December 2007
Global health security definition:
The term ‘health security’ was originally coined to refer to the access of a population to health services on the individual level. Health security describes the availability of medical treatment, clinical facilities, outpatient and inpatient services, and clean air and water for each member of society. According to an unpublished Surgeon General’s Report, ‘global health’ is “the health of populations—of humanity at large.”[i] ‘Global health security,’ therefore, includes the consequences of such individual health access, or lack thereof, on a worldwide scale. The larger meaning of the term includes the ability to manage ongoing disease threats and the security concerns that come about with poor access to adequate medical care.
The health of people worldwide becomes a direct security concern of governments everywhere, not only a moral human interest, due to the rapid spread of infectious diseases across political boundaries, the deleterious effects poor health may have on global economies, and the instability that may be incited or exacerbated by poor health conditions, thereby endangering national security.
Ensuring public health is more than simply halting the spread of diseases, however. It is an effort to improve overall health in every aspect, including reducing the incidence of chronic diseases, providing adequate nutrition, improving environmental conditions, and enhancing mental health.
Rapid spread of health risks across international borders:
In an ever globalizing world, people are crossing borders more frequently than ever. As individuals travel around the world, so do the diseases they carry, allowing infectious diseases to spread more quickly and to more people than ever before. People travel for business and pleasure at unprecedented levels, migrant laborers bridge distant communities, and livestock is shipped all over the globe. Consequently, a health threat affecting one area or one nation can no longer be isolated.
The idea of global public health began to receive much attention with the rapid spread in 2002 and 2003 of Severe Acute Respiratory Syndrome (SARS) from southern China to Japan, then through Southeast Asia, and carried onto airplanes and into Singapore, Canada, and other countries. The speedy transmission of this new pathogen raised awareness of the dangers that infectious illnesses pose to countries with even the most developed of public health infrastructures.
Diseases, however, are not the only health threat that may spread rapidly across borders. Other agents deleterious to public health may be quickly disseminated as well. The WHO, consequently, employs broad definitions of ‘public health risk,’ ‘disease,’ and ‘event’ to incorporate into the global health framework the “accidental or intentional release of pathogens or chemical or radionuclear materials.”[ii] Global health security interests, therefore, call for surveillance and response capabilities able to confront possible biological attacks, nuclear spills, or the spread of any material detrimental to public health and the environment.
Economic effects of poor health:
Healthy people are better able to make contributions that benefit everyone and take advantage of those benefits, making public health a global good. When suffering from substandard health, an individual is unable to be as productive in society as he or she otherwise would be. Citizens who are infirm, undernourished, or do not receive proper medical attention are unable to contribute in their full capacity, leaving the whole world deprived of their possible economic, scientific, artistic, or humanitarian contributions. When one is ill, it is very difficult to go to work, to study, or to raise one’s children. With widespread epidemics, chronic health problems, or environmental factors that create inferior health conditions, teachers, soldiers, police officers, governmental leaders, and even active parents may become unable to function effectively, thereby seriously undermining the economic and social stability of an area. Lower productivity in all sectors of the economy may also cause an economic downturn that can affect not only local populations, but outside trading partners as well.
Economic factors have a great impact on national security. Indeed, according to the Bulletin of the World Health Organization, “promoting economic development and preventing economic instability are core priorities for every government, and are generally the primary motivations underlying national security policy.”[iii] It is far more difficult for a country with an ailing economy to provide effective and comprehensive health services to its citizens, or any other type of public service. Furthermore, economic stagnation often leads to internal and international friction. Crime, political or social violence, and displacement all tend to be exacerbated by poverty, which, in turn, leads to greater health risks and further instability.
