New Global Challenges: Health and Security from HIV to SARS
Geneva Centre for Security Policy
Historically, disease in other places was seen as an impediment to exploration, and a challenge to winning a war. Cholera and other diseases killed at least three times more soldiers in the Crimean War than the actual conflict. Malaria, measles, mumps, smallpox and typhoid felled more combatants than did bullets in the American civil war. And the Panama canal went over-schedule because of “tropical” diseases – then unknown, untreatable and often fatal.
Today on that front, there are very few unknowns. Globalization has connected Bujumbura to Bombay, and Bangkok to Boston. In an interconnected and interdependent world, bacteria and viruses travel almost as fast as email messages and money flows. There are no health sanctuaries. No impregnable walls between the world that is healthy, well-fed, and well-off, and another world which is sick, malnourished and impoverished. Globalization has shrunk distances, broken down old barriers, and linked people together. It has also made problems half way around the world everyone’s problem. And we know that, like a stone thrown on the waters, a difficult social or economic situation in one community can ripple and resonate around the world.
Now, there are solutions for those diseases which plagued the explorers, soldiers and colonialists of historical times. We know how to prevent and treat malaria. There are vaccines for yellow fever. There are treatments for TB. The striking feature is, while we diligently take anti-malarials and top up our vaccinations when we travel to developing countries - the people living there, those threatened most by these diseases - don’t have this access. 3,000 children in Africa die each day from malaria. They die of vaccine preventable diseases – like measles, by the hundreds of thousands. And, people are dying, by the millions every year, of HIV/AIDS.
Today, we cannot look only at health as an issue of how many get ill and how many recover. Who lives, and who dies. We must look at why. And we must broaden the debate, to accept that health is an underlying determinant of development, global security and stability. For this we can consider the short, sharp shock of conflict. And, perhaps more importantly, the silent and eerie march of diseases which devastate populations over time. These are the stones with the largest ripples. And the ones that go unnoticed until it is too late.
Twenty years ago, HIV was a spectre, all but invisible on the horizon. It was considered a disease which affected specific minorities - gay men and intravenous drug users. Science was slow to respond. The rare cancer, Kaposi's sarcoma, was a marker, and a sentence to die a painful, slow and often lonely death.
The world took more notice with the realization that the human immunodeficiency virus knew no borders. Given the right vector, it could infect anyone – man, woman, gay, straight, healthy and haemophiliac. By 1990 in wealthy countries, we were screening blood donors and teaching our kids how to protect themselves against HIV. Condom use had increased. Incidence declined. And then anti-retrovirals were made available to those who could afford them. People in countries with health insurance gained access, giving tremendous hope for a longer, healthier life. In short, HIV diminished - for those in rich countries - as an urgent public health problem.
Today, more than 42 million people are HIV positive. 30 million of them are living in sub-Saharan Africa. They are trying to survive in some of the poorest countries and conditions – with no access to the most basic health care - much less sophisticated and expensive treatment. Many have died. Many are dying. They are mothers and fathers, teachers, and nurses and other health professionals, civil servants, miners, and soldiers. They are leaving a huge social and professional gap – an imminent threat to countries struggling to develop. They are leaving orphans, penniless grandmothers caring for their children’s children, family members and communities frightened, hurt, stigmatized. Health systems stretched well beyond their often frail capacities. We will see the effects of this unfolding tragedy for decades to come.
Take Southern Africa. A number of political, economic and social factors have played a role in creating a situation where more than 12 million people in that region have been affected by famine. No sudden event has caused the crisis. Rather, it comes as the result of a long process of under-investment in human resources. This process has been compounded by the AIDS pandemic which, for example, has reversed much of the tremendous progress Botswana had achieved and is now becoming a profound burden in South Africa, as well as Zimbabwe, Zambia, and Malawi.
We see a downward spiral, making countries increasingly weak. The important challenge is to address the underlying causes and arrest the descent, before we are forced to deal with the ultimate consequences - famine, unrest and human suffering. Consequences which will touch everyone – the loss of so much human potential will indeed resonate around the world.
Let us think of other areas where HIV is creeping in – China, India, the Central Asian Republics. Knowing the impact in so many other areas, we cannot stand on the sidelines, only to see another HIV crisis unfold before our eyes with the economic, social, and political devastation it will bring.
The short, sharp impact of conflict more quickly brings to light the inevitable links between health and security. The obvious – the war wounded, soldiers and civilians. The medium-term impact– people uprooted, displaced to camps with little sanitation or health services, schools disrupted, and food insecurity. In Liberia this week, hundreds are suffering cholera because there is not enough clean drinking water. In Iraq this week insecurity continues to make it difficult for health workers to go to hospitals, and care for patients. In the Congo, where more than three million people have died through years of violent conflict, many people are traumatised – their mental health is precarious, not to mention the scores of diseases which continue to attack, kill and debilitate hundreds of thousands of people. This too will resonate – these conflicts may spill into other countries, people will leave their own countries out of fear or necessity, professionals will be lost, health and education systems will stretch, crack and break. They will take years to repair.
