[Paleopsych] Pol.Sci.Q: Albert B. Knapp: The HBV and HCV Pandemics: Health, Political, and Security Challenges
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Albert B. Knapp: The HBV and HCV Pandemics: Health, Political, and
Political Science Quarterly 120.2 (2005): 243-251
[First, the summary from CHE, 5.7.21
The Chronicle of Higher Education: Magazine & journal reader
A glance at the summer issue of Political Science Quarterly: Ignoring
the dangers of hepatitis B and C
Hepatitis B and hepatitis C infect nearly 2 billion people worldwide,
but HIV, which affects 30 million individuals, gets much more
attention, writes Albert B. Knapp, an associate clinical professor of
medicine at New York University.
If officials do not try harder to curb the spread of hepatitis, it
could increasingly harm underdeveloped nations, which do not do as
comprehensive a job of preventing and treating the virus as Western
countries do, writes Dr. Knapp.
Both hepatitis B and hepatitis C, if left untreated, cause chronic
liver infection, which could result in death. Hepatitis C, for which
no vaccine exists, is more difficult to treat than hepatitis B, which
does have a vaccine.
"If left unaddressed, by the end of the decade, these viruses could
pose a greater danger than the HIV epidemic, not only as a
public-health problem, but for the alarming political and security
threats they present," writes Dr. Knapp.
Hepatitis could weaken developing nations politically and financially
by diverting money from economic development and cutting the size of
their work force and military, Dr. Knapp writes. Those countries
should try to raise public awareness about hepatitis, he says.
Western countries and large, multinational pharmaceutical companies
should develop and donate cheaper therapies to underdeveloped nations
to reduce the viruses' impact there, Dr. Knapp writes. They should
also increase efforts to make a hepatitis-C vaccine and a
longer-lasting hepatitis-B vaccine.
"What we lack ... is both a clear political focus and a collective
political will, without which the consequences for everyone may be
catastrophic," Dr. Knapp writes.
The article, "The HBV and HCV Pandemics: Health, Political, and
Security Challenges," is available online to subscribers and for
purchase at http://www.psqonline.org
[I do not know why Adobe "Professional" omitted spaces between word in part of
ALBERT B. KNAPP is an associate clinical professor of Medicine
(Gastroenterology & Hepatology) at the New York University Medical School as
well as an attending physician at both the Lenox Hill Hospital and the NYU
Hospitals Center. He is the author of over 15 peer-reviewed research
publications as well as a textbook on Gastroenterology and Hepatology.
Hepatitis B (HBV) and hepatitis C (HCV) infect nearly 2 billion people
worldwide, but only recently have health officials in the developed world begun
to recognize them as a serious health, political, and security challenge. If
left unaddressed, by the end of the decade, these viruses could pose a greater
danger than the HIV epidemic, not only as a public health problem, but for the
alarming political and security threats they present.
Although HBV and HCV are two very different viral entities, both can result in
chronic liver infection with eventual progression to cirrhosis, liver cancer,
and death. HBV and HCV are found worldwide, with the highest number of cases
clustered in sub-Saharan Africa, Egypt, and East Asia. Therapy has improved
dramatically during the past thirty years, but both cure and worldwide
eradication remain elusive goals. I will briefly review the distinctive
pathophysiology of both HBV and HCV before addressing the public health,
political, and security implications of these two pandemics.
Hepatitis B Virus
HBV is a large and complex DNA-based virus first identified in 1967.1 More than
1.5 billion people are believed to be infected worldwide, and the highest
levels are in sub-Saharan Africa and East Asia, where infection rates of up to
20 percent are common. Viral spread can be either vertical (mother-to-child) or
horizontal (early child-to-child contact or through risky sexual behavior).
Infection from improperly sterilized intravenous needles (such as among IV drug
users) and contaminated blood or blood products account for a smaller but
important percentage of cases worldwide.
1 Those who have a scientific background may wish to refer to the excellent
review article focusing on the molecular biology of HBV by Donald Ganem and
Alfred M. Prince, "Hepatitis B Virus Infection--Natural History and Clinical
Consequences," New England Journal of Medicine 350 (March 2004): 1118-1129.
