Confronting Africa’s Health Challenges
Jeremy Youde
Department of Political Science
University of Minnesota Duluth
jyoude@d.umn.edu
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Are sick people as big a threat to the stability and security of sub-Saharan Africa as arms
proliferation and civil conflict? Health and disease have emerged as major themes in analyzing
the state of politics and security in sub-Saharan Africa in recent years. Political scientists have
paid increasing attention to health and disease in general, challenging and refining notions of
their importance to the global community, and much of this attention has focused on Africa. This
attention has had some beneficial elements, such as highlighting the importance of sub-Saharan
Africa’s importance to international politics more broadly.
While there appears to be a growing consensus on the importance of health and disease
for African politics and security, understandings and interpretations of that importance vary
widely. We find ourselves in a situation where most people agree that health matters, but large
disagreements exist over how and why it matters. Resolving, or at least understanding, the nature
of these differences has important implications for both academic analysis and policymaking.
This paper seeks to offer an understanding of the current state of the debate over the
relationship between health and security in Africa. To do this, I will examine how the role of
health in security politics has changed, how scholars and policymakers have assessed the nature
of this relationship, and the consequences they have foretold.
The first section of the paper will examine the debates over the relationship between
health and security in Africa. Security, particularly in the post-Cold War era, remains a highly
contested term, and much of the tumult centers on the appropriateness of incorporating nonmilitary elements into a broader understanding of security. In particular, it will examine the
ongoing debates over expanding the realm of security to include non-military threats such as
health. The second section focuses on the nature of the challenge posed by health and infectious
disease to sub-Saharan Africa. Initial reports suggested that disease posed a direct threat to
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African states, but more recent work presents a more nuanced and less linear relationship. The
third section will examine the hypothesized political, economic, and military consequences of
high rates of HIV infection in sub-Saharan Africa. HIV/AIDS has received the vast majority of
attention within the larger debates about health, so examining these hypothesized relationships
can be quite instructive. The fourth section will discuss which issues have been overlooked in the
current conceptualization of African health and security. Not all diseases are treated equally, and
this unequal treatment has major consequences. The final section will re-examine the basic
question of whether the security framework is most appropriate for addressing health problems
and inequities in sub-Saharan Africa.
Does health matter for security?
With the demise of the Cold War, security studies scholars grappled with questions of the
nature of security in the new international environment. Traditional understandings of security
focused exclusively on military and physical threats within a state-centric framework. A number
of researchers questioned the applicability of this paradigm in the post-Cold War era. While the
military-focused, state-centric model may have been appropriate in a bipolar world, they
challenged the model’s usefulness in a world facing numerous serious non-military threats (such
as environmental degradation, refugee flows, illicit drugs, crime, and food scarcity) with only
one superpower (Kolodzeij 1992). Calls for incorporating non-traditional threats under the rubric
of ‘security’ also called for greater attention paid to the threats faced by individuals rather than
states. For most of the world’s inhabitants, the threat of nuclear warfare was far more remote and
less threatening than the exhaustion of their land’s capability to sustain agriculture or the
eruption of a civil war in their country.
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At the same time, many scholars argued that incorporating new issues into security
studies would dilute the term’s meaning. Walt argues that security studies should remain focused
on its traditional realm, “the study of the threat, use, and control of military force” (Walt 1991:
212). He and his colleagues argue that this not only provides more intellectual coherence to the
field, but also that it maintains a high level of analytical and methodological rigor. Adding nonmilitary issues to security studies would also decrease the field’s ability to offer useful policy
suggestions to government officials (Walt 1991: 213). In a now-seminal article, Deudney
explicitly argued against the expansion of security into new realms, such as environmental
degradation (Deudney 1990). While not denying the challenges environmental changes pose to
the international community, including it and other ‘new’ security threats led to inappropriate
policy suggestions and engendered us-versus-them thinking that directly contradicted the
international cooperation necessary to address these problems.
While this debate emerged in the pages of international relations journals, the AIDS
epidemic entered the public consciousness. International organizations began to create programs
dedicated to preventing the disease’s spread, offering treatment (though such options were
almost non-existent in the late 1980s and early 1990s), and raising public awareness of the
disease. As researchers gathered more and more information about the extent of AIDS’ spread in
some countries and noted the demographic trends associated with the disease, some began to call
AIDS a threat to economic development, governance, and national security. In the final year of
the Reagan Administration, the US government commissioned a report which forecasted future
trends and potential threats to American national security. It noted that AIDS could weaken
national militaries, heighten concerns about foreign visitors spreading the disease, and pose large
financial and social costs. Noting the already-high infection rates in Central Africa, the authors
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wrote, “Given the dearth of trained people in most of the African societies, the projected early
morbidity and early demise of the managerial and political elite suggest that a significant degree
of political and economic instability may arise in the next 5 years” (Population and Development
Review 1989: 598).
The emergence of AIDS and the potential threats it posed coincided with the emergence
of the human security paradigm. With the end of the superpower rivalry of the Cold War, a
movement developed to redefine conceptualizations of security away from its traditional statecentric focus on military and physical concerns and toward a more individual-level conception of
security. The United Nations Development Program, in particular, embraced this redefinition of
security. In its 1994 Human Development Report, the authors defined human security as:
It means, first, safety from such chronic threats as hunger, disease, and repression.
And second, it means protection from sudden and hurtful disruptions in the
patterns of daily life—whether in homes, in jobs, or in communities (United
Nations Development Program 1994: 22).
UNDP then went on to disaggregate security into seven distinct realms: economic, food, health,
environmental, personal, community, and political security. By so doing, UNDP hoped to change
the conversation within the international community, shift the referent of security away from the
state and toward the individual, and develop an all-encompassing, integrative redefinition of
security. As this broadened definition of security took hold and gained prominent advocates,
health gradually became incorporated into the realm of security issues (McInnes 2008: 276-277).
Advocates of human security emphasized its relevance to the real challenges threatening
most people in their daily lives. Nuclear weapons did not cause most people a great deal of
concern or worry on a regular basis; not being able to provide for their families did. Infectious
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disease fits into this conception of security, as extensive illness prevents people from working,
wipes out household savings, and threatens the social fabric of society. That said, there exists no
clear consensus of how to define health security. In some instances, its definition focuses on
protection against microbial threats. At other times, the definition centers on new global
challenges that lack adequate international responses, the emergence of new actors into the
security arena, or direct links with a government’s specific foreign policy interests (Aldis 2008:
371-372).
