The Ebola epidemic in the Democratic Republic of the Congo (DRC) highlights the urgent need to strengthen cooperation between security, health, and development actors. As the disease spreads, the World Health Organization (WHO) has declared an international health emergency. In crisis situations like these, the interdependencies between health and security are highly complex. Which population groups and which diseases are perceived as suspected health risks, and why, is a normative question for donor countries. It has political consequences above all for affected developing countries. Where health and security are common goals, it is not enough to contain infectious diseases in developing countries. Instead, resilient, well-functioning, and accessible health systems must be established. This fosters the implementation of the human right to health, creates trust in state structures, and takes into account the security interests of other states. In the United Nations (UN) Security Council, the German government could advocate for policies based on the narrative “stability through health.”
Since August 2018, the Ebola fever has again been rampant in the northeast of the DRC. To date, more than 2,500 people have fallen ill, more than 1,700 of whom have died. The outbreak is hitting a conflict-ridden region where state authorities are mistrusted and militias commit violent acts. Attacks on humanitarian and medical personnel also claimed civilian lives, including a WHO staff member. As a result, international organizations were forced to reduce or stop their relief efforts. The difficult security situation disrupts public order, the delivery of health care, and affects disease control. WHO has now declared a “public health emergency of international concern” (PHEIC) after the epidemic spread beyond the border into Uganda and to the Congolese city of Goma. WHO now needs greater international support and asked all, but especially neighboring countries, to keep their borders open so that international assistance can arrive to the DRC.
Due to the epidemic, people in the outbreak-affected and opposition-dominated provinces were not permitted to participate in the presidential election in 2018. Moreover, parts of the population rejected Ebola aid measures right from the start. This expression of resentment must be considered against the backdrop of long-standing deprivation of basic human needs, for which the population received scant attention from the international community. Only now, with a highly contagious disease outbreak, has global attention turned toward the crisis region, although there has been a lack of adequate international assistance for a long time. This situation forms the breeding ground for disease outbreaks, undermines the trust of the population in the state, and further destabilizes it.
Health and Security – a Controversial Concept with Tradition
The first International Sanitary Conference in 1851 is known to be the starting point for international health cooperation. Since then, high-income countries have pushed the development of an international regime of infectious disease control, also because of their own security interests. Especially health and security actors have established the concept of so-called global health security in scientific debates and international relations.
In 2007, WHO identified the following topics as relevant to health security:
Conflicts and humanitarian crises
Strengthening health systems
Diseases with significant effects on economic stability
Chemical, biological, and nuclear attacks and accidents
Emerging and reemerging (infectious) diseases
In addition, antimicrobial resistance (AMR) is nowadays considered relevant for security. This diversity in health topics shows that there is no uniform definition of so-called global health security. Nevertheless, WHO’s binding international health regulations (IHRs) are commonly understood as the international agreement on global health security. The IHRs comprise requirements for the prevention, notification, and control of infectious diseases for all WHO member states. In the event of a serious, unexpected, and unusual cross-border outbreak, WHO can declare a “health emergency of international concern” to better coordinate international assistance and make recommendations to the international community. The affected countries are required to report disease cases immediately to WHO. In addition, all countries are obligated to keep their borders open and to not restrict travel or trade. However, these rules are not always followed. Sometimes disease cases are concealed, and the movement of goods and travelers are restricted due to fears about the spreading of the disease. This weakens the affected state, its market, and its people.
Assessing who or what is perceived as a health risk and the underlying reasons reveals links between health and security. Health issues can be “securitized” by an actor by identifying a suspected health risk (e.g., in the form of an infectious disease). This actor then promotes this identified risk and thus advocates for the risk to be accepted by other actors. Motivated by their own security interests, dominant actors can intensify and accelerate this process of securitization by directing the discourse in a targeted manner. Persons with certain (infectious) diseases can thus be portrayed as a collective risk. Thereby national security interests can prevail over the individual’s right to health.
The prioritization of national security interests becomes particularly obvious when high-income countries provide money and expertise almost exclusively for the detection of – and the response to – infectious diseases and the defense against bioterrorism. Prevention and rehabilitation, on the other hand, are often neglected. The central goal of the new “Health Security Strategy” of the United States is to protect its own population and that of partner countries against infectious diseases.
Investments in health security flow primarily to developing countries. However, in developing countries, many people suffer from cardiovascular diseases, tumors, and diabetes in addition to infectious diseases (double burden of disease). Locally, health systems often lack funds for needs-based health care that does not focus primarily on infectious disease control. A sound scientific assessment of health risks in the local context is therefore indispensable as a basis for national and international political action.
