Human Security in Disease and Disaster [1 ed.] 0367652978, 9780367652975

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Human Security in Disease and Disaster

This timely new textbook lays bare the ways in which disease and disaster can turn politicians into global leaders or national liabilities. It explains the impact of crises on development and human security and explores how states and societies can respond more effectively. Written primarily for the student of politics, but also drawing from public health, public policy, and environmental studies, the book investigates the threats posed by disease and disasters, and demonstrates how states can shape the ways in which these crises unfold. Case studies include: • Diseases such as Covid-19 and Ebola • “Natural” disasters such as Typhoon Haiyan and the 2010 Haiti earthquake • Manmade disasters such as the Yemen and Congo civil wars or famine The book delves deep into how state response to these challenges can impact political and economic stability and ends by exploring the role played by international institutions and international cooperation in addressing common challenges. This introductory textbook is perfect for undergraduate and masters courses exploring the expanding politics and human security issues surrounding disease and disasters. It will also be of interest to think tanks and policy communities looking for fresh insights to bring into professional practice. Natasha Lindstaedt is Professor and Deputy Dean of Education for Social Sciences, University of Essex, UK.

Human Security in Disease and Disaster Natasha Lindstaedt

First published 2022 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2022 Natasha Lindstaedt The right of Natasha Lindstaedt to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Lindstaedt, Natasha, author. Title: Human security in disease and disaster / Natasha Lindstaedt. Description: Abingdon, Oxon ; New York, NY : Routledge, 2022. | Includes bibliographical references and index. Identifiers: LCCN 2021012598 (print) | LCCN 2021012599 (ebook) Subjects: LCSH: Human security. | Disasters. | Diseases. Classification: LCC JC576 .L56 2022 (print) | LCC JC576 (ebook) | DDC 362.1/042—dc23 LC record available at https://lccn.loc.gov/2021012598 LC ebook record available at https://lccn.loc.gov/2021012599 ISBN: 978-0-367-65301-9 (hbk) ISBN: 978-0-367-65297-5 (pbk) ISBN: 978-1-003-12880-9 (ebk) DOI: 10.4324/9781003128809 Typeset in Goudy by Apex CoVantage, LLC

To René

Contents

List of tablesix List of boxesx Acknowledgementsxi Introduction

1

PART I

Key challenges11   1 Human security, health, and disaster

13

  2 Infectious diseases

42

 3 Disasters

67

PART II

Drivers of disease and disaster89   4 Globalization, climate change, and disease

91

  5 Globalization, climate change, and disasters

121

PART III

Disease and disaster vulnerability135  6 Poverty

137

  7 Conflict

164

viii  Contents PART IV

Impact of disease and disaster185   8 Economic impacts

187

  9 Social and political impacts

216

PART V

Response243 10 Authoritarian regimes, democracy, and populism

245

11 The state and disease management

273

12 The state and disaster management

300

13 Global health governance

317

14 Disaster governance

343

Conclusion

362

Glossary366 Index372

Tables

1.1 2.1 2.2 4.1 6.1 6.2 8.1 10.1

Pillars of human security Top causes of death in developing countries Modes of transmission of infectious diseases Zoonotic diseases Top ten countries for disaster deaths in absolute numbers, 1996–2015 Top ten countries for disaster deaths per 100,000 inhabitants, 1996–2015 Ten most costly disasters Selected countries and the percentage of deaths due to infectious disease, maternal, neo-natal, and nutritional diseases 10.2 Differences between populist authoritarian and authoritarian leadership 12.1 Most powerful earthquakes since 1950

17 47 50 99 153 154 200 246 258 305

Boxes

1.1 1.2 1.3 2.1 2.2 2.3 3.1 3.2 4.1 4.2 5.1 5.2 6.1 6.2 6.3 6.4 7.1 7.2 8.1 9.1 9.2 10.1 13.1 14.1 14.2

History of human security concept Sustainable development Biological weapons Pandemic history Non-communicable diseases What is a flu pandemic? 2004 Tsunami Hurricane Maria Zoonotic diseases Antimicrobial resistance Fires in the Amazon Climate change and the developing world Curse of the Tropics? Neglected Tropical Diseases Gender, disease, and disaster Colonialism and infectious disease Conflict and HIV/AIDS Complex emergencies Disease, disaster, and education Knock-on health effects of a pandemic Psychological impact of disease and disaster Natural resources: curse or blessing? SARS and global cooperation Disaster governance and early warning systems for tsunamis Famine early warning networks

19 25 30 44 46 48 69 71 98 106 123 128 140 142 144 146 168 169 197 225 230 252 327 352 356

Acknowledgements

Thank you to the team at Routledge and Taylor and Francis Group for agreeing to support this book. In particular, thank you to Helena Hurd for her enthusiasm for the idea. Thank you to the Government Department at the University of Essex and the students in Social Science for being so interested in a module on this topic. Thank you to my parents, Jeff and Yvette, for their constant support. Thank you to Annika and Karolina for being so entertaining during lockdown and for giving me the time to work on the book. And finally, thanks to René for everything!

Introduction

2020 was an exceptional year. On March  11th, the World Health Organization (WHO) officially declared that the world was in the midst of a pandemic. Covid-19 has completely besieged states, which have faced difficult decisions about how to contain and mitigate the crisis. The outbreak has grounded flights, stifled economic growth, and completely overwhelmed hospitals. Almost every country around the globe has been affected by a microscopic virus. Borders, military power, and even economic capacity have become irrelevant for countries, while at the same time race, socio-economic status, and co-morbidities have played an important role in determining who would succumb to the disease. The media and governments have offered a plethora of reports about how to cope with the crisis and address the symptoms, but little information has been provided about Covid-19’s root causes. Left out of the conversation is the role of unbridled development, massive changes in food production, greater encroachment into natural habitats, and persistent civil war and instability in spawning more disease outbreaks (and more disasters as well) (Heymann et al., 2015; Weiss and McMichael, 2004). Instead, the attention has focused on the race to find a vaccine. Undoubtedly the achievements of science in developing vaccines to target Covid19 have been incredibly impressive. But this pharmaceutical response neglects the reasons why diseases spark and the underlying factors that single out certain communities more than others. Destruction of our environment and ensuing climate change, poverty, and inequality have played a far more substantial role than political actors have openly admitted. This is in spite of the warnings from the United Nations’ Intergovernmental Panel on Climate Change (IPCC) – that climate change is the greatest existential threat facing humanity and should be treated with greater urgency. However, because climate change is not always experienced directly by the Global North, adequate progress to address this issue has yet to take place. The IPCC claims that limiting global warming to 1.5°C compared to 2°C could go hand in hand with a more equitable society, while also having clear benefits to humans and natural ecosystems. But while taking a sustainable approach to development has been touted for some time now, the global community has not done enough to make meaningful and necessary changes. In addition to the failure to address climate change, government priorities when it comes to health security have also been underwhelming. Previous reports had built scenarios that governments should have been paying closer attention to, with the WHO repeatedly informing its member states that they were not prepared to deal with a global pandemic. Even after the SARS, swine flu, and Ebola pandemics, global health security was marginalized again. Pandemics and epidemics, and to some extent disasters, have some political elasticity. They only increase in global political importance when we are in the midst of one. As these crises fade, their political importance also diminishes. The Covid-19 pandemic has illustrated that

DOI: 10.4324/9781003128809-1

2  Introduction the spread of infectious disease outbreaks has serious political and economic ramifications, and yet it is not clear that the world will take a different approach to health security in the aftermath. For the moment, however, global and public health and more specifically the challenges of dealing with infectious diseases have been brought to the forefront for policymakers and governments. The pandemic had spurred some leaders to declare to their publics that they were ‘at war,’ while in some cases the military was brought in to provide logistical support. At the same time, never before had so many scientists, researchers, and policymakers been focused on resolving one single issue. In spite of these efforts, progress in global health cooperation and prioritizing health security may be short-lived. Some scholars have noted that global health is largely focused on protecting the world economic order and geo-political stability (Benatar et al., 2009; Heymann et al., 2015; King, 2002; Sell and Williams, 2020). As such, global health governance is more concerned with diseases that interrupt trade, manufacturing, and tourism. Top priorities are maintaining the health of military personnel, ensuring that multi-national corporations are productive, and that travellers and expats are secure. If this is the approach to health and disaster security, this makes it all the more difficult to address the issues of human security. A human security approach should in theory shift priorities away from the needs of powerful nation-states and closer towards the needs of the most vulnerable. This would necessitate examining not just who is the most vulnerable but why. The main diseases that affect the poor are the same diseases that are expected to worsen with climate change, such as diarrhoea and malaria. Children are the most at risk to these types of shocks, which often has an irreversible impact on their ability to learn and to earn future income. Thus, more than ever, there is greater need for a one health approach which recognizes the interconnectedness of humans, animals, and environmental health, and that takes into account the developmental drivers of disease vulnerability. It’s also important to acknowledge the irrelevance of borders when it comes to health security threats. Vaccine nationalism will pose an issue in achieving global health security. While the world momentarily celebrates the announcements of effective vaccines to target Covid-19, we are also learning of new variants that are more infectious and possibly more fatal. As countries race to vaccinate their populations, it becomes clear that some players have a huge advantage. Most countries around the world do not have their own domestic vaccine production capabilities. This means that as vaccines become available, there may not be enough supply to meet global demand. While high income countries may believe that this will have a limited impact on their citizens, as low-income countries struggle to vaccinate their populations, new variants may form that will become impervious to pharmaceutical interventions. The pandemic has already illustrated that a state-centric approach will backfire. The same can be said of disasters, especially those related to climate change, such as droughts, wildfires, storms and floods. The intensity, duration, and to some extent the frequency of climate-related disasters are on the rise, though disproportionately affecting the Global South. Bangladesh, for example, is one of the most climate-vulnerable countries in the world and faces frequent storms and flooding. In November of 2019, Cyclone Bulbul, which was only a Category 3 storm, slammed the coast. And though there were only 41 fatalities (far fewer than with past cyclones), over 72,000 metric tons of crops were lost, worth a total value of $31 billion (Daily Bangladesh, 2019). The loss of crops has an impact on a country that is already food insecure, but also on those it trades with. Climate change in

Introduction  3 Bangladesh and the threat of constant storms generates more eco-refugees and internally displaced persons (IDPs) that puts pressure on already overcrowded urban areas (Ahsan, 2019; Akter, 2009; Chaturvedi and Doyle, 2010). It may appear that massive storms that hit Bangladesh have no impact elsewhere, but the interconnected nature of the world today demonstrates that this view is short-sighted. Failure to address climate change will potentially result in more instability and displacement. Though under-prioritized, in many ways, disasters constitute a major breach of security. They disrupt the normal functioning of society and impede the ability to cope. Disasters also can plunge vulnerable groups deeper into poverty, creating poverty traps. In addition to poverty, disasters have other unfortunate knock-on effects. Infectious diseases often follow, creating complex humanitarian emergencies. Given how common disasters have become, it is all the more surprising that disaster preparedness involves being ready to respond after a disaster hits, rather than prevention – either long term by tackling climate change or short term by engaging in extensive disaster risk mitigation. Given the changing and interrelated nature of threats to the world today, the book uses a human security approach to better understand what constitutes a threat, where threats exist, and what groups are most likely to be affected and why. In doing so the book examines pre-existing approaches to dealing with security and identifies some of the errors of these approaches. Where possible, the book also offers solutions that are grounded in evidencebased studies. The book explains how threats compound one another and create human insecurity traps, which can only be attended to by turning security studies on its head. This requires shifting priorities about what security means, and the role that the past ‘solutions’ to insecurity play in generating greater insecurity and vulnerability. Though there are many different issues that people confront on a daily basis, we focus on health security and disaster security, both of which are related to environmental security. As the book will show, the impacts of health and disaster insecurity have far-reaching effects on food security, personal security, community security, economic security, and political security. Many crises are complex, overlap, and spill into all aspects of people’s lives. The book argues that the best way to tackle these problems is through an approach that emphasises sustainable development, prevention, and good governance. The book also acknowledges that there is an important role to be played by major international actors in global health and disaster governance. Though these actors have made errors in managing global health and disasters, the solution is not less coordination; instead, it’s important to find ways to make institutions and organizations more effective. Additionally, while it may seem that a public health issue would be irrelevant to students of political science, the Covid-19 crisis has demonstrated just how interrelated the challenges facing governments are to other disciplines. Concerns of public health and natural hazards will be increasingly important to governments as they crossover to impact a host of different areas including development studies, disaster studies, environmental studies, humanitarian studies, human rights, public health and public policy, to name a few. The global effort to combat the crisis illustrates the importance of inter-disciplinary approaches to understanding the key issues, threats, and challenges facing humanity. This book attempts to capture the intersection of development studies, comparative politics, and human security studies. While the book will explore the lessons from public health, public policy, and environmental studies, the book is geared towards the student of politics who wants to better understand the threats posed by infectious diseases and disasters and emergencies, the role of states in handling these challenges, and the role

4  Introduction of international actors in cooperating to mitigate these threats. In doing so the book also contemplates how diseases and disasters impact regimes and how states can shape the way these crises unfold. One of the interesting lessons of the coronavirus pandemic was that, regardless of wealth and power, the disease could bring countries to their knees. But this is not the case with most infectious diseases and disasters which have had an overwhelmingly negative impact on the developing world. It is therefore important to look at the reasons as to why this is the case, which requires an exploration into the challenges facing developing countries. In doing so, the book incorporates studies from the development literature to better understand these challenges and the relationships between disease, disaster, and development. The book begins with an introduction to development studies and human security studies. These two disciplines overlap and connect in understanding the challenges posed by disease and disaster. The book then aims to introduce the student of politics to the various different infectious diseases that have impacted humanity, along with the different disasters that have increased in frequency. The book then explores the drivers of disease and disaster by looking at the global contributors to disease and disaster and the internal contributors to disease and disaster vulnerability, namely poverty and civil war. This is followed by an investigation into the ways in which diseases and disasters impact development and the state, including economic growth, poverty, inequality, political stability, democracy, education, and societal trust and cohesion. The book then looks at the response from the state and explores best practices and the strengths of technocratic over populist forms of leadership. The book also looks at whether or not regime type matters in addressing diseases and disaster and the role of international organizations in addressing these issues. The final chapters acknowledge, however, that there have been numerous challenges for the international community in tackling health and disaster security. We explain why this has been the case, the ways in which these international regimes have evolved, and what scope there is for global cooperation. What follows is a detailed look at each chapter:

Part I: Key challenges Chapter 1: Human security, health, and disaster Chapter 1 begins by introducing the concepts of human security and development. While the concept of human security has often been conceived as an important contribution to international relations studies, it brings to light the inputs of other disciplines, such as development studies and comparative politics. In fact, the United Nations has acknowledged that human security encompasses the intersection between conflict, poverty, and development. As the General Assembly noted, human security is an approach that attempts to address cross-cutting challenges to survival and livelihood and is prevention oriented. The chapter starts by defining human security and explaining how it is measured. The chapter then offers an introduction to the literature on human security and development and explains how the challenges of diseases and disaster are captured by these literatures (Burgess and Gräns, 2012; McInnes and Lee, 2006; Rushton, 2011). We also hone in on the importance of health, disaster, and environmental security, and where approaches sit in the development and security literatures. The main aim of the chapter is to provide a foundation for understanding why disease and disaster are important security issues and why they have been under-prioritized in the past.

Introduction  5 Chapter 2: Infectious diseases Chapter 2 introduces readers to some one of the key threats to human security – infectious diseases. The chapter begins by defining diseases and pathogens. This is followed by an explanation of what pandemics/epidemics are and how they may differ from endemic diseases. The chapter explains the extent to which these diseases threaten human security and the major trends in infectious diseases. The chapter then offers an overview of the big three diseases (malaria, tuberculosis, and HIV/AIDS), along with neglected tropical diseases and other viral infectious diseases, such as Covid-19, SARS, and Ebola. In this overview, the chapter explains how these diseases are transmitted and the symptoms they carry. Chapter 3: Disasters Chapter 3 introduces readers to the major disasters that pose a threat to human security, namely floods, droughts, earthquakes, volcanoes, hurricanes, cyclones and typhoons, and wildfires. According to the United Nations, in the past several decades, disasters have affected over 4 billion people, causing $2 trillion in economic damage. Though disaster related-deaths are much lower than diseases (10,000 died in disasters in 2019), the economic losses are colossal (costing over $232 billion) and have a devastating impact on development and on those who are the most vulnerable. Over 2 million people were displaced due to disasters in 2019 alone. The chapter begins by first defining what we mean by ‘natural’ disasters, and then offers a brief introduction to the impact of disasters. This is followed by an explanation of the trends of disasters, which countries are most vulnerable to disasters and how disasters impact human security. The chapter also explains how disasters intersect with food security.

Part II: Drivers of disease and disaster Chapter 4: Globalization, climate change, and disease Chapter 4 looks at the impact of globalization and climate change on infectious disease (Banholzer et al., 2014; Wu et al., 2017). The chapter is organized into three main impacts – how global factors impact the spark of disease and disaster, the spread of disease, and how diseases and disasters are managed. Before doing so, globalization and climate change are defined. The chapter then highlights the impact of deforestation, increased urbanization, international trade, and industrial farming. As globalization drives humans to engage in behaviour that destroys traditional patterns of consumption, massive changes have unfolded that threaten eco-systems and that spark disease outbreaks. For example, in Guinea where the Ebola outbreak emerged in 2014, 20% of its forests have been lost since 1990 (Bausch and Schwarz, 2014). The chapter explains in detail how this impacts human security and highlights the intersection between environmental and health security. Chapter 5: Globalization, climate change, and disaster Chapter 5 looks at the impact of globalization and climate change on the frequency and intensity of disasters (Van Aalst, 2006). There is a scientific consensus that climate change, which is accelerated by globalization, is driving more meteorological hazards and in some cases making these natural hazards more intense. Drawing from Chapter 4’s definitions of globalization and climate change, the chapter shows why there are more intense storms,

6  Introduction droughts, and wildfires. This chapter also goes into further detail about the connection between climate change and deforestation, and what the repercussions are of this negativefeedback loop. Like the previous chapter, Chapter 5 explains in detail how natural hazards impact human security and the links between environmental security and disaster security.

Part III: Disease and disaster vulnerability Chapter 6: Poverty Chapter 6 goes over the diseases of poverty and how poverty creates disease and disaster vulnerabilities (Alsan et al., 2011; Bhutta et al., 2014; Oxlade and Murray, 2012). We start by defining different types of poverty, including abject poverty, structural poverty, and conjunctural poverty. We also explore two different approaches to understanding poverty: the basic needs approach and the capabilities approach. We then look at the relationship between poverty and disease spark, disease spread, and disease management, while also covering how poverty collides with natural hazards to create major disasters. In addition to looking at the relationship between diseases and poverty, the chapter also covers how poverty affects disaster resilience. It is often the poorest nations that are the worst affected by shocks from disasters, with more than 90% of disaster-related deaths occurring in developing countries from 1996–2015 (UN Report, 2016). This chapter explains why this is the case and the ways in which poverty threatens human security. Chapter 7: Conflict Following from the previous chapter, Chapter 7 also looks at vulnerabilities but focuses on how conflict generates greater vulnerability to disease and disaster. We start by defining conflict and state failure as a starting point to understand these relationships. The chapter then explores how conflict affects disease spark, disease spread, and disease management, while also looking at how conflicts impact disaster mitigation and response. With conflict, citizens are more vulnerable to dying from disease than battle wounds (Hoeffler, 2008). Conflict displaces large populations into overcrowded settlements with inadequate water and sanitation leading to high rates of illness. Conflict also destroys health systems and infrastructure needed to battle disease and undermines public access to education, all of which makes it much more difficult to fight diseases and bounce back from disasters.

Part IV: Impact of disease and disaster Chapter 8: Economic impacts Chapter 8 explores the global economic and macro-economic consequences of diseases and disasters. After defining what we mean by economic growth, poverty, and inequality, this chapter explains in much more detail how diseases and disasters impact development, such as rates of growth, inequality, and poverty in both the developed and developing world. Diseases and disasters lead to huge economic losses and hinder overall economic growth by cutting into labour productivity, lessoning the movement of goods, services, and people, slowing the growth of human capital in the case of the former, and destroying capital and infrastructure in the case of the latter (Cavallo et al., 2013; Hallegatte and Przyluski, 2010). This chapter goes in depth into how diseases and disaster impact economic security.

Introduction  7 Chapter 9: Political and societal impacts Chapter 9 examines the psychological, societal, institutional, and political impacts of disease and disaster. The chapter begins by examining how societies are impacted by disaster and disease, including looking at how it impacts mental health, inter-personal trust, conflict, and domestic violence (Parkinson and Zara, 2013; Pfefferbaum and North, 2020). The chapter then looks at how diseases and disasters strain the state and its capacity to provide other services and affect human capital (Ezrow et al., 2015; Price-Smith, 2001). The chapter then explores a number of questions regarding the political implications of crises and what typical patterns emerge. Before doing so, key concepts such as democratic breakdown, autocratic breakdown, and autocratization are defined. The chapter then asks, in what instances do politicians, regimes, and governments fall apart (Flores and Smith, 2013)? Why do crises often lead to democratic backsliding? In doing so the chapter helps to understand the effects of disease and disaster on community, personal, and political security.

Part V: Response Chapter 10: Authoritarian regimes, democracies, and populism Are democracies better than authoritarian regimes at managing crises posed by disease and disaster? Chapter  10 explores whether there is an authoritarian advantage and investigates how regimes react to these crises (Baekkeskov and Rubin, 2017; Burkle, 2020). To do so, the chapter first defines what we mean by democracies and authoritarian regimes. The chapter then explains what disadvantages and advantages authoritarian regimes have in managing diseases and reviews the studies that have demonstrated that democracies perform better on most health outcomes. This chapter also explores how populist leaders have responded to these crises compared to technocratic counterparts. To do so the chapter conceptualises populist authoritarianism. Though populist leadership often rises in the wake of a crisis either by imagining a crisis or overexaggerating one, once in power, populists do the opposite. They downplay the dangers and may be slower to act. But can any generalizations be made about their record in managing diseases and disasters? Chapter 11: The state and disease management Disease (and disaster management) often necessitates technical and scientific expertise. Chapter 11 explores the role of the state in ensuring health security. By the state we are referring to public care systems and agencies involved in environmental management, engineering, urban planning, education, agriculture, water management, and sanitation. After providing greater detail about what constitutes state institutions, this chapter explores how states can build capacity to handle challenges posed by disease, starting with endemic diseases followed by pandemic disease events. The key success stories are highlighted to illustrate what states can do to reduce the prevalence and alleviate the adverse effects of disease (Ezrow, 2015; Ezrow et al., 2015; Juzych et al., 2007). In particular, the chapter focuses on how the state can address some of the most important infectious diseases, including the big three – malaria, HIV/AIDS and tuberculosis – using case studies to illustrate. The chapter also explains past approaches to tackling diseases in the developing world.

8  Introduction Chapter 12: The state and disaster management Chapter 12 follows from the previous chapter to explain how the state can play a role in disaster management. Disasters are taking place at greater frequency and ferocity due to man-made climate change. Though the chapter does not explore how states can address climate change, it does look to what the state can do to prevent both climate-induced and non-climate-induced hazards from becoming huge disasters. The chapter begins by defining disaster risk management and then explores in further detail the role of the state in addressing disasters, most specifically earthquakes, storms, and droughts. As the chapter shows, the state is critical in determining how disastrous a natural hazard will be. The chapter explains why this is the case, using case studies in Chile, Japan, Bangladesh, and the Cayman Islands to illustrate. Chapter 13: Global health governance Chapter 13 provides an overview of the various international institutions, international organizations, and NGOs and their role in supporting disease management. However, the main focus of the chapter is on the evolution of the World Health Organization (WHO) and its role today in promoting global health. The chapter explores the reason why the WHO has been able to assert its role, alongside with the criticisms that it has faced for mishandling various challenges of disease control and limitations in containment, mitigation, and coordination. The chapter begins by defining what we mean by international health and public health and then follows with an overview of the different approaches to public health and strategies of cooperation on global health. The chapter also looks at the role of vaccines, medication, and how international organizations and NGOs can deliver services that are vital to ensuring public health. The chapter closes with the major challenges to global health today and what the obstacles are to achieving global health security. Chapter 14: Disaster governance Chapter 14 looks at the state of global disaster governance. In doing so, the chapter explains the role that international organizations, which direct and coordinate international disaster governance within the United Nations system, have taken in urging states to adopt specific policies in disaster mitigation and disaster preparedness plans. The chapter starts by defining disaster governance and explaining what the key institutions are that attend to these issues. This is followed by an overview of how disaster governance has evolved. The chapter then looks at the challenges facing disaster governance, such as integrating disaster risk reduction with climate change adaptation and ensuring that there is greater equity in disaster risk reduction.

Conclusion The final chapter concludes by providing an overview of the main themes of the book and offers final thoughts on health and disaster security.

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10  Introduction Parkinson, D. and Zara, C., 2013. The hidden disaster: Domestic violence in the aftermath of natural disaster. The Australian Journal of Emergency Management, 28(2), pp. 28–35. Pfefferbaum, B. and North, C.S., 2020. Mental health and the Covid-19 pandemic. New England Journal of Medicine, 383(6), pp. 510–512. Price-Smith, A.T., 2001. The health of nations: Infectious disease, environmental change, and their effects on national security and development. Boston, MA: MIT Press. Rushton, S., 2011. Global health security: Security for whom? Security from what?  Political Studies, 59(4), pp. 779–796. Sell, S.K. and Williams, O.D., 2020. Health under capitalism: A global political economy of structural pathogenesis. Review of International Political Economy, 27(1), pp. 1–25. UNISDR. 2016. Poverty and death: Disaster mortality (pp.  1–22). United Nations Office for Disaster Risk Reduction. https://reliefweb.int/report/world/poverty-death-disaster-and-mortality-1996-2015. Accessed May 12th, 2021 Van Aalst, M.K., 2006. The impacts of climate change on the risk of natural disasters. Disasters, 30(1), pp. 5–18. Weiss, R.A. and McMichael, A.J., 2004. Social and environmental risk factors in the emergence of infectious diseases. Nature Medicine, 10(12), pp. S70–S76. Wu, T., Perrings, C., Kinzig, A., Collins, J.P., Minteer, B.A. and Daszak, P., 2017. Economic growth, urbanization, globalization, and the risks of emerging infectious diseases in China: A review. Ambio, 46(1), pp. 18–29.

Part I

Key challenges

1 Human security, health, and disaster

Introduction The World Economic Forum’s Global Risk Report released on January 15, 2020, ranked a pandemic in 10th place in terms of its potential impact, while also noting that any infectious disease outbreak was highly unlikely (World Economic Forum, 2006, 2020). The same report also failed to see how a pandemic could be connected to other security risks. Less than two months later, the World Health Organization (WHO) declared Covid-19 a global pandemic. Though Covid-19 is only 80–120 nm in diameter, it has proven to be much more disruptive and deadly than an intercontinental ballistic missile (Sekhawat et al., 2020). The human costs have been tremendous in loss of life (over a million plus deaths due to neglect of other illnesses), increases in people living with a disability, increases in poverty, and malnutrition. The costs to the global economy have also been substantial. By October of 2020, the International Monetary Fund (IMF) estimated that Covid-19 would cost over $39 trillion in lost output (Elliot, 2020). And though many in the field of health security had sounded the alarm about the potential dangers of a pandemic and the importance of being prepared, most countries have been completely ill equipped to manage it. Instead, governments have continued to prioritize traditional security needs over health security. Case in point: the costs of implementing badly needed upgrades to public health systems in low- and middle-income countries for pandemic preparedness amounts to about $4.5 billion a year, while global military spending still exceeds $1 trillion annually (Lancet, 2020; Sands et al., 2016). World leadership is still fixated on traditional threats to security, namely national security. While the threats to national security from other states and violent non-state actors remain ever present, these threats actually pale in comparison to a host of other risks and threats to human security. Part of the issue is that security is still conceived of in a state-centric fashion. Even with globalization and the growing interconnected nature of our world, the level of analysis continues to be the state. This chapter lays out how security is conceived of by looking at an alternative to the state-centric approach – a human security approach. The chapter explains why human security has become increasingly important, how the approach emerged, and how it is measured. The chapter then brings in human development approaches and explores the ways human security is complimentary and in what ways they differ. The chapter then turns to define health security (and disaster security) and the controversies surrounding the securitization of health. While the securitization of health may be welcomed by some who want to put health issues to the forefront, critics charge that it is being used as a pretext to pursue a power politics agenda. We close the chapter by examining environmental security and how this conflicts and compliments development approaches. Outlining the human

DOI: 10.4324/9781003128809-3

14  Key challenges security approach provides a foundation for understanding all of the issues related to disease and disaster. Key concepts

What is human security? Human security emerged as a concept that has the potential to link seemingly divergent fields and to capture and address some the world’s most pressing issues. The Commission on Human Security, which was first tasked with defining the concept, proposed that the objective of human security was to safeguard human lives while promoting long-term human flourishing and fulfilment (Alkire, 2002). The concept also supported enhancing human freedoms and protecting people from a variety of different threats to their well-being. This was a clear move away from threat-defence dynamics toward solidarity and universality. As stipulated by the United Nations Development Programme’s (UNDP) 1994 Human Development Report, human security is loosely defined, as people’s freedom from fear and want. In that report, it was argued that human security had four important components: it is universal; it is best ensured through prevention; it is people-centred; and its components are interdependent. In what follows we explain each of these four components. The book will address each of these issues in each chapter where appropriate. One of the key components of human security is the importance of how interconnected the world is. A threat to individuals in another country could pose a threat to security at home (MacFarlane and Khong, 2006). Threats are borderless, closely connected, and potentially crippling in their effects on societies worldwide. When humans face a threat, so does the international security (Burgess and Gräns, 2012). At the same time, human security may be understood differently in different countries and contexts. Human security also focuses on prevention. The preventive actions that human security advocates include fair trade, universal access to healthcare, and universal access to education. Provision of this serves as a preventive tool against hunger, disease, repression, and poverty. Because the human security approach is people-centred, it takes the view that preventive activities should be bottom up and community driven. Incorporating local needs and actors into the account, understanding the warning signs, and understanding how insecurity can be prevented is integral to the human security approach. Human security is a concept that challenges traditional notions of national security. It moves away from state conceptions of security that focused on the safety of states from military aggression to one that focuses on the safety of the individual. The 1994 UNDP Report focused on the security of people (though grouped by country) and not the security of countries. The heart of the human security agenda is protecting lives, focusing on the health and well-being of people, and prioritizing their fundamental freedoms. Applying a human security approach looks at various aspects of people’s livelihoods including economic, food environment, and health. Understanding socio-economic development sheds light on the insecurities that impoverished people face in the developing world – income insecurity, threats of physical violence, health insecurity, fragile health services, absence of social safety nets, which can lead to a cycle of poverty. It is recognition that these concepts are interrelated building blocks to human security. For example, a step towards reducing disease is a step towards reducing poverty, which could help prevent war and violence. On the flip side, endemic disease impoverishes communities and disrupts the provision of education.

Human security, health, and disaster  15 Environmental degradation has led to population movements into other, more fragile ecological settings and threatens livelihoods. In the complex global networks that we live in, the breakdown of one element in the system leads to breakdowns throughout the system, which leads to vicious cycles – or human insecurity traps. Due to the interdependence of threats, no threat should be in a hierarchy over another. Various threats can spread across a given country and spill into other countries and regions. Types of threats Human security approaches assume that there are two types of threats that people face – those that are direct or indirect. Direct threats to human security usually come from violence. Direct threats may be deliberate or intentional caused by one group to another, such as by states, terrorist groups, rebel factions, or paramilitary groups. Organs of the state may also threaten human security by violating human rights or using violence against their own citizens. Deliberate policies of social exclusion also constitute direct threats. Indirect threats come from economic crises, deprivation, disease, disasters, underdevelopment, population displacement, environmental degradation, poverty, and inequality. Indirect threats are actions by groups or institutions where the by-product impacts human security. For example, mining and forestry policies may have negative environmental consequences which are destabilizing for a community’s subsistence. Indirect threats may also be the result of omission or the failure to act, to protect, and to prevent. Indirect threats require distinct strategic responses. In this book we focus on both indirect and direct threats to security. Some human security threats are objective, tangible and measurable such as poverty, unemployment, lack of access to healthcare, and education. These can be grouped in to threats that impact ‘freedom from want.’ These types of threats can be measured by looking at absolute poverty lines, by reference to falling below a minimum consumption basket or looking at inequality rates. Other threats to human security are subjective and much more difficult to measure, such as the sense that you cannot control your own destiny, low feelings of self-worth, feelings of exclusion and capability deprivation, and fear of crime and other threats. These types of threats are often categorized as ‘freedom from fear.’ Some human security threats have a longer time horizon and are chronic threats, such as hunger, endemic infectious diseases, non-communicable diseases, and poverty. Other threats are sudden can case massive disruption in daily life, like natural hazards, sudden economic crisis, or an epidemic disease outbreak. These types of threats also require more immediate action as they are more imminent, acute, and move at greater speed. Threats also differ in their severity. Some threats cause threats to human life, while other cause chronic morbidities (Lovendal and Knowles, 2006). Types of risks There are also many different types of risks that humans face. Risks vary by how exposed and sensitive individuals/communities are and how resilient they are. Individuals/communities are more exposed and sensitive if they live in an area where threats can cause harm. The widespread devastation caused by natural hazards demonstrate the vulnerability of increasingly concentrated poor populations in ecologically fragile environments. For example, individuals/communities situated close to an area that is prone to landslides or flooding will be more affected by threats than those who don’t. Individuals/communities that are resilient

16  Key challenges have the capacity to cope with a threat better. In countries with wholly inadequate support systems, short-term devastations can rapidly translate into long-term regional economic and political instability. To illustrate, a massive earthquake had a much different impact on San Francisco, United States (US), than it did in Port-a-Prince, Haiti. In the case of Haiti, the 7.0 earthquake all but decimated the educational and health systems and led to a massive cholera outbreak and huge loss of life. Over 300,000 people died and approximately $8 billion in damages were caused (Reuters, 2011). In contrast, the 6.9 earthquake that hit San Francisco in 1989 did cause $5 billion in damages, but only 67 people died (History, 2018). Though poverty and inequality don’t necessarily always cause insecurity, both amplify vulnerabilities to physical and psychological harms (Adger and Winkels, 2014). People who are more impoverished face higher exposure and lower levels of resilience which intensifies the impact of any threat (for more on this see Chapter 5). The poor have fewer options available to them and less ability to influence resource allocation and distribution. For example, living outside of the formal economy makes people more vulnerable. The lack of access to healthcare and nutrition makes the poor more likely to face diseases and less resilient in overcoming them. Poverty-related diseases, malnutrition, lack of basic sanitation, and environmental pollution and degradation kill more people annually than armed conflict (Ball, 2001; Our World in Data, 2017). Measuring human security Measuring human security is a difficult endeavour because it encompasses so many overlapping issues. However, there are generally two positions on how human security should be measured: those who want a broad/expansive definition and those who want a narrow conception. The narrow conception focuses on conflict and human rights abuses. The broad conception addresses numerous challenges to human safety, well-being, and dignity. These differences have translated into a distinction between viewing human security as freedom from want and/or as freedom from fear. The narrow approach was advocated by a group of countries led by Canada and Norway that sought to emphasize free from fear. This approach helped to inform the 2001 Report of the International Commission on Intervention and State Sovereignty and the Human Security Report that was first published in 2005. These reports focused on protecting individuals from civil war, genocide, and population displacement or direct dangers to human life (Kerr, 2006). Those in favour of an expansive conceptualization argue that this is essential to understand contemporary crises. The expansive approach, which incorporated both fear and want, is evident in the way in which the 1994 UNDP Report defined human security. Expansive approach to human security The UNDP Human Development Report identified seven categories of threats to human security. Economic security entails security from poverty and unemployment. Food security, or security of food, is the prevention of hunger and famine. Personal security is security from physical violence, crime, terrorism, domestic violence, and child labour. Community security is security from inter-ethnic, religious and other identity-based tensions, and civil conflict. Political security is security from political repression and human rights abuses. Environmental security is security from environmental degradation, resource depletion, natural hazards and pollution. Finally, health security is security from deadly infectious diseases, unsafe food and water that can cause illnesses, and lack of access to basic healthcare (Bajpai, 2000).

Human security, health, and disaster  17 Health security is provided by ensuring that there is basic healthcare and services, an interconnected surveillance system to identify disease outbreaks at all levels, universal education and knowledge on health-related issues, access to accurate information, and communitybased knowledge. Environmental security is provided by ensuring that there are sustainable practices regarding natural resources and working to prevent environmental degradation such as desertification and deforestation, an environmental recovery process, and an aim to protect bio-diversity. There should also be investments made to reduce various types of vulnerability to natural hazards. Building early warning systems and mitigation efforts, such as barriers to storm surge, are also important. An important subset of environmental security is disaster security. For the most part, the human security literature has focused more on environmental security and less specifically on disaster security, which looks at how to reduce vulnerabilities to natural hazards. For some in the disaster resilience literature, vulnerability and insecurity are synonymous. For others, vulnerability is just a component of insecurity. Regardless of how insecurity and vulnerability are perceived, much of the disaster security literature uses the terms vulnerability and resilience over insecurity and security. Though all aspects of human security are equally important, this book focuses on health, environmental, and disaster security, with an understanding that all of the threats to human security are interconnected. Thus, the book acknowledges that different human security threats are affected by and drive other threats. For example, civil conflict amplifies the conditions that make disease more rampant as does poverty (for more on this see Chapters 6 and 7). Natural hazards also worsen economic well-being, health, and access to food. Global warming makes infectious diseases more prevalent. These threats to human security are mutually reinforcing. Violent conflicts can lead to more poverty, which can lead to more resource depletion and more infectious diseases. More infectious disease can lead to more poverty, which in turn can lead to more conflict and instability. Though this book embraces a human security approach, it’s important to note that the concept of human security has faced its share of criticism. Most of the critiques lodged are related to its conceptual ambiguity and imprecise definition (Chandler, 2008; Duffield and Waddell, 2006). Critics charge that as the concept is so fuzzy, it includes everything, and is too vague to operationalize making it meaningless (Paris, 2001). By being too vague, this gives little guidance about what should be studied. The human security agenda has also given rise to the heated debate in academic circles over the scope of the human security concept. Some claim that the focus on everything means that nothing is prioritized, making the framework not operable (Khong, 2001). Is the

Table 1.1  Pillars of human security Type of security

Security from

Economic Security Food Security Personal Security Community Security Political Security Environmental Security

Poverty and unemployment Hunger and famine Physical violence, crime, terrorism, domestic violence, and child labour Inter-ethnic, religious and other identity-based tensions, and civil war Political repression and human rights abuses Environmental degradation, resource depletion, disasters, and pollution Deadly infectious diseases, unsafe food, lack of access to basic healthcare

Health Security

18  Key challenges focus on development only to prevent conflict and violence, or is the focus of development seen as an aim on its own? They warn that bringing in so many issues will dilute everything. The expansive views of human security give a ‘laundry list’ that can include everything from disease, to lack of education, and access to clean drinking water, malnutrition, environmental degradation, rapid population growth, to political repression, violence, and armed conflict (Ball, 2001). Criticisms of the broad interpretation also claim that the more threats there are, the more difficult it is to find connections between them. When the focus has been narrowed down, this has taken place in an arbitrary and incoherent way (Paris, 2001). In some cases, threats are based on probabilities, while other times threats are based on perceptions, ethical concerns, and/or pragmatic considerations. Additionally, scholars have argued that threats are prioritized in terms of the interests of those with power and not the interests of those who are vulnerable and marginalized (Booth, 2007; Duffield and Waddell, 2006; Paris, 2001). As a result, the human security discourse may enable powerful states or international organizations to intervene more in the name of security in weaker states (McCormack, 2008). Critics also claim that development agencies were also eager to jump on the human security bandwagon in order to frame development concerns as security concerns so that they could gain funding for their programs. Re-labelling and re-packaging human development as a security concern creates a greater sense of urgency and helps to attract more resources (Khong, 2001). Methodologically, the approach suffers from the fact that the dependent and independent variables appear to be conflated, making it almost impossible to figure out what is causing what (Mack, 2004, 2005). Insecurity, for example, can be both a cause and a consequence of violence. Any threat can be studied as a dependent or as an independent variable. Insecurity can be a cause and a consequence of violence. The seeds of such a middle ground are contained in the 2003 Commission on Human Security (CHS) report, co-chaired by Sadako Ogata and Amartya Sen, which sought to refine and make more precise the earlier and more expansive UNDP definition. In spite of these criticisms, we see the utility of the approach in asking us to reconsider what security really means. Human security approaches also probe what makes us vulnerable, what are the ramifications of these threats as well as whether the strategies to address security offer resolution or actually generate new threats. Past ways of addressing security have failed to address these vulnerabilities. In the section that follows we lay out in more detail how traditional approaches to security differ. Theory and background on human security

Human security and security studies After the Soviet Union (USSR) collapsed and the Cold War ended, the traditional threat of a bi-polar nuclear war and armed conflict between great powers all but disappeared. This allowed room for a wider debate to emerge about broadening the concept of security (Debiel and Werthes, 2006). International security studies turned to focus more on the loss of human life and human rights violations in conflicts that were mostly taking place in the developing world (Duffield and Waddell, 2006). Traditional theories (Realism and Liberalism) in international relations had mostly missed examining non-traditional threats and actors and offered solutions based on states increasing their military spending to internally balance against threats to their security (Buzan et al., 1998).

Human security, health, and disaster  19 Realism, for example, is a state-centric approach that champions the primacy of territorial integrity of the nation over security of the individual. Traditional views of security have focused on the importance of the military to ensure territorial integrity of the state, with foreign and defence policy intent on preventing inter-state conflicts and threats to sovereignty. Security threats come from organized violence from other states. For Realists, security is derived from the balance of power among states within an anarchic system and threatening to use force and retaliate where necessary (Mearsheimer, 2001). For Liberals, security is achieved through the spread of democracy, democratic norms, and international trade. Security can be realized collectively through cooperation and using a collective response to attain peace (Keohane, 2012). International institutions can play an important role in helping states cooperate, but the foundations of Liberal theories still focus on international security over human security, meaning the absence of war as a measure for security. This narrow definition of security from the dominant theories in International Relations has translated into high levels of military spending, with military expenditures still equal to the combined income from 49% of the world’s population (SIPRI, 2020). However, after the Cold War ended it seemed inappropriate to think about security in such a narrow way (Kaldor, 2007). In academic and policy-making circles, the need to analyze root causes and find solutions to end human suffering driven by threats other than inter-state war prompted the expansion of the idea of security. Analysts started to recognize that environmental degradation and disasters such as epidemics, famine, earthquakes, and droughts were also important threats to security. Debates also emerged about considering a global approach to security that focused on individual and communal protection rather than national protection. This focus on community and a broader conception of security led to not only the idea of human security but ecological security as well. Human security focuses on providing for the basic needs of individuals and thinking of how to achieve global security, while ecological security was derived from protecting against threats to the environment and biological systems with policies looking not only at environmental security but also epidemiological security (Fidler, 2003). This ecological security approach expands on the human security approach to protect non-humans and natural resources as well. It was also argued that human security could not be realized without ensuring the integrity of the eco-systems. With human and ecological security, humans and non-humans are co-equal with the state. State security is a means but not an end (Tadjbakhsh and Chenoy, 2007). Security instead comes from ensuring personal safety, physical safety, the provision of basic needs and freedoms, equality and sustainability, and achieving an absence of threats to well-being. Though states are involved in promoting human and ecological security, so too are international institutions, organizations, NGOs, grassroots organizations, and local actors. Human security should complement state security while strengthening human development at the same time.

Box 1.1  History of human security concept The absence of inter-state wars but the prevalence of civil wars required more focus on post-conflict recovery and the various issues that post-conflict countries face. This context helps to explain the motivations behind the early conceptualization of human security. The concept was first formulated in the 1992 Agenda for Peace, proposed by

20  Key challenges United Nations Secretary General Boutros Boutros Ghali, which stressed the indispensable role of the United Nations (UN) in taking on an integrated approach to human security. As he saw it, a human security approach was important to peace making, peacekeeping, and post-conflict management. The concept was further crystallized in 1994 by the UNDP Human Development Report. The UNDP devoted an entire chapter of its 1994 Human Development Report to the dimensions of human security, adopting the language of human security within its reports. Human security was also used as an organizing concept for the 1995 Copenhagen UN Conference on Social Development. The 1990s ushered in a series of other humanitarian catastrophes that had significant consequences for how security should be approached from international organizations, such as the UN. The 1990s was a turbulent period for the UN after the failure to protect and prevent the Rwandan genocide and the inability of important peacekeeping efforts to achieve their objectives. In this context, UN Secretary General Kofi Annan adopted the human security agenda in the 1999 Millennium Declaration to compensate for these failures. He called for human security to encompass economic development, social justice, environmental protection, democratization, disarmament, and respect for human rights and the rule of law (Hampson and Penny, 2008). The World Bank’s understanding of human security was also articulated in its 1999 paper, ‘Security, Poverty Reduction & Sustainable Development: Challenges for the New Millennium.’ This report advanced that traditional notions of security were giving way to more contemporary understandings of the term which included human security and challenging the notion that threats only came from war. The World Bank also produced a series of studies which highlighted the connections between poverty, health, and insecurity, titled Voices of the Poor, in 2000. In these reports, it was argued that the poor suffer far more from multiple deprivations associated with poverty than they do from conflict. To tackle these issues, the Bank’s 2000/2001 report identified three pillars of poverty reduction. The report argued that investing in human capital was critical to improving security threats and vulnerabilities from economic shocks, disasters, poor health, and personal violence. The report also identified several areas for international cooperation including infectious diseases, the environment, agricultural advances, post-conflict reconstruction and reducing the arms trade. By 2001, the Commission on Human Security (CHS) was established to promote a better understanding of what human security means and to develop the concept as an operational tool.1 The Commission understood that the concept was fluid and would change over time, but that it was critical to treat threats to individuals as equally important as traditional threats to the state (Tadjbakhsh and Chenoy, 2007). In May 2003, the Commission on Human Security submitted a report titled Human Security Now to the UN. This report described human security as complementary to state security, but with an emphasis on human rights and human development. One of the ten policy recommendations of the Commission referred to health, with a priority placed on ensuring universal access to basic healthcare. After this report was submitted, a Human Security Unit was established in the UN Office for Coordination of Humanitarian Affairs (UN OCHA). This gave human security an organizational base within the UN structure, and gradually the human security concept moved more into mainstream politics.

Human security, health, and disaster  21 The concept of human security was further developed by the UN under Annan. In 2003 a high-level panel was established that looked at threats and challenges that went beyond traditional security concerns, and in 2004 a report, entitled A More Secure World: Our Shared Responsibility that looked further in-depth at these challenges, was produced. In that same year, Annan had asked a UN High-level panel on Threats, Challenges and Change to review the meaning of security in the 21st century. The following year, at the World Summit, the member states also committed to the principle of the Responsibility to Protect. This went beyond protecting citizens from threats of physical violence but also included threats posed by food, healthcare, environmental degradation, and poverty.

The rise of human security approaches As explained in Box 1.1, the reports by intergovernmental organizations of the 1990s and early 2000s reflected the growing realization in both the policy and academic communities that poverty in particular was linked to a host of different insecurities, including threats to health and well-being, that were far more damaging than the threats from nuclear annihilation (King and Murray, 2001). There were also concerns that though globalization had brought about much positive change, many people were not able to reap the benefits of globalization and were being adversely affected by a host of other new threats and issues. The acceleration of globalization processes not only revealed the growing gap between the world’s rich and poor but also increased awareness of the risks of transnational harm (economic shocks, new diseases, etc.) that could adversely affect vulnerable populations. We lay out the new conflicts, threats, actors, and diseases which helped to popularize the human security approach which has become more widely used. Though the threat of a great power war ended, new conflicts emerged that posed significant threats to human security. Wars were no longer between states but within states, many of which were sparked by ethnic and religious divisions. These new forms of conflict generated high civilian death tolls and large numbers of refugees (Kaldor, 2007). Other traditional concerns were also replaced by transnational concerns, such as rising terrorist attacks on civilians and organized crime. Though the prevalence of inter-state conflict has dissipated (since the end of the Cold War), the number of people who have died as a direct or an indirect result of conflict has grown. It was clear that security could not be achieved by relying on military defence of national borders to protect the state; it was becoming increasingly critical to understand how to protect vulnerable people and communities as well. In addition to new threats of violence, it was acknowledged that there were new threats to humans on a global level that transcended the state. These new threats were always present, but an awareness of these threats was now being more sufficiently accounted for. These included the depletion of resources, over-population, pollution, environmental degradation, poverty and inequality, and disease. Additionally, although ‘security’ is usually equated with physical violence, the insecurities of daily life among ordinary people, especially the poor, gained visibility in the 1990s. Just as there were new wars and different types of threats emerging, new actors also appeared on the scene: international organizations, private investment companies, NGOs, and non-state entities. These actors were playing a more active role in international relations. For example,

22  Key challenges security analysts cautioned that violent non-state actors could use non-conventional forms of warfare, such as bioterrorism. Though bioterrorism has thus far generated few deaths comparatively speaking, it heightens vulnerabilities. Notable examples are the 1995 sarin attacks in Tokyo, Japan, and the anthrax attacks in 2001 in the US (Human Security Center, 2005). Although anthrax caused only five direct deaths in the US, the still-unsolved attacks virtually paralyzed some systems of American society, including the postal system and Congress (Clarke et al., 2006). The 1990s also witnessed a rise in new infectious diseases and a rise in re-emerging diseases, or diseases that had been once eradicated (known as emerging and re-emerging infectious diseases, ERIDs). Since the 1970s, about 40 new infectious diseases have been discovered (BCM, 2020). Resistance to common antibiotics was becoming more common, and there were growing concerns of new drug-resistant strains of tuberculosis. New epidemics were having a devastating impact. These include cholera in Latin America, the plague in India, Ebola virus in Africa, dengue fever in Asia, West Nile Fever and new strains of measles in the southern United States, and bovine spongiform encephalitis (mad cow disease) and hoof-and-mouth viruses in Europe (Davies, 2008). These diseases arrived through imported water and food or were brought in by travellers from overseas. There was also a concern in the West that these potentially epidemic infections from the developing world would threaten the health and economic well-being of communities in Western countries. Globalization was increasing human travel, and countries like the US were concerned that interconnectedness between poor and wealthy travellers increased the risk of infection spreading across the globe. Western countries were also concerned that internal instability caused by infectious diseases and disaster in developing countries could spill over and threaten international and regional stability as well as international trade. As Chapters 8 and 9 will explain, epidemics may undermine the capacity of the state to provide basic healthcare and protection, while epidemic diseases may also contribute to economic decline and greater economic inequalities which will further social disorder and unrest. The biggest of these threats, however, initially came from HIV/AIDS. By the early part of the 21st century, there had been more than 40 million people infected by the HIV virus and more than 25 million deaths. The death toll from AIDS had exceeded the Black Death in the 15th century. The number of people who died from AIDS in the first decade of the 21st century will far outweigh the number of people who die from conflict during the same period. There was also a huge economic burden caused by the disease, greater social fragmentation, and concerns that the disease could be used as a weapon of war through rape. There was even a reluctance to send or receive peacekeepers due to the risk of infection and the infection rate among security forces (Tripodi and Patel, 2004). Nearly two decades after it had been discovered, AIDS was declared by the UN Security Council to be a threat to national security, especially in impoverished and political fragile countries in Africa. In 2000 the UN Security Council held a special session on the HIV/AIDS threat to Africa, which led to Security Resolution 1308, the first meeting ever dedicated to health (Rushton, 2010). This resolution recognized that HIV/AIDS was a threat to stability and security. Though no formal decision was adopted, there was consensus that AIDS was a security threat, necessitating a collective response. The UN Security Council was concerned that HIV/AIDS crisis would make states unwilling to send troops on peacekeeping missions and to receive them (McInnes, 2006). This is in spite of the fact there is little evidence of this being a problem, with the possible exception of Sierra Leone. There is also not conclusive evidence that HIV infection rate amongst the military has led to instability (McInnes and Lee, 2006; McInnes and Rushton, 2013). Additionally, an entire session of the UN General Assembly was devoted to HIV/AIDS, and a Global Fund for AIDS, Tuberculosis, and Malaria was launched in 2002. The AIDS

Human security, health, and disaster  23 crisis also attracted the attention of the security policy community, prompting US Secretary of State Colin Powell and former US ambassador to the UN and Director of the Global Business Council to describe the disease as a direct threat to stability. HIV/AIDS funding increased from $300 million in 1996 to $15.6 billion by 2008 (Relief Web, 2011). The AIDS crisis moved health beyond the social policy and development agendas and into the realms of foreign and security policy (Eberstadt, 2002; Elbe, 2002; Ostergard, 2002). Human security and development Just as the field of security studies has evolved over time, so too has the field of development. After World War II, early meanings of development were focused on rebuilding economies in the developed world as a way of preventing the rise of communism. Early studies of development, drawing from Modernization Theory, took a more linear approach to development, with early conceptions of development focusing entirely on national income, per capita income, and economic growth. The World Bank initially promoted free trade, foreign private investment, and raising productivity as a means of raising the living standards of countries. However, when Robert McNamara became World Bank president in 1968, the Bank became more committed to improving the productivity levels of developing countries and recognized that development had a social objective that should be aimed at eliminating poverty and global injustices. McNamara paid particular attention to issues such as overpopulation, urbanization, land reform, income redistribution, healthcare, and the environment. Meanwhile, noted economist Dudley Seers claimed that GNP/capita was not sufficient to measure development in 1970 (Seers, 1972). The Bank started to use social indicators to measure development, which went beyond just looking at economic growth. Though these were positive steps to understanding development, at the end of the 1970s, it became clear that modernization was not improving the circumstances of the most impoverished nations. This realization helped to spawn the basic needs movement in the 1970s that emphasized a different approach to development. Noted scholar and Nobel Prize winning economist Amartya Sen (1983) expanded on the definition of development with his theory of capabilities. Sen highlighted five basic freedoms which included: political and participative freedoms, such as civil rights, freedom of speech, elections; economic opportunities to help people work to pay for what they may need to consume, such as food, clothing, and housing; social opportunities, such as education and healthcare; transparency guarantees, such as an open government and societies with high levels of social trust; and protective security, such as law and order and social safety nets for the unemployed and to prevent people from living in abject poverty. Development, as he sees it, is the process of ‘enlarging people’s choices,’ (UNDP, 1990, 1) and expanding freedoms and capabilities enables people to live the types of lives that they would value (Sen, 1999). Thus, the human capability approach to poverty reduction emphasizes empowering the poor, to facilitate their participation in society and chances of moving upwards in the socio-economic ladder (Lok-Dessallien, 1998). For Sen, all of these freedoms are crucial to development. Only states that provide a host of different freedoms will enable individuals to pursue trade and other productive endeavours. Ideas of development started to emphasize that development could be achieved through education and by meeting nutritional needs and healthcare needs (Schultz, 1972, 1981, 1988). Heavily influenced by Sen, in 1990, the UNDP began to publish its annual Human Development Report. This reflected another shift towards human development. Along with the Human Development Report, the UNDP also annually publishes the Human Development Index to capture development. Though this is a fairly narrow measure, it offers a broader

24  Key challenges composite measure of development than economic growth by focusing on per capita incomes levels, literacy rates, and life expectancy. This shift was also reflected in the World Bank’s definition of economic development, which, according to the World Development Report of 1991, was defined as improving living standards, improving education, healthcare, and environmental protection. The human development school emerged in the 1990s, building on a series of previous reactions against the dominant paradigm that development was measured by economic growth and evolving out of the basic needs approach. The human development school argued that growth was insufficient since it could be achieved while poverty and deprivation and environmental degradation continued. Human development holds that socio-economic policies should focus on people and their well-being and enlarging people’s choices, improving dignity and self-esteem. Human development could apply to any country regardless of whether they were rich or poor, crime ridden or stable, at war or at peace. Security-development nexus As a previous section explained the early attempts to understand development were dominated by a state-centred approach to development that remained intact until the late 1980s. By the 1990s, influential development circles (such as the work by the UNDP’s Mahbub ul Haq and Nobel Laureate Amartya Sen) became increasingly dissatisfied by these approaches and worked to redefine development by placing the emphasis on well-being, welfare, and safety of individuals and communities, not states (Haq, 1995; Sen, 2000a). By doing so, this not only redefined development approaches but also security approaches. Thus, the human security approach evolved at a time while security and development approaches were concurrently evolving. Human security encompasses the intersection of the development and security literatures, highlighting the connection between development and security and recognizing that there are interlinkages between peace, development, and human rights (Buur et al., 2007). By merging security and development together, known as the security-development nexus, both the development and security fields saw advantages. The development community saw this as an opportunity to attract more funding from that traditionally allocated for the military, while the security community believed that a more holistic approach to security would reap more optimal outcomes as well. Resources were relocated to pressing areas of development with particular attention to human development (Kerr, 2006). For many scholars and policymakers in the developing world, international development has always been influenced by the interests of great powers, with official development often closely tied to ideological imperatives. Development, from the point of view of the developing world was used to exercise social, economic, and political control over it. From this vantage point, linking security to development would only intensify this trend. This would enable activities that are actually focused on security to be relabelled under the development umbrella. There were concerns that official development policy would focus less on poverty reduction, with development assistance being raided by foreign and security policy agencies. Since the mid-1990s, the reconfiguration of the security-development nexus produced a new relation of governance, empowering these organizations to act in the developing world, resulting in unprecedented types/levels of interventions. However, proponents of human security approaches counter that past conceptions of development and security failed to adequately target and serve the interests of individuals. By merging the two fields together, there was much to be learned from their approaches.

Human security, health, and disaster  25 These approaches are also important to understanding how to tackle diseases and disasters. The following section lays out the similarities and differences between human security and human development approaches. Differences between human security and human development Human security and development share much in common. Both are people-centred, multidimensional, address chronic poverty, and have a broad view of human fulfilment. Both also advocate bottom-up agency. Both also measure material and physical concerns while also looking at basic dignity. Both understand that development and achievement may go alongside undesirable outcomes for people. The concept of human development refers to the broad approach of expanding people’s choices or capabilities not only in terms of income but also in areas such as health, education, technology, the environment, employment. Both human security and human development approaches emphasize the promotion of sustainable development, and how national development might affect human development. For more on this, see Box 1.2. International agencies have long held that these goals are interconnected. For example, in 2001, the World Bank argued that sustainable development was not possible without human security.

Box 1.2  Sustainable development Sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their needs (World Commission on the Environment and Development, 1987). By the 1980s, it became more widely understood that development needs to be sustainable. Sustainable development approaches were the result of a growing awareness of the global links between environmental problems, poverty, inequality, and well-being. The term was first used in 1980 in the World Conservation Strategy. It was later more clearly expressed in the Brundtland Report (also known as the 1987 report called Our Common Future by the World Commission on the Environment and Development), which recognized the dependency of humans on the environment to meet the needs and well-being in a much wider sense than merely exploiting resources. While emphasizing the importance of poverty and inequality (the Brundtland Report was especially critical of past growth models for not reducing poverty or narrowing the gaps between rich and poor), the Brundtland Report warned that environmental destruction would limit forms of economic growth. This approach recognizes that ecology and the economy are becoming ‘more and more interwoven, locally, regionally, nationally and globally,’ (World Commission on the Environment and Development, 1987, 35). Humanity depends on the environment both for now and the future. This approach argues that the globe is interconnected, and environmental problems are not only local but global. Local actions can have an international effect. Pollution can cross boundaries. Meanwhile, environmental problems threaten people’s health and livelihood and can threaten future generations. Thus, this approach offers a definition of development that looks at environmental, cultural, and social factors. It also sees increasing participation and eradicating poverty and inequality as key elements of development (World Commission on Environment and Development, 1987, 49).

26  Key challenges Thus, human security affects and is affected by development processes. Obstacles to development create human insecurities, and therefore, improvements in human development will enhance human security. At the same time, human development is difficult to achieve when the minimum conditions for human security do not exist (Jolly and Ray, 2006, 2007; Thomas, 2001). Thus, though, in many instances, security and development are collapsed and interlinked, they are not the same concept. Human development aims to increase people’s choices, opportunities, and freedoms, while human security is about assuring that people have the freedom to exercise their choices safely (Alkire, 2010). Human development also goes further in terms of what constitutes a basic need. The goal of human security is to address basic needs, while human development goes beyond concerns that are not basic, such as the long-term objective of human fulfilment. Human development is more focused on long-term processes of institution building and capacity building, with longer time horizons and the goal of incurring durable change. Human security deals with short-term emergencies and short time horizons. For example, human security approaches are sometimes focused on emergency relief for flood victims and food for work programs after a drought, which would not be part of the human development approach. Human development is focused on growth and equity, while human security approaches acknowledge that people may be faced with sudden insecurities and deprivations as a result of various threats including conflict, economic crises, diseases, and disasters. These crises can reverse years of development. While human development is a positive concept, less attention had been devoted to protecting people during economic downturns and in periods of conflict and violence. Where there is a high degree of human insecurity, people concentrate their energies on basic survival, safety, and protecting livelihoods and have little or no opportunity to enhance their choices and capabilities to improve their overall quality of life. Human security complements human development by addressing those particular contingencies and working to mitigate, eliminate, and control contingencies in the short term. Human security puts more emphasis on what types of deliberate investments can be made in the prevention of threats, such as conflict, terrorism, epidemic disease outbreak, or an economic crisis. Development is less concerned with preventive activities (with the exception of preventing climate change, famine, and soil degradation) and is more concerned with engendering progress. Human security focuses on the root causes of threats, whatever their origin, and seeks to create capacities that enable people to prevent, mitigate, and cope with threats and risks (Sen, 2000b). In other words, whereas human development is concerned with achieving positive outcomes, human security seeks to avoid negative outcomes. Both are critical to understanding how to properly address disease and disaster.

Health security and development While the field of international development was evolving to take into account a more comprehensive approach to measuring and understanding development, past assumptions about the relationship between health and development persisted. In the 1950s, there was tremendous optimism that infectious diseases could be controlled due to the huge achievements taking place in medicine and in the social sciences. International public health authorities were predicting in the late 1960s that infectious diseases would be eliminated by the end of the 20th century (Spinney, 2019). The dominant assumption (drawing from Modernization Theory) about development and health was that as countries developed along with

Human security, health, and disaster  27 scientific and technical progress, these developments would ensure the eradication and control of infectious diseases (Gilman, 2003; Wimmer, 2000). Societies would become healthier when they were wealthier, which meant that focusing on economic growth should be the key objective. This optimistic vision of human health was known as Mortality Transition Theory or Epidemiologic Transition Theory (Omran, 1977). This constituted a transition from infectious diseases with high mortality rates at a young age as a primary cause of death to a pattern dominated by deaths due to non-communicable diseases with higher mortality rates at much older ages (Omran, 1998). Many advances were made in the post-World War II period, notably the eradication of smallpox in 1980. Life expectancy around the world was increasing on the aggregate, which was a major contrast to the past. In fact, until the second half of the 19th century, life expectancy rates remained unchanged (Mackenbach, 1994; McKeown, 2009). The death rate was always high, peaking during epidemics, famines, and to a lesser extent, conflicts. Death rates often exceeded the birth rate. However, improvements in the second half of the 19th century led to a decline in mortality rates that has been interrupted only by conflicts and the 1918–19 flu pandemic. In particular, the introduction of antibiotics significantly reduced mortality rates. Due to these achievements in medicine, public health professionals in industrialized nations believed that all industrial societies would eventually achieve the same success (Tulchinsky and Varavikova, 2014). However, in states which witnessed state collapse, and thus the collapse of their public health systems, life expectancy levels stalled or even declined. Some countries had life expectancies that were worse off than they had been several decades prior. Modernization theory had been making several assumptions about development that had implications for diseases. It was assumed that development could take place in the context of geo-political stability, strong institutions to implement policies, and sustained political will to prevent epidemics and tackle diseases. The experience of conflict-ridden failed states illustrated that tackling diseases with economic growth alone would not be sufficient. In 2000, the WHO aimed to re-establish itself after the 1990s, which were generally perceived to be disastrous for the organization when, during the 1990s, the World Bank emerged as the biggest funder of global health. The Commission on Macroeconomics and Health was established by the WHO in 2000, initiated by Gro Harlem Brundtland as WHO director general. It was tasked with assessing the place of health in global economic development. The Commission argued that without infectious disease control, low-income countries would not able to improve their health outcomes, even as economic growth increased (Das and Samarasekera, 2011). Greater investment in health services and extending health service coverage would be necessary for improvements to take place in health. Thus, in contrast to modernization theorists, the Commission argued that the causal arrow pointed the other way: poverty could not be reduced until endemic infectious diseases were adequately dealt with. Poor countries could save millions of lives each year, reduce poverty, and spur economic development (and promote global security) if developed countries committed just 0.1% of their national income to investing in health in poor countries (WHO, 2001). Health and disaster security As mentioned before, human security is a concept that encompasses the health and wellbeing of people and prioritizes livelihoods and fundamental freedoms by protecting people from acute socioeconomic threats, vulnerabilities, and stress (Chattu et al., 2020). Global health has been increasingly drawn into these human security debates, with the term health

28  Key challenges security being used in a series of major policy papers on health and human security. The mission of global health is to prevent and treat unnecessary health insecurities. Global health has risen markedly on the international agenda over the past decade, due to the growing consensus that premature and unnecessary loss of life is considered the greatest insecurity people face. It became clear that human security – or protecting people from severe threats and widespread threats – is dependent on the health of a population. Additionally, health programs are affected by conflict and other emergencies, creating entirely new challenges for global health. Often, conflicts expose the long neglect of basic public health services, where the social trust that underlies health services has eroded. The WHO also advanced that the right to health is a matter of social justice (WHO, 2003). When populations were affected by a crisis or conflict, their right to health was being compromised. To achieve human security, this would necessitate multi-sectoral engagement with the health sector, as traditional approaches to security or development would not be able to deliver. Health security and disaster security are located at the intersection of several different academic disciplines (such as the development field and security field) that do not share a common theoretical approach or academic methodology. Because of this, there is no consensus on how to define the term health security, and there continue to be different perceptions, priorities, and agendas (Rushton, 2011). Health and disaster security involve practitioners in security studies, foreign policy, international relations, environmental politics, disaster studies, development theory. Health security involves the work of international organizations, such as the WHO, UNOCHA, and United Nations International Children’s Emergency Fund (UNICEF). Disaster Security involves the United Nations Office for Disaster Risk Reduction (UNDRR), UNOCHA, UNICEF, and UN Disaster Assessment and Coordination system. One of the largest international NGOs, the International Federation of Red Cross also plays a role in both disaster and health security. In spite of disagreements on the definition, various organizations such as the United Nations (UN), the WHO, the Asia-Pacific Economic Cooperation (APEC), and the European Union (EU) generally agree that health security focuses on emerging diseases, global infectious diseases, deliberate release of chemical and biological materials, violent conflict and humanitarian emergencies, disasters and environmental change and radioactive accidents. The linkages between health and development were further developed by the UN Millennium Development Goals – four out of eight of which focused on reducing infant, child, and maternal mortality and morbidity along with tackling malnutrition. The emphasis on health and disaster in the development agenda had certain advantages. Health and disaster issues have the benefit of being less ideological and more likely to be based on science. As a result, they should be more likely to be uncontroversial. Health and disaster also issues where multilateral action and cross-sectoral participation are essential. Because health and disaster threats tend to necessitate an immediate response, consensus is achieved more rapidly. Nevertheless, while optimists argued that public health and disaster security would provide new opportunities for creative synergies between critical academic fields, others were more cynical. This was particularly the case for securitizing health. In the following section we lay out what these criticisms are. Securitization of health The idea of securitizing health has been fairly controversial. Just as there has been significant and growing opposition to the use of a ‘security’ justification for development, so too is there opposition to using security to justify global health cooperation. There is also criticism

Human security, health, and disaster  29 of the link of foreign policy interests to health problems on the grounds that it injects great power politics into health and humanitarian matters (Mcinnes and Lee, 2006). There can be no limit as to what actions could be justified under the pretence of protecting global health (Feldbaum and Lee, 2004). Developing countries have been especially critical of security being used to justify interventions. In the US, public health in particular became an add-on to security policy while community clinics and programmes focused on poverty suffered. The focus on health issues that would cause instability also meant that all of the resources were channelled towards communicable diseases that could impact the West and not all of the non-communicable diseases, such as cancer, diabetes, and respiratory and cardiovascular diseases. The increased attention to infectious disease as a ‘new security risk’ has mostly focused on a few infections and the potential of these diseases to move from the developing to the developed world. The diseases that have received large levels of attention have included the West Nile virus, Ebola, and monkey pox. But these diseases have had a relatively low number of cases compared to diarrhoeal disease, which causes almost 1.6 million deaths each year with one third of the deaths being children (Dadonaite et al., 2019). The instrumentalization of health was part of the soft power thesis which advances that states can persuade other states to do what they want them to do when they are able to create a positive image for themselves as legitimate and capable (Nye, 2008). In contrast to hard power which is based on deploying the military or making threats, soft power involves getting optimal outcomes without resorting to any force or threat of force. In 2000, for example, ­President George W Bush pledged $15 billion for a Presidential Emergency Plan for AIDS Relief (PEPFAR) (Bendavid and Bhattacharya, 2009). However, this would be channelled through the US State Department and US embassies and not through global health agencies. Health aid was being used as a part as a diplomacy strategy just as much as a development policy. Thus, there was an early perception that public health was on security agendas due to the security risks faced by great powers rather than actual health risks to human security. Much of the attention on infectious diseases has been due to the economic and security concerns of Western countries rather than the concerns for global public health. Policies based on the fears of Western countries have sometimes been counter-productive, such as when it was proposed that the US introduce mandatory screening for tuberculosis of immigrants, even though this policy had little health benefit (Coker and van Weezenbeek, 2001). It was the US that pioneered the trend of putting infectious diseases as a national security concern and a key part of national security strategies since the 1990s. As early as 1996, President Bill Clinton identified the need to improve US bio-defence capabilities and develop surveillance and response mobile units. The United States Department of Defence (US DoD) has had Global Emerging Infectious Surveillance and Response System (DoD-GEIS) mobile laboratories overseas in order to respond to outbreaks and emergent diseases. It is noteworthy that labs have not been situated in agencies such as the Agency for International Development (USAID) or the Centre for Disease Control (CDC), but instead with the Defence Department. This was because the US government believed that disease epidemics in foreign countries could threaten US national interests, and therefore a response to infectious diseases was a key strategy of US national security. The US Department of Defence worked with over 500 sites and with partners in 75 countries to strengthen surveillance (Johns et al., 2011). In 2000, the US National Intelligence Council published a report that claimed that persistent disease burden was likely to provoke economic decay, social fragmentation, and political destabilization. The report argued that the biggest impact would be in the developing world, though it would have implications for US national security as well (Noah and Fidas, 2000).

30  Key challenges In Europe, the WHO European Region has been emphasizing since 2000 the need to improve the capacity of member states to detect and respond to epidemics in a timely manner and to collect the data necessary to exercise control measures. In the UK, the British Foreign Office declared that, in 2003, the spread of disease was a risk to peace and development (Foreign and Commonwealth Office, 2003). The G8 meetings of heads of state in Okinawa (2000) and in Genoa (2001) similarly accorded high political priority to this health and human security threat. Strengthening the core capacities of public health entered foreign policy arenas in order to advance human security concerns, though mostly of Western states (McInnes and Lee, 2006). This trend of linking development and security was also often part of a counter-terror strategy. It permitted the reallocation of scarce resources based on whether or not they were willing to participate in the war on terror rather than on their development needs. For example, in 2002, US think tanks and a former ambassador to NATO argued that the 9/11 terror attacks necessitated that health would play a role in domestic and foreign policy in order to fight the war on terror (Collier and Lakoff, 2008; D’Arcangelis, 2017; Murphy, 2004). There were concerns that biological weapons would be used by terrorist groups, requiring greater surveillance of disease outbreaks (for more on this see Box 1.3, Biological weapons) (MacIntyre et al., 2018).

Box 1.3  Biological weapons Bioterrorism and biological warfare is the intentional use of an agent (either naturally created or engineered) that could cause death, disease, or other biological malfunctions in a human or another living organism in order to intimidate a population or coerce government action. While bioterrorism is executed by a non-state actor, biological warfare is committed by a country. Experts are mixed on the threat and likelihood of a biological attack. While some feel that the chances are low because there are challenges in cultivating the agent, weaponizing it, and deploying it, others warn that even if the risk is small, the successful dissemination of a dangerous pathogen could be catastrophic (Galamas, 2011; Green et al., 2019). During the Cold War but more in earnest since 9/11, countries have become increasingly concerned that biological weapons would be used by terrorist groups and ‘rogue’ states on innocent civilians and could have a devastating impact. By doing so this led to a more serious merging of security issues and health-related issues. Because terrorism was considered to be such an intense threat to society in the West, the surveillance of diseases were prioritized and more funding allocated to do so (Schuler, 2004). The most pressing threats to human security came from biological weapons that could be transmitted from person to person and which had a high mortality rate, such as anthrax, botulism, plague, smallpox, tularaemia, Ebola, Marburg, Lassa, and Machupo viruses (Broussard, 2001). These were disease agents that could be manipulated to make them even more dangerous. Other agents, such as brucellosis, ricin toxin, typhus fever, were moderately easy to disseminate but resulted in low mortality rates and were placed into a different threat category (Sewell, 2003). Biological weapons have been used historically weaponized in the past. Smallpox was weaponized against the Native Americans by the colonists during the 18th

Human security, health, and disaster  31 century, allegedly through giving out ‘smallpox blankets,’ according to historian Francis Parkman (Jacobs, 1991; Patterson and Runge, 2002). Diseases were also weaponized more recently in the 20th century. The Japanese used plague as a weapon during its war with China in the late 1930s and 1940s. Two cities in China were bombarded with bombs that were filled with plague-infested fleas. Cholera and shigella were also used as weapons in other battles. Over 580,000 Chinese people died as a result of Japan’s use of biological weapons (Hay, 2004). During the Cold War, more than 100 countries came together to sign the Biological and Toxin Weapons Convention (BTWC) in 1975 (Gerstein and Giordano, 2017). It aimed to end the development and production of bio-weapons. In spite of the commitment from countries, there were concerns that non-state actors were not committed. There were also concerns that states were not exactly adhering to the agreement that they had signed. As of 2021, there are only two known sources of the smallpox virus, which are both in the WHO reference laboratories, but there are concerns that violent non-state groups have unknown quantities of the virus and possibly other remains of the Soviet biological weapons program. In addition to Russia, other countries that have been viewed with suspicion by the West regarding their potential to use biological weapons include China, Iran, North Korea, Syria, and Cuba (Martin et al., 2007). These countries have denied that they pose a threat. Thus far, biological weapons have not caused a huge death toll compared to infectious diseases, such as diarrhoeal diseases. However, major investments have been made in preventing biological attacks, coming at a huge expense relative to other security threats. In 2002, the state of New York spent $34 million on a program to fight bioterrorism, but spent only $1.2 million to reduce heart disease, which accounted for 37% of all deaths in the state (Frank, 2005). In North Dakota at the same time, $7 million was spent on preventing bioterrorism, while only $300,000 was spent on preventing heart disease and stroke (Frank, 2005). Though biological weapons are a threat to humanity, their likelihood of making an impact remains relatively low compared to other threats to human security.

In 2009, the US National Security Council declared that it would work with partner countries and regions to assist their efforts to comply with the WHO’s International Health Regulations (IHR), as part of a strategy to counter biological threats to the US government (Nuzzo and Gronvall, 2011). The US was also willing to fund the Global Outbreak Alert and Response Network (GOARN) and Strategic Health Operations Centre (SHOC) at the WHO to help to monitor and report on disease outbreaks. Like the EU and the US, Australia and Canada have also referred to their public health strategy as a security response, aiming to create a network of surveillance and control of infectious diseases, with a preparedness programme in place to respond in the event of an attack involving biological and chemical agents (Castillo-Salgado, 2010). Public health systems were being used as early warning tools of possible bio-terrorist attacks. Health workers were also moved to the forefront to engage in health diplomacy as part of foreign policy of Western powers. But questions arose about whether or not health workers could be considered neutral (which was important to their credibility) if they were associated with foreign and security policy. This would also impede in efforts to create diverse

32  Key challenges alliances that are critical to responding to global health challenges. For example, the Bill and Melinda Gates Foundation has ensured that it is distinct from US global health policy and US foreign policy in order to play a major part in global health (Harman, 2016). In spite of these reservations, there have been proposals that health services request support from government defence and security budgets since health services often have to operate on the front lines of conflict (Aldis, 2008). A senior WHO official agreed with the suggestion to fund public health activities from security budgets and recommended that governments create a special body that can address both public health and national security in order to ensure that these sectors are working together (Rodier, 2007).

Environmental security Much of this chapter has focused on the importance of health security, but it has been increasingly acknowledged that human security depends on environmental security (Busby, 2021; Busby et al., 2018; Kaldor, 2018; Parry, 2011; UNDP, 2021). Environmental security is safety from environmental dangers originating within or across national borders. As a result of pollution, greenhouse gas emissions, land degradation, water scarcity, coastal and marine degradation, climate change, and sea level rise, there are a host of new threats to human security that people across the world face (Barnett, 2009). This also includes repairing environmental damage caused by conflict and the threats coming from natural hazards. Environmental security looks at the impact of environmental issues on peace, conflict, stability, health, nutrition, and quality of life. Environmental security encompasses food security, energy security, water security, and emerging notions of adaptation and resilience to hazards, sometimes referred to as climate security. One of the issues that the book focuses on is the impact of natural hazards, both those that have no connection to climate change and those that are directly affected. This line of research looks at the extent to which a community is negatively impacted by a natural hazard – or their vulnerability. The World Disaster Report gave an annual average of people killed and affected by disasters in Nigeria as 96,786; this constitutes 0.09% of people killed in the world in total (Oni and Okanlawon, 2013). In Lagos State alone in Nigeria, over 100 buildings have collapsed since 1978 (ibid.). This indicates that Nigeria is especially vulnerable if a disaster hits. The issue of environmental security rose to some initial prominence during the Cold War with international summits held in the 1970s on the environment alongside new international environmental agreements. The first major global environmental summit was the 1972 United Nations Conference on the Human Environment. By 1987 a landmark report, Our Common Future (also known as the Brundtland Report) was released by the UN’s World Commission on Environment and Development, which focused on sustainable development. It was here where the term environmental security was first introduced. This report would lead five years later to the 1992 UN Conference on the Environment and Development. Other conferences would be held every five years in 1997 and 2002. These conferences led to major multi-lateral environmental threats on climate change. In the meantime, more articles and research projects emerged on environmental security. More states were recognizing that environmental issues were big enough to warrant calling them security issues. Environmental security has taken on new meaning as sustainability and the protection of natural resource have become essential elements of security. More scholarship has been done to understand the impact of environmental catastrophes, such as those caused by natural hazards (Lloyd and Shepherd, 2020; Vallero and Letcher, 2012;

Human security, health, and disaster  33 Van Aalst, 2006). For example, there is greater recognition of how a flood can disrupt agricultural production, spread disease, destroy infrastructure, and cause migration across borders, which can all threaten human security. Scholarship noted that the military was not well suited to dealing with environmental problems. Though the most powerful discourse about security is about national security and the risks to the nation-state, the concept of environmental security has been central to the process of deepening and broadening the content of security. As previous mentioned, the 1994 Human Development Report, by the UNDP was also important to elevating the importance of environmental crises. Great powers, including the US were acknowledging the threats posed by environmental degradation, though these concerns were mostly driven by how the environment affected their own strategic interests. The US drew up a security strategy called Strengthening National Security through Environmental Protection which focused on how environmental threats could affect US interests abroad, such as the destruction of Haiti’s forests. The CIA also created the Central Intelligence Environmental Center to track environmental issues and provide data to the international community in the 1990s (though this was shut down in 2015) (Plautz, 2015). In spite of these concerns, there still is a greater priority placed on human-made disasters, such as armed conflicts. The actual threats that people struggle with following a disaster are similar to those of an armed conflict, such as lack of food, water, disease, shelter, and social order. Disasters can have a huge impact on health and quality of life. Case in point, Indonesian forest fires have caused more than 20 million cases of smoke-related respiratory illnesses (Frankenberg et al., 2005; McCall, 2019). Additionally, there is increasing evidence that there is an interconnection between the environment and security, as social tensions are rising over natural resource depletion, while at the same time, environmental issues are more visible in countries affected by conflict (Bernauer et al., 2012; Raleigh and Urdal, 2007). Development studies have also been interested in environmental security and sustainability, but approach them by examining the impact of environmental challenges on development, poverty, and inequality. Environmental security approaches may look more in depth at the interdependence of threats and people from an environmental standpoint. Like health security, environmental security necessitates collective action. However, in contrast to health security, environmental security issues can serve as a driver of conflict. Scholars have tested this relationship, which has thus far been inconclusive. Nevertheless, the UNDP also argued that environmental issues would directly or indirectly induce conflict and instability (Detraz and Betsill, 2009). Though there were some positive developments in the areas of cooperation in water resources and acknowledgement of the value of multilateral participation when it comes to addressing environmental issues, other scholars pointed to the negative impacts of environmental degradation on human security and conflict (Detraz and Betsill, 2009). Disaster security and development As mentioned previously, an important subset of environmental security is disaster security. The development literature has mostly acknowledged that disasters have a huge impact on human development and have altered the quality of life of people affected. It was also recognized that development may reduce fatalities and help societies be more resilient in the face of a disaster (Ferreira et al., 2013). However, most of the earlier disaster resilience literature has focused on immediate survival, with less emphasis on addressing the proximate and underlying risks and human vulnerability (Wisner et al., 2004; Godschalk et al., 1998; Cutter et al., 2003).

34  Key challenges Today there is more theoretical and qualitative consensus that development dynamics drive disaster risk, and that disaster risks and impacts can constrain and affect development in wide reaching ways. As Chapter 5 will explain in more detail, it is low-income countries that suffer a disproportionate number of fatalities when a natural hazard hits. In fact, the UNDRR had acknowledged that most of the fatalities have taken place in low-income countries (Wallemacq and House, 2018). This is in spite of the fact that of all the people in the world exposed to disasters, only 11% of those exposed are from low-income countries (ibid.). Additionally, at the individual level, rich people are generally less affected, living in less dangerous areas, and better able to overcome losses. Those who are poor, marginalized, elderly, are more likely to be victims – as are women and children. Like the health security literature when it comes to infectious diseases, the disaster literature recognizes that there are certain groups that are more susceptible to being victimized by a natural hazard; they have less capacity to anticipate, cope with, adapt, and recover from natural hazards. Human security approaches in dealing with disasters encourages us to think of the needs of the most vulnerable. Some geographic areas are more at risk of natural hazards than others. Natural hazards do not affect individuals, societies, and countries evenly, and they also do not affect regions evenly. In the case of natural hazards, it is Asia that is disproportionately affected in terms of victims, with Bangladesh, China, and India bearing the brunt. When it comes to economic burden of losses, most of the losses take place in high income countries. The IMF estimated that economic damage due to disasters has grown from an average of $20 billion in the 1990s to $100 billion during the 2000–2010 period (Laframboise and Loko, 2012). This is due to increased exposure of population (greater populations) and assets (more valuable assets). Some of the most expensive disasters in the world have taken place in some of the countries with the biggest GDPs, such as the US, China, and Japan. However, when taken as a percentage of GDP, disasters from 1985–1999 amounted to a roughly 2–3% of GDP loss for richest countries and closer to 14% of GDP loss for poorer countries (Abramovitz, 2001). Disasters constitute exogenous shocks to the economy but have a less far-reaching impact than a pandemic. We are still learning the economic impact of the Covid-19 pandemic, but it is clear that the impact is severe, long term, and will have a massive effect on low-income countries in particular. Policy makers are already predicting that inequalities will increase as a result of the pandemic. In addition to looking at the impact of disaster events, a subset of disaster security looks at resilience. It has been noted that one way to achieve resilience is to utilize a sustainable development approach. For the most part, the disaster literature has argued that reducing disaster risk and achieving sustainable development are complimentary goals (Collins, 2009; Collins et al., 2015). Disasters impact development, while disaster recovery requires environmental, societal, and economic sustainability. Human security approaches in dealing with disasters encourage using bottom-up approaches to rebuilding and ensuring that resilience measures take into account the needs of the community. Disaster and development approaches are emphasized in the Hyogo Framework for Action and later the Sendai Framework, which was recognized as a way of achieving sustainable development goals (Olowu, 2010). However, though the goals of the frameworks are lofty, there are several areas of concern. While the framework made significant progress in building institutions, policies, and legislation to reduce disaster risk, many low-income countries were not able to make much progress towards managing disaster risk drivers. Additionally, the framework failed to sufficiently integrate disaster risk considerations into important development

Human security, health, and disaster  35 decisions. Development continued at a rapid pace with little attention to potential increase in risks from natural hazards. Thus, new risks were being generated much more quickly than risks were being reduced. Moreover, both frameworks for action avoided mentioning the term human security (Wanner, 2020). In spite of these issues, disasters are universal, much more so than conflict as of late. Disasters illustrate that even the most highly industrialised countries have some vulnerability. As such, it is not surprising that disaster resilience, reducing the impacts of disasters and strengthening communities, continues to be an important area of concern (Santos and Leitmann, 2016).

Conclusion As the chapter explained, traditional approaches to security have focused on securing the nation state from threats emanating from other states. Meanwhile, traditional approaches to development argued that if states achieved economic development, this was a panacea for all other problems and threats. While traditional security approaches failed to acknowledge the prevalence of new threats and the types of threats people actually endure, modernization theory failed to address the role development plays in creating more threats. In an attempt to tackle health, environmental, and more specifically disaster security, it needs to be emphasised that development approaches that ignore the costs of economic growth and development are bound to create a vicious circle. Additionally, the prescriptions of traditional security approaches have also failed to bring more security, neglecting more pressing threats to the individuals, while also offering solutions that generate new threats to security. This chapter sought to introduce the concept of human security and why it is important to understanding the impact of infectious diseases and natural hazards. By taking a human security approach, the impact of diseases and disaster are investigated at all levels, including internationally, regionally, nationally, sub-nationally, and individually. On the one hand, the approach focuses on how individuals are affected by threats and what really makes someone vulnerable. On the other hand, it is also acknowledged that some local problems can eventually have an international impact, and the impact of a threat can be universal. Human security approaches also understand the way different threats are interconnected, as the threat of one issue may be connected to the threat of another issue. For example, climate change may drive more intense meteorological events, which can create hardships, poverty, and disease. Because there are so many interrelated drivers of insecurity, it is important to take a preventive approach that addresses the underlying causes, with an understanding that the solutions need to tackle issues head on before crises become untenable. This necessitates a strategy grounded in sustainable development, which understands how environmental degradation and unbridled development create insecurity. Many of the solutions to both disease and a disaster event are focused on mitigation more than on prevention. Unless the root problems of insecurity are addressed, a disaster event can generate new vulnerabilities. Haiti was more vulnerable to disaster after its massive earthquake in 2010 due to environmental degradation, unregulated growth in urban areas, and poverty. Understanding the deep root causes of insecurity can help to build more resilient societies that are safe from chronic threats of poverty, violence, disease, and disaster. Before addressing some of these underlying causes of health and disaster insecurity, the next chapter introduces what we mean by infectious diseases. Why are infectious diseases a major threat to human security, and which diseases pose the biggest threats?

36  Key challenges

Key Questions? 1

What are the pros and cons of a broad versus a narrow view of human security? What are the issues with the human security concept? 2 What are the ways in which human security approaches challenge traditional approaches to security? 3 What do traditional development approaches such as Modernization Theory fail to understand about the impact of development? 4 What are the controversies around the securitization of health? 5 In what ways are human security and human development approaches compatible? In what ways do they differ?

Note 1 This was chaired by Amartya Sen and Sadaka Ogata.

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2 Infectious diseases

Introduction Infectious diseases continue to be a major concern for human security. Though noncommunicable diseases such as heart disease and strokes cost more lives each year, infectious diseases cause about 12 million deaths annually and account for 15–20% of total global mortality (Our World in Data, 2017). Most of these deaths could have been prevented through existing drugs and vaccines and simple access to food and drinking water free of contamination (WHO, 2020b). Three diseases – AIDS, tuberculosis, and malaria – continue to account for a large share of deaths attributed to infectious diseases. When deaths from diarrhoeal disease and lower respiratory infections are added, these five diseases alone are responsible for much of the total infectious disease burden. Nevertheless, there have been huge improvements in preventing deaths. From 2000–2020 there was a 30% reduction in TB deaths, with 1.4 million deaths in total in 2020. There were 59% fewer deaths from AIDS in 2019 than in 2000, with 690,000 deaths in 2019. Annual malaria deaths have also been more than halved since 2000, with 409,000 deaths in 2019. There has also been a reduction in diarrheal deaths from 1.9 million to 1.1 million between 2000 and 2019 (WHO, 2019a, 2020b). Though the developed world has largely eradicated many infectious diseases thanks to the success of vaccination programs, among other things, outbreaks of infectious disease are still fairly common in the developing world. Six of the top ten causes of death in low-income countries are still communicable diseases (WHO, 2019a, 2020b). Sub-Saharan Africa has been particularly affected. The average global life expectancy for women is 75 years, but for a woman in Africa it is 63 years. Not only are citizens in poor states more likely to contract infectious diseases, but outbreaks of disease are more likely to keep them poor (Barrett et al., 2019). Nevertheless, it is not just the developing world that has to worry about infectious diseases. The Covid-19 crisis has illustrated that no country is immune to a pandemic event. With millions affected around the globe, our increasingly interconnected world has spread pathogens to every continent including Antarctica (de Sousa et al., 2017). In this chapter, we discuss the problem of infectious disease vulnerabilities by introducing the various types of disease threats. We start by looking at the key trends in infectious diseases. We explain what infectious diseases are, how pervasive they are in the developed and developing world, and what their consequences are for health. To help with our understand­ing of infectious diseases, we differentiate between pandemic events and endemic disease burdens. We then provide an overview of the most notable infectious diseases, HIV/AIDS, malaria, tuberculosis (TB), diarrhoeal diseases, other neglected tropical diseases, Ebola, and finally coronaviruses. In doing so, we explain how these diseases are transmitted, how infectious they are, how deadly they are, and how prevalent they are. These all have important implications for health security.

DOI: 10.4324/9781003128809-4

Infectious diseases  43 Key concepts

What is a disease? A disease is any condition that impairs the body’s ability to function, and an infectious disease is any disease caused by a pathogen that can spread indirectly or directly from one person to another. Before exploring how infectious diseases affect the body it is important to clarify what we mean by pathogens. A pathogen is simply a germ that causes a disease. Germs, which are often referred to as microbes, are found everywhere. Most are harmless, but as noted, some cause diseases and can be deadly. Pathogens spread through direct contact with a person who is sick – through kissing, touching, and sexual contact, contact with infected blood, saliva, maternal transmission, or aerosols (coughing and sneezing). Pathogens can also spread through indirect contact, such as by touching something that has germs on it. Pathogens can also spread through insect or animal bites (which is vector to person) and through contaminated water, food, soil, and plants. There are four different types of pathogens to highlight: bacteria, fungi, parasites, viruses (Henry, 2020; Wolfe et al., 2007). Bacteria are one-celled microbes that give off toxins or harmful chemicals that can make people sick. Common forms of bacterial infections include strep throat, urinary tract infections, or tuberculosis (TB). Fungi are primitive plant-like organisms, such as mushrooms, mould, mildew, and yeasts. Athlete’s foot is a common fungal infection. Parasites are microbes that survive by living on or in other living things. Protozoa and worms are usually grouped together as parasites. Malaria is an infection that is caused by a protozoan parasite. Finally, there are viruses, which are tiny capsules that contain genetic material that invade cells and multiply, killing, damaging, and changing these cells and making people sick. Viral infections include HIV/AIDS and the common cold (Anderson and May, 1992). Pathogens cause an infection by colonising the skin or the internal mucosal surfaces of the respiratory, gastro-intestinal, or urological tracts. The pathogens must then overcome or bypass the innate immune defences. If a pathogen is able to do so, adaptive immune responses will take place, which usually clears the infection. When the immune system is unable to do so, an infectious disease results. Infectious diseases agents that grow or metabolise in the cells or within the body fluids not only damage the tissues but also produce and release toxins or enzymes that interfere with how the body functions. The disease agent can then damage and spread to other organs and/or systems. Another problematic response is when the immune system tries to fight the infection by turning against itself, known as immunopathology (which helps to explain why some Covid-19 suffers are long-haulers) (Méthot and Alizon, 2014). In these instances, the immune response may do more damage than the actual pathogen. Pathogens vary in terms of how virulent they are, which is the degree to which the pathogen can damage the host; the ease of human-to-human transmission; how transmissible it is during the incubation period; and the length of the incubation period (Guerrant et al., 2011). Of particular interest to epidemiologists is how infectious pathogens are. How many susceptible people, on average, one infected person can infect is known as the replication number/ reproduction number, or R0. For example, Covid-19 was initially thought to have replication number of 2.5, but by July of 2020, it was thought to be has high as 5.7 (Sanche et al., 2020). This number could be much higher given all of the asymptomatic cases and lack of testing. This means that an infected person would likely infect on average 5.7 people. The various mutations of Covid-19 first identified in the UK, South Africa, and Brazil reportedly have infectious rates that are much higher (BBC News, 2021; Mahase, 2021). In contrast, the rate for SARS is 3.5 and for MERS is 0.8 (see more about both later in the chapter); influenza,

44  Key challenges 1.5; Ebola, 2; mumps, 4.5; both smallpox and rubella, 6; while measles is 16 making it one of the most contagious infectious diseases (Guerra et al., 2017; Pitlik, 2020).

What are pandemics, epidemics, and endemic diseases? Broadly speaking, there are two different types of disease threats to human security: endemic diseases threats that are constantly present; and epidemic and pandemic diseases events which are extreme and unpredictable. The former should be prioritized higher on security agendas but tend to be overlooked by other threats, while the latter have raised alarm bells from health security experts for some time now. An epidemic is a disease that affects a large number of people within a community, population, or region, with new cases of the disease exceeding what would be expected in a significant way or an out-of-season transmission. In contrast, a pandemic is an epidemic that has spread across multiple countries and/or continents – or essentially an epidemic that can travel.1 Pandemics, by definition, have a wider geographic extension. Both epidemics and pandemics are often associated with novel diseases – or a new variant of an existing pathogen – where there is minimal population immunity which makes it easier for a large part of the population to be infected (Grennan, 2019). They also have a high case fatality rate (meaning younger people can die as well) and a high attack rate (meaning explosively fast transmission from person to person). Diseases with low rates of transmission or low rates of fatality and morbidity are rarely classified as pandemics even if they spread to many countries. Epidemics and pandemics are not to be confused with diseases that are endemic to a region. A disease that is endemic belongs to a particular group of people or territorial area but does not tend to spread to other countries or spike in numbers over time (Maudlin et al., 2009). Instead, it is a constant presence, such as malaria in parts of Asia and Africa or HIV/AIDS which still is a pandemic but has also become endemic to Africa. Once there is an outbreak that is greater than the number anticipated or single case in a new area, if it is not completely controlled then it can become an epidemic. For example, dengue fever outbreaks have taken place in Hawaii periodically (Johnston et  al., 2020). However, these outbreaks have been controlled and have not spread to other parts of the US (to become endemic to Hawaii or an epidemic) or to the world (to become a pandemic). An outbreak is considered ‘out of control’ once it reaches the threshold where each victim is infecting two others.

Box 2.1  Pandemic history Pandemics have plagued humanity since early times. The Bubonic plague, also known as the Black Death, originated from rats and spread to humans via infected fleas. It killed up to 75 million people many centuries ago and wiped out 30–50% of Europe’s population. It took more than 200 years for the continent’s population to recover (Dunham, 2008). Smallpox killed somewhere between 50 to as many as 300 million people (Flight, 2011). In Europe during the 1800s, an estimated 400,000 people were killed each year by smallpox (Riedel, 2005). In the US, smallpox decimated the Native American population and, combined with other infectious diseases, killed upwards of 90% (Koch et al., 2019). In the last 150 years, there have been a series of flu pandemics

Infectious diseases  45 that have killed one million each, such as the Russian flu (1889–1980), the Asian flu (1957–1958), and the Hong Kong flu (1968–1970). In the early years, people believed that pandemics were the wrath of gods and spirits, which led to disastrous responses. However, the practice of quarantine actually began in the 14th century to protect coastal cities from plague epidemics. Port authorities required ships that arrived in Venice from ports that could be carrying disease to sit at anchor for 40 days before landing. This explains the origin of the word quarantine, which comes from the Italian words quaranta giorni, or forty days (Chatterjee and Chauhan, 2020). By the 19th century, geography and statistical analysis were used to better understand disease outbreaks. During a cholera outbreak in Europe in 1854, Dr John Snow concluded that cholera was spreading through tainted water. He decided to display neighbourhood mortality data directly on a map, which revealed that there were a cluster of cases around a specific water pump (Brody et al., 2000). As Chapter 4 will explain, the move to agrarian communities led to a huge increase in the scale and spread of disease. Widespread trade created new opportunities for human and animal interactions that spread disease, with malaria, tuberculosis, leprosy, influenza, smallpox, and others first appearing during these early years. Larger cities, exotic trade routes, and increased interactions with different people, animals, and ecosystems made pandemics more likely to occur.

Trends in infectious diseases Prior to the discoveries in modern science during the 19th century, life expectancy was just 29 years in 1800. Many people died in infancy due to disease or infection during childbirth or a wound. As so many citizens were dying of disease, cities were only able to keep up their populations through an infusion of migrants. Infectious diseases were responsible for the largest global burden of premature deaths and disability until the end of the 20th century, when they were surpassed by non-communicable diseases (for more on this see Box 2.2). Advances in sanitation, vaccines, and anti-biotics were able to drastically increase life expectancy rates. Death rates from infectious diseases have dropped by 0.8% each year due to improvements in medicine through the last century (Lipsitch and Santillana, 2019). While advancements in treating bacterial infections have been impressive, there are few anti-viral drugs that can treat emerging viral infections (for more on this see Box 2.3). To date, only smallpox has been completely eradicated, in 1979, after a vaccine was created. This means that the most important intervention is to break the chain of transmission. This has proven to be difficult to do at times and, as Chapters 11 and 12 will reveal, requires tremendous coordination and state capacity. In spite of this, there has been tremendous progress in reducing mortality rates for most infectious diseases. In low-income countries from 2000 to 2010, the number of deaths from HIV/AIDS, TB, and malaria fell by 46%, 36%, and 35%, respectively (Norheim et al., 2015). As previously mentioned, these trends have continued from 2010–2020. Re-emergence of diseases Though the number of deaths due to the big three diseases has declined, the number of disease outbreaks in total has increased each year. Since 1980, there have been more than

46  Key challenges three times as many outbreaks per year. The term emerging and re-emerging diseases (ERD) refers to infectious diseases which have been increasing or threatening to increase in the near future (Lederberg, 2000; Nii-Trebi, 2017). The WHO focuses on research to understand the emergence of new diseases and their reappearance. There are at least 30 known infectious diseases that have been identified as re-emerging or spreading globally. One of the notable concerns is that TB is making a deadly comeback. Though there has been marked improvements in reducing death tolls, nearly one-third of the earth’s total population has latent TB infections (for more on this, see the section on TB). In addition to TB, we have also have witnessed numerous outbreaks of cholera, anthrax, yellow fever, dengue fever, chikungunya, typhoid, West Nile, artemisinin-resistant malaria, and plague (Levitt et al., 2010; Zumla and Hui, 2019). In December of 2015, the WHO convened a meeting of scientists and public health experts to prepare for how to prioritize emerging disease pathogens with the greatest risk of epidemic or pandemic potential, based on how severe the outbreak could be and the inadequacy or non-availability of medical responses (WHO, 2015). The seven diseases prioritized were Crimean-Congo haemorrhagic fever, Filovirus diseases (Ebola virus disease and Marburg), highly pathogenic emerging Coronaviruses relevant to humans (MERS Co-V and SARS), Lassa fever, Nipah, Rift Valley Fever, and a ‘new disease,’ which is unknown but will require urgent action. Three other diseases, chikungunya, Severe Fever with Thrombocytopenia Syndrome, and Zika, were also considered important. Tuberculosis, malaria, avian influenza, and dengue were not included because they already generate major funding (NiiTrebi, 2017).