While the larger debates over the merits of human security and its impact on international
policymaking go beyond the scope of this article1, understanding the basic terrain of the debate is
critical for understanding the literature on health and security. Most writers who have addressed
the health/security linkages at least make reference to human security, and some explicitly situate
the connections between AIDS and security within the human security framework. Even writers
who disavow the utility of human security make references to the literature. While the usefulness
of the human security paradigm is an active area for debate, it has become de rigueur to make at
least passing references to it within the AIDS and security literature.
While many of these debates focus on contemporary concerns, we should be mindful of
the numerous historical examples of where ill health has undermined national and international
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See Liotta (2005), MacFarlane et al. (2006), and Paris (2001), among others, for more
comprehensive treatments of the debates over human security and its place within the field of
security studies.
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security in its traditional sense. One scholar remarks, “It is curious that the pernicious effects of
epidemics on states and societies should be well established in the domain of science and yet be
paid little attention in the domain of political science” (Price-Smith 2009: 35). Thucydides’
(1980) account of the Peloponnesian War pays particular attention to the deleterious
consequences of an epidemic on Athens’ ability to fight. Spreading rapidly and killing
mercilessly, this unnamed disease undermined the city-state’s ability to field an effective military
while also weakening the social, economic, and political structures necessary to fight Sparta.
McNeill (1977) exhaustively details how disease epidemics thwarted leaders’ abilities to conquer
new territories or expand their realms. Indeed, he ties the demise of the Byzantine Roman
Empire in the 6th Century CE directly to the so-called “plague of Justinian”—which may have
been the first known manifestation of bubonic plague in Europe (McNeill 1977: 126). Zinsser
saw a direct link between plague and societal insecurity, arguing that “panic bred social and
moral disorganization; farms were abandoned, and there was a shortage of food; famine led to
displacement of populations, to revolution, to civil war, and, in some instances, to fanatical
religious movements which contributed to profound spiritual and political transformations”
(Zinsser 1934: 129). Crosby (1986) argues smallpox (inadvertently) allowed Hernando Cortes to
conquer the militarily-superior Aztecs because the disease ravaged Tenochtitlan and severely
undermined the Aztecs’ faith in their government and religious structures (Crosby 1986: 200).
Fastforwarding to the 20th Century, Crosby (2003) argues that the influenza pandemic spread
particularly among military members during World War I, which weakened their fighting
capabilities. Using German and Austro-Hungarian mortality data, Price-Smith finds a distinct
and direct correlation between the rise in influenza-related mortality and the collapse of their war
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efforts. Not only did influenza weaken and kill those fighting, but it also prevented necessary
war materiel from getting to troops in a timely manner (Price-Smith 2009: 68-75).
State of disease in sub-Saharan Africa
Infectious diseases pose a particular threat to sub-Saharan Africa. The World Health
Organization’s Global Burden of Disease provides valuable statistical data to demonstrate this
sad fact. Strikingly, Africa is the only region in the world where infectious and communicable
diseases are responsible for the majority of deaths. In 2004, Africa experienced 11.3 million
deaths. Of these, 7.7 million—68 percent of all deaths on the continent—were attributable to
communicable diseases, maternal conditions, and nutritional deficiencies (World Health
Organization 2004). Infectious diseases, like AIDS, tuberculosis, and malaria, collectively
caused 4.85 million deaths—63 percent of deaths from communicable diseases, and 43 percent
of all deaths. AIDS was the leading killer among infectious diseases, causing 1.65 million deaths,
followed by diahrreahal diseases (1.00 million), malaria (806,000), and tuberculosis (405,000).
Noncommunciable conditions, such as cancer, stroke, heart disease, and diabetes, took 2.80
million lives in Africa in 2004 (25 percent of all deaths).
To put Africa’s disease burden into a global context, no other region of the world had a
majority of its deaths come from communicable illnesses. Globally, communicable diseases were
responsible for 17.97 million out of 58.77 deaths worldwide in 2004—just over 30 percent.
Noncommunicable conditions, on the other hand, caused 35.01 million deaths, or nearly 60
percent of the worldwide total. Among the rest of the world’s regions, the Eastern Mediterranean
has the highest percentage of deaths from communicable conditions at 38.5 percent of its 2004
deaths, followed by South-East Asia (36.9 percent), Americas (13.6 percent), Western Pacific
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(12.9 percent), and Europe (6.0 percent) (World Health Organization 2004). These stark figures
hammer home the reality that Africa’s communicable disease burden more than twice as high as
the world average and far exceeds all other regions in the world.
Sub-Saharan Africa has the unfortunate distinction of being home to the greatest number
of potential international health concerns. Between September 2003 and September 2006, the
World Health Organization verified 685 events of potential international health concerns. These
concerns include infectious diseases that have the potential to spread internationally and become
epidemics. Of these 685, Africa was the source of 288—42 percent of all incidents over this
three-year period (World Health Organization 2007: x). Further, sub-Saharan Africa is
responsible for 42 percent of the 10.2 million annual deaths in children under 5. This gives the
continent a child mortality rate 7 times that seen in Europe (Boschi-Pinto et al. 2009). Burkle
(2009) argues that 75 percent of all disease epidemics arise from conflict situations, and that the
majority of these conflict situations have emerged on the African continent. He cites problems
like cholera and dysentery in Rwanda and the Democratic Republic of Congo, outbreaks of
Marburg hemorrhagic fever in Angola during the civil war there, and leprosy in Sudan. “Poverty
and preventable diseases still plague many parts of the globe. Sub-Saharan Africa remains one of
the most severely affected [regions],” explains Aitsi-Selmi (2008: 597).
While HIV/AIDS receives the bulk of attention when discussing health and disease in
Africa (and will be the subject of a later section), it is not the infectious disease plaguing the
continent. A brief review of some of the other infectious disease burdens facing Africa will
demonstrate the myriad of challenges.
One striking fact about the distribution of death in sub-Saharan Africa is that younger
people are at the highest risk. In 2004, 46 percent of all deaths in sub-Saharan Africa occurred
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among those under the age of 15, while 20 percent occurred in those over 60. By contrast, those
under 15 accounted for only 1 percent of deaths in wealthy countries and 24 percent in Southeast
Asia (World Health Organization 2004: 8).
