By Greg Witt, GMU Biodefense PhD student
Since at least the fifth century BCE, when the Plague of Athens contributed to the outcome of the Peloponnesian War, states have recognized the detrimental effect that infectious diseases can have on their stability and security. In the modern era, as the focus of governments shifted from traditional concerns about national security to encompass new threats to economic prosperity, access to food, and public health – collectively known as “human security” – efforts to combat the risks posed by disease have been given an even higher priority. Nowhere is this connection more central than in the burgeoning field of health security, defined by the World Health Organization as “…the activities required to minimize the danger and impact of acute public health events.” However, just as the burdens imposed on societies by disease pose a threat to the security of states and populations, the inverse is equally true: insecurity tends to exacerbate the harmful effects of disease by displacing vulnerable people, impeding access to medical care, and breeding mistrust against government institutions. This can lead to a vicious cycle in which intrastate conflict reduces the capacity of states to respond to public health crises, which in turn makes it harder to prevent further violence.
This dilemma was the central topic of an event hosted by the Nuclear Threat Initiative (NTI) on January 15 titled “Battling Insecurity, Mistrust, and Disease: Are We Capable of Reining in Epidemics in Complex Environments?” The event was a follow-on to a series of technical workshops hosted by NTI and the Africa Centres for Disease Control and Prevention (Africa CDC) as part of the Initiative to Strengthen Biosecurity and Biosafety, which aims to resolve safety and security gaps related to biological threats in Africa. Opening remarks were delivered by NTI Co-Chair and Chief Executive Officer Ernest Moniz, who highlighted the complex, intertwined relationship between conflict and infectious disease and the consequent risks this connection poses to international and health security in Sub-Saharan Africa. Dr. Moniz described a tabletop exercise conducted by NTI and partner institutions as part of the 2019 Munich Security Conference, in which a fictional country in the midst of domestic unrest experienced a deliberate terrorist attack utilizing a highly-lethal biological agent. The results of this simulation were, in his words, “eye-opening, and not in a good way.”
The evening’s keynote speaker was Dr. Wilmot James, Visiting Professor of Political Science and Pediatrics at Columbia University. For most of the past decade he served as an opposition parliamentarian in South Africa, acting as the Shadow Minister for Health, Trade and Industry, and Basic Education at various times over that period. The presentation was dedicated to Sheik Humarr Khan, Sierra Leone’s only resident expert on viral hemorrhagic fevers at the time of the 2014-2016 West African Ebola outbreak, as well as all those who put their lives at risk to combat infectious disease. Dr. Khan led the country’s response to the epidemic before dying from the virus. Of the 28,000 cases of Ebola in Guinea, Sierra Leone, and Liberia, nearly 600 were among health care workers, half of whom ultimately died from the disease.
Dr. James began his lecture with a set of questions that are straightforward yet devilishly difficult to answer: can humanity defeat infectious disease? And if not, how can we minimize the risks that they pose? Even under the best of circumstances, such as those found in relatively peaceful, high-income countries, combating disease can present an enormous challenge. In lower- and middle-income countries experiencing protracted internal conflicts, the task becomes almost insurmountable. This is the exact situation facing much of Sub-Saharan Africa, which contains 22 of the 31 countries considered to have a high risk of state collapse and a significant number of the world’s “hot spots” for emerging and reemerging infectious diseases. Central Africa in particular is an ideal testing ground for determining how to effectively respond to outbreaks in volatile regions.
While Sub-Saharan Africa has only one ongoing conflict that can be classified as a war (defined by the Uppsala Conflict Data Program as involving at least “1000 battle-related deaths in a specific calendar year”), it has more intrastate conflicts below this threshold than any other part of the world. Among this group of nations, none has experienced more bloodshed over the past 25 years than the Democratic Republic of the Congo (DRC). The country is still reeling from the aftermath of the Second Congo War, which killed upwards of five million people in the DRC and neighboring states between 1998 and 2003. Across large stretches of territory, particularly along the eastern border in the Albertine Rift, the Congolese government has never been able to reassert effective control, leaving a power vacuum in these areas that has been filled by countless armed militias. In just the provinces of North and South Kivu, it is estimated that almost 100 discrete combatant groups are currently under arms.
