Review of International Studies (2006), 32, 5?23 Copyright
p30
British International Studies Association
doi:10.1017/S0260210506006905
Health, security and foreign policy
COLIN McINNES AND KELLEY LEE*
Abstract. Over the past decade, health has become an increasingly important international
issue and one which has engaged the attention of the foreign and security policy community.
This article examines the emerging relationship between foreign and security policy, and global
public health. It argues that the agenda has been dominated by two issues ? the spread of
selected infectious diseases (including HIV/AIDS) and bio-terror. It argues that this is a
narrow framing of the agenda which could be broadened to include a wider range of issues. We
o?er two examples: health and internal instability, including the role of health in failing states
and in post-conflict reconstruction; and illicit activities. We also argue that the relationship
between global public health, and foreign and security policy has prioritised the concerns of the
latter over the former ? how selected health issues may create risks for (inter)national security
or economic growth. Moreover the interests of the West are prominent on this agenda,
focusing (largely though not exclusively) on how health risks in the developing world might
impact upon the West. It is less concerned with the promotion of global public health.
Health has risen markedly on the international agenda over the past decade. Key to
this increased prominence have been two issues: the emergence and spread of
infectious diseases such as HIV/AIDS, SARS and new drug-resistant strains of TB;
and the risk from biological weapons, especially bio-terrorism.
1
There is of course
nothing new about health as an international issue: infectious diseases have never
recognised state boundaries and systems of international cooperation attempting to
* This article draws on discussions held at meetings in Australia, Canada, the UK and the US at
which the authors were participant observers. These include a Conference on Health as a Foreign
Policy Issue held at Ditchley Park, England in March 2002; Symposium on Global Health and
Foreign A?airs held by The Nu?eld Trust in London in March 2003; a Trilateral Meeting on
Global Health and Security hosted by RAND in Washington in April 2003; UK-Australia Seminar
on Health and Foreign Policy hosted by the Commonwealth Government of Australia in Canberra
in September 2003; Workshop on Rapid Assessment of the Economic Impact of Public Health
Emergencies of International Concern held at the University of Toronto in January 2004; and
Meeting on HIV/AIDS and Other Infectious Diseases, Project on the G20 Architecture in 2020,
Costa Rica, 12?13 November 2004. We are grateful to participants at these meetings although the
authors remain wholly responsible for the material in this article. Research for this article was made
possible from funding from The Nu?eld Trust and The Nu?eld Health and Social Services Fund.
We would like to thank John Wyn Owen and Alan Ingram for their support and assistance in this
work.
1
Arguably a third important area where public health has impacted upon the international agenda
has been tobacco control, not least the successful conclusion of the Framework Convention on
Tobacco Control (FCTC). Tobacco-related diseases remain the single greatest cause of preventable
deaths in the world. Tobacco sales have earned the industry record profits since the 1990s as
companies have shifted their attention to the developing world, facilitated by trade liberalisation.
The World Health Organisation under Gro Harlem Brundtland campaigned for comprehensive
tobacco control measures worldwide, supported by the FCTC. Although the WHO presents this as
5
control their spread long pre-date the establishment of the World Health Organis-
ation in 1948.
2
Moreover, there has long been humanitarian concern for international
health development through the work of charitable foundations, nongovernmental
organisations (NGOs), governments and multilateral organisations. What is di?erent
about recent attention to health issues is the apparently successful attempt to move
health beyond the social policy and development agenda, into the realms of foreign
and security policy.
3
In the United States for example, health issues (and most
particularly HIV/AIDS) have been the focus of, or figured prominently in, a variety
of foreign policy speeches from key members of the administration.
4
In 1999 the State
Department cited the protection of human health as one of its strategic missions,
5
and in its Strategic Plan for Financial Years 2004?9 stated:
a successful partnership between the public health and foreign policy communities, as Je? Collin
points out, this smacks somewhat of hagiography. The reality is that the public health community,
particularly WHO, initiated and led this international e?ort. Working with the foreign policy
community on tobacco control proved an uphill task at times. Working with them on infectious
disease and bio-terror proved much easier. Je? Collin, ?Tobacco Control?, unpublished paper for
The Nu?eld Trust.
2
The beginnings of sustained international cooperation on health were the International Sanitary
Conferences held during the nineteenth century. These originated in concerns over the risk to
European states from the transmission of acute and epidemic infectious diseases from outside the
continent. Given the potential of such diseases to spread rapidly across national borders and cause
high rates of morbidity and mortality, as well as disrupt burgeoning trade routes, international
cooperation was pursued to mitigate the risks involved. Institutions such as the Organisation
International d?Hygiene Publique (OIHP) were therefore created to build surveillance and reporting
systems to support such cooperation.
3
For example, the Millennium Development Goals agreed in 2000 set three out of eight goals, eight
of the 18 targets and 18 of the 48 indicators as related directly to health; the UN Security Council
session of January 2000 was devoted to the threat in Africa from HIV/AIDS; UN Security Council
Resolution 1308 of July 2000 addressed the need to combat the spread of HIV/AIDS during
peacekeeping operations; United Nations Special Session on HIV/AIDS held in June 2001 declared
the disease a security issue; World Health Assembly Resolution 54.14 adopted in May 2001 on
?Global health security: epidemic alert and response? focused on revision of the International Health
Regulations; the G8 Summit held in Genoa in July 2001 agreed the creation of the Global Fund to
Fight HIV/AIDS, Tuberculosis and Malaria; and WHO?s adoption of the first international health
treaty, the Framework Convention on Tobacco Control, in May 2003. The driving force behind this
shift originated largely within the public health sector, motivated by a desire to secure greater
political attention to global public health needs. Key players included WHO Director-General Gro
Harlem Brundtland, President of the US Institute of Medicine Ken Shine, former World Bank
economist Je?rey Sachs, and former US Ambassador to the UN and President of the Global
Business Coalition on HIV/AIDS, Richard Holbrooke. The target was both the foreign and security
policy communities. From the perspective of public health advocates, di?erences between the two
communities have so far not been deeply explored, and the two are broadly (though not always)
seen in the same light. For the purposes of analysing public health engagement with these policy
communities, this lack of distinction is taken as given.
4
See for example George W. Bush, ?President speaks on fighting global and domestic HIV/AIDS?,
31 January 2003, available at: ?http://www.state.gov?, accessed on 16 January 2004; Paula J.
Dobriansky, ?The fight against HIV/AIDS? and ?The emerging security threat of HIV/AIDS: Russia?
both available at: ?http://www.state.gov?, accessed on 16 January 2004; Colin L. Powell,
?Presentation at HIV/AIDS plenary, September 22, 2003?, available at: ?http://www.state.gov?,
accessed on 16 January 2004. In addition, US President Clinton issued a Presidential Decision
Directive in 1996 calling for a more focused US policy on infectious diseases; the US House
International Relations Committee passed the Global Access to HIV/AIDS Prevention, Awareness,
Education and Treatment Act in June 2001 authorising large increases for international
programmes; and US O?ce of National AIDS Policy shifted its focus from domestic to
international e?orts in 2001.
5
See State Department, United States Strategic Plan for International A?airs, first revision
(Washington, DC: Department of State, 1999), pp. 9 and 41.
6 Colin McInnes and Kelley Lee
The United States has a direct interest in safeguarding the health of Americans and in
preventing the threats posed by diseases worldwide. Epidemic and endemic diseases can
undermine economic growth and stability, and threaten the political security of nations,
regions and the international community . . . emerging infectious diseases of epidemic or
pandemic proportions . . . pose a serious threat to American citizens and the international
community
6
In the UK, the FCO?s 2003 strategy paper raised the spread of disease as an ill-e?ect
of globalisation and a risk to peace and development,
7
although most of the attention
to international health issues in Whitehall has traditionally come from the Depart-
ment for International Development (DfID), whose White Paper on International
Development also makes the links between globalisation and poor health.
8
In
Australia, communicable disease is raised (albeit briefly) as a global challenge in its
2003 White Paper on foreign and trade policy,
9
while Foreign Minister Downer
acknowledged that ?disease and global health issues certainly add to the uncertainty
we face in the conduct of our foreign policy?.
