WORLD HEALTH PROBLEMS AND GLOBAL HEALTH SECURITY
"Poverty breeds disease -- just as disease breeds poverty" (Gro Harlem Brundtland)

    In a globalized world, there are no health sanctuaries.  Bacteria and viruses travel fast, and with astonishing ease, many health issues transcend borders.  There are really no such things as "foreign" diseases.  An unhealthy population is a recipe for a "failed state," and an unhealthy world is a recipe for "failed humanity."  No sustainable development can ever occur without tackling disease and malnutrition; no international security can prevail if crisis-ridden countries are ignored; and little hope exists for the spread of freedom and democracy until global health is put on the security agenda.  Global health security is usually considered an interdisciplinary field combining epidemiology, development economics, demography, medical sociology, international relations, and safety/security studies which adds a global scope to the dictionary (American Heritage) definition of public health as the science and practice of protecting and improving the health of a community, as by preventive medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards.    

    In an average five years alone, the WHO (World Heath Organization) verifies more than 1100 epidemic events (Chan 2007).  Some of the more notable ones have been the West Nile epidemic of 1999, the Uganda Ebola outbreak of 2000, the SARS epidemic of 2003, and the Avian (Bird) Flu epidemic of 2006.  Other than epidemics, WHO considers three diseases crucially important to monitor:  HIV/AIDS; tuberculosis, and malaria.  WHO tabulates that about five and a half million lives are lost every year to these three diseases alone.  To be sure, there are other global health priorities, such as prenatal and primary care, sexual hygiene, mental illness, immunization, and the health consequences of tobacco, to name a few.  One in sixteen women die during childbirth in the poorest countries of the world, and some ten million in those same areas are expected to die from tobacco-related illnesses by 2020 (Koop et. al. 2002).  In addition, numerous countries manifest enormous problems with "local" health issues like occupational health and injuries in the workplace (Frumpkin 2005).

    Public health problems are aggravated in conflict-ridden areas.  A 2007 WHO Report (pdf) suggests that cholera is a common illness in such places.  Cholera is a bacterial infection that causes diarrhea, rapid dehydration, and death.  It occurs when poverty, war, or disasters force people into crowded conditions with poor sanitation, and is essentially a "dirty water" disease.  During the Iraq War, for example, the cholera problem approached epidemic proportions, and spread into Iran via Iraqi refugees.  There were many reasons for the problem.  Air attacks ruined many Iraqi water facilities, and those that were left undamaged were poorly conceived in the first place.  Water basically flows downward from Turkey to Iraq, and the Turks often conveniently had their dams under construction.  Further, government restrictions on chlorine -- a chemical used to disinfect water -- aggravated the problem, but such restrictions became necessary when insurgents started using chlorine in truck bombs.                       

    It is customary to distinguish between communicable diseases which spread among human populations in a region (epidemic) or globally (pandemic) because they are infectious (contagious), and non-communicable diseases (NCD) which are not infectious but the result of genetic or lifestyle factors.  All diseases are bad because they increase the so-called "disease burden" of society which consists in part of premature deaths, disabilities, healthcare costs, and reduced quality of life and well-being of people and societies.  Some societies experience a "double burden" with outbreaks of both communicable and non-communicable diseases.  However, worldwide estimates point to NCD as contributing to the vast majority (60%) of disease burdens (Murray et. al. 2001; Hough 2004).  Diseases tend to cluster in some populations so that several "co-morbidities" can exist at once; NCD tend to have multiple causes (multifactorial etiology); and demographic changes pose significant challenges (as do globalization and urbanization).  While NCD are non-transferable, this does not mean they pose less of a "threat" since all diseases require "care" but a communicable disease is typically fought with a "cure" (vertical) strategy while NCD are typically fought with a "prevention" (horizontal) strategy.  The following table summarizes the top diseases in both categories:  

    The diseases most likely to bring about the next pandemic are malaria, smallpox, West Nile virus, Ebola, and dengue fever.  Three of these are caused by mosquitoes (malaria, West Nile Virus, and dengue fever).  Malaria is carried by the Anopheles mosquito, which is common to Latin America, spreading to North America, and controlled only by DDT in Africa.  Malaria kills by destroying blood cells and the kidneys.  The West Nile virus appeared out of nowhere in North America during 1999, but is believed to be carried by mosquitoes who caught it from birds.  It now exists in 43 states, where it infects about 4,000 people a year, but only about 1,000 or so die from it at present.  Dengue fever is carried by two kinds of mosquitoes, Aedes aegypti and Aedes albopictus, which thrive in tropical climates, but the Aedes species has been found as far north as Chicago.  Smallpox is most likely spread by bioterrorism or accident, and there is no known cure other than biosafety quarantine.  Ebola acts so quick and deadly that where it flares up, the epidemic usually burns itself out before help arrives and/or a risk of widespread transmission occurs.  Cases have cropped up in Africa and Europe.  Ebola destroys the linings of the blood vessels, and is spread by contact with bodily fluids, but the worst fear is if it ever mutates and becomes transmissible by air -- all of mankind will probably be wiped out if and when that happens.