Box 2.2  Non-communicable diseases Non-communicable diseases (NCDs) are the leading cause of premature deaths, with 15 million people dying between the ages of 30–69 (WHO, 2018b). In spite of this, most of the framing of health security focuses on infectious diseases. NCDs, in contrast to infectious diseases, can rarely be cured and require life-long management and costly treatments, which poses a major threat to individual and collective health security. For example, dementia affects 50 million people worldwide, 60% of whom live in low- and middle-income countries (WHO, 2018b). These numbers are expected to almost triple to 135 million worldwide. The costs of caring for dementia-related care is more than $800 billion or slightly less than the 17th biggest economy in the world (Wimo et al., 2018). Like infectious diseases, NCDs are also impacted by globalization. However, in this case it is due to lifestyle changes, such as tobacco use, alcohol intake, poor diet, and lack of exercise. As individuals diverge from traditional lifestyles, stress levels have increased, upping the propensity for hypertension. Public healthcare systems are still poorly equipped to address these issues (Bertram et al., 2018; Boutayeb and Boutayeb, 2005; Oldman, 2019). ‘Lost years of life’ measures how many years shy of the realistic life expectancy people die. In Africa many people die early due to infectious diseases like pneumonia, malaria, and diarrhoea which are treatable in countries with strong healthcare systems. In

Infectious diseases  47 China, infectious diseases used to be the leading cause of lost years of life, but improvements have resulted in strokes eclipsing them. In other parts of the world, disease is not the leading cause of lost years, but these cases are the exception such as Syria (war), Venezuela (violent crime), and Saudi Arabia (traffic accidents). According to the WHO (2018b), over 85% of the ‘premature’ deaths that take place between the ages of 30 and 69 occur in low- and middle-income countries. Though NCDs are not the subject of this book, the preventive approach of investing in public healthcare and sustainable development and enhancing global cooperation and multi-sectoral coordination that the book advocates applies to addressing NCDs as well.

Infectious disease and human security Though often under-prioritized as a security threat, pathogens are more effective killers than guns, bombs, or any weapon of mass destruction. Because viruses are both virulent and infectious, they are the most likely to cause a pandemic, which is considered to be a major threat to human security. Prior to the Covid-19 pandemic, the WHO claimed that the pathogen most likely to cause a pandemic was influenza (WHO, 2018a). Many experts have warned that it is not a matter of if there will be another influenza pandemic but when. As we have seen with the recent SARS and Covid-19 pandemics, coronaviruses are highly dangerous and can spark pandemics as well. The danger of influenza viruses in particular is their genetic instability. Other viruses that cause disease have been more stable, such as measles, mumps, and smallpox. These viruses have been contained and, in some cases eliminated, through vaccinations, which have been made effective by the stability of those viruses. This ensures that antibodies are developed so Table 2.1  Top causes of death in developing countries • Heart Disease: this causes 7.4 million deaths globally with 75% taking place in low- and middleincome countries. This is the disease of blood vessels not supplying blood to the heart. • Lower respiratory infections: this causes 1.5 million deaths globally each year, 42% of which occur in developing countries. This is the leading cause of death in children under 5 years. • HIV/AIDS: this caused 690,000 deaths globally. This was, but no longer is, the leading cause of death in Africa. • Perinatal conditions or maternal deaths: this is the death of an infant with the first week of life or the death of a mother in children birth. Approximately 2.8 million babies die around the world within the first week of life, deaths which are very preventable. • Stroke or cerebrovascular diseases: five million people die globally from a stroke each year. • Diarrheal diseases: approximately 525,000 children under the age of 5 years die from diarrhoeal diseases each year. These diseases can be prevented by drinking clean water and practicing good sanitation habits. • Malaria: over 400,000 die each year globally, mostly young children and pregnant women. • TB: there were 1.4 million deaths in 2019. TB is treatable but, without treatment, the death rate is high. • Chronic obstructive pulmonary diseases: there were 3.17 million deaths, 90% of which occur in low- or middle-income countries. • Traffic accidents: 1.25 million people die in car accidents each year, 90% of which are in low- or middle-income countries due to unsafe cars and inadequate law enforcement. Note: Unless noted, the year for the data was 2017

48  Key challenges that people are immune. In contrast, influenza viruses have a high mutation rate and are constantly changing as they circulate, making it harder to eliminate them in spite of the creation and administration of flu vaccines. Like influenza, coronaviruses are also ribonucleic acid viruses that have high mutation rates, which means that they tend to evade immunity and may be more resistant to drugs and potentially vaccines (Estola, 1970; Peters et al., 2020).2 As Covid-19 has mutated into many different more infectious and more virulent variants, there is growing concern that vaccinations will not be able to keep up (Williams and Burgers, 2021). Probabilistic modelling tools are valuable for assessing pandemic risk and estimating the burden of pandemics. The risk of a pandemic is affected by two factors: the spark risk (for more on this see Chapter 4) – or where a new infectious or re-emerging disease is likely to arise – and the spread risk, or how likely a disease is to diffuse through human populations through either human-to-human transmission (such as SARS) or, much less likely, through vector to human transmission (such as the Zika virus). The chances of having an influenza pandemic that would have a global mortality rate of 0.0008 – or about 600,000 deaths – have a 3% probability of taking place in any given year (Colizza et al., 2007; Tizzoni et al., 2012). The chance of an influenza pandemic taking place that has a case fatality rate of 0.008 – or about 6 million deaths – is 1%. The probability of having a pandemic as deadly as the 1918 flu is less than 0.02% (Colizza et al., 2007; Madhav et al., 2017). A pandemic that causes large morbidity and mortality rates can completely overwhelm a healthcare system. In overburdening the state, the flu can indirectly cause death rates to more than double because of the lack of healthcare for other ailments and diseases (Simonsen et al., 2013). This has an especially detrimental effect on the developing world, which may not have healthcare systems that are equipped to deal with a surge in health issues. But it is not just pandemics that are a major threat to human security; endemic diseases also incur huge costs on many countries around the world. Most countries with a high disease burden are in the developing world and have not been given adequate support for diseases that don’t travel effectively, such as neglected tropical diseases. As Chapter 1 explained, it was not until the AIDS crisis in the 1980s that infectious diseases were escalated to a human security issue due to fears that the virus would wipe out states and their militaries in Africa and create tremendous instability. True, HIV/AIDS has taken an enormous toll on the state and society in Africa and elsewhere around the world. However, there are many other endemic disease killers that have not garnered enough attention from security specialists even though the morbidity and mortality rates should generate more attention, such as diarrhoeal diseases.

Box 2.3  What is a flu pandemic? A flu pandemic is when influenza spreads on a global scale and infects a large proportion of the population. When influenza viruses infect humans, they can lead to the onset of respiratory disease with the possibility of affecting the upper respiratory tract (nasal passages, throat) and lower respiratory tract (lungs). Influenza pandemics have occurred repeatedly throughout history, roughly every couple of decades. The timing, however, cannot be predicted with certainty and the pandemic can come in multiple waves. In addition to the deadly 1918–19 (often erroneously referred to as the Spanish

Infectious diseases  49 flu) flu which killed up to 50  million people, there were also the 1957–58 and the 1968–69 flu pandemics that took a huge toll, killing at least one million people each (Trilla et al., 2008).3 When a flu pandemic takes place, it is distinguished from normal flu season by having a higher attack rate, or a higher number of people experiencing clinical symptoms of infection. For example, the attack rate for the 1918–19 flu was 25% compared to 10% in a normal flu season in the United States, decreasing the lifespan in the US by ten years (Ezekiel, 2003; MacKellar, 2007). Additionally, a flu pandemic can affect people at any age and will cause much wider disruption. While, the seasonal flu can lead to 650,000 deaths each year due to respiratory diseases, a flu pandemic has a higher case fatality rate and is more infectious (WHO, 2017a). The most notable example is the 1918–19 flu, which killed more people than the total death toll of World War I (MacKellar, 2007). The death rate was 2.7% to 5.4% of the population, and it dramatically affected life expectancy rates across the world (Roser, 2020). In the US, the life expectancy rate dropped suddenly from 51 years in 1917 to 39 years in 1918 (Walsh, 2020). To some extent, the threat of a pandemic flu has become more important in government agendas and was added as a new threat to national security strategies in some countries (Beach et al., 2020).4

What are the major infectious diseases? Almost all deaths and half of all premature deaths from infectious diseases result from five diseases – AIDS, pneumonia, TB, diarrhoeal diseases, and malaria in 2016 (Roser and Ritchie, 2016). We look at the big three, AIDS, malaria, and TB, but also at diarrhoeal diseases, Ebola, NTDs, and coronaviruses. There is an interconnected nature of these diseases to other diseases, making them a big threat to human security. For example, there is a growing body of evidence that non-pregnant HIV-positive individuals are more vulnerable to malarial infection and to severe disease than those without HIV infection, and that this susceptibility is related to the degree of immunosuppression (Abu-Raddad et al., 2006; Alemu et al., 2013; Froebel et al., 2004; González et al., 2012). Malaria is closely linked to other diseases, perhaps by making individuals more susceptible to other infections. HIV is also connected with TB, as millions of people are estimated to be coinfected with TB and HIV, with TB being the leading cause of death of HIV-infected individuals in Africa. Up to 70% of HIV positive people in Africa are also coinfected with TB (WHO; Letang et al., 2020). This coinfection makes it more difficult to diagnose TB and increases the risk of side effects for treatment. Sexually transmitted diseases, such as genital ulceration, gonorrhoea, and infections with chlamydia and trichomonas, also increase the infectiousness of HIV-positive men and women and the susceptibility of HIV-negative individuals to HIV infection during unprotected heterosexual contact (CDC, 2021). Malaria is an infectious disease transmitted through mosquitoes that belong to the genus anopheles, which are vectors of the parasite (or a vector-borne disease). It is passed through female mosquitoes which bite humans and transmit infected blood from one person to the next. The female mosquitoes use the proteins from human blood to make a batch of eggs, which are often laid in water, including marshes, puddles, and irrigation channels. The mosquitoes usually bite from around dusk to dawn. Malaria is therefore not endemic in places that are dry, cold, or high in altitude, given the key role of water for egg laying as well as the

50  Key challenges Table 2.2  Modes of transmission of infectious diseases* Water-based: transmission through contact with water (through bathing or wading) containing organisms, such as helminths (worms) Water-washed: transmission caused by lack of water linked to inadequate personal, domestic, or agricultural hygiene, such as trachoma, which causes blindness Water-borne: transmission through ingestion of water – such as during drinking and, to some extent, bathing, such as cholera Vector-borne: transmission through vectors (like rodents or mosquitoes). Mosquitoes, a common vector, proliferate in stagnant pools of water, such as yellow fever and dengue fever. The global burden of vector-borne diseases accounts for more than 17% of infectious diseases in humans (Burkett-Cadena and Vittor, 2018). Fomite/contact transmission: transmission through direct contact with an infectious person, such as touching during a handshake, or with an article or surface that has become contaminated. Ebola requires close contact – it is not airborne – as does rhinovirus, which often causes the common cold, and norovirus, which often causes stomach upset. Droplet transmission: transmission through large droplets from sneezes and runny noses. Air-borne (aerosols): transmission through exposure to virus-containing respiratory droplets comprised of smaller droplets and particles that can remain suspended in the air over long distances and time, such as measles, smallpox. Diseases like Covid-19 spread through air, droplets, and close contact. Food-borne: transmission is through eating food contaminated with bacteria, viruses, parasites, such as salmonella; foodborne diseases are caused by contamination of food and occur at any stage of the food production, delivery, and consumption chain. Blood-borne: transmission is through contaminated blood and other body fluids, such as HIV and hepatitis B and C. Some blood-borne diseases can be contracted through sexual contact or intravenous drug use. Diseases that are transmitted through insect vectors (such as Zika virus, West Nile virus, and malaria) are classified as vector-borne even though the causative agent can be found in the blood. *It’s important to note that some diseases have multiple modes of transmission.

fact that malaria parasites cannot develop at temperatures lower than 16.7oC (Waite et al., 2019). Even in warm climates, transmissions are higher during the rainy season. Eggs will hatch in less than a week, potentially leading to a rapid spread of the disease (Blanford et al., 2013). According to the World Health Organization (WHO), as of 2019 there were 229 million cases of malaria worldwide. The WHO also claims that there were over 400,000 deaths each year due to malaria (though some health journals allege that the number could be as high as a million), 94% of which occur in Africa (WHO, 2020c). Along with India, 19 countries in sub-Saharan Africa carry 85% of the global malaria burden. Six countries accounted for more than half of all of the malaria cases worldwide: Nigeria (25%); the DRC (12%); Uganda (5%); Cote d’Ivoire, Mozambique and Niger have 4% each (WHO, 2020c). Malaria has an especially hard effect on child mortality rates (WHO, 2019b). In fact, 61% of all malaria deaths worldwide are children under the age of 5 years and over two-thirds are under 14 years. Malaria accounts for upwards of 15% of all deaths in that age group in Africa (ibid.). Additionally, pregnant women who contract malaria face heightened risks for offspring with premature birth and low birth weight. Despite malaria mortality rates falling by 25% since 2000, in the world, every two minutes a child dies of malaria, posing a major threat to human security (WHO, 2020c). The symptoms of malaria include fever, headache, and nausea. Pregnant women who contract malaria can experience spontaneous abortions, while babies born to mothers with the disease often have a low birth weight, which in turn can increase risk of infant mortality.

Infectious diseases  51 Once transferred to the body, the infection can travel to the liver and multiply and enter the red blood cells. Children with severe incidences of malaria can have lifelong cognitive problems as well as learning disabilities (Fernando et al., 2010; John et al., 2008). Their immune systems are also compromised, making them more susceptible to other illnesses. The type of malaria also affects fatality: the strains in the Americas have lower fatality rates than those in Africa. One of the more serious forms, cerebral malaria, for example, affects over a half million children each year in Africa and kills anywhere from 10% to 40% of patients (Postels and Birbeck, 2013). AIDS/HIV: Human Immunodeficiency Virus (HIV) is a sub-microscopic parasite that lives and reproduces in the cells of host organisms (Putzel, 2003). HIV infection makes a person vulnerable to opportunistic infections, such as chronic diarrhoea, persistent fever, and pulmonary tuberculosis, as cells that are important for the functionality of the immune system are slowly lost. Over time, HIV disease transitions into Acquired Immune Deficiency Syndrome, typically knows as AIDS. By the time a person has contracted AIDS, the immune system is severely weakened and opportunistic infections take over the body, leading to prolonged illness and eventually death. Since the discovery of AIDS in 1981, more than 30 million people in the world have died of AIDS or AIDS-related diseases (Avert, 2020). The HIV virus spreads from one person to the next through the transmission of contaminated body fluids. The most common mode of transmission is through unsafe sex, followed by the passing of the infection from mother to infant through breast milk (chances are between 15% and 45%), the use of infected blood, and lastly intravenous drug use (Volmink and Marais, 2008; Avert, 2020). There is a gendered component to the transmission of the HIV virus; women are more vulnerable to contracting the disease than men (Türmen, 2003). There are several reasons for why this is the case, both biological and sociological. First, there is a greater biological concentration of HIV in semen than in vaginal secretions. Second, cultural norms put women at greater risk. Women in many parts of the world often have little say in their sexual practices and, due to social and economic disadvantages, may have to use sex in return for money, food, or shelter. In particular, female sex workers are most at risk of contracting HIV. In Kenya it was estimated that 29% of all sex workers are infected with HIV (Musyoki et al., 2015). Practices such as female circumcision also increase the risk of contracting HIV for women, while male circumcision actually has the opposite effect (Brewer et al., 2007; Siegfried et al., 2005). Though women are more at risk of getting AIDS, men are also vulnerable, particularly those who are mobile workers, defined as those who do not return home at the end of a work day. These include truck drivers, construction workers, itinerant traders, and soldiers. In the 1980s, for example, a third of Ugandan truck drivers and just about as many Ugandan soldiers were infected with HIV. When mobile workers return home, they spread the virus into their communities, compounding the problem (Gysels et al., 2001). As of 2019, there are about 38 million people worldwide living with HIV, 90% of them in the developing world and 69% of them in sub-Saharan Africa (UNAIDS, 2020). In fact, of the top 25 states in the world with the highest HIV prevalence all but two are in Africa. And in at least eight African states, the infection prevalence is greater than 10% of the adult population (for those 15–49 years old). This is true even though HIV/AIDS was unknown to Africa just 30 years ago. Looking at data from 2019, Swaziland has the highest prevalence of HIV in the world, with 27% of the population infected, followed by Lesotho with 22.8%, Botswana with 20.7% (down from a high of 38.8%), South Africa with 19%, Mozambique with 12.4%, Zimbabwe with 12.8%, and Namibia with 11.5% (UNAIDS, 2020). In terms of

52  Key challenges the total population infected, South Africa tops the list with 7.1 million citizens living with HIV (ibid.). In 2000 due to HIV/AIDS, life expectancy in sub-Saharan Africa was 15 years lower than it would have been otherwise (Putzel, 2003). Today, with the improvements in medicine and knowledge of how the disease spreads, life expectancy rates have increased approaching levels pre-epidemic. The estimated number of deaths annually from HIV/AIDS has declined from 2 million in 2005 to 690,000 in 2019, the lowest number since 1998 (UN AIDS, 2020). In spite of the progress made, globally, it is one of the most fatal infectious diseases, second only to tuberculosis, and remains a major threat to human security. AIDS killed 690,000 people in 2019 (though this is an improvement from 2005 when it killed 2 million people), accounting for 1.7% of all deaths worldwide. The death toll caused by AIDS is especially high in Southern Africa, causing 28% of all deaths in South Africa and Botswana, 24% of all deaths in Mozambique, 23% in Namibia, and 17% in Kenya. In contrast, AIDS accounted for less than 0.1% of deaths in Europe. The AIDS crisis in Africa has been far more destructive than conflict. In 1998, 200,000 Africans died due to conflict, while 2 million died due to AIDS (UN AIDS, 2020). Tuberculosis (TB) is a common infectious disease caused by different strains of mycobacteria that overwhelmingly affects those living in the developing world, constituting the leading cause of death of an infectious agent. Though TB usually attacks the lungs, it can affect other parts of the body as well. The primary symptoms of active TB include a chronic cough, fever, night sweats, and weight loss. Once the infection has spread to other organs, it can lead to many other symptoms. One-third of people around the world have latent TB. This means that they have been affected by the bacteria but are neither ill nor capable of transmitting the disease (WHO, 2020d). TB is spread through casual contact and is transmitted through the air when an individual with an active case of TB coughs or sneezes and the bacterium is inhaled. The symptoms initially are very mild, which can delay treatment and transmit the bacteria to others. Additionally, some people are asymptomatic, which also facilitates the spread. It is estimated that up to one third of all active TB cases are unknown to the health system, and someone ill with TB could infect up to 15 other people in one year. While the risk of falling ill with TB is 10% for those who have latent TB, someone with a compromised immune system such as HIV, diabetes, or suffering from malnutrition has a much higher risk of falling ill (WHO, 2020d). TB and HIV/AIDS are inseparably connected, as those infected with HIV are 16–27 times more likely to develop TB (Martinson et al., 2011; WHO, 2021). The HIV infection reactivates latent TB infections and accelerates the progression of any newly acquired TB infections. In addition, TB is an illness that expedites the progression of HIV to AIDS. It is responsible for over 30% of all AIDS-related deaths, making it the leading cause of death for people living with AIDS. TB is more easily contractible in the developing world because of compromised immunity and large rates of HIV infection and AIDS. In the developing world, TB primarily affects those who are in the most productive years of their lives, adolescents and young adults in Africa. Over 80% of all of those with TB are between the ages of 15 and 49 (children do contract TB but it does not tend to become active cases until they are adults) (WHO, 2020d). There are huge costs as a result of low productivity, due to illness, loss of financial support, and loss of life. In contrast, in Western countries, TB is a disease that mainly afflicts older people and those who are immune compromised. Efforts to combat the disease in the developing world have highlighted the importance of investing in the existing public healthcare systems rather than simply relying on standalone programs. In Tanzania, a new program launched in 1978 which relied on government

Infectious diseases  53 hospitals and clinics to provide treatment. The program required that patients were properly registered and the details of those who were cured were recorded so that public health authorities could show healthcare workers where TB services were working well and where they could be improved (Gradmann, 2019). The program proved that TB cases could decline in the developing world using the existing public healthcare system. Combatting TB requires a sophisticated healthcare system that can diagnose, isolate new cases, and properly treat the disease. Without treatment, up to 28–53% of people ill with TB who are HIV negative will die, and 65–94% of people with TB will die who are HIV positive (UNOPS, 2015). Since 2000, over 50 million people have been saved through effective diagnosis and treatment – a six- to nine-month course of anti-microbial drugs that must be administered and used with the support of a trained individual. For most individuals these drug treatments are costly, with the least expensive drugs costing hundreds of dollars (Kendall et al., 2018; Marks et al., 2014). China has achieved the most progress in reducing the TB mortality rate by 80% between 1990–2010 by injecting money into its public healthcare system for detection, diagnosis, and treatment, setting up a better drug supply system and keeping better records of progress (Wang et al., 2007). However, given the strains on already stretched healthcare systems in most countries in the developing world, eradicating TB, once a reachable goal, has become much more difficult. Another increasing concern is the high incidence of multi-drug resistant TB which requires even more treatment, more costs, and represents a threat to individuals and healthcare systems (Gagneux et al., 2006). Ebola is a virus that attacks the immune system and causes extreme loss of fluid and often death. The disease prevents blood clotting and can lead to internal and external bleeding. Eight to ten days after an individual has been infected, they may experience fever, muscle pain, headache, and sore throat. This is then followed by vomiting, diarrhoea, rash, and bleeding. Severe dehydration can lead to death within a week of initial symptoms. Because the early symptoms are similar to other maladies, it is not easy to diagnose Ebola. Though the mortality rate with Ebola was very high (50–90%), with proper supplies, trained personnel, and a new drug trialled in 2019, the disease has a possible cure rate of 90% (BBC News, 2019). Ebola was first identified in 1976 when two outbreaks took place at the same time in South Sudan and in the Democratic Republic of Congo in a village near the Ebola River (Chan, 2014; Dixon and Schafer, 2014). From 1976 onwards, there have been over 25 outbreaks (Rosello et al., 2015). The most recent outbreak in the Congo in 2019 was declared a world health emergency (Ilunga et al., 2019). The DRC has been referred to as a reservoir for the disease, with approximately ten outbreaks since the disease was first discovered there. The largest outbreak, however, occurred in West Africa in Guinea, Sierra Leone, and Liberia from 2014 to 2016, killing 11,316 people and affecting more than 28,000 people (Felter and Renwick, 2020). This is more than ten times the number of people killed in all of the previous outbreaks combined. Before that, the largest outbreak was in Uganda in 2000, which killed 224 people (Lamunu et al., 2004). Ebola outbreaks were historically very small but hit urban areas in 2014. The 2014 outbreak reportedly began with a single boy in rural Guinea in late 2013 and quickly spread to both rural and urban communities throughout Guinea, Liberia, and Sierra Leone (Grépin, 2015). Ebola originated from the handling of infected chimpanzees, gorillas, fruit bats, monkeys, antelope, and porcupines and can afflict both humans and animals. People have contracted the disease in subsequent outbreaks from contact with animals – usually bats but sometimes primates – or from cooking or eating contaminated foods. The virus is then transmitted from person to person through close contact with blood, secretions, or other bodily fluids. Unlike

54  Key challenges the common flu and the measles which are airborne, Ebola is relatively less infectious, with a lower transmission rate. For example, a Scottish nurse flew from London to Glasgow while infected with Ebola, but no other passengers were infected as a result (McInnes, 2018). It has been described as a disease of social intimacy, because it is transmitted mostly through very intimate social interactions, such as to loved ones taking care of the sick and to community members tasked with burying those who have died (Richards et al., 2015). Healthcare workers are particularly vulnerable. Mortality rates of healthcare workers during the 2014 outbreak were high, including 8% in Liberia, 7% in Sierra Leone, and 1% in Guinea (Evans et al., 2015). During the first outbreak of the virus in the DRC in 1976, the Yambuku Mission Hospital, located at the epicentre of the outbreak had to close because 11 out of its 17 staff members had died of the disease (Bremen et al., 2016). Nearly 20 years later, 24% of the cases in the 1995 outbreak were healthcare workers (Rosello et al., 2015). Working with a person infected with Ebola requires personal protective equipment, including gloves, mask, and protective googles. Without proper training and/or gear, healthcare workers can be susceptible to catching it. Ebola infections require a laboratory test to be properly diagnosed, but these tests are an extreme bio-hazard risk and should be conducted under biological containment conditions (Quinn, 2016). Due to the huge risks to medical personnel, many healthcare workers fled in fear, which caused the entire healthcare system to collapse. The lack of capacity meant that Ebola treatment centres became places where the infected went to die alone. Infectious dead bodies were piling up and rotting in the streets. In Liberia, instead of building new Ebola care centres, crematoria were built (McInnes, 2016). In addition to the deaths caused by Ebola, lack of routine care for malaria, HIV/AIDS, and TB led to an estimated additional 10,600 deaths in Guinea, Liberia, and Sierra Leone, nearly equalling the Ebola death toll (Parpia et al., 2016). Funds, medical resources, and personnel were diverted, leading to a drop in the proportion of vaccinated children in Liberia by over 30%, reaching as high as 58% in some counties (Wesseh et al., 2017). Sierra and Leone and Guinea also saw drops in vaccinations (Elston et al., 2017; Sun et al., 2017). One study in Guinea demonstrated that the Ebola outbreak led to a 31% drop in outpatient visits for routine maternal and child health services (Barden-O’Fallon et  al., 2015). There was also a 60% drop in visits from children under 5 years old for diarrhoea and a 60% drop in visits for acute respiratory illnesses. In Sierra Leone, visits to public facilities for reproductive care fell by 40% during the outbreak (Rohwerder, 2020). Other basic services, such as pre-natal consultations and anti-retroviral therapies and treatments, were also reduced. The outbreak also impacted schools, food security, and employment. Ebola is contained by ensuring that those infected are placed under quarantine to keep the virus away from the general population during its 21-day incubation period. A public awareness campaign to inform the population about physical contact is also important. Families are encouraged to bring in sick relatives to a clinic rather than care for them at home (Kucharski et al., 2015). Additionally, traditional burials, which include washing and touching the dead, are discouraged because the deceased are more infectious. As cremation of the dead was a less acceptable cultural practice, it had to be mandated to limit the impact of transmission (Kobayashi et al., 2015). Diarrheal diseases: In 2017, almost 1.6 million people died from diarrheal diseases globally, one-third of whom were children younger than 5 years old (Dadonaite et al., 2019). In fact, the majority of deaths from diarrhoeal diseases affect those under 5 years. One out of every child under 5 years of age that dies is due to diarrheal disease, making it one of the leading causes of child mortality around the world, falling just behind preterm birth complications

Infectious diseases  55 and pneumonia (WHO, 2017b). This translates to over 1,300 young children dying each day, or about 480,000 children a year (WHO, 2017b). Most deaths from diarrhoea occur among children less than 2 years of age. Deaths from diarrheal diseases is completely preventable, but in poor countries with weak healthcare systems, the death rate is much higher. In Madagascar, Chad, and the Central Republic, 3/1,000 children die from diarrhoeal diseases, compared to a rate of .001/1000 in developed countries (Dadonaite et al., 2019). Deaths are more likely in countries that lack access to clean water, that do not have access to the rotavirus vaccines, and where malnutrition is common. Diarrhoeal diseases are caused by a wide range of agents, including parasitic, viral, or bacterial pathogens (Mokomane et al., 2018). The most common viral pathogen is rotavirus, and the most common bacterial pathogens are shigella and cholera. Cholera, for example, is a disease that is carried in water and affects the digestive tract. It affects an estimated 3–5 million people worldwide, causing between 21,000–43,0,000 deaths a year, overwhelmingly affecting the poor and countries without proper sanitation (WHO, 2019c; Wang et al., 2016). Cholera is transmitted in developed countries by eating food that is contaminated, while in developing countries it is more likely by ingesting contaminated water. Therefore, water that has been purified and filtrated helps to protect people from getting infected. Hygiene is also important to stemming the spread of cholera. Hand-washing after using the toilet is an important way of preventing the transmission of cholera. When cholera is properly treated, it has a mortality rate of less than 1%, but many people underestimate the speed and volume of fluids required to recover (WHO, 2019c). Rotavirus infection is the most common cause of severe diarrhoea in infants and young children around the world and continues to effect morbidity rates as well. However, rotavirus vaccines have made a notable impact on the reduction of rotavirus-related deaths, preventing almost 29,000 child deaths globally in 2016; full vaccine use could have prevented over 83,000 deaths. The vaccine also helped defray the costs to healthcare systems. Since rotavirus vaccines were introduced, from 2008–2016, the number of diarrhoeal-related hospital admissions has been reduced by 40% (Dadonaite and Ritchie, 2019). Oral rehydration therapy (ORT) is another solution that has reduced the death toll from diarrhoeal diseases. It is simple, cheap (costing $0.50 per packet), and effective and has been called by The Lancet medical journal the most important medical advance of the 20th century (Glass and Stoll, 2018). Since 1990, the number of children dying from diarrhoeal diseases has fallen by two-thirds. Since its introduction in the late 1970s, ORT is estimated to have saved 50 million people (Dadonaite, 2019). For example, the number of people who died annually from diarrhoeal diseases in 1990 was 2.6 million, while in 2020 the number of annual deaths has reduced to just over a million (WHO, 2020b). The diarrhoea mortality rate per 100,000 children decreased by 69.6% from 1990–2017 (Troeger et al., 2020). Diarrhoea causes death because it can lead to life-threatening dehydration. To treat it, the infected person requires a huge amount of fluid. ORT (or sometimes referred to as ORS or oral rehydration salts) is a mixture of water, salt, and sugar and is administered orally without the need for special medical assistance. Before ORT was developed, the therapy for diarrhoea was an expensive intravenous rehydration therapy (IVT) which involved administering a saline solution in the hospital (Glass and Stoll, 2018). However, because most people afflicted would not have access to a hospital setting, work was conducted to find a more viable alternative. In spite of promise of its effectiveness, it was not until 1978 that the WHO created the diarrhoeal disease control program to help popularize the use of ORT around the world. Though ORT does not prevent or stop diarrhoea, it reduces the chance of dying and

56  Key challenges speeds up recovery (Guerrant et al., 2003). Diarrheal diseases are completely preventable through access to clean and safe drinking water and proper sanitation. This includes regular handwashing and safe disposal of human waste. Long-term prevention requires investment in clean water and sanitation (Cairncross et al., 2010). Neglected tropical diseases (NTDs) include bacterial infections (such as trachoma and leprosy), protozoan infections (such as Chagas disease) and helminth infections (such as hookworm and guinea worm), and some diarrhoeal diseases. NTDs leave 1.6 billion people with chronic infections and cause 185,000 deaths. NTDs are grouped together based on their disfiguring impact, their geographic location, and their relationship with poverty. The diseases are common in rural and impoverished areas of low-income countries, due to the lack of access to clean water, health services, adequate housing, and good sanitation. Women and children are most likely to face infection since they are more exposed to NTDs and face barriers in accessing treatment. NTDs are endemic to almost 150 countries, with the majority of the burden affecting the poorest countries in Africa (sub-Saharan Africa or SSA), Asia, and Latin America. Over 40% of the global NTD burden is concentrated in Africa (SSA) (WHO Africa, 2018). In the case of SSA, NTDs account for a burden of disease that may be equivalent of up to one-half of SSA’s malaria disease burden and more than double that caused by tuberculosis. The greatest number of cases of NTDs result from soil-transmitted helminth infections (which include roundworm, hookworm, and whipworm), with possibly as many as 1.5 billion people affected. Infections, such as hookworm, occur in almost 50% of SSA’s poorest people, including 40–50 million children and 7 million pregnant women (Hotez and Kamath, 2009). After hookworm, schistosomiasis (102  million cases) is the second most prevalent NTD (KFF, 2020, 2). Though NTDs have a low mortality rate, morbidity rates are high and can lead to long-term problems, which is measured by disability-adjusted life years (DALYs) (Conteh et al., 2010; Hotez et al., 2014). DALYs are calculated by looking at the number of years of a person’s life lost to ill health. Infection with an NTD may result in severe disability, leading to disfigurement, blindness, and malnutrition, and negatively affects cognitive development, childhood growth, intellectual growth, and education. The problems can persist for years and affect health and performance for decades after an infection has supposedly cleared. For example, trachoma is the leading cause of preventable blindness. Over 130 million people have high intensity intestinal helminth infections which affect cognitive abilities and can lead to dysentery and anaemia. NTDs are also connected to other major diseases. Studies from Malawi showed that women infected with hookworms were at 1.8 times higher risk of having malaria than uninfected women, and studies from Thailand showed an increased susceptibility to malaria in patients with soil-transmitted helminth infections (Hotez et al., 2006). Building a more integrated healthcare system can help in the delivery of other interventions. It also ensures that health services are delivered to communities that are hard to reach and lack health facilities. The Dominican Republic was able to sustain a lymphatic filariasis program in spite of reduced external funding because it had developed an integrated health system that was able to maintain the program (Gyapong et al., 2010). Strengthening of primary health-care activities is essential if neglected tropical disease control is to be integrated into the general health service. General services are more comprehensive and flexible in dealing with the community. General healthcare programs may also be better at pooling resources to coordinate activities. NTDs are the result of the environmental and socio-economic conditions that impoverished people live in. The development and management of water resources has significant

Infectious diseases  57 health implications. For example, improving sanitation and irrigation methods could make an impact in preventing the spread of NTDs. Inter-sectoral collaboration is needed to address the challenges of NTDs. Environmental sectors, health sectors, and education sectors need to collaborate to come up with comprehensive approaches in dealing with these diseases (Gyapong et al., 2010). NTDs have begun to receive more attention because achieving the Millennium Development Goals of 2020 and their successor, the Sustainable Development Goals for 2030, would be impossible without addressing the challenges of NTDs. Coronaviruses are single stranded, positive-sense enveloped RNA viruses that cause many different types of diseases. Human coronaviruses cause the common cold. Covid19, SARS, and MERS are coronaviruses that are zoonotic (see Box 4.1 on zoonoses in Chapter 4). SARS was a new virus that caused an outbreak of pneumonia in 8000 cases in 2002–2003, leading to 775 deaths, and had a case fatality rate of between 7–11% (Yang et al., 2020), though the WHO estimated it as low as 3% (WHO, 2003). It spread to over 30 countries and 5 continents. It was thought that the reservoir host was the Asian civet cat or a bat, with the initial transmission (or spark) taking place from host to human through open markets. SARS is transmitted primarily through contact of the mucous membranes with either respiratory droplets or fomites, such as by touching a contaminated object and then touching a mucous membrane. The symptoms are similar to the flu and include fever, a persistent dry cough, headache, muscle pains, difficulty breathing (Carfì et al., 2020). SARS was considered to be the first infectious disease to emerge in a globalized society in the 21st century. The disease began in southern China in November 2002 and began to spread internationally in February 2003. Fortunately, by July 2003, the global outbreak was contained, and since 2004, there have not been any known cases of SARS reported. However, if SARS had been more contagious, it could have become one of the worst pandemics since the 1918–1919 flu (Yang et al., 2020). MERS first emerged when a 60-year-old man in Saudi Arabia came down with severe pneumonia, though an outbreak of the virus did not occur until two years later in 2014. In total, MERS resulted in a total of 2494 cases and 858 deaths and spread to 27 countries. MERS likely originated from bats with dromedary camels serving as the intermediate host. Like SARs, MERs causes pneumonia in humans, but has a much higher fatality rate, 35% (Lu et al., 2020). Much of the spread of MERs was due to infections from staying in a hospital, known as nosocomial spread (Hui, 2016). MERs did not spread as rapidly as SARS, mostly because there was a much lower rate of human-to-human transmission. Much of the transmission appeared to be taking place from animal host to human (Azhar et al., 2019). However, healthcare workers faced particularly high risks of being infected by both MERS and SARs, with 18.6% of MERS cases and 21% of SARS cases occurring in healthcare workers (Chen et al., 2020). The high-risk procedures involved in treating SARS and MERS patients exposed healthcare workers to greater chances of being infected.5 In 2020, the world learned about Covid-19. In spite of the fact that it was impossible to escape news on the coronavirus, there are still many unknowns. Covid-19 is referred to as a novel virus because it has not been observed previously in humans. Common symptoms include a fever, achiness, a constant cough and loss of one’s sense of smell. Its most likely reservoir is bats, though pangolins have been identified as the likely intermediate host (Zhang et al., 2020). Pangolins are an endangered animal and the most trafficked animal in the world. As trading pangolins is illegal this would explain why they were not listed at the Wuhan market, making it more difficult to identify pangolins as the source of the virus (Aguirre et al., 2020) (for more on the spark of diseases, see Chapter 4).

58  Key challenges Covid-19 is highly infectious disease that spreads through aerosols. Complicating things further is that many people who contract the virus are asymptomatic (could be anywhere from 20–40%) (Mizumoto and Chowell, 2020; Mizumoto et al., 2020). We do know that both pre-symptomatic and asymptomatic individuals are contagious, but it is still unclear to what extent (Gandhi et al., 2020; Moghadas et al., 2020; Ren et al., 2020; Tindale et al., 2020). We also don’t know what factors make some individuals more likely to spread the virus than others. Covid-19 has mostly affected the elderly and those with other co-morbidities, but it has also caused long-term complications for people who are young and were relatively healthy (Lithander et al., 2020; Sanyaolu et al., 2020). Many young healthcare workers have succumbed to the virus, leading some to speculate that this was the result of exposure to a heavier viral load (Heneghan et al., 2020; Herron et al., 2020). Nevertheless, this theory has not been fully substantiated. Additionally, the effects for those who are labelled long-haulers is still unclear (Baig, 2020; Rubin, 2020). Early data on Covid-19 has suggested that about onethird of patients who were hospitalised have neurological effects of disease (Dutchen, 2020). Also, still a work in progress is what types of treatment works best, as different medicines have different rates of success for different people. What is clear is that treatment needs to take place early, because the disease can take over suddenly and make it nearly impossible for its victim to breathe (Sousa et al., 2020). By the end of 2020, it was announced that numerous vaccines had been created, some with a 95% effectiveness rate.

Conclusion The main objective of this chapter was to provide an explainer of what infectious diseases are and what impact they may have on human security. If we look at diseases from this standpoint, it is the diseases with the highest death toll and morbidity rates that have had the biggest effect. HIV/ADS, TB, and malaria have all contributed significantly to human insecurity. Because of this, these three diseases have also received a lot of attention and funding, and there has been tremendous progress in decreasing mortality rates. Neglected tropical diseases have earned their name for being perennially forgotten in health security frameworks. These are diseases that mostly affect the poor and which are unlikely to impact the developed world. As explained in Chapter 1, much of what drives the international response to diseases is extent to which they affect powerful actors in the international system. Human security approaches intend to rectify this problem by moving issues that affect the most vulnerable to the top of the agenda, over threats that are perceived to be more urgent to the West. In explaining what the major diseases are, the chapter also aimed to demonstrate the difference between pandemics (caused by new sparks of diseases, such as Ebola, Covid-19, and SARs) and endemic diseases (such as TB, malaria, HIV/AIDS, and NTDs). Here again we see how priorities are shaped. In spite of the tremendous death toll and economic disruption caused by the Covid-19 pandemic, it is still the diseases that have become endemic that pose the greatest long-term threats to human security. This does not mean that addressing new diseases with pandemic potential do not deserve our attention, only that more attention should also be placed in tackling endemic infectious diseases that undermine economic development, create poverty traps, cause high rates of morbidity, and have killed millions of people. In the chapter that follows we provide an explanation of what natural hazards are and what makes a natural hazard a disaster. As the chapter will demonstrate, though disasters are not as great a threat to human security as diseases are, there are multiple knock-on effects of disasters that have important implications for other disasters, disease, health, and poverty.

Infectious diseases  59

Key questions 1 2 3 4 5

In what ways are pandemics different to endemic diseases? How might they differ in terms of how they impact human security? Why has there been so much funding and attention for the big three diseases (AIDS, malaria, and TB)? Is this attention justified? Why do you think NTDs have been neglected thus far? How would you describe the major trends in infectious diseases? Where is there room for optimism, and what trends are concerning? In your estimation, what diseases requires the most global attention from a human security approach?

Notes 1 Pan means all, while demos means people in Greek. 2 For example, it was reported that the AstraZeneca-Oxford vaccine was not effective against the South African variant of Covid-19 (BBC News, 2021). 3 In contrast to the name, the virus did not originate in Spain – and most likely originated in New York (Olson et al., 2005). However, as Spain was neutral during WWI it was free to report on the severity of the pandemics, while the other countries fighting were more reluctant to do so, to not weaken morale. 4 High-level simulation exercises were carried out to test cross-government levels of preparedness. New government strategies on pandemic flu were set out. Wide-ranging international diplomatic initiatives on pandemic flu were also launched, and the threat was extensively discussed at a high level in a plethora of regional and international organizations. 5 Such as the use of nebulizers, endotracheal suction and intubation, cardiopulmonary resuscitation, nasogastric feeding, and high flow-rates of oxygen.

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3 Disasters

Introduction The 21st century has set some terrible records for disasters. One of the deadliest tsunamis hit Southeast Asia in 2004. The costliest and one of the deadliest hurricanes hit the southern coast of the US just one year later. In 2008, a deadly cyclone hit Myanmar and Sri Lanka, killing over 100,000 people. One of the deadliest earthquakes on record hit Haiti in 2010, while one of the costliest earthquakes hit Japan in 2011. In 2019 and 2020, some of the worst wildfires in history hit Brazil, Australia, and California in the US. In total, in 2019 and 2020 there were over 400 disaster events recorded for each year. Disasters affect every corner of the globe and every country no matter how wealthy. Unlike endemic infectious disease burdens that may predominantly affect certain regions of the world, disasters have a much wider reach. While the first chapter laid out the various challenges to human security, and the preceding chapter looked at the role of infectious diseases, this chapter focuses on disasters. We turn to discuss disasters because they are intimately connected with infectious disease, development, climate change, and of course, human security. The chapter first offers an overview of disasters and disaster trends and then clearly explains each type of disaster. The chapter then turns to examine how disasters and diseases intersect. One of the themes of this book is the interdependence of security issues, and disasters offer a good example of the intersectionality of environmental and health security. Disasters often constitute compound events which lead to other emergencies. Thus, disasters are good examples of where different threats can interact, creating human insecurity traps. Key concepts

What are ‘natural’ disasters? Disasters are extreme geologic processes such as floods, hurricanes, tornadoes, volcanic eruptions, earthquakes, tsunamis, storms. (Note that in this book we are not referring to ‘manmade’ disasters, such as oil spills.) Disasters are major threats to human security, threatening human survival, damaging the economic and social foundations of people’s wellbeing, and traumatizing survivors, family members, and friends of the victims. Disasters are usually rapid and massive impacts of the natural environment on the socio-economic system, taking place within a defined location and with a limited endurance (Bankoff, 1999). However, in the case of droughts and drought-induced famines, they can sometimes be slowly developing disasters, where entitlements slowly erode as a crisis unfolds.

DOI: 10.4324/9781003128809-5

68  Key challenges The term ‘natural’ disaster is really a misnomer. They should actually be referred to as natural hazards. Disasters are an outcome of an interaction between geophysical events, conditions and/or hazards and vulnerable populations. Once a natural hazard collides with humans and there are casualties, they become disasters, an intersection that is far from natural. Potentially hazardous events do not need to end in a disaster, but disaster occurs where there are exposed people and assets that are vulnerable to the hazard. The UN defines a ‘natural’ disaster as ‘the consequences of events triggered by natural hazards that overwhelm local response capacity and seriously affect the social and economic development of a region’ (Brookings, 2006). In other words, a disaster is a crisis that overwhelms society and presents risk or potential danger to life or property (Alexander, 2018). Many scholars argue that ‘natural’ disasters are socially constructed events that are influenced by demographic and socio-economic characteristics, social norms, and government policy. Because of this, we will mostly refer to these ‘natural’ disasters as disasters, because we are discussing instances where hazards meet human populations, and as natural hazards when we are referring to the naturally occurring physical phenomena. Classifying disasters Disasters are extreme events that differ from the mean and are classified in different ways. Some classify disasters by the damage caused. But other times disasters are classified by other factors, such as whether 10 or more people were killed, whether 100 people or more were affected, whether a state of emergency has been declared, and/or whether calls for international assistance have been made. A mega-disaster event is one that kills more than 100,000 people. Natural hazards are also classified by the type of threat or root cause, such as geophysical threats (earthquakes and volcanoes); hydrological threats (floods and landslides); meteorological threats (storms and extreme temperatures); and climatological threats (droughts and wildfires). Tsunamis are often classified as a subtype of earthquakes because they are caused by seismic activity (Bolt et al., 2013). Trends in disasters There are about 400 disasters per year, affecting approximately 200 million people. This is double the number reported 20 years ago. From 1950–1999, disasters have caused over 4 million deaths and have adversely affected over 4 billion people (Bankoff, 1999). Since 2000, disasters have killed on average 60,000 people per year globally, representing roughly 0.01% to 0.4% of deaths (Our World in Data, 2020). Of all disasters, flooding was previously the deadliest, killing over 9  million people in the last century (Bankoff, 1999). As of 2020, the deadliest disasters per event are earthquakes, which constitute 55% of the deaths. Earthquakes claimed 750,000 lives from 1994–2013. Deaths from floods have become much lower, though they still impact more people than any other disaster. Flooding from 1994–2013 had accounted for 43% of all recorded events, affecting nearly 2.5 billion people (CRED, 2015). Tsunamis were the deadliest sub-type of earthquake, with 79 deaths for every 1,000 people affected. Droughts also have a tremendous impact, affecting more than one billion people between 1994 and 2013, 25% of the global total (ibid.). Disasters are also incredibly costly. It has been estimated that the average ‘major’ disaster costs around $500 million (Smith, 2013). Nevertheless, because disasters are so unpredictable and so variable, there is a wide range in costs from year to year. The average cost of disasters was $270 million in 2019, compared to the high of $875 million in 2011 (Our World in Data, 2020).

Disasters  69 Though disasters affect every area of the globe, they do not affect all regions equally. Africa experiences the fewest, with 10% occurring there (Our World in Data, 2020). Asia, by contrast, experiences the most disasters, 42% of all disasters occurring in this region, incurring high death tolls. Asia holds 60% of the world’s population, but over 80% of the world’s disaster deaths take place in this region (Ezrow et al., 2015). China, in particular, is very disaster prone. In China in the summer of 1931, extreme cyclone activity led to a series of floods that killed possibly as many as four million people, making it the worst disaster recorded in history in terms of death toll. Asia has also experienced its fair share of disasters, with cyclones being the most damaging. Most notably, a cyclone hit East Pakistan (what is now Bangladesh) in 1970 killing as many as one million people (for more on this, see the case study in Chapter 6) (Haque et al., 2012). Disasters have also hit Latin America and the Caribbean particularly hard. In the 20th century, the region was affected by over 1,300 disasters, with 972 disasters taking place from 1970–2000, or 32 per year. The region has also seen high levels of fatalities due to disasters. In the last century there have been over 450,000 fatalities, with over 225,000 fatalities from 1970–2000, or an average of 7,500 per year (Charvériat, 2000). One of the notable trends in disasters is that some types of disasters are occurring with greater frequency than in the past. As Chapter 4 will explain, human contributions are increasing the likelihood and intensity of disasters (Mooney, 2007). Due to human abuse of the environment, there are more climatological disasters taking place. Climate-related events constitute 91% of disasters that occurred from 1994–2013 (UNISDR, 2015). Floods and storms account for 71% of the global total (ibid.). In the ten most disaster-affected countries, climate-related events were more frequent than the geophysical disasters. Nevertheless, the increase in disasters is not solely because there are more natural hazards but because there are greater levels of vulnerability in some areas of the world. The number affected is so much greater than in the past because there are more people in absolute numbers and more people living in vulnerable areas, thus more people at risk any time a natural hazard strikes. The proportion of the world’s population that is living in flood-prone river basins has increased by 114% (UNISDR, 2015). Those living along cyclone-exposed coastlines has increased by 192% in the past 30 years (ibid.). More than half of the world’s large cities with populations of over 2 million are highly vulnerable to seismic activity. Reducing the threat from disasters requires a sustainable development approach. The literature on disasters has focused on the impacts of natural hazards. The study of disasters has shifted from the focus on how natural hazards impact humans to how the human activities raise the chance of disasters. Climate change, population growth, and economic development have made people more vulnerable to disasters. As previously mentioned, many disasters are also compound events. For example, an earthquake can trigger a landslide or a fire, causing more death and destruction. For more on compound events, see Box 3.1 on the 2004 Tsunami.

Box 3.1  2004 Tsunami On the day after Christmas at 7:59 in the morning a 9.1 magnitude earthquake, one of the largest ever recorded, took place along a fault line in the Indian Ocean. The earthquake lasted for ten minutes and released as much power as several thousand atomic

70  Key challenges bombs. The largest faults in the world, known as megathrust faults, are all under water, but they are far enough from land that the tremors from the earthquake may not necessarily be felt on land. However, this earthquake was an example of how one natural hazard can cause another hazard. Within minutes, the earthquake had triggered a massive tsunami that propelled a gigantic column of water that pummelled the shores of Indonesia, Thailand, and Sri Lanka in a matter of hours. Indonesia, which was closest to the epicentre of the earthquake was hit by waves of 100–130 feet (30–40 meters) within 20 minutes (Roos, 2020). The city of Banda Aceh was completely engulfed and more than 100,000 of its citizens were killed instantly. Buildings, houses, and trees all folded under the pressure of the waves. Thailand was hit 90 minutes later, but the coastal provinces were also caught off guard. The death toll reached 5,400. Another hour later, on the other side of the Indian Ocean, waves hit the coast of India and Sri Lanka, killing another 40,000 people and leaving hundreds of thousands homeless. Earthquakes on their own are quite destructive, but usually the bulk of the casualties are injuries, not deaths, as many people survive them. Tsunamis, however, are one of the most difficult disasters to survive and leave few alive and injured. In total, the Boxing Day Tsunami claimed more than 230,000 lives (Taylor, 2014). The tsunami that hit Southeast Asia seems like a black swan event in many ways. It took place in a location that was far enough from the earthquake that most people could not feel it; and there was not a history of tsunamis hitting the coastlines. This was also the most extreme tsunami since the tsunami that followed the 8.6 magnitude earthquake in Chile, which levelled Hilo, Hawaii, within 15 hours of the earthquake (Atwater, 1999).

Natural hazards and human security Why do natural hazards become ‘natural’ disasters? Many scholars have noted that human activity has created the conditions for disaster events (Alexander, 2018; Cutter et al., 2008; Weichselgartner and Bertens, 2000). Societies differ in terms of how they mitigate and prepare for a natural hazard event. The degree to which a society is unaffected by natural extremes reflects their ability to adapt to hazards. Negligent or inappropriate responses to natural hazards can result in disasters negatively impacting vulnerable populations much more than others. States that provide proper zoning and building regulations and invest in interventions to mitigate the threat of disasters are better able to bounce back and prevent high casualties (for more on this, see Chapter 12). Societies that have lower levels of poverty, more people with access to insurance, savings, and income are better prepared (for more on this, see Chapter  6). These factors make citizens more economically resilient. Also important is where people live, the quality of the building they live in, and the hazard protection that they have constructed. Another important factor is how healthy the individuals are who face disasters and the robustness of the healthcare systems that they have access to. Societies that are already weakened by the prevalence of endemic diseases and poor healthcare systems will struggle to survive. Social capital is also determinative in shaping resilience in disasters. Societies with high levels of social capital, or

Disasters  71 social network, experience a faster recovery. In fact, social capital serves as the core engine of recovery. Disasters constitute a major threat and danger to human security in both developing and developed countries (Hallegatte, 2016). However, as Chapter 6 will explain, disasters lead to much higher casualties in low-income countries. The number of deaths, injuries, and displacements decrease as a state’s income level rises (Kahn, 2005). This is also true within states (even high-income countries), where the poorest sectors of the citizenry typically suffer the worst outcomes. For example, Hurricane Katrina was incredibly deadly for the poorest segments of the population in the US. With Hurricane Katrina, two-thirds of the 1800 deaths were by drowning due to storm surges and floods which affected people who did not have the means to evacuate on time. Disasters occur more frequently due to geography and where infrastructure is often lacking to withstand them. Not only are developing states located in zones that are more likely to be affected by volcanic activity, seismicity, and flooding, but citizens in developing states are more vulnerable to the impact of disasters because their states are poorly equipped to deal with them (Alcántara-Ayala, 2002). Low-income countries will struggle to offer basic services, may see a rise in crime, and see reversals in human capital (Rodriguez-Oreggia et al., 2013). Disasters also reduce nutritional intake and education as schools and other infrastructure are ruined or damaged. Hundreds of millions of people are displaced by disasters, and displacement can last a long time, which has many other negative repercussions on human security and well-being. Furthermore. as disasters are economically costly, disaster events can plunge vulnerable people deeper into poverty, making poverty traps more enduring.

Box 3.2  Hurricane Maria On September 20, 2017, Hurricane Maria struck Puerto Rico with winds of 155 mph, downing weather stations, ripping through roofs, and cutting off electricity to 100% of the island. As a Category 4 storm, this was the strongest storm to hit Puerto Rico in nearly a century. The storm incurred a death toll of over 3,000, caused $94 billion in damages, and plunged Puerto Rico’s 3.4 million residents into a humanitarian crisis. As much as 80% of crop value was destroyed, leading to a loss of $780 million (Sheetz, 2017). With almost half of its residents living below the poverty line and many unemployed, the devastation was far reaching. Years later the island has still not completely recovered. 2017 was the costliest hurricane season on record in the Atlantic, costing almost $300 billion in damage, and with the most Category 5 storms (Miller, 2018). Hurricane Irma, a Category 5 storm, hit multiple island nations and the coastal US in early September of 2017 and cost over $50 billion. Though it was the fourth costliest hurricane on record in the US, the hurricane cost 134 people their lives, far fewer than Hurricane Maria. Puerto Rico is a protectorate of the US and, as such, its citizens are US citizens eligible for support from Federal Emergency Management Agency (FEMA), but FEMA was criticized for its lacklustre response under the Trump administration to properly support Puerto Ricans.

72  Key challenges Stockpiles of drinking water worth $22 million were left on a tarmac without being distributed. Much of the island’s residents had to live under blue tarps, and as many as 62% of FEMA applicants were denied assistance to rebuild their homes (Amnesty International, 2018). Further complicating matters, all applications had to be made online at a time when there was no electricity. Adding more frustration to the island residents, a federal court decided on August 30th that Puerto Rican citizens temporarily housed in the US, would lose their FEMA support on September 15th (ibid., 2018).

What are the major types of disasters? 2020 was a particularly bad year for human security. While the coronavirus pandemic raged on, the world also appeared to be literally on fire. Wildfires that burned across California and Australia ravaged millions of acres. At the same time, other regions of the world were drenched in rainfall, with Hurricane Zeta, Hurricane Delta, Hurricane Eta, and Hurricane Iota slamming the southern US and the Caribbean (Thompson, 2020). In addition to wildfires and hurricanes, there are many other types of disasters that require our attention. Disasters are interconnected to other threats and, in some cases, are interlinked with other disasters making them compound events. Storms can generate mudslides, earthquakes can trigger tsunamis, and droughts can spark wildfires or increase the likelihood of floods and the like. In this section we detail the many different types of disasters. Here we focus on five: tropical storms (hurricanes, typhoons, cyclones and floods); droughts; wildfires; earthquakes; and volcanic eruptions. The book does not focus on avalanches (which kill about 150 people each year) or tornadoes, which are born in storms (Howard, 2019). Tropical cyclones, hurricanes, or typhoons are rapidly rotating storms that have a lowpressure centre, strong winds, and heavy rain. They usually originate over tropical oceans, blowing counter-clockwise in the northern hemisphere and clockwise in the southern hemisphere. Those that occur in the northwest Atlantic Ocean or northeast Pacific Ocean are often referred to as hurricanes; those that occur in the northwest Pacific Ocean are known as typhoons; and those that occur in the Atlantic basin, the Indian Ocean, and parts of the Pacific Ocean are simply known as tropical cyclones (Fitzpatrick, 1999). The regions at the greatest risk of tropical cyclones are Asia and Latin America (Peduzzi et al., 2012). On average, 13 tropical storms hit the Caribbean during hurricane season, six of which become hurricanes (Moore, 2019). A tropical cyclone becomes as a tropical disturbance in warm ocean waters when the surface temperature is at least 26.5oC (80oF). Hurricanes deliver enormous energy, drawing heat from the warm water. Once they reach 119 km per hour (74 mph), they become a hurricane (Kantha, 2013). Tropical cyclones are rated on a five-point Saffir-Simpson scale that is based on wind speed (Berlemann, 2016). When they reach a Category 3, they are considered to be a major event. A Category 5 storm denotes that the wind speed is more than 253km an hour (157 mph). The strongest Atlantic storm was Wilma in 2005, with winds of 294 km an hour (183 mph) (Feher et al., 2020). Once a hurricane hits land, it can be incredibly destructive, producing huge storm surge from ocean water that is pushed by the wind. In addition to storm surge, the most dangerous aspects of hurricanes are flooding. Both storm surge and flooding account for 75% of the deaths from 1963–2012 in the Atlantic according to the National Hurricane Center (Woodward, 2016). Hurricanes also spawn tornadoes

Disasters  73 and destructive high winds. Torrential rains can lead to mudslides. In the case of Hurricane Katrina, which hit the coast of Louisiana in 2005, one study showed that 67% of the people died from direct exposure in flooding (Insurance Journal, 2009). In the past, cyclones and other extreme storms were very deadly, killing nearly two million people worldwide in the 19th and 20th centuries (Bankoff, 1999). However, as of 2020, most cyclones kill fewer people thanks to improvements in prognostics that enable us to give citizens ample notice to evacuate before a disaster strikes (WHO, 2020a). In 2020 roughly over 1,300 people died in storms, costing over $66 billion in damage. 2020 was also the most active Atlantic hurricane season on record (UNOCHA, 2020). Hurricanes are becoming more intense (in terms of strength) and slow moving (in terms of how quickly they pass over land). Up until 2020, 2017 and 2018 were the most active hurricane seasons on record. Hurricane Harvey dropped almost 52 inches of rain on the coast of Texas in August of 2017. Climate scientists claim that this was driven by the warming of the Gulf of Mexico, which was 2oF degrees warmer than 30 years prior (Russell et al., 2020; Trenberth et al., 2018; Van Oldenborgh et al., 2017). Increases in warmth create two problems: the warmer atmosphere produces more water vapor for making rain; and warming temperatures slow down these storms leading to more problems when they hit land, elongating and extending the landfall and increasing storm surge, high winds, and rainfall. As a result, hurricanes have become more costly. Hurricane Katrina, which landed in 2005, is the most expensive hurricane on record coming at a cost of $125 billion (Frame et al., 2020). Floods occur when water fills up land that is normally dry through excessive rain, a ruptured dam or levee, melting snow, or from a large storm that causes a huge surge on land. Floods usually take days to develop which gives people time to evacuate (known as riverine floods), but flash floods can generate with little warning and can sweep everything in their path (Parker, 2000). One of the dangers of flooding is that residents can be without power and clean water, which leads to outbreaks of infectious waterborne diseases such as cholera. When the floodwaters finally recede, affected areas are covered in mud and silt and the landscape can be contaminated with untreated sewage and pesticides. Mould can quickly take over structures that have water damage. Floods are economically costly, causing more than $40 billion in damage each year worldwide, with death tolls of around 100 a year (Nunez, 2019). Floods affect planted crops and cause tremendous damage to infrastructure. In the past, floods were incredibly dangerous and killed millions of people (Courtney, 2018). Earthquakes are seismic waves that are created when the earth’s crusts release energy. Earthquakes with epicentres that are offshore can disrupt the seabed enough to trigger a tsunami. Earthquakes can also stimulate volcanic activity and create landslides. About a half a million earthquakes occur annually with only one fifth of those actually being felt. Every day, thousands of earthquakes occur, though most are just small tremors (Stein and Wysession, 2009). The vast majority (about 80–90%) of earthquakes occur in the Pacific Ring of Fire, which is a 40,000-kilometre seismic belt in the Pacific Ocean (Williams, 2015). Most earthquakes occur where tectonic plates – or the giant slabs of rock that the earth’s upper layer consist of – slide against each other, better known as fault lines or fault zones. When immense stress builds up between plates and this stress is released quickly, it can send massive vibrations over hundreds of miles through the rock and up to the earth’s surface (Bolt et al., 2013). In other cases, when tectonic plates are stretched, this can cause quakes to occur even far away from fault lines. Strong earthquakes of 7–7.9 and anything over 8 magnitude or more are considered great (Hough, 2016). Earthquakes are destructive not only because they cause buildings to collapse, but also because of ensuing mud slides, fires, tsunamis, and floods.

74  Key challenges About a million total deaths have occurred in the last century due to earthquakes, with every year varying considerably (Alexander, 2018). In the last 50 years, the deadliest years by far were 1970 (78, 219 deaths); 1976 (281,482 deaths); 1990 (52,947 deaths); 2004 (228,792 deaths); 2008 (88,084 deaths). The deadliest year was 2010 with the Haitian earthquake (319,319 deaths). Between 1998–2017, 750,000 people died in earthquakes globally, constituting more than half of all deaths related to disasters (WHO, 2020a). The Global Earthquake Model Foundation has created an earthquake risk map to assess which parts of the world are most at risk of earthquakes and where disasters are likely to be the most damaging (Pagani et al., 2020). This model not only looks at the potential for earthquakes to take place and but also how vulnerable and exposed people are to earthquakes in different parts of the world. It looks at how fragile buildings are, how densely populated earthquake-prone regions are, what past fatalities have been, and what potential economic losses could be to create an open-source mapping of the hazard zones. China faces the biggest risks from earthquakes because it has the world’s largest population. As such, it accounts for half of all earthquake fatalities, with the 1976 earthquake killing over 242,000 people and the 1556 Shaanxi earthquake killing as many as 830,000 people (Feng et al., 2020). Japan has recorded the most earthquakes but this is partially because it has the best ability to record tremors (Yamasaki, 2012). Japan is the most expensive country to rebuild and sits on the Pacific Ring of Fire, one of the most active earthquake zones in the world. Earthquakes are fairly common in places as wide-ranging as the United States, Guatemala, Chile, Peru, New Zealand, and Greece due to their location near earthquake epicentres, but in reality, they can occur anywhere. Iran is also especially earthquake-prone because it straddles the Eurasian and Arabic tectonic plates, with its capital, Tehran, most at risk. Turkey is also at risk, with its largest city, Istanbul, sitting on top of an active fault line. In both Turkey and Iran, many buildings are at risk of crumbling as so few buildings are up to code. The Philippines and Indonesia also sit on the Ring of Fire, making both countries vulnerable to volcanoes and earthquakes. Mexico is also earthquake-prone because it sits atop three of the world’s largest tectonic plates. As Mexico City is on a former lakebed, its soft soil makes a smaller earthquake feel much worse. Pakistan, India, and Bangladesh – all which have huge populations – are prone to earthquakes. The region could be on top of an active megathrust fault that could cause an earthquake of 9.0 or greater. If this were to happen in the case of Bangladesh, at least 140 million people could be affected (Paul and Bhuiyan, 2010). Earthquakes are particularly damaging to developing countries that are already struggling with poverty, costing the world about $40 billion a year on average.1 In 2010, an earthquake in Haiti killed an estimated 300,000 people, and Haiti is still struggling to rebuild itself from the damage inflicted. That earthquake destroyed hospitals, communications systems, and transportation networks making it even more difficult for the state to respond to the crisis. Even worse, the conditions were so poor that they led to a devastating outbreak of cholera and looting and violence became common. Tsunamis in the aftermath of an earthquake can also be extremely destructive (Wright and Rathje, 2003). The 2004 tsunami in the Indian Ocean, for example, killed about a quarter of a million people and injured many more. Over a decade later, many areas affected are still struggling to recover. Volcanic eruptions are ruptures in the crust of the earth that lead to the release of hot lava and volcanic ash. Volcanoes form along the boundaries of the earth’s tectonic plates (Sigurdsson et al., 2015). Like earthquakes, the majority (75%) of active volcanoes are located in the Pacific Ring of Fire (the zone from the southern tip of South America across the west coast of

Disasters  75 North America, through the Bering Sea to Japan, and then to New Zealand), though there are volcanoes on every continent (National Geographic, 2020). Latin American and Asian states are typically the most frequently affected by volcanic eruptions. There are 1500 active volcanoes worldwide today, with around 50 eruptions each year. In spite of the dangers, volcanoes have attracted human settlement, and more than 10% of the world lives within 100 kilometres of a volcano that was active during historic times (Freire et al., 2019). Central America and Southeast Asia are the regions that are highest at risk, with Indonesia facing the greatest threat of volcanoes. In fact, two-thirds of all volcano-related deaths have taken place there (Smith, 2013). Some volcanoes cause explosive eruptions while others just spew out lava, known as an effusive eruption. The latter are more common when the magma (or the igneous rocks that are below the earth’s surface) becomes more runny or less sticky, which enables the gas to escape and for the magma to flow down the slopes of the volcano. When molten rock is less runny, it traps the gases creating a pressure cooker that leads to an explosive eruption (Sigurdsson et al., 2015). The dangers from volcanoes come from the pyroclastic flows, avalanches of hot rocks, ash, and toxic gases that speed down the slope at up to 724 kilometres per hour (450 mph) and volcanic mudflows (Andrews, 2017). Volcanic ash is also dangerous – it is heavy, dangerous to inhale and builds up quickly. Volcanic ash can cause major problems, causing weak structures to collapse and possible power outages. Volcanic eruptions are the least destructive of the disasters discussed here, and associated death tolls are still typically quite a bit lower than from tropical cyclones or earthquakes. The deadliest eruption in recorded history was an 1815 explosion of Mount Tambora in Indonesia, which killed around 10,000 people (Kessler, 2008). The blast was so powerful that it created a huge crater 4 miles across and 3,600 feet deep. Hot ash and gas flew up 28 miles into the sky, which produced pyroclastic flows when it came down. Volcanic ash and gas that shot up into the atmosphere managed to block the sun, cooling the surface of the earth and causing a year without summer. This then led to starvation and disease, killing an additional 82,000 people. One of the more recent devastating volcano eruptions was the 1982 eruption of El Chichón in Mexico, which killed about 3,500 people (Jiménez et al., 1999). Since the year 1500, the death toll from volcanoes is about 280,000 people in total, with the majority of the deaths coming from just six eruptions. Since the year 2000, about 2,000 people have died from volcanoes (Brown, 2018). Most of the victims of volcanoes die from pyroclastic flows, or volcanic mudflows, but in Cameroon, 1,500 people died from carbon dioxide, a volcanic gas, in 1986 (ibid.). Some earthquakes can be triggered by volcanic activity. Both earthquakes and volcanoes lie on the edges of tectonic plates, and because of this, earthquakes can sometimes be triggered by the movement of magma within the volcano. Thus, earthquakes that are caused by clogged magma are a warning sign of volcanic eruptions. Other warning signs of a volcanic eruption include increased gas emissions and the bulging of the volcano’s sides. In theory, governments should be able to read warning signs and ensure safe evacuation. Executing evacuations, however, depends on the will of governments to do so. The government in Colombia was well aware that a volcanic eruption was likely prior to the eruption of the Nevado del Ruiz volcano in Tolima, Colombia, in November of 1985, which killed 22,000 people. Reportedly, the government had received multiple warnings from organizations to evacuate the area in September of 1985, after a series of earthquakes had taken place, but refused to do anything about it (Voight, 1990).

76  Key challenges Droughts: Droughts constitute an extended period when there is a lack of rainfall (known as meteorological droughts); that affects soil moisture and crop growth (known as agricultural droughts); and that affects river flows, aquifers, and surface reservoirs (known as hydrological droughts) (Wanders et al., 2015). Though there is no standard, quantitative definition of a drought, droughts are still discrete weather events. Drought events have multiple and interrelated characteristics, such as severity, duration, peak intensity, and recurrence interval. Droughts last longer than other hazards, and the onset is much slower and can gradually increase in intensity and duration. They are also more spatially extensive and can differ in location and timing. Multi-year droughts are now common, which some scientists perceive to be a transitional phase in climate change (Ayanlade et al., 2018; Usman and AbdulKadir, 2014). Droughts are predicted by looking at low accumulations of rainfall, lack of soil moisture, and high air temperatures. However, many countries in Africa lack the ground stations to record this data, with some lacking the ability to even measure rainfall (Le Coz and van de Giesen, 2020). Droughts also have multiple eco-hydrological and socio-economic impacts, which makes them incredibly costly with losses in the billions. Droughts are one of the most expensive weather-related disasters in the world (Freire-González et al., 2017). This is because droughts cause not only huge direct losses but indirect losses as well. Most of the direct losses hit the poorest communities. Billions of people rely on agriculture as their main source of income. Thus, if severe droughts lead to water shortages in an area dependent on agriculture, the health and wellbeing of livestock and crops are put at risk. Studies have shown that droughts have significant negative impacts on poorer farming communities which have less diversified livelihoods and few economic alternatives (Araujo et al., 2016; Ifeanyi-Obi, 2016). Droughts have negatively affected agriculturally richer regions in Africa as well. In the spring of 2018, an El Niño event affected southern Africa’s annual rainfall, which delayed the sowing date by a few weeks. The drought continued into 2019 with multiple countries in Southern Africa facing a reduced rainfall, leading to poor crop yields and a rise in hunger in the region (Lin and Qian, 2019). By May of 2019, Namibia also had to declare a state of emergency in response to the drought, extending it again in October. Compounding matters, Namibia’s 2019 drought was preceded by another drought which developed from 2013–2016, affecting over 450,000 people, and causing massive food insecurity (Kapuka and Hlásny, 2020). Droughts also incur tremendous indirect costs. Droughts raise the risk of wildfires, damage the habitat, increase food prices, and raise the risk of famine. Droughts can lead to increased indirect mortality and morbidity rates through reduced food intake which exacerbates health problems and the ability to fight off diseases. Droughts can lead to poor water quality and sanitation, expediting diseases. During drought, food production declines and there is water scarcity. Floods contribute to disease outbreaks (such as malaria, typhoid, diarrhoea, and Rift Valley fever among animals), and households lying in steep areas are exposed to landslides and massive destruction of property (Brown et al., 2014; Chase and Knight, 2003; Martin et al., 2008; Rieckmann et al., 2018). Droughts can also lead to migration and internal displacement, with as many as 700 million people at risk of being displaced because of droughts by 2030 (WHO, 2020b). Droughts cause shortages in the water available for industry and reduce hydropower (there is less electricity due to the decrease in water flow through hydroelectric dams). Droughts may not always have losses that are visible outside of the agricultural sector, which can lead to undervaluing the overall economic impact. The societal impacts of a drought are slow to develop and may endure for years.

Disasters  77 Droughts have had a huge impact on human security in terms of loss of life as well. From 1900 to 2016, almost 12 million people died due to droughts. The period from 1970 to 2012 saw almost 680,000 people die from droughts, mostly due to severe droughts in Africa in 1975 and 1983–1984 (WMO, 2014). Every year, an estimated 55 million people are affected by droughts (WHO, 2020b). Wildfires are any type of uncontrolled fire (rolling flames) that spreads across wildland, including forests, grasslands, pasturelands, and peatlands and can travel up to 14 mph, or essentially a 4-minute mile. Extreme wildfires are technically known as pyro-cumulonimbus wildfires. Essentially, these are fires which are driven by dangerous conditions, leading to fatalities and considerable damage (Di Virgilio et al., 2019). Wildfires are normally not caused naturally. Across the world, less than 10% of wildfires start naturally, with the rest started by humans, due for example to unattended camp and debris fires, cigarettes, arson, or a downed power line (Insurance Information Institute, 2020). Fires are also started to clear land for agriculture, which is the main reason why there are so many fires in Africa (home to 70% of the world’s fires according to NASA data) (Petesch, 2019). Fires may occur from the hot sun or can naturally spark during a spell of dry weather or a drought when green vegetation becomes bone-dry land that is easily flammable or when lightening strikes. In the US, 84% of all wildfires are started by humans, while in Canada, 55% of wildfires are actually started by lightning (Goss et al., 2020)! Here it is important to point out that the issue of lightening illustrates the vicious cycle of climate change. Lightening happens more frequently in warmer weather. For every degree of Celsius warming, the chance of lightening increases by 12%, in a study of the US (Harvey, 2017). Thus, the increased frequency of lightening due to man-made climate change could lead to more fires, and studies have shown that lightening ignitions in North America have increased since 1975 (Harvey, 2017). Paradoxically there are some benefits from fires. Firefighters sometimes stop wildfires with controlled burning, which creates a backfire to remove the undergrowth, brush, and litter from a forest which serve as fuel for a wildfire. Naturally occurring wildfires also play a role in nature, because they return trapped nutrients to the soil and act as a disinfectant to remove the disease-ridden plants and insects from an ecosystem (Pausas and Keeley, 2019). Wildfires thin out the forest canopy to allow more sunlight to reach the floor, allowing a new generation of seedlings to grow. Sequoias also rely on fire for their seeds to open up (Meyer and Safford, 2011). However, the benefits of fires in forests that are equipped to handle them is far eclipsed by the destruction that fires have caused. In the US, destruction from wildfires has increased substantially in the last 20 years. On average, 72,400 wildfires cleared an average of 7 million acres of US land each year since 2000 (Wolters, 2019). This is doubled the land scorched in the 1990s. In 2015, more than 10 million acres of land were burned in the US, the largest wildfire season on record. Though the number of wildfires has not changed much in the past several decades, the total acres burned has increased each decade. Unfortunately, there are also big losses from wildfires due to poor housing planning. In the US, many homes in California and Colorado have been built in red zone areas for fires, with 250,000 people settled in Colorado’s red zone alone (Goldenberg, 2012). Ignoring zoning laws poses greater risks to human security. Though the direct death toll from wildfires is relatively low, indirect deaths have been attributed to the smoke and polluted air. Studies have demonstrated that wildfires worsen air quality significantly and pose longterm health risks (Burke et al., 2021; Reid et al., 2016). The smoke released from wildfires is one of the most dangerous air pollutants to human health (Balmes, 2018). Wildfire smoke

78  Key challenges can hang in the air for weeks and even months and can travel vast distances. As a result, air pollution from forest fires is estimated to cause more than 300,000 premature deaths around the world (Neill, 2020). In the case of the 2019 Australian bushfires, the smoke from the fires killed 12 times more people than the fires themselves (ibid.).

Are famines ‘natural’ disasters? A famine is a widespread scarcity of food leading to mass starvation that has a wide range of causes and impacts. Famines have posed a huge threat to human security. In the past, it was thought that famines were driven by geological factors, such as a drought. Today, scholars recognize that famines do not occur entirely because of an extreme weather event (Ravallion, 1997; Sen, 1980; Von Braun et al., 1999). Though they are driven by droughts, for example, they constitute a social problem and are characterised by a breakdown in social relationships (Vieira et al., 2020). Thus, poverty is a more direct cause of a famine, though climatic events can serve as a catalyst. Famines do not cause starvation evenly across a country, as famines hit segments of society very differently. Government leaders and the wealthy never starve during a famine. This is because famines are affected by different entitlements (Sen, 1980). Some people lack the political, economic, and social power to attain the food they need to survive when there are issues in the food supply. A famine occurs when there are groups of people who are economically and socially vulnerable, living in countries that are poorly governed. For example, during the 1990s, the worst droughts and floods in China’s modern history had only a marginal effect on the country’s adequate food supply. This contrasts with the drought that hit China in 1960–1961 which was used as a pretext for the cause of death of over 30 million people (Devereux, 2000). The Chinese government officially blamed the famine on the drought which lowered grain supply that, in itself, would have caused only a small fraction of the eventual, death toll. Thus, the deaths attributed to the famine were driven by factors other than just the extreme weather event. Famines are exacerbated in countries where people do not have the means to leave the affected area to gain access to food and where there is a limited public transport infrastructure to ensure that prompt relief takes place. Famines can be measured in various ways. A famine could constitute 20% of households facing an extreme lack of food, measured by food consumption rates in both quality and quantity and the extent to which assets have been sold off to buy food. A food security crisis is also deemed a famine when more than 30% of the population is two standard deviations below the median weight for their given height. Famines can also be measured by mortality rates, where two people out of every 10,000 and at least four children under 5 years old out of every 10,000 are dying per day (Maxwell et al., 2020). Famines are also not an event, like natural hazards, but constitute a process which takes place over time. Some economists have argued that famines may develop when a drought is combined with a poorly functioning market system (that may encourage speculation, price bubbles, or hoarding) (Ravallion, 1997) or inadequate food distribution system (Sen, 1981). Low crop productivity from drought conditions can lead to food insecurity as the demand for crops exceeds the supply. When these drought conditions persist, it is the most impoverished and vulnerable who pay the most (Adegboyega et al., 2016; Lybbert and Carter, 2015). It’s important to note that famines don’t always happen during dry extreme weather events. Famines can also happen when there is severe flooding. In these cases, people may worry that there will be shortages, which leads to panic buying and price speculation, as happened in the famine that hit Bangladesh in 1974 (Sen, 1981).

Disasters  79 In addition to flooding and droughts, famines may be more likely to develop during a conflict. From 2015–2019, the risk of famine rose 80% to 85 million people around the world, mostly driven by the conflicts in Syria and Yemen (Voosen, 2020). True, droughts, storms, and global warming also play a role, but famines are affected more by food distribution issues rather than food availability. In Africa, many famines have been associated with civil war as well. Conflicts can block the arrival of humanitarian aid which is often a vital lifeline for those caught in the cross hairs of warring parties, such as has been the case in Yemen since 2015. People often do not die in a famine from starvation, but from an inability to fight off infectious diseases and other illnesses (Mokyr and Gráda, 2002). Malnourished people have compromised immune systems and are more likely to contract and face more severe and prolonged episodes of disease. In particular, people need certain micronutrients, such as vitamins, minerals, and essential amino acids to fend off diseases and infections (Farhadi and Ovchinnikov, 2018; Katona and Katona-Apte, 2008). In malnourished people, especially children, there is a drop in functional T-lymphocytes, one of the major components of the adaptive immune system (Ambrus and Ambrus, 2004). Famines associated with a drought are often accompanied by a scarcity of clean drinking water. Scarce access to water makes it more difficult to maintain hygiene standards and sanitation routines, which increases the threat of diseases like cholera and dysentery. As droughts may lead to increased migration of individuals searching for food, facilitating the spread of infectious diseases. Measles, in particular, has been a huge killer during famines in African countries with low vaccination rates (Mahamud et al., 2013; Talley and Salama, 2003).

Disasters and health As the section on famine explained, disasters can impact the spread of infectious diseases and have a major impact on health. Earthquakes and hurricanes can completely destroy public health systems. Disasters may cause traumatic injuries, which forces people into hospitals where nosocomial transmission of diseases can take place. Storms can wipe out crop production leading to greater food insecurity and thus affect the ability to fight off infectious diseases. The 1976 earthquake that hit Guatemala killed 23,000 people and displaced 1.5 million people, but most of the deaths took place in the post-disaster phase from a combination of malnutrition and disease (Spencer et al., 1977; Charvériat, 2000). Furthermore, a massive natural hazard can wipe out electricity, which is deadly for those in need of electricity for medical equipment. In Africa, Latin America, and Asia, outbreaks of cholera, diarrhoea, malaria, and dengue fever have been common after a major storm (Cambaza et al., 2019; Lemaitre et al., 2019; Moreno, 2006). Exposure to contaminated environments after a natural hazard event makes people more susceptible to infectious diseases. Flooding can cause contamination of drinking water supplies with untreated sewage and wastewater, which comes with a greater vulnerability to waterborne diseases. Excessive precipitation can cause sewage systems to overflow, which can spread viral and bacterial infectious diseases. Hepatitis viruses A and E are transmitted through contaminated food and water and thrive in conditions where there is poor sanitation. Severe flooding in China led to an increase in these types of infections (Liang and Messenger, 2018). In Puerto Rico after Hurricane Maria, flooding led to the spread of leptospirosis, a blood infection caused by the bacteria Leptospira (Polgreen and Polgreen, 2018). Flooding also led to outbreaks of other diseases when people drank contaminated water. After the 2004 tsunami and Hurricane Katrina, contaminated

80  Key challenges floodwater led to bacterial infections requiring antibiotics (Liang and Messenger, 2018). When disasters destroy sanitation systems, this facilitates the spread of diarrhoeal diseases, which contributes to 40% of the deaths after a disaster event (Kouadio et al., 2012). Poor hygiene, sanitation, lack of access to clean water, and contaminated food increases vulnerability. For coastal parts of Bangladesh, surface water is the main source of drinking water. When the water becomes contaminated after a disaster hits, there is a perfect recipe for the spread of diseases. Water-related disasters affect food and drinking water, which increases the transmission risk of infectious diseases, such as diarrhoea, hepatitis, malaria, dengue, pneumonia, eye infections, and skin diseases (Lemonick, 2011; Yang et al., 2012). Storms disrupt the environment on multiple levels and can eliminate pre-existing barriers separating hosts and agents. Dramatic changes in the amount of rain can increase the rodent population and increase human-rodent interaction. Storms can also affect vector-borne diseases; for example, dengue fever infection rates have spiked after massive storms. Though the initial stage of a storm, with high winds and heavy flooding, can reduce vector populations and disrupt breeding sites, the recovery phase often leads to new vector breeding sites as there are more pools of standing water. Massive storms led to huge dengue fever outbreaks in Cuba after Hurricane Michelle in 2001, in Pakistan after flooding took place there in 2010, and in the Philippines after Typhoon Haiyan struck in 2013 (Liang and Messenger, 2018). Droughts also provide new breeding grounds for mosquitoes because desiccated riverbeds provide an impermeable surface to trap pools of water. For example, though vector-borne diseases often spread after extreme precipitation events, the Zika virus spread during a period of drought (Paz and Semenza, 2016). After a destructive event, people are often placed in crowded and unsanitary conditions, with contaminated food and water supplies and little access to important immunizations (Noji, 2005). People who have been displaced after a disaster are more likely to encounter vectors of diseases. Contaminated food and water, disrupted sewage, and poor sanitation and hygiene among people living in close quarters facilitates the spread of gastro-intestinal pathogens that can lead to outbreaks. After Hurricane Katrina, an outbreak of norovirus, a diarrhoeal disease, affected more than 1,000 evacuees and relief workers in temporary shelter in Houston, Texas, over a period of 11 days (Centers for Disease Control and Prevention, 2005). A smaller outbreak hit a shelter in New York after Hurricane Sandy in 2012 (Ridpath et al., 2015). Another diarrheal illness, rotavirus, broke out in a shelter in India following the 2004 tsunami (Liang and Messenger, 2018). Immediately after Hurricane Mitch in 1998, acute respiratory infections increased from 295 to 1,205 per 100,000 residents in Nicaragua among displaced people living in more crowded conditions. A similar surge in acute respiratory infections also took place in Aceh province in Indonesia following the 2004 tsunami (Liang and Messenger, 2018). Fires have a negative impact on health because they affect air quality (Ford et al., 2018). As mentioned previously, smoke from wildfires can travel thousands of miles and is associated with greater rates of hospitalization for respiratory diseases and heart disease. Ash and debris from burned homes and buildings expose people to toxic chemicals such as asbestos and heavy metals. Emissions from fires are expected to increase by up to 101% on average by the end of the century (Hurteau et al., 2014). Wildfires have an effect on our health, and are responsible for 5–8% of the deaths from poor air quality (Finlay et al., 2012). The Indonesian fires of 2015 led to 19 deaths and caused 500,000 people to suffer from respiratory illnesses (Uda et al., 2019).

Disasters  81

Conclusion Disasters are not as deadly as infectious diseases, but they have a massive impact on human security, both directly and indirectly. Floods in northwest Pakistan in 2010, for example, affected over 20 million people, leaving many vulnerable to disease and malnutrition (Murthy and Christian, 2010). Wildfires have destroyed biodiversity in Brazil. An earthquake in Japan in 2011 triggered a tsunami, which then caused a massive nuclear accident. This chapter laid out all of the various types of disasters, what we mean by disasters, what the impacts are, and the current trends. On the one hand, there is room for optimism as the death toll from disasters has decreased significantly over time. On the other hand, the number of vulnerable people is increasing, as are the costs. We are less vulnerable to dying in a disaster but more vulnerable to being affected. More worrisome is the trend that some hazards are occurring with greater frequency and intensity due to Anthropocene (man-made) climate change. Thus, disasters can be thought of as a symptom of a much greater problem. This chapter touched upon the connections between climate change and disasters, but the next chapter will cover this relationship in greater detail. The following chapters will explain how global dynamics, such as climate change and various economic dimensions of globalization, spark disease outbreaks and disaster events. Globalization has also affected the human-to-human transmission and has affected how states manage and respond to both diseases and disasters.

Key questions 1

Why are floods no longer the deadliest disaster event? Why are earthquakes the deadliest now? 2 Given your understanding of human security, which type of disaster poses the biggest threat to human security? 3 What are the biggest indirect health impacts of disasters? 4 Why are disasters compound events? Do you think this is more the case than for diseases? 5 Do you think famines should be categorized as ‘natural’ disasters?

Note 1 www.globalquakemodel.org/who-we-are

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86  Key challenges Sen, A., 1981. Ingredients of famine analysis: Availability and entitlements. The Quarterly Journal of Economics, 96(3), pp. 433–464. Sheetz, M., September 25, 2017. Hurricane Maria wiped away around 80% of Puerto Rico’s agricultural industry. CNBC News. www.cnbc.com/2017/09/25/hurricane-maria-wiped-away-about-80-percentof-puerto-ricos-farming-industry.html. Accessed January 10, 2021 Sigurdsson, H., Houghton, B., McNutt, S., Rymer, H. and Stix, J. eds., 2015. The encyclopedia of volcanoes. Amsterdam, Netherlands: Elsevier. Smil, V., 1999. China’s great famine: 40 years later. BMJ, 319(7225), pp. 1619–1621. Smith, K., 2013. Environmental hazards: Assessing risk and reducing disaster. Abingdon-on-Thames, UK: Routledge. Spencer, H., Romero, A., Feldman, R., Campbell, C., Zeissig, O., Boostrom, E. and Long, E.C., 1977. Disease surveillance and decision-making after the 1976 Guatemala earthquake. The Lancet, 310(8030), pp. 181–184. Stein, S. and Wysession, M., 2009. An introduction to seismology, earthquakes, and earth structure. Hoboken, NJ: John Wiley & Sons. Talley, L. and Salama, P., 2003. Assessing field vaccine efficacy for measles in famine-affected rural Ethiopia. The American Journal of Tropical Medicine and Hygiene, 68(5), pp. 545–546. Taylor, A., December 26, 2014. Ten years since the 2004 Indian Ocean Tsunami. www.theatlantic.com/ photo/2014/12/ten-years-since-the-2004-indian-ocean-tsunami/100878/ Thompson, A., December 22, 2020. A running list of record-breaking natural disasters in 2020. Scientific American. www.scientificamerican.com/article/a-running-list-of-record-breaking-natural-disas ters-in-2020/. Accessed December 20, 2020 Trenberth, K.E., Cheng, L., Jacobs, P., Zhang, Y. and Fasullo, J., 2018. Hurricane Harvey links to ocean heat content and climate change adaptation. Earth’s Future, 6(5), pp. 730–744. Uda, S.K., Hein, L. and Atmoko, D., 2019. Assessing the health impacts of peatland fires: A  case study for Central Kalimantan, Indonesia. Environmental Science and Pollution Research,  26(30), pp. 31315–31327. UNISDR, November 23rd, 2015. UN report finds 90 per cent of disasters are weather-related. www. un.org/sustainabledevelopment/blog/2015/11/un-report-finds-90-per-cent-of-disasters-are-weatherrelated/. Accessed January 16, 2020 UNOCHA, October 12, 2020. 2020 Atlantic hurricane season on pace to become the most active ever. www.unocha.org/story/2020-atlantic-hurricane-season-pace-become-most-active-ever. Accessed January 7, 2021 Usman, M.T. and AbdulKadir, A., 2014. An experiment in intra-seasonal agricultural drought monitoring and early warning in the Sudano-Sahelian Belt of Nigeria. International Journal of Climatology, 34(7), pp. 2129–2135. Van Oldenborgh, G.J., Van Der Wiel, K., Sebastian, A., Singh, R., Arrighi, J., Otto, F., Haustein, K., Li, S., Vecchi, G. and Cullen, H., 2017. Attribution of extreme rainfall from Hurricane Harvey, August 2017. Environmental Research Letters, 12(12), p. 124009. Vieira, R.M.D.S.P., Sestini, M.F., Tomasella, J., Marchezini, V., Pereira, G.R., Barbosa, A.A., Santos, F.C., Rodriguez, D.A., do Nascimento, F.R., Santana, M.O. and Campello, F.C.B., 2020. Characterizing spatio-temporal patterns of social vulnerability to droughts, degradation and desertification in the Brazilian northeast. Environmental and Sustainability Indicators, 5, p. 100016. Voight, B., 1990. The 1985 Nevado del Ruiz volcano catastrophe: Anatomy and retrospection. Journal of Volcanology and Geothermal Research, 42(1–2), pp. 151–188. Von Braun, J., Teklu, T. and Webb, P., 1999. Famine in Africa: Causes, responses, and prevention. International Food Policy Research Institute. Baltimore, MD: Johns Hopkins University Press. Voosen, P., 2020. The hunger forecast. Science, 368(6488), pp. 226–229. Wanders, N., Wada, Y. and Van Lanen, H.A.J., 2015. Global hydrological droughts in the 21st century under a changing hydrological regime. Earth System Dynamics, 6(1), pp. 1–15. Weichselgartner, J. and Bertens, J., 2000. Natural disasters: Acts of God, nature or society? On the social relation to natural hazards. WIT Transactions on Ecology and the Environment, 45.

Disasters  87 WHO, 2020a. Earthquakes. www.who.int/health-topics/earthquakes#tab=tab_1. Accessed December 16, 2020 WHO, 2020b. Droughts. www.who.int/health-topics/drought#tab=tab_1. Accessed December 19, 2020 Williams, M., July  10, 2015. What is the pacific ring of fire? Universe Today. www.universetoday. com/59341/pacific-ring-of-fire/. Accessed January 17, 2021 Wolters, C., December  5, 2019. How wildfires get started and how to stop them. National Geographic. www.nationalgeographic.com/environment/natural-disasters/wildfires/#:~:text=An%20 average%20of%2072%2C400%20wildfires,10%20million%20acres%20of%20land. Woodward, J., September  1st, 2016. This is how people die in hurricanes. The Island Packet. www. islandpacket.com/news/weather/hurricane/article99415187.html. Accessed January 16, 2020 World Meteorological Association (WMO)., 2014. Atlas of mortality and economic losses from weather, climate and water extremes (1970–2012). https://library.wmo.int/index.php?lvl=notice_ display&id=16279#.YCO19JP7SqB. Accessed December 19, 2020 Wright, S.G. and Rathje, E.M., 2003. Triggering mechanisms of slope instability and their relationship to earthquakes and tsunamis. Pure and Applied Geophysics, 160(10), pp. 1865–1877. Yamasaki, E., 2012. What we can learn from Japan’s early earthquake warning system. Momentum, 1(1), p. 2. Yang, K., LeJeune, J., Alsdorf, D., Lu, B., Shum, C.K. and Liang, S., 2012. Global distribution of outbreaks of water-associated infectious diseases. PLoS Neglected Tropical Diseases, 6(2), p. e1483.

Part II

Drivers of disease and disaster

4 Globalization, climate change, and disease

Introduction Despite the growing number of threats to human security, with advances in modern medicine and science, life expectancy continues to rise. In 1900 life expectancy around the world was 32 years, yet today it is as high as 73 years. Nevertheless, though there is reason for optimism for what the global community can achieve, there have been other side-effects of global progress that have left the world more vulnerable than ever. In the 21st century, there are more weather-related natural hazards as well as more new and re-emerging diseases. Diseases have also spread to regions where they were not previously endemic: cholera spread to South America in 1991 after almost a century of being absent there; Rift Valley fever spread to the Arabian Peninsula in 2000 after it had previously been confined to Africa; the tsetse fly that transmits African sleeping sickness returned to areas in Africa where it had previously been under control. This chapter explores the impact of globalization and climate change on infectious diseases. As the chapter will explain, globalization has complicated environmental security – or the protection of the ecosystem, disaster security, and health security. Globalization, as measured by unsustainable development, global trade, and movement of goods and services, has hastened climate change and has motored environmental degradation, which has had detrimental effects on infectious diseases. In exploring these relationships, we first examine what we mean by globalization and clarify the dimensions of globalization that we are examining. We then turn to define climate change to provide a baseline for understanding what climate change entails and how it may spark diseases. We then go over the global factors that explain why there are more infectious diseases than in the past – in other words, the factors that spark an outbreak in humans, and the global factors that facilitate the spread of disease from human to human. This is followed by a discussion of the global factors that undermine the management of diseases. Key concepts

What is globalization? This chapter focuses on the significant impact of globalization on infectious diseases and disasters. Proponents of globalization argue that unprecedented economic growth and interdependence would lift all boats, raising life expectancy rates and enabling states to pull themselves out of poverty and despair. It is true that, since 1950, life expectancy rates have risen significantly around the globe. Economic growth has taken place, and for some states, like

DOI: 10.4324/9781003128809-7

92  Drivers of disease and disaster China, 400–500 million people were pulled out of poverty, making impressive gains in life expectancy, income, and literacy rates (Huang, 2011). Globalization has helped to diffuse technology and improved transportation and connected the world more easily. In spite of all of these benefits, globalization has its critics. One of the biggest concerns with globalization is that it has intensified transnational threats such environmental degradation. The bulk of the chapter addresses the impact of globalization-driven environmental degradation. Additionally, others argue that while overall gains have been made in life expectancy and income, much of the gains are skewed towards the rich countries. Mainstream economists and politicians touted the benefits of globalisation, with little concern for the economic, political, and social consequences. Globalization is defined by enormous increases in trade, goods, and investment and unprecedented levels of economic interdependence.1 Massive improvements to technology and transportation that facilitate the free movement of people, services, and capital have driven globalization, leading to an increasingly interdependent global society (Beck, 2018; Held, 2006). Globalization has also led to the weakening of state sovereignty and the strengthening of multi-national corporations and multi-lateral institutions. Globalization is represented by a huge push for industrialization, modernization, urbanization, and capitalist development. It is not just that countries are propelled to trade freely, they are also compelled to reorient their economies around exports and create economies of scale to ensure greater levels of efficiency. The drive to produce more products and services has led to extraordinary levels of environmental destruction, such as rapid deforestation rates to cut down trees in order to create room to produce goods needed to export on a massive scale. Globalization has also led to huge changes in the demographics of countries in the developing world. Globalization introduced competition from low-wage manufacturing in the lower income countries, which helped to drive down wages. As import competition increased, factories closed down or moved abroad to take advantage of cheap labour in developing countries. Workers were lured to congregate in urban areas to take advantage of these opportunities, but this took place in an unregulated and poorly managed fashion. Cities could not cope with the huge levels of migration to urban areas. Slums and shanty towns emerged from the lack of urban planning. Sanitation services could not handle the influx of people living in crowded conditions with suboptimal access to water and other services. Globalization has also led to economic crises. Increasing levels of economic interdependence have made countries more vulnerable and sensitive to booms and busts. These booms and busts usually affect those who are rich and highly skilled quite differently than those who are poor and less skilled. While financial elites are often bailed out, low-income citizens are forced to fend for themselves. When developing countries amassed greater levels of debt, they were obliged to accept loans that were structured by the International Monetary Fund (IMF) and other international financial institutions and donors. But these loans came with a catch: states must adhere to new policies that would streamline the state and open up the economy to foreign goods and services.

What is climate change? Anthropogenic (man-made) climate change or global warming is caused by increasing concentrations of greenhouse gases, such as carbon dioxide, oxides of nitrogen, methane, and chlorinated hydrocarbons (CFCs). Greenhouse gases trap heat in the atmosphere because they prevent radiation from escaping into space. The main greenhouse gas, CO2, is emitted when humans burn fossil fuels, such as coal and oil, which has occurred at a much greater

Globalization, climate change, and disease  93 frequency since the Industrial Revolution. Changes in agriculture and land use also have caused atmospheric greenhouse gas concentrations to rise. The atmosphere has responded to these increases in greenhouse concentration with higher temperatures, affecting both land and oceans. The rise of surface warming in the Northern Hemisphere is greater than during any other century in the past thousand years (Meyer, 2019). Climate change also refers to long-term statistical shifts in weather.2 This includes changes in average weather conditions (including temperature, precipitation, wind, and sunshine) and changes in the average number of extreme weather events. The consensus on climate change is that it is mostly driven by human activities. As a result of climate change, not only are global average temperatures increasing but global sea levels are rising and the Arctic sea ice is shrinking (Nerem et al., 2018). From 2006 and 2016, we’ve seen the global sea level rise at a rate that is 2.5 times faster than for almost all of the 20th century (Meyer, 2019). Ocean water is becoming warmer and more acidic and more extreme weather events are occurring. Climate change also leads to ecosystem degradation, which puts added pressure on agricultural productivity (Figueres et al., 2017). This can lead to issues such as crop failure, malnutrition, starvation, increased population displacement, and resource conflict. Climate change, or global warming more specifically, is not occurring in a uniform fashion temporally. It is occurring twice as fast during the winter and night-time periods, and faster at high latitudes than in the tropics. Warming occurring disproportionately at high latitudes during the winter has led to a northern migration of ticks that carry tick-borne encephalitis and Lyme disease (Brownstein, 2005). After over 150 years of industrialization, global trade, deforestation, and large-scale agriculture, greenhouse gases in the atmosphere have risen to levels not seen in three million years. In October of 2018, the UN Intergovernmental Panel on Climate Change (IPCC) issued a special report warning a 2°C increase in global temperature will do irreparable damage to ecosystems and the planetary climate system. Even a rise of 1.5°C will have a massive impact and would still require that all aspects of society engage in far-reaching changes to prevent further damage (UN, 2020). In the sections that follow, we explain how climate change and globalization impact diseases. Globalization, climate change, and diseases Globalization has brought about tremendous change, which has mostly been unchecked, and has had far-reaching implications. We focus on ecological and economic dimensions of globalization – the intensification of economic interrelations around the world – which has driven unsustainable growth. The specific aspects of globalization examined here include the impact of environmental degradation and mass urbanization; the mass production and trade of livestock and bushmeat; and the free movement of animals, goods, services, and people. These factors help explain why there are more infectious diseases than ever and why they spread more quickly. We also look at how the diminishing capacity of the state, as a result of pressures from increasingly powerful international financial institutions, has impacted our ability to manage diseases.

