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The Elliott School of International Affairs
The George Washington University
April 25, 2002

Disease Migration in Latin America and the Caribbean and its Implications for the United States and for U.S. and Global Policy

Presented at the Woodrow Wilson International Center for Scholars by George C. Fidas Intelligence Officer-in-Residence

Good afternoon. It's a pleasure to participate in this panel discussion on Disease Migration in Latin America and the Caribbean and its Implications for the United States and for U.S. policy co-sponsored by the Better World Campaign and the Wilson Center's Conflict Prevention and Environmental Change and Security Projects and the Latin America Program. I would like to start with a brief discussion about disease migration in the region. I will then focus briefly on the disease threat to the U. S. and the U.S. response and close with some thoughts about the U.S. and global policy choices that lie ahead.

The resurgence and spread of the infectious disease threat in Latin America and the Caribbean is due to changes in human demographics and behavior, environmental degradation, and broader social, economic, and technological developments — as well as to mutations in pathogens — all of which are occurring globally.

• Although population growth in the region has slowed considerably, the still large number of births and an aging population create strong demands on healthcare delivery systems for the very young and old alike.
• The movement of people from countryside to city continues apace and the region is now among the most urbanized in the world. Some 75 percent of the population lives in urban areas where all sorts of diseases are introduced and flourish among decaying and crowded slums, poor sanitation, and inadequate preventative healthcare and treatment.
• At the same time, a substantial number of people move from city to countryside, or from one part of the country to another in search of work, oftentimes carrying diseases with them or falling victim to those in their new habitat because they lack the resistance that people already there have built up over time.
• And while Latin American and Caribbean countries are widely associated with legal and illegal emigration to the US and Europe, the region also has millions of intra-regional immigrants who move from one country to another in search of a better life and serve as vectors for the spread of diseases in the process. Argentina and Venezuela have been destination countries, though the economic difficulties there may slow or reverse such immigration.
• Environmental problems include still poor and deteriorating drinking water and sanitation systems for nearly a third of the population in most countries and urban areas. These cause and spread a variety of diarrheal and other diseases; cross-border air pollution; and damage to the ozone layer that will contribute to global warming and eventually spread malaria and other mosquito borne diseases beyond and above the region's tropical areas.
• Other changes include rising cross-regional travel and commerce that hasten the spread of diseases such as TB, pneumonia, and food-borne diseases because of the globalization of the world's food supply.
• As the region moves into the middle stages of economic development and access to healthcare broadens, the dangers and incidence of inappropriate use of antibiotics are increasing, fostering microbial resistance to anti-malarial drugs, penicillin, and anti-tubercular drugs that have made many of them practically useless. Invasive medical procedures are also furthering the spread of hospital infections.
• Finally, natural disasters such as Hurricane Mitch in 1998 and El Nino-related flooding, civil conflicts, and repeated economic crises constrain the capacity of health care systems to respond. Meanwhile the increasing privatization of health care (now predominant in the region) makes it difficult for people to purchase adequate preventative and remedial care when they see their incomes and savings go down in times of economic crisis in places such as Ecuador, Argentina, Brazil, Mexico, and Peru. Even Cuba's much-vaunted health care delivery system (one of the few benefits of Communism) is deteriorating commensurate with the deterioration of its economy.

Nonetheless, Latin American and Caribbean 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. Health care capacity is substantially more advanced in Latin America and the Caribbean than in Sub-Saharan Africa and somewhat better than mainland Asia's. An estimated 70 to 90 percent of populations have access to basic health care in Chile, Costa Rica, and Cuba on the upper end of the scale; 50 to 70 percent in Mexico, Venezuela and Argentina; and 40 to 50 percent in Brazil and most of the Andean and Central American states at the bottom end of the scale. Nonetheless, infectious diseases such as malaria, dengue, and chagas disease, are still a major problem in the region, while the risks from new and reemerging diseases such as HIV/AIDS, cholera, and TB remain substantial.

