Show Summary Details

Page of

Printed from Oxford Research Encyclopedias, Politics. Under the terms of the licence agreement, an individual user may print out a single article for personal use (for details see Privacy Policy and Legal Notice).

date: 01 December 2022

# Infectious Disease as a Foreign Policy Threat

• Rebecca Katz, Rebecca KatzCenter for Global Health Science and Security, Georgetown University
• Erin SorrellErin SorrellCenter for Global Health Science and Security, Georgetown University
•  and Claire StandleyClaire StandleyCenter for Global Health Science and Security, Georgetown University

### Summary

The last 30 years have seen the global consequences of newly emerging and re-emerging infectious diseases, starting with the international spread of HIV/AIDS, the emergence of Ebola and other hemorrhagic fevers, SARS, MERS, novel influenza viruses, and most recently, the global spread of Zika. The impact of tuberculosis, malaria, and neglected tropical diseases on society are now better understood, including how these diseases influence the social, economic, and political environment in a nation. Despite international treaties and norms, the specter of intentional use of infectious disease remains present, particularly as technological barriers to access are reduced. The reality is that infectious diseases not only impact population health, but also have clear consequences for international security and foreign policy.

Foreign policy has been used to coordinate response to infectious disease events and to advance population health around the world. Conversely, collaboration on infectious disease prevention, preparedness, and response has been used strategically by nations to advance diplomacy and improve foreign relations. Both approaches have become integral to foreign policy, and this chapter provides examples to elucidate how health and foreign policy have become intertwined and used with different levels of effectiveness by governments around the world. As the scope of this topic is extensive, this article primarily draws from U.S. examples for brevity’s sake, while acknowledging the truly global nature of the dynamic between infectious diseases and foreign policy, and noting that the interplay between them will vary between countries and regions.

In 2014, U.S. President Barak Obama called upon global partners to, “change our mindsets and start thinking about biological threats as the security threats that they are—in addition to being humanitarian threats and economic threats. We have to bring the same level of commitment and focus to these challenges as we do when meeting around more traditional security issues”. With world leaders increasingly identifying disease as threats to security and economic stability, we are observing infectious diseases—like no other time in history—becoming an integral component of foreign policy.

### Subjects

• Contentious Politics and Political Violence
• World Politics

### Introduction and Background

#### Evolution of the Link Between Foreign Policy and Disease

Foreign policy is formed by the objectives that direct actions and relationships of one state in its interactions with other states; it centers on national and regional priorities as well as the policies or behavior of other states. States implement foreign policy to safeguard national and international security; to stimulate trade and investments; to grow their economic power; to use political and economic development to foster stability in other states; and to provide humanitarian assistance in countries of strategic importance (Fidler, 2006). Foreign policy relies on diplomacy for implementation.

While public health has historically played a prominent role in the pursuit of foreign policy it has rarely been perceived as such, standing instead as a separate entity and one of low prominence in states’ hierarchy of foreign policy objectives. However as early as the 14th century, policies such as sanitary cordons were established, to prevent plague from entering Croatia’s Dalmatian Coast, while the 14 international sanitary conventions, initiated in 1851, led to a series of international agreements on the standardization of quarantine regulations to prevent the importation of three priority diseases: plague, yellow fever, and cholera (Tognotti, 2013). Twelve states were represented at the first of the International Sanitary Conferences hosted by France. Each country sent two delegates, a physician and a diplomat, although the physicians were not invited back after their votes were contrary to the diplomats (Howard-Jones, 1975). Fifty years later, an integrated mosquito control program against malaria and yellow fever, enforced by military units, supported the construction of the Panama Canal, a strategic route for international maritime trade. These are just a few examples of how health and disease have been intertwined with the pursuit of foreign policy interests.

Over the last few decades, however, a major transition occurred, positioning global health as a more relevant topic for foreign policy. Starting primarily in the 1990s, a significant body of research has been put forward to characterize the nature of the interplay between global health and foreign policy issues, particularly the nexus between health and security issues (including Brower & Chalk, 2003; Price-Smith, 2002; and popularized by Garrett, 1994). As one example, Fidler presents three possible interpretations for the growing relationship between global health and foreign policy. The first interpretation argues that global health is an important objective of foreign policy in itself, becoming a “preeminent political value for 21st-century humanity” (Fidler, 2005). In this way, health re-directs state focus and priorities that had traditionally defined foreign policy. In his second perspective, Fidler proposes global health is a “tool, an instrument of statecraft, the value of which extends no farther than its utility in serving the material interests and capabilities of the state.” In this view, health is an issue that policy makers consider among other state interests and does not re-direct interest of health’s impact, for example, on national and global security priorities: “When diseases threaten, or show the potential to threaten, national security, military capabilities, geopolitical or regional stability, national populations, economic power, and trade interests, foreign policy makers take notice” (Fidler, 2005). Fidler’s final perspective interprets global health and foreign policy as an evolving, dynamic association recognizing that they interchange in which entity leads action. Health as a foreign policy issue did not profoundly change the policy dialogue, but it did require policy-makers to consider how they view national interests, forming their political strategies around diseases that threaten domestic interests (Fidler, 2007).

In the last few decades, global health issues have become part of the international dialogue as legitimate topics in foreign policy, resulting in increased attention to—and funding for—select global health issues. Of particular note, global health has impacted policies and strategies for security, economic development, and the provision of humanitarian assistance. Policy makers and public health experts alike have increasingly framed certain health threats and risks, such as the reemergence of long-standing infectious diseases, new deadly infectious diseases with pandemic potential, or acts of biological terrorism as security challenges. In the United States, this framing can be traced to policy shifts in the early 1990s and policy directives from the mid-1990s (White House, 1996); in 2000, the United Nations Security Council took the unprecedented move of passing a resolution on an infectious disease issue, given the perceived threat posed by the HIV/AIDS epidemic to national and global security (UNSCR, 2000). Perhaps most explicitly, in 2007, the Ministers of Foreign Affairs for seven countries issued a declaration that called on the global community to broaden the scope of foreign policy to include health as one of the most critical issues of our time (Amorim et al., 2007). Infectious disease outbreaks coupled with weak health systems (disease surveillance, infrastructure, work force, and resources) in developing countries increases the likelihood of population movement to seek better care and can be further impacted by limits on economic growth, and increases in the division of social classes, whereas improvements in health systems and human resources can impact gains from the global market in both health goods and services. States supported health as a social value and human right by supporting first the United Nations Millennium Development Goals (MDGs) and now the Sustainable Development Goals (SDGs), as well as advocating for high-income countries to support global health initiatives (Kickbusch, 2011).

The somewhat recent inclusion of global health as a key player in foreign policy has exposed some consequences of their previous separation. The global health community did not always prioritize considerations of protecting sovereignty or promoting national interests in their advocacy schemes, nor did political leaders and figureheads normally factor in population health in the success of their governments or geographical conquests. The 1978 Declaration of Alma Ata is an example of the detachment of global health policy and foreign policy (Fidler, 2007). The declaration, viewed as a major milestone by the global health community and the World Health Organization (WHO), identified primary health care as the key to the attainment of the goal of “Health for All” by the year 2000 (Declaration of Alma-Ata, 1978). Unfortunately, the declaration was unveiled at a tumultuous time in foreign affairs. Economic disruption due to the 1973 oil crises had led to a new period of foreign policy in the Middle East; the Soviet invasion of Afghanistan and the Iranian Revolution in 1979 further disrupted the global order. As such, while WHO was introducing its most ambitious global strategy for health, the political positioning of super powers was shifting (Fidler, 2007). Interestingly, Alma Ata came at the end of a massive global effort to eradicate smallpox, which involved coordination of governments and populations to promote a health endeavor, including cessation of conflict, to enable vaccination efforts. This campaign, however, often operated in the absence of official actions and relied more on informal negotiations than formal diplomatic actions.

