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Mapping
the Global Future
Global
Trends
2015
Global
Trends
2010
Special
Products
Conference
Reports
Research
Supported by
the NIC
The
Global Infectious Disease Threat and
Its Implications for the United States
January
2000
The
Estimate was produced under the auspices of David F. Gordon,
National Intelligence Officer for Economics and Global
Issues. The primary drafters were Lt. Col. (Dr.) Don Noah
of the Armed Forces Medical Intelligence Center and George
F. of the NIC. The Estimate also benefited from a conference
on infectious diseases held jointly with the State Department's
Bureau of Intelligence and Research, and was reviewed
by several prominent epidemiologists and other health
experts in and outside the US Government. We hope that
it will further inform the debate about this important
subject. Comments and inquiries may be directed to:
DR.
GORDON
NATIONAL INTELLIGENCE
COUNCIL
Washington, DC 20505
John
C. Gannon
Chairman, National Intelligence Council
A
full version PDF file has been provided 
Preface
I am pleased
to share with you this unclassified version of a new National
Intelligence Estimate on the reemergence of the threat
from infectious diseases worldwide and its implications
for the United States.
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.
In June 1996,
President Clinton issued a Presidential Decision Directive
calling for a more focused US policy on infectious diseases.
The State Department's Strategic Plan for International
Affairs lists protecting human health and reducing the
spread of infectious diseases as US strategic goals, and
Secretary Albright in December 1999 announced the second
of two major U.S. initiatives to combat HIV/AIDS. The
unprecedented UN Security Council session devoted exclusively
to the threat to Africa from HIV/AIDS in January 2000
is a measure of the international community's concern
about the infectious disease threat.
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. It then assesses
the infectious disease threat from international sources
to the United States; to US military personnel overseas;
and to regions in which the United States has or may develop
significant equities.
Key
Judgments
New and reemerging
infectious diseases will pose a rising global health threat
and will complicate US and global security over the next
20 years. These diseases will endanger US citizens at
home and abroad, threaten US armed forces deployed overseas,
and exacerbate social and political instability in key
countries and regions in which the United States has significant
interests.
Infectious
diseases are a leading cause of death, accounting for
a quarter to a third of the estimated 54 million deaths
worldwide in 1998. The spread of infectious diseases results
as much from changes in human behavior--including lifestyles
and land use patterns, increased trade and travel, and
inappropriate use of antibiotic drugs--as from mutations
in pathogens.
Twenty well-known
diseases--including tuberculosis (TB), malaria, and
cholera--have reemerged or spread geographically since
1973, often in more virulent and drug-resistant forms.
At least
30 previously unknown disease agents have been identified
since 1973, including HIV, Ebola, hepatitis C, and Nipah
virus, for which no cures are available.
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. Acute lower respiratory infections--including
pneumonia and influenza--as well as diarrheal diseases
and measles, appear to have peaked at high incidence
levels.
Impact
Within the United States
Although
the infectious disease threat in the United States
remains relatively modest as compared to that of
noninfectious diseases, the trend is up. Annual
infectious disease-related death rates in the United
States have nearly doubled to some 170,000 annually
after reaching an historic low in 1980. Many infectious
diseases--most recently, the West Nile virus--originate
outside US borders and are introduced by international
travelers, immigrants, returning US military personnel,
or imported animals and foodstuffs. In the opinion
of the US Institute of Medicine, the next major
infectious disease threat to the United States may
be, like HIV, a previously unrecognized pathogen.
Barring that, the most dangerous known infectious
diseases likely to threaten the United States over
the next two decades will be HIV/AIDS, hepatitis
C, TB, and new, more lethal variants of influenza.
Hospital-acquired infections and foodborne illnesses
also will pose a threat.
Although
multidrug therapies have cut HIV/AIDS
deaths by two-thirds to 17,000 annually since 1995,
emerging microbial resistance to such drugs and continued
new infections will sustain the threat.
Some 4 million
Americans are chronic carriers of the hepatitis
C virus, a significant cause of liver cancer
and cirrhosis. The US death toll from the virus may
surpass that of HIV/AIDS in the next five years.
TB,
exacerbated by multidrug resistant strains and HIV/AIDS
co-infection, has made a comeback. Although a massive
and costly control effort is achieving considerable
success, the threat will be sustained by the spread
of HIV and the growing number of new, particularly illegal,
immigrants infected with TB.
Influenza
now kills some 30,000 Americans annually, and epidemiologists
generally agree that it is not a question of whether,
but when, the next killer pandemic will occur.
Highly virulent
and increasingly antimicrobial resistant pathogens,
such as Staphylococcus aureus, are major sources
of hospital-acquired infections that kill some 14,000
patients annually.
The doubling
of US food imports over the last five years is one of
the factors contributing to tens of millions of foodborne
illnesses and 9,000 deaths that occur annually,
and the trend is up.
Regional
Trends
Developing
and former communist countries will continue to
experience the greatest impact from infectious diseases--because
of malnutrition, poor sanitation, poor water quality,
and inadequate health care--but developed countries
also will be affected:
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.
