I mentioned in part 2 of the introduction the role that war plays in the emergence and transmission of infectious disease. Accurate numbers are difficult to come by, but currently, it’s estimated that approximately 120 million people worldwide are affected in some way by conflict. In 2003, it was estimated that more than 72 countries were identified as unstable, and various conflicts have resulted in over 42 million refugees and internally displaced people worldwide. War and its concomitant devastation and social upheaval leaves its victims at an increased risk of disease transmission to begin with due to poor sanitation, collapse of public health and medical facilities and support personnel, crowding in refugee camps, breaks in supply chains of food, medicine, and other necessary items, malnutrition and depression, and other factors. Population displacement and movement can lead to mixing and sharing of infectious agents, resulting in outbreaks of disease among naive individuals. Rape may be used as a tool of war, spreading sexually transmitted diseases and/or leaving victims pregnant and at further risk of illness or death. Additionally, when disease breaks out, the duration of the epidemic is often longer than in a stable area. Drug resistance can emerge quickly in these populations: for those who do have access to treatment, the antimicrobial may not be appropriate to treat the infection, or it may be taken improperly. For example, drugs may be taken until the user is feeling better, and further doses may be hoarded or given or sold to others, leaving the disease incompletely treated.
There are several examples (discussed below) of emerging infections that have occurred in recent decades in war-torn regions.
(A disclaimer: I won’t even pretend that I’m doing the conflict in these regions justice and this will be horribly simplistic, so keep that in mind when reading the very brief histories of conflicts I’ll mention).
Ebola and Marburg in the Democratic Republic of Congo and Sudan. The history of the conflict in the DRC (formerly Zaire) alone dates back well over a hundred years, to the beginning of Belgian colonialism. When they pulled out in 1960, they left political control of the country to its people, but after only a few months the country was led by a dictator, Mobutu Sese Soko (elected president in 1965), leaving the country largely in chaos and poverty. Overthrown in 1997, the country has suffered from ongoing internal conflicts (with other countries joining in on one side or the other) since. A fragile peace agreement was signed in 1999 but fighting continued, and the new president was assasinated in 2001. At that time, an OxFam report noted some appalling statistics:
More than two million people are internally displaced; of these, over 50 per cent are in eastern DRC. More than one million of the displaced have received absolutely no outside assistance.
It is estimated that up to 2.5 million people in DRC have died since the outbreak of the war, many from preventable diseases.
There are 2,056 doctors for a population of 50 million; of these, 930 are in Kinshasa.
In the Sudan, the latter half of the 20th century was almost a continuous civil war, leading to approximately 4 million displaced and 2 million deaths. In Darfur alone since 2003, tens of thousands of deaths have been estimated with an additional 2 million displaced. Refugee influxes from Chad and Ethiopia, along with poor government infrastructure have served to exacerbate the situation.
These two countries together have seen the majority of the world’s Ebola deaths. In 1976-7, a concurrent outbreak occurred in the two countries, resulting in 600 deaths and much fear. (The outbreaks were not due to a common source; different strains of the Ebola virus were involved). Ebola returned to the DRC in 1995, killing almost 300, and a Marburg outbreak there lasting from 1998-2000 resulted in an additional 150 cases (just over 100 deaths). Ebola came back yet again in the DRC in 2001, with 58 cases and 44 deaths. Uganda, a country that borders both the DRC and Sudan, also had an outbreak in 2000, with 425 cases of the disease. This outbreak was due to the Sudan strain of the virus; it has been hypothesized that Sudanese rebels may have unintentionally introduced the virus into the country, though this has not been confirmed.
Marburg in Angola. Following independence from Portugal, Angola has suffered through 30 years of civil war. Estimates suggest that 1.5 million have been killed, and up to 4 million displaced during this time, and the population has been generally left in poor health with any public health infrastructure decimated. A Marburg outbreak began there in October 2004 in a Northern province bordering DRC. The outbreak lasted a year, resulting in the largest Marburg outbreak in history: 252 cases, 227 deaths. As noted by CIDRAP, ” when the outbreak was identified, the province had one hospital and four doctors for 1.5 million people in the region.” Because of this, it took almost 6 months for the outbreak to even be identified–it was called to the attention of world authorities in March 2005, but retrospective studies found cases at least as far back as 2004.
Lassa virus in Sierra Leone. After a decade-long civil war in Sierra Leone (1991-2002), UN peacekeepers left this past December, but stability remains uncertain. The war resulted in the displacement of more than 2 million people (roughly a third of the country’s population), and the death of tens of thousands. As populations fled, rats were able to overtake abandoned houses and fields, leading to a population boom in these rodents, which carry Lassa virus, another virus capable of causing hemorrhagic fever. What was currently a sporadic infection has now become an endemic disease. Though numbers are difficult to track, it has been reported that up to 15% of hospital admissions in Sierra Leone are for Lassa fever.
Malaria in Afghanistan and Tajikistan. Following the collapse of the Soviet Union in 1991, Tajikistan suffered through 5 years of civil war. Though fighting has been reduced, it remains the poorest country of the former USSR. A pathogen that has increased the suffering of the population is Plasmodium–malaria. Prior to 1991, mosquito spraying was routine; this ended when Tajikistan gained its independence. Of course, mosquitoes alone don’t spread malaria–they must be infected with the parasite, which appears to be coming into the country via the return of ethnic Tajiks from Afghanistan, where malaria is endemic.
Obviously, this is only the tip of the iceberg, and I’ve concentrated on a few of the high-profile pathogens in severely war-torn regions because their numbers are generally better tracked and these outbreaks get more attention. In addition, other old terrors such as tuberculosis and rotavirus (and many more) also become even worse killers in populations ravaged by war. And clearly, all the hand-wringing and peace efforts in the world aren’t going to end the outbreak of combat–the best we can do is to provide aid whenever possible, work to minimize the outbreak, assist in providing resolution to the conflict, and raise awareness about the situation.
Image from http://lmno4p.org/images/war/03.30_basra_2.jpg