Health Security and Bad Governance

Sometimes it helps to read the end of a news story first.

An article by Adam Nossiter published yesterday in the New York Times ("Cholera Epidemic Envelops Coastal Slums in West Africa") concludes with an observation from Jane Bevan, a sanitation specialist working with UNICEF in West Africa: "We know governments have the money for other things. I'm afraid sanitation is never given the priority it deserves."

The article describes a serious cholera outbreak centered in the slums of Freetown, Sierra Leone and Conakry, Guinea. Sierra Leone reports over 11,600 cases of cholera since January with 1,000 new cases each month. According to Doctors Without Borders, 250 to 300 people have died in Freetown and Conakry since February.

Cholera is a highly contagious disease caused primarily by exposure to the feces of an infected person. It causes vomiting and diarrhea leading to dehydration and electrolyte imbalances that, if not treated with rehydration therapy, may be fatal.

Heavy rains, which have caused flooding in shanty towns where sanitary toilets are rare, must be listed among the immediate causes of this outbreak. The existence of the shanty towns in Freeport and Conakry, however, owes much to a decade of civil war in Sierra Leone that drove many people from the countryside to the cities and to over fifty years of dictatorship in Guinea with similar effects on the distribution of population there. But if Jane Bevan is correct, these causes of the cholera outbreak could have been averted--or at least significantly mitigated--if the governments of Sierra Leone and Guinea had allocated resources in a way that took the health of their people into account. And this is something that Article 25 of the Universal Declaration of Human Rights seems to require. (See also Article 12 of the International Covenant on Economic, Social and Cultural Rights.)

The primary responsibility of government--anywhere--is to ensure the security of its citizens. This responsibility is commonly, but improperly, framed in terms of national security with a focus on external military threats. But the most serious threats affecting people all over the world--that is, the threats most likely to kill or threaten the well-being of people, even in a state like Sierra Leone that has recently emerged from conflict--are not generally military threats. Disease, poverty, environmental degradation, climate change, political repression, and a host of other "soft" threats are what people must face more often than the "hard" threat of war. It is important, consequently, for governments (even in the developed world) to shift their focus from national security to human security.

Infectious Disease, Human Security, and Social Media

The concept of human security is based, in part, on a widening of our understanding of what constitutes a security threat beyond the traditional focus on military threats in the concept of national security.  Human security includes concern for military threats, but it also encompasses threats related to food shortages, pollution, poverty, and disease.  Health insecurity, in fact, is one of the most persistent and problematic of all forms of insecurity if we judge such things in terms of lethality and impact on quality of life.  Consider that the wars of the twentieth century were responsible for roughly 100 million deaths while smallpox (now eradicated) killed somewhere between 300 and 500 million people during the same period.

One of the keys to gaining the upper hand in the war with microbes is understanding--and responding rapidly--to the spread of infectious diseases.  For humans to continue with business as usual when communicable diseases are running rampant among the population is to give a tremendous assist to the bugs.  Especially now, when, for the first time in human history, over half the world's population lives in urban areas, failing to get a flu shot, to cough into a sleeve, to stay home when running a fever, or to avoid crowded spaces can jeopardize the health--and sometimes the lives--of others.  The problem, however, is that sometimes infectious diseases are spread before their human carriers even know they are sick.  By the time the coughing, sneezing, vomiting, or other unpleasantness arrives, the viruses causing the symptoms may have already been spread.  Infectious diseases are often stealthy.

The solution, as public health experts have known for a long time, is to ensure that healthy people take precautions against the spread of disease as soon as those less fortunate begin to manifest symptoms.  The key to my continued health, in other words, is to take note of your illness and to avoid you (like the plague, as it were).  But if I take note of your illness only after you've shaken my hand or sneezed in my general vicinity, it's too late.  I may already have what you have.  The key, therefore, is public monitoring and reporting of the fact that an infectious disease is making its way through the local population.

