Civil War & the Global Threat of Pandemics

Civil War & the Global Threat of Pandemics Paul H. Wise & Michele Barry Abstract: This essay confronts the collision of two potential global threats: the outbreak of infectious pandemics and the outbreak and protraction of civil wars. Specifically, it addresses the potential that civil wars can elevate the risk that an infectious outbreak will emerge; the possibility that civil wars can reduce the ca- pacity to identify and respond to outbreaks; and the risk that outbreaks in areas of civil conflict can generate political and security challenges that may threaten regional and international order. Both global health governance and international security structures seem inadequate to address the health and security challenges posed by infectious outbreaks in areas of civil conflict. New approaches that better integrate the tech- nical and political challenges inherent in preventing pandemics in areas of civil war are urgently required. The West African Ebola outbreak is thought to have begun with little Emile Ouamouno, a one-year-old who died in December 2013 in the village of Melian- dou, Guinea. By the time the outbreak was declared PAUL H. WISE is the Richard E. over in January 2016, an official tally of some 11,300 Berhman Professor of Child Health people had died and more than 28,000 had been in- and Society and Professor of Pe- fected in the three most heavily affected countries: diatrics and Health Policy at the Guinea, Sierra Leone, and Liberia. The economies and Stanford University School of health care systems of these three countries had been Medicine, and Senior Fellow at devastated, which in turn resulted in more suffering the Freeman Spogli Institute for International Studies at Stanford and countless lost lives. The armed forces of the af- University. fected countries had been mobilized, as were units from the United Kingdom and the United States, in- MICHELE BARRY is Senior Associ- cluding the famed 101st Airborne Division (Air As- ate Dean of Global Health, Direc- tor of the Center for Innovation in sault). While the impact of this outbreak in death, Global Health, Professor of Med- human suffering, and fear was catastrophic, this es- icine, Senior Fellow at the Woods say raises the question of what might the impact of Institute, and Senior Fellow at the an Ebola outbreak have been if it had occurred not in Freeman Spogli Institute at Stan- 2013 but in 2000, when Guinea, Sierra Leone, and Li- ford University. beria were embroiled in brutal civil wars. This ques- (*See endnotes for complete contributor tion seems particularly relevant given that the 2013 biographies.) Ebola outbreak exposed current global health struc- © 2017 by the American Academy of Arts & Sciences doi:10.1162/DAED_a_00460 71 Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & tures as largely incapable of operating ef- epidemiology and politics that always ac- the Global fectively in countries with poor health sys- companies a global infectious outbreak. The Threat of Pandemics tems and weak governance, characteristics Centers for Disease Control and Prevention likely to be particularly apparent in areas (cdc) defines a pandemic as “an epidem- plagued by protracted civil unrest. In such ic that has spread over several countries or settings, global health imperatives may col- continents, usually affecting a large num- lide with global security structures, a colli- ber of people.”1 It involves epidemiology sion for which neither arena of global gov- since it has at its core the dynamics of dis- ernance appears adequately prepared. ease progression and infectious transmis- The interaction between epidemic dis- sion from individual to individual. Howev- ease and civil conflict has evolved dramat- er, the definition also recognizes that pan- ically over the centuries. The past sever- demics must cross national borders, an al decades have witnessed the predomi- inherent acknowledgement that pandem- nance of protracted civil conflicts that do ics relate to notions of state sovereignty and not readily conform to traditional bound- governance. aries between war and peace. Rather, pro- The majority of the approximately four longed, churning instability has become hundred emerging infectious diseases that common with periods of relative calm in- have been identified since 1940 have been terrupted by eruptions of violent, often zoonoses: infections that have been trans- vicious conflict. While the diseases asso- mitted from animals to humans. Common- ciated with these new forms of war have ly, the infectious agent lives in the animal also evolved, what has altered the threat host, often without causing any discernable of war-generated epidemics forever is the disease. The animals thereby serve as a “res- unprecedented potential for rapid dissem- ervoir” for the infectious agent. The jump, ination throughout the world. or “spillover,” from the animal host to hu- This discussion is premised on the dual man populations can be due to an unusual- recognition that global infectious pandem- ly close contact, such as slaughtering