10
One of the clearest statements in terms
of making the link between health and foreign policy, however, came in the 2002
report of the Romanow Commission on The Future of Health Care in Canada. The
report was critical that ?the broader area of health promotion is very much an
afterthought in Canada?s foreign policy? and argued that ?we have an opportunity to
ensure that access to health care is not only part of our own domestic policy but also
a prime objective of our foreign policy as well?. The report continued that ?Canada?s
health care system is not immune to international developments? and that Canada
should use its international good standing to take a leadership role ?to help improve
health and health care around the world?.
11
The recommendations of the Romanow
Commission were not much evidenced by the Canadian government?s subsequent
consultation paper on foreign policy, although health issues did receive greater
attention in the summary of responses to the paper.
12
However, Prime Minister Paul
Martin supported the inclusion of health in e?orts to organise a summit of Group of
20 (G20) leaders to address the global challenges from infectious diseases.
Health concerns are therefore beginning to emerge on the foreign and security
policy agenda of Western states, although they have not supplanted more traditional
concerns.
13
This policy shift can be most clearly observed in relation to biological
6
Strategic Plan Fiscal Years 2004?2009: Security, Democracy, Prosperity (Washington, DC: US
Department of State and US Agency for International Development, 2004), p. 76.
7
Foreign and Commonwealth O?ce, UK International Priorities: A Strategy for the FCO, Cmnd 6052
(London: HMSO, 2003), p. 13.
8
Department for International Development, Eliminating World Poverty: Making Globalisation Work
for the Poor (London: HMSO, 2000), pp. 21 and 34.
9
Department of Foreign A?airs and Trade [Australia], Advancing the National Interest: Australia?s
Foreign and Trade White Paper available at: ?http://www/dfat.gov.au/ani?, accessed on 20 January
2004.
10
Alexander Downer, ?Why Health Matters in Foreign Policy?, available at: ?http://
www.foreignminister.gov.au/speeches/2003?, accessed on 16 January 2004.
11
Roy J. Romanow, Building on Values: The Future of Health Care in Canada, Final Report of
Commission on the Future of Health Care in Canada (the Romanow Commission). Available at
?http://www.healthcarecommissoin.ca?, accessed on 20 January 2004.
12
Department of Foreign A?airs and International Trade [Canada], A Dialogue on Foreign Policy and
A Dialogue on Foreign Policy: Report to Canadians, both available at: ?http://
www.foreign-policy-dialogue.ca?, accessed on 20 January 2004.
13
For a fuller discussion on health and foreign policy see Colin McInnes, ?Background paper: health
and foreign policy?, available at ?http://www.nu?eldtrust.org.uk/global_health/pubs.php?, accessed
on 13 May 2004.
Health, security and foreign policy 7
weapons, where not only is disease (such as smallpox) considered a potential weapon,
but public health systems are seen as part of the defence (even deterrent) against the
use of such weapons.
14
More dramatic, however, in terms of global health impact has
been the HIV/AIDS pandemic. In a little over two decades, the spread of the disease
is such that UNAIDS estimates up to 44 million people are infected and that over 3
million died of AIDS in 2004 alone, of which 510,000 were children.
15
The scale of the
catastrophe has, of course, prompted humanitarian concerns; but HIV/AIDS has
also begun to be considered within a security context, particularly in relation to
national and regional stability. This was highlighted by the 2000 UN Security
Council special session on the HIV/AIDS threat to Africa and the subsequent
Security Council Resolution 1308 which recognised ?that the HIV/AIDS pandemic,
if unchecked, may pose a risk to stability and security?.
16
Concerns raised in the
security context include the disproportionate HIV infection rate among security
forces, the economic burden caused by the disease, increased social fragmentation,
reluctance to send or receive peacekeepers due to the risk of infection, and even its use
as a weapon of war, principally through rape.
17
The spread of acute and potentially epidemic infections from the developing world
more generally, including Ebola, West Nile virus and monkeypox, has also height-
ened concerns within the security community over risks to the health and economic
well-being of citizens and communities in Western countries. Although the causal
factors for the spread of such diseases are complex, globalisation, including increased
population mobility, features prominently. The 2002?03 SARS outbreak is a good
example of the extent and speed with which new diseases can spread. The disease
14
See for example the comments of President George W. Bush in signing the Public Health Security
and Bioterrorism Response Act, that ?Protecting our citizens against bioterrorism is an urgent duty
of . . . American governments. We must develop the learning, the technology and the health care
delivery systems that will allow us to respond to attacks with state of the art medical care
throughout our entire country.? ?Transcript: Bush signs bioterror bill?, O?ce of the Press Secretary,
The White House, 12 June 2002, available at ?http://japan.usembassy.gov/e/p/tp-se1440.html?,
accessed on 13 May 2004. See also Elizabeth Prescott, ?SARS: A Warning?, Survival, 45:3 (2003)
pp. 207?26.
15
UNAIDS, Global Summary of the AIDS Epidemic, December 2004, p. 1, available at
?http://www.unaids.org/wad2004/report_pdf.html?, accessed on 12 May 2005. Due to the social
stigma of HIV/AIDS infection in many societies, as well as weaknesses in capacity to collect health
information, data on morbidity and mortality remain estimates, although UNAIDS believes that the
accuracy of its estimates is improving. See UNAIDS, AIDS Epidemic Update: December 2003,p.1,
at ?http://www.unaids.org?, accessed on 13 May 2004.
16
The full text of Resolution 1308 is available at ?http://www.reliefweb.int?. See also Security Council
Press Release SC/7068, ?Examining implications of HIV/AIDS for UN peacekeeping operations?,
28 June 2001, available at ?http://www.un.org/News/Press/docs/2001/sc7086.doc.htm?, accessed on
13 May 2004. The Security Council session was followed by a special session of the General
Assembly on HIV/AIDS in 2001.
17
See for example International Crisis Group, HIV/AIDS as a Security Issue, June 2001, available at:
?http://www.crisisweb.org?, accessed on 2 February 2002; Stefan Elbe, ?HIV/AIDS and the Changing
Landscape of War in Africa?, International Security, 27:2 (2002), pp. 159?77 and Strategic
Implications of HIV/AIDS, Adeplhi Paper 357 (Oxford: IISS/OUP, 2003); R. Ostergard, ?Politics in
the Hot Zone: AIDS and National Security in Africa?, Third World Quarterly, 23:2 (2002), p. 342; P.
Chalk, ?Infectious Disease and the Threat to National Security?, Jane?s Intelligence Review,
September 2001, pp. 48?50. Much of this literature, however, fails to distinguish between HIV
infection and AIDS. Soldiers infected by HIV may not see their health (and therefore operational
e?ciency) a?ected for a number of years. Indeed AIDS may not appear until they have left the
armed forces. Although this may raise issues over the treatment of those infected (especially the cost
and the opportunity cost in terms of military budgets), the operational consequences may not be as
severe as initially feared.
8 Colin McInnes and Kelley Lee
began in southern China in November 2002 and began to spread internationally in
February 2003. WHO issued global alerts on 12 and 15 March 2003, by which time
the disease had already spread from China to Taiwan, Singapore, Vietnam and
Canada. By the time the disease came under control in August 2003, 8,422 cases had
been identified in 29 countries with 908 fatalities.
18
SARS also highlighted sensitivi-
ties to economic e?ects. Although the number of cases and deaths from the initial
SARS outbreak was relatively small in comparison for instance with tuberculosis,
19
for the foreign policy community particular attention was paid to the considerable
economic losses caused.
20
One estimate placed the losses at US$100 billion.
21
The
macroeconomic e?ects of disease and poor health had already achieved attention,
principally through the WHO Commission on Macroeconomics and Health,
22
but
SARS gave this a public and political prominence previously lacking. SARS also
demonstrated how policy responses to emerging and re-emerging infectious diseases
(ERIDs) can elicit a ?garrison mentality? in an e?ort to prevent the spread of
infection. Stricter border controls and attempts to regulate migration have been key
features in state responses to the spread of infectious disease, potentially disrupting
the free movement of goods, people and services.