Most people infected with HBV show no symptoms of the disease. Ten to twenty
percent of cases progress insidiously over a twenty- to thirty-year span,
leading to cirrhosis, liver cancer, and, ultimately, death. Detection requires
expensive individual blood-screening studies as well as vigilant monitoring of
the nations blood supply. Consequently, the likelihood that someone with the
infection will be diagnosed and treated depends on both geography and
socioeconomic status. Patients in developed countries with access to medical
care usually are diagnosed earlier in the infectious cycle and are better
candidates for costly but effective oral antiviral therapy. Those, however, in
either underserved areas of the West or in the developing world usually get
medical attention at a more advanced stage of the disease, by which time, even
if available, antiviral therapy is less effective. At that point, treatment
generally is palliative but, given the massive number of patients, even this is
costly for those countries with meager healthcare infrastructures and budgets.
Hepatitis C Virus
HCV is simpler in molecular design but far deadlier than HBV. It is a close
cousin of both the dengue and yellow fever viruses. HCV initially was
characterized in 1989.2 As with HIV, the genetic material of HCV is RNA, and
this results in a high degree of genetic instability, or mutability, rendering
the virus not only more infective and adaptive but exceedingly difficult to
treat. At least 250 million people worldwide are estimated to have contracted
HCV. But, unlike HBV, the incidence of chronic infection with ineluctable
cirrhosis, liver cancer, and death far exceeds 50 percent. HCV is spread
horizontally, in most cases, through improperly sterilized needles used by IV
drug users or as the result of a contaminated blood supply. Maternal
transmission and sexual promiscuity are other important risk factors. Low
socioeconomic status plays a role in the likelihood of infection, but experts
dont quite understand the link.
On the basis of some very elegant epidemiological research, HCV is thought to
have originated as a zoonotic (animal-to-human) mutation somewhere in the
Pacific Theater during the Second World War. HCV insidiously infected large
numbers of Japanese troops in China and Southeast Asia, and they eventually
repatriated the virus.HCV reached the West in a circuitous fashion via infected
French and American veterans of the Indochinese conflicts. Worldwide
dissemination ensued from contamination of the blood supply in both Western
Europe and the United States, and from a surge in infected IV needles shared by
drug users or, in the case of at least one country, by lax sanitary controls
during a massive national vaccination program.
2 For further in-depth details, please see G.M. Lauer and B.D. Walker,
"Hepatitis C Virus Infection," New England Journal of Medicine 345 (July 2001):
Unlike HBV, treatment forHCVis not only costly but also most unsatisfactory at
any stage of the disease. Overall therapeutic success is reported at 60
percent, but this is misleading, because those patients with the most-common
variant of HCV have response rates of only 40 percent. The economic impact of
the disease is extraordinary. Antiviral treatment for one year can exceed
$25,000 per person in the United States, but the actual cost is far higher due
to both frequent drug side effects and co-morbidity issues. Patients who do not
respond to treatment may require liver transplantation. In the West, HCV
infection is currently the most common reason for such transplants. In fact,
nearly 6,000 were done in the United States in 2004, at an individual price
conservatively estimated at $150,000. This excludes the requisite lifetime cost
of the expensive, but mandatory, immunosuppressive drug therapy and specialized
medical care that all transplant recipients must receive.
Meanwhile, drug therapy and surgery are simply out of reach for most people in
the developing world because of costs and lack of sophisticated medical
support. Consequently, in underdeveloped nations, the average patient receives
basic palliative therapy, languishes, wastes away, and dies.
Public Health Challenges
HBV and HCV present important challenges for the world healthcare establishment
in detection, therapy, and containment strategies. Overall success varies from
nation to nation, depending on the underlying quality and sophistication of a
particular states medical infrastructure as well as its ability and political
will to commit vast sums of money to combating the virus. Let us review each of
the key challenges for fighting these infections.
Detection is based on blood screening. Given that both HBV and HCV are
clinically undetectable for a major part of their destructive cycles, universal
screening of all citizens, and especially of the blood supply, is the ultimate
approach. However, realistically, only a small percentage of a nations
population is likely to be effectively screened--even in the most motivated and
sophisticated of societies. Therefore, public health planners have refined
their strategy toward screening of all "high risk" individuals, but even so,
their success in detecting the virus is limited. In the United States,
officials estimate that they have identified only about 50 percent of those who
have HCV, despite an aggressive national healthcare campaign. On the other
hand, public health officials have succeeded brilliantly in detecting and
eliminating both viruses from the blood supply in the developed world. What is
more, despite the prohibitive cost of the viral detection kits, some inroads
have been made in ensuring the safety of blood supplies in developing
Treatment strategies vary between the West and developing nations. Earlier
viral detection in developed countries means that patients get treatment at an
earlier stage of the infection, with good success at curing HBV and improving
results in treating HCV. The story in the underdeveloped world is starkly
different; typically, the average infected patient seeks treatment in the later
and more debilitating stages of either disease. Successful outcomes are rare,
and the cost of even simple supportive care is relatively quite high and
strains alreadylimited healthcare budgets. In reaction, many poorer nations,
encouraged by tactics learned during the HIV struggle, have begun to demand
significant discounts, rebates, or frank allocations of medications from the
major manufacturers, while requesting increases in dedicated foreign financial
aid to combat the viruses. In addition, several Western and non-Western
pharmaceutical concerns have begun to develop cheaper antiviral medications
based on chemical synthetic processes with lower research and development
Containment strategies of different degrees of efficacy and expense have been
developed for both the West and the developed world. These include
encouragement of universal condom use and prophylactic HBV vaccination. Condoms
have gained broader social acceptance during the past two decades as an
effective means of preventing the spread of HIV. Condoms also have been shown
to help seriously curtail HBV transmission in several large epidemiological
studies of gay men in New York City. We suspect that condom use should have a
similarly salutary effect on curbing HCV transmission. But because sexual
spread is a secondary route for this virus, the anticipated decrease may be
Vaccination indeed represents the optimal containment strategy and has been the
most effective tool in eradicating other communicable diseases worldwide. Dr.