Asia
and the Pacific, where multidrug resistant TB, malaria,
and cholera are rampant, is likely to witness a dramatic
increase in infectious disease deaths, largely driven
by the spread of HIV/AIDS in South and Southeast Asia
and its likely spread to East Asia. By 2010, the region
could surpass Africa in the number of HIV infections.
The former
Soviet Union (FSU) and, to a lesser extent, Eastern
Europe also are likely to see a substantial increase
in infectious disease incidence and deaths. In the FSU
especially, the steep deterioration in health care and
other services owing to economic decline has led to
a sharp rise in diphtheria, dysentery, cholera, and
hepatitis B and C. TB has reached epidemic proportions
throughout the FSU, while the HIV-infected population
in Russia alone could exceed 1 million by the end of
2000 and double yet again by 2002.
Latin
American countries generally are making progress
in infectious disease control, including the eradication
of polio, but uneven economic development has contributed
to widespread resurgence of cholera, malaria, TB, and
dengue. These diseases will continue to take a heavy
toll in tropical and poorer countries.
The Middle
East and North Africa region has substantial TB
and hepatitis B and C prevalence, but conservative social
mores, climatic factors, and the high level of health
spending in the oil-producing states tend to limit some
globally prevalent diseases, such as HIV/AIDS and malaria.
The region has the lowest HIV infection rate among all
regions, although this is probably due in part to above-average
underreporting because of the stigma associated with
the disease in Muslim societies.
Western
Europe faces threats from several infectious diseases,
such as HIV/AIDS, TB, and hepatitis B and C, as well
as from several economically costly zoonotic diseases
(that is, those transmitted from animals to humans).
The region's large volume of travel, trade, and immigration
increases the risks of importing diseases from other
regions, but its highly developed health care system
will limit their impact.
Response
Capacity
Development
of an effective global surveillance and response
system probably is at least a decade or more away,
owing to inadequate coordination and funding at
the international level and lack of capacity, funds,
and commitment in many developing and former communist
states. Although overall global health care capacity
has improved substantially in recent decades, the
gap between rich and poorer countries in the availability
and quality of health care, as illustrated by a
typology developed by the Defense Intelligence Agency's
Armed Forces Medical Intelligence Center (AFMIC),
is widening.
Alternative
Scenarios
We have examined
three plausible scenarios for the course of the infectious
disease threat over the next 20 years:
Steady Progress
The least likely scenario projects steady progress whereby
the aging of global populations and declining fertility
rates, socioeconomic advances, and improvements in health
care and medical breakthroughs hasten movement toward
a "health transition" in which such noninfectious diseases
as heart disease and cancer would replace infectious diseases
as the overarching global health challenge. We believe
this scenario is unlikely primarily because it gives inadequate
emphasis to persistent demographic and socioeconomic challenges
in the developing countries, to increasing microbial resistance
to existing antibiotics, and because related models have
already underestimated the force of major killers such
as HIV/AIDS, TB, and malaria.
Progress
Stymied
A more pessimistic--and more plausible--scenario projects
little or no progress in countering infectious diseases
over the duration of this Estimate. Under this scenario,
HIV/AIDS reaches catastrophic proportions as the virus
spreads throughout the vast populations of India, China,
the former Soviet Union, and Latin America, while multidrug
treatments encounter microbial resistance and remain prohibitively
expensive for developing countries. Multidrug resistant
strains of TB, malaria, and other infectious diseases
appear at a faster pace than new drugs and vaccines, wreaking
havoc on world health. Although more likely than the "steady
progress" scenario, we judge that this scenario also is
unlikely to prevail because it underestimates the prospects
for socioeconomic development, international collaboration,
and medical and health care advances to constrain the
spread of at least some widespread infectious diseases.
Deterioration,
Then Limited Improvement
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.
Economic,
Social, and Political Impact
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,
especially in the worst case scenario outlined above:
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.
Implications
for US National Security
As a major
hub of global travel, immigration, and commerce with wide-ranging
interests and a large civilian and military presence overseas,
the United States and its equities abroad will remain
at risk from infectious diseases.
Emerging
and reemerging infectious diseases, many of which are
likely to continue to originate overseas, will continue
to kill at least 170,000 Americans annually. Many more
could perish in an epidemic of influenza or yet-unknown
disease or if there is a substantial decline in the
effectiveness of available HIV/AIDS drugs.
Infectious
diseases are likely to continue to account for more
military hospital admissions than battlefield injuries.
US military personnel deployed at NATO and US bases
overseas, will be at low-to-moderate risk. At highest
risk will be US military forces deployed in support
of humanitarian and peacekeeping operations in developing
countries.
The infectious
disease burden will weaken the military capabilities
of some countries--as well as international peacekeeping
efforts--as their armies and recruitment pools experience
HIV infection rates ranging from 10 to 60 percent. The
cost will be highest among officers and the more modernized
militaries in Sub-Saharan Africa and increasingly among
FSU states and possibly some rogue states.
Infectious
diseases are likely to slow socioeconomic development
in the hardest-hit developing and former communist countries
and regions. This will challenge democratic development
and transitions and possibly contribute to humanitarian
emergencies and civil conflicts.
