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Pulse readings: Public health and security

Is a state’s security better achieved by military and diplomatic expenditure or by investment in health, nutrition and housing? Healthy bodies and minds form the nucleus of true security, says Swarna Rajagopalan

Severe acute respiratory syndrome (SARS), avian flu and H1N1 or swine flu have captured the headlines in recent years, underscoring how globalisation alters the spread of disease. The profound, negative impact of the HIV and AIDS epidemic in sub-Saharan Africa has also moved people to frame health issues in terms of security.

While these epidemics have attracted a lot of media and policy attention and there is a lot of funding for HIV and AIDS work, public health activists point out that other diseases continue to quietly take larger numbers of lives. From a human security point of view, we see that there is a strong case to be made for considering public health an important dimension of security. To do so is to signal the magnitude of a threat, to underscore its urgency and to give it priority in policy agendas—that is, to make a political judgement.  

The 2007 World Health Report theme was ‘Public health security’ and the recommendations at the end could easily be about disarmament, migration or any other international security issue:

  • Full implementation of an international regime (in this case, International Health Regulations 2005).
  • Global cooperation in surveillance, alerts and response between intergovernmental, state, private and civil society sectors.
  • Open sharing of knowledge, technologies and materials.
  • Global responsibility for capacity- building.
  • Cross-sector collaboration within governments.
  • Increased global and national resources for training, surveillance, research, response networks and prevention.

The resemblance is hardly coincidental. 

There are at least three aspects to understanding the mutual impact of public health issues and traditional security assessments:

  • The challenge of preventing illness and disease in society.
  • The impact that security crises like conflicts have on public health conditions.
  • Weapons of mass destruction and public health security.

Public health security 

The World Health Report defined public health security as “the reduced vulnerability of populations to acute threats to health” (2007: vii).  In recent decades, demographic change, migration, globalisation, environmental degradation and the emergence of new diseases and new strains of old ones like influenza have converged to create public health crises that are global. They identify three sources of public health scares: infectious diseases, food-borne diseases and accidental or deliberate outbreaks.  

In the decades after the Second World War, the emphasis was on eradicating or preventing the old diseases that had caused a large number of deaths across communities: influenza, smallpox, cholera, tuberculosis, for instance. Over the decades, these vector-borne diseases which had been brought under control have re-emerged in mutant forms that are more virulent and resistant to existing drugs. Moreover, poor drinking water, poor hygiene and lack of sanitation facilitated the spread of infections like malaria, jaundice (hepatitis B), bubonic plague, diphtheria and most recently, dengue and chikungunya.  

But nothing prepared the world for the scare caused by the emergence and spread of HIV and AIDS. Where the disease originated and how it spread were not known in the first few years after the disease was first identified; we still do not know how to cure it. Between the late-1970s and today, HIV and AIDS has spread across the world, with disastrous social and political consequences in some places. The global death toll from this disease now approaches 30 million and in India alone 2.5 million. We are only just beginning to comprehend the many profound social consequences of this epidemic.  

The mutually reinforcing snowballing effect of globalisation, public health and security has been in evidence with each wave of influenza and stomach infection that has rapidly spread worldwide. Air travel and global trade in raw and processed foods are the two main factors facilitating this spread. With air travel, humans are not the only vectors as aircraft also transport insects like mosquitoes and virus and bacteria embedded in their furnishings. Airline food, prepared in one place and consumed mid-air, can also transmit disease. As mad cow disease and its successors show, the current popularity of exotic foods and the need for food imports in some areas carries local crop and livestock issues far beyond their patch of land. Measures to limit the spread of the infection have affected trade and economic sectors as much as the diseases affected individuals.  

Structural inequity makes a less celebrated contribution to the decline of public health standards. More children die of diarrhoea and pneumonia a year than twice the annual HIV/AIDS death toll, according to the World Health Organisation. Cholera and malaria also persist, showing that clean drinking water and hygienic, sanitary living conditions are pipe-dreams in many communities across the world. The investment in HIV and AIDS research is far higher than in these areas, and that may be a mistake for two reasons. First, these diseases can be easily taken care of with better living conditions. Second, in HIV+ people, poor living conditions contribute to secondary infections that make their situation worse.  

Ironically, better living conditions that alter food habits and lifestyles are also contributing to poor health. Diabetes diagnoses have increased manifold in the last 20 years, and heart disease is also far more common than it used to be. Some of these statistics may have to do with greater access to diagnostic and medical care, but the trend is real nonetheless and has consequences for society and security, as healthcare costs rise. People between 35 and 64 seem most likely to be diagnosed with diabetes, at the most productive phase of their lives. Eighty per cent of all new cases are likely to emerge in developing countries, it is estimated. Better medical facilities mean that people can survive disease better, but the money that it takes to keep them alive and functional is money not spent on the next generation. 

This section would be incomplete without a mention of gender violence, which has been recognised as a public health issue. Growing levels of violence even in societies at peace and rapid social change are contributing to growing levels of violence against women, children and sexual minorities. The very large numbers that are vulnerable by virtue of belonging to these groups accord to this problem a critical quality but unless we adopt a gender-sensitive lens, it is not possible to discern the connection between gender, health and security.  

Security crises and public health 

People die in conflicts; but short of that most extreme health consequence, are several others of which societies and states must take cognisance. Very broadly, we can think of three kinds of consequences that follow from these conditions. 

The most obvious health consequences follow from the violence of conflict itself. Both combatants and civilians are likely to be injured during fighting, through the detonation of landmines and when caught in crossfire. Torture is another reality of conflict, leaving victims permanently scarred physically and emotionally. The use of sexual violence as a weapon of war has only recently been recognised as such by the UN, but this is one of the oldest military practices.  