The World Health Organization has compiled the ten leading causes of disease burden,
using a measure of DALYs (disability-adjusted life years). Each DALY is the equivalent of one
year of full health, and is the sum of years of life lost due to premature mortality and years lost
due to disability due to a health condition. This measure allows us to see the burden of both
diseases that cause early death with little disability and diseases that cause high levels of
disability but little death (World Health Organization 2004: 40). As of 2004 (the most recent year
for which statistics are available), the top three causes of DALYs were HIV/AIDS (12.4 percent
of DALYs), lower respiratory infections (11.2 percent), and diaherreal diseases (8.6 percent).
These three were responsible for nearly one-third of sub-Saharan Africa’s DALYs. Other leading
causes of disease burden included malaria, tuberculosis, and protein-related deficiencies (World
Health Organization 2004: 45). Table 1 shows the complete list of DALYs in sub-Saharan
Africa, while Table 2 shows the leading causes of death in sub-Saharan Africa among different
age groups.
[INSERT TABLE 1 ABOUT HERE]
[INSERT TALE 2 ABOUT HERE]
Let us examine some of the leading causes of disease burden in sub-Saharan Africa.
HIV/AIDS
Twenty-two million people in sub-Saharan Africa are HIV-positive. This is
approximately two-thirds of all the cases of the disease worldwide. During 2007, UNAIDS
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estimates that 1.9 million more Africans contracted the virus, while 1.5 million died of AIDS
(UNAIDS 2008). Infection rates vary widely throughout sub-Saharan Africa. While some
countries like Senegal and Niger have infection rates of approximately 1 percent of adults, three
countries—Botswana, Lesotho, and Swaziland—have adult HIV infection rates of over 20
percent. The vast majority of cases in sub-Saharan Africa are transmitted via heterosexual
intercourse. As a consequence, sub-Saharan Africa has high rates of mother-to-child HIV
transmission. Reports estimate that ninety percent of the world’s two million HIV-positive
children live in sub-Saharan Africa (AVERT 2009a). Transmission also occurs among men who
have sex with men and through the use of unclean needles (due either to injection drug use or
reusing unsterilized needles in health care facilities) (UNAIDS 2007: 9, 13-15).
The demographic breakdown of HIV cases in sub-Saharan Africa reveals three
fascinating patterns. First, the epidemic is concentrated overwhelmingly among women. Sixtyone percent of all infections in the region are among women (Asburn et al. 2009: 1). This is a
significant deviation from the epidemic as a whole, which has a nearly even split between males
and females (UNAIDS 2008). Second, there exist age disparities within infection rates. Women
15-24 are the most vulnerable to HIV infection, in some countries with twice the infection rates
than men 15-24 (Ashburn et al. 2009: 1). Men infected with HIV in Africa tend to be older.
Third, deaths due to AIDS have had a dramatic effect on life expectancy rates in many parts of
sub-Saharan Africa. Demographers estimate that sub-Saharan Africa as a whole would have an
average life expectancy of 61 years today without the presence of AIDS. Due to AIDS, though,
average life expectancy has dropped to 47 (AVERT 2009b). The effects are even more
pronounced in countries with high prevalence rates. Swaziland, with the highest adult HIV
prevalence rate, has a life expectancy at birth of 31 years—less than half the projected rate in the
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absence of AIDS (CIA 2009). In many countries, this means that life expectancy rates today are
lower than they were when the country achieved independence.
Lower Respiratory Infections
Lower respiratory infections (LRIs) include pneumonia, emphysema, and acute
bronchitis. These are diseases that target the trachea, bronchi, and lungs and are generally more
serious than upper respiratory infections. They can be either viral or bacterial in origin. In 2004,
LRIs caused 1.417 million deaths in sub-Saharan Africa, more than any other region. Further,
they are the leading cause of mortality in children under the age of 5, and the number of deaths
from LRIs increased between 2002 and 2004. Though access to antibiotics has increased in
recent years, many children in Africa lack access to health care facilities to receive treatment in a
timely manner. Further, the overuse and abuse of antibiotics has led to an increase in antibioticresistant LRIs (Lim et al. 2006). Treating these cases puts an even greater burden on alreadystretched health care resources.
Diarrheal Diseases
Diarrheal diseases include diarrhea, cholera, and dysentery. Diarrheal diseases caused
more than 1 million deaths in sub-Saharan Africa in 2004, accounting for nearly half of all such
deaths worldwide. While these illnesses can be viral, bacterial, or parasitic in origin, they are
primarily transmitted via contaminated water. Water may be contaminated with human or animal
feces in areas with inadequate sanitation systems. The recent cholera epidemic in Zimbabwe, for
example, is a direct result of the collapse of the country’s sanitation infrastructure due to its dire
economic situation. NGOs working on diarrheal diseases note that, despite the heavy disease
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burden caused by these illnesses, they receive far less funding than other infectious diseases.
Governments spent $1.5 billion on sanitation between 2004 and 2006—one-tenth the amount
devoted to HIV/AIDS and one-third spent on malaria, even though neither disease kills as many
children as diarrhea, cholera, and dysentery (Eagle 2009).
Malaria
Malaria is a vector-borne disease caused by parasites transmitted by infected mosquitoes.
Once infected, the parasites colonize the liver and infect red blood cells. Fever, vomiting, and
headache appears 10 to 15 days after exposure. Malaria can become fatal if it interrupts the
supply of blood to vital organs. Each year, between 300 and 500 million cases of malaria occur
worldwide, causing between 1.5 and 2.7 million deaths annually. Ninety percent of these cases
occur in sub-Saharan Africa (Nchinda 1998: 398). In 2004 alone, malaria caused 806,000 deaths
in sub-Saharan Africa—90.7 percent of all deaths worldwide from the disease.
During the 1950s and 1960s, the World Health Organization led an international effort to
eradicate malaria, primarily through vector control strategies relying heavily on DDT and other
insecticides. While this strategy initially showed some promise, it quickly became apparent that
mosquitoes were developing resistance to the insecticides and common treatment methods. As a
result, the number of cases of malaria in sub-Saharan Africa between 1982 and 1995 was four
times as high as those between 1962 and 1981 (Packard 2007: 175). Today, malaria is
responsible for 20 percent of all mortality in children under 5, and every country in Africa
(except for Libya) is considered endemic for the disease. WHO figures cite malaria as causing up
to 40 percent of public health expenditures, 30 to 50 percent of hospital admissions, and up to 60
percent of outpatient visits in the region (WHO 2009b). Thirty-five sub-Saharan African
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countries today have intensive malaria, and economic analysis suggests that malaria causes these
countries—which are already largely poor—grow 1.3 percent less annually. Cutting the rate of
malaria by 10 percent, on the other hand, could allow these states to grow by 0.3 percent (Gallup
and Sachs 2001).
