caribbean countries (except cuba), where 2 percent of the population is infected. malaria is prevalent in the amazon basin. dengue reemerged in the region in 1976, presenting both as the usual form and the more lethal dengue hemorrhagic fever (dhf). hepatitis b and c prevalence is greatest in the amazon basin, bolivia, and central america, while dhf is particularly prevalent in brazil, colombia, and venezuela. yellow fever has made a comeback over the last decade throughout the amazon basin, and there have been several recent outbreaks of gastrointestinal disease attributed to e. coli infection in chile, argentina, bolivia and peru hemorrhagic fevers are present in almost all south american countries, and most hantavirus pulmonary syndrome occurs in the southern cone. the middle east and north africa region has substantial tb and hepatitis b and c prevalence, but conservative social mores, climatic factors, and the high level of health spending in the oil-producing states tend to limit some globally prevalent diseases, such as hiv/aids and malaria. the region has the lowest hiv infection rate among all regions, although this is probably due in part to above-average underreporting because of the stigma associated with the disease in muslim societies. the region's conservative social mores, climatic factors, and high levels of health spending in oil-producing states tend to limit some globally prevalent diseases, such as hiv/aids and malaria, but others, such as tb and hepatitis b and c, are more prevalent. the region's advantages are partially offset by the impact of war-related uprooting of populations, overcrowded cities with poor refrigeration and sanitation systems, and a dearth of water, especially clean drinking water. health care capacity varies considerably within the region, according to the afmic typology. israel and the arabian peninsula states minus yemen are in far better shape than iraq, iran, syria, and most of north africa. ninety to 100 percent of the israeli population and 70 to 90 percent of the saudi population have good access to health care. elsewhere, access ranges from less than 40 percent in yemen to 50 to 70 percent in the smaller gulf states, jordan and tunisia, while most north african states fall into the 40- to-50-percent category. western europe threats from several infectious diseases, include both those transmitted by humans, such as hiv/aids, tb, and hepatitis b and c, as well as from several economically costly zoonotic diseases (that is, those transmitted from animals to humans). the region's large volume of travel, trade, and immigration increases the risks of importing diseases from other regions, but its highly developed health care systems will limit their impact. its status as a hub of international travel, commerce, and immigration, moreover, dramatically increases the risks of importing new diseases from other regions. tens of millions of west europeans travel to developing countries annually, increasing the prospects for the importation of dangerous diseases, as demonstrated by the importation of typhoid in 1999. some 88 percent of the regional population growth in the first half of the decade was due to immigration; legal immigrants now comprise about 6 percent of the population, and illegal newcomers number an estimated 6 million. nonetheless, the region's highly developed health care infrastructure and delivery system tend to limit the incidence and especially the death rates of most infectious diseases, though not the economic costs. access to high-quality care is available throughout most of the region, although governments are beginning to limit some heretofore generous health benefits, and a growing antivaccination movement in parts of western europe, such as germany, is causing a rise in measles and other vaccine-preventable diseases. the afmic typology gives somewhat higher marks to northern over some southern european countries, but the region as a whole is ranked in the highest category, along with north america. tb, especially its multidrug resistant strains, is on the upswing, as is co-infection with hiv, particularly in the larger countries, with some 50,000 tb cases reported in 1996. hepatitis c prevalence is growing, especially in southern europe. western europe also continues to have several zoonotic diseases, among which is the deadly new variant creutzfeldt–jakob disease (nvcjd), linked to the bovine spongiform encephalopathy or "mad cow disease" outbreak in the united kingdom in 1995 that has since ebbed following implementation of strict control measures. other recent disease concerns include meningococcal meningitis outbreaks in the benelux countries and leishmaniasis-hiv co-infection, especially in southern europe. response capacity development of an effective global surveillance and response system probably is at least a decade or more away, owing to inadequate coordination and funding at the international level and lack of capacity, funds, and commitment in many developing and former communist states. although overall global health care capacity has improved substantially in recent decades, the gap between rich and poorer countries in the availability and quality of health care. in most poorer countries, health care—ranging from basic pharmaceuticals and postnatal care to costly multidrug therapies—remains very limited. market forces drive private pharmaceutical companies, and many developed country government research programs, to focus on drugs needed in their environment, not necessarily those of the poorer countries. this is generating a growing controversy between rich and poorer nations over such issues as intellectual property rights, as some developing countries make their own copies, not always with permission, of drugs under patent protection. developing countries also are less willing to make microbial samples available to companies that will make commercial vaccines from them, which may be too costly for the country that provided the sample. a global composite measure of health care infrastructure devised by dia's armed forces medical intelligence center (afmic) assesses factors such as the priority attributed to health care, health expenditures, the quality of health care delivery and access to drugs, and the extent of surveillance and response systems. typology of worldwide medical care capacity (1999) a major obstacle to effective global surveillance and control of infectious diseases will continue to be the quality of national health statistical reporting by many developing countries and lack of followthrough to properly direct aid and to follow recommended health care practices. those areas of the world most susceptible to infectious disease problems are least able to develop and maintain the sophisticated and costly communications equipment needed for effective disease surveillance and reporting. in addition to the barriers dictated by low levels of development, revealing