Spark of infectious diseases As mentioned earlier, we are examining the causal factors behind the spark of a novel disease outbreak or the spark of a re-emerging infectious disease outbreak. By this we are referring to what causes the index case (first case) of a new outbreak. Thus, we are looking at outbreaks of

94  Drivers of disease and disaster diseases that are not endemic, and in a later section we will look at factors that facilitate transmission in a community. Most emerging infectious diseases are caused by pathogens that are already present in the environment. The environment and changes to habitats have a huge influence on what will advantage or disadvantage pathogens, vectors, and host defences. Some pathogens need to have a vector or some sort of intermediate host in order to finish their lifecycles (McMichael, 2004). New diseases emerge when provided with environmental conditions that are favourable to infect a new host (Aguirre and Taborb, 2008). When they evolve into a new variant, they cause a new disease. This is rare, but is occurring at greater frequency than in the past (Woolhouse and Gowtage-Sequeria, 2005; Jones et  al., 2008). Since the mid 1980s, at least 30 threatening new infectious diseases have emerged (Mukherjee, 2017). There are numerous reasons why there are more diseases than in the past. This includes cross-species transfer, changes in population of reservoir hosts or intermediate vectors, pathogenic evolution, and microbial genetic mutation as well as our increased ability to recognize diseases. However, this chapter will focus on climate change, the human-environment relationship, and the way that people engage in activities that interfere with ecological and environmental conditions. Changed interactions between humans and wildlife or domestic animal populations is the most probable facilitator of many different types of diseases (Chastel, 2004; Genné, 2007; Snowden, 2008). Unsustainable development, such as deforestation and urbanization, drives these changes in human and animal interactions. Deforestation also leads to habitat fragmentation, which disrupts the predator-prey relationships which are critical to preventing increase in vectors and pathogens. We also focus on the global demands of the livestock industry and the wild animal trade. This suggests that environmental sustainability is a foundation for disease prevention (Prüss-Üstün et al., 2016). Climate change and diseases As the chapter has already noted, the frequency and intensity of extreme weather events is on the rise due to climate change (Lubchenco and Karl, 2012). Global warming and more extreme weather have changed ecosystems and the weather patterns that impact infectious diseases, their vectors and hosts. In particular, extreme weather events (both high levels of rainfall and droughts) can spawn a new disease or spark a new outbreak of a re-emerging disease. An extreme precipitation event can influence the transport and dissemination of new infectious agents to create a new outbreak (Wu et al., 2016). Rainy seasons can cause an increase in faecal pathogens as heavy rain may stir up sediments in water, leading to the accumulation of faecal microorganisms (García-Aljaro et al., 2019). Floods flush pathogens into waterways which gives rise to water-borne diseases. Floods also foster fungi, which is associated with lung disease in children (Alderman et al., 2012). Salmonellosis and cholera are diseases that show increased outbreaks due to greater flooding. High levels of rain after a long drought can also lead to an increase in pathogens, causing a disease outbreak (Wilby et al., 2005). Diarrhoeal disease increased in Latin America after El Niño brought heavy flooding (Kovats et al., 2003). Flooding has also increased the risks of outbreaks of leptospirosis (Weil’s diseases) in poor regions in Central and South America and South Asia by inundating open sewers and streets (Ahern et al., 2005; Patz et al., 2003; Schneider et al., 2017). Hurricane Mitch hit Central America in November of 1998, dumped huge levels of precipitation, and

Globalization, climate change, and disease  95 killed over 11,000 people. In the aftermath, Honduras reported 30,000 cases of cholera, with Venezuela facing a similar outbreak the following year due to intense flooding. In February of 2000, floods hit Mozambique displacing hundreds of thousands of people and leading to an outbreak of typhoid and cholera (Ahern et al., 2005). Disasters, such as floods, lead to changes in the microbe’s ecological position, which makes disease outbreaks more likely. Excessive rain supports mosquito production and survival rates, as various mosquito vectors reproduce in small natural ponds of clean water (Gage et al., 2008). Though excessive strong rains can destroy their breeding cites, mosquito populations usually multiply within weeks (Kuhn et al., 2005). Excessive rain offers more mosquito breeding sites, which can accelerate larval development of some mosquito vectors (Hoshen and Morse, 2004). A study of malaria risk after El Niño events has demonstrated a five-fold increase in malaria epidemic risk (Wu et al., 2016). Outbreaks of malaria in Ecuador, Peru, and Bolivia were related to heavy rains from El Niño (Kovats, 2000). High rainfalls and higher temperatures in the highlands of Kenya have been associated with higher cases of malaria several months later as well (Githeko and Ndegwa, 2001). Heavy rains in Honduras during Hurricane Mitch led to 1,700 cases of malaria and over 1,000 cases of dengue fever (OCHA, 1998). Hotter temperatures can also give rise to new outbreaks of other waterborne diseases, such as diarrhoea, cholera, and schistosomiasis. Increasing hot weather that raises the temperature of water and food can support microbe reproduction cycles, such as bacteria. The reproduction of salmonella bacteria increases as temperature rise between 7 °C and 37 °C (Nguyen and Yuk, 2013). Climate change could increase the burden of diarrhoea by up to 10% by 2030 in some regions of the world, as higher temperatures are favourable to the development of pathogens (Campbell-Lendrum et al., 2003). Influenza, on the other hand, thrives in cold climates and during Asian dust storm days (Lowen et al., 2007; Chen et al., 2010). Thus, as the climate becomes more extreme (both colder and hotter) this furthers the development of many different types of diseases. Climate change, which drives drops in precipitation also causes shortages of clean surface water, which can lead to outbreaks of water borne diseases. A shortage of water raises the likelihood that humans will be in contact with water-borne pathogens (Funari et al., 2012; Hunter, 2003). Water scarcity during a drought and man-made pools of water being stored also drives the multiplication of mosquitoes, which can spark a new outbreak. Droughts in normally wet regions can offer pools of stagnant water that serve as breeding places for mosquito vectors, while low-flowing rivers concentrate water-borne pathogens (Hofstra, 2011; Kovats et al., 2003). Droughts also affect zoonotic and vector-borne diseases by decreasing the number of predators, which then increases the number of vectors and reservoir hosts. Spikes in the number of reservoir hosts can spark new infectious diseases and amplify disease transmission. Droughts lead to the decline of amphibians and dragonflies which consume mosquitoes. Droughts in California reduced the numbers of owls, eagles, falcons, and hawks that prey on rodents. Intense rains that eventually followed led to a proliferation of insects and nuts which rodents feed on, helping the rodent population to flourish (Epstein, 2001; Prugh et al., 2018). This boosted the population of rodents more than tenfold, leading to the emergence of a new rodent-borne viral disease HPS, which had been dormant (Economist, 2019; Kjemtrup et al., 2019). Diseases transmitted by rodents increase during heavy rain and flooding due to different patterns of human-rodent contact. During these periods, rodents are more likely to enter human dwellings looking for food. Heavy rainfall also encourages excessive wild grass seed production which then supports the number of rodents (Diaz, 2014).

96  Drivers of disease and disaster Environmental degradation Many scholars concur that global capitalism is a system that drives unsustainable practices of production, waste, and consumption that has destructive environmental and social consequences (Baer, 2012; Gough, 2017; Klein, 2015; Koch, 2011; Wright and Nyberg, 2015). While we don’t delve into the debate of whether the market can resolve the existential threats posed by climate change, deforestation, and destruction of the biosphere or whether capitalism is completely incapable of doing so, we do focus on how globalization has thus far created demands that have far reaching impacts for infectious diseases and disasters. The huge global market demand for specific products that come from specific environments (deforestation is largely driven by four products: beef, soy, palm oil, and wood products) has sped up environmental degradation and deforestation in many countries around the world (Persson et al., 2014). The most concerning impact of deforestation is its impact on the environment. After the burning of fossil fuels, deforestation is the second-leading cause of climate change (Derouin, 2019). Deforestation accounts for nearly 20% of greenhouse gas emissions, roughly the same as the annual emissions from 600  million cars (Union of Concerned Scientists, 2013). Tropical deforestation is especially important. If tropical deforestation were a country, it would rank only behind China and the US in carbon dioxideequivalent emissions (Carlson et al., 2018). Because trees are important in absorbing carbon dioxide, which can mitigate man made greenhouse gas emissions, deforestation rates pose huge threats to environmental security. The World Bank estimates that about 3.9 million square miles (10 million square km) of forest have been lost since the beginning of the 20th century (Derouin, 2019). In the past 25 years, the forests have shrunk to an area no bigger in size than South Africa. In the case of the Amazon, about 17 percent of the rainforest has been destroyed over the past 50 years, and recently, losses have been on the rise (Irfan, 2019). In the Amazon rainforest, areas which have been converted to agricultural land have higher soil and air temperatures exacerbating drought conditions, which has other, knock-on effects for disease sparks. In addition to affecting greenhouse gas emissions, deforestation has been linked to a spike in infectious diseases. Rising needs for industrial farming, agricultural plantations, and natural resource extraction has led to land conversion projects that raise the risk for infectious disease risks. Over 25 million kilometres of roads have been estimated for development in the next 30 years, with 90% of these taking place in developing nations with high levels of bio-diversity (Alamgir et al., 2017). The destruction of natural habitats has allowed unprecedented human access to pathogens. One study demonstrated that as many as one in three outbreaks of new and emerging diseases are linked to land use change, like deforestation (Loh et al., 2015). Deforestation, for example, has been linked to the emergence and re-emergence of Lassa fever, Lyme disease, and Nipah virus to name a few (Löscher and Prüfer-Krämer, 2009). The reasons why deforestation can spark disease outbreaks are three-fold. First, deforestation can drive animals that carry diseases out of the forests and into closer contact with humans. As animals are pushed into new areas, this will lead to more spill-overs of infectious diseases (Allen et al., 2017). Changes to landscapes drive primates, which are known to carry a number of different viruses, closer to humans as they search for food (Bloomfield et al., 2020). Animals carrying diseases also flock to deforested plantations and industrial farms where they are more likely to interact with humans and domesticated animals. Impoverished families may also look for resources to support and feed their families that place them in contact with animals that carry viruses. Deforestation also affects where mosquitoes breed and

Globalization, climate change, and disease  97 puts them in closer contact with human settlements. Second, deforestation has a negative impact on biodiversity (Tollefson, 2020). Thus, if a bat sneezes in a forest that is rich with biodiversity, the chances are higher that a pathogen that carried in that sneeze will land on another animal rather than a human. When humans come in closer contact with animals, this can change forest habitat, unwittingly making humans hosts for pathogens. Changes to biodiversity can facilitate the spread and abundance of pathogens (Afelt et al., 2018). The third factor is that land use change, such as deforestation forces modifications in vector abundance. Mosquitoes, particularly those that are vectors of pathogens, favour deforestation according to a study of 87 mosquito species (Burkett-Cadena and Vittor, 2018). Thus, deforestation creates more breeding sites for mosquitoes. With the case of Ebola which broke out in Guinea in 2014, deforestation was taking place at rapid rates due to unchecked natural resource exploitation by foreign mining and timber operations (Bausch and Schwarz, 2014). Deforestation brought infected wild animals in closer contact with humans, which sparked the emergence of the outbreak. The index case of the Ebola outbreak was supposedly caused by an 18-month boy’s interaction with a hollow tree that was infested with fruit bats in his backyard in a remote village in Guinea (Syed, 2019). Bats have been pushed closer into villages by deforestation which has destroyed 80% of their habitat, because of demands from foreign mining and timber interests (Rott, 2020). The habitat loss due to deforestation has caused a mass exodus of fruit bats searching for food and moving to feed on cultivated fruit trees (Chua et al., 2002). Deforestation in India, Bangladesh, and Malaysia, which caused changes in the movements and densities of fruit bats, led to the emergence of Nipah virus (Afelt et al., 2018). In Liberia, deforestation for palm oil plantations attracts forest-dwelling mice that are lured by palm fruit around the plantations. Humans can then contract Lassa virus when they come into contact with food or other things that have been contaminated with virus-carrying rodent faeces or urine. Virus-carrying rodents flock to deforested areas in South America as well (Gottwalt, 2013). Deforestation has also led to an increase in disease-carrying mosquitoes. Clearing forests creates an ideal habitat along the edges of the forest for the Anopheles mosquito to breed (Mordecai et al., 2019). There are higher numbers of mosquito larvae in warm, partially shaded pools that form besides roads cut into the forests and puddles behind debris where the water is no longer taken up by trees (Vittor et al., 2006, 2009). Many disease-carrying mosquitoes prefer to breed on the fringe of a recently cleared forest rather than deep in the woods (Sutherst, 2004). In South America, deforestation of the Amazon, largely driven by the expansion of agriculture, has brought a surge in malaria. In Brazil in the 1960s, malaria eradication campaigns brought down annual cases of malaria to 50,000. By 2000, there were 600,000 cases. Mosquito biting rates of malarial-carrying mosquitoes in deforested settlements in the Peruvian Amazon were 278 times higher than in other settlements in the Amazon (Vittor et al., 2006). Furthermore, livestock that graze on cleared land held to nourish and multiply various disease vectors, which can in turn spread to humans (Gale et al., 2009). Some of the highest rates of deforestation in the world are taking place in Malaysia, mostly in Borneo with the massive drive for palm oil, an inexpensive and stable oil (Ananthalakshmi, 2019). This deforestation, in turn, has caused a huge increase in malaria in the region (Raja et al., 2020). A study that looked at the relationship between deforestation and malaria cases found that, from 2003–2015, a 10% yearly increase in deforestation led to a 3% rise in malaria cases (MacDonald and Mordecai, 2019). Though deforestation has not led to a rise in malaria cases everywhere, studies have demonstrated that deforestation will drive a surge in malaria

98  Drivers of disease and disaster cases in the Amazon and Central Africa and, notably, in Malaysia (Friedrich, 2016; Guerra et al., 2006; Vittor et al., 2006, 2009). Urbanization By 2030 it is expected that urban land will cover 1.2 million square meters, twice as much as in 2000. In developing countries, 90% of population growth is projected to occur in cities. Feral forms of sub-urbanization where humans and nature have more direct encounters is likely to spark more disease outbreaks (Falco et al., 2008). Urbanization is a key driver of land-use change that is likely to increase at an unprecedented rate in the coming decades, particularly in developing countries. As areas grow increasingly urbanized this poses issues for sparking diseases. Urban-adapted (otherwise known as synanthropic) wildlife is abundant in cities, and is composed of species that can spread diseases to humans. Human activities that increase exposure to populations of synanthropic wildlife also increase the risk of pathogens spilling over to humans. Urbanization changes the structure of wildlife communities which leads to lower levels of bio-diversity and increases in abundance of synanthropic species- and in turn host abundance (called the dilution effect) (Hassell et al., 2017). This increase in synanthropic population density can raise contact rates with human and increase the risk of pathogen transmission (SantiagoAlarcon and MacGregor-Fors, 2020). This is the case with rodents, and has become increasingly the case with mosquitoes that have adapted to urban environments. The environment in urban cities has in particular been favourable to rat populations. Poor housing, with inadequate water supplies, sanitation and waste management are favourable to pathogen carrying rodents. In Chinese cities, the incidence of some infectious diseases has been linked to urban growth, growing rat population, and increase rat – human contact (Neiderud, 2015). Different types of mosquitoes have also now learned to thrive in urban surroundings, especially overcrowded areas with poor sanitation and draining facilities, sparking new outbreaks (Alirol et al., 2011). The key vector for Dengue fever is the Aedes aegypti mosquito which has increased alongside urbanization. With cases rising around the world, including India and Latin America, urbanization has been cited as a possible reason. The Aedes aegypti mosquitoes lay their eggs in human made artificial water containers, which assist with their urban transmission cycle. Thus, in urban areas, where water has to be stored and collected due to a lack of reliable water and sanitation, this provides breeding sites for Aedes aegypti mosquitoes (Gubler, 2011). The Culex mosquito, which spread West Nile virus and Japanese encephalitis also breeds in nasty pools of underground water in city drains (Valdelfener et al., 2019).

Box 4.1  Zoonotic diseases Zoonotic diseases (also called zoonoses) are diseases that pass from animals to humans, and they account for 60% of all known infectious diseases and 75% of all emerging infectious diseases (Salyer et al., 2017). Although many zoonotic pathogen spillovers arise in domestic animals, including livestock, the majority (71.8 %) of zoonotic EIDs arise from wildlife species (Jones et al., 2008). Thus, zoonoses from wildlife represents

Globalization, climate change, and disease  99 the biggest threat to global health of all of the emerging infectious diseases (Cleaveland et al., 2007; Jones et al., 2008). Not surprisingly, the most devastating pandemics in human history, the Black Death, Spanish influenza, and HIV/AIDS, were all caused by zoonoses from wildlife (Morens and Fauci, 2013). Most pathogens that infect animals are unable to make the jump to humans, but 33% of those studied have spilled over (Taylor et al., 2001). Many zoonotic diseases are benign, but many others such as Lyme disease and coronavirus are harmful, and in some cases fatal. Zoonoses can be transmitted in many ways, including direct exposure such as animal and insect bites; touching sick animals; consuming undercooked meat, unpasteurized milk, or contaminated water or indirect contact through exposure to animal faeces (Wolfe et al., 2005). Pathogens are also shared through animal urine and droppings which may be aerosolized and infect other susceptible animals and humans. The types of pathogens that can be transmitted by animals to humans include bacteria, parasites, fungi, and viruses. Most zoonotic pathogens are not adapted to humans and only emerge sporadically through spillover events and can lead to a localized outbreak, which is known as a stuttering chain- or a short chain of transmission that has not yet achieved a sustained chain of transmission (Lo Iacono et al., 2016). Epidemics in pandemic proportions emerge due to sustained secondary host transmission of pathogens.

Intensive livestock production Another driver of infectious disease is the livestock sector, including livestock keeping practices, production systems and movements of livestock and animal products. Not only does the livestock sector contribute to CO2 emissions of greenhouse gases on par with global transport, but it also has facilitated spillovers of diseases to humans (Steinfeld et al., 2006). As the global demand for meat products increased so too did the production. From 1980 to 2004 world meat production nearly doubled to 260 million tons (FAO, 2006). To meet this demand livestock production continues to expand. While livestock production was once family centred and small, today the global demands for livestock has led to intensive systems where animals are placed in crowded conditions. Intensive animal production began in the US over 70 years ago for poultry and swine, and is increasingly taking place in the developing world (Manale, 2006). In the case of the US, 6% of the nation’s hog farms produced 75% of the pigs, and 2% of the country’s egg farms produced 90% of the country’s egg-laying hens (MacDonald and McBride, 2009). The intensive model of animal production is fairly Table 4.1  Zoonotic diseases Bats: Ebola virus; SARS; MERS; rabies; Nipah virus; Hendra virus Birds: bird flu (H1N1, H5N1); salmonella; psittacosis Cats: toxoplasmosis; Pasteurella; ringworm Cows: Escherichia coli; ringworm; salmonellosis Dogs: rabies; noroviruses; Pasteurella; salmonella; ringworm; hookworm Rodents: Hantavirus pulmonary syndrome; plague; rat-bite fever; salmonellosis Mosquitoes: malaria; dengue; West Nile virus; Zika virus; Chikungunya virus Ticks: Lyme disease; Rocky Mountain spotted fever; Powassan disease

100  Drivers of disease and disaster efficient and productive, but raises all kinds of concerns about waste absorption, sustainability and zoonotic risks (Delgado et al., 2001). Some of the most highly infectious diseases, such as bird flu, have emerged from livestock production systems and industrial farming (Jones et al., 2013). A wild host species can spread the disease to domesticated animals through contact with them, which can spread quickly when the domesticated animals raised for food are placed in crowded and sub-optimal conditions. Large scale poultry production poses many risks for sparking diseases. Bird flu or avian influenza, circulates naturally in wild bird populations that come into contact with large homogenous populations of birds in poultry farms that are not isolated from wild animals and make contact with wildlife reservoirs (Gilbert et al., 2014). When birds raised for food are placed in crowded conditions, with reduced immune function from stress, and with limited genetic variability this presents greater likelihood of pathogen pollution, as a different species interact with each other. These sites act also as amplifiers of disease during the emergence of large-scale outbreaks, as the density of poultry has almost doubled in most countries between 1990 and 2008 (Steinfeld et al., 2006). Pork farming poses many risks as well, as dense stocking conditions enable viruses to transmit efficiently among pigs, and spillover to humans. Planting orchards next to pig farms may make it easier to use swine manure for fertilizer, but it also gives pigs greater exposure to bats (Chua et al., 2002). In the case of the Nipah virus outbreak in Malaysia in 1998 and 1999, pigs were likely infected by feeding on fruit that were contaminated by bat saliva or urine from bats (who had been displaced by deforestation) that lived near the pigs. The outbreak was only controlled after one million pigs were culled. The index case of large outbreaks of diseases from pigs took place at one of the largest hog operations in Malaysia with nearly 30,000 animals (Ludwig et al., 2003). Nipah virus is a density dependent pathogen, that requires a threshold of susceptible hosts to erupt (Newman et al., 2005). Thus, the amplification of the virus was likely facilitated by the population size and stocking density of pigs (along with the influx of young and immunologically unprepared pigs) (Olival and Daszak, 2005). A further issue is the narrowly focused breeding schemes. This leads to genetic bottlenecking, which hinders host evolution for resistance (Ebert and Hamilton, 1996). Movement of animals in the livestock industry Diseases have spread to humans through the transport of livestock. Holding different populations of animals together during transport can result in viral recombination, which leads to unpredictable new strains of the virus – and can also facilitate the transmission of viruses from animals to humans (Greger, 2007). With modern industrial livestock production, animals are transported long distances to slaughter, bringing viruses with them (Specter, 2005). In the US, thousands of truckloads of cattle are moved per day, which can potentially spark a disease outbreak because long distance transport increases the likelihood of faecal shedding of zoonotic disease agents (Greger, 2007). A study found that the prevalence of Salmonella in the faeces in cattle to be 18% before they were transported and 46% after being trucked for 30–40 minutes (Barham et al., 2002). That same study that looked at the hides of cattle found an increase of Salmonella of 6% before transport to 89% afterwards (ibid.). Pigs are also susceptible to sparking outbreaks. In the US, pigs travel across the country, being born on the East Coast, fattened in the Midwest, and slaughtered on the West Coast. This process takes place because it is cheaper to transport animals to where the feed is, rather than to transport the feed to where the animals are (Heinz and Srisuvan, 2001). While this process is more cost efficient for the pork industry, it sparks more disease outbreaks due to the stress

Globalization, climate change, and disease  101 of transport (Wuethrich, 2003). In the case of the Nipah Valley virus, a 1998 outbreak that occurred among Malaysians happened after they were exposed to infected pigs that were transported around the country. The subsequent trucking of infected pigs to five states in Malaysia and into Singapore resulted in 229 human cases, nearly half of which (48%) ended in fatality (Uppal, 2000). Overall, the transport and crowding of animals in poorly ventilated and stressful environments for long periods is ideal for spreading disease (Greger, 2007; Perry et al., 2013). Wild animal trade and markets Another driver of disease is the wild animal trade. The wildlife trade is posing a significant threat to human and animal health (Chomel et al., 2007; Daszak et al., 2007; Jones et al., 2008; Pavlin et al., 2009; Swift et al., 2007). Legal and illegal wildlife trade affects 25% of all bird and mammal species around the world, and generates up to $10 billion a year (Ribeiro et al., 2019). Illegal wildlife trade is the second-largest black market worldwide, after narcotics (Toledo et al., 2012). The bulk of animals traded are live birds, as approximately 5 million lives birds are transported each year around the world (Ribeiro et al., 2019). Though it is difficult to find accurate data on the wildlife trade, some have estimated that in East and Southeast Asia, tens of millions of wild animals cross borders each year regionally and around the world for use as food, pets, or in traditional medicine. Monkey pox was accidentally introduced into the US in 2003 after a prairie dog was infected with legally imported African rodents (CDC, 2003). A past study estimates that the wildlife trade generates in excess of one billion direct and indirect contacts between humans and domesticated animals annually (Karesh and Cook, 2005; Karesh et al., 2005). Legal animal trading centres can act as mixing bowls for animals to interact before they are shipped elsewhere, often while they are still alive. The illegal wildlife trade is even more problematic because it makes it more challenging to trace and identify unknown potential diseases. Wild animal markets are particularly problematic for sparking zoonotic disease outbreaks. The combination of interspecies mixing in crowded conditions, and the immunosuppressive impact of stress can spark infections (Padgett and Glaser, 2003). The broad range of tissue and fluid exposures associated with hunting and butchering wild animals at wild animal markets may make these wildlife interactions especially risky (Wolfe et al., 2000). With the case of SARS, the spark was started by the preponderance of people handling, killing and selling caged wild animals that were used for food at wild markets (Guan et al., 2003; Xu et al., 2004). The palm civet was indicated as a potential host, which are eaten as a delicacy in Guangdong Province (Woo et al., 2006). After the SARS outbreak, the Chinese government supposedly confiscated more than 800,000 wild animals from the markets of Guangdong (BBC News, 2003). In response to Covid-19, China placed a temporary ban on wildlife on January 26, 2020 (McNeil et al., 2020). The transport of animals for education and sporting events can be dangerous as well. In the case of the Marburg virus, a highly virulent filovirus, its spark was not in Africa but in Marburg, Germany after a laboratory that had received monkeys from Uganda. Monkeys destined for the research in the US have caused an importation of the Ebola virus (Jahrling et al., 1990). The international movement of horses for equestrian competitions has been associated with the spread of equine influenza (Guthrie et al., 1999; Waghmare et al., 2010). Furthermore, when live animals are transferred by plane, they are able to spark international outbreaks by inadvertently transporting virus carrying mosquitoes and their eggs (Sprenger, 1987).

102  Drivers of disease and disaster Bushmeat trade Recently a growing number of emerging zoonotic diseases have been linked to the bushmeat trade, which is illegal (Wolfe et al., 2005). Bushmeat hunting and butchering has been connected to outbreaks of monkey pox virus (LeBreton et al., 2006); Ebola virus (Cunningham, 2005); simian foamy viruses (Calattini et al., 2007); and human T-lymphotropic viruses (Zheng et al., 2010). Human monkey pox was linked to the hunting of red colobus monkeys (Bonnell et al., 2010). When looking at the blood samples from 573 freshly butchered primates in bushmeat markets, there was evidence of 18.4% rate of infection of Simian Immunodeficiency Virus (SIV), the precursor to HIV (Peeters et al., 2002). As bushmeat hunting, globalization, and human interconnectedness increase, so does the potential for emerging infectious diseases. Technological improvements in modern tools enable hunters to catch more animals and sell a larger part of their catch (Bowen-Jones and Pendry, 1999; Bowen-Jones, 2003). Access to firearms and creating new roadways for oil exploration dramatically increased the amount of bushmeat consumed (Fa and Yuste, 2001). After over 140 km of roads were constructed in the northern Congo, the time it took to take a hunting trip was reduced from 12 to 2 hours (Wilkie et al., 2001). Bushmeat consumption had historically been consumed at the local level, but with increased transportation routes, the trade has expanded and responded to international demand. Due to increased global trade networks, new pathogens are able to spread beyond communities to urban areas. Urban populations have created a huge demand for bushmeat, with bushmeat hunters earning over twice as much as they would trading more traditional sources of livestock (Bennett et al., 2002). With few or no restrictions to hunting and selling bushmeat in place, there is little incentive for trade to cease (Karesh and Noble, 2009; Walelign et al., 2019). Consumers living in developed countries are also willing to pay high prices for bushmeat, considered culturally as a highly valued product (Gombeer et al., 2021). It was estimated that bushmeat resale in specific markets is twice as much as domestic sold meat. The bushmeat trade has become a multi-million-dollar business due to a growing human domestic population and the demands of the international market. Millions of tons per year of bushmeat are traded and consumed from the Central African forests (Fa et al., 2006). About 5 tons of bushmeat per week arrive at Charles de Gaulle airport in Paris (Chaber et al., 2010), with 8.6 tons arriving per year Zurich and Geneva airports (Falk et al., 2013). In Europe, African bushmeat is an organised and clandestine luxury market. Confiscated primates at US airports were found to have been infected with various viruses including retrovirus (simian foamy virus) (Smith et al., 2012). This expanding trade network links hunters to consumers, and with many people along this commodity chain coming into contact with bushmeat, the opportunity for disease spillover can occur at many points. For example, the commodity chain supplying bushmeat to an urban market in Ghana includes hunters, wholesalers, market traders, restaurant owners, and consumers (Mendelson et al., 2003). The bushmeat commodity chain supplying an urban market in Democratic Republic of the Congo is comprised of hunters, porters who carry the meat to the road, the bicycle traders who transport the meat into town, and the marketstall owners who sell the bushmeat to consumers (de Merode and Cowlishaw, 2006). About 128,000 bats are sold each year from Ghana through a commodity chain that spans 400 km (Kamins et al., 2011). Understanding what the commodity chain is important due to the fact that pathogens remain dangerous even after animals are killed. For example, the Ebola virus remains infectious on monkey carcasses for at least a week, with the viral RNA detected after several months (Prescott et al., 2015).

Globalization, climate change, and disease  103

Spread of infectious diseases This section explores the factors that facilitate the spread of infectious diseases. This can include the human-to-human transmission of a novel or re-emerging disease, and the spread of endemic diseases in the community, and spread to new countries and regions. Pathogens have several advantages that they are able to exploit in the spread of diseases between human to human – they are mobile, invisible and have a silent incubation period. This makes it very difficult to stop the spread. An infectious agent can move between cities around the world within hours, without detection when it crosses borders. With climate change, high rates of population growth and population density, crowded conditions are the perfect opportunity for diseases to spread. Climate change Climate affects the geographical range of infectious diseases, while temperature and precipitation affect their reproduction and survival. Because of this, changes in climate and extreme weather conditions can impact the spread of endemic infectious diseases (and the intensity of an outbreak), by the way that they influence vectors, pathogens, host defences and habitat (Ostfeld and Brunner, 2015; Wu et al., 2016). As such, many studies have demonstrated that climate change can contribute to increased human susceptibility to and spread of infectious diseases, which include vector borne diseases, water borne diseases, airborne diseases and food-borne diseases (Altizer et al., 2013; Bouzid et al., 2014; Costello et al., 2009; Kovats, 2000; Kovats et al., 2001). Hotter temperatures have been found to impact the survival rate of disease vectors which could potentially impact both the spark and the spread of disease. For example, in the case of vector-borne diseases, the transmission rate is affected by vector survival and reproduction rate, the vector’s biting rate and the pathogen’s incubation rate within the vector. The best temperature for the survival of mosquitoes is somewhere between 17 and 32 degrees Celsius (Mordecai et al., 2019). Rising temperatures also influence the reproduction and extrinsic incubation period of pathogens (the extrinsic incubation period is the time it takes for parasites to develop in the mosquito after it ingested an infected bloodmeal) (Harvell et al., 2002). The extrinsic incubation period of falciparum malarial protozoa reduces from 26 days at 20 degrees Celsius to 13 days at 25 degrees Celsius (Reiter, 2001; Wu et al., 2016). Transmission of Anopheles-borne falciparum malaria occurs where temperatures exceed 16 °C, which is optimal for the survival of the mosquito and which speeds up the incubation rate of the parasite. Thus, higher temperatures not only increase the lifespan of the mosquito but also decrease the extrinsic incubation period of the parasite. Because female mosquitoes (the only ones that bite) live for about six weeks understanding the factors that affect the extrinsic incubation rate are important to controlling mosquito borne diseases. Higher levels of humidity can also be important in vector survival. When the monthly relative humidity is under 60%, the lifespan of a mosquito vector is too short to cause diseases like dengue fever or malaria to be transmitted (Segun et al., 2020; Wu et al., 2016). Thus, locations with high temperatures but low humidity are not conducive for the survival of many vectors (Gage and Kosoy, 2005). This also means that when humid areas face dry spells, mosquito vectors may move to non-traditional areas (Senior, 2008). Insects and insect-borne diseases are now being reported at high elevations in east and central Africa, Latin America and Asia (thus affecting the spread as well).

104  Drivers of disease and disaster Expanding warmer and tropical conditions may extend the season, providing better conditions for transmission. Warm nights and warm winters favour insect survival. Even a small increase in temperature can significantly increase the transmission of malaria. Globally, warming of 2 to 3 degrees Celsius could increase the number of people who are at risk for contracting malaria by up to 5% which is more than 150 million people (MGH Institute, 2018). At the same time, increasing temperatures may widen the range of where malaria will spread. The development of malaria parasites ceases when temperature exceeds 33° – 39 °C, which means that as global warming increases some mosquitoes will disappear from regions where temperature rises above certain thresholds (Beck-Johnson et al., 2013; Ohm et al., 2018). Higher temperatures will mean that mosquitoes will find new habitats and spread to more regions of the world as higher temperatures are a conducive environment for mosquitoes and their pathogens to thrive (Patz and Olson, 2006). Climate change will also affect those who did not live in malarial zones and who have no naturally acquired immunity against it. With global warming, water scarcity will become a broader and more severe issue, which may lead to more diarrhoea cases worldwide (Lloyd et al., 2007). Water scarcity affects water quality and hygiene habits that are important to preventing the spread of diarrhoeal diseases, and other water-borne diseases. Water scarcity can also facilitate the spread of water-washed diseases, such as shigella which causes dysentery (Stanke et al., 2013). Due to issues of climate change and water scarcity, the UN estimates that there could be an estimated additional 48,000 deaths from diarrhoeal illnesses from those under the age of 15 (UNHCR, 2017). Urbanization Just as urbanization leads to the spark of infectious diseases, it also facilitates its spread. Urban areas that are well managed may be able to prevent the spread of diseases in cases where the public is well informed about infectious diseases and where there are effective sanitation and water management practices. However, overcrowded slums and shanty towns that lack fresh water and with poor sanitation facilities are breeding grounds for the spread of infectious diseases. In urban areas, buildings that lack proper ventilation systems can be efficacious in spreading respiratory tract infections. In urban settings, people are in close contact with one another, and these areas can become hot spots for the rapid spread of emerging infectious diseases, such as SARS and bird flu. In many parts of Africa, rapid urbanization has facilitated the spread of diseases. Unchecked urbanization was another issue concerning the spread of the Ebola crisis, as West Africa is one of the fastest urbanizing regions in the world (Ali et al., 2016). When Ebola erupted only in small unconnected villages as it did in the 1807s, outbreaks would flare up and then disappear. With population growth, Ebola has made its way to urban areas of Africa. While biological factors explain why diseases like Ebola emerged/sparked in Africa, it is ultimately social and behavioural factors that explain why the outbreaks have spread and become epidemics (Heymann, 2005). Asian cities also have high population density, which has expedited spread of airborne diseases, like tuberculosis which thrives in urban settings. Studies looking at the slum settlements in Dhaka, Bangladesh, have found a high prevalence of TB twice as high as the national average and four times higher than urban levels overall. There has also been a shift in occurrences of mosquito-borne illnesses into urban and periurban areas with rapid urban development (Franklinos et al., 2019; Tolle, 2009). In particular, the Aedes aegypti mosquito has moved from the tropics to cities due to Asian and African

Globalization, climate change, and disease  105 industrialization and urbanization. Normally preferring to breed in tiny pools of water found in holes in trees, the mosquito has found new breeding grounds in urban areas, breeding in water receptacles (Rose et al., 2020). In India, unplanned urbanization has contributed to the spread of P. vivax malaria (Akhtar, 2002) and dengue (Gubler, 2011). Urban slums where people are exposed to contaminated water can facilitate the spread of infectious diarrhoeal diseases, such as cholera, as has been the case in parts of Latin America (Lloyd et al., 2007). Much of Africa’s population now lives in urban areas in crowded slums where diarrhoeal disease infections have been high. However, good hygiene practices and improved sanitation can decrease the spread of infectious diarrhoeal diseases. In Salvador, Brazil, which has a population of 2.5 million, improving the sewerage coverage from 26% to 80% of households led to a 22% reduction in cases of diarrhoeal disease (Barreto et al., 2007). International travel and commerce The speed and volume of modern trade and travel offer unprecedented opportunities for infectious diseases to spread around the globe, often to immunologically naïve populations (Avila, 2008; Pavia, 2007). With globalization and the vast improvements in modern transport systems, there has been a huge growth in tourism, increasing from 25 million tourist arrivals in 1950 to over a billion in 2013 (UNTWO, 2015). There are not only more tourists but more international refugees, more migrants, and more international shipping. Currently, over 4 billion trips are taken by air every year. In the past, it took a year to get around the world; today, we can circle the globe in less than 24 hours. Someone infected with an infectious disease could fly all around the world while the disease was in its incubation stage before showing any symptoms thus helping to spread the disease to several continents. Road networks now connect people living in remote areas to urban areas, enabling a faster spread of zoonotic diseases across the globe (Sönmez et al., 2019). Mosquitoes can be carried overland in boats and planes and are able to survive these trips, having the potential to infect even non-travellers near airports at their new destination, as is the case with airport malaria. If there are suitable environmental conditions, the vector can become endemic to a new region. For example, the Aedes aegypti and Ae. albopictus mosquitoes, which are responsible for diseases such as dengue, Chikungunya, and Zika viruses, were introduced to new regions where they were previously unknown. At least one of these vectors is now present on every continent except Antarctica. Dengue fever was endemic to Asia in the 1950s but has spread to Latin America and is now endemic there. Chikungunya virus was originally endemic to Africa and Asia, but caused local outbreaks in Italy in 2007 and France in 2017 and has spread to 46 countries, affecting over 3 million people (Wahid et al., 2017). In the case of the Chikungunya outbreak in Italy, it was caused by the return of a single traveller from India (Poletti et al., 2011). When it comes to infectious coronaviruses and certain types of influenzas, air travel has facilitated a high-speed spread of diseases that can turn a local outbreak into a worldwide pandemic. The SARS, H1N1, and Covid-19 pandemics illustrate how fast diseases can spread. In the case of SARS, after first being detected in 2003, it spread to 29 countries in less than a year. Swine flu spread to 213 countries. As of 2021, Covid-19 has spread to all but 13 island countries. In fact, the timing of Covid-19 could not have been much worse for containing the spread of the virus. As the outbreak started before Chinese New Year celebrations had begun, this meant that 85 million people would make 3 billion trips during the holiday, enabling the efficient spread of the virus to all parts of China and the globe (Chen et al., 2020).

106  Drivers of disease and disaster The mobility of workers was also cited as a reason for the spread of HIV/AIDS in Africa. While the epidemic has hit all African countries, it was the richer countries in the southern part of Africa that were affected the most. One reason for this was that the region had more mobile workers, such as male truck drivers, miners, and loggers who worked away from home. These groups were exposed to a frequent rotation of sex workers which facilitated the spread of HIV/AIDS to the labourers’ partners (Nisbett and Monath, 2001). Building and maintaining transport infrastructure often involves sending teams of men away from their families for extended periods of time, increasing the likelihood of multiple sexual partners. The people who operate transport services (truck drivers, train crews, sailors) spend many days and nights away from their families. A survey of bus and truck drivers in Cameroon found that they spent an average of 14 days away from home on each trip and that 68% had had sex during the most recent trip and 25% had had sex every night they were away (All Africa, 2003). The mining sector is a key source of foreign exchange for many countries, particularly in Africa. Most mining is conducted at sites far from population centres, forcing workers to live apart from their families for extended periods of time. They often resort to commercial sex. Many become infected with HIV and spread that infection to their spouses and communities when they return home. Highly trained mining engineers can be very difficult to replace. As a result, a severe AIDS epidemic had seriously threatened mine production (Corno and De Walque, 2012). HIV/AIDS has also spread through drug trafficking routes, particularly in Central Asia. Heroin trafficking, in particular, has been intertwined with HIV outbreaks, and there is a higher prevalence of HIV along these routes in Central Asia (Beyrer and Stachowiak, 2003). Other studies have shown that overland heroin export routes have led to rising injecting drug use and HIV infection in Southeast Asian countries, such as Myanmar, China, and Vietnam. At the height of the HIV/AIDS crisis, it was mostly injecting drug users who were spreading HIV, representing 77% of the cases in Malaysia in 1995; 70% of the cases in Vietnam in 1996; and 70% of the cases in the northeast state of Manipur, India, in 1998 (Beyrer et al., 2000).

Box 4.2  Antimicrobial resistance The WHO has warned that one of the greatest threats to global health is the decreasing number of effective antimicrobials (antivirals, antifungals, anti-parasitic agents, and antibiotics). Along with increasing cases of infectious diseases, there are also increasing cases of diseases that are resistant to drugs and cost up to 100 times more to treat (WHO). There are different strains of malaria that are resistant to artemisinin (a group of drugs that are used to treat malaria, such as chloroquine, sulfadoxine, and pyrimethamine) starting in Asia then spreading to Africa (Dondorp et al., 2010). Drug-resistant tuberculosis has made it much more costly to treat the disease. Unfortunately, we do not have adequate surveillance information of the scale of drug-resistant diseases. One of the causes of resistance is the imprudent use of antibiotics in humans and animals. The overuse of antimicrobials in intensive animal farming has been particularly problematic (Woolhouse et al., 2015). Antimicrobials are given to animals as a prophylactic (preventive medicine) in order to prevent the spread of zoonotic diseases, but also to mitigate the overcrowded and suboptimal conditions that livestock endure.

Globalization, climate change, and disease  107 For example, both avian and swine flu are managed through regular vaccinations of livestock. However, feeding animals antimicrobials serves as a catalyst for the development of zoonotic diseases that are resistant to drugs. Up to 90% of antimicrobial agents that are most un-metabolised may be excreted by livestock and can contaminate the environment if there is not proper waste management (Manyi-Loh et al., 2018).

Management of infectious diseases Some scholars argue that globalization and the triumph and perpetuation of the neo-liberal world order has had a largely negative impact on public health (Collins et al., 2016; Rotarou, and Sakellariou, 2017). Globalization led to the rise in importance of international financial institutions, such as the International Monetary Fund (IMF), the World Bank (WB), and the World Trade Organization (WTO), which used their leverage to encourage states to pursue neo-liberal policies of trade liberalization, privatization, currency devaluation, and cuts to social spending. For heavily indebted, low-income countries, in order to receive badly needed loans, the IMF, and to a lesser extent the WB, demanded that loan recipients adhere to these policies, known collectively as structural adjustment programs (SAPs). In theory, privatization would improve the allocation of resources, ensure a more effective delivery of health services, reduce corruption, and undercut authoritarian regimes – which used public sector jobs as a way of purchasing support (Gandhi, 2010; Lust-Okar, 2006; Stuckler et al., 2010). In practice, public health mostly suffered – or at least resulted in uneven outcomes (Kentikelenis et al., 2015; Rowden, 2013). Cuts to public healthcare spending impacted the quality of care for patients and health equity (Loewenson, 1993). Professional staff fled to the private sector and to other, highincome countries (Unger et al., 2006). Preventive healthcare programs disappeared. Primary healthcare was neglected as most resources went towards larger, specialized facilities that catered to affluent people and foreigners (Rowden, 2013). User fees were introduced in 1990s to recoup some of the costs, which were often prohibitively expensive for the poor (Zikusooka et al., 2009). In Africa the push for privatization along with high debt repayments caused some public health systems to decay. NGOs have tried to step in to help out but are only able to do so in a disjointed manner (Rowden, 2013). Privatised healthcare in West Africa and the use of user fees was a recipe for disaster in managing Ebola (Boozary et al., 2014). Cuts to other states agencies also had negative implications for public health and for stemming the spread of infectious diseases (Hoddie and Hartzell, 2014). Cuts in education meant that fewer people were literate and informed about how to stop the spread of infectious diseases; cuts in food support meant that more people were nutritionally deficient and less capable of fighting off diseases; cuts in public transport made it more difficult for individuals to access health services; cuts in water supplies limited clean water making it easier for infectious diseases to spread (Stuckler and Basu, 2009). Studies have found that the SAPs were detrimental to overall public health systems and had a particularly negative impact on infectious diseases, with higher incidences of disability and death (Hoddie and Hartzell, 2014; Rowden, 2013). These programs also led to a harmful effect on public health performance in the long term. International financial institutions also encouraged states to engage in trade liberalization and currency devaluation. Devaluation made imports more expensive and created serious obstacles for acquiring medical supplies and other important equipment (Kaseje, 2006).

108  Drivers of disease and disaster Additionally, trade liberalization often limited the ability of states to implement policies to abrogate trade rules, such as eliminating tariffs. As poorer states were being forced to eliminate tariffs on imports, there was a major loss of public revenues (Khattry and Rao, 2002; Aizenman and Jinjarak, 2009). This in turn, limited public expenditures on healthcare, water, sanitation, and other services of the state that are critical to dealing with infectious diseases. Critics have also charged that the WTO, which is tasked with managing global trade, works at the behest of its most powerful members, at the expense of public health in developing income countries (Buzan, 2004; Drahos, 2003; Joseph, 2013). Agreements are set up that benefit richer countries and that regulate the enforcement of policies that are disastrous for lower income countries. One of the most controversial agreements was the TradeRelated Aspects of Intellectual Property (TRIPS) agreement. The TRIPS agreement was an important agreement to protect intellectual property rights of pharmaceutical companies who worked on life-saving drugs and vaccines (Collins, 2003). The pharmaceutical industry argues that patents need to be protected in order to ensure that companies can recoup the massive costs in research and development and further incentivize more research. However, these drugs and vaccines were often sold at prices that were prohibitively expensive, making it nearly impossible for people in the developing world to take advantage of, due to multilateral enforcement (Hubbard and Love, 2004). In many developing countries, medicine procurement is the single greatest public expenditure (WHO, 2004). At the WTO Doha declaration in 2001, key negotiations took place which led to a shift that was more favourable to developing countries to increase their access to medicine (Bernhardt, 2014; Crump and Druckman, 2016). Market entry by generic producers in the south and intense lobbying finally forced prices down. For example, the Indian drug company, Cipla, called the bluff of major pharmaceutical manufacturers by offering drugs to Doctors Without Borders/Médecins Sans Frontières (MSF) for $360 per patient per year instead of the industry price of $10,000 (Boseley, 2016). Thus, a growing number of countries have been able to successfully issue compulsory licences for anti-retroviral medicines, yet not a single country has exported medicines produced under compulsory license. For example, when Thailand issued compulsory licenses on anti-retrovirals in 2006, the pharmaceutical company, Abbott, withdrew seven of its drugs from the country (although it reversed this later). Thailand was then placed on a Priority Watch List as a country that does not respect patents (Flynn, 2007). Globalization and the booms and busts that accompany economic interdependence have complicated the state’s ability to manage diseases. Nevertheless, we acknowledge that globalization is not all bad for human health. On the contrary, without improvements in technology and greater communication and cooperation, some of the most important advances in modern medicine would not have been achievable. The Covid-19 vaccines were created at warp speed due to the scientific and medical communities’ accomplishments and collaborations. Ensuring that everyone accesses the vaccine is also requiring global cooperation. The WHO working with Gavi (the Vaccine Alliance) and the Coalition for the Epidemic Preparedness Innovations (CEPI), aims to pool donor funding and countries’ purchasing power to coordinate the fair distribution of Covid-19 vaccines though an initiative called COVAX. While initiatives like COVAX are essential to ending the pandemic, increased cooperation is needed to address overburdened health systems in low-income countries. Some of these initiatives will be spelled out in more detail in Chapter 12, but the take-away from this chapter is that, in the area of public health, more multilateral cooperation is needed, not less. In spite of some of the negative effects of globalization, multi-national and multi-sectoral

Globalization, climate change, and disease  109 cooperation was responsible for the eradication of smallpox and more recently for the eradication of wild poliovirus in Africa (Killeen et al., 2020). Globalization, when properly managed, can be conducive to making gains in human security.

Conclusion Scholars have noted that the power and influence of multi-national corporations to pursue unbridled profits has come at huge costs to health and disaster security (Bettcher and Lee, 2002; Huynen et al., 2005; Kawachi and Wamala, 2006; Labonté et al., 2011). Neoliberal globalization has motored a type of development (including agribusiness, resource extraction, mass manufacturing, etc.) that is not sustainable. It has expedited environmental degradation, air and water contamination, and raise in fossil fuel use, driving climate change which is linked to more infectious diseases. Globalization has also resulted in changes in our ecosystems that have facilitated the emergence and re-emergence of infectious diseases (Aguirre and Tabor, 2008; Patz et al., 2000; Patz et al., 2008). Recent evidence shows that there is a link between infectious diseases and biodiversity loss and habitat fragmentation (Cleaveland et al., 2007; Gottdenker et al., 2014; Maganga et al., 2014). Increasing levels of trade and travel also make it easier for outbreaks to become epidemics and, potentially, pandemics. Finally, globalization has weakened the state’s capacity and ability to regulate. This has affected the state in addressing diseases. Greater gaps between rich and poor have created more vulnerabilities and liabilities at both ends of the spectrum. In theory, globalization should offer opportunities to enhance human security. However, as the chapter has demonstrated, when globalization goes unchecked, it has a catastrophic impact on disease prevention, exacerbating vulnerabilities of millions of people around the world. In the chapter that follows, we examine the impacts of globalization and climate change on disasters.

Key questions 1 Globalization has many positive impacts, but this chapter mainly outlined its negative role in driving disease and development. Is this unfair? What might be the benefits of globalization in health security? 2 What aspect of globalization is most culpable in facilitating the spark of diseases? Based on your answer, what is the solution? 3 How can globalization be managed to stem the spread of diseases without disrupting the global economy? Are these two goals incompatible? 4 Do you agree that globalization has caused states to become less capable of managing diseases? Why or why not? 5 Can we develop and adequately prevent the spark of new and re-emerging diseases at the same time?

Notes 1 While the first wave of globalization started in the 19th century, it came to an end in the beginning of World War I. The second wage of globalization started after World War II but really kicked into gear when the Cold War ended. 2 What is the difference between weather and climate? Weather is a description of atmospheric conditions over a short period of time, while climate refers to the behaviour of the atmosphere over a long periods of time.

110  Drivers of disease and disaster

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5 Globalization, climate change, and disasters

Globalization – or the increase in cross-border economic activities in the form of international trade of goods and services, foreign direct investment, capital market flows, and labour migration – has its proponents. Supporters of globalization highlight the benefits that come from greater efficiency in trading not just goods and services but through sharing technology, information, ideas, and financial support. Critics charge, however, that globalization has brought about environmental catastrophe, increasing inequalities, social dislocation, and rising vulnerabilities to both disease and disaster. The previous chapter provided great detail about globalization’s impact on disease; this chapter goes over how globalization and disasters are connected by looking specifically at the role of climate change and environmental degradation – which have been accelerated by globalization – in sparking disasters, and how globalization may have undermined how disasters are managed. As the chapter will show, global factors – such as man-made climate change, international commerce, increasing mobility of goods and people, the stipulations of international institutions, and the demands of global capitalism – all play a role in dealing with disasters. We close the chapter by exploring the positive impacts of globalization – namely improvements in technology, communications, and innovations in finance and insurance to address disaster risk.

Globalization and disasters In addition to impacting infectious diseases, globalization has affected disasters in two ways. Globalization is linked with the spark of natural hazards and globalization also impacts the ability of the state to mitigate disasters and manage the response. While there have also been positive gains from global cooperation in addressing disasters, it’s undeniable that anthropogenic climate change, driven by globalization, is in turn generating more vulnerabilities to disasters. In measuring globalization, we are looking specifically at the role of climate change and deforestation in sparking more natural hazards. We also look at how the diminishing capacity of the state, as a result of pressures from increasingly powerful international financial institutions, has impacted our ability to manage disasters. Spark of natural hazards As the previous chapter explained, climate change, which has been accelerated by globalization, has had a significant impact. Not only does a warmer atmosphere hold more water vapor which insulates escaping heat, enhancing further greenhouse warming, more evaporation also fuels more intense, tropical-like downpours, while warming and drying of Earth’s surface intensifies the pressure gradients that draw in winds (Dessai et al., 2004). As a result,

DOI: 10.4324/9781003128809-8

122  Drivers of disease and disaster there is generally greater unpredictability along with more hot days and more heatwaves. Some regions have faced greater heavy precipitation events, while other regions have faced greater droughts. Climate change has led to more flooding, landslides, avalanches, soil erosion, increased risk of fires, increased risks hurricanes, cyclones and typhoons, and increased coastal erosion (Van Aalst, 2006). Thus, climate change is significantly increasing the likelihood and severity of compound hazards. In the last 30 years, the number of climate-related disasters has tripled. The number of floods, for example, has quadrupled since 1980 and doubled since 2004 (Science Daily, 2018). There will also likely be a greater frequency of El Niño events. Extreme events are often followed by other destabilizing weather events with cascading negative impacts on society (for more on this, see Chapter 9). Light rains after a drought can spark wildfires while warm winter rains after a cold spell can lead to ice storms. Warm winters can create instability in the snowpack, leading to avalanches. We outline some of types natural hazards which cannot be disentangled from climate change, namely wildfires, storms, and droughts (Schiermeier, 2018). Deforestation, climate change, and wildfires It’s not entirely clear how climate change, deforestation, droughts, and fires intersect, but there is a relationship and a dangerous feedback loop taking place. In a vicious cycle, disasters and deforestation play their part in worsening climate change, while deforestation and climate change leave us more vulnerable to fires and droughts. Higher sea temperatures from climate change double the likelihood of drought. Climate change intensifies drought in deep soils, making it harder for trees to regenerate, which also makes it harder to fight off climate change, leading to more fires (Schlaepfer et al., 2017). Scientists can try to understand the influence of climate change by tracking fire severity. Deforestation, droughts, and climate change make fires more likely and more intense. Studies have demonstrated that deforestation and rapid land-use change, leads to climate change and dryer, hotter temperatures (Malhi et al., 2008; Nobre et al., 1991; Nobre et al., 2016; Shukla et al., 1990). This then makes fires much stronger, destroying more forests. Once a forest is hit by fire it becomes drier, more flammable, but also more porous. With more holes in the forest, there is more wind and sunlight, which makes fires more intense. Climate change is also causing vegetation to dry out, drawing out moisture from plants onto the land, which creates tinderbox conditions. These factors all intersect in making fires more likely and more severe. The fires in turn cause more greenhouse gases to be released. Fires emit carbon dioxide and smoke constituents (or particulate matter) into the atmosphere that affect climate change and lead to more fires (Xu et al., 2020). For example, the smoke from the wildfires in Indonesia in 2015 caused as much greenhouse gases to be released as Brazil’s total emissions (Jong, 2019). This concerns certain forests which contain heavy deposits of carbon-rich peat. A really bad fire could release thousands of years of carbon accumulation. Unprecedented heat in the Arctic fuelled zombie fires in Siberia, which ripped across vast stretches of permafrost and threatened to release millions of tons of carbon (Dunne, 2020). Additionally, due to warmer and drier conditions, there is much less tree regeneration after wildfires in this century compared to the 20th century in both dry and moist forests (StevensRumann et al., 2018). This means that the period of recovery to pre-fire tree densities will be much longer, as there are fewer post-fire wet periods as well (Millar and Stephenson, 2015; Rother & Veblen, 2016).

Globalization, climate change, and disasters  123 Even without deforestation, rising temperatures alone may cause a surge in wildfires in the future. In other countries where deforestation is not the cause of wildfires, we are still seeing a surge in fires with climate change creating conditions for this to happen. Australia’s unprecedented bushfires were 30% more likely due to climate change (Phillips, 2020). Australian wildfires were also more destructive than ever because of record temperatures which had left the soil exceptionally dry, burning through 10 million hectares and killing at least 28 people and over a billion native animals. El Niño events in southeast Asia in 2015–2016, which brought about hot and dry weather, made the fire season in Indonesia much more powerful (already worsened by the practice of draining peatlands). Several studies have claimed that, globally, the number of days when wildfires are likely to burn has risen with climate change (Jones et al., 2020; Liu et al., 2010; Williams et al., 2019).1 California has experienced unprecedented wildfire activity. Some of the most deadly and intense fires the state has ever faced have occurred in 2017, 2018, 2019, and 2020. These fires have coincided with the state’s warmest years on record, as the number of days with weather conditions conducive to wildfires has doubled since the 1980s due to climate change. Because of a warmer and drier climate, California is likely to face even more wildfires of greater intensity (Westerling, 2018). More deaths have been attributed to these fires than during any California earthquake since the San Francisco “Great Quake” of 1906. A 2017 study that analyzed all extreme wildfire events that caused serious economic and social damage from 2002–2013 found that 96% occurred during periods of hot and dry weather. Nevertheless, though climate change is making regions more susceptible to wildfires, the total area burned by wildfires each year has decreased by up to a quarter in the past two decades (Andela et al., 2017). This presents questions about what the role of climate change is in starting wildfires, and why the impact of these fires is so much worse than in the past.

Box 5.1  Fires in the Amazon Fire used to be rare in the Amazon. High moisture levels underneath the canopy of healthy forests prevented dead leaves, small branches, and twigs from becoming flammable (Ray et al., 2005). During the dry season in the Amazon, trees can tap into deep soil water, sometimes 15 meters underground. There were also few ignition sources to start wildfires compared to today. In the 1960s and 1970s there were massive investments in infrastructure which started a wave of environmental destruction in the Amazon (Nepstad et al., 2001). By the 1980s, deforestation was taking place at rates that made it increasingly difficult for the forests to protect themselves against fire. Fire continued to be used as a management tool to clear deforested areas, but spill over started to take place into standing forest. Climate change and rising drought conditions also worsened the Amazon’s capacity to defend itself. When a drought occurs, the trees have to rely on more extreme strategies to survive, by shedding leaves, twigs, and branches to regulate their water balance (Cochrane, 2003; Cochrane and Barber, 2009). The thinner canopy then allows for more solar radiation which further dries out the undergrowth in the forest. At the same

124  Drivers of disease and disaster time, the leaves and twigs that have been shed accumulate on the floor of the forest, making the area more flammable. Deforestation and logging activities further thin out the canopy, increasing the intensity and likelihood of wildfires (Alencar et al., 2006). As of 2020, the Brazilian Amazon has lost close to 800,000 km of forest, of an area twice the size of Germany. If the rate of deforestation continues, not only will 16% of the forests will be burned by 2050 but studies claim that this will accelerate us towards an irreversible climatic tipping point (Brando et al., 2020; Nobre et al., 2016). After a severe drought hit the Amazon in 1997–1998, a disproportionate number of leaves, branches, and twigs fell, creating the ignition to make the Amazon much more flammable. Trees in the Amazon are not able to adapt to resist fire-related damage (Brando et  al., 2020). Severe droughts and fires have catastrophic and long-lasting ecological effects (Silvério et al., 2019). If droughts only occurred occasionally, high intensity wildfires would be rare. However, with climate change, we are seeing a rise in droughts and wildfires in the Amazon. Already, the Amazon has experienced three widespread droughts in the 21st century which triggered massive forest fires. The Amazon’s trees are being replaced by shallow-rooted vegetation which diminishes water cycling. Together with the rise in temperature from climate change and the lengthening dry season, we are seeing a longer and more intense fire season (Brando et al., 2020). As mentioned before one of the major drivers of deforestation is the clearing of forests for human development, including making room for livestock and other agricultural products. Fires are often started to clear forests. Peatlands, which are a type of wetlands that covers 3% of the global land surface, are also often drained of their natural moisture. Thus, the drive for development is having a significant impact on the security of the Amazon.

Climate change and storms Climate change increases the severity of hurricanes, cyclones, typhoons, and floods as well. Warmer air holds more moisture which increases the chances of more rainfall. Every summer there are usually an average of 17 named storms and 10 hurricanes, 6 of which are classified as major. The Atlantic hurricane season in 2017 broke many records and caused tremendous damage (from Harvey, Irma, and Maria), which scientists believe was driven by record heat in the Gulf of Mexico (Lin and Shullman, 2017; Trenberth et al., 2018; Van Oldenborgh et al., 2017). The hurricane seasons of 2018 and 2019 also broke records as being the most active ever. Hurricane Irma broke records as the longest duration as a Category 5 storm. The longer it stays in an area and the slower it moves, the more damage a hurricane can cause. Storms carrying more moisture additionally create opportunities for severe flooding to occur in new locations. More than half of the homes damaged from Hurricane Harvey’s flooding, for example, were outside of the 500-year flood plain (Pralle, 2019). These changing patterns of hazards increase the likelihood of surprises that will overwhelm coping capacity and increase the likelihood of cascading impacts. Sometimes multiple natural hazards hit the same area in quick succession. In March of 2019, a devastating cyclone hit Mozambique, leaving millions without food or basic services.

Globalization, climate change, and disasters  125 Six weeks later another cyclone hit Mozambique, reaching areas that no tropical cyclone had ever hit before (Charrua et al., 2021). Because climate change is likely to increase the intensity of precipitation events, it is also more likely that there will be more urban flash floods (Douglas et al., 2008; Kundzewicz et al., 2014, 2019). Just a small rise in the sea level can increase the likelihood of destructive floods (Jongman et al., 2012; Field et al., 2014). Hurricane Harvey dumped 127 billion tons of water on the US Gulf States, which led to flooding that made evacuations more difficult. The flooding also caused power outages and spread dangerous pathogens from the treatment plants that became overrun with wastewater.

Case study: deforestation and flooding in Pakistan As the chapter has explained, there is strong evidence that climate change is driving changing weather patterns with an increase in the severity of extreme weather. In the case of Pakistan, this phenomenon is having a devastating impact on livelihoods as natural hazards are becoming more severe, exemplified by one of the most devastating floods in Pakistan’s history – the 2010 Pakistan floods (for more on this see Box 14.1). One of the reasons that floods have become more destructive is the substantial change in land use in the Indus Valley and the uplands that surround it in order to accommodate Pakistan’s growing population. This expansion has led to deforestation in the upland area for timber, which has reduced the ability of the forest ecosystem to retain water. This has, in turn, increased surface water runoff and soil erosion, which have increased the amount, speed, and sediment load of the headwaters that enter into the river system. This has then led to repeated landslides which have damaged the riparian infrastructure, leading to more silt accumulation downstream. The low areas of the river basin have been cleared of shrublands, deforestation of mangroves has taken place in the floodplains, and fertile wetlands have been drained to make way for people to move in and to grow crops (Webster et al., 2011). Along the way, railways and roads have been constructed, which has interrupted the natural ebb and flow of the monsoon flood waters. As a result, there is greater flow of water coming from the highlands, and the water carrying capacity of the river channel, wetlands, and flood plains has been reduced. The means that the river system is unable to absorb heavy rainfall and much of the infrastructure, such as embankments, dams, and drainage channels, that were built to protect against heavy flooding are of substandard quality and not well maintained by the government (D’Souza, 2012; Oxley, 2011). This all exposes a large number of people to serious risks from flooding when it rains. Climate change and droughts A drought is a discrepancy between the amount of water nature provides and the amount of water that humans and the environment demand. However, because human demand is at play, droughts cannot be looked at as only a physical issue. Droughts have become more prevalent and enduring over time, and most scientists believe that this is due to climate change – or temperatures warming over the past century. Climate change has resulted in precipitation falling as rain rather than snow, with snow melting earlier. When the snow melts earlier, this leads to lowered water supply, particularly for an area that relies on snowpack for water supply (Gu et al., 2019).

126  Drivers of disease and disaster As more greenhouse gas emissions are released into the air, air temperatures rise and more moisture evaporates from bodies of water. Higher atmospheric temperatures have also led to increased evaporation from soil and vegetation, which increases the intensity and duration of a drought. Essentially, land has become drier over time. Climate change has also resulted in short and heavy precipitation events instead of light to moderate and relatively frequent rain. When rainfall does come to drought-stricken areas, the drier soils it hits are less able to absorb the water, which can augment the chances of flooding (Jansson and Hofmockel, 2020; Trenberth, 2006). Many scientists have warned that climate warming is likely to lead to more droughts that will last longer and be more intense (Cook et al., 2018; Trenberth et al., 2014; Williams et al., 2015), though one study claims that these estimates may be overestimated (Sheffield et al., 2012). The number of people exposed to droughts could increase by 9–17% in 2030 and 50–90% in 2080 (Winsemius et al., 2015). Many regions will be more likely to experience more frequent and more severe droughts (Schwalm et al., 2017). Droughts have severely affected Africa, most notably Ethiopia in 1983–1985, the Sahel in 2012, East Africa in 2011, and Southern Africa in 2010 and 2018–2020. China has faced significant droughts in 2010– 2011 as has the US (California) in 2011–2017 and Australia in the 2000s. In Latin America, droughts have plagued Chile in 1998–1999 and Brazil in 2014–2017.

Management of disaster risk and response As explained in Chapter 3, ‘natural’ disasters are not really natural. They are also not really disasters until a hazard has intersected with vulnerable entities. Protecting people from natural hazards requires regulation and some degree of state autonomy – something that global forces have weakened by encouraging deregulation and a diminished role of the state in order to promote growth and unbridled development. As the chapter has already explained, the pursuit of SAPs has affected institutional effectiveness. This, in turn, has impacted the state’s ability to prevent high death tolls associated with disasters (Strömberg, 2007; Escaleras et al., 2007). Wider gaps between rich and poor have also played a role in increasing risks. Unsustainable (and unmanaged development) development has come at great costs. Regulations to enforce building codes and laws requiring residents to have insurance have, in some cases, been relaxed in order to prioritize the private sector (Leal and Miquilena, 2010). As such, risk mapping has not taken place or zoning laws have been not been adhered to. The government has, in some cases, retreated from protecting people from potential hazards in order to promote development. Lack of environmental planning due to lax state regulations makes societies more vulnerable to natural hazards when they hit. In particular, urbanization has been recognized as a major factor in increasing disaster risk. Megacities, like Mumbai, Tehran, Manila, Lagos, Cairo and Mexico City, face huge vulnerabilities. In many of these cases, this urban development has taken place without much consideration of vulnerabilities to natural hazards, leading many people to be exposed (Garschagen and Romero-Lankao, 2015). In the case of Pakistan, urbanization has taken place in an unplanned and disorderly manner, and at a rapid pace (for more on Pakistan, see Box 4.5). An absence of planning around land use and improper building codes have enhanced haphazard settlement in areas that increase disaster risk. Disaster risk reduction measures have not been implemented because they would be at odds with urban development (Ali et al., 2015). ***

Globalization, climate change, and disasters  127 In the case of New Orleans and Hurricane Katrina (2005), the drive to develop without state interference had a devastating effect on the poorest communities. One of the issues that made Hurricane Katrina more devastating were the actions that had taken place before the hurricane hit. The Bush administration opened up hundreds of square miles of wetland to development, claiming that the market should guide these decisions. This ended up eroding the natural protection that New Orleans had from a major hurricane. In addition to poor zoning laws, the government failed to drain bayous that were clogged with debris. Another issue was that the New Orleans District US Army Corps of Engineers’ budget was cut by more than half, which prevented making improvements to pumps and levees (Vest and Rood, 2005). Levees were inadequately built and maintained in order to save costs. Once the hurricane hit, the government was not quick to respond. At the time of Hurricane Katrina, Federal Emergency Management Agency (FEMA) was led by a political appointee with little relevant experience. Though Katrina was being described by the National Weather Service as a hurricane of unprecedented strength, FEMA only sent out staff of search and rescue teams after the hurricane hit. FEMA was widely criticised for its lacklustre response. Overall, the handling of Hurricane Katrina by the Bush administration was considered to be a total disaster (Parker et al., 2009). Though far less damaging than Hurricane Katrina, Hurricane Harvey was particularly devastating for the city of Houston. Houston grew without zoning restrictions or planning for adequate drainage or building codes. Local authorities did little to stop the city’s unbridled growth into the floodplains. Thousands of homes were built next to and inside the boundaries of the two biggest reservoirs that were designated by the Army Corps of Engineers in the 1940s after destructive floods hit the city. Houston residents voted several times against enacting a zoning code to protect themselves from massive storms in spite of the risks (Trenberth et al., 2018). A similar story affected India when it was hit by a massive storm in August of 2017. Changes in land use and land cover and topographical alterations affect the extent of possible flooding, with 8.6% of the city of Mumbai situated in a highly vulnerable zone. In order to build houses in Mumbai, wetlands and mangroves which had acted as natural water drains were cleared and cut. When the storm landed, the water had nowhere to go and ended up decimating slums and poorly constructed homes (Zope et al., 2017). Unplanned urbanization and rapid infrastructural development are major reasons for the increase in flooding in natural areas that had been used to retain and detain water. In addition to the retreating role of the state, another one of the impacts of globalization is that it has generated bigger gaps between rich and poor, which in turn has created greater vulnerabilities to natural hazards (Wolfensohn and Bourguignon, 2004). Increased mobility of capital and people have created new patterns of exposure and vulnerability. As the costs of living have increased for the poor, many people have been pushed to live in more crowded and high-risk locations. The poor have not been able to afford the necessary maintenance to ensure that their homes are disaster proof. Rising costs of living in Jamaica led poorer people to ignore maintenance, resulting in greater disaster vulnerability. As a result, Hurricane Gilbert damaged more than 100,000 low-income homes (Wisner, 2004). At the same time, growing wealth has increased hazard exposure, increasing the costs of disasters, with the most expensive disasters taking place in the last two decades (Hallegate, 2011). The 2011 Tohuku Earthquake and Tsunami in Japan cost $360 billion in economic damages (Amadeo, 2020). Greater investments in areas that are high risk for disaster can lead to immense losses.

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Box 5.2  Climate change and the developing world Climate change has often been referred to as a threat multiplier (Werrell and Femia, 2015). It will not only lead to more natural hazards, but it also has the potential to lead to more famine, more hardship and more displacement. Climate change is a root cause of new forms of migration (Bettini, 2017; Brown, 2008; Martin, 2010; Piguet et al., 2011). Climate change has the biggest impact on those living in the developing world (for more on the intersection between disasters and poverty, see Chapter 6). More than 20 million people each year have to flee their homes because of climate-related issues. Adapting to climate change and coping with damage could cost developing countries up to $300 billion by the year 2030 (United Nations Environment Programme, 2016). In 2019, deadly floods and landslides forced 12  million from their homes in South Asia, with scientists saying that the monsoon rains had been intensified by rising seasurface temperatures. Severe droughts have wiped out crops and livestock in the Horn of Africa in 2011, 2017, and 2019. Rising temperatures and droughts will gradually push places that are currently marginally viable for agriculture into chronic crisis and make communities more vulnerable to the outbreak of bushfires and droughts (Dale et al., 2001; Glasser, 2020). Climate change has led to increased risks of drought in the Central American Dry Corridor. In Honduras and Guatemala, almost half of the population is rural and over 75% of the rural population lives in poverty (Marrone, 2016). Compounding this, both countries are among the top ten countries in the world threatened by climate change. In rural areas, extreme climate change reduces agricultural productivity, leading some to sell what little land they own to finance their migration. The adverse effects of climate change have left many families critically short of food. The World Bank Group estimates that climate migration will increase in the coming decades, and Latin America could see up to 3.9 million climate migrants by 2050 (World Bank, 2018). Though the developing world faces the biggest impact from climate change, it is the developed world that contributes the most to climate change. Only 7% of annual emissions are produced by the entire region of sub-Saharan Africa compared to 13% by the United States. Latin America produces 9% of annual emissions, while the Middle East and North Africa produces 8%. China, which is no longer a low-income country produces 23% of global emissions (Baker and Mitchell, 2020). In China’s case, millions were lifted out of poverty due to unmatched economic growth rates and industrialization. But when economic growth comes hand in hand with large emissions, these achievements have clear consequences. In fact, climate change will push more than 67 million people deeper into poverty by 2030 (Hallegate and Walsh, 2020)

Positive impacts of globalization? Surely globalization is not all bad. The chapter (and the previous one) has mostly focused on the specific dimensions of globalization that might generate negative outcomes, but there are positive effects as well. Globalization has driven economic growth in Japan

Globalization, climate change, and disasters  129 and helped the country bounce back after disaster. Despite increasing global vulnerability and exposure, globalization has also helped shape new disaster risk-management opportunities. Globalization also has increased labour mobility, which enables those affected by disaster to move to less disaster-prone areas. This mobility can serve as a mechanism for spreading risk geographically (Kreimer et al., 2003). Additionally, improvements in the ease with which money can be transferred has facilitated the transfer of remittances across borders to support resilience. Globalization has also brought with it more options for the use of financial risk transfer, such as insurance, reinsurance, and hedging transactions in capital markets (Ghesquiere and Mahul, 2010). Additionally, the informational revolution has facilitated the transfer of knowledge and technology, which has helped researchers and practitioners exchange ideas and data on disaster reduction techniques. Globalization has also led to the rapid spread of global communication which has enabled the rapid dissemination of information in real time to assist in warning people, coordinating evacuations, and in the delivery of aid, while social media platforms have been used to raise funds more efficiently. Crowd sourcing campaigns after an earthquake hit Nepal in April of 2015, helped raise $15 million from 750,000 people around the world within one week (Karkee, 2015). Enhancements in transport have also improved rescue efforts, and improvements in technology have helped with early warning systems. As a result of better monitoring and forecasting of certain types of disasters, there is more accuracy in informing people so that they have time to protect themselves and find safety. Some of these improvements in technology have saved millions of lives when it comes to disasters and diseases.

Conclusion This chapter focused on the role of globalization and climate change in affecting disasters. While climate change is fuelling the spark of disasters across the globe, globalization – and the growing power of liberal, international financial institutions – is in some cases limiting the state’s ability to properly mitigate and manage disasters. Globalization also generates greater levels of urbanization (such as mega-cities), bigger gaps between rich and poor and greater vulnerabilities. Simply put, globalization generates greater human vulnerability to disasters by fostering demographic changes that put more people at risk and by limiting the state’s ability to prevent and respond properly to these risks. However, globalization is a two-sided coin. While the risks have increased, globalization has also brought about greater cooperation (to be discussed in more detail in Chapters 13 and 14) and enhanced communications and technology in ways that facilitate disaster risk mitigation and response. In the two chapters that follow, we turn to look at what factors affect disease and disaster vulnerability. In other words, what makes people more vulnerable to disease and to natural hazards becoming disasters. In the next chapter we explain that poverty facilitates the spread of infectious diseases, that poor individuals are more vulnerable and susceptible to contracting infectious diseases, and that low-income countries struggle more to manage infectious disease outbreaks. We also look at how poverty and disasters intersect. Here the relationship focuses on how poverty at the level of the individual makes people more defenceless when a natural hazard hits, thus creating more complex humanitarian emergencies. Low-income countries are also less equipped to handle natural hazards when they strike, posing obstacles to managing the impact.

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Key questions 1 2 3 4 5

How does climate change and deforestation interact to impact the spark of disasters? Do you think that globalization has affected states’ abilities to manage disasters? Is it fair to say that the impact of globalization on disaster security has been mostly negative? Why or why not? Why do rising inequalities, generated by globalization, lead to more disaster vulnerability for both rich and poor? Which type of disaster is impacted the most by globalization? Why do you think that is the case? Are geological disasters exempt?

Note 1 In 2018 a report from the Intergovernmental Panel on Climate Change (IPCC) concluded that limiting global warming to 1.5oC rather 2oC would decrease the average wildfire risk worldwide.

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Part III

Disease and disaster vulnerability

6 Poverty

Introduction In spite of the fact that millions of people have been lifted out of poverty, there are 700 million people, 10% of the world’s population, living off of $1.90 a day (UN Sustainable Development, 2020). This is an improvement from 1990, when 36% of the population lived on under $1.90 a day. However, with the Covid-19 crisis, this number will likely reverse for the first time in years (ibid.). Many studies have argued that poverty creates conditions that are more favourable to the spread of infectious diseases (Bonds et al., 2010; Eisenstein, 2016; Hotez and Kamath, 2009; Marmot, 2006). More impoverished people are more vulnerable to infections, and affected populations have less access to preventive care and treatment and are therefore less able to recover when they are ill. As a result, infectious diseases disproportionately affect people living in poor and marginalised communities. It is not just poor countries that are more vulnerable to infectious diseases but also poor households in any country that are more likely to be affected. Thus, studies have shown that household poverty influences susceptibility to pathogens and disease severity, burdening the poorest households the most (de Glanville et al., 2019). For example, in the UK the most deprived quintile had a mortality rate that was three times higher from swine flu in 2009 than the richest quintile (Rutter et al., 2012). In Canada, those with low education levels and living in economically deprived neighbourhoods were also more likely to be hospitalized with swine flu (Lowcock et al., 2012). Other studies also demonstrated that ethnic groups living in socio-economically deprived areas had greater rates of contracting swine flu (Inglis et al., 2014). Lower income countries are more likely to face endemic diseases and are more likely to struggle in managing disease outbreaks. Poverty, or economic insecurity, creates a vicious cycle whereby poverty drives diseases, and diseases cause poverty to persist (for more on the latter, see Chapter 7). In the previous chapter, we looked mostly at factors that lead to the spark and the spread of infectious diseases and certain types of natural hazards. In this chapter, we look at what makes individuals more vulnerable to disease and disaster. We start by defining poverty and different types of poverty. We then turn to briefly explore the relationship between poverty and the spark of disease outbreaks. We then explain how poverty makes people at the individual level more vulnerable to contract infectious diseases and to struggle to withstand them. After doing so, we go over how poverty intersects with disease management at national levels. In other words, why do low-income countries struggle in managing infectious diseases? The chapter closes by looking at how poverty creates vulnerabilities when natural hazards hit at both the individual and national level.

DOI: 10.4324/9781003128809-10

138  Disease and disaster vulnerability Key concepts

What is poverty? There are several different ways of measuring poverty. Absolute poverty measures poverty in terms of the amount of money necessary to meet basic needs, while relative poverty measures relative deprivation to the local community or nation to which an individual belongs (Townsend, 2014). Poverty is also distinguished by the severity – with abject poverty considered to be the most severe. Abject poverty is defined by the United Nations as ‘a condition characterized by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education and information,’ (UN 1995b). It depends not only on income but also on access to services. Structural poverty consists of poverty that is long-term and attributable to personal and social circumstances, such as being landless and/ or unemployed. Conjunctural poverty is poverty that takes place during a time of a crisis and is caused by a specific economic shock or a period of conflict or political instability (or a sudden disaster or pandemic) (Gray and Moseley, 2005). There are two different approaches to looking at poverty that go beyond looking at income levels. These are: a basic needs approach and a capabilities approach. A basic needs approach examines poverty by how much money people have and whether they have access to food, shelter, education, sanitation, safe drinking water, and healthcare. There are some countries (like Brazil) whose per capita income levels may not be that low but where pockets of the country do not have access to safe drinking water and healthcare, for example. A capabilities approach, which was developed by Amartya Sen (1981, 2006), sets out that poverty is not just inadequate income but low levels of capabilities and opportunities. Thus, this measurement looks at how resilient people are. For example, recovering from a crisis such as a famine, depends on not only asset levels but also social networks, something that is often not measured by survey data on income (Davies, 2016). In examining the role of infectious diseases and poverty it is important to differentiate between poverty at the individual or household level and poverty at the state level, or poverty of low-income countries. Poorer individuals are more vulnerable to diseases and poorer countries are more likely to have a high disease prevalence. At the individual level, most of the global poor live in rural areas are poorly educated, employed in agricultural sector, and are under the age of 18. But it is not just rural poor who are affected but also those living in urban slums who are the most vulnerable to diseases. It is the poorest states that are most afflicted with infectious diseases and incur the highest death tolls, both per capita and in absolute terms according to data from 1996 to 2015 (UNDRR, 2016). Low-income countries that have weak healthcare systems and lack the resources to adequately tackle diseases with a multi-sectoral approach are vulnerable. Lowincome countries with high birth rates are also more prone to infectious disease transmission because they have such a larger percentage of their population which is immunologically naïve and likely to perpetuate epidemics. Poverty and infectious diseases Poverty and disease are inextricably linked. In fact, many infectious diseases track closely with poverty, both at the country level and household level (Oxlade and Murray, 2012). At the household level, a study in the US found that the poorest individuals were 2.5 times more likely to develop TB than the richest individuals. People who live in conditions of

Poverty  139 poor sanitation and poor nutrition and thus with weak immune systems are more vulnerable to TB (Oxlade and Murray, 2012). TB rates rise and fall in association with measures of socio-economic development and social protection (Saunders and Evans, 2020). There is also an association between socio-economic status and malaria infection risk and HIV/ AIDS.1 Neglected tropical diseases disproportionately affect the poorest people in the world. In the case of the US, multiple studies have claimed that, during the swine flu pandemic, there were higher rates of hospitalization among the poor, those living in poorer neighbourhoods, and minorities (Quinn and Kumar, 2014). Additionally, at the national level, studies demonstrated that the 1918 flu was worse in low-income countries compared to high-income countries, due to malnutrition and co-morbidities, poor access to medical care, and higher rates of disease transmission (Almond and Mazumder, 2005; Grantz et al., 2016; Oppenheim and Yamey, 2017). In what follows, we explain why poverty creates disease vulnerabilities. Many studies have investigated the links between infectious diseases and poverty – looking at the role of highrisk living conditions, poor nutrition, indoor air pollution, lack of access to proper sanitation, poor education and health education, crowded and unsanitary living conditions, and lack of access to clean water.

Poverty and disease spark Poverty can lead to the spark of diseases because it forces individuals to engage in more high-risk behaviour for their own survival. For example, those who work in close contact with livestock and other animals are the most at risk from zoonotic diseases. As the previous chapter explained, deforestation (forest clearing, farming, irrigating the land, and raising livestock and/or non-timber forest products) is a driver in sparking diseases, as it has important ecological effects on vector habitat and on human exposure to different vectors (Aron and Patz, 2001; Donohoe, 2003). Rural poor households are more likely to be directly dependent on forest products and services (Byron and Arnold, 1999). In forested areas, communities that live on the edges are more exposed to different types of zoonotic diseases, such as Ebola. Bats which are common in African and Asian forests are a likely reservoir for many diseases (Pigott et  al., 2014). People living on the edge of forests are also more likely to contract other infectious diseases such as malaria because these areas are popular habitats for mosquitoes (for more on this, see Chapter 4). Malaria also occurs more frequently in forest workers in Thailand, because they have to encounter the preferred breeding site for mosquitoes (Pattanayak et al., 2006). As Chapter 4 explained, a growing number of emerging zoonotic diseases have been linked to bushmeat hunting, trade, and consumption (Wolfe et al., 2005). Humans have killed and consumed bushmeat (or wild animals) for food for millions of years (Boesch, 1994).2 Each year it’s estimated that almost 600 million wild animals are caught and consumed in the Congo Basin alone (Fa et al., 2002, 2003). However, with over 30 different species of primates hunted, this presents huge risks for the cross-species disease transmission, the zoonotic diseases (Dunay et al., 2018). The highest risk of disease transmission takes place when bushmeat is being butchered, as butchering involves using sharp tools that can lead to cuts, open wounds, and infection. But for the rural poor, there are few options available to eating and trading bushmeat. Income from bushmeat sales is lucrative for those living in poverty with few alternative sources of income. Bushmeat consumption is also a critical part of the diet for those living in rural poverty. Studies have demonstrated that removing the consumption of bushmeat could raise

140  Disease and disaster vulnerability malnutrition rates and cases of anaemia (Van Vliet et al., 2017). In fact, many studies have argued that bushmeat consumption is an important component in the local diets of poor individuals because it improves their access to diverse and nutritious food sources (Brashares and Gaynor, 2017; Cawthorn and Hoffman, 2015; Friant et al., 2020).

Box 6.1  Curse of the Tropics? It has been argued that the tropics are particularly prone to diseases compared to other parts of the world (Sachs and Warner, 1997). Indirectly, certain climates and soil quality make agricultural production much more difficult leading to higher levels of malnutrition, which make it harder to manage diseases (Herrick, 2000). Soils derive disproportionately from a very old type of rock, which is low in micronutrients and varies considerably between localities. Tropical climates are also more hospitable to disease vectors, such as mosquitoes which only thrive in certain temperatures, moist environments, and where there are still pools of water. The tropics also have the right temperature and soil for hookworm eggs to hatch, one of the NTDs (Hotez, 2011). Because their geographical conditions and tropical climates are breeding grounds for infectious diseases, states in the tropics have more citizens who are sick and/or dying than states with more temperate climates. However, effective interventions can make a difference. The climate of the southern part of the US was ideal for many infectious diseases, such as malaria, typhoid fever, yellow fever, and hookworm to thrive, but after extensive state interventions these diseases no longer exist in these areas.

Poverty and disease spread Studies have also demonstrated that poor people are more vulnerable to infectious diseases because they are more likely to lack access to clean water and proper sanitation. This not only spreads diseases but exacerbates the severity (Bosch et al., 2001; Garriga and Foguet, 2013). Over 80% of disease in developing countries is related to poor drinking water and sanitation (UN, 2003). Over 785 million people do not have access to clean water, while 2 billion people do not have access to sanitation, such as flushed a toilet (WHO, 2019). Only about half of the population in sub-Saharan Africa has access to clean water. In rural parts of India, Indonesia, South Africa, and Guatemala to name a few, the level of access to running water is under 10% (Banerjee and Duflo, 2007). In Brazil, up to 30 million people do not have access to basic sanitation which makes it difficult to regularly wash hands (Shadmi et al., 2020). As Chapter 2 explained, though diarrhoeal diseases are completely treatable through oral rehydration therapy (ORT), they still claimed 1.6  million lives in 2017 (Dadonaite, 2019). Inadequate sanitation and water access play an important role in spreading diarrhoeal diseases and other gastrointestinal infections (Marmot, 2005). Not having access to clean water makes it more difficult to wash hands frequently to prevent the spread of respiratory infections. In the case of Monrovia, Liberia, and the Ebola epidemic, those who didn’t have access to basic sanitation in urban slums such as Monrovia were at far greater risk of being infected.

Poverty  141 Lack of access to clean water was associated with higher rates of respiratory infections in Venezuela. Contaminated water in Nairobi slums where there is no piped water provide ideal conditions for the spread of cholera and typhoid (Berkley et al., 2005; Kariuki et al., 2006). Schistosomiasis is transmitted through exposure to contaminated water (King, 2010). Zika was more prevalent in neighbourhoods in Brazil that were less likely to be connected to a water source (Fuller et al., 2017). The propagation of hookworm (and other soil-transmitted helminths and schistosomes) also depends on inadequate sanitation, such as the absence of a latrine and thus accumulation of human faeces on soil. In rural parts of Cote d’Ivoire, poor children demonstrated higher infection rates of hookworm than children from richer families due to the lack of a latrine and flush toilets (Coulibaly et al., 2012). Another factor in spreading infectious diseases is the quality of housing and the level of overcrowding (Nkosi et al., 2019). The UN estimates that 863 million people, or one third of people in the developing world, live in urban slums. When social distancing is required, it is more impoverished people who are the least able to do so. Economically disadvantaged people are more likely to live in overcrowded accommodation, where they have less access to outdoor space. Crowding in low-income households and neighbourhoods is a mechanism for exposure to different diseases. In Brazil, millions of people live in slums which makes it impossible to avoid overcrowding, which may explain why it has one of the highest number of cases of Covid-19 in the world (Shadmi et al., 2020). In the case of SARS, the virus was more likely to spread in poor areas of Hong Kong due to overcrowding and poor infrastructure (Bucchianeri, 2010). The same can be said of Ebola, which spread most rapidly through poor families living in crowded conditions. TB is more likely to spread in crowded conditions (such as prisons, homeless centres, and urban slums) that are poorly ventilated because it spreads through airborne droplets. Malarial infection is also higher in overcrowded areas because high concentrations of carbon dioxide and other chemicals are more likely to attract mosquitoes (Ricci, 2012). Impoverished families that live in poorly constructed makeshift settlements with dirt floors, thatch roofs, and walls with cracks and holes are ideal for spreading many different diseases. The poor are more likely to become infected with Chagas disease, because the insect vectors known as triatomines prefer to inhabit wall cracks. People living in homes with dirt floors have an increased risk of infection for hookworm. People living in homes without proper screens, modern walls, and protective coverings struggle to prevent mosquitoes from entering, just as those who don’t own bed nets are unable to prevent being bitten during the night. Poor households are also more susceptible to respiratory infections because of greater exposure to burning biomass fuels in poorly ventilated areas (Torres-Duque et al., 2008). Poor households are more likely to use animal dung, crop residues, or wood to cook their food and to heat their homes (Faizan et al., 2019). Exposure to this type of biomass smoke increases the risk of acute lower respiratory infections (ALRI) in children, such as pneumonia – the single most important cause of death in children younger than 5 years (Smith, 2000). Working conditions that affect certain occupations increase the risk of contracting infectious diseases. Those who work in the healthcare profession represented a disproportionately large share of total cases in the West African outbreak of Ebola (Evans et al., 2015). Mobile workers (construction, mining, trucking, agriculture, forestry, fishing, and shipping) and sex workers have had an increased risk of contracting HIV. Agricultural workers who must work during the rainy season, when there is greater availability of water for female mosquitoes to breed in, have a greater chance of contracting malaria. Financially poorer people are often employed in occupations that do not provide opportunities to work from home (Patel et al., 2020). They are more likely to have unstable work

142  Disease and disaster vulnerability conditions and incomes. Poorer people may also have to rely on crowded public transport to get to work, further increasing their risks. The financial uncertainty gives the poorer income groups few options to social distance. The precarious nature of their jobs and income also heightens stress, which weakens the immune system and makes the poor more susceptible to a range of diseases. Poverty increases exposure to diseases and diminishes the immune system’s ability to fight it (Patel et al., 2020). Education level is also important in promoting better health outcomes and can affect people’s vulnerability to disease. In particular, the education of mothers is important. More educated mothers tend to have fewer and healthier children. Rising maternal literacy rates are also associated with better case notification rates of diseases and the seeking out of early treatment and lower child mortality rates (Bado et al., 2016; LeVine and Row, 2009). In a study in Ethiopia, mothers with low educational attainment were able to reduce mortality rates among children under 5 years old when given information about anti-malarial drugs (Kidane and Morrow, 2000). Education plays a vital role in preventing the spread of numerous infectious diseases, such as malaria, TB, and many neglected tropical diseases. Education can help reduce vector borne diseases by encouraging people to remove stagnant water, which provides insect breeding sites, from near their homes and by using bed nets (Adongo et al., 2005). Educated parents are also more likely to know what causes malaria to be transmitted – whereas poorly educated individuals may believe myths that exposure to the sun causes malaria (Oladimeji et al., 2019). Education is also important in stemming the spread of HIV (Gallant and MatickaTyndale, 2004; Kelly, 2002). Lower levels of education are linked to higher rates of HIV infection (Vandemoortele and Delamonica, 2000). Educated parents were more likely to seek formal treatment for malaria when their child develops symptoms. This serves to reduce the risk of progression of the disease. Education is also important in diagnosing and preventing TB, with studies showing that low educational attainment is correlated with delayed treatment and a failure to complete treatment. Traditional beliefs may espouse that TB is associated with witchcraft, which prevents those who are afflicted from seeking and adhering to treatment because they may believe that the disease is incurable (Kigozi et al., 2017).

Box 6.2  Neglected Tropical Diseases List of common NTDs • Dengue Fever • Rabies • Trachoma • Buruli ulcer • Endemic treponematoses (including yaws) • Leprosy • Chagas disease (American trypanosomiasis) • Human African trypanosomiasis (sleeping sickness) • Leishmaniasis • Cysticercosis

Poverty  143 • Dracunculiasis (Guinea-worm disease) • Echinococcosis • Foodborne trematode infections • Lymphatic filariasis (elephantiasis) • Onchocerciasis (river blindness) • Shistosomiasis (bilharziasis) • Soil-transmitted helminthiases (intestinal parasitic worms) NTDs are diseases of poverty – they tend to affect those who have little economic power, voice, and visibility. Currently, of the world’s 2.7 billion impoverished individuals, more than a billion people suffer from NTDs. As they are infectious diseases that don’t tend to travel widely, they are not well researched. Although they lead to 20–60 million DALYs lost, making them as devastating as the big three diseases, NTDs also don’t garner enormous attention from the pharmaceutical industry. They are linked with the big three in that people suffering from NTDs may be more susceptible to HIV/AIDS and to suffering greater morbidity when facing malaria or TB (Hotez and Kamath, 2009). In spite of this, there is still so little drug research and development on NTDs, with only a handful of drugs available and no vaccines. The drugs that do exist were developed decades ago and are toxic to ingest in most cases. For example, an arsenic-containing compound is used to treat the late stages of African trypanosomiasis, which can have other potent side effects (Hotez, 2011). NTDs cause chronic disability, affecting intellectual and cognitive development. They have a particularly detrimental impact on children, impairing child growth and affecting a child’s ability to retain information. Schistosomiasis and hookworm affect children’s ability to learn in school (King and Dangerfield-Cha, 2008; Hotez et  al., 2004). They also have a particularly bad effect on women, affecting female reproductive health and impairing pregnancy outcomes. They can also affect worker productivity, such as lymphatic filariasis, guinea worm, and river blindness which cause adults to miss work, leading to billions in annual losses. They also can cause disfigurement and blindness, which leads to a substantial reduction in future wage-earning capacity as well as social stigmas (Hotez et al., 2006b). Substandard housing, lack of access to safe water and sanitation, and inadequate vector control contribute to the efficient transmission of infection of NTDs. NTDs, like all infectious diseases, are also more likely to affect those living under conditions of conflict or post-conflict (Beyrer et al., 2007; Hotez and Thompson, 2009). As public services are interrupted and people are forced to migrate and live in crowded and sub-optimal conditions, this can lead to a resurgence of different NTDs. For example, decades of war in Angola and Sudan led to an influx of cases of African sleeping sickness and guinea worm (Ekwanzala et al., 1996).

More impoverished people also have less access to healthcare and essential treatment (Bhutta et al., 2014; Singh and Singh, 2008). This is in spite of the fact that most infectious diseases are completely treatable and preventable. Case in point: it is estimated that almost all child diarrhoeas are completely treatable (CDC, 2020; WHO, 2018). But poorer people are more likely to wait as long as possible to seek healthcare, usually when an illness is at

144  Disease and disaster vulnerability its more advanced stages. Delaying healthcare treatment can affect the prognosis for many diseases, such as TB. The poor may avoid healthcare treatment due to an inability to pay for health services, inaccessibility and distance of healthcare clinics and services, or due to misconceptions about modern health services. Health services may also appear to be inaccessible due to cultural and language barriers or poor treatment of minority patients. Poor people may also believe that they cannot afford treatment. Poverty prevents those affected from purchasing the cheap oral rehydration therapy sachets that could easily save lives. Richer families can also afford anthelminthic drugs to treat hookworm (Hotez et al., 2006a). In the case of Covid-19, the costs to treat and hospitalize are prohibitively high in some countries, deterring the poor from seeking treatment. With the 2009 flu pandemic, the death rate was three times higher in the poorest fifth of England’s population than in the richest (Spinney, 2020). With poor access to high quality healthcare, poor people are also more likely to suffer from other co-morbidities, such as heart diseases, diabetes, and pulmonary diseases, (Braveman et al., 2010; Lutfey and Freese, 2005; Oates et al., 2017). These co-morbidities worsen their chances of fighting off illnesses. It is well-documented that co-morbidities are a strong predictor of Covid-19 severity (Guan et al., 2020; Singh et al., 2020). In the case of Brazil, studies have shown that it is the poorest quintile that suffers from diabetes, heart disease, and hypertension. In fact, of all the people who suffer from these illnesses, 54% attended only elementary school (Shadmi et al., 2020). Malnutrition also impacts the ability of infected people to manage diseases and recover. Poor nutritional status makes people more vulnerable to disease progression and leads to reduced physical capacity and stunting. Malnutrition has an impact on learning and affects future health and productivity rates (Banerjee et al., 2011). Roughly 870 million people suffer from chronic undernourishment, almost all of whom live in developing countries, with Africa seeing a rise in malnourished people. India accounts for 25% of the world’s malnourished in spite of the fact that India is the second biggest grower of rice and wheat (FAO UN, 2020). Children who suffer from malnutrition are more likely to suffer illnesses, with poor nutrition affecting child mortality rates of at least 50% of the 11 million children under 5 years who die each year (UNICEF, 2020). For example, vitamin deficiencies, such as vitamin A, can lead to blindness, with 500,000 children becoming blind each year. Nutritional status affects the progression from TB infection to disease – as those with low body mass and food storages have been associated with an increase in TB infection and mortality rates, particularly those lacking in vitamin D, iron, and zinc. Malnutrition is also associated with poor response to antimalarial drugs. In fact, every disease that children face is worsened severely by malnutrition (ibid.). Inequalities in nutrition during a pandemic ensure that those who already struggle with food security will suffer the most during lockdowns. With schools being closed, this deprives many children of their only nutritious meal of the day. Studies have shown that poor nutrition for pregnant mothers affects the health of their children, future cognition, and educational achievements later in life (Shadmi et al., 2020).

Box 6.3  Gender, disease, and disaster Both women and children are most vulnerable of contracting and dying from infectious diseases (Gerberding, 2004). While children under the age of 5 years are at risk of dying from a number of preventable diseases, women also face the brunt of challenges.3 As

Poverty  145 managers of food distribution, women tend first to cut down their own food consumption in times of shortage in order to preserve more for other family members, thus putting themselves at risk before their families. If food is scarce, women are less likely to eat, making them more vulnerable when they contract diseases (Darnton-Hill et al., 2005; Hasan et al., 2019). When women get sick, they are less likely to seek treatment for certain diseases or to consult modern health services (Hancock, 2020; Kutzin, 1993; Vlassoff, 1994). This is often because women lack access to information, causing them to be poorly informed about their health and unable to recognize symptoms. Women are also more likely to be illiterate and may have lower levels of education, which puts them at greater risk of contracting various diseases. Women may also be unable to take off time to go to clinics due to work and caring responsibilities. When they do seek treatment, women are often treated poorly by staff. Cultural factors may also be at play when it comes to how women attend to their own illnesses. Married women in India, for example, are less likely to receive and complete treatment for TB because they want to keep their illness a secret so that they are not shunned (Balasubramanian et al., 2004). Similar results were shown regarding women’s treatment-seeking behaviour in Vietnam and Bangladesh (Johansson et al., 2000; Ahsan et al., 2004). Further case studies have shown that women have been less likely to seek treatment for malaria in Thailand and less likely to seek treatment for leishmaniasis in Colombia (Ettling et al., 1989; Velez et al., 1997). Studies have also demonstrated that women are also more vulnerable to HIV infection, with more than half of all new infection being among women and young girls (Avert, 2020; Dunkle et  al., 2004; Higgins et  al., 2010; Türmen, 2003). Biological, socio-economic, and cultural factors are at play. Biologically, women are slightly more at risk of contracting HIV than men during intercourse because semen contains a higher viral load (Chakraborty et al., 2001). Additionally, greater proportions of genital mucosa and vaginal bacteria may also make women more susceptible (McClelland et al., 2018). More significant are the structural factors that affect women’s susceptibility, including lower levels of education, higher levels of poverty, greater challenges in negotiating condom use, and high levels of gender-based and intimate partner violence. One study in Brazil showed that 79% of HIV positive women experienced violence prior to their diagnosis (Gundersen et al., 2016). Women working as sex workers and in dense sexual networks are also more likely to contract HIV. In sub-Saharan Africa one out of every five new infections is a young woman or adolescent female, with young women being twice as likely to be infected as their male counterparts (UNAIDS, 2017). African American women also face higher rates of infection for HIV/AIDS. New infections among for this group is 15 times higher than for white women (KFF, 2020). In general, women are also more vulnerable to disasters than men, with women comprising the majority of those who die in disasters. Women usually have fewer resources to prepare, mitigate, and rebuild. Women have less income and fewer employment options and have more limited mobility due either to cultural and/or socio-economic factors. Disasters tend to exacerbate existing gender inequalities and pre-existing vulnerabilities. Where societies are divided along class, caste, or racial lines, they tend to be more vulnerable to crises than societies which are cohesive, neighbourly, and in which there is a high degree of mutual care-taking. Groups and individuals who are excluded from decision-making and other social power structures tend to be more vulnerable than those who share or hold power (Anderson and Woodrow, 1991).