Health, Security, and Stability
Health as a non-traditional security issue has appeared on the agenda of the UN Security Council more and more frequently since 2000. On the one hand, this is due to new, serious health crises in unstable political contexts. On the other hand, the Security Council is progressively discussing issues that follow an expanded security logic, such as climate change as a security problem.
The 2014 Security Council resolution on the outbreak of Ebola fever in West Africa explicitly and directly described an infectious disease as a threat to peace and security. The Security Council thus launched the first collective health mission of the UN (the United Nations Mission for Ebola Emergency Response, UNMEER). However, the protection of public health is a constitutional task of WHO. Its independently staffed Ebola Interim Assessment Committee therefore advised against further UN missions in the event of future health crises.
In October 2018, the WHO Director-General addressed the UN Security Council regarding the situation in the DRC. The Security Council adopted Resolution 2439, calling for the protection of and access for health workers. Since May 2019, there has been a UN emergency coordinator for the Ebola outbreak: David Gressly was previously deputy head of the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO) peacekeeping mission in the DRC and personifies the interface between health and security.
The previous Security Council resolutions with an explicit reference to health either established a link between health risks and peace, stability, and security or dealt with the protection of humanitarian personnel, especially peacekeepers. However, little attention was paid to preventing epidemics and building resilient and efficient health systems. These issues are the responsibility of the Economic and Social Council (ECOSOC).
In the future, health challenges can be better addressed by taking a closer look at the interdependencies between health, security, and stability. This includes the social, political, economic, and military conditions and repercussions of health. For several years, the economic consequences of HIV/AIDS destabilized the seriously affected regions of Africa. Disease-related absences from work led to productivity losses, higher costs for medical care, and reduced levels of international investment. This can result in growing income disparities, poverty, and ultimately social and political strife. For 41 countries in sub-Saharan Africa, where around five percent of the population is infected with HIV, model calculations have shown a reduction of the gross domestic product of more than two percent per year. If there is a high burden of disease, trust in public health structures declines and state services can no longer be financed. Therefore, diseases can even mark a turning point in the devolution from a fragile to a failed state.
Time for a New Narrative
Germany aims to strengthening a value-driven multilateralism. In the context of global health, this could be put into practice, for example, at the interface between health, security, and stabilization. The term “global health security” should be scrutinized critically. It is an expression of the dominance and interests of high-income countries and neglects the actual needs of the populations in partner countries. In order to enforce the right to health, global health policy actors must take into account the interests of and trade-offs with other policy fields, act as moderators, and stand up for health priorities and health-related ethical implications. This includes support for healthy living conditions, preventive measures, the detection and treatment of acute and chronic diseases, as well as rehabilitation. It is therefore important not to solely focus on the treatment of infectious diseases. A new narrative could help to increase the credibility of the German commitment to global health policy in United Nations fora. Thereby partners could also be found in the Global South. Instead of threat scenarios, the shared risks and shared vulnerability of all people could become the focus of attention, and the narrative “stability through health” could be pursued. This could be a turning point away from the concept of global health security and toward the striving for equivalence between health, security, and stability.
Germany’s Scope for Action
Germany could address issues on the Security Council’s agenda that lie at the interface of health, security, and stability. This would provide an opportunity to apply the narrative “stability through health” by using a synergistic approach. Local needs for comprehensive health care and the treatment of infectious diseases would then have to be negotiated between partner countries – as would the protection of humanitarian actors and institutions – in an integrated manner. In the Security Council, the Arria-formula meetings – named after Diego Arria, the former Venezuelan ambassador to the UN – are a suitable forum for strengthening a debate around epidemic prevention and preparedness. Within this forum, impending humanitarian crises can be considered in their wider systemic context. This format can also be used to promote new and stronger alliances in global health policymaking.
Donor and recipient countries should join forces to strengthen health systems, also as part of bilateral development cooperation. To this end, the concept of Universal Health Coverage should be prioritized in accordance with WHO recommendations. This would mean promoting universal access to needs-based health services and preventing affected persons from suffering financial hardship due to high private health expenditures.
The Ebola outbreak in the DRC demonstrates the urgent need for intensified cooperation. This applies not only to cooperation between health, security, and development actors at the local and national levels, but also between WHO, the Security Council, and ECOSOC. The common goal of German global health actors should be to establish and sustain resilient, accessible, and well-equipped health systems that care for people’s needs and prevent, detect, and respond to infectious disease. The Federal Foreign Office and the Federal Ministries for Economic Cooperation and Development; for Health; for Education and Research; and for Defense could therefore pay greater attention to the social function of the health sector as a stabilizing factor.
Daniel Gulati and Maike Voss are researchers in the Global Issues division at SWP. Both work in the “Global Health” project, which is funded by the German Federal Ministry for Economic Cooperation and Development.
© Stiftung Wissenschaft und Politik, 2019
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(English version of SWP‑Aktuell 41/2019)