Although poverty often creates conditions detrimental to individual and public health, such as overcrowding, poor nutrition, and poor access to medicines or clean water, neither national nor individual wealth is a prerequisite for good public health. Cuba is one country with few economic resources that has managed to provide all of its citizens access to effective healthcare. With an average per capita GDP of $4,100 in 2006,[iv] and per capita expenditure on health care totaling $229 in 2004,[v] Cuba has been able to provide universal healthcare coverage, local doctors throughout the island, a comprehensive array of vaccines administered to each child, and various medicines at a low cost. The average life expectancy, 75 years for males and 79 years for females in 2005,[vi] rivals the average life expectancy of countries with much higher GDP’s per capita. The United States, for example, had a per capita GDP of $43,800 in 2006[vii] and a total per capita expenditure on healthcare of $6,096 in 2005, yet claimed a life expectancy rate similar to that in Cuba: 75 years for males and 80 years for females.[viii]
One way that Cuba is able to achieve such results on a very low budget is through emphasis on illness prevention and health promotion, two central components to global health. Vaccines are a central part of the Cuban healthcare system, and are distributed to the public through the school systems and community vaccine drives. Public education about nutrition, healthy behavior, risks and warning signs also plays a major role in promoting public health. Government-sponsored informative campaigns also focus on preventing chronic diseases, such as heart disease and diabetes. Another factor affecting public health is early detection of outbreaks and mass mobilization of the population to contain them. This was seen in Cuba during outbreaks of Dengue fever, when authorities organized the public to spray insecticide on local breeding areas of the mosquito that carries the disease. Overall health and wellness is promoted in other, less overt ways, as well, such as through group exercise activities for senior citizens, and easily-accessible mental health services.
Example: The SARS Outbreak of 2003
Severe Acute Respiratory Syndrome (SARS) surfaced in southern China in November of 2002. The illness, which is caused by a virus newly recognized during the outbreak, SARS-CoV, is spread through ‘respiratory droplets’ that were propelled into the air when an infected person coughed or sneezed, and may also be airborne.
According to WHO reports, 8,098 people were reported sick with SARS worldwide between November 2002 and July 2003, with over 800 deaths. The virus was spread through several Asian countries and as far as Canada, Singapore and Germany, mainly due to airplane travel.
It is estimated that the SARS outbreak, which affected Asian countries most severely, cost the region approximately $60 billion in gross expenditure and business losses, according to the 2007 WHO world health report [a].
Instability and the danger for national security:
When health conditions are poor enough, such as may occur in the case of a nuclear spill or an infectious epidemic, stability and national security are threatened. When the police force is depleted due to illness, serious civil unrest may ensue. If, perhaps, an entire region no longer has access to clean water, mass displacement may cause social tensions within and between countries. Internal displacement may strain the job market, fostering resentment among local populations. A perceived inability of the government to address and effectively counteract a widespread health threat, be it an infectious epidemic, a widespread chronic illness, or the release of a biological weapon, could even incite a dismantling of that government, and possibly others in the area.
Additionally, cooperation between nations to improve health enhances a country’s security through the dialogue, interaction and good will involved in assisting another nation to build its health infrastructure, monitoring the flow of people and animals for disease transmission at the borders, and providing medical care in case of urgent need. Such positive engagement strengthens ties between nations, creating channels of communication that can ease tensions and conflict. Global health provides a framework through which nations can engage in constructive diplomatic interaction, bolstering both their international and internal security, and providing a public good to every individual, state and economy.
Example: The AIDS epidemic
[b]
In 1999, President Bill Clinton declared the HIV/AIDS pandemic a threat to U.S. national security. Despite the relatively low prevalence of the disease within U.S. borders, Clinton acknowledged the danger that HIV/AIDS posed to national and global economies, internal stability, and international peace. Clinton justified this new outlook on the pandemic by asserting that the disease will “endanger U.S. citizens at home and abroad, threaten U.S. armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests”[b].
