health security - Graduate Institute of International and Development

IHEID Executive Course on
Global Health Diplomacy
Course Manager and
Research Assistant
Health security
Structure of the workshop
 I) Introduction to the concept health security
– Definition
– The health security components: the identified threats
– Health security: health and national security or human
 II) The instrument in support of health security: the
2005 International Health Regulations
 III) The Copenhagen consensus (exercice)
 IV) The case-study
Health security
 « It refers to the activities both proactive and reactive
to minimize vulnerability to acute public health events
that endanger the collective health of national
populations. Global public health security widens this
definition to include acute public health events that
endanger collective health of populations living across
geographical regions and international boundaries. It
also covers a wide range of complex and daunting
issues, from the international stage to the individual
household, including the health consequences of
human behaviour, weather-related events and
infectious diseases, natural catastrophes and manmade disasters ».
2007 World Health Report
Health security components: the threats
 Human causes of health insecurity
Inadequate investment
Unexpected policy shifts
Consequences to conflicts
Microbial evolution
Food-borne diseases
 Weather-related events and infectious diseases
 Major epidemics
• Iinfluenza
 Other public health emergencies
• Chemical and radioactive events
Human causes of health insecurity
Inadequate investment
Reduced vigilance, inadequate surveillance and a relaxing adherence to
preventive programmes provoked the emergence or re-mergence of:
• Dengue (1.2 million cases were reported by WHO in 1998 from
56 countries)
• Malaria
 This phenomena exists mainly in developing nations, with notably in
connection with the adjustment policies supervised by the Bretton
Woods in the 80’s and 90’s.
Human causes of health insecurity
• Unexpected policy shift: the case of polio in
Northern Nigeria
Some unsubstantiated claims on the safetiness of oral polio vaccines
(risk of sterilization of young people) in Northern Nigeria led 2
local governments to suspend the polio immunization.
The terrifying result is the:
• Large outbreak of polio in the North Nigeria causing the
paralysis of thousands children
• Reinfection of the south of the country
• Spread of the outbreak to polio-free countries (Afghanistan,
Egypt, India, Niger, Pakistan, Somalia)
• The cost is about US $450 million
Human causes of health insecurity
 Conflicts
The collateral effects of the conflicts from health dimension are as follows:
• The weakening of health systems
• Reduced capacities in detecting, preventing and responding to
infectious diseases
Example: the outbreak of cholera in Democratic Republic of Congo
in 1994
In July 1994, between 500 000 and 800 000 people crossed the boarder to
escape from the Rwandese genocide and arrived at Goma (Congo).
During the first month after their arrival, more than 50 000 refugees
The spread of transmission was highly related to the contamination with
Vibrio cholera of the only avaibale source of water resource, Lake Kivu.
Human causes of health insecurity
 Microbial evolution and antibiotic resistance
The continuing and increasing resistance to anti-infective drugs do
represent a major threat to health security and is a major factor in the
emergence and re-emergence of infectious diseases.
Human causes of health insecurity
 Food-borne diseases
Although the safety of food has dramatically improved overall, progress
is uneven and food-borne outbreaks remain common in many
countries. In addition, some new food-borne diseases have emerged
and create considerable concern, such as the recognition of the new
variant of Creutzfeldt-Jakob disease associated with bovine spongiform
Human causes of health insecurity
 Bioterrorism
According to the CDC, a bioterrosism attack is the deliberate release
of viruses, bacteria, or other germs (agents) used to cause illness
or death in people, animals, or plants.
 Kofi Annan, the Former U.N Secretary-General defined it as a major
concern 2004 when he indicated that “we need to pay much closer
attention to biological security to build an effective global defence
against bioterrorism and overwhelming natural outbreaks of
deadly infectious disease”.
Bioterrorism cases
 Anthrax: By 2001, a total of 22 persons are thought to have been
infected: 11 each with cutaneous and inhalation anthrax. The five
patients who died were all infected with inhalation anthrax.
The offensive prompted a profound rethinking of threats to national
and international security. It showed the potential of bioterrorism to
cause not just death and disability, but social and economic disruption
on an enormous scale both in the United States and internationally.