Over time, global health and foreign policy became more formally intertwined, even prior to the evolution of the field in the academic space. This can be seen in the 1990s, when debt packages were tied to investments in health, the United Nations Security Council (UNSC) held special sessions on HIV/AIDS, and revised trade policies to improve access to drugs were established (Kassalow, 2001). International frameworks and policy directives have been another mechanism by which linkages between foreign policy and health have been formalized, with a much longer and involved history.

#### Global Health Policy Directives: The Nexus Of Health and Foreign Policy—International Sanitary Regulations and Beyond

In 1951, the International Sanitary Regulations were adapted into a single set of regulations and became binding on all WHO Member States. The regulations maintained the objective of the conferences held a century earlier, focusing on disease control measures while ensuring as little interference in international trade as possible. Eighteen years later, the regulations were revised and named the International Health Regulations [IHR(1969)] (Katz & Fischer, 2010). The revised regulations focused on objectives to “strengthen the use of epidemiological principles as applied internationally, to detect, reduce, or eliminate the sources from which infection spreads, to improve sanitation in and around ports and airports, to prevent the dissemination of vectors and, in general, to encourage epidemiological activities on the national level, so that there is little risk of outside infection establishing itself” (WHO, 1983).

Towards the end of the 20th century, it became evident to many member states that the IHR were inadequate. States parties were noncompliant, WHO had limited abilities to conduct surveillance and outbreak response, and the regulations only covered three dated priority diseases (Fidler & Gostin, 2006). In the late 1990s, the ability of the regulations to provide the tools for preparedness and response to emerging and re-emerging diseases, including hemorrhagic diseases, led to a resolution at the 1995 World Health Assembly (WHA) to revise the IHR to better address current threats to global health (WHA, 1995). However it took the 2002–2003 outbreak of Severe Acute Respiratory Syndrome (SARS) to motivate the international political community to revise the IHR, in part due to the inability of WHO during the SARS outbreak to compel nations to provide information, even when doing so would be in the global interest. SARS provided the evidence that disease epidemics are a direct and continuing threat to health and economic interests and provided the political momentum to act, advancing diplomacy on global health (Feldbaum, Lee, & Michaud, 2010; Keogh-Brown & Smith, 2008). In May 2005, the WHA adopted the Revised International Health Regulations, known as IHR (2005), which entered into force in 2007 and called on states parties (now 196) to develop the core capacities required to detect, assess, report, and respond to any potential “public health emergency of international concern,” regardless of origin (WHA, 2005). The IHR (2005) combines epidemiological evidence and evidence-based decision making with the diplomacy of state sovereignty such as standards and obligations, to enforce legally binding regulations in the service of global health (Gostin, 2008; WHO, 2005).

The identification of a novel human influenza strain and subsequent declaration of a pandemic in 2009 tested the IHR (2005), leading to the first declaration of a public health event of international concern (PHEIC). The IHR (2005) proved its value providing mechanisms for rapid communication and cooperation between Mexico, the United States, WHO, and others, while at the same time highlighting concerns about the balance between global governance of disease control measures and national sovereignty (Katz & Fischer, 2010). Since the 2009 flu pandemic H1N1, WHO has declared three additional PHEICs: wild type polio and Ebola in 2014, and Zika in 2016.

In support of achieving global compliance with the IHR (2005), the United States in coordination with 26 other countries, WHO, the United Nations Food and Agriculture Organization (FAO), and the World Organization for Animal Health (OIE), committed in February 2014 to the Global Health Security Agenda (GHSA), an effort to promote global health security as an international priority, and specifically to elevate and accelerate progress towards a world safe from disease threats (HHS, 2014). The GHSA aims to develop capacity to prevent, detect, and respond to disease outbreaks while aligning with the IHR (2005), the OIE, Performance of Veterinary Services (PVS) pathway, and other health security frameworks. Country leaders and the GHSA Steering Group developed and approved 11 action packages to meet the GHSA objectives. These action packages, each led by a country (or countries), are organized under the frameworks Prevent, Detect, and Respond. As of November 1, 2016, 55 countries had committed to the objectives outlined in the action packages Importantly, the GHSA has raised the level of political discourse on infectious diseases to beyond Ministries of Health, and has made biological threats a topic for discussion amongst world leaders.

There are now over 50 multilateral agreements related to health, with almost a dozen devoted explicitly to infectious diseases (Kates & Katz, 2011). Additionally, the United States alone has hundreds of bilateral agreements related to health, demonstrating how official instruments of foreign policy are used to pursue health goals (U.S. Treaties in Force, 2016). These agreements now range from outlining cooperation on HIV, TB, and malaria to providing guidelines and regulations for sharing biomedical samples of influenza for research, development of medical countermeasures, and shared benefits.

These are just a few examples of global health policies that cover a broad set of interest including national security as well as economic, political, and humanitarian concerns. To combat an array of global health security threats, policymakers and the global health community must work together. Response to these issues requires various foreign policy tools including but not limited to improved disease surveillance systems, investments in health education, work force training, immunization, and effective preparedness and response strategies.

### Global Trends in Disease

To understand the dynamics that underlie the relationship between foreign policy and infectious disease, global trends in both must be examined. While the focus of this chapter is infectious diseases, it is critical to address the broader context of global health, particularly the growing burden of non-communicable disease. According to the World Health Organization, chronic conditions, including heart disease, cancer, and diabetes, cause approximately 38 million deaths each year; three-quarters of these deaths occur in lower and middle income countries (CFR, 2014). Indeed, non-communicable diseases have overtaken infectious illness as the leading causes of death and disability, even in developing countries, leading populations that still suffer from significant infectious pathogens to buckle under a double burden of disease (WHO, 2015). Moreover, the chronic nature of many non-communicable illnesses places an extreme strain on already under-resourced health systems and personal finances, stagnating economic growth, and entrenching poverty.

These trends in non-communicable diseases are driven by a number of factors, including demographic changes such as increasing urbanization and population longevity; the globalization of world markets and supply chains, promotion of products that are damaging to health, including refined sugars and tobacco; and lack of access to preventive healthcare, often due to poverty or weak health systems. These trends look set to continue, making non-communicable diseases and their drivers ever more important to foreign policy considerations. However, the threat of infectious diseases persists, and although notable progress has been made in recent decades, particularly with respect to the “Big Three” of HIV/AIDS, tuberculosis, and malaria, as well as vaccine-preventable infections and neglected tropical diseases, there are worrying signs of re-emergence of diseases previously thought to be controlled, as well as emergence of new pathogens whose impact cannot fully yet be predicted, particularly in light of rapid globalization, climate change, and increasing global population density. This review of global trends in infectious disease prevalence and burden concludes with an overview of efforts to forecast what the future holds with respect to infectious disease.