EVOLVING THREATS TO HUMANITY

    The threat spectrum is much broader than the above discussion would indicate.  Viruses, microbes, and toxins are continually evolving and becoming quite unpredictable.  Genetic engineering and nanotechnology are adding to this unpredictability.  Nanotechnology is the science of building things from basic materials that range from 1 to 100 billionths of a meter, and some experts think it represents a grave threat (Kellman 2007).  For example, a nanotech-antipersonnel weapon could be built to be about the size of a suitcase and carry enough lethal doses of botulinum -- as many as fifty billion toxin-carrying devices -- to kill every human being on the planet many times over.  Moreover, the field of nanotechnology is actively researching the processes of self-replication.  There is a high potential for accident and abuse.

    For its part, nature doesn't need any help to evolve, because bacteria, parasites, viruses, fungi, and cancer cells are all continually evolving on their own.  All of these things are pathogens (biological agents that cause disease or illness), and many pathogens are becoming drug-resistant pathogens.  This means that nothing works anymore (antibiotics, vaccines, chemotherapy, etc.) to neutralize their effects.  When a bacterium evolves like this, it is called a "superbug."  Usually, such development is a natural part of the organism's evolution, and the reader probably already knows that sulfa drugs and penicillin are already useless against things like Staph infections (it was the first bacterium in which penicillin resistance was found - in 1947 -- and in 1967, gonorrhea became resistant to penicillin).  Despite little incentive to do so, pharmaceutical companies have been busy inventing new classes of antibiotics every year, but the race has always been close.  In 2004, the Center for Disease Control started noting an unusual increase in the evolution of drug-resistant pathogens.  Pathogens recently showing signs of drug-resistance include: streptococcus, pneumonia, E. coli, salmonella, and the bug that causes gastroenteritis.  DDT also isn't working well against parasites like mosquitoes anymore; viruses are mutating; sprays don't always work against the fungi which cause athlete's foot and ringworm; and cancer (responsible for 13% of all deaths) thwarts epidemiology because of its changing incidence (remission factors).  In fact, not only are pathogens becoming drug-resistant, but they are becoming extensively drug-resistant, the most well-known case involving Andrew Speaker and the 2007 Tuberculosis Scare.

The 2007 Extensively Drug-Resistant Tuberculosis Scare

During May of 2007, after being diagnosed with TB and cautioned not to travel, Atlanta injury lawyer, Andrew Speaker (shown here with his fiancée), took multiple commercial flights to and around Europe to arrange his wedding. Once in Europe, CDC officials back in the states determined his strain of TB was even rarer than originally thought. Advised to check into an Italian hospital, Speaker instead took a commercial flight to Canada, crossed into the U.S. by rental car (a DHS employee was fired for not catching him at the border), and reported to CDC, who promptly put him under involuntary quarantine (the first time such powers were used since 1963). It turned out he only had multi-drug resistant tuberculosis (MDR-TB) instead of the more lethal and contagious extensively drug-resistant tuberculosis (XDR-TB). Lawsuits are pending, internationally, from numerous contactees during his travels.

    The only other case involving international quarantine (Canada alone quarantined over 5000 people) in recent years was the SARS Outbreak in China, SE Asia, and Canada from 2002-2004.  SARS is indicated via a "probable" diagnosis involving an atypical pneumonia or respiratory distress syndrome.  Antibiotics are totally ineffective, and patients have to be completely isolated, preferably in negative pressure rooms, with full barrier precautions.  This epidemic emerged suddenly, infected over 8,000 people, and claimed over 700 lives.  Since no cure has been found yet, the world remains on alert.  The website, SARS: An Open Scar, offers some good documentaries and timelines.  The causative agent behind the syndrome has been discovered to be a coronavirus (SARS-CoV) that may have jumped from animals to humans (zoonosis), as is suspected with Ebola.  The SARS Outbreak is often studied as a lesson in how NOT to handle a medical disaster (e.g., China's lack of cooperation) as well as some best practices on how to handle them (e.g., Singapore's use of a central hospital).