Edward Jenner pioneered this technique in England at the end of the 18th
century in an attempt to curb smallpox outbreaks. Vaccination, however, has
several drawbacks: It is currently available only for HBV prevention (although
an effective HCV vaccine is now in development and could be ready by the end of
this decade). Furthermore, inadequately supervised vaccination programs using
reusable but improperly sterilized needles or syringes may unintentionally lead
to the massive spread of other communicable diseases.
HBV vaccination has become mandatory for young school children in the West
since the early 1990s, after it was shown to dramatically decrease viral
incidence. The ultimate example is Taiwan, where, following a ten-year
mandatory vaccination program for all children, the measurable incidence of HBV
plummeted from more than 10 percent to less than 1 percent in this cohort.3 A
universal HBV vaccination program for children in the United States,
underwritten and signed into law by then-President Bill Clinton in 1993, will
probably rank as one of his most important legislative contributions. The only
flaw in universal vaccination programs is that the present HBV vaccine is
thought to have an effective life of only five to ten years and, therefore,
must be supplemented by regular booster shots. Although logistically possible
in preschool and high school populations, regular booster programs for adults
present a logistical nightmare.
3 For more details on this fascinating study, see M-H. Chang, C-J. Chen, M-S.
Lai, et al., "Universal Hepatitis B Vaccination in Taiwan and the Incidence of
Hepatocellular Carcinoma in Children," New England Journal of Medicine 336
(June 1997): 1855-1859.
Meanwhile, developing countries have yet to benefit from this containment
effort, because the vaccines are very expensive. Recently, several newer and
less-costly alternatives have been developed with poorer nations in mind.
Immunological relief for those countries may yet be in sight.
It bears noting, also, that vaccination programs are not risk free. If
administered improperly, a large program, however well intentioned, can
actually serve as a vector of transmission for another infectious agent. Such
is the case in Egypt, a nation that presents a cautionary tale of good
intentions and poor execution that produced disastrous results. The parasite
schistosomiasis, endemic to the entire Nile River Valley and first described
during the time of the Pharaohs, has been a major cause of debilitating liver
and bladder disease in large numbers of villagers in both Egypt and the Sudan.
From 1958 through 1982, the Egyptian government undertook a massive
anti-schistosomal campaign to eradicate this scourge. Tragically, the reusable
needles and syringes used in the public health effort were improperly
decontaminated, and many of the vaccines became co-infected with HCV.
Subsequently, HCV infection rates surged in the vaccinated group, making
Egypts infection rate the highest in the world: More than 20 percent of the
Egyptian population has evidence of HCV infection. By comparison, in
neighboring Sudan, which is just as hard hit by schistosomiasis but which did
not pursue a campaign of mass vaccination, the rate of HCV is only 4 percent.4
4 For a thorough review of this distressing topic, see C. Frank, M.K. Mohamed,
G.T. Strickland, et al., "The Role of Parenteral Anti-schistosomal Therapy in
the Spread of Hepatitis C Virus in Egypt," Lancet 355 (March 2000): 887-889.
Political and Security Issues
There is no evidence that HBV and HCV have been used as weapons of bioterror.
From the point of view of todays terrorists, neither HBV nor HCV would be
considered as prime bioterror agents, given their relatively slow spread, the
twenty- to thirty-year effective lag time before the appearance of significant
symptoms, and the relative invulnerability of most nations blood supplies.