And most recently, the shortest, sharpest shock of all – an outbreak which captured imaginations, often more column inches than the war in Iraq, and always more headlines than Aids, TB or malaria. Severe Acute Respiratory Syndrome put the world on high alert, and drove unprecedented cooperation to stop a disease which had an immediate and negative impact on markets, on tourism, on trade. And, on hospitals, even in the most well-developed countries with the most advanced health systems.
One person infected, staying at an international hotel, put the world at risk. And unlike other diseases which we can prevent or treat, SARS was undiagnosable, untreatable, and, for one of every six people, fatal.
The way the world responded to SARS was global public health at its best. Scientists put aside their differences and drives to be the first, and came together, to share sequencing and study results. Doctors from around the world came together in virtual conferences, to share advice on how best to treat patients. Public health authorities from opposite sides of the globe flew to Geneva, to share their experiences with SARS, their success and failures with 192 member states at the World Health Assembly. And as a result, in just four short months, we have identified a new disease and contained a global outbreak, which could have become a global catastrophe.
The short sharp shock made us all stand up and pay attention. Due to the speed of science and using the best evidence, we quickly knew that SARS could infect men and women, people who were gay or straight, sick or healthy. Governments were committed. Resources made available. People made aware. Health workers given tools for action. Information shared across borders. In short, there was global mobilisation to fight a global threat. The result – we probably won’t find ourselves 10 years down the road with SARS also endemic in the countries which can least afford it – devastating lives and economies. Because we acted to make sure that wouldn’t happen. And, we found that it was in everyone’s interest to act. In today’s connected societies, there was no choice. It was impossible to hide SARS in a world with the internet and email. Impossible to pretend it didn’t exist, or that it was already contained. The consequences of doing so were mistrust in government, and in economies. Societies have been shaken to their foundation, fundamental questions raised about the handling of disease, of media and information, of constituents.
But to better understand the even wider picture, we must go back to the slow creep of disease. Who is affected? And why? These diseases we can protect ourselves against – malaria, TB, HIV, measles, diarrhoeal diseases, respiratory infections - are impacting people in the poorest countries – where economies don’t grow, where social unrest, unemployment and the threat of civil conflict force the stagnation of health and education systems.
I am not talking about small numbers. Between 1990 and 2000, the human development index declined in nearly 30 countries. Well over a billion people - more than one fifth of the world's population - are unable to meet their daily minimum needs. Almost one third of all children are undernourished. In many countries which have seen economic growth, increasing inequality means that the poorest part of the population has seen little or none of the benefits from this growth. The average African household consumes 20 per cent less today than it did 25 years ago!
A world where a billion people are deprived, insecure and vulnerable is an unsafe world. The separation between domestic and international health problems is losing its usefulness as people and goods travel across continents. More than two million people cross international borders every single day, about a tenth of humanity each year. And of these, more than a million people travel from developing to industrialised countries each week.
We also know that, in poor countries where people feel powerless, and watch as much of the world gets richer, they can bundle hatred and channel it in the most devastating ways. A giant construction site where the World Trade Centre used to be will always remind us of a world of conflict, a world divided. It exposes a new awareness of our vulnerability.
We must counter this manipulation of despair. We should seek to engage even more strongly with countries in crisis, to promote the values of democracy and justice.
There are many more compelling reasons for engaging in and supporting the rebuilding of weak and failed states. Diseases are spreading, mainly as a result of reduced efforts to control them and health systems weakened by poverty. We cannot afford to have large neglected areas where the population is left to fend for itself against diseases.
Take Ebola, for example, with a 90% fatality rate when left untreated. So far, it has been contained because it has been confined to small villages far from big cities. Health systems, like that of Uganda, have done a fine job in isolating patients and restricting spread. They could do this with the help of international specialists from WHO and CDC because the security situation was good.
What if an outbreak takes place in a devastated central African country where there is no local health care? What if the security situation was so bad that we could not send in international experts to advise and assist in containing the outbreak? What if infected people started fleeing into cities, to neighbouring countries and eventually out of the region? The most recent Ebola outbreak occurred in Congo – neighbouring the Democratic Republic of the Congo where conflict continues to ravage much of the country and its people.
We can also think of places where the provision of health was a bridge for peace. Efforts to eradicate polio have brought entire regions together – 16 countries across west Africa, where health workers cross borders to vaccinate children in neighbouring villages. Where warring factions have laid down their weapons and picked up a vaccine vial. Where 60 million children were protected against polio in less than a week.
Just a few weeks ago, the world came together in the largest act of unity for health. 192 countries adopted the Framework Convention on Tobacco Control – the first truly international health treaty. Implementation of the treaty will see tobacco advertising banned, increases in the price of tobacco products, efforts to control smuggling and more smoke free places.