a disease outbreakmay harm national prestige, commerce, and tourism. for example, nearly every country initially denied or minimized the extent of the hiv/aids virus within its borders, and even today, some countries known to have significant rates of hiv infection refuse to cooperate with who. only a few, such as uganda, senegal, and thailand, have launched major preventative efforts, while many who members do not even endorse aids education in schools. similarly, some countries deny the existence of cholera within their borders. inadequate commitment to infectious disease control policies at country level aid programs to prevent and treat infectious diseases in developing countries depend largely on indigenous health workers for their success and cannot be fielded effectively in their absence. training indigenous workers appears more effective than educating the general public of these countries. international organizations such as who and the world bank, institutions in several developed countries such as the u.s. centers for disease control and prevention, and nongovernmental organizations (ngos) will continue to play an important role in strengthening both international and national surveillance and response systems for infectious diseases. development of an integrated global surveillance and response system probably is at least a decade or more away. this owes to the magnitude of the challenge; inadequate coordination at the international level; and lack of funds, capacity, and, in some cases, cooperation and commitment at the national level. some countries hide or understate their infectious disease problems for reasons of prestige and fear of economic losses. total international health-related aid to low- and middle-income countries—some $2–3 billion annually—remains a fraction of the $250 billion health bill of these countries. who has the broadest health mandate under the un system, including setting priorities, coordinating global health surveillance, and emergency assistance in the event of disease outbreaks. health experts give who credit for major successes, such as the eradication of smallpox, near eradication of polio, and substantial progress in controlling childhood diseases, and in expanding primary health care in developing countries. who defenders blame continued member state parsimony that has kept who's regular biennial budget to roughly $850 million for several years and forced it to rely more on voluntary contributions that often come with strings attached as the cause of its shortcomings. this situation led to lack of focus at the top level as well as overly optimistic forecasts. the 1998 election of gro harlem brundtland as secretary general, along with a series of reforms, including expansion of the emerging and other communicable diseases surveillance and control (emc) division, has placed who in a better position to revitalize itself. internal oversight and transparency have been expanded, programs and budgets are undergoing closer scrutiny, and management accountability is looming larger. bruntland has moved quickly to revitalize top management, mostly from outside the organization, including from the private sector. she also strengthened country offices and to make the regional offices more responsive to central direction. who is increasing its focus on the fight against resurgent malaria, while a better-funded emc is expanding efforts to establish a global surveillance and response system in cooperation with unaids, unicef, and national entities such as the u.s. cdc, the u.s. dod, and france's pasteur institute. margaret chan, the current director-general, is still being assessed; there were questions about her performance as chief of public health for hong kong. who competes for resources with other un agencies that are involved in health care. the united nations children's fund (unicef) focuses on children's health. the united nations aids program (unaids) focuses on improving the response capacity toward hiv/aids at the country, regional, and global levels in cooperation with other un agencies. other un agencies involved in health care issues include the un development program (undp); the un family planning agency (unfpa); the un high commissioner for refugees (unhcr); the un educational, scientific and cultural organization (unesco); the international labor organization (ilo); the food and agricultural organization (fao); and the world food program (wfp). alternative scenarios the 1999 estimate looked at three plausible scenarios for the course of the infectious disease threat over the next 20 years: steady progress to a "health transition" in which such noninfectious diseases as heart disease and cancer would replace infectious diseases as the overarching global health challenge. the intelligence community states this is unlikely, givem inadequate emphasis to persistent demographic and socioeconomic challenges in the developing countries, to increasing microbial resistance to existing antibiotics, and because related models have already underestimated the force of major killers such as hiv/aids, tb, and malaria. "progress stymied" is a more pessimistic—and more plausible—scenario projects little or no progress in countering infectious diseases over the duration of this estimate. under this scenario, hiv/aids reaches catastrophic proportions as the virus spreads throughout the vast populations of india, china, the former soviet union, and latin america, while multidrug treatments encounter microbial resistance and remain prohibitively expensive for developing countries. multidrug resistant strains of tb, malaria, and other infectious diseases appear at a faster pace than new drugs and vaccines, wreaking havoc on world health. although more likely than the "steady progress" scenario, the ic judges this unlikely, because it is overoptimistic about the prospect of development, collaboration, and medical advances to constrain the spread of at least some widespread infectious diseases. "deterioration, then limited improvement" is judged most likely by the ic. the infectious disease threat—particularly from hiv/aids—worsens during the first half of our time frame, but decreases fitfully after that, owing to better prevention and control efforts, new drugs and vaccines, and socioeconomic improvements. in the next decade, under this scenario, negative demographic and social conditions in developing countries, such as continued urbanization and poor health care capacity, remain conducive to the spread of infectious diseases; persistent poverty sustains the least developed countries as reservoirs of infection; and microbial resistance continues to increase faster than the pace of new drug and vaccine development. more positive demographic changes such as reduced fertility and aging populations; gradual socioeconomic improvement in most countries; medical advances; expanded international surveillance and response