Second, conflict creates conditions that generate their own problems. Hospitals are targeted and medical facilities may be lost as collateral damage in the hostilities. The conflict-displaced live in camps where medical facilities may be very minimal and outstripped by demand. Access from living settlements to medical facilities may be hampered by mines and roads that are cordoned off. In such situations, permission may be required to exit camps and that adds delay to providing emergency care.  

Living conditions also decline in conflict zones. Malnutrition, short supply of clean water and declining hygiene contribute to the spread of diseases like malaria and cholera which in the absence of treatment, sometimes are fatal. In camps for the displaced, safe access to clean toilets is an issue across the board, but women and girls are disproportionately disadvantaged. Lack of privacy and access to toilets causes urinary and other infections among girls and women. Emergency supplies sometimes fail to include sanitary supplies. Those who set up medical facilities forget that reproductive healthcare remains a need even during conflict and displacement.  

Third, violent conflict in one part of a country has consequences all around. Sometimes it takes the form of other violent actions, such as terrorist attacks. More insidious however, are the ways in which people change over time. Exposure to news of violence, injury and death desensitises people to the point where they tolerate rising levels of violence in popular culture, in daily interactions and in other political contexts. Where guns are easily available, they are acquired as status symbols or to settle scores. Rising levels of domestic violence as well as violence against women in public spaces are corollaries of such an acceptance.  

On the other hand, if living with a daily but distant death-toll makes people impervious on one level, a climate of bereavement, grief and trauma takes its toll across society. Not just those who fight, but their families, friends and neighbourhoods are so traumatised. With each act of violence, the circle grows to embrace more people. Most societies live with the psychological scars of conflict, but few have the mental health resources to cope with trauma on that scale.  

New weapons, new public health insecurities 

Days after 9/11, post offices handled letters containing anthrax spores around the United States. Apart from the few who died immediately thereafter, it has still not been established whether symptoms exhibited by others exposed to anthrax are related to that exposure. Nevertheless, it is a fact that for weeks, there was panic that the sequel to 9/11 was a biological weapons attack on the United States, intended to kill or make Americans fall ill.  

Human beings are as ingenious in the creation of deadly weapons as they are in the creation of artistic works. The use of atomic weapons at Hiroshima and Nagasaki remains with us as evidence that we are also willing to use the weapons we create. For decades, the world documented the long-term impact of the use of these two bombs on generations of Japanese who had been exposed to radioactive emissions in 1945 or whose children were born with genetic defects. During the Cold War years, where politics was fuelling an arms race, discussing the health consequences of a nuclear attack or a leak at a nuclear installation was one of the most accessible ways for anti-nuclear or disarmament activists to make their point. When there was an explosion at the Chernobyl power plant in 1986, it reinforced this point to opponents of nuclear power.  

In the post-9/11 age, memories of Hiroshima, Chernobyl and of the 9/11 images, compounded by a most lurid cinematic imagination, have fuelled tremendous anxiety about weapons of mass destruction. This anxiety made it possible for the second Bush administration to successfully use the pretext of searching and destroying them in order to attack Iraq.  

There are three types of weapons of mass destruction that people usually discuss. Chemical weapons are made by exploiting the lethal and toxic qualities of elements and compounds, and usually they target large groups of people. Aum Shinrikyo’s attempt to release sarin into the Tokyo subway system is an example, and the kind of eventuality that inspires public anxiety. Biological weapons use viruses and bacteria to cause harm, and may be introduced into food or water, or other items that could circulate widely, resulting in epidemics. They are deadlier than chemical weapons because they can reproduce in the human body and spread. Nuclear weapons harness the energy released during nuclear reactions for large-scale destruction. They leave a legacy of radioactive poisoning in all surviving life. Of these three kinds of WMD, only nuclear weapons are relatively new; chemical and biological warfare are not. All three methods have one thing in common: making surviving populations ill is an important objective. In the case of nuclear weapons, it applies to blast survivors, but with the others, it is illness which may lead to incapacitation or death.  

So what, or why health itself is a security issue 

    “Health and human security are tightly linked. Good health is ‘intrinsic’ to human security, since human survival and good health are at the core of ‘security’. Health is also ‘instrumental’ to human security because good health enables the full range of human functioning. Health permits human choice, freedom, and Development.”

From a traditional perspective, population is one of the four elements of a state and one of the key sources of state-power. This is why Mussolini, for instance, encouraged people to have more children. The quality of population is also important: not too young, not too old, and certainly, not infirm. This is why countries with large but undernourished, unskilled populations with low life expectancies are not considered powerful. States need healthy populations to work, produce and fight for them. Healthy citizens also have healthy children, so that the state’s own continuation is assured. 

Realists would suggest that money spent on healthcare might be better invested in the military and diplomatic appurtenances of state power. An economics professor once declaimed to our class: “A hungry man is an angry man.” From a human security point of view, the point of the state is to assure to citizens a better quality of life, and therefore, it is investment in human needs such as health, nutrition and housing that is a better priority. A society of citizens who live well and are able to grow to their creative potential finds fulfilment without prejudice to the safety and survival of others. That is true security, and healthy bodies and minds form its nucleus.  

  1. UNAIDS, A Global View of HIV Infection,
  2. AVERTing HIV and AIDS,, accessed July 8, 2009.
  3. Laura MacInnis, Salt, sugar and water avert diarrhoea deaths – WHO, Reuters/ The Star Online, March 10, 2009.
  4. Diabetes facts, World Diabetes Foundation, Accessed, July 10, 2009.
  5. Lincoln Chen, Health as a Human Security Priority for the 21st Century, Paper for Human Security Track III, December 7, 2004.

Infochange News & Features, July 2009