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The Globalization of Disease
I N T R O D U C T I O N
Globally, infectious diseases remain the leading killers of human beings' More than- a olr"r.".if r d"rths todav are linked to infectious diseases, with the developing world ficins the brunt of the prlblem. More than 40 million people live with HII and more than "i
million die of 6IDS each year. Infectious diseases-such as malaria, influenza, tuberculosis, dengue, and yellow iever-claim millions of lives in the developing world
"r"t y"rt, -lth tti" very young and the very old being the primary.victims ln the case of AlbS,-more womett are b"l.omiog victims due to poverty, discrimination, violence, raditional values and beliefs aboui women's roles in relation to men's roles, and women,s involvement in survival sex (i.e., having sex to feed their families and to pro- tect themselves from physical abuse and economic deprivation)' Diseased populations are vulnerable to contracting other diseases due to compromised immune systems' For example, many individuals riho suffer from HIV/AIDS die ftom tuberculosis, a highly infectious disease.
The emergence and reemergence and spread of infectious diseases demonstrate both the realiti and the dangers of globalization. As we discuss various infectious dis- eases, it will bicome increasingly obvious that our fate is determined to a large extent by developments that are largely beyond our control, that national boundaries are essentially meaningless, that liuman beings share a comrnon 'lestiny, and that the con- cerns about natioial security are increasingly inseparable from global and human security, or the well-being of ordinary individuals.
Iniectious diseases are intertwined with numerous global issues and are insepara- ble from political, economic, and cultural components of globalization' Ethnic con- flicts make populations n:lnerable to infectious diseases. Fighting contributes to the .oll"ps" of pobli. tewices, which means that many people die ftom what would ordi- narily be triatable diseases, such as diarrhea and respiratory in{ections. Conflics also create refugees, overcrowding, and unsanitary conditions, thereby creating environ- ments conducive to tlte spread of infectious diseases. Many infectious diseases are closely linked to poverty, global inequality, and low levels of economic development' . Environmental degradation and deforestation expose humans to a variety of infectious diseases. ThJy aho contribute to global warming and flooding, which facil- itate the emergence ofinfectious diseases. Rising temperatures in winter enable germs to survive in large numbers' and flooded areas become potent breeding grounds for
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Globalization of Infectious Diseases 297
mosquito-related diseases and cholera. Rapid population growth and urbanization bring more people closer together and into contact with infectious diseases.
Illegal drrg use, especially intravenous drug use, spreads diseases, such as HfV/AIDS.
As we will discuss, AIDS contributes to a growing number of orphans; many of them become street children who are vulnerable to human rraflicking and recruitment into criminal gangs. Finally, trade has long been a major facilitator of the spread of hfec- tious diseases. Consequendy, trade suffers gready when outbreaks occur, as we will see with the spread of SARS in 2003. In many ways, rrade liberalization contributes to the spread of infectious diseases by reducing the role of rnany govemments in providing essential basic health care and other services. Infectious diseases have far-reaching social, economic, demographic, security, and political consequences.
This chapter first examines the globalization of infectious diseases, the concept of human security, and the nature and spread of infectious diseases. Given the global significance and far-reaching consequences of HIV/AIDS, this chapter focuses on AIDS, particularly in Africa. Africa is the epicenter of the AIDS pandemic. Within Africa, South Mrica is the most adversely affected country. This chapter concludes with a discussion of global responses to the growth, persistence, and transmission of infectious diseases.