    A longstanding global health problem (known about since 1900) has been Transmissible Spongiform Encephalopathies (TSEs), also known as prion diseases, which represent a spectrum of diseases with overlapping signs and symptoms, but generally cause the brain to develop little holes in it which ends up making the brain look like a sponge (hence the word "spongiform").  There are many varieties of TSE, but what they all have in common is a resistance to normal forms of sterilization, such as boiling or irradiation.  Unlike other diseases which are spread by microbes, the TSE infection vector involves the spread of a mutated protein (a prion protein) either by ingestion of foodstuff, blood transfusion, or contact with something so contaminated.  Most people became aware of the problem during the Mad Cow Disease Scare of 1995, which actually involved only a rare, incurable, human variant (Creutzfeldt-Jakob disease) of a small subset of TSE called Bovine Spongiform Encephalopathy (BSE).  The latest figures (as of 2007) indicate that 165 people (mostly in Great Britain) have died from a rare variant of it called vCJD.  It is known that BSE-infected beef has been in the food chain since the 1980s, and new cases of human infection are discovered every year.  The disease has a long incubation period, generally measured in decades.  The full extent of the outbreak is not fully known, but governments around the world have been busy inspecting cattle herds and killing thousands of cows worldwide as well as implementing all sorts of bans on cattle feed and beef imports.  Places where cows are found infected do not correlate with places where humans are found infected, due to the globalized nature of food distribution.  The following table and map depict the extent of the problem:

Places Most Affected by BSE (# cows)	Global Map of Human Infections (# humans)
1. UK (183,823) 2. Ireland (1,353) 3. France (900+) 4. Portugal (875) 5. Switzerland (453) 6. Spain (412) 7. Germany (312) 8. Belgium (125) 9. Italy (117) 10. Netherlands (75)
Canada and the U.S. have only had a handful of infected cows, but a high number of infected humans.

A PERSPECTIVE ON THE HIV/AIDS CRISIS

    Space does not permit going into the HIV/AIDS crisis in detail, particularly its viral subtypes or epidemiology.  Suffice it to say that despite the existence of drugs which slow down the disease's progress, there is no known cure.  Although a few cases exist beforehand, it was first discovered in 1981 by the CDC among a group of homosexual men in Los Angeles, and a number of theories exist about its original source (most theories pointing to contact with primates in Africa -- see The Origin of HIV and the First Cases of AIDS).  The WHO spun off a rather special U.N. program called UNAIDS in 1986 devoted entirely to the AIDS problem.  The disease is a retrovirus which destroys the immune system.  Some 25 million people have died from it since 1981; some 5 million are newly infected every year; and worldwide, some 40 million are living with the infection.  Two-thirds of those "living with the infection" reside in Africa, as the following map shows:

The AIDS Pandemic

Sub-Saharan and Southern Africa is the most infected region, where women are more likely infected than men, certain cultural practices exacerbate the problem, and some political leaders are in denial. In India, China, and the Middle East, the disease is spread primarily via drug use and prostitution; in Latin America and the Caribbean via mother-to-child transmission; in Europe via sexual contact among youth; and in the USA via use of methamphetamine and other injectable drugs. In the USA, African Americans make up about 47% of the total HIV-positive population. In Africa, about 50% of police and armed forces are infected (Price-Smith 2001).

    In 2007, President Bush committed $15 billion to the Emergency Plan For AIDS Relief (PEPFAR) which stands as the largest international health initiative ever undertaken by one nation to address a single disease.  The program hopes to provide antiretroviral treatment (ART) to 2 million infected people, prevent 7 million new infections, and support care for 10 million people (the "2-7-10 goals").  The plan targets 15 countries, most of which are in Africa.  To date, nearly one million people have been provided ART, but there is controversy over those numbers since half may have already been receiving treatment via the Global Fund, which is only partially supported by the U.S., being a new kind of international organization that is a foundation but also a kind of public-private partnership (much like GAVI, the Global Alliance for Vaccines and Immunization).  Many of these private firms are often confused as being part of the United Nations family, the WHO being the foremost agency in that regard.  Within the field of AIDS policy, fierce debate exists among which agencies are the most effective.  PEPFAR tends to be motivated by moral-religious considerations; the Global Fund by big business considerations; and WHO by the academic concept of "human security," a vague sustainable development term which loosely means that global security can be achieved by addressing the underlying problem of individual vulnerability and powerlessness.  Regarding PEPFAR, however, Dietrich (2007) lists the following ideological disputes that impair the plan's effectiveness:

• PEPFAR does not fund needle exchanges (this being prohibited under U.S. law), which is not a problem in Africa where drug use is not a major source of infection, but is in India, China, and the Middle East.

