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Emerging and Re-Emerging Disease: International Public Health

Arguments: The Return of "Microbialpolitik"
As infectious diseases become a global threat, policymakers relearn an old lesson
David P. Fidler*
Foreign Policy
Winter 2001


In 2000, the world's most powerful nations chose to make infectious diseases a high-profile issue. The Group of Eight industrialized countries pledged to help developing nations cut AIDS cases by 25 percent and tuberculosis and malaria deaths by half, all by 2010. For the first time in its history, the United Nations Security Council passed a resolution on infectious diseases, calling for steps to counter the impact of AIDS on the health of international peacekeepers. In the United States, even the skeptical Central Intelligence Agency and the stingy U.S. Congress issued reports about, and appropriated funds to fight, new and reemerging infectious diseases that threaten U.S. and global security.

The staggering human catastrophe wrought by aids is one big reason why infectious diseases, long the purview of obscure public-health organizations, have become a top-tier concern for diplomats and policymakers. But the rise of disease diplomacy stems from more than HIV's emergence. From refugees who spread shigella and malaria while fleeing across borders to business travelers and vacationers who carry pathogenic microbes on intercontinental flights, the potential for the global spread of infectious diseases has never been higher. As a result of this "globalization of public health," First World governments increasingly recognize that they can no longer protect their citizens without international cooperation.

The globalization of public health manifested by the threat of infectious diseases is not, however, new. The expansion of travel and trade in the first half of the 19th century raised concerns in Europe and North America about the importation of diseases from Asia, Africa, and Latin America. Overcrowded living conditions, inadequate sewage systems, and unclean drinking water made those living in Europe and North America vulnerable to contagion—a fact underscored by periodic cholera epidemics that swept through their cities between the 1830s and 1890s. Realizing that national strategies, such as quarantine, were useless without international cooperation, European governments launched a series of international sanitary conferences and treaties that spanned the second half of the 19th and first half of the 20th centuries. Indeed, outside the arenas of war, diplomacy, and trade, infectious diseases provoked perhaps the earliest and most intense process of internationalization. In this meeting of realpolitik and pathogens, microbialpolitik—the international politics of infectious disease control—was born.

In the latter half of the 20th century, however, great-power interest in international infectious disease control waned. For developed countries, international cooperation largely took the form of the technical humanitarianism of the World Health Organization (WHO, established in 1948) and nongovernmental organizations. At first glance, this decline in disease diplomacy seems counterintuitive. The speed and volume of global trade and travel continued to grow, creating unprecedented opportunities for pathogens to spread worldwide. But industrialized countries had (literally) cleaned up their acts and regained national control of public health through sanitation reforms; their cities were no longer breeding grounds for cholera epidemics or tuberculosis. Moreover, scientific research led to advances in drugs and vaccines that helped industrialized countries reduce the ravages of dreaded diseases such as polio and tuberculosis. By the late 1960s, many scientists and public health officials believed that infectious diseases were destined for the ash heap of history.

Yet, as fear of infectious diseases declined in industrialized nations, every year pathogenic microbes and parasites continued to kill millions of people in the developing world, where poor socioeconomic conditions provided a fertile incubator for tuberculosis, malaria, acute respiratory infections, measles, and diarrheal diseases, as well as new scourges such as AIDS. And the situation is getting worse. Nearly a quarter century after the WHO initiated a program to improve primary healthcare worldwide, the disparities in health standards between rich and poor nations have widened. Spending on public health by developing nations has been declining, and international public health assistance to low- and middle-income countries (about $2 billion to $3 billion annually) remains a mere fraction of their total health needs (roughly $250 billion). As a result, developing countries harbor deepening reservoirs of dangerous diseases that the forces of globalization can spread with ease.

Today, developed countries—like the aristocratic courtiers in Edgar Allan Poe's Masque of the Red Death who believed that crenellated castle walls would protect them from the pestilence without—are belatedly realizing the cost of their complacency about infectious diseases and microbialpolitik. Public health systems in developed countries have deteriorated in the last three decades, increasing their vulnerability. Most disturbing of all, antimicrobial resistance in common bacterial infections, tuberculosis, malaria, and other diseases threatens to take public health back to the preantibiotic era. The very weapons that allowed developed countries to neglect the globalization of public health have lost much of their effectiveness. The "reglobalization" of public health is well underway, and the international politics of infectious disease control have returned.

When microbialpolitik first appeared, nations stumbled about in disease diplomacy because no one knew how microbes caused illness and death. The development of "germ theory" stabilized international cooperation on infectious disease control in the late 19th century. Today, germ theory doesn't work wonders for disease diplomacy as it did more than 100 years ago. Will scientific progress again rescue microbialpolitik from futility? Will genome research be for disease diplomacy tomorrow what germ theory was in yesteryear? Maybe, but for millions in developing countries who are dying from infectious diseases, contemporary disease diplomacy has so far proved to be a cruel disaster.


Note *: David P. Fidler is associate professor of law at Indiana University School of Law, Bloomington and author of International Law and Infectious Diseases (Oxford University Press, 1999).  Back