Refugees and Infectious Diseases

As violence continues to plague war-torn South Sudan, even after efforts at ceasefires, refugees continue to pour out of the world’s newest country into the surrounding region. To date, up to 2 million displaced individuals have sought sanctuary in neighboring Uganda, Kenya, Democratic Republic of the Congo (DRC), Ethiopia, and Sudan. Regardless of destination, the incredible volume of people and the lacking resources of their host nations have forced refugees into overcrowded camps with little infrastructure. As the international community stands idly by, a 72% aid gap remains to address the crisis. Furthermore, in the United States and much of Europe, nationalist movements have spurred suspicion of refugees and have pushed for fewer admissions of asylum seekers.

    The dire situation of many refugees in the area surrounding South Sudan certainly calls for more support from developed nations to address the humanitarian crisis. However, an often overlooked aspect of the South Sudanese refugee crisis is the spread of infectious diseases. In fact, health concerns raise serious issues for US strategic interests in the region as well as public health around the world. By ignoring the refugee crisis in South Sudan, through both a lack of aid funding and asylum, the United States is, perhaps counterintuitively, increasing its own susceptibility to health crises and that of a region vital to US security and economic interests.

    Infectious diseases and conflicts are strongly correlated. For instance, over the course of Syria’s civil war, the nation’s hospitals have been destroyed and deprived of healthcare workers, leading to outbreaks of polio and leishmaniasis both within the country and in refugee camps in Lebanon. Many of these infectious disease threats, such as polio, have been eliminated through an extensive internationally-led eradication campaign. Now, Lebanon’s own robust healthcare system has managed to mostly contain the infectious disease threat to Syria, where health problems, unfortunately, continue to persist due to the ongoing conflict. Thankfully, the Syrian infectious disease crisis benefited from the global health community’s strong prioritization of polio. Plus, it a neighboring state capable of handling the increased health burden of refugees.

The South Sudanese crisis, by contrast, largely lacks both international attention and strong, stable governments and healthcare systems in host nations. With little international aid available, the poor conditions of refugee camps in the region have provided a starting point for numerous epidemics, most notably cholera, which has spread throughout the region. The epidemic is currently afflicting Kenya, the DRC, and Sudan, having originated from refugee populations and having since spread to general populations. Upwards of 1,000 individuals in Kenya, 3,000 in the DRC, and 15,000 in Sudan have contracted cholera, with case fatality rates typically in the low single digits.

    The damage from infectious diseases like cholera extends beyond the direct human casualties, with health crises often serving as a catalyst for political and social disruption. One study found a strong correlation between infectious diseases and civil wars, with evidence suggesting diseases lead to xenophobia and ethnocentrism, thereby producing an environment conducive to intrastate conflict. Although civil wars certainly cause outbreaks, controls in the study indicated that diseases were still a cause of intrastate conflict. Another study by Brown University’s Professor Robert Blair and colleagues examined Liberian public opinion of government during the 2014 Ebola outbreak. It found that mistrust of the government led to reduced compliance with health care measures and that those who witnessed or experienced hardships (such as seeing a victim of the disease) were less likely to trust the government. Noncompliance with health measures is a significant problem, which leads to increases in the severity of the outbreaks, bringing about more distrust. Taking these two examples together suggests diseases have a potent ability to undermine government trust and social cohesion.

    Instability within these nations presents an obstacle for US foreign policy objectives in the region. The US has had a strong relationship with South Sudan since its foundation, having been instrumental in promoting the country’s independence. Having poor relations with Sudan under the Obama administration, the US viewed an independent South as a potential partner, one that would serve as an example of democratic state-building and provide stability to the region. South Sudan’s vast oil reserves also made it an attractive economic partner. While sanctions on Sudan initially prevented access to South Sudanese oil, the US has since exempted South Sudan and attempted to invest in its oil. With the decaying of South Sudan’s political integrity, the US is losing a potential regional ally and ability to counter recent Chinese investment in South Sudan’s oil industry. While China’s own position in South Sudan is also weakened by the civil war, the US if currently farther behind in influence. Ingratiating itself with South Sudan could give the US more soft power to lessen the gap with China. Regionally, Kenya is a partner in counterterrorism while the DRC has vast mineral reserves of interest to the US.

    The South Sudanese refugee crisis and subsequent infectious disease threat concerns not only American foreign policy, but US domestic health as well. This is not to say, however, that refugees themselves have a strong chance of transmitting infectious diseases to the general populations of developed nations like the US. On the contrary, most infectious diseases present among refugee populations have very low infectiousness in countries with more established healthcare systems and infrastructure. Cholera, for instance, would be unable to spread through the water supply of countries like the US due to its advanced sanitation system compared to South Sudan and the surrounding region. Even tuberculosis is less likely to spread where nutrition and housing are generally better. Regardless, the case rate of tuberculosis among Syrian refugee populations, for instance, is not any higher than that of Europe. As such, the acceptance of refugees into developed countries poses no significant risk to spreading disease.