23
This article presents two key arguments. First, the manner in which public health
issues have begun to appear on foreign and security policy agendas reflects more the
concerns of the latter than those of public health. The emphasis to date has been on
public health as a foreign policy and security risk, rather than on how foreign and
security policy can facilitate or hinder public health. Second, the agenda has been
dominated by two issues, the spread of selected acute and potentially epidemic
infections and the risk of bio-terror. Yet, from the perspective of seeing health as
threats to foreign policy and security, there are other issues which could be of equal
concern. This article identifies two such examples ? illicit activities and internal state
instability. The focus of this article therefore is on the issues which are, or which
might appear, on this developing agenda. Our main argument is to critique the
narrow framing of the agenda to privilege one set of concerns over another. In the
Conclusion, however, we briefly open this up to identify some of the other questions
raised by closer cooperation between the two policy communities.
18
WHO, Severe Acute Respiratory Syndrome (SARS): Report by the Secretariat, EB113/33, 27
November 2003 (Geneva: WHO, 2003), p.1. For details of the geographic spread of cases see WHO,
Summary of Probable SARS Cases with Onset of Illness 2002 to 31 July 2003, 31 December 2003,
available at ?http://www.who.int/csr/sars/country/table2004_04_21/en/?, accessed on 13 May 2004.
See also Kelley Lee, ?Decision making in the face of public health emergencies of international
concern? in R. Smith and N. Drager, Rapid Assessment of the Economic Impact of Public Health
Emergencies of International Concern: The Case of SARS (Geneva: WHO, in press); and Prescott,
pp. 211?3.
19
G. F. Zhou and G. Y. Yan, ?Severe Acute Respiratory Syndrome Epidemic in Asia?, Emerging
Infectious Diseases, 9:12 (2003).
20
For example Downer, ?Why Health Matters in Foreign Policy?.
21
National Intelligence Council, SARS: Down But Still a Threat, Intelligence Community Assessment
ICA 2003?09 (Washington, DC: National Intelligence Council, 2003).
22
Reports from the Commission and details of its work can be found at its homepage:
?http://www.cmhealth.org/cmh_papers&reports.htm?.
23
See, for example, Peter Spiro, ?The Legal Challenges SARS Poses?, available at ?http://
www.cnn.com/2003/LAW/04/29/findlaw.analysis.spiro.sars/?, accessed on 14 May 2004. Concerns
over the spread of SARS from Toronto led the United States? Centers for Disease Control and
Prevention (CDC) to issue health alerts to travellers, including those from Toronto. CDC, ?Update:
Severe Acute Respiratory Syndrome ? United States, 2003?, available at: ?http://www.cdc.gov/mmwr/
preview/mmwrhtml/mm5217a4.htm?, accessed on 13 May 2004.
Health, security and foreign policy 9
Infectious disease: a new security risk?
Health issues have been creeping up foreign and security policy agendas for some
time. Although this movement was accelerated by 9/11 and subsequent concerns over
bio-terrorism, its origins lie with the attempt to develop a new security agenda in the
aftermath of the Cold War, one focused on novel risks and areas of concern. In this
context ERIDs, with their capacity to cross national borders, threaten the well-being
of domestic populations, and undermine the economic and military capabilities of
states, began to find a place as a security issue. In 2000 for example, the US National
Intelligence Council identified a range of risks from the spread of infectious disease,
including increased social fragmentation, economic decline, political polarisation and
tension leading to the risk of instability.
24
Of particular concern though was
HIV/AIDS. By the mid to late 1990s, amid evidence of failure to stem the spread of
the disease, HIV/AIDS began to attract the keen attention of the security policy
community, prompting US Secretary of State Colin Powell to declare that it ?now
represents so great a threat to stability in Africa, Asia and Latin America that it needs
to be regarded as a national security issue?.
25
Similarly, Richard Holbrooke, former
US ambassador to the UN and Director of the Global Business Council on
HIV/AIDS, described the disease as ?a direct threat to social, political and economic
stability?.
26
While HIV/AIDS has received particular focus, other acute infections of poten-
tially epidemic proportions have also received attention. At the 54th World Health
Assembly in May 2001, WHO urged member states to participate actively in
improving epidemic alert and response measures to ensure ?global health security?.
27
A number of countries have already sought to strengthen disease surveillance and
monitoring systems at the national and regional levels. For example, in 2000 the EU
published an evaluation of arrangements for managing epidemiological emergencies
involving more than one EU member state.
28
In the UK, the Department of Health
commissioned an internal study of the public health implications of increased
population mobility including infectious disease control.
29
Similar issues were raised
in a study funded by The Nu?eld Trust to review UK public health measures
concerning population mobility and tobacco control in the context of growing
24
US National Intelligence Council, The Global Infectious Disease Threat and Its Implications for the
United States, National Intelligence Estimate NIE99-17D (2000), available at: ?http://www.cia.gov/
cia/publications/nie/report/nie99?17d.html?, accessed 5 August 2002.
25
Quoted in J. Gow, ?The HIV/AIDS Epidemic in Africa: Implications for US Policy?, Health A?airs,
21:3 (2002), p. 57.
26
Quoted in J. Lobe, ?Spread of AIDS Seen as a Security Threat?, Third World Network, available at:
?http://www.twnside.org.sg/title/threat.htm?, accessed 5 August 2002.
27
World Health Assembly Resolution 54.14, Global Health Security: Epidemic Alert and Response
(Geneva: WHO, 2001).
28
H. Brand et al., An Evaluation of the Arrangements for Managing an Epidemiological Emergency
Involving More than One EU Member State (Bielefeld: LOGD, 2000).
29
The report remains unpublished by the UK Department of Health. The UK Conservative Party
announced plans to control immigration to prevent the spread of HIV and TB in the run-up to the
2005 General Election. See BBC News, ?Tories plan migrant health checks?, ?http://news.bbc.co.uk/
1/hi/uk_politics/4265461.stm?, accessed on 15 May 2005; and politics.co.uk, ?Conservatives would
turn away immigrants with TB?, ?http://www.politics.co.uk/election-2005/conservatives-would-
turn-away-immigrants-with-tb-$13008625.htm?, accessed on 15 May 2005.
10 Colin McInnes and Kelley Lee
transborder health risks.
30
Japan, Australia and the US have all reviewed their
policies on border control in light of growing concerns of the perceived risk from
certain infectious diseases.
31
In many cases, recommended policy responses have been
focused on e?orts to moderate perceived risks through control of population flows
across borders or increased at-the-border screening. Examples include proposals for
mandatory screening of all migrants in the UK for HIV/AIDS and in the US for
tuberculosis.
32
The increased attention to infectious disease as a ?new security risk? has largely
been focused on selected infections that have the potential to move from the
developing to industrialised world.
33
In 2002?03 SARS joined a list of such diseases
which now includes West Nile virus, Ebola and monkeypox. However, by construct-
ing the link between infectious disease and security in this manner, the global health
agenda risks becoming inappropriately skewed in favour of the interests of certain
populations over others. By any measure, notably data on the Global Burden of
Disease, these infections have caused a relatively minor number of cases compared,
for example, to diarrhoeal disease. The latter, due overwhelmingly to unsafe water
supply, sanitation and hygiene in the developing world, causes 1.8 million deaths
each year, with 90 per cent of these deaths being children.
34
Perhaps ironically, some public health o?cials have been keen to emphasise the
security implications of ERIDs as a means of pushing health higher on policy
agendas, both domestically and internationally (including G8 Summits and the
World Economic Forum). These initiatives have not always identified the risks
involved in a securitising move and the result has been increased concern, not for
shifting patterns of health and disease of world populations as a whole, but for
selected infections that potentially threaten the privileged few.
35
This risks leading to
30
Je? Collin and Kelley Lee, Globalisation and Public Health: A Review and Assessment of Public
Health Measures in the UK Concerned with Transborder Health Risks (London: The Nu?eld Trust,
2002).
31
J. Gerard Power and Theresa Byrd, US-Mexico Border Health: Issues for Regional and Migrant
Populations (London: Sage, 1998). Australia, Department of Immigration and Multicultural and
Indigenous A?airs, ?The Health Requirement?, Fact Sheet, Canberra, 2004. At the Japan/ASEAN
Summit held in November 2001, the Japan-ASEAN Information and Human Network for
Infectious Disease Control was formed.
