Global Health and International Security

Historically in the West, disease was often 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 did 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, in an interconnected world, bacteria and viruses travel almost as fast as e-mail and financial flows. Globalization has connected Bujumbura to Bombay and Bangkok to Boston. There are no health sanctuaries. No impregnable walls exist between a world that is healthy, well-fed, and well-off and another that is sick, malnourished, and impoverished. Globalization has shrunk distances, broken down old barriers, and linked people. Problems halfway around the world become everyone's problem. Like a stone thrown on the waters, a difficult social or economic situation in one community can ripple and reverberate around the world. Now, there are solutions for those diseases that plagued early explorers, soldiers, and colonists. We know how to prevent and treat malaria. There are vaccines for yellow fever and treatments for tuberculosis (TB). Although travelers from industrialized nations diligently take antimalarials and update vaccinations when visiting developing countries, the people living there do not have access to these precautions. Three thousand African children die each day from malaria. They die of vaccine-preventable diseases, like measles, by the hundreds of thousands, and millions of people are dying every year from HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome). Today, we cannot view health solely as an issue of how many people get ill and how many recover, of who lives and who dies. We must look at why. And we should broaden debate to accept that health is an underlying determinant of development, security, and global stability. We must consider the impact of armed conflict and, perhaps more importantly, the silent march of diseases that devastate populations over time--these are the stones that cause the largest ripples, and the ones that go unnoticed until it is too late. Twenty years ago, HIV was a specter, all but invisible on the horizon. It was considered a disease that affected specific minorities--gay men and intravenous drug users. Science was slow to respond. The world took more notice with the realization that HIV knew no borders. Given the right vector, it could infect anyone--man, woman, gay, straight, healthy, and hemophiliac. By 1990, wealthy countries were screening blood donors and teaching children how to protect themselves. Condom use increased and incidence declined. Then antiretrovirals were made available to those who could afford them. HIV diminished as an urgent public health problem in rich countries. In 2003, more than 42 million people are HIV positive, with 30 million living in sub-Saharan Africa. Many are dying and many have died. These people are mothers and fathers, nurses and other health professionals, teachers, civil servants, miners, and soldiers. They are leaving a huge social and professional gap, which presents an imminent threat to countries struggling to develop. Those who remain are orphans, penniless grandmothers caring for their children's children, and family members and communities who are frightened, hurt, and stigmatized. Health systems are stretched well beyond their often frail capacities. We will see the effects of this tragedy for decades to come. A number of political, economic, and social factors have combined to create a situation in which more than 12 million people in southern Africa have been affected by famine. No sudden event has caused the crisis. Rather, it comes as the result of a long process of underinvestment in human resources. …