tion, and the epidemic spread of emerging infections can impact with great force far beyond their nominal zones of incidence. As a matter of both enlightened self-interest and, perhaps, a newly transnational ethical sensibility, it is essential that the United States and other developed countries incorporate in their response to emerging infectious diseases close attention to public health in the developing world.

WAR AND FAMINE

War and famine are closely linked. Not only do they both lead to severe disruptions in food distribution and consumption, but in fact a frequent causal relationship exists between the two. As of April 2001, the Food and Agriculture Organization (FAO) was tracking 16 countries with “food emergencies” (i.e., catastrophic declines in crop production) in sub-Saharan Africa; 9 of these emergencies were directly related to civil strife (FAO, 2001). So-called “complex humanitarian emergencies” provoked by the combined conditions of famine and war contribute directly to the spread of infectious diseases and have fairly consistent sequelae, including malnutrition, measles, diarrheal diseases, respiratory tract infections, and malaria (Toole and Waldman, 1990).

War

Between 1990 and 1998, 108 wars worldwide claimed 5.5 million lives (Wallensteen and Sollenberg, 1999). Conditions of armed conflict generally result in a breakdown of domestic stability, loss of food security, and destruction of the medical infrastructure. While acquiring reliable data in war-torn regions is difficult, millions of people are thought to die each year not from direct acts of violence, but from inadequate health services (Roberts, 2001; Toole et al., 1993; Toole and Waldman, 1990). According to one recent study, for example, patients with tuberculosis whose chemotherapy was disrupted because of war were three times more likely to die than those who were fully treated during peacetime (Gustafson et al., 2001). As noted, such disruption in treatment not only affects an individual’s risk of death, but also increases the risk of the emergence of drug-resistant strains (Khan and Laaser, 2002; Federation of American Scientists, 2002).

The direct human cost of battle pales in comparison with the human cost of its aftermath. Of the countries in which humanitarian emergencies were designated by the National Intelligence Council in 1999, well over half were the sites of high-intensity conflict (Wallensteen and Sollenberg, 2001). These upheavals had consequences far beyond their nominal zones of incidence. A recent estimate put the number of war refugees worldwide at a full 1 percent of the global population (Summerfield, 1997). In the



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