146  Disease and disaster vulnerability

Poverty and disease management As the chapter explained, disease and poverty are part of a vicious cycle. Poorer people at the household level are more vulnerable to disease. Not surprisingly, lower income countries are also less equipped to manage diseases due to low levels of healthcare spending and investment. As of 2019, there are 29 countries that are considered low-income countries – or with per capita incomes of around $1,026 or less (World Bank, 2019). Lower middle-income countries are those with per capita incomes of $1,026–$3,995. Nearly half of the global population lives in lower- and middle-income countries but only 3.3% of global health spending occurs here. Annual spending per capita ranges from $15 to $329 (Dieleman et al., 2019). Meanwhile, more than 85% of the disease burden takes place in developing countries (Boutayeb, 2010; Boutayeb and Helmert, 2011). For example, in the case of tuberculosis (TB), at the country level, 98% of the world’s active TB cases are in developing countries. World Health Organization data (2018) looking at healthcare spending as percentage of GDP from 2000 to 2016 reveals that all countries except low-income are spending more: high income countries spent on average 4.5% of their GDP on health in 2000 while in 2016 this rose to over 6%; upper middle-income countries spent 2.9% of their GDP on health in 2000, but spent 3.7% in 2016; lower middle-income countries spent 1.8% in 2000 but increased this to 2.25% in 2016; low-income countries only spent 1.5% in 2016, which represented no change since 2000 (WHO, 2018). As a result, impoverished countries perform poorly on social indicators such as life expectancy and child mortality rates. In the case of Africa, spending on healthcare has improved in some countries but has not reached levels necessary to tackle the health issues the region faces (Micah et al., 2019). Africa makes up 16% of the global population, but holds 23% of the disease burden. In spite of this, in 2015 it only accounted for 1% of the total global health expenditures (Ogbuoji et al., 2019). In the developing world it is also the poorest quintile that receives the least benefits in areas of health investment and the richest that receives the most (Chu et al., 2000; Gupta et al., 2003). Countries that are richer are able to extract more and provide more. Poverty affects the state in numerous ways when it comes to infectious disease mitigation. Poverty affects the ability of the state to collect revenues, which in turn make it nearly impossible (unless the state can rely on a steady supply of revenues from resources such as oil and gas) for the state to provide many services or develop administratively. Fighting and managing infectious diseases requires a multi-sectoral approach, extensive funding in public healthcare, research and development (Ezrow, 2015). The state needs to be able to train and pay for doctors, nurses, and other medical personnel. The state needs to build functioning hospitals and clinics, laboratories and research centres. The state needs to procure medical equipment, personal protective equipment, vital medicines, vaccines, treatment and diagnostic aids (Ezrow et al., 2015). The state also needs to invest in environmental engineering, agricultural development, vector management, sanitation, clean water, and public health education programmes. Low-income countries lack the revenues needed to invest in these areas.

Box 6.4  Colonialism and infectious disease Thus far the chapter has not delved into some of the historical reasons why states may be too poor to adequately address infectious diseases. Modernization theory, as explained in Chapter 1, argued that all countries, regardless of their history could catch

Poverty  147 up to high-income countries simply by following the pattern of development of the West – embarking on industrialization, encouraging urbanization and mass consumption, and investing in modern forms of education. Critical to this process was rejecting traditional cultures and embracing modern ideas about development and progress. Modernization theory also championed science, technological development, upward mobility, and economic growth. Nevertheless, modernization theory drew sharp criticism in the 1960s and 1970s for ignoring colonial histories (and skewed views of the development process in the West), which made it much more difficult for low-income countries to achieve similar gains. This was not just because many countries in the developing world became trapped by dependency or were stuck exporting primary products to the developed world that generated little foreign exchange; there were also other serious implications of colonial rule for health. It has been well documented that one of the biggest victims of European exploration were the Native American populations of the Americas. Whether intentionally or unintentionally, infectious disease brought by the Europeans had a devastating effect on immunologically naïve native populations. Though the precise magnitude may be up for debate, the consensus is that the introduction of Old World diseases contributed to the depopulation of the indigenous people (Lovell, 1992). Smallpox is a notable example of having been weaponized to wipe out indigenous groups. But it was not just the indigenous groups in the Americas that felt this impact, but also those in South Asia, Southeast Asia, and Africa (Alchon, 2002; Hewa, 1995). In particular, Africa has suffered significantly from the colonial period. Unequal terms of trade, which have carried on since decolonization, have reinforced existing dependent relationships, giving many African states less revenues needed to address health issues. Burundi, for example, which was colonized by Germany and Belgium, generates one-third of the country’s total export income from coffee (Tea and Coffee Journal, 2019). This did not happen by accident. The Belgians restructured the Burundian economy to focus almost entirely on the production of coffee (Oketch and Polzer, 2002). But coffee exports do not bring in substantial revenues (as Burundi is more of a small-time exporter) and coffee is prone to fluctuations in the market, which makes Burundi particularly vulnerable. As such, many African states which saw their economies restructured to meet the needs of colonial powers are still perpetually cashstrapped and unable to adequately invest in healthcare. As Chapter 4 explained, the debt crisis has not helped matters. African healthcare policy and outcomes cannot be divorced from important processes that took place that are both politico-historical and socio-economic (Gros, 2015). Colonial efforts to create export economies meant that many people were forced to work in mining and agriculture with few occupational protections from disease. Large-scale plantation agriculture put many at risk of contracting malaria and worm diseases. Colonial authorities also conscripted people to work in forced labour far away from their families, a situation which encouraged promiscuity with the presence of sex workers. Those who escaped forced labour fled further into the forests where they may have been interacting more with animals, sparking zoonoses (Chitnis et al., 2000). Africans were also forced to abandon indigenous forms of learning which emphasized indigenous technological skills which fit the needs of African societies; instead, European powers focused on teaching reading and writing to fit the needs of colonials who

148  Disease and disaster vulnerability wanted to recruit Africans to work in the colonial apparatus (Ocheni and Nwankwo, 2012). This had an impact on traditional forms of medicine. Colonial powers used both civil and criminal laws to marginalize most forms of African therapeutics (Tilley, 2016). Instead of collaborating with indigenous medical experts, colonialists pushed through modern medical practices at great cost. Colonial policies engaged in forced removals of populations in order to distance groups from an insect vector. Drug treatment programs developed were arsenic-based and near deadly in effective dosages (Tilley, 2016). Massive inoculation campaigns, where syringes were reused between patients or without sterilization procedures, led to the transmission of bloodborne pathogens, such as hepatitis C, across entire populations (Lachenal, 2017). Arm-to-arm inoculation campaigns may have quickly passed viruses through a series of hosts, which enabled the emergence of more virulent pathogen strains (Chitnis et al., 2000). Scholars have noted that the colonial enterprise, which was characterised by environmental destruction, rapid urbanization, migration, forced labour coupled with medical oversights, created the perfect environment for the simian virus to transform into a human virus, or HIV (Chitnis et al., 2000; Giles-Vernick et al., 2013).

In dealing with a pandemic, poor countries are also at a disadvantage for similar reasons. As mentioned previously, they are less likely to have invested in an effective public health system and have a less developed system in place to engage in early detection, such as a robust surveillance infrastructure in order to identify, investigate, and monitor surges (Morse, 2007). This is also necessary in order to properly mobilize personnel and resources when health facilities are overwhelmed with patients. Health systems must be able to prevent transmission inside clinical facilities and hospitals (Baxi et al., 2014; Maloney et al., 1995; Riley et al., 2003). Low-income countries may also lack the institutional capacity to plan, manage and allocate resources, and coordinate the implementation of these plans. Institutional capacity takes a long time to construct and is nearly impossible to build without proper financial investment. Low-income states are also less likely to have invested in transportation infrastructure in order to impact the effectiveness of disease surveillance and to ensure that there is a rapid response, ensuring that medical personnel can access patients (Greiner et al., 2020). The state must be aware of non-pharmaceutical measures to limit the spread and have strong communication infrastructure to communicate to the public what to do to prevent the spread (Chan et al., 2010). Risk communication plays an important role in managing public health emergencies, such as informing citizens of what to do and identifying where there are information gaps and rumours. Developing countries tend to have populations with lower literacy rates and education levels, which can undermine efforts to communicate public health advice and susceptibility to adhere to expert guidance (Spengler et al., 2016). Low-income countries may also struggle to provide their publics with adequate economic resources required to incentivize the right behaviours to prevent disease transmission (Oppenheim et al., 2019). Guatemala is one of the poorest countries in Latin America with little investment in healthcare. This has been particularly problematic during the pandemic, as the country only has 400 intensive care beds and fewer than 50 respirators. Little social and economic support has been provided (Shadmi et al., 2020). A presidential decree that closed down public transport left hundreds of thousands of Guatemalans who live in rural areas without transport or

Poverty  149 communication with the government. With a shut-down of transport, food quickly became scarce and prices increased. Schools closed down which drove up malnutrition among poor children who were reliant on the free meals that schools provided. Over 54% of children were chronically malnourished, and malnutrition rates have skyrocketed since the pandemic hit (Shadmi et al., 2020). Peru faced similar problems. Despite having one of the world’s strictest lockdowns, Peru struggled to contain Covid-19. With over 70% of people working in the informal sector with little savings and few social safety nets, these stay-at-home orders were ignored in order to survive (Pighi Bel and Hornton, 2020). Due to unplanned urbanization, many poor families lived in crowded makeshift houses (about 12% of the population) with poor water access, making it more difficult to wash hands and maintain higher levels of hygiene (Naranjo Bautista, 2020). With only 38% of Peruvians having access to a bank account, this also made it difficult for the population to receive any financial support from the government (Pighi Bel and Hornton, 2020). The healthcare system was also inadequate to handle the pandemic. Peru was also far behind the region in terms of the number of doctors, nurses, and hospital beds per capita. These weaknesses were even worse in rural areas (Petrera et al., 2013). Peru also provides little social protection, leaving a third of the population without access to the health insurance system (Naranjo Bautista, 2020). Poverty and underlying structural challenges have affected Peru’s ability to respond. In addition to dealing with more infectious diseases, more impoverished countries also face more drug-resistant microbes (for more on this, see Box 4.2 in Chapter 4). Many of the most common childhood diseases in developing countries are not always curable by the older antimicrobials that are available. As a result, acute bacterial respiratory infections kill millions of children each year. Resistance to life-saving drugs is a biological process that happens when there is exposure of certain microbes to an antimicrobial that leads to a mutation and subsequent emergence of microbes that are resistant to other antimicrobials. Key to preventing this is regulating the dispensation, use, and quality of antimicrobials. Poverty drives the rise of drug-resistant microbes for several reasons. First, at the country levels, poorer countries may lack effective regulation, drug sensitivity testing, and surveillance of antimicrobials which means that the quality and potency of the medication may be sub-standard (Okeke, 2006; Okeke, 2010; Petti et al., 2006). In countries such as Nigeria, Kenya, Uganda, Bangladesh, and Pakistan, there is no strict control over availability of falsified agents. For example, a 500-mg capsule of ciprofloxacin in Vietnam only contained the equivalent of 20 mg of ciprofloxacin (Planta, 2007). Studies have found that there are many counterfeit drugs floating around the market in developing countries (Chokshi et al., 2019; Sharma et al., 2017). Second, at the individual level, poor people may not be able to afford to pay for quality medication and may access drugs that are not regulated. As a result, many individuals can access drugs without a prescription from a trained individual (Sharma et al., 2017). For example, a study in Bangladesh showed that 22.7% of medications were dispensed by pharmacies without a prescription (Saha and Hossain, 2017). Thus, it is not surprising that one study showed that there was a rise in resistant strains of Shigella to ciprofloxacin, one of the important antibiotics used to treat it, from 0% in 2004 to 44% in 2010 (Puzari et al., 2018). Poorer people may also be more likely to buy the least expensive (and least potent drug) assuming that it will be just as effective. Poor people may also only complete a partial course of therapy because they cannot pay for the full course, or they believe that they will save money if they save the rest of the course for later. Inappropriate use of antimicrobials exerts selective pressures that contributes to resistance (Chokshi et al., 2019).

150  Disease and disaster vulnerability It is not just poor countries that are struggling with these issues, but poor households in higher income countries as well. In the US, where poor people may not have access to health insurance, people are more likely to engage in cost-cutting measures to access drugs needed to treat illnesses such as saving antibiotics and crossing the border into Mexico to purchase antimicrobials without a prescription (Planta, 2007). Poverty and disasters The chapter has thus far laid out how poverty increases disease vulnerabilities, both at the individual and state level. Thus, it should come as no surprise that the poor people are disproportionately affected by disasters, as are low-income countries. Poverty creates greater vulnerability to shocks, such as earthquakes, major storms, droughts, and floods. Most of the work on disasters has examined the economic costs (to be covered in Chapter 8), but this section will explore how poverty interacts with disasters and why poorer people and poorer countries are more susceptible to disaster when a natural hazard hits.

Poverty and disaster vulnerability Poverty at the individual level increases vulnerability to disaster. Scholars have placed emphasis on the economic, social, and political conditions that put some people at more risk to disasters than others. The poor are more vulnerable to disasters because they are more likely to live in places that are more prone to natural hazards and thus more dangerous. Some populations living on volcanic soil in the Philippines and Indonesia support population densities of more than 1,000 people per square kilometres (Bankoff, 1999). Poorer people are often forced to live in areas where there is less natural and infrastructural protection from disasters. People in developing countries are more vulnerable to environmental degradation than those in the developed countries (McMichael et al., 2004). As a result of deforestation for example, poor people may be forced to live in areas that lack a natural buffer against the effects of tropical storms. The poor are also more likely to live in homes that are poorly constructed and made of less durable materials. The poor often live where the work is such as living on land that may be less desirable because it makes them more vulnerable. Rich people in contrast, tend to live in areas that are less prone to flooding, in homes that are more secure (De Silva and Kawasaki, 2018; Rufat et al., 2015). High concentration of ownership in the hands of the few also affects where poor people can live, limiting their access to land that is less exposed to natural hazards. Large landowners in Honduras have driven out small farmers, forcing peasants to migrate to steep hillsides where agricultural practices have caused soil erosion and siltation of rivers. Rural and impoverished population centres are also at risk due to unequal patterns of land ownership, which have forced the rural poor to adopt unsustainable practices of agriculture (such as overusing the land) which make the land more prone to disasters. In many countries in Africa, Latin American, and Asia, it is the poorest people who are more exposed to and more affected by drought. Poverty also affects the coping skills of those affected by disasters. The poor may lack the means to flee in cars if a tropical storm is about to hit. They may have to rely on public transport and may not know where a safe shelter is. Some countries may lack effective public transport to help the poor arrive at a safe location. The poor may also lack devices that allow them to be communicated with to hear early warnings to leave. They may lack education needed to understand what to do to protect themselves. Those of lower income may also not

Poverty  151 have the means to stay in alternative lodging to ensure their safety. Additionally, the poor may lack the resources to rebuild their houses and/or have the social networks to stay with family and friends (Few, 2003; Rufat et al., 2015). Impoverished people are also forced to migrate to urban areas and lack access to safe building sites. The poor may have few alternatives but to live in overcrowded slums on steep hillsides, poorly constructed houses, or in areas that are prone to disasters (Smith, 2013). The development in urban slopes increases the risk of flooding the lower lying areas, where many of the poor may also reside (Pielke et al., 2003). For example, earthquakes killed 66,000 in Peru in 1970 and 23,000 in Guatemala in 1976 (Charvériat, 2000). Both earthquakes disproportionately affected the poor, who did not have the means for self-protection and lived in flimsier houses on steep slopes (Wisner et al., 2004). Not only does poverty and marginalization cause the poor to be more likely to face a natural hazard but it also means that they are less equipped to deal with natural hazards when they hit. Making matters worse for the poor, many disasters are compound events. Thus, oftentimes, states are still recovering from one disaster when they are struck by another. Haiti offers a good example of this. The 2010 Haitian earthquake not only killed as many as 300,000+ people, it also devastated the Haitian economy. Prior to the earthquake, Haiti was one of the poorest states in the Western Hemisphere. The earthquake made an already dire situation much worse. After the earthquake hit, the capital city, Port-au-Prince, was virtually impassable. Nearly six months after it occurred, only 2% of the rubble from the earthquake had been cleared, making it impossible for economic activities to take place. A year later, things were not much better, with only 5% of the rubble removed (Ezrow et al., 2015). Haiti’s poverty made an adequate response difficult. Insufficient resources were dedicated to rubble collection, and camps for the displaced were erected that had no electricity, running water, or sewage systems. Such conditions paved the way for a cholera epidemic later that year (said to have been brought in by foreign aid workers). An additional 8,000 people were killed at a rate of 50 deaths per day due to the disease (Frerichs, 2016). Crime was also widespread, particularly violence against women and girls. By 2012, about a half a million Haitians remained homeless (Oxfam, 2012). This situation made it all the more difficult for Haiti to deal with Tropical Storm Isaac in 2012, which killed 29 people, and Hurricane Sandy, also that year, which killed 55 people, or Hurricane Matthew in 2016, which killed 546 people (Marcelin et al., 2016). Even though it has been a number of years since the 2010 earthquake, Haiti is still suffering its impact, and the repeated disasters that have come its way have just made the situation worse (Pichler and Striessnig, 2013). Disasters can have a devastating impact on infectious diseases in contexts of dire poverty. In the case of Haiti, the 2010 earthquake, which displaced 10% of the population led to a cholera epidemic that had spread across the entire country by December of 2010 (Relief Web, 2020). With many people living in refugee camps with only intermittent access to drinking water and little sanitation provision, deaths were occurring two hours after symptoms were identified, which gave little time for individuals afflicted to receive life-saving treatments such as oral rehydration solution (ORS) (Farmer et al., 2011). The poor may be also more likely to live near a hazardous waste site or near chemical facilities which, when a catastrophic accident takes place, increases the risk of being exposed to toxic substances. Since Hurricane Harvey hit the Southern US, residents in Houston are dealing with chronic health issues from being exposed to high levels of toxic chemicals that leaked from flooded oil and gas industry sites (Milman, 2017). The poor also may lack insurance and a financial buffer, which means that when a disaster strikes, they are forced to live in makeshift camps or temporary settlements that are

152  Disease and disaster vulnerability conducive to spreading infectious diseases (Sawada and Takasaki, 2017). The poor usually struggle to pay insurance and may not trust putting their money into insurance (Kunreuther and Michel-Kerjan, 2013; Kunreuther and Lyster, 2016). When the poor do receive support after a disaster, it is often not enough to improve their ability to cope (Hallegatte et al., 2020).

Case study: Cyclone Bhola Cyclone Bhola that struck what is now Bangladesh and parts of India in November of 1970 was the deadliest cyclone on record. As many as 500,000 people died and reports claimed that there were few survivors. The powerful winds of the storm pushed water up to 20 feet high (6 meters) across the landscape, ripping away entire villages. Ravaging the coastline of the Bay of Bengal, the whole area hit was low lying, only a few feet above sea level causing total destruction. For a period of time, 25% of what was is now Bangladesh’s total land was underwater (Naeem, 2020). The storm had a massive impact on livelihoods, as it wiped out crops, livestock, and damaged water supplies. Over one million cattle were lost and crop losses were severe. Rice crops were wiped out, and sugarcane and banana trees were heavily damaged. Nut trees including coconuts survived the storm, but the nuts were wiped away, costing farmers one year of harvest. Additionally, as many as 46,000 of the 77,00 fishermen in the region died, destroying 65% of the coastal fishing industry. This greatly affected malnutrition rates for the region since 85% of the protein comes from fish (Gunn, 2010). Three months after the storm, 75% of the population was receiving food from relief workers, and over 150,000 relied upon aid for half of their food (Paul, 2009). Because so many bodies were washed away in the water, this damaged water supplies, causing a widespread outbreak of cholera and typhoid, leading to an even larger death toll. The storm was incredibly powerful, but it was not the most powerful storm on record, at only 115 miles per hour and a Category 3 storm. The problem was that in Bangladesh in 1970 there were no protective embankments (Kusky and Cullen, 2010). This meant that people in the area where the storm hit were incredibly vulnerable in the event of a major storm. Another issue was that people living in the area had few protections if a storm hit their homes. Houses were also constructed of weak material, such as bamboo with thatched roofs, that were easily crushed by the storm. About 85% of the homes in the area were destroyed, with 50 million people displaced. Almost 30% of the victims were young children, while over 20% of the victims were the elderly (Reilly, 2009). A greater proportion of women than men died (for more on reasons why this may be the case, see Box 6.3). The most vulnerable had little to protect them when the storm came. The government also had little knowledge of the population and how to reach them. The census had not been taken in over ten years meaning that there were thousands and thousands of people who were unaccounted for by the state, many of whom were migrant workers. There were not enough shelters to house people and there was poor communication to the area. Compounding matters, road networks were poor and there were few means of transport to help people flee to safety. Warnings of a huge storm were issued, but it was impossible to communicate to many people living in distant coastal areas (Paul, 2009). Many were asleep when the storm hit with no chance to escape (ibid.). The intersection of poverty and nature created one of the worst disasters on record. ***

Poverty  153

Poverty and disaster management The previous section explained the relationship between poverty at the household level and disaster vulnerability. In this section we look at poverty at the national level and how this may impact the management of disasters. Low-income countries, by definition, are financially strapped. These countries lack the resources to invest in disaster vulnerability reduction. They are unable to collect revenues, which in turn makes it nearly impossible for the state to provide many services. Impoverished countries that cannot extract funds from incomes and profits from capital gains have to rely on commodities which can fluctuate, causing the fiscal budget to vary by as much as 100% within a fiscal year (Sindzingre, 2004). This makes it difficult to devote resources to education, healthcare, infrastructure, agriculture, water and sanitation services, and other areas that are critical to the management and mitigation of disasters. This in turn has a direct impact on those who are impoverished. In particular, poorer countries have less money to invest in roads and bridges that may be unable to withstand earthquakes or floods. Buildings may be constructed with cheap materials. More impoverished states may lack disaster warning systems, communication technology, or proper response to disasters. Low-income and lower-middle income countries are also disproportionately affected by disasters, constituting the top ten countries in terms of disaster mortality incidence in absolute numbers (with the exception of Russia and China) and per 100,000 residents (see Table 6.1 and 6.2) (UNDRR, 2016). Essentially, the poorer the country, the higher the number of disaster deaths there are likely to be. It is also striking that none of the high-income countries which appear on the 2015 top ten list for economic losses from disasters (such as the US, Japan, the UK, Australia, and Chile) appear among the countries suffering the highest disaster mortality. In absolute terms, low- and middle-income countries bore the brunt of disaster mortality between 1996 and 2015. On average, 327 people died per disaster in low-income countries in the past 20 years, almost five times more than the average toll in high-income countries (UNISDR, 2016). There is also a clear progression in the number of deaths per 100,000 inhabitants in poorer nations, with low-income countries suffering more than five times the number of disaster deaths compared to high-income countries.

Table 6.1  Top ten countries for disaster deaths in absolute numbers, 1996–2015 Haiti: Indonesia: Myanmar: China: India: Pakistan: Russia: Sri Lanka: Iran: Venezuela: Source: UNDRR, 2016

229,6994 182,136 139,515 123,937 97,691 85,400 58,545 36,433 32,181 30,319

154  Disease and disaster vulnerability Table 6.2  Top ten countries for disaster deaths per 100,000 inhabitants, 1996–2015 Haiti: Myanmar: Somalia: Honduras: Sri Lanka: Venezuela: Indonesia Nicaragua: Afghanistan: Pakistan:

2,461 280 268 217 185 113 80 70 57 55

Source: UNDRR, 2016

***

Conclusion Chronic disease and repeated external shocks from natural hazards intensify poverty traps. The poor are more vulnerable to diseases and disaster and have fewer coping strategies to bounce back and be resilient. As many of the poorest people are living in low-income countries, the paucity of state revenues to invest in healthcare and disaster risk mitigation compounds the problem. But it is not only low-income countries that are impacted but also poor people living anywhere who are the most at risk. Various forms of economic insecurity, such as poverty, affects people’s choices and capacity. The poor are more likely to engage in higher risk professions which make them more vulnerable to both disease and disaster and are more likely to live in conditions that do not foster resilience or offer much protection. The poor may not be able to afford health insurance and disaster insurance nor have the luxury to access healthcare clinics or flee to safety when they need to. The chapter also explained that poorer people are more vulnerable to being the index case of a new outbreak due to some of the risks of where they live, how they need to feed themselves, and other occupational hazards. While there have been huge improvements in terms of reducing global poverty, with the number of extremely poor people dropping from 1.9 billion in 1990 to 689 million in 2017, global poverty is falling at a slower rate in the last several years (World Bank, 2020). Compounding matters, more than 40% of the poor live in conflict-affected countries (ibid.). Not only are their livelihoods being destroyed, they also face increasing risks to disease and disaster and are more likely to face a humanitarian crisis. In the chapter that follows, we explain why this is the case.

Key questions 1 2 3

The chapter claimed that poverty may play a role in sparking new diseases. Compare and contrast the impact of global factors in sparking new diseases and the role of poverty. What do you think is more important and why? Why are poorer people more likely to die of Covid-19? What role do socio-economic factors play in making women more vulnerable to disease and disaster?

Poverty  155 4 5

What type of natural hazard are the poor most vulnerable to and why? Why are low-income states more likely to struggle in managing disease and disaster? Are there any outliers to this argument?

Notes 1 The big three diseases – tuberculosis, malaria, HIV/AIDS – account for nearly 18% of the disease burden in the poorest countries. 2 Bushmeat includes any type of animal from rodents to elephants, including primates, porcupines, and antelope, for example. 3 Women are also more likely to care for sick household members (Harman, 2016; Songwathana, 2001). 4 Other data has put the death toll in Haiti at far higher numbers.

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7 Conflict

Introduction The previous chapter explained how poverty (both at the state and individual level) is a source of vulnerability for diseases and disasters. Just as poverty, disease, and disaster tend to go hand in hand, so too do diseases, poverty, and conflict. Research from the World Bank estimates that by 2030 up to two-thirds of the global extreme poor will be living in countries that are fragile and affected by conflict (2020). Not surprisingly, there is also a link between conflict and infectious diseases. The high death tolls from conflicts are usually not due to deaths in combat. Instead, most of the deaths are attributable to the spread of disease and severe malnutrition (Brown, 2003; Fürst et al., 2009; Murray et al., 2002; Verwimp, 2011). In fact, infectious diseases, alone or in combination with malnutrition, account for the most deaths in conflicts and complex emergencies (Connolly et al., 2004). Examples abound of conflict-afflicted countries that have faced a serious disease outbreak that has cost many lives. An outbreak of Marburg haemorrhagic fever hit Angola in 2005 and the Democratic Republic of the Congo (DRC) in 1998. A cholera epidemic ravaged the DRC in the aftermath of the 1994 Rwanda crisis (Heymann et al., 2015). There was also a significant resurgence of sleeping sickness (human African trypanosomiasis) in the 1990s, mostly in conflict-affected areas of Angola, DRC, and Southern Sudan. Violence in the DRC has also upended efforts to contain the spread of the pneumonic plague, sleeping sickness, and river blindness and, currently, conflict is undermining efforts to control Ebola in the North Kivu region. Violence in Nigeria and Pakistan have also made is more difficult to eradicate polio, a highly infectious disease that has recently made a comeback. Regions around the world that are plagued by chronic violence and conflict, struggle to contain infectious diseases. As the last chapter mentioned, conflicts often affect countries that are already impoverished and have weak states (Atwood, 2003; Rotberg, 2010). Conflict not only makes it more difficult for the state to respond to disease outbreaks and disaster events, but conflicts create conditions that facilitate the spread of diseases and make people more vulnerable to disasters. After first explaining what we mean by conflict, the chapter explains how conflict interacts with infectious diseases. We close by looking at the connection between conflict and disaster. Though there are fewer instances of disasters hitting countries engaged in conflict, when a disaster does strike, conflict complicates any type of response or mitigation. Conflicts, which constitute an important indicator of community insecurity, worsen many other different dimensions of human security.

DOI: 10.4324/9781003128809-11

Conflict  165 Key concepts

What are conflicts? Conflicts are events where hostilities are carried out by two or more parties that result in violence. Conflict-affected areas are countries where states do not have the capacity or the will to protect their populations from violence, which can lead to chronic instability and disruption. Thus, we include in this chapter explanations of how instability and disease and disaster mix. Also, the chapter mostly examines examples of civil conflict or areas where there are two organized groups of warring parties within the same state or country rather than inter-state conflict, which is far less common. Conflict-affected states are often affected by state failure – where the state can no longer perform its basic security and development functions, and the state ceases to have effective control over parts or all of its territories and borders (Ezrow and Frantz, 2013). Once the state lacks the capacity to maintain a monopoly over the legitimate use of force and provide adequate security for its citizens, it becomes nearly impossible for the state to provide other public goods such as healthcare, proper sanitation, and disaster preparedness. As a result of civil conflict, one of the organized groups may exercise de facto control over communities of vulnerable people. Non-state actors – ethnic militias, secessionist groups, warlords, guerrilla groups, and other militias – may hold power over parts of the territory, given that the state is unable to disarm and disband them. There may also be areas that have a ‘state within a state’ operating, with independent policy forces, judiciaries, and economies (Bøås and Jennings, 2005). At the same time, criminal violence could erupt because the state cannot control the sale and distribution of firearms nor protect its people from unauthorized violence (Boutwell and Klare, 1999). In other words, violent instability is a symptom of the loss of control over the use of force. Conflict-affected states also generate large numbers of displacement, both internally displaced persons and refugees. An internally displaced person (IDP) is someone who is forced to flee their home but stays somewhere within the same country. A refugee is someone who is forced to flee but moves outside of their country of origin. As of the end of 2019, there are almost 46 million IDPs and 26 million refugees, and if all of the displaced people were placed in one country, it would be the 21st largest population in the world. In both cases, IDPs and refugees are living in precarious and terrible conditions where they may be beyond the reach of support from the state and from humanitarian aid. According to the United Nations Refugee Agency (UNHCR), 80% of the world’s displaced people live in countries or territories affected by severe malnutrition and food insecurity (2020). The combination of conflict, displacement, and failed spaces is usually a recipe for disaster when it comes to diseases and disasters, with children facing the biggest risks and comprising 40% of those displaced (ibid.). In the ten countries with the worst child mortality rates, seven of the ten are facing some form of conflict and complex emergency. Disease and conflict As the chapter noted earlier, conflicts go hand in hand with infectious diseases. Civil wars directly affect all the major contributors to health: exposure to disease, medical care, public health interventions, and overall socio-economic conditions. Conflicts tend to prolonged events that can last decades. Even when they end, conflict-affected countries are prone to

166  Disease and disaster vulnerability relapse, with 40% of countries doing so after a brief period of peace (Collier, 2003). In the conflict between Armenia and Azerbaijan, over 1.2  million people were displaced in the early 1990s, which resulted in the disruption of health services and a resurgence of epidemics such as diphtheria, measles, hepatitis, TB, typhoid, and malaria (King, 2008). The conflict resumed in 2020, and there are fears that this will lead to a resurgence of these diseases. Health security requires a strong and effective health system before a crisis to ensure that health services are available and accessible to all (Heymann et al., 2015). However, most conflicts today are occurring in failed and failing states that already have weak health services and infrastructure. These states have a chronic shortage of trained medical personnel and lack the health infrastructure and access to medicines needed for their populations.

Conflicts and disease spark Conflicts may spark disease outbreaks by the ways in which they affect human behaviour. Conflicts compel and induce people to move to areas where they are more likely to be exposed to pathogens. Those involved in conflict, such as active combatants, may have to retreat into forests and may be more exposed to vectors and animals that harbour diseases. War also drives populations to marginal subsistence strategies, such as increasing the consumption of bushmeat (for more on the effects of this, see Chapters 4 and 5) and forest-based livelihoods. War may force people to move into areas involved in resource extraction in order to survive financially. In 2003, the index case of yellow fever sparked in Colombia – the largest outbreak in fifty years – because of an influx of workers who had migrated to illegal drug production areas and had not been immunised (Beyrer et al., 2007). During conflicts, it is also more difficult to regulate resource extraction. Most conflicts have failed spaces that have been taken over by insurgents, criminals, and warlords. These violent non-state actors have increased the epidemiological risk of diseases in their de facto zones by accelerating environmental degradation (Gilman, 2014). Warlords and other criminal insurgents can create pseudo-sovereign states where they have free reign to loot and plunder natural resources in order to fund low-intensity conflicts. This type of unregulated natural resource extraction can have important consequences on the environment and be a driver of disease spark (as explained in Chapter 4). Widespread illegal logging, for example, can destabilize the habitat for numerous species, including bats, the most likely reservoir for Ebola. For example, in the West African conflicts in the 1990s, warlords exported over 343,000 m3 of timber from Liberia to Europe from 1991 to 1992, clearing large swathes of tropical rainforest in the process (Ellis, 2006). Because these areas were under the control of warlords and not national governments, there was no environmental oversight of any of these activities. Thus, low-intensity warfare has accelerated environmental destruction, which raises the risk of zoonotic crossover (Hirschfeld, 2020). Recent studies have demonstrated a relationship between deforestation, habitat fragmentation, and Ebola virus outbreak in Africa and Nipah and Hendra viruses and possibly SARS in Asia (McCoy, 2014; Olivero et al., 2017; Olivero et al., 2020; Rulli et al., 2017; Hotez, 2016).

Conflicts and disease spread Conflicts affect the spread of infectious diseases primarily because wars lead to mass displacement and more people are forced to live in crowded and unsanitary conditions. Conflict is the leading driver of internal displacement and refugee movements (IDMC, 2015). For example, the conflict in Rwanda generated 1.4 million IDPs and caused another

Conflict  167 1.5 million refugees to neighbouring countries in Zaire, Tanzania, and Burundi. Making matters worse, most of the refugees and IDPs were already coming from situations of public health collapse and where there were serious food security issues. Conflict leads to displacement into temporary settlements or camps, where the displaced live in overcrowded shelters without adequate sanitation or access to safe water and food. In contrast to the displacement generated by disasters, those who are displaced by conflict may live in makeshift camps for years. These conditions give rise to epidemics of infectious diseases. Acute respiratory infections affect refugees and IDPs living in overcrowded conditions with inadequate shelter, particularly in colder conditions. As acute respiratory infections are spread through aerosol transmission, closer conditions facilitate the spread, leading to high morbidity and mortality rates in refugee camps, as has been the case in Pakistan and Tanzania (Kamugisha et al., 2003; Nájera Villagrana and García Naranjo Santisteban, 2019; Rajabali et al., 2009). Overcrowding and high rates of acute respiratory infections amplify the risk of epidemic meningococcal disease affecting refugee camps in the DRC in 2002 and Sudanese refugee camps in 1994 (Connolly et al., 2004). New strains of infectious diseases may bloom in these conditions. Lacking sanitation, access to clean water, and hygiene can lead to the spread of diarrhoeal diseases, typhoid fever, guinea worm, and typhus to name a few. Diarrhoeal diseases in particular flourish in crowded camp conditions, accounting for more than 40% of the deaths in an acute phase of an emergency, with over 80% of those affected under 2 years old (WHO, 2020a). Polluted water that has been contaminated by faecal matter can enter poorly sealed wells. Water can also become contaminated during transport and storage. The scarcity of clean water, soap, and cooking pots also exacerbates this problem. In 1994, an influx of 800,000 refugees from Rwanda entered the DRC, which led to a scarcity of clean water and overcrowded conditions (Office of the UN High Commissioner for Refugees, 2000). Within one month, there were 50,000 deaths due to diarrhoeal diseases (60% from cholera and 40% from shigella dysentery) (Connolly et al., 2004). Epidemic diseases, such as tuberculosis, measles, pneumonia, cholera, typhoid, paratyphoid, and dysentery, are most likely to emerge in situations where there is overcrowding, unsafe drinking water, poor sanitation. Additionally, the exposure to disease vectors remains acute during these types of emergencies. Malaria also spreads in overcrowded conditions and temporary makeshift abodes that provide inadequate protection and shelter from mosquitoes. These condition increase bite frequency which promotes the transmission cycle. As a result, it was reported in the 1990s that 75% of all deaths in refugee camps were due to infectious disease (Toole and Waldman, 1997; UNHCR, 1995). At the time, the major causes of morbidity and mortality among refugees were measles, diarrhoeal diseases, acute respiratory infections, and malaria (UNHCR, 1995). In a study of refugee camps that covered the period of 2009–2017, the main infectious disease outbreaks were caused by measles, cholera, and meningitis, which are all vaccine preventable (Altare et al., 2019). IDPs and refugees may also be more vulnerable to infection due to malnutrition, which compromises people’s immune systems, and low vaccine coverage. They also face higher levels of anguish and mental stress. Mortality rates are higher among refugees than the normal population, about five to twelve times above the normal rate (Toole, 2000). In Sudanese refugee camps, an outbreak of visceral leishmaniasis caused an estimated 100,000 deaths from 1984–1991 (WHO, 2020b). In the case of the Syrian conflict, the war has led to the displacement of more than six million Syrians, with another five million fleeing the country. As the healthcare system has fallen apart, the conflict has seen the re-emergence of the infectious challenges of tuberculosis, cutaneous leishmaniasis, polio, and measles (Ozaras et al., 2016).

168  Disease and disaster vulnerability Infectious diseases can spread from conflict situations through the movement of refugees and relief workers and through other animals, goods, and services. Refugees may carry infectious diseases, such as TB, that have long incubation periods (Cookson et al., 2015). The WHO had reported in 1997 that over 85% of refugees originate from, and stay within, countries with high tuberculosis burdens (Toole and Waldman, 1997). Things have improved since the 1990s but are still worrisome. As of 2015, 20% of the world’s refugees originated from a country with a high TB burden, and 30% sought refuge in a high TB-burden country (Boyd and Cookson, 2019). The forced movement of peopled due to conflict has also led to the spread of vector-borne diseases, like malaria. One of the risk factors with malaria is the displacement of people from endemic areas to non-endemic areas and vice versa. Exposing people who are non-immune heightens the risk of malaria in local communities, especially if there are favourable conditions for the mosquito vectors, such as stagnant water, flooding, and humidity. Before the civil war began in Tajikistan, only several hundred cases of malaria were being reported annually. However, civil war led to massive population displacement and deteriorating living conditions. More than 100,000 people fled to Afghanistan, which reintroduced the malaria parasites when they returned in 1994. This led to the first outbreak of Plasmodium falciparum malaria in Tajikistan in 35 years, with annual cases rising to 500,000 per year (Matthys et al., 2008). Once the war ended and the state could reinstate malaria control, the incidence of malaria was reduced by 50% within two years (WHO, 2015a). Population movement and a breakdown of the healthcare system led to a massive malaria epidemic in Burundi in 2000– 2001 (Etchegorry et al., 2001). An outbreak of cutaneous leishmaniasis was reported for the first time in the North-West Frontier province of Pakistan in 1997 originating from an Afghan refugee camp (Rowland et al., 1999). Controlling an outbreak in a country hosting refugees is complicated by numerous factors as well, including language barriers and cultural differences (Morris et al., 2009; Sahlool et al., 2012). There may be health workers who are inexperienced and unprepared to deal with new types of infectious diseases that are not endemic to their country. In the case of Turkey, which has a fairly equitable healthcare system, tensions existed between Syrian refugees and healthcare providers due partially to sectarian differences. Physicians working in the camps also sometimes struggled to communicate with Syrian refugees because of language barriers, which affected the quality of healthcare delivery (Sahlool et al., 2012). Conflicts with other countries can also facilitate the spread of diseases. When troops move around, they may carry with them infectious diseases. In the case of the Ebola outbreak in Uganda in 2000–2011 which killed 224 people, the virus was reportedly carried by troops either from the Ugandan military or Sudanese rebels returning from fighting in the Congo. Civil war has also facilitated the spread of diseases by driving people living in rural areas to urban areas, which has spread vector-borne diseases with it (Beyrer et al., 2007). For more on the role of soldiers, refugees, and conflict and the spread of the HIV/AIDS virus see Box 7.1.

Box 7.1  Conflict and HIV/AIDS For a number of years, many policymakers had believed that conflict was the fastest way by which HIV/AIDS was spreading (Copley, 1999; Ghobarah et al., 2003; Miles, 2003). As the chapter has explained, conflict encourages population movement, disrupts access to health services, destroys and damages critical infrastructure. Conflict raises the risk

Conflict  169 that uninfected populations will come into contact with infected individuals. Conflicts brings together soldiers and non-combatants in ways that may encourage risky sexual interactions and, even worse, sexual assault and rape (Iqbal and Zorn, 2010). During conflicts, women and girls are particularly vulnerable to sexual assault and exploitation which predisposes them to contracting sexually transmitted diseases, such as HIV/ AIDS. Rape was used as a weapon in the conflict in Rwanda (Sharlach, 2000). In this case, soldiers act as vectors of the disease, and some studies have claimed that there was a high HIV prevalence rate amongst soldiers and insurgents (Ghobarah et al., 2003). Some authors have also claimed that a correlation exists between migrating populations and HIV rates, arguing that refugees could also serve as vectors of HIV/AIDS (Lurie et al., 2003). Nevertheless, there is little empirical proof that this is the case. In fact, some studies demonstrated that conflict-affected refugees and IDPs were not more likely to be infected with HIV and that armed conflict had no epidemiologically measurable impact on HIV infection at a population level (Davenport and Loyle, 2009; Spiegel, 2004; Spiegel et al., 2007). Other studies showed that inter-state conflict had no statistically significant effect on HIV prevalence, though civil conflict was associated with a lower HIV prevalence – with rates possibly higher if a country were not at war (Paxton, 2012). Thus, the role of conflict in spreading HIV/AIDS is not straightforward, and future research needs to try to understand why there are such huge discrepancies in these relationships.

Food emergencies One of the consequences of war that affects people’s ability to fight off diseases is food insecurity. In war, crops and inputs to produce crops may be deliberately destroyed, which forces people off land that they would otherwise farm to produce food for sale and subsistence. Transporting and delivering food may also become more difficult as food may be confiscated by violent groups during transport or may spoil due to improper storage care. As a result, conflicts often lead to a food crisis that leave children malnourished and unable to fight off infections. For more on complex emergencies, see Box 7.2. It may be a vicious cycle, with the infection accelerating malnutrition or starvation, increasing susceptibility to numerous pathogens. The most common scenario is that malnutrition is followed by an epidemic. When a new disease is introduced into a region that does not have immunity to diseases, this makes the situation more severe. Studies in children have shown that malnourishment raises the risk of death significantly, particularly for diarrhoeal diseases and measles (Pelletier et al., 1995; Young and Jaspars, 1995). More severe measles occur at a higher frequency in malnourished children, as measles rapidly depletes stores of vitamin A.

Box 7.2  Complex emergencies A complex emergency is a crisis in an area where there is an acute emergency layered over ongoing instability, conflict and violence, social inequality and poverty (Keen, 2008). Complex emergencies are generated by conflict, state failure, a mass movement of people, food insecurity, disaster, disease, and massive economic failure (such as steep

170  Disease and disaster vulnerability declines in GDP, skyrocketing unemployment, hyperinflation, or devaluation of the currency) (Salama et al., 2004). Complex emergencies are more likely to take place in countries where the state cannot accommodate all groups in society and where there is insufficient institutional capacity to react to these crises (Ezrow and Frantz, 2013). Complex emergencies entail mass suffering of people requiring immediate and widespread humanitarian relief. Examples of complex emergencies are when a disaster hits a conflict zone; when an infectious disease breaks out during a conflict; when a failed state faces a disease outbreak; or when a disaster event sparks a famine. Very few studies have looked at the prevalence of disasters and complex emergencies, but a quantitative analysis of the period from 1995–2004 found that 27% of the largest disasters occurred in areas with at least one ongoing complex emergency, while 87% of the largest complex emergencies were hit by at least one disaster (Spiegel et al., 2007b). Complicating matters further, complex emergencies often involve disease, disaster, and conflict at the same time.

Conflicts and the management of infectious diseases Conflicts impact the management of diseases in numerous ways. Civil wars affect the resources available to spend on healthcare in general. During a conflict, the economy is usually in freefall, which reduces the pool of tax revenues that states can collect for public healthcare provision. Additionally, what little revenues the states have may be more likely allocated for security. Conflicts can completely damage and disrupt healthcare systems, reducing the ability to properly treat diseases and provide essential services. Conflicts affect coordination, management, oversight, and monitoring. Every aspect of a healthcare system is affected by conflict. Conflicts directly affect the critical infrastructure of the state. Though international humanitarian law protects health resources, in practice, they are often damaged (Afzal et al., 2019). Often health facilities, personnel, and infrastructure are deliberately targeted, including medical facilities, sanitation systems, and power and water supply lines (Ghobarah et al., 2004). In Afghanistan, hospitals were particularly vulnerable to attack – leaving millions of people without access to critical care (Zurcher, 2012). Hospitals in Liberia were systematically destroyed, with equipment dismantled and mutilated (Ghobarah et al., 2003; Valand et al., 2020). Just prior to the conflict in Syria there were improvements taking place in healthcare, with infant, child, and maternal mortality rates falling by almost 40%. By 2014, 60% of state hospitals, 38% of healthcare facilities, and 78% of ambulances had been destroyed or seriously damaged (Ozaras et al., 2016). In the case of Sierra Leone, during the civil war in the 1990s, only 16% of the health centres were functioning in 1996, mostly in Freetown, the capital (McPake et al., 2015). Conflict not only destroys health infrastructure but may also cause trained staff to flee. In cases where staff have not already fled, there still may be high levels of absenteeism. Staff are often forced to work in dangerous and sub-optimal conditions for little or no pay. With the flight of medical professionals, rural areas are often the most affected. In the case of the conflict in the Cote d’Ivoire, a study showed that 75–88% of health personnel fled rebelcontrolled areas, and 72–90% of health facilities ceased to operate (Betsi et al., 2006). More inexperienced staff may have to take over senior positions, and it may be impossible to offer training to medical care workers.

Conflict  171 Conflict often destroys transportation infrastructure such as roads, bridges, and railroad systems. Conflict zones are often inaccessible to health workers, which can leave millions of people trapped without access to medical care. With roads mined, travel can be impossible making it more difficult to access medical care (Garry and Checchi, 2020). It also makes it more difficult to disburse relief supplies, medicine, clean water, and food. Public healthcare workers have been prevented from reaching high risk rural areas that are held by rebel groups (Beyrer et al., 2007). Chagas disease and yellow fever made a comeback in Colombia because people living in rebel-controlled areas had little access to treatment and to proper healthcare (ibid.). Conflict also damages and disrupts electricity and communications infrastructure (Garry and Checchi, 2020). Healthcare information systems are not operational (Nyanga et al., 2019). Educational systems and programmes, critical to equipping individuals with information essential to preventing the spread of infectious diseases, are interrupted, and medical education is suspended (Challoner and Forget, 2011). The irregular access to health facilities and lack of regulation can contribute to pathogen resistance (see Box 4.2) to drugs during conflicts. This may be the result of inappropriate use and disbursement of outdated drugs or to poor treatment compliance due to insufficient quantities. Studies of refugee populations have demonstrated that there was significant drug resistance in TB patients and comparatively more drug resistance than in other populations generally (Gayer et al., 2007). When drugs are not administered properly, drug-resistant strains of diseases develop and, in turn, weaken resistance to other diseases. Conflict also makes it more difficult for health systems to access drugs and procure other necessary vital equipment. Health systems and supply chains break down. In these conflict-affected countries, pockets of territory are governed by violent non-state actors or pseudo-states which provide little, if anything, in terms of health services either due to little capacity or will (Ezrow and Frantz, 2013). In the case of Colombia, many infectious diseases spread in conflict zones that were controlled by violent non-state actors. For example, leishmaniasis is easily treatable but requires medication and therapy which was owned by the government. Those living in rebel-controlled areas could not access this treatment, exposing them to chronic and recurrent morbidity (Beyrer et al., 2007). Another big issue with conflicts is that they disrupt programmes in place to mitigate the spread of diseases. Of particular concern is the interruption in the administration of vaccines during conflicts. In most cases, health facilities are overwhelmed with other tasks or health facilities are too damaged to perform their normal functions. But there have also been cases of insurgencies which managed to hijack thousands of vaccines (Beyrer et al., 2007). The disruption in supply chains and the collapse of healthcare systems make it difficult to ensure high vaccine coverage. For example, in Sierra Leone, only about half of the children under 3 years of age received all of their immunizations due to the conflict in the 1990s (Senessie et al., 2007). Children living in conflict-affected countries suffer the most. More than two-thirds of the children who have not received their essential vaccines live in countries with conflict-zones (Ngo et al., 2020). Measles can be controlled by vaccination programmes, but when these programmes break down, it can lead to large-scale epidemics. As a result of the interruption of these vaccination programmes, epidemics of measles have been a major cause of mortality in camp settings, accounting for much of the death toll in camps in Afghanistan, Iraq, Sudan, and Somalia; both Sudan and Somalia faced surges of polio as well (Grundy and Biggs, 2019). As many as 70% of the 3,400 cases of polio reported between 2010 and 2016 were in conflict-affected countries (Ngo et al., 2020). Due to the interruption of routine

172  Disease and disaster vulnerability vaccination programmes, many conflict-affected African countries witnessed a resurgence of yellow fever, which is easily preventable through inoculations. Yellow fever outbreaks took place during conflicts in Angola in 1988; in Liberia six times in the 1990s and early 2000s; in Sierra Leone in 2003; in Côte d’Ivoire in 2000 and 2001; in Guinea in 2001 and 2005; and in Sudan in 2003 and 2005 (Ahmed and Memish, 2017; Gayer et al., 2007). Conflicts also affect the spread of diseases because of the breakdown of basic control measures, including early diagnosis (to ensure that patients are being isolated to prevent further infections), surveillance, and contact tracing. In the case of malaria, absence of early treatment protracts the time that the parasite remains in the blood, spreading the disease when a mosquito bites again (White, 2017). Conflicts also affect drug administration programs, which are key to stopping the spread of treatable infectious diseases. Not being able to access health services interrupts TB control, leading to lower cure rates, lower case detection, and higher rates of multi-drug resistance. Conflicts also impact surveillance capacity. Conflicts create a void in healthcare personnel, as many flee or are killed or injured. The lack of staff means that there are fewer personnel who can work in the labs and engage in surveillance of diseases (McPake et al., 2015). For example, malaria was endemic to the Caucasus, but after World War II, the Soviet system enacted policies to keep the disease at bay. War and state failure brought it back after the Soviet Union collapsed (Garrett, 2003; Zurcher, 2007). The health infrastructure had completely eroded, and there was little public health surveillance in these de facto zones, which brought back measles and diphtheria (Zurcher, 2007). In the DRC, enclaves controlled by violent non-state groups have made it incredibly challenging to offer surveillance for diseases and to get the Ebola virus under control (Wells et al., 2019). In failed states, there is almost no epidemiological surveillance. As a result, outbreaks that originate in these pseudo-states can go undetected until they spread into areas where there is a functioning health sector (Gostin et al., 2019). The areas of Nigeria that became captured by Boko Haram were afflicted with numerous epidemics of cholera, polio, measles, and malaria (Awosusi, 2017; Burki, 2016). It was estimated that this may have been because 35% of the health facilities in the Nigerian provinces that were controlled by Boko Haram were destroyed, with another 30% badly damaged (Reuters, 2016; Roberts, 2017). Conflicts undermine state efforts to ensure that there is proper vector control, as disease vectors proliferate in environments of statelessness and insurgency. Unsanitary and overcrowded conditions, along with an accumulation of garbage, led to an excess of rodents in post-war Kosovo that led to a tularaemia outbreak among displaced persons in 1999–2000 (Boui and Errami, 2007). The population had fled villages to escape the bombings; when they returned, buildings were not only destroyed but food stores and wells were contaminated and the rodent population had increased significantly. Without an effective state apparatus to collect waste and dispose of it properly, vectors multiplied and disease spread. Vector control was also an issue during the civil wars in Liberia and Sierra Leone in the 1990s. Due to the conflict, villages were abandoned and people were forced to relocate to overcrowded camps. This provided new opportunities for vectors, like rodent populations, to increase as garbage was not being collected. There was also no rodent control or surveillance, and healthcare facilities were unable to function. As a result of these conditions, these wartorn countries saw a rise in a number of diseases, including Lassa fever. Malaria had almost been controlled in Afghanistan during the 1960s and 1970s with effective vector control programmes, however, the civil war, which effectively began in 1978, led to its resurgence. Vector control programmes to decrease the population of mosquitoes were interrupted which helped malaria make a comeback. Violence in Colombia also weakened an

Conflict  173 already vulnerable vector-control programme. Vector-control programmes reach only 16.7% of the population in high-risk areas (Beyrer et al., 2007). Conflicts have also led to a rise of nosocomial transmissions of diseases. During conflicts, healthcare facilities are not as capable of engaging in proper infection control practices, which have amplified outbreaks of diseases such as Ebola in the DRC, Sierra Leone, Sudan, and Uganda (Shears and O’ Dempsey, 2015). Staff were unable to engage in barrier nursing – ensuring that there was adequate protective equipment for medical staff and proper disinfection of contaminated objects – due to shortage of staff and equipment (McPake et al., 2015). The post-conflict period poses huge constraints on governments in terms of healthcare spending. Conflict often takes place in a context where existing disease control programs may have already been failing, and health infrastructures may have already been weak. Reconstruction of infrastructure and rebuilding the army, police, and administrative institutions are often prioritized first (DeRouen, 2000). Rebuilding a healthcare system is difficult in contexts of low national capacity, corruption, and past experiences with poor governance. NGOs and other agencies may try to step in to provide healthcare but will struggle to coordinate. Another issue is trying to rebuild the numbers of healthcare personnel. As many of the most highly trained heath care professionals often flee, it is difficult to reverse this loss of human capital and bring them back after a war has ended (Ghobarah et al., 2004). In the case of Sierra Leone, the post-conflict legacy severely impacted the country’s healthcare system. Capacity levels were low as there were not enough hospital beds, trained personnel, and laboratories. In fact, in the northern and southern regions of the country, the labs ceased to function at all. Low staff morale was also a problem as staff were not paid and were funded by informal payments from patients, which caused absenteeism. This made it very difficult for medical personnel to be effective in managing the Ebola outbreak, because citizens had low levels of trust of medical personnel, which was a by-product of the conflict period (McPake et al., 2015).

Case study: Syria The conflict in Syria which started in 2011 has cost over 400,000 their lives and appears to have no end in sight. Much of the medical infrastructure has been destroyed, and many healthcare workers have fled. This has had serious ramifications for Syria’s ability to fight infectious diseases. The Syrian healthcare system has been integrated into the battlefield, with both the regime and rebel groups targeting medical facilities as a tactic of warfare. As many as 40% of Syria’s ambulances were destroyed and 57% of the public hospitals damaged within three years of fighting (Stone-Brown, 2013). Hundreds of doctors have been killed which has led over 100,000 doctors to flee the country. Facilities used to produce pharmaceutical products have also been destroyed. Before the conflict, 90% of the pharmaceutical needs were produced locally, but this dropped to only about 10% within three years (Sharara and Kanj, 2014). In addition to medicine shortages, there are constant power outages that make it difficult for healthcare services to function in conflict-affected areas. Government immunization efforts have all but stopped in conflict zones. Vaccination coverage in Syria is estimated to have dropped from 91% in 2010 to as low as 45% in some regions by 2013 (Sharara and Kanj, 2014). Over half of the children born since the conflict broke out are not vaccinated. The Assad regime was uninterested in confirming reports that there were polio cases in opposition-held areas, which then impeded the delivery of vaccines to these locations. In addition to polio, other infectious diseases such as measles, hepatitis,

174  Disease and disaster vulnerability meningitis, leishmaniasis, and scabies have spread, creating a major health crisis (Petersen et al., 2013). Syria had not reported a case of polio since 1999, but by 2013 health workers started to see young children exhibiting signs of polio, a disease that is highly contagious and debilitating (Sharara and Kanj, 2014). The government, distracted by the war effort, responded in a slow and uneven manner as the cases were concentrated in areas controlled by rebel groups opposed to the Assad regime (Ismail et al., 2016). Polio is a virus that lives in sewage, water, and contaminated food and thrives in crowded and unsanitary conditions where people lack access to clean water. Sanitation and water supply in rebel-held areas have been destroyed or at least abandoned by the government. Raw sewage is pumped directly into the Euphrates River, which provides drinking water and washing water to villages. Malnourished children are especially affected (Shrivastava and Shrivastava, 2017). Measles has also swept through Syria, including Aleppo and the northern regions, with over 7,000 confirmed cases due to overcrowded and unsanitary conditions (Ozaras, 2016). Measles was then spread to neighbouring Lebanon and Jordan by refugees. Syria also faced an outbreak of leishmaniasis (which had been endemic to parts of Syria around Aleppo for decades) which then spread to Lebanon in 2013 where 96.6% of the cases were among Syrian refugees (Al-Salem et al., 2016; Sharara and Kanj, 2014).

Case Study: Yemen Yemen is a country of over 28 million people that has faced a devastating conflict since 2015. Prior to the outbreak of the conflict, Yemen was already a very weak state that struggled with poor performance on many health indicators including life expectancy (66 years) and child mortality rates (42.9/1000) (World Bank Data, 2020). In contrast, its neighbour Saudi Arabia has a life expectancy of 75 years and child mortality rates of 7/1000. Thus, Yemen was already ill-prepared to deal with an insurgency and internationalized conflict that served as a perfect breeding ground for the spread of infectious diseases. As the conflict ensued, less than 50% of the existing health facilities were functional and there was a serious shortage of medical staff, medicine, and equipment (UN News, 2017). Many healthcare workers also fled the country in the thousands since many had not received any salary (ibid.). Over 16 million people had no access to basic healthcare. By 2018, the conflict had left more than 20 million people in need of humanitarian assistance with over 7 million facing acute needs (UN OCHA, 2018). The Ministry of Public Health and Population had no operational budget which resulted in a huge disruption in public health services. Maternal and newborn services, including immunizations, were only available in 35% of the functional health facilities and the electronic surveillance system had broken down (Dureab et al., 2019). This led to an upsurge in diphtheria cases, a vaccine-preventable disease (ibid.). The conflict also led to huge population movements which further increased mortality and morbidity rates. Compounding matters, Yemen is a country that has faced numerous droughts and is one of the most water-stressed countries in the world. The WHO (2015b) reported that only 53% of the population had access to improved sanitation facilities and 55% had access to drinking water from improved water sources. Bombing had destroyed water and sanitation infrastructure, with many sanitation workers striking. A fuel shortage led to the disruption of sewage management, as a lack of electricity made it impossible to run water pumps. Saudiled airstrikes have also destroyed vital infrastructure, including hospitals and public water systems, particularly in rebel-controlled areas. With millions of people displaced and living in

Conflict  175 crowded and unsanitary conditions, the situation has not improved (Qadri et al., 2017). Over 14 million people require assistance in terms of access to safe drinking water and sanitation (UN OCHA, 2018). In October of 2016 a cholera epidemic broke out, reaching its peak in 2017. This outbreak became the largest cholera epidemic in recorded epidemiologic history (Federspiel and Ali, 2018). In total, there have been over 2  million cases and almost 4,000 deaths since October 2016. The outbreak spread at an unprecedented speed and was directly related to the country’s ongoing conflict (Blackburn et al., 2020). Cholera is particularly sensitive to conflict as it thrives in conditions of poverty, overcrowding, poor hygiene, and a lack of access to clean water (Dureab et al., 2018). Houthi-controlled areas faced a much worse cholera outbreak. As many as 77.7% of the cholera cases and 80.7% of the deaths from cholera occurred in Houthi-controlled areas, compared to 15.4% of the cases and 10.4% of the deaths elsewhere (Kennedy et al., 2017). At the same time as the cholera outbreak, Yemen also faced a famine. At least 17 million still face food insecurity, 7 million are at risk for famine, and 2 million children are malnourished making it more difficult for those fighting infectious diseases to survive (UN OCHA, 2018). Rebel control of the key port of Hudeidah, where humanitarian aid is delivered, has made it more difficult to deliver not only medical supplies and chlorine but also food to deal with the humanitarian emergency (Kennedy et al., 2017).

Case study: the Democratic Republic of Congo (DRC) The North Kivu province of the DRC has been involved in another protracted conflict. More than 70 armed groups have formed along ethnic and political lines in the mineral-rich region over disagreements regarding entitlements. Chronic conflict in the northern region of the DRC has made it almost impossible to engage in vaccinating, tracking, tracing, surveilling, and containing the Ebola virus, which has broken out yet again (the twentieth Ebola outbreak since Ebola was discovered in the DRC in 1976) (Kraemer et al., 2020; Wells et al., 2019). In fact, the DRC is experiencing one of its worst outbreaks ever, with thousands of cases and deaths. In the DRC, the health response was based on using an alert system where anyone with a mobile phone would report a case, and rapid reaction teams would be deployed to investigate, track and test patients, and then monitor anyone who may have been in contact. After attacks took place, vaccination campaigns had to be suspended. Public health responders in the region were not able to respond and follow up with those in contact with an infected individual. Complicating matters, healthcare workers have been kidnapped and targeted, with some killed and others gravely injured. The targeting of healthcare workers has a detrimental effect on vaccination efforts in particular. The sound of gun fire and mortar shells clattering all night has exhausted healthcare workers and created conditions that are not safe enough for epidemiologists and public health workers to effectively do their jobs (Maxmen, 2019). At the heart of the conflict, the town of Beni continues to treat patients, but its entire machinery to respond to Ebola has come to a complete halt. The combination of community mistrust and armed attacks are making it impossible for healthcare workers to operate. In contrast, the Ebola outbreak that took place in the conflict-free Equateur province to the west was successfully contained by a vaccination and public awareness campaign (Wells et al., 2019). Community mistrust of the government is another pressing issue (Moran, 2018). In the past the Congolese army was implicated in human rights abuses, including killings, rapes, and pillaging. Communities are unable to distinguish between healthcare workers, who work for

176  Disease and disaster vulnerability the Ministry of Health and the army. Heavy security around the disease control teams has raised suspicions that the response is being driven by political factors. High levels of distrust have caused delays in contract tracing and in isolating patients during the critical early stages of the infection. People have also been reluctant to seek diagnosis and treatment, and some have travelled into no-go zones. A family from a town near Beni spread the disease to other small towns by refusing to be monitored by health workers. Hostilities also increased after elections were postponed to limit the transmission, leading to a spike in violence (Wells et al., 2019). Politicians are not helping matters, with some proclaiming their doubts over the extent of the virus outbreak while others believe that the virus was manufactured to target a certain group of people. UN peacekeepers, NGOs, and those working in humanitarian efforts have also been treated with suspicion for failing to protect the population (Moran, 2018). To deal with this mistrust, the government has considered a number of unorthodox options, such as asking community health workers to not use ministry labels when investigating cases and using survivors of the disease who are immune to the virus to enter communities without having to use conspicuous vehicles that tie them to the government. Conflict and disasters Thus far very little has been written about how conflicts may affect disasters as it is an underresearched area. Conflicts don’t directly spark natural hazards (the indirect mechanism would be through the negative impact of militarization and conflict on climate change), but when they do strike, a conflict may limit the state’s ability to respond and provide relief and affect the resilience of the individual and community to recover. In fact, almost 60% of the deaths from disasters have taken place in states that are affected by conflict and fragile (ODI, 2019). When conflicts and natural hazards collide, the chances of disaster are much higher.

Conflict and disaster vulnerability As the chapter has already laid out, conflicts cause displacement, with many forced to flee to areas that are vulnerable to natural hazards (Siddiqi et al., 2019). As conflicts undermine the regulation of zoning laws, more people move to unsafe areas in hazard-prone locations. Thus, those living in conflict-affected countries are more likely to be exposed to a natural hazard. Conflict also affects the coping skills of individuals affected by a natural hazard. People may be living in housing that is less secure because they have been forced to move. People may lack the financial capacity due to the conflict to fortify their homes to protect them if a natural hazard strikes. Conditions of war also leave people politically and socially vulnerable to food shortages. People suffering from malnutrition due to the lack of available food will find it more difficult to survive when a natural hazard hits. A conflict-affected country may reduce the options of where people can safely flee to, forcing people to move to inappropriate lands. In the case of the mudslides that hit Colombia in 2017, almost 80% of the victims were also victims of conflict (Siddiqi et al., 2019). Violence in the Bajo Putumayo region had forced them to flee to Mocoa. Lacking resources, many people built their own homes without support from disaster planning authorities, increasing their vulnerability to natural hazards. Disasters also particularly hit refugees who are already vulnerable and defenceless against natural hazards. Many states that host refugees do not include refugees in their disaster riskreduction architecture. Vulnerabilities persist for post-conflict societies which may lack the coping options and capacity that they had in the past to bounce back after facing a natural hazard (Mason, 2014).

Conflict  177 Conflicts also make it more difficult to deliver humanitarian aid after a natural hazard hits. Roads may be impassable and violent groups may try to hijack relief aid. In the case of Pakistan, the military’s conflict with the Taliban frustrated relief efforts after the northwest region was hit by massive floods in 2010. Some humanitarian groups refused to supply aid to areas with greater control by violent non-state groups, which in turn caused splits in the wider UN humanitarian response (Mason, 2014). An ongoing war between the Liberation Tigers of Tamil Eelam (LTTE) and government forces created deeper vulnerabilities for citizens who were victims of the 2004 Tsunami. International aid to survivors was blocked by both the government and the LTTE. Due to years of conflict, only 30% of the population had access to latrines, clean water, and sanitation, making it that much more difficult to cope after the tsunami (Briggs et al., 2009). The impact of floods in 2006 that hit Somalia were also exacerbated by the ongoing conflict as relief efforts were unsuccessful in delivering sufficient food for communities due to the fighting (Menkhaus, 2007). Ethiopia has also faced recurrent droughts and food shortages that have at times been worsened by conflict. The Somali region of Ethiopia has been the worst affected as most of the inhabitants are pastoralist and agro-pastoralist communities (Devereux, 2006). Both droughts and conflict have led to high mortality rates and massive displacement, while food security issues coupled with poor health infrastructure have been a persistent problem. Measles outbreaks have taken place in remote locations that are hard for NGOs and humanitarian organizations to reach (Grais et al., 2011). Such communities were also not extensively immunized. The measles epidemic and acute malnutrition accounted for 22% of the deaths of children under 5 years and 17% of the deaths for children from 5–14 years of age among Somali refugees (Polonsky et al., 2013). As these examples illustrate, if a natural hazard strikes in the context of an ongoing conflict, this usually brings disease, malnutrition, and other serious threats to human security.

Conflict and disaster management Conflict-affected and fragile states not only struggle to protect and support citizens after a disaster strikes, but also to engage in disaster relief preparedness and mitigation. Under the demands of a conflict, disaster relief preparedness is a low priority for the government – and is not a priority at all in zones controlled by de facto states and rebel groups. Conflicts divert national and international financial resources that could be used for mitigation for the war effort (Wisner et al., 2004). States in conflict will lack the technical capacity and resources to engage in long-term disaster resilience. Conflicts disrupt the implementation of disaster risk-reduction strategies, such as investing in better infrastructure and research in disaster prevention. Conflict destroys infrastructure which intensifies natural hazards, such as when irrigation systems, dams or levees are destroyed. Conflicts also destroy the capacity of governments to collect hazard data or engage in early warnings communication. Early warning technology and communications of natural hazards may be destroyed during a conflict (Wisner et al., 2004). It is also impossible to apply local knowledge for the mitigation of risks from extreme events during conflicts (Wisner et al., 2004). Conflicts also severely affect the capacity of the state to respond after a disaster has taken place. High military expenditures shift resources away from disaster relief. Human capital is diverted to fighting a conflict rather than engaging in response strategies. Health facilities may be deliberately destroyed in the conflict, making it harder to treat those that have been injured by a disaster. Evacuations are complicated if there are landmines (Wisner et al.,

178  Disease and disaster vulnerability 2004). For political and logistical reasons, conflicts interfere with the delivery of aid, relief, and recovery. During a conflict, it’s impossible to engage in participatory methods to empower and engage socially vulnerable groups to recover after a disaster. In the case of the conflict in Sri Lanka, the civil war hampered the post-tsunami recovery efforts in the north and east, handicapping the state’s ability to provide adequate relief (Briggs et al., 2009). A 1990 earthquake in Iran that killed 50,000 people was further complicated by the conflict with Iraq (Badri et al., 2006).

Conclusion Conflict is a major challenge for human security. Like climate change, it is a threat multiplier. Disease outbreak or disaster that take place during an ongoing conflict often lead to complex humanitarian emergencies, misery, and human suffering. Conflict cripples healthcare facilities, destroys sanitation systems, kills personnel, causes tremendous displacement, and obstructs humanitarian access. All of this destruction makes it difficult for the state to respond (to be discussed in more detail in Chapters 11 and 12). And conflict does not just make it more difficult to manage disease and disasters but may lead to the spark of diseases as well. Warlords left unchecked are free to take advantage of natural resources and put people into greater contact with potential disease hosts and vectors. Complicating matters further, conflicts create massive displacement, which puts people in closer contact with one another, often in appalling conditions. The lack of sanitation and clean water facilitates the rapid spread of infectious disease to people when they are at their most vulnerable. If a natural hazard hits during this time, the threats are magnified. Conflict dramatically increases disease and disaster vulnerabilities. While the previous chapter examined how poverty creates greater vulnerabilities to disease and disaster, in the next chapter we change course to look at how diseases and disaster impact economic security. Both diseases and disasters have significant economic impact. We explain the ways in which this is the case and why threats to economic security are so intense.

Key questions 1 2 3 4 5

The chapter laid out the arguments for why conflicts spark new disease outbreaks. Do you agree with this? Do you think an argument can be made that conflicts spark disasters? What is the biggest threat that conflicts pose to disease management? What are complex humanitarian emergencies? How do diseases, disaster, and conflict create these types of emergencies? Using the case studies of the chapter (DRC, Syria, or Yemen), explain how conflict affected the epidemiology of disease. What are the biggest threats to human security facing refugees?

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Part IV

Impact of disease and disaster

8 Economic impacts

Introduction This chapter explores the economic impact of diseases and disasters. For the most part, both diseases and disasters have a negative impact on economic security. In some cases, these impacts are marginal, while in other cases the impact is far-reaching and long-lasting. Pandemics, for example, have the potential to be more devastating than wars and financial crises. Some pandemics are referred to as black swan events – a term used in the world of finance to indicate an event of enormous economic magnitude that is an outlier with low probability of taking place (Taleb, 2007; Walter, 2020). There is no agreement, however, on whether or not Covid-19 fits this label (Murphy et al., 2020; Sanmarti, 2020). Nevertheless, Covid-19 has been the most expensive pandemic in history thus far, costing the global economy in the trillions and counting because of the enormous levels of economic disruption. Endemic disease presence also has a negative impact and plays an important role in causing poverty traps (or economic insecurity) to persist. As far as disasters go, some of the most expensive disasters in history have been earthquakes, some at a magnitude that may constitute a black swan event (Asongu, 2012). Two out of the three most expensive earthquakes in history took place in Japan, with the 2010 earthquake and tsunami costing over $360 billion and the 1995 earthquake costing $131 billion. The 2008 earthquake that took place in China was also costly, costing the country $148  billion. Flooding is the most common disaster (accounting for 43% of all recorded events in the last 20 years), and the costs can be quite extensive (Myers, 2016). Hurricanes and cyclones are the second most frequent (accounting for 28% of all recorded events), and in the last several decades hurricanes and cyclones have become increasingly expensive. A series of three hurricanes that hit the US in 2005 (Katrina) and 2017 (Harvey and Maria) cost the US over $350 billion. But while these events incur huge costs, it is not clear that disasters impact economic growth rates significantly. We explore why that may be the case. While disasters don’t necessarily impact macroeconomic indicators, they do cause greater poverty rates at the household level. The results on how disasters impact inequality are mixed. As the chapter will lay out, the costs that diseases and disasters impose are both direct and indirect. A direct cost may come from the disease/disaster event itself, such as to loss of life, capability, and any direct impact on infrastructure. Indirect costs arise from long-term factors, such as costs incurred with the destruction of business activity due to the inability to access roads or the costs to the airline industry of fewer people wanting to fly. These losses include the cost of business interruption caused by disruptions of water or electricity supplies and longer-term consequences of infrastructure and capital damages, such as is the case with

DOI: 10.4324/9781003128809-13

188  Impact of disease and disaster disasters. Before exploring these relationships, we define economic growth and economic inequality (for a definition of poverty both at the national level and the household level, see Chapter 6). Key concepts Economic growth is simply the increase in the production of goods and services over time. It is the quantitative rise in the scale of physical dimensions of the economy and is used to calculate the strength and momentum of an economy (Daly, 1987). Economic growth is also the measure most often used by economists to demonstrate that economic development is taking place. This is done by looking at growth in gross national product (GNP) – the total value of all finished goods and services that are produced in a given financial year, whether businesses/ citizens were located domestically or abroad; or by looking at the growth in gross domestic product (GDP) – the total value of all finished goods and services in a given financial year that are produced domestically (Salvatore, 2012). We focus on both global economic growth rates and domestic rates of growth. Economic inequality is much more complicated and controversial to measure and define. In short, inequality constitutes disparities in income and wealth. The GINI index is often used to measure income inequality (or the inequality in the distribution of household income among the population of one country), but it does not take into account the disparities in wealth and assets (Chakravarty, 1988; Cornia, 2004). Thus, it is not capturing inequality in land ownership, inequality in education, or inequality in healthcare which have far-reaching effects on human security. For example, a child born in countries that perform poorly on health indicators is 60-times more likely to die than a child born in a country with the best health. (Our World in Data, Inequality, 2020a). There are also three different levels of inequality. Economic inequality takes place between countries (with Luxembourg having the highest nominal per capita income rate and Burundi having the lowest, according to the IMF in 2020). Overall, inequality between countries is declining slightly (World Bank, 2016). Economic inequality also takes place within countries, with some of the highest inequality rates in the world in Latin America and parts of Southern Africa. Inequality within countries is a constant concern and continues to rise (ibid.). Additionally, there is global inequality which refers to the differences between all individual people in the world (Cornia, 2004). According to the World Economic Forum, the richest 1% have more than double the wealth of 6.9 billion people (Whiting, 2020). The facts on gender are also disheartening, as the world’s 22 richest men have more money than all of the women in Africa. Nevertheless, the focus of this chapter is primarily on inequality within countries and less so on the global level. Economic impact of diseases While pandemics and epidemics have taken place regularly in history and more frequently as of late, they are more unpredictable than diseases that are endemic to a region. Additionally, though earthquakes have occurred throughout history, they are also harder to predict than storms that can be monitored by meteorologists which offers more time to board up infrastructure. For the most part, economists have been in agreement that it is the unpredictable disease events like pandemics and epidemics that have the potential to be the most economically catastrophic for countries (Barro et al., 2020; Jordà et al., 2020; McKibbin and Sidorenko, 2006).

Economic impacts  189 An infectious disease crisis such as a flu pandemic could cost economies billions if not trillions in total losses when taking into account mortality costs. The World Bank estimated that the costs of a flu pandemic similar to the 1918–1919 flu would cost about 5% of the global GDP or about $3 trillion (Burns et al., 2006). Another widely cited study estimated that the global economic cost of a 1918–1919 type pandemic would be close to 12.6% of GDP with the greatest impact on non-OECD countries (McKibbin and Sidorenko, 2006). In a more recent assessment, it was found that, at a global scale, a moderately severe influenza pandemic would cost of 0.6% of global income (due to income loss and mortality) (Fan et al., 2018). This is particularly the case since few countries were compliant with the IHR of 2005, leaving them unprepared for infectious disease breakouts (for more on this, see Chapter 11). For many years, however, there was no consensus in the literature on the economic consequences of diseases that are endemic to a particular region. In the 1980s, for example, when the HIV/AIDS epidemic gained momentum, a number of researchers believed that its effects would be marginal at most on macroeconomic outcomes. Some researchers even argued that the decreases in population growth due to HIV/AIDS would lead to increases in GDP per capita. The World Bank’s René Bonnel, for example, wrote in a paper on the impact of HIV/ AIDS on economic growth, ‘In some cases as Botswana, per capita income was projected to increase as a result of HIV/AIDS’ (Bonnel, 2000, 2). And as one 1997 study put it, ‘there is more flash than substance to the claim that AIDS impedes national economic growth’ (Bloom and Mahal, 1997, 120). Despite these initial assessments, the negative economic consequences of HIV/AIDS as well as other endemic infectious diseases are now widely accepted. For example, one study demonstrated that the economy of Botswana is 20% smaller in the twenty years since the AIDS epidemic began than it would have been (Jefferis et al., 2008). Thus, the chapter will explain the impact of the unpredictable disease events with pandemic potential (such as Covid-19, SARS, Ebola, MERS, Zika) but also endemic infectious diseases (such as HIV/AIDS, malaria, TB, and other neglected tropical diseases). All infectious disease scenarios affect economic outcomes in several ways: they impact macroeconomic indicators such as GDP growth and GDP/capita; they also impact poverty rates, driving more people deeper into poverty; moreover, because diseases affect the poorest households the most, they also impact inequality rates.

Diseases and economic growth It is not surprising that a massive disease event could have a negative impact on economic growth; however, it is now widely agreed that diseases that have become endemic to certain regions have had significant impacts on economic growth as well (Chima et al., 2003; Gallup and Sachs, 2001; McCarthy et al., 2000; Sachs and Malaney, 2002). Much of the impact comes from lower levels of labour productivity, lower levels of investment, and decreased tourism receipts. With surprise disease events the economic impacts are far-reaching. Almost every sector of the economy can be affected, while unemployment rates skyrocket. The following goes over how diseases can impact economic growth. After several decades of denying the economic impact of endemic diseases, studies in the last several decades have highlighted the negative impact (Dixon et al., 2001; Greener, 2002; McDonald and Roberts, 2006). The overall impact of AIDS on the macro-economy is small at first but increases significantly over time. HIV/AIDS has caused declines in per capita income of about 20% (Dixon et al., 2002). A simulation model of the economy of Cameroon concluded that the annual growth rate of GDP could have been reduced by as much as two percentage points during the 1987–1991 period because of AIDS (Stover and Bollinger,

190  Impact of disease and disaster 1999). Malaria also imposes huge costs to a country’s income, economic growth, and the long-term level of economic development, slowing growth by up to 3% a year (Gallup and Sachs, 2001). Other studies have noted that the malaria penalty to GDP ranges from 0.41% in Ghana to up to 8.9% in Chad (Okorosobo et al., 2011). In sub-Saharan Africa, malaria is believed to cost over $12 billion each year and GDP per capita is thought to be about a third less than it would have been had malaria been eradicated in 1960. Some researchers estimate that per capita growth rates would increase by over 1% in malaria-prone states if health conditions were to improve (Gallup and Sachs, 2001). NTDs also impose huge costs to low- and middle-income countries, causing up to $7 trillion in economic losses between 2011 and 2025 (Bloom et al., 2011). A comparison of the levels of development in states with malaria versus those without it is telling. In 1995, the average GDP per capita of states with malaria was about $1500; it was more than five times that number in states without it. In fact, in more than a third of states with intense strains of malaria, growth rates were actually negative from 1965 to 1990 (Ezrow et al., 2015). Furthermore, the development trajectories of states that have eradicated malaria illustrate the impact. The southern region of the US, for example, has traditionally been significantly poorer than the rest of the country. It was not until malaria was eliminated from the South that it began to catch up. In 1950 when malaria still existed, the South had only 60% of the per capita income of the rest of the US; this number rose to 68% by 1960 when malaria no longer existed (Barro et al., 1991). Additionally, Taiwan and Jamaica were able to surpass their neighbours economically after they were able to eradicate malaria (in 1961 and 1958, respectively). In Nepal, as well, the southern plains, called the Terai, were uninhabitable until malaria was eradicated in the early 1950s; now the Terai is the richest and most agriculturally productive part of the country (Gallup and Sachs, 2001). The biggest impacts to the global economy have come from ‘surprise’ disease events that become pandemics.1 In many studies of pandemics, analysis has understandably focused on short-term impacts but these impacts are immense (Jordà et al., 2020). All parts of the economy face disruption – agriculture, manufacturing, and especially services. There are also concerns of shortages and rise in prices of staple goods. The question with pandemics/epidemics is whether or not it will lead to economic scarring or the accumulation of economic scar tissue (Baldwin and di Mauro, 2020). Economic scarring (which used to be referred to as hysteresis) is an economic term that refers to how transitory economic conditions can affect long-term growth. Thus, in contrast to the economic effects of endemic diseases that are constant, surprise disease events constitute potential cases of scarring due to the fact that the economic impact may last longer than the duration of the outbreak. Before Covid-19 one of the most significant disease events was the SARS pandemic. The total cost of SARS was over $54 billion, wiping $40 billion off of world markets (Oberholtzer et al., 2004). Others say the costs were as high as $100 billion to the world economy, with costs of $48  billion in China alone (McKercher and Chon, 2004; Siu and Wong, 2004). With Covid-19, the overall impact of the pandemic is unknown, but there have been some early predictions made. The OECD predicts a massive slump in the biggest economies, with all countries facing a long haul back to previous levels of activity. Within six months of the discovery of the virus, GPD growth was down by 12.1% in the Euro area and 11.9% in the European Union (Eurostat, 2020). In the Germany and the UK, economic growth fell by over 10% by August of 2020 (ibid.). While many European countries are facing contractions of double digits, the US economy shrank by an annual rate of 32.9% between April and June, the biggest contraction since WWII (Rushe, 2020).

Economic impacts  191 There are also huge regional economic impacts of disease epidemics even if they don’t reach pandemic potential. The economic impact of the Ebola virus in West Africa was enormous, with a total loss estimated to be $2.8 billion for the three most affected countries and approximately $500 million across the rest of the continent (World Bank, 2015). This also impacted growth rates. At the beginning of 2014, it was expected that growth in Liberia would be 5.9%, in Sierra Leone 11.3%, and in Guinea 4.5%. Instead, actual growth was only 2.2% in Liberia, 4% in Sierra Leone, with shrinking growth rates in Guinea. The impact on Liberia was so harsh that more than 70% of households reported that they did not have enough money to purchase food (Kastelic and Kastelic, 2015). More recent estimates claim that the crisis cost closer to $54 billion, or more on par with the costs of SARS. This new estimate comes from looking at the impact of deaths that came from non-Ebola causes which amounted to almost $19  billion (Huber et al., 2018). This could refer to the losses from deaths and illnesses that resulted from avoiding hospitals and clinics for routine immunizations and check-ups (for more on this, see Box 8.1). Thus, scholars argue that some of the economic costs of disease outbreaks are likely to arise out of individual preventive actions rather than from direct infections (Philipson, 2000). The reduction in demand caused by avoidance of activities and prophylactic workplace absenteeism (avoiding going to work to prevent getting sick) could exceed the economic impact of direct morbidity and mortality for some epidemics. Public opinion surveys showed that 23% of respondents in Hong Kong thought they were very likely or somewhat likely to become infected with SARS even though there was a post infection rate of 0.0026% (Leung et al., 2004). In Taipei, 74% of those surveyed thought that there was a high likelihood of dying from SARS even though the mortality rate was 11% (Liu et al., 2005). Even in the US, 16% felt that they or their family members would become infected with SARS over the next 12 months during the height of the epidemic (Brahmbhatt and Dutta, 2008). In contrast to endemic diseases, pandemics/epidemics are much more impacted by the interconnectedness of the global economy and lockdowns (and other blunt non-pharmaceutical interventions). The response to a pandemic leads to actions that have far greater economic costs than the direct costs associated with the disease event. There are huge economic costs when there are uncoordinated efforts of millions of individuals trying to avoid infection (Brahmbhatt and Dutta, 2008). These include the closing of international borders, the cancelling of holidays and conferences, the disruption of trade, and the banning of importation of consumer goods from afflicted countries. These interventions can be controversial due to the negative economic effects but may be necessary in cases where countries are unable to effectively track and trace. For example, in a study of the 1918–1919 flu, it was demonstrated that cities that employed non-pharmaceutical interventions early in the pandemic grew faster after the pandemic ended because of the number of lives saved (Correia et al., 2020). Nevertheless, if policies are adopted but compliance is low, there will be limited impact; or if lockdowns take place in a staccato fashion, they will be ineffective (Gurdasani et al., 2020). Thus far, due to these lockdown measures, Covid-19 is causing economic disruption at unprecedented speed and scale (Baldwin and di Mauro, 2020; Gopinath, 2020; Lilley et al., 2020). If a pandemic outbreak leads to school closures (more on the impacts of school closures in Chapter 8), this can have serious negative consequences for the economy. A study of one week of school closures in Taiwan during the swine flu outbreak found that 27% of families could not go to work, with 18% losing income as a direct result (Chen et al., 2011). An estimate in March of 2020 in the UK suggested that protracted closures could cost 3% of UK GDP (Adams, 2020).

192  Impact of disease and disaster With pandemics, it is the service sectors (travel, tourism, beauty, restaurants, cinemas, etc.) that are the hardest hit, with other sectors varying by country. Many countries in which tourism is relatively important could potentially be affected more severely by shutdowns and limitations on travel. At the other extreme, countries with relatively sizeable agricultural and mining sectors, including oil production, may experience smaller initial effects from containment measures, although output will be subsequently hit by reduced global commodity demand. Shutting down businesses for two months would mean that 30% of European firms would face severe liquidity issues (Demmou et al., 2021). During normal times, firms exist and enter the economy in an efficient manner – with non-productive firms exiting while productive firms enter and remain. In a pandemic, there are a large number of viable firms under threat. This means that a large amount of capital (both job specific and organisational) dissolves when the firm goes under. As businesses are forced to close down in the wake of a surprise disease outbreak, this can lead to skyrocketing unemployment rates. During the first wave of the pandemic (spring of 2020) more than 20  million were unemployed in the US, and the unemployment rate may have been as high as 16% (Kochnar, 2020). By December of 2020, the number of unemployed fell to 10.7 million with 6.7% unemployed (US Department of Labour, 2021; US Bureau of Labour Statistics, 2021). The UK faces up to 2.6 million unemployed by mid-2021 (King, 2021). In the case of SARS, even after it was contained, unemployment in Hong Kong continued to increase, growing to 8.7% by July 2003 (Siu and Wong, 2004). Tourism, in particular, is negatively affected by surprise disease outbreaks (Gössling, 2002; Page and Yeoman, 2007; Gössling et al., 2020). In the case of SARS, losses to the tourism sector in Beijing alone amounted to $1.4 billion, or 300 times the direct cost of medical treatment for SARS cases in the city (Beutels et al., 2009). International visitor arrivals in Hong Kong dropped by 65% from the previous year’s figure during April and airlines consequently had to cancel flights (Pacific Asia Travel Association, 2021). Between March and April 2003, total visitor arrivals fell by 63% (Noy and Shields, 2019). MERS also affected tourism to Saudi Arabia costing over $5 billion, while MERS cost South Korea a 10% drop in accommodation (ibid.). Swine flu did major damage to Mexico’s tourism industry, costing $2.8 billion (Rassy and Smith, 2013). Though Ebola did not have a massive impact on economic growth rates in the rest of Africa, the effects were far-reaching in terms of tourism. Travel bookings fell across Africa by up to 70% even in places that were thousands of kilometres away from the outbreak (Das, 2016). In the case of Covid-19, the impact on tourism and the travel industry has been even more catastrophic. By March 2020 the British airline FlyBe had declared bankruptcy (Perper and Slotnick, 2020). Other major airlines have requested tens of billions in state aid, noting that the situation is far more severe and grave than the impact of 9/11. Compared to other disruptive events, none have led to long-term declines in tourism, with only SARS causing a slight drop in international arrivals (Karabulut et al., 2020). Covid-19 may have a much longer and unprecedented impact on the tourism industry. The World Travel and Tourism Council (WTTC) has warned that 50 million jobs in the global travel and tourism sector are at risk due to cancellations (Nicola et al., 2020). The World Tourism Organization (UNWTO) has projected a 20–30% drop in international arrivals in 2020 that would translate into losses of tourism receipts of US$300–450 billion, though this could be as much as $2.1 trillion in 2020 (Gössling et al., 2020). Tourism also suffers when endemic infectious diseases are widespread, robbing states of reaping the benefits of another source of income. For example, Greece, Spain, and Italy now

Economic impacts  193 generate significant income from their tourism industries. But this was not always the case. All three states had issues with malaria, with Greece the hardest hit. Prior to malaria eradication efforts that all three undertook in the 1930s and 40s, their tourism industries were underdeveloped and there were few tourists. Once malaria was eliminated, however, they were able to stimulate demand for tourism and tap into the tourism industry as a revenue generator (Sachs and Malaney, 2002). Pandemics also pose huge challenges to the hospitality industry, through the enforced shut down of hotels, restaurants, bars and cafes – virtually all parts of the hospitality chain. These industries are likely to bear the brunt of surprise outbreaks (Nicola et al., 2020). Though these businesses may be able to eventually resume, there is no way to catch up. When people avoid restaurants and the cinema during a lockdown, there is a low likelihood that they will go twice as much once social distancing measures are no longer in place. The cancelling of events and shutting down of attractions is immediately felt in all parts of a supply chain, affecting catering and laundry. MERS in South Korea cost a 10% drop in food sectors in 2015. With SARS in Hong Kong, the retail and hospitality industries were also negatively impacted (Siu and Wong, 2004). Not surprisingly, hourly workers face the biggest hardships. It has also led to serious liquidity problems in much of the industry (Gössling et al., 2020). Pandemics also have the propensity to lead to supply shocks with disruptions in trade. A supply shock in one nation or industry can lead to a supply shock in other industries and nations – such as when an input necessary to make a product is no longer producible. For example, manufacturing giants such as China, Japan, and South Korea account for 25% of US imports and over 50% of US imports of electronics. China is also the US’s biggest source of medical devices (Noy and Shields, 2019). Any disruption could therefore have serious impacts on US companies. International trade disruptions increase the costs of doing trade – air cargo capacity decreased by 25% from February to August of 2020 and over 10% in 2020, compared to the previous year (IISD, 2020; Polek, 2021). Disease outbreaks of zoonotic origin can lead to disruptions in trade due to the abrupt banning of products. When there was a Rift Valley fever virus in the late 1990s, Saudi Arabia and Yemen banned live animal exports from nine African countries. With 90% of Somalia’s total income coming from livestock exports, this caused a loss of over 75% of exports for a total of $300  million (Smith et  al., 2019). The 1998 Nipah virus outbreak in Malaysia (which led to 109 deaths), cost the government $97 million in compensation for the culling of 1.1 million pigs and $229 million in indirect costs in lost tax revenues and losses in international trade, with total costs closer to $582 million (Kulkarni et al., 2013; McLean and Graham, 2019; Tee et al., 2009). Pork exports dropped by 80% during the outbreak and remained reduced by 30% in the long term (Smith et al., 2019). Swine flu cost Mexico’s pork industry $27 million by the end of 2009 (Rassy and Smith, 2013). The MERS outbreak in South Korea led to a huge drop in the country’s exports, with the economy growing only at 0.3% in the second quarter of 2015, a six-year low (BBC News, 2015). After the occurrence of avian influenza, the consumption of poultry products fell by more than 80% on average in the market of Jilin province in China, affecting the income of many farm workers (Zhang and Liu, 2016). Infectious diseases (whether endemic or epidemic/pandemic) also have a huge impact on labour productivity, which is critical to economic growth both directly and indirectly. In the case of pandemics, the costs to labour are often indirect. Much of the costs associated with pandemics come from the shuttering of businesses that leave many employees facing furloughs or redundancies. This can have knock-on effects of capital depreciation as employees lose their skills and suffer from mental health effects, an example of economic scarring

194  Impact of disease and disaster (Arulampalam et al., 2003; Tumino, 2015). Some of the costs to labour productivity are also direct, stemming from the afflicted losing time that they can work. As endemic diseases are a constant concern, their impact on productivity is more farreaching. Many infectious diseases kill or impair individuals who are often in the prime of their lives. With Ebola, the age group of 15–44 years, or those engaged in the labour force and parents of young children, accounted for 57% of all infections, with 16,000 children losing their parents (Smith et al., 2019). HIV/AIDS has had a particularly harsh toll on adults in their most productive stage. AIDS is the leading cause of death for those between the ages of 10–24 years in Africa and the second cause of death globally (Avert, 2020). As a result, infectious disease outbreaks mean more days of the year in which potential workers must stay home. NTDs like hookworm have a huge impact on worker productivity and the number of days that those affected can work (Hotez, 2008). Though few adults end up dying from malaria, it is nearly impossible to work while suffering from the disease (Singh et al., 2019). It has been well-documented, for example, that US efforts to build the Panama Canal in the early 20th century were stalled due to malaria outbreaks and did not gain momentum until malaria became controllable (Dehné, 1955). As HIV/AIDS compromises immune systems, making those afflicted prone to repeated infections, this makes it difficult to work if the disease is in its more advanced stages. In a sugar mill in South Africa, for example, more than a quarter of all workers tested were HIV positive in a 1999 study; these workers took 55 additional days of sick leave during the last two years of their lives than their healthy counterparts (Bollinger and Stover, 1999). Because so many adults die from HIV/AIDS it also reduces the pool of available workers, many of whom only recently entered the work force. These deaths occur to workers in their most productive years. As younger, less experienced workers replace these experienced workers, worker productivity is reduced. During the height of the AIDS crisis in the early 2000s, it was estimated that some southern African countries would lose between one-quarter and one-third of their skilled and educated population (Lisk, 2002). Much of these losses affected the education sector and the health sector (for more on this, see Chapter 8). In South Africa for example, a 2000 report showed that 20% of student nurses working in the healthcare sector were HIV positive (Altenroxel, 2000). One of the industries most affected by infectious diseases is agriculture. Agriculture is the largest sector in most African economies (and economies in the developing world) accounting for a large portion of production and a majority of employment. Infection disease outbreaks mean that fewer workers are available to harvest food which leads to increases in costs of basic food items. This can be true of cases of surprise disease outbreaks in the short term but endemic diseases as well. In the case of the Ebola crisis in Liberia, rice harvest fell by 25% due to the lack of workers and fear of people meeting in groups (Das, 2016). Studies of AIDS have shown that the virus has had adverse effects on agriculture including loss of labour supply during crucial periods of planting and harvesting (Barnett et al., 1995; Tibaijuka, 1997). In countries where food security is an issue, any declines in production can have dire consequences. Farmers may also be more likely to switch to less labour-intensive crops, which may affect cash crops for exports. A past study showed that the death of a breadwinner due to AIDS in the case of Zimbabwe could cut the output of maize in small-scale farming and communal areas by 61%, cotton by 47%, and groundnuts by 37% (Stover and Bollinger, 1999). Malaria also affects agricultural productivity, particularly because there tends to be high levels of malaria during the farming season (Attanayake et al., 2000). This can cause changes in planting patterns to minimize the overlap between peak agricultural work and malaria season, which impacts agricultural productivity (Asenso-Okyere et al., 2011).

Economic impacts  195 The effects of low levels of productivity leads to other economic issues that impact economic growth and balance of payment concerns. Low levels of domestic productivity rates lead to a reduction in exports, while imports of expensive health products may increase, leading to a balance of payment pressures. In cases where export sectors that constitute strategic sectors of the economy, such as mining in South Africa, the impact of productivity issues is severe. A shortage of workers also leads to higher wages, which leads to higher domestic production costs. Higher production costs lead to a loss of international competitiveness, which can cause foreign exchange shortages. Another reason why infectious diseases are economically detrimental is that they decrease investment. Typically, this is more pertinent to endemic disease areas, but pandemic disease events can also cause huge drops in private investment. The Covid-19 crisis could see huge drops in investment. One study estimated that if private investment were halved it would reduce investment by about 7–9% of GDP which would have an impact on potential output (Demmou et al., 2021). Investors also tend to avoid putting their resources in places where infectious diseases are endemic because there is simply too much economic uncertainty to make it worth their while. A study found that in the median sub-Saharan African country, foreign direct investment (FDI) would increase by as much as 33% if malaria and HIV/AIDS were to be eradicated (Azemar and Desbordes, 2009). A London-based mining and metal company that opted to invest $1.4 billion to construct an aluminium smelter in Mozambique demonstrates the risks. Within two years there were 7,000 cases of malaria among employees and 13 deaths due to the disease (Rosen et al., 2003). Not surprisingly, HIV/AIDS prevalence has also deterred investment. Businesses have to dedicate more resources to healthcare for sick employees, training workers to replace employees on sick leave, and covering sick-leave allowances. In fact, there is even a term for the high costs of running a business in HIV/AIDS-endemic areas: the AIDS tax (ibid.). In the pre-ART era, this accounted for as much as 10.8% of total compensation costs (Feeley et al., 2009). In the post-ART era, the AIDS tax is estimated to be about 1–2% (Rosen et al., 2007). Businesses also face huge costs in dealing with deaths of employees. These costs include the time needed to recruit and train new workers. Businesses also deal with labour absenteeism due to illness or caring responsibilities or time off needed to attend funerals and grieve. Labour turnover can lead to a less experienced labour force that is less productive. One study examining several firms in Botswana and Kenya showed that the most significant factors in increased labour costs were absenteeism due to HIV or AIDS and increased burial costs (Song’ony, 2008). Others have noted that the biggest expense was due to healthcare costs (Rosen et al., 2004). Research on the impact of HIV/AIDS on corporations and national economies has documented the magnitude of morbidity and mortality within the workforce. By the mid-1990s, researchers were recording rising mortality rates within the workplace in African countries with high HIV prevalence; it was assumed that these deaths were related to HIV/AIDS illness (Biggs and Shah, 1997; Dorrington et al., 2001). In Zimbabwe, by the mid-1990s, the Railway Corporation had an annual employee turnover rate of 15%, with more than 10% of the workforce dying from AIDS-related illness. Similar effects were noted throughout the region. Barclays Bank of Zambia, for example, lost more than a quarter of its employees to the disease during the height of the crisis (Poku, 2002). Firms face productivity losses as well as higher costs (the so-called ‘AIDS tax’) as a result of increased benefits and training requirements. Numerous studies have calculated the extent of negative impact in individual firms (George et al., 2014; Rosen et al., 2004; Rosen et al., 2007; Simon et al., 2000). These

196  Impact of disease and disaster diseases affect not just those who are infected, but also their caretakers, who are often forced to stay home from work as well. The cumulative effect is that infectious diseases hurt labour productivity and economic output.

