outbreak, including an intentional biological attack, can undermine national and international security (National Intelligence Council, 2000). Only very recently has the impact of major infectious diseases on global economic health become a central topic for discussion among world leaders, resulting in significant investments of global resources by the United Nations and major industrial nations. Although numerous infectious diseases— such as tuberculosis, malaria, cholera, plague, and infections with drug-resistant pathogens—have been major destabilizing forces (Chukwuani, 1999; Eandi and Zara, 1998), none has had a more devastating and far-reaching impact than the HIV pandemic in sub-Saharan Africa. The 28.5 million people infected with HIV in the region (UNAIDS, 2002) affect all sectors of society—from the household to industry to the broader regional economy (Dixon et al., 2002; Morris et al., 2000; Topouzis and du Guerny, 1999). With its disproportionate impact on young working adults, the pandemic has greatly intensified labor shortages, leading to catastrophic socioeconomic decline in the regions of highest incidence (Baier, 1997). It is expected that by 2010, per capita gross domestic product (GDP) in some of the hardest-hit countries will drop by 8 percent (UNAIDS and WHO, 2001); heavily affected countries could lose more than 20 percent of GDP by 2010. Decreased productivity translates into weaker prospects for economic growth and long-term development, and also means that fewer resources are available to invest in public health, thereby amplifying and perpetuating the original disease problem. The global security threat from AIDS will only increase as other densely populated nations, such as India and China, continue to struggle with the pandemic.

This report is the successor to a 1992 Institute of Medicine report, Emerging Infections: Microbial Threats to Health in the United States, that first examined the impact of new and reemerging infectious diseases on the United States. Ten years later, the impact of the global burden of infectious diseases on the United States has only increased. Infectious diseases unknown in this country just a decade ago, such as West Nile encephalitis and hantavirus pulmonary syndrome, have emerged to kill hundreds of Americans—and the long-term consequences for survivors of the initial illnesses are as yet unknown. Other known diseases, including measles, multidrug-resistant tuberculosis, and even malaria, have been imported and transmitted within the United States in the last 10 years. Moreover, gains made against sexually transmitted diseases have slowed or reversed in certain population groups. Compounding the threat posed by these infectious diseases is the continuing increase in antimicrobial resistance, which has become pervasive not only in the United States, but worldwide. Further exacerbating the situation is the fact that, despite the link between public health investment and infectious disease control, the United States has diminished its public health capacity to recognize and respond to infectious disease



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