substitute for the old Soviet state safety net. In 2002, about 30 percent of the population was living below the minimal standard. The total number of people living under conditions of poverty increased from 2.2 million in 1993–1995 to 57.8 million in 1997–1998. Fully 10 percent of impoverished individuals have reached a social low point and are rejected by society. At least one million children are neglected and homeless. Russia is a geoeconomic vacuum, with a GDP only about 1.5 percent of the world average. Its external debt totals $138 billion, and about 25 percent of the state budget is earmarked to serve this debt. Considerable internal debt also remains. The outflow of capital in 2001 was an estimated $17 billion, which is comparable to the $15.9 billion foreign investment in Russia for the entire period between 1992 and 1998. Since 1991, negative global influences—illegal drugs; self-destructive behaviors; and the marketing of tobacco, alcohol, and junk food products

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary by transnational corporations—have intensified. Transnational tobacco companies control about 65 percent of local tobacco production, and the level of production of tobacco products in Russia increased from 150 billion cigarettes in 1990 to 400 billion in 2001. The country has experienced a parallel increase in the number of individuals who smoke. Russia’s current public health problems developed in parallel with but lagged behind its social and economic changes, as illustrated by the decline in public health following the economic crisis of August 17, 1998, which resulted in a fourfold devaluation of the national currency during a 2-week period. Many public health indicators have been steadily declining since 1964, despite two short periods of improvement from 1985 to 1987 and 1995 to 1998. Impoverishment has resulted in large-scale undernourishment and increasing rates of morbidity and mortality, and a considerable portion of the Russian population has become party to the vicious cycle of poverty, disease, and premature death. Infectious diseases are becoming more prevalent as living and social standards fall; the leading cause of death from infectious and parasitic diseases is TB, which killed about 30,000 people in 2000 (see below for additional statistics on rates of mortality from infectious diseases). In 2000, the average life expectancy in Russia was 59 years for men and 72.2 years for women. Lower life expectancy is particularly drastic among males as a result of poverty, substance abuse, and disease. Russia’s public health problems are further complicated by the reality that, because of insufficient funding, infectious diseases among the considerable flow of migrants from states of the former Soviet Union are neither monitored nor controlled. At present, Russia has about 5.5–12 million illegal migrants. By 2010, the number of illegal migrants in Russia is predicted to be as high as 19 million, representing 15 percent of the population. The situation is complicated by the fact that most of these migrants come from developing countries with unfavorable sanitary conditions, including Afghanistan and Iraq. The administration of Vladimir Putin has developed revised policies for legal migration into Russia, along with revised pronatalist, health-promoting policies, in an effort to compensate for the current low rate of population growth. The death rate currently exceeds the birth rate by a factor of 1.7. As President Putin claimed in his first address to the national parliament on July 8, 2000, this rate of population growth is insufficient for the normal functioning of Russia, and if it continues will threaten the survival of the nation. President Putin predicted that the national population may decrease by as much as 22 million over the course of the next 15 years. In addition to the increase in the mortality rate, since 1990 some 100,000 individuals have left the country each year to obtain permanent residence abroad.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Russia’s experience shows how even the availability of natural resources and an educated population cannot guarantee a country’s integration into the global economy, nor can it ensure internal social stability or good public health if social security and public health are not identified as priorities as part of planned political, social, and economic changes. The ruling elite’s underestimation of the importance of public health can have profound repercussions for national security; the economy; and survival at the national, regional, and global levels. In 2001, the leading cause of death in the Russian Federation was cardiovascular disease (865.2 deaths per 100,000 persons), which is typical of most developed countries. The second was injuries, including homicides, suicides, accidents, and poisoning (225.2 deaths per 100,000); the third was cancer (203.9 deaths per 100,000); the fourth was pulmonary disease, including influenza, pneumonia, TB, and various other infectious and non-infectious diseases (65.1 deaths per 100,000); and the fifth was other infectious and parasitic diseases (24.3 deaths per 100,000). The sections below provide some specific infectious disease statistics, including, for comparative purposes, differences in rates of morbidity and mortality from hepatitis between Russia and the United States. Hepatitis A9 From 1967 to 2001, morbidity and mortality from hepatitis A was much higher in Russia than in the United States. Although the figures from before 1990 are questionable because diagnosis was based mainly on etiology (the enzyme-linked immunosorbent assay [ELISA] test was not used for diagnosis until after 1990), the mortality rate in Russia has still been much greater than that in the United States. In 1967 there were approximately 1,500 deaths from hepatitis A per 100,000 persons in Russia, compared with fewer than 50 deaths per 100,000 in the United States. In 1990 there were slightly more than 1,500 deaths per 100,000 in Russia, versus nearly zero deaths per 100,000 in the United States. In the late 1990s, mortality rates in Russia dropped to fewer than 50 deaths per 100,000. Although the cause of this decline is unclear, it may have been due to a declining birth rate and a decrease in the population of children under 10 years of age. Nevertheless, a significant percentage of the population had no antibodies against the hepatitis A virus, and the mortality rate from the disease is again on the rise, approaching 100 deaths per 100,000 in 2001 (tempered in some outbreak areas by vaccination). 