Diseases and poverty Both surprise disease events and endemic infectious diseases impact poverty rates, though much more work has been done on the impact of endemic diseases. What we can observe is that extreme poverty is suffered disproportionately in areas where infectious diseases thrive (Farmer, 2001; Jong-Wook, 2003). Many endemic diseases are diseases of poverty, which are both driven by poverty and drive people further into poverty (or poverty traps). While studies have shown that countries that have endemic diseases are more likely to be poor (Wooral et al., 2005; Gallup and Sachs, 2001), there is also evidence that an increase in communicable diseases lead to increases in poverty headcount in a panel of selected countries (Anser et al., 2020). There is also an abundant literature that has confirmed that diseases like HIV/AIDS, TB, and malaria impose huge costs at the household level (Bi and Tong, 2014; Chuma et al., 2010; Sharma, 2003; Spence et al., 1993; Whiteside, 2002; Worrall et al., 2005). The prevalence of malarial infection largely affected the poorest households as compared to those which are less impoverished (Were et al., 2019). Additionally, the economic burden of malaria in proportion to the annual income of the household was significantly higher among households with low socio-economic status than among households with middle or high socioeconomic status. For example, at the household level, a study in Ghana found that malaria consumes 34% of the income for the poor whereas the rich spend only 1% of their income (Teklehaimanot and Mejia, 2008). A study looking at the impact of malaria in Kenya and Nigeria found that malaria costs as much as 18% of annual income in Kenya and 13% in Nigeria (Onwujekwe, 2013). HIV/AIDS has also posed a tremendous burden on poor households. A study examining the costs of AIDS in Cote d’Ivoire found that the average household spent 80% of their medical expenses when a household member became ill, while seeing a serious drop in their income levels (Bollinger et al., 1999b). Up to 70% of households reported that their incomes dropped significantly during the Ebola outbreak (UNDP, 2014). AIDS also has a negative impact on rural household food security and income and worsens rural poverty (Gillespie and Gillespie, 2006). NTDs also pose a serious problem for the poor. Diseases like onchocerciasis and trachoma cause blindness, making it more difficult to generate income. Leprosy and lymphatic filariasis cause deformities that hinder all chances of economic productivity. Sleeping sickness can cause severe disabilities before it eventually kills its victims. Chagas disease can cause young adults to develop heart conditions, putting them in hospitals rather than in the labour force. Chronic hookworm infection in childhood can reduce future wage-earning capacity by 43% (Bleakley, 2009). A study in Orissa, India, showed that people with chronic lymphatic filariasis lost 68 working days per year, leading to a huge loss in income (Banerjee and Duflo, 2007). Poor households also are less likely to get medical treatment for themselves or their children (ibid.). Households also suffer a disease burden, as one of the breadwinners may no longer be able to generate income (which is more likely with TB and HIV/AIDS), and they must dedicate both time and resources towards dealing with sick family members. In fact, in sub-Saharan Africa, anywhere from 70–90% of all sicknesses are dealt with at home and not in the hospital

Economic impacts  197 (Hopkins et al., 2007; Roy et al., 2016; Trape et al., 2002). Family members helping sick relatives lose wages because they cannot attend work (or go to school if they are a student), precisely at a time when they have more expenses due to treatment costs. AIDS and TB, in particular, can also strike the family’s primary source of income which leads to losses associated with the illness or the victim and those needing to care for the sick patient. In a worstcase scenario, the patient dies which imposes funeral expenses along with permanent losses of income if the patient was the main breadwinner. The death of a family member because of AIDS also leads to a reduction in savings and investment. Diseases also impose significant direct healthcare costs, such as seeking consultation and testing, attaining drugs needed for treatment, and expensive hospital stays. Patients and their families face expenses that are immediate and unpredictable, commonly forcing them to borrow money or sell any assets they have. A study conducted in South East Nigeria reported that the cost of malaria treatment among adult patients was significant (Onwujekwe et al., 2010). In Uganda, the economic impact of HIV-related deaths was stronger than other types of deaths, as households lost much of their savings in order to pay for healthcare and funeral expenditures. In Ethiopia, a small study of 25 AIDS-afflicted rural families found that the average cost of treatment, funeral, and mourning expenses amounted to several times the average household income (Bollinger et al., 1999a). Similarly, a study on Côte d’Ivoire showed that households with an HIV/AIDS-infected family member spent twice as much on medical expenses as other households (Stover and Bollinger, 1999). This leaves households with fewer resources to devote to education costs or investments. TB also has an impoverishing effect because many tuberculosis patients cannot afford to pay for treatment. For poor patients in Malawi, the total cost of tuberculosis treatment accounted for 248% of monthly expenditure compared with 124% of the monthly expenditure of better-off patients (Kemp et al., 2007). There are also large medical expenditures associated with TB diagnosis that affects the poorest households most (Liu et al., 2020). A study of TB cases in Ethiopia found that 48% and 35% of annual household income was lost due to TB treatment and pretreatment costs, respectively (Vassall et al., 2010). There are also costs that come from travel to clinics and lost days of work in seeking a diagnosis, which can take time. In Malawi, TB patients lost an average of 22 workdays, while in Zambia patients missed on average 18 workdays while waiting to be diagnosed with TB (Barter et al., 2012). Travel costs were also significant in terms of time and money, particularly for those living in rural areas far from clinics, to achieve a diagnosis and treatment (ibid.). Coping strategies to deal with these costs include reducing food consumption, which has other negative knock-on effects, and selling assets or borrowing. Tasks are reallocated to other household members, which means that children may be removed from school to either work or take care of a sick parent (McIntyre et al., 2006).

Box 8.1  Disease, disaster, and education One of the reasons why infectious diseases have a big economic impact is that they lead to slowed growth of human capital. This takes place primarily through their impact on the education levels of those affected, but also indirectly when students are taken out of school or are malnourished due to a loss of income and rising costs. Children who become infected with infectious diseases, such as malaria, diarrhoeal diseases, or other

198  Impact of disease and disaster NTDs, may also be too ill to attend school. Water-based and water-borne illnesses are particularly problematic. Each year, children lose over 440 million school days because of these type of illnesses, 272 million days of which are for diarrheal diseases alone. Studies have also demonstrated that hookworm infections may reduce school attendance by as much as 20–30% (Bleakley, 2003). In addition to the impact of absenteeism, children who are afflicted with diseases face long-term challenges. Chronic bouts of malaria negatively affect cognitive development and can lead to anaemia, renal damage, and appetite suppression, all of which lower classroom productivity levels and student attendance. Many NTDs may not cause high mortality rates, but they have often long-term devastating effects on education. Diseases, such as worm infections, can have serious impacts on children’s physical growth and cognitive abilities, affecting memory, reasoning ability, and reading comprehension (Hotez et al., 2004). Much of the effects are attributable to anaemia, because the disease causes intestinal blood loss (Hotez and Kamath, 2009) and because the disease aggravates malnutrition (Roche et al., 2010; Stephenson et al., 2000; Walton and Allen, 2011). In addition to loss of blood, chronic hookworm can cause pain all over the body, nausea, headaches, and fatigue. As a result, studies have argued that children infected with hookworm advance through school at a slower rate (Nokes and Bundy, 1994). Upwards of 90% of the 50 million school-aged children that have been infected with hookworm are also at greater risk of being infected with malaria at the same time (Brooker et al., 2006). As a contrast to this, states that do not suffer from widespread infectious diseases have better educational outcomes. For example, many states that have been able to eradicate malaria, like Sri Lanka and Paraguay, saw their educational attainment and literacy rates skyrocket afterwards (Lucas, 2010). Pandemics also have a negative impact on poverty, and will likely increase income inequalities as well. A 2006 study found that Americans born or in utero during the 1918–1919 flu, exhibited reduced educational attainment, higher rates of physical disability, lower levels of income, lower socioeconomic status, compared to other cohorts born in similar locations and circumstances (Almond, 2006). The long-term impact of Zika virus has not been easy to quantify as yet on educational levels and future earnings, but those born with microcephaly (a condition of the disease) will have lifelong learning issues due to impaired cognitive development, delayed motor functions and speech, and difficulties with coordination and balance. The Zika virus outbreak in Brazil may leave a generation of children born with neurological disorders that will impose lifelong limitations (Ribeiro and Kitron, 2016). On a positive note, the percentage of children born with microcephaly to mothers who contracted Zika is lower than originally thought, at 4–6%. However, researchers are finding that some children are born asymptomatic and develop problems later on, such as suffering from seizures and other issues with brain development (Huang, 2019). Studies have demonstrated that disasters affect education outcomes (Shah and Steinberg, 2017). A study of the 1976 Guatemalan earthquake found that it negatively affected school completion rates (Stein et al., 2003). The 1998 earthquake in Nepal also led to reductions investment in education, which reduced school participation (Paudel and Ryu, 2018). Hurricane Mitch and Tropical Storm Agatha caused a drop in student enrolment in Central American countries affected (Adelman and Székely, 2016) while El Salvador’s 2001 earthquake depressed school attendance (Santos, 2010). Recent

Economic impacts  199 studies have shown that floods are disastrous for education for those who experience these phenomena during their early years of life (Caruso, 2017; Garbero and Muttarak, 2013). The impact of disasters can impact females more than males. A study looking at flooding in Indonesia found that for girls experiencing a high level of flooding during early childhood, this had long term negative effects on their socio-economic status and educational attainment (Maccini and Yang, 2009). Disasters indirectly impact educational attainment through malnutrition. A study found that Hurricane Mitch in Nicaragua increased the probability of malnourishment by 9% and led to reduction in investment in education (Baez and Santos, 2007). A storm in Guatemala led to coping mechanisms of withdrawing children from school (Baez et al., 2016).

Covid-19 will also have a largely negative impact on the poor, with increases in the number of poor rising by more than half a billion (Sumner et al., 2020). There could be increases in poverty rates of 180 million for those living under $1.90 a day; 280 million for those living under $3.20 a day and 250 million for those living under $5.50 a day if the global economy contracts by 10%. In some regions, the adverse impacts of the Covid-19 pandemic could return poverty levels similar to those recorded 30 years ago. This would constitute the first recorded increase in the absolute number of the poor in decades (Sumner et al., 2020). Thus, Covid-19 poses a real threat to the UN Sustainable Development Goals (SDGs) for ending poverty by 2030, an important aspect of economic security. The need to employ lockdown measures impacts the poor the most because they often work in jobs that cannot be done remotely. The poor often work in informal sectors and rely on daily hands-on labour income which is not attainable when self-isolating (Robalino, 2020). Unless there are proper safety nets in place, the poor in developing countries cannot afford to comply with lockdown measures due to the urgency to feed themselves and their families (Bargain and Ulugbek, 2020). They may also be more likely to face co-morbidities and have poor health insurance coverage which increases their risks (Lim et al., 2016). The poor may also not be able to gain access to testing which will make it more likely that the disease will spread more quickly within their communities (Sumner et al., 2020). As Chapter 6 explained, large and densely populated areas with widespread poverty are more vulnerable to airborne pandemics. Furthermore, healthcare disparities largely affected poor communities more than non-poor (Cinaroglu and Baser, 2019). It is those who work in areas with the lowest annual earnings and the lowest education levels who are the most vulnerable during a pandemic (Gössling et al., 2020). A further issue is that displaced workers who have been furloughed or have been made redundant may face lasting wage penalties of 8–10% (Tumino, 2015).2 Economic impact of disasters

Disasters and economic growth Over the last 50 years, the number of recorded disasters has increased significantly, especially those related to global warming (Helmer and Hilhorst, 2006; Van Aalst, 2006). The overall economic impact of disasters is in the billions. Japan’s 2011 earthquake and tsunami cost over $360 billion (far greater than the cost of SARS, but less than the cost of Covid-19);

200  Impact of disease and disaster Hurricane Katrina cost up to $250 billion; Hurricane Harvey cost $125 billion; Hurricane Maria cost $90 billion. Haiti’s earthquake of 2010 cost $8.5 billion. The costs are certainly immense and are growing on average by year, with 2017 serving as one of the costliest years for disasters. Though the most expensive disasters have taken place in developed countries, it is developing countries which bear the brunt. The World Bank claims that 97% of deaths related to disasters occur in developing countries, and poor countries experience much higher economic losses as a share of GDP than rich countries due to disasters (McDermott et al., 2014). In the case of Latin America – a region that faces a high propensity of all different types of disaster – the costs have been significant. The most damaging landslides (25% of them) have destroyed a minimum of $400 million in infrastructure in addition to affecting property values, forestry, and agriculture (Hilker et al., 2009). Earthquakes are also incredibly costly, with one in four earthquakes generating more than $180 million in damage to infrastructure by destroying buildings and other rigid structures (Samadzadegan and Zarrinpanjeh, 2008). Floods vary in terms of damage. Some generate no damage, while other floods, like the ones that affected El Salvador in 1982 and generated damages of $280 million, are extremely costly (Caruso, 2017). Some of the most severe damage from disasters has impacted Asia, which faces frequent disasters of all types. As mentioned before, the most expensive disaster in history was the 2011 earthquake in Japan, with other earthquakes costing $197 billion in 1995 and $28 billion in 2004. An earthquake in China in 2008 was also one of the most expensive on record. But earthquakes are not the only disaster affecting the continent – the region faces constant threats of flooding and storms as well. Floods that hit Thailand in 2011 caused $45 billion in damage. Flooding in China cost $20 billion in 2020 and in 1998 with another $12.6 billion in costs in 1996. Flooding in North Korea cost $15 billion in 1995. A cyclone in India in 2020 cost $13 billion and another in 1990 cost $8 billion in damage. Myanmar’s 2008 Cyclone cost almost $13 billion. A tropical cyclone in Japan in 1991 and 2004 caused almost $10 billion in damage each. In the Philippines, which has to deal with almost all types of disasters including earthquakes, floods, landslides, storms, and volcanic eruptions, there were 14 cyclones in one year resulting in more than $1 billion in damage. The US is also prone to costly disaster events, with 7 out of the 20 most expensive disasters in the last several decades taking place in the US alone (Our World in Data, 2020b).

Table 8.1  Ten most costly disasters Location

Year

Cost

Tohuku earthquake, Japan Hurricane Katrina, US Hurricane Harvey, US Sichuan earthquake, China Hurricane Maria, Puerto Rico Hurricane Sandy, US Hurricane Irma, US Thailand floods US droughts New Zealand earthquake

2011 2005 2017 2008 2017 2012 2017 2011 2012 2011

$360 billion $161 billion $125 billion $110 billion   $90 billion   $70 billion   $50 billion   $42–45 billion   $30 billion   $25.5 billion

Source: Brink News, 2019

Economic impacts  201 Disasters are very costly to states’ economies, both financially and in terms of human life. There are two impacts of direct damage from disasters: loss of labour which includes human deaths, disabilities, or injuries, and loss of capital associated with losses of physical assets, such as houses, factories, and infrastructure. The loss of labour leads to lower levels of productivity, which impacts the economic growth of a country and can have a permanent negative impact (Berlemann and Wenzel, 2016; Jaramillo, 2009; Noy and Nualsri, 2007). Disruptions in health and education services are more likely to hamper the current stock of human capital and the future accumulation of skilled human capital (Baez et al., 2010). However, the disaster literature, which mostly focuses on growth, is more inconclusive about the overall economic impact of disasters (Cavallo and Noy, 2011; Fiala, 2017; Noy and DuPont, 2016). Much of the impact depends on the economic strength of the country afflicted. As previously mentioned, it is developing countries that are the most high-risk of disasters compared to developed countries (World Risk Report UNU-EHS, 2016). Developing countries are more sensitive to the economic shocks of disasters than developed ones largely due to their limited capacity to cope with the economic and financial consequences of such events (Fomby et al., 2013; Loayza et al., 2012). One study found that climatic natural hazards, in particular, have an adverse macro-economic impact in low-income countries and are associated with a 2% decline in GDP the following year (Raddatz, 2009). Richer countries with higher levels of per capital income, risk financing mechanisms, and better infrastructure are better able to absorb the economic shocks of disasters (Ghesquiere and Mahul, 2010; Kahn, 2005; Noy, 2009). Poorer countries have fewer funds available to mobilize and may be forced to divert social welfare funds to mitigate the impact. Moreover, countries that face frequent disasters will lose investment in the atmosphere of uncertainty (Keen et al., 2003; Fiala, 2017). Developed states, which usually have better systems in place to deal with disasters, still experience serious costs when they are hit. Hurricane Katrina, for example, cost the United States over $150 billion in damages in 2005 (see Table 8.1). Yet, developed states’ economies are better able to afford these costs (or at least quickly repay the debts incurred by them) because they were in better economic positions to begin with. In addition, because developed states have superior infrastructure and early warning systems in place to minimize the effects of disasters, loss of life is less than it would be in other conditions. Economic development typically brings improvements in safety (Toya and Skidmore, 2007). The World Disaster Report demonstrated that only 2% of all deaths recorded from disasters between 1991 and 2000 took place in countries that score high on the Human Development Index (HDI). More than two-thirds took place in countries with low scores on the HDI, even though more than half of the disasters take place in countries with medium scores on the HDI (Wisner et al., 2004). Additionally, one study has shown that if a state with a population of 100 million people increased its GDP per capita from $2,000 to $14,000, it would suffer 700 fewer deaths due to disasters per year (Kahn, 2005). In other words, though developed states also suffer significant costs from disasters, they are better able to rebound from them and better structured to weather them than are developing states. The economic consequences of disasters in developing states can be truly staggering. Disasters can impact industrial output if businesses are destroyed. Trade and commerce can be disrupted when road infrastructure is damaged. Hurricane Mitch, which hit Central America in 1998, killed 9,000 people, affected over three million more, and caused Honduras to lose 80% of its GDP and Nicaragua 49% (Villacís, 2004). The hurricane cost the Central American region as a whole $6 billion. Those numbers, unfortunately, are not atypical. The

202  Impact of disease and disaster Mexico City earthquake of 1985, for example, caused between $3 and $4 billion worth of damages (Live Science, 2011). In 1988 Hurricane Joan hit Nicaragua and caused it to lose 32.57% of its GDP. Jamaica lost 28.2% of its GDP due to Hurricane Gilbert in 1988 (Ezrow et al., 2015). Yet, in spite of these huge costs, hurricanes don’t have a huge negative impact on economic growth rates. A study of hurricanes found that a country’s economic growth will only fall on average of 0.45%, 28% of which is caused by richer individuals moving away from the affected area (Strobl, 2011). Nevertheless, though disasters can be costly, some studies find that disasters can have a positive impact on economic growth in the short-to-medium term. Following a disaster event, reinvestment in capital stocks and the upgraded technology may accelerate growth. This theory is known as creative destruction. Hazards offer opportunities to make improvements much more quickly. Older buildings are replaced with more modern and hazard-proof facilities that can also improve productivity and impact growth rates (Okuyama, 2003). A few older studies support this view (Albala-Bertrand, 1993; Okuyama, 2003; Otero and Marti, 1995) and some recent studies have found that the positive impacts of disasters were limited to specific economic sectors (e.g., the agricultural sector) and affected by disaster types (e.g., floods) (Fomby et al., 2013; Loayza et al., 2012). Another study looking at geologic disasters from 1965 to 2008, also argued that the frequency of these types of disasters is associated with higher economic growth rates (Ahlerup, 2013). However, this literature has mostly used case studies and has been criticised by cross-national work that has argued that hazards pose a negative impact on national growth rates (Raddatz, 2009; Loayza et al., 2012; Noy, 2009; Hochrainer, 2009) or at least have no significant impact on long term economic growth (Cavallo et al., 2010). Studies that have focused on specific types of disaster have noted that floods have a mixed impact on growth depending on when floods take place. Flooding that takes place that can provide an abundant supply of water throughout the year may trigger higher growth in agricultural-based economies (Cunado and Ferreira, 2014; Fomby et al., 2013). In contrast, droughts have a negative impact on agricultural growth, though this impact may be more limited on total GDP growth (Fomby et al., 2013; Loayza et al., 2012). In comparison to moderate droughts, severe droughts on average have very strong negative effects on annual GDP. Earthquakes can lead to some short- and medium-term economic growth when repair of damage generates greater investment in the construction sector and public infrastructure. However, in developing countries, earthquakes can negatively impact non-agricultural growth (Panwar and Sen, 2019). Severe storms can also impact agricultural growth by damaging crops, irrigation facilities, tools, and machinery (Fomby et al., 2013). Unlike moderate disasters, all severe disasters show strong negative effects on economic growth (Panwar and Sen, 2019).

Disasters and poverty Not surprisingly, the more severe a disaster’s effects on an economy, the worse the outcomes for poverty (Bui et al., 2014). The poor are more vulnerable in both response and recovery, and regions exposed to disasters may experience higher poverty and inequality than those less affected (Fothergill and Peek, 2004; Krueger et al., 2010; Rodriguez-Oreggia, 2010; Toya and Skidmore, 2007). Thus, the poor will bear the direct damages of disasters disproportionally at higher levels and shares of their household income compared to richer households. Disasters disproportionately affect the poor because they are less likely to be prepared. They are less likely to respond to warnings to evacuate (possibly having nowhere to shelter)

Economic impacts  203 and they are more likely to suffer debilitating injuries or death, which may impair their future income potential. Overall, they will face greater obstacles during the response, recovery, and reconstruction phase as well. Housing, supplies, and equipment may be uninsured, and the losses that accrue to informal activities are not included in disaster impact assessments (Pelling, 2003a). The poor are more likely to hold their wealth in vulnerable forms, such as livestock. In a study that looked at the massive impact of the drought in Ethiopia in 1984–1985, it took over a decade for asset-poor households to bring their livestock back to pre-famine levels (Dercon, 2004). Furthermore, as poor households that are exposed to natural hazards are often uninsured, they are more likely to reduce their investment in productive assets and instead choose low return activities to hedge against risks, which perpetuates poverty (Cole et al., 2013). Thus, there is a negative feedback loop in which poor households are forced to settle in risky zones with cheaper rent but are likely to engage low-return activities, making it more difficult to rise from poverty. In contrast, the rich can finance reconstruction using their savings. They are more likely to have insurance and will have better access to loans and credit. Richer households live in abodes that are structurally better prepared to deal with damage and can take more risks to participate in higher return, higher risk activities. Studies have noted the negative impact of floods and droughts on poverty. In a study of Mexico, poverty rose by up to 3.7% due to disasters (Rodriguez-Oreggia et al., 2013). A study that looked at Peru from 2003 to 2008, found that one additional disaster per year increased poverty rates from 16% to 23% at the provincial level (Glave et al., 2008). In the city of Trinidad, Bolivia, poverty rates rose by 12% after flooding took place in 2006 (Perez-De-Rada and Paz, 2008). In Bangladesh, which was hit by Cyclone Aila in 2009, per capita income levels plummeted from $15,000 to $10,000, poverty rates increased from 41% to 63%, and unemployment rose from 11% to 60% just in one year (Akter and Mallick, 2013). Much of the issue for the poor is that disasters are not single, discrete events. Vulnerable people will suffer repeated, and mutually reinforcing shocks which will not only erode their ability to accumulate resources and savings but will also affect their ability to generate future income (Wisner et al., 2004). When household assets and income-generating assets (such as shops, factors, crops, cattle, and arable land) are damaged or destroyed, this leads to losses in income. The poor are more likely to have informal and irregular income meaning that any disruption either directly or in the aftermath will lead to a loss of income. Some disasters have labour market effects as well, which leads to more permanent losses in wages (Banerjee and Duflo, 2007). Disasters can also affect the poor by making land unsuitable for agricultural production, which impacts employment of the rural poor. Hurricanes can wash out arable land or permanently affect the salinity of the soil. In Honduras, it took over four years for banana production to return to its normal levels after Hurricane Mitch. This had a strong effect on unemployment and under-employment levels. As a result, the rate of unemployment immediately rose to 32% in Honduras (Charvériat, 2000). In 2008, Cyclone Nargis hit Myanmar (which killed 140,000 people) causing major damage to embankments and streams, which made the fields more prone to more flooding, more saline, and more susceptible to pest infestation. Agricultural yields decreased as a result. Some households tried to borrow money but ended up more in debt. Disasters can also cause logistical problems in food distribution which can raise prices and lead to drops in consumption, impacting food security. Per capita consumption levels fell by 13% in Guatemala after Tropical Storm Agatha hit. Food expenditures fell by 10% (Baez et al., 2016). This was mostly attributable to losses in food infrastructure and transport, which caused a 17% increase in food prices almost a year after the storm. Disasters can also destroy

204  Impact of disease and disaster supplies, seeds reserves, and other productive assets which can cause food price shocks. In the case of Pakistan’s deadly 2010 floods, 2.1 hectares of land were destroyed which led to problems for food production (Kirsch et al., 2012). Richer households may escape some of these problems as studies have showed that consumption levels between those exposed and those not exposed to a flood were no different for those in the top quintile. However, those exposed in the bottom quintile were consuming 80% below the minimum daily caloric intake (Deen, 2015; Doocy et al., 2013). Another impact of disasters comes in the aftermath when critical infrastructure has been destroyed, which can have negative consequences for health and well-being. In the case of the 2010 Haiti earthquake, the contamination of the drinking water led to a massive cholera outbreak that killed almost 10,000 people (Pilkington, 2019). Thus, it is not just the disaster event that leads to high death tolls but also the aftermath (Pelling, 2003b). Health conditions often worsen in overcrowded shelters and unsanitary conditions. These conditions, in turn, lead to poverty traps that are difficult to recover from. Another long-term impact of disasters is that they may lead the poor to invest less in the education of their children leading to longer term poverty traps (Carter and Barrett, 2006). A study in Mexico showed that children who have been temporarily taken out of school because of a disaster were 30% less likely to continue with their education (De Janvry et al., 2006). Temporary changes can lead to permanent shifts that come at the expense of a child’s human capital and future earning potential. Though the literature is fairly conclusive that disasters lead to greater levels of poverty, there is not consensus on how disasters impact inequality rates. Some studies have argued that disasters do not lead to huge increases in inequality rates, primarily because poor households have few material assets to lose and can quickly resume activities, whereas wealthier households may lose more costly assets (Abdullah et al., 2016; Keerthiratne and Tol, 2018). Another reason why inequality rates may not increase is if the state offers substantial government support for the poorer households in response (Feng et al., 2016). In a study of floods from 1965–2004, one study found that disasters increased income inequality in the short run, but this impact dissipated after ten years (Yamamura, 2015). However, in another study looking at household-level data in Vietnam, it was found that disasters reduce incomes because the poor are unable to work. The poor are also more likely to receive earnings in sectors that face downturns, such as weather-dependent agriculture. And though they have few assets to begin with, they are more likely to lose these assets completely. The end result is that this lowers expenditures, raising both poverty rates and inequality (Bui et al., 2014). Another study of the 2006 Typhoon that affected the Philippines echoed these results, finding that there were lower consumption rates among the poor, which raised consumption inequality at the local level (Sakai et al., 2017). When the causal arrow was reversed, it was found (in a study of 26 countries, looking at 269 earthquakes that measured 6 or more on the Richter scale) that economic inequality was associated with greater fatalities (Anbarci et al., 2005).

Conclusion This chapter has laid out the economic impact of disease and disaster by focusing on economic growth, poverty, and inequality – that is, economic security. While endemic diseases and major disease events can have a massive impact on the economy, disasters don’t necessarily affect economic growth in a significant way. Endemic and major diseases events, however, do impact poverty, further enabling poverty traps to persist. This is particularly true with

Economic impacts  205 diseases of poverty like NTDs that cause losses in school attendance and labour productivity. Growing poverty is usually accompanied by increases in inequality as well. Disasters also disproportionately affect the poor (see Chapter 6). They are more likely to be the victims of a natural hazard and are more likely to struggle to bounce back after a disaster hits. Though there is mixed evidence about how this impacts inequality, the main take-away is that disasters reverse any gains made in poverty reduction. In the next chapter, we go more in-depth into the social and political effects of disease and disaster – or the impact on political and community security and other aspects of well-being. As Chapter 1 explained, threats are interrelated, and the economic impacts of disease and disaster are intertwined with other social and psychological impacts. While it may be difficult to pinpoint the direct effects of disease and disaster, we lay out what studies have uncovered and how economic, social, and political issues are connected.

Key questions 1 2 3 4 5

Why has Covid-19 been so impactful on affected countries’ economies? Why have some countries’ economies been less affected than others? Why are endemic diseases, like malaria, AIDS, and TB, poverty-inducing? Why are disasters more costly in rich countries? What is a bigger challenge for economic security for the poor: endemic diseases or disasters? Why so? Do you agree that disasters can be good for growth? Why or why not?

Notes 1 Technically these events are predictable, but it is hard to pinpoint exactly when they will take place. 2 A study has demonstrated that displaced workers in Nordic countries, with more robust welfare systems, face smaller falls in earnings compared to employees in countries in other parts of Europe and the US (Upward and Wright, 2015).

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214  Impact of disease and disaster Tibaijuka, A.K., 1997. AIDS and economic welfare in peasant agriculture: Case studies from Kagabiro Village, Kagera Region, Tanzania. World Development, 25(6), pp. 963–975. Toya, H. and Skidmore, M., 2007. Economic development and the impacts of natural disasters. Economics Letters, 94(1), pp. 20–25. Trape, J.F., Pison, G., Spiegel, A., Enel, C. and Rogier, C., 2002. Combating malaria in Africa. Trends in Parasitology, 18(5), pp. 224–230. Tumino, A., 2015. The scarring effect of unemployment from the early’90s to the Great Recession  (No. 2015–05). ISER Working Paper Series. UNDP, October 3rd, 2014. Socio-economic impact of the Ebola virus disease in Guinea, Liberia and Sierra Leone, 1(3). Report. Upward, R. and Wright, P., 2015. Don’t look down: New evidence on job loss in a flexible labour market. Nottingham Centre for Research on Globalisation and Economic Policy, Nottingham, UK: University of Nottingham. US Bureau of Labour Statistics, May 7th, 2021. The employment situation April 2021. News Release. https://www.bls.gov/news.release/pdf/empsit.pdf. Accessed May 15th, 2021 US Department of Labour, January  2021. News release. www.bls.gov/news.release/pdf/empsit.pdf. Accessed May 14th, 2021 Van Aalst, M.K., 2006. The impacts of climate change on the risk of natural disasters. Disasters, 30(1), pp. 5–18. Vassall, A., Seme, A., Compernolle, P. and Meheus, F., 2010. Patient costs of accessing collaborative tuberculosis and human immunodeficiency virus interventions in Ethiopia. The International Journal of Tuberculosis and Lung Disease, 14(5), pp. 604–610. Villacís, C., 2004. Latin American CASES. Asian disaster reduction center. www.adrc.asia/publications/ recovery_reports/pdf/Mitch.pdf. Accessed January 20, 2021 Walter, C., 2020. Financial Black swans: Unpredictable threat or descriptive illusion? In Societies under threat (pp. 173–186). Cham: Springer. Walton, E. and Allen, S., 2011. Malnutrition in developing countries. Paediatrics and Child Health, 21(9), pp. 418–424. Were, V., Buff, A.M., Desai, M., Kariuki, S., Samuels, A.M., Phillips-Howard, P., Ter Kuile, F.O., Kachur, S.P. and Niessen, L.W., 2019. Trends in malaria prevalence and health related socioeconomic inequality in rural western Kenya: Results from repeated household malaria cross-sectional surveys from 2006 to 2013. BMJ Open, 9(9), p. e033883. Whiteside, A., 2002. Poverty and HIV/AIDS in Africa. Third World Quarterly, 23(2), pp. 313–332. Whiting, K., January 20, 2020. 5 shocking facts about inequality, according to Oxfam’s latest report. World Economic Forum. www.weforum.org/agenda/2020/01/5-shocking-facts-about-inequality-accordingto-oxfam-s-latest-report/. Accessed December 10, 2020 Wisner, B., Blaikie, P., Blaikie, P.M., Cannon, T. and Davis, I., 2004. At risk: Natural hazards, people’s vulnerability and disasters. London, UK: Psychology Press. World Bank, January  20, 2015. Ebola: Most African countries avoid major economic loss but impact on Guinea, Liberia, Sierra Leone remains crippling. www.worldbank.org/en/news/press-release/2015/01/20/ ebola-most-african-countries-avoid-major-economic-loss-but-impact-on-guinea-liberia-sierraleone-remains-crippling. Accessed November 20, 2020 World Bank, 2016. Taking on inequality. https://openknowledge.worldbank.org/bitstream/handle/ 10986/25078/9781464809583.pdf?sequence=24&isAllowed=y. Accessed December 3, 2020 World Risk Report UNU-EHS, 2016. World Risk Report 2016: Inadequate infrastructure pushes up the risk of disaster. August 25th, 2016. United Nations University. Science Daily. https://www.science daily.com/releases/2016/08/160825084651.htm#:~:text=The%20World%20Risk%20Report%20 2016,floods%2C%20cyclones%2C%20or%20earthquakes. Accessed May 15th, 2021 Worrall, E., Basu, S. and Hanson, K., 2005. Is malaria a disease of poverty? A  review of the literature. Tropical Medicine & International Health, 10(10), pp. 1047–1059.

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9 Social and political impacts

In 2010 a massive earthquake hit Haiti, with the epicentre lying 25 km west of the capital Port-au-Prince. In the aftermath, hundreds of thousands were killed and over 1.5 million people were displaced. In addition to these casualties, the earthquake completely levelled hospitals, churches, government buildings, commercial buildings, all forms of transport, and communication systems. In the town of Léogâne, 90% of the buildings did not survive the earthquake. Even prisons were affected. The Port-au-Prince Prison Civile was ruined, enabling 4,000 inmates to escape. The damage of the earthquake was so severe that it would have lasting consequences on Haiti for years to come. Though much has been rebuilt, nearly a decade later, Haiti is still being gripped by riots, protests, and unrest. Massive earthquakes, such as the one that struck Haiti, impose tremendous costs on society. But it is not just disasters that have an impact. With Covid-19, another catastrophic event, the repercussions have also been far-reaching. Disease outbreaks and disasters are the natural meeting ground between humans and microscopic organisms and natural hazards. They cause tremendous human suffering, dislocation, and disruption and have significant social and political consequences. As the previous chapter covered the vast economic impacts of diseases and disaster, this chapter will explain the impact that diseases and disasters have on society, politics, and the state, most specifically in the areas of health and education. These effects constitute threats to political and community security as well as threats to overall well-being. After first looking at the effects of diseases, the chapter turns to the consequences of disasters. We start the chapter by defining important political concepts.

Key concepts Autocratization, sometimes also referred to as democratic backsliding, democratic decay, or democratic decline, is the process by which democratic institutions, governance, and transparency are undermined. It takes place through a series of discrete changes in the rules and informal procedures that shape not only elections, but also civil liberties, political rights, and various mechanisms of accountability. With autocratization, actors who are not accountable to the electorate, such as shadow leaders and multi-national corporations, increase in power (Ercan and Gagnon, 2014). Autocratization can take place in democracies, autocracies, and all the regimes in between. In contrast to democratic breakdown, autocratization is the gradual degradation of a democratic system. Some of the changes are subtle and not easy to notice right away. This could mean that elections become less competitive, and power becomes more arbitrary, but electoral mechanisms have not been undermined entirely. Media freedoms, civil society, and freedoms of speech and association may be under attack and face intimidation but remain

DOI: 10.4324/9781003128809-14

Social and political impacts  217 legally protected. Autocratization also differs from autocratic breakdown, which is a clear point in time where an autocratic regime ends, such as due to a coup, a revolution, or because regime elites decided to hold elections and the incumbent regime was voted out of power.

Social and political impacts of diseases Though there may be more attention on the direct health impacts of catastrophic disease outbreaks, there are significant social impacts that bear exploring. These extreme disease events can lead to social unrest, conflict, increased domestic violence, and displacement. Endemic infectious diseases and pandemic/epidemic disease events both have significant effects on state capacity and are particularly disruptive to the delivery of health services and education. We close this section with an exploration of how pandemic disease events have impacted politics, looking at how Covid-19 in particular has affected autocratization, or democratic decline. While the mishandling of the virus has led to frustration and even protests, many leaders have taken advantage of this moment and secured their grips on power further. Disease and society Conflict, instability, and displacement and disease Pandemics in particular can cause unrest and possibly violence when quarantines, lockdowns, and curfews are imposed. Social psychologists have investigated the subsequent lockdown response of higher levels of stress hormones, placing the body into survival mode (Limcaoco et al., 2020; Giallonardo et al., 2020; Buheji et al., 2020). Quarantines have been associated with concerning coping behaviours (such as increased drug and alcohol abuse) and higher levels of anxiety and mental health issues due to social isolation and limitations on freedom (Lau et al., 2005; Mak et al., 2009; Reissman et al., 2006; Yeung and Fung, 2007). Known as the parasite stress theory – countries that face infectious disease contagion will also face higher levels of violence (Thornhill and Fincher, 2014). In a study looking at states in the US as the unit of analysis, it was found that infection severity leads to greater incidence of homicides and child maltreatment (Thornhill and Fincher, 2011). Though quarantines are usually short-term measures, the effects can persist in the years after a pandemic. The Ebola crisis caused great tensions within Guinea and Sierra Leone. Incumbent politicians in all three countries affected were accused of using the crisis to cement political control against the opposition. In turn, the opposition was accused of undermining efforts to control the epidemic (Qureshi, 2016). In opposition-dominated areas of Sierra Leone, lockdown measures were delayed over concerns that they would be perceived as politically motivated. Riots broke out in Sierra Leone and Liberia that led to fatal shootings by the police and army (Elston et al., 2017). Additionally, an outbreak that happens in the context of high levels of political polarization after a civil war or in countries with fragile institutions may engender more challenges. Societies that have any tension with security could see these tensions lead to riots and violent clashes with security (McCoy, 2014). In the case of the Ebola outbreak in Liberia, latent political tensions from previous conflicts between warring factions returned. Healthcare workers were threatened and there were attacks on public health personnel and health facilities (McCoy, 2014). In Guinea, in addition to facing constant threats and being ostracized by their own communities, a team of eight healthcare workers were targeted and killed (Elston et al., 2017).

218  Impact of disease and disaster In the past, colonial governments in Africa used to enforce quarantines in order to control diseases, like cholera, and to employ population relocation measures. These policies were met with deep resentment, which have had a long-term residual effect on state-society relations today. In 2014, the Liberian government attempted to impose a lockdown but faced intense resistance. After riots took place in the capital Monrovia, the government put up checkpoints and a buffer zone – blockading 70,000 people in – which further increased tensions (Roberts, 2020). Some societies naturally fear that the government is assuming far-reaching power to take advantage of health emergencies. The protests in Berlin, Germany, that were organized by far-right groups in August of 2020 to protest wearing masks and other precautions illustrates the backlashes governments face when trying to control a highly infectious disease. Outbreaks of new diseases can also cause the public to panic, to a degree which may cause citizens to question government intervention. Controlling a population may necessitate using the security apparatus, which can further damage societal trust of the state. Early studies looking at the impact of cholera outbreaks in Europe found that, because the disease illustrated clear class divisions between those who lived in areas with contaminated water and those who did not, social discrepancies gave rise to extreme social tensions and riots, particularly in the slums of the UK during the 19th century (Cohn, 2017). With no less than 70 riots around the world, tensions arose over fears that the government was withholding information from cholera-ridden areas (ibid.). Studies that have looked at the effect of disease on conflict have been hard to come by. As Chapter 7 explained, there is a rich literature that has investigated the impact of conflict on disease, but not the reverse. Conflicts definitely exacerbate disease outbreaks and undermine treatment. However, less clear is the role of disease outbreaks in causing conflict. Some studies have claimed that countries that suffer from persistent disease threats face obstacles to social organization, fostering social norms that lead people to care only about their in-group (Thornhill et al., 2009). As previously mentioned in this chapter, a study by two of the same authors claimed that the stress of being in an endemic disease environment increases the likelihood of aggression (Thornhill and Fincher, 2011). Referred to as parasite stress theory, infectious diseases cause greater caution in interacting with out-groups and greater prejudice against them, thus greater aggression towards unfamiliar people. These conditions of fractiousness and distrusting dynamics creates an environment ripe for conflict (Letendre et al., 2010). The most recent work looking at the impact of the Covid-19 pandemic has shown that, in many conflict-affected countries, violence remains unabated or has even escalated (Polo, 2020). As the pandemic has worsened and social and economic inequalities have become entrenched, the risk for conflict has increased (Cederman et al., 2011). Job losses lead to higher levels of unemployment, which may especially lead unemployed youth to join rebel groups (Azeng and Yogo, 2013). This is compounded by the rise in food prices due to supply chain issues, which raises grievances (Hendrix and Haggard, 2015). Additionally, stigmatization of disease means that certain groups have been further marginalized (Polo, 2020). A large-scale infectious disease outbreak can also cause widespread panic, which can lead to population migration. This migration, in turn, poses further risks of spreading an outbreak as migrants face poor sanitation and nutrition (Toole and Waldman, 1990). An outbreak of the plague in Surat India in 1994 caused 500,000 people, 20% of the population, to flee, even though at the time there were only a few cases reported (Barret and Brown, 2008). Migration (see Chapter 6) also raises the chances of spreading the outbreak. These population movements can also have destabilizing effects.

Social and political impacts  219 Domestic violence and disease One of the major social consequences of infectious disease lockdowns are rises in domestic violence (Devries et al., 2013; Capaldi et al., 2012; Onyango et al., 2019). This is attributable to the added economic stress that lockdowns cause and the general increase in mental health disorders that arise during lockdowns. Exacerbating matters is the inability of women to temporarily escape an abusive partner and reduced health service availability and access to first responders. One study in China argued that the number of domestic violence cases tripled during lockdown (Graham-Harrison et al., 2020; Zhang, 2020). A study in Jianli county in China (central Hubei province) found that the police received 162 reports of domestic partner violence in February during the lockdown, which was three times the number of reports from the same month the previous year (Wanqing, 2020). A survey of frontline workers in Australia revealed that there was a significant increase in pleas for help (Lattouf, 2020). This is noteworthy given that anecdotal evidence from the Covid-19 pandemic suggests that women may be less willing to seek help because of perceived risks of contracting viruses. Not only have women accounted for 60–75% of the deaths of the 2014 Ebola epidemic, they have also faced greater levels of sexual violence due to Ebolarelated economic stressors (Menéndez et al., 2015; Peterman et al., 2020). One of the consequences of pandemic-induced spikes in sexual violence are increased fertility rates. Just one study of a district in Sierra Leone found that, due to forced sex, there was a 25% increase in teen pregnancy in 2014 compared to the previous year (Elston et al., 2016). Other parts of Sierra Leone reported increases in teen pregnancies by as much as 65%. In total, over 18,000 girls became pregnant during the epidemic (Onyango et al., 2019). Fertility rates also rise because many women and girls living in poverty face pressure to have sex for financial survival (Robinson and Yeh, 2011; Gausman et al., 2019). Disease and the state Infectious diseases also impose huge costs on the state – not only because treating diseases is costly, but because diseases directly affect the workforce of state employees. In countries where endemic diseases, like HIV/AIDS and TB, are prevalent, affecting people in the prime of their lives, there are huge government costs in loss of human capital. States have to spend more on training to deal with absenteeism among state employees, sick leave pay, and health bills (for more on this, see Chapter  7). In the early years of HIV/AIDS, there were many deaths among government ministers, leading to fears that the state institutions would be hollowed out since some of the most experienced and capable state employees were dying. For example, developing water resources and ensuring proper sanitation requires skilled engineers and a number of trained individuals to ensure maintenance of these services. These engineers can be very susceptible to HIV because they are often mobile workers (for more on this, see Chapter 4). As a result, some of the most highly skilled state workers have become sick, affecting state capacity. Some researchers have argued, for example, that, in Benin and Mozambique, the prevalence of HIV/AIDS among civil servants had hampered the capacity of bureaucracies there to administer state services (Boutayeb, 2009). When government employees face infectious diseases, the state is challenged to provide high-quality services. The security institutions have also been affected by diseases, most notably HIV/AIDS. While all infectious diseases have an impact, HIV/AIDS has made a huge mark. In the late 1990s and early 2000s, the HIV prevalence rate in African militaries was incredibly high. This had the effect of not only leading to absenteeism but also to decreased readiness and

220  Impact of disease and disaster capacity (Elbe, 2006). The effect of weakening security forces raises the risk of civil war as it provides an opening for violent non-state actors (Fearon and Laitin, 2003). Shorter pandemics are not likely to sap the strength of the military, but endemic diseases that affect people in the prime of their lives can sap the strength of personnel. In the case of a sudden disease outbreak, the costs on the state of containing the outbreak are immense. The state may need to spend more on contract tracers, isolating infectious cases, building new facilities to treat patients, accessing new medical supplies and protective equipment. This happens in a context in which the costs of quarantining and disruptions to the economy may lead to less tax revenue available to make these investments (Herstein et al., 2016). Endemic diseases pose huge obstacles to a state’s capacity to collect revenues. HIV/AIDS and malaria lower the size of the workforce, reducing in turn the size of the taxable population. States that are badly affected generate less revenue income, while income is precisely what is needed to address healthcare costs and offer better assistance. Even those individuals who are part of the workforce have lower wages when they contract infectious diseases with lost workdays, decreasing the taxes states are able to collect. As previously explained, diseases place tremendous strain on the state and its available revenues to spend in social welfare, human capital investment, and on education outcomes. As state budgets are exhausted by increasing healthcare costs, there are negative effects on available funds for education. For example, the treatment of HIV/AIDS is still very expensive for developing countries. On average, treatment for an AIDS patient for one year is about as costly as educating ten primary school students for one year (Colombus and Wusu, 2001). Governments will thus face numerous trade-offs as to where to spend their money, which may limit investment in primary school education. Less funding available for education is just one challenge. Diseases also have significant overall impacts on human capital due to absentee rates which affect long-term educational attainment. In the most extreme cases, diseases can reduce the number of children attending school because of high child-mortality rates. In Swaziland, for example, HIV/AIDS was predicted to impact the size of the primary school population for each grade by 30% (Gachuhi, 1999). In the face of pandemics, governments have historically closed schools to slow the spread of disease. For example, in response to Ebola, schools closed for six to eight months across Guinea, Liberia, and Sierra Leone, affecting an estimated five million children (World Bank, 2015). As a result, these five million children lost almost a year of education (Elston et al., 2017). With the outbreak of the H1N1 flu epidemic, schools closed across a range of countries, including the United States, France, China, Thailand, and Serbia (Cauchemez et al., 2014). Even short-term school closures can impact children’s long-term opportunities and create demographic shifts at the margin by leading to more teen pregnancies. With the Covid-19 pandemic, during the first wave, 138 countries have closed their schools, while other countries have implemented regional or local closures, affecting 80% of children worldwide. Thus far, studies are predicting that Covid-19 should lead to a decrease in the acquisition of human capital, even for students who miss school for a relatively short period of time (Burgess and Sievertsen, 2020). For example, a study in Belgium found that disadvantaged pupils who had to learn from home where more likely to fall behind (Maldonado and De Witte, 2020). Other studies have pointed to huge losses in future earnings as a result of school days lost to school closures. A study in the UK found that those from low socio-economic backgrounds who won’t go to university may lose out on as much as £22,500 for males and £14,600 for females due to school closures (Halterbeck et al., 2020).

Social and political impacts  221 In addition to losing valuable days of learning and, in turn, future income, school closures can exacerbate malnutrition since schools provide food for children, and studies demonstrate that school lunches lead to improvements in academic performance (Alaimo et al., 2001; Anderson et al., 2017). In contrast, malnutrition is associated with low educational attainment. Just looking at European countries, as much as 6.6% of school children within the EU cannot afford a meal with adequate levels of protein every second day. It is estimated that in the US, this percentage is as high as 14% (Van Lancker and Parolin, 2020). Thus it is no surprise that, during the summer holidays, there is a loss in academic achievement equivalent to a month of education for those coming from low socio-economic status. This means that months of home learning will have a negative effect for children from lowincome families, affecting both their mental health and academic potential. Children from low-income families may not have access to a computer or reliable internet or may lack proper heat or cooling to work from home. While learning can continue unimpeded for children from high-income families, children from lower income families may struggle to complete schooling online if they are in precarious housing conditions. These discrepancies in home environments will likely widen the gap between children from lower income and higher income families (Van Lancker and Parolin, 2020). With endemic diseases, like HIV/AIDS, malaria, TB, diarrhoeal diseases, and other NTDs, human capital is affected by absenteeism of sick members of staff. At the height of the HIV/ AIDS crisis, there were falls in enrolment rates of up to 36% in some parts of Africa (Bates et al., 2004). In some cases, this is because teachers and students have become sick, while in many other cases this is because the child has to take on a new role as caregiver for a sick family member or has to work in order to help pay for medical bills and make up for loss of income if the breadwinner is afflicted. States with high levels of infectious diseases lose days of teaching due to large numbers of sick staff. At the height of the crisis in Africa, the numbers were staggering. In Botswana, for example, it is estimated that over a third of all teachers were HIV positive (Nleya and Segale, 2015). Zambia’s Ministry of Education reports that over 2% of its teachers died in 1996 alone (Gachuhi, 1999), a number that was greater than the total number of teachers it produced in its teacher-training colleges that year. In Malawi, the rate of infection among teachers in 2011 was almost one-third, with more than four teachers dying per day due to AIDS (Ijumba, 2011). Experts estimated that this amounts to huge losses, as the death or absence of a single teacher affects the education of anywhere from 20 to 50 children, numbers that are much higher for school administrators (Coombe, 2004; Grassly et al., 2003). Infectious diseases pose huge costs on the healthcare agencies which are tasked with containing outbreaks and dealing with endemic diseases. Infectious diseases place a heavy burden on the public health system, stretching the capacity of already limited health facilities. In 2016 it was reported that Nigeria spent $424 million to fight malaria, while the DRC spent $189.2 million and Tanzania $183.6 million. Uganda, Ghana, Mozambique, Angola, Zambia, and India all spent well over $100 million annually to combat malaria. This does not include out of pocket expenses which was 19% of total malaria spending in 47 at risk countries and 43.5% of total health spending (Haakenstad et al., 2019). In Mozambique, malaria is the leading cause of seeking healthcare, accounting for 45% of outpatient consultations and 24% of hospital admissions in 2015 (Alonso et al., 2019). The median household health costs of addressing an uncomplicated case of malaria is about 15% of monthly expenditures for a family, while the cost of a severe case is three times the mean monthly expenditure per capita (ibid.). Treatment is even more costly for HIV/AIDS. As countries go further into debt to pay for healthcare expenditures, the revenues available to invest in needed preventive care,

222  Impact of disease and disaster surveillance, diagnostics, and treatment grow more limited. Healthcare workers in South Africa are still under-resourced and overburdened, with the public healthcare system unable to effectively implement its HIV treatment program (Allinder and Fleischman, 2019). Infections among healthcare workers also undermine state healthcare capacity. Those in the healthcare industry who are the most vital in helping the population withstand outbreaks are also the most susceptible to contracting many infectious diseases. With the Ebola crisis, it was estimated that 2.7%, 10.3%, and 10.7% of healthcare workers were infected in Guinea, Liberia, and Sierra Leone, respectively. Additionally, over 500 healthcare workers died and the health workforce declined by 1.45% in Guinea, by more than 8% in Liberia, and by almost 7% in Sierra Leone (Smith et al., 2019). These losses caused many healthcare facilities to close down (Huber et al., 2018). The loss of healthcare workers led to increased maternal and infant mortality rates that posed direct costs of almost $19 billion (Evans et al., 2015). In the case of Guinea, understaffing due to the sickness and death of employees led to the closure of 45 facilities, with a 31% drop in outpatient visits for routine maternal and child services (Barden-O’Fallon et al., 2015). In Liberia, in a hospital where 25% of the surgeons died of Ebola, surgical activity plummeted to 3% of what was expected. During the 1976 Ebola outbreak in the Democratic Republic of Congo, one of the hospitals at the epicentre of the outbreak was closed because nearly 65% of staff members had the disease. Nearly 20 years later in the DRC, 24% of the cases were occurring among health workers (Rosello et al., 2015). Other infectious diseases have also impacted health workers. State resources that are devoted to the development of human capital face devastating consequences when high-skilled workers contract infectious diseases at high rates. Disease and politics Disease and autocratization Very few studies have looked at the relationship between autocratization and disease. As such, this section will only focus on the impact of Covid-19 on autocratization. To our knowledge, there are no studies that confirm that endemic diseases lead to autocratization or autocratic stability. There is a correlation between endemic disease presence and authoritarianism, but there are a host of confounding factors that may be driving this relationship. For example, Africa continues to have the highest infectious disease burden in the world (Vos et al., 2020). At the same time, most of Africa is still authoritarian which makes it difficult to determine the political impact of endemic diseases.1 True, there is no country with a high malaria prevalence that is a fully consolidated democracy. Nigeria (where there are 380 cases of malaria per 1,000 people) has been democratizing, but it is not a full democracy. On the other hand, both Botswana and South Africa are democracies but have had some of the highest HIV/ AIDS prevalence rates in the world and regionally. More research is needed to understand how endemic diseases may impact authoritarian durability. At the moment, it’s too difficult to determine the direction of causality. In light of this, we look at the political impact of a major disease crises, such as a pandemic. Crises are very risky for democracies – they are opportunities for governments to crack down and not return to the status quo. Crises have the potential to undermine democratic values and thrust authoritarianism forward, and historically, emergency measures have tended to become the new normal. Not surprisingly, as a result of this extraordinary crisis with Covid19, extraordinary laws have had to be introduced. This is known as pandemic backsliding: the

Social and political impacts  223 extent to which governments are violating democratic standards for emergency provisions in response to the Covid-19 crisis (Varieties of Democracy, 2020). While some emergency provisions may need to be in place, such as temporary limits on personal freedoms, we are witnessing some leaders abusing these tools to enable more permanent autocratization. Authoritarian leaders and would-be autocrats are engaging in authoritarian entrepreneurship or experimenting with what might be possible in this new reality. As protests violate the necessity to social distance, countries have faced little push-back in banning them. This gives autocrats and would-be autocrats room to push through authoritarian measures without risking dissent. Questioning the government can be seen as traitorous or unpatriotic, while many citizens crave calm and order and a robust national response to the crisis. The response in some cases has been disproportionate to the crisis, or at least not necessary for addressing the outbreak. There are certainly difficult trade-offs that governments have to weigh in balancing human rights, civil liberties, human security, health, well-being, and economic welfare. The UN special rapporteurs on human rights cautioned, however, that emergency responses need to be proportionate, necessary, and non-discriminatory. The response from governments in the name of public health should not be used as a pretence to repress civil liberties and political rights. But because of the lethality of the virus and the need to social distance, civil liberties have been curtailed everywhere and on a massive scale. Freedom of assembly has been restricted as has freedom of movement. In some cases, elections will have to be postponed to safeguard voters. In many countries around the world, these extreme measures have been taken to save lives. However, some countries have also used the virus as a reason to suppress political activity. In Uganda, President Yoweri Museveni used the outbreak to ban elections, public rallies, and political gatherings (Daily Monitor, 2020). In Bolivia, elections were postponed by the interim president Jeanine Áñez, who has since consolidated more power and announced her plan to run for election (Ramos and Machicao, 2020). Checks and balances have been ignored in the name of the need for decisive action and greater executive power. Many countries have also used the virus to push forward legislation without any debate. In Romania, an emergency vote was passed that gave the premier full powers without any opposition (Daragahi, 2020). In the UK, the parliament rushed through a bill that would give the government the power to detain and isolate people indefinitely. The legislation gives tremendous power to border agents and the police which could lead to individuals being indefinitely detained (Gebrekidan, 2020). Many countries are seeing their leaders being given emergency powers. In the Philippines, Rodrigo Duterte declared a state of calamity for six months and has been granted emergency powers by Congress (McCarthy, 2020). In El Salvador, President Nayib Bukele requested emergency powers enabling him to limit not just travel and assembly but also free speech. Other regimes have used the virus to undermine the press and the opposition. Egypt revoked the credentials of correspondents who had reported research that criticized Egypt for politically managing the official cases. Jordan ordered a closure of all print and news outlets (McCarthy, 2020). Additionally, an emergency defence law gave power for the Prime Minister Omar Razzas to deal firmly with anyone who spreads rumours, false news, or sows panic (ibid.). In Cambodia, Hun Sen’s regime used the pandemic to arrest those who spoke out about the crisis, targeting the media and the opposition. In Thailand, Prime Minister Prayuth Chan-ocha has the authority to impose curfews and censor the media. Anyone who is perceived to be criticizing the government’s response to the crisis has been sued (Gebrekidan, 2020). In the Philippines, Duterte threatened to shoot anyone who creates chaos. The

224  Impact of disease and disaster president has warned that he would crack down on ‘fake news,’ but it is Duterte who is the arbiter of what is fact and fiction (McCarthy, 2020). In Turkey, Recep Erdoğan used existing laws to investigate anyone who criticises the government’s handling of the pandemic on social media. Since the start of the pandemic, hundreds of people have been detained for disobeying these laws (Amnesty International, 2020). Municipalities that are controlled from the opposition are also banned from accepting donations which they were collecting to help people affected by the pandemic. The regime wants to ensure that it can take full credit for handling the pandemic (Buyuk, 2020). Other countries are becoming much more militarized in response to the crisis. In El Salvador, security forces were given the power to crack down on those who violated quarantine and police used pepper spray on thousands of street vendors and others who had flooded the streets demanding financial support. Opponents of this have charged that Bukele is using a public health crisis and to militarize society and suspend civil liberties (Maza, 2020). In Chile, a state of catastrophe was declared and the military was sent out to police the streets in order to mute dissent and protests in public squares. Soldiers have been also deployed to patrol the streets in Serbia (Gebrekidan, 2020). Another trend is the use of surveillance and devices to track citizens’ movements and behaviour and to collect personal data on smart phones. Once surveillance measures are brought in to fight the virus, it will be more difficult to eliminate them in the future. In Cambodia, a state of emergency was declared that allows Hun Sen to use surveillance of the population (Maza, 2020). Though Singapore has been lauded for its early handling of the crisis, civil liberties, such as rights to privacy, have been violated in order to control the virus – with public support. The health ministry has posted detailed information online about each coronavirus patient. Invasive surveillance systems are in place that have been praised by citizens for slowing infections. In Montenegro, the government has published the names and addresses of citizens who are supposed to be in quarantine as a means of ensuring that they comply with these orders. Even in democratic countries like Italy, Austria, and Germany, the state is using mobile phone data to track the movement of their citizens. Monitoring citizens is critical to containing the virus but carries risks of aggrandizing government power vis-à-vis its citizens. Populist authoritarians, in particular (for more on this, see Chapter 10), have taken advantage of high levels of public anxiety and targeted minorities and foreigners. In India, Prime Minister Narendra Modi used the crisis to demonize peaceful Muslim protesters, who have objected to the new controversial citizen law. In the US, the Trump administration took advantage of the crisis to push for sweeping powers to eliminate the legal protection for asylum seekers and detain individuals without a trial. A pared-down proposal had to be submitted after this was met with resistance from Congress. By late April, Trump declared a moratorium, effectively suspending all legal immigration. In Israel, Russia, and Hungary, in particular, the virus has been used as a way of further autocratizing their regimes and prolonging the rule of their leaders. In Israel, Prime Minister Benjamin Netanyahu used the crisis to declare a state of emergency and then used his emergency powers to delay his corruption trial. After Netanyahu failed to form a government three times in the past year, his biggest opponent in the parliament, Benny Gantz allowed Netanyahu to stay in office for at least two more years, claiming that the crisis required unity. Though the Knesset had a slight majority that was centre-left, the speaker of the parliament agreed to freeze the parliament, enabling Netanyahu to govern unfettered. Netanyahu also blocked the parliament from sitting and granted extraordinary domestic surveillance powers to the internal intelligence agency (Bieber, 2020). The cabinet was able to bypass

Social and political impacts  225 the parliament to enable Shin Bet (the Israeli Security Agency) to use technology that was developed for counterterrorism to tap into the data of mobile phones used by suspected coronavirus patients, or anyone in the vicinity of these suspected patients. Netanyahu has also dominated the airways with daily televised briefings on the crisis but has refused to take any questions from the press (Srivastava, 2020). In Russia, Vladimir Putin has also taken advantage of the crisis to expand his power. In March, Putin moved to push for the passage of a complex series of constitutional amendments that would change the structure of the Russian governments and enable Putin to remain in power until 2036. Knowing that no protests could take place in response to this move because of social distancing concerns, Putin saw an opportunity to increase his power. A referendum was to be held on April 22, 2020, to approve this but has now been postponed to a later date. As Russia is concerned about both containing the virus and preventing any unrest, the government has increased surveillance on the public, with better facial recognition software that is tied to a network of cameras (with over 1780,000 cameras set up in Moscow alone) that are, in theory, designed to catch individuals who are not quarantining (Reevell, 2020). Social media is constantly being monitored to scan for anyone spreading false information. Authorities are looking into measures that would require individuals to submit reasons online for leaving their homes, with their movements being tracked through smart phones. In Hungary, Viktor Orbán took advantage of the pandemic to implement sweeping reforms that effectively give Orbán total power. On March 30, 2020, the government ruled that he can rule by decree for an indefinite period and has the power to suspend existing laws. Parliamentary oversight was suspended, and there is no sunset clause in the law as to when it will end. In theory, the parliament could vote to end his power, but as the Fidesz party controls two-thirds of the parliament, it is unlikely that the parliament will vote to do so. Orbán had invoked an emergency law in 2015 after the European migration crisis, and his majority parliament kept renewing the law. Elections and referendums were suspended, adding the concerns that one-man rule could go on indefinitely. Hungary also made it a criminal offense to spread misinformation about coronavirus, a law that targets journalists. Anyone who disseminates information that hinders the government’s response to the epidemic could be imprisoned for up to five years. The legislation gives broad powers to the public prosecutor to decide what constitutes false information. Hungary also permanently amended two articles of the criminal code to further limit freedom of expression and penalize people who break quarantine orders and curfews with fines. On top of that, Hungary ended the legal recognition of transpeople (Walker, 2020).

Box 9.1  Knock-on health effects of a pandemic One of the big concerns with the Covid-19 pandemic has been how the focus on the crisis has affected other health issues. Many people have lost access to treatment for a host of different communicable and non-communicable diseases. During the swine flu outbreak, there were more deaths due to acute myocardial infarction (heart attack) and stroke (Rubinson et al., 2013). In the case of Ebola in West Africa, the loss of treatment for malaria, HIV/AIDS, and TB nearly totalled the death toll caused by Ebola (Parpia et al., 2016). A 50% reduction in treatment led to an additional 1,091 deaths from HIV/AIDS, 2714 deaths from TB, and 6,818 deaths from malaria in all three

226  Impact of disease and disaster countries (Smith et al., 2019). The number of children under 5 years of age treated for malaria in Sierra Leone declined by 39% nationally from May to September 2014 (USAID, 2019). The need to divert funds, medical resources, and personnel has meant a decrease in immunizations (for more on the knock-on health effects of epidemics, see Box 9.1). This was a major concern during the Ebola crisis and continues to be a concern with Covid-19 (Patnaik, 2020). In the case of Ebola, vaccination campaigns and community vaccination activities were suspended in all three countries over safety concerns. In Sierra Leone, in September of 2014, there were 75% less children under the age of 1 year who were fully vaccinated (Elston et al., 2017). Vaccinations for measles was 20% lower than what it had been the previous year (ibid.). Overall, hospitals and health clinics in general witnessed sizable drops in treating patients. In Sierra Leone, there was a 70% reduction in weekly admissions and a 50% reduction in major surgical procedures recorded from May to October of 2014, with a 50% reduction from April to June in the case of Liberia (Brolin Ribacke et al., 2016). Hospitals and health clinics also witnessed a respective 60% and 25% decrease in visits for diarrhoea and a 58% and 23% decrease for visits for acute respiratory illness (ibid.). In Guinea, visits to public facilities for reproductive healthcare fell by as much as 41% during the outbreak and a drop in births taking place at health clinics (Camara et al., 2017). As for Covid-19, there are concerns that there will be increased morbidity and mortality for a number of infectious and non-communicable diseases. It will likely have a terrible impact on tuberculosis – the leading infectious killer. A study found that, even if a lockdown caused a temporary 50% reduction in TB transmission, a three-month suspension of TB services, followed by another ten months of trying to restore services to normal would, over the next five years, cause an additional 1.19 million TB cases (Cilloni et al., 2020).

Social and political impacts of disasters Disaster and society Conflict, instability, and displacement and disaster Though there have been few attempts to bridge disaster studies with international relations, there are a growing number of studies that have examined how and whether disasters lead to civil conflict. Much of the literature argues that there is a relationship. Disasters may affect the propensity for conflict in numerous ways. First, they disrupt economic development and may increase income inequality by causing a scarcity of resources (for more on this, see Chapter 7). This competition for scarce resources may occur along ethnic lines, which may trigger more grievances and outbursts. Disasters also create mass disruption, destroying physical infrastructure, preventing the adequate distribution of food and medical supplies. Second, disasters weaken state capacity to such an extent that it creates a power vacuum, which presents opportunities for those who are aggrieved to engage in violent resistance.

Social and political impacts  227 A past study that looked at 12 countries over 14 years found that there was a direct and positive linkage between disaster severity and political unrest (Drury and Olson, 1998). The study did not cover a wide sample of countries, however, and did not differentiate between different types of disasters. Political unrest was measured by demonstrations, riots, armed attacks, and strikes. Another study showed that earthquakes that took place from 1975 to 2002 were more likely to lead to anti-regime rebellions and civil war (Brancati, 2007). Further work has echoed these results, but expanded to look at all disasters occurring between 1950 and 2000 (Nel and Righarts, 2008). The study found that disasters increased risk of conflict both over the short and medium term, especially in low- and middle-income countries, mixed regimes, and among those affected by inequality and sluggish economic growth (ibid.). Earthquakes and volcanic eruptions posed the highest risk of conflict, but climaterelated disasters, such as flooding and hurricanes, also posed a risk. However, other studies have claimed that disasters put countries at lower risk of civil war and may even mollify existing rivalries (Slettebak, 2012; Akcinaroglu et al., 2011). Some sociological research on post-disaster behaviour has found that antisocial behaviour drops during and after disasters as communities come together to help one another. Rooted in studies by Durkheim (1952), sociologists have found that disasters have contributed to increased social cohesion and a general sense of unity (Fritz, 1996). Another study also claimed that disasters can bring about political reconciliation, pointing to the successful negotiations that took place in Aceh Indonesia after the 2004 Indian Ocean tsunami (Billon and Waizenegger, 2007). In spite of these findings, examples abound of disasters preceding conflicts. The Bhola cyclone that hit East Pakistan in November of 1970 was the deadliest cyclone on record, killing upwards of 500,000 people. The West Pakistan-dominated government’s lacklustre response enraged the public, deepening divisions between the two wings of the country. In just over a year, the two wings had split apart, with Bangladesh forming in the East (Hossain, 2018). Additionally, quantitative studies have demonstrated a link between disasters and conflict, although this is dependent on some economic and political factors. One study that looked at data for 187 countries demonstrated that disasters may increase the risk of civil conflict in the short and medium term. This especially affects low- and middle-income countries with high levels of inequality, sluggish economic growth, that are neither fully democratic or autocratic (Nel and Righarts, 2008). Other works have argued that disasters may also play a role in lengthening civil conflicts. In a study that analyzed 224 armed civil conflicts in 86 countries between 1946 and 2005, it was found that disasters increased the duration of conflicts. The argument is that disasters decrease the capacity of the state to repress an insurgency while making it easier for insurgent groups to avoid being captured. Disasters take a huge toll on the government financially which reduces the resources available to engage in counter-insurgency campaigns and nation-building efforts in conflict areas. Disasters also cause extensive infrastructural damage which makes it disproportionately harder on the state to respond. As a result, conflicts become more protracted after a disaster has taken place (Eastin, 2016). The ongoing civil war in Syria may attest to the role that disasters play in driving and elongating conflict. Before the war broke out in Syria, the country faced a prolonged spell of drought that severely affected the eastern and southern parts of the country and upwards of 60% of Syria’s agricultural land. Water scarcity affected over a million people, forcing 60,000 people to migrate to urban areas. While pressures increased on urban areas, rural

228  Impact of disease and disaster areas continued to be aggrieved due to the government’s unwillingness to properly address the crisis. Protests erupted in these neglected countryside villages and towns, starting in the Deraa province, the region hardest hit by the drought (Gleick, 2014). Nevertheless, the drought-conflict thesis has been disputed by another study that claimed that interviews with Syrian refugees proved that migrants who left the northeast due to the drought conditions did not participate to any significant degree in the Arab Spring protests of 2011 and returned home as soon as the protests started (Selby et al., 2017). Adding to this research are studies that claim that countries affected by climate-related disaster face no additional risk of civil war (Omelicheva, 2011; Theisen et al., 2011; Nardulli et al., 2015). There is abundant literature on the impact of climate-related disasters and migrations and population displacement (Marchiori and Schumacher, 2011; Naudé, 2008; Poston et al., 2009). There are predictions that the upcoming years will see up to a billion people displaced because of climate-related issues and disasters (Burrows and Kinney, 2016). This is particularly true of disasters that affect agriculture such as droughts but holds for earthquakes as well (Halliday, 2006). While most of the studies investigating this relationship have looked at migration from developing countries, past studies have also looked at interstate migration in the US, finding that disasters can trigger migration that leads to long-term labour supply shocks (Belasen and Polachek, 2013; Hori et al., 2009). When confronting a disaster event, individuals without resources have few other coping strategies other than fleeing to other locations. In many cases, it is those with the fewest resources and skills who are forced to flee, but recent studies have revealed that climate-related disasters can cause a brain drain of skilled citizens as well (Drabo and Mbaye, 2015). Domestic violence and disaster In addition to looking at conflict and disaster, some studies have looked at the impact of disasters on domestic violence. Though there is scarce data, due to the issues of under-reporting of this type of violence, a host of studies have examined the relationship (Le Masson et al., 2016). Not surprisingly, events that cause stress, economic hardship, loss of social networks, and dislocation will also cause a rise in intimate partner violence. There is stress that comes from the total destruction of infrastructure (such as health, transport, sanitation, welfare, etc.) and housing, which can lead to spikes in domestic violence. As these services contract, more pressure is put on people, raising the probability of domestic violence. Equally, because disasters destroy homes, women may be forced to flee to risky and unsafe settings where they may be exposed to sexual violence and harassment (Castañeda Camey et al., 2020; Bermudez et al., 2019; First et al., 2017). Case studies in both developed and developing countries have found that domestic violence increased in countries after earthquakes, hurricanes, and floods (Gearhart et al., 2018; Parkinson and Zara, 2013). In New Zealand after the earthquake in 2010, there was a 53% increase in callouts for domestic violence (Houghton, 2010). In the case of the US, there was a 400% increased demand for women’s shelters after floods hit the Missouri River in 1993 (Enarson, 2012). After Hurricane Katrina, another study found that there was a fourfold increase in intimate partner violence (Anastario et al., 2009), while another study found that intimate physical violence increased by 98% (Schumacher et al., 2010). After the 2008 earthquake in Sichuan, China, a study showed that all types of family violence increased, including psychological aggression and physical aggression (Chan and Zhang,

Social and political impacts  229 2011). Nevertheless, other studies have cautioned that this relationship may be affected by economic factors (Gearhart et al., 2018). A study looking at four states of India that were affected by the 2004 Tsunami found that it was mostly those who were of a lower socioeconomic status who saw an increase in domestic violence (Rao, 2020). A study of the 2010 Haitian earthquake found that those that lived in areas that faced higher devastation from the earthquake faced higher levels of physical and sexual violence (Weitzman and Behrman, 2016). Disasters have other psychological effects as well, which are explained in greater details in Box 9.2. Disasters and the state Disasters have calamitous consequences on the state as well because they negatively affect the very infrastructure that is needed to help them withstand future ones. Roads, infrastructure, communications systems, and rapid response are often destroyed when a massive disaster event takes place. For example, communication systems are vital to getting the word out about a disaster and orchestrating the response. In Haiti after the 2010 earthquake, however, they stopped functioning. There was no public telephone system available. Making matters worse, few public officials had working mobile phones prior to the earthquake. Roads were destroyed. To rebound from such an impact requires significant investment. And yet, disasters also make revenue collection difficult. In the case of the 1985 Colombian volcanic eruption, the death toll was higher because the disaster destroyed much of the state’s infrastructure. On the day of the eruption, evacuation attempts were undermined when a severe storm taking place at the same time restricted communication. Roads, highways, and bridges were in ruins. Additionally, the main hospital in Armero was completely destroyed by the eruption. Local towns set up temporary relief clinics, but the inaccessibility of vital antibiotics caused over 150 to die from infections or other complications (Marti and Ernst, 2008). Returning to the example of the 2010 Haitian earthquake, educational institutions were particularly hard hit. Over 15,000 primary schools, 1,500 secondary schools, and the three main universities in Port-au-Prince were completely destroyed. Due to delays with customs and the damage to much of Haiti’s infrastructure, it was a logistical challenge to transport heavy goods, such as chairs and tables, for the classroom into Haiti. In the aftermath, makeshift tents were used to teach in. With the total physical destruction of the quake, many child survivors were tasked with caring for loved ones who were injured and were not afforded the opportunity to return to school. The Minister of Education at the time, Joel Jean-Pierre, asserted that the education system in Haiti had collapsed (Cawthorne, 2010). Haiti’s experience with the 2010 earthquake is again illustrative of how disasters can weaken the state. Over 50 healthcare centres and hospitals were destroyed, making it more challenging to give medical attention to those in need. The earthquake ruined a nursing school in the capital and severely damaged the primary midwifery school. Earthquakes in Japan have done tremendous damage to hospitals and created staff shortages, making it more difficult to treat patients (Ochi et al., 2016). In Iran, a 2012 earthquake caused major structural damage to the second floor of the Ahar Baqeraluloom Hospital near the epicentre. In spite of the damage, the hospital still had to admit people who were injured (Pouraghaei et al., 2012).

230  Impact of disease and disaster

Box 9.2  Psychological impact of disease and disaster Not surprisingly, both infectious diseases and major disasters are stressful and can lead to a host of different psychological problems. Past data on epidemics and pandemics have demonstrated that they can cause psychosocial suffering, increased risk of depression, anxiety, and suicide (Cheung et al., 2008; Choi et al., 2020; Dsouza et al., 2020; Khan et al., 2020; Mamun et al., 2020; Pakpour and Griffiths, 2020; Pakpour et al., 2020). This could be caused by directly experiencing the physical illnesses, caring for and grieving for the loss of loved ones, and/or dealing with added economic stresses and constrained coping responses (Sergeant, 2020). Healthcare workers, in particular, are vulnerable to mental health issues brought on by the stressful nature of their jobs during a pandemic (Amerio et al., 2020; Tan et al., 2020). Additionally, people with pre-existing psychiatric disorders will be disproportionately impacted by diseases through direct and indirect biological effects (Asmundson et al., 2020). In terms of pandemics where quarantines are issued, studies have demonstrated that these measures can be associated with traumatic stress symptoms, depression, and loneliness (Ahorsu A 2020; Brooks et al., 2020; Groarke et al., 2020; Killgore et al., 2020). A study of those quarantined during the MERS crisis in South Korea found that persistent anxiety lingered months after the quarantine (Jeong et al., 2016). Pandemics may also cause businesses to close causing undue stress on business owners and furloughed workers. Transportation shutdowns not only make it more difficult to get to work but also to access medication and mental health support for those with preexisting mental health disorders. School closures are particularly hard on lower income families who are disproportionately affected psychologically compared to those from more privileged backgrounds (Cauchemez et al., 2009). School routines are important coping mechanisms for young people with mental health issues (Bahn, 2020). Many schools provided educational and speech therapy for children with special needs (Lee, 2020). Like diseases, the psychological impacts of disasters have been well documented. Survivors of disaster events often face mental health issues in the aftermath (Madakasira and O’Brien, 1987; Neria, 2008; Steinglass and Gerrity, 1990). Some studies have noted that almost half of all people affected by disaster experience some form of depression and/or post-traumatic stress (Kar, 2009). Sometimes these mental health issues extend years beyond the actual event. One of the most studied disorders after disasters is PTSD – a disabling reaction caused by catastrophic events (Lowell et al., 2018; Neria et al., 2008). Though depression onset has been less studied, there have been studies that have looked at this relationship as well. Women tend to face more depression following a disaster than men, because they may have less effective coping strategies available to them. Additionally, people with less support structures are also more vulnerable to mental health issues after a disaster strikes. This also goes for adults who were unemployed. Because earthquakes are among the most destructive disasters in terms of death toll per event, survivors of earthquakes often suffer from long-lasting mental health problems (Neria et  al., 2008). The incidence of PTSD after earthquakes is reportedly almost 25% according to meta-analysis (Dai et al., 2016). After the 1988 Spitak

Social and political impacts  231 earthquake in Armenia, many survivors faced chronic post-traumatic stress, yet few had access to mental health services. After the 2008 Wenchuan earthquake in China (which killed almost 70,000 people, with 18,000 missing and 375,000 injured), the initial prevalence of PTSD was 62.8% among 409 survivors of Qingchuan County, one of the hardest hit areas (Wang et al., 2011). Meteorological and geological disasters have a huge impact on mental health issues. Those who have survived mudslides in Mexico experienced PTSD, particularly in areas where there were mass casualties and displacement. Those who survived the 2004 Tsunami and Hurricane Katrina have also dealt with post-traumatic stress. As many as 40% of children in regions affected by the tsunami in Sri Lanka reportedly suffered from PTSD (Neuner et al., 2006). In the case of Hurricane Katrina, a study found that 39% of victims experienced moderate symptoms of PTSD, with 24% reporting severe symptoms (Satcher et  al., 2007). A  cyclone that struck India in 1999 led to a high prevalence of PTSD and depression, with almost a third of victims reporting that these mental health problems lingered (Kar et al., 2004). Similar depressive symptoms were found after major destructive storms in Bangladesh, India, Nicaragua, and Sri Lanka (Tang et al., 2014). Children are particularly vulnerable to stress after disasters hit (Dyregrov et  al., 2018). Around the world, 175 million children each year are affected by disasters that can be attributed to climate change (Codreanu et  al., 2014). The wide estimate is that 5–43% of children will be affected by PTSD after a disaster hits (Kar, 2009). Children exposed to the eruption of Eyjafjallajökull in 2010 were more likely to have increased respiratory symptoms and anxiety, even three years after the eruption (Hlodversdottir et al., 2018). In a study of 300 children that included several follow up studies after the 2008 earthquake in China, it was concluded that PTSD was more severe in the immediate aftermath but decreased over time. Meanwhile, depression was less severe at the beginning but worsened with time (Cheng et al., 2018).

Disasters and politics Autocratic breakdown Historians have long noted that major disasters have played a critical role in bringing down regimes (Finer, 1997; Perry, 2002). For example, disaster events that crippled agriculture in China led to the overthrow of the Yuan Dynasty (Mote, 2003). More recent work has shed light on the impact of disasters on authoritarian stability. Though disasters do not directly cause political change, they do act as catalysts or tipping points that put into motion potentially provocative social processes (Pelling and Dill, 2006, 2010). A notable cross-national statistical study demonstrated that disasters truncate a leader’s survival in office for the following reasons (Flores and Smith, 2013). Disasters facilitate anti-regime collective action (particularly in urban areas) and expose regime incompetence, eroding public support for the government over time. We explain these arguments in more detail. Disasters can lead to authoritarian breakdown because these events facilitate anti-regime protests (Flores and Smith, 2013). More specifically, disasters force together large numbers of

232  Impact of disease and disaster people, and such physical proximity helps overcome barriers to collective action. Autocrats appear attuned to this threat. For instance, when Cyclone Nargis struck Burma in 2008, the military junta sought to prevent survivors from seeking assistance in larger towns and villages. Within a week of the disaster, the army began forcibly dispersing survivors from makeshift camps, schools, and monasteries (Flores and Smith, 2013). It is also contended that authoritarian regimes are most vulnerable to disasters that occur in urban rather than rural settings (Flores and Smith, 2013). Disasters that afflict the capital city or other densely populated urban areas are more likely to stimulate protest than those in rural or remote areas. In China, the government’s poor response to the remote province of Qinghai after an earthquake in 2010 faced few political consequences for its inaction. But when an earthquake hit Sichuan in 2008 (which killed more than 10,00 children), protests broke out over building code violations and the poor construction of public-school buildings. The government responded with a more robust relief effort, and the regime was able to weather the crisis (Wong, 2008). Finally, disasters have occasionally proved destabilizing when they serve to expose regime incompetence or corruption. In Nicaragua, a massive earthquake that hit Managua in 1972 served as a catalyst for a multi-class insurrection to oust the Somoza regime that had ruled for decades (Drury and Olson, 1998). After it became known that the regime was siphoning off foreign aid that had been donated by the international community, there was widespread public anger. Many sectors of the economy, such as the manufacturing sector, were hit hard by the earthquake, causing these groups to withdraw their support for the regime (Olson, 2000). The regime also excluded key business elite from the reconstruction boom. As a result of the earthquake and how it was dealt with, the Sandinista party, a revolutionary movement, became a more visible threat to the Somoza regime (Midlarsky and Roberts, 1985). An earthquake that hit Guatemala in 1976 led to shock to the military regime, forcing it to change its policy direction (Bates, 1982). The 1972 and 1976 earthquakes in Nicaragua and Guatemala jeopardized the survival of the governments largely due to popular discontent over the way that disaster response was handled (Ferris, 2011). Disasters can also have important implications for democracy. In both non-democratic regimes and democracies, the rate of anti-government protests almost doubles after a major earthquake. After Hurricane Katrina battered the Gulf Coast states in 2005, the Bush administration’s poor performance in addressing the calamity resulted in Republicans losing congressional seats in 2006 and 2008. On average, almost 40% of democracies experience anti-government protests within a two-year period after a disaster event has taken place (Quiroz and Smith, 2010). This doubles if the event is a major earthquake – or one that has more than 200 casualties. In looking at countries from 1976 to 2007 – in any two-year period, 40% of democracies replace their leader after a major disaster event; if this is after a major earthquake has happened, 91% of democracies replace their leaders (ibid.).

Conclusion In this chapter we explained the variety of mechanisms through which infectious diseases and disasters hurt society and the state. The cumulative effect is that societies and states with high rates of infectious disease burden and disasters face serious challenges. Diseases and disasters have far-reaching repercussions on society, impacting crime, domestic violence, displacement, conflict, societal cohesion, and mental health, while the state is often overwhelmed, particularly in the areas of health and education. We highlighted the challenges of major disease events, which impose strains on societies and the state with impacts that are

Social and political impacts  233 long-lasting and extend far beyond the initial event. But it is not just society and the state that feel the reverberations of disease and disaster, but politics as well. Politics is often shaken up by any major event, whether it be a disaster or a disease outbreak. While disasters are more likely to lead to authoritarian breakdown, Covid-19 has led to pandemic backsliding. In the next chapter we look to politics again but, instead of looking at the impact of disease and disaster, we investigate what influence politics has on mitigating risk and addressing security threats. Understanding the political impact of disease and disaster in this chapter has been fruitful to better identifying what needs to be done, as discussed in the chapters that follow. More specifically, we examine what role regime type plays in driving optimal outcomes when it comes to disease and disaster management. While these relationships are not always clear cut, there are lessons to be learned.

Key questions 1 2 3 4 5

What is more likely to drive conflicts: disease or disaster? Explain why you think that may be the case. Do disasters have a negative impact on societal cohesion? Why or why not? Why is it that disasters are more likely to lead to breakdown, while pandemic backsliding is more likely to follow a major disease event? Why do countries with a high infectious disease burden face so many challenges when it comes to education outcomes? In the last chapter we talked about economic scarring after a pandemic. What types of social scarring might take place after a pandemic?

Note 1 As of 2020, 8 countries in Africa out of 50 are considered democratic by Varieties of Democracy.

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Part V

Response

10 Authoritarian regimes, democracy, and populism

Introduction The previous chapter looked at what impact disease and disaster may have on regimes. In this chapter we look at the reverse, or how regime type may impact the management of disease and disaster. In particular, we hone, in on the political institutions of the state and whether or not there are free and fair elections to overturn the executive, what checks may exist on the executive and whether or not the laws afford civil liberties and encourage transparency. Political institutions are the institutions of the state engaged in decision-making, articulating policy, and the selection of public officials. These include executives, legislatures, and elections. To better understand the impact of authoritarian rule, we start by looking at how authoritarian regimes perform when it comes to health in general and then more specifically at studies that look at diseases that are endemic. We conclude that authoritarian regimes do not have a health advantage when it comes to managing endemic diseases, and we explain the theoretical reasons for why this is the case. We follow this with an examination of how authoritarian governments have handled pandemic disease outbreaks, with a major focus on Covid-19. At the time of this writing, it is not clear that there is a democratic or authoritarian advantage when it comes to managing the Covid-19 pandemic. However, there is a clear link between authoritarianism and human insecurity, which has other knock-on effects. It’s not just that authoritarian regimes violate human rights and affect human dignity; authoritarian regimes pose a huge threat to the global community in spreading new infectious disease outbreaks because they block the flow of information that is critical to early containment. In addition to the dangers of preventing pandemics, the chapter will explore some of the problems of authoritarianism when it comes to managing disasters. Covid-19 has also put the spotlight on other forms of rule and misrule. While there is no conclusive evidence that democrats have contained Covid-19 better than autocrats, there may be a populist handicap. The chapter will demonstrate why populist leadership styles may be detrimental to handling diseases. Before doing so, we explain what we mean by authoritarian and democratic regimes. Key concepts

What are democracies and autocracies? Amartya Sen (1994) famously wrote that no famine had ever taken place in a democracy. More recent studies have concurred that famines only take place in authoritarian regimes

DOI: 10.4324/9781003128809-16

246  Response (Murray et al., 2013). For Sen, the reason why this was the case was because democracies have a huge informational advantage. Information flows freely, which is critical to preventing catastrophic events, such as a disease outbreak, from becoming an epidemic and/or a drought from leading to a famine. In addition to the free flow of information, what are other key characteristics of democracies? Democracies are regimes that hold free and fair elections which lead to turnover in power of the executive. Because democracies have regular elections, elected officials have to be accountable to their citizens and must work to represent their interests. As previously mentioned, democracies allow citizens to exercise civil liberties that are important in ensuring transparency and access to accurate information. In contrast, authoritarian regimes (in this chapter, the terms authoritarian regimes, autocracies, and dictatorships are used interchangeably) may hold elections, but there is no turnover in power of the executive. Incumbent autocratic regimes hold a huge advantage that ensures victory time and again. There is little accountability and often little representation. Some civil liberties may be allowed, but any information that could challenge the stability of the regime is usually repressed. Authoritarian regimes may earn some legitimacy from their citizens if they are able to govern and perform well, but the cases of this occurring are more the exception than the rule. Somewhere in the middle are grey-zone regimes which have autocratic and democratic characteristics. These regimes tend to have an uneven economic performance, are prone to higher levels of corruption, and tend to be unstable (Kendall-Taylor et al., 2019). Most of the literature thus far has not looked at the impact of hybrid regimes on health because it is only Table 10.1 Selected countries and the percentage of deaths due to infectious disease, maternal, neonatal, and nutritional diseases Chad: 73% Nigeria: 71% Mozambique: 66.5% Sierra Leone: 66% Burkina Faso: 65.1% Central African Republic: 65% Guinea: 64% South Sudan: 63.7% Sub-Saharan Africa: 63% Liberia: 62.4% Zambia: 62% Democratic Republic of Congo: 61% Cameroon: 61% Angola: 59.5% Togo: 58.9% Zimbabwe: 57.5% Tanzania: 56.6% Kenya: 56% Botswana: 49% South Africa: 45.7% Afghanistan: 37% Yemen: 37% Haiti: 36.6% India: 33.6% Source: Our World in Data, 2017

Bolivia; 27.6% South Asia: 26.7% Myanmar: 25% Peru: 23% Southeast Asia: 18% Venezuela: 15% Colombia: 14.3% Vietnam: 14% Brazil: 13.8% Iraq: 13.5% North Africa and Middle East: 12.8% Latin America and the Caribbean: 11.7% Japan: 8.9% China: 7% UK: 6.9% South Korea: 6.4% US: 5.24% France: 5% Western Europe: 4.5% Russia: 4.1% Eastern Europe: 3.7% East Asia: 3.6% Germany: 3.5% New Zealand: 3.1%

Authoritarian regimes, democracy, populism  247 more recently that distinctions have been made between these regimes and democracies and autocracies – and because there is little agreement about how to draw the line of what constitutes a full democracy and a full autocracy. Thus, for the purpose of this chapter we bunch regimes that are more democratic into one category against regimes that are more autocratic. The two key markers to distinguish democracies from authoritarian regimes in this chapter are whether there are free and fair elections that lead to turnover in power and whether there are civil liberties that ensure the free flow of information. Political institutions and health

Regime type and health Comparative politics has long explored the difference between democracies and autocracies on a number of outcomes including economic growth, economic equality, conflict, and human development. Many studies have also looked at the link between regime type and democracy (for more on the link between resources and health see Box 10.1). For the most part, the literature has argued that democracies perform better than authoritarian regimes on a number of scores, including life expectancy, infant and child mortality rates, and health expenditures (Baum and Lake, 2003; Besley and Kudamatsu, 2006; Bollyky et al., 2019; Ghobarah et al., 2004; Kaufman and Segura-Ubiergo, 2000; Lake and Baum, 2001; Lin et al., 2012; Muntaner et al., 2011; Vollmer and Ziegler, 2009). Though there has been a sharp decline in infant mortality rates around the world, a study looking at the period from 1950–1999 demonstrated that democracies significantly outperformed autocracies (Navia and Zweifel, 2003). Controlling for income, another study found that moving from the most autocratic to the most democratic regime implies significant gains in life expectancy and drops in infant mortality rates (Bueno De Mesquita et al., 2005). According to the literature, democracies are more likely to perform better due to a representation effect; a participation effect; an accountability effect; and a selection effect (Besley and Kudamatsu, 2006). We lay out how this is the case. Democracies have to represent a public which may push for issues, such as better healthcare, and the redistribution of resources and public services in general. In needing to represent the public, democratic leaders may focus more on outcomes that directly improve life expectancy. Adding to this, the public also has better channels and avenues to participate in the decision-making process. Democracies enable knowledge networks and interest groups that drive good policy. In contrast, in countries like China, the government refuses to allow domestic NGOs and activists to establish direct links with their counterparts overseas. Citizens in democracies exercise greater autonomy to speak freely about health issues and concerns and benefit from a free flow of information going from the public to the government and back again (Wigley and Akkoyunlu-Wigley, 2011). Citizens in a democracy also have greater capacity to express themselves and serve as active agents of change (Sen, 1999). Democracies also demand accountability to a broad base of citizens, whereas autocracies are mostly focused on pleasing a smaller elite group (Ezrow and Frantz, 2011). As a result, democracies are more likely to redistribute more resources to health and provide access for a larger group of voters. Norms of equality also increase support for accessible health services. Failure by democracies to pay attention to health issues and make tangible improvements may affect re-election chances (Nelson, 2007). Finally, democracies may have better selection of competent political leaders to implement policies and are more likely to elect more educated leaders (Besley and Reynal-Querol, 2011). Most dictatorships in history have emerged as the result of a military coup, where a

248  Response high-ranking member of the military with little political experience seizes power and rules with an iron fist with little concern about outcomes. In other instances, authoritarian leaders emerge because of hereditary conditions, creating a crapshoot in terms of outcomes. Personalist and populist leaders often emerge at a point of institutional fragility. They take advantage of weakening of institutions and further expedite institutional decay (Lindstaedt, 2021). As the chapter later will show, this type of leadership is often the most ineffective in fighting diseases. Further to these mechanisms, some authors argue that democracies tend to have lower levels of corruption which ensures that the implementation of policy takes place (Kolstad and Wiig, 2016; Rock, 2009). Uganda, led by authoritarian leader Yoweri Museveni since 1986, was involved in a series of scandals, including selling anti-malaria drugs at higher prices (5,000 Ugandan shillings) than the recommended 3,500 Ugandan shillings and the theft of at least US$1.6 million from the $45.3 million disbursed by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) by government officials and community workers (Mackey and Liang, 2012). Uganda currently ranks 166th of all countries in terms of life expectancy. Democracies are also associated with higher levels of access to clean water, which is critical to preventing infectious diseases and leads to a rise in life expectancy (Lake and Baum, 2001). Though China has performed very well in lowering the number of deaths due to infectious diseases, the country still has issues with water scarcity and water management. In 2010, there was water scarcity in two-thirds of China’s 600 cities. In these cities, 80% had no sewage treatment facilities, 90% of groundwater was polluted, and major rivers were incredibly polluted by the dumping of chemicals and fertilizers (Jie, 2016). Further studies in 2018–2019 confirmed that 90% of China’s groundwater is contaminated (Burkle, 2020). This means that tap water is not safe to drink due to water contamination from the dumping of toxic human and industrial waste. Additionally, poor oxygen levels have eradicated normal organisms in all major rivers. Democracies, in contrast, offer more citizens access to clean water because investing in these services is critical to support from the public (Besley and Kudamatsu, 2006). In spite of these positive conclusions about democracy, several studies have countered that there is an authoritarian advantage when it comes to health outcomes (Shandra et al., 2004). According to this argument, authoritarian regimes do not have to deal with bureaucratic and public resistance or with political gridlock which may prevent implementation of unpopular policies. Authoritarian regimes are best suited to handle situations that require simple solutions and rigid planning and implementation (Golinowska and Sowa, 2007). Authoritarian regimes may also be better equipped to deal with situations that require high levels of mobilization and cheap public interventions. As a result, they are able to have a positive impact on social outcomes, such as immunization rates and, in turn, infant mortality rates (Gauri and Khaleghian, 2002; Nelson, 2007). Another study argued that autocracies also perform better in ensuring that there are higher numbers of physicians and hospital beds per 1,000 people (Truex, 2017). More recent work has highlighted that the type of authoritarian regime matters. One study demonstrates that single-party regimes have lower infant mortality rates compared to military regimes (led by a military junta, as in Myanmar) and monarchies (led by a ruling family, as in Saudi Arabia) (McGuire, 2013). Regimes that are led by a single party, such as the Communist Party in China, the People’s Action Party in Singapore, and the Communist Party in Vietnam, function to some extent like democracies in that there is deliberation before decisions take place and there are numerous checks on the leadership. The party often

Authoritarian regimes, democracy, populism  249 recruits technocrats into the party who have some expertise and experience, rather than only cronies (Ezrow and Frantz, 2011). Single-party regimes also seek legitimacy and as such tend to promote an ideology that is indoctrinated into its citizens from a young age. Part of this indoctrination includes convincing citizens of the achievements of the regimea and offering few informational alternatives to these narratives (Lindstaedt, 2021). Another study claims that electoral autocracies (or authoritarian regimes that hold multiparty elections) have an advantage when it comes to disease outcomes (Miller, 2015); other studies argue that authoritarian variation has to do with time horizons; dictators who believe they face shorter time horizons are less likely to invest in healthcare spending (Yan and Lin, 2020). Political leaders with short time horizons lack the incentives to invest in addressing long term health problems as well as in disaster preparedness (Dionne, 2011; Healy and Malhotra, 2009). These studies would then give credence to the argument that personalist regimes (which have the shortest time horizons due to an absence of institutionalised mechanisms for turnover in power) will be the worst in disease management. Personalist regimes are run by one person and are also known as one-man rule. There are no checks on the dictator’s power and the dictator tends to rule with an iron fist (Geddes, 1999; Frantz and Ezrow, 2011). Personalist regimes are free to make decisions at their whim, since there is no one surrounding the dictator who can either challenge the dictator or wants to. As a result, personalist regimes are erratic and tend to perform poorly on almost all indicators (Frantz and Ezrow, 2011). Personalist regimes that are rich in lucrative natural resources, such as oil, may decide to invest nominally in human capital, but the outcomes are lacklustre given their assets (ibid.). In the area of health, disease, and disaster, personalist regimes have purposely curtailed public health infrastructure and education. They prefer not to invest in their people, because an educated and healthy population poses a greater risk to their power. The other issue is that personalist regimes surround themselves and fill government offices with their cronies and other loyalists (Decalo, 1985; Ezrow and Frantz, 2011; Geddes, 1999). The state is therefore filled with individuals with low skills who have no incentive to properly do their jobs. The minister of health may be someone without any experience in medicine, for example. The lack of checks on their power also means that the personalist leader is free to steal from the state with impunity. Without elites or an empowered democratic public to challenge the dictator, the ruler is able to embezzle state funds for his benefit at the expense of investing in healthcare, disease prevention, or disaster preparedness. Siphoning state funds is common in personalist dictatorships because they are often paranoid that their time in power will be limited.1 The dictator also encourages an environment of false reporting and politically managing facts. If the truth is not helpful, it is swept under the rug (Egorov and Sonin, 2011; Frantz and Ezrow, 2009). Take Turkmenistan for example. In 2000, The Turkmen government stopped reporting some of its health indicators to the WHO, making its most recent data up to 1998. It did not provide credible data on HIV and denies that there are any new infections in spite of the fact that there is a sizable population of injecting drug users and sex workers. The government also tried to cover up an outbreak of the plague. Health workers were told to keep silent about the outbreak and were ordered to diagnose it as food poisoning, and soldiers surrounded the facilities where people were being treated (Rechel and McKee, 2007). In 2004, the government placed an unofficial ban on diagnosing communicable diseases, such as tuberculosis (TB), measles, dysentery, cholera, and hepatitis, with doctors reportedly prohibited from mentioning these diseases in any documents, including death certificates. Additionally, the

250  Response country has low levels of expertise in diagnosing diseases. The World Bank also reported that there is little commitment to control TB (ibid.). True, politically managing the numbers and hiding disease outbreaks can happen in single-party regimes as well (as the case study of China will illustrate), but these regimes usually have more potential whistle blowers who are willing to come forward. Single-party regimes are also more capable of handling health challenges because they tend to invest in health in order to achieve their programmatic outcomes of economic growth and economic expansion. How different types of dictatorship approach disease depends largely on the type of disease. Diseases that may affect people in the prime of their lives and affect urban areas that are needed to motor the economy may be taken more seriously by single-party regimes than diseases that affect rural areas. Personalist regimes usually have very little incentive to adequately address any infectious diseases, but there are exceptions. Paul Kagame (a personalist leader) of Rwanda has invested in the overall healthcare of Rwandans and has won accolades from the international community for his commitment to infectious disease control (Iyer et al., 2018). Yoweri Museveni (another personalist leader) of Uganda has also worked hard to target the AIDS crisis with some success (Allen and Heald, 2004). But for every Museveni and Kagame there are many others (like Idriss Déby of Chad and Paul Biya of Cameroon) who have allowed infectious diseases to run rampant with little investment or preventative measures in place to address them. Thus, for the most part, the literature espousing an authoritarian advantage lacks robust quantitative evidence. Nevertheless, there have been notable case studies that have demonstrated strong results from authoritarian regimes. Child mortality rates have decreased under Augusto Pinochet in Chile; life expectancy in Cuba (78.66 years) is higher than in the US (78.54 years); life expectancy in Singapore (82.9 years) and Hong Kong (84.68 years) is even higher than in Australia (82.5 years); life expectancy in China was 44 years in 1960, but government efforts under its authoritarian regime have lifted this to 76 years today. Much of the health successes in authoritarian regimes took place in communist single-party regimes (see Box 8.1) that had specific long-term objectives to achieve. In order to ensure that labour remained productive, communist countries worked to provide basic sanitation and universal health coverage for their citizens. In line with this argument, one study argued that autocracies have done well in countering infectious diseases that threaten people when they are at their most productive age, while more likely to ignore health threats that affect older populations (Rosenberg and Shvetsova, 2016). This counters the argument that authoritarian regimes have an interest in preventing human development because improved health and education outcomes may enable citizens to mobilize against their regimes. However, as some recent work has already highlighted, concern for productivity may mostly be taking place in single-party regimes (McGuire, 2013). Regardless of the variation within dictatorships, other recent works have emphasized that democracies lead to more positive health outcomes than autocracies in general. A study that used a dataset covering more than 170 countries from 1900–2012 found that democratic rule, measured by looking at the quality of competitive elections, has consistently had positive outcomes on a population’s health, even when taking good governance into account (Wang et al., 2019). We can also see a correlation in the role of regime type on disease management. Recall from Chapter 2 the concept of DALY (disability adjusted life year). This measurement looks at the overall disease burden as demonstrated by the number of years lost due to poor health, disability, or early death. One DALY equals one lost year of healthy life. In 2017, 28% of the

Authoritarian regimes, democracy, populism  251 DALYs was attributable to infectious diseases (Our World in Data, 2017). To date, there are no studies that have examined how regime type affects DALYs due to infectious disease. However, the data available shows that countries with the highest DALYs recorded for infectious diseases are in authoritarian regimes in sub-Saharan Africa. The only democracies that perform poorly on this measure are South Africa with 21,500 DALY rates out of 100,000, Botswana with 17,400, and India with 13,200. This compares with the country that has the highest DALY rate: authoritarian Central African Republic which records 53,800 (Our World in Data, 2017). That being said, almost every country in the world has improved on this score, whether they are authoritarian or democratic, but democratic regimes have improved the most. At the moment, most authoritarian regimes are unable to respond to new challenges and lack advanced medical technologies. They may be unable and unwilling to innovate, factors which led to the collapse of the Soviet health system (Golinowska and Sowa, 2007). The need to innovate and respond to new challenges is especially important in addressing infectious diseases. While authoritarian regimes may be able to implement vaccinations, they may be unwilling to adequately deal with all endemic diseases if the leadership sees no benefit in doing so for their political survival.