GLOBALIZATION OF INFECTIOUS DISEASES
Although infectious diseases dominated the daily existence of almost all human soci- eties throughout history the ability ofrich corntries to eliminate many leading diseases diminished global concern and the sense of urgency about eradicating t}le diseases that were concentrated in the developing world. The rapid spread of globalization, especially starting in the 1980s, urderscored links between infectious diseases in poor countries and outbreaks of these diseases in rich countries' The most dramatic devel- opment was the discovery of HIV/AIDS in the United States, Western Europe, and other rich countries. Although perceived initially as a disease limited primarily to homosexuals, HMAIDS began to spread to the general population through blood transfusions, intravenous drug usage, and heterosexual practices. Furthermore, prominent people who were suffering fiom the disease fought to put it on both the domestic and global agendas. By the 1990s, there was a definite shift toward recogniz- ing the globalization of infectious diseases. Many of the diseases tltat were believed to have bein eradicated in rich countries reemerged and were placed on the global agenda. Two factors explain this reemergence: (1) grtwing ruistance to nmn 0n antibi-
otis; arrd Q) the deaana ng i.nt7act ofnnD epidentict.The new epidemics inclrrded cholera in Latin America, particularly in Peru; plague in India; the Ebola virus in Africa;
dengue fever in Asia; West Nile virus in the United States; and bovine spongiform encephalitis (rnad cow disease) in Europe.r
Global Tiaoel and Contmanications Human beings are the most ef&cient transmit- ters ofdiseases. In the past, large proportions ofpopulations were killed by plagues as people traveled to distant places. The Plague ofJustinian, which occurred in 541 A.D., ier,astat"d Europe. In the twelfth and thirteenth centuries, the bubonic plague,
294 CHAPTER 12 The clobalization of Disease
Deadly viral disease lhat originated in South China in 2002
knonn as the Black Death, killed 25 million (or one of every three) Europeans. The decimation of Native American nopulations by Europea" J#.rr", iJ ,""afrer example of how travelers spread infectious dir."r.r. i4;;;'";;;.h A;; and other Asian
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Furtlermore, gradual increases in the earth,s ."-p.rr;;;-4.";;;bal warming) are conducive to the global spread ofdrseases.
Ethnic ConJlicts s.nd Wars Ethnic conflicts, widespread violence, and wars havealways contibuted to the outbreak of disease L"a .ni"-,rr" ,p".'# of infectious dis_
eases. Combat2nts are often more likely to die fiom infectious dir"'Jr"", tt arr fio_
".n "1 fighting. It is estimated that more than *"_.r,ira, ,i*r" irffilti,ooo a""*, i. tt . American Civil War were caused by_infe.,i.* di.*;;. F;ilhl#Jr., .h" _or,"_.r,.
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HUMAN SECURITY AND INFECTIOUS DISEASES
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3OO CHAPTER 12 The Globalization of Disease
UN Millennium Development Goals Four of the goals concenlrale on health-related
assues
Pathogens Organisms capable of causing disease Epidemics When infectious diseases spread to a large number of peoPle
Pandemics Long-lasting.
catastrophic global epidemics Hosts
Organisms that carry diseases Zoonosis
Links between human security and human health were reinforced by anthrax bioterrorism in the United States shortly after the 2001 terrorist attacks and the unrelenting spread of the HIV/AIDS pandemic. These developments are augmented by links between health and economic development on the global agenda, especially the UN Millennium Development Goals. In fact, four of the eight Millennium Goals concentrate on health-related issues. The globalization of infectious diseases threatens buntan security in several ways. Flrrr, diseases kill far more people than wars.
Secozl, disease undermines public confidence in the state, thereby eroding its legiti- macy. Third., disease weakens the economic foundations of human seatrity. Fout"tb, disease pro{oundly affects social order and stabiliry. Fijih, the spread of infectious diseases contributes to regional instability. Sirrl, disease can be used in biowarfare and bioterrorism.8
INFECTIOUS DISEASES
The microbes (such as bacteria), viruses, parasites, and fiurgi that are the agents of infectious diseases are integral components of the nanrral and human enyironments.
Throughout recorded history orr.