“For the United States, the threat that infectious diseases from refugee populations pose to US interests in East and Central Africa and to US domestic health requires a concerted effort to provide proper support to refugees”

The threat to US health, instead, comes from the long-term progression of diseases in nations that are susceptible to the diseases. Multi-drug resistant organisms (MDRO) are one such potential problem. MDROs are bacteria or other microorganisms that have developed resistance to drugs like antibiotics. These drugs act as an artificial selection mechanism, with microorganisms able to resist them being more likely to survive. The result is the eventual evolution of a population of microorganisms that completely resists antibiotics or other drugs. This process is accelerated when antibiotics are used more than necessary, or an antibiotic treatment is not strong enough to completely kill a bacterial infection. While most MDROs now only resist a handful of drugs, those resistant to all known antibiotics have infected individuals and will only become more widespread, with deadly results. With the US and Europe heavily relying on antibiotics for treatment, MDRO will become an extremely dangerous threat to these nations.

Numerous studies have found that rates of MDROs are significantly higher among refugee populations, due to poor medical care leading to overprescription of antibiotics, use of expired antibiotics or incomplete treatment regimens due to shortage of antibiotics. With many South Sudanese refugees living with access to relatively poor and limited medical care, the rise of MDROs will accelerate among what is a very considerable population of 2 million refugees. An increase of MDROs in the near future increases the possibility of MDROs spreading to the US. Because the vast majority of MDROs are not completely resistant to antibiotics, refugees with MDROs do not pose a significant immediate threat to US health as long as they receive proper health screening and subsequent care. However, ignoring the refugee crisis allows MDROs to continue to evolve into more resistant forms. Reducing the number of refugees without access to proper healthcare by granting them asylum and increasing aid is the best option to slow the rise MDROs and their risk to the US.

The same principle applies to other emerging infectious diseases (EIDs) that could come out of East and Central Africa. HIV, for example, was once an EID originating in Africa, and has since spread throughout the world and continues to affect 1.1 million people in the United States. Other emerging infectious diseases include Ebola, Hepatitis C, and SARS; in short, a wide variety of diseases that have affected all parts of the world. Preventing the spread of emerging infectious diseases like these is contingent on developing regional health systems. With its great biodiversity, sub-Saharan Africa is a particularly good place for diseases to emerge. A large population of refugees remaining in poor conditions in and around South Sudan would provide a source of people susceptible to contracting EIDs where the diseases could then spread to nearby populations. Through repeated, everyday travel between infected nations, EIDs could feasibly spread to farther parts of the world, including the United States. The spread of Zika to the US demonstrates that singular mass travel events like the 2016 Rio Olympics have little effect on EID spread. Zika was instead introduced to the US through repeated travel by infected individuals. Likewise, accepting refugees will not significantly increase the risk of EID spread to the US. However, letting EIDs spread regionally from a refugee population will eventually threaten the US.

For the United States, the threat that infectious diseases from refugee populations pose to US interests in East and Central Africa and to US domestic health requires a concerted effort to provide proper support to refugees. Current aid efforts typically react to cholera or other infectious disease outbreaks as they occur through vaccination campaigns or similar responses. This is not enough to achieve a sustainable solution to the rise of infectious diseases, as there will still be large populations in overcrowded conditions with limited infrastructure, healthcare, and nutrition. More effective aid programs instead target the central issues of the refugee crisis like poor camp conditions. Uganda and its “no-camp policy” is a prime example. Taking the bulk of South Sudanese refugees, Uganda experienced cholera outbreaks in 2016, but the nation’s quick response coupled with an effective refugee relocation program, has enabled the nation to keep diseases under control by eliminating the conditions that allow an outbreak to start. Despite taking half of the South Sudanese refugee population, Uganda’s success in handling the refugee crisis by allocating farming land and houses to refugees should serve as an example to the United States. The US could follow Uganda’s plan and integrate South Sudanese refugees into its own country and economy, or provide money and resources to other nations in the region to implement similar strategies.

These practical advantages of addressing the South Sudanese refugee crisis should not overshadow the humanitarian aspects. Displaced people in the region are suffering, and to place strategic concerns above moral ones is disrespectful to human rights. The benefits to US health and strategic interests should instead be seen as secondary advantages that complement the ethical importance of providing asylum and aid to South Sudanese refugees. Asylum and proper aid will reduce the occurrence and spread of infectious diseases, allowing for a more stable East and Central Africa that supports US foreign policy interests and protecting the United States from long-term public health threats like MDROs and EIDs.

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