HIV/AIDS, tuberculosis, and malaria together account for the largest number of deaths globally per year. According to the Global Burden of Disease Study 2015, HIV incidence peaked in 1997 with approximately 3.3 million new infections per year, dropped to about 2.6 million per year in 2005, and has remained relatively constant around this level since that time (GBD, 2015 HIV collaborators, 2016). However, the number of people living with HIV/AIDS has continued to grow, partially due to increased longevity of patients, with significant decreases in mortality from a peak of almost two million deaths per year in 2005 to about 1.2 million in 2015. These positive statistics point to the successes of large-scale interventions that have integrated improved diagnostic testing, psychosocial counseling, improved access to life-saving anti-retroviral drugs, and a strong emphasis on prevention, including male circumcision and safe sex education and practices. Prevention of vertical transmission from mother to child has been particularly successful; according to UNAIDS (2015), over a million new infections were prevented between 2009 and 2014 due to provision of antiretroviral medicine to expectant and nursing mothers.

Tuberculosis (TB) remains one of the leading causes of death worldwide, responsible for an estimated 1.8 million deaths in 2015, of which 0.4 million were in individuals co-infected with HIV, highlighting the additive negative impact of these two diseases; one in three HIV deaths is due to TB (WHO, 2016a; WHO, n.d.). Rates of mortality, prevalence, and incidence have all decreased in recent decades. Key to the success in reducing TB deaths has been effective diagnosis and improved access to treatment; together, these interventions are estimated to have saved 43 million lives between 2000 and 2014. While these numbers are moving in the right direction, the growing challenge of multidrug resistant (MDR) tuberculosis has impacted progress; while levels globally have remained more or less steady, certain regions of the world are experiencing an on-going epidemic. In Eastern Europe for example, up to one third of new TB patients are diagnosed with MDR TB (Falzon et al., 2014). Of concern is the re-emergence of TB as a public health threat in high-income countries, linked with migration. WHO has conditionally approved testing for targeted latent TB screening and treatment for incoming migrants from high-risk countries, though concerns remain regarding the efficacy of such programs, as well as the overall incidence of TB in migrant populations (Pareek, Greenaway, Noori, Munoz, & Zenner, 2016).

The data for malaria also generally present a positive picture, with significant decreases in numbers of cases (37% reduction) and deaths (60% reduction) since 2000. The annual number of global deaths due to malaria is estimated to have fallen below 500,000 for the first time in history; a remarkable achievement (WHO, 2015). Improved point-of-care rapid diagnostics, innovative funding mechanisms to improve access to appropriate treatment, prevention of malaria in pregnancy and congenital malaria through intermittent preventive treatment, and large-scale distribution of long-lasting insecticide treated bednets (LLINs) can all be credited with contributing to these successes. Overall mortality and morbidity rates continue to lag in Africa compared to the rest of the world (90% of malaria deaths occur in sub-Saharan Africa), though the region has managed to reduce deaths in children under five by 71%, compared to 65% worldwide (Ryan et al., 2015). As a vector-borne disease, one challenge facing future malaria control efforts may be climate change, with rising temperatures and changing rainfall patterns expected to result in a net increase in the overall population at risk of infection (Caminade et al., 2014).

The common gains seen across HIV, TB, and malaria are owed in large part to bold and innovative intervention strategies that came into being in the early 2000s, backed by novel funding approaches. In 2003, President George W. Bush signed Public Law 108-25, known as the “United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003,” which appropriated $15 billion USD over five years to support activities to combat the three diseases, under the President’s Emergency Plan for AIDS Relief (PEPFAR) (P.L. 108-25, 2003). While controversial due to its emphasis on abstinence for prevention of new infections, the bill nonetheless represented the largest single contribution in history dedicated to tackling an infectious disease threat and was reauthorized in 2008, and again in 2013 (HR 5501-2, 2008; Ottenhoff, 2013). Launched in 2005, the President’s Malaria Initiative (PMI) became the focus of the U.S. effort dedicated to fighting malaria. On a global level, in 2002, the Global Fund to fight AIDS, TB, and Malaria was established as a multi-sectorial financing institution to support locally managed HIV/AIDS, TB, and malaria control projects in dozens of countries, investing approximately$4 billion USD per year. In 2013, U.S. bilateral funding (via PMI) and the Global Fund accounted for two thirds of all global funding for malaria control. While significant funds have been directed to global health activities over the past two decades, advocates note that increased expenditures will be required to achieve further reductions in transmission and meet global targets (Lancet H.I.V., 2016).

In contrast to the Big Three diseases, vaccine-preventable diseases and neglected tropical diseases present somewhat different trends and challenges. Vaccine-preventable diseases, including polio, measles, pertussis, tetanus, and many others, were widely seen as targets for elimination, given they can be prevented through cheap, safe, and effective immunizations. Indeed, immunization was responsible for impressive reductions in death and disability in the 1980s and 1990s and was placed at center stage at the Millennium Summit in 2000 as a key strategy for reducing deaths among children under five by 2015. Unfortunately, issues of vaccine access and delivery, particularly in remote, strife-ridden, and/or impoverished areas has resulted in many millions of children—as many as 24 million per a 2007 estimate—not receiving their full course of routine childhood immunizations (UNICEF, 2009). Polio, for example, has stubbornly resisted a global final push for eradication. Despite cases decreasing more than 99% since 1988, tiny pockets of transmission persist in conflict- and poverty-ridden regions of Afghanistan and Pakistan, with occasional cases also detected in northern Nigeria (GPEI, 2016). However, there are signs of success: deaths from measles, one of the leading causes of death in young children, were reduced by 79% between 2000 and 2015 due to vaccination, to an historic low of just over 130,000 (WHO, 2016b). In high income countries, misleading reports over the safety of vaccines has led to a reduction or stagnation in vaccination rates in certain populations, resulting in highly publicized outbreaks of diseases like measles and mumps. In Europe, the number of measles cases doubled between 2007 and 2014 (WHO EURO, 2015).

Neglected tropical diseases (NTDs), such as soil-transmitted helminths, schistosomiasis, lymphatic filariasis, and leishmaniasis, are diseases of poverty that tend to result in relatively low numbers of total deaths per year but have a disproportionately large impact on morbidity, with estimates that they account overall for over 26 million disability-adjusted life years (DALYs) (Hotez & Utzinger, 2014). Despite these impacts, NTDs were, until recently, largely overlooked by the global community, earning them the “neglected” moniker. Recent funding initiatives by the Bill and Melinda Gates Foundation, USAID, and others, as well as new advocacy and coordination efforts such as the London Declaration, have emphasized the opportunities for effecting large impacts on NTD burden through relatively simple and achievable interventions, such as improved water, sanitation, and hygiene (WASH) facilities, improved rapid diagnostics, and increased access to safe and affordable medication for treatment (London Declaration, 2012). These efforts provide an optimistic view of the future with respect to reducing the burden of NTDs; integration of NTD control strategies with other health interventions may result in further opportunities for cost-effective expansion of control efforts (Hotez et al., 2006).

