The invisible pilgrims

By Aditya Bhattacharji, Daniil Davydoff, and Scott Rosenstein

Attacks on U.S. interests in the Middle East are not the only security threats to have emerged from the region in recent weeks. In epidemiological circles, concern has been mounting over the discovery of a novel coronavirus in Saudi Arabia, just as Muslims from all over the world begin the annual hajj pilgrimage to Mecca at the end of October.

In the coming weeks, much-needed surveillance and scientific analysis will likely yield important details regarding this virus's threat to human health. But healthcare system shortfalls in some of the countries that dispatch the most pilgrims present obstacles to disease monitoring. And regardless of the microbe's eventual health, economic, and political impact, these deficits are a vivid reminder of institutional challenges to global disease prevention and control.

Little is known about the novel pathogen, but it does belong to the same family as the virus behind the 2003 SARS outbreak, a previously unknown microbe that killed nearly 800 people and sickened more than 8,000. SARS revealed the political and economic  risks attendant to emerging infectious diseases. But attention to these dangers has increased considerably since SARS, and this novel virus has thus far been confirmed in only two patients, one of whom is under intensive care at a hospital in London.

Whether it's a heretofore unknown virus, polio, or a host of other pathogens, the upcoming Hajj presents significant public health risks. The annual event attracts millions of pilgrims every year and is therefore an "ideal environment for spreading infectious diseases," according to the U.S. CDC. Although the Saudi government has mandated several vaccinations and dedicated considerable resources to lower infectious disease risks, its personnel cannot track pilgrims once they have left the country. And while the WHO has already issued basic case definitions for identifying infected patients, healthcare system deficiencies abroad could allow potential cases to slip through the cracks and go underreported.

Home to roughly 200 million Muslims, Indonesia is sending the world's largest contingent of hajj pilgrims (approximately 200,000). At home, the vast majority relies upon a decentralized healthcare system that suffers from poor information sharing and one of the most inadequately staffed healthcare workforces of any ASEAN nation. Those with means increasingly seek medical treatment abroad. The trend has become pronounced enough for Indonesian president Susilo Bambang Yudhoyono to implore the public, in August 2012, to utilize domestic medical facilities, despite having availed of foreign medical care himself. Indonesia is ill-equipped to track diseases over a territory that spans 17,500 islands even under normal circumstances. There's been speculation that an individual returning home from the Hajj was responsible for the reintroduction of polio into Indonesia in 2004 (via a strain of the disease traceable back to northern Nigeria).

As the second-largest Muslim majority country, Pakistan's quota for pilgrims is more than 179,000, though only about 95,000 Pakistani Muslims plan to take part in the hajj. Even so, recent developments in the country's healthcare sector could impede epidemiological surveillance of returning pilgrims. In 2011, Pakistan devolved its health ministry, relegating previously centralized functions to a variety of provincial and federal-level institutions. Responsibilities for disease surveillance are now fragmented between multiple government agencies and power struggles are reportedly common. While Pakistan may eventually develop a more cohesive public health system, the current state of surveillance is worrisome in the run-up to the hajj.

Some smaller contributors of pilgrims, such as Syria, may also be ill-prepared to catch cases of infection. Current unrest in that country, which has produced considerable strain on the healthcare system, could severely slow down the detection of unusual disease symptoms.

Should pilgrims come home with an infection acquired during the pilgrimage, there may be little to stop the disease from going undetected and infecting others. Whether the newly discovered coronavirus turns into a significant public health threat or not, its emergence reveals the danger that exists when health services are compromised, but the evolution and spread of disease are not.

Scott Rosenstein is director and Aditya Bhattacharji and Daniil Davydoff are analysts in Eurasia Group's Global Health practice.