Although precise and accurate data on HIV/AIDS levels are difficult to collect in many countries, particularly relating to prevalence rates within the armed forces, estimates state that AIDS has become the leading cause of death in military and police forces in certain African countries, totaling more than half of in-service mortalities [b]. High death rates and incapacitation due to the disease can have a crippling effect on security forces, making national borders difficult to defend against attack, limiting forces available for peacekeeping missions, and creating challenges to maintaining social order in a peaceful way through police forces. Some countries have barred people who are HIV positive from enlisting in the military. Russia’s military has turned away 9,000 potential draftees who tested HIV positive in the last five years, including 5,000 within the last two years alone [b].
As it is a costly and complicated process to train new military recruits, the absence of experienced members of the armed forces due to illness hinders the growth and efficacy of the military. Indeed, a rapid spread of HIV/AIDS, or a ‘second wave’, could “destabilize powerful countries and regions critical to the United States and, by extension, global strategic interests” [b]. Three nations at risk include Russia, India and China, all of whom have nuclear capabilities. Although a direct impact of HIV/AIDS on the political and economic capabilities of these nations may be far away, particularly due to their large populations, “increased instability in any of these countries would have major political, economic, and military repercussions” [b].
The health consequences of HIV/AIDS can be felt not only in the military, however, but throughout society and with very dangerous consequences. As the disease affects the ability of “politicians, teachers, police, and health care professionals” to perform their jobs, “governance and social service structures are weakened,” causing a decline in public confidence, and “a climate of social unrest and disorder”[c].
Economic conditions are also greatly affected by the pandemic. One study noted that notes that within households in sub-Saharan Africa, “when one family member becomes infected with HIV/AIDS, the family’s income tends to fall between 40 and 60 percent” [c]. Consequently, children in such households or youths orphaned by AIDS are “more likely to drop out of school due to an inability to pay school fees or because of the social stigma attached to being an AIDS orphan [c].” This, in turn, may lead younger generations to turn to crime, sex work, gangs and militias, or radical social groups.
A declining able-bodied workforce hurts the national and international economy as well. As productivity falls, so must exports and the foreign exchange necessary to import goods and services. Particularly labor intensive industries, such as mining, often suffer most, causing prices for such commodities to increase on the global market. The incapacitation of a large part of the workforce also causes a drop in human capital severe enough to discourage foreign investment, further hurting the economy of the home nation, as well as the investing nation. As the economy suffers, national income similarly declines, causing poverty and malnutrition. Additionally, a widespread “[decline] in national income can make societies more susceptible to extremist tendencies and violent revolutionary movements [c],” thereby threatening domestic, as well as international, security.
Even if no violence ensues from the pandemic, however, the ensuing poverty brought about by poor health and an individual or societal inability to work leads to migratory employment, poverty, hunger, or unsanitary living conditions that exacerbate health conditions and encourage additional spread of disease.
Global health surveillance and response:
Because threats to public health cross international boundaries with such speed and ease, the need for advanced surveillance, response and treatment capabilities in every country is crucial. Countries cannot effectively safeguard their citizens’ health by developing an advanced domestic health sector alone; they must also work with other countries to strengthen and improve the health capabilities of each nation.
The SARS outbreak in 2002-2003 emphasized the need for effective national and international health surveillance and disease reporting. After allegations that the Chinese government had “concealed critical information” when the outbreak first emerged, the WHO pushed to revise the International Health Regulations in order to create more rigorous reporting regulations and allow the WHO to bypass state governments in order to collect information from in-state actors.[ix]
An effective national surveillance system would require information sharing among various sectors that collect data on human health, animal health, national security and biological threats, and environmental conditions. Even if such information gathering is achieved, as Julie Fischer, head of the Henry L. Stimson Center’s Global Security program, explains, “A database is only as good as the data that goes into it, which means that the various entities that collect data on health threats (from clinics to zoos) require resources appropriate to the challenge of making information available” to an administrative public health department in a timely fashion.[x] Gathering the comprehensive information necessary to identify and address a public health threat, she adds, would require “a sea change in the cultures of agencies and professionals accustomed to looking at threats only in one specific context.”[xi]
Organizations active in global health security:
Global health is promoted by various partners. The United Nations sponsors ten programs and five allied agencies to engage in global public health security and are funded, like the WHO, by member country governments.