In addition to the infectious diseases that have plagued humanity for centuries, the emergence of new infectious diseases poses a continuous and insidious threat. Studies have shown that emerging infectious disease (EID) events have increased in frequency since 1940, now resulting in approximately one new disease a year (Jones et al., 2008). Among these recorded EID events, the majority have resulted from spillover of disease from animal populations into humans; recent examples include HIV (thought to have originated in chimpanzees), Ebola virus (bats are hypothesized to be the reservoir), and Severe Acute Respiratory Syndrome (also originating in bats) (Leroy et al., 2005; Li, Zhengli, & Yu, 2005; Sharp & Hahn, 2011). Another important category of emerging infectious diseases relates to mutations in existing pathogens that change their pathogenicity or transmission, such as the emergence of novel influenza strains or antimicrobial resistance genes in bacteria, both of which may also be mediated or impacted by transmission between different animal species and humans. The causes behind disease emergence and spread are varied and likely additive, and include biodiversity loss, climate change, agricultural intensification, globalization, urbanization, breakdown in public health measures, and microbial adaptation (Jones et al., 2008; Morse, 1995; Keesing et al., 2010). Global attention has been focused most recently on the Zika virus, which, through a combination of mutation, global transport networks, dense urban populations, and perhaps also climatic factors, has rapidly invaded the Western hemisphere and caused hundreds of thousands, if not millions, of cases (WHO, 2016c).

The concern over EIDs, and particularly the fear of a new global pandemic, has resulted in numerous efforts designed to predict how and where the next pathogen might originate. Such predictive capability might allow for prevention of the pathogen emergence in humans, or at minimum improved preparedness and response capabilities. To date, it has been difficult to design models to predict the emergence of infectious diseases; the “hot spots” risk map produced by Jones and colleagues notoriously predicted an extremely low likelihood of disease emergence from the Arabian peninsula, which turned out to be the geographical origin of the novel coronavirus responsible for MERS (Jones et al., 2008). It is likely that technological advances, as well as improved data collection, will improve forecasting; efforts such as USAID’s PREDICT program and the proposed Global Virome Project are seeking to address the data gap by identifying and cataloging all viruses, with an emphasis on those viral families most likely to cause harm (Carroll, 2016; UC Davis, 2016). Integrating these data with information on drivers, such as climate change and antigenic drift, may yet provide more robust tools, for predicting not only the emergence and spread of novel pathogens, but also shifts in prevalence, virulence, and transmission in those infectious diseases that already exist.

### Infectious Diseases and Foreign Policy Today

The global health community has been making the same arguments about the intersect of health and foreign policy for over 15 years, arguing that supporting public health worldwide enhances national security and improves foreign relations, in addition to addressing population health needs (Kassalow, 2001; Neureiter, 2001). And just like today, the argument is presented in an almost desperate need to convince decision makers how important the infectious disease threat is.

The calls for improved disease surveillance, health investment, disease prevention, workforce development, and access to care are the same. The global community has supported these areas over the past 15 years, with more investment than ever before, including massive increases in funding from developed nations, public private partnerships, and philanthro-capitalists. Yet, there is still much more to do: more systems to build, more diseases to fight, and more people to train.

The acceptance of the infectious disease threat as national security and foreign policy concerns are documented in the U.S. National Security Strategies. Strategies under the George W. Bush administration explicitly discussed pandemics and bioterrorism as real threats. The 2015 U.S. National Security Strategy prioritizes infectious diseases as a key global threat requiring specific strategies and engagement across multiple sectors of government (White House, 2015).

In addition to prioritizing infectious diseases as key to national and international security, there is a transition in the notion of sustainability and capacity building related to global health assistance programs. In a 2001 CFR report, the authors cite Brent Scowcroft, the national security advisor in the 1980s and 1990s, who declared, “We [the US] don’t consult, we don’t ask ahead of time. We behave to much of the world like a latter-day colonial power.” The report then went on to say, “We have to be interested in what others think about their own future, rather than projecting our solutions onto them” (Kassalow, 2001). Since 2001, we have seen a shift in thinking that is slowly starting to become practice. Donor supported efforts to build capacity to fight infectious diseases are beginning to focus on longer term efforts in partner countries, and the global health agenda is shifting to be less donor driven. This was seen in the development of the Sustainable Development Goals (SDGs), which involved a more inclusive process than the previous Millennium Development Goals (MDGs). It is not a perfect process yet, but the shift is happening, and we are seeing arguments for how this approach also enhances foreign policy.

It is now generally accepted that engagement with nations to build capacity to fight infectious disease supports population health and builds relationships between nations that may be used to facilitate discussions on a range of issues. Bollyky and Goosby note that this engagement in population health and relationship building also enables the establishment of a dialogue that can help transition global health from donor-recipient relationships to partnerships where governments invest in their own population health, build programs in collaboration, and plan for long-term sustainability of health endeavors (Bollyky & Goosby, 2016).

### Pathways Between Health and Foreign Policy

Foreign policy has been used to coordinate response to infectious disease events and to advance population health around the world. Conversely, collaboration on infectious disease prevention, preparedness, and response has been used strategically by nations to advance diplomacy and improve foreign relations through health or medical diplomacy engagements, often considered a projection of “soft power.” Both approaches have become integral to foreign policy, and health and foreign policy have become intertwined and used with different levels of effectiveness by governments around the world.

In this section we explore the different pathways between health and foreign policy, starting with examples of soft power health engagements to support foreign relations. We then look at an example of how instability leads to disease, including the relationship between population movement and the burden of infectious diseases. The next set of pathways demonstrate how infectious disease cause social disruption, including market failure, and finally, we explore how infectious disease impacts, and is impacted by, military forces.

#### Soft Power Engagement: Fighting Infectious Disease to Support Foreign Relations

##### Medical Diplomacy: Examples of China and Cuba

China and Cuba provide complimentary yet contrasting examples of how health services can be used as a soft power tool for diplomacy, notably to secure international recognition, develop bilateral ties, and potentially gain access to profitable economic opportunities.

Both countries started experimenting with health diplomacy in the 1960s, sending medical teams to Algeria in the wake of its devastating war of independence and civil unrest (Anshan, 2011; Gleijeses, 1996). Motivations for the missions included a strong anticolonial sentiment (particularly for Cuba), gaining international recognition, and exporting Communist ideologies while performing the ethical duty of providing health care to those in need (Werlau, 2013).

For Cuba, investment in healthcare services and education has been a hallmark of the regime since the 1959 revolution, leading to health indicators that rival that of the United States (Keck & Reed, 2012). A small island nation, geopolitically and economically isolated during the Cold War, Cuba’s highly trained medical doctors were an export gratefully received by dozens of developing countries around the world, gaining Cuba public praise along with hard-currency payments. This influx of income became increasingly important as the Cold War came to an end and Cuba was hit by the economic impact of continuing embargoes without Soviet subsidy. It is also worth noting that Cuba exploited medical diplomacy in the opposite direction as well, by offering free medical and veterinary education on the island to hundreds of foreigners, further increasing international ties, and serving to export Cuban revolutionary ideologies abroad when these students completed their degrees and returned home (Feinsilver, 2008).

China’s initial forays in medical diplomacy also began with sending medical teams to developing countries, particularly in Africa, to build prestige and recognition. However, as China has grown economically and its international influence has correspondingly increased, the emphasis and motivation of its health diplomacy efforts have also shifted. Rather than focus on medical personnel, recent Chinese investments in health diplomacy have tended to involve larger infrastructure projects, such as building hospitals or clinics (Anshan, 2011). These investments are seen as increasingly important in China’s diplomatic relations with African nations, whose voices (and votes) are valued by Beijing in international fora such as the United Nations and the World Trade Organization (WTO), and where China has significant economic interests (China Daily News, 2015; Knowledge & Wharton, 2011).

