Elephants in the Room

In Fragile States, Disease Outbreaks Don’t Stay Local for Long

U.S. health aid can also promote stability, mitigate extremism, and avoid costly longer-term military interventions.

A health worker waits to handle an unconfirmed Ebola patient at a newly built, Médecins Sans Frontières-supported Ebola treatment center in Bunia, Democratic Republic of the Congo, on Nov. 7, 2018.
A health worker waits to handle an unconfirmed Ebola patient at a newly built, Médecins Sans Frontières-supported Ebola treatment center in Bunia, Democratic Republic of the Congo, on Nov. 7, 2018. John Wessels/AFP/Getty Images

The deadly Ebola virus is taking a toll on the Democratic Republic of the Congo. Since its reemergence this year, some 1,625 people have died, and on July 17, the World Health Organization declared the outbreak a public health emergency of international concern. It has menaced communities across the country’s north, and individual cases have now reached the city of Goma, near the Congo-Rwanda border, and even spilled into Uganda.

In fragile states like Congo—beset by poverty, instability, and weak governance—not only do disease outbreaks routinely expand into neighboring countries, but they also tend to aggravate other health problems. For example, after the last Ebola outbreak weakened Congo’s already fragile and overtasked health system, the North Kivu province, where the outbreak is centered, saw an eightfold increase in the incidence of malaria. Simply put, it may be too much to expect a country like Congo to contain an outbreak while also dealing with a host of other problems, including a patchwork of simmering conflicts, hundreds of thousands of refugees and millions of internally displaced people, incursions by Islamist terrorists, and poor governance. Flaring up again this July, Congo’s experiences may be extreme, but they are shared across fragile states. Yemen and Bangladesh are also experiencing interlocking crises of conflict and global health threats.

U.S. policymakers should ask themselves what they can do to best mitigate the challenge of global health crises in fragile states. Local threats often don’t stay that way for long, but with the right measures, the United States can help prevent them and in so doing keep itself safe, too.

Policymakers concerned with stability, for their part, would be wise to back increased funding for multilateral and bilateral global health programs, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the President’s Emergency Plan for AIDS Relief (PEPFAR). Investment in health aid is not just a way to prevent the spread of disease but to shore up regional stability, which is in the broader interest of the United States. It also enhances the United States’ humanitarian credentials.

Bangladesh is instructive here. The arrival of more than 700,000 Rohingya Muslim refugees, fleeing human rights abuses and poor governance in neighboring Myanmar, has raised the risk of disease outbreaks, particularly of tuberculosis, and also complicated access to health care due to immense distances to health centers and the denial to the Rohingya of formal refugee status.

In response, the Global Fund has chosen Bangladesh as one of 12 countries in which to use catalytic funding, that is, resources used to incentivize countries’ own action or collaboration. In Bangladesh’s case, the money would support innovative programs that aim to detect cases of tuberculosis that would otherwise be missed by public health systems. Doing so is crucial to preventing the spread of the disease and ensuring patients receive treatment. To that end, on June 25, the Bangladeshi Health and Family Welfare Ministry and the U.S. Agency for International Development announced a partnership focused on strengthening diagnostic services, detection, and treatment of tuberculosis, and preventive therapy.

Fighting conflict and instability, which is in the broader interest of the United States, means accounting for—and addressing—the compounding global health crises that both result from and perpetuate political violence. In Yemen, years of brutal war have created a massive health crisis. Only 51 percent of health facilities in the country are fully functional. Those still running are faced with widespread shortages of medicine and equipment. Around 80 percent of the population urgently needs humanitarian assistance to get by. Meanwhile, the country has been dealing with the worst cholera outbreak on record, which emerged in 2016, a year after the fighting began.

Public health crises only further weaken stability and trust in institutions, and they hand terrorist groups an opportunity to recruit—pertinent in all three cases. Addressing health must thus be part of an overall approach; global health aid addresses the needs of displaced people in conflict zones and fragile states, which in turn helps secure stability.

U.S. President Donald Trump has proposed marked cuts to U.S. global health funding. Yet Congress is in a position to not just to sustain global health aid but to boost it. There is bipartisan interest in fragile states, as seen in the Global Fragility Act of 2019—a bill specifically targeted to “combat international extremism by addressing global fragility and violence and stabilizing conflict-affected areas.” It has been championed by Rep. Eliot Engel, the chairman of the House Foreign Affairs Committee; the committee’s ranking member, Rep. Michael McCaul; Democratic Sen. Chris Coons; and Republican Sens. Todd Young and Lindsey Graham, who chairs the subcommittee charged with determining foreign aid funding levels. But the health dimension needs addressing, too. While Graham is a longtime backer of the Global Fund and PEPFAR, such health programs with high marks on efficacy should be scaled up as well to address fragility.

Channeling global health aid to fragile states can help mitigate the humanitarian disasters caused by poor governance and conflict. But it can also lead to more capable, accountable, and inclusive governance. In areas where the Global Fund works to end epidemics, there have been tangible improvements in political freedom, control of corruption, governmental accountability, and the rule of law. Including the voices of affected populations, civil society groups, and external monitors has helped the Global Fund support fragile governments so that they can meet their population’s needs.

The United States has vital interests in promoting stability, mitigating extremism, and avoiding costly longer-term military interventions. All of these efforts are well served by investing in robust global health aid. Washington also wins good will from addressing those most in need, as a much-needed complement to its use of hard power. As the United States reconsiders its strategic priorities in the world, increased global health aid must be among them.

Shannon Kellman is the deputy policy director at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria.

Mark P. Lagon is chief policy officer at the Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, and a distinguished senior scholar at Georgetown University’s Walsh School of Foreign Service.

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