9   This section is based on the workshop presentation by Netesov (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Hepatitis B10 The situation with hepatitis B is similar to that with hepatitis A, with significantly greater mortality occurring in Russia than in the United States over the course of the past 25 years or so. In 1993, hepatitis B was responsible for between 150 and 200 deaths per 100,000 persons in Russia; by 2000, this number had risen to greater than 400. However, a significant decrease in morbidity occurred in Russia in the early 1990s, when the new, sensitive diagnostic ELISA test was introduced, resulting in quicker access to treatment. Unfortunately, the sudden drop was interrupted by a huge increase in intravenous drug use (a primary means of contracting the infection), which continues to this day (although there was a small decrease in 2003 due to the U.S. presence in Afghanistan, where the poppy fields are located). Measles, Mumps, and Diphtheria In 1993, there was a large increase in measles incidence in Russia, from fewer than 2,000 infections per 100,000 persons in 1992 to more than 4,000 infections per 100,000 in 1993. Although the jump in incidence was due in part to a vaccine shortage, it was caused largely by media propaganda and a widespread suspicion that the measles vaccination was harmful. Since then, however, the incidence of measles has fallen to practically zero. A similar phenomenon occurred with mumps in Russia in the late 1990s, although there is still a significant incidence of the disease, despite the implementation of revaccination procedures. In 1995, there were fewer than 3,000 mumps infections per 100,000 people; this figure rose to almost 10,000 by 1999. By 2001, the incidence had dropped to fewer than 2,000 infections per 100,000. Diphtheria incidence also experienced a dramatic jump in the mid-1990s, again because of both suspicion that the vaccine was harmful and a vaccine shortage. In 1992, there were fewer than 500 infections per 100,000 persons; in 1994, there were more than 2,000. The incidence is now less than it has been in over a decade and is continuing to decline. Tuberculosis Roughly 2 million people die each year from TB worldwide (WHO, 2002b), with the vast majority of these deaths (98 percent) occurring in 10   This section is based on the workshop presentation by Netesov (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary developing countries (Mukadi et al., 2001). In 2000, approximately 8.7 million new TB cases were reported worldwide, of which an estimated three to four percent were multidrug-resistant (Jaramillo, 2002). In most countries, the average incidence of TB has recently been increasing by approximately three percent per year; however, the increase is much higher in Eastern Europe (eight percent per year) and African countries most affected by HIV (10 percent per year). Just 23 countries account for 80 percent of all new TB cases. In 2000, over half of these cases were concentrated in five countries: India, China, Indonesia, Nigeria, and Bangladesh. Although Zimbabwe and Cambodia report fewer total cases, they possess the highest global rates per 100,000 population (562 and 560, respectively) (WHO, 2001b). If present trends continue, more than 10 million new cases of TB are expected to occur worldwide in 2005, mainly in Africa and Southeast Asia; by 2020, nearly one billion people will be newly infected, 200 million will develop the disease, and 35 million will die (WHO, 2002a). The global resurgence of TB is not confined to developing countries. From 1990 to 1995, TB incidence in Russia increased by 70 percent, with more than 25,000 persons dying from the disease each year (Netesov and Conrad, 2001). The increased incidence is compounded by the spread of multidrug-resistant TB, especially in prisons, where patients typically self-administer treatment. Because most prison clinics experience massive shortages of drugs, the majority of patients are unable to complete their full course of treatment, a situation that fosters the emergence of multidrug-resistant TB. Indeed, the rate of multidrug-resistant TB among TB isolates in Russian prisons is an astonishing 40 percent, compared with just 6 percent in the general population. The overall rate of TB per capita in prison populations (i.e., including both multidrug-resistant TB and other forms of the disease) is nearly 100 times higher than in the Russian population at large. Syphilis The estimated global burden of new cases of infection with Treponema pallidum among adults in 1999 was 12 million (WHO, 2001a). As with other sexually transmitted diseases, the greatest number of cases occurs in South and Southeast Asia and sub-Saharan Africa (four million each), followed by Latin America and the Caribbean (three million). Although the primary and secondary syphilis rates in the United States declined by 90 percent from 1990 to 2000, the disease remains an important problem in the South and among certain subgroups. The newly independent states of the former Soviet Union have recently seen a dramatic rise in syphilis rates, from 5–15 per 100,000 in 1990 to 120–170 per 100,000 in 1996 (WHO, 2001a).