The 2014 West African Ebola crisis provides a useful snapshot of the current status of Chinese and Cuban medical diplomacy. In keeping with its traditional strengths, Cuba sent a team of highly trained medical personnel to the region during the outbreak; indeed, its medical personnel contribution was the single largest of any country (Kupferschmidt, 2014). These teams were welcomed by the beleaguered nations, who noted long histories of friendship with Cuba (Mark, 2014). A testament to its success in providing medical education, Guinea’s appointed lead for the Ebola response was a medical doctor who received his training in Cuba. In contrast, China provided a much more varied and extensive portfolio of assistance to the region during the outbreak. Overall, the Chinese government is thought to have contributed over $100 million to the outbreak response, including construction of a treatment center in Liberia, deployment of hundreds of medical and public health personnel, and procurement of critical medical supplies (Taylor, 2015). This significant level of assistance was likely motivated by a combination of factors, including a desire to improve perceptions of Chinese engagement in the region, as well as internal pressure to “do something,” given the thousands of Chinese workers and estimated$15 billion worth of economic activity by Chinese firms in the region.

#### Instability Leading to Disease: Relationship Between Population Movement and Disease

##### Population Movement

The root cause for the spread of plague in medieval times, as well as the global spread of HIV in the late 20th century, was human population movement, a term that encompasses the myriad of ways that people travel from one area to another. Population movement occurs because of two main mechanisms termed by Nathaniel as push or pull factors (Nathaniel, 2003). People are pushed from their existing location based on armed conflicts, natural disasters, poverty, drought, or famine, or they can be pulled to a new destination seeking better social and economic opportunities, or political stability. In this way, push and pull factors can occur simultaneously to promote and/or sustain population movement. The same factors that push populations, such as political instability or conflict, also directly promote the spread of communicable disease resulting in breakdowns in public health measures; cessation of disease control programs such as measles, malaria, and leishmaniasis; and diversion of resources from public health programs to defense. Other factors promoting the spread of disease, including densely populated areas of multi-ethnic compositions and immune status, inadequate sanitation, and crowded living conditions, occur at the place of refuge or relocation. The UN High Commissioner for Refugees (UNHCR) Global Trends on Forced Displacement, in a 2015 report, estimates that 65.3 million people, or one person in 113, were displaced from their homes by conflict and/or persecution in 2015; this includes refugees (21.3 million), internally displaced persons (IDPs) (40.8 million), and those seeking asylum (3.2 million) (UNHCR, 2016). There are more people on the move today than there have been since the end of World War II, which can directly impact health and welfare.

One of the major challenges with mass population displacement is that of geographical concentration. In 2016, over half of the world’s refugees came from three countries: the Syrian Arab Republic (4.9 million), Afghanistan (2.7 million), and Somalia (1.1 million), and they were hosted in only ten countries, each bordering a conflict zone. In 2016, for the second year in a row, Turkey hosted the largest number of refugees at 2.5 million. Pakistan is second, hosting 1.6 million, followed by Lebanon (1.1 million), the Islamic Republic of Iran (979,400), Ethiopia (736,100), and Jordan (664,100). Lebanon hosted the largest number of refugees in relation to its national population, with 183 refugees per 1,000 inhabitants; Jordan was second at 87 per 1,000 (Bilak et al., 2016).

Forced displacement is usually associated with conflicts that result in large refugee populations (Somalia, Afghanistan); a new or reignited conflict or war (Syria, Yemen, Ukraine); or natural disasters (Nepal, Haiti). The Internal Displacement Monitoring Centre (IDMC) Global Report on Internal Displacement indicated that there were 8.6 million new cases of IDPs in 2015, an average of 24,000 people displaced a day, with 4.8 million displaced in the Middle East alone (Bilak et al., 2016). Yemen, Syria, and Iraq accounted for more than half. In total there were 40.8 million IDPs worldwide as a result of conflict and violence at the end of 2015, 2.8 million more than 2014, the highest figure recorded to date. Disasters, categorized as floods, storms, earthquakes, volcanic eruptions, wildfires, landslides, and extreme temperatures, displaced roughly 19.2 million people across 113 countries in 2015, more than twice the number who fled conflict and violence that year (UNHCR, 2016).

##### The Emergence and Re-Emergence of Disease due to Population Movement

Mass population movement creates new opportunities for the spread and establishment of common and novel infectious diseases. In these environments, a once controllable disease can lead to an epidemic. One of the diseases most frequently associated with challenged environmental infrastructure is cholera, an easily preventable disease; yet it has caused many large-scale outbreaks in refugee camps globally (Lam, McCarthy, & Brennan, 2015). The health needs of displaced populations vary considerably, including chronic disease, maternal and child health, infectious disease, and mental health, and the pressure these requirements place on health systems and the workforce is immense. When considering internal displacement, the burden of infectious disease can compound national political destabilization and further conflict. Damage to health systems infrastructure during and in the aftermath of conflict and political instability is often the main reason for failing health and communicable disease in an affected population. Damage to the physical environment—including food safety and supply, sewage treatment and water safety—also adversely affects population and animal health. International guidelines and standards, provided by the United Nations outline principles related to protection from displacement; protection during displacement; humanitarian assistance; and the return, resettlement, and reintegration of IDPs (UNHCR, 2004). However, obtaining the financial and technical support required for implementation is a major challenge.

For those who seek refuge in another country, the burden placed on the host country to provide food, shelter, and other basic needs is overwhelming. Unfortunately this burden has fallen primarily to low-income and middle-income countries (LMICs), which in absence of a refugee population, face their own national disease burdens. For example, the spillover of refugees and communicable diseases into Lebanon, Jordan, and Iraq demonstrates the rippling consequences of the protracted Syrian conflict.

The Syrian refugee crisis has attracted much media attention, largely due to the atrocities inflicted by Bashar al-Assad’s government on its citizens, and the emergency and gain of influence of the Islamic State of Iraq and Syria (ISIS).1 Of the 5.8 million total refugees, over one million have settled in Jordan, a country with a tradition of receiving refugees since its independence. More than two million Palestinian refugees now live in Jordan; most have been granted full citizenship.2 Jordan has also received a steady influx of Iraqi refugees since the 2003 Gulf War. While Iraqi refugees face challenges in obtaining legal employment they receive free access to health and education services in Jordan (IRINnews, 2013). In total, there are roughly 2.5 million refugees (Syria, Iraq, Yemen, Libya) accounted for in Jordan.

##### Impact on Jordan’s Health Systems

Jordan has one of the most advanced and modern health systems in the Middle East, comprised of several levels of care, from village health centers to specialty hospitals, providing primary care to roughly 97% of its citizens (WHO EMRO, 2006). In a matter of a year, impacts from the refugee crises on economic growth, fiscal health, and the ability to provide basic services have threatened to undermine the country’s progress. Jordan faces an increased prevalence and risk of infectious disease among host communities as well as major demands for health services (maternal child, mental health, chronic disease, communicable disease), infrastructure, and medicine with an associated financial strain; increased occupancy rates in hospitals and health centers placing a strain on the healthcare work force; and, possibly of greatest long-term impact, a reversal in important global health indicators and goals, including Millennium Development Goals (MDGs) (Gharaibeh, 2015).