Infectious
disease-related embargoes and restrictions on travel
and immigration will cause frictions among and between
developed and developing countries.
The probability
of a bioterrorist attack against US civilian and military
personnel overseas or in the United States also is likely
to grow as more states and groups develop a biological
warfare capability. Although there is no evidence that
the recent West Nile virus outbreak in New York City
was caused by foreign state or nonstate actors, the
scare and several earlier instances of suspected bioterrorism
showed the confusion and fear they can sow regardless
of whether or not they are validated.
Figure
1
Leading Causes of Death, 1998
Discussion
Patterns
of Infectious Diseases
Broad
advances in controlling or eradicating a growing
number of infectious diseases--such as tuberculosis
(TB), malaria, and smallpox--in the decades after
the Second World War fueled hopes that the global
infectious disease threat would be increasingly
manageable. Optimism regarding the battle against
infectious diseases peaked in 1978 when the United
Nations (UN) member states signed the "Health for
All 2000" accord, which predicted that even the
poorest nations would undergo a health transition
before the millennium, whereby infectious diseases
no longer would pose a major danger to human health.
As recently as 1996, a World Bank/World Health Organization
(WHO)-sponsored study by Christopher J.L. Murray
and Alan D. Lopez projected a dramatic reduction
in the infectious disease threat. This optimism,
however, led to complacency and overlooked the role
of such factors as expanded trade and travel and
growing microbial resistance to existing antibiotics
in the spread of infectious diseases. Today:
Infectious
diseases remain a leading cause of death (see figure
1). Of the estimated 54 million deaths worldwide in
1998, about one-fourth to one-third were due to infectious
diseases, most of them in developing countries and among
children globally.
Infectious
diseases accounted for 41 percent of the global disease
burden measured in terms of Disability-Adjusted Life
Years (DALYS) that gauge the impact of both deaths and
disabilities, as compared to 43 percent for noninfectious
diseases and 16 percent for injuries.
Although
there has been continuing progress in controlling some
vaccine-preventable childhood diseases such as polio,
neonatal tetanus, and measles, a White House-appointed
interagency working group identified at least 29 previously
unknown diseases that have appeared globally since 1973,
many of them incurable, including HIV/AIDS, Ebola hemorrhagic
fever, and hepatitis C. Most recently, Nipah encephalitis
was identified. Twenty well-known diseases such as malaria,
TB, cholera, and dengue have rebounded after a period
of decline or spread to new regions, often in deadlier
forms (see table 1).
These trends
are reflected in the United States as well, where annual
infectious disease deaths have nearly doubled to some
170,000 since 1980 after reaching historic lows that
year, while new and existing pathogens, such as HIV
and West Nile virus, respectively, continue to enter
US borders.
Source:
US Institute of Medicine, 1997; WHO, 1999.
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 (see figure 2).
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. HIV/AIDS probably
will cause more deaths than any other single infectious
disease worldwide by 2020 and may account for up
to one-half or more of infectious disease deaths
in the developing world alone.
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 due to a lack of adequate
medical and administrative personnel, the stigma associated
with many diseases, or the reluctance of countries to
incur the trade, tourism, and other losses that such revelations
might produce. 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. Changes in methodologies, moreover,
can produce differing results. The ranking of AIDS mortality
ahead of TB mortality in figure 2, for example, partly
owes to the fact that HIV-positive individuals dying of
TB were included in the AIDS mortality category in the
most recent WHO survey.
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.
Glossary
Infectious
Disease
An illness due to a specific infectious agent that
is spread from an infected person, animal, or inanimate
reservoir to a susceptible host, either directly or indirectly,
through an intermediate plant or animal host, vector,
or the inanimate environment.
Endemic
The constant presence of a disease or infectious agent
within a given geographic area.
Epidemic
The occurrence in an area of a disease or illness in
excess of what may be expected on the basis of past experience
for a given population (in the case of a new disease,
such as AIDS, any occurrence may be considered "epidemic").
Pandemic
A worldwide epidemic affecting an exceptionally
high proportion of the global population.
Prevalence
The number of existing cases of a disease among a total
or specified population in a given period of time; usually
expressed as a percent or as the number of cases per thousand,
10,000, and so forth.
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.
Hepatitis
B and C. Hepatitis B, which caused at least 0.6
million deaths in 1997, is highly endemic in the developing
world, and some 350 million people worldwide are chronic
carriers (see figure 6). The less prevalent but far more
lethal hepatitis C identified in 1989 has grown dramatically
and is a significant contributor to cirrhosis and liver
cancer. WHO estimated that 3 percent of the global population
was infected with the hepatitis C virus by 1997 (see figure
7), which means that more than 170 million people were
at risk of developing the diseases associated with this
virus. Various studies project that up to 25 percent of
people with chronic hepatitis B and C will die of cirrhosis
of the liver and liver cancer over the next 20 to 30 years.
Lower
respiratory infections, especially influenza and
pneumonia, killed 3.5 million people in 1998, most of
them children in developing countries, down from 4.1 million
in 1993. Owing to immunosuppression from malnutrition
and growing microbial resistance to commonly used drugs
such as penicillin, these children are especially vulnerable
to such diseases and will continue to experience high
death rates.