32
Richard Coker and K. Lambregts van Weezenbeek, ?Mandatory Screening and Treatment of
Immigrants for Latent Tuberculosis in the USA: Just Resistant?? The Lancet, 1 November 2001,
pp. 270?6.
33
A crucial report setting this agenda came from the Board on International Health of the US
Institute of Medicine. See Institute of Medicine, America?s Vital Interest in Global Health: Protecting
Our People, Enhancing our Economy and Advancing our National Interests (Washington, DC:
National Academy Press, 1997). See also for example Jennifer Bower and Peter Chalk, The Global
Threat of New and Reemerging Infectious Diseases: Reconciling US National Security and Public
Health Policy (Santa Monica, CA: RAND, 2003), pp. 61?74. Although the major theme is that
disease may spread to the United States and elsewhere in the West, an important sub-theme is of
concern that the economic burden of disease elsewhere may harm economic growth globally, thus
a?ecting Western economies. See also A.M. Kimball and K. Taneda, ?Emerging Infections and
Global Trade: A New Method for Gauging Impact?, paper presented at Workshop on the Rapid
Assessment of the Economic Impacts of Public Health Emergencies of International Concern,
University of Toronto, January 2004.
34
WHO, ?Facts and Figures: Water, Sanitation and Hygiene Links to Health?, Geneva, 2004.
Available at ?http://www.who.int/water_sanitation_health/publications/factsfigures04/en/print.html?
(accessed 31 March 2005).
35
C. Murray and A. Lopez, Global Burden of Disease (Cambridge, MA: Harvard University Press,
1994), and ?Progress and Directions in Refining the Global Burden of Disease Approach: A
Response to Williams? Discussion Paper? (Geneva: WHO, 2000).
Health, security and foreign policy 11
a fortress mentality which seeks to control the transmission of infectious agents by
regulating the flow of certain mobile populations, goods and services. For example,
the Institute of Medicine proposed that the US introduce mandatory screening for
tuberculosis (TB) of immigrants from high-prevalence countries, a proposal sup-
ported by the Centers for Disease Control and Prevention (CDC). The policy also
argued for provision of a permanent residence card (green card) to be linked to the
completion of an approved course of preventive treatment.
36
As Coker and van
Weezenbeek convincingly demonstrate, not only do such policies have dubious public
health benefits (not least because of the number of migrants, legal and illegal, not
covered by such a scheme) but it overestimates the risks involved.
37
The concern over infectious diseases may therefore be understandable from a
foreign and security policy perspective since they appear to pose risks to domestic
populations, regional stability and economic growth. But this focus is problematic
from a global public health perspective. Not only are the broader determinants of
health underplayed (including poverty) but, from a global perspective, the health
risks to populations in the industrialised world pall in comparison to those elsewhere.
Moreover the focus on the spread of infectious disease obscures dangers from
non-communicable diseases (including tobacco-related illnesses) which are related to
foreign policy through international trade. In short, the attention given to the spread
of infectious disease speaks more to the concerns of Western foreign (including
economic) and security policy than it does for the concerns of global public health.
Bio-terrorism
In the aftermath of 9/11, much of the attention to the links between health and
security policy has been focused on the perceived threats from biological weapons,
most worryingly as wielded by terrorist organisations and/or ?rogue states? (what has
been termed bio-terrorism).
38
Renewed concerns over biological weapons, however,
had begun to emerge in the early to mid 1990s, supported by intelligence reports of
a potential proliferation of materials to produce such weapons following the
break-up of the Soviet Union.
39
Political and economic instability in the region,
36
Institute of Medicine, Ending Neglect: The Elimination of Tuberculosis in the United States
(Washington, DC: Division of Health Promotion and Disease Prevention, 2004).
37
Coker and van Weezenbeek, ?Mandatory Screening and Treatment of Immigrants?.
38
In his 2003 evidence to Congress, for example, the Director of the CIA referred to this as a matter
of ?grave concern?. See CIA, ?DCI?s Worldwide Threat Briefing: The Worldwide Threat in 2003:
Evolving Dangers in a Complex World?, 11 February 2003, p. 4, available at: ?http://www.cia.gov/
public_a?airs/speeches/2003/dci_speech_02112003.html?, accessed on 14 May 2004. See also The
White House, ?Biodefense for the 21st century?, 30 April 2004, available at: ?http://
www.whitehouse.gov/homeland/20040430.html?, accessed on 14 May 2004. The link between public
health and bio-terrorism in the US is apparent, for example, in the 2002 Public Health Security and
Bioterrorism Preparedness and Response Act and in the work of the CDC. See CDC Terrorism and
Preparedness and Response Strategy, version March 2004, available at: ?http://www.bt.cdc.gov/
planning/tprstrategy/index.asp?, accessed on 14 May 2004. The so-called Bioterrorism Act is
available at: ?http://www.fda.gov/oc/bioterrorism/PL107?188.pdf?.
39
On the problem of Russian biological weapons ?leakage?, see Jonathan Tucker, ?Biological Weapons
Proliferation from Russia: How Great a Threat?, paper presented at the 7th Carnegie International
Non-Proliferation Conference, 11?12 January 1999, Washington DC, available at
?http://www.ceip.org/programs/npp/tucker.htm?, accessed on 2 February 2004. See also G.
Christopher, T. Cieslak, J. Pavlin and E. Eitzen, ?Biological Warfare: A Historical Perspective?,
Journal of the American Medical Association (hereafter JAMA), 278:5 (1997), pp. 412?17.
12 Colin McInnes and Kelley Lee
accompanied by growing lawlessness and the rise of organised criminal groups, raised
fears that materials were being sold to terrorist organisations and ?rogue states? such
as Iraq, Iran, Libya, Syria, Cuba, and North Korea.
40
While selective attacks using
biological weapons have been carried out in the past, the increased potential for
causing harm to mass populations and the relatively low cost of such weapons are
believed to make the weapons especially attractive to such groups. The use of
biological weapons by Iraq against its Kurdish population in 1988, suspicions that
the same government was stockpiling anthrax, botulinum toxin, smallpox and other
agents prior to the Gulf War of 1991?92, the attempt by followers of Rajneesh
Bhagwan to spread salmonella in the US, and the attack on the Tokyo subway using
sarin by the Aum Shinrikyo cult in 1995, all contributed to a heightened sense of
awareness that ?non-traditional terrorists? were becoming better organised, some
seeking access to biological weapons. Indeed, in an age of ?asymmetric warfare?, fears
began to be expressed that biological weapons could become a weapon of choice not
only for terrorists but for states seeking an edge over the powerful in terms of
conventional military weaponry.
41
Even before 9/11 there was growing discussion between the public health and
security communities among the G8 countries of the need to improve preparedness
and response measures in the event of a major bio-terrorist attack. Within the public
health community, the focus was on enhancing response and recovery from such an
event, recognising that ?we will not be able to prevent every act of BW (biological
weapon) terrorism?.
42
Indeed, arguing that ?the greatest payo? in fighting BW
terrorism lies in improving our response to an incident?, much e?ort was undertaken
to anticipate strategic targets, improve surveillance,
43
draft contingency plans
44
stockpile vaccines and treatments, and train and inoculate health personnel.
45
Within
the security policy community, e?orts were made from 1994 to negotiate a legally
binding instrument to strengthen the Biological and Toxin Weapons Convention
(BWC) signed in 1972,
46
press rogue states to disarm, and improve intelligence on
terrorist organisations.
The anthrax attacks following 9/11 brought into sudden focus the potential risks
from terrorists wielding biological weapons. WHO encouraged countries to
40
David Fidler, ?Facing the Global Challenges Posed by Biological Weapons?, Microbes and Infection,
1999:1, pp. 1059?66; D. Leigh, ?Iraq Stockpiled Anthrax in Run-up to Gulf War?, The Guardian,
15 October 2001. Evidence has recently emerged that the strain of anthrax found in Iraq ? anthrax
14578 ? may have originated in US labs. See comments by Senator Riegle, Congressional Record
(Senate), 9 February 1994, available at: ?http://www.svsu.edu/zboles/index/iraq/
ussuppliesiraqgas.htm?, accessed on 15 May 2005.