 Smallpox: Such a threat is therefore not new. “Could it not be contrived
to send the smallpox among those disaffected tribes of Indians “. Sir Jeremy
Amherst, British Commander-in-chief in the American colonies in July
1763, reported about the smallpox-infested blankets distributed to the
Shawnee and Delaware people
Weather-related events and infectious
(The Rift Valley fever case)
 Climate conditions combined to environmental, epidemiolgical and
socioeconomic factors contribute to expose populations to more
infectious disease.
 The Rift Valley fever is particularly relevant. The El Nino phenomenon
is by a higher rainfall increasing the breeding sites of mosquitoes, in
connection with non-vaccinated cattle which transmit the virus from
animals to humans. From December to March 1998, a large oubreak of
Rift Valley fever occured in Kenya, Somalia and Tanzania
 Number of cases: 89000
 478 unexpected deaths
 Consequences:increase of blindness, meningo-encephalitis…
Major epidemics
 SARS: It represents the first severe disease of the 21st century
with its features of a public health threat: “it spreads from person
to person, requires no vector, displays no particular geographical
affinity, incubates silently for more than a week, mimics the
symptoms of many other diseases, takes its heaviest toll on
hospital staff, and kills around 10% of those infected”. Scientists
believe that SARS virus first cropped in the Guangdong province,
an agriculture area of 80 million inhabitants where local farmers
practise traditional farming methods and live in close contact
with chicken, ducks, fish and pigs, and which are shown to
spread the disease to humans. After China, Vietnam, Singapore,
and Canada were affected by the disease.
Major epidemics (SARS)
According to the World Health Report, the total
economic cost of SARS in Asia was US $20 billion in
gross national product for 2003 or a more dramatic US
$60 billion of gross expenditure and business losses.
Thus, SARS is probably the best illustration that
pathogens will call for a strengthened global
cooperation in order to stop its spreading
Major epidemics (Influenza)
« Coming on the heels of the SARS outbreak, the
prospect of an influenza pandemic sparked immediate
alarm around the world and with good reason. Far
more contagious, spread by coughing and sneezing
and transmitted during an incubation period too short
to allow for contact tracing and isolation, pandemic
influenza would extend the devastating consequences
that had been seen with SARS in Asia and Canada to
every corner of the world within a matter of months ».
– WHO 2007 World Health Report
Other public health emergencies
 Chemical and radioactive events: some selected major
chemical incidents
 1976-Seveso (Italy): chemical plant explosion caused by dioxin (226000
people were evacuated)
 1984-Bhopal (India):chemical plant leak (methyl-inocyanate) causing
more than 2800 deaths, 20000 injured
 2001-Toulouse (France): factory explosion (ammonium-nitrate) causing
30 deaths and more than 2500 injured
 2006-Abidjan (Côte d’Ivoire):toxic waste (hydrogen, sulphide, sodium
hydroxide) causing more than 100000 injured and 10 deaths
Health and national security
 National security was seen as the state’s ability to defend
itself against external threats and describes the
philosophy of international security predominance based
on the rise of State-Nations. Today, globalization as a
process of interaction and integration among the
people, companies and governments of different
nations, driven by international trade and investment
and aided by information technology, is disrupting such
a conceptual frame.
Health and national security
The national security approach will now rely on:
 Health of the population as an issue from a strategic
 Health in war
 Infectious diseases (SARS, HIV/AIDS, tuberculosis)
 The Bioterrorism threat
Human Health (1)
 This conception is people-centered rather that the
security state-based.
 Its main focus is to protect individuals through their
well-being and respond to ordinary people's needs in
dealing with sources of threats.
Human Security v. National Security?
Human Development Report: the 1994 Human Development
Report of the U.N.D.P is a major contribution for the recognition of
human security as a crucial concept.
This publication asserted that human security relies on the freedom
from hunger and the freedom from want, which involves intrinsically
the absence of hunger, illness, war and violence. As it suggested,
increasing human security would imply a certain number of
actions such as “investing in human development, engaging
policy makers to address the emerging peace dividend, giving the
United Nations a clear mandate to promote and sustain
development, enlarging the concept of development cooperation
so that it includes all flows, not just aid, agreeing that 20 percent
of national budgets and 20 percent of foreign aid be used for
human development, and establishing an Economic Security
The two components of health security described here are
very important insofar as they are the keys of interpretation
of global health challenges.