Figure
2
Leading Infectious Disease Killers, 1998
Diarrheal
diseases--mainly spread by contaminated water
or food--accounted for 2.2 million deaths in 1998, as
compared to 3 million in 1993, of which about 60 percent
occurred among children under five years of age in developing
countries. The most common cause of death related to diarrheal
diseases is infection with Escherichia coli. Other
diarrheal diseases include cholera, dysentery, and rotaviral
diarrhea, prevalent throughout the developing world and,
more recently, in many former communist states. Such waterborne
and foodborne diseases will remain highly prevalent in
these regions in the absence of improvements in water
quality and sanitation.
Figure
3
Global HIV/AIDS Prevalence, 1998
Figure 4
Estimated TB Incidence, 1997 Figure
5
Malaria-Endemic Regions, 1997
Figure 6
Estimated Hepatitis B Prevalence, 1997
Measles.
Despite substantial progress against measles in
recent years, the disease still infects some 42
million children annually and killed about 0.9 million
in 1998, down from 1.2 million in 1993. It is a
leading cause of death among refugees and internally
displaced persons during complex humanitarian emergencies.
Measles will continue to pose a major threat in
developing countries (see figure 8), particularly
Sub-Saharan Africa, until the still relatively low
vaccination rates are substantially increased. It
also will continue to cause periodic epidemics in
areas such as South America with higher, but still
inadequate, vaccination rates.
Factors
Affecting Growth and Spread
With few exceptions,
the resurgence of the infectious disease threat is due
as much to dramatic changes in human behavior and broader
social, economic, and technological developments as to
mutations in pathogens (see table 2). Changes in human
behavior include population dislocations, living styles,
and ual practices; technology-driven medical procedures
entailing some risks of infection; and land use patterns.
They also include rising international travel and commerce
that hasten the spread of infectious diseases; inappropriate
use of antibiotics that leads to the development of microbial
resistance; and the breakdown of public health systems
in some countries owing to war or economic decline. In
addition, climate changes enable diseases and vectors
to expand their range. Several of these factors interact,
exacerbating the spread of infectious diseases.
Source: Adapted from US Institute of Medicine, 1997.
Human Demographics and Behavior
Population growth and urbanization, particularly
in the developing world, will continue to facilitate
the transfer of pathogens among people and regions.
Frequent and often sudden population movements within
and across borders caused by ethnic conflict, civil
war, and famine will continue to spread diseases
rapidly in affected areas, particularly among refugees.
As of 1999, there were some 24 major humanitarian
emergencies worldwide involving at least 35 million
refugees and internally displaced people. Refugee
camps, found mainly in Sub-Saharan Africa and the
Middle East, facilitate the spread of TB, HIV, cholera,
dysentery, and malaria. Well over 120 million people
lived outside the country of their birth in 1998,
and millions more will emigrate annually, increasing
the spread of diseases globally. Behavioral patterns,
such as unprotected with multiple partners and
intravenous drug use, will remain key factors in
the spread of HIV/AIDS.
Figure
7
Estimated Hepatitus C Prevalence, 1998
Figure 8
Reported Measles Incidence Rates, 1996
Technology,
Medicine, and Industry
Although technological breakthroughs will greatly facilitate
the detection, diagnosis, and control of certain infectious
and noninfectious illnesses, they also will introduce
new dangers, especially in the developed world where they
are used extensively. Invasive medical procedures will
result in a variety of hospital-acquired infections, such
as Staphylococcus aureus. The globalization of
the food supply means that nonhygienic food production,
preparation, and handling practices in originating countries
can introduce pathogens endangering foreign as well as
local populations. Disease outbreaks due to Cyclospora
spp, Escherichia coli, and Salmonella spp.
in several countries, along with the emergence, primarily
in Britain, of Bovine Spongiform Encephalopathy, or "mad
cow" disease, and the related new variant Creutzfeldt-Jakob
disease (nvCJD) affecting humans, result from such food
practices.
Economic
Development and Land Use
Changes in land and water use patterns will remain major
factors in the spread of infectious diseases. The emergence
of Lyme disease in the United States and Europe has been
linked to reforestation and increases in the deer tick
population, which acts as a vector, while conversion of
grasslands to farming in Asia encourages the growth of
rodent populations carrying hemorrhagic fever and other
viral diseases. Human encroachment on tropical forests
will bring populations into closer proximity with insects
and animals carrying diseases such as leishmaniasis, malaria,
and yellow fever, as well as heretofore unknown and potentially
dangerous diseases, as was the case with HIV/AIDS. Close
contact between humans and animals in the context of farming
will increase the incidence of zoonotic diseases--those
transmitted from animals to humans. Water management efforts,
such as dambuilding, will encourage the spread of water-breeding
vectors such as mosquitoes and snails that have contributed
to outbreaks of Rift Valley fever and schistosomiasis
in Africa.
