Health and international security. (US policy on world health)

A fundamental national security obligation of governments is providing and assuring the safety and well-being of their citizens. To the extent authorities lapse in these duties, unmitigated health burdens will add to discontent, conflict, and desire for political change. Accordingly, examining the nexus between conflict, disease, and instability, and challenging assumptions that medical and human rights emergencies are isolated and self-limiting, would establish global health in a strategic context for the security interests of the United States in the post-cold war era. The goal of this article is to make such an examination.

A World Besieged by Disease

In terms of disease, the earth remains a dangerous, unstable habitat. Early in this century, a great influenza pandemic killed nearly 20 million people worldwide, 500,000 in the United States alone.(1) Today, in spite of antibiotics and vaccines, myriads of infectious and chronic diseases ravage continents and countries with impunity, afflicting millions and evading containment.

The global extent of disease is staggering. According to the World Health Organization (WHO), more than 2 billion people are seriously ill at any one time with diseases that account for over 50 million deaths annually.(2) Malaria alone infects up to 500 million people each year while tuberculosis (TB) scourges 1.9 billion people, or one-third of the world's population, and kills 3 million people annually.(3) At present rates, by the year 2005, 2 billion people will be infected by TB, a prospect that triggered WHO's 1993 declaration of a "global tuberculosis emergency." In sub-Saharan Africa, diseases striking children - diarrhea, parasites, and respiratory illnesses - cause such high rates of mortality that the median age of death in the region is a mere 5 years, compared to nearly 75 years in advanced countries.(4)

Political instability and disease often reinforce each other. Once dormant, cholera has struck several continents, often in tandem with armed conflict or large-scale upheaval. Disease heightened political competition among ethnic rivals during the Rwandan crisis. As throngs of refugees crowded into camps in neighboring Zaire and Tanzania, the wretched conditions erupted into a fury of cholera, dysentery, and other highly communicable diseases. The United Nations (UN) urged the refugees to return home to halt rampant propagation of disease and to encourage restoration of order in Rwanda. Hutu authorities in the camps, however, openly discouraged repatriation to deny the Tutsis their claim to rule.(5) Hutu refugees were caught between enduring the squalor of the camps or returning to Rwanda, where they risked death under Tutsi rule.

Adding to the world's burden of illness is the threat of "new and reemerging diseases" caused by microorganisms that have previously been quiescent or have arisen renewed by mutation. Outbreaks by these pathogens are striking with frightening and deadly frequency. In recent years, the emergence of legionnaires' disease, Lyme disease, AIDS, drug-resistant tuberculosis, gonorrhea, and malaria, and the reappearance of previously suppressed entities such as plague, cholera, hanta virus, and "flesh eating" variants of streptococcus, have defied the medical armamentarium. The most recent outbreak of Ebola virus in Zaire, which incited emergency measures by U.S. and international health authorities, demonstrates the pathogens' power to wreak sudden havoc.

With rapid population growth, industrialization, integrated markets, international travel, and environmental changes, new patterns of interactions between man and reservoirs of disease-causing microorganisms will instigate opportunities for rogue pathogens to affect regional stability. The 1994 plague outbreak in India, for example, had an impact far beyond its epidemiological boundaries. The ensuing panic resulted in abrupt shutdowns of major industries, including aviation, exports, and tourism, as stigmatization of products fanned irrational fears of contamination. The outbreak cost India's economy nearly $2 billion.(6)

AIDS

Over the past decade, the explosive emergence of the human immunodeficiency virus (HIV) has propelled AIDS to the forefront of global concerns. No other disease has equaled AIDS in dominating policies and commanding societal fears. From its beginning, the unrelenting propagation of HIV has come to signify the failure of medical and political systems alike to contain an international health emergency.

As AIDS accelerates, its political dimension is emerging as a major destabilizing factor. HIV's infiltration into the middle class, ruling elites, and military personnel of developing countries poses unique threats to security. In these countries, government officials risk recrimination should their actions be perceived as having helped spread the disease. HIV within military ranks diminishes morale and readiness. Furthermore, rumors among and perceptions by local populations that peacekeeping troops from other countries harbor the virus could complicate deployments. Even wealthy countries are not immune to the destabilizing political impact of AIDS. HIV blood testing scandals in Germany, France, and Switzerland have resulted in national uproars and compelled the dismissal or prosecution of government and other officials.

Eastern Europe, Russia, and the newly independent states of the former Soviet Union are especially vulnerable to AIDS. With rampant poverty, drug use, …