"rr."rto.s have been extremely r,'ulnerable to and mosdy defenseless against infebtious diseases. Pathogens (i.e., organisms capable of causing disease) have routinely dernolished societies. In rnany cases, there are outbreaks ofdiseases; that is, essentially localized, endemic occurrences.l44ren infec- tious diseases spread to a relatively large number of people, they are classified as epidernics. Although epidemics generally impact populations worldwide, pandenics are long lasting, catastrophic, and truly global in rJreir consequences. Two factors that have alwals been at the root ofinfectious disease tlreats to human populations are (i) social, economic, and environmental conditions that enable infectious diseases to exist among human hosts; and (2) various means oftransmission to new populations. As our ancestors developed agriculture and rnoved from isolated villages to more densely populated areas, they were exposed to more diseases.9 A.ltering the natural environ- ment enables microbes to infect humans. Humans are infected when they come into contact with naftiral hosts (i.e., organisms that carry diseases). The hosts are not neg- atively affected by the disease. tansmission of hfectious diseases can occur within a single species or from one species to another, Humans often infect other humans, But host animals also infect humans, a transmission known as zoonosis. Infectious dis- eases are transmitted through air, water, direct contact with the host,s bodily fluids, and sexual activity, as well as through vectors, such as mosquitoes and other insects.
Jb better understand contemporary concerns about infectious diseases, we will dis- cuss the problem within the framework of epidemiologic transition theory. Each tansition is characterized by "a unique pattern of diseases that is ultimately related to modes ofsubsistence and social structure."l0 There are basically thru distinct epidemio- logic transitions. The first transition, as we mentioned earlier, occurred when our ancestors established agricultural communities. Think about sanitation problems in permanendy setded areas and the close interaction of humans and their domesdcared animals. Both of $ese sinrations provided favorable environments for the dispersal of infectious diseases. Cattle, goats, sheep, pigs, and fowl transmitted tuberculosis, Transmission of
diseases from host animals to humans First Transition Related to the establishment of agricultural communities
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INFLUENZA AND AVIAN FLU
The spread of H5N1 avian,f$ (bird flu) in 2006 to areas beyond Asia galvanized slobal efforts to prevent ot ottt"ith th" impact of an influenza pandemic' Of all the il"r. -i".i.*:frse"se,, i"flo"n'" demandi the unique and urgent aftention of the
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fifteen hundred microbes known to cause disease in humans' influenza continues to dominate rn terms of overall mortality' Every year' 5 to 1 0 per- i""i
"i *. e--rcan population gets the flu and.atout thirty-six thousand of them die. Even in normal times, an "!ti*at"d 1.5 million.people worldwide die from influenza infections or related tt;;i;;"t each year'* Influenza' which is a viral infection of the respiratory tract, is'very contagious,and poses serious threats to chil-
ffi,;;:iddr;J-all'ra""ri *tr-' io^p'oi''i"d i'''-o''e svstems' It is estimated
that three influenza pandemrcs t" the tte"ti"th century killed more than 50 million
;:#:;#;;"i fl.' p""d"-it of 1918-1920 is generallv regarded as the rnost lethal plagle in history causrng- roughlv 50 million diaths worldwide' Pandemics in
i957 and 1968, whictt o,ig"t"t"o i" dhiira and Hong Kong' together killed more than
lnfluenza and Avian Flu 3Ol
Plague of Justinian Named after the Roman emPeror, it devastated EuroPe around 541 A.D.
Black Death Bubonic Plague that killed roughlY 25 million peoPle throughout EuroPe
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lnfluenza
A contagious viral infection of the respiratory tracr SDanish Flu Most lethal influenza Pandemic
3O2 CHAPTER '12 The Globalization of Disease
Reassort
2.5 million people.ll Given the efficienry with which flu is transmitted through the air, close contact is not required for people to become infected. Furthermore, it is very difiicult to identi!' and quarantine infected people who are spreading the disease.