This tobacco Convention had many opponents – many actively fighting to undermine the spirit and the letter. But those who wanted, and needed it most prevailed. Developing countries made the strongest push to see the convention adopted. Through this instrument, they have the power to keep the tobacco industry from encroaching further. And the power to reverse the current trend, which if left to fester, would kill 10 million people every year by 2020. That is foresight – for health, development, and for global security. It illustrates the world creating a global public good. The Framework Convention on Tobacco Control is one solution. It is not the only one. For diseases themselves, there are solutions. Treatment for HIV and TB. Preventive tools including vaccines against measles, and polio and whooping cough. But how to get them into the hands of those who need them most? The answer is investment, in people.
As the 18 leading economists and health experts who formed my Commission on Macroeconomics and Health have argued, disease holds back development and weakens societies. Malaria alone taxed Africa's combined GDP by about 100 $ billion compared to what it could have been if that disease had been tackled 30 years ago, when effective control measures first became available.
The Commission has presented a definitive argument for the need to invest in health as part of a basic development strategy. It shows, quite simply, how investments in health are an important pre-requisite for economic development.
The Commissioners concluded that health systems spending ten or twelve dollars per capita on health are not able to provide even the most basic health services to the people they serve. Their Report calls for a six-fold increase in health expenditures in the developing world.
The Commission focused on a few key diseases and issues which, if tackled, could hugely improve health outcomes for the poorest: AIDS, TB, malaria, children's diseases and maternal conditions. As many as eight million lives saved each year and a six-fold return on the investment in terms of economic growth would be the result if we managed to channel enough resources into health for the poorest countries to achieve the Millennium Development Goals.
In fact, competition in a global market place will not provide enough incentives for poor countries to move out of poverty. The idea that little help should be given to any country apart from supporting free-market reforms and democracy, is now fortunately being seriously challenged.
But even among those of us who share the belief that development assistance is a crucial part of any attempt to create a better and more secure world, strict prioritizing of aid has become a matter of necessity. After a decade of shrinking resources for international development assistance, donors have become increasingly focused on achieving measurable results.
I am myself a strong proponent of this approach. We do need to direct aid into activities and interventions that give concrete and measurable outcomes if we are to build a momentum for increasing development assistance. And more aid is needed if we are to meet the Millennium Development Goals, to which all countries have committed.
Humanitarian aid and development assistance have contributed greatly to reduced suffering and increased security. We should expect even more: after a decade of shrinking resources for international development, donors have become increasingly focused on support for quality programmes that promise to yield measurable results. It is a sign of hope that key donors have made commitments to raise, not lower, their levels of ODA.
Through the Global Alliance for Vaccines and Immunization, through the Global Fund to fight AIDS, TB and Malaria, and a number of other alliances and partnerships, we have developed a new set of tools to turn resources into effective action. The common denominators for these new tools are that they respond to the countries' own priorities, they process funds rapidly, they reward results and they are transparent.
The last decade brought a wealth of experience on how to strengthen weak states, prevent failure and rebuild countries wrecked by conflict. It also brought some examples of how not to do it. What we learned in Cambodia, in the Balkans and in East Timor and are learning is that it takes a combination of feasible political solutions, security, basic justice and stability, and humanitarian intervention.
Unless all these elements are working together, it is much harder to re-establish a viable government and functioning services. This is all too apparent in Afghanistan, where the challenges threaten to undermine the process of getting the country onto a firm footing. Ladies and Gentlemen:
We see the change disease brings to our world. And we see that foresight, investment and cooperation can make the difference. HIV has been with us for three decades, and the impact on societies and economies is too well known. By contrast, the global effort to contain SARS with determination and speed limited the impact to thousands, not hundreds of thousands, of cases. We still face threats from the environment, and what humans can do to manipulate it. We have already had one anthrax scare. Each of us in this room has probably considered the threat of bioterrorism.
SARS jumped from nature to humans - a rare occurrence requiring perfect conditions. And while far from a simple undertaking, bioterrorism is controlled by people, not nature. How to counter this threat?
The tools are in fact the same. Boosting capacity for disease surveillance is key to detecting all disease – whether created by nature, or humans. Currently, the system is not strong enough. Our experience with SARS exposed the weaknesses. Globally, including in developing countries, we must strengthen disease surveillance and control. SARS was a warning, which pushed even the most advanced public health systems to the breaking point. We must take this opportunity now to rebuild our public health protections.
This means more public health specialists, who can tell us where a disease came from, and where it is going. But, we can only find disease when we have the tools to look for it. Disease surveillance and response systems are critical, with strong national, regional and global linkages in reporting. And, governments need to invest more in infection control.
At the last World Health Assembly in May, member states adopted a resolution which would see revised and strengthened International Health Regulations. The key is a system where infectious diseases are found, reported, and stopped. Depending on the threat, this will require continued international cooperation – a system where all recognize that any disease, no matter if it is affecting rich or poor, will touch us all at some point.
Commitment, foresight, investment and cooperation. This is what is needed to fight the ongoing battle against the diseases which are with us now. And for the next outbreak, of SARS, or, perhaps a new, more infectious and more deadly illness. We may have very little time. Let us use it wisely.
Ultimately, improving peoples lives remains the bottom line. The way that we, as an international community, work to address current crises and prevent future ones, will determine whether we succeed, or fail, in our shared efforts to advance global development, growth, security and peace.