International
Travel and Commerce
The increase in international air travel, trade, and tourism
will dramatically increase the prospects that infectious
disease pathogens such as influenza--and vectors such
as mosquitoes and rodents--will spread quickly around
the globe, often in less time than the incubation period
of most diseases. Earlier in the decade, for example,
a multidrug resistant strain of Streptococcus pneumoniae
originating in Spain spread throughout the world in a
matter of weeks, according to the director of WHO's infectious
disease division. The cross-border movement of some 2
million people each day, including 1 million between developed
and developing countries each week, and surging global
trade ensure that travel and commerce will remain key
factors in the spread of infectious diseases.
Note: Antimicrobial resistance occurs when a disease-carrying
microbe (bacteria, virus, parasite, or fungus) is
no longer affected by a drug that previously was
able to kill the microbe or prevent it from growing.
Even among populations of microorganisms that are
susceptible to a particular antimicrobial agent,
at least a small percentage of those organisms are
naturally resistant, and their proportion will grow
as the others succumb to the antimicrobial agent.
Eventually this process renders the agent ineffective
against the microorganism.
Source: US Institute of Medicine,
1997; WHO, 1999.
Microbial Adaptation and Resistance
Infectious disease microbes are constantly evolving,
oftentimes into new strains that are increasingly
resistant to available antibiotics. As a result,
an expanding number of strains of diseases--such
as TB, malaria, and pneumonia--will remain difficult
or virtually impossible to treat. At the same time,
large-scale use of antibiotics in both humans and
livestock will continue to encourage development
of microbial resistance. The firstline drug treatment
for malaria is no longer effective in over 80 of
the 92 countries where the disease is a major health
problem. Penicillin has substantially lost its effectiveness
against several diseases, such as pneumonia, meningitis,
and gonorrhea, in many countries. Eighty percent
of Staphylococcus aureus isolates in the
United States, for example, are penicillin-resistant
and 32 percent are methicillin-resistant. A US Centers
for Disease Control and Prevention (USCDC) study
found a 60-fold increase in high-level resistance
to penicillin among one group of Streptococcus
pneumoniae cases in the United States and significant
resistance to multidrug therapy as well. Influenza
viruses, in particular, are particularly efficient
in their ability to survive and genetically change,
sometimes into deadly strains. HIV also displays
a high rate of genetic mutation that will present
significant problems in the development of an effective
vaccine or new, affordable therapies.
Breakdown in Public Health Care
Alone or in combination, war and natural disasters,
economic collapse, and human complacency are causing
a breakdown in health care delivery and facilitating
the emergence or reemergence of infectious diseases.
While Sub-Saharan Africa is the area currently most
affected by these factors, economic problems in
Russia and other former communist states are creating
the context for a large increase in infectious diseases.
The deterioration of basic health care services
largely accounts for the reemergence of diphtheria
and other vaccine-preventable diseases, as well
as TB, as funds for vaccination, sanitation, and
water purification have dried up. In developed countries,
past inroads against infectious diseases led to
a relaxation of preventive measures such as surveillance
and vaccination. Inadequate infection control practices
in hospitals will remain a major source of disease
transmission in developing and developed countries
alike.
Climate Change
Climatic shifts are likely to enable some diseases
and associated vectors--particularly mosquito-borne
diseases such as malaria, yellow fever, and dengue--to
spread to new areas. Warmer temperatures and increased
rainfall already have expanded the geographic range
of malaria to some highland areas in Sub-Saharan
Africa and Latin America and could add several million
more cases in developing country regions over the
next two decades. The occurrence of waterborne diseases
associated with temperature-sensitive environments,
such as cholera, also is likely to increase.
Regional
Trends and Response Capacity
The overall level of global health care capacity
has improved substantially in recent decades, but
in most poorer countries the availability of various
types of health care--ranging from basic pharmaceuticals
and postnatal care to costly multidrug therapies--remains
very limited. Almost all research and development
funds allocated by developed country governments
and pharmaceutical companies, moreover, are focused
on advancing therapies and drugs relevant to developed
country maladies, and those that are relevant to
developing country needs usually are beyond their
financial reach. This is generating a growing controversy
between rich and poorer nations over such issues
as intellectual property rights, as some developing
countries seek to meet their pharmaceutical needs
with locally produced generic products. Malnutrition,
poor sanitation, and poor water quality in developing
countries also will continue to add to the disease
burden that is overwhelming health care infrastructures
in many countries. So too, will political instability
and conflict and the reluctance of many governments
to confront issues such as the spread of HIV/AIDS.
A global composite measure of health care infrastructure
devised by DIA's Armed Forces Medical Intelligence
Center (AFMIC) assesses factors such as the priority
attributed to health care, health expenditures,
the quality of health care delivery and access to
drugs, and the extent of surveillance and response
systems. The AFMIC typology highlights the disparities
in health care capacity (see figure 9), as do various
WHO, UNAIDS, and World Bank studies.
Sub-Saharan Africa
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.