Public health authorities in every state of the United States and in most of the world's countries collect information regarding the spread of infectious disease.  In fact, laws mandate that hospitals and clinics report on the incidence of various diseases that have been diagnosed and treated.  Massachusetts, in 1874, was the first state in the United States to initiate the systematic reporting of illness by physicians.  Michigan, in 1883, was the first to require such reports.  Today, the Centers for Disease Control and Prevention (CDC) collects aggregate data on disease and mortality from the states.  The World Health Organization (WHO) performs a similar function on the global level.

Reporting of this type is essential for epidemiologists.  It can help health care providers to know what is happening when people start appearing for treatment with symptoms that could be explained by a variety of different conditions.  It can allow pharmaceutical companies to know when to ramp up production of particular vaccines and where to ship those that they have produced.  But it may not be timely enough to let me know that I shouldn't ride the subway into work tomorrow because a bunch of people in my city starting coughing and sneezing in just the last 24 hours and some of them are likely to tough it out and go to work tomorrow in spite of the fact that they're spewing pestilence.

This is where social media may help.  A new website call Sickweather (with changing mottoes that include "cough into your elbow," "we be illin'," and "don't touch me") is attempting to map the spread of various illnesses in real time by collecting the clues we post on Facebook, Twitter, and other social media regarding our state of health.  So when people Tweet about being up with a sick kid all night or update their Facebook status with something like "my head is so full of mucus it could explode," Sickweather takes that information and (presumably after a "whoa, dude, TMI") includes it in the database of illness reports.  By mapping the location of those who post their health reports (when location can be determined), Sickweather is able to generate a sickweather map.  Sickweather also invites visitors to the site to log in and fill out a quick health report.  (Calling all hypochondriacs!)

There are some, ahem, bugs to be worked out, no doubt, but the concept seems to be full of potential.  John Metcalfe of The Atlantic reports on Sickweather here if you need a bit more information.

There's much to be learned about human behavior, and threats to human security, by mining our online data.  In fact, I suspect one could track (and issue warnings about) outbreaks of karaoke, wine snobbery, and Angry Birds expertise in much the same way that Sickweather is handling illness.

"Red nose at morning, sailors take warning."  Seriously, you should check out Sickweather just for its ever-changing tag lines.

First and Third

We tend to do a lot of aggregating in international relations. While this is largely unavoidable, it's worth reminding ourselves from time to time that ascribing particular characteristics to the entities we study may cause us to overlook significant variations within them. States, which are still the entities we study most intensively, are commonly labeled "free" or "unfree," "democratic" or "authoritarian," "developed" or "developing," and so on. But a "free" state may have pockets of oppression (think of the period of racial segregation in the United States) and a "democratic" state may have subunits that fail to respect democratic norms (think of machine politics in Chicago or in South Texas a generation ago). Likewise, a "developing" state may have elites who control enormous wealth (think Equatorial Guinea) and a "developed" state may have pockets of poverty that mirror conditions in the developing world.

This point has been brought home by the visit of the Remote Area Medical Foundation to Los Angeles. For one week--August 11-18--an organization that began in 1985 with the objective of bringing medical care to distant parts of the developing world is offering free services to people in Los Angeles who, because they are uninsured or underinsured, have no way to pay for the care they need. Thousands of people have lined up each day at the Forum, the former home of the Lakers, to wait for tooth extractions, eye exams, diagnoses of illnesses, and treatments for chronic conditions.

Los Angeles Times columnist (and author of The Soloist) Steve Lopez has been spending some time at the Forum. In a column today, he reports that a number of the doctors who are volunteering at the Forum have noted parallels between their volunteer experiences in the Third World and what they are seeing at the Forum. One of them, Dr. Greg Pearl, when asked to note the differences between what he has seen in the developing world and what he is seeing at the Forum said, "Here, the patients speak English."

The United States is among the "rich fat few" rather than the "skinny poor many" (to use expressions I recall from a lecture by Inis Claude), but it has its pockets of Third World conditions. One of these pockets is populated by close to 50 million people without access to routine health care. Lopez's column--which is well worth reading--is aptly titled: "At free clinic, scenes from the Third World."