By 2015, Jordan had received 1.5 million Syrian refugees, accounting for roughly 25% of the entire population of the country. Estimates indicate that 53% of the Syrian refugee population is under 18 years of age (Gharaibeh, 2015). This influx of refugees created two separate health challenges: detecting and responding to public health events in crowded refugee populations in the short term, and managing the strain on Jordan’s national health system in the mid- to long term.

The devastated health care infrastructure in Syria has severely impacted the health of incoming refugees to Jordan. The cessation of vaccine programs has left millions of Syrian citizens vulnerable to vaccine-preventable diseases, including polio and measles. Of the 1.8 million Syrian children born since the conflict, over 50% are unvaccinated (Sharara & Kanj, 2014). Overcrowding, unsanitary conditions, and the efficient transmissibility of measles make the Syrian population highly susceptible and increase the risk of spread. In Jordan, 24 cases of measles were reported in 2012, while over 200 cases were reported in 2013. The Zaatari refugee camp in Al Mafraq Governorate, built in 2012, one of five camps along the Syria border, filled quickly to its capacity of 120,000 by early 2013, becoming the fourth largest population center in Jordan. It is currently housing 80,000 people (UNHCR, 2016). A combination of bilateral donors, multilateral organizations, international and national non-governmental organizations (NGOs), and faith-based organizations, working in coordination with the Jordan Ministry of Health, the WHO, and UNHCR, launched a massive vaccination campaign in November 2013 and established ongoing active disease surveillance, clinics, and laboratories, and strengthened water and sanitation systems in response to fears that infectious disease outbreaks in Zaatari might threaten not only the camp’s residents, but adjacent communities and their precarious water supplies (Gavlak, 2013). While the international community responded to needs in the camps, the real strain was felt among the most northern governorates and urban centers in Jordan. Roughly 85% of Syrian refugees (not registered with UNHCR), reside outside the camps in Jordanian communities. By July 2013, Ministry of Health officials reported that surgical operations and cancer treatments provided to Syrians by Jordan’s public hospital system had climbed more than six-fold between 2011 and 2013. Syrian patients disproportionately utilized neonatal incubators in the public hospitals of Jordan’s northern governorates (Murshidi, Hijjawi, Jeriesat, & Eltom, 2013). The demand for financial support was shadowed by the significant concern and drain on finite human resources from both the local and national level. Health care workers and ministry officials tried to balance on-going provisions of health care for their citizens as well as the new workload of crisis management.

Jordan has been forced to set in place various mechanisms to maintain a functional health care system, while addressing the influx of refugees and their associated disease burden. The experience in Jordan demonstrates that the impact of population movements and the infectious disease burden that comes with such movements, impacts national and regional political stability, economies, agriculture, veterinary health, chronic and mental health, food safety, and water quality.

##### Migration-Linked Establishment of Urogenital Schistosomiasis Transmission in France

Schistosomiasis is a neglected tropical disease caused by trematode flukes of the genus Schistosoma. The life cycle is complex and requires freshwater snails as an intermediate host, and also a vertebrate terminal host, such as humans. Terminal hosts are infected through contact with water contaminated by schistosome larvae, which can penetrate directly through the skin during activities such as washing and bathing. Once infected, terminal hosts continue the life cycle by excreting eggs in urine or feces (depending on the species) near freshwater sources harboring appropriate snails.

The disease is predominantly found in less economically developed countries, where it is a disease of the poor; however, it used to be widespread across the Mediterranean, with reports of human cases in Portugal as late as the 1950s (Berry et al., 2014). Improvements in sanitation and hygiene, as well as improved diagnostics, treatment, and snail control, had led to the disease being considered eliminated from Europe.

In 2014, a cluster of urogenital schistosomiasis cases were detected in French and German patients who all reported travel to Corsica in the summer of 2013. None had recently traveled to schistosomiasis-endemic countries. Investigations in the 1960s had revealed a cattle form of schistosomiasis on Corsica, but no human cases, though the appropriate intermediate host snails were known to be present in major waterbodies, including the Cavu River, a popular bathing site for tourists (Berry et al., 2016; Calavas & Martin, 2014). French authorities banned bathing in the river during the summer of 2014, but new cases were detected in 2015 after the ban was lifted, indicating persistent transmission (Berry et al., 2016). Genetic analysis revealed that the infections were caused by two different species of schistosome—one associated predominantly with cattle, and the other with human infections—as well as hybrids of the two species. All samples were closely related to populations from Senegal, suggesting a West African introduction through an infected traveler (Boissier et al., 2016).

This example highlights the growing potential for introduction and re-emergence of vector and snail-borne pathogens through human population movement into previously disease-free, but ecologically and climatically favorable, regions of the world. Control of these new transmission foci will therefore require not only a public health response, but also a careful and considered foreign policy perspective, to prevent non-evidence based backlash against migrants and travelers.

#### Disease Causing Social Disruption

##### Forever Young: The “Youth Bulge” and Social Instability in Southern Africa

It is well recognized that improved health services targeting mothers, newborns, and young children have resulted in impressive reductions in child mortality across most of the world (WHO, 2016d). In countries where fertility rates remain high, such as across much of the developing world, the result has been a “youth bulge,” where children and youth make up a large proportion of the overall population (Lin, 2012). In 2015, youth under 15 accounted for more than 40% of the population in 35 (out of a total of 44) countries in sub-Saharan Africa; in contrast, this proportion is just 18% and 19% in the United Kingdom and the United States, respectively (World Bank, 2016). The youth bulge is an important demographic phenomenon as it has been associated with civil instability; some studies have noted a higher rate and intensity of civil conflict in countries with high proportions of youth, though it is equally important to note this has not been demonstrated to be a causal relationship (Beehner, 2007; Cincotta, 2004; Sommers, 2011). However, the demographic shift does tend to reduce employment opportunities for young people, forcing them to seek opportunities in the informal sector or rely on family networks, thus reducing the financial resilience of caregivers, which in turn can lead to overall societal economic instability.

In southern Africa, while fertility rates are lower than elsewhere on the continent, the challenge of the youth bulge has been compounded by the HIV/AIDS epidemic. Improved access to testing and treatment has reduced mortality in recent years, but many of the generation who were first infected in the 1990s and early 2000s (as high-risk adolescents at the time) did not have access to treatment at the time and succumbed to the disease. The impact of this “lost generation” can be seen in demographic data for countries such as Botswana and South Africa, where life expectancy for people born in the 1960s–1980s plummets in the 1990s–2000s, before slowly regaining ground (Preston-Whyte, 1994). Similarly, while increased roll-out of interventions to prevent mother-to-child transmission of HIV have been very successful in recent years, and have stabilized and even reduced the incidence of new infections in infants, these efforts were not introduced soon enough to protect the current generation that are entering adolescence now. Indeed, the number of adolescents on anti-retroviral therapies (ARTs) increased between 10- and 20-fold between 2004 and 2014, and it is anticipated that these increases will continue in the number of 15–19-year-olds on ARTs through 2025 (Maskew et al., 2016).

This presents significant societal challenges, not least for how the health system must adapt to cope with this demographic block. While HIV prevalence among adolescents is falling, condom use is reported to be low, as is uptake of voluntary testing and counseling services (UNFP, 2012). Young women are also known to be particularly vulnerable to HIV transmission, and studies have shown that young people overall are at risk of being lost to follow up, particularly as they transition between child-oriented health services and those geared towards adults (Jewkes, 2010; Leach-Lemens, 2016; Muula, 2008). Health systems may need to change how they approach HIV-infected adolescents and consider cohort-specific interventions that not only target the health and behavioral issues predominant in this age group, but also incorporate economic and social support mechanisms to address the other challenges associated with the youth bulge.