Throughout the world, large commercial poultry farms, as wellas rhe proliferaion of chickens kept by families, haae proaid,ed id.eal cmditiorc for the aoian Jla to tpread . Futherrnorc, rapid population grorth, especially in fuia, has given rise to densely populated urban areas. For example, during the 1968-1969 influenza pandemic, China had 790 million people and i2.3 rnillion chickens and other poultry. China now has 1.3 billion people and
13 billion chickens.l5 Poultry, pigs, and people living together or in close proximity enhances the transmission of avian flu from animals to humans. Although the avian flu had caused eighty-eight deaths out of a total of 165 cases globally by early 2006, trans- mission from human to human had not occurred. The globai community feared that the virus would undergo changes enabling it to reassort (i.e., mix genes with other human influenza viruses that are also present). This process can produce an entirely new viral strain, capable of sustained human-to-human transmission. If such a virus has never existed, humans will lack immunity and the global population will be rrulnerable to con- tracting the disease. The new strain would be easily transmitted fiom person to person, thereby causing a new pandemic. Approximately 1.7 million Americans would die, and t-here would be rougtrJy 180 mill-ion to J60 million dear-hs globalJy.16
By 2006, humans had been infected in several countries outside Asia, such as Tirrkey, kaq, India, and lran. Dead birds infected with the H5N1 virus have been dis- covered in Russia, Romania, France, Croatia, Austria, Greece, Germany, and Nigeria.
Migratory birds are believed to be primarily responsible for spreading the disease to other birds. The rnigratory route over East Asia overlaps with the Central Asian fly- way, which overlaps with fl1.rvays to Africa and Europe. The deadly form of tie H5N1 strain in Asia had not been found in North and South America, where migratory pat- terns are separate fiom those in Europe, A-fiica, and Asia.17 However, when the H5N1 virus was detected in Nigeria in early 2006, the global community became increas-
ingly concerned about the ability of the virus to spread lrom human to human, given Africa's widespread poverty and the inability of the governments to deal with any health crisis.
Responding to the threat of a pandemic, governments, international organiza- tions, and nongovernmental organizations (NGO$ have concentrated on quarantine and tIe extensive culling of birds in affected areas. European countries were advised by the Animal Production and Health Division of the IJN Food and Agriculture Organization to require travelers to fill out forms detailing their travel history and the agricultural products in their possession, which is the practice in the United States. Increased checks of airline passengers and their belongings are also regarded as effective countermeasures.l S A major obstacle to an effective global response is the weakness of governments and poverty, which will eventually undermine global coop- eration. As we will see, poor countries lack adequate resources to deal with routine health problems, and fighting avian flu is not their principal priority. Within rich countries, governments have allocated resources to develop vaccines, primarily Tamiflu, to deal witl a pandemic, However, even in rich countdes, there is insuffi- cient rnedication for all oftheir inl.rabitants. Furthermore, in 2007 there was a signifi- cant decline in concern about avian flu. Few cases were reported in 2008.
Mutation of viruses that enhance chances of human-to-human transmission of disease
Medicine used to treat patients infected with the avian flu
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MALARIA, DENGUE, AND YELLOW FEVER
&Ialaria, dengue, ar.rd vellow fever are found primarily in d.re Ti-opics and are transmitted bv moscuitoes. These are the most conmon vector-borne diseases The spread of human settlements ar.rd various activities in forested areas have led to increased contact with mosquitoes tltat carry the viruses that cause these diseases. Global transportation and globai warming have enabled these diseases to spread and grow outside tropical areas: Discarded tires, bottles, cans, and other containers that collect water become fer- tile breeding glounds for mosquitoes. Humans contract malaria when bitten by female mosquitoes. Malarial parasites infect red blood cells, causing chills, fever, and often cleath. Of the estimated 100 millior.r to 500 n.rillion people infected with malaria each year, roughll. 1.5 nillion die from the disease.l9 Dengue, a viral disease, is transmitted ty -orq.,ito.t that acquire the virus when they suck blood from an infected person, replicate the r.irus in their s"vstem, and transnit it to dre next person they bite' Dengue is markecl by fever, severe headaches, muscle and bone pain, shock, and fatal hemorrhag- ing. Theie are .o.,ghly 50 million cases of dengue infection worldwide each year':0 Yilow fever is enclemic in Africa, Asia, Lati' America, and several Caribbea' islands lt