Need for a reconciliation of the two since all health-related
challenges need a global cooperation of different actors,
governments of course but in close connection with
organizations, NGOs and alliances.
Most of those challenges are intrinsically linked to poverty
and health for development is a precious tool to address it.
2005 International Health
 « The world has changed dramatically since 1951, when WHO
issued its first set of legally binding regulations aimed at
preventing the international spread of disease. At that time, the
disease situation was relatively stable.Concern focused on only six
“quarantinable” diseases: cholera, plague, relapsing fever,
smallpox, typhus and yellow fever. New diseases were rare, and
miracle drugs had revolutionized the care of many well-known
infections. People travelled internationally by ship, and news
travelled by telegram ».
Margaret CHAN, WHO Director General, A safer future, WHO
2007 World Health Report
Few basic data elements
 It is estimated that 2.1 billion airline passengers travelled in 2006 .
 An outbreak or epidemic in one part of the world is only a few
 Infectious diseases can not only spread faster, they appear to be
emerging more quickly than ever before.
 Since the 1970s, new diseases have been identified at the
unprecedented rate of one or more per year. There are now at
least 40 diseases that were unknown a generation ago.
 More than 1100 epidemic event were verified by WHO the last five
Need for an efficient instrument to
combat infectious diseases
 The revision of the IHR was adopted by the World Health
Assembly in May 2005, and came into force on 15th of June
2007. It includes all diseases and health events that may
constitute a public health emergency of international concern.
194 States parties to the IHR revised
 Philosophy of the instrument: To have the necessary global
framework to prevent, detect, assess and provide a
coordinated response to events that may constitute a public
health emergency of international concern (Article 2 IHR).
 The Regulations now cover public health emergency
of international concern whatever
 their origin or source (Article 1.1), including:
(1) naturally occurring infectious diseases, whether of
known or unknown etiological origin;
(2) the potential international spread of noncommunicable diseases caused by chemical or
radiological agents in products moving in
international commerce; and
(3) suspected intentional or accidental releases of
biological, chemical, or radiological substances.
 The seven areas of work for IHR (2005)
1. Foster global partnerships
2. Strengthen national disease prevention, surveillance, control
and response systems
3. Strengthen public health security in travel and transport
4. Strengthen WHO global alert and response systems
5. Strengthen the management of specific risks
6. Sustain rights, obligations and procedures
7. Conduct studies and monitor progress
1) Foster global partnerships:
Partnership is required between all countries to share
technical skills and resources, to support capacity
strengthening at all levels, to support each other in times
of crisis.
Partnership between different sectors (e.g. health,
agriculture, travel, trade, education, defence) is also
essential to build coherent alert and response systems
which cover all public health threats, and, at the time of
events, are able to rapidly mobilize the required resources
in a flexible and responsive way.
2) Strengthening national disease prevention
By strengthening national public health systems,
specifically in the area of disease surveillance and response,
countries can detect, assess, and respond to public health
threats in a timely manner and prevent international spread.
3) Strengthening public health security in
health and travel
The control of diseases at border crossings remains a
fundamental element of the Regulations. A number of IHR
(2005) requirements apply to designated airports, ports and
ground crossings.
They entail close collaboration with other UN
organizations (see list)
IHR implementation
 List of international organizations involved in the
implementation of the IHR:
:: International Atomic Energy Agency
:: International Air Transport Association
:: International Civil Aviation Organization
:: International Labour Organization
:: International Maritime Organization
:: International Shipping Federation
:: Food and Agriculture Organization of the United Nations
:: World Organisation for Animal Health (OIE)
4) Strengthen WHO global alert and response systems:
Effective global systems for alert and response are critical
to provide global risk assessment, support countries that
request assistance, mobilize international resources and
coordinate international response. Such systems monitor
global public health threats, assess risks, and complement
national alert and response systems.
5) Strengthen the management of specific risks
It includes control programmes for:
 The improvement of international control efforts to
contain, eliminate, or eradicate epidemic-prone diseases
 the reduction of the public health risks associated with
chemical, toxic and environmentally induced events.