an in- ics have the potential to threaten the inter- fected animal, and may be associated with national order and that civil wars may en- a mutation in the infectious microbe mak- hance the risk that such a pandemic will ing it more likely to infect a human host. emerge and have a global impact. Three re- Human immunodeficiency virus (hiv) is lated mechanisms are of central concern: the iconic disease that emerged from a spill- 1) the possibility that civil wars can elevate over from a simian host. Emergent infec- the risk that an infectious outbreak with tious diseases can also require arthropod pandemic potential will emerge; 2) the pos- blood-seeking insects for transmission such sibility that civil wars can reduce outbreak as mosquitoes or ticks. Mosquitos serve as surveillance and control capacities, result- “vectors” in such diseases as malaria, yel- ing in silent global dissemination; and low fever, and zika, and involve cycles of 3) the potential that infectious outbreaks mosquito transmission from reservoir an- emerging in areas plagued by civil conflict imals with spillover to humans. The emer- can generate complex political and security gence of a zoonosis with the potential for challenges that can threaten traditional no- pandemic spread generally occurs when tions of national sovereignty and enhance there is a change in the long-standing ecol- incentives for international intervention. ogy of human-animal-infectious agent interaction. The importance of this ecolog- Interestingly, the very definition of a pan- ical relationship has been recognized by demic foretells the intricate dance between the One Health Initiative, which links hu- 72 Dædalus, the Journal of the American Academy of Arts & Sciences Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 man and veterinarian medicine within a as Severe Acute Respiratory Syndrome Paul H. new ecological framework.2 For the most (sars) in Southern China and h1n1 in- Wise & Michele part, human factors, such as the expansion fluenza likely in Mexico, there is consid- Barry of human populations into previously for- erable overlap between the hotspots for ested areas, domesticated animal produc- emerging infections and hotspots of civil tion practices, food shortages, and alter- conflict. Of particular concern is the role ations in water usage and flows, have been of social disruption and forced migration the primary drivers of altered ecological in generating the conditions for pandem- relationships. There is also substantial evi- ic emergence. Combat operations and the dence that climate change is reshaping eco- threat of violence invariably generate the logical interactions and vector prevalence migration of civilian populations into saf- adjacent to human populations.3 Enhanced er locations, often into forested or other re- trade and air transportation have increased mote areas where intense interaction with the risk that an outbreak will spread wide- wildlife populations is more likely. In addi- ly. While infectious outbreaks can be due tion, the search for food among these refu- to all forms of infectious agents, including gee populations may require the hunting of bacteria, parasites, and fungi, viruses are of nontraditional forms of wildlife, such as ro- the greatest pandemic concern. dents, bats, or primates, which can greatly New infectious agents can emerge any- elevate the risk of zoonotic spillover. For ex- where humans inhabit the planet. Howev- ample, the dangerous Ebola, Marburg, and er, the science of emerging infections sug- Nipah viruses are carried by bats, and the vi- gests that the greatest danger of pandemic rus that caused the 2002–2004 sars out- generation lies in tropical and subtropical break was also likely transmitted by bats. regions where humans and animals, par- While the emergence of new human dis- ticularly wild animals, are most likely to eases is not confined to areas plagued by interact. Recent analyses have suggested war, populations fleeing civil war may also that the “hotspots” for emerging infec- intensify the early human-to-human trans- tious diseases lie in Eastern China, South- mission of emerging infections.6 Refugee east Asia, Eastern Pakistan, Northeast In- camps are usually characterized by people dia and Bangladesh, Central America, and living in extremely close proximity to one the tropical belt running through Central another, often crowded into makeshift shel- Africa from Guinea, through Nigeria, the ters, elevating the risk of transmission. In Democratic Republic of the Congo (drc), addition, malnutrition and poor hygiene Rwanda, and Burundi, and into Ethiopia.4 and sanitation can also elevate the risk of These hotspots have been identified using infection. However, while the impact of civ- sophisticated analytic models but general- il conflict on pandemics may elevate the risk ly approximate areas where new or intense that a new infectious disease will emerge, human activity coincides with high wild- the greater concern is that civil conflict will life and microbial diversity.

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