Tuberculosis
Tuberculosis is a surprisingly common infection, with approximately one-third of the
world’s population having been infected with the bacilli that cause the disease. In most cases, the
immune systems keep the bacteria in check and people feel no ill effects. Approximately 10
percent of these latent infections become active, characterized by chronic coughs, weight loss,
chest pain, fever, and night sweats. Without treatment, tuberculosis can kill more than 50 percent
of its victims. The treatment regimen entails a six-month course of antibiotics, taken on a
consistent basis. Tuberculosis killed 405,000 people in sub-Saharan Africa in 2004, with more
than 2 million additional people falling ill with the disease (WHO 2005).
As with malaria, tuberculosis rates in sub-Saharan Africa have increased dramatically in
recent years. Between 1990 and 2003, the rate of infection in the region more than doubled, from
149 cases per 100,000 population to 343 cases. During this time, nearly every other region in the
world experienced a decrease in tuberculosis rates (Chaisson and Martinson 2008: 1089). Much
of the blame for startling increase in tuberculosis in sub-Saharan Africa belongs to HIV.
Tuberculosis is the most common coinfection among HIV-positive persons, as their immune
systems cannot keep tuberculosis bacilli walled off any longer. As a result, 30 to 40 percent of
HIV-positive adults die of tuberculosis (Chaisson and Martinson 2008: 1089). Rising infection
rates also put the general population at greater exposure to the disease, as it is spread through
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droplets in the air caused by coughs and sneezes. Each infected person not receiving treatment
can infect an additional 10 to 15 people (WHO 2007b). The other major cause of increased
tuberculosis rates is inadequate access to treatment. Failure to diagnose an active infection early
or inconsistent access to drugs has led to forms of tuberculosis which are increasingly resistant to
treatment. These new strains, known as multidrug-resistant tuberculosis (MDR-TB) and
extensively drug-resistant tuberculosis (XDR-TB) are far more difficult and expensive to treat.
Recent studies suggest that, on average, two percent of the tuberculosis cases in sub-Saharan
African states are MDR-TB (Amor et al. 2008). XDR-TB was first discovered in South Africa in
2006, and the country reported more than 300 cases of the disease by the end of that year (Singh
et al. 2007).
Security implications of disease in Africa
With growing debates over the nature of security, a growing number of scholars and
policymakers have wondered about the ethical considerations of expanding or restricting the
definition of security. Securitization theory, popularized by the Copenhagen School, can play a
particularly important role here. Elbe calls it “the only systematic scholarly study of the ethical
implications of widening the security agenda to include an array of non-military issues” (Elbe
2006: 124), while Huysmans calls it the most original and controversial contribution to security
studies in years (Huysmans 1998: 480).
Securitization theory focuses on how and why certain issues become security concerns in
the first place. A wide range of non-military issues, like HIV/AIDS, environmental degradation,
poverty, hunger, and global warming, could conceivably be security issues, but not all will
successfully make it to the national security agenda. What determines which issues succeed?
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Securitization theory focuses on the performative nature of speech acts. Calling something a
security issue or security threat constitutes a performative speech act, in which the words used to
describe something themselves function as an activity. Describing an issue as a security issue
gives that issue a special social quality for policymakers. “By saying the words, something is
done,” according to Buzan, Waever, and de Wilde (1998: 26). The designation itself brings with
it certain connotations, and implies a certain sort of response. It also affects how other parties
view the issue and its place on the political agenda. In essence, the act of securitizing an issue
(by calling it a security issue) effectively forms an agreement among political actors. Waever
notes that the security label “does not merely reflect whether a problem is a security problem, it
is also a political choice” (1995: 65). Choosing to designate something as a security issue (or as a
development issue, or a human rights issue, or any other type of issue) is thus be a political tool
to advance particular goals and aims.
The major implication of securitization theory is that we cannot use some sort of
empirical criteria to determine which issues are security issues. We instead have to look at the
intersubjective understandings of a particular issue to understand whether it holds a place on a
nation’s security agenda. It is less about any particular qualities of the issue itself, and more
about how the issue is discussed, debated, and presented in public. For securitization theory, an
issue becomes securitized when:
1. securitizing actors (like political leaders) declare that
2. a referent object (something threatened, such as the state or the military) is
3. existentially threatened by some force and therefore requires
4. emergency measures to protect against the threat (Buzan, Waever, and de
Wilde 1998: 24-36).
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Buzan, Waever, and de Wilde emphasize that securitization requires all four criteria to be
successful. These criteria also show that not all issues that undergo the securitization process will
necessarily be securitized.
The audience is quite important, too, as they have to accept the argument. The
securitizers must convince their audience that this threat poses such an existential challenge to
them that the government must be allowed to take extraordinary measures—and they must do so
in a way that resonates within a given political context. The government must be able to suspend
the rules of normal politics in order to save the lives of the populace. Successful securitization
must be audience-centered and fit within an understood and accessible context (Balzacq 2005). If
audiences do not accept the need to adopt emergency measures or doubt that an issue
existentially threatens the referent actor, then it does not become a security issue.
Securitization, then, becomes a political choice on the part of the government2.
Securitizers choose, for some reason, to elevate a given issue into the realm of security. Buzan,
Waever, and de Wilde themselves caution against securitizing non-military issues, arguing that it
represents “a failure to deal with issues as normal politics” (1998: 29). Reaching for
2
A fascinating and contentious debate has emerged in recent years over securitization’s
normative content and the methods of desecuritizing an issue. Some have argued that
securitization is a political act by politicians, and that securitization merely provides a framework
for analysts to understand those moves (Taureck 2006, Waever 2000). Others have claimed that
analysts using the securitization framework co-constitute and legitimate the securitizers’ efforts
(Aradau 2004, 2006). Similarly, the meaning and methods of desecuritization remains
underspecified in most Copenhagen School literature (c.a.s.e collective 2006: 455), and debates
exist as to desecuritization’s implications for politics (Aradau 2004).
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extraordinary powers signals a failure by existing political institutions to accommodate this new
issue in a timely and beneficial manner.
The discussions of securitizing health and disease in Africa have focused almost
exclusively on HIV/AIDS. Though recent analyses have broadened this focus to include diseases
like malaria and tuberculosis, the analytical gaze (and, consequently, most of the evidence
offered in this section) pays the vast majority of attention to HIV/AIDS.