is estirnated that thirry thousand people die each year ofyellow fever. Synptoms ir.rclude feveq muscle pain, backaches, headaches, shivering, loss ofappetite, nausea, and vomiting' After a few days most people who are infected improve and their s1'mptoms drsappear'
Pharmaceutical Companies' Role in Fighting
The increasing globalization of infectious diseases h a s c o n t r i b u t e d t o a g r o w i n g a w a r e n e s s o f t h e connectedness among rich and poor countries and the need for increased cooperation between them to deal with these problems. Diseases are closely
l i n k e d t o a v a r i e t y o f g l o b a l c o n c e r n s . i n c l u d i n g malnutrition, inadequate education, poverty. and inequality. Roughly 460 million people are affected b y H I V / A I D S , t u b e r c u l o s i s , a n d m a l a r i a . w h i c h together are responsible for an estimated 5-6 million deaths each year. Although there is an abundance of expensive drugs avallable in wealthy societies, more than a third of the world's population lacks adequate access to essential medications Phar- m a c e u t i c a l c o m p a n i e s a r e p r i m a r i l y c o n c e r n e d with developing drugs that are pro{itable. This means that most medical research focuses over- whelmingly on diseases in rich countries ln 2006,
Bill Gates, chairman of lvlicrosoft. decided to con- centrate less on leading his company and more on working with the Bill and Melinda Gates Founda- tion to find ways to reduce the spread of infectious diseases. Between 1999 and 2006, the Bill and Meiinda Gates Foundation gave $908'5 million to the Global Alliance for Vaccines and lmmunization to fight infectious diseases. During the same period, governments worldwide contributed a t o t a l o f $ 7 9 1 . 5 m i l l i o n . P h a r m a c e u t i c a l c o m p a n i e s have largely resisted providing inexpensive drugs that would cure those suffering from infectious diseases in developing countries.
What policies do you think the global commu- n i t y c o u l d d e v e l o p a n d i m p l e m e n t t o i n f l u e n c e pharmaceutical companies to produce medicines for poor countries?
Source: Erika Check, " Ouesl lor the Cu re," Foreign Policy 155 \JulylAugust 2006)i 28-37'
3O4 CHAPTER 12 The Globalization o{ Disease
Global Malaria Campaign lntensified the use of DDT to control malaria
However, approximately 15 percent of infected individuals erperience a toxic phase, in which they develop jaundice, abdominal pains, bleeding, and kidney failure. Roughly halfofthose who enter the toxic phase die within ten to fourteen days.2l Malaria is by far tlre most pervasive and deadly ofthese three diseases.
Malaria Globally, Africa suffers the most from malaria. More than 90 percent of malaria deaths occur there, despite the relative ease with which the disease can be pre- vented and cured. In many ways, the prevalence of malaria in Afiica is a manifestation of that continent's endemic poverty. Malaria was once believed to be caused by swarnp air. The role that mosquitoes play in transn.ftting the disease vras not discovered until 1898. Several factors have contributed to the increase of malaria in different parts of the world. As popz lation presmres have influenced farmers to cultivate areas bordering on swamps and as agroforestry has grown, mosquitoes have multiplied and have more opportunities to infect humans. The consnnnion of dams and in igation rystems for agri- culture has radically altered the natural environment and provided breeding places for mosquitoes. Natural disasters, such as earthquakes, often destroy sanitation facilities, cause severe flooding, and allow standing water to accumulate in which mosquitoes breed. Finally, global warming is widely believed to be responsible for increased rain- fall and higher temperatures, which can result in flooding. These environmental con- dirions facilirate the spread of malaria.22
Pregnant women and children bear the heaviest burdens. Malaria during preg- nanry threatens the child's development, both in the uterus and as an infant. Mothers who have had limited exposure to malaria parasites and therefore less immuniry are extremely r.'ulnerable during pregnancy when dreir immunity is generally lower. Often, malaria infections cause anemia, which often results in maternal mortality. Malaria usu- ally causes low-birth-weight babies, brain darnage, and cognitive impairment.2l
Efforts to eradicate malaria began in 1898, when the connection between mosqui- toes and the disease was discovered. In addition to draining swamps and removing standing v/ater from arornd homes, insecticides and larvicides were used. Quinine was also used to treat infections. A major breakthrough in fighting malaria came after World War II when DDT was applied. DDT was first used in 1939 as an agricultural insecticide in Switzerland. However, it was during the war that its public health appli- cations were discovered. The Allies had used DDT to control typhus epidemics.