Multilateral organizations and other independent, nongovernmental groups also play a role. Regional banks, for example, may fund health initiatives, while the multilateral Medecins Sans Frontieres (Doctors without Borders) bring their health services to underserved areas around the world.
Individual governments also play a role by giving international, bilateral aid to address public health concerns. Aid can be given directly in medicines, health personnel, food supplies, or capital to invest in public health infrastructure.
Private foundations have played a leading role in promoting pubic health around the world, as well. Many philanthropic funds support research, health campaigns, or the distribution of health products where resources are scarce. They often face fewer political hurdles in exercising their public health objectives.[xii]
WHO International Health Regulations of 2005:
The International Health Regulations (IHR) were originally developed by the WHO in 1969 to face the international threat of four infectious diseases: cholera, plague, smallpox and yellow fever. In 2005, they were rewritten to create a framework for improving international public health in the areas of infectious and chronic diseases, accidentally or intentionally released pathogens, and severe environmental contamination. The International Health Regulations (IHR) 2005 are “legally binding regulations adopted by most countries to contain the threats from diseases that may rapidly spread from one country to another,” as well as “other public health emergencies that may affect populations across borders, such as chemical spills, leaks and dumping, or nuclear melt-downs.”[xiii]
Adopted in May of the same year, the IHR 2005 officially went into effect on June 17, 2007. One main change from the IHR 1969 to the IHR 2005 is the shift in focus from preventing the spread of illness between borders, to the localized containment of it at the source, no matter where it may break out. They, furthermore, do not limit the scope of international surveillance to a set number of diseases, but rather include any possible health threat that may arise. Based on the belief that “no country can fully protect its citizens in isolation or through traditional border controls,”[xiv] the IHR 2005 establishes rules for cooperation, and works to build effective public health infrastructure and surveillance in every country.
To make the new international public health regulations effective, however, states must do more than simply report incidence of disease quickly despite the possible danger it may pose to tourism or trade. They must also invest in their public health infrastructure and organize it to be capable of detecting disease outbreaks both locally and internationally as they occur – a feat that requires highly sensitive surveillance and analyses systems.[xv] Furthermore, as one country can not protect the health of its citizens alone, international cooperation to establish such systems and share the information they gather is crucial.
The new WHO regulations therefore mandate “global cooperation in surveillance and outbreak alert and response; open sharing of knowledge, technologies and materials, including viruses and other laboratory samples, necessary to optimize secure global public health; global responsibility for capacity building within the public health infrastructure of all countries; cross-sector collaboration within governments; and increased global and national resources for training, surveillance, laboratory capacity, response networks, and prevention campaigns.”[xvi] The revisions of 2005 provide the WHO much greater power, including the ability to circumvent national governments in order to collect health data from individuals inside the country.
Barriers to global health:
There are some challenges to ensuring good public health on a global scale, however. According to the WHO’s annual report, at least 39 new pathogens have been identified since 1967, including HIV, Ebola hemorrhagic fever, Marburg fever and SARS.[xvii] Preexisting diseases have also mutated into a new form, become drug resistant, or morphed from an illness of animals to one that infects human beings, like the H5N1 influenza, commonly known as avian flu. Weak public health systems exacerbate the danger of a naturally-occurring infectious disease outbreak, since limited or inadequate access to effective healthcare makes illness more difficult to prevent or treat, opening the opportunity for it to spread.
The WHO recognizes human barriers to a successful global public health infrastructure, as well. It lists “inadequate investment in public health resulting from a false sense of security in the absence of infectious disease outbreaks; unexpected policy changes such as a decision temporarily to halt immunization in Nigeria, which led to the re-emergence of polio cases; conflict situations when forced migration obliges people to live in overcrowded, unhygienic and impoverished conditions heightening the risk of epidemics; and animal husbandry and food processing threats such as the human form of bovine spongiform encephalopathy (BSE) and Nipah virus.”[xviii]