##### Disease-Causing Societal Disruption: Market Failure and Wide Spread Impact on Society: The Case Of Influenza

Influenza is a viral zoonotic pathogen that has a wide host range and is responsible for seasonal epidemics and occasional pandemics in humans. Wild aquatic birds are known to be the primary reservoirs of influenza viruses and are responsible for introducing avian influenza (AI) viruses into domestic poultry and swine, the intermediate hosts for influenza transmission, and a necessary step for viral adaptation to humans (Alexander, 2000; Webby & Webster, 2001). While direct avian-to-human transmission of influenza has occurred in the past, most notably infections with highly pathogenic H5, H7, and H9 subtypes, the virus typically requires re-assortment (antigenic shift) or adaptation (antigenic drift) in an intermediate host before establishing itself in the human population (Poovorawan, Pyungporn, Prachayangprecha, & Makkoch, 2013). There have been four documented human pandemics since the start of the 20th century: H1N1 in 1918, H2N2 in 1957, H3N2 in 1968, and H1N1 in 2009.

While a seasonal flu has a manageable impact on domestic and global economies, a pandemic flu has the potential for a severe economic crisis (Elhadad, 2014). A worldwide influenza pandemic would impact travel, trade, tourism, food, investment, and financial markets. Influenza outbreaks, like other zoonotic diseases, not only affect population morbidity and mortality rates, and the associated healthcare costs; they also impact the available food supply (poultry and pork industries) and global supply chains.

In December 2014, highly pathogenic avian influenza (HPAI) H5 was detected in domestic poultry in America’s Midwest. This outbreak, which continued until June 2015, caused outbreaks in 21 states, affecting 211 commercial and 21 backyard flocks (CRS, 2015). More than 48 million chickens, turkeys, and other poultry were euthanized to control the outbreak. The cost to the poultry industry was enormous, with losses estimated at $3.3 billion, accounting for direct costs of management and response, and the indirect costs of multisectoral engagement. During the outbreak, 18 U.S. trading partners imposed bans on all shipments of U.S. poultry and products, and 38 trading partners imposed partial or regional bans on shipments from states or parts of states with HPAI cases. China, Russia, and South Korea, three of the top ten importers pf U.S. poultry meat in 2014, banned all imports of U.S. poultry. While there were no reports of human infection, the effects to business and the cost of the response, over$950 million, was devastating (Belkhiria, Alkhamis, & Martínez-López, 2016). This outbreak could have been exponentially worse had it occurred in a low-resource country with ineffective response and control mechanisms and/or had the virus demonstrated effective in human-to-human transmission.

A 2008 World Bank report estimated the macroeconomic impact of human pandemics with mild, moderate, and severe scenarios based on McKibbin and Sidorenko’s analysis (Burns, van der Mensbrugghe, & Timmer, 2008; McKibbin & Sidorenko, 2006). Each scenario assumes that control efforts are comparable to those observed during previous epidemics (attack rate, the pathogenicity of the virus, and the adequacy of control measures) and reflects differences in population density, poverty, and the quality of healthcare available. The report found that, on a global scale, a mild pandemic would reduce output by less than 1% GDP, a moderate outbreak by more than 2%, and a severe pandemic by almost 5%, resulting in a major global recession. Ten years later, a report by Fan, et al, found that the probably income loss from a pandemic would be 4–5% of GNI; expected losses would be $80 billion per year (Fan, Jamison, & Summers, 2016). #### Stresses on Military Forces and Military Forces Spreading Disease ##### Infectious Diseases as Stressors on Military Forces Infectious diseases and war have been linked throughout human history, to the extent that the conditions of war foster the spread of disease, while disease also impacts the process and outcome of conflicts. Examples of infectious diseases affecting or being affected by war are numerous, such as the plague of Athens in 430 bce while besieged by Sparta, which may have reduced the population of the city by as much as a third, leading to the city’s defeat in the first Peloponnesian war; or the influence of the First World War on the emergence and transmission of influenza in 1918, and many others (Littman, 2009; Smallman-Raynor & Cliff, 2004; Soupios, 2004). As military forces are particularly vulnerable to infectious disease threats (as well as spreading them), troop protection has become a critical consideration in military strategy and a significant source of investment (Thompson, Swerdlow, & Loeb, 2005). For example, the U.S.military spends a significant level of resources on both direct disease prevention and control efforts (such as education, training, and materiel), but it also invests heavily in infectious disease research, spending$47 million in 2010, for example (Murray & Horvath, 2007). This investment is seen as a saving against traditional defense expenditures, reflecting a decision-making process that explicitly integrates foreign policy considerations (Research America, n.d.).

The ways in which infectious diseases have impacted, and been impacted by the U.S. military throughout its history is clearly demonstrated through the example of malaria. Malaria has been a major cause of morbidity for American troops in every overseas military campaign in the 20th century, encompassing tens of thousands of cases and many millions of sick days for servicemen and women (Beadle & Hoffman, 1993; Malaria Vaccine Initiative, n.d.,). Malaria’s importance to the military has driven an enormous level of scrutiny, which in turn has had a major impact on the availability of public health interventions for the treatment and control of the disease. The U.S. military had a hand in the development, testing, and wide-scale deployment of the majority of anti-malarial compounds that contribute to saving millions of lives each year.

The impact that malaria has had on the U.S. military cannot be understated. Its history dates back to the Revolutionary War, when malaria was endemic across much of the southeastern United States. It is believed that use of quinine by the U.S. military dates back as early as 1830 and was used for treatment of cases during the Second Seminole War (Kitchen, Vaughn, & Skillman, 2006). Its use became widespread as a prophylactic among troops during the Civil War, particularly by the Union Army; some historians have suggested it might have been a factor contributing to the Confederates’ defeat (Magill, 2016).

Quinine, extracted from the bark of the cinchona tree, remained the primary form of anti-malarial medication well into the 20th century. Its ubiquity as a treatment and prophylactic drove the Germans to look for synthetic alternatives during World War I, as the majority of countries producing cinchona bark were held under Allied control. This situation was reversed in World War II, after the Japanese invasion of Java, which produced more than 90% of the world’s cinchona, leaving the Allies without a reliable supply. In response, the U.S. Army developed a systematic and organized approach to malaria research during the war years, which led to the development of a number of groundbreaking new compounds for malaria treatment and prophylaxis in humans, such as chloroquine (precursors for other important later drugs, such as primaquine and mefloquine, were also discovered during this era), as well as vector control, the most famous of which was DDT (Hays, 2000; Kitchen et al., 2006). These efforts were critical to stem the severe impact of malaria on U.S. servicemen both at home and abroad, and particularly in the high-risk malaria zones of Southeast Asia and the South Pacific. Indeed, malaria control may have had a significant role in the outcome of the Pacific theatre, due to General MacArthur’s astute recognition of the impact it was having on U.S. troops, and the implementation of a campaign under the General’s direct supervision that included vector control, behavioral education, and access to atabrine (a compound related to chloroquine), which reduced case incidence by 95% (Thompson et al., 2005).