Complete eradication of malaria was achieved in such places as the United States, Southern Europe, Sri Lanka, and much of Brazil by massive DDT spraying.2+ Success in reducing malaria problems influenced the World Health Organization (l4rHO) to initiate its Global Malaria Campaign in 1955 to intensif' the use of DDT to con- trol malaria. Howeveq by the 1960s malaria began to reemerge in countries that had made significant progress in eliminating it because marry countries were unable to continue the highly organized and costly spray program essential for success.
Furthermore, widespread use of DDT engendered resistance to it at a time when more people were becoming aware of its danger to human health and the environ- ment. As we discussed in Chapter 9, the toxicity ofpesticides was stressed by Rachael Carson in her influential book, Se/ezr Spnhg. The WHO adopted a more comprehen- sive approach that included strengthening basic health selvices, focusing on the unique social and economic conditions in each region, and concentrating on treating
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Tuberculosis 3O5
Horizontal Approach
malaria patients. Krown as the horizontal approach, tlis new strategy emphasized control and containment, as opposed to complete eradication.zs This .Lnge *"s doe pardy to limited supplies ofDDT and escalating costs, as efforts to ban the uie of DDT were increasingly successful. Both interest in and funding for malaria control declined during the lS70s. which enabled the disease ro spread.
- Concerned about the proliferation of infectious diseases, the U.S. Agency for International Development (JSAID) in 1997 cooperated with the World Bank, the WHO, and otier international agencies to form the Afiica Initiative for Malaria Control (ALNI). AII,I was expanded to become a more comprehensive global initia_
tive known as Roll Back Malaria (RBM) in 1998. Amajor oblective of tl-re RBM cam_
p a i g r w a s r o r e d u c e m a l a r i a - r e l a t e d m o r r a l i w b v h a l f b r 2 0 I 2 .
The globalization of infectious diseases has contributed to increased global awareness of malaria and has engendered renewed efforts to eradicate it. Furtherlnore, many individuals and NGOs are involved in these efforts. Rotarians worldwide have made eradicating malaria a major goal. In 1993, Drake Zimmerman of the Rotarv Ch,b of Normal, Illinois, played a leading role in distributing bed nets treated with safe insecticides to reduce malaria problems. The emphasis on bed nets was influenced by the growing ineffectiveness and health hazards ofother approaches, such as indoor sprayng and the use ofchloroquine. Other organizations, such as the United Nations Children's Fund (LINICEF), play a leading role in providing bed nets. An insecticide- treated bed net costs around $3. However, even at that pric; many poor families can_
not afford to purchase them. Based on recommendations ofJefirey Sachs, the LrN Secretary General's special adviser on the Millennium DevelopmenjGoals, these bed nets are heavily subsidized or given away. A special initiative to eradicate malaria in Zambia was launched in 2006. Using $35 miliion donated by the Bill and Melinda Gates Foundation, Zambias objective is to provide bed nets io g0 percent ofits pop_
ulation by 2009' An additional $82 million was donated by international organizations and governments to supply the most effective malaria drugs to every publil clinic and to pay for coordinated spraying programs across Zambia.26 Death iaies from malaria declined significantly in 2008 due to increased use of mosquito nets and artemisinin, a new medicine.