Figure
9
Typology of Countries by Health Care Status
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 s 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. Sub-Saharan
Africa also suffers from yellow fever, while trypanasomiasis
or "sleeping sickness" is making a comeback in the
DROC and Sudan, and the Marburg virus also appeared
in DROC for the first time in 1998. Ebola hemorrhagic
fever strikes sporadically in countries such as
the DROC, Gabon, Cote d'Ivoire, and Sudan (see figure
11).
Asia and the Pacific
Although the more developed countries of Asia and
the Pacific, such as Japan, South Korea, Australia,
and New Zealand, have strong records in combating
infectious diseases, infectious disease prevalence
in South and Southeast Asia is almost as high as
in Sub-Saharan Africa. The health care delivery
system of the Asia and Pacific region--the majority
of which is privately financed--is particularly
vulnerable to economic downturns even though this
is offset to some degree by much of the region's
reliance on traditional medicine from local practitioners.
According to the AFMIC typology, 90 to 100 percent
of the populations in the most developed countries,
such as Japan and Australia, have access to high-quality
health care. Forty to 50 percent have such access
among the large populations of China and South Asia,
while southeast Asian health care is more varied,
with less than 40 percent enjoying such access in
Burma and Cambodia, and 50 to 70 percent in Thailand,
Malaysia, and the Philippines. In South and Southeast
Asia, reemergent diseases such as TB, malaria, cholera,
and dengue fever are rampant, while HIV/AIDS, after
a late start, is growing faster than in any other
region.
TB caused 1 million deaths in the Asia and Pacific
region in 1998, more than any other single disease,
with India and China accounting for two-thirds of
the total. Several million new cases occur annually--most
in India, China and Indonesia--representing as much
as 40 percent of the global TB burden. HIV/AIDS
is increasing dramatically, especially in India,
which leads the world in absolute numbers of HIV/AIDS
infections, estimated at 3-5 million. China is better
off than most of the countries to its south, but
it too has a growing AIDS problem, with HIV infections
variously estimated at 0.1-0.4 million and spreading
rapidly. Regionwide, the number of people infected
with HIV could overtake Sub-Saharan Africa in absolute
numbers before 2010.
Figure
10
Malaria Mortality Annual Rates Since 1900
There were 19.5 million new malaria infections
estimated in the Asia and Pacific region in 1998,
many of them drug resistant, and 100,000 deaths
due to malaria. Acute respiratory infections, such
as pneumonia, cause about 1.8 million childhood
deaths annually--over half of them in India--while
dengue (including dengue hemorrhagic fever/dengue
shock syndrome) outbreaks have spread throughout
the region in the last five years. Waterborne illnesses
such as dysentery and cholera also take a heavy
toll in poor and crowded areas. Asian, particularly
Chinese, agricultural practices place farm animals,
fowl, and humans in close proximity and have long
facilitated the emergence of new strains of influenza
that cause global pandemics. Hepatitis B is widely
prevalent in the region, while hepatitis C is prevalent
in China and in parts of southeast Asia. In 1999
the newly recognized Nipah virus spread throughout
pig populations in Malaysia, causing more than 100
human deaths there and a smaller number in nearby
Singapore.
Figure
11
Health care workers take a rest during the outbreak
of Ebola hemorrhagic fever in Zaire, now the Democratic
Republic of the Congo, in 1995, Eighty percent of
those who become ill died.
Latin America
Latin American countries are making considerable
progress in infectious disease control, including
the eradication of polio and major reductions in
the incidence and death rates of measles, neonatal
tetanus, some diarrheal diseases, and acute respiratory
infections. Nonetheless, infectious diseases are
still a major cause of illness and death in the
region, and the risk of new and reemerging diseases
remains substantial. Widening income disparities,
periodic economic shocks, and rampant urbanization
have disrupted disease control efforts and contributed
to widespread reemergence of cholera, malaria, TB,
and dengue, especially in the poorer Central American
and Caribbean countries and in the Amazon basin
of South America. According to the AFMIC typology,
Latin America's health care capacity is substantially
more advanced than that of Sub-Saharan Africa and
somewhat better than mainland Asia's, with 70 to
90 percent of populations having access to basic
health care in Chile, Costa Rica, and Cuba on the
upper end of the scale. Less than 50 percent have
such access in Haiti, most of Central America, and
the Amazon basin countries, including the rural
populations in Brazil.
Cholera reemerged with a vengeance in the region
in 1991 for the first time in a century with 400,000
new cases, and while dropping to 100,000 cases in
1997, it still comprises two-thirds of the global
cholera burden. TB is a growing problem regionwide,
especially in Brazil, Peru, Argentina, and the Dominican
Republic where drug-resistant cases also are on
the rise. Haiti does not provide data but probably
also has a high infection rate. HIV/AIDS also is
spreading rapidly, placing Latin America third behind
Sub-Saharan Africa and Asia in HIV prevalence. Prevalence
is high in Brazil and especially in the Caribbean
countries (except Cuba), where 2 percent of the
population is infected. Malaria is prevalent in
the Amazon basin. Dengue reemerged in the region
in 1976, and outbreaks have taken place in the last
few years in most Caribbean countries and parts
of South America. Hepatitis B and C prevalence is
greatest in the Amazon basin, Bolivia, and Central
America, while dengue hemorhagic fever is particularly
prevalent in Brazil, Colombia, and Venezuela. Yellow
fever has made a comeback over the last decade throughout
the Amazon basin, and there have been several recent
outbreaks of gastrointestinal disease attributed
to E. coli infection in Chile and Argentina. Hemorrhagic
fevers are present in almost all South American
countries, and most hantavirus pulmonary syndrome
occurs in the southern cone.