The Korean and Vietnam Wars also provided cause for military research into anti-malarial compounds. In the former, troops were returning home with relapsing malaria, caused by Plasmodium vivax, which can result in long-term sequelae in the liver. Going back to precursors identified during World War II, the U.S. Army developed primaquine as a treatment specifically for relapsing malaria and performed large-scale studies on its use as a prophylactic in the 1950s and 1960s (Kitchen et al., 2006). However, it is the Vietnam War that was the impetus for the next major step forward in the military’s malaria research apparatus; tens of thousands of troops were deployed to high-risk transmission zones during the conflict, and with the malaria parasite in the region now largely resistant to chloroquine, rates of infection among U.S. servicemen reached as high as 1% per day. This precipitated the establishment of a drug discovery program at the Walter Reed Army Institute of Research (WRAIR) that ran from 1963 to 1976 (Croft, 2007). U.S. troops were not the only ones impacted by malaria during the Vietnam War; indeed, Northern Vietnamese leaders were also concerned at the impact the disease was having on their soldiers and requested assistance from the People’s Republic of China. Chairman Mao and Premier Zhou responded by setting up Project 523, a program largely analogous to WRAIR’s on the other side of the Pacific, and which involved hundreds of scientists, working across dozens of laboratories, all searching for new medications, with an emphasis on compounds isolated from traditional Chinese medicine (Miller & Su, 2011). Through this effort, Chinese scientists identified artemisinin in the 1970s; today, artemisinin and its derivatives are the major component of all front-line drugs recommended by WHO for the treatment of uncomplicated malaria (Cui & Su, 2009).

Despite the withdrawal of U.S. troops from Iraq and Afghanistan, culminating in 2011 and 2014, respectively, U.S. servicemen and women continue to deploy to bases in regions at risk of malaria transmission; consequently, the military continues to maintain a significant investment in malaria countermeasure research and development, spending over \$20 million per year between FY07 and FY13 (Moss & Michaud, 2013). Both the Army and the Navy have malaria-specific research programs; the Army’s is the Military Malaria Research Program (MMRP) at WRAIR, based in Maryland but working collaboratively with bases in Thailand and Kenya, with the mission to reduce morbidity and mortality from malaria not only in the military, but also in vulnerable populations around the world (WRAIR, n.d.). Its analogue in the Navy is housed in the Naval Medical Research Center (NMRC), with the primary objective of developing a safe and effective pre-exposure vaccine; it works in collaboration with centers in Africa, Asia, and South America (NMRC, 2016). WRAIR is also a collaborator in the vaccine-development project. These programs demonstrate the enduring linkages between malaria and the U.S. military, and highlight the significant public health benefits that can be derived.

##### Pestilence or Peace? Transmission of HIV and Cholera by UN Peacekeepers

The deployment of peacekeepers is one of the United Nation’s best-known tools for supporting countries in the difficult transition from conflict to peace, or in times of specific vulnerability, such as in the aftermath of a natural disaster. However, their status as foreign troops in environments that may be particularly prone to public health threats has also led to several instances where they have been implicated in the transmission of disease, notably HIV in the 1990s and early 2000s, and cholera in Haiti in 2010.

In 2000, the UN Security Council took the unprecedented move of acknowledging that peacekeepers were associated with increased risk of HIV transmission, based on their behavior during deployment and presence in high-risk countries (Pisik, 2000). While few concrete examples of transmission are described in the peer-reviewed literature, one instance involves Indonesian troops, stationed in Cambodia in the early 1990s, who used sex workers (including in neighboring Thailand while on leave) and were later identified as HIV-positive (Ledgerwood, 1994; Patel & Tripodi, 2007). Of more general concern was that large numbers of peacekeepers were being assigned to countries with high HIV incidence; in addition, many peacekeepers themselves come from countries with high HIV burdens. As an example, 37% of all peacekeepers in the early 2000s hailed from countries with “high” HIV prevalence (defined as greater than 5%) (UNAIDS, 2003). Given that the UN had also declared HIV to be a risk to societal and political stability, particularly for those countries suffering from conflict or in the recovery phase, a requirement was put into place that all UN peacekeeping missions would need to include an HIV education and community engagement component. While reducing the risks of transmission to deployed peacekeepers while also supporting public health seemed like a win-win scenarios, challenges with implementation resulted in slow progress through the early 2000s (Altman, 2005; Davies & Rushton, 2015; GAO, 2001).

While the full extent to which UN peacekeepers contributed to HIV transmission during missions will likely never be known, cholera in Haiti provides a much more stark and recent example of the catastrophic consequences of disease introduction into a vulnerable environment. The UN peacekeeping mission in Haiti, known as MINUSTAH, was first established in 2004. In October 2010, nine months after the cataclysmic earthquake that leveled Haiti’s infrastructure and resulted in hundreds of thousands of fatalities, cases of cholera were confirmed by the Haitian National Public Health Laboratory. The disease had never been reported on Haiti in recorded history, immediately leading to suspicions of an outside introduction. Molecular and epidemiological investigations later traced the pathogen to a Nepalese origin and identified a UN peacekeeper’s camp, which was found to have faulty sanitation pipes leading from the toilets into a local river, as the likely source (Davies & Rushton, 2015; Frerichs, Keim, Barrais, & Piarroux, 2012). Despite the mounting evidence, including an independent review panel, which released its finding in 2011, it was not until August 2016 that the UN Secretary General admitted the UN likely played a role in the outbreak and then finally issued a formal apology in Haiti in December 2016 (Katz, 2016; UN, 2016). Among the panel’s recommendations were enhanced health screening procedures for peacekeepers prior to deployment—a lesson that perhaps should already have been learned with HIV—and execution of health impact assessments for peacekeepers and their missions (Davies & Rushton, 2015).

Overall, these examples highlight the role that a globalized military presence can play in spreading infectious disease, particularly in the most vulnerable corners of the world, as well as the responsibilities of both national and multilateral military forces in ensuring health protection for their personnel and the communities they serve.

### The Future of Infectious Disease and Foreign Policy

In 2014, U.S. President Barak Obama called upon global partners to “change our mindsets and start thinking about biological threat as the security threats they are—in addition to being humanitarian threats and economic threats. We have to bring the same level of commitment and focus to these challenges as we do when meeting around more traditional security issues” (Obama, 2014). With world leaders increasingly identifying disease as threats to security and economic stability, we are observing infectious diseases—like no other time in history—becoming an integral and explicit component of foreign policy.

The rise of infectious disease as a higher priority in foreign policy has the potential to improve health outcomes around the world, yet there is some reticence among the public health community, as more fully integrating disease into foreign policy may securitize health in ways that could harm health outcomes (Loewenson, Modisenyane, & Pearcey, 2013). The foreign policy community has different priorities, norms, and goals, and it will be important to document the positive and negative impacts of more fully integrating disease into foreign policy.

### Notes

• 1. At the writing of this article, Syria’s civil war is now in its sixth year and has caused one of worst displacement crises since World War Two. As of December 2015, fighting and violence had forced more than 10.9 million people, or over half of the country’s pre-war population, to flee their homes. Of the total, at least 6.6 million people have been internally displaced.

• 2. About 370,000 people live in one of the ten recognized camps overseen by the United Nation Relief and Works Agency for Palestinian Refugees, or UNWRA, and nearly 10,000 more Palestinians have recently fled from Syria into Jordan (IRINnews, 2013).