As the threat of Severe Acute Respiratory Syndrome (SARS) continues to spread across the globe, countries are bracing themselves for the worst yet to come. According to recent figures, SARS has already infected more than 2,000 people and killed at least 111 in 20 countries. With no known cure in sight, medical teams have been working feverishly to contain the problem while the clock ticks away with more reported casualties. Government authorities have been deploying various strategies to cope with the silent killer. In Singapore for example, mechanisms have been quickly set in place to prevent further spread of the disease. These include quarantine of infected patients, issuing travel advisories to SARS- affected countries, immigration checks and border controls, massive public information programmes and even closure of schools.
But while Singapore and other affected countries were prompt to act, China had been severely criticised for initially playing down the seriousness of the problem and its slowness to respond to the request by the World Health Organisation (WHO) to allow its medical team to go to Guangdong where the infectious pathogen was said to have started. In a recent press statement, WHO’s Director-General, Gro Harlem Brundtland, pronounced that had the Chinese authorities acted earlier and with more openness, the outbreak of the disease would have taken a different course.
China’s belated response has been perceived as due to the authorities’ concern about economic fall-out if the information about SARS is leaked. But the slow process of silence- denial to acknowledgement and cooperation is not really surprising given the prevailing attitude towards infectious diseases. Most, if not all countries—China included—treat infectious diseases as medical problems, thus meriting a medical response. That is probably why it took four-and-a half months after the first known case of SARS before the Chinese authorities alerted the WHO. The delay was reportedly due to bureaucratic procedures to first classify SARS as a Category B disease before local health authorities would be required to report this to the central government. Then there was the problem of how to handle this type of disease, i.e. whether this would fall under the framework of the International Health Regulations (IHR) wherein reporting of infectious diseases to WHO becomes imperative.
The IHR is a global disease surveillance system which requires member states to notify the WHO within 24 hours of outbreaks of infectious diseases. WHO, however, has no enforcement power and instead relies mostly on persuasion and recommendation to encourage countries to comply. Moreover, the present IHR covers only 3 diseases—cholera, yellow fever and plague and does not cover all other emerging or re-emerging infectious diseases. As there are no multilateral arrangements to deal with global health emergencies, the lack of coordination at both local and national level in alerting the international community comes as no surprise. Several factors account for these shortcomings, two of which are highlighted below.
Attitudes and Approaches
While infectious diseases have been conventionally regarded as medical problems in a rapidly changing global environment the threats brought on by them are no longer confined to medical/health risks alone. With the outbreak of SARS, the disruption of business activities, its impact on travel and tourism and more importantly–on economic growth– are among the serious repercussions that necessitate defining the SARS problem in strategic terms.
With globalisation the scale, speed and reach of movement of people and goods are unprecedented. These movements in turn have shaped the appearance, spread and distribution of infectious diseases not just in humans but also in animals. The SARS case is instructive. There are speculations that the infectious pathogen may have come from an animal (e.g. chicken) and has managed to get into humans. In a densely populated Chinese province of Guangdong where human and animal contact is extremely close, transmission and spread of infection is much more rapid while containment of the disease becomes more difficult. Compounded by the massive movement of people in and out of China and the ease of international air travel, the reach of the SARS disease to cover more than 20 countries is not surprising. Indeed, in a globalised world, no community can be entirely immune from these contagious diseases.
SARS is certainly not the first case that illustrates the nexus between movement of people and goods with the nature and spread of infectious diseases; the HIV/AIDS pandemic is still present. There is still a wide gap between the extent of the HIV/AIDS threat and an adequate and cohesive international action. Within a few years after its discovery, HIV/AIDS had spread to every continent and every country. So far, 25 million people have died of AIDs and the about 3 million people a year continue to succumb to the disease. Yet there is still no concerted international action to deal with it.
In 2000, the United Nations Security Council declared AIDS as a national security threat, followed by similar political endorsements at the G-8 meetings in Okinawa and Genoa. But despite these initiatives, AIDS, tuberculosis, malaria and now SARS are still seen by many countries as health diseases/problems, not as human security threats. When the United States first pushed for HIV/AIDS to be discussed in the Security Council, many nations protested for procedural reasons—they felt that the Security Council was not the appropriate forum for what are perceived as “social and economic issues”.
However, unless the linkage between infectious diseases and human security is recognised, most countries will still “medicalise” infectious diseases like SARS rather than “securitise” them until the outbreak of the disease(s) reaches alarming proportions. The experience of Sub-Saharan Africa with AIDS reveals that the socio-economic and political effects are more devastating than the effects of war.
Thus, going beyond the medical approach to securitising infectious diseases must become more of a norm rather than an exception. In the case of SARS, this requires more than official pronouncements that SARS is a national security issue. An integrated approach with the participation of various ministries, government agencies and the medical sector in coping with SARS is an important step. Singapore has adopted such an approach while others like Malaysia, Indonesia and Thailand are following suit.
Iceberg of Poverty
While the linkage between infectious diseases and human security has been forcefully validated by the SARS outbreak, understanding the risks and vulnerabilities posed by infectious diseases is just the tip of the iceberg. There are underlying challenges that also need to be addressed to cope with the threats of infectious diseases. These are the absence and/or lack of basic health care and the poor health infrastructure prevalent in many developing countries. Poverty and infectious diseases are fellow travellers. The risks of poverty-related diseases are compounded by malnutrition and environmental threats, especially the lack of clean water and sanitation. Add in crowded conditions and poor hygiene, these become perfect breeding grounds of infectious diseases.
Strategies for Protection and Empowerment
Coping with infectious diseases requires multi-dimensional responses. Among the imperatives is the importance of building a good mechanism for global disease surveillance and control. The Global Outbreak Alert and Response Network was initiated by the WHO in 1997 and maintained by Health Canada. It has a network of 100 existing laboratory and disease reporting systems. However, for this to be successful, cooperation at both local and national level is crucial. For new infectious diseases like SARS that has several unknowns in epidemiology and treatment—the race to discover these things requires multilateral coordination at many levels.
Unless mindsets and attitudes are changed to regard infectious diseases as more than a health problem, it would be difficult to get certain governments to act promptly and decisively. Health must be approached as a security priority at all levels. And, governments must be made accountable to both the local and international community in ensuring health and security. The globalisation of health risks also means that leadership must be exercised by the United Nations with the support of the global public. Reducing health threats to security will therefore require comprehensive cooperation among diverse actors and nations.
The other equally important issue is the need to develop the public health system, especially among the poorer communities who are the most vulnerable The WHO Commission on Macroeconomics and Health has reported that of the 17.7 million people who die every year from infectious diseases, about half could actually be saved had basic health care been provided. It is said the way to save lives in the future is not dependent on discoveries today but more about getting the basics right, e.g. getting tetanus shots for children…and providing safe drinking water for more villages. Perhaps this situation is best encapsulated in the remark of a Cambodian physician who said that “in our country, the real killers are poverty, ignorance, fear and corruption…disease just administers the coup de grace.”
About the Author
Dr Mely Caballero-Anthony is an Assistant Professor at the Institute of Defence and Strategic Studies
Commentaries / East Asia and Asia Pacific / Non-Traditional Security / Southeast Asia and ASEAN
Last updated on 02/10/2014