41
For example, CIA, ?DCI?s Worldwide Threat Briefing?, p. 4.
42
J. Simon, ?Biological Terrorism: Preparing to Meet the Threat?, JAMA, 278:5 (1997), p. 428.
43
R. L. Shapiro, C. Hatheway, J. Becher and D. L. Swerdlow, ?Botulism Surveillance and Emergency
Response?, JAMA, 278:5 (1997), pp. 433?5.
44
J. B. Tucker, ?National Health and Medical Services Response to Incidents of Chemical and
Biological Terrorism?, JAMA, 278:5 (1997), pp. 362?8.
45
D. R. Franz, P. B. Jahrling, A. M. Friedlander et al., ?Clinical Recognition and Management of
Patients Exposed to Biological Warfare Agents?, JAMA, 278:5 (1997), pp. 399?411. On 2 December
2002 the UK government announced its intention to inoculate a limited number of key health
personnel with the smallpox vaccine in order to create strategically available emergency health
personnel in the event of a biological attack. See CDR Weekly, Interim Guidelines for Smallpox
Response and Management published by the Department of Health, 5 December 2002, available at
?http://www.hpa.org.uk/cdr/PDFfiles/2002/cdr4902.pdf?, accessed on 15 May 2005.
46
G. Pearson, ?The Complementary Role of Environmental and Security Biological Control Regimes
in the 21st Century?, JAMA, 278:5 (1997), pp. 369?72.
Health, security and foreign policy 13
strengthen regional and global surveillance and response measures through the
Global Outbreak Alert and Response Network,
47
and a series of meetings by the
Global Health Security Group of the G8, formed in 2001, have been held to discuss
global public health security.
48
Not least, in June 2002 US President George W. Bush
signed the Public Health Security and Bio-terrorism Bill.
49
There was also a
proliferation of public health literature on how to increase domestic measures to
protect against, and respond to, various biological weapons. Other issues raised
include clinical diagnosis and management,
50
and use of quarantine measures.
51
Diplomatic e?orts were also made to achieve a more e?ective BWC.
52
However, there
has been a clear tension between an internationally versus a domestically focused
strategy. This is particularly apparent over vaccines. Although anthrax initially
occupied popular attention after 9/11, fears of other infectious agents were soon
raised. The US government had already ordered 40 million doses of smallpox vaccine
in April 2001.
53
Following the anthrax attacks in September 2001, the US stepped up
its stockpiling of the smallpox vaccine, joined by other countries including the UK.
54
Given this large scale purchasing, stocks worldwide were soon in short supply.
Similarly, worldwide supplies of the antibiotic Cipro used to treat anthrax, rapidly
became in short supply. This resulted in foreign policy tensions over hoarding of
essential drugs by the US.
55
The US and other Western states (including the UK,
56
Canada and Australia)
have all increased their e?orts to improve domestic capacity to respond to public
health emergencies caused by bioterrorism.
57
Policy responses in the US have also
seen priority given to traditional security measures, notably e?orts to shore up ?at the
47
WHO, ?Countries Need to Plan E?ectively for ??Deliberate Infections?? ? WHO Leader Urges Health
Ministers?, WHO Press Release, 24 September 2001. The Global Outbreak Alert and Response
Network is a system of 72 global and regional networks of laboratories, public health experts, and
internet-based information systems that continually monitor reports and rumours of disease events
around the world. The system is backed by WHO and expertise from more than 250 laboratories,
and is linked to the International Health Regulations.
48
See, for example, Health Canada, ?Ministerial Statement?, Fourth ministerial meeting on health
security and bioterrorism, Berlin, 7 November 2003. Available at ?www.hc-sc.gc.ca/english/media/
releases/ 2003/ministerial_statement.htm?.
49
Linda D. Kozaryn, ?Bush Signs Health Security, Bioterrorism Act? American Forces Press Service
13 June 2002, available at: ?http://www.defenselink.mil/news/Jun2002/n06132002_200206133.html?,
accessed on 14 May 2004. The Bioterrorism Act is available at: ?http://www.fda.gov/oc/bioterrorism/
PL107?188.pdf?.
50
H. C. Lane and A. Fauci, ?Bioterrorism on the Home Front: A New Challenge for American
Medicine?, JAMA, 286:20 (2001), pp. 2595?7.
51
J. Barbera et al., ?Large-Scale Quarantine Following Biological Terrorism in the United States?,
JAMA, 286: 21 (2001), pp. 2711?17.
52
These e?orts are detailed on the Biological and Toxic Weapons Convention website at:
?http://www.opbw.org/?. See also the resource page on strengthening the BWC held by the
Department of Peace Studies, University of Bradford: ?http://www.bradford.ac.uk/acad/sbtwc/?.
53
J. Laurance, ?US on Alert for Smallpox Terror Attack?, Independent on Sunday, 22 April 2001.
54
The UK Department of Health holds pre-11 September stocks for 3 million people which could be
diluted to cover 15 million people. J. Meikle, ?Wanted: More Smallpox Vaccine?, The Guardian,
28 October 2002.
55
K. Singh, ?War Profiteering: Anthrax, Drug Transnationals and TRIPS?, paper prepared for the
Asia-Europe Dialogue Project (2001), available at ?http://www.ased.org?.
56
For example, the UK Public Health Laboratory Service (PHLS), now the Health Protection
Agency, issued guidelines for action in the event of an anthrax attack. UK PHLS, Anthrax:
Provisional PHLS Guidelines for Action in the Event of a Deliberate Release (London: CDSC, 2001).
57
See, for example, information on measures promoted or endorsed by the US Department of Health
and Human Services at ?http://www.hhs.gov/disasters/index.shtml#bioterrorism?.
14 Colin McInnes and Kelley Lee
border? controls and improve systems of intelligence intended to prevent a bio-
terrorist attack. The focus on improving domestic capacity, however, added to
criticism over the US government?s decision to pull out of negotiations on the BWC,
reinforces the sense that national measures were being prioritised over international
cooperation. The public health community, in contrast, has focused on developing
e?ective responses in the likelihood that biological weapons are used. These measures
are divided between improving international surveillance and monitoring, and
strengthening domestic public health systems. What is clear however is that
bio-terrorism?s presence on the international agenda is because of the security risk it
represents to the West, not because of its significance as a health risk; and that
although public health systems have been involved in devising methods to protect
against attack, this is within a national security context where national interests are
paramount, as seen by the stockpiling of drugs and the prioritising of domestic
concerns.
Health, internal instability and failing states
Considerable attention has therefore focused on the links between health and foreign
and security policy in the two areas of infectious disease and bio-terror. The attention
devoted to these two issues, however, has suggested a rather narrow agenda with only
limited points of contact between the policy communities. What we now attempt to
do is to demonstrate how the agenda is somewhat broader than this and provide
examples of two other policy areas where public health intersects with the foreign and
security communities. The first of these is internal instability, where links have been
made but not to the same extent or with the same priority as for bio-terrorism and
infectious disease; the second, illicit trade, where the links remain relatively under-
explored.
The problem of internal instability loomed high on the international agenda for
much of the 1990s. A key concern was that internal instability could spill over into
the international, threatening regional stability and international trade.
58
But the
focus on internal instability and ?failed states? also reflected human rights concerns
which transcended traditional ideas of state sovereignty.
59
Although the attention
given to these problems has been overtaken by the ?war on terrorism?, concern over
internal instability and failed states continues. The Bush Administration?s 2002
National Security Strategy, for example, argued that ?When violence erupts and
states falter, the United States will work with friends and partners to alleviate
su?ering and restore stability?, although subsequent paragraphs made clear its
concern that such states might be linked with terrorism and that US actions in these
circumstances were not necessarily divorced from the war on terror.
60
The UK?s 2003
58
Typical of this is UK Prime Minister Tony Blair?s comment on intervention in Kosovo, that ?We
must act . . . to save the stability of the Balkan region, where we know chaos can engulf all of
Europe?. Statement by the Prime Minister in the House of Commons, 23 March 1999, available at
?http://www.fco.gov.uk/news/newstext.asp?2149? accessed on 20 June 1999.
