National Security, Health, and Responding to Emergencies

10 October 2016, 2315 EDT

Why don’t government officials respond to global health emergencies the same way that they respond to national security crises? This is the question Congresswoman Rosa DeLauro (D-CT) raised last week. She was speaking at the public launch of a new report by the Brenthurst Foundation on international society’s failure to respond to the Ebola outbreak in West Africa in a timely manner—but much of the conversation focused on the current response to Zika.

If military officials said they needed $1.9 billion to prevent a global crisis, she argued, Congress would not hesitate to approve the money. Unfortunately, health emergencies don’t receive the same level of attention. “Why aren’t we listening to the generals of public health?” she asked. Instead of making the long-term investments to strengthen health systems and improve detection and treatment capabilities, DeLauro noted, we lurch from one crisis to another.

I sympathize with DeLauro’s comments (check out my book about global health governance—it makes a great gift, I swear), but we need to disentangle what she is saying. Rep. DeLauro is actually talking about two different issues, and those two issues raise different concerns for international society.

First, there’s the question of whether health emergencies are like other international security crises. In the late 1990s and early 2000s, academics and policymakers argued that health crises were national security problems. A disease like AIDS could hollow out militaries, increase societal instability, and destabilize governments—all of which would lead to traditional sorts of international security crises. A 1999 National Intelligence Estimate called infectious disease a rising challenge to US and international security, while a 2002 National Intelligence Estimate highlighted how rising HIV/AIDS rates in five key countries could destabilize international order. The United Nations Security Council even held a special session in 2000 devoted to HIV/AIDS’ threat to global peace and security.

Here’s the problem, though: the dire predictions have not come to pass. This is not to diminish the widespread suffering HIV/AIDS and other infectious diseases have caused, nor does it ignore the tremendous work governments and nongovernmental organizations have done to improve access to health care and drugs. Rather, the issue is that infectious diseases like HIV/AIDS, Ebola, and Zika have not caused states to collapse. Even the National Intelligence Council backed off its initial claims about AIDS’ threat to national and international security in a 2005 discussion paper. This isn’t to say that infectious disease outbreaks aren’t problems or shouldn’t be addressed within international society; it is simply an acknowledgement that the nature of the challenge they pose is different from traditional national security threats.

Framing health emergencies as national security crises may bring attention to them, but they may not bring the right sort of resources or focus. A national security frame brings to mind an us-v-them mentality, casting those who are infected as the enemy. It can also encourage stigmatizing the sick, which in turn discourages people from seeking treatment or accessing services. Thus, trying to frame a disease outbreak in national security terms can actually exacerbate the problem it is ostensibly trying to address.

Second, DeLauro highlights the difference between short-term emergency responses and long-term capacity building. The more capacity that states have to provide health care, conduct ongoing surveillance to identify outbreaks before they spread far, and deal with emergencies, the less likely infectious disease epidemics become. This is a good thing. Indeed, this is exactly why the International Health Regulations require states to develop and maintain disease surveillance capacities.

Unfortunately, donor states appear far less interested in supporting these long-term efforts at strengthening health care systems and enhancing disease surveillance capabilities. Of the more than $35 billion pledged for global health programs in 2015, less than 8 percent goes for health systems strengthening. Even though stronger health systems are more beneficial overall, governments tend to “stovepipe” their donations to disease-specific programs—giving money specifically for malaria, for instance. These sorts of allocations tend to reflect the priorities of the donors rather than the recipients, and they create narrow programs that may not help the health system as a whole. As Adia Benton points out in her book HIV Exceptionalism, disease-specific programs distort national priorities and essentially create a hierarchy of disease.

This is exactly the sort of problem the World Health Organization has faced. More than 80 percent of WHO’s budget comes from voluntary pledges—money that states choose to give to WHO, but only for specific programs. As a result, immediately before the Ebola outbreak, WHO was forced to cut its budget for both outbreak and crisis response and infectious diseases while increasing its spending on noncommunicable diseases. This wasn’t a reflection of WHO’s priorities, but rather the priorities of the donor states.

If building stronger health systems is so important, why don’t states fund it? It’s simply not sexy. Its effects are more diffuse. It is harder to quantify the results. It doesn’t have the same cachet as deploying emergency funds to address a specific outbreak. Donors instead seem interested in more short-term, piecemeal approaches instead of long-term, integrated systems.

There is nothing today that prevents countries from putting more of their global health funding toward health systems strengthening. What needs to happen, though, is a shift in thinking, focusing more on the long-term strategy as opposed to the short-term responses.