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. Health care capacity varies considerably
within the region, according to the AFMIC typology.
Israel and the Arabian Peninsula states minus Yemen
are in far better shape than Iraq, Iran, Syria,
and most of North Africa. Ninety to 100 percent
of the Israeli population and 70 to 90 percent of
the Saudi population have good access to health
care. Elsewhere, access ranges from less than 40
percent in Yemen to 50 to 70 percent in the smaller
Gulf states, Jordan and Tunisia, while most North
African states fall into the 40- to 50-percent category.
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. TB, including
multidrug resistant varieties, is more problematic,
especially in Iran, Iraq, Yemen, Libya, and Morocco,
with an estimated 140,000 deaths in 1998. Malaria
is significant only in Iran, Iraq, and Yemen, but
diarrheal and childhood diseases caused 0.3 million
deaths each in 1998. Other prominent or reemerging
diseases in the region include all types of hepatitis,
with Egypt reporting the highest prevalence worldwide
of the C variety. Brucellosis now infects some 90,000
people; leishmaniasis and sandfly fever also are
endemic in the region; and various hemorrhagic fevers
occur, as well.
The Former Soviet Union and Eastern Europe
The sharp decline in health care infrastructure
in Russia and elsewhere in the former Soviet Union
(FSU) and, to a lesser extent, in Eastern Europe--owing
to economic difficulties--are causing a dramatic
rise in infectious disease incidence. Death rates
attributed to infectious diseases in the FSU increased
50 percent from 1990 to 1996, with TB accounting
for a substantial number of such deaths. According
to the AFMIC typology, access to health care ranges
from 50 to 70 percent in most European FSU states,
including Russia and Ukraine, and from 40 to 50
percent in FSU states located in Central Asia. This
is generally supported by WHO estimates indicating
that only 50 to 80 percent of FSU citizens had regular
access to essential drugs in 1997, as compared to
more than 95 percent a decade earlier as health
care budgets and government-provided health services
were slashed. Access to health care is generally
better in Eastern Europe, particularly in more developed
states such as Poland, the Czech Republic, and Hungary,
where it ranges from 70 to 90 percent, while only
50 to 70 percent have access in countries such as
Bulgaria and Romania. More than 95 percent of the
population throughout the East European region had
such access in 1987, according to WHO.
Crowded living conditions are among the causes
fueling a TB epidemic in the FSU, especially among
prison populations--while surging intravenous drug
use and rampant prostitution are substantially responsible
for a marked increase in HIV/AIDS incidence. There
were 111,000 new TB infections in Russia alone in
1996, a growing number of them multidrug resistant,
and nearly 25,000 deaths due to TB--numbers that
could increase significantly following periodic
releases of prisoners to relieve overcrowding. The
number of new infections for the entire FSU in 1996
was 188,000, while East European cases totaled 54,000.
More recent data indicate that the TB infection
rate in Russia more than tripled from 1990 to 1998,
with 122,000 new cases reported in 1998 and the
total number of cases expected to reach 1 million
by 2002. After a slow and late start, HIV/AIDS is
spreading rapidly throughout the European part of
the FSU beyond the original cohort of intravenous
drug users, though it is not yet reflected in official
government reporting. An estimated 270,000 people
were HIV-positive in 1998, up more than five-fold
from 1997. Although Ukraine has been hardest hit,
Russia, Belarus, and Moldova have registered major
increases. Various senior Russian Health Ministry
officials predict that the HIV-positive population
in Russia alone could reach 1 million by the end
of 2000 and could reach 2 million by 2002. East
European countries will fare better as renewed economic
growth facilitates recovery of their health care
systems and better enables them to expand preventive
and treatment programs.
Diphtheria reached epidemic proportions in the
FSU in the first half of the decade, owing to lapses
in vaccination. Reported annual case totals grew
from 600 cases in 1989 to more than 40,000 in 1994
in Russia, with another 50,000 to 60,000 in the
rest of the FSU. Cholera and dysentery outbreaks
are occurring with increasing frequency in Russian
cities, such as St. Petersburg and Moscow, and elsewhere
in the FSU, such as in T'bilisi, owing to deteriorating
water treatment and sewerage systems. Hepatitis
B and C, spread primarily by intravenous drug use
and blood transfusions, are on the rise, especially
in the non-European part of the FSU. Polio also
has reappeared owing to interruptions in vaccination,
with 140 new cases in Russia in 1995.