Concerns about the security implications of disease in Africa tend to fall in one of thee
categories: economic, political, and military. These three channels, according to the causal
mechanisms of health security, could exacerbate economic deprivation, foster the breakdown of
social institutions, and erode the legitimacy and authority of democratic political institutions and
bureaucracies (Peterson and Shellman 2006: 6-8).
From an economic perspective, the effects of disease have the potential to be dire.
Nguyen and Stovel make the connection between disease and economics explicit. They write,
“There is widespread agreement that HIV/AIDS causes or exacerbates economic vulnerability”
(2004: 37). This is particularly problematic, as significant erosion in socioeconomic conditions in
highly-afflicted states poses the leading threat to development in Africa (Nguyen and Stovel
2004: 35). Reports by the United Nations Development Program note that AIDS causes
household incomes to decline by up to 80 percent. In addition, AIDS-afflicted households can
see a 15 to 30 percent decline in food consumption (UNDP 2001). Another United Nations
organization, the Food and Agricultural Organization, estimated in 2001 that AIDS killed 26
percent of the agricultural workforce in the ten most-afflicted sub-Saharan African states
(International Crisis Group 2001). The education sector also faces severe effects from
HIV/AIDS. Teachers form the foundation of the education system, and a well-functioning
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education system is crucially important for political and economic development. Unfortunately,
teachers appear to be particularly vulnerable to HIV infection. A 2001 report estimated HIV
infection rates among teachers in southern Africa and found prevalence rates of 33 percent
(South Africa), 40 percent (Zambia), 40 percent (Malawi), and 70 percent (Swaziland) (Peterson
and Shellman 2006: 6).
Politically, HIV/AIDS can introduce greater uncertain into the realm of governance.
Butler notes that the HIV/AIDS epidemic could threaten to undermine the institutional and
bureaucratic framework necessary for a functioning democracy. The loss of skilled civil service
personnel and the basic organs of political competition could work against the tide of
democratization that swept across sub-Saharan Africa in the 1990s (Butler 2005: 5-7). A
government’s failure to adequately address the epidemic could also weaken its legitimacy among
the public (Butler 2005: 7), though recent public opinion analysis suggests that evaluations of a
government’s AIDS policies are not significantly weakening support for governments in subSaharan Africa (Youde 2009). Strand et al. found that Zambia has experiences a significant
increase in the number of parliamentary by-elections due to MP death since AIDS emerged in
the country. Between 1990 and 2003, the years when Zambia’s AIDS prevalence rates were at
their highest, the country held 38 such by-elections. By comparison, the country only had 14 byelections due to death between 1964 and 1984. More strikingly, the deaths between 1990 and
2003 were disproportionately among younger members. Fifteen of the 38 were between 40 and
49, while only 2 such deaths occurred among MPs over the age of 70 (Strand et al. 2006: 96-97).
While not all of these deaths are due to AIDS, Strand et al. highlight that “70 percent of the MPs
who died between 1990 and 2003 would have been in their most sexually active phase during
parts of that time period” and hence at risk of contracting the virus (2006: 97). In 2000,
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Zimbabwean President Robert Mugabe announced that AIDS had killed at least three cabinet
ministers and numerous traditional chiefs. Kenyan civil service officials declared that AIDS
caused 86 percent of employee deaths in 1998 and 75 percent of police deaths between 1996 and
1998 (International Crisis Group 2001: 15-16). A 2003 report asserted that at least one-quarter of
the South African police personnel were HIV-positive (Price-Smith 2003: 24).
The military is of particular interest to discussion of security and particularly problematic
for the spread of HIV in sub-Saharan Africa. Most estimates suggest that infection rates among
military members are at least twice as high as those for the general population. This translates
into HIV infection rates of 40 to 60 percent (Elbe 2006: 121). More importantly, though, AIDS’
impact on the military could undermine military effectiveness and lead to the loss of experienced
commanders, in turn undermining the military’s institutional role within the state and its ability
to contribute to peacekeeping operations throughout the continent (Ostergard and Tubin 2004:
117). This could encourage non-state actors to take advantage of the state’s perceived weakness
and challenge governments.
Why would AIDS have such a detrimental impact on the military? AIDS, not war, is the
leading cause of death among southern African militaries, accounting for over 50 percent of all
in-service and post-service mortality (Heinecken 2009: 62). Reports suggest that between 40 and
80 percent of military members in the region are HIV-positive (Heinecken 2001: 121-122).
Having such a large cohort of people with a fatal disease poses a massive challenge to any
political institution. The challenge is particularly acute for the military for three reasons. One, it
compromises military performance and effectiveness. If a large number of your people are sick,
you cannot be as effective a force. It also decreases your opportunities to contribute to
international security. The South African National Defense Force has had to curtail its
20
involvement in international peacekeeping and joint military exercises because they have not
been able to field large enough contingents of HIV-free soldiers (Heinecken 2003: 291-292).
Two, high rates of AIDS within society decreases the pool of potential recruits. There are fewer
healthy people available to replace those already in the military who fall victim to AIDS. Finally,
militaries suffer from a loss of leadership. The upper ranks of any military are crucially
important for instilling a sense of discipline in new recruits and for ensuring operational
effectiveness. As AIDS kills these people, the military not only loses their experience, but also
faces a smaller pool of available replacements. Militaries face the prospect of protecting their
nation’s security with less-experienced leaders (Ostergard 2002: 344). A shrinking recruiting
cohort and diminished command efficacy could threaten the military’s ability to contribute
positively to society and weaken its basic structure (Elbe and Ostergard 2007: 87).
Being in the military also increases the risk of soldiers contracting AIDS. According to
Singer, military members tend to be young men, away from home and their traditional social
structures, with money to spend and a need to prove their manliness. As a result, soldiers often
avail themselves of commercial sex workers, who are themselves at a heightened risk of being
HIV-positive (Singer 2002: 148). After putting themselves at risk of infection, the soldiers often
engage in sexual relations with the local population, perpetuating the virus’ spread (Elbe 2002:
163). Singer notes that peacekeepers deployed abroad are at such heightened risk for contracting
HIV that the United Nations now mandates AIDS education as a required component of any
peacekeeping mission it organizes (Singer 2002: 152). Again, the military’s ability to perform its
duties and protect the state is weakened by AIDS.
Some suggest that high rates of AIDS in the military increase the likelihood of hostilities.
Soldiers who already face an early death from an infectious disease may be more prone to taking
21
risks, and states may be more willing to attack other states if they perceive them to be weakened
by AIDS (Singer 2002: 148; Heinecken 2001: 123). A military weakened by high rates of illness
and death due to AIDS may also be vulnerable to attack by regional competitors who see it as
vulnerable and less able to mount an effective defense (International Crisis Group 2001: 21-22).