59
See, in particular, Nicholas J. Wheeler, Saving Strangers: Humanitarian Intervention in International
Society (Oxford: Oxford University Press, 2000).
60
The White House, National Security Strategy of the United States, p. 9. Available at
?http://www.whitehouse.gov/nsc/nss.html?, accessed on 16 January 2004.
Health, security and foreign policy 15
Defence White Paper similarly commented that ?Weak and failing states are an
increasing problem for the stability of several regions especially on NATO?s borders
and in Africa?, though it too made a link with international terrorism by commenting
that such states ?can contain areas of ungoverned territory which provide potential
havens and sources of support for terrorist groups?.
61
What is unclear is the extent to
which poor health can contribute to internal instability,
62
and whether improved
health and better health care provision can stabilise states, particularly in a
post-conflict environment.
The argument that poor health can prove destabilising has two parts. The first
is that poor health undermines the economic and social structures of the state. Not
least, confidence in the state is reduced if it cannot provide a basic level of health
care and protection against disease.
63
Poor health provision may contribute to
social disorder by highlighting inequalities; but it may also present a government
as ine?ective regardless of whether it has the resources to deal with vital health
issues. Poor health may also contribute to economic decline, fuelling discontent,
by: forcing increased government spending on health as a percentage of GDP;
reducing productivity due to worker absenteeism and the loss of skilled personnel;
reducing investment (internal and external) because of a lack of business confi-
dence; and by raising insurance costs for health provision.
64
The second part of the
argument is that the tools of maintaining order, principally the security forces, are
particularly vulnerable to sexually transmitted diseases (STDs) including HIV/
AIDS.
65
To what extent this second argument holds for poor health more
generally is, however, uncertain. Prima facie it would seem reasonable to expect
security forces to receive better health provision in these circumstances, simply
because state survival might hinge on this. But the social world is rarely as
clear-cut as this and, even when it is, the law of unintended consequences may
operate (for example, better health care for security forces may reinforce images of
inequality, thus fuelling discontent).
The reverse of the coin is that state failure can lead to deteriorating health through
economic weaknesses, the collapse of state institutions including the public health
infrastructure, and the breakdown of social order leading to violent conflict. External
assistance to secure a failing state may therefore lead to positive health outcomes
within that state. Failed states might also have regional health implications. Most
obviously internal instability may lead to mass migration (as happened in Rwanda
and Kosovo, for example), creating vectors for the spread of infectious disease. The
breakdown of law and order may also provide a fertile ground for the development
of organised crime leading to an increase in illicit trade, including tra?cking in drugs,
weapons smuggling and people. All of these may have regional (or even global)
health implications. The problem of failed or failing states may have traditionally
been seen as a foreign policy problem, but the health implications at a national,
regional and global level should not be underestimated.
61
Ministry of Defence, Delivering Security in a Changing World: Defence White Paper, Cmnd 6041?I
(London: HMSO, 2003), p. 5.
62
Stefan Elbe for example has examined the impact of HIV/AIDS on stability. See his Strategic
Implications of HIV/AIDS.
63
US National Intelligence Council, The Global Infectious Disease Threat.
64
See, for example, ibid. and R. Ostergard, ?Politics in the Hot Zone?, p. 344.
65
See, for example, P. Chalk, ?Infectious Disease and the Threat to National Security?, p. 49; J. Lobe,
?Spread of AIDS Seen as a Security Threat?.
16 Colin McInnes and Kelley Lee
As an example to demonstrate the relationship between poor health and internal
instability we use the results of the CIA?s State Failure Task Force.
66
This study
identifies three major variables in explaining state failure: (a) quality of life; (b)
openness to trade; and (c) level of democracy. Health can contribute, directly and/or
indirectly, to all of these. On quality of life, the study argues that the well-known
linkage between infant mortality rates and the likelihood of conflict
67
is not a causal
relationship; rather, high infant mortality rates indicate a poor quality of life, which
in turn is a causal factor. In so doing the study appears to suggest that health is not
itself directly a causal factor in state failure, but may be a contributory factor or
indeed a reflection of imminent state failure. However, the study does not rigorously
examine health in relation to the quality of life as a key variable. The second key
variable, openness to trade, can also be a?ected by health conditions. The US
National Intelligence Council for example estimated that infectious diseases would
continue to disrupt trade and commerce on a regular basis throughout all regions of
the world.
68
Examples of such disruptions include SARS, HIV/AIDS in South Africa,
avian influenza in Asia, BSE and vCJD in the UK, plague in India, and cholera in
Peru in the early 1990s. All of these threatened trade with and/or investment in states
a?ected. Finally with regard to levels of democracy as a factor in state failure, the link
with health is made explicitly in the 2002 US National Security Strategy. Here health
is seen as part of the ?infrastructure of democracy?. The Strategy argues that health
aid will only be e?ective if allied to good governance. The controversial implication
of this is that health aid should be linked not to need ? reflecting the humanitarian
motives supposedly underpinning development aid ? but to good governance and
democratic reforms.
69
Health aid is therefore politicised in a manner which may
disadvantage yet further those at greatest need. But as regards state stability, the
assertion is clear: that democracy and good governance allow the e?ective transmis-
sion of aid, relieving health problems, but that corrupt or ine?ective governance is
wasteful of aid, leading to deteriorating health and increased social dissatisfaction.
The vicious cycle of poor health leading to conflict leading to worsened health may
also be reversed. There is a growing body of work on how initiatives to improve
health may be used to improve state stability, not least ?health as a bridge to peace?
initiatives.
70
Examples include the work of WHO in Bosnia-Herzegovina
71
and in the
Maluku Islands in Indonesia.
72
In Bosnia-Herzegovina there is anecdotal evidence
that WHO and DfID programmes to rebuild the health system after the conflict
66
D. C. Esty et al., ?State Failure Task Force Report: Phase II Findings?, Environmental Change and
Security Project Report Issue 5 (1999), available at ?http://ecsp-si-edu/pdf/Report5?Sect2.pdf?,
accessed 8 August 2002. Other studies of state failure exist which may similarly be used to
demonstrate this link; our use of the CIA study is simply to demonstrate the potential links rather
than to prioritise one set of findings over another.
67
For example, US National Intelligence Council, The Global Infectious Disease Threat.
68
US National Intelligence Council, The Global Infectious Disease Threat.
69
The National Security Strategy of the United States, pp. 21?3 and especially p. 23.
70
Department of Emergency and Humanitarian Action, Conflict and Health, Working Paper (Geneva:
WHO, 2000). See also WHO, ?From Health Relief to Health Reconstruction: WHO Brief for
Afghan Support Group Meeting, 5?7 December 2001?, available at: ?http://www.reliefweb.int?,
accessed on 5 August 2002.
71
WHO, Peace through Health: Summary of WHO peace building experiences, principles and strategies
in Bosnia and Herzegovina (WHO/EUR/PAR, November 1999).
72
WHO, ?Peacebuilding through Health?, Health in Emergencies (8), available at: ?http://
www.reliefweb.int/w/Rwb.nsf/s/CF7700C552584AE2C12569CF0065A20A?, accessed on 5 August
2002.
Health, security and foreign policy 17
assisted in overcoming separatist attitudes, reducing volatility and improving social
cohesion. The negotiation of ceasefires to allow the delivery of humanitarian aid and
immunisation programmes not only served as a respite from conflict, they acted as a
confidence-building measure to allow negotiations for an end to the conflict.
73
On the
other hand, WHO has recognised that health interventions which are based purely
upon short-term considerations may have no e?ect upon peacebuilding, and may
even prolong conflict.
74
Although the idea of health as a bridge to peace is widely associated with WHO,
the role of health in conflict prevention has been picked up elsewhere. The Bush
administration for example has implicitly identified health as a weapon in the fight
against terror.
75
Improved health systems may be used as part of nation-building and
to reinforce democratic principles; denying medical aid through sanctions may also
put regimes under pressure, forcing change. However both the principles and practice
of the Bush administration have been challenged. Health for nation-building has not
been particularly evidenced by US policies in Afghanistan and Iraq, while the
e?ectiveness and morality of such sanctions have been questioned.