Nevertheless, if left untreated, HBV and HCV pose significant longterm social
and financial threats to political stability. HBV, for example, has already
brought disaster, despair, and chaos to large swaths of sub-Saharan Africa,
where billions of dollars were diverted from critical economic development
efforts to fight these pandemics. If not checked, HBV and HCV risk imperiling
the entire African continent.
The West has successfully controlled both infections with only minimal
financial, political, and security concerns. In contrast, the pandemics are
likely to further enfeeble the economies of those nations least equipped to
cope with the huge economic toll they could exact.
Individual citizens of any nation typically look to their governments to ensure
their healthcare security. That security hinges on the ability of the state to
protect its citizens from contracting either virus, either through preventive
programs, such as HBV vaccination, a secure blood supply, and condom campaigns,
or by aggressively treating the disease with antiviral medications and liver
transplantation. The wealthier the state and the more sophisticated the
healthcare system, the more its citizens expect of their public health
To meet those expectations, governments are coming under increasing political
pressure to redirect public spending into such preventive measures as
education, research, and healthcare infrastructure. Such moves should include
widespread HBV vaccination, condom usage, and safeguarding of the blood supply,
because multiple epidemiological studies attest to their overall effectiveness
and relative lack of expense. And, to a large degree, wealthier nations have
done just that. In doing so, these societies have averted wholesale epidemics
with the attendant societal and political disruption they threaten. Indeed, the
eradication of both HBV and HCV from the Western worlds blood supply is to
date, among their greatest public health successes. In the United States, the
chances of contracting either HBV or HCV from contaminated blood have fallen to
1:63,000 and 1:130,000, respectively. Although impressive, these results pale
in comparison to HIV prevention, where the rate of accidental contraction is
1:493,000. Clearly, further work, in the sense of even more-sensitive HBV and
HCVblood detection technology, is needed, and this should be driven by
enlightened public policy. HBV vaccination and universal condom usage in the
West have also been effective and must be encouraged and expanded.
But the prognosis for poorer nations, lacking both the financial base and
medical infrastructure, in combating HBV and HCV is far less sanguine. These
nations must make both prevention and containment strategies high priorities
and summon the political will to raise public awareness of the diseases to the
same degree they already have achieved in the HIV campaign. Implementing the
same preventive measures already in place in the West is critical to the poorer
states future economic and political health. Failure to protect the population
will result in skyrocketing rates of infection, with many of the same political
and security repercussions many poorer nations already have suffered from the
faster-acting HIV epidemic. As the pool of HBV-HCV-infected citizens widens, no
segment of the population will be safe, with the disease spreading to include
farmers and workers, as well as the middle and upper classes. With so many
layers of society swept up by the pandemics, nations will be hobbled
Foreign Policy Implications
HCV in U.S. Prisons
Needle Exchange Controversy
but legislators must summon the needed courage to implement this important
and rational program. The economic costs of not interceding, combined with
the potential social chaos and political turmoil threatening portions of
sub-Saharan Africa, should galvanize the West to aggressively pursue
o medical funding for research and development of cheaper and longer-lasting
o development of an HCV vaccine that would be available by the end of the
decade and that would complement these other protective measures;
o more-effective and less-costly anti-viral medications;
o more-sensitive blood detection technology for the screening of both highrisk
individuals and the blood supply.
In the interim, the West should make a collective decision to fund HBV
vaccination, blood supply screening, and HBV antiviral programs for those
nations deemed at risk. It is ironic that HIV, a virus affecting 30 million
people worldwide, commands far more attention, both politically and research
dollar- wise, than both HBV and HCV, which together afflict nearly 2 billion
people. President George W. Bushs 2004 State of the Union speech pledge of $10
billion (USD) for treatment of HIV in Africa deserves both praise and support.
But we should bear in mind that worldwide deaths as a result of HCV alone
surpassed those of HIV in 2000 and are expected to rise sharply, according to
an unclassified national intelligence estimate published during the last year
of the Clinton administration.5 Efforts should be made to expand President
Bushs program in order to includeHBVand HCV. The European Economic Community
and Japan should be encouraged to share the additional financial burden.
5 See: www.aegis.com/news/boc/2000/BC00093.html.
The world has the potential to severely curtail or even rid itself outright of
both HBV and HCV within the next generation. We find ourselves closer than we
think to major breakthroughs in antiviral therapy, screening, and vaccination
technology and, given our prior experience with smallpox and HIV, we possess
the requisite logistical expertise to mount a successful worldwide viral
eradication campaign. What we lack, however, is both a clear political focus
and a collective political will, without which the consequences for everyone
may be catastrophic.
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