More problematically, AIDS itself is becoming a weapon of war. HIV-positive soldiers
have reportedly raped women and girls as they have retreated to cause a “slow genocide” (Elbe
2002: 153). By targeting civilians and deliberately attempting to spread AIDS, these soldiers aim
to undermine the society and gradually make it collapse—at which time the departing soldiers
can return and finish their original mission (Elbe 2002: 169-171). Not only does this further
burden already weakened health systems in conflict zones and spread the disease to new areas,
but it also serves to weaken the social fabric (Elbe 2002: 174)—which itself contributes to the
disease’s spread within that country (Heinecken 2001: 126). This may change the power balance
within the region and instill a mistrust of the military as an institution.
Is security the right framework for promoting health in Africa?
It is undeniable that Africa’s infectious disease burden places enormous strains on
governments and societies throughout the continent. The losses associated with premature death
dampen the abilities of governments throughout the continent to build stronger, more robust
polities and economies Reducing the disease burden would increase gross domestic products
throughout the continent, allow for the reallocation of government funds, and create an
environment more hospitable to foreign investment. Infectious disease and health are
undoubtedly important humanitarian issues for sub-Saharan Africa. The question arises, though,
as to whether they are also security issues.
22
Writing on the securitization of HIV/AIDS, Elbe acknowledges that securitization brings
with it certain dangers. It alters the nature of power, moving away from a sovereign, state-based
conceptualization toward one that seeks to regulate populations and normalize behaviors
according to impersonal norms. As a result, securitization redefines the social contract and
creates ‘risk groups’ that may be the targets of stigmatization (Elbe 2009). Despite these dangers,
though, he argues that the benefits of securitization outweigh the negatives. Securitizing AIDS
has moved it up the political agenda and forced politicians to pay attention to a disease that they
would otherwise ignore (Elbe 2009: 163-174).
While it may be tempting to categorize infectious diseases in Africa as security issues or
threats, it appears increasingly unlikely that such a strategy will be effective over the long term.
The contentiousness over the meaning of health security and the nature of the health challenges
faced by sub-Saharan African states suggest that human rights or humanitarianism may be more
appropriate frameworks for promoting health and the development of a strong health care
infrastructure throughout Africa.
As evidenced above, there exists no clear consensus as to what health security means.
Aldis outlines four different conceptions of the term. The first focuses on protection against
threats coming from external sources. The second deals with new global health-related
challenges that have emerged yet lack adequate responses. The third concentrates on the
emergence and role of new actors in addressing health concerns, such as nongovernmental
organizations and public-private partnerships. The fourth concerns how health has become linked
with the foreign policy interests of a state (Aldis 2008: 371-372). This confusion poses a problem
for African states, as it may lead to a cacophony of responses with no clear framework for
23
addressing concerns. Different actors operating from disparate understandings of health security
throughout Africa could work at cross-purposes with each other.
How could this happen? Four big concerns emerge for securitizing health within subSaharan Africa. First, a security framework focuses on a state protecting itself against threats
rather than a broader, more holistic sense of global well-being. The irony in such a juxtaposition
is that promoting global well-being and paying attention to the underlying determinants of health
and disease would ultimately provide greater levels of protection. A security and threat posture
frequently ignores the diseases and illnesses that cause the highest levels of mortality and
privileges those diseases that most concern Western states. Diarrheal diseases rarely, if ever, are
conceptualized as security threats, even though they are one of the most common killers in subSaharan Africa. Avian influenza, on the other hand, receives disproportionate attention, despite
the fact that Africa as a whole has recorded only 83 cases (all but two of which were in Egypt)
(World Health Organization 2009).
Second, securitizing health narrows the range of diseases that receive attention and tends
to focus on specific diseases themselves rather than the broader public health infrastructure. Most
of the diseases that animate discussions of health security pose the greatest potential threat to
Western states—SARS, avian influenza, swine flu. These diseases certainly have the potential to
exact heavy costs on the international community, and taking precautionary measures to avoid
negative consequences is certainly advised. However, focusing on these theoretical threats
instead of the very real and already apparent infectious diseases threats facing sub-Saharan
Africa distracts attention and finite resources. A focus on discrete diseases leads to stovepiping—
creating programs and systems that address one illness or concern but do little to address broader
measures of health. It is a focus on disease rather than a focus on health, yet health is more than
24
the absence of disease. Because measles, mosquito-borne diseases, and diarrheal diseases are
largely absent from industrialized countries, they receive little if any attention from the security
framework. The benefits Elbe associates with the securitization of AIDS have not translated to
health more broadly, nor are they likely to do so. Thus, the illnesses with the greatest mortality
and morbidity burdens in sub-Saharan Africa are largely left out.
Third, despite efforts otherwise, the security framework still largely casts its analytical
gaze at national, rather than human, security (McInnes 2008: 285). Policymakers and academics
tend to think about security in terms of what could threaten the state. The language of security
studies emphasizes direct threats—those that are readily apparent and provide a linear causal
relationship to safety. It focuses on direct risks to state structures (particularly the military),
potential epidemic diseases, and bioterrorism, though these are not the problems that dominate
the African health agenda (McInnes and Lee 2006: 9). The nature of infectious disease, as
described above, is better understood as an indirect, nonlinear threat. An infectious disease
outbreak in and of itself is highly unlikely to bring a state to its knees or lead to armed conflict
between two states. However, if state structures are already weakened or atrophied, and if a
government lacks the governance capabilities to deal with an additional stressor, then it is
possible that infectious disease could pose a serious risk to a state. It is this latter scenario that
most challenges African states. If they are already weakened, then they may lack the reserve
capacity and capability to handle an additional stressor. The outbreak of cholera in Zimbabwe is
not in and of itself an existential threat to the Zimbabwean state; rather, it represents a stressor
that could challenge the state’s ability to provide basic services. More importantly, though,
Zimbabwe’s cholera outbreak poses a great burden on the people whose access to health services
is already greatly compromised by the weakness of the state. A national security framework does
25
little for explaining why the international community should care about this outbreak, yet this is
the mindset that still dominates most discussions on the nexus between health and security.
Fourth and finally, the direct security effects envisioned by advocates of AIDS
securitization (and health securitization more broadly) are largely speculative and overstated.