Regime type and endemic diseases With the exception of HIV, there have been few studies in comparative politics about political institutions and endemic diseases, with most of the literature focused on infant and child mortality rates and life expectancy. One of the few studies looking at the relationship between regime type and malaria demonstrated that it is resource-rich dictatorships that perform the worst in controlling malaria, compared to resource-rich democracies (Chang, 2020). Studies that have looked at the HIV/AIDS crisis have found that democracies tend to perform better than autocracies in terms of providing access to treatment by antiretroviral drugs for HIV patients (Baum and Lake, 2003; Besley and Kudamatsu, 2006). These studies caution that the results do not mean that democracy prevents the spread of HIV/AIDS, rather that democracies are more likely to be responsive to the needs of groups affected by HIV/AIDS. Democracies respond to HIV treatment as a public good, while autocracies may target treatment to supporters and party members only. We shed light on some examples of democratic regimes and their record in providing HIV treatment. In Latin America, Costa Rica – an established democracy – is the only country in Central America to provide universal access to antiretroviral therapy (ART or ARV) to people living with HIV/AIDS, as mandated by law since 1996 (Wheeler et al., 2001). Additionally, Brazil was one of the first countries to provide free treatment when it established a programme in 1996 under the democratic leadership of president Fernando Henrique Cardoso (Benzaken et al., 2019). Argentina and Uruguay (both democracies) also provide broad access to ARV treatment (Perez et al., 2015). Nigeria’s transition away from authoritarianism has also helped make inroads in the HIV/AIDS crisis. With 3.1 million people living with HIV/AIDS in Nigeria, the country took important steps to offer better access to treatment. Citizens normally have to pay for healthcare expenses out of their own pocket, but since 2006, the government has provided free ARV treatment at designated facilities (National Population Commission, 2014). In Africa, one of the star performers is Botswana. Botswana is considered one of the most long-standing democratic countries in Africa, but it was also one of the countries that was hit the hardest by the AIDS crisis, having an HIV/AIDS prevalence rate of 26.3% in 2000

252  Response (Avert, 2019). To tackle this, the government of Botswana has made substantial progress in developing its overall health infrastructure and addressing the HIV/AIDS crisis. In addition to working on an aggressive information campaign to prevent the spread of AIDS from both sexual relations and mother-to-child transmission, the government has also worked to offer more treatment to its afflicted citizens. The government was one of the first in the world to offer free routine testing, counselling, and treatment (Escudero et al., 2019). It was also the first country in sub-Saharan Africa to establish public clinics to provide ARV treatment to those infected (Wester et al., 2005). Though demographic projections indicate that AIDS mortality has already peaked in Botswana, the number of ART recipients will double over the next decade. Of the estimated 380,000 people living with HIV in 2017, 320,000 have access to treatment to keep them well. In Botswana, 83% of those infected with HIV know their status and 87% of these are on treatment (Gaolathe et al., 2020). Because of this treatment, Botswana has decreased mortality rates from HIV/AIDS from 12.8/100,000 to 1.16/100,000 after just one year. (Farahani et al., 2014). AIDS-related deaths have decreased from a peak of 18,000 in 2002 to 4,800 in 2018. New infections have decreased significantly, from 18,000 in 2005, to 10,000 in 2010, and down to 8,500 in 2018, with HIV prevalence in Botswana down to 20.3% (Avert, 2019). Botswana has also invested in specialised laboratories, state of the art healthcare facilities, information systems, and training of its healthcare workers. For example, as of 2012, more than 9000 healthcare workers had received training from the Botswana Ministry of Health’s Knowledge Innovation and Training Shall Overcome AIDS Training Program. Botswana has also initiated creative partnerships between the private and public sectors in order to alleviate the shortages in the public sector by enabling private physicians to share the burden of patients (Williams et al., 2016). In addition to these case studies, empirical work has also supported the claim that democracies have, on average, performed better when it comes to prioritizing the HIV/AIDS crisis (Justesen, 2012). Some other studies have highlighted that, while democracies tend to perform better in providing treatment for HIV/AIDS, what matters more is the electoral system (Barnett and Whiteside, 2006). Even in countries with a higher prevalence rate, the groups affected by HIV/AIDS still constitutes a minority of the electorate (an exception may be Botswana which has a plurality system but where HIV/AIDS affected over a quarter of the population at one point). Thus, electoral systems that cater to the majority’s interests, such as plurality systems, tend to generate fewer incentives to address the HIV/AIDS crisis. In contrast, proportional representation systems that represent minorities are more likely to respond to the needs of those affected by HIV/AIDS and are more likely to offer wide coverage of ARV treatment (Justesen, 2012)

Box 10.1  Natural resources: curse or blessing? Are natural resources a curse or a blessing? In the last several decades many studies have asked this question and have examined the impact of natural resource wealth on numerous indicators, including state capacity, economic growth, and regime type. Much of the literature argued that natural resource wealth is detrimental to state capacity, leads to economic underperformance, and facilitates authoritarian stability and corruption (Thies, 2010; Bhattacharyya and Hodler, 2010; Prichard et al., 2018;

Authoritarian regimes, democracy, populism  253 Ross, 2015; Van der Ploeg, 2011). The argument goes that natural resource wealth goes directly into the state without the need to create extractive institutions to tax its citizens or to find ways to stimulate wealth creation. Instead, the state can rest easy and coast with a steady inflow of natural resource revenues that can be used to buy off supporters, which serves to maintain authoritarian stability without needing to provide public goods. Essentially, natural resource wealth disincentivises both the creation of an effective bureaucracy and investment in human capital. Adding to this literature, recent studies have investigated what the implications are of natural resource wealth and health outcomes. In theory, natural resource wealth should have more funds available for public health, which would lead to better health outcomes (Sterck, 2016). However, resource-rich countries have mostly underperformed. In particular, some studies have argued that natural resource wealth may negatively affect healthcare spending (Cockx and Francken, 2014; Hong, 2018; Kim and Lin, 2017; Zhan et  al., 2015). In a study of six Gulf Cooperation Council member states, it was demonstrated that health expenditures per capita are lower than Organisation for Economic Co-operation and Development (OECD) countries of similar income levels (Klautzer et  al., 2014). Another study revealed that a $10 per capita increase in oil led to a 1% decrease in healthcare spending (Hong, 2017). Past work has demonstrated that child mortality rates are higher in resource-rich countries (Maklouf et al., 2017; Wigley, 2017). Studies looking at the relationship between natural resources and infectious diseases have also found a positive association. Resource-rich countries are generally bad at controlling and managing malaria, TB, and HIV/AIDS (De Soysa and Gizelis, 2013; Wigley, 2017). Evidence from one study shows that 50% (21 out of 42 if we include missing values) or even 70% (21 out of 30 if not) of states that eradicated malaria and reported zero malaria cases have average resource rents of 5% or less (Chang and Wei, 2019). The argument for why this is the case is that resource-rich countries don’t have incentives to invest in infrastructure that would lead to human capital creation and disease control. Instead, they offer hand-outs to appease their supporters and invest in their security institutions to maintain the regime’s grip on power. They are also plagued by rent seeking and corruption because the state uses the resources ineffectively to pay off cronies, as this perpetuates regime stability. Because resource-rich countries do not need to tax the public, there is little accountability and pressure to provide certain services such as education, infrastructure, and healthcare. Thus, some of the same mechanisms that contribute to authoritarian stability in resource-rich states also help explain why resource-rich countries perform poorly in controlling diseases. Another issue with resource-rich states is that extracting the resource has serious implications for ecological stability, which can lead to a higher prevalence of disease. Mining, deforesting, and oil extracting activities can lead to outbreaks of malaria in resource-rich countries (Chang and Wei, 2019). These activities also generate water pollution and greenhouse gas emission, which are conducive to the adaptation and survival of mosquitoes (Kweka et  al., 2016; Nkya et  al., 2013; Vittor et  al., 2009). These labour-intensive activities increase migration around these areas, which facilitates disease transmission (Castellanos et al., 2016; Knoblauch et al., 2014). Without proper investment in sanitation and water management, conditions are ripe for malaria to thrive (Chang and Wei, 2019).

254  Response Thus, it is not surprising that a high number of malaria cases are found in resourcerich countries. Nigeria, which is rich in oil, contributes to 25% of the estimated cases of malaria infections in the world (WHO, 2019). Cote d’Ivoire and Mali are also malaria hot spots and have lucrative extractive industries. Most of the malaria cases in Southeast Asia are in countries that are rich in natural resources, such as Myanmar and Indonesia. In Latin America, nearly all of the cases of malaria were found in the gold mining areas of Brazil, Venezuela, and French Guiana (de Oliveira et al., 2013; Douine et al., 2018).

Regime type and a pandemic crisis Just as few studies have looked at the relationship between endemic diseases and regime type, even fewer studies have investigated the relationship between pandemic disease outbreak and political institutions. Covid-19 will change this, as there will likely be an abundance of new studies that will tackle Covid-19 management from every discipline. Initial studies have shown a correlation between democracy and huge outbreaks, but we are still early in looking at the overall response to the disease (Cepaluni et al., 2020). It’s important to note that pandemic response is different than the normal demands of public health. It requires quick implementation and extensive public compliance. Thus, there is a distinction to be made between a routine crisis and a novel crisis. In a routine crisis, political leaders may defer to operational commanders with training for an effective response. The danger with a new crisis is that regimes will not be agile enough to quickly recognize that there is a crisis and try to downplay it. By doing so, the regime may only attempt to address the outbreak after it has become widespread and more threatening. The early weeks, even days of a crisis are critical to getting control over it, and the lack of free information in authoritarian regimes makes it more difficult to rapidly address outbreaks. In spite of their low levels of transparency, authoritarian regimes have boasted that their regimes are better equipped to deal with crises and outbreaks. Vietnam, Hong Kong, and Singapore have all managed Covid-19 with some success. In the case of SARS, though there was a huge cover-up by the Chinese government, China received praise for mobilizing its medical staff to take on huge sacrifices, such as not permitting them to leave their places of work for up to three months, effectively cutting them off from their families and friends. Those healthcare workers who refused were fired. The Chinese government then used television ceremonies to publicize the heroic efforts of healthcare workers to maintain morale (Schwartz, 2012). In the case of Covid-19, China also touted its accomplishments. After serving as the epicentre of the outbreak, China now claimed that it was able to contain the crisis and stem the uptick of new cases. The Chinese government used its extensive coercive power to impose an unprecedented cordon sanitaire to restrict the movement of more than 50 million people across Hubei province (Kavanagh, 2020). A lockdown was also put in place in over 80 cities, so strict that in many places just one person was permitted to leave the house every other day (Fang et al., 2020). For its efforts, the WHO praised China for setting a new standard for outbreak response (WHO, 2020). The regime, led by Xi Jinping, has used the pandemic as an opportunity to showcase to the world its capacity as a global power.

Authoritarian regimes, democracy, populism  255 In spite of this self-adulation, the early handling of the crisis by the regime made the crisis considerably worse. After the SARS crisis, the government spent about $100 million in setting up the largest direct reporting network system in the world. The system was supposed to allow any doctor at any level to directly report signs of a disease outbreak to the central government in real time. In practice this system did little to prevent the spread of the disease to the outside world (Farrell, 2020). Instead, during the early days of the crisis, from late December 2019 into the middle of January 2020, the Chinese authorities concealed that there was a problem, actively undermining the timely flow of crucial public health information. The regime quashed reports that the virus had human-to-human transmission. In late December the director of an emergency room service in Wuhan Central Hospital, Ai Fen posted information on a Chinese messaging app about the mysterious illness (Kuo, 2020). The government immediately reprimanded her for doing so. Another eight doctors who had posted information about the illness were called in and told by the government to stop spreading false information and disturbing the public order. Another medical professional, Dr Li Wenliang was also chastised for trying to publicize the virus. He died a hero several week later. Instead of acting quickly, all whistle blowers were silenced by the Chinese government and forced to recant (ibid.). On December 31, 2019, the Chinese authorities finally informed the World Health Organization that there were dozens of cases of a mysterious illness in Wuhan, but failed to reveal that the virus had already been sequenced in laboratories and was similar to SARS, meaning that it was transmissible to humans (CNBC, 2020). Because of this lack of transparency, the WHO tweeted on January 18, 2020 that the preliminary investigation by the Chinese demonstrated that there was no evidence that the virus was transmissible from human to human (ibid.). Meanwhile, the Wuhan Health Commission continued to insist that there were no new cases. At this crucial point, China concealed information that could threaten the party’s reputation and grip on power. Although less clumsy than with SARS, the government kept all non-Party groups that could have helped prevent the spread of the virus out of the loop. By January 20th, China changed its tact and announced that the virus was spreading from human to human and three days later, the regime put Wuhan and three other cities on strict lockdown. In spite of this measure, five million people left Wuhan before the lockdown was in place for Chinese New Year on January 25th and the regime refused to cancel the Chinese New Year celebrations (Beauchamp, 2020). Chinese officials blamed local and provincial authorities, but the Wall Street Journal reported that President Xi was personally involved in how the disease was handled during the decisive early period (ibid.). These missteps had serious consequences. One recent study found that if China had locked down Wuhan three weeks earlier, it would have reduced the number of cases by 95%, which would have significantly limited the geographical spread of the disease (Lai et al., 2020). The case of China illustrates the cracks in the ‘authoritarian advantage’ arguments. There is not a clear authoritarian advantage when it comes to societal acceptance of restrictions on freedom that may hurt the collective. Some democratic societies were prepared to accept restrictions on freedom and personal data. In many democracies, privacy protections were relaxed to help alert people to get tested. In the case of South Korea, lax privacy rules allowed the state to use credit card, CCTV, and GPS tracking data of people who had the virus to anonymously publicize the results to trace contacts. Quarantines have also been used in most democracies to enclose the outbreak (Morgan and Wang, 2020). Certainly there are more authoritarian societies that are accustomed to dealing with invasions of privacy than democracies, but this is not always the case.

256  Response Furthermore, though authoritarian regimes are more willing and able to quarantine and surveil their publics, they are also more likely to deal with a crisis with a cover up and disinformation campaign even if it undermines their ability to respond effectively (Shih, 2020). Authoritarian regimes have incentives to cover up the severity of a crisis and to politically manage the data to make themselves appear more in control. In contrast, democracies benefit from a free flow of information and transparency and can make use of all sorts of reports to respond more appropriately to danger (Sen, 1994). In contrast, in authoritarian regimes like China, government employees are used to screen and censor online content and guide online discussions, prohibiting any comments that may spur mobilization and collective action (King et al., 2013). The Chinese government has a long history of secrecy from their disastrous responses to the Great Leap Forward (where an estimated 20–30 million people died of famine). Secrecy and order are placed ahead of confronting the truth about a crisis. In the case of SARS in China, as late as April 3, 2003, the Minister of Health insisted that SARS was being managed effectively by the government and provincial leaders tried to prevent any criticism of the regime to surface in the national and foreign media (Tai and Sun, 2011). The mass media in China even failed to publish the WHO global alert about SARS (Zhang and Fleming, 2005). The government also tried to restrict the WHO inspection team’s access to SARS cases (Baekkeskov and Rubin, 2017). There have also been a handful of leaders in authoritarian regimes who have acted as though their countries were completely immune. In Turkmenistan, leader Gurbanguly Berdymukhamedov made the dubious claim that it has no cases of coronavirus, in spite of its proximity to hard-hit Iran. Berdymukhamedov suppressed news about the virus and banned it from being publicly discussed (Kakissis, 2020). In Belarus, President Alexander Lukashenko called the coronavirus a ‘psychosis’ that can be fixed with vodka and saunas. Lukashenko appeared on national television playing ice hockey and hugging other players (Williams and Tétrault-Farber, 2021). In North Korea, Kim Jong Un also initially declared that there were no cases, though the government received funds from the WHO to combat the virus and diagnostic tests from the Russian government and was one of the first countries to shut its borders (Eberstadt, 2020). Authoritarian regimes are also usually more concerned with appearing competent than actually being competent. This image of competence, in most cases, is only an illusion. Most modern authoritarian regimes are low on skill and competence, choosing to mostly blame others when they fail to deliver on any promises. Authoritarian regimes also threaten to punish journalists, bureaucrats, healthcare workers, and other whistle-blowers who might expose information that is negative for the regime. By arresting whistle-blowers, this delays a public health response (Burkle, 2020). Authoritarian regimes also provide their own public and an international audience with misinformation, controlling narratives and inflating how well they are doing, while also exploiting the open information environment in democracies to sow discord. Authoritarian regimes have tried to float narratives that democracies have been unable to manage the Covid-19 crisis. In particular, China has tried to exploit the crisis by downplaying the outbreak of the coronavirus in China since opening up again and publicizing its role in providing aid and equipment, (though some of the equipment has proven to be defective). Russia also sent supplies to Italy and the US, though the company that made ventilators that were sent to the US was conspicuously under US sanctions since 2014. In reality, Germany and France have sent more face masks to Italy than China, but China has publicized its efforts more (Ferraresi, 2020).

Authoritarian regimes, democracy, populism  257 Another issue of authoritarian regimes is many have very low levels of trust and interpersonal trust. Governments of China and Singapore are more of the exception than the rule. Many authoritarian regimes also have high levels of corruption, which fosters low levels of legitimacy in the government. While these low levels of trust don’t necessarily translate into regime overthrow, there are serious implications for how these regimes perform when a disease outbreak takes place. States that have performed the best in dealing with outbreaks have high levels of trust in the government and are willing to comply with orders without the government having to resort to using force. They trust that the information that the government is providing is accurate and that obeying these orders makes sense. These societies also have high level of interpersonal trust which makes them more likely to engage in communityminded behaviour that benefits the greater good, like Japan, South Korea, and Taiwan. In Iran, trust in the government is low and the government faces a legitimacy crisis, which complicated its response to the Covid-19 crisis (World Values Survey, 2020). In these instances, illegitimate governments make poor decisions to please society in the short run to salvage any challenges to their regime. This is what exacerbated the crisis in Iran, as religious leaders in Qom refused to close the holy pilgrimage sites (Tlozek, 2020). The public was also concerned about misinformation, which made it difficult to ascertain what was true and what was false. In Guinea, in the case of Ebola, years of dictatorship, economic mismanagement, and corruption have fostered high levels of distrust in the government. In 2009, protests ended with a massacre of more than 150 people, which further contributed to growing tensions (Field, 2019). As a result of these low levels of trust, when the Ebola virus broke out in Guinea several years later, the community hid the sick, conducted funerals in secret, and worked to elude any contact tracing. Most societies with high levels of trust in the state and high levels of capacity tend to be democratic. But low levels of trust have also affected populist regimes as well. Voters in Brazil and the US have chosen to trust their state governors rather than the central government to lead them (Greer et al., 2020). The following section turns the discussion to focus on populist regimes and explains the dangers of populist governments in dealing with disease outbreaks.

Populism and disease Key concepts

What is populist authoritarianism? Though more robust studies will be needed to investigate this relationship, thus far the governments that have failed the most to deal with the Covid-19 crisis are regimes led by populist authoritarians.2 As of March of 2021, four out of the top five countries with the most cases were all led by populist governments: the 1-US, 2-Brazil, 3-India, 5-the UK – while Turkey and Italy round out the top ten. Russia under Vladimir Putin takes the 4th spot, but Russia is a personalist authoritarian regime.3 Populist authoritarian leaders are democratically elected leaders who break onto the scene by pointing to the flaws in the established system. The elites are painted as a self-serving cartel that controls the apparatus of the state and which has neglected the common man. Populists argue that the nation’s former politicians are part of a corrupt elite that has been condescending and unrepresentative of the true people. The populist leader, on the other hand, has no links to the establishment. Populists advocate overturning the political establishment (or in other words, the ‘deep state’) but have no answer

258  Response about what should replace it. They promise fantasies and vague policy initiatives that, in many cases, are impossible to fulfil. Though in the past, authoritarian populism attached itself to the left, the last several decades has seen the rise of right-wing authoritarian populism. The following paragraphs explain why these types of regimes might perform so poorly when it comes to dealing with infectious disease outbreaks. One of the biggest issues for populist regimes is that they hollow out the state institutions to such an extent that they are unable to deal effectively with a crisis. State capacity is very important for dealing with a crisis as the state needs to be able to extract resources efficiently and implement policies effectively. States need to have established pathways to compel compliance with protocols, and they need to rely on expertise from a host of different specialists in crisis and disaster management. Populists struggle to come through in a crisis because they thrive off of emotions and empty rhetoric and rarely rely on science and expertise. They prefer hiring those who are loyal, such as ill-equipped family members, to fill key positions over non-partisan experts who can provide advice grounded in science and facts. Populist authoritarians are anti-science, which makes it more difficult to offer guidance rooted in evidence (Lindstaedt, 2021). Populist authoritarian leaders also want to sow divisions in society in order to create an usversus-them mentality. Citizens are divided into two groups: those who support the populist leader and those who represent the enemy of the state, usually minorities, immigrants, and anyone that holds views that disagree with the leader. Populist leaders rile up their support base and exacerbate political polarization and politicize issues that normally would require a technical response. In cementing political identities, populists make it more difficult to unite the public in a coherent response to a crisis. In the case of Covid-19, the practice of wearing masks became politicised, with right-wing populists claiming that it was a violation of their freedoms. In Brazil, Jair Bolsonaro used a homophobic slur to mock people who wore masks (Phillips, 2020). In the US, President Donald Trump refused to wear a mask in public and did not encourage his supporters to do so.4 Wearing a mask in the US became symbolic of what political party you belonged to. Another issue with populist regimes is that, because society is so polarised and divided, there are very low levels of trust. Many Western populist democracies have faced declining levels of trust since the 2008 financial crisis, the precursor to the rise of right-wing authoritarian populism. In the case of Italy, which has lower levels of trust in the government, mobile phone data showed that movement continued at 40% above normal levels even though Lombardy was in lockdown (Sylvers and Stancati, 2020). Trust in the government in the US

Table 10.2  Differences between populist authoritarian and authoritarian leadership Populist authoritarian leaders

Authoritarian leaders

Aim to hollow out the state Anti-science Anti-establishment; anti-elite; a political outsider Aim to create huge divisions in society

Do not always attempt to weaken the state Are not always anti-science Are often part of the elite establishment May have scapegoats, but generally aim for little division in society Are not democratically elected Repress the media Usually corrupt, but not always

Are democratically elected Have a love/hate relationship with the media Corrupt

Authoritarian regimes, democracy, populism  259 was also at an all-time low. In the 1960s, 75% of the public trusted the government. In 2020 it was as low as 17% (Gallup, 2020a). Though more people trust government medical advice, Gallup polls have found that over a third of Italians and nearly 30% of Americans did not trust government medical advice (Gallup, 2020b). For Americans, they had to deal with the challenging situation of hearing contradictory messages from the government, from medical experts, and from the president. Low levels of trust in India meant that newly infected individuals displaying symptoms were reluctant to come forward and get tested (Pathak, 2020). Populism and state capacity Thus far, the few studies that have looked at the Covid-19 crisis have determined that state capacity and state society relations are far more important than regime type in determining how well a country responds to a crisis (Greer, 2020). State capacity refers to the infrastructural apparatus available to countries to implement their policies. It also includes the physical infrastructure and the professionalism, quality, experience, and expertise of their employees. States that have nationalized schools and health systems have higher levels of state capacity. High state capacity gives leaders more tools to deal with a crisis. By contrast, authoritarian populist regimes are anti-elites, anti-establishment, and against the deep state, making it more difficult to respond to health crises. Though populist leadership often rises in the wake of a crisis either by imagining a crisis or overexaggerating one; once in power, populists do the opposite. Populist leaders mostly downplay the dangers. Trump called it a hoax that was spread by the Democrats and fake news. The media in Turkey and Serbia initially claimed that their populations were immune from infection. Once these populist authoritarian leaders realized that the crisis could not be ignored, they doubled down on their authoritarianism and took advantage of the possibilities that come from declaring state emergencies. In the case of Covid-19, the countries that were the quickest in taking the virus seriously have had the best results. Populist regimes were quick to reject the severity of the Covid-19 pandemic, with the likes of Trump and Bolsonaro of Brazil declaring that it was just like the flu or would magically disappear. The populist Guatemalan leadership and its top doctor said that the virus would disappear as the temperatures rose (Shadmi et al., 2020). Narendra Modi of India took the outbreak more seriously, but the state did not have the testing capacity to identify newly infected patients and trace their contacts. Moreover, by May, Modi did an about-turn and told Indians that they would have to learn to live with the virus and would need to get back to business (Kazmin, 2020). Though India has an incredibly low death rate from Covid-19, there are claims that the government is not accurately recording the deaths of its citizens (Yeung and Survi, 2020). At the time of this writing, the US, Brazil, and India have the most cases in the world. Others, like Boris Johnson of the UK, dismissed the coronavirus as an exaggerated threat until he contracted the virus himself. Also important was how well the government was able to work with the healthcare system and the capacity and quality of the healthcare system to deal with the inflow of patients. States such as South Korea, Taiwan, Singapore, and Hong Kong have high levels of state capacity, effective bureaucracies with well trained personnel, high quality public infrastructure, and in particular, strong local healthcare departments. These systems were better prepared to organize and contain an outbreak. As previously mentioned, populist authoritarian regimes do not want to invest in state capacity and attempt to weaken it to amplify their own power. Populists are suspicious of experts and aim to fill the state with loyalists, eschewing experienced individuals for new blood.

260  Response Right-wing authoritarian populist regimes have also tended to do away with action plans and preparedness committees in order to streamline state spending (Lindstaedt, 2021). In contrast, technocratic states (such as Singapore, Hong Kong, Taiwan, and South Korea) already had action plans in place to ensure a swift response, though many had the advantage of having learned important lessons after the SARS and MERS outbreaks. Testing widely took place immediately, which allowed for extraordinary tracking of where infected individuals had been. These states had a testing methodology in place, and results were produced quickly as well. In the case of South Korea, tests were ready by early February 2020. By early March, for example, Vietnam was carrying out more tests per capita than the United States (Kleinfeld, 2020). Anyone who thought they could be infected was tested and isolated. India decided not to test widely. This was not just because of low levels of capacity but a deliberate design to keep numbers low. Modi’s initial draconian three-week lockdown was imposed without warning, planning, policy deliberations, and transparency, thrusting 140 million vulnerable workers into a crisis as they could not afford to survive (Kazmin, 2020). In the case of Guatemala, the response from the government has been incoherent and weak. Rules and policies around curfews have changed almost daily (Shadmi et al., 2020). But it’s important to caution that much more work needs to be done to better understand the relationship between populism and disease management. While state capacity is argued to lead to better development outcomes (Acemoglu et al., 2015; Asadullah and Savoia, 2018; Bardhan, 2005), it is difficult to disentangle the impact of populist leadership due to a limited sample size. In our overview of populism, we are using case studies, and it is still too soon to generalise. In spite of that, we offer the case of Trump to highlight the issues of populist authoritarian regimes and offer contrast with Taiwan, a highly technocratic government.

Case study: Trump and Covid-19 The United States has been a leader in medical research and innovation for many years, offering world class medical care to those who can afford it. In spite of these assets, when Covid-19 spread to the US, it was unable to contain its spread and quickly became the world leader in Covid-19 cases and deaths. Much of the blame fell on the shoulders of its thenpresident, Donald Trump, who was criticised for a slow and bungled response to the crisis (Lopez, 2020; Tollefson, 2020). Though the historic neglect and underfunding of state and local public health systems did not help matters, there were clear missteps by the Trump administration and failures of leadership that worsened the crisis. Even before the pandemic hit US soil, the US was made more vulnerable by actions (or inaction) by the Trump administration. Trump’s initial misstep was that he failed to maintain the important health infrastructure that was needed to protect the country from infectious diseases. In 2018, Trump had allowed the White House pandemic office to be disbanded. His initial response was mostly hostile to impartial expertise and to science. Instead, he politicized the crisis and avoided testing to preclude knowing that people were contracting the virus because it would impact the economy and, therefore, his re-election chances. Fearful of upsetting his own base, he also took little decisive action while speaking off the cuff about various cures and panaceas that were not grounded in evidence. He then persistently attacked anyone who contradicted him, while daily touting his success and asking for kudos. Countries that were the most effective in stemming the outbreak were those that could test widely and quickly (at least during the first wave). Early on in the crisis, only 12 state or local labs in the US could perform their own testing. Though Trump tweeted that everything was fine, testing was slow and test results were slow in coming. In the US, it could take up

Authoritarian regimes, democracy, populism  261 to a week to receive the results of a coronavirus test. In Singapore, the results came in three hours (Sim, 2020). The lack of testing and the misinformation about the availability of testing was one of the most dangerous early errors of the administration. The Trump administration bragged on a daily basis that testing capacity was expanding rapidly. In reality, the US government labs had processed only 352 Covid-19 tests in all of February (Biesecker et al., 2020). Initially, tests were only available for those that had travelled from China or had a fever severe enough to be hospitalized. Due to the lack of tests, there was no way to engage in sophisticated contact tracing and quarantining. In April, the US still had fewer tests per 1,000 people than South Korea. Experts criticized that an earlier start in identifying and isolating cases could have prevented such a large outbreak (Morgan and Wang, 2020). There were also no early attempts to coordinate social distancing across the states. With over 3,000 counties, some without health departments, the absence of a centralised federal response led to huge variation in the response within states and between states (Altman, 2020). The patchwork US health system was not shored up by the government to offer support and ensure that hospitals had personal protective equipment, ventilators, and enough personnel to assist the huge spike in cases. Controversially, Trump decided to leave everything up to the governors to sort out. Governors were told that they would take the lead when it came to re-opening their states. After doing so, Trump then declared that he would decide when to re-open the country because as president he had total authority (Durkee, 2020). Trump’s response to the crisis could have been predicted. In dealing with any sort of crisis or disaster, having a professionalized civil service is key. The civil service is not only an important pillar to constrain government power, but it is also necessary to have an effective response to diseases and other health emergencies. Under Trump, sweeping changes have been made to senior appointments, filling the posts with individuals who are only loyal to the President or with incompetent family members (Acemoglu, 2020). As a result, the executive agencies have become more unprofessional and partisan. Trump’s behaviour created an environment where bureaucrats were fearful of speaking up, needing to sugar-coat the reality for him or risk losing their jobs. It’s not just the media that Trump has found fault with. Trump publicly attacked any civil servant who contradicted him. Trump’s administration also undermined and suppressed government scientists who were studying the virus. His appointees have used the US Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) as political tools to serve the administration’s own interests. These agencies were ordered to put out false information and tout potentially harmful Covid-19 treatments (Tollefson, 2020). Due to all of these factors, the US was the country that had by far the most cases of any country and the most deaths. A contrast to the US is the government of Taiwan. As part of its special relationship with China, Taiwan faces numerous challenges in dealing with a host of different issues, including infectious disease outbreaks. Taiwan faced a difficult battle in dealing with SARS because China initially blocked information-sharing between the WHO and Taiwan, which meant it could only obtain information from the WHO website, which was not as up to date as was needed (Schwartz, 2012). Taiwan was better prepared, however, to deal with Covid-19. After being notified by Chinese officials on December 31st about the suspected cases, Taiwan sent a team of experts to China by mid-January and stopped all flights from Wuhan by January 26th. The government then repurposed private production of masks to quadruple the amount available and distributed over 6.5 million masks, 84,000 litres of hand sanitizers, and 25,000 forehead thermometers. The government used surveillance technology to accurately trace cases and take fast

262  Response action to stop the spread (Scher, 2020). To incentivize citizens to stay home, the government quickly put together a welfare programme for affected citizens. Taiwan has also been very open and transparent, offering advice about the pandemic, in comparison to China which has ordered that any research into the origins of the virus seek party approval (Gan et al., 2020). Disasters and regimes Disasters represent a specific type of crisis for regimes to deal with. On the one hand, it is not the same as dealing with an endemic disease, which is a known security threat that remains constant. However, a natural hazard event is also more likely to take place than a pandemic outbreak. As a result of their greater frequency, most governments tend to be better prepared for disasters then they are for pandemics. Even earthquakes, which are the hardest natural hazard events to predict, can be prepared for, since countries that are earthquake prone know that there is always a likelihood that they may occur. With advanced technology, we are also better able to predict when hurricanes will hit, with what strength, and where. To some extent, volcanoes can be predicted; if volcanologists can install proper instrumentation on a volcano and monitor the data, they can make predictions about eruptions. Floods can usually also be predicted to ensure that people take cover and evacuate. Nevertheless, while massive improvements have been made in technology in forecasting disasters, preventing high casualties from natural hazards not only entails high levels of state capacity but also a will to invest in the planning and preparations needed and to adequately respond with relief. A number of scholars have argued that democracies are far better than autocracies in preventing high casualties from disasters due mostly to a greater incentive to do so (Kahn, 2005; Smith and Flores, 2010; Flores and Smith, 2013). In a study of 4300 natural hazards across 57 countries, it was found that countries that are more democratic and more economically equal face a much lower death toll from natural hazards comparatively speaking (Kahn, 2005). The 7.0 earthquake that hit Haiti in January 2010 killed 222,000 people. The next month an 8.0 earthquake, that was 500 times stronger, hit Chile but killed only 500 people. In the case of Chile, stricter building codes and quick reaction from the government to coordinate international and domestic relief effort were critical. Haiti, in contrast, has no national building code. The government was accused of stealing the international aid rather than dispensing it (Flores and Smith, 2013). In 1906 and 1989, massive earthquakes hit San Francisco, CA, and Mexico City, Mexico, respectively. Though their GDP per capita were similar as was the size of the earthquake, the one in Mexico killed three times as many people. In South Asia, a 2001 earthquake that hit democratic India killed 20,000 people. The 2005 smaller earthquake that hit authoritarian Pakistan killed more than 80,000 people. There may also be a positive impact when countries democratize, as countries that previously were authoritarian are better able to prevent mass casualties after democratization. Earthquakes in Peru and Mexico have been more devastating during autocratic rule than democratic rule (Smith and Flores, 2010; Flores and Smith, 2013). Four decades ago, a 7.9-magnitude quake struck Peru, killing about 66,000 people. In 2001, an even stronger earthquake hit but killed fewer than 150 people. The difference was that in 2001, Peru was a democracy, whereas in 1970 it was not. An earthquake of 7.1 magnitude that hit Mexico City in 2017 led to 370 deaths instead of thousands. Past research in this area has noted that political survival lies at the heart of disaster politics (Smith and Flores, 2010; Flores and Smith, 2013). Democracies can punish ineffective governments during election time that do not respond well to disasters. Autocracies may have to face uprisings, revolutions, or violent coups, but the odds are that

Authoritarian regimes, democracy, populism  263 the public may do nothing. Take the case of Cyclone Nargis that hit Myanmar in 2008. The death toll was over 138,000, making it the sixth deadliest cyclone of all time. Not only did the military regime do virtually nothing to help the communities worst affected, it also blocked the arrival of international aid. Afterwards, survivors were prevented from seeking assistance in larger towns and villages. Within a week of the disaster, the army started forcibly dispersing survivors from makeshift camps, schools, and monasteries. By letting people die in outlying areas, the government forestalled the possibility of protest. Ironically, the disastrous performance by the government in handling the crisis set off some initial steps towards political liberalisation of the regime (for more on the political effects of disasters, see Chapter 9). The poorest classes in dictatorships are the most vulnerable to loss of life when natural hazards strike. Citizens living in democratic states can put pressure on their governments to ensure that they are safe, and governments in turn must adhere to these demands or risk being voted out of power. Citizens can demand that safety standards are enforced and precautionary measures are in place if they live in areas that are prone to disasters (Toya and Skidmore, 2007). When Cyclone Nargis hit Myanmar, at the time it was still one of the most authoritarian regimes in the world and had been heavily criticised for targeting minority groups and neglecting the poor. Given that the cyclone affected the poor and the powerless, the local authorities were not proactive in planning and response. No information on cyclone shelters in Myanmar was published, and there were delays in reaching people because the international community was not allowed to access the most affected areas. Studies have demonstrated that the quality of institutions also matters in determining disaster risk (Anbarci et al., 2005; Costa, 2012; Escaleras et al., 2007; Kahn, 2005; Raschky, 2008). Democracies are less prone to the corruption (Nur-tegin and Czap, 2012) which can exacerbate death counts by incentivizing officials not to enforce building codes, infrastructure standards, or zoning requirements (Kahn, 2005, 25–26). In a study looking at 334 earthquakes in 42 countries, it was found that public sector corruption is associated with greater fatalities (Escaleras et al., 2007). Corruption can also serve as a barrier to effective disaster assistance because corrupt governments are less likely to efficiently and fairly distribute payouts. Authoritarian leaders may use disasters to pilfer national accounts or humanitarian aid packages or privilege trusted supporters with private funds. In Nicaragua, after a 1972 earthquake that killed between 3,000 and 7,000 people, injured approximately 15,000, and displaced 300,000 people, the government engaged in kleptocratic behaviour. Instead of helping the victims, dictator Anastasio Somoza Debayle, stockpiled foreign aid and tried to declare emergency powers. Authoritarian regimes may also mismanage the aid that is given to them. Political leaders may use the relief checks to distribute only to their political supporters and family members. Firms that are loyal to the regime may benefit from lucrative reconstruction projects (Pelling, 2003). A study in Pakistan demonstrated that relief aid was distributed only to supporters of the regime in power after the floods of 2001 (Mustafa, 2003). Authoritarian regimes may also be more likely to reject international aid, particularly if it comes from democracies. Disasters in politically sensitive areas, such as the capital, may threaten autocrats, but high casualty events in remote areas may not. In China, in 2008, an earthquake that hit Sichuan was taken seriously, with the government offering relief operations that garnered the approval of the international community. In contrast, a 2010 earthquake that hit the remote province of Qinghai was mostly ignored by the government with few repercussions for the government’s inaction (Wei et al., 2013).

264  Response Within democracies there can also be variations in the response to disasters. In the US, the president has unilateral control over the declaration of disasters. This allows the president to offer more support to states that are strategically important to his political party. Governments may spend less on politically weak or hostile regions, as has been shown in the US (Garrett and Sobel, 2003; Cohen and Werker, 2008). A study looking at India showed that state governments were only responsive to people who lived in areas that had better access to information and electoral accountability (Besley and Burgess, 2002).

Populism and disasters In terms of how populist authoritarian regimes have responded to disasters, there are not any studies, to our knowledge, that have investigated these relationships. However, there may be a relationship between populist authoritarianism (particularly right-wing populism) and a failure to tackle climate change and protect the environment. As environmental security is closely tied to disaster security, it is important to note what studies have thus far looked at these relationships. Case studies have illustrated that populist authoritarian regimes have not been supportive of environmental protection, which has knock-on effects on disaster prevention. In the US under Trump, there was a war declared on science and environmental protection (Tollefson, 2020). The president and his appointees halted policies to decrease greenhouse gas emissions and weakened regulations to limit pollution and protect the environment (ibid.). Brazil has also faced its share of environmental degradation under Bolsonaro, with far greater destruction of the Amazon (for more on this see Box 5.1) and a rise in wildfires in the Amazon (Casado and Londoño, 2019). The rise of the Law and Justice Party in Poland has been singled out as a reason why Poland is lagging in European climate policy and energy transition (Żuk and Szulecki, 2020). In addition to studies looking at populist leadership, there have been quantitative work done that has looked at the connection between populist attitudes in the public and lack of support for environmental protection and the urgency of addressing man-made climate change. Studies looking at populist attitudes in the public have found that, in Europe and the US, individuals who exhibit strong populist attitudes are less likely to believe in humaninduced climate change and more likely to support policies that roll back the fight against climate change (Huber, 2020; Lockwood, 2018; Yan et al., 2021). As the UN’s Intergovernmental Panel on Climate Change (IPCC) has made it urgently clear that much needs to be done to prevent irreversible changes to the environment and more climate-related disasters, there is a greater emergency in addressing what shapes these climate change-sceptic attitudes and how climate policy can generate cross-cutting support from both leaders and the public.

Conclusion Regimes vary in terms of how much they prioritize health and disaster security, and though it’s not totally straightforward, regime type matters in disease and disaster management. The evidence shows that, when it comes to general health outcomes and managing endemic diseases, democracies tend to perform better. We highlighted the reasons why and what the mechanisms are of democratic governance that might give them an advantage on this score. At the same time, authoritarian regimes have made some impressive accomplishments in the areas of health. We explained why that may be the case and which types of authoritarian rule are more likely to achieve positive outcomes in health.

Authoritarian regimes, democracy, populism  265 Nevertheless, while some authoritarian regimes can be lauded for their successes in reducing endemic infectious disease prevalence, when it has come to managing pandemics and, most notably, the Covid-19 crisis, the question of an authoritarian advantage is very controversial. China’s missteps in failing to be transparent about the virus caused the outbreak to be dramatically worse than it might have been. The Chinese government has tried to sell a competing narrative that it has succeeded in controlling the virus while democratic regimes have floundered. In particular some of the biggest and well-established democracies have shown little ability in 2020 to get virus outbreaks under control, such as the US, India, and Brazil. These three countries conspicuously were all led by authoritarian populists in 2020. They possessed some of the worst qualities of authoritarians for managing disease outbreaks, while also sharing the vulnerabilities of democracies. More research needs to be done in this area in order to better understand if a relationship exists, because many Western liberal democracies have also struggled to control their Covid-19 outbreaks. Moreover, the US, Brazil, and India have huge populations, and their per capita infection rates are not much worse than some other non-populist democracies.5 In the area of disaster risk, the chapter mostly looked at the relationship between regime type and disaster management, along with a few studies that examined the impact of populism and environmental security. The results were conclusive that democracies perform better when it comes to addressing disasters. The incentives to manage disaster risk in authoritarian regimes appears to be low. As disaster politics is about political survival, this would explain why there is so much variation on regime type. In the next chapter, we look at the specifics of what the state can do to best manage diseases and disasters.

Key questions 1

Why is it that personalist regimes are the worst performers when it comes to health? What might explain why Rwanda under Paul Kagame has defied these odds? 2 Do democratic publics always care about healthcare and health outcomes? If so, what obstacles exist in democracies to achieving positive health outcomes in disease management? 3 Why do pandemics pose specific risks to human security when they are sparked in authoritarian regimes? 4 With so few cases of populist rule, is it fair to say that populist leaders performed the worst in managing their Covid-19 outbreaks? 5 Why don’t authoritarian regimes perform better when managing disasters? Though there have not been any studies on this, how do you think populists might manage a major earthquake or hurricane?

Notes 1 Because personalist regimes have not institutionalised turnover in power, they live in constant fear that they will be ousted in a coup or killed. They feel that they have short time horizons and need to make the most of their time in power. 2 At the end of 2020, the author contends there were 18 populist governments in power. 3 Some may contend that Russia under Vladimir Putin and the UK under Boris Johnson should be considered populist. 4 Both Trump and Bolsonaro contracted Covid-19 and recovered. 5 In the case of India, the infection rate and death rate per million people is still low, but there are questions about how well the cause of death is being reported.

266  Response

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11 The state and disease management

Introduction What can governments do to prevent, manage, and address disease events and endemic diseases? While international efforts are important (as later chapters will address), the state and the state’s relationship with society are critical to success in tackling these challenges. Taking a slight turn from focusing on the political institutions, we focus on the administrative institutions and specific policies. The administrative institutions (heretofore also referred to as the state) need to be filled with personnel who are competent, well paid, impartial, and committed to public service in order to craft and implement sound policies. The state also needs to be considered legitimate in the eyes of the public so that it has the public’s trust and can easily mobilize society to comply with directives. Thus, as the previous chapter explained, this is more likely to happen in states that are transparent and not personalistic. A commitment to science and research is also critical to responding properly. The chapter begins by explaining what we mean by state capacity. We then turn to look at the role of the state in tackling diseases in the developing world and how the state has been weakened in these efforts. The chapter then explains the role of state in combating infectious diseases that are endemic, with special attention to HIV/AIDS, tuberculosis, and malaria, known as the big three diseases. The chapter then focuses on pandemics and the state (which affect states of all income levels and geographic locations) and what challenges the state faces in responding to these notable types of disease events. Key concept

What is state capacity? In the last chapter we explained the role of political institutions in dealing with diseases and disasters. This chapter looks at what the state can do to prevent, mitigate, and manage diseases, while the following chapter will look at disaster governance. By the state, we are referring to the administrative institutions – the institutions charged with administering the policies of the state as well as regulating and delivering services. These include state ministries and bureaucratic agencies. The state has capacity when it can carry out and enforce regulations that are responsible for providing essential goods and services to the public in many areas. Disease and disaster management (to be explored in the next chapter) are basic products that require state intervention. Administrative institutions are essential to ensuring that government policies are translated into actions and outcomes. Administrative

DOI: 10.4324/9781003128809-17

274  Response institutions ‘make a difference when it comes to the legitimacy of the regime and policy outcomes’ (Hyden et al., 2004, 3). In addition to the implementation of state policies, we look at which types of policies are the most effective. However, we note that administrative officials are not directly playing a role in policymaking as political officials do. They are only responsible for carrying out the laws and guidelines stipulated by policymakers. That being said, even the best-laid plans and policies are bound to fail if the state does not have the capacity to tackle collective action problems. Capacity entails that state agencies are well funded; that state officials are well qualified and experienced; that state officials are well trained and well paid; and that state agencies work together to tackle issues that require multisectoral cooperation (Ezrow and Frantz, 2013). As Chapters 4 and 5 explained, globalization has in some cases weakened the strength and capacity of the state to engage in preventive care and respond to crises (Gills, 2000; Ibrahim, 2013). State capacity and diseases State capacity encompasses the ability of the state to resolve problems and achieve its objectives. States consist of a number of different agencies and institutions that are critical to these efforts, including public healthcare systems and other agencies of the state that need to be coordinated with such as water management, environmental management, education, welfare, and agriculture. In the developed world, the state has been capable of ensuring that most infectious diseases do not become endemic. As Chapter 6 explained, the relationship may be somewhat cyclical. The more developed a state is, the less likely it is to suffer from a high infectious disease burden. For example, in Chad, which is deeply impoverished, almost 67.7% of the deaths are attributable to infectious diseases compared to 3.16% in Italy (Our World in Data, 2017). In comparison, the deaths in nearby Tunisia from infectious diseases are 5.9%. Thus, though environmental factors (described in Chapter 4) are at play, there is a clear role for the state to help manage infectious diseases. Approaches to tackling diseases in the developing world Though state capacity is vital in combatting major public health problems, past approaches to dealing with infectious diseases in the developing world have failed to incorporate the state. Though endemic infectious diseases are deeply connected to development, practitioners have yet to practice an approach that understands the significance of the problem and how it must be tackled. Endemic infectious diseases are more than just a medical problem; they are a major challenge for development. Because of this, infectious diseases necessitate a comprehensive and long-term response that encourages state building rather than undermining it. Donors, international agencies, and economic advisors have not always made the connection between the role of the state and development. In particular, there has been a disconnect between economists of the major international financial institutions (IFIs) and how state capacity affects development and healthcare. Tackling infectious diseases necessitates a strong and capable state, well-trained and well-paid staff at all levels of government, especially at the local level, and coordination efforts from multiple agencies of the state (Ezrow et al., 2015). A strong and effective public healthcare system enables the state to engage in a multipronged approach that includes providing information on prevention, surveillance, diagnostics, and treatment. In spite of this, as explained in Chapter 4, major IFIs encouraged cutting spending in public health.

The state and disease management  275 The massive cuts in social spending came at a time when HIV/AIDS was devouring the African continent (Ismi, 2004). Heads of state in the African Union pledged in 2001 to allocate 15% of their budgets to healthcare, but this commitment has largely not been realized (WHO, Abuja Declaration, 2011). The average healthcare expenditure in Africa in 2015 reached 5.1% of GDP, compared to the world average of 9.8% (World Bank, 2020). Fewer than 50% of the African population has access to modern health facilities (Akanle and Adésìnà, 2018). Weak state capacity exacerbates the transmission of diseases, limiting the ability of the public healthcare system to treat infectious diseases. As the Democratic Republic of Congo’s state has fallen apart, the rate of malaria has also spread. There has been an increase in malaria even in urban areas. In Kinshasa, from 1960–2000, the rate of malaria prevalence increased by almost 1,400%, from 380,000 people to 5.29 million in 2003 (Ferrari et al., 2016). Major donors and international agencies have relied on vertical programs for implementing disease control programs which operate outside the existing general healthcare structure. Substantial funds for public health are channelled through an independently governed structure that is completely autonomous from the public health services (Brown et al., 2014; Magnussen et al., 2004). Vertical programs only address a specific healthcare need and have a limited time commitment. Vertical programs can be successful when a vaccine is available, such as the WHO’s drive to eradicate smallpox were successful.1 For many other diseases, however, this option of administering a vaccine is not available yet, and patients may have a range of different needs that cannot be dealt with by implementing a temporary strategy orchestrated from above. Vertical programs also create institutional duplication and may lead to inefficiencies as facilities may be used incorrectly by recipients. Vertical programs may also undermine state capacity by reducing the responsibility of the state to improve its healthcare services (Brown, 2001). Integrated programs, in contrast, rely on the state to provide their own targets, resource allocation, and coverage (Doherty et al., 2010). Disease control specialists working as technical advisors are integrated within the existing public healthcare system. Though more integrated programs may be slower to build coverage and may not be as easy for donors to monitor, they are built to be a long-term rather than a short-term solution. The organizational structures that require independent staff for each vertical disease program are very expensive and difficult to maintain. Further issues are that they are often unsustainable and bypass and compromise the existing health programs. Infectious diseases necessitate focusing on building the capacity of a public healthcare system, in addition to other agencies of the state rather than just relying on a vertical program. By doing so, these services not only target diseases but also deliver better general care (Unger et al., 2003). In contrast, vertical programs may divert human and financial resources away from poorly resourced systems and create islands of excellence (Gyapong et al., 2010). Instead of strengthening existing institutions, vertical programs weaken them. In many countries in the developing world, the ministries of health have been largely left out of most disease control programs. Many experts have believed that vertical disease control programs are best planned without the involvement of the ministry of health (Rowden, 2013). Mistrust has been very high in the past between international malaria experts and local ministries. Ministries of health can play a critical role, however, as they may be more aware of the specific health needs of the countries they are responsible for and how to best incorporate the solutions offered to the specific context within which they are operating (Ezrow et al., 2015). For example, in Eritrea, the ministry of health played a pivotal role in creating a new strategy to improve the National Malaria Control Program. As a result of

276  Response the highly motivated ministry of health, Eritrea has one of the most successful anti-malaria programs (Mufunda et al., 2007). In 1998 there were 264,023 cases of malaria, but by 2018 there were only 46,440 cases. In spite of some successes in the developing world, the international community often assumes that the state cannot be trusted to implement programs. Supranational commissions have been created to establish supra-ministerial programs that circumvent the power and capacity of the state and have marginalized the health sectors and medical professions in the countries they are trying to help. NGOs and private organizations are presumed to be better able to do so, as they have been used to fill the vacuum left by state withdrawal from social provision (Hearn, 1998; Islam, 2019). Ministries of health are treated as incompetent instead of closely involved to establish comprehensive programs. This creates institutional multiplicity and redundancy. The supranational organization can lead to confusion and conflict between ministries over funds. In order to gain access to funds, ministries have incentives to duplicate rather than focus on what they do best. This model has yet to prove successful anywhere. The state has not been given a say in deciding what is or is not appropriate for their context. Parallel structures of government end up weakening rather than strengthening existing organizations of public authority (Pfeiffer et al., 2008). For the state to gain the sustainable capacity to meet the challenges of malaria, existing state institutions need to be reinforced not weakened. The programs being implemented lack exit strategies, and local governments become dependent on them – with no local capacity being encouraged (Garret, 2007). This makes it difficult to transfer operations or avoid an abrupt abandonment. Donors should work on building effective local health infrastructures. Unless workable ‘local institutions have already been established it becomes difficult for countries to manage when assistance programs leave’ (Garret, 2007, 38). For example, in order to provide treatment for those suffering from malaria, systems must be in place to ensure that people are knowledgeable about prevention and are receiving treatment. States in the developing world have typically been weak and therefore ineffective in dealing with the various diseases that afflict their populations. In order to tackle these challenges better, the state needs to be strengthened in the following ways. First there needs to be more training for technicians and high-level specialists within the public healthcare system. Health facilities lack workers that have the skills to meet the most basic standards of care. The current training for staff and personnel is often inadequate. This is important in applying the technology to support vector control programs (Sharp et al., 2007). In the case of Eritrea, additional training was provided to regional public healthcare staff. Many health workers (as much as 75%) were retrained. Eritrea has also begun to better train healthcare workers by introducing malaria training into the curricula of health-affiliated colleges (Yukich et al., 2009). The training of health officials, personnel, and technicians has been a key factor in reducing malaria prevalence in the country (Nyarango, 2006, 33). There also needs to be better pay, incentive structures, and career paths for those working in public health to ensure that skilled staff members do not leave. One of the biggest problems that most countries in the developing world face is the loss of its healthcare workers. In 2009, Tanzania had a workforce of 25,000 though it needed 90,000 (O’Shea et al., 2009). There are very few trained staff members, and those who are trained are often lured to work in developed countries. Because of low pay, there are few incentives for staff to be productive (ibid.). NGOs and international agencies also pilfer staff of local organizations to work for them, taking some of the best and brightest away from key organizations. This is done without much thought about the consequences. As of 2020 Tanzania has increased its number of

The state and disease management  277 healthcare workers but is still lagging behind the WHO’s recommendations.2 It has a doctorto-population ratio of only 0.3 per 10,000 individuals nationwide and only 25% of the doctors are in rural areas (Sirili et al., 2019). Of the 871 medical officers trained in Ghana between 1993 and 2002, 604 practice overseas (Garret, 2007). In 2000, at the height of the AIDS crisis, only 360 of the 1,200 trained doctors in Zimbabwe remained in the country (Chikanda, 2005). In all of sub-Saharan Africa, which is home to 24% of the global disease burden, there is a deficit of almost one million doctors (Sirili et al., 2019). Because of insufficient personnel in Ghana, a 2002 study found that 72% of all clinics and hospitals were unable to provide a full range of services. Additionally, 43% were not able to provide child immunizations and 77% were not able to provide 24-hour emergency services, such as safe childbirth (Garret, 2007, 26). As of 2019, the problem persists, as there are only 1.1 doctors for every 10,000 people, well below the regional average of 2 (Home Office, 2019). In contrast, the world average is 16 doctors per 10,000, and countries like Switzerland, Sweden, and Germany have 40 per 10,000 inhabitants (World Bank, 2020b). In 1980, Zimbabwe filled 90% of its nursing positions – today only 30% are filled. Only 50 of the 600 doctors trained in Zambia remain in the country (Garret, 2007). From 1997–2007, Kenya lost 1,670 physicians and 3,900 nurses. Malawi reportedly had one doctor for every 40,000 people (World Bank, 2020b). Some have cautioned that this discounts all of the other medical personnel in the country, but of the 60 nurses that Malawi trains every year, it loses about 100, with more than half emigrating to the UK (Mansanjala, 2018). Though Guinea Bissau has been the recipient of many donated supplies, the drugs are stuck in a warehouse because the country lacks doctors to distribute them. Western NGOs and industrialized countries have not helped matters by recruiting medical staff from the developing world. Those working for NGOs have the opportunity to make a hundred times what they could earn at governmentrun clinics (Garret, 2007, 29). Additionally, training and pay levels should not just be applied to the national level but to the regional and local levels as well. Involving local government is important in order to give them a sense of ownership over the success of the project. Local authorities can prioritize spending based on local needs, which gives them a strong sense of ownership (Barat, 2006). Eritrea’s fight against malaria benefited from training and deploying more public health technicians at community clinics. Countries, like Malaysia, have also had success in controlling malaria by using local knowledge at the state and district level and emphasizing the importance of local input. In India, a renewed focus on controlling malaria by focusing on district level capacity has seen impressive results. In India, experienced public healthcare staff members were hired at the district level. Additionally, all district level staff members were given additional training in malaria control. Malaria health workers from high-performing districts were also shifted to districts that were experiencing more problems (Barat, 2006). As a result, India had over 2 million cases in 2000 but by 2013 this number had been cut in half to 881,730 cases. As the previous paragraphs have highlighted, past approaches to dealing with infectious diseases have weakened state capacity rather than enhanced it. For example, Malaysia has been able to control malaria by investing in its overall public healthcare system. Per capita healthcare spending has steadily risen to $348 in 2017 up from $143 in 2003 (World Data Atlas, 2018). Moreover, past approaches have not incorporated local-level governments. The following sections illustrate the importance of enlisting the entire public health system in fighting infectious diseases, instead of relying on stand-alone clinics. In addition to a strong public healthcare system at all levels of government, it is important to build capacity in other areas of the state such as environmental, engineering, and agricultural management.

278  Response Multisectoral collaboration is important to ensuring that infectious diseases are targeted from different angles.

The state and endemic infectious diseases In the fight against infectious diseases, the state can be involved in numerous ways. States need to invest in the public healthcare system and involve their ministry of health. States need to pay and train healthcare workers well at all levels of the healthcare system and have sufficient personnel. States also need to ensure that the public healthcare system has the capacity to conduct diagnostics and surveillance of cases. States need to ensure that they know the accurate number of supplies and treatment. The state can also play a role in prevention through education campaigns and distributing prevention tools, such as free bed nets in the case of malaria, distributing condoms in the case of HIV, and collaborating with other agencies of the state. Finally, the states can also work with local communities to ensure that policies have widespread support. Combatting infectious diseases requires a sophisticated healthcare infrastructure to provide all of these services. In order to gain control over endemic diseases, surveillance is necessary to record the number of cases that exist and communicate this information to health facilities. Surveillance includes recognizing the places where transmission is continuing. When testing for diseases is widespread and encouraged, the public health system can use this information to know what next steps to take. For example, in cases where quarantines are necessary, such as malaria, with extensive testing, those individuals who have contracted malaria can be quarantined to prevent the chances that they will be bitten again by a mosquito which will then transmit the disease to someone else. Since most malaria surveillance systems are poor, only around 10% of the global cases are detected. South Africa and Swaziland have more sophisticated systems and use a malaria information system to document all malaria cases and notify health facilities. In South Africa, staff members also conduct random household visits to confirm cases (Sharp et al., 2007). Additionally, many states need to have access to diagnostic tools. Much of Africa does not have rapid diagnosis capabilities for many different infectious diseases (Bastiaens et al., 2014). Rapid and cheap diagnostics are needed in endemic states to conserve the use of those drugs that are the most effective. This situation, though far from ideal, is improving. In the case of malaria, the number of diagnostic tests nearly doubled from 88 million to 155 million from 2010 to 2011 (Ezrow et al., 2015). India’s successful malaria control program focused on ensuring that early diagnoses were taking place by expanding its laboratory diagnostic capacity. In the case of human African trypanosomiasis, rates of transmission have been greatly curtailed by aggressive case identification particularly in post-conflict countries, such as Angola and the DRC (Hotez et al., 2008). In 2009, the number of cases reported dropped below 10,000 for the first time in 50 years, and in 2018 there were only 977 cases recorded (WHO, 2020c). The state needs to provide accessible treatment for those suffering from infectious diseases as this is often an important step in containing the disease and preventing the disease from spreading. For example, in the case of malaria, treatments have reduced mortality rates by 60% globally from 2000 to 2015 (Cibulskis et al., 2016). But many malaria cases still go untreated or rely on home remedies. A study that took place from 2011–2013 in Burkina Faso found that only 1–9% of sick children visit a community health worker, citing difficulty of access (Druetz et al., 2015). Having accessible public health clinics makes it easier for malarial patients to receive proper treatment. Using antenatal clinics, anti-malaria drugs

The state and disease management  279 can be distributed to at-risk pregnant women. States can also ensure that the most effective medicine is used as treatment rather than home remedies. States can work to procure the best medicines to local clinics, such as Artemisinin-based Combination Therapy (ACT), which is noted to be the most effective treatment for tackling the most virulent types of malaria (Bhattarai et al., 2007; Steketee et al., 2008). Many NTDs can be eliminated through mass drug administration and treating with one or two drugs once a year (Brady et al., 2006; Lammie et al., 2006). HIV can be treated with ARV therapy with great results if patients are offered early treatment. The health systems need to develop more sophisticated information systems to support healthcare delivery. There not only need to be accurate health system data but also information regarding shortages; the supply chain suffers from weak managerial oversight and poor procurement and distribution. Offering treatment at the point of care is one of the most effective ways of curbing malaria mortality rates. National governments need to ensure that procurement processes are fast and administered efficiently. In addition, supplies of needles and clean syringes are particularly important in stemming the spread of HIV to those who have other infectious diseases (Avert, 2019). States can also provide important information about how to prevent the transmission of diseases. One of the simplest and most cost-effective things states can do is educate the population about the importance of using condoms to prevent the spread of HIV/AIDS, treating and re-treating bed nets to prevent the spread of malaria, and covering the mouth when sneezing or coughing and washing hands to prevent the spread of tuberculosis. In addition to educating the population about prevention tools, it has been demonstrated that free distribution of bed nets is important to combating malaria (Cohen and Dupas, 2010; Teklehaimanot et al., 2007). The distribution of bed nets has been shown to dramatically reduce mortality rates, particularly among children. Child mortality rates dropped by about 8% a year in Senegal, Rwanda, and Kenya following the widespread distribution of bed nets in those states and in Vietnam by as much as 37% (Barat, 2006). In Kenya, this involved the government distributing nets free of charge, increasing usage from less than 10% of all households in 2003 to six times that in 2008 (Ezrow et al., 2015). In Eritrea, bed nets are freely distributed at ante-natal clinics and to the general population in malarious regions by community health agents (Yukich et al., 2009, 51). Communities were also involved in the distribution of treated bed nets and in learning more about environmental management. This led to an increase in bed net usage from 20% to 63% in five years. Thus, the state can make an impact by ensuring that treated bed nets are available free of charge or at highly subsidized sales to pregnant women through ante-natal clinics (Steketee et al., 2008). Finally, states can engage in research to better inform state-led disease control programs about how to proceed. Eritrea is developing capacity in entomology and epidemiology at national and sub-national levels to help inform their disease programs of what its priorities should be (Barat, 2006). Improving research on infectious diseases in the specific countries/ regions that have a heavy disease burden provides more up to date and precise information about weather patterns, vector behaviour, and which treatments are most effective. Infectious diseases require coordination and involvement from multiple agencies of the state. Central governments are important to ensuring that multiple sectors of the government are involved. Controlling or eliminating infectious diseases requires that ministries of health are linked to other government ministries, such as environment, education, agriculture, and tourism, along with municipal entities such as engineering, sanitation, and water resources. Instead of having departments working in a compartmentalized manner, more intersectoral collaboration for successful environmental and health management and planning is necessary

280  Response (Mutero et al., 2006). This includes the human and animal health services, agriculture agencies, and waste and water management and sanitation practices. For example, when trash collection is not taking place, rates of dengue fever escalate. There should be environmental health units within government ministries responsible for irrigation. Environmental health officers work with district-level entomologists in order to best understand the vulnerabilities at different localities. Furthermore, these ministries and agencies can be all the more effective when they are also linked to community groups. In dealing with vectors in particular, environmental agencies of the state need to be involved. Environmental management is the planning and organizing of environmental factors to produce unfavourable conditions for vectors. It entails installing, cleaning, and maintaining drains and systematically eliminating standing pools of water and modifying human habitation and behaviour in ways that reduces human-vector contact. Environmental methods also exist to naturally reduce larval habitats, such as intermittent irrigation. In Chinese and African rice fields, for example, intermittent irrigation curtailed larval development while at the same time saving water and reducing methane emissions (Mutero et al., 2006). Irrigation infrastructure and management systems can also be designed to lessen the risk of larval development by minimizing incidences of standing and/or slow-moving water. In addition, household wastewater systems can be improved to ensure that water is disposed in ways that reduce the chances of mosquito breeding. Environmental methods of controlling vectorborne diseases in Africa have rarely been applied (compared to Asia and Latin America), but when they have been applied, they have been successful – particularly in the early decades of the 20th century (Keiser et al., 2005). For example, applying environmental management in the copper mining areas in Dar es Salaam in Tanzania and in Zambia’s copper mines in 1929 was successful (Keiser et al., 2005; Killeen et al., 2002; Utzinger et al., 2002). However, environmental management requires training individuals to acquire more specialized skills, which the state needs to encourage. Many diarrhoeal diseases and vector-borne diseases can be prevented by using improved weather forecasting to predict meteorological hazards. Governments can use this knowledge to predict when severe droughts will take place and when there are risks of cyclones. By knowing this information, states can warn residents through a public education and awareness campaign about the dangers that come from different types of severe weather and reduce the risk of both diarrhoeal and vector-borne diseases (Sahai et al., 2020). During the El Niño event, the Pacific ENSO Application Centre (PEAC) alerted governments, which used this information to warn the public (Lynch and Brunner, 2010). As a result, fewer children than normal were admitted to the hospital for severe diarrhoeal disease. In addition to environmental management agencies and meteorological agencies, one of the most important government ministries in fighting off infectious diseases is water and sanitation. Water projects tend to be planned and managed in isolation from other aspects of development. However, experts in engineering, agriculture and health need to work together. Over 80% of the diseases in developing countries is related to poor drinking water and sanitation (UN, 2003). As many as 85,700 children under 15 years of age die from diarrhoea linked to unsafe water, sanitation, and hygiene facilities (UN, 2019). This is over twice the number of children who die from conflict (30,900) (ibid.). Provision of sufficient clean water (for which minimum agreed-upon standards exist), adequate sanitation for excreta disposal, and management of medical and other solid waste can reduce diarrhoeal disease, typhoid fever, vector-borne disease, and scabies. In a past study of 144 water and sanitation interventions, improved water supply and sanitation resulted in substantial reductions in morbidity from diarrhoea (26%), ascariasis (29%), guinea worm infection (78%), schistosomiasis (77%),

The state and disease management  281 trachoma (27%) and a median reduction of 65% in diarrhoea-specific mortality and 55% in general child mortality (Esrey et al., 1991). A recommendation was that water supply practices be integrated into health programs. Public education on issues of water, latrine use, and hygiene are also vital in any water and sanitation programme. Additionally, the provision of appropriate and sufficient water containers, cooking pots, and fuel early in the relief response can reduce the risk of cholera by ensuring that water storage is protected and that food is cooked (Taylor et al., 2015). Chlorination of water is essential, but supplementary home chlorination might be necessary if acceptable, as is provision of soap and sufficient fuel or firewood for cooking (DuBois et al., 2006). Even the presence of soap used mainly for bathing and washing clothes (200 g per person per month) without education regarding hand washing was associated with 27% fewer episodes of diarrhoea (Connolly et al., 2004).

Addressing HIV/AIDS There are currently two ways of addressing the HIV/AIDS epidemic: prevention and treatment. Prevention requires a multi-faceted approach, however. First, a state needs to maintain a supply of clean needles in the medical industry so that patients are not mistakenly infected with the disease. States also have to regulate the public health system to ensure that blood banks are regulated and reduce the chances that blood transfusions will transmit the disease. Diagnostic tests need to be accessible to citizens and carried out regularly on the population. This is particularly important for the prevention of the transmission of the disease from mothers to their newborn babies or to the children they breastfeed. New paediatric HIV infections have dropped due to starting HIV-infected mothers on ART at the first pre-natal visit and to continue with lifelong ART. The most cost-effective preventions are mother-tochild transmission (Sarkar et al., 2019). As a result of these suggested protocols, new paediatric HIV infections dropped by 52% from 2010–2019 (UNAIDS, 2020). Most interventions showed increased cost-effectiveness when prioritizing specific groups (Sarkar et al., 2019). Condoms also have to be easily available for citizens to minimize the spread of the disease through sexual activity. Condom use, for example, is said to reduce the chance of HIV infection by 70%, and the risk of infection is less than 1% among monogamous couples who use condoms consistently (Smith et al., 2015). Prevention can also be encouraged through education, so that individuals know how to protect themselves and others from contracting the disease. Though treatment for HIV/AIDS also exists, it is a more expensive approach to addressing the disease than prevention. Once diagnosed, HIV-positive individuals must have access to the right drugs to delay the onset of AIDS. There are a number of effective drugs currently on the market for this, though they are expensive. The combination of drugs needed to treat HIV effectively cost as much as $15,000 per year in 2002 (Berwick et al., 2002). Since then, improvements have taken place with the manufacturing of cheaper generic drugs. In Africa, the cost is about $75 in 2018; in the US the cost rose to $39,000 (Rosenberg, 2018). Many hospitals in the developing world also lack access to these drugs as well as other drugs that can help combat the opportunistic infections that accompany HIV infection (Bertozzi et al., 2006). AIDS and Senegal Though HIV/AIDS has had a devastating impact on the quality of life for many living in the developing world, there are a number of success stories, or cases of developing states

282  Response implementing sound policies to combat HIV/AIDS. Here, we highlight the experience of Senegal. Senegal has had a history of public health initiatives that made it better prepared than other countries for dealing with sexually transmitted infectious diseases. For one, it legalized prostitution so that commercial sex workers would have to register with the state. Since 1969, sex workers of 21 years of age can register at local clinics and access free testing for sexually transmitted diseases (Lépine and Treibich, 2020). This led to a general surveillance program and treatment for sexually transmitted diseases, implemented in the 1970s. A national program to fight sexually transmitted diseases was launched in 1978. And as early as 1970, the state put in place policies to ensure safe blood transfusions to control the spread of infections (Putzel, 2003). Once AIDS reached Senegal in 1986, the government moved quickly to respond to the crisis and took proactive measures to curb the spread. The government established a National AIDS Programme in 1986 to coordinate its response, and in contrast to other countries which have had a revolving door of political appointees, the leadership in Senegal has been stable and experienced. The government also set up a HIV/AIDS surveillance system in 1989 and put forth an aggressive education programs to inform the public about HIV/AIDS. Education campaigns took place in schools and communities. Collaboration also took place with NGOs to help with broad-based education programs. The state worked with NGOs to develop training programs to raise HIV/AIDS awareness among members of parliament and with community leaders and the media (Putzel, 2003). Surveys conducted in 2017 indicated that over 90% of the public was aware of how to prevent the disease and 70% of respondents reported that they used condoms, which the state had made widely available (Lakhe et al., 2020). Sex workers were also targeted and encouraged to practice safe sex. In the same survey, over 85% of the adult population was estimated to have easy access to condoms in urban areas and 99% of FSW reported easy access to condoms. A past study demonstrated that by 1997, 99% of sex workers surveyed had reported that they had easy access to condoms (Meda et al., 1999). The government also implemented the usage of systematic HIV screenings of all bags of blood that were used for blood transfusions. In Senegal, since 2010, a law has been in place which stipulates that HIV screenings must be offered free of charge, anonymously, and using rapid diagnostic tests (RDTs) (Lakhe et al., 2020). Senegal was also one of the first countries in sub-Saharan Africa to endorse and support early and broad access to antiretroviral therapy (ART) for people living with HIV (Lyons et al., 2017). Senegal has had strong leadership throughout the AIDS crisis. At the 1992 summit of the Organization of African Unity, Abdou Diouf, Senegal’s then president (1981–2000), asked other African leaders to commit to fighting AIDS. Additionally, Senegal has benefited from support from community leaders, such as religious leaders who have spoken publicly about AIDS and have encouraged open discussion to dispel rumours (Parkhurst, 2017). All of these factors contributed to the low level of HIV prevalence in Senegal. It is currently around 0.5% which is one of the lowest rates in Africa. At the height of the AIDS crisis in Africa, Senegal was recording 5,500 new HIV cases per year. By 2017, this number had dropped to 1,400 (WHO, 2017a).

Addressing tuberculosis Efforts to combat the TB in the developing world have highlighted the importance of investing in the existing public healthcare systems rather than simply relying on vertical programs.

The state and disease management  283 In Tanzania, a new program launched in 1978 that relied on government hospitals and clinics to provide treatment. The program required that patients were properly registered and the details of those who were cured were recorded so that public health authorities could show healthcare workers where TB services were working well and where they could be improved (WHO, 2012). The program proved that TB cases could decline in the developing world using the existing public healthcare system. China has also achieved progress in reducing the TB mortality rate by 80% between 1990–2010 by injecting money into its public healthcare system for detection, diagnosis, and treatment; setting up a better drug supply system; and keeping better records of progress (Wang et al., 2007). Combatting TB requires a sophisticated healthcare system that can diagnose, isolate new cases, and properly treat the disease. The WHO advises that states ensure that there is early detection of TB and early detection of all cases of drug resistant TB. It is also important to scale up the diagnostics and introduce new molecular diagnostic testing platforms to allow for early and accurate diagnosis of TB and any drug resistance. This requires training for how to use these testing platforms. States also need to ensure that they are properly recording the cases of TB and recording deaths due to TB. Improving and expanding information technology is important in order to ensure that electronic medical records are up to date for effective disease control (Lönnroth et al., 2010). The current strategy of most states is passive case finding, which consists of waiting for patients who are ill to seek treatment. This makes it difficult to engage in early detection. Thus, another important strategy is to map out the high-risk groups and plan systematic screening for active TB to improve early case detection. This reduces the risk of transmission and ensures that actives cases access early treatment. The World Health Organization currently recommends that anyone with a continuous cough for three weeks seek treatment for TB (Lönnroth et al., 2010). States should also work to integrate TB care with maternal and child health services in order to provide comprehensive care at the community level, remove access barriers, reduce delays in diagnosis and treatment, and improve the management of the disease in women and children (WHO, 2012). In high-risk countries, using the current BCG vaccine can be effective in reducing mortality rates in those under 5 years of age (Du Preez et al., 2019; WHO, 2018). States need to work to ensure that those who have been diagnosed have access to treatment. Only 57% of those afflicted with drug-resistant TB have completed treatment (WHO, 2020b). This is largely because drug-resistant forms of TB require treatment that is very expensive and often too costly for those afflicted. Offering free treatment is critical to controlling the disease, and thus it is important to treat patients regardless of their ability to pay for the costs of treatment. States need to strengthen regulatory frameworks to ensure that there is affordable access to medicine and diagnostics and other healthcare services. Those who are being treated need to be monitored to ensure that they are being treated properly until they are cured. Governments can also work with HIV programmes to decrease the burden of TB and HIV infection in people at risk of or affected by both diseases. HIV accelerates the disease, moving it from latent to active. About 25% of all TB deaths are due to AIDS, and similarly, 25% of all AIDS deaths are due to TB (WHO, 2015). Therefore, it is important to ensure that HIV patients receive ARV treatment, which substantially reduces the incidence of active TB and can reduce mortality rates due to TB (Churchyard et al., 2014). Expanding preventive therapy can reduce the transmission from TB patients to contacts. Additionally, in terms of preventing care, a comprehensive public health system can work to mitigate the threat of TB. TB is more likely to become active in patients who smoke, who

284  Response drink heavily, use drugs, have diabetes, suffer from immune compromising disorders, and are malnourished (WHO, 2020b). Public healthcare systems need to properly communicate what the risk factors are and work with society to prevent and manage co-morbidities. TB needs to be approached as one of several public health priorities that could be managed in conjunction with other important ones, such as reproductive health, vaccinations, alcohol, and drug abuse prevention, HIV/AIDS services, and/or diabetes care. Recent studies looking at South Africa have found that the transition from hospital-focused TB treatment model to one that focused on out-patient alternatives (or ambulatory care where same day services can be conducted) can reduce costs by 42% (Sinanovic et al., 2015). Community based delivery of TB treatment and services reduces the dangers of hospital transmission but also improves patient quality of life. However, to manage diseases effectively, healthcare integration requires some strategic planning to integrate healthcare safely. A crowded clinic with long waiting times is not an ideal environment for someone with active TB or an immunosuppressed HIV patient (Kwan and Ernst, 2011). Local healthcare clinics need to be wellfunded and prepared to deal with this, and this may necessitate home visits by roving health personnel to help active TB patients to prevent the spread of the disease to others. Tuberculosis in Romania Though there are some lingering issues, Romania is considered to be a case of TB success. Romania has the highest TB burden of any country in the EU, holding 27.4% of the cases and an incident rate that is about seven times greater than the EU average (Golli et al., 2019). However, some progress has been achieved by implementing the DOTS strategy, or five key elements: government commitment, diagnosis through bacteriology, standardised and supervised treatment, uninterrupted drug supply, and regular programme monitoring. The Ministry of Health piloted the strategy in 1997, and by 2005 the plan was implemented across the country as part of a National Strategic Plan. TB services were integrated within the public health services to avoid being stand-alone programmes that are vulnerable to fluctuations in donor funding. TB patients, once diagnosed, are placed in a treatment hospital for the initial treatment phase (37 days for drug-susceptible patients and 120 days for drug-resistant patients). Treatment continues after being discharged through a pulmonary dispensary or their family doctors (de Colombani et al., 2015). Food vouchers were given to treatment compliant TB patients, but this programme has since been discontinued (ibid.). Though Romania has more than halved its TB rate in the past decade, budget cuts from the Ministry of Health threaten to reverse this trend (ibid.). Given the strains on already stretched healthcare systems in most countries in the developing world, eradicating TB, once a reachable goal, has become much more difficult.

Addressing malaria The positive news with malaria is that the cycle of transmission between humans and mosquitos can be broken, either through avoiding or killing mosquitoes (WHO, 2020a). Thus, malaria can in theory be eliminated. Historically, malaria eradication has involved a heavy hand from the state with multisectoral coordination. In the mid-20th century, the US was able to get rid of malaria by observing successes in parts of Cuba and the Canal Zone of Panama. It launched a public awareness campaign, carried out house spray applications, and engaged in water and larvicide management to try to reduce malarial infections in the southern part of the country where malaria was a problem. This effort began in 1947, at which

The state and disease management  285 point 15,000 malaria cases were reported. By 1951, however, malaria was considered eradicated from the US (Faust, 1951). Eliminating malaria is far more involved than just controlling malaria and requires a multipronged approach. One method of elimination involves larval source management (LSM), which targets the aquatic stage of the problem by reducing vector larval habitats. This can be achieved by draining, removing, or filling breeding sites, which kills mosquitoes before they can spread malaria to humans. Larvae, unlike adult mosquitos, are immobile and therefore cannot avoid this type of control strategy by simply changing habitats (Fillinger and Lindsay, 2006). Beyond reducing the number of mosquitoes, LSM also makes it more difficult for female mosquitoes to find sites to lay eggs, reducing transmission risks (Fillinger and Lindsay, 2006). This method requires monitoring open water sources both inside and outside of households as well as wetlands and other aquatic areas (Fillinger and Lindsay, 2006). To be effective, irrigation methods have to be improved in conjunction so that fields are dry enough to disable completion of the larval cycle (Walker and Lynch, 2007). Though LSM has been successful in dealing with malaria in a number of places, it is less common today. One reason for this is that other methods have emerged that are easier to implement. Many parts of sub-Saharan Africa, for example, have far too many small and temporary habitats for mosquitoes for LSM to be feasible. Spraying and treatments can be applied to homes and other areas instead to kill mosquitoes, effectively preventing them from biting and infecting other humans (Curtis and Mnzava, 2000). For example, indoor residual spraying (IRS) entails the application of insecticide to community areas and homes, killing or repelling mosquitoes when they rest on housing fixtures, walls, ceilings, and other areas where mosquitoes could potentially come in close contact with humans. The primary insecticide spray used to do this early on was DDT (dichlorodiphenyltrichloroethane), which was discovered in 1941 and is both effective and inexpensive. Such a strategy led to encouraging results in Taiwan, Latin America and the Caribbean, Italy, and the Balkans, for example, and most of the time eliminated malaria in less than ten years. Though DDT was later banned in 1972 due to its toxicity for animals, other somewhat more expensive insecticides exist that are also effective. Yet, even IRS programs are not as widespread as would be desired: only 5% of people at risk of contracting the disease are protected by it. Though much of the developed world has concentrated on eradication as the solution to malaria, states in much of the developing world and particularly in sub-Saharan Africa have emphasized controlling it. In the Southern Cone countries, aggressive measures to target mosquitoes through spraying have been effective in reducing Chagas disease (Horstick and Runge-Ranzinger, 2018). In addition to IRS, improving the quality of housing, ensuring that there are screens and few openings for vectors to enter also plays an important role in containing diseases (Beier et al., 2008). A third method of controlling malaria which is cost-effective and simple is using insecticide treated bed nets (ITNs). In places where window screens do not exist, treated bed nets can offer individual protection. Bed nets can be a very cost-effective method of controlling the disease because they irritate and trap mosquitos in search of a human host. Each treated net costs around $10 and can cover more than one family member. Though bed nets are being used more and more, they are used only by about half of the at-risk population (World Malaria Report, 2019). In 2018, in all of the 11 most highly burdened malaria countries, 40% of the population sleeps under an ITN, with the highest percentage in Uganda (80%) and the lowest in Nigeria (40%) (World Malaria Report, 2019). In contrast, when over two million treated bed nets were distributed to residents in the Sichuan Province of China, this led to large declines in malaria infection rates (Cheng et al., 1995). By 2015, China only had

286  Response 43 new cases of malaria, mostly coming from Myanmar (Lai et al., 2017). Though the uptake of ITNs has been lower in Africa, a public campaign delivered by health workers to increase the use of bed nets had a positive impact on increasing the uptake of ITNs in Ghana (Adjah and Panayiotou, 2014). A final strategy for malaria control involves treatment and testing. There is no vaccine for malaria, but treatments to deal with it have improved dramatically, reducing global mortality rates since 2010 by 180,000 deaths in 2018, 85% of which were reduced in Africa (World Malaria Report, 2019). When treatment and testing for malaria is widespread and encouraged, the public health system can quarantine those individuals who have contracted it to prevent the chances that they will be bitten again by a mosquito carrier which will then transmit the disease to someone else. The problem with this strategy is that it requires that states have access to diagnostic tools, as well as low-cost treatments. Much of Africa, for example, does not have rapid diagnosis capabilities for malaria, and reliable diagnosis requires experienced lab technicians with technical expertise and proper equipment (Boyce et al., 2017). In the case of Burkina Faso, a 2003 study revealed that 69% of infants from the age of 6–31 months were treated at home and never made it to a clinic (Boelee et al., 2010). Those who can afford anti-malarial drugs may take them even if they do not have malaria to ensure that they do not suffer the negative consequences of the disease. Overuse of these drugs, however, can lead to the parasites becoming more resistant to them (Hyde, 2007). For this reason, rapid and cheap diagnostics are needed in endemic states to conserve the use of those drugs that are the most effective. This situation, though far from ideal, is improving. The number of rapid diagnostic tests (RDTs) has grown from 88 million in 2010 to 412 million in 2018 (World Malaria Report, 2019). Using approaches like these, there have been a number of successes in malaria elimination. Since 1945, 79 states have gotten rid of malaria (bringing the total number of malariafree states up to 109). Of the 106 countries that still face ongoing transmission in 2000, 57 reduced their malaria incidence by more than 75% by 2015, with an additional 18 countries reducing their incidence by more than 50% (World Malaria Report, 2016). Malaria and Vietnam The major lesson from the Vietnam case is that investing in the overall capacity of the public healthcare system (at both local and national levels) coupled with multi-sectoral collaboration is an effective way to fight malaria. Vietnam is chosen as a case study because it is one of the few countries to have made huge increases in public healthcare spending as part of an overall strategy for malaria control. In 1992, Vietnam had over 1.3 million malaria cases and 2,658 deaths (though down from 4,646 deaths in 1991). The decay of the health system and loss of funding contributed to the surge in death toll. The government responded by establishing the National Institute of Malariology, Parasitology and Entomology (NIMPE). The government also reinvested in the public healthcare system, tripling the budget; the overall budget for malaria control increased 10-fold over a 4-year period (Barat, 2006). By 2017, there were less than 5,000 cases and 9 deaths (WHO, Vietnam, 2017a). According to the World Malaria Report, malaria has declined in Vietnam by over 80% in the last decade (2019). How did Vietnam achieve success in its fight against malaria? First, Vietnam invested in its existing public healthcare system. In 1992, the Vietnamese government made fighting malaria a major priority. The budget to fight malaria increased from $500,000 to more than $6 million. This constituted the largest amount spent by the government for fighting

The state and disease management  287 a disease. Overall, the Vietnamese government opted to increase spending on the public healthcare system, with 6.6% of Vietnam’s GDP spent on healthcare in 2013. In 1992 alone there was a 60% increase in health expenditures. Per capita spending on healthcare has steadily increased, growing from $14.50 in 1995, to $17.50 in 1999. By 2018, this number rose to $151.69 being spent on healthcare per person (World Bank, 2020). The Ministry of Health in Vietnam was also directly involved in the health activities and funding for the malaria control program. The state used the Ministry of Health to set up an agreeable work plan and strategy. Steering committees were set up to better connect the government with healthcare workers and to set goals and monitor progress (Erhart et al., 2007). Instead of having an organization that worked outside the public healthcare system, Vietnam integrated technically sound expertise into the existing system of healthcare. Thus, technical expertise did not supplant the public healthcare system but assisted and supported it, working together to develop guidelines and strategies. The National Malaria Control Program, which is managed by the NIMPE, collaborates horizontally from the central to village level (Morrow et al., 2009). Specialized staff worked within the general healthcare system. There is also multi-sectoral collaboration. The Ministry of Health also collaborates with the environmental agencies and the National Institute of Hygiene and Epidemiology (Erhart et al., 2007). The state has worked to ensure that malarious areas are targeted with a comprehensive spraying program to target vectors. To improve the quality of care, Vietnam paid and trained workers within the existing health system better. Poor training of staff can undermine diagnosis and treatment. Though the overall health budget increased, the budget to pay healthcare workers increased at an even faster rate. Increasing salaries helped improve the quality of the overall health network. Healthcare workers were offered greater compensation. All healthcare staff have more resources available to them than in the past to make them more effective (Takashima et al., 2017). Vietnam also paid close attention to training local healthcare professionals and providing them with adequate resources. Vietnam’s healthcare system is decentralized and consists of four administrative levels: central, provincial, district, and commune. There are hospitals at every level with the exception of the commune level where a health station is in place. Preventive care takes place at every level. Health stations are to act in close communication with provincial and district level medical institutions. Health stations reportedly have doctors and nurses at 80% of all stations and all have village healthcare workers (World Health Organization, 2016). At the district and commune level, the budget has also increased to improve the quality of care provided by healthcare workers. Increases in the budget go towards providing healthcare workers with greater compensation and to increase incentives. The budget was also increased to ensure that district and commune healthcare workers have more commodities, supplies, and better training (ibid.). In particular, in areas that had high prevalence of malaria, village health workers were given the resources necessary to engage in early treatment, surveillance and prevention (Ezrow, 2015). Vietnam also improved training of healthcare workers involved in case management and surveillance. Lab capacity was improved to execute this and case workers were better trained in collecting data to gain accurate information (Erhart et al., 2007). Having accurate information helps to ensure that there are enough supplies and resources to treat malaria. Finally, the state also worked with the community and embarked on an education campaign to educate the population on malaria prevention methods. One aspect of the campaign was distributing and educating about the importance of using insecticide-treated bed nets. Bed nets were then distributed to impoverished settings with the assistance of local actors, such as youth leagues, women’s unions, and village heads (Wangdi et al., 2018).

288  Response

The state and pandemics In contrast to endemic diseases, infectious disease outbreaks with pandemic potential require preparation for an event that much of the population may have never experienced before. The population may be asked to take on measures that may seem excessive in the moment. Yet in other cases, the state may need to prevent an overreaction from the public and total panic. Both cases require the state to be prepared and to have an effective communication strategy with accurate information. The governance of responding to a pandemic is complex. It requires coordination across international institutions (more on this in Chapter  13), but also with national and subnational institutions (Hooghe and Marks, 2003). It requires a strong and capable state that is effective in a number of sectors. In order to prevent the spark of a new outbreak, this requires multisectoral collaboration involving the health, veterinary, agricultural, educational, wildlife and environment, and sanitation sectors. Zoonotic risks can be mitigated by routine animal surveillance – controlling animal reservoirs, monitoring high risk populations – such as people involved in animal husbandry, animal slaughter, and the like – and maintaining robust animal health infrastructure (Jonas, 2013; Hughes et al., 2010; LeBreton et al., 2012; Yu et al., 2014). Once a new disease outbreak has sparked, states also need an adequate laboratory capacity to identify the viruses or other infectious agents of concern. Because most laboratories capable of performing the requisite tests are located in capital cities or regional centres, this generally means that samples must be routinely collected and transported long distances. In many low-income areas, even relatively sophisticated laboratories may lack the biosafety capabilities to test for highly infectious agents. Strong responsive communication networks are essential for early outbreak detection, both for coordinating the requisite investigations as well as for integrating data derived from various sources. Poor communication among clinicians and public health authorities can delay the reporting of an outbreak. The public health infrastructure must also have the capacity to identify, trace, manage, and treat cases (Whitelaw et al., 2020). Rapid identification of a disease with pandemic potential is incredibly important. A one-week delay in applying control measures in the case of SARS could have tripled the size of the outbreak (Wallinga and Teunis, 2004). With a major outbreak, the strength of the health system can really be put to the test. A small flu outbreak in a country with a robust health system will likely only have a small impact on the delivery of other health services. In contrast, a fragile health system could collapse completely with just a small disruption. As with endemic diseases, pandemic disease outbreaks are fought off best with universal health coverage.3 The availability of essential services and medicines is critical to ensuring that citizens get help when they need. The most cost-effective strategy for increasing pandemic preparedness is investing in strengthening core public health infrastructure. Already having the infrastructure in place can make a huge difference. In the case of the Ebola crisis, Nigeria benefited from having a robust infrastructure for polio eradication, having built a public health emergency operations’ centre that was quickly converted to deal with Ebola. Additionally, Nigeria benefited from a group of trained epidemiologists who coordinated extensive contact-tracing efforts to control the outbreak. As a result, the country was free of the disease after 3 months and 19 locally transmitted cases. The most effective systems in dealing with disease crisis events are those designed for everyday use and can be scaled up for an emergency or existing infrastructure that can be repurposed

The state and disease management  289 (Heymann et al., 2015). Mali was able to handle the Ebola crisis by using an existing laboratory to test for Ebola cases (Diarra et al., 2016). Successful planning for pandemic events includes the ability to respond with a surge capacity and to scale up the delivery of health interventions that are proportionate with the severity of the event. With the Ebola crisis in West Africa, health facilities in Guinea, Sierra Leone, and Liberia were quickly overwhelmed by the rising number of patients with Ebola; large numbers of health workers became ill and died. Many facilities were shuttered or restricted their services to patients with suspected Ebola infection. States need to stockpile vaccines and medicines, including antibiotics and antivirals. They need to stockpile personal protective equipment, such as masks and gowns, as well as ventilators (Morens et al., 2008). There needs to be a sustained supply of disinfectants, sterilizing material, and single-use injection supplies so that shortages do not occur and force breaches in infection control. During a pandemic, health systems can use these stockpiles rather than having to reactively procure these supplies from external sources or have to produce the supplies in a rush (Jennings et al., 2008). These stockpiles need to be regularly refreshed if they have an expiration date. Channels and systems for disseminating and using these stockpiles must be in place. Countries need to have the infrastructure to transport supplies and personnel quickly (Madhav et al., 2017). This includes a strong road and transportation system and a sound communications network. Local technical capacity is critical to communicating and improving surge capacity, as is the infrastructure to communicate (Kaji et al., 2006). For poorer countries that require foreign assistance, coordination is facilitated if customs processes are streamlined in order to access critical medical supplies and drugs. There must be mechanisms in place to coordinate the deployment and operations of external medical teams. Local absorptive capacity, or the ability to use foreign aid, is often low in countries that need it the most (Eissa, 2020). The epidemiology of disease is always entangled with issues of governance but also with public communication. There must be adequate communications infrastructure to channel information and to undertake effective risk communications. Once a pandemic has started, a coordinated response should be implemented focusing on situational awareness and a public health messaging campaign. The messaging must be clear and simple and delivered by credible sources. Health communication that fails to convey the right information can have huge consequences (Vaughan and Tinker, 2009). States need to disseminate basic information about the disease as quickly as possible – such as how the pathogen is transmitted, how patients are managed, and what constitutes proper protective behavioural measures. For example, a Lassa virus outbreak in Nigeria was avoided by disseminating information about how to avoid exposure to rodents (Odionye et al., 2019). Infectious disease outbreaks with pandemic potential affect populations differently. Some of the reasons for this are societal and demographics factors, such as how immunologically naïve a population is, how well the immune system of the population can respond to the virus, and how mobile a population is. But equally important are the cultural behaviours of a community, the likelihood that a population will comply with official recommendations, the levels of education of a population, and previous knowledge of infectious disease prevention measures (Harper et al., 2020; Roma et al., 2020). The messaging needs to take into account how literate the populations is, what cultural sensitivities exist, and how familiar the culture is with science (Bedrosian, 2016). It’s important to respect the concerns and practices of local communities in order to properly implement health policies and practices (Nichter, 2008). In the case of a Malawian refugee camp that was dealing with repeated cholera outbreaks, the more cost-effective solution of

290  Response chlorinating the water was rejected. However, household contamination was prevented by using a water bucket and spout, which was more familiar to the population and more culturally acceptable. Cultural reasons were cited as obstacles to ensuring that the community in the DRC used oral rehydration treatment during the 1994 cholera outbreak in Goma, which led to a fatality rate of 48% (Siddique et al., 1995). Public health officials also need to quickly identify any rumours and address anxieties. This proved to be difficult in the case of the Ebola crisis in 2014. Many communities rejected the information from experts that clashed with traditional healing and burial practices (Roca et al., 2015). In both Guinea and Liberia, low levels of trust undermined compliance. Though Conakry had established an Ebola treatment centre, disenfranchised residents mistrusted the government and were afraid of being isolated from their families (Dhillon and Kelly, 2015). In Liberia, families were performing unsafe burials for the dead in secret (Fallah et al., 2016). Governments also had to contend with rumours that the disease was created by the government (Epstein et al., 2014). In unstable contexts, citizens may be more likely to believe a rumour that confirms a pre-existing belief (Greenhill and Oppenheim, 2017). Just countering a rumour with scientific facts is not enough. Eventually, grassroots efforts made an important difference. Public meetings were held to discuss fears and concerns. Suggestions were brought up about how to connect with those living in slums and how to formulate public health practices that were compatible with ethnic customs of the community. Local community organizations, which can lead community-based health initiatives are more likely to be successful (Fielding et al., 2013; Teutsch and Fielding, 2013). Trusted local leaders may be needed to explain the risks involved and sources of the disease, a strategy that was effective in dealing with the Nipah virus outbreak in Bangladesh in 2010 (Chakraborty et al., 2016; Teutsch and Fielding, 2013). Additionally, evidence-informed strategies that nudge rather than force populations to comply may encourage wider adoption of behaviours that are critical to stemming the spread of an outbreak. To ensure compliance there must also be capacity to mobilize financial resources to weather the economic shocks and offer financial support for those afflicted and those shielding from the disease outbreak.

Case study: the state and Covid-19 The previous chapter argued that there is no such thing as an authoritarian advantage when it comes to diseases. There will be authoritarian success stories, but the risks that come from authoritarian governments are incredibly high. The one key factor in explaining the success rates of countries that have done well is that they have built up an effective state apparatus and have established strong state-society relations. In some cases, these states are autocratic, or were autocratic in the past, but in most cases these countries are democracies. Two of the most democratic countries in Latin America (the centre of one of the biggest epicentres) are also doing the best in battling Covid-19 – Costa Rica and Uruguay. Both have impressive healthcare systems to tackle the virus along with high levels of democratic satisfaction and trust in the state. In the case of Uruguay, the government undertook an aggressive testing strategy and used contact tracing through an app, which enabled tests to be requested and home visits. Uruguay also increased the number of testing laboratories from one to 25 and sent scientists abroad for more training (Taylor, 2020). The communication strategy from the government was also coherent – with one clear message. Other standouts have had experience in dealing with other diseases which made it easier to deal with the pandemic. Having a national health system in place helped. Taiwan has had

The state and disease management  291 a strong health infrastructure, a clearly communicated plan, expert medical professionals, and total enforcement of rules related to quarantines. Mask-wearing was widespread as were efforts to social distance (Yang and Huang, 2020; Ng et al., 2020). The strong public healthcare system in Mauritius has provided mostly free health services for the population. As the state had experience with testing and tracing to eradicate malaria and dengue fever, the government was more ready to tackle Covid-19 when it arrived on the island. Adherence to the lockdown measures was high and the government encouraged adherence through wage assistance schemes and by distributing food (Sun and Wah, 2020). As the chapter explained, Vietnam has had experience in fighting off diseases effectively. Vietnam shares a land border with China and has a population of 95 million people but had only just over 2,000 cases as of February of 2021 with a death rate of 0.4 per million. Vietnam reported its first case in January and treated the disease as a serious threat from the start. Airport screenings took place, foreign visitors faced travel bans, and there was a 14-day quarantine period for all international travellers. Schools were closed and public events were cancelled. The state rolled out a program of extensive contact tracing as well as quarantines (Huynh, 2020). Any groups of people who lived near confirmed cases were quickly tested and isolated – even third tier contacts were isolated. The government also launched an app that could engage in contact tracing in large cities. Treatment and quarantine in hospitals were provided free of charge for people. The communications campaign was accurate, effective, and extensive. The communications campaign widely shared details on symptoms, preventive measures, and testing sites. Government websites, mass media, and text messages were used, to name a few, to communicate these messages. The primary public health system had been strengthened after dealing with SARS and swine flu. Wearing masks was strictly enforced well before the WHO’s recommendations (Trevisan et al., 2020; Nguyen and Vu, 2020).