6) Sustain rights, obligations and
 It is essential that all relevant national and WHO staff be
fully aware of, and understand, the new rights, obligations
and procedures laid out in the Regulations.
 In addition, a number of legal bodies and procedures (e.g.
National IHR Focal Points, WHO IHR contact points,
international roster of experts, emergency and review
committees) must be identified and/or set up and
7) Conduct studies and monitor progress:
 Monitoring and evaluating the implementation of the IHR
is essential to its success. This will allow proposals for its
Legal basis for adopting IHR
 Constitution of WHO
Article 21
“The Health Assembly shall have authority to adopt regulations
(a) sanitary and quarantine requirements and other procedures designed
to prevent the international spread of disease (…);
Article 22
“Regulations adopted pursuant to Article 21 shall come into force for
all Members after due notice has been given of their adoption by the
Health Assembly except for such Members as may notify the DirectorGeneral of rejection or reservations within the period stated in the
Main content (1)
 Subsidiary role of WHO for other Public Health
Emergencies of International concern
 Article 2 Purpose and scope
The purpose and scope of these Regulations are to prevent,
protect against, control and provide a public health
response to the international spread of disease in ways that
are commensurate with and restricted to public health risks,
and which avoid unnecessary interference with international
traffic and trade.
Main content (2)
Article 4 Responsible authorities
Article 5 Surveillance
Article 6 Notification
Article 10 Verification
Article 12 Determination of a public health emergency of
international concern
 Article 13 Public health response
Main content (3)
 The Global Outbreak Alert and Reponse Network (GOARN) is a
technical collaboration of existing institutions and networks who pool
human and technical resources for the rapid identification,
confirmation and response to outbreaks of international importance.
It helps:
 combating the international spread of outbreaks
 ensuring that appropriate technical assistance reaches affected states
 contributing to long-term epidemic preparedness and capacity building.
Partners: scientific institutions in Member States, medical and
surveillance initiatives, regional technical networks, networks of
laboratories, United Nations organizations (e.g. UNICEF, UNHCR),
the Red Cross (International Committee of the Red Cross,
International Federation of Red Cross and Red Crescent Societies and
national societies) and international humanitarian nongovernmental
organizations (e.g. Médecins sans Frontières, International Rescue
IHR adoption indicates that public health was
identified as a central governance challenge nationally
and internationally in the 21st century.
 The Regulations provide a framework that supports
not only improved international cooperation on health
but also the strengthening of national health systems
 For the past few years, there have been isolated reports of a mysterious
disease appearing throughout the world. The disease, known as
Spontaneous Aging Syndrome (SAS), caused affected persons bodies to
degenerate rapidly, as if decades of aging were taking place within the
space of a few days. There is no treatment yet for the disease although
major pharmaceutical companies in the West are already conducting
research into potential vaccines and cures. The disease is believed to be
caused by a new mutation of a common sexually transmitted virus.
 The fact that only a few cases have arisen suggests that it is not easily
transmissible. However, scientists are concerned that this will change as
the virus continues to mutate. If SAS eventually mutates into a form
that is more easily transmitted, millions of people throughout the world
could become infected and die.
Copenhagen consensus
 Lack of education, living conditions of
children, conflicts, living condition of
women, hunger and malnutrition, money
laundering, population of migration,
vulnerability to natural disasters, land
degradation, drugs, unsafe water and lack
of sanitation, air pollution, terrorism,
financial instability, deforestation, diseases,
arms proliferation, climate change,
subsidies and trade barriers.
 You are a government official of a low-income country with no
research or drug manufacturing capacity. You have been called to an
urgent meeting by the President, as a case of SAS has now just been
detected in your country. To prepare for this meeting, you will now
discuss the discussion with your colleagues from relevant ministries
(health, trade, environment, justice, finance, planning…) in order to
advice the Prime Minister on how to address this issue consistent with
ethics and international human rights obligations. An important factor
for your group to consider is how the religious and cultural taboos in
your country will affect the country’s response efforts, given that the
virus has been spreading through sexual transmission.
What immediate actions do you propose to respond to the
current case?
What long-term plan do you propose for addressing the threat
of a larger outbreak?