Western Europe
Western Europe faces threats from a number of emerging
and reemerging infectious diseases such as HIV/AIDS,
TB, and hepatitis B and C, as well as several zoonotic
diseases. Its status as a hub of international travel,
commerce, and immigration, moreover, dramatically
increases the risks of importing new diseases from
other regions. Tens of millions of West Europeans
travel to developing countries annually, increasing
the prospects for the importation of dangerous diseases,
as demonstrated by the importation of typhoid in
1999. Some 88 percent of regional population growth
in the first half of the decade was due to immigration;
legal immigrants now comprise about 6 percent of
the population, and illegal newcomers number an
estimated 6 million. Nonetheless, the region's highly
developed health care infrastructure and delivery
system tend to limit the incidence and especially
the death rates of most infectious diseases, though
not the economic costs. Access to high-quality care
is available throughout most of the region, although
governments are beginning to limit some heretofore
generous health benefits, and a growing antivaccination
movement in parts of Western Europe, such as Germany,
is causing a rise in measles and other vaccine-preventable
diseases. The AFMIC typology gives somewhat higher
marks to northern over some southern European countries,
but the region as a whole is ranked in the highest
category, along with North America.
After increasing sharply for most of the 1980s
and 1990s, HIV infections, and particularly HIV/AIDS
deaths, have slowed considerably owing to behavioral
changes among high-risk populations and the availability
and funding for multidrug treatment. Some 0.5 million
people were living with HIV/AIDS in 1998, down slightly
from 510,000 the preceding year, and there were
30,000 new cases and 12,000 deaths, with prevalence
somewhat higher in much of southern Europe than
in the north. TB, especially its multidrug resistant
strains, is on the upswing, as is co-infection with
HIV, particularly in the larger countries, with
some 50,000 TB cases reported in 1996. Hepatitis
C prevalence is growing, especially in southern
Europe. Western Europe also continues to suffer
from several zoonotic diseases, among which is the
deadly new variant Creutzfeldt-Jakob disease (nvCJD),
linked to the bovine spongiform encephalopathy or
"mad cow disease" outbreak in the United Kingdom
in 1995 that has since ebbed following implementation
of strict control measures. Other recent disease
concerns include meningococcal meningitis outbreaks
in the Benelux countries and leishmaniasis-HIV co-infection,
especially in southern Europe.
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.
WHO
WHO has the broadest health mandate under the UN
system, including establishing health priorities,
coordinating global health surveillance, and emergency
assistance in the event of disease outbreaks. Health
experts give WHO credit for major successes, such
as the eradication of smallpox, near eradication
of polio, and substantial progress in controlling
childhood diseases, and in facilitating the expansion
of primary health care in developing countries.
It also has come under criticism for becoming top
heavy, unfocused in its mission, and overly optimistic
in its health projections. WHO defenders blame continued
member state parsimony that has kept WHO's regular
biennial budget to roughly $850 million for several
years and forced it to rely more on voluntary contributions
that often come with strings attached as the cause
of its shortcomings.
The election last year of Gro Harlem Bruntland
as Secretary General, along with a series of reforms,
including expansion of the Emerging and other Communicable
Diseases Surveillance and Control (EMC) Division,
has placed WHO in a better position to revitalize
itself. Internal oversight and transparency have
been expanded, programs and budgets are undergoing
closer scrutiny, and management accountability is
looming larger. Bruntland has moved quickly to streamline
upper-level management and has installed new top
managers, mostly from outside the organization,
including from the private sector. She also is working
to strengthen country offices and to make the regional
offices more responsive to central direction. WHO
is increasing its focus on the fight against resurgent
malaria, while a better-funded EMC is expanding
efforts to establish a global surveillance and response
system in cooperation with UNAIDS, UNICEF, and national
entities such as the US CDC, the US DoD, and France's
Pasteur Institute.
Other
UN Agencies Involved in Health Care
WHO competes
for resources with the many other UN agencies that are
increasingly involved in health care. The United Nations
Children's Fund (UNICEF) focuses on children's health.
The United Nations AIDS Program (UNAIDS) focuses on improving
the response capacity toward HIV/AIDS at the country,
regional, and global levels in cooperation with WHO and
other UN agencies. Other UN agencies involved in health
care issues include the UN Development Program (UNDP);
the UN Family Planning Agency (UNFPA); the UN High Commissioner
for Refugees (UNHCR); the UN Educational, Scientific and
Cultural Organization (UNESCO); the International Labor
Organization (ILO); the Food and Agricultural Organization
(FAO); and the World Food Program (WFP).
The World
Bank
The growing sense that health is linked inexorably
to socioeconomic development, has prompted the World
Bank to expand its health activities. According to
a 1997 study by the US Institute of Medicine, the
most significant change in the global health arena
over the past decade has been the growth in both financial
and intellectual influence of the World Bank, whose
health loans have grown to $2.5 billion annually,
including $800 million for infectious diseases. Health
experts generally welcome the Bank's greater involvement
in the health sector, viewing it as efficient and
responsive in areas such as health sector financial
reform. Some remain concerned that the Bank's emphasis
on fiscal balance can sometimes have a negative health
and social impact in developing countries. Some developing
countries resent what they perceive as the domination
of Bank decisionmaking and priority setting by the
richer countries.
Nongovernmental
Organizations
Another major change in the global health arena over the
last decade is the increasingly important role of NGOs, | |