Conclusion The chapter argued that managing diseases both endemic and epidemic/pandemic in nature requires an effective state and, in particular, strong health institutions. Addressing the tremendous challenges that diseases pose to society and the state requires excellent state-society relations, where the state has earned the legitimacy from the public and where compliance with state directives is high. To do so necessitates that the state has created trust through the delivery of public health goods so that there is faith in the healthcare system. But relying on just the healthcare sector is not enough in managing infectious diseases. It also requires strong collaboration with other agencies of the state, including those that manage water and sanitation, the environment, urban planning, and communications. Even when dealing with a pandemic or a specific endemic disease, studies have demonstrated that a robust public health system is where money should be invested instead of stand-alone clinics that are designed to provide targeted support. This is important since, when a disease outbreak takes place, it is likely that other aspects of care are neglected, leading to a higher death toll than that of the outbreak. To avoid these types of knock-on effects requires substantial funding in the health sector focused on preventing care, equal and affordable care for everyone, and understanding how interconnected healthcare issues are. For example, with the case of Covid-19, it has been found that those that suffer other comorbidities, such as heart disease, are more likely to be affected. Thus, a healthcare focused only on buying ventilators and building Covid-19 wards would not adequately address the underlying issues that drives vulnerability. Taking a holistic

292  Response approach to healthcare focused on building a strong overall healthcare provision is the best way to also tackle infectious diseases. The next chapter builds upon the information provided about the role of the state and turns to look at how the state can mitigate disasters. As the chapter will reveal, the role of the state is critical in dampening the impact on the most vulnerable and decreasing the number of casualties.

Key questions 1 Why is multi-sectoral collaboration important to tackling endemic diseases such as malaria? 2 What are the differences in the role of the state in addressing endemic diseases compared to tackling pandemics? 3 Why is a weak state unable to properly respond to endemic diseases? 4 Why have strong states around the world failed in containing Covid-19? 5 Compare and contrast what is needed of the state to eradicate and control malaria, TB, and HIV/AIDS? Which diseases presents the most challenges for the state?

Notes 1 The smallpox vaccine program led to the eradication of the disease in 1980. Currently 70% of children in developing countries receive inexpensive vaccines through the WHO immunization program which are estimated to save three million lives each year. 2 https://touchfoundation.org/our-work/healthcare-workers/ 3 Studies have shown that privatization was not a magic bullet (Mills, 1998; McPake and Hongoro, 1995). In a case in Southern Africa, there were no increased efficiencies gained when a hospital was leased to private companies. Private care came at a higher cost because the profit margins more than offset any efficiency savings (Unger et al., 2006, p. 7). Strong democratic governments in developed countries may possess the regulatory resources to properly regulate quality healthcare delivery in the private sector (Unger et al., 2006, 7).

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12 The state and disaster management

Introduction This chapter looks at the role of the state in managing disasters. As Chapter 5 explained, disasters are taking place at greater frequency and ferocity due to man-made climate change. States around the world play a role in contributing to these issues. However, the scope of this chapter will be on how states mitigate and manage disasters and won’t explore how states address the environmental drivers of disasters. As has already been argued in earlier chapters, a sustainable approach to development is important to preventing droughts, wildfires, and the intensity of meteorological disasters. However, most of the environmentally vulnerable countries are not responsible for man-made driven climate change. Therefore, we focus more on what states can do to prevent hazards from becoming huge disasters, as the role of the state is critical in determining how disastrous a natural hazard will be. As the chapter will illustrate, an earthquake of equal magnitude could lead to thousands of casualties in one country and fewer than 100 in another. We explain why this is the case. Key concept

What is disaster risk management? The previous chapter explained what the state is to provide a foundation for understanding what state institutions can do in addressing diseases and disasters. Here we explain what disaster risk management is, as the concept has not been clearly defined in the book thus far. Disaster risk management is simply the application of disaster risk reduction strategies and policies to lessen disaster risk. The UNDRR further groups disaster risk management into different categories, such as prospective disaster risk, corrective disaster risk, and compensatory disaster risk management (UNDRR, 2021). Prospective disaster risk management focuses on avoiding or increasing new risks – such as future risks. This can involve using land more appropriately to prevent droughts from becoming more impactful. Corrective disaster risk management attempts to address current disaster risks, such as planting mangroves to protect populations from storm damage (Renaud et al., 2016). Compensatory disaster risk management involves strengthening the resilience of societies that deal with disaster risk in order to minimize disaster losses. This can take place by providing financial support, insurance, credit, and other social safety nets (Lavell and Maskrey, 2014). An integrated risk management approach would take a holistic approach by incorporating all of the drivers of risk, the mitigation options, and the importance of emergency management (Paton and Johnston, 2017).

DOI: 10.4324/9781003128809-18

The state and disaster management  301 State capacity and disasters Adequately dealing with disasters involves both preparations to minimize their impact and rapid responses once they occur. Though the link between disasters and development has been repeatedly demonstrated, governments and lending agencies do not integrate natural hazards into project plans. Most state budgets and international funding for disasters come from relief and reconstruction, instead of prevention and preparedness measures (Kellett and Caravani, 2013). In general, building robust political and administrative institutions, with specific agencies focused on disaster prevention is critical to dealing effectively with disasters. The first component of prevention and preparedness is an early warning system (Zschau, J. and Küppers, 2013). Scientists have improved their abilities to track the location of tropical cyclones, though it is still difficult to estimate with precision their intensity. Offering an early warning of an earthquake is a tougher task. At best, early warning systems can provide regions with information that one is in progress. With volcanoes, the locations and level of activity is usually known, given that classification systems can rate whether volcanoes are active, dormant, or extinct. Alert systems exist that can determine the states of volcanic activity, as well, providing information regarding whether an active volcano’s levels are normal or not (Potter et al., 2014). Many countries in the developing world do not have the ability to respond to early warnings, however. For example, the 2002 volcanic lava that destroyed 40% of Goma in the Democratic Republic of Congo had been forecast, but Goma lacked the institutional capacity to respond to the predictions made (Pelling, 2003). Early warning systems in all of these areas have become much better overall, such that large death tolls should be preventable through forecasting, preparation, and evacuation, but communication systems must be advanced to spread the word about impending disasters (Ezrow et al., 2015). The state’s ability to invest in the infrastructure required to minimize the costs and impact of a disaster is also incredibly important (Coburn and Spence, 2002). Buildings must be updated to help them withstand trauma. For example, in the case of earthquakes, adequate and enforced seismic building codes are the most important factor in preventing high casualties and destruction (Jordan et al., 2011). In particular, states need to have modernized health facilities to assist injured people, which need to be up to code. A recommendation of the Hyogo Framework for Action (see Chapter 13) for disaster preparedness, was that all new hospitals be constructed with a level of resilience so that they had the capacity to remain functional in disaster situations (Radovic et al., 2012). This means that building codes for hospitals are incredibly important to saving lives. If a disaster destroys a hospital, the loss of life of doctors and nurses is a huge blow to human capital. These facilities and their expertise are important for reducing the death toll. Hospitals are also important because when they are severely damaged, stricken communities won’t be able to access needed medical resources, such as equipment and supplies (National Research Council, 1991). Schools are also important buildings for resilience. Schools must be constructed up to code to not only protect children and their teachers from serving as potential death traps but also because schools can serve as primary shelters for evacuees during disasters (ibid.). The failure to construct buildings up to code is illustrated in the case of the Armenian earthquake. Armenia experienced a major earthquake when it was still a part of the Soviet Union in 1988 that registered 6.8 on the Richter scale. Reports were that somewhere between 20,000 and 60,000 people were killed, mostly in the city of Spitak where the epicentre was completely destroyed (OCHA, 1988). Half of its residents were killed and the rest were left

302  Response homeless. Armenia’s earthquake caused so much damage due to how poorly buildings were constructed. Around 350 multi-story buildings that were poorly constructed collapsed, as did unreinforced stone masonry houses and poorly constructed apartment blocks. Hospitals and factories that were poorly built were destroyed including 130 factories, which put 170,000 people out of work (ibid.). The damage to the hospitals was so severe that two-thirds of the doctors in the region were killed in the quake making it even more difficult to respond to the needs of those injured. Buildings in the Soviet Union were notably poorly built due to high levels of corruption in the Armenia Communist government at the time (Verluise, 1995). The state can reduce the potential impact of geological or meteorological risks through public engineering projects. For example, the state can play an important role in reducing landslide risk. It can stabilize landslides by drilling deep wells to drain or pump water out of soils that are saturated. The state can intercept debris flows with small dams and direct the run-off from storms into sewers (Davis, 2006). The state can plant trees to help reduce landslide risk, with fast growing shrubs best suited to help (Mertens, 2018). States can implement non-structural measures to prevent high casualties, by implementing land use restrictions and building codes and by preventing environmental degradation. To address landslides, the state can identify and map high landslide risk zones to avoid activity within these areas to reduce the risk to life (Forbes et al., 2013). Land-use restrictions are important to preventing disaster from major storms as is the implementation of building codes. After Hurricane Gilbert hit Jamaica in 1988, over 30,000 homes were destroyed. The losses were blamed on the lack of preparedness, such as poor maintenance of rental property and lack of compliance with building codes (Wisner et al., 2004). An example from Mexico, a country prone to earthquakes, helps illustrate how a proactive state can make a difference. The state’s capital, Mexico City, is built on the bed of an ancient lake, making it vulnerable to disasters like earthquakes. In 1985, the city experienced a major earthquake that reportedly killed more than 10,000 people. Prior to the earthquake, buildings in the city were constructed using materials of varying quality and type over different periods of time (Davis, 2014). Some were better built than others; in a number of places housing standards left much to be desired. Enforcement was lax because of high levels of government corruption (Alcántara-Ayala, 2002). After the earthquake, the government in power at the time, led by the Institutional Revolutionary Party (PRI) and President Miguel de la Madrid, tried to downplay the death toll and even ordered a news blackout. The government did little to address the situation until nearly 40 hours after the earthquake hit. In the aftermath of the 1985 earthquake, the Mexican government implemented a number of changes to prevent a future one from having such a devastating impact. It put in place an alert system to send electronic messages and an early warning to other areas. It also set up an alarm system to go off in the event of another earthquake hitting the capital. The government created a Civil Protection Committee to organize drills with rescue workers, the police, hospital staff, and metro personnel; and evacuation drills are now conducted annually. A number of highly trained specialists are now available for disaster response, and new construction in the city must comply with strict building codes (Guerrero, 2017). High-quality administrative institutions are critical to ensuring that these policies are ­adequately implemented. This requires a well-organized and efficient bureaucracy with state officials who are well-trained and who can execute public awareness campaigns, devise clear codes for construction, map hazard zones, install early warning systems, and orchestrate the construction of dykes, levees, and avalanche barriers. The bureaucratic agency to deal with disasters must also be experienced and already in place before a disaster hits (Ezrow et al., 2015).

The state and disaster management  303 The importance of the state’s administrative institutions is also illustrated by the series of floods that hit the Rio de Janeiro neighbourhood of Baixada Fluminense in 1988. In the aftermath, 289 people died, 734 were injured, 18,560 were left homeless, and there was major damage to infrastructure. In response to the floods, Rio’s local government created a special unit to coordinate activities and help receive external funds in the form of a $175 million loan from the World Bank (Ezrow et al., 2015). One of the goals of the World Bank-funded project was to help the state and municipal governments develop flood prevention programs and provide more available funds to maintain environmental infrastructure in Baixada Fluminense, especially given that deforestation of the steep hillsides had increased the risk factors. In spite of the good intentions of these efforts, the objectives of the flood reconstruction project were not realized. The key problem was that Rio’s municipality had difficulty in coordinating with the agencies at the national level due to the state’s ‘rapid turnaround of management staff, and staff members’ overlapping and unclear responsibilities’ (Pelling, 2003). Because the administrative institutions of the state were not well trained and constantly shifting positions, it was difficult to implement a long-term disaster prevention and response plan that would be helpful. Another example of the importance of an effective state agency to implement proper building codes and incorporate societal input is the Vargas floods and mudslide tragedy in Venezuela in December 1999. After massive floods hit an area just north of the capital Caracas, as many as 30,000 people were killed (Rudenstine and Galea, 2012). Because so little attention had been paid to urban planning in Venezuela, the floods were incredibly destructive. Many impoverished Venezuelans lived in illegal housing built on slopes that were not fit for construction. These illegal homes were very fragile and risk-prone, yet little was done to stop continued construction. Land development and environmental policies in Venezuela, like many Latin American cities, were haphazard, with construction completely unregulated (Ezrow et al., 2015). Minor catastrophes take place every year during the rainy season, but the victims are rarely noticed, and little is done in terms of prevention. Though the state was well intentioned, it lacked the organizational capacity to respond effectively. It attempted to create a new institution, Corpo Vargas, to respond to the disaster, but it is difficult to create a well-functioning disaster relief agency in the immediate aftermath of a crisis. Recruiting staff, establishing new policies and legal frameworks in an ad hoc manner created major bottlenecks, delays, and uncertainty (Clinton, 2006). Thus, though the government was financially equipped to respond (it had allocated over $200 million to restore basic services and benefited from several hundreds of millions in international aid for reconstruction and vulnerability reduction), it took too long to offer compensation and make decisions about urban rezoning. An ad hoc program was implemented to move victims into homes that were over 400 kilometres away from their original homes. But because victims had not been consulted, this plan was rejected by most victims. The state did not understand that the relocation plan would make it too difficult for the victims to recover financially if they were so far removed from their original homes (Stager, 2009). In the case of Haiti, previous disasters from four deadly hurricanes meant that the country had little time to recover before the 2010 earthquake hit (Benjamin et al., 2011). Haiti did not have effective measures for hazard and disaster management in place. Many people lived in areas that were vulnerable to disaster such as hillsides and riverbeds. There was not proper zoning of housing and buildings were not constructed to be up to code, or codes were outdated and not enforced. There were no earthquake preparedness and response programs in place. Thus, once the earthquake hit, the government was completely paralyzed (DesRoches et al., 2011). Already depleted by the four hurricanes that had struck the

304  Response country a few years prior, the government was not able to mobilize quickly in the aftermath and was completely dependent on foreign aid. Education also plays an important role in disaster mitigation and can reduce the number of human fatalities (Padli et al., 2018; Toya and Skidmore, 2007). Improving literacy rates and education levels contributes to reducing the impact of disasters (Eisensee and Strömberg, 2007). People can learn to reduce disaster risk and moderate the impact by living in an ecologically sustainable manner and undertaking programmes to prevent and mitigate disaster risk. In contrast, people who are illiterate are often the most vulnerable – it will be important for them to informed of potential disasters, preparation, and actions that need to be taken to protect themselves (Siagian et al., 2014). A study of children in Bangladesh, Ethiopia, and Malawi found that children with more biological human capital, such as health and nutritional status, are less affected by adverse effects of flooding; the rate of investment in intellectual human capital increases with the initial human capital stock after disasters, achieving a faster recovery (Yamauchi et al., 2009a). Countries with higher human development level have an easier time with disaster mitigation, preparedness planning, disaster reduction, and management strategies, and with follow-up strategies post disaster. It is simply much easier to communicate with citizens and to ensure directives are complied with if the population can read and comprehend the preventive measures that need to be taken and how to best prepare for and deal with a disaster. In a study that looked at disasters in 151 countries from 1960–2003, it was found that countries with higher levels of education have fewer disaster deaths and lower economic damage (Toya and Skidmore, 2007). These results were criticised by another study that looked at 73 country records and found that years of schooling was insignificant (Padli et al., 2010). It’s important to have a strong and capable government at the local level as well. Though central government capacity is important, it is somewhat diluted if the local government lacks the capacity to implement directives. In the case of Pakistan, the government created the Pakistan National Disaster Management Authority to manage natural hazards after the 2005 Kashmir earthquake. But there are huge gaps between what the government’s policies are and the local practices. There is a lack of resources and capacity at the local level to carry out the policies (Ahmed, 2013). The low levels of sub-state capacity severely slowed down its response to catastrophic floods that took place in 2010. Governments also need to have pre-disaster rules in place or codified information about how the government will respond to a disaster (at both the national and local levels). Part of this includes having a concrete method of procuring materials, which may necessitate agreements with industry associations to execute plans quickly (Tanaka, 2011). It is critical to ensure that the procurement system is as transparent as possible to avoid wasting critical funds. These rules and plans need to be in place ahead of time to ensure that the process of rebuilding and offering shelter is done with expediency and speed.

Addressing earthquakes As the previous section highlighted, in order to properly address and mitigate the risks from earthquakes requires good governance (low levels of corruption), preferably democratic governance. The following section will use case studies to illustrate the important preparations that need to take place. One of the most important preparations is to ensure that buildings are up to code to withstand the tremors. After a devastating earthquake hit Alaska in the US in 1964, the most powerful earthquake on record in the US (registering 9.2 on the Richter scale), the

The state and disaster management  305 Table 12.1  Most powerful earthquakes since 1950 9.4–9.6: Valdivia, Chile, May 22, 1960, 9.2: Prince William Sound Alaska, US, March 27, 1964 9.1–9.3: Indian Ocean, Indonesia, December 26, 2004 9.1: Tohoku earthquake, Japan, March 11, 2011 9.0: Kamchatka, Soviet Union, November 4, 1952 8.8: Offshore Maule, Chile, February 27, 2010 8.7: Assam India and Tibet, China, August 15, 1950 8.7: Rat Islands Alaska, US, February 4, 1965 8.6: Andreanof Islands, Alaska, US, March 9, 1957 8.6: Sumatra, Indonesia, March 28, 2005 8.6: Indian Ocean, Sumatra, Indonesia, April 11, 2012

state revised its building codes to prevent future disaster. The state of Alaska formed the Alaska Seismic Hazards Safety Commission, and the state uses the International Building Code which is considered to be the best standard for seismic safety for buildings (West et al., 2014). Buildings must be designed to resist ground motion, based on the location and earthquake history of the building. Structural connections, such as beams and columns, must be reinforced to prevent shaking and damage. Brick buildings are particularly dangerous for earthquake zones because they can fall apart during a tremor and crush people. Where brick buildings are already erected, they need to be wrapped and reinforced with steel and concrete (Tolon and Ural, 2014). As mentioned in an early section, education is also important in earthquake response. Schools need to do training drills for both children and adults to know what to do. In Alaska, special packets have been developed by the state to help school personnel create and revise their earthquake emergency procedures (Hosseini and Izadkhah, 2006). The public needs to be educated in terms of earthquake preparedness about what to do and how warning systems will work. There needs to be strategic locations for human resources and supplies, and schools and other businesses need to know where these are located.

Case study: a tale of two earthquakes Haiti was not the only country to experience a massive earthquake in 2010. Just one month later, Chile experienced an even bigger earthquake that registered at 8.8 on the Richter scale. While Haiti’s earthquake killed possibly as many as 300,000, the Chilean earthquake killed about 525 people. This is in spite of the fact that the Chilean earthquake released 500 times the energy as the Haitian earthquake (Lovett, 2010). Chile was able to prevent a high death toll due to better governance, including capacity in the public sector and control over corruption. Chile developed disaster risk management institutions, laws, and policies early because of their long history of disasters. The 1928 Talca earthquake pushed authorities and workers to implement Disaster Risk Reduction (DRR) measures within their general laws of construction and urbanization. By 1939, there were earthquake resistant construction standards developed. Additionally, massive earthquakes in 1960 and 1965 prompted greater coordination between actors in disaster response (such as the military and firefighters), relief and planning (such as government institutions) (Sandoval and Voss, 2016). As such there are many rules, laws, regulatory frameworks, and institutions involved in disaster risk reduction that work together.

306  Response In earthquake mitigation, reducing corruption is particularly important. Over the years, Chile has established more effective building codes which have been periodically upgraded to take into account previous earthquakes. In many countries building codes exist but are not regularly enforced due to corruption. State officials charged with ensuring that buildings are up to code may be susceptible to bribes to look the other way. In the case of Chile, most of the buildings were up to code and were able to withstand the strength of the earthquake (Boroschek et al., 2014). Earthquakes that have taken place in Turkey and China which did not have buildings up to code saw many residential buildings and schools completely collapse (Atmaca et al., 2020; Zhao et al., 2009). In the case of Chile, most of the homes were not decimated, which reduced the number of fatalities due to buildings collapsing. Most of the deaths from the earthquake were actually from the tsunami that followed. Chile has also mandated that materials like rubber and counterweights are built into architectural designs that allow buildings to bend and sway rather than break during earthquakes. In Haiti, buildings rose with little input from engineers and bribes to government inspectors. There were many structures that had little reinforcement and were built on weak foundations, including schools. This even affected the federal ministry buildings in Haiti: 13 out of 15 collapsed (Lovett, 2010). The earthquake affected more than two million people, but, in Chile, most buildings were built to protect lives. There were few structural collapses though 260,000 homes, 4000 schools, and 70% of hospitals were damaged, as well as roads, highways, electricity, and telecommunications networks and military installations (Platt, 2019). A much as 20% of the population in the city of Maule, which was closest to the epicentre, were made homeless (ibid.). The displaced were given the option to move to stay at their damaged properties or to move to a temporary housing village nearby (Kaufmann, D. and Tessada, 2010). Displaced people were housed in temporary timber housing (which were one room, 18 square meter chalets, and grants were provided for tools and supplies to those who could work to repair their homes (Hinrichs et al., 2011). Within six weeks, 60% of the public infrastructure that had been damaged by the earthquake had been repaired and 11,000 emergency housing units had been built (Platt, 2019). Moderate tax increases helped to rebuild and reconstruct the damage. The budget was also reallocated to ensure that reconstruction was prioritized. In disaster management, insurance can play a role in not just resilience but also in accountability. Insurance is important to establish safer building practices, to disseminate risk information, and to promote financial responsibility (Siembieda et al., 2012). Chile has a law that holds building owners accountable for losses in a new building for ten years. In Pakistan, after the 2005 Kashmir earthquake which killed over 86,000 people, there was no insurance (Platt, 2019). In Chile, insurance companies paid out about $8  billion in losses covering. Claims were settled quickly without needing much litigation. This did lead to a jump in the cost of premiums, but having rapid payments from insurers and the government facilitated the recovery (Useem et al., 2015). In spite of the strength of Chile’s response, there were things that could have been handled better. The Chilean Navy failed to coordinate with the national emergency office to ensure that the tsunami alert took place in a timely fashion and to ensure to communication to the affected localities (Kaufmann and Tessada, 2010). The government also delayed deploying the military to assist in relief efforts and to ensure law and order out of concerns that this could backfire, given the country’s history with military rule under Pinochet (Platt, 2019). The warning system relied on the internet and the telephone system which were disabled during the power-grid failure (Vijaykumar, 2015). The power failure also made it difficult to disperse essential supplies to the most afflicted cities in the south. Chile will still need

The state and disaster management  307 to improve the tsunami warning system, ensure that there is a backup power, and establish an emergency communications system. Local officials were able to still save lives by blaring evacuation instructions through bullhorns after the earthquake struck to make up for the failure of the more sophisticated tsunami alert (ibid.). To be adequately prepared for a disaster, it is necessary to establish a network of actors and institutions that can engage quickly in decision-making and coordinate effectively between local, regional, and national levels (Platt, 2019). In Chile, there were few fires after the earthquake because the electricity grid was immediately shut down. In some countries, it is unclear what agency or department is responsible for what. There is an urgent need after an earthquake to coordinate. In the Chilean case, the relevant authorities met regularly with residents and the business community in the affected areas to ensure that there was adequate local participation and consultation. There was effective and close coordination between emergency managers in local areas and fire and police personnel. For the most part, the Chilean government showed a commitment to rebuilding and to involving local people in the decision-making process (Platt, 2019). To further illustrate the benefits of the improvements that the Chilean government has made since the 2010 quake, on September 16, 2015, Chile was hit by another massive earthquake of 8.3 on the Richter scale. Only a few hundred homes were damaged, and 15 people were killed. This contrasts to the 8.1 magnitude earthquake that hit Nepal on April 25th of the same year that killed over 8,000 people and displaced almost three million (Vijaykumar, 2015). Earthquakes can be incredibly deadly but having a strong and effective state can make a huge difference. ***

Case study: earthquakes in Japan Japan frequently faces natural hazards in its location where several continental and oceanic plates meet. As a result, the country has experienced many earthquakes which sometimes trigger tsunamis. The most devastating earthquake to hit Japan took place in 1923 and killed 100,000 people. Due to these vulnerabilities, Japan has implemented regulation to better prepare the country for earthquakes. The strongest earthquake the country had ever experienced happened in March of 2011, triggering a tsunami and nuclear accident. Over 15,000 people died, the majority of whom in the tsunami that swept the coastline (Oskin, 2017). This contrasted with the 1995 Kobe earthquake that led to 6,000 deaths, 5,000 of which occurred within the first few seconds when buildings collapsed (Kaufmann and Penciakova, 2011). Since the Kobe earthquake, Japan had implemented and enforced stricter building codes. The buildings are stronger than those even in earthquake-prone California. Japan spent hundreds of millions on developing an earthquake early-warning system in 2007. Japan improved its system to detect early shock waves by creating a network of more than 1,000 seismometers around the country. The sophisticated system pings phones, televisions, and radios across the country. Trains are stopped to provide people a few extra seconds to prepare for a pending earthquake. In the case of the 2011 quake, within a minute after the earthquake hit, alerts were sent to millions of mobile phones, trains were halted, and broadcast warnings were provided. Phone signals went dead to allow more bandwidth for emergency services. The internet continued to function to allow people to communicate, while rolling blackouts were used by the government to save energy. The government had also educated and drilled its public on what to do (ibid.).

308  Response The government had tried to prepare for the tsunami, but this is a case where planning was not enough. Seawalls were installed along 40% of the coastline (Kaufmann and Penciakova, 2011). Though some of the seawalls were about 45-feet high, the tsunami was much bigger and spilled over into communities (Suppasri et al., 2013). Japan had invested in an early warning system for tsunamis which issued a warning within three minutes of the earthquake, but the communications infrastructure was damaged. To address these issues, the government quickly mobilized 100,000 troops to conduct search and rescue (Suppasri et al., 2013). Immediately after the disaster, the government held an emergency meeting that was headed by the prime minister and departments, such as the ministry of transport, agriculture, forestry, fisheries, finance, health, and the foreign ministry (this contrasted with the way the president of Pakistan, Ali Zardari, handled the 2010 floods – he carried on with an official visit to Europe at the height of the calamity). The ministry of health was charged with providing vehicles for supplying water and ensuring that hospitals were designated for dealing with those who had been exposed to radiation (Zaré and Afrouz, 2012). Other ministries were tasked with providing food, portable toilets, blankets, radios, gas oil, torches, dry ice, and other essential items. Eight days after the disaster event, temporary housing construction began, with the first buildings ready in one month. Social workers, medics, and first responders were dispatched to the zone that was most affected. The health ministry worked to ensure that infectious diseases would not spread, as people were encouraged to wear masks. All of the ministries were working together to coordinate their actions (Kaufmann and Penciakova, 2011). In spite of the strength of the Japanese government, it faced more challenges than just the earthquake and tsunami. The government also had to deal with the incredibly dangerous nuclear accident that was caused by the tsunami. Radiation levels were 1000 times above normal levels inside the plant (Dwyer and Mosk, 2011). People living in the area of the Fukushima meltdown had to be immediately evacuated. The earthquake was the most expensive disaster in history, costing over $360 billion (Oskin, 2017). Though the Bank of Japan responded by pumping $700 billion into the economy to stabilize the stock market, the disaster resulted in a 0.47% decline in Japan’s real GDP growth a year after the disaster (Kaufmann and Penciakova, 2011). Japan has since recovered, but this would not have been possible without extensive preparation for these types of disasters. ***

Addressing storms The state can play a positive role in shielding populations from the devastating effects of disasters, as a number of studies have emphasized (Kahn, 2005; Raschky, 2008). Thus, in order to best manage major storms and floods there are a number of mitigations that the state can do. As mentioned in a previous section, there is a need for better planning to increase engineering mitigation measures, such as building levees and seawalls. The state needs to also enforce zoning codes to prevent building in floodplains (National Research Council, 1991). The state must work to ensure that the infrastructure is durable; building codes need to have minimum specifications for design and construction. The management of the water and drainage systems is important in order to ensure that water and sewer systems are resilient, as they are at risk of being flooded. The state must develop emergency response plans, which includes evacuation routes and designated shelters (Colten et al., 2008). Before a storm is about to hit, gas and electricity supplies may need to be cut off to prevent fires.

The state and disaster management  309 The importance of the state is illustrated in the examples of Haiti, Cuba, and Australia. In 2008 massive hurricanes hit both Haiti and Cuba, but while only four people died in Cuba, as many as 800 died in Haiti (Ferris, 2010). In Cuba, citizens learn in school about the dangers of hurricanes and how to prepare and respond. Before the hurricane hits, local communities organize work to clean up any potentially dangerous debris. The state also has an evacuation plan that it coordinates with local communities. Pre-organized emergency teams work to ensure that there is enough food, water, and medical treatment. Resources are then made available to the public to help with the reconstruction process (Newman et al., 2017). In the case of Australia, when Cyclone Yasi hit northern Queensland in 2011, it had the potential to cause major casualties. Though it was a Category 5 storm, it only led to one death (Haque et al., 2012). This was due to quick movement of the government to implement an evacuation plan. An evacuation plan was completed more than four hours before the cyclone struck using the early warning system. The Cayman Islands offers another good example of the importance of good governance. As the Cayman Islands are susceptible to hurricanes due to their location, the government has worked hard to reduce the potential damage of major storms through a number of efforts. In addition to establishing an early warning system, the state puts together a new national hurricane plan every year to take stock of any mistakes made. The budget is sufficient to ensure that staff are well trained and well paid and that there are enough resources available for hurricane preparation. As such, the government has the capacity to evacuate the public and stockpile and deliver food (Ahrens and Rudolph, 2006). The state also works with citizens and the private sector to ensure that disaster preparedness is a priority for all (Adger et al., 2005; Tompkins and Hurlston, 2003). Across the government agencies, there is coordinated long-term risk planning of infrastructure projects and how they should be constructed. This coordination extends to land use planning which must also follow clear guidelines. Across the Cayman Islands, there are a range of laws and regulations that control and guide different departments to ensure consistency (Tompkins and Hurlston, 2003). As a result of these efforts, the death toll in the Caymans is comparatively lower than its neighbours. Hurricane Ivan of 2004, for example, was as strong as Hurricane Katrina but led to only two fatalities. In fact, there have only been five fatalities from hurricanes in the past 30 years. The Cayman Islands shows that the risks of disasters can be mitigated when states take an active role in improving preparation and implementing a plan that has an eye on long-term objectives. This contrasts with the US government’s handling of Hurricane Katrina in 2005. With Hurricane Katrina, the US government was widely criticized for making a number of serious and fatal mistakes. Prior to the storm hitting the Gulf states, and in particular the vulnerable city of New Orleans, Louisiana, the government did little to prepare and mitigate for disaster. New Orleans had a pre-Katrina poverty rate of 23%, which was twice the national average. The city was also segregated, with no evacuation plan in place for the 112,000 mostly poor African Americans who did not have cars, some of whom had disabilities. For years the government neglected to maintain the city’s old levees. Not surprisingly, within three hours of the storm hitting, three major (and over 50 minor) levee breaches flooded the city. The government also failed to ensure that there were enough supplies before the hurricane hit (Brinkley, 2006; Moynihan, 2009; Van Heerden, 2007). As many as 30,000 people had to be evacuated to the Superdome in Houston, Texas, but this shelter was inadequate to address basic needs. Evacuees were not allowed to leave the premises though they

310  Response faced unbearable heat, darkness, the smell of sewage, and a lack of food and water. In total, there were six deaths recorded at the Superdome. After the hurricane hit, the federal government appeared to be paralyzed. The federal government agency, known as the Federal Emergency Management Agency (FEMA), would not arrive for another two days. FEMA received more criticism for requiring paperwork and certification before allowing people to be evacuated. It took nearly a week until 40,000 troops arrived to restore law and order (Pao, 2015; Smith, 2006). Accusations were lodged to the federal government that its slow response was racially motivated. As a result of government failures, 1800 people died, almost all of which were preventable. Post-Katrina was also dominated by corrupt reconstruction projects for which hundreds of billions of dollars in contracts were awarded to major corporations (Smith, 2006). Poor planning and preparation also affected Houston when Hurricane Harvey hit in 2017. Houston allowed an entire neighbourhood to be built in areas that were deemed prone to flooding if a massive storm hit. As early as 1996, a report urged the city to take steps to reduce the risk, such as improving infrastructure and planning (Thompson, 2017). Houston did not have flood evacuation zones, by which a city is broken down into zones based on historical patterns of flooding to ensure that those in the most dangerous zones self-evacuate first. Instead, some people were struck and either died from drowning or had to be rescued from their roofs (ibid.). ***

Case study: Bangladesh and the Cyclone Preparedness Program Bangladesh is a country prone to being hit by devastating cyclones. At the same time, its Cyclone Preparedness Program exemplifies a successful attempt by the state to buffer citizens from the negative effects of disasters. The key to the program’s success is its emphasis on community participation in disaster preparedness. Bangladesh is particularly vulnerable with 40% of the total global storm surges recorded and seven of the deadliest cyclones in the past 50 years. The two deadliest cyclones took place in 1970 and 1991 with almost 500,000 and 140,000 deaths, respectively (Haque et al., 2012). In the last 20 years, Bangladesh has managed to reduce the number of deaths and injuries from cyclones. A severe cyclone that hit the country in 2007 caused 4,234 deaths, which was a massive reduction from the big cyclones of the past. Following the cyclone in 1970 that killed about a half of a million Bangladeshis, it became obvious that the state needed to do more to protect its citizens. The government of Bangladesh, along with the Bangladesh Red Crescent Society, began a project to modernize coastal warnings and evacuations. The Cyclone Preparedness Program currently covers 11 districts that span 3,500 villages. It focuses on issuing warnings, building shelters, and operating relief centres. It also assists in evacuations and search and rescue efforts (Ahrens and Rudolph, 2006). Additionally, an awareness campaign focuses on disseminating information about the cyclone warning signals and preparedness measures. Posters, leaflets, and films are used to demonstrate how to prepare. Building shelters and getting people to use them is incredibly important to reducing the death toll during storms. People often prefer to wait-and-see rather than move to a shelter. But shelters made of brick generally save lives, as death rates can more than double in populations that don’t access shelters. Prior to 2007, there were only 1500 shelters, which could each offer refuge for up to 5000 people in coastal districts (Haque et al., 2012). After Cyclone

The state and disaster management  311 Sidr, the government built an additional 2000 shelters. Building the shelters was important, but it was also critical to maintain them, as only 40% of the shelters available when Cyclone Sidr hit in 1991 were usable due to extreme flooding (Bern et al., 1993). The government also worked to construct coastal embankments and improve coastal forest cover. Since 1960, the country has been constructing embankments to protect the coast. Reforestation has also been used to save lives; mangrove forests in the southwestern parts of Bangladesh reduced the death toll of the cyclone that hit the country in 1999 (Paul, 2009). Nevertheless, there are many other policies that the state should implement. Because Bangladesh has a high level of population density, it is important to ensure that cyclone shelters are within 2 km walking distance of households and villages. Geographic Information Systems and remote sensing technology can help determine the best locations in terms of access, road networks, and population density. The government can identify potential locations for shelters, such as local government buildings, schools, and mosques. This should be given the highest priority in cyclone-preparedness programmes. As Bangladesh is now fully covered by mobile telecommunication networks, it is possible to distribute cyclone warning messages via mobile phones. For those without phones, colourful hot air balloons can be used in coastal and remote areas of Bangladesh as cyclone-warning messages. The development of a mangrove forest zone is also important to reducing cyclone vulnerability, particularly since sea levels continue to rise and tropical storms are growing increasingly intense due to climate change. Building codes need to be enforced in coastal zones to ensure that concrete houses are raised 3 meters off the ground (Haque et al., 2012). Incorporating local knowledge is important to better understanding how to mitigate risk. Part of the reason the program works is that it involves local populations. More than 30,000 village volunteers have been organized into teams of 12. Each team has radio equipment to monitor weather reports, sirens, first aid kits, and rescue equipment. Though volunteers do not receive payments, they are given some assistance to enable them to attend training sessions (Ahrens and Rudolph, 2006). Planners can also with society to educate residents about the areas with the highest flooding risk. The government should administer an awareness campaign that highlights the intersection between public health and hygiene issues, targeting children and those most vulnerable. As a result of the Cyclone Preparedness Program, when another cyclone hit in 1994, around 750,000 people were safely evacuated and the death toll was only 127 (Akhand, 2003). Improvements such as these illustrate how the state can work with society to harness the energy of its population to dampen the impact of disasters. ***

Addressing droughts As Chapter 3 explained, droughts are a climatic event, where the effects accumulate slowly over time and can linger for years. Because of this, droughts are referred to as a creeping phenomenon (Tannehill, 1947). In spite of their slow onset, droughts cannot be prevented. However, the state can play an important role in producing interventions to prepare and cope with droughts, to develop more resilient eco-systems, to better recover from droughts, and to mitigate their impact (Solh and van Ginkel, 2014). One of the important interventions is to monitor and predict droughts better. The state can use expertise from scientists who use prediction models to better understand when a drought may occur. The state needs to be aware of the amount of stored water available for

312  Response domestic use, stock, and irrigation. Droughts can also be monitored using satellite observations and by collecting information on rainfall, crop conditions, and water availability. The state can also choose to use innovative and technological approaches to manage drought risk. In mitigating droughts, it is important for the state to be engaged in soil and water conservation. Brazil has had a long and detailed history of managing and adapting to droughts, with the constitution stipulating that water is a limited resource which belongs to the federal or state government. In the state Ceará, one of the poorest states in Brazil, there are recurrent droughts and the communities living there are very vulnerable to the impact. However, the adoption of new water management policies (initiated between 1987 and 1996) helped make Ceará a pioneer in water resource management in Brazil. Some of these policies include state and basin water resource plans, bulk water-use permits, bulk water charges for exercising those permits, and a water resources information system (Gutiérrez et al., 2014). It is important for the state to work directly with the agricultural industry. Agriculture is one of the sectors that suffers most from the impact of droughts, but mitigation strategies can help the agricultural sector prevent catastrophe (Rey et al., 2017). This involves sharing knowledge about the importance of proper irrigation, crop rotation, and tillage practices (Koschke et al., 2013). It is important for the state to incentivize what types of crops are grown. Food legumes (or pulses), such as chick peas and lentils, are critical to enhancing food security (Solh and van Ginkel, 2014). Legumes are not only cheap and healthy sources of protein, they contribute to soil health. They can be grown with low levels of rainfall. Governments can incentivize the growth of pulses through assisted programs. In India, there has been success in increasing the production of pulses through its Accelerated Pulses Production Programme which offers financial support and agricultural extension (Reddy, 2015).

Conclusion Though most of the focus on disasters is on responding to a human catastrophe after a disaster hits, this chapter has illustrated the importance of prevention and mitigation. Prevention and preparation are especially important because most hazards have the potential to be compound events. As Chapter 3 explained, a hurricane can damage electrical wires and spark fires. States need to prepare to face not just the disaster but the multiple what-ifs that can lead to further casualties. In preparation for disasters the state has to ensure that there is investment in infrastructure, that there are proper early-warning systems in place, and that the population is well educated and ready to respond. Much of the groundwork needs to take place years before in the planning, and states need professional and well-trained personnel. In the area of disaster mitigation, corrupt states are much more vulnerable; disaster mitigation requires drawing from expertise and strictly following the rules and regulations. Failure to do so will result in much higher death tolls. The example success stories were not possible without good governance, though the role of society and private sector is also important. In the chapters that follow, we look at the role of the international community and international regimes in addressing the major threats to human security. For the most part, we focus more heavily on the challenges facing international organizations and regimes charged with managing disease and disaster, rather than the success stories. However, we also highlight how these regimes have evolved and become more developed to tackle the various challenges in disease and disaster governance.

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Key questions 1 Why is corruption so important to addressing disasters? 2 What are the mitigation strategies advocated in this chapter that utilize a sustainable development approach? 3 What are the key lessons from the way that Chile and Japan have managed earthquakes? What are the obstacles for Haiti in trying to adapt these lessons? 4 Why was Hurricane Katrina in the US such a catastrophe? What are the best practices that need to be adopted to address major storms? 5 Why is disaster mitigation a low priority for many countries around the world?

References Adger, W.N., Hughes, T.P., Folke, C., Carpenter, S.R. and Rockström, J., 2005. Social-ecological resilience to coastal disasters. Science, 309(5737), pp. 1036–1039. Ahmed, Z., 2013. Disaster risks and disaster management policies and practices in Pakistan: A critical analysis of Disaster Management Act 2010 of Pakistan. International Journal of Disaster Risk Reduction, 4, pp. 15–20. Ahrens, J. and Rudolph, P.M., 2006. The importance of governance in risk reduction and disaster management. Journal of Contingencies and Crisis Management, 14(4), pp. 207–220. Akhand, M.H., 2003. Disaster management and cyclone warning system in Bangladesh. In Early warning systems for natural disaster reduction (pp. 49–64). Berlin, Heidelberg: Springer. Alcántara-Ayala, I., 2002. Geomorphology, natural hazards, vulnerability and prevention of natural disasters in developing countries. Geomorphology, 47(2–4), pp. 107–124. Atmaca, B., Demir, S., Günaydın, M., Altunışık, A.C., Hüsem, M., Ateş, Ş., Adanur, S. and Angın, Z., 2020. Lessons learned from the past earthquakes on building performance in Turkey. Journal of Structural Engineering and Applied Mechanics, 3(2), pp. 61–84. Benjamin, E., Bassily-Marcus, A.M., Babu, E., Silver, L. and Martin, M.L., 2011. Principles and practice of disaster relief: Lessons from Haiti. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(3), pp. 306–318. Bern, C., Sniezek, J., Mathbor, G.M., Siddiqi, M.S., Ronsmans, C., Chowdhury, A.M., Choudhury, A.E., Islam, K., Bennish, M. and Noji, E., 1993. Risk factors for mortality in the Bangladesh cyclone of 1991. Bulletin of the World Health Organization, 71(1), p. 73. Boroschek, R., Bonelli, P., Restrepo, J.I., Retamales, R. and Contreras, V., 2014. Lessons from the 2010 Chile earthquake for performance based design and code development. In Performance-based seismic engineering: Vision for an earthquake resilient society (pp. 143–157). Dordrecht: Springer. Brinkley, D., 2006. The great deluge: Hurricane Katrina, New Orleans, and the Mississippi gulf coast. New York, NY: William Morrow. Clinton, W.J., 2006. Lessons learned from tsunami recovery: Key propositions for building back better. New York: Office of the UN Secretary-General’s Special Envoy for Tsunami Recovery. Coburn, A.W. and Spence, R.J., 2002. Earthquake protection (p. 420). Chichester: Wiley. Colten, C.E., Kates, R.W. and Laska, S.B., 2008. Community resilience: Lessons from New Orleans and hurricane Katrina. CARRI Report, 3, pp. 2–4. Davis, D.E., 2014. Reverberations: Mexico City’s 1985 earthquake and the transformation of the capital. Cities of the Global South Reader, p. 203. Davis, M., 2006. Planet of slums. London, UK: Verso. DesRoches, R., Comerio, M., Eberhard, M., Mooney, W. and Rix, G.J., 2011. Overview of the 2010 Haiti earthquake. Earthquake Spectra, 27(S1), pp. S1–S21. Dwyer, D. and Mosk, M., March 11, 2011. Emergencies at 5 Japanese Nuclear Reactors; radiation levels spike at most-affected site. ABC News. https://abcnews.go.com/International/japan-earthquakenuclear-power-reactor-damaged-high-radiation/story?id=13114181. Accessed December 10, 2020

314  Response Eisensee, T. and Strömberg, D., 2007. News droughts, news floods, and US disaster relief. The Quarterly Journal of Economics, 122(2), pp. 693–728. Ezrow, N., Frantz, E. and Kendall-Taylor, A., 2015. Development and the state in the 21st century: Tackling the challenges facing the developing world. London, UK: Macmillan International Higher Education. Ferris, E., March 3rd, 2010. Natural disasters, conflict, and human rights: Tracing the connections. The Brookings Institution. Presented at Brookings-Bern Project on Internal Displacement, TX. Forbes, K., Broadhead, J., Brardinoni, A.D., Gray, D. and Stokes, B.V., 2013. Forests and landslides: The role of trees and forests in the prevention of landslides and rehabilitation of landslide-affected areas in Asia Second edition. Rap Publication, p. 02. Guerrero, R., October 13, 2017. What Mexico did to reduce 80% of its disaster-related deaths. IDB. https://blogs.iadb.org/sostenibilidad/en/como-hizo-mexico-para-reducir-el-80-de-las-muertes-pordesastres-2/. Accessed December 10, 2020 Gutiérrez, A.P.A., Engle, N.L., De Nys, E., Molejón, C. and Martins, E.S., 2014. Drought preparedness in Brazil. Weather and Climate Extremes, 3, pp. 95–106. Haque, U., Hashizume, M., Kolivras, K.N., Overgaard, H.J., Das, B. and Yamamoto, T., 2012. Reduced death rates from cyclones in Bangladesh: What more needs to be done? Bulletin of the World Health Organization, 90, pp. 150–156. Hinrichs, R., Jones, L., Stanley, E.M., & Kleiner, M. (2011). Report on the 2010 Chilean earthquake and Tsunami response. U.S. Geological Survey Open-File Report 2011–1053, 1(1), pp. 1–68. Hosseini, M. and Izadkhah, Y.O., 2006. Earthquake disaster risk management planning in schools. Disaster Prevention and Management: An International Journal, 15(4), pp. 649–661. Jordan, T.H., Chen, Y.T., Gasparini, P., Madariaga, R., Main, I., Marzocchi, W., Papadopoulos, G., Sobolev, G., Yamaoka, K. and Zschau, J., 2011. Operational earthquake forecasting. State of knowledge and guidelines for utilization. Annals of Geophysics, 54(4). Kahn, M.E., 2005. The death toll from natural disasters: The role of income, geography, and institutions. Review of Economics and Statistics, 87(2), pp. 271–284. Kaufmann, D. and Penciakova, V., 2011. Japan’s triple disaster: Governance and the earthquake, tsunami and nuclear crises. Washington, DC: Brookings Institution. Kaufmann, D. and Tessada, J., 2010. Natural disaster, national diligence: The Chilean earthquake in perspective. Washington, DC: Brookings Institution. Kellett, J. and Caravani, A., 2013. Financing disaster risk reduction. A 20 Year Story of International Aid. ODI, pp. 1–60. Koschke, L., Fürst, C., Lorenz, M., Witt, A., Frank, S. and Makeschin, F., 2013. The integration of crop rotation and tillage practices in the assessment of ecosystem services provision at the regional scale. Ecological Indicators, 32, pp. 157–171. Lavell, A. and Maskrey, A., 2014. The future of disaster risk management. Environmental Hazards, 13(4), pp. 267–280. Lovett, R., March 1st, 2010. Why Chile fared better than Haiti. Nature. www.nature.com/ news/2010/100301/full/news.2010.100.html. Accessed December 1st, 2020 Mertens, K., Jacobs, L., Maes, J., Poesen, J., Kervyn, M. and Vranken, L., 2018. Disaster risk reduction among households exposed to landslide hazard: A crucial role for self-efficacy? Land Use Policy, 75, pp. 77–91. Moynihan, D.P., 2009. The response to hurricane Katrina. International Risk Governance Council, pp. 1–11. National Research Council, 1991. A safer future: Reducing the impacts of natural disasters. Washington, DC: National Academies Press. Newman, P., Beatley, T. and Boyer, H., 2017. Resilient cities: Overcoming fossil fuel dependence. Washington, DC: Island Press. OCHA, December 8, 1988. USSR earthquake Dec 1988 UNDRO situation reports 1–14. Relief Web. https://reliefweb.int/report/armenia/ussr-earthquake-dec-1988-undro-situation-reports-1–14 Oskin, B., September  13, 2017. Japan earthquake  & tsunami of 2011: Facts and information. Live Science. www.livescience.com/39110-japan-2011-earthquake-tsunami-facts.html. Accessed December 20, 2020

The state and disaster management  315 Padli, J., Habibullah, M.S. and Baharom, A.H., 2010. Economic impact of natural disasters’ fatalities. International Journal of Social Economics, 37(6), pp. 429–441. Padli, J., Habibullah, M.S. and Baharom, A.H., 2018. The impact of human development on natural disaster fatalities and damage: Panel data evidence. Economic Research-Ekonomska istraživanja, 31(1), pp. 1557–1573. Pao, M., August 27, 2015. Swept up in the storm: Hurricane Katrina’s key players, then and now. NPR. www.npr.org/2015/08/27/434385285/swept-up-in-the-storm-hurricane-katrinas-key-players-thenand-now?t=1610717556076. Accessed December 1st, 2020 Paton, D. and Johnston, D., 2017. Disaster resilience: An integrated approach. Springfield, IL: Charles C Thomas Publisher. Paul, B.K., 2009. Why relatively fewer people died? The case of Bangladesh’s cyclone Sidr.  Natural Hazards, 50(2), pp. 289–304. Pelling, M., 2003. The vulnerability of cities: Natural disasters and social resilience. London, UK: Earthscan. Platt, S., 2019. Planning recovery and reconstruction after the 2010 Maule earthquake and tsunami in chile. In Urban resilience for risk and adaptation governance (pp. 285–304). Cham: Springer. Potter, S.H., Jolly, G.E., Neall, V.E., Johnston, D.M. and Scott, B.J., 2014. Communicating the status of volcanic activity: Revising New Zealand’s volcanic alert level system. Journal of Applied Volcanology, 3(1), p. 13. Radovic, V., Vitale, K. and Tchounwou, P.B., 2012. Health facilities safety in natural disasters: Experiences and challenges from South East Europe. International Journal of Environmental Research and Public Health, 9(5), pp. 1677–1686. Raschky, P.A., 2008. Institutions and the losses from natural disasters. Natural Hazards and Earth System Sciences, 8(4), pp. 627–634. Reddy, A.A., 2015. Recent trend in pulses production and trade: Way forward. Pulses: Challenges & Opportunities, p. 14. Renaud, F.G., Nehren, U., Sudmeier-Rieux, K. and Estrella, M., 2016. Developments and opportunities for ecosystem-based disaster risk reduction and climate change adaptation. In: Renaud, F., SudmeierRieux, K., Estrella, M. and Nehren, U. (eds.) Ecosystem-based disaster risk reduction and adaptation in practice. Advances in natural and technological hazards research (Vol. 42). Cham, Switzerland: Springer. https://doi.org/10.1007/978-3-319-43633-3_1. Accessed May 15th, 2021 Rey, D., Holman, I.P. and Knox, J.W., 2017. Developing drought resilience in irrigated agriculture in the face of increasing water scarcity. Regional Environmental Change, 17(5), pp. 1527–1540. Rudenstine, S. and Galea, S., 2012. Vulnerabilities and capacities: Venezuela floods and mudslides – December 14–16, 1999. In The causes and behavioral consequences of disasters (pp. 29–38). New York: Springer. Sandoval, V. and Voss, M., 2016. Disaster governance and vulnerability: The case of Chile. Politics and Governance, 4(4), pp. 107–116. Siagian, T.H., Purhadi, P., Suhartono, S. and Ritonga, H., 2014. Social vulnerability to natural hazards in Indonesia: Driving factors and policy implications. Natural Hazards, 70(2), pp. 1603–1617. Siembieda, W., Johnson, L. and Franco, G., 2012. Rebuild fast but rebuild better: Chile’s initial recovery following the 27 February 2010 earthquake and tsunami. Earthquake Spectra,  28(1_suppl 1), pp. 621–641. Smith, N., July 11, 2006. There’s no such thing as a natural disaster. Social Science Research Council. https://items.ssrc.org/understanding-katrina/theres-no-such-thing-as-a-natural-disaster/. Accessed November 30, 2020 Solh, M. and van Ginkel, M., 2014. Drought preparedness and drought mitigation in the developing world‫ ׳‬s drylands. Weather and Climate Extremes, 3, pp. 62–66. Stager, H., 2009. Post-disaster opportunities: An assessment of reconstruction activities following the 1999 debris flows in Vargas State, Venezuela (Master’s thesis, University of Waterloo). Suppasri, A., Shuto, N., Imamura, F., Koshimura, S., Mas, E. and Yalciner, A.C., 2013. Lessons learned from the 2011 Great East Japan tsunami: Performance of tsunami countermeasures, coastal buildings, and tsunami evacuation in Japan. Pure and Applied Geophysics, 170(6–8), pp. 993–1018.

316  Response Tanaka, S., March 2011. Sustainable a public procurement system for largescale natural disasters: The case of the temporary housing program after the east Japan Earthquake. The International Public Procurement Conference, United States. Tannehill, I.R., 1947. Drought, its causes and effects. LWW, 64(1), p. 83. Thompson, S., September  5th, 2017. As Houston grew, officials ignored ‘once-in-a-lifetime’ chance to spare thousands from flooding. Dallas News. https://www.dallasnews.com/news/texas/2017/09/05/ as-houston-grew-officials-ignored-once-in-a-lifetime-chance-to-spare-thousands-from-flooding/. Accessed May 15th, 2021 Tolon, M. and Ural, D.N., 2014. Lessons learned from the 1964 Alaska earthquake in disaster management. Tenth U.S. National Conference on Earthquake Engineering Frontiers of Earthquake Engineering. Tompkins, E.L. and Hurlston, L.A., 2003. Report to the Cayman Islands’ Government: Adaptation lessons learned from responding to tropical cyclones by the Cayman Islands’ Government, 1988–2002. Tyndall Centre Working Paper 35. Tyndall Centre for Climate Change Research, University of East Anglia, Norwich, UK. Toya, H. and Skidmore, M., 2007. Economic development and the impacts of natural disasters. Economics Letters, 94(1), pp. 20–25. Useem, M., Kunreuther, H. and Michel-Kerjan, E., 2015. Leadership dispatches: Chile’s extraordinary comeback from disaster. Redwood City, CA: Stanford University Press. Van Heerden, I.L., 2007. The failure of the New Orleans levee system following Hurricane Katrina and the pathway forward. Public Administration Review, 67, pp. 24–35. Verluise, P., 1995. Armenia in crisis: The 1988 earthquake. Detroit, MI: Wayne State University Press. Vijaykumar, D., September 18, 2015. What Chile did right. The New Humanitarian. https://reliefweb. int/report/chile/what-chile-did-right. Accessed December 3, 2020 West, M.E., Haeussler, P.J., Ruppert, N.A., Freymueller, J.T. and Alaska Seismic Hazards Safety Commission, 2014. Why the 1964 Great Alaska earthquake matters 50 years later. Seismological Research Letters, 85(2), pp. 245–251. Wisner, B., Blaikie, P., Blaikie, P.M., Cannon, T. and Davis, I., 2004. At risk: Natural hazards, people’s vulnerability and disasters. London, UK: Psychology Press. Yamauchi, F., Yohannes, Y. and Quisumbing, A., 2009a. Natural disasters, self-insurance and human capital investment: Evidence from Bangladesh, Ethiopia and Malawi. Washington, DC: The World Bank. Yamauchi, F., Yohannes, Y. and Quisumbing, A., 2009b. Natural disasters, self-insurance, and human capital investment. Policy Paper Working Paper 4910. Zaré, M. and Afrouz, S.G., 2012. Crisis management of Tohoku; Japan earthquake and tsunami, 11 March 2011. Iranian Journal of Public Health, 41(6), p. 12. Zhao, B., Taucer, F. and Rossetto, T., 2009. Field investigation on the performance of building structures during the 12 May 2008 Wenchuan earthquake in China. Engineering Structures,  31(8), pp. 1707–1723. Zschau, J. and Küppers, A.N. eds., 2013.  Early warning systems for natural disaster reduction. Cham, Switzerland: Springer.

13 Global health governance

Introduction Though there are many important players in the field of global health governance, cooperating to achieve global public goods is very challenging. States are often self-interested and concerned with retaining their sovereignty. Strong states may agree on paper to specific regulations and recommendations but in practice may act to preserve their interests. In other cases, global public goods provision is complicated by state weakness as governments are not able to comply with guidelines and directives that are required for international agreements. Whether it is due to a lack of will or lack of capacity, coordinating and cooperating in the areas of global health and disaster governance is a work in progress. Coordination has in some ways become better, yet at the same time the problems facing states have become more daunting, more global, and more interdependent. When it comes to global health governance there is a very long history of the World Health Organization (WHO) working to manage global health along with a number of other important actors. This chapter mostly focuses on the WHO, its history, how it has evolved into the organization it is today, and the other international health regimes that are in place. In spite of the rising scope and power of the WHO, there are numerous challenges to global health governance, which the chapter lays out. Key concepts

What is international health? International health centres on intergovernmental cooperation to establish bodies, organizations, regimes, and agencies to address health issues of mutual interest across regional or national boundaries.1 International health, however, has tended to reflect the prevailing political and economic order. In other words, the interests of the most powerful countries drive policy and action in the area of global public health. Thus, international assistance has been dictated by power imbalances and geopolitics, rather than genuine health needs. This contrasts with collective health which emphasises the role of ordinary people, communities, health workers, smaller organizations, and social movements in shaping and promoting public health. By the 21st century, international health was refashioned as global health and geared towards improving health of all people around the world. More emphasis was placed on protecting people from any global health threat regardless of national borders (Macfarlane et al., 2008). In spite of these efforts, international health and global health are contested

DOI: 10.4324/9781003128809-19

318  Response concepts. Policymaking is still skewed in favour of powerful countries and corporate interests rather than on where the greatest needs are.

What is public health? Public health is the science and art of preventing disease, prolonging life, and promoting physical health through organized community efforts (Winslow, 1984). Public health is concerned with the health of a population, focusing on the prevention of disease and disability (Childress et al., 2002). To do so, it promotes collecting and using epidemiological data and population surveillance in order to understand and deal with the multi-dimensional causes (environmental, social, and behavioural) of disease and disability in a population. It focuses on controlling community infections, educating individuals and the community on the principles of hygiene, organizing medical and nursing services to prevent disease, and the sanitation within the environment (Winslow, 1920). This contrasts with medicine, which focuses on the treatment and cure of individual patients and involves physician-patient relationships. Public health involves multiple government agencies, organizations, experts and members of the community to development, implement and assess interventions (Childress et al., 2002). There have been numerous approaches to public health, resulting in different priorities and solutions. What follows is an overview of the different approaches that underpin how global health governance is approached. These different perspectives explain why the institutional arrangements appear to be so fragmented and disjointed. Approaches to public health Biomedical approaches to public health have focused on using developments in medical knowledge and practice, such as drugs and vaccines, to improve the health of individuals and populations (Baum, 1995). In the post-World War II period, there was optimism that advances in medicine could target one disease at a time. After the success of using antibiotics to treat bacterial infections, the identification of the structure of DNA in 1953 to study diseases caused by defective genes, and the discovery of the vaccines and prophylactics to treat infectious diseases, there was the belief that, with the right scientific tools, health interventions through vertical programmes could make big improvements (Tulchinsky and Varavikova, 2014). The solution was therefore to build institutions to ensure cooperation, using technocratic knowledge and evidence to make advances. Since the mid-1990s, this biomedical approach has been the basis of most global health initiatives. Large amounts of funding through public-private partnerships (such as the Global Fund to Fight HIV/AIDS, malaria, and TB)2 have gone towards disease-focused vertical programs to develop and administer new vaccines and drugs. The United Nations International Children’s Emergency Fund (UNICEF), and the Rockefeller Foundation, pushed for the creation of the Task Force for Child Survival, Child Vaccine Initiative, and Global Polio Eradication Initiative. But this approach ignored the complexity of causes that cause illnesses and injuries and focused on a magic bullet that would resolve much deeper problems. As biomedical approaches were located in the natural sciences, they neglected social, political, and economic factors that contribute to disease and poor health. Longerterm strategies were recognized as necessary to improve health, but biomedical approaches were often more focused on finding medical solutions. Additionally, biomedical approaches did not emphasize the impact of disease, which diseases should be tackled, and where

Global health governance  319 interventions should take place. Subsequent approaches offered perspectives to answer these questions. In the 1980s and 1990s, economic approaches made their way to public health to justify investment in disease prevention by focusing on the true economic impact of avoidable diseases and what constitutes the most cost-effective interventions (Brown et al., 2006). These approaches gained traction just as the World Bank was becoming more active in the developing world. In 2000, the WHO Commission on Macroeconomics and Health was set up to increase investment in economical interventions. Led by Jeffrey Sachs, it comprised the world’s leading economists, public health experts, development professionals, and policy makers (Sachs, 2001). The Commission was influential in supporting initiatives such as privatepublic partnerships like the Global Fund to Fight HIV/AIDS, malaria, and TB, and including health in the Millennium Development Goals (Tan et al., 2003). This approach supports market-based incentives for drug research and ensuring that intellectual property rights are protected for large pharmaceutical companies (Pogge et al., 2010). However, because this approach is led by economic rationalism, the priority has been on addressing diseases in countries deemed to be more economically important, such as the BRIC countries, and focusing on diseases that affect healthy adults, such as HIV/AIDS (Harmer et al., 2013). By the early 1990s, another shift took place with the growth in emerging and re-emerging disease and a decline in public health systems around the world. Health sector aid was also decreasing as there were declining levels of support for the WHO and the prospects of international health cooperation. During this time, then director-general of the WHO, Gro Harlem Brundtland, pushed diplomatically to raise the profile of global health, leading to greater prominence of the term health security (for more on this, see Chapter 1). Diseases were refashioned as an urgent threat to security, necessitating greater preparedness for public health emergencies, such as a potential influenza pandemic or bioterrorism attack. This generated greater funding for health, but also distorted resource allocation in areas that were viewed by some to be counterproductive to health goals (Feldbaum et al., 2006). The solutions focused mostly on improved disease surveillance, early warning systems, border screenings, and improving homeland defence. Similar to economic approaches, it was only strategically important countries that were prioritized. By the mid-1990s, there were increasing concerns about human rights, and the importance of health as a human right. There was growing attention to the persistent inequalities in public health. In order to raise attention to the importance of health as a human right, a Special Rapporteur on the Right to Health by the UN Commission on Human Rights was appointed in 2002. This Commission, led by Paul Hunt, tackled issues such as poverty, neglected diseases, and ensuring equal access to healthcare (Hunt, 2006). Ensuring equal access to essential medication was an important issue in the health as a human rights movement. All of these approaches have played a role in shaping global health responses. But in order to generate a collective response, states need to be willing to cooperate in the first place. Cooperation in the area of global health has become more intensive due to the growing collective threats of disease and disaster but only since the early 2000s. The following section explains the challenges to global cooperation and why cooperation has taken place in spite of these challenges. Strategies of cooperation on global health There are two dominant approaches to cooperation in global health. The traditional approach focuses on horizontal strategies of cooperation and draws from the literature in international

320  Response relations theory which guided international cooperation during the mid-19th century until World War II. The other approach focuses on vertical strategies of cooperation (not to be confused with vertical and integrated public health programs) which challenge traditional views of state sovereignty and became more prominent in the post-World War II period. Before explaining how these two different approaches work, we briefly lay out the logic of international cooperation theory (Ooms et al., 2008). As Chapter  1 briefly explained, International Relations theory was dominated by two approaches to security and cooperation, Realism and Liberalism. International Cooperation Theory (ICT) sits in the Liberal tradition and focuses on how states can overcome the anarchic system and learn to cooperate (Milner, 1991). Realism has traditionally argued that cooperation in an anarchic world is complicated by a number of factors, most notably that states value their sovereignty too much and will be unwilling to comply for the greater good if there are costs in doing so (Grieco, 1988; Mearsheimer, 1994). Realists argue that states are free to maximize their independence if there is no actor that can adequately punish states for not cooperating – usually a hegemon or a powerful state (Mearsheimer, 1994). As states are driven by relative gains and self-interest, cooperation will be unlikely to take place when it is believed that the costs outweigh the benefits, especially if there is no way to predict the actions of other states (Grieco et al., 1993). ICT contrasts with Realist approaches, arguing that cooperation is possible as the benefits of doing so often outweigh the costs. As a starting point, both Realists and Liberals believe that states are rational and self-interested actors. However, Liberals argue that rational states will cooperate because of the benefits of reciprocity and the costs of not cooperating. In other words, states are aware that there is a shadow of the future and that not cooperating in the present could lead to costs in the future (Keohane, 1986). States may also cooperate because they worry about their reputation, with reputational effects being important in diplomacy and resolving disputes (Sartori, 2005; Tomz, 2007). International institutions can play an important role in providing states with accurate information, coordinating multi-lateral actions, incentivizing cooperative actions, and in punishing defectors (Keohane and Martin, 1995; Ostrom, 1990; Ostrom and Keohane, 1995). In the field of global health, the question is to what extent international institutions are needed to incentivize and coordinate cooperative action. Returning to the two approaches, horizontal approaches argue that states are the dominant actors in the international system, but that laws can be used to structure cooperation in the area of public health. Horizontal governance is essentially governance among sovereign states and intergovernmental organizations. With this view, infectious diseases are exogenous threats to a state’s national interests that are best dealt with through some international cooperation, such as managing trade and travel between states. The biggest concern with horizontal approaches is ensuring that the dominant powers’ trade interests are being served; there is little concern with how a state’s public health system is organized (Ng and Ruger, 2011). An example of horizontal approaches to governance is regulations that came out of the International Sanitary Conferences starting in 1851. These regulations focused on preventing the spread of diseases while also ensuring minimal interference with world trade and travel. States reported outbreaks of cholera, plague, and yellow fever and were required to limit measures that restricted trade and travel in dealing with an outbreak. Overall, the main objective was to secure the interests of high-income countries in order to contain a disease at the source (Fidler, 2005; Gostin and Katz, 2016). In contrast to horizontal approaches, vertical approaches to global health see infectious diseases as threats that affect states from within, rather than threats to a state’s interests

Global health governance  321 and power. Thus, the objective is less focused on managing traffic of pathogens between states and more focused on reducing the threats of disease within states while taking into account threats to the individual and human security. Vertical approaches to global health have informed the WHO’s shift towards eradicating diseases and not just managing diseases. Alongside this, there was also an effort to invest in improving general health systems and improve access to primary care, which was seen as a human right (Davies et al., 2015; Gunn et al., 2008; Rushton, 2011). In many developing countries, domestic public healthcare systems were inadequate and unable to provide basic services critical to limiting the spread and mortality of infectious diseases. Vertical approaches not only emphasised the role of the state in eradicating and dealing with infectious diseases but also included non-state actors, such as NGOs (Clinton et al., 2017). The necessity to build strong health systems is illustrated by the quote published in the Lancet: ‘The idea that the health of every nation depends on the health of all others is not an empty piety but an epidemiological fact’ (Al-Mazrou and Bloom, 1997). In the section that follows, we highlight the key events that spearheaded global health development with regards to fighting infectious diseases. Evolution of global health During the 19th century there were significant findings in fighting diseases. The germ theory of disease transmission (which states that germ can lead to disease) was widely accepted. Concurrently, there were major bacteriological and parasitological findings by Louis Pasteur, Robert Koch, Patrick Manson, and Carlos Finlay. The Pasteur Institute, which studied vaccines and diseases, was founded in the late 1880s and was supported with massive funding. Public health had the capacity to verify diseases, and there were growing effective disease control measures (Park, 2017). At this time, national health agencies sought to centralize power and implement modern public health measures. Around this time, the first international non-governmental agency, the Red Cross was founded to promote humanitarian assistance in 1863. At the same time, international health was characterized by large imperial blocks such as Europe, the Americas, and Australia. Each imperial power had its own health office that was charged with controlling epidemics and organizing medical care. In colonial regions, tropical health research institutes were set up to provide support. The main tool however for dealing with infectious diseases was cordon sanitaires, a sanitary cordon which was a guarded line restricting the movement of people from a specific area infected by a disease to prevent its spread. These types of quarantines, which had been used since the 14th century, were a blunt tool of preventing diseases from spreading but were also an obstacle to trade (Birn, 2009). For the most part, imperial powers were reluctant to share information with commercial and political rivals. For example, in the early 19th century, there were numerous cholera conventions signed by states to stem the spread of cholera, but Britain refused to sign them, out of commercial self-interest, and was able to negotiate deals to sidestep them (Maglen, 2002). Early global health regimes Pressure started to mount on states to organize ways in which they dealt with infectious diseases, to fend off epidemic diseases that were not only destroying livelihoods, but which were also disrupting trade and generating social unrest. There were concerns that, without an international agreement to coordinate action, states would continue to be driven by selfinterest and defect from cooperative agreements.

322  Response One of the first notable results of international cooperation in the area of global health was initiated with the International Sanitary Conference held in Paris in 1851. The aim of the convention was to control the spread of the plague, yellow fever, and cholera through maritime traffic. This event was the start of intense diplomatic activity in the area of infectious diseases and led to a series of large conferences, international conventions, and regulations. These conferences illustrated early on the competing goals of protecting health and minimizing restrictions to traffic and trade that were caused by quarantines. Eventually international cooperation generated a series of regional and global organizations to manage cooperation in global health such as the Pan-American Sanitary Bureau in 1905 (later named the PanAmerican Health Organization); the Office International d’Hygiène Publique in 1907; and the Health Organization of the League of Nations in 1919 (Birn, 2009). Most of the meetings and agreements that took place during this period were set up to share information on outbreaks and continue to enforce quarantines. Concurrently, large foundations were set up to support global health outcomes, such as the Rockefeller Foundation in NY in 1913 and Save the Children in London in 1919. The Rockefeller Foundation initially conducted campaigns in public health and field research on hookworm, malaria, and yellow fever, while Save the Children was first set up to alleviate child starvation and later worked to improve children’s healthcare and education and provide emergency aid in disasters and conflict (Birn, 2014). In the case of the Pan-American Sanitary Bureau (PASB), the US was motivated to provide regional leadership in public health as it was a major importer of different transmissible diseases due to large scale immigration. It also wanted to improve public health to protect its troops stationed abroad from tropical diseases, and by the 1870s, the US Martin Hospital Service was publishing epidemic outbreak news in weekly bulletins (Cirillo, 2004). All immigrants and cargo ships had to present certificates of health signed by the US consul and a medical officer in the departing port under an 1893 Presidential Act, and ships and passengers were inspected for quarantine. When Cuba became a protectorate of the US in 1898, an ordinance was declared which included screening houses and domestic water containers that breed mosquitoes, daily inspections of houses and yards by sanitarians, and fines for property owners who had mosquito larvae on their premises. These efforts, along with reporting and isolating every case of yellow fever, led to a notable decline of the disease in Havana. When the US took over the construction of the Panama Canal after the French Compagnie Universelle du Canal Interoceanique de Panama went bankrupt, the US worked to exterminate mosquitoes, clear jungles, and drain swamps. Piped water supplies were built to eliminate the barrels that were producing mosquitoes. Houses were screened and bed nets were distributed. Quinine was also used as a prophylactic against malaria. Any person suffering from a fever was isolated behind a mosquito-proof screen (Gubler, 1998; Le Prince and Orenstein, 1916). The PASB, which was run out of the US Public Health Service and headed there until 1947 by US Surgeon Generals, also established region-wide protocols for the reporting and control of epidemic diseases, which led to the 1924 Sanitary Code that was signed by all 21 PASB members (Birn et al., 2009). It reflected the US’s hegemonic interests in Latin America to cover investments in oil, fruit, mining, metallurgy, real estate, railroads, banking, and other industries. International health was largely affected by power and influence, which hampered cooperation on infectious diseases which undermined trade and economic growth (Fee et al., 2016). Generally, the first half of the 20th century was very tumultuous, with war, disease, and economic disaster affecting life expectancy and quality of life. In 1943 the UN Relief and

Global health governance  323 Rehabilitation Administration (UNRRA) was organized to provide food, shelter and other aid to displaced people and refugees, but there were other more pressing health issues that necessitated greater collaboration. The lack of international coordination in dealing with infectious diseases created a demand for an international security regime, which was institutionalized with the creation of the World Health Organization (WHO) on April 7, 1948, which was known as World Health Day. After the WHO was established, this had important implications for the way that infectious diseases were approached; international health was institutionalized at the WHO during this time. The first change was that it centralized into one single agency the functions of a number of international and regional organizations. The WHO was also given tremendous power to use the World Health Assembly (WHA) to adopt legally binding regulations, such as sanitary and quarantine requirements, that could enter into force automatically by a deadline for non-dissenting states. Another change was that controlling infectious disease became a key part of the WHO mandate (McCarthy, 2002). The aims of the WHO were codified with the adoption of the International Sanitary Conventions in 1951, which were revised and renamed the International Health Regulations in 1969, after a series of international health agreements. The revised version set out to create a collaborative global framework to enhance health security against four infectious diseases (cholera, yellow fever, plague, and smallpox), while also ensuring a minimum impact on trade and travel.3 Countries were required to report within 24 hours when there was a disease outbreak of one of the four diseases, and there were predetermined actions that would be implemented at borders, with norms and standards for airports and seaports. These regulations were designed to prevent the spread from public transport by rodents and insects that could carry infectious diseases. The organization was to be informed on a weekly basis of the number of cases and deaths from the previous week. Further notification was necessary when the affected area was deemed to be free from infection (Fidler, 2005). In addition to the cooperation taking place in working to stop the spread of the diseases identified by the IHR, there were other networks established to address the threat of pandemic influenza. The most institutionalized example of this is the Global Influenza Surveillance and Response System (GISRS), which comprises a voluntary multi-lateral network of labs and research centres that share samples of pathogens to help identify them and their genetic structure (Ziegler et al., 2018). Established in cooperation with the WHO in 1952, the cooperation by the GISRS is critical in being able to diagnose influenza viruses and create vaccines and antivirals. GISRS performs surveillance and response functions for seasonal influenza (which typically takes place in winter months) and pandemic influenza or a novel virus where there is no immunity that causes unusual outbreaks (Hay and McCauley, 2018). Overall, the post-war period was a time of institution building, with numerous sanitary treaties signed, greater levels of international research, and education campaigns on infectious disease launched. However, the post war global health institutions emphasized trade, economic growth, and political stability over deeper level cooperation in the area of controlling infectious diseases (Birn, 2009). In the second half of the 20th century, there were greater efforts in controlling infectious diseases in low- and middle-income countries where the infectious disease burden was greatest. Huge advances had taken place in refrigeration, water purification techniques, sewage systems, vaccines, and antimicrobial drugs. One of these efforts was the global campaign to eradicate malaria. While the Aedes aegypti mosquito was nearly eliminated from the Americas, efforts to expunge the Anopheles mosquito were unsuccessful (Baird, 2000; Soper, 1963). Africa was also largely bypassed by the World Health Organization’s global malaria

324  Response eradication campaign, due to the perceptions that it was too logistically challenging, though cynics charge it was due to a lack of will (Tilley, 2016). Nevertheless, the WHO had some early successes in coordinating campaigns to control and eradicate a number of infectious diseases, such as polio, yaws, measles, whooping cough, and a range of neglected tropical diseases. Huge improvements were also taking place in the war on typhus, the bubonic plague, cholera, and diphtheria. The crowning achievement was the eradication of smallpox in 1977. This success helped the WHO and UNICEF to establish a programme to provide vaccines to children at risk of other childhood infectious diseases, known as the Expanded Programme on Immunization (EPI) (Keja et al., 1988). All of these successes brought optimistic thinking about the possibilities of medical science to end of epidemic diseases that threatened public health, and there was confidence that new treatments, new vaccines, and knowledge of pathogens would ensure that this continued. In the 1970s, the definition of public health was changing from a narrower concept to one that encompassed physical, mental. and social well-being and not just the absence of disease. The core functions of fighting infectious diseases became a part of a broader vision of health governance, eventually sitting within the framework of the UN’s Sustainable Development Goals (SDGs). Representative of these changes, the WHO and UNICEF launched the health for all process in 1978 (Rawaf et al., 2008). The goals of fighting infectious diseases in low-income countries through vertical programs (not to be confused with vertical approaches to public health), such as vaccination programs, were integrated with horizontal programs that focused on health systems as a whole, such as ensuring that access to safe water, proper sanitation, and other disease prevention mechanisms were in place. This program noted that the first way to prevent the international spread of disease was to ensure that universal health coverage, or affordable, sustainable, and equitable health services are accessible to everyone (ibid.). By the late 1980s, this confidence in the global fight against infectious diseases plummeted. Efforts to control malaria and tuberculosis had not been successful, and the resurgence of stronger pathogens, such as meningitis and dengue fever, and the worldwide progression of the HIV-AIDS pandemic caused concern. In fact, since the late 1980s, a new infectious pathogen has been discovered each year, such as Lassa and Marburg haemorrhagic fevers in Africa, variants of Creutzfeldt-Jakob disease in Europe, meningococcal meningitis W135, Nipah virus in Malaysia, and the West Nile virus in the Americas (Cupertino et al., 2020; Davies, 2009). Progress in global health regimes By the 1990s, there was an awareness that infectious disease outbreak could pose a threat to citizens’ health as well as to economic and political stability. As the IHR was (and continues to be) the WHO’s main tool to address infectious diseases, in May of 1995, it was agreed that the IHR needed to be revised.4 There were many issues driving the need for reform. The three main diseases no longer reflected the risks posed by infectious diseases. Along with AIDS, other diseases were being discovered, such as Ebola in 1976, while other diseases were resurging (Gostin, 2016). There was more pessimism that science and innovation alone could resolve these problems and more optimism that global cooperation could limit the risks if response capacities were enhanced and global surveillance mechanisms were put in place. With the world becoming increasingly globalized (see Chapter 4), there were growing concerns that pathogens were more likely to spread more quickly without some international cooperation to address this. Additionally, the US Institute of Medicine had produced a report

Global health governance  325 in 1992 that claimed that the key to countering the threat of emerging and re-emerging infectious diseases was to detect disease emergence early through the establishment of effective disease surveillance systems at the national and international level (Anderson and Gray, 2014). The objectives of this report echoed concerns that the WHO had been articulating for some time. There were other concerns as well with the IHR. The WHO was dependent on governments notifying the WHO when an outbreak took place. There was no incentive to encourage compliance with this, and there was little the WHO could do if a country did not comply. Cooperation rested entirely on the good will of states to share information. The WHO lacked any independent investigatory capacity or mandate (Plotkin and Kimball, 1997). Countries that did decide to report were not protected from unnecessary damage from other states overreacting and unnecessarily disrupting international trade and travel. There was also no information about how the WHO and the affected country would cooperate to contain the disease. Countries were also tasked with little oversight to implement preventive measures (Baker and Fidler, 2006). SARS and revision of the IHR These aforementioned issues had needed to be resolved for some time, but the impetus behind the revision was the SARS outbreak in 2002–2003. In the aftermath, the WHA launched a revision of the IHR which was completed and adopted by May of 2005 after a ten-year revision process and entered into force in June of 2007. Instead of three diseases listed, any biological chemical or nuclear event (either natural, accidental, or intentional) was included. Thus, going beyond traditional infectious diseases, this turned the WHO into an early warning tool for terrorist attacks, which injected a political dimension into its implementation (Fidler, 2004; Heymann, 2006). Under Articles 5 and 6 of the IHR, states must assess all unusual health events occurring on their territory and notify the WHO of any event that constituted a public health emergency of international concern (PHEIC). Events must be reported if two of four criteria are met: Is the public impact of the event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? Is there a significant risk of international trade or travel restriction? Additionally, there was a list of diseases which included smallpox, wildtype poliovirus, a human influenza caused by a new subtype, and or SARS that required reporting to the WHO immediately even if it was only for a single case and regardless of the context in which the disease occurred. Other pandemic prone diseases that would trigger further assessment are: cholera, pneumonic plague, yellow fever, and viral haemorrhagic fevers. An algorithm was devised for states to use in determining whether or not a particular event represents a PHEIC and therefore whether or not it is ‘notifiable’ (Baker and Fidler, 2006). Once notified, it is only the director general of the WHO who can independently declare a PHEIC and issue guidelines for control measures and response (Kamradt-Scott, 2018). The director general consults with the affected state to hear the emergency committee, which is composed of experts from a roster of experts supplied by the affected state. The director general selects specific experts to be part of this committee, which are tasked with informing the director general whether an event constitutes a PHEIC. This limits the power of the WHO to some extent, but also politicises decision-making since the committee’s selection is open to political interference. Regardless of these concerns, in theory, the director general uses scientific principles and evidence and risk assessment regarding health,

326  Response international spread, and interference with international traffic to declare a PHEIC. This must be accompanied by temporary non-binding recommendations that the affected states must take on. The director general can then terminate the PHEIC, which automatically expires three months after it was declared if it has not been extended, changed, or ended earlier (Baker and Forsyth, 2007). PHEICs have been declared five times, with swine flu (H1N1) in 2009; Ebola and polio in 2014; Zika in 2016; and Covid-19 in January of 2020. Declarations were accompanied by international responses to increase vaccination, strengthen lab capacities and research efforts, screen international travellers – although the WHO still avoided recommending that flights be suspended – and borders closed. In the case of polio, although there were only a few cases discovered in Afghanistan, Pakistan, and Nigeria, these small pockets put global eradication at risk (Toole, 2016). MERS was not declared to be a PHEIC because most of the transmission was taking place in hospital settings. Other disasters that did not generate an Emergency Committee convened by the director general included cholera in Haiti after the earthquake or chemical weapons in Syria. Confusion still exists as to what events warrant consideration by an Emergency Committee and a potential PHEIC declaration (Durrheim et al., 2020). Zika was declared to be a PHEIC on February 1, 2016, due to its association with the neurological disease Guillain-Barré syndrome (GBS) and foetal abnormalities, known as microcephaly, rather than for the Zika virus itself. The revised IHR also prohibits national authorities from taking unilateral measures in the event of a PHEIC that go against the advice of the WHO and that unnecessarily damage travel and trade. This allows the WHO to bypass political borders when it comes to global surveillance to ensure that information flows freely to prevent epidemics and pandemics. The rationale behind trying to ensure a uniform response was due to some missteps that led to overreactions. In the case of India, overreaction had disastrous economic consequences costing about $2 billion in trade alone after there were reports of a handful of illnesses and deaths in Gujurat that may have been caused by the plague (Cash and Narasimhan, 2000). Though the etiological agent (causal factor) was never actually confirmed, an overreaction led to widespread panic with as many as 500,000 people fleeing the area. Schools were closed, flights were cancelled, imports were restricted, and travels warnings and quarantines were issued. The WHO concluded that the reaction and response to the outbreak was excessive and unnecessary. An overreaction to a 1991 outbreak of cholera in Peru cost the country $700 million in trade (Cash and Narasimhan, 2000). The new protocols encourage that states cooperate and share information, offering realtime evidence-based actions at the borders. Any state that fails to fulfil its obligations could face a collective response and intervention from different global actors such as the WHO, the UN, and NGOs (Elbe, 2010). On request, the WHO can provide technical support and mobilize the Global Outbreak Alert Response Network (GOARN). In the case of SARS, unofficial reports about a severe and contagious respiratory illness circulated for months before SARS was officially recognized by any government (Davies et al., 2015). The WHO was then not able to publicly comment until the affected countries gave the WHO official notice. Under the new IHR, the WHO can gain information from nongovernmental sources, which helps prevent such large gaps in information on an outbreak. This new power and responsibility of information-gathering covers all available scientific evidence and other relevant information, including unofficial reports, media, and social media platforms. When it receives an unofficial report, the WHO seeks verification from the affected state (Fidler and Gostin, 2006).

Global health governance  327

Box 13.1  SARS and global cooperation The SARS outbreak illustrated some of the challenges of cooperating under weak global health regimes, but it also eventually increased the power and scope of the WHO. Prior to the 2005 reforms, the purpose of the IHR was to prevent, protect, and control, provide a public health response to the international spread of disease. On the other hand, it also claimed that it would do so in ways that avoid unnecessary interference with international traffic and trade (Nuzzo and Gronvall, 2011). Depending on the nature of the infectious disease, this can be very difficult to accomplish. In the case of SARS, though it did not fall under the category of a notifiable disease, almost all member states cooperated fully with the WHO and reported cases within their territories. The notable exception was China. China did not cooperate fully with the WHO when the SARs outbreak was discovered (Goldizen, 2016; Huang, 2004). In fact, it did everything it could to cover up the news of the outbreak and minimize its significance. Although SARS cases emerged in November  2002, China delayed notifying the WHO until February 2003. China took two additional months before permitting WHO epidemiologists to enter Guangdong province, where the outbreak originated (Fleck, 2003; Kreuder-Sonnen, 2019). Nevertheless, SARS was eventually contained, because the WHO was able to access non-state sources of epidemiological information, such as media reports, that played a critical role (Fidler, 2004). As the Chinese government was initially completely unwilling to be transparent, information came from non-government sources, such as Chinese doctors and media reports about the extent of the problem in China. The government, at the time, misunderstood the power of the internet, email, and mobile phones to share information. As a result, China was forced to accept the scale of the epidemic, cooperate with the WHO, and even cooperate with Taiwan (Shen, 2004). After SARS, the WHO emerged as a more influential actor within global governance as it illustrated the need to terminate relying on traditional horizontal strategies to govern the spread of infectious diseases, or germ governance (Fidler, 2004). The WHO demonstrated unprecedented power in recommending that travellers postpone non-essential travel to member states that were affected by the epidemic (Abraham, 2007). States complained but did not publicly challenge the WHO.5 Instead of taking on a state, the WHO issued directives to travellers to avoid travel in certain countries. Some global health experts believed that, because of SARS, public health may have entered a post-Westphalian phase (Fidler, 2003; Hein et al., 2007). The outbreak of SARS also tested outbreak surveillance and response systems strengthened following heightened anxiety about the possibility of bioterrorism. The WHO worked to create several Global Public Goods for Health (GPGH). These included, surveillance information, scientific research on the cause of SARs, and guidelines regarding how to clinically manage SARS cases. Significant achievements were made in global cooperation in identifying the causative agents of SARS, developing guidelines for how to treat it, and global surveillance of the virus (Biao and Wong, 2003). States, inter-governmental organization, nonstate actors all participated to provide the GPGH, demonstrating the importance of hybrid forms of germ governance in order to tackle infectious diseases with pandemic potential (Fidler, 2004).

328  Response States were also tasked with strengthening eight core capacities in public healthcare, including improving, within five years, their surveillance, verification, and response strategies as well as five other capacities concerning points of entry and specific hazards. For each of these 13 core capacities, the WHO identified attributes and actions that states need to assess (Fidler, 2005; WHO, 2008)). On request, the WHO can collaborate with countries to evaluate their public health capacities and then assist with technical cooperation, logistical support, and mobilizing financial resources to strengthen capacity in the areas of surveillance and response. Some of this support comes in the form of providing a network of specialized national laboratories and institutes and using a global database of experts in specific diseases and epidemiological techniques to offer assistance (WHO, 2008). The WHO was also empowered to recommend and coordinate measures to help contain the international spread of disease, including public health actions at ports, airports, and land borders, and on means of transportation that involve international travel. For designated airports, ports, and ground crossings, the revised IHR introduces special provisions for travellers, including the obligation to treat them with respect for their dignity, human rights, and fundamental freedom (WHO, 2008). Though there were marked improvements, the revised IHR still left the WHO ineffective in certain ways. There were still no guarantees that governments would accurately and promptly report infections. Governments still had economic reasons to delay sharing information for fear that travel and trade restrictions can be imposed. This happened yet again with China and the Covid-19 pandemic.6 This also happened with the 2014 Ebola crisis, with West African states delaying their reports (Siedner et al., 2015). Saudi Arabia also delayed in reporting MERS (Zumla et al., 2015). Governments have failed to share important information about international travellers due to confusion about what constitutes patient privacy or out of defiance of their international obligations under Article 45 of the IHR. Illustrating the tensions between national interest and collective interests, the WHO still lacks the power to question members states’ actions fearing that going too far would risk a hostile response from a member state. For example, China voiced their criticism after being rebuked by the WHO in 2003 over the SARS outbreak. Though the WHO can name and shame states that don’t meet their obligations, this can undermine future cooperation with affected states. Additionally, there is no way to sanction states that overreact. Russia was vexed when the WHO voiced concern about Russia banning pork during the 2009 swine flu crisis. Draft proposals that would grant the WHO equivalent autonomy in managing other public health emergencies were rejected by member states in order to safeguard their sovereignty (Kamradt-Scott, 2016). Challenges for global health governance Challenges facing global health regimes The WHO’s role has evolved since it was formed in 1948. Today the WHO’s main role is to coordinate, advise, and assist governments upon request. It does not have the power to legislate, to execute decrees, or to sanction states that do not comply to regulations. It is also not a first responder – nor does it have the manpower to fill that role. Governments have resisted enabling the WHO to become more powerful or having a greater operational role. Thus instead, the WHO has mostly focused on drawing on networks such as GOARN to gather expertise to assist national health authorities in responding to a crisis (Wenham, 2015).

Global health governance  329 As the chapter has explained, the WHO has lacked the operational capacity and culture to respond to these issues within its decentralized structure. The autonomy of regional directors has undermined the WHO’s ability to respond in a unified way (Gostin and Katz, 2016). Furthermore, effectiveness was undermined by low levels of capacity in the WHO’s regional and country offices. The WHO is structured into six regional offices and one central headquarters in Geneva, with the former being largely autonomous and prone to infighting and duplicating services (Lee, 2014). Much of the weakness of the WHO can be blamed on low levels of funding. Not since the failure of the malaria eradication program has the WHO retained a huge staff numbers that could be deployed in a health emergency. But properly responding to global health concerns not only requires coordination and management of all of the different stakeholders, it also demands more funding and human resources (Fidler, 2005). Instead of increasing funding and staffing for surveillance and response activities, the WHO’s funding was cut by $600 million in 2011, notably affecting its epidemic response capabilities (Gostin and Katz, 2016). There was also a 51% cut in spending by member states in 2013 for the WHO’s outbreak and crisis response budget for 2014–2015 (Kamradt-Scott, 2016). Just one year before the Ebola crisis broke out, the department that was central to emergency response capacity was reduced from 90 staff to 36 (ibid.). It was assumed that the regional offices would increase their own capacity, but this did not happen. Overall, the WHO failed to address the low levels of capacity in their regional and country offices, which undermined effectiveness. Though the WHO has more than doubled its budget from 2000–2001, its entire budget for 2020–2021 is still only $5.84 billion (WHO).7 The World Bank became increasingly involved in health reform in the 1990s with the decline in health provision through state welfare and the introduction of new forms of financing and user-fees (Buse and Gwin, 1998). Prior to this point, international financial institutions like the World Bank did not see that tackling infectious diseases was a major development problem and believed that economic development would resolve health issues, not the other way around. By the 1980s, the World Bank acknowledged that diseases were a serious impediment to economic progress. The Bank then became more prominent while the WHO was declining in prominence due to confusion about the WHO’s mandate and some internal disputes. In 1993 the Bank announced that it was increasing its spending on disease prevention, reaching over $3 billion by 2003. As a result, the Bank became the unrivalled source for financial resources, and it used its status as a lender and non-political specialist within the wider body of the UN to be a major player in global health, instead of the UNDP (Buse, 1994). Health policy reform was very top down during this time (Lee and Goodman, 2002). The Bank wanted to take a different approach from the WHO and started to develop non-health ministry specific interventions with governments. The WHO had prioritized strengthening the relationship with health ministries and engaging mostly with the public health sector. In contrast, the Bank wanted to see a rise in private sector and other non-state actors in dealing with health issues. The Bank also supported communities which bore the brunt of health crises and wanted to fund collective action, and hold governments to account and ensure transparency and participation in decision-making (Harman, 2009; Ruger, 2005). Issues with IHR monitoring and compliance Another concern was the lack of compliance with building capacity in public health systems and surveillance. Though these new state capacity requirements were clearly set out and IHR Monitoring Tool self-assessments could be made, as many as 80% of member states had

330  Response not met their obligations on surveillance and response capacities by the June 2012 deadline (WHO, 2012). The WHO was aware of these problems, but the revised IHR still did not adequately create a compliance mechanism to build confidence and ensure accountability. Many states were unable to comply even after the seven-day grace period. Those that did provide assessments produced unreliable ones, possibly driven by their interest to appear compliant (Gostin and Katz, 2016). Developing countries have lacked the capacity to make the necessary upgrades to their health systems. Many states with limited resources struggle to prioritize building a system to react to an unknown threat, when they were barely able to meet everyday health needs of their citizens (Balabanova, 2010; WHO, 2009). When Ebola started in 2014, only 64 out of 196 states that had signed the IHR had met the requirements. Eighty-one states required another extension until 2016. States that did not comply were supposed to submit a concrete plan to reach full implementation, but as many as 48 states failed to respond to the WHO altogether (Gostin and Katz, 2016). Concerns remained that the WHO had no way of ensuring compliance and lacked the capacity to manage a dangerous outbreak (Heymann et al., 2015). Though these recommendations were considered in the reform process, the recommendations were not executed. In light of all of these issues, on February 13, 2014, 30 countries launched the Global Health Security Agenda (GHSA) (Katz et al., 2014). This was developed with the WHO, the Food and Agricultural Organization of the UN (FAO), and the World Organization for Animal Health (OIE). The GHSA was formulated in order to advance the implementation of the IHR, with the aims of strengthening core capacities and working collectively (Tappero et al., 2015). The GHSA provides a framework with clear targets and milestones to accelerate progress in strengthening public health systems necessary to protect global health security. Today, this is a global partnership that involves more than 60 nations and organizations. For the US, which took the lead on this, the failure to comply with the IHR made states around the world more vulnerable to preventing, detecting, and responding to the deliberate use of biological weapons. The US, working with multiple federal agencies such as Defense, Health and Human Services, State, Agriculture, and the Centers for Disease Control and Prevention, advocated building resilient national bio-security systems that could ensure that dangerous pathogens were secured with biosafety and biosecurity best practices in place. Nations were also tasked with ensuring that there was a nationwide laboratory network with a specimen referral system reaching at least 80% of its population and with effective modern diagnostics in place to detect epidemic-prone diseases (Heymann et al., 2015). Other requirements included a rapid bio-surveillance electronic reporting system meeting WHO, OIE, and FAO requirements, a dedicated workforce in the medical and public health field, including at least one trained field epidemiologist per 200,000 people and a public health emergency operations centre that had the capacity to respond to emergencies within two hours (Tappero et al., 2015). A scorecard, or self-evaluation tool (known as the Joint External Evaluation Tool, JEET), was developed to facilitate what national authorities should prioritize in order to achieve these objectives (WHO, 2018). In spite of these efforts to help low-income states comply with the IHR regulations, there were still concerns that the response process within the WHO was not transparent – and was vulnerable to political pressures. The other issue was that the WHO could only respond in the case of an extreme crisis and lacked mechanisms in place to engage in cases that were short of a full-blown emergency. These issues were illustrated in full in the case of the West African Ebola outbreak in 2014 (for more on this see the case study on Ebola). ***

Global health governance  331

Case study: why Ebola was disastrous for WHO? Though the 2014 Ebola outbreak in West Africa would have been challenging under any circumstances, the consensus was that this was a disaster for WHO leadership (KamradtScott, 2016; O’Dowd, 2015; Wenham, 2017). Several years after the swine flu (H1N1) pandemic, the WHO had already faced criticisms for not ensuring that states have greater capacity to manage a PHEIC. In the case of swine flu, there were concerns that the WHO had overreacted and mishandled the crisis and which led to three independent investigations, all of which concluded the WHO’s integrity had not been compromised (KamradtScott, 2018). Response teams were not able to engage with local communities, which caused further distrust of the health authorities. Many incompetent staff made the Ebola outbreak a debacle. As a result of the WHO’s poor response, the UN denied the WHO of its leadership by creating the UN Mission for Ebola Emergency Response (UNMEER), which was established by the UN Secretary General, rather than by the Security Council. It took way too long for the WHO to identify the outbreak in the community and to raise an alert. Overall, the international response was slow and cumbersome with little coordination. The WHO’s bumbled response also caused panic around the world (Moon et al., 2015). The Ebola crisis demonstrated the problems with the IHR. Because Guinea, Liberia, and Sierra Leone had such low levels of health capacity, they were unable to comply with the surveillance and response obligations of the regulations. There was no multi-lateral strategy to address these issues facing low-income countries. The Ebola crisis also demonstrated that the WHO relationship with regional and country offices in Africa was weak (Wenham, 2017). The WHO Regional Office for Africa (AFRO) and country offices impeded deployment of international aid workers and equipment. Most importantly, the WHO failed to mobilize adequate funding and human resources until the epidemic was completely out of control. The WHO eventually took action to correct these early mistakes, but this came at a cost of thousands of lives (Gostin, 2016). The crisis unfolded first in Guinea, where Ebola went undetected for three months in 2014. Ebola was initially suspected to be Lassa fever. Within hours of confirmation that the agent was Ebola, the WHO secretariat mobilized a response team via the Global Outbreak and Response Network (GOARN). Liberian and Sierra Leonean health officials were alerted to start surveillance. On March 18, 2014, MSF declared that there was a massive emergency in Guinea with Ebola – ‘of a magnitude never before seen’ (Pagano and Poncin, 2016). The GOARN team began an assessment of local conditions and presented it to the WHO in April. In April, the WHO mobilized technical support and resources to assist the affected countries. By May 7, 2014, 113 technical experts were deployed to assist the health authorities in Guinea, Liberia and Sierra Leone and the WHO African regional office – with far more people mobilized than during previous Ebola outbreaks (WHO, 2015). Experts were deployed in coordination, surveillance, epidemiology, infection prevention and control, clinical case management, anthropology, logistics, laboratory services, risk communication, social mobilisation, finance, health informatics, and resource mobilisation (WHO, 2014). Nevertheless, there was confusion because the Minister for Health of Guinea reported that the outbreak was under control in May of 2014 (WHO, 2015). West African countries, worried about the implications of an outbreak, tried to downplay the crisis. By June cases were rising in Guinea and Sierra Leone and to a lesser extent Liberia, with pressure to declare a PHEIC, but there was concern that this could damage relations between the affected countries (Kamradt-Scott, 2016). Still the WHO secretariat was unwilling to challenge official reports from the affected countries.