76
Further, a
number have argued that improving health care during a conflict may also be
counter-productive on two grounds: it delays reaching the breaking point where one
or both sides decide that they must sue for peace; and medical aid may be diverted
from civilians to the military, allowing the latter to fight on.
77
Overall, the idea of health as a bridge for peace has attracted considerable
attention. However, there is suspicion among some that it is ?ideology that is driving
the movement at present?.
78
Critically, the evidentiary base appears slim and overly
reliant on anecdotal evidence rather than rigorous and systematic empirical work.
79
Moreover, there has been little conceptual work done on key questions including:
what works and why? What conditions are susceptible to such an approach? What
level and form of health investment is required? When might it backfire and allow a
conflict to continue? Can it be used to assist in ending conflicts, or just in post-conflict
reconstruction? And can it be used to prevent conflict?
Health, globalisation and illicit activities
A second example of how the agenda might be broadened concerns illicit activities.
A defining feature of globalisation is the increased flow of human social relations
across territorially-based boundaries, notably the state. But alongside legal activities,
73
A. Vass, ?Editorial: Peace through Health?, British Medical Journal, 323, 3 November 2002, p. 1020;
WHO Europe, WHO/DFID Peace Through Health Programme: A Case Study Prepared by the WHO
Field Team in Bosnia and Herzegovina (Copenhagen: WHO, 1998); Graeme MacQueen and Joanna
Santa Barbara, ?Peacebuilding through Health Initiatives?, British Medical Journal,321,29July
2000, pp. 293?6.
74
A. Manenti, Health as a Potential Contribution to Peace. Realities from the Field: What WHO has
learned in the 1990s (Geneva: WHO, 2001), p. 1. Available at ?http://www.who.int/disasters/hbp/
developing/HBP_WHO_learned_1990s.pdf?, accessed 1 November 2004.
75
The National Security Strategy of the United States, especially p. 23.
76
R. Horton, ?Public Health: A Neglected Counterterrorist Measure?, The Lancet, 358 (2001),
pp. 1112. G. MacQueen, ?Iraq: Harm Reduction through Health?, The Lancet, 360 (2002), p. 1031.
77
For example, Vass, ?Editorial?, p. 1020.
78
Vass, ?Editorial?, p. 1020.
79
This point might be made more generally about the links between health and stability. Although
there are good reasons to believe that such links might exist, the empirical evidence remains patchy.
18 Colin McInnes and Kelley Lee
globalisation has entailed a wide range of illicit activities. Indeed the undermining of
the state?s ability to control certain types of transborder flows, which circumvent
state boundaries, has enabled such activities to flourish. By the mid-1990s organised
crime was becoming a global network, with the groups involved closely linked by
supply and demand chains beyond the reach of national authorities.
80
It is now
estimated that organised crime generates US$750 billion annually, much of it
?washed? by complex financial transactions into the global economy. At least three
81
forms of illicit activity link health, foreign and security policy (see Table 1). First, the
tra?cking of illicit drugs has become a major challenge for both policy communities.
Estimates of the total value of all sales of illicit psychoactive substances range from
US$180 bn to US$300 bn. It is estimated that as much as US$122 bn annually is
spent in the US and Europe on the three most popular drugs ? heroin, cocaine and
cannabis. Of this, as much as US$85 bn is laundered or invested in other enterprises,
80
A good contemporary account is A. Nicaso and L. Lamothe, Global Mafia: The New World Order
of Organized Crime (Toronto: Macmillan Canada, 1995).
81
Other forms of illicit activity with health implications are arms smuggling, illegal dumping of
pollutants such as toxic substances, and the unregulated collection and use of biologicals including
organs and blood products.
Table 1. The foreign policy and health implications of illicit activities.
Illicit activity Foreign policy implication Health implication
Tra?cking of illicit drugs Revenues used to support
organised criminal activity,
terrorism
Increases and sustains
widespread addiction to illicit
drugs
Increased morbidity and
mortality from the use of
illicit substances
Smuggling of people Undermining of immigration
policy
Destabilisation of local
community
Financial burden on host
country
Lucrative source of earnings
for organised crime
Health risks to undocumented
migrants when being
smuggled
Increased risk of transmission
of STDs from commercial sex
workers
Smuggling of goods Loss of revenue for national
economy
Revenues used to support
organised criminal activity,
terrorism
Increases supply of (e.g.)
cheaper cigarettes
Increases morbidity and
mortality from
tobacco-related diseases
Illegal weapons sales Increased availability of
weapons among terrorist
organisations and civilian
populations
Increased risk of injury or
death from weapons
Health, security and foreign policy 19
a sum larger than the GNP of three-quarters of the 207 economies in the world.
82
This makes illicit drug tra?cking one of the biggest commercial activities in the world
and a major source of ill health. Importantly, globalisation has fuelled a restructuring
and growth of the illicit drug trade since the 1960s when there occurred a surge in
demand in the US and Western Europe. The drug trade has increasingly become a
transnational phenomenon, benefiting from global communications, transportation
and financial systems (to launder proceeds).
Second, there has been a growing illegal trade in the smuggling and tra?cking
of people since the end of the Cold War. Definitions of undocumented migration
vary and reliable data is di?cult to obtain. Yet it is now widely believed that
smuggling and tra?cking of people is worth an estimated US$6 bn, making it
more lucrative than the global trade in illicit weapons. The UN has estimated that
four million men, women and children become victims of tra?cking each year.
83
Some are captives taken as payment by mercenary armies. Some, especially young
girls, are sold by their destitute families. Many are duped into slavery by
fraudulent employment brokers who promise legitimate employment. In Europe,
for example, there has been a significant increase since the mid-1990s in the
tra?cking of women from eastern Europe for forced prostitution. The trade is
closely linked to organised criminal groups who are experienced at handling illicit
drugs, weapons and other contraband.
84
In the US it has recently been estimated
that 6 million out of a total 27 million foreign-born residents were believed to be
?illegal aliens?, while Moscow is believed to have 400,000 undocumented foreign
workers.
85
In the UK, high-profile cases of deaths of undocumented migrants hint
at the degree of organised smuggling of migrants currently taking place across the
English Channel.
86
The health implications of this growing trade arise from the
risks to the health of the illegal migrants themselves, both during transit and at
the point of destination where access to health care can be restricted. Illegal
migrants may live in impoverished conditions, increasingly the risk of infections
such as tuberculosis. They may engage voluntarily or otherwise in commercial sex
work which increases the risk of contracting sexually-transmitted diseases. The
neglected health needs of this population can, in turn, pose public health risks to
the wider host community.
87
82
Paul Stares, Global Habit: The Drug Problem in a Borderless World (Washington, DC: Brookings
Institution, 1996); and UN O?ce on Drugs and Crime, Global Drugs Report 2000 (New York:
United Nations, 2001). See also UN O?ce on Drugs and Crime, Drugs and Crime Trends in Europe
and Beyond, 29 April 2004, available at: ?http://www.unodc.org/pdf/factsheets/
unodc_factsheet_eu_29?04?2004.pdf?, Global Illicit Drug Trends 2003 available at:
?http://www.unodc.org/pdf/trends2003_www_E.pdf?, both accessed on 13 April 2005.
83
Interpol, People Smuggling: Challenge and Response, Interpol Fact Sheet (2004), available at
?www.interpol.int?.
84
USAID, ?Women as Chattel: The Emerging Global Market in Tra?cking?, Gender Matters
Quarterly, 1 February 1999.
85
S. Camarota, Immigration from Mexico: Assessing the Impact on the United States (Washington,
DC: Center for Immigration Studies, 2001); P. Stalker, Workers without Frontiers: The Impact of
Globalization on International Migration (Boulder, CO: Lynne Rienner, 2000).
86
Collin and Lee, Globalisation and Public Health.
87
While the health risks arising from undocumented migration are real, the authors do not support
policy proposals that target all migrants for testing, underpinned by threats of deportation or
exclusion. Rather, such measures will discourage at risk populations from identifying themselves,
putting the host population at further risk. See Collin and Lee, Globalisation and Public Health for a
discussion of this issue.