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary HIV/AIDS In less than 20 years, HIV/AIDS has become a pandemic requiring an unprecedented global response. More than 60 million people have been infected with HIV worldwide, and 20 million have died from AIDS, leaving an estimated 40 million adults and children living with HIV. Roughly 14 million children are living without one or both parents who died from the disease. In 2001 alone, it is estimated that five million people became HIV positive worldwide, 800,000 of them children (UNAIDS, 2002). Nearly one-third of those living with HIV/AIDS—11.8 million—are between 15 and 24 years of age (UNAIDS, 2002). Over the last decade, HIV/AIDS has increased dramatically in Russia. Although most people still contract the infection through intravenous drug use, more and more women are becoming infected through sexual transmission. As more women become infected, mother-to-child transmission also increases, causing a spillover into the general population. Specific projections of the number of anticipated HIV/ AIDS cases are difficult because the incidence of HIV infection is declining in some populations and increasing in others, HIV testing continues to be voluntary, and reporting may be incomplete. Generally, the number of cases is expected to rise in areas where poverty, poor health systems, poor access to health care services, and gender inequality are prevalent; where resources for health care and prevention are limited; and where a high degree of stigma and denial is associated with HIV infection (Monitoring the AIDS Pandemic Network, 2000). THE EXPERIENCE OF THE EUROPEAN COMMUNITY11 Many would agree that the development of the new European Community over the past 20 or 30 years has largely been a success story in both political and economic terms. Currently, the European Union comprises 15 states, and the hope is that it will expand eastward and add five new countries by 2004. Along with the success of the European Union, however, have come several new challenges associated with the movement of people, capital, and resources, all of which have important implications for the emergence, reemergence, and control of infectious diseases. The effects of 11   This section is based on the workshop presentation by Kurth (2002). The Robert Koch Institute, a German federal institute, performs many of the same tasks carried out by the National Institute of Allergy and Infectious Diseases and CDC in the United States. The Institute conducts basic and applied research and is responsible for surveillance and other aspects of health reporting in both Germany and the European community in general.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary this increased movement on infectious diseases and the manner in which the European Union responds could serve as a model for what might happen or could be done globally in the prevention and control of emerging infectious diseases. That being said, however, the accomplishments of the European community have arguably been more feasible than what will likely be the case in other regions of the world because European countries share common historical, cultural, economic, and religious back-grounds. At the same time, it is important to note that Europe has never intended to create a “United States of Europe.” Rather, the intent is to remain a loose union of states, respecting the different nations’ individual profiles and cultural differences. Movement of People There have been, and will continue to be, large movements of people across the borders within the European Union, as passports were abolished about four years ago. Within the Union, one can settle anywhere and attempt to make a living wherever one chooses. The labor market is free, and people are entitled to a job in any of the Union’s 15 countries. This movement of people creates problems for the border countries, especially those to the south—Italy, Spain, and to a lesser extent Greece—where migrants and refugees from Africa and the Middle East first arrive. At present, as many have seen in the media, boats of refugees are turned back weekly, even though it is usually difficult to recognize where they have come from. Much of this movement is for economic reasons, and the problem is expected only to become worse in the future. Not only is Europe the host of a large immigrant population, but Europeans, and especially Germans, also travel a great deal. Europeans make eight million trips overseas each year, involving 28 million border crossings. Thus, even though Europe is far north of the tropics, many tropical infectious disease killers, such as malaria, yellow fever, dengue, and even hemorrhagic fevers, are being imported on a large scale. In response to this situation, the European Union has established a Europe-wide rapid alert system, which is integrated into a larger worldwide rapid alert network. Movement of Resources The European community has probably been sharing resources on a much greater scale than could ever be achieved at the international level. Much of the current budget of the European Commission, which far exceeds $100 billion annually, is spent on infrastructural aid (e.g., establish-

