Furthermore, areas controlled by nonstate actors such as the so-called Islamic State (ISIS), or areas too dangerous for the safe movement of health professionals, hinder the international community’s ability to accurately assess the health situation on the ground. As of spring 2016, ISIS controls territory in northern and eastern Syria, as well as parts of western Iraq, where they rule their “state” with an iron fist. But unlike a real state, there are no adequate health facilities to address the potential growth of existing diseases and the emergence of new ones. The same situation exists in Libya, where territory in the east is under the control of nonstate actors like ISIS and various militia groups.
All these factors together indicate MENA could become the next global hot zone of disease, and unfortunately, the region currently lacks the capabilities to develop appropriate countermeasures. There have been some success stories, such as the containment of Iraq’s cholera outbreak in 2015. But a rapid response only occurred because the local government was able to partner with international organizations such as UNICEF and WHO and freely operate in government-controlled territory.
If diseases in MENA’s conflict zones remain uncontained and untreated, it’s increasingly likely they will cross into regions not experiencing conflict. It’s possible this has already occurred.
Dr. Hotez reported in Vice that Southern Europe has recently experienced an unusual change in disease patterns. Schistosomiasis, a parasitic disease classified as an NTD prevalent in Africa and the Middle East, has surprisingly made an appearance in Corsica off the coast of France. Dengue fever, the mosquito-borne virus infection, is pervasive in the Middle East and is now growing in Portugal, Italy and Spain, as are other infections.
What has triggered the arrival of these diseases in Europe? Is it from the influx of refugees from war zones in the Middle East and Africa? It remains a question to Dr. Hotez and his fellow scientists: “We don’t really know. But I think southern Europe is an area we are going to have to look at very closely.”
Politics, Economics and Zika
Perhaps more troubling is that political and economic turmoil, short of conflict, can also promote the spread of disease. We are now seeing this phenomenon in the middle-income countries of Venezuela and Brazil, where the Zika virus—an infection from the bite of an Aedes aegypti mosquito that can cause a serious birth defect called microcephaly—and other tropical diseases have emerged.
The socialist-ruled Venezuela has gone from one of Latin America’s most prosperous nations to the brink of collapse. Under the tutelage of the Hugo Chavez and Nicolás Maduro–led governments, political and economic mismanagement and a nonexistent public health plan have led to a Venezuelan health system unable to treat patients and a reemergence of tropical diseases.
The Lancet reported that Malaria cases have substantially increased since 1998. There were an average 1,497 cases per week in 2014 alone. A shortage in the national stockpile of antimonial drugs has left cases of leishmaniasis and schistosomiasis untreated. There have also been an increasing number of outbreaks of the mosquito-borne dengue and chikungunya viruses in recent years. These viruses are carried by the same mosquito that spreads the Zika virus, of which there are already an estimated 412,000 cases.
If Venezuela continues on its path of failed public services and triple-digit inflation, there is little hope that the litany of tropical diseases emerging will be contained within its borders. This situation mimics the early stages of the Ebola epidemic previously seen in West Africa, except this epidemic is located in a large, oil-rich country near the United States.
The same can be said of Brazil, whose economic growth has severely slowed over the last few years. According to Forbes, unemployment is over 11 percent and the debt burden is 67.3 percent of Brazil’s GDP. Furthermore, the Brazilian government faces its worst political crisis in decades. President Dilma Rousseff has been suspended from the presidency and 303 members of congress are marred in a corruption scandal. And two months before Rio de Janeiro hosts the 2016 Summer Olympics, Rio’s governor requested urgent financial help to avoid “a total collapse in public security, health, education, transport and environmental management.”
While political and economic chaos engulfs Brazil, the country is simultaneously trying to manage the Zika virus outbreak that burst onto the scene in early 2015. The Brazilian Ministry of Health reported over ninety-one thousand cases of Zika by March 2016. The virus has rapidly spread from Brazil across the tropical Americas and been declared a “public health emergency of international concern” by the World Health Organization. Over two hundred public health experts have called for the Olympics to be moved from Brazil or delayed for fear that thousands of foreign tourists will further spread the virus globally.
As in MENA and sub-Saharan Africa, most of Latin America does not make vaccines. According to Dr. Hotez, Brazil used to stand apart, but “with all the corruption and economic instability they have lost ground.” Now the rapid spread of the Zika virus threatens to hit the impoverished urban neighborhoods of the U.S. Gulf Coast where the Aedes aegypti mosquito thrives in the humid summer heat. Unfortunately, it’s unlikely Zika vaccines will be created in time to counter the epidemic this year.
Science Policy within Foreign Policy
The rapid spread of diseases across Africa, the Middle East and the Americas has shown conflict and instability can promote the emergence of disease epidemics. But what can be done by developed countries to proactively combat potential outbreaks originating in conflict zones? In a PLOS report Dr. Hotez says there is an “urgent need to develop and possibly stockpile new vaccines for the major NTDs emerging out of MENA” and other conflict zones. But major multinational pharmaceutical companies are unlikely to lead the charge because NTDs like schistosomiasis and leishmaniasis are not yet of global concern.
Small steps have been taken in the United States. In 2014 the U.S. Department of State selected Dr. Hotez to serve as U.S. Science Envoy to the MENA region. His mandate was to seek out nonprofit partners willing to develop vaccines for NTDs afflicting many of the conflict zones in MENA. The Sabin Vaccine Institute now works with King Saud University in Riyadh, Saudi Arabia, to build capacity for vaccine research and development in the Middle East.
While an important step, it still pales in comparison to U.S. military expenditures in conflict zones abroad. The threat of infectious diseases swiftly crossing international borders must be examined as not only a health issue, but elevated to a security issue. There is precedent for this. Climate change has slowly emerged as a nontraditional security threat of concern to global leaders, defense officials, intelligence agencies and diplomats. Thus, the U.S. national security apparatus has started planning for potential contingencies involving the effects of climate change on the global security environment. The same high-level concern should be applied to the risk of conflict and instability providing the necessary habitats for infectious diseases to explode on regional and subsequently global levels.
Dr. Hotez believes this will require an unprecedented dialogue between experts from a variety of fields, and not those solely from the health and science communities. Notably, this dialogue must include those who study conflict, political violence and economics. Such experts understand where tensions are likely to erupt into full-scale conflict; they understand which foreign governments are susceptible to implosion due to a mismanagement of government resources; and, they understand the mechanisms the United States and other major powers use to respond to crises. They will be essential in beginning future conversations with environmental health experts, biomedical scientists and epidemiologists to truly comprehend the intersection of conflict and disease. Only then can policymakers begin to formulate policies that incorporate disease control and disease technologies into U.S. foreign policy. Hotez refers to this concept as “vaccine diplomacy,” and believes it could become a game changer in U.S. diplomatic relations.
Aptly put by Dr. Hotez, “Figuring out how to better incorporate science policy into foreign policy is, I think, going to be an important twenty-first-century challenge.”
Kip T. Whittington is a freelance consultant, the International Security Editor at Fair Observer, and an editorial assistant at War on the Rocks. He has worked in public diplomacy for the U.S. Department of State in Saudi Arabia and as a research associate with the Near East South Asia Center for Strategic Studies in Washington, D.C. Follow him on Twitter @KipTWhit. Please note that the views expressed in this article are those of the author and individuals explicitly stated and do not represent the official policy or position of any current or previous employers.
Image: Woodland mosquito (does not carry Zika virus). Flickr/Katja Schulz