TUBERCULOSIS
Lirks between tuberculosis and the HMAIDS pandemic reinvigorated global interest in diminishing the spread ofnrberculosis. The combination of nrberculosis and AIDS is lethal, with each disease contributing to the rapid progress of t}re other. HIV weak- ens the immune system, making it easier for an HlV-positive person to conffact tuber_
culosis. In Afiica, the epicenter of the HIV/AIDS pandemic, HIV is the single most important factor determining the increased incidence of tuberculosis.2T The resur_
gence oftuberculosis underscores how globalization is instrumental in the transmission of infectious diseases and how increasing numbers ofsocieties are ulable to avoid the consequences. Migration from poor countries is a sigrificant cause ofthe reemergence of tuberculosis in rich countries. In the United Siates, Sweden, Norway, Ca"nada, Australia, Denmark, France, and otler European counfties, a large proportion ofnew
Strategy that emphasized the control and contain- ment, as opposed to the eradication, of malaria
Bill and Melinda Gates Foundation Provides bed nets to Zambia to con- trol the spread of mala fla
306 CHAPTER 12 The Globalization of Disease
Balkan Conflict Occurred from
1992 to 1995 and contributed to the quadrupling of tuberculosis in the
Balkans
cases of tuberculosis, as high as half in some countries, is found in immigrants' In fact' Mexico, the Philippines. China, India, and Memam-countries tha-t are maior sources of miErants to th" Ilnited States-have some of the highest rates of tuberculosis in the worli High rates of illegal immigration reduce the ability of governrnents to screen ard er.hlie infectious ttigt"tts. luberculosis is also rampant in refugee camps For exarnple, during the Ballian conflict (between 1992 and 1995), nrberculosis cases q"ratirpi"a. Si#f"rly, famine and civil war throughout A'frica have.spawned significant J.orah in tuberculosis cases. Overcrowding in urban areas, rapid growth of prison iopulations (panicularly in the United States), the rapid gro'wth in global travel on air- 'olin",
rllth il-it.d aii circularion, and the global trend toward privatizing public i.realth care systems (which generally deprives the poor ofadequate medical teatment) have contributed to the reemergence of tuberculosis in affluent countries'
The WHO estimates that someone ir the world is newly infected with tuberculo- sis bacilli every second and that one-third of the world's population is infected with tuberculosis.2dMore than 1.7 million die fiom tuberculosis each year, with the highest number of deaths in Southeast Asia. However, the highest monality rarc per capita is in Africa, due primarily to the prevalence of HIV/AIDS' In the mid-nineteenth century' tuberculosis was the leading iause of death in Europe and North America' It was a ter- rif,irg disease because it c6uld not be prevented from spreading and it was incurable' Being-transmitted through the air, changing one's behavior provided no protection' As sociai, economic, and sanitary conditions improved in Errrope and North America, tuberculosis began to recede. Furthermore, survivors of the disease developed greater immunity to it."The discovery of effective medicines starting in 1944 to control tuber- culosis diminished the epidernic, with wealthier countries experiencing steady declines in tuberculosis-related deaths.29 By 1991, pharmaceutical companies had abandoned manufacturing streptomycin, a dmg commonly used to treat tuberculosis, and many developed
"oint i"i shaiply reduced spending on programs designed to combat the disease. Sanitariums, which had proliferated tJteat tuberculosis patiens' were closed, giving the perception that tuberculosis was no longer a major public concem Although irrrr.ioooi
"t."r *iahitr rich countries continue to experience cases oftuberculosis, the grp L"w""n rich and poor had created a general_sense of hdifference to the disease.
Four factors hnte confiibated to tuberc'uhsis as a global disease:
1. Whereas tuberculosis declined in rich counties, it increased in the developing world.
2' Many poliq'rnakers and the general population in wealthy counffies underes- ti*aied the degt"e to which-their hialth was intemuined with that of people in other parts of the world.
3. The emeigence ofthe HIV/AIDS pandemic rejuvenated tuberculosis, creating new concerns for wealthy countries.
4. The world was unprepared for an increase in outbreaks of multi-dmg-resistant tuberculosis,3o
Faced with the global spread of tuberculosis, various governmental and nongovern- mental organizalons rej-uvenated efforts to diminish the transmissjon of the disease.
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