What does the future look like? Will there be a reduction in number of infections?
Given that leishmaniasis is a communicable disease, the likelihood of infection varies directly with the rate of exposure to the vector and the measure of prevalence within a specific area. Increased contact with sandflies increases the risk of being bitten by a fly carrying the Leishmania promastigote and contracting the disease. Similarly, the chances of a sandfly ingesting a parasitized blood cell and continuing the protozoan lifecycle become higher when there are a greater number of individuals within the population who have leishmaniasis. In Afghanistan and Iraq, there is both a high prevalence of the disease within the local populations and suitable conditions for sandfly breeding. American troops serving in the Middle East are at an even greater risk for infection than local residents are because leishmaniasis is not endemic within the United States. According to the World Health Organization, individuals who have not been previously exposed have decreased levels of resistence to Leishmaniasis and are at a much higher risk of contracting the disease.(2) Even though measures to reduce exposure to the vector are already in place, cases of cutaneous and visceral leishmaniasis continue to emerge among soldiers returning from the Middle East. If there is to be any further decrease in the rates of infection in American troops, there must first be a reduction in the prevalence of leishmaniasis within Afghanistan and Iraq.
In Afghanistan, the migration of individuals from rural communities to major cities has contributed to the transmission of leishmaniasis to military personnel. In any part of the world, urbanization is a risk factor for the spread of communicable diseases. Placing a large number of people in a confined area increases the opportunity for transmission among individuals.(16) Epidemiology expert P. Desjeux notes that urbanization is particularly worrisome in developing countries where “facilities for housing, drinking-water and sanitation are inadequate”.(9) In Afghanistan, this phenomenon has been accentuated by nationwide instability attributable to twenty years of violence and civil war. With the government focusing on security, sanitation has largely been ignored, creating an ideal breeding ground for the sand fly vector.(17) The impact of this is particularly evident in Kabul. The number of cases of cutaneous leishmaniasis in the general population increased from 14,153 in 1994 to 270,000 in 2001, affecting over 10% of the city’s population at the start of the 21st century.(9) The increased opportunity for vector/host interaction combined with the unprecedented prevalence of cutaneous leishmaniasis places American soldiers entering Afghanistan at an incredibly high risk for infection.
At present, the potential to reduce the burden of leishmaniasis in Afghanistan is small as little political will exists to control the infection. Over the past twenty years, Afghanistan has been embroiled in a civil war that has not only contributed to the unsanitary conditions that allow the disease to flourish, but has also destroyed the country’s public health system. Reithinger et al used survey analysis to estimate that only 20% of leishmaniasis patients are both diagnosed and treated in Kabul.(18) Under the present public health system, there is no opportunity to reduce the prevalence of the disease by stopping transmission of the protozoa from humans to the sandfly. With violence still presently continuing in Afghanistan, rebuilding a health care system that can effectively combat leishmaniasis is not a priority. The only other hope for Afghanistan is international aid. However, because cutaneous leishmaniasis is not fatal and the visceral form is uncommon, international groups tend to overlook leishmaniasis and instead focus on reducing the higher profile diseases such as tuberculosis, and malaria along with causes of premature death such as infant mortality and trauma.(17) As Operation Enduring Freedom continues in Afghanistan, soldiers will go on being exposed to leishmania at extremely high rates.
While the high prevalence of leishmaniasis in Afghanistan is due to the patterned behavior and continued violence, the increased prevalence of leishmaniasis in Iraq is not characteristic of the country. It can however be attributed to the state of emergency following Operation Iraqi Freedom. According to Integrating International Responses to Complex Emergencies, Unconventional War, and Terrorism author Frederick Burkle, Iraq’s health statistics prior to the US invasion were comparable to developed countries. Although the prevalence of leishmaniasis had increased over the past decade, it was because of better surveillance techniques that were able to diagnosis cases that would have previously gone undetected, rather than demonstrable breakdowns in healthcare of sanitation.(19) Following the US invasion and subsequent occupation of Iraq in 2003, rates of leishmaniasis began to increase. Compromises in sanitation and water supply became common in the ensuing months due to violence and destruction, leading to new urban breeding grounds for sand flies.(20) Additionally, the health care infrastructure was completely destroyed. WHO estimates “75% of all health-care structures, including the public health laboratory network and centers for disease control, were affected.”(21) Even in areas where hospitals remained intact, Iraqis feared traveling to health centers because of the continuing violence.(22) With increased number of breeding grounds and the public health system in dissaray, leishmaniasis continued to increase, with officials fearing an epidemic in 2005.
In contrast to Afghanistan, the political will in Iraq exists to control leishmaniasis. Since 2003, international aid agencies have implemented communicable disease control programs and noted a decline in the prevalence of leishmaniasis.(23) Additionally, efforts are being made to rebuild the public health system in Iraq. In March 2007, the Iraqi government launched a five-year reconstruction program. One of the priorities of the program is reducing morbidity and mortality from preventable causes, including communicable diseases like leishmaniasis. One of its particular projects is “to improve and modernize Iraq’s national disease surveillance system”.(24)
Nonetheless, obstacles still exit to controlling leishmaniasis. Continuing violence and insecurity threaten both the infrastructure and personnel of Iraq’s healthcare system: hospitals continue to suffer damage and insecurity forces doctors and nurses to evacuate their homes and relocate. However, continued international aid and political support in the rebuilding process make controlling leishmaniasis probable in Iraq.
Another important determinant of the future of Leishmaniasis in Afghanistan and Iraq is the level of US military adherence to prevention policies. Researchers at WRAMC and WRAIR have made it clear that reducing rates of infection is possible through a number of self-protection methods. The USACHPPM has distributed information to military personnel in the Middle East that describes such methods in a clear and straightforward manner. However, compliance is necessary to achieve the decreased rates of infections. Currently there are two main barriers to reaching self-protection: access to necessary repellent systems and correct use of materials once they are received.
Firstly, due to the nature of the current conflicts in Iraq and Afghanistan, many troops are not receiving the insect repellent, IDAs, and bednets they need to protect themselves. In some instances, goods cannot reach the troops because of where they are stationed, but there are also cases of general inefficiencies that come with trying to run such a large operation: orders get lost, incorrectly cancelled, or delivered to incorrect bases.(25) It makes it much harder for military personnel to implement self-protection without the proper equipment.
Secondly, many troops simply do not comply with the self-protection recommendations set forth by the USACHPPM. The sweltering heat forces many people to wear only t-shirts and shorts when they are off-duty. Also,insufficient knowledge of how to use a bednet results in incomplete sealing and subsequent exposure to sandflies. Finally, some soldiers do not use the DEET insect repellent because they do not like the smell or believe in its efficacy.(25)
The US military cannot expect to successfully lower infection rates unless they can convince all the troops that self-protection is important and worth doing on a regular basis. If used consistently, these methods can drastically reduce the chances of being bitten by sand flies.
Political will and mobility both within Iraq and Afghanistan and within the international community are the primary factors that will influence the risk of leishmaniasis infection in American soldiers serving in the Middle East. Although control of communicable disease is not a priority in Afghanistan, Iraq can reduce the prevalence of leishmaniasis if political will is sustained. Unfortunately, even under the best circumstances in which stable public health systems exist in both countries and sanitation issues have been resolved, leishmaniasis will not be eradicated because of the animal reservoirs. However, adherence to Army prevention methods in combinationwith decreased prevalence of leishmaniasis in the general population of the Middle East provides the best chance of ending leishmaniasis infections