Impact of Latin American, Caribbean and Global Disease Trends on the United States

Because microbes know no boundaries and the accelerated global and regional movement of people, goods, and foodstuffs associated with globalization are hastening the spread of dangerous diseases around the globe, including the United States, it has gotten the attention of the US health policy community, and most recently, the US national security policy community.

• Although not as significant a threat as non-communicable diseases, the trend is up. Annual infectious disease deaths have nearly doubled to nearly 200,000 annually after reaching an historic low in 1980; nearly 1 million Americans are HIV positive and another 5 million are at risk due to their life style; 4 million Americans are chronic carriers of the deadly hepatitis C virus that may soon surpass AIDS-related deaths if it hasn't already; and food-borne illnesses, influenza, multi-drug resistant TB, and drug- resistant hospital infections also are up substantially over the last decade. In addition, some diseases, thought to have been eliminated long ago, have reemerged, such as malaria, cholera, and dengue, albeit in small numbers. Most of these diseases originate abroad and are introduced into the US through travel, migration, and commerce, much of it originating in Latin American and Caribbean countries.
• The growing health threat from infectious diseases was enough to prompt an interagency review by the US health policy community in the mid-1990s, which concluded with the signing of a Presidential Decision Directive by President Clinton in June 1996 calling for a more focused US effort to combat infectious diseases. The State Department's Strategic Plan for International Affairs the following year listed protecting human health and reducing the spread of infectious diseases as U.S. strategic goals, while in December 1999 State launched the second of two major U.S. initiatives to combat HIV/AIDS
• But it was not until a National Intelligence Estimate in January 2000 linked the well-known health risks of infectious diseases at home with the prospect of disease-related social disintegration, economic decay, and political instability and conflict abroad that the Clinton Administration declared AIDS, in particular, to be a national security threat and launched a major effort in Congress, the UN, and with US economic partners and international lending institutions to secure more funding and focus on infectious diseases. The Bush Administration has followed suit, with Secretary Powell and Vice President Cheney reaffirming that AIDS is a national security issue, doubling the amount of international spending on AIDS that already had been doubled by Clinton to its current $1 billion and supporting the establishment of a global coalition to combat AIDS, TB and malaria.

It is fair to say that since the millennial year, developed country leaders lead by the United States finally have become sensitized to the potentially catastrophic impact of AIDS and other deadly diseases such as TB and malaria and are determined to roll them back.

• This stems not so much from a greater appreciation of their health dangers to developed countries, which are still seen as manageable-but by a concern that such diseases' impact may undercut virtually every other Western assistance program in developing countries and also foment great socio-economic and political instability requiring developed country intervention.
• Increasingly, security-related concerns are being augmented by moral imperatives as policymakers become more aware of the devastating toll of AIDS and other killers. (Witness Senator Helms recent op-ed item to that effect and his call for an additional $500 million in assistance to fight AIDS.)

With the notable exception of Brazil, Thailand, Uganda, Senegal, and a few others, most developing countries have been ambivalent about this increased attention to AIDS and related diseases, welcoming the prospect of greater assistance, but still reluctant to admit to the scope of the problem for reasons of national prestige, and a focus on broader policy priorities such as socio-economic development.

• In the view of many, led by South African President Mbeki, AIDS is a function of underlying poverty, malnutrition, and poor health care infrastructure that must be dealt with first. This attitude is beginning to change as substantial developed country funds are being committed to AIDS, TB, and malaria, but the international community will have to monitor their use to guard against their diversion to non-health projects.

Key Policy Issues and Choices Ahead

As the international donor community and hard-hit countries in the Caribbean, Latin America and elsewhere contemplate their responses to AIDS, TB, malaria and other diseases, they will face a variety of complex policy issues and choices.

First, policymakers must assess the salience of the issue, including its political salience, since this will influence the attention and resources it is likely to receive.