332  Response A PHEIC was finally declared in early August of 2014, five months after cross-border spread had taken place and with few additional measures to assist affected countries (Soghaier et al., 2015). There was concern that the WHO did not have enough personnel (doctors, nurses, drivers, and contract tracers) to manage the high numbers of cases. In September, MSF called for unprecedented military intervention (Šehović, 2017). The UN Security Council met on September 15, 2014, and passed Resolution UNSC 2176 which authorised the extension of the UN mission to Liberia by three months to provide more support in containing the virus. US President Barack Obama then declared that 3000 military personnel to support affected countries on September  16th (Mason and Harding Giahyue, 2014). On September  18th, the UN Security Council passed Resolution UNSC2177, declaring the outbreak a threat to international peace and security. Secretary-General Ban Ki-Moon obtained authorisation from the UN General Assembly the following day to create the UN’s first-ever public health mission – the United Nations Mission for Ebola Emergency Response (UNMEER) (Butler, 2014). Further complicating matters were the weak healthcare systems in West Africa to deal with the crisis. Many healthcare workers lacked training in emergency preparedness and response. Healthcare workers were also forced to operate without appropriate equipment or adequate pay. The unsafe environments that healthcare workers were operating in caused more than 800 healthcare workers to become sick (NBC News, 2015). Ebola led the WHO, the WB, and the EU to reconsider how to approach global health security and create new policies and programmes that could counter threats posed by diseases and to develop new strategies to ensure health security and achieving the benchmarks set out by the IHR. Nevertheless, over five years after the Ebola crisis, healthcare workers are still not prepared to address the existing and emerging health threats. The Ministry of Health in Liberia does not have the capacity or funding to hire, distribute, and retain newly-trained health workers to deal with gaps (Budy, 2015). The direct economic burden of the 2014 Ebola outbreak is estimated to be between $2.8 billion and US$32.6 billion of lost gross domestic product. With the comprehensive economic and social costs factored in, the cost to the global economy was estimated at over US$51 billion, with US$18 billion in deaths from non-Ebola causes (Peters et al., 2020). *** WHO and Covid-19 The Covid-19 crisis presented another challenge for the WHO. After facing numerous criticisms for its failure to respond quickly with the Ebola crisis, the novel coronavirus presented the WHO with far greater challenges due to complaints that the organization was unable to provide advice that was consistent with science. One of the biggest missteps centred around the explanations of the way that the virus was transmitted. The WHO promoted the view that the virus was transmitted mostly through the air when someone sneezed or coughed through large droplets, rejecting the idea that it is airborne and could infect people when inhaled (Associated Press, 2020). Though the coronavirus does not seem to hang in the air for hours, it is most infectious when people are in prolonged contact at close range, especially indoors, which is what scientists would expect from aerosol transmission. In early April of 2020, a group of 36 experts urged the WHO to reconsider its stance given the growing evidence that the coronavirus was being transmitted through the air and not through fomite transmissions or by touching tainted surfaces (Mandavilli, 2020). These

Global health governance  333 warnings were largely ignored, and the committee’s advice remained unchanged. Thus, instead of advocating early on that everyone wear face masks, the WHO advised frequent handwashing. It was also confusing in its stance on the role of asymptomatic transmissions. While some scientists believed that asymptomatic transmissions were playing a major role in spreading the pandemic, the WHO clarified that asymptomatic carriers were not a major driver of transmission. Clarity on this is crucial given that 35% of people who contract Covid19 may be asymptomatic (CDC, 2020). Part of the issue for the WHO is that the organization’s infection prevention and control committee is bound by a cautious and rigid view of scientific evidence, which makes it slow to respond in updating guidance. It needs to diversify its expertise to gain more informed opinions, but it may also need to relax its criteria for proof during a fast-moving pandemic. Scientists are now rushing to publish preliminary research in order to get ahead of an outbreak. Another issue is that the WHO has a shrinking budget and has to be careful about what it says and who it offends. It managed to offend Donald Trump by appearing biased towards China, resulting in the US, which accounts for 15% of all WHO funding, leaving the organization (Solender, 2020). Worried about pushing for policies that some countries cannot handle or diverting scarce resource from other important programs, the WHO has often resorted to a risk-averse approach. *** Obstacles to cooperation in health security As Realists would predict, ensuring cooperation even in the area of global health governance (which should in theory be a universal need) has been complicated by competing notions of sovereignty, national interests, power asymmetries, and concerns about relative gains. The current global health security regime has privileged national interest over collective action, making it difficult to ensure that there is full cooperation. The existing system for detecting and responding to outbreaks also have few international standards for sharing biological samples and specimens (Nuzzo and Gronvall, 2011). States will often agree in principle to an agreement and then not implement the regulations that they agreed to. According to realists, states will only engage in cooperation when they see a chance of relative gains for themselves over others in the international system. Liberals counter that states are interested in cooperating when they can benefit from absolute gains and gains for the entire international community regardless of how their relative position changes (O’Neill, 2009). However, there remain disincentives for reporting disease outbreaks which make it difficult to ensure that diseases are contained. No state can ever be compelled to cooperate or adhere to an international agreement; participation is voluntary to some extent. There are also often not effective ways to punish states that defect or refuse to cooperate (Mearsheimer, 1994). In some cases, states’ attitudes towards one another have been affected by a history of international conflict and tensions. The pursuit of relative gains vis-à-vis other states drives interactions between them, making lasting cooperation unlikely unless maintained by a powerful state (Grieco et al., 1993; O’Neill, 2009). Powerful states don’t always want to cooperate, although state cooperation is critical to ensuring that global cooperation takes place. The failure of a powerful state to cooperate can affect the willingness of other states to participate and cooperate fully (Snidal, 1985). Another challenge is that there is substantial political interference in public health (Burkle Jr., 2017). Chapter 10 addressed some of the issues of governance and politics in greater

334  Response depth, including populism, corruption, and authoritarianism. Governance issues undermine the capacity to act and achieve collective goals. International legal frameworks are affected by lack of political action and constant interference. Furthermore, negotiators and state representatives are accountable to their domestic constituencies, complicating international health negotiations and how much states are willing to compromise (Chaudoin, 2014; Janusch, 2016; Milner, 1997). States have different national interests, and it is rare that these interests completely coincide with each other. North-South politics is another challenge facing international health cooperation. At the heart of the international politics of global health is the divide between North and South over global health priorities, negotiating practices, distribution of obligations and their associated costs. Developing countries have often been marginalized (Baylis, 2020). Many countries in the North have the capacity to enhance their public health and surveillance and response systems and pay for vaccines and medicines that are necessary to fight infectious diseases. Countries in the South often cannot afford to make these upgrades and pay for costly and vital medicines, yet they are expected to cooperate when it comes to reporting outbreaks, sharing virus samples, and surveillance. Furthermore, because the rise of infectious disease is tied to climate change (for more on climate change cooperation, see Chapter 14), developed countries’ arguments are seen by the South as an attempt by the rich, developed countries to evade responsibilities and to avoid changes in their wasteful energy habits by shifting responsibility to the low-income countries (Roberts and Parks, 2006). Concerns that developing countries were being forced to cooperate with little benefit eventually came to a head in 2007 when Indonesia refused to share its human samples of H5N1 influenza with the WHO’s Global Influenza Surveillance and Response System. Indonesia believed that the system was unfair – developing countries were expected to share viral specimens without any benefits in return (Heymann et al., 2015). Vaccines and medicines produced were incredibly expensive, and sharing the samples went towards producing solutions that developing countries could often not benefit from. Indonesia claimed that it had the right to withhold samples because the virus was identified in its territory which was protected by the UN Convention on Biological Diversity (CBD). According to Indonesia’s arguments, human pathogens were characterized as genetic resources which required mutually agreed-upon terms for sharing of the benefits, like other natural resources (Fidler, 2008). In response, public health advocates argued that, in dealing with infectious diseases, a multilateral response is imperative, which may override concerns of sovereignty. The WHO also held an Intergovernmental Meeting on Influenza Viruses and Benefit Sharing in November of 2007. The EU’s president at the time attempted to introduce the term global health security which would prevail over all other laws. Brazil, Indonesia, Thailand, and India disagreed with the term and the meeting ended without an agreement (Shashikant, 2007). Other countries in the Global South also rejected the use of global health security to justify international agreements that wouldn’t benefit all countries. Though the WHO had relied on goodwill to cooperate in enabling surveillance and response, the IHR does not force states to share pathogens. As Indonesia’s stance was supported by other developing countries, the World Health Assembly worked on creating a nonlegally binding framework that would incentivize compliance for developing countries. The result was the Pandemic Influenza Preparedness Framework (PIP). The PIP framework regulated the cycle of pandemic influenza surveillance and response. Countries were encouraged to share their virus samples, and in doing so, they would benefit from diagnostics, antiviral medication, and vaccines (Fidler and Gostin, 2011).

Global health governance  335 The North-South divide has also affected the speed and substance of decisions being made in global health. Disagreements have ensued about what constitutes an emergency and how to act. For example, there are concerns that decisions of when to declare a PHEIC have been politicised and focused on safeguarding the interests of high-income countries at the expense of low-income countries (McInnes, 2016). The WHO was criticised for overreacting to swine flu and declaring a public health emergency – as it was affecting high-income countries – but also faced criticism for waiting too long to declare a PHEIC in the case of Ebola, which mostly affected low-income countries. Ebola was considered to be an emergency several months before a PHEIC was finally declared by the WHO in August of 2014 (for more on this, see the case study in this chapter). In many ways, Africa, with the possible exception of South Africa, has become increasingly marginalized as a player in global economics and politics (Fidler, 2015; Labonte, 2004). Obstacles to global health equity Another challenge in global health are the growing inequalities in access to quality care. As previously explained, the unequal distribution of power in the international system has driven policies that perpetuate more health inequities. The imbalances of power between donors and local health advocates leads to a top-down imposition of donor priorities without taking into account local needs (Reddy et al., 2018). Locally, public health advocates have been asking for more investment in strengthening public health systems in general. Donors, in contrast, tend to focus on vertical programmes that can be implemented from above, such as a vaccination programme (Ng and Ruger, 2011). Donors have been mostly interested in short-term technological solutions based on medical countermeasures, such as experimental drugs and vaccines. Using medicine to resolve health issues is known as the pharmaceuticalization of global health (Elbe, 2010; Roemer-Mahler and Elbe, 2016). A result of the pharmaceuticalization of global health is greater inequality in access to health goods and services. Rising prices of drugs and medicines marginalize people of low income who cannot afford the costs. One of the most controversial agreements related to this topic is the TRIPs agreement, or the Agreement on Trade-Related Aspects of International Property Rights, signed in 1994 (for more on this, see Chapter 4), which initially prevented low-income countries from generating their own generic drugs to treat various diseases to protect intellectual property rights. Another source of health inequity is vaccination availability. Because of the expense of vaccinations, few high-risk countries practice routine childhood immunizations against yellow fever, even though this is ten times more cost-effective and prevents more cases and deaths than emergency immunization campaigns (Monath et al., 2016). Thus, another obstacle to global health cooperation are the inherent gaps in wealth between rich and poor countries. Global health has tended to respond to global health emergencies rather than address chronic issues. Donors have had short-term priorities that present problems for implementing long-term investments. A consequence of the short-term, top-down process is that it is reactive and fails to involve local government. Instead, there is a standard humanitarian toolkit. A  field hospital and base camps are erected with emergency resources deployed (Farmer et al., 2013). Global health has also tended to invest in a single disease campaign rather than invest in public health systems and the various agencies that are associated with this. For example, the polio eradication program was the largest funded project for the WHO in 2014. It drew up to 38% of the organization’s staff in Africa, though there were fewer than 200 cases

336  Response worldwide (Fortner and Park, 2017). Much of this is because donors distort and drive priorities and policies for the lower income countries. A result of the inequalities that shape global health regimes, containment has been favoured over prevention in dealing with infectious disease threats; as such, public health systems have seen low levels of investment. Even the strongest and wealthiest states in the world could invest more in their public healthcare systems to ensure that they are better prepared to deal with infectious disease outbreaks. For low-income countries, which are barely able to cope with routine health issues, a disease outbreak can completely overwhelm a healthcare system (Ottersen et al., 2017). As much of the burden of global surveillance falls on the shoulders of developing countries, this complicates the task of tracking and tracing infectious disease outbreaks. Low-income countries may lack trained personnel, diagnostic labs, and funding necessary to support surveillance and accurately reporting on an outbreak. Thus far, the WHO has mostly focused on addressing early warning surveillance as opposed to investing in labs, diagnostics, and risk communication in low-income countries (Davies et al., 2015). The IHR specifically demonstrates the focus mostly on surveillance and emergency capacity rather than on domestic health systems. Prevention measures are distinguished from detection and rapid response capacity, even though proper surveillance is dependent on public health (Rushton, 2011). For the most part, short-term solutions are sought out that are donor led and technology based. By failing to offer greater support to public health systems, it is more difficult for low-income (and middle-income) states to cooperate fully in germ governance.

Conclusion Global health governance is complicated by many factors. The anarchic system, the role of powerful states in multi-lateral institutions, and persistent economic and political inequalities are just a few of the challenges facing global health cooperation. In spite of this, global health regimes have come a long way in providing more guidelines, support, and coordination to better promote health. Within the last 70 years, tremendous ground has been gained in global health governance, starting with the creation of the WHO in 1948 (as well as other organizations and networks that have followed). Once an organization that had almost no power or influence, the WHO today is tasked with managing and coordinating a host of health-related issues. From AIDS, to SARs, to Ebola, to H1N1, to Covid-19, the WHO has faced a herculean task. For the most part, the organization has moved two steps forward and one step back by learning from past mistakes. Some of these missteps were inevitable and not owing to its own missteps but due to the organization’s fundamental weakness vis-à-vis state actors. SARS, in particular, illustrated the need for the WHO to emerge as a stronger organization, and the subsequent revision of the IHR demonstrated the organization’s flexibility to increase its influence and power. The previous handling of an outbreak has shaped the WHO’s approach to each subsequent case. The overreaction to H1N1 led to the underreaction to Ebola, which constituted by far one of the organization’s biggest failures. Though many lessons were learned from the mishandling of Ebola, the Covid-19 crisis has posed an even greater threat to global health security. Though the WHO has tried to convince states to comply to its health regulations and report outbreaks early, in the area of infectious diseases, just one non-compliant actor has proven to be incredibly disruptive to containment. Covid-19 has also demonstrated that the WHO is too cautious in its assessments and advice and too vulnerable to the political whims of state leaders. The Covid-19 crisis has also demonstrated that even high-income countries are defenceless to a highly infectious disease, as the disease has hit almost every corner of the globe. This necessitates

Global health governance  337 greater coordination (in line with horizontal approaches) and greater support and prioritization of public health systems (in line with vertical approaches). But global cooperation has been difficult, and the chapter demonstrated why these issues may persist. In the chapter that follows, we look at disaster governance, which covers both disasters and environmental security. The challenges of cooperating in these areas are nearly identical to the challenges of cooperating in global health governance. States are self-interested, the system is plagued by inequalities, and ensuring compliance is difficult. We explain how well developed disaster governance has become and what scope there is for greater intersectoral cooperation.

Key questions 1 2 3 4 5

Why did the International Health Regulations need to be reformed? Do Realist interpretations of international cooperation explain why the world has struggled to manage Covid-19? If so, what reasons best explain this? To what extent was the WHO to blame for the 2014 Ebola crisis? What factors further exacerbate persistent global health inequities? What is the biggest challenge facing the WHO?

Notes 1 An organization is a group or organized structure of people working together with the aim of achieving collective goals. An agency is an organization with a defined purpose often administratively relatedly to or subsumed under a larger governmental or inter-governmental structure. 2 Bill and Melinda Gates Foundation is now the largest funder of global health research and it concentrates on improving access to vaccines and drugs to fight diseases in developing countries and investing in research to develop effective, affordable, and practical health solutions. 3 Smallpox was removed in 1981. 4 In 1995, the World Health Assembly passed Resolution WHA48.7 calling on the Director-General to begin preparing a revised version of the regulations. 5 This is in spite of the fact that this cost an estimated $30–$100 billion in losses to the global economy. The travel advisory that the WHO issued for Toronto, Canada, cost Toronto over $1 billion (Paquin, 2007). 6 www.cnbc.com/2020/06/02/china-delayed-releasing-coronavirus-info-frustrating-who.html 7 www.who.int/about/accountability/budget

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14 Disaster governance

Introduction In the area of disaster governance, at first glance, it may seem that international coordination between countries is less vital. In comparison to global health governance, a highly infectious virus can travel from country to country (as we’ve seen with Covid-19), whereas some disasters may only affect one country or specific part of a country. However, the issues related to climate change affect all countries, with some countries, mostly in the developing world, paying a much bigger price. Additionally, even though earthquakes may only affect one country in terms of the damage, there are spill-over effects that necessitate coordinated action, both to reduce risk and to properly respond to threats to human security. And, as we’ve seen with the 2004 Indian Ocean Tsunami, with some disasters, multiple countries across several continents can be affected. When it comes to disaster governance, though some international cooperation takes place, there is no organizational equivalent to the World Health Organization. Nevertheless, though disaster governance is not as developed as global health governance, it continues to advance. In this chapter we focus on the two international frameworks that address the key issues in disaster governance. The governance frameworks that addresses disasters most directly are Disaster Risk Reduction (DRR) followed by Climate Change Adaptation (CCA). CCA is often considered separate to disaster governance but can be complimentary to DRR. For the most part, the chapter focuses on the history of DRR, detailing what institutions promote DRR, what their tasks are, and how these institutions have formed. As the book has explained, both DRR and global health security need to be tackled using a sustainable development framework. To do so necessitates better integration of DRR and CCA. This chapter explores what the challenges are of doing so and the current obstacles facing disaster governance. Key concepts

What is disaster governance? In contrast to the study of public health governance, much less research has been devoted to the topic of disaster governance. There is extensive research on disaster management, disaster legislation, disaster risk reduction policies and programs but there is still a dearth of research that is devoted to the field of global governance in hazards and disasters. In spite of this, there continue to be new forms of collaboration, including global, regional cooperation, and public-private partnerships and joint ventures.

DOI: 10.4324/9781003128809-20

344  Response The need for disaster governance is important because – like infectious diseases – disasters don’t always respect borders. Disasters can affect more than one country and can affect supply chains in the global economy, having a reach far beyond the immediate area of impact. For example, managing the Rhine River basin involves cooperation among nine European countries and the European Union (Tierney, 2012). Thus, managing disaster risk requires cross-border collaboration and complex governance arrangements. It requires a form of collaborative governance that brings together many different types of organizations to resolve all of the problems associated with disasters. As disasters can have huge impact on rich industrialized countries, there is some momentum around coordinating action on disasters. As world population grows, there are more people who are vulnerable. Though there is a not a single disaster risk reduction regime, there is greater convergence on key norms and greater will to comply. Disaster governance is defined as the processes and structure of public policy decision making and management that engages people across different public agencies and levels of government in the public, private, and civic spheres to carry out reducing disaster-related risks (Emerson, 2012). It includes the laws, frameworks, regulations, and informal norms as well as the institutions and practices that aim to reduce the impact of disasters. More specifically, Disaster Risk Reduction (DRR) is the development and application of policies, strategies, and practice to minimize vulnerabilities, hazards, and the unfolding of disaster impacts throughout a society in the context of sustainable development ( Gall et al., 2014; Tierney, 2012). DRR focuses on reducing disaster risk and impacts through enhancing understanding about and awareness of risks, risk governance, promoting risk prevention measures and vulnerability reduction as well as emergency preparedness for better and more timely responses. It builds on the need to tackle root causes and fundamental challenges to reduce the possibility of hazards transforming into disasters and on managing consequences (UNISDR, 2016). Disaster governance is also closely tied to environmental governance which absolutely necessitates cooperation at the global level. It also works on interventions aiming to change environment-related incentives and spreading information and knowledge. Though disaster governance is related to environmental governance, these linkages have not been acknowledged extensively in practice. One aspect of environmental governance is Climate Change Adaptation (CCA). CCA is defined as an adjustment in natural or human systems in response to climate and their effects (IPCC, 2007, 2014). CCA is mainly about building the capacity of people, societies, and ecosystems to adapt to changing climate conditions – including extreme events and slow onset environmental change. CCA strategies aim to reduce vulnerability to climate change impacts across local, national, and international interventions. At the community level, strategies include improvements to agricultural systems, such as crop diversification or the introduction of hazard-resistant crop varieties; risk assessments and associated plans; the protection of natural resources; early warning systems; education and awareness measures; and protection of water resources (UNFCCC, 2006). At the national level, some countries have developed National Adaptation Programmes of Action (NAPAs), which identify adaptation strategies to mitigate against climate change. CCA and DRR are interconnected in many ways and there are many opportunities for joint action. Both concern reducing vulnerability and raising social capacity and building resilience to reduce and manage climate risks (Islam et  al., 2020). Both share a common understanding of risk and emphasize long-term sustainable development to help communities protect against and prepare for hazards. DRR’s extensive history and knowledge of

Disaster governance  345 how to deal with a variety of hazards can help guide CCA towards a better understanding of current impacts and future changes in climatic conditions and climatic variability. DRR and CCA typically overlap in the area of disaster preparedness and prevention/risk reduction, although there is growing attention to mainstreaming climate change considerations in post‑disaster recovery and reconstruction. Similar to global health governance, disaster governance includes interaction between the public and private sectors and civil society, relying on both formal institutions and informal norms. Global actors work with the private sector to encourage the practice of following disaster risk reduction, such as ensuring that supply-chain partners comply with disaster-risk activities. Governance includes horizontal and vertical linkages that span local, national, regional, and international levels, though local-level action is best suited to reducing disaster risk. Horizontal governance relationship refers to actor networks that operate within a local geographic area. Vertical disaster governance involves the cooperation of local, supralocal entities, national governments, regional governances, and international actors (Renn, 2008). Civil society organizations and NGOs play a significant role in disaster governance. At the international level, the Global Network of Civil Society Organizations for Disaster Reduction (GNDR) lists 1036 members spread across over 100 countries. NGOs are very important at the community level in collaborating with countries in the emergency management frameworks. There are many NGOs and international organizations that work on disaster response, such as the International Federation of Red Cross and Red Crescent (IFRC). The IFRC is the world’s largest humanitarian organization. It plays a key role in the area of disaster relief. It works with the Red Cross and the Red Crescent, which are national organizations in capacity building, training, assessment, and post-disaster response. The organization also looks at disaster law. Oxfam is another massive international NGO constituting 15 NGOs operating in 90 countries. Evolution of global disaster governance In comparison to global health governance, global disaster governance has been a more recent project. It was not until 1971 that the Office of the UN Disaster Relief Coordinator (UNDRO) was established to deal with disaster relief. It would later become the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) in 1991. UNOCHA has 35 offices in mostly developing countries and works to coordinate among national and international NGOs in the area of disaster response. To compliment UNOCHA, the Inter-Agency Standing Committee was created in 1992, which is an inter-agency forum of the UN and non-UN humanitarian partners that tackles humanitarian issues. It is charged with coordinating disaster-related activities across various UN programs, along with the International Organization for Migration and the NGO sector. By 2005, the Inter-Agency Standing Committee established a cluster system by which global- and country-level lead agencies are designated for crises/disaster-related activities, such as search and rescue, logistics, emergency telecommunications, shelter, food, and recovery support. Meanwhile, the UNOCHA was tasked with working closely with the Secretariat that handled the International Decade for Natural Disaster Reduction (IDNDR) (1990–1999). Prior to this decade or recognition being launched there was not much interest in disaster risk reduction from the policy world compared to other issues of human security (Lechat, 1990; Mal et al., 2018). However, the IDNDR was very influential, spotlighting disaster risk and using

346  Response the expertise of large scientific and technical groups. Many of the global disaster governance strategies were influenced by the activities that took place during the IDNDR. One result of the IDNDR was the launch of the UN World Conference on Disaster Risk Reduction, which was held in Yokohama, Japan, in 1994. This produced the Yokohama Strategy and Plan for a Safer World (de la Poterie and Baudoin, 2015). Countries involved pledged to make changes to their policies that would help to diminish disaster risks and losses. Countries would need to cooperate to work on mutual aid agreements and early warning systems. Countries would also have to coordinate how to implement regional agreements. The IDNDR also influenced the Millennium Development Goals, which included in the original roadmap objectives for how to reduce losses from disasters in developing countries, such as building early warning systems and encouraging governments to engage in disaster risk reduction, to address the vulnerabilities facing major cities. Another direct result of the IDNDR (and the increasing incidence and scale of disasters), was the creation of the United Nations International Strategy for Disaster Reduction (UNISDR) in 1999, which was renamed the United Nations Office for Disaster for Risk Reduction (UNDRR) in 2019. The UNISDR coordinates with the World Bank and the Global Facility for Disaster Reduction and Recovery (GFDRR), along with other regional actors (such as ASEAN, Pan American Health Organizations, the Applied Geoscience and Technology Division of the Secretariat of the Pacific Community, the European Union, and the African Union). The UNISDR also encourages collaboration among public and private sector groups to reduce disaster risk and sponsored capacity building activities. The UNISDR notably launched the Hyogo Framework for Action 2005–2015 (HFA) which was a non-binding agreement adopted at the 2nd World Conference on Disaster Reduction, held in Kobe, Japan, in 2005. The devastating 2004 Boxing Day Tsunami had just taken place in Southeast Asia three weeks before the World Conference was held, which gave the conference a huge boost in terms of press coverage and attention. The HFA was endorsed by 168 countries to reduce losses from disaster by 2015. It built on the Yokohama Strategy and Plan of Action to ensure that disaster risk reduction was a national and local priority. It also emphasised the importance of building strong institutions in order to implement these objectives. The HFA was focused on identifying, assessing, and monitoring disaster risks and enhancing early warning systems, while using knowledge and education to build resilience. It was also important to reduce disaster risk factors and strengthen disaster preparedness. The UNISDR monitored and reported on countries’ progress towards achieving the HFA goals. In March of 2015, the Sendai Framework for Disaster Risk Reduction was adopted by the UN member states, following the HFA, with the aim of reducing disaster risk and losses by the year 2030. It establishes new metrics for state compliance and new priorities for action. The Sendai Framework is a 15-year approach to disaster risk reduction that is people-centred and voluntary. In addition, while technical and scientific expertise is still important, the Sendai Framework recognized that there should be greater involvement of social scientists to understand how to prepare for and deal with disaster, as disasters clearly have significant social and economic consequences (Aitsi-Selmi et al., 2015). To monitor global progress, the Global Platform for Disaster Risk Reduction was established by the UNISDR in 2007. The Global Platform for Disaster Risk Reduction was a biennial forum to monitor global progress on the HFA and Sendai Framework. The signatories agreed to submit a bi-annual self-evaluation of what had been accomplished within the indicators of the UNISDR. In addition to the self-report, there was also a mid-term review that took place in 2011. The findings showed that the implementation of the HFA was very uneven across many of the component indicators and in general (UNSDR, 2010–2011).

Disaster governance  347 Various regional organizations developed their own frameworks for encouraging disaster risk reduction. The African Union established the African Regional Strategy for Disaster Risk Reduction. ASEAN produced its own agreement on disaster response, the ASEAN Agreement on Disaster Management and Emergency Response (AADMER), which aims to improve capacity through greater coordination and cooperation in the region. In 2010, the Arab League also adopted its Arab Strategy for Disaster Risk Reduction. Some countries in Europe have formed disaster risk reduction alliances. In addition to regional organizations, regional platforms were created to enable governments, NGOs, scientists, practitioners, and the private sector to share experience and communicate about how to implement the HFA and later the Sendai Framework. Further programmes of action were created for developing countries, and additional conferences were held on sustainable development and for small island nations. Global cooperation in disaster risk reduction and response There have been numerous examples of disaster risk reduction cooperation since the HFA was created. Disaster risk reduction requires support for populations both before and after a disaster has hit. It requires financial support to help those vulnerable be more resilient. It also requires that countries cooperate in sharing information and technologies. In both cases, the major global institutions play a role in facilitating various forms of disaster risk reduction cooperation. One of the global initiatives that resulted from the HFA was the World Bank’s Global Facility for Disaster Reduction and Recovery (GFDRR), which was founded in 2006. The GFDRR is focused on reducing disaster losses in developing countries and small island developing states. The GFDRR established collaborations among key entities involved in disaster risk reduction, including the International Federation of Red Cross and Red Crescent Societies (IFRC), which took over the Secretariat of the Consortium in 2003. It also tries to foster cooperation among developing countries and developed countries (Linnerooth-Bayer and Hochrainer-Stigler, 2015). The World Bank has also worked to offer post-disaster financing mechanisms to provide governments and individuals with resources after a disaster has taken place that can be repaid later. This is important because it is not always easy for the poor or lowincome countries to access credit from commercial lenders in the post-disaster context. Since the 1980s, the World Bank has worked to rectify this problem by providing over hundreds of loans for recovery and reconstruction and disbursing billions of dollars. Actors can also take out loans from internationally backed microlending institutions. The loans can be applied for before a disaster hits, which means that the money can be disbursed quickly after the government declares an emergency. Historically, however, loans have been used as international emergency assistance which governments receive after a major disaster. Another aspect of disaster governance involves ways in which to spread risk – or at least share the costs of risk (Surminski et al., 2016). The most recognized form of international risk transfer is insurance which pools money to distribute for disasters for at-risk households, businesses, and governments. This book has thus far not focused much on the issue of health insurance which is important to spreading the risk for those who face disease and may not seek treatment to avoid catastrophic healthcare costs. The same problem affects disasters, as those with less means are often not covered by insurance, making the impact of a disaster and any attempt to bounce back much more difficult.

348  Response Societies differ considerably in terms of what insurance arrangements are available for different types of hazards. In most developing countries, disaster losses are not properly covered by insurance for the poor (Sawada and Takasaki, 2017). In these instances, the nation-state is to act as the insurer of last resort, but the aid available may be insufficient. Even in richer countries like the US, Hurricane Katrina illustrated how little support the federal government was able to offer many of the most impoverished people affected by the hurricane. When relying on national insurance is not enough, an insurer may purchase reinsurance from a private reinsurance company, which spreads risks to its international shareholders. Other ways to transfer risks include having the government issue a catastrophe bond to move risks directly to the international capital markets (Etzion et al., 2019). Many small countries can also form a catastrophe insurance pool which diversifies risks and better enables them to purchase reinsurance. Global cooperation is important in disaster risk management because disasters have an impact that transcends borders. One area of disaster risk reduction that necessitates greater cooperation and coordination is the use of global information systems. Information systems support data, information, and knowledge processes efficiently and have significant potential to support governments, NGOs, and other responders in a crisis (Dorasamy et al., 2013). Other areas of potential cooperation include the use of telemedicine (or the practice of caring for patients remotely), which is important to savings lives when a disaster strikes (Latifi and Tilley, 2014). All of these tasks require strong information and communication infrastructure. The WHO and the UN’s International Telecommunication Union (ITU) work to provide assistance in post-disaster events by helping to improve communications in countries afflicted by disasters. The ITU, one of the UN’s oldest agencies, helps countries (especially developing countries) improve their communications infrastructure. Countries also need to cooperate in using a Common Alert Protocol, which is critical to ensuring that the media can effectively communicate alerts. With disasters that cross borders, there is a need for a regional transport cooperation. There are many other areas in which sharing technologies can be helpful, including how to protect and build against sea level rise: dikes, levees, floodwalls, seawalls, detached breakwaters, floodgates, tidal barriers, saltwater intrusion barriers, and wetland restoration (Klein et al., 2005). Cooperation on disasters requires collaboration on earth observations. One of the platforms that facilitates the use of space-based technologies for disaster management and emergency response is the United Nations Platform for Space-based Information for Disaster Management and Emergency Response (UN-SPIDER). UN-SPIDER has been operational since December of 2006 and uses earth observation and meteorological satellites to support disaster management by providing accurate and timely information for disaster risk reduction and disaster response and recovery (Zollner, 2018). Another earth observation programme is coordinated and managed by the European Commission in partnership with the European Space Agency, which helps with disaster management and response while providing a comprehensive picture of the health of the earth (Lorenzo-Alonso et al., 2019). Another international asset is the International Charter for Space and Major Disasters. This is a non-binding charter which offers the transmission of satellite data to relief organizations. It came into effect after the UNISPACE III conference, fully operating by November 1, 2000. The charter is tasked with providing data for immediate emergency response, but cannot provide any help with rehabilitation, reconstruction, prevention, preparedness, scientific research, or on droughts. It is only for the coverage of storms, floods, fires, landslides, and earthquakes (Martinis et al., 2017).

Disaster governance  349 Integrating disaster risk reduction and climate change adaptation One of the biggest challenges for disaster governance is that, although it is closely related to and inter-dependent with other areas of governance, it has not always been prioritised or clarified as to where it should sit. Disaster governance is not just handled by one set of institutions but instead is dealt with by several somewhat overlapping areas of governance. As explained earlier in this chapter and in Chapter 1, these areas of governance are referred to as Disaster Risk Reduction (DRR), Climate Change Adaptation (CCA), and Sustainable Development. Before delving into some of the issues in integrating DRR with CCA, it’s important to highlight the lack of synergy between disaster governance and development studies early on. Up until the 1990s, disaster issues did not figure prominently in the sustainable development debate (Tierney, 2014). There was very little attention on integrating sustainable development with disaster reduction efforts. In fact, early approaches to development ignored disasters completely. But for many decades, in the name of sound development, natural resources were exploited to generate exports to repay foreign debt. These projects contributed to substantial environmental degradation which exacerbated the severity of disasters, with more flooding and landslides, for example, caused by deforestation for timber exports. Development agencies during the 1980s were not effective in accounting for disasters, which has led to an inefficient use of development funds (Tierney, 2012, 2014). Even up to the 1990s, disaster reduction was not incorporated into the mission statements of major development institutions. These mission statements have been revised, however, to integrate disaster loss reduction with development (Kelman, 2017). DDR and CCA have also struggled to be more integrated, despite many similarities. They both aim to manage climate-related hazards through reducing vulnerability and exposures, increasing resilience, and transferring and sharing risks to reduce impacts (Thomalla et al., 2006). They both want to promote a long-term approach to disaster management. The challenge is that they are managed in different communities of research and practice different approaches and frameworks and are planned and funded by different government agencies and organizations (Birkmann and von Teichman, 2010). These two areas face some barriers that inhibit collaboration, such as the silo mentality of both agencies and academic disciplines (Forino et al., 2015). However, scientific organizations are important to helping these two fields better integrate. These organizations can help not only with research but also to build cooperative networks, support actions related to climate change and disasters, and share scientific evidence with a broad range of users. With regard to international frameworks, the Sendai Framework is the main guiding global instrument for DRR while the United Nations Framework Convention on Climate Change (UNFCCC) and the Paris Agreement (which is a 2016 agreement within the UNFCCC) guide action on CCA. There has been some effort by these frameworks to integrate the CCA and DRR. The Hyogo and Sendai Frameworks for Action called for more multidisciplinary approaches to DRR when considering climate change but did not establish how to develop them (Kelman, 2015). At the same time the United Nations Framework Convention on Climate Change (UNFCCC, 2008) adopted the Bali Action Plan which recognized the importance of using DRR strategies for extreme weather events. Additionally, the UNISDR (UNDRR, 2009) recommended that CCA and DDR be linked in a poverty reduction and development framework. In order for these two frameworks to be better integrated, they may need to have the same organizational home at the international level (Mitchell et al., 2010).

350  Response There is a consensus that both DRR and CCA should be integrated into wider development planning, but there are differences in their point of view (e.g . Glantz, 2003; O’Brien et al., 2006).1 At various international meetings such as the UNISDR meeting on DRR and CCA integration, it was emphasised that action that addresses the interlinked challenges of disaster risk, sustainable development and climate change are a core priority. As such, the Sendai Framework specifies that addressing climate change is important to reducing disaster risk and the Framework serves as a guide for implementing the disaster risks in the SDGs. There are 25 targets related to DRR in 10 of the 17 SDGs. Goal 13 of the SDGs was to take urgent action to fight climate change and its impact, by strengthening resilience and adaptive capacity to climate related hazards. Article 7.1 of the Paris Agreement (UNFCCC, 2015) also provides an opportunity for integrating DRR and CCA action by calling for enhancing adaptive capacity, strengthening resilience and reducing vulnerability to climate change and to update these DRR strategies by 2020. These goals also require that CCA and DRR are integrated into development agendas. There are many opportunities for integration in national development agendas and to establish collaborative policies in governments for those that work in climate change and disaster risk reduction with those that work in: agriculture, education, economic development, infrastructure water resources management, health and urban planning (Rivera and Wamsler, 2014). There are also opportunities for integration when dealing with developing and small developing island nations, these groups are especially vulnerable to climate change and disaster events (Begum et al., 2014). In spite of these openings for collaboration, integration has been undermined by the differences between the DRR and CCA frameworks. DRR and CCA have separate platforms, different political constituencies and different structures of accountability. There are different expectations and pressures on different UN agencies, and there may also be some competition over resources and support (Peters et al., 2016). There is a lot more funding for CCA and only moderate funding for DRR (Kellet and Sparks, 2012). Many DRR programmes are expected to be funded by humanitarian budgets and coordinated by humanitarian aid departments, which traditionally focus on response rather than prevention, which is making it more difficult to achieve convergence with both CCA and with the broader development agenda. There are also still issues with communication and collaboration between DRR and CCA. Furthermore, the CCA looks mostly at global policy agendas to guide action, while DRR looks more locally as well (Ireland, 2010). There are also differences substantively. DRR focuses on all hazards and understands that climate change is just one factor influencing certain hazards (Mercer, 2010). DRR looks at underlying vulnerabilities, root causes of vulnerability in the context of development, and acknowledges that vulnerable people have multiple exposures to multiple threats (Wisner at el, 2004). DRR policies and strategies view disasters as socio-economic and political in origin (Wisner et al., 2004; Kelman and Gaillard, 2010). DRR look at the wider social, economic, political, and environmental situation and sees climate change as just one factor of many that is to blame for disastrous events (Mercer, 2010). DRR acknowledges that vulnerable people have multiple exposures to multiple threats that are not all climate-related. CCA looks less at poverty, social deprivation, lack of resources, and poor education as a reason why there is community vulnerability, and instead uses climate change as the source of all problems (Mercer, 2010). Additionally, CCA may focus more on making predictions, while DRR focuses on existing risks with strategies based on current and historical evidence (Mitchell and van Aalst, 2008). There are also differences in the power that these frameworks have to ensure compliance. The Sendai Framework is still voluntary, as are the SDGs. As the Sendai Framework is used

Disaster governance  351 to implement the SDGs, it is still not clear how the SDGs will be realized (Mysiak et al., 2018). In comparison, the Paris Agreement is a partially legally binding treaty with countries required to report regularly on their greenhouse gas emissions, adaptation action, and the planning taking place through their National Adaptation Plans (NAPs). The Paris Agreement takes place under the United Nations Framework Convention on Climate Change, and therefore has a little more bite to it (UNFCCC). Challenges for disaster governance Disaster governance and health governance share similar challenges. One of the issues is that many of the developing countries that are the most affected by disasters lack the state capacity to prepare or respond to major disasters (Sawada and Takasaki, 2017; Ezrow et al., 2015; Ezrow and Frantz, 2013). Wars complicate disaster relief efforts and give rise to humanitarian emergencies (for more on this, see Chapter 6). In weak states, there are still issues with weak or non-existing land-use controls, no regulations on buildings, the expansion of informal settlements, and no disaster preparedness plans. In spite of these comprehensive and interrelated concerns, when it comes international disaster governance, there is no real equivalent to the WHO. International institutions, such as the United Nations and the World Bank, play an important role in disaster governance, particularly in developing countries, but the absence of an organization to coordinate and address all of the root causes of disaster vulnerability means that disaster governance has much it can improve upon. One such issue is that, like health governance, there is a tendency to neglect prevention. Nevertheless, it is increasingly acknowledged that some of the work in disaster governance takes place before a natural hazard has occurred. Prevention involves both climate change adaptation and disaster risk reduction. This includes doing vulnerability assessments, enforcing building codes and disaster-resistant construction practices; enforcing local land-use regulations; setting up community and regional planning agencies; setting up entities charged with floodplain and coastal management; setting up organizations and institutions that seek to improve population protection efforts, such as evacuation planning and training; developing early warning systems and other education and training programs (for more on early warning systems, see Box 14.1 and 14.2). In 2010, the World Bank estimated that the costs of adapting developing countries to be ready for climate-related disaster risks would be well over $100 billion each year, but donor countries are not always able to make specific funding commitments. At the 2010 UNFCCC negotiations in Cancun, the developing world agreed to establish a Green Climate Fund, with the goal of raising $100 billion per year by the year 2020 to help the developing world respond to climate change (UNFCCC, 2011). The issue with these efforts and agreements in pre-disaster preparedness is that, ultimately, they are voluntary; there is no effective global enforcement mechanism. This highlights the tension that exists in efforts to cooperate globally on international agreements and achieve a global public good. Conflict still exists between the importance of compliance to international agreements and retaining one’s sovereignty. The HFA had no concrete targets and was too vague to deliver concrete outcomes at the national level (Gaillard and Mercer, 2013; Lavell and Maskrey, 2014). Many countries report that there has been progress in disaster preparedness even when in practice this has not taken place. There still is a lack of will to prioritize disaster risk reduction and to do so – so that it meets the needs across an entire country. This results in uneven capacity that impacts communities differently. As mentioned previously, the Sendai Framework and the SDGs are voluntary, while the Paris Agreement is semi-binding but saw one of the biggest world powers, the United States, declare that it

352  Response would leave in 2017. A new administration has pledged otherwise, but similar challenges to ensuring compliance remain. Like global health governance, disaster governance would be enhanced with a greater focus on how it relates to development. Reducing risk to disasters is important in reducing poverty, but these connections are not implemented in practice. The World Bank estimated that countries can save $7 in disaster recovery costs for every $1 spent on risk reduction measures. Therefore, it is important to develop performance targets and indicators to assess the extent to which disaster risk reduction is integrated into development policies. There needs to be greater acknowledgement that economic development should not undermine environmental and disaster security. The HFA and the Sendai Framework recognized that sustainable development, poverty reduction, good governance, and DRR are mutually supportive objectives (UNDRR, 2007; UNISDR, 2016). But in many countries (including the UK, India, Indonesia, Zimbabwe, South Africa, and the Philippines), DRR has not been part of the broader development agenda, thus impeding implementation (Djalante et al., 2012).

Box 14.1  Disaster governance and early warning systems for tsunamis On the 26th of December in 2004 a massive 9.1 earthquake erupted in the Indian Ocean, triggering a tsunami of waves as high as 30 meters in Indonesia. Without a proper early warning system about the pending tsunami, over 227,000 people died (AP News, 2014). A network that detects tsunamis and earthquakes around the Pacific Ocean (called the Pacific Tsunami Warning Center operational since 1949) warned the US and Australia but they were unable to reach the authorities in the countries affected in the Indian Ocean in time, as it was not clear where to send the warnings. There was an absence of coordination as to which national contacts to communicate with. In many places, no evacuation measures were taken. Due to issues with funding, the Indian Ocean lacked the equivalent type of warning centre and there was no international plan for the Indian Ocean (Spahn et al., 2014). Governments were alerted in some cases, but many governments were slow to act or did not have a plan in place. In Indonesia, there had been an early warning system (a seismograph designed to detect earthquakes that cause tsunamis) on the island of Java since 1996, but it lacked the telephone connection to relay the news of the impending disaster to the government in Jakarta (BBC News, 2018). This prevented the government from issuing a tsunami warning, and 131,028 people died in Indonesia (AP News, 2014). As a result of the absence of an early warning system, many people died that could have evacuated in places much further away from the epicentre such as Somalia (176), the Seychelles (3), the Maldives (82), India (10,749), Sri Lanka (31,229), Myanmar (90), and Thailand (5,395) (AP News, 2014). In most of these cases, there was ample time to warn people to flee to safety. It took two hours before the tsunami waves hit Thailand, India, and Sri Lanka, and seven hours before the Tsunami travelled to Africa. In the Pacific, 90% of the fatalities due to tsunamis come from those that are

Disaster governance  353 close to the epicentre. In the case of the Indian Ocean tsunami, 50% of the fatalities were people who were not close to the epicentre (WHO, 2013). The lack of technology was only part of the issue. It was possible using the earthquake data for the Indonesian authorities to detect that the earthquake was powerful enough to trigger a tsunami. But protocols, such as sirens blasting on the streets, were not in place to warn people so that they could evacuate. The last time an event of similar magnitude took place in the Indian Ocean was in 1883 (Pelinovsky, 2005). Thus, there was not enough education of the community about what happens when there is earthquake. The exception was the village of Simeulue in Indonesia which had educated villagers from generation to generation about the 1907 Tsunami tragedy through poems and stories. As a result, when the tsunami hit in 2004, the people in the village were prepared and knew what steps needed to be taken to save lives (McAdoo et al., 2006; Suciani et al., 2018). Tsunamis are rare, which is why many people are unprepared for them. Destructive tsunamis occur about twice a year and ones that cause ocean-wide devastation occur once every 15 years on average. Over 80% of the tsunamis have taken place in the Pacific, around the Ring of Fire, which is why the Pacific Ocean Tsunami Warning System has been in operation to keep an eye on the region (National Geographic, 2020). The scientific community at the time was not aware that a tsunami of that magnitude could take place in the Indian Ocean. Scientists are now more aware that tsunami events can take place thousands of years apart (Rubin et al., 2017). At the UN Conference held in Kobe, Japan, in 2005 which led to the HFA, it was agreed that an early warning system in the Indian Ocean should be established. It consisted of 25 seismic stations that relay information to 26 national tsunami information centres automatically through SMS and email within two minutes. The Indian Ocean warning system (officially known as the Indian Ocean Tsunami Early Warning and Mitigation System) has been able to help provide warning within 15 minutes of an earthquake to evaluate whether it is necessary to evacuate a coastal area. For example, after an earthquake occurred off the coast of Indonesia in September of 2007, the warning system helped the Foreign Minister of Disaster Management in Sri Lanka to get the authorities to evacuate the coastal area within 45 minutes to ensure everyone was safe. The early warning system ensures that there is monitoring of seismic and sea level activity with a network that works with round-the-clock communication (Thomalla and Larsen, 2010). UNESCO’s Intergovernmental Oceanographic Commission (IOC) has helped support the development of technical, educational, and communications plans that have scientific basis but take into account cultural nuances. What is still needed is to ensure that there is further communication between governments and civilians at risk. National governments usually warn citizens through radio and television broadcast messages, SMS, radio, sirens, and loudspeakers. In April of 2012 there was a massive earthquake of 8.6 on the Richter scale off the coast of Sumatra which the Indonesia Meteorological Service was able to detect and then issue a tsunami warning for within five minutes. Later warnings were sent to other centres in other countries and to the Pacific Tsunami Warning Centre in Hawaii. Though the tsunami was nowhere near as powerful, people were warned and had time to evacuate to safety (Chatfield and Brajawidagda, 2013).

354  Response Given how infrequent tsunamis take place, keeping these types of systems going and maintaining vigilance is expensive and requires the political will to maintain them. Had a better warning system been in place in the Indian Ocean in 2004, it could have saved hundreds of thousands of lives.

Obstacles to disaster risk reduction equity In the area of disaster governance, there has been a greater emphasis on response than on mitigation and prevention of disasters (Tierney, 2012). Disaster governance tends to respond to the event after it has occurred without addressing in full the preventive activities and investments that need to take place. Disasters are treated as unique, crisis-oriented, discrete events that require a quick response and delivery of humanitarian aid. The goal is generally focused on meeting short-term needs. Relief organizations have often failed to address underlying causes of disaster vulnerability in low-income countries. Additionally, constantly operating in response mode exacerbates existing inequalities between developed and developing countries. Aid is disbursed in a way that may facilitate greater dependency. Disaster-stricken people are often viewed as helpless victims, and aid is distributed as a form of charity (Hannigan, 2013). Thus, there still needs to be more focus on building capacity for local people to take control over the issues that affect their lives. The safety of vulnerable individuals is enhanced by increasing their capacity. Though DRR has evolved significantly in the past four decades, there remain issues with the decision-making processes in addressing disaster risks. In DRR decision-making and programming, representatives of marginalised groups are not systematically involved or consulted (Hyden, 2008). DDR tends to be very donor-driven and driven by international organizations (Hannigan, 2013). Sometimes the donors are driven more by what they perceive the needs to be than the actual needs (for more on this see the Case study on Pakistan’s 2010 floods). The donor driven nature of assistance can lead to weak local ownership. ***

Case study: international funding and the Pakistan 2010 floods Disasters that have a massive death toll tend to receive more support than disasters that affect more people (Alexander, 2018). The Indian Ocean tsunami is a perfect example of this. The countries affected by the Indian Ocean tsunami received a record amount of support (only the Haitian 2010 earthquake received more), attracting a record $13 billion in donations (Knox, 2015). When the UN coordinated its fundraising appeal for the Indian Ocean Tsunami, it received more than twice the percentage of needs met. This contrasts with the way that the international community responded to the July 2010 floods that hit Pakistan. Though this constituted the worst disaster to hit Pakistan since its independence and affected over 20 million people, the UN struggled to galvanize the same type of funding as it had for other disasters (Deen, 2015). One of the issues with disaster response is that donors don’t always tend to respond proportionately in terms of need. The floods ended up affecting more people than the 2004 Tsunami, the 2005 Kashmir earthquake, and the 2010 Haitian earthquake combined, but in spite of the huge number of people affected, the international community failed to mobilize

Disaster governance  355 the same level of generosity. The UN coordinated appeal to help out with the floods in Pakistan only generated about 24% of the necessary funds one month after the appeal was made (Ayele, 2014). One month after the Haiti 2010 earthquake appeal took place, it was 49% funded – more than double that of the Pakistan floods – even though the earthquake affected far fewer (2.1 million) people. Pakistan received just $16.36 per person affected compared to the $1,249.80 for each person affected by the Indian Ocean tsunami (Zaidi, 2010). The Haitian earthquake amassed pledges of nearly $1 billion within the first ten days. Typhoon Haiyan in the Philippines in 2013 also struggled to gain enough funding, reaching 55% of its target, even though it was one of the most powerful storms on record and displaced over 11 million people (Ayele, 2014). In responding to disaster, any response needs to be as swift as possible to save lives and prevent loss, but the lack of funding for the floods in Pakistan and Typhoon Haiyan led to delays in disbursing funding. UN staff in Pakistan described the situation as among the most difficult that they have ever faced, with humanitarian organizations working around the clock to deliver badly needed assistance. Routes were blocked, dams and barrages were in danger of breaking, bridges had collapsed, there was no dry land to build tents, the water had been contaminated facilitating the spread of infectious diseases (such as cholera), there was a shortage of supplies, and there was no proper sanitation (Ferris, 2010). Further complicating matters, the country faced a very difficult security situation with an ongoing conflict involving violent non-state actors, such as the Pakistani Taliban. The Taliban also undermined the aid efforts by urging the Pakistani government to not accept Western aid and by attacking international aid groups. Due to historical tensions with India, Pakistan was also slow to receive much aid from its neighbour, which initially sent a condolence note instead (Fair, 2011). The US envoy to Pakistan, Richard Holbrooke, stated that international recognition of the disaster had not ‘been sufficient to its dimensions,’ in part because floods are ‘rolling crises’ that are always ‘underestimated’ (Council of Foreign Relations, 2010). The lacklustre level of international support for the Pakistani floods was attributed to several other factors as well. One is that there was little media attention on the floods. In comparison, the Boxing Day Tsunami took place at a time when the media could put all of their efforts into covering the tsunami. The tsunami also attracted a lot of financial support because many Westerners travel to Southeast Asia and were caught on the beaches when the disaster happened. Thousands of Westerners died, with Germany and Sweden each losing over 500 citizens. There was media and donor fatigue of covering disaster events after the January 2010 Haitian earthquake. Donor activity was also low due to the perception that the Pakistani government was incompetent and corrupt (Ayele, 2014). Studies have demonstrated that there is no clear relationship between humanitarian need and humanitarian funding (Cosgrave, 2009; Stapleton et al., 2010). There are many different factors at play as to which events generate large amounts of aid compared to others. Some posited that the lack of aid to Pakistan was on political grounds. Others say that earthquakes tend to generate more attention than floods. Still other studies have cautioned that political considerations or strategic behaviour does not determine the amount of post-disaster aid (Becerra et al., 2014). Regardless of the reasons, there is still work to be done in ensuring that the response to a disaster matches the needs of those affected. *** Failing to incorporate local communities into DRR policies is a missed opportunity. The UNDRR has highlighted the importance of community-based, local, and indigenous

356  Response approaches to disaster risk management. These approaches recognize that local communities are able to provide assessments of hazards, vulnerability, and capacities and should be more involved in the planning and implementation of local action for disaster risk reduction. Local communities can play a huge role in disaster mitigation, particularly in the areas of climaterelated disasters. For example, in the case of droughts, local knowledge can be used to better understand the coping strategies that have worked such as risk-reducing mechanisms in crop production. Farmers may plant crops in different ecological zones, grow a variety of crops, and grow crops off farms to increase the diversity of the system. Wild foods such as berries, leaves, and roots can be an important source of food (Campbell, 1990). Some studies have also noted that indigenous knowledge of seasonal change has the potential to fill gaps in climate data, particularly in the area of seasonal rainfall forecasting (Orlove et al., 2010; Roncoli, 2006; Roncoli et al., 2002). The integration of indigenous and scientific climate knowledge could enable more precise drought monitoring (for more on famine warning systems, see Box 14.2) as it uses both climatic and contextual data (Leclerc et al., 2013).

Box 14.2  Famine early warning networks It is not only tsunamis that require an early warning system but famines as well. The book has not focused as much on famines, but as they are related to droughts and are a major threat to human security, it is important to bring them to focus. A famine is always driven more so by political and socio-economic factors than due to a lack of rainfall. This means that there is plenty of scope for governments and the international community to prevent a full-blown humanitarian crisis. In spite of this, the international community is not always quick to respond to these types of crises (Bailey, 2012). The 2011 famine that hit Somalia highlights this issue. The Famine Early Warning Systems Network (FEWS NET) issued a warning about an impending food crisis nearly a year before the famine was officially declared. The international community did not take action until it was too late, and by that time, nearly two-thirds of the population (or 4 million people) were in urgent need of humanitarian aid. As a result of the famine, 258,000 people died, many of whom could have been saved with quicker action (Maxwell and Fitzpatrick, 2012). The UN made an announcement about the famine which did trigger an increase in donations, but these donations came in when it was already too late for early intervention and prevention.

Not incorporating local actors is problematic for better understanding how to meet the needs of the most vulnerable who face multiple risks. Their socio-economic status and/or political exclusion prevents them from participating in decision-making that affects their lives. Women in particular have not been fully integrated into DRR policy and practice (Enarson et al., 2018; Fordham, 2003). People with disabilities have also been excluded. People who are most at risk are marginalized and don’t have access to information they might need to increase their resilience ((McDermott et al., 2016; Stough and Kelman, 2018). This limits DRR interventions in being able to strengthen people’s resilience to natural hazards. The HFA and Sendai Framework national reports have demonstrated that only about 20% of the countries conducted gender-disaggregated vulnerability and capacity assessments. Only 36% of all countries have reported how disaggregated data on gender can

Disaster governance  357 be applied to recovery activities. By failing to recognize the needs of diverse socio-economic groups, DRR lacks information needed to understand how to best bounce back. For example, in small villages in Indonesia, it was found that women had a better understanding of where floods and landslides were likely to occur because they were the ones who worked in these areas, and they were the ones who were most vulnerable to these types of disasters (Widjaja and Carr, 2012). Yet women have not been sufficiently involved in disaster preparedness and risk-reduction planning. Implementing DRR strategies is a top-down process that ignores social dynamics and power. Disaster management requires a whole community approach that recognizes the role of local actors and bottom-up approaches to disaster management.

Conclusion This chapter explored what institutions are in place to manage disasters and what challenges disaster governance faces. Disaster governance still relies predominantly on governments to prepare for disasters and manage the aftermath. Compliance to international regimes and frameworks is patchy, but in spite of these issues, the role of the international community in responding to disasters has become more extensive. The challenges remain about how to ensure that disaster risk reduction is integrated in sustainable development policies and, more critically, with climate-change adaptation plans. Disaster governance needs to be applied more to prevention than just response. For the moment, that is still the predominant focus of governments, NGOs, and international organizations. A final issue is that disaster governance is still a top-down affair that does not incorporate the views of those who are the most vulnerable and the most affected by disasters. Because of this, it is still not entirely clear if funds are donated out of human need or perceived damages. Ensuring that disaster risk reduction is a more bottom-up process can ensure that there is greater commitment and ownership in engaging in meaningful prevention and mitigation.

Key questions 1 2 3 4 5

In what ways is disaster governance not as developed as global health governance? What are the most important frameworks for cooperating in disaster governance? For what reason has compliance been challenging? In what areas do disaster governance and environmental governance overlap? What have been the challenges of integrating disaster governance with development? What factors drive donors to respond to disasters?

Note 1 The integration of DRR into CCA and development policies was already a key discussion point at the 2009 Global Platform for Disaster Risk Reduction meeting (IISD, 2010) and as a result of the United Nations Framework Convention on Climate Change (UNFCCC) Conference of the Parties 13th meeting in Aspect Differences Signs of Convergence DRR/CCA Activities.

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Conclusion

This was not the first pandemic, nor will it be the last, but it is unlikely that the world will be the same in its aftermath. There had been dire warnings about the dangers of a pandemic for some time now (three influenza pandemics of the 20th century contributed to millions of fatalities), but few countries were prepared for the toll that the Covid-19 outbreak would take. And while the pandemic has raged on, the planet has been struck by unprecedented wildfires across the United States, extraordinary heat in Siberia, and massive storms hitting Central America and Southeast Asia. There is no mistaking that the forces of globalization are propelling an increased frequency of disasters and the discovery of novel (and potentially fatal) diseases (Alexander, 2006; Gostin and Ayala, 2017; Kamradt-Scott and McInnes, 2012). Yet in spite of the enormity of these crises, it is not clear whether policymakers will learn any lessons and many questions remain unanswered. Will states continue to pursue unsustainable development – such as deforestation, destruction of bio-diversity, and greater human encroachment into the natural habitats of animals? Will there be more effort to properly adhere to zoning laws to protect people from natural hazards and greater investment in disaster risk mitigation and infrastructure? Will urbanization and overcrowding continue amidst underinvestment in proper sanitation? Will states continue to prioritize massive amounts of military spending, military sales, and military interventions, all of which generate far more insecurity than intended? Will the pharmaceutical industry continue to be driven more by profits than needs? Will states pay lip-service to the idea of a one-health agenda to ensure that there is public healthcare for all but fail to take any steps to implement it? Will the WHO and other international organizations related to health, the environment, and disasters continue to struggle for power and influence? Given that the biggest threats to human security come from health and environmental insecurity, in some ways it’s surprising that these issues are not at the top of the agenda even when we are not in the midst of a pandemic. At the same time, security studies and development studies (to a lesser degree) have been dominated by outdated conceptions of security and development that have failed to take into account what development and security look like in practice. As the book has demonstrated, there are new threats, new actors, and new global dynamics that need to be accounted for. For these reasons the book has advocated taking a human security approach to understanding these threats and looking more closely at what makes people vulnerable. One of the biggest issues in public health is the costs for the poor, both for medical care and for treatment. This causes genuine stress and despair, creating many hardships for those who are impoverished. But as the book has shown, a threat to some is actually a threat to all.

DOI: 10.4324/9781003128809-21

Conclusion  363 If the cost of treating multidrug-resistant tuberculosis is roughly $50,000 per patient over 18 months, this highly infectious disease can spread and take a toll on global health (Manjelievskaia et al., 2016). That’s just one example of the risks. The cost of treating hepatitis C – an infectious disease that left untreated can cause life threatening damage to the liver – in the United States is $84,000 for 12 weeks of treatment, which may be prohibitively expensive for the average person to afford (Gompf, 2020). Here is where universal healthcare can make a big difference in making these types of treatments more affordable. Without universal healthcare, the soaring costs of medicine has led to an industry of falsified medicines. This not only leads to drug resistant forms of infectious diseases (like tuberculosis) but also premature deaths from those falsified medicines that contain poisonous ingredients (Heymann et al., 2015). Just in Africa, falsified antimalarial drugs kill 120,000 people a year (Acri, 2018). The costs of healthcare also contribute to poverty traps. Roughly 400 million people around the world do not have access to basic healthcare, with the biggest burden being in Asia and Africa (WHO, 2015). In Africa, over 11 million people fall into poverty due to the rising costs of healthcare (Edmond, 2019). With that in mind, in 2001, Thailand rolled out a Universal Coverage Scheme – a scheme that was heavily criticized at first. Since it has been introduced, it has not only grown in popularity, but there have been lower infant mortality rates and a significant drop in impoverishment from medical costs (ibid.). Investing in healthcare is just one type of preventive action that can make a huge impact on human security. Other preventive actions must tackle the natural hazards that countries face by ensuring that people are not living in danger zones, that there is vegetation that can protect the vulnerable, and that building codes are safely implemented. Tackling poverty and addressing conflict are other important steps to eradicating disease and misery. Preventive action is needed to ensure that issues of human insecurity don’t become full-blown complex humanitarian emergencies. In order to do so, it’s important that the international community prioritize the security risks that affect the poor. In particular, it’s important to address disease vulnerabilities in low-income countries. There is an assumption that diseases like Ebola are confined to the African continent, but the 2014 outbreak demonstrated that this was not the case. Infectious diseases can spread far and wide. Additionally, if we take a human security perspective, the lives of Ebola victims in low-income countries should matter as much as the lives of citizens in high-income countries. This also means that focusing on eradicating neglected tropical diseases, which have easy solutions (such as treating diarrhoeal diseases) but continue to wreak havoc on the poor and impact well-being, livelihoods, and long-term development should be prioritized. In spite of calls from organizations, such as the WHO and the UNDP, to invest more in healthcare, poverty reduction, environmental protection, clean water and sanitation, and agricultural sustainability, the major state actors have a traditional view of security and still prioritize traditional forms of security spending. Case in point: globally, almost $2 trillion is spent on the military each year. The US spent approximately $720 billion on the military in 2020 yet was unable to provide clean water to Texans after a winter storm in February of 2021 when pumps failed after years of poor investment in infrastructure. The reduced water pressure led to harmful bacteria growing in the water and Texans were ordered to boil water to avoid contracting diseases. As the Texas example illustrates, threats are interconnected. A massive winter storm hit and caused at least ten people in Texas to freeze to death and millions to suffer from power outages and burst pipes. This, in turn, caused the spread of bacterial diseases in the water.

364  Response But without electricity, the more than 11 million people who were left without access to clean drinking water did not have the capacity to hear the guidance from the local government to boil water before drinking it. This outcome was preventable, however. The government in Texas failed to enforce clean water regulations and led the US in the most widespread waterquality violations, according to Environmental Protection Agency (EPA) data (Langin, 2018). Meanwhile, predatory electric companies have taken advantage of customers who did have electricity by charging thousands of dollars, in some cases stripping people of their life savings (Hersher, 2021). While these threats are affecting the country with the biggest GDP in the world, how do threats play out for the poor in low-income countries? In these cases, a disaster can plunge the poor deeper into poverty and debt as they struggle to regain their lives. A resultant injury or exposure to diseases makes it impossible to find gainful employment. Failure to earn any income makes it difficult to feed one’s family. This, in turn, exacerbates the ability to fight off diseases which can incur huge financial and personal costs. If this is taking place in a context of displacement, the way out of these human insecurity traps seems nearly impossible. In order to address human insecurity traps, a sustainable development approach is essential. We need to be mindful that the root causes of new diseases and greater frequency of disasters are reflective of the impacts of rapid demographic, environmental, social, and other changes to our way of life. Thus, the frequency of these events is not just happening in a vacuum. Warmer temperatures are increasing the intensity and duration of droughts and storms, respectively (Mukherjee et al., 2018; Trenberth, 2020; Trenberth et al., 2018). Deforestation is helping to spread infectious diseases and spark new and re-emerging diseases (Bauhoff and Busch, 2020). Virtually every type of disease from water borne diseases (i.e. cholera) to vector-borne diseases (i.e. malaria) may be affected by climate change (Metcalfe et al., 2017). 2021 and the years that follow are a critical period for the international community’s ability to make positive progress in addressing climate change, environmental degradation, preservation of the eco-system, and infectious diseases. We briefly highlight several solutions. Planting spekboom in South Africa has been noted as just one solution with many positive impacts. The South African government has created employment opportunities to have people plant spekboom, a plant that could sink large quantities of carbon to create a cooler microclimate (and may bring more rain) and that survives in any type of weather (Matthews, 2020). Planting mangroves is also important to mitigating storm damage. Mangroves reduce storm surge by slowing the flow of water and decreasing surface waves – by more than 85% over one kilometre of mangroves (McIvor et al., 2012). Another solution to the problem of diseases and disasters is to rely on local knowledge to compliment the advances of the scientific community. For example, local knowledge in Ghana has helped to better understand Buruli ulcers, a poorly understood bacterial infection. Local knowledge in Southeast Asia and Latin American has been helpful in identifying where vectors that transmit Chagas disease and dengue fever hide out (Gaddy, 2020). While significant improvements have taken place in terms of global life expectancy, the 21st century has generated new threats many of which are becoming increasingly urgent. As the world has become more interconnected, this has resulted in gains of cooperation at a global scale but has also led to greater sensitivities and vulnerabilities. Understanding the deep root causes and the extent and impact of insecurity can help to build more resilient societies that are safer from chronic threats of not just disease and disaster but also displacement, conflict, malnutrition, and poverty.

Conclusion  365

References Acri, K.M., 2018. Pharmaceutical counterfeiting: Endangering public health, society and the economy (pp. 1–87). Fraser Institute. www.fraserinstitute.org/sites/default/files/pharmaceutical-counterfeitingendangering-public-health-society-and-the-economy.pdf. Accessed February 20, 2021 Alexander, D., 2006. Globalization of disaster: Trends, problems and dilemmas. Journal of International Affairs, 59(2), pp. 1–22. Bauhoff, S. and Busch, J., 2020. Does deforestation increase malaria prevalence? Evidence from satellite data and health surveys. World Development, 127, p. 104734. Edmond, C., April 15, 2019. Thailand gave healthcare to its entire population and the results were dramatic. www.weforum.org/agenda/2019/04/thailand-gave-healthcare-to-its-entire-population-and-theresults-were-dramatic/. Accessed February 19, 2021 Gaddy, H.G., 2020. Using local knowledge in emerging infectious disease research. Social Science & Medicine, 258, p. 113107. Gompf, S.G., 2020. Hepatitis C cure: Symptoms, transmission, treatments, and costs. Medicine Net. www.medicinenet.com/hepatitis_c_cure_symptoms_and_treatment_costs/article.htm#can_i_ drink_alcohol_if_i_have_hepatitis_c. Accessed February 21, 2021 Gostin, L.O. and Ayala, A.S., 2017. Global health security in an era of explosive pandemic potential. Journal of National Security Law & Policy, 9, p. 53. Hersher, R., February 21, 2021. After days of mass outages, some Texas residents now face huge electricity bills. National Public Radio. www.npr.org/sections/live-updates-winter-storms-2021/2021/ 02/21/969912613/after-days-of-mass-outages-some-texas-residents-now-face-huge-electric-bills. Accessed February 21, 2021 Heymann, D.L., Chen, L., Takemi, K., Fidler, D.P., Tappero, J.W., Thomas, M.J., Kenyon, T.A., Frieden, T.R., Yach, D., Nishtar, S. and Kalache, A., 2015. Global health security: The wider lessons from the west African Ebola virus disease epidemic. The Lancet, 385(9980), pp. 1884–1901. Kamradt-Scott, A. and McInnes, C., 2012. The securitisation of pandemic influenza: framing, security and public policy. Global Public Health, 7(supplement 2), pp. S95–S110. Langin, K., 2018. Millions of Americans drink potentially unsafe tap water. How does your county stack up.  Science,  12. www.sciencemag.org/news/2018/02/millions-americans-drink-potentially-unsafetap-water-how-does-your-county-stack. Accessed February 22, 2021 Manjelievskaia, J., Erck, D., Piracha, S. and Schrager, L., 2016. Drug-resistant TB: Deadly, costly and in need of a vaccine. Transactions of the Royal Society of Tropical Medicine and Hygiene, 110(3), pp. 186–191. Matthews, A., February 4, 2020. How shrubs can help solve climate change. BBC Future Planet. www. bbc.com/future/article/20200203-the-south-african-plant-fighting-climate-change. Accessed February 21, 2021 McIvor, A.L., Spencer, T., Möller, I. and Spalding, M., 2012. Storm surge reduction by mangroves. Natural Coastal Protection Series: Report 2. Cambridge Coastal Research Unit Working Paper 35. ISSN 2050–7941. Metcalf, C.J.E., Walter, K.S., Wesolowski, A., Buckee, C.O., Shevliakova, E., Tatem, A.J., Boos, W.R., Weinberger, D.M. and Pitzer, V.E., 2017. Identifying climate drivers of infectious disease dynamics: Recent advances and challenges ahead. Proceedings of the Royal Society B: Biological Sciences, 284(1860), p. 20170901. Mukherjee, S., Mishra, A. and Trenberth, K.E., 2018. Climate change and drought: A perspective on drought indices. Current Climate Change Reports, 4(2), pp. 145–163. Trenberth, K.E., 2020. Understanding climate change through Earth’s energy flows. Journal of the Royal Society of New Zealand, 50(2), pp. 331–347. Trenberth, K.E., Cheng, L., Jacobs, P., Zhang, Y. and Fasullo, J., 2018. Hurricane Harvey links to ocean heat content and climate change adaptation. Earth’s Future, 6(5), pp. 730–744. WHO, June 12, 2015. New report shows that 400 million do not have access to essential health services. www. who.int/mediacentre/news/releases/2015/uhc-report/en/. Accessed February 19, 2021

Glossary

Abject poverty  extreme poverty or the more severe type of poverty. Anthropocene climate change  man-made climate change. Antimicrobials  an agent that kills or slows the spread of micro-organisms, such as antibiotics to target a bacterial infection. Anti-retroviral therapy (ART)  the combination of therapies used to treat HIV. Though it cannot cure HIV infection, it prolongs the life of those living with HIV. Artemisinins  group of drugs used in the treatment of malaria. Avalanche  a rapid downward flow of snow over a steep slope. Avalanches only occur on slopes of less than 30 degrees, when snowpack is very unstable. Autocratization  the process of becoming increasingly authoritarian. Barrier nursing  stringent infection control techniques to prevent the infection of medical staff. Big three diseases  the three infectious diseases that combined have received the most funding – HIV/AIDS, tuberculosis, and malaria. Biological weapons  toxins or infectious agents such as bacteria and viruses that are disseminated with the intent to kill or harm. Black Swan events  a metaphor to describe an event that has a major surprise impact. Central American Dry Corridor  a tropical dry forest region in Central America which is very vulnerable to climate change, with many of the rural residents living in poverty and dependent on crops for their livelihood. Chikungunya fever  a vector-borne illness spread by mosquitoes that causes fever, joint pain, headache, muscle pain and possibly a rash. There is no treatment available. Cholera  an acute diarrhoeal infection caused by ingesting contaminated food or water. Cholera is a bacterial infection which is easily treatable, but fatal if not treated immediately. Conjunctural poverty  temporary poverty experienced when people are affected by a crisis, such as a disaster. Cordon sanitaire  the restriction of people to a defined area in order to prevent the spread of infectious diseases DALY  the sum of the years of life lost to due to premature mortality and years lived with a disability. Deforestation  the permanent removal of trees to make room for agriculture or grazing, construction, or manufacturing. Dengue fever  a vector-borne illness spread by mosquitoes that may cause fever, rash, muscle, and joint pain; in severe cases it may cause bleeding and shock. Those who are

Glossary  367 infected a second time are at greater risk for developing severe disease. In 2019, a vaccine for dengue fever was approved. Drug resistant microbes  (see pathogen resistance): when microbes evolve in ways to sufficiently protect them from the effects of antimicrobials. Ecological security  the security of the ecosystem, including nature, humans, and animals. Economic scarring  medium to long term damage to an economy. Electoral autocracies  autocracies that hold multi-party elections. El Niño events  major meteorological events that could last months to years, and occur roughly every five years. More specifically these events are a band of warm ocean water that develops in the central and east-central equatorial Pacific Ocean. Endemic  a disease that belongs to a particular group of people or territorial area but does not tend to spread to other countries or spike in numbers over time. Etiological agent  the causal agent of a disease. Expanded Programme on Immunization  Launched by the WHO in 1974, this program aimed at expanding immunization programs throughout the world. The goal was to ensure that immunizations were available to every child against poliomyelitis, measles, diphtheria, pertussis, tetanus, and tuberculosis. Epidemic  a disease that affects a large number of people within a community, population, or region, with new cases of the disease exceeding what would be expected in a significant way, or an out-of-season transmission. Epidemiologic Transition Theory  the changes taking place in population patterns due to improvements in health. This transition, which include changes in fertility rates, life expectancy, mortality, and leading causes of death, occurs when a country is becoming fully developed. Extrinsic incubation period  the time it takes an organism to develop in the intermediate host. In the case of malaria, it describes the time it takes for parasites to develop in the mosquito after the mosquito has ingested an infected bloodmeal. Famine  an extreme scarcity of food, often caused by natural hazards, crop failure, conflict, and various government policies. Flash floods  the rapid flooding of rainfall in a low-lying area that takes place so quickly that the ground cannot cope or drain quickly enough. In these cases, roads can suddenly become rivers. Fomite transmissions  when viruses or bacteria that remain on surfaces cause infections. Germ governance  concerns how societies, both within and internationally, respond to pathogenic challenges. Germ theory of disease transmission  the theory that microorganisms known as pathogens (or germs) can lead to disease. This disease became the prominent theory of disease in the 19th century. Global Influenza Surveillance and Response System  a global network of laboratories that aim to monitor the spread of influenza and inform the WHO to help control the spread; founded in 1952. Global Outbreak Alert and Response Network (GOARN)  a network of technical and public health institutions, laboratories, and NGOs that work to observe and respond to epidemics; founded in 2000. Great Leap Forward  a major campaign led by the Communist government of China which ran from 1958–1960 to restructure the economy of China from an agricultural one into an advanced industrial economy. The attempt to fast-track industrialization and the

368  Glossary neglect of agriculture led to the death of 20–30 million people, while the government officially blamed the crisis on a bad drought. Helminths  parasitic worms which survive by eating off of a living host, with a population of about 7 billion. Horizontal strategies of cooperation  strategies of cooperation (in the area of health, for example) between states such as the International Health Regulations of 1851. Human capital  the strength, knowledge, skills, and creativity of a population that is needed for economic development. Human Development Index  a composite index of life expectancy, education, and per capita income that was developed by the United Nations Development Programme in 1990 as a more holistic way of measuring development Human Insecurity Traps  a condition where a host of different challenges undermine one’s security, such as conflict making people more vulnerable to disease, which may make people more impoverished and more vulnerable to natural hazards. Hyogo Framework for Action  A blueprint for Disaster Risk Reduction that was established in 2005–2015 by the United Nations and adopted at the second World Conference for Disaster Reduction, held in Kobe, Japan, in 2005. Immunopathology  an inappropriate immune response to an infection. Incubation period  the number of days from which you are infected with a pathogenic organism and you may see symptoms. Index case  the first identified case of a particular infectious disease. Indoor residual spraying  a strategy for dealing with mosquito vectors, such as those that cause malaria, which involves spraying the walls and surfaces with an insecticide that can kill mosquitoes. Insecticide-treated bed nets  a low-cost strategy to preventing the spread of diseases like malaria, where a person or persons sleep (and when mosquitoes are likely to bite) under the protection of an insecticide-treated bed net. Integrated health programs  (also known as horizontal programmes, integrated health services or horizontal approaches): programs that seek to tackle overall health problems on a long-term basis through the creation of general health services that can tackle a variety of health issues including disease control activities. International Decade for Disaster Reduction  the decades of the 1990s during which the United Nations General Assembly declared that there would be greater internationally coordinated efforts to reduce human vulnerability and social and economic disruption caused by disasters, especially in developing countries. International Health Regulations  a set of regulation passed initially by 64 countries in 1951, revised again in 1969 and 2005, which established a set of rules to support the global outbreak alert and response system to infectious diseases. International Monetary Fund (IMF)  a major international financial institution that works to facilitate international trade, foster global monetary cooperation, and secure financing. To do so, it often works with deeply indebted countries to restructure their debt by providing them with loans that come with conditions that recipient countries must implement in order to receive the funds. The IMF has come under heavy criticisms for setting conditions that have limited state capacity in low-income countries. International Sanitary Conferences  a series of 14 conferences held (starting in 1851), which aimed to reduce to a safe minimum the conflicting and costly quarantine requirements in place to prevent the spread of infectious diseases. The conferences played a major role in the formation of the WHO.

Glossary  369 Lassa fever  a zoonotic viral disease caused by exposure to food or household items that have been contaminated with urine or faeces of infected rats. Human-to-human transmission (particularly nosocomial transmission) is possible, but unlikely. There is treatment for Lassa fever and the case fatality rate is 1%. About 80% of people who are infected are asymptomatic, while 20% may develop severe disease affecting the liver, spleen, and kidneys. Other symptoms are fever, muscle weakness, and vomiting. The disease is endemic in parts of West Africa. Larval source management (LSM)  the targeted management of mosquito breeding sites, with the objective of reducing the number of mosquito larvae and pupae. LSM includes draining water, flushing streams to manipulate water levels, applying biological and chemical insecticide to bodies of water (known as larviciding), and introducing natural predators of mosquitoes to bodies of water such as predatory fish or invertebrates. Measles  a highly contagious virus that is spread through the air by respiratory droplets produced from coughing or sneezing. Symptoms include cough, runny nose, inflamed eyes, sore throat, fever, and a rash. Most symptoms don’t appear until 10 to 14 days after being exposed. Measles is preventable through a vaccine but there is no treatment. MERS  (Middle East respiratory syndrome): a zoonotic respiratory coronavirus with a case fatality rate of 35%. Human-to-human transmission is unlikely except in hospital settings. MERS originated in the Middle East with dromedary camels considered the most likely host animal. Modernization Theory  a popular theory of development in the mid-20th century that argued that development was possible for all countries if they modernized their economic systems and cultures. The theory was used to explain the transition that takes place from traditional society to a modern society. Monkeypox  a zoonotic viral disease that is often transmitted from animal to human (though human to human transmission is also possible). Symptoms include fever, rash, and swollen lymph nodes. The case fatality rate is 10%; there is a vaccine available but no treatment. Mortality Transition Theory  (see the Epidemiologic Transition Theory). Mudslides  a rapid surging flow of mud and debris that can accompany heavy rains or come after droughts, earthquakes, or volcanic eruptions. Nipah virus  a zoonotic viral infection that can lead to acute respiratory illness and fatal encephalitis (inflammation of the brain). Transmission mostly occurs from humans interacting with infected animals rather than human-to-human transmission. There is no cure or vaccine. Non-communicable diseases  diseases that are not infectious and cannot be spread from person to person. These include diseases such as heart disease, cancer, and strokes. Non-governmental Organizations (NGOs)  organizations that are not associated with a specific government and are often engaged in humanitarian activities. Norovirus  the highly contagious virus that most often causes the stomach flu, with symptoms that include vomiting and diarrhoea. Nosocomial spread  disease transmission that takes place in a hospital setting. One Health Approach  A collaborative, multisectoral, and transdisciplinary approach to health which works at the local, regional, national, and international level to achieve optimal health outcomes. The approach recognizes the interconnection between people, animals, plants, and their shared environment. Oral rehydration therapy  a type of fluid replacement used to prevent and treat dehydration caused by diarrhoea. It is comprised of water and small amounts of sugar and salts.

370  Glossary Pandemic  an epidemic that has spread across multiple countries and/or continents. Pandemic backsliding  the trend, first noticed with Covid-19, where governments use the pandemic as a pretext to autocratize their regimes or become increasingly more autocratic. This includes restricting civil liberties, having more draconian laws in place, and increasing the power of the executive. Pathogen  a germ that causes a disease. Pathogen resistance  the resistance to infectious diseases. Parasite stress theory  a theory that human behaviour is affected by parasites stresses. In this book, we used it to explain a rise in conflict or inter-personal violence, but the theory goes beyond that, claiming that geographical variation in infectious disease has an impact on family relations, personality, mating systems, systems of government, religiosity, and xenophobia. Pharmaceuticalization of global health  a model of public health that focuses on finding pharmaceutical remedies to health problems instead of looking at socio-economic, cultural, environmental, or institutional solutions. Plague  a bacterial infection that is transmitted by fleas, though human-to-human transmission is also possible. The disease is rare today but was responsible for approximately 25 million deaths. Symptoms include fever, chills, headache, muscle aches, and notably swollen lymph nodes. Bubonic plague requires urgent treatment with strong antibiotics. Plurality systems  electoral systems where a plurality of votes is needed to win a seat in government. Proportional representation systems  an electoral system where the proportion of votes roughly translates into the proportion of seats in a government. Public health emergency of international concern (PHEIC)  an extraordinary event that the WHO can declare poses a significant health risk. Since 2009, PHEICs have been declared six times, for swine flu (2009); polio (2014); Ebola (2014); Zika virus (2015); Ebola (2018); Covid-19 (2020). Replication number/reproduction number  a number that indicates how infectious a disease is. The R refers to the number of individuals the average person infects. Rhinovirus  the viral infection that causes the common cold. SARS (severe acute respiratory syndrome)  a zoonotic respiratory coronavirus with a case fatality rate of 10%. Symptoms include a fever, dry cough, muscle aches, headache, and difficulty breathing. SARS originated in China with a bat being the most likely host animal. Like Covid-19, there is no cure, but the virus is less contagious. Security-Development Nexus  the overlapping interests in the fields of security and development. Sendai Framework  A blueprint to prevent new and reduce existing disaster risks that was established in 2015–2030 by the United Nations. The framework was adopted at the third UN World Conference on Disaster Risk Reduction in Sendai, Japan, in 2015. Smallpox  a disfiguring and deadly disease that has now been eradicated through a global vaccination campaign in the 20th century. Those infected experienced flu-like symptoms and a rash that appeared all over the face and body. There is no treatment for smallpox, and the case fatality rate depends on the type of strain – with ordinary smallpox having a case fatality rate of 30%. Soft Power  in international politics, this consists of the power to persuade and co-opt rather than to use force. It is often based on the attractiveness of a nation’s culture, values, and policies.

Glossary  371 State failure  where the state can no longer perform its basic security and development functions, and the state ceases to have effective control over parts or all of its territories and borders. Structural adjustment programs (SAPs)  loans that are given out by the IMF and World Bank which carry conditions that aim to restructure the recipient country’s economy. Policies advocated include currency devaluation, spending cuts, privatization, and trade liberalization. Structural poverty  poverty that is derivative of the way that an economy is structured. Stuttering chain  a group of cases of disease that are connected by an unbroken series of transmission events, but have not achieved a sustained chain of transmission. Sustainable development  development that meets the needs of the present without compromising the needs of the future. Synanthropic  a wild/undomesticated animal or plant that benefits from living near human beings. Tornado  a violent rotating column of air that extends from a thunderstorm to the ground and may have wind speeds of up to 300 miles per hour. Trachoma  a disease of the eye caused by a bacterial infection. Trachoma is the leading cause of preventable blindness, but can be cured with antibiotics if treated early. Tsunami  a series of enormous waves that are often caused by earthquakes, volcanoes, or other underwater explosions. United Nations Framework Convention on Climate Change  an international environmental treaty to address climate change that was first signed by over 150 countries at the United Nations Conference on Environment and Development (better known as the Earth Summit) in Rio in June of 1992. UN Millennium Development Goals  Eight international goals for development that the United Nations adopted in 2000 to be implemented by 2015. UN Sustainable Development Goals  a collection of 17 interlinked goals, set by the UN General Assembly in 2015, designed to achieve a more sustainable and equitable future by the year 2030. Vaccine nationalism  when countries become possessive of vaccine supplies to be used within their own borders. Vertical health programs  stand-alone programmes to address a given health problem. Vertical strategies of cooperation in global health  Global health cooperation that focuses on containing diseases within borders. Viral recombination  when at least two viral genomes co-infect the same host cell and exchange genetic segments that some genes from both parents. West Nile Fever  a vector-borne illness spread by mosquitoes that may cause fever, headache, vomiting, and rash. Most cases are asymptomatic. Yellow fever  a vector-borne illness spread by mosquitoes that may cause fever, headaches, and nausea and in severe cases may cause heart, liver, and kidney conditions. Though there is no treatment; there is a vaccine. Zika Virus  a vector-borne illness spread by mosquitoes that may cause a rash, fever, and joint pain. Rarely, it can trigger paralysis, and in pregnant women, it can sometimes cause birth defects. Zoonoses  (zoonotic diseases): diseases that can be transmitted from humans to animals.

Index

1918 – 19 Flu 27, 48 – 9, 57, 189, 99, 139, 191, 198 9/11 30, 192 abject poverty 6, 23, 138 acute lower respiratory infections (ALRI) 54, 80, 141, 149, 167 addressing storms 308 – 9 African sleeping sickness 91, 142 – 3, 164 African Union 275, 346 – 7 AIDS see HIV AIDS tax 195 aIr-borne transmission 50, 54, 103 – 4, 332 Annan, Kofi 20 – 1 anthrax 22, 30, 46 antibiotics 22, 27, 80, 106, 149 – 50, 229, 289, 318 antimicrobials 106 – 7, 149 – 50 ASEAN 346 – 7 Asian flu 45 Asia Pacific Economic Cooperation (APEC) 28 attack rate 44, 49 autocratization 7, 216 – 7, 222 – 3 bacteria 43, 45, 50, 52, 55, 79, 80, 95, 99, 145, 149, 363 – 4 barrier nursing 173 basic needs approach 138 Bill and Melinda Gates Foundation 32, 337 Biological and Toxin Weapons Convention 31 biological weapons 30 – 1, 330 Biya, Paul 250 Black Death 22, 44, 99 black swan event 70, 187 blood-borne transmission 50 Boko Haram 172 Bolsonar, Jair 258 – 9, 265 Boutros-Ghali, Boutrous 20 Brundtland, Gro Harlem 27, 319 Brundtland Report (or Our Common Future) 25, 32 Bush, George W/Bush administration 29, 127, 232 capabilities approach 138 case fatality rate 44

Center for Disease Control (CDC) 29, 261 Central American Dry Corridor 128 Chagas disease 56, 141 – 2, 171, 196, 285, 364 Chikungunya 46, 99, 105 child mortality rates 50, 54 – 5, 78, 142, 144, 146, 165, 170, 174, 177, 247, 250 – 1, 253, 279 chlamydia 49 cholera 22, 45 – 6, 50, 55, 91, 218, 249, 281, 320 – 6, 355, 364; and conflict 31, 164, 167, 172; and disasters 73 – 4, 79, 94 – 5; in the DRC 290; in Haiti 204; in Malawi 289; and poverty 105, 141, 151 – 2; in Yemen 175 Clinton, Bill 29 Cold War 18 – 9, 21, 30 – 2, 109 complex emergencies 3, 129, 164, 169 – 70, 178, 363 cordon sanitaire 254, 321 Covid–19 1 – 3, 5, 42 – 3, 47 – 8, 57 – 9, 105, 216, 225 – 6, 343, 362; and autocratization 217, 222 – 3, 233; and China 101, 256, 265, 328; and conflict 218; declared a pandemic 13; and domestic violence 219; and economic impact 34, 137, 187, 189 – 92, 195, 199; and Peru 149; and poverty 141, 144, 199; management of covid-19 245, 290 – 1; mode of transmission 50; and regime type 254 – 65; and social impact 220; and Trump 260 – 1; vaccines 108; and the WHO 332 – 3, 336 Crimean-Congo haemorrhagic fever 46 cyclones: Cyclone Bhola 69, 152, 227, 310; Cyclone Nargis 67, 200, 203, 232, 263; see also addressing storms DALY 56, 143, 250 – 1 Déby, Idriss 250 deforestation 5 – 6, 17, 92 – 7, 100, 121 – 5, 139, 150, 166, 349, 362, 364 democratic breakdown 7, 216, 233 dengue fever 22, 44, 46, 50, 79 – 80, 95, 98 – 9, 103 – 4, 142, 291, 324, 364 diarrhoeal diseases 28, 31, 42, 47 – 9, 54 – 6, 80, 94, 104 – 5, 140, 167, 169, 197, 221, 363 diphtheria 166, 172, 174, 324

Index  373 Doctors Without Borders/ Médecins Sans Frontières 108, 331 – 2 domestic violence 7, 16 – 7, 217, 219, 228 – 9, 232 droplet transmission 50, 57, 332 drought 2, 5 – 6, 8, 19, 26, 67 – 8, 72, 76 – 80, 150, 200, 246, 300; addressing droughts 311 – 2; and climate change 94 – 6, 122 – 8, 280, 364; and disaster governance 348, 356; in Ethiopia 177, 203; and poverty 202 – 3; in Syria 227 – 8; in Yemen 174 Duterte, Rodrigo 223 – 4 dysentery 56, 79, 104, 167, 249 earthquakes: addressing earthquakes 304 – 5; Chilean earthquake of 2010 305 – 7; Haitian earthquake of 2010 16, 35, 67, 74, 151, 154, 200, 204, 216, 229, 262, 305 – 6, 326, 354 – 5; Kashmir earthquake of 2005 306, 354; Managua earthquake of 1972 232, 263; Mexico City earthquake of 1985 262, 302; Nepal earthquake of 2015 129, 307; San Francisco earthquake of 1989 16, 262; Sichuan earthquake of 2008 187, 200, 228, 232, 263; Shaanxi earthquake of 1556 74; Spartak earthquake of 1988 231, 301 – 2; Tangshan earthquake of 1976 74; Tohuku Japan earthquake 2011 67, 81, 127, 199 – 200, 305, 307 – 8 Ebola 1, 4 – 5, 22, 29 – 30, 42, 44, 46, 49 – 50, 53 – 4, 58, 99, 107, 324, 336; and animal trade 101 – 4; and conflict 166, 168, 173; declared a PHEIC 326, 331 – 2, 335; in the DRC 164, 172 – 3, 175, 222; and poverty 139; in West Africa 97 – 9, 140 – 1, 191 – 6, 217, 219, 222, 225, 257, 288 – 90, 328 – 32, 355, 363 ecological security 19 economic scarring 190, 193 El Niño 76, 94 – 5, 122 – 3 Epidemiologic Transition Theory 27, 367, 369 European Union (EU) 28, 190, 344, 346 famine 16 – 9, 26 – 7, 67, 76, 78 – 9, 128, 170, 245 – 6; in Ethiopia 203; Great Leap Forward in China 256; in Yemen 175 Famine Early Warning System 356 FEMA 71 – 2, 127, 310 fertility rates 219 Filovirus diseases 46, 101 flash floods 73, 125 floods: Pakistan Floods of 2010 81, 125, 204, 308, 354 – 5 fomite transmission 50, 57, 332 food-borne transmission 50, 103 fungi 43, 94, 99 G8 30 germ 43 Germ Theory of Disease Transmission 321

Germ Governance 327, 336 Global Emerging Infectious Surveillance and Response System (DoD GEIS) 29 Global Fund for AIDS, Tuberculosis, and Malaria 22, 248 Global Health Security Agenda (GHSA) 330 Global Influenza Surveillance and Response System (GISRS) 323, 334 Global Outbreak Alert and Response Network (GOARN) 31, 326, 328, 331 Global Public Goods for Health (GPGH) 327 gonorrhoea 49 Great Leap Forward 256 Haq, Mahbub ul 24 Hendra virus 99, 166 HIV/AIDS 5, 7, 22 – 3, 42 – 54, 58, 99, 273; and Conflict 168 – 9; and Economic Impact 189, 194 – 5; and Globalization 106; and Global Response 318 – 9, 324; and Impact on the State 219 – 22, 225; and Poverty 139, 143, 145, 196 – 7; and Regime Type 251 – 3; and State Response 275, 279, 281 – 4 Hong Kong flu 45 hookworm 56, 99, 140 – 1, 143 – 4, 194, 196, 198, 322 Houthis 175 human capital 6 – 7, 71, 173, 197, 201, 204, 219, 221 – 2, 249, 253, 301 Human Development Index (HDI) 201 human insecurity traps 3, 15, 67, 364 humanitarian aid 79, 165, 175 – 7, 350, 354 – 6 hurricanes: addressing storms 308 – 9; Hurricane Gilbert 127, 202, 302; Hurricane Harvey 73, 124 – 5, 127, 151, 187, 200, 310; Hurricane Irma 124; Hurricane Katrina 71, 73, 79 – 80, 127, 187, 200 – 1, 228, 231 – 2, 309 – 10, 348; Hurricane Maria 71, 79, 124, 187, 200; Hurricane Matthew 151; Hurricane Mitch 80, 94 – 5, 198 – 9, 201, 203; Hurricane Sandy 80, 151, 200 Hyogo Framework for Action 34, 301, 346 – 7, 349, 351 – 3, 356 IDNDR 345 – 6 immunopathology 43 incubation period 43 index case 93, 100, 154, 166 indoor residual spraying 285 infant mortality rates 50, 170, 222, 247 – 8, 251, 363 influenza 48 insecticide treated bed nets 285 – 6 integrated programs 56, 275, 320, 324 International Health Regulations 31, 323 – 4, 325 – 34, 336 International Monetary Fund (IMF) 13, 34, 92, 114

374  Index International Red Cross 28, 345 International Sanitary Conventions 322 – 3 Johnson, Boris 259, 265 Kagame, Paul 250 larval source management 285 Lassa virus 30, 46, 96 – 7, 172, 289, 324 leishmaniasis 142, 145, 167 – 8, 171, 174 leprosy 45, 142, 196 leptospirosis 79, 94 liberalism 18 – 9, 320, 333; neo-liberalism 107, 109, 128 Liberation Tigers of Tamil Eelam (LTTE) 177 Lyme disease 93, 96, 99 lymphatic filariasis 56, 133, 196 Machupo virus 30 malaria 2, 5, 7, 43 – 7, 49 – 51, 54, 56, 58, 99, 221, 225, 273, 364; anti-malarial drugs 144, 363; and climate change 103 – 6; conflict 166 – 8, 172; deaths 42; and deforestation 97; and economics costs 190, 193 – 6; and global response 322 – 4, 329; and natural hazards 76, 79 – 80, 95; and natural resources 253 – 4; and regime type 222, 248, 251; and poverty 139 – 46, 196 – 8; and state failure 275; and state response 276 – 9, 284 – 7, 291 Marburg virus 30, 46, 101, 324 McNamara, Robert 23 measles 22, 44, 47, 50, 54, 79, 166 – 7, 169, 171 – 4, 177, 226, 249, 324 meningitis 167, 174, 324 MERS 43, 46, 57, 99, 192 – 3, 230, 260, 326, 228 microbe 43, 95, 149 modernization Theory 23, 27, 35, 146 – 7 Modi, Narendra 224, 259 monkey pox 28, 101 – 2 Mortality Transition Theory 27; see also Epidemiologic Transition Theory mudslides 72 – 3, 176, 231 Museveni, Yoweri 223, 248, 250

parasites 43, 50, 99, 103 – 4, 276 Parasite Stress Theory 217 – 8 Paris Agreement 349 – 50, 363 pathogen resistance 171 Pinochet, Augusto 250, 306 plague 22, 30 – 1, 44 – 6, 99, 164, 218, 249, 320, 323 – 6 pneumonia 46, 49, 55, 57, 80, 141, 164, 167, 325 polio 109, 164, 167, 171 – 4, 288, 318, 324 – 6, 335 populism 7, 245, 258 – 60, 264 – 5, 334 Powell, Colin 23 Presidential Emergency Plan for AIDS Relief (PEPFAR) 29 protozoa 43, 56, 102 Public Health Emergency of International Concern (PHEIC) 325 – 6, 331 – 2, 335 public-private partnerships 318 – 9, 343 Putin, Vladmir 225, 257, 265 quarantines 45, 54, 217 – 18, 224 – 5, 230, 255 – 6, 278, 286, 291, 321 – 3, 326 realism 18 – 9, 320, 333 replication number/reproduction number 43 resource curse 252 – 3 Rift Valley Fever 46, 76, 91, 193 Rockefeller Foundation 322 rotavirus 55, 80 Russian flu 45

Oral Rehydration Therapy 55, 140, 144

Saffir-Simpson scale 72 Salmonella 50, 95, 99 – 100 SARS 1, 4 – 5, 43, 46 – 7, 57 – 8, 99, 166, 260 – 1, 288, 291; and China 254 – 6; and economic impact 189 – 93, 199; mode of transmission 48; and poverty 141; and the revision of the IHR 325 – 8; and urbanization/globalization 104 – 5; and wild animal trade 101; and the WHO 336 Save the Children 322 schistosomiasis 56, 95, 141, 143, 280 security-development nexus 24 Sen, Amartya 18, 138, 245; theory of capabilities 23 – 4, 138; see also capabilities approach Sendai Framework for Action 34, 346 – 7, 349 – 52, 356 Simian Immunodeficiency Virus (SIV) 102 smallpox 27, 30 – 1, 44 – 5, 47, 50, 109, 147, 275, 292, 323 – 5, 337 soft power 29 Structural Adjustment Programmes (SAPs) 107, 126 stuttering chain 99 sustainable development 1, 20, 25, 32, 36 swine flu 1, 105, 107, 137, 139, 191 – 3, 225, 291, 326, 328, 331, 335 synanthropic 98

Pacific Ring of Fire 73 – 4, 353 pandemic influenza 47 – 8, 99, 319, 323, 334, 362

Thrombocytopenia Syndrome 46 tick-borne encephalitis 93

neglected tropical diseases 5, 42, 48, 56 – 8, 139, 142, 324, 363 Netanyahu, Benjamin 224 – 5 Nipah virus 46, 96 – 7, 99 – 101, 166, 193, 290, 324 non-communicable diseases 15, 27, 29, 42, 45 – 6, 225 – 6 norovirus 50, 80, 99 North Atlantic Treaty Organization (NATO) 30 nosocomial transmission 57, 79, 173

Index  375 Tokyo Sarin Attacks 22 trachoma 50, 56, 142, 196, 281 TRIPs 108, 335 Trump, Donald 71, 224, 258 – 61, 264 – 5, 333 tsunamis 67 – 8, 72 – 4, 356; Boxing Day Tsunami of 2004 67, 69 – 70, 79 – 80, 177 – 8, 227, 229, 231, 343, 346, 352 – 5; Chile Tsunami of 2010 306 – 7; Japan Tsunami of 2011 81, 127, 187, 199, 308 tuberculosis 5, 7, 29, 43, 45 – 6, 52, 56, 226, 249, 273, 324; Addressing TB 279, 282 – 3; and conflict 167 – 8; costs of treatment 197; deaths 42; drug resistant forms 22, 363, 106; and HIV/AIDS 51; and poverty/urbanization 104, 146; in Romania 284 typhoid 46, 76, 95, 140 – 1, 152, 167, 280 typhoons 1, 5, 72, 122, 124; Typhoon Haiyan 1, 80, 204, 355; see also addressing storms UNICEF 28, 318 United Nations 4 – 5, 8, 20, 28, 32, 351 United Nations Mission for Ebola Emergency Response (UNMEER) 332 United Nations Development Programme (UNDP) 14, 16, 18, 20, 23 – 4, 33, 329, 363 UNDP Human Development Report 14, 23, 33 UNDRR 28, 34, 300, 346, 355 UNFCC 349 – 50 UN General Assembly 4, 22, 332 UN Intergovernmental Panel on Climate Change (IPCC) 1, 93, 264 UNISDR 346, 349 – 50 UN Office for Coordination of Humanitarian Affairs (UN OCHA) 20, 28, 345 UN Security Council 22, 31, 331 – 2 UN SPIDER 348 UN Sustainable Goals 57, 199, 324, 350 US AID 29, 226

vaccine nationalism 2 vector-borne transmission 50, 80, 103 vertical programs 275, 282, 318, 324 viral recombination 100 volcanic eruptions/volcanoes 5, 67 – 8, 71 – 5, 200, 227, 262, 301; Colombian volcanic eruption of 1985 229 warlords 165 – 6, 178 water-based transmission 50 water-borne transmission 50, 80, 102 water-washed transmission 50, 104 West Nile Fever 22, 46, 50, 98 – 9, 324 wildfires: Amazon wildfires 123 – 4, 264; Australian wildfires 67, 72, 123; California wildfires 67, 72, 123; Indonesian wildfires of 2015 80, 122 – 3 World Bank 20, 23 – 5, 27, 96, 107, 174, 200, 250, 319, 329, 346 – 7, 351 – 2 World Economic Forum 13, 188 World Health Organization 1, 8, 13, 50, 146, 283, 351, 363; see also Chapter 13 World Trade Organization (WTO) 107 – 8, 112 World War I 49, 109 World War II 23, 27, 109, 172, 318, 320 worms 43, 50, 56, 143 Xi, Jinping 254 – 5 yellow fever 50, 140, 166, 171 – 2, 320, 322 – 3, 325, 335 Zika virus 46, 48, 50, 80, 99, 105, 141, 189, 198, 226 Zoonotic (zoonoses) 57, 95, 98 – 102, 105 – 7, 139, 166, 193, 288