20 Colin McInnes and Kelley Lee
Third, there has been an increase in the smuggling of contraband (including illegal
weapons sales), some of which have direct health implications. Not the least of these
is tobacco which causes an estimated 4.9 million deaths annually, a figure expected to
rise to 10 m by 2030. The transborder problem of cigarette smuggling has become a
major problem in the context of the globalisation of the tobacco industry, including
a clear shift from traditional markets in North America and Western Europe to the
developing world. Smuggling occurs when cigarettes manufactured legally are
exported without domestic taxes, for sale abroad. These untaxed cigarettes are then
illegally brought back into the producer country to be sold at a cheaper price on the
black market. There is growing evidence that transnational tobacco companies are
themselves implicated in smuggling operations, resulting in litigation and public
investigations in the US, UK, Canada and elsewhere.
88
Smuggling enables tobacco
companies to give international brands a local market presence and to undermine
e?orts by governments to raise cigarette taxes. It is estimated that one-third of the
total number of cigarettes consumed worldwide are smuggled.
89
The scale of
smuggling operations, the complex transborder networks of supply and distribution
that exist, the central role of organised crime in such activities, the laundering of
financial proceeds through the global financial system, and di?culties of national
authorities in preventing such activities, make tobacco smuggling an issue that defies
national boundaries.
The e?ective control of illicit activities such as these is in the shared interests of the
health, foreign policy and security communities (see Table 1). The increased supply
of illicit drugs,
90
greater availability of lower-priced (untaxed) cigarettes and alcohol,
and public health risks to and from undocumented migrants have clear adverse
impacts on health; the challenges of controlling illicit activities have been a
long-standing source of foreign policy tensions; and the substantial funds earned
from illicit activities have been found to support the activities of known terrorist
organisations and organised criminal networks, creating serious security risks. So far
such issues have remained outside emerging policy agendas, taxing the multiplicity of
government ministries involved to work more closely together across sectors and
internationally. Yet, with the continued acceleration of globalisation, it is likely that
these issues will increase in significance.
As with health as a bridge to peace, the evidentiary base for understanding the
impact of illicit activities on health, foreign policy and security remains slim. This is
largely due to the di?culties of obtaining accurate and comprehensive data.
Concerns about greater cooperation between the health and intelligence communities
can also prevent the development of e?ective and appropriate policy measures, with
medical professionals largely unwilling and unable to play a role in national security
or law enforcement (for example, medical sta? reporting of undocumented migrants
seeking treatment). Nonetheless, there is growing research on health-related illicit
88
F. Abrams, ?Tobacco firm may face inquiry over ??smuggling?? ?, The Guardian, 17 February 2000;
and L. Joosens, Tobacco Smuggling, Tobacco Control Factsheets, International Union Against
Cancer, 2002, available at ?http://factsheets.globalink.org/en/smuggling.html?.
89
P. Jha and F. Chaloupka (eds.), Tobacco Control in Developing Countries (Oxford: Oxford
University Press, 2000).
90
This includes the illegal production and consumption of narcotics, the growing manufacture and
distribution of counterfeit pharmaceuticals, and the poorly regulated use of legal drugs such as their
sale on the black market. The latter two raise concerns about the undermining of therapeutic
e?ectiveness of existing drugs, resulting for instance in the spread of drug-resistant infections.
Health, security and foreign policy 21
activities based on interviews, survey data and documentary sources.
91
More detailed
research on what are the trends in illicit activities, what populations are at risk, and
how the health and security communities can work more coherently to address
shared needs, is urgently needed.
Conclusion
This article has examined the manner in which the public health community has
begun to develop a relationship with the foreign and security policy communities. Its
focus has been on the issues which have begun to appear on this new agenda, and it
has made two key arguments. The first is that the agenda has been dominated by the
concerns of foreign and security policy, not of global public health. The relationship
between the two policy communities tends to be unidirectional, namely how selected
health issues may create risks for (inter)national security or economic growth, and
how therefore they might be issues of concern to foreign and security policy. The
agenda is not one of how foreign and security policy can promote global public
health.
92
Australian Foreign Minister Alexander Downer?s 2003 comment that global
health could no longer be confined to health ministries, but must also be the concern
of foreign ministries, implicitly suggests that what is driving this relationship are
foreign policy concerns for protecting the national interest, not a concern for
improving global public health.
93
Moreover the interests of the West are prominent
on this agenda. Although this is not intended to dismiss humanitarian concerns in the
West for health crises elsewhere, particularly HIV/AIDS, attention has generally
focused on how health risks in the developing world might impact upon the West.
The second argument is that the agenda to date has been dominated by two issues:
infectious diseases (including HIV/AIDS as a special case) and bio-terror. We argue
that this is a narrow framing of the agenda and o?er two examples of other issues
which might be accorded greater attention. The first of these concerns the relation-
ship between health and internal instability. Although this has received some limited
attention it has failed to achieve particular prominence. This is despite continuing
concerns in both the foreign and especially the security policy communities over
internal instability, and the recognition in the public health community that internal
instability is often detrimental to public health. The second, illicit activities, has
received almost no attention despite very clear shared interests between public health
and foreign and security policy on these issues.
This emerging relationship between public health, and foreign and security policy,
however, raises a number of other questions beyond simply the manner in which the
current agenda is framed. Although these wider questions are not the focus of this
article, they are of broader concern to the issues raised here and it would therefore be
91
See for example Je? Collin, Eric LeGresley, Ross MacKenzie, Sue Lawrence and Kelley Lee,
?Complicity in Contraband: British American Tobacco and Cigarette Smuggling in Asia?, Tobacco
Control, 2004, 13 (Supp. II): ii 104?ii 111; Joanna Busza, Sarah Castle and Aisse Diarra, ?Tra?cking
and health?, British Medical Journal, 328 (2004), pp. 1369?71; and Guilhem Fabre and Michel
Schiray, Globalisation, Drugs and Criminalisation (Paris: UNESCO, 2002).
92
The notable exception to this is the FCTC, though as noted above this proved an uphill task for the
public health community. See Collin and Lee, Globalisation and Public Health.
93
Downer, ?Why Health Matters in Foreign Policy?.
22 Colin McInnes and Kelley Lee
remiss not to identify them. In particular we would highlight two questions. The first
concerns the agenda itself and, in particular, the lack of conceptual clarity over what
WHO and others term ?global health security?. The growing awareness of links
between the various interested sectors has led to a series of meetings in recent years,
regionally and internationally, and from the G8 to more locally based initiatives.
These meetings have in turn led to initiatives such as the Global Fund, Millennium
Development Goals and FCTC. The existence of some common ground, however,
has obscured more fundamental di?erences stemming from the lack of a shared
conceptual understanding of health and security. In particular there is a lack of
clarity over two questions crucial to the framing of a future agenda: whose health and
whose security is at risk; and what issues should be part of the global health security
agenda (and which are not).
94
Second, there remain unresolved questions over how the two sectors should
cooperate and, indeed, whether such cooperation is in their mutual interest. Although
some within the public health community have welcomed a closer relationship
positively, in that it could give global health issues greater political prominence
followed by more action and resources, others view this as problematic because of the
skewing of the agenda. This emerging agenda leans inappropriately towards certain
issues which, while important to the foreign and security policy communities, are not
of highest priority for the public health agenda. Moreover, there are concerns over
the role of medical personnel and other health professionals if this link is drawn more
tightly. Specifically, could security or other political concerns impinge inappropri-
ately upon the actions of health personnel? The tensions over reporting of undocu-
mented migrants by health personnel is a good example. From the perspective of
immigration policy or, given recent anti-terrorism concerns, security or law enforce-
ment, health personnel may be required to report undocumented migrants. However,
from a public health perspective, such actions not only politicise the role of health
personnel, but are contrary to basic public health principles and good practice.
Addressing these questions is beyond the scope of this article. Nevertheless, how they
are answered is likely to have an e?ect upon which issues form part of the emerging
agenda and which do not. This article suggests that this agenda so far is narrowly
conceived, prioritising the foreign and security policies of Western countries. Without
a broader understanding of the shared challenges facing the health, foreign policy
and security communities, responses could ultimately be counter-productive to all
concerned.
94
We attempt to address these questions in Colin McInnes and Kelley Lee, ?Health and Security?,
Politik 8:1 (2005), pp. 33?45.
Health, security and foreign policy 23