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary ing new factories and other activities and processes necessary to raise living standards). Before unification, Europe was divided into two economic regions: the poor (e.g., Portugal, southern Spain, Greece, and Ireland) and the rich (especially the areas surrounding Paris, Munich, London, and the Scandinavian countries). Unification has leveled these disparate living standards to some extent; today there is a smaller difference between the poorest and richest regions of Europe compared with poor and rich countries worldwide as described by workshop participants. However, these same infrastructural efforts have also been associated with some negative developments. For example, an attempt was made to lower the cost of agricultural products by subsidizing them to an extent that was unfair to both the United States and developing countries, which generally have very little to sell to Europe except food. Limits to Unification The harmonization and standardization that characterize the unification of Europe have not proceeded without the deleterious influence of national egos. In October 2001, for example, when the consequences of September 11, 2001, were being discussed, there was talk about stockpiling smallpox vaccine. The discussion was terminated after only about 2 hours, however, when it became clear that no European country was prepared to have the stockpile stored or located in a different country. This unwillingness was due to apprehension that, should a crisis arise, the country with the stockpile would not deliver it as quickly as possible or as needed and agreed upon. The final decision was that each country had to have its own stockpile. Thus there are limits to globalization, even on the European scale. REFERENCES Acheson D. 2002 (April 16). Globalization of the Food Supply. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Barry M. 2002 (April 16). Considering the Resources and Capacity for the Response. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Cash R. 2002 (April 16). Impediments to Global Surveillance and Open Reporting of Infectious Diseases. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Cetron M. 2002 (April 16). The World and Its Moving Parts. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Corber S. 2002 (April 16). A Response to the Shifting Trends. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Demin A. 2002 (April 16). Social Aspects of Public Health Challenges in a Period of Globalization: The Case of Russia. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Freedman DO, Kozarsky PE, Weld LH, Cetron MS. 1999. GeoSentinel: The global emerging infections sentinel network of the International Society of Travel Medicine. J Travel Med 6(2):94–98. Gardner P. 2002 (April 17). New Directions in Capacity Building. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Gordon D. 2002 (April 16). The Global Infectious Disease Threat. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Grondin D. 2002 (April 16). Global Migration and Infectious Diseases. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Heyman D. 2002 (April 16). Invited Discussion: Response to the Shifting Trends. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. IOM (Institute of Medicine). 2000. Ending Neglect: The Elimination of Tuberculosis in the United States. Washington, D.C.: National Academy Press. Jaramillo E. 2002. DOTS-Plus & the Green Light Committee. Presentation at “Meet the Expert” Session of the 33rd IUATLD World Conference on Lung Health, Montreal, Canada. Palais de Congres. WHO/CDS/STB/TBS. October 6–10. Kimball AM. 2002 (April 16). Considering the Resources and Capacity for the Response. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Kurth R. 2002 (April 17). The Global Application of Tools, Technology, and Knowledge to Counter the Consequences of Infectious Diseases: A Discussion of Priorities and Options. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Leaning J. 2002 (April 16). Health, Human Rights, and Humanitarian Assistance: The Medical and Public Health Response to Crisis and Disasters. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary LeDuc J. 2002 (April 17). The Global Application of Tools, Technology, and Knowledge to Counter the Consequences of Infectious Diseases: A Discussion of Priorities and Options. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Miller J. 2002 (April 16). A Response to the Shifting Trends. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Monitoring the AIDS Pandemic Network. 2000 (July 9–14). The Status and Trends of the HIV/AIDS Epidemic in the World Symposium of the XIII International AIDS Conference. Washington, D.C.: Monitoring the AIDS Pandemic Network. Mukadi YD, Maher D, Harries A. 2001 (Jan 26). Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharan Africa. AIDS 15(2):143–152. Netesov SV. 2002 (April 17). The Current Situation and Perspectives of International Collaboration in the Field of Biomedical Sciences: The Example of the State Research Center of Virology and Biotechnology, VECTOR. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Netesov SV, Conrad JL. 2001. Emerging infectious diseases in Russia, 1990–1999. Emerg Infect Dis 7(1):1–5. Erratum in: Emerg Infect Dis 7(3):491. NIC (National Intelligence Council). 2000 (December). Global Trends 2015: A Dialogue About the Future with Nongovernment Experts. Washington, D.C.: CIA. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2002. AIDS Epidemic Update. UNAIDS/02.46E. Geneva, Switzerland: WHO. UNAIDS and WHO. 2001. AIDS Epidemic Update: December 2001. UNAIDS/01.74E-WHO/ CDS/NCS/2001.2. Geneva, Switzerland: UNAIDS/WHO. Weis SE, Moonan PK, Pogoda JM, Turk L, King B, Freeman-Thompson S, Burgess G. 2001. Tuberculosis in the foreign-born population of Tarrant County, Texas by immigration status. Am J Respir Crit Care Med 164(6):953–957. WHO (World Health Organization). 2001a. Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections, Overview and Estimates. Geneva, Switzerland: WHO. WHO. 2001b. World Health Report 2001: Global Tuberculosis Control. Geneva, Switzerland: WHO. WHO. 2002a. Coordinates 2002—Charting Progress against AIDS, TB, and Malaria. [Online]. Available: http://www.who.int/infectious-disease-news/ [accessed July 27, 2005]. WHO. 2002b. Tuberculosis. [Online]. Available: http://www.who.int/mediacentre/factsheets/who104/en/index.html [accessed July 27, 2005].