Bioterrorism and Military Health Risks

G20 Health Ministers Forum, World Economic Forum

Davos, Switzerland
25 January 2003

Your Excellencies, Friends,

At last year's World Health Assembly, WHO's Member States supported our longstanding policy that one of the most effective methods of preparing for deliberately caused disease is to strengthen public health surveillance and response activities for naturally or accidentally occurring diseases.

In public health, we often say that if one person is infected, the whole world is at risk. Last year's anthrax incidents have taught us how vulnerable even the most sophisticated societies are to the deliberate use of chemical and biological agents to cause harm. Since then, WHO has worked globally to improve awareness and assist countries in building up their preparedness.

Disease surveillance and control has immediate civilian benefits, since it improves protection against all disease outbreaks, whatever the cause.

When we discuss biological and chemical weapons, three things should be kept in mind:

Firstly, it is not only anthrax or smallpox which can have the potential of wreaking havoc on populations in times of conflict: malaria, cholera and dysentery, AIDS, measles, respiratory infections - these are enemies we must take seriously wherever there is conflict.

Secondly, the approaches and methods we use to prepare for, detect and respond to biological and chemical weapons use are very similar to those we use for ordinary disease outbreaks.

And thirdly, although early use of chemical agents on the battlefield mainly affected combatants, we have over the past two decades seen a willingness to use biological and chemical agents to target civilians. To prepare for and respond to such use is considerably more complex and difficult than to protect military personnel.

The dangers of biological and chemical weapons is not new. As early as 1970, WHO issued a guidance manual for countries on how to build up preparedness and respond to a possible attack. This manual was reissued, fully revised and updated, in 2002.

Clearly, these issues took on a new urgency after the events in the United States in the fall of 2001.

WHO has been closely involved in advising Member States on their preparedness for any biological or chemical event including smallpox. One of these initiatives was taken by G7 health ministers and Mexico, who began a series of meetings and informal contact. WHO is actively involved in this process, including expanding our global smallpox vaccine stockpile.

We are regularly consulted on the availability of smallpox vaccine and other aspects of such preparedness. WHO continues to maintain its reserve stock of vaccine for use as an emergency supply in the case of an outbreak, and works with countries to advocate investment in public health preparedness and response for disease outbreaks and public health emergencies. Such investment provides a clear and sustainable public health benefit whether outbreaks are naturally or deliberately caused.

Our response to a deliberate release of biological or a chemical agent would occur along the same lines as our response to an outbreak of infectious disease or an accidental chemical release. We would focus on the public health implications and assist countries to manage them.

Global public health concerns are also what determines WHO relations with military health institutions. Although military health institutions are non-traditional partners for WHO, the organization has been mandated to collaborate with "all potential technical partners in the area of epidemic alert and response". In many outbreak settings, particularly those associated with complex humanitarian emergencies, the military can be key to epidemic alert and response.

WHO has been engaging military health assets for public health by forming collaborating centre relationships with military laboratories in developing countries and engaging military health assets in epidemic response.

We have established a civil–military liaison activity to facilitate military contributions to epidemic alert and response activities. Since 1992, WHO has been in official relations with the International Committee on Military Medicine (ICMM) since 1952, the largest intergovernmental military medical organization involving some 110 Member States.

WHO is planning to explore avenues for further partnership with the Committee with a view to accessing technical expertise on epidemic alert and response to epidemics, be they natural or deliberate in origin.

WHO will also examine the development of new tools, within our mandate to contain or mitigate the effects of natural occurrence, accidental release or deliberate use of biological, chemical agents and radionuclear material. Such tools could include modelling of possible scenarios of natural occurrence, accidental release or deliberate use of such agents and collective mechanisms concerning the global public health response.

In last year's Resolution at the World Health Assembly, countries also committed to putting in place national disease-surveillance plans which are complementary to regional and global disease-surveillance mechanisms, and to collaborate in the rapid analysis and sharing of surveillance data of international humanitarian concern.

The Member States have also committed to collaborate and provide mutual support in order to enhance national capacity in field epidemiology, laboratory diagnoses, toxicology and case management. This is important, since the capacity for both surveillance and response obviously varies tremendously between countries.

Countries have agreed to treat any deliberate use as a global public health threat, and to respond to such a threat by sharing expertise, supplies and resources in order rapidly to contain the event and mitigate its effects.

Before I end, let me remind us all that biological and chemical weapons are not the only health threat in war. Throughout history, the deadly comrades of war and disease have accounted for a major proportion of human suffering and death. The generals of previous centuries knew that disease was a bigger enemy than the army they would face across the battlefield.

Despite the advances in both medicine and weapons technology throughout the 20th century, disease has continued to be the most formidable enemy, at least for the civilian population.

Armed conflict always amplifies factors that lead to increased incidence of infectious diseases among civilians. Mass movement of populations, overcrowding, lack of access to clean water, poor sanitation, lack of shelter, and poor nutritional status all increase the population's vulnerability to disease. In addition, the collapse of public health infrastructure and the lack of health services hampers control programmes such as vaccination or vector control.

During conflict, populations are often suddenly displaced and relocated to temporary settlements or camps. We have seen crude mortality rates over 60 times higher than normal in such situations.

Unless targeted prevention and control measures, like measles vaccination, provision of safe water and basic sanitation are implemented, death rates can suddenly shoot up. For instance, the outbreak of cholera and dysentery in Goma, former Zaire, in June, 1994, killed more than 12 000 Rwandan refugees in just 3 weeks.

In many conflict situations, ongoing war has led to “chronic emergencies” affecting entire countries and with long rehabilitation phases, such as, Afghanistan, Angola, Somalia, and the Democratic Republic of the Congo.

Very often, populations are dependent in the long term on non-governmental organizations for the most basic health services—in Afghanistan, over 70% of health-care services are provided by such organizations. Rebuilding the public health infrastructure in these countries might be seen as a priority but it rarely receives the long-term investment required from the international community.

Prevention and control programmes deteriorate in war-torn areas, with a consequent increase in vector-borne diseases such as malaria, sleeping sickness, yellow fever, tuberculosis and AIDS; and vaccine-preventable diseases such as measles. In Afghanistan, malaria was well controlled before civil strife began in 1979. However, in the past 20 years the disease has resurged, with 2–3 million cases per year. The increasing prevalence of HIV/AIDS in conflict situations from poor injection safety, lack of treatment for sexually transmitted infections, increased incidence of sex work, and lack of condoms are also major threats to the long-term health of these populations.

There are few if any differences between the work we do to prevent the threat of disease in war and the threat of disease in peace. Let us all do our utmost to protect populations from disease wherever and whenever it occurs.

Thank you.