While it is indeed true that high rates of infectious disease can have a deleterious effect on a
state’s social, political, and economic institutions, there is little empirical evidence of direct
military effects or civil conflict (Peterson and Shellman 2006). Barnett and Prins (2006) argue
that much of the discussion about disease’s security effects rests on “factoids” and anecdotes that
do not provide robust, reliable information. McInnes (2006) concurs, asserting that making
blanket statements about the security implications of infectious disease across the entire African
continent overstates and overgeneralizes the risk. Further, the statistical evidence for the
relationship between poor health and internal instability remains ambiguous at best. The Central
Intelligence Agency’s State Failure Task Force found that high infant mortality rates are a sign
of poor quality of life, which is in turn a causal factor for internal instability. This finding
suggests that infectious disease and poor health has an indirect effect on state security, not the
direct effect commonly ascribed within the securitization literature (McInnes and Less 2006: 1617). These findings do not diminish the fact that poor health and infectious disease have severe
effects on life within a state, nor do they suggest that infectious disease is not a problem with
which African government need to grapple. They do suggest, though, that an argument that
focuses on the direct security effects goes too far. By overstating the case, securitizers risk
provoking a backlash when the hypothesized effects fail to materialize.
Along these same lines, a security framework begs two important questions: security for
whom and security from what? The health security discourse that has developed over the last 10
26
to 15 years has generally answered the first question by focusing on Western states. “Health
security risks” or “new security risks” are those diseases that Western states fear could emerge
from Africa and potentially come to their shores (McInnes and Less 2006: 11-12). It is not a
discourse about health in general, nor is it even a discourse about helping Africa. It is instead a
discourse that envisions Africa largely as an emitter of disease. What happens within African
states with health concerns is irrelevant unless it could emerge and spread to industrialized states.
This skews the international agenda, focusing attention away from those health issues that most
directly affect African states and publics. The broader determinants of health, such as poverty
and access to clean water and proper sanitation, receive short shrift. Packard reminds us that
malaria eradication efforts failed not just because mosquitoes developed resistance to DDT and
other insecticides. Instead, those efforts focused solely on the transmission vectors without
examining the underlying social and economic conditions that put people at risk of contracting
the disease in the first place (Packard 2007).
Africa itself receives short shrift, too. Africa is not important in this construction because
of the suffering from infectious disease or the disproportionate child mortality burden it
experiences; it is only important insofar as it could potentially be the source of diseases that
could threaten wealthy industrialized states. Africa is more of a signifier than a participant in the
larger conversation about international health policy.
If the above is true and the security framework has largely come to dominate the
discussion of African health, why is this the case? McInnes and Lee, while approving of the
increased attention health has received within the international agenda, highlight “the apparently
successful attempt to move health beyond the social policy and development agenda, into the
realms of foreign and security policy” (2006: 6). One answer might be “forum-shifting.” Health
27
is, in many ways, a cross-cutting issue that could potentially fit within a number of different
policy arenas. By shifting health away from the realms of social and development policy and
toward foreign and security policy, advocates seek to operate within the diplomatic arenas which
are likely to bring them more attention, more resources, and more favorable outcomes (Fidler
2009: 29). Security, for better or worse, commands far more attention and far more resources
than social policy or international development. Policymakers may attention to security issues,
particularly security threats. Security threats grab public and political attention in a way that
development policy fails to do. A security discourse may get policymakers to focus on Africa in
a way that they may otherwise be unlikely to do.
While this strategy may have led Western states to pay more attention to Africa and
health issues, it does not appear to be a useful long-term strategy. Aldis documents a growing
suspicion of health securitization. Developing state governments are increasingly uncomfortable
with the framework because of the associated loss of control and policy autonomy. Since the
health security discourse largely focuses on those diseases that could threaten developed states,
developing states like those in Africa find their health policies increasingly dominated by
responding to developed state concerns. This leads to the creation of more stovepiped programs
that have too little overlap to address the majority of health concerns. It also undermines state
sovereignty and autonomy, as health programs in African states become increasingly dependent
upon donor requests and conditionalities (Netherlands Ministry of Foreign Affairs 2005: 8). As a
result, governments in sub-Saharan Africa are increasingly reluctant to accept the categorization
of health as a security concern (Aldis 2008: 372-373).
Furthermore, conceptualizing health as a security issue frequently leads to a crisisoriented mentality. New and novel diseases receive disproportionate attention, and attention
28
focuses on epidemic diseases that threaten to spread beyond borders (Fidler 2009: 29). Endemic
diseases, which are responsible for the majority of Africa’s disease mortality and morbidity
burden, receive less attention because they are assumed to be part of the fabric of the country. A
short-term crisis mentality may lead to rapid, immediate responses, but addressing the underlying
determinants of health requires long-term, sustained commitments. A crisis-based response
emphasizes defensive measures, but pays less attention to long-term processes like prevention,
strengthening the public health infrastructure, and building surveillance capabilities in
developing countries (Feldbaum 2009: 2). While praising the President’s Emergency Plan for
AIDS Relief (PEPFAR), Patterson notes that its relatively quick passage demonstrated a belief
among policymakers that AIDS was less a long-term development issue and more of a short-term
fix. “Emergencies require quick attention, but the implication is that an emergency can be fixed
relatively rapidly” (Patterson 2006: 139).
Fixing a country’s health care infrastructure or ensuring that children have access to lifesaving vaccinations will not emerge from a crisis mentality. That sort of sustained attention will
likely only emerge from a framework that recognizes the value of addressing health concerns in
Africa as human rights or humanitarian issues. As Feldbaum notes, “Addressing most global
health issues cannot be justified by national security considerations…some serious global health
issues will likely never be linked credibly to US national security interests. Such issues will have
to rely on moral, humanitarian, or other frameworks to win US funding and political support”
(2009: 8). Instead of focusing on security-based concerns, foreign governments that want to
promote improved health in Africa should base their assistance and commitment on values of
generosity, compassion, sharing, and creating the necessary preconditions for economic
29
development and global prosperity (Committee on the US Commitment to Global Health 2008:
7).
Finally, and perhaps most importantly, attempting to create a direct, linear relationship
between health and security may actually work against its advocates’ desires. Barnett and Dutta
find no conclusive evidence for a direct link between HIV prevalence and state fragility (2008:
17), while Sato (2008) uncovers no statistically significant relationship between AIDS and state
fragility among low-income countries under stress. Peterson describes the paradox thusly:
By overdrawing the link between infectious disease and security, however, public
health and human security advocates sabotage their own attempts to motivate
developed nations to fights AIDS in Africa and elsewhere…Linking an urgent
issue to security may raise awareness, but it likely will also hinder much of the
cooperation that human security and public health advocates seek and that the
disastrous humanitarian and development effects of infectious diseases demand
(2007: 38).