• Are these diseases just a serious health issue, alongside other major non-communicable killers such as heart disease and cancer? Or are they truly a national and global security issue whose accompanying social, economic, and political impact calls for a more robust and multi-sectoral effort?
• The trend is toward highlighting the AIDS threat, in particular, but opinion will likely remain divided on this in developed countries and elsewhere. Ironically, many developing and former communist countries who have the most to gain by labeling AIDS a security threat also oppose that nomenclature because they associate it with interventionism by the US and NATO on behalf of more traditional security concerns. Clearly, AIDS and other killer diseases will be far better funded if they are seen both as a serious health and security issue.

Second, regardless of whether it is a serious health or also a security threat, policy choices need to be made along three dimensions: spending for health versus spending for other objectives such as education; treating AIDS versus treating other serious illnesses; and preventing HIV infection versus treating those with AIDS.

• AIDS will pose difficult budgetary dilemmas in the poorest countries in the Caribbean, Central America, and Sub-Saharan Africa where annual treatments for one AIDS patient can cost as much as educating several primary school students. Few developing countries will be willing to allocate their already scarce resources toward more health spending--so any increase will depend on external assistance and further debt rescheduling where money saved is committed to improving health care delivery as well as other sectors.
• The priority given to AIDS compared to other illnesses will remain controversial in developing countries, who fear that AIDS will overwhelm their already meager health budgets, more than half of which is already devoted to AIDS in the hardest hit countries.
• Although virtually all known HIV infected individuals in North America and Europe have access to both prevention and treatment programs, most developing countries can do neither. Even with anti-retroviral drug treatment costs dropping to below $ 1,000 annually, only about one percent or 250,000 HIV-infected people are on anti-viral therapy, 100,000 of them in Brazil, and most of the others in the more advanced developing countries in Latin America and Asia. By contrast, only 30 of 1 million HIV-infected people in Malawi were taking such drugs in 2000.
• While a few countries such as Thailand, Uganda, and Senegal have made substantial progress by focusing on prevention, Brazil is the only developing country to make such drugs available for free to all those in need of them, at a cost to the government last year of some $500 million or 4 percent of its health budget. It has done so because of committed leadership and by manufacturing its own drugs and jawboning foreign firms for much lower prices, though not without creating controversy over intellectual property rights. This policy has cut AIDS deaths by about 50 percent and new infections to 20,000 annually. Still, of the 530,000 estimated HIV positive people in Brazil, 80 percent do not even know it — so much remains to be done. The number of those in Africa who do not even know they are HIV positive is some 90 percent. Even in the US, Dr. Fauci at NIH estimates that one-third of HIV positive Americans are unaware of their infection and continue to spread the disease.

Third, the emerging international coalition in the form of the Global Fund to Fight AIDS, TB and Malaria will remain fragile even though it is off to a good start with some $2.08 billion in pledges, including $500 million for the US and promises of more to come; the election yesterday of Richard Feachem, a university professor and former World Bank official as its director (over the US candidate, Ambassador George Moose), and its consideration of a first round of grants from 300 applications in 100 countries.

• It will remain particularly dependent on the commitment of the major developed countries (which will depend to some degree on responsiveness to their wishes), agreement on the allocation of aid, and resolution of the intellectual property rights issue respecting anti-AIDS drugs.

One likely source of major controversy will be whether to focus on treatment as well as prevention. Bilateral assistance programs, including those of the US, are currently geared to prevention over the far more costly treatment of AIDS, as are those of the Global Fund. Pressure is likely to grow from NGOs and other entities for treatment, however. The WHO and several other UN organizations already are calling for a $12 billion dollar treatment program for AIDS, TB and Malaria in a report released in early February.

Fourth, even with plummeting drug prices and growing international commitment and assistance, no international aid effort, no matter how well conceived and executed, will succeed unless the recipient countries show similar resolve and receptivity to its goals and make their own best efforts to use their own financial and human resources to combat the infectious disease threat.

This may be especially true for most Latin American and Caribbean countries, whose higher health capacity and resources relative to the poorest in the region and in Sub-Saharan Africa, will incline international donors to be more parsimonious toward them.