Egypt's Real Crisis: The Dual Epidemics Quietly Ravaging Public Health

By Laurie Garrett & Steven A. Cook

A combination of avian flu and foot and mouth disease risk destroying the protein supply, eroding public trust, and further destabilizing the Arab world's most populous country.

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Birds fly over the Great Pyramid of Giza, Egypt, as cases of avian flu increase in the Arab world's most populous country. / AP

Lost in the recent political jockeying and protest violence leading up to Egypt's May 23 presidential elections is the unfolding public health disaster there. Avian flu and foot and mouth disease are running rampant, killing people and livestock as well as inflating the price of food. It's a serious health and economic issue, but it has potentially much larger implications for Egypt. This little-discussed crisis is beginning to resemble those that occur in failed states.

The Egyptian state, which was not particularly well-prepared for public emergencies even before the February 2011 revolution brought it into near-chaos, has little capacity to cope with the outbreaks threatening not only Egypt, but also Sudan, Israel, the West Bank, Gaza Strip, and Jordan. Egypt's public health infrastructure barely functions. The sorts of social services that groups like the Muslim Brotherhood have provided over many years fall far short of what is needed to combat the current crisis. Cairo does not have the money to throw at the problem, having burned through more than half of its foreign currency reserves in the 15 months since Mubarak's fall.   

Ground zero for Egypt's public health emergency is Libya, where last year, in the midst of civil war, foot and mouth disease swept through the country, killing more than 10 percent of its sheep and cattle. Smugglers subsequently brought infected sheep across the Libyan border, setting off a foot and mouth disease (FMD) wildfire that Egyptian officials have been unable to slow. 

Within four weeks, FMD killed thousands of cattle, buffalo, sheep, goats, camels, and other livestock across Egypt. In March, the United Nations Food and Agriculture Organization declared a "catastrophe," warning that the epidemic in Egypt was threatening human food supplies for all of the Middle East and North Africa. The particular viral strain responsible for the epidemic, officially called SAT2, is a new one, against which standard FMD vaccines are useless. SAT2 was first found in Sudan in 1977, the same year it was also thought to have been eliminated. It appears to have resurfaced there in 2010, spread to Libya, then Egypt, and now the Palestinian Territory. Consequently, public and veterinary health officials in Israel, Saudi Arabia, Jordan, and elsewhere around the  region are on high alert.

For Egypt, which is reeling from the economic repercussions of last year's revolt against the Mubarak regime and ongoing political instability, the FMD epidemic is a serious blow. The loss of thousands of cattle, buffalo, and camels has resulted in a significant spike in the price of meat from Egypt's remaining livestock, which leaves a relatively poor population with only one unaffected source of protein: chickens. Yet Egypt is also in the sixth year of avian influenza H5N1 epidemic. Despite vaccination and control efforts, the deadly H5N1 virus, which swept into Egypt from Asia, persists. Given the popularity of home-raised chickens in the country, where many households, rural and urban, possess flocks, controlling the infection would be a daunting undertaking for any government. Millions of the animals are estimated to have either died from infection or been killed off by veterinary authorities, according to the UN's Food and Agriculture Organization, in failed control efforts. The World Health Organization now ranks Egypt second in the world, after Indonesia, in human cases of the avian flu, which thus far has reportedly  killed 60 Egyptians and infected about 100 more. Recently, a strain of the virus has spread to Egyptian ducks; this new strain carries mutations that are thought to play a role in enabling transmission between mammals. This is a particularly worrisome development because some Egyptians have caught the flu from their animals but have not yet passed it onto other people. Once the virus begins to spread between humans, an epidemic becomes far, far more likely.

There are only two well-established methods for controlling these viral animal diseases: through mass vaccination of more than 90% of all vulnerable animals, or via quarantine and culling measures that identify and slaughter all FMD-infected herds and H5N1-contaminated flocks. In either case, governance is the key. These are big, difficult undertakings, and they require public trust in the state. Poor farmers are far less likely to cooperate with such a program, which asks them to risk, their livelihood, with faith that government will provide adequate compensation for culled animals.

In Egypt, where the military's ability to exert its authority has diminished over time, the transitional civilian cabinet is ineffective, and a variety of political forces jockey for advantage as the presidential election draws near, the government looks increasingly unable to deal with the FMD crisis, and people are furious about it. When more than 7,000 cattle died in March, protesters took the streets to demonstrate against the al Gharbiyya governorate. Unable to get help from the state or compensation for dead animals, impoverished famers dumped animal carcasses into water systems and canals, and on the doorsteps of local officials. By late April, the animal death toll topped 20,000, as the infection spread to the Red Sea and South Sinai governorates as well as the Palestinian territories. When local veterinary experts tried to impose quarantines on infected herds, camel drivers threatened to block Egypt's main highways, insisting on the right to use their beasts regardless of contamination concerns.

In early April, the Egyptian government announced it would buy $1.8 million worth of a vaccine manufactured to treat the specific strain of FMD threatening Egypt's livestock. The first stocks arrived at the end of April. Though vaccinations have begun, it is unclear when they will become widely available. Even if a mass vaccination of Egypt's hoofed livestock could be accomplished, despite the uncertainty of Egypt's politics and limited capacities of its sprawling bureaucracy, it will -- like all vaccines -- take two weeks before the benefits of immunization take effect. Under the best-case scenario, control of FMD would not be realized until June or July. As for bird flu, it's doubtful that Egypt could stop the viral spread of the disease, portending more human cases and deaths. 

Observers have spent a lot of time and effort trying to understand Egypt's post-Mubarak trajectory, but this path will be much more than just the twists and turns of Egyptian politics. Public health is a critical factor for the country's transition and its future. Even if presidential elections are smooth, if the military hands power to civilians with no problems, and if Egyptians get down to the hard work of writing a constitution, uncontrolled foot and mouth disease and avian flu -- along with their attendant economic and human costs -- could risk everything. If the international community wants to help guide the Arab world's most populous country through its post-Mubarak crisis, addressing the country's twin epidemics would be a particularly high-impact way to do it. Absent a global response, Egypt will likely experience continued political instability and violence, and potentially widespread malnutrition that would surely affect Libya, Sudan, Gaza, Israel, the West Bank, Jordan, and beyond. Endless debates about the Muslim Brotherhood's commitment to democratic change or the military's intentions are interesting, but not as important as a coordinated international effort to pull Egypt back from the public health brink. 

This article available online at:

http://www.theatlantic.com/international/archive/2012/05/egypts-real-crisis-the-dual-epidemics-quietly-ravaging-public-health/257072/