Addressing health in Africa requires international cooperation and a willingness to share among
states. Security encourages governments to think narrowly about their own interests and how
they can gain or preserve their advantages over others. Humanitarian health objectives are
largely at odds with this state-centric model of security because the former offers a far more
inclusive vision and responsibility than the latter (Feldbaum et al. 2006: 196).
Nattrass, one of the leading experts on AIDS and its impact on societies, echoes some of
these same themes. She sees a link between the disease and economic security, but challenges the
notion that it is linked to state security (Nattrass 2003: 2). AIDS undermines democracy because
it undermines the economic foundations of a society, and she acknowledges that this could in
30
turn have an indirect impact on global security, but she asserts that this connection is too far
removed and overlooks the very real and direct connections between AIDS and economics
(Nattrass 2003: 8-9). These connections, she argues, are the ones that will impact the most
people in the most direct manner. Instead of calling AIDS a security threat, Nattrass wants to
keep attention on economic and humanitarian issues. She sees little benefit in calling AIDS
orphans a threat to state security as Singer does (Singer 2002: 151), saying that this obscures the
humanitarian dimensions of children losing their parents prematurely and being forced to take
jobs and raise their siblings. The language of security distracts the international community from
AIDS’ far more direct impacts. Advocates of human security argue that including economics,
food, the environment, and freedom from violence makes sense because these are the threats
most people face in their day-to-day life. Nattrass largely agrees, but does not see why we need
to call these threats a security issue.
Suggestions and conclusions
In this paper, I have argued that security is not the most appropriate framework for
encouraging national and international action on infectious disease in sub-Saharan Africa.
Infectious diseases cause a disproportionate share of the region’s morbidity and mortality, and
the international community clearly has an interest in reducing the spread of AIDS, malaria,
tuberculosis, diarrheal diseases, and lower respiratory infections. Calling these diseases security
threats or issues, while potentially attention-grabbing, distracts attention from the nature of the
threat posed by these diseases and skews funding.
If security is inappropriate, what is a better framework for encouraging action and
attention? I propose conceptualizing infectious disease as a human rights or development issue
31
instead of a security issue. Such a framework would emphasize the connections between human
rights as written in the Universal Declaration of Human Rights, the International Covenant on
Civil and Political Rights, and the African Charter of Human and Peoples’ Rights, among others,
and good health. People need to be healthy in order to take advantage of and realize their
inherent human rights, and numerous human rights charters explicitly recognize a right to health.
Some, like the African Charter of Human and Peoples’ Rights and the South African Bill of
Rights, go even further and specify a positive obligation for the government to ensure the good
health of their citizenry.
Using a human rights or development framework for addressing infectious disease in
Africa instead of security has four distinct advantages. First, it emphasizes the long-term nature
of these issues. Neither human rights nor development can be realized in a few short years. They
are an ongoing project, requiring constant attention and vigilance. Doing so requires the active
attention of both local governments and the international community in a collaborative manner.
Second, this framework encourages paying attention to a wider range of infectious
diseases and health threats in sub-Saharan Africa. Some of the leading causes of death in the
region, like malaria, lower respiratory infections, and diarrheal diseases, overwhelmingly affect
children. As such, they are highly unlikely to receive attention within a security framework. Few
would argue that the deaths of children under the age of five is likely to destabilize a country,
provoke international aggression, or lead to the collapse of a national government. The security
framework encourages this selective attention, emphasizing those diseases that may have
military implications rather than those that have the greatest effects on the population as a whole.
This has helped to distort health spending, with AIDS receiving a disproportionate share of
health-related aid from international sources (Shiffman 2007). A human rights or development
32
framework pays attention to a wider range of infectious diseases because it has a more holistic
approach. Children may not militarily relevant, but their survival and prosperity can lead to
greater economic prosperity and political development over time.
Third, a human rights or development framework resonates with developing narratives,
Over the past 20 years, AIDS activists have come to situate their claims for treatment and
prevention programs in human rights terms (Youde 2008b). Universal access to antiretroviral
drugs has gained currency as an international norm, altering existing paradigms about
pharmaceutical access and health care expenditures (Youde 2008a). Tapping into this emerging
consensus will allow for greater long-term success.
Finally, a human rights framework allows for greater participation from non-state actors.
Security is widely seen as the sole domain of the state. Given the challenges ill health poses to
sub-Saharan Africa, though, it is highly unlikely that state governments on their own can
adequately address them. A human rights and development framework, on the other hand,
recognizes the value of reaching out to and incorporating voices from nongovernmental
organizations, philanthropic organizations, and private business. Incorporating all of these
difference groups along with governments and finding mechanisms for coordination heightens
the chance that important concerns will be addresses and less prominent diseases will not be
neglected.
Calling health in sub-Saharan Africa may initially appear attractive, and its discourse has
been dominant in recent years. However, its shortcomings limit its efficacy. The infectious
disease threat in sub-Saharan Africa is real and significant, but a security framework has not and
will not produce the sort of long-term attention necessary to adequately address the issue.
33
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Table 1. Leading Causes of DALYs in Sub-Saharan Africa, 2004.
Disease
DALYs (millions)
Percent of total DALYs
HIV/AIDS
46.7
12.4
Lower respiratory infections
42.2
11.2
Diahhreal diseases
32.2
8.6
Malaria
30.9
8.2
Neonatal infections
13.4
3.6
Birth asphyxia/trauma
13.4
3.6
Prematurity/low birth weight
11.3
3.0
Tuberculosis
10.8
2.9
Traffic accidents
7.2
1.9
Protein-energy malnutrition
7.1
1.9
Source: World Health Organization 2004: 45
40
Table 2. Leading Causes of Death in Sub-Saharan Africa by Age, 2002.
0-4 years
5-14 years
15-29 years
All Ages
infections
HIV/AIDS
HIV/AIDS
infections
HIV/AIDS
Tuberculosis
Malaria
Diarrheal
Traffic
diseases
accidents
Violence
infections
Perinatal
Measles
Lower respiratory
Diarrheal
infections
diseases
Traffic
Perinatal
accidents
conditions
Lower respiratory
Malaria
Lower respiratory
conditions
Trypanosomiasis
HIV/AIDS
Source: World Health Organization 2002
Lower respiratory