• PEPFAR does not fund abortions, which pretty much prohibits aid from realizing its potential in places like Latin America where mother-to-child transmission is a common source of infection

• PEPFAR encourages condom programs, but there are either problems with distribution, or the rise of user dissatisfaction and stigmatization associated with them around the world

• PEPFAR encourages abstinence and "be faithful" campaigns, but this has backlashed in places like Europe and Russia where youth "just wanna have fun" (abstinence-only campaigns tend to produce the highest rates of unwanted pregnancies in societies where they are emphasized)

• PEPFAR gives significant funding to faith-based organizations, as opposed to secular ones, which flies in the face of many national governments and cultures of different religions

    In addition, restrictions exist under international trade and intellectual property laws which conflict with any human-rights approach to global health security.  This has long been a problem, and was first recognized as a problem by the Doha Agreement of 2001.  Forman (2007) recounts the many issues in this regard, but the major problem is prohibitive pricing.  For example, it still costs about $30,000 per year to treat a person with hepatitis C, while at the same time, prices have plummeted for the antiretroviral drugs needed for HIV/AIDS treatment.  Even though drug costs are lower in some countries because they impose price controls, most citizens of most countries cannot afford the drugs they need.  Various countries are trying different insurance schemes.  Inequities abound.  Standard pharmaceutical products fall sharply in price when generic equivalents are introduced, but many companies, organizations, and countries have entered into agreements to only use brand names.  The U.S., for its part, encourages such treaties and agreements, because they protect the profits of American pharmaceutical companies.  Multinational pharmaceutical companies often neglect "diseases of the tropics" not because the science is impossible but because in cold economic terms, there is no market.  While certainly such companies have saved many peoples' lives, their responsibility to shareholders requires that they focus on the diseases of developed countries -- the so-called diseases of affluence and longevity.

THE OBESITY EPIDEMIC AND RICH COUNTRIES

    It may seem odd to mention obesity at this point, but self-inflicted diseases are dangerous too.  One of the diseases of affluence is obesity, the simplest measure of which is waist circumference (for men >40 in.; for women >35 in.).  The CDC announced that the epidemic began in the United States during the year 2000.  It was around that time when it was discovered that 280,000 deaths occur every year as a consequence of obesity (Allison et al. 1999).  The number of overweight- or obesity-related deaths increased to about 400,000 per year, and because of this, it may very well be that today's young generation may be the first generation ever to have a lower life expectancy than their parents or grandparents (Olshansky et al. 2005).  The WHO estimates the average world life expectancy at 64.3, and up until now, the US-Canadian figure has been the world's highest at 76.9, but globally, it may be averaging out, since Africa hovers at 51.4 and Asia at 66.3 (Hough 2004).

    Obesity is a global problem.  It often coexists with under-nutrition in developing countries, and is not restricted to industrialized societies.  The WHO estimates that worldwide, over 1 billion people are obese, with the problem somewhat centralized in places like North America, the United Kingdom, Eastern Europe, the Middle East, the Pacific Islands, Australasia, and China.  In some countries like Samoa, 75% of the population is obese.  Most experts conclude that excessive nutrient intake and sedentary lifestyle are the main causes; others blame the fast-food and snack-food industry, especially for the globalized patterns of the problem.  Smoking cessation is a known cause of obesity, but the global trend is in the opposite direction for tobacco use.  Smoking is on the rise in many countries.  More than half of the world's smokers live in fifteen countries: China, India, Indonesia, Russia, Bangladesh, Brazil, Mexico, Turkey, Pakistan, Egypt, Ukraine, Philippines, Thailand, Vietnam and Poland; and about 5 million people die every year globally from tobacco use.

    It used to be that, in some cultures, obesity was regarded as a sign of status, but today, it is increasingly seen as a social stigma.  There are still some countries where being "fat" is tolerated (parts of Africa, the Middle East, certain Indian and Pacific Island cultures), but in places where the tide has turned, "fat liberationist" groups are emerging to fight against weight discrimination and argue for public health right access to expensive weight loss surgery.  Currently, the United States has the highest rates of obesity in the developed world, as depicted state-by-state below:

The Obesity Epidemic in the United States

64% of American adults are overweight and 16% of American children are likewise. These percentages are increasing at about 2 to 3 percent a year. 16% of active duty U.S. military are obese, and it is currently the largest single cause of discharge of soldiers. States with the most obese are Mississippi, Alabama, West Virginia, Louisiana, Kentucky, and Tennessee. Many states have created obesity programs in schools to mandate exercise and change lunchroom habits, but only Colorado (at 17% obese) might meet the federal government's goal of each state being down to 15% obese by 2010.

THE "BIBLICAL" DISEASES AND POOR COUNTRIES

    The so-called "Biblical" diseases are the "tropical" diseases; not only the "big three" of HIV/AIDS, tuberculosis, and malaria which account for 5.6 million deaths annually (3.2 of those deaths occuring in sub-Saharan Africa alone), but what Hotez (2007) calls the "neglected tropical diseases" (NTDs) which are found described in various ways in the Bible.  The NTDs include the following: parasitic infections caused by worms (lymphatic filariasis, commonly known as elephantiasis, onchocerciasis, commonly known as river blindness, ascariasis, hookworm, whipworm, guinea worm, schistosomiasis, oriental liver fluke, and cysticercosis) and protozoa (African sleeping sickness, kala-azar, Chagas disease), as well as three bacterial infections -- trachoma, leprosy, and Buruli ulcer.  Each disease mentioned here almost exclusively affects poor people living in rural areas in poor countries.  Approximately 500,000 people die annually from NTDs.  Relatively inexpensive deworming treatments would go a long way toward eliminating this disease burden.  The following table puts the problem in comparison by measuring impact in terms of disability-adjusted life years (the years of life lost from premature death or disability):

The Disease Burden of Poor Countries
1. Lower respiratory infections	91.4
2. HIV/AIDS	84.6
3. Unipolar depression	67.3
4. Diarrheal diseases	62.0
5. Ischemic heart diseases	58.6
6. Neglected tropical diseases	56.6
7. Cerebrovascular diseases	49.2
8. Malaria	46.5
9. Road traffic accidents	38.7
10. Tuberculosis	34.7

THE FUTURE OF GLOBAL HEALTH SECURITY

    Governments are notoriously coy about releasing health statistics. They have also been known to deny or downplay disease epidemics.  Many nations in today's world make their living off of tourism, and a decline in tourism revenue (as well as public embarrassment) account for much of the cover-up and non-transparency.  It is also the case that the global health industry is becoming a big business.  There is lots of money involved.  There are also lots of agencies, often working disjointedly, with each criticizing the other, and all moving toward some functionalist vision of global health being dominated by IGOs and NGOs (like Doctors Without Borders).  However, there are also multinational corporations pursuing their own interests, and foundations which represent islands of charitable humanitarianism.  The future isn't so bright for any securitization of disease threats, at least at the international level.  A few nation-states might recognize some problems as security threats, but there is a long way to go before concerted world recognition of health security is a reality, just as international law has a long way to go before health security becomes recognized as a fundamental part of any human security guarantee.

INTERNET RESOURCES
BBC Health Security News
Brundtland Report: Our Common Future
BSE (Mad Cow Disease) in Canada
CFR Issue Page for Global Health
CIA Report on Global Infectious Disease Threats (NIE 99-17D)
Drug-Resistant TB in Russia
Economic Costs of Malaria
European Strategy for Noncommunicable Diseases (pdf)
Global Council to Fight AIDS, Tuberculosis, and Malaria
Global Health Council-The Voice for Global Health
GlobalizationandHealth.com
GlobalHealthReporting.org
Global Issues: Health Overview
Harvard Initiative for Global Health
HIVInsite Gateway
International Conference for Emerging Infectious Diseases
International Society for Infectious Diseases
ObesityinAmerica.org
PandemicFlu.gov
The Threat of Sick Livestock
UNAIDS Report on the Global AIDS Epidemic
U.N. World Health Organization (WHO)
U.S. National Institutes of Health
World Bank Health, Nutrition & Population Division
World Health Organization Epidemic and Pandemic Alert System
World Organization for Animal Health (OIE)

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Frumkin, H. (Ed.) (2005). Environmental health: From global to local. San Francisco: Jossey Bass.
Hotoz, P. (2006). "The Biblical diseases and U.S. vaccine diplomacy." Brown Journal of World Affairs 12(2): 247-58. (pdf)
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Last updated: Sept. 30, 2008
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