In spite of its modest death toll compared to many of conflicts in Sub-Saharan Africa, this civil unrest in the Kivu region poses an acute threat to global health security due to the severe outbreak of Ebola virus disease that has been raging there since August 2018. As of January 20, 2020, the World Health Organization (WHO) has estimated the total number of cases to be 3,416, with 2,237 fatalities, making it the second largest Ebola epidemic ever. The outbreak is serious enough that the WHO took the extraordinary step of declaring it a Public Health Emergency of International Concern (PHEIC), only the fifth time this measure has been taken. However, the volatile political situation in Kivu has exacerbated the public health crisis by preventing the Congolese government and international aid groups from being able to mount a coordinated response to the epidemic. Even more worryingly, there have been hundreds of attacks against frontline health care workers, often prompted by a mistrust of authority among the local population. This insecurity has undoubtedly had a negative impact on efforts to control the outbreak.
To help resolve the crisis, the WHO has established a 40-person team to ensure that critical medical supplies are delivered and deployed in the Kivu region, and other international groups such as the United Nations Children’s Fund (UNICEF) and Médecins Sans Frontières (MSF) have provided invaluable assistance. However, there is only so much that these organizations can achieve since the public health community cannot solve political crises. MONUSCO, the United Nations peacekeeping operation in the DRC, has helped to stabilize the situation. Despite the deployment of 18,300 UN peacekeepers and $8.7 billion spent on the mission over the past two decades, the country has perpetually been on the verge of becoming a failed state. The United States and other high-income countries need to play a more active role in promoting peace and development in Sub-Saharan Africa, with the ultimate goal being to increase the capacity of African states.
Public health requires cooperation among many stakeholders, but Dr. James contended that only governments have the capacity to respond to massive crises such as large-scale outbreaks of infectious disease at the necessary scale. When populations lack faith that their governments are capable of effectively responding to such crises, social breakdown is possible. Just such an eventuality is occurring in Kivu, as demonstrated by the attacks on health care workers. Dr. James pointed out that, even in these dire circumstances, there have been several developments that bode well for the future. The international community, and the WHO in particular, have learned from one of the key mistakes during the 2014-2016 West African Ebola epidemic and are now engaging in sustained community outreach. Accurate information about an infectious disease is essential to controlling its spread, and this information must be disseminated to policymakers, public health workers, and the general populace in a timely manner. In addition, civil institutions and non-governmental organizations (NGOs) have stepped into areas lacking government control to engage with locals and act as trusted neutral parties. The Africa CDC has emerged as one such organization and has performed admirably in the role.
Dr. James concluded his talk by considering how biological threats may change over the next several decades, which he dubbed “a new species of trouble.” In his view, the WHO’s 1988 announcement of the international campaign to eradicate polio represented the high-water mark for the belief that infectious disease would be definitively defeated in the foreseeable future. Since then, countless emerging and reemerging infectious diseases have rendered that vision implausible just as the forces of climate change, globalization, and urbanization have made the world even more susceptible to epidemics. On the anthropogenic side, advances in genetic engineering and synthetic biology could herald the arrival of ever more dangerous pathogens that could be released, either accidentally or intentionally, onto an unsuspecting populace.
In addition to its recently released Global Health Security Index, NTI has championed several initiatives to mitigate these threats, such as preventing nefarious actors from gaining access to dangerous pathogens (biosecurity), preventing laboratory-acquired infections and accidental pathogen release (biosafety), and instilling a culture of responsible science and the oversight of dual-use research. However, the speed of innovation in biotechnology has tended to outpace the implementation of the necessary safety and security measures. To ensure that future outbreaks can be prevented from turning into pandemics, dedicated international funding mechanisms are needed to fill the preparedness gap, especially in lower- and middle-income countries. Only by working together can humanity hope to someday attain the lofty goal of a world free from infectious